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.

SAFE HAVEN HOSPITAL OF TREASURE VALLEY 8050 WEST NORTHVIEW STREET BOISE, ID May 25, 2016
VIOLATION: GOVERNING BODY Tag No: A0043
Based on staff interview, review of medical records, policies, medical staff bylaws, governing board bylaws, credentialing files and meeting minutes, it was determined the hospital's governing body failed to assume responsibility for determining, implementing, and monitoring policies. Additionally, the governing body failed to provide the oversight and supervision necessary to ensure patients received safe and appropriate care. This resulted in deficient practices that placed the health and safety of one patient in immediate jeopardy of serious harm, impairment, or death, and had the potential to impact all patients receiving treatment at the facility. Findings include:

1. Refer to A 044 as it relates to the governing body's failure to ensure the reappointment process was followed for existing medical staff.

2. Refer to A 046 as it relates to the governing body's failure to ensure the appointment of applicants to the hospital's medical staff was based on the considered recommendations of the existing medical staff.

3. Refer to A 048 as it relates to the governing body's failure to ensure that medical staff bylaws, and any revisions, were submitted by the medical staff and approved by the governing body.

4. Refer to A 065 as it relates to the governing body's failure to ensure the "BYLAWS FOR MEDICAL STAFF" were adhered to and patients were admitted and discharged by physicians only.

5. Refer to A 115 Condition of Participation for Patient Rights as it relates to the failure of the governing body to ensure patients' rights were protected and promoted. This relates to the failure of the hospital to ensure the grievance process accurately defined the differences between complaints and grievances and patients were informed of the address of the State agency where a complaint could be filed and failed to ensure a process was established for a clearly explained procedure for the submission of patients written or verbal grievance to the hospital. Additionally, as it relates to the governing body's failure to ensure the on-going safety of all patients receiving treatment in the facility.

6. Refer to A 340 as it relates to the governing body's failure to ensure the medical staff conducted periodic appraisals of all members

7. Refer to A 341 as it relates to the governing body's failure to ensure the medical staff examined the credentials of all candidates and made recommendations for appointment to the governing body.

8. Refer to A 395 Condition of Participation for Nursing Services as it relates to the failure of the governing body to ensure nursing services were supervised to effectively meet the safety needs of patients.

9. Refer to A 431 Condition of Participation of Medical Record Services as it relates to the failure of the governing body to ensure medical records were accurate, complete and dated, timed and authenticated according to hospital policies and procedures.

These systemic negative practices seriously impacted the ability of the hospital to provide safe and effective services.
VIOLATION: MEDICAL STAFF Tag No: A0044
Based on staff interview, review of medical staff bylaws, review of governing board (the hospital's governing body) bylaws and credentialing files, it was determined the hospital's governing body failed to ensure the reappointment process was followed for existing medical staff. This failure interfered with the medical staff and governing body's ability to verify that all medical staff requirements were met and had the potential to negatively impact patient care in the hospital. Findings include:

"Bylaws of the Medical Staff," which were not dated, timed or signed, were reviewed during the survey. The bylaws included a section regarding the appointment process. It stated "...Bi-annually, all members of the medical staff shall apply for reappointment and renewal or changes in clinical privileges. The emphasis of the reappointment process shall be on a review of the results of quality assessment and improvement on the applicant's continuing medical activities..." Additionally, the bylaws included "...The Administrator or their designee, at least ninety (90) days prior to the expiration date of each staff member's appointment year, shall request the privileges for which they wish to be considered...Each appointee who desires reappointment shall, at least forty-five (45) days prior to such expiration date, send his reapplication to the Administrator or their designee."

"Bylaws of the governing board," which were not dated, timed or signed, were reviewed during the survey. The section of the bylaws about medical staff organization included "...governing board approval and reappointment shall be made at least every two years..."

Credentialing files were reviewed for evidence of the hospital's reappointment process. The reappointment process was not adhered to as follows:

The credentialing file for Psychiatric Provider A, who was an MD and the Medical Director of the hospital, was reviewed on 5/24/16. The "Application for Appointment" form was signed by Psychiatric Provider A on 3/31/14. The application was also signed by the Medical Director, at the time on 4/24/14, and by the governing board Chairman on 4/29/14. There was no evidence Psychiatric Provider A had applied for reappointment since 3/31/14. Additionally, there was no evidence the governing board had approved reappointment since 4/29/14.

During an interview on 5/24/16 beginning at 10:20 AM, the Interim Administrator reviewed the staff credentialing files and confirmed the reappointment for Provider A was not current. Additionally, he confirmed the hospital did not have current and complete staff credential files. The Interim Administrator stated the previous Administrator maintained the staff files, and the responsibility was recently delegated to the Business Officer.

The hospital's medical staff reappointment requirements were not met.
VIOLATION: MEDICAL STAFF - APPOINTMENTS Tag No: A0046
Based on staff interview, review of governing board bylaws and credentialing files, it was determined the hospital's governing body failed to ensure appointment of applicants to the hospital's medical staff was based on the considered recommendations of the existing medical staff. This resulted in the potential for new applicants to be appointed to the medical staff without having been thoroughly vetted and without the full consideration of the existing medical staff. This failed practice had the potential to negatively impact the care provided to all patients in the hospital. Findings include:

"Bylaws of the governing board," which were not dated, timed or signed, included a section titled "Medical Staff Organization." This section stated "There shall be bylaws and rules and regulations developed and adopted by the medical staff consistent with Hospital policy..." Additionally, the document stated "...Appointment for medical staff shall be made by the governing board upon recommendation of the medical staff and shall be documented." The hospital did not adhere to the governing board bylaws.

Credentialing files for the hospital's psychiatric providers were reviewed during the survey. The files did not include evidence the existing medical staff's recommendations were considered, prior to the appointment of the applicants, as follows:

- Psychiatric Provider B's file included a form "Physician/Practitioner seeking appointment." The Chairman of the Governing Board signed the form on 2/08/16, and checked a box next to the statement "Recommend granting full appointment to the medical staff..." The Medical Director signed the form on 5/11/16, and checked a box next to the statement "I concur with the recommendations to grant full appointment to the medical staff..." There was a lapse of 93 days between Psychiatric Provider B's appointment by the governing board, and the Medical Director granting full appointment.

- Psychiatric Provider C's file included a form "Physician/Practitioner seeking appointment." The Chairman of the governing board signed the form on 2/08/16 and checked a box next to the statement "Recommend granting full appointment to the medical staff..." The Medical Director signed the form on 5/11/16, and checked a box next to the statement "I concur with the recommendations to grant full appointment to the medical staff..." There was a lapse of 93 days between Psychiatric Provider C's appointment by the governing board, and the Medical Director granting full appointment.

During an interview on 5/24/16 beginning at 10:20 AM, the Interim Administrator reviewed the provider credential files. He confirmed Provider B and C's files were not complete before they assumed responsibility for patient care in the hospital.

The hospital did not take into consideration the recommendations of the existing medical staff before appointing psychiatric providers.
VIOLATION: MEDICAL STAFF - BYLAWS AND RULES Tag No: A0048
Based on staff interview, review of governing board bylaws, and review of governing body meeting minutes, it was determined the hospital failed to ensure that medical staff bylaws, and any revisions, were submitted by the medical staff and approved by the governing board. This failure resulted in the potential for the medical staff to operate under ineffective bylaws, which could have had a negative impact on the quality of care provided to all patients in the hospital. Findings include:

The "Bylaws of the Governing Board," which were not dated, timed or signed, were reviewed. The bylaws stated "There shall be Bylaws and rules and regulations developed and adopted by the Medical Staff consistent with Hospital policy...These Bylaws and rules and regulations shall be reviewed at least once a year and revised to reflect changes in Hospital policy and applicable laws and regulations...The Medical Staff Bylaws shall be reviewed no less than annually."

During an interview on 5/24/16, beginning at approximately 10:50 AM, the Interim Administrator stated the governing board met quarterly throughout the year. He stated the CEO of the organization was the only voting member of the board. The Interim Administrator stated other non-voting board members included the VP of Compliance, the VP of Operations and the VP of Finance.

The Interim Administrator provided governing board meeting minutes for 8/24/15, 11/16/15 and 4/08/16.

The governing board minutes, dated 11/16/15, were reviewed. They stated staff from the Boise hospital and Pocatello hospital were in attendance, as well as the CEO of the organization. The section of the minutes, "Pocatello hospital...," stated "Medical staff by-laws revised and [Name of Pocatello Hospital Administrator] to send file to [Name of Boise Hospital Administrator]." This was the only documentation found in the minutes provided for the year that discussed medical staff bylaws.

There was no documentation included in the minutes the medical staff bylaws for [Name of the Boise Facility] were revised, reviewed and/or approved by the governing board.

On 5/24/16, beginning at approximately 10:50 AM, the Interim Administrator confirmed the governing board meeting minutes did not include documentation of review and approval of the medical staff bylaws.

The governing board did not adhere to the governing board bylaws and failed to provide evidence the hospital's medical staff bylaws were revised, reviewed and/or approved annually.
VIOLATION: CARE OF PATIENTS - ADMISSION Tag No: A0065
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview, review of medical records, review of medical staff bylaws and credentialing files, it was determined the hospital failed to ensure patients were admitted and discharged by physicians only. This practice allowed 1 of 4 discharged patients (Patient #20) whose records were reviewed, to receive inpatient care without the oversight of a physician. This failed practice had the potential to negatively impact the care provided to all patients in the facility. Findings include:

The "Bylaws of the Medical Staff," which were not dated, timed or signed, included the section "Allied Health Professionals," which stated Licensed Nurse Practitioners and Physician Assistants were included as Allied Health Professionals. Under the section of "Prerogatives" for Allied Health Professionals, the bylaws stated "Independent Allied Health Professionals shall:...Not admit or discharge patients at the hospital."

The credentialing file for Psychiatric Provider D, an FNP, was reviewed. Granted privileges included "...Psychopharmacology, Diagnosis of Psychiatric Disorders, Treatment of Psychiatric Disorders, Recommendation for Treatment and Concurrent Treatment of Patient (if requested by Attending Physician)..."

Privileges for admitting and discharging patients without physician oversight were not included as part of the privileges for Psychiatric Provider D.

Psychiatric Provider D did not adhere to her privileges or medical staff bylaws as follows:

Patient #20 was a [AGE] year old male who was admitted on [DATE], at 12:01 AM. His diagnoses included bipolar disorder, alcohol use disorder, benzodiazepine use/overuse and general anxiety.

Patient #20 was admitted , treated, and discharged by an FNP during his admission. There was no documentation of communication between the FNP or a psychiatrist included in Patient #20's record. Examples include:

- Patient #20's record included an "Initial Psychiatric Assessment," which was completed and dictated by Psychiatric Provider D, an FNP, on 5/07/16. The assessment was co-signed by Psychiatric Provider A, who was a psychiatrist and the Medical Director, on 5/09/16 at 11:00 AM, 1 day after Patient #20 was discharged by the FNP.

- "Alcohol Detox Orders," were signed by an RN on 5/06/16 at 9:45 PM. The document stated orders were obtained by telephone from Psychiatric Provider D, an FNP. The FNP signed the orders on 5/08/16 at 9:00 AM. The orders were not co-signed by a psychiatrist.

- "Physicians Orders," dated 5/08/16 at 9:15 AM, included "D/C [discharge] home." The orders were signed by Psychiatric Provider D. However, the orders were not co-signed by a psychiatrist. Additionally, a "Discharge Summary" was signed by Provider D on 5/08/16, but the summary was co-signed by Psychiatric Provider A, a physician, on 5/09/16, 1 day after Patient #20 was discharged by the FNP.

- Patient #20's record included a "Discharge Summary," dictated by Psychiatric Provider D, an FNP, on 5/08/16. The summary was co-signed by Psychiatric Provider A on 5/09/16, 1 day after Patient #20 was discharged by the FNP.

During an interview on 5/23/16 from 2:30 to 2:45 PM, the Medical Director reviewed Patient #20's record. She stated the hospital did not have a policy that stated a physician must oversee the admission and management of each patient. The Medical Director stated it was the expectation that a psychiatrist would see each patient within 24 hours of admission. She stated she was not consulted before Patient #20's discharge. The Medical Director stated "This one fell through the cracks."

Patient #20 was admitted , treated and discharged by an FNP who was not privileged for admission or discharge by the hospital.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on a review of hospital policy, an admission packet, a wall poster on a patient unit, and staff interview, it was determined the hospital's grievance process did not accurately define the differences between complaints and grievances, did not inform the patients of the address of the State agency where a complaint could be filed, and did not include a functioning grievance committee. This had the potential to interfere with submission and resolution of complaints of all patients receiving care in the hospital. Findings include:

1. The hospital policy "Patient Rights & Responsibilities GRIEVANCE REPORTING," dated 5/2016, was reviewed.

a. The policy included the following definition of a complaint:

"Complaint - relatively minor request (verbal or written) that are resolved at a staff level with or without the assistance of the patient representative in a timely manner. If a complaint or concern cannot be remedied promptly by staff present then it will be considered a grievance. A complaint is considered resolved when the reporting party is satisfied with the actions taken on their behalf."

The grievance process definition of a complaint did not take into account a written complaint was always considered a grievance.

During an interview on 5/23/16 at 2:20 PM, the Interim Administrator stated the definition of complaints in the policy was an error and would be corrected.

The definition of complaints was in error. This had the potential for complaints that qualified as grievances to not receive required follow-up and follow-through.

b. The above policy referenced having a grievance committee, as follows:

"The Grievance Reporting Committee is composed of the Social Services Director/Designee, Hospital Administrator, CNO, QAPI Coordinator, and mental health provider. The Social Service Director serves as the Chairperson of the committee. Each reported grievance is reviewed and responsibility is delineated by the Chairperson for data collection, as part of the investigation process."

There was no documentation provided, upon request, related to grievance committee activity.

During an interview on 5/23/16 at 2:20 PM, the Interim Administrator stated there were no meeting minutes to provide. He stated there was a new process in place that had not yet been started.

The process for resolving grievances, as stated in the policy, was not active.

2. The grievance process did not include consistent information on how to file a grievance, including all of the appropriate contact information, as follows:

a. A patient admission packet was reviewed. The admission packet included a section titled "Grievance Process." Although it included the phone number of the State Agency for filing a complaint, it did not include the address for filing a grievance with the State Agency.

b. A poster on a corridor wall of the patient area was reviewed in the morning of 5/24/16 at 8:30 AM. The poster included information for patients on how to file a grievance with the CEO or VP of Operations by email or telephone. It did not include the address of the hospital to file a non-electronic written complaint, or the address and telephone number of the State Agency to file a verbal or written complaint.

During an interview of 5/23/16 at 2:20 PM, the Interim Administrator confirmed the address of the State agency was not provided to patients or caregivers.

The information on how to file a complaint/grievance with the State Agency was incomplete.

3. Refer to A 121 as it relates to the failure of the hospital to ensure a process was established for a clearly explained procedure for the submission of a patient's written or verbal grievance to the hospital.

The grievance process did not accurately define the differences between complaints and grievances, did not inform the patients of the address of the State agency where a complaint could be filed, or include a clearly explained procedure for the submission of a complaint/grievance, and lacked evidence of a functioning grievance committee.
VIOLATION: PATIENT RIGHTS: PRIVACY AND SAFETY Tag No: A0142
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of patient records, policies, and staff interview, it was determined the facility failed to ensure patients were provided with appropriate supervision necessary to keep them safe from self-harm for 5 of 22 patients (#2, #3, #4, #5, and #21) whose records were reviewed. This failure placed Patient #2, Patient #3, Patient #4, Patient #5 and Patient #21 in immediate jeopardy of serious harm, impairment or death; and created confusion amongst the staff regarding the observation status of patients, documentation inconsistencies and non-adherence to hospital policy and may have contributed to Patient #2's self-injury. Additionally, these systemic failures had the potential to negatively impact all patients receiving care in the facility. Findings include:

The hospital failed to enforce their policy for levels of observation. The hospital policy titled "Suicide/Homicide Precautions Protocol," dated 5/01/13, stated the levels of observation for patients at the hospital included:

- "15 minute checks - observe every 15 minutes for patient safety; initiate frequent verbal contact (indications: expressed vague, suicidal ideation without a plan: no demonstrated self-destructive behavior; may have chronic suicidal thoughts; exhibits poor impulse control)."

- "Line of Sight (LOS) - Keep the patient in the line of sight at all times. Indications for LOS would be patient's previous or recent suicide attempt, active suicide ideation with or without a suicidal plan."

- "1:1 (serious suicide risk) - observation with 1:1 contact at all times. Indications for 1:1 would be patient's verbalization of clear intent to harm self, has concrete/specific plan, exhibits disorganized and/or psychotic behavior."

The hospital policy stated staff were to "Obtain physician order for appropriate 'Precaution' level as soon as possible." The policy also stated "Discuss and reevaluate effectiveness of current interventions during Treatment Team Meetings for continuation, increase/decrease, or discontinuation of current 'Precaution Level'."

Additionally, the policy stated the patients were to be assessed for the presence of destructive, suicidal or homicidal behavior, thoughts, verbalizations and/or intent at least every 8 hours or as their conditions change. The nursing flow sheets were developed for 12 hour shifts, and the flow sheets did not include behavior risk assessments every 8 hours.

The hospital census report on 5/18/16, included 12 patients (Patient #1 - #3 and #6 - #14) who were identified as having suicidal ideations and/or suicide attempts. On 5/19/16, 12 patients (Patients #2, #6, #7, #9, #10, #12, and #14 - #19) were identified as having suicidal ideations and/or attempts. The hospital policy was not implemented, observation status was not documented accurately, and there was lack of clarity among staff as to defining levels of observation for patients as follows:

1. Patient #2 was a [AGE] year old female who was admitted to the hospital at 2:55 AM on 5/09/16. She had ingested large quantities of over the counter medications in an attempted suicide.

a. Patient #2 was initially evaluated in the emergency room (ER) of an acute care hospital, and then transferred to the psychiatric hospital. Patient #2's "Certification and Recertification" form, dated 5/09/16, completed by the physician, stated Patient #2 "is suicidal and has self harm urges ...". However, her 5/09/16 "Nursing Flow Sheet," timed 3:45 AM, documented she was placed on 15 minute checks.

Patient #2 was not placed on LOS or 1:1 observation per the hospital policy.

b. The following shift (day shift 5/09/16), Patient #2's record included a "Nursing Flow Sheet," by the RN at 1:46 PM, which stated Patient #2 denied suicidal ideations, but felt depressed and anxious. Her documentation noted she continued on 15 minute checks.

In an "Initial Psychiatric Assessment," completed on 5/09/16, by the Medical Director, she noted Patient #2 "has active suicidal ideation, with plans and intent."

The Medical Director documented that Patient #2 was on the appropriate safety protocol which was 15 minute checks. However, according to the hospital policy, the above assessment would indicate 1:1 observation. Patient #2 was not placed on 1:1 observation per the hospital policy.

c. The "Nursing Flow Sheet," dated 5/10/16 for the night shift, documented Patient #2's category of observation was 15 minute checks. However, the narrative section included a note by the RN at 1:30 AM that stated "Pt in room lying down at start of shift. At 1945 [7:45 PM] pt got up, grabbed her bedding off her bed and went to the bathroom and laid down on the floor of the shower, crying. Pt stated she was having strong urges to bang her head against the wall and throw furniture and she felt safer on the floor of her shower." The RN documented "Monitor 1:1 for safety."

The "Psychiatric Technician Charting/ADL's and Observations" note for 5/10/16 night shift, included documentation that Patient #2 had self harm urges and was on LOS observation level.

According to the hospital policy, Patient #2 was monitored appropriately at LOS, however, the documentation of the RN and PT was not consistent. Patient #2's actual observation level was unclear.

d. A "Nursing Flow Sheet," dated 5/11/16, for the day shift, included documentation that stated Patient #2's category of observation was LOS. However, at 12:55 PM, in the narrative section, the RN documented that Patient #2 remained on 1:1 for safety. The RN documented Patient #2 continued to be suicidal, had self-harm urges, depression and anxiety.

A "Psychiatric Technician Charting/ADL's and Observations" note for 5/11/16, for day shift, the PT documented Patient #2 was on 1:1 at 10:00 AM, and 1:00 PM. The PT documented Patient #2 was on LOS at 3:21 PM, 4:00 PM, and 7:00 PM. The front of the "Psychiatric Technician Charting/ADL's and Observations" note had a check mark at both 15 minute checks and 1:1 observation.

The documentation was unclear as the RN and the PT documented both LOS and 1:1.

e. The "Nursing Flow Sheet," dated 5/12/16, for day shift, stated Patient #2's category of observation was LOS. At 11:15 AM, the RN documented Patient #2 continued to have SI, SH urges, depression and anxiety. She also noted Patient #2 was isolating, withdrawn, and was not attending group therapy sessions.

Patient #2's record included a "Physician's Order," dated 5/12/16, at 2:30 PM, to "trial off LOS," and her observation level was decreased to every 15 minutes checks.

In a "Psychiatric Technician Charting/ADL's and Observations" note dated 5/12/16, at 1:40 PM, the PT documented Patient #2 was on LOS. The PT documented Patient #2 was on 15 minute checks at 2:30 PM.

According to the hospital policy, the above nursing assessments would have required Patient #2 to remain on LOS. However her physician ordered her observation to be reduced.

f. The "Nursing Flow Sheet," dated 5/12/16, for the night shift, documented Patient #2's category of observation was LOS. The RN documented "Patient reports SI, self-harm urges, depression and anxiety. Will monitor." It was not clear what "will monitor" included, or if her observation level changed.

However, in the "Psychiatric Technician Charting/ADL's and Observations" note, dated 5/12/16 for night shift, Patient #2 remained on 15 minute checks for the entire shift.

According to the hospital policy, the above nursing assessments would have required Patient #2 to remain on LOS. However, she was monitored at 15 minute checks.

g. The "Nursing Flow Sheet," dated 5/13/16 for day shift, stated Patient #2's category of observation was LOS. The RN documented Patient #2 was isolating in her room, not attending groups, and continued to have SI, SH, depression and anxiety.

However, in the "Psychiatric Technician Charting/ADL's and Observations" note, dated 5/13/16 for day shift, Patient #2 remained on 15 minute checks for the entire shift.

According to the hospital policy, the above nursing assessments would have required Patient #2 to remain on LOS. However, she was monitored at 15 minute checks.

h. A "Nursing Flow Sheet," dated 5/13/16, for night shift, documented Patient #2's category of observation was LOS. Later that shift, at 10:10 PM, the RN documented Patient #2 had self harmed. She stated Patient #2 claimed she removed the hinge pin from the bathroom door and swallowed it (A door hinge connects the door to the wall and is held in place with a solid pin). The pin was described by Patient #2's RN as approximately 4 inches in length. The "Nursing Flow Sheet" included documentation by the RN that she contacted the physician to report the incident and received orders to place her on 1:1 observation. However, the RN did not write the verbal order to change her level of observation.

The "Psychiatric Technician Charting/ADL's and Observations" note for 5/13/16, for night shift, documented Patient #2's category of observation was 15 minute checks. Patient #2 was documented as being on LOS at 8:20 PM.

Patient #2's record included documention of escalation in behavior. Her observation status was not increased in accordance with hospital policy and she successfully carried out her self-harm intentions.

On 5/14/16 at 2:55 PM, the PA-C ordered an X-Ray of Patient #2's abdomen. She was transferred to an acute care facility on 5/14/16, at approximately 3:30 PM. Her record documented she had a procedure performed to remove the door pin from her small intestine. Patient #2 was returned to the hospital after the procedure and placed on LOS observation.

During an interview on 5/18/16 at 3:05 PM, the day shift RN stated all patients were placed on 15 minute checks upon admission. She said the level of observation could be increased, by an RN or MD, to more frequent intervals if the patient attempted to self-harm after admission.

The hospital failed to follow their policy and ensure Patient #2 was provided with the appropriate supervision necessary to keep her safe.

2. Patient #5 was a [AGE] year old female who was admitted on [DATE]. Her diagnoses included schizoaffective disorder depressive type, borderline personality disorder, and mild intellectual disability. She was admitted to the hospital on a voluntary basis.

a. Patient #5's record included "Nursing Flow Sheet" forms, dated 4/16/16 through 4/28/16. The forms were documented on by the assigned RN for each 12 hour shift. The assigned RNs documented a suicide/homicide assessment every 12 hours, per their shift. However, the assessment was not completed every 8 hours per the hospital policy.

During an interview on 5/19/16 at 8:30 AM, a Charge Nurse was questioned regarding suicide/ homicide assessment and reassessment. The Charge Nurse verified documentation was done once every 12 hours or as needed and not every 8 hours per Policy.

Patient #5 was not assessed or reassessed for suicide/ homicide every 8 hours per the hospital policy.

b. Patient #5's record included documentation on "Nursing Flow Sheets," "MD Progress Notes," and "MD Initial Psychiatric Assessment." The above forms did not document the correct observation level as compared to Patient #5's evaluation on the following dates:

Patient #5's record included an MD "Initial Psychiatric Assessment" form, dated 4/17/16, and signed by a psychiatrist. The form stated Patient #5 had suicidal ideation with a plan. Per the hospital policy, Patient #5 should have been on 1:1 observation. However, Patient #5 was documented as being on every 15 minute checks.

Patient #5's record included an "MD Progress Note" dated 4/22/16, and signed by a psychiatrist. The note stated Patient #5 had suicidal ideation without a plan. Per the hospital policy, Patient #5 should have been on LOS observation. However, Patient #5 was documented as being on every 15 minute checks.

Patient #5's record included a "MD Progress Note" dated 4/24/16, 4/26/16, and signed by a psychiatrist. The note documented Patient #5 disclosed actual self-harm. Per the hospital policy, Patient #5 should have been on 1:1 observation. However, she was documented as being on every 15 minute checks.

Patient #5's record included a "Nursing Flow Sheet," dated 4/18/16 at 3:40 PM, and signed by an RN. The form documented she had suicidal ideation with a plan. Per the hospital policy, Patient #5 should have been on 1:1 observation. However, she was documented as being on every 15 minute checks.

Patient #5's record included "Nursing Flow Sheet" forms dated 4/19/16, 4/21/16, 4/23/16, and 4/25/16 signed by an RN. The forms documented Patient #5 disclosed actual self-harm. Per the hospital policy, Patient #5 should have been on 1:1 observation. However, Patient #5 was documented as being on every 15 minute observation.

Patient #5's record included "Nursing Flow Sheet," dated 4/27/16 and 4/28/16, signed by an RN. The form stated Patient #5 had suicidal ideation without a plan. Per the hospital policy, Patient #5 should have been on LOS observation. However, she was documented as being on every 15 minute checks.

During an interview on 5/18/16 at 3:05 PM, an RN Charge Nurse reviewed Patient #5's record. She was questioned regarding suicide/ homicide precautions and patient observation status. The Charge Nurse stated all patients were admitted as every 15 minutes checks. The RN Charge Nurse also stated that patients with self-harm were designated 1:1 observation. The Charge Nurse stated that patients who had suicidal ideation without a plan were designated every 15 minute checks. The Charge Nurse stated patients who had suicidal ideation and exhibited self-harm were designated as LOS checks.

During an interview on 5/19/16 at 8:30 AM, a second RN Charge Nurse reviewed Patient #5's record. She was questioned regarding suicide/ homicide precautions and patient observation status. The Charge Nurse stated all patients were admitted as every 15 minutes checks and it was up to the physician to increase the level of observation.

The hospital failed to meet the safety needs of Patient #5 by failing to assign the appropriate level of observation based on on-going evaluation and hospital policy.

3. Patient #4 was a [AGE] year old female who was admitted on [DATE] at 2:10 AM. Her admitting diagnoses included mood disorder, substance use, rule out bipolar and rule out psychosis.

Patient #4's record included "Nursing Flow Sheet" forms, dated 4/30/16 through 5/02/16. The forms were signed, dated and timed by an RN for each 12 hour shift. The flow sheet indicated a suicide/homicide assessment was documented every 12 hours by an RN. However, the assessment was not completed every 8 hours per the hospital policy.

A day shift RN Charge Nurse was interviewed on 5/19/16 at 8:30 AM regarding suicide/ homicide assessment and reassessment. The RN Charge Nurse confirmed the assessments were completed every 12 hours or as needed, not every 8 hours per hospital policy.

The medical record for Patient #4 did not reflect a suicide/homicide assessment was completed and documented every 8 hours per the hospital policy.

The "Initial Psychiatric Assessment," dated 4/30/16 and signed by a physician, indicated Patient #4 drove from her place of residence in the State of WA to Boise, forced her way into the home of her ex-husband, threatened to knock herself out and began to cry and scream. The psychiatric evaluation documented the police were notified and transported her to an ED for evaluation. The psychiatric assessment stated Patient #4 was "placed on a hold" and brought to [Name of Psychiatric Hospital].

A "Medical Consultation," dated 4/30/16 and signed by a PA-C and co-signed by a physician, included "...She forced her way into the home. She started having bizarre behavior, aggressive."

The "Initial Assessment for Admission," dated 4/30/16 at 9:00 PM, and signed by an RN, indicated Patient #4 was "making suicidal statements" when at the home of her ex-husband. Also included in the assessment was a "Nursing Admission/Treatment Summary." The summary included Patient #4 was "making suicidal statements ...delusional statements about being controlled and being raped ..." when at the home of her ex-husband.

The "High Risk Notification Alert/Initial Treatment Planning" document, dated 4/30/16 at 2:10 AM, included a check mark beside the following statement: "Suicidal: (Plan, Intent, Means, Access, Verbalization, History, etc.) Indicator(s): Pt made suicidal statements about no [sic] wanted to live anymore."

The "Master Treatment Plan," dated 4/30/16, included a section for "Social Work," which stated Patient #4 "wanted to jump out in front of a car so that her daughter would be happier ...She was reporting suicidal ideation at the ED with a plan to drive off a cliff or a bridge ..."

Nursing flow sheets, co-signed by an RN, were reviewed. At the top of each page was a category for "Alerts." One of the choices was for "Suicide." Also included was "Categories for Observation." Patient #4 was documented as suicidal on 4/30/16, 5/01/16, 5/02/16, and 5/03/16. The observation level marked was for staff checks of Patient #4 every 15 minutes.

During an interview with the day shift RN Charge Nurse on 5/18/16, beginning at approximately 3:00 PM, the various levels of patient observation status were discussed. The RN Charge Nurse said that the practice of the hospital was to place all patients on every 15 minute checks at the time of admission, regardless of the patients' histories and/or admitting status. She said patients were not placed on line of sight observation or 1:1 observation when admitted . She said the only patients placed on 1:1 observation at the time of admission were patients with a CPAP, patients who use portable oxygen and patients with any type of a metal brace on the lower body. She stated patients may later be placed on line of sight observation or 1:1 observation if behavior warrants such.

An evening shift RN Charge Nurse was interviewed on 5/19/16 beginning at approximately 8:30 AM. She said the hospital's general rule is to place all new admissions on every 15 minute checks, unless otherwise directed by a physician.

The level of observation assigned to Patient #4 through out her stay did not accurately reflect her safety needs.

4. Patient #21 was a [AGE] year old female who was admitted on [DATE] at 3:40 PM. Her diagnoses included bipolar disorder, alcohol use disorder, alcohol withdrawal, history of withdrawal seizures, chronic neck and back pain, history of fatty liver and recent overdose on Doxepin (an anti-depressant.)

Patient #21's record included "Nursing Flow Sheet" forms, dated 4/24/16 at 4:30 PM through 4/25/16 at 2:55 PM. The forms were signed, dated and timed by an RN. However, the assessment was not completed every 8 hours per the hospital policy.

A day shift RN Charge Nurse was interviewed on 5/19/16 at 8:30 AM regarding suicide/homicide assessment and reassessment. The RN Charge Nurse confirmed the assessments were completed every 12 hours or as needed, not every 8 hours per hospital policy.

The medical record for Patient #21 did not reflect a suicide/homicide assessment was completed and documented every 8 hours per the hospital policy.

The "Initial Assessment for Admission," dated 4/25/16 and signed by a physician, indicated Patient #21 was voluntarily admitted to the facility after having presented to a local ER with suicidal ideations and a plan to hang herself. The assessment included that Patient #21 also thought about "drinking herself to death, so she drank three fifths of vodka on the day of admit."

The "Medical Consultation," dated 4/25/16, signed by a PA-C and co-signed by a physician, included "...The patient stated that in the last six months she has been drinking about a fifth of vodka per day. She was having suicidal ideation, thought about wanting to hang herself. Lately she has been drinking a lot. Her family found her unconscious. She was brought to [Name of Acute Care Hospital] ER. After she was medically stabilized, she was transferred to [Name of Psychiatric Facility] for further evaluation."

The "Short Stay Summary," dated 4/25/16, and signed by a physician, included an addendum. The addendum stated "...Despite regular doses of Ativan, she continued to deteriorate and eventually began to demonstrate symptoms of DTs. For this reason she was transferred back to the emergency room and was medically admitted ."

The "Initial Assessment for Admission," dated 4/24/16 at 4:05 PM, and signed by an RN, indicated Patient #21 was "...starting to hallucinate due to ETOH Detox...She has a history of ETOH withdrawal seizures...Pt fell recently down her stairs...Pt is a very high fall risk."

The "High Risk Notification Alert/Initial Treatment Planning" document, dated 4/24/16 at 4:45 PM, included a check mark beside the following statements: "Suicidal: (Plan, Intent, Means, Access, Verbalization, History, etc.) Indicator(s): HX OF SUICIDE ATTEMPTS: CUT WRISTS, OVERDOSE, DRINK ETOH EXCESSIVELY TO CAUSE DEATH, INCREASED SI-PLAN TO HANG SELF!"

The "Master Treatment Plan," dated 4/30/16, untimed, contained a section for "Social Work," which included "...[Patient name] presented to the ED with her family due to increased suicidal ideation with a plan to hang herself. PT (Patient) states she then changed her mind and instead decided to drink herself to death. per initial complaint during triage, pat's family contacted after pt ingested 3 fifths of vodka and spoke about hanging herself, and attempting to slit her wrists yesterday. PT [Patient] informed ED [Emergency Department] she took and OD [Overdose] of Doxepin 3 days prior and continues to make suicidal statements with a plan..."

Patient #21's "Nursing Flow Sheets," were reviewed. At the top of each page was a category for "Alerts." One of the choices that a nurse could check mark was for "Suicide." Also included was "Categories for Observation." The observation choices were "Q15, 1:1, LOS, LOS after meals, and Other."

Patient #21's nursing flow sheet, dated 4/24/16 at 4:30 PM, included a check mark beside "Suicide, Cheeking, Self Harm, Hallucinations, Detox, Fall Risk, Seizure and High Risk Medications." A check mark beside "Q15" indicated the category of observation was every 15 minute checks.

The DNS was interviewed on 5/24/16, beginning at approximately 1:15 PM. He reviewed Patient #21's record and confirmed that based on documentation of an on-going evaluation, she should have been placed on "LOS" observation, as opposed to "Q15" minute checks, when she was admitted to the hospital.

By failing to assign the appropriate level of observation based on hospital policy and on-going evaluation, the hospital failed to consistently meet the safety needs of Patient #21.

5. Patient #3 was a [AGE] year old male admitted on [DATE]. His diagnoses included schizophrenia, bipolar disorder, and psychosis.

A hospital policy "Elopement of a Patient and Elopement," revised 5/05/16, stated "A patient is to be placed on elopement precautions if the patient is at risk for leaving the hospital without consent/prior authorization or has a history of attempting to leave the hospital without consent/prior authorization." Additionally, the policy stated "Depending on the severity of the elopement attempt or history of elopement, the patient will be placed on a 1:1 or LOS category of observation. Patient will remain on 1:1 or LOS until provider evaluates for safety."

Patient #3's record included an "Initial Assessment for Admission," dated 5/17/16, and signed by an RN. The form stated patients who score 15 or higher on the "risk factors of elopement" questions would be placed on elopement precautions. Patient #3 scored a 9 out of a possible 32. On the elopement risk form, Patient #3 was not identified as an elopement risk. However, documentation in Patient #3's record stated he was a risk for elopement. Examples include:

a. The hospital's daily census report, dated 5/17/16 and 5/18/16, were reviewed. Both census forms documented Patient #3 was designated as "E" for elopement risk.

There was no documentation in Patient #3's record which indicated he was an elopement risk. Patient #3 was on "every 15 minute" checks. However, per the policy, Patient #3 should have been on either 1:1 or LOS observation.

b. Patient #3's record included an "Admission Physician Orders and Medication Reconciliation" form dated 5/17/16, and signed by an RN. The form stated Patient #3 was designated as an elopement risk under "safety precautions."

c. Patient #3's record included a "Psychiatric Technician Charting/ADL's & Observations" form dated 5/17/16, for the night shift. The form stated Patient #3 was designated as an elopement risk under "Alerts."

During an interview on 5/18/16 at 3:05 PM, a Charge Nurse was questioned regarding elopement precautions. The RN Charge Nurse stated there must be signs at doors and the elopement precaution designated patient must have a staff member assigned to them as either 1:1 or LOS. The RN Charge Nurse was not aware of a "risk factors of elopement" scoring for patients upon admission to designate whether or not they were an elopement risk.

During an interview on 5/19/16 at 11:30 AM, a Psychiatric Technician (PT) was questioned if current elopement risk patients were on the unit. The PT stated there were no elopement risk patients in the hospital at that time of the interview however, later in the same interview, she stated there was an elopement risk patient earlier in the shift who was discharged . The PT stated she did not know if there were any elopement risk designated patients on the unit. "Nursing Shift Notes" census, dated 5/18/16, documented there were two elopement risk designated patients currently on the unit.

The PT was questioned regarding the various elopement warning signs on the unit. The PT stated the signs were up only when they had an elopement risk patient on the unit, however, she stated she thought they were up all the time. The PT stated she was not aware whether or not there were patients who were at risk for elopement.

The medical record for Patient #3 did not reflect documentation of an accurate elopement assessment in accordance with hospital policy.
VIOLATION: MEDICAL STAFF PERIODIC APPRAISALS Tag No: A0340
Based on staff interview, review of hospital policies, review of medical staff bylaws and credentialing files, it was determined the hospital failed to ensure the reappraisal process was followed for existing medical staff. This failure interfered with the medical staff's ability to verify that all medical staff requirements were met and had the potential to negatively impact patient care in the hospital. Findings include:

Credentialing files were reviewed during the survey for evidence of the hospital's reappraisal processes. The reappraisal process was not adhered to as follows:

The credentialing file for Psychiatric Provider A, who was both a psychiatrist and the Medical Director of the hospital, was reviewed on 5/24/16. The most recent information in the file about appointment or reappointment was the, "Application for Appointment." The form was signed on 3/31/14 by the applicant. It was signed on 4/24/14 by the individual who was the Medical Director at that time and on 4/29/14 by the Chairman of the governing board. There was no evidence Psychiatric Provider A had applied for reappointment since 3/31/14 and no evidence the governing board had approved reappointment since 4/29/14. Additionally, evidence could not be found indicating Provider A had been through a reappraisal process.

"Bylaws of the Medical Staff," which were not dated, timed or signed, were reviewed during the survey. They included the following:

In a section about exercise of privileges, the bylaws said "Periodic re-determination of clinical privileges and the increase or curtailment of the same shall be based upon the direct observation of the appointee's participation in and the delivery of medical care."

In a section about modification of privileges, the bylaws said "The procedure for reviewing and granting privileges shall follow the same procedure as for reappointment.

In a section about the appointment process, the bylaws said "...Bi-annually, all members of the medical staff shall apply for reappointment and renewal or changes in clinical privileges. The emphasis of the reappointment process shall be on a review of the results of quality assessment and improvement on the applicant's continuing medical activities..." The bylaws also included "...The Administrator or their designee, at least ninety (90) days prior to the expiration date of each staff member's appointment year, shall request the privileges for which they wish to be considered...Each appointee who desires reappointment shall, at least forty-five (45) days prior to such expiration date, send his reapplication to the Administrator or their designee."

Policies related to the hospital's medical staff and governing board were requested during the survey. On 5/25/16 at approximately 12:45 PM, the interim Administrator for the hospital stated policies related to the medical staff and the governing board could not be found.

During an interview on 5/24/16 beginning at 10:20 AM, the Interim Administrator reviewed the staff credentialing files and confirmed the reappointment for Provider A was not current. Additionally, he confirmed the hospital did not have current and complete staff credential files. The Interim Administrator stated the previous Administrator maintained the staff files, and the responsibility was recently delegated to the business officer.

The hospital's medical staff reappraisal process was not followed.
VIOLATION: MEDICAL STAFF CREDENTIALING Tag No: A0341
Based on staff interview and review of hospital policies, governing board bylaws and credentialing files, it was determined the hospital failed to ensure membership to the medical staff was based on the existing medical staff's recommendations to the governing board. This resulted in the potential for new applicants to be appointed to the medical staff without a thorough examination of credentials and without the full consideration of the existing medical staff. This failed practice had the potential to negatively impact the care provided to all patients in the hospital. Findings include:

"Bylaws of the Governing Board," which were not dated, timed or signed, included a section, "Medical Staff Organization." Contained within this section was "There shall be Bylaws and rules and regulations developed and adopted by the Medical Staff consistent with Hospital policy..." Also included was "...Appointment for Medical Staff shall be made by the Governing Board upon recommendation of the Medical Staff and shall be documented." The hospital did not adhere to the governing board bylaws as follows:

Credentialing files for the hospital's psychiatric providers were reviewed during the survey. The files did not contain evidence that the existing medical staff's recommendations were considered prior to the appointment of the applicants as follows:

Psychiatric Provider B, an MD, had a form in his file titled, "Physician/Practitioner seeking appointment." The Chairman of the governing board signed the form on 2/08/16 and checked a box beside the statement, "Recommend granting full appointment to the medical staff..." The Medical Director signed the form on 5/11/16 and checked a box beside the statement, "I concur with the recommendations to grant full appointment to the medical staff..." After Psychiatric Provider B was appointed by the governing board on 2/08/16, the file indicated approximately 93 days lapsed before the recommendation to grant full appointment was obtained from the Medical Director.

Psychiatric Provider C, a PA, had a form in her file titled, "Physician/Practitioner seeking appointment." The Chairman of the governing board signed the form on 2/08/16 and checked a box beside the statement, "Recommend granting full appointment to the medical staff..." The Medical Director signed the form on 5/11/16 and checked a box beside the statement, "I concur with the recommendations to grant full appointment to the medical staff..." After Psychiatric Provider C was appointed by the governing board on 2/08/16, the file indicated that approximately 93 days lapsed before the recommendation to grant full appointment was obtained from the Medical Director.

Policies related to the hospital's medical staff and governing board were reviewed. On 5/25/16 at approximately 12:45 PM, the interim Administrator for the hospital stated policies related to the medical staff and the governing board could not be found.

During an interview on 5/24/16 beginning at 10:20 AM, the Interim Administrator reviewed the provider credential files. He confirmed Provider B and C's files were not complete before they assumed responsibility for patient care in the hospital.

Two psychiatric providers were granted privileges without evidence of the medical staff's recommendations to the governing board.
VIOLATION: MEDICAL STAFF BYLAWS Tag No: A0353
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of medical records, medical staff bylaws and credentialing files, it was determined the hospital failed to ensure the "Bylaws of the Medical Staff" were adhered to and patients were admitted and discharged by physicians only. This practice allowed 1 of 4 discharged patients, (Patient #20) whose records were reviewed, to receive inpatient care without the oversight of a physician. This failed practice had the potential to negatively impact the care provided to all patients in the facility.

The "Bylaws of the Medical Staff," which were not dated, timed or signed, included the section "Allied Health Professionals." Definitions were included in this section for "Licensed Nurse Practitioners ...Physician Assistants." Under the section of "Prerogatives" for Allied Health Professionals, the bylaws stated "Independent Allied Health Professionals shall:...Not admit or discharge patients at the hospital." The bylaws for medical staff were not adhered to as follows:

The credentialing file for Psychiatric Provider D, an FNP, was reviewed during the survey. Granted privileges included "...Psychopharmacology, Diagnosis of Psychiatric Disorders, Treatment of Psychiatric Disorders, Recommendation for Treatment and Concurrent Treatment of Patient (if requested by Attending Physician)..." Privileges for admitting and discharging patients without physician oversight were not included.

Patient #20 was a [AGE] year old male who was admitted to the facility 5/07/16 at 12:01 AM. His diagnoses included bipolar disorder, alcohol use disorder, benzodiazepine use/overuse and general anxiety. Orders were received to discharge Patient #20 from the facility on 5/08/16 at 9:15 AM.

The "Initial Psychiatric Assessment" was completed and dictated by Psychiatric Provider D, an FNP, on 5/07/16 and included no time. The assessment was co-signed by Psychiatric Provider A, who was a physician and the Medical Director, on 5/09/16 at 11:00 AM.

The "Discharge Summary" was completed and dictated by Psychiatric Provider D, an FNP, on 5/08/16 and included no time. The assessment was co-signed by Psychiatric Provider A, a physician and the Medical Director, on 5/09/16 at 11:00.

"Alcohol Detox Orders" were signed by an RN on 5/06/16 at 9:45 AM. The document indicated orders were obtained by telephone from Psychiatric Provider D, an FNP. The FNP signed the orders on 5/08/16 at 9:00 AM. The orders were not co-signed by a physician.

"Physician's Orders," dated 5/08/16 at 9:15 AM, included "D/C home." The orders were signed by Psychiatric Provider D, an FNP. The orders were not co-signed by a physician.

During an interview on 5/23/16 from 2:30 to 2:45 PM, the Medical Director reviewed Patient #20's record. She stated the facility did not have a policy that stated a physician must oversee the admission and management of each patient. She stated it was the expectation that a psychiatrist would see each patient within 24 hours of admission. The Medical Director stated she was not consulted before Patient #20's discharge. She stated "This one fell through the cracks."

There was no documentation in the record indicating the admission and discharge processes for Patient #20 were overseen by a physician. The "Bylaws of the Medical Staff" were not enforced.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on review of policies, medical record review, staffing assignment records and staff interview, it was determined the facility failed to ensure that RNs evaluated and implemented observation levels appropriate to the individual needs of patients. This failure resulted in inadequate monitoring of patients which led to a patient self harm, injury and hospital transfer. Findings include:

Refer to A 142 as it relates to the failure of the hospital to ensure patients were placed on appropriate observation levels as determined by nursing assessments and facility policy.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of patient records and staff interview, it was determined the facility failed to ensure safe and accurate medication administration for 1 of 22 patients (#2) whose records were reviewed. This resulted in the administration of a medication that was specifically ordered by her physician to not be administered. Findings include:

Patient #2 was a [AGE] year old female who was admitted to the facility on [DATE], after an attempted suicide by ingestion of ibuprofen and Benadryl. Her record documented she was transferred to the facility after initial treatment in a hospital emergency room .

An order dated 5/10/16 at 10:30 AM, signed by Patient #2's physician, stated "No ibuprofen, No Benadryl - s/p [status post] OD." The order was noted by the nursing staff on 5/10/16 at 10:40 AM.

Patient #2's record included documentation by the LPN she administered ibuprofen 600 mg on 5/15/16 at 2:00 PM, due to a complaint of a migraine and sore throat.

During an interview on 5/19/16 at 11:30 AM, Patient #2's physician reviewed her record and confirmed she wrote the order that ibuprofen not be administered. She confirmed Patient #2's record included documentation it was given. She stated the LPN made a medication error.

The DNS was interviewed on 5/19/16 at 12:30 PM. He confirmed Patient #2's record documented ibuprofen was administered without an order. The DNS stated he was not aware of the medication error.

Patient #2 received a medication that was ordered not to be given.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0431
Based on staff interview and review of medical records, policies, and incident reports, it was determined the hospital failed to ensure patient medical records were accurate and complete. This resulted in a lack of documentation that patient care was comprehensive and individualized according to their needs and compliant with physician orders. Findings include:

1. Refer to A 438 as it relates to the lack of documentation describing patients' level of observation.

2. Refer to A 450 as it relates to incomplete medical records.

The cumulative effect of these negative systemic practices resulted in a lack of comprehensive, accurate patient information being documented.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of patient records and staff interview, it was determined the facility failed to ensure accurate documentation for 1 of 22 patients (#2) whose records were reviewed. This had the potential to result in a failure to meet the patients' needs and provide inadequate care. Findings include:

1. Patient #2 was a [AGE] year old female admitted on [DATE], after an attempted suicide. Additional diagnosis included major depression and generalized anxiety disorder.

a. Patient #2's record included nursing flow sheets that had conflicting observation status documentation, as well as, inaccurate documentation. Examples include but are not limited to:

i. "Nursing Flow Sheet," dated 5/11/16 for day shift, the section titled "Categories of Observation," both 15 minute and LOS were checked. However, 15 minute had "error" written under it. The "error" was not accompanied by an initial, date, or time, to indicate who wrote it, when they wrote it, and what time it was written. Additionally, in the narrative documentation on the flow sheet the RN documented Patient #2 was on a 1:1 observation level.

ii. "Nursing Flow Sheet," dated 5/11/16 for night shift, the section titled "Categories of Observation," both 15 minute and LOS were checked. However, the 15 minute had "error" written under it. The "error" was not accompanied by an initial, date, or time, to indicate who wrote it, when they wrote it, and what time it was written.

iii. "Nursing Flow Sheet," dated 5/12/16 for day shift, the section titled "Categories of Observation," both 15 minute and LOS were checked. However, the 15 minute had "error" written under it. The "error" was not accompanied by an initial, date, or time, to indicate who wrote it, when they wrote it, and what time it was written.

iv. "Nursing Flow Sheet," dated 5/12/16 for night shift, the section titled "Categories of Observation," both 15 minute and LOS were checked. However, the 15 minute had "error" written under it. The "error" was not accompanied by an initial, date, or time, to indicate who wrote it, when they wrote it, and what time it was written.

v. "Nursing Flow Sheet," dated 5/13/16 for day shift, the section titled "Categories of Observation," both 15 minute and LOS were checked. However, the 15 minute had "error" written under it. The "error" was not accompanied by an initial, date, or time, to indicate who wrote it, when they wrote it, and what time it was written.

vi. "Nursing Flow Sheet," dated 5/13/16 for night shift, the section titled "Categories of Observation," both 15 minute and LOS were checked. However, the 15 minute had "error" written under it. The "error" was not accompanied by an initial, date, or time, to indicate who wrote it, when they wrote it, and what time it was written. Additionally, in the narrative documentation on the flow sheet the RN documented Patient #2 was on a 1:1 observation level.

vii. "Nursing Flow Sheet," dated 5/14/16 for day shift, the section titled "Categories of Observation," both 15 minute and LOS were checked. However, the 15 minute had "error" written under it. The "error" was not accompanied by an initial, date, or time, to indicate who wrote it, when they wrote it, and what time it was written.

viii. "Nursing Flow Sheet," dated 5/14/16 for night shift, the section titled "Categories of Observation," both 15 minute and LOS were checked. However, the 15 minute had "error" written under it. The "error" was not accompanied by an initial, date, or time, to indicate who wrote it, when they wrote it, and what time it was written.

ix. "Nursing Flow Sheet," dated 5/16/16 for day shift, the section titled "Categories of Observation," both 15 minute and LOS were checked. However, the 15 minute had "error" written under it. The "error" was not accompanied by an initial, date, or time, to indicate who wrote it, when they wrote it, and what time it was written.

x. "Nursing Flow Sheet," dated 5/16/16 for night shift, the section titled "Categories of Observation," both 15 minute and LOS were checked. However, the 15 minute had "error" written under it. The "error" was not accompanied by an initial, date, or time, to indicate who wrote it, when they wrote it, and what time it was written. Additionally, in the narrative documentation on the flow sheet the RN documented Patient #2 was on a 1:1 observation level.

xi. "Nursing Flow Sheet," dated 5/17/16 for day shift, the section titled "Categories of Observation," both 15 minute and LOS were checked. However, the 15 minute had "error" written under it. The "error" was not accompanied by an initial, date, or time, to indicate who wrote it, when they wrote it, and what time it was written. Additionally, in the narrative documentation on the flow sheet the RN documented Patient #2 was on a 1:1 observation level.

xii. "Nursing Flow Sheet," dated 5/17/16 for night shift, the section titled "Categories of Observation," both 15 minute and LOS were checked. However, the 15 minute had "error" written under it. The "error" was not accompanied by an initial, date, or time, to indicate who wrote it, when they wrote it, and what time it was written. Additionally, in the narrative documentation on the flow sheet the RN documented Patient #2 was on a 1:1 observation level.

During an interview on 5/19/16 beginning at 8:30 AM, the night shift Charge RN described the levels of observation. She stated most patients were placed on 15 minute checks when they were admitted . She stated LOS was an increased level of observation, and that was preferred over 1:1, as it provided the patient more "space". She stated LOS required the patient to be visualized at all times by a staff member. The Charge RN described 1:1 as "within arm's reach." She stated that was the highest level of observation at the facility. The Charge RN confirmed the documentation on the Nursing Flow Sheets was inconsistent.

b. Patient #2's record included forms titled "Psychiatric Technician Charting/ADL's and Observation." The forms were completed each shift, and included documentation of the patients' activities during observations. It was unclear what level of observation Patient #2 was in the following PT notes:

i. 5/10/16 night shift, the section titled "Categories of Observation," LOS was checked. However, the PT narrative section of the form documented Patient #2 was on a1:1 observation level.

ii. 5/14/16 day shift, the section titled "Categories of Observation," 15 minute was checked. However, the PT narrative section of the form documented Patient #2 was on a 1:1 observation level.

iii. 5/14/16 night shift, the section titled "Categories of Observation," 15 minute was checked. However, the PT narrative section of the form documented Patient #2 was on a 1:1 observation level.

iv. 5/15/16 night shift, the section titled "Categories of Observation," 15 minute was checked. However, the PT narrative section of the form documented Patient #2 was on a LOS observation level.

v. 5/16/16 day shift, the section titled "Categories of Observation," 15 minute and 1:1 were checked. However, the PT narrative section of the form documented Patient #2 was on 1:1 and LOS observation level.

vi. 5/16/16 night shift, the section titled "Categories of Observation," 1:1 was checked. However, the PT narrative section of the form documented Patient #2 was LOS observation level.

vii. 5/17/16 day shift, the section titled "Categories of Observation," 15 minute was checked. However, the PT narrative section of the form documented Patient #2 was LOS observation level.

During an interview on 5/19/16 beginning at 8:30 AM, the night shift Charge RN reviewed the "Psychiatric Technician Charting/ADL's and Observation" forms. She confirmed the level of observation documentation was not clear.

The facility failed to ensure documentation accurately reflected Patient #2's observation level.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview, it was determined the facility failed to ensure patient medical record entries were complete, signed, dated and timed for 3 of 22 patients (#2, #4, and #21) whose records were reviewed.

1. Patient #2 was a [AGE] year old female admitted on [DATE], after an attempted suicide. Additional diagnoses included major depression and generalized anxiety disorder.

a. Patient #2's record included dictated and transcribed "Daily Progress Notes," "Medical Consultations," a "Social History," and "Initial Psychiatric Assessment." The documents included the dates when the evaluations occurred, as well as, the dates of dictation and transcription. However, they did not include the time of the evaluation. This resulted in a lack of clarity as to when the assessment findings were first noted. Examples include, but were not limited to, the following:

i. "Initial Psychiatric Assessment" - Date of evaluation, dictation, and transcription 5/09/16. The document did not include a time as to when the assessment was performed. The assessment included "She has active suicidal ideation with plans and intent." Additionally, the assessment stated "She was put on appropriate safety protocols."

ii. "Medical Consultation" - Date of evaluation, dictation, and transcription 5/09/16. The document did not include a time as to when the assessment was performed.

iii. "Progress Note" - Date of evaluation, and dictation 5/10/16. Transcription was performed 5/11/16. The document stated Patient #2 was angry, uncooperative, and refused to speak with the psychiatrist. The document did not include a time as to when the assessment was performed.

iv. "Progress Note" - Date of evaluation, dictation, and transcription 5/11/16. The document stated Patient #2 was having suicidal and self-harming thoughts. The document also stated "Yesterday she flooded her room, so she was put on one-on-one." The document did not include a time as to when the assessment was performed.

v. "Progress Note" - Date of evaluation, dictation, and transcription 5/13/16. The document stated Patient #2 had illogical thought process, made poor eye contact, and very angry. The document did not include a time as to when the assessment was performed.

vi. A "Master Treatment Plan," dated 5/13/16, but not timed, stated Patient #2 was suicidal and having self harm urges. The "Master Treatment Plan" was signed by the Psychiatrist, SW, and RN.

vii. "Progress Note" - Date of evaluation and dictation 5/14/16. Document was transcribed 5/15/16. The Psychiatrist documented "She apparently did swallow a piece of metal from a door handle, and she had to be sent to the emergency room where she had an endoscopy done, and it eventually was removed. She is now on one-to-one observation." The document did not include a time as to when the assessment was performed. It was unclear when the psychiatrist performed his evaluation and dictation, as an xray was not ordered until after an assessment by the medical PA-C on 5/14/16 at 2:55 PM. At that time it was confirmed that Patient #2 had a foreign body in her abdomen and she was transferred to an acute care facility. Patient #2 was out of the facility from 4:30 PM until 10:15 PM. The progress note by the psychiatrist was dictated in past tense to indicate he evaluated Patient #2 after her return from the hospital, however, there was no further documentation he saw Patient #2 at that time.

viii. "Progress Note" - Date of evaluation and dictation 5/15/16. Date of transcription 5/16/16. The Psychiatrist documented Patient #2 admitted to suicidal ideation and was unable to contract safety in the hospital at that time. The document did not include a time as to when the assessment was performed.

During an interview on 5/19/16 beginning at 10:49 AM, the DON stated he was unsure of when the medical or psychiatric team evaluated patients. He stated any orders would be dated and timed, but the dictated notes did not include a time, so he was unsure when they saw the patients.

Physician progress notes did not consistently include the times Patient #2 was evaluated or the dictation times.

b. A document titled "PHQ-9" (Patient Health Questionnaire), was implemented by the facility on 5/20/16. The PHQ-9 was a suicide risk assessment, which was to be completed by the RN on the day shift for each patient. The following PHQ-9 assessments were incomplete as follows:

i. Patient #20's record included a PHQ-9, dated 5/21/16 and 5/22/16, however, there was no staff name or time on the to indicate the individual that performed the assessment.

During an interview on 5/23/16 beginning at 3:30 PM, the DON reviewed the PHQ-9 assessments, and confirmed they did not include the staff name and time the assessment was performed.

The facility failed to ensure documentation was complete and accurate.





2. Patient #4 was a [AGE] year old female who was admitted on [DATE] at 2:10 AM. Her admitting diagnoses included mood disorder, substance use, rule out bipolar and rule out psychosis.

Patient #4's record included dictated and transcribed "Daily Progress Notes," "Medical Consultations" and an "Initial Psychiatric Assessment." The documents included a date when the evaluation occurred, as well as, the date of dictation and transcription. However, they did not include the time of the evaluation. This resulted in a lack of clarity as to when the assessment findings were first noted. Examples include but are not limited to:

a. "Initial Psychiatric Assessment" - Date of evaluation, dictation, and transcription 4/30/16. The document did not include a time the assessment was performed.

b. "Medical Consultation" - Date of evaluation, dictation, and transcription 4/30/16. The document did not include a time the assessment was performed.

c. "Progress Note" - Date of evaluation, dictation and transcription 5/01/16. The document did not include a time the assessment was performed.

d. "Progress Note" - Date of evaluation and dictation was 5/02/16. The date of transcription was 5/03/16. The document did not include a time the assessment was performed.

e. "Progress Note" - Date of evaluation, dictation, and transcription 5/03/16. The document did not include a time the assessment was performed.

f. Progress Note - Date of evaluation and dictation was 5/04/16. Date of transcription was 5/05/16. The document did not include a time the assessment was performed.

During an interview on 5/19/16 beginning at 10:49 AM, the DON stated he was unsure of when the medical or psychiatric team evaluated patients. He stated any orders would be dated and timed, but the dictated notes did not include a time, so he was unsure when they saw the patients.

Patient #4's record included documents that were not accurately timed.

3. Patient #21 was a [AGE] year old female who was admitted on [DATE] at 3:40 PM. Her diagnoses included bipolar disorder, alcohol use disorder, alcohol withdrawal, history of withdrawal seizures, chronic neck and back pain, history of fatty liver and recent overdose on Doxepin (an anti-depressant).

Patient #21's record included a dictated and transcribed "Medical Consultation," an "Initial Psychiatric Assessment" and a "Short Stay Summary." The documents included a date when the evaluation occurred, as well as, the date of dictation and transcription. However, they did not include the time of the evaluation. This resulted in a lack of clarity as to when the assessment findings were first noted. Examples include but are not limited to:

a. "Medical Consultation" - Date of evaluation, dictation, and transcription 4/25/16. The document did not include a time the assessment was performed.

b. "Initial Psychiatric Assessment" - Date of evaluation, dictation, and transcription 4/25/16. The document did not include a time the assessment was performed.

c. "Short Stay Summary" - Date of evaluation was 4/25/16. Date of dictation and transcription was 4/29/16. The document did not include a time the assessment was performed.

Patient #4's record included documents that were not accurately timed.