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.

AURORA LAS ENCINAS HOSPITAL 2900 E DEL MAR BLVD PASADENA, CA June 28, 2013
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews, the facility failed to ensure the physicians were accountable for the quality of care provided to 5 of 30 sampled patients (Patients 1, 2, 14, 23 and 29). The physician failed to sign the patients received risk assessments tools and the physician's orders within 48 hours per facility's policy.

Findings:

a. During a review of the clinical record for Patient 23, the face sheet indicated the patient was admitted to the facility on on [DATE] with diagnosis of bipolar disorder (condition in which a person has periods of depression and periods of being extremely happy).

A review of the Risk Assessment Tool - Locked Unit dated June 23, 2013 indicated Patient 23 had mild anxiety level for all three shifts and that the psychosis (loss of contact with reality) had decreased. However, further review of the risk assessment tool on June 26, 2013 (three days later) indicated the daily review by attending clinician was not signed by the physician and was not dated or timed. Also a review of the risk assessment tools dated June 24 and 25 were not signed by the physician.

b. A review of the facesheet indicated Patient 29 was admitted to the facility on on [DATE] with diagnosis of bipolar disorder.

A review of the Risk Assessment Tool - Locked Unit dated June 21, 2013 indicated Patient 29 had moderate anxiety level and that the psychosis had not changed. However, further review of the risk assessment tool on June 26, 2013 (three days later) indicated the daily review by attending clinician was not signed by the physician and was not dated or timed.

During an interview with the director of nursing (DON) on June 26, 2013 at 10:35 a.m., she stated the physician was to sign the risk assessment tool as this was very important.

A review of the facility Board of Directors meeting minutes dated March 28, 2013 indicated the risk assessment tool - locked unit form, was presented at the meeting. However, the meeting minutes was approved without action.

The facility policy and procedure titled "RN Assessment Form/Risk Assessment Form" dated March 2003 indicated the night shift would initiate the appropriate daily Risk Assessment Form to be completed by each shift by the registered nurse (RN) working on the opened and locked units. However; the policy failed to include a review and completion by the physician.

During an interview with the DON on June 26, 2013 at 2:35 p.m., she stated if the policy did not indicate the physician reviewing and signing the risk assessment form, she would have to inform the medical executive committee, because it should be included in the facility's policy.






c. A review of Patient 14's record indicated:

1. The physician's telephone order dated September 10, 2011 at 7:20 p.m., indicated to admit patient to Cherokee Unit. The physician signed but did not date and time the order.
2. A review of the physician's telephone order dated September 11, 2011, at 8:20 p.m., indicated to administer Motrin 600 mg by mouth (for pain relief) every 6 hours as needed. The physician signed but did not date and time the order.
3. The physician's telephone order dated September 16, 2011 at 3:40 p.m., indicated to rescind transportation with escort order. The physician signed but did not date and time the order.
4. A review of the physician's telephone order dated September 19, 2011, at 11:15 a.m., indicated to arrange transportation with female escort to Court 95 on September 20, 2011 at 0800. The physician signed but did not date and time the order.





d. The clinical record for Patient 1 was reviewed on June 25, 2013, at 11:10 a.m. The Physician's Order dated June 14, 2013, at 1:45 p.m. indicated a telephone order to transfer patient to "Mariah East unit". The ordering physician did not sign the order until June 19, 2013 (five days later). The signature was dated, but not timed.

e. The clinical record for Patient 2 was reviewed on June 25, 2013, at 2:40 p.m. The Physician's Order dated June 20, 2013, at 2 p.m. indicated a telephone order to order a cane for the patient was not signed by the ordering physician until June 24, 2013, at 7:30 a.m.

During the interview with the director of nursing (DON) on June 28, 2013, at 1:15 p.m., the DON stated, "What can I say? The doctor did not sign."

The facility policy titled "Medications" reviewed/revised on July 2012 indicated "C. Telephone Orders ...The prescriber shall countersign the order within (48) hours." "This shall also apply to any telephone orders whether for medication or not."
VIOLATION: CONTRACTED SERVICES Tag No: A0083
Based on record review and interview, the facility's governing body failed to ensure that a contractor of services complied with the conditions of participation and standards for the contracted services. The dietary consultant contract had not been renewed since 2008.

Findings:

During a review of the contracted services on June 27, 2013, the nutritional services agreement for the dietary consultant was reviewed. The agreement was entered into, effective the first day of October 2008. Further review of the contract indicated the term of the agreement was for a period of one year and that it would not automatically renew at the end of the first year.

During an interview with the chief executive officer (CEO) on June 27, 2013 at 3:10 p.m., he stated usually the contracts would renew every 1 - 2 years. The CEO stated the agreement for the dietary consultant was an old one and he would look for a more updated agreement.

During an interview with the CEO on June 28, 2013 at 8:50 a.m., he stated he did not find an updated contract agreement for the dietary consultant.

A review of the Quality Assessment and Performance Improvement committee minutes dated January 2013, indicated there was no assessment of the contracted services and no implementation to improve the contracted activities.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the facility staff failed to maintain documentation that Patient 8 was furnished with patient's rights information related to the hospital's policy on smoking, telephone, valuable, visiting hours and discharge process.

Findings:

On June 25, 2013, at 8:50 a.m., during the tour of the 2 East unit with charge nurse ( RN 3), Patient 8 was observed in bed appeared to be asleep.

According to the facesheet, Patient 8 was admitted to the facility on on [DATE], at 4:50 p.m., for continuous dependent use of opioid.

A review of the Patient Education/ Orientation To hospitalization dated June 23, 2013 at 6 p.m., indicated a staff member started the process. However, the other topics such as unit tour/orientation, hospital tour, telephones, policy on smoking, valuable, visiting hours, discharge process, etc as stipulated on the form did not have written evidence to indicate it was done.

On June 26, 2013, at 1 :20 p.m., during an interview with the DON she stated areas/topics that was written in the Patient Education/Orientation To hospitalization should be marked by the staff who provided such orientation to the patient.

A review of the facility's policy on Patient Orientation indicated upon admission to the hospital, a member of the nursing staff will meet with each patient individually for orientation. This process would include the following: completion of orientation database, checking of personal belongings, assignment to room, activities, groups and schedule, tour of unit and grounds, review of unit and pragmatic guidelines, a copy of unit handbook and the patient schedule would be given and if applicable attendance at Patient Orientation Group.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interview, the facility failed to ensure 8 of 30 sampled patients (Patients 1, 2, 3, 4, 10, 11, 12 and 13) had a properly executed informed consent for the use of anti-psychotic, anti-convulsant, and mood altering medications.

Findings:

a. The clinical record for Patient 1 was reviewed on June 25, 2013, at 11:10 a.m. The "Antipsychotic/Anti-manic Adult Medication Information & Consent" form for Seroquel was signed by Patient 1. However, the line for the date and time of when Patient 1 signed the consent for the Seroquel use was left blank.

The "Antipsychotic/Anti-manic Adult Medication Information & Consent" form for Saphris was signed by Patient 1. However, the line for the date and time of when Patient 1 signed the consent for the Saphris use was left blank.

The "Antidepressants Adult Medication Information & Consent" form for Wellbutrin XL was signed by Patient 1. However, the line for the date and time of when Patient 1 signed the consent for the Wellbutrin XL use was left blank.

b. The clinical record for Patient 2 was reviewed on June 25, 2013, at 2:20 p.m. The Antipsychotic/Anti-manic Adult Medication Information & Consent form for Seroquel was signed by Patient 2. However, the line for the date and time of when Patient 2 signed the consent for Seroquel was left blank.

c. The clinical record for Patient 3 was reviewed on June 26, 2013, at 9:10 a.m. The Antipsychotic/Anti-manic Adult Medication Information & Consent form for Seroquel was signed by Patient 3. However, the line for the date and time of when Patient 3 signed the consent for Seroquel was left blank.

d. The clinical record for Patient 4 was reviewed on June 25, 2013, at 9:55 a.m. The Anticonvulsants/Mood Stabilizers Adult Medication Information & Consent form for Neurontin was signed by Patient 4. However, the line for the date and time of when Patient 4 signed the consent for Neurontin was left blank.

During the interview with the director of nursing (DON) on June 28, 2013, at 1:15 p.m., the DON reviewed the medication consent form for Patients 1, 2, 3, and 4. The DON stated "the patients did not date and time. If it was me, I would put date and time. The doctor at least should. Everything you do should have date and time."

The facility policy titled "Medications Which Require Consent" reviewed/revised May 2012 indicated "Prior to administration of a psychotropic medication requiring informed consent, the physician will review with the patient the appropriate consent form and both will sign the form." The policy failed to include the need for the signees to write the date and time the informed consent was signed.





e. Patient 10 was admitted to the facility on on [DATE], at 9:40 a.m., for
recurrent severe major depressive disorder without psychotic features.

A review of the Antipsychotic/Anti-Manic Adult Medication Information and Consent for medications Seroquel 50 - 800 mg daily indicated a patient signature but no date and time.

A review of the Anticonvulsants/Mood Stabilizers Adult Medication Information and Consent for Lithium 600-800 mg/day and Neurontin 300-3600 mg/day indicated a patient signature but no date and time.

A review of the Antidepressants Adult Medication Information and Consent for Remeron 15-45 mg/day indicated a patient signature but no date and time.

The Medication Administration Record (MAR) dated June 24, 2013, indicated the first dose of medications: Seroquel 600 mg; Lithium 600 mg; Neurontin 600 mg and Remeron 45 mg were administered.

f. Patient 11 was admitted to the facility on on [DATE] at 9:36 p.m., for Schizo-Affective Schizophrenia unspecified state.

A review of the Antipsychotic/Anti-Manic Adult Medication Information and Consent for Seroquel 50-800 mg/day indicated a physician signature and date but no time.

According to the MAR dated June 12, 2013, at 10 p.m., the first dose of Seroquel 100 mg was administered.

g. Patient 12 was admitted to the facility on on [DATE] at 2 p.m., for bipolar disorder, alcohol and cocaine dependent use.

A review of the Anticonvulsants/Mood Stabilizers Adult Medication Information and Consent for medication Lamictal 25-400 mg/day indicated a patient signature but no date and time. The physician signed and dated but there was no time when the consent was obtained.

A review of the Anticonvulsants/Mood Stabilizers Adult Medication Information and Consent for medication Neurontin 300-3600 mg/day failed to show the documentation to indicate the time the physician obtained the consent.

According to the MAR dated June 23, 2013, at 5 p.m., the first dose of Neurontin 300 mg was administered.

h. Patient 13 was admitted to the facility on on [DATE], at 5:28 p.m., for bipolar disorder, alcohol/opoid type drug dependent and alcohol withdrawal. The patient was discharged on [DATE].

A review of the Anticonvulsants/Mood Stabilizers Adult Medication Information and Consent for medication Neurontin 300-3600 mg/day indicated a patient signature but no date and time. The physician signed consent on October 24, 2011 but did not include the time.

A review of the Antipsychotic/Anti-Manic Adult Medication Information and Consent for medication Seroquel 50-800 mg/day indicated a patient signature but no date and time. The physician signed on 10/24/11 but did not include the time.

The MAR dated October 23, 2011, at 9 p.m., indicated medications Neurontin 300 mg and Seroquel 200 mg were first administered.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**




Based on record review and staff interview, the facility failed to ensure a patient had the right to be free from all forms of abuse or harassment. On October 29, 2011, Patient 13 had expressed that on October 28, 2011, the facility's mental health worker 1 (MHW 1 - Patient 13's ex-boyfriend) had sent six (6) text messages to him which were sexually graphic involving photographic and offer to perform oral sex. This incident was not reported to the Department of Public Health as required.

Findings:

A review of Patient 13's clinical record indicated he was admitted to the facility on on [DATE], at 5:28 p.m., for bipolar disorder (condition in which a person has periods of depression and periods of being extremely happy), combinations of opioid type drug with any other drug and alcohol dependency. On December 2, 2011 at 2 p.m., the patient was discharged .

A review of the facility's report revealed on October 29, 2011, at 3:30 p.m., during 1:1 therapy session, Patient 13 had expressed that on October 28, 2011, mental health worker 1 had sent six (6) text messages which were sexually graphic involving photographic and offer to perform oral sex.

The report indicated as soon as the facility became aware, the investigation was started. The report indicated the patient's right representative met with the patient. The Police Department in the local area was called, met with the patient and left without filing the case. The Mental Health Department was called and the incident was reported.

On June 28, 2013, at 8 a.m., during an interview, the director of risk, quality and utilization review stated that she did not report the incident to the Department of Public Health because she already reported it to the Department of Mental Health.

The facility's policy on Reporting Suspected Inpatient Sexual Activity/ Abuse indicated all appropriate agencies that, in accordance with licensure, will be notified by telephone and in writing by the director of clinical services or his/her designee.

A review of the personnel file for MHW 1 indicated the employee was hired at the facility on March 9, 2009 as mental health worker (MHW). On November 10, 2011, MHW 1 was terminated for violation of company policy.

A review of the Employee Handbook indicated under Ethics..., (3) The Company is proud of the reputation which its employee have developed the courtesy, friendliness and quality patient care, employees who do not conduct themselves in such a manner as to maintain this reputation may be subject to strict disciplinary measures. (4) The ability of the patient to rely on hospital employees as concerned and caring individuals who remain objective in their guidance is one of the tenets of a safe, therapeutic relationship. When employees interact with patients in a personal manner, the relationship may no longer be objectively safe and therapeutic. Thus, the Company enforces a policy of non-fraternalization with current and former patients. While there are conceivably exceptions, the general expectation was that employees are not to establish a personal relation with current or former patient. (5) The Company recognizes that there are times when peers, friends, families, or neighbors of employees seek hospitalization for emotional well-being. In these circumstances, it will be the policy of the Company that the relationship remain of the nature it was prior to admission, assuming this was in the patient's best therapeutic interest. More specifically, it was Company's policy that employees shall not be allowed to be involved in the treatment process of a peer, friend, family member or neighbor and if an employee chooses to become personally involved with a patient (or former patient), the employee will be expected to resign his or her position with the Company immediately.

Review of the Staff Assignment revealed MHW 1 worked in 2 East/D unit on October 27 and 28, 2011, and was not scheduled to work up to the time the employee was terminated.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on observations, interviews, and record reviews, the facility failed to ensure there were adequate numbers of licensed staff to provide nursing care to all patients as needed. During the review of the staff assignments of day, evening, and night shifts from June 12 to June 26, 2013 revealed inadequate number of licensed staff members in five different units as per the facility staffing policy of one licensed nurse per six patients.
In Unit 1 South, there were 8 days (June 14, 20, 21, 22, 23, 24, 25, and 26, 2013) that the facility failed to provide 1 licensed nurse to 6 patients.
In Unit 2 East/CDW, there were 11 days (June 14-26, 2013) that the facility to provide 1 licensed nurse to 6 patients.
In Unit 2 West, there were 12 days (June 12, 14, 15, 16, 17, 18, 19, 21, 22, 23, 24, 26, 2013) that the facility failed to provide 1 licensed nurse to 6 patients.
In Unit Mariah East and West, there were 15 days (June 12-26, 2013) that the facility failed to provide 1 licensed nurse to 6 patients.
This deficient had the potential to cause the facility's inability to provide the nursing assessment and patient care needs.

Findings:

a. During the tour of Unit First Floor on June 25, 2013, at 8:25 a.m., there was one Registered Nurse (RN), a Licensed Psychiatric Technician (LPT), and one Mental Health Worker (MHW) observed working in the unit. Ten patients were observed in the unit. The "1st Floor Shift Report" indicated there were 10 patients in the unit at the time of observation. The "Patient Assignment for the Shift" dated June 25, 2013 day shift indicated there was one RN, one LPT, and 1 MHW working in the unit for that shift.

During the tour of Unit 1 South on June 25, 2013, at 8:50 a.m., there was one RN and three MHWs observed working in the unit. Twelve patients were observed in the unit. The "1 South Shift Report" indicated there were 12 patients in the unit at the time of observation. The Patient Assignment for Shift dated June 25, 2013 day shift indicated there were one RN and three MHWs working in the unit for that shift.

During the review of the staffing assignment for 1 South from June 12, 2013 to June 26, 2013, the "Staff Assignment" and the "Daily Acuity Report" indicated the following:

1. On June 14, 2013, the night shift had a census of 8, there was 1 licensed nursing staff working in the unit. The census required 2 licensed nurses. The facility failed to provide a Daily Acuity Report for this day.

2. On June 15, 2013, the day shift had a census of 8, there was 1 licensed nursing staff working in the unit. The census required 2 licensed nurses. The evening shift had a census of 10, there was 1 licensed nursing staff working in the unit. The census required 2 licensed nurses. The night shift had a census of 10, there was 1 licensed nursing staff working in the unit. The census required 2 licensed nurses. The facility failed to provide a Daily Acuity Report for this day.

3. On June 16, 2013, the day shift had 10 patients with only 1 licensed nursing staff working in the unit. The census required 2 licensed nurses. The evening shift had 12 patients with only 1 licensed nursing staff working in the unit. The census required 2 licensed nurses. The night shift there was 1 licensed nursing staff working in the unit, but the facility failed to provide a "Patient Assignment for Shift/Patient Classification Form" during the survey. The census in the Staff Assignment sheet was left blank for 1 South. The facility failed to provide a Daily Acuity Report for this day.

4. On June 17, 2013, the day shift there were 12 patients with only 1 licensed nursing staff working in the unit. The census required 2 licensed nurses. The evening shift there were 8 patients with 1 licensed nursing staff working in the unit. The census required 2 licensed nurses. The night shift there were 12 patients with 1 licensed nursing staff working in the unit. The census required 2 licensed nurses.

5. On June 18, 2013, the day shift census was 11, there was 1 licensed staff working in the unit. The census required 2 licensed nurses. Evening shift had a census of 9, there was 1 licensed nursing staff working in the unit. The census required 2 licensed nurses. Night shift had 1 licensed nursing staff recorded working in the unit, but the facility failed to provide a Patient Assignment for Shift/Patient Classification Form during the survey. The census in the Staff Assignment sheet was left blank for 1 South.

6. On June 19, 2013, the day shift had 10 patients and there was only 1 licensed nursing staff working in the unit. The census required 2 licensed nurses. The evening shift had a census of 8, there was 1 licensed nursing staff working in the unit. The census required 2 licensed nurses. There were 10 patients in the unit on night shift with 1 licensed nursing staff. The census required 2 licensed nurses.

7. On June 20, 2013, there were 8 patients in the unit on day shift and evening shift with 1 licensed nursing staff working each shift. There were 10 patients in the unit of night shift with 1 licensed nursing staff. The census required 2 licensed nurses.

8. On June 21, 2013, there were 10 patients in the unit on day shift with only 1 licensed nursing staff working in the unit. The census required 2 licensed nurses. There were 11 patients in the unit on evening shift with 1 licensed nursing staff working in the unit. The census required 2 licensed nurses. There were 12 patients in the night shift with 1 licensed nursing staff working in the unit. The census required 2 licensed nurses.

9. On June 22, 2013, the day shift had a census of 12, and there was 1 licensed nursing staff working in the unit. The census required 2 licensed nurses. The unit census on the evening shift was 11 and there was only 1 licensed nursing staff working in the unit. The census required 2 licensed nurses. The night shift had a census on 12 and was staffed with 1 licensed nurse for the shift. The census required 2 licensed nurses.

10. On June 23, 2013, the day, evening, and night shifts had 12 patients in the unit per shift. The unit was staffed with only 1 licensed nursing staff for all three shifts. The census required 2 licensed nurses for each shift.

11. On June 24, 2013, there were 12 patients in the unit on day shift and night shift. The census required 2 licensed nurses for each shift. There was only 1 licensed nursing staff working in the unit for both shifts. The unit census was 9 on the evening shift. The census required 2 licensed nurses. There was only 1 licensed nursing staff working in the unit during the shift.

12. On June 25, 2013, there were 12 patients in the unit on day shift. There was only one licensed nurse on the Patient Assignment for Shift/Patient Classification Form and only one licensed nurse observed in the unit. The Staff Assignment indicated there were 2 licensed persons working in the unit during the day shift. The evening shift census was 11 with only 1 licensed staff assigned to the unit. The census required 2 licensed nurses. The night shift census in the Staff Assignment sheet was left blank for 1 South. The facility failed to provide a Patient Assignment for Shift/Patient Classification Form for the evening and night shifts. The facility failed to provide a Daily Acuity Report for this day.

13. On June 26, 2103, there were 11 patients in the unit on day shift. The census required 2 licensed nurses. There was only 1 licensed nurse working in the unit. The unit census was 10 in the evening shift. The census required 2 licensed nurses. There was only 1 licensed nurse working in the unit for that shift. The unit census was 9 for the night shift. The census required 2 licensed nurses. There was only 1 licensed nurse working in the unit for that shift.

During an interview with RN 1, staff in 1st Floor Unit, on June 25, 2013, at 8:45 a.m., RN 1 stated the unit was staffed with 1 RN, 1 LPT, and 1 MHW for that shift with 10 patients. RN 1 stated that was the usual staffing for the unit. RN 1 stated the supervisor or the relief nurse comes in for her breaks. If there was an emergency in the unit, one of the other staff members calls a code/ask for help.

During an interview with RN 2, staff in 1 South Unit, on June 25, 2013, at 8:50 a.m., RN 2 stated the unit had a census of 12 with herself and three MHW working in the unit for the shift.

During the interview with the director of nursing (DON) on June 28, 2013, at 11 a.m., the DON stated floor charge nurse fills out the Patient Classification Form, which in turn gets transferred to the Acuity Report. The DON stated the "system accommodates the highest acuity possible." The DON stated for 1 South Unit, the unit does not have a medication area and the nurse from the 1st Floor Unit gives the medications for that unit. The DON stated "Right now, the licensed nurse covers both 1st Floor and 1 South." The DON stated, "For the time period reviewed, the number of the licensed personnel was not achieved per policy."

The facility policy titled "Patient Classification/Nursing Staffing Report" revised June 2012 indicated the Charge Nurse on each unit will complete an assessment of the individualized nursing care requirements on the patient's assigned to the unit. Each shift will complete the acuity clinical indicators for patient care at least 2 hours prior to the next shift and forward to RN Supervisor and/or Nursing Administrative Assistant to plan for appropriate staffing. All records of acuity and daily staffing sheets will be bundled together with STAFFING form and filed in the Nursing Office on the following morning. This document will constitute a record of staffing pattern and will be maintained on file for 7 years. "As the facility increases in patient census, the following minimum staff/patient ratio will be followed for all shifts with increased staff provided based upon patient acuity: 6 patients:1 licensed staff."





b. On June 25, 2013, at 8:25 a.m., an initial tour to the units (2 East/Chemical Dependency Wing and 2 West) was conducted with the respective charge nurses on the units. The 2 East/CDW has a total of 27 beds, open units, usually for voluntary admit patients for detox. At the time the census was 23. The 2 East is the transitional unit, with total of 13 beds and for patients on 5150 (or 72-hour hold, is a means by which someone who is in serious need of mental health treatment can be transported to a designated psychiatric inpatient facility for evaluation and treatment for up to 72-hours against their will) danger to self/danger to others (DTS/DTO). The census on that day was 11.

The Staff Assignment dated June 12, 2013 through June 26, 2013, on the three shifts, day (7a-3p), evening (3p-11p) and night (11p to 7a), for both units was reviewed and revealed the following:

2 East/CDW

1. On June 14, 2013, for day shift, the census was 14 patients which required 3 licensed staff (RN/LPT) and there were 2 licensed staff on duty. For the evening shift, the census was 14 patients which required 3 licensed staff and 2 licensed staff on duty. For the night shift, the staff assignment sheet failed to indicate the census at that time, thus the staffing requirement could not be determined.

2. On June 15, 2013, for day shift, the census was 20 patients which required 4 licensed staff and 3 licensed staff on duty. For the evening shift, the census was 22 patients which required 4 licensed staff and 3 licensed staff on duty. For the night shift, the staff assignment sheet failed to indicate the census at the time, thus staffing requirement could not be determined.

3. On June 16, 2013, for the day shift, the census 21 patients which required 4 licensed staff and the licensed staff on duty was 3. For the evening shift, the census was 26 patients which required 5 licensed staff and the staff on duty was 3. For the night shift, the census was 22 patients which required 4 licensed staff and the licensed staff on duty was 2.

4. On June 17, 2013, for the day shift, the census 25 patients which required 5 licensed staff and the licensed staff on duty was 3. For the evening shift, the census was 22 patients which required 4 licensed staff and the staff on duty was 3. For the night shift, the census was 17 patients which required 3 licensed staff and the licensed staff on duty was 2.

5. On June 19, 2013, for the evening shift, the census was 14 patients which required 3 licensed staff and the staff on duty was 2. The medication nurse was shared by the 2 East and 2 West for medication passes.

6. On June 20, 2013, for the night shift, the census was 19 patients which required 4 licensed staff and the licensed staff on duty was 2.

7. On June 21, 2013, for the day shift, the census 19 patients which required 4 licensed staff and the licensed staff on duty was 3. For the evening shift, the census was 17 patients which required 3 licensed staff and the staff on duty was 2. For the night shift, the census was 19 patients which required 4 licensed staff and the licensed staff on duty was 2.

8. On June 22, 2013, for the day shift, the census 19 patients which required 5 licensed staff and the licensed staff on duty was 3. For the evening shift, the census was 19 patients which required 4 licensed staff and the licensed staff on duty was 2. For the night shift, the census was 19 patients which required 4 licensed staff and the licensed staff on duty was 2.

9. On June 20, 2013, for the day shift, the census 20 patients which required 4 licensed staff and the licensed staff on duty was 3. For the evening shift, the census was 20 patients which required 4 licensed staff and the licensed staff on duty was 2. For the night shift, the census was
25 patients which required 5 licensed staff and the licensed staff on duty was 2.

10. On June 24, 2013, for the day shift, the census 25 patients which required 5 licensed staff and the licensed staff on duty was 3. For the evening shift, the census was 25 patients which required 5 licensed staff and the staff on duty was 3. For the night shift, the census was 24 patients which required 4 licensed staff and the licensed staff on duty was 3.

11. On June 25, 2013, for the night shift, the census was not documented and the licensed staff on duty was 3, unable to ascertain the staffing meet and/or not meeting the required staffing.

12. On June 26, 2013, for the evening shift, the census was 15 patients which required 3 licensed staff and the licensed staff on duty was 2. For the night shift, the census was 22 patients which required 4 licensed staff and the licensed staff on duty was 2.

2 West

1. On June 12, 2013, for the day shift, the census 10 patients which required 2 licensed staff and the licensed staff on duty was 1. For the night shift, the census was 12 patients which required 2 licensed staff and the licensed staff on duty was 2, however one (1) licensed staff was the medication nurse.

2. On June 13, 2013, for the night shift, there was no written documentation of the census for this shift, thus the staffing requirement was not ascertain if met or unmet.

3. On June 14, 2013, for the day shift, one licensed nursing staff working in the unit. For night shift, there were two (2) licensed nursing staff working in the unit. However, the facility failed to provide a Patient Assignment for shift/Patient Classification Form for the two (2) shifts during the survey.

4. On June 15, 2013, for the night shift, the census was 11 patients which required 2 licensed staff and the licensed staff on duty was 2. However, one (1) of the nurses was medication nurse.

5. On June 16, 2013, for the day shift, the census was 13 patients which required 3 licensed staff and the licensed staff on duty was 2. For the evening shift, the census was not documented thus the staffing requirement was not ascertain if met or unmet. For the night shift, the census was 13 patients which required 3 licensed staff and the licensed staff on duty was 1.

6. On June 17, 2013, for the day shift, the census was 13 patients which required 3 licensed staff and the licensed staff on duty was 2. For the evening shift, the census was 13 patients which required 3 licensed staff and the licensed staff on duty was 1. For the night shift, the census was 11 patients which required 2 licensed staff and the licensed staff on duty was 1.

7. On June 18, 2013, for the night shift, the census was 13 patients which required 3 licensed staff and the licensed staff on duty was 2.

8. On June 19, 2013, for the day shift, the census was 13 patients which required 3 licensed staff and the licensed staff on duty was 2. For the night shift, the census was 9 patients which required 2 licensed staff and the licensed staff on duty was 2. However one (1) was a medication nurse for the whole unit.

9. On June 21, 2013, for the night shift, the census was 13 patients which required 3 licensed staff and the licensed staff on duty was 1.

10. On June 22, 2013, for the day shift, the census was 13 patients which required 3 licensed staff and the licensed staff on duty was 2. For the evening shift, the census was 12 patients which required 2 licensed staff and the licensed staff on duty was 1. For the night shift, the census was 13 patients which required 3 licensed staff and the licensed staff on duty was 2.

11. On June 23, 2013, for the night shift, the census was 13 patients which required 3 licensed staff and the licensed staff on duty was 1.

12. On June 24, 2013, for the day shift, the census was 13 patients which required 3 licensed staff and the licensed staff on duty was 1.

13. On June 25, 2013, for the night shift, the census was not documented, thus unable to ascertain if the staffing requirement was met or unmet.

14. On June 26, 2013, for the day shift, the census was 8 patients which required 2 licensed staff and the licensed staff on duty was 1. The other licensed nurse on duty was the medication nurse for the whole unit.





c. On June 26, 2013 at 10:30 a.m., in the locked units of Mariah West and Mariah East the following licensed nursing staff were on duty. On Mariah West, RN 3, RN 4 and LVN 1 with a patient census of 14 (maximum of 15 patients possible). On the connecting locked unit of Mariah East RN 4 was on duty for a patient census of 7 (maximum of 7 possible).

On June 26, 2013 at 11.45 a.m. during an interview with RN 3, who was assigned to Mariah East, RN 3 stated, "The two units share the LVN who gives out the medication for the two units."

During an interview on June 26, 2013 at 1:30 p.m. with LVN 1, when asked what was the normal staffing for the two units LVN 1 stated "Normally there is one or two RN's on Mariah West and one RN on Mariah East and they share a LVN between the two units for medication."

During an interview with the DON on June 26, 2013 at 11:05 a.m., she was asked to explain how the staffing ratio was determined, she stated "We follow the staffing ratio per the facility policy unless the acuity of the patients are high". When showed the facility policy titled "Patient Classification/Nursing Staffing Report" last revised 6/12, she was asked to explain the grid on page four of the policy indicating the core staffing for the units in the facility. She stated that the units should have a total of 1 licensed staff per 6 patients with a minimum of 1 RN at all times. When asked to review the staffing for locked Mariah West and Mariah East units she stated "per that policy we should have another licensed person on Mariah East, but we never staff that way so I guess I need to change that policy.

A review of the facility's documentation provided titled "Staff assignment" and "Daily Acuity Report" and "Patient Classification Form" indicated the following:

1. On June 12, 2013, at Mariah West, there were 13 patients on day shift with 2 assigned licensed staff. The required staffing was 3 licensed staff. There were 13 patients on the evening shift with 2 licensed staff assigned. The census required 3 licensed staff. There were 15 patients on the night shift with 2 licensed staff. The census required 3 licensed staff.

2. On June 12, 2013 at Mariah East, there were 7 patients on day shift with 1 licensed staff. The census required 2 licensed staff. There were 7 patients on the evening shift with 1 licensed staff. The census required 2 licensed staff. There were 7 patients on the night shift with 1 licensed staff. The census required 2 licensed staff.

3. On June 13, 2013, at Mariah West, there were 15 patients on the evening shift with 2 licensed staff working. The census required 3 licensed staff. There were 15 patients on the night shift with 2 assigned licensed staff. The census required 3 licensed staff.

4. On June 14, 2013 at Mariah West, there were 14 patients on the day shift with 2 licensed staff. The census required 3 licensed staff. There were 14 patients on the evening shift with 2 licensed staff.

5. On June 14, 2013 at Mariah East, there were 7 patients on the day shift with 1 licensed staff assigned. The census required 2 licensed staff. There were 7 patients on the evening shift with 1 licensed staff. The census required 2 licensed staff. There were 7 patients on the night shift with 1 licensed staff. The census required 2 licensed staff.

6. On June 15, 2013, at Mariah West, there were 15 patients on the day shift with 2 licensed staff. The census required 3 licensed staff. There were 15 patients on the night shift with 2 licensed staff. The census required 3 licensed staff.

7. On June 15, 2013 at Mariah East, there were 7 patients on all three shifts with 1 licensed staff each shift. The census required 2 licensed staff per shift.

8. On June 16, 2013 at Mariah West, there were 16 patients on the day shift with 2 licensed staff until 11 a.m. The census required 3 licensed staff. There were 16 patients on the evening shift with 3 licensed staff working from 3 p.m. to 7 p.m., then 2 licensed staff the rest of the shift. The census required 3 licensed staff. There were 16 patients on the night shift with 2 licensed staff. The census required 3 licensed staff.

9. On June 16, 2013 at Mariah East, there were 7 patients on all shifts with 1 licensed staff each. The census required 2 licensed staff per shift.

10. On June 17, 2013 at Mariah West, there were 16 patients on the day shift with 2 licensed staff. The census required 3 licensed staff. There were 13 patients on the evening shift with 2 licensed staff. The census required 3 licensed staff. There were 15 patients on the night shift with 2 licensed staff. The census required 3 licensed staff.

11. On June 17, 2013 at Mariah East, there were 7 patients on all shifts with 1 licensed staff each shift. The census required 2 licensed staff each shift.

12. On June 18, 2013 at Mariah West, there were 16 patients on the day shift with 2 licensed staff. The census required 3 licensed staff. There were 15 patients on the night shift with 2 licensed staff. The census required 3 licensed staff.

13. On June 18, 2013 at Mariah East, there were 7 patients on the day shift and night shift with 1 licensed staff each shift. The census required 2 licensed staff.

14. On June 19, 2013 at Mariah West, there were 16 patients on the day shift with 2 licensed staff. The census required 3 licensed staff. There were 13 patients on the evening shift with 2 licensed staff. The census required 3 licensed staff. There were 12 patients on the night shift with 2 licensed staff. The census required 3 licensed staff.

15. On June 19, 2013 at Mariah East, there were 7 patients on the day shift with 1 licensed staff. The census required 2 licensed staff.

16. On June 20, 2013 at Mariah West, there were 14 patients on the day shift with 2 licensed staff. The census required 3 licensed staff. There were 14 patients on the night shift with 2 licensed staff. The census required 3 licensed staff.

17. On June 20, 2013 at Mariah East, there were 7 patients on all shifts with 1 licensed staff each shift. The census required 2 licensed staff each shift.

18. On June 21, 2013 at Mariah West, there were 13 patients on evening shift and night shift with 2 licensed staff each shift. The census required 3 licensed staff per shift.

19. On June 21, 2013 at Mariah East, there were 7 patients on all shifts with 1 licensed staff each shift. The census required 2 licensed staff per shift.

20. On June 22, 2013 at Mariah West, there were 15 patients on day shift and evening shift with 2 licensed staff each shift. The census required 3 licensed staff per shift. There were 16 patients on the night shift with 2 licensed staff. The census required 3 licensed staff.

21. On June 22, 2013 at Mariah East, there were 7 patients on all shifts with 1 licensed staff each shift. The census required 2 licensed staff per shift.

22. On June 23, 2013 at Mariah West, there were 16 patients on all shifts with 2 licensed staff each shift. The census required 3 licensed staff.

23. On June 23, 2013 at Mariah East, there were 7 patients on all shifts with 1 licensed staff each shift. The census required 2 licensed staff per shift.

24. One June 24, 2013 at Mariah West, there were 16 patients on day shift and evening shift with 2 licensed staff each shift. The census required 3 licensed staff per shift.

25. On June 24, 2013 at Mariah East, there were 7 patients on all shifts with 1 licensed staff each shift. The census required 3 licensed staff per shift.

26. On June 25, 2013 at Mariah West, there were 15 patients on the day shift with 2 licensed staff. The census required 3 licensed staff.

27. On June 25, 2013 at Mariah East, there were 7 patients on all shifts with 1 licensed staff each shift. The census required 2 licensed staff each shift.

28. On June 26, 2013 at Mariah West, there were 13 patients on the evening shift with 2 licensed staff. The census required 3 licensed staff. There were 14 patients on the night shift with 2 licensed staff. The census required 3 licensed staff.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the facility's registered nurse failed to evaluate the care for each patient in accordance with accepted standards of nursing practice and hospital policy for 7 of 30 sampled patients (Patients 1, 2, 4, 6, 25, 29 and 30). Licensed nursing staff did not accurately document in the medical record and did not note clinician's orders by signature, date and time for these patients. This failure had the potential for delayed or missed interventions for the affected patients.

Findings:

a. The clinical record for Patient 1 was reviewed on June 25, 2013, at 11:10 a.m. The Admission Orders dated June 14, 2013, at 6 a.m. indicated for vital signs to be done every shift while the patient is awake.
The "Vital Sign Flow Sheet" for Patient 1 indicated there was no documentation of vital signs for June 15, 2013, at 1600. The line had the date and time written on it but no vital sign values.

b. The clinical record for Patient 2 was reviewed on June 25, 2013, at 2:20 p.m. The Vital Sign Flow Sheet indicated a missing blood pressure and pain level assessment on June 22, 2013, at 4 p.m. There was missing temperature reading documentation on June 23, 2013, at 10 a.m. On June 24, 2013, there was no time when a blood pressure reading of 120/90 was done.

During the interview with the DON (director of nursing) on June 27, 2013, at 1:15 p.m., the DON reviewed the Vital Sign Flow Sheets for Patients 1 and 2 and stated the vital signs were incomplete. The DON further stated the staff needs to write the reason why the vital sign was sign completed.

During the interview with the DON on June 27, 2013, at 1:15 p.m., the DON reviewed the Physician's Orders for Patients 4 and 6 and stated the nurse did not sign the physician's order for the medications for Patient 4. The DON stated "It was not signed, this is an error." For the missing nurse notation and signature for the discharge order for Patient 6, the DON stated "chart may be off the unit, nurse signs discharge after-care. I will review the chart and see if she had signed that." The DON did not provide any proof to the surveyor that the nurse signed the discharge order for Patient 6 prior to the end of survey.






c. During a review of the clinical record for Patient 25, the facesheet indicated the patient was admitted to the facility on on [DATE] with diagnosis of schizophrenia (a severe mental disorder). A review of the vital sign flow sheet dated June 13, 2013 indicated the staff person had signed, dated and timed the document, however the vital signs for Patient 25 were not recorded.

During an interview with the director of nursing on June 26, 2013 at 2:30 p.m., she stated vital signs were performed every shift for a stable patient and it was important to accurately chart in the medical record. The DON also stated the staff person would be counseled.

The facility policy and procedure titled "Vital Signs" dated February 2013 indicated the assigned staff member who monitored the patient at the time the vitals signs were determined would record all vital signs on the Vital Signs Record.

d. A review of the facesheet indicated Patient 29 was admitted to the facility on on [DATE] with diagnosis of bipolar disorder (a disorder characterized by mania and alternating with periods of depression).

During a review of the clinical record for Patient 29, the Psychiatric History and Evaluation dated, June 19, 2013 indicated the treatment plan was to admit Patient 29 to the facility on a 5150 for danger to self and danger to others and that the patient would be stabilized with mood stabilizer Seroquel (an antipsychotic medication) to be started in the morning, bedtime and prn (as needed) basis.

A review of the Physician's Order dated June 25, 2013, indicated Patient 29 was to receive Seroquel 200 mg by mouth, one dose now, however the registered nurse did not document the date and time of the physician's order.

The facility policy and procedure titled "Noting Clinician's Orders" dated January 2007, indicated the clinician's orders shall be noted only by Licensed Nursing Staff who have completed the Medication Administration Program and that the charge nurse should check through all charts at the end of the shift for possible orders that have not been noted. The policy further indicated under procedure: to signify that the orders have been noted by signature, date and time in the designated space.

e. A review of the facesheet indicated Patient 30 was admitted to the facility on on [DATE] with diagnoses which included paranoid schizophrenia (a type of schizophrenia characterized by delusions of grandeur and paranoia). A review of the Integrated Assessment Tool dated the admission day indicated a point of contact assessment, a risk assessment and a functional impairment assessment, however the registered nurse did not sign, date or time the document to indicate completion of these assessments.

During an interview with the DON on June 28, 2013 at 9 a.m., she stated the registered nurse needed to sign and review the integrated assessment tool to ensure completion.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and record reviews, the nursing staff failed to ensure a nursing care plan/treatment plan was developed and kept current for 3 of 30 sampled patients (Patients 1, 10 and 24). The physician and the registered nurse did not sign the patient's treatment plan, which caused an increased risk in the revision and update of the patient's treatment plan to foster consistency and continuity in the care of the patient.

Findings:

a. The clinical record for Patient 1 was reviewed on June 25, 2013, at 11:10 a.m. The "Individualized Interdisciplinary Treatment Plan Cover Sheet" indicated Patient 1 was admitted to the facility on on [DATE] with an admitting diagnosis of schizoaffective bipolar type, severe (a psychiatric diagnosis that describes a mental disorder characterized by recurring abnormal mood and psychotic components).

The "Interdisciplinary Treatment Team Patient Treatment Summary Signature Page" dated June 18, 2013 indicated a brief summary of present and/or on-going problems, observations, discharge planning, justification for continued stay, disposition, and follow-up for Patient 1. The Registered Nurse (RN) failed to sign the document.

During the interview with the DON on June 27, 2013, at 1:15 p.m., the DON reviewed the treatment plan summary dated June 18, 2013 for Patient 1 and stated the nurse was supposed to sign the treatment plan.






b. Patient 10 was admitted to the facility on on [DATE], at 9:40 a.m., for major depressive disorder (an illness that involves the body, mood, and thoughts) and combinations of drug dependence excluding opiod type drugs.
The Initial Treatment Plan (first 72 hours) dated June 23, 2013, addressed the patient to be at risk for danger to self. The goal was for patient to be free from self-injury, and the interventions were complete contraband check , begin every 15 minutes checks, encourage patient to seek staff when fears losing control, encourage/support verbal expression, assess for potential loss of control and administer PRN (as needed) medications.
The Initial Treatment Plan was signed by the patient, RN/Clinician and Case Manager. The Physician failed to sign this treatment plan.
On June 27, 2013, at 1:15 p.m., after a review of the treatment plan, the DON stated it should have been signed by the physician.






c. During a review of the clinical record for Patient 24, the facesheet indicated the patient was admitted to the facility on on [DATE], with diagnosis of bipolar disorder (a disorder characterized by mania and alternating with periods of depression).

A review of the Individualized Interdisciplinary Treatment Plan dated June 20, 2013 indicated Patient 24 became increasingly depressed, anxious, panicky, moody and having racing thoughts, threatening staff and assaulting peers. The Interdisciplinary Treatment Team signature page indicated the patient's current medications were Adderal (brain stimulant) twice a day for attention deficit disorder, Thorazine every night (antipsychotic), Tegretol every night (anticonvulsant) and Wellbutrin every morning (an antidepressant). However, a review of the signature page on June 25, 2013 (five days later) indicated the physician did not sign the treatment plan.

During an interview with the director of nursing (DON) on June 25, 2013 at 3:10 p.m., she stated the physician was the leader of the treatment team and the facility appreciated the direction the physician provided. The DON stated the treatment plan should be initiated by the third day after admission and the physician did not sign it.

The facility policy and procedure titled "Interdisciplinary Treatment Plan" dated January 2012, indicated the purpose was to provide appropriate communication between team members that fosters consistency and continuity in the care of the patient. The policy indicated the team shall consist of the physician and representatives of each clinical discipline involved in the treatment as appropriate and that ultimate responsibility for the development and implementation of the treatment plan would rest with the physician.

The facility governance plan dated March 2013 indicated individual treatment plans were developed to meet the specific clinical needs of every patient utilizing an integrated multi-disciplinary approach.
VIOLATION: WRITTEN MEDICAL ODERS FOR DRUGS Tag No: A0406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the facility failed to ensure all orders for drugs and biologicals were documented and signed by an authorized practitioner for 3 of 30 sampled patients (Patient 13, 26 and 29).

Findings:

a. During review of Patient 13's medical record indicated he was admitted to the facility on on [DATE], at 5:28 p.m., for bipolar Disorder, opioid and alcohol dependency and alcohol withdrawal.

On admission the physician ordered vital signs every two (2) hours for the first 48 hours, then routine every shift while awake. Also the physician ordered medication Tylenol 325 mg 2 tabs orally every four (4) hours as needed (PRN) for mild pain.

A review of the Every Two hours (Q2) Detox Vital Signs Record indicated the following documentation:

1. On October 23, 2011, at 2200, the patient's pain level was 2/10 and at 1800 and 2000 it was 0/10.

2. On October 24, 2011, at 2400 through 0600, the pain level was 0/10. At 0800 through 1800 and 2200, the section for pain was blank. At 2000, the patient's pain level was at 6/10.

3. On October 25, 2011, at 2400 through 0800 and 1200 the patient's pain level was 0/10. At 1000 and 1400, the patient's pain level was 8/10 and 9/10.

A review of the Medication Administration Record (MAR) indicated on October 23, 24 and 25, 2013, the patient was administered Motrin 600 mg by mouth every four hours for pain.

On June 27, 2013, at 1:20 p.m., during an interview with DON while showing her the medical records, she concurred that there was no physician's order for Motrin that was administered to the patient. She further stated there should be a physician order prior to administering the medication to patients.





b. A review of the physician's orders dated June 19, June 22 and June 23, 2013 indicated Patient 26 received Magnesium Citrate and Ativan, however there was no physician signature, date or time for these medications.

c. A review of the physician's orders dated June 22, 2013 indicated Patient 29 received Percocet (pain relief medication), however there was no physician signature, date or time for this medication.

The facility policy titled "Medications" reviewed/revised on July 2012 indicated "C. Telephone Orders ...The prescriber shall countersign the order within (48) hours." "This shall also apply to any telephone orders whether for medication or not."