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 May 24, 2013
VIOLATION: GOVERNING BODY Tag No: A0043
Due to the nature of the deficiencies, the facility failed to comply with the Condition of Governing Body. The governing body of the hospital failed to ensure that the hospital's senior clinical management team (Chief Executive Officer, Director of Nursing and Medical Director) had the authority to manage resources to design and maintained a safe and effective inpatient geriatric psychiatry treatment program that met the needs of the patients.

The facility failed to meet the following standard under the Condition of Governing Body:

A 049 - Governing Body - Medical Staff Accountability
The governing body failed to ensure that there was medical staff involvement in the planning, policy/procedure and program development, determination of safe admission and exclusion criteria for patients, as well as appropriate numbers and skill levels in the medical staff, to meet the needs of the patients.

A 057 - Governing Body - Chief Executive Officer
The governing body failed to ensure that the Chief Executive Officer (CEO), whom they had appointed to be responsible for managing the hospital, actually had control of budget, resources, programs and management processes to effectively address the needs of the hospital to improve patient care.

A 065 - Governing Body - Care of Patients - Admission
The governing body failed to ensure that decisions about appropriate admission of patients, and the required level of care and supervision, were made by the medical staff.

A 084 - Governing Body - Contracted Services
The governing body failed to ensure that contracted services for lab testing, emergency medical care in an acute care hospital, and the physical environment in the hospital, related to showers, water temperature and ambient temperature were provided in a safe and effective manner to meet the needs of patients.
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
Based on staff interview and review of facility documents, the governing body failed to ensure that the medical staff were accountable for the quality of care provided to patients.

FINDINGS:

1. The governing body failed to ensure that there was medical staff involvement in the planning, policy/procedure and program development, determination of safe admission and exclusion criteria for patients, as well as appropriate numbers and skill levels in the medical staff, to meet the needs of the patients.

a) Review of Medical Executive Committee (MEC) Meeting Minutes for 07/31/12 through 1/4/13 revealed that no MEC meetings were held after the 9/11/12 meeting, except for ad hoc meetings with a 4-man quorum to make medical staff appointments. An agenda with attached reports was provided for a MEC meeting that was to be held on 03/28/13, but there were no minutes to indicate that the meeting had actually been held. Review of meeting minutes revealed that the last in-depth meeting of the MEC was held on 09/11/12 and that there was no evidence in the minutes of any policy/procedure development or review.

b) In an interview on 05/24/13 at 10:00 a.m., the Director of Nursing stated the policies for the Facility come from the corporate office. The DON stated " we are not allowed to write policies for the facility, headquarters does that. "

c) Review of the medical Staff Bylaws on 05/20/13 revealed that the medical staff was supposed to meet at least quarterly and that they were to participate in the development and evaluation of patient care programs.

d) Reference Tag A 065 - Governing Body - Care of Patients - Admission
for findings related to the governing body failure to ensure that decisions about appropriate admission of patients, and the required level of care and supervision, were made by the medical staff.

e) Reference Tag A 057 - Governing Body - Chief Executive Officer - for findings related to the failure of the governing body to ensure that the Chief Executive Officer (CEO), whom they had appointed to be responsible for managing the hospital, actually had control of budget, resources, programs and management processes to effectively address the needs of the hospital, in collaboration with the medical staff, to improve patient care.
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on staff/provider interviews and review of facility documents and meeting minutes, the governing body failed to ensure that the Chief Executive Officer (CEO), whom they had appointed to be responsible for managing the hospital, actually had control of budget, resources, programs and management processes to effectively address the needs of the hospital to improve patient care.

Findings:

1. The governing body failed to ensure that the corporate entity that owned the hospital did not interfere with the CEO's ability to appropriately manage the hospital s/he was appointed to administer. Key management functions, such as development of the operating budget, programs, policies/procedures and utilization of staff and other resources to develop a safe and viable geriatric psychiatry program, with collaboration from the hospital's medical staff, were co-opted by the corporate owner entity's
administrative staff.

The failure created actual outcomes including inadequate staffing, unsafe patient care setting, inconsistent application of admission criteria and lack programs and management processes to provide optimum patient care for geriatric psychiatry patients.

The failures related to inadequate staffing created an Immediate Jeopardy situation that was declared to the facility on [DATE] at 4:00 p.m. and remained at the time of exit from the survey on May 24, 2013.


a) On 05/16/2013 at 12:30 p.m., during an interview with staff member # 12, the intake process was discussed. The staff member confirmed that there was significant pressure from the hospital's owner corporate entity to accept patients. S/he stated that they used to have to get approval from the Psychiatric Medical Director before accepting a patient, but not now. S/he stated that they are expected to take 80 patients per month and that the admissions were heavily monitored on a daily basis by the hospital's owner corporate entity. S/he stated that intake calls were supposed to be on a 30 minutes turnaround time, meaning that a decision to accept the patient, or not, needed to happen within 30 minutes. When asked if s/he had ever been instructed not to accept patients because of the level of acuity or lack of staff, s/he stated "never." S/he stated that the admission decisions were "all about numbers and census, not about patient acuity."

b) On 05/16/13 at 11:00 a.m. provider # 6 was interviewed and expressed concerns about that the the hospital's pattern of taking patients with too many complex medical issues. S/he expressed concerns that the nurse had the skills to manage some of the medical issues and the knowledge of the medications medications utilized to manage those issues. S/he provided anecdotal examples of a lack of nursing knowledge in assessing and medicating patients with unstable blood sugar and with anticoagulation therapy.

c) On 05/17/13 at approximately 10:00 a.m., the former psychiatric medical director, who has given notice that s/he will be leaving, was interviewed. S/he agreed to answer surveyor questions about identified concerns about the perceived lack of staff to adequately care for and monitor the patients. S/he was also asked to answer surveyor questions about the appearance that staff/providers were being pressured to accept patients with significant medical co-morbidities and severe dementia that made them inappropriate for active psychiatric treatment and created additional demands for staffing due to acuity. S/he was also asked to provide information about the level of psychiatric staffing that was available, since s/he was leaving, the board had just appointed a new medical director who was also new to the facility, and a third psychiatrist was on a leave and it was unclear when or if s/he would be returning.

S/he confirmed that pressure to admit patients, even if medically complex or with significant dementia was real, experienced by many staff/providers and appeared to be coming from the hospital's owner corporate entity. S/he stated that after s/he was hired as medical director after the last survey (07/12/12), in which another Immediate Jeopardy situation had been declared and subsequently removed, and a state conditional license was instituted. S/he worked closely with the CEO and the medical staff to try to identify a realistic assignment level for the psychiatrists at 15 patients per psychiatrist with the nurse practitioner not taking patient assignments, but supplementing the psychiatrists and helping with weekend coverage. With the number of psychiatrists available, that would cause the census to be held at 30, even though they had a capacity for 40.

S/he stated that s/he was also aware of the lack of nursing staff to handle the complex geriatric patients, as well as be able to provide closer supervision of certain high-risk patients that required Line of Sight (LOS) or 1:1 levels of supervision patients. When asked, s/he acknowledged that there had been occasions when s/he had been asked to change a LOS or 1:1 order because they did not have enough nursing staff to supervise the patient at that level. When discussing the admission criteria, s/he stated that last summer/fall after s/he was first appointed as medical director s/he also worked with the other providers, the admissions staff and the CEO to standardize the admission criteria to avoid taking patients that were medically complex/fragile or had significant dementia. S/he stated that the plan that included a limit on census, provider assignment capped at 15 patients and application of the more limiting exclusion criteria was initiated and was working well. S/he believed that the patients were getting better active psychiatric treatment and the staff were able to adequately monitor the patients.

S/he stated that the plan was stopped because of the decrease in census. The pressure to accept patients that were outside of the written admission criteria, and with higher supervisor needs, even if LOS or 1:1 staffing was not available, has replace the prior plan, in an attempt to increase the census. When asked, s/he acknowledged that there was the perception was that the CEO no longer had the authority to address lack of adequate staffing, inappropriate admissions or a higher psychiatrist to patient ratio.

d) On 05/20/13 at 2:00 p.m., during interview with a provider (#5), s/he stated that "sometimes they take a patient they shouldn't in order to ensure they won't lose the referral source."

e) On 05/20/13 at 5:00 p.m., the CEO was interviewed about the budget process under the Condition of Governing Body and to try to determine what authority the CEO currently had to resolve the issues being identified in the survey.

When asked about the budget process, the CEO stated that s/he provided input into the budget, related to staffing and patient volume last fall during the budget process. S/he stated that after the survey in July, 2012 and the application of the state conditional license, s/he created a plan to address the issues identified. S/he stated the plan included a new nursing plan to increase nursing skills and establish a stable team.

S/he stated that things were going in a good direction last fall and s/he was very involved in resolving the issues, until a new Chief Operating Officer (COO) was hired by the hospital's owner corporate entity. S/he stated the focus changed. S/he stated the focus immediately changed to a tremendous focus on operations (marketing and intake calls). S/he stated that the Vice President of Clinical Operations (VP/CO) and the COO reviewed every single call that came into the facility about an admission. S/he also stated that hospital's owner corporate entity conducted "test calls" for admissions and then the entity would call up and direct them to interrupt whatever projects they were working on to fix whatever issues were identified by the test calls and call monitoring.

Related to the budget preparation, the CEO stated that the budget that s/he had been submitted (which had been reviewed and approved by Corporate entity Central Budget Office and Vice President of Finances) prior to the change of corporate leadership. S/he stated the final budget was returned in January, 2013 at the beginning of the new fiscal year with everything changed without his/her knowledge or input. The revised budget had an increase in the number of admissions and the staffing grid was revised down, for a decrease in staff. When asked, s/he confirmed that s/he did not have the authority to make a budget, adjust staffing, or stop admissions when warranted by acuity, provider shortage or staff shortage. In addition, s/he confirmed that policies/procedures were developed at the corporate entity level and that s/he did not have the authority to develop and approve policies for the hospital.

Regarding the interim Chief Nursing Officer (CNO) that was hired in March, 2013, oriented by the VP/CO, and who primarily collaborated with the VP/CO rather than the CEO, she confirmed that that interim CNO would be leaving soon. S/he stated that a new CNO has been offered the permanent position and s/he felt that s/he was qualified and that they could work together, if s/he had the authority/resources, to address the clinical issues identified.

f) In an interview on 05/24/13 at 10:00 a.m., the interim Director of Nursing stated the policies for the Facility come from the corporate office. The DON stated "we are not allowed to write policies for the facility, headquarters does that."

g) Reference to A 0392: Nursing Services - Staffing and Delivery of Care - for findings related to the Facility's failure to have adequate staff to prevent falls, aggression and assaultive behavior, nonconsensual sexual contact and the provision of basic needs of feeding, hydration, toileting and hygiene.
VIOLATION: CARE OF PATIENTS - ADMISSION Tag No: A0065
Based on staff/provider interviews and review of facility documents and medical records, the governing body failed to ensure that decisions about appropriate admission of patients, and the required level of care and supervision, were made by the medical staff.

Findings:

1. The governing body failed to ensure that the clinical decision to accept or deny admission to a patient, based on the condition and needs of the patient, was made by appropriate member(s) of the medical staff, rather than by non-provider admission staff or the senior management staff of the hospital's owner corporate entity. The failure created the potential for negative patient outcomes.

a) On 05/16/13 at 2:00 p.m. during an interview with the interim Director of Nursing (DON), s/he described the difficult process when new patients were admitted , or patient observation levels (Line of Sight and 1:1) were ordered that required additional staff, and there were no more staff resources. The DON stated that s/he would have to ask the nurse to go back to the psychiatrist to try to get him/her to reconsider the need for the order, because they did not have enough staff to provide the Line of Sight (LOS) or 1:1 level of supervision being ordered.

b) Reference Tag A 0057 - Governing Body - Chief Executive Officer for findings related to activities directed by the senior management staff of the hospital's owner corporate entity, and particularly the Chief Operating Officer and the Vice President of Clinical Operations to co-opt the clinical decision-making responsibility of the medical staff related to the decision to admit or decline a patient. The co-opted process was driven by business goals rather than by individual patient clinic needs, as determined by a medical practitioner.
VIOLATION: CONTRACTED SERVICES Tag No: A0084
Based on staff interviews and review of facility documents, the governing body failed to ensure that services performed under a contract were provided in a safe and effective manner.

Findings:

1. The governing body failed to ensure that contracted laboratory services were provided timely, and in accordance with the contract, to ensure that patient laboratory testing and results were available to the physician to provide timely diagnosis and treatment. The failure created the potential for negative patient outcomes.

a) Review of the Governing Board Meeting Minutes for 05/22/12 through 4/30/13 revealed ongoing concerns about poor performance by the contract lab related to timely STAT tests and reporting of critical lab values. There was no evidence that any action was taken to resolve the ongoing problems with the labs performance.

Review of Medical Executive Committee (MEC) Meeting Minutes for 07/31/12 through 1/4/13 revealed that concerns were identified by the Quality Council report at the 09/11/12 MEC meeting regarding ongoing problems with STAT labs and statements that a review of of the contract was pending. The 09/11/2 MEC meeting also contained a very detailed report provide by the Chief Executive Officer (CEO) outlining attempts beginning 06/05/12 to meet with the lab contractor to attempt to resolve the problems with lab services. The reported indicated that the last contact prior to the report was on 09/04/12, which indicated that a plan to resolve the problems had not been received. The report indicated that the contractor had made a commitment to provide a new action plan by 09/07/12. There was no indication that the plan had been received or implemented prior to the CEO report to the MEC on 09/11/12. The report also closed with the statement "(Hospital) researching alternative lab contractors. Will give 30-day notice if necessary and terminate (lab contractor) contract if not resolved." Since no MEC meetings were held after the 9/11/12 meeting, except for ad hoc meetings with a 4-man quorum to make medical staff appointments, the lab issue had not been addressed formally by the medical staff in the MEC, to push for resolution of the issue.

b) Review on 5/20/13 of Performance Improvement Analysis Reports for February, 2013 and March, 2012 revealed the following, in part:

February, 2013 Report - "Conclusions: (Contract lab) performance had been showing some improvement since initiating routine M-F draws, reducing the number of labs ordered STAT, but timeliness of turnaround time dropped again in February. Contractual requirements for turnaround time of STAT lab results are not being met. Annual review of contract services is being conducted.
Plan - Actions: Monitor (contract lab) data and performance to improve timeliness. Arrange another meeting with (contract lab) and (hospital)leadership. Consider whether contract revision is needed. Continue auditing of (hospital) STAT lab logs to ensure full compliance."

March, 2013 Report - "Conclusions: While there was some improvement in the turn-around time in January results (70%), March results slipped to an unacceptable (64%).
Plan - Actions: (Lab contractor) action plan has been implemented. Plan to proceed with alternate lab will be implemented if less than 4 hours is not in excess of 80% for April 2013. Continuing of (hospital) STAT lab logs to ensure full compliance."

c) On 05/17/13 at approximately 9:30 a.m. during an interview, a provider (#4) stated that the lab problems related to delays with STAT testing and critical lab results reports were ongoing. S/he stated that these problems made management of the patient's medical problems, as well as dosage adjustments for medical and psychiatric medications difficult. S/he stressed that these problems were even more significant because of the types of complex medical patients that the facility was accepting in order to maintain a higher census. S/he emphasized that they needed a realizable lab service to be able to safely manage those patients with complicated medical problems that they were being pressured to accept.

On 05/20/13 at approximately 3:30 p.m., during and interview with another provider (#5), s/he stated that the lab services lab draws and results were not being received timely and not in the 5 hour window for STAT labs. S/he state that managing the more medically complex patients that the hospital was admitting required more timely and responsive lab services.

On 5/20/13 at 5:00 p.m., the CEO was asked about the problems with the contracted lab services and s/he stated that they had seen some temporary improvement with the contractor, but had decided that they were going to change contract labs because the improvement was not sustained. S/he stated that the hospital was currently negotiating a contract with a different lab, but the contract was not in effect until July. S/he confirmed that they were continuing to utilize the lab that was problematic. The surveyor reminded the CEO that the same problems had been identified with the contract lab at the last survey of 07/12/12, and that the facility had stated then that they were in the process of looking for another contract lab. The CEO was unable to provide an explanation for the delay in addressing the problem with the lab's performance for almost a year.

2. The facility failed to address coordination and communication problems with the primary acute care hospitals that accepted their patients for transfer for emergency care. The facility had a transfer agreements with these facilities to accept their patients, but the facilities did not always call, or send paperwork from the emergency departments (ED's) before patient were returned to the facility, which interfered with continuity of care. The failure to address this problem created the potential for negative patient outcomes.

a) On 05/17/13 at 4:00 p.m., staff #15 and #16 stated that the acute care hospitals ED's did not always call with hand-off communication or send paperwork back with the patient after a visit to the ED for emergency care.

b) Review on 05/20/13 of a 2012 Performance Improvement Scorecard Report that was provide with the Governing Board meeting minutes for the past year revealed the following findings:
The report contained information only for the 1st and 2nd quarters of 2012. In the area of "21C. Emergency Services," it stated "51 patient sent to ED for evaluation/treatment, 45 returned with information from ED. RN's to call ED when no information received."

c) On 5/20/13 at 5:00 p.m., the CEO was asked about the problems with the contracted acute care hospital/ED services and whether any action had been taken to address this issue under the contracts/transfer agreements. S/he stated that s/he was not aware of the problem, therefore it had not been addressed.

d) Review of Governing Board and MEC meeting minutes revealed no evidence that this issue had been addressed in either group, despite the fact that it had been identified as a problem and tracked on a quality report (Performance Improvement Scorecard Report).

3. The Governing Board failed to ensure that the facility's contract with the host hospital was utilized to address facility problems such as a broken shower, a pattern of cold water for showering patients, and an intercom system that failed to work during an emergency medical situation and poor control of the temperature of the unit on the first survey day. The failure created negative patient outcomes for patients who were unable to received timely showers and were housed on an uncomfortably hot patient care unit.

a) During tours/observations that were conducted on 05/13/13 between 10:00 a.m. and 2:00 p.m., a shower in the phase I area was observed to "out-of -services"/broken and still leaking water into the shower. In the shower with the broken shower head, tile was observed to be loose and mold was observed around the tile/shower head. Staff present stated the hospital was getting estimates for repair of the shower.

During the tour, surveyors observed that the patient care areas were uncomfortably warm and patients and staff appeared overheated. One patient on Phase I unit sitting in the dayroom complained that s/he was "too hot." The temperature was in a more comfortable range during the subsequent days of the survey.

b) On 05/14/13 at approximately 12:30 p.m., during an interview with a staff member (#21), s/he stated that there were 3 showers/heads in Phase I and only one of the showers had warm water, so that it could be used to shower patients. S/he stated that there were only 8 patient showers given that day out of 22 patients, because of the lack of working showers and insufficient staff. S/he also stated that no showers had been given over the weekend, because of the problems with the showers and lack of staff.

On 5/17/13 at approximately 10:00 a.m., a provider (#4) was interviewed about emergency responses to medical situations. The provider stated that there had been one emergency situation in which the intercom system did not work, so that the hospitalist physician (based in the host hospital), who was supposed to respond to a Code, did not get the page and there was a significant delay in the response. Despite the delay, there was no negative outcome for the patient, because the other staff and providers initiated emergency care to support the patient.

4. The Governing Body failed to comply with its own Bylaws with regarding to management of contracted services.

a) Review on 5/17/13 of the Governing Body Bylaws, Revised 1/18/13 revealed the following, in part: "ARTICLE VIII QUALITY OF PROFESSIONAL SERVICES AND PATIENT CARE EVALUATION 8.6 Telemedicine, Emergency and other Contracted Services. (c) Other Contracted Services. The Governing Board shall be ultimately responsible for ensuring that all contracted services furnished in the Hospital be furnished in a safe and effective manner and in compliance with all applicable Medicare conditions of participation."

b) Review of Governing Board meeting minutes revealed that the governing body had received reports of continued lack of compliance with their lab contract, but failed to take definitive action to resolve the issue with the lab, even though it had been identified as a problem in the first 2 quarters of 2012 and had been cited in the previous CMS survey in July, 2012. The minutes revealed no evidence that the issues related to coordination/cooperation with the acute care hospitals and building maintenance issues with the host hospital had been addressed.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on the manner and degree of deficiencies cited, the Facility failed to be in compliance with the Condition of Participation of Patient Rights. The Facility failed to protect and promote each patient's rights.

The Facility failed to meet the following standard under the Condition of Patient Rights:

Reference Tag A-0144 - Patient Rights - Care in a Safe Setting:
The Facility failed to provide adequate staff to ensure a physically and emotionally safe environment that protected the dignity and comfort of the patient population.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on tours, observations, staff interviews, and reviews of medical records and documents, the Facility failed to provide adequate staff to ensure a physically and emotionally safe environment that protected the dignity and comfort of the patient population.

This failure resulted in negative patient outcomes including increased incidents of falls, patient-to-patient/staff aggression and non consensual sexual contact.

FINDINGS:

Reference to A 0392: Nursing Services - Staffing and Delivery of Care - for findings related to the Facility's failure to have adequate staff to prevent falls, aggression and assaultive behavior, nonconsensual sexual contact and the provision of basic needs of feeding, hydration, toileting and hygiene.
VIOLATION: QAPI Tag No: A0263
Based on the manner and degree of deficiencies, the Facility failed to comply with the condition of Quality Assessment and Performance Improvement (QAPI).

The Facility failed to ensure its QAPI program reflected the complexity of the Facility's services, involved all hospital departments and focused on prevention and reduction of harm to patients.

The Facility failed to meet the following standards under the Condition of QAPI

A 0264 QAPI - Program Scope
The Facility did not set priorities for performance improvement that focused on indicators related to adverse patient events such as medication errors, infections, aggressive/assaultive behaviors, non consensual sexual activity and patient falls.

A 0309 482.21 (e) EXECUTIVE RESPONSIBILITIES
The Facility's governing body, medical staff and administrative officials did not ensure that the Facility's QAPI priorities were defined, implemented and maintained to decrease adverse events and improve patient safety.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on record review and interviews the Facility failed to develop and implement an ongoing program that identified and showed measurable improvement in medication errors.

FINDINGS:

1. The Facility did not have an adequate Quality Assurance Performance Improvement (QAPI) program that would reduce medical errors.

a) The Facility's Incident Report was reviewed. There were 20 incidences of medication errors documented from January 2013 to April 2013.

b) The Facility's "Scope of Performance Improvement Activities" (Scope) for 2013 was reviewed

The document contained no plan or discussion regarding medication errors or a plan to reduce the incidence of medication errors.

c) The Facility's Performance Improvement Analysis Report (Report) was reviewed for January, February, March and April 2013. The report documented 20 "medication variances" for the 3 month period.

The plan documented was to "continue Medication PI workgroup to evaluate the variances and develop strategies and interventions to minimize medication variances." The Facility submitted no documentary or other evidence that a Medication PI workgroup existed.

A review of the April and May 2013 training calendar revealed that no staff training on medication administration was scheduled. There was no evidence of or continued monitoring or evaluation of medication errors.

d) In an interview on 05/14/13 at 3:30 p.m., Staff member # 14 stated that the education packets s/he delivered to the staff were given to him/her by the Director of Nurses (DON). The Staff member confirmed that there was no education given to the staff on medication errors or other patient care issues. S/he stated that s/he was unaware of any ongoing Facility quality initiatives.

In an interview on 05/16/13 at 10:24 a.m., Staff member #6 stated his concern that some of the nurses needed better competencies and education in the area of medication administration as there had been many mistakes.

In an interview on 5/20 at 4:15 p.m., Staff member #3 admitted that the quality program was incomplete and lacked specified plans to address the issues identified. S/he confirmed that the quality program had not been evaluated for effectiveness.

Staff member # 3 admitted that s/he does not "see post information" regarding the issues and s/he does not conduct regular audits of issues identified.

2. The Facility did not have an infection control program that was integrated into the QAPI program

a) A review of the Facility's Performance Analysis Improvement Report (Report) revealed one report from January 2013. The Report documented the number of urinary tract infections from January, February and March. The Report stated that the plan of action was that pharmacy would track infections per antibiotic order and that "the number of infections we are tracking covers more than the urine culture reports we get from [outside laboratory]."

There was no evidence of a methodology or mechanism to track and trend infections and no evidence of a plan to address the reasons for the infections in order to reduce the incidences of infections.

The Report did not address how or if staff would be educated regarding infection control and prevention.

b) In an interview on 05/20/13 at 4:30 p.m., Staff member #3 admitted that s/he did not monitor the infection control program because the DON collected the data was responsible for tracking the data.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on record review and interviews the Facility failed to develop and implement an ongoing program that identified, tracked, analyzed and implemented preventive actions for adverse patient events.

This failure resulted in increased incidents of medication errors, patient falls, urinary tract infections (UTIs).

FINDINGS:

1. The Facility did not have an adequate Quality Assurance Performance Improvement (QAPI) program that would reduce medication errors.

a) The Facility's Incident Reports from January 2013 to April were reviewed. There were 20 incidences of medication errors documented for that timeframe.

b) The Facility's Scope of Performance Improvement Activities (Scope) for 2013 was reviewed. The document contained no plan or discussion regarding medication errors or a plan to reduce the incidence of medication errors.

c) The Facility's Performance Improvement Analysis Report (Report) was reviewed for January, February, March and April 2013. The report documented 20 "medication variances" for the 4 month period.

The plan documented was to "continue Medication PI workgroup to evaluate the variances and develop strategies and interventions to minimize medication variances." The Facility submitted no documentary or other evidence that a Medication PI workgroup existed or that any interventions or strategies were developed and implemented.

A review of the April and May 2013 training calendar revealed that no staff training on medication administration was scheduled. There was no evidence of or continued monitoring or evaluation of medication errors.

d) The Facility's infection occurrence reports were reviewed. From January 1, 2013 to April 30, 2013, 23 patients had urine cultures that were positive for urinary tract infections. Of the 23 urine cultures collected, 9 were positive for Escherichia Coli (E.Coli) (bacteria found in human stool). In January 2013, Patients #50, #51 and #52, in February 2013, Patients #53 and #54, in March 2013, Patient #55 and April 2013, Patients #56, #57 and #58 were positive for E.Coli.

e) In an interview on 05/14/13 at 3:30 p.m., Staff member # 14 stated that the education packets s/he delivered to the staff were given to him/her by the Director of Nurses (DON). The Staff member confirmed that there was no education given to the staff on medication administration or other patient care issues. S/he stated that s/he was unaware of any ongoing Facility quality initiatives.

In an interview on 05/16/13 at 10:24 a.m., Staff member #6 stated his concern that some of the nurses needed better competencies and education in the area of medication administration as there had been many mistakes.

In an interview on 5/20 at 1615 p.m., Staff member #3 admitted that the quality program was incomplete and lacked specified plans to address the issues identified. S/he confirmed that the quality program had not been evaluated for effectiveness.

Staff member #3 admitted that s/he does not "see post information" regarding the issues and s/he does not conduct regular audits of issues identified.

2. The Facility's infection control program was not integrated into the QAPI program.

a) A review of the Facility's Performance Analysis Improvement Report (Report) revealed that there is only one report from January 2013. The "HAI/Infection control" report has the date reported as "01/22/13." The start date is "01/01/13" with an end date of "03/31/13." The report listed the monthly reporting collected from pharmacy antibiotic tracking and [outside laboratory] cultures.

The Report stated that the "plan" going forward was for the pharmacy to track infections per antibiotic order from the pharmacy.

There was no evidence of other methodologies or mechanisms to track and trend infections and no evidence of a plan to address the reasons for the infections in order to reduce the incidences of infections.

The Report did not address how or if staff would be educated regarding infection control and prevention.

In interview on 05/24/13 at 10:00 a.m., the Director of Nurses admitted that the Facility does not have training for staff regarding Healthcare Acquired Infections (HAI), including urinary tract infections.

b) In an interview on 05/20/13 at 4:30 p.m., Staff member #3 admitted that s/he did not monitor the infection control program because the DON collected the data was responsible for tracking the data for infection control.

3) The Facility did not analyze the frequency, severity and causes of patient falls and implement preventive actions and training in order to minimize or eliminate falls.

a) The Facility's Incident Report (Report) was reviewed. The Report documented 16 patient falls for January 2013, 30 falls for February 2013, 11 falls for March and 24 for April 2013.

b) The Facility's Performance Improvement Analysis Reports from 01/01/13 through 4/23/13 were reviewed.

Patient falls from February 2013 were reported in the March 2013 report as 18 with some patients suffering multiple falls. The falls reduction plan included continuation of the Fall Reduction PI workgroup, daily fall reviews, treatment plan revisions to indicate fall risk, and staff training.

Patient falls from March 2013, reported in April 2013 were 11. The Facility Performance Improvement Analysis Report shows the falls reduction plan as continuation of the Fall Reduction PI workgroup, daily fall reviews, treatment plan revisions to indicate fall risk, and staff training.

There is documentation of 2 Fall Reduction PI workgroup meetings on 02/27/13 and 04/01/13 where falls interventions were discussed including non skid socks, addition of chair alarms, patient engagement and staff training. A review of the Facility's April 2013 and May 2013 Training Calendar revealed no evidence of falls prevention training.

c) In an interview on 05/20/13 at 4:15 p.m., Staff member #3 could not produce audits of fall prevention activities currently in place and could not describe the effectiveness of measures put in place since January 2013.

Staff member #3 stated that the out of state corporate entity receives a "quarterly scoreboard" which includes falls but not other patient safety issues facing the Facility i.e. urinary tract infections. S/he stated that "interventions come from my group." S/he stated that s/he meets annually with "cohorts" from different facilities to discuss.

d) In an interview on 05/20/13 at 2:15 p.m., Staff member #1 acknowledged that, although s/he had attended some meetings, s/he was not consistently engaged in the quality program. S/he stated that s/he had been focused on operations.

d) Reference to A 0392: Nursing Services - Staffing and Delivery of Care - for findings related to the Facility's failure to have adequate staff to prevent falls, aggression and assaultive behavior, nonconsensual sexual contact and the provision of basic needs of feeding, hydration, toileting and hygiene.
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
Based on observations, document review and interviews, the Facility's governing body, medical staff and administrative officials failed to ensure that the QAPI priorities were defined, implemented and maintained to decrease adverse events and improve patient safety.

This failure resulted in an increase in medication errors, patient falls, patient assaultive/aggressive behaviors and non consensual sexual activity between patients.

FINDINGS:

1. The Facility did not ensure that it had developed an effective QAPI program with appropriate priorities for improved patient safety and that improvement activities were monitored and maintained.

a) The Facility's Performance Improvement Analysis Reports (Reports) for January 2013 through April 2013 were reviewed. There was no evidence that an effective plan to prevent patient falls, medication errors, patient assaultive/aggressive behaviors and non consensual sex between patients was in place.

b) Those Reports do not show that there was an ongoing QAPI reporting committee with members that met regularly to discuss and evaluate the QAPI program, prioritize patient safety issues and proactively set a plan to prevent or minimize events.

c) In an interview on /5/20/13 at 2:35 p.m., Staff member #1 admitted that although she had attended a meeting she had not been appropriately involved with the quality program and could not articulate a vision for the program. S/he stated that his/her focus had been on operations and trying to repair "broken" departments since her arrival. S/he confirmed that the Director of Nurses reported lists of the number of infections and falls but that s/he was unaware of the plan for prevention or minimization of the events.

d) Reference to A 0392: Nursing Services - Staffing and Delivery of Care - for findings related to the Facility's failure to have adequate staff to prevent falls, aggression and assaultive behavior, nonconsensual sexual contact and the provision of basic needs of feeding, hydration, toileting and hygiene.
VIOLATION: NURSING SERVICES Tag No: A0385
Due to serious degree of deficient practice in failing to provide essential nursing services thereby protecting patients from preventable harm, the hospital was out of compliance with the Condition of Nursing Services. An immediate jeopardy was called on 05/16/13, at 4:00 p.m., which remained in place as of the exit date of 5/24/13.

The Facility failed to meet the following standard under the Condition of Nursing Services:

A 392- Nursing Services - Staffing and Delivery of Care - The Facility failed to plan appropriately and provide staff in adequate numbers to respond to each individual patient's nursing needs in a safe and effective manner around the clock. The facility failed to plan for and provide the appropriate staff to keep patients safe and attend to their basic requirements of care.

This failure contributed to a high number of preventable incidents and outcomes including patient falls, assaultive and sexual behaviors against other patients, and urinary tract infections likely to have been caused from a lack of appropriate personal hygiene and toileting.

The survey included a sample of 32 patients, of which 11 patients required transfer to the emergency room . One patient, who was transferred after multiple falls, suffered a cardiac arrest in the emergency department. In addition there were 6 patients with one or more falls, 10 patients with urinary tract infections, and 3 patients with aggressive/assaultive behavior.
There were 2 incidents of non-consensual sexual contact involving four patients.

The Facility asked physicians to change their orders to remove the 1:1 or Line of Sight levels of supervision to protect patients, as the Facility lacked sufficient staff to carry out patient supervision orders, as written. At the same time the Facility was requesting these order changes due to lack of adequate staffing, the Facility continued to admit additional patients.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, interviews and record review the Facility failed to plan appropriately and provide staff in adequate numbers to respond to each individual patient's nursing needs in a safe and effective manner around the clock. This failure had the potential to cause harm to all patients served by the facility.

Failure to plan for and provide the appropriate staff to keep patients safe and attend to their basic requirements of care contributed to a high number of preventable incidents and outcomes including patient falls, assaultive and sexual behaviors against other patients, and urinary tract infections likely to have been caused from a lack of appropriate personal hygiene and toileting.

FINDINGS:

1. The Facility failed to provide adequate staff to monitor and protect patients including conducting the expected 15-minute checks and those requiring close observation to protect them from harm, including known fall risks, or from harming others including 1:1 (one patient to one staff) and Line of Sight (LOS) observation

a) According to the Facility policy, Provision of Care, Treatment and Services, Level of Observation, (undated):
All patients were to be monitored, at minimum, once in every 15 minute block of time. Staff were directed to make direct visual contact, and observe sleeping patients for breathing.

Patients placed on Line of Sight (LOS) for unpredictable risk of harm to self (including accidents such as falls) or others must be within visual range of assigned staff at all times. No more than 3 LOS patients will be assigned to one staff member. During time of personal hygiene or other care needs, the staff should be in visual or hearing range of each patient ordered to be on LOS individual patient.

"1:1, the highest level of observation, is for patients that are unpredictable and at risk for harming themselves or others." Staff assigned to monitor 1:1 patients have no other assignments and must remain within visual range and close proximity to the patient at all times.
b) The numbers of staff assigned per shift was determined according to a grid related to patient census. The patient census on 05/13/13 was 33. The Facility's staffing grid required a staffing level of 3 RNs and 5 BHTs for the combined units. The actual number of staff present on the shift on Side A and Side B was 3 RNs and 3 BHTs, which was insufficient staffing to meet the requirements of the grid staffing tool. In addition, the Facility did not provide additional staff for 1:1 or LOS patient supervision needs.

c) Review of Patient #5's medical record revealed an admission date of [DATE]. According to her Psychiatric Evaluation dated 04/25/13, Patient #5 was admitted with a recent diagnosis of rhabdomylisis and recent history of falls. Other diagnoses included mood disorder, severe vascular dementia and history of cerebral vascular accident (CVA). The Facility's Incident Reports documented 6 falls for Patient #5 during times staff were assigned to provide LOS observation. Interviews and the patient's record also illustrates facility practice to decline and negotiate with physicians and nurse practitioners regarding the levels of observation necessary for a given patient not because of patient needs but due to staffing constraints.

The record showed that the Patient fell on [DATE] and again on 04/26/13. In response, on 04/26/13 at 3:50 p.m. a psychiatric nurse practitioner order was received for "1:1 level observation secondary to two falls within the last twenty four hours." A nurse progress note dated 04/26/13 at 6:00 p.m. stated that Staff member #11 called the Director of Nurses (DON) to approve the level 1:1 observation order for Patient #5 and the DON "declined the order."

An alternate order was then received from the psychiatric nurse practitioner on 04/26/13 at 9:40 p.m. to "d/c 1:1, initiate Line of Sight (LOS), while awake and fall precautions." After the DON declined the 1:1 order for patient #5, the admission register showed that on 04/26/13, two additional patients were admitted at 6:30 p.m. and 10:43 p.m.
In an interview on 05/15/13, at 3:10 p.m., regarding Patient #5, Staff member #11 confirmed that the Director of Nurses (DON) requested him/her to call the physician and/or nurse practitioner to downgrade a 1:1 observation status order for a patient due to unavailability of staff.

In an interview on 05/15/13, the psychiatric nurse practitioner stated that s/he told Staff member #11 that s/he would discontinue the 1:1 observation status order for Patient #5 due to unavailability of staff, if Staff member #11 would agree to have staff "watch her very carefully." Staff member #11 stated that the "the team made [Patient #5] an unofficial 1:1."

Patient #5 suffered subsequent falls on 04/29/13, and 05/02/13. The patient fell again twice on 05/07/13, the last time at 9:30 p.m. hitting her face causing bleeding. The patient was sent to the emergency department (ED) at 10:30 p.m. by ambulance. According to nursing documentation dated 05/08/13 at 2:45 a.m., the patient had coded (suffered a cardiac arrest).

c) The Facility's Incident Reports from January 2013 to April 2013 were reviewed which showed a high number of falls within the facility including - 16 falls were reported in January 2013, 30 falls were reported in February 2013, 11 falls were reported in March 2013, 25 falls were reported in April 2013.

d) Multiple staff interviews illustrated chronic understaffing that created the potential for harm to both patients and staff.

In interviews conducted on 05/13/13, between 2:30 p.m. and 4:40 p.m., staff members #10, #20, #22 reported a chronic staffing shortage in the Facility that led to the staff's inability to adequately monitor and protect patients from falls. Staff members stated that the staffing levels were not appropriate, and they were unable to monitor and witness falls and dangerous behaviors because staff was unavailable.

In interviews conducted on 05/15/13, between 11:30 a.m. and 3:30 p.m., with staff members #13, #11, confirmed that the staffing was chronically short and that the shortage had worsened over the last 4 months as "good staff was leaving." The staff members stated that on 05/12/13 - 1 Behavioral Health Tech (BHT) was assigned 21 patients. The staff members stated that they asked for additional help but were refused and told to "make it work."

In an Interview on 05/20/13 at 10:53 a.m., Staff member #24, a consultant, provided reports to the Facility monthly, frequently identified concerns with staffing. S/he reviewed a two week staffing period for April 2013 and found that the Facility was consistently staffing below the minimum requirements of the staffing grid.

In a conference call discussion with the Facility on 05/22/13 at 4:30 p.m., to discuss inadequate staffing, the Director of Nurses stated that the night staffing grid number for RNs would include the night nursing supervisor, which meant that there would be one less RN available for direct patient care. S/he confirmed that along with being the clinical resource and administrative support, the night nursing supervisor was also responsible for conducting chart audits and taking admission calls after 9:00 p.m.

2. The Facility did not provide adequate staff to assist patients with feeding, hydration, toileting and hygiene.

a) During the facility tour and observations on 05/13/13 between 10:00 a.m. and 1:00 p.m., there were no tasks of toileting or offering of supplemental fluids were observed for the patients throughout the facility outside of meal times.

b) In interviews conducted on 05/14/13 between 10:00 a.m. and 4:30 p.m., staff members #21, #18, #19, #16 reported that they were not able to give showers over the weekend. One staff member stated that on one shift s/he was assigned 12 patients and also assigned 15-minute checks. The staff members stated that most of the patients on Side A are incontinent and need toileting, however, it is difficult to accomplish because it takes more than one staff member to shower or toilet the patients and there is not enough staff to leave the floor and have the remaining patients monitored.

In an interview on 05/14/13 at 3:11 p.m., Staff member #20, reported that it took 2 staff to toilet and shower patients. S/he stated that the staff frequently had to prioritize duties and were unable to assist patients with hygiene and toileting activities.

c) A Facility document titled Intake/Output, Weight, Sleep and Shower List, For Side A was reviewed on 05/13/13. The list revealed a lack of patient hygiene activities. For instance, Patient #33 had not been showered since 05/05/13, Patient #34 had not been showered since 05/06/13, Patients #35, #36, #37, #38, #39 had not been showered since 05/09/13, Patients #40, #41 and #42 had not been showered since 05/10/13, Patients #43 and #44 had not been showered since 05/11/13, and Patients #45, #46, #47, #48 and #49 had not received showers at anytime.

d) The Facility's infection occurrence reports were reviewed. From January 1, 2013 to April 30, 2013, 23 patients had urine cultures that were positive for urinary tract infections. Of the 23 urine cultures collected, 9 were positive for Escherichia Coli (E.Coli) (bacteria found in human stool). In January 2013, Patients #50, #51 and #52, in February 2013, Patients #53 and #54, in March 2013, Patient #55 and April 2013, Patients #56, #57 and #58 were positive for E.Coli.

In an interview on 05/16/13 at 10:25 a.m., Staff member #6 stated that a combination of psychotropic medication and lack of adequate toileting and hydration contributed to the high incidence of urinary tract infections (UTIs) and ED visits related to dehydration.

In an interview on 05/14/13 at 1:41 p.m., Staff #7 stated that the combination of psychotropic medication and inadequate hydration contributed to increased incidences of hospitalization s for Rhabdomyolysis (breakdown of muscle fibers that leads to the release of muscle fiber contents (myoglobin) into the bloodstream. Myoglobin
often causes kidney damage).

3. The Facility did not provide adequate supervision for patients with a history of assaultive/aggressive behavior, leaving patients unprotected from patient-on-patient attacks and abuse.

a) The Facility's Incident Reports showed that from January 2013 to April 2013, there were 58 documented incidents of patient-to-patient/staff aggression.

b) On 05/15/13 at 11:48 a.m., Staff member # 13 reported that "on Sunday (05/12/13) there were 21 patients, the BHT was alone, and patients were getting beat up and scratched."

4. The Facility did not provide adequate staffing to protect the patients from sexual abuse from other patients.

a) The Facility's Incident Report revealed inappropriate sexual events between Patient #2 and Patient #32 on 05/10/13 and Patient #28 and Patient #24 on 02/08/13.

b) In an interview on 05/20/13 at 1:22 p.m. Staff member #5 stated that "if you have patients having sex on the unit, then you know staffing is not adequate."

c) A review of the records for Patient #2, #24 and #28 revealed that the patients had cognitive impairment diagnoses that interfered with the their ability to consent to sexual activity.

5. In an interview with the Chief Executive Officer (CEO) on 05/20/13 at 2:36 p.m., the Facility's budgetary process was reviewed in relation to insufficient staffing to ensure appropriate and safe patient care. During the interview the CEO acknowledged that although s/he provided input, the final budget was provided to her/him by the Chief Financial Officer (CFO) of the out-of-state corporation that owned the hospital. The CEO stated that the final budget provided to him/her in October, 2012, did not reflect the staffing requirements s/he submitted for the budget. In addition, the CEO stated that the admission quotas were significantly above those s/he had submitted for the budget.
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on the manner and degree of deficiencies, the Facility failed to comply with the Condition of Infection Control. The Facility failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases and failed to appoint an appropriate person(s) designated as an infection control officer(s).

The Facility failed to ensure an active program for the prevention, control, and investigation of infections and communicable diseases.

The Facility failed to meet the following standards under the Condition of Infection Control:

A 0748 - INFECTION CONTROL OFFICER(S):
A person or persons must be designated as infection control officer or officers to develop and implement policies governing control of infections and communicable diseases.

A 0749 - INFECTION CONTROL OFFICER(S) RESPONSIBILITIES:
The infection control officer or officers must develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel.

A 0756 - RESPONSIBILITIES OF CHIEF EXECUTIVE OFFICER, MEDICAL STAFF, AND DIRECTOR OF NURSING SERVICES:
The chief executive officer, the medical staff, and the director of nursing must ensure that the hospital-wide quality assurance program and training programs address problems identified by the infection control officer or officers and be responsible for the implementation of successful corrective action plans in affected problem areas.
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on interviews and record review the Facility failed to designate a qualified infection control officer(s) to develop and implement policies on infection control and communicable diseases.

This failure resulted in 23 patients with urine cultures positive for urinary tract infections. Of the 23 urine cultures collected, 9 were positive for Escherichia Coli (E.Coli) (bacteria found in human stool), likely to have been caused from a lack of appropriate personal hygiene and toileting.

FINDINGS:

1. The Facility did not have a qualified person as an infection control officer who was qualified through ongoing education, training, experience, or certification to oversee the infection control program.

a) Personnel files were reviewed on 05/17/13 showed the Director of Nurses (DON) job description had no evidence the DON was designated as the infection control officer. There was no documentation showing the DON had education, experience, or certification in infection control and prevention.

b) In an interview on 05/24/13 at 10:00 a.m., the Director of Nursing stated s/he was designated as the Infection Control Officer. The DON stated s/he had not provided the Facility with supporting documentation of his/her qualifications. The DON also stated s/he had not had any ongoing education since initially receiving training in infection control in 2011.

c) The Facility's infection occurrence reports were reviewed. From January 1, 2013 to April 30, 2013, 23 patients had urine cultures that were positive for urinary tract infections. Of the 23 urine cultures collected, 9 were positive for Escherichia Coli (E.Coli) (bacteria found in human stool). In January 2013, Patients #50, #51 and #52, in February 2013, Patients #53 and #54, in March 2013, Patient #55 and April 2013, Patients #56, #57 and #58 were positive for E.Coli.

2. The Infection Control Officer did not develop or implement Facility Infection Control Policies.

a) Review of the Facility's Policy and Procedures index on 05/14/13 at 2:00 p.m. revealed there were no policies/procedures for infection control or prevention.

b) In an interview on 05/24/13 at 10:00 a.m., the interim Director of Nursing stated the policies for the Facility come from the corporate office. The DON stated "we are not allowed to write policies for the facility, headquarters does that."
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, record review and interviews, the Facility failed to provide an environment that prevented the potential transmission of infectious and communicable diseases. The Facility did not develop, implement, and maintain a process to identify and reduce urinary tract infections (UTI).

This failure contributed to the exposure of patients to infectious and communicable diseases.

FINDINGS:

1. The Facility had no policy or procedure for addressing infection control issues. The Director of Nurses (DON)/ Infection Control Officer did not monitor or evaluate the infection control program.

a) Review of the Facility's Policy and Procedures index on 05/14/13 at 2:00 p.m. revealed there were no policies/procedures for infection control or prevention.

b) In an interview on 05/24/13 at 10:00 a.m., the Director of Nursing stated the policies for the Facility come from the corporate office. The DON stated "we are not allowed to write policies for the facility, headquarters does that."

2. The Facility did not conduct infection control meetings with the staff.

a) A review on 05/14/13 of the Facility's Staff Training calendar for April and May revealed no staff education topics related to infection control/prevention was offered.

b) In interviews conducted on 05/14/13 between 10:00 a.m. and 4:30 p.m., staff members #21, #20, #18, #19, #16 reported they do not receive infection control training during staff meetings or at any other time.

c) A review on 05/14/13 of the Facility's Staff Meeting Minutes lacked evidence of discussions of urinary tract infections or any other infection control or prevention practices.

3. The Director of Nurses (DON)/ Infection Control Officer did not coordinate with federal, state, and local emergency preparedness and health authorities to address communicable disease threats, bioterrorism, and outbreaks

a) In a telephone interview on 05/24/13 at 10:00 a.m., the Director of Nursing stated there were no policies, procedures or education regarding emergency preparedness and health authorities to address communicable disease threats, bioterrorism, and outbreaks.

b) Review of the Facility's Policy and Procedures index on 05/14/13 at 2:00 p.m. revealed there were no policies/procedures for emergency preparedness and health authorities to address communicable disease threats, bioterrorism, and outbreaks.
VIOLATION: LEADERSHIP RESPONSIBILITIES Tag No: A0756
Based on record review and interviews, the Facility failed to ensure the chief executive officer, the medical staff, and the director of nursing provided a quality assurance and training program for infection control and prevention that included corrective actions taken to address problems identified related to infectious and communicable diseases.

This failure contributed to the exposure of patients to infectious and communicable diseases.

FINDINGS:

1. The chief executive officer, the medical staff, and the director of nursing failed to ensure the hospital-wide quality assurance and training program to address problems identified by the infection control officer.

a) In a telephone interview on 05/24/13 at 10:00 a.m. the interim Director of Nurses (DON)/Infection Control Officer (ICO) stated the Facility does not have its own policies.

"The policy's are generated from the corporation and if we
are needing local policies, we are not allowed to write policies, we have to go to the corporate office."

The DON/ICO stated "I don't know what National Standards the Facility follows, it's a corporation infection control plan and not locally developed. We use an infection control consultant."

b) In interviews conducted on 05/14/13 between 10:00 a.m. and 4:30 p.m., staff members #21, #20, #18, #19, #16 reported they do not receive infection control training during staff meetings or at any other time.

c) In interview on 05/24/13 at 10:00 a.m., the interim Director of Nurses/Infection Control Officer admitted the Facility does not discuss with staff about Healthcare Acquired Infections (HAI), including urinary tract infections.

d) A review on 05/14/13 of the Facility's Nursing Staff Meeting Minutes lacked evidence of discussions of urinary tract infections or any other infection control or prevention practices.

2. The chief executive officer, the medical staff, and the director of nursing failed to implement an effective corrective action plan for identified infection control problem areas.

a) In a telephone interview on 05/24/13 at 10:00 a.m., the interim Director of Nurses/Infection Control Officer revealed there were "studies done on urinary tract infections but the Facility had not done any followup. The corporation had requested just the numbers."

b) Review on 05/14/13 at 2:00 p.m. of the Facility's Policy and Procedures index revealed there were no policies/procedures for infection control.

c) On 05/24/13 at 11:00 a.m. a review of the Facility's document, with no contract date and not signed, "Professional Services Agreement, The Infection Control Consultant's Services", revealed the consultant shall provide professional oversight of outcomes from reports generated at the Facility and develop and implement surveillance tools. There was no documentation the consultant, after receiving the infection occurrence reports from the facility, provided any oversight, development or implementation of outcomes. This included the reports received regarding the urinary tract infections the Facility had identified.

d) On 05/14/13 the Facility's infection occurrence reports were reviewed. From January 1, 2013 to April 30, 2013, 23 patients had urine cultures that were positive for urinary tract infections. Of the 23 urine cultures collected, 9 were positive for Escherichia Coli (E. Coli) (bacteria found in human stool). In January 2013, Patients #50, #51 and #52, in February 2013, Patients #53 and #54, in March 2013, Patient #55 and April 2013, Patients #56, #57 and #58 were positive for E. Coli.