The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ST. LUKE'S BEHAVIORAL HOSPITAL, LP 1800 EAST VAN BUREN PHOENIX, AZ Jan. 25, 2012
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
Based on review of hospital policy/procedure, medical records and staff interview, it was determined that the hospital failed to require that restraint or seclusion was in accordance with a written modification to the patient's plan of care for 4 of 4 patients (Pt's # 18, 24, 25 and 26).

Findings include:

Review of the policy/procedure titled Seclusion, Physical Hold, and Restraints required: "...At the time of the face-to-face assessment the LIP or qualified RN:...Revises the patient's treatment plan, and services as need...."

Review of Medical Records revealed:

Pt # 18's record contained documentation that he was in seclusion on 11/26/11 from 2315 until 11/27/11 at 0015; on 11/27/11 from 0910 until 1510; on 11/29/11 from 0145 until 0225; on 11/29/11 from 0400 until 0440; on 11/29/11 from 0620 until 0645; and on 12/2/11 from 1130 until 1235. A nurse administered a "chemical restraint" to Pt #18 on 11/27/11 at 1127 and on 11/29/11 at 0645.

The RN Seclusion/Restraint Progress Note for each of these dates revealed documentation of interventions used to de-escalate the situation before placing the patient in seclusion/restraints.

The Seclusion/Restraint Patient Debriefing form for each of these dates had a section titled Treatment Plan Update that revealed: "...this information must be documented on Patient Treatment Plan/Progress Note...Problem: Difficulty maintaining safe behavior when...Goal(s) related to problem...Patient Objective(s)...." This information was not documented on the Multidisciplinary Treatment Plan.

The Multidisciplinary Treatment Plan form dated 11/26/11, 11/27/11, 11/29/11 and 12/2/11, did not contain documentation of the use of seclusion/chemical restraint or least restrictive interventions attempted.

Pt # 24's record contained documentation that she was physically restrained on 10/29/11 from 2105 until 2115. A nurse administered a "chemical restraint" on 10/31/11 at 1700.
The patient was in seclusion on 10/31/11 from 1655-1900, and in mechanical restraints from 1835 until 1900.

The RN Seclusion/Restraint Progress Note for each of these dates revealed documentation of interventions used to de-escalate the situation before placing the patient in seclusion/restraints.

The Seclusion/Restraint Patient Debriefing form for each of these dates had documentation on problem, goals and patient objectives, but this information was not documented on the Multidisciplinary Treatment Plan.

The Multidisciplinary Treatment Plan form dated 10/29/11 and 10/31/11, did not contain documentation of the use of seclusion/chemical restraint or least restrictive interventions attempted.

Pt # 25's record contained documentation that he was in seclusion on 10/20/11 from 1445 until 1615, and that he was physically restrained for administration of a "chemical restraint" on 10/20/11 at 1800.

The RN Seclusion/Restraint Progress Note revealed documentation of interventions used to de-escalate the situation before placing the patient in seclusion/restraints.

The Seclusion/Restraint Patient Debriefing form contained documentation on problem, goals and patient objectives, but this information was not documented on the Multidisciplinary Treatment plan.

The Multidisciplinary Treatment Plan form dated 10/20/11, did not contain documentation of the use of seclusion/chemical restraint or least restrictive interventions attempted.

Pt #26's record contained documentation that she was in seclusion on 10/11/11 from 0920 until 1000, and was physically restrained for administration of a "chemical restraint" at 0920. She was in seclusion on 10/12/11 from 1000 until 1300, and was physically restrained for administration of a "chemical restraint" at 1200. She was in seclusion on 10/13/11 from 1005 until 1105.

The RN Seclusion/Restraint Progress Notes revealed documentation of interventions used to de-escalate the situation before placing the patient in seclusion/restraints.

The Seclusion/Restraint Patient Debriefing forms had documentation on problems, goals and patient objectives, but this information was not documented on the Multidisciplinary Treatment plan.

The Multidisciplinary Treatment Plan forms dated 10/11/11, 10/12/11, and 10/13/11, did not contain documentation of the use of seclusion/chemical restraint or least restrictive interventions attempted.

Nurse Manager, employee # 20, confirmed in an interview conducted on 1/24/12 at 0805 hours, that Restraint/ Seclusion usage and least restrictive interventions attempted were not documented on the Multidisciplinary Treatment Plan for Pt's. # 18, 24, 25 and 26.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of Hospital documents, policies/procedures, medical records, observation, and interview, it was determined the hospital failed to protect and promote each patient's rights as evidenced by:

(A131) failing to protect the rights of the patient's legal representative to make informed decisions regarding the patient's care;

(A143) failing to protect the patient's right to privacy;

(A144) failing to protect the patient's right to receive care in a safe setting;

(A145) failing to protect a patient from sexual abuse;

(A166) failing to require that restraint or seclusion is in accordance with a written modification to the patient's plan of care;

(A167) failing to determine whether restraint was implemented in accordance with safe and appropriate restraint techniques for a patient who was injured during restraint as required by hospital policy;

(A168) failing to require that the use of restraint be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient;

(A178) failing to require that a patient be seen face-to-face within 1 hour after a restraint or seclusion is used for the management of violent or self-destructive behavior or after restraint is used for forced medication;

(A179) failing to require that the 1 hour face-to-face assessment include an evaluation of the patient's medical condition; and

(A196) failing to require training of RN's to conduct the one hour face-to-face assessment including training to complete an evaluation of the patient's medical condition.

The cumulative effect of these systemic problems resulted in the hospital's failure to protect and promote each patient's rights.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policy/procedure, medical record and staff interview, it was determined the hospital failed to protect the rights of the patient's legal representative to make informed decisions regarding the patient's care for 3 of 3 patients with legal guardians (Pt's #4, 24 and 36) as evidenced by:

1. failure to require informed consent from a legal guardian for administration of psychotropic medications for Pt # 24; and

2. failure to require two witnesses for telephone (verbal) consent for administration of medication as required by the facility's policy for Pt's #4, 24 and 36.

Findings include:

1. The hospital policy/procedure titled "Consent for Minors" required: "...the right to give consent for a minor is restricted to parents, stepparents, legally appointed guardians who present a court order of guardianship, foster parents, persons with temporary care of the minor...CPS (Child Protective Services) must come to the facility, sign the COA (Conditions of Admission) giving consent to evaluate and give contact information to the unit staff once on the unit...once the information and COA have been obtained, CPS may leave the facility, however, CPS must be available by phone if additional information is required...consent is to be obtained in writing...consent is required for the administration of any psychotropic medication...."

Review of medical records:

Patient # 24, a minor female was admitted on [DATE] with Bipolar Disorder, mixed type with psychotic features, increased disruption and aggression, danger to self and danger to others. Child Protective Services (CPS) had guardianship custody of this child. The guardian identified on the form signed consent for admission and treatment on 10/28/11 at 1800 hours. Pt # 24 was discharged on [DATE].

Pt # 24's medical record contained a form titled Child and Adolescent Guardian Information. Review of this document revealed: "...Intake staff complete the information below and unit staff please note the information below...This patient is a minor and has a guardian named below who must sign all paperwork, as well as give consent for all medications and procedures...."

On 10/29/11 at 1540 hours, phone consent was obtained from patient #28's mother for the administration of Geodon.

On 10/31/11 at 1110 hours, phone consent was obtained from patient # 28's mother for the administration of Vistaril (Hydroxyzine).

On 11/8/11 at 1740 hours, phone consent was obtained from patient # 28's mother for the administration of Folic Acid.

Nurse manager, employee #20, confirmed on 1/24/12 at 0910 hours, that phone consents for medication were obtained from the patient's mother, who is not the legal guardian.

2. Review of the hospital policy /procedure titled Consent For Minors required: "...verbal consent should be witnessed by one other staff member and so noted in the documentation...."

On 10/29/11 at 1540 hours, phone consent was obtained for the administration of Geodon to Pt #28. There was no documentation in the medical record of a second witness.

On 10/31/11 at 1110 hours, phone consent was obtained for the administration of Vistaril (Hydroxyzine) to Pt #28. There was no documentation in the medical record of a second witness.

On 11/8/11 at 1740 hours, phone consent was obtained for the administration of Folic Acid to Pt #28. There was no documentation in the medical record of the RN who obtained the consent or the second witness.

Nurse manager, employee # 20, confirmed on 1/24/12 at 0910 hours, that there was no RN signature for the phone consent for Folic Acid and no second witness for the phone consents for Geodon, Vistaril, and Folic Acid.

Pt #4 was admitted on [DATE]. The medical record contained two forms titled Informed Consent for Medications. One form was used to document consent for administration of Seroquel. On 10/18/11, at 1800, an RN documented on the Seroquel form: "...Mom gave phone consent...." The form contained the signature of the RN, but it did not contain the signature of a second witness as required by policy/procedure. The second form was used to document consent for administration of Depakote. On 10/19/11, at an undetermined time, an RN documented on the Depakote form: "...Telephone consent obtained from (F) (Father)...." The Depakote form did not contain the signature of two witnesses as required.

The Quality Educator confirmed during an interview conducted on 1/23/12, that the telephone consents were not signed by two witnesses as required.

Review of hospital policy/procedure titled Medication Consent revealed: "...If the legal guardian or surrogate decision maker is not present, telephone consent may be obtained by a Registered Nurse who shall write and sign the consent. For phone authorization a witness is required to co-sign the consent...."

Pt #36 was an adult patient, admitted to the Psychiatric Intensive Care (PIC) area of Adult Psychiatric 1 unit (AP1) on 12/30/11. Pt #36's medical record contained documentation that he had a legal guardian. On 12/31/11, an RN signed a form titled Informed Consent for Medications for administration of Clozaril, indicating that she obtained telephone consent from the patient's guardian. The form did not contain a co-signature of a second witness for telephone consent.

The Director of Quality confirmed during interview conducted on 1/12/12, that a second witness was required and that the consent did not follow hospital policy.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on review of hospital policy/procedure, direct observation, review of hospital documents, and interviews, it was determined that the hospital failed to protect the patient's right to privacy for 2 of 2 patients who were assigned to beds in the PIC dayroom (Pts #36 and 3).

Findings include:

Review of hospital policy/procedure titled Patient's rights and Responsibilities revealed: "...Patient's rights are as follows:...To be treated with dignity, respect, and consideration...To privacy in treatment...."

Observation of the PIC area:

The PIC area of the AP1 Unit is an enclosed, locked area which can be viewed from a glass-enclosed nurses' station. The PIC area contains six private patient rooms, listed on the "Station Census" as rooms 121-A, 122-A, 123-A, 124-A, 125-A, and 126-A. Staff seated in the enclosed nurses' station can view the entire Day Room, but cannot view the individual patient rooms which are located in short hallways on either side of the Day Room. The Day Room is a common patient area within the locked PIC. A television is mounted on the wall and a table surrounded by stools is also located in the Day Room where patients eat meals. Several cushioned chairs are located in the Day Room. The remainder of API is known as Psychiatric Acute Care (PAC) and contains 16 beds. The PAC patient rooms are all semi-private.

During tour on 1/11/12, Employee #20 explained that any patient that requires constant observation is placed in the PIC Day Room day and night.

On 1/11/12, Pt #36 was observed sitting on a hospital bed in the PIC Day Room and his gown did not cover his private parts.

On 1/12/12, the CNO informed the surveyor that the "980 beds" are used rarely and only if there are no other beds available in the community for the particular patients. She confirmed that these beds are placed in the PIC Day Room, referred to as "980." Review of the AP1 "Station Census" sheets and the "Daily Patient Assignment Sheets" revealed the following:

on 12/30/11, at 2228, Pt #3, a female, occupied bed 980, Pt #37, a female, occupied bed 981 and Pt #36, a male, occupied bed 982;
on 12/31/11, at 0543, Pt #3 occupied bed 980, Pt #37 occupied bed 981 and Pt #36 occupied bed 982;
on 12/31/11, at 1419, Pt #3 occupied bed 980 and Pt #36 occupied bed 982;
on 12/31/11, at 2155, Pt #36 occupied bed 982 and Pt #3 occupied room/bed 121;
on 01/01/12, at 0536, Pt #3 occupied bed 980 and Pt #36 occupied room/bed 121;
on 01/01/12, at 1402, Pt #3 occupied bed 980 and Pt #36 occupied room/bed 121;
on 01/01/12, at 2253, Pt #3 occupied bed 980 and Pt #36 occupied room/bed 121;
on 01/02/12, at 0436, Pt #3 occupied bed 980 and Pt #36 occupied room/bed 121;
on 01/02/12, at 1500, Pt #3 occupied bed 980 and Pt #36 occupied room/bed 121;
on 01/02/12, at 2100, Pt #3 occupied bed 980 and Pt #36 occupied room/bed 121;
on 01/03/12, at 0719, Pt #3 occupied bed 980 and Pt #36 occupied room/bed 121;
on 01/03/12, at 1459, Pt #3 occupied bed 980 and Pt #36 occupied room/bed 121;
on 01/03/12, at 2142, Pt #3 occupied bed 980 and Pt #36 occupied room/bed 121;
on 01/04/12, at 0715, Pt #3 occupied bed 980 and Pt #36 occupied room/bed 121;
on 01/04/12, at 1509, Pt #3 occupied bed 980 and Pt #36 occupied room/bed 121;
on 01/04/12, at 2111, Pt #36 occupied bed 980, Pt #38, a female, occupied bed 981, and Pt #3 occupied room/bed 121. Pt #3 continued to occupy room/bed 121 until 1/11/12, when she was moved out of PIC and into a room in the PAC area of AP1;
on 01/05/12, at 0716, Pt #36 occupied bed 980 and Pt #38, a female, occupied bed 981;
on 01/05/12, at 1506, Pt #36 occupied bed 980;
on 01/06/12, at 0029, Pt #36 occupied bed 980;
on 01/06/12, at 0726, Pt #36 occupied bed 980;
on 01/06/12, at 1449, Pt #36 occupied bed 980;
on 01/06/12, at 2211, Pt #36 occupied bed 980;
on 01/07/12, at 0510, Pt #36 occupied bed 980;
on 01/07/12, at 1421, Pt #36 occupied bed 980;
on 01/07/12, at 2055, Pt #36 occupied bed 980 and Pt #39 (a female) occupied bed 981;
on 01/08/12, at 0526, Pt #36 occupied bed 980 and Pt #39 occupied bed 981;
on 01/08/12, at 2309, Pt #36 occupied bed 980 and Pt #39 occupied bed 981;
on 01/09/12, at 0001, Pt #36 occupied bed 980 and Pt #39 occupied bed 981;
on 01/09/12, at 0711, Pt #36 occupied bed 980 and Pt #39 occupied bed 981;
on 01/09/12, at 1454, Pt #36 occupied bed 980 and Pt #39 occupied bed 981;
on 01/09/12, at 2215, Pt #36 occupied bed 980 and Pt #39 occupied bed 981;
on 01/10/12, at 0717, Pt #36 occupied bed 980 and Pt #39 occupied bed 981;
on 01/10/12, at 1437, Pt #36 occupied bed 980;
on 01/10/12, at 2239, Pt #36 occupied bed 980;
on 01/11/12, at 0710, Pt #36 occupied bed 980;
on 01/11/12, at 1442, Pt #36 occupied bed 980;
on 01/11/12, at 2000, Pt #36 occupied room/bed 121 and Pt #3 occupied room 142A which is a room in the PAC section of AP1, outside of PIC.

Review of the "Station Census" sheets revealed that at least one patient was consistently placed in a "980 bed" in the PIC Day Room from 12/30/11 through 1/11/12. In addition, on 12/30/11, 12/31/11, 1/4/12, 1/5/12, and 1/7/12 through 1/10/12, male and female patients were placed in beds in the PIC Dayroom at the same time.

Employee #20, confirmed during interview on 1/13/12, that patients are moved to PIC to "980 beds" when they cannot be managed on another unit or on the PAC side of AP1.

Employee #31 confirmed during interview on 1/12/12, that if a patient won't "contract for safety" when s/he is assessed in Intake, that patient will be admitted to the PIC Day Room.

Patient privacy is not maintained when a patient bed or beds are placed in the day room.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policy/procedure, medical record, hospital documents, and interviews, it was determined that the hospital failed to protect the patients' right to receive care in a safe setting as evidenced by:

1. failing to prevent 2 of 2 patients who required inpatient hospitalization due to altered mental status and or impaired capacity for rational thinking from leaving the hospital (Pts #1 and 2);

2. failing to provide for safety of 1 of 1 patient (Pt #40) who was physically assaulted by another patient (Pt #1);

3. failing to prevent sexual contact between 2 adult patients, which was initially reported by female pt as rape (Pt #8); and

4. failing to provide an environment that is free of fixtures, surfaces, and/or equipment conducive to self-injury or suicide for individuals in the lobby area awaiting intake assessments or admission.

Findings include:

1. Facility Policy and Procedure titled "Occurrence Report: Patient/Visitor/Employee" dated 9/99 revised 4/11 revealed: "...All personnel should report unusual occurrences, which may result in actual or potential harm to...patients...Unusual Occurrence: Is any circumstance that is inconsistent with the routine operation of the facility or the routine care of a particular patient...."

Facility Policy and Procedure titled "Code Gray" dated 9/82 revised 6/10 revealed: "...When a unit...is treating a patient who becomes combative or needs to be physically controlled for the patient's safety, it is the responsibility of the charge nurse or primary nurse to request a Code Gray...patient safety will be the primary concern...Document events and behavior on the Nursing Notes...."

Facility Policy and Procedure titled "Smoking Policy/Regulations" dated 6/84 revised 9/09 revealed: "...Patients will be allowed to smoke in designated areas only. Smoking areas are monitored by staff...."

Facility Policy and Procedure titled "Code Green" dated 8/02 revised 2/11 revealed: "...Facility shall take all reasonable precautions to prevent those inpatients with altered mental status or who are not capable of rational thinking from leaving the facility...If patient begins to demonstrate wandering behavior the nursing staff will intervene with redirection or diversional activities to minimize risk...If the patient is not found on hospital grounds, the primary nurse of patient will initiate the following guidelines: 1. The patient physician, family/guardian, Administration/Administrator-on-call, the Risk Manager and Security are to be notified. Security will contact the Local Police Department immediately...2. Document patient's elopement in the medical record with complete report of action implemented and update administration and the chief nursing officer...3. Follow Patient Follow up post elopement policy and Complete Post Elopement Interaction report form...."

Review of hospital policy/procedure titled Patient Follow-up Post Elopement revealed: "...It is the policy of this hospital, that in the event of an elopement of a patient in which the patient is not returned to the unit, there will be timely follow-up completed in an attempt to locate the patient, to determine the status of the patient's mental and physical health, and to offer resources and assistance to the patient and/or family as needed...If a patient elopes from a unit and is not returned to the unit there will be follow-up initiated within four hours and extending up to 24 hours by the Social Services Department...The Social Worker...or designee will call all possible locations where it is likely the patient will go...in the event the elopement was after regular business hours, this first follow up call will be made first thing the next day...If the patient is not located on the first call that will be documented on 'Post Elopement Interaction Report'...At 24 hours post elopement...another attempt will be made...In the event the patient is located during an all (sic) the 'Post Elopement Interaction Report' will be used to guide an assessment of the patients (sic) current well being...the patient will be asked if he or she feels they need to return to the hospital...The outcome of the discussion will be documented on the 'Post Elopement Interaction Report' form...it will be sent to Medical Records for scanning in to the patient's record...."

Patient # 1 was admitted on [DATE] with a diagnosis of Mood Disorder and Psychosis.

Review of the Intake Admission Assessment form revealed: "...Pt brought to...Emergency Department...He was reporting SI (Suicidal Ideations)...wanting world to end...Patient is very slow to answer questions, appears to be responding to questions, appears to be responding to internal stimuli and...need for world to end though he appears unable to describe plan due to confusion...." Quality Educator confirmed documentation in an interview conducted on 1/12/12 at 1200.

Review of Inpatient Admission Orders written on 1/24/11 at 1505 by MD # 1 revealed no level of observation ordered for Pt #1 on admission. Quality Educator confirmed in an interview conducted on 1/12/12 at 1200, that there was no documentation in the medical record of orders for observation levels.

RN # 24's Nurses Notes dated 11/24/11 at 1630 revealed: "...pt was admitted to AP-4 unit...Patient was extremely confused, preoccupied with thought blocking. He was A&Ox4 (Alert and Oriented to person, place, time, and situation) without hesitation to self, date, day and where he is and where he came from. He denies SI...He was very paranoid. After assessment he continuously attempted to leave unit. He was placed on Q (every) 15 minute obs (observation). Supervisor notified and NP (Nurse Practitioner) called with orders received for meds...." Quality Educator confirmed in an interview conducted on 1/12/12 at 1200, that there was documentation of the patient attempting to leave the unit.

RN # 32's Nurses Notes dated 11/24/11 at 1917 revealed: "...patient tried to escape by going to AP-3 several times, not redirectable. Pt appears responding to internal stimuli...." Quality Educator confirmed in an interview conducted on 1/12/12 at 1200, that there was documentation of the patient continuing to attempt to leave the unit with no documentation of notification of doctor of patient attempts to leave the unit.

Order written on 11/25/12 at 1130 am by Nurse Practitioner revealed: "...Pt to be moved to 980 bed - visible to nursing staff...." CNO confirmed order on 1/12/12 at 1700. Lead Nurse Manager also confirmed order on 1/17/12 at 1445.

Review of Psychiatric Evaluation dated 11/25/11 at 1352 written by MD # 7 revealed: "...The patient is a very poor historian, was seen on PIC unit after he attempted to put a bed sheet around his neck on the regular floor, attempting to kill himself...He was not able to describe any further symptoms to me and upon further inquiry, first he stated he never wanted to kill himself yesterday then he said he did and currently denied any suicidal ideation...stated he did not know why he is in the hospital...put the patient on the PIC on the 980 bed with direct observation from nursing. Given previous attempt in the hospital yesterday and poor historian we will observe him...." Lead Nurse Manager confirmed documentation on 1/17/12 at 1445.

RN # 40's Nurses Notes dated 11/25/11 at 1420 revealed: "...no insight about tieing a bed sheet around neck last night and wanting to kill self. Pt would answer a question with a different answer when asked at different times. Doesn't know why he is here and doesn't want to be here. When asked why he put the sheet around neck, pt stated 'I just wanted to kill myself cause my brother left me here'. pt has been moved to a 980 bed per MD order for closer watch...Pt to remain on PIC for observation...." Lead Nurse Manager confirmed documentation on 1/17/12 at 1445.

RN # 41's Nurses Notes dated 11/25/11 at 1910 revealed: "...at 1605 pt climbed over wall on smoking patio and eloped. Code green called. Pt's brother, doctor and police called. Pt returned...at 1640 with...security. family and doctor informed...." Lead Nurse Manager confirmed documentation on 1/17/12 at 1445.

Progress Notes written by MD # 7 on 11/26/11 at 0930 revealed: "Pt AWOL yesterday, brought back by police, does not remember incident...very scared about being here...refusing CT scan...." Lead Nurse Manager confirmed documentation on 1/17/12 at 1445.

Review of progress notes written by MD # 7 on 11/26/11 at 0930, revealed that MD #7 did not indicate special precaution orders. The physician indicated: "...On PIC...." Lead Nurse Manager confirmed documentation on 1/17/12 at 1445.

Progress Notes written by MD # 7 on 11/26/11 at 0930, revealed Plan/ Recommendations as: "...Ct close observation/med stabilization...2. staffing...." Lead Nurse Manager confirmed documentation on 1/17/12 at 1445.

Review of facility documentation revealed the hospital did not follow their policy and supervise the patient. Patient # 1 has a history of being a danger to self and others. This was not addressed on the plan of care. There was no indication that 1 to 1 staffing was addressed for patient #1. The Lead Nurse Manager was aware of all related incidents and appropriate supervision was not assigned.
The order was for the patient to be "...visible to nursing staff..." and for close observation on the PIC unit. The patient was still allowed to smoke even after incidents of attempting to leave nursing units and attempting suicide. The facility did not provide a safe setting for the patient. Further review of the facility documentation revealed there was no change in facility policy or procedures after the patient elopement to prevent it from occurring in the future. The patient's orders were not changed to reflect any measures to prevent him from elopement. His level of observation prior to the elopement was ordered "...Pt to be moved to 980 bed- visible to nursing staff...." This order was written at 1130 on 11/25/11. The medical record contained no documentation of orders that the patient privileges or smoking privileges were changed after the patient returned from his elopement. Lead Nurse Manager in an interview conducted on 1/17/12 at 1445, confirmed that the 980 bed is the strictest level on PIC, and that even with a 980 bed order the patients are still allowed to go out and smoke. They are only observed from the window of the milieu. On tour of PIC on 1/17/12 at 1505, it was observed that from the window on PIC the whole smoking patio is not visible. The smoking patio is an 'L' shaped patio with the top part of the 'L' not visible from the window of the PIC unit. Lead Nurse Manager in an interview conducted on 1/17/12 at 1505, confirmed that staff on PIC observe the smoking patio from the window on PIC, and that the whole smoking patio is not visible to staff from this window.

Pt #2 was transferred to the facility from a hospital Emergency Department on 12/12/11 via ambulance transport. The patient's provisional diagnosis was Psychosis.

Review of the medical record revealed:

Intake staff documented on the Intake Admission Assessment at 1200: "...Change in energy level...(increased) agitated...hallucinations...Auditory...6
months...delusions...Grandiose...Judgment...Impaired...fair reliability-delusions & impaired memory...Presenting Problem...Psychosis...Pt states...he has been playing 3 video games & feels like he has been part of the game. Pt also reports that God has been talking to him & instructing him. Uncle concerned over bizarre behavior including 'acting out' scenes from video games...Pt admitted for psychotic symptoms...."

On 12/12/11, at 2000, an RN documented: "...at times he exhibitted (sic) bizarre behaviors, such as hugging other patients or kissing them on head...."

On 12/12/11, at 2330, an RN documented a Late note: "...At 1105 the night shift BHT (Behavioral Health Tech) reported to nursing staff that patient was not in his room...performed thorough searches of the unit and notified the house supervisor of the believed patient elopement. Another systematic search of the unit was performed under the direction of the house supervisor. I gave...report to the house supervisor, informing her of my most recent assessment: that patient was not imminently dangerous to self or others, and that during the shift he demonstrated alterations in his thought process, intermittently...at approximately 2015...the patient took...Haldol 5 mg PO (by mouth)...Benadryl 50 mg PO...house supervisor called 'code green' and directed the staff persons to search the premises. The patient was not found...."

The medical record did not contain any additional documentation regarding notification of physician, family, Security; or any action implemented after calling the 'code green' as required by policy. The medical record did not contain documentation of implementation of the Patient Follow-up Post Elopement policy/procedure. It did not contain the Post Elopement Interaction Report form.

The Director of Quality confirmed during an interview conducted on 1/24/12, that the medical record did not contain the required documentation following a 'code green' or the documentation required by policy/procedure Patient Follow-up Post Elopement, including the Post Elopement Interaction Report form.

2. Facility Policy and Procedure titled "Abuse/Neglect/ Exploitation" dated 12/93 revised 4/11 revealed: "...The hospital will protect patients...from abuse...from anyone including...other patients...."

Patient # 40 was admitted on [DATE] with a diagnosis of Schizophrenia, paranoid type.

RN # 41's Nurses Notes dated 11/25/11 at 1910, revealed: "... At 1700 pt (#1) hit another pt (#40) in the face. doctor called. does not want to petition at this time...pt took IM willingly...." Quality Educator confirmed documentation in an interviewed conducted on 1/12/12 at 1200.

RN # 41's Nurses Notes dated 11/25/11 at 1900 revealed: "...at 1700 another pt (#1) punched (#40) in the face. (#40) did not physically retaliate...." Quality Educator confirmed documentation in an interview conducted on 1/20/12 at 1215.

RN # 40's Nurses Notes dated 11/26/11 at 1430, revealed: "...Pt (#1) grabbed peers papers from table and stuffed in pants. Tech requested papers be removed, pt (#1) stated 'What papers,' pt (#1) sat on ground, tech removed papers without incident. Pt (#1) refused to listen to staff, non cooperative, walking around staff. PRN ativan 1 mg PO given at 1415. At 1440 pt (#1) was standing on table in milieu refused redirection to get off table. Pt(#1) jumped up and activated fire sprinkler system. Code gray called; psych tech on scene attempting to redirect patient, this RN assisted other pts off the unit, while pts being escorted off unit, this pt (#1) physically assaulted peer (#40) by chocking (sic) peer (#40). This RN and Tech sepereted (sic) pts; peer (#40) was safely moved to PAC side...." Lead Nurse Manager confirmed documentation did not contain an assessment of the patient #1's mental or physical status on 1/17/12 at 1445.

RN # 40's Nurses Notes dated 11/26/11 at 1900, revealed: "...At 1445 pt (#40) woke up due to the noises on unit; while escorting pt off unit to PAC a peer (#1) grabbed pt (#40) by the gown and started choking pt (#40) with gown. Staff X 2 sepereted (sic) pts (#1 and 40). This pt (#40) escorted to PAC, assessed and noted abrasion to Left side of mouth and redness to neck. Pt (#40) was taken to...emergency room ...." Quality Educator confirmed documentation in an interview conducted on 1/20/12 at 1215.

Review of facility documentation revealed the hospital did not follow their policy and supervise the patients to keep patients safe. Patient # 1 has a history of being a danger to self and others. This was not addressed on the plan of care. There was no indication that 1 to 1 staffing was addressed for patient #1. The Lead Nurse Manager was aware of all related incidents and appropriate supervision was not assigned.

3. Pt #8 was admitted on [DATE], on amended court ordered treatment.

Review of medical record:

Review of the patient's psychiatric evaluation, dictated on 4/23/11 revealed:

Pt #8's original court order was due to her being "persistent and acutely disabled" and due to "...paranoia, auditory hallucinations, aggression, and refusing all care...." She had been doing well in a care center until a few days prior to admission when she "...began displaying increasing paranoia and thoughts refusing to let staff do her laundry, refusing to go to the cafeteria, refusing to see a counselor. She was isolating. this progressed to bizarre behaviors including disrobing during a visit from family...became agitated, refused care on medication, tried to elope telling staff that she has Jesus feet and then assaulted a nurse...Insight and judgment is moderately to severely impaired, as evidenced by her decisions...AXIS DIAGNOSES: AXIS: Psychotic disorder, not otherwise specified, mood disorder, not otherwise specified...Global Assessment of Functioning currently is equal to 30 to 35...."

Review of the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision (DSM-IV-TR) revealed: "...Global Assessment of Functioning (GAF) Scale...21-30...Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communication or judgment...31-40...Some impairment in reality testing or communication OR major in several areas, such as work or school, family relations, judgment, thinking, or mood...."

On 4/25/11, at 0500, an RN documented: "...At 0108 staff found this pt in a male pt's room, in a male pt's bed with the naked male pt on top of her. Staff member verbally prompted the female pt out of the room and also staff assisted the female pt to her feet from the male pt's bed to the nursing station. At 0110 pt received ativan 2 mg to aid pt with anxiety r/t (related to) needing redirection to leave a male pt's room. At 0115 pt once again tried to get back into bed with the male pt reporting 'I need to get my underwear I left in there.' Staff verbally cued pt to leave the room so a staff member can get the pt's underwear. Pt then began to report 'I was raped, I need a rape kit' Pt sat down with staff to process situation and when pt continued to claim she was raped nursing supervisor notified. In the mean time at 0210 one staff member continued to monitor this pt's resting on the opposite side of the unit from the male pt's room. Nursing supervisor followed hospital policy and once police arrived on the unit the female pt began claiming 'I was almost raped, we almost had intercourse but he did put his tongue down my throat.' When interview with pt and police ended at 0315 no charges were made and pt was moved into a room on the other side of the unit...Physician notified, no new orders made...."

At 0731, an RN documented: "...No signs of sexual abuse noted on pt. No new marks, cuts, or bruises...."

On 4/25/11 at 1500, a physician documented: "...'I was raped. OK it was attempted rape. I want to sign out AMA. Here is the AM'...Pt was very delusional...."

Review of hospital document completed by Security personnel revealed: "...On...April 25, 2011...0130 hrs...(Pt #8)...claimed that she had been raped by another patient...She said she had gone in his room by mistake and laid in bed while...got on top of her held her hands down and stuck his tongue in her mouth. She then said he removed her underwear and almost penetrated her vagina with his penis. The tech saw her go into the room and responded immediately and removed her from the room. She was then caught a second time in his room and had to be physically removed...She claimed she want back for teddy bear and underwear...Phoenix PD (Police Department) interviewed both party's and found that the involvement of the incident was consentual (sic) between both parties. No further investigation was declared necessary at this time...."

Review of Phoenix Police Department Report, based on interviews of both patients, revealed: Pt #8 reported to the police that she had mistakenly entered the male patient's room and lay in bed with the male patient. She felt him kissing her and he removed her underwear and got on top of her with an "erection." She told him to get off and to leave. Then the hospital staff entered the room. Pt #8 returned to the male patient's room to get her underwear and teddy bear. The male patient reported that he had been asleep and felt some one come into his bed and begin to kiss him. He removed Pt #8's underwear and got on top of her. Then hospital personnel entered the room.

The Nurse Manager of the AP5 unit confirmed during interview conducted on 1/24/12, that the nursing documentation should have included additional assessment of the patient, to include evidence of sexual contact. The Nurse Manager and the Director of Quality confirmed that neither the medical record nor hospital documents contained documentation of assessment or interview of the patients by clinical personnel regarding what actually was "consensual." They confirmed that Pt #8's mental disorder would affect the definition of consensual for her. The Director of Quality indicated that the hospital policy titled Allegation of Physical or Sexual Abuse of a Patient by an Employee or Patient Or Death of a Patient Through an Intentional or Accidental Act by a Patient or Employee requires Security personnel to gather statements as directed by the Risk Manager.

4. The survey team directly observed the following environmental safety hazards while on site during survey conducted from 1/11/12 through 1/25/12:

The women's restroom, men's restroom and unisex restroom, which are all available for individuals waiting in the lobby, contained the following environmental safety hazards:

Exposed plumbing fixtures on all toilets and the urinal; exposed pipes under each bathroom sink; faucet fixtures on all sinks;

Guard rails surrounding one toilet in the women's restroom and the toilet in the men's restroom;

Toilet paper holders in the women's and men's restrooms composed of metal bars which are held in place with padlocks; and

Metal fixtures at the top of each bathroom door which form a V-shape.

The Director of Quality confirmed during interview conducted on 1/17/12 at 1330, that individuals who are waiting in the lobby are not supervised by hospital personnel. Many of these individuals are admitted due to danger to self, danger to others, or psychosis. Personnel is not consistently stationed at the front desk. She confirmed that the bathrooms contain fixtures that are safety hazards.

The Patient Safety Officer confirmed during interview and tour conducted on 1/20/12, that the fixtures in the bathrooms are safety hazards.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policy/procedure, review of hospital documents, and interviews, it was determined that the hospital failed to protect the patients from sexual abuse for 1 of 1 patients (Pt #10).

Findings include:

Review of hospital policy/procedure titled Patient's rights and Responsibilities revealed: "...Patient's rights are as follows:...To be treated with dignity, respect, and consideration...."

Review of hospital policy/procedure titled Abuse/Neglect/ Exploitation revealed: "...The Hospital will protect patients, to best of its ability, from abuse...from anyone, including...other patients...All incidents of physical abuse and allegations of physical abuse or sexual abuse and/or allegations of sexual abuse which occur while any patient/client is under the supervision...shall be reported...All incidents of physical abuse, allegations of physical abuse or sexual abuse relayed to any caregiver in this hospital, whether the information is from the alleged perpetrator or relayed by the victim will be reported to the police and CPS...Hospital personnel learn of any of the following the employee will report the information to a peace officer...Paraprofessional employees will report the event to a supervisor who will handle the reporting responsibility. In this hospital all patients under the care of the hospital are considered to be vulnerable adults...or other sexual molestation...Hospital personnel shall refer suspected cases of recent sexual or physical assault to the Emergency Department for evaluation...if any of the above...if...occurs while the patient is in treatment at St. Luke's Behavioral Health Center an occurrence report must be generated...Staff will protect patient from potential abuse...."

Medical Record revealed:

Patient #10 was admitted on [DATE], with a diagnosis of Mood Disorder, Polysubstance Abuse, Seizure Disorder and a history of domestic violence.

RN # 32 Progress Notes written on 2/17/11 at 1717 revealed: "...Patient c/o (complained of) anxiety 10/10 r/t (related to) roommate sexually touching her. given Vistaril 50 mg PO PRN and changed room...."

RN #32 in an interview conducted on 1/20/12 at 1011 am, revealed she was familiar with the facility policy and procedure titled Abuse/Neglect/ Exploitation. She did not report the incident to her supervisors. she did not feel the incident was sexual in nature even though she charted "...roommate sexually touching her...." RN #32 did not feel it required an incident report.

Review of facility documentation and policies and procedures revealed that the facility did not follow their policy when it came to reporting this incident.

The Director of Quality confirmed in an interviewed conducted on 1/20/12 at 1000, that there was no documentation of facility incident report of this event for this patient. There is no documentation of patient assessment, patient interview or emergency room visit as required as stated in the facility policy and procedure.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policy/procedure, medical record and interview, it was determined that a restraint which resulted in physical injury to 1 of 1 patient was not evaluated to determine whether the restraint was implemented in accordance with safe and appropriate restraint techniques as required by hospital policy (Pt #4).

Findings include:

Review of hospital policy/procedure titled Seclusion, Physical Hold and Restraints revealed: "...Physical holding techniques...considered to be restraints include...Physically holding a patient in a manner that restricts the patient's movement against his or her will which also may include 'therapeutic holds'; and...Physically holding a patient during a forced psychotropic medication procedure...Patient Debriefing and Staff Postvention...Immediately after, within 24 hours after the use of restraint...face-to-face debriefings conducted by a behavioral health professional occur with the patient...The following information will be documented on the Patient Debriefing Form:...If any individual was injured, circumstances that caused the injury and a plan to prevent future injuries...A Postvention with all staff involved in restraint...will be held immediately after the event or within 24 hours of the event. The Postvention will identify effective as well as ineffective interventions during the restraint...expected and unexpected outcomes, and any other concerns related to the event. This information will be forwarded to the unit supervisor...."

Patient #4 was admitted on [DATE]. On 10/20/11 at 2057, an RN documented on a Seclusion/Restraint Progress Note: "...Pt became agitated when told to take his medication. Jumped over a chair and postured at staff...Pt became agitated, postured at staff and was placed in a CPI (Crisis Prevention Institute) hold for four minutes while injection was given...Physical/Injury Post Event:...patient has abrasion to left elbow...."

Review of the form titled Behavioral Restraint Use Physician's Order Form revealed that an RN completed the "On-Site Face to Face Assessment" on 10/20/11 at 2007: "...Left elbow...'Rug burn', dime size diameter abrasion superficial...."

Review of the Patient Debriefing section of the Seclusion/Restraint Progress Note form revealed that it did not contain documentation of the circumstances that caused the injury and a plan to prevent future injuries as required by hospital policy/procedure.

On 1/23/12, the surveyor requested the Postvention documentation from the CNO. The CNO provided a copy of the Secusion (sic) Restraint Review Tool which contained documentation: "Patient debriefing completed...Post-vention form completed...." A copy of the Seclusion/Restraint Progress Note which included the Patient Debriefing described above was the only attached documentation.

The CNO and Quality Director confirmed during interviews conducted on 1/23/12, that documentation did not include the circumstances of the patient injury, a plan to prevent future injuries and effective/ineffective interventions as required by policy.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on review of hospital policy/procedure, medical record and interview, it was determined that the hospital failed to require that the use of restraint be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient for 1 of 5 patients who was restrained and/or secluded (Pt #30).

Findings include:

Review of the hospital policy/procedure titled Seclusion, Physical Hold and Restraints revealed: "...Emergency Behavior Management Restraint...If a restraint or seclusion is necessary a physician's order will be obtained prior to initiation, unless the situation is an emergency, in which case the order must be obtained either during the emergency application of the restraint or seclusion, or immediately (within a few minutes) after the restraint or seclusion has been applied. Failure to immediately obtain an order is viewed as an application of restraint or seclusion without an order...."

Review of Pt #30's medical record contained nursing documentation that the patient was physically restrained for administration of Ativan as a "chemical restraint" on 1/6/12. The restraint documentation revealed that the order used for the Ativan to be administered was from an order on 1/4/12 that was written as a PRN (as needed) order for anxiety. The RN's documentation on the narrative nursing notes revealed the patient was physically held to administer the Ativan to the patient. There was no documentation of a physician's order for the chemical or physical restraint on 1/6/12.

The CNO reviewed the medical record on 1/17/12, and confirmed during interview that the medical record did not contain an order for the chemical and/or physical restraint.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of policies and procedures, medical records, and interviews, it was determined that the hospital failed to require that a patient be seen face-to-face within 1 hour by a physician or licensed independent practitioner, or trained RN or physician assistant after a restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of others and/or after restraint is used for forced medication for 2 of 4 patients (Pts #18 and 26).

Findings include:

Review of the hospital policy/procedure titled Seclusion, Physical Hold and Restraints revealed: "...physical holding techniques that are...considered to be restraints include...physically holding a patient during a forced psychotropic medication procedure...a face-to-face physical assessment of the patient's physical and psychological well-being is performed within one hour after the initiation of behavioral management seclusion or restraint by a LIP (Licensed Independent Practitioner) who is either onsite or on-call at the time that the restraint or seclusion is initiated; or an RN who has met the competency requirements to perform face-to-face assessments...."

Pt # 18 was admitted on [DATE]. On 11/26/11 at 2327, an RN documented: "...posturing at the staff and throwing punches in the air...result, pt was put into seclusion...pt walked on...own...at 2327 pt was still agitated, yelling at staff and posturing...." The medical record contained an order for Seclusion Only, three hours, dated 11/26/11 at 2315 hours. The form titled "Seclusion and Restraint Monitoring /Progress Note contained documentation with an initial entry dated 11/26/11 at 2320 hours. The On-site Face-To-Face Assessment form contained a signature of assessing LIP, employee # 36 with a date of 11/26/11 and time 0045 hours.

On 12/2/11 at 1130 hours, an RN documented: "...pt threw water on two staff members...pt spit in a staff members face...pt refusing to calm self or engage in diversional activity and threatening to spit on staff again...pt went to seclusion per Dr...order...." The medical record contained an order for Seclusion Only, Three hours, dated 12/2/11 at 1130 hours. The Seclusion and Restraint Monitoring/Progress Note contained documentation with an initial entry at 1135 hours dated 12/2/11. The On-Site Face-To-Face form contained a signature of assessing LIP for employee # 33 with a date of 12/2/11 but the time is blank.

Nurse Manager, employee # 20 confirmed, during an interview conducted on 12/24/11 at 0805 hours, that the medical record did not contain documentation of a face-to-face evaluation within one hour of the initiation of the restraints for patient # 18 on 11/26/11 and 12/2/11.

Pt # 26 was admitted to this facility on 10/8/11 under an Amended Court Order Treatment (ACOT) for a diagnosis of Schizophrenia, paranoid type, that included persecutory, visual and olfactory hallucinations. The patient had a Special Treatment Plan (STP) that included the administration of IM (intramuscular) Haldol, IM Benadryl and IM Ativan if the patient refused to take oral (PO) medication. The patient attacked staff and/or other patients multiple times (6 times) and was placed in seclusion and required a physical hold for staff to administer IM medications. There was a written physician order for each physical hold for forced medication. There was no documentation of the 1-hour face-to-face evaluation by a Licensed Independent Practitioner (LIP) or trained RN.

Nurse Manager, employee # 20 confirmed in an interview conducted on 1/24/12 at 0940 hours, that a face-to-face assessment was not completed each time patient #26 was physically held for forced medication administration (6 times).
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policy/ procedure, hospital documents, medical records and staff interview, it was determined that the hospital failed to require that a face-to-face assessment of the patient within one hour of a restraint, used for the management of violent or self-destructive behavior, included an evaluation of the patient's medical condition for 4 of 4 patients (Pt's # 18, 24, 25 and 26).

Findings include:

Review of the hospital policy and procedure titled Seclusion, Physical Hold and Restraints revealed: "...a face-to-face physical assessment of the patient's physical and psychological well-being is performed within one hour after the initiation of behavioral management seclusion or restraint by a LIP who is either onsite or on-call at the time that the restraint or seclusion is initiated; or an RN who has met the competency requirements to perform face-to-face assessments...LIP or qualified RN...assesses the patient's physical and psychological status and behavior...."

Review of the On-Site Face To Face Assessment form revealed the section titled Physical Well Being. This section contained the following two statements: "...No Injuries and status physical unchanged subsequent to event (WNL)..." and "...Injuries noted: Injury Location...Description...Recommendation...." The individual completing the assessment, places a mark by one statement and completes the information if the patient sustained injuries during the restraint.

Review of the medical records:

Pt # 18 was admitted on [DATE] with Psychosis, Polysubstance Dependency and Agitation. Patient was on Court Ordered Treatment and had a history of violence toward others. There were no acute medical problems and/or known drug allergies. Medical record documentation contained Physician orders for Restraint/Seclusion on 11/27/11, 11/29/11 (three times), and 12/2/11. The On-Site Face to Face Assessment form for each date in Seclusion/Restraints did not contain documentation of a physical assessment or evaluation of medical condition for this patient.

Pt # 24 was a minor child brought to this hospital by his/her guardian, Child Protective Services (CPS) on 10/28/11 for danger to self, danger to others, behavior extremely disruptive, and aggressive to self by injuring self. Medical history included obesity, and medical record revealed "...patient expressed history of sleep apnea...." Medical record documentation contained Physician orders for Physical restraint 10/21/11, Seclusion (2 hours) 10/21/11, Chemical restraint 10/31/11 and Mechanical Restraint 10/31/11. The On-Site Face to Face Assessment form for each date in Seclusion/Restraints did not contain documentation of a physical assessment or evaluation of medical condition for this patient.

Pt # 25 was a minor male child admitted [DATE] for mood disorder, aggression, agitation, oppositional defiant disorder, rule out post traumatic stress disorder, and history of attempting to choke a younger brother three times. Medical history non-specific; enlarged bilateral breast. Medical record documentation contained Physician orders for Physical restraint, Seclusion (one hour) and Chemical Restraint on 10/20/11 with an additional Seclusion order for a period lasting 30 minutes on 10/20/11. The On-Site Face to Face Assessment form for the dates in Seclusion/Restraints did not contain documentation of a physical assessment or evaluation of medical condition for this patient.

Pt # 26 was admitted on an amended court order treatment (ACOT) and special treatment plan (STP) 10/8/11 for Schizophrenia, Paranoid Type, Non-compliant with medications, and assaultive to others. Medical record documentation revealed no history and physical (H&P) completed due to the patient refusing H&P to be done by the physician. Psychiatric Evaluation documentation revealed no reported major medical problems, except in past, patient refused to eat. Medical record documentation contained Physician orders for Physical Restraint, Seclusion (3 hours) and Chemical restraint on 10/11/11, and Seclusion (3 hours) on 10/12/11 and 10/13/11. The On-Site Face to Face Assessment form for each date in Seclusion/Restraints did not contain documentation of a physical assessment or evaluation of medical condition for this patient.

Nurse manager, employee # 20, confirmed in an interview conducted on 1/24/12 at
0940 hours, that the face to face assessments completed by an RN or LIP within one hour of seclusion/restraint did not include a physical assessments of the patients as required by hospital policy/procedure, or meet the CMS requirement of an evaluation of the patients' medical condition.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0196
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of policies and procedures, medical records, hospital training materials, employee personnel files and interview with staff, it was determined the hospital failed to require 3 of 3 RN's, (employee's # 6, 33 and 36) conducting the one hour face-to-face assessment for 3 of 4 patients, (Pt's # 18, 24 and 25) were trained and demonstrated competency in completing a comprehensive review of the patient's condition.

Findings include:

The hospital policy titled Seclusion, Physical Hold and Restraints required: "...Simultaneous use of restraint and seclusion is only permitted if the patient is continually monitored face-to-face by an assigned, trained staff member...a face-to-face physical assessment of the patient's physical and psychological well-being is performed within one hour after the initiation of behavioral management seclusion or restraint by a LIP who is either onsite or on-call at the time that the restraint or seclusion is initiated; or an RN who has met the competency requirements to perform face-to-face assessments...RN assesses the patient's physical and psychological status, and behavior...assess the patient's reaction to the intervention...determine the appropriateness of the emergency intervention used...works with the patient and staff to identify ways to help the patient regain control...determine whether the emergency safety situation has passed...revises the patient's treatment plan and services as needed...assesses and determines if any complications resulted from the restraint used...."

Review of medical records revealed the following:

Pt # 18 was admitted on [DATE]. On 11/26/11 at 2215 hours, documentation in the medical record revealed a physician order for Seclusion Only, Three hours. On 11/26/11 at 0045 hours, employee # 36 completed an on site face-to-face assessment.

On 12/2/11 at 1130 hours, documentation in the medical record revealed a physician order for Seclusion Only, Three hours. On 12/2/11 at "..._____...." (Blank) time, employee # 33 completed an on site face-to-face assessment.

Pt # 24 was admitted on [DATE]. On 10/29/11 at 2130 hours, documentation in the medical record revealed a physician order for Physical Restraint, One hour. On 10/29/11 at 2145 hours, employee # 36 completed an on site face-to-face assessment.

On 10/31/11 at 1700 hours, documentation in the medical record revealed a physician order for Seclusion Only, Two hours. On 10/31/11 at 1755 hours, employee # 6 completed an on site face-to-face assessment.

Pt # 25 was admitted [DATE]. On 10/20 at 1445 hours, documentation in the medical record revealed a physician order for Physical Restraint, Seclusion Only; One hour, Chemical Restraint; Vistaril 25 mg IM x 1. On 10/20/11 at 1545 hours, employee # 6 completed an on site face-to-face assessment.

Review of the training material used to train RN employee's (# 6, 33 and 36), to conduct the one hour face-to-face assessment, revealed the following forms: "...BH (behavioral health) Seclusion & Restraint Update Skills Checklist, On-site Face To Face Assessment, Behavioral Restraint Use Physician's Order Form, RN Seclusion/Restraint Progress Note, Seclusion/Restraint Monitoring/Progress Notes, and Seclusion/Restraint Patient Debriefing. This training material is the same information given to all RN staff as part of their Annual Competency training. The educational program did not address the specific requirements for the training of RN's and PA's to assess the patients' medical condition, and the staff conducting the training did not have specialized training themselves in conducting an assessment of patient's medical conditions.

Review of personnel files for employees (# 6, 33 and 34), revealed they received the same annual Restraint/Seclusion training that all RN's in the facility received on an annual basis, as part of their yearly required competency training. There was no specific training documented addressing content to evaluate the patient's immediate situation, the patient's reaction to the intervention, medical and behavioral condition as well as review and assessment of the patient's history, medications and lab values.

The Chief Nursing Officer, employee # 2, confirmed on 1/23/12 at 1530 hours, the educational training that the RN/PA staff who perform the one hour face-to-face assessments do not receive specific training in the assessment of medical conditions as required by CMS.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on document review, review of medical records and interviews, it was determined that the hospital failed to analyze the causes of adverse patient events, implement preventive actions and mechanisms that include feedback and learning throughout the hospital as evidenced by:

1. failure to identify nursing assessment and patient supervision issues related to 2 adverse patient events identified by the facility (Pt's #1, and 8) and 1 request for review by an external agency (Pt #13);

2. failure to identify in the review of an adverse patient event (Pt #2) that policy/procedure was not followed;

3. failure to identify the practice of placing patients who require close supervision in beds located in the day room (Pt #1); and

4. failure to identify that documentation required by seclusion/restraint policy was not complete (Pt #4).

Findings include:

1. Review of facility report documentation of an adverse event regarding Pt #1's AWOL revealed: "...Description of actions taken to prevent recurrence: The patient's privilege status was changed and he was no longer allowed on the patio...."

Cross reference Tag A 144 #1 for information regarding Pt #1. Pt #1 was on PIC with no special precautions noted in the physician orders other than "...on PIC...." Following his elopement, the physician did not write orders for any change in privilege status or restriction from the patio.

Cross reference Tag A 395 #5 for information regarding Pt #1. Quality review did not identify that the medical record did not contain documented nursing assessment after the patient was found post suicide attempt on 11/25/11, or after the patient returned from an elopement.

Review of facility report documentation of an adverse event regarding Pt #8's allegation of sexual contact revealed: "...The staff members were given additional instructions and techniques to assist them in monitoring patients who are psychotic, wander and have inappropriate sexual behaviors...."

Cross reference Tag A144 #3 for information regarding Pt #8. The hospital could not provide documentation that the hospital identified further nursing assessment as indicated for the care of the patient.

Cross reference Tag A 0821 for information regarding Pt #13 and findings related to her therapeutic discharge.

The hospital's Corrective Action Plan included revision of the Therapeutic Discharge policy to include:

a. verification of the patient being seen by a physician prior to an unanticipated discharge. The Quality Educator clarified, on 1/13/12, that the physician is required to see the patient within 24 hours prior to the patient's discharge;

b. nursing re-assessment of self harm risk and patient's emotional status at the time of discharge;

c. a mechanism to ensure the patient has discharge medications as clinically appropriate; and

d. a mechanism to ensure the patient has a discharge plan in place that is timely and clinically appropriate.

The hospital provided documentation of staff education related to the revised Therapeutic Discharge policy/procedure. However, the corrective action did not include any follow-up or monitoring activity to measure actual implementation of the revised policy/procedure or sustained improvement. On 1/13/12, the Director of Quality confirmed that the hospital does not have a mechanism to identify patients who are discharged by means of a Therapeutic Discharge. In addition, The Corrective Action Plan did not identify the need to improve the nursing assessment of the patient's medical condition at the time of a therapeutic discharge. It did not identify the need to provide pertinent discharge instructions regarding risks related to discontinuation of medication.

2. Review of facility report documentation of an adverse event regarding Pt #2s AWOL revealed: "...The staff initiated the (Code Green) elopement procedure which included an overhead announcement and description of the patient, designated staff searching the facility for the patient and...Security looking for the patient...." Neither the report nor follow-up by Quality Department staff identified the fact that the staff did not document, in the medical record, notification of physician, family, Security; or any action implemented after calling the "code green" as required by policy. Quality Department staff did not identify the fact that the staff did not document implementation of the Post Elopement policy/procedure.

3. Cross reference Tag A144 #1 for information regarding Pt #1 and his transfer to the PIC area of AP1 in a "980" bed.

Cross reference Tag A143 for information regarding the use of the "980 beds."

4. Review of the facility's Performance Improvement Committee Reporting Schedule 2012 revealed that Seclusion and Restraint data is reported quarterly. On 1/24/12, the Director of Quality reviewed the Quality Plan with the surveyor and confirmed that Seclusion and Restraint data was reported quarterly in 2011 as well. Documentation of the content of the assessment required for the 1 hour face-to-face and the documentation of evaluation of injury sustained during restraint had not been addressed in the Seclusion and Restraint data.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on review of hospital documents and interviews, it was determined the hospital failed to provide an organized nursing service 24-hours per day with an adequate number of registered nurses and competent nursing staff to assess patients' care needs and deliver, assign and supervise the care required by each patient as evidenced by:

(A395) failing to require that a registered nurse supervise and evaluate the nursing care of each patient;

(A397) failing to require that a registered nurse assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available;

(A404) failing to require that nursing staff administer medications according to a physician's orders.

The cumulative effect of these systemic problems resulted in the hospital's failure to provide an adequate, organized nursing service.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, hospital documents, interviews and hospital policy/procedure, it was determined that the hospital failed to require that a registered nurse supervise and evaluate the nursing care of each patient as evidenced by:

1. failing to document RN supervision of the care provided by an LPN to 2 of 2 patients in the Psychiatric Intensive Care (PIC) area of Adult Psychiatry 1 (AP1) (Pts #36 and 3) and patients in Adult Psychiatry 5 (AP5) assigned to an LPN;

2. failing to supervise the care provided by a Psych Tech for 1 of 1 patient in the PIC (Pt #36) and patients in AP5 assigned to an LPN;

3. failing to document review of laboratory results and notify the physician for 1 of 1 patient in the PIC with elevated laboratory results (Pt #36);

4. failing to require that nursing personnel document observation of patients as required by policy/procedure;

5. failing to document nursing assessments after a change in condition for 1 of 1 patient (patient # 1); and

6. failing to document nursing assessment for 1 of 1 female patient who alleged sexual contact with a male patient (Pt #8).

Findings include:

1. Patient #36, diagnosed with Schizoaffective Disorder, was admitted to the Psychiatric Intensive Care (PIC) area of Adult Psychiatry 1 (AP1), on 12/30/11, due to verbal aggression, agitation, and threatening behavior toward others. He had a history of violence, as well as a history of noncompliance with treatment, rapid deterioration with increase in psychotic symptoms and assaultive behavior.

Review of Pt #36's medical record and the Daily Patient Assignment Sheets for PIC revealed that Pt #36 was assigned to an LPN during the following shifts:

12/30/11 2300-0730 12/31/11;
1/2/12 2300-0730 1/3/13;
1/3/12 0700-1530;
1/3/12 2300-0730 1/4/12;
1/4/12 0700-1530;
1/4/12 2300-0730 1/5/12;
1/5/12 0700-1530;
1/6/12 0700-1530.

Review of nursing documentation in Pt #36's medical record revealed that the only chart entry by an RN during the above shifts was an RN's signature written after the LPN's signature. On 1/5/12, an RN did not sign after the LPN signature.

Review of the Daily Patient Assignment Sheets for the above shifts revealed that an RN was not assigned to any of the patients in PIC who were assigned to the LPN, including Pt #36.

Pt #3 was admitted on [DATE] with a diagnosis of Schizoaffective Disorder. She has a history of Diabetes mellitus, hypertension, and obesity. On 12/30/11 at 1845, Pt #3 was moved to the PIC area of AP1. On 1/9/12, Pt #3 was assigned to an LPN during the 0700-1530 shift. Review of nursing documentation revealed that the only chart entry by an RN during the above shift was an RN's signature written after the LPN's signature.

Review of the Daily Patient Assignment Sheets for the day shift (0700-1530) on the following dates revealed that an LPN was assigned to Pts #36 and #3, and that an RN was not assigned responsibility for either of the patients:

1/9/12 0700-1530;
1/10/12 0700-1530; and
1/11/12 0700-1530.

Employee #30 confirmed during interview conducted on 1/12/12, that the RN does not see the patients assigned to the LPN. She stated that the RN cosigns the LPN's notes. Employee #20 confirmed during interview conducted on 1/13/12, that the LPN who has been providing care to Pt #36 on the day shift attends the treatment planning meetings and writes the nursing updates to Pt #36's treatment plans. She confirmed that neither Pt #36's medical record, nor the Daily Patient Assignment Sheets contain documentation that an RN is responsible for supervision of Pt #36's care when he is assigned to an LPN.

RN #31, a Charge Nurse, confirmed during interview conducted on 1/12/12, that she informally sees some of the patients in PIC who are assigned to the LPN. She confirmed that neither the medical record nor the Daily Patient Assignment Sheet contain documentation that an RN is supervising the care of the patient who is assigned to the LPN. She cosigns the LPN's charting.

Review of the AP5 Daily Patient Assignment Sheets for the day shift (0700-1530) on 1/13/12, revealed that an LPN was assigned to 8 patients, and that an RN was not assigned responsibility for the 8 patients.

RN #43 confirmed during interview conducted on 1/13/12, that she does not see the LPN's patients. She co-signs the physician orders, reviews the LPN's assessments, reviews the LPN's documentation and co-signs the LPN's charting. She confirmed that the assignment sheet does not contain documentation that an RN is supervising the care of the patient who is assigned to the LPN.

Review of the hospital policy/procedure titled Reassessment of Patients (2/11) revealed: "...Every patient will be reassessed by a Registered Nurse a minimum of once every 8 hours...The RN may delegate portions of data collection that contribute to the care planning process for patients and the ongoing nursing care/reassessment of the patient. Components of the data collection may be delegated to UAP (Unlicensed Assistive personnel)...Registered Nurses retain responsibility for patient assessments and reassessments, interpretation of data, care planning and education. The RN may delegate to the LPN collection of data that contributes to the care planning process and the care of the patient...."

On 1/25/12, the CNO confirmed that the RN's signature did not meet the requirement that the patient be reassessed by a Registered Nurse a minimum of once every 8 hours.

2. Review of Pt #36's medical record revealed that a Psych Tech recorded elevated blood pressure readings on 12/31/11, 1/1/12, 1/2/12, 1/3/12, 1/4/12, 1/5/12, 1/6/12, 1/7/12, 1/8/12, 1/11/12, 1/12/12, 1/13/12, and 1/14/12. The patient's highest diastolic blood pressure was 106 on 1/6/12, and his highest systolic blood pressure was 161 on 1/7/12. The patient's pulse was 123 on 1/14/12. The medical record did not contain documentation that the RN reviewed the blood pressure or pulse readings. The patient's multidisciplinary treatment plan included monitoring of the patient's hypertension, but it did not contain specific goals or interventions to address the patient's hypertension.

Employee #20 confirmed during interview conducted on 1/13/12, that Pt #36's medical record did not contain documentation that an RN had reviewed the patient's blood pressure readings.

Employee #30 confirmed during interview conducted on 1/12/12, that the LPN assigned to patients in PIC, including Pt #36, supervises the care provided by the Psych Tech.

RN #43, stated during interview conducted on 1/13/12, that nurses on AP5 are paired with Psych Techs to provide care to the AP5 patients. The nurse (whether RN or LPN) that is paired with the Psych Tech supervises the care that the Psych Tech provides to patients.

3. On 12/31/11, physician #6 completed Pt #36's History and Physical. Physician #6 documented: "...Repeat BMP (Basic Metabolic Panel); if BUN (Blood Urea Nitrogen) and creatinine is high, patient needs to be seen by a nephrologist...."

Review of Pt #36's laboratory results revealed: 12/31/11 BUN: 34 (High) and 1/2/12 BUN: 37 (High); 12/31/11 Creatinine: 2.1 (High) and 1/2/12 Creatinine: 2.2 (High).

On 1/12/12, review of Pt #36's medical record revealed that it did not contain documentation by a physician or a nurse that the patient's BUN and Creatinine results had been reviewed. Interview with the patient's attending physician on 1/13/12, revealed that he was not aware of the continued elevation of Pt #36's BUN and Creatinine and Physician #6's recommendation for a nephrologist. He confirmed that he expected that the nurse would notify him and he had not been notified.

4. Review of the hospital policy/procedure titled Special Observation Precautions revealed: "...Patients assigned to PIC status will automatically be observed and documented on every 15 minutes using the Special Observations Precautions Assessment form...."

Review of Pt #36's Special Observation Precautions Assessment Sheet on 1/12/12, at 1310, revealed that neither the Psych Tech nor the LPN had documented observation of the patient at 1230, 1245, or 1300. In addition, the Special Observation Precautions Assessment Sheets for four other patients in the PIC were blank for 1230, 1245, and 1300. The LPN assigned to the PIC confirmed that the Psych Tech was helping on the Psychiatric Acute Care (PAC) side of AP1 and that the LPN was watching the patients. However, direct observation revealed that PIC patients were allowed to leave the PIC area to spend time in the PAC area and the LPN could only visualize the patients within the PIC area. The Psych Tech responsible for completing the Special Observation Precautions Assessment Sheets was not available on the PIC from 1220 until 1310 and the Psych Tech recorded the entries after 1310 with the assistance of the LPN.

Review of the documentation completed by the Psych Techs for patients on the Adult Psychiatric and Detoxification unit for dates 1/2/12 through 1/16/12 revealed:

a Psych Tech did not document hourly rounds from 0600 through 0800 (2 hours) for 9 out of the 14 days;

a Psych Tech did not document hourly rounds from 2200 through 2400 (2 hours) for 2 out of 14 days; and

a Psych Tech did not document hourly rounds from 2100 through 2400 (3 hours) on 1/16/12.

The nurse manager for the Adult Psychiatric 3 (AP3) unit confirmed that the hour rounds were to be documented on the rounds form that the surveyor was reviewing during the tour of the unit on 1/17/12. She was aware of the failure of the Psych Tech to document hourly rounds on 1/16/12, however she had not identified a trend of failure to document the hourly rounds on the additional days.

Review of hospital policy, NPSG 15.01.01 titled Suicide Prevention dated as revised 02/2011, revealed: "...Low Suicide Risk:...Minimum of hourly round contact...Safety rounds in patient bedrooms at each shift change...."

The rounds documentation that was incomplete was for patients on AP3 who were identified as Low Suicide Risk and there was no documented evidence that the rounds were completed and documented.

The CNO confirmed during an interview conducted on 1/17/12, that there was no documentation to demonstrate that the hourly rounds were completed.

5. Facility Policy and Procedure titled "Reassessment of Patients" dated 11/03 revised 2/11 revealed: "...Every patient will be reassessed by a RN a minimum of once every eight hours... RN retain responsibility for patient assessments, and re-assessments, interpretation of data, care planning and education...."

Facility Policy and Procedure titled "Nursing Standards of Care/Practice" dated 4/94 revised 06/07 revealed: "...Reassessment of the patient shall be performed and documented by the RN...when warranted by changes in the patient's condition...The physician shall be notified when significant abnormalities or changes are noted on reassessment...."

Facility Policy and Procedure titled "Code Gray" dated 9/82 revised 6/10 revealed: "...When a unit...is treating a patient who becomes combative or needs to be physically controlled for the patient's safety, it is the responsibility of the charge nurse or primary nurse to request a Code Gray...patient safety will be the primary concern...Document events and behavior on the Nursing Notes...."

Patient # 1 was admitted on [DATE] to AP-4 with a diagnosis of Mood Disorder and Psychosis.

RN # 24's Nurses Notes dated 11/24/11 at 2300 revealed: "...This RN walked into pt (patient) room, found he had tied a sheet around his neck with 2 knots and he was pulling on sheet by leaning on the wall floor and sliding down. Report called and code gray called resulting in patient being transferred to PIC unit for closer observation. He allowed this RN to untie sheet and cooperatively went with staff via WC (wheelchair) to PIC unit...." Quality Educator confirmed in an interview conducted on 1/12/12 at 1200, that there was no documentation of the RN assessment of the patient's mental and physical status after this event. The Quality Educator also confirmed there was no documentation of transfer orders to PIC unit.

RN # 40's Nurses Notes dated 11/25/11 at 1420 revealed: "...slow to respond to questions, no insight about tieing a bed sheet around neck last night and wanting to kill self. Pt would answer a question with a different answer when asked at different times. Doesn't know why he is here and doesn't want to be here. When asked why he put the sheet around neck, pt stated 'I just wanted to kill myself cause my brother left me here'. pt has been moved to a 980 bed per MD order for closer watch...Pt to remain on PIC for observation...." Lead Nurse Manager confirmed documentation on 1/17/12 at 1445.

RN # 41's Nurses Notes dated 11/25/11 at 1910 revealed: "... at 1605 pt climbed over wall on smoking patio and eloped. Code green called. Pt's brother, doctor and police called. Pt returned...at 1640 with...security. family and doctor informed...." Quality Educator confirmed in an interview conducted on 1/12/12 at 1200, that there was no documentation of the RN assessment of the patient's mental and physical status when patient returned after elopement.

Review of facility documentation and policies and procedures revealed that the facility did not follow their policy when it came to nursing assessment and re-assessments. RN assessments were not completed for patient #1 after significant events or issues pertaining to the care of the patient. The Quality Educator confirmed in an interview conducted on 1/12/12 at 1200, that there was no documentation of the RN assessment of the patient's mental and physical status after the events of tieing a sheet around his neck and the elopement from the facility.

6. Cross reference Tag A0144 #3 for information regarding Pt #8.

The Nurse Manager of the AP5 unit confirmed during interview conducted on 1/24/12, that the nursing documentation should have included additional assessment of the patient, to include evidence of sexual contact. The Nurse Manager and the Director of Quality confirmed that neither the medical record nor hospital documents contained documentation of assessment or interview of the patients by clinical personnel regarding what actually was "consensual." They confirmed that Pt #8's mental disorder would affect the definition of consensual for her. The Director of Quality indicated that the hospital policy titled Allegation of Physical or Sexual Abuse of a Patient by an Employee or Patient Or Death of a Patient Through an Intentional or Accidental Act by a Patient or Employee requires Security personnel to gather statements as directed by the Risk Manager.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on review of hospital policy/procedure, hospital documents, direct observation and interviews, it was determined that the hospital failed to require that patient assignments are based on patient acuity and that each patient is assigned to a registered nurse.

Findings include:

Review of hospital policy titled Patient Assignments revealed: "...takes all reasonable steps to assure that there are sufficient numbers of qualified nursing staff members available at all times to meet the nursing care needs of patients...Staffing...is based on complexity of patient-care needs...The charge nurse will make assignments with consideration of the following factors:...complexity of the patient's condition including diagnosis, co-occurring conditions, age/developmental functioning of the patient and required nursing care...dynamics of the patient's status as evidenced by an individualized acuity system...complexity of the assessment/reassessment required for the patient...type of technology employed in providing nursing care...degree of supervision required by each individual member of the nursing staff...availability of supervision appropriate to the assessed and current competence of the individual being assigned to provide nursing care...physical design of the environment...."

Review of hospital policy titled Inpatient Staffing/Acuity Plan and Patient Acuity Tools revealed: "...assign an acuity level next to each patient's name based on the following criteria:...Level 1:...Patient independent...May be ready for discharge...Patient is on a 1:1...Level 2: Patient needs routine rounds...has fleeting psychotic symptoms...Has passive DTS/DTO (Danger To Self/Danger To Others) symptoms...Requires QID (four times a day) Accu-cheks...Requires dressing change...Moderate withdrawal symptoms requiring meds every 4 hours...Has moderate pain requiring meds every 4 hours...At moderate risk for fall...Level 3: Patient required seclusion or restraint on this shift...Requires
PIC unit with every 15 minute checks...Sexually acting out...Disruptive-intrusive-requiring increased monitoring...Actively psychotic, manic, aggressive, DTS/DTO behaviors...In acute withdrawal...Confusion Disoriented...."

Review of the Daily Patient Assignment Sheets and the Individualized Patient Acuity Tools revealed that an LPN was assigned to all of the patients in PIC and the patients were assessed with the following acuities during the following shifts:

12/30/11 2300-0730 (9 patients: all acuity level 3);
1/2/12 2300-0730 (7 patients: all acuity level 3);
1/3/12 0700-1530 (7 patients: 6 acuity level 3 and 1 acuity level 2);
1/3/12 2300-0730 (7 patients: 6 acuity level 3 and 1 acuity level 2);
1/4/12 0700-1530 (7 patients: 6 acuity level 3 and 1 acuity level 2);
1/4/12 2300-0730 (8 patients: all acuity level 3);
1/5/12 0700-1530 (8 patients: all acuity level 3);
1/6/12 0700-1530 (7 patients: all acuity level 3);
1/9/12 0700-1530 (8 patients: all acuity level 3);
1/10/12 0700-1530 (8 patients: all acuity level 3);
1/11/12 0700-1530 (7 patients: all acuity level 3); and
1/12/12 0700-1530 (6 patients).

The patients in the PIC area had been assessed with the highest acuity ratings of patients in the AP1 unit and no RN was assigned to the PIC patients. The PIC area has 6 patient rooms. During those shifts where an LPN was assigned to more than 6 patients, the additional patients were placed in "980" beds in the day room.

Review of the AP1 Daily Patient Assignment Sheet for the 0700-1530 shift on 1/12/12, revealed that the Charge RN was assigned to patients in rooms 141-144; an RN was assigned to patients in rooms 145-148; and an LPN was assigned to patients in the PIC area (rooms 121-126).

RN #31 confirmed during interview conducted on 1/12/12, that she makes the assignments by assigning the nurses to patients they were assigned to on the preceding day. If the nurses did not work on the unit the preceding day, she makes assignments by consecutive room numbers. The LPN has been working in the PIC area. When she has a day off, an RN replaces her. An RN was not assigned to the LPN's patients.

Review of the AP5 Daily Patient Assignment Sheet for the 0700-1530 shift on 1/13/12, revealed that the Charge RN was assigned to patients in beds 183A-186B; RN #44 was assigned to patients in beds 165A-182B, and an LPN was assigned to patients in beds 161A-164B.

RN #43 confirmed during interview conducted on 1/13/12 that she assigned RN #44 to the "middle" rooms because s/he had worked with those patients the preceding day. She assigned the LPN to the "top" rooms because several of those patients were being discharged and an LPN can do discharges but not admissions. Then she assigned herself to the "bottom" section of patients.

An RN was not assigned to the LPN's patients.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on review of hospital policy/procedure, medical record and interview, it was determined that the hospital failed to require that the nurse clarify physician orders prior to administration of a patient's home medication, and document the dose of Morphine administered to patient #22.

Findings include:

Review of hospital policy titled Medication Administration revealed: "...Verify that the medication is being administered at the proper time, in the prescribed dose and by correct route...."

Patient #22's medical record revealed the patient was on Morphine sublingual at home. The physician orders included the continued use of this medication with the following written orders: Morphine 20mg/ml (milligrams/milliliter) sublingual 0.25 BID (twice a day) Pain; Morphine .25 every 4 hours PRN (as needed) pain; and Morphine .5 every 4 hours PRN Pain. The physician's orders did not specify when to administer .25 or .5 for pain.

The orders did not specify the degree of pain for which the PRN dosages were indicated, i.e., when the nurse was to utilize the PRN .25 or the PRN .5 dosage. The orders also did not specify a maximum dosage of morphine to administer in 24 hours.

The medication administration record (MAR) for Patient #22 revealed, "Home Medication" listed on the routine MAR sheet for the BID order and "Home Medication" listed on the PRN MAR sheet. Neither sheet included the dosage of "Home Medication." In addition, the PRN MAR sheet did not contain separate entries for documentation of administration of the .5 and .25 dosages of Morphine.

The nurse documented the time of administration of each dose of Morphine to the patient, but did not document the dosage of Morphine administered.

Review of the narcotic sign out for the patient's home medication indicated that the nurse removed .25 each time the supply of home medication was accessed. However, the nurse did not document, on the MAR, the dose that s/he administered.

The Nurse Manager and CNO confirmed during interview conducted on 01/17/2012, that the nurse did not clarify an unclear physician's order or document the dose of Morphine administered to the patient.
VIOLATION: REASSESSMENT OF A DISCHARGE PLAN Tag No: A0821
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of policy and procedure, medical record and interview, it was determined that the hospital failed to reassess the patient's discharge plan when there were factors that affected continuing care needs or the appropriateness of the discharge plan as evidenced by:

1. failure to provide prescriptions or document that the patient had access to medication at home for 1 of 4 patients who discharged against medical advice (AMA) (Pt #35) according to policy;

2. failure to document interventions by staff to prevent a patient from leaving AMA as required by hospital policy for 1 of 4 patients who discharged AMA; and

3. failure to provide prescriptions or document that the patient had access to medication at home and failure to assess the patient's condition at discharge for 1 of 1 patient who was discharged by Therapeutic Discharge (Pt #13).

Findings include:

Review of the policy/ procedure titled Inpatient Discharge Planning and Patient Discharge revealed: "...Discharge planning and process is conducted regardless of discharge type (i.e.:Therapeutic discharge, Discharge Against Medical Advice, etc.)...at the time of discharge, the patient...will receive written discharge instructions and recommendations for continuum of care...Role of Physician...completion of Discharge Order form and Medication Reconciliation Form of discharge medications...role of Nursing...medical follow up...review of safety and educational needs...medication reconciliation understood, acknowledgement of understanding of discharge instructions...Role of the Nursing Department is defined as follows:...Document discharge progress note to include:...Assessment of Physical Condition...."

1. Review of the policy /procedure titled Discharge Against Medical Advice required: "...if physician agrees to discharge the patient AMA, follow procedure for routine discharge...this includes...attending physician completing discharge order (including appropriate medications)...."

Review of Medical Record revealed:

Patient #35 was admitted to this facility on 11/24/11, for psychosis following a domestic violence episode, related to paranoid delusions. The patient had a history of taking crystal methamphetamine. The patient also had secondary diagnoses of [DIAGNOSES REDACTED]

Chart documentation revealed the form titled Leaving Hospital Against Advice. The Physician's order sheet contained a T.O.R.B. (Telephone order read back) that required: "...discharge patient AMA to family...continue Abilify 30 mg PO daily as before admission...continue Benadryl 25 mg PO HS as before admission...continue Xanax 0.5 mg PO TID as before...."

The Medication Reconciliation Admission/Discharge form listed the following medications:

Depakote ER 500 mg oral Daily for seizures
Depakote ER 500 mg oral 2 Tabs bedtime for seizures
Abilify 30 mg oral Daily for mood
Diphenhydramine 25 mg oral Bedtime for sleep (Benadryl)
Cartia XT 180 mg oral Daily for HTN (hypertension)
Atenolol 50 mg oral Daily for HTN
Lisinopril 40 mg oral 2 tabs Daily for HTN
Pravastatin 20 mg oral Daily in evening for cholesterol
Glipizide 5 mg oral Daily for DM (Diabetes Mellitus)
Metformin 1000 mg oral 2 x daily for DM
Alprazolam 0.5 mg oral 3 x daily for anxiety (Xanax)
Ibuprofen 600 mg oral 2 x daily for Ankle
Prolixin 10 mg oral Bedtime for Psychosis

The following medications were checked on the Medication Reconciliation form for the patient to resume taking after discharge: Abilify, Diphenhydramine, Cartia, Atenolol, Lisinopril, Pravastatin, Glipizide, Metformin, Alprazolam and Prolixin.

Review of the form titled Patient Discharge Instructions revealed that Pt # 35 initialed the statement, "...Medications from home were returned to me..." as N/A (non-applicable). There is no documentation on the Discharge Instruction sheet or Nurses' notes that the patient received prescriptions or had a supply of medications at home.

Chief Nursing Officer (CNO), employee # 2, confirmed in an interview conducted on 1/25/12 at 1130, hours that there was no documentation in the chart that patient # 35 received his/her Medication Reconciliation sheet or that the patient was given prescriptions.

2. Review of the policy /procedure titled Discharge Against Medical Advice required: "...Patients admitted for chemical dependency who deny thoughts of self harm or harm to others cannot be placed on a 24 hour hold...notify Nursing Supervisor of AMA...document the event in the patient's medical record...note should include...reason patient gives for leaving AMA...Nursing interventions attempted to have patient not leave AMA...time physician contacted regarding patient's request for AMA...."

Review of Pt #35's medical record revealed no documentation of notification to the Nursing Supervisor about the AMA discharge, reason patient wanted to leave and/or nursing interventions attempted to prevent the patient from leaving AMA.

Chief Nursing Officer (CNO), employee # 2, confirmed in an interview conducted on 1/25/12 at 1130 hours, that there was no documentation in Pt #35's chart that the Nursing Supervisor was called, and/or documentation of nursing interventions attempted to convince the patient to remain in treatment at the facility as required by policy.

3. Review of medical record revealed:

Pt #13 was admitted on [DATE], with a provisional diagnosis of [DIAGNOSES REDACTED]...."

She had been admitted previously on 3/31/10 for polybenzodiazepine detoxification. She was discharged on [DATE], but became depressed, anxious, and irritable; expressed a desire to die; complained of racing thoughts and diminished sleep; and relapsed on polybenzodiazepines. She was therefore readmitted on [DATE] to the chemical dependency unit.

The patient had Insulin dependent Diabetes mellitus and required routine insulin as well as sliding scale insulin and Metformin. She had hypertension and her blood pressure was controlled on medication. The patient was on Synthroid for [DIAGNOSES REDACTED]. The patient was status post gastroplasty for weight reduction. The patient received Methadone, Phenobarbital and Clonidine for management of withdrawal and Eskalith, Depakote, Seroquel, Vistaril and Ambien for management of her mood, anxiety, and sleep. Her discharge diagnoses included [DIAGNOSES REDACTED]..."

Pt #13 was discharged therapeutically on 4/22/10.

Review of Pt #13's Medication Administration Record revealed that the patient was receiving the following medications at the time of her discharge on 4/22/10:

Clonidine HCL (patch) topical once per week;
Divalproex (Depakote) Tablet two times daily;
Insulin NPH;
Humulin-R Insulin;
Novolog Insulin;
Levothyroxine 75 Mcg Tablet daily;
Lisinopril 10Mg tablet daily;
Lithium CR Tablet 450Mg two times daily;
Metformin HCl 500 Mg, 2 tablets with breakfast and dinner daily;
Quetiapine (Seroquel) 200 Mg 2 tablets at bedtime;
Hydroxyzine Pamoate (Vistaril) 50 mg 1 capsule every 4 hours as needed for anxiety; and
Zolpidem (Ambien) 10Mg at bedtime as needed for sleep.

Review of a physician's progress note dated 4/20/2010 and timed 1622 revealed: "...'I'm depressed...I'm tired of living in the fog' Isolated, in bed. Poor sleep...Medications:...Side effects reported...LE (Lower Extremity) akathesia...(decrease) QTP (Quietiapine)...Assessment...hopeless...helpless...Suicidal ideation...No intent or plan...Mood...Depressed: (rated on a 1-10 scale) 8...Anxious: 8-9...Pt elects to proceed (with) ECT (Electro Convulsive Therapy)...."

Review of a physician's progress note dated 4/21/2010 and timed 1541 revealed: "...Pt seen & eval'd...paperwork for ECT completed & to serve as today's Prog Note...."

Review of nursing progress notes on 4/22/10 revealed:

1100: "...Pt rates dep 6, anx 6, denies s/i (suicidal ideation) contracts for safety in the hospital only...."
1130: "Pt's BS (Blood Sugar) (at) breakfast was 168, 6 units of scheduled novolog administered by pt...24 units of scheduled NPH given...Pt's BS (at) lunch = 347, 8 units of reg insulin given...6 units of scheduled novolog given...."
1300: "...Peer reported pt had Valium & Ativan in room. Room search done & Valium & Ativan found in empty soap container. Dr...notified...."

On 4/22/10, at 1000, an RN wrote on the physician's order sheet: "...UDS (Urine Drug Screen) PNJ (Per Nursing Judgment) d/t (due to) suspected use of narcotics by pt...pt refused...."

On 4/22/10, at 1335, an RN wrote a physician's telephone order: "...Therapeutically discharge pt today...."

At 1635 an RN wrote: "...Pt was therapeutically discharged . Reviewed medication reconciliation with no discharge medication. Pt denied suicidal thoughts. She denied pain. Pt planned to follow up with PCP (Primary Care Physician) & to call (name of behavioral health agency). Pt demanded her pills that were found in soap bottle be returned. Pills were returned to patient's son & he signed to accept responsibility for them. Pt packed belongings. Pt & her son were walked to lobby...."

The Discharge Instructions form contained documentation that the patient was instructed to contact a behavioral health agency and a case manager. The name of a partial hospitalization program was written with the date 4/28/10 and time 8AM. The social worker also documented: "...Gave pt...list to call on placement options...." The form contained documentation: "...next level of medication provider: PCP...(name of Dr.)...4/27/10...1:45...Fax:...."

The Medication Reconciliation Admission/Discharge form contained documentation that the patient was to continue Insulin NPH 22 units (subcutaneous) twice daily, Insulin Novolin R 6 units (subcutaneous) twice daily, Lisinopril 10 mg (oral) daily, and Synthroid 75 mcg (oral) daily. An RN completed the form and wrote: "...No discharge medication..." across the section of the form titled New Discharge Medications.

The medical record did not contain documentation that the patient had prescriptions or a home supply of medications for management of her diabetes, [DIAGNOSES REDACTED] or hypertension. It did not contain documentation that she was to continue any psychiatric medications, even though her discharge diagnoses included [DIAGNOSES REDACTED]..." The physician had not discontinued her Depakote, Lithium, Seroquel, or Vistaril prior to discharge. In addition, the medical record did not contain documentation of a nursing assessment or instructions regarding the patient's ingestion of the Valium and/or Ativan which was found in her room. The medical record did not contain nursing assessment or instructions regarding risk related to overdose, intoxication, or withdrawal from those medications or risk related to abrupt discontinuation of her other psychotropic medications which she had been taking in the hospital. The nurse did not document Pt #13's physical condition at the time of discharge.

The Quality Educator confirmed the findings during interview conducted on 1/11/12.

The CNO confirmed during interview conducted on 1/24/12, that the nursing documentation at the time of Pt #13's discharge, did not include necessary information regarding her medical condition after possible ingestion of unauthorized medication.