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 POCATELLO 1200 HOSPITAL WAY POCATELLO, ID April 3, 2015
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, and staff interview, it was determined the hospital failed to ensure patients and/or their representatives were informed of all of their rights in advance of providing services. This impacted 2 of 17 patients (#11 and #13) whose records were reviewed and had the potential to impact all patients receiving services at the hospital. Failure to inform patients of their rights limited their ability to make informed decisions about their care. Findings include:

1. Patient #11 was a [AGE] year old female admitted on [DATE], from a skilled nursing facility, with diagnoses of psychosis, bipolar disorder and congenital brain injury with mental disability.

Patient #11's medical record for her hospital admission of 11/25/14 to 11/29/14, was reviewed. Her record included a letter of guardianship and conservatorship. The letter stated Patient #11 was impaired to the extent she was unable to make responsible decisions.

Patient #11's record did not include documentation of contact with her guardian, to obtain consent for services or to discuss patient rights, care planning or treatment. Patient #11's record did not include a signed receipt of notice of patient rights.

During an interview on 4/01/15 at 4:00 PM, RN C reviewed Patient #11's record and confirmed it did not include consent forms, receipt of notice of patient rights or documentation of contact with her guardian.

The facility failed to inform Patient #11, and her guardian, of her rights.

2. Patient #13 was a [AGE] year old male admitted on [DATE], with diagnoses of psychosis and depression.

Patient #13's medical record for his hospital admission of 1/01/15 to 1/05/15, was reviewed. His record did not include a signed receipt of notice of patient rights.

During an interview on 4/01/15 at 4:20 PM, RN C reviewed Patient #13's record and confirmed it did not include a receipt of notice of patient rights.

The facility failed to inform Patient #13 of his rights.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on staff interview and review of QAPI documents, it was determined the hospital failed to ensure the QAPI program used data to identify opportunities for improvement. Also, the hospital failed to identify high-risk, high-volume, or problem prone areas in order to focus its QAPI program. This prevented the hospital from analyzing its processes in order to improve them. Findings include:

1. The goals the hospital used in 2014 included:

a. Safety checks will be completed 100% of the time with each shift.
b. No major prohibited items will be found.
c. A 10% decrease in falls within the next 30 days.
d. All infections will be tracked.
e. All skin problems will be tracked.
f. Staff will have no "occurrences" in the next 30 days.
g. The hospital will have "...zero medication errors."
h. The hospital will have a decrease of "other occurrences" within 30 days.
i. Patients will attend at least 70% of groups.

Data summaries for 2014:

a. Data summaries stated compliance with contraband checks in January 2014 was 69% on days and 84.5% on nights. The percentages rose and fell throughout the year. The summary for November 2014 was 57% on days and 57% on nights. The rates rose again in December 2014 with 90% on days and 100% on nights being completed for both months. Although it improved at the end of the year, the goal was not met for 2014.

There was no documentation to show the data gathered was used to improve compliance with contraband checks. The reasons for improvement or decline were not analyzed. The only action documented to improve compliance for the entire year was education to remind staff to complete the checks.

b. There was no documentation to show the data gathered was used to decrease the number of prohibited items patients kept. Data summaries stated contraband items were found each month in 2014. No analysis was documented and no action was taken to address the failure to meet the goal.

c. There was no documentation to show the data gathered was used to decrease the number of falls. Data summaries stated falls were recorded each month in 2014. The number of falls was not adjusted to account for changes in the hospital's census. The number of falls varied widely from 1 in February 2014 to 18 in September 2014. There was no analysis of causes for the falls other than patient diagnosis. There was no documentation action was taken to decrease the number of falls.

d. There was no documentation to show the data gathered was used to prevent infections. The hospital was required to monitor and track infections per regulation. No analysis of infections was documented. No actions to decrease the number of infections was documented.

e. There was no documentation to show the data gathered was used to decrease the number of skin problems. There was no documented analysis of causes. No actions to decrease the number of skin problems was documented.

f. There was no documentation to show the data gathered was used to decrease the number of staff occurrences. There was no documented analysis of causes of staff occurrences. No actions to decrease the number of staff occurrences was documented.

g. There was no documentation to show the data gathered was used to decrease medication errors. Data summaries stated medication errors were recorded each month in 2014. The number of errors varied from month to month. There was no analysis of causes. No corrective action was documented.

h. Other occurrences were not defined. Summaries for 2014 noted events including:

i. A patient who was allergic to strawberries ate strawberry jam in February 2014.
ii. A patient left against medical advice in March 2014.
iii. A patient dropped an oxygen canister on his foot in June 2014.
iv. A separate summary stated 3 occurrences were reported from April through June 2014 but the summary did not state what those occurrences were.
v. A summary noted 4 occurrences were reported in September 2014 but did not state what those occurrences were.
vi. A summary documented 2 patient to patient altercations and 1 incident of destruction of property in October 2014.
vii. A summary documented an overdose, a death, and arm scratches in November 2014.
viii. A December 2014 summary noted 2 patient to patient altercations, seizures, self-harm occurrences, and a patient with a physical decline.

There was no documentation to show the data gathered was used to decrease the number of other occurrences. A specific analysis of the above occurrences was not documented. No plan to decrease the number of other occurrences was documented.

The goal of attendance at groups was largely met. Analysis of the data and action taken affecting the percentage of compliance was not documented.

The Interim Quality Director was interviewed on 4/01/15 beginning at 3:05 PM. She stated she had only been at the hospital for 2 days. She said she did not know of other QAPI documents with more information. She stated she did not know how data had been used to improve care.

The hospital failed to use hospital data to assess care. The lack of data prevented the hospital from identifying opportunities for improvement.

2. A specific QAPI plan, including quality indicators, priorities, and time frames, was not documented between 1/01/14 and 3/31/15. No documents that identified high-risk, high-volume, or problem-prone areas to assess were present.

The Interim Quality Director was interviewed on 4/01/15 beginning at 3:05 PM. She stated she did not know of other QAPI documents with more information.

The hospital did not identify high-risk, high-volume, or problem-prone areas for evaluation.
VIOLATION: CONTENT OF RECORD - INFORMED CONSENT Tag No: A0466
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of patient medical records, and staff interview, it was determined the hospital failed to ensure written consent forms for treatment and procedures were properly executed to include the signature of the patient or legal representative, 2 of 17 (#11 and #13) patients whose records were reviewed. This had the potential to result in treatment being provided without the consent of the patient or legal representative. Findings include:

The hospital's policy, titled "Admission Procedure" effective 9/18/11, stated "Upon admission, the Social Worker or Charge RN must obtain Consent for Services. This form is signed by either the patient or the patient's legal guardian, and provides the hospital and associated physicians, the right to provide treatment..." This policy was not followed for all patients. Examples include:

1. Patient #11 was a [AGE] year old female admitted on [DATE], from a skilled nursing facility, with diagnoses of psychosis, bipolar disorder and congenital brain injury with mental disability.

Patient #11's medical record for her hospital admission of 11/25/14 to 11/29/14, was reviewed. Her record included a letter of guardianship and conservatorship. The letter stated Patient #11 was impaired to the extent she was unable to make responsible decisions.

Patient #11's record did not include documentation of contact with her guardian, to obtain consent for services. Patient #11's record did not include a signed consent form.

During an interview on 4/01/15 at 4:00 PM, RN C reviewed Patient #11's record and confirmed it did not include a signed consent form, or documentation of contact with her guardian.

Patient #11's medical record did not include an informed consent form signed by her legal guardian.

2. Patient #13 was a [AGE] year old male admitted on [DATE], with diagnoses of psychosis and depression.

Patient #13's medical record for his hospital admission of 1/01/15 to 1/05/15, was reviewed. His record did not include a signed consent form.

During an interview on 4/01/15 at 4:20 PM, RN C reviewed Patient #13's record and confirmed it did not include a signed consent form.

Patient #13's medical record did not include a signed informed consent form.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on staff interview and review of medical records, policies, incident reports, Medical Staff Bylaws, QAPI documents, and meeting minutes, it was determined the hospital's Governing Board failed to assume responsibility for determining, implementing, and monitoring policies and failed to oversee the hospital's QAPI program. The Governing Board failed to provide oversight and supervision necessary to ensure patients were protected from abuse and neglect and received safe and appropriate psychiatric, medical, and nursing services. This resulted in deficient practices that placed the health and safety of one or more patients in immediate jeopardy of serious harm, impairment, or death, and had the potential to impact all patients receiving services at the facility. Findings include:

1. Refer to A049 as it relates to the Governing Body's failure to ensure it held the Medical Staff accountable for the quality of care provided.

2. Refer to A057 as it relates to the failure of the Governing Body to ensure the Administrator assumed responsibility for managing the hospital, including developing and monitoring systems of care.

3. Refer to A064 as it relates to the failure of the Governing Body to ensure Medicare patients were under the care of a doctor of medicine or a doctor of osteopathy.

4. Refer to A093 as it relates to the failure of the Governing Body to ensure written policies and procedures for the appraisal of emergencies, including the hospital's responsibilities for initial treatment and referral, had been developed.

5. Refer to A115 Condition of Participation for Patient Rights as it relates to the failure of the Governing Body to ensure patients' rights were protected and promoted and as it relates to the failure of the hospital to identify, and respond to, patients' initial and ongoing needs. This resulted in the use of physical and chemical restraints by staff that were not trained which resulted in patient injuries.

6. Refer to A263 Condition of Participation for QAPI as it relates to the failure of the Governing Body to ensure a hospital wide data driven QAPI program was fully developed, implemented, and maintained.

7. Refer to A338 Condition of Participation for Medical Staff as it relates to the failure of the Governing Body to ensure the Medical Staff was organized, and was responsible for the quality of medical care provided to patients.

8. Refer to A385 Condition of Participation for Nursing Services as it relates to the failure of the Governing Body to ensure nursing services were organized and supervised to effectively meet the health care and psychiatric needs of patients.

9. Refer to A799 Condition of Participation for Discharge Planning as it relates to the failure of the Governing Body to ensure a discharge planning process was in place that met the needs of all patients.

These systemic negative practices seriously impeded the ability of the hospital to provide safe and effective services.
VIOLATION: LICENSURE OF NURSING STAFF Tag No: A0394
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of employee records and staff interview, it was determined the hospital failed to ensure nursing personnel for whom licensure is required had valid and current licenses, for 4 of 11 nurses (LPN A, and RN C, E and F) whose records were reviewed. Failure to ensure appropriate and current licensure had the potential to interfere with the quality and safety of patient care. Findings include:

The personnel records of 9 RNs were reviewed for evidence of current RN licensure. RN E's record included a limited RN license that expired on [DATE]. There was no verification of a current license. RN C and RN F's records included RN licenses that expired on [DATE]. There was no verification of current licenses.

The personnel records of 2 LPNs were reviewed for evidence of current LPN licensure. LPN A's record included a license that expired on [DATE]. There was no verification of a current license.

During an interview on 4/03/15 at 3:30 PM, the Human Resources Director reviewed the employee files and confirmed the 4 nurses' records did not include evidence of current licensure.

The hospital failed to ensure all nursing staff were currently licensed to practice.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of clinical records, hospital policies, and staff interviews, it was determined the facility failed to ensure an RN provided sufficient supervision and assessment of patients' needs to ensure appropriate patient care was provided for 10 of 17 patients (#1, #5, #7, #8, #10, #11, #12, #16, #15 and #17) whose records were reviewed. The lack of nursing assessment and oversight resulted in the lack of interventions and physician notification of deterioration in patients' medical conditions which led to the death of 3 patients (#10, #11, and #12) and had the potential to adversely impact the health and safety of all patients receiving services at the facility. Findings include:

1. The hospital failed to provide nursing services necessary to identify and address patients' deteriorating health status, which contributed to the deaths of Patients #10, #11, and #12, as follows:

a. Patient #10 was a [AGE] year old male admitted on [DATE], from an ALF. His psychiatric diagnoses were conduct disorder and depression. Additional diagnoses included [DIAGNOSES REDACTED].

Patient #10's record included an Inpatient Psychiatric Evaluation, completed by the NP on 11/07/14. The evaluation documented he was admitted from an ALF due to verbally aggressive behaviors, inappropriate defecation and inappropriate sexual behavior. The evaluation stated "He has a bowel obsession....he refused to use the bathroom."

Patient #10's record included an Admission History and Physical, completed by the MD on 11/07/14. It documented Patient #10 had a bowel obsession and refused to use the bathroom. Additionally, it documented possible anorexia (loss of appetite) stating "He is on Megace without a diagnosis otherwise." Nursing 2015 Drug Handbook listed indications for Megace, including anorexia, or unexplained significant weight loss.

Patient #10's Psychiatric Evaluation and History and Physical indicated risks related to bowel function and poor appetite. Patient #10 exhibited signs and symptoms of [DIAGNOSES REDACTED]

On 11/07/14:
-Patient #10's record documented his weight upon admission as 132.2 pounds.

On 11/09/14:
-Patient #10's weight was documented as 129.9 pounds, a loss of 2.3 pounds in 2 days.

On 11/10/14:
-A Nursing flow sheet, signed by the RN at 3:06 AM, documented Patient #10 complained of pain rated as a 4 on a scale of 1-10, however, the location of the pain was not documented.
-A nurses note, signed by the RN at 7:55 AM, documented Patient #10 refused to come to breakfast and stated he was "hurting," however, it did not document an assessment of the pain to determine the severity or location of his pain.

On 11/11/14:
-Patient #10's weight was documented as 127.4 pounds, a loss of 4.8 pounds in 4 days.

On 11/12/14:
-A nurses note, signed by the RN at 11:50 AM, documented Patient #10 was agitated about being in pain, however, it did not document an assessment of the pain to determine the severity or location of his pain.
-A meal intake flow sheet documented Patient #10 refused dinner.

On 11/14/14:
-A nurses note, signed by the RN at 3:50 AM, documented Patient #10 vomited, however, it did not document a physical assessment was completed.
-A nurses note, signed by the RN at 11:00 AM, documented Patient #10 had a small appetite, and when encouraged to eat lunch, he refused.
-A meal intake flow sheet documented Patient #10 refused dinner.

On 11/15/14:
-Patient #10's medication administration record documented he was given Mylanta 30 cc po for nausea, at 3:55 AM.
-A nurses note, signed by the RN at 8:15 AM, documented he was eating very little.
-The meal intake flow sheet documented Patient #10 refused breakfast and lunch. His intake at dinner was not documented.
-A nurses note, signed by the RN at 10:10 PM, documented Patient #10 vomited, his physician was notified, and a new medication order was obtained. However, there was no documentation of a physical assessment or Patient #10's response to the medication, including the effectiveness.

On 11/16/14:
-A nurses note signed by the RN at 8:05 AM, documented he ate very little and complained of a stomach ache, however, it did not document a physical assessment or the severity of the pain.
-A nurses note, signed by the RN at 12:05 PM, documented he refused most of his lunch.
-A nurses note, signed by the RN at 6:05 PM, documented Patient #10 refused to come to dinner.

On 11/17/14:
-A nursing flow sheet, signed by the RN at 7:50 AM, documented he complained of a stomach ache, however, it did not document a physical assessment or the severity of the pain.
-A nurses note, signed by the RN at 8:05 AM, documented Patient #10 ate very little and complained of a stomach ache.
-A Patient Behavior Shift Summary for the day shift, 6:00 AM to 6:00 PM, documented Patient #10 did not eat any of his meals and kept sliding out of his chair.
-Patient #10's weight was documented as 123 pounds, a loss of 9.2 pounds in 10 days.

Patient #10's record included a flow sheet that documented he did not have a bowel movement on all shifts, from 11/07/14 to 11/17/14. His nursing admission assessment did not document his last bowel movement prior to admission, so it was unclear how long it was since his last bowel movement. Patient #10's admission assessment, completed by the RN on 11/07/14, stated his abdomen was round and bowel sounds were present, however, his record did not document another nursing assessment of his abdomen prior to 11/17/14, to determine distension, tenderness, or quality of bowel sounds.

Patient #10's medication orders included Hydrocodone/APAP to be given 4 times per day. According to Nursing 2015 Drug Handbook, constipation is a very common adverse effect of Hydrocodone. It stated constipation should be treated aggressively. However, Patient #10's record did not document physician notification of his constipation. Patient #10's admission physician orders included a Fleet's enema to be given as needed if no bowel movement in 3-4 days. However, administration of a Fleet's enema was not documented during his 10 day hospitalization .

Patient #10's record documented the MD was called on 11/15/14, to report his nausea and vomiting. A medication for nausea was ordered and administered. However, his record did not document the MD was contacted the following day to report his continued complaints of nausea and stomach pain, as well as, his weight loss and lack of bowel movements.

A nurses note dated 11/17/14 at 5:00 PM, documented the MD was notified Patient #10 was not feeling well, and orders were received. However, his record did not document the MD was notified of his weight loss, complaints of pain and nausea, and lack of bowel movements. Patient #10's record included an order dated 11/17/14, untimed, for Dulcolax 5 mg, 2 tablets to be given every 12 hours for 3 doses, and Senna-S, 2 tablets to be given daily. Patient #10's MAR documented a 6:00 PM dose of Dulcolax was given, however, it did not document his condition at the time it was administered, or if he had difficulty swallowing the 2 tablets.

A nurses note dated 11/17/14 at 5:55 PM, and signed by the RN, documented a P.T. reported Patient #10 did not look well, and sounded "rattily." The RN's assessment noted hypoactive bowel sounds and crackles throughout his lungs. MD orders were obtained to transfer Patient #10 to the ED at an acute care hospital. The RN noted she placed phone calls to begin to arrange transport to the hospital. A nurses note dated 11/17/14 at 6:15 PM, documented staff reported Patient #10 was not breathing. The RN documented Patient #10 was unresponsive and 911 was called at that time.

Patient #10's record included a death certificate with date and time of death documented on 11/17/14 at 6:20 PM. The cause of death was listed as cardiorespiratory failure.

During an interview on 4/01/15 at 4:30 PM, the RN reviewed Patient #10's record and confirmed he lost 9.2 pounds and his bowels did not move during his hospitalization . She stated the MD should have been notified of his weight loss and bowel status, as well as his complaints of pain and nausea.

During an interview on 4/01/15 at 2:00 PM, the MD stated he would have expected the nurses to inform him of Patient #10's significant weight loss. Additionally, he stated he should have been informed by the nurses that Patient #10 complained of pain and nausea, and did not have a bowel movement for 10 days.

During an interview on 4/03/15 at 1:15 PM, the NP stated the nurses did not inform her of Patient #10's weight loss or lack of bowel movements during his hospitalization . However, the NP's notes, dated 11/16/14, the day prior to Patient #10 death, stated he was "...improving on his current medications as evidenced by no sexually inappropriate behavior towards staff or other patients, and no inappropriate defecation noted."

Patient #10's admission evaluations documented he was at risk for weight loss and bowel complications. During his 10 day hospitalization he complained of pain and nausea, had no bowel movements, and lost 7% of his body weight. However, he was not thoroughly assessed by the nursing staff, and significant signs and symptoms were not reported to the MD. Therefore, interventions were not initiated to address his medical problems and Patient #10 died at the hospital on [DATE].

b. Patient #11 was a [AGE] year old female admitted on [DATE], from a SNF. Her psychiatric diagnoses were psychosis, bipolar disorder and congenital brain injury with mental disability. Additional diagnoses included [DIAGNOSES REDACTED]. She died at the acute care hospital on [DATE].

The National Institutes of Health website, accessed 4/08/15, defined renal insufficiency as "the slow loss of kidney function over time. The main job of the kidneys is to remove wastes and excess water from the body." It defined CHF as "a condition in which the heart can't pump enough blood to meet the body's needs. The weakening of the heart's pumping ability causes blood and fluid to back up into the lungs, and the buildup of fluid in the feet, ankles and legs, called edema."

Patient #11's record included a nursing admission assessment, dated 11/25/14, and signed by RN C. The cardiac section of the assessment included check boxes to document location and degree of edema, however, the boxes were blank with a question mark next to them. Therefore, it was unclear if Patient #11 had edema at the time of admission to the facility. Her record did not document additional assessments of edema during her hospitalization .

Patient #11's record included a document titled "Treatment Plan." Problem 4, dated 11/26/14, was identified as renal insufficiency. However, there was no plan documented to address her renal insufficiency, and the document did not include interventions, notes or updates. CHF was not identified as a problem on the treatment plan.

Patient #11's record included admission orders, signed by the RN on 11/25/14, and signed by the NP on 11/26/14, that contained orders for laboratory tests, including a CMP. The National Institutes of Health website, accessed 4/08/15, stated a CMP includes BUN and creatinine levels, tests done to assess kidney function. Patient #11's record documented her blood was drawn and sent to the laboratory on 11/26/14, however, her record did not contain results of the blood tests, and there was no documentation to indicate the results were reviewed by the RN, NP or MD.

Patient #11's Inpatient Psychiatric Evaluation documented a diagnosis of [DIAGNOSES REDACTED].

Patient #11's record documented her blood was drawn for a Hgb A1C and sent to the lab on 11/26/14, however, her record did not include results of her Hgb A1C. Additionally, her record did not include evidence of random blood sugar readings. Therefore, her diabetes was not monitored during her hospitalization .

During an interview on 4/01/15 at 4:00 PM, RN C reviewed Patient #11's record and confirmed it did not include results of her blood tests. She stated it was possible Patient #11's blood was not drawn, or the tests were completed but the results were not obtained and put in her record. RN C stated it was the responsibility of the ward clerk to access laboratory results on-line and put them in the patient's chart, and stated that was not always done. She stated the RN was responsible to follow up on laboratory results if the results are not in the patient's record. Additionally, it was the RN's responsibility to report abnormal results to the MD.

Patient #11's record included a nurses note, dated 11/26/14 at 3:30 PM, that documented a foley catheter was inserted. Her record also included an intake and output flow sheet. The flow sheet documented a fluid intake of 2640 ccs between 11/26/14 at 5:00 PM and 11/27/14 at 7:30 PM. The first documentation of foley catheter urine output was 310 ccs on 11/27/14 at 7:30 PM, 28 hours after the catheter was inserted. This indicated a urine output of approximately 11 ccs per hour.

The Lippencott Manual of Nursing Practice, 10th edition, released 5/2013, stated a urinary output of less than 30 ccs per hour is abnormally low and should be reported to the physician. However, Patient #11's low urine output and discrepancy between intake and output was not reported to the MD.

Patient #11's flow sheet documented a fluid intake of 2840 ccs in the next 24 hours. However, it documented only 200 ccs of urine was emptied from the foley catheter bag on 11/28/14 at 7:07 PM, in the same 24 hour period. This indicated a urine output of approximately 8 ccs per hour.

Patient #11's record did not document her weight at the time of her admission. The first weight recorded was 315.4 pounds on 11/27/14. Her weight was documented as 318 pounds on 11/28/14, indicating a 2.6 pound weight gain in one day. Per the Mayo Clinic website, accessed on 4/09/15, a rapid weight gain can be a sign of fluid retention due to insufficient cardiac or renal function. However, Patient #11's low urine output, discrepancy between intake and output, and significant weight gain were not reported to the MD.

Patient #11's nursing admission assessment documented her respiratory status was normal and her lung sounds were clear. A nurses note, dated 11/28/14 at 9:40 PM, stated lung sounds were diminished in all lobes. The note did not document the MD was notified of the change in her respiratory status.

Patient #11's urine output was documented as 100 ccs on 11/29/14 at 6:30 AM, approximately 11.5 hours after the last measurement. This indicated a urine output of approximately 9 ccs per hour. Patient #11's fluid intake during the same period was documented as 960 ccs.

Patient #11's blood pressure, documented on 11/29/14 at 6:30 AM, was 80/50. The National Institutes of Health website, accessed 4/08/15, stated a blood pressure less than 90/60 is abnormally low. Patient #11's record did not documented her low blood pressure, low urine output, and discrepancy between intake and output for a 3 day period were reported to the MD.

Patient #11's record included a nurses note, dated 11/29/14 at 12:20 PM. The note stated the MD was notified Patient #11 had less than 75 ccs of urine output for the shift. Orders were obtained to start intravenous fluids and obtain blood for a CMP, however, a nurses note stated the nurses were unable to insert the IV or draw the blood. A nurses note at 2:00 PM stated orders were received to transport Patient #11 to the ED at an acute care hospital. A nurses note at 3:10 PM stated Patient #11 was transported to the ED via the facility's van.

A Social Services Progress Note, dated 11/30/14 at 9:00 AM, documented Patient #11 was in the acute care hospital's ICU due to renal insufficiency. She expired at the acute care hospital on [DATE].

Patient #11's ED record at the acute care hospital documented she was unresponsive, had a temperature of 92.5, blood pressure of 68/45, 3 + pitting edema in her lower extremities, and oxygen saturation level of 84% on 4 liters of oxygen. The Mayo Clinic website, accessed on 4/13/15, stated:

- Normal body temperature ranges between 97 and 99.

- "Swelling of the foot, ankle and leg can be severe enough to leave an indentation, or 'pit,' when you press on the area. This swelling (edema) is the result of excess fluid in your tissues - often caused by congestive heart failure..."

- "Normal pulse oximeter readings range from 95 to 100 percent, under most circumstances. Values under 90 percent are considered low."

Patient #11's laboratory results while in the ED included a BUN of 37 (normal value 7-25) and creatinine of 2.3 (normal value 0.6-1.0), indicating decreased kidney function.

The ED physician's assessment stated "[Patient #11] is critically ill with [DIAGNOSES REDACTED], septic shock, acute on chronic respiratory failure, acute on chronic kidney disease, and multiple medical problems."

The acute care hospital's death summary stated "The [Patient #11] was admitted on [DATE], with recurrent healthcare-associated pneumonia and aspiration pneumonias. After a lengthy hospital stay, with very little progression despite BiPAP and other modalities, the patient's status continued to decline. Family members were contacted, decision was made to place the patient on comfort care measures. On the evening of 12/31/2014, patient passed away from respiratory failure secondary to recurrent healthcare associated pneumonias."

Patient #11's record did not document the MD was notified of her decreased urine output, rapid weight gain or low blood pressure. During an interview on 4/01/15 at 4:00 PM, RN C stated the P.T.s empty the catheter bags and document the urine output on their flow sheet. Additionally, the P.T.s were responsible for obtaining patient weights daily and vital signs, including blood pressure, every shift. She stated the RNs do not always review the flow sheets documenting intake/output, weights and vital signs. RN C reviewed Patient #11's record and stated the P.T.s should have reported her decreased urinary output to the RN on duty, so the MD could be notified. However, RN B stated she did not think the P.T.s had been instructed when to report intake/output levels or discrepancies. She confirmed Patient #11 should have been weighed daily and her weight gain should have been reported to the RN.

During an interview on 4/03/15 at 12:55 PM, the NP stated she was not notified of Patient #11's low urine output. She stated a urine output of less than 40 cc's per hour should be reported to the physician.

During an interview on 4/02/15 at 4:15 PM, the MD stated he was not notified of Patient #11's weight gain, diminished lung sounds or low blood pressure. He stated he was not notified of her decreased urine output until 11/29/14 at 12:20 PM.

Patient #11 was known to have a history of renal insufficiency and CHF. Her record documented adequate fluid intake, however her urine output, ranging from 8-11 cc's per hour, was well below the normal output of at least 30 cc's per hour. Her weight gain of 2.6 pounds in 24 hours was an additional indication of possible renal or congestive heart failure. Patient #11's record did not document an assessment of edema. The nurses did not promptly notify Patient #11's physician of her decreased urine output, rapid weight gain, diminished lung sounds or low blood pressure. Therefore, her symptoms were not addressed in a timely manner, and medical care at the acute care hospital was delayed.

c. Patient #12 was an [AGE] year old male admitted to the facility on [DATE], for psychiatric treatment related to dementia and psychosis. Additional diagnoses included [DIAGNOSES REDACTED]

Patient #12's admission orders included a mechanical soft diet with "Nectar thick" liquids. His admission orders also included an order for a Speech Therapy evaluation, however, his record did not indicate an evaluation was performed.

A nurses note, dated 12/29/14 at 8:07 AM, and signed by the RN, documented Patient #12 required assistance with meal and fluid intake, his diet was changed to pureed consistency until his Speech Therapy evaluation could be completed. She also noted Patient #12 had difficulty swallowing and had frequent coughing.

On the nurses note later that day, at 12:05 PM, the RN documented Patient #12 had difficulty with swallowing and required small portions and nectar thick liquids.

That evening at 7:45 PM, the RN documented Patient #12 was calling for help. He wanted water, so she assisted him with drinking a cup of water. She noted the Medication Nurse also gave him 8 ounces of fluids. The nurse did not indicate if Patient #12 was receiving thickened liquids. She documented Patient #12 coughed and sputtered after drinking.

On 12/30/14 at 1:00 PM, the RN documented in the nurses notes that Patient #12 continued to choke on his food.

At 7:00 PM, the RN documented Patient #12 had decreased oxygen saturation at 81%. The RN noted he was coughing and breathing shallow, his lips were bluish in color, and he was started on oxygen. She noted EMS was called and Patient #12 was transferred to an acute care hospital.

Patient #12's record included documentation he was admitted to the hospital with a diagnosis of [DIAGNOSES REDACTED]" Patient #12's record noted he was placed on comfort measures and died [DATE].

Patient #12's record included a form titled "ADL Sheets." The form included documentation by the P.T.s of such activities for each patient including oral hygiene, toileting, bowel and bladder elimination, skin care, and meal intake.

Patient #12's form documented he had no bowel movements in the 5 days that he was at the facility.

His medication record included orders for Dulcolax 5 mg BID, and indicated he received the medication throughout his stay. Additionally, Patient #12's MAR included PRN medications of Senna 1 tablet BID, (none were given), Milk of Magnesia 30 ml, BID, (for which he received 1 dose on 12/29/14), and Fleets enema, ordered for constipation/no BM for 3-4 days, (which was not administered). Patient #12's record did not indicate his physician was notified of his constipation.

During an interview on 4/01/15 at 3:30 PM, RN C reviewed Patient #12's record and confirmed Speech Therapy was ordered, and was not able to find evidence an evaluation took place. She stated the ward clerk would call when an evaluation was ordered, but stated there was no method to follow up to ensure the speech therapist was notified. The RN stated she was not aware that Patient #12 was documented as having no bowel movement for 5 days. She stated the nursing staff depended on the P.T.s to alert them when a patient had not had a BM.

Patient #12's record included orders for a Speech Therapy evaluation, which was not performed. His record indicated on 12/29/14, on 3 separate occasions, he was having difficulty with swallowing fluids, his medications, and his food, and he was not treated for constipation.

Patients #10, #11, and #12's records documented significant decline in their health status which was not identified, assessed or reported to the MD, which contributed to their deaths.

During an interview on 4/01/15 at 2:00 PM, the MD stated the nurses in the facility are "psych" nurses, and he did not expect them to do "heavy medical nursing." He stated "If patients are sick we send them out." He stated if the hospital was expected to provide medical care, "They need to train the nurses."

Due to the inability of the nursing staff to identify, address, and report significant health concerns, the facility would not be able to ensure the health and safety of the patients receiving services at the facility. This placed all patients in immediate jeopardy and at risk of suffering serious harm, impairment and death.

The co-owner of the facility was notified of the immediate jeopardy verbally on 4/03/15, and in writing on 4/07/15.





2. A policy "Skin Assessment & Care," revised 9/09/12, stated "Skin assessments will be done upon admission, by an RN, to facility within the first (24) hours. After completion of the initial skin assessment the patient shall be monitored for skin issues weekly and as the need arises." Additionally, surgical wounds were to be monitored for signs or symptoms of [DIAGNOSES REDACTED]

a. Patient #5 was admitted on [DATE] to 3/25/15. His H&P documented he had numerous abdominal surgeries over the previous 5 months, including post-operative complications. The H&P documented Patient #5 had a midline surgical incision which was being held with large retention sutures with rubber tubing around them that bridged over the incision. The physician documented in the H&P the sutures were to be removed in 2 days.

Patient #5's record included a weekly skin integrity review sheet. The review sheet included 2 entries dated 3/09/15 and 3/23/15.

On 3/09/15, the LPN documented Patient #5 had scabs with multiple open areas, redness at the incision site, and drainage. There were no measurements documented and no description of the drainage.

On 3/23/15, the LPN documented Patient #5 had open area at the incision site with redness in color. There were no measurements documented.

Patient #5's record did not include documentation that his skin was assessed by nursing during week 2 of his admission.

A nursing note signed by the RN, dated 3/12/15 at 7:15 AM, documented she had spoken to Patient #5 about removing his sutures. Patient #5 stated to the RN he would only allow his surgeon to remove them.

There was no documentation the physician was notified. Additionally, there was no documentation in Patient #5's record whether the sutures were removed while he was at the facility.

During an interview on 4/01/15 at 5:20 PM, the RN reviewed the record and confirmed wound assessments were required to be documented weekly. She confirmed Patient #5's wounds were not documented per policy and there were no measurements for Patient #5's post-operative wounds.

Patient #5's wounds were not assessed and addressed by nursing staff in accordance with facility policy.

b. Patient #8 was admitted to the facility on [DATE]. His medical record from 3/06/15 to 3/24/15, as well as records from ED visits on 3/23/15 and 3/24/15, at an acute care facility, were reviewed.

Patient #8's record included an admission skin assessment on 3/07/15. His record also included a form titled "Weekly Skin Integrity Review Sheet." The sheet did not include any further skin assessments after 3/07/15. Patient #8 was due to have a skin assessment each week, due 3/14/15 and 3/21/15. The weekly sheet in Patient #8's record included an entry dated 3/19/15, with the word "refused." The record did not indicate any further attempts were made to assess his skin.

During an interview on 4/01/15 at 3:30 PM, RN C reviewed Patient #8's record and confirmed skin assessments were not performed weekly as per facility policy. The RN stated if a patient refuses a skin check, the staff is supposed to then re-attempt, and a good opportunity is when the patient is showering.

c. Patient #11's record included a skin assessment completed on 11/25/14, and signed by the RN. The assessment documented 2 blisters on her lower legs, measuring 6 cm by 2 cm, and 7 cm by 1 cm. The assessment documented dressings were applied to the blisters on Patient #11's lower legs.

A nurses note, dated 11/28/14 at 4:45 pm, stated a blister on Patient #11's left lower leg ruptured and a dressing was applied. A nurses note, dated 11/28/14 at 9:40 PM, stated blisters on Patient #11's right lower leg "popped" and were cleaned and wrapped in gauze. However, Patient #11's record did not include orders or protocols related to wound care, to include frequency, or products to be used to cleanse and cover the blisters.

During an interview on 4/01/15 at 4:00 PM, RN C reviewed Patient #11's record and confirmed there were no orders or care plan related to wound care to her lower leg blisters.

The facility failed to ensure skin assessments were completed and identified needs were appropriately addressed.

3. The hospital's policy "Nursing Process - Vital Signs" effective 8/23/11, stated "A daily assessment of vital signs and weight is completed on every patient, unless there is a reason to complete the vitals signs and/or weights more frequently." Additionally it stated "The RN assesses the patients' vital signs and refers significant problems to the MD or mid level provider for follow-up, evaluation, and treatment if needed."

An additional hospital policy "Nursing Process - Weights protocol," effective 8/23/11, stated "All patients are weighed daily and the weights are documented in the patients chart." The policies were not implemented, as follows:

a. A vital sign record form documented Patient #5 had a temperature of 100.9 at 2:00 PM on 3/12/15. There was no documentation the physician was notified. Additionally, there was no documentation by the RN this was reassessed or addressed.

At 8:30 PM on 3/12/15, the RN documented Patient #5 had a temperature measurement of 106 and felt hot with pain. The RN documented medication was given for his high temperature and pain. There was no documentation the physician was notified.

During an interview on 4/01/15 at 5:20 PM, the RN reviewed the record and confirmed the physician should have been called for the elevated temperatures.

Patient #5's abnormal vital signs were not assessed and addressed by nursing staff in accordance with facility policy.

b. Patient #16 was a patient in the hospital from 3/15/15 to 3/26/15, with diagnoses of [DIAGNOSES REDACTED]. His record did not include documentation of his weight.

During an interview on 4/03/15 at 11:00 AM, the NP reviewed his record and confirmed his weight was not documented for the 4 days he was in the hospital. The NP stated patients were to be weighed daily.





5. Patients were not provided with appropriate diabetic care, as follows:

a. Patient #1 was admitted to the facility on [DATE] to 3/31/15, from a local ED. His diagnoses included [DIAGNOSES REDACTED]#1 was hoping he would die.

His H&P, dated 3/26/15, and signed by the MD, documented Patient #1's blood glucose level was 296 mg/dl upon admission. The American Diabetes Association website accessed 4/7/15, stated a normal (non-diabetic) blood glucose means levels between 70 and 130 mg/dl before meals, and less than 180 two hours after starting a meal.

Patient #1's record included physician verbal orders, dated 3/16/15 at 9:15 AM, to check his blood glucose level before each meal and at bedtime. The verbal order included a standard sliding scale for Humalog insulin (a quick acting insulin). The American Diabetes Association website, accessed 4/07/15, defined a sliding scale as a set of instructions for adjusting insulin on the basis of blood glucose test results, meals, or activity levels. The standard sliding scale ordered for Patient #1 included instructions to phone the physician if the blood glucose levels were lower than 70 mg/dl or greater than 450 mg/dl.

A blood glucose log was included in Patient #1's record. The log documented blood glucose levels during Patient #1's admission. Patient #1's blood glucose levels were recorded as follows:

- 3/27/15 at 9:00 PM: 5
VIOLATION: MEDICAL STAFF Tag No: A0338
Based on staff interview and review of medical records, Medical Staff Bylaws and contracts, it was determined the facility failed to ensure the Medical Staff was organized and was responsible for the quality of medical care provided to patients. The Medical Staff failed to provide basic care for patients and failed to monitor the care practitioners did provide. This resulted in patients with unmet medical needs. A determination of immediate jeopardy was identified at A347 for the failure of the hospital to provide basic medical care and oversight. This systemic failure had the potential to result in serious harm or death to all patients receiving services at the facility. Findings include:

1. Refer to A347 as it relates to the facility's failure to ensure the Medical Staff was well organized and was responsible to the hospital's Governing Board. In addition refer to A347 as it relates to the failure of the hospital to ensure the medical staff assumed responsibility for care provided to patients or that an individual physician was responsible for the conduct of the Medical Staff.

The Co-owner of the facility was verbally notified of the Immediate Jeopardy to patients' health and safety on 4/03/15 at 5:00 PM, and in writing on 4/07/15.
VIOLATION: CARE OF PATIENTS - PRACTITIONERS Tag No: A0064
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of medical records, it was determined the hospital's Governing Board failed to ensure 14 of 14 Medicare patients (#1, #2, #3, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16), whose records were reviewed, were under the care of a doctor of medicine or a doctor of osteopathy. The lack of care by a physician prevented the hospital from providing comprehensive care to patients. Findings include:

Safe Haven Hospital of Pocatello specialized in the treatment of patients with psychiatric conditions.

Fourteen Medicare patients, whose records were reviewed, were treated at the hospital for psychiatric illnesses. None of these patients had documented examinations or treatment by a psychiatrist. Examples include:

a. Patient #1's medical record documented a [AGE] year old male who was a patient in the hospital from 3/26/15 to 3/31/15. His face sheet identified him as a Medicare patient. His diagnoses schizoaffective disorder, substance dependence, and PTSD. His record did not contain documentation that he was examined or treated by a physician for his psychiatric disorders.

b. Patient #2's medical record documented a [AGE] year old female admitted to the hospital from 3/25/15 to 3/31/15. Her face sheet identified her as a Medicare patient. Her psychiatric diagnoses were psychosis, delusions, and paranoia. Her record did not contain documentation that she was examined or treated by a physician for her psychiatric disorders.

c. Patient #3's medical record documented a [AGE] year old female admitted to the hospital from 9/24/14 to 10/03/14. Her face sheet identified her as a Medicare patient. Her psychiatric diagnoses were psychosis and dementia. Her record did not contain documentation that she was examined or treated by a physician for her psychiatric disorders.

d. Patient #6's medical record documented a [AGE] year old male admitted on [DATE], with diagnoses of psychotic disorder with delusions, dementia, and chronic depression. He was discharged on [DATE]. His face sheet identified him as a Medicare patient. His record did not contain documentation that he was examined or treated by a physician for his psychiatric disorders.

e. Patient #7's medical record documented a [AGE] year old male admitted on [DATE], with diagnoses of scizoaffective disorder and bipolar disorder. He was discharged on [DATE]. His face sheet identified him as a Medicare patient. His record did not contain documentation that he was examined or treated by a physician for his psychiatric disorders.

f. Patient #8's medical record documented a [AGE] year old male admitted on [DATE], with diagnoses of dementia, psychosis, and PTSD. He was discharged on [DATE]. His face sheet identified him as a Medicare patient. His record did not contain documentation that he was examined or treated by a physician for his psychiatric disorders.

g. Patient #9's medical record documented a [AGE] year old male admitted on [DATE], with diagnoses of schizoaffective disorder and borderline personality disorder. He was discharged on [DATE]. His face sheet identified him as a Medicare patient. His record did not contain documentation that he was examined or treated by a physician for his psychiatric disorders.

h. Patient #10's medical record documented a [AGE] year old male admitted on [DATE]. His face sheet identified him as a Medicare patient.
His psychiatric diagnoses were conduct disorder and depression. He expired at the hospital on [DATE]. His record did not contain documentation that he was examined or treated by a physician for his psychiatric disorders.

i. Patient #11's medical record documented a [AGE] year old female admitted on [DATE]. Her face sheet identified her as a Medicare patient. Her psychiatric diagnoses were psychosis, bipolar disorder and congenital brain injury with mental disability. Patient #11 was transferred to an acute care hospital on [DATE]. His record did not contain documentation that he was examined or treated by a physician for his psychiatric disorders.

j. Patient #12's medical record documented an [AGE] year old male who was a patient in the hospital from 12/26/14 to 12/30/14. His face sheet identified him as a Medicare patient. His diagnoses were psychosis and dementia. His record did not contain documentation that he was examined or treated by a physician for his psychiatric disorders.

k. Patient #13's medical record documented a [AGE] year old male who was a patient in the hospital from 1/01/15 to 1/05/15. His face sheet identified him as a Medicare patient. His diagnoses were psychosis and depression. His record did not contain documentation that he was examined or treated by a physician for his psychiatric disorders.

l. Patient #14's medical record documented a [AGE] year old male who was a patient in the hospital from 2/24/15/15 to 2/27/15. His face sheet identified him as a Medicare patient. His diagnoses were schizoaffective disorder and suicidal ideation. His record did not contain documentation that he was examined or treated by a physician for his psychiatric disorders.

m. Patient #15's medical record documented a [AGE] year old man who was a patient in the facility from 3/15/15 to 3/26/15. His face sheet identified him as a Medicare patient. His diagnoses were Schizoaffective Disorder and Borderline Personality Disorder. His record did not contain documentation that he was examined or treated by a physician for his psychiatric disorders.

n. Patient #16's medical record documented a [AGE] year old male who was a patient in the hospital from 3/15/15 to 3/26/15. His face sheet identified him as a Medicare patient. His diagnoses were psychotic disorder, dementia, and chronic depression. His record did not contain documentation that he was examined or treated by a physician for his psychiatric disorders.

Patients (#1, #2, #3, #6, #7, #9, #10, #11, #13, #14, #15, and #16 all had 1 visit by the Family Practice Physician to conduct a history and physical. However, he did not admit or discharge patients or participate in their psychiatric care. Patients #8 and #12 had a history and physical conducted by the PA and were not seen by a physician during their hospitalization .

One psychiatrist perticipated in the care of patients at the hospital. She was interviewed on 4/03/15 beginning at 1:55 PM. She stated she lived in Florida. She stated she did not see patients or provide any direct services. She stated no psychiatrist provided services directly to patients at the hospital. She stated all direct services were provided by 1 NP with 2 NPs as her backups. She stated she did not directly supervise the NPs. She stated she did not document her services to the hospital except for her co-signature on psychiatric evaluations and discharge summaries.

Medicare patients were not under the care of a physician.
VIOLATION: EMERGENCY SERVICES Tag No: A0093
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of documents, it was determined the hospital's Governing Board failed to ensure written policies and procedures for the appraisal of emergencies, including the hospital's responsibilities for initial treatment and referral, had been developed. This directly impacted the care of 1 of 1 patient (#5), who was discharged from the hospital and who returned seeking emergency care. The lack of direction to staff for the appraisal of emergencies had the potential to delay the treatment of persons with emergency medical conditions. Findings include:

1. Safe Haven Hospital of Pocatello specialized in the treatment of patients with psychiatric conditions. It did not operate an ED or routinely evaluate patients for admission. Instead, it relied on other hospitals and community physicians to determine if patients were appropriate for admission.

Patient #5 was a [AGE] year old male admitted to the hospital from 3/09/15 to 3/25/15, for schizophrenia and depression.

Patient #5's medical record documented he was discharged from the facility on 3/25/15 at 3:30 PM, to a local homeless shelter.

A timeline, provided on 4/03/15 at 3:30 PM by the SNF AIT, outlined the events that happened after Patient #5's discharge from the facility:

- Patient #5 was discharged at 3:30 PM
- Patient #5 was refused admittance to shelter because it was not open
- Patient #5 returned to shelter at 9 PM and was refused admittance again
- Patient #5 returned to shelter at 1 AM and was refused admittance. He was reportedly bleeding from an unknown source at this time. Police were contacted by a shelter staff member.
- During the course of the evening (the time was not documented) Patient #5 returned to the hospital and requested assistance. The staff member who went to the door refused to let him in stating the hospital did not offer emergency services. The staff member told Patient #5 he needed to leave. Patient #5 "returned banging on the doors and windows of the facility a couple more times. Finally the nurse called the police and he took off."
- Patient #5 went to the hospital's corporate office around 7:15 AM on 3/27/15. He did not have any personal belongings, wallet or ID. His face was "badly banged up." He had tape across his nose.
- The corporate office found placement for Patient #5 in an ALF.

The Director of Social Services was interviewed on 4/03/15 at 3:40 PM. She confirmed Patient #5's discharge and subsequent return to the hospital.

Patient #5 presented to the hospital requesting treatment. Staff turned him away without providing an assessment of his condition.

2. RN E, the charge nurse on duty, was interviewed on 4/03/15 beginning at 10:10 AM. She stated, if a person came to the hospital and requested emergency care, staff would tell him to go to the acute care hospital for medical screening. She looked at policies on her computer. She stated she did not think there was a policy to direct staff if persons requested emergency care.

The hospital had not developed policies to direct staff if persons came to the hospital and requested emergency care.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0165
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of patient records and staff interview, it was determined the agency failed to ensure that physical restraints used were the least restrictive to ensure safety. This directly impacted 2 of 3 sample patients (#4 and #8) for whom restraints were used. This resulted in the potential excessive restraints to be used, when less intrusive ones would suffice. Findings include

1. Patient #8's record documented a [AGE] year old male who was at the facility from 3/06/15 to 3/24/15 for psychiatric services related to dementia, and psychosis with behavioral disturbances. Additional diagnoses included HTN and PTSD.

- On 3/07/15 at 9:00 AM, an "Occurrence Report," written by the RN on duty, noted Patient #8 hit a staff member and another patient. He was noted to be restrained by P.T. D. Additionally, the Occurrence Report documented Patient #8 had another physical altercation with P.T. D, his behavior escalated, and he struck a patient. The report documented he was physically restrained, and administered an IM injection. Patient #8 was placed on 1:1 status, and remained on that status throughout his stay at the facility. The types of restraints used by staff to restrain Patient #8 were not specified. Patient #8's record did not include evidence that the least restrictive type of restraints necessary to protect Patient #8 and others were used.

-A P.T. note attached to an "Occurrence Report" dated 3/07/15 at 3:15 PM stated Patient #8 was aggressive toward another patient and P.T.s were able to remove him from the day room. The note also said the RN had called for all male staff on the attached SNF. Patient #8's record also included a nurses note, documented on 3/07/15 at 3:45 PM, which stated he was physically aggressive and was redirected to his room with the assist of family and staff. He was then given an injection of Geodon IM 20 mg. Patient #8's record did not include documentation of the actions were necessary to "redirect" Patient #8 to his room. Additionally his record did not include documentation of the type of restraint used to restrain Patient #8 for the IM injection. Patient #8's record did not include evidence that the least restrictive type of restraints necessary to protect Patient #8 and others were used.

- On 3/08/15, an "Occurrence Report," written by the RN on duty, noted at 9:30-10:30 AM, Patient #8 became agitated and was threatening P.T. D. The report indicated P.T. D performed a Mandt hold on Patient #8, and then 4 employees were required to assist him back to his room. There was no documentation in Patient #8's record that described the type of Mandt restraint used. A nurses note documented at 10:50 AM on 3/08/15 also stated Patient #8 continued to "go after staff" and was given an IM injection of 20 mg Geodon. The type of restraint used to allow the IM injection was not specified. The nurses note went on to say that after the injection Patient #8 continued to require physical redirection by staff. There was no documentation to describe the "redirection " used by staff. Patient #8's record did not include evidence that the least restrictive type of restraints necessary to protect Patient #8 and others were used.

- An "Occurrence Report," dated 3/08/15 at 2:00 PM, was completed by the RN on duty. The RN documented Patient #8 was aggressive to another patient and that P.T.s were able to get him moved out of the day room. The RN documented she called for any male aide on the attached SNF to come to the psychiatric hospital. Patient #8 was given an injection but did not calm down until 5:00 PM according to the documentation on the Report. The type of restraint used to allow for the IM injection and actions of the SNF male aide were not described. Patient #8's record did not include evidence that the least restrictive type of restraints necessary to protect Patient #8 and others were used.

- On 3/12/15, Patient #8's MAR indicated he was administered Geodon 20 mg IM at 3:00 PM. The P.T. narrative indicated Patient #8 was visited by his son, and complained of pain, for which he was medicated with Tylenol at 5:00 PM. A nurses note, also documented at 3:00 PM on 3/12/15, stated "Patient seems to be agitating another patient, which in turn seems to agitate the patient. Patient pacing and getting louder. Medicated per MAR." The type of restraint used to restrain Patient #8 to allow the IM injection, was not documented. Patient #8's record did not include evidence that the least restrictive type of restraint necessary to protect Patient #8 and others was used.

- On 3/14/15, an "Occurrence Report", written by the RN on duty, noted at 4:00 PM, Patient #8 was involved in a physical altercation with another patient. The report documented he was physically redirected by staff, and was assisted to his room. In his room he began to swing at staff, was restrained on a total of 4 occasions, and administered Zyprexa IM. There was no documentation to describe the "redirection" used by staff or the technique used to assist him to his room. Additionally, there was no documentation describing the type of restraints used the 4 restraints. Patient #8's record did not include evidence that the least restrictive type of restraints necessary to protect Patient #8 and others were used.

-On 3/16/15 Patient #8's MAR stated he received Haldol 5 mg IM at 8:55 PM. His record included an "Emergency Treatment Override Orders for Seclusion," completed by the NP and RN at 9:30 PM. He was noted to be agitated, hit the staff, punched the fire door, his knuckles were bleeding. A nurses note, dated 3/16/15 at 7:40 PM indicated Patient #8 He was escorted to the seclusion room after grabbing the RN's wrist. The nurses note indicated Patient #8 resisted and staff continued to escort him to seclusion. It further stated "Staff into seclusion room and stabilized pts arms" and Haldol injection given. There was no documentation in Patient #8's record that described how staff "escorted" him to the seclusion room or the type of restraint used to stabilize his arms. Patient #8's record did not include evidence that the least restrictive type of restraints necessary to protect Patient #8 and others were used.

- A 3/18/15 at 6:05 PM Emergency Treatment Override Orders for Hold and Restraint form, indicated Patient #8 was physically restrained using a "Staff Hold" to allow for an IM injection of Geodon 20 mg and placement in seclusion. A tech note documented at the time of the incident, stated Patient #8 was agitated and combative at the beginning of the shift and that he was getting worked up from other patients. There was no documentation describing the type of restraint hold used. Patient #8's record did not include evidence that the least restrictive type of restraints necessary to protect Patient #8 and others were used.

-A P.T. note, documented on 3/21/15 at 6:30 AM, indicated Patient #8 was agitated and P.T. D came to help and Patient #8 was restrained twice. The type of restraints used were not described. Patient #8's record did not include evidence that the least restrictive type of restraints necessary to protect Patient #8 and others were used.

During an interview on 4/02/15 beginning at 10:45 AM, the NP reviewed Patient #8's record and confirmed there was no documentation of less restrictive interventions before restraints were implemented. She stated male staff members would increase Patient #8's agression, and confirmed the male staff were summoned to assist when Patient #8's agitation escalated.

The facility failed to ensure staff specifically described the type of restraints, redirections, escorts, and holds used. This precluded the facility from ensuring the least restrictive restraint interventions were used.

2. Patient #4 was a [AGE] year old male admitted on [DATE] to 3/16/15, from an ALF. His psychiatric diagnoses included schizophrenia, depression, and mild mental disability.

-On 3/08/15 at 8:00 AM, the RN documented Patient #4 became agitated and started yelling at other patients and staff. The RN documented Patient #4 was verbally threatening a peer with physical aggression. Patient #4 was physically removed to his room. There was no documentation what preceeded Patient #4's agitation and verbal aggression towards his peer. The RN did not include a description of what type of restraint was used to phyically remove Patient #4. Additionally, there was no documentation how the RN or other staff members intervened prior to physically restraining Patient #4. Patient #4's record did not include evidence that the least restrictive type of restraint necessary to protect Patient #4 and others was used.

-On 3/14/15 at 4:05 PM, the RN documented Patient #4 was yelling and shaking his fist at peers. The RN documented Patient #4 was physically seperated from his peer. There was no documentation what preceeded Patient #4's yelling and threatening manner. The RN did not include a description of what type of restraint was used to physically seperate Patient #4 from the other patient. Patient #4's record did not include evidence that the least restrictive type of restraint necessary to protect Patient #4 and others was used.

During an interview on 4/01/15 at 3:00 PM, RN C reviewed the record and confirmed Patient #4 was physically restrained. She confirmed there was no documentation of less restrictive interventions prior to using physical restraints. RN C confirmed the record did not have documentation describing the physical restraints used.

The facility failed to ensure staff specifically described the type of restraints, redirections, escorts, and holds used. This precluded the facility from ensuring the least restrictive restraint interventions were used.
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
Based on staff interview and review of Medical Staff Bylaws and meeting minutes, it was determined the hospital's Governing Board failed to ensure it held the Medical Staff accountable for the quality of care provided. The lack of oversight by the Governing Board resulted in a lack of participation in patient care by the Medical Staff. Findings include:

A Boise psychiatrist served as Medical Director for the hospital through 3/31/15. In this report he is referred to as the prior Medical Director.

1. Three Governing Board meetings were documented between 1/01/14 and 3/31/15. Meeting minutes documented the prior Medical Director was present at all 3 meetings. These included:

"Governing Board Committee Minutes" were dated 1/16/14. The minutes stated the prior Medical Director stated he would teleconference the treatment team meeting with the hospital.

"Governing Board Committee Minutes" were dated 4/29/14. The minutes stated the prior Medical Director again stated he would teleconference the treatment team meeting with the hospital.

"Governing Board Committee Minutes" were dated 7/24/14. The minutes stated the prior Medical Director stated he would go to the hospital 1 time a month. The minutes stated The prior Medical Director mentioned concerns regarding increased falls and medication errors, nursing staff issues, and a request for an EKG machine.

No other discussion of the medical staff at Governing Board meetings was documented.

The Co-owner was interviewed on 4/01/15 at 9:30 AM. She confirmed these were the only Governing Board meeting minutes available and confirmed the lack of documentation of Medical Staff activities.

2. "SAFE HAVEN HOSPITAL BYLAWS OF THE GOVERNING BOARD," not dated, stated "PATIENT CARE. It is Hospital policy that every patient shall be under the care of a physician...a physician shall be on duty or on call at all times and shall provide onsite supervision when necessary." Further, the Bylaws stated "The Governing Board requires quarterly meetings of the Medical Staff."

The prior Medical Director was interviewed on 4/02/15 beginning at 4:45 PM. He confirmed he had served as Medical Director from 9/25/13 through 3/31/15. He stated while he was Medical Director the Medical Staff consisted of 2 psychiatrists, including himself, another psychiatrist, and a Family Practice Physician.

The prior Medical Director stated no Medical Staff meetings had been held during the 18 months he was the Medical Director. The prior Medical Director stated there was no documentation of Medical Staff Activities. The prior Medical Director stated the hospital had no peer review program or other process to evaluate members of the Medical Staff.

The prior Medical Director stated during his time as Medical Director he lived in Boise, Idaho which is approximately 235 miles from the hospital. He stated he had not treated any patients at the hospital. He stated he started visiting the hospital in 2014. He stated since then he had been coming to the hospital one time a month until 2 or 3 months ago. He stated his activities at the hospital were not documented.

The prior Medical Director stated psychiatric care was primarily provided by one NP. He stated 2 other NPs served as her backup when she was not available. He stated the primary NP was supervised by the other psychiatrist who lived in Florida.

He stated a Family Practice Physician also had privileges at the hospital to provide for patients' medical care. The prior Medical Director stated he had not had contact with the Family Practice Physician.

The Family Practice Physician was interviewed on 4/01/15 beginning at 1:30 PM. The Family Practice Physician stated he did not know the name of the prior Medical Director and had not met him. The Family Practice Physician stated he worked at a wound clinic and was not available to the hospital until after 3:00 PM.

The Florida psychiatrist was interviewed on 4/03/15 beginning at 1:55 PM. She stated she last visited the hospital in February of 2015. She said she was scheduled to come to the hospital on April 9, 13, 14, and 15 of 2015 and then she would not come to the hospital again until the end of May 2015. She stated she did not directly supervise the NPs. She stated she did not know if the hospital had a formal process to supervise NPs.

The Governing Board did not ensure the Medical Staff was organized. The Governing Board did not ensure the Medical Staff was accountable. The Governing Board did not ensure physicians examined and treated patients. The Governing Board did not ensure the Medical Staff monitored and evaluated medical care provided to patients.

The Governing Board failed to enforce its Bylaws.

3. "BYLAWS OF THE MEDICAL STAFF OF SAFE HAVEN HOSPITAL," not dated, stated NPs were defined as Allied Health Professionals. Article VIII Section I of the bylaws stated "All Allied Health Professionals providing direct patient care in the hospital shall do so under the direct supervision of the attending psychiatrist."

The Florida psychiatrist was interviewed on 4/03/15 beginning at 1:55 PM. She stated all direct services were provided by NPs. She stated she teleconferenced with the primary NP 2 times a week. She stated she did not directly supervise the NPs. She stated she did not know if the hospital had a formal process to supervise NPs.

The Governing Board did not enforce Medical Staff Bylaws to directly supervise the NPs.
VIOLATION: MEDICAL STAFF ACCOUNTABILITY Tag No: A0347
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of medical records, Medical Staff Bylaws and contracts, it was determined the hospital failed to ensure the Medical Staff was well organized and was responsible to the hospital's Governing Board. In addition, the hospital failed to ensure the medical staff assumed responsibility for care provided to patients or that an individual physician was responsible for the conduct of the Medical Staff. This affected the care of 17 of 17 patients (#1 - #17) whose records were reviewed. The lack of care and oversight by the medical staff had the potential to result in serious harm or death to all patients receiving services at the facility. Findings include:

1. PATIENT CARE BY THE MEDICAL STAFF:

a. Medical care was provided by 1 Family Practice Physician and 1 PA who served as his backup.

A "PROFESSIONAL SERVICES AGREEMENT: MEDICAL SERVICES," dated 5/01/12, stated the Family Practice Physician would provide "including but not limited to, histories and physicals and basic medical care to patients at Safe Haven Hospital." The agreement stated the physician would be available by phone and come to the hospital when necessary for "basic medical services and care." This was not done.

Medical services were not sufficient to meet patients medical needs. Examples include:

i. Patient #10 was a [AGE] year old male admitted on [DATE]. His psychiatric diagnoses were conduct disorder and depression. Additional diagnoses included [DIAGNOSES REDACTED].

Patient #10's record included an Inpatient Psychiatric Evaluation, completed by the NP on 11/07/14. The evaluation documented he was admitted from an assisted living facility due to verbally aggressive behaviors, inappropriate defecation and inappropriate sexual behavior. The evaluation "He has a bowel obsession....he refused to use the bathroom."

Patient #10's record included an "ADMISSION HISTORY AND PHYSICAL," completed by the MD on 11/07/14. It documented Patient #10 had a bowel obsession and refused to use the bathroom. Additionally, it documented possible anorexia (loss of appetite) stating "He is on Megace without a diagnosis otherwise." Nursing 2015 Drug Handbook listed indications for Megace, including anorexia, or unexplained significant weight loss.

On 11/07/14 Patient #10's record documented his weight upon admission as 132.2 pounds. On 11/09/14 Patient #10's weight was documented as 129.9 pounds, a loss of 2.3 pounds in 2 days. On 11/11/14 Patient #10's weight was documented as 127.4 pounds, a loss of 4.8 pounds in 4 days.

A nurses note signed by the RN on 11/15/14 at 10:10 PM, documented patient #10 vomited, the Family Practice Physician was notified, and an order for Phenergan for nausea was obtained. No documentation was present that the physician examined the patient.

On 11/17/14 a Nursing flow sheet, signed by the RN at 7:50 AM, documented he complained of a stomach ache, however, it did not document a physical assessment, or the severity of the pain. A Nurses note signed by the RN at 8:05 AM, documented Patient #10 ate very little and complained of a stomach ache. A Patient Behavior Shift Summary for the day shift, 6:00 AM to 6:00 PM, documented Patient #10 did not eat any of his meals and kept sliding out of his chair. Patient #10's weight was documented as 123 pounds, a loss of 9.2 pounds in 10 days.

Patient #10's record included a flow sheet that documented he did not have a bowel movement on all shifts, from 11/07/14 to 11/17/14. His nursing admission assessment did not document his last bowel movement prior to admission, so it was unclear how long it was since his last bowel movement.

A nurses note dated 11/17/14 at 5:00 PM, documented the MD was notified Patient #10 was not feeling well, and orders were received for 2 bowel medications, Dulcolax and Senna. No documentation was present that the physician examined the patient.

A nurses note dated 11/17/14 at 5:55 PM, and signed by the RN, documented a CNA reported Patient #10 did not look well, and sounded "rattily [sic]." The RN's assessment noted hypoactive bowel sounds and crackles throughout his lungs. MD orders were obtained to transfer Patient #10 to the ED at an acute care hospital. The RN noted she placed phone calls to begin to arrange transport to the hospital. A nurses note dated 11/17/14 at 6:15 PM, documented staff reported Patient #10 was not breathing. The RN documented Patient #10 was unresponsive and 911 was called at that time. She also documented Patient #10 had a Do Not Resuscitate order. The circumstances of Patient #10's death were not documented.

Patient #10's record included a death certificate with date and time of death documented 11/17/14 at 6:20 PM. The cause of death was listed as cardiorespiratory failure. The certificate was signed by the Family Practice Physician.

Except for the history and physical on 11/07/14, Patient #10's medical record did not contain documentation of a physical assessment by a physician for the 10 days he was hospitalized .

During an interview on 4/01/15 at 2:00 PM, the Family Practice Physician confirmed there were no progress notes to indicate Patient #10 was examined by a physician after the history and physical on 11/07/14.

The Family Practice Physician failed to monitor Patient#10's medical status for 10 days prior to his death.

ii. Patient #11 was a [AGE] year old female admitted on [DATE]. Her psychiatric diagnoses were psychosis, bipolar disorder and congenital brain injury with mental disability. Additional diagnoses included [DIAGNOSES REDACTED]. She died at the acute care hospital on [DATE].

An "ADMISSION HISTORY AND PHYSICAL," conducted on 11/26/14, stated Patient #11 was morbidly obese and had chronic edema that is bordering on [DIAGNOSES REDACTED] (swelling caused by obstruction of the lymph system).

Patient #11's record included a nurses note, dated 11/29/14 at 12:20 PM. The note stated the Family Practice Physician was notified Patient #11 had less than 75 cc's of urine output for the shift. Orders were obtained to start intravenous fluids and obtain blood for a complete metabolic panel, however, a nurses note stated the nurses were unable to insert the IV or draw the blood. A nurses note at 2:00 PM stated orders were received from the Family Practice Physician to transport Patient #11 to the ER at an acute care hospital. A nurses note at 3:10 PM stated Patient #11 was transported to the ER via the facility's van.

Patient #11's ED record at the acute care hospital documented she was unresponsive, had a temperature of 92.5, blood pressure of 68/45, 3 + pitting edema in her lower extremities, and oxygen saturation level of 84% on 4 liters of oxygen. The Mayo Clinic website, accessed on 4/13/15, stated "Normal pulse oximeter readings range from 95 to 100 percent, under most circumstances. Values under 90 percent are considered low."
The ED physician's assessment stated "[Patient #11] is critically ill with [DIAGNOSES REDACTED], septic shock, acute on chronic respiratory failure, acute on chronic kidney disease, and multiple medical problems."

Patient #11 expired at the acute care hospital on [DATE].

Patient #11's record did not document a physician examined her for medical follow up for the 3 days after her history and physical on 11/26/14.

During an interview on 4/02/15 at 4:15 PM, the Family Practice Physician confirmed there were no progress notes to indicate Patient #11 was examined by a physician after the history and physical on 11/26/14.

The Family Practice Physician failed to monitor Patient #11's medical status for 10 days prior to her transfer.

iii. Patient #8's medical record documented a [AGE] year old male admitted on [DATE] for care related to dementia, psychosis, PTSD and HTN. A history and physical was documented by the Physician Assistant on 3/08/15.

A nurses note, on 3/23/15 at 10:50 AM, documented Patient #8 had a generalized seizure lasting 2.5 minutes. Afterwards, he was treated at a nearby hospital ED. The record documented he returned to Safe Haven hospital on [DATE] at 5:30 PM. On 3/24/15 at 2:50 PM, Patient #8 was again transferred to the ED at the other hospital for altered mental status. Patient #8's medical record from the receiving hospital documented he was admitted and was treated for fractures of both arms and 1 hip. No documentation was present stating Patient #8 was examined by a Safe Haven physician during his 18 day stay or by the PA except for the admission history and physical.

RN C was interviewed on 4/01/15 beginning at 3:30 PM. She confirmed Patient #8's record did not contain physician documentation.

iv. Patient #12 was an [AGE] year old male admitted to the facility on [DATE] for psychiatric treatment related to dementia and psychosis. Additional diagnoses included [DIAGNOSES REDACTED]

Patient #12's admission orders included a mechanical soft diet with "Nectar thick" liquids. His admission orders also included an order for a Speech Therapy evaluation, however, his record did not indicate the evaluation was performed.

In a nurses note dated 12/29/14 at 8:07 am, the RN documented Patient #12 had difficulty swallowing and had frequent coughing. A nurses note later that day, at 12:05 PM, documented Patient #12 had difficulty with swallowing and required small portions and nectar thick liquids.

On 12/30/14 at 7:00 PM, the RN documented Patient #12 had decreased oxygen saturation levels at 81%. (Normal is above 90%.) The RN noted he was coughing and breathing shallowly. He was started on oxygen and was transferred to an acute care hospital.

No documentation was present stating Patient #12 was examined by a physician during his 4 day stay or that he was examined by a medical practitioner after his history and physical.

The Family Practice Physician was interviewed on 4/02/15 beginning at 4:15 PM. He stated he did not remember Patient #12. He agreed Patient #12's medical record did not document contact with a physician.

v. A medical history and physical was documented for all patients whose records were reviewed. Two medical records (Patients #8 and #12) documented the history and physicals were conducted by a Physician Assistant. The other records documented the history and physicals were conducted by a Family Practice Physician. The medical records of Patient #8 and Patient #12 did not contain documentation that any physician saw them during their hospitalization .

None of the 17 medical records reviewed (Patients #1 - #17) contained documentation that patients were examined by the Family Practice Physician or the medical Physician Assistant except for the completion of the history and physical.

The Family Practice Physician was interviewed on 4/02/15 beginning at 4:15 PM. When asked about the lack of practitioner visits, he stated if he had to see patients every day he would quit.

RN B was interviewed on 4/02/15 beginning at 5:00 PM. She stated the Family Practice Physician was not responsive to nurses' queries about patients. She stated she had called the physician to clarify orders he had written. She stated the physician told her not to call him. She stated he would only accept text messages if she wished to communicate with him.

The prior Medical Director was interviewed on 4/01/15 beginning at 1:30 PM. He stated the hospital had no peer review or other process to evaluate the care provided by physicians.

The hospital failed to ensure initial and ongoing medical care was provided by the Medical Staff.

b. The Florida psychiatrist, interviewed on 4/03/15 beginning at 1:55 PM, said she had a teleconference with the primary NP 2 times a week. She stated she discussed with the NP all patients who were admitted to the hospital. She stated the NP conducted all Psychiatric Evaluations (a comprehensive assessment of patients' psychiatric status and needs on admission) and she, the physician, edited them. She stated she reviewed all patients' Discharge Summaries. She stated she was available by telephone for consultation most of the time.

The Florida psychiatrist stated there was no record of her activities except for her co-signature on Psychiatric Evaluations and Discharge Summaries.

The psychiatrist did not treat patients or document her activities.

2. MEDICAL STAFF OVERSIGHT:

a. Safe Haven Hospital of Pocatello specialized in the treatment of patients with psychiatric conditions.

The hospital did not have a functional medical staff. A contract with a psychiatrist, dated 9/25/13, documented he became Medical Director on that date. The psychiatrist was interviewed on 4/02/15 beginning at 4:45 PM. He confirmed he had served as Medical Director through 3/31/15. He stated he no longer worked for the hospital. He stated while he was Medical Director there were 3 physicians, including himself, on the Medical Staff.

The prior Medical Director stated during his time as Medical Director he lived in Boise, Idaho, which is approximately 235 miles from the hospital. He stated he had not treated any patients at the hospital. He stated he started visiting the hospital in 2014. He stated since then he had been coming to the hospital one time a month until 2 or 3 months ago. He stated his activities at the hospital were not documented.

The prior Medical Director stated psychiatric care was primarily provided by one NP. He stated 2 other NPs served as her back up when she was not available. He stated the primary NP was supervised by a psychiatrist who lived in Florida. He stated a Family Practice Physician also worked at the hospital to provide for patients' medical care. The prior Medical Director stated he had not had contact with the Family Practice Physician. The Medical Director stated no Medical Staff meetings had been held while he was the Medical Director.

The prior Medical Director stated there was no record of his activities at the hospital. He further stated the hospital did not have a peer review program or other process to evaluate care provided by members of the Medical Staff.

When asked how the hospital ensured patients were under the care of a physician, the prior Medical Director referred the surveyor to the Florida physician.

"BYLAWS OF THE MEDICAL STAFF OF SAFE HAVEN HOSPITAL," not dated, stated NPs were defined as Allied Health Professionals. Article VIII Section I of the bylaws stated "All Allied Health Professionals providing direct patient care in the hospitals shall do so under the direct supervision of the attending psychiatrist."

The psychiatrist in Florida was interviewed on 4/03/15 beginning at 1:55 PM. She stated she did not see patients or provide any direct services. She stated she lived in Florida. She stated all direct services were provided by NPs. She said she had a teleconference with the primary NP 2 times a week. She stated she discussed all patients who were admitted to the hospital with the NP. She stated the NP conducted all Psychiatric Evaluations (a comprehensive assessment of patients' psychiatric status and needs on admission) and she, the physician, edited them. She stated she reviewed all patients' Discharge Summaries. She stated she was available by telephone for consultation most of the time.

The Florida psychiatrist stated there was no record of her activities except for her signature on Psychiatric Evaluations and Discharge Summaries. She stated she did not know if the hospital had a formal process to supervise the NPs.

The Florida psychiatrist stated she had agreed to be the hospital's current Medical Director but said she had not signed the contract yet. She stated she last visited the hospital in February 2015. She said she was coming to the hospital on April 9, 13, 14, and 15 of 2015, and then she would not come to the hospital again until the end of May 2015.

The Florida psychiatrist stated the hospital did not have a peer review program or other process to evaluate members of the Medical Staff.

The Family Practice Physician was interviewed on 4/01/15 beginning at 1:30 PM. He stated he did not know the name of the Medical Director and had not met him, referring to the Medical Director between September 2013 and March 2015.

An RN was interviewed on 4/02/15 beginning at 5:00 PM. She stated she called the Family Practice Physician in mid-March 2015 to clarify some orders he had written. She stated the physician told her not to call him and he would only accept text messages if she wished to communicate with him.

The Medical Staff did not oversee care at the hospital.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, staff interview, and review of medical records and facility policies, it was determined the facility failed to ensure nursing services were organized and supervised to effectively meet the health care needs of psychiatric patients who had additional medical conditions and needed ongoing monitoring of their health status needs. This resulted in immediate jeopardy to the health and safety of 3 patients and had the potential to affect the health and safety of all patients in the facility. Findings include:

1. Refer to A386 as it relates to the failure of the facility to ensure nursing services were organized under the authority of a director of nursing services.

2. Refer to A392 as it relates to the lack of adequate numbers of RNs, LPNs, and other personnel to ensure the patients' needs were met in a safe and timely manner.

3. Refer to A394 as it relates to the failure of the facility to ensure nursing personnel had valid and current licensure.

4. Refer to A395 as it relates to the failure of the facility to ensure a registered nurse provided each patient with initial and ongoing evaluation of his/her health care needs and supervised the delivery of nursing services. These failures led to the death of 3 patients and created the potential for all patients to sustain serious injury, harm or death.

5. Refer to A396 as it relates to the failure of the facility to ensure nursing staff developed and kept current, a care plan for each patient.

6. Refer to A405 as it relates to the failure of the facility to administer medications as ordered by the physician.

The cumulative effects of these systemic failures significantly impede the ability of the hospital to provide nursing services of sufficient scope and quality.
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on observation, record review and staff interview, it was determined the facility failed to ensure nursing services were organized under the authority of a director of nursing services responsible for nursing staff and care provided in the hospital. This failure directly impacted 17 of 17 patients (#1 - #17), whose records were reviewed and had the potential to impact all patients receiving care at the hospital. This resulted in lack of oversight of nursing personnel, lack of development of patient interdisciplinary treatment plans, and negatively impacted the quality of care provided to patients. Findings include:

A job description, titled "Chief Nursing Officer (CNO) - Hospital," revised 3/2015, listed duties and responsibilities. Responsibilities related to treatment plan process included:
-"Consult and coordinate with health care team members to assess, plan, implement and evaluate resident care plans."
-"Consult patient, write long and short term goals and nursing interventions, and obtain patient signature."
-"24 hour coverage is expected, if you cannot be reached, assign another person to cover."

Upon arrival at the facility on 3/30/15 at approximately 1:15 PM, surveyors were greeted by an employee who introduced himself as the Administrator in Training for the attached SNF. He stated the Administrator of the hospital was out of town for the week. He stated the hospital's CNO resigned in January and they were currently interviewing to fill that role.

During an interview on 4/01/15 at 9:35 AM, the co-owner of the hospital stated the CNO resigned in January and they were currently looking for a replacement. She stated the Administrator was currently acting as CNO. Additionally, she stated the Administrator was out of town for a week and no one was designated to oversee clinical services while she was out of town.

During an interview on 4/01/15 at 9:20 AM, RN C stated nobody had been designated as acting CNO while the Administrator was on vacation. She stated she did not know who she would call if she needed to notify the CNO of an event.

During an interview on 4/03/15 at 10:10 AM, RN E stated she thought the Administrator was also the CNO. She stated there had been no formal announcement but she assumed the Administrator took over the CNO role. She stated she did not know who the Acting Administrator was or who the Acting CNO was on the date of the interview (while the Administrator was out of town).

During an interview on 4/02/15 at 5:00 PM, RN B stated her first day on the job was 3/23/15. She stated it was her understanding there was no CNO. When asked who she would call with a question or problem, she stated she did not know.

The facility failed to ensure nursing services were organized under the authority of a director of nursing services.

2. Refer to A392 as it relates to the facility's failure to ensure a CNO was appointed to ensure adequate numbers of RNs, LPNs, and other personnel were provided to meet the patients' needs in a safe and timely manner.

3. Refer to A396 as it relates to the facility's failure to ensure a CNO was appointed to ensure staff developed and kept current, a care plan for each patient.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, record review, staff interview, review of staff and patient grievances, incident reports, and policies, it was determined the hospital failed to ensure 1) patients were protected from abuse and neglect, 2) treatment and nursing POCs were developed and implemented, 3) sufficient numbers of trained staff were available to safely care for patients with behavioral concerns, 4) restraints and seclusion were safely and appropriately implemented by trained staff, and 5) staff were trained to meet patients' behavioral and health care needs. This resulted in 1 of 3 sanple patients (#8), who were placed in restraints or seclusion, sustaining bilateral arm fractures and a shatter pelvis, 5 unidentified patients who submitted written grievances experiencing mental anguish and fear, and endangered the health and safety of all patients residing in the facility. Findings include:

1. Refer to A117 as it relates to the failure of the facility to inform each patient or patient's representative, of the patient's rights, in advance of furnishing or discontinuing patient care.

2. Refer to A122 as it relates to the failure of the facility to review, investigate, and respond to patient grievances.

3. Refer to A130 as it relates to the facility's failure to include the patient and/or family in the development and implementation of the plan of care.

4. Refer to A131 as it relates to the facility's failure to ensure patient participation in treatment planning.

5. Refer to A143 as it relates to the failure of the facility to ensure patients' privacy during physician and NP assessments and evaluations.

6. Refer to A144 as it it relates to the facility's failure to ensure patients health and safety were not placed in immediate jeopardy and that all patients were provided care in a safe setting.

7. Refer to A145 as it relates to the facility's failure to ensure patients were free from all forms of abuse, neglect, and harassment. This resulted in immediate jeopardy to the health and safety of all patients residing in the facility.

8. Refer to A154 as it relates to the failure of the facility to ensure patients were not inappropriately restrained, placed in seclusion, or chemically restrained.

9. Refer to A164 as it relates to the failure of the facility to use less restrictive interventions before implementing chemical and physical restraints.

10. Refer to 165 as it relates to the failure of the facility to ensure the use of restraint as the least restrictive intervention.

11. Refer to A166 as it relates to the failure of the facility to modify patients' plan of care when restraints, seclusion, or chemical restraints were implemented.

12. Refer to A167 as it relates to the failure of the facility to ensure staff were trained in appropriate restraint and seclusion techniques.

13. Refer to A168 as it relates to the failure of the facility to ensure physician and NP orders were in place when implementing restraints and seclusion.

14. Refer to A178 as it relates to the failure of the facility to ensure patients were assessed face to face within 1 hour after implementation of seclusion or restraint for violent behavior.

15. Refer to A185 as it relates to the failure of the facility to ensure documentation of the type of restraint interventions used.

16. Refer to A186 as it relates to the failure of the facility to ensure documentation of attempts of less restrictive interventions prior to implementation of restraint and/or seclusion.

17. Refer to A194 as it relates to the failure of the facility to ensure staff were trained and utilized safe restraint and seclusion techniques.

18. Refer to A200 as it relates to the failure of the facility to require appropriate staff education, training, and knowledge in the use of nonphysical intervention skills.

19. Refer to A206 as it relates to the failure of the facility to ensure all patient care staff had education, training, and certification in cardiopulmonary resuscitation.

The cumulative effect of these systemic failures prevented the facility from ensuring patients were protected from serious harm and provided care in a safe and effective manner.

The co-owner of the facility was verbally notified of the Immediate Jeopardy to patients' health and safety on 4/03/15 at 5:00 PM, and in writing on 4/07/15.
VIOLATION: DISCHARGE PLANNING Tag No: A0799
Based on record review, policy review, and staff interview, it was determined the facility failed to ensure identification of patients' discharge needs, patients' and/or family members were counseled on discharge needs, and reassessment of the patients' discharge plan for factors that affected care needs, or appropriateness of the discharge plan for patients. These failures had the potential to cause undue stress, increase the likelihood of readmission, and possible negative outcomes for all patients. Findings included:

1. Refer to A 806 as it relates to the facility's failure to evaluate each patients' capacity for self-care or the possibility of needing post hospital services.

2. Refer to A 810 as it relates to the facility's failure to ensure appropriate arrangements were made before discharge to avoid unnecessary delays in the discharge process.

3. Refer to A 821 as it relates to the facility's failure to reassess the discharge plan for factors affecting continuing care needs or the appropriateness of the discharge plan.

4. Refer to A 837 as it relates to the facility's failure to ensure patients were referred for follow-up or ancillary care as needed following hospitalization .

5. Refer to A 843 as it relates to the facility's failure to ensure that discharge planning was reassessed on an ongoing basis.

The cumulative effect of these negative systemic practices significantly impeded the facility's ability to ensure discharge of patients was timely, ongoing and comprehensive, as well as appropriate to each patient's individual needs.
VIOLATION: REASSESSMENT OF A DISCHARGE PLAN Tag No: A0821
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review, and staff interview, it was determined the hospital failed to reassess each patient's discharge plan for appropriateness for 2 of 17 patients (#5 and #13) whose records were reviewed. This had the potential to negatively effect patient discharge outcomes. Findings include:

1. Patient #5 was a [AGE] year old male admitted on [DATE] to 3/25/15, from an ALF. His psychiatric diagnoses included schizophrenia and depression.

Patient #5's record included a social history completed by an LMSW on 3/13/15. The social history documented recommendations for coordination of discharge placement and aftercare, and Patient #5 was to return to an ALF.

Social service progress notes documented working on Patient #5's discharge placement beginning on 3/14/15, 5 days after admission. The SS Assistant documented at 3:57 PM, she spoke with the Administrator for Patient #5's previous ALF and they would not take him back upon discharge.

On 3/25/15 at 1:15 PM, the LMSW documented she spoke with an ALF and they indicated Patient #5 may be accepted if his wounds were cultured for MRSA and came back negative. A nursing note dated 3/25/15, documented Patient #5's wounds were cultured by the RN at 9:45 AM. There were no results from the wound culture in Patient #5's record.

The LMSW documented Patient #5 did not want to stay at the hospital and he wanted to go to the shelter. Patient #5 was discharged from the facility on 3/25/15 at 3:30 PM, to a local shelter.

During an interview on 4/03/15 at 12:55 PM, the Director of Social Services reviewed the record and confirmed the plan was for Patient #5 to return to his previous ALF. She confirmed the wound culture was not done prior to the day of discharge.

The facility did not ensure Patient #5's discharge plan was reassessed and updated to reflect his wound affecting discharge placement.





2. Patient #13 was a [AGE] year old male admitted on [DATE], with diagnoses of psychosis and depression.

Patient #13's record included an order for Seroquel 25 mg to be given daily at bedtime. The order was signed by the NP on 1/04/15 at 6:05 PM. Per the Nursing 2015 Drug Handbook, Seroquel is an antipsychotic medication that requires careful monitoring, due to the risk of adverse reactions.

Patient #13's record included a MAR with a handwritten entry of Seroquel 25 mg to be given daily at 8:00 PM. The entry noted the start date for the Seroquel was 1/05/15. Seroquel was not administered to Patient #13 at bedtime on 1/04/15, as ordered.

Patient #13's record included a social service progress, dated 1/05/15. The note stated "When SS discussed discharges with [NP] she reported that due to staffing [patient] was being discharged ."

During an interview on 4/03/15 at 2:45 PM, the SS Assistant who wrote the note confirmed Patient #13 was discharged on [DATE], to an ALF, due to lack of sufficient staff.

Patient #13's nurses notes documented he was discharged to an ALF on 1/05/15 at 4:45 PM. He did not receive a dose of Seroquel prior to his discharge.

Patient #13's record included a copy of discharge instructions, including discharge medication orders, that were sent to the ALF. The discharge medication order form included an area to document the number of antipsychotics ordered upon discharge, along with any special instructions. The section was blank, although Seroquel, an antipsychotic was included in his discharge medication orders. Additionally, there was no documentation stating he had not received Seroquel during his hospitalization . The ALF staff were not informed they would be administering his first dose, meaning he should be closely monitored for adverse effects.

During an interview on 4/01/15 at 4:20 PM, RN C reviewed Patient #13's record. She stated when a new medication is ordered the first dose should be given that day unless the order states otherwise. She stated medications ordered for bedtime are administered at 8:00 PM. RN C confirmed Patient #13 should have been given a dose of Seroquel at 8:00 PM on 1/04/15. She reviewed the discharge instructions and confirmed the ALF staff was not informed Patient #13 did not receive Seroquel in the hospital.

The facility did not ensure Patient #13's discharge plan was reassessed and updated to reflect his new medication, and his unanticipated discharge.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, record review, staff interview, review of grievance documentation and review of policies, it was determined the hospital failed to 1) respond to patient and staff written allegations of abuse, 2) investigate serious patient injuries to determine cause and implement corrective actions, and 3) ensure sufficient numbers of trained staff were available to safely care for patients with behavioral concerns 4) ensure patients were not subjected to abuse by staff 5) ensure patients were under the care of physician 6) ensure patients were provided with health services necessary prevent their deterioriation and death. This resulted in 1 of 3 sample patients (#8) for whom restraints and/or seclusion were used, sustaining bilateral arm fractures and a shatter pelvis, 5 unidentified patients who submitted written grievances experiencing mental anguish and fear, 3 patients (#10, #11, #12) experiencing health deterioration and death due to lack of health service. The multiple systemic system failures, individually, and in combination, endangered the health and safety of 6 of 6 patients (#7, #9, #17, #18, #19, and #20) residing in the facility during the survey, as well as, all future admissions. Findings include:

1. Refer to A145 as it relates to the failure of the facility to ensure patients were protected from abuse.

2. Refer to A347 as it relates to the failure of the hospital to provide basic medical care and oversight, necessary to protect patients from serious harm or death.

3. Refer to 395 as it relates to the failure of the facility to provide patients with health services necessary to avoid physical deterioration and death.

The cumulative effect of these serious systemic failures prevented the faciliy from providing care and services necessary to protect patients from serious injury, harm, or death.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and review of medical records, QAPI documents, and policies, it was determined the hospital failed to ensure the QAPI program identified adverse patient events, analyzed their causes, and implemented actions to prevent further adverse events. This negatively affected the care of 3 of 17 patients (#5, #8, #10) whose records were reviewed. This impeded the hospital's ability to develop measures to prevent further adverse events. Findings include:

1. Patient #8 was a [AGE] year old male admitted to the facility on [DATE] for care related to dementia, psychosis, HTN, and PTSD. His medical record from 3/06/15 to 3/24/15 was reviewed, as well as records from ED visits on 3/23/15 and 3/24/15 at an acute care facility were reviewed.

Patient #8's medical record from the receiving hospital stated he was admitted with 2 upper arm fractures and 1 hip fracture.

A Pocatello police detective was interviewed on 3/31/15 beginning at 11:25 AM. He stated he had come to the hospital on [DATE] and talked with staff about allegations of abuse to Patient #8.

The Co-Owner was interviewed on 4/02/15 beginning at 12:45 PM. She stated an incident report had not been filed related to the fractures and potential abuse. She stated an investigation of events had not begun until 4/01/15. She stated action had not been taken related to the events.

The hospital failed to investigate a dangerous adverse patient event and failed to take action to protect patients.

2. Patient #5 was a [AGE] year old male admitted to the hospital from 3/09/15 to 3/25/15, for schizophrenia and depression.

Patient #5 was discharged from the facility on 3/25/15 at 3:30 PM, to a local homeless shelter. The shelter had limited hours and did not open until 5:00 PM.

A timeline was received on 4/03/15 at 3:30 PM from the SNF AIT, which outlined the events that happened after Patient #5's discharge from the facility:

- Patient #5 was discharged at 3:30 PM.
- Patient #5 was refused admittance to shelter because it was before 5:00 PM.
- Patient #5 returned to shelter at 9:00 PM and was refused admittance.
- Patient #5 returned to shelter at 1:00 AM and was refused admittance. He was reportedly bleeding from an unknown source at this time. Police were contacted by a shelter staff member.
- During the course of the evening (the time was not documented) Patient #5 returned to the hospital and requested assistance. The staff member who went to the door refused to let him in stating the hospital did not offer emergency services. The staff member told Patient #5 he needed to leave. Patient #5 "returned banging on the doors and windows of the facility a couple more times. Finally the nurse called the police and he took off."
- Patient #5 went to the hospital's corporate office around 7:15 AM on 3/27/15. He did not have any personal belongings, wallet or ID. His face was "badly banged up." He had tape across his nose.
- The corporate office found placement for Patient #5 in an ALF.

The Director of Social Services was interviewed on 4/03/15 at 3:40 PM. She confirmed Patient #5's discharge and subsequent return to the hospital. She stated an incident report had not been written. She said she was not aware of an investigation into the events.

The hospital failed to investigate a dangerous adverse patient event.

3. Patient #10 was a [AGE] year old male admitted on [DATE]. His psychiatric diagnoses were conduct disorder and depression. Additional diagnoses included history of a stroke, seizure disorder, non-insulin dependent diabetes, and constipation. Patient #10 expired at the hospital on [DATE].

Patient #10's record documented his weight upon admission as 132.2 pounds. Patient #10's record documented a steady decline in weight during his stay. On 11/17/14 Patient #10's weight was documented as 123 pounds, a loss of 9.2 pounds in 10 days. Patient #10's record documented the frequent refusal of meals.

Patient #10's record included a flow sheet that documented no bowel movement on all shifts, from 11/07/14 to 11/17/14. Additionally, the nursing admission assessment did not document his last bowel movement prior to admission.

Patient #10's nursing and P.T. notes documented weight loss, complaints of pain and nausea, poor intake and lack of bowel movements, however, there was no documentation these significant finding were reported to his MD.

Patient #10's History and Physical by the MD was dated 11/07/14. There were no progress notes to indicate the MD saw Patient #10 after 11/07/14 and his death on 11/17/14.

There was no documentation of the medical care or nursing care that Patient #10 received prior to his death.

The MD was interviewed on 4/01/15 beginning at 1:30 PM. He confirmed no investigation had been conducted into Patient #10's death or care.

The hospital failed to investigate events leading to Patient #10's death and failed to evaluate the medical care provided.

4. A "SAFE HAVEN INVESTIGATION REPORT," completed on 10/07/14, stated Patient #23, who had dementia, wandered into Patient #22's room. The report stated Patient #22 thought Patient #23 was going to rape her and she struck him in the left eye. The Patient #23 suffered 2 small lacerations. Witness statements were gathered. Nursing notes surrounding the event were reviewed.

The report concluded there was no attempted rape. No investigation was documented regarding staff monitoring and supervision of patients.

The person responsible for investigations no longer worked at the hospital and was not available for interview.

The hospital failed to analyze the event to prevent further injuries to patients.

5. A "Patient Occurrence Report," completed on 11/18/14, documented Patient #24 was a [AGE] year old male who was admitted on [DATE]. The report included "NURSE'S NOTES," dated 11/15/14 at 3:50 PM which stated the Patient #24 reported he had "overdosed" on 7 Oxycodone, a narcotic pain reliever. "NURSE'S NOTES," dated 11/15/14 at 4:00 PM, stated the patient was lying down and told staff he had taken "at least 70 Oxy, whatever was left in the bottles." The note stated he was alert but drowsy. At 4:03 PM, orders were received to transport the patient to a nearby Emergency Department. At 4:05 PM, a note stated the patient was blue, was not breathing, and had no pulse. CPR was initiated and the patient was transferred. He was treated at another hospital and was transferred back to Safe Haven on 11/16/14 at 12:30 AM.

Witness statements were obtained.

A "Root Cause Analysis Worksheet," not dated, was completed. The worksheet stated the patient obtained a large amount of pain medication and tried to commit suicide. The worksheet stated "WHY?" and included 5 answers. These included "Inventory possibly not thoroughly checked by staff...Personal search of pt was possibly not done or not done thoroughly...Possible incomplete room and personal checks...Depression...Borderline Trait."

The analysis did not determine whether staff followed the policy regarding contraband checks or if the policy was sufficient to protect patients. The analysis did not assess if emergency care provided to the patient was sufficient. The worksheet stated the plan was to hold staff accountable for contraband checks and "By educating staff and making them accountable for doing them right."

The person who conducted the root cause analysis no longer worked at the hospital and was not available for interview.

The hospital failed to sufficiently analyze the event to prevent further injuries to patients.

6. A "Patient Occurrence Report," completed 12/08/14, documented Patient #25 hit Patient #26 with a drawer taken from an end table. The investigation noted the Patient #26, who was assaulted, had a 1 to 1 caregiver assigned to him. A "Root Cause Analysis Worksheet," not dated, was completed. The worksheet stated Patient #26 was physically assaulted by Patient #25. The worksheet stated "WHY?" and included 5 answers. These included Dementia...labile...Aggression...Confusion...Psychosis [not otherwise specified]." The analysis did not examine how Patient #25 was able to get the weapon (the drawer) or how the Patient #25 was able to assault the victim without the 1 to 1 staff intervening to prevent the attack. No recommendations were made to prevent further attacks.

The person who conducted the root cause analysis no longer worked at the hospital and was not available for interview.

The hospital failed to sufficiently analyze the event to prevent further injuries to patients.

7. The Interim Quality Director was interviewed on 4/01/15 beginning at 3:05 PM. She stated the hospital did not have a specific procedure to conduct causal analyses of adverse patient events.

The hospital failed to develop procedures to investigate adverse patient events.

8. Data summaries stated falls were recorded each month in 2014. An untitled and undated document listed QAPI goals. These included a 10% decrease in falls within the next 30 days. At the time there were only 2 falls for that month. The goal was not clear. The number or falls was not adjusted to account for changes in the hospital's census. The number of falls varied widely from 1 in February to 18 in September. There was no analysis of causes for the falls other than patient diagnosis. There was no documentation action was taken to decrease the number of falls. No further documents were available that tracked or analyzed falls as of 4/01/15.

The Interim Quality Director was interviewed on 4/01/15 beginning at 3:05 PM. She stated she had only been at the hospital for 2 days but confirmed it did not appear as if falls were being analyzed or actions were taken to reduce falls.

Falls were not analyzed.

9. Data summaries stated medication errors were recorded each month in 2014. The number of errors varied from month to month. There was no analysis of causes. No corrective action was documented except to "educate" nurses. An undated document titled "Medication Errors" summarized medication errors for 2014. It stated "The Problem Goal for 2014 was to have no medication errors each month. This did not occur and needs to be re-evaluated and goal change to try and decrease medication errors for each month. For the year 2015 QAPI will take a closer look and track exactly what medication errors are occurring and who is responsible, in order to better pinpoint the problems that exist." No further documents were available that tracked or analyzed medication errors as of 4/01/15.

The Interim Quality Director was interviewed on 4/01/15 beginning at 3:05 PM. She confirmed it did not appear as if medication errors were being analyzed

Medication errors were not analyzed.
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
Based on staff interview and review of medical records, policies, incident reports, Medical Staff Bylaws, QAPI documents, and meeting minutes, it was determined the hospital's Governing Board failed to ensure the Administrator assumed responsibility for managing the hospital, including developing and monitoring systems of care. This resulted in the inability of the hospital to provide necessary services to promote the health and safety of patients. Findings include:

The governing body must appoint a chief executive officer who is responsible for managing the hospital.

1. No person was designated to be responsible for managing the hospital.

Upon arrival at the facility on 3/30/15 at approximately 1:15 PM, surveyors were greeted by an employee who introduced himself as the Administrator in Training for the attached SNF. He stated the Administrator of the hospital was out of town for the week. He stated he was the hospital's liaison for the surveyors. He stated he did not work for the hospital and did not know about much about the hospital. When interviewed later on 4/01/15 at 9:05 AM, the SNF AIT stated nobody was appointed as Acting Administrator for the hospital while the Administrator was out of town that week.

During an interview on 4/01/15 at 9:35 AM, the Co-owner of the hospital stated the Administrator was out of town for a week and no one was designated to oversee clinical services while she was out of town.

In addition to not having an Administrator at the time of the survey, the hospital also lacked a CNO. The Administrator was interviewed by phone on 4/02/15 beginning at 2:15 PM. She stated she assumed the role of the Interim CNO in January 2015 when the former CNO resigned. She stated there was no documentation stating she was the Interim CNO. She stated an Acting CNO had not been appointed while she was out of town.

During an interview on 4/01/15 at 9:35 AM, the Co-owner of the hospital stated the CNO resigned in January and they were currently looking for a replacement. She stated the Administrator was currently acting as CNO.

During an interview on 4/01/15 beginning at 9:05 AM, RN C, the Charge Nurse, stated nobody was designated as Acting CNO while the Administrator was out of town. She stated she did not know who to call if there was a nursing problem.

During an interview on 4/03/15 at 10:10 AM, RN E stated she thought the Administrator was also the CNO. She stated there had been no formal announcement but she assumed the Administrator took over the CNO role. She stated she did not know who the Acting Administrator was or who the Acting CNO was on the date of the interview (while the Administrator was out of town.)

During an interview on 4/02/15 at 5:00 PM, RN B stated her first day on the job was 3/23/15. She stated it was her understanding there was no CNO. When asked who she would call with a question or problem, she stated she did not know.

The Administrator failed to appoint an onsite Administrator in her absence and failed to officially appoint a CNO and inform nursing staff of who to contact if nursing issues arose.

2. The Administrator did not implement a treatment planning process.

The policy "ICTP, Comprehensive," dated 1/31/12, stated "An ICTP that includes measurable objectives and time tables to meet the patient's mental, psychological, and psychosocial needs shall be developed for each patient." The policy included a procedure to develop and monitor a comprehensive treatment plan for patients. The policy and procedure were not followed.

The records of 17 patients (#1 - #17) with an admitted range of 9/24/14 to 3/31/15, were reviewed. None of the 17 patient records contained a documented treatment plan. Goals were not identified, and interventions were not specified in order to direct staff in caring for these patients.

During an interview on 4/03/15 at 10:30 AM, the NP stated ITCPs had not been developed since the CNO left in January. She confirmed patients currently did not have ITCPs.

On 4/02/15 beginning at 11:50 AM, a Treatment Team group consisting of RN C, the Director of Social Services, and the Program Director was observed. They discussed patients' needs and progress at the hospital. They did not develop or document written treatment plans.

The Director of Social Services stated the group reviewed patients' problem lists but she said there were no written treatment plans. She stated she was not aware of a procedure to develop and review treatment plans.

The Administrator failed to ensure patients had written treatment plans to direct staff.

3. The Administrator did not ensure processes were developed and maintained to evaluate persons with medical and psychiatric emergencies. Refer to A93 as it relates to the failure of the hospital to develop written policies and procedures for the appraisal of emergencies, including the hospital's responsibilities for initial treatment and referral.

4. The Administrator did not ensure patients' rights were protected and promoted. Refer to A115 as it relates to the lack of staff training and monitoring regarding the safe use of restraints and seclusion and the inability of the hospital to protect patients from harm.

5. The Administrator did not ensure a comprehensive QAPI program was developed and maintained. Refer to A263 as it relates to lack of a QAPI program that collected and utilized data to analyze hospital processes and suggest ways to improve patient care.

6. The Administrator did not ensure the Medical Staff was organized and accountable for medical care provided to patients. Refer to A338 as it relates to the failure of the Medical Staff to provide basic care and services and to monitor medical care provided to patients.

7. The Administrator did not ensure nursing services were organized. Refer to A385 as it relates to the failure of the nursing service to meet the nursing needs of patients with acute and chronic medical and psychiatric conditions.

8. The Administrator did not ensure the discharge planning program was sufficient to meet the needs of patients. Refer to A799 as it relates to the inability of the discharge planning program to identify patients' discharge planning needs and implement plans to meet patients' needs.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on staff interview and review of policies and QAPI documents, it was determined the hospital failed to ensure the QAPI program showed measurable improvement in indicators and failed to analyze quality indicators. The hospital failed to use data to monitor the effectiveness and safety of services. The hospital failed to specify the frequency and detail of data collection. This prevented the hospital from identifying ways to improve care. Findings include:

1. The hospital's policy titled "QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PLAN" was dated effective 6/01/13. The policy stated the hospital would organize "Performance Improvement Teams" to address "quality/departmental concerns." The policy stated an interdisciplinary "PI Committee" would meet "...at least monthly" to review and analyze data, review the status and effectiveness of PI projects, and discuss the need for additional projects.

The policy was not specific. For example, the policy had a section for "Data Collection" which contained general language such as "Data collection will be incorporated into existing processes and procedures" and "Data will be tracked and trended." Under the section labeled "Action to be Taken," the plan stated "Actions may include" and contained a list of items such as "Changing Process or System."

The Interim Quality Director was interviewed on 4/01/15 beginning at 3:05 PM. She stated the hospital had ongoing quality activities but a plan had not been developed that defined the overall QAPI program and directed staff as to how to carry out those activities.

A specific QAPI plan, including quality indicators, priorities, and time frames, was not documented between 1/01/14 and 3/31/15.

2. No plan to assess processes of care for patients had been developed. For example, the hospital did not assess its medication delivery system, nursing care provided to patients, discharge planning process, system to obtain laboratory testing, or other processes related to caring for patients.

The hospital did monitor the percentage of safety checks being conducted and the percentage of patients who attended groups. However, there was no plan to use this data to examine ways to increase compliance.

An untitled and undated document listed QAPI goals. There was no documentation to show how long these items had been measured or how the data would be used.

The goals included:

a. Safety checks will be completed 100% of the time with each shift.
b. No major prohibited items will be found.
c. A 10% decrease in falls within the next 30 days.
d. All infections will be tracked.
e. All skin problems will be tracked.
f. Staff will have no "occurrences" in the next 30 days.
g. The hospital will have "...zero medication errors."
h. The hospital will have a decrease of "other occurrences" within 30 days.
i. Patients will attend at least 70% of groups.

Data summaries for 2014:

a. Data summaries stated compliance with contraband checks in January 2014 was 69% on days and 84.5% on nights. The percentages rose and fell throughout the year. The summary for November 2014 was 57% on days and 57% on nights. The rates rose again in December 2014 with 90% on days and 100% on nights being completed for both months. Although it improved at the end of the year, the goal was not met for 2014. The reasons for improvement or decline were not analyzed. The only action documented to improve compliance for the entire year was education to remind staff to complete the checks.

b. Data summaries stated contraband items were found each month in 2014. No analysis was documented and no action was taken to address the failure to meet the goal.

c. Data summaries stated falls were recorded each month in 2014. The goal was not clear. The number or falls was not adjusted to account for changes in the hospital's census. The number of falls varied widely from 1 in February to 18 in September. There was no analysis of causes for the falls other than patient diagnosis. There was no documentation action was taken to decrease the number of falls.

d. The hospital was required to monitor and track infections per regulation. The goal did not reflect any analysis of infections or promote actions to decrease the number of infections.

e. The goal for skin problems did not define the terms. Reported skin problems included injuries such as abrasions from patients hitting a wall, bruises, old scabs, and scratches as well as rashes and a pressure sore. There was no documented analysis of causes or refinement of the problem.

f. The goal for staff occurrences did not define the terms. Reported staff occurrences included a smashed finger, back injuries, a fall, and a seizure. There was no documented analysis of causes or refinement of of the problem.

g. Data summaries stated medication errors were recorded each month in 2014. The number of errors varied from month to month. There was no analysis of causes. No corrective action was documented.

The goal of zero medication errors was not achieved and it is questionable whether this was a realistic goal. There was no documentation to demonstrate that staff questioned achievability of the goal or that the goal was modified in order to achieve compliance.

h. Other occurrences were not defined. Summaries for 2014 noted events including:

i. A patient who was allergic to strawberries ate strawberry jam in February 2014.
ii. A patient left against medical advice in March 2014.
iii. A patient dropped an oxygen canister on his foot in June 2014.
iv. A separate summary stated 3 occurrences were reported from April through June 2014 but the summary did not state what those occurrences were.
v. A summary noted 4 occurrences were reported in September 2014 but did not state what those occurrences were.
vi. A summary documented 2 patient to patient altercations and 1 incident of destruction of property in October 2014.
vii. A summary documented an overdose, a death, and arm scratches in November 2014.
viii. A December 2014 summary noted 2 patient to patient altercations, seizures, self-harm occurrences, and a patient with a physical decline.

A specific analysis of the above occurrences was not documented. The goal was not refined and no plan to decrease the number of occurrences was documented.

i. The goal of attendance at groups was largely met. Analysis of the data and action taken affecting the percentage of compliance was not documented.

The Interim Quality Director was interviewed on 4/01/15 beginning at 3:05 PM. She stated she had only been at the hospital for 2 days but confirmed the unclear goals and the lack of investigation documentation.

The hospital failed to analyze quality indicators or to use data to monitor the effectiveness and safety of services.

3. None of the above goals included a plan to gather data, including the frequency and detail of data collection.

The Interim Quality Director was interviewed on 4/01/15 beginning at 3:05 PM. She confirmed the QAPI goals did not include the frequency and detail of data collection. She stated she was not aware of a QAPI plan that included these items.

The hospital failed to specify the frequency and detail of data collection.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0206
Based on review of personnel records and staff interview, it was determined the hospital failed to ensure all appropriate staff were certified in the use of cardiopulmonary resuscitation. This resulted in an unsafe environment for all patients. Findings include:

The personnel records of eighteen direct care employees were reviewed, including 8 RN, 2 LPN, 7 P.T. and 1 Program Assistant. The records of RN A, C and H, LPN B, and P.T. A, B, D, E and F, and the Program Assistant did not contain documentation of CPR certification. The records of RN E, LPN A, and P.T. C contained CPR certificates that were expired.

During an interview on 4/03/15 at 3:30 PM, the Human Resources Director confirmed all direct care staff were required to have current CPR certification. She reviewed the personnel records and confirmed 13 of the 18 records reviewed did not include documentation of current CPR certification.

Appropriate hospital personnel were not certified in cardiopulmonary resuscitation.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0167
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policy and personnel files, and staff interview, it was determined the facility failed to ensure restraints were safely implemented for 1 of 3 patients reviewed (#8) for whom restraints and seclusion were used. This resulted in an inability of the facility to ensure physical restraints and seclusion were implemented in a safe and appropriate manner. Findings include:

1. Patient #8's record documented a [AGE] year old male who was at the facility from 3/06/15 to 3/24/15 for psychiatric services related to dementia, and psychosis with behavioral disturbances. Additional diagnoses included HTN and PTSD.

During an interview on 4/03/15 at 4:00 PM, P.T. H stated she was a P.T. on duty the day before Patient #8 had the seizure on 3/23/15. She stated she did not have Mandt or any kind of restraint training since her hire at the facility. P.T. H stated she witnessed an event that she reported to the RN on duty, but felt no action was taken.

She stated P.T. D did not like Patient #8, and stated that P.T. D did not want to be his 1:1. She stated when Patient #8 had aggressive behavior; P.T. D would be the 1st to jump in to restrain him.

P.T. H stated on Sunday 3/22/15, Patient #8 did not sleep for about a day and a half, and he was agitated. She stated that about 6:30 AM, she asked him if he was tired, Patient #8 stated "yes," so she took him to his room. She stated he sat on the bed, then Patient #8 grabbed her by the throat, she brought his hand down and then went to get assistance from P.T. D. When they entered the room, Patient #8 tried to punch P.T.D so he grabbed Patient #8 with his arms under Patient #8's armpits and pulled his arms up and outward. (Similar to a Full Nelson wrestling move). Patient #8 attempted to fight him off, and P.T.D held him again in that manner and threw him face down on the bed, with his body on him to pin him down. He asked P.T. H to hold Patient #8's legs. He held Patient #8 down until after the RN gave him a shot. P.T. D's personnel file was reviewed. It did not include evidenc of Mandt training.

The reported type of restraint is not an approved Mandt or other therapeutic hold and presents a danger to patients.
Patient #8 was not restrained in a safe and appropriate manner.

2. The facility policy "Use of Seclusion and Restraint," dated 1/25/14, defined restraint as "Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition."

The Administrator was interviewed on 4/02/15 at 2:15 PM. She stated that all direct patient care staff were trained in Mandt technique for patient restraint. She stated the only physical holds used in the facility were Mandt holds, and although they would be "hands on," they were Mandt holds, and not considered a restraint. This was inconsistent with the definition included in the hospital's policy

During an interview on 4/03/15 at 4:10 PM, the SNF AIT stated the hospital required all direct care staff to complete Mandt training upon hire and annually. He stated the hospital provided the training several times a year. The Mandt Systems website, accessed 4/07/15, stated "The Mandt System is a comprehensive, integrated approach to preventing, de-escalating, and if necessary, intervening when the behavior of an individual poses a threat of harm to themselves and/or others."

The personnel records of eighteen direct care employees were reviewed, including 8 RN, 2 LPN, 7 P. T. and 1 Program Assistant. The employee files of RN B and H, LPN A and B, P.T. B, D, E, F and G, and the Program Assistant did not contain documentation of Mandt training. The employee files of RN C, D, E and G, and P.T. A and C contained Mandt training certificates that were expired. Two staff files included evidence of current Mandt training.

During an interview on 4/03/15 at 3:30 PM, the Human Resources Director confirmed the hospital required annual Mandt training for all direct care staff members. She reviewed the personnel files and confirmed 10 of the 18 files reviewed did not include documentation of Mandt training, and 6 of the 18 records reviewed contained Mandt training certificates that were expired.

The facility failed to ensure staff were sufficiently trained to safely and appropriately perform restraints.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0196
Based on review of personnel files and staff interview, it was determined the hospital failed to ensure all appropriate staff (RN B, C, D, E, G and H, LPN A and B, P.T. A, B, C, D, E, F and G, and the Program Assistant) were trained and able to demonstrate competency in the application of restraints, implementation of seclusion, and in providing care for a patient in restraint or seclusion. This resulted in an unsafe environment for all patients. Findings include:

The hospital's policy titled Restraints, effective 1/25/12, outlined training requirements related to restraint and seclusion for direct care staff. It stated all direct care staff would receive ongoing training in the causes of threatening behaviors, and techniques used to prevent injury. Additionally, it stated staff who are authorized to physically apply restraint or seclusion received additional training in physical holding techniques and take down procedures.

During an interview on 4/03/15 at 4:10 PM, the SNF AIT stated the hospital required all direct care staff to complete Mandt training upon hire and annually. He stated the hospital provided the training several times a year. The Mandt Systems website, accessed 4/07/15, stated "The Mandt System is a comprehensive, integrated approach to preventing, de-escalating, and if necessary, intervening when the behavior of an individual poses a threat of harm to themselves and/or others."

The personnel records of eighteen direct care employees were reviewed, including 8 RN, 2 LPN, 7 P. T. and 1 Program Assistant. The employee files of RN B and H, LPN A and B, P.T. B, D, E, F and G, and the Program Assistant did not contain documentation of Mandt training. The employee files of RN C, D, E and G, and P.T. A and C contained Mandt training certificates that were expired.

During an interview on 4/03/15 at 3:30 PM, the Human Resources Director confirmed the hospital required annual Mandt training for all direct care staff members. She reviewed the personnel files and confirmed 10 of the 18 files reviewed did not include documentation of Mandt training, and 6 of the 18 records reviewed contained Mandt training certificates that were expired.

Appropriate hospital personnel were not trained in the care of patients in restraint or seclusion.
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
Based on record review and staff interview, it was determined the facility failed to ensure patients or their representatives participated in the development and implementation of plans of care for 17 of 17 patients (#1- #17) whose records were reviewed. This failure resulted in the inability of patients to make informed decisions regarding their care, including medications, treatments and discharge plans. Findings include:

The records of 17 patients (#1 - #17) with admitted range of 9/24/14 to 3/31/15, were reviewed. The 17 patient records did not include treatment plans or nursing care plans. Goals were not identified, and interventions were not initiated to identify a course of treatment and minimize the risk of complications related to psychiatric or medical diagnoses.

During an interview on 4/03/15 at 10:15 AM, the NP confirmed the records did not include treatment plans or nursing care plans. She stated the CNO was responsible for creating the treatment plan, however, the facility did not currently have a CNO, so treatment plans were not being created.

During an interview on 4/01/15 at 9:35 AM, the co-owner of the hospital stated the CNO resigned in January and they were currently looking for a replacement.

During an interview on 4/01/15 at 9:20 AM, RN C stated in the past treatment plans were developed by the CNO. She stated the nurses did not have time to create treatment plans. Additionally, she said, "We don't have a DON [CNO] so it's not happening."

The facility failed to ensure patients were included in the development of a plan of care.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**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 patients or their representatives were involved in care planning and treatment, for 3 of 17 patients (#11, #13, and #15) whose records were reviewed. This had the potential to result in the inability of patients or their representatives to make informed decisions about their care. Findings include:

1. Patient #11 was a [AGE] year old female admitted on [DATE], from a skilled nursing facility, with diagnoses of psychosis, bipolar disorder and congenital brain injury with mental disability.

Patient #11's medical record for her hospital admission of 11/25/14 to 11/29/14, was reviewed. Her record included a letter of guardianship and conservatorship. The letter stated Patient #11 was impaired to the extent she was unable to make responsible decisions.

Patient #11's record did not include documentation of contact with her guardian, to obtain consent for services or to discuss care planning and treatment. Patient #11's record did not include an admission agreement or a consent for services.

During an interview on 4/01/15 at 4:00 PM, RN C reviewed Patient #11's record and confirmed it did not include signed consent forms. Additionally, she confirmed there was no documentation of contact with Patient #11's guardian.

The facility failed to obtain consent for services from Patient #11's guardian, and failed to include her guardian in decisions regarding her care.

2. Patient #13 was a [AGE] year old male admitted on [DATE], with diagnoses of psychosis and depression.

Patient #13's medical record for his hospital admission of 1/01/15 to 1/05/15, was reviewed. His record did not include a signed consent for services or an admission agreement. Additionally, his record did not include a care plan or treatment plan developed and discussed with Patient #13.

During an interview on 4/01/15 at 4:20 PM, RN C reviewed Patient #13's record and confirmed it did not include a signed consent for services or indication of his participation in development of his treatment plan.

The facility failed to obtain consent for services from Patient #13, and failed to allow him the opportunity to make informed decisions about his care.

3. Patient #15 was a [AGE] year old man who was a patient in the facility from 3/15/15 to 3/26/15, with diagnoses of Schizoaffective Disorder and Borderline Personality Disorder.

A nurses note, dated 3/23/15 at 6:15 PM, documented Patient #15 refused to take an increased dose of Seroquel. The note stated "Pt [patient] verbalizes not being happy about Provider making changes in his medication without talking to him first."

During an interview on 3/30/15 at 3:35 PM, the NP stated she met with the psychiatrist by teleconference 2 times a week, and discussed all patients treatment plans. She confirmed the psychiatrist did not see Patient #15.

During an interview on 4/03/15 at 10:15 AM, the NP reviewed the record and confirmed there was no documentation of Patient #15's involvement in his treatment plan.

Patient #15 was not given the opportunity to be involved in decisions regarding his medication changes.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on observations, record review, and staff interview, it was determined the facility failed to ensure personal privacy was provided for 2 of 7 current patients (#9 and #17) whose care was observed, and had the potential to impact all patients receiving care at the facility. This had the potential to result in patient confidentiality not being protected. Findings include:

1. The unit was locked with double doors that opened into a large hallway. The hallway to the right was short, and had two leather oversized chairs against the wall. The chairs were facing the hallway, and on multiple occaisions providers were observed speaking with family and/or patients. The area was open, close to patient rooms and the locked unit doors. Patients and staff were observed to walk by the individuals in the chairs.

a. On 4/01/15 at 2:00 PM, Patient #9 was observed with his wife, talking to the social worker. He was in a wheelchair, and his wife was sitting in the large leather chair, talking with the social worker in the other chair. Their conversation was overheard by a surveyor, they were discussing Patient #9's pending discharge, and plans for his placement. It was in a high traffic area, staff, visitors, and patients could hear confidential information.

b. During an interview on 4/03/15 at 3:45 PM, the Director of Social Services confirmed that patient and family meetings are often conducted in the sitting area at the end of the hallway.

2. The dining/multipurpose room included a couch, large recliner chairs, a large table surrounded by chairs, a TV, and craft supplies. Meals were served in the room. Group activities were also completed in the room. Patient and provider interviews, evaluations, and other interactions were observed in the room as follows:

a. On 4/01/15 at 4:00 PM, the NP was observed talking with Patient #20, who was admitted to the facility the night before. The conversation was overheard by 3 other patients sitting at a table playing scrabble, as well as, a surveyor, and the other staff that were in the room. The patient was sitting at the dining table, facing the open doorway that went into the hall, and close to the patio area where patients could go outside. The location of the patient and the NP was in a high traffic area. The conversation continued for approximately 30 minutes, during which time the patient disclosed personal information, and stated that he was feeling suicidal and homicidal.

b. During a tour of the facility on 3/30/15 beginning at 2:00 PM, an open notebook was observed on the dining table. The book included patient information related to bathing schedules, oral intake, bowel movements, and other personal information. A P.T. was asked about the book. She stated it was for the techs to record patients' ADL information. She stated it was usually kept in the dining area for the staff to enter their documentation.

During an interview on 4/02/15 at 8:45 AM, Patient #17 stated she did not feel that her privacy was protected. She stated interviews with the providers occurred in the dining area, or "down the hall." She stated her room just had a bed and no chair, so she was not able to talk with anyone in her room.

During an interview on 4/02/15 at 5:00 PM, the NP was asked about her conversation with the patient in the dining room. She confirmed the activity was an "Initial Psychiatric Evaluation," and she stated she had first obtained his permission to talk in that area. The NP then stated she does not have a private area to talk to patients. She stated she routinely met with patients in the dining area.

The facility did not ensure patient privacy and confidentiallity was maintained.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, record review, staff interview, review of staff and patient grievances and review of policies, it was determined the hospital failed to 1) respond to patient and staff written allegations of abuse, 2) investigate serious patient injuries to determine the cause and implement corrective actions, and 3) ensure sufficient numbers of trained staff were available to safely care for patients with behavioral concerns. This resulted in 1 of 3 sample patients (#8) for whom restraints and/or seclusion were used, sustaining bilateral arm fractures and a shatter pelvis, 5 unidentified patients who submitted written grievances experiencing mental anguish and fear, and endangered the health and safety of all patients receiving services at the facility. Findings include:

A facility policy titled "Abuse and neglect policy/Inservice," included the following definitions:

-Physical Abuse includes slapping, hitting, bruising, beating, or any other intentional act that causes someone physical pain, injury, or suffering. Physical abuse also includes excessive forms of restraints use to confine someone against their will.

- Emotional Abuse is threatening, humiliating, or intimidation an individual and causing them emotional pain, distress or anguish. Emotional abuse can be verbal or non-verbal; It includes insults, yelling and threats of harm or isolation.

- Neglect takes place when, intentionally or not, a caregiver fails to support the physical, emotional or social needs of the resident. Neglect can include denying food or medications, health services, or contact with friends and family.

The policy also noted, "The first thing that occurs when a staff member is accused of abusing a resident is that the accused goes on immediate suspension. The administrator (or designee) will investigate the allegation of abuse. If the allegation of abuse is substantiated the appointed member of administration will call and report all of our findings to the Bureau of facility standards. If the suspected abuse case is determined to be abuse the staff member is then dismissed as an employee."

The facility grievance and complaint logs was reviewed. They contained numerous patient and staff complaints that included allegations of abuse. There was no documentation the complaints and grievances were reviewed, acknowledged, or investigated by facility administration. No actions were taken to ensure patients were protected from further abuse. Examples include:

1. Patient #8 was a [AGE] year old male admitted to the facility on [DATE] for care related to dementia, psychosis, HTN, and PTSD. His medical record from 3/06/15 to 3/24/15 was reviewed, as well as, records from ED visits on 3/23/15 and 3/24/15, and admission at an acute care facility were reviewed. Patient #8 was not protected from harm as follows:

a. During an interview on 4/03/15 beginning at 4:00 PM, P.T. H described an event that occurred when she requested assistance from a peer. She stated P.T. D did not like Patient #8. She stated when Patient #8 exhibited aggressive behavior, P.T. D was the first to jump in to restrain him. She described an incident that occurred on Sunday 3/22/15. She stated Patient #8 did not sleep for about a day and a half, and he was agitated. She stated Patient #8 grabbed her by the throat, she brought his hand down and then went to get the assistance from P.T. D. When he entered the room, Patient #8 tried to punch P.T. D, so he grabbed Patient #8 with his arms under Patient #8's armpits and pulled his arms up and outward. Patient #8 attempted to fight him off, and P.T. D held him again in that manner and threw him face down on the bed, with his body on him to pin him down. Patient #8 was held down until after the RN gave him a shot. She stated she felt that P.T. D used excessive force, and reported the incident to the RN on duty. P.T. H stated she has submitted grievances about P.T. D's behavior, but felt no action has been taken by the facility. She also stated she had not received Mandt or any kind of restraint training since her hire at the facility.

P.T. H stated Patient #8 slept most of the day on 3/22/15, and then when he got up, he was noted to be 'shuffling' around, dragging his legs, like he could not put pressure on his legs and not walking like he usually did. P.T. H demonstrated to the surveyors a slow shuffling movement, as well as, the hold maneuver P.T. D used on Patient #8. It was similar to a Full Nelson wrestling move. She said she had filed complaints against P.T. D at least once a week since January, 2015. P.T. H stated P.T. D leaves his 1:1 assignments unsupervised, he picks on patients to provoke behavior, and says things intentionally to make patients angry.

Nurses notes documentation on 3/23/15 at 10:45 AM, noted Patient #8 was observed by facility staff to have a seizure. He was observed to yell, bring his hands upwards about shoulder height, and fall straight back, landing flat on the floor. His seizure lasted approximately 2-2.5 minutes. After the seizure was over, paramedics were called to take him to the ED of an acute care hospital for assessment. He was transported to the hospital by EMS, and was not accompanied by facility staff.

An incident report was not initiated by the RN or the NP which described the seizure, or the transfer to acute care hospital. At the acute care hospital Patient #8 was noted to be poetical, sleepy, and non-verbal. X-Rays of were taken of Patient #8's cervical, lumbar, and thoracic spine. Labs were drawn. He was determined to be stable to be discharged the same day to return to Safe Haven with a tech and the van driver.

The staff [P.T. A] that arrived to pick up Patient #8, was interviewed. She stated that when she removed the pulse oximeter sensor from his finger, he winced in pain. She stated he was unable to stand up, and was transferred to the wheelchair with assistance from the van driver and the ED RN. A physical assessment by an RN was not completed when Patient #8 arrived back at the facility.

Patient #8 was noted to be sleepy, was placed in bed, and remained there throughout the night. Staff documented that night "Pt appeared tired, He did not eat very much. Pt slept thru the night, talking in his sleep. Pt stated in loud voice 'NO, NO' when staff changed his clothes and took vitals."

The P.T. assigned to Patient #8 on 3/24/15 day shift, documented "Pt resting/sleeping AM. Talking restless sleep. Appears [to be] having night terrors (?) talking in sleep saying 'Don't Push Me Down,' 'I hate cigarettes.' Pt stating he is in pain, mentions heart hurting - very lethargic. Ate some lunch, appears more alert. Complaining of cramp pain."

On 3/24/15, at 8:40 AM, P.T. C noted Patient #8 was in bed and was not acting like he normally did and grimaced with movement of his right leg, and when she moved his left arm, he grimaced. The patient was administered Tylenol for pain at 10:30 AM.

Patient #8 was sent back to the ED on 3/24/15, after a text order was received from the MD on 3/24/15 at 2:30 PM, stating "Send pt to the ER for x-rays of bilateral upper & lower extremities d/t [due to] decreased ROM & grimacing [with] movement."

An admission H&P from the receiving hospital, dictated on 3/24/15 at 10:06 PM, noted: "...was brought to the ER in return today, because of significant altered mental status and inability to respond or speak, which he had been doing previously. Upon arrival in the ER, the patient was examined and family notably reported that the patient was repeatedly lifting his left leg and moaning in apparent pain." The H&P noted "Diffuse intermittent bruising across body, Bruising appears to be old and near staging with no large mass effect of bruising noted, but left arm bruise is quite large on the medial and superior aspect of upper arm."

A consultation report, dictated 3/25/15 at 10:02 AM, noted: "...There is a question of seizure versus stroke. His initial workup was negative. He was then taken to the Emergency Department as noted above on [March 24th], where a chest, abdomen, and pelvis CT revealed a comminuted right acetabular fracture. The patient was also found to have rhabdomyolysis and lactic acidosis. He was admitted to the Intensive Care Unit for further monitoring. Orthopedics was consulted. Because of bruising on his upper arms, bilateral Humeri x-rays were performed today, on March 25th, demonstrating bilateral completely displaced two part proximal humerus fractures."

At the hospital where Patient #8 was admitted , in a progress note on 3/25/15 at 6:44 PM, an RN documented a meeting with Patient #8's family and the Orthopedic Surgeon that was held that afternoon at 12:00 PM:

" Dr.[name] met with patient's wife and son. Dr.[name] reviewed injury findings. He explained the injury pattern was strange and not consistent. He explained the significance of the hip fracture. He discussed that the hip fracture is so complex that it will need to be repaired at [another hospital in another state]. He explained that without repair, the patient would need to heal as is. Once fracture is healed, he would anticipate that patient would not have any motion in his extremity and it would continue to be very painful. He would likely be bedridden the remainder of his life. He also reported to wife and son that patient had bilateral humerous fractures. These fractures appear to be in about the same spot that is not consistent with a fall. He explained that both humerus fractures would need repairing with pins and possibly ORIF [Open Reduction and Internal Fixation]. He has also noted some bruising on the right lower extremity and plans to take the patient to radiology for further radiology exams."

An investigation of the restraint, seizure, and care leading to Patient #8's admission at the receiving hospital was not completed by the facility.

b. Patient #8 was not protected from self harm while in seclusion and from the verbal and physical aggression of other patients. Examples include:

* 3/14/15, In a narrative note attached to an Occurrence Report, written by a P.T., indicated Patient #8 was in the dining room. He was noted to have a verbal interchange with another patient, both Patient #8 and the other patient started yelling and hitting each other. Patient #8 was noted to be restrained by a total of 4 staff. He was taken to his room by the 4 staff, and medicated by the RN.

* On 3/16/15, an Emergency Treatment Override Order for Seclusion, dated 3/16/15 and signed by an NP at 9:30 PM, documented Patient #8 was placed in Seclusion for violent/self destructive behavior to himself and others. The NP documented he spoke with Patient #8 through the seclusion room door, and Patient #8 was noted to be highly agitated. He also documented Patient #8 had bloody knuckles related to hitting doors prior to being placed in seclusion. Patient #8 received Haldol 5 mg IM before being placed in seclusion. Nurses notes from 6:15 PM to 9:20 PM included the following documentation: "Pt behavior became more and more agitated. Staff attempt to deescalate. Pt told staff to 'get out' and then pushed staff into the wall. Pt exit seeking then came away from doors and charged staff with his fist doubled up and then punched staff in arm. After he hit staff he went by staff and punched fire door which caused knuckles to bleed. Pt attempted to strike this nurse and grabbed this nurse by wrists. fell ow nurse assisted in removal of pt hands from wrists and escorted pt to seclusion room. Pt resisted and staff continued to escort pt to seclusion. Order for seclusion obtained by provider and Zyprexa 10 mg IM which was unavailable. Provider then ordered Haldol 5 mg. Pt hitting the walls and window on seclusion door. "

* A nurses note, dated 3/18/15 from 5:00 PM to 8:00 PM, described Patient #8's aggressive behavior. "Medication nurse attempted to give patient a PRN by mouth for agitation, this was ineffective, patient refused. While staff continued to attempt to get the patient to de-escalate, he was getting into the face of staff and patients. He was raising his fists at his 1:1 and this nurse. Patient began to shove and hit at this nurse and another staff. After more attempts at trying to de-escalate the patient, the patient was escorted into the seclusion room. Restraint protocol started. PRN medication given IM by RN. Patient banging his fists, feet and shoulders into the walls and door of the seclusion room. Attempts to get the patient to stop were unsuccessful. This continues for over 40 minutes."

The facility failed to ensure Patient #8 was protected from staff abuse, assualt by other patients, and self harm.

2. The following staff and patients grievances and staff interviews include allegations of staff to patient abuse by P.T. D. The written staff and patient grievances did not include evidence of investigation, action, or resolution. They further demonstrate the facility was aware of, yet failed to act, to formal reports of by P.T. D's abusive behavior:

Patient Grievances -

a. One grievance dated 12/15/14, the patient wrote "Nurse [name] and teck [P.T. D] co-insided one with the other to force me into an arguable instance that lead to an anxiety attack." The back section of the form to indicate the grievance was addressed, and resolved, remained blank.

b. A grievance dated 12/15/14, stated "[P.T. D] was near the TV. I walked in sat down on the reclyner (sic) and asked if I could watch TV. And he said 'We are not doin that crap and that's just how it is.' With attitude." The form included a question "How do you want the suggestion/grievance corrected?" The patient wrote "I want him to stop belittling the patients." The back section of the form to indicate the grievance was addressed, and resolved, remained blank.

c. A grievance dated 12/15/14, a patient wrote "I was sitting eating my dinner and [patient name] started talking about his girlfriend. [P.T. D] pops off said something sexual about his girlfriend. That got [patient name] to get very upset & [patient name] said i'll (sic) kill you before you touch my girl. [P.T. D] popped off and said that will get you more time here & [patient name] exploded." The form included a question "How do you want the suggestion/grievance corrected?" The patient wrote "I want him to stop belittling the patients when no one is around. His attitude is horrible." The back section of the form to indicate the grievance was addressed, and resolved, remained blank.

d. Another grievance dated 12/15/14, by a different patient, complained of P.T. D's disrespect to patients when asking about a smoke break. The form included a question "How do you want the suggestion/grievance corrected?" The patient wrote "He need to talke (sic) beter (sic) to clients and tret (sic) us beter (sic). We are people." The back section of the form to indicate the grievance was addressed, and resolved, remained blank.

e. In a grievance dated 3/28/15, a patient wrote "[P.T. D] AM tech - My 2nd day here I complained that he just threw my belongings in my room. He was told not to talk or even look at me but he continued to do so. Today (Saturday) he starts making comments to me 1st thing when I woke up. I've been ignoring it and staying in my room most of the day. I've said thank you to him; have a good lunch, thanks when he lit my cigs, and staying in my room all day to avoid him. Now he's on the phone talking about me, saying I'm the one being an ass to someone. I'm so sad. Today I get to see my service puppy and should be happy. This was approved by [name of NP]. He walked by me while ago saying I can't see my dog. Also another staff let me keep muscle rub, dog treats for tonight & some trail mix. He tore my room up in a search but I was compliant. This harassment is not right. He even brings others ice but not me when I asked." The grievance did not include documentation of an investigation, actions take, or resolution.


Staff Interviews and grievances -

a. P.T. E stated that he did not get along with P.T. D. He stated P.T. D was bossy to residents as well as, other P.T.'s. He stated P.T. D would tease residents, and intentionally push them to the point of eliciting negative behaviors. He described an incident when P.T. D had a 1:1 and while walking down the hall with the resident, tapped him on the far shoulder. The resident would look around as if looking to see who was tapping him. He stated the resident thought he was going crazy.

P.T.E described another incident in 2/2015 when a resident was acting out, and he demonstrated how P.T. D grabbed the resident around his arms from behind, and sat him on the floor forcibly.

P.T. E was questioned as to who was in charge of nursing at the hospital, and he stated he did not know. He said he knew who was the Administrator, but had never met the CNO, and did not know if the hospital had one.

b. Submitted by P.T. E on 3/30/15: "My first Saturday working at Safe Haven, I watched P.T. D walk behind patients, tap them on shoulder and move to other side or kind of hide from them. I have also heard him tell a patient to "Shut up, you are annoying." P.T. D pawns off his 1:1's a lot more often than he should, going out to sneak off for smokes with the girls. Flirts a little with co-workers. This occurred on 2/07/15. P.T. D and I also on this day argued a little because he came up to me, pointed and told me I needed to catch up on Q 15's (every 15 minute patient checks) and to do it now. I asked him to please not delegate to me but to ask me to do something. That's when he walked away and said 'whatever.' Before working on this day I wanted to change schedule and work the weekends. After working I changed my mind and almost decided to just quit my job. He teases a lot of our patients and can be pretty inappropriate towards both patients and co-workers with the jokes and teasing." As of 5:00 PM on 4/03/15 no action had been by the facility to investigate the allegations and protect patients from potential abuse or mistreatment.

c. Submitted by P.T. I, on 3/30/15: In the allegations P.T. I noted P.T. D engaged in inappropriate sexual behavior towards her, which made her feel intimidated and afraid to come to work. She further stated "...on March 21st I was with a patient 1:1 and I asked P.T. D to take a patient to the restroom and he took the patient and left her in the hall and left outside. P.T. D is verbally abusive to patients, saying things like 'If you don't respect me, I will take away all your privileges from you." As of 5:00 PM on 4/03/15 no action had been by the facility to investigate the allegations and protect patients from potential abuse, neglect, or mistreatment.

During an interview on 4/03/15 at 5:00 PM, the Co-Owner confirmed the grievances had not been addressed, and was not able to provide an explanation for the failure of the facility to investigate, take action, and resolve the grievances.


The facility did not ensure patients were protected from abuse.


3. A policy "Staffing of Nursing Care, Acuity Based," effective 1/04, stated "To provide safe, effective nursing care designed to support improvements and innovations in nursing practice based on both the needs of the patients to be served and the mission statement. The plan supports both standards of nursing practice and nursing standards of care. The CNO of Safe Haven is responsible and accountable to ensure that consistent standards are utilized. This plan provides an overview of the unit, which includes staffing plans based on acuity data and core staffing date. Staffing is based upon patient census and acuity. Based on census and patient acuity, the needs of the unit are evaluated on a shift or partial shift basis by the Staffing Coordinator, in collaboration with the charge nurse, in order to provide optimal patient care that is fiscally sound."

The following algorithm was included in the policy based on patient census:

a. Day shift staffing requirements

-1 RN per shift

-1 to 5 patients, 1 P.T.

-6 to 8 patients, 1.5 P.T.

-9 to 13 patients, 2 P.T.s

-14 patients, 3 P.T.s

-1 to 6 patients, 0 LPN

-7 to 10 patients, 1 LPN

-11-14 patients, 1.33 LPNs

b. Night shift staffing requirements

-1 RN per shift

-1 to 8 patients, 1 P.T.

-9 to 14 patients, 1.5 P.T.s

-1 to 8 patients, 0 LPN

-9 to 14 patients, 1 LPN

The algorithm in the policy stated core staffing consisted of a minimum of 1 RN and 1 P.T. The policy stated, "Psych tech [psychiatric technicians] shifts- if the staffing ladder accounts for 1.5 aides, this means that one full 12 hour shift is approved and one 6 hour shift is approved. The hours may be divided amongst the scheduled Psych tech staff at the direction of the Charge RN as long as the hours stay within the approved total of 18 hours."

Additionally, the policy stated "LPN shifts- if the staffing ladder accounts for 1.33 LPN's, this means that one full 8 hour shift from 0700- 1500 [7:00 AM to 3:00 PM] is approved. At a census of 11 the LPN staff may then cover the remaining four hours of the 12 hour shift to 1900 [7:00PM]. The hours may not be allotted any other way."

Assignment sheets were done for each 12 hour shift, day and night. The assignment sheet included sections for patient's names, level of monitoring, names of P.T.s working, and 2 hour time periods for the shift. The name of the RN in charge and the date were listed at the top of the form, it also differentiated whether it was the assignments for day or night shift. The bottom of the assignment sheet also included a section with an algorithm. The algorithm was used for staffing the facility with P.T.s depending on the census.

The section for P.T.s was numbered 1 through 5, with their names written next to the numbers. The number, corresponding to the P.T., was written in the columns broken down into 2 hour time periods for the shift. The 2 hour time period columns corresponded to patient names. For example: P.T. 1 would be assigned from 6:00 AM to 8:00 AM with one patient, then from 8:00 AM to 10:00 AM P.T. 1 would be assigned to another patient. P.T.'s would not be assigned to 1 patient for the entire 12 hour shift. According to the assignment sheets reviewed they would rotate between the patients.

The algorithm at the bottom of the assignment sheet was used for determining staffing of the facility. The algorithm for staffing P.T.s was based on census, rather than acuity. The algorithm was listed as follows:

- Patient census 0, P.T. 0 hours

- Patient census 1, P.T. 8 hours

- Patient census 2-5, P.T. 12 hours

- Patient census 6-10, P.T. 16 hours

- Patient census 11-12, P.T. 24 hours

- Patient census 13-14, P.T. 26 hours

The policy, assignment sheet, and algorithms did not include using aides from the adjoining SNF when additional staff was required for patient restraint.

A maximum of 14 patients would be admitted at one time. If a patient was being monitored as a 1:1 (close monitoring of the patient was required and the assigned P.T. must be within arm's reach of the patient at all times), 1 tech would be assigned for monitoring the patient and was not included in the algorithm.

A policy, "Suicide/Homicide Precautions Protocol," revised 10/12, stated a precaution level was assigned for the protection of patients requiring a safety intervention. The following precaution levels were identified and defined:

-15 minute checks: Patient was observed every 15 minutes for safety

-Line of sight (LOS): Keep patient in the line of sight at all times

-1:1 monitoring: Observation with 1:1 contact at all times

On 12/05/14 at 4:30 AM, an "Occurrence Report," completed by the RN on duty, documented a patient had an altercation with his roommate. The report included a nurses note documenting the patient was placed on "1:1/LOS." The policy did not include a definition for "1:1/LOS."

During an interview on 4/01/15 at 4:55 PM, RN C confirmed an assignment sheet was to be filled out for each shift. She stated an LPN was scheduled for medications if the patient census was greater than 8, otherwise the LPN worked 7:00 AM to 11:00 AM and came back and worked 5:00 PM to 9:00 PM. RN C stated she coordinated the staffing of P.T.s. RN C stated P.T.s worked a 12 hour shift, but depending on the algorithm they may work 4 hours, 8 hours, or the full 12 hours. She explained when 16 hours were allotted based on census, 1 P.T. would work 12 hours and another P.T. would work for 4 hours. RN C stated staffing of P.T.s was not acuity or behaviorally based, but is based on the algorithm.

During an interview on 4/02/15 at 5:05 PM, RN B confirmed the algorithm was what she used to schedule the P.T. hours. She further confirmed staffing for P.T.s was based on census and algorithm, it was not acuity or behaviorally based.

Use of the staffing algorithm, without consideration of patient acuity was not sufficient to ensure patient needs were met, as follows:

On 3/07/15 at 3:15 PM, a P.T. note attached to an "Occurrence Report," stated Patient #8 was aggressive toward another patient and P.T.s were able to remove him from the day room. The note also said the RN had called for all male staff on the attached SNF. Patient #8's record also included a nurses note, documented on 3/07/15 at 3:45 PM, which stated he was physically aggressive and was redirected to his room with the assist of family and staff. Patient #8's record did not include documentation of the actions which were necessary to "redirect" Patient #8 to his room.

On 3/08/15 at 2:00 PM, an "Occurrence Report," completed by the RN on duty documented Patient #8 was aggressive to another patient and that P.T.s were unable to get him moved out of the day room. The RN documented she called for any male aide on the attached SNF to come to the psychiatric hospital.

During an observation on 4/02/15 at 12:00 PM, 5 patients were currently in the facility. In the dayroom there were 2 patients and 2 P.T.s present. One patient was in her assigned room, and 1 patient was observed walking in the hall. Another P.T. was observed in the nursing station behind a locked door. No RN was observed on the unit. After approximately 5 minutes, the RN was observed entering the patient unit from the other side of the locked doors.

An interview was conducted with P.T. E at 12:10 PM on 4/02/15. He stated there were 5 patients in the hospital and 3 of the patients were on 1:1 monitoring. P.T. E stated he did not feel staffing was adequate that day because only 3 P.T.s were scheduled to work. Three patients required 1:1 monitoring, therefore, the 2 remaining patients were not assigned a P.T.

During an interview on 4/02/15 at 5:05 PM, RN B stated she was a concerned about safety at the facility. She stated staffing was based on census rather than acuity. Therefore, additional staff were not added when 1 or more patients exhibited behaviors that required close observation and possible intervention, to prevent injury to themselves or others.

Further, Patient #13's record documented he was a patient in the hospital from 1/01/15 to 1/05/15, with diagnoses of psychosis and depression. His record included a social service progress note, dated 1/05/15. The note stated "When SS discussed discharges with [NP] she reported that due to staffing [patient] was being discharged ."

During an interview on 4/03/15 at 2:45 PM, the SS Assistant who wrote the note stated she remembered the conversation with the NP. She stated during the Treatment Team meeting it was determined there was not enough staff to take care of the number of patients currently in the hospital, therefore someone had to be discharged . She stated Patient #13 was closest to his planned discharge date so he was the one to be discharged .

The facility failed to ensure staffing levels were sufficient to ensure individual patient's needs, including safety, were met.

3. Also refer to A395 as it relates immediate jeopardy to patients' health and safety as a result of the facility's failure to provide health services necessary to prevent the physical deterioration and subsequent death of 3 patients.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and staff interview, it was determined the facility failed to ensure methods of restraint and seclusion were only imposed to ensure the immediate physical safety of the patient or others and/or were discontinued at the earliest possible time for 2 of 3 patients (#4 and #15) who were restrained and whose records were reviewed. This resulted in the potential for the unnecessary use of restraint. Findings include:

1. Patient #15 was a [AGE] year old man admitted to the facility on [DATE], with diagnoses of Schizoaffective Disorder and Borderline Personality Disorder.

The facility's policy, "Refusal of Medications and Treatments-Treatment Override," effective 6/19/11, stated "admitted patients have the right to refuse specific modes of treatment. Possessing this right, they are entitled to due process proceedings prior to being administered medication treatment against their will, unless involuntary treatment is necessary because of emergency. During hospitalization , involuntary administration of medication treatment may be used when an emergency exists or a patient is deemed to be gravely disabled or dangerous. Override of a patient's treatment refusal can occur provided certain conditions are met."

Patient #15's record included documentation of medication administration under "show of force" by hospital staff. The incident was documented as follows:

-A nurses note, dated 3/17/15 at 11:10 AM, and signed by the RN, stated "Due to his agitation, this nurse was instructed to attempt to get the patient to take oral Geodon. Patient refused. At that time, the Provider [name of NP] left the room and got a show of force (men) and the medication nurse [name of nurse] who had some Geodon injectable. After a short explanation, the patient agreed to take the PO pill. However, even though the patient was asked to open his mouth and show that he had indeed swallowed the pill, after a short period of time, the patient had removed the medication from his mouth and threw it on the table. The Provider, again, left the room to get a show of force at which time the patient was convinced to take the injection. He was unhappy about this."

Patient #15's record did not document an emergency situation in which he was a danger to himself or others, at the time of the medication administration.

During an interview on 4/01/15 at 4:45 PM, the RN reviewed Patient #15's record and confirmed it documented the use of intimidation related to medication administration.

The facility failed to ensure Patient #13's right to refuse medication, and to be free from intimidation.





2. Patient #4 was a [AGE] year old male admitted on [DATE] to 3/16/15, from an ALF. His psychiatric diagnoses included schizophrenia, depression, and mild mental disability.

Patient #4's record included documentation of physical restraint by staff for verbal aggression.

A nurses note signed by the RN, dated 3/08/15 at 8:00 AM, documented Patient #4 became agitated and started yelling at other patients and staff. The RN documented Patient #4 was threatening a peer with physical aggression and was physically redirected to his room. There was no documentation of what preceeded Patient #4's agitation and verbal aggression towards his peer.

The RN documented she was unable to verbally redirect Patient #4 . It was unclear whether the RN attempted verbal redirection prior to his agitation or after he was physically redirected to his room. There was no documentation, other than verbal redirection, to indicate non-physical interventions were attempted to address Patient #4's negative behaviors prior to use of a physical restraint.

During an interview on 4/01/15 at 3:00 PM, the RN reviewed the record and confirmed physical redirection was considered a restraint. She confirmed there was no documentation related to what preceeded his agitation and yelling. The RN confirmed the record was not clear whether any other interventions were attempted prior to restraining Patient #4.

Patient #4's record did not include documentation of non-physical interventions attempted prior to physical restraint.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0164
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of patient records, policies, and staff interviews, it was determined the facility failed to ensure less restrictive interventions were attempted before implementing physical restraints and seclusion for 2 of 3 patients (#4 and #8) for whom seclusion and/or physical restraints were used. This resulted in a lack of appropriate assessment to determine if a less restrictive intervention may have prevented unnecessary use of restraint and or seclusion. Findings include:

1. Patient #8's record documented a [AGE] year old male who was at the facility from 3/06/15 to 3/24/15 for psychiatric services related to dementia, and psychosis with behavioral disturbances. Additional diagnoses included HTN and PTSD.

a. Patient #8 was physically restrained and secluded on multiple incidents without evidence of less restrictive interventions used or considered. Examples include:


- On 3/07/15 at 9:00 AM, an "Occurrence Report," written by the RN on duty, noted Patient #8 hit a staff member and another patient. He was noted to be restrained by P.T. D. Additionally, the Occurrence Report documented Patient #8 had another physical altercation with P.T. D, his behavior escalated, and he struck a patient. The report documented he was physically restrained, and administered an IM injection. A corresponding P.T. note, untimed, stated "Pt. was pacing the floor-fist clenched tight - yelling out, threatening hands, male tech tryed (sic) to get him under a more controlled mind - Pt swung his elbow up and hit the tech on his jaw." Patient #8 was placed on 1:1 status, and remained on that status throughout his stay at the facility. Patient #8's record did not include documentation of the type of restraint used to restrain Patient #8 for the IM injection. Patient #8's record did not include documentation of less restrictive alternatives tried or considered prior to the use of restraint.


-A P.T. note, attached to an "Occurrence Report" dated 3/07/15 at 3:15 PM stated Patient #8 was aggressive toward another patient and P.T.s were able to remove him from the day room. The note also said the RN had called for all male staff on the attached SNF. Patient #8's record also included a nurses note, documented on 3/07/15 at 3:45 PM, which stated he was physically aggressive and was redirected to his room with the assist of family and staff. He was then given an injection of Geodon IM 20 mg. A second P.T. note attached to the Occurrence Report, documented by P.T D on 3/07/15 at 4:00 PM, stated "I was walking in the hall to the front door cause the door bell rang when [Patient #8] swung at me, I blocked that hit, then after he elbowed me in chin." Patient #8's record did not include documentation of the actions necessary to "redirect" Patient #8 to his room or if he was blocked from leaving the room. Additionally his record did not include documentation of the type of restraint used to restrain Patient #8 for the IM injection. Patient #8's record did not include documentation of less restrictive alternatives tried or considered prior to the use of restraint.


- On 3/08/15, an "Occurrence Report," written by the RN on duty, noted at 9:30-10:30 AM, Patient #8 became agitated and was threatening P.T. D. The report indicated P.T. D performed a Mandt hold on Patient #8, and then 4 employees were required to assist him back to his room. A nurses note documented at 10:50 AM on 3/08/15, also stated Patient #8 continued to "go after staff" and was given an IM injection of 20 mg Geodon. The nurses note went on to say that after the injection Patient #8 continued to require physical redirection by staff. There was no documentation of antecedents to the behaviors that occurred prior to Patient #8 becoming agitated and subsequently, aggressive. A nurses note documented on the same date at 11:00 AM, stated Patient #8 was "physically assisted" to the seclusion room. Patient #8's record did not include documentation of less restrictive alternatives tried or considered prior to the use of restraint.


- An "Occurrence Report," dated 3/08/15 at 2:00 PM, was completed by the RN on duty. The RN documented Patient #8 was aggressive to another patient and that P.T.s were able to get him moved out of the day room. The RN documented she called for any male aide on the attached SNF. Patient #8 was given an injection but did not calm down until 5:00 PM according to the documentation on the Report. Patient #8's record did not include documentation of less restrictive alternatives tried or considered prior to the use of restraint, required to give the IM injection.


- On 3/12/15, Patient #8's MAR indicated he was administered Geodon 20 mg IM at 3:00 PM. The P.T. narrative indicated Patient #8 was visited by his son, and complained of pain, for which he was medicated with Tylenol at 5:00 PM. A nurses note, also documented at 3:00 PM on 3/12/15, stated "Patient seems to be agitating another patient, which in turn seems to agitate the patient. Patient pacing and getting louder. Medicated per MAR." Patient #8's record did not include documentation of less restrictive alternatives tried or considered prior to the use of restraint, required to give the IM injection.


- On 3/14/15, an Occurrence Report, written by the RN on duty, noted at 4:00 PM, Patient #8 was involved in a physical altercation with another patient. The report documented he was physically redirected by staff, and was assisted to his room. In his room he began to swing at staff, was restrained on a total of 4 times, and administered Zyprexa IM. In a narrative note attached to Occurrence Report, written by a P.T., indicated Patient #8 was in the dining room. He was noted to have a verbal interchange with another patient, both Patient #8 and the other patient started yelling and hitting each other. There was no documentation in Patient #8's record of less restrictive interventions tried or considered prior to the use of restraints.


-A P.T. note, documented on 3/21/15 at 6:30 AM, indicated Patient #8 was agitated and P.T. D came to help and Patient #8 was restrained twice. Patient #8's record did not include documentation of less restrictive alternatives tried or considered prior to the use of restraint.


b. Patient #8's record did not include evidence the above incidents were thoroughly investigated and causal analyses completed. There was no documentation of actions taken or follow up completed. Patient #8's record did not include a treatment and/or care plan. Individualized interventions directed at reducing or eliminating the need for behavioral restraints and seclusion were not developed and implemented for Patient #8. These failed practices precluded the facility from taking proactive steps to reduce the number of restraints and seclusion and ensure less restrictive interventions were utilized for Patient #8.


During an interview on 4/02/15 beginning at 10:45 AM, the NP reviewed Patient #8's record and confirmed there was no documentation of less restrictive interventions before restraints were implemented. She stated male staff members would increase Patient #8's agression, and confirmed the male staff were summoned to assist when Patient #8's agitation escalated.

Patient #8 was physically restrained and placed in seclusion without evidence that less restrictive interventions tried or considered.


2. Patient #4 was a [AGE] year old male admitted on [DATE] to 3/16/15, from an ALF. His psychiatric diagnoses included schizophrenia, depression, and mild mental disability.

Patient #4's record included the following documented incidents of physical restraint.

A nurses note signed by the RN, dated 3/08/15 at 8:00 AM, documented Patient #4 became agitated and started yelling at other patients and staff. The RN documented Patient #4 was verbally threatening a peer with physical aggression. Patient #4 was physically removed to his room. There was no documentation what preceeded Patient #4's agitation and verbal aggression towards his peer. Additionally, there was no documentation how the RN intervened prior to physically restraining Patient #4.

A nurses note signed by the RN, dated 3/14/15 at 4:05 PM, documented Patient #4 was yelling and shaking his fist at peers. There was no documentation what preceeded Patient #4's yelling and threatening manner. The RN documented Patient #4 was physically seperated from his peer. There was no documentation of interventions the RN attempted to address Patient #4's verbal aggression before he was physically restrained.

Patient #4's record did not include a nursing or treatment care plan for interventions related to his verbal aggression and agitation.

During an interview on 4/01/15 at 3:00 PM, RN C reviewed Patient #4's record and confirmed there was no documentation of less restrictive interventions before restraints were implemented

Patient #4 was physically restrained without evidence that less restrictive interventions tried or considered.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policy, record review, and staff interview, it was determined the facility failed to ensure the patients' POCs were modified to reflect the use of restraint or seclusion for 3 of 3 patients (#4, #8 and #15) for whom restraints or seclusion were used. This resulted in a lack of direction to staff regarding ways to decrease restraint/seclusion usage and ways to keep the patient safe. Findings include:

1. Patient #8's record documented a [AGE] year old male who was at the facility from 3/06/15 to 3/24/15 for psychiatric services related to dementia, and psychosis with behavioral disturbances. Additional diagnoses included HTN and PTSD. He experienced the following incidents of restraint and seclusion:

- On 3/07/15 at 9:00 AM, an "Occurrence Report," written by the RN on duty, noted Patient #8 hit a staff member and another patient. He was noted to be restrained by P.T. D. Additionally, the Occurrence Report documented Patient #8 had another physical altercation with P.T. D, his behavior escalated, and he struck a patient. The report documented he was physically restrained, and administered an IM injection. Patient #8 was placed on 1:1 status, and remained on that status throughout his stay at the facility. The types of restraints used by staff to restrain Patient #8 were not specified.

-A tech note attached to an "Occurrence Report" dated 3/07/15 at 3:15 PM stated Patient #8 was aggressive toward another patient and P.T.s were able to remove him from the day room. The note also said the RN had called for all male staff on the attached SNF. Patient #8's record also included a nurses note, documented on 3/07/15 at 3:45 PM, which stated he was physically aggressive and was redirected to his room with the assist of family and staff. He was then given an injection of Geodon IM 20 mg. Patient #8's record did not include documentation of the actions were necessary to "redirect" Patient #8 to his room. Additionally his record did not include documentation of the type of restraint used to restrain Patient #8 for the IM injection.

- On 3/08/15, an "Occurrence Report," written by the RN on duty, noted at 9:30-10:30 AM, Patient #8 became agitated and was threatening P.T. D. The report indicated P.T. D performed a Mandt hold on Patient #8, and then 4 employees were required to assist him back to his room. There was no documentation in Patient #8's record that described the type of Mandt restraint used. A nurses note documented at 10:50 AM on 3/08/15 also stated Patient #8 continued to "go after staff" and was given an IM injection of 20 mg Geodon. The type of restraint used to allow the IM injection was not specified. The nurses note went on to say that after the injection Patient #8 continued to require physical redirection by staff. There was no documentation to describe the "redirection " used by staff.

- An "Occurrence Report," dated 3/08/15 at 2:00 PM, was completed by the RN on duty. The RN documented Patient #8 was aggressive to another patient and that P.T.s were able to get him moved out of the day room. The RN documented she called for any male aide on the attached SNF to come to the psychiatric hospital. Patient #8 was given an injection but did not calm down until 5:00 PM according to the documentation on the Report. The type of restraint used to allow for the IM injection and actions of the SNF male aide were not described.

- On 3/12/15, Patient #8's MAR indicated he was administered Geodon 20 mg IM at 3:00 PM. The P.T. narrative indicated Patient #8 was visited by his son, and complained of pain, for which he was medicated with Tylenol at 5:00 PM. A nurses note, also documented at 3:00 PM on 3/12/15, stated "Patient seems to be agitating another patient, which in turn seems to agitate the patient. Patient pacing and getting louder. Medicated per MAR." The type of restraint used to restrain Patient #8 to allow the IM injection, was not documented.

- On 3/14/15, an "Occurrence Report", written by the RN on duty, noted at 4:00 PM, Patient #8 was involved in a physical altercation with another patient. The report documented he was physically redirected by staff, and was assisted to his room. In his room he began to swing at staff, was restrained on a total of 4 occasions, and administered Zyprexa IM. There was no documentation to describe the "redirection" used by staff or the technique used to assist him to his room. Additionally, there was no documentation describing the type of restraints used the 4 restraints.

-On 3/16/15 Patient #8's MAR stated he received Haldol 5 mg IM at 8:55 PM. His record included an "Emergency Treatment Override Orders for Seclusion," completed by the NP and RN at 9:30 PM. He was noted to be agitated, hit the staff, punched the fire door, his knuckles were bleeding. A nurses note, dated 3/16/15 at 7:40 PM indicated Patient #8 He was escorted to the seclusion room after grabbing the RN's wrist. The nurses note indicated Patient #8 resisted and staff continued to escort him to seclusion. It further stated "Staff into seclusion room and stabilized pts arms" and Haldol injection given. There was no documentation in Patient #8's record that described how staff "escorted" him to the seclusion room or the type of restraint used to stabilize his arms.

- A 3/18/15 at 6:05 PM Emergency Treatment Override Orders for Hold and Restraint form, indicated Patient #8 was physically restrained using a "Staff Hold" to allow for an IM injection of Geodon 20 mg and placement in seclusion. A tech note documented at the time of the incident, stated Patient #8 was agitated and combative at the beginning of the shift and that he was getting worked up from other patients. There was no documentation describing the type of restraint hold used.

-A tech note, documented on 3/21/15 at 6:30 AM, indicated Patient #8 was agitated and P.T. D came to help and Patient #8 was restrained twice. The type of restraints used were not described.

The NP was interviewed on 4/03/15 beginning at 10:30 AM. She stated patients did not have nursing POCs or treatment plans. She stated it was the CNO's job to develop those plans. She said since the CNO resigned in January, 2015, POCs and treatment plans were not developed.

Patient #8 did not have a POC or treatment plan to modify and incorporate restraints and seclusion into.





2. Patient #15 was a [AGE] year old man who was a patient in the facility from 3/15/15 to 3/26/15, with diagnoses of Schizoaffective Disorder and Borderline Personality Disorder.

Patient #15's record included "EMERGENCY TREATMENT OVER RIDE ORDERS FOR HOLD AND RESTRAINT" dated 3/17/15 at 12:45 PM, signed by RN C and the NP. The form documented "seclusion room"
as the type of physical restraint.

Patient #15's record documented he was placed in the facility's seclusion room on 3/17/15, from 12:45 to 1:45 PM.

Patient #15's record did not include documentation of updates to his POC during or after the use of seclusion. Patient #15's record did not include a nursing or a treatment plan of care.

During an interview on 4/01/15 at 4:45 PM, RN C reviewed Patient #15's record and confirmed it did not include a nursing or treatment plan of care, therefore, there was no update in his plan of care related to the use of seclusion.

The facility failed to ensure a plan of care for Patient #15 was developed and updated to include use of seclusion.






3. Patient #4 was a [AGE] year old male admitted on [DATE] to 3/16/15, from an ALF. His psychiatric diagnoses included schizophrenia, depression, and mild mental disability.

Patient #4's record included the following documented incidents of physical restraint.

A nurses note signed by the RN, dated 3/08/15 at 8:00 AM, documented Patient #4 became agitated and started yelling at other patients and staff. The RN documented Patient #4 was verbally threatening a peer with physical aggression. Patient #4 was physically removed to his room. There was no documentation what preceeded Patient #4's agitation and verbal aggression towards his peer. Additionally, there was no documentation how the RN intervened prior to physically restraining Patient #4.

A nurses note signed by the RN, dated 3/14/15 at 4:05 PM, documented Patient #4 was yelling and shaking his fist at peers. There was no documentation what preceeded Patient #4's yelling and threatening manner. The RN documented Patient #4 was physically seperated from his peer. There was no documentation of interventions the RN attempted to address Patient #4's verbal aggression before he was physically restrained.

Patient #4's record did not include a nursing POC or treatment plan.

During an interview on 4/01/15 at 3:00 PM, RN C reviewed the record and confirmed there were no nursing or treatment care plans for Patient #4, therefore it was not updated.

Patient #4's record did not have a care or treatment plan to address his physical and verbal aggression.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of patient records, facility policy, and staff interviews, it was determined the facility failed to ensure physician orders were obtained for the use of restraint for 2 of 3 sample patients (#4 and #8) who were restrained or placed in seclusion. This resulted in patients being restrained and secluded without evidence of physician oversight and input. Findings include:

A facility policy "Restraints," effective 1/25/12, stated "All seclusion and restraint shall be ordered by a physician credentialed by Safe Haven Hospital." No orders were found for the following restraints:

1. Patient #8's record documented a [AGE] year old male who was at the facility from 3/06/15 to 3/24/15 for psychiatric services related to dementia, and psychosis with behavioral disturbances. Additional diagnoses included HTN and PTSD.

Patient #8 experienced the following incidents of restraint, for which a LIP or physician order was not found in his record.

- On 3/07/15 at 9:00 AM, an "Occurrence Report," written by the RN on duty, noted Patient #8 hit a staff member and another patient. He was noted to be restrained by P.T. D. Additionally, the Occurrence Report documented Patient #8 had another physical altercation with P.T. D, his behavior escalated, and he struck a patient. The report documented he was physically restrained, and administered an IM injection. Patient #8 was placed on 1:1 status, and remained on that status throughout his stay at the facility. The types of restraints used by staff to restrain Patient #8 were not specified.

-A P.T. note attached to an "Occurrence Report" dated 3/07/15 at 3:15 PM stated Patient #8 was aggressive toward another patient and P.T.s were able to remove him from the day room. The note also said the RN had called for all male staff on the attached SNF. Patient #8's record also included a nurses note, documented on 3/07/15 at 3:45 PM, which stated he was physically aggressive and was redirected to his room with the assist of family and staff. He was then given an injection of Geodon IM 20 mg. Patient #8's record did not include documentation of the actions were necessary to "redirect" Patient #8 to his room. Additionally his record did not include documentation of the type of restraint used to restrain Patient #8 for the IM injection.

- On 3/08/15, an "Occurrence Report," written by the RN on duty, noted at 9:30-10:30 AM, Patient #8 became agitated and was threatening P.T. D. The report indicated P.T. D performed a Mandt hold on Patient #8, and then 4 employees were required to assist him back to his room. There was no documentation in Patient #8's record that described the type of Mandt restraint used. A nurses note documented at 10:50 AM on 3/08/15 also stated Patient #8 continued to "go after staff" and was given an IM injection of 20 mg Geodon. The type of restraint used to allow the IM injection was not specified. The nurses note went on to say that after the injection Patient #8 continued to require physical redirection by staff. There was no documentation to describe the "redirection " used by staff.

- An "Occurrence Report," dated 3/08/15 at 2:00 PM, was completed by the RN on duty. The RN documented Patient #8 was aggressive to another patient and that P.T.s were able to get him moved out of the day room. The RN documented she called for any male aide on the attached SNF to come to the psychiatric hospital. Patient #8 was given an injection but did not calm down until 5:00 PM according to the documentation on the Report. The type of restraint used to allow for the IM injection and actions of the SNF male aide were not described.

- On 3/12/15, Patient #8's MAR indicated he was administered Geodon 20 mg IM at 3:00 PM. The P.T. narrative indicated Patient #8 was visited by his son, and complained of pain, for which he was medicated with Tylenol at 5:00 PM. A nurses note, also documented at 3:00 PM on 3/12/15, stated "Patient seems to be agitating another patient, which in turn seems to agitate the patient. Patient pacing and getting louder. Medicated per MAR." The type of restraint used to restrain Patient #8 to allow the IM injection, was not documented.

- On 3/14/15, an "Occurrence Report", written by the RN on duty, noted at 4:00 PM, Patient #8 was involved in a physical altercation with another patient. The report documented he was physically redirected by staff, and was assisted to his room. In his room he began to swing at staff, was restrained on a total of 4 occasions, and administered Zyprexa IM. There was no documentation to describe the "redirection" used by staff or the technique used to assist him to his room. Additionally, there was no documentation describing the type of restraints used the 4 times he was restrained in his room.

-On 3/16/15 Patient #8's MAR stated he received Haldol 5 mg IM at 8:55 PM. His record included an "Emergency Treatment Override Orders for Seclusion," completed by the NP and RN at 9:30 PM. He was noted to be agitated, hit the staff, punched the fire door, his knuckles were bleeding. A nurses note, dated 3/16/15 at 7:40 PM indicated Patient #8 He was escorted to the seclusion room after grabbing the RN's wrist. The nurses note indicated Patient #8 resisted and staff continued to escort him to seclusion. It further stated "Staff into seclusion room and stabilized pts arms" and Haldol injection given. There was no documentation in Patient #8's record that described how staff "escorted" him to the seclusion room or the type of restraint used to stabilize his arms.

- A 3/18/15 at 6:05 PM Emergency Treatment Override Orders for Hold and Restraint form, indicated Patient #8 was physically restrained using a "Staff Hold" to allow for an IM injection of Geodon 20 mg and placement in seclusion. A tech note documented at the time of the incident, stated Patient #8 was agitated and combative at the beginning of the shift and that he was getting worked up from other patients. There was no documentation describing the type of restraint hold used.

-A P.T. note, documented on 3/21/15 at 6:30 AM, indicated Patient #8 was agitated and P.T. D came to help and Patient #8 was restrained twice. The type of restraints used were not described.

During an interview on 4/02/15 at 10:45 AM, the NP reviewed Patient #8's record and confirmed there were no orders for the incidents that physical restraints were implemented. She stated she was not at the facility each time the restraint incidents occurred.

Patient #8 was restrained on multiple occassions without physician authorization.





2. Patient #4 was a [AGE] year old male admitted on [DATE] to 3/16/15, from an ALF. His psychiatric diagnoses included schizophrenia, depression, and mild mental disability.

Patient #4's record included documentation of physical restraint by staff for verbal aggression.

A nurses note signed by the RN, dated 3/08/15 at 8:00 AM, documented Patient #4 became agitated and started yelling at other patients and staff. The RN documented Patient #4 was threatening a peer with physical aggression. There was no documentation what preceeded Patient #4's agitation and verbal aggression towards his peer. Patient #4 was physically restrained and taken to his room by staff.

Patient #4's record did not include orders for physical restraints. Additionally, there was no documentation of the type of restraint or hold which was used by staff when he was moved to his room.

During an interview on 4/01/15 at 3:00 PM, the RN reviewed the record and confirmed the documentation of physical restraint. She stated physically moving a patient to their room was considered a restraint. The RN confirmed there were no orders for the physical restraint.

Patient #4's record did not include orders for physical restraint used by staff members.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of patient records, facility policies, and staff interview, it was determined the facility failed to ensure patients were evaluated by an authorized trained practitioner within 1 hour of the initiation of restraint or seclusion for 2 of 3 patients (#4 and #8), who were restrained and whose records were reviewed. The failure to evaluate patients that were restrained or placed in seclulsion had the potential for missed opportunities to identify factors that may have contributed to the negative behavior, as well as, identification of immediate medical or behavioral needs. Findings include:

1. Patient #8's record documented a [AGE] year old male who was at the facility from 3/06/15 to 3/24/15 for psychiatric services related to dementia, and psychosis with behavioral disturbances. Additional diagnoses included HTN and PTSD.

Patient #8 experienced the following incidents of restraint, for which a one hour face to face medical and psychiatric assessment was not documented.

- On 3/07/15 at 9:00 AM, an "Occurrence Report," written by the RN on duty, noted Patient #8 hit a staff member and another patient. He was noted to be restrained by P.T. D. Additionally, the Occurrence Report documented Patient #8 had another physical altercation with P.T. D, his behavior escalated, and he struck a patient. The report documented he was physically restrained, and administered an IM injection. Patient #8 was placed on 1:1 status, and remained on that status throughout his stay at the facility. The types of restraints used by staff to restrain Patient #8 were not specified. There was no documentation of a one hour face to face assessment for the two restraint incidents.

-A tech note attached to an "Occurrence Report" dated 3/07/15 at 3:15 PM stated Patient #8 was aggressive toward another patient and P.T.s were able to remove him from the day room. The note also said the RN had called for all male staff on the attached SNF. Patient #8's record also included a nurses note, documented on 3/07/15 at 3:45 PM, which stated he was physically aggressive and was redirected to his room with the assist of family and staff. He was then given an injection of Geodon IM 20 mg. Patient #8's record did not include documentation of the actions were necessary to "redirect" Patient #8 to his room. Additionally his record did not include documentation of the type of restraint used to restrain Patient #8 for the IM injection. There was no documentation of a one hour face to face assessment for the two restraint incidents.

- On 3/08/15, an "Occurrence Report," written by the RN on duty, noted at 9:30-10:30 AM, Patient #8 became agitated and was threatening P.T. D. The report indicated P.T. D performed a Mandt hold on Patient #8, and then 4 employees were required to assist him back to his room. There was no documentation in Patient #8's record that described the type of Mandt restraint used. A nurses note documented at 10:50 AM on 3/08/15 also stated Patient #8 continued to "go after staff" and was given an IM injection of 20 mg Geodon. The type of restraint used to allow the IM injection was not specified. The nurses note went on to say that after the injection Patient #8 continued to require physical redirection by staff. There was no documentation to describe the "redirection " used by staff. There was no documentation of a one hour face to face assessment for the restraints used.


- An "Occurrence Report," dated 3/08/15 at 2:00 PM, was completed by the RN on duty. The RN documented Patient #8 was aggressive to another patient and that P.T.s were able to get him moved out of the day room. The RN documented she called for any male aide on the attached SNF to come to the psychiatric hospital. Patient #8 was given an injection but did not calm down until 5:00 PM according to the documentation on the Report. The type of restraint used to allow for the IM injection and actions of the SNF male aide were not described. There was no documentation of a one hour face to face assessment for the restraints used.

- On 3/12/15, Patient #8's MAR indicated he was administered Geodon 20 mg IM at 3:00 PM. The P.T. narrative indicated Patient #8 was visited by his son, and complained of pain, for which he was medicated with Tylenol at 5:00 PM. A nurses note, also documented at 3:00 PM on 3/12/15, stated "Patient seems to be agitating another patient, which in turn seems to agitate the patient. Patient pacing and getting louder. Medicated per MAR." The type of restraint used to restrain Patient #8 to allow the IM injection, was not documented. There was no documentation of a one hour face to face assessment for the restraint required for the IM injection.


- On 3/14/15, an "Occurrence Report", written by the RN on duty, noted at 4:00 PM, Patient #8 was involved in a physical altercation with another patient. The report documented he was physically redirected by staff, and was assisted to his room. In his room he began to swing at staff, was restrained on a total of 4 occasions, and administered Zyprexa IM. There was no documentation to describe the "redirection" used by staff or the technique used to assist him to his room. Additionally, there was no documentation describing the type of restraints used the 4 restraints. There was no documentation of a one hour face to face assessment for the restraints used.

-On 3/16/15 Patient #8's MAR stated he received Haldol 5 mg IM at 8:55 PM. His record included an "Emergency Treatment Override Orders for Seclusion," completed by the NP and RN at 9:30 PM. He was noted to be agitated, hit the staff, punched the fire door, his knuckles were bleeding. A nurses note, dated 3/16/15 at 7:40 PM indicated Patient #8 He was escorted to the seclusion room after grabbing the RN's wrist. The nurses note indicated Patient #8 resisted and staff continued to escort him to seclusion. It further stated "Staff into seclusion room and stabilized pts arms" and Haldol injection given. There was no documentation in Patient #8's record that described how staff "escorted" him to the seclusion room or the type of restraint used to stabilize his arms. There was no documentation of a one hour face to face assessment for the restraints and seclusion used.


- A 3/18/15 at 6:05 PM Emergency Treatment Override Orders for Hold and Restraint form, indicated Patient #8 was physically restrained using a "Staff Hold" to allow for an IM injection of Geodon 20 mg and placement in seclusion. A tech note documented at the time of the incident, stated Patient #8 was agitated and combative at the beginning of the shift and that he was getting worked up from other patients. There was no documentation describing the type of restraint hold used. There was no documentation of a one hour face to face assessment for the restraints and seclusion used.

-A tech note, documented on 3/21/15 at 6:30 AM, indicated Patient #8 was agitated and P.T. D came to help and Patient #8 was restrained twice. The type of restraints used were not described. There was no documentation of a one hour face to face assessment for the restraints used.

During an interview on 4/02/15 at 10:45 AM, the NP reviewed Patient #8's record and confirmed the episodes in which he was physically restrained and/or placed in seclusion a 1 hour face to face was not documented.

The facility failed to ensure a 1 hour face to face evalualtion was performed after the use of restraints and seclusion.

2. Patient #4 was a [AGE] year old male admitted on [DATE] to 3/16/15, from an assisted living facility. His psychiatric diagnoses included schizophrenia, depression, and mild mental disability.

Patient #4's record included documentation of physical restraint by staff for verbal aggression.

A nurses note signed by the RN, dated 3/08/15 at 8:00 AM, documented Patient #4 became agitated and started yelling at other patients and staff. The RN documented Patient #4 was threatening a peer with physical aggression. There was no documentation what preceeded Patient #4's agitation and verbal aggression towards his peer. Patient #4 was physically restrained and taken to his room by staff.

During an interview on 4/01/15 at 3:00 PM, the RN reviewed the record and confirmed the documentation of physical restraint. She stated physically moving a patient to their room was considered a restraint. The RN confirmed a 1 hour face to face was not performed.

Patient #4's record did not include documentation a 1 hour face to face was performed after the use of restraint.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0185
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of patient records and staff interview, it was determined the facility failied to ensure the records of 3 of 3 patients (#3, #4 and #8) for whom restraints were used, documented the type of restraint interventions used. The created the risk of patients being subjected to inappropriate, and potentially harmful, restraint techniques. Finding include:

1. Patient #8's record documented a [AGE] year old male who was at the facility from 3/06/15 to 3/24/15 for psychiatric services related to dementia, and psychosis with behavioral disturbances. Additional diagnoses included HTN and PTSD.

- On 3/07/15 at 9:00 AM, an "Occurrence Report," written by the RN on duty, noted Patient #8 hit a staff member and another patient. He was noted to be restrained by P.T. D. Additionally, the Occurrence Report documented Patient #8 had another physical altercation with P.T. D, his behavior escalated, and he struck a patient. The report documented he was physically restrained, and administered an IM injection. Patient #8 was placed on 1:1 status, and remained on that status throughout his stay at the facility. The types of restraints used by staff to restrain Patient #8 were not specified. Patient #8's record did not include evidence that the least restrictive type of restraints necessary to protect Patient #8 and others were used.

-A P.T. note attached to an "Occurrence Report" dated 3/07/15 at 3:15 PM stated Patient #8 was aggressive toward another patient and P.T.s were able to remove him from the day room. The note also said the RN had called for all male staff on the attached SNF. Patient #8's record also included a nurses note, documented on 3/07/15 at 3:45 PM, which stated he was physically aggressive and was redirected to his room with the assist of family and staff. He was then given an injection of Geodon IM 20 mg. Patient #8's record did not include documentation of the actions were necessary to "redirect" Patient #8 to his room. Additionally his record did not include documentation of the type of restraint used to restrain Patient #8 for the IM injection. Patient #8's record did not include evidence that the least restrictive type of restraints necessary to protect Patient #8 and others were used.

- On 3/08/15, an "Occurrence Report," written by the RN on duty, noted at 9:30-10:30 AM, Patient #8 became agitated and was threatening P.T. D. The report indicated P.T. D performed a Mandt hold on Patient #8, and then 4 employees were required to assist him back to his room. There was no documentation in Patient #8's record that described the type of Mandt restraint used. A nurses note documented at 10:50 AM on 3/08/15 also stated Patient #8 continued to "go after staff" and was given an IM injection of 20 mg Geodon. The type of restraint used to allow the IM injection was not specified. The nurses note went on to say that after the injection Patient #8 continued to require physical redirection by staff. There was no documentation to describe the "redirection " used by staff. Patient #8's record did not include evidence that the least restrictive type of restraints necessary to protect Patient #8 and others were used.

- An "Occurrence Report," dated 3/08/15 at 2:00 PM, was completed by the RN on duty. The RN documented Patient #8 was aggressive to another patient and that P.T.s were able to get him moved out of the day room. The RN documented she called for any male aide on the attached SNF to come to the psychiatric hospital. Patient #8 was given an injection but did not calm down until 5:00 PM according to the documentation on the Report. The type of restraint used to allow for the IM injection and actions of the SNF male aide were not described. Patient #8's record did not include evidence that the least restrictive type of restraints necessary to protect Patient #8 and others were used.

- On 3/12/15, Patient #8's MAR indicated he was administered Geodon 20 mg IM at 3:00 PM. The P.T. narrative indicated Patient #8 was visited by his son, and complained of pain, for which he was medicated with Tylenol at 5:00 PM. A nurses note, also documented at 3:00 PM on 3/12/15, stated "Patient seems to be agitating another patient, which in turn seems to agitate the patient. Patient pacing and getting louder. Medicated per MAR." The type of restraint used to restrain Patient #8 to allow the IM injection, was not documented. Patient #8's record did not include evidence that the least restrictive type of restraint necessary to protect Patient #8 and others was used.

- On 3/14/15, an "Occurrence Report", written by the RN on duty, noted at 4:00 PM, Patient #8 was involved in a physical altercation with another patient. The report documented he was physically redirected by staff, and was assisted to his room. In his room he began to swing at staff, was restrained on a total of 4 occasions, and administered Zyprexa IM. There was no documentation to describe the "redirection" used by staff or the technique used to assist him to his room. Additionally, there was no documentation describing the type of restraints used the 4 restraints. Patient #8's record did not include evidence that the least restrictive type of restraints necessary to protect Patient #8 and others were used.

-On 3/16/15 Patient #8's MAR stated he received Haldol 5 mg IM at 8:55 PM. His record included an "Emergency Treatment Override Orders for Seclusion," completed by the NP and RN at 9:30 PM. He was noted to be agitated, hit the staff, punched the fire door, his knuckles were bleeding. A nurses note, dated 3/16/15 at 7:40 PM indicated Patient #8 He was escorted to the seclusion room after grabbing the RN's wrist. The nurses note indicated Patient #8 resisted and staff continued to escort him to seclusion. It further stated "Staff into seclusion room and stabilized pts arms" and Haldol injection given. There was no documentation in Patient #8's record that described how staff "escorted" him to the seclusion room or the type of restraint used to stabilize his arms. Patient #8's record did not include evidence that the least restrictive type of restraints necessary to protect Patient #8 and others were used.

- A 3/18/15 at 6:05 PM Emergency Treatment Override Orders for Hold and Restraint form, indicated Patient #8 was physically restrained using a "Staff Hold" to allow for an IM injection of Geodon 20 mg and placement in seclusion. A tech note documented at the time of the incident, stated Patient #8 was agitated and combative at the beginning of the shift and that he was getting worked up from other patients. There was no documentation describing the type of restraint hold used. Patient #8's record did not include evidence that the least restrictive type of restraints necessary to protect Patient #8 and others were used.

-A P.T. note, documented on 3/21/15 at 6:30 AM, indicated Patient #8 was agitated and P.T. D came to help and Patient #8 was restrained twice. The type of restraints used were not described. Patient #8's record did not include evidence that the least restrictive type of restraints necessary to protect Patient #8 and others were used.

During an interview on 4/02/15 beginning at 10:45 AM, the NP reviewed Patient #8's record and confirmed there was no documentation of the type of restraints the staff used when he was restrained. The NP stated she took Mandt training in 2010, when she worked at the facility as an RN, but her certification expired. The NP was unable to describe the methods of restraint the staff used when physically restraining Patient #8.

The facility failed to ensure staff specifically described the type of restraints, redirections, escorts, and holds used on Patient #8.

2. Patient #4 was a [AGE] year old male admitted on [DATE] to 3/16/15, from an assisted living facility. His psychiatric diagnoses included schizophrenia, depression, and mild mental disability.

Patient #4's record included documentation of physical restraint by staff for verbal aggression.

A nurses note signed by the RN, dated 3/08/15 at 8:00 AM, documented Patient #4 became agitated and started yelling at other patients and staff. The RN documented Patient #4 was threatening a peer with physical aggression. There was no documentation what preceeded Patient #4's agitation and verbal aggression towards his peer. Patient #4 was physically restrained and taken to his room by staff.

During an interview on 4/01/15 at 3:00 PM, the RN reviewed the record and confirmed the documentation of physical restraint. She stated physically moving a patient to their room was considered a restraint.

Patient #4's record did not include documentation of the type of restraint used.

3. Patient #15 was a [AGE] year old man who was a patient in the facility from 3/15/15 to 3/26/15, with diagnoses of Schizoaffective Disorder and Borderline Personality Disorder.

A nurses note, documented at 9:00 PM on 3/22/15, stated Patient #15 eloped, was followed by hospital staff, hit and spit at hospital staff, and was "escorted back to the hospital by 2 male staff. The note further stated Patient #15 continued to be upset and when he returned he punched the entry door and slammed his door multiple times. Patient #15 was documented as stating he wanted the police called so he could go to jail. There was no documentation of the type of "escort" used by the 2 male staff to return Patient #15 to the hospital.

In an interview on 4/01/15 at 4:45 PM RN C reviewed Patient #15's record and confirmed the escort back to the facility was considered a restraint.

Patient #15's record did not include documentation of the type of restraint used.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0186
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of patient records, policies, and staff interviews, it was determined the facility failed to ensure less restrictive alternatives were attempted before implementing physical restraints and seclusion for 2 of 3 patients (#4 and #8) for whom seclusion and physical restraints were used. This resulted in a lack of appropriate assessment to determine if a less restrictive intervention may have prevented unnecessary use of restraint and or seclusion. Findings include:

1. Patient #8's record documented a [AGE] year old male who was at the facility from 3/06/15 to 3/24/15 for psychiatric services related to dementia, and psychosis with behavioral disturbances. Additional diagnoses included HTN and PTSD.

Facility staff did not document the type of restraints, holds, redirection, and assistance used for Patient #8. A treatment plan or POC was not found in Patient #8's record, to guide staff on individualized less intrusive interventions to utilize. Patient #8 experienced the following incidents of restraints without specific documentation of alternative intervention used.

- On 3/07/15 at 9:00 AM, an "Occurrence Report," written by the RN on duty, noted Patient #8 hit a staff member and another patient. He was noted to be restrained by P.T. D. Additionally, the Occurrence Report documented Patient #8 had another physical altercation with P.T. D, his behavior escalated, and he struck a patient. The report documented he was physically restrained, and administered an IM injection. Patient #8 was placed on 1:1 status, and remained on that status throughout his stay at the facility. The types of restraints used by staff to restrain Patient #8 were not specified.

-A P.T. note attached to an "Occurrence Report" dated 3/07/15 at 3:15 PM stated Patient #8 was aggressive toward another patient and P.T.s were able to remove him from the day room. The note also said the RN had called for all male staff on the attached SNF. Patient #8's record also included a nurses note, documented on 3/07/15 at 3:45 PM, which stated he was physically aggressive and was redirected to his room with the assist of family and staff. He was then given an injection of Geodon IM 20 mg. Patient #8's record did not include documentation of the actions were necessary to "redirect" Patient #8 to his room. Additionally his record did not include documentation of the type of restraint used to restrain Patient #8 for the IM injection.

- On 3/08/15, an "Occurrence Report," written by the RN on duty, noted at 9:30-10:30 AM, Patient #8 became agitated and was threatening P.T. D. The report indicated P.T. D performed a Mandt hold on Patient #8, and then 4 employees were required to assist him back to his room. There was no documentation in Patient #8's record that described the type of Mandt restraint used. A nurses note documented at 10:50 AM on 3/08/15 also stated Patient #8 continued to "go after staff" and was given an IM injection of 20 mg Geodon. The type of restraint used to allow the IM injection was not specified. The nurses note went on to say that after the injection Patient #8 continued to require physical redirection by staff. There was no documentation to describe the "redirection " used by staff. Patient #8's record did not include evidence that the least restrictive type of restraints necessary to protect Patient #8 and others were used.

- An "Occurrence Report," dated 3/08/15 at 2:00 PM, was completed by the RN on duty. The RN documented Patient #8 was aggressive to another patient and that P.T.s were able to get him moved out of the day room. The RN documented she called for any male aide on the attached SNF to come to the psychiatric hospital. Patient #8 was given an injection but did not calm down until 5:00 PM according to the documentation on the Report. The type of restraint used to allow for the IM injection and actions of the SNF male aide were not described.

- On 3/12/15, Patient #8's MAR indicated he was administered Geodon 20 mg IM at 3:00 PM. The P.T. narrative indicated Patient #8 was visited by his son, and complained of pain, for which he was medicated with Tylenol at 5:00 PM. A nurses note, also documented at 3:00 PM on 3/12/15, stated "Patient seems to be agitating another patient, which in turn seems to agitate the patient. Patient pacing and getting louder. Medicated per MAR." The type of restraint used to restrain Patient #8 to allow the IM injection, was not documented.

- On 3/14/15, an "Occurrence Report", written by the RN on duty, noted at 4:00 PM, Patient #8 was involved in a physical altercation with another patient. The report documented he was physically redirected by staff, and was assisted to his room. In his room he began to swing at staff, was restrained on a total of 4 occasions, and administered Zyprexa IM. There was no documentation to describe the "redirection" used by staff or the technique used to assist him to his room.

- A 3/18/15 at 6:05 PM Emergency Treatment Override Orders for Hold and Restraint form, indicated Patient #8 was physically restrained using a "Staff Hold" to allow for an IM injection of Geodon 20 mg and placement in seclusion. A tech note documented at the time of the incident, stated Patient #8 was agitated and combative at the beginning of the shift and that he was getting worked up from other patients. There was no documentation describing the type of restraint hold used.

-A P.T. note documented on 3/21/15 at 6:30 AM, indicated Patient #8 was agitated and P.T. D came to help and Patient #8 was restrained twice. The type of restraints used were not described.

During an interview on 4/02/15 beginning at 10:45 AM, the NP reviewed Patient #8's record and confirmed there was no documentation of less restrictive interventions before restraints were implemented. She stated male staff members would increase Patient #8's agression, and confirmed the male staff were summoned to assist when Patient #8's agitation escalated. The NP confirmed there were no Treatment or Behavioral POC's initiated to address his agitation.

Patient #8 was physically restrained and placed in seclusion no less than 8 times without evidence that less restrictive interventions tried or considered.

2. Patient #4 was a [AGE] year old male admitted on [DATE] to 3/16/15, from an assisted living facility. His psychiatric diagnoses included schizophrenia, depression, and mild mental disability.

Patient #4's record included the following documented incidents of physical restraint.

A nurses note signed by the RN, dated 3/08/15 at 8:00 AM, documented Patient #4 became agitated and started yelling at other patients and staff. The RN documented Patient #4 was verbally threatening a peer with physical aggression. Patient #4 was physically removed to his room. There was no documentation what preceeded Patient #4's agitation and verbal aggression towards his peer. Additionally, there was no documentation how the RN intervened prior to physically restraining Patient #4.

A nurses note signed by the RN, dated 3/14/15 at 4:05 PM, documented Patient #4 was yelling and shaking his fist at peers. There was no documentation what preceeded Patient #4's yelling and threatening manner. The RN documented Patient #4 was physically seperated from his peer. There was no documentation of interventions the RN attempted to address Patient #4's verbal aggression before he was physically restrained.

Patient #4's record did not include a nursing or treatment care plan for interventions related to his verbal aggression and agitation.

During an interview on 4/01/15 at 3:00 PM, RN C reviewed the record and confirmed there were no nursing or treatment care plans for Patient #4.

Individualized treatment and nursing care plans were not developed and implemented for Patient #4, to promote the use of use of least restrictive alternatives.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0194
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policy and personnel files, and staff interview, it was determined the facility failed to ensure restraints were safely implemented for 1 of 3 patients reviewed (#8) for whom restraints and seclusion were used. This resulted in an inability of the facility to ensure physical restraints and seclusion were implemented in a safe and appropriate manner. Findings include:

1. Patient #8's record documented a [AGE] year old male who was at the facility from 3/06/15 to 3/24/15 for psychiatric services related to dementia, and psychosis with behavioral disturbances. Additional diagnoses included HTN and PTSD.

During an interview on 4/03/15 at 4:00 PM, P.T. H stated she was a P.T. on duty the day before Patient #8 had the seizure on 3/23/15. She stated she did not have Mandt or any kind of restraint training since her hire at the facility. P.T. H stated she witnessed an event that she reported to the RN on duty, but felt no action was taken.

She stated P.T. D did not like Patient #8, and stated that P.T. D did not want to be his 1:1. She stated when Patient #8 had aggressive behavior; P.T. D would be the 1st to jump in to restrain him.

P.T. H stated on Sunday 3/22/15, Patient #8 did not sleep for about a day and a half, and he was agitated. She stated that about 6:30 AM, she asked him if he was tired, Patient #8 stated "yes," so she took him to his room. She stated he sat on the bed, then Patient #8 grabbed her by the throat, she brought his hand down and then went to get assistance from P.T. D. When they entered the room, Patient #8 tried to punch P.T.D so he grabbed Patient #8 with his arms under Patient #8's armpits and pulled his arms up and outward. (Similar to a Full Nelson wrestling move). Patient #8 attempted to fight him off, and P.T.D held him again in that manner and threw him face down on the bed, with his body on him to pin him down. He asked P.T. H to hold Patient #8's legs. He held Patient #8 down until after the RN gave him a shot. P.T. D's personnel file was reviewed. It did not include evidenc of Mandt training.

The reported type of restraint is not an approved Mandt or other therapeutic hold and presents a danger to patients.

Patient #8 was not restrained in a safe and appropriate manner.

2. The facility policy "Use of Seclusion and Restraint," dated 1/25/14, defined restraint as "Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition."

The Administrator was interviewed on 4/02/15 at 2:15 PM. She stated that all direct patient care staff were trained in Mandt technique for patient restraint. She stated the only physical holds used in the facility were Mandt holds, and although they would be "hands on," they were Mandt holds, and not considered a restraint. This was inconsistent with the definition included in the hospital's policy

During an interview on 4/03/15 at 4:10 PM, the SNF AIT stated the hospital required all direct care staff to complete Mandt training upon hire and annually. He stated the hospital provided the training several times a year. The Mandt Systems website, accessed 4/07/15, stated "The Mandt System is a comprehensive, integrated approach to preventing, de-escalating, and if necessary, intervening when the behavior of an individual poses a threat of harm to themselves and/or others."

The personnel records of eighteen direct care employees were reviewed, including 8 RN, 2 LPN, 7 P. T. and 1 Program Assistant. The employee files of RN B and H, LPN A and B, P.T. B, D, E, F and G, and the Program Assistant did not contain documentation of Mandt training. The employee files of RN C, D, E and G, and P.T. A and C contained Mandt training certificates that were expired. Two staff files included evidence of current Mandt training.

During an interview on 4/03/15 at 3:30 PM, the Human Resources Director confirmed the hospital required annual Mandt training for all direct care staff members. She reviewed the personnel files and confirmed 10 of the 18 files reviewed did not include documentation of Mandt training, and 6 of the 18 records reviewed contained Mandt training certificates that were expired.

The facility failed to ensure staff were sufficiently trained to safely and appropriately perform restraints.

3. Also refer to A185 as it relates to the failure of the facility to specifically describe the type of restraints used to manage patients' behavior. This failure precludes the facility from ensuring the interventions used are safe and appropriate.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0200
Based on review of personnel files and staff interview, it was determined the hospital failed to ensure all appropriate staff (RN B, C, D, E, G and H, LPN A and B, P.T. A, B, C, D, E, F and G, and the Program Assistant) were trained and able to demonstrate competency in the use of non-physical intervention to redirect a patient and prevent a patient situation from escalating. This had the potential to result in an unsafe environment for all patients. Findings include:

The hospital's policy titled Restraints, effective 1/25/12, stated seclusion and restraint would be used in emergency situations only when "Positive, individualized, alternative nonphysical intervention procedures have failed."

During an interview on 4/03/15 at 4:10 PM, the SNF AIT stated the hospital required all direct care staff to complete Mandt training upon hire and annually. He stated the hospital provided the training several times a year. The Mandt Systems website, accessed 4/07/15, stated "The Mandt System is a comprehensive, integrated approach to preventing, de-escalating, and if necessary, intervening when the behavior of an individual poses a threat of harm to themselves and/or others."

The personnel records of eighteen direct care employees were reviewed, including 8 RN, 2 LPN, 7 P. T. and 1 Program Assistant. The employee files of RN B and H, LPN A and B, P.T. B, D, E, F and G, and the Program Assistant did not contain documentation of Mandt training. The employee files of RN C, D, E and G, and P.T. A and C contained Mandt training certificates that were expired.

During an interview on 4/03/15 at 3:30 PM, the Human Resources Director confirmed the hospital required annual Mandt training for all direct care staff members. She reviewed the personnel files and confirmed 10 of the 18 files reviewed did not include documentation of Mandt training, and 6 of the 18 records reviewed contained Mandt training certificates that were expired.

The facility failed to ensure staff responsible for the care of psychiatric patients were appropriately trained in the use of nonphysical intervention techniques.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, medical record review, and staff interview it was determined the facility failed to ensure thorough nursing care plans were developed, evaluated, and revised for 17 of 17 patients (#1 - #17) whose records were reviewed. Lack of a complete care plan had the potential to result in unaddressed patient care needs and interfere with coordination of patient care among staff members. Findings include:

During an interview on 4/03/15 at 10:15 AM, the NP stated a nursing care plan should be part of an interdisciplinary treatment plan, however, the development of a nursing care plan was the responsibility of the CNO, and as they did not currently have a CNO, it was not being done.

During an interview on 4/01/15 at 4:00 PM, RN C stated the CNO was in charge of creating nursing care plans. She said, "We don't have a DON [CNO] so it's not happening."

The records of 17 patients (#1 - #17) with admitted range of 9/24/14 to 3/31/15, were reviewed. The 17 patient records did not include nursing care plans to address patient needs. Goals were not identified, and interventions were not initiated to minimize the risk of complications related to psychiatric or medical diagnoses. Examples included, but were not limited to, the following:

1. Patient #11 was a [AGE] year old female admitted on [DATE], from a SNF. Her psychiatric diagnoses were psychosis, bipolar disorder and congenital brain injury with mental disability.

Patient #11's record included an Inpatient Psychiatric Evaluation, completed by the NP, and dated 11/26/15. It documented her medical problems as morbid obesity, diabetes, chronic renal insufficiency, chronic pain, CHF, hypoxia (inadequate oxygen supply to the body), epilepsy, [DIAGNOSES REDACTED], constipation, edema, [DIAGNOSES REDACTED], and GERD.

Patient #11's record included an Admission History and Physical, completed on 11/26/14 and signed by the MD. Continuing illnesses included chronic renal insufficiency, DM type 2, and CHF.

Patient #11's record did not include a nursing care plan to address her needs related to her medical problems. Therefore, goals were not identified, and interventions were not initiated to minimize the risk of complications related to her co-morbidities.

During an interview on 4/01/15 at 4:00 PM, RN C reviewed Patient #11's record and confirmed it did not include a nursing care plan to address her co-morbidities of renal insufficiency, CHF, diabetes and constipation. RN C stated interventions were not developed at the time of Patient #11's admission, or updated during her hospitalization , to address her escalating symptoms.

The facility did not ensure a nursing care plan was developed to address Patient #11's medical problems.

2. Patient #10 was a [AGE] year old male admitted on [DATE], from an ALF. His psychiatric diagnoses were conduct disorder and depression.

Patient #10's record included an Inpatient Psychiatric Evaluation, completed by the NP on 11/07/14. The evaluation documented Patient #10 had a bowel obsession and refused to use the bathroom. It documented Patient #10's medical problems as [DIAGNOSES REDACTED], constipation, DM type 2, CVA (stroke), and chronic pain.

Patient #10's record included an Admission History and Physical, completed on 11/07/14 and signed by the MD. Continuing illnesses included diabetes mellitus type 2, and possible anorexia (loss of appetite), stating "He is on Megace without a diagnosis otherwise." Nursing 2015 Drug Handbook listed indications for Megace, including anorexia, or unexplained significant weight loss.

Patient #10's record did not include a nursing care plan to address his needs related to constipation, anorexia or diabetes.

During an interview on 4/01/15 at 4:30 PM, RN C reviewed Patient #10's record and confirmed it did not include a nursing care plan. RN C confirmed a nursing care plan related to his DM was not created, therefore nursing interventions were not developed to monitor his blood sugar levels.

During an interview on 4/03/15 at 1:15 PM, the NP reviewed Patient #10's record and stated she was not aware of his poor nutritional intake and lack of bowel movements. She confirmed his medical needs were not addressed during his hospitalization .

The facility did not ensure a nursing care plan was developed to address Patient #10's medical problems.

3. Patient #15 was a [AGE] year old man who was a patient in the facility from 3/15/15 to 3/26/15, with diagnoses of [DIAGNOSES REDACTED]

Patient #15's Inpatient Psychiatric Evaluation completed by the NP on 3/15/15, and History and Physical completed by the MD on 3/15/15, documented diagnoses of [DIAGNOSES REDACTED]

Patient #15's record did not include a nursing care plan to address his needs related to hepatitis. Additionally, there was no documentation of a plan to prevent the transmission of Hepatitis to other patients and/or clinical staff.

During an interview on 4/01/15 at 4:45 PM, RN C reviewed Patient #15's record and confirmed it did not include a nursing care plan. Additionally, she confirmed Patient #15 was not placed on precautions to prevent the possible transmission of Hepatitis B and C through his body fluids.

The facility did not ensure a nursing care plan was developed to address Patient #15's medical needs and to prevent the spread of communicable disease.





4. Patient #1 was a [AGE] year old male admitted to the facility on [DATE] to 3/31/15, from a local ED. His psychiatric diagnoses included [DIAGNOSES REDACTED]

Patient #1's record included an Admission H&P, completed on 3/26/15 and signed by the MD. The H&P documented diagnoses which included insulin dependent DM, diabetic neuropathy of extremities, chronic back pain, and Hepatitis C.

The record did not include a nursing care plan to address Patient #1's needs related to his medical problems. No goals were identified and interventions were not initiated to minimize the risk of complications related to his DM or to prevent the spread of his Hepatitis C while admitted to the facility.

During an interview on 4/03/15 at 1:40 PM, the NP reviewed the record and stated she did not address or assess medical problems with patients. She stated this was the responsibility of the MD.

During an interview on 4/01/15 at 5:40 PM, the RN reviewed the record and confirmed there was not a nursing care plan.

5. Patient #5 was a [AGE] year old male admitted on [DATE] to 3/25/15, from an ALF. His psychiatric diagnoses included [DIAGNOSES REDACTED]

Patient #5's record included an Inpatient Psychiatric Evaluation, completed on 3/10/15 and signed by the NP. It documented his medical problems were GERD, chronic pain, and a subtotal colectomy (removal of part of the colon).

Patient #5's record included an Admission H&P, completed on 3/09/15 and signed by the MD. His continuing illnesses included post-operative pulmonary embolism, anticoagulation therapy, GERD, history of MRSA (Methicillin resistant Staphylococcus aureus), and COPD. The MD documented Patient #5 had retention sutures on his abdomen upon admission, and they would need to be removed.

The record did not include a nursing care plan to address Patient #5's needs related to his medical problems. No goals were identified and interventions were not initiated to minimize the risk of complications related to his surgical incision or sutures, anticoagulation therapy, or to test or monitor for MRSA while admitted to the facility.

During an interview on 4/01/15 at 5:20 PM, the RN reviewed the record and confirmed there was no nursing care plan to address Patient #5's medical issues. She confirmed Patient #5 should have been monitored for signs and symptoms of [DIAGNOSES REDACTED]. The RN also stated she was unaware of Patient #5's history for MRSA. She stated his wounds were cultured for MRSA and came back negative. Further, the RN stated Patient #5's bleeding times were tested as ordered by the pharmacist. She confirmed there was no nursing care plan related to changes in his anticoagulation therapy, laboratory testing, or history of blood clots in the lung.

Nursing failed to ensure a nursing care plan was developed to address Patient #5's medical problems.

6. Patient #4 was a [AGE] year old male admitted on [DATE] to 3/16/15, from an ALF. His psychiatric diagnoses included [DIAGNOSES REDACTED]

Patient #4's record included an Inpatient Psychiatric Evaluation, completed on 3/03/15 and signed by the NP. It documented his medical problems were seizures, [DIAGNOSES REDACTED], organic brai[DIAGNOSES REDACTED], constipation, and history of tremors.

Patient #4's record included an Admission H&P, completed on 3/02/15 and signed by the MD. His continuing illnesses included seizures, [DIAGNOSES REDACTED], organic brai[DIAGNOSES REDACTED], tremors, history of urinary retention, and constipation.

The record did not include a nursing care plan to address Patient #4's needs related to his medical problems. No goals were identified and interventions were not initiated to minimize the risk of complications related to his seizures or to address his constipation while admitted to the facility.

Patient #4's Inpatient Psychiatric Evaluation and Admission H&P included a diagnosis of [DIAGNOSES REDACTED]

During an interview on 4/01/15 at 5:10 PM, the RN reviewed the record and confirmed there was no nursing care plan. She stated it was the CNO's responsibility to write those but since the previous CNO left in January of 2015, no care plans had been written.

Nursing failed to ensure a care plan was developed and included in the record for Patient #4 for his medical problems.

7. Patient #7 was a [AGE] year old male admitted to the facility on [DATE] to 4/01/15, from an ALF. His psychiatric diagnoses included [DIAGNOSES REDACTED]

Patient #7 was sent to a local hospital on [DATE] for an x-ray, the day after his admission, after punching a wall with his right hand the previous day. The nurse's note for the previous day, 3/23/15, did not include documentation of Patient #7 hitting a wall.

Patient #7 was evaluated by the physician on 3/24/15 for his admission H&P. Under the section Review of Systems the physician documented Patient #7 had right hand pain. Patient #7 stated to the physician he hit a door. The physician documented Patient #7 had swelling over the mid portion of his right hand and the area was tender when touched.

On 3/25/15, the nursing note documented Patient #7 refused to wear the splint prescribed for his right hand. The nursing note did not have documentation the physician was notified.

A nurses note dated 3/31/15, documented Patient #7 complained of a vibrating sensation in his arm. However, the note did not specify which arm. There was no further musculoskeletal assessment documented. The nursing note had no documentation the physician was notified.

Patient #7's discharge orders documented he was to make an appointment with the orthopedic physician for follow up related to a boxer's fracture in his right hand. The facility did not have an occurrence report for Patient #7's hand fracture related to hitting a wall after admission.

During an interview on 4/01/15 at 5:05 PM, the RN reviewed the record and confirmed Patient #7 had a fracture to his right hand. Additionally, she confirmed a nursing care plan related to his fractured hand was not developed, and interventions were not implemented to monitor his injury.

Nursing failed to develop and document a care plan for Patient #7.





8. Patient #17 was a [AGE] year old female admitted to the facility on [DATE] for psychiatric treatment related to schizoaffective disorder, and borderline personality disorder. Additional diagnoses included [DIAGNOSES REDACTED]

Patient #17's record did not include a nursing care plan to address her needs related to her medical problems.

During an interview on 3/30/15 at 9:45 AM, RN C confirmed Patient #17's record did not include a Nursing POC or a Psychiatric Treatment POC.

Patient #17's record did not include a Nursing plan of care.

9. Patient #12 was an [AGE] year old male admitted to the facility on [DATE] for psychiatric treatment related to dementia and psychosis. Additional diagnoses included [DIAGNOSES REDACTED]

Patient #12's record did not include a nursing care plan to address his needs related to his medical problems.

During an interview on 4/01/15 at 3:30 PM, RN C reviewed Patient #12's record and confirmed a nursing plan of care was not developed.

Patient #12's record did not include a Nursing plan of care.

10. Patient #8 was a [AGE] year old male admitted to the facility on [DATE], for care related to dementia, psychosis, HTN, and PTSD. His medical record from 3/06/15 to 3/24/15, as well as, records from ED visits on 3/23/15, and 3/24/15, at an acute care facility, were reviewed.

Patient #8's record did not include a Nursing plan of care.

During an interview on 4/01/15 at 3:30 PM, RN C reviewed Patient #8's record and confirmed a nursing plan of care was not developed.

Patient #8's record did not include a Nursing plan of care.





11. Patient #2 was a [AGE] year old female who was a patient in the facility from 3/25/15 to 4/01/15, with diagnoses of [DIAGNOSES REDACTED]

Patient #2's record did not include a nursing care plan. Her record did not include direction to staff to care for her psychosis, her memory, her neuropathic pain, or her asthma.

An interview was conducted with the NP on 4/03/15 beginning at 3:50 PM. She confirmed Patient #15 did not have a documented nursing POC.

The facility did not ensure a nursing care plan was developed to address Patient #2's psychiatric and medical needs.

12. Patient #3 was a [AGE] year old female who was a patient in the facility from 3/25/15 to 4/01/15, with diagnoses of [DIAGNOSES REDACTED]

Patient #3's record did not include a nursing care plan. Her record did not include direction to staff to care for her psychosis, her memory, or her chronic pain.

An interview was conducted with the NP on 4/03/15 beginning at 3:50 PM. She confirmed Patient #3 did not have a documented nursing POC.

The facility did not ensure a nursing care plan was developed to address Patient #3's psychiatric and medical needs.

13. Patient #9 was a [AGE] year old male who was a patient in the facility from 3/25/15 to 4/02/15, with diagnoses of [DIAGNOSES REDACTED]

Patient #9's record did not include a nursing care plan. His record did not include direction to staff to care for his schizoaffective disorder, borderline personality disorder, asthma, Hepatitis C, chronic pain, seizure disorder, or his [DIAGNOSES REDACTED].

An interview was conducted with the NP on 4/03/15 beginning at 3:50 PM. She confirmed Patient #9 did not have a documented nursing POC.

The facility did not ensure a nursing care plan was developed to address Patient #9's psychiatric and medical needs.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview, record review, policy review, and observation, it was determined the facility failed to ensure medications were properly dispensed and ordered for 9 of 17 patients (#1, #4, #5, #7, #8, #13, #15, #18, and #19) whose records were reviewed and/or medication administrations were observed. This failed practice resulted in the potential for errors in dosage, medication delivery, and possible adverse reactions. Findings include:

1. A hospital policy titled "Administration of Medications," revised 1/31/04, stated "Accurate patient identification will be made by photo identification. A photo of each patient will be placed in the MAR and one placed in the patient record." However, the patient records and MARs did not include patient photos.

Two nurses were observed on two separate days preparing and administering medications. The medication room was located in a small room behind the nurses' station. The MAR for each patient was in a binder. The MAR did not include a picture of the patient. When the medications were ready to be administered, the nurse left the medication room to give the medications to the patients.

a. During an observation of medication administration on 3/30/15 beginning at 1:55 PM, LPN B was observed preparing and administering medications. LPN B was observed to take medications to two separate patients.

i. LPN B approached Patient #18 and called out her first name. She gave her the medications without verification of her identity. Patient #18 asked LPN B what she was getting, and the LPN told her what the medication was.

ii. LPN B then administered Patient #19's medication. She went to Patient #19 and stated "It's time for your medication." She did not verify Patient #19's identity. After administering the medication, she returned to the medication room to sign the MAR.

b. During an observation of medication administration on 3/31/15 beginning at 1:45 PM, RN D was observed preparing and administering medications. RN D was observed to give medications to Patient #7 and Patient #18. She approached the patients and stated their names. She stated "I have your normal medications." Both Patient #7 and Patient #18, asked what medications they were taking. RN D provided more information by naming the medication and why it was prescribed. Patients did not have wristbands with their identification on them, and there were no photographs in the MAR to identify patients by photo.

During an interview on 3/30/15 beginning at 2:20 PM, LPN B stated wristbands with patient names and information were not used in the facility.

During an interview on 3/31/15 at 1:55 PM, RN D stated patients did not wear wristbands with patient names or information on them. She stated she verified their identity by sight.

During an interview on 4/01/15 beginning at 3:30 PM, RN C reviewed and confirmed the medication administration policy. She stated the facility at one time had a camera to take patient photos, but it broke and was not replaced.

The facility failed to ensure the proper identity of patients prior to administering medication.

2. The patients' MAR included a section for the clinician to sign with their initials, to indicate the medication was administered. Each dose of medication administered would therefore have initials in the section under the corresponding date and time. However, nursing staff failed to document medications were administered, patient refusal of medications, as well as the reasons for refusal of medications.

a. Patient #8 was a [AGE] year old male admitted to the facility on [DATE] for care related to dementia, psychosis, HTN, and PTSD. His medical record from 3/06/15 to 3/24/15, as well as, records from ED visits on 3/23/15 and 3/24/15 at an acute care facility were reviewed.

Patient #8's 3/16/15 MAR included 6 pages of medications that were scheduled to be routinely administered. The following medications were not documented as given:

- Folic Acid 1 mg at 8:00 AM,
- B Vitamin Complex 1 tablet at 8:00 AM,
-Vitamin C 500 mg at 8:00 AM,
- Metoprolol 12.5 mg at 8:00 AM,
- Prazosin HCL 1 mg at 8:00 AM,
- Aspirin 81 mg at 8:00 AM,
- Lipitor 40 mg at 8:00 AM,
- Levothyroxine 50 mcg at 8:00 AM,
- Memantine 5 mg at 8:00 AM,
- Prednisone 1 mg at 8:00 AM,
- Venlafaxine 75 mg at 8:00 AM,
- Cholecalciferol 5,000 units at 8:00 AM,
- Multivitamin 1 tablet at 8:00 AM,

During an interview on 4/01/15 beginning at 3:30 PM, RN C reviewed Patient #8's MAR. She confirmed the initials of the clinician were missing for the medications to be administered on 3/16/15 at 8:00 AM. RN C was not able to determine if the medications were not administered, or if the clinician did not sign for them.

Patient #8's MAR did not reflect if medications were administered, refused, or not documented as given.

b. Patient #15 was a [AGE] year old man admitted to the facility on [DATE], with diagnoses of Schizoaffective Disorder and Borderline Personality Disorder.

i. The back of Patient #15's MAR included a section titled "PRN and Medications Not Administered," to document the date, time, medication and reason for a PRN given or a medication not given.

Patient #15's MAR included the following medications to be administered daily at 8:00 AM :
-Vitamin D 1000 Units
-Folic Acid 1 mg
-B Vitamin Complex 1 tab
-Vitamin C 500 mg

On 3/15/15, 3/18/15, 3/19/15, 3/21/15, 3/23/15, 3/24/15, 3/25/15, and 3/26/15, the MAR included circled initials for the 4 medications, indicating the medications were not administered. However, there was no documentation on the back of the MAR stating the reason the medications were not administered.

Patient #15's MAR included Zyprexa 10 mg po/IM twice a day, beginning 3/20/15. On 3/23/15, 3/24/15, and 3/26/15, the MAR included circled initials for the morning and evening doses. On 3/21/15, the MAR included circled initials for the morning dose. On 3/22/15, the MAR included circled initials for the evening dose. However, there was no documentation on the back of the MAR stating the reason the medication was not administered.

ii. Nursing staff failed to document the time and/or reason PRN medications were administered to Patient #15.

- An entry on the MAR documented Zyprexa 10 mg IM was administered on 3/15/15, however, the time of administration was not documented.

- Patient #15's MAR included Geodon 40 mg po (by mouth) PRN, and stated "can override with 20 mg IM if PO dose refused." An entry on the MAR documented Geodon 20 mg IM was given on 3/20/15. The time of administration was not documented. Additionally, there was no documentation of refusal of the po medication, or of the reason for the PRN medication.

During an interview on 4/01/15 at 4:45 PM, RN C reviewed Patient #15's record and confirmed the reasons PRN medications were given and the reasons scheduled medications were not given was not documented on his MAR.

Patient #15's MAR did not include documentation of the reason PRN medications were given, or the reason scheduled medications were not given.





3. Patient medication reconciliation was incomplete and nursing administered medications to patients without a provider order.

a. Patient #15 was a [AGE] year old man admitted to the facility on [DATE], with diagnoses of Schizoaffective Disorder and Borderline Personality Disorder.

Patient #15's record included a MAR, that listed medications and the times they were to be administered to him by hospital staff. The MAR, effective 3/15/15, included Seroquel, Vitamin D, Folic Acid, B Vitamin Complex, Vitamin C, MOM, antacid of choice, and Tylenol.

However, Patient #15's record included a hospital admission order form dated 3/15/15, and signed by the RN and the NP. A section of the form included standing orders, which stated "Please put a check mark in the appropriate boxes." The boxes next to the following medications were not checked:

- Vitamin D 1000 units daily
- Folic Acid 1 mg daily
- B Vitamin Complex 1 tab daily
- Vitamin C 500 mg daily
- MOM 30 cc by mouth every 12 hours for constipation
- Antacid of choice 30 cc by mouth 4 times a day as needed
- Tylenol 650 mg for mild discomforts

Another section of the form included Patient #15's pre-admission medication, Seroquel, 300 mg daily. The section included boxes next to "Continue" and "Stop" to indicate if the medication was to be given while the patient was in the hospital. Neither box contained a check mark.

During an interview on 4/01/15 at 3:25 PM, the hospital's pharmacist reviewed Patient #15's record and confirmed his admission orders, signed by the NP, did not include check marks next to the medications, making it unclear if they were to be administered. She stated she talked to the RN on duty on 3/16/15, who said the medications were to be given to Patient #15. She stated she did not speak with the NP who signed the orders, to verify the medication orders.

During an interview on 4/03/15 at 10:15 AM, the NP reviewed Patient #15's admission orders and confirmed the boxes were not checked. She stated the boxes should be checked by the provider to confirm the medications were to be administered.

The facility failed to ensure Patient #15's medications were ordered by a provider.

b. Patient #1 was a [AGE] year old male admitted to the facility on [DATE] to 3/31/15, from a local ED. His psychiatric diagnoses included schizoaffective disorder, substance dependence, and PTSD.

Patient #1's record included a hospital admission order form dated 3/26/15, and signed by the NP. A section of the form included standing orders, which stated "Please put a check mark in the appropriate boxes." The boxes were not checked for the following medications:

- Vitamin D 1000 units daily
- Folic Acid 1 mg daily
- B Vitamin Complex 1 tab daily
- Vitamin C 500 mg daily

Patient #1's MAR documented he received each of these medications daily from 3/26/15 to 3/31/15.

During an interview on 4/03/15 at 4:40 PM, the NP reviewed the record and confirmed these medications were not ordered. She further confirmed the medications were given to Patient #1 without an order.

Medications were administered to Patient #1 without a provider order.

c. Patient #4 was a [AGE] year old male admitted on [DATE] to 3/16/15, from an ALF. His psychiatric diagnoses included schizophrenia, depression, and mild mental disability.

Patient #4's record included a hospital admission order form dated 3/02/15, and signed by the NP. The admission order form included a section for medication reconciliation of current medications. Patient #4's current medications were listed in the medication reconciliation section with the name, dosage, route, and frequency. Twenty seven medications were listed.

Next to the name of each medication were two boxes. One box was labeled "Continue" and the other box was labeled "Stop." Neither of the boxes were marked for the 27 current medications that were listed for Patient #4.

A medication tracking record was created daily for Patient #4 during his admission. The medication tracking record listed the medications prescribed for Patient #4, including changes to his medications and dosages during his stay. PRN medications were also included on the form.

Patient #4's current medications were listed on his MAR and the medication tracking record dated 3/02/15. He was receiving the medications beginning 3/02/15.

During an interview on 4/03/15 at 4:50 PM, the NP reviewed the record and confirmed Patient #4's current medications were not ordered on his admission to be continued. She further confirmed the medications were given to Patient #4 without an order.

Patient #4's current medications were given without a provider order to continue them.

d. Patient #5 was a [AGE] year old male admitted on [DATE] to 3/25/15, from an ALF. His psychiatric diagnoses included schizophrenia and depression.

Patient #5's record included a hospital admission order form dated 3/09/15, and signed by the NP. The admission order form included a section for medication reconciliation of current medications. Patient #5's current medications were listed in the medication reconciliation section with the name, dosage, route, and frequency. Eleven medications were listed.

Next to the name of each medication were two boxes. One box was labeled "Continue" and the other box was labeled "Stop." Neither of the boxes were marked for the 11 current medications that were listed for Patient #5.

A medication tracking record was created daily for Patient #5 during his admission. The medication tracking records listed the medications prescribed for Patient #5, including changes to his medications and dosages during his stay. PRN medications were also included on the form.

Patient #5's current medications were listed on his MAR and the medication tracking record dated 3/09/15. He was receiving the medications beginning 3/09/15.

During an interview on 4/03/15 at 1:35 PM, the NP reviewed the record and confirmed Patient #5's current medications were not ordered on his admission to be continued. She further confirmed the medications were given to Patient #5 without an order.

Patient #5's current medications were given without a provider order to continue them.

e. Patient #7 was a [AGE] year old male admitted to the facility on [DATE] to 4/01/15, from an ALF. His psychiatric diagnoses included schizoaffective disorder, bipolar disorder, and substance abuse.

Patient #7's record included a hospital admission order form dated 3/23/15. The admission order form included a section for standing orders and another section listed Patient #7's current medications. On the form it documented Patient #7 was currently taking 16 medications and those medications were to be continued. Additionally, the form included orders for Patient #7 to receive the standing order medications. The hospital admission order form was not signed by the psychiatrist or the NP.

Patient #7's record included physician verbal orders for admission to the facility. A telephone order dated 3/23/15 at 7:10 PM, and signed by the RN, documented Patient #7 was admitted to the facility and his current medications were to be continued. The telephone order did not include standing order medications. Patient #7's current medications were not listed on the order form. The admission order was not signed by the NP as of 4/03/15.

The MAR's included in Patient #7's record documented he received the standing order medications daily beginning 3/24/15, until his discharge. Additionally, his current medications were listed and documented as taken daily by Patient #7 beginning on 3/23/15.

During an interview on 4/03/15 at 4:50 PM, the NP reviewed the record and confirmed the admission order was not signed on either document. She confirmed Patient #7 was receiving medications listed on the medication reconciliation form.

Medications were administered to Patient #7 without a signed order by a provider.

4. Nursing did not administer ordered medications to patients.

Patient #13 was a [AGE] year old male admitted on [DATE], with diagnoses of psychosis and depression.

Patient 13's record included an order for Seroquel 25 mg to be given daily at bedtime. The order was signed by the NP on 1/04/15 at 6:05 PM.

Patient #13's record included a medication administration record with a handwritten entry of Seroquel 25 mg to be given daily at 8:00 PM. The entry noted the start date for the Seroquel was 1/05/15. Seroquel was not administered to Patient #13 at bedtime on 1/04/15, as ordered.

During an interview on 4/01/15 at 4:20 PM, RN C reviewed Patient #13's record. She stated when a new medication is ordered the first dose should be given that day unless the order states otherwise. She confirmed Patient #13 should have been given a dose of Seroquel at bedtime on 1/04/15.

During an interview on 4/03/15 at 11:10 AM, the NP who wrote the Seroquel order stated it was to be started on 1/04/15. She was unable to explain why Patient #13 did not receive the first dose at bedtime on 1/04/15.

Patient #13 did not receive his medication as ordered.
VIOLATION: CONTENT OF RECORD - CONSULTS Tag No: A0464
**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 consultative findings were implemented in the plan of care for 2 of 17 patients (#1 and #5) whose records were reviewed. This resulted in a lack of comprehensive and individualized treatment for patients admitted to the hospital and had the potential to negatively effect their treatment. Findings include:

a. Patient #5 was a [AGE] year old male admitted on [DATE] to 3/25/15, from an ALF. His psychiatric diagnoses included schizophrenia and depression.

Patient #5's record included a nutritional assessment dated [DATE], and signed by the RD and dietary manager. The dietary manager documented she was unable to assess his caloric, protein, or fluid needs because no weight was documented in the record. She also documented no laboratory results were available in the record.

The hospital admission orders dated 3/09/15, included orders for the following tests: CMP (complete metabolic panel), CBC (complete blood count), Free T4, TSH (thyroid stimulating hormone), RPR (a test for syphilis), UA (urinary analysis), B12, Folate, and PT/INR (prothrombin time and international normalized ratio.) Patient #5's record had laboratory results dated [DATE], for UA and PT/INR. There were no other laboratory results in the record.

The dietary manager documented a request for Patient #5's weight and 2 laboratory tests, a CMP and BMP (basic metabolic panel). The record did not include orders for the laboratory tests requested. Patient #5 was not weighed until 3/14/15, 3 days after dietary requested the weight.

b. Patient #1 was a [AGE] year old male admitted to the facility on [DATE] to 3/31/15, from a local ED. His psychiatric diagnoses included schizoaffective disorder, substance dependence, and PTSD.

Patient #1's record included a nutritional assessment dated [DATE], and signed by the dietary manager. The dietary manager documented Patient #1 needed a carbohydrate controlled diet.

Included in the record were orders for blood glucose levels to be measured 4 times daily. Patient #1's blood glucose levels were consistently elevated from 172 mg/dl to 540 mg/dl during his admission.

The hospital orders had no diet ordered for Patient #1 upon admission. There were no further orders documented in the record for a special diet.

During an interview on 4/03/15 at 1:40 PM, the NP reviewed the records and confirmed no special diet was ordered for Patient #1. She stated she did not read the recommendations from the RD or dietary manager in patient records. The NP stated if there are concerns the RD or dietary manager would talk with her personally. The NP confirmed the conversations are not documented in patient's records.

During an interview on 4/01/15 at 5:20 PM, RN C reviewed the record. She confirmed Patient #5's weight was not recorded until 3/14/15. The RN stated "I never even see the dietary assessment." She stated she was unaware of the request for the laboratory tests and for Patient #5's weight.

Patient's nutritional consultations and recommendations were not reviewed or implemented by a provider or nursing staff involved in their care.
VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
**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 ordered test results and information necessary to monitor patients' conditions were documented in the record for 3 of 17 patients ( #5, #10, and #11) whose records were reviewed. This failure had the potential to result in an incomplete record which may effect comprehensive patient care. Findings include:

1. Patient #5 was a [AGE] year old male admitted on [DATE] to 3/25/15, from an ALF. His psychiatric diagnoses included schizophrenia and depression.

Patient #5's record included a medical evaluation, which was completed on 3/10/15. The medical evaluation documented an extensive history of abdominal surgeries with associated complications over the last 5 months. During 1 of his admissions Patient #5 was hospitalized for a 2 month period. At that time Patient #5 had a tracheostomy, PEG tube, MRSA, and repair of wound dehiscence with significant malnutrition problems. Upon his admission to the facility Patient #5 had large retention sutures to his abdomen which were to be removed 2 days after his admission to the hospital.

a. On 3/09/15, the LPN documented Patient #5 had scabs with multiple open areas, redness at the incision site, and drainage. There were no measurements documented, and no description of the drainage. Additionally, there were no VS documented on the date of his admission.

On 3/23/15, the LPN documented Patient #5 had open area at the incision site with redness in color. There were no measurements or drainage documented.

The nurses notes did not include documentation regarding Patient #5's wounds or his history of MRSA.

On 3/25/15 at 1:15 PM, the LMSW documented she spoke with an ALF and they indicated Patient #5 may be accepted if his wounds were cultured for MRSA and came back negative. A nursing note dated 3/25/15, documented Patient #5's wounds were cultured by the RN at 9:45 AM. There were no results from the wound culture in Patient #5's record.

During an interview on 4/01/15 at 5:20 PM, RN C reviewed the record and confirmed the wound culture was done on the day of Patient #5's discharge. She stated she was unaware of Patient #5's history of MRSA. RN C further confirmed weekly wound measurements were not completed.

b. On 3/12/15 at 2:00 PM, the VS record documented Patient #5 had an elevated temperature of 100.9. There was no documentation the P.T. notified the RN of the elevated temperature. Additionally, there was no documentation the physician was notified or the temperature was treated with medication.

On 3/20/15 at 8:44 PM, the nurses note documented Patient #5 had an elevated temperature of 100.4. There was no documentation the P.T. notified the RN of the elevated temperature. Additionally, there was no documentation the physician was notified or the temperature was treated with medication.

During an interview on 4/01/15 at 5:20 PM, RN C reviewed the record and confirmed elevated temperatures were documented for Patient #5. RN C confirmed the MD was not notified of the elevated temperature measurements.

Patient #5's record did not contain the information necessary to monitor his condition appropriately.






2. Patient #10 was a [AGE] year old male admitted on [DATE], from an ALF. His psychiatric diagnoses were conduct disorder and depression. Additional diagnoses included history of a stroke, seizure disorder, non-insulin dependent diabetes, and constipation.

Patient #10's record included a nursing flow sheet, signed by the RN on 11/08/14 at 9:35 AM. The flow sheet contained sections to document assessment of Patient #10's physical and behavioral status, pain, and current safety precautions in effect. However, the flow sheet was blank. Patient #10's record did not include a nursing assessment for the day shift on 11/08/14.

Patient #10's record included a nursing flow sheet, signed by the RN on 11/09/14, untimed. The flow sheet contained sections to document assessment of Patient #10's physical and behavioral status, pain, and current safety precautions in effect. However, the flow sheet was blank. Patient #10's record did not include a nursing assessment for the day shift on 11/09/14.

During an interview on 4/01/15 at 4:30 PM, RN C reviewed Patient #10's record and confirmed the 2 nursing flow sheets were blank and there was no patient assessment documented during those 2 shifts.

Patient #10 record did not include an assessment of his physical and behavioral status on every shift.

3. Patient #11 was a [AGE] year old female admitted on [DATE], from a SNF. Her psychiatric diagnoses were psychosis, bipolar disorder and congenital brain injury with mental disability. Additional diagnoses included renal insufficiency, CHF and diabetes.

Patient #11's admission orders included the following laboratory tests: CMP, CBC, Free T4, TSH, RPR, UA, B12, Folate, Depakote level and Hgb A1C. An entry on Patient #11's MAR, initialed by the RN, documented her blood was drawn and sent to the laboratory on 11/26/14.

Patient #11's record included results of a UA. However, her record did not include results of the blood tests ordered at the time of admission.

During an interview on 4/01/15 at 4:00 PM, RN C reviewed Patient #11's record and confirmed it did not include results of the blood tests drawn on 11/26/14. She stated the laboratory results are available through the laboratory's website, and it was the responsibility of the unit clerk to access the website, print the results and put them in the patients' chart. RN C confirmed the test results were not always accessed online, printed and placed in the patient's chart.

Patient #11's medical record did not include results of the laboratory tests completed on 11/26/14.
VIOLATION: CONTENT OF RECORD - DISCHARGE SUMMARY Tag No: A0468
**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 discharge summaries were completed for 2 of 16 patients (#12 and #14) who were discharged and whose records were reviewed. This resulted in the potential lack in continuity of care. Findings include:

1. Patient #14 was a [AGE] year old male admitted to the facility from 2/24/15 to 2/27/15, for psychiatric care related to schizoaffective disorder with acute exacerbation and suicidal ideation. Additional diagnoses included depression, paranoia, and hypothroidism. His record did not include a discharge summary.

2. Patient #12 was an [AGE] year old male admitted to the facility from 12/26/14 to 12/30/14, for psychiatric care related to dementia and psychosis. Additional diagnoses included UTI and constipation. His record did not include a discharge summary.

During an interview on 4/03/15 at 3:40 PM, the NP reviewed Patient #12's record and confirmed it did not include a discharge summary. She stated the team of NP's and the Psychiatrist would share the load of dictating discharge summaries, and stated she knew some were overdue and should have been done.

Discharge summaries were not included in closed records.
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review, and staff interview, it was determined the facility failed to ensure patients' capacity for self-care or need for post-hospital services was evaluated during the discharge process for 1 of 16 discharged patients (#5) whose records were reviewed. This failure had the potential to negatively impact patients who were discharged by placing them in an inappropriate aftercare setting and at risk of not receiving follow-up treatment as needed or ordered to maintain their health status. Findings include:

1. Patient #5 was a [AGE] year old male admitted on [DATE] to 3/25/15, from an ALF. His psychiatric diagnoses included schizophrenia and depression.

Patient #5's psychiatric evaluation was completed on 3/10/15 by the NP. The psychiatric evaluation documented he did not know why he was admitted to the facility and included documentation that Patient #5's speech was slurred during the beginning of the interview, and he was oriented to self and only partially to place. The psychiatric evaluation further documented Patient #5 was "unaware of the world around him" and his judgment was "Markedly impaired." Patient #5 was to be assessed for dementia.

Patient #5's record included a medical evaluation, which was completed on 3/10/15. The medical evaluation documented an extensive history of abdominal surgeries with associated complications over the last 5 months. During 1 of his admissions Patient #5 was hospitalized for a 2 month period. At that time Patient #5 had a tracheostomy, PEG tube, MRSA, and repair of wound dehiscence with significant malnutrition problems. Upon his admission to the facility Patient #5 had large retention sutures to his abdomen which were to be removed 2 days after his admission to the hospital.

Patient #5's record included a social history completed by an LMSW on 3/13/15. The social history documented recommendations for coordination of discharge placement and aftercare, and Patient #5 was to return to an ALF.

Patient #5 was discharged from the facility on 3/25/15 at 3:30 PM, to a local shelter. Included on his discharge medication list was an antibiotic for infection. There was no follow up appointment scheduled with Patient #5's surgeon or a primary care provider. The discharge instructions documented his diagnoses as chronic schizophrenia with R/O dementia.

Patient #5's record included an Inpatient Diagnoses form which documented he had schizophrenia, borderline intellectual functioning, and issues with primary support. On 3/23/15, a Psychiatric Progress Note documented Patient #5 had limited judgement and insight, and he had grave disability. The progress note further documented Patient #5 had an active mental disorder present and persistent inability to care for himself, or that he may be cared for in a less restrictive environment. There was no further documentation by the NP prior to his discharge.

Additionally, Patient #5's discharge instructions included a medication list with an antibiotic for infection. Patient #5 had numerous abdominal surgeries, including post-operative complications, documented in his H&P, over the previous 5 months. Patient #5's record did not include progress notes from the MD after the initial H&P was completed. On 3/23/15, the LPN documented Patient #5 had an open area at the incision site with redness in color. There was no documentation of measurements of the open area. The discharge instructions did not include a scheduled follow up appointment with Patient #5's surgeon or a primary care provider.

During an interview on 4/03/15 at 12:55 PM, the Director of Social Services reviewed the record and confirmed the discharge plan was for Patient #5 to return to an ALF. She stated the discharge plan had not changed until the day of his discharge. The Director of Social Services confirmed Patient #5's follow-up and post-discharge needs were not comprehensively assessed.

The facility failed to assess Patient #5's ability for self-care and post-hospital needs prior to his discharge.
VIOLATION: QAPI PERFORMANCE IMPROVEMENT PROJECTS Tag No: A0297
Based on staff interview and review of policies and QAPI documents, it was determined the hospital failed to ensure distinct quality improvement projects were developed and conducted. This prevented the hospital from analyzing process in order to identify ways to improve care. Findings include:

1. The hospital's policy titled "QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PLAN" was dated effective 6/01/13. The policy stated the hospital would conduct "PI projects." The policy stated the projects would last between 3 and 12 months and would be interdisciplinary.

No PI projects that included an in depth review of processes related to patient care were documented from 1/01/14 through 3/31/15.

The Interim Quality Director was interviewed on 4/01/15 beginning at 3:05 PM. She stated the hospital had not conducted PI projects since at least 1/01/14.

The hospital failed to conduct distinct quality improvement projects.
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
Based on staff interview and review of medical records, QAPI documents, and policies, it was determined the hospital's Governing Board failed to ensure the QAPI program defined and maintained a hospital wide QAPI program. This prevented the hospital from analyzing and improving care. Findings include:

1. The hospital's policy titled "QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PLAN" was dated effective 6/01/13. The policy was not specific. For example, the policy had a section for "Data Collection" which contained general language such as "Data collection will be incorporated into existing processes and procedures" and "Data will be tracked and trended." Under the section labeled "Action to be Taken," the plan stated "Actions may include" and contained a list of items such as "Changing Process or System."

A specific plan for QAPI activities and oversight was not documented.

The Interim Quality Director was interviewed on 4/01/15 beginning at 3:05 PM. She stated the hospital had ongoing quality activities but a plan had not been developed that defined the overall QAPI program and directed staff as to how to carry out those activities.

The Governing Board failed to define the QAPI program.

2. The hospital's policy titled "QUALITY ASSESSMENT PERFORMANCE IMPROVEMENT PLAN" was dated effective 6/01/13. The policy did not define the role of the Governing Board except to state it would review the QAPI program and plan annually.

Three Governing Board meetings were documented from 1/01/14 to 3/31/15. "Governing Board Committee Minutes," dated 1/16/14, mentioned goals and tracking for contraband, skin issues, restraints and the readiness of a blood glucose machine. "Governing Board Committee Minutes," dated 4/29/14, repeated verbatim the language from the 1/16/14 minutes. "Governing Board Committee Minutes," dated 7/24/14, mentioned the number of infections, skin problems, falls, staff occurrences, and readmissions.

None of the Governing Board Minutes documented discussion or analysis of QAPI data or plans or projects.

The SNF AIT was the hospital liaison with surveyors in the absence of the Administrator. He was the was interviewed on 4/02/15 beginning at 3:20 PM. He confirmed these were all of the Governing Board Minutes and no other documentation of the Board's involvement with the QAPI program was available.

The Governing Board failed to oversee and monitor the QAPI program.

3. No PI projects that included an in depth review of processes related to patient care were documented from 1/01/14 through 3/31/15.

The Interim Quality Director was interviewed on 4/01/15 beginning at 3:05 PM. She stated the hospital had not conducted PI projects since at least 1/01/14.

The Governing Board failed to ensure the QAPI program included PI projects.
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
**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 referrals were made for follow-up or ancillary care for 1 of 16 patients (#5) who were discharged and whose records were reviewed. This failure had the potential to negatively impact discharged patients by resulting in deteriorated health status or possible readmission to an acute care facility. Findings include:

1. Patient #5 was a [AGE] year old male admitted on [DATE] to 3/25/15, from an ALF. His psychiatric diagnoses included schizophrenia and depression.

Patient #5's record included a medical evaluation, which was completed on 3/10/15. The medical evaluation documented an extensive history of abdominal surgeries with associated complications over the last 5 months. During 1 of his admissions Patient #5 was hospitalized for a 2 month period. At that time Patient #5 had a tracheostomy, PEG tube, and repair of wound dehiscence with significant malnutrition problems. Upon his admission to the facility Patient #5 had large retention sutures to his abdomen which were to be removed in 2 days of his admission to the hospital.

Patient #5's record included social history completed by a LMSW on 3/13/15. The social history documented recommendations for coordination of discharge placement and aftercare, and Patient #5 was to return to an ALF.

Patient #5's discharge instructions included a medication list with an antibiotic for infection. Patient #5 had numerous abdominal surgeries, including post-operative complications, documented in his H&P, over the previous 5 months. Patient #5's record did not include any progress notes from the medical physician after the initial H&P was completed. The H&P documented Patient #5 had a midline surgical incision which was being held with large retention sutures with rubber tubing around them that bridged over the incision. On 3/23/15, the LPN documented Patient j#5 had open area at the incision site with redness in color. There was no documentation of measurements of the open area. The discharge instructions did not include a scheduled follow up appointment with Patient #5's surgeon or a primary care provider.

Patient #5 was discharged from the facility on 3/25/15 at 3:30 PM, to a local shelter. Included on his discharge medication list was an antibiotic for infection. There was no follow up appointment scheduled with Patient #5's surgeon or a primary care provider.

An email, detailing events after Patient #5's discharge, was received by surveyors on 4/03/15 at 3:30 PM. Patient #5 was discharged from the facility on 3/25/15 at 3:30 PM, to a local shelter. The email dated 4/03/15 at 2:32 PM, and written by the VP of the hospital, was addressed to the SNF AIT.

The email documented a timeline of events that occurred after Patient #5's discharge from the hospital. Patient #5 was driven to the shelter by a hospital van after picking up his prescriptions. He was told by the shelter employees it was too early for admittance and to return between 5:00 and 6:00 PM. Patient #5 returned to the shelter several times over the course of the evening and he also went back to the facility requesting to be let in. He was refused admittance and went to the facility's corporate office the next morning. The corporate office then arranged for Patient #5 to be admitted to an ALF, after 2 encounters with police, missing personal effects, and a bloody face. There was no other documentation in the facility of Patient #5's return during the middle of the night on 3/25/15

Patient #5 was not referred or given a follow up appointment with his primary care provider or surgeon to monitor his post-operative incision or completion of his antibiotic regimen.

During an interview on 4/03/15 at 12:55 PM, the Director of Social Services reviewed the record and confirmed the plan was for Patient #5 to return to his previous ALF. She confirmed the discharge plan did not include follow up with his surgeon or a primary care physician.

During an interview on 4/01/15 at 5:20 PM, RN C reviewed the record and confirmed discharge orders did not include a follow-up appointment with his surgeon.

Patient #5's discharge orders did not include a follow-up appointment with a physician for his abdominal wounds.
VIOLATION: REASSESSMENT OF DISCHARGE PLANNING PROCESS Tag No: A0843
Based on staff interview and review of quality documents, it was determined the hospital failed to ensure a system, including a review of discharge plans, had been developed and implemented to reassess its discharge planning process on an on-going basis. This seriously impeded the hospital's ability to analyze its discharge planning process and implement corrective actions. Findings include:

A review of the hospital's discharge planning process, including a review of discharge plans, was not documented.

The Director of Social Services was interviewed on 4/03/15 beginning at 1:50 PM. She stated the hospital did not have a system to review its discharge planning process. She stated the hospital did not review discharge plans for quality and completeness.

The hospital did not review its discharge planning process.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on observation, review of policies, occurrence reports, and patient records, and staff interview, it was determined the facility failed to provide adequate numbers of staff to meet patient needs in 5 of 5 months (December 2014 - April 2015) for which patient census information and occurrence reports were reviewed. This failure resulted in the facility's inability to effectively manage the inappropriate behaviors of Patients #8 and #21, resulted in the inappropriate discharge of Patient #13, and had the potential to adversely affect the health and safety needs of all patients receiving services at the facility. Findings include:

1. A policy "Staffing of Nursing Care, Acuity Based," effective 1/04, stated "To provide safe, effective nursing care designed to support improvements and innovations in nursing practice based on both the needs of the patients to be served and the mission statement. The plan supports both standards of nursing practice and nursing standards of care. The CNO of Safe Haven is responsible and accountable to ensure that consistent standards are utilized. This plan provides an overview of the unit, which includes staffing plans based on acuity data and core staffing date. Staffing is based upon patient census and acuity. Based on census and patient acuity, the needs of the unit are evaluated on a shift or partial shift basis by the Staffing Coordinator, in collaboration with the charge nurse, in order to provide optimal patient care that is fiscally sound."

The following algorithm was included in the policy based on patient census:

Day shift staffing requirements

-1 RN per shift

-1 to 5 patients, 1 P.T.

-6 to 8 patients, 1.5 P.T.s

-9 to 13 patients, 2 P.T.s

-14 patients, 3 P.T.s

-1 to 6 patients, 0 LPN

-7 to 10 patients, 1 LPN

-11-14 patients, 1.33 LPNs

Night shift staffing requirements

-1 RN per shift

-1 to 8 patients, 1 P.T.

-9 to 14 patients, 1.5 P.T.s

-1 to 8 patients, 0 LPN

-9 to 14 patients, 1 LPN

The algorithm in the policy stated core staffing consisted of a minimum of 1 RN and 1 P.T. The policy stated, "Psych tech [psychiatric technicians] shifts- if the staffing ladder accounts for 1.5 aides, this means that one full 12 hour shift is approved and one 6 hour shift is approved. The hours may be divided amongst the scheduled Psych tech staff at the direction of the Charge RN as long as the hours stay within the approved total of 18 hours."

Additionally, the policy stated "LPN shifts- if the staffing ladder accounts for 1.33 LPN's, this means that one full 8 hour shift from 0700- 1500 [7:00 AM to 3:00 PM] is approved. At a census of 11 the LPN staff may then cover the remaining four hours of the 12 hour shift to 1900 [7:00PM]. The hours may not be allotted any other way."

Assignment sheets were completed for each 12 hour shift, day and night. The assignment sheet included sections for patients' names, level of monitoring, names of P.T.s working, and 2 hour time periods for the shift. The name of the RN in charge and the date were listed at the top of the form. It also differentiated whether it was the assignments for day or night shift. The bottom of the assignment sheet also included a section with an algorithm. The algorithm was used for staffing the facility with P.T.s depending on the census.

The section for P.T.s was numbered 1 through 5, with their names written next to the numbers. The number corresponding to the P.T. was written in the columns broken down into 2 hour time periods for the shift. The 2 hour time period columns corresponded to patient names. For example: P.T. 1 would be assigned from 6:00 AM to 8:00 AM with one patient, then from 8:00 AM to 10:00 AM, P.T. 1 would be assigned to another patient. P.T.s would not be assigned to 1 patient for the entire 12 hour shift. According to the assignment sheets reviewed, they would rotate between the patients.

The algorithm at the bottom of the assignment sheet was used for determining staffing of the facility. The algorithm for staffing P.T.s was based on census, rather than acuity. The algorithm was listed as follows:

- Patient census 0, P.T. 0 hours

- Patient census 1, P.T. 8 hours

- Patient census 2-5, P.T. 12 hours

- Patient census 6-10, P.T. 16 hours

- Patient census 11-12, P.T. 24 hours

- Patient census 13-14, P.T. 26 hours

A maximum of 14 patients could be admitted at one time. If a patient was being monitored as a 1:1 (close monitoring of the patient was required and the assigned P.T. must be within arm's reach of the patient at all times), 1 tech would be assigned for monitoring the patient and was not included in the algorithm.

A corresponding policy for close monitoring, titled "Suicide/Homicide Precautions Protocol," revised 10/12, stated a precaution level was assigned for the protection of patients requiring a safety intervention. The following precaution levels were identified and defined:

-15 minute checks: Patient was observed every 15 minutes for safety

-Line of sight (LOS): Keep patient in the line of sight at all times

-1:1 monitoring: Observation with 1:1 contact at all times

On 4/01/15 at 4:55 PM, RN C confirmed an assignment sheet was to be filled out for each shift. She stated an LPN was scheduled for medications if the patient census was greater than 8, otherwise the LPN worked 7:00 AM to 11:00 AM and came back and worked 5:00 PM to 9:00 PM. RN C stated she coordinated the staffing of P.T.s. RN C stated P.T.s worked a 12 hour shift, but depending on the algorithm they may work 4 hours, 8 hours, or the full 12 hours. She explained when 16 hours were allotted based on census, 1 P.T. would work 12 hours and another P.T. would work for 4 hours. RN C stated staffing of P.T.s was not acuity or behaviorally based, but was based on the algorithm.

During an interview on 4/02/15 at 5:05 PM, RN B confirmed the algorithm was what she used to staff the P.T. hours. She further confirmed staffing for P.T.s was based on census and algorithm, it was not acuity or behaviorally based.

However, the use of the staffing algorithm, without consideration of patient acuity was not sufficient to ensure patient needs were met, as follows:

a. During an observation on 4/02/15 at 12:00 PM, 5 patients were observed at the facility. In the dayroom there were 2 patients and 2 P.T.s present. One patient was in her assigned room, and 1 patient was observed walking in the hall. A third P.T. was observed in the nursing station behind a locked door. No RN was observed on the unit. After approximately 5 minutes, the RN was observed entering the patient unit from the other side of the locked doors.

An interview was conducted with P.T. E at 12:10 PM on 4/02/15. He stated there were 5 patients in the hospital and 3 of the patients were on 1:1 monitoring. P.T. E stated he did not feel staffing was adequate that day because only 3 P.T.s were scheduled to work. Three patients required 1:1 monitoring, therefore, the 2 remaining patients were not assigned a P.T.

During an interview on 4/02/15 at 5:05 PM, RN B stated she was a concerned about safety at the facility. She stated staffing was based on census rather than acuity. Therefore, additional staff were not added when 1 or more patients exhibited behaviors that required close observation and possible intervention, to prevent injury to themselves or others.

b. On 3/07/15 at 3:15 PM, a P.T. note attached to an "Occurrence Report," stated Patient #8 was aggressive toward another patient and P.T.s were able to remove him from the day room. The note also said the RN had called for all male staff on the attached SNF. Patient #8's record also included a nurses note, documented on 3/07/15 at 3:45 PM, which stated he was physically aggressive and was redirected to his room with the assist of family and staff.

Additionally, on 3/08/15 at 2:00 PM, an "Occurrence Report," completed by the RN on duty, documented Patient #8 was aggressive to another patient and that P.T.s were unable to get him moved out of the day room. The RN documented she called for any male aide on the attached SNF to come to the psychiatric hospital. The actions of the SNF male aide were not described.

The hospital's policy, assignment sheet, and algorithms did not include using aides from the adjoining SNF when additional staff were required for patient restraint.

c. On 12/05/14 at 4:30 AM, an "Occurrence Report," completed by the RN on duty, documented Patient #21 had an altercation with his roommate. The report included a nurses note documenting Patient #21 was placed on "1:1/LOS." However, the facility's
"Suicide/Homicide Precautions Protocol," did not include a definition for "1:1/LOS."

Without clear instruction to staff, it would not be possible to determine if adequate numbers of staff were present to meet patient needs.

d. Patient #13's record documented he was a patient in the hospital from 1/01/15 to 1/05/15, with diagnoses of psychosis and depression. His record included a social service progress note, dated 1/05/15. The note stated "When SS discussed discharges with [NP] she reported that due to staffing [patient] was being discharged ."

During an interview on 4/03/15 at 2:45 PM, the SS Assistant who wrote the note stated she remembered the conversation with the NP. She stated during the Treatment Team meeting it was determined there were not enough staff to take care of the number of patients that were in the hospital, therefore someone had to be discharged . She stated Patient #13 was closest to his planned discharge date so he was the one who was discharged .

The facility failed to ensure adequate number of staff were provided to meet patients' health and safety needs.
VIOLATION: TIMELY DISCHARGE PLANNING EVALUATIONS Tag No: A0810
**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 discharge planning needs were identified and developed for 1 of 17 patients (#5) whose records were reviewed. This failure resulted in inappropriate discharge to a homeless shelter, rather than returning to an ALF setting. Findings include:

1. Patient #5 was a [AGE] year old male admitted on [DATE] to 3/25/15, from an ALF. His psychiatric diagnoses included schizophrenia and depression.

Patient #5's psychiatric evaluation was completed on 3/10/15 by the NP. The psychiatric evaluation documented he did not know why he was admitted to the facility and included documentation that Patient #5's speech was slurred during the beginning of the interview, and he was oriented to self and only partially to place. The psychiatric evaluation further documented Patient #5 was "unaware of the world around him" and his judgment was "Markedly impaired." Patient #5 was to be assessed for dementia.

Patient #5's record included a medical evaluation, which was completed on 3/10/15. The medical evaluation documented an extensive history of abdominal surgeries with associated complications over the last 5 months. During 1 of his admissions Patient #5 was hospitalized for a 2 month period. At that time Patient #5 had a tracheostomy, PEG tube, MRSA, and repair of wound dehiscence with significant malnutrition problems. Upon his admission to the facility Patient #5 had large retention sutures to his abdomen which were to be removed in 2 days after his admission to the hospital.

Patient #5's record included social history completed by a LMSW on 3/13/15. The social history documented recommendations for coordination of discharge placement and aftercare, and Patient #5 was to return to an ALF.

Social service progress notes documented working on Patient #5's discharge placement beginning on 3/14/15, 5 days after admission. The SS Assistant documented at 3:57 PM, she spoke with the Administrator for Patient #5's previous ALF and they would not take him back upon discharge.

On 3/25/15 at 1:15 PM, the LMSW documented she spoke with an ALF and they indicated Patient #5 may be accepted if his wounds were cultured for MRSA and came back negative. A nursing note dated 3/25/15, documented Patient #5's wounds were cultured by the RN at 9:45 AM. There were no results from the wound culture in Patient #5's record.

The LMSW documented Patient #5 did not want to stay at the hospital and he wanted to go to the shelter. She documented Patient #5 was competent to make decisions, but did not necessarily make the best choices. Patient #5 was discharged from the facility on 3/25/15 at 3:30 PM, to a local shelter.

During an interview on 4/03/15 at 12:55 PM, the Director of Social Services reviewed the record and confirmed the plan was for Patient #5 to return to his previous ALF. She confirmed the wound culture was not done prior to the day of discharge.

During an interview on 4/01/15 at 5:20 PM, the RN reviewed the record and confirmed the wound culture was done on the day of Patient #5's discharge.

The facility failed to ensure appropriate laboratory tests and arrangements were made for Patient #5 to prevent a delayed discharge.
VIOLATION: QAPI Tag No: A0263
Based on staff interview and review of policies and QAPI documents, it was determined the hospital failed to ensure a hospital wide data driven QAPI program was fully developed, implemented, and maintained. This resulted in the hospital's inability to monitor its services and improve the quality of patient care based on relevant data. Findings include:

1. Refer to A273 as it relates to the failure of the hospital to ensure the QAPI program showed measurable improvement in indicators and the failure to analyze quality indicators. Additionally, refer to A273 as it relates to the hopital's failure to use data to monitor the effectiveness and safety of services, and to specify the frequency and detail of data collection.

2. Refer to A283 as it relates to the failure of the hospital to ensure the QAPI program used data to identify opportunities for improvement and failed to identify high-risk, high-volume, or problem prone areas in order to focus its QAPI program.

3. Refer to A286 as it relates to the failure of the hospital to ensure the QAPI program identified adverse patient events, analyzed their causes, and implemented actions to prevent further adverse events.

4. Refer to A297 as it relates to the failure of the hospital to ensure distinct quality improvement projects were developed and conducted.

5. Refer to A309 as it relates to the failure of the hospital to ensure the Governing Board defined and maintained a hospital wide QAPI program.

The cumulative effect of these negative systemic practices prevented the hospital from identifying deficient practices and taking action to correct them.
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on review of the facility's grievance file and staff interview it was determined the facility failed to review, investigate and resolve patient grievances within a reasonable time frame. This resulted in potential for poor quality of care and placed patients at risk of harrassment and abuse by staff. Findings include:

A facility policy titled "Grievances/Complaints," effective 9/13/11, included the following procedures:

-Grievances will be collected from a locked box by the Administrator/designee Monday through Friday, excluding holidays.

-The administrator or designee will be responsible for grievance complaint investigation.

-Upon receipt of a written grievance complaint, the Administrator/designee will investigate the allegations and develop a report of such findings within 24 hours of receiving the grievance complaint.

This policy was not followed. Examples include:

1. One grievance written by a patient dated 12/15/14, stated "Nurse [name] and teck (sic) [P.T. D] co-insided (sic) one with the other to force me into an arguable (sic) instance that lead to an anxiety attack." The back section of the form, used to indicate the grievance was addressed, and resolved, was blank.

2. A grievance written by a patient dated 12/15/14, stated "[P.T. D] was near the TV. I walked in sat down on the reclyner (sic) and asked if I could watch TV. And he said 'We are not doin that crap and that's just how it is.' With attitude." The form included a question "How do you want the suggestion/grievance corrected?" The patient wrote "I want him to stop belittling the patients." The back section of the form, used to indicate the grievance was addressed, and resolved, was blank.

3. A grievance written by a patient dated 12/15/14, stated "I was sitting eating my dinner and [patient name] started talking about his girlfriend. [P.T. D] pops off said something sexual about his girlfriend. That got [patient name] to get very upset & [patient name] said i'll kill you before you touch my girl. [P.T. D] popped off and said that will get you more time here & [patient name] exploded." The form included a question "How do you want the suggestion/grievance corrected?" The patient wrote "I want him to stop belittling the patients when no one is around. His attitude is horrible." The back section of the form, used to indicate the grievance was addressed, and resolved, was blank.

4. Another grievance, dated 12/15/14, complained of P.T. D's disrespect towards patients when asking about a smoke break. The writer of the grievance did not include any further details related to the incident. The form included a question "How do you want the suggestion/grievance corrected?" The patient wrote "He need to talke (sic) beter (sic) to clients and tret (sic) us beter (sic). We are people." The back section of the form, used to indicate the grievance was addressed, and resolved, was blank.

5. A grievance, written by a patient dated 3/28/15, stated "[P.T. D] AM tech. My 2nd day here I complained that he just threw my belongings in my room. He was told not to talk or even look at me but he continued to do so. Today (Saturday) he starts making comments to me 1st thing when I woke up. I've been ignoring it and staying in my room most of the day. I've said thank you to him; have a good lunch, thanks when he lit my cigs, and staying in my room all day to avoid him. Now he's on the phone talking about me, saying I'm the one being an ass to someone. I'm so sad. Today I get to see my service puppy and should be happy. This was approved by [name of NP]. He walked by me while ago saying I can't see my dog. Also another staff let me keep muscle rub, dog treats for tonight & some trail mix. He tore my room up in a search but I was compliant. This harrasment is not right. He even brings others ice but not me when I asked." The grievance did not include documentation of investigation or resolution.

6. In a grievance dated 3/26/15, a patient wrote "[tech name] was belittling me, condescending me, made me keep begging making negative comments, faces, telling me to sit down. Refuses to light my cig. She got another patient upset when she finally...lit one. I went to a corner, sat in the sun. Then 2 other patients came over to me. We sat and enjoyed our smokes...with no discussion of incidents. When I told her Thank You, she loudly says to [another tech] "someone is going to lose smoke privleges." The form included a question "How do you want the suggestion/grievance corrected?" The patient wrote "Remind the staff we are their paycheck, adults, and attempting (with their help) to better ourselves. Snide comments, looks, etc from them is Never OK." The grievance did not include documentation of investigation or resolution.

During an interview on 4/03/15 at 4:20 PM, the Program Director stated patients could complete a form titled "Suggestion/Grievance/Compliment" and insert it in a box on the nursing unit. He stated it was his responsibility to retrieve the forms from the box, sort and distribute them to the appropriate person. He stated he gave forms related to nursing to the CNO, and all others to the Administrator. However, since the CNO resigned on 1/24/15, all forms were given to the acting Administrator. He stated after a grievance was resolved, the action taken was documented on the back of the form and the form was returned to him to be filed in the Grievance binder.

During the same interview, the Program Director stated he had given 6-12 grievances to the Administrator in the last 2-3 months, however, the grievances had not been returned to him for filing. He stated as far as he knew, no action had been taken to resolve the grievances submitted in the last 2-3 months.

During an interview on 4/03/15 at 5:00 PM, the Co-Owner confirmed the grievances had not been addressed, and was not able to provide an explanation for the failure of the facility to investigate, take action, and resolve the grievances.

The facility failed to review, investigate, and respond to patient grievances.