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 Jan. 12, 2018
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, policy review and staff interview, it was determined there was no evidence that 1 of 5 patients (Patient #3) in the sample of medical record reviews, were informed of their patient's rights. Findings included:

The hospital policy entitled "Patient's Rights Bill of Rights" stated, "The individual...shall be requested to sign and date a copy of the Patient's Bill of Rights form prior to admission to acknowledge receiving a written and verbal explanation of those rights...The signed form shall be filed in the patient's medical record...When the individual receiving services is unable or unwilling to sign document, which confirms that rights have been orally communicated, a brief explanation of the reason should be entered onto that document along with the signatures of the person who explained the rights and a third-party witness, preferably by a family member, legal guardian or friend, if available, or by another staff member..."

Review of Patient #3's medical record (admitted [DATE]) revealed no evidence that he/she was informed of his/her rights.

This finding was confirmed by Director of Nursing A on 1/12/18 at 11:55 AM.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on policy review and staff interview, it was determined that the hospital failed to secure staff keys to permit access in and out of a locked unit, thereby failing to ensure security for 15 of 15 inpatients on the Middle Unit (Patient #'s 1, 2, 5, 6, 8, 9, 13, 14, 16 and 18 - 23) during evening/night shift on 1/8 through 1/9/18. Findings included:

The hospital policy entitled "Key Issuance" stated, "...Monitor and control issuance of keys...for...staff...to ensure the safety of patients and staff...Any lost, misplaced or stolen keys must be reported immediately...Staff will keep keys on their person at all times."

A. During an interview on 1/12/18 between 9:40 AM and 10:52 AM, Patient #2 reported the following incident:

- on 1/8/18, a Mental Health Technician (MHT) left hospital keys on top of the nurse's desk in the Middle Unit, unattended
- during shift change at 11:15 PM, he/she reached over the counter and took the keys
- at 3:00 AM, he/she took one (1) key off the ring, then returned the key ring to staff
- he/she took the one (1) key and forced it into a bottle of lotion
- at 8:00 AM staff conducted a room and body search to find the missing key

These findings were confirmed by Director of Nursing (DON) A on 1/12/18 between 10:51 AM and 10:58 AM.

B. During an interview on 1/12/18 between 2:04 PM and 2:30 PM, MHT #2 stated that:
- his/her hospital keys were taken on 1/8/18 while he/she was talking to another person
- he/she identified that hospital keys were missing at 11:20 PM and immediately reported this to the supervisor
- Patient #2 returned the hospital key ring minus the one key he/she had removed which allowed access to/from the locked Middle Unit
- the search for the missing key started around 7:15 AM
- the hospital keys should have been on his/her person and he/she had left the hospital keys unattended
VIOLATION: PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS Tag No: A0147
Based on observation, policy review and staff interview, it was determined that the hospital failed to ensure patient medical record confidentiality for 14 of 14 Middle Unit patients (Patient #'s 1, 2, 6 - 16 and 20) in the sample. Findings included:

The hospital policy entitled "General Policy on Confidentiality of Protected Health Information (PHI) and Release of Protected Health Information" stated, "...all employees...have a responsibility to protect and preserve confidentiality for all patients. Protected heath information is...any written, electronic, or verbal information about a current or former patient that is personal and private...including...existence in treatment...medical records are confidential documents...safeguard...against access, loss...use by unauthorized individuals..."

A. During a Middle Unit observation with Director of Nursing (DON) A on 1/12/18 at 11:05 AM, the following was witnessed and confirmed:
- Patient #6's medical record was found unattended on the nursing desk, with confidential patient information protruding from the patient's record
- viewable information included the patient's name, address, social security number, telephone numbers and admitting diagnoses

B. During an interview on 1/12/18 at 9:40 AM, Patient #2 reported the following incident which occurred on the evening of 1/11/18:
- Patient #2 had a meeting with a non-hospital visitor in a consult room
- shift report documents with confidential information (names, room assignments, treatment diagnoses, issues and concerns, precautions and notes) on other Middle Unit patients and a voice recorder, with the patient information recorded for staff shift reports, were left unsecured in the consult room
- Patient #2 took the unsecured documents and recorder, and listened to the recording

During an interview on 1/12/18 between 10:51 AM and 10:58 AM, DON A:
- confirmed that both the voice recorder and patient documentation had been taken by Patient #2
- reported that an investigation had been initiated
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on medical record review, policy review and staff interview, it was determined that for 1 of 5 patients (Patient #1) in the sample of medical record reviews, nursing staff failed to administer medications in accordance with physician's orders. Findings included:

The hospital Registered Nurse (RN) "Job Description" stated, "...Administer patient medications as prescribed by physician in a safe, accurate and timely manner..."

The hospital policy entitled "Diabetic Care" stated, "...Blood glucose levels will be tested at the frequency ordered by the physician...Nursing staff will participate with...monitoring...Insulin will be administered per physician's order and recorded on the MAR (Medication Administration Record)..."

Review of Patient #1's medical record revealed:

1. Physician orders dated 12/18/17
- finger stick treatment before meals and at bedtime (7 AM, 11 AM, 4 PM and 10 PM)
- Insulin Lispro sq (subcutaneous) 100 units/ml (milliliter) before meals and at bedtime

- If BS (blood sugar):
150 - 200 give 2 units sq
201 - 250 give 4 units sq
251 - 300 give 6 units sq
301 - 400 give 8 units sq
401 - 500 give 10 units if BS > (greater than) 500 or less than equal to 70, call physician

2. MAR documentation revealed inaccurate insulin doses given on the following dates:
- 1/3/18 at 8:00 AM, BS 303: given 4 units, should have been given 8 units
- 1/9/18 at 9:52 AM, BS 263: no evidence any insulin given to patient, should have been given 6 units

These findings were confirmed by Director of Nursing A on 1/12/18 between 1:30 PM and 2:00 PM.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on medical record review, policy and document review and staff interview, it was determined that entries in the medical record were not accurate for 1 of 5 patients (Patient #1) in the sample. Findings included:

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

The hospital policy entitled "Diabetic Care" stated, "...Blood glucose levels will be tested at the frequency ordered by the physician...Insulin will be administered per physician's order and recorded on the MAR (Medication Administration Record)..."

A. Review of Patient #1's medical record revealed:

1. Physician orders dated 12/18/17
a. Finger stick treatment before meals and at bedtime (7 AM, 11 AM, 4 PM and 10 PM)

b. Insulin Lispro sq (subcutaneous) before meals
and at bedtime

2. MAR
a. 1/5/18 10:00 PM dose
- signed off at 8:54 AM
b. 1/8/18 4:00 PM dose
- signed off at 9:41 PM
c. 1/9/18 7:00 AM dose
- signed off at 12:35 PM
d. 1/9/18 11:00 AM dose
- signed off at 5:22 PM

During an interview on 1/12/18 between 1:30 PM and 2:00 PM, Director of Nursing A:
- confirmed the above findings of inaccurate documentation
- reported insulin was administered at the ordered times
- reported the electronic signature did not reflect the time the medication was actually administered
VIOLATION: CONTENT OF RECORD - DISCHARGE SUMMARY Tag No: A0468
**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 2 discharged patients (Patient #5) in the sample, the medical record failed to contain a discharge summary. Findings included:

The hospital policy entitled "Chart Documentation Requirements" stated, "...Discharge summary to include...recapitulation of the patient's hospitalization ...brief summary of the patient's condition on discharge...Discharge Summary completed within 30 days of discharge..."

Review of Patient #5's medical record on 1/12/18 revealed:
- patient was discharged on [DATE]
- no evidence of a discharge summary (46 days since discharge)

These findings were confirmed by Director of Nursing A on 1/12/18 at 12:05 PM.