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OPTIONS BEHAVIORAL HEALTH SYSTEM 5602 CAITO DRIVE INDIANAPOLIS, IN 46226 March 5, 2015
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review, and interview, the director of nursing service failed to ensure the fall policy was implemented for 2 of 2 patients with a fall episode (patients #3 and #6); failed to ensure that nursing personnel implemented physician orders for lab work, or delayed in the implementation of lab orders, for 3 of 4 closed patient records (patients #1, #2, and #4); and failed to monitor the receipt of lab results for physician review for 2 of 6 open records (Patients #7 and #8).

Findings:
1. Review of the policy "Fall Assessment & Precautions", policy number CTS-226, last reviewed on 2/2014, indicated:
a. On page one under "Policy", it reads: "...In the event of a fall occurrence,...the patient will be re-assessed every day until the patient scores below 6 on the fall assessment...".
b. On page one under "Procedure", it reads in item 2.: "2. Patients will be scored as follows: 0-5 = low risk 6-12 = moderate risk 13-35 = high risk".
c. On page two under "Procedure", item #5., it reads: "5. Re-Assessment After a Fall - Charge RN (registered nurse)/Primary RN - Fall Precautions for Moderate-High Risk:...Fall risk identified on treatment plan...".
d. On page two under "Procedure", item #6., it reads: "6. Re-Assessment after a Fall - Charge RN/Primary RN: Re-assess fall risk every day...".

2. Review of medical records indicated:
a. Patient #3:
A. Was a [AGE] year old admitted on [DATE] with an admission fall risk score of 13 (per policy, a high risk).
B. fell on [DATE] at 8:30 AM.
C. Lacked documentation of being care planned for falls, either before, or after the fall.
D. Lacked documentation of re assessment of a fall risk every day after the fall.
b. Patient #6:
A. Was a [AGE] year old admitted on [DATE] with an admission fall risk score of 11 (moderate fall risk).
B. fell on [DATE] at 8:35 AM.
C. Lacked documentation of re assessment of a fall risk every day after the fall.

3. At 11:30 AM on 3/5/15, interview with staff member # 53, a unit RN (registered nurse), indicated:
a. There have not been daily fall risk assessments completed for pt. #6 since their fall of 2/26/15.
b. It is currently not a process to complete daily fall risk assessments on patients after a fall.

4. Review of medical records indicated:
A. Pt. #1 was a [AGE] year old admitted on Tuesday, 6/17/14, with admission labs ordered for: CBC, CMP, albumin, protein, B12, TSH, Folate, and a urinalysis - dip, that weren't submitted by nursing to the contracted lab until 6/29/14, with results on 6/30/14 only for: Albumin, Folate/Folic Acid, Vitamin B12, Ammonia, and valproic acid. (These labs were not present in the chart upon medical record review and had to be retrieved from the contracted lab on 3/3/15.)
B. Pt. #2 was a [AGE] year old admitted on Saturday, 6/21/14, with admission labs ordered that weren't drawn and sent by nursing to the contracted lab until Tuesday, 6/24/14, with results to the facility the morning of 6/25/14.
C. Pt. #4 was an [AGE] year old patient admitted on Thursday, 9/18/14 with admission orders for labs that included a VDRL and ammonia level. Blood was drawn and sent on Monday, 9/22/14, but the VDRL and ammonia were not checked on the lab requisition form and results for those two tests were lacking in the medical record.
D. Pts. #7 and #8 were admitted to the facility on [DATE] (Friday) with admission labs ordered and lab requisitions indicating specimens were drawn on 2/28/15. There were no lab results in either medical record by 1:00 PM on 3/4/15 (Wednesday).

5. At 3:15 PM on 3/3/15, interview with staff member #50, the CEO (chief executive officer), indicated:
a. Labs for patient #1 were not present on this closed record, and had to be requested from the contracted lab company today, 3/03/15, indicating they were not available for physician review, and treatment, before the patient's discharge on 7/1/14.
b. There was "no explanation" for 6/17/14 ordered labs, for pt. #1, not being drawn until 6/29/15.
c. It is not clear in a policy, or in the lab contract, what the expectation for receipt of lab reports is for the contracted lab company. There is no facility policy.
d. When patients are admitted on Friday afternoon, Saturday, or Sunday, admission labs not picked up until a Monday delays physician care and treatment of the elderly, frail patients admitted to the gero psych unit.
e. Pt. #2 was admitted on Saturday and should have had labs drawn on Monday, 6/23/14, not Tuesday, 6/24/14.
f. Pt. #4 was admitted on a Thursday, 9//18/14 and should have had labs drawn on Friday, 9/19/14.

6. At 1:05 PM on 3/4/15, interview with staff member #53, a unit RN, indicated this staff member had called the contracted lab company on 3/3/15 for results of labs sent for patients #7 and #8, with labs not yet received. (A second call the AM of 3/4/15 resulted in the receipt of lab reports for pts. #7 and #8.)

7. At 4:10 PM on 3/4/15, interview with staff member #55, the medical physician for the facility, indicated:
a. The medical records, and labs, of patients #1, 2, and 4 were reviewed and it was agreed that labs were delayed, or not sent by nursing staff, as listed in 4. above.
b. There have been previous conversations with the contracted lab company regarding weekend lab pick up needs and receipt of lab reports. It was thought that the process had improved.
c. Lab results are available on line, but it is unknown if nursing personnel have the password to be able to access these for a more timely placement in patient medical records.