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.

OSAWATOMIE STATE HOSPITAL PSYCHIATRIC 500 STATE HOSPITAL DRIVE OSAWATOMIE, KS Oct. 30, 2014
VIOLATION: NURSING SERVICES Tag No: A0385
Based on medical record review, document review, and staff interview the hospital's nursing staff failed to supervise and evaluate the care for each patient; failed to provide necessary medications to treat patient medical needs; failed to correctly transcribe physician orders; failed to clarify physician orders; failed to obtain laboratory tests and physician consultation; failed to notify physician of changes in patient's condition; failed to develop and keep current patient plans of care based on ongoing assessments and patient responses to interventions (refer to A-0395 and A-0396) and failed to ensure the safe use of medications (refer to A-0405). These failures resulted in the deterioration of patients' physical condition. The lack of an effective nursing service resulted in an immediate jeopardy identified on 10/30/14.



The cumulative effect of the systematic failure to supervise and evaluate the care for each patient; to provide necessary medications to treat patient medical needs; to correctly transcribe physician orders; to clarify physician orders; to obtain laboratory tests and physician consultation; to notify physician of changes in patient condition; to develop and keep current patient plans of care and to ensure the safe use of medications resulted in the hospital's inability to provide care in a safe and effective manner. .
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


The hospital reported a census of 258 patients with a licensed bed capacity of 206 beds. Based on observation, medical record review, document review, and staff interview the hospital ' s nursing staff failed to supervise and evaluate the care of each patient and provide necessary medications to treat patients' medical needs, correctly transcribe physician orders, clarify physician orders, and obtain ordered laboratory tests and physician consultation that resulted in the deterioration of patient's physical condition for two of twenty five sampled patients (patient #'s 9 and 24). Failure to supervise and evaluate patient's medical conditions places patients at risk for inadequate care.




Findings include:


- Registered Nurse Position Description reviewed on 10/22/14 at 4:30pm directed nursing staff to "...respond to, assess, intervene and provide direction in both physical and psychiatric
crisis/emergency situations..." and "...perform direct nursing care to insure individualized quality patient care by utilizing appropriate Hospital/Nursing Service standards..." and
..."communicate all known medical issues to unit physician and document such..."


- The hospital ' s patient care policy " Assessment " reviewed on 10/29/14 at 3:40pm directed, " ...Initial and ongoing assessments are crucial to determine the appropriate care, treatment and services needed to meet the patients ' needs. During the course of hospitalization , the patients' needs may change; therefore it is important that reassessments are performed when clinically indicated".


- The hospital ' s medical management policy " Preparation, administration and Documentation of Medications " reviewed on 10/29/14 at 3:40pm directed, " ...Any missed dose (of medication)-Report all missed doses to the RN (registered nurse) who will inform the physician ... "


- The hospital's nursing policy "Assessment of Wounds/Major Injuries reviewed on 10/29/14 at 4:55pm directed "...A. ACTION BY NURSING STAFF 1. Treatments, Dressing Changes, and Assessment During each treatment application &/or dressing change, the RN/LPN will assess and document the following in a Progress Note: Location, Size...Dressing...Color, Temperature, Edema, Odor, Moisture and Appearance of Skin around the wound and if Exudate and drainage are present. 4. Assessment of Peripheral Edema (swelling) from the initial time of occurrence the RN/LPN will; Establish a Temporary Issue addressing the location and type of edema (pitting or non-pitting) Write a Progress Note which includes the details of the initial assessment, and the location and type of the edema, physician notification, and any type of treatment the patient received Enter into the Patient Care System a Nurses order for the protocol of assessment of the edema as follows; a) RN/LPN to Assess and Document (insert edema site) every shift RN/LPN are to document in a Progress Note the following per protocol with each assessment: Location, Size (circumference may be measured using a cloth or paper measuring tape Skin Integrity-color, temperature, moisture, Appearance Pitting or Non-pitting edema.


- The hospital's Nursing Services (LD-3.21) policy directed "...Nursing care is the provision of care that is essential to the prevention of illness, helpful in the promotion, maintenance and restoration of health (both mental and physical), and well-being...D. STANDARDS OF PRACTICE Nursing services follows standards of nursing practice which are adapted for use ..., but based upon the American Nurse's Association's "Psychiatric-Mental Health, " Scope and "Standards of " Practice, 2007, and the "Code of Ethics for Nurses with Interpretive Statements, 2001".


- Patient #9's closed medical record review on 10/27/14 revealed an admission date of [DATE] with a psychiatric diagnosis of [DIAGNOSES REDACTED]


- Physician's Diagnostic Orders dated 8/24/14 at 9:10pm requested a urinalysis and urine drug screen. Lab Result notes reported on 9/2/14 indicated that no specimen was submitted for urinalysis or drug screen. The medical record lacked any nursing documentation of notification to the physician of inability to obtain patient #9's urine sample.



- Physician staff G assessed patient #9 on 8/26/14 for medical issues. Physical examination
indicated patient #9 had swelling of the legs and a superficial ulcer on the tip of the second toe left foot. Physician staff G ordered Coreg (a medication to lower blood pressure, digoxin ( a medication used to treat irregular heart rates by making the heart beat slower and stronger), clindamycin (an antibiotic) 150mg (milligrams) three times a day by mouth, physical therapy for hydrotherapy (whirlpool baths) and a pain medication.


- Patient # 9's Medication Administration Record and Vital Sign Report Sheets reviewed on 10/30/14 revealed nursing staff directed to check blood pressure prior to administration of Coreg (a medication to lower blood pressure). The medical record lacked evidence the nursing staff documented the patient's blood pressure prior to the administration of the Coreg on 8/27/14 8:00pm, 8/28/14 7:31pm, 8/29/14 7:40pm, 9/3/14 7:45pm, 9/8/14 8:22pm, 9/11/14 7:01pm, 9/12/14 8:28pm, 9/15/14 7:36am and 7:43pm, and 9/17/14 7:19pm.


- Patient # 9's Medication Administration Record and Vital Sign Report Sheets reviewed on 10/30/14 revealed nursing staff directed to check apical pulse (heart sound heard over the lowest superficial part of the heart through a stethoscope) prior to administration of Digoxin (a medication used to treat irregular heart rates by making the heart beat slower and stronger). The medical record lacked evidence the nursing staff documented the patient's apical pulse prior to the administration of digoxin on the following days: 8/28/14, 8/29/14, 8/30/14, 9/1/14, 9/2/14, 9/3/14, 9/5/14, 9/6/17, 9/7/14, 9/8/14, 9/10/14, 9/11/14, 9/12/14, 9/14/14, 9/15/14, 9/16/14, 9/17/14, 9/19/14, 9/23/14, 9/24/14, and 9/25/14.


- Nursing Care Plan #7opened 8/24/14 directed "Patient will comply with all tests and treatment related to the wound for the next 5 days. Intervention: Encourage patient to comply with treatment as ordered. Encourage patient to take medication as ordered. Change dressing as ordered. Monitor for s/sx (symptoms) of complications and immediately notify the doctor " .


- Patient #9's medical record lacked evidence the Nursing Care Plans addressed the patient's peripheral edema found on initial assessment including establishing a temporary issue addressing the location and type of edema; writing a progress note which includes the details of the initial assessment and the location and type of the edema, and any type of treatment the patient received. The medical record lacked evidence the nursing staff entered progress notes following the protocol for the assessment of edema including: location, size, skin integrity and appearance.


- Nursing notes on 8/25/14 lacked documentation of any assessment or attempted assessment of patient #9's left 2nd toe wound.



- Nursing progress note dated 8/26/14 at 2:25pm indicated patient #9 refused am meds, refused to talk to the Interdisciplinary Team (IDT) refused assessment of left 2nd toe. The medical record lacked evidence nursing staff notified the physician the patient refused their medications or refused assessment of their toe wound or nursing staff encouraged the patient to comply with their treatments.


- Nursing progress notes on 8/26/14 at 9:43pm indicated patient #9 started on an antibiotic for wound to left 2nd toe but lacked any assessment of the wound.


- Physician progress note written on 8/27/14 revealed assessment completed by physician staff H on 8/26/14: Extremities, pitting edema grade 2, no calf tenderness both legs...Has superficial ulcer tip of second toe left foot.


- Nursing notes on 8/27/14 lacked documentation of any assessment or attempted assessment of patient #9's left 2nd toe wound.



- Nursing progress notes on 8/28/14 at 9:53pm indicated patient #9 with pretibial (the area of the leg in front of the shinbone) edema and refused to allow the nurse to assess the infected toe. The medical record lacked evidence of nursing staff notification to the physician regarding the refusal of the assessment or nursing staff encouraged the patient to comply with their treatments or nursing staff described the peripheral edema assessment protocol.



- Nursing notes on 8/29/14 lacked documentation of any assessment or attempted assessment of patient #9's left 2nd toe wound.


- Nursing notes on 8/30/14 at 9:25pm and 9:31pm indicated patient #9 refused all nighttime medications including their antibiotic. The medical record lacked evidence nursing notified the physician that patient #9 refused their medications including the antibiotic or encouraged the patient to comply with their treatments.


- Nursing notes on 8/30/14 lacked documentation of any assessment or attempted assessment of patient #9's left 2nd toe wound.


- Nursing notes on 8/31/14 lacked documentation of any assessment or attempted assessment of patient #9's left 2nd toe wound.


- Nursing notes on 9/1/14 at 1:57pm indicated patient #9 complained of feet and body pain rated at 10 on a 1-10 scale and they received pain medication. The medical record lacked documentation of any nursing assessments of patient #9 infected left 2nd toe.



- On 9/2/14 at 2:46am patient #9 complained of left foot pain at a 7 on a scale of 1-10 and received pain medication. The medical record lacked evidence of any nursing assessments of patient #9 infected left 2nd toe.


- Physical therapy (PT) evaluation and treatment notes on 9/2/14 at 10:13am indicated patient had whirlpool therapy for ten minutes followed by debridement (removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue) of left 2nd toe. Tip of toe has open sore measuring 1.0 cm (centimeter) X 0.7 cm. wound cleanser applied and covered with gauze bandage and taped in place.



- Patient #9 requested pain medication for right foot pain on 9/3/14 at 2:43am.The medical record lacked evidence of any nursing assessment of patient #9's right foot or their infected left 2nd toe or nursing staff encouraged the patient to comply with their treatments.


- Nursing notes on 9/3/14 at 12:40pm and 12:49pm indicated patient #9 continued on an antibiotic for the wound to the left 2nd toe and had complained of foot pain twice and received pain medication and the patient refused to allow the wound on the left 2nd toe to be examined. The medical record lacked evidence nursing notified the physician patient #9 refused assessment of their left 2nd toe or they encouraged them to comply with their treatments.


- Nursing notes on 9/3/14 at 10:21pm indicated patient continues on antibiotic with no adverse effects and lacked evidence of any nursing assessment or attempted assessment of their infected left 2nd toe.


- PT treatment notes on 9/4/14 at 9:31am indicated patient had eschar (dead tissue that falls off (sheds) from healthy skin) still covering most of open area of their left 2nd toe wound.


- Nursing notes on 9/4/14 at 10:30pm indicated patient continues on antibiotic with no adverse effects and lacked evidence of any nursing assessment or attempted assessment of their infected left 2nd toe.


- Licensed Practical Nursing staff progress notes on 9/4/14 at 10:49pm indicated patient #9 requested pain medication at 4:03pm and at 9:30pm for left foot pain rated "over10" both times. The medical record lacked any evidence of any nursing assessment of the left foot.



- Nursing progress notes on 9/5/14 at 12:31pm indicated patient #9 continued on antibiotic, refused an assessment of their toe and had requested pain medication in the morning for complaint of body pain. The medical record lacked evidence nursing notified the physician patient #9 refused assessment of their infected toe or encouraged them to comply with their treatments.


- Nursing progress notes on 9/6/14 at 5:15am indicated patient #9 requested and received pain medication for right foot pain twice during the night. The medical record lacked evidence of nursing assessments of patient #9's right foot or their infected left 2nd toe during this shift or any time on 9/6/14.


- Nursing progress notes on 9/7/14 at 0751 indicated patient #9 received pain medication at 5:50am for foot pain. The medical record lacked evidence of nursing assessments of patient #9's infected left 2nd toe.


- Nursing progress note on 9/7/14 at 9:23pm indicated patient refused all nighttime medications. RN was notified. The medical record lacked evidence nursing staff notified the physician of the missed medications or nursing staff encouraged the patient to comply with their treatments.


- Nursing notes on 9/8/14 at 5:36am indicated patient #9 requested and received pain medication for foot pain at 12:57am. The medical record lacked evidence of nursing assessments of patient #9's infected left 2nd toe.


- PT treatment notes on 9/9/14 at 10:28am indicated debridement of left 2nd toe completed and eschar still covering most of open area.



- Nursing progress notes on 9/9/14 at 10:55pm indicated patient requested pain medication for unrated left foot and ankle pain at 8:22pm. The medical record lacked any nursing assessment of the infected left 2nd toe.


- General progress notes on 9/10/14 at 2:30pm indicated patient #9 wanted a nurse to give them pain medication for his left foot saying that it was "more swollen and painful." and refused to allow staff to assess their toe. The medical record lacked evidence nursing notified the physician when patient #9 refused assessment of their infected toe or the nursing staff encouraged the patient to comply with their treatments.


- Medical Physician staff H did not assess patient #9 again until 9/10/14 at 4:21pm (two weeks after the initial infected toe assessment) for left foot pain. Staff H indicated patient #9's left foot up to mid leg swollen, tender and left second toe has open ulcer, tender, no active bleeding, swelling and [DIAGNOSES REDACTED]tous. Patient #9 currently took pain medication and an antibiotic. The medical record lacked evidence that a medical physician had assessed the patient since the initial consultation on 8/26/14.


- PT treatment notes on 9/11/14 at 9:45am indicated patient refused to complete his whirlpool treatment and allow the therapist to place a dressing on his toe. The medical record lacked evidence that nursing or therapy staff notified the physician of the patient ' s refusal or encouraged them to comply with their treatments.


- Nursing notes on 9/11/14 at 11:37pm indicated patient #9 became agitated about their foot hurting and requested to see the physician. The medical record lacked evidence the nursing staff notified the physician of the patient's request or performed any assessment of the infected left 2nd toe.



- Nursing notes on 9/12/14 at 5:14am indicated patient #9 requested and received pain medication. The medical record lacked evidence of an assessment of patient #9 ' s infected toe.


- Nursing notes on 912/14 at 2:47pm indicated patient #9 requested pain medication and refused assessment of their 2nd toe left foot. The medical record lacked evidence the nursing staff encouraged the patient to comply with their treatment.


- Nursing notes on 9/13/14 at 1:38am indicated patient stated "I stay in bed all day because the cold floors hurt my foot to walk on...." and at 8:37am indicated patient #9 refused their morning medications including their antibiotic. The medical record lacked evidence nursing staff notified the physician patient #9 refused all their medications including the antibiotic and any evidence nursing staff encouraged the patient to comply with their treatments.


- Nursing notes on 9/14/14 lacked any evidence of documentation of assessment of the patient's infected left 2nd toe.


- Nursing notes on 9/15/14 at 2:01pm indicated patient #9 requested pain medication for their left toe pain and rated their pain at a 10. They continue on antibiotic. Patient #9 stated they could hardly walk and patient #9 was encouraged to elevate their foot. The medical record lacked documentation of any assessment of their infected left 2nd toe on 9/15/14.


- General progress note on 9/16/14 at 11:36 indicated that the patient stated that staff have not been taking care of their toe. The medical record lacked evidence nursing staff encouraged the patient to comply with their treatment.


- PT treatment notes on 9/16/14 indicated that the patient refused their therapy. The medical record lacked evidence therapy or nursing staff notified the physician of the patient ' s refusal or encouraged the patient to comply with their treatments.


- Physician Reorder Sheet *Non-medicated Treatments* dated 9/17/14 directed nursing staff to: Document assessment of diabetic ulcer on 2nd toe left foot every shift starting 9/17/14. If patient refuses assessment, document.


- Nursing notes on 9/17/14 at 6:08am indicated patient #9 requested and received pain medication for foot pain at 5:21am. The medical record lacked evidence nursing assessed patient #9 ' s infected toe.



- Nursing progress in treatment notes on 9/17/14 at 9:06pm indicated patient #9 had been non-compliant with medications including antibiotic and pain medication for his toe. The progress in treatment note lacked any different nursing interventions or goals addressing patient #9 ' s non-compliance.


- Nursing notes on 9/17/14 at 11:40pm indicated patient #9 had concerns about their toe and requested an assessment, dressing change, and pain medication. Nursing staff applied ointment and wrapped their toe. The medical record lacked nursing staff documentation of the wound including the exact location, size, type of dressing, the color, temperature, presence of edema, odor, moisture and appearance of the skin around the wound and if exudate and drainage are present. The medical record lacked evidence of physician orders for nursing staff to follow regarding the dressing change to the infected left 2nd toe.


- Physician staff H did not assess patient #9 again until 9/18/14 (eight days after last medical exam) for a follow up for their left foot pain. Assessment revealed left second toe tender, [DIAGNOSES REDACTED]tous, no discharge, plantar surface of the second toe gangrene, dryness and ingrown nails. Patient #9 continued on antibiotic and refused to go for hydrotherapy. Physician staff H ordered Hibiclens (a skin cleanser and antiseptic) solution to left foot daily for 7 days, a podiatry consultation, CBC (complete blood count) and BMP (basic metabolic panel) lab tests and a wound culture of the left second toe.


- Patient #9's medical record lacked evidence the podiatry consultation from 9/18/14 was ordered. The medical record lacked evidence that nursing staff notified the physician of the missed consultation. The lab result notes reported on 9/25/14 indicated the patient refused to complete lab tests (BMP and CBC) ordered on [DATE] at10:15am. The medical record lacked any nursing documentation indicating the patient refused their labs or that nursing staff notified the physician of the patient's refusal. The lab result notes reported on 9/25/14 indicated that no specimen was submitted for left toe wound culture ordered on [DATE]. The medical record lacked any nursing documentation of the missed wound culture or notification to the physician of the inability to obtain the specimen.



The Administrative Nursing staff A interviewed on 10/30/14 at 12:00pm acknowledged patient #9's medical record lacked evidence nursing staff scheduled a podiatry consult, obtained a wound culture and documented efforts to encourage compliance with medications or treatments.


- General progress notes on 9/18/14 at 1:12pm indicated that the patient refused to go to physical therapy. The medical record lacked evidence nursing staff encouraged the patient to comply with their treatments.


- Nursing notes on 9/18/14 at 2:14pm indicated patient #9 requested pain medication and an assessment of their left 2nd toe. The nursing staff documented the toe had no drainage; skin is discolored and dark in color on the bottom. The medical record lacked complete documentation of the wound including the temperature, presence of edema, odor, or moisture and dressing applied.


- PT treatment notes on 9/18/14 indicated patient refused therapy. The medical record lacked evidence the therapy or nursing staff notified the physician of the patient ' s refusal and lacked documentation the nursing staff encouraged the patient to comply with their treatments.


- Nursing notes on 9/19/14 at 1:51am indicated patient received pain medication and refused assessment of the affected area. The medical record lacked evidence the nursing staff notified the physician of the patient ' s medication refusal and encouraged the patient to comply with their treatments.



- Nursing notes on 9/19/14 at 2:21pm indicated patient #9 refused assessment of their toe. The medical record lacked evidence nursing staff encouraged the patient to comply with their treatments.



- Nursing notes on 9/19/14 at 6:21pm indicated patient #9 refused to allow assessment of their toe. The medical record lacked evidence nursing staff encouraged the patient to comply with their treatment.



- Nursing notes on 9/19/14 at 10:39pm indicated the nurse noticed patient #9 limping and offered them pain medication. The patient refused medication or assessment of the left second toe. The medical record lacked evidence nursing notified the physician of the change in condition for patient #9 or encouraged them to comply with their treatments.


- The medical record lacked nursing staff documentation of an assessment of patient #9's infected left 2nd toe the night shift of 9/19/14.


- Nursing notes on 9/20/14 10:03am indicated patient refused all his morning medications. The medical record lacked evidence nursing staff notified the physician of the missed medications and nursing staff encouraged patient #9 to comply with their treatments.


- Nursing notes on 9/20/14 at 2:30pm indicated patient #9 refused assessment of their infected second toe. The medical record lacked evidence nursing staff encouraged the patient to comply with their treatments.


- Nursing notes on 9/20/14 at 10:39pm indicated patient refused assessment of his left 2nd toe. The medical record lacked evidence the nursing staff encouraged the patient to comply with their treatments.



- Nursing notes on 9/21/14 at 7:34am indicated patient #9 received pain medication at 2:39am and refused assessment of their infected toe. The medical record lacked evidence the nursing staff encouraged the patient to comply with their treatments.


- General progress notes on 9/21/14 at 1:26pm indicated patient stated "I'm refusing medications from now". The Medication Administration Record indicated that patient had refused medications the morning of 9/20/14 and 9/21/14. The medical record lacked evidence that nursing staff notified the physician either day of the patient's refusal to take their medications and to encourage them to comply with their treatments.


- Nursing notes on 9/21/14 at 9:04pm indicated patient #9 refused assessment of their infected toe. Nursing notes on 9/21/14 at 9:46pm indicated patient #9 refused all medications. The medical record lacked evidence nursing notified the physician patient #9 refused their medications or encouraged the patient to comply with their treatments.


- Nursing notes on 9/22/14 at 12:10am indicated patient #9 requested and received pain medication and allowed the nurse to assess their infected toe but refused a dressing. The medical record lacked nursing documentation of the wound description including size, color, drainage, temperature, presence of edema, odor, and moisture and any evidence nursing staff encouraged the patient to comply with their treatments.



- Nursing notes on 9/22/14 at 2:12pm indicated patient #9 refused assessment of their infected toe and morning medications. The medical record lacked evidence the nursing staff notified the physician of the missed medications or the nursing staff encouraged the patient to comply with their treatments.


- Nursing notes on 9/22/14 at 9:54pm indicated patient #9 requested and received pain medications at 5:33pm and refused their evening medications. The medical record lacked evidence the nursing staff notified the physician of the missed medications or encouraged the patient to comply with their treatments. The medical record lacked documentation of a nursing staff assessment of the patient's infected left 2nd toe on the evening shift 9/22/14.


- Nursing notes on 9/23/14 at 6:04am indicated patient #9 requested and received pain medications and refused to allow assessment of their foot. The medical record lacked evidence the nursing staff encouraged the patient to comply with their treatments.


- The medical record lacked documentation of a nursing staff assessment of the patient's infected left 2nd toe on the day, evening, and night shifts 9/23/14 and the day and evening shifts 9/24/14.


- Nursing progress notes on 9/25/14 indicated at 1:40am nursing staff assessed patient #9's toe. Documentation indicated "the entire foot is red with flaking dry skin. The end of the second toe is black with white flaking skin around the tip 1 cm vertically and 1.5 cm across distal to the nailbed. Proximal to the nailbed the skin appears darker and lower on the toe next to the third toe a half circle 1 cm at the base appears darker. The skin between the great toe and the second toe is intact and the skin between the second toe and third toe is intact." The wound assessment lacked documentation of the temperature, presence of edema, odor, and moisture and type of dressing applied. The medical record lacked evidence the physician was notified of the change in the patient's condition.


- Medical Physician staff H did not assess patient #9 until 9/25/14 (7 days after the last exam) at 10:49am and found his left leg to be [DIAGNOSES REDACTED]tous, tender, warm, swollen, left first toe tender, planter surface gangrene. Physician staff H documented the patient has known history of diabetes mellitus and the patient is noncompliant with the antibiotic treatment. Patient #9 required transfer to an acute care hospital on [DATE] for left leg cellulitis and gangrene and underwent amputation of the second toe of his left foot.



- Physician progress notes on 9/30/14 indicated patient #9 remained at the medical hospital and required an amputation of the left second toe.



- Nursing staff failed to: monitor vital signs prior to administration of medications, supervise and evaluate the nursing care needs of patient #9, create care plans to address the patient's peripheral edema, revise the patient's care plan regarding compliance with treatments, obtain physician orders for dressing change, notify the patient's physician of the patient's medication refusals or changes in condition, schedule a podiatry consultation, obtain laboratory tests, obtain a wound culture, and to encourage patient #9 to comply with their treatments. These failures resulted in the deterioration of the patient's physical condition and necessitated a transfer of the patient to a higher level of care and an amputation of a toe.




- Patient #24's closed medical record reviewed on 10/29/14 revealed a transfer date of
6/13/14 from a community hospital with a psychiatric diagnosis of [DIAGNOSES REDACTED]

- Admission evaluation notes on 6/14/14 revealed Physician staff J's knowledge that patient #24's history included a DVT diagnosed approximately three to four months ago. A lab test completed on 6/13/14 at the hospital the patient transferred from showed a non-therapeutic Protime International Normalized Ratio (PT/INR- a test to measure the time it takes for blood to clot) of 1.1 (Therapeutic level is 2-3). Physician staff J ordered lab tests including a PT/INR, comprehensive metabolic panel (CMP) and a complete blood count (CBC) to be drawn on 6/16/14.

- Physician orders dated 6/13/14 required Coumadin (medication used to prevent harmful
blood clot from forming or growing larger) 5mg by mouth every other day and Coumadin 7.5mg every other day. Physician orders directed staff to begin Coumadin 7.5mg on 6/14/14 and Coumading 5 mg on 6/15/14.


- Pharmacist Staff B provided printed page of patient #24 ' s medication order entered by the nursing staff on 6/13/14. The printed page revealed nursing staff entered a Coumadin order of 5mg to be given every day at 8:00pm and a Coumadin order of 7.5mg to be given every day at 8:00pm. Pharmacist Staff B indicated this would be an unsafe dosage of Coumadin.


- Pharmacist Staff B provided a fax sent on 6/13/14 at 10:59pm to nursing staff on patient #24's unit requesting clarification of the Coumadin dose. Fax indicated that "this is a significant dosage increase. Order is not adequate for entry. Entered at approximately 200% of written dose". The medical record lacked evidence that nursing staff responded to the request for clarification.


- ADON staff A, interviewed on 10/30/14 at 9:10am indicated faxes are used for communication between nursing staff and pharmacy for order clarification. Nursing
is to follow up with the doctor after receiving a request for clarification request fax from the pharmacist.


- Patient #24's nursing care plan dated 6/14/14 directed "...Patient will have therapeutic lab
values for Coumadin therapy within three days..." Interventions included: "Follow up with labs as ordered. Administer anti-coagulant as ordered. Monitor patient for increase bleeding, bruising".


- Patient #24's Treatment Plan dated 6/14/14 directed "Patient will have no complications associated with DVT/PE during hospitalization ". Interventions included: "will evaluate health status and monitor symptoms as needed to treat DVT/PE: prescribe and monitor response to coumadin..."


- Nursing progress note on 6/14/14/ at 8:49pm indicated that patient #24 refused 08:00am and 08:00pm medications (including the Coumadin). The medical record lacked documentation nursing staff notified the physician at the time of the patient's medication refusal. Nursing documentation lacked an assessment of patient #24's lower extremities.


- Coumadin did not appear on the Medication Administration record (MAR) after 6/14/14. However, patient #24's medical record failed to contain a discontinue order for Coumadin The medical record lacked evidence the nursing staff were aware of the Coumadin missing from the MAR.


- Assistant Director of Nursing (ADON) staff A interviewed on 10/29/14 at 1:50pm acknowledged patient #24's chart lacked evidence of a discontinue order for Coumadin.



- Nursing progress note on 6/15/14 at 10:20pm indicated the patient refused all nighttime medications. The medical record lacked documentation nursing staff notified the physician at the time of the patient's refusal to take their medications and lacked nursing documentation of an assessment of the patient's lower extremities.


- Pharmacist Staff B reported a follow up phone call and an additional fax dated 6/16/14 to the nursing unit to clarify the coumadin dosage as nursing staff failed to respond to the initial request. Note attached to the fax stated "Warfarin(Coumadin) needs to be reviewed- pharmacy's 2nd request pt (patient) has missed 2 doses." Staff B revealed nursing staff failed to respond to the second request to clarify the order. Staff B indicated patient #24 " fell through the cracks after the third or fourth day " .


- Pharmacist staff B interviewed 10/30/14 at 10:05am indicated they did not have a good
process for clarification of medication orders. Pharmacist Staff B revealed failure to receive timely clarifications from the units. Pharmacist Staff B indicated there needs to be a different procedure; " the fax system does not adequately address medication orders needing timely clarification, entry or administration and they do not have a systems of checks and balances since alterations can take place at any point of entry in
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



The hospital reported a census of 258 patients with a licensed bed capacity of 206 beds. Based on observation, medical record review, document review, and staff interview the hospital ' s nursing staff failed to develop and keep current a nursing care plan for two of 25 sampled patient's (patient #'s 9 and 24).

Nursing staff's failure to develop appropriate nursing interventions, to keep the care plan updated by performing ongoing assessments of the patient's needs and responses to the interventions placed patients at risk for inadequate care.



Findings include:


- Registered Nurse Position Description reviewed on 10/22/14 at 4:30pm directed nursing staff to "...respond to, assess, intervene and provide direction in both physical and psychiatric
crisis/emergency situations..." and "...perform direct nursing care to insure individualized quality patient care by utilizing appropriate Hospital/Nursing Service standards..." and
..."communicate all known medical issues to unit physician and document such..."


- The hospital ' s patient care policy " Assessment " reviewed on 10/29/14 at 3:40pm directed, " ...Initial and ongoing assessments are crucial to determine the appropriate care, treatment and services needed to meet the patients ' needs. During the course of hospitalization , the patients' needs may change; therefore it is important that reassessments are performed when clinically indicated".


- The hospital ' s medical management policy " Preparation, administration and Documentation of Medications " reviewed on 10/29/14 at 3:40pm directed, " ...Any missed dose (of medication)-Report all missed doses to the RN (registered nurse) who will inform the physician ... "


- The hospital's nursing policy "Assessment of Wounds/Major Injuries reviewed on 10/29/14 at 4:55pm directed "...A. ACTION BY NURSING STAFF 1. Treatments, Dressing Changes, and Assessment During each treatment application &/or dressing change, the RN/LPN will assess and document the following in a Progress Note: Location, Size...Dressing...Color, Temperature, Edema, Odor, Moisture and Appearance of Skin around the wound and if Exudate and drainage are present... 4. Assessment of Peripheral Edema (swelling) from the initial time of occurrence the RN/LPN will; Establish a Temporary Issue addressing the location and type of edema (pitting or non-pitting) Write a Progress Note which includes the details of the initial assessment, and the location and type of the edema, physician notification, and any type of treatment the patient received Enter into the Patient Care System a Nurses order for the protocol of assessment of the edema as follows; a) RN/LPN to Assess and Document (insert edema site) every shift RN/LPN are to document in a Progress Note the following per protocol with each assessment: Location, Size (circumference may be measured using a cloth or paper measuring tape Skin Integrity-color, temperature, moisture, Appearance Pitting or Non-pitting edema.


- The hospital's Nursing Services (LD-3.21) policy directed "...Nursing care is the provision of care that is essential to the prevention of illness, helpful in the promotion, maintenance and restoration of health (both mental and physical), and well-being...D. STANDARDS OF PRACTICE Nursing services follows standards of nursing practice which are adapted for use ..., but based upon the American Nurse's Association's "Psychiatric-Mental Health, " Scope and "Standards of " Practice, 2007, and the "Code of Ethics for Nurses with Interpretive Statements, 2001".


- Patient #9's closed medical record review on 10/27/14 revealed an admission date of [DATE] with a psychiatric diagnosis of [DIAGNOSES REDACTED]


- Physician's Diagnostic Orders dated 8/24/14 at 2110 requested a urinalysis and urine drug screen. Lab Result notes reported on 9/2/14 indicated that no specimen was submitted for urinalysis or drug screen. The medical record lacked any nursing documentation of notification to the physician of inability to obtain patient #9's urine sample.



- Physician staff G assessed patient #9 on 8/26/14 for medical issues. Physical examination
indicated patient #9 had swelling of the legs and a superficial ulcer on the tip of the second toe left foot. Physician staff G ordered clindamycin (an antibiotic) 150mg (milligrams) three times a day by mouth, physical therapy for hydrotherapy (whirlpool baths) and a pain medication.



- Patient # 9's Medication Administration Record and Vital Sign Report Sheets reviewed on 10/30/14 revealed nursing staff directed to check blood pressure prior to administration of Coreg (a medication to lower blood pressure), The medical record lacked evidence the nursing staff documented the patient's blood pressure prior to the administration of the Coreg on 8/27/14 8:00pm, 8/28/14 7:31pm, 8/29/14 7:40pm, 9/3/14 7:45pm, 9/8/14 8:22pm, 9/11/14 7:01pm, 9/12/14 8:28pm, 9/15/14 7:36am and 7:43pm, and 9/17/14 7:19pm.


- Patient # 9's Medication Administration Record and Vital Sign Report Sheets reviewed on 10/30/14 revealed nursing staff directed to check apical pulse (a heart sound heard directly over the apex of the heart by means of a stethoscope) prior to administration of Digoxin (a medication used to treat irregular heart rates by making the heart beat slower and stronger). The medical record lacked evidence the nursing staff documented the patient's apical pulse prior to the administration of digoxin on the following days: 8/28/14, 8/29/14, 8/30/14, 9/1/14, 9/2/14, 9/3/14, 9/5/14, 9/6/17, 9/7/14, 9/8/14, 9/10/14, 9/11/14, 9/12/14, 9/14/14, 9/15/14, 9/16/14, 9/17/14, 9/19/14, 9/23/14, 9/24/14, and 9/25/14.



- Nursing Care Plan #7opened 8/24/14 directed "Patient will comply with all tests and treatment related to the wound for the next 5 days. Intervention: Encourage patient to comply with treatment as ordered. Encourage patient to take medication as ordered. Change dressing as ordered. Monitor for s/sx (symptoms) of complications and immediately notify the doctor."


- Patient #9's medical record lacked evidence the Nursing Care Plans addressed the patient's peripheral edema found on initial assessment including establishing a temporary issue addressing the location and type of edema; writing a progress note which includes the details of the initial assessment and the location and type of the edema, and any type of treatment the patient received. The medical record lacked evidence the nursing staff entered progress notes following the protocol for the assessment of edema including: location, size, skin integrity and appearance.


- Nursing notes on 8/25/14 lacked documentation of any assessment or attempted assessment of patient #9's left 2nd toe wound.



- Nursing progress note on dated 8/26/14 at 2:25pm indicated patient #9 refused am meds, refused to talk to IDT, refused assessment of left 2nd toe. The medical record lacked evidence nursing staff notified the physician the patient refused their medications or refused assessment of their toe wound or nursing staff encouraged the patient to comply with their treatments.


- Nursing progress notes on 8/26/14 at 9:43pm indicated patient #9 started on an antibiotic for wound to left 2nd toe but lacked any assessment of the wound.


- Physician progress note written on 8/27/14 revealed assessment completed by medical physician staff H on 8/26/14: Extremities, pitting edema grade 2, no calf tenderness both legs...Has superficial ulcer tip of second toe left foot.


- Nursing notes on 8/27/14 lacked documentation of any assessment or attempted assessment of patient #9's left 2nd toe wound.
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- Nursing progress notes on 8/28/14 at 9:53pm indicated patient #9 with pretibial (the area of the leg in front of the shinbone) edema and refused to allow the nurse to assess the infected toe. The medical record lacked evidence of nursing staff notification to the physician regarding the refusal of the assessment or nursing staff encouraged the patient to comply with their treatments or nursing staff described the patient's peripheral edema per protocol.



- Nursing notes on 8/29/14 lacked documentation of any assessment or attempted assessment of patient #9's left 2nd toe wound.


- Nursing notes on 8/30/14 at 9:25pm and 9:31pm indicated patient #9 refused all nighttime medications including their antibiotic. The medical record lacked evidence nursing notified the physician that patient #9 refused their medications including the antibiotic or encouraged the patient to comply with their treatments.


- Nursing notes on 8/30/14 lacked documentation of any assessment or attempted assessment of patient #9's left 2nd toe wound.


- Nursing notes on 8/31/14 lacked documentation of any assessment or attempted assessment of patient #9's left 2nd toe wound.


- Nursing notes on 9/1/14 at 1:57pm indicated patient #9 complained of feet and body pain rated at 10 on a 1-10 scale and they received pain medication. The medical record lacked documentation of any nursing assessments of patient #9 infected left 2nd toe.



- On 9/2/14 at 2:46am patient #9 complained of left foot pain at a 7 on a scale of 1-10 and received pain medication. The medical record lacked evidence of any nursing assessments of patient #9 infected left 2nd toe.



- Patient #9 requested pain medication for right foot pain on 9/3/14 at 2:43am.The medical record lacked evidence of any nursing assessment of patient #9's right foot or their infected left 2nd toe or nursing staff encouraged the patient to comply with their treatments.


- Nursing notes on 9/3/14 at 12:40pm and 12:49pm indicated patient #9 continued on an antibiotic for the wound to the left 2nd toe and had complained of foot pain twice and received pain medication and the patient refused to allow the wound on the left 2nd toe to be examined. The medical record lacked evidence nursing notified the physician patient #9 refused assessment of their left 2nd toe or they encouraged them to comply with their treatments.


- Nursing notes on 9/3/14 at 10:21pm indicated patient continues on antibiotic with no adverse effects and lacked evidence of any nursing assessment or attempted assessment of their infected left 2nd toe.



- Nursing notes on 9/4/14 at 10:30pm indicated patient continues on antibiotic with no adverse effects and lacked evidence of any nosing assessment or attempted assessment of their infected left 2nd toe.


- Licensed Practical Nursing staff progress notes on 9/4/14 at 10:49pm indicated patient #9 requested pain medication at 4:03pm and at 9:30pm for left foot pain rated "over10" both times. The medical record lacked any evidence of any nursing assessment of the left foot.



- Nursing progress notes on 9/5/14 at 12:31pm indicated patient #9 continued on antibiotic, refused an assessment of their toe and had requested pain medication in the morning for complaint of body pain. The medical record lacked evidence nursing notified the physician patient #9 refused assessment of their infected toe or encouraged them to comply with their treatments.


- Nursing progress notes on 9/6/14 at 5:15am indicated patient #9 requested and received pain medication for right foot pain twice during the night. The medical record lacked evidence of nursing assessments of patient #9's right foot or their infected left 2nd toe during this shift or any time on 9/6/14.


- Nursing progress notes on 9/7/14 at 0751 indicated patient #9 received pain medication at 5:50am for foot pain. The medical record lacked evidence of nursing assessments of patient #9's infected left 2nd toe.


- Nursing progress note on 9/7/14 at 9:23pm indicated patient refused all nighttime medications. RN was notified. The medical record lacked evidence nursing staff notified the physician of the missed medications or nursing staff encouraged the patient to comply with their treatments.


- Nursing notes on 9/8/14 at 5:36am indicated patient #9 requested and received pain medication for foot pain at 12:57am. The medical record lacked evidence of nursing assessments of patient #9's infected left 2nd toe.



- Nursing progress notes on 9/9/14 at 10:55pm indicated patient requested pain medication for unrated left foot and ankle pain at 8:22pm. The medical record lacked any nursing assessment of the infected left 2nd toe.


- General progress notes on 9/10/14 at 2:30pm indicated patient #9 wanted a nurse to give them pain medication for his left foot saying that it was "more swollen and painful." and refused to allow staff to assess their toe. The medical record lacked evidence nursing notified the physician when patient #9 refused assessment of their infected toe, reported the change in condition, assessed the patient's peripheral edema per protocol or encouraged the patient to comply with their treatments.



- Medical Physician staff H did not assess patient #9 again until 9/10/14 at 4:21pm (two weeks after the initial infected toe assessment) for left foot pain. Staff H indicated patient #9's left foot up to mid leg swollen, tender and left second toe has open ulcer, tender, no active bleeding, swelling and [DIAGNOSES REDACTED]tous. Patient #9 currently took pain medication and an antibiotic. The medical record lacked evidence that a medical physician had assessed the patient since the initial consultation on 8/26/14.



- PT treatment notes on 9/11/14 at 9:45am indicated patient refused to complete his whirlpool treatment and allow the therapist to place a dressing on his toe. The medical record lacked evidence nursing staff notified the physician of the patient's refusal to have a dressing placed on their toe or they encouraged the patient to comply with their treatments.


- Nursing notes on 9/11/14 at 11:37pm indicated patient #9 became agitated about their foot hurting and requested to see the physician. The medical record lacked evidence the nursing staff notified the physician of the patient's request or performed any assessment of the infected left 2nd toe.



- Nursing notes on 9/12/14 at 5:14am indicated patient #9 requested and received pain medication. The medical record lacked evidence of an assessment of patient #9 ' s infected toe.


- Nursing notes on 912/14 at 2:47pm indicated patient #9 requested pain medication and refused assessment of their 2nd toe left foot. The medical record lacked evidence the nursing staff encouraged the patient to comply with their treatment.


- Nursing notes on 9/13/14 at 1:38am indicated patient stated "I stay in bed all day because the cold floors hurt my foot to walk on...." and at 8:37am indicated patient #9 refused their morning medications including their antibiotic. The medical record lacked evidence nursing staff notified the physician patient #9 refused all their medications including the antibiotic and any evidence nursing staff notified the physician of the patient ' s medication refusal and encouraged the patient to comply with their treatments.


- Nursing notes on 9/14/14 lacked any evidence of documentation of assessment of the patient's infected left 2nd toe.


- Nursing notes on 9/15/14 at 2:01pm indicated patient #9 requested pain medication for their left toe pain and rated their pain at a 10. They continue on antibiotic. Patient #9 stated they could hardly walk and patient #9 was encouraged to elevate their foot. The medical record lacked documentation of any assessment of their infected left 2nd toe on 9/15/14.


- General progress note on 9/16/14 at 11:36 indicated that the patient stated that staff have not been taking care of their toe. The medical record lacked evidence nursing staff encouraged the patient to comply with their treatment.


- PT treatment notes on 9/16/14 indicated that the patient refused their therapy. The medical record lacked evidence nursing staff or therapy staff notified the physician that the patient refused therapy and encouraged the patient to comply with their treatments.


- Physician Reorder Sheet *Non-medicated Treatments* dated 9/17/14 directed nursing staff to: Document assessment of diabetic ulcer on 2nd toe left foot every shift starting 9/17/14. If patient refuses assessment, document.


- Nursing notes on 9/17/14 at 6:08am indicated patient #9 requested and received pain medication for foot pain at 5:21am. The medical record lacked evidence nursing assessed patient #9 ' s infected toe.



- Nursing progress in treatment notes on 9/17/14 at 9:06pm indicated patient #9 had been non-compliant with medications including antibiotic and pain medication for his toe. The progress in treatment note lacked updates, revisions, or any different nursing interventions or goals in the care plans addressing patient #9's non-compliance.


- Nursing notes on 9/17/14 at 11:40pm indicated patient #9 had concerns about their toe and requested an assessment, dressing change, and pain medication. Nursing staff applied ointment and wrapped their toe. The medical record lacked nursing staff documentation of the wound including the exact location, size, type of dressing, the color, temperature, presence of edema, odor, moisture and appearance of the skin around the wound and if exudate and drainage are present. The medical record lacked evidence of physician orders for nursing staff to follow regarding the dressing change to the infected left 2nd toe.


- Medical Physician staff H did not assess patient #9 again until 9/18/14 (eight days after last medical exam) for a follow up for their left foot pain. Assessment revealed left second toe tender, [DIAGNOSES REDACTED]tous, no discharge, plantar surface of the second toe gangrene, dryness and ingrown nails. Patient #9 continued on antibiotic and refused to go for hydrotherapy. Physician staff H ordered Hibiclens (a skin cleanser and antiseptic) solution to left foot daily for 7 days, a podiatry consultation, CBC (complete blood count) and BMP (basic metabolic panel) lab tests and a wound culture of the left second toe.


- Patient #9's medical record lacked evidence the podiatry consultation from 9/18/14 was ordered. The medical record lacked evidence that nursing staff notified the physician of the missed consultation. The lab result notes reported on 9/25/14 indicated the patient refused to complete lab tests (BMP and CBC) ordered on [DATE] at10:15am. The medical record lacked any nursing documentation indicating the patient refused their labs or that nursing staff notified the physician of the patient's refusal. The lab result notes reported on 9/25/14 indicated that no specimen was submitted for left toe wound culture ordered on [DATE]. The medical record lacked any nursing documentation of the missed wound culture or notification to the physician of the inability to obtain the specimen.



The Administrative Nursing staff A interviewed on 10/30/14 at 12:00pm acknowledged patient #9's medical record lacked evidence nursing staff scheduled a podiatry consult, obtained a wound culture and documented efforts to encourage compliance with medications or treatments.


- General progress notes on 9/18/14 at 1:12pm indicated that the patient refused to go to physical therapy. The medical record lacked evidence nursing staff or therapy notified the physician of the patient ' s refusal to attend therapy and that nursing staff encouraged the patient to comply with their treatments.


- Nursing notes on 9/18/14 at 2:14pm indicated patient #9 requested pain medication and an assessment of their left 2nd toe. The nursing staff documented the toe had no drainage; skin is discolored and dark in color on the bottom. The medical record lacked complete documentation of the wound including the temperature, presence of edema, odor, or moisture and dressing applied.


- PT treatment notes on 9/18/14 indicated patient refused therapy. The medical record lacked evidence nursing staff or therapy notified the physician of the patient ' s refusal to attend therapy and that nursing staff encouraged the patient to comply with their treatments.
.


- Nursing notes on 9/19/14 at 1:51am indicated patient received pain medication and refused assessment of the affected area. The medical record lacked evidence the nursing staff encouraged the patient to comply with their treatments.



- Nursing notes on 9/19/14 at 2:21pm indicated patient #9 refused assessment of their toe. The medical record lacked evidence nursing staff encouraged the patient to comply with their treatments.



- Nursing notes on 9/19/14 at 6:21pm indicated patient #9 refused to allow assessment of their toe. The medical record lacked evidence nursing staff encouraged the patient to comply with their treatment.



- Nursing notes on 9/19/14 at 10:39pm indicated the nurse noticed patient #9 limping and offered them pain medication. The patient refused medication or assessment of the left second toe. The medical record lacked evidence nursing notified the physician of the change in condition for patient #9 or encouraged them to comply with their treatments.


- The medical record lacked nursing staff documentation of an assessment of patient #9's infected left 2nd toe the night shift of 9/19/14.


- Nursing notes on 9/20/14 10:03am indicated patient refused all his morning medications. The medical record lacked evidence nursing staff notified the physician of the missed medications and nursing staff encouraged patient #9 to comply with their treatments.


- Nursing notes on 9/20/14 at 2:30pm indicated patient #9 refused assessment of their infected second toe. The medical record lacked evidence nursing staff encouraged the patient to comply with their treatments.


- Nursing notes on 9/20/14 at 10:39pm indicated patient refused assessment of his left 2nd toe. The medical record lacked evidence the nursing staff encouraged the patient to comply with their treatments.



- Nursing notes on 9/21/14 at 7:34am indicated patient #9 received pain medication at 2:39am and refused assessment of their infected toe. The medical record lacked evidence the nursing staff encouraged the patient to comply with their treatments.


- General progress notes on 9/21/14 at 1:26pm indicated patient stated "I'm refusing medications from now". The Medication Administration Record indicated that patient had refused medications the morning of 9/20/14 and 9/21/14. The medical record lacked evidence that nursing staff notified the physician either day of the patient's refusal to take their medications and to encourage them to comply with their treatments.


- Nursing notes on 9/21/14 at 9:04pm indicated patient #9 refused assessment of their infected toe. Nursing notes on 9/21/14 at 9:46pm indicated patient #9 refused all medications. The medical record lacked evidence nursing notified the physician patient #9 refused their medications or encouraged the patient to comply with their treatments.


- Nursing notes on 9/22/14 at 12:10am indicated patient #9 requested and received pain medication and allowed the nurse to assess their infected toe but refused a dressing. The medical record lacked nursing documentation of the wound description including size, color, drainage, temperature, presence of edema, odor, and moisture and any evidence nursing staff encouraged the patient to comply with their treatments.



- Nursing notes on 9/22/14 at 2:12pm indicated patient #9 refused assessment of their infected toe and morning medications. The medical record lacked evidence the nursing staff notified the physician of the missed medications or the nursing staff encouraged the patient to comply with their treatments.


- Nursing notes on 9/22/14 at 9:54pm indicated patient #9 requested and received pain medications at 5:33pm and refused their evening medications. The medical record lacked evidence the nursing staff notified the physician of the missed medications or encouraged the patient to comply with their treatments. The medical record lacked documentation of a nursing staff assessment of the patient's infected left 2nd toe on the evening shift 9/22/14.


- Nursing notes on 9/23/14 at 6:04am indicated patient #9 requested and received pain medications and refused to allow assessment of their foot. The medical record lacked evidence the nursing staff encouraged the patient to comply with their treatments.


- The medical record lacked documentation of a nursing staff assessment of the patient's infected left 2nd toe on the day, evening, and night shifts 9/23/14 and the day and evening shifts 9/24/14.


- Nursing progress notes on 9/25/14 indicated at 1:40am nursing staff assessed patient #9 ' s toe. Documentation indicated "the entire foot is red with flaking dry skin. The end of the second toe is black with white flaking skin around the tip 1 cm vertically and 1.5 cm across distal to the nailbed. Proximal to the nailbed the skin appears darker and lower on the toe next to the third toe a half circle 1 cm at the base appears darker. The skin between the great toe and the second toe is intact and the skin between the second toe and third toe is intact." The wound assessment lacked documentation of the temperature, presence of edema, odor, and moisture and type of dressing applied. The medical record lacked evidence the physician was notified of the change in the patient's condition.


- Medical Physician staff H did not assess patient #9 again until 9/25/14 ( 7 days since the last exam) at 10:49am and found the patient ' s left leg [DIAGNOSES REDACTED]tous, tender, warm, swollen, left first toe tender, plantar surface gangrene. Physician Staff H documented patient has known history of diabetes mellitus and patient is non-compliant with the antibiotic treatment. The patient required transfer to an acute care hospital for left leg cellulitis and first toe gangrene requiring amputation of the second toe of the left foot.



- Nursing staff failed to monitor vital signs prior to administration of medications, to create care plans to address the patient's peripheral edema, to revise the patient's care plan regarding compliance with treatments, to obtain physician orders for dressing change, to notify the patient's physician of the patient's medication refusals or changes in condition, to schedule a podiatry consultation, to obtain laboratory tests including a wound culture, and to encourage patient #9 to comply with their treatments. These failures resulted in the deterioration of the patient's physical condition and necessitated a transfer of the patient to a higher level of care and an amputation of a toe.



- Patient #24's closed medical record reviewed on 10/29/14 revealed an transfer date of
6/13/14 from a community hospital with a psychiatric diagnosis of [DIAGNOSES REDACTED]

- Admission evaluation notes on 6/14/14 revealed Physician staff J's knowledge that patient #24's history included a DVT diagnosed approximately three to four months ago. A lab test completed on 6/13/14 at the hospital the patient transferred from showed a non-therapeutic Protime International Normalized Ratio (PT/INR-test to measure the time it takes for blood to clot) results of 1.1 (Therapeutic PT/INR level is 2-3). Physician staff J ordered lab tests including a PT/INR, comprehensive metabolic panel (CMP) and a complete blood count (CBC) to be drawn on 6/16/14.

- Physician orders dated 6/13/14 required Coumadin (medication used to prevent harmful
blood clot from forming or growing larger) 5mg by mouth every other day and Coumadin 7.5mg every other day. Physician orders directed staff to begin Coumadin 7.5mg on 6/14/14 and Coumadin 5 mg on 6/15/14.


- Pharmacist Staff B provided printed page of patient #24 ' s medication order entered by the nursing staff on 6/13/14. The printed page revealed nursing staff entered a Coumadin order of 5mg to be given every day at 8:00pm and a Coumadin order of 7.5mg to be given every day at 8:00pm. Pharmacist Staff B indicated this would be an unsafe dosage of Coumadin.


- Pharmacist Staff B provided a fax sent on 6/13/14 at 10:59pm to nursing staff on patient #24's unit requesting clarification of the Coumadin dose. Fax indicated that "this is a significant dosage increase. Order is not adequate for entry. Entered at approximately 200% of written dose". The medical record lacked evidence that nursing staff responded to the request for clarification.


- ADON staff A, interviewed on 10/30/14 at 9:10am indicated faxes are used for communication between nursing staff and pharmacy for order clarification. Nursing is to follow up with the doctor after receiving a request for clarification request fax from the pharmacist.


- Patient #24's nursing care plan dated 6/14/14 directed "...Patient will have therapeutic lab
values for Coumadin therapy within three days..." Interventions included: "Follow up with labs as ordered. Administer anti-coagulant as ordered. Monitor patient for increase bleeding, bruising".


- Patient #24's Treatment Plan dated 6/14/14 directed "Patient will have no complications associated with DVT/PE during hospitalization ". Interventions included: "will evaluate health status and monitor symptoms as needed to treat DVT/PE: prescribe and monitor response to coumadin..."


- Nursing progress note on 6/14/14/ at 8:49pm indicated that patient #24 refused 8:00am and 8:00pm medications (including the Coumadin). The medical record lacked documentation nursing staff notified the physician at the time of the patient's medication refusal. Nursing documentation lacked an assessment of patient #24's lower extremities to monitor for symptons of a DVT.


- Coumadin did not appear on the Medication Administration record (MAR) after 6/14/14. However, patient #24's medical record failed to contain a discontinue order for Coumadin The medical record lacked evidence the nursing staff were aware of the Coumadin missing from the MAR.


- Assistant Director of Nursing (ADON) staff A interviewed on 10/29/14 at 1:50pm acknowledged patient #24's chart lacked evidence of a discontinue order for Coumadin.



- Nursing progress note on 6/15/14 at 10:20pm indicated the patient refused all nighttime medications. The medical record lacked documentation nursing staff notified the physician at the time of the patient's refusal to take their medications and lacked nursing documentation of an assessment of the patient's lower extremities. The medical record lacked evidence nursing staff revised or updated their nursing plans of care regarding the patient's noncompliance with medications and treatments.


- Pharmacist Staff B reported a follow up phone call and an additional fax dated 6/16/14 to the nursing unit to clarify the Coumadin dosage as nursing staff failed to respond to the initial request. Note attached to the fax stated "Warfarin(Coumadin) needs to be reviewed- pharmacy's 2nd request pt (patient) has missed 2 doses." Staff B revealed nursing staff failed to respond to the second request to clarify the order. Staff B indicated patient #24 " fell through the cracks after the third or fourth day " .



- Nursing progress note on 6/16/14 at 5:37pm indicated patient has been non-compliant with treatment and medications and lab work. The medical record failed to contain any documentation of further attempts by nursing staff to ensure lab work necessary to monitor the patient's medical conditions was performed and lacked nursing documentation of an assessment of the patient's lower extremities. The medical record lacked evidence of any lab specimens received for testing during the patient's admission. The medical record lacked any updates to the patient's plans of care regarding patient's non-compliance with medications and treatments.


- Nursing progress note on 6/17/14 at 10:09am indicated the patient refused all their morning medications. The medical record lacked documentation nursing staff notified the physician at the time of the patient's refusal to take their medications and lacked nursing documentation of an assessment of the patient's lower extremities.


- Nursing progress note on 6/17/14 at 9:54pm indicated the patient refused all their nighttime medications. The medical record lacked documentation nursing staff notified the physician at the time of the patient's refusal to take their medications and lacked nursing documentation of an assessment of the patient's lower extre
VIOLATION: LIFE SAFETY FROM FIRE Tag No: A0710
The hospital reported a census of 258 patients with a licensed bed capacity of 206. Based on observation, interview and document review, the hospital failed to ensure they met life safety code requirments.The hospital's failure to meet life safety code requirements resulted in the Centers for Medicare/Medicaid Services identifying an immediate jeopardy on 10/21/14 at 3:30pm. The immediate jeopardy was removed on 10/21/14 at 4:07pm with the implementation of a fire watch and lasting until each building has been reduced to at/or below capacity.


The failure to comply with the standards for life safety from fire placed all patients at risk for injury and/or death in the event of a fire.



Findings include:


- The hospital must meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association.


- During the tour conducted of the facility on 10/21/14 by the Fire Marshal, the facility was found to be 52 patients or 25% over capacity. Personal belongings and beds blocked exit access and impeded exit paths.This deficient practice increased the risk to patients and staff of evacuating the facility in a timely manner in case of a fire or other emergency.


- Refer to the Fire Marshal Statement of Deficiency (ASPEN # QQ7R21) Form-CMS-2786 dated 10/30/14 for additional information
VIOLATION: GOVERNING BODY Tag No: A0043
The hospital reported a census of 258 patients with a licensed bed capacity of 206. Based on observation, policy review, and staff interview, it was determined the hospital's governing body failed to function effectively and assume full responsibility for determining, implementing, and monitoring policies/procedures governing the hospital's total operation. The governing body failed to ensure the hospital met the Conditions of Participation requirements for Patient's Rights (refer to A-0115, A-0119, A-0143, and A-0144, Nursing Services (refer to A-0385, A-0395, A-0396 and A-0405), Pharmaceutical Services (refer to A-0490, A-0500, and A-0505), Physical Environment (refer to A-0700, A-0701, A-0710, and A-0713), and Infection Control (refer to A-0747 and A-0749).

The cumulative effect of the systemic failure to assure the governing body met the requirements for Patient's Rights, Nursing Services, Pharmaceutical Services, Physical Environment, and Infection Control resulted in the hospital's inability to provide care in a safe effective manner.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, document review, and staff interview the hospital failed to follow their grievance process regarding patient complaints (refer to A-0119), failed to provide for the privacy of patients in four of five over crowded patient care buildings (refer to A-0143), and failed to provide for the safety of patients in five of five over crowded patient care buildings (refer to A-0144).



The cumulative effect of the systematic failure to follow their grievance process regarding patient complaints, to provide for the privacy of patients in four of five over crowded patient care buildings, and provide for the safety of patients in five of five over crowded patient care buildings resulted in the hospital's inability to provide care in a safe and effective manner.
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


The hospital reported a census of 258 patients with a bed capacity of 206 beds. Based on medical record review, patient interview, staff interview, and hospital policy review the hospital failed to follow their grievance process regarding patient care complaints for four of twenty four sampled patients (patient #'s 2, 3, 8, and 9). The failure to meet the minimum requirements for grievance resolution has the potential to affect all patients receiving care at the hospital.

Findings include:


- The hospital Patient Handbook provided to patients during admission, reviewed on 10/20/14 at 4:30pm, directed, "...The Patient Advocate Program supports a process through which a patient can seek solutions to problems, concerns, grievances and requests..."
- The hospital's policy for Patient Complaints and Grievances, reviewed on 10/22/14 at 11:40am directed, "...A patient grievance is a formal or informal written or verbal complaint that is made to the hospital by a patient or the patient's representative, regarding the patient's care when the complaint is not resolved at the time of the complaint by staff present...Any complaint that cannot be resolved to the patient's satisfaction relatively quickly without an investigation (usually within 2 hours or less), includes any element that meet the criteria of a grievance...grievances will be forwarded to the hospital Patient Advocate...The hospital patient advocate will: log the receipt of the grievance, forward the grievance to the hospital designee assigned to investigate patient grievances. Grievances must be addressed and returned within five days to the Patient Advocate...maintain the tracking log...see that the grievance is resolved or if not resolved to the patient's or patient representative's satisfaction...send a resolution letter within seven days of the receipt of the grievance...Information obtained throughout the investigation process shall be documented within the Grievance Tracking System as the investigation progresses...The Patient Advocate or designee shall compile a final summary of the investigation and response to the grievance with actions taken to resolve the grievance on the patient's behalf..."

- Patient #2's medical record review on 10/23/14 revealed an admission date of [DATE] with a diagnosis of mood disorder and psychotic disorder. Review of the hospital's grievance log on 10/20/14 at 4:30pm revealed patient #2 voiced a grievance on 10/2/14 regarding inappropriate admission and medication issues. The log indicated the complaint went to the patient's team meeting and the team considered discharge in the next few days. The log indicated patient #2 had been discharged on [DATE]. The investigative note indicated the investigator spoke with patient #2 about the incident. The hospital lacked evidence they followed their grievance process and compiled a summary of an investigation, response to the grievance, actions taken, or sent a resolution letter within seven days.

- Patient #3's closed medical record reviewed on 10/22/14 revealed an admission date of [DATE] with a psychiatric diagnosis of mood disorder and psychotic disorder. Review of the hospital's grievance log on 10/20/14 at 4:30pm revealed patient #3 voiced a grievance on 6/27/14 regarding two patients of the opposite sex harassed them and called them names. Patient #3 did not feel that staff had addressed the problem. Investigative notes indicated during discussion of the incident with patient #3 the two patients made gestures towards patient #3. The investigative note indicated the investigator spoke with staff about the incident. The hospital lacked evidence they followed their grievance process and compiled a summary of an investigation, response to the grievance, actions taken, or sent a resolution letter within seven days.
- Patient #8 approached the surveyor on 10/21/14 at 9:00am interview revealed they voiced a complaint that a patient of the opposite sex had exposed their genitals which frightened them and hospital staff did nothing about the situation. Patient #8 indicated they had been scared during this time and staff did not look into the situation.

Social Work staff U interviewed on 10/21/14 at 10:30am regarding patient #8's complaint, they were aware of the allegation that a patient of the opposite sex had exposed their genitals to patient #8. Staff U indicated there were no witnesses and unit staff met with both patients involved in the incident. Patient #8 reported the incident happened at 3:00pm and didn't report the incident until 11:00pm. Unit staff placed both patients on one-on-one and had patient #8 seen by the medical doctor.

- Patient #8's medical record review on 10/23/14 and 10/27/14 revealed an admission date of [DATE] with psychiatric diagnoses of anxiety disorder and personality disorder. Nursing note on 9/22/14 at 23:52 indicated patient #8 came to the nurses ' station and reported they had been sexually traumatized today and a patient of the opposite sex had exposed their genitals and could not sleep and was upset. Nursing notes on 9/22/14 at 23:57 indicated patient #8 had been placed on one-on-one due to the incident. Nursing notes on 9/23/14 at 12:06am indicated patient #8 on fifteen minute checks. Nursing notes on 9/23/14 at 2:05am indicated the physician received notification of the patient report. Psychiatric Physician staff X assessed patient #8 on 9/23/14 at 4:05am and the medical doctor staff H assessed patient #8 on 9/23/14 at 1:58pm. Review of the "Time Check Sheet" used to document patient observation revealed patient #8 had been on one-on-one observation on 9/23/14 between 9:30am to 9:50am (20 minutes).
Social Work staff U interviewed on 10/23/14 at 9:30am indicated they were unaware of the need to notify the Patient Advocate or assist patient #8 to file a grievance.

Social Work staff U interviewed on 10/27/14 at 3:30pm acknowledged patient #8's medical record indicated a one-on-one observation on 9/23/14 between 9:30am to 9:50am and acknowledged poor documentation of one-on-one observations.

- Patient Advocate staff V interviewed on 10/22/14 at 10:20am lacked knowledge of an incident/complaint involving patient #8 on 9/22/14.
The hospital lacked evidence they followed their grievance process and compiled a summary of an investigation, response to the grievance, actions taken, or sent a resolution letter within seven days on patient #8.

- Patient #9's medical record review on 10/27/14 revealed an admission date of [DATE] with a psychiatric diagnosis of major depressive disorder with severe psychotic features and medical diagnosis of diabetes mellitus. Review of the hospital's grievance log on 10/20/14 at 4:30pm revealed patient #9 voiced a grievance on 9/18/14 regarding their care. The investigative note indicated the investigator spoke with patient #9 about the incident, had copies of patient #9's nursing progress notes, and a note indicating patient #9 had been transferred to a medical hospital. The hospital lacked evidence they followed their grievance process and compiled a summary of an investigation, response to the grievance, actions taken, or sent a resolution letter within seven days.

Risk Manager staff W interviewed on 10/27/14 at 12:30pm acknowledged the hospital's grievance/complaint process failed to follow policy and procedure and lacked evidence of notification to the patient and/or family of resolution of complaints.

The hospital failed to establish a grievance procedure for documenting the existence, submission, investigation, and disposition of patient #'s 2, 3, 8, and 9 verbal grievance and ensure the effective operation of the grievance process to address patient concerns in a timely manner.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
The hospital reported a census of 258 patients with a licensed bed capacity of 206. Based on observation, interview and document review, the hospital failed to provide for the privacy of patients in four of five over crowded patient care buildings (Managing and Preventing Symptoms (MAPS) unit A1 building, Managing and Preventing Symptoms (MAPS) unit A2 building, Stepping Stone Program (SSP), unit B2 building, Positive Living Skills (PLS) unit C1 building, Continuing Care Program (CCP), unit B1 building, and Healthy Options, Plans, and Experiences (HOPE) unit C2 building). This deficient practice failed to provide privacy to patients receiving care in the hospital.

Findings include:

- The hospital's Patient Rights provided to patient on admission to the hospital reviewed on 10/20/14 at 4:30pm directed, "...While a patient you have the following rights...to personal privacy..."

- Managing and Preventing Symptoms (MAPS) unit A1 building toured on 10/20/14 between 4:24pm to 5:10pm revealed nineteen patient rooms with a bed capacity of 30 patients. Registered Nurse staff P reported a current census of 36 patients. Observation of rooms 146, 147, 148, 150, 159, and 161 revealed semi-private rooms with three names on the door nameplate each room contained three beds with two beds against one wall with the beds against each other and approximately four-inch space between a bed and clothes closet. The rooms lacked a method to provide privacy between the two beds on the same wall. The rooms had two closets, with one closet blocked by a bed and two dressers for the three patients.

- Managing and Preventing Symptoms (MAPS) unit A2 building toured on 10/21/14 between 9:10am to 10:35am revealed eighteen patient rooms with a bed capacity of 30 patients. Mental Health Technician staff Q reported a current census of 37 patients. Observation of rooms 137, 138, 139, 140,141, and 142 revealed semi-private rooms with three names on the door nameplate each room contained three beds with two beds against one wall with the beds against each other and approximately four-inch space between a bed and clothes closet. The rooms lacked a method to provide privacy between the two beds on the same wall. The rooms had two closets, with one closet blocked by a bed and two dressers for the three patients.

- Stepping Stone Program (SSP), unit B2 building toured on 10/21/14 between 10:00am to 11:30am revealed 16 patient rooms with a bed capacity of 26 patients. Administrative staff D reported a current census of 33 patients with a report of two admissions, which will bring the census to 35 patients. Observation of rooms 134, 135, 150, 151, 152, 153, 154, and 155 revealed semi-private rooms with three names on the door nameplate and each room contained three beds with two beds against one wall with the beds against each other and approximately a four-inch space between a bed and/or dresser and the clothes closet. The rooms lacked a method to provide privacy between the two beds on the same wall. The rooms had two dressers and two closets for the three patients.

Observation during tour of Stepping Stones Program, (SSP), unit B2 building on 10/21/14 at 11:00am revealed room 152 with three beds, two dressers, and two clothes closets. Patient #11's bed (cot) was the third bed in the room. Bags of patient #11's belongings, shoes, and clothes were on the floor at the foot of the bed (that was approximately four inches from the closet) and under the bed. Patient #11 interview on 10/21/14 at 11:00am expressing concerns to Nurse Manager staff D that they has no were to put their belongings. Nurse manger staff D asked them to work it out with their roommates.


- Positive Living Skills (PLS) unit C1 building toured on 10/22/14 between 10:45am to 11:10am revealed eighteen patient rooms with a bed capacity of 30 patients. Registered Nurse staff S reported a current census of 37 patients. Observation of rooms 126, 160, and 161 revealed semi-private rooms which contained three beds with two beds against one wall with the beds against each other and approximately four-inch space between a bed and clothes closet. The rooms lacked a method to provide privacy between the two beds on the same wall. The rooms had two closets, with one closet blocked by a bed and one dresser for the three patients.

Register Nurse staff S interviewed on 10/22/14 at 11:10 acknowledged they have to put three patients in rooms at times and indicated they had to take all patients.

- Continuing Care Program (CCP), unit B1 building toured on 10/21/14 between 2:20pm to 3:00pm revealed 18 patient rooms with a bed capacity of 30 patients. Administrative staff D reported a current census of 33 patients. Observation of rooms 136, 137, 141, 140, and 157 revealed semi-private rooms with three names on the door nameplate and each room contained three beds with two beds against one wall with the beds against each other and approximately a four-inch space between a bed and/or dresser and the clothes closet. The rooms lacked a method to provide privacy between the two beds on the same wall. The rooms had two dressers and two closets for the three patients.


- Healthy Options, Plans, and Experiences (HOPE) unit C2 building toured on 10/22/14 between 2:30pm to 2:55pm revealed nineteen patient rooms with a bed capacity of 30 patients. Registered Nurse staff T reported a current census of 35 patients. Observation of rooms 167, 168, 169, 170, and 172 revealed semi-private rooms which contain three beds with two beds against one wall. The rooms lacked a method to provide privacy between the two beds on the same wall. The rooms had two closets blocked with beds and two dressers for the three patients. Observation of room 131 revealed a semi-private room with three patients which lacked a method to provide privacy between two beds. Room 127 a semi-private room contained four beds with one privacy curtain for the entire room.

- The hospital's census tracking called "Section Population" reviewed on 10/29/14 at 2:30pm revealed the facility's census met capacity on seven days in the last six months (180 days) and for the last four months the census remained between 216 to 260 patients daily (ten to 54 patients over capacity).


The hospital failed to honor patient rights and provide for the privacy of patient in four of five over crowded patient care buildings.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
The hospital reported a census of 258 patients with a licensed bed capacity of 206. Based on observation, interview and document review, the hospital failed to provide for the safety of patient in five of five over crowded patient care buildings (Managing and Preventing Symptoms (MAPS) unit A1 building, Crisis Stabilization Program (CSP), unit EB (East Biddle), Managing and Preventing Symptoms (MAPS) unit A2 building, Stepping Stone Program (SSP), unit B2 building, Positive Living Skills (PLS) unit C1 building, Continuing Care Program (CCP), unit B1 building, and Healthy Options, Plans, and Experiences (HOPE) unit C2 building). This deficient practice increased the risk to patients and staff of evacuating the facility in a timely manner in case of a fire or other emergency.

Findings include:

- The hospital's Patient Rights provided to patients on admission reviewed on 10/20/14 at 4:30pm directed, "...While a patient you have the right...to receive care in a safe setting..."

- Kansas Statues K.S.A. 59-2949 reviewed on 10/29/14 at approximately 4:20pm directed, "...A mentally ill person may be admitted to a treatment facility as a voluntary patient when there are available accommodations and the head of the treatment facility determines such person is in need of treatment..."

- Kansas Statues K.S.A. 59-2968 reviewed on 10/29/14 at approximately 4:20pm directed "...No patient shall be admitted to a state psychiatric hospital pursuant to any of the provision of this act, including any court-ordered admission, if the secretary has notified the supreme court of the state of Kansas and each district court to which has jurisdiction over all or part of the catchments area served by a state psychiatric hospital, that the census of a particular treatment program of the state psychiatric hospital has reached capacity and that no more patients may be admitted ..."

- The hospital's Census Management Initiative reviewed on 10/29/14 at approximately 4:20pm directed, "...The Census Management Initiative adds a diversionary process for admissions...When the patient census reaches one hundred eighty-five (185) or acuity necessitates...may seek census assistance (from another state hospital)..."

- Managing and Preventing Symptoms (MAPS) unit A1 building toured on 10/20/14 between 4:24pm to 5:10pm revealed nineteen patient rooms with a bed capacity of 30 patients. Registered Nurse staff P reported a current census of 36 patients. Observation of rooms 146, 147, 148, 150, 159, and 161 revealed semi-private rooms with three names on the door nameplate each room contained three beds with two beds against one wall with the beds against each other and approximately four-inch space between a bed and clothes closet. The rooms lacked a method to provide privacy between the two beds on the same wall. The rooms had two closets, with one blocked by a bed and two dressers for the three patients.

- Crisis Stabilization Program (CSP), unit EB (East Biddle) toured on 10/20/14 between 4:20pm to 5:15pm revealed 30 private patient rooms with a bed capacity of 30 patients. Administrative staff D reported a current census of 41 patients. Observation of rooms 211, 212, 213, 220, and 223 revealed private rooms with two names on the door nameplate each room contained two beds, one against each long wall of the room. The rooms had one closet and one dresser for both patients. The rooms contained a portable privacy divider between the two beds, sitting on the floor, made up of PVC (polymerized vinyl chloride) pipes with a blue piece of material attached at the top and bottom of the frame. The privacy divider when touched or moved lacked stability and rendered it a trip hazard, because of the proximity to each of the two beds in the rooms.

- Managing and Preventing Symptoms (MAPS) unit A2 building toured on 10/21/14 between 9:10am to 10:35am revealed eighteen patient rooms with a bed capacity of 30 patients. Mental Health Technician staff Q reported a current census of 37 patients. Observation of rooms 137, 138, 139, 140,141, and 142 revealed semi-private rooms with three names on the door nameplate each room contained three beds with two beds against one wall with the beds against each other and approximately four-inch space between a bed and clothes closet. The rooms lacked a method to provide privacy between the two beds on the same wall. The rooms had two closets, with one blocked by a bed and two dressers for the three patients.

- Stepping Stone Program (SSP), unit B2 building toured on 10/21/14 between 10:00am to 11:30am revealed 16 patient rooms with a bed capacity of 26 patients. Administrative staff D reported a current census of 33 patients with a report of two admissions, which will bring the census to 35 patients. Observation of rooms 134, 135, 150, 151, 152, 153, 154, and 155 revealed semi-private rooms with three names on the door nameplate and each room contained three beds with two beds against one wall with the beds against each other and approximately a four-inch space between a bed and/or dresser and the clothes closet. The rooms lacked a method to provide privacy between the two beds on the same wall. The rooms had two dressers and two closets for the three patients.

- Positive Living Skills (PLS) unit C1 building toured on 10/22/14 between 10:45am to 11:10am revealed eighteen patient rooms with a bed capacity of 30 patients. Registered Nurse staff S reported a current census of 37 patients. Observation of rooms 126, 160, and 161 revealed semi-private rooms which contained three beds with two beds against one wall with the beds against each other and approximately four-inch space between a bed and clothes closet. The rooms lacked a method to provide privacy between the two beds on the same wall. The rooms had two closets, with one blocked by a bed and one dressers for the three patients.

Register Nurse staff S interviewed on 10/22/14 at 11:10 acknowledged they have to put three patients in rooms at times and indicated they had to take all patients.

- Continuing Care Program (CCP), unit B1 building toured on 10/21/14 between 2:20pm to 3:00pm revealed 18 patient rooms with a bed capacity of 30 patients. Administrative staff D reported a current census of 33 patients. Observation of rooms 136, 137, 141, 140, and 157 revealed semi-private rooms with three names on the door nameplate and each room contained three beds with two beds against one wall with the beds against each other and approximately a four-inch space between a bed and/or dresser and the clothes closet. The rooms lacked a method to provide privacy between the two beds on the same wall. The rooms had two dressers and two closets for the three patients.


- Healthy Options, Plans, and Experiences (HOPE) unit C2 building toured on 10/22/14 between 2:30pm to 2:55pm revealed nineteen patient rooms with a bed capacity of 30 patients. Registered Nurse staff T reported a current census of 35 patients. Observation of rooms 167, 168, 169, 170, and 172 revealed semi-private rooms which contain three beds. The rooms had two closets blocked with beds and two dressers for the three patients. Observation of room 131 revealed a semi-private room with three patients and room 127 a semi-private room with four beds.

- The Fire Marshal inspected the facility on 10/21/14, 10/28/14 and 10/29/14. The report cited the facility for patient safety compromised due to overcrowding-the 2000 Life Safety Code Table 7.3.1.2 requires 120 square feet per person. The facility had 52 patients or 25% over capacity on 10/21/14. On 10/28/14 the facility had 37 patients over capacity and on 10/29/14 the facility had 34 patients over capacity which affected exit access by impeding the exit path with personal belongs and additional beds. This deficient practice increased the risk to patients and staff of evacuating the facility in a timely manner in case of a fire or other emergency. The Fire Marshall found the facility over capacity in all five patient buildings and an immediate jeopardy was called. A fire watch was instituted to remove the immediate jeopardy starting on 10/21/14 and lasting until each building reaches capacity. Refer to the Fire Marshal Statement of Deficiency dated 10/30/14 for additional information.

- The hospital's census tracking called "Section Population" reviewed on 10/29/14 at 2:30pm revealed the facility's census met capacity on seven days in the last six months (180 days) and for the last four months the census remained between 216 to 260 patients daily (ten to 52 patients over capacity).


The hospital failed to provide care in a safe setting in five of five patient care buildings.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
The hospital reported a census of 258 patients with a licensed bed capacity of 206. Based on observation, policy/procedure review, manufacturer ' s guidelines, and staff interview the nursing staff failed to ensure the safe use of medications in four of seven observed medication rooms. This practice placed patients at risk for the use of unsafe medications.

Findings include:

- The Hospital's Provision of Care Procedures Manual policy, titled, " STORAGE AND Findings include: SECURITY OF MEDICATION" reviewed on 10/22/14 at 3:50pm directed, "...Multi-dose vials for injection may be used for 28 days after opening. When it is first used, it is dated with expiration date and initialed...Medications that are expired or damaged are placed in the return bin for pharmacy staff to take action except for controlled medications...Any medications expiring during the month of the inspection are replaced by pharmacy staff..."

- The manufacturer's guidelines for the use of Novalog insulin reviewed on 10/22/14 at 8:35am directed, "...After initial use a vial may be kept at temperatures 30 degrees Celsius (C) (86 degrees Fahrenheit (F) for up to 28 days..."

- The manufacturer's guidelines for the use of Lantus insulin reviewed on 10/22/13 at 8:35am directed, "...Open (in-use) vials must be discarded 28 days after being opened..."

- The manufacturer's guidelines for the use of Aplisol (tuberculin PPD, diluted) reviewed on 10/22/14 at 8:35am directed, "...Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency..."

- The refrigerator in the medication room of the Stepping Stones Program (SSP), unit (B2), building observed on 10/21/14 at 10am revealed an open (in-use) 10 ml vial of Lantus insulin that lacked a date. The nursing staff failed to follow the Hospital ' s policy/procedure and manufacturer's guidelines to ensure the safe use of insulin for the patients.

Staff E, Registered Nurse, interviewed on 10/21/14 at 10:00am acknowledged the open vial of insulin lacked an expiration date and staff failed to follow the Hospital's policy/procedure and manufacturer's guidelines for the safe use of the insulin.

- The refrigerator in the medication room of the Continuing Care Program (CCP) , unit (B1), building observed on 10/21/14 at 11:20am revealed an open (in-use) 10 milliliter (ml) vial of Novalog insulin that lacked a date, and an open (in-use) 10 ml vial of Lantus insulin that lacked a date. The nursing staff failed to follow the Hospital's policy/procedure and manufacturer's guidelines to ensure the safe use of insulin for the patients.

Administrative staff D, Registered Nurse (RN) interviewed on 10/22/14 at 2:20pm acknowledged the open vials of insulin lacked an expiration date and staff failed to follow the Hospital's policy/procedure and manufacturer ' s guidelines for the safe use of the insulin.

Pharmacist staff B, interviewed on 10/22/14 at 3:50pm explained they were unaware of the unlabeled insulin vials on the units and explained that the Hospital policy directed that when the staff opens a multi-use vial they must put an expiration date on the vial when they first open it.

- The refrigerator in the medication room of the Positive Living Skills (PLS), unit (C1) building, observed on 10/21/14 at 2:22pm revealed an open (in-use) 10 ml vial of Novalog insulin with a written date on it of 8-20 and an open (in-use) vial of tuberculin PPD testing solution with a written date on it of 7/28/14. The nursing staff failed to follow the Hospital's policy/procedure and manufacturer's guidelines to ensure the safe use of insulin and tuberculin PPD testing solution for the patients.

Nursing staff I, Licensed Practical Nurse (LPN), acknowledged the open vials of insulin and tuberculin testing solution with the written dates on them that indicated the medications were expired. Staff I acknowledged staff failed to follow the Hospital's policy/procedure and manufacturer's guidelines for the safe use of the insulin and tuberculin PPD testing solution.

- An upper center cabinet in the medication room of the Healthy Options, Plans, and Experiences (HOPE), unit (C2) building observed on 10/22/14 at 2:05pm revealed an open (in-use) 473 ml bottle of Potassium Chloride oral solution (cherry flavored) with an expiration date of 7/14. The nursing staff failed to follow the Hospital's policy/procedure and manufacturer's guidelines to ensure the safe use of the Potassium Chloride solution.

Administrative staff D, RN, acknowledged the open (in-use) bottle of Potassium Chloride with an expiration date that indicated the medication had expired and staff failed to follow the Hospital's policy/procedure and manufacturer's guidelines for the safe use of the Potassium Chloride solution..
VIOLATION: PHARMACEUTICAL SERVICES Tag No: A0490
Based on medical record review, document review, and staff interview the hospital's pharmacy failed to develop a tracking system for clarification of medication orders, failed to monitor the effectiveness of medications, and failed to coordinate medication needs for patients (refer to A-0500). The hospital's pharmacy failed to ensure outdated drugs and biologicals are not available for patient use (refer to A-0505). The lack of an effective pharmacy tracking system for clarification of medication orders and failure to monitor medication therapy and coordinate medication needs for patients resulted in an immediate jeopardy identified on 10/30/14.



The cumulative effect of the pharmacy's systemic failure to develop a tracking system for clarification of medication orders, to monitor the effectiveness of medication therapy and coordinate medication needs for patients and failure to ensure outdated drugs and biologicals were not available for patient use resulted in the hospital's inability to provide care in a safe and effective manner.
VIOLATION: DELIVERY OF DRUGS Tag No: A0500
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



The hospital reported a census of 258 patients with a bed capacity of 206 beds. Based on medical record review, document review, and staff interview the hospital pharmacy lacked a tracking system for clarification of medication orders and failed to complete a thorough investigation of a medication event for three of twenty five sampled patients (patient's #9, #24 and #25). The hospital's pharmacy's failure to supervise and coordinate all the activities of pharmacy services resulted in deterioration of a patient's medical condition and medication errors/omissions.


Findings include:


- The American Society of Health-System Pharmacists (ASHP) Guidelines: Minimum Standard for Pharmacies in Hospitals directs: "...A. Reviewing Patient Responses to Medication Therapy ...Medication therapy monitoring includes a proactive assessment of patient problems and an assessment of a. The therapeutic appropriateness of the patient ' s medication regimen...d. Patient adherence to the prescribed medication regimen... j. Assessment of the effectiveness of the patient ' s medication. ...Antimicrobial Stewardship and Infection Prevention and Control. Pharmacists should monitor patients' laboratory reports of microbial sensitivities or applicable diagnostic markers and advise prescribers.


- Patient #9's closed medical record review on 10/27/14 revealed an admission date of [DATE] with a psychiatric diagnosis of [DIAGNOSES REDACTED]#9 had swelling of the legs and a superficial ulcer on the tip of the second toe left foot. Physician staff G ordered clindamycin (an antibiotic) 150mg (milligrams) three times a day by mouth, physical therapy for hydrotherapy (whirlpool baths), and a pain medication.

- Physician staff H did not assess patient #9 again until 9/10/14 (two weeks later) for left foot pain. Staff H indicated patient #9's left foot up to mid leg swollen, tender and left second toe has open ulcer, tender, no active bleeding, swelling and [DIAGNOSES REDACTED]tous. Patient #9 currently used a pain medication and clindamycin.

- Physician staff H did not assess patient #9 again until 9/18/14 (8 days later) for a follow up for their left foot pain. Assessment revealed left second toe tender, [DIAGNOSES REDACTED]tous, no discharge, plantar surface of the second toe gangrene, dryness and ingrown nails. Patient #9 continued on the antibiotic clindamycin. Physician staff H ordered a wound culture of the left second toe. Patient #9's medical record lacked evidence of wound culture results and the hospital pharmacy was monitoring the effectiveness of the antibiotic the patient had been on for 23 days.

- Assistant Director of Nursing staff A interviewed on 10/30/14 at 12:00pm acknowledged nursing staff failed to obtain the wound culture ordered on [DATE] to determine if patient #9 received the appropriate antibiotic.

- Nursing progress notes on 9/25/14 at 1:40am indicated patient #9 's entire foot is red with flaking dry skin. The end of the second toe is black with white flaking skin around the tip. Nursing documentation indicated patient #9 refused their antibiotic 30% of the time. Medical record lacked evidence the hospital pharmacy addressed the patient's adherence to the antibiotic drug regimen.

- Physician staff H did not assess patient #9 again until 9/25/14 at 10:49am and documented left leg [DIAGNOSES REDACTED]tous, tender, warm, swollen, left first toe tender, plantar surface gangrene, Patient has known history of diabetes mellitus and patient is noncompliant with the antibiotic treatment. Patient required transfer to an acute care hospital for left leg cellulitis and first toe gangrene and required amputation of the left second toe. Patient #9's medical record revealed patient #9 remained on the antibiotic clindamycin for 31 days and their wound continued to deteriorate.

- Patient #9's medical record lacked evidence the hospital's pharmacist tracked the antibiotic use and its effectiveness, addressed patient's compliance with their drug regimen, and monitored for labs (cultures or other diagnostic marker).


- Patient #24 ' s closed medical record reviewed on 10/29/14 revealed a transfer date of
6/13/14 from a community hospital with a psychiatric diagnosis of [DIAGNOSES REDACTED]

- Admission evaluation notes on 6/14/14 revealed Physician staff J's knowledge that patient #24's history included a DVT diagnosed approximately three to four months ago. A lab test completed on 6/13/14 at the hospital the patient transferred from showed a non-therapeutic Protime International Normalized Ratio (PT/INR-test to measure the time it takes for blood to clot) results of 1.1 (Therapeutic PT/INR level is 2-3). Physician staff J ordered lab tests including a PT/INR, comprehensive metabolic panel (CMP) and a complete blood count (CBC) to be completed on 6/16/14. The medical record revealed the facility failed to complete the ordered lab tests. Patient #24's medical record failed to reveal any lab tests (PT/INR) completed to test the patient's clotting time from admission to discharge.


- Physician orders dated 6/13/14 required Coumadin (medication used to prevent harmful
blood clots from forming or growing larger) 5mg by mouth every other day and Coumadin 7.5mg by mouth every other day. Physician orders directed staff to begin Coumadin 7.5mg on 6/14/14 and Coumading 5.0 mg on 6/15/14.

- Pharmacist staff B indicated they faxed a clarification request of the Coumadin order to the
Nurses ' station on patient #24 ' s unit on 6/13/14 because nursing staff entered the
Coumadin order as 5mg to be given every day at 8:00pm and 7.5mg to be given every day at
8:00pm. Pharmacist staff B provided the printed page of patient #24 ' s medication order received by the pharmacy verifying the incorrect order entry by the nursing staff and indicated that this would be an unsafe dosage of Coumadin.


- Patient #24's Medication Administration Record (MAR) revealed they refused the 7.5mg Coumadin dose on 6/14/14. The medical record lacked evidence patient #24 received any dose of Coumadin during their admission.


- Pharmacist staff B indicated pharmacy staff failed to receive a response from nursing staff after the clarification fax sent on 6/13/14 prompting a " follow up phone call " and an additional clarification fax to the nursing unit on 6/16/14. Note attached to the fax stated "Warfarin (Coumadin) needs to be reviewed-pharmacy's 2nd request pt (patient) has missed 2 doses." Pharmacist staff B revealed nursing staff failed to respond to the fax and clarify the
order. Pharmacist Staff B indicated that they put the medication on hold. Pharmacist staff B indicated patient #24 "fell through the cracks after the third or fourth day ".



- Patient #24's medical record failed to contain a discontinue order for Coumadin. However, Coumadin did not appear on the MAR after 6/14/14. The patient did not receive any Coumadin from 6/14/14-6/20/14.


- Assistant Director of Nursing (ADON) staff A interviewed on 10/29/14 at 1:50pm acknowledged patient #24's chart lacked evidence of a discontinue order for Coumadin.


- ADON staff A interviewed on 10/30/14 at 9:10am indicated nursing is to follow up with the doctor after receiving a request for clarification fax from pharmacy. Staff A indicated faxes are used for communication between nursing staff and pharmacy for order clarification.


- Medical Director Staff C interviewed on 10/29/14 at 3:55pm revealed pharmacy is supposed to make sure an RN or doctor knows about the issue so clarification can be given. Staff C acknowledged a fax to the units' nurses' station would not be proper procedure.


- Pharmacist staff B interviewed 10/30/14 at 10:05am indicated the facility did not have a good process for clarification of medication orders. Pharmacist Staff B revealed failure to receive timely clarifications from the units. Pharmacist Staff B further indicated there needs to be a different procedure; " the fax system does not adequately address medication orders needing timely clarification, entry or administration and they do not have a system of checks and balances since alterations can take place at any point of entry in the current system ' . Pharmacist Staff B revealed there is no way to know if anyone received the fax unless someone calls the pharmacy back. Pharmacist Staff B revealed they filled out an incident report on 6/16/14.


- Medical Director staff C interviewed on 10/30/14 at 10:30am indicated they had no knowledge of patient #24 not receiving Coumadin as ordered by a physician.



- Investigative notes of the incident completed by the risk manager staff W reviewed on 10/30/14 at 9:05am revealed a failure to transcribe an order involving nursing service. The notes confirmed nursing incorrectly entered Coumadin order.



- Review of the hospital's policies on 10/29/14 revealed the hospital pharmacy failed to develop new policies and procedures for medication clarification requests since this incident in June.


- Nursing notes dated 6/20/14 at 9:09pm revealed patient #24 required admission to an Intensive Care Unit at another hospital with a diagnosis of [DIAGNOSES REDACTED]



- The hospital's pharmacy's failure to provide a tracking system for clarification of medications and their practice to place a medication on hold without consultation with a physician contributed to a patient not receiving medications necessary to treat the patient's medical condition and led to deterioration of a patient's physical condition requiring admission to an intensive care unit.





- Patient #25's closed medical record reviewed on 10/30/14 revealed an admitted
6/19/2014 with a psychiatric diagnosis of [DIAGNOSES REDACTED]
of cardiac arrhythmias (irregular heart rate).


- Physician orders on 6/20/14 at 0830 directed the patient to receive digoxin (a medication used to treat irregular heart rates by making the heart beat slower and stronger) .125mg every morning and a digoxin level lab test.


- Patient #25's medical record reviewed on 10/30/14 revealed a medication reconciliation form completed on 6/20/14 at 0830 including a digoxin order of .125 mg every Monday Wednesday and Friday. The medical record and MAR lacked evidence the reconciliation form was received in pharmacy with the change in frequency.


- Pharmacist staff B interviewed on 10/29/14 at 2:45pm revealed the medication order for patient #25 lacked the correct frequency-patient #25 was taking the medication three times a week at home not daily as ordered. Pharmacist Staff B indicated they faxed a clarification to the nurse ' s station on patient #25 ' s unit on 6/20/14 for the digoxin and a laboratory request for digoxin level as this is a high risk medication. The medical record lacked evidence the nursing staff responded to the clarification order.



- Medication administration record (MAR) revealed nursing staff documented patient refused digoxin 0.125mg on Saturday 6/21/14, received digoxin 0.125mg on Sunday 6/22/14, and received digoxin 0.125mg on Monday 6/23/14.


- Laboratory results sheet revealed the patient had digoxin level drawn on 6/20/14 at 12:30pm and the results were available for review 6/21/14 at 6:12am. The patient's digoxin level was low- <0.5 mcg/L (normal range 0.8-2.0 mcg/L). The medical record lacked evidence pharmacy was aware of the lab result.


- Pharmacist staff B interviewed on 10/29/14 at 2:45pm revealed pharmacy staff failed to receive a response from nursing staff from the fax sent on 6/20/14 prompting a follow up fax dated 6/23/14 stating "...Pharmacy is discontinuing this med, due to high risk. Med w/o (without) obtaining sufficient lab values for safe use..."


- The medical record lacked evidence of a discontinue order for the digoxin. However, the medication Digoxin did not appear on the MAR on 6/24/14.


- Physician's order dated 6/23/14 at 10:40am requested digoxin level at 1400. The medical
record lacked evidence pharmacist staff B was notified or aware of the ordered digoxin level.


- Physician ' s order dated 6/25/14 revealed an order for digoxin .125mg to be given every Monday, Wednesday, and Friday.


- The MAR revealed patient #25 was given digoxin .125mg on Thursday 6/26/14 and Friday 6/27/14.


- Pharmacist staff B interviewed 10/30/14 at 10:05am indicated patient #25 would have received a week's worth of digoxin in three days if the patient had not refused the dose on Saturday 6/21/14 and they were not aware of the digoxin level ordered on [DATE] or 6/23/14 or their results. Pharmacist Staff B revealed they filled out an incident report on 6/24/14.


- Investigative notes of the incident report completed by the risk manager staff W reviewed on 10/30/14 at 12:00pm revealed pharmacy failed to obtain an order prior to discontinuing ordered digoxin.


- Review of hospital policies on 10/29/14 failed to reveal the hospital pharmacy developed any new policies and procedures for medication clarification requests since this incident in June.


- The hospital's pharmacy lacked a tracking system for clarification of medication orders. The hospital's pharmacy's practice of discontinuing medications without obtaining an order in consultation with the physician or nursing staff contributed to a patient not receiving medications necessary to treat the patient's medical condition.
VIOLATION: UNUSABLE DRUGS NOT USED Tag No: A0505
The Hospital reported a census of 258 patients with a licensed bed capacity of 206. Based on observation, policy/procedure review, manufacturer's guidelines, and staff interview the hospital's pharmacy failed to ensure outdated drugs and biologicals are not available for patient use for four of seven observed medication rooms, and one of one dental clinic. This failure placed patients at risk to receive outdated drugs and biologicals.
Findings include:
- The Hospital's Provision of Care Procedures Manual policy, titled, "STORAGE AND SECURITY OF MEDICATION" reviewed on 10/22/14 at 3:50pm directed, "...Multi-dose vials for injection may be used for 28 days after opening. When it is first used, it is dated with expiration date and initialed...Medications that are expired or damaged are place in the return bin for pharmacy staff to take action except for controlled medications ...Any medications expiring during the month of the inspection are replaced by pharmacy staff..."

- The manufacturer's guidelines for the use of Novalog insulin reviewed on 10/22/14 at 8:35am directed, "...After initial use a vial may be kept at temperatures 30 degrees Celsius (C) (86 degrees Fahrenheit (F) for up to 28 days..."

- The manufacturer's guidelines for the use of Lantus insulin reviewed on 10/22/13 at 8:35am directed, "...Open (in-use) vials must be discarded 28 days after being opened..."

- The manufacturer's guidelines for the use of Aplisol (tuberculin PPD, diluted) reviewed on 10/22/14 at 8:35am directed, "...Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency..."

- The refrigerator in the medication room of the Stepping Stones Program (SSP), unit (B2), building observed on 10/21/14 at 10:00am revealed an open (in-use) 10 ml vial of Lantus insulin that lacked a date on the vial. The hospital's pharmacy failed to ensure outdated and unusable drugs were not available for patient use.

Staff E, Registered Nurse, interviewed on 10/21/14 at 10:00am acknowledged the open vial of insulin lacked a date.

- The refrigerator in the medication room of the Continuing Care Program (CCP) , unit (B1), building observed on 10/21/14 at 11:20am revealed an open (in-use) 10 millileter (ml) vial of Novalog insulin that lacked a date, and an open (in-use) 10 ml vial of Lantus insulin that lacked a date. The Hospital's pharmacy failed to ensure outdated and unusable drugs were not available for patient use.

Administrative staff D, Registered Nurse (RN) interviewed on 10/22/14 at 2:20pm acknowledged the open vials of insulin lacked a date.

Pharmacist staff B, interviewed on 10/22/14 at 3:50pm explained they were unaware of the unlabeled insulin vials on the units and explained that the Hospital policy directs that when the staff opens a multi-use vial they must put an expiration date on the vial when they first open it.

- The refrigerator in the medication room of the Positive Living Skills (PLS), unit (C1) building, observed on 10/21/14 at 2:22pm revealed an open (in-use)10 ml vial of Novalog insulin with a written date on it of 8-20 and an open (in-use) vial of tuberculin PPD testing solution with a written date on it of 7/28/14. The hospital's pharmacy failed to ensure outdated and unusable drugs were not available for patient use.

Nursing staff I, Licensed Practical Nurse (LPN), acknowledged the open vials of insulin and tuberculin testing solution with the written dates on them that indicated the medications were beyond their expiration dates.

- An upper center cabinet in the medication room of the Healthy Options, Plans, and Experiences (HOPE), unit (C2) building observed on 10/22/14 at 2:05pm revealed an open (in-use) 473 ml bottle of Potassium Chloride oral solution (cherry flavored) with an expiration date of 7/14. The hospital's pharmacy failed to ensure outdated and unusable drugs were not available for patient use.

Administrative staff D, RN, acknowledged the open (in-use) bottle of Potassium Chloride with an expiration date that indicated the medication had expired.

- The medication cabinets in the dental clinic observed on 10/22/14 at 4:00pm revealed the following dental products used for dental procedures exceeded the end date for use:
Two- tubes of Acroseal (root canal filling material) with an expiration date of 2/14.
Two- 1 ml syringes of Fusio liquid dentin (used to fill teeth after removal of the decay) with an expiration date of 12/13.
Three-packages of Take 1 Advanced (used to make impressions of the patient ' s teeth) with an expiration date of 7/14.
One-1ml syringe of folwable composite (a fluid material used to fill a cavity) with an expiration date of 10/12.
One-1 ml syringe of flowable composite with an expiration date of 11/13.
One-1 ml syringe of flowable composite with an expiration date of 7/12.
One-1 ml syringe of flowable composite with an expiration date of 10/12.
One-1 ml syringe of flowable composite with an expiration date of 3/12.
One-1 ml syringe of flowable composite with an expiration date of 5/13.
One-1 ml syringe of flowable composite with an expiration date of 4/11
Two-1 ml syringes of flowable composite with an expiration date of 7/14.
One-1 ml syringe of flowable composite with an expiration date of 9/10
One-1 ml syringe of flowable composite with an expiration date of 12/13.
One-1 ml syringe of flowable composite with an expiration date of 7/13.
One-1 ml syringe of flowable composite with an expiration date of 1/13.
One-20 gram tube of Tubli-Seal (a root canal sealer) with an expiration date of 4/14.
One-3 gram tube of flowable composite with an expiration date of 1/14.
Laboratory staff F, interviewed on 10/22/14 at 4:00pm acknowledged the expired dental products in the dental clinic.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on observation, document review, and staff interview the hospital failed to provide for the safety and well-being of patients in five of five over crowded patient care buildings (refer to A-0701) failed to meet the life safety code requirements (refer to A-0710) and ensure proper, storage and prompt disposal of trash (refer to A-0713). The lack of an effective program to manage patient census resulted in an immediate jeopardy identified on 10/21/14 at 3:30pm by the Centers for Medicare/Medicaid Services and removed with a fire watch instituted on 10/21/14 at 4:07pm and lasting until each building reached at/or below capacity. Refer to the Fire Marshal Statement of Deficiency Form CMS-2786 (ASPEN# QQR721) dated 10/30/14 for additional information.




The cumulative effect of the systematic failure to provide for the safety of patient in five of five over crowded patient care buildings and proper storage and disposal of trash resulted in the hospital's inability to provide care in a safe and effective manner.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
The hospital reported a census of 258 patients with a licensed bed capacity of 206. Based on observation, interview and document review, the hospital failed to provide for the safety and wellbeing of patients in five of five over crowded patient care buildings (Managing and Preventing Symptoms (MAPS) unit A1 building, Crisis Stabilization Program (CSP), unit EB (East Biddle), Managing and Preventing Symptoms (MAPS) unit A2 building, Stepping Stone Program (SSP), unit B2 building, Positive Living Skills (PLS) unit C1 building, Continuing Care Program (CCP), unit B1 building, and Healthy Options, Plans, and Experiences (HOPE) unit C2 building). This deficient practice increased the risk to patients and staff of evacuating the facility in a timely manner in case of a fire or other emergency.

Findings include:

- Kansas Statues K.S.A. 59-2949 reviewed on 10/29/14 at approximately 4:20pm directed, "...A mentally ill person may be admitted to a treatment facility as a voluntary patient when there are available accommodations and the head of the treatment facility determines such person is in need of treatment..."

- Kansas Statues K.S.A. 59-2968 reviewed on 10/29/14 at approximately 4:20pm directed "...No patient shall be admitted to a state psychiatric hospital pursuant to any of the provision of this act, including any court-ordered admission, if the secretary has notified the supreme court of the state of Kansas and each district court to which has jurisdiction over all or part of the catchments area served by a state psychiatric hospital, that the census of a particular treatment program of the state psychiatric hospital has reached capacity and that no more patients may be admitted ..."

- The hospital's Census Management Initiative reviewed on 10/29/14 at approximately 4:20pm directed, "...The Census Management Initiative adds a diversionary process for admissions...When the patient census reaches one hundred eighty-five (185) or acuity necessitates...may seek census assistance (from another state hospital)..."

- Managing and Preventing Symptoms (MAPS) unit A1 building toured on 10/20/14 between 4:24pm to 5:10pm revealed nineteen patient rooms with a bed capacity of 30 patients. Registered Nurse staff P reported a current census of 36 patients. Observation of rooms 146, 147, 148, 150, 159, and 161 revealed semi-private rooms with three names on the door nameplate each room contained three beds with two beds against one wall with the beds against each other and approximately four-inch space between a bed and clothes closet. The rooms lacked a method to provide privacy between the two beds on the same wall. The rooms had two closets, with one blocked by a bed and two dressers for the three patients.

- Crisis Stabilization Program (CSP), unit EB (East Biddle) toured on 10/20/14 between 4:20pm to 5:15pm revealed 30 private patient rooms with a bed capacity of 30 patients. Administrative staff D reported a current census of 41 patients. Observation of rooms 211, 212, 213, 220, and 223 revealed private rooms with two names on the door nameplate each room contained two beds, one against each long wall of the room. The rooms had one closet and one dresser for both patients. The rooms contained a portable privacy divider between the two beds, sitting on the floor, made up of PVC (polymerized vinyl chloride) pipes with a blue piece of material attached at the top and bottom of the frame. The privacy divider when touched or moved lacked stability and rendered it a trip hazard, because of the proximity to each of the two beds in the rooms.

- Managing and Preventing Symptoms (MAPS) unit A2 building toured on 10/21/14 between 9:10am to 10:35am revealed eighteen patient rooms with a bed capacity of 30 patients. Mental Health Technician staff Q reported a current census of 37 patients. Observation of rooms 137, 138, 139, 140,141, and 142 revealed semi-private rooms with three names on the door nameplate each room contained three beds with two beds against one wall with the beds against each other and approximately four-inch space between a bed and clothes closet. The rooms lacked a method to provide privacy between the two beds on the same wall. The rooms had two closets, with one blocked by a bed and two dressers for the three patients.

- Stepping Stone Program (SSP), unit B2 building toured on 10/21/14 between 10:00am to 11:30am revealed 16 patient rooms with a bed capacity of 26 patients. Administrative staff D reported a current census of 33 patients with a report of two admissions, which will bring the census to 35 patients. Observation of rooms 134, 135, 150, 151, 152, 153, 154, and 155 revealed semi-private rooms with three names on the door nameplate and each room contained three beds with two beds against one wall with the beds against each other and approximately a four-inch space between a bed and/or dresser and the clothes closet. The rooms lacked a method to provide privacy between the two beds on the same wall. The rooms had two dressers and two closets for the three patients.

- Positive Living Skills (PLS) unit C1 building toured on 10/22/14 between 10:45am to 11:10am revealed eighteen patient rooms with a bed capacity of 30 patients. Registered Nurse staff S reported a current census of 37 patients. Observation of rooms 126, 160, and 161 revealed semi-private rooms which contained three beds with two beds against one wall with the beds against each other and approximately four-inch space between a bed and clothes closet. The rooms lacked a method to provide privacy between the two beds on the same wall. The rooms had two closets, with one blocked by a bed and one dressers for the three patients.

Register Nurse staff S interviewed on 10/22/14 at 11:10 acknowledged they have to put three patients in rooms at times and indicated they had to take all patients.

- Continuing Care Program (CCP), unit B1 building toured on 10/21/14 between 2:20pm to 3:00pm revealed 18 patient rooms with a bed capacity of 30 patients. Administrative staff D reported a current census of 33 patients. Observation of rooms 136, 137, 141, 140, and 157 revealed semi-private rooms with three names on the door nameplate and each room contained three beds with two beds against one wall with the beds against each other and approximately a four-inch space between a bed and/or dresser and the clothes closet. The rooms lacked a method to provide privacy between the two beds on the same wall. The rooms had two dressers and two closets for the three patients.


- Healthy Options, Plans, and Experiences (HOPE) unit C2 building toured on 10/22/14 between 2:30pm to 2:55pm revealed nineteen patient rooms with a bed capacity of 30 patients. Registered Nurse staff T reported a current census of 35 patients. Observation of rooms 167, 168, 169, 170, and 172 revealed semi-private rooms which contain three beds. The rooms had two closets blocked with beds and two dressers for the three patients. Observation of room 131 revealed a semi-private room with three patients and room 127 a semi-private room with four beds.

- The Fire Marshal inspected the facility on 10/21/14, 10/28/14 and 10/29/14. The report cited the facility for patient safety compromised due to overcrowding-the 2000 Life Safety Code Table 7.3.1.2 requires 120 square feet per person. The facility had 52 patients or 25% over capacity on 10/21/14. On 10/28/14 the facility had 37 patients over capacity and on 10/29/14 the facility had 34 patients over capacity which affected exit access by impeding the exit path with personal belongs and additional beds. This deficient practice increased the risk to patients and staff of evacuating the facility in a timely manner in case of a fire or other emergency. After finding the facility being over capacity in all five patient buildings a fire watch was instituted starting on 10/21/14 and lasting until each building had been reduced to capacity. Refer to the Fire Marshal Statement of Deficiency (ASPEN # QQ7R21) Form-CMS-2786 dated 10/30/14 for additional information.

- The hospital's census tracking called "Section Population" reviewed on 10/29/14 at 2:30pm revealed the facility's census met capacity on seven days in the last six months (180 days) and the last four month's census remained between 216 to 260 patients daily (ten to 54 patients over capacity).
VIOLATION: DISPOSAL OF TRASH Tag No: A0713
The hospital reported a census of 258 patients with a licensed bed capacity of 206. Based on observation, policy/procedure review and staff interview the hospital failed to ensure proper, storage and prompt disposal of trash for two of two trash dumpsters observed.

Findings include:

- The hospital's policy/procedure titled, "Maintenance of Grounds" reviewed on 10/29/14 directed, "Trash Clean-up...Trash bins on campus are serviced three (3) times a week (Monday, Wednesday, Friday)...Containers are maintained in a clean, sanitary condition by the contractor..."
- Observation of the trash dumpster across the street from CCP, unit B1 building on 10/19/14 at 10:40am revealed the trash dumpster completely full and not covered.
- Observation of the trash dumpster by CCP, unit B2 building on 10/21/14 at 11:25am revealed the trash dumpster completely full and not covered.
- Observation of the trash dumpster by CCP, unit B2 building on 10/21/14 at 4:00pm, the same dumpster seen at 11:25am overflowing with trash, not covered and a black cat sitting on top of the trash in the dumpster.
The Hospital failed to follow their policy/procedure that directed, " Containers are maintained in a clean sanitary condition."
Administrative staff D, Registered Nurse (RN) interviewed on 10/21/14 at 11:25pm acknowledged the completely full trash dumpsters not covered. Staff D explained the contracted service picks up the trash on Monday, Wednesday, and Friday.
VIOLATION: INFECTION CONTROL Tag No: A0747
The hospital reported a census of 258 patients with a licensed bed capacity of 206. Based on observation, policy review, and staff interview the hospital's infection control officer failed to develop and maintain an active infection control system (refer to A-0749).

The cumulative effect of the systemic failure to develop and maintain an active infection control system resulted in the hospital's inability to provide care in a safe and effective manner.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


The hospital reported a census of 258 patients with a licensed bed capacity of 206. Based on observation, policy review, and staff interview the hospital's infection control officer failed to develop and maintain an active infection control system ensuring hospital personnel followed basic infection control practices for two of two observed glucometer (blood sugar analyzer) tests, one of one observed patient nebulizer in the treatment room, one of one observed handling of dirty laundry, two of two observed disposition of laundry, two of two observed trash bins, and one of one patient with a wound culture ordered (patient #9). The infection control officer failed to maintain a surveillance, data collection, and reporting system to track infection control issues. This deficient practice places patients at risk for hospital-acquired infections.

Findings include:

- The hospital's "INFECTION PREVENTION AND CONTROL PROGRAM" reviewed on 10/22/14 at 10:30am, stated, "...Osawatomie State Hospital (OSH) through a hospital wide infection prevention and control activities, monitor patient care, employee health, policies and procedures and education relating to infection prevention and control...INFECTION PREVENTION RESPONSIBILITIES OF INFECTION PREVENTION COMMITTEE, ...reviewing conclusions, recommendations and actions taken relating to the evaluation of healthcare associated incidence rates, epidemiological significant outbreaks, unusual pathogens and personnel infections...forwarding minutes to the Medical Staff and Nursing Administrative Committees ..."

- The hospital's "Infection Prevention Procedure, REPORTING AND CONTROL OF INFECTION" reviewed on 10/26/14 at 3:30pm directed, "...The purpose of the following procedure is to: Provide a system for early identification, reporting and evaluation of infections of patients and personnel; Provide definitions for Healthcare Associated Infections (HAI), for determination of baseline rates of infections within the hospital and for performance improvement activities..."

- The hospital's policy/procedure, "HAND HYGIENE" reviewed on 10/22/14 at 10:30am directed, "...Hand Antisepsis Using Alcohol-Based Hand Rubs, B. Indication for Use if Hands are Not Visibly Soiled 1. Before and after having direct contact with patients. Before preparing medications...After removing gloves...During medication pass, if the patient is touched or if an object is handled that the patient has touched..."

- The hospital's policy/procedure titled, "Maintenance of Grounds" reviewed on 10/29/14 directed, "Trash Clean-up...Trash bins on campus are serviced three (3) times a week (Monday, Wednesday, Friday)...Containers are maintained in a clean, sanitary condition by the contractor..."

- Nursing staff L, Registered Nurse (RN), observed on 10/20/14 at 4:00pm, performed a finger stick glucometer test on patient #26 in the treatment room wearing gloves on both hands. Staff L removed the glove from their left hand, reapplied a glove to their left hand without performing hand hygiene, and performed a finger stick glucometer test on patient #27, staff L then removed the gloves from their hand and performed hand hygiene. Staff L failed to remove both gloves, failed to perform hand hygiene, and failed to reapply unused gloves after performing the finger stick glucometer test on patient #26 and before performing the finger stick glucometer test on patient #27.

Administrative staff N, Quality Assessment/Quality Improvement director, interviewed on 10/22/14 provided documentation of a survey (using questions and observations) the hospital conducted regarding the use of hand hygiene in the month of August 2014. Staff N explained hand hygiene will be a measure that the hospital will track for the next year.
The infection control officer lacked evidence or documentation of any current or ongoing monitoring of compliance with hand hygiene.
- Observation of the treatment room in the Continuing Care Program (CCP), unit B1 building on 10/21/14 at 11:20am revealed a nebulizer machine (used for breathing treatments) with the oxygen mask and tubing connected to the machine. The machine had a label on it with patient #28's name. The oxygen mask and tubing lacked a date when staff opened them and attached them to the nebulizer machine.
Administrative staff D, Nurse Manager, RN, interviewed on 10/21/14 at 11:20pm acknowledged the oxygen mask and tubing lacked a date when opened and connected to the nebulizer machine. Staff D disconnected the oxygen mask and tubing from the nebulizer and discarded them, explaining they are to be labeled with a date when they are opened and attached to the nebulizer and discarded in 24 hours.

- Observation in the hall of Crisis Stabilization Program (CSP) unit East Building (EB) on 10/21/14 at 1:55pm revealed a housekeeping staff member dragging two bags of soiled laundry, one in each gloved hand to the soiled utility room. Removed their gloves when exiting the utility room, and performed hand hygiene.

- Observation in the soiled utility room of CCP, unit B1 building on 10/21/14 at 2:20pm revealed a door in the soiled utility room that went to the outside. Two soiled laundry bags laid outside by the door on the ground.
Administrative staff D, Nurse Manager, RN, interviewed on 10/21/14 at 2:20pm acknowledged the soiled lined bags on the ground and the potential for infection control issues. Staff D explained the laundry staff picks up the soiled linen in the morning.
Laundry staff O, interviewed on 10/22/14 at 10:55am confirmed staff put the soiled laundry outside of the soiled utility room in large laundry carts. The maintenance staff picks up the soiled laundry each morning. Staff O lacked knowledge of staff putting the soiled laundry bags on the ground outside.
The Hospital lacked evidence of policies/procedures regarding the handling of the soiled laundry.

- Observation of the trash dumpster across the street from CCP, unit B1 building on 10/19/14 at 10:40am revealed the trash dumpster completely full and not covered.

- Observation of the trash dumpster by CCP, unit B2 building on 10/21/14 at 11:25am revealed the trash dumpster completely full and not covered.

- Observation of the trash dumpster by CCP, unit B2 building on 10/21/14 at 4:00pm, the same dumpster seen at 11:25am overflowing with trash, not covered and a black cat sitting on top of the trash in the dumpster.

The Hospital failed to follow their policy/procedure that directs, " Containers are maintained in a clean sanitary condition.

Administrative staff D, Nurse Manager, RN interviewed on 10/21/14 at 11:25pm acknowledged the completely full trash dumpsters not covered. Staff D explained the contracted service picks up the trash on Monday, Wednesday, and Friday.

- Patient #9's closed medical record review on 10/27/14 revealed an admission date of [DATE] with a psychiatric diagnosis of major depressive disorder with severe psychotic features and medical diagnosis of diabetes mellitus. Physician staff G assessed patient #9 on 8/26/14 for medical issues. Physical examination indicated patient #9 had swelling of the legs and a superficial ulcer on the tip of the second toe left foot. Physician staff G ordered clindamycin (an antibiotic) 150mg (milligrams) three times a day by mouth, physical therapy for hydrotherapy (whirlpool baths) and a pain medication. Physician staff H on 9/10/14 assessed patient #9 for left foot pain. Staff H indicated patient #9's left foot up to mid leg swollen, tender and left second toe has open ulcer, tender, no active bleeding, swelling and erythematous. Patient #9 currently used a pain medication and an antibiotic. Physician staff H did not assess patient #9 again until 9/18/14 for a follow up for their left foot pain. Assessment revealed left second toe tender, erythematous, no discharge, and plantar surface of the second toe gangrene, dryness and ingrown nails. Patient #9 continued on antibiotic and refused to go for hydrotherapy. Physician staff H ordered Hibiclens solution to left foot daily, a podiatry consultation, and a wound culture of the left second toe. Patient #9's medical record lacked evidence patient #9 received a podiatry consultation or a wound culture. Nursing progress notes on 9/25/14 indicated at 1:40am patient #9 allow them to assess their toe. Documentation indicated the entire foot is red with flaking dry skin. The end of the second toe is black with white flaking skin around the tip. Nursing documentation indicated patient #9 refused their antibiotic 30% of the time and had been refusing Hibiclens order. Physician staff H did not assess patient #9 again until 9/25/14 at 10:49am found the patient ' s left leg erythematous, tender, warm, swollen, left first toe tender, planter surface gangrene, and the patient has known history of diabetes mellitus, patient is noncompliant with the antibiotic treatment. Patient #9 required transfer to an acute care hospital on [DATE] for left leg cellulitis and gangrene and underwent amputation of the second toe of the left foot.

Administrative staff A, Assistant Director of Nursing, interviewed on 10/30/14 at 12:00pm acknowledged patient #9's medical record lacked evidence nursing staff scheduled a podiatry consult or obtained a wound culture.

- Review of the "Report of Infection" form for patient #9 on 10/30/14 at 9:45am revealed a skin-cutaneous type of infection, cultures-none, generalized signs/symptoms (drainage purulent, pain/tenderness, and swelling/edema. Staff R, Registered Nurse (RN) submitted patient #9's "Report of Infection" to Infection Control staff on 8/26/14 at 9:59pm.

Nursing staff M, Employee Health/infection control interviewed on 10/22/14 at 3:50pm acknowledged they started collecting infection reports of patients from the nursing staff in January 2014. Staff M explained they do not have the data information completed or ready for report to the infection control committee or environment of care committee, no follow-up on reports has occurred.

Staff A, interviewed on 10/30/14 at 12:00pm acknowledged staff M, (infection control staff) receives the "Report of Infection" from the nursing units and reviews the reports to determine what supplies the nursing staff needs.

Staff A and F, interviewed on 10/22/14 at 1:30pm acknowledged the hospital failed to maintain an active infection control program. Staff A explained the hospital appointed them as infection control officer a couple of weeks ago. Staff F explained they held the position of co-chairman of the infection control program, the previous infection control practitioner left in October of 2013. Review of the infection control meeting minutes provided by Staff F revealed, an infection control committee meeting held on 2/14/13, 8/21/14, 9/18/14, and 10/16/14. Staff A and F explained there have been no focused infection control surveillance or monitoring since October 2013.