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.

NORTHLAKE BEHAVIORAL HEALTH SYSTEM 23515 HIGHWAY 190 MANDEVILLE, LA March 21, 2014
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observations, record reviews, and interviews, the hospital failed to meet the requirements for the Condition of Participation of Patient Rights as evidenced by:

1) Failing to ensure that MHTs (Mental Health Technicians) observed patients according to Physician's Orders and hospital policy for:
--2 (R17, R18) of 4 current patients on suicide precautions (SP) and visual contact (VC) on Esplanade I Unit (acute adult unit),
--2 of 5 current patients on visual contact (R20, R21),
--1 of 2 patients on suicide precautions and visual contact (#8) on Esplanade II Unit (acute adult unit),
--3 of 10 current patients on visual contact on the Decatur Unit (#7, R22, R23) (acute adult unit) (see findings in tag A0144) and

2) Failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for acute care psychiatric patients admitted for being a danger to self or others. (see findings in tag A0144).
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observations, record reviews, and interviews, the hospital failed to ensure that patients received care in a safe setting as evidenced by:

1) Failing to ensure that MHTs (Mental Health Technicians) observed patients according to Physician's Orders and hospital policy for
--2 (R17, R18) of 4 current patients on suicide precautions (SP) and visual contact (VC) on Esplanade I Unit (acute adult unit),
--2 of 5 current patients on visual contact (R20, R21)
--1 of 2 patients on suicide precautions and visual contact (#8) on Esplanade II Unit (acute adult unit), and
--3 of 10 current patients on visual contact on the Decatur Unit (#7, R22, R23) (acute adult unit);

2) Failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for acute care psychiatric patients admitted for being a danger to self or others.

3) Failing to ensure a patient on physician-ordered visual contact precautions (#9) did not leave her room and physically assault another patient for 1 of 1 closed record reviewed for incidents from a total of 32 closed records and 8 active records; and

Findings:

1) Failing to ensure that MHTs observed patients according to Physician's Orders and hospital policy:
Review of the hospital policy titled "Precautions", policy number TX7-1001 presented as a current policy by S15DON (Director of Nursing), revealed that the types of precautions included suicide precautions, elopement precautions, fall precautions, seizure precautions, withdrawal precautions, visual contact, and one-to-one. Further review revealed that visual contact precautions was defined as providing more intense supervision of a client with high acuity by maintaining visual contact of the client at all times. Suicide precautions was used to reduce the risk of suicide and protect the client from self-harm and included levels I, II, and III based on acuity of symptoms.

Review of the hospital policy titled "Suicide Precautions", policy number PE-0400 and presented by S15DON as a current policy, revealed that the level of suicide precaution must be written on the Physician Order Sheet by the physician. Levels are designated as I being Low Risk, II being Moderate Risk, and III being High Risk. Review of the attached precaution levels revealed Level I required visual contact of the patient, Level II required close observation on the unit within visual range of the staff at all times, and Level III required sleep with constant visual contact and one-to-one care and interaction within arm length at all times.

Review of the Document titled "Patient Observation and Locator Form", side 2, revealed in part:
Suicide Precaution- (Designated VC (visual Contact) or 1:1) accompany patient to bathroom/shower.
Visual Contact: (within eyesight) Remains within visual contact at all times, on and off the unit.

Esplanade I Unit
Patient R17
Review of the Psychological Evaluation for Patient R17 dated 03/14/14 at 1:49 p.m. revealed he was a [AGE] year old male admitted on [DATE] with diagnosis which included Anxiety and Major Depressive Disorder. Review of the Initial Care Orders for Patient R17 dated 03/14/14 at 2:45 p.m. revealed he was ordered to be on suicide precautions and VC observation for unpredictable behavior.

In an observation on 03/17/14 at 10:35 a.m. on the Esplanade unit, Patient R17 was sitting in the dining room with no visual observation from a staff member.

Patient R18
Review of the medical record for Patient R18 revealed she was a [AGE] year old female admitted on [DATE] with diagnosis which included Depressive Disorder and Bipolar Disorder. Review of the Initial Care Orders for Patient R18 dated 03/14/14 at 1:30 a.m. revealed she was ordered to be on suicide precautions and VC for unpredictable behavior.

In an observation on 03/17/14 at 10:40 a.m. on the Esplanade unit, Patient R18 was in the day room with no visual observation from a staff member.

In an observation on 03/17/14 at 10:45 a.m. on the Esplanade unit, Patient R17 and Patient R18 were in the dining room with no visual observation from a staff member.

In an interview on 03/17/14 at 11:10 a.m. with S5RN Charge Esplanade I, she said all patients under visual contact are not able to constantly be visualized because of short staffing. She also said the patients were able to go to the bathrooms unattended. S5RN Charge also verified there were towels in the bathrooms.

Esplanade II Unit
Patient #8
Review of the medical record for Patient #8 revealed he was a [AGE] year old man admitted on [DATE] with diagnosis which included Depressive Disorder. Review of the Initial Care Orders for Patient #8 dated 03/14/14 at 11:30 p.m. revealed he was ordered to be on suicide precautions and VC for unpredictable behavior.

In an observation on 03/17/14 at 11:40 a.m. on the Esplanade 2 unit, Patient #8 walked into his bedroom and shut the door. Further observation revealed he had no direct visulaization from the staff.
Patient R20
Review of the medical record for Patient #R20 revealed he had been admitted on [DATE] with diagnosis which included Schizophrenia. Review of the Initial Care Orders for Patient R20 dated 01/31/14 at 4:30 a.m. revealed he was ordered to be on VC for unpredictable behavior.

In an observation on 03/17/14 at 11:45 a.m. on the Esplanade 2 unit, Patient R20 walked into the day room with no visualization from the staff.

Patient R21
Review of the medical record for Patient R21 revealed he was a [AGE] year old male admitted on [DATE] for diagnosis which included Psychotic Disorder. Review of the Initial Care Orders for Patient R21 dated 03/15/14 at 10:45 a.m. revealed he was ordered to be on VC for a history of violence.

In an observation on 03/17/14 at 11:46 a.m. on the Esplanade 2 unit, Patient R21 was observed going into his bedroom alone and shutting the door.

In an interview on 03/17/14 at 11:25 a.m. with S32MHT, she said she was not able to keep visual contact on all of the patients she was assigned. S32MHT said if the patients went into their rooms she would check on them every 15 minutes. S32MHT also said she did not go into the restrooms with the patients. S32MHT said she did not necessarily keep visual contact on suicidal patients because she had 34 years of experience to determine if a suicidal patient was serious or not about killing themselves. S32MHT said visual contact only meant the staff member needed to know where the patients were at all times, not to keep them in sight at all times.

Decatur Unit
Patient #7
Review of the medical record for Patient #7 revealed she was a [AGE] year old female admitted on [DATE] with diagnosis which included Schizoaffective Disorder. Review of the Initial Care Orders for Patient #7 dated 01/10/14 at 6:50 p.m. revealed she was ordered to be on VC for unpredictable behavior.

In an observation on 03/17/14 at 12:20 p.m. on the Decatur unit, Patient #7 was on the telephone in the lobby without being visualized. At 12:30 p.m. she went into her room and shut the door without staff present.

Patient R22
In an observation on 03/17/14 at 12:20 p.m. on the Esplanade 2 unit, Patient R22 was sitting in a room by herself with no visualization by staff in progress. Review of the medical record for Patient R22 revealed she was a [AGE] year old female newly admitted with a diagnosis of Major Depressive Disorder and had no physician orders at the time of the observation. Further review revealed she had been PEC'd (Physician's Emergency Certificate) for suicidal ideations.

Patient R23
Review of the medical record for patient R23 revealed she had been admitted on [DATE] for a diagnosis of Psychotic Disorder. Review of the Initial Care Orders for Patient R23 dated 03/11/14 at 7:37 p.m. revealed she was ordered to be on VC for unpredictable behavior.

In an observation on 03/17/14 at 12:30 p.m. on the Esplanade 2 unit, Patient R23 walked out of her bedroom where she had been unobserved for an undetermined amount of time.

In an interview on 03/21/14 at 2:05 p.m. with S33Psychiatrist, she said she noticed the patients were not continuously being watched according to the observation levels ordered by the physician.

In an interview on 03/20/14 at 12:17 p.m. with S29RN, she said it would be impossible to view all of the children on the units at all times, because they are all over the place.

2) Failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for acute care psychiatric patients admitted for being a danger to self or others:

During the initial hospital tour on 03/17/14 at 10:15 a.m., the following observations were made:
Adult Services Men: Esplanade I Unit
a. Round doorknobs (not anti-ligature) on all doors throughout the unit;
b. Exposed pipes on toilets in bathroom;
c. Interior door hinges protruding enough to facilitate potential ligature risk;
d. Four light fixtures in the bathroom which were not secured allowing access to the four fluorescent bulbs (housed within each fixture) which could easily have been removed;
e. Towels noted in the bathroom in a large plastic tub;
f. Two bathroom stall door handles not flush to door allowing potential ligature risk;
g. Bathroom stall door hinges separated widely enough to facilitate potential ligature risk;

In an interview on 03/17/14 at 10:30 a.m., S18Medical Director verified the towels in the bathrooms were a potential ligature risk. S18Medical Director also confirmed the bathroom's interior door hinges were a ligature risk and shouldn't have been in the bathroom.

Adult Services Women: Esplanade I
a. Round doorknobs (not anti-ligature) on all doors throughout the unit;
b. Shower curtain torn in a strip at the bottom in the shower stall;
c. Sheets and blankets noted in the bathroom in a plastic tub;
d. Four light fixtures in the bathroom which were not secured allowing access to the four fluorescent bulbs (housed within each fixture) which could easily have been removed;
e. Exposed pipes on toilets in the bathroom;
f. Two bathroom stall door handles not flush to door allowing potential ligature risk;
g. Bathroom stall door hinges separated widely enough to facilitate potential ligature;
h. Unprotected Water Temperature control valve box with knobs to adjust water temps for showers was noted to be open. A hinge with padlock was hanging loosely and not attached to the wall. The hot water temperature gauge had a maximum temperature of 140 degrees. No temperature control knobs were present in the shower and the water temperature had to be controlled by the valves.

In an interview on 03/17/14 at 11:00 a.m. with S5RN Charge Esplanade I, she said the boxes which housed the water temperature control valves for adjusting the water temperature in the shower were never locked. She agreed the box with the water temperature controls should have been locked, and they posed a potential safety risk for the patients.
Observation on 03/17/14 at 10:40 a.m. on Esplanade Unit I revealed the Biohazard door was unlocked and contained 3 red bins with large red plastic bags in each bin. During the observation S5RN Charge Nurse indicated that the Biohazard Room door was supposed to be kept locked. She further indicated that the plastic bags were not supposed to be accessible to psychiatric patients.
Observation on 03/17/14 at 10:45 a.m. on Esplanade Unit I revealed a large garbage can with a plastic liner on the unit. During the interview S5RN Charge Nurse indicated plastic bags were not allowed on patient units.

During the initial hospital tour on 3/17/14 at 11:20 a.m., the following observations were made: Esplanade II Unit:
a. Round doorknobs (not anti-ligature) were observed on all doors throughout the unit;
b. Plastic bags noted in the garbage cans in the multipurpose room;
c.Unprotected Water Temperature control value box withknobs to adjust water temps for showers wwas noted to be open. The hot water temperature gauge had a maximum temperature of 140 degrees. No temperature control knobs were present in the shower and the water temperature had to be controlled by values.
d. Four light fixtures in the bathrooms which were not secured allowing access to the four fluorescent bulbs (housed within each fixture) which could be easily have been removed;
e. Bed sheets were noted to be overflowing out of the soiled linen bins.

Room "a" on Esplanade 2 Unit:
a.Towels were noted in hamper
b.A gooseneck faucet with flanged handles was noted on the sink;
c. Exposed toilet plumbing;
d. A slatted fold up shower seat was noted in the shower, with pipe hardware securing it to the wall;
e.Door handles were not flush to the two bathroom stall doors allowing a potential ligature risk;
f. Unprotected Water Temperature control valve box with knobs to adjust water temps for showers was noted to be open and the lock broken (it was unable to be locked). The hot water temperature gauge had a maximum temperature of 140 degrees. No temperature control knobs were present in the shower and the water temperature had to be controlled by the valves;
g.. Door hinges separated widely enough for potential ligature anchor on the bathroom stall doors;
h. Four light fixtures in the bathroom which were not secured allowing access to the four fluorescent bulbs (housed within each fixture) which could easily have been removed;
On 03/18/14 at 5:40 a.m. during an off-hour entry tour conducted on Live Oak Unit, the following observations were made:
Live Oak Unit
Bathroom for Room "b" and Room "c""
a. A large pile of sheets, towels, and clothing noted in the corner of the room on the floor;
b. Two bathroom stall doors had hinges set wide enough apart to allow potential for ligature;
c. Door handles not flush to the two bathroom stall door to allow for potential ligature;
d. Exposed toilet plumbing.

Observation on 03/17/14 at 1:00 p.m. of Room "d" on the Live Oak Unit revealed a hole in metal plate covering a window. The hole had the perimeter bent inwards with 7 sharp, jagged edges. Also, the bottom of the metal plate was observed to have jagged edges. Three of the four patients housed in Room "d" were under visual precautions for unpredictable behaviors and 1 of the four patients was under visual precautions for suicide precautions.

In an interview on 03/18/14 at 5:35 a.m. with S10RN Charge, she said visual contact at night was conducted as every 15 minutes rounds, like a bed check. She also said patients on Suicide Precautions were allowed to go to the bathroom alone. She said staff would unlock the bathroom door to allow the patients to go to the bathroom with the door closed.

In an interview on 03/18/14 at 5:40 a.m. with S10RN Charge Nurse, she confirmed upon observation of the sheets and towels in the bathroom that the sheets and towels posed a potential ligature risk.

Cypress Unit

An observation on 03/17/14 at 2:08 p.m. of Room "e" on the Cypress unit revealed a missing fire alarm cover on the wall leaving wires exposed. Further review revealed the plate was off of the fire alarm cover in the hall and dayroom also leaving exposed wires.

3) Failing to ensure a patient on physician ordered visual contact precautions did not leave her room and physically assault another patient:

Review of the medical record for Patient #9 revealed she was a [AGE] year old girl who had been admitted on [DATE] at 10:25 a.m. with diagnosis which included Major Depressive Disorder, Posttraumatic Stress Disorder, and Attention Deficit/Hyperactivity. Further review revealed she was ordered to be on constant visual contact for violence.

Review of the medical record for Patient #9 revealed while she remained on physician ordered visual contact the following progress note dated 12/05/13 at 7:45 p.m. by S34MHT was written: "Client (Patient #9) was in dayroom when she stated another client made a face at her. This client then went over and hit and pulled the hair of the other client. Staff interviewed and placed client in seclusion room until 7:53 p.m. when she was allowed to go to her room and take her medication. She refused her IM (intramuscular) medication and had to be placed in a manual hold to receive medication. She then lay in bed and after staff left her room she ran to the other client's room and hit her several times. She was placed back in locked seclusion room until calm."
In an interview on 03/21/14 at 1:20 p.m. with S15DON, she said if Patient #9 was on constant visual contact, she should not have been able to leave her room to hit another patient.
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interviews and record reviews, the hospital failed to ensure the medical staff was accountable to the governing body for the quality of care provided to patients as evidenced by:

1) Having patients placed on psychiatric inpatient units for several hours without having physician's admission orders for 2 (#6, #9) of 10 (#1- #10) patients' records reviewed for admission orders from a sample of 10 patients;
2) Having S28Nurse Practitioner (NP) perform a psychiatric evaluation for Patient R3 on 02/18/14 without having privileges granted by the Governing Body to perform psychiatric evaluations; and
3) Failing to have S28NP follow the privileges granted by the Governing Body as evidenced by failure to consult with her collaborating physician, S18Medical Director, when sending a patient to the Emergency Department (ED) for evaluation of a seizure and upon the patient's return from the ED for 1 of 1 patient's record reviewed for evaluation of a seizure from a total of 10 sampled patients and 28 random patients (R3).
Findings:

1) Having patients placed on psychiatric inpatient units for several hours without having physician's admission orders:
Review of the hospital's policy titled "Intake and Admission", policy number CC-1300 and presented as a current policy by S15DON (Director of Nursing), revealed that the Admissions Department was to notify the admitting physician when the patient arrived, and the patient should be seen within one hour by the physician. Further review revealed that patients arriving before 3:00 p.m. will be admitted by the attending physician or his/her back-up, and patients arriving after 3:00 p.m. will be "worked up" by the Duty Doctor. The physician will explain his findings and recommendations to the patient in the initial interview, obtain consent for treatment and medications, and will complete the admission orders.

Patient #6 Review of Patient #6's medical record revealed he was a [AGE] year old male admitted on [DATE] at 12:30 p.m. (per admission summary sheet) with diagnoses including the following: Seizures, Diabetes, Schizophrenia, Depression, and a history of previous suicide attempts times two per hanging. Further review revealed the patient was admitted with suicidal ideation with a plan to hang himself. His legal status was involuntary admission per PEC (Physician's Emergency Certificate).
Review of the RN (Registered Nurse) Assessment of Risk/Initial Care Needs form for Patient #6 revealed his admitted was listed as 3/14/14 and his unit arrival time was 1:55 p.m.
Review of Patient #6's Initial Care Orders revealed they were obtained on 3/14/14 at 6:00 p.m. (4 hours and 5 minutes after his arrival on the unit). Further review revealed the following orders: Special nursing precautions: Suicide precautions: VC (visual contact) and seizure precautions.
Patient #9
Review of the medical record for Patient #9 revealed she was a [AGE] year old girl who arrived on the Willow II unit on 11/24/13 at 11:00 a.m. after being PEC'd (Physician's Emergency Certificate) for suicidal behaviors, violent behaviors, being a danger to herself and dangerous to others.

Review of the Interdisciplinary Progress Notes for Patient #9 revealed she had arrived to the unit at 11:00 a.m. on 11/24/13 and had an initial assessment by a RN (Registered Nurse). Further review revealed the following note in part:: "At approximately 1:15 p.m., pt. (patient) was sitting on the sofa watching television with other peers when she asked Patient R7 what was wrong with her. Patient #R7 began to get defensive and both pt's (patients) were escalated into a verbal confrontation. Both this writer and MHT attempted to deescalate the situation, but was unsuccessful. Patient #R7 then began physically hitting client and kicking her while she was on the ground. A code was attempted to be called but overhead system was not working, so patients were still engaged in the fight until staff was able to be called individually by unit. At 1:40 p.m., 1 mg (milligram) of Ativan PO (by mouth) was given and patient was reassessed 30 minutes later."

Review of the medical record for Patient #9 revealed she did not have admission orders written until 11/24/14 at 3:00 p.m. (4 hours after arriving on the unit).

In an interview on 3/20/14 at 7:56 a.m. with S21RN, he said he worked in admissions and was a house supervisor. S21RN said the Initial Care Orders (admit orders) for patients should be filled out by the physician before the patient arrives on the floor.

In an interview on 3/20/14 at 4:17 p.m. with S18Medical Director, he said when a patient arrived on a unit at the hospital the nurse did an admission assessment. S18Medical Director said he was called for admission orders after the nursing assessment because after the nurse did the assessment he was better prepared to write orders. S18Medical Director said he was basing his orders on the nursing assessments.

In an interview on 3/21/14 at 2:05 p.m. with S33Psychiatrist, she said the patients needed to be evaluated and have orders written before they arrived on the units. S33Psychiatrist said a patient is not truly a patient until the admission orders were written. S33Psychiatrist also said it was not appropriate for Patient #9 to be on the unit for several hours without admission orders because she was not a patient until the orders were written. S33Psychiatrist said sometimes patients were on the units for several hours before she was even notified they were at the hospital.

2) Having S28NP perform a psychiatric evaluation for Patient R3 on 02/18/14 without having privileges granted by the Governing Body to perform psychiatric evaluations:
Review of Patient R3's Psychiatric Evaluation revealed she was a [AGE] year old female admitted on [DATE] with diagnoses of Substance-Induced Mood Disorder, Depression by history, Polysubstance Abuse, Seizures, GERD (Gastroesophageal Reflux Disease), TIA (Transischemic Attack), and Hypertension. Further review revealed the Psychiatric Evaluation was performed by S28NP on 02/18/14 at 2:56 p.m.

Review of S28NP's credentialing file revealed she was appointed to the hospital's Courtesy Medical Staff for the period of 01/29/14 to 01/28/16. Review of her "Medical Staff Request for Privileges - Registered Nurse Practitioner" revealed S28NP requested privileges for "Medical Consultation: Providing Consultation to Psychiatrists or Other Medical Specialists for General Medical Problems or Conditions Outside the General Experience of Such Specialists" and "Other: As determined by Patient Care Need, and Demonstration of Education, Training, Competency and Proficiency" with an additional note of "Privileges granted must be performed in accordance with Approved collaborative agreement, and with physician Consultation available. Documentation that a collaborative physician has been consulted is required for those patients sent to an Emergency Department for evaluation for all patients Returning from Emergency Department evaluation. Such Documentation is also required on all code blue interventions." Further review revealed the privileges were approved by S18Medical Director on 01/29/14 and by S9Administrator on 01/29/14.

In an interview on 03/20/14 at 11:52 a.m., S28NP indicated, when asked is she medically managed psychiatric inpatients, that she would continue the patient's home medications or send the patient to the Medical Clinic for their History and Physical Examination. She further indicated that she sent patients to the Medical Clinic for acute medical issues.

In an interview on 03/21/14 at 3:00 p.m., S42Credentialing Coordinator indicated she was responsible for the credentialing process at the hospital, but she was "fairly new." After reviewing S28NP's credentialing file and request for and approval of privileges, she confirmed that S28NP had not been privileged as a Psychiatric Nurse practitioner, but rather as a Medical NP. S42Credentialing Coordinator offered no explanation for this occurrence.

In an interview on 03/21/14 at 4:26 p.m. with S9Administrator, S18Medical Director, S15DON, and S1Director of Risk Management present, S18Medical Director had no comment when informed that review of S28NP's credentialing file revealed she did not have privileges as a Psychiatric Nurse Practitioner. When asked if he was aware that S28NP was not privileged to perform the psychiatric evaluations and write the orders for psychiatric treatment of the inpatients, S18Medical Director answered, "Obviously I wasn't."

3) Failing to have S28NP follow the privileges granted by the Governing Body:
See findings of review of S28NP's credentialing file in #2 above.

Review of Patient R3's medical record revealed she was a [AGE] year old female admitted on [DATE] with diagnoses of Substance-Induced Mood Disorder, Depression by history, Polysubstance Abuse, Seizures, GERD, TIA, and Hypertension. Review of the nurse's "Progress Notes" revealed Patient R3 had a seizure, and Code Blue (call for help for a patient emergency) was called at 8:45 a.m. on 02/19/14. Further review revealed Patient R3 was transported to the acute care hospital's ED and returned from the ED on 02/19/14 at 1:40 p.m. Further review revealed the MHT (Mental health Technician) called the nurse for help at 1:55 p.m.. Code Blue was called. Patient R3 had a one inch laceration over her left eye which was "bleeding heavily" after having another seizure in the day room on the unit. Further review revealed Patient R3 was transported by ambulance to at 2:20 p.m. to the acute care hospital.

Review of the "MD (medical doctor) Progress Notes" revealed an entry on 02/19/14 at 9:00 a.m. by S28NP that Patient R3 was found sitting in her room, unable to speak, by another patient. Further review revealed "pt oriented to person, place & (and) time. BP (blood pressure) 140/92. O2 (oxygen) sats (saturation) 88% (per cent) on RA (room air). NRB (non-rebreather) mask applied. O2 sats (increased) 100%. Hx (history) of TIA. (void sign) facial droop noted. (bilateral) equal hand grip. 5/5 gross motor strength. MAE (moves all extremities) (without) difficulties. Code Blue called. Pt to be transported to ER (emergency room ) for further evaluation." There was no documented evidence that S28NP documented seizure activity or that she had consulted her collaborating physician S18Medical Director about transferring Patient R3 for evaluation.

Review of the "MD Progress Notes" revealed an entry on 02/19/14 at 2:00 p.m. by S28NP that she observed Patient R3 on the unit with seizure activity, and a laceration noted to the right head with bleeding noted. Further review revealed S28NP documented that orders were present to transport to the ED. There was no documented evidence that S28NP documented that she had consulted her collaborating physician S18Medical Director about transferring Patient R3 for evaluation of seizure activity.

Review of Patient R3's "Doctor's Order Sheet" revealed the following orders written by S28NP with no documented evidence of a verbal or telephone order from S18Medical Director:
02/19/14 at 8:50 a.m. - please send to ER for medical evaluation of possible seizure activity;
02/19/14 at 2:00 p.m. - please send back to ER for medical evaluation of witnessed seizure activity and head injury. There was no documented evidence of physician orders received to treat Patient R3 upon her return from the ED on 02/19/14 at 1:40 p.m.

In an interview on 03/20/14 at 11:52 a.m., S28NP indicated that she witnessed Patient R3's seizure and sent her to the ED. She further indicated that there should have been orders for treatment between the 2 ED visits, and either her or S18Medical Director should have been contacted for orders. When informed that review of Patient R3's medical record revealed no documented evidence that she consulted with S18Medical Director about sending Patient R3 to the ED for evaluation as required by her privileges, S28NP had no explanation to offer.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on record reviews and interview, the hospital failed to ensure its quality assessment and performance improvement (QAPI) program showed measurable improvement in identified problems on 12/17/13 with appropriate use of visual contact by the physicians as evidenced by observations of patients with physician-ordered precautions of visual contact (VC) and one-to-one (1:) not being monitored according to hospital policy. Findings:

Review of the QAPI meeting minutes of 12/17/13, presented by S1Director of Risk Management, revealed that the appropriate use of VC by physicians was identified as a problem. The recommendation was that a group would meet to look at the precautions policy and arrive at a plan to ensure the appropriate use of VC. Further review revealed that S18Medical Director would follow-up with the physicians about the appropriate use of VCs and share data provided by S1Director of Risk Management.

Review of the QAPI meeting minutes for 02/25/14 revealed that discussion was held regarding the appropriate use of VCs by physicians. Further review revealed it was agreed that the expiration time of VCs will be changed to 48 hours as an interim step, with the plan to eventually phase down to expiration after 8 hours. Physicians and nurses were to be notified of the change. Further review revealed the policy would be revised by S1Director of Risk management, and the action was closed.

Review of the hospital's policy titled "Precautions", presented by S15Director of Nursing as the current policy, revealed that it had last been revised on 03/19/13 (not after the meeting of 02/25/14 as stated in the minutes). Further review revealed the physician order for VC was valid for a maximum of 7 days and must be renewed to continue the precaution. There was no documented evidence that the "Precautions" policy was revised to reflect that an order for VC would expire in 48 hours as planned at the QAPI meeting of 02/25/14.

Observations on 03/18/14 at 5:20 a.m. revealed that 2 patients ordered to be on one-to-one observation were not being observed by a staff member within arm's reach of the patient as required by hospital policy on the Live Oak Unit, and and 8 of 8 patients with physician orders for Visual Contact (VC) on the Live Oak Unit were not being observed visually at all times by a staff member on 03/18/14 at 5:30 a.m.

Observations on 03/17/14 from 10:35 a.m. to 12:30 p.m. revealed patients with physicians' orders for VC were not being visually observed within line of sight by a staff member.

In an interview on 03/21/14 at 3:05 p.m., S1Director of Risk Management indicated the hospital looks at the number of patients on VC, but they don't have anything specific tracking or analysis related to the observations by staff. He further indicated that they had identified that 50% (per cent) of the patients were on VC, and that's hard to manage. He confirmed that the QAPI plan for December 2013 and February 2014 were basically the same. He could offer no explanation for the decisions made at the 02/25/14 meeting not being implemented relative to the "Precautions" policy.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services as evidenced by:

1) Failing to ensure the nursing service department had adequate numbers of Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Mental Health Technicians (MHTs) to provide adequate supervision of high risk patients according to physician's orders and hospital policy.
a) The hospital failed to ensure patients ordered to be on one-to-one observation were observed by a staff member within arm's reach of the patient as required by hospital policy for 2 of 2 patients with physician orders for one-to-one observation on the Live Oak Unit on 03/18/14 at 5:20 a.m. and 8 of 8 patients with physician orders for Visual Contact (VC) on the Live Oak Unit were observed visually at all times by a staff member on 03/18/14 at 5:30 a.m..
b) The hospital failed to ensure patients with an ordered observation level of constant visual contact were observed within sight of a staff member for 2 (R17, R18) of 4 current patients on suicide precautions (SP) and VC on Esplanade I Unit (acute adult unit), 2 of 5 current patients on visual contact (R20, R21) and 1 of 2 current patients on suicide precautions and visual contact (#8) on Esplanade II Unit (acute adult unit), and 3 of 10 current patients on visual contact on the Decatur Unit (#7, R22, R23) (acute adult unit) (see findings in tag A0392).

An Immediate Jeopardy situation was identified on 03/18/14 at 1:10 p.m. and reported to S9Administrator. The immediate jeopardy was a result of the hospital failing to ensure there were adequate numbers of RNs, LPNs, and MHTs to provide nursing care to all patients with physician's orders for 1:1 observation and visual contact due to suicidal precautions, unpredictable behavior, homicidal precautions, aggressive behaviors and histories of violence. On 03/17/14 from 10:35 a.m. to 12:30 p.m., there were observations made of patients with physicians' orders for VC not having visual contact (line of sight) maintained by a staff member. On 03/18/14 at 5:20 a.m. to 5:55 a.m. there were 2 patients with physician's orders for 1:1 observation (within arms' length at all times) being observed by staff members seated at the doors of the patient's rooms and not within arms' length of the patient. Further observation on 03/18/14 at 5:20 a.m. revealed 1 MHT was assigned 11 patients. 9 of the 11 patients she had been assigned were ordered to be on VC at all times but were in 8 separate bedrooms. The hospital also failed to develop a policy indicating how many patients on visual contact one staff member could observe to ensure the patient's safety needs are met.

As the result of the hospital's action plan, the Immediate Jeopardy situation was removed on 03/21/14 at 11:45 a.m. due to the hospital doing the following:
1) Admissions to Northlake Behavioral Health System was suspended beginning on 03/18/14.
2) The decision to allow or continue suspension of new admissions will continue until hospital leadership is satisfied that there is 100% (per cent) compliance with the "Precautions" policy and the corrective action plan among all staff working on the units. Staff will not be allowed to work until they have received and completed training.
3) designated rooms on each unit were identified as a "safety bedroom" where patients on VC will be placed to ensure compliance with the policy.
4) Patients on VC will be grouped together on their assigned unit when not in their "safety bedroom" to ensure compliance with the policy. This includes times in the day room or other common areas of their assigned unit.
5) Beginning immediately, re-training will take place with the nurses, physicians, therapists, and direct care staff on requirements of the policy regarding supervision of patients on 1:1 and VC or who need a higher level of supervision due to safety concerns and the expectations of the staff. Training will occur at the beginning of the shift via updated policies, handouts, and presentations. Each staff member will sign an attestation that they have received and understood the updated policy and training materials. Staff will not be allowed to work until they have received and completed the training.
6) The current policy on "Precautions" has been reviewed and modified to clarify the levels of observation and to ensure compliance with supervision requirements of the policy for patients on 1:1 and VC. The policy will be reviewed every 30 days for the next 6 months by the leadership team to assess effectiveness.
7) An emergency meeting of the Medical Staff was held to review any changes to the existing policy, the requirements for ordering 1:1 or VC, and the policy guidelines for reassessments of a patient on 1:1 or VC.
8) The Governing Board met to review and approve any changes or revisions to the existing policy and to review the action plan.
9) A section will be added to the "leadership rounds" form, the every 15 minute observation form, and the "Camera Review Form" to specifically assess and monitor compliance with the policy. Leadership team members will be re-trained on changes to the forms. A member of the leadership team will provide direct observation of staff and patients via "leadership rounds" on the unit. Leadership rounds will be completed at a minimum of 2 times a day at random shifts on each unit by a designated member of the leadership team with an expected goal of 100% compliance. If compliance is not achieved, staff re-education or progressive disciplinary action will occur as indicated. If 100% compliance is met by 05/20/14, leadership rounds will be completed at a minimum of once per day at random shifts on each unit until the hospital has sustained the goal of 100% compliance for at least 90 days. If compliance is not achieved, staff re-education or progressive disciplinary action will occur as indicated. As of 08/20/14 leadership rounds will be completed at a minimum of 3 times a week at random shifts on each unit unless it is determined that increased frequency is needed.
10) Camera reviews will be conducted at a minimum of 2 times per shift on each unit by a member of the leadership team with a goal of 100% compliance. If compliance is not achieved, staff re-education or progressive disciplinary action will occur as indicated. Camera reviews will then be conducted at a minimum of one time per shift on each unit, with 2 times per shift reinstated if less than 100% compliance is maintained during a 7 day period. If compliance is not achieved, staff re-education or progressive disciplinary action will occur as indicated.
11) Three random every 15 minute observation forms will be reviewed per unit per shift until the hospital has sustained the goal of 100% compliance for at least 90 days. If compliance is not achieved, staff re-education or progressive disciplinary action will occur as indicated. As of 06/20/14 one random observation form will be reviewed per unit per shift, with three forms reviewed reinstated if less than 100% compliance is maintained during a 7 day period. If compliance is not achieved, staff re-education or progressive disciplinary action will occur as indicated.
12) If it is noted in any of the above monitoring that the established policy and procedure is not being adhered to, the following actions will occur: observation rounds forms will be reviewed at the morning FLASH meeting; the manager conducting the rounds or observation will address the non-compliance immediately through the disciplinary process and report the non-compliance to the Chief Executive Officer and the Department Manager; the offending staff will be re-educated on the policy and procedures and undergo progressive disciplinary action as indicated; there will be ongoing refresher training through change of shift briefings, annual training, and monthly newsletters as well as annual competencies, performance evaluations, and supervision to ensure sustained compliance with the policy and procedures.
13) All patients currently on VC were re-assessed by S18Medical Director and the Medical Staff for the continued need for VC in keeping with the requirements for reassessment of patients per policy.
14) Copies of the policy will be placed in admissions and at each nursing station to ensure nursing, clinical, direct care staff, and physicians understand the policy and have a guide to refer to when making decisions.
15) Copies of Staff Guidelines: Levels of Observation/Guidelines for Supervision will be placed in the admission office and each nursing station for all staff to easily access.
16) The Governing Board will review the revised policy and effectiveness through review of monthly leadership reports, camera reviews, and 24 hour reports every 30 days until the Board is satisfied that the hospital is in full compliance with the policy.
17) A section was added to the existing chart audit forms to specifically ensure reassessments of patients on 1:1 or enhanced precautions/VC are being completed and communicated appropriately.
18) VC and 1:1 data will be reviewed at daily FLASH meetings to ensure reassessments are occurring per policy.

Non-compliance continues at the condition level.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observations, record reviews, and interviews, the hospital failed to ensure the nursing service had adequate numbers of Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Mental Health Technicians (MHTs) to provide adequate supervision of high risk patients according to physician's orders and hospital policy as evidenced by:

1) Failing to ensure patients ordered to be on one-to-one observation were observed by a staff member within arm's reach of the patient as required by hospital policy for 2 of 2 patients with physician orders for one-to-one observation on the Live Oak Unit on 03/18/14 at 5:20 a.m. and 8 of 8 patients with physician orders for Visual Contact (VC) on the Live Oak Unit were observed visually at all times by a staff member on 03/18/14 at 5:30 a.m.;

2) Failing to ensure patients with an ordered observation level of constant visual contact were observed within sight of a staff member for 2 (R17, R18) of 4 current patients on suicide precautions (SP) and VC on Esplanade I Unit (acute adult unit), 3 of 5 current patients on visual contact (R1, R20, R21) and 1 of 2 patients on suicide precautions and visual contact (#8) on Esplanade II Unit (acute adult unit), and 4 of 10 current patients on visual contact on the Decatur Unit (#7, R22, R23, R30) (acute adult unit);

3) Failing to ensure a patient on physician-ordered visual contact precautions (#9) did not leave her room and physically assault another patient for 1 of 1 closed record reviewed for incidents from a total of 32 closed records and 8 active records; and

4) Failing to ensure a staff member was available to keep a patient on visual contact while the majority of the patients were off the unit. This deficient practice allowed a patient ordered to be on visual contact to corner a nurse in the medication room for 1 (R14) of 1 closed patient record reviewed with this type of incident from a total of of 32 closed records and 8 active records.

Findings:

1) Failing to ensure patients ordered to be on one-to-one observation were observed by a staff member within arm's reach of the patient as required by hospital policy for 2 of 2 patients with physician orders for one-to-one observation on the Live Oak Unit on 03/18/14 at 5:20 a.m. and 8 of 8 patients with physician orders for VC on the Live Oak Unit were observed visually at all times by a staff member on 03/18/14 at 5:30 a.m.:

Review of the hospital policy titled "Precautions", policy number TX7-1001 presented as a current policy by S15DON (Director of Nursing), revealed that the types of precautions included suicide precautions, elopement precautions, fall precautions, seizure precautions, withdrawal precautions, visual contact, and one-to-one. Further review revealed that visual contact precautions was defined as providing more intense supervision of a client with high acuity by maintaining visual contact of the client at all times. Suicide precautions was used to reduce the risk of suicide and protect the client from self-harm and included levels I, II, and III based on acuity of symptoms. One-to-one was defined as providing maximum observation of a client with one staff member assigned to remain within arm's reach of the client at all times.

Review of the "Live Oak Bed Assignment" upon entering the unit on 03/18/14 at 5:20 a.m. revealed Patient 4 and Patient R29 were ordered to be on one-to-one (1:1) observation. Further review revealed 8 patients had physician orders for VC, 2 patients had no special precautions ordered, and 1 patient was ordered to be on suicide precautions which included either VC or 1:1 as ordered by the physician.

Observation on 03/10/14 at 5:20 a.m. revealed S37RN (Registered Nurse) was seated at the door of Patient #4's room. Further observation revealed S37RN was not within arm's reach of Patient #4.

In an interview on 03/18/14 at 5:20 a.m., S37RN indicated she was supposed to be within arm's reach when she observed a patient 1:1. When asked if she was within arm's reach of Patient #4, she answered, "No." She indicated that she doesn't feel comfortable being all the way in a male patient's room.

Review of Patient #4's "Doctor's Order Sheet" revealed an order on 03/12/14 at 2:35 p.m. from S33Psychiatrist to place Patient #4 on 1:1 precautions for unpredictable behavior, intrusiveness, aggression, and do not discontinue 1:1 without authorization from S33Psychiatrist.

Observation on 03/18/14 at 5:21 a.m. revealed S11MHT sitting outside in the hall outside Patient R29's room.

Review of Patient R29's "Doctor's Order Sheet" revealed a verbal order received from S44Psychiatrist to place Patient R29 on 1:1 for violent behavior.

In an interview on 03/18/14 at 5:21 a.m., S11MHT indicated that 1:1 meant that she would sit and watch the patient, and when the patient went to the bathroom, she would stand outside the bathroom door (observation while standing outside the opened bathroom door revealed no visibility of the inside of the toilet stall which was surrounded by a wall). After asking S11MHT if she could see Patient R29 when he went to the bathroom, she answered, "No." S11MHT indicated that when a patient was ordered to be on 1:1 observation, she was supposed to be within arm's length of the patient. When asked if she was within arm's length of Patient R29 while seated in the chair outside his room (approximately 9 to 12 feet between the chair and the bed), she answered, "I was told in orientation to sit outside the room."

Observation on 03/18/14 at 5:30 a.m. revealed S12MHT seated in the dayroom reading a book with the television on.

In an interview on 03/18/14 at 5:30 a.m., S12MHT indicated she was responsible for observing 11 patients (all patients except Patients #4 and R29). During the interview the observation records for the 11 patients being observed by S12MHT revealed no documented evidence of the type of observation that the patients had ordered. When asked what the level of observations were for each patient, S12MHT answered, "I don't know." When asked how she knew what she was supposed to do, S12MHT answered, "I go every 15 to 20 minutes , just go check on them."

In an interview on 03/18/14 at 5:45 a.m., S10RN Charge Nurse indicated that 1:1 observation meant the patient was to be within arm's reach of the observer at all times. She further indicated that VC meant the observer had to be able to see the patient at all times, and at night the patient room doors have to be open, and the MHT is to make rounds every 15 minutes. When asked why VC is not maintained at night, S10RN Charge Nurse answered, "they do rounds." When asked if patients were within visual contact at all times as ordered during the night, she answered, "No." When asked why the physician orders were not followed, she answered, "I don't know, I think it's a staffing issue." When asked who is responsible for the MHTs, S10RN Charge Nurse answered, "I am, it's my responsibility to make sure the observation sheets are accurate and complete."

In an interview on 03/18/14 at 5:55 a.m., S13RN House Supervisor indicated the staff ratio is 1 staff to 5 patients. He further indicated that communication from S9Administrator to S15DON has been that the ratio is the hospital's guideline of what they try to staff, but the ratio could go higher. When asked if it's possible for 1 MHT to observe 11 patients, 9 of whom were on VC, who were in different rooms throughout the unit, he answered "It's not."

In an interview on 03/18/14 at 6:25 a.m., when informed of the above observations, S15DON indicated that the RN should have had some of the 11 patients to observe. When asked how one RN with the responsibility as the only RN for 13 patients be expected to help observe 11 patients, 9 of whom are supposed to be on VC, S15DON answered, "It's not easy is it?" S15DON indicated that the MHTs are taught in orientation that they are to be in arm's length for 1:1 observation and in sight of the patient on VC.

In an interview on 03/18/14 at 6:35 a.m., S9Administrator indicated that "talking about VC precautions isn't practical without looking at the layout of the building."

In an interview on 03/18/14 at 9:45 a.m., S15DON indicated the hospital did not have a policy for the number of patients a staff member can observe. During this same interview with S43Human Resource Director present, he indicated that 1 staff member cannot observe 9 patients in different rooms who are on VC precautions "unless you're Superman."

2) Patients with an ordered observation level of constant visual contact not being observed by staff.
See the "Precautions" policy described under #1 above.

Review of the hospital policy titled "Suicide Precautions", policy number PE-0400 and presented by S15DON as a current policy, revealed that the level of suicide precaution must be written on the Physician Order Sheet by the physician. Levels are designated as I being Low Risk, II being Moderate Risk, and III being High Risk. Review of the attached precaution levels revealed Level I required visual contact of the patient, Level II required close observation on the unit within visual range of the staff at all times, and Level III required sleep with constant visual contact and one-to-one care and interaction within arm length at all times.

Review of the Document titled "Patient Observation and Locator Form", side 2, revealed in part:
Suicide Precaution- (Designated VC or 1:1) accompany patient to bathroom/shower.
Visual Contact: (within eyesight) Remains within visual contact at all times, on and off the unit.
One To One (Arms Reach): observe sleep while maintaining precaution.

Esplanade I Unit
Patient R17
Review of the Psychological Evaluation for Patient R17 dated 03/14/14 at 1:49 p.m. revealed he was a [AGE] year old male admitted on [DATE] with diagnosis which included Anxiety and Major Depressive Disorder. Review of the Initial Care Orders for Patient R17 dated 03/14/14 at 2:45 p.m. revealed he was ordered to be on suicide precautions and VC observation for unpredictable behavior.

In an observation on 03/17/14 at 10:35 a.m. on the Esplanade unit, Patient R17 was sitting in the dining room with no visual observation from a staff member.

Patient R18
Review of the medical record for Patient R18 revealed she was a [AGE] year old female admitted on [DATE] with diagnosis which included Depressive Disorder and Bipolar Disorder. Review of the Initial Care Orders for Patient R18 dated 03/14/14 at 1:30 a.m. revealed she was ordered to be on suicide precautions and VC for unpredictable behavior.

In an observation on 03/17/14 at 10:40 a.m. on the Esplanade unit, Patient R18 was in the day room with no visual observation from a staff member.

In an observation on 03/17/14 at 10:45 a.m. on the Esplanade unit, Patient R17 and Patient R18 were in the dining room with no visual observation from a staff member.

In an interview on 03/17/14 at 11:10 a.m. with S5RN Charge Esplanade I, she said all patients under visual contact are not able to constantly be visualized because of short staffing. She also said the patients were able to go to the bathrooms unattended and there were towels in the bathrooms.

Esplanade II Unit
Patient R1
Review of Patient R1's medical record revealed he was a [AGE] year old male admitted on [DATE] and was ordered to be on VC for unpredictable behavior.

Observation on 03/17/14 at 11:40 a.m. revealed Patient R1 was seated in the dayroom without a staff member present to observe him.

Patient #8
Review of the medical record for Patient #8 revealed he was a [AGE] year old man admitted on [DATE] with diagnosis which included Depressive Disorder. Review of the Initial Care Orders for Patient #8 dated 03/14/14 at 11:30 p.m. revealed he was ordered to be on suicide precautions and VC for unpredictable behavior.

In an observation on 03/17/14 at 11:40 a.m. on the Esplanade 2 unit, Patient #8 walked into his bedroom and shut the door. Patient #8 had no direct visualization from a staff member.

In an observation on 03/17/14 at 11:50 a.m. on the Esplanade 2 unit, Patient #8 went into the female bathroom unattended and unobserved.

Patient R20
Review of the medical record for Patient #R20 revealed he had been admitted on [DATE] with diagnosis which included Schizophrenia. Review of the Initial Care Orders for Patient R20 dated 01/31/14 at 4:30 a.m. revealed he was ordered to be on VC for unpredictable behavior.

In an observation on 03/17/14 at 11:45 a.m. on the Esplanade 2 unit, Patient R20 walked into the day room with no visualization from the staff.

Patient R21
Review of the medical record for Patient R21 revealed he was a [AGE] year old male admitted on [DATE] for diagnosis which included Psychotic Disorder. Review of the Initial Care Orders for Patient R21 dated 03/15/14 at 10:45 a.m. revealed he was ordered to be on VC for a history of violence.

In an observation on 03/17/14 at 11:46 a.m. on the Esplanade 2 unit, Patient R21 was observed going into his bedroom alone and shutting the door.

In an interview on 03/17/14 at 11:25 a.m. with S32MHT, she said she was not able to keep visual contact on all of the patients she was assigned. S32MHT said if the patients went into their rooms she would check on them every 15 minutes. S32MHT also said she did not go into the restrooms with the patients. S32MHT said she did not necessarily keep visual contact on suicidal patients because she had 34 years of experience to determine if a suicidal patient was serious or not about killing themselves. S32MHT said visual contact only meant the staff member needed to know where the patients were at all times, not to keep them in sight at all times.

In an interview on 03/17/14 at 11:30 a.m., S6RN Charge Nurse of Esplanade Unit II indicated she had 9 patients on the unit today with the staff of herself and 2 MHTs. She further indicated that she very rarely has an LPN staffed. She further indicated there are usually 2 RNs on the night shift with 2 MHTs. S6RN Charge Nurse indicated she couldn't explain why 2 RNs were scheduled at night and only 1 RN on the day shift. She further indicated the unit lost about 4 RNs within the last month, and she doesn't get much help.

Decatur Unit
Patient #7
Review of the medical record for Patient #7 revealed she was a [AGE] year old female admitted on [DATE] with diagnosis which included Schizoaffective Disorder. Review of the Initial Care Orders for Patient #7 dated 01/10/14 at 6:50 p.m. revealed she was ordered to be on VC for unpredictable behavior.

In an observation on 03/17/14 at 12:20 p.m. on the Decatur unit, Patient #7 was on the telephone in the lobby without being visualized. At 12:30 p.m. she was observed going into her room and shutting the door without staff present.

Patient R22
In an observation on 03/17/14 at 12:20 p.m. on the Esplanade 2 unit, Patient R22 was sitting in a room by herself with no visualization by staff in progress. Review of the medical record for Patient R22 revealed she was a [AGE] year old female newly admitted with diagnosis which included Major Depressive Disorder. Further review revealed she had been PEC'd (Physician's Emergency Certificate) for suicidal ideations.

Patient R23
Review of the medical record for Patient R23 revealed she had been admitted on [DATE] for diagnosis which included Psychotic Disorder. Review of the Initial Care Orders for Patient #R23 dated 03/11/14 at 7:37 p.m. revealed she was ordered to be on VC for unpredictable behavior.

In an observation on 03/17/14 at 12:30 p.m. on the Esplanade 2 unit, Patient R23 walked out of her bedroom where she had been for an undetermined amount of time unobserved.

Patient R30
Observation on 03/17/14 at 11:25 a.m. revealed Patient R30, who was ordered to be on VC for unpredictable behavior, was in the television room 2 other patients with no staff member observing Patient R30.

In an interview on 03/21/14 at 2:05 p.m. with S33Psychiatrist, she said she noticed the patients were not continuously being watched on the observation levels ordered by the physicians.

In an interview on 3/20/14 at 12:17 p.m. with S29RN, she said it would be impossible to view all of the children on the units at all times because they are all over the place.

3) Failing to ensure a patient on physician ordered visual contact precautions did not leave her room and physically assault another patient:
Review of the medical record for Patient #9 revealed she was a [AGE] year old girl who had been admitted on [DATE] at 10:25 a.m. with diagnosis which included Major Depressive Disorder, Posttraumatic Stress Disorder, and Attention Deficit/Hyperactivity. Further review revealed she was ordered to be on constant visual contact for violence.

Review of the medical record for Patient #9 revealed while she remained on physician-ordered visual contact the following progress note dated 12/5/13 at 7:45 p.m. by S34MHT was written: "Client (Patient #9) was in dayroom when she stated another client made a face at her. This client then went over and hit and pulled the hair of the other client. Staff interviewed and placed client in seclusion room until 7:53 p.m. when she was allowed to go to her room and take her medication. She refused her IM (intramuscular) medication and had to be placed in a manual hold to receive medication. She then lay in bed and after staff left her room she ran to the other client's room and hit her several times. She was placed back in locked seclusion room until calm."
In an interview on 03/21/14 at 1:20 p.m. with S15DON, she said if Patient #9 was on constant visual contact, she should not have been able to leave her room to hit another patient.

4) Failing to ensure there was a staff member available to keep a patient on visual contact while the majority of the patients were off the unit:
Review of Patient R14's medical record revealed he was a [AGE] year old male admitted [DATE] with diagnoses which included Oppositional Defiant Disorder, Moderate Mental Retardation, and ADHD (Attention Deficit Hyperactivity Disorder).

Review of Patient R14's progress notes revealed he was on VC precautions for aggression/unpredictable behavior. Further review of Patient R14's progress notes revealed the following:
11/20/13 at 10:00 a.m., Code: NS (nursing department): Team needed for Patient R14 who was experiencing increasing agitation following several hours of redirection. Patient #R14 appeared to go out of his way to do everything against the rules. He was rapping an inappropriate song and was not re-directable. Earlier he had thrown food at another client. Patient R14 cornered housekeeper in her supply closet, cornered this writer (S35RN, only staff on unit) in office and med (medication) room. S30Psychologist was able to de-escalate Patient R14. Will continue to monitor.

In an interview on 03/21/14 at 1:22 pm with S35RN (Live Oak Adolescent Unit), she was asked if the nurses were ever left alone on the unit and she replied, "Yes". She explained she was left alone on the unit frequently, because school required one MHT in each classroom. She said this requirement often resulted in the nurses being left alone on the unit. S35RN explained staffing ratios were 4 patients per staff member (excluding nurses). S35RN further explained at some point the staffing ratio changed, and nurses were being included as one of the 4 staff members in the staffing ratios. She said at times there would be 12-13 kids on the unit with 2 MHTs. She said most of the patients were on VC status. She described VC as rounds conducted every 15 minutes, so all patients were seen. She further explained patients who were in their rooms were also checked on at 15 minute intervals. S35RN described one incident in particular when she was alone on the unit and Patient R14 was acting out. She said he was after her, and he trapped her in the medication room which connected two units. She said she called a code green, and S30Psychologist was able to de-escalate Patient R14. S35RN explained code green response time was situational and at times response time was slow if other units were short staffed, if codes were called on all 3 units, or if codes were called back-to-back.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure the nursing staff developed and kept current a comprehensive nursing care plan including medical diagnoses for 6 (#3, #5, #6, #7, #9, R15) of 12 (#1-#10, R14, R15) patients' records reviewed for care plans from a sample of 10 patients and 30 random patients.
Findings:

Review of the Hospital Policy and Procedure titled Treatment Planning, Policy # TX.1-0200, effective 07/01/13, revealed in part:
3. The Master Treatment Plan/Individualized Service plan is to be completed within:
a. 72 hours for acute care admissions to Adult and Adolescent
c. Seven (7) days for Extended Care admissions to DNP (Developmental Neuro Psychology) or Youth (DHH Custody)
5. For all patients, the Treatment Plan is to be revised whenever there is a significant change in status.
E. Medical Problems/all units:
Axis III diagnosis must be addressed in the treatment plan
H. Treatment Plan/Individualized Service Plan (ISP) Modification
1. The treatment plan/ISP must be updated to reflect change in patient condition; the following requires modification of the treatment plan prior to scheduled update:
a. Newly diagnosed medical condition with ongoing treatment.
b. Use of F/R, A/R, L/S.
d. Precautions added for violence, suicide, elopement.

Patient #3
Review of patient #3's medical record revealed he was a [AGE] year old male admitted on [DATE] with diagnoses of Depression, ADHD (Attention Deficit Hyperactive Disorder) by history, and Obesity. Further review revealed he was PEC'd (Physician's Emergency Certificate) on 02/10/14 at 8:00 p.m. due to being dangerous to self and others, suicidal, homicidal, and violent. He was CEC'd (Coroner's Emergency Certificate) on 02/12/14 at 12:35 p.m. due to being dangerous to self and others.

Review of Patient #3's "Multidisciplinary Master Treatment Plan" revealed the nurse developed a nursing care plan for "Depressed Mood" and "Suicidal Ideation". Review of his nursing documentation revealed Patient #3 had periods where the nursing staff documented that he was "snorting" Prozac, an egg and screws were found in his room, he was isolating in his room and picked apart wood with the staff finding a long splinter of wood in his room, he ripped a mattress open and stole another patient's shoes, metal discs and tacks were found in his room, and he took the metal plate off the thermostat. Review of his nursing care plan revealed no documented evidence that a care plan was developed for his diagnosis of Obesity and ADHD and that it was revised to address the behaviors listed above.

Patient #5
Review of Patient #5's medical record revealed he was a [AGE] year old male admitted on [DATE] with a history of Bipolar Disorder and Substance Abuse. Review of his Psychiatric Evaluation revealed he had a history of Hypertension, Chronic Back Pain, GERD (Gastroesophageal Reflux Disease), Asthma and recently treated for Bronchitis. Further review revealed he was PEC'd on 03/16/14 at 1:05 p.m. due to complaints of taking an overdose of Remeron and being a danger to self. Review of his "RN Assessment of Risk/Initial Care Needs" documented by S45RN on 03/17/14 at 9:30 p.m. revealed his blood pressure was 153/108.

Review of Patient #5's "Master Problem List" documented by S45RN revealed his identified psychiatric/behavioral problems were altered thought, chemical dependency, sleep disturbance, suicidal ideation, violence or injury to self, and withdrawal from alcohol and/or drugs. Review of the nursing care plans initiated by S45RN revealed suicidal ideation, withdrawal from alcohol and/or drugs, depressed mood, and chemical dependency were developed with no documented evidence of the clinical interventions to be used to work towards Patient #5's goals. Further review revealed no documented evidence that a care plan was initiated for his identified medical problems, specifically Hypertension (had elevated blood pressure upon admission).

In a telephone interview on 03/21/14 at 9:30 a.m., S45RN offered no explanation for not care planning Patient #5's medical diagnoses. She indicated that the physician came on the unit and addressed his elevated blood pressure, so she didn't need to document that she notified the physician.

Patient #6
Review of Patient #6's medical record revealed an admission date of [DATE] and diagnoses of Hypertension, Diabetes Mellitus Type II, Dyslipidemia, Schizophrenia, Suicidal Ideation, and Depression.

Review of Patient #6's current plan of care revealed Hypertension, Diabetes Mellitus Type II, and Dyslipidemia were not identified as problems on the patient's care plan.

In an interview on 03/21/14 at 4:20 p.m. with S15DON (Director of Nursing), she said the care plans should have been inclusive of all medical and psychological diagnoses and she verified they were not all inclusive. She also verified Patient #6's care plan did not include his medical diagnoses and was therefore not all inclusive.

Patient #7
Review of the medical record for Patient #7 revealed she was a [AGE] year old female admitted on [DATE] at 6:00 p.m. with diagnoses of Diabetes, Hypertension, and Schizophrenia.
Review of the care plans for Patient #7 revealed only 2 problems listed: Mania and Altered thoughts.
In an interview on 03/18/14 at 2:40 p.m. with S4Youth Services Nurse Manager, she said the medical problems of Diabetes and Hypertension were not included for Patient # 7 on her plan of care.

Patient #9
Review of the medical record for Patient #9 revealed she was a [AGE] year old girl who had been admitted on [DATE] at 10:25 a.m. with diagnoses of Major Depressive Disorder, Post-traumatic Stress Disorder, and Attention Deficit/Hyperactivity.

Review of the Interdisciplinary Progress Notes for Patient #9 revealed she had arrived to the unit at 11:00 a.m. Further review revealed Patient #9 had a physical altercation at 1:15 p.m. with Patient R7 and received a cut on her lip.

Review of the medical record for Patient #9 revealed while she remained on physician-ordered visual contact the following progress note dated 12/05/13 at 7:45 p.m. by S34MHT was written: "Client (Patient #9) was in dayroom when she stated another client made a face at her. This client then went over and hit and pulled the hair of the other client. Staff interviewed and placed client in seclusion room until 7:53 p.m. when she was allowed to go to her room and take her medication. She refused her IM (intramuscular) medication and had to be placed in a manual hold to receive medication. She then lay in bed and after staff left her room she ran to the other client's room and hit her several times. She was placed back in locked seclusion room until calm."
Review of the care plan for Patient #9 revealed the only problem initiated on the care plans was Depression. There was no documented evidence that her care plan was revised after the altercation on 12/05/13 that resulted in aggression and seclusion.

Patient R15
Review of the medical record for Patient R15 revealed he was a [AGE] year old who had been admitted on [DATE] at 7:00 a.m. under the custody of DHH (Department of Health and Hospitals). Patient R15's admitting diagnoses were listed as Conduct Disorder, childhood-onset type, Impulse Control Disorder, and Polysubstance Dependence.

Review of a progress note for Patient R15 dated 11/26/13 at 5:15 p.m. revealed the patient was shadow boxing with Patient R16 who got too close and hit Patient R15 in the face. Further review revealed Patient R15 was documented as punching Patient R16 repeatedly which caused him to hit his head on a metal frame.
Review of the care plan for Patient R15 revealed under the Problem listed as "Social Skills", the goal was listed as: Recognize and honor the personal boundaries of others as shown by the termination of inappropriate physical contact and sexual comments in the next 30 days. The target date was listed as 08/01/13 and the status was listed as "A" . Further review of a legend revealed "A" meant the goal had been achieved. No new problem for "violence" or new goal date for the previously identified problem of "Social Skiils" had been initiated after the fight between Patient R15 and Patient R16 on 11/26/13.
In an interview on 03/20/14 at 2:37 p.m. with S30Psychologist, she said it appeared that the nursing staff initiated the treatment plans for the patients and then there was an inconsistent response. S30Psychologist indicated the patients' care plans were not individualized and generic.

In an interview on 03/20/14 at 2:59 p.m. with S16RN, she said the patient care plans were generic and not individualized to the patients. S16RN said she does not add anything to the care plans to make them individualized to the patients. S16RN also said goals were not updated for the patients.

In an interview on 03/21/14 at 2:18 p.m. with S33Psychiatrist, she said the diagnoses are not appropriate on the patient's treatment plans. S33Psychiatrist also said the treatment plans were pre-printed, not individualized, not patient-specific and not all inclusive of the patient's medical and psychiatric diagnoses. She said, "It is just a list."
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on record reviews and interviews, the hospital failed to administer drugs as ordered by the practitioner responsible for the care of the patient as evidenced by failing to notify the patient's physician of dose related concerns identified by the pharmacist which resulted in the delay of administration of the patient's medication for 1 (#10) of 10 patients' records reviewed for medications from a total sample of 10 patients.
Findings:

Review of the hospital policy entitled: Medication Administration, revised 04/03/13, revealed the following, in part:
Policy:
Proper procedure for the safe administration of medication will be followed. For Nursing Service, medication is to be administered by authorized RN's (registered nurses) or authorized LPN's (licensed practical nurses) according to applicable laws and guidelines.
Purpose:
To provide conditions which promote safe and accurate medication administration.
Procedure:
A. Medication review
1. Standards require that all new medications be reviewed by a pharmacist prior to administration. All orders must be scanned to Pharmacy immediately for review/release. New medication cannot be given until reviewed and cleared by pharmacy.
4. Pharmacy will review the medications. Concerns will be addressed directly with the physician.
5. After hours, in the absence of on-site pharmacy: the on-call Pharmacy is available to review orders until 11p.m. nightly.
a. Orders written after hours will be reviewed by the after hour, on-call Pharmacy.
b. Because of this process, the writing of after hour orders for new medications should be completed by 10:30 p.m. in order to allow time for review. Otherwise, admit medications should be deferred until the morning dose. The order should specify begin medications tomorrow.
c. After hour admissions: night time admissions should be scheduled to allow completion of medication orders by 10:30 p.m.
1. The RN ' s in admissions will assume the responsibility for processing the admit order to the on call pharmacy. The medication will not be sent to the unit until cleared.

Review of Patient #10's medical record revealed the following orders:
11/14/13, 3:52 p.m. Increase Focalin XR 60 mg (milligrams) p.o. (by mouth) daily, 1st dose 11/15/13 in a.m.
11/14/13, 5:05 p.m. Order clarification: Focalin XR 40mg (milligrams) p.o. daily, 1st dose 11/15/13 in a.m.
11/15/13, 12:00 p.m. May give Focalin XR 40 mg (milligrams) p.o. x (times) one now please.

Review of Patient #10's physician progress notes, dated 11/15/13, revealed the following:
Subjective: Intrusive and disruptive all morning. Given Thorazine as PRN (as needed).... (unable to read word) until approximately 12 noon. Given Focalin XR 40 mg dose (unavailable this a.m. from pharmacy- leading to need for Thorazine). Will observe response to stimulant. Continues to require 1:1 (one-to-one) and persistent redirection.

Review of Patient #10's MAR revealed the following:
Focalin XR 15 mg po daily administered on 11/14/13 at 8: 00 a.m.
11/14/13 Increase Focalin XR 40 mg po daily, 1st dose in a.m. (11/15/13)
11/15/13 Increase Focalin XR 40 mg po daily 1st dose in a.m. (11/15/13): with a hand written notation, "See below" written in the space where the dose should have been documented.
11/15/13 May give Focalin XR 40 mg po x 1 NOW: dose administered at 12:15 p.m.

In an interview on 03/20/14 at 1:54 p.m. with S40Pharmacist, she said she had questioned Patient #10's order for Focalin XR 40 mg. She said that was a high dose, and they questioned the dose. She explained the pharmacy would have communicated back to the nurse that the dose was high. S40Pharmacist said the nurse should have notified the MD about the identified concern regarding the dose of the medication. S40Pharmacist further explained the pharmacy would have followed up by the end of the day, if they had not heard back from the nurse about the dose in question. S40Pharmacist said if a medication dose was in question, the afterhours call center would have written a note that the issue needed to be clarified, and the order rewritten. She said if they knew which physician it was, they would also call the physician directly.

On 03/21/14 at 10:59 a.m. a telephone interview was attempted with S37RN (RN who administered Focalin XR doses on 03/14/14 and 03/15/14). There was no answer. A second attempt was made on 03/21/14 at 11:05 a.m. to interview S37RN by telephone, and again there was no answer.

In an interview on 03/21/14 at 2:18 p.m. with S33Psychiatrist, she said Patient #10 was admitted on a weekend and received Thorazine (ordered as needed) to manage his behaviors. S33Psychiatrist said she felt the patient may not have required the PRN Thorazine doses if he had received the 40mg Focalin XR dose that was ordered to control his behaviors. She said the nurse did not call her to inform her that pharmacy was questioning the Focalin dose. S33Psychiatrist also said the pharmacist had not called her regarding concerns about the 40mg Focalin XR dose. S33Psychiatrist said she reviewed Patient #10's chart and noticed the 40 mg Focalin XR dose was not administered as ordered for administration on 11/15/13 at 8:00 a.m. She asked why the medication was not given, and she was told pharmacy said the medication was not available.