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.

UNITY PSYCHIATRIC CARE - HUNTSVILLE 5315 MILLENIUM DRIVE, NW HUNTSVILLE, AL 35806 March 10, 2015
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, policy and procedure, record review, and interview. it was determined the facility failed to ensure the staff:

1. Provided medications and TED (ThromboEmbolic Disease) Hose according to physician's orders. Refer to A 392

2. Response to ordered and PRN (as needed) medications were documented. Refer to A 392

3. Had physician's orders that were complete and accurate. Refer to A 392

4. Provided and documented wound care as ordered. Refer to A 392

5. Documented wound care and skin assessment per policy. Refer to A 392

6. Documented specific procedures performed including lab tests performed by venipuncture and urinary catherization. Refer to A 392

7. Provided treatment plans that were individualized to meet the needs of the patients. Refer to A 397

This affected Medical Record (MR) #s 5, # 4, # 1, # 2, # 9, # 10, # 11 and # 8 (8 of 8 records reviewed), and had the potential to negatively affect all patients served by this facility.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, review of the facility's policy and procedure, Board of Nursing Standards of Practice, Lippincott Manual of Nursing Practice, and medical records, and interview it was determined the facility failed to ensure:

1. The patient's received medications and TED (ThromboEmbolic Disease) Hoses according to physician's orders.

2. The staff documented the patient's response to ordered and PRN (as needed) medications.

3. Physician's orders were complete and accurate.

4. The staff provided and documented wound care as ordered.

5. The staff documented wound care and skin assessments per policy

6. The staff documented specific procedures performed including lab tests performed by venipuncture and urinary catherization

This affected Medical Record (MR) #s 5, # 4, # 1, # 2, # 13, # 7, # 9, # 10, # 11, # 8, # 3 and # 15 (8 of 8 records reviewed), and had the potential to negatively affect all patients served by this facility.

Findings include:

Policy and Procedure: PRN (as needed) Medications

Policy: "An order which is written to allow a medication to be given on an as-needed basis is a "PRN". PRN medications are medications that comprise the patient's regular medical regimen and are not intended to be considered chemical restraints...

Procedure:

3. When administered, the nurse shall document the reason that the PRN was given and effectiveness.

4. The physician continually assesses the use and the effectiveness of PRN medications and revises orders as needed."

*************

Policy and Procedure Wound Care:

Policy: These recommended guidelines are for identifying those patients at risk for compromised skin and for implementing preventative measures and treatment protocols. The LPN (Licensed Practical Nurse) or RN (Registered Nurse) will notify the physician for specific wound treatment upon admission or on day of wound development.

Procedure:
" 5. Pressure Ulcer Documentation

a. Once a pressure ulcer is identified an assessment must be documented. This must reflect that Physician and family were notified and what treatment/interventions were initiated.

b. The Weekly Wound Progress Note must be initiated by the nurse. The date of onset and location must be documented. This will be completed weekly and PRN (as needed).

c. Daily wound treatment documentation must be completed on the Treatment Administration Record.

d. Pressure ulcers must be assessed and measured at least once a week on the same day of the week...

f. Weekly documentation is to be recorded on a Weekly Wound Progress Note...

3) Wound Measurement- When documenting the size of all wounds, the nurse should include length, width, depth and tunneling or undermining (if present) in centimeters (CM)...

7. Wound Cleansing...
b. For small skin tears and abrasions, you can use the saline ampule. Do not use the ampule on pressure ulcers, other ulcers or wounds except small skin tears due to inadequate PSI (pound per square inch) that can be achieved."

************

Lippincott Manual of Nursing Practice 10th Edition:
Chapter 21 page 780

General Procedures and treatment Modalities:
" catherization:... Record time, procedure, amount and appearance of urine."

************

Alabama Board of Nursing: Chapter 610-X-6-.06 Documentation Standards;
Standards of Nursing Practice:
1. The standards for documentation of nursing care provided to patients by registered nurses and licensed practical nurse are based on principles of documentation regardless of the documentation format.
2. Documentation of nursing care shall be:
a. Legible to include signature.
b. Accurate
c. Complete. Complete documentation includes reporting and documenting on appropriate records a patient's status, including signs and symptoms, responses, treatment, medications, other nursing care rendered, communication of pertinent information to other health team members and unusual occurrences involving the patient.
d. Timely
i. Charted at the time or after the care..."

1. MR # 5 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbances.

Medications:

Review of the physician's order dated 1/19/15 revealed an order for:

Seroquel 50 mg (milligrams) P.O. (by mouth) daily and 100 mg every night.

Zoloft 100 mg PO daily

Namenda XR 28 mg PO daily

Ensure 240 ml (milliliters) PO three times a day if meal intake is < 50%.

Review of the January 2015 Medication Administration Record (MAR) revealed no documentation the patient received:

Seroquel 100 mg the night of 1/19/15

Seroquel 50 mg on 1/30/15 and 1/31/15

Ensure 240 ml on:

1/20/15 breakfast - 0% consumed
1/21/15 breakfast - 25 % consumed
1/24/15 supper - 25% consumed
1/26/15 breakfast, lunch and dinner - 25 % consumed
1/27/15 lunch and supper - 25% consumed
1/28/15 supper - 25% consumed
1/30/15 breakfast, lunch and dinner -0 to 25 % consumed
1/31/15 lunch - 25% consumed
2/1/15 breakfast - 25% consumed
2/4/15 lunch - 25% consumed
2/5/15 breakfast, lunch and dinner -0 to 25 % consumed
2/6/15 breakfast - 25% consumed

Review of the physician's order dated 1/21/15 revealed an order for Bactrim DS (Double Strength) PO twice a day times 7 days, D/C (discontinue) Zoloft and add Cymbalta 30 mg PO Daily.

Review of the January 2015 MAR revealed no documentation the patient received the Bactrim morning dose on 1/22/15.

Review of the February 2015 MAR revealed no documentation the patient received the following medications:

February 2, 2015 - Namenda XR (extended release) 28 mg, Seroquel 50 mg Cymbalta 30 mg, and Exelon Patch 9.5 mg

Further review of the February 2015 MAR revealed the patient received Zoloft 100 mg on 2/1/15, 2/3/15, 2/4/15, 2/5/15, 2/6/15 and 2/7/15 and the Zoloft was discontinued on 1/21/15.

Wounds:

Review of the Initial Skin assessment dated [DATE] revealed documentation the patient had no wounds.

Review of the Weekly Skin assessment dated [DATE] revealed documentation the patient had no wounds.

Review of the Weekly Skin assessment dated [DATE] revealed documentation the patient had a skin tear with arrow pointing to the right lower arm. There was no documentation of the size, appearance, or drainage.

Review of the Weekly Skin assessment dated [DATE] revealed documentation the patient had the following:

A. A skin tear with arrow pointing to the right lower arm, "old" written beside the arrow.

B. A skin tear with arrow pointing to the left arm, "old" written beside the arrow. This skin tear had no previous documentation in the medical record.

There was no documentation of the size, appearance, or drainage of either wound.

An interview was conducted on 3/11/15 at 3:00 PM with Employee Indentifer (EI) # 2, Director of Nurses, who verified the above findings.

2. MR # 4 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbances.

Medications:

Review of the physician's orders dated 2/3/15 revealed no documentation the physician signed the orders. The orders included Geodon 10 mg (milligrams) IM (intramuscular) PRN every 6 hours for severe agitation and Thigh High TED Hose.

Review of the Nurse Progress Note dated 2/19/15 at 5:30 PM revealed the nurse administered Geodon 10 mg IM for combative behaviors. Review of the MAR revealed no documentation the patient had received Geodon on 2/19/15 at 5:30 PM.

Review of the Nurse Progress Note dated 2/22/15 at 10:15 PM revealed the nurse administered Geodon 10 mg IM due to kicking and slapping at the staff. Review of the MAR revealed no documentation the patient had received Geodon on 2/22/15 at 10:15 PM.

Review of the physician's order dated 2/24/15 revealed an order to discontinue Amitiza. Further review of the physician's orders in the medical record revealed no documentation of a physician order to begin Amitiza.

Further review of the physician's order dated 2/24/15 revealed an order to start Linzess 145 mcg (micrograms) daily.

Review of the physician's order dated 2/26/15 revealed an order to discontinue Linzess.

Review of the March MAR revealed the patient received Linzess 145 mcg on 3/1/15, after it had been discontinued on 2/26/15.

Review of the February MAR revealed no documentation the Thigh high TED hose were removed the night of 2/11/15, 2/12/15, 2/16/15, 2/17/15, 2/18/15, 2/23/15 and 2/24/15.

Review of the March MAR revealed no documentation the Thigh high TED hose were:

Removed the night of 3/6/15, 3/7/15, 3/8/15 and 3/9/15. Placed on the morning of 3/3/15.

During observations of care on 3/9/15 between 10:50 AM and 12:30 PM and 3/10/15 between 9:00 and 11:00 AM, MR # 4 was not wearing TED hose.

Wounds:

Review of the Initial Skin assessment dated [DATE] revealed the patient had reddened areas to the left lower leg and both heels and a bruise to the back of the right arm.

Review of the Weekly Skin assessment dated [DATE] revealed the patient had reddened areas to the both lower legs and both heels and a bruise to the right arm.

There was no documentation of a Weekly Skin Assessment the weeks of 2/16/15 and 2/23/15.

Review of the Weekly Skin assessment dated [DATE] revealed the patient had a sore on the left lower leg. There was no documentation of the size, appearance, drainage or when the sore developed.

An interview was conducted on 3/11/15 at 2:00 PM with EI # 1, Regional Director of Hospital Operations, who verified the above findings.

3. MR # 1 was admitted to the facility on [DATE] with a diagnosis of Dementia with related Behavior Disturbance.

Review of the March MAR revealed no documentation the Thigh high TED hose was placed on MR # 1 the morning of 3/3/15.

Review of the 3/2/14 Admission Orders revealed multiple lab tests including Vitamin D Hydroxy, RPR (rapid plasma reagin), UA C& S (obtain straight cath specimen) and Thigh high TED hose ordered.

Review of the 3/2/15 Initial Nursing Assessment and 3/2/15 Patient Progress notes documentation did not include venipuncture to obtain the ordered lab tests and straight cath performed to collect the UA C& S.

Record review did include results of 3/2/15 lab tests and the UA C&S.

Review of the March MAR revealed no documentation the Thigh high TED hose was placed on MR # 1 the morning of 3/3/15.

A 3/11/15 1:30 PM interview was conducted with EI # 2 who confirmed staff failed to document procedures performed.

4. MR # 2 was admitted to the facility on [DATE] with a diagnosis of Paranoid Schizophrenia, chronic with acute exacerbation.

Review of the 1/9/15 Admission Orders revealed multiple lab tests including a CBC, CMP, UA C& S obtain straight cath specimen was ordered.

Review of the 1/9/15 Initial Nursing Assessment and 1/9/15 Patient Care notes revealed the following documentation "...tolerated lab work..." There was no documentation the lab tests were performed or the procedure performed to obtain the lab specimens. There was no documentation straight cath for UA C&S was performed.

Record review revealed results of lab work dated 1/9/15. The UA C& S results, collection and service date was 1/12/15.

Review of the 1/12/15 Nurse Patient Care notes documentation did not include a straight cath to collect the UA C&S.

Review of the 1/12/15 physician orders revealed the following order: "give new dose of Haldol Dec (Deconate) on 1/13/15". The medication order did not include the dosage or route for Haldol Deconate. There was no documentation staff notified the physician to clarify the medication order.

Review of the 1/12/15 8:00 AM Patient Care Note documentation revealed the patient was "wheezing", physician notified.

Review of the January 2015 MAR revealed Duoneb was "ordered x 1" (administer 1 time) and administered at 2:00 PM as a prn (as needed) medication.

The 1/12/15 at 2:00 PM MAR entry did not reveal the results of the prn Duoneb treatment or who administered the Duoneb.

Review of the 1/12/15 Patient Care Note documentation failed to revealed the therapeutic response to the Duoneb treatment, if the wheezing improved or not.

Staff failed to document in the medical record procedures performed.

In a 3/11/15 12:31 PM interview with EI # 1, the findings were confirmed.

In an interview on 3/11/15 at 12:31 PM, EI # 1, Regional Director of Hospital Operations, confirmed the above findings.

5. MR # 13 - An observation of wound care was performed on 3/10/15 at 1:10 PM for an unsampled patient. Wound care was performed to the patient's left forearm by EI # 4, Assistant Director of Nursing.

Review of the medical record documentation revealed a weekly skin assessment, dated 3/5/15 for a left arm skin tear, measurements 4 cm (centimeter) (length) by 3 cm (width), less than 0.1 cm (depth). There was no wound appearance, drainage/odor documented, the section was left blank.

The above document also included documentation of an additional skin tear to the right leg, 6 cm by 5 cm, (no depth documented), appearance bruised fluid-filled tear, no drainage. There was no documentation the right leg skin tear had a dressing on it.

During the 3/10/15 1:10 PM wound care observation, the surveyor noted the right leg skin tear had a transparent dressing on it.

There was no physician's order for a transparent dressing. There was no documentation staff had applied a transparent dressing or that the patient had the dressing on the right leg when admitted to the hospital.

Further review of the patient's medication treatment record dated 3/6/15 to 3/9/15 revealed wound care was ordered to the right forearm. The staff had documented that wound care was provided to the right forearm for 4 days.

The patient's wound was on the left forearm. There was no physician's order for wound care to the left forearm from 3/6/15 to 3/9/15.

On 3/11/15 at 11:30 AM in an interview with EI # 1, Regional Director of Hospital Operations confirmed the above findings.

6. MR # 7 was admitted to the hospital 12/23/14 with a diagnosis of Dementia with related Behavior Disturbance and Bipolar Disorder.

Review of the 12/23/14 Admission Orders revealed multiple lab tests including a Complete Blood Count (CBC), Complete Metabolic Profile CMP), urinalysis with culture and sensitivity (UA C& S) per straight cath (catheter) specimen ordered by the physician.

Review of the 12/23/14 Initial Nursing Assessment and 12/23/14 Patient Care notes did not include documentation a venipuncture was performed to obtain lab tests or that straight catherization to collect the UA C& S was performed.

Review of the 12/24/14 Nurse Patient Care notes did not include documentation the above procedures were performed.

Medical record review did include the results of the CBC, CMP, UA C& S results, date of service was 12/24/14.

Record review revealed physician orders dated 12/31/14 10:00 AM for "wound care to area on right side of back under scapula: Cleanse with NS (normal saline), pat dry and apply hydrogel and dry dressing. Change daily and prn (as needed)".

Review of the 12/31/14 Weekly Skin Assessment documentation did not reveal the wound care ordered was performed. Review of the 12/31/14 Patient Care notes documentation did not reveal the specific wound care that was provided to the "area to the right side of the patient's back".

A 3/11/15 1:55 PM interview was conducted with EI # 2, DON who reported the facility did not have a policy for urinary catherization, but used the Lippincott Manual as a reference for procedures. EI # 2 confirmed staff failed to document care ordered and procedures performed.
7. MR # 9 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbances.

During the observation of a medication pass conducted on 3/10/15 at 8:55 AM and review of the March 2015 routine medication list revealed no documentation the patient's 3/3/15 8:00 AM medications were administered by the Skilled Nurse (SN) as follows:

Namenda Tab 10 mg, 1 tablet (tab) PO two times a day.
Sertraline Tab 50 mg, 1 tab PO every day.
Tradjenta Tab 5 mg, 1 tab PO every day.
Vitamin E 400 mg, 1 capsule PO every day.

In an interview conducted on 3/11/15 at 1:55 PM with EI # 1, the aforementioned findings were verified.

8. MR # 10 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavior Disturbances.

During the observation of the medication pass conducted on 3/9/15 at 4:30 PM the SN was observed to administer to MR # 10 the medications Carbidopa / Levadopa 25/250 mg tablet and Miralax 17 Grams mixed with 4 ounces of water in a 4 ounce plastic cup found on the nurse medication cart.

Review of the March 2015 routine medication list revealed documentation the SN had administered Carbidopa / Levadopa 25/ 200 mg 1 by mouth 3 times a day, 8:00 AM, 1:00 PM and 5:00 PM and Miralax 17 Grams with 8 ounces of water every day 5:00 PM since 3/1/15. The MAR did not reflect the correct dosage for the Carbidopa / Levadopa. The Miralax was not mix with the correct amount of ordered water.

In an interview conducted on 3/11/15 at 1:55 PM with EI # 1, the aforementioned findings were verified.

9. MR # 11 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbances.

Medications:

During the observation of a medication pass conducted on 3/10/15 at 8:45 AM the SN administered the following morning medications of
Colace 10 mg capsule, Vitamin B 12 1000 mcg tablet, Lorsartan 50 mg tablet, Namenda 10 mg tablet, Cymbalta 60 mg capsule, Actos 15 mg tablet, Proscar 5 mg tablet, Vitamin D 3 1000 IU (international units) capsule, and Miralax 17 grams mixed with a 4 ounce cup of water. The patient only received the Miralax water for the medication administration. The Miralax was not mix with the correct amount of ordered water.

Review of the 3/7/15 physician orders revealed Miralax 17 grams mixed in 8 ounces of water every day.

Wounds and Procedures:

Review of the 1/9/15 Initial Skin Assessment revealed the SN documentation as:
Pressure Ulcer
Stage: "Unstageable"
Location: "Left heel"Size: "3 x 3.5"
Appearance: "Black"
Drainage: "No"

Skin Tears
Location: "Left and right elbow"
Size: "blank"
Appearance: "healing"

Review of the MR revealed no physician orders for the pressure ulcer or skin tears.

Review of the 1/11/15 Patient Care note revealed the skilled nurse (SN) documentation at 5:00 PM, "Patient in dining room, calm, apologetic, vs (vital signs stable) flushed catheter with Normal Saline 30 milliliter (ml)."

Review of 1/13/15 7:35 AM Patient Care note revealed the SN documentation as, "Complains of pain to lower abdomen with manipulation of Foley catheter...irrigated with 20 ml of normal saline"

Review of the medical record revealed there were no physician orders to flush the patient's foley catheter.

The SN failed to obtain physician orders before providing care, provide privacy by flushing catheter in dining room, obtain physician orders for wound care and failed to report the findings of abdominal pain to the physician.

10. MR # 8 was admitted to the facility 11/12/14 with diagnoses including Alzheimer's Dementia with behavioral disturbances.

Review of the 11/12/14 5:00 PM Initial Nursing Assessment on arrival to the facility revealed documentation of the patient stating, "I'm in so much pain!"

Further review of the 11/12/14 at 5:00 PM Initial Nursing Assessment revealed the SN documentation of the patient's description of current pain at a score of 7 (Severe) using the Pain Assessment of Wong - Baker FACES Pain Rating Scale, and the 1 - 10 pain scale.
Location: "All over"
Quality: "ache"
Duration: "constant"

Review of the 11/12/14 Admit Medication Form revealed the patient was ordered Hydrocodone/ APAP (Acetaminophen) 5/325 mg 1/2 to 1 tab every 8 to 12 hours PRN and the time of last dose was 11/10/14. The verbal orders were obtained by EI # 7, Admission Coordinator at 3:43 PM.

Review of the 11/13/14 8:00 AM Nursing Patient Care Note revealed documentation, "patient appeared to be in distress. complained of back pain...".

Further review of the 11/13/14 8:00 AM Nursing Patient Care Note revealed at 11:40 AM the patient was transferred to the dining room.

At 12:00 PM the patient was found with head down on table and eyes closed, unresponsive... appears to be expired.

At 12:07 PM the staff were unable to obtain vital signs other than a temperature of 85.8. The patient was pronounced expired.

Review of the MAR revealed no documentation the patient received any ordered medication for the complaints of severe pain.

The SN failed to provide the patient with ordered pain medication.

Review of 11/13/14 Special Precautions -- Special Monitoring form revealed documentation the patient was in group room from 9:15 AM to 11:00 AM. The 10:45 AM and 11:00 AM documentation were written over to indicate Dining Room.

In an interview conducted on 3/11/15 at 1:55 PM with EI # 1, the aforementioned findings were verified.


11. MR # 3 was admitted on [DATE] with diagnoses including Dementia with Behavioral Disturbances.

Review of the 2/11/15 Admission Orders revealed multiple lab tests including a CBC, CMP, Vitamin B 12, Vitamin D Hydroxy, and UA C& S obtain straight cath (catheter) specimen was ordered.

Review of the 2/11/15 Initial Nursing Assessment and 2/11/15 Patient Care notes documentation did not include a venipuncture to obtain the ordered lab tests and a straight catherization for the UA C& S.

Review of the 2/11/15 Nurse Patient Care notes did not include documentation the above procedures were completed.

MR review did include results of the CBC, CMP, Vitamin B 12, Vitamin D Hydroxy, and UA C& S results, date of service documented was 2/11/15.

Review of the 2/17/15, 2/18/15, 2/19/15, and 3/5/15 physician orders revealed orders for a UA C&S to be obtained.

Review of the MR revealed lab results for UA C&S for 2/19/15 and 3/5/15.

Review of the Nurse Patient Care notes did not include documentation the above procedures were collected or how the patient tolerated the procedure.

Record review revealed a 2/18/15 physician's order for CBC. There was no documentation in the Patient Care note the labs were obtained from the patient.

Review of 2/18/15 lab results revealed documentation from the lab the specimen was hemolyzed and was unusable and needed to be recollected.

Review of the MR revealed no documentation who received the lab notification of the hemolyzed blood specimen or physician notification.

Review of the 3/1/15 11:30 PM Physician's Verbal Order for D5 (Dextrose 5 %) 1/2 NS at 75 ml (milliliter)/ hour x 3 liters obtained from Medical Director by RN.

Review of the 3/2/15 Nurse Progress Note revealed at 1:15 AM 24 gauge IV (Intravenous) was started to left hand. Infusing D5 1/2 NS at 75 cc(cubic centimeters)/ hr (hour).

Review of the 3/2/15 at 8:00 AM SN entry revealed no documentation of the IV site.

Review of the 3/2/15 3:47 PM SN entry revealed documentation the bag was changed with no description of the IV site.

Review of the 3/2/15 10:00 PM SN entry revealed documentation no signs of infiltration.

Review of the 3/2/15 Graphic / Intake & Output (I & O) Record revealed documentation of IV intake as:
7 - 3: "560"
3 - 11: Blank - no documentation
11 - 7: Blank - no documentation

The 3/2/15 I & O record did not reflect SN documentation regarding IV intake.

Review of the 3/3/15 2:00 AM SN entry revealed documentation of no signs of infiltration.

Review of the 3/3/15 8:00 AM SN entry revealed the documentation of, "Patient refused to eat breakfast. Two attempts made by 2 different staff members. Patient slapped food away and hit staff for attempting to feed her. IV in left hand infiltrated and discontinued this morning. Will attempt to start another IV to get bag 3/3 of D5 1/2 NS".

The SN failed to document a description of the IV site or physician notification of that the IV fluids had been stopped due to infiltration.

Review of the 3/3/15 2:38 PM Physician Progress Note by EI # 9, Internal Medicine Physician revealed the following documentation, "IV was infiltrate on left arms with big edema. IV site was changed to the right hand..."

Review of the 3/3/15 6:46 PM Nurse Progress Note revealed the IV was restarted in right hand with 20 gauge catheter and D5 1/2 NS at 70 ml/ hr.

The SN failed to follow the physician orders for the IV infusion rate, document the number of attempts for IV or describe the IV site.

Review of the 3/3/15 I & O Record revealed the documentation of IV intake of:
7 - 3: Blank - no documentation
3 - 11: "1000"
11 - 7: Blank - no documentation

Review of the 3/4/15 Nurse progress notes made at 1:00 AM, 1:45 AM, 8:20 AM, 12:15 PM, 4:38 PM, and 8:00 PM revealed no documentation of the patient's IV infusion, the IV site or discontinuation of the IV.

Review of the 3/4/15 I & O Record revealed no SN documentation for the IV intake for the 3 shifts.

Review of the 3/4/15 9:19 PM Physician Order revealed an order for 2 liters of IV fluid of D5 1/2 NS at 70 ml /hr.

Review of the 3/5/15 2:00 AM Nurse progress note revealed documentation the IV was restarted with a 24 gauge catheter to left arm with 3 attempts.

Review of 3/5/15 6:48 PM Nurse progress note revealed no documentation of IV assessment.

Review of the 3/5/15 8:00 PM Nurse progress note revealed documentation of SN inability to restart the IV.

The nursing staff failed to document the discontinuation or infiltration of the IV started at 2:00 AM.

Review of the 3/5/15 8:00 PM Unsigned Physician's Verbal order revealed the order to restart IV on day shift 3/6/15.

Review of the 3/6/15 Nurse progress notes revealed entries were made at 9:00 AM and 11:40 AM with no documentation of IV attempts.

The next entry note revealed no time of the note and the staff inability to restart the IV. There was no documentation of the number of attempts made to restart the IV, the physician was notified of inability to restart the IV or that a verbal order was received to stop the IV fluids.

Review of the 3/6/15 I & O Record revealed the documentation of IV intake of:
7 - 3: arrow pointing to 3 - 11 shift
3 - 11: "300"
11 - 7: "700"
There was no documentation the patient had IV fluids infusing at the time stated.

In an interview conducted on 3/11/15 at 3:00 PM with EI # 2, DON, it was confirmed the nursing staff failed to follow physician orders, document procedures and patient assessments in the medical record, notify the physician of changes in patient. It was also confirmed the facility had no policy for these procedures.

13. MR # 15 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Dementia with Behavioral Disturbances (Severe).

An observation in the dining room was conducted on 3/9/15 at 11:55 AM to 12:45 PM. While observing another patient the surveyor noted at 12:00 PM that MR # 15's drink was spilled across the table on to the MHT's paperwork. MR # 15 was then observed at 12:10 PM to throw their uneaten plate of food to the floor.

At 12:21 PM the RN picked up the uneaten plate of food and offered to get the patient more food. The surveyor did not observe more food given to the patient. The surveyor asked the RN about the patient's lack of food, she stated, "I gave him an Ensure".

The surveyor noted only 1 RN and 1 LPN in the Dining Room, assisting two patient's with one on one feeding. There were a total 12 patients in the Dining Room.

The facility's staffing pattern results in limited opportunity for the RN to provide direction and supervision of non-professional nursing personnel in the provision of nursing care.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on observations during facility tour with hospital staff by the Fire Safety Compliance Officer and staff interviews, it was determined that the facility was not constructed, arranged and maintained to ensure patient safety.

Findings Include:

Refer to Life Safety Code violations.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observations, review of Centers for Disease Control (CDC) hand hygiene guidelines for healthcare settings, policy and procedures and interviews, it was determined the staff failed to:

a) Perform hand hygiene per policy.

b) Maintain clean surfaces in patients room and the facility medication cart after contact with contaminated medical equipment.

c) Wear appropriate personal protective equipment (gloves) when cleaning contaminated surfaces.

Finding include:

Administrative Policy and Procedure
Hand Hygiene
Revised 1-2008

"Policy: Hand Hygiene is a critical component of patients' safety and saves lives...
Procedure:
Improved adherence to hand hygiene...has been shown to terminate outbreaks in health care facilities...and reduce overall infection rates.
CDC is releasing guideline to improve adherence to hand hygiene...
...The use of gloves does not eliminate the need for hand hygiene. Likewise, the use of hand hygiene does not eliminate the need for gloves...Hand rubs should be used before and after each patient just as gloves should be changed before and after each patient."


CDC Guidelines to Hand Hygiene Volume 51, Published 2002

Recommendations

"1. Indications for handwashing and hand antisepsis

B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described in items 1C-J. Alternatively, wash hands with an antimicrobial soap and water in all clinical situations described in items 1C-J.
C. Decontaminate hands before having direct contact with patients.
F. Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient).
G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled.
H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care.
I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.
J. Decontaminate hands after removing gloves ..."

Hand Hygiene In Healthcare Settings

"Hand Hygiene Basics...

How to Handwash?

Apply enough soap to cover. Rub hands palm to palm; all hand surfaces; Wet hands with water; Right palm over left dorsum with
interlaced fingers and vice versa...Rinse hands with water; Dry hands thoroughly with a single use towel; Use towel to turn off faucet; Your hands are now safe."

1. An observation of care was conducted on 3/10/15 at 8:00 AM with Employee Identifier (EI) # 6, Licensed Practical Nurse. EI # 6 performed blood glucose testing for 2 unsampled patients.

EI # 6 entered the patient's room, laid the glucose monitor, supplies and 2 insulin pens on the table. EI # 6 donned gloves. EI # 6 did not perform hand hygiene before donning gloves.

EI # 6 performed the blood glucose test, placed the glucose monitor on the table and discarded the lancet to the sharps container.

EI # 6 then administered insulin using a FlexPen and discarded the lancet to the sharps container. EI # 6 removed gloves and laid the dirty gloves on the patient's table. EI # 6 then documented on the patient's medication record.

EI # 6 did not perform hand hygiene after glove removal.

EI # 6 did not clean the table in patient's room. There was no barrier placed on the table for the glucose monitor.

EI # 6 gathered the medication record, glucose monitor, FlexPens and supplies and returned to the locked medication cart in the hallway in front of the nurse station. EI # 6 laid the glucose monitor on the cart, opened the medication record binder, replaced the medication record and performed hand hygiene with hand sanitizer.

EI # 6 then opened the medication cart, replaced the FlexPens, retrieved Dispatch disinfectant wipes and cleaned the glucose monitor. EI # 6 removed and discarded gloves and the disinfectant wipe.

EI # 6 did not perform hand hygiene after glove removal. EI # 6 did not clean the top of the medication cart after laying the glucose meter on top of the med cart following glucose testing.

EI # 6 opened the medication binder, retrieved the next patient's medication record, opened the medication cart and retrieved a FlexPen. EI # 6 went to the dining room and informed the patient of the need to go to the patient's room for blood glucose testing.

EI # 6 donned gloves, no hand hygiene was completed prior to gloving, performed the blood glucose testing, discarded the sharps, removed his/her dirty gloves and laid the gloves on the table in the patient's room.

EI # 6 did not perform hand hygiene before donning and after glove removal.

EI # 6 charted on the medication record, gathered the glucose meter and supplies including the dirty gloves and exited the room.

EI # 6 did not clean the table in the patient's room following contact with the glucose monitor and dirty gloves.

EI # 6 discarded the gloves into the trash in the hallway at the medication cart. EI # 6 placed the glucose monitor and FlexPen on top of the medication cart, obtained clean gloves and laid the clean gloves on the medication cart. EI # 6 then used hand sanitizer, donned gloves and cleaned the glucose monitor with a disinfectant wipe.

EI # 6 failed to perform hand hygiene before and after glove removal. EI # 6 failed to clean the patient's table after performing blood glucose testing. EI # 6 failed to clean the glucose monitor before placing it on a clean surface, the medication cart. EI # 6 failed to clean the medication cart top after contact with contaminated medical equipment.

In a 3/11/15 9:55 AM interview with EI # 2, the Director of Nursing (DON)/ Infection Control Officer confirmed staff did not follow facility infection control practices.

2. An observation of wound care was performed on 3/10/15 at 1:20 PM with EI # 3, Assistant Director of Nurses (ADON) in exam room # 2.

EI # 3 cleaned the exam table with a Dispatch wipe, removed and discarded gloves, obtained a paper towel and wiped the table with the paper towel. EI # 3 failed to perform hand hygiene following glove removal.

EI # 3 then opened a pack of white barrier towels. EI # 3 washed his/her hands with soap and water at the sink. EI # 3 dried his/her hands with a paper towel, then turned the faucet off with clean hands.

EI # 3 did not use paper towels to turn off the faucet.

EI # 5, Registered Nurse (RN) assisted EI # 3 and removed the old dressings from the patient's right arm wound. EI # 3 cleansed the wounds with normal saline (NS), patted dry with gauze. While gloved, EI # 3 measured 1 of 2 wounds with a paper tape measure.

EI # 3 removed his/her right glove and did not perform hand hygiene. EI # 3 then opened a three drawer cart, retrieved another tape measure and measured the second wound.

EI # 3 completed wound care to the two right arm wounds, removed and discarded gloves and began charting on the medical record. EI # 3 did not perform hand hygiene after glove removal.

EI # 3 washed his/her hands with soap and water, dried hands with paper towels, then turned faucet off with clean hands.

EI # 3 did not use paper towels to turn off the faucet.

On 3/10/15 at 1:43 PM in Exam room 2, a second unsampled patient had wound care performed by EI # 3, assisted by EI # 5.

EI # 3 performed hand hygiene at the sink and turned the faucet off with clean hands.

EI # 5 donned gloves and removed the dressing from the unsampled patient's left elbow. EI # 3 poured NS over the wound, holding a paper towel underneath the wound to absorb (catch) excess NS. The NS solution, an area approximately 4 inches by 3 inches was observed on the Exam room floor.

EI # 3 completed wound care to the left elbow, removed and discarded his/her gloves. EI # 3 then obtained a paper tape measurer and measured the wound. EI # 3 did not perform hand hygiene after glove removal. EI # 3 was not wearing gloves when measuring the open wound.

EI # 3 and EI # 5 identified a right lower leg wound covered with a transparent dressing. At 2:05 PM, EI # 5 exited the room, returned with EI # 9, the Internal Medicine physician. EI # 9 donned a glove to his/her right hand, palpated the wound site, then provided verbal orders for care of the right leg wound.

EI # 9 removed and discarded his/her right glove, opened the Exam room door and exited. EI # 9 failed to perform hand hygiene before donning and after glove removal.

After completing wound care to the patient's right leg, EI # 5, with only the right hand gloved, placed 2 paper towels on the exam room floor to absorb the excess NS. EI # 5 then picked up the paper towels from the floor using the ungloved left hand. EI # 5 completed cleaning the floor with Dispatch wipes using the gloved right hand.

EI # 5 did not wear a glove on the left hand while cleaning the contaminated surface, the exam room floor.

In an interview on 3/10/15 at 4:10 PM, EI # 5 verified hand hygiene had not been performed per policy and staff failed to wear gloves when in contact with contaminated surfaces.

In an interview conducted on 3/12/15 9:55 AM with EI # 2, Director of Nurses, confirmed staff failed to perform infection control practices per hospital policy.
VIOLATION: LIST OF HOME HEALTH AGENCIES Tag No: A0823
Based on an interview it was determined the facility failed to devise a choice/ list of home health / hospice agencies being offered to patients/ caregivers referred to home health or hospice. This had the potential to affect all patient served by this facility.

Finding include:

In an interview on 3/11/15 at 10:05 AM with Employee Identifier # 8, Discharge Planner, it was revealed the hospital did not provide a "Freedom of Choice" letter to patients with referrals to home health or hospice.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on review of medical record and policies and procedure and interview, it was determined in 1 of 7 records reviewed the facility failed to ensure the treatment plan was individualized to meet the needs of the patients. This affected MR # 7, 1 of 3 patients with wounds. This had the potential to negatively affect all patients served by the facility.


Findings include:

"Policy and Procedure:

Treatment Plan
Revised 9/2014

Policy: Each patient will have an individualized comprehensive treatment plan that will be based on an inventory of the patient's strengths and disabilities, and the treatment team, along with the patient shall meet no less than every 7 days to review the patient treatment.

Procedure:

4. The treatment team will review the patient's goals and progress and record their findings on the Treatment Review Note.

9. Each patient's master treatment plan is reviewed weekly...to evaluate progress...changes in interventions and status...
c. Newly identified problems will be discussed for additions to the master treatment plan..."


1. MR # 7 was admitted to the hospital 12/23/14 with a diagnosis of Dementia with related Behavior Disturbance and Bipolar Disorder.

Record review included 12/23/14 10:00 AM documentation titled Non-Ulcer Weekly Progress Note that revealed a skin tear, an open abrasion to the right hand, measuring 1.5 cm (centimeter) length (L), 1 cm (width)(W), less than 0.1 cm (depth)(D). Wound care was performed with NS (normal saline) cleansing, patted dry and bandage applied.

Review of the 12/23/14 Treatment Medication Record documentation included 12/23/14 orders to "Clean (R) [right] hand with NS. Apply hydrogel. Apply gauze. Nurse documentation revealed the above care was performed 12/24/14 and 12/25/14 as initialed on the medication record.

Review of the 12/30/14 Master Treatment Plan did not include the right hand wound and 12/23/14 wound care orders.

Review of the Treatment Medication Record documentation included 12/31/14 orders for wound care to area on (R) side of back under scapula. Cleanse with NS, pat dry apply hydrogel and dry dressing. Change daily and prn (as needed).

Review of the 12/31/14 10:00 AM Non-Ulcer Weekly Progress documentation revealed an "open area to right hand, proximal second phalange area", measured 1 cm (L) by 1.5 cm (W) and less than 0.1 cm (D).

Review of the 1/2/15 Master Treatment Plan revealed the following problems: Violence, Anxiety, Insomnia, Fall Risk and Urinary Tract infection.

MR # 7's Master Treatment Plan did not include and was not updated with skin integument alterations. There was no update to the 1/2/15 Master Treatment Plan for the right hand wound.

In an interview 3/11/15 at 1:55 PM, Employee Identifier # 2, the Director of Nursing confirmed the treatment plan did not initially reflect nor was updated for treatment and care of MR # 7's wounds.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, facility's policy and procedure, and Neurological Assessment Flowsheets Guidelines and interview, it was determined the facility failed to ensure the staff:

1. Completed the Special Observations as per policy and legend.

2. Completed the Neurological Assessment Flowsheets according to the guidelines.

3. Completed the Psychiatric Nursing Flowsheets for precaution monitoring as ordered.

This affected Medical Record (MR) # s 5, 4, 7, 1, 2, 6, and 8 (7 of 8 records reviewed) and had the potential to affect all patients served by this facility.

Findings include:


Policy and Procedure : Special Observation

Policy: " All patients entering the program are assessed for their degree of risk behaviors during the admission process...
Staff monitoring is instituted to prevent patients from harming themselves or others. Any change in the patient's behavior that would indicate a listed precaution will be assessed and the Medical Director notified of the assessment. The Medical Director will order the appropriate precaution level. In all cases the least restrictive level that protects the safety of the patient or milieu is used.

Procedure:

1. Precautions (each patient will be assessed and assigned individual interventions to meet their needs and abilities):
a. ADL (activities of Daily Living) Precaution 30 minute checks by staff.
b. Fall Prevention 30 minute checks by staff...
c. 15 minute checks by staff include the following precautions...
5) Seizure
6) Assault...

2. Description of Precaution Levels
a. 30 Minute Checks
10. All patients with an order for fall or ADL precautions will be monitored at a minimum (ADL precautions are used to alert staff of increased risk of violence during care)...

Each sheet is for one 24 hour period. The staff will authenticate their signature and initials at the bottom of the form. Then the nurse will place the precaution form under the nurses note tab of the chart."

Neurological Assessment Flowsheet Guidelines:

Complete form (included vital signs) every 15 minutes for 1 hour; every 30 minutes for x 3 hours; every hour x 8 hours; every 2 hours x 12 hours; every 4 hours x 24 hours.

An interview was conducted with Employee Identifier (EI) # 1, Regional Director of Hospital Operations on 3/11/15 at 2:00 PM. The surveyor asked when the Neurological Assessment Flowsheets were completed and the response was, "When ever the patient falls and is suspected they hit their head or if the patient show neurological symptoms".

1. MR # 5 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbances.

Review of the Special Precautions -- Special Monitoring form dated 2/6/15 revealed the following ledged for the patients' location:

B = Bathroom
H = Hallway
PR = Patient Room
DR = Dining Room

Review of the Special Precautions -- Special Monitoring form dated 2/6/15 revealed the patient was in the Dining Room asleep between 8:15 and 9:30 PM. Further review of the Special Precautions -- Special Monitoring form dated 2/6/15 revealed no documentation the nurse reviewed the form.

Further review of the Special Precautions -- Special Monitoring form dated 2/6/15 revealed at 9:45 PM the patient was in the Hallway and at 10:00 to 10:15 PM the patient location was BR. There was no documentation on the Special Precautions -- Special Monitoring form dated 2/6/15 what BR meant for location.

Review of the Nurse Event dated 2/6/15 revealed the Nurse Event took place at 10:00 PM. The Nurse Event dated 2/6/15 stated the patient was lying on floor with a pillow under her head.

Review of the Family Complaints dated 2/11/15 revealed the following, "...(family member) wants to know why the patient was left to wander by ...(patient) (when...already had a fall and high propensity to fall as well as a very unsteady gait) and the nurses notes reflected that...(patient)... lying in the dining room with a pillow under her head..."

Review of the Neurological Assessment Flowsheet which began 2/2/15 at 3:10 PM revealed the following:

2/2/15 at 3:10 PM - no documentation of pupils size and response
2/2/15 at 3:25 PM - no documentation of pulse, respirations, temperature, and pupils size and response.
2/3/15 at 6:55 AM - no documentation of pulse, respirations and temperature.
2/3/15 at 8:55 AM - no documentation of a blood pressure.

An interview was conducted on 3/11/15 at 3:00 PM with Employee Identifier (EI) # 2, Director of Nurses. EI # 2 stated that there was no documentation where BR was on the Special Precautions -- Special Monitoring dated 2/6/15 and verified the above findings.

2. MR # 4 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbances.

Review of the Special Precautions -- Special Monitoring forms revealed the following:

2/8/15 - no documentation of an assessment between 6:00 to 7:00 PM.

2/12/15 - no documentation of an assessment between 10:15 to 11:15 AM.

2/12/15 - no documentation of an assessment between 4:00 to 5:00 PM.

2/12/15 - no documentation of an assessment between 7:00 to 9:45 PM.

2/12/15 - no documentation of where the patient was between 9:45 to 10:45 PM.

3/4/15 - no documentation of an assessment between 2:15 to 3:15 PM.

Review of the Neurological Assessment Flowsheet which began 2/6/15 at 2:35 PM revealed no documentation of vital signs (VS) at 3:20 PM.

Review of the Neurological Assessment Flowsheet which began 3/1/15 at 3:00 PM revealed no documentation of VS between 3:00 and 6:30 PM.

An interview was conducted with EI # 1, Regional Director of Hospital Operations on 3/11/15 at 2:00 PM. EI # 1 verified the above findings.

3. MR # 7 was admitted to the hospital 12/23/14 with a diagnosis of Dementia with related Behavior Disturbance and Bipolar Disorder.

Review of the Admission Orders documentation revealed MR # 7 was placed on Fall, Seizure and Assault precautions.

Review of the Special Precautions -- Special Monitoring form dated 12/24/15, 12/25/4 and 12/27/14 did not include the type precautions to be monitored. The "Type of Precaution" for monitoring was blank on the above dates.

Review of the Special Precautions -- Special Monitoring form dated 12/28/14 failed to include Assault and Seizure precaution monitoring as ordered.

Review of the Psychiatric Nursing Assessment Flowsheets documentation failed to reveal the following precautions monitored:

12/24/14 - 8:00 AM and 10:00 PM, no fall, assault and seizure precautions
12/25/14 - 8:00 AM and 10:00 PM, no assault precautions
12/26/14 - 8:00 AM and 10:00 PM, no assault precautions
12/27/14 - 8:00 AM and 10:00 PM, no assault precautions
12/28/14 - 8:00 AM and 10:00 PM, no assault precautions
12/29/14 - 8:00 AM and 10:00 PM, no assault precautions
12/31/14 - 8:00 AM, no assault and seizure precautions
1/2/15 - 8:00 AM, no assault and seizure precautions

In an interview 3/11/15 at 1:55 PM, EI # 2 confirmed the findings.


4. MR # 1 was admitted to the hospital 3/2/15 with a diagnosis of Dementia with related Behavior Disturbance.

Review of the Admission Orders documentation revealed MR # 7 was placed on Fall, Activity of Daily Living (ADL) and Assault precautions.

Review of the 3/4/15 Special Precautions -- Special Monitoring form did not include the type precautions to be monitored.

The 3/4/15 Special Precautions -- Special Monitoring form did not include initials of the person monitoring or the location of the patient from 2:30 PM to 2:45 PM and 2:45 PM to 3:00 PM.

Review of the documentation on the Psychiatric Nursing Assessment Flowsheets failed to include the following precautions were monitored:

3/2/15 - 8:00 AM and 10:00 PM, no fall and assault precautions
3/3/15 - 8:00 AM and 10:00 PM, no fall and assault precautions
3/4/15 - 8:00 AM, no fall precautions
3/4/15 - 8:00 AM and 10:00 PM, no assault precautions
3/5/15 - 8:00 AM, no fall and assault precautions

In an interview on 3/11/15 at 1:30 PM, EI # 2 confirmed the above findings.

5. MR # 2 was admitted to the hospital 1/9/15 with a diagnosis of Paranoid Schizophrenia, chronic with acute exaceberation.

Review of the Admission Orders documentation revealed MR # 2 was placed on Fall Precautions.

Review of the 1/9/15 Special Precautions -- Special Monitoring form, failed to include the type precautions that required monitoring.

Review of the documentation on the Psychiatric Nursing Assessment Flowsheets failed to reveal the following precautions were monitored:

1/11/15 - 8:00 AM, no fall precautions
1/13/15 - 8:00 AM and 10:00 PM, no fall precautions

In an interview on 3/11/15 at 12:31 PM, EI # 1 confirmed the above findings.

5. MR # 6 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance.

Review of the 3/5/15 Special Precautions -- Special Monitoring form revealed documentation at 3:00 PM patient in group. There was no documentation of patients status from 3:15 to 4:45 PM.

Further review of the 3/5/15 Special Precautions -- Special Monitoring form revealed no documentation the nurse reviewed the form.

In an interview conducted on 3/11/15 at 3:00 PM with EI # 2 the aforementioned findings were verified.

6. MR # 8 was admitted to the facility on [DATE] with diagnoses including Dementia Alzheimer's Type.

Review of the 11/12/14 Admission Orders documentation revealed MR # 8 was placed on fall precautions with every 15 minute checks.


Review of the 11/12/14 and 11/13/14 Special Precautions -- Special Monitoring form revealed no documentation as to the precautions to be monitored.

The "Type of Precaution" ordered to be for monitored was blank the above dates.

Further review of the MR revealed the patient expired on [DATE], in the dining room at 12:07 PM and was taken to the hallway. Then the patient was transferred to the patient's room.

Review of Special Precautions -- Special Monitoring form revealed documentation of the staff member's initials between 11:45 AM until 7:15 PM. The patient did expire at 12:07 PM.

There was no documentation the Special Precautions -- Special Monitoring forms were reviewed by the nursing staff.

In an interview conducted on 3/11/15 at 1:40 PM with EI # 1, the aforementioned findings were confirmed.
VIOLATION: UNUSABLE DRUGS NOT USED Tag No: A0505
Based on review of the Center for Disease Control (CDC) Guidelines, observations and interviews, it was determined the facility failed to ensure:

A. Supplies available for patient use were not expired.
B. Medications available for patient used were not expired.
C. Multi use vials were labeled with the date, time and person who opened the vial.

This affected Medical Record (MR) # 3, and had the potential to affect all patients served by this facility.

Findings include:

"Basic Safe Injection Practice Messages by the CDC

CDC evidence-based guidelines define safe injection practices under Standard Precautions. These include one-time use of needles and syringes and limiting sharing of medication vials. Vials labeled as "single dose" or "single use" should not be used on multiple patients. A large single-dose/single-use vial may appear to contain adequate drug to treat more than one patient. However, single-dose/single-use vials typically lack antimicrobial preservative and can become contaminated and serve as a source of infection when they are used inappropriately. Therefore, they should only be used for a single patient and a single procedure.

If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.

During a tour of the facility conducted on 3/9/15 at 10:40 AM in patient room an intravenous (IV) pole held a mechanical pump with an empty bag of Dextrose 5 and 45 % (D5 1/2) Normal Saline (NS) 1000 milliliters (ml). The tubing attached to the bag revealed a small white label with 3/6/15 written on it.

It was confirmed at the time of the tour of facility by Employee Identifier (EI) # 3, Administrator, the patient had been receiving IV fluids and the empty bag had not been disposed of.

A tour of the medication room on 3/9/15 at 11:30 AM revealed a large orange unlocked tackle box labeled, "IV and PRN's (as needed)" The following expired medications and supplies were found:

3- 1 ml vials of Vitamin K, expired 3/01/15.
1- 2 ml vial of Digoxin 500 micrograms (mcg) 2 ml, expired 2/15.
1- IV start kit, expired 9/13.
1- # 20 Jelco IV Catheter, expired 1/15.

A tour of the exam room # 2 on 3/9/15 at 11:45 AM revealed a treatment cart with the following medications were opened and not labeled with an open date:

1- 0.5 ml tube of Bactroban Ointment.
1- 1 ounce (oz) tube of Benadryl Ointment.

and the following expired items:

1- 1 oz tube of Triple Antibiotic Ointment, expired 1/15.
1- 2 oz tube of Desitin Ointment, expired 10/28/14.
1- 100 ml plastic container of NS open with 3/3 written on the top.

In an interview conducted on 3/11/15 at 1:55 PM with EI # 1, Regional Director of Hospital Operations (RDHO) the aforementioned findings were verified.

During a tour of the facility laboratory room on 3/9/15 at 10:40 AM, 6 green top clot lab specimen tubes, expired 12/2013 were found. EI # 3, Administrator, present during the tour, verified the finding.

On 3/9/15 at 11:35 AM in the pharmacy medication room refrigerator, the following were expired, open, not labeled and improperly stored:

1 vial Novolog 100 unit/ml open, labeled 1/23/15.
1 vial Tuberculin Purified Protein Derivative 1 ml (Tubersol) 10 tests, open and not labeled.
3 boxes of Bisca-Eval 10 mg laxative, storage directions were "store room temperature."

An interview conducted on 3/9/15 at 11:45 with EI # 7, Licensed Practical Nurse/ Admission Coordinator, present during the tour, verified the above findings.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on the review of medical records, Medical Staff Bylaws and Rules and Regulations of the Medical Staff and interviews, it was determined the Medical Staff failed to ensure:

1. Verbal orders were accepted by a licensed nurse and signed, dated, and timed by the Medical Staff within 48 hours. Refer to V 049

2. The attending physician or designee made rounds daily and completed at least a daily progress note on each patient. Refer to V 049

3. The facility followed their own policy for Patients' Laundry and Patient Belongings. Refer to V 049

4. The facility followed the policy for Hepatitis B Immunization. This affected Employee Identifiers (EI) # 10, and # 14, which was 2 of 14 employee Files reviewed. Refer to V 049

5. The facility followed the Job Descriptions for personnel maintaining a current CPR (cardiopulmonary resuscitation) card. This affected EI # 10, # 14, # 15, and # 16, which was 4 of 14 employee files reviewed. Refer to V 049

6. The staff followed the Morse Fall Scale for 2 of 3 active medical records reviewed. Refer to A 144

7. That 5 of 7 physician were credentialed by the Medical Staff. Refer to A 341

8. The staff provided medications and TED (ThromboEmbolic Disease) Hose according to physician's orders. Refer to A 392

9. The staff responded to ordered and PRN (as needed) medications were documented. Refer to A 392

10. Physician's orders were complete and accurate. Refer to A 392

11. The staff provided and documented wound care as ordered. Refer to A 392

12. The staff documented wound care and skin assessment per policy. Refer to A 392

13. The staff documented specific procedures performed including lab tests performed by venipuncture and urinary catherization. Refer to A 392

14. The staff provided treatment plans that were individualized to meet the needs of the patients. Refer to A 397

15. The staff performed hand hygiene per policy. Refer to A 749

16. The staff maintained clean surfaces in patients room and the facility medication cart after contact with contaminated medical equipment. Refer to A 749

17 The staff wore appropriate personal protective equipment (gloves) when cleaning contaminated surfaces. Refer to A 749

18. The staff had devised a choice/list of home health/hospice agencies being offered to patients/caregivers referred to home health or hospice. Refer to A 823
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on the review of medical records, Medical Staff Bylaws and Rules and Regulations of the Medical Staff and interviews, it was determined the Medical Staff failed to ensure:

1. Verbal orders were accepted by a licensed nurse and signed, dated, and timed by the Medical Staff within 48 hours.

2. The attending physician or designee made rounds daily and completed at least a daily progress note on each patient.

3. The facility followed their own policy for Patients' Laundry and Patient Belongings.

4. The facility followed the policy for Hepatitis B Immunization. This affected Employee Identifiers (EI) # 10, and # 14, which was 2 of 14 employee Files reviewed.

5. The facility followed the Job Descriptions for personnel maintaining a current CPR (cardiopulmonary resuscitation) card. This affected EI # 10, # 14, # 15, and # 16, which was 4 of 14 employee files reviewed.

This affected Medical Records (MR) # 5, # 4, # 7, # 1, # 2, # 6 and # 3 (7 of 8 records reviewed) and had the potential to negatively affect all patients served by the hospital.

Findings include:


Medical Staff Bylaws of Behavioral Healthcare Center at Huntsville
Adopted by the Medical Staff, effective August 1, 2013
Approved by the Board of Directors, effective August 1, 2013

2.A.2. Responsibilities "...
(e) participate in quality assessment and monitoring activities as may be assigned by committee chairs, including the evaluation of provisional appointees...
3.B.2. Medical Director
(f) provide day-to-day liaison on medical matters with the Administrator;
4.D: Medical Staff role in performance
Improvement functions:
(1) Medical Staff functions that focus on systematic monitoring and performance improvement shall at a minimum, include measurement, assessment and improvement of the following;...
(c) use of medications;...
(a) education of patients and families..."

************

The Rules and Regulations of the Medical Staff Behavioral Healthcare Center at Huntsville, Inc.

" 1. Criteria for Admission
1.1... These criteria are identified in the Hospital's Utilization Review Plan and in each program narrative. Waiver of any of these criteria must be approved by the Medical Director...

2. Admission
2.1 Patients may be admitted to the hospital only by Medical Staff with Clinical Privileges to do so...
2.2 A medically appropriate inpatient should meet one or more of the following criteria:
(a) Threat to others requiring 24-hour professional observation...

3. Care and Treatment of Patients
3.4 The attending physician may be present at the treatment team meetings. The Medical Director shall review and approve all treatment plans formulated by the treatment team...
3.6 Only a physician or the attending Medical Staff may lower the level of observation.
3.9 A treatment plan shall be completed within 10 days of admission and initiated 3 days after admission.
3.10 The attending physician or designee shall make rounds daily and complete at least a daily progress note on each patient.
5.3 (b) Medical Staff must complete a discharge summary fifteen (15) days of discharge...
5.4 (a) A verbal order shall be considered to be written if accepted by a licensed nurse and signed, dated, and timed by the Medical Staff within 48 hours.
(f) Physician orders are required for admission, discharge, medication, treatments, restriction of patient rights and special precautions.

************

Policy and Procedure: Patient Laundry

Policy:

"BHC-H (Behavioral Healthcare Center at Huntsville) will have contracted laundry facilities available for cleaning patient's personal clothing and linens."

*************

Policy and Procedure: Patient Belongings

Policy:

"Shelf and drawer space is provided for patients' storage of personal belongings. Patients are responsible for their own belongings and valuables and are encouraged to send all valuables and personal items home. If the patient has no one to take belongings home, the belongings and valuables will be listed on a 'Patient Inventory" form and placed in the designated storage room or unit safe. The patient is informed that BHC-H does not recommend keeping valuables in the patient's possession and that if the patient chooses to do so, the patient assumes complete responsibility for any loss."

Procedure:
" ...
2. Discharge Procedure...
b. The patient signs patient Inventory Form indicating receipt of listed items. The items placed in the safe are returned to the patient and inventoried just prior to departing the unit.
c. Property that has been placed in storage and identified at the time of discharge as 'missing' shall be searched for by the staff. The 'missing' items should be highlighted on a copy of the inventory sheet. The sheet is then sent to the business office. When items are found the business office will mark off and send item to patient. The investigative authority rest with the Nurse Manager. The ultimate determination of the belongings' whereabouts and/or value of said belongings determined lost shall rest with the Nurse Manager in cooperation with BHC-H Administration. Replacement of items/cost is made only in rare circumstances."

************

Facility Policy: Hepatitis B Immunizations for Staff

Policy:

Employees who may be exposed to blood or body fluids are eligible on a voluntary basis to receive immunization for Hepatitis B at no cost to the employee. The identified "at risk" employees include RN's (Registered Nurses), LPNs (Licensed Practical Nurses), Mental Health Technicians (MHT), Physicians, Therapist, Admission Coordinator, and Maintenance personnel.

Procedure:

4. If the employee does not wish to be immunized, they will be asked to sign a declination form, which will be placed in their personnel file. The employee can change their mind at any time and receive the immunization.

5. If the employee wishes to be immunized:
a. The employee will give a copy of ... the Patient Informed Consent form.
b. The HR (Human Resources) Manager will keep track of the dates for the next shot. The form will be given to the LPN when the next round is due.
c. Whoever provides the immunization should have the employee read and sign a patient informed consent form on the Hepatitis B Vaccine.
d. The Hepatitis B vaccine is given on Day 0, day 30 and six months...

************

Job Description: Activities Therapist

Procedure:

A. Qualifications

3. Certification - CPR...

**********

Job Description: Mental Health Technician

Procedure:

A. Qualifications

3. Certification - ...CPR certification is required prior to direct patient care

***********

Job Description: Registered Nurse

Procedure:

A. Qualifications

3. Certification - CPR...

************

Job Description: Licensed Practical Nurse (LPN)

Procedure:

A. Qualifications

4. Certification - CPR...

1. MR # 5 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbances. MR # 5 was discharged to another hospital on [DATE].

Review of the Admission Orders dated 1/19/15 revealed no documentation the Medical Staff signed, dated, and timed the order.

Review of 2 verbal orders dated 2/7/15 at 2:00 PM and the other 2:15 PM revealed no documentation the Medical Staff signed, dated, and timed the orders.

Review of the Clothing Inventory dated 1/19/15 revealed the patient had brought 5 pair of pants, 5 shirts, 2 sets of pajamas, 2 bras, 3 pair of socks, 2 pair of shoes, 1 jacket, 1 coat, a tote bag and 4 coat hangers when admitted to this facility.

Review of the facility's Family Complaint dated 2/11/15 revealed there were 3 pairs of pants missing from MR # 5 inventory. MR # 5 had 2 bras her/his belongings that were not MR # 5 and had on a bra at the time of discharge that was not MR # 5 and was on inside out.

An interview was conducted on 3/10/15 at 8:15 AM with EI # 3, Administrator. The surveyor asked for the facility's policy on Patient Laundry. Employee Identifier (EI) # 3 stated there was no policy in place for the facility to laundry the patients' clothes. The facility had stopped laundering the patient's cloths the evening of 3/9/15, after the surveyor requested the policy.

On 3/11/15 at 2:00 PM, the surveyor asked Employee Identifier (EI) # 1, Regional Director of Hospital Operations for the patient's inventory list with the highlighted items that had been returned and the inventory list could not be submitted.

2. MR # 4 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbances.

Review of the physician's Progress Notes revealed no documentation of a Progress Note for 2/22/15, 2/28/15 and 3/1/15, which were all on the weekend.

3. MR # 7 was admitted to the hospital 12/23/14 with a diagnosis of Dementia with related Behavior Disturbance and Bipolar Disorder.

Review of the Admission Orders dated 12/23/14 revealed the Medical Staff signed, dated, and timed the order on 1/8/15 at 9:30 AM.

The telephone/verbal order was not signed by Medical Staff within 48 hours.


4. MR # 1 was admitted to the hospital 3/2/15 with a diagnosis of Dementia with related Behavior Disturbance.

Review of the Admission Orders dated 3/2/15 revealed no documentation the Medical Staff signed, dated, and timed the order.

The telephone/verbal order has not been signed by Medical Staff.


5. MR # 2 was admitted to the hospital 1/9/15 with a diagnosis of Paranoid Schizophrenia, chronic with acute exaceberation.

Review of the Admission Orders dated 1/9/15 revealed the Medical Staff signed, dated, and timed the order on 1/15/15 at 11:20 AM.

The telephone/verbal order was not signed by Medical Staff within 48 hours.

Medical Staff failed to follow the facility policy for physician signature for verbal orders.

6. MR # 6 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Recurrent Severe.

Review of the MR revealed no Physician Progress Note for Saturday 1/10/15. The patient was transferred to an acute care facility on 1/13/15.

In an interview conducted on 3/11/15 at 1:50 PM with EI # 1, Director of Hospital Operations, the aforementioned findings were verified.

7. MR # 3 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbances.

Review of the 2/11/15 Admission Orders revealed documentation by EI # 7, Admission Coordinator, receipt of a physician's verbal order on 2/11/15 at 12:06 PM. Further review revealed no documentation the physician had signed the orders as of 3/10/15 4:00 PM.

Review of the 3/1/15 Physician's verbal order for IV (Intravenous) fluid was not signed by the physician as of 3/10/15 4:00 PM.

Review of the 3/5/15 Time of order was unclear due to documentation write over by the RN. The Physician's verbal order, "Cath urine for UA (urinalysis) C&S (culture and sensitivity). Leave catheter in if residual greater than 300 ml(milliliters)" was not signed by the physician as of 3/10/15 at 4:00 PM.

Review of the 3/5/15 12:55 PM Physician's verbal order for collection of BMP (Basic Metabolic Profile) today was not signed by the physician as of 3/10/15 at 4:00 PM.

Review of the 3/5/15 8:00 PM Physician's verbal order to restart IV on dayshift 3/6/15 was not signed by the physician as of 3/10/15 at 4:00 PM.

Review of the MR revealed no documentation of a Physician's Progress Note for Sunday 2/22/15 or Saturday 2/28/15.

In an interview conducted on 3/11/15 at 1:50 PM with EI # 1, the aforementioned findings were verified.

************

Hepatitis Vaccines and CPR

1. EI # 10, Mental health Technician was hired on 10/22/14.

Review of the Hepatitis B Antibodies collected 10/22/14 revealed a level of < 8.0, which is not immune to Hepatitis B.

Review of the Hepatitis B Vaccine Acceptance Form signed by EI # 10 on 10/22/14 revealed no documentation the vaccinations had started. This is 41/2 months after hire.

Review of personnel files on 3/11/15 at 1:00 PM revealed no documentation of a cardiopulmonary resuscitation (CPR) documentation.

2. EI # 14, Activities Director was hired on 10/22/14.

Review of the Hepatitis B Antibodies collected 8/19/14 revealed a level of < 8.0, which is not immune to Hepatitis B.

Review of the Hepatitis B Vaccine Acceptance Form signed by EI # 13 on 8/19/14 revealed no documentation the vaccinations had started. This is 6 months after hire.

Review of personnel files on 3/11/15 at 1:15 PM revealed no documentation of a cardiopulmonary resuscitation (CPR) documentation.

In an interview conducted on 3/11/15 at 2:25 PM with EI # 13, Human Resource Director, the aforementioned findings were verified.

3. EI # 15, Certified Registered Nurse Practitioner (CRNP) was hired on 4/9/14.

Review of personnel files on 3/11/15 at 1:00 PM revealed EI # 15's personnel file did not contain CPR documentation.

On 3/11/15 at 1:20 PM, a written and verbal request for current CPR documentation on the CRNP was presented to EI # 13. No CPR documentation was provided.

A telephone interview was conducted on 3/18/15 at 11:30 AM with EI # 3, Administrator, who stated EI # 15 did not have a current CPR.

4. EI # 16, Licensed Practical Nurse (LPN) was hired on 10/6/14.

Review of the personnel files on 3/11/15 at 1:00 PM revealed the CPR certification for EI # 16 had expired on [DATE].

In an interview conducted on 3/11/15 at 2:25 PM with EI # 13, Human Resource Manager,
the aforementioned findings were verified.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, observations and interviews, it was determined the facility failed to ensure the staff followed the Morse Fall Scale for 2 of 3 active medical records reviewed. This included Medical Records (MR) # 4, and MR # 3 and had the potential to affect all patients served by this facility.

Findings include:

Facility Morse Fall Scale

Fall Risk is based upon Fall Risk factors and it is more than a Total Score. Determine Fall Risk Factors and Target Interventions to Reduce Risk. Complete on admission, weekly and as needed.

Morse Fall Score:

High Risk = 46 and higher
Moderate Risk = 25 - 45
Low Risk = 0 - 24

Interventions:

Low Risk :
Orient patient to environment on admission.
Clutter free environment.
Application of appropriate footwear.

Moderate Risk:
All previous interventions.
Safety alarm (chairs/bed/body) as appropriate.
Fall precautions every 30 minutes.
Bed in low position at HS (hour of sleep) (unless otherwise specified).
Non-skid socks at HS (May also wear during the day).

High Risk:
All previous interventions.
Yellow bracelet.
Restorative therapy.

1. MR # 4 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbances.

Review of the patient's Morse Fall Score for 2/3/15, 2/7/15, 2/12/15, 2/19/15, 2/23/15, and 3/1/15 revealed a score of 75.

Review of an Nurse Event Note dated 2/6/15 at 2:35 PM revealed the patient had an observed fall in the Activities Room.

Review of an Nurse Event Note dated 3/1/15 at 3:00 PM revealed the patient had a fall in the Activities Room.

During observations of care on 3/9/15 between 10:50 AM and 12:30 PM and 3/10/15 between 9:00 and 11:00 AM, MR # 4 did not have on
a yellow bracelet.

2. MR # 3 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance.

Review of the patient's Morse Fall Score for the dates of 2/11/15, 2/19/15, and 2/26/15 revealed a score of 50, and on 3/3/15 it revealed a score of 70.

During observations of care on 3/9/15 between 11:50 AM and 12:30 PM and 3/10/15 between 8:00 and 9:00 AM, MR # 3 did not have on
a yellow bracelet to indicate patient was at risk for falls.

In an interview conducted on 3/11/15 at 3:00 PM with Employee I Indentifer # 2, Director of Nurses, the aforementioned findings were verified.
VIOLATION: MEDICAL STAFF CREDENTIALING Tag No: A0341
Based on review of physician credentialing files reviewed and interview, it was determined 5 of 7 physician credentialing files failed to contain medical staff appointment documentation. This affected Physician Indentifer (PI) # 3, # 4, # 5, # 6 and # 7 and had the potential to negatively affect all patients served by the facility.

Findings include:

1. Review of PI # 3 credentialing file revealed no documentation of medical staff appointment.

2. Review of PI # 4 credentialing file revealed no documentation of medical staff appointment and Drug Enforcement Agency (DEA) certification.

3. Review of PI # 5 credentialing file revealed no documentation of medical staff appointment.

4. Review of PI # 6 credentialing file revealed no documentation of medical staff appointment and DEA certification.

5. Review of PI # 7 credentialing file revealed no documentation of medical staff appointment and DEA certification.

A telephone interview was conducted on 3/19/15 at 11:30 AM with Employee Identifier # 3 Administrator. EI # 3 stated there was no other documentation in the physician credentialing files.