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.

COVINGTON BEHAVIORAL HEALTH 201 GREENBRIER BLVD COVINGTON, LA Nov. 29, 2011
VIOLATION: MEDICAL STAFF - APPOINTMENTS Tag No: A0046
Based on record review and interviews, the governing body failed to: 1) ensure temporary privileges were granted according to the medical staff bylaws for 1 of 1 physician with temporary privileges from a total of 6 credentialed physicians (S21) and 2) ensure the nurse practitioner had been credentialed and privileged by the governing board for 1 of 2 nurse practitioners' files reviewed from a total of 2 nurse practitioners at the hospital (S19). Findings:

1) Ensure temporary privileges were granted according to the medical staff bylaws:
Review of Physician S21's credentialing file revealed he submitted a "Louisiana Standardized Credentialing Application" on 10/10/11, 3 days after he had been granted temporary privileges (bylaws required receipt of an application prior to granting temporary privileges). Review of a letter dated 10/07/11 addressed to Physician S21 and signed by Administrator S1 revealed, in part, "... This letter is to inform you that you have been granted temporary privileges for a period of 90 days during administrative processing of your Application for Staff Appointment and Privileges...". Further review revealed no documented evidence that a request for clinical privileges had been submitted with an application as required by the medical staff bylaws prior to granting temporary privileges. Further review revealed no documented evidence of written concurrence of the Medical Executive Committee to grant temporary privileges to Physician S21 as required by the medical staff bylaws.

Review of S21's "Medical Staff Initial Appointment Approval Sheet" revealed, in part, "...The application for appointment to the Medical Staff of Greenbrier Behavioral Health as submitted to the Medical Executive Committee has been reviewed and it is our recommendation to the Governing Board that the application be considered as follows: Action Favorable (box not checked) Unfavorable (box not checked)... The application for Clinical Privileges has been carefully reviewed by the Medical Executive Committee, applying established criteria. We find that the Practitioner's request for clinical privileges meets (box not checked) / does not meet (box not checked) criteria... Favorable (box not checked) Unfavorable (box not checked)". Further review revealed the recommendation for appointment was signed by Medical Director S27 on 10/14/11. Further review revealed no documented evidence of the date that the governing board representative signed the form. Further review revealed Medical Director S27 signed the recommendation for privileges on 10/14/11, and there was no documented evidence of the date that the governing board representative signed the form. There was no documented evidence that a request for clinical privileges had been submitted by Physician S21.

Review of the "Medical Staff Bylaws", approved 11/30/07 and submitted by Administrator S1 as the current copy of the bylaws, revealed, in part, "...Article V - Delineation of Clinical Privileges Section 1: Criteria Each initial application for Staff appointment must contain a request for the specific privilege desired by the applicant. The initial determination as to clinical privileges shall be based upon the applicant's education and training, demonstrated competence and references. ... Each Medical Staff member shall exercise only those clinical privileges specifically granted to him/her by the Medical Staff and the Board... Section 5: Temporary and Emergency Privileges Upon written concurrence of the Medical Staff/Medical Executive Committee, temporary and emergency privileges may be granted by the Chief Executive Officer (Hospital Administrator) of the Hospital after the receipt of an application for Staff appointment, including a request for specific temporary privileges, an appropriately licensed practitioner (MD) may be granted temporary privileges for a period of time not to exceed 90 days...".

In a face-to-face interview on 11/29/11 at 10:10am, Human Resources and Medical Staff Credentialing Director S23 confirmed Physician S21's application was dated after the date of his temporary privileges being granted. S23 further confirmed there was no request for clinical privileges in Physician S21's credentialing file. S23 further confirmed that Physician S21's initial appointment to the medical staff was approved by Medical Director S27 and the governing board representative without having reviewed and approved S21's clinical privileges.

2) Ensure the nurse practitioner had been credentialed and privileged by the governing board:
Review of Nurse Practitioner S19's credentialing file revealed no documented evidence of a collaborative practice agreement with Physician S21. Further review revealed no documented evidence that S19 had requested clinical privileges and no documented evidence that her appointment and clinical privileges had been recommended by the Medical Executive Committee and approved by the Governing Board.

In a face-to-face interview on 11/29/11 at 7:40am, Administrator S1 indicated it was her understanding that Nurse Practitioner S19 had been appointed and privileged by the governing body, and she couldn't explain why the signature form was not in her (S19) credentialing file. S19 further indicated she would obtain the Allied Health Professional Policy and Procedure Manual for review. The Allied Health Professional Policy and Procedure Manual was not presented as of the time of the completion of the survey.

In a face-to-face interview on 11/29/11 at 10:10am, Human Resources and Medical Staff Credentialing Director S23 indicated Nurse Practitioner S19's collaborative agreement was supposed to be sent to her by Physician S21's office staff, but she had not received it. S23 indicated Nurse Practitioner S19 was working under Physician S21 and had not been credentialed. S23 could offer no explanation for one nurse practitioner (S18) being credentialed and privileged and S19's credentialing and privileging not being conducted in the same manner.

Review of the "Medical Staff Bylaws", approved 11/30/07 and submitted by Administrator S1 as the current copy of the bylaws, revealed, in part, "...Article XII - Allied Health Professionals The Medical Executive Committee, subject to approval of the Board, shall adopt an Allied Health Professional Policy and Procedure Manual. The Allied Health Professional Policy and Procedure Manual shall relate to the proper conduct of Allied Health Professional Staff organizational activities as well as embody the level of practice that should be required of each Allied Health Professional in the Hospital...".
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, record review, and interviews, the hospital failed to meet the Condition of Participation for Patient Rights as evidenced by:

Failing to provide services to meet the safety needs of patients as evidenced by Patient #2 choking himself by tying a rolled paper scrub top around his neck while under ordered modified visual contact (MVC) that was not implemented and Patient #2 eloping from the hospital grounds by jumping over a 6 foot wooden fence while ordered to be on one-to-one (1:1) observation and being left in the outdoor area observed by one mental health tech (MHT) who was responsible for the observation of another 1:1 patient and 8 other patients (see findings in tag A0144).

Hospital Administrator S1 and Corporate Director of Inpatient Services S13 were notified on 11/23/11 at 1:00pm of an immediate jeopardy situation. The immediate jeopardy situation was a result of the hospital failing to provide services to meet the safety needs of patients as evidenced by Patient #2 choking himself by tying a rolled paper scrub top around his neck while under ordered modified visual contact (MVC) that was not implemented and Patient #2 eloping from the hospital grounds by jumping over a 6 foot wooden fence while ordered to be on one-to-one (1:1) observation and being left in the outdoor area observed by one mental health tech (MHT) who was responsible for the observation of another 1:1 patient and 8 other patients.

A plan of removal developed by Administrator S1, Corporate Director of Inpatient Services S13, and Corporate Compliance Officer S14 was (MDS) dated [DATE] at 3:45pm. Review of the plan of removal revealed the following:
1) Prior to the evening shift of 11/23/11, all present staff were educated on the observation levels (1:1, VC, MVC, SO) with a review of unit restrictions. Staff were informed that any violation of observation levels will result with disciplinary action up to and including termination. Disciplinary action was conducted with Administrator S1, Director of Nursing S2, and a MHT based on the incident identified.
2) The above education was completed with all staff prior to the start of the following night and day shifts. All staff will be required to complete the training by 12/02/11, and no staff will be allowed to work on any unit without the training and completion of a written observation test. The Administration team consisting of the Administrator, Director of Nursing, Assistant Director of Nursing (DON), Compliance Officer, Director of Social Services, and the scheduler will be responsible for completion of the staff education.
3) Beginning on the evening shift of 11/23/11 and continuing daily, the observation logs on all units were checked by Administration to ensure that they were completed correctly.
4) Random observations on each shift were performed by Administration to ensure that observation levels, the acuity sheet, and the assignment sheets were completed correctly.
5) An Acuity and Staffing Monitor tool was created to audit for observation logs, acuity sheets, and assignment sheets. This tool will be completed each shift daily by Administration for 3 months; if after 3 months 100% (per cent) compliance is met, the audit will be performed weekly for an additional 3 months. After completion of the second 6 month period, if 100% compliance is achieved, ongoing monthly monitoring will be conducted.
6) Monthly compliance data of the daily Acuity and Staffing Monitor tool will be added to both the Performance Indicator and Risk Management reports.
7) A Levels of Observation and Acuity test was developed and administered to the unit staff by the DON. Staff must score 100% on the test prior to being allowed to work. All staff will have completed the test by 12/02/11. The test will be added to all New Hire paperwork and re-orientation which occurs annually.
8) A "quick view" of observation levels was created by the DON and Assistant DON and distributed to all staff and was posted in the nursing stations, the medication room, and attached to the observation clipboards.
9) The following forms were revised: a) changed observation log to include that the RN must sign it every 6 hours; b) changed the Unit Assignment Sheet to reflect observation levels with staffing and duties assigned (all nurses were educated at an in-service on 11/28/11); c) changed the Acuity Staffing sheet to reflect a change in observation level, staffing pattern if needed, time of 1:1 start and end, and added the number of unit restrictions(all RNs and LPNs were trained on all new forms at a mandatory meeting on 11/28/11; any staff not present at the meeting will be trained by 12/02/11, and no staff will be able to work their shift until the training is completed).
10) Education by the DON and the Assistant DON was completed at an in-service meeting on 11/28/11 that included a review of the following policies and procedures: Elopement risk and precautions; Levels of Observation-Therapeutic Safety Measure; Assessing/Tracking of Client Acuity. This review will occur at every staff in-service meeting for the next 3 months.
11) Administration and Corporate Staff will add the number of elopements and the acuity and staffing monitor tool data to the Performance Improvement and Risk Management reports for tracking. All such reports are reviewed quarterly at Corporate Board meetings.
12) A Root Cause Analysis will be conducted within 72 hours of all sentinel events which will be followed up with a Plan of Action to correct any identified problems in the analysis. This will be completed by Administration.
13) Incident reports will be reviewed to ensure documentation of any incident. All staff involved with a sentinel event will provide a written statement and documentation. This will be overseen by Administration.

On 11/28/11 at 3:45pm, Administrator S1, Corporate Director of Inpatient Services S13, and Corporate Compliance Officer S14 were notified that the Immediate Jeopardy was lifted. Condition level non-compliance remained for the Condition of Participation for Patient Rights.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, record review, and interviews, the hospital failed to ensure the patients received care in a safe setting as evidenced by: 1) failure to provide services to meet the safety needs of patients as evidenced by Patient #2 choking himself by tying a rolled paper scrub top around his neck while under ordered modified visual contact (MVC) that was not implemented and Patient #2 eloping from the hospital grounds by jumping over a 6 foot wooden fence while ordered to be on one-to-one (1:1) observation and being left in the outdoor area observed by one mental health tech (MHT) who was responsible for the observation of another 1:1 patient and 8 other patients; 2) having an outdoor patient area (used to have patient functions) that was accessible from a locked door leading from the cafeteria with a folded chair leaning against the building next to a 6 foot wooden fence that presented a means for patients to elope and having the wooden fence with a locked double gate that had wooden support boards criss-crossed across the gate that presented a means of the climbing the gate to elope; 3) having the outdoor area of Unit A surrounded by a 6 foot wooden fence to the right and back boundary and a leaning 6 foot chain link fence to the left boundary that was leaning forward and able to be shaken and moved using one hand; having a large patch of overgrown bushes to the right of the exit door and near the fence that presented a means of hiding from the view of the staff; having a 6 foot chain link fence 32 feet from the left of the exit door that surrounded a swimming pool filled with 5 feet of stagnant water and pine needles; 4) having the outdoor area accessible to Units B and C surrounded by a 6 foot chain link fence with multiple areas covered by overgrown trees and brush that presented a means for patients to hide; having the outdoor area accessible to 4.73 acres of wooded walking area surrounded by 1358 feet of walking trail that could be used by patients as a means of hiding; having a sidewalk to the right of the exit door of Unit C (and accessible to Unit B) leading to a 6 foot chain link fence that surrounded a swimming pool filled with 5 feet of stagnant water and pine needles; 5) having long electrical, printer, computer, or internet cords in areas accessible to patients that could be used as a means of strangulation; 6) having unlocked offices and cabinets accessible to patients that contained paint, scissors, heavy 2 foot metal rod, and a metal drawer divider that could be used as weapons against others or to injure oneself; and 7) having an unlocked supply closet that contained equipment and hazardous chemicals. Findings:

1) Failure to provide services to meet the safety needs of patients as evidenced by Patient #2 choking himself by tying a rolled paper scrub top around his neck while under ordered modified visual contact (MVC) that was not implemented and Patient #2 eloping from the hospital grounds by jumping over a 6 foot wooden fence while ordered to be on one-to-one (1:1) observation and being left in the outdoor area observed by one mental health tech (MHT) who was responsible for the observation of another 1:1 patient and 8 other patients:
Review of Patient #2's "Physician Admit Orders & (and) Preliminary Tx (treatment) Plan dated 11/11/11 at 1300 (1:00pm) and received by verbal order to RN (registered nurse) S15 from Physician S17 revealed the admitting diagnosis was Mood Disorder. Further review revealed the ordered observation level was modified visual contact (MVC) due to "suicidal, homicidal &/or violent behaviors".

Review of Patient #2's medical record revealed he had an order for protective custody signed 11/10/11 at 7:46pm, he had a PEC (physician emergency certificate) signed on 11/11/11 at 8:09am due to being gravely disabled, and he had a CEC (coroner's emergency certificate) signed on 11/13/11 at 11:17am due to being dangerous to self and gravely disabled.

Review of Patient #2's "Nursing Progress Note" dated 11/11/11 at 1600 (4:00pm) by RN S15 revealed, in part, "Client was in room alone. MHT S16 was @ (at) nurses' desk & looked up to see pt (patient) walking around in room (with) gown around neck. MHT ran into room & removed gown from pt's neck. Pt was cyanotic, responsive, had bright red blood in mouth..." Further review of an entry by RN S15 on 11/11/11 at 1605 (4:05pm) revealed "Nurse Practitioner S18 on unit and notified of incident. Client placed on 1:1 for safety".

Review of Patient #2's "Nursing Admission Assessment" documented by RN S15 revealed Patient #2 was admitted on [DATE] at 3:00pm, and she began his assessment at 3:30pm. Review of Patient #2's "Observation Log" revealed MHT S16 documented Patient #2 was cooperative, awake, and in the dayroom from 3:00pm through 3:45pm, and he (#2) was in his room cooperative, in his room, and awake from 4:00pm through 4:30pm.

Review of Patient #2's "Physician Orders - Routine" revealed a telephone order received by RN S15 from Nurse Practitioner S18 to "place patient on 1:1 for safety (after) patient found (with) gown around his neck".

In a face-to-face interview on 11/23/11 at 8:20am, RN S15 confirmed she performed Patient #2's admission assessment and was responsible for his care after his admission until the end of the shift. S15 indicated after Patient #2's skin assessment and contraband search were completed, he was brought to his room for her to complete her nursing assessment. S15 further indicated she completed Patient #2's nursing assessment, evaluated him (#2) to determine if he was suicidal and determined that he was not suicidal, and left Patient #2's room with the door to the room left open. S15 further indicated MHT S16 was sitting at the nursing station, looked up, and saw Patient #2 in his room with something around his neck. S15 further indicated MHT S16 ran in Patient #2's room and noted that he (#2) had a paper scrub tied tightly around his neck, and he (#2) was cyanotic but always responsive. RN S15 indicated that MVC meant the patient had to be in the line of sight of a staff member at all times. S15 further indicated MHT S16 could see Patient #2 when he walked to the foot of the bed, but S16 could not see all areas of the room while seated at the nursing station. S15 confirmed that hospital policy was not followed related to MVC when Patient #2 strangled himself.

In a telephone interview on 11/23/11 at 9:10am, MHT S16 indicated at the time of Patient #2's strangulation, he (S16) was observing two other patients who were ordered to be on 1:1, and he had not received extra help to perform these observations. S16 further indicated while he was with another patient down the room from the nursing station, he went to the nursing station to answer a ringing telephone. S16 further indicated as he hung up the telephone, he saw Patient #2 in his room with something around his neck. MHT S16 indicated he went into Patient #2's room and unwrapped the scrub tie from his neck. S16 further indicated Patient #2 was "very blue and purple, coughed up blood, had blood in his eyes, but never lost consciousness".

Review of the "Assignment Sheet" dated 11/11/11 from 7:00am to 7:00pm revealed no documented evidence Patient #2 was assigned to a MHT for observation from the time of admission through the end of the shift, when he was first to be observed as MVC and then 1:1.

Review of Patient #2's "Nursing Progress Note" dated 11/12/11 at 1730 (5:30pm) and documented by RN S12 revealed, in part, "...able to contract for safety to go to meals in cafeteria & outside to smoke; However @ smoke break (after) lunch, pt ran & 1240 (12:40pm) jumped over fence, headed to Hwy (highway) 21 & went into wooded area; 911 called police were able to apprehend pt & bring him back to unit. 11/12/11 1320 (1:20pm) pt returned to unit at 1310 (1:10pm)...".

Review of Patient #2's "Observation Log" dated 11/12/11 revealed MHT S9 documented Patient #2 was cooperative, in his room, and awake at 12:30pm. Further review revealed the next documentation at 12:45pm and 1:00pm revealed "eloped". There was no documented evidence that Patient #2 had been taken outdoors for a smoke break.

In a face-to-face interview on 11/22/11 at 11:10am, Administrator S1 confirmed no staff was assigned to Patient #2 according to the assignment sheet for 11/11/11. She indicated a MHT can't observe more than one patient when assigned to observe a patient 1:1. After review of the assignment sheets for 11/11/11 and 11/12/11, Administrator S1 confirmed the number of staff assigned the observation of patients was not adequate to provide the ordered observations. S1 further indicated the assignment was not being done correctly by the RN.

In a face-to-face interview on 11/22/11 at 1:10pm, MHT S9 indicated she observed Patient #2 on 11/12/11 from 7:30am to 7:00pm. She further indicated when outside for the smoke break, 4 patients were seated next to the wall, 3 patients were seated at the picnic table under the canopy, one patient was seated at the table around the corner, and Patient #2 began to walk away from the covered area. S9 further indicated there were about 10 patients outside with 2 MHT's. S9 indicated when the cigarette lighter she was using to light the patients' cigarettes failed to work, she went inside the hospital to get another lighter. S9 further indicated while MHT S10 was left to observe 10 patients, one of whom was 1:1 (Patient #2), Patient #2 jumped the fence. MHT S9 indicated 1:1 observation meant the staff had to be within arm's length of the patient and able to visually see the patient at all times. S9 confirmed she did not follow hospital policy for the observation of Patient #2 1:1 when he eloped.

In a face-to-face interview on 11/22/11 at 1:40pm, MHT S10 indicated he remembered Patient #2's elopement. S10 further indicated he didn't remember how many patients were outside at the time of the elopement, but he did confirm he (S10) was alone outside with Patient #2 who was ordered to be on 1:1 and other patients.

Review of the "Assignment Sheet" for 11/12/11 for 7:00am to 7:00pm revealed MHT S10 was assigned the observation of one 1:1 patient, 3 patients on MVC, and 2 patients on special observation. Further review revealed MHT S9 was assigned the observation of Patient #2 1:1, assisted with the 1:1 observation of another patient, 3 patients on special observation, and 2 patients on MVC.

In a face-to-face interview on 11/22/11 at 4:55pm, MHT S9 confirmed she was responsible for observing Patient #2 1:1 when he eloped. S9 further indicated she was also assigned the observation of 5 other patients and assistance with observing another patient 1:1. MHT S9 indicated she should not be observing other patients when she was assigned to observe a patient 1:1, but "when you're short-staffed, you do the best you can do".

In a face-to-face interview on 11/22/11 at 5:10pm, MHT S10 indicated he could not observe a patient 1:1 while observing 5 other patients, and he couldn't observe 2 patients who were 1:1 while on a smoke break with 8 other patients.

Review of the hospital's incident report log from 01/11 through 10/11 and the November incident reports revealed the following: elopement by Patient #2 on 11/12/11 from Unit A; attempted elopement on 11/02/11 at 1:15pm from Unit C; elopement on 08/11/11 at 8:45pm from Unit B; attempted elopement on 08/13/11 at 10:00pm; elopement on 07/16/11 at 5:20pm from Unit A; elopement on 05/05/11 at 1:35pm from Unit A; and elopement on 01/04/11 from Unit B at 12:18pm.

Review of the hospital policy titled "Levels of Observation - Therapeutic Safety Measures", effective 09/01/03, revised 05/28/10, and submitted by Administrator S1 as their current observation policy, revealed, in part, "I. Purpose To provide a consistent, therapeutic approach to ensure a safe environment for the patients within the facility. ... III. Procedure A. The following levels of observation are approved for utilization when clinically indicated: 1. Special Observation (S.O.) a. Location of patient is known at all times. The patient is observed with visual checks every 30 minutes documented on flow sheet. 2. Visual Contact (V.C.) a. The patient must be in sight of a staff member at all times and documented every 15 minutes on flow sheet. b. Patients placed on V.C. status must have a physician's order. ... d. The following precautions must have a V.C. status ordered: Suicide Precautions Fall Precautions Homicidal Precautions 3. One-to-One Nursing Care a. One-to-one nursing care is where a staff member is assigned to a patient to care for them in constant attendance at all times. A complete visual of the patient, from head to toe, is required. Documentation occurs every 15 minutes. The staff member must be within arms length of the patient at all times. b. Patients on 1:1 status must have a physician's order. ... d. The following criteria indicates the need for a 1:1 status: 1) The patient is actively suicidal or homicidal and requires staff constant intervention to maintain safety... 4. Modified Visual Contact (M.V.C.) a. The patient is observed within line of sight of staff during all waking hours, with documentation on location graph every 15 minutes. b. The patient is allowed to sleep in his/her room at night with door ajar. Staff checks patient every 15 minutes and documents checks on location graph. c. All patients admitted to the inpatient acute units are on MVC status unless on another indicated level. ... F. All 1:1 status patients are to be assigned to a staff member, as well as all other levels of observation as indicated on assignment sheet...".

2) Having an outdoor patient area (used to have patient functions) that was accessible from a locked door leading from the cafeteria with a folded chair leaning against the building next to a 6 foot wooden fence that presented a means for patients to elope and having the wooden fence with a locked double gate that had wooden support boards criss-crossed across the gate that presented a means of the climbing the gate to elope:
Observation on 11/21/11 at 2:30pm revealed an outdoor area accessed by a locked door leading from the cafeteria. Further observation revealed area to the right of the door located by the air conditioning unit had a folding chair propped against the building that could be used by patients to climb over the 6 foot wooden fence that was about 3 feet from the chair. Further observation of the area revealed the large double locked wooden gate had criss-crossed boards across each gate that could provide a step for patients to use to climb the 6 foot wooden fence attached to the gates.

In a face-to-face interview during this observation on 11/21/11 at 2:30pm, Administrator S1 indicated this area was used at times to hold functions with the patients and staff. S1 confirmed the chair located near the fence could be used by a patient to climb the fence, as well as the boards across the gate.

3) Having the outdoor area of Unit A surrounded by a 6 foot wooden fence to the right and back boundary and a leaning 6 foot chain link fence to the left boundary that was leaning forward and able to be shaken and moved using one hand; having a large patch of overgrown bushes to the right of the exit door and near the fence that presented a means of hiding from the view of the staff; having a 6 foot chain link fence 32 feet from the left of the exit door that surrounded a swimming pool filled with 5 feet of stagnant water and pine needles:
Observation on 11/21/11 at 4:40pm of the outside area used for smoke breaks for patients on Unit A revealed a covered area immediately upon exiting the building. Further observation revealed around the right corner of the building was a picnic table that could not be seen when one was standing under the covered area. Further observation revealed a large patch of overgrown bushes in the outside area that blocked full view of the area. Observation revealed to the left of the covered area was a sidewalk surrounded on one side by the building and the other side by a 6 foot chain-link fence surrounding a swimming pool that was filled with 5 feet of stagnant water with pine needles. The entire length of the sidewalk could not be viewed when one was standing under the covered area. Further observation revealed the 6 foot wooden fence to the left of the outside area was leaning and could be moved by using one hand.

Observation on 11/21/11 at 4:40pm of the outside area of Unit A revealed 11 patients were on smoke break with one MHT assigned to observe.

In a face-to-face interview on 11/21/11 at 4:45pm, Administrator S1 confirmed that having one MHT observing 11 patients presented a severe elopement risk.

4) Having the outdoor area accessible to Units B and C surrounded by a 6 foot chain link fence with multiple areas covered by overgrown trees and brush that presented a means for patients to hide; having the outdoor area accessible to 4.73 acres of wooded walking area surrounded by 1358 feet of walking trail that could be used by patients as a means of hiding; having a sidewalk to the right of the exit door of Unit C (and accessible to Unit B) leading to a 6 foot chain link fence that surrounded a swimming pool filled with 5 feet of stagnant water and pine needles:
Observation of the outdoor area used for patient smoke breaks on Unit B and accessible to patients from Unit C on 11/21/11 at 3:20pm revealed a covered gazebo upon exiting the building that was situated on elevated land. Further observation revealed that after walking approximately 235 feet was a 6 foot chain link fence with multiple areas covered with overgrown trees and brush that presented a means for patients to hide. Further observation revealed a 32 foot fallen tree that was propped on one end on the ground and one end on the fence that provided a walking path for a patient to walk and climb over the fence to elope. Further observation of the area revealed access to 4.73 acres of wooded walking area (measurements provided by Environment of Care Director S6) surrounded by 1358 feet of walking trail. These observations were made with Administrator S1 present.

Observation of the outdoor area used by patients on Unit C on 11/21/11 at 4:20pm revealed a sidewalk to the right of the exit door leading to a 6 foot chain link fence that surrounded a swimming pool filled with 5 feet of stagnant water and pine needles.

In a face-to-face interview on 11/21/11 at 4:20pm, Environment of Care Director S6 indicated he had been employed at the hospital for 2 years, and to his knowledge, the pool had always contained water. S6 measured the depth of the water in the pool during this interview.

5) Having long electrical, printer, computer, or internet cords in areas accessible to patients that could be used as a means of strangulation:
Observation of the gym on 11/21/11 at 1:50pm with Administrator S1 present revealed plastic liners used for trash receptacles in the gym and the bathrooms, a wall telephone with approximately 5 feet of plastic cord hanging and a spiraled cord to the handset that could be used for strangulation.

Observation of the activity therapy room on 11/21/11 at 2:00pm revealed an unlocked closet that contained 5 shelves filled with paint and supplies and a large black container without a label designating the contents within. During the observation Administrator S1 indicated the cabinet should be locked. Further observation revealed long electrical cords hanging from the stereo.

6) Having unlocked offices and cabinets accessible to patients that contained paint, scissors, heavy 2 foot metal rod, and a metal drawer divider that could be used as weapons against others or to injure oneself:
Observation on 11/21/11 at 2:00pm revealed an unlocked staff member's office that could be accessed from the activity therapy room. Inside the office was a printer, computer, and internet electrical cords, plastic liners in the trash receptacle, a pair of scissors on the desk, and an unlocked cabinet containing 8 long cords, a 2 foot metal rod, and a 2 foot by 1 1/2 inch heavy flat rod and a flat metal drawer divider, all which could be used as weapons against patients or a means to hurt oneself. These observations were confirmed by Administrator S1.

7) Having an unlocked supply closet that contained equipment and hazardous chemicals:
Observation on 11/21/11 at 2:10pm revealed an unlocked supply closet that contained the following:
a) popcorn machine with electrical cord stored with chemicals;
b) multiple bottles of water stored with chemicals;
c) one 5 gallon container of Hi-Tech Liquefier (floor stripping) labeled as "danger/corrosive";
d) 5 one gallon containers of Renew Cleaner with a warning of "harmful or fatal if swallowed";
e) one gallon of Beyond Green Cleaning labeled as "hazardous to humans and domestic animals";
f) 2 five gallon ShowPlace floor finish with a label of "avoid contact with skin and eyes and keep out of reach of children";
g) 2 loose plastic bags on the floor;
h) floor fan and buffer with electrical cords.
Observation of the locked area behind the kitchen that contained vending machines that were accessible to patients with staff present revealed an unattended housekeeping cart that contained the following items:
a) box of gloves and plastic liner in the trash receptacle;
b) brooms with handles;
c) 2 one quart bottles of Comet Disinfecting Bathroom Cleaner labeled as harmful if swallowed;
d) 1 one quart bottle of Febreze Fabric Refresher labeled with "use only on fabrics";
e) 1 fifteen and a half ounce spray Refresh Hospital Disinfectant Deodorant labeled as harmful if absorbed through skin; f) 1 one quart Crew Emerel Multi-Surface Creme Cleanser labeled as moderate hazard rating (causes eye and skin irritation). These observations were confirmed by Administrator S1.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews, the hospital failed to ensure a patient was free from neglect as evidenced by failure to provide adequate staff to meet the ordered observation levels of a patient that resulted in a patient choking himself and eloping and failed to identify the occurrence as neglect, objectively investigate the events in a timely and thorough manner, implement corrective action, and self-report the occurrences to the state for 1 of 1 patient who had choked himself and eloped from a total of 8 sampled patients (#2). Findings:

Review of Patient #2's "Physician Admit Orders & (and) Preliminary Tx (treatment) Plan dated 11/11/11 at 1300 (1:00pm) and received by verbal order to RN (registered nurse) S15 from Physician S17 revealed the admitting diagnosis was Mood Disorder. Further review revealed the ordered observation level was modified visual contact (MVC) due to "suicidal, homicidal &/or violent behaviors".

Review of Patient #2's medical record revealed he had an order for protective custody signed 11/10/11 at 7:46pm, he had a PEC (physician emergency certificate) signed on 11/11/11/ at 8:09am due to being gravely disabled, and he had a CEC (coroner's emergency certificate) signed on 11/13/11 at 11:17am due to being dangerous to self and gravely disabled.

Review of Patient #2's "Nursing Progress Note" dated 11/11/11 at 1600 (4:00pm) by RN S15 revealed, in part, "Client was in room alone. MHT S16 was @ (at) nurses' desk & looked up to see pt (patient) walking around in room (with) gown around neck. MHT ran into room & removed gown from pt's neck. Pt was cyanotic, responsive, had bright red blood in mouth..." Further review of an entry by RN S15 on 11/11/11 at 1605 (4:05pm) revealed "Nurse Practitioner S18 on unit and notified of incident. Client placed on 1:1 for safety".

Review of Patient #2's "Nursing Admission Assessment" documented by RN S15 revealed Patient #2 was admitted on [DATE] at 3:00pm, and she began his assessment at 3:30pm. Review of Patient #2's "Observation Log" revealed MHT S16 documented Patient #2 was cooperative, awake, and in the dayroom from 3:00pm through 3:45pm, and he (#2) was in his room cooperative, in his room, and awake from 4:00pm through 4:30pm.

Review of Patient #2's "Physician Orders - Routine" revealed a telephone order received by RN S15 from Nurse Practitioner S18 to "place patient on 1:1 for safety (after) patient found (with) gown around his neck".

In a face-to-face interview on 11/23/11 at 8:20am, RN S15 confirmed she performed Patient #2's admission assessment and was responsible for his care after his admission until the end of the shift. S15 indicated after Patient #2's skin assessment and contraband search were completed, he was brought to his room for her to complete her nursing assessment. S15 further indicated she completed Patient #2's nursing assessment, evaluated him (#2) to determine if he was suicidal and determined that he was not suicidal, and left Patient #2's room with the door to the room left open. S15 further indicated MHT S16 was sitting at the nursing station, looked up, and saw Patient #2 in his room with something around his neck. S15 further indicated MHT S16 ran in Patient #2's room and noted that he (#2) had a paper scrub tied tightly around his neck, and he (#2) was cyanotic but always responsive. RN S15 indicated that MVC meant the patient had to be in the line of sight of a staff member at all times. S15 further indicated MHT S16 could see Patient #2 when he walked to the foot of the bed, but S16 could not see all areas of the room while seated at the nursing station. S15 confirmed that hospital policy was not followed related to MVC when Patient #2 strangled himself.

In a telephone interview on 11/23/11 at 9:10am, MHT S16 indicated at the time of Patient #2's strangulation, he (S16) was observing two other patients who were ordered to be on 1:1, and he had not received extra help to perform these observations. S16 further indicated while he was with another patient down the room from the nursing station, he went to the nursing station to answer a ringing telephone. S16 further indicated as he hung up the telephone, he saw Patient #2 in his room with something around his neck. MHT S16 indicated he went into Patient #2's room and unwrapped the scrub tie from his neck. S16 further indicated Patient #2 was "very blue and purple, coughed up blood, had blood in his eyes, but never lost consciousness".

Review of the "Assignment Sheet" dated 11/11/11 from 7:00am to 7:00pm revealed no documented evidence Patient #2 was assigned to a MHT for observation from the time of admission through the end of the shift, when he was first to be observed as MVC and then 1:1.

Review of Patient #2's "Nursing Progress Note" dated 11/12/11 at 1730 (5:30pm) and documented by RN S12 revealed, in part, "...able to contract for safety to go to meals in cafeteria & outside to smoke; However @ smoke break (after) lunch, pt ran & 1240 (12:40pm) jumped over fence, headed to Hwy (highway) 21 & went into wooded area; 911 called police were able to apprehend pt & bring him back to unit. 11/12/11 1320 (1:20pm) pt returned to unit at 1310 (1:10pm)...".

Review of Patient #2's "Observation Log" dated 11/12/11 revealed MHT S9 documented Patient #2 was cooperative, in his room, and awake at 12:30pm. Further review revealed the next documentation at 12:45pm and 1:00pm revealed "eloped". There was no documented evidence that Patient #2 had been taken outdoors for a smoke break.

In a face-to-face interview on 11/22/11 at 11:10am, Administrator S1 confirmed no staff was assigned to Patient #2 according to the assignment sheet for 11/11/11. She indicated a MHT can't observe more than one patient when assigned to observe a patient 1:1. After review of the assignment sheets for 11/11/11 and 11/12/11, Administrator S1 confirmed the number of staff assigned the observation of patients was not adequate to provide the ordered observations. S1 further indicated the assignment was not being done correctly by the RN.

In a face-to-face interview on 11/22/11 at 1:10pm, MHT S9 indicated she observed Patient #2 on 11/12/11 from 7:30am to 7:00pm. She further indicated when outside for the smoke break, 4 patients were seated next to the wall, 3 patients were seated at the picnic table under the canopy, one patient was seated at the table around the corner, and Patient #2 began to walk away from the covered area. S9 further indicated there were about 10 patients outside with 2 MHT's. S9 indicated when the cigarette lighter she was using to light the patients' cigarettes failed to work, she went inside the hospital to get another lighter. S9 further indicated while MHT S10 was left to observe 10 patients, one of whom was 1:1 (Patient #2), Patient #2 jumped the fence. MHT S9 indicated 1:1 observation meant the staff had to be within arm's length of the patient and able to visually see the patient at all times. S9 confirmed she did not follow hospital policy for the observation of Patient #2 1:1 when he eloped.

In a face-to-face interview on 11/22/11 at 1:40pm, MHT S10 indicated he remembered Patient #2's elopement. S10 further indicated he didn't remember how many patients were outside at the time of the elopement, but he did confirm he (S10) was alone outside with Patient #2 who was ordered to be on 1:1 and other patients.

Review of the "Assignment Sheet" for 11/12/11 for 7:00am to 7:00pm revealed MHT S10 was assigned the observation of one 1:1 patient, 3 patients on MVC, and 2 patients on special observation. Further review revealed MHT S9 was assigned the observation of Patient #2 1:1, assisted with the 1:1 observation of another patient, 3 patients on special observation, and 2 patients on MVC.

In a face-to-face interview on 11/22/11 at 4:55pm, MHT S9 confirmed she was responsible for observing Patient #2 1:1 when he eloped. S9 further indicated she was also assigned the observation of 5 other patients and assistance with observing another patient 1:1. MHT S9 indicated she should not be observing other patients when she was assigned to observe a patient 1:1, but "when you're short-staffed, you do the best you can do".

In a face-to-face interview on 11/22/11 at 5:10pm, MHT S10 indicated he could not observe a patient 1:1 while observing 5 other patients, and he couldn't observe 2 patients who were 1:1 while on a smoke break with 8 other patients.

In a face-to-face interview on 11/22/11 at 2:40pm, Administrator S1 indicated she did not identify the choking and elopement of Patient #2 as neglect, did not perform any type of investigation of the events, implement any corrective action, and did not self-report to the state as neglect.

In a face-to-face interview on 11/29/11 at 11:45am, Risk Manager/QAPI (quality assessment performance improvement) S22 indicated a root cause analysis and resulting corrective action plan had not been conducted for the choking and elopement of Patient #2.

Review of the hospital policy titled "Patient Abuse and/or Neglect", effective 09/01/03 and revised 09/28/06 and submitted by Administrator S1 as their current policy for abuse and neglect, revealed, in part, "...It is the policy of Greenbrier, in accordance with state and federal law, that suspected cases of abuse and or neglect of adults will be reported to the appropriate protective services agency. ... Definitions: ... Neglect is a form of abuse in which there is failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. ... B. The hospital will maintain a mechanism for reporting, determining, and conducting remediation of violations...". Review of the entire policy revealed no documented evidence that a system was in place to identify an occurrence of neglect, objectively investigate the event in a timely and thorough manner, implement corrective action, and self-report the occurrence to the state.

Review of the hospital policy titled "Assessing and Tracking of Client Acuity", effective 05/31/10, revised 06/08/10, and submitted by Administrator S1 as the current policy for staffing, revealed, in part, "...the hospital shall utilize the levels of observation for determining patient acuity & (and) staffing needs. ... A. At admission, clients will be placed on MVC (modified visual contact) unless they are homicidal, suicidal, or at fall risk. Then they will be placed on VC (visual contact) or 1 to 1. B. RN (registered nurse) Charge Nurses for Unit A and B will complete the Levels of Observation for Determining Acuity/Staffing Sheet, at the beginning of each shift. ... E. If the client's behavior changes and the Charge Nurse assesses that the level of observation needs to be changed, they will contact the Psychiatrists on call and get an order. F. The Charge Nurse will communicate with the DON (director of nursing) and Administrator on-call when acuity levels increase. If more staff is needed, PRN (as needed) staff will be called in. ...I. Intake will contact the DON and Administrator when census is trending up or down to assure that staffing patterns meet the needs of the staff and clients".
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure a patient's plan of care was modified with the use of restraints or seclusion for 1 of 3 patients' records reviewed who had restraints or seclusion used from a total of 8 sampled patients (#7). Findings:

Patient #7
Review of Patient #7's medical record revealed he was admitted on [DATE] with a diagnosis of Schizophrenia, Paranoid Type. Further review revealed Patient #7 was PEC'd (physician emergency certificate) on 11/16/11 at 1656 (4:56pm) due to being dangerous to others. Further review revealed he was CEC'd (coroner's emergency certificate) on 11/18/11 at 1702 (5:02pm) due to being dangerous to others, gravely disabled, violent.

Review of Patient #7's "Physician Orders - Restraint/Seclusion" received by verbal order on 11/18/11 at 11:45am from Medical Director S27 by RN (registered nurse) S24 revealed he was placed in 5 point leather restraints, locked seclusion, and administered a chemical restraint on 11/18/11 at 11:45am.

Review of Patient #7's "Seclusion Restraint Flow" dated 11/18/11 at 11:15am and signed by RN S24 on 11/18/11 at 12:00pm revealed "care plan addresses problem behaviors? objectives? outcomes? interventions?" with the choice of "yes" circled.

Review of Patient #7's "Interdisciplinary Treatment Plan Problem - Poor Impulse Control" dated 11/18/11, with no documented evidence of the time it was initiated by RN S24, revealed the problem of poor impulse control was related to a history of mental illness as evidenced by oppositional behaviors. Further review revealed no documented evidence that short-term goals, long-term goals, and clinical interventions had been documented by RN S24. Further review revealed no documented evidence Patient #7's treatment plan had been modified with the use of restraints and seclusion.

In a face-to-face interview on 11/29/11 at 2:10pm, Director of Nursing S2 confirmed Patient #7's care plan was incompletely documented for poor impulse control and did not include a modification with the use of restraints and seclusion.

Review of the hospital policy titled "Seclusion and Restraint", effective 09/01/03, revised 12/09/09, and submitted by Administrator S1 as the current policy for the use of restraints and seclusion, revealed, in part, "...Registered Nurse documents in patient's plan of care: assessed problem, objectives and goals, interventions, responsible staff, and reassessment...".
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0174
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure restraint or seclusion was discontinued at the earliest possible time as evidenced by patients documented as cooperative and calm being left in restraints until the conclusion of the ordered time for 1 of 3 patients' records reviewed who were restrained and in seclusion from a total of 8 sampled patients (#7). Findings:

Patient #7
Review of Patient #7's medical record revealed he was admitted on [DATE] with a diagnosis of Schizophrenia, Paranoid Type. Further review revealed Patient #7 was PEC'd (physician emergency certificate) on 11/16/11 at 1656 (4:56pm) due to being dangerous to others. Further review revealed he was CEC'd (coroner's emergency certificate) on 11/18/11 at 1702 (5:02pm) due to being dangerous to others, gravely disabled, violent.

Review of Patient #7's "Physician Orders - Restraint/Seclusion" received by verbal order on 11/18/11 at 11:45am from Medical Director S27 by RN (registered nurse) S24 revealed he was placed in 5 point leather restraints, locked seclusion, and administered a chemical restraint on 11/18/11 at 11:45am. Further review of the narrative describing specific behaviors revealed "refusing medications, (arrow up) agitation & (and) verbal threats to staff (to choke & punch); uncooperative (with) IM (intramuscular) PRN (as needed) & hit staff member (with) closed fist".

Review of Patient #7's "Seclusion Restraint Flow" revealed a column labeled "Hourly RN Eval (evaluation)" and a column labeled "Staff Initials". Further review of Patient #7's "Seclusion Restraint Flow" dated 11/18/11 at 11:15am and signed by RN S24 on 11/18/11 at 12:00pm revealed the following "Seclusion Restraint Observation":
11:15am by RN S24 - "cooperative & (and) calm. apologetic & appears sincere";
12:00pm by RN S24 - "cooperative & calm. apologetic & appears sincere" (column for hourly evaluation includes four 15 minute time intervals);
12:15pm with no documented evidence of the RN performing the evaluation - (no) distress, completely cooperative & non-violent;
1315 (1:15pm) by RN S24 - calm, cooperative.
Review of Patient #7's medical record revealed he was removed from restraints and seclusion on 11/18/11 at 1:45pm. Further review revealed no documented evidence of assessed behaviors that warranted Patient #7 to remain in restraints and seclusion for 4 hours.

In a face-to-face interview on 11/29/11 at 2:10pm, Director of Nursing S2 confirmed there were no behaviors documented that warranted Patient #7 to remain in seclusion and restraints, and that according to the documentation, Patient #7 was not released at the earliest possible time from seclusion and restraints.

Review of the hospital policy titled "Seclusion and Restraint", effective 09/01/03, revised 12/09/09, and submitted by Administrator S1 as the current policy for the use of restraints and seclusion, revealed, in part, "...Release From Seclusion/Leather Restraint: Restraint should be discontinued at the earliest possible opportunity. Release criteria will be based on the guidelines established with the patient at the initiation of restraint/seclusion. The criteria will be based on the alleviation of the danger to self or others, demonstrated by the patient's current behavior. The R.N. through ongoing assessment will determine when the patient has met criteria to be released...".
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interviews, the hospital failed to ensure a patient who was restrained or placed in seclusion was evaluated within 1 hour after the initiation of the intervention by a registered nurse (RN) to evaluate the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion as evidenced by failure to perform the evaluation according to hospital policy and failure to have evidence that the RN had been trained to perform the face-to-face evaluation for 1 of 3 patients' records reviewed who were placed in restraint or seclusion from a total of 8 sampled records (#7). Findings:

Patient #7
Review of Patient #7's medical record revealed he was admitted on [DATE] with a diagnosis of Schizophrenia, Paranoid Type. Further review revealed Patient #7 was PEC'd (physician emergency certificate) on 11/16/11 at 1656 (4:56pm) due to being dangerous to others. Further review revealed he was CEC'd (coroner's emergency certificate) on 11/18/11 at 1702 (5:02pm) due to being dangerous to others, gravely disabled, violent.

Review of Patient #7's "Physician Orders - Restraint/Seclusion" received by verbal order on 11/18/11 at 11:45am from Medical Director S27 by RN (registered nurse) S24 revealed he was placed in 5 point leather restraints, locked seclusion, and administered a chemical restraint on 11/18/11 at 11:45am. Further review of the narrative describing specific behaviors revealed "refusing medications, (arrow up) agitation & (and) verbal threats to staff (to choke & punch); uncooperative (with) IM (intramuscular) PRN (as needed) & hit staff member (with) closed fist".

Review of Patient #7's "Seclusion Restraint Flow" initiated 11/18/11 at 11:15am by RN S24 revealed the pre-printed form included "RN Face:Face Eval (evaluation) within 60 min (minutes) of seclusion/restraint" with "yes" circled. Further review revealed no documented evidence of a time written in the column labeled "time done". Review of the entire medical record revealed no documented evidence of documentation in the chart of an evaluation within 1 hour after the initiation of Patient #7's seclusion and restraints that included the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion as required by hospital policy.

Review of RN S24's personnel file revealed her CPI (crisis prevention intervention) certification had expired 10/11. Further review revealed S24's yearly evaluation required her to be have verification of current CPI. Further review of S24's personnel file revealed no documented evidence that she had been trained on performing the face-to-face evaluation within 1 hour of initiating seclusion or restraints. There was no documented evidence of an assessment of competency in the application of restraints, the alternative methods for managing behavior, restraint reduction, proper and safe use of restraints, and policy and procedure on seclusion and restraints as required by hospital policy.

In a face-to-face interview on 11/29/11 at 2:10pm, Director of Nursing S2 confirmed the 1 hour face-to-face evaluation after the initiation of Patient #7's restraints and seclusion was not performed according to hospital policy by RN S24. S2 further confirmed RN S24 had no documented evidence of an assessment of competency related to the use of restraint and seclusion and in performing the face-to-face evaluation within 1 hour of initiating seclusion or restraints.

Review of the hospital policy titled "Seclusion and Restraint", effective 09/01/03, revised 12/09/09, and submitted by Administrator S1 as the current policy for the use of restraints and seclusion, revealed, in part, "...The physician, psychiatric mental health nurse practitioner, or a trained registered nurse must see and evaluate the patient face-to-face to perform an assessment within 1 hour after the initiation of the seclusion and/or restraint. This evaluation should be documented in the chart and include patient's immediate situation, patient's reaction to the intervention, patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion. The RN completing the face-to-face evaluation must consult with the treating physician as soon as possible after the evaluation and document such... Staff Education: All direct care staff shall receive ongoing education and training in the proper and safe use of seclusion and restraints before they participate in restraint use. Staff who apply mechanical restraints must have competency assessed and documented in their file. This education also covers alternative methods for managing behavior, restraint reduction, proper and safe use of restraints, and policy and procedure on seclusion and restraints...".
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0182
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure the RN (registered nurse) who performed the face-to-face evaluation after the initiation of restraints and seclusion consulted with the attending physician as soon as possible after the evaluation for 1 of 3 patients' records reviewed who had restraints or seclusion implemented from a total of 8 sampled patients (#7). Findings:

Patient #7
Review of Patient #7's medical record revealed he was admitted on [DATE] with a diagnosis of Schizophrenia, Paranoid Type. Further review revealed Patient #7 was PEC'd (physician emergency certificate) on 11/16/11 at 1656 (4:56pm) due to being dangerous to others. Further review revealed he was CEC'd (coroner's emergency certificate) on 11/18/11 at 1702 (5:02pm) due to being dangerous to others, gravely disabled, violent.

Review of Patient #7's "Physician Orders - Restraint/Seclusion" received by verbal order on 11/18/11 at 11:45am from Medical Director S27 by RN (registered nurse) S24 revealed he was placed in 5 point leather restraints, locked seclusion, and administered a chemical restraint on 11/18/11 at 11:45am. Further review of the narrative describing specific behaviors revealed "refusing medications, (arrow up) agitation & (and) verbal threats to staff (to choke & punch); uncooperative (with) IM (intramuscular) PRN (as needed) & hit staff member (with) closed fist".

Review of Patient #7's "Seclusion Restraint Flow" initiated 11/18/11 at 11:15am by RN S24 revealed the pre-printed form included "RN Face:Face Eval (evaluation) within 60 min (minutes) of seclusion/restraint" with "yes" circled. Further review revealed no documented evidence of a time written in the column labeled "time done" which made it impossible to determine that the evaluation was performed within 1 hour of initiation of the restraints and seclusion. Further review revealed RN S24 consulted with Medical Director at 11:15am, the time the restraints and seclusion was implemented. Review of the entire medical record revealed no documented evidence that RN S24 consulted with Medical Director S27 after she conducted the face-to-face evaluation of Patient #7 that was to be done within 1 hour after the initiation of restraints and seclusion as required by hospital policy.

In a face-to-face interview on 11/29/11 at 2:10pm, Director of Nursing S2 confirmed the consultation with Medical Director S27 by RN S24 was documented at the time of initiation of restraints and seclusion and not within 1 hour after the initiation of Patient #7's restraints and seclusion.

Review of the hospital policy titled "Seclusion and Restraint", effective 09/01/03, revised 12/09/09, and submitted by Administrator S1 as the current policy for the use of restraints and seclusion, revealed, in part, "...The RN completing the face-to-face evaluation must consult with the treating physician as soon as possible after the evaluation and document such...". Further review revealed no documented evidence that the policy required the consultation to include, at a minimum, a discussion of the findings of the 1 hour face-to-face evaluation, the need for other interventions or treatments, and the need to continue or discontinue the use of restraint or seclusion.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0196
Based on record review and interview, the hospital failed to ensure the staff were trained and demonstrated competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion as evidenced by failure to have documented training and competency assessment for 3 of RNs' (registered nurse) personnel files reviewed for restraint and seclusion education and competency (S24, S25, S26) and 2 of 3 MHTs' (mental health tech) personnel files reviewed for restraint and seclusion education and competency (S9, S16). Findings:

Review of RN S24's personnel file revealed she was hired on 02/05/10. Further review revealed no documented evidence of an assessment of competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion and for performing the face-to-face evaluation of a patient within 1 hour after initiation of restraints or seclusion.

Review of RN S25's personnel file revealed she was hired on 02/10/11. Further review revealed no documented evidence of an assessment of competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion and for performing the face-to-face evaluation of a patient within 1 hour after initiation of restraints or seclusion.

Review of RN S26's personnel file revealed she was hired on 09/01/10. Further review revealed no documented evidence of an assessment of competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion and for performing the face-to-face evaluation of a patient within 1 hour after initiation of restraints or seclusion.

Review of MHT S9's personnel file revealed she was hired on 09/28/05. Further review revealed S9's CPI (crisis prevention intervention) certification had expired 07/10, and S9 did not receive retraining on CPI until 11/03/11, more than 15 months after it had expired. Further review revealed no documented evidence that MHT S9 had been assessed for competency with application of restraints and providing care for a patient in restraint or seclusion.

Review of MHT S16's personnel file revealed his date of hire was 08/14/09. Further review revealed no documented evidence that MHT S16 had been assessed for competency with application of restraints and providing care for a patient in restraint or seclusion.

In a face-to-face interview on 11/29/11 at 2:10pm, Director of Nursing S2 confirmed the employees' files listed above did not have documentation of competency assessments for the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion and for performing the face-to-face evaluation of a patient within 1 hour after initiation of restraints or seclusion for the RNs.

Review of the hospital policy titled "Seclusion and Restraint", effective 09/01/03, revised 12/09/09, and submitted by Administrator S1 as the current policy for the use of restraints and seclusion, revealed, in part, "...Staff Education: All direct care staff shall receive ongoing education and training in the proper and safe use of seclusion and restraints before they participate in restraint use. Staff who apply mechanical restraints must have competency assessed and documented in their file. This education also covers alternative methods for managing behavior, restraint reduction, proper and safe use of restraints, and policy and procedure on seclusion and restraints...".

Review of the hospital policy titled "Assignment of Patient Care to Nursing Staff Members", effective 09/01/03, revised 04/25/10, and submitted by Administrator S1 as the policy for assignment of patient care, revealed, in part, "...All personnel having direct contact with patients shall have current CPR (cardiopulmonary resuscitation) certification and CPI certification...".
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on observation, record review, and interview, the hospital failed to implement corrective action to make changes that will lead to improvement of identified opportunities as evidenced by: 1) having a 17% (per cent) compliance rate for documentation and a 50% compliance rate for discharge summaries completed within 30 days of discharge that contributed to delinquent charts greater than 30 days past discharge, 2) having the compliance of the quality control testing of the blood glucose machine drop from 94% in the first quarter to 90% in the second quarter and 82% in the third quarter with no corrective action plan for improvement implemented, and 3) having decrease in refrigerator temperature monitoring in the first quarter that had no corrective action implemented and was not continued to be monitored into the remaining quarters of the year. Findings:

1) Having a 17% compliance rate for nursing documentation and a 50% compliance rate for discharge summaries completed within 30 days of discharge that contributed to delinquent charts greater than 30 days past discharge:
Review of the discharge summaries presented by Administrator S1 on 11/29/11 revealed 39 unsigned discharge summaries for Physician S17 that were dictated for patients who had been discharged greater than 30 days prior to 11/29/11. Further review revealed 5 unsigned discharge summaries for Medical Director S27 that were dictated for patients who had been discharged greater than 30 days prior to 11/29/11.

Review of a list of patient records presented by Administrator S1 on 11/29/11 that were incomplete due to the clinical staff needing to add medical record documentation or to sign notes revealed 1145 patient medical records dating as far back as 07/12/10.

Review of the "Performance Improvement Committee Minutes" for the 3rd quarter of 2011 held on 10/11/11 at 12:10pm revealed a random audit of 80 charts was performed to check for dating and timing of each entry necessary for patient safety and quality of care. Further review revealed the threshold was 100%. Further review revealed the 1st quarter compliance rate was 13%, the 2nd quarter compliance rate was 10%, and the 3rd quarter compliance rate was 17%. Further review of the meeting minutes revealed no documented evidence of corrective action to be implemented.

Review of the "Performance Improvement Scorecard" revealed the threshold for completing discharge summaries within 30 days of discharge was 100%. Further review revealed the following compliance rate by month for 2011: January 67%, February 93%, March 31%, April 80%, May 75%, June 100%, July 60%, August 60%, September 70%, and October 50%. Review of the QAPI (quality assessment performance improvement) meeting minutes revealed no documented evidence of corrective action to be implemented.

In a face-to-face interview on 11/29/11 at 11:45am, Risk Manager/QAPI S22 indicated they began using the scorecard in April 2011. She further indicated a monthly list of staff with delinquent medical records was sent to the Department Heads, and it was to be monitored by the Department Heads. She could provide no explanation for the delinquent medical record rate continuing to be below threshold. No documented evidence of a corrective action plan that addressed the delinquent medical records was provided to the survey team by the completion of the survey.

In a face-to-face interview on 11/29/11 at 11:45am, Corporate Director of Inpatient Services S13 indicated the fallouts (compliance rates below threshold) went to the Corporate quarterly meeting at which time the indicator was reviewed to determine the corrective action. During the interview a request was made to view any corrective action plan that addressed this issue. No documented evidence of a corrective action plan that addressed the delinquent medical records was provided to the survey team by the completion of the survey.

2) Having the compliance of the quality control testing of the blood glucose machine drop from 94% in the first quarter to 90% in the second quarter and 82% in the third quarter:
Observation of the blood glucose monitoring control solution for Unit B on 11/21/11 at 2:50pm revealed 2 vials of Quintet control solution. Further observation revealed the high level container was labeled "8-5", and the control solution was labeled "8-5-1" as the discard dates.

Review of the Unit B OneTouch Ultra 2 Blood Glucose Monitoring Machine Quality Control Log revealed the following instructions: "Control solution tests must be run once a week - every Friday night during night shift. Also do a control solution test: 1. to practice the test process instead of using blood 2. whenever you open a new vial of test strips 3. if you suspect the meter or test strips are not working properly, 4. if you have had repeated unexpected or inconsistent blood glucose results 5. if you drop or damage the meter". Further review revealed no documented evidence a check was performed on 09/23/11, 09/30/11, 10/07/11, 10/14/11, 10/21/11, 10/28/11, 11/04/11, 11/11/11, and 11/18/11.

In a face-to-face interview on 11/21/11 at 2:50pm, LPN (Licensed Practical Nurse) S3 indicated the dates on the blood glucose monitoring control solutions was not clear. S3 further indicated the solution is usually good for 30 days after it was opened. S3, after review of the control log, confirmed the blood glucose monitoring quality control was not performed every Friday.

Review of the "Performance Improvement Committee Minutes" for the 3rd quarter of 2011 held on 10/11/11 at 12:10pm revealed an indicator was that quality control testing would be completed on the blood glucose machine weekly (there was no documented evidence of the threshold for this indicator). Further review revealed the compliance rate for 1st quarter was 94%, for 2nd quarter 90%, and for 3rd quarter 82%. There was no documented evidence of the corrective action that was to be implemented to address the decrease in compliance.

In a face-to-face interview on 11/29/11 at 11:45am, Risk Manager/QAPI S22 could offer no explanation for a corrective action plan not being implemented for the decrease in compliance of quality control testing of the blood glucose machine.

3) Having decrease in refrigerator temperature monitoring in the first quarter that had no corrective action implemented and was not continued to be monitored into the remaining quarters of the year:
Observation of the lab specimen refrigerator on Unit C on 11/21/11 at 3:50pm revealed no documented evidence of a refrigerator temperature log.

Review of the refrigerator logs for Unit A for October 2011 and November 2011 revealed 5 columns labeled as # (number)11, #10, #7, #8, and #12. Further review revealed no documented evidence whether the refrigerators stored medications or lab specimens and whether the temperatures listed in each column were a refrigerator temperature or a freezer temperature. Further observation revealed the following directions: "log temperature + (plus) initials daily, refrigerator should be 34-40 (degrees) F (Fahrenheit) and freezer 0-10 (degrees) F, give maintenance a work order if repair needed". Further observation revealed no documented evidence that a temperature was recorded on 10/02/11, 10/03/11, 10/09/11, 10/11/11, 10/12/11, 10/18/11, 10/23/11, 10/28/11, 10/31/11, 11/02/11, 11/09/11, 11/14/11, 11/15/11, and 11/16/11.

Review of the "Performance Improvement Committee Minutes" for the first quarter held on 04/19/11 at 12:00pm revealed an indicator was developed for refrigerator temperature control testing. Further review revealed each refrigerator was to contain a thermometer, maintained at 36 degrees F (Fahrenheit) to 46 degrees F, and nursing staff was to check each refrigerator nightly and document the temperatures on the log. Further review revealed the compliance for January 2011 was 88%, February 81%, and March 70%. Further review revealed no documented evidence of a corrective action plan to address the decrease in compliance with monitoring the refrigerator temperatures. Review of the 2nd and 3rd quarter QAPI meeting minutes revealed no documented evidence that refrigerator temperatures continued to be a quality indicator.

In a face-to-face interview on 11/29/11 at 11:45am, Risk Manager/QAPI S22 indicated the performance improvement scorecard was implemented in April 2011. S22 confirmed the refrigerator temperature monitoring was not added to the scorecard, even though it fell out of compliance in the 1st quarter.

Review of the hospital policy titled "Plan for Improving Organizational Performance", revised 11/12/07 and submitted by Administrator S1 as their current QAPI plan, revealed, in part, "...It is the goal of this plan to provide a mechanism and process designed to identify opportunities to improve care and services by measuring, assessing, and improving care in a systematic and ongoing manner. ...D. Responsibilities of the Performance Improvement Committee include: ... 4. Assurance of compliance with regulatory agency standards and requirements. 5. Reporting to the Medical Executive Committee and Governing Board on Performance Improvement initiative, goals, and significant issues. 6. Establishing organization-wide Performance Improvement measures that are strategically aligned. ... The committee will be utilized for design, measurement, assessment and improvement of processes of care as identified... The Performance Improvement Committee responsibilities include: a. Meet at least quarterly... to review quality assessment and improvement performance data... b. Receive quality assessment and improvement reports from units/departments/committees related to their functional area. ... d. Receive suggestions for functional improvement opportunities. Evaluate these suggestions and determine what action will be taken, if any. ... H. Performance Improvement Structure and Information Flow: ... 1. Findings of the PI monitoring and evaluation activities will be grouped as: ... b. System or processes or care... 2. Actions will include: a. Changing the support system; b. Providing individual education...
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on record review and interview, the hospital failed to track adverse patient events as evidenced by failure to include suicide attempts and elopements on the list of patient incidents tracked on the performance improvement scorecard. Findings:

Review of the Performance Improvement Scorecard" for 2011 revealed the inpatient incidents that were tracked were: emergency room visits with a breakdown of causes for the visit, seclusion/restraint, labs, medication related, falls, legal status, policies and procedures, total staff incidents, visitor incidents, and other. There was no documented evidence of suicide attempts and elopements being identified as an area of incident reports to be tracked.

Review of Patient #2's medical record revealed he attempted to choke himself on 11/11/11 by tying a rolled paper scrub top around his neck while under ordered modified visual contact (MVC) that was not implemented, and Patient #2 eloped from the hospital grounds on 11/12/11 by jumping over a 6 foot wooden fence while ordered to be on one-to-one (1:1) observation and being left in the outdoor area observed by one mental health tech (MHT) who was responsible for the observation of another 1:1 patient and 8 other patients.

Review of the hospital's incident report log from 01/11 through 10/11 and the November incident reports revealed the following: elopement by Patient #2 on 11/12/11 from Unit A; attempted elopement on 11/02/11 at 1:15pm from Unit C; elopement on 08/11/11 at 8:45pm from Unit B; attempted elopement on 08/13/11 at 10:00pm; elopement on 07/16/11 at 5:20pm from Unit A; elopement on 05/05/11 at 1:35pm from Unit A; and elopement on 01/04/11 from Unit B at 12:18pm.

In a face-to-face interview on 11/29/11 at 11:45am, Risk Manager/QAPI (quality assessment performance improvement) S22 indicated the hospital treats elopements and suicide attempts like any other incident report. She further indicated they do not perform a root cause analysis or implement a corrective action plan. S22 confirmed elopements and suicide attempts were not specifically tracked on the scorecard and were included under the section "other" under incident reports.

Review of the hospital policy titled "Plan for Improving Organizational Performance", revised 11/12/07 and submitted by Administrator S1 as their current QAPI plan, revealed, in part, "...D. Responsibilities of the Performance Improvement Committee include: ... 8. Reviewing and providing oversight for sentinel event root cause analyses. ...VI. Priorities for Improvement ... Priorities for Performance Improvement are established by the PI Committee based upon the mission and vision of the strategic plan, which includes and considers: ... 10. High Risk ... 13. Sentinel Event Alerts... VII. Facility-Wide Performance/Outcome Indicators The following performance/outcome indicators are collected and analyzed on a regular basis for potential performance improvement activity. 1. Occurrence Reports ... 9. Adverse Treatment Outcomes (...Elopements, Suicide Attempts...)...".
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on record review and interview, the hospital failed to perform a root cause analysis as required by hospital policy for an attempted suicide on 11/11/11 and an elopement on 11/12/11 for 1 of 1 patient who attempted suicide and eloped from a total of 8 sampled patients (#2) and for 6 elopements or attempted elopements that occurred between 01/04/11 and 11/02/11. Findings:

Review of Patient #2's medical record revealed he attempted to choke himself on 11/11/11 by tying a rolled paper scrub top around his neck while under ordered modified visual contact (MVC) that was not implemented, and Patient #2 eloped from the hospital grounds on 11/12/11 by jumping over a 6 foot wooden fence while ordered to be on one-to-one (1:1) observation and being left in the outdoor area observed by one mental health tech (MHT) who was responsible for the observation of another 1:1 patient and 8 other patients. There was no documented evidence of a root cause analysis performed after the suicide attempt or the elopement to identify the cause, implement corrective action, and reduce the likelihood of recurrence.

Review of the hospital's incident report log from 01/11 through 10/11 and the November incident reports revealed the following: elopement by Patient #2 on 11/12/11 from Unit A; attempted elopement on 11/02/11 at 1:15pm from Unit C; elopement on 08/11/11 at 8:45pm from Unit B; attempted elopement on 08/13/11 at 10:00pm; elopement on 07/16/11 at 5:20pm from Unit A; elopement on 05/05/11 at 1:35pm from Unit A; and elopement on 01/04/11 from Unit B at 12:18pm. There was no documented evidence of a root cause analysis performed after each elopement or attempted elopement to identify the cause, implement corrective action, and reduce the likelihood of recurrence.

In a face-to-face interview on 11/29/11 at 11:45am, Risk Manager/QAPI (quality assessment performance improvement) S22 indicated the hospital treats elopements and suicide attempts like any other incident report. She further indicated they do not perform a root cause analysis or implement a corrective action plan. S22 confirmed a root cause analysis had not been performed after Patient #2's attempted suicide and elopement.

Review of the hospital policy titled "Sentinel Events and Conducting a Root Cause Analysis", effective 09/01/3 and submitted by Administrator S1 as the current policy for handling sentinel events, revealed, in part, "...It is the policy of Greenbrier to allow for a process to recognize sentinel events and initiate effective follow-up to reduce the likelihood of recurrence. Definitions Sentinel Event - A sentinel event is an unexpected occurrence involving death or serous (serious) physical or psychological injury, or the risk thereof. ...Root Cause Analysis - Root cause analysis is a process for identifying the basic or casual factors that underline variation in performance, including the occurrence or possible occurrence of a sentinel event. A root cause analysis focuses primarily on systems and processes ... It progresses from special causes in clinical processes to common causes in organizational processes and identifies potential improvements in processes or systems that would tend to decrease the likelihood of such events in the future, or determines, after analysis, that no such improvement opportunities exist. ... III. Procedure ... Sentinel Events will be reported immediately to the Director of Nursing and the Director of Total Quality Improvement. B. The Director will immediately initiate the following steps: 1. Determine if a Sentinel Event has occurred. 2. Notify the Director of Nursing and the Administration. ...4, Initiate Sentinel Event review procedure/root cause analysis... 6. Determine sequence of events and causal factors. 7. Complete the Critical Incident Analysis Form. 8. Flowchart the events that led up to the Sentinel Event. 9. Identify the root causes. 10. Take action to prevent recurrence of event. The product of the root cause analysis is an action plan that identifies the strategies that the organization intends to implement to reduce the risk of similar events occurring in the future. The plan should address responsibility for implementation, oversight, pilot testing as appropriate, time lines, and strategies for measuring the effectiveness of the actions. 11. Evaluate effectiveness of actions implemented".
VIOLATION: NURSING SERVICES Tag No: A0385
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, record review, and interviews, the hospital failed to meet the Condition of Participation for Nursing Services as evidenced by:

Failure to provide adequate staff to meet the ordered observation levels of patients as evidenced by: a) observation on 11/21/11 at 4:40pm revealed 1 MHT (mental health tech) attending 11 patients (some of whom were on modified visual contact) while outdoors on a smoke break and unable to view all areas at all times and b) review of the assignment sheet for 11/11/11 revealed 1 MHT assigned the observation of one 1:1 (one-to-one) patient and 1 MHT assigned the observation of 1 patient on VC (visual contact), 6 patients on MVC (modified visual contact), and 5 patients on SO (special observation), the assignment sheet for 11/12/11 revealed 1 MHT assigned observation of one 1:1 patient, 3 patients on MVC, 2 patients on SO and 1 MHT assigned observation of two 1:1 patients, 2 patients on MVC, and 3 patients on SO, and the assignment sheet for 11/21/11 revealed 2 MHTs were each assigned the observation of 10 patients, 1 who was ordered 1:1 observation, 11 patients who were on MVC, and 8 patients who were on SO (see findings in tag A0392).

Hospital Administrator S1 and Corporate Director of Inpatient Services S13 were notified on 11/23/11 at 1:00pm of an immediate jeopardy situation. The immediate jeopardy situation was a result of the hospital failing to provide adequate staff to meet the ordered observation levels of patients as evidenced by: 1) observation on 11/21/11 at 4:40pm revealed 1 MHT (mental health tech) attending 11 patients (some of whom were on modified visual contact) while outdoors on a smoke break and unable to view all areas at all times and 2) review of the assignment sheet for 11/11/11 revealed 1 MHT assigned the observation of one 1:1 (one-to-one) patient and 1 MHT assigned the observation of 1 patient on VC (visual contact), 6 patients on MVC (modified visual contact), and 5 patients on SO (special observation) and the assignment sheet for 11/12/11 revealed 1 MHT assigned observation of one 1:1 patient, 3 patients on MVC, 2 patients on SO and 1 MHT assigned observation of two 1:1 patients, 2 patients on MVC, and 3 patients on SO.

A plan of removal developed by Administrator S1, Corporate Director of Inpatient Services S13, and Corporate Compliance Officer S14 was (MDS) dated [DATE] at 3:45pm. Review of the plan of removal revealed the following:
1) Prior to the evening shift of 11/23/11, all present staff were educated on the observation levels (1:1, VC, MVC, SO) with a review of unit restrictions. Staff were informed that any violation of observation levels will result with disciplinary action up to and including termination. Disciplinary action was conducted with Administrator S1, Director of Nursing S2, and a MHT based on the incident identified.
2) The above education was completed with all staff prior to the start of the following night and day shifts. All staff will be required to complete the training by 12/02/11, and no staff will be allowed to work on any unit without the training and completion of a written observation test. The Administration team consisting of the Administrator, Director of Nursing, Assistant Director of Nursing (DON), Compliance Officer, Director of Social Services, and the scheduler will be responsible for completion of the staff education.
3) Beginning on the evening shift of 11/23/11 and continuing daily, the observation logs on all units were checked by Administration to ensure that they were completed correctly.
4) Random observations on each shift were performed by Administration to ensure that observation levels, the acuity sheet, and the assignment sheets were completed correctly.
5) An Acuity and Staffing Monitor tool was created to audit for observation logs, acuity sheets, and assignment sheets. This tool will be completed each shift daily by Administration for 3 months; if after 3 months 100% (per cent) compliance is met, the audit will be performed weekly for an additional 3 months. After completion of the second 6 month period, if 100% compliance is achieved, ongoing monthly monitoring will be conducted.
6) Monthly compliance data of the daily Acuity and Staffing Monitor tool will be added to both the Performance Indicator and Risk Management reports.
7) A Levels of Observation and Acuity test was developed and administered to the unit staff by the DON. Staff must score 100% on the test prior to being allowed to work. All staff will have completed the test by 12/02/11. The test will be added to all New Hire paperwork and re-orientation which occurs annually.
8) A "quick view" of observation levels was created by the DON and Assistant DON and distributed to all staff and was posted in the nursing stations, the medication room, and attached to the observation clipboards.
9) The following forms were revised: a) changed observation log to include that the RN must sign it every 6 hours; b) changed the Unit Assignment Sheet to reflect observation levels with staffing and duties assigned (all nurses were educated at an in-service on 11/28/11); c) changed the Acuity Staffing sheet to reflect a change in observation level, staffing pattern if needed, time of 1:1 start and end, and added the number of unit restrictions(all RNs and LPNs were trained on all new forms at a mandatory meeting on 11/28/11; any staff not present at the meeting will be trained by 12/02/11, and no staff will be able to work their shift until the training is completed).
10) Education by the DON and the Assistant DON was completed at an in-service meeting on 11/28/11 that included a review of the following policies and procedures: Elopement risk and precautions; Levels of Observation-Therapeutic Safety Measure; Assessing/Tracking of Client Acuity. This review will occur at every staff in-service meeting for the next 3 months.
11) Administration and Corporate Staff will add the number of elopements and the acuity and staffing monitor tool data to the Performance Improvement and Risk Management reports for tracking. All such reports are reviewed quarterly at Corporate Board meetings.
12) A Root Cause Analysis will be conducted within 72 hours of all sentinel events which will be followed up with a Plan of Action to correct any identified problems in the analysis. This will be completed by Administration.
13) Incident reports will be reviewed to ensure documentation of any incident. All staff involved with a sentinel event will provide a written statement and documentation. This will be overseen by Administration.

On 11/28/11 at 3:45pm, Administrator S1, Corporate Director of Inpatient Services S13, and Corporate Compliance Officer S14 were notified that the Immediate Jeopardy was lifted. Condition level non-compliance remained for the Condition of Participation for Nursing Services.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on observation, record review, and interviews, the hospital failed to provide adequate staff to meet the ordered observation levels of patients as evidenced by: 1) observation on 11/21/11 at 4:40pm revealed 1 MHT (mental health tech) attending 11 patients (some of whom were on modified visual contact) while outdoors on a smoke break and unable to view all areas at all times and 2) review of the assignment sheet for 11/11/11 revealed 1 MHT assigned the observation of one 1:1 (one-to-one) patient and 1 MHT assigned the observation of 1 patient on VC (visual contact), 6 patients on MVC (modified visual contact), and 5 patients on SO (special observation), the assignment sheet for 11/12/11 revealed 1 MHT assigned observation of one 1:1 patient, 3 patients on MVC, 2 patients on SO and 1 MHT assigned observation of two 1:1 patients, 2 patients on MVC, and 3 patients on SO, and the assignment sheet for 11/21/11 revealed 2 MHTs were each assigned the observation of 10 patients, 1 who was ordered 1:1 observation, 11 patients who were on MVC, and 8 patients who were on SO. Findings:

1) Observation on 11/21/11 at 4:40pm revealed 1 MHT attending 11 patients (some of whom were on modified visual contact) while outdoors on a smoke break and unable to view all areas at all times:
Observation on 11/21/11 at 4:40pm of the outside area used for smoke breaks for patients on Unit A revealed a covered area immediately upon exiting the building. Further observation revealed around the right corner of the building was a picnic table that could not be seen when one was standing under the covered area. Further observation revealed a large patch of overgrown bushes in the outside area that blocked full view of the area when standing under the covered area. Observation revealed to the left of the covered area was a sidewalk surrounded on one side by the building and the other side by a 6 foot chain-link fence surrounding a swimming pool that was filled with 5 feet of stagnant water with pine needles. The entire length of the sidewalk could not be viewed when one was standing under the covered area. Further observation revealed the 6 foot wooden fence to the left of the outside area was leaning and could be moved by using one hand.

Observation on 11/21/11 at 4:40pm of the outside area of Unit A revealed 11 patients, some of whom were on MVC, were on smoke break with one MHT assigned to observe.

In a face-to-face interview on 11/21/11 at 4:45pm, Administrator S1 confirmed that having one MHT observing 11 patients presented a severe elopement risk.

Review of the hospital's policies and procedures revealed no documented evidence of a policy that addressed the numbers of patients that could be observed by 1 staff member.

2) Review of the assignment sheet for 11/11/11 revealed 1 MHT assigned the observation of one 1:1 (one-to-one) patient and 1 MHT assigned the observation of 1 patient on VC (visual contact), 6 patients on MVC (modified visual contact), and 5 patients on SO (special observation), the assignment sheet for 11/12/11 revealed 1 MHT assigned observation of one 1:1 patient, 3 patients on MVC, 2 patients on SO and 1 MHT assigned observation of two 1:1 patients, 2 patients on MVC, and 3 patients on SO, and the assignment sheet for 11/21/11 revealed 2 MHTs were each assigned the observation of 10 patients, 1 who was ordered 1:1 observation, 11 patients who were on MVC, and 8 patients who were on SO:
Review of the assignment sheet for Unit A for 7:00am to 7:00pm on 11/11/11 revealed the staff consisted of 1 RN, 1 LPN (licensed practical nurse), and 2 MHTs. Further review revealed 1 MHT was assigned the observation of 1 patient who was on 1:1 observation. Further review revealed 1 MHT and the LPN were assigned the observation (with no designation as to which patients were observed by which staff member) of 1 patient on "strict" VC, 6 patients on VC, and 5 patients on SO.

Review of Patient #2's "Physician Admit Orders & (and) Preliminary Tx (treatment) Plan dated 11/11/11 at 1300 (1:00pm) and received by verbal order to RN (registered nurse) S15 from Physician S17 revealed the admitting diagnosis was Mood Disorder. Further review revealed the ordered observation level was modified visual contact (MVC) due to "suicidal, homicidal &/or violent behaviors".

Review of Patient #2's "Nursing Progress Note" dated 11/11/11 at 1600 (4:00pm) by RN S15 revealed that Patient #2 attempted suicide by tying a gown around his neck which resulted in him being found by MHT S16 cyanotic, responsive, and with bright red blood in his mouth.

Review of Patient #2's "Physician Orders - Routine" revealed a telephone order received by RN S15 from Nurse Practitioner S18 to "place patient on 1:1 for safety (after) patient found (with) gown around his neck".

Review of the "Assignment Sheet" dated 11/11/11 from 7:00am to 7:00pm revealed no documented evidence Patient #2 was assigned to a MHT for observation from the time of admission through the end of the shift, when he was first to be observed as MVC and then 1:1.

Review of the "Levels of Observation For Determining Acuity Staffing" for Unit A for 11/12/11 for 7:00am to 7:00pm revealed the staff included 1 RN, 1 LPN, and 2 MHTs. Further review of documentation next to the RN and LPN names revealed the notation "helping (with) 1:1s", and documentation next to the 2 MHTs' names revealed the notation "sharing 3 1:1s". Review of the "Assignment Sheet" revealed 1 MHT was assigned the observation of one 1:1 patient, 3 patients on MVC, 2 patients on SO, and the sharing of another 1:1 patient. The other MHT was assigned the observation of one 1:1 patient, sharing the other 1:1 patient, 2 patients on MVC, and 3 patients on SO.

Review of the "Assignment Sheet" for Unit A for 11/12/11 for 7:00pm to 7:00am revealed the staff included 1 RN, 1 LPN, and 2 MHTs. One MHT was assigned the observation of 1 patient on 1:1, 2 patients on MVC, and 3 patients on SO. The other MHT was assigned the observation of 2 patients ordered to be on 1:1 observation, 3 patients on MVC, and 2 patients on SO.

Review of the assignment sheet for 11/21/11 revealed 2 MHTs were each assigned the observation of 10 patients, 1 who was ordered 1:1 observation, 11 patients who were on MVC, and 8 patients who were on SO.

In a face-to-face interview on 11/22/11 at 11:10am, Administrator S1 confirmed Patient #2 was not placed on the assignment sheet by the RN on 11/11/11. S1 further indicated a MHT, when assigned the observation of a 1:1 patient, cannot be responsible for observing any other patient. After review of the assignment sheets for 11/11/11, 11/12/11, and 11/21/11, S1 confirmed the number of staff present was not adequate to meet the patient's care needs and the ordered observation levels for the patients on Unit A.

In a face-to-face interview on 11/22/11 at 11:30am, MHT S7 indicated when there's just 2 MHTs on a shift, there's a lot "not getting done such as spending more time with patients". S7 further indicated yesterday (11/21/11) the shift she worked had only 2 MHTs with 20 patients, one of whom was on 1:1 observation.

Review of the hospital policy titled "Levels of Observation - Therapeutic Safety Measures", effective 09/01/03, revised 05/28/10, and submitted by Administrator S1 as their current observation policy, revealed, in part, "I. Purpose To provide a consistent, therapeutic approach to ensure a safe environment for the patients within the facility. ... III. Procedure A. The following levels of observation are approved for utilization when clinically indicated: 1. Special Observation (S.O.) a. Location of patient is known at all times. The patient is observed with visual checks every 30 minutes documented on flow sheet. 2. Visual Contact (V.C.) a. The patient must be in sight of a staff member at all times and documented every 15 minutes on flow sheet. b. Patients placed on V.C. status must have a physician's order. ... d. The following precautions must have a V.C. status ordered: Suicide Precautions Fall Precautions Homicidal Precautions 3. One-to-One Nursing Care a. One-to-one nursing care is where a staff member is assigned to a patient to care for them in constant attendance at all times. A complete visual of the patient, from head to toe, is required. Documentation occurs every 15 minutes. The staff member must be within arms length of the patient at all times. b. Patients on 1:1 status must have a physician's order. ... d. The following criteria indicates the need for a 1:1 status: 1) The patient is actively suicidal or homicidal and requires staff constant intervention to maintain safety... 4. Modified Visual Contact (M.V.C.) a. The patient is observed within line of sight of staff during all waking hours, with documentation on location graph every 15 minutes. b. The patient is allowed to sleep in his/her room at night with door ajar. Staff checks patient every 15 minutes and documents checks on location graph. c. All patients admitted to the inpatient acute units are on MVC status unless on another indicated level. ... F. All 1:1 status patients are to be assigned to a staff member, as well as all other levels of observation as indicated on assignment sheet...".

Review of the hospital policy titled "Assignment of Patient Care to Nursing Staff Members", effective 09/01/03, revised 04/25/10, and submitted by Administrator S1 as the policy for assignment of patient care, revealed, in part, "...The registered nurse with designated responsibility to assign patient care to nursing staff members within the patient care unit will possess sufficient clinical managerial knowledge and experience. Assignment of nursing staff will include consideration of: ... Technology utilization and nursing staff skills. Degree of supervision required by nursing staff. ... Employee's clinical skills will be taken into consideration prior to making assignments. ...10. Staff will be assigned to patients based on patient needs and staff ability to provide care...".

Review of the hospital policy titled "Assessing and Tracking of Client Acuity", effective 05/3/10, revised 06/08/10, and submitted by Administrator S1 as the current policy for determination of acuity and staffing, revealed, in part, "...the hospital shall utilize the levels of observation for determining patient acuity & (and) staffing needs. ... A. At admission, clients will be placed on MVC unless they are homicidal, suicidal, or at fall risk. Then they will be placed on VC or 1 to 1. B. RN Charge Nurses for Unit A and B will complete the Levels of Observation for Determining Acuity/Staffing Sheet, at the beginning of each shift. Information and staffing pattern is reviewed at report. C. Using the Acuity Staffing sheet each level of observation is assigned a point value. SO = .25; MVC = .50; VC = .75; 1 to 1 = a staff member and is not part of the point value system. There will be an RN, LPN on each unit. A score of 3 = 1 staff member, 6 = 2 staff members, ... After clients are in bed for sleep at 10pm, the acuity scale will change to 4.5 per staff member until the clients arise at 6:15 am. ... E. If a client's behavior changes and the Charge Nurse assesses that the level of observation needs to be changed, they will contact the Psychiatrists on call and get an order. F. The Charge Nurse will communicate with the DON (director of nursing) and Administrator on-call when acuity levels increase. If more staff is needed, PRN (as needed) staff will be called in. ... H. Monday through Friday during the morning team meeting, the Hospital Administrator, DON, Unit Scheduler, and other members of the Leadership Team will review the acuity and staffing patterns for the day. I. Intake will contact the DON and Administrator when census is trending up or down to assure that staffing patterns meet the needs of the staff and clients". Review of the duties of the MHT attached to the policy revealed the MHT was responsible for the additional duties as listed: 1) smoking; 2) unit cleanliness; 3) room checks; 4) group exercise times 3; 5) group: priority / goals; 6) group: OT (occupational therapy) / RT (recreational therapy); 7) Group: Nursing; 8) Group: Life skills; 9) Group: Community; 10) Group: Current events; 11) Group: Wrap up; 12) EKG (electrocardiogram); 13) Meals; 14) Admits: legal paperwork, call and fax PEC, MMSE (mini mental status exam), Hudson, phone call; 15) Discharge: MMSE, Hudson, patient satisfaction survey; 16) Delinquent: MMSE, Hudson self-assessment; 17) Weekend recreation; 18) Vital signs; 19) Location graph; 20) Sharps; 21) Transportation; 22) Make up chart packets; 23) Stuff charts; 24) Trash; 25) Dirty linen; 26) Refrigerator; 27) Patient hygiene; 28) Diet / snack sheet; 29) Order supplies.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, record review, and interview, the hospital failed to ensure the RN (registered nurse) supervised and evaluated the nursing care for each patient as evidenced by: 1) failure to assess patients who required a change in observation level for 1 of 8 sampled patients (#4); 2) failure to supervise the ordered observation of patients provided by the MHTs (mental health tech) which resulted in a patient choking himself by tying a rolled paper scrub top around his neck while under ordered modified visual contact (MVC) that was not implemented (#2) and a patient eloping from the hospital grounds by jumping over a 6 foot wooden fence while ordered to be on one-to-one (1:1) observation and being left in the outdoor area observed by one MHT who was responsible for the observation of another 1:1 patient and 8 other patients (#2) for 1 of 8 sampled patients; and 3) failure to notify a family member and the physician after a patient attempted suicide and eloped as required by hospital policy for 1 of 8 sampled patients (#2). Findings:

1) Failure to assess patients who required a change in observation level:
Review of Patient #4's medical record revealed he was admitted on [DATE] with the diagnosis of Schizophrenia. Review of Patient #4's "Physician Admit Orders & (and) Preliminary Tx (Treatment) Plan" dated 11/07/11 at 0150 (1:50am) revealed an order for modified visual contact (MVC).

Review of Patient #4's "Physician Orders - Routine" revealed an order on 11/08/11 at 2210 (10:10pm) to discontinue MVC and place Patient #4 on strict VC (visual contact). Further review revealed an order on 11/11/11 at 2100 (9:00pm) to place Patient #4 on 1:1 (one-to-one). Review of the "Nursing Progress Note" for 11/11/11 from 7:00pm to 7:00am (11/12/11) revealed no documented evidence of an assessment by the RN of the behaviors exhibited by Patient #4 that warranted him to be changed from visual contact to 1:1 observation.

In a face-to-face interview on 11/28/11 at 4:55pm, Director of Nursing confirmed there was no RN assessment documented to indicate the behaviors exhibited by Patient #4 when his level of observation was changed.

Review of the hospital policy titled "Levels of Observation - Therapeutic Safety Measure", effective 09/01/03, revised 05/28/10, and submitted by Administrator S1 as the current policy levels of observation, revealed, in part,"... The R.N. is to assure that the location graphs reflect V.C. and 1:1 status with 15-minute checks. Documentation in the progress note should include level of observation and reason...".

2) Failure to supervise the ordered observation of patients provided by the MHTs:
Review of Patient #2's "Physician Admit Orders & (and) Preliminary Tx (treatment) Plan dated 11/11/11 at 1300 (1:00pm) and received by verbal order to RN (registered nurse) S15 from Physician S17 revealed the admitting diagnosis was Mood Disorder. Further review revealed the ordered observation level was modified visual contact (MVC) due to "suicidal, homicidal &/or violent behaviors".

Review of Patient #2's medical record revealed he had an order for protective custody signed 11/10/11 at 7:46pm, he had a PEC (physician emergency certificate) signed on 11/11/11 at 8:09am due to being gravely disabled, and he had a CEC (coroner's emergency certificate) signed on 11/13/11 at 11:17am due to being dangerous to self and gravely disabled.

Review of Patient #2's "Nursing Progress Note" dated 11/11/11 at 1600 (4:00pm) by RN S15 revealed, in part, "Client was in room alone. MHT S16 was @ (at) nurses' desk & looked up to see pt (patient) walking around in room (with) gown around neck. MHT ran into room & removed gown from pt's neck. Pt was cyanotic, responsive, had bright red blood in mouth..." Further review of an entry by RN S15 on 11/11/11 at 1605 (4:05pm) revealed "Nurse Practitioner S18 on unit and notified of incident. Client placed on 1:1 for safety".

Review of Patient #2's "Physician Orders - Routine" revealed a telephone order received by RN S15 from Nurse Practitioner S18 to "place patient on 1:1 for safety (after) patient found (with) gown around his neck".

In a face-to-face interview on 11/23/11 at 8:20am, RN S15 confirmed she performed Patient #2's admission assessment and was responsible for his care after his admission until the end of the shift. S15 indicated after Patient #2's skin assessment and contraband search were completed, he was brought to his room for her to complete her nursing assessment. S15 further indicated she completed Patient #2's nursing assessment, evaluated him (#2) to determine if he was suicidal and determined that he was not suicidal, and left Patient #2's room with the door to the room left open. S15 further indicated MHT S16 was sitting at the nursing station, looked up, and saw Patient #2 in his room with something around his neck. S15 further indicated MHT S16 ran in Patient #2's room and noted that he (#2) had a paper scrub tied tightly around his neck, and he (#2) was cyanotic but always responsive. RN S15 indicated that MVC meant the patient had to be in the line of sight of a staff member at all times. S15 further indicated MHT S16 could see Patient #2 when he walked to the foot of the bed, but S16 could not see all areas of the room while seated at the nursing station. S15 confirmed that hospital policy was not followed related to MVC when Patient #2 strangled himself.

In a telephone interview on 11/23/11 at 9:10am, MHT S16 indicated at the time of Patient #2's strangulation, he (S16) was observing two other patients who were ordered to be on 1:1, and he had not received extra help to perform these observations. S16 further indicated while he was with another patient down the room from the nursing station, he went to the nursing station to answer a ringing telephone. S16 further indicated as he hung up the telephone, he saw Patient #2 in his room (which was located across from the nursing station) with something around his neck. MHT S16 indicated he went into Patient #2's room and unwrapped the scrub tie from his neck. S16 further indicated Patient #2 was "very blue and purple, coughed up blood, had blood in his eyes, but never lost consciousness".

Review of the "Assignment Sheet" dated 11/11/11 from 7:00am to 7:00pm revealed no documented evidence Patient #2 was assigned to a MHT for observation from the time of admission through the end of the shift, when he was first to be observed as MVC and then 1:1.

Review of Patient #2's "Nursing Progress Note" dated 11/12/11 at 1730 (5:30pm) and documented by RN S12 revealed, in part, "...able to contract for safety to go to meals in cafeteria & outside to smoke; However @ smoke break (after) lunch, pt ran & 1240 (12:40pm) jumped over fence, headed to Hwy (highway) 21 & went into wooded area; 911 called police were able to apprehend pt & bring him back to unit. 11/12/11 1320 (1:20pm) pt returned to unit at 1310 (1:10pm)...".

Review of Patient #2's "Observation Log" dated 11/12/11 revealed MHT S9 documented Patient #2 was cooperative, in his room, and awake at 12:30pm. Further review revealed the next documentation at 12:45pm and 1:00pm revealed "eloped". There was no documented evidence that Patient #2 had been taken outdoors for a smoke break.

In a face-to-face interview on 11/22/11 at 11:10am, Administrator S1 confirmed no staff was assigned to Patient #2 according to the assignment sheet for 11/11/11. She indicated a MHT can't observe more than one patient when assigned to observe a patient 1:1. After review of the assignment sheets for 11/11/11 and 11/12/11, Administrator S1 confirmed the number of staff assigned the observation of patients was not adequate to provide the ordered observations. S1 further indicated the assignment was not being done correctly by the RN.

In a face-to-face interview on 11/22/11 at 1:10pm, MHT S9 indicated she observed Patient #2 on 11/12/11 from 7:30am to 7:00pm. She further indicated while outside for the smoke break, 4 patients were seated next to the wall, 3 patients were seated at the picnic table under the canopy, one patient was seated at the table around the corner, and Patient #2 began to walk away from the covered area. S9 further indicated there were about 10 patients outside with 2 MHT's. S9 indicated when the cigarette lighter she was using to light the patients' cigarettes failed to work, she went inside the hospital to get another lighter. S9 further indicated while MHT S10 was left to observe 10 patients, one of whom was 1:1 (Patient #2), Patient #2 jumped the fence. MHT S9 indicated 1:1 observation meant the staff had to be within arm's length of the patient and able to visually see the patient at all times. S9 confirmed she did not follow hospital policy for the observation of Patient #2 1:1 when he eloped.

In a face-to-face interview on 11/22/11 at 1:40pm, MHT S10 indicated he remembered Patient #2's elopement. S10 further indicated he didn't remember how many patients were outside at the time of the elopement, but he did confirm he (S10) was alone outside with Patient #2 who was ordered to be on 1:1 and other patients.

Review of the "Assignment Sheet" for 11/12/11 for 7:00am to 7:00pm revealed MHT S10 was assigned the observation of one 1:1 patient, 3 patients on MVC, and 2 patients on special observation. Further review revealed MHT S9 was assigned the observation of Patient #2 1:1, assisted with the 1:1 observation of another patient, 3 patients on special observation, and 2 patients on MVC.

In a face-to-face interview on 11/22/11 at 4:55pm, MHT S9 confirmed she was responsible for observing Patient #2 1:1 when he eloped. S9 further indicated she was also assigned the observation of 5 other patients and assistance with observing another patient 1:1. MHT S9 indicated she should not be observing other patients when she was assigned to observe a patient 1:1, but "when you're short-staffed, you do the best you can do".

In a face-to-face interview on 11/22/11 at 5:10pm, MHT S10 indicated he could not observe a patient 1:1 while observing 5 other patients, and he couldn't observe 2 patients who were 1:1 while on a smoke break with 8 other patients.

Observation of the outdoor area used for smoke breaks for patients on Unit A on 11/21/11 at 4:40pm revealed 11 patients outdoors with 1 MHT observing the patients.

In a face-to-face interview on 11/21/11 at 4:45pm, Administrator S1 confirmed that having 11 patients observed by 1 MHT presented a severe risk for elopement.

Observation on 11/21/11 at 4:50pm revealed Patient #2, who was ordered 1:1 observation, walked into the day room while MHT S7 (who was providing 1:1 with Patient #2) walked to the exit door to let other patients into the building. Further observation at this time revealed MHT S7 did not have continuous eye contact with and was not within arm's length of Patient #2 when she walked to the exit door. This observation was confirmed by Administrator S1.

Observation on 11/21/11 at 5:00pm revealed Patient #2 walking across the room in front of the nursing station while MHT S7, who was assigned to observe Patient #2 1:1, remained to the side of the nursing station talking to another staff member while not having continuous eye contact and being located within arms length of Patient #2. This observation was confirmed by Administrator S1.

Observation on 11/22/11 at 10:37am revealed MHT S11, who was assigned to observe Patient #2 1:1, walking multiple times with her back to Patient #2 while he paced away from S11.

In a face-to-face interview on 11/22/11 at 10:57am, Patient #2 indicated his bathroom door was closed when he used the bathroom or showered, and the MHT was usually in the nursing station. He further indicated he had never had a MHT present inside the bathroom with him when he used the bathroom or showered.

In a face-to-face interview on 11/22/11 at 10:57am, MHT S11 indicated she had allowed Patient #2 to use the bathroom today with the door closed while she stood outside the door. S11 confirmed she did not follow the observation policy, because she did not continuously have eye contact with and have Patient #2 within arm's length at that time. S11 further confirmed there had been times earlier today when she had her back to Patient #2 and did not have him within arm's length as required by policy for 1:1 observation.

Review of the hospital policy titled "Levels of Observation - Therapeutic Safety Measures", effective 09/01/03, revised 05/28/10, and submitted by Administrator S1 as their current observation policy, revealed, in part, "I. Purpose To provide a consistent, therapeutic approach to ensure a safe environment for the patients within the facility. ... III. Procedure A. The following levels of observation are approved for utilization when clinically indicated: ...3. Visual Contact (V.C.) a. The patient must be in sight of a staff member at all times and documented every 15 minutes on flow sheet. b. Patients placed on V.C. status must have a physician's order. ... d. The following precautions must have a V.C. status ordered: Suicide Precautions Fall Precautions Homicidal Precautions 3. One-to-One Nursing Care a. One-to-one nursing care is where a staff member is assigned to a patient to care for them in constant attendance at all times. A complete visual of the patient, from head to toe, is required. Documentation occurs every 15 minutes. The staff member must be within arms length of the patient at all times. b. Patients on 1:1 status must have a physician's order. ... d. The following criteria indicates the need for a 1:1 status: 1) The patient is actively suicidal or homicidal and requires staff constant intervention to maintain safety... 4. Modified Visual Contact (M.V.C.) a. The patient is observed within line of sight of staff during all waking hours, with documentation on location graph every 15 minutes. b. The patient is allowed to sleep in his/her room at night with door ajar. Staff checks patient every 15 minutes and documents checks on location graph. c. All patients admitted to the inpatient acute units are on MVC status unless on another indicated level. ... F. All 1:1 status patients are to be assigned to a staff member, as well as all other levels of observation as indicated on assignment sheet. G. The R.N. is to assure that the location graphs reflect V.C. and 1:1 status with 15-minute checks...".

3) Failure to notify notify a family member and the physician after a patient attempted suicide and eloped as required by hospital policy:
Review of Patient #2's medical record revealed he was admitted on [DATE] with the diagnosis of Mood Disorder. Further review revealed tried to choke himself by tying a paper scrub top around his neck on 11/11/11 at 4:00pm which resulted in him becoming cyanotic, had bright red blood in his mouth, and suffered subconjunctival hemorrhage. Further review revealed Patient #2 eloped on 11/12/11 at 12:40pm.

Review of the entire medical record revealed no documented evidence the RN notified the physician or a family member after the attempted suicide and the elopement. Nurse Practitioner S18 was called for each occurrence.

In a face-to-face interview on 11/23/11 at 8:20am, RN S15 indicated if Nurse Practitioner S18 had not been present at the hospital, she (S15) would have called the physician. S15 further indicated she did not notify a family member after the suicide attempt.

In a face-to-face interview on 11/23/11 at 8:45am, Administrator S1 indicated the family should be notified after an event if after consulting with the physician, the physician directs the RN to make the call.

In a face-to-face interview on 11/23/11 at 9:20am, Nurse Practitioner S18 indicated she was onsite during both incidents with Patient #2. After reviewing the medical record, S18 indicated she did not see a progress note documented for her visit, but she thought she probably incorporated the the visit with her psychiatric evaluation. S18 indicated she conferred with Psychiatrist S28 after the attempted suicide. S18 further indicated she didn't recall speaking with Nurse Practitioner S19 or Physician S21 after they examined Patient #2.

Review of the hospital policy titled "Notification of Family/Significant Other - Emergency", with no documented evidence of an effective or revised date and submitted by Administrator as the current policy for notification of family after an event, revealed, in part, "...1. As soon as possible after the occurrence of an emergency situation, the individual in charge of the unit/program or designee shall contact the patient's physician (or on call physician in the attending's absence) to apprise the physician of the situation. 2. Staff shall consult the physician as to the process to be followed in notifying the patient's family or significant other... 3. Staff shall document the physician's order and shall proceed as advised by the physician. 4. Staff shall document that the physician was notified of the event and the time of said notification. 5. Staff shall write a progress note documenting that the family / significant other was notified, the time, and the content of the conversation (if appropriate)...".
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure each patient's nursing care plan was kept current as evidenced by failure to include medical diagnoses of the patient and to modify the plan with changes in the patient's condition for 3 of 8 sampled patients (#2, #4, #7). Findings:

Patient #2
Review of Patient #2's "Physician Admit Orders & (and) Preliminary Tx (treatment) Plan dated 11/11/11 at 1300 (1:00pm) and received by verbal order to RN (registered nurse) S15 from Physician S17 revealed the admitting diagnosis was Mood Disorder.

Review of Patient #2's medical record revealed he had an order for protective custody signed 11/10/11 at 7:46pm, he had a PEC (physician emergency certificate) signed on 11/11/11/ at 8:09am due to being gravely disabled, and he had a CEC (coroner's emergency certificate) signed on 11/13/11 at 11:17am due to being dangerous to self and gravely disabled.

Review of Patient #2's medical record revealed he tried to choke himself by tying a paper scrub top around his neck on 11/11/11 at 4:00pm, and he eloped on 11/12/11 at 12:40pm.

Review of Patient #2's "Psychiatric Evaluation" performed by Nurse Practitioner S18 on 11/11/11 at 2230 (10:30pm) revealed Patient #2's "Problems/Preliminary Treatment Plan" included 1) agitated aggressive behavior, 2) suicide attempt - harm to self, and 3) homicidal threats".

Review of Patient #2's "Plan of Treatment - Interdisciplinary" revealed RN S15 identified the following problems: 1) Disturbed thoughts, 2) Mood Disorder - depressed, 3) Attempted suicide, and 4) Non-compliant with medications, all initiated on 11/11/11. Further review revealed the problem of risk for infection was added on 11/12/11 by RN S12.

Review of Patient #2's Plan of Care for Disturbed Thoughts revealed no documented evidence of the symptoms or behaviors exhibited by Patient #2 related to this problem, and no documented evidence of long term goals, a target date for achieving the goals, and the clinical interventions to be implemented. Review of the Plan of Care for Mood Disturbance Depressed revealed no documented evidence of a target date for achieving the goals and no clinical interventions to be implemented. Review of the Plan of Care for Infection revealed the short term goal was "patient will maintain normal vital signs". There was no documented evidence of parameters to be used to measure whether this goal was accomplished. Further review revealed the long term goal was that "patient will consume adequate nutrition/hydration daily by time of discharge". There was no documented evidence of the measurement to be used to determine when this goal would be met. Further review revealed the clinical interventions were actions to be taken by the nursing staff and not patient-focused interventions. Further review revealed no documented evidence a plan of care was initiated for the problems identified by Nurse Practitioner S18: agitated aggressive behavior, suicide attempt, and homicidal threats. There was no documented evidence of a plan of care initiated for ensuring safety for Patient #2 related to his elopement.

Review of Patient #2's medical record revealed a consult was ordered on [DATE] due to bilateral conjunctival hemorrhage secondary to choking himself and for an elevated pulse on 11/15/11. Review of Patient #2's plan of care revealed no documented evidence it was modified to include these additional problems.

Patient #4
Review of Patient #4's medical record revealed he was admitted on [DATE] with the diagnosis of Schizophrenia. Review of the "Psychiatric Evaluation" performed on 11/07/11 by Nurse Practitioner S18 revealed the "Problems/Preliminary Treatment Plan" included 1) Bipolar Disorder mixed with suicidal ideations, 2) Suicidal Ideation with depression, 3) Labile Moods, and 4) Marijuana Abuse.

Review of Patient #4's medical record revealed he was treated for a urinary tract infection, a rash to his left calf, and received diabetic education.

Review of Patient #4's "Plan of Treatment" revealed the identified problems on 11/07/11 were disturbed thoughts, disturbed sleep pattern, and risk for violence. Review of the "Interdisciplinary Treatment Plan Problem - Disturbed Thoughts" revealed no documented evidence of the clinical interventions to be implemented to address this problem. Further review revealed the target date for the short term goals was 11/14/11 and the target date for the long term goals was 11/19/11. Further review revealed as of 11/28/11 (date of review of this medical record) there was no documented evidence whether the goal had been met or that the goals and interventions had to be modified. Review of the treatment plan for disturbed sleep pattern revealed the target date for achieving the goals was 11/14/11. Further review revealed no documented evidence whether the goal had been met or that the goals and interventions had to be modified as of 11/28/11. Review of the treatment plan for risk for violence revealed the target dates for achieving the goals was 11/14/11 and 11/21/11. Further review revealed no documented evidence whether the goal had been met or that the goals and interventions had to be modified as of 11/28/11. Further review revealed no documented evidence that a treatment plan had been initiated for the identified problems of suicidal ideations, marijuana abuse, urinary tract infection, the rash to the left calf, and diabetes.

Patient #7
Review of Patient #7's medical record revealed he was admitted on [DATE] with a diagnosis of schizophrenia. Further review revealed he was PEC'd on 11/16/11 at 1656 (4:56pm) due to being dangerous to others. Further review revealed he was CEC'd on 11/18/11 at 1702 (5:02pm) due to being dangerous to others and gravely disabled.

Review of Patient #7's "Physician Orders - Restraint/Seclusion" received by verbal order on 11/18/11 at 11:45am from Medical Director S27 by RN (registered nurse) S24 revealed he was placed in 5 point leather restraints, locked seclusion, and administered a chemical restraint on 11/18/11 at 11:45am.

Review of Patient #7's "Plan of Treatment" revealed his identified problems were 1) disturbed thoughts, 2) medication non-compliance, and 3) poor impulse control. Review of the "Interdisciplinary Treatment Plan Problem - Disturbed Thoughts" initiated on 11/17/11 revealed no documented evidence of symptoms or behaviors exhibited by Patient #7 for which the problem was identified. Further review revealed no documented evidence of the clinical interventions to be implemented. Review of the "Interdisciplinary Treatment Plan Problem - Poor Impulse Control" initiated 11/17/11 revealed no documented evidence of symptoms or behaviors exhibited by Patient #7 for which the problem was identified. Further review revealed no documented evidence of the clinical interventions to be implemented. Further review a treatment plan for poor impulse control was also initiated on 11/18/11 with no documented evidence of short term goals, long term goals, and the clinical interventions to be implemented. Further review revealed no documented evidence Patient #7's treatment plan was modified with the use of physical and chemical restraints and seclusion on 11/18/11.

In a face-to-face interview on 11/28/11 at 4:55pm, Director of Nursing indicated the nursing care plans were supposed to be reviewed daily and charting should reflect the treatment plan. S2 further indicated the treatment plan should be updated with changes in the patient's condition.

In a face-to-face interview on 11/29/11 at 2:10pm, Director of Nursing S2 confirmed Patient #7's care plan was incompletely documented for poor impulse control and did not include a modification with the use of restraints and seclusion. S2 further indicated the care plans for Patients #2 and #4 were incomplete, did not include medical diagnoses, and were not updated/modified with changes in their condition.

Review of the hospital policy titled "Seclusion and Restraint", effective 09/01/03, revised 12/09/09, and submitted by Administrator S1 as the current policy for the use of restraints and seclusion, revealed, in part, "...Registered Nurse documents in patient's plan of care: assessed problem, objectives and goals, interventions, responsible staff, and reassessment...".
VIOLATION: VENTILATION, LIGHT, TEMPERATURE CONTROLS Tag No: A0726
Based on observation, record review, and interviews, the hospital failed to ensure refrigerators that were used to store medications and lab specimens were monitored for proper temperature as evidenced by incomplete or absent temperature logs. Findings:

Observation of the lab specimen refrigerator on Unit C on 11/21/11 at 3:50pm revealed no documented evidence of a refrigerator temperature log.

Review of the refrigerator logs for Unit A for October 2011 and November 2011 revealed 5 columns labeled as # (number)11, #10, #7, #8, and #12. Further review revealed no documented evidence whether the refrigerators stored medications or lab specimens and whether the temperatures listed in each column were a refrigerator temperature or a freezer temperature. Further observation revealed the following directions: "log temperature + (plus) initials daily, refrigerator should be 34-40 (degrees) F (Fahrenheit) and freezer 0-10 (degrees) F, give maintenance a work order if repair needed". Further observation revealed no documented evidence that a temperature was recorded on 10/02/11, 10/03/11, 10/09/11, 10/11/11, 10/12/11, 10/18/11, 10/23/11, 10/28/11, 10/31/11, 11/02/11, 11/09/11, 11/14/11, 11/15/11, and 11/16/11.

In a face-to-face interview on 11/21/11 at 3:50pm, Administrator S1 confirmed the lab refrigerator was not checked daily and no corrective action was taken when the temperature was out-of-range.

Review of the hospital policy titled "Refrigerator Temperature Control Testing", effective 09/01/01 and submitted by Administrator S1 as the current policy for refrigerator checks, revealed, in part, "...Greenbrier will ensure that the appropriate temperatures of all refrigerators are maintained in an effort to promote proper functioning and protection of its contents. ... A. Each refrigerator will contain a thermometer. B. Each refrigerator shall be maintained at 36 degrees F - 46 degrees F. C. Nursing Staff shall check each refrigerator daily and document the temperature on a log sheet. D. If the refrigerator reaches below or above the approved temperature, the medications shall be removed and stored in another area. Maintenance shall be informed and the refrigerator serviced...". Further review revealed no documented evidence of the approved freezer temperatures and what was to be done related to lab specimen refrigerators.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on record review and interview, the hospital failed to ensure the RN (registered nurse) assigned the nursing care of patients to staff who were determined to be competent as evidenced by: 1) failure to performance competency assessments for 2 of 3 MHTs' (mental health tech) personnel files reviewed for competency (S9, S16) and 2) failure to provide training in performing the face-to-face evaluation within 1 hour of initiating restraints or seclusion and perform competency assessments for 3 of 3 RNs' personnel files reviewed (S24, S25, S26). Findings:

1) Failure to performance competency assessments for MHTs:
MHT S9
Review of MHT S9's personnel file revealed she was hired on 09/28/05. Further review revealed S9's CPI (crisis prevention intervention) certification had expired 07/10, and S9 did not receive retraining on CPI until 11/03/11, more than 15 months after it had expired. Further review revealed no documented evidence that MHT S9 had been assessed for competency.

MHT S16
Review of MHT S16's personnel file revealed his date of hire was 08/14/09. Further review revealed no documented evidence that MHT S16 had been assessed for competency.

2) Failure to provide training in performing the face-to-face evaluation within 1 hour of initiating restraints or seclusion and perform competency assessments for RNs:
RN S24
Review of RN S24's personnel file revealed she was hired on 02/05/10. Further review revealed no documented evidence of an assessment of competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion and for performing the face-to-face evaluation of a patient within 1 hour after initiation of restraints or seclusion.

RN S25
Review of RN S25's personnel file revealed she was hired on 02/10/11. Further review revealed no documented evidence of an assessment of competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion and for performing the face-to-face evaluation of a patient within 1 hour after initiation of restraints or seclusion.

RN S26
Review of RN S26's personnel file revealed she was hired on 09/01/10. Further review revealed no documented evidence of an assessment of competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion and for performing the face-to-face evaluation of a patient within 1 hour after initiation of restraints or seclusion.

In a face-to-face interview on 11/29/11 at 2:10pm, Director of Nursing S2 confirmed the MHTs' files did not have documentation of competency assessments for the duties performed by the MHTs. S2 further confirmed the RNs' personnel file did not have evidence that they had been trained and determined to be competent to perform the face-to-face evaluation within 1 hour after a patient had been placed in restraints or seclusion.

Review of the hospital policy titled "Assignment of Patient Care to Nursing Staff Members", effective 09/01/03, revised 04/25/10, and submitted by Administrator S1 as the policy for assignment of patient care, revealed, in part, "...Before assuming responsibilities for patient care, all new hires will be assigned to orientation. ... The registered nurse with designated responsibility to assign patient care to nursing staff members within the patient care unit will possess sufficient clinical managerial knowledge and experience. Assignment of nursing staff will include consideration of: ... Technology utilization and nursing staff skills. Degree of supervision required by nursing staff. ... Employee's clinical skills will be taken into consideration prior to making assignments. ...All personnel having direct contact with patients shall have current CPR (cardiopulmonary resuscitation) certification and CPI certification...During the hiring process, staff skills are evaluated through their review of the job description and self-evaluation as well as review of their experience, training and education conducted by the Director of Nursing or designee... 3. The plan for staff competency outlines those specific skills required for staff working with adult psychiatric patient population. ... 10. Staff will be assigned to patients based on patient needs and staff ability to provide care...".
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure drugs and biologicals were administered according to physician's orders and accepted standards of practice for 1 of 8 sampled patients (#4). Findings:

Patient #4
Review of Patient #4's medical record revealed he was admitted on [DATE] with the diagnosis of Schizophrenia.

Review of Patient #4's "Physician Orders - Routine" revealed the following medication orders:
11/08/11 at 1300 (1:00pm) - Cipro 500 mg (milligrams) by mouth BID (twice a day) for 7 days;
11/16/11 at 1835 (6:35pm) - Metoprolol 25 mg by mouth BID for 2 weeks;
11/20/11 at 8:15pm - Cogentin 0.5 mg by mouth BID;
11/22/11 at 1400 (2:00pm) - Lotrisome cream to rash BID;
11/23/11 at 10:05am - Omeprazole 20 mg by mouth every day.

Review of Patient #4's MARs (medication administration record) revealed the following:
1) Cipro 500 mg was circled as not given at 9:00am on 11/09/11, at 9:00am on 11/10/11, at 9:00pm on 11/10/11, and at 9:00am on 11/11/11 with no documented evidence of the reason it was held except on 11/10/11 (unable to determine which time) when it was documented "for C&S (culture and sensitivity); there was no documented evidence that Cipro was attempted to be given at 9:00pm on 11/08/11 which was the next scheduled time of administration after the order was written. Further review revealed the first dose of Cipro was administered on 11/11/11 at 9:00pm, 78 hours after it was ordered, and there was no documented evidence that the physician was notified that the Cipro was being held.
2) Metoprolol 25 mg was hand-written on the MAR on 11/16/11 with no note written to record the apical pulse on the MAR and to hold if the pulse is 60 or less and call the physician. Review of the printed MARs received from the pharmacy revealed the note to record the apical pulse on the MAR and to hold if the pulse is 60 or less and call the physician. Review of the MARs and the nurses' notes revealed no documented evidence the apical pulse of Patient #4 was checked prior to the administration of Metoprolol on 11/16/11 at 9:00pm, on 11/17/11 at 9:00am and 9:00pm, on 11/25/11 at 9:00am and 9:00pm, on 11/26/11 at 9:00am, and on 11/27/11 at 9:00pm.
3) There was no documented evidence the first dose of Cogentin 0.5 mg was administered at 9:00pm on 11/20/11, which was after the order was received. Further review revealed no documented evidence of the reason the Cogentin was not administered as ordered or that the physician was notified of the missed dose.
4) There was no documented evidence that Lotrisome cream was administered as ordered at 9:00pm on 11/22/11, when the order was received at 2:00pm that day. Further review revealed no documented evidence of the reason the Lotrisome cream was not administered as ordered or that the physician was notified of the missed dose.
5) There was no documented evidence that the Omeprazole 20 mg was administered until 9:00am on 11/24/11, when the order was received on 11/23/11 at 10:05am.

In a face-to-face interview on 11/28/11 at 4:55pm, Director of Nursing S2 confirmed the above findings related to medication administration for Patient #4. S2 indicated he did not think there was a problem in obtaining the medications, but rather a documentation problem. He indicated the apical pulse should be documented on the MAR prior to the nurse administering Metoprolol. S2 confirmed that no incident reports had been completed for these medication variances.

Review of the hospital policy titled "Medication Orders", effective 09/01/03, revised 04/22/09, and submitted by Administrator S1 as one of their current policies for medication administration, revealed, in part, "...B. Frequency of Administration: 1. Times - All Units: a. q.d. (every day) 9 a.m. b. b.i.d. 9 a.m. & 9 p.m....". Further review revealed no documented evidence that the policy addresses first dose medications, including parameters within which nursing staff are allowed to use their own judgment regarding the timing of the first and subsequent doses, which may fall between scheduled dosing times; retiming of missed or omitted doses; medications that will not follow scheduled dosing times; patient units that are not subject to following the scheduled dosing times; and the actions to be taken when medications eligible for scheduled dosing times are not administered within their permitted window of time.

Review of the hospital policy titled "The MAR and Transcription of Physician's Orders", effective 09/01/03, revised 05/13/09, and submitted by Administrator S1 as one of their current policies for medication administration, revealed, in part, "...C. If unable to carry out the order as written, notify the physician. Chart specific details and reason for not carrying out the orders in the progress notes... J. Medication Administration Record Form ... 3. Documentation of routine medications: ... g. When a dose is omitted, the nurse will circle his/her initials on the MAR at the appropriate time corresponding to the omitted dose...".

Review of the hospital policy titled :Medication Record", with no documented evidence of an effective or revised date and submitted by Administrator S1 as one of their current policies for medication administration, revealed, in part, "...3. Documentation of routine medications: ... e. Nursing will use the MAR to document all doses given or omitted. Omitted times will be circled with an explanation written on the back of the form...".

Review of the hospital policy titled "Medication Variances", effective 09/01/03, revised 03/05/09, and submitted by Administrator S1 as one of their current policies for medication administration, revealed, in part, "...Variances in the administration of medication area are defined as: A. Omissions-any dose not given as ordered ... F. Wrong time-any drug given at other than the time limits set for daily administration. ... III. Procedure A. Staff shall report immediately to the attending physician all variances in the administration of medications. ... C. An Occurrence Report is prepared by the R.N. when he/she discovers that a medication variance in administration has been made. The original is sent to the Director of Nursing who reviews them and sends a copy to Pharmacy for review...".
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0431
Based on record review and interview, the hospital failed to meet the Condition of Participation for Medical Record Services as evidenced by:

1) Failing to develop and implement a system to ensure that all medical records were promptly completed no later than 30 days after discharge as evidenced by having 44 medical records without signed discharge summaries within 30 days after discharge and by having 1145 incomplete medical records awaiting medical record entries or completion of required signatures by the clinical staff dating as far back as 07/12/10 (see findings at tag A0438).
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on observation, record review, and interviews, the hospital failed to: 1) develop and implement a system to ensure that all medical records were promptly completed no later than 30 days after discharge as evidenced by having 44 medical records without signed discharge summaries within 30 days after discharge and by having 1145 incomplete medical records awaiting medical record entries or completion of required signatures by the clinical staff dating as far back as 07/12/10 and 2) medical records would be protected from water damage that could occur if the sprinkler system was activated. Findings:

1) Develop and implement a system to ensure that all medical records were promptly completed no later than 30 days after discharge:
Review of the discharge summaries presented by Administrator S1 on 11/29/11 revealed 39 unsigned discharge summaries for Physician S17 that were dictated for patients who had been discharged greater than 30 days prior to 11/29/11. Further review revealed 5 unsigned discharge summaries for Medical Director S27 that were dictated for patients who had been discharged greater than 30 days prior to 11/29/11.
Review of a list of patient records presented by Administrator S1 on 11/29/11 that were incomplete due to the clinical staff needing to add medical record documentation or to sign notes revealed 1145 patient medical records dating as far back as 07/12/10.

In a face-to-face interview on 11/28/11 at 11:55am, Director of Medical Records S20 indicated the last delinquent record rate she could find was dated 07/12/10. She further confirmed they currently did not have a system in place to track delinquent records or to compute a delinquency rate.

Review of the hospital policy titled "Chart Analysis, revised 12/04/08 and submitted by Corporate Director of Inpatient Services S13 as their current policy for completion of medical records, revealed, in part, "...C. The charts are reviewed for deficiencies and missing items are tagged for appropriate staff. The deficiencies are then entered on the deficiency list. Deficient charts are maintained in the Health Information Management Department for completion of deficiencies. A colored indicator tag is used whenever a signature is needed. A different colored tag is used for each service that needs to complete the record. ... 9. Discharge Summary a. A discharge summary must be completed by the treating psychiatrist on all patients that remain in the hospital over 48 hours and on all deaths, within 30 days of discharge and must include final diagnosis.

2) Medical records would be protected from water damage that could occur if the sprinkler system was activated:
Observation of the medical record room on 11/28/11 at 12:15pm revealed open-faced metal file shelves that contained patient medical records. Further observation revealed one box of patient medical records that was to be sent out for storage located on the floor next to the filing shelf. Further observation revealed two rolling carts with patient medical records stored on the open shelves. Further observation revealed the medical record room was sprinklered.

In a face-to-face interview on 11/28/11 at 12:15pm, Administrator S1 confirmed the medical record room was sprinklered, and the storage system for patient medical records provided no protection from water damage in the event that the sprinkler system was activated.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observation, record review, and interview, the hospital failed to ensure the facility and equipment was maintained to provide an acceptable level of safety for patients as evidenced by: 1) having peeling, unsecured floor tiles in the gym, a cracked, uneven sidewalk on the walking trail accessible to patients on Unit B and C, and large broken tree limbs on the outdoor grounds accessible to patients on Units B and C and 2) failure to perform a check of emergency supplies daily as required by policy, to perform blood glucose monitoring machine control checks at least weekly as required by policy, and to label the blood glucose monitoring control solution upon opening a new container as required by hospital policy. Findings:

1) Having peeling, unsecured floor tiles in the gym, a cracked, uneven sidewalk on the walking trail accessible to patients on Unit B and C, and large broken tree limbs on the outdoor grounds accessible to patients on Units B and C:
Observation of the gym used by patients on 11/21/11 at 1:50pm revealed a stage area with 3 steps leading to the stage. Further observation revealed 10 separate areas with the floor tile not secured and able to be lifted by hand. This presented a fall risk for all patients in the hospital who were taken to the gym. This observation was confirmed by Administrator S1.

Observation on 11/21/11 at 3:20pm of the outdoor area accessible to patients on Units B and C revealed 1358 feet of walking trail that had broken concrete on the sidewalk that caused approximately a 4 inch uneven drop in a triangular shape that could cause one to fall. Further observation revealed a 32 foot fallen tree that was propped on one end on the ground and one end on the fence that provided a walking path for a patient to walk and climb over the fence to elope. Further observation revealed multiple large broken tree limbs on the grounds that presented a hazard to walking safely in the area. These observations were made with Administrator S1 present.

In a face-to-face interview on 11/29/11 at 11:45am, Risk Manager/QAPI (Quality Assessment Performance Improvement) S22 indicated she and Environment of Care Director S6 performed monthly safety rounds, but the focus was inside the building and not the exterior grounds.

Review of the hospital policy titled "Safety Policies", effective 09/03, revised 03/10, and submitted by Administrator S1 as their current policy related to safety, revealed, in part, "...B. Plant, Building And Ground: Environment of Care department will be responsible for the following: ... 2. Insuring that the managers are held accountable for the safety performance of their employees relative to the general safety standards and the safe operation of equipment to include the work area. 3. Providing the necessary recommendations on the safety conditions of the building and ground of this facility. ... D. Facility Inspections: ... All public areas of the facility will be inspected by the Safety Director on a monthly basis. ... 2. Results of Safety Inspections: The following items are the desired results, which are produced from the department safety inspections: ... d. To determine unsafe patient, visitor and employee behavioral trends requiring modification.

2) Failure to perform a check of emergency supplies daily as required by policy and to perform blood glucose monitoring machine control checks at least weekly:
Observation of the emergency supplies on 11/21/11 at 3:50pm revealed the ambu bag was placed in a plastic bag. Further observation revealed no documented evidence that the tubing needed to connect the ambu bag to the oxygen cylinder was present or attached to the ambu bag. Further observation revealed the tubing for use of the suction machine was contained in the original package with the paper covering peeled back. This prevented the cleanliness of the tubing to be maintained. These observations were confirmed by Director of Nursing S2.

Review of the "Emergency Supplies Daily Checklist" revealed the following directions for completion of the check and documentation of the form: "1. Check emergency supplies daily 2. Initial the appropriate date checked 3. If seal has been broken, complete inventory 4. Sign to support initials". Review of the checklists dated September 2011, October 2011, and November 2011 revealed no documented evidence the emergency supplies had been checked on the following dates: 09/07/11, 09/20/11, 09/22/11, 09/26/11, 10/01/11, 10/05/11, 10/07/11, 10/10/11, 10/11/11, 10/19/11, 10/24/11, 11/02/11, 11/09/11, and 11/16/11.

In a face-to-face interview on 11/21/11 at 3:50pm, Administrator S1 confirmed the emergency supply checklist had not been completed daily, and thus could not determine that the supplies had been checked daily as required by hospital policy.

Observation of the blood glucose monitoring control solution for Unit B on 11/21/11 at 2:50pm revealed 2 vials of Quintet control solution. Further observation revealed the high level container was labeled "8-5", and the control solution was labeled "8-5-1" as the discard dates.

Review of the Unit B OneTouch Ultra 2 Blood Glucose Monitoring Machine Quality Control Log revealed the following instructions: "Control solution tests must be run once a week - every Friday night during night shift. Also do a control solution test: 1. to practice the test process instead of using blood 2. whenever you open a new vial of test strips 3. if you suspect the meter or test strips are not working properly, 4. if you have had repeated unexpected or inconsistent blood glucose results 5. if you drop or damage the meter". Further review revealed no documented evidence a check was performed on 09/23/11, 09/30/11, 10/07/11, 10/14/11, 10/21/11, 10/28/11, 11/04/11, 11/11/11, and 11/18/11.

In a face-to-face interview on 11/21/11 at 2:50pm, LPN (Licensed Practical Nurse) S3 indicated the dates on the blood glucose monitoring control solutions was not clear. S3 further indicated the solution is usually good for 30 days after it was opened. S3, after review of the control log, confirmed the blood glucose monitoring quality control was not performed every Friday.

Review of the hospital policy titled "Glucose Quality Control Testing for Quintet Blood Glucose Monitoring System", effective 09/01/03, revised 02/11/10, and presented by Administrator S1 as the current policy for blood glucose monitoring quality controls, revealed, in part, "...When Should a Quality Control Test Be Performed? Before executing a blood glucose test with meter for the first time. When opening and using a new vial of test strips, When replacing a Smart Code Key, check the meter by using the "Check Key". When the meter is dropped or splashed with liquids, Whenever test results are not consistent with symptoms. Whenever checking if the system is working properly. Whenever practicing testing and checking correct procedure. ... Precaution: When opening a new vial of Quintet Control Solution, write the discard date on the label. The expiration date of Quintet Control Solution is 3 months after opening the vial, or the expiration date printed on the label, which ever comes first...". Further review of the policy revealed no documented evidence that the policy included the requirement that the check be done every Friday as noted on the quality control log.

Review of the hospital policy titled "Emergency Equipment", effective 09/01/03, revised 09/28/06, and submitted by Administrator S1 as the current policy for checking the emergency supplies", revealed, in part, "...C. The night shift will inspect the emergency medication box every 24 hours to ensure that it remains sealed, and that all other items listed on the checklist are present...".