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.

DOVER BEHAVIORAL HEALTH SYSTEM 725 HORSEPOND ROAD DOVER, DE 19901 March 11, 2013
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
Based on medical record review, policy review and staff interview, it was determined that the medical records for 3 of 3 restrained and/or secluded inpatients (Patient #'s 3, 4 and 5) in the sample, lacked a written modification to the plan of care addressing the use of restraints and or seclusion. Findings include:

The hospital policy entitled "Guidelines for the Use of Restraints and Seclusions" stated, "...Physical restraints: The application of any manual method that immobilizes or reduces the ability of the patient to move his or her arms, legs, body, or head freely (also named therapeutic hold, protective hold, or manual restraint)...Seclusion...involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving...Physical restraints (holds)...Treatment Plan Review/Revision: When the patient has presented behavior that is dangerous to themselves or others so that restraint/seclusion were indicated, a review and modification of the treatment plan is indicated..."

Medical record review revealed the following:

A. Patient #3

Review of the "Restraint/Seclusion Order/Record" dated 11/15/12 revealed:
- Patient determined to be a danger to himself/herself or others
- Physical restraint initiated at 10:20 AM as per physician's order

There was no documented evidence to support that the plan of care was modified to include the physical restraint intervention.

On 3/6/13 at 9:17 AM, Director of Nursing A reviewed the medical record and confirmed this finding.

B. Patient #4

1. Review of the "Restraint/Seclusion Order/Record" dated 1/31/13 revealed:
- Patient determined to be a danger to himself/herself
- Physical restraint initiated at 10:15 PM as per physician's order

2. Review of the "Restraint/Seclusion Order/Record" dated 2/1/13 revealed:
- Patient determined to be a danger to himself/herself and others
- Seclusion initiated at 12:45 AM as per physician's order

There was no documented evidence to support that the plan of care was modified to include the physical restraint and seclusion interventions.

On 3/6/13 at 9:20 AM, Director of Nursing A reviewed the medical record documentation and confirmed this finding.

C. Patient #5

Review of the "Restraint/Seclusion Order/Record" dated 6/4/12 revealed:
- Patient determined to be a danger to others
- Physical restraint initiated at 12:30 AM per physician's order

There was no documented evidence to support that the plan of care was modified to include the physical restraint intervention.

On 3/6/13 at 9:25 AM, Director of Nursing A reviewed the medical record documentation and confirmed this finding.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, staff interview and policy review, it was determined that the hospital failed to maintain environmental surface cleanliness and integrity in a manner to assure patient safety and well-being in 4 of 12 patient care/support areas on the environmental tour. Findings include:

The hospital policy entitled "General Cleaning and Sanitation" stated, "All patient and non-patient rooms shall be thoroughly cleaned and/or disinfected..."

The hospital policy entitled "Physical Environment" stated, "...Furnishings and equipment are maintained to be safe and in good repair...Patient care areas are safe, clean, functional and comfortable..."

Hospital staff accompanied the surveyor during an environmental tour of the hospital on [DATE]. The following was observed and confirmed at the time of discovery by Director of Environment of Care A and Director of Risk Management and Performance A.

A. New East Unit from 10:25 AM to 11:00 AM
1. Medication room -- taped signs on walls and medication refrigerator

B. Middle Unit from 11:00 AM to 11:10 AM
1. Patient Room 1341 -- cove base separating from wall
2. Housekeeping closet -- damaged walls at floor sink
3. Clean utility room -- four (4) taped, paper signs
4. Medication room (shared by Middle Unit and Adolescent Unit) -- floor (especially under and around the refrigerator) very soiled, taped signs, tape residue on cabinet door

C. Middle Adolescent Unit from 11:10 AM to 11:30 AM
1. Day Room -- stickers on refrigerator door, old stickers on drawer face, back splash behind faucet damaged and separated from counter
2. Laundry -- two (2) taped, paper signs in laundry room

D. West/Dual Diagnosis Unit from 11:35 AM to 11:55 AM
1. Soiled utility room -- two (2) holes in drywall at flushing rim sink
2. Patient Room 1129 -- screw protruding from rear of closet interior
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on medical record review, policy review and staff interview, it was determined that for 5 of 30 patients (Patient #'s 4, 5, 8, 19 and 21) in the sample, the medical record failed to contain a date and/or year of entry. Findings include:

The hospital policy entitled "Chart Documentation Requirements" stated, "...Each entry is to be dated and timed..."

Medical record review revealed the following:

A. Patient #4
Staff failed to document the year of medical record entry on the following dates:
- "Medication Administration Record" for 1/28 (3 entries) and 1/29 (3 entries)
- "Seclusion/Restraint Observation Record" dated 2/1

Director of Nursing A reviewed the medical record on 3/6/13 at 9:20 AM and confirmed this finding.

B. Patient #5
Staff failed to document the year and/or date of medical record entry on the following dates:
- "PRN (as needed) Pain and PRN Medication Administration Record" for 6/6 at 9:15 PM (no year of entry)
- "PRN Pain and PRN Medication Administration Record" at 5:55 PM (no date of entry)
- "Progress Note" entered at 6:00 AM (no date of entry)

Director of Nursing A reviewed the medical record on 3/6/13 at 9:25 AM and confirmed this finding.

C. Patient #8
The physician failed to document the year of medical record entry on the following dates:
- "Physician's Orders" for 2/14 at 9:20 AM, 2/18 at 10:30 AM, 2/20 at 10:20 AM, 2/21 at 9:40 AM, 2/25 at 10:10 AM and 2/27 at 9:50 AM

Director of Nursing A reviewed the medical record on 3/4/13 at 3:07 PM and confirmed this finding.

D. Patient #19
Staff failed to document the year of medical record entry on the following dates:
- "Blood Glucose Flowsheet" for 3/6 at 6:00 AM and 3/7 at 7:30 AM

Director of Nursing A reviewed the medical record on 3/7/13 at 11:52 AM and confirmed this finding.

E. Patient #21
Staff failed to document the time of medical record entry on the following date:
- "Physician's Orders" for 3/6/13

Director of Nursing A reviewed the medical record on 3/7/13 at 11:50 AM and confirmed this finding.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on record review, document review and staff interview, it was determined that the hospital failed to provide the patient or the patient's representative a phone number and address for lodging a grievance with the State agency for 68 of 68 inpatients and for 61of 61 outpatient program participants. Findings include:

The hospital document entitled "Adult Inpatient Handbook", provided to all patients at the time of hospital admission stated, "...Patient Rights...Patients admitted to Dover Behavioral Health System receive a copy of their rights with the patient handbook...Patients who do not agree with their treatment plan or feel that their rights have been violated may utilize the hospital's Grievance and Appeal Procedure by discussing their concerns with the treatment team. Further discussion is provided by the Patient Advocate at (phone numbers)...who will attempt to resolve the complaint...Patients and family members may address ethical concerns by submitting them in writing to our facility..."

The hospital document entitled "Handbook of the Adult Partial hospitalization Program" stated, "...the program has a procedure for allowing patients and others to register a complaint. Patients with complaints should notify their Physicians, Nurse, Social Worker or other staff...staff will help resolve the issue. Additional complaints can be addressed by contacting the patient advocate...'Patient Advocacy Contacts'...(name of State agency provided with phone number)..."

Review of hospital documents failed to provide evidence that the notification of patient rights included the following:

A. Dover Campus
1. Inpatient
a. "Adult Inpatient Handbook" and "Patient Rights And Responsibilities" document included in the admission folder, contained no information related to the right to file a grievance with the State agency and/or the State agency's phone number or address

On 3/6/13 at 2:50 PM, Director of Admissions A reviewed the patient rights information given to inpatients and confirmed this finding.

b. Posted "Patient Advocacy Contacts" signs failed to include the State agency's address.

On 3/6/13 at 10:00 AM, Director of Nursing A, present at the time of observation, confirmed this finding.

2. Outpatient
a. "Handbook of the Adult Partial hospitalization Program" document referenced in the handbook entitled "Patient Advocacy Contacts", provided the State agency's phone number, however, the phone number was incorrect and the State agency's address was not included in the contact information

On 3/8/13 at 11:40 AM, Director of Admissions A reviewed the patient rights information given to outpatients and confirmed this finding.

b. There were no posted "Patient Advocacy Contacts" signs on the outpatient adult or adolescent units.

Director of Nursing A confirmed this finding during a hospital tour conducted on 3/6/13 between 9:55 AM and 10:05 AM.
-----
B. Georgetown Campus
1. Outpatient Programs
a. "Handbook of the Adult Partial hospitalization Program" document provided the State agency's phone number, however, the phone number was incorrect and the State agency's address was not included in the contact information

On 3/8/13 at 11:40 AM, Director of Admissions A reviewed the patient rights information given to outpatients and confirmed this finding.

b. Posted "Patient Advocacy Contacts" signs on the outpatient adult and adolescent units included the State agency's phone number. However, the phone number was incorrect and the State agency's address was not included in the contact information.

On 3/5/13 at 12:15 PM, the Chief Executive Officer, present at the time of the observation, confirmed this finding.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, document review and staff interview, it was determined that for 1 of 5 complainants (Complainant #1) in the sample who submitted written grievances, the hospital failed to provide written notice of the results of the grievance decision to the complainant. Findings include:

The hospital policy entitled "Patient and Family Grievances/The Role of the Patient Advocate" stated, "...A written complaint is always considered a grievance...patient advocate will provide written notification to...patient and/or family member who made a grievance within 5 working days...if the investigation is not or will not be completed within 7 days, the hospital will follow-up with a written response in 30 days of the date of the complaint..."

A. Complainant #1

Review of the grievance file revealed the following:
- the hospital was in receipt of a written complaint letter dated 3/8/12 from a patient's family member (Complainant #1) to the Chief Executive Officer
- the family member expressed concerns related to patient care, patient safety and communication issues identified during the [AGE] year old patient's hospitalization
- no written response to Complainant #1

On 3/4/13 at 11:35 AM, Patient Advocate A, present at the time of the grievance file review, reported that the concerns had been investigated and confirmed that the file failed to provide evidence of a written response to the complainant at the conclusion of the investigation.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on medical record review, policy review and staff interview, it was determined that for 1 of 1 patients (Patient #8) in the sample with a new diagnosis of infection, nursing staff failed to revise the plan of care. Findings include:

The hospital policy entitled "Nursing Standards of Care" stated, "...The nurse participates in evaluation of treatment plan, focusing on accuracy of problem definition...patient's response to treatment is regularly documented in the medical record using the nursing plan of care as reference...Nursing plan of care is revised based on evaluation data..."

Medical record review revealed the following:

A. Patient #8

1. Review of "Physician's Orders" dated 2/27 (no year of entry) at 10:10 AM, included a medical consult for the evaluation of Patient #8's complaints of cough, sore throat and stuffy nose.

2. Review of the "Consultation Form" completed by Medical Consultant A on 2/28/13 at 7:00 PM, included a diagnosis of upper respiratory infection, with a plan to treat with medication and a re-evaluation if symptoms persisted.

3. Review of Medical Consultant A's "Physician's Orders" dated 2/28/13 at 7:00 PM, included medication orders for the administration of Motrin for three days for an upper respiratory infection.

4. Review of the "Master Treatment Plan" and "Treatment Plan Review Update" documentation failed to provide documentation to support that the care plan was updated to reflect the new diagnosis of an upper respiratory infection, three day treatment plan and/or continued symptom monitoring.

On 3/4/13 at 2:50 PM, Director of Nursing A reviewed the medical record and confirmed these findings.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, policy review, job description review and staff interview, it was determined that staff failed to follow the hospital's infection control policies for 1 of 6 patients (Patient #22) in the sample observed during patient care. Findings include:

The hospital job description entitled "Infection Control Nurse" stated, "...duties...Develop, implement, update and enforce the hospital's infection control policies and procedures..."

The hospital policy entitled "Hand Washing" stated, "...personnel shall wash their hands, to prevent the spread of infections...after removing gloves..."

A. Patient #22

The following was observed during wound care treatment provided by licensed practical nurse (LPN) A on 3/7/13 at 11:43 AM:

- Washed hands
- Opened non-stick dressing package and Bacitracin (antibiotic) ointment
- Hands sanitized
- Donned gloves
- Applied Bacitracin ointment to sutured areas on left wrist/forearm
- Applied non-stick dressing and gauze-like netting sleeve over dressing to secure dressing
- Removed gloves
- Replaced cap on Bacitracin ointment, picked up used dressing packaging
- Opened door with key, entered locked room, disposed of dressing material in clear trash bag
- Hands sanitized

LPN A failed to perform hand hygiene:
- After glove removal

Director of Nursing A, present at the time of the observation, confirmed that LPN A failed to follow the hospital's hand washing policy for infection prevention during the provision of care.
VIOLATION: CONTENT OF RECORD Tag No: A0449
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, policy review and staff interview, it was determined that for 1 of 3 Medicare patients (Patient #15) in the sample, the medical record failed to contain the physician's certification that the admission of the Medicare patient was necessary. Findings include:

The hospital's policy entitled "Admission/Continued Stay/Discharge Criteria" stated that Dover Behavioral Health System, "...uses pre-approval medical necessity criteria for admissions...for Inpatient...stays..."

The hospital's "Utilization Management Plan 2012" stated, "...Physician Certification & Re-Certification forms are completed on all Medicare patients on days 1, 12, 18 and subsequent...periods...The purpose of the physician's signature is to certify that admission...is medically necessary..."

A. Patient #15

Review of the medical record revealed:
- Patient #15 was a Medicare recipient admitted on [DATE]
- No completed Medicare certification form signed by the physician to certify that admission was medically necessary

On 3/8/13 at 9:50 AM, Director of Nursing A reviewed the medical record and confirmed this finding.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, staff interview and policy review, it was determined that the hospital failed to ensure an acceptable level of safety, quality and cleanliness of patient care equipment and supplies in 4 of 12 patient care/support areas. Findings include:

The hospital policy entitled "General Cleaning & Sanitation" stated, "All patient and non-patient rooms shall be thoroughly cleaned and/or disinfected, keeping in mind standard precautions and infection control..."

The hospital policy entitled "Administrative Policy on Safety Program" stated, "The Dover Behavioral Health Systems shall provide a safe, sanitary environment for patients, employees, and visitors..."

Hospital staff accompanied the surveyor during an environmental tour of the hospital on [DATE]. The following was observed and confirmed at the time of discovery by Director of Environment of Care A and Director of Risk Management and Performance Improvement A.

A. New East Unit from 10:25 AM to 11:00 AM
1. Supply Room -- two (2) torn vinyl mattress covers, torn plastic pillow cover

B. Middle Unit from 11:00 AM to 11:10 AM
1. Patient Room 1341 -- damaged, uncleanable laminate desk surface
2. Day Room -- three (3) torn, uncleanable seat cushion covers

C. Middle Adolescent Unit from 11:10 AM to 11:30 AM
1. Nurse Station -- one (1) soiled fabric chair seat

D. West/Dual Diagnosis Unit from 11:35 AM to 11:55 AM
1. Clean supply room -- twelve (12) corrugated shipping boxes used to store disposable scrub wear
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on medical record review, policy review and staff interview, it was determined that staff failed to obtain an order for the use of restraints for 1 of 3 physically restrained patients (Patient #4) in the sample. Findings include:

The hospital policy entitled "Guidelines for the Use of Restraints and Seclusions" stated, "...Restraint...shall be used in emergency situations only and requires an order from the physician...order for use of restraint...will be recorded in the medical record and include...reason for using restraint...Time limits...type of restraint..."

Medical record review revealed the following:

A. Patient #4

1. Review of the "Restraint/Seclusion Order/Record" dated 1/31/13 revealed:
- Patient determined to be a danger to himself/herself
- Medication restraint initiated at 11:45 PM
- Physical restraint initiated at 11:45 PM (2 staff members held patient during administration of injectable medication)

Review of the "Restraint/Seclusion Order/Record" and other medical record documentation failed to provide evidence of a physician's order for the use the physical restraint intervention.

Interview with Director of Nursing A on 3/6/13 at 9:20 AM confirmed this finding.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on medical record review, policy and job description review and staff interview, it was determined that nursing staff failed to follow physician's orders for 1 of 30 patients (Patient #27) in the sample. Findings include:

The hospital policy entitled "Nursing Standards of Care" stated, "The patient can expect treatment modalities (the plan of care, etc.) to be evaluated and updated on a continual basis..."

The hospital policy for "Nursing Care" entitled "Lab Services" stated, "...Laboratory services are provided as ordered by the attending physician..."

The hospital job description entitled "Nurse Manager" stated, "...Nurse Manager...Reviews documentation of patient progress in the medical record...labs are placed on the chart..."

The hospital policy entitled "Chart Documentation requirements" stated, "...Documentation of patient care must be performed to communicate the treatment provided...Documentation in the progress notes...Lab tests not performed and why..."

A. Patient #27
Review of the medical record revealed:

1. "Physician's Orders" dated 3/5/13 at 3:55 PM for a CBC (complete blood count)

2. "Standing Admission Orders" dated 3/5/13 at 9:00 PM for the following blood tests:
a. Chemzyme+
b. CBC with differential
c. Thyroid

3. No evidence that the blood tests were drawn/obtained as ordered by the physician.

On 3/8/13 at 3:00 PM, Director of Nursing A reviewed the medical record and confirmed this finding.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on observation, policy review and staff interview, it was determined that the hospital failed to maintain the building in a manner to ensure compliance with the Life Safety Code (LSC) for the safety of all 68 inpatients and all 39 outpatient program participants. The hospital failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association (see the attached CMS-2567 referencing the LSC deficiency).
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on medical record review, policy review and staff interview, it was determined that for 1 of 30 patients (Patient #16) in the sample, nursing staff failed to administer medications in accordance with the physician's orders. Findings include:

The hospital policy entitled "Medication Administration" stated, "...nurses...administer medications...as ordered by the physician..."

Review of Patient #16's medical record revealed:

A. Staff failed to administer the medication, Kayexelate (used to treat a high level of potassium) as ordered.

1. "Physician's Orders" dated 2/22/13 at 4:55 PM
- "Kayexelate 15 gm (grams) PO (by mouth) daily, 1st dose today"

2. "Medication Administration Record" (MAR)
- 2/22/13 - No Kayexelate administered
- 2/23/13 - No Kayexelate administered
On 3/6/13 at 2:50 PM, Director of Nursing A reviewed the medical record and confirmed this finding.
VIOLATION: LIFE SAFETY FROM FIRE Tag No: A0710
Based on observation, policy review and staff interview, it was determined that for 68 of 68 inpatients and for 39 of 39 outpatient program participants, the hospital failed to meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association (see the attached CMS-2567 referencing a Life Safety Code deficiency).
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

I. Based on medical record review, policy review and staff interview, it was determined that for 1 of 4 patients (Patient #16) in the sample with a physician ordered dietary evaluation, the registered dietitian (RD) failed to promptly document a dietary evaluation as ordered. Findings include:

The hospital policy entitled "Nutritional Screening/Assessment/Consultations" stated, "...A nutritional assessment is completed for patients determined to be at nutritional risk. The assessment is completed by a dietician within 72 hours of notification by nursing staff...or receipt of a physician's order..."

A. Patient #16
Review of the medical record revealed the following:

1. "Physician's Orders"
2/19/13 6:00 PM - "Dietary Evaluation: HTN (hypertension) Cardiac"

2. "Nutrition Assessment"
a. Dietary consult documented as completed by RD A on 2/25/13 (6 days after the physician's order)
b. RD A failed to document any interventions, education or dietary recommendations related to the ordered consult to evaluate the patient's nutritional needs for hypertension and/or cardiac disease

RD A was interviewed on 3/6/13 from 2:20 - 2:35 PM and confirmed the following:
- nutritional assessment was not documented as completed within 72 hours as per hospital policy
- nutritional assessment did not address the patient's hypertension and cardiac disease

II. Based on medical record review, policy review, document review, video surveillance review and staff interview, it was determined that for 1 of 30 patients (Patient #1) in the sample, staff failed to complete "Patient Property and Valuables" inventory records according to policy. Findings include:

The hospital policy entitled "Contraband Search Guidelines" stated, "...All patients should have their belongings searched for potentially hazardous items...on admission...Any belongings brought in to the patient after admission should also be searched prior to delivery to the patient...Nursing staff should document in the medical record that a search has been conducted...findings..."

The hospital policy entitled "Patient Valuables" stated, "...Nursing staff will retrieve and secure...inventory...valuables, the items will be logged...patient belongings will be inspected and logged...on admission...patients and staff are to sign...Copies of updated receipts shall be placed on the patient's medical record..."

A. Patient #1
On 2/26/13 the State agency received a complaint regarding Patient #1 being discharged with cigarettes that did not belong to Patient #1.

Review of the medical record revealed that Patient #1 was admitted on [DATE] and discharged on [DATE]. Review of documentation related to patient property inventory and property searches revealed the following:

1. The medical record contained one (1) undated "Patient's Property and Valuables" form, completed by staff and signed by the patient to document the patient's property.

2. Review of "Hospital Visit Logs" and observation of video surveillance tapes with Director of Nursing A on 3/5/13 between 9:45 AM and 10:15 AM revealed:
- Patient #1 received a visitor on 2/19/13 at 6:19 PM
- Visitor brought in a small duffel bag
- Duffle bag given to receptionist at hospital entry
- Video monitors captured bag removal from receptionist's counter
- Duffle bag taken to hospital's Middle Unit
- Duffle bag placed behind nurse's desk
- At 9:12 PM, duffle bag could no longer be visualized on video surveillance tapes

3. Review of the medical record failed to provide evidence to support that staff updated Patient #1's existing valuables form or that staff completed a new valuables form to capture the contents of the duffle bag and/or the presence of contraband when/if the bag was searched.

On 3/5/13 at 10:25 AM, Director of Nursing A reviewed the medical record and confirmed that staff had failed to document:
- The date the "Property and Valuables" form was completed
- That property brought in on 2/19/13 was inventoried

B. Patient #16
Review of the medical record revealed that Patient #16 was admitted on [DATE]. Review of documentation related to patient property inventory revealed the following:

1. The "Patient Property and Valuables" form was completed and signed by registered nurse (RN) A on 2/19/13, however Patient #16 did not sign the form as required by policy.

Director of Nursing A reviewed the medical record on 3/6/13 at 2:50 PM and confirmed this finding.

III. Based on medical record review, policy review and staff interview, it was determined that for 2 of 30 patients (Patient #'s 1 and 16) in the sample, staff failed to provide accurate and complete documentation for group therapy sessions. Findings include:

The hospital policy entitled "Chart Documentation Requirements" stated, "...Each entry is to be dated and timed...All documentation must be accurate...empty spaces are not left in documentation..."

The hospital policy entitled "Suicide Risk Assessment" stated, "...Risk assessments are completed by Social Workers or Nursing Supervisors when patients indicate suicidal ideation on community meeting sheet...Nursing staff informs...social worker when the patient has expressed...suicidal ideation...social worker...meets with the patient and completes a risk assessment...evaluates the patient's risk to self...If the severity is high...nurse will contact the psychiatrist to discuss...When a social worker is not present...nursing supervisor will complete the Suicide Risk Assessment..."

Medical record review revealed the following:

A. Patient #1
Review of the medical record revealed the following:

1. "Group Notes"
a. The facilitator documented "No" that the patient did not attend the session, but failed to complete the corresponding entry "If no, why not?" for the following group sessions:

- 2/10/13 Expectations of Treatment Education Group
- 2/19/13 Education Group
- 2/21/13 Education Group

b. The facilitator failed to complete entries for the following group sessions:

- 2/11/13 (Safety Plan...Group Therapy session) - patient attendance/non attendance and reason; affect, participation, cognition and progress
- 2/11/13 (later session: topic not entered) - Group topic, modality, start time, stop time
- 2/14/13 (session after community meeting: topic not entered) - Group topic, Modality, Start Time, Stop Time, Facilitator Signature

c. The facilitator documented the patient attended the "Wrap Up" session and participated on 2/8/13; however, the 2/8/13 "Meeting and Wrap Up" form included conflicting documentation that Patient #1 did not attend this session.

Interview with Director of Nursing A on 3/1/13 at 11:55 AM confirmed these findings.

B. Patient #16
1. "Group Notes"
- The facilitator failed to document the reason the patient did not attend the Education Group conducted on 2/21/13 at 4:00 PM. The entry line "Did Patient Attend?...If no, why not?" was left blank.
- The facilitator entered "No Show", but failed to provide a reason for the patient not attending the session

2. "Meeting and Wrap Up...Community Meeting AM (morning)"
- Review of the 2/24/13 documentation revealed that Patient #16 responded "Yes - Sometime" to Question #4, "Are you feeling suicidal?"
- No documentation to support that Patient #16's expressed suicidal ideation was communicated to the nurse, therapist or psychiatrist on 2/24/13

Review of the medical record revealed no documentation to support that a "Risk Assessment" was completed as per policy.

Director of Nursing A reviewed the medical record on 3/6/13 at 2:50 PM and confirmed these findings. Director of Nursing A reported that the therapist should have been notified and that the Risk Assessment form should have been completed as per policy.
VIOLATION: WRITTEN POLICIES AND PROCEDURES Tag No: A0885
Based on policy and document review and staff interview, it was determined that the hospital policy for organ, eye and tissue donation failed to include the hospital's responsibility for timely referral of each patient whose death was imminent or who had died . Findings include:

The Organ Procurement Organization (OPO) document entitled "Memorandum of Agreement" dated 2/16/2007 stated, "...Donor Institution shall: Work collaboratively...in implementation and maintenance of current policies...All policies and procedures shall meet the requirements of applicable federal and state law...timely referral of each patient whose death is imminent or who has died , whichever is earlier..."

The Eye Bank document entitled "Memorandum of Agreement" (undated) stated, "...Donor Institution...Agreement governs the referral of donor organs and tissues to (name of OPO) and Eye bank...Exhibit A...In the case of patient death, contact to the OPO is at or near the time of the patient's death."

The hospital policy entitled "Organ, Eye & Tissue Donation" stated, "...It is the policy of the Dover Behavioral Health System to only accept patients who are medically stable. Patients who become medically unstable are transferred to an appropriate general acute care hospital...If the patient dies during transfer to...acute care hospital, it is the receiving hospital's responsibility to notify the Organ Procurement Organization...Procedure...intake assessment, the intake coordinator refers the patient and/or the patient's guardian to the Organ Donation Handout in the patient's admission folder..."

In accordance with the "Memorandum of Agreement", the "Organ, Eye & Tissue Donation" policy failed to address the hospital's responsibility for timely referral of each patient whose death was imminent or who had died .

Interview with the Chief Executive Officer (CEO) on 3/8/13 at 10:22 AM confirmed this finding.
VIOLATION: AUTOPSIES Tag No: A0364
Based on review of hospital documents, policy review and staff interview, it was determined that medical staff failed to develop policies related to autopsies. Findings include:

Review of policies and hospital documents entitled "Medical Staff By-Laws" and "Medical Staff Rules and Regulations" revealed:

- No documented reference to autopsy
- No defined mechanism for documenting permission to perform an autopsy
- No system for notifying the attending practitioner when an autopsy was being performed
- No documented reference to what cases should be referred to the medical examiner for autopsy

During an interview with the Chief Executive Officer (CEO) and Director of Nursing A on 3/8/13 at 3:07 PM, the CEO confirmed that the hospital had no "autopsy specific policy".