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.

SONORA BEHAVIORAL HEALTH HOSPITAL 6050 NORTH CORONA ROAD TUCSON, AZ Sept. 21, 2012
VIOLATION: GOVERNING BODY Tag No: A0043
Based on review of governing body meeting minutes, medical staff bylaws, rules and regulations, credential files, hospital documents, contracted services, hospital policies/procedures, medical records, and interviews, it was determined that the hospital failed to have an effective governing body responsible for the conduct of the hospital, as evidenced by:

(A 0049) failing to ensure that the medical staff be accountable to the governing body for the quality of care provided to patients; and

(A 0093) failing to require that the medical staff have written policies and procedures for appraisal of emergencies, initial treatment, and referral of patients when appropriate.

The cumulative effect of these deficient practices resulted in the hospital's failure to meet the requirements of the Condition of Participation (COP) for the Governing Body.
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical staff bylaws, rules and regulations, hospital policies and procedures, other hospital documents, medical records, Nursing Drug Handbook 2011 and staff interview, it was determined the hospital failed to ensure that the medical staff be accountable to the governing body for the quality of care provided to patients as evidenced by:

1. failing to require that the medical staff have policies and procedures for management of the Adults in their Detoxification Program;

2. failing to identify in the CINA protocol how frequently RN or LPN staff is to perform withdrawal assessments and vital signs for 1 of 1 patients receiving Clonidine (patient # 23);

3. implementing a Protocol with incomplete medication orders for 3 of 3 patients (Pt's # 22, 23 and 33);

4. failing to require that a physician complete a History and Physical which includes findings from the patient's emergency room visit immediately prior to the patient's transfer to the hospital for 1 of 1 patient who originated as an emergency room transfer and subsequently required transfer back to a medical facility (Pt #1);

5. failing to require that the physician address via treatment plan and/or physician orders, a patient's basic physical needs for nutrition, hydration and elimination for 1 of 1 patient who was transferred to a medical facility due to dehydration (Pt #1); and

6. failing to require completion of required medical consultation ordered by attending psychiatrist.

Findings include:

1. Review of the Medical Staff Bylaws, Rules and Regulations of the Medical Staff revealed: "General responsibilities of staff membership...abide by the Medical Staff bylaws, Rules and Regulations and all other standards, policies, procedures and rules of the Facility...account to the Board for patient care processes and outcomes...Each attending practitioner agrees to the design of the Hospital's treatment programs and agrees to practice in accordance with the program model. Each clinical Practitioner will adhere to all written Hospital policies, procedures, protocols and guidelines, including without limitation Hospital policies addressing multidisciplinary treatment plans for situations where such plans are appropriate...."

Review of the facility program description for Adult Detoxification revealed: "...Medically- Managed Detoxification is provided to patients who are assessed to have a substance abuse disorder...a need for 24- hour medical management of bio-medical, emotional, and behavioral conditions and complications, with addictions...."

Review of the Medical Executive Committee (MEC) minutes revealed: "...MEC reviewed standing protocols and formats for: Alcohol Detox/CIWA; Opiate Detox/CINA...approved...."

The facility does not have policies and procedures for the management of the Clinical Institute Withdrawal Assessment- Narcotic (CINA) and Clinical Institute Withdrawal Assessment- Alcohol (CIWA) detoxification protocols.

The medical director confirmed in an interview on 9/21/12 at 0800 hours, that the hospital does not have policies and procedures for the medical management of its adult Detoxification program.

2. Review of the protocol for CINA identified that the medication Clonidine, (an antihypertensive drug) is part of the treatment regimen in the protocol. Clonidine can have many adverse reactions for the patient including: CNS, cardiovascular, GI, GU, metabolic and skin changes. The protocol does not address how often the RN or LPN staff are to complete the withdrawal assessment evaluation, and how often vital signs are to be monitored. Review of the Opiate Detox Protocol identified the following standing medication orders:"...Clonidine 0.1 mg PO q 2 hours, PRN Opiate Withdrawal evidenced by any positive CINA items 2, 3, 4, 5, 7, 10...."

Review of the Nursing 2011 Drug Handbook identified the following nursing consideration when administering Clonidine Hydrochloride: Monitor blood pressure and pulse rate frequently.

Patient # 23 was admitted with opiate dependency. This patient was placed on CINA protocol on admission. The patient was assessed every 4 hours on 8/25/12 until 2103 hours. The next CINA assessment was not until 8/26/12 at 0600 hours. On 8/27/12 the patient was assessed at 0900 hours. The next assessment was not until 8/27/12, 2100 hours. Last CINA documentation on 8/27/12 at 2200 hours revealed: "...asleep...reg resp 16...."
This patient received Clonidine 0.1 mg PO 8/25/12 at 2102 hours, 8/26/12 at 0600, 0900, 1500, 1700 and 2230 hours and 8/28/12 at 1745 hours.

The medical director confirmed in an interview on 9/21/12 at 0800 hours, that the CINA protocol does not specify how often to monitor vital signs when patients are receiving Clonidine. The medical director also confirmed that the vital signs need to be checked every two hours if the patient is given Clonidine, and that sometimes the patients may have to have the vital signs be checked every fifteen minutes depending on the patient.
3. Review of the Medical Staff Rules and Regulations revealed: "...medications prescribed will specify dosage, frequency, route of administration, rationale, date, and time of order...."

Review of the Opiate Detox Protocol identified the following standing medication orders:
"...Clonidine 0.1 mg PO q 2 hours, PRN Opiate Withdrawal evidenced by any positive CINA items 2, 3, 4, 5, 7, 10. [if diastolic BP is below 60 or systolic below 98, must notify practitioner prior to administering any further doses]...Bentyl 10 mg PO QID PRN Opiate Withdrawal evidenced by positive CINA items 1, or 6...Pseudoephedrine 30 mg PO q 6 hours, PRN Opiate Withdrawal evidenced by positive CINA items 8 or 9...Ativan 1 mg PO q 2 hours, PRN anxiety/agitation associated with Opiate Withdrawal. [Not linked to CINA SCALE. Hold for excessive sedation, [DIAGNOSES REDACTED], dysarthria, or ataxia]...."

Review of the medical records for 3 of 3 patients, (Pt's # 22, 23 and 33) revealed the CINA withdrawal assessment sheet identified clinical symptoms for nursing staff to assess I.E. Lacrimation, Nausea and Vomiting, Anxiety, Sweat/Chills, Nasal Congestion, Abdominal Cramps, Restlessness, Tremor, Muscle Aches and Goose Flesh. The assessment sheet does not have a correlating number assigned to each symptom (to determine positive CINA item). The documentation of the current medication orders on the Protocol are incomplete based on the way the assessment tool is written.

Medical record for patient # 22 revealed that the patient received the following doses of medication: Bentyl 10 mg PO and Pseudoephedrine 30 mg PO on 9/17/12 at 2045 hours;
Pseudoephedrine 30 mg PO 9/18/12 at 1710 hours; and
Bentyl 10 mg PO 9/18/12 at 1100 and 1710 hours.

There is no documented evidence on the MAR identifying what symptoms generated the patient receiving these medication.

Patient # 23 received the following medications:
Bentyl 10 mg PO 8/25/12 at 1200 midnight, 8/26/12 at 0600, 1300, 8/27/12 at 0345 hours; and Clonidine 0.1 mg PO 8/25/12 at 2102 hours, 8/26/12 at 0600, 0900, 1500, 1700 and 2230 hours and 8/28/12 at 1745 hours.

There is no documented evidence on the MAR identifying what symptoms generated the patient receiving these medication.

Patient # 33 received the following medications:
Pseudoephedrine 30 mg PO on 9/20/12 at 2335 hours.

There is no documented evidence on the MAR identifying what symptoms generated the patient receiving these medication.

The Medical Director confirmed in an interview on 9/21/12, that the way the medication orders are written on the Detox protocol, there is no way to determine that patients are getting what medications they should be.

Employees # 11 and 25, confirmed in interviews on 9/20/12 and 9/21/12, that the CINA assessment sheets on the charts for patients # 22, 23 and 33 did not contain numbers assigned next to the clinical symptoms on the form.

4. Review of Rules and Regulations of the Medical Staff revealed: "...The following shall be included in the H & P (History and Physical Examination):...Chief Complaint...History of present illness...Current medications...Review of systems...Identification of potential problems needing further assessment...Prior medical work-up...Laboratory findings...Impression...."

Review of medical record:

Pt #1's medical record contained documentation from the referring medical facility's emergency room . The documentation was available in the medical record at the time that the physician completed the H & P.

ED Triage documentation: "...May-08-2012, 0724...Focused Assessment: Pt. has multiple compaints (sic). Pt. family states she has been suffering increased depression. Pt. family states pt. is not able to do ADL's at home. pt family states she has increased weakness on left side over past few days...."

Emergency Services Physician Documentation: "...5/8/12, 0745...CC/HPI (Chief Complaint/History of Present Illness): Progressive weakness...(not) eating (for) last several days. (not) hungry, vomitted (sic) once. (decreased) movement arms (no) diarrhea. (no) dysuria. (no) vaginal d/c (discharge) (depressed) mood. (no) S.I. (Suicidal Ideation)...PMHx (Past Medical History): Ovarian cysts. Depression...."

Laboratory tests completed at the referring hospital: "...May-08-2012, 2359...(low) Albumin Serum...(low) Phosphorous-Blood...(high) Thyroid Stimulating Hormone...Large (amount of) Blood, Urine...Large (amount) Leukocyte Esterase, Urine...Present...Bacteria, Urine...Present...Squamous Epithelial Cell...."

ED Psychiatry Consultation: "...5/8/12, 1315: "...History of Present Illness...complaint of inability to perform ADL's...or move her arms for several days...states she is here 'because I cannot move my arms'...[DATE]...Pap...Ovarian cysts found and OCP (Oral Contraceptive Pills) started...Medical History...Depression, ovarian cysts R & L (Right & Left)...Major Depressive Disorder...R/O (Rule Out) Somatoform disorder...Recommendations:...Neurology consult to evaluate new onset upper extremity weakness, unusual eye movements and generalized weakness...Transfer to level I facility...once medically clear and evaluated by Neurology...."

The patient was assessed in the current hospital's Assessment and Referral department on 5/9/12, at 0800. The physician completed the H & P on 5/10/12 and dictated it at 0826.

Review of the H&P: "...Chief Complaint:...admitted ...for history of depression...History of Present Illness: Presently, the patient is extremely tired, but answering questions...Past Medical History: unavailable...Current Medications: The patient is on Keflex for urinary tract infection...Laboratory Values: The patient has had a complete metabolic profile (CMP) with a CBC (Complete Blood Count), which were normal...Genitourinary: negative for polyuria, hematuria, dysuria or frequency...Bones, Joints and Muscles: Negative for joint pain, swelling, trauma, previous surgeries or limited range of motion...Neurologic: No...difficulty with...unilateral weakness...Motor Strength: Strong equal grip, strong equal push/pull lower extremities...Impression: This is a patient who was admitted for a history of depression disorder. Presently, she has urinary tract infection, which she is taking keflex for. The patient is continue (sic) on that medication...."

Review of the Psychiatric Evaluation completed on 5/9/12 at 1114, revealed: "...Chief Complaint...'I can't move my arms'...History of Present Illness: [DIAGNOSES REDACTED]. She complains of inability to move her arms and has difficulty standing up...she has not eaten or has only eaten small bites of food in the last 48 hours and that she is not hungry...Medical History: Significant for obesity, rule out UTI (Urinary Tract Infection), ovarian cyst...."

The Medical Director confirmed during interview conducted on 9/21/12, that the content of the H & P should reflect that the physician was aware of the ER physician's findings which preceded the patient's transfer. He confirmed that Pt #1's H & P did not. He confirmed that the H & P contained discrepancies and did not include findings from the ER evaluation or the laboratory results. He confirmed that the laboratory results were not normal and the H & P referenced a normal CMP. The H&P contained no documentation of the family report of patient's left upper body weakness or generalized weakness. It contained no documentation or need for follow-up of the patient's reduced nutritional intake for several days. The Medical Director confirmed that the H &P did not meet the expected standards.

5. Review of Medical Staff Bylaws revealed: "...The responsibilities of the Medical Staff are: to account to the Board for the patient care processes and outcomes rendered by all Members...to monitor, enforce...these Bylaws and Rules and Regulations and Facility policies...."

Review of the Rules and Regulations of the Medical Staff revealed: "...The Attending Practitioner is responsible for ensuring that each of his patients has an individualized comprehensive treatment plan...Only Practitioners may write orders for the following:...Nutritional assessment...."

Review of hospital policy titled Treatment Planning revealed: "...Ultimate responsibility for the development and implementation of the treatment plan shall rest with the physician...."

Cross reference Tag 395 #4 for information regarding Pt #1 and her declining intake and output.

Cross reference Tag 396 #2 for information regarding Pt #1's need for a nutritional assessment.

Physician #4 confirmed during interview conducted on 9/19/12, that she was the psychiatrist who completed Pt #1's intake evaluation and was assigned as her attending psychiatrist. She confirmed that Pt #1's medical record contained documentation that she met criteria for a referral to a dietician for a nutritional assessment and that a nutritional assessment was not ordered.

Physician #4 confirmed that nursing documentation reflected decrease in the patient's intake and output, but she last saw the patient on 5/11/12 (Friday) and the on-call physician assumed care starting Friday through Sunday.

Physician #4 stated that the treatment plan did address the patient's physical needs. Review of the plan revealed: "...Short Term Goals...Patient will be willing to be as independent as possible, participate in performing daily hygiene ADLs and ask for assistance when needed...Interventions...Staff will daily assure that pt is getting adequate hygiene, grooming, activity and nutritional needs met by observing patient, eliciting feedback in areas pt needs assistance and document that pt is demonstrating understanding of importance of consistent and independent ADLs...Cue pt consistently with instructions for ADLs and provide assistance when appropriate and provide consistent positive feedback for successful self-care Empower pts independence daily throughout hospital stay...."

The DON confirmed during interview conducted on 9/19/12, that the patient's treatment plan did not contain nursing interventions related to the patient's intake and output or the need for a nutritional assessment.

6. Review of Medical Staff Bylaws revealed: "...The responsibilities of the Medical Staff are: to account to the Board for the patient care processes and outcomes rendered by all Members...."

Review of Rules and Regulations of the Medical Staff revealed: "...The Attending Practitioner is responsible for requesting consultation when indicated...Only practitioners may write orders for the following:...medical consultation other than initial history and physical...Consultants must make record entries, dated and timed, whenever they see a patient...."

See above #4 for information regarding Pt #1's diagnostic lab results from referring hospital.

Cross reference Tag 395, #4 for information regarding Pt #1, her declining intake and output, her other physical difficulties and eventual transfer to an emergency room .

Cross reference Tag 396, #2 for information regarding Pt #1's need for a nutritional assessment,

Review of Pt #1's medical record revealed that the attending psychiatrist wrote an order on 5/11/12 at 0900: "...(name of contracted medical physician group) consult for (decreased) Phosphorous...."

Pt #1's medical record did not contain documentation that a physician completed a medical consult as ordered.

Physician #5 confirmed during interview conducted on 9/20/12, that he was the psychiatrist responsible for the care of Pt #1 from 5/11/12 through 5/13/12. He stated that when a physician writes an order for a consult, the nursing staff communicates that order to the contracted medical physician group. He stated that the consultation should be completed within 24 hours and that Pt #1 needed to be seen within 24 hours. By 5/13/12, the patient needed to be seen medically and he gave a telephone order for the nurse to transfer the patient to the emergency room .
VIOLATION: EMERGENCY SERVICES Tag No: A0093
Based on review of hospital policies/procedures,and staff interviews, it was determined the
hospital failed to require that the medical staff be accountable for the appraisals of the patients in an emergency as evidenced by their protocol to call 911.

Findings include:

Review of the hospital policy/procedure titled "Medical Emergency" revealed: "...A medical emergency exists when a patient presents with a medical condition that extends beyond the scope of care...and must be treated immediately...Medical emergencies can be, but are not limited to, a fall with fracture, seizure, severe symptoms of EPS(Extrapyramidal Symptoms), extreme high or low blood sugar levels that cannot be managed, chest pain, physical or sexual assault...the nurse, attending practitioner or their designee will call 911 to arrange for emergency transport by ambulance. The nurse will contact the...attending practitioner no later than one hour of patient transport to emergency care...."

The Medical Director confirmed in an interview conducted on 9/21/12, that the policies for medical emergencies was a question for the DON.

The DON and Director of Outpatient Clinic confirmed in an interview conducted on 9/21/12, that there is no policies in place with supporting care for a fall with fracture, seizure, severe symptoms of EPS, extreme high or low blood sugar levels that cannot be managed, chest pain, physical or sexual assault; and the policy for medical emergency is just calling 911 and transporting without notification. The DON also confirmed that the Medical Staff has not approved any other policies and procedures for emergencies and the nurses need to call the medical staff for any orders.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on direct observation, review of hospital documents, medical records, hospital policies/procedures and interviews, it was determined the hospital failed to protect and promote each patient's rights as evidenced by:

(A 144) failing to provide care to patients in a safe setting;

(A 168) failing to use restraint or seclusion in accordance with the order of a physician or other licensed independent practitioner;

(A 166) failing to require that restraint be in accordance with a written modification to the patient's plan of care;

(A 169) failing to require that the use of restraint or seclusion is never written as a standing order or on an as needed basis (PRN);

(A 178) failing to assure that a patient be seen face-to-face within 1 hour after the initiation of a seclusion or restraint used for the management of violent or self-destructive behavior;

(A 179) failing to require that the patient who is secluded and/or restrained for management of violent or self-destructive behavior be seen face-to-face within 1 hour after the initiation of the intervention to evaluate the patient's medical condition; and

(A 194) failing to provide training required for staff competence to safely implement the one hour face-to-face evaluation of a patient secluded or restrained for the management of violent or self-destructive behavior.

The cumulative effect of these systemic problems resulted in the hospital's failure to protect and promote each patient's rights.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on review of hospital documents, medical records, direct observation and interview, 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 provide an environment that is free of equipment conducive to self-injury or suicide for children and/or adolescents on the milieu of the unit;

2. failing to provide an environment that is free of fixtures conducive to self-injury or suicide for patients being evaluated for admission to the facility in the lobby and intake rooms;

3. failing to keep patient free of intentional infliction of physical, mental, or emotional pain unrelated to the patient's medical condition for 1 of 1 patient (Pt #2) by not following orders for a 1 to 1; and

4. failing to require that staff members have the skills and knowledge necessary to effectively monitor a patient in a 1 to 1 situation for 1 of 1 patient (Pt #2).

Findings include:

1. On 9/21/12, direct observation of the milieu in the Child and Adolescent Units revealed the following safety hazards: sixteen folding chairs and three folding tables.

Employee # 24 confirmed, on 9/21/12, that these chairs and tables area safety hazard to the patients.

2. On 9/21/12, direct observation revealed the following safety hazards:

The two bathrooms in the lobby which patients utilize when waiting for admission/ and or evaluation to the facility had the lever style door handles.

The two intake rooms where patients where evaluated had lever style door handles.

Employee #4, the Patient Safety Officer, confirmed the safety hazards during tour conducted on 9/21/12.

3. Cross reference Tag A 0395 for information regarding Pt's # 2 and the policy/procedures titled "Use of 1 To 1's or Restricted Roommate Status," "Levels of Observations," "Patient's Rights and Responsibilities," "Re-Assessment of Patient Needs," "Treatment Planning," "Behavioral Health Technician's Job Description," "Registered Nurse's Job Description."

Employee #5 confirmed that the patient's treatment plan did not address the patient's requirement for supervision, or any consideration to provide for closer supervision.

4. Cross reference Tag A 0395 for information regarding Pt's # 2 and the policy/ procedures titled "Levels of Observations" and the Job Descriptions for Behavioral Health Technicians.

Review of facility's employee # 8 file revealed there is no documentation of orientation to the unit or 1 on 1 training. The Orientation training in the file was not signed by Employee # 5.

Employee # 19 confirmed in an interview conducted on 9/19/12, that the Employee # 8's file did contain the orientation to the unit or the training for 1:1.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
**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 the hospital failed to require that restraint be in accordance with a written modification to the patient's plan of care for 1 of 1 patient who was restrained multiple times (Pt #2).

Findings include:

Review of hospital policy titled Provision of Care: Restraint revealed: "...The treatment plan shall be reviewed and revised following the first episode of restraint to include measures to prevent recurrence. Additional review of the treatment plan, with revisions as indicated, will occur if the patient is restrained on more than one occasion...."

Review of medical record revealed:

Pt #2 was admitted on [DATE]. On 8/10/12 at 0450, she was physically and mechanically restrained due to an immediate threat to her own safety. An RN documented on 8/10/12 at 0605: "...What revisions need to be made to the Treatment Plan?...Review meds, review behavior plan (with) pt for alternatives...."

Pt #2 was restrained on 8/11/12. An RN documented on 8/11/12: "...What revisions need to be made to the Treatment Plan?...No cafeteria...finger foods only...."

Review of the patient's Interdisciplinary Treatment Plan; Problem/Goals Interventions, revealed that it did not contain a behavior plan with alternatives or any revisions made on 8/10/12 related to the purpose of the restraint on 8/10/12 at 0450 or threat to the patient's immediate physical safety. The treatment plan did not contain revision on 8/11/12 related to eating in the cafeteria or finger foods.

The DON confirmed during an interview conducted on 9/19/12, that the patient's treatment plan did not contain the above revisions which were documented at the time of the restraint.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on review of hospital policy/procedure, Rules and Regulations of the Medical Staff, medical records and interview, it was determined that the hospital failed to require that the use of restraint or seclusion be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient for 7 of 9 restraint episodes of 4 patients who were restrained for the management of violent or self-destructive behavior (Pts #2, 12,13 and 14).

Findings include:

Review of hospital policy/procedure titled Provision of Care: Seclusion revealed: "...Seclusion may only be ordered by a practitioner (Physician or Nurse Practitioner)...The order shall indicate the reason and maximum duration of seclusion...."

Review of hospital policy procedure titled Provision of Care: Restraint revealed: "...Restraint may only be ordered by a practitioner (Physician or Nurse Practitioner)...The order shall indicate the reason and maximum duration of restraint...."

Review of the Rules and Regulations of the Medical Staff of the hospital revealed: "...Restraints or Seclusion used for Emergency Behavior Management Reasons...Orders...A Practitioner must order the Restraints or Seclusion...If a practitioner is not immediately available, a specifically trained registered nurse may initiate Restraints or Seclusion based on appropriate assessment of the patient. A Practitioner will be notified as soon as possible thereafter to obtain an order...Orders...orders dictated over the telephone shall be signed, dated, and timed by the person who took the order and shall include the name of the Practitioner giving the order. The Practitioner must acknowledge that the read-back is accurate...."

Review of medical records revealed:

Pt #2's medical record contained a form titled Restraint/Seclusion Practitioner Order. A physician's name was written in the space designated for "Verbal/Phone Order by:" The Date 8/10/12 and Time 1641 were recorded next to the physician's name. The space for signature of the individual who recorded the order was blank. The order did not include a maximum duration for restraint. An RN signed that he noted the order on 8/10/12 at 1730. The physician signed the order on 8/19/12. Nursing staff documented that restraint was initiated at 1641 and discontinued at 1712. Restraint included a physical hold as well as mechanical 4 point restraints.

Pt #2's medical record contained a form titled Restraint/Seclusion Practitioner Order with a telephone order recorded by an RN on 8/12/12 at 1800, for Physical Restraint and Chemical Restraint. The order did not include a maximum duration for restraint. The patient was restrained by physical hold for an injection and remained in the seclusion room with staff for 10 minutes.

Pt #2's medical record contained a form titled Restraint/Seclusion Practitioner Order with a telephone order for Physical Restraint and Chemical Restraint recorded by an RN on 8/13/12 at 1000. The order did not include a maximum duration for restraint. The patient was restrained by physical hold for an injection.

Pt #2's medical record contained a form titled Restraint/Seclusion Practitioner order with a telephone order recorded by an RN on 8/17/12 at 0040, for Physical Restraint and Chemical Restraint. The order did not include a maximum duration for restraint. The patient was restrained by physical hold for 30 minutes.

Pt #12's medical record contained a form titled Restraint/Seclusion Practitioner Order. The space designated for "Verbal/Phone Order by": contained a physician's name. The space for Date and Time were blank. The space for signature of the individual who recorded the order was blank. The form did not contain a physician's signature. Nursing staff documented that restraint was initiated at 1335 and discontinued at 1427.

Pt #13's medical record contained a form titled Restraint/Seclusion Practitioner Order. The space designated for "Verbal/Phone Order by:" contained an RN's signature with the date 7/21/12 and time 1055. A physician's name was not written in the space for the order and the form did not contain a physician's signature. A mark was placed by "Seclusion" as the "Type" and a mark was placed by "2 hours youth 9-12" for the "Maximum Duration." An RN documented at 1400: "...At approx 1000, pt was outdoors with child group; Had altercation (with) 7 yo male peer (pushing & grabbing basketball) Pts were separated and asked to come indoors. Pt became oppositional and cursing at staff. Escorted in to Time Out room. Pt began kicking at staff and S&R (Seclusion and Restraint) door was closed to block pt's kicks...pt appeared to be having (increased) anxiety/panic reaction. Pt was escorted outdoors where he was able to process with staff...."

Pt #14's medical record contained a form titled Restraint/Seclusion Practitioner Order. The space for Physical Restraint was marked. The space designated for 'Verbal/Phone Order by:" contained a physician's name. The Date 7/29/12 and Time 1400 were recorded next to the physician's name. The space for signature of the individual who recorded the order was blank. An RN signed that she noted the order, but did not record a date or time.

The DON confirmed during an interview conducted on 9/19/12, that the medical records listed above did not contain the required elements for physicians' orders for seclusion and/or restraints.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0169
Based on review of hospital policy/procedure, Rules and Regulations of the Medical Staff, medical records and interview, it was determined that the hospital failed to require that orders for the use of restraint or seclusion never be written as a standing order or on an as needed basis for 1 of 4 patients who were restrained for the management of violent or self-destructive behavior (Pt #2).

Findings include:

Review of hospital policy/procedure titled Provision of Care: Restraint revealed: "...Orders for restraint shall never be written as a standing order or on as needed basis (PRN)...."

Review of Rules and Regulations of the Medical Staff revealed: "...Restraints and Seclusion...The use of Restraints or Seclusion shall not be based on standing orders or as needed ("PRN") orders...."

Pt #2's medical record contained a physician's telephone order written by an RN on 8/11/12 at 2050: "...Restraints for patient safety...."

The DON confirmed during an interview conducted on 9/19/12, that the order would be considered to be a PRN or standing order and was not permitted.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
Based on review of hospital policy/procedures, medical records and interview, it was determined that the hospital failed to require that a practitioner or trained registered nurse see and evaluate the patient within one hour after the initiation of seclusion or restraint for 2 of 6 restraint/seclusion episodes of 1 patient who was restrained or secluded for the management of violent or self-destructive behavior (Pt #2).

Findings include:

Review of hospital policy/procedure titled Provision of Care: Seclusion revealed: "...A practitioner or trained registered nurse shall conduct an in-person evaluation of the patient within one hour of initiation of seclusion to assess physical and psychological status...."

Review of hospital policy procedure titled Provision of Care: Restraint revealed: "...A practitioner or trained registered nurse shall conduct an in-person evaluation of the patient within one hour of initiation of restraint to assess physical and psychological status...."

Review of Pt #2's medical record revealed that nursing staff recorded that restraint was initiated on 8/10/12 at 1641, and discontinued at 1712. An RN documented the In-Person Evaluation on 8/10/12 at 1820.

Review of Pt #12's medical record revealed that nursing staff recorded that physical restraint was initiated on 7/2/12 at 1334 and mechanical restraint was initiated at 1335 and discontinued at 1427. An RN documented the In-Person Evaluation on 7/2/12 at 1800.

The DON confirmed during an interview conducted on 9/19/12, that the RN did not complete the In-Person Evaluation within one hour of the initiation of the restraints as required by policy/procedure.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
Based on review of hospital policies/procedures, medical records and interview, it was determined that the hospital failed to require that the patient who is secluded and/or restrained for management of violent or self-destructive behavior be seen face-to-face within 1 hour after the initiation of the intervention to evaluate the patient's medical condition, other than injuries, for 9 of 9 restraint episodes of 4 patients (Pts #2, 12, 13 and 14).

Findings include:

Review of hospital policy/procedure titled Provision of Care: Seclusion revealed: "...A practitioner or trained registered nurse shall conduct an in-person evaluation of the patient within one hour of initiation of seclusion to assess physical and psychological status...."

Review of hospital policy procedure titled Provision of Care: Restraint revealed: "...A practitioner or trained registered nurse shall conduct an in-person evaluation of the patient within one hour of initiation of restraint to assess physical and psychological status...."

Review of medical records revealed:

Nursing documented that Pt #2 was physically restrained on 8/10/12 from 0450 until 0522 and in mechanical restraints from 0522 until 0615. At 0530, Employee #17 documented evaluation of the patient's medical condition: "...Vital Signs: B/P 110/72...Pulse 80...Respirations 16...Awake, crying, struggling, 0600-0615 Pt appears to have slight puffiness to (right) eye area, ice pack applied...."

Nursing documented that Pt #2 was physically and mechanically restrained on 8/10/12 from 1641 until 1712. At 1820, Employee #7 documented evaluation of the patient's medical condition: "...Vital Signs: B/P 120/80...Pulse 102...Respirations 18...." The space for documentation of further evaluation was marked with a null sign.

Nursing documented that Pt #2 was physically and mechanically restrained on 8/11/12 from 2050 until 2100. At 2120, Employee #13 documented evaluation of the patient's medical condition: "...Vital Signs: B/P 117/77...Pulse 98...Respirations 18...VSS (Vital Signs Stable, skin dry, warm, intact, (no) visible injury, pt has (no) c/o (complaint of) pain or discomfort at this time...."

Nursing documented that Pt #2 was physically restrained on 8/12/12 from 1800 until 1802 and remained in the seclusion room with a staff member for 10 minutes. At 1800, an RN documented: "...Patient began throwing furniture and hitting her head on the wall...." Employee # 14 documented evaluation of the patient's medical condition: "...No physical injury noted...."

Nursing documented that Pt #2 was physically restrained on 8/13/12 from 1030 until 1032. At 1030, an RN documented: "...Patient began cutting herself with pencil. Banging her head on wall. Choking herself with her hands...escorted to quiet room...hitting fists on wall...held for (less than) 2 minutes to give IM medications...." At 1010, Employee #14 documented evaluation of the patient's medical condition: "...No injuries noted or reported by patient...."

Nursing documented that Pt #2 was physically restrained on 8/17/12 from 0040 until 0110. At 0040, an RN documented: "...Pt began attempting to cut her wrists (with) pencils...pt began hitting her head against chair. Restrained from hurting self...." An RN signed the In-Person Evaluation on 8/17/12 at 0110. The section designated for documentation of evaluation of the patient's medical condition was blank.

Nursing documented that Pt #12 was physically restrained on 7/2/12 from 1334 until 1335 and mechanically restrained from 1335 until 1427. At 1730, an RN documented: "...Pt complained ...0900 that 'I can't think right & I feel confused'...Pt oriented to self & situation but not time of day. A few minutes later, pt was observed sitting on the floor near her bedroom door rocking, saying 'I feel confused'...Pt's behavior escalated throughout the am. She repeatedly layed on the floor near the pharmacy door...Staff...redirected pt. At approximately 1315 pt...more agitated & was banging her head on the floor...she attempted to break plexiglass at the nursing station...hitting her head against the floor...removed to seclusion room...placed in 4 pt restraints...." At 1800, Employee #29 documented evaluation of the patient's medical condition: "...(L) ring finger sustained a superficial laceration as pt was actively thrashing around during the application of wrist restraints...."

Nursing documented that Pt #13 was escorted and placed in seclusion on 7/21/12 at 1000, for approximately 2 minutes. At 1400, an RN documented: "...Pt became anxious when door to T.O (Time Out) door was closed. Pt appeared to have panic reaction...." At 1015, Employee #30 documented evaluation of the patient's medical condition: "...VS (Vital Signs) not done-No injury to pt or staff...."

Nursing documented that Pt #14 was physically restrained on 7/29/12 at 1400, for approximately 2 minutes to receive intramuscular medication. At 1600, an RN documented: "...Patient was sitting in group at 1350. Became agitated...began pacing and throwing his hands up in to the air...Began hitting walls...lying on floor. Medication administered in buttocks...." At 1410, Employee #14 documented evaluation of the patient's medical condition: "...Vital Signs: B/P 107/67...Pulse 96...Respirations 18...." The space for documentation of further evaluation was blank.

The DON confirmed during an interview conducted on 9/19/12, that the In-Person Evaluations completed by the RN's for Pts #2, 12, 13 and 14 after a restraint/seclusion did not contain documentation of the nurses' evaluation of the patients' medical conditions.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0194
Based on review of hospital policy/procedure, hospital documents and interviews, it was determined that the hospital failed to provide training required for staff competence to safely implement the one hour face-to-face evaluation of a patient secluded or restrained for the management of violent or self-destructive behavior.

Findings include:

Review of hospital policy/procedure titled Provision of Care: Seclusion revealed: "...A practitioner or trained registered nurse shall conduct an in-person evaluation of the patient within one hour of initiation of seclusion to assess physical and psychological status...."

Review of hospital policy procedure titled Provision of Care: Restraint revealed: "...A practitioner or trained registered nurse shall conduct an in-person evaluation of the patient within one hour of initiation of restraint to assess physical and psychological status...."

Review of medical records revealed:

Review of the medical records of Pts #2, 12, 13 and 14 revealed that Employees #7, 13, 14 and 17 documented In-Person Evaluations. The hospital was unable to provide documentation of training for Employees #13, 14 or 17 to conduct the In-Person Evaluations prior to the dates when the employees conducted the evaluations. (See Tag 0179 for information regarding the In-Person Evaluations completed by Employees #7, 13, 14 and 17). Documentation of training provided to Employee #7 contained: "...Training Modality: Didactic with written material and forms...." The hospital was unable to provide documentation of competency of Employee #7 to conduct the In-Person Evaluation.

The DON confirmed during interview conducted on 9/19/12, that the hospital was unable to provide documentation of Employees' #13, 14 and 17 training to conduct the In-Person Evaluations. She also confirmed that the documentation of Employee #7's training did not include competency to perform the In-Person Evaluations.
VIOLATION: MEDICAL STAFF PERIODIC APPRAISALS Tag No: A0340
Based on review of Medical Staff Bylaws, rules and regulations, credential files for 4 of 4 physicians (# 2, 3, 4 and 5) and staff interviews, it was determined the medical staff failed to periodically conduct appraisals of its members.

Findings include:

Review of the Medical Staff Bylaws revealed: "...The Medical Director, or his designee, shall have responsibility for oversight of the care provided by the professional...It shall be the responsibility of the Medical Director to design and implement effective programs to monitor and assess the quality of professional practice and to promote the quality of practice...The Medical Staff shall conduct regular patient care reviews and studies of practice and patient care outcomes within the facility in conformity with a written quality management plan approved by the MEC and Board...Medical Director may make informal comments or suggestions either orally or in writing, which shall be discussed with the Member...A summary of such statements shall be kept in the Member's credential file...."

While on site, review of the Medical Staff Bylaws revealed that reappraisals of the medical staff are conducted a minimum of every two years. The medical director confirmed, during an interview conducted on 9/21/12, that he conducts appraisals yearly.

Review of credential files for 4 of 4 physicians (# 2, 3, 4, and 5) revealed no written appraisals in their files.

The medical director confirmed, in an interview conducted on 9/21/12 at 0800 hours, that he does not currently have structured written appraisals of his members. He currently has an informal process for appraising his staff.
VIOLATION: MEDICAL STAFF BYLAWS Tag No: A0353
Based on review of the hospital's Medical Staff Bylaws, Rules and Regulations of the Medical Staff, medical records and interviews, it was determined that the hospital failed to require that the medical staff enforce its bylaws as evidenced by:

1. failing to require that a physician sign telephone orders within 48 hours, as required, for 3 of 6 telephone orders for restraints of Pt #2; and

2. failing to require that a physician complete the discharge summary within 15 days following patient's discharge, as required, for 1 of 1 adolescent patient discharged Against Medical Advice (Pt #3).

Findings include:

Review of the Medical Staff Bylaws revealed: "...The responsibilities of the Medical Staff are...to monitor, enforce, review...these Bylaws and Rules and Regulations and Facility policies...."

1. Review of the Rules and Regulations of the Medical Staff revealed: "...All orders for medication and/or treatment for patients admitted to the Hospital shall be in writing...An order shall be considered to be written if dictated by telephone to a licensed nurse...and signed within forty-eight (48) hours...."

Review of Pt #2's medical record revealed:

An RN recorded a telephone order for physical and mechanical restraint on 8/10/12 at 0525. A physician signed the order on 8/19/12.

An RN recorded a telephone order for seclusion, physical and mechanical restraint on 8/10/12 at 1641. A physician signed the order on 8/19/12.

An RN recorded a telephone order for chemical and mechanical restraint on 8/11/12 at 2050. A physician signed the order on 8/19/12.

The DON confirmed during interview conducted on 9/19/12, that the physician did not sign the orders for restraints within 48 hours as required.

2. Review of the Rules and Regulations of the Medical Staff revealed: "...Discharge Documentation...The record of each discharged patient must have a discharge summary, signed by the Attending Practitioner...Completion of Medical Records...All discharge summaries and other medical record documentation shall be completed within fifteen (15) days following the patient's discharge...."

Review of Pt #3's medical record revealed:

A physician wrote an order on 2/26/12 at 1:30 PM: "...DC (Discharge) from (name of hospital) AMA (Against Medical Advice)...."

A physician wrote the Psychiatric Discharge Note on 3/26/12:...Pt refused medication...did (mother). Pt refused to stay adequate time to stabilize. See DC Summary...."

A social worker completed Discharge Instructions on 3/26/12. An RN completed Discharge Instructions on 3/26/12 at 1640.

The Discharge Summary was dictated by the physician on 6/28/12 at 0949, transcribed on 6/28/12 at 1115 and signed on 7/5/12.

The CEO confirmed during interview conducted on 9/18/12, that the Discharge Summary was not completed and in the medical record within 15 days of the patient's discharge as required. He also confirmed that the physician's discharge note, written on 3/26/12, referred to the DC Summary which was not dictated until 6/28/12.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on review of hospital policies/procedures, hospital documents, medical records and interviews, it was determined that the hospital failed to provide an organized nursing service 24 hours per day with a method to assess patient care needs in order to determine and provide an adequate number of registered nurses to assess patients' care needs and deliver, assign and supervise the care required by each patient as evidenced by:

(A 386) failing to have policy/procedure to delineate responsibilities for patient care of the patient in need of medical detoxification;

(A 392) failing to require adequate numbers of licensed registered nurses to meet the patient care needs;

(A 395) failing to require that a registered nurse supervise and evaluate the nursing care for each patient;

(A 396) failing to ensure that the nursing staff develop and keep current a nursing care plan for each patient;

(A 397) 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; and

(A 405) failing to require that medications be administered in accordance with accepted standards of practice and the orders of practitioners responsible for a patient's care.

The cumulative effect of these systemic problems resulted in the hospital's failure to provide an adequate, organized nursing service.
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on review of hospital policies/procedures, hospital documents, medical records, and interviews, it was determined that the hospital failed to have a well-organized nursing service plan with documented delineation of responsibilities for patient care as evidenced by failing to have a written policy/procedure related to a nursing protocol for how frequently RN/LPN staff assess patients while withdrawing from Narcotics as evidenced in 3 of 3 patient records reviewed (Pt's # 22, 23 and 33).

Findings include:

The facility did not have a written policy and procedure for the management of the Clinical Institute Withdrawal Assessment- Narcotic (CINA) Protocol.

Cross reference Tag 0049 for further information regarding no policy and procedure for how frequently RN/LPN staff assess Detox withdrawal symptoms.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policy/procedure, interviews and hospital documents, it was determined that the nursing service failed to require adequate numbers of licensed registered nurses to meet the patient care needs.

Findings include:

Review of hospital policy/procedure titled Nursing Staff Allocation revealed: "...Purpose...To assure appropriate and adequate nursing staff coverage...Patients are classified to identify the intensity of nursing care and level of observation required by the individual patient/family to aid in decision making regarding staffing...."

The DON confirmed during an interview conducted on 9/21/12, that the Nursing Care Acuity Tool is the tool which is utilized to assess and record the patients' care needs for determining staffing and patient assignments. She was unable to provide an explanation as to how the patient acuity ratings/scores were utilized to determine the number and type of nursing staff required to meet the patients' care needs. She confirmed that the hospital did not have a written description of how the patient acuity ratings are utilized to determine the number of nursing staff required, and that the Nursing Care Acuity Tool requires revision since the categories of nursing care activities and patient care requirements do not accurately reflect the care needs of the hospital's patient population.

Cross reference Tag 395 #1, 2, 3, 4 and 5 which contains information regarding Pts #2, 4, 16, 3, 1, 19 and 23. The information contains reference to instances where the hospital failed to require that an RN supervise and evaluate the nursing care for each patient.

The Youth Unit has a capacity for 22 patients; Acute Adult Unit has a capacity for 12 "acute" patients; and the Adult Unit has a capacity for 22 patients.

Review of the Staffing Day Schedules and Staffing Night Schedules from [DATE] through [DATE], revealed that 2 RN's are routinely scheduled on the Adult and Youth Units from 0700 until 2300. One RN is routinely scheduled on those units from 2300 until 0700.

Employee #32 stated during interview conducted on 9/20/12, that the Adult Unit and Acute Adult Unit are staffed on the basis of a 1:5 staff to patient ratio between 0700 and 2300 and the Youth Unit is staffed on the basis of a 1:4 staff to patient ratio between 0700 and 2300. The one staff could be RN or BHT. The same ratio is not used from 2300 and 0700 because the patients are in bed. No more than 2 RNs have been allocated to the Adult or Youth Units from 0700-2300 regardless of census or patient care needs. No more than 1 RN has been allocated to the Adult or Youth Units between 2300 and 0700 or the Acute Adult Unit from 0700-1900 or 1900-0700 regardless of census or patient care needs.

The DON confirmed during an interview conducted on 9/21/12, that she did not have any documentation of reduced patient care needs, reduced patient acuity ratings or clinical rationale to support the reduction in RN's during the hours of 2300 to 0700.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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

1. failing to provide required supervision/observation for 1 of 1 patient (Patient # 2) who was on a 1 to 1;

2. failing to follow physician's orders for 1 of 1 patient (Patient # 16) for Intake and Output and 1 of 1 adolescent patient, discharged AMA, for diagnostic laboratory tests (Pt #3);

3. failing to assign an RN to supervise and evaluate the care of each patient;

4. failing to contact attending psychiatrist when there was a significant unexplained change in medical condition for 1 of 1 patient who required transfer and admission to a medical facility (Pt #1);

5. failing to assess a patient upon return from an emergency room for 2 of 2 patients who were transported for evaluation of their medical conditions (Pts #19 and 23); and

6. failing to provide required supervision/observation of 1 of 1 patient (Patient # 4) that had a change in behavior.

Findings include:

1. Review of the hospital policy/procedure titled Patient's Rights and Responsibilities revealed: "...Each patient has the right to...To be free from...Abuse...."

Facility Policies titled "Levels of Observation "revealed: "...All patients will be closely observed in compliance with physician orders and prescribed protocols...One-to-One Observation (1:1)...Staff will stay within close proximity of the patient on 1:1 observation...Guidelines for 1:1...Actively attempting to harm self or others...Demonstrated unpredictable behavior...."

Review of Behavioral Health Technician's Job Description Revealed: "...Under the supervision of the Registered Nurse, provides direct patient care to patients as assigned...Maintains a safe and efficient working and treatment environment per facility policies and procedures...Act to preserve patient...safety...Document as required including patient observations/activity...."

Review of Registered Nurse's Job Description Revealed: "...Maintains a safe...environment per facility policies and procedures...Communicated effectively with the treatment team to ensure safe, quality care is provided to all patients...Provides supervision to...Behavioral Health Technicians...Assess patients for risk of danger to self or others...Perform ongoing observation of the patients and milieu...Intervene appropriately with patients experiencing a behavioral crisis situation, i.e...threatening behavior...."

Review of medical record revealed the following:

Pt #2 was admitted on [DATE], with a history of bipolarity with racing thoughts and psychotic features, cocaine abuse, depression and suicidal ideation. Patient had attempted to overdose prior to admission. The patient evidenced extreme dangerousness to self and to staff when they tried to intervene during her inappropriate behaviors during the hospitalization . On 8/10/12 Pt # 2 was transferred to the Acute Unit. The patient required one to one observation.

On 8/15/12, RN # 5 documented: "...Pt (patient) hitting head early in shift. Easily redirected. Took HS (hour of sleep) meds (medications) and sat out in day area. Assaulted by another pt. Small cut left cheek, under eye, near nose, Glasses broken. Pt given Tylenol 500 mg for discomfort, ice pack, Ativan 2 mg PO (by mouth) for anxiety. Pt continues to sit in day area reading /drawing...."

MD #2 wrote orders each day for the patient to remain on 1:1 when awake, including 8/13/12, through 8/17/12.

Review of hospital document titled Patient Observations for Patient # 2 for 8/15/12, revealed that the Patient #2 was on line of sight. The DON confirmed during an interview conducted on 9/18/12, that the documentation shows "...line of sight... "on 8/15/12. The DON also confirmed that the Physician #2's orders were written for 1:1 for observation on 8/13/12, 8/14/12 and 8/15/12. The DON also confirmed the night shift revealed Employee # 8 was assigned to Patient # 2 from 7 pm -11 pm.

Patient # 4 hit patient # 2 in the face and broke glasses. Patient # 2 was sent to the ER for facial X-rays due to this incident.

Review of the hospital document titled Patient Observation for Patient #2 for 8/15/12, revealed that Employee # 8 documented the following: "...8:00...angry, inappropriate hitting wall...8:15...receiving meds in room...8:30...angry, fighting verbally with pt (patient)...Struck in face by other pt, glasses broken...crying...8:45...staff talking to pt, sitting, quiet...9:00...sitting, quiet, pt calming down...."

Employee # 8 stated during an interview conducted on 9/18/12, that the order for 1 to 1 while awake meant the patient was to have someone close enough to keep an eye on them in the same room. He confirmed that at the time of the incident he was not in arms reach of the patient, and had his back to the patient. Employee # 8 confirmed that he witnessed Patient #2 having a verbal altercation with another patient prior to Patient # 2 being hit by Patient # 4.

Employee # 5 stated during an interview conducted on 9/19/12, that the order for 1 to 1 while awake meant the patient was to have supervision within arms length and in view at all times of the person who was assigned to do the 1 to 1. Employee # 5 stated the Employee # 8 was not in arms reach of the patient at the time of the incident, and had his back turned to Patient #2. Employee # 5 confirmed that she witnessed Patient #2 having a verbal altercation with another patient prior to Patient # 2 being hit by Patient # 4.

Employee # 10 stated during an interview conducted on 9/19/12, that the order 1 to 1 while awake meant the patient was to have supervision within arms length and in view at all times of the person who was assigned to do the 1 to 1. Employee # 10 stated the Employee # 8 was not in arms reach of the patient at the time of the incident, and had his back turned to Patient #2. Employee # 10 confirmed that she witnessed Patient #2 having a verbal altercation with another patient prior to Patient # 2 being hit by Patient # 4.

2. Patient #16:

The Facility did not have a Policy or procedure for Intake and Output available for surveyor review.

Review of Registered Nurse's Job Description Revealed: "...Review practitioner orders...Documentation for medical records and reports is timely...and in required format...Document as required ...."

Review of Patient # 16's medical record revealed Physician order dated 9/12/12 at 1630 : "...Start I and O (Intake and Output)...."

Review of Patient # 16's medical record revealed no documentation of Intake or Output for dates 9/12/12 through 9/20/12. There was no order to discontinue the Intake or Output.

Employees # 11 and 21 confirmed in interviews conducted on 9/20/12 that the medical record for Patient #16 did not contain documentation of recorded intake or output for the dates of 9/12/12 through 9/20/12. The employees also confirmed there was no order to discontinue the intake and output for Patient # 16.

Pt #3:

Review of hospital policy/procedure titled Patient Care: Laboratory Services/Critical Lab Reporting revealed: "...All patients are to receive accurate and timely completion of all lab procedures ordered by their Practitioner...Purpose: to ensure that all patients receive laboratory services as ordered and results are considered in all the patients' treatments...Procedures:...On receipt of a practitioner's order for laboratory procedures, Nursing will completely fill out the Lab Requisition...Notify laboratory of all routine and stat procedures, which require a courier to pick up specimens for transport to the lab...All orders must be signed off as 'noted' after double-checking that the transcription steps are accurate and complete...Laboratory results will be received via fax on the nursing units. The Nurse is to review and sign off on report...."

Review of Pt #3's medical record revealed:

An RN wrote physician admission telephone orders on 3/22/12 at 1210: "...Diagnostic/Labs...CBC (Complete Blood Count) with differential, CMP 12 (Comprehensive Metabolic Panel), RPR (Rapid Plasma Reagin), TSH (Thyroid Stimulating Hormone), HgA1C (a test for diabetes), Lipid Profile, UA (Urinalysis), Urine Toxicology, Urine HCG (Human Chorionic Gonadotropin) and Tuberculin Skin Test...."

The Admission Orders form did not contain documentation that a nurse "noted" the orders. An RN documented: "...3/22/12 2345- 24(hr) Chart (check with) MAR (Medication Administration Record)...."

On 3/25/12, a physician wrote an order: "...Labs to chart please...."

On 9/18/12, the surveyor noted that the medical record did not contain admission laboratory results. ordered on [DATE]. Employee #28 contacted the lab on 9/18/12 and confirmed that the lab never received the requisition for the diagnostic lab tests ordered on [DATE]. She confirmed that nursing staff is responsible for completing the requisition and placing it on the unit for the phlebotomist prior to drawing the specimen.

Pt #3 was discharged Against Medical Advice on 3/26/12.

3. Review of hospital policy/procedure titled Nursing Staff Allocation revealed: "...The care of all patients will be prescribed, delegated and coordinated by an RN, even though the care itself may be provided by a non-RN.

Review of the patient assignment sheet for the Youth Unit, Day Shift on 9/20/12, revealed that an LPN was assigned to 9 of the 19 patients. The patients were listed consecutively in order of room numbers on the assignment sheet.

Employee #27 confirmed that the RN and LPN divide the patients by room numbers and have their separate patient assignments. S/he confirmed that the LPN's assignments were not delegated by the RN and that when the LPN is not working on the unit, an RN has the same patients. S/he confirmed that the RN is not assigned to the LPN's patients and does not assess the LPN's patients or document an RN assessment on the charts of the LPN's patients unless an incident occurs which requires the RN's attention.

Cross reference Tag 0397 for information regarding assignment sheets which contain RN's names with no patients' names listed as assigned to the RN/s.

The DON confirmed during interview conducted on 9/21/12, that the assignment sheets did not reflect which RN was responsible for the supervision and evaluation of the care of the patients.

4. Review of policy/procedure titled Re-assessment of Patient Needs revealed: "...Re-assessments provide the mechanism for determining ongoing treatment needs of the patient. Re-assessments also serve as a measurement tool to determine progress in treatment, and/or patient response to a specific treatment. Re-assessments are conducted as required, or more frequently if clinically indicated...Procedure:...Documentation of re-assessments is evident in the patient record...."

Review of policy/procedure titled Clinical-Patient Care: Medical Consultation revealed: "...The consulting medical practitioner is to be contacted for consultation when a patient presents with a medical condition beyond the scope of psychiatric and nursing care at (hospital)...Purpose: To ensure medical care is provided timely and appropriately...The nurse is to contact the attending psychiatrist when he/she recognizes a significant, unexplained change of the patient's medical condition...Upon determination that a non-emergent medical condition warrants medical consultation, the nurse is to contact the medical practitioner immediately for consultation and/or orders...The guidelines for determining non-emergent medical conditions include, but are not limited to:...unexplained pulse above 108...Significant decrease or refusal to eat or drink in excess of 24 hours...Significant unexplained change or absence of Urination that exceeds 24 hours...."

Review of medical record revealed:

Patient # 1 was admitted on [DATE] with depression, weakness of arms, possible [DIAGNOSES REDACTED], decreased appetite over 48 hours, and possible urinary tract infection.

The attending psychiatrist wrote a progress note on 5/10/12 at 1055: "...Pt remains unable to voluntarily move body (at) all times...."

The attending psychiatrist wrote an order on 5/11/12 at 0900: "...(name of contracted medical physician group) consult for (decreased) Phosphorous...."

The attending psychiatrist completed a progress note on 5/11/12 at 1615: "...Pt found lying on floor Unable to perform ADL's (Activities of Daily Living)...muscle fxn (function) changes moment to moment but pt consistently 'unable' to move arms. (increased) abilities obvious when pt is (not) paying attn...."

Employee #6 documented on 5/12/12 at 0142: "...Pt unwilling to assist us in lifting her head up. When pillow moved from under her head she didn't help to lift her head up. arms are limp to sides (at) beginning of shift. Now pt has moved off of back & turning from side to side...."

Employee #11 documented on 5/12/12 at 1250: "...Pt continues to refuse to help staff assist her. Pt requires assistance to toilet, eat, & ambulate. Pt sat on floor in bathroom staff was unable to lift her then layed (sic) on floor. Pt moved to bed (with) hoyer lift...Pt's parents called and are concerned, would like to talk with psychiatrist about moving pt to medical facility...."

Employee #6 documented on 5/13/12 at 0247: "...Pt (with) foul smell to peri area & discharge...(no) urine in briefs...."

Employee # 6 documented on 05/13/12 at 0430: "...no urine, encouraged fluids pt is refusing. offered (every) 4 (hours)...She able (sic) to drink out of straw initially then she started to refuses (sic) to drink out of straw. Pulse...132 Bpm (Beats per minute). fluids encouraged. Will recheck (at) 0500. No s/s (signs/symptoms) SOB (Shortness of Breath) or pain...."

The graphic form contained entries on 5/13/12 at 0500: "...(temperature) 100...(pulse) 128...(respirations) 16...(Blood Pressure) 127/78...." The spaces designated for Intake and/or Output were blank. The medical record contained no additional nursing progress note or assessment at 0500.

Employee # 14 documented on 5/13/12 at 1200: "...patient has not voided. Refused fluids and meals...Asked staff to blow nose for her. Total care. Refusing to or appears unable to move. Yelling out. Patient is acting as though she is a quadriplegic. Will continue to monitor closely...."

The graphic form did not contain vital sign entries on 5/13/12 after 0530. Nursing did not document intake and/or output from 5/11/12 1500-2330 shift through 5/13/12. The last recorded intake of "Ensure" was 5/12/12 at 0800. The patient was transferred to an emergency room on [DATE] at 1630.

The medical record did not contain documentation that the psychiatrist was notified of the progressive, significant, unexplained changes in the patient's medical condition.

The psychiatrist recorded a "late entry" progress note on 5/13/12 at 1700: "...Nursing staff reported no fluid intake in 36 (hrs) and no urine output in 24 (hrs). Pt appears dehydrated must send ER for evaluation of Dehydration NOW...Impression: Acute Dehydration...."

Nursing staff who were interviewed could not recall specific information regarding attempts to contact the psychiatrist.

On 09/19/12 at 0820, the DON confirmed that the medical record did not contain documentation that nursing contacted the psychiatrist regarding the progressive changes in the patient's condition.

5. Review of hospital policy/procedure titled Re-assessment of Patient Needs revealed: "...Re-assessments provide the mechanism for determining ongoing treatment needs of the patient. Re-assessments also serve as a measurement tool to determine progress in treatment, and/or patient response to a specific treatment. Re-assessments are conducted as required, or more frequently if clinically indicated...Documentation of re-assessments is evident in the patient record...."

Review of medical records revealed:

Pt #19

An RN recorded a physician's telephone order on 8/9/12 at 1625: "...Send pt to (name of hospital) for (complaint of ) chest pain/(history) of blood clots in lungs...."

Pt #19 returned to the hospital after the ER visit. The medical record did not contain the date and time of the patient's return to the hospital, or a nursing re-assessment.

Pt #23

A physician recorded an order on 8/29/12 at 0750: "...Send to ER for abnormal EKG (Electrocardiogram) & unstable vital signs...."

Pt #23 returned to the hospital after the ER visit. The medical record did not contain the date and time of the patient's return to the hospital, or a nursing re-assessment.

The Medical Director confirmed during an interview conducted on 9/21/12, that the medical records did not contain the required assessments or documentation.

6. Facility Policies titled "Levels of Observation" revealed: "...All patients will be closely observed in compliance with physician orders and prescribed protocols...."

Review of the hospital policy/procedure titled "Re-Assessment of Patient Needs" revealed: "...Re-assessments are conducted as required, or more frequently if clinically indicated...If information from the re-assessment renders information that has potential to immediately affect patient safety...the attending practitioner is consulted with immediately...Documentation of consult and subsequent practitioner order is noted in the patient chart...The treatment team is advised of any treatment information gained from re-assessment that may compromise patient safety...The treatment team...will revise the treatment plan as indicated from re-assessment information...."

Facility Policies titled "Levels of Observation " dated 7/21/11 revealed: "...All patients will be closely observed in compliance with physician orders and prescribed protocols...The physician will order one of three levels of observation at time of admission and as the patient's condition warrants a change: Actively attempting to harm self or others...Demonstrated unpredictable behavior..Patient failed LOS (Line of Sight)...unsafe at lower level of care...."

Review of Behavioral Health Technician's Job Description revealed: "...Maintains a safe and efficient working and treatment environment per facility policies and procedures...ensure safe, quality care is provided to all patients...Observe whether specialized services may be needed and communicate to the Charge Nurse/RN...Act to preserve patient...safety...."

Review of Registered Nurse's Job Description Revealed: "...Maintains a safe...environment per facility policies and procedures...Communicated effectively with the treatment team to ensure safe, quality care is provided to all patients...Provides supervision to...Behavioral Health Technicians...Complete nursing reassessments per policy...at any time a change is status is observed or reported by team members...Identify the need for additional assessments...Communicate the identified need to the attending practitioner or the consultant, per policy...Assess patients for risk of danger to self or others...ongoing through hospitalization ...communicate concerns to the attending practitioner and team members through verbal and written methods...Perform ongoing observation of the patients and milieu...Intervene appropriately with patients experiencing a behavioral crisis situation, i.e...threatening behavior...."

Patient # 4 hit patient # 2 in the face and breaking the glasses. Patient # 2 was sent to the Emergency Department for facial X-rays due to this incident. Patient # 4 was not placed on more restrictive level of observation after the incident.

Employee # 5 confirmed in an interview conducted on 9/19/12, that the facility did not follow their Policy and Procedure as evidenced by not placing Patient #4 on a more restrictive level of observation after the incident.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on facility policy and procedures, facility documents and interview with staff, it was determined the hospital failed to ensure that the nursing staff develop, and keep current a nursing treatment plan for each patient as evidenced by:

1. failing to require current treatment plans for 2 of 2 patients who were involved in assaultive behavior (Patients #2 and 4); and

2. failing to initiate and keep current a care plan which addressed a patient's physical needs for nutrition, hydration and elimination for 1 of 1 patient who required transfer to a medical facility (Pt #1).

Findings:

1. Facility Policy titled "Levels of Observation" revealed: "...The Interdisciplinary Treatment Plan will include or be revised to include the 1:1 observation...The RN will assess the need for continued 1:1 observation every shift and document the assessment in the medical record...."

Facility Policy titled "USE of 1 TO 1's or RESTRICTED ROOMMATE STATUS" revealed: "...If a 1 to 1 observation level...is implemented...The use of...1 to 1 is discussed in every treatment team staffing and reviewed for ongoing need...The medical record progress notes indicate the use of 1 to 1...."

Review of the hospital policy/procedure titled "Treatment Planning" revealed: "...Each patient...shall have a written, individualized treatment plan...The Treatment Plan shall be reviewed and updated as frequently as clinically indicated by the patients anticipated length of stay and treatment issues...."

Patient # 4 hit patient # 2 in the face and breaking the glasses. Patient # 2 was sent to the Emergency Department for facial X-rays due to this incident.

Employee # 5 confirmed in an interview conducted on 9/19/12, that this incident was not included on Patient#4's treatment plan as per the facility policy and procedure. Employee # 5 also confirmed that the 1:1 for Patient #2 was not documented in the treatment plan as per the facility policy and procedure.

2. Review of facility policy/procedure titled "Patient Care: Treatment Planning" revealed: "...The RN will initiate the treatment plan. This initial plan shall include high risk and critical medical problems and appropriate physician and nursing intervention...."

Review of medical record revealed:

Pt #1's medical record contained a form titled Nursing Assessment, Nutritional Screen: "...A yes response will initiate a Nutrition Consult by RD (Registered Dietician)...."

An RN circled "Yes" by the statement: "...Decreased oral intake, less than 50% of usual intake...."

The space designated for the RN to indicate that a consult request was completed was blank.

Cross reference Tag 395, #4 for information regarding Pt#1's intake and output and other physical care needs.

The Initial Treatment Plan, initiated by Employee # 17, on 05/9/12, did not address the patient's decreased oral intake noted at the time of her admission. Pt #1's treatment plan was not revised to address the patient's intake and output. This was confirmed by the DON on 09/19/12 at 0820.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on review of hospital policies/procedures, hospital documents and interviews, it was determined that the hospital failed to require that a registered nurse assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs.

Findings include:

Review of hospital policy/procedure titled Nursing Staff Allocation revealed: "...Assessment of patients takes place prior to assignment of staff...Staff capability is matched to patient needs...patient care responsibilities are assigned to nursing staff based on four general considerations including: the patient acuity, environment in which nursing care is provided, staff competency, and supervision required by and available to each nursing staff member assigned responsibility...Ensuring that staff only care for patients they are competent to care for...Patients are classified to identify the intensity of nursing care and level of observation required by the individual patient/family to aid in decision making regarding staffing and patient care assignment...."

Review of hospital policy/procedure titled Nursing; Acuity System revealed: "...The RN staff will proactively assess the acuity of each patient identifying potential and actual risks and care needs for each patient. these assessments will assist in identifying the appropriate number and skill mix of assigned staff...Purpose...To provide a process for the nursing department staff to assist in evaluating the optimal nurse to patient ratio and level of care to ensure safe, quality patient care...Procedure: The acuity patient work sheets will be completed on both the day and night shift. The RN caring for the patient will complete the Nursing Care Activities Worksheet...The acuity report will assist in determining the staff scheduled for the next shift. The report must be completed 3 hours prior to the end of the shift so appropriate staffing needs for the next shift can be addressed...."

Review of the Nursing Care Acuity Tool Shift: Day or Night...Unit Adult...Acute...Youth revealed that the RN completing the tool circles the applicable unit and shift. The tool contains categories of Nursing Care Activities and Patient Care Needs. Six categories are utilized for BHT "points" and 5 categories are utilized for RN "points."

Employee #27 confirmed during interview conducted on 9/20/12, that the Acuity Tool is utilized to record patient acuity and related patient care needs. S/he confirmed that the night shift RN's record patient care needs and submit the tool to the Nursing Service Dept/Staffing Office 3 hours prior to the end of the night shift. The shifts are twelve hours: 0700-1900 and 1900-0700. The Acuity Tool completed by the night shift is not available or utilized for making patient assignments on the day shift. The nurses on the day shift of the Youth Unit divide the patients in half by room number. Assignments are not based on patient acuity/care needs for the Behavioral Health Technicians' (BHT) assignments. The Youth Unit is staffed with 2 RN's from 0700-2300 and 1 RN from 2300-0700. S/he was unaware of the means by which the acuity scores were used to determine the number of staff required.

Employee #31 confirmed during interview conducted on 9/20/12, that the RN's patient assignments on the Adult Unit are made by room number, not patient acuity. S/he also confirmed that the BHT's make their own assignments by dividing the patients' 15" observation sheets. Employee #31 also stated that the categories included on the Acuity Tool for nurse responsibilities do not include all of the patient care activities that a nurse is responsible to deliver. The tool does not reflect pertinent aspects of patients' conditions which impact patients' care needs. S/he also stated that the Adult Unit is staffed with 2 RN's from 0700-2300 and 1 RN from 2300-0700. S/he was unaware of the means by which the acuity scores were used to determine the number of staff required.

Employee #11 confirmed during interview conducted on 9/20/12, that there is 1 RN scheduled on the Acute Adult Unit and therefore is assigned to all of the patients. S/he confirmed that the assessment of patient acuity/care needs is not used in making patient assignments. S/he stated that the Unit has never been staffed with more than 1 RN. S/he confirmed that the BHT's determine their patient assignments by dividing the patients in half. S/he was unaware of the means by which the acuity scores were used to determine number of staff required.

The DON confirmed during an interview conducted on 9/21/12 that the Nursing Care Acuity Tool is the tool which is utilized to assess and record the patient's care needs to be used for determining staffing and patient assignments. She also confirmed that the tool requires revision since the categories of nursing care activities and patient care requirements do not accurately reflect the care needs of the hospital's patient population.

Review of the following patient assignment sheets revealed:

9/18/12, Day Shift, Acute Adult Unit: No patient names or room numbers were written as assignments for
the RN, or two BHT's;
9/18/12, Night Shift, Adult Unit: No patient names or room numbers were written as assignments for the 2
RN's or 3 BHT's;
9/17/12, Night Shift, Adult Unit: No patient names or room numbers were written as assignments for the 2
RN's;
9/17/12, Day Shift, Adult Unit: Consecutive room numbers were written as assignments for the
2 RN's and the word "All" was written as the assignment for the 3 BHT's. The assignment sheet did not contain specific patients' names;
9/17/12, Day Shift, Acute Adult Unit: "All charts" was written as the assignment for the 1 RN and no
patient names or room numbers were written as assignments for the 2 BHT's;
9/17/12, Night Shift, Youth Unit: "Ca...(Name)'s kids" was written as the assignment for 1 BHT and "Ch...(Name)'s kids" was written as the assignment for the 2nd BHT. (The RN's names were Ca (Name) and Ch (Name));
9/17/12, Night Shift, Acute Adult Unit: the word "All" was written as the assignment for the RN and 2
BHT's;
9/16/12, Night Shift, Adult Unit: Consecutive room numbers were written as the assignments for the 2
RN's and 2 BHT's; the assignment for the "float" BHT was blank; and
9/16/12, Day Shift, Adult Unit: Consecutive room numbers were written as the assignments for the 2 RN's
and 3 BHT's.

The DON confirmed during an interview conducted on 9/21/12, that patient care assignments are not based on assessment of the patient's needs and that many of the assignment sheets listed above do not contain patient names or room numbers.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on review of hospital policies/procedures, medical records, observation and staff interviews, it was determined the hospital failed to follow accepted standards of practice for medication administration requiring that medications be administered:

1.) in accordance with proper infection control practices as evidenced by 11 of 11 patients (patients #15, 16, 17, 25, 34-40); and

2.) in accordance with a complete medication order as evidenced by 3 of 3 patients (Pt's # 22, 23 and 33).

Findings include:

The hospital policy titled "Medication Administration" revealed: "The administration of medications is by or under the supervision of appropriately licensed personnel and in accordance with hospital policy, pertinent laws, scopes of practice and governmental rules and regulations...The nurse assigned to medication administration insures that proper infection control activities are maintained; hands are washed prior to handling medications...and appropriate aseptic techniques are used when handling medications...."

1.) The hospital policy titled "Hand Hygiene" revealed: "...To prevent cross contamination between the patient, personnel...thus reducing the risk of infection...Waterless antiseptic agents are available for use in between patient contacts...patient care tasks...Decontaminate hands before having direct contact with patients...Decontaminate hands after contact with a patient's intact skin...."

Direct observation of medication administration on 9/20/12 at 0845, revealed Employee #11 touching patient # 16's armband and then the medications in the souffle cup. She then touched the "MAR" (Medication Administration Record). No hand washing or sanitizing was observed.

Direct observation of medication administration on 9/20/12 at 0855, revealed Employee #11 touching patient # 25's armband and then the medications in the souffle cup. She then touched the MAR. No hand washing or sanitizing was observed.

Direct observation of medication administration on 9/20/12 at 0856 revealed Employee #11 touching patient #34's armband and then the medications in the souffle cup. She then touched the MAR. No hand washing or sanitizing was observed.

Direct observation of medication administration on 9/20/12 at 0900 revealed Employee #11 touching patient #35 's armband and then the medications in the souffle cup. Employee #11 was also observed in administering the Nicotine Patch to Patient # 35's left arm and removing the old Nicotine patch. She then touched the MAR. No hand washing or sanitizing was observed.

Direct observation of medication administration on 9/20/12 at 0903 revealed Employee #11 touching patient #36 's armband and then the medications in the souffle cup. She then touched the MAR. No hand washing or sanitizing was observed.

Direct observation of medication administration on 9/20/12 at 0910 revealed Employee #11 touching patient # 38's armband and then the medications in the souffle cup. She then touched the MAR. No hand washing or sanitizing was observed.

Direct observation of medication administration on 9/20/12 at 0916 revealed Employee #11 touching patient # 37's armband and then the medications in the souffle cup. She then touched the MAR. No hand washing or sanitizing was observed.

Direct observation of medication administration on 9/20/12 at 0918 revealed Employee #11 touching patient #39 's armband and then the medications in the souffle cup. Employee #11 was also observed in administering the Nicotine Patch to Patient # 39's arm. She then touched the MAR. No hand washing or sanitizing was observed.

Direct observation of medication administration on 9/20/12 at 0922 revealed Employee #11 touching patient # 17's armband. Employee #11 was also observed in administering the Nicotine Patch to Patient # 17's arm. She then touched the MAR. No hand washing or sanitizing was observed.

Direct observation of medication administration on 9/20/12 at 0926 revealed Employee #11 touching patient # 15's armband and then the medications in the souffle cup. She then touched the MAR. No hand washing or sanitizing was observed.

Direct observation of medication administration on 9/20/12 at 0929 revealed Employee #11 touching patient # 40's armband and then the medications in the souffle cup. She then touched the MAR. No hand washing or sanitizing was observed.

Employee # 11 confirmed during an interview conducted on 09/20/12, that she did not wash or sanitize her hands between patients.

2.) Cross Reference tag 0049 # 1 and 3 for further information related to incomplete medication orders on the CINA protocol for Narcotic withdrawal.

Employee # 25 confirmed in an interview on 9/20/12, that the CINA assessment sheets did not have numbers on the sheet next to the symptoms. Staff did not document on the MAR the reason the patient was receiving the medication. The medication orders were incomplete as written.