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 April 19, 2016
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on record review and interview, the hospital's governing body failed to identify and promptly resolve grievances. This deficient practice was evidenced by the hospital's failure to initiate the grievance process related to an allegation of potential neglect regarding the injuries Patient #2 sustained during a violent patient-to-patient altercation during which the patient was punched 12 times (in 11 seconds) in the face and head.

Findings:

Review of the hospital policy titled, Patient Comments/Complaints, Policy #: RI-0900, revealed in part, it is the policy of the hospital to respond promptly and effectively to patient comments/complaints/grievances and to evaluate and promote patient satisfaction with services provided. The purpose was to assure quality, accessibility and accountability of mental health services which provide the treatment, rehabilitation, community support, and recovery to our patients at this hospital. Patients are encouraged, if they are dissatisfied with any aspect of their care, to express their dissatisfaction, verbally or in writing, to any staff member providing services. Patient Grievance- ( as defined by Centers for Medicare & Medicaid Services (CMS) Interpretive Guidelines reference 482.13(a) (2): A formal or informal written or verbal complaint that is made to the hospital by a patient or patient's representative when a patient issue cannot be resolved promptly by staff present. If a complaint cannot be resolved promptly by staff, or it is referred to the Patient Rights Officer, it is to be considered a grievance. Patient grievances also include situations where the patient or patient representative calls or writes to the hospital about concerns related to care or services. Allegations of abuse have additional reporting requirements, but they are also considered grievances.

Review of the hospital's complaint/grievance log for the last 2 months revealed no documented evidence of a complaint/grievance referencing an allegation of potential neglect regarding injuries Patient #2 sustained during a violent patient-to- patient altercation during which Patient #2 was punched 12 times (in 11 seconds) in the face and head.

Review of Patient #2's medical record revealed the patient had been involved in a patient-to-patient physical altercation on 04/03/16, at 9:42 p.m.. Further review revealed Patient #2 had sustained a swollen left eye, right cheek, and upper lip. Additional review revealed no documented evidence that Patient #2's neurological status had been evaluated after the altercation and for the duration of the shift. Review of the supplemental medical records revealed Patient #2 had been evaluated in the Medical Clinic on 04/04/16, and had been sent to the ED (emergency department) for evaluation, x-rays, and treatment on 04/05/16. Patient #2 was also sent to an Eye Specialist on 04/11/16, for evaluation due to a previous history of having had surgery on both of his eyes.

Review of the hospital-provided videotape of the altercation that occurred on 04/03/16, revealed Patient #2 had been punched in the face and head 12 times in 11 seconds by Patient #4. Patient #2 was observed to lie motionless on the floor for almost a minute after Patient #4 had been separated from Patient #2.

In an interview on 04/19/16, at 6:09 p.m., with S3Program Dir, she confirmed she had spoken to Patient #2's sister regarding the injuries he had sustained in the physical altercation that had occurred on 04/03/16, between Patient #2 and Patient #4. S3ProgramDir indicated Patient #2's sister had been surprised and very upset to see her brother's injuries and "beaten up" appearance. S3ProgramDir indicated Patient #2's sister had been afraid someone (the staff) had let that happen to him, delaying response because the staff didn't like him. She said Patient #2's sister had been concerned that staff may have delayed action and allowed her brother to be "beaten up" before stopping the altercation. S3ProgramDir further indicated she had told the patient's sister that she would review the video of the altercation. S3ProgramDir indicated she had felt, in that moment that she had spoken to Patient #2's sister, that she (Patient #2's sister) was on a fact-finding mission. She said she did not document the sister's concerns as a grievance, because she had not felt it was a complaint/grievance. S3ProgramDir indicated the very minute the conversation occurred with Patient #2's sister, she and Patient #2's sister were on the same page. She indicated at that point when they all became aware that the patient was injured, the patient was sent out for assessment. S3ProgramDir said the assumption at that point had been that the nurse had done everything according to hospital policy, and the physician had been notified. She indicated the patient had been seen in the medical clinic on 04/04/16. She said he was sent to the ED on 04/05/16, per his sister's request him. She indicated this was a huge failure on the part of the nurse who was the weak link in the system and not a system breakdown. She indicated Patient #2's sister expressed to her (S3ProgramDir) that she wanted someone else to put eyes on what happened to her brother. Patient #2's sister indicated she had called the police, because she wanted someone outside the hospital to investigate the incident. S3ProgramDir said Patient #2's sister was directed to voice her concerns to DHH. S3ProgramDir indicated she had emailed S1Adm while she was talking to Patient #2's sister and informed him of Patient #2's sister's concerns regarding the physical altercation involving her brother (Patient #2) and Patient #4 that had resulted in her brother sustaining physical injuries. S3ProgramDir indicated she had reviewed the videotape of the altercation from the standpoint of rapidity to which the staff responded to the altercation and not from the nursing/clinical aspect.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on record review and interview, the hospital failed to assure any incidents of abuse, neglect, and/or harassment were reported and analyzed, and the hospital was in compliance with applicable local, State, and Federal Laws and Regulations. This deficient practice was evidenced by the hospital's failure to report an allegation of neglect (regarding physical injuries Patient #2 sustained during a patient-to-patient altercation) within 24 hours to the Department of Health and Hospitals.

Findings:

Review of the Louisiana Revised Statutes, Title 40. Public Health and Safety, Chapter 11, State Department of Health and Hospitals revealed "Department" shall mean the Department of Health and Hospitals. "Unit" means the Medicaid fraud control unit created within the office of criminal law of the Department of Justice and which is certified by the secretary of the United States Department of Health, Education and Welfare. Regarding 2009.20. Duty to make complaints; penalty; immunity, "Abuse" is the infliction of physical or mental injury or the causing of the deterioration of a consumer by means including but not limited to sexual abuse, or exploitation of funds or other things of value to such an extent that his health or mental or emotional well-being is endangered. "Neglect" is the failure to provide the proper or necessary medical care, nutrition, or other care necessary for a consumer's well-being. Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, ... having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit or local law enforcement agency of such abuse or neglect. When the department receives a report of sexual or physical abuse, whether directly or by referral, the department shall notify the chief law enforcement agency of the parish in which the incident occurred of such report. Such notification shall be made prior to the end of the business day subsequent to the day on which the department received the report.

Review of the hospital policy titled, Abuse /Neglect of Patients/Reporting Allegations, Policy # RI-0800, presented as current by S2DON, revealed it is the policy of this hospital to preserve the right of each person receiving services to be free from abuse. All form of abuse of patients by employees and affiliates of this hospital are prohibited. The purpose of the policy is to ensure all patients are free from all forms of abuse and neglect. Statutory Definition of Abuse from 42CFR 51.2 (Protection and Advocacy for the Mentally Ill) revealed "Neglect" means a negligent act or omission by an individual responsible for providing services in a facility rendering care or treatment which caused or may have caused injury or death to an individual with mental illness or which placed an individual with mental illness at risk for injury or death, and includes, but is not limited to, acts or omissions such as failure to carry out an appropriated individual program or treatment plan; provide adequate nutrition, clothing, or healthcare; and the failure to provide a safe environment which also includes failure to maintain adequate numbers of appropriately trained staff. Further review revealed the hospital was to notify DHH Health Standards section of all allegations, no matter how irrational the allegation may be, within 24 hours. Hospital Abuse/Neglect Initial Report (Form HSS-HO-41) is completed electronically, saved to folder and emailed to the CEO, DON, risk manager, and attending MD. A printed copy is emailed to the Program Desk Manager at Health Standards Section. The Rights Officer will conduct objective investigations of allegations of abuse and neglect in a timely and thorough manner. Specific responsibilities and timelines include: 1. Patient Rights Officer will view the videotape ( if surveillance footage is available) within 24 hours of the initial report. 2. Collect witness statements, interview patients. 3. Completes full report for CEO's (Chief Executive Officer) review within 72 hours of the initial allegation. If extenuating circumstances delay the completion of the report past 72 hours, the Patient Rights Officer must report those circumstances to the CEO and CEO may authorize an extended timeframe. Immediately upon completion of the investigation, the Patient Rights Officer will report the findings of the investigation to the patient if the patient made the allegation.

Review of the Abuse/Neglect Reports submitted to DHH for the last 2 months revealed no documented evidence of an Abuse/Neglect report of allegations of potential neglect regarding injuries Patient #2 sustained during a patient-to-patient physical altercation that occurred on 04/03/16.

Review of Patient #2's medical record revealed the patient had been involved in a patient-to-patient physical altercation on 04/03/16, at 9:42 p.m.. Further review revealed Patient #2 had sustained a swollen left eye, right cheek, and upper lip. Additional review revealed no documented evidence that Patient #2's neurological status had been evaluated after the altercation, for the duration of the shift. Review of the supplemental medical records revealed Patient #2 had been evaluated in the Medical Clinic on 04/04/16 and had been sent to the ED for evaluation, x-rays and treatment on 04/05/16. Patient #2 was also sent to an Eye Specialist on 04/11/16 for evaluation due to a previous history of having had surgery on both of his eyes.

Review of the hospital-provided videotape of the altercation that occurred on 04/03/16. revealed Patient #2 had been punched in the face and head 12 times in 11 seconds by Patient #4. Patient #2 was observed to lie motionless on the floor for almost a minute after Patient #4 had been separated from Patient #2.

In an interview on 04/19/16, at 6:09 p.m., with S3Program Director, she confirmed she had spoken to Patient #2's sister regarding the injuries he had sustained in the physical altercation that had occurred on 04/03/16, between Patient #2 and Patient #4. S3ProgramDir indicated Patient #2's sister had been surprised and very upset to see her brother's injuries and "beaten up" appearance. S3ProgramDir indicated Patient #2's sister had been afraid someone (the staff) had let that happen to him, delaying response because the staff didn't like him. She said Patient #2's sister had been concerned that staff may have delayed action and allowed her brother to be "beaten up" before stopping the altercation. S3ProgramDir further indicated she had told the patient's sister that she would review the video of the altercation. S3ProgramDir indicated she had felt, in that moment that she had spoken to Patient #2's sister, that she was on a fact-finding mission. She said she did not document the sister's concerns as a grievance, because she had not felt it was a complaint/grievance. S3ProgramDir indicated the very minute the conversation occurred with Patient #2's sister, she and Patient #2's sister were on the same page. She indicated at that point when they all became aware that the patient was injured, the patient was sent out for assessment. S3ProgramDir said the assumption at that point had been that the nurse had done everything according to hospital policy and the physician had been notified. She indicated the patient had been seen in the medical clinic on 04/04/16. She said he was sent to the ED on 04/05/16, per his sister's request. She indicated this was a huge failure on the part of the nurse who was the weak link in the system and not a system breakdown. She indicated Patient #2's sister expressed to her (S3ProgramDir) that she wanted someone else to put eyes on what happened to her brother. Patient #2's sister indicated she had called the police, because she wanted someone outside of the hospital to investigate the incident. S3ProgramDir said Patient #2's sister was directed to voice her concerns to DHH. S3ProgramDir indicated she had emailed S1Adm while she was talking to Patient #2's sister and informed him of Patient #2's sister's concerns regarding the physical altercation involving her brother (Patient #2) and Patient #4 that had resulted in her brother sustaining physical injuries. S3ProgramDir indicated she had reviewed the videotape of the altercation from the standpoint of rapidity to which the staff responded to the altercation and not from the nursing/clinical aspect.
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:


Failing to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:


1) Failing to ensure the level of observation was reassessed and appropriate precautions were implemented for patients (#2, #4) who were exhibiting disruptive, aggressive, and/or violent behaviors (see findings in tag A0395).


2) The RN failed to conduct a comprehensive nursing assessment of Patient #2 to include an assessment of vital signs, level of consciousness, and neurological status after Patient #2 was involved in a physical altercation on 04/03/16 (see findings in tag A0395).


An Immediate Jeopardy situation was identified on 04/14/16 at 4:55 p.m. and reported to S1Adm. The immediate jeopardy was a result of the hospital failing to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:


1) Failure to ensure the level of observation was reassessed and appropriate precautions were implemented for patients who were exhibiting disruptive, aggressive, and/or violent behaviors:


a) Documentation revealed Patient #2 had threatened to kill staff on 03/31/16, at 7:08 p.m., and continued with disruptive and intrusive behavior at 8:00 p.m. Patient #2 was ordered to be on CSS since the time of admission on 07/14/15, through the current date (defined as to directly observe location and activity of patient documented every 10 minutes). There was no increased level of observation implemented at this time. Review of the hospital-provided video revealed on 04/03/16, Patient #2 and Patient #4 were involved in a patient-to-patient physical altercation. The only documentation by the RN was Patient 32 had a "swollen left eye, right cheek, and upper lip." Following the violent altercation between Patient #2 and Patient #4 the RN failed to increase the observation status of both patients. As of 04/14/16, Patient #2 and Patient #4 remained at CSS level of observation which placed the unit census of 18 at risk for injury. There were 18 patients on the unit on 04/03/17 (7 patients on every 10 minute observation, 11 patients on every 15 minute observation) with 1 RN, 1 LPN, and 4 MHTs. The hospital had no policy and procedure for the management of patients exhibiting aggressive and violent behavior.


b) Documentation revealed Patient #4 was evaluated as being unpredictable and violent in the milieu on 04/04/16, by the NP, extremely violent, labile, and paranoid and actively attempting to hit staff and peers on 04/08/16, by S6Psychiatrist, and seen individually due to violent, unpredictable behavior by the NP on 04/11/16. Patient #4, who was on CSS level of observation, hit Patient #3 in the right eye in an unprovoked assault on 04/12/16, that resulted in Patient #3's eye being reddened with no bruising noted. Patient #4's level of observation was not reassessed for the need to increase the level of observation. This was the second altercation involving this patient. The failure to increase the observation level of Patient #4 following the first violent altercation on 04/03/16, placed the unit with a census of 18 at risk for injury and resulted in a second altercation on 04/12/16, with Patient #3 who was injured in the altercation.


2) The RN failed to conduct a comprehensive nursing assessment of Patient #2 to include an assessment of vital signs, level of consciousness, and neurological status after Patient #2 was involved in a physical altercation on 04/03/16. The only documentation by the RN was Patient #2 had a "swollen left eye, right cheek, and upper lip." Review of the hospital-provided video revealed on 04/03/16, Patient #2 and Patient #4 were involved in a patient-to-patient physical altercation. Further review of the video revealed no observation of the RN assessing Patient #2 while he remained motionless on the floor for approximately one minute after the altercation. Review of the video revealed the MHT stood around Patient #2 while he lay on the floor. A MHT rolled Patient #2 to his side from a face-down position, and Patient #2 rolled back to a face-down position when he was released. Patient #2 required staff assistance to be placed in a chair. Patient #2 was not assessed and/or evaluated by a licensed independent practitioner/physician until the next day.


The hospital presented a second plan of correction (after revisions were made to the first plan) on 04/19/16, at 11:00 a.m. that included the following:


1) For any patient exhibiting disruptive, aggressive, and/or violent behaviors, the level of observation is reassessed and appropriate precautions implemented and documented in the clinical record. The form "Critical Injury/Incident Reporting Assessment (RN)" is used to document the level of observation reassessment and appropriate precautions implemented. RNs will be trained on documentation requirement by 04/18/16. Any staff not trained will not be allowed to work until training has been completed.


2) Immediately following a patient injury, the RN conducts a comprehensive nursing assessment including an assessment of vital signs, level of consciousness, and neurological status. The form "Critical Injury/Incident Reporting Assessment (RN)" is used to document the comprehensive nursing assessment including an assessment of vital signs, level of consciousness, and neurological status. RNs will be trained on documentation requirement by 04/18/16. Any staff not trained will not be allowed to work until training has been completed.


3) Compliance monitoring of corrective actions: 100% (per cent) of events reflecting patients exhibiting disruptive, aggressive, and/or violent behaviors will be audited for 90 days. The results of quality audits will be reviewed by the Performance Improvement Committee. The audit will include: (1) Documentation of level of observation reassessment and appropriate precautions after a patient exhibits disruptive, aggressive, and/or violent behaviors. (2) Comprehensive nursing assessment including an assessment of vital signs, level of consciousness, and neurological status after a patient injury.


Review of Patient #4's medical record revealed while the Immediate Jeopardy Situation remained in place, at 4:15 p.m. on 04/15/16, Patient #4 leaned over the nurse's station "dutch door" (a half door separating the nurse's station from the foyer where patients are able to walk to get to the day rooms and group room) attempting to unlock the door. Further review revealed Patient #4 would not follow verbal redirection and stood at the door, causing the nurse to exit the nurse's station via another exit. Further review revealed shortly after this incident, Patient #4 moved from the nurse's station door and stood at the door used to exit the unit that opened to the outside courtyard of the building. The RN attempted to get to the exit door to allow a male MHT to enter the building. Patient #4 abruptly lunged at this RN with an attempt to strike the RN, but the RN was able to remain at a safe distance and avoid the strike. Patient #4 remained at CSS level of observation after the above two occurrances of aggression/violence.


Review of Patient #4's Progress Notes revealed the RN documented at at 3:45 p.m., on 04/16/16, that Patient #4 "jumped the nurses door & (and) got into the face of RN." Patient #4's level of observation, which was CSS, was not increased at this time.


Review of Patient #4's RN Progress Note on 04/17/16, at 8:00 a.m., revealed "he is aggressive and intrusive @ (at) nsg (nursing) station." Review of physician orders revealed a telephone order was received on 04/17/16, at 8:10 a.m. to place Patient #4 on VC.


Review of Patient #4's "Progress Notes" revealed an entry dated 04/16/16 (should read 04/17/16), at 8:00 a.m., that Patient #4 hit Patient R1, and Patient R1 fought back and injured Patient #4's left eye. Further review revealed Patient #4 was sent to the emergency department for evaluation of the left eye and returned to the unit on 04/17/16, at 1:00 p.m., with after care instructions for Corneal Abrasion, Sinusitis, and Facial Contusion. Review of physician orders revealed a telephone order was received on 04/17/16, at 3:30 p.m., to change Patient #4's status from VC to 1:1.


Observation on 04/19/16, from 4:30 p.m. to 4:35 p.m., in the day room revealed Patient #4, who was ordered to be on 1:1 level of observation and being observed by S20MSS, did not remain in S20MSS' line of sight for 2 separate observations of approximately 20 seconds each when S20MSS was watching television. Patient #4 was not in the peripheral vision of S20MSS during these observations.


Observation on 04/19/16, at 4:55 p.m., revealed Patient #4 was outdoors in the courtyard with S12MHT observing him 1:1. Further observation revealed S12MHT and Patient #4 walked toward the unit to re-enter the building with S12MHT walking with Patient #4 walking behind him (eye contact not maintained at this time). This observation was made in the presence of S2DON.


Due to the above observations, medical record review, and the need for staff to be re-educated on policies and procedures that were revised since they received their initial education following the identification of the Immediate Jeopardy situation, the Immediate Jeopardy remains in place as of the time of exit on 04/19/16, at 7:28 p.m.


3) The RN failed to assess and document the assessment of each patient exhibiting a change in condition related to exhibited behaviors that required the administration of PRN medications for 2 (#3, #4) of 5 patient records reviewed for RN assessment with a change in condition from a sample of 5 patients.


4) The RN failed to assess patient's wounds as evidenced by failure of the RN to assess Patient #5's wound to his right foot upon admit and notify the physician when Patient #5 repeatedly refused to have ordered medication applied and to document an assessment of Patient #1's Cellulitis. This deficient practice was evident for 2 (#1, #5) of 2 patient records reviewed with wounds from a sample of 5 patients.


5) The RN failed to assess a patient for cheeking medications, report medications presented by the patient to the MHT to the physician, and obtain physician orders for cheeking precautions for 1 (#1) of 1 patient record reviewed with a failure to report a patient cheeking medications from a sample of 5 patients.


6) The RN failed to assess each patient after admission to an acute care hospital upon the patient's return to this hospital and obtain physician orders for treatment for 2 (#1, #3) 2 patient records reviewed with an admission to an acute care hospital from a total of 5 sampled patients. The hospital's policy was contradictory, with one place stating a reassessment was to be done when there is a transfer from a different level of care and one place stating that patients who are still clinically admitted to the hospital will not require readmission/reassessment.

(See findings in tag A0395).
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, record reviews, and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:


1) Failing to ensure the level of observation was reassessed and appropriate precautions were implemented for patients who were exhibiting disruptive, aggressive, and/or violent behaviors as evidenced by:


a) Documentation and review of a hospital-provided video revealed Patient #2, who had threatened to kill staff and continued with disruptive and intrusive behavior and ordered to be on Close Staff Sight (CSS) with no increased level of observation, was involved in a patient-to-patient physical altercation on 04/03/16. Following the violent altercation, the RN failed to increase the observational status of both patients.


b) Documentation revealed Patient #4 was evaluated as being unpredictable and violent in the milieu on 04/04/16, by the NP, extremely violent, labile, and paranoid and actively attempting to hit staff and peers on 04/08/16, by S6Psychiatrist, and seen individually due to violent, unpredictable behavior by the NP on 04/11/16. Patient #4, who was on CSS level of observation, hit Patient #3 in the right eye in an unprovoked assault on 04/12/16, that resulted in Patient #3's eye being reddened with no bruising noted. Patient #4's level of observation was not reassessed for the need to increase the level of observation. This was the second altercation involving this patient. With an Immediate Jeopardy Situation identified on 04/14/16, at 4:55 p.m., Patient #4's level of observation was not increased and resulted in Patient #4 attacking another Patient R1 on 04/17/16. Patient R1 retaliated and struck Patient #4 in the left eye and lip that resulted in a Corneal Abrasion and Facial Contusion to Patient #4's face and left eye.


2) The RN failed to conduct a comprehensive nursing assessment of Patient #2 to include an assessment of vital signs, level of consciousness, and neurological status after Patient #2 was involved in a physical altercation on 04/03/16.


3) The RN failed to assess and document the assessment of each patient exhibiting a change in condition related to exhibited behaviors that required the administration of PRN medications for 2 (#3, #4) of 5 patient records reviewed for RN assessment with a change in condition from a sample of 5 patients.


4) The RN failed to assess patient's wounds as evidenced by failure of the RN to assess Patient #5's wound to his right foot upon admit and notify the physician when Patient #5 repeatedly refused to have ordered medication applied and to document an assessment of Patient #1's Cellulitis. This deficient practice was evident for 2 (#1, #5) of 2 patient records reviewed with wounds from a sample of 5 patients.


5) The RN failed to assess a patient for cheeking medications, report medications presented by the patient to the MHT to the physician, and obtain physician orders for cheeking precautions for 1 (#1) of 1 patient record reviewed with a failure to report a patient cheeking medications from a sample of 5 patients.


6) The RN failed to assess each patient after admission to an acute care hospital upon the patient's return to this hospital and obtain physician orders for treatment for 2 (#1, #3) 2 patient records reviewed with an admission to an acute care hospital from a total of 5 sampled patients. The hospital's policy was contradictory, with one place stating a reassessment was to be done when there is a transfer from a different level of care and one place stating that patients who are still clinically admitted to the hospital will not require readmission/reassessment.


Findings:


1) Failing to ensure the level of observation was reassessed and appropriate precautions were implemented for patients who were exhibiting disruptive, aggressive, and/or violent behaviors:


Review of the hospital policy titled "Level of Observation and Precaution", presented as the current policy by S2DON, revealed that it is the policy of the hospital to appropriately assess patients for high risk behaviors and to order and maintain special precautions to protect the welfare of the patient. CSS was defined as to directly observe location and activity of patient documented every 10 minutes. VC was defined as to provide more intense supervision of a patient by maintaining visual contact of patient at all times. 1:1 was defined as to provide maximum observation of a patient with one staff member assigned within 3 to 6 feet of visual contact of the patient at all times during waking hours and from the bedroom doorway during sleeping hours. Review of the justification of observation revealed CSS was increased frequency of observation based on escalation of symptomatic behaviors that is not at the level that requires visual contact. VC was indicated for patients who were medically compromised, or on suicide precaution, extremely confused or disoriented, exhibiting assaultive behaviors and constant elopement risk. 1:1 was for the presence of acute medical problems and for patients who were actively suicidal or assaultive while in the milieu.


a) Documentation and review of a hospital-provided video revealed Patient #2, who had threatened to kill staff and continued with disruptive and intrusive behavior and ordered to be on Close staff Sight (CSS) with no increased level of observation, was involved in a patient-to-patient physical altercation on 04/03/16. Following the violent altercation, the RN failed to increase the observational status of both patients.


Patient #2

Review of Patient #2's medical record revealed an admission date of [DATE], with admission diagnoses of [DIAGNOSES REDACTED]


Review of Patient #2's medical record revealed the following nursing entries:

03/10/16, 8:00 p.m.: Increased agitation, getting in peers faces;

03/23/16, 8:10 p.m.: Patient hyperverbal, argumentative with staff, hostile with peers, agitated, unable to redirect;

03/31/16, 7:08 p.m.: Patient paranoid, intrusive, threatening to staff, very demanding, states," I'm will kill ya'll";

03/31/16, 8:00 p.m.: Above behavior continues, no change, intrusive and disruptive.;

04/04/16, 8:00 p.m.: Patient intrusive, threatening staff and peers.


Review of hospital incident reports revealed documentation of a patient-to-patient physical altercation involving Patient #2 and Patient #4 that had occurred on 04/03/16. Further review revealed Patient #2 had initiated the altercation by striking Patient #4.


Review of Patient #2's MHT observation sheets revealed the patient had been on CSS level of precautions at the time of the altercation on 4/3/16, and had remained on CSS as of 04/19/16, with no documented evidence of increased precaution levels at anytime following the altercation. Further review revealed the following entries, in part:

03/31/16: Several prompts to keep hands to self; client was agitated throughout shift w/ staff and peers; Client was redirected throughout shift. Could not keep hands to self. Client cursing staff and peers during 7-3 shift.

04/01/16: Client needed verbal warning not to hit peers.;

04/02/16: Yelling cursing at staff and peers

04/03/16: Yelling cursing at staff and peers and keeps upsetting peers on unit.


On 04/14/16, at 9:40 a.m. an observation was made of Patient #2. He was observed attending group with the Social Worker. When a staff member addressed him as "Mr. (patient's first name) he responded," It is just (patient's first name), not Mr.(patient's first name) ". His mood was agitated. When an interview was attempted by the surveyor with the patient, he was noted to be in an agitated, paranoid state. He asked the surveyor, "who are you, why are you here and who is sending you to ask me these questions?" He walked away and came back and repeated the same questions. The interview was ended due to the patient's agitated, paranoid state.


Patient #4

Review of Patient #4's medical record revealed he was admitted on [DATE], with a presenting problem of Psychosis. Review of Psychiatric Evaluation conducted on 11/10/15, revealed diagnoses of [DIAGNOSES REDACTED]


Review of Patient #4's physician orders revealed he was ordered to be on CSS level of observation on 02/01/16, at 8:55 a.m.


Review of Patient #4's medical record revealed he remained on CSS level of observation at the time of the physical altercation with Patient #2 on 04/03/16. Further review revealed no documented evidence that Patient #4's level of observation was increased after the altercation.


In an interview on 04/14/16, at 12:08 p.m., with S2DON, she confirmed Patient #2 had been involved in a physical altercation with Patient #4 on 04/03/16. She indicated Patient #2 had thrown the first punch in the altercation. S2DON reviewed Patient #2's and Patient #4's medical record and confirmed neither patient had orders for increased precaution levels at anytime following the altercation on 04/03/16. S2DON also confirmed both patients were currently on CSS precautions.


In an interview on 04/19/16, at 12:22 p.m., with S8RN, he confirmed he had been working the night of the altercation between Patient #2 and Patient #4. He indicated Patient #2 could be aggressive and would antagonize other patients in an attempt to get them to lash out. S8RN confirmed Patient #2's observation level had not been changed from CSS after the altercation on 4/3/16, even though the patient had exhibited violent, aggressive behavior.


In an interview on 04/19/16, at 4:31 p.m., with S12MHT, he indicated Patient #2 is always in someone's face. S12MHT described Patient #2's behavior as aggressive and antagonistic toward staff and other patients. S12MHT indicated Patient #2 should have been placed on 1:1 Supervision or Visual Contact level of observation due to his behavior.


b) Documentation revealed Patient #4 was evaluated as being unpredictable and violent in the milieu on 04/04/16, by the NP, extremely violent, labile, and paranoid and actively attempting to hit staff and peers on 04/08/16 by S6Psychiatrist, and seen individually due to violent, unpredictable behavior by the NP on 04/11/16. Patient #4, who was on CSS level of observation, hit Patient #3 in the right eye in an unprovoked assault on 04/12/16, that resulted in Patient #3's eye being reddened with no bruising noted. Patient #4's level of observation was not reassessed for the need to increase the level of observation. This was the second altercation involving this patient. With an Immediate Jeopardy Situation identified on 04/14/16, at 4:55 p.m., Patient #4's level of observation was not increased and resulted in Patient #4 attacking another Patient R1 on 04/17/16. Patient R1 retaliated and struck Patient #4 in the left eye and lip that resulted in a Corneal Abrasion and Facial Contusion to Patient #4's face and left eye.


Review of Patient #4's medical record revealed he was admitted on [DATE]. Review of his physician progress notes revealed the following documentation:

04/04/16, at 11:10 a.m., by S18NP - client remains unpredictable and violent in milieu; was in physical altercation with peer last night which client denies;

04/08/16, by S6Psychiatrist - continues to be extremely violent and labile and paranoid; actively attempt to hit staff and peers; has punched peers and staff in head and caused peer to go to hospital because he was violent;

04/11/16, at 11:40 a.m., by S18NP - client seen individually due to violent, unpredictable behavior.

Review of Patient #4's MHT Progress Note dated 04/03/16, revealed Patient #4 got into an altercation with Patient #2.


Review of the hospital's "Investigation Report" revealed on 04/03/16, at 9:42 p.m., Patient #2 punched Patient #4, who was on CSS level of observation, and Patient #4 chased Patient #2 and hit him (Patient #2) in the face multiple times. Patient #4's level of observation remained at CSS after the altercation.


Review of Patient #4's RN Progress Note documented on 04/12/16, by S19RN revealed at approximately 5:40 p.m., Patient #4 hit Patient #3 in the right eye in an unprovoked assault that resulted in Patient #3's eye being reddened with no bruising noted. Patient #4's level of observation was not reassessed for the need to increase the level of observation. This was the second altercation involving this patient.


An Immediate Jeopardy Situation was identified on 04/14/16, at 4:55 p.m., as a result of the RN failing to ensure the level of observation was reassessed and appropriate precautions were implemented for patients who were exhibiting disruptive, aggressive, and/or violent behaviors.


While the Immediate Jeopardy Situation remained in place, review of the RN Progress Note documented at 4:15 p.m., on 04/15/16, revealed that Patient #4 leaned over the nurse's station "dutch door" (a half door separating the nurse's station from the foyer where patients are able to walk to get to the day rooms and group room) attempting to unlock the door. Further review revealed Patient #4 would not follow verbal redirection and stood at the door, causing the nurse to exit the nurse's station via another exit. Further review revealed shortly after this incident, Patient #4 moved from the nurse's station door and stood at the door used to exit the unit that opened to the outside courtyard of the building. The RN attempted to get to the exit door to allow a male MHT to enter the building. Patient #4 abruptly lunged at this RN with an attempt to strike the RN, but the RN was able to remain at a safe distance and avoid the strike. Patient #4 remained at CSS level of observation after the above two occurrances of aggression/violence.


Review of Patient #4's Progress Notes revealed the RN documented at at 3:45 p.m. on 04/16/16, that Patient #4 "jumped the nurses door & (and) got into the face of RN." Patient #4's level of observation, which was CSS, was not increased at this time.


Review of Patient #4's RN Progress Note on 04/17/16, at 8:00 a.m., revealed "he is aggressive and intrusive @ (at) nsg (nursing) station." Review of physician orders revealed a telephone order was received on 04/17/16, at 8:10 a.m., to place Patient #4 on VC.


Review of Patient #4's "Progress Notes" revealed an entry dated 04/16/16 (should read 04/17/16), at 8:00 a.m., that Patient #4 hit Patient R1, and Patient R1 fought back and injured Patient #4's left eye. Further review revealed Patient #4 was sent to the emergency department for evaluation of the left eye and returned to the unit on 04/17/16, at 1:00 p.m., with after care instructions for Corneal Abrasion, Sinusitis, and Facial Contusion. Review of physician orders revealed a telephone order was received on 04/17/16, at 3:30 p.m., to change Patient #4's status from VC to 1:1.


Observation on 04/19/16 from 4:30 p.m. to 4:35 p.m. in the day room revealed Patient #4, who was ordered to be on 1:1 level of observation and being observed by S20MSS, did not remain in S20MSS' line of sight for 2 separate observations of approximately 20 seconds each when S20MSS was watching television. Patient #4 was not in the peripheral vision of S20MSS during these observations.

In an interview on 04/19/16, at 4:42 p.m., S2DON indicated she could see where distance precautions would be appropriate to implement for Patient #4.


In an interview on 04/19/16, at 4:50 p.m., S20MSS indicated 1:1 meant that the patient would be between 3 to 6 feet of the MHT at all times, and he had eye contact with the patient at all times. He confirmed that when he watched television, he couldn't see Patient #4 while he (Patient #4) was seated to his right, and the television was to his left.


Observation on 04/19/16, at 4:55 p.m., revealed Patient #4 was outdoors in the courtyard with S12MHT observing him 1:1. Further observation revealed S12MHT and Patient #4 walked toward the unit to re-enter the building with S12MHT walking with Patient #4 walking behind him (eye contact not maintained at this time). This observation was made in the presence of S2DON.


In an interview on 04/19/16, at 4:55 p.m., at the time of the above observation, S2DON indicated "it looks like we have work to do" (meaning re-education of staff regarding 1:1 observation of patients).


2) The RN failed to conduct a comprehensive nursing assessment of Patient #2 to include an assessment of vital signs, level of consciousness, and neurological status after Patient #2 was involved in a physical altercation on 04/03/16:


Review of the hospital-provided videotape of the altercation that occurred on 04/03/16, revealed Patient #2 had been punched in the face and head 12 times in 11 seconds by Patient #4. Patient #2 was observed to lie motionless on the floor for almost a minute after Patient #4 had been separated from Patient #2.


Review of Patient #2's medical record revealed Patient #2 had sustained a swollen left eye, right cheek, and upper lip in a physical patient to patient altercation on 04/03/16. Additional review revealed no documented evidence that Patient #2's neurological status, vital signs or level of consciousness had been assessed/evaluated after the altercation, for the duration of the shift. Review of the supplemental medical records revealed Patient #2 had been evaluated in the Medical Clinic on 04/04/16, and had been sent to the ED for evaluation, x-rays and treatment on 04/05/16. Patient #2 was also sent to an Eye Specialist on 04/11/16, for evaluation due to a previous history of having had surgery on both of his eyes.

In an interview on 04/19/16, at 11:04 a.m., with S10MHT, she indicated she had observed , through the window of the nurses station, Patient #2 appearing to "fly through the air" and when he landed on the floor he appeared to be "knocked out". She also indicated Patient #4 jumped on Patient #2 immediately after he was on the floor, unconscious. S10MHT said she called out to S8RN and told him 2 patients were fighting. S10MHT indicated it "took a little while for Patient #2 to come to from being out."


In an interview on 04/14/16, at 2:00 p.m., with S6Psychiatrist (Medical Director), he indicated when medical staff is called in the middle of the night their medical decisions are based on patient status as reported by the nurses. S6Psychiatrist said the medical staff usually err on the side of caution and send patients out to the ED for evaluation and treatment. S6Psychiatrist indicated if he had been told Patient #2 had been punched in the face and head 12 times he would have sent the pt. to the ED for evaluation.


In an interview on 04/14/16, at 2:30 p.m., with S5NP, she indicated she had been made aware of Patient #2's injuries from the altercation on 04/03/16 by a phone call. S5NP indicated the information reported to her regarding Patient #2's status/injuries had not appeared to be urgent in nature. S5NP further indicated the nurse (S8RN) reported the patient had no apparent damage in the eye, face area and was also told there was no loss in function. S5NP indicated if there was any loss of function she would have sent the patient out to the ED. S5NP indicated if she had been told the pt. had been punched 12 times in the face and head, she would have sent him out to the ED.

In an interview on 04/19/16, at 12:22 p.m., with S8RN he indicated he was on the night of the altercation between Patient #2 and Patient #4. S8RN said on 04/03/16, at approx. 9:45 p.m. he heard a tech yelling Patient #4 was hitting Patient #2 and Patient #2 was on the floor. S8RN said he saw Patient #2 face down on the floor and the Techs were standing around him. S8RN indicated he had not seen the altercation because he had been in the back of the nurses' station. S8RN said he called Patient #2's name. S8RN indicated Patient #2 was moving slowly with a small amount of blood on his lip, swelling under his right eye and on the brow of his left eye. He said he was told by the MHTs that the patient was unconscious, but when he rolled him over he was conscious with his eyes open. S8RN indicated the RN supervisor was notified of the incident as well as the MD/NP on call. S8RN indicated he had reported to S5NP that Patient #2 and Patient #4 had gotten into a physical altercation and Patient #2 had sustained injuries to his left eyebrow, under his left eye and had a small amount of blood on his lip. S8RN further indicated he had told S5NP the patient was conscious, up walking and talking. S8RN indicated he had not documented neurological checks, level of consciousness checks or vital signs. S8RN indicated Patient #2 was up walking and talking until midnight. He said he was, "the same old Patient #2", up and about, in and out of dayroom, so he didn't feel the need to initiate neurological checks . He indicated he had known Patient #2 had been hit in the face. S8RN said he guessed, based upon staff report of the patient being "out" that may have warranted initiation of neurological checks. He confirmed he had not reported to S5NP on call that staff had reported the patient had been "out" because when he turned him over the patient's eyes were open.

In an interview on 04/19/16, at 6:09 p.m., with S3Program Director, she confirmed she had spoken to Patient #2's sister regarding the injuries he had sustained in the physical altercation that had occurred on 04/03/16 between Patient #2 and Patient #4. S3ProgramDir indicated Patient #2's sister had been surprised and very upset to see her brother's injuries and "beaten up" appearance. S3ProgramDir indicated at that point when they all became aware that the patient was injured, the patient was sent out for assessment. S3ProgramDir said the assumption at that point had been that the nurse (S8RN) had done everything according to hospital policy and the physician had been notified. She indicated the patient had been seen in the medical clinic on 04/04/16. She said he was sent to the ED on 04/05/16, per his sister's request. She indicated this was a huge failure on the part of the nurse who was the weak link in the system and not a system breakdown.


3) The RN failed to assess and document the assessment of each patient exhibiting a change in condition related to exhibited behaviors that required the administration of PRN medications:


Review of the policy titled "Assessments", presented as a current policy by S2DON, revealed that reassessments are required when there is a significant change in patient's status, condition, or diagnosis.


Review of the hospital policy titled "Medication Administration", presented as a current policy by S2DON, revealed that PRN medications were to be documented on the MAR (medication administration record) with the date and time that the medication was given. The authorized RN/LPN must also document the reason for the administration of a PRN medication in the progress notes. Patient response to the PRN must be documented by the RN/LPN in the patient progress notes.


Patient #3

Review of Patient #3's physician's orders revealed an order on 01/21/16, at 3:15 p.m., for Zyprexa 10 mg (milligram) tablet, 1 tablet by mouth, every 8 hours PRN for agitation.


Review of Patient #3's MARs revealed he received one Zyprexa 10 mg tablet by mouth on 03/21/16 at 8:35 p.m., on 03/25/16 at 8:02 p.m., 03/28/16 at 8:14 p.m., and on 04/03/16 at 7:50 p.m., with no documented evidence of an assessment by the RN of the behaviors exhibited that warranted administration of the PRN medication and no documented evidence of an assessment of the patient's response to the medication.


Patient #4

Review of Patient #4's physician orders revealed orders dated 03/01/16 and 03/29/16 for Benadryl 50 mg, Haldol 5 mg, and Ativan 2 mg by mouth every 4 hours PRN agitation. Further review revealed the medications could be administered IM (intramuscularly) if the oral medication was refused.


Review of Patient #4's MARs revealed he was administered Benadryl 50 mg (orally), Haldol 5 mg (orally), and Ativan 2 mg IM at 2:17 p.m. on 03/01/16. Review of his RN Progress Note for the day shift (7:00 a.m. to 7:00 p.m.) of 03/01/16 revealed the "Comments" section had a notation of "B52 p.o." (by mouth), and the "Notes" section had documentation that read "Aggressive, poor concentration. Flat. He is currently laying down after attacking RN during interview (with) NP." There was no documented evidence of the time this note was written to determine that an assessment of his behavior was conducted at the time of the administration of PRN medications with an assessment of his response to the medication. Further review revealed Benadryl 50 mg, Haldol 5 mg, and Ativan 2 mg was administered by mouth on 03/02/16 at 8:00 p.m., on 03/04/16 at 10:55 a.m., on 03/24/16 at 8:12 p.m., on 03/26/16 at 8:00 p.m., on 03/29/16 with no documented evidence of the time they were administered, on 04/02/16 at 7:15 p.m., and on 04/04/16 at 8:10 p.m. with no documented evidence of an assessment by the RN of the behaviors exhibited that warranted administration of the PRN medication and no documented evidence of an assessment of the patient's response to the medication.


In an interview on 04/14/16, at 12:05 p.m., S2DON indicated the RN is supposed to document an assessment if the patient requires PRN medication. When informed that the hospital's policy doesn't read that the assessment with a change in condition needs to be conducted by a RN, S2DON indicated the policy should read that the assessment needs to be done by a RN.


In an interview on 04/19/16, at 1:00 p.m., S8RN indicated the role of the LPN is to give medications, do chart audits, and sometimes relieve the MHTs. He further indicated the LPN also gives PRN medications. S8RN indicated the LPN usually documents the behavior exhibited that warrants PRN medications. He further indicated he observes the patient before the LPN gives the PRN medication, but he doesn't document an assessment.


In an interview on 04/19/16, at 2:05 p.m., S14RN indicated the LPN is supposed to let the RN know a patient is agitated before giving PRN medication. She further indicated it's the RN who makes the decision to give a PRN medication. She further indicated there should be documentation by the RN of the patient's behavior exhibited when a PRN medication is given.


4) The RN failed to assess Patient wounds:

Review of the policy titled "Assessments", presented as a current policy by S2DON, revealed that reassessments are required when there is a significant change in patient's status, condition, or diagnosis and when there is a transfer from one program to another or to a different level of care.


Patient #1

Review of Patient #1's medical record revealed an order on 03/29/16, at 12:10 p.m., to send Patient #1 to the ED (emergency department) for pain and swelling to his lower extremities. Review of documentation from the hospital to which Patient #1 was transferred revealed "They state he has been having complaints of gradual onset, progressively worsening redness and swelling on BLE (bilateral lower extremities) 1 (times) 1 week, RLE > LLE (right lower extremity greater than left lower extremity. Denies fevers, constitutional symptoms. No prior history." Further review revealed Patient #1 was discharged from the acute care hospital on [DATE], with discharge instructions including keep legs elevated as tolerated, keep legs clean and dry, and apply ointment twice a day and finish the oral antibiotics as prescribed.


Review of Patient #1's RN Progress Notes from 03/15/16, to 03/28/16, revealed no documented assessment of leg pain, redness, or swelling. Review of the RN Progress Note of 03/29/16, revealed a note by S19RN of "taken to hospital for pain in lower legs." There was no documented evidence of an assessment by S19RN of patient #1's legs.


Review of Patient #1's RN Progress Note documented on 03/31/16, at 12:00 p.m. revealed Patient #1 was discharged from the acute care hospital, was on antibiotics, cream for Tinea Pedis, and was scheduled to be evaluated in the medical clinic on 04/01/16. There was no documented evidence of an assessment by a RN of Patient #1's legs for redness, swelling, tenderness, and warmth.


Review of Patient #1's evaluation from the medical clinic on 04/01/16 revealed his examination included "both lower extremities has swelling, redness, warm, and tenderness, the right lower leg is worse that the right (as written), both feet has tinea pedis infection between the toes." Bactrim DS by mouth was ordered for 10 days and Tinactin 1% (per cent) Cream to be applied to the affected area of both feet twice a day.


Review of the RN Progress Notes from 04/01/16 through 04/12/16, revealed no documented evidence of a RN assessment of Patient #1's legs for redness, swelling, tenderness, and warmth.


In an interview on 04/14/16, at 1:30 p.m., S2DON confirmed there was no documentation of a RN assessment of Patient #1's Cellulitis following his return from the acute care hospitalization and following days afterward.


Patient #5

Review of Patient #5's "Interdisciplinary Progress Notes" on 02/26/16, at 1:55 p.m., revealed he arrived with 3+ pitting edema bilaterally to the legs and a burn to the right foot. He was sent to the ED for evaluation. He returned to this hospital on [DATE], at 6:15 p.m., with a telephone order from S6Psychiatrist to apply Bacitracin ointment 15 grams to open blister three times a day for 1 week. A clarification order was received on 02/27/16, at 5:45 p.m., to wash the wound with mild soap and water once daily, apply antibiotic ointment to the burn twice a day, and apply non-stick bandage to wound and wrap and secure with Kerlix twice a day.


Review of Patient #5's medical visit documentation of S7MD on 03/07/16, at 4:51 p.m., revealed right foot on dorsal area has an open wound with surround tissue swelling, redness, and tenderness with no drainage. Further review revealed diagnoses of [DIAGNOSES REDACTED]% to affected area externally once a day and Augmentin tablet 875-125 mg, 1 tablet orally twice a day for 10 days.


Review of physician orders revealed an order from S5NP on 03/23/16, at 2:30 p.m., that included the following: apply Silvadene Cream 1% to burn area on top of right foot once daily. Keep area dry as possible. Apply non-adherent dressing to burn area after application of Silvadene 1% Cream and wrap with Kerlix. No Bandaid to burn area until seen by medical clinic and re-evaluated with orders to discontinue wound care therapy. There was no documented evidence of a physician's order to discontinue wound care to Patient #5's wound.


Review of Patient #5's RN admit assessment performed on 02/26/16, at 9:17 p.m., revealed he had a send degree burn to the right foot and bilateral lower extremity 3+ pitting edema. There was no documented evidence of an assessment by the RN that included measurement of the wound, the appearance of the surrounding tissue, and the presence or absence of drainage and odor.


Review of the RN Progress Notes and Interdisciplinary Progress Notes for Patient #5 revealed the following documentation related to the wound:

02/27/16, (day shift) with no documented evidence of the time the entry was written - dressing on foot when arrived;

02/27/16, (night shift) with no documented evidence of the time the entry was written - burn to right foot, dressing change per LPN;

02/28/16, (day shift) with no documented evidence of the time the entry was written - wound care "preformed" as ordered;

02/28/16, (night shift) with no documented evidence of the time the entry was written - burn to right foot, dressing change per LPN;

02/29/16, (night shift) with no documented evidence of the time the entry was written - top of right foot second degree burn, skin blistering/peeling; no drainage noted; no signs/symptoms of [DIAGNOSES REDACTED]

03/03/16, at 8:00 a.m. - patient refused antibiotic ointment and dressing change; notified charge nurse and NP;

03/06/16, (day shift) with no documented evidence of the time the entry was written - insisted foot be dressed a certain way, would not allow LPN to dress foot;

03/07/16, (day shift) with no documented evidence of the time the entry was written - burn wound looking "prurulent"; to medical clinic at 3:15 p.m. for evaluation and treatment of wound;

03/13/16, (day shift) with no documen
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 an individualized and comprehensive Master Treatment Plan for 4 (#1, #2, #3, #4) of 5 patient records reviewed for a comprehensive treatment plan from a sample of 5 patients.


Findings:


Review of the hospital's policy titled "Treatment Planning", presented as a current policy by S2DON, revealed that treatment planning shall be performed by an interdisciplinary treatment team led by the treating physician. The treatment plan is the collection of identified patient problems, based on findings from assessment/reassessment, and diagnostic testing, with related plan of care for each active problem. The Master Treatment Plan is to be completed within 72 hours for acute care admissions to the adult unit. The nurse in charge of the unit is responsible for the completion of the treatment plan. The treatment plan must be updated to reflect change in patient condition that includes newly diagnosed medical condition with ongoing treatment and precautions added for violence, suicide, and elopement. In these instances, the treatment plan is updated by a handwritten addition to the current treatment plan.


Review of the hospital policy titled "Assessments", presented as a current policy by S2DON, revealed that reassessments are required when there is a significant change in a patient's status, condition or diagnosis, and when there is a transfer from one program to another or to a different level of care. Further review revealed when a patient is transferred to another facility and is admitted to said facility for medical care, the hospital will complete an administrative discharge in the system that will be completed by the RN who is facilitating the medical transfer. The patient will not be clinically discharge from the hospital unless the attending psychiatrist determines that he/she can reasonably expect that the length of stay at the other medical facility will exceed 7 days /the legal commitment status expires prior to the 7 day period. Patients who are still clinically admitted to the hospital will not require readmission/reassessment. These statements are contradictory, as a need for admission to an acute care hospital for a medical issue and then to return to the psychiatric hospital is associated with a significant change in a patient's status and/or condition and a change in the level of care.


Patient #1

Review of Patient #1's master treatment plan revealed identified problems included altered thoughts, ineffective management of blood pressure, fatigue related to impaired metabolic status, and ineffective management of chronic pain related to right shoulder pain.


Review of Patient #1's medical record revealed an order on 03/29/16, at 12:10 p.m., to send Patient #1 to the ED (emergency department) for pain and swelling to his lower extremities. Review of documentation from the hospital to which Patient #1 was transferred revealed "They state he has been having complaints of gradual onset, progressively worsening redness and swelling on BLE (bilateral lower extremities) 1 (times) 1 week, RLE > LLE (right lower extremity greater than left lower extremity. Denies fevers, constitutional symptoms. No prior history." Further review revealed Patient #1 was discharged from the acute care hospital on [DATE], with discharge instructions including keep legs elevated as tolerated, keep legs clean and dry, and apply ointment twice a day and finish the oral antibiotics as prescribed.


Review of Patient #1's evaluation from the medical clinic on 04/01/16, revealed his examination included "both lower extremities has swelling, redness, warm, and tenderness, the right lower leg is worse that the right (as written), both feet has tinea pedis infection between the toes." Further review revealed diagnoses of [DIAGNOSES REDACTED]


There was no documented evidence that Patient #1's treatment plan was revised to include goals and interventions related to Cellulitis and Tinea pedis.


In an interview on 04/14/16, at 1:30 p.m., S2DON confirmed his care plan was not revised with the new diagnoses of [DIAGNOSES REDACTED]


Review of Patient #1's physician orders revealed he was Routine Precautions. Review of his RN Progress Note signed on 04/12/16, at 5:15 a.m., by S8RN revealed "client appeared to be compliant however he gave 3 pills to the 11p-7a MHT this a.m. and told her to "take these they are poisons." There was no documented evidence this was reported to the physician to obtain "cheeking precautions".


In an interview on 04/14/16, at 1:30 p.m., S2DON indicated when S8RN documented that Patient #1 gave 3 pills to the MHT, S8RN should have thought about cheeking, notify the physician, notify pharmacy, implement cheeking precautions, and revised the treatment plan. She further indicated "I'm speechless."


Review of Patient #1's medical record revealed he was transferred to the acute care hospital for evaluation of pain and swelling of the lower extremities on 03/29/16. He returned after hospitalization on [DATE], with diagnoses of [DIAGNOSES REDACTED]


Review of Patient #1's RN Progress Note of 03/31/16, revealed vital signs were documented at 12:00 p.m. with no documented evidence of a full assessment of Patient #1 that included an assessment of his lower extremities. Since treatment plans are based on reassessment, and no reassessment was conducted, Patient #1's treatment plan was invalid.


In an interview on 04/14/16, at 1:30 p.m., S2DON confirmed Patient #1's treatment plan should have been updated upon his return from an acute care hospitalization .


Patient #2

Review of Patient #2's medical record revealed an admission date of [DATE], with admission diagnoses of [DIAGNOSES REDACTED].


Review of hospital incident reports revealed documentation of a patient-to-patient physical altercation involving Patient #2 and Patient #4 that had occurred on 04/03/16. Further review revealed Patient #2 had initiated the altercation by striking Patient #4.


Review of Patient #2's Master Treatment Plan revealed no documented evidence that violent aggressive behavior had been addressed as an identified problem in Patient #2's Master Treatment Plan.


In an interview on 04/14/16, at 12:08 p.m., with S2DON, she confirmed Patient #2 had been involved in a physical altercation with Patient #4 on 04/03/16. She indicated Patient #2 had thrown the first punch in the altercation. S2DON reviewed Patient #2's Master Treatment Plan and confirmed violent aggressive behavior had not been addressed on the plan after the altercation on 04/03/16. S2DON agreed violent aggressive behavior should have been addressed in Patient #2's Master Treatment Plan. She indicated there is always room for improvement and maybe they should have done a better job.


In an interview on 04/19/16, at 12:22 p.m., with S8RN, he confirmed he had been working the night of the altercation between Patient #2 and Patient #4. He indicated Patient #2 could be aggressive and would antagonize other patients in an attempt to get them to lash out. S8RN confirmed he had not updated Patient #2's treatment plan to address the issue of aggression/violent behavior after the physical altercation between Patient #2 and Patient #4 on 04/03/16.


In an interview on 04/19/16, at 4:31 p.m., with S12MHT, he indicated Patient #2 is always in someone's face. S12MHT described Patient #2's behavior as aggressive and antagonistic toward staff and other patients. S12MHT indicated Patient #2 should have been placed on 1:1 Supervision or Visual Contact level of observation due to his behavior.


Patient #3

Review of Patient #3's medical record revealed he was sent to the acute care hospital on [DATE], for evaluation of low blood pressure, weakness, and increased disorientation. Review of his physician orders revealed an order on 01/19/16, at 3:50 p.m. to give medications (list of 6 medications) per discharge orders from the acute care hospitalization . There was no documented evidence of physician orders for diet and level of observation.


Review of Patient #3's RN Progress Note signed 01/19/16 (should be 01/20/16), at 4:30 a.m. revealed no documented evidence of a comprehensive assessment post hospitalization . Since treatment plans are based on reassessment, and no reassessment was conducted, Patient #3's treatment plan was invalid.


In an interview on 04/14/16, at 1:30 p.m., S2DON confirmed there was no documentation of a RN assessment of Patient #1's Cellulitis following his return from the acute care hospitalization and following days afterward. She indicated there should be documentation of an assessment of the patient upon their return from a hospitalization and the care plan should be updated.


Patient #4

Review of Patient #4's treatment plan revealed identified problems included altered thought, poor impulse control, ineffective management of blood pressure, and risk for infection related to [DIAGNOSES REDACTED].


Review of Patient #4's medical record revealed he was admitted on [DATE]. Review of his physician progress notes revealed the following documentation:

04/04/16, at 11:10 a.m., by S18NP - client remains unpredictable and violent in milieu; was in physical altercation with peer last night which client denies;

04/08/16 ,by S6Psychiatrist - continues to be extremely violent and labile and paranoid; actively attempt to hit staff and peers; has punched peers and staff in head and caused peer to go to hospital because he was violent;

04/11/16, at 11:40 a.m., by S18NP - client seen individually due to violent, unpredictable behavior.


Review of Patient #4's MHT Progress Note dated 04/03/16, revealed Patient #4 got into an altercation with Patient #2.


Review of the hospital's "Investigation Report" revealed on 04/03/16, at 9:42 p.m., Patient #2 punched Patient #4, who was on CSS level of observation, and Patient #4 chased Patient #2 and hit him (Patient #2) in the face multiple times.


There was no documented evidence that Patient #4's treatment plan was revised to include goals and interventions for aggressive, assaultive, and violent behavior.


In an interview on 04/14/16, at 12:08 p.m., with S2DON, she confirmed Patient #2 had been involved in a physical altercation with Patient #4 on 04/03/16. She indicated Patient #2 had thrown the first punch in the altercation. S2DON reviewed Patient #4's Master Treatment Plan and confirmed violent, aggressive behavior had not been addressed on the plan after the altercation on 04/03/16. S2DON agreed violent, aggressive behavior should have been addressed in Patient #4's Master Treatment Plan. She indicated there is always room for improvement and maybe they should have done a better job.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on record reviews and interviews, the hospital failed to ensure the RN assigned the nursing care of each patient to nursing personnel in accordance with the patient's needs and the qualifications and competence of the nursing staff available as evidenced by having documented evidence of counseling sessions with nurses related to performance of nursing duties with no documented evidence of retraining or re-education of the nurse and re-evaluation of competency for 2 (S8, S13) of 3 (S8, S9, S13) nursing personnel files reviewed.


Findings:


S8RN

Review of S8RN's personnel file revealed a "Corrective Action Form" was signed by S8RN and S9RNSup on 01/06/16. The section that read "This notice serves as (please check): verbal counseling, written counseling, performance improvement plan (PIP), suspension without pay, suspension with pay, final warning, termination" had no documented evidence that any of the boxes were checked. The infraction checked was tardiness and company policy violation. The description of events leading to corrective action included that S8RN "has been documented to have excessive tardiness with noted infractions on the following dates/times: 11/24 @ (at) 7:07 p.m.; 11/29 @ 7:04 p.m.; 12/3/15 @ 7:07 p.m.. Violation of Policy #HR.025." The section titled "Additional Counseling/Training Needed" was marked "Yes" and included "S8RN has been provided review of NBHS (initials of hospital) Policy #HR.025 and has identified area for improvement as it relates to time and attendance. Review of the section titled "Performance Improvement Plan (PIP) has "Yes; S8RN will be monitored for 90 days, at which time he will be observed for timely arrival for scheduled shifts and the effectiveness of completing all nursing duties per his job description. It is with understand that failure to display compliance with policy #HR-025 can lead to further disciplinary actions."


Review of S8RN's "Job Description Evaluation", signed by S8RN and his supervisor on 02/10/16 and S17HR on 01/31/16, revealed his score for "Nursing Duties" was a "6" out of "10" available points (key for performance rating was 1 to 5, with 1 being unacceptable and 5 being outstanding) with comments of "poor time management and completion of nursing duties (charting, report, updates)"; his score for Communication and Professionalism was "3" (meets full requirements) with comments of "incomplete hand off communication"; his score for Admissions and Discharges of Patient was "3" with comments of "incomplete process of admitting and discharging patients"; his score for Medication Management was "3" with comments of "ineffective management of orders to date"; his score of for Physician Orders was "2" (needs improvement) with comments of "non-compliance with OTD (order to date) procedure/policy"; Tardiness score was "0" ("0" was not a score on the performance key; lowest score was "1") with comments of suspension and PIP for being tardy (list of 29 days from 01/21/15, to 12/03/15).


Review of the "Attestation Statement: RN, LPN, and Nursing Employees" signed by S8RN on 03/26/16, revealed the statement of "I certify that I reviewed and understand the information on the below listed sections and completed necessary competency evaluation as necessary. I had the opportunity to ask and receive answers to any questions related to this information. I have completed my annual training test and competencies that are required for 2016. There was no documented evidence of a competency evaluation other than S8's self-assessment of competency.


Review of S8RN's personnel file revealed no documented evidence of retraining or re-education of nursing care issues identified in his performance evaluation completed on 02/10/16.


Review of S8RN's personnel file revealed an "Acute/Residential RN, RNS (RN Supervisor), and LPN Competency and Skills Verification", "All Staff Age-Related Competency Verification", and "Nursing Basics Competency and Skills Verification" was completed on 04/17/16, and 04/18/16, by S16RN (5 days after the current survey had begun and 67 days after his need for improvement had been identified).


In an interview on 04/19/16, at 1:15 p.m., S8RN indicated he wasn't suspended in January when his corrective action form was done. When asked if he had any retraining after his performance evaluation was reviewed with him that identified nursing care issues, S8RN indicated he only had a review of the orders to date policy. He further indicated he did not receive any retraining until 04/17/16, when his PIP follow up was done.


In a telephone interview on 04/19/16, at 5:20 p.m., S16RN Manager indicated suspension is part of the policy for tardiness, but she didn't know if he had been suspended or maybe was already scheduled to be off at the time. She further indicated when S8RN returned after he returned from his time off at that time, she monitored him by performing chart audits and found no further problems, so his file was closed at that time (referring to the corrective action). S16RN Manager offered no explanation when told that review of S8RN's personnel file revealed no documented evidence of monitoring or chart audits conducted by S16RN Manager.


In an interview on 04/19/16, at 5:55 p.m., S17HR indicated annual evaluations are written in December, and she requests a PIP for any employee who scores a "2" or "3" on their evaluation. She further indicated S8RN was to be monitored for 90 days and re-evaluated after his corrective action was done on 01/06/16. After reviewing S8RN's personnel file, S17HR confirmed there was no documented evidence of retraining or competency evaluation after his performance evaluation was done on 02/10/16 until the surveyors arrived.


S13LPN

Review of S13LPN's personnel file revealed a "Corrective Action Form" was signed by S9RNSup on 03/07/16, with S13LPN initialing that she refused to sign the form on 03/07/16. Further review revealed it was a written counseling for the dates of 08/24/15, and 09/07/15, for medication errors for the 3rd quarter of 2015. The description of events leading to the corrective action included the following: "Upon medication audit it was found that on 08/24/15 @ 7:43 p.m. and 09/07/15 @ 8:00 p.m., S13LPN failed to follow policy and procedure related to Medication Administration Violation of Policy #NS.5048. Neither box of "yes" or "no" was checked next to the question of whether additional counseling/training was needed. Next to Performance Improvement Plan (PIP) was "N/A" (not applicable).


Review of S13LPN's personnel file revealed a "Corrective Action Form" was signed by S9RNSup on 03/07/16 with S13LPN initialing that she refused to sign the form on 03/07/16. Further review revealed it was a written counseling for the dates of 04/06/15, for medication error for the 2nd quarter of 2015. The description of events leading to the corrective action included the following: "Upon medication audit it was found that on 04/06/15 @ 7:00 p.m., 06/29/15 # 8:01 p.m., and 06/30/15 @ 4:03 a.m. S13LPN failed to follow policy and procedure related to Medication Administration Violation of Policy #NS.5048. Neither box of "yes" or "no" was checked next to the question of whether additional counseling/training was needed. Next to Performance Improvement Plan (PIP) was "N/A."


Review of S13LPN's "Job Description and Evaluation: LPN - Medication Nurse", signed by S13LPN and S9RNSup on 03/07/16, and by S17HR on 01/31/16, revealed S13LPN was scored with a "3" (meets full requirements) or "4" (very good) in all areas being evaluated that included transcribing medication orders, faxing a copy of medication orders to the pharmacy and placing them in the pharmacy box, and transcribing all non-medication orders according to protocol completing all required forms and notifications.


Review of S13LPN's personnel file revealed no documented evidence of retraining or re-education related to the identified medication administration violations.


In a telephone interview on 04/19/16, at 4:52 p.m., S13LPN indicated counseling occurred sometimes last year regarding medication administration, but she wasn't provided any documentation of the counseling. She doesn't remember the details of it. When asked if she received any re-training or re-education after having been counseled regarding medication administration issues, she answered "no, they don't do that over there." She further indicated one of the counseling's was over a year old when it was presented to her, and she thought if it was important enough to write up, why would they wait a year to address it.