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.

THE BROOK HOSPITAL - DUPONT 1405 BROWNS LANE LOUISVILLE, KY May 9, 2017
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to protect and promote patient rights and failed to provide care in a safe setting for four (4) of fifteen (15) sampled patients, Patients #3, #4, #5, and #8. The facility did not put in place interventions to reduce fall risk and address patients' incontinent care needs for Patients #4, #5, and #8. In addition, the facility did not release Patient #3 from seclusion as soon as criteria was met and failed to contact the physician to obtain an order to extend the time in seclusion.


Refer to A 0144, A 0154, and A 0171
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure patients at risk for falls and incontinent care needs received care in a safe setting for three (3) of fifteen (15) sampled patients, Patient #4, #5, and #8. Observation of Patient #4's room revealed a puddle of liquid was beside the bed; the bed linens were wet and wet clothing was hanging over the bathroom door and heating/air conditioning unit. Patient #5 sustained three (3) falls, two (2) with injuries, on 05/04/17, 05/05/17, and 05/07/17. Observation of Patient #8's bed revealed a stain in the middle of the bed that was light yellow to brown in color covered with a blanket.

The findings include:

Review of the facility's policy, Fall Risk Precaution, dated November 2016, revealed the purpose of the policy was to identify patients who were at risk of falling in order to decrease the incidence of patient falls and provide a safe environment for the patient. The policy stated the facility would utilize protective measures for patients who may be assessed for risk of falling and take all necessary precautions where a fall risk exists. The facility would initiate Fall Risk Precautions for patients identified at risk for falls at the time of admission or anytime during the course of the stay. Throughout the stay, patients would be reassessed and nursing staff would document accordingly in the progress note any incident of falls and the need for continued precautions. Nursing staff would alert all staff members to the Fall Risk Precaution and the high risk factors associated with the risks of falls. Nursing staff would reassess fall risk precautions as the patient status changed each shift, and would monitor the patients for changes in ambulation status and environmental risk factors. Nursing staff would determine and limit patients' participation in activities that could pose an increased risk for falls. Staff would maintain a heightened awareness of environmental factors that may increase the risk of potential for falls, and communicate the risk factors to the Housekeeper or Maintenance. The facility would identify causative factors, i.e. medications, impulsivity, environmental, etc., and remove or mitigate falls risk to prevent occurrence. Nursing staff would document interventions, assessments, and notifications made in a progress note.

Review of the facility's policy, Patient Rights and Responsibilities, dated December 2012, revealed the purpose of the policy was to support the fundamental human dignity and the civil and constitutional statutory rights of the individual patient and recognize and respect personal dignity of the patient at all times. The facility would treat patients with human dignity and in an environment that contributes to a positive self-image. Medical care and treatment would be provided in accordance with the highest standards accepted in medical practice to the extent that the facilities, equipment, and personnel were available. The patient would receive prompt evaluation and care and treatment. Continued review of the Patient's Rights policy revealed the facility had established the following patient responsibilities and would be informed on admission: to carry out normal housekeeping tasks as appropriate, such as making the bed, straightening one's room and bathroom, maintaining personal clothing, be responsible for being honest and direct, telling staff about feelings related to personal issues, treatment, hospital environment, or other issues affecting the patient's well-being and care.

Review of the facility's policy, Physical and Sanitary Surveillance Plan, dated November 2011, revealed the purpose of the policy was for the establishment and implementation of a comprehensive surveillance program that assured all patient care units and general facility areas were maintained in a clean, sanitary, and attractive manner. The policy stated housekeeping staff was responsible for cleaning any spills, bowel movements, vomit, urine, etc., for patients/clients during their scheduled shifts. Thereafter, it would be the responsibility of the nursing staff on the unit to clean. Housekeeping would clean daily: the patient rooms, all baths, offices, medicine rooms, nurses' stations, visiting rooms, and lounges.

Review of the facility's policy, Reassessment of Patients, dated February 2016, revealed the purpose of the policy was to ensure patients were reassessed during their treatment experience by various disciplines to evaluate the patient's progress and response to care, treatment, and services. The policy stated the Registered Nurse would reassess patients using a bio-psycho-social approach under the following circumstances: change in patient medical condition, change in mental status, every shift when a patient was on one to one, with the use of restraint/seclusion procedures, and for medication side effects. Nursing staff would document the assessment in the medical record, charting any significant data collected from reassessment. During change of shift report, nursing staff would report significant data obtained during reassessments. In addition, nursing staff would identify patients needing reassessments during upcoming shifts.

1. Observation of Patient #4's room, on 05/05/17 at 8:05 AM, revealed no one was in the room; however, a puddle of liquid was beside Patient #4's bed and the bed linens were wet. Continued observation revealed wet clothing hanging over the bathroom door and over the heating/air conditioning unit, which was set to heat at seventy-eight (78) degrees.

Interview with Patient #4, on 05/05/17 at 10:45, revealed the patient had urinated on himself/herself while in the bed around 7:30 AM. Patient #4 stated he/she had washed his/her clothes in the sink and hung them on the door and on the heater to dry.

Review of Patient #4's clinical record revealed the facility admitted the patient on 05/02/17, with diagnoses of Schizophrenia, Hepatitis C, and Alcohol Abuse.

Review of Patient #4's Treatment Plan, implemented 05/02/17, revealed the goal for the patient was he/she would complete the acute phase of alcohol withdrawal prior to discharge or transfer to a chemical dependency facility. The plan did not have goals or interventions related to incontinence, Hepatitis C, or Schizophrenia.

Interview with Mental Health Associate (MHA) #2, on 05/05/17 at 8:50 AM, revealed Patient #4 had urinated on himself/herself while walking down the hall and in the bed on 05/04/17. The MHA stated he believed the patient was lazy because he/she could get up to go smoke, but would not get up to go to the bathroom. He revealed Patient #4 was elderly and confused; requiring assistance for some tasks and was not as high functioning as the other patients on the unit. He stated he had noticed on his fifteen minute rounds that Patient #4 had washed his/her clothing in the sink and hung them to dry over the door and over the heating unit around 7:00 AM on 05/05/17. However, he was not aware the patient had urinated on the floor or in the bed. MHA #2 stated there was a washer and dryer on the unit for the patients to use and staff could assist if necessary. He stated he tried to use tough love to motivate Patient #4 to do more for himself/herself, but the patient had self-loathing issues and did not want to do more for himself/herself. The MHA revealed the urine on the floor was a fall hazard and the clothing on the heater was a fire hazard. According to MHA #2, on his fifteen minute rounds, he was required to monitor for safety concerns and address them. He stated he should have addressed the wet linens, the puddle on the floor, and the clothes on the heater. Continued interview with MHA #2 revealed the MHAs completed a shift-to-shift report each day and nursing provided patient specific information to them. However, he had not received specific direction regarding toileting or incontinent care for Patient #4. He stated normally the elderly patients went to the Gero-Psych Unit, but since the patient was detoxing, the facility placed him/her on the Adult Unit where staff was used to taking care of those types of patients. MHA #2 stated it was the responsibility of staff to provide care in a safe environment and not addressing Patient #4's care needs related to incontinence, laundry, and urine on the floor, did not provide that safe setting.

Interview with MHA #4, on 05/05/17 at 9:30 PM, revealed Patient #4 was elderly and experienced urinary incontinence frequently. She stated usually the patients with those conditions would go the Gero-Psych Unit because staff there were used to providing care they needed. MHA #4 revealed the facility did not train staff to provide that type of care to the patients on the Adult Unit. She stated the patients on the Adult Unit were higher functioning patients and could take care of their own activities of daily living. According to MHA #4, the facility expected patients on the Adult Unit to make their own bed and do their own laundry. She stated Patient #4 used a rolling walker and needed staff assistance with incontinence care, laundry, and changing bed linens. She was unaware Patient #4 had washed clothes in the bathroom sink and hung the clothes to dry over the door and across the heater. She stated staff completed fifteen minute rounds to check on patients and monitor for safety concerns. MHA #4 revealed if staff saw clothes on rounds drying on the heater, they should remove them because it was a potential fire hazard. Continued interview with MHA #4 revealed every patient had a sheet that staff documented fifteen minute checks and the sheet had patients' issues and interventions to implement; however, Patient #4's sheet had no information regarding urinary incontinent care needs. She stated it was staff's responsibility to provide care in a safe environment and if Patient #4' needs were not met, staff was not providing a safe setting.

Interview with RN #3, on 05/05/17 at 10:22 AM, revealed she had not taken care of Patient #4 before and the report sheet staff used did not have information stating the patient was incontinent. RN #3 stated she had heard from the MHAs that the patient had a history of incontinence. She revealed staff should have updated the treatment plan and put interventions in place to promote the patient's dignity related to incontinence care. According to RN #3, the patient was confused at times and needed assistance with activities of daily living. She stated she thought the patient was at a disadvantage because the patient's room was at the end of the hall, preventing nursing staff from providing closer supervision. She revealed a puddle of urine was found on the floor after the surveyor was in the room and wet clothes were over the door and heater. RN #3 stated those conditions created a fall and fire hazard. Continued interview with the RN revealed Patient #4's needs were not met in a safe environment because staff did not address the clothing on the heater, urine on the floor, and nursing staff did not revise the treatment plan to include fall precautions.

Interview with the DON, on 05/08/17 at 3:00 PM, revealed it was determined on 05/05/17, Patient #4's care needs would be met better on the Gero-Psych Unit, and the patient was moved to that unit. She stated staff on the Adult Unit were used to providing care to higher functioning patients that were continent and mobile. She revealed she expected staff to monitor for safety hazards such as floors wet with urine and wet clothing over heaters. She stated if patients were not able to care for their own laundry needs and/or change their own bed linens; she expected staff to provide that service for the patients. The DON stated she also expected nursing staff to revise the treatment plan with goals that addressed Patient #4's care needs, such as incontinence care and laundry needs, and communicate the interventions to staff. She stated she expected staff to provide care to patients in a safe environment; however, urine on the floor, clothing on a heater, and not revising the treatment plan after a fall, was not providing care in a safe setting.

2. Observation of Patient #5, on 05/05/15 at 8:01 AM, revealed the patient in a red long sleeved shirt with tan pants sitting in a wheelchair at the table in the common area.

Observation of Patient #5, on 05/08/17 at 11:50 AM, revealed the patient in a wheelchair sitting at a table in the common area eating lunch. Patient #5 had stitches to the right cheek, a cut to the left outer eye, a large scab to the left elbow, a healing skin tear to the left forearm, and a round red abrasion to the right side of the forehead.

Review of Patient #5's clinical record revealed the facility admitted the patient on 05/01/17, with diagnoses of Bipolar Disease, Schizoaffective Disease, and Alcohol Abuse.

Review of Patient #5's Comprehensive Psychiatric Evaluation, dated 05/01/17, revealed the patient was extremely disheveled with poor hygiene. The Evaluation noted Patient #5 was confused, paranoid, delusional, and had been drinking alcohol. The Evaluation continued to note the patient's concentration and memory was impaired, and he/she had poor judgement.

Review of Physician Medication Orders, dated 05/01/17, revealed Patient #5 was on Haldol 10 mg, Lithium 300 mg, Inderal 20 mg, Zoloft 100 mg, and Trazadone 100 mg. Continued review of the orders, dated 05/04/17 and timed 10:30 AM, revealed the patient was put on Seizure Precautions.

Review of Patient #5's Nursing Admission Assessment, dated 05/01/17, revealed nursing staff noted the patient was not at risk for falls on admission and denied urinary incontinence/urgency issues. Nursing staff documented under Risks Identified, the patient was experiencing psychosis due to a current psychotic break. Nursing staff noted the reason for admission was Patient #5 heard voices, exhibited bizarre behavior, and paranoia. Nursing staff noted under Mental Status upon Admission, Patient #5 had a depressed mood, memory was not intact, and displayed disturbed thought processes due to thinking people wanted to poison him/her. In addition, the patient had flight of ideas and rapid speech.

Review of the 7:00 AM to 3:00 PM Nursing Daily Progress Note for Patient #5, dated 05/04/17, revealed the patient was found sitting in the corner of his/her room in a puddle of urine. The Progress Note did not state the patient was at risk for falls or seizures. Under the Intervention section, nursing noted there was no need to update treatment plan goals or interventions to promote patient safety related to fall prevention.

Review of the 3:00 PM to 11:00 PM Nursing Daily Progress Note for Patient #5, dated 05/04/17, revealed nursing noted the patient was at risk for falls; however, review of the Treatment Plan implemented on 05/01/17, revealed no revisions with interventions to promote patient safety related to fall risk or incontinence. Further review of the Progress Note revealed nursing staff did not state the patient was on Seizure Precautions.

Review of a Nursing Patient Kardex, not dated, revealed the Situation and Background sheet (S/B sheet) was used to give shift-to-shift report; however, it did not note Patient #5 used a wheelchair, was incontinent, or was on Fall or Seizure Precautions.

Interview with Registered Nurse (RN) #8, on 05/05/17 at 8:10 AM, revealed after finding Patient #5 on the floor on 05/04/17, he helped the patient up off the floor and clean up. He stated the patient was assisted with dressing and was given an incontinent brief to wear. RN #8 stated staff used the S/B sheet to give report and updated it as necessary when patients' condition and care needs changed. He stated staff should have updated the form after Patient #5 was found on the floor in a puddle of urine and required assistance with activities of daily living. He stated patient care needs to promote a safe environment would not be met if all pertinent information was not passed on to the next shift in report.

Review of Patient #5's Nursing Daily Narrative Progress Note, dated 05/05/17 and timed 9:45 AM, revealed the patient was found lying on his/her back on the floor by staff with a laceration approximately one (1) centimeter in length to the outer left eye and a skin tear to the left forearm. Review of the Transfer and Referral Record, dated 05/05/17, revealed the facility sent Patient #5 to the Emergency Department after falling out of a chair and hitting his/her head.

Review of Patient #5's Nursing Daily Progress Notes, dated 05/05/17 for 3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shifts, revealed nursing had not reassessed Patient #5's laceration to the outer left eye or skin tear to the left forearm. Continued review of the Progress Notes, dated 05/06/17 for 7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM, and 11:00 PM to 7:00 AM shifts, revealed staff did not document reassessments of Patient #5's eye or skin tear.

Review of Patient #5's Treatment Plan, implemented on 05/01/17, revealed no revisions with interventions were made to promote patient safety or reduce falls after Patient #5 sustained a laceration and skin tear from the fall on 05/05/17.

Review of Patient #5's Master Treatment Plan, initiated on 05/01/17, revealed the plan was not revised with goals or interventions related to fall risks until 05/06/17. The Goal initiated on 05/06/17, stated the patient would not have injuries related to falls throughout the length of stay. The interventions stated nursing staff would assist the patient in identifying fall risk prevention measures, which included using a wheelchair, non-skid footwear, and requesting assistance.

Interview with RN #3, on 05/05/17 at 10:22 AM, revealed she was informed in report that Patient #5 had incontinent episodes, but was not aware the patient was found on the floor in a puddle of urine the day before. She stated the patient was at a disadvantage because he/she was placed in a room at the end of the hall, which was too far away from the nurses' station for staff to provide supervision. RN #3 revealed around 9:45 AM, staff found Patient #5 on the floor in his/her room. She stated she was not exactly sure how the patient fell because the patient was unable to tell them what happened. According to RN #3, the patient told her he/she had a history of seizures, but her assessment of the patient did not reveal a seizure might be the cause of the fall. She stated the facility sent the patient to the Emergency Department for evaluation of a cut to the outer left eye. She stated due to Patient #5's age, diagnosis of Seizures, Alcohol abuse, Hallucinations, and confusion, he/she was a falls risk and nursing staff should have placed the patient on falls precautions on 05/04/17, to promote patient safety.

Interview with Mental Health Associate (MHA) #2, on 05/05/17 at 8:50 AM, revealed staff found Patient #5 on the floor in a puddle of urine on 05/04/17. He stated the patient had urinary incontinence but was not sure if staff provided the patient a brief. MHA #2 revealed staff checked on all patients every fifteen minutes but no other fall precaution interventions were implemented for Patient #5 after he/she was found on the floor. MHA #2 stated staff found Patient #5 again on the floor on 05/05/17, with a cut to the eye and a skin tear requiring an Emergency Department visit. According to MHA #2, Patient #5 was elderly and was not as high functioning as the other patients on the unit were. He stated Patient #5 was ambulatory upon admission but now required a wheelchair. MHA #2 stated he did not receive any information regarding falls precautions from nursing or other MHAs during shift-to-shift report regarding Patient #5. He stated falls precautions were implemented to promote patient safety; however, Patient #5 was not on falls precautions prior to the fall on 05/05/17.

Review of Patient #5's Nursing Daily Progress Note, dated 05/07/17 and timed 4:15 PM, revealed staff heard a yell for help and found Patient #5 lying on the bathroom floor, trembling, breathing rapidly, and bleeding from a cut to the right side of the face. The facility sent the patient to the Emergency Department and he/she returned with stitches to the right cheek.

Review of Patient #5's Treatment Plan, implemented on 05/01/17, revealed the plan was not revised to reflect additional goals or interventions to promote patient care in a safe environment after the fall with injury on 05/07/17, or for wound care related to the laceration to the cheek.

Interview with RN #6, on 05/08/17 at 12:05 PM, revealed she was in the nurses' station when she heard a yell for help. She stated she went to investigate and found Patient #5 on the floor in his/her bathroom bleeding profusely from a cut on the cheek. In addition, RN #6 stated the patient had a five (5) inch bruise to the chest wall, several on both arms, both knees were bruised and an abrasion/red area to the right side of the forehead. She stated the patient must have hit his/her forehead during the fall. RN #6 stated the patient told her that he/she was trying to use the bathroom prior to the fall. She stated she made all the necessary calls and documentation regarding the fall while RN #5 provided care to the patient until the ambulance arrived. According to RN #6, she did not revise the treatment plan or add interventions to promote a safe environment or prevent another fall because Patient #5 was not her assigned patient. She stated it was staff's responsibility to ensure the patient received care in a safe environment; and she should have ensured interventions were in place to protect the patient from further falls.

Interview with RN #5, on 05/08/17 at 1:30 PM, revealed he heard Patient #5's bed alarm going off and entered the room to find the patient on his/her knees in the bathroom bleeding from a cut to the face. He stated the patient had walked from the bed to the bathroom unassisted and fell . He stated the patient was confused and non-compliant with asking for help. RN #5 revealed the patient was on falls precautions already but since he/she was confused, reminding him/her not to get up without assistance was not effective and the bed alarm was reactive because when it alarmed, it meant the patient was already up. He stated he did not update the treatment plan or add additional fall interventions because he could not think of any to add. RN #5 stated he did not document a reassessment of the patient's injuries after he/she returned to the facility because the focus of the documentation was psychiatric. He stated nursing staff could document in the progress note or add a note under medical concerns on the daily progress note form, but he did not. According to RN #5, staff should reassess a patient after a change in condition and communicate to the oncoming shift and if not, the patient would not receive care in a safe setting.

Interview with the Director of Nursing (DON), on 05/08/17 at 3:00 PM, revealed nursing staff were not assessing patients and documenting their findings according to her expectations. She stated she reviewed Patient #5's medical record, on 05/08/17, and determined additional documentation and assessments were needed and requested staff to complete another Fall Risk Screen Addendum, which scored the patient at a sixteen (16) for high risk to fall. The DON stated she also reviewed the medical record for the potential root causes of the falls. She stated she determined the patient was non-compliant with asking for assistance due to confusion. She revealed Patient #5 was very restless, confused, and his/her safety awareness was very low. She stated staff reminded the patient to call for assistance; however, that was an ineffective intervention due to the patient's confusion. The DON stated she was not aware nursing staff had not revised the treatment plan with interventions to promote a safe environment after the falls on 05/04/17 and 05/05/17, to include goals and interventions for incontinence, falls, seizure precautions, and wound care. According to the DON, it was her expectation for staff to provide care and services in a safe setting. That included instituting falls precaution interventions timely after finding a patient on the floor, reassessing patients after a change in condition until resolved, and documenting those assessments. She stated urine on the floor and wet clothing over the door and heating unit was not providing care in a safe setting.

Interview with the Chief Executive Officer, on 05/08/17 at 3:30 PM, revealed he was not aware staff had not revised Patient #5's treatment plan to ensure the patient received care in a safe environment. He stated staff should have put interventions in place to prevent further injury, provide wound care, incontinent care, and seizure precautions. He stated it was his expectation that staff follow facility policies and procedures and treat patients with respect and dignity. He stated if staff did not, then patients would not receive care in a safe setting.

3. Observation of Patient #8's bed with the DON, on 05/03/17 at 11:45 AM, revealed a blanket covering the sheet. The DON removed the blanket, which revealed a large ring shaped dry stain in the middle of the bed that was light yellow to brown in color. The DON stated Patient #8 must have urinated in the bed last night.

Review of Patient #8's clinical record revealed the facility admitted the patient on 04/25/17, with diagnoses of Attention Deficit Hyperactivity Disorder, Disruptive Mood Dysregulation, and Aggression.

Review of Patient #8's Nursing Admission Assessment, dated 04/25/17, revealed urinary incontinence was not reported as an issue.

Review of Patient #8's Treatment Plan, implemented 04/25/17, revealed goals related to aggression, and homicidal and suicidal ideations. Interventions included: educating the patient on the benefits of taking medication, assist the patient in identifying relaxation skills, and for staff to provide psychotherapy groups to help the patient identify with ways to manage anger. There were no revisions made to address Patient #8's urinary incontinence to ensure care in a safe setting.

Interview with MHA #5, on 05/03/17 at 1:45 PM, revealed he worked 7:00 AM to 3:00 PM on the Child Psych Unit. He stated he was not aware Patient #8's bed sheet had a large dry urine stain on it. MHA #5 revealed when he made fifteen minute rounds and started waking up the patients for breakfast, Patient #8 did not tell him the sheets were wet. He stated it was the responsibility of the patient to tell staff if they had wet the bed. MHA #5 stated if it were on the treatment plan, then they would monitor for urine soaked or dried urine on the sheets. He stated if patients did not tell staff about wet sheets or if staff did not monitor for them, patients could return to sleep in a dry, urine stained bed. He stated that would not be receiving care in a safe setting.

Interview with MHA #6, on 05/03/17 at 2:00 PM, revealed she worked 7:00 AM to 3:00 PM and was taking patients' vital signs while MHA #5 was getting patients up for breakfast and was not aware Patient #8 was incontinent during the night. She stated the unit did have other patients that were incontinent at night, but none that she knew had treatment plan interventions for staff to implement. MHA #6 stated patients may be too embarrassed about their incontinence and not want to tell staff. She revealed it would be important for staff to know if patients had urinary incontinence in order to monitor for urine soaked sheets. She stated it was a dignity issue and staff needed to help maintain patient dignity in order to provide care in a safe setting.

Interview with RN #6, on 05/03/17 at 2:30 PM, revealed the Child Psych Unit had several patients that were incontinent at night, but no treatment plan interventions were in place that she could remember for those patients. She stated they would give pull-ups to patients if needed. RN #6 stated patients might be too embarrassed to tell staff they had wet the bed. She stated the MHAs should notice during rounds if a patient had wet the bed and assist the patients if needed. If not, then patients would not receive care in a safe setting.

Interview with the DON, on 05/08/17 at 3:00 PM, revealed she expected staff to provide care and services related to incontinence for patients on the Child Psych Unit. She stated patients did have responsibilities on the unit; however, staff was to monitor and assist patients when needed. She stated according to policy and procedure, staff was to deliver care in a safe setting and not addressing a patient's incontinence needs was not providing safe care.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, and review of the facility's policy, it was determined the facility failed to ensure patients were released from seclusion as soon as possible for one (1) of fifteen (15) sampled patients, Patient #3. Record review revealed Patient #3 remained in seclusion after staff assessed the patient had met criteria for release.

The findings include:

Review of the facility's policy, Seclusion/Restraint (S/R), dated December 2016, revealed the purpose of the policy was to provide guidelines for the use of seclusion and/or restraint at the facility. Seclusion and Restraint use was to be implemented as a last resort to ensure the safety of patients and others. S/R procedures were considered to be unusual, high-risk events that warrant timely assessment and continuous monitoring. The leadership team developed S/R training and competency protocols that were required for all clinical staff prior to patient interventions. These competencies focus on implementation, assessment, monitoring, and application while raising staff awareness about how S/R interventions may be experienced by the patient. Staff was educated to discontinue S/R at the earliest time possible when the patient could demonstrate compliance with identified release criteria. Nursing staff would determine if S/R was appropriate due to lack of patient response to less restrictive nonphysical interventions. Nursing staff would also initiate, in an emergency, S/R as a protective measure provided that a physician order was obtained as soon as possible, but no longer than thirty (30) minutes after the initiation of the S/R. The Physician provided the verbal or written order for the employment of S/R. The order was to be documented on the Seclusion Restraint Order/Progress Note form and include: the reason/purpose for seclusion and restraint intervention, type of restraint, and be time limited not to exceed one hour for children ages nine (9) and under.

Review of Patient #3's clinical record revealed the patient was seven (7) years old and admitted on [DATE], with diagnoses of Aggression and Autism.

Review of a Seclusion/Restraint Order/Progress Note, dated 03/20/17, revealed nursing staff noted Patient #3 had been out on the playground and was pushing and hitting other children and was told he/she would not be able to go to the Cafe due to his/her behaviors. The patient began to hit, kick, and bite staff. Staff implemented a restraint hold on Patient #3 at 4:15 PM, and the physician was called at 5:00 PM and gave an order for the restraint with a timeframe of one (1) hour for a patient less than ten (10) years old. The form stated S/R was implemented for the minimum time necessary to ensure the safety of self or others and would be discontinued as soon as possible without exceeding the ordered timeframe. The specific behavioral criteria to terminate the S/R was that the patient would not physically threaten imminent harm to self or others. Continued review revealed the patient was held for thirty-five (35) minutes and then nursing implemented a seclusion at 4:50 PM. Documentation revealed Patient #3 remained in seclusion until 6:30 PM. Review of Patient #3's documented behaviors at 5:50 PM and 6:05 PM, revealed the patient was making verbal threats, crying, and screaming. Staff noted at 6:20 PM, the patient was crying and refusing to talk. The patient was released from seclusion and was noted as processing with staff at 6:30 PM. The patient had met the criteria for release of not physically threatening imminent harm to self or others from 5:50 PM to 6:30 PM, without staff discontinuing the seclusion per the physician ordered criteria.

Interview with the Children's Unit Manager, on 05/05/17 at 11:40 PM, revealed she had initiated the restraint hold and seclusion on Patient #3 because of the physical behavior of kicking and biting. She stated Registered Nurse (RN) #1 obtained the orders for the restraint and seclusion and monitored the patient during the seclusion time. The Unit Manager stated S/R could be traumatizing for patients and there were standards and criteria for staff to follow to prevent possible traumatizing effects. The Unit Manager revealed if a patient met the physician ordered criteria for release, nursing staff was required to release the patient from S/R. She stated the patient should have been released at 5:50 PM. She stated she performed audits of the S/R forms and did not remember reviewing Patient #3's S/R form. According to the Children's Unit Manager, it was determined after surveyor review that staff did not follow S/R policy and procedures and re-education was needed.

Interview with RN #1, on 05/05/17 at 11:50 AM, revealed she had called to obtain the order for the restraint of Patient #3. She stated the restraint turned into a seclusion because of the patient's behaviors. She revealed the criteria for release from S/R was for the patient not to physically threaten imminent harm to others. RN #1 stated the criteria documented from 5:50 PM until release was not imminent or physically threatening of harm to self or others and met criteria for release. She stated the seven (7) year old patient was not released because of the verbal threatening of harm. According to RN #1, a least restrictive intervention staff could have used was verbal de-escalation. She stated if staff did not follow policy and procedure, patient care needs would not be met.

Interview with the Director of Nursing, on 05/05/17 at 12:10 PM, revealed staff placed Patient #3 in a restraint hold due to behaviors of kicking and biting. She stated nursing staff did not release the patient when he/she met the physician ordered release criteria. She revealed Unit Managers were to perform audits of the S/R forms to determine if staff followed policy and procedures. She stated it surprised her that staff did not release Patient #3 after he/she met the criteria. She stated if she had known, she would have re-educated staff regarding expectations and policy.

Interview with the Chief Executive Officer (CEO), on 05/08/17 at 3:30 PM, revealed it was his expectation that staff follow S/R policy and procedures. He stated he expected staff to treat patients with respect and provide quality care and services to them. The CEO stated he was not aware the facility's auditing processes did not determine staff had not followed S/R policy. He revealed the facility had some work to do in regards to their processes and staff education.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0171
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, and review of the facility's Seclusion/Restraint policy, it was determined the facility failed to contact the physician to obtain an order to extend the time in seclusion for one (1) of fifteen (15) sampled patients, Patient #3. The patient went from a restraint to seclusion at 4:50 PM and staff contacted the physician at 5:55 PM, to continue the seclusion, which at that time the patient had met the criteria for release from seclusion.

The findings include:

Review of the facility's policy, Seclusion/Restraint (S/R), dated December 2016, revealed the purpose of the policy was to provide guidelines for the use of seclusion and/or restraints at the facility. Seclusion and Restraint use was to be implemented as a last resort to ensure the safety of patients and others. S/R procedures were considered to be unusual, high-risk events that warrant timely assessment and continuous monitoring. The leadership team developed S/R training and competency protocols that were required for all clinical staff prior to patient interventions. These competencies focus on implementation, assessment, monitoring, and application while raising staff awareness about how S/R interventions may be experienced by the patient. Staff was educated to discontinue S/R at the earliest time possible when the patient could demonstrate compliance with identified release criteria. Nursing staff would determine if S/R was appropriate due to lack of patient response to less restrictive nonphysical interventions. Nursing staff would also initiate, in an emergency, S/R as a protective measure provided a physician order was obtained as soon as possible, but no longer than thirty (30) minutes after the initiation of the S/R. The Physician provided the verbal or written order for the employment of S/R. The order was to be documented on the Seclusion Restraint Order/Progress Note form and include: the reason/purpose for seclusion and restraint intervention, the type of restraint, and be time limited not to exceed one (1) hour for children ages nine (9) and under.

Review of Patient #3's clinical record revealed the patient was seven (7) years old and admitted on [DATE], with diagnoses of Aggression and Autism.

Review of a Seclusion/Restraint Order/Progress Note, dated 03/20/17, revealed nursing staff noted Patient #4 had been out on the playground and was pushing and hitting other children and was told he/she would not be able to go to the Cafe due to his/her behaviors. The patient then began to hit, kick, and bite staff. Staff implemented a restraint hold on Patient #3 at 4:15 PM, and the physician was called at 5:00 PM, and gave an order for the restraint with a timeframe of one (1) hour for a patient less than ten (10) years old. The form stated S/R was implemented for the minimum time necessary to ensure the safety of self or others and would be discontinued as soon as possible without exceeding the ordered timeframe. The specific behavioral criteria to terminate the S/R was that the patient would not physically threaten imminent harm to self or others. Continued review revealed the patient was held for thirty-five (35) minutes and then nursing implemented seclusion at 4:50 PM. Documentation revealed at 5:15 PM, no new order was obtained for the continued seclusion of Patient #3 after the one (1) hour timeframe had ended. Patient #3 remained in seclusion and nursing documented at 5:20 PM and 5:35 PM, the patient was kicking, striking, crying, and screaming while in the seclusion room. Staff documented Patient #3's behavior at 5:50 PM and 6:05 PM, as making verbal threats, crying, and screaming. Further review of the S/R form revealed nursing staff obtained a new order at 5:55 PM for the continued seclusion of Patient #3 at which time the patient met the criteria for release because the patient was not physically threatening imminent harm to self or others. The patient was noted at 6:20 PM, as crying and refusing to talk. The patient was released from seclusion and was noted as processing with staff at 6:30 PM. The patient had met the criteria for release of not physically threatening imminent harm to self or others from 5:50 PM to 6:30 PM, without staff discontinuing the seclusion per the physician ordered criteria.

Interview with the Children's Unit Manager, on 05/05/17 at 11:40 PM, revealed according to the facility S/R policy and procedure, nursing staff should have released Patient #3 from seclusion after the one (1) hour time frame or called the physician prior to or at 5:15 PM, to ask to extend the one (1) hour seclusion timeframe if the patient was still threatening imminent harm to self or others. She stated according to nursing staff documentation, Patient #3's behaviors from 5:15 PM until 5:50 PM, still met seclusion criteria. However, after reviewing Patient #3's S/R form, the patient met the criteria for release at 5:50 PM, and staff should have released the patient from the seclusion room, but did not. The Unit Manager stated the timeframes were ordered based on age appropriateness and developmental stages. She revealed if staff did not follow policy and procedures for S/R, patient care needs would not be met.

Interview with Registered Nurse (RN) #1, on 05/05/17 at 11:50 AM, revealed she should have started another packet of forms to cut down on the confusion with the S/R timeframes. She stated the timeframe of one (1) hour was given for developmental reasons because children may not be able to handle longer S/R times. RN #1 revealed she thought the policy and procedure stated staff had to contact the physician within an hour of the S/R. However, she should have called within thirty (30) minutes, which would have been at 5:15 PM, to ask the physician to extend the seclusion time. She stated she did not call until 5:55 PM, to extend the time. RN #1 stated after reviewing the form, the patient met criteria for release at 5:50 PM, so the patient was in seclusion for forty (40) minutes without an extended timed order. According to RN #1, if staff did not follow S/R policy and procedure, patient care need would not be met.

Interview with the Director of Nursing (DON), on 05/05/17 at 12:10 PM, revealed the S/R policy instructed staff on the age appropriate timeframes patients were to be placed in S/R. She stated staff had thirty (30) minutes to call and get an order for S/R after initiation. The DON stated Patient #3 was placed in restraint at 4:15 PM, and RN #1 should have called at 5:15 PM, to extend the ordered time of the S/R instead of at 5:55 PM, otherwise the patient should have been removed from seclusion. She stated after reviewing Patient #3's S/R forms, it was determined the facility audits had not identified staff had not called to get a time extension order or that the patient had not been released timely. She stated if she had known, she would have provided education to the staff regarding her expectations and policy and procedure. She revealed if staff did not follow the S/R policy and procedure, patient care needs would not be met.

Interview with the Chief Executive Officer (CEO), on 05/08/17 at 3:30 PM, revealed he expected staff to follow policy and procedures regarding S/R. He stated he also expected staff to provided quality care and services. The CEO stated since nursing staff had not called Patient #3's physician timely to obtain an extended timeframe order for the S/R, the facility did not follow policy. He stated the patient should have been released timely once behavior criteria were met. According to the CEO, if staff did not follow and implement S/R policies correctly, patient care needs would not be met.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to update the plan of care for patients identified at risk for falls and having involuntary urination care needs for three (3) of fifteen (15) sampled patients, Patient #4, #5, and #8.

The findings include:

Review of the facility's policy, Treatment Planning Process, dated June 2016, revealed the purpose of the policy was to provide a complete, individualized plan of care based on an integrated assessment of the patient's specific needs and problems and prioritization of those needs/problems to provide appropriate communication between team members that fosters consistency and continuity in the care of the patient, and to formulate a plan of care that meets the patient's objectives and needs. Based on assessments of clinical needs, the treatment plan shall describe patient strengths and disabilities, active problems to be addressed, goals and objectives of treatment, clinical interventions prescribed, patient progress in meeting treatment goals and objectives, and criteria for termination of treatment and provision for aftercare. Treatment shall be reviewed and evaluated at scheduled intervals appropriate to the patient's needs and anticipated length of stay. Additional reviews shall be completed if there was a significant change in the patient. Nursing staff initiated the Master Treatment Plan within eight (8) hours of admission. The initial plan shall be based on the presenting problems, physical health, and emotional/behavioral status to include appropriate physician and nursing interventions as determined by the initial assessments and the physician orders. Nursing staff would add newly identified problems to the Master Treatment Plan and initiate a new/revised short-term goal if indicated. The Treatment Team would review and update the Treatment Plan according the patient's progress and response to treatment.

1. Observation of Patient #4's room, on 05/05/17 at 8:05 AM, revealed no one was in the room; however, a puddle of liquid was beside Patient #4's bed and the bed linens were wet. Continued observation of the room revealed wet clothing hanging over the bathroom door and over the heating/air conditioning unit, which was set on heat at seventy-eight (78) degrees.

Interview with Patient #4, on 05/05/17 at 10:45, revealed the patient had urinated on himself/herself while in the bed around 7:30 AM. Patient #4 stated he/she had washed his/her clothes in the sink and hung them on the door and on the heater to dry.

Review of Patient #4's clinical record revealed the facility admitted the patient on 05/02/17, with diagnoses of Schizophrenia, Hepatitis C, and Alcohol Abuse.

Review of Patient #4's Treatment Plan, implemented 05/02/17, revealed the goal for the patient was he/she would complete the acute phase of alcohol withdrawal prior to discharge or transfer to a chemical dependency facility. The plan did not have goals or interventions related to incontinence, Hepatitis C, or Schizophrenia.

Interview with Mental Health Associate (MHA) #2, on 05/05/17 at 8:50 AM, revealed Patient #4 had urinated on himself/herself while walking down the hall and in the bed on 05/04/17. He stated Patient #4 was elderly and confused; requiring assistance for some tasks and was not as high functioning as the other patients on the unit. MHA #2 stated he had noticed on his fifteen minute rounds that Patient #4 had washed his/her clothing in the sink and hung them to dry on the door and heating unit around 7:00 AM on 05/05/17. However, he was not aware the patient had urinated on the floor or in the bed. MHA #2 revealed he tried to use tough love to motivate Patient #4 to do more for himself/herself, but the patient had self-loathing issues and did not want to do more for himself/herself. He stated on his fifteen minute rounds, he was required to monitor for safety concerns and address them. According to MHA #2, he should have addressed the wet linens, puddle on the floor, and the clothes on the heater. He stated the MHAs completed a shift-to-shift report each day and nursing staff provided patient specific information to them; however, he had not received specific direction regarding toileting or incontinent care for Patient #4.

Interview with MHA #4, on 05/05/17 at 9:30 PM, revealed Patient #4 was elderly and experienced urinary incontinence frequently. She stated usually the patients with those conditions would go to the Gero-Psych Unit because staff on that unit was more experienced with providing the type of care needed. MHA #4 stated the patients on the Adult Unit were higher functioning patients and per the unit rules, patients were to take care of their own activities of daily living. She stated patients on the Adult Unit were expected to make their own bed and do their own laundry. She revealed Patient #4 used a rolling walker and needed staff assistance with incontinent care, laundry, and changing bed linens. She stated staff completed fifteen minute rounds to check on patients and monitor for safety concerns. According to MHA #4, every patient had a sheet that staff documented their fifteen minute checks on and the sheet had patients' issues and interventions to implement; however, Patient #4's sheet had no information regarding incontinent care needs.

Interview with RN #3, on 05/05/17 at 10:22 AM, revealed she had not taken care of Patient #4 before and the report sheet staff used did not inform her that Patient #4 experienced incontinence. She stated the patient was noted as Hepatitis C positive, but did not see a treatment plan goal related to the diagnosis. She revealed it was important for the MHAs to know about the diagnoses and what interventions to put in place. RN #3 stated she had heard from the MHAs that Patient #4 had a history of incontinence. She stated staff should have updated the treatment plan and interventions put in place to promote the patient's dignity related to incontinent care. She stated staff should have assisted the patient with frequent toileting to prevent accidents. RN #3 revealed the MHAs reported to her the patient was confused at times and needed assistance with activities of daily living; however, that was not on her report sheet. RN #3 stated staff would not meet the patient needs if staff did not communicate patient's change in condition from the nursing admission assessment in order for the treatment plan to be revised accordingly.

Interview with the Director of Nursing (DON), on 05/08/17 at 3:00 PM, revealed if it was determined after the nursing admission assessment, that a patient was incontinent, not able to care for themselves, not able to wash their laundry, and not able to change their own bed linens, then she expected staff to provide that service and revise the treatment plan with goals that addressed those care needs. The DON stated she expected nursing staff to communicate the treatment plan interventions. She stated if staff did not revise the treatment plan when a patient's needs changed, then their needs would not be met.

2. Observation of Patient #5, on 05/08/17 at 11:50 AM, revealed the patient in a wheelchair sitting at a table in the common area eating lunch. Patient #5 had stitches to the right cheek, a cut to the left outer eye, a large scab to the left elbow, a healing skin tear to the left forearm, and a round red abrasion to the right side of the forehead.

Review of Patient #5's clinical record revealed the facility admitted the patient on 05/01/17, with diagnoses of Bipolar Disease, Schizoaffective Disease, and Alcohol Abuse.

Review of a Comprehensive Psychiatric Evaluation, dated 05/01/17, revealed Patient #5 was extremely disheveled with poor hygiene. The Evaluation noted Patient #5 was confused, paranoid, delusional, and had been drinking alcohol. The Evaluation continued to note the patient's concentration and memory was impaired, and he/she had poor judgement.

Review of Physician Medication Orders, dated 05/01/17, revealed Patient #5 was on Haldol 10 mg, Lithium 300 mg, Inderal 20 mg, Zoloft 100 mg, and Trazadone 100 mg. Continued review of Physician Orders, dated 05/04/17 and timed 10:30 AM, revealed the patient was put on Seizure Precautions.

Review of Patient #5's Nursing Admission Assessment, dated 05/01/17, revealed nursing staff noted the patient was not at risk for falls on admission and denied urinary incontinence/urgency issues. Nursing staff documented under Risks Identified, the patient was experiencing psychosis due to a current psychotic break. Nursing staff noted the reason for admission was Patient #5 heard voices, exhibited bizarre behavior, and paranoia. Nursing staff noted under Mental Status Upon Admission that Patient #5 had a depressed mood, memory was not intact, and displayed disturbed thought processes due to thinking people wanted to poison him/her. In addition, the patient had flight of ideas and rapid speech.

Review of a 7:00 AM to 3:00 PM Nursing Daily Progress Note, dated 05/04/17, revealed staff found Patient #5 sitting in the corner of his/her room in a puddle of urine. The Progress Note did not state the patient was at risk for falls or seizures. Under the Intervention section, nursing staff noted there was no need to update the treatment plan goals or interventions.

Review of a 3:00 PM to 11:00 PM Nursing Daily Progress Note, dated 05/04/17, revealed nursing staff noted Patient #5 was at risk for falls. However, review of the Treatment Plan, implemented 05/01/17, revealed no revisions with interventions to address Patient #5's fall risk or incontinence. Further review of the Progress Note revealed nursing staff did not state Patient #5 was on Seizure Precautions. Continue review of the Treatment Plan revealed no revisions with interventions to address Patient #5's history of seizures.

Review of a Nursing Patient Kardex, not dated, revealed the Situation and Background sheet (S/B sheet) was used to give shift-to-shift report; however, it did not state Patient #5 used a wheelchair, was incontinent, or was on Fall or Seizure Precautions.

Interview with Registered Nurse (RN) #8, on 05/05/17 at 8:10 AM, revealed after finding Patient #5 on the floor on 05/04/17, he helped the patient up off the floor and clean up. He stated the patient was assisted with dressing and was given an incontinent brief to wear. RN #8 stated staff used the S/B sheet to give report and updated it as necessary when a patient's condition and care needs changed. He stated staff did not update the form, after finding Patient #5 on the floor in a puddle of urine, noting the patient required assistance with activities of daily living. He revealed patient care needs would not be met if not all pertinent information was passed on to staff in report and the treatment plan revised.

Review of a Nursing Daily Narrative Progress Note, dated 05/05/17 and timed 9:45 AM, revealed Patient #5 was found lying on his/her back on the floor by staff with a laceration approximately one (1) centimeter in length to the outer left eye and a skin tear to the left forearm.

Review of a Treatment Plan, implemented 05/01/17, revealed staff made no revisions with interventions to address Patient #5's laceration or skin tear acquired after the fall on 05/05/17.

Review Patient #5's Master Treatment Plan, initiated 05/01/17, revealed the plan was not revised with goals or interventions related to fall risks until 05/06/17. The goal initiated on 05/06/17, stated the patient would not have injuries related to falls throughout the length of stay. The interventions stated nursing staff would assist the patient in identifying fall risk prevention measures, which included using a wheelchair, non-skid footwear, and requesting assistance.

Interview with RN #3, on 05/05/17 at 10:22 AM, revealed she had been informed in report that Patient #5 had incontinent episodes, but was not aware the patient was found on the floor in a puddle of urine the day before. She stated around 9:45 AM, staff found Patient #5 on the floor in his/her room. RN #3 stated the facility sent the patient to the Emergency Department to evaluate a cut to the outer left eye. She stated due to Patient #5's age, diagnosis of Seizures, Alcohol Abuse, Hallucinations, and confusion, he/she was a fall risk and nursing staff should have placed the patient on fall precautions on 05/04/17. She stated review of the patient's treatment plan revealed staff had not revised it after staff found the patient on the floor in a puddle of urine.

Interview with MHA #2, on 05/05/17 at 8:50 AM, revealed staff found Patient #5 on the floor in a puddle of urine on 05/04/17. He stated the patient had urinary incontinence but was not sure if staff provided the patient a brief. He stated staff checked on all patients every fifteen minutes but no other fall precaution interventions were implemented for Patient #5 after he/she was found on the floor. MHA #2 stated staff found Patient #5 again on the floor on 05/05/17, with a cut to the eye and a skin tear requiring an Emergency Department visit. He revealed Patient #5 was elderly and ambulatory upon admission but now required a wheelchair. MHA #2 stated he did not receive any information regarding fall precautions from nursing staff or other MHAs during shift-to-shift report regarding Patient #5.

Review of a Nursing Daily Progress Note, dated 05/07/17 and timed 4:15 PM, revealed staff heard a yell for help and found Patient #5 lying on the bathroom floor, trembling, breathing rapidly, and bleeding from a cut to the right side of the face. The facility sent the patient to the Emergency Department and he/she returned with stitches to the right cheek.

Review of Patient #5's Treatment Plan, implemented on 05/01/17, revealed staff had not revised the plan to reflect additional goals or interventions after the fall with injury on 05/07/17, or for wound care related to the laceration to the cheek acquired from the fall.

Interview with RN #6, on 05/08/17 at 12:05 PM, revealed she was in the nurses' station when she heard a yell for help. She stated she went to investigate and found Patient #5 on the floor in his/her bathroom, bleeding profusely from a cut on the cheek. In addition, RN #6 stated the patient had a five (5) inch bruise to the chest wall, several on both arms, both knees were bruised, and had an abrasion/red area to the right side of the forehead. She stated the patient must have hit his/her forehead during the fall. RN #6 stated the patient told her that he/she was trying to use the bathroom prior to the fall. She revealed she made all the necessary calls and documentation regarding the fall while RN #5 provided care to the patient until the ambulance arrived. She stated she did not revise the treatment plan or add interventions to prevent another fall because Patient #5 was not her assigned patient. RN #6 stated the treatment plan directed patients' plan of care and if not implemented, care needs would not be met.

Interview with RN #5, on 05/08/17 at 1:30 PM, revealed he heard Patient #5's bed alarm going off and entered the room to find the patient on his/her knees in the bathroom, bleeding from a cut to the face. He stated the patient had walked from the bed to the bathroom unassisted and fell . RN #5 stated the patient was confused and non-complaint with asking for help. He revealed the patient was on fall precautions already but since he/she was confused, reminding him/her not to get up without assistance was not effective and the bed alarm was reactive, because when it alarmed, it meant the patient was already up. RN #5 stated he did not update the treatment plan or add additional fall interventions because he could not think of any to add.

Interview with the Director of Nursing (DON), on 05/08/17 at 3:00 PM, revealed she was not aware nursing staff had not revised the treatment plan after the falls on 05/04/17 and 05/05/17, to include goals and interventions for incontinence, falls, seizure precautions, and wound care. She stated if the treatment plan were not revised and implemented, the patient's care needs would not be met.

Interview with the Chief Executive Officer, on 05/08/17 at 3:30 PM, revealed he was not aware staff had not revised Patient #5's treatment plan to reflect interventions for falls, wound care, incontinence care, and seizure precautions. He stated it was his expectation that staff followed facility policies and procedures and treated patients with respect and dignity. He stated if staff did not do so, patient care needs would not be met.

3. Observation of Patient #8's bed with the DON, on 05/03/17 at 11:45 AM, revealed a blanket covering the sheet. The DON removed the blanket, which revealed a large ring shaped dry stain in the middle of the bed that was light yellow to brown in color. The DON stated Patient #8 must have urinated in the bed last night.

Review of Patient #8's clinical record revealed the facility admitted the patient on 04/25/17, with diagnoses of Attention Deficit Hyperactivity Disorder, Disruptive Mood Dysregulation, and Aggression.

Review of a Nursing Admission Assessment, dated 04/25/17, revealed no documentation that urinary incontinence was an issue for Patient #8.

Review of Patient #8's Treatment Plan, implemented 04/25/17, revealed goals related to aggression, and homicidal and suicidal ideations. Interventions for staff to implement included educating the patient on the benefits of taking medication, assist the patient in identifying relaxation skills, and for staff to provide psychotherapy groups to help patient identify with ways to manage anger. However, there were no revisions made to address Patient #8's urinary incontinence.

Interview with MHA #5, on 05/03/17 at 1:45 PM, revealed he was not aware Patient #8's bed sheet had a large dry urine stain on it. He stated when he made his fifteen minute rounds and started waking up the patients for breakfast, Patient #8 did not tell him the sheets were wet. He stated it was the responsibility of the patient to tell staff if they had wet the bed. He stated if it were on the treatment plan, then staff would monitor for urine soaked or dried urine on the sheets. MHA #5 stated in the past, if a patient had treatment plan interventions related to incontinence, some of the interventions for staff would be to limit fluids prior to bedtime, toilet prior to bed, and to provide a pull-up. He revealed it was the responsibility of the patient to remove their wet clothing and sheets, place them in their personal basket, and bring it to the front of the unit for staff to wash on the night shift. He stated performing these types of interventions would meet the needs of an incontinent patient.

Interview with MHA #6, on 05/03/17 at 2:00 PM, revealed she was taking patients' vital signs while MHA #5 was getting patients up for breakfast and was not aware Patient #8 was incontinent during the night. She stated the unit did have other patients that were incontinent at night, but none had treatment plan interventions for staff to implement. She revealed patients may be too embarrassed about their incontinence and not want to tell staff. MHA #5 stated it would be important for staff to know if patients had urinary incontinence in order to monitor for urine soaked sheets. She stated it was a dignity issue and staff needed to help maintain patient dignity.

Interview with RN #6, on 05/03/17 at 2:30 PM, revealed the Child Psych Unit had several patients that were incontinent at night, but no treatment plan interventions were in place that she could remember for those patients. She stated they would give pull-ups to some patients if needed. RN #6 revealed the patients might be too embarrassed to tell staff they had wet the bed. She stated MHAs should notice during rounds if a patient had wet the bed and assist the patient if needed. If not, then patient care needs would not be met.

Interview with the DON, on 05/08/17 at 3:00 PM, revealed she expected staff to provide care and services related to incontinence to patients on the Child Psych Unit. She stated patients did have responsibilities on the unit; however, staff was to monitor and assist patients when needed. She stated she was not aware staff had not revised Patient #8's treatment plan to include interventions related to incontinence. She stated staff should have revised the treatment plan and implemented interventions in order to meet patient care needs.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure patients received medications as ordered by the prescribing physician for treatment for one (1) of fifteen (15) sampled patients, Patient #1. In addition, the facility failed to notify the physician of the missed medication in order to obtain further direction.

The findings include:

Review of the facility's policy, Patient Right's, dated December 2012, revealed patients have the right to receive medications upon admission.

Review of the facility's policy, Medication Administration, dated February 2013, revealed nursing staff were to notify the physician of missed dosages and obtain further orders as necessary.

Review of Patient #1's clinical record revealed the facility admitted the patient on 03/06/17, with diagnoses of Disruptive Mood Dysregulation Disorder, Impulse Control, and Attention Deficit Hyperactivity Disorder.

Review of admitting Physician Orders, dated 03/06/17, revealed orders for Patient #1 to receive Trileptal 150 mg by mouth two (2) times a day for mood and Wellbutrin 100 mg by mouth once daily for depression.

Review of a Medication Administration Record, dated March 2017, revealed nursing staff documented Patient #1 was not administered two (2) doses of Trileptal on 03/07/17 or 03/08/17, as ordered, because it was unavailable. In addition, nursing staff documented Patient #1 did not receive Wellbutrin as ordered, on 03/07/17 or 03/08/17, because the drug was not available.

Interview with Registered Nurse (RN) #2, on 05/03/17 at 2:30 PM, revealed Patient #1's Trileptal and Wellbutrin dosages were not available at the administration times. She stated those medications were also not available in the emergency medication box. She stated she did not call the pharmacy to determine what was causing the delay because it could take a couple of days to get medications for newly admitted patients. RN #2 revealed pharmacy made deliveries to the facility three (3) times a day but had not delivered Patient #1's medications. She stated she did not notify her supervisor regarding pharmacy not delivering the patient's medications in order for them to try to resolve the issue. She stated she also did not contact Patient #1's physician to make her aware the medication was not available and to ask for further guidance.

Interview with Patient #1's Physician, on 05/08/17 at 12:45 PM, revealed staff had not contacted her regarding Patient #1's medication not being available and subsequently not administered as ordered on [DATE] and 03/08/17. She stated staff contacted her for discharge orders on 03/08/17, because Patient #1 and the patient's family were not happy with the care received at the facility. She stated the patient was discharged against medical advice but she was not given the specifics of why the family was not happy with the care and services. She stated if the patient did not receive medications as ordered, nursing staff should have contacted her, and they could have discussed options for the patient.

Interview with the Pharmacist, on 05/08/17 at 12:48 PM, revealed pharmacy had received Patient #1's physician orders for the Trileptal 150 mg and Wellbutrin 100 mg; however, there was a misunderstanding regarding whether those drugs were home medications or medications that were to be administered in the facility. He stated there was a failure on the part of pharmacy staff to contact the physician or the facility to clarify the intent of the order. He stated it was important for patients to receive the physician ordered medications to ensure the patients received the required care and services to meet their needs.

Interview with the Director of Nursing, on 05/05/17 at 12:10 PM, revealed the facility process was for nursing staff to fax the physician's admission medication orders to pharmacy. Pharmacy delivered medications three (3) times a day and if there was a problem with receiving medications from pharmacy, she stated she expected nursing staff to call the pharmacy to determine the issue. She stated if nursing staff continued to have problems receiving medications, they were to alert her so she could also intervene to resolve the issue. She revealed she was not aware there had been an issue with Patient #1 not receiving medication as ordered. She stated if staff did not administer medications as ordered, the facility would not be meeting the patient's care needs.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure adequate nursing services were provided to meet the needs of patients for four (4) of fifteen (15) sampled patients, Patients #1, #4, #5, and #8. Patient #1 did not receive physician ordered medications to treat diagnoses for two (2) days and staff did not notify the physician to obtain further direction. Patient #5's care plan was not updated for risk for falls and the patient sustained falls with injuries. In addition, Patients #4, #5, and #8's care plans were not updated related to incontinent care needs.

Refer to A 0396 and A 0405