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.

OPTIMA SPECIALTY HOSPITAL 1131 RUE DE BELIER LAFAYETTE, LA July 20, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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

1) Failing to ensure the environment was free of ligature, suffocation, and electrocution risks as evidenced by:

a) Ligature risk associated with electrical beds in Rooms "a", "b", and "c". Patient #2, with a diagnosis of Bipolar Disorder Depressed, type severe with 4 GAD (generalized anxiety disorder) , Amphetamine Use Disorder, and Benzodiazapine Use Disorder and observation precautions of Aggressive Behavior/Assault, and Patient #3, with a diagnosis of Mood Disorder and observation precautions of Suicide/Self-Harm, were assigned to Room "b". The hospital did not have a waiver for the use of electric beds, and there was no documented evidence of increased observations or precautions with the use of electric beds with patients on Aggression and Self-Harm Precautions.

b) Suffocation risk associated with a plastic mattress cover in Room "c". The bed had a plastic mattress covering with a zipper that opened at the foot of the bed that extended across the mattress width to approximately 8 inches on each side that presented a risk for suffocation.

c) Electrocution risk associated with 4 to 5 uncovered outlets in Rooms "a", "b", "c", "d", "e", "f", "g", "h", "i", "j", "k", "l", "m", and "n" that were exposed and presented a safety risk to patients with psychiatric diagnoses. Uncovered electrical outlets were also present in Rooms "d" and "e" which were also used by patients.

d) Ligature risk associated with plumbing fixtures as the sink faucets in all patient bathrooms, community shower rooms, and hall sink were elongated and presented a ligature risk to patients (see findings in tag A0144).

An Immediate Jeopardy situation was identified on 07/18/16 at 3:45 p.m. and reported to S1ADM. The Immediate Jeopardy was a result of the hospital failing to ensure the environment was free of ligature, suffocation, and electrocution risks.

The hospital presented a plan to lift the Immediate Jeopardy, and the Immediate Jeopardy situation was lifted on 07/20/16 at 3:20 p.m. The plan included the following:

1) Ligature risks associated with having 3 electrical beds in Rooms "a", "b", and "c":
Plan of action:
a) All electrical beds with 10 foot cords and 10 foot call bell cords were immediately removed on 07/18/16.
b) Mandatory training for nursing staff on risk mitigation actions, including increased monitoring and plant anomalies was completed on 07/20/16. No other direct care staff will be permitted to work with patients until such time as they have received this education. Content of patient safety training included the following: review of policies "Nursing Rounds-Safety/Q (every) 15 Minute Checks" and "Precautions Levels and Records"; all extra equipment is removed immediately from patient care areas; electrocution risk posed by electrical equipment; all electrical equipment cords must be secured to prevent ligature risks; when electrical equipment is in use, monitoring will be elevated to LOS (line of sight) for both patients in a patient room; all electrical equipment in patient care area common spaces will be monitored at all times; avoidance of leaving patients unattended by staff in areas in which self-harm could occur; ligature risk monitoring/prevention. Training will occur during new hire orientation, annually, and as needed. Documentation of training is maintained in each employee's education file.
Monitoring Plan:
a) Direct care staff will conduct daily shift safety rounds; any deficiencies will be addressed immediately; Director of Nursing will report results of the safety rounds daily during the morning Leadership Meeting, monthly during the PI (performance improvement) meeting, and quarterly during the MEC (medical executive committee) meeting.
b) ADM /ADM on call or designated Director will conduct daily rounds to ensure safety of the patient care areas. Any deficiencies will be addressed immediately. ADM will report the results of the ADM rounds daily during the morning Leadership Meeting, monthly during the PI meeting, and quarterly during the MEC meeting.
c) The Director of Risk Management and the Director of Environment of Care will conduct monthly rounds to ensure ongoing safety measures and safety of the patient care areas. Any deficiencies will be addressed immediately. The Risk Manager will report the results monthly during the PI meeting and quarterly during the MEC meeting.

2) Suffocation Risk associated with the plastic mattress cover with zipper:
Plan of action:
a) The zippered mattresses were removed with the electric beds on 07/18/16. No other zippered mattress covers remain in the hospital.
b) Mandatory training for all direct care staff on risk mitigation actions, including increased monitoring and suffocation risk related to zippered mattresses was completed on 07/20/16. No other direct care staff will be permitted to work with patients until such time as they have received this education. Content of patient safety training included the following: review of policies "Nursing Rounds-Safety/Q 15 Minute Checks" and "Precautions Levels and Records"; suffocation risks; all extra equipment is removed immediately from patient care areas; any mattresses with zippers will not be allowed into the hospital.
Monitoring Plan:
a) Direct care staff will conduct daily shift safety rounds; any deficiencies will be addressed immediately; Director of Nursing will report results of the safety rounds daily during the morning Leadership Meeting, monthly during the PI meeting, and quarterly during the MEC meeting.
b) ADM /ADM on call or designated Director will conduct daily rounds to ensure safety of the patient care areas. Any deficiencies will be addressed immediately. ADM will report the results of the ADM rounds daily during the morning Leadership Meeting, monthly during the PI meeting, and quarterly during the MEC meeting.
c) The Director of Risk Management and the Director of Environment of Care will conduct monthly rounds to ensure ongoing safety measures and safety of the patient care areas. Any deficiencies will be addressed immediately. The Risk Manager will report the results monthly during the PI meeting and quarterly during the MEC meeting.

3) Electrocution Risk associated with 4 to 5 uncovered outlets in patients' rooms and all cited rooms:
Plan of action:
a) All cited room outlets and Restraint/Seclusion Room outlets were covered and secured with tamper resistant screws on 07/19/16.
Monitoring Plan:
a) Direct care staff will conduct daily shift safety rounds; any deficiencies will be addressed immediately; Director of Nursing will report results of the safety rounds daily during the morning Leadership Meeting, monthly during the PI meeting, and quarterly during the MEC meeting.
b) The Director of Risk Management and the Director of Environment of Care will conduct monthly rounds to ensure ongoing safety measures and safety of the patient care areas. Any deficiencies will be addressed immediately. The Risk Manager will report the results monthly during the PI meeting and quarterly during the MEC meeting.

4) Ligature Risk associated with elongated sink faucets and patient shower rooms:
Plan of action:
a) Contractor conducting the ligature risk mitigations for all patient bathrooms, shower rooms, and restraint/seclusion room has been given a deadline of 07/21/16 to fit all rooms with anti-ligature faucets.
b) Patients deemed at high or severe risk of suicide and/or self-harm behaviors as scored on the Suicide Risk Assessment will be immediately placed on LOS observation level while in the patient's assigned room unless the patient's room has already been renovated or the patient has already been placed on a 1:1 (one-to-one).
c) Patient placed on Aggression Precautions by the physician/licensed independent practitioner via data gathered during the intake assessment and/or nursing assessment will be immediately placed on LOS observation level while in the patient's assigned room unless the patient's room has already been renovated or the patient has already been placed on a 1:1.
d) Mandatory training for nursing staff on risk mitigation actions, including increased monitoring and plant anomalies was completed on 07/22/16, prior to working with patients. No other direct care staff will be permitted to work with patients as till such time as they have received this education. Content of patient safety training will include the following: review of policies "Nursing Rounds-Safety/Q 15 Minute Checks" and "Precautions Levels and Records"; avoidance of leaving patients unattended by staff in areas in which self-harm could occur; ligature risk monitoring/prevention. Training will occur during new hire orientation, annually, and as needed. Documentation of the training is maintained in each employee's education file.
Monitoring Plan:
a) Director of Environment of care or designated personnel will conduct daily safety rounds and report progress of listed items toward completion in the daily Leadership Meeting.
b) ADM, ADM on call, or designated Director will conduct rounds daily to ensure safety of the patient care areas and appropriate observation monitoring is being maintained. Adverse findings will be corrected immediately. ADM will report adverse findings to leadership daily.

As a result of the Immediate Jeopardy plan of lifting (MDS) dated [DATE] at 3:20 p.m., Immediate Jeopardy situation was removed.

Non-compliance continues at the Condition level.

2) Having safety hazards such as non-tamper-resistant screws on patient room entrance door hinges, patient bathroom door hinges, doors in Room "e", plastic coverings on the wall of the seclusion room, and shelves in patient rooms; sharp edges to plumbing covers in Room "e" and the left-side shower room; protruding hinges above doors in Rooms "e", "o", and the hall doors leading to the patient room corridor; toilet tissue dispenser in patient rooms with the rod holding the roll of tissue able to be pulled downward, creating the means to serve as a ligature risk; loose hand rails in the right side shower room and the bath at the end of the hall; plastic floor mats that were loose and provided a risk for falls; black rubber stripping around plumbing to the sink in the right shower room and the baths at each end of the hall that was able to be peeled and used as a ligature risk (infection control issue); bed in seclusion room with approximate 4 inch by 4 inch openings on each side of the bed that presented a ligature risk (see findings in tag A0144).
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on record reviews and interview, the hospital failed to ensure patients were informed of the phone number and address for lodging a grievance with the State agency as evidenced by failure to include the State agency's phone number and address in the "Patient and Family Handbook" and consent form and developing a procedure to inform patient's of this information.
Findings:

Review of the hospital policy titled "Grievance-Procedure Patient & (and) Family", presented as a current policy by S1ADM, revealed no documented evidence of a procedure for informing patients or their representative of the State agency phone number and address for lodging a grievance.

Review of the patient "Consent For Admission and Treatment" and the "Patient Bill of Rights" revealed no documented evidence that each included the process for patients or their representative to lodge a grievance with the State agency and included the phone number and address for the State agency.

In an interview on 07/20/16 at 9:00 a.m., S14RM confirmed the hospital's grievance policy doesn't include the process for patients to be informed that they have the right to file a grievance with the State agency that includes the State agency phone number and address. After reviewing Patient #1's medical record, S14RM confirmed there was no documented evidence in the record that Patient #1 or his representative was informed of the process for lodging a grievance with the State agency and the phone number and address of the State agency. He confirmed this information was not included in the "Patient and Family Handbook" and the "Patient Bill of Rights."
VIOLATION: PATIENT RIGHTS: TIMELY REFERRAL OF GRIEVANCES Tag No: A0120
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure its grievance process included a mechanism for timely referral of patient concerns regarding premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization. This resulted in Patient #1 being discharged with his medical power of attorney not being informed of the process for appealing the discharge if she thought Patient #1 was being prematurely discharged for 1 (#1) of 3 (#1, #R1, #R2) closed patient records reviewed for notification of rights from a total of 5 sampled patients and 2 random patients.
Findings:

Review of the hospital policy titled "Grievance-Procedure Patient & (and) Family", presented as a current policy by S1ADM, revealed that a patient grievance is a formal or informal written or verbal complaint that is made by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation, or a Medicare beneficiary billing complaint related to rights and limitations. Further review revealed no documented evidence that the policy addressed the process for filing a complaint related to premature discharge.

Review of the "Patient and Family Handbook", presented by S1ADM, revealed no documented evidence that the procedure related to filing a complaint with the Quality Improvement Organization (QIO) was included in the handbook.

Review of the postings placed on the inpatient unit presented by S14RM revealed no documented evidence that information related to the QIO was included in the forms posted.

Review of the hospital policy titled "Informed Consent", revealed no documented evidence of the procedure for informing the patient of his/her rights, obtaining a signature on the consent, and how to manage informing of rights when the patient has medical power of attorney in place.

Review of the "Power of Attorney", dated 10/15/15 and included in Patient #1's medical record, revealed S17FM was named as Patient #1's agent. Further review revealed the following information: "In accordance with the terms of Louisiana Civil Code Article 2997, this mandate expressly authorizes my attorney-in-fact to make all care decisions, other than declarations of life-sustaining procedures ... including, but not limited to surgery, medical expenses, nursing home residency, hospitalization , medication and/or authority to access or disclose information in accordance with the Health Insurance Portability & Accountability Act."

Review of Patient #1's medical record revealed he was admitted on [DATE] and had a PEC enacted on 06/04/16 at 4:00 p.m. that included the following information: patient presents with bizarre behavior, wandering at apartment complex; disturbing the public; awake and alert; rapid speech; flight of ideas; gravely disabled. Further review revealed Patient #1 had a CEC enacted on 06/05/16 at 2:35 p.m. that included the following information: oriented; depressed mood; dangerous to self and gravely disabled. Review of S3MD's progress note documented on 06/09/16 at 8:45 p.m. revealed the following information: subjective - "see two of you. I didn't sleep well."; progress - setback; evidence for continued care - medical issue management (had medical consult following a fall), abnormal mental status, medication management.

Review of Patient #1's "Consent For Treatment" revealed it included the hospital's discharge policy information and was signed by Patient #1 on 06/05/16 at 8:08 a.m. while he was under a PEC and prior to having a CEC enacted. There was no documented evidence that the consent for treatment was signed by Patient #1's POA S17FM.

Review of "An Important Message From Medicare About Your Rights" revealed if the patient thinks he/she is being discharged too soon, the patient has the right to an appeal by a QIO. The patient must contact the QIO no later than the planned discharge date and before he/she leaves the hospital. If this done, the patient will not have to pay for services received during the appeal. If the patient does not appeal and decides to stay in the hospital past the planned discharge date , the patient may have to pay for any services received after that date. Further review revealed the form was signed on 06/05/16 (day of admit) and on 06/10/16 (day of discharge) by Patient #1. There was no documented evidence that the notice of discharge rights was signed by Patient #1's POA S17FM.

Review of the "Patient Responsibility Worksheet", presented by S15DP from the business office records, revealed the patient's estimated liability was calculated using information the hospital received from the patient's health insurance, and the form was signed by Patient #1 and S16FA on 06/10/16 (day of discharge). There was no documented evidence that the "Patient Responsibility Worksheet" was signed by Patient #1's POA S17FM.

Review of the "Promissory Note", presented by S15DP from the business office records, revealed the amount that was owed by Patient #1 with a hand-written note of "unable to make payment aware of early out & collections." The form was signed by Patient #1 and S16FA on 06/10/16 with no documented evidence of S17FM's signature.

In a telephone interview on 07/19/16 at 8:17 a.m., S17FM, Patient #1's daughter and POA, indicated her father was admitted to another psychiatric hospital on [DATE] and discharged on [DATE]. She indicated she was never made aware that she could appeal his discharge, and had she been, she would have appealed the discharge. She indicated that during the family session held on 06/09/16 by telephone with her, her brother, and S5LMSW, she and her brother were informed their father would be out of coverage the next day, and they weren't planning on discharging him until the following week. She indicated she called S16FA the morning of 06/10/16 to find out how much the charges would be and was told it would be $600 per day, and the only payment installment plan the hospital was willing to agree to was a 6 month period of $215 per month. S17FM indicated she told S16FA that neither her father nor the family could afford to pay that. She further indicated about 30 minutes later, she received a call from the hospital informing her that she needed to come get her father, since he was being discharged . When she arrived, she noticed her father was still very manic and bizarre. She commented to the nurse that they were discharging him too early.

In an interview on 07/19/16 at 3:25 p.m., S9NP indicated based on her assessment of Patient #1, he looked rested, he had good energy, was in a pleasant mood the morning of discharge, and had been actively participating in groups and interacting with peers. She further indicated she didn't know anything about Patient #1's psychiatric lifetime days being used by 06/10/16.

In an interview on 07/20/16 at 9:45 a.m., S15DP indicated the therapist is typically the person who gets the Medicare Rights notice signed at discharge. She further indicated if a patient has a POA, all required signatures during the patient's stay should be signed by the POA. S15DP confirmed the discharge appeal rights should be signed by the POA, and Patient #1's rights form was not signed by his POA. She indicated usually the business office gets in touch with the POA to make arrangements about a payment plan and confirmed there's no documentation of such a discussion in Patient #1's business office records. S15DP indicated S16FA had documented forms for Patient #1, but she isn't available for interview since she's currently on leave. S15DP indicated the business office personnel is supposed to notify the discharge planner, the patient's therapist, and the utilization nurse if the patient out of days, and these individuals pass the information on the physician. She indicated S16FA informed her that Patient #1 had a limited number of psychiatric days on 06/06/16, and she and the utilization nurse informed S5LMSW, Patient #1's therapist and S3MD. She further indicated she notified S3MD about 2 or 3 times of the "imminent end of days", and she (S3MD) "held fast to the later discharge date , and after seeing Patient #1, S3MD deemed him stable to be discharged on [DATE].

In an interview on 07/20/16 at 11:35 a.m., S3MD indicated "evidence for continued care" means it's what continued care is expected for hospitalization . She further indicated it doesn't necessarily mean the patient requires continued hospitalization . When asked if patient 31 required continued hospitalization when she saw him on 06/09/16, she indicated he needed care, because he was pending a medical evaluation after a fall, and he continued to have anxiety issues. She further indicated the next day after he was evaluated medically, he could have been discharged if medical made no recommendations. When informed that the medical evaluation had recommendations to notify medical for a decrease in neurovascular status, presence of nausea and vomiting, and increased sleepiness, S3MD indicated S9PNP saw Patient #1 on 06/10/16 and found no issues, so he could be discharged . S3MD indicated she was never informed that Patient #1's psychiatric lifetime days would expire on 06/10/16. When informed that a previous interviewee had indicated that she informed S3MD 2 or 3 times of the "imminent end of days", S3MD again indicated she was never told. S3MD indicated it was a problem that financial issues had not been discussed with Patient #1's POA until the day before discharge.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on record review and interview, the hospital failed to ensure its policy for informed consent included the process for informing the patient of his/her rights, obtaining a signature on the consent, and how to manage informing of rights when the patient has medical power of attorney in place as evidenced by failure of the hospital to obtain informed consent of the patient's POA for 1 (#1) of 5 patient records reviewed for informed consent from a total of 5 patient records.
Findings:

Review of the hospital policy titled "Informed Consent", revealed no documented evidence of the procedure for informing the patient of his/her rights, obtaining a signature on the consent, and how to manage informing of rights when the patient has medical power of attorney in place.

Review of the "Power of Attorney", dated 10/15/15 and included in Patient #1's medical record, revealed S17FM was named as Patient #1's agent. Further review revealed the following information: "In accordance with the terms of Louisiana Civil Code Article 2997, this mandate expressly authorizes my attorney-in-fact to make all care decisions, other than declarations of life-sustaining procedures ... including, but not limited to surgery, medical expenses, nursing home residency, hospitalization , medication and/or authority to access or disclose information in accordance with the Health Insurance Portability & Accountability Act."

Review of Patient #1's medical record revealed his "Consent For Treatment" revealed it included the hospital's discharge policy information and was signed by Patient #1 on 06/05/16 at 8:08 a.m. while he was under a PEC and prior to having a CEC enacted. There was no documented evidence that S17FM was informed of patient rights, and the consent for treatment was not signed by Patient #1's POA S17FM.

Review of "An Important Message From Medicare About Your Rights" revealed if the patient thinks he/she is being discharged too soon, the patient has the right to an appeal by a QIO. Further review revealed the form was signed on 06/05/16 (day of admit) and on 06/10/16 (day of discharge) by Patient #1. There was no documented evidence that S17FM was informed of the patient's discharge rights, and the notice of discharge rights was not signed by Patient #1's POA S17FM.

In a telephone interview on 07/19/16 at 8:17 a.m., S17FM, Patient #1's daughter and POA, indicated she was never made aware that she could appeal his discharge, and had she been, she would have appealed the discharge.

In an interview on 07/20/16 at 4:20 p.m., S1ADM confirmed the hospital's consent policy doesn't include a process for obtaining the signature of the patient and the process to be followed when the patient has a medical POA.

In an interview on 07/20/16 at 9:45 a.m., S15DP indicated if a patient has a POA, all required signatures during the patient's stay should be signed by the POA. S15DP confirmed the discharge appeal rights should be signed by the POA, and Patient #1's rights form and consent for treatment were not signed by his POA.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, record reviews, and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by:
1) Failing to ensure the environment was free of ligature, suffocation, and electrocution risks as evidenced by:
a) Ligature risk associated with electrical beds in Rooms "a", "b", and "c".
b) Suffocation risk associated with a plastic mattress cover in Room "c" that had a zipper opening at the foot of the bed that allowed the cover to be opened and used for suffocation.
c) Electrocution risk associated with 4 to 5 uncovered outlets in Rooms "a", "b", "c", "d", "e", "f", "g", "h", "i", "j", "k", "l", "m", and "n" that were exposed and presented a safety risk to patients with psychiatric diagnoses.
d) Ligature risk associated with plumbing fixtures as the sink faucets in all patient bathrooms, community shower rooms, and hall sink were elongated and presented a ligature risk to patients.
2) Having safety hazards such as non-tamper-resistant screws on patient room entrance door hinges, patient bathroom door hinges, doors in Room "e", plastic coverings on the wall of the seclusion room, and shelves in patient rooms; sharp edges to plumbing covers in Room "e" and the left-side shower room; protruding hinges above doors in Rooms "e", "o", and the hall doors leading to the patient room corridor; toilet tissue dispenser in patient rooms with the rod holding the roll of tissue able to be pulled downward, creating the means to serve as a ligature risk; loose hand rails in the right side shower room and the bath at the end of the hall; plastic floor mats that were loose and provided a risk for falls; black rubber stripping around plumbing to the sink in the right shower room and the baths at each end of the hall that was able to be peeled and used as a ligature risk (infection control issue); bed in seclusion room with approximate 4 inch by 4 inch openings on each side of the bed that presented a ligature risk.
Findings:

1a) Ligature risk associated with electrical beds in Rooms "a", "b", and "c":
Observation of the patient rooms on 07/18/16 at 9:55 a.m. revealed Room "a" had an electric bed with accessibility to springs when the mattress was lifted and handrails on each side of the bed that could be a potential ligature risk. The bed had an approximate 10 feet call bell cord attached to it that could be a potential ligature risk. Further observation revealed Room "b" had an electric bed plugged into the receptacle by an approximate 10 feet electrical cord, and the same length call bell cord was attached to the bed. Further observation revealed Room "c" had an electric bed plugged into the receptacle by an approximate 10 feet electrical cord.

Patient #2, with a diagnosis of Bipolar Disorder Depressed, type severe with 4 GAD (generalized anxiety disorder) , Amphetamine Use Disorder, and Benzodiazapine Use Disorder and observation precautions of Aggressive Behavior/Assault, and Patient #3, with a diagnosis of Mood Disorder and observation precautions of Suicide/Self-Harm, were assigned to Room "b". The hospital did not have a waiver for the use of electric beds, and there was no documented evidence of increased observations or precautions with the use of electric beds with patients on Aggression and Self-Harm Precautions.

In an interview on 07/18/16 at 9:55 a.m., S1ADM indicated a patient was currently using the electric bed in Room "c", and she didn't have a waiver issued for the use of electric beds. She further indicated no increased observations or precautions were put in place to observe for potential injury related to the use of electric beds that had ligature risks.

1b) Suffocation risk associated with a plastic mattress cover in Room "c" that had a zipper opening at the foot of the bed that allowed the cover to be opened and used for suffocation:
Observation on 07/18/16 at 9:55 a.m. revealed Room "c" had an electric bed with a mattress that had a plastic covering. The plastic covering had a zipper opening on the foot of the mattress that extended across the width of the mattress and up approximately 8 inches on each side that allowed the plastic covering to become a risk for suffocation.

During the above observation on 07/18/16 at 9:55 a.m., S1ADM confirmed the plastic mattress covering presented a risk for suffocation.

1c) Electrocution risk associated with 4 to 5 uncovered outlets in Rooms "a", "b", "c", "d", "e", "f", "g", "h", "i", "j", "k", "l", "m", and "n" that were exposed and presented a safety risk to patients with psychiatric diagnoses:
Observation on 07/18/16 at 9:55 a.m., with S1ADM present, revealed the electrical receptacles throughout the hospital, particularly in Rooms "a", "b", "c", "d", "e", "f", "g", "h", "i", "j", "k", "l", "m", and "n", were uncovered, exposed, and presented a safety risk of electrocution to patients with psychiatric diagnoses. This observation was confirmed by S1ADM at the time of the observation.

1d) Ligature risk associated with plumbing fixtures as the sink faucets in all patient bathrooms, community shower rooms, and hall sink were elongated and presented a ligature risk to patients:
Observation on 07/18/16 at 9:55 a.m. revealed the sink faucets in all patient bathrooms (Rooms "a", "b", "c", "f", "g", "h", "i", "j", "k", "l", "m", "n"), community shower rooms and bathrooms, in Rooms "e" and "o", and in the hall near the community showers were elongated and presented a ligature risk to patients. This observation was confirmed by S1ADM.

An Immediate Jeopardy situation was called on 07/18/16 at 3:45 p.m. as a result of the above-listed ligature, suffocation, and electrocution risks (see findings in tag A0115).

2) Having safety hazards such as non-tamper-resistant screws on patient room entrance door hinges, patient bathroom door hinges, doors in Room "e", plastic covering on the wall of the seclusion room, and shelves in patient rooms; sharp edges to plumbing covers in Room "e" and the left-side shower room; protruding hinges above doors in Rooms "e", "o", and the hall doors leading to the patient room corridor; toilet tissue dispenser in patient rooms with the rod holding the roll of tissue able to be pulled downward, creating the means to serve as a ligature risk; loose hand rails in the right side shower room and the bath at the end of the hall; plastic floor mats that were loose and provided a risk for falls; black rubber stripping around plumbing to the sink in the right shower room and the baths at each end of the hall that was able to be peeled and used as a ligature risk; bed in seclusion room with approximate 4 inch by 4 inch openings on each side of the bed that presented a ligature risk:
Non-tamper-resistant screws:
Observation during the tour of the hospital on [DATE] at 9:55 a.m. revealed the hinges on the entrance door to patient rooms and bathrooms, the plastic covering on the wall of the seclusion room, and the shelves in Room "f" had non-tamper-resistant screws that, if tampered with by psychiatric patients, could become a risk for safety. This observation was confirmed by S1ADM at the time of the observation.

Sharp edges to plumbing covers:
Observation during the tour of the hospital on [DATE] at 9:55 a.m. revealed plumbing covers to the sink in Rooms "e" and the left-side shower room had sharp edges that could be used for self-harm. This observation was confirmed by S1ADM.

Protruding hinges above doors in Rooms "e", "o", and the hall doors leading to the patient room corridor:
Observation during the tour of the hospital on [DATE] at 9:55 a.m. revealed the hinges to the top side of the doors in Rooms "e" and "o" and the hall doors leading to the patient room corridor protruded and could present a ligature risk. Further observation revealed 4 interior doors in Room "o" had hinges wide enough apart to be a ligature risk. These observations were confirmed by S1ADM at the time of the observation.

Toilet tissue dispenser in patient bathrooms:
Observation during the tour of the hospital on [DATE] at 9:55 a.m. revealed the toilet tissue dispenser in patient rooms had a rod that holds the roll of tissue able to be pulled downward, creating the means to serve as a ligature risk. S1ADM confirmed this observation and indicated all patient bathrooms had this type of tissue dispenser.

Loose handrails:
Observation during the tour of the hospital on [DATE] at 9:55 a.m. revealed the handrails in the right-side shower room and the bathroom at the end of the hall near the community shower rooms were loose and presented a safety risk for falls. This observation was confirmed by S1ADM at the time of the observation.

Plastic floor mats:
Observation in the community bathroom near the laundry room on 07/18/16 at 9:55 a.m. revealed a plastic floor mat that was loose and presented a risk for falls. This observation was confirmed by S1ADM.

Black rubber stripping around plumbing to sinks:
Observation on 07/18/16 at 9:55 a.m. of the left shower room and both community bathrooms had a black rubber stripping around the sink plumbing cover that was loose and could be torn apart and presented a ligature risk. This observation was confirmed by S1ADM.
VIOLATION: PATIENT VISITATION RIGHTS Tag No: A0215
Based on observation, record reviews, and interview, the hospital failed to ensure its policy regarding visitation rights of patients included any clinically necessary or reasonable restriction or limitation that the hospital may need to place on such rights and the reason for the clinical restriction or limitation.
Findings:

Observation on 07/18/16 at 9:20 a.m. revealed a sign posted at the hospital entrance door with visiting times of Tuesday from 6:30 p.m. to 7:30 p.m. and Saturday from 3:30 p.m. to 4:30 p.m.

Review of the hospital policy titled "Visitation", presented as a current policy by S1ADM, revealed that the facility shall not impose rigid and restrictive visiting hours. Visitors will be permitted during unit-specified visiting hours. Individualized visitation times will also be attempted to accommodate families on a daily basis, as requested.

Review of the "Patient and Family Handbook", presented by S1ADM, revealed that visiting times for patients is Tuesday from 6:30 p.m. to 7:30 p.m. and Saturday from 3:30 p.m. to 4:30 p.m. Further review revealed general rules included that exceptions to these hours may be available, if necessary, with a Doctor's order. Further review revealed visitation with family members is encouraged but limits may be needed under specific circumstances based on your progress in treatment.

In an interview on 07/20/16 at 1:45 p.m., S1ADM was asked if visitation 1 hour a day for 2 days of the week was not viewed as rigid and restrictive. She indicated they meet requests for visitation outside these times "a lot." She further indicated she thought the hospital's practice met the regulations with the accommodations they made when requested. S1ADM indicated they had been in discussion recently and had discussed changing the policy.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:
1) Failing to develop a policy for the RN assessment of a patient after a fall. The hospital policy only addressed the procedure for a RN assessment of patients after a fall when they hit their head. This resulted in failure of the RN to document in the medical record a thorough assessment of a patient after a fall that included neurovascular and skin assessments for 1 (#1) of 1 patient experiencing a fall from a sample of 5 patient records reviewed for RN assessment after a fall.
2) Failure of the RN to notify the licensed practitioner of a patient experiencing an increase in pulse rate for 1 (#4) of 1 patient experiencing increase pulse rate from a sample of patient records reviewed for RN assessment.
3) Failing to develop a procedure for assuring that medical consults are conducted as ordered which resulted in medical consults not being conducted as ordered for 2 (#R2) of 6 (#1 - #5, #R2) patient records reviewed for completion of medical consults from a sample of 5 patients and 2 random patients.
Findings:

1)Failing to develop a policy for the RN assessment of a patient after a fall. The hospital policy only addressed the procedure for a RN assessment of patients after a fall when they hit their head which resulted in failure of the RN to document a thorough assessment of a patient after a fall that included neurovascular and skin assessments:
Review of the hospital policy titled "Fall Assessment & (and) Precaution", presented as a current policy by S1ADM, revealed the procedure for assessment after a fall if a patient falls and hits his/her head. There was no documented evidence that the policy addressed the procedure for conducting an assessment of any patient who falls.

Review of Patient #1's "Multidisciplinary Notes Nursing" revealed an entry on 06/09/16 at 7:05 a.m. by S8RN as follows: patient fell forward onto floor in front of staff and patients; stated he felt dizzy and saw double; vital signs were blood pressure 135/65, pulse 65, respiration 18, temperature 98 degrees, oxygen saturation 98 per cent, blood sugar 111; awake, alert, oriented times 3; states he fell on right knee; patient placed in wheelchair for safety; will continue to monitor for safety; called daughter to inform of fall. There was no documented evidence of a neurovascular and skin assessment conducted by S8RN.

Review of the Medical Consult ordered on [DATE] at 8:00 a.m. by S3MD revealed S7MNP conducted an evaluation on 06/09/16 at 8:30 p.m. (more than 12 hours after the fall). Further review revealed S7MNP documented a right knee contusion, a 2 centimeter (CM) by 2 cm bruise to the right knee, no hematoma, no open wound, neurovascular intact, awake, alert, and oriented times 3, calm and pleasant, no nausea and vomiting, patient awake, Cranial Nerves I -XII intact. Recommendations included to notify medical for any signs and symptoms of decreased neurovascular status, nausea and vomiting, and excessive sleepiness.

Review of Patient #1's medical record revealed no documented evidence of an assessment of vital signs, neurovascular status, presence or absence of nausea and vomiting, and presence or absence of excessive sleepiness as ordered by S7MNP.

In an interview on 07/20/16 at 7:35 a.m., S8RN indicated Patient #1 fell on his knee, and she reported that he complained of being dizzy to the nurse who relieved her at the end of her shift. She further indicated medication had been increased that could have caused the dizziness, and he didn't hit his head. S8RN indicated she reported the fall to S3MD who gave an order for a medical consult. She indicated she probably did a "mini-neuro check but didn't complete a neuro flow sheet and didn't document the mini-neuro check." She confirmed that the MNP's recommendations were an order, and an assessment of neurovascular status, presence or absence of nausea and vomiting, and presence or absence of excessive sleepiness should have been done. S8RN indicated the policy for reassessment after a policy is vague, because it refers to a patient hitting his/her head. She confirmed she didn't document a skin assessment.

In an interview on 07/20/16 at 10:40 a.m., S7MNP indicated when she writes recommendation on a medical consult form, they are orders for the staff to implement.


2) Failure of the RN to notify the licensed practitioner of a patient experiencing an increase pulse rate:
Review of Patient #4's "Graphic Sheet/I&O Sheet" revealed the following documented pulse rate: 07/14/16: 4:00 p.m. 102; 07/15/16: 8:00 a.m. 120, 8:00 p.m. 103; 07/16/16 8:00 a.m. 111; 07/17/16 8:00 a.m. 8:00 p.m. 111; 07/18/16 8:00 a.m. 120.

Review of Patient #4's "Multidisciplinary Notes Nursing revealed no documented evidence that the physician was notified of the increase in pulse rate for Patient #4.

Review of Patient #4's Physician orders revealed an order written on 07/16/16 at 7:40 a.m. by S9PNP " Med Consult- abnormal labs, increase pulse."

In an interview on 07/19/16 at 3:50 p.m., S9PNP confirmed that she ordered a medical consult for Patient #4 for abnormal labs and increased pulse on 07/16/16. S9PNP indicated that all consults should be performed within 24 hours. S9PNP indicated that upon review of the graphic chart she discovered that Patient #4's pulse rate was over 100 each day since admission, and she was concerned since Patient #4 had a medical history of CAD, HTN, and her lipid panel was elevated. S9PNP indicated that the nursing staff failed to communicate to the practitioners that the patient had been experiencing an elevated pulse rate.

3) Failing to develop a procedure for assuring that medical consults are conducted as ordered which resulted in medical consults not being conducted as ordered:
Review of the hospital policy titled "Medical Consultation", presented as a current policy by S1ADM, revealed no documented evidence that a procedure was developed for tracking medical consults to assure they were conducted as ordered.

Review of Patient #4's Medical record revealed an order written on 07/16/16 at 7:40 a.m. by S9PNP for a Medical Consult for "abnormal labs and increase pulse." Further review of the medical record review no documented evidences that the medical consult was completed as of 07/19/16.

In an interview on 07/19/16 at 2:30 p.m., S12RN confrmed that the Medical Consult was ordered and it should have been completed 24 hours after the order was written. S12RN indicated that the night nurse is responsible for making sure that all orders written during the day are completed by performing a 24 hour chart check.

Patient #R2
Review of Patient #R2's "Physician Discharge Summary" revealed 3 separate medical consults were ordered as follows: abnormal labs and leg pain; upper neck pain; dry cough and allergy.

Review of Patient #R2's entire medical record revealed no documented evidence that a medical consult was conducted as ordered for abnormal labs and leg pain and for dry cough and allergy.

In an interview on 07/20/16 at 1:40 p.m., S2IDON confirmed there was no documented evidence that the medical consult ordered for abnormal labs and leg pain and for dry cough and allergy was done. She indicated the policy doesn't address the time frame in which the ordered medical consult has to be completed and the process for tracking that its done. She further indicated no process is currently in place for checking for completed medical consults other than that the night nurse is responsible for doing a 24 hour chart audit each night.
VIOLATION: CONTENT OF RECORD - DISCHARGE SUMMARY Tag No: A0468
Based on record reviews and interviews, the hospital failed to ensure discharge summaries delegated to the psychiatric nurse practitioner were co-authenticated and dated by the psychiatrist responsible for the patient during his/her hospital stay to verify its content as evidenced by failure to have co-authentication by S3MD for 2 (#1, #R1) of 3 (#1, #R1, #R2) delegated discharge summaries from a total of 3 discharged patient records reviewed for discharge summary completion.
Findings:

Review of the hospital policy titled "Discharge Summary", presented as a current policy by S1ADM, revealed the attending physician/Licensed Independent Practitioner" is responsible for the completion of the Discharge Summary. Signature of the physician and the Licensed Independent Practitioner is required signifying review.

Patient #1
Review of Patient #1's "Physician Discharge Summary" revealed it was dictated by S4LPN for S9PNP on 06/24/16 at 6:22 a.m. and signed by S9PNP on 07/17/16 at 12:34 p.m. There was no documented evidence that S3MD had co-authenticated the discharge summary.

Patient #R1
Review of Patient #R1's "Physician Discharge Summary" revealed it was dictated by S4LPN for S9PNP on 06/22/16 at 7:24 a.m. and signed by S9PNP on 07/06/16 at 11:25 a.m. There was no documented evidence that S3MD had co-authenticated the discharge summary.

In an interview on 07/20/16 at 11:35 a.m., S3MD indicated she wasn't aware that she had to co-sign the discharge summaries that were done by the nurse practitioner.
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure the discharge planning evaluation included an evaluation of the likelihood of a patient's capacity for self-care or of the possibility of the patient being cared for in the environment from which he/she entered the hospital as evidenced by failure to have documented evidence of such an evaluation for 2 (#1, #2) of 5 patient records reviewed for a discharge planning evaluation from a total sample of 5 patients and 2 random patients.
Findings:

Review of the hospital policy titled "Discharge Planning", presented as a current policy by S1ADM, revealed that discharge planning commences upon admission. Further review revealed discharge planning should encompass areas including a review of any daily living changes the patient may need to decrease relapse potential.

Patient #1
Review of Patient #1's medical record revealed he was admitted on [DATE] and discharged on [DATE]. Review of his "Integrated Assessment/Psychosocial" conducted on 06/05/16 at 8:16 a.m. revealed he lived alone in an apartment and potential barriers/problems for discharge planning included issues around personal safety. There was no documented evidence of what the specific personal safety issues were.

Review of the "Psychosocial Assessment" conducted on 06/06/16 at 3:21 p.m. by S5LMSW revealed barriers/obstacles to the treatment process included "self-destructive, poor boundaries, limited insight/judgment." Further review revealed he lived alone in an elder apartment. The section of housing/placement needs had no check marks in any of the choices which included group home, nursing home/assisted living, lack of transportation, long term rehabilitation program, homeless shelter/emergency housing, and other. There was no documented evidence of an evaluation of the likelihood of Patient #1's capacity for self-care or of the possibility of him being cared for in the environment from which he entered the hospital.

Review of the "Multidisciplinary Notes Clinical Services" documented by S5LMSW on 06/06/16 at 3:34 p.m. revealed Patient #1's daughter reported he had an episode that led him to spend $349.00 on 50 CDs and 5 bottles of rubbing alcohol, and he was found sitting in his apartment community blasting his music with a picture of his deceased father with Ziploc bags on the chairs. Further review revealed the daughter reported that she would not like her father placed in a nursing home at this time, was considering assisted living, and would like him to have assistance. There was no documented evidence of an evaluation to determine Patient #1's capacity for self-care or of the possibility of him being cared for in the environment from which he entered the hospital.

In an interview on 07/20/16 at 9:45 a.m., S15DP reviewed Patient #1's discharge planning documentation. She indicated there should be documentation indicating whether the living arrangement upon admit was appropriate after discharge. She confirmed that she did not see such an evaluation in Patient #1's medical record.

Patient #2
Review of Patient #2's medical record revealed she was admitted on [DATE]. Review of her "Integrated Assessment/Psychosocial" conducted on 07/15/16 at 7:45 p.m. revealed she had a recent change in residence as evidenced by documentation that she was living with her father, but her father was now in jail as of the previous night. Further review revealed potential barriers/problems for discharge planning revealed difficulty with housing, relapse prevention, lack of support systems, and financial problems.

Review of Patient #2's "Case Management/Social Services Rounds" documented by S5LMSW on 07/16/16 at 9:40 a.m. revealed the discharge plan was "TBD" (to be discussed), patient reports she is not sure who will pick her up, and she stated she lives with her father.

As of the time of the medical record review on 07/18/16 at 11:00 a.m., there was no documented evidence of an evaluation of Patient #2 to determine the likelihood of her capacity for self-care or of the possibility of her being cared for in the environment from which she entered the hospital (her father's home).

In an interview on 07/19/16 at 2:40 p.m., S11CSW indicated the only discharge planning she documented for Patient #2 was the plan for her to attend an intensive outpatient or partial hospitalization program after discharge. When the documentation of the "Integrated Assessment/Psychosocial" conducted on 07/15/16 at 7:45 p.m. was reviewed, S11CSW indicated there should have been documentation by the social worker who met with Patient #2 over the weekend. She further indicated it doesn't usually take 4 days to start discharge planning. She further indicated she knows that a patient coming in over a weekend "isn't an excuse, but that's probably what happened."
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
Based on record reviews and interviews, the hospital failed to ensure the patient and family members were counseled to prepare them for discharge as evidenced by failure to have documented evidence of education on what to do when concerns, issues, or problems arise, including who to call and when they should seek emergency assistance, and a written list of all medications the patient should be taking after discharge with clear indication of changes from the patient's pre-admission medications for 3 (#1, #R1, #R2) of 3 closed medical records reviewed for discharge planning from a total sample of 5 patients and 2 random patients. Findings:

Review of the hospital policy titled "Discharge Planning", presented as a current policy by S1ADM, revealed that discharge planning begins upon admission. The RN/therapist/discharge planner documents final discharge plans on the "Discharge Instruction Form" including appointments set up, medications to be taken post-discharge, dietary needs post-discharge, community resources to be utilized after discharge, and discharge instructions are provided to the patient in a manner that is understandable. There was no documented evidence that the policy provided for education of the patient and family members on what to do when concerns, issues, or problems arise, including who to call and when they should seek emergency assistance, and a written list of all medications the patient should be taking after discharge with clear indication of changes from the patient's pre-admission medications.

Review of the "Discharge Instruction" for Patients #1, #R1, and #R2 revealed no documented evidence that they were informed of what to do when concerns, issues, or problems arise, including who to call and when they should seek emergency assistance. Further review revealed the instructions included a list of active discharge medications with no documented evidence of a clear explanation of changes in medications from the patient's pre-admission medications.

In an interview on 07/20/16 at 1:45 p.m., S1ADM reviewed the discharge instruction form of Patient #1. She confirmed the instruction sheet didn't provide a place to document that the patient was instructed on what to do if problems arose after discharge and who to contact. She also confirmed the discharge instructions included a list of active medications at discharge but didn ' t provide a clear indication of the changes made in medications at discharge from what the patient was taking prior to admission.