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.

HAVEN BEHAVIORAL SENIOR CARE OF NORTH DENVER 8451 PEARL STREET SUITE 100 THORNTON, CO July 12, 2012
VIOLATION: GOVERNING BODY Tag No: A0043
Based on the manner and degree of deficiencies cited the facility failed to be in compliance with the Condition of Participation of Governing Body. The facility's governing body failed to ensure that care provided in the facility by facility staff and contracted staff met the Conditions of Participation.

The facility failed to be in compliance with the following Conditions of Participation:

A 0115 - Patient Rights: The hospital failed to comply with the Condition of Patient Rights. The facility failed to protect and promote each patient's rights. This failure created an Immediate Jeopardy (IJ) situation related to the facility's failure to investigate allegations of physical abuse as well as the facility's failure to ensure that physical and chemical restraints were being used in a safe and effective manner.

A 0338 - Medical Staff: The hospital failed to ensure that the medical staff operated under the bylaws approved by the governing and was responsible for the quality of medical care provided to patients by the hospital.

A 0385 - Nursing Services: The facility failed to ensure the appropriate oversight of nursing services which lead to incomplete nursing documentation in patient medical records, lapses in carrying out physician orders, lack of complete and current nursing staff policies, incomplete care planning, incomplete nurse staffing records, and lack of documentation of orientation of non-employee nurses.

A 0700 - Physical Environment: The facility failed to ensure that the host hospital, which provided food and nutrition services to the facility under a contractual agreement, maintained the food and dietary department, and its facilities and supplies, to ensure the safety of the patient when providing food and nutrition services.

Additionally the facility failed to meet the following standards under the Condition of Governing Body:

A 0049 - Medical Staff - Accountability: The governing body failed to ensure that the medical staff was accountable to the governing body for the quality of care provided to patients.

A 0084 - Contracted Services: The governing body failed to institute and maintain a system to routinely evaluate the services provided to patients to ensure they were provided in a safe and effective manner. The findings created the potential for negative patient outcomes.
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
Based on medical record review, staff interviews and review of facility documents, the governing body failed to ensure that the medical staff was accountable to the governing body for the quality of care provided to patients.

Findings:

1. Failure of the Governing Body to Ensure that the Medical Staff Enforced Bylaws, Rules and Regulations:

a. Reference Tag A 0353 for findings related to the medical staff's failure to enforce bylaws, rules and regulations related to medical records, use of restraint, physicians on-call and professional standards/peer review.

2. Failure of the Governing Body to ensure that the Medical Director Provided Oversight Related to Psychiatric Provider Practice and Use of Oversight of Restraint Use in the Facility:

a. Reference Tag A 0347 for findings related to the medical director's failure to provide oversight of psychiatric provider coordination of services.

b. Reference Tag A 0353 for findings related to the medical director's failure to ensure that the medical staff enforced their bylaws, rules and regulations.

c. Reference Tags A 0145 and 0154 for findings related to the to use of restraints, without physician orders, to provide personal care and emergency psychotropic medications, without the consent or cooperation of the patients.
VIOLATION: CONTRACTED SERVICES Tag No: A0084
Based on a review of medical records, staff/physician interviews and review of facility documents, the governing body failed to institute and maintain a system to routinely evaluate the services provided to patients to ensure they were provided in a safe and effective manner. The findings created the potential for negative patient outcomes.

The findings were:

1. The facility failed to ensure that contracted dietary services allowed the facility to comply with Conditions of Participation.

a. Reference Tag A 700 - Condition of Participation of Physical Environment - for findings related to the hospital's failure to comply with the Condition of Participation of Physical Environment. The facility failed to ensure that the host hospital, which provided food and nutrition services to the facility under a contractual agreement, maintained the food and dietary department, and its facilities and supplies, to ensure the safety of the patient when providing food and nutrition services.
b. Reference Tag A 701 - Maintenance of Physical Plant - for findings related to the facility's failure to ensure that the condition of the physical plant and overall hospital environment was maintained by the host hospital in such a manner that the safety and well-being of patients were assured. The facility failed to ensure that the host hospital, which provided food and nutrition services to the facility under a contractual agreement, maintained a clean environment in the food and dietary department for the safe preparation and storage of food.

c. Reference Tag A 724 - Facilities, Supplies, and Equipment Maintenance - for findings related to the facility's failure to ensure that the host hospital, which provided food and nutrition services to the facility under a contractual agreement, maintained the facilities, supplies and equipment in the food and dietary department to ensure an acceptable level of safety and quality.

2. The facility failed to adequately monitor the provision of laboratory services by a contracted provider.

a. A review of the facility's policy titled "Critical Lab Values and STAT Lab Management" that was last revised 12/2011 revealed:

"Procedure:
STAT Test results will be called by the Lab technologist within 5 hours of the draw to the RN. All STAT orders are to be documented on the log.
Log consist of:
a) Order date and time
b) Time order called to lab
c) Test ordered
d) Date/time lab drawn - if test not drawn within 1 hour, call [Contracted Lab personnel], lab representative
e) Time results received - if not received within 5 hours, call the lab for results and if needed, call [Contracted Lab personnel].
f) Physician notified."

b. A review of Sample Patient #1's medical record was conducted on 07/02/12. The record contained orders for "STAT" laboratory studies to be conducted that was written on 06/04/12 at 12:15 p.m. A note in the patient's record by the facility's Risk Manager dated 06/04/12 at 2:45 p.m. stated that the contracted laboratory had not drawn the patient's STAT labs. According to the laboratory results, the laboratory technician drew the patient's labs at 4:35 p.m. (4 hours and 20 minutes after the initial order for a STAT lab draw). Results were received by the facility at 8:47 p.m. (8 hours and 32 minutes after the initial order for a STAT lab draw).

c. A review of the tracking log maintained by the facility in accordance with the above referenced policy revealed that the facility's staff did not complete the log in its entirety a majority of the time, including Sample Patient #1's laboratory order, draw, and results.

d. An interview was conducted with the facility's Quality Assessment and Risk Manager on 07/09/12 at 2:48 p.m. S/he confirmed that the tracking log had missing information. S/he stated s/he was not aware of any follow up that was completed with facility staff regarding the completion of the log to evaluate the contracted laboratory service. S/he stated that the facility received reports from the contracted laboratory service that provided draw time response and result reporting response times that the facility used to evaluate the contracted service. S/he stated that this data was often 30-60 days later than the end of the month and did not have any data for June 2012.

e. An interview with the facility's CEO was conducted on 07/05/12 at 12:53 p.m. S/he stated that s/he had been disappointed with the response from the contracted laboratory services in the case of Sample Patient #1 and had requested that the contracted laboratory service investigate the failure to meet the expected response time.

3. The facility failed to ensure that when rehabilitation services were ordered on Sample Patient #17 that the contracted provider of rehabilitation services provided the ordered services.

a. A review of Sample Patient #17's medical record on 07/05/12 revealed that the physician caring for the patient ordered for physical therapy to evaluate and treat the patient on 06/14/12. The patient was discharged from the facility on 06/28/12. The medical record did not contain documentation from a physical therapist or other provider that indicated that the rehabilitation services were provided for the patient.

b. An interview with the facility's Chief Executive Officer was conducted on 07/06/12. S/he confirmed that Sample Patient #17's record contained the order for physical therapy. S/he confirmed that there was not documentation that the patient received the ordered physical therapy. S/he stated that the contracted physical therapy staff did not see the patient.

c. On 07/06/12 at 12:59 p.m. a binder that contained consults for physical or occupational therapy services was provided for review. The sheets within the binder revealed that the log contained an entry for Sample Patient #17, but did not document the completion of the consult or documentation to explain why the services were not provided.

4. Specific Failure Related to Nursing Services:

a. Reference Tag A 398 - Supervision of Contracted Staff - for findings related to nursing services failure to ensure non-employee nursing personnel who were working in the hospital were under adequate supervision of the director of nursing service and their clinical activities were evaluated to ensure that the nursing care provided was safe and effective.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on the manner and degree of deficiencies cited, the hospital failed to comply with the Condition of Patient Rights. The facility failed to protect and promote each patient's rights.

On 7/12/12 at 11:30 a.m., the determination was made that an Immediate Jeopardy (IJ) situation existed related to the facility's failure to investigate allegations of physical abuse as well as the facility's failure to ensure that physical and chemical restraints were being used in a safe and effective manner. The facility was notified of the IJ situation on 7/12/12 at 12:45 p.m. and the IJ situation remained at the time of exit.

The facility failed to meet the following standards under the Condition of Patient Rights:

A 0145 - Patient Rights: Free from Abuse/Harassment
The facility failed to ensure that patients were free from all forms of abuse. The facility failed to document investigations into allegations of abuse against patients by facility staff. The failure placed all patients in the facility at risk of being subjected to abuse.

A 0154 - Use of Restraint or Seclusion
The facility failed to ensure that all patients were afforded the right to be free from inappropriate physical or chemical restraints.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on interviews, record review, and policy/procedure review the facility failed to ensure that patients were free from all forms of abuse. The facility failed to document investigations into allegations of abuse against patients by facility staff. The failure placed all patients in the facility at risk of being subjected to abuse.

Findings:

1. Abuse Allegation #1:

a. An interview with the facility's Director of Human Resources was conducted on 7/11/12 at 10:28 a.m. S/he stated that in April 2012 s/he had received a verbal allegation from another employee of the facility that Behavioral Health Technician (BHT)#1 had used a towel in a shower to restrain a patient. S/he stated that s/he then went to the facility's Nurse Manager to relay the allegation to him/her. S/he stated that the Nurse Manager then approached BHT#1 to address the allegation.

b. An interview with the facility's Nurse Manager was conducted on 7/11/12 at 12:28 p.m. S/he stated that s/he had received the complaint from the Director of Human Resources regarding BHT#1. S/he stated that BHT#1 had "used a towel to secure the patient's arms" which s/he confirmed would have constituted a restraint. S/he confirmed that the use of the towel as a restraint was not consistent with the facility's practices and expectations. S/he stated that s/he did not consider the allegation one of abuse; rather that it was a "unique teaching" that was needed.

c. An interview with the facility's Risk Manager was conducted on 7/11/12 at 1:57 p.m. S/he stated that s/he was not aware of the allegation described above prior to 7/11/12.

d. A review of facility documents revealed that there was no documentation of an investigation performed by the facility. The facility provided documentation that BHT#1 was counseled about the incident..

2. Abuse Allegation #2:

a. An interview was conducted with the facility's Director of Human Resources on 7/11/12 at 10:28 a.m. S/he stated that in May 2012 s/he had received a verbal allegation from BHT#2 (an employee of the facility) that BHT#1 had been physically abusive against patients. S/he stated that s/he asked BHT#2 to place her concerns in writing.

b. An internal facility document dated 5/21/12 written by BHT#2 stated that s/he was concerned that BHT#1 was physically abusive to patients. BHT#2 alleged that BHT#1 had "grabbed [Sample patient #22's] hand and in a quick maneuver which I have witnessed [BHT#1] using before firmly pressed [Sample patient #22's] thumb-knuckle towards his/her palm. [The patient] cried out 'ouch, ouch, ouch you're hurting me' and [BHT#1] held the position on [the patient's] thumb and led him/her away."

c. An interview was conducted with the facility's Risk Manager on 7/10/12 at 12:20 p.m. S/he stated that an investigation was conducted regarding the allegations of abuse by BHT#1 against Sample patient #22. S/he stated that s/he could not provide documentation to the surveyor's for review. A subsequent interview conducted on 7/10/12 at 1:07 p.m. revealed that s/he had spoken with 3 additional BHTs as part of his/her investigation into the allegations of physical abuse by BHT#1. S/he provided the internal facility documents maintained to document the investigation of the allegation of abuse.

d. A review of internal facility documents maintained by the facility's Risk Manager revealed that the documents contained sparse notes without details of what was said or which staff were interviewed and when.

3. Abuse Allegation #3:

a. An internal facility document dated 5/21/12 written by BHT#2 stated that s/he was concerned that BHT#1 was physically abusive to patients. BHT#2 alleged that when Sample patient #21 was "attempting to get out of his geri-chair (a normal behavior for this patient given his/her mental status)" s/he heard BHT#1 "shout to the patient from across the room telling him/her to 'sit down', the patient did not comply, again [BHT#1] shouted 'sit down'." (In the document, BHT#2 stated that there was no response from the patient.) "[BHT#1] then walked over grabbed the patient by his/her right arm and right leg and shoved him/her back onto the geri-chair, the patient started fighting with his/her free left hand. [BHT#1] then grabbed both hands and firmly locked them across the patient's chest. The patient continued the struggle, kicking his/her legs and grumbling incoherently, yet [BHT#1] held on. I walked to [BHT#1] and told him/her to 'let him/her go', s/he did not and the struggle continued. Frustrated, I walked away and went to speak with the charge nurse."

b. An interview with the facility's Risk Manager was conducted on 7/10/12 at 1:07 p.m. S/he stated that s/he had no notes regarding the investigation that was conducted in regards to this allegation. S/he stated that s/he would normally take notes when conducting interviews and would then destroy the notes after submitting an occurrence report to the State when allegations met reporting criteria. S/he stated that s/he had not reported this allegation as an occurrence to the State.

4. The facility failed to have a policy that addressed how allegations of abuse were to be investigated.

a. A review of the facility's policies/procedures throughout the survey revealed that the facility had a policy addressing reporting of patient abuse. The policy stated, "Reports of Abuse or Neglect that occur while the patient is hospitalized will be thoroughly investigated by the Risk Manager or other staff as assigned by the Chief Executive Officer in addition to following the required reporting."

b. An interview with the facility's Risk Manager was conducted on 7/10/12 at 1:50 p.m. S/he stated that s/he could not locate a policy that stated how an investigation of allegations of abuse were to be conducted and documented.

c. An interview with the facility's corporate Vice President of Clinical Operations was conducted on 7/10/12 at 2:47 p.m. s/he stated that s/he would expect that investigations performed by the facility into allegations of abuse would be documented in some form.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based on record review, staff interview, and policy/procedure review the facility failed to ensure that all patients were afforded the right to be free from inappropriate physical or chemical restraints.

Findings:

1. The facility failed to ensure that when patients were physically restrained in order for involuntary, emergency medications to be administered to patients that the staff treated the episodes as physical restraints.

a. An interview with RN#1 on 7/11/12 at 11:29 a.m. revealed that the facility routinely would hold down patients for the administration of "emergency medications." S/he stated that if patients would not take their medications and the physician determined that the patient would need the medication as an injection, an order would be written for an "emergency medication." S/he stated that it was rare that a patient would allow an "emergency medication" injection to be performed and therefore would have to be held down for the safety of all involved. S/he stated that s/he had been trained that holding a patient down was not considered a physical restraint unless the patient was held for more than 5 minutes.

b. A review of the facility's records revealed that a log maintained to document the instances when patients received "Emergency Involuntary Medication" revealed that the log contained 128 entries since 1/1/12. A review of a sample of 22 patient records revealed that there were instances of patients receiving emergency involuntary medications ordered by physicians that were not included in the log.

c. A review of the facility's "Restraint Log" revealed that the facility had not recorded any instance of a patient being physically restrained.

d. An interview with the facility's Nurse Manager was conducted on 7/11/12 at 12:28 p.m. S/he stated that the facility had been under the impression that as long as a physical hold that met the definition of a physical restraint under the regulations was less than 5 minutes than it was not considered a physical restraint episode. S/he stated that s/he was now clear that any time a patient was held in a way that restricted movement and did not allow for the patient to easily escape that it was considered a physical restraint and should be handled as such. S/he confirmed that the facility's policy did not mention the 5 minute exception that s/he had referred to and that the policy did adequately address the regulations. S/he stated that the facility's nursing staff had not yet been reeducated regarding the facility's policy and the facility's practice that was not in compliance with the regulations.

2. The facility failed to ensure that when patients were physically restrained by staff by being held that the staff treated the episodes as physical restraints

a. A review of the facility's policy titled, "Restraint, Physical" stated the following:
"Policy
A restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. This policy applies to physical restraint only-mechanical restraint is not utilized.
Restraint is ordered by a practitioner only for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member or others.
Use of restraint is only employed as a last resort in emergency situations, after less-intrusive and non-physical interventions have been attempted or ruled-out. Orders for restraint shall never be written as a standing order or on as needed basis (PRN).
PROCEDURE
A trained registered nurse may initiate restraint in the absence of a practitioner. The attending/covering practitioner will be contacted during the initiation of restraint or immediately after.
The order shall indicate the reason and maximum duration of restraint.
The registered nurse will document behaviors which led to the need for the use of restraint in the Restraint/Seclusion progress notes and the RN Restraint/Seclusion Assessment.
Restraint episodes will be documented on the following forms: Restraint/Seclusion Flow Sheet, RN Restraint/Seclusion Assessment, Restraint/Seclusion Practitioner Order, Restraint/Seclusion progress notes and Patient Debriefing."

b. An interview with the facility's Nurse Manager was conducted on 7/11/12 at 12:28 p.m. S/he stated that the facility had been under the impression that as long as a physical hold that met the definition of a physical restraint under the regulations was less than 5 minutes then it was not considered a physical restraint episode. S/he stated that s/he was now clear that any time a patient was held in a way that restricted movement and did not allow for the patient to easily escape that it was considered a physical restraint and should be handled as such. S/he stated that staff received Crisis Prevention Institute (CPI) training which included physical interventions for violent patients. S/he stated that the techniques taught were designed to limit the mobility of individuals and would be considered a physical hold. S/he confirmed that the facility's policy did not mention the 5 minute exception that s/he had referred to and that the policy did adequately address the regulations. S/he stated that the facility's nursing staff had not yet been reeducated regarding the facility's policy and the facility's practice that was not in compliance with the regulations.

3. The facility failed to ensure that when patients were prescribed and received injections of medications used as a restriction to manage the patients' behaviors that the facility staff treated the episodes as chemical restraints.

a. A review of the facility's policy titled, "Restraint, Chemical" stated the following:
"POLICY
Chemical Restraint is defined as a drug or medication used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition. These medications are used in addition to or in replacement of the patient's regular drug regimen to control extreme behavior during an emergency.
PRN medications related to the diagnosis and presenting condition which are ordered in response to exacerbation of normally anticipated symptoms and included in the plan of care for the patient are considered standard treatment and would not be classified as Chemical Restraint. Medication categorized as chemical restraint is administered only after less restrictive efforts at assisting the patient in regaining control have been attempted or ruled out.
PROCEDURE
Patients will be administered medication categorized as chemical restraint on the direction of the attending/covering practitioner. When medication categorized as chemical restraint is ordered the following actions will be taken:
The R.N. will document behaviors which led to the need for the use of chemical restraint in the Restraint/Seclusion progress notes and the RN Restraint/Seclusion Assessment.
The patient shall be monitored and reassessed through continuous in-person observation until determination by the practitioner or the trained registered nurse that the chemical restraint has ended, based on assessment of the behavioral and medical condition of the patient.
Vital signs will be taken immediately following administration of the medication and then minimum q 30 minutes x 2. The practitioner will be notified immediately if the vital signs are abnormal.
Chemical restraint episodes will be documented on the following forms: Restraint/Seclusion Flow Sheet, RN Restraint/Seclusion Assessment, Restraint/Seclusion Practitioner Order, Restraint/Seclusion progress notes and Patient Debriefing."

b. An interview with the facility's Nurse Manager was conducted on 7/11/12 at 12:28 p.m. S/he stated that the facility did provide medications upon the order of a physician that would be considered chemical restraints. S/he stated that it was his/her understanding that if the patient received the medication orally normally, then the receipt of the medication as an injection would not be considered a chemical restraint. S/he stated that the injection of a medication that would limit or decrease the patient's ability to interact with their environment would be considered a chemical restraint. S/he stated that the facility had seen an increase in the prescription of injectable medications that could be considered chemical restraints recently. S/he stated that s/he had educated the nursing staff that it was appropriate to question orders that appeared to be chemical restraints and spoken to the facility's medical staff members.

c. A review of the facility's "Restraint Log" revealed that in 2012, there had been 4 episodes of chemical restraints (on 2/15/12, 4/24/12, 4/27/12 and 4/27/12). Additional review of the facility's "Emergency Involuntary Medication Log" revealed that the log contained 48 entries in 2012 that would be considered chemical restraints according to the definition given by the Nurse Manager and regulations.

d. A review of Sample Patient #21's record revealed that the patient was prescribed emergency medications on two separate occasions. On 5/11/12 at 1:00 p.m. the patient was prescribed Zyprexa (an antipsychotic) 5 mg and Benadryl (an antihistamine) 100 mg to be injected every 6 hours as needed. On 5/11/12 at 1:00 p.m. the patient received the ordered medication as an injection. The patient received an additional dose on 5/12/12 at 9:45 a.m. On 5/13/12 at 11:30 a.m. the patient was prescribed Zyprexa 10 mg and Benadryl 100 mg to be injected one time. The patient received the ordered medication as an injection on 5/13/12 at 11:40 a.m. On both days, the patient was violent and was "hitting and grabbing staff" and required the medication as an intervention to restrict the patient's behavior. The patient was not receiving Benadryl prior to the injections. The "Emergency Involuntary Medication Log" contained only the dose that was given on 5/13/12 at 11:40 a.m. The patient's chart did not contain the required restraint documentation as described in the policy above.
VIOLATION: MEDICAL STAFF Tag No: A0338
Based on the manner and degree of deficiencies cited, the hospital failed to comply with the Condition of Participation of Medical Staff. The hospital failed to ensure that the medical staff operated under the bylaws approved by the governing and was responsible for the quality of medical care provided to patients by the hospital.
The facility failed to meet the following standards under the Condition of Medical Staff :

A 0347 - Medical Staff Accountability
The hospital failed to ensure that the medical staff was organized and accountable to the governing body for the quality of medical care provided to the patients. The hospital also failed to have an individual physician who assumed responsibility for the organization and conduct of the medial staff.

A 0353 - Medical Staff Bylaws
The hospital failed to ensure that the interim medical director's exerted oversight over physician practice, in the form of on-site involvement and review of patient evaluation and treatment, on-site monitoring of restraint use and medical record deficiencies, documentation and timely reporting of a serious adverse drug reaction and peer review activities related to the psychiatric provider staff.
VIOLATION: MEDICAL STAFF ACCOUNTABILITY Tag No: A0347
Based on staff interviews and review of facility documents and medical records, the hospital failed to ensure that the medical staff was organized and accountable to the governing body for the quality of medical care provided to the patients. The hospital failed to have an individual physician who assumed responsibility for the organization and conduct of the medial staff. The failure created the potential for negative patient outcomes.

Findings:

1. The facility failed to have a permanent psychiatric medical staff to provide the specialized medical care required in a psychiatric hospital setting:

a. On 07/02/12 at approximately 11:0 a.m., the newly appointed Chief Executive Officer (CEO) was interviewed about his/her recent appointment. S/he stated the previous CEO left several months ago and the corporate senior vice president of quality had served as the interim CEO until 5/21/12 when the current CEO assumed the position. S/he identified other staff changes since the last survey in April, 2012, the most significant being that both of the psychiatrists, including the one serving as the medical director for the facility, had resigned since the last survey. S/he stated that the medical director's last day was 05/04/12 and the other psychiatrist's last day was 04/16/12. S/he stated that they were staffing the hospital with locum tenens psychiatrists through a physician placement agency. S/he stated that they still had their full psychiatric nurse practitioner to help with consistency and they were recruiting psychiatrists. S/he stated that they had found a psychiatrist that they were in the process of hiring to be the medical director, but that s/he would not be able to assume the new position until August 1, 2012. S/he stated that they were continuing to look for a second permanent psychiatrist.

b. On 07/05/2012 at 10:44 a.m., the corporate senior vice president of quality, who had flown in from the corporate headquarters that day to assist with the survey was interviewed. S/he stated that s/he had served as the CEO after the previous CEO left. She stated that s/he had functioned in that role for 7 weeks. S/he stated that she was in the position when both psychiatrists left. S/he stated that the medical director had initially provided a letter of intent to resign in February, 2012 with the plan to resign in 90 days. S/he stated that at one point, s/he had considered staying longer to help transition to new psychiatrist, but later changed his/her mind because of family demands. S/he stated the other psychiatrist gave 30 days notice of his/her plans to resign. When asked about what mechanisms were in place to ensure continuity of care and to limit the number of changes of psychiatrist for each individual patient with the use of multiple locum tenens psychiatrists, s/he stated that they attempted to get locum tenens that could make a commitment for several weeks. S/he also stated that the psychiatric nurse practitioner (NP) was coordinating assignment of psychiatrists to the patients as there were new locum tenens psychiatrists and new patient admissions. S/he clarified that the NP was coordinating the locum tenens psychiatrist assignments "within his/her scope of practice." When asked if they they had a system to track the number of different psychiatrists that each patient had to work with during the hospitalization , s/he said s/he was unaware of a system in place. When asked how patients and their families were notified about changes of attending psychiatrist every time there was a new locum tenens psychiatrist, s/he deferred to the social worker and the NP.

c. On 07/05/2012 at 11:47 a.m., the CEO, the Director of Social Work and the NP were interviewed about the director scheduling the locum tenens psychiatrists for a few weeks after the previous medical director left until the NP came back from vacation. From that time going forward, the NP was making assignments of the locum tenens psychiatrists as the temporary attending psychiatrists for the newly admitted and continuing patients. When asked how patients and their families were notified about changes of attending psychiatrist every time there was a new locum tenens psychiatrist, the social worker said that they did not have a policy or practice of notifying families if the attending psychiatrist changed. S/he stated that a family would be notified if they asked about something that required physician involvement. The NP stated stated that s/he that his/her practice was to call every new patient's family and that s/he tells all new locum tenens psychiatrists to call families when they take over a case. When asked about care-planning the issue of the patient having to experience multiple attending psychiatrist changes, they stated that they did not address it in the care plan. They stated that the only information about attending changes on the care plan was in the area on the form where the attending psychiatrist was listed. They stated that when there was a change of attending psychiatrists, the previous attending would be crossed out and the new attending psychiatrist's name would be entered.

d. Reference Tag A 0353 for findings related to medical staff members' failure to comply with bylaws, rules and regulations related to completion of medical records, restraint orders and on-call duties.

2. Failure of the Hospital to Have a Medical Director Who Assumed Responsibility for the Organization and Conduct of the Medial Staff:

a. Reference Tag A 0353 for findings related to the interim medical director's failure to exert oversight over physician practice, in the form of onsite involvement and review of patient evaluation and treatment, on-site monitoring of restraint use and medical record deficiencies, documentation and timely reporting of a serious adverse drug reaction and peer review activities related to the psychiatric provider staff. The psychiatric provider staff consisted of one psychiatric nurse practitioner (who was providing the on-site orientation and coordinating patient assignments) and a staff of temporary locum tenens contract psychiatrists.

b. Reference Tags A 0145 and A 0154 for findings related to the to use of restraints, without physician orders, to provide personal care and emergency psychotropic medications, without the consent or cooperation of the patients.
VIOLATION: MEDICAL STAFF BYLAWS Tag No: A0353
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, facility documents and staff interview, the hospital and medical staff failed to enforce the medical staff's bylaws and rules and regulations to carry out its responsibilities.

Findings:

1. Failure to Enforce Medical Staff Rules and Regulations Related to Professional Standards/Peer Review:

a. Review of the Medical Staff Rules and Regulations on 07/05/12 revealed the following, in part:
"20.0 STANDARDS OF PRACTICE
20.1 In general, the standards of practice of psychiatry in the Hospital will be governed by the standards of practice prevailing within the community. The Governing Board, however, holds the Medical Director and the Medical Staff accountable for the quality of practice within the Hospital. In furtherance of that responsibility, all members of the Medical Staff and all members of the AHP (Allied Health Professionals) Staff must abide by the following provisions addressing patient chart review and other issues relating to standards of practice:
A monthly sampling of medical records for each Practitioner shall be reviewed by the Medical Staff or by such committee or function of the Medical Staff as is designated for such peer review purposes in the Medical Staff Bylaws. Outside physicians may be utilized with the Governing Board approval.
-Any other medical record may be referred to peer review because of perceived unanticipated outcome or treatment complications."

b. On 07/09/2012 at 2:15 p. m., the director of medical records and medical staff office was interviewed and stated that no random peer review of 3 cases for each physician had been conducted since the previous medical director had resigned 05/04/12. S/he stated that the previous medical director had been reviewing 3 random cases per physician every quarter, with the last review having been completed March, 2012. Regarding incomplete medical records, s/he stated that s/he audited medical records daily and created a report of medical record deficiencies (e.g.. order and other required co-signatures) that was currently being provided to the chief nursing officer, the nurse manager and the CEO. S/he stated that the report had previously gone to the former medical director, who had dealt directly with the physicians to ensure that medical record deficiencies were corrected.

c. On 07/06/2012 at 3:43 p. m., corporate senior vice president of quality, who had served as the interim CEO until 5/21/12 when the current CEO assumed the position, was interviewed. S/he stated that they had determined that one of the locum tenens psychiatrists was copying old progress, adding to them and sometimes not providing an original signature of the altered work.

d. An e-mail provided by the CEO and director of medical records and medical staff office was reviewed on 7/9/12. The e-mail indicated that the director of medical records and medical staff office had been the person assigned to speak to the physician about not photocopying progress notes and not providing original signatures.

e. During an interview on 07/09/2012 at 2:15 p.m., the director of medical records and medical staff office confirmed that s/he had been the staff member that had to discuss the charting problems with the physician who was photocopying his/her notes and not providing original signatures. S/he acknowledged that it was a difficult conversation to have with physician. S/he stated that previously, that would have been handled by the medical director, on a physician-to-physician basis.

2. Failure to Enforce Medical Staff Rules and Regulations Related to On-Call:

a. Review of the Medical Staff Rules and Regulations on 070/5/12 revealed the following, in part:
"11.0 ON-CALL
There is a Physician possessing skills and knowledge in behavioral health and medical services who is on-call to the Hospital on a 24-hour basis to cover assessments, admissions, and emergencies. All Physicians who are members of the Active Medical Staff must participate in the on-call roster unless exempted by Medical Director.
The Medical Director shall be administratively responsible for maintain the Hospital's on-call roster.
On-call Physicians are required to respond to calls/pages by the Hospital within fifteen (15) minutes and if necessary, to be physically present at the Hospital within one hour."

b. On 07/05/2012 at 11:47 a.m., the Psychiatric Nurse Practitioner (NP) was interviewed and stated that in the first month after the former medical director left, the locum tenens psychiatrists were not willing to take off-hours on-call responsibilities. S/he stated that when s/he was or one of the other locum tenens psychiatrists were working, the corporate medical director, who lived/practiced in another city two hours away, was the listed on-call psychiatrist.

c. Review of the facility on-call schedules for May, 2012 and June, 2012 revealed the following, in part:
In May, 2012, the corporate medical director, who lived/practiced in another city two hours away, was the listed on-call psychiatrist for May 8th, 9th, 10th, 15th,16th, 17th, 22th, 23th, 24th, 29th, 30th and 31th.
In June, 2012, the corporate medical director, who lived/practiced in another city two hours away, was the listed on-call psychiatrist for June 8th.

d. On 07/11/2012 at 12:29 p.m., the Chief Executive Officer (CEO) was interviewed and stated that s/he had spoken to the corporate medical director by telephone that day and s/he had confirmed that s/he had never been in the facility during his/her tenure as the interim medical director.

e. Review of the medical record for sample patient #8 revealed that on 05/31/12, an emergency medication was a telephone order by the interim medical director (corporate medical director). The record contained a photocopy of the original order sheet with a signature of the interim medical director (corporate medical director).

f. On 07/11/2012, 12:33 p.m., the nurse manager was interviewed about the emergency medication order for sample patient #8. S/he stated that the order was express mailed to the interim medical director (corporate medical director), s/he signed and returned the order. S/he confirmed that s/he never actually saw or evaluated the patient for which s/he order the emergency medication.

3. Failure to Enforce Medical Staff Rules and Regulations Related to Medical Records:

a. Review of the Medical Staff Rules and Regulations on 070/5/12 revealed the following, in part:
"7.0 MEDICAL RECORDS
7.13 Discharge Documentation
The record of each discharged patient must have a discharge summary, signed by the Attending Physician, of the patient's hospitalization and recommendations concerning follow-up or aftercare, developed in conjunction with the community treatment agency as appropriate, as well as a brief summary of the patient's condition on discharge. The discharge summary must also include the reason for hospitalization , significant findings, procedures performed and treatments rendered, progress in meeting treatment goals, the name, dosage, frequency of any medications ordered for the patient at the time of discharge and the DSM Five Axis discharge diagnosis.
7.14 Completion of Medical Records - All discharge summaries and other medical record documentation shall be completed within fifteen (15) days following the patient's discharge. Incomplete records exceeding fifteen (15) days following discharge will be considered delinquent. Disciplinary measures, as specified in the Medical Staff Bylaws, would be instituted against the Practitioner who fails to complete medical records within the specified time frame."

b. On 09/03/12, an e-mail from the corporate senior vice president for quality improvement to the current CEO, dated 07/02/12, with reference to a prior e-mail from him/her dated 05/19/11, contained the following, in part:
"Protocol for Nurse Practitioners with Medicare, including Manage Medicare patients:
- Patient must be assigned to one of the psychiatrists as the attending physician
- If the NP does the psych eval (within 24 hours) the attending or covering psychiatrist must review and sign within 72 hours of admission. If any question regarding the psych eval the psychiatrist is to meet with the patient and document an addendum
- Attending psychiatrist or covering physician is to make rounds on the patient at least twice a week with a progress note
- Attending psychiatrist to co-sign the discharge summary
The regulatory requirement is to have a psychiatrist as the attending. The other items are what I consider minimum quality requirements and are not negotiable. Reminder - this applies only if allowed by state regulations."

c. Review of 20 sample medical records during the survey revealed that 4 records ( sample patients #8, #9, #10, #12) contained psychiatric progress notes that appeared to be photocopied from previous notes and did not appear to have original signatures. Two records (sample patients #3 and #8) contained psychiatric evaluations performed by the psychiatric nurse practitioner that were not co-signed by the attending psychiatrist. Three records (sample patients #6, #8 and #10) contained discharge summaries dictated by the psychiatric nurse practitioner that were not co-signed by the attending psychiatrist. Three records (sample patients #2 and #4 and #10) contained discharge summaries that had been dictated by a provider, the dictations contained areas signified by a line indicating missing information, and the provider/attending had not corrected the or signed/cosigned the dictations. Three records (sample patients #3, #14 and #15) contained dictated psychiatric evaluations that had not been corrected or signed by the attending. Four additional records (sample patients #16, #17, #18 and #20) contained psychiatric evaluations that had not been signed by the attending psychiatrist. These medical records findings were confirmed by multiple facility staff during the survey.

4. Failure of the Medical Staff to Document and Report a Serious Adverse Drug Reaction:

a. On 07/06/12 at 1:30 PM the medical record for sample patient #10 was reviewed. The patient was admitted on [DATE], discharged on [DATE], and readmitted on [DATE]. he nursing admission note from 05/04/12 stated that the patient had a known history of [DIAGNOSES REDACTED] (NMS), a rare but life-threatening reaction to a neuroleptic or antipsychotic medication, from an admission to this facility in April, 2012. This condition was not noted in the patient's history and physical or psychiatric evaluations and was not listed under allergies. The syndrome was not mentioned on the initial treatment plan dated 05/04/12 and was not made part of the patient's on-going interdisciplinary team care planning.

b. Review of the Medical Staff Rules and Regulations on 070/5/12 revealed the following, in part:
"7.0 MEDICAL RECORDS
7.5 The Attending Physician shall be held responsible for all of their documentation in the medical record, unless an official transfer of the patient to the care of another Attending Physician has taken place an has been documented in the medical record."

c. On 07/10/12 at 3:00 p.m., the pharmacist was interviewed about the adverse drug reaction related to sample patient #10. S/he stated that s/he had not yet reported the drug reaction per hospital policy because s/he had not been notified about the reaction until last week, after the surveyors identified the concern in the medical record. S/he referred to the policy /procedure entitled "Performance Improvement Reactions: Adverse (Untoward) Drug." S/he provided a copy of a form, entitled "Medication Variance Report," that should have been completed and provided as a notification to the pharmacy. S/he stated that to his/her knowledge, no such report was generated. S/he stated that had s/he been aware of the incident at the time, back in April, 2012, s/he would have done a drug interaction report to look in more depth at the patient's medication history to look for any medication combinations that could have been a factor in the NMS and could have provided that to the acute care providers treating the patient's NMS reaction. S/he stated that the adverse drug reaction, per policy would have been reported to the FDA (Food and Drug Administration),
as required, taken to the facilities' Pharmacy and Therapeutics Committee for Medical Staff Review and the reaction should have been prominently flagged as an allergy in the patient's medical record and pharmacy system. S/he stated that the previous medical director had taken a leadership role in working with the pharmacy, hospital staff and medical staff when an adverse drug reaction occurred in the past. S/he was unsure what factors contributed to the the gap in reporting/documenting the adverse drug reaction appropriately, in the case of Sample patient #10.

5. Failure to Enforce Medical Staff Rules and Regulations Related to Restraint and Seclusion:

a. Review of the Medical Staff Rules and Regulations on 070/5/12 revealed the following, in part:
"9.0 RESTRAINT AND SECLUSION
9.1 General Guidelines for the Use of Restraint and Seclusion
Medical Staff acknowledges that each patient has the right to be free of Restraint and Seclusion that are not medically necessary or that are used as a means of coercion, discipline, convenience or retaliation.
Each patient shall be treated under the least restrictive conditions consistent with his/her condition and shall not be subjected to unnecessary use of Restraint and Seclusion.
Restraint or Seclusion should be ordered only after alternatives appropriated to the patient's
behavior have been considered and found ineffective and when the benefits to the patient are greater than the associated risks with using the Restraint or Seclusion.
Restraint and Seclusion can only be order by a Practitioner.
9.2 Restraint or Seclusion Used for Emergency Behavior Management Reasons
Orders - A Practitioner must order the Restraint or Seclusion, the use of which is limited to Emergency Situations. If a Practitioner is not immediately available, a specifically trained registered nurse may initiate Restraint or Seclusion based on appropriate assessment of the patient. A Practitioner will be notified as soon as possible thereafter to obtain an order.
9.4 Notification and Review
The Medical Director shall review all Restraint and Seclusion cases monthly and shall investigate unusual or unwarranted patterns or utilization"

b. Reference Tags A 0145 - Patient Rights: Free from Abuse/Harassment and A 0154 - Patient Rights: Use of Restraint or Seclusion for finding related to use of restraints, without physician orders, to provide personal care and emergency psychotropic medications, without the consent or cooperation of the patients.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on interviews and document review the facility failed to maintain all nurse assignment sheets in order to provide documentation of past staffing which reflected when nurses worked shifts and if the staffing met requirements of nursing qualifications and patient needs.

Findings:

1. The facility failed to maintain all nurse assignment sheets for the time period reviewed of 05/01/12 through 06/30/12.

a) On 07/03/12 at 9:00 a.m. the facility's policy titled "Assignment of Nursing Staff" revised June, 2011 was reviewed. The policy stated that assignment of nursing staff would be dependent on the qualifications of each nurse as well as the needs and acuity level of patients. The policy stated that nurse staffing assignment sheets would be maintained by the Director of Nursing (DON).

b) On 07/05/12 at 8:40 a.m. review of the facility's nurse staffing assignment sheets was conducted. Assignment sheets were requested for 05/01/12 through 06/30/12, a total of 61 days. Documents revealed that for the day/evening shifts on the Phase I section of the facility, 7 of 61 days nurse staffing assignment sheets were missing. On the Phase II section of the facility, 8 of 61 days nurse staffing assignment sheets were missing. Documents revealed that for the night shift on the Phase I section of the facility, 22 of 61 days nurse staffing assignment sheets were missing. On the Phase II section of the facility, 46 of 61 nurse assignment sheets were missing.

c) On 07/05/12 at 9:54 a.m. the facility's CEO was informed of the missing nurse assignment sheets for 05/01/12 through 06/30/12. The CEO stated that s/he would ask the Nurse Manager to locate the missing assignment sheets.

d) On 07/05/12 at 2:03 p.m. an interview was conducted with the facility's DON who reviewed the nurse assignment sheets obtained by surveyors. The DON stated that s/he would ask the Nurse Manager to locate the missing sheets as this was an "ungodly amount to be missing."

e) On 07/05/12 at the time surveyors exited the facility, the CEO confirmed that the surveyors had received all the nurse staffing sheets that existed and also confirmed that staffing sheets were missing from the facility's documents.
VIOLATION: SUPERVISION OF CONTRACT STAFF Tag No: A0398
Based on personnel file review, staff interview, and review of the facility's policies/procedures the facility failed to ensure that all non-employee files contained proper orientation documentation to the facility as evidenced in 13 of 19 agency nursing staff files reviewed. This failure did not ensure non-employee nurses adhered to the policies and procedures of the hospital. This created the potential for negative patient outcome.

The findings were:

1. The facility failed to maintain documentation of orientation to the facility in 13 of 19 agency nursing staff files reviewed.

a. The policy and procedure titled "Agency Staff," that was last revised May 2011, stated the following:
"PROCEDURE
1. Agency personnel are booked through local registries. An Agency Employee Profile is completed by the agency on each agency personnel working at HBND and kept on file at HBND. DON/designee will ensure that all required documentation is obtained prior to being accepted for assignment to the hospital.
4. Agency personnel will be oriented to the hospital and instructed regarding their individual assignment of the shift charge Nurse or nursing staff. Director of Social Services (social services staff), prior to working. Agency personnel will be given an orientation packet prior to or upon arrival for their review and completion. Orientation will be documented on the agency Orientation Checklist and include:
a. Fire
b. Safety
c. Infection Control
d. Confidentiality
e. Reading Haven's Agency Orientation Manual.
5. Agency staff member complete the Agency Orientation Sheet, verifying completion of these requirements.
9. An agency evaluation will be completed on all registry/agency personnel at the end of each shift worked by the supervising HBND personnel and/or Director of the department for three work shifts.
13. An agency binder is located in the nursing station and will be maintained by the Director of Nursing. The nurse in charge of the shift will review the nursing agency file to assure that all required documents have been obtained. The nurse in charge will also review any performance evaluations to identify any potential areas of weakness."

b. On 07/02/12 a list of all nursing staff, including agency/pool staff was requested and provided. The facility maintained a personnel file for each agency staff member. The personnel files contained a form titled "Haven Behavioral - North Denver Agency Orientation."

c. Sample agency personnel file #1 was a Certified Nurses' Aide (CNA) who had been to the facility most recently on 06/14/12. The personnel file contained a form titled "Haven Behavioral - North Denver Agency Orientation" that was initialed by the CNA and signed on 05/03/11. The form did not have any indication that the orientation was conducted or verified by a facility charge nurse or designee.

d. Sample agency personnel file #2 was a Certified Nurses' Aide (CNA) who had been to the facility most recently on 06/14/12. The personnel file contained a form titled "Haven Behavioral - North Denver Agency Orientation" that was initialed by the CNA and signed on 05/03/12. The form did not have any indication that the orientation was conducted or verified by a facility charge nurse or designee.

e. Sample agency personnel file #3 was a Certified Nurses' Aide (CNA) who had been to the facility most recently on 06/10/12. The personnel file contained a form titled "Haven Behavioral - North Denver Agency Orientation" that was initialed by the CNA and signed on 04/20/11. The form did not have any indication that the orientation was conducted or verified by a facility charge nurse or designee.

f. Sample agency personnel file #4 was a Certified Nurses' Aide (CNA) who had been to the facility most recently on 06/05/12. The personnel file contained a form titled "Haven Behavioral - North Denver Agency Orientation" that was initialed by the CNA and signed on 06/05/12. The form did not have any indication that the orientation was conducted or verified by a facility charge nurse or designee. Additionally, the Agency Orientation form contained a line on the bottom of the form for the "Signature of Nursing Supervisor/Unit Nurse" that was left blank.

g. Sample agency personnel file #5 was a Certified Nurses' Aide (CNA) who had been to the facility most recently on 06/14/12. The personnel file contained a form titled "Haven Behavioral - North Denver Agency Orientation" that was initialed by the CNA and signed on 10/27/11. The form did not have any indication that the orientation was conducted or verified by a facility charge nurse or designee. Additionally, the Agency Orientation form contained a line on the bottom of the form for the "Signature of Nursing Supervisor/Unit Nurse" that was signed by the same person that signed the "Agency Employee Profile" on the line provided for the "Signature of Agency Representative" which listed his/her title as "Staffer," not Charge Nurse.

h. Sample agency personnel file #7 was a Certified Nurses' Aide (CNA) who had been to the facility most recently on 06/05/12. The personnel file contained a form titled "Haven Behavioral - North Denver Agency Orientation" that was initialed by the CNA and signed on 05/29/12. The form did not have any indication that the orientation was conducted or verified by a facility charge nurse or designee. Additionally, the Agency Orientation form contained a line on the bottom of the form for the "Signature of Nursing Supervisor/Unit Nurse" that was left blank.

i. Sample agency personnel file #8 was a Certified Nurses' Aide (CNA) who had been to the facility most recently on 06/11/12. The personnel file contained a form titled "Haven Behavioral - North Denver Agency Orientation" that was initialed by the CNA and signed on 06/02/12. The form did not have any indication that the orientation was conducted or verified by a facility charge nurse or designee. Additionally, the Agency Orientation form contained a line on the bottom of the form for the "Signature of Nursing Supervisor/Unit Nurse" that was left blank.

j. Sample agency personnel file #9 was a Certified Nurses' Aide (CNA) who had been to the facility most recently on 06/10/12. The personnel file contained a form titled "Haven Behavioral - North Denver Agency Orientation" that was initialed by the CNA and signed on 06/04/12. The form did not have any indication that the orientation was conducted or verified by a facility charge nurse or designee. Additionally, the Agency Orientation form contained a line on the bottom of the form for the "Signature of Nursing Supervisor/Unit Nurse" that was left blank.

k. Sample agency personnel file #11 was a Certified Nurses' Aide (CNA) who had been to the facility most recently on 06/08/12. The personnel file contained a form titled "Haven Behavioral - North Denver Agency Orientation" that was initialed by the CNA and signed on 08/26/11. The form did not have any indication that the orientation was conducted or verified by a facility charge nurse or designee. Additionally, the Agency Orientation form contained a line on the bottom of the form for the "Signature of Nursing Supervisor/Unit Nurse" that was left blank.

l. Sample agency personnel file #14 was a Registered Nurse (RN) who had been to the facility most recently on 06/18/12. The personnel file contained a form titled "Haven Behavioral - North Denver Agency Orientation" that was initialed by the RN and signed on 06/18/12. The form did not have any indication that the orientation was conducted or verified by a facility charge nurse or designee. Additionally, the Agency Orientation form contained a line on the bottom of the form for the "Signature of Nursing Supervisor/Unit Nurse" that was left blank.

m. Sample agency personnel file #15 was a Certified Nurses' Aide (CNA) who had been to the facility most recently on 06/14/12. The personnel file contained a form titled "Haven Behavioral - North Denver Agency Orientation" that was initialed by the CNA and signed on 03/21/12. The form did not have any indication that the orientation was conducted or verified by a facility charge nurse or designee.

n. Sample agency personnel file #16 was a Registered Nurse (RN) who had been to the facility most recently on 06/11/12. The personnel file contained a form titled "Haven Behavioral - North Denver Agency Orientation" that was initialed by the RN and signed on 12/05/11. The form did not have any indication that the orientation was conducted or verified by a facility charge nurse or designee. Additionally, the Agency Orientation form contained a line on the bottom of the form for the "Signature of Nursing Supervisor/Unit Nurse" that was signed by the same person that signed the "Agency Employee Profile" on the line provided for the "Signature of Agency Representative" which listed his/her title as "Staffer," not Charge Nurse.

o. Sample agency personnel file #18 was a Registered Nurse (RN) who had been to the facility most recently on 06/09/12. The personnel file contained a form titled "Haven Behavioral - North Denver Agency Orientation" that was initialed by the RN and signed on 06/18/12. The form did not have any indication that the orientation was conducted or verified by a facility charge nurse or designee. Additionally, the Agency Orientation form contained a line on the bottom of the form for the "Signature of Nursing Supervisor/Unit Nurse" that was left blank.

p. An interview with the facility's Director of Nursing (DON) was conducted on 07/03/12 at 12:26 p.m. S/he stated that s/he had been in the facility since 01/31/12. S/he stated that the expectation for agency staff was that the agency staff member would "be oriented by our staff." The DON stated that the person responsible for the maintenance of the personnel files for the agency staff was expected to follow up on any issues with the agency personnel. The DON confirmed that the person responsible for the maintenance of the personnel files was not a nurse and was not a supervisor. S/he stated that the staff member was s/he was clerical and was the staffing coordinator.

q. An interview with the Nurse Manager was conducted on 07/03/12 at 1:08 p.m. S/he stated that s/he had been in the role of the Nurse Manager since 12/2011. S/he stated that the staffing coordinator was relied upon to ensure that the proper documentation was present in the personnel files for the agency staff. S/he stated that prior to an agency staff member coming to the facility the staffing coordinator reviews the personnel file and that no one else reviewed the file prior to the agency staff member providing care within the facility.

r. An interview with the staff member that was responsible for the maintenance of the agency staff personnel files was conducted on 07/03/12 at 2:50 p.m. S/he stated that when s/he knew that an agency staff member was coming into the facility, s/he would place the paperwork to be completed into the charge nurse's box or kardex for them to review with the agency staff member. S/he stated that when issues were brought up with the performance of agency staff, s/he would discuss the issue with the agency. When asked if nursing leadership had role in agency staff oversight, s/he stated that sometimes there will be a conversation between the Nurse Manager and him/her. S/he stated that the DON had no oversight or involvement with agency staff.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on the manner and degree of deficiencies cited, the facility failed to comply with the Condition of Nursing Services. The facility failed to ensure the appropriate oversight of nursing services which lead to incomplete nursing documentation in patient medical records, lapses in carrying out physician orders, lack of complete and current policies including nursing staff policies, incomplete care planning, incomplete nurse staffing records, and lack of documentation of orientation of non-employee nurses.

The facility failed to meet the following standards under the Condition of Nursing Services:
TAG A 386 - ORGANIZATION OF NURSING SERVICES
The facility failed to ensure that nursing documentation of patient observations were performed per physician orders and the facility's policies, that nursing assessments and reassessments were complete, that patient care was performed as ordered by physicians, and that policies and procedures related to nursing staff were correct and current in policy manuals.
TAG A 396 - NURSING CARE PLAN
The facility failed to ensure that care planning was developed, updated when necessary, and carried out per facility policies as evidenced in 7 of 20 medical records reviewed.
TAG A 397- PATIENT CARE ASSIGNMENTS
The facility failed to maintain nursing assignment sheets in order to provide documentation of past staffing which reflected when nurses worked shifts and if the staffing met requirements of nursing qualifications and patient needs.
TAG A 398 - SUPERVISION OF CONTRACT STAFF
The facility failed to ensure that all non-employee files contained proper orientation documentation to the facility as evidenced in 13 of 19 agency nursing staff files reviewed. The facility did not ensure non-employee nurses adhered to the policies and procedures of the hospital.
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and document review the facility failed to ensure appropriate oversight of nursing services. Nursing documentation regarding patient observation was not performed per physician orders and facility policies, nursing assessments and reassessments of patients were found to be incomplete, patient care was not performed as ordered by physicians, and policies and procedures related to nursing staff were not current in the policy manuals.

Findings:

1. The facility failed to ensure that nursing services were carried out per facility policies with regard to the documentation of nurse progress notes for patients receiving line of sight or 1:1 observation.

a). On 07/09/12 at 11:00 a.m. the facility's policy titled, "Nursing Flow Sheet & Progress Note", revised June 2011, was reviewed. The policy stated that for patients receiving line of sight or 1:1 monitoring per a physician's order, nurses would document in the progress notes twice per shift. The facility's policy titled, "Level of Observation", revised May, 2011 was reviewed and revealed that nursing staff could not discontinue or lessen the observation level of patients without a physician's order.

b). On 07/05/12 review of the facility's weekly and monthly staffing documents revealed that for this facility, a shift is a twelve hour period from 7:00 a.m. to 7:00 p.m., the day/evening shift, and from 7:00 p.m. to 7:00 a.m., the night shift.

c). From 07/03/12 through 07/10/12 review of patient medical records was conducted for documentation of line of sight and 1:1 observation of patients. Of 20 medical records reviewed, 3 were found to have orders for line of sight or 1:1 observation (sample patients #3, #8, and #20). Three of 3 records revealed that nursing staff did not document progress notes per the facility's policy of 2 notes per shift for these patients with orders for line of sight or 1:1 observation.

d) On 07/03/12 at 10:00 a.m. review of the medical record for sample patient #3 revealed a physician's order on 05/17/12 at 7:00 p.m. for 1:1 observation due to fall risk status. The record was reviewed for presence of nurse progress notes for a two week period, 05/17/12 through 05/31/12. No physician order was found in the patient record to discontinue or lessen the level of observation during this time period. The record revealed the following nurse progress notes: 1 on 05/17/12 at 11:30 p.m., 1 on 5/18/12 at 1:30 p.m., 2 on 5/19/12 at 5:00 a.m. and 11:00 p.m., 2 on 05/20/12 at 1:30 p.m. and 11:40 p.m., 1 on 05/21/12 at 11:30 p.m., 1 on 05/22/12 at 11:45 p.m., 2 on 05/24/12 at 5:00 a.m. and 6:00 p.m., 1 on 05/25/12 at 3:00 p.m., 1 on 05/26/12 with no time documented in the note, 1 on 05/27/12 at 11:30 p.m., 2 on 05/28/12 at 3:00 p.m. and 11:55 p.m., 2 on 05/29/12 at 11:00 a.m. and 11:45 p.m., 3 on 05/30/12 at 2:00 p.m., 5:15 p.m. and 11:55 p.m., 3 on 5/31/12 at 3:00 a.m., 3:30 p.m., and 00:15 a.m. Only one date, 05/23/12, revealed documentation of two notes per shift per the facility's policy. Each note contained documentation by nursing staff that the patient remained on 1:1 observation. No physician order was found in the patient record to discontinue or lessen the level of observation.

e) On 07/10/12 at 1:33 p.m. review of the medical record for sample patient #8 revealed an order for line of sight observation on 05/16/12 at the time of admission, 1:30 p.m., and a physician order to discontinue line of sight observation on 05/19/12 at 5:00 p.m.. The record revealed the following nurse progress notes: 2 on 5/16/12 at 6:00 p.m. and 11:30 p.m., 2 on 05/17/12 at 11:40 a.m. and 11:30 p.m., and 2 on 5/18/12 at 4:30 p.m. and 11:10 p.m. Of the 3 dates reviewed, none contained 2 nurse progress notes per shift, per the facility's policy.

Medical record review for sample patient #8 revealed an order on 05/27/12 at 10:30 a.m. for 1:1 observation, and on 06/04/12 at 10:00 a.m. an order to discontinue 1:1 observation and begin line of sight observation. The record was reviewed for the presence of nurse progress notes for a two week period, 05/27/12 through 06/09/12. No physician order was found in the patient record to discontinue or lessen the level of observation during this time period. The record revealed the following nurse progress notes: 2 on 05/27/12 at 1:30 p.m. and 7:15 p.m., 2 on 05/28/12 at 3:20 p.m. and 11:10 p.m., 2 on 05/29/12 at 11:50 a.m. and 10:40 p.m., 2 on 05/30/12 at 12:30 p.m. and 6:00 p.m., 2 on 05/30/12 at 12:30 p.m. and 6:00 p.m., 1 on 06/01/12 at 4:38 p.m., 1 on 06/02/12 at 11:30 a.m., 1 on 06/03 at 1:20 p.m., 1 on 06/04/12 at 5:30 p.m., 1 on 6/5/12 at 12:10 p.m., 2 on 06/06/12 at 11:45 p.m. and 6:00 p.m., 1 on 06/07/12 at 2:00 p.m., 2 on 06/8/12 at 9:50 a.m. and 9:30 p.m., and 1 on 06/9/12 at 11:36 a.m. Only one date, 05/31/12, contained documentation of two notes per shift per the facility's policy.

f) On 07/09/12 at 10:38 a.m. review of the medical record for sample patient # 20 revealed an order on 05/06/12 at 12:05 a.m. for 1:1 monitoring due to escalated behavior. On 05/09/12 the order was changed to line of sight monitoring. The record was reviewed for the presence of nurse progress notes for a two week period, 05/06/12 through 05/19/12. No physician order was found in the patient record to discontinue or lessen the level of observation during this time period. The record revealed the following nurse progress notes: 1 on 05/06/12 at 12:30 a.m., 1 on 05/07/12 at 10:30 p.m., 4 on 05/08/12, 2 on 05/09/12 at 4:55 a.m. and 10:15 p.m., 1 on 05/10/12 at 10:00 p.m., 1 on 05/11/12 at 11:50 p.m., 1 on 05/12 12 at 11:35 p.m., 1 on 05/13/12 at 11:30 p.m., 4 on 05/14/12, 3 on 05/15/12 at 5:04 p.m., 6:20 p.m., and 11:10 p.m., 2 on 05/16/12 at 11:30 a.m. and 11:40 p.m., 2 on 05/17/12 at 2:30 p.m. and 11:00 p.m., and 2 on 05/19/12 at 6:00 a.m. and 10:48 p.m. Of the 14 days reviewed, 2 contained documentation of 2 nurse progress notes per shift per the facility's policy. No documentation could be found in the record of nursing notes on 05/18/12.

g) On 07/09/12 at 3:33 p.m. an interview was conducted with the facility's Nurse Manager regarding documentation of nurse progress notes. S/he stated that nurse progress notes should be documented a minimum of 1 time every 24 hours unless the patient was on 1:1 observation in which case nurse notes would be documented 1 time each shift. The facility's policy was reviewed with the Nurse Manager regarding required documentation of 1:1 and line of sight observations by nursing staff.

h) On 07/11/2012 at 3:00 p.m. an interview was conducted with the facility's CEO and the Vice President of Clinical Operations to inform them of the findings related to lack of nursing progress notes with regard to line of sight and 1:1 observation. Because findings were related to items that were not found in the records, the CEO and Vice President were asked twice if they would like to review the records to confirm that the documentation was not present. The CEO and Vice President declined to review the records and the Vice President stated that she did not need to review the records and would accept the surveyors' findings.

2. The facility failed to ensure that nursing services were carried out per facility policy with regard to documentation of nursing reassessment of patients.

a) On 07/09/12 at 11:15 a.m. the facility's policy titled, "Nursing Flow Sheet & Progress Note", revised June 2011, was reviewed. The policy stated that a reassessment of patients would be conducted by nursing staff on days and evenings. This reassessment would be in addition to a written nurse progress note.

b) From 07/03/12 through 07/10/12 review of patient medical records was conducted for completeness of the patient reassessment forms. Six of 20 patient records were found to have missing or incomplete nursing reassessment documentation (sample patients #3, #7, #11, #12, #13, and #17).

c) On 07/03/12 at 2:15 p.m. the medical record for sample patient #3 was reviewed and the following reassessment documentation was noted: 05/12/12 at 11:30 p.m. contained no documentation of breath sounds or date of last bowel movement; 05/13/12 at 11:20 p.m. contained no documentation of skin condition or breath sounds; 5/14/12 at 2:50 p.m. contained no documentation of the suicide risk assessment section, breath sounds, or date of last bowel movement; 05/14 12 at 11:55 p.m. contained no documentation of appetite, skin condition, or breath sounds; 5/27/12 at 12:40 p.m. contained no documentation of breath sounds; 05/28/12 at 3:00 p.m. contained no documentation of breath sounds. No comment or note was found explaining why the assessments were not completed by nursing staff.

d) On 07/06/2012 at 1:24 p.m. the medical record of sample patient #7 was reviewed and the following reassessment documentation was noted: 03/31/12 at 6:00 p.m. no breath sounds were documented; 03/31/12 at 11:00 p.m. contained no documentation of breath sounds; 04/01/12 at 12:18 p.m. contained no documentation of urinary status, ambulation, breath sounds, or date of last bowel movement; 04/01/12 at 11:00 p.m. contained no documentation of mood; 04/03/12 at 1:55 p.m. contained no documentation of aggression or skin condition; 04/04/12 at 10:00 p.m. contained no documentation of breath sounds; 04/05/12 at 4:00 p.m. contained no documentation of mood, aggression, skin condition, or breath sounds. No comment or note was found explaining why the assessments were not completed by nursing staff.

e) On 07/09/12 at 12:20 p.m. the medical record for sample patient #11 was reviewed and the following reassessment documentation was noted: 05/20/12, evening shift, was blank, containing no documentation of any reassessment data; 05/26/12 at 11:30 p.m. contained no documentation of thought processes, breath sounds, or date of last bowel movement; 05/30/13, with no time documented, contained no documentation in the psychiatric assessment section, and no breath sounds; 06/03/12 at 11:15 p.m. contained no documentation of urinary status or ambulation; 06/09 at 1:10 p.m. contained no documentation of breath sounds; 06/12/12 at 11:00 p.m. contained no documentation of oral intake; 06/18/12 at 12:00 p.m. contained no documentation of breath sounds. No comment or note was found explaining why the assessments were not completed by nursing staff.

f) On 07/09/12 at 11:43 a.m. the medical record for sample patient #12 was reviewed and the following reassessment documentation was noted: 06/30/12 at 11:30 a.m. contained no documentation of breath sounds; 06/30/12 at 11:10 p.m. contained no documentation of mood, behavior, appetite, breath sounds, or date of last bowel movement; 07/01/12 at 12:00 p.m. contained no documentation of breath sounds; 07/02/12 at 12:25 p.m. contained no documentation of affect or mood. No comment or note was found explaining why the assessments were not completed by nursing staff.

g) On 07/10/12 at 9:51 a.m. the medical record for sample patient #13 was reviewed and the following reassessment documentation was noted: 06/22/12 at 10:00 p.m. contained no documentation of behavior, though processes, appetite, oral intake, breath sounds, or date of last bowel movement; 06/23/12 at 11:30 p.m. contained no documentation of breath sounds; 06/24/12 at 11:10 p.m. contained no documentation of appetite or breath sounds; 06/25/12 at 11:20 p.m. contained no documentation of appetite, skin condition, or breath sounds; 06/26/12 at 9:50 p.m. contained no documentation of mood or date of last bowel movement; 06/27/12 at 3:10 p.m. contained no documentation of breath sounds; 06/27/12 at 11:00 p.m. contained no documentation of mood or date of last bowel movement; 06/28/12 at 10:00 p.m. contained no documentation of medication or oral intake; 06/29/12 at 9:23 a.m. contained no documentation of breath sounds; 06/29/12 at 11:30 p.m. contained no documentation of the date of last bowel movement; 06/30/12 at 3:30 p.m. contained no documentation of breath sounds; 06/30/12 at 11:05 contained no documentation of breath sounds; 07/02 at 10:55 p.m. contained no documentation of vital signs, appetite, or breath sounds; 07/03/12 at 11:34 a.m. contained no documentation of breath sounds; 07/03/12 at 11:30 p.m. contained no documentation of appetite or breath sounds; 07/05/12 at 11:55 p.m. contained no documentation of vital signs, appetite, urinary status, ambulation, or skin condition; 07/09/12 at 6:00 p.m. contained no documentation of vital signs or breath sounds; 07/09/12 at 11:15 p.m. contained no documentation of vital signs, breath sounds or the date of last bowel movement. No comment or note was found explaining why the assessments were not completed by nursing staff.

h) On 07/05/12 at 10:46 a.m. the medical record for sample patient #17 was reviewed and the following reassessment documentation was noted: 06/06/12 at 5:00 p.m. contained no documentation of breath sounds or date of last bowel movement; 06/06/12 at 9:45 p.m. contained no documentation of breath sounds or date of last bowel movement; 06/08/12 at 10:30 p.m. contained no documentation of date of last bowel movement; 06/08/12 at 11:30 p.m. contained no documentation of breath sounds or date of last bowel movement. No comment or note was found explaining why the assessments were not completed by nursing staff.

i) On 07/06/2012 at 12:03 p.m. an interview was conducted with the facility's CEO to discuss the reassessment documentation for sample patient #17. The CEO stated that the expectation for nursing documentation on this form was that no areas should be left blank or not documented on unless a section was not applicable and in such case the nurse would make a note reflecting that. S/he stated that documentation of "new admit" for date of last bowel movement was not appropriate.

j) On 07/09/2012 at 3:33 p.m. an interview was conducted with the facility's Nurse Manger regarding the expectations of nursing documentation. The Nurse Manager stated that patient reassessments should be conducted by nursing staff each shift, day and night shifts, and that no blanks should be left on the reassessment form.

3. The facility failed to ensure that nursing staff carried out patient care per physician orders.

a) On 07/09/12 the facility's policy titled "Nursing Procedures", revised May, 2011, was reviewed. The policy stated that nursing staff would follow physicians' orders as written.

b) On 07/02/12 at 12:09 p.m. the medical record for sample patient #1 was conducted. The initial nursing assessment indicated that the patient needed assistance ambulating, bathing, and dressing, used a wheelchair, had a foley catheter in place due to urinary incontinence, and had a sacral pressure sore at the time of admission on 06/01/12 that was documented on a drawing in the patient record. The record revealed a physician order written on 06/01/12 at 11:30 p.m. for a wound care consultation to be scheduled by nursing staff as follow up to the existing sacral wound. On 06/04/12 at 11:30 p.m. the patient was discharged to home at the request of family. No documentation was found in the patient's record indicating that a consultation for wound care was scheduled. In addition, for the dates 06/02/12, 06/03/12, and 06/04/12 the nursing reassessment sheets show no documentation that the sacral wound was observed by nursing staff. The section of the reassessment form for "open wounds" was left blank as was the physical diagram for indicating where wounds are located. No documentation was found in the nurse progress notes indicating that nursing staff followed up on the status of the existing sacral wound.

c) On 07/05/12 at 10:46 a.m. the medical record for sample patient #17 was conducted. The patient was admitted on [DATE] and discharged on [DATE]. On 06/14/12 a physician order for physical therapy was noted in the medical record. No documentation was found in the record to indicate that the patient received physical therapy during hospitalization .

4. The facility failed to ensure that all policy and procedure binders throughout the facility contained the same correct and current policies and that nursing staff had access to all current policies in order to provide guidance for quality patient care.

a) On 07/02/12 at 10:36 a.m. the CEO was asked to supply the facility's policy and procedure binder to surveyors.

b) On 07/02/12 at 11:15 a.m. after reviewing the policy binder and the table of contents, surveyors requested policies specific to transfer of patients who needed medical care that could not be provided by the facility, because a transfer policy could not be located in the table of contents or in the policy binder. Surveyors also requested the facility's adverse drug reaction policy which was not present in the policy binder.

c) On 07/02/12 at 12:51 p.m. an interview was conducted with the facility's Nurse Manager. S/he was asked if the facility had a transfer policy to be used when patients are transferred to another hospital for medical care. The Nurse Manager stated that the facility did not have a transfer policy. S/he stated that in February, 2012, s/he developed a "cheat sheet" for nursing staff to use when transferring patients out of the facility for medical care. The Nurse Manager provided a two page document dated 04/16/12 titled "Checklist" which included instructions to nursing staff on how to admit, discharge, and transfer patients and how to carry out the E-Med (emergency medication) process and how to carry out radiology and stat orders. The document contained 11 sets of initials, but no names or dates of when nursing staff received the education contained in this document.

d) On 07/02/12 at 1:24 p.m. the CEO stated that the table of contents for the policy binder presented to surveyors was not current. S/he gave a copy of the adverse drug policy to surveyors and stated "this is the current policy." The CEO stated that the policy manual at the nurses station was different from the one s/he provide to surveyors and that the adverse drug reaction policy was "not on the floor", meaning that the policy was not available to nursing staff. S/he stated that the manuals were "just recopied." The CEO stated that only the pharmacy had copies of the policies related to adverse drug reaction.

e) On 07/02/12 at 1:45 p.m. an interview was conducted with the facility's Director of Nursing (DON) who stated that the facility did not have a transfer policy for nurses to refer to when transferring patients to another facility to receive medical care. The DON stated that s/he had recently trained nursing staff on the expectations of how to correctly transfer patients. When asked what prompted this training the DON stated that s/he was "tired of hearing from patient's family members" that they had not been informed about transfers out of the facility to another hospital.

f) On 07/06/12 at 10:57 a.m. an interview was conducted with the facility's CEO to review the facility's policy titled "Nursing Flow Sheet & Progress Note" last revised June, 2011, as the instructions in the policy did not match the flow sheet document found in patient medical records. The facility's CEO stated that the policy referred to an assessment sheet that the facility no longer uses and that the policy had not been changed to reflect the actual document that is being used to record patient information. The CEO agreed that the policy binder was not current and correct with regard to this policy.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interviews and document review the facility failed to ensure that care planning was developed, updated when necessary, and carried out per facility policies. Seven of 20 medical records reviewed revealed issues present in the records that were significant for the patient's health and safety but were not included in care planning.

Findings:

1. Review of 20 patient medical records revealed lack of care planning, and/or implementation of plans, for significant issues for 7 patients (sample patients #1, #7, #9, #10, #11, #12, and #17).

a) On 07/02/12 at 2:17 p.m. the facility policy titled, "Treatment Plan-Interdisciplinary" revised June, 2011, was reviewed. The policy stated that the RN would initiate the treatment plan within 8 hours of admission and that the initial plan would include high risk and critical medical problems, appropriate physician and nursing interventions determined by the initial assessment, and the physician's orders. Within 72 hours of admission the interdisciplinary team, made up of the physician, RN, social worker and other disciplines, would develop a treatment plan and would review the plan a minimum of two times per week. The treatment plan would also contain documentation of discharge planning.

b) On 07/02/12 at 12:09 p.m. the medical record for sample patient #1 was reviewed. Documentation revealed an initial treatment plan dated 06/01/12 with the following medical conditions to be addressed: hypertension, and care of an existing sacral ulceration.

The documented plan to address hypertension, beginning 06/01/12, was to monitor the patient's blood pressure 2 times /day. Review of the patient's medical record on 07/02/12 at 12:09 p.m. revealed that on 06/02/12 the patient had only one set of vital signs, documented at 10:40 p.m.. The Nursing Assessment document revealed that on 06/02/12 at 6:50 p.m. when other assessment information was documented, no vital signs were obtained and no nursing note was present explaining why vital signs were not obtained and documented.

The documented plan to address the sacral ulcer present upon admission was to, beginning 06/03/12, turn the patient every 2 hours, apply barrier cream every 2 hours, conduct care of the peritoneal area every 2 hours, and to assist the patient with toileting every 2 hours. Review of the patient record for 06/03/12 and 06/04/12 revealed no documentation present in the record for these two days that the patient was turned or that barrier cream was applied, or that cleaning/care of the patient's peritoneal area was conducted. The patient was discharged against medical advice at the request of family on 06/04/12 at 11:30 p.m. A physician note dated 06/04/12 at 11:00 p.m. stated that the patient's family was "convinced that they could do a better job with the patient at home."

c) On 07/06/12 at 1:24 p.m. the medical record for sample patient #7 was reviewed. The patient was admitted on [DATE] and discharged on [DATE]. The initial nursing assessment revealed a skin tear on the patient's left lower arm upon admission. A nursing progress note from 04/02/12 at 3:55 p.m. revealed that the skin tear on the patient's left elbow was cleaned and a new dressing was placed. Skin assessments were not documented by nursing staff on 04/03/12 and 04/05/12. No documentation could be found in the patient's record that this issue was included in care planning.

d) On 07/09/12 at 1:47 p.m. the medical record for sample patient #9 was reviewed. The patient was admitted on [DATE] and discharged on [DATE]. The record revealed that on 05/18/12 at 8:00 p.m. the patient experienced a fall while getting into bed. The record revealed that on 05/26/12 at 4:20 p.m., the patient was found on the floor next to his bed as the chair alarm was sounding. The patient denied injury and neurological checks were initiate. The interdisciplinary treatment plan dated 05/11/12, the date of admission, revealed that the patient was a fall risk, however, no individual care plan documentation was found in the medical record reflecting that this issue was care planned for fall risk with goals and interventions documented as part of a plan.

e) On 07/06/12 at 1:30 p.m. the medical record for sample patient #10 was reviewed. The patient was admitted on [DATE], discharged on [DATE], and readmitted on [DATE]. The nursing admission note from 05/04/12 stated that the patient had a known history of [DIAGNOSES REDACTED] (NMS), a life-threatening reaction to a neuroleptic or antipsychotic medication, from an admission to this facility in April, 2012. This condition was not noted in the patient's history and physical or psychiatric evaluations and was not listed under allergies. The syndrome was not mentioned on the initial treatment plan dated 05/04/12 and was not made part of the patient's on-going interdisciplinary team care planning.
On 05/11/12 at 1:38 p.m. a nursing note revealed that the patient eloped through a window and was found by local police prior to the facility becoming aware that the patient was missing. No documentation was found in the patient's record indicating that this patient's escape risk was not made part of the patient's plan of care.
f) On 07/09/12 at 2:30 p.m. the medical record for sample patient #11 was reviewed. The patient was admitted on [DATE] and discharged on [DATE]. Review of the medical record revealed that on the dates 06/14/12 through 06/19/12 the patient did not have a bowel movement per the document titled "Graphic Form." Review of the medication administration record revealed that no ordered, as needed, medications were administered to the patient during this time to aid with bowel movements. A nursing assessment dated [DATE] revealed that the last bowel movement occurred on 06/13/12 when a suppository was administered to the patient. Lack of bowel movements was not included in care planning for the patient.

g) Review of the facility's document titled "Constipation Management Protocol" revised 12/30/11, revealed steps for staff to take to help ensure that patients have regular bowel movements and that patients identified at risk for no bowel movement would have care planning for this issue.

h) On 07/09/12 at 11:43 a.m. the medical record for sample patient #12 was reviewed. The record revealed the patient was admitted on [DATE] and discharge on 07/02/12. The nursing assessment at the time of admission revealed the patient reported pain of 10/10 in his/her hip and pelvic area that had been present for 2 1/2 months and that the patient stated, "it hurts all the time." The initial interdisciplinary treatment plan dated 06/27/12 revealed that mood disturbance and psychosis and medical problems of urinary tract infection and GERD would be addressed in the patient's care plan. The issue of 10/10 rating for hip and pelvic pain was not included in the patient's plan of care.

i) On 07/05/12 at 10:46 a.m. the medical record for sample patient #17 was reviewed. The record revealed that the patient was admitted on [DATE] and discharged on [DATE]. A nursing note from 06/08/12 at 10:30 p.m. revealed that the patient experienced a seizure at 9:30 p.m. and was transferred to another hospital at 9:40 p.m. for further observation. The record revealed that the patient returned to the facility on [DATE]. The front of the patient's record contained a sticker stating "Seizure precautions." No documents could be found in the record indicating that the issue of seizures was made part of the patient's care plan. Review of the facility's policy titled "Seizure Precautions" revised June, 2011 revealed that seizure activity would be incorporated into patients' care planning.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on the manner and degree of deficiencies cited, the hospital failed to comply with the Condition of Participation of Physical Environment. The facility failed to ensure that the host hospital, which provided food and nutrition services to the facility under a contractual agreement, maintained the food and dietary department, and its facilities and supplies, to ensure the safety of the patient when providing food and nutrition services.
The facility failed to meet the following standards under the Condition of Physical Environment:
TAG A 701 - MAINTENANCE OF PHYSICAL PLANT
The facility failed to ensure that the condition of the physical plant and overall hospital environment was maintained by the host hospital in such a manner that the safety and well-being of patients were assured. The facility failed to ensure that the host hospital, which provided food and nutrition services to the facility under a contractual agreement, maintained a clean environment in the food and dietary department for the safe preparation and storage of food.
TAG A 724 - FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE
The facility failed to ensure that the host hospital, which provided food and nutrition services to the facility under a contractual agreement, maintained the facilities, supplies and equipment in the food and dietary department to ensure an acceptable level of safety and quality.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on tour/observation, staff interviews and review of hospital documents, the facility failed to ensure that the host hospital, which provided food and nutrition services to the facility under a contractual agreement, maintained a clean environment in the food and dietary department for the safe preparation and storage of food. The failure placed all patients, visitors and staff who consumed food prepared/served from the host hospital food and dietary department at risk of food borne illness.
Findings:
1. Host Hospital Food Services Department Tours/Observations with Concurrent Staff Interviews:
On 7/9/12 at approximately 2:30 p.m., the food and dietary department of the host hospital was toured with the Chief Executive Officer of the facility being surveyed, the host hospital Food Services manager and the host hospital plant operations director. Observations and concurrent interviews with the staff were conducted throughout the tour.
Findings:
a. The floor in the kitchen was covered with red square tile with white grout. In the area by the large unit of cooking surfaces and grills, the tile looked very dirty with a black greasy substance that was dripping down the vertical square tiles and grout on the platform on which the cooking equipment was mounted. The black greasy substance also extended onto the tiled floor in front of the cooking/grilling equipment. The grouted areas appeared especially dirty from the black greasy substance. It appeared to be long-term accumulation of grease and dirt from cooking at the unit. When asked about the frequency of cleaning and techniques to clean the tile and the grouted areas, the director of plant operations for the host hospital stated that the floors were cleaned daily and that they were doing deep cleaning in some areas of the department, as needed. When asked if the grout was sealed to prevent the dirt and grease from absorbing into the grout, s/he stated that the grout was already sealed, by its very nature, and did not require an extra sealant.
b. During a tour of the alcove area where the mechanical dishwasher was located, there was standing water on the floor in the doorway. The staff member rinsing dishes to place in the machine and the food services manager both stated that the standing water was due to a "floor drain back up."
2. Host Hospital Dietary Policy/Procedure Review:
Review on 7/10/12 of the host hospital Dietary policy/procedure manual revealed that the manual contained no guidelines for general cleaning and safe use of cleaning equipment and chemicals in areas where food was stored, prepared and served.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on tour/observation, staff interviews and review of hospital documents, the facility failed to ensure that the host hospital, which provided food and nutrition services to the facility under a contractual agreement, maintained the facilities, supplies and equipment in the food and dietary department to ensure an acceptable level of safety and quality. The failure placed all patients, visitors and staff who consumed food prepared/served from the host hospital food and dietary department at risk of food borne illness.
Findings:
1. Host Hospital Dietary Policy/Procedure Review:
a. On 7/10/12, the host hospital dietary policy/procedure entitled " Infection Control - Proper Food Handling " was reviewed and revealed the following, in part:
" PURPOSE: Preventing food borne illness.
POLICY: The following procedures are vital to infection control and must be considered in addition to those covered in previous sections.
M. All food items that are prepped in-house must be labeled and dated with production date. Items must be discarded 3 days after production date.
N. Packaged food items with expiration dates do not need to be dated and will be disposed of on the expiration date located on the packaging. "

b. On 7/10/12, the host hospital dietary policy/procedure entitled " Dietary - Scope of Care" was reviewed and revealed the following, in part:
"PURPOSE:
To maintain fresh, quality product.
POLICY:
In order to ensure quality of spices and herbs, spices are to be kept no longer than one year after opening and three years after unopened.
PROCEDURE:
All spice containers will be dated and taken from storeroom with month and year. Any spice still on shelf after one year will be discarded."

c. On 7/10/12, the host hospital dietary policy/procedure entitled " Dietary - Scope of Care" was reviewed and revealed the following, in part:
"PROCEDURE:
Food Services
A. High quality food service is provided to patients. This includes patient meal service and catering for special functions sponsored by the hospital. All foods are prepared using sanitation, preparation and service techniques which will maintain quality, retain nutrients, flavor and enhance aesthetic appeal. Patient meals are prepared to coincide with the diet prescription ordered by the physician and patient food preferences.
Performance Assurance Program
A. The Food Services Department will participate in the hospital-wide Performance Improvement Program to ensure high quality food services are provided to the patients. Monitors to identify problems will be ongoing and will reflect the plan of care of the hospital.
B. Identify opportunities for improving food safety to enhance patient health and promote consistent food safety services."

d. Review on 7/10/12 of the host hospital Dietary policy/procedure manual revealed that the manual contained no guidelines for labeling prepared foods once opened, inspecting previously opened food containers for evidence of bacterial growth or contamination, or for discarding prepared foods once they were opened. The manual also contained no guidelines for inspection of produce or how long it should be kept after the delivery date. The manual contained no guidelines for securing opened container of bulk frozen foods to prevent airborne contamination. The manual contained no guidelines for use of the 3-compartment sink used for manual dishwashing to ensure correct water temperature controls, chemical concentrations and immersion times and regular testing of the concentrations with a test strip. Finally, the manual contained no guidelines for proper cleaning of equipment such as the electric meat slicer, the floor-mounted electric mixer, the refrigerators and freezers and for general cleaning and safe use of cleaning equipment and chemicals in areas where food was stored, prepared and served.

2. Host Hospital Food Services Department Tours/Observations with Concurrent Staff Interviews:
On 7/9/12 at approximately 2:30 p.m., the food and dietary department of the host hospital was toured with the Chief Executive Officer of the facility being surveyed, the host hospital Food Services manager and the host hospital plant operations director. Observations and concurrent interviews with the staff were conducted throughout the tour.
Observations in the Food Services Department:
a. Loaves of white bread were found sitting on counters, under-counter shelving and on bread racks along with buns. None of the loaves or packaging of bread products contained any dates, such as production dates, open dates, last use dates, or discard dates. The food service director stated that bread was not usually kept longer than a week.
b. A repairman was observed working on an ice-making unit in the open kitchen kitchen area near serving and food preparation stations. The unit was open and there appeared to be large collection on the inner walls of the unit with what looked like a combination of light brown slime mold and mineral deposits. When asked about the conditions in the icemaker, the director of plant operations stated that the machine was not used for patients. S/he stated it was used for the cafeteria and catering and never for patient use. The dirty cloth tool bag, used by the repairman, was later found sitting on shelving containing non-perishable food in cans, bottles and boxes on shelving. The dirty/greasy-appearing tool bag was sitting on cases of canned foods. The bag was removed and returned to the repairman when the surveyor asked about the bag.
c. Tour of a walk-in refrigerator with primarily produce contained a previously-opened, plastic-lined, cardboard box that contained some kind of greens. When asked to identify the contents, the food services director stated s/he thought it was rosemary. On further inspection, s/he determined that it was mint. There was a large patch of what appeared to be grayish-white mold in the box on the top layer of mint. The patch appeared to be an oval area of mold growth. The patch was approximately 3 inches by 4 inches. The director confirmed that the mint appeared to have mold growth. There was no date on the box stating when it should be discarded. The director stated that the only date they used on any of the produce was the delivery date sticker on the boxes and bags from the supplier. S/he was unable to describe a standard for how long produce was kept after delivery. In the same refrigerator was found a container of grapefruit that was labeled "use by 2/12/12." In addition, a cardboard box with a supplier delivery sticker of 4/18/12 contained approximately 2 dozen limes. Approximately 4-5 of the limes were completely withered and brown and there were brown patches on at least 4-5 more of the limes. The director removed the limes from the cooler when s/he was shown the condition of the limes in the box. S/he said they should be discarded. One shelf contained a large bag of cabbage heads with a date of 6/13/12. Two heads of cabbage were sitting on the shelf in front of the bag. They both appeared to having black moldy patches on the outer leaves. The director was unable to say how long those cabbages had been there. S/he stated that they usually have that condition of mold on the outer leaves of the head, but they remove the outer leaves and then use the cabbage. A cardboard box was found on lower shelf containing more heads of cabbage. The cabbage heads appeared much more moldy with a bluish-back mold on the leaves and covering the site where the cabbage head was harvested from the stalk. The manager again stated that the cabbage was frequently moldy, but the mold was removed with removal of the outer leaves, and the cabbage would be use. The cooler also contained a previously-opened, plastic-lined cardboard box containing dried cranberries. The box was folded closed, but there was no evidence of an attempt to seal the plastic liner to protect the dried cranberries from airborne contamination or leakage of liquids from other boxes in the cooler.
d. Tour of a walk-in freezer located near the shelves of canned goods revealed that breaded frozen cod was in a previously-opened, plastic-lined cardboard box. There was no attempt to seal the plastic bag to protect the contents from cross-contamination. There was no evidence of labeling of contents of the freezer for date opened or a discard date. On the floor outside of the freezer was a large plastic jug of bottled water that appeared to be partially full, sitting on the floor in front of the shelving that contained cases of canned goods. When asked about the bottle on the floor, the director stated that the bottle was serving as a doorstop for the freezer. There was no label on the bottle stating that it was being used for that purpose and was not to be used as drinking water or for cooking. The plant operations manager stated that the bottle was one that had been taken from their supply of surplus emergency drinking water that was stored in another area. Both directors assured the surveyor that the staff all knew that the bottle was used as a doorstop and the contents would never be used for cooking or drinking water.
e. On some of shelving that held shelf-stable stocks of food and canned goods, a previously-opened, large cardboard milk carton-shaped box, containing dehydrated sliced potatoes, was found open to the air, without the opening of the box secured, creating the potential for airborne or vermin contamination of the contents.
f. In one of the refrigerated pantries was found a covered Styrofoam cup containing a white liquid. The cup and lid had no label or marking indicating the contents, date opened, or a discard date. The food service manager asked another staff member and determined that it was "lactate," a milk substitute. S/he acknowledged that the cup should have been properly labeled and dated. In another refrigerated pantry, two large covered disposable drinking cups were found to contain a liquid which was believed to be iced tea. The cups and lids were not labeled identifying the contents or a preparation or discard date. The director of food services again confirmed that the cups should have been labeled and dated.
g. A large, previously-opened plastic container of yogurt, was found in one of the refrigerated pantries with a date on the lid of 6/8/12. The director was asked how long the opened container would be kept. S/he stated that they use a standard of discarding "perishable" foods after 3 days, but for something in a manufacturer's container, they go by the manufacturer's expiration date, whether the containers was previously opened or never opened. When asked it they adjusted the discard date to factor in the possibility of an earlier expiration dated due to cross-contamination/bacterial growth once a sealed container was opened, the director stated that they did not factor that in, but merely relied on manufacturer's expiration dates.
h. A shelf of spices and herbs was observed with some plastic lids sitting open and no evidence of dating of the bottles when opened.
i. Another refrigerated pantry contained a very large mixing bowl that appeared to contain tuna fish salad. The bowl had been covered with plastic cling wrap, but the wrap was loose and not sealing the bowl from airborne or drip contamination of the contents. The director of plant operations stated that that pantry's contents were not for patient food. S/he stated that the tuna was for the cafeteria line. In the other side of the same pantry were found patient snack servings of what appeared to be canned fruit with pre-printed stickers with a date and patient names on them. The food services director did confirm these were for patients. The pre-printed stickers had the date of 7/6/12, which would have been longer than the discard date for "perishable" food, according to the director of food services. S/he stated that the labels were actually printed the day before the food was placed in the single serving containers, so that even though it appeared that they were 4 days old, they were only 3 days old. There were lots of pre-printed labels on the counter that had not been used. It appeared that it would be very difficulty to accurately rely on those labels to know when a food had actually been prepared, versus when the label was printed, to ensure an accurate and safe discard date for "perishable" foods. The containers had no other dating with the black markers that appeared on some of the labeled foods. The pantry also contained half of a purple onion wrapped in cling wrap, with no dates. A very large institutional size glass jar of olives, with approximately two inches of contents in the bottom of the jar, contained no open or discard date. Again, the director of food services stated that they relied on the manufacturer's expiration date for a discard date.
j. Another refrigerated cart/tower with racks for holding trays of foods contained foods that the director stated were for use that day. There were trays of white bread sandwiches wrapped in cling wrap and Styrofoam covered containers with the contents appearing to be canned fruit, flavored gelatin and pudding. There were also salads covered in cling wrap. No contents of that refrigerated cart were labeled with contents or date of preparation or expiration date. The food services director stated that the food was not labeled unless it was not used the day it was prepared.
k. Another refrigerated cart/tower with racks for holding trays of food was observed near one of the cooking stations. The upper trays contained condiments and jars of gravy/sauce bases. No jars were dated with open or expiration date, other than the manufacturer's expiration date. A jar of vegetable base with the lid unscrewed and ajar on top of the container had no dating of any kind, including no manufacturer's expiration date. Approximately 3/4 of the way down the cart was a tray of raw meat patties covered with cling wrap and dated with the day's date in black marker. Stored below the raw meat on lower racks were other non-meat foods including a square metal contain with contents identified by a staff member as cooked rice, which was covered in cling wrap. There was no date on the container of rice. On the bottom of the cart under the lowest rack, there was a large dark red stain on the white interior surface of the cart. The stain appeared to be dried blood from dripping meat products.
l. A large open closet contained shelving with food preparation and storage equipment, as well as what appeared to be punch/serving bowls. They appeared dusty and were open to the air. The director of plant operations stated that area was for storage for the catering that was also done by the food service department. In the other side of the open closet the cleaning supplies and cleaning products and a janitorial floor shower drain were observed. The janitorial supplies were separated from the catering supplies by a partial wall that ran perpendicular to the open doorway and partially separated the two parts of the closet. The janitorial area appeared dirty on the walls and floor. A rack of hanging cleaning equipment included a broom. The directors of food services and plant operations were asked if they were aware that the state licensure requirements prohibited dry dusting and sweeping in any area of the hospital, to prevent airborne contamination. They both acknowledged that they were unaware of that regulation.
m. Observation of the meat slicer sitting on a countertop revealed that the slicing surfaces appeared clean on visual inspection, but the lower part of the machine below the sliding cradle appeared to be contaminated with old grease and dirt and the same was found at the control area of the slicer.
n. Observation of a floor-mounted electric mixer revealed that the bowl and mixing blades were not present, but the mixer support frame, which held the bowl in position was heavily covered with a white dried substance that appeared to be a long-term accumulation of flour and batters from the machine. When asked how often the mixer was cleaned, the director of food services stated that it was cleaned every day and that the staff had just done some mixing with the machine. The crusted accumulation of what appeared to be flour and batters was observed to be evident up and down the length of the mixer support stand and did not appear to have been recently cleaned.
o. Observation of the 3 sinks for manual washing and rinsing of pots and large items revealed that the two outer sinks had hoses running to the automatic sanitizer dispenser above both sinks. The middle sink did not have a hose to supply any chemicals to that sink. All three sinks were empty. There was no evidence of any marks on the sink or measuring system to insure the correct amount of water was used with the automatic dispensers. The director of plant operations stated that the chemicals were automatically dispensed with the push of a button and the systems was checked regularly to make sure the dispensers function properly. S/he stated that records of the checks were available for review to the surveyor. The surveyor asked it the staff did checks of the water solutions on a daily basis to ensure that they had the correct/effective dilutions's and temperatures. S/he stated the staff did them every day, but they kept no record of the testing. There were two previously-opened tubes of test-strips sitting on a lower shelf below the sinks. The test strips had no expiration or efficacy dates visible on the tubes. The tubes appeared covered in dust.
p. Reference Tag A 701 for additional tour/observation finding related to dirty areas on the floor by the cooking /grilling areas and the standing water in the dishwasher alcove related to a "floor drain back-up."

3. On 07/06/2012, at 1:12 p.m., the food services director for the host hospital was interviewed about staff training, orientation, competencies and specific training about safe food handling. The director stated that none of the staff had taken one of the standardized safe food handling courses, but that's/he had taken one at a previous dietary job. S/he state his/her certificate would be good for one more year. S/he stated that s/he had come to the position in December, 2012. S/he stated that a few of the staff had the books to take the safe food handling course, but that no one had taken the test to get the certificate. S/he stated that at the time of his/her hire, there was discussion about having staff get the training, but it had not happened, S/he stated that new staff were being trained by older staff and they kept a record of their orientation and competencies.