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.

LIBERTY HEALTHCARE SYSTEMS, LLC 4673 EUGENE WARE ROAD BASTROP, LA Dec. 19, 2013
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure that each patient or their representative had the right to participate in the development and implementation of his/her plan of care as evidenced by a patient's mother expressing the desire to speak with her son's psychiatrist and the psychiatrist not calling the mother as requested for 1 of 1 patient's record reviewed with a request for the psychiatrist to call from a sample of 7 patients (#3).
Findings:

Review of Patient #3's medical record revealed he was a [AGE] year old male admitted on [DATE] at 9:45 a.m. with diagnoses of Attention Deficit Hyperactive Disorder (ADHD), Bipolar Disorder, Oppositional Defiant Disorder, and Major Depression.

Review of "Documentation of Family Contacts, Family Sessions & (and) Individual Sessions" dated 11/29/13 and signed by S11Therapist revealed a family and individual session was held with Patient #3 and his mother. S11Therapist documented that Patient #3's mother verbalized that she didn't agree with Patient #3's doctor's judgement about him being discharged and requested that Patient #3's doctor contact her (mother). Further review revealed that Patient #3's mother also requested a written letter from the doctor stating that Patient #3 wasn't a harm to himself or others. Further review of the documentation of the session revealed that Patient #3's mother dismissed talking further with S11Therapist and Patient #3 and reiterated again that she wanted to be contacted by Patient #3's doctor.

Review of Patient #3's entire medical record revealed no documented evidence that S6Medical Director (admitting psychiatrist) contacted Patient #3's mother as she had requested to discuss her son's discharge.

In a telephone interview on 12/18/13 at 9:00 a.m., S6Medical Director indicated he never spoke with Patient #3's mother, but he "kept in touch with social services". He further indicated that he thought he may have tried to call her and got a recording, but he's not sure if he would have documented it in the patient's record. When asked if any staff member had told him that Patient #3's mother requested that he call her, S6Medical Director answered "yes I think so, that's why I tried to call her".
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure the patient and/or patient representative had the right to make informed decisions regarding his or her care. This was evidenced by the hospital's failure to ensure a patient's (R2) legal guardian was notified in a timely manner of a change in the patient's condition that required the patient (R2) to be transported to the Emergency Department of an acute care hospital. The patient (R2) sustained an injury following a physical altercation with a peer and was referred to the acute care hospital where a CT (computerized tomography) scan of the head was performed. The patient's legal guardian was not notified until 5 hours and 22 minutes after the injury and 1 hour and 22 minutes after the patient returned from the acute care hospital. This was noted for 1 of 1 patient's record reviewed for injury from a sample of 7 patients (R2). Findings:

Review of Patient R2's medical record revealed the patient was a [AGE] year old male admitted on [DATE]. Review of the "Interdisciplinary Flowsheet" dated 12/11/13 at 9:00 a.m. revealed documentation by S31RN indicating that Patient R2 was pushed and kicked in the head by an aggressive patient while on the unit. Further documentation revealed at 10:25 a.m. Patient R2 was transported to the Emergency Department (ED) of the acute care hospital for a CT (computed tomography) of the head. S31RN documented that Patient R2 returned to the hospital from the ED on 12/11/13 at 1:00 p.m. There was no documented evidence that S5Psychiatrist (attending physician) or Patient R2's mother was notified at the time of the incident or at the time Patient R2 was transported to the ED. Documentation revealed that S5Psychiatrist was not notified until 2:20 p.m. on 12/11/13 which was 5 hours and 20 minutes after the incident occurred and 1 hour and 20 minutes after Patient R2 returned from the ED. Documentation revealed that Patient R2's mother was not notified until 12/11/13 at 2:22 p.m. which was 5 hours and 22 minutes after the incident occurred and 1 hour and 22 minutes after Patient R2 returned from the ED.

In a face-to-face interview on 12/19/13 at 9:00 a.m., S2 DON indicated S5 Psychiatrist and Patient R2's mother were notified upon her instruction after requesting contact times to document in the report to DHH. S2 DON indicated they should have been contacted when the incident occurred and were not.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on record reviews and interview, the hospital failed to ensure that each patient or their representative was provided the address and telephone number for lodging a grievance with the State agency as evidenced by having the incorrect address and telephone number for the State agency listed on the form provided to patients or their representative.
Findings:

Review of the hospital's policy titled "Patient Complaint And Grievance Resolution", policy number 1019, revised 01/10, and presented as a current policy by S1Administrator, revealed patients and patient representatives are informed of the complaint and grievance procedure in the Patient Handbook that is given to every patient upon admission to the hospital.

Review of the form in the hospital's Patient Handbook titled "Complaint/Grievance Process Patient Representative/Advocacy Program" revealed the incorrect address and telephone number listed for reporting grievances to the State agency.

In a face-to-face interview on 12/19/13 at 9:00 a.m., S1Administrator confirmed that the number listed on the form provided to patients and their representatives in the Patient Handbook did not have the correct address and telephone number for the State agency.
VIOLATION: PATIENT RIGHTS Tag No: A0115
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 patient and/or patient representative had the right to make informed decisions regarding his or her care. This was evidenced by the hospital's failure to ensure a patient's (R2) legal guardian was notified in a timely manner of a change in the patient's condition that required the patient (R2) to be transported from the psychiatric hospital to the Emergency Department of an acute care hospital. The patient (R2) sustained an injury following a physical altercation with a peer and was referred to the acute care hospital where a CT (computerized tomography) scan of the head was performed. The patient's legal guardian was not notified until 5 hours and 22 minutes after the injury occurred and 1 hour and 22 minutes after the patient returned to the psychiatric hospital from the acute care hospital's Emergency Department. This was noted for 1 of 1 random patient's record reviewed for injury from a sample of 7 patients (R2) (see findings in tag A0131);

2) Failing to ensure patients were free from neglect as evidenced by a random patient (R2) who was ordered to be on line of sight observation being attacked by a peer on 12/11/13 that resulted in injury that required a CT (computed tomography) Scan of the head to be done. There was no documented evidence of re-training or changes in processes following the event to ensure that a future situation was prevented. This had the potential to affect the 15 patients who were admitted at the time of the survey on 12/16/13 (see findings in tag A0145);
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observations, record reviews, and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by having exposed plumbing in the patient bathrooms, plastic liners in garbage cans accessible to patients, sharp edges on bathroom fixtures, exposed long electrical cords, shower curtains hung by round plastic hooks on PVC rods that could provide a means of strangulation by hanging, a metal handrail in the boys' shower room with a 2 1/2 inch opening between the rail and the wall of the shower which presented the opportunity for hanging or strangulation, and shower handles in the boys' shower stalls that provided a means of hanging, all which could present a safety risk for psychiatric patients.
Findings:





Observation on 12/16/13 at 9:20 a.m. revealed the following:
a) Toilet tank lid was not secured in the bathroom between the restraint and seclusion room.
b) Plastic liner was noted to be in the trash can located in the bathroom between the restraint and seclusion room.
c) Lavatory was noted to be leaking in the bathroom between restraint and seclusion room.
d)Paper towel dispenser was noted to have sharp edges in the bathroom between restraint and seclusion room.
e) Seclusion room door was noted to be without taper proof screws and 4 screws were noted to have sharp edges.
f) Plexiglas in seclusion room with scratches and rough edges with the words f... you engraved in the inside of the window.
g) Exposed cords, wires on a television, DVD, and Wii game located in the corner of the dayroom near the restraint room.

In a face-to-face interview on 12/16/13 at 9:30 a.m., S1 Administrator confirmed the above findings and confirmed they presented a safety risk to psychiatric patients.

Observation of the boys' and girls' shower rooms on 12/16/13 at 10:20 a.m. and 10:45 a.m. respectively revealed the shower curtains were plastic and attached by closed plastic rings to a PVC rod. Further observation revealed some of the rods did not come off when pulled which provided a means for patients to use the curtain rod as a means of hanging oneself. When the rod could be removed by pulling it off the wall, the rod could be used as a weapon to hurt oneself or peers, and the curtains could be removed and used for strangulation. Further observation in the boys' shower room revealed a metal handrail with a 2 1/2 inch opening between the rail and the wall of the shower which presented the opportunity for a patient to tie fabric to it and use it to strangle or hang oneself. The shower handles in the boys' shower stalls were of the type that allowed a cloth to be wrapped around it and used for hanging. All of these observations were confirmed at the time of the observations by S1Administrator.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on record reviews and interviews, the hospital failed to ensure patients were free from neglect as evidenced by a random patient (R2) who was ordered to be on line of sight observation being attacked by a peer on 12/11/13 that resulted in injury that required a CT (computed tomography) Scan of the head to be done. There was a delay in staff intervention at the time of the altercation by the nearest staff available to the location of the altercation. There was no documented evidence of re-training or changes in processes following the event to ensure that a future situation was prevented. This had the potential to affect the 15 patients who were admitted at the time of the survey on 12/16/13.
Findings:




Review of R2's admission orders written on 12/9/13 at 2350 revealed R2's observation level was, day (7 a.m.-9 p.m. ) line of sight & night (9 p.m.-7 a.m.) q 15 ( every 15 minutes).

Review of the Interdisciplinary Flowsheet dated & timed 12/11/13 at 0900 by S31 RN(no longer on staff) indicated that R2 was pushed out of a chair, kicked in the head by "an aggressive pt. (patient ) on the unit." S31 RN documented that a MHT(Mental Health Technician) grabbed pt.(patient) by the chest removing other pt.(patient) from this pt.(R2). According to S31 RN who documented an assessment of R2 immediately after the incident there was "bruising to left upper forehead area, raised area to back of head and a small cut in the mouth with bleeding controlled." S31 RN documented on 12/11/13 at 0915 orders were written for X-ray CT (computed tomography) of head.

Review of R2's record revealed his observation level was LOS line of sight on 12/11/13 on the date of the incident. Review of the close observation sheet by the MHT for 12/11/13 revealed observation checked every 15 minutes with initial of the MHT. Further review of the close observation sheet revealed at 0900 (time of the incident) R2 was in the dayroom with documented observation every 15 minutes.

In a face-to-face interview on 12/18/13 at 10:35 a.m., S2 DON (Director of Nursing) indicated R2's observation level at the time of the incident was line of sight.

In a face-to-face interview on 12/18/13 at 2:15 p.m., S22MHT indicated she was the only MHT in the room with 5 young patients and 5 older male patients when Patient #7 physically attacked Patient R2. She further indicated she was assigned the observation of the 5 young patients, and the MHT assigned to the 5 older male patients was in another building doing laundry. S22MHT indicated a counselor was seated at the table with Patient R2 while Patient #7 sat alone at another table across the room. She further indicated after she heard a noise, she turned and saw Patient #7 punching Patient R2. By the time she reached the 2 patients a few moments after seeing them in the altercation, She surrounded her arms around Patient #7's chest to remove him from Patient R2. When asked what the counselor seated at the table with Patient R2 when the altercation began did when the altercation began, S22MHT answered "she was frozen". When asked where the nurse was at the time of the altercation, S22MHT answered that she (S31RN who is no longer employed) was "frozen".

In a face-to-face interview on 12/19/13 at 9:00 a.m. with S1Administrator and S2DON present, S2DON indicated Patient #7 was not being monitored appropriately when the altercation took place. S1Administrator indicated Patient #7 had an altercation the previous day that was not documented or reported by S31RN until this altercation occurred, and that is the reason S31RN no longer works at the hospital. She further indicated that the counselor seated at the table with Patient R2 told her she didn't intervene, because she didn't think she was the one to step in at the moment. S1Administrator further indicated that she (S1Administrator) actually thinks the counselor was in shock, because she had never witnessed an event such as this. S1Administrator indicated that she thought it all related back to the staff not being trained effectively on crisis prevention strategies.

Review of the "Hospital Abuse/Neglect Initial Report" sent by S2DON to DHH (Department of Health and Hospitals) and the "Performance Indicator Out Of Threshold" documented by S2DON revealed the interventions to address the event included that a "read and sign in-service" would be done with all direct care staff to review the current policies number 7003, 7005, and 7006. Further review revealed that once the policy had gone through review by the Performance Improvement Committee, any changes would be reviewed with the staff, and the proposed date for completion of the review by the Performance Improvement Committee is 12/23/13.

In a face-to-face interview on 12/19/13 at 9:00 a.m., S2DON indicated she had not presented the "read and sign in-service" yet and not made any changes to to the policies. She confirmed that no action had been taken since the event to prevent a recurrence of the situation.
VIOLATION: MEDICAL STAFF PRIVILEGING Tag No: A0355
Based on record reviews and interview the hospital failed to ensure that Advanced Practice Registered Nurses' (APRN) privileges were approved by the Medical Executive Committee and the Governing Body as evidenced by failure to have signatures by the Chairman of the Medical Board and Chairman of the Governing Body approving the privileges of 2 of 3 APRNs whose credentialing files were reviewed for privileges from a total of 3 credentialed APRNs (S15, S16).
Findings:

Review of the Medical Staff Bylaws, presented by S1Administrator as the current bylaws, revealed the organized medical staff was responsible for planning and implementing the privileging process that included developing and improving a delineation of privileges and processing the application. Upon approval of the medical executive Committee, it will be recommended to the Governing Board that the application be accepted or rejected. When final action has been taken by the Governing Board, the Administrator or Chief of Staff is authorized to transmit the decision to the candidate for membership.

Review of S15APRN's credentialing file revealed his "Delineation of Privileges Privilege Request Form" was dated and signed by S15APRN on 05/06/13. Further review revealed "Approved as requested" had a check mark in the blank. There was no documented evidence of a signature by the Chairman of the Medical Board and the Chairman of the Governing Body as required by having a line for their signature with a date (lines were blank).

Review of S16APRN's credentialing file revealed her "Delineation of Privileges Privilege Request Form" was dated and signed by S16APRN on 09/19/13. There was no documented evidence of a signature by the Chairman of the Medical Board and the Chairman of the Governing Body as required by having a line for their signature with a date (lines were blank).

There was no documented evidence presented of a Medical Executive Committee Meeting and a Governing Board Meeting since 01/07/13.

Review of 7 sampled patient records and 10 sampled random patients's records revealed S16APRN had performed the History and Physical examination for Patients #2, #6, and R2. Further review revealed she had provided treatment of a patient after an altercation with a peer and ordered the patient to be sent to the acute care hospital for a CT (computerized tomography) Scan of the head.

In a face-to-face interview on 12/18/13 at 10:50 a.m., S1Administrator presented the meeting minutes for the Medical Executive Committee Meeting and the Governing Board Meeting held on 01/07/13. She confirmed there had not been another meeting at which S15APRN's and S16APRN's privileges had been approved. She offered no explanation when informed that the Medical Staff Bylaws did not address the process for privileging APRNs at the time of their initial appointment to the medical Staff.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observations, record reviews, and interviews, the hospital failed to ensure the requirements for the Condition of Participation for Nursing Services were met as evidenced by:

1) Failing to to effectively supervise and evaluate the nursing care of each patient. This was evidenced by:

a) Failure to ensure the consistent implementation of physician orders for 1 of 7 current sampled patients (#6) and 4 of 10 current random sampled patients (R3, R4, R8, and R10) ordered to be on a LOS (Line of Sight) status and
b) Failure to obtain a physician order for the level of observation that a patient is to be placed on for 3 of 10 current random sampled patients (R5, R6, and R7) (see findings in tag A0395) and

2) Failing to ensure there was an adequate number of mental health technicians (MHTs) to provide the observation level as ordered by the physician and according to the MHT-to-patient ratio according to hospital policy for 17 of 18 days of staffing assignments reviewed from 12/01/13 to 12/18/13 (see findings in tag A0392).
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on record reviews and interviews the hospital failed to ensure there was an adequate number of mental health technicians (MHTs) to provide the observation level as ordered by the physician and according to the MHT-to-patient ratio according to hospital policy for 17 of 18 days of staffing assignments reviewed from 12/01/13 to 12/18/13.
Findings:

Review of the hospital policy titled "Plan For The Provision Of Nursing Care In Psychiatric Specialty Areas", policy number 7003, revised 03/10, and presented as a current policy by S1Administrator, revealed that in striving to assure optimal, achievable, quality nursing care and a safe patient environment, nurse staffing and patient assignment shall be based upon identified minimum staffing requirements and actual patient needs as assessed through use of the acuity tool. Further review revealed that staffing is based upon patient census and acuity and includes a mixture of RNs (registered nurses), LPNs (licensed practical nurses), and MHTs. Further review revealed that core staffing consisted on 1 RN, 1 LPN, and 1 MHT and adjusted according to patient census, acuity level, and patient safety. An average daily census of 12 patients with low acuity would have 1 RN, 1 LPN, and 2 MHTs for the day, evening, and night shifts. Review of the entire policy revealed no documented evidence of an acuity tool.

Review of the "24 Hour Assignment Sheet" for 12/01/13 through 12/18/13 presented by S2DON (Director of Nursing) revealed MHTs were assigned more than 6 patients (some days with as many as 10 patients) on 12/02/13 through 12/18/13.

In a face-to-face interview on 12/17/13 at 2:35 p.m., S9Therapist Intern indicated the MHT-to-patient ratio used to be 1 MHT to 5 patients, but it was changed to 1 MHT to 9 patients. She further indicated there are times that 1 MHT goes to do laundry (laundry room located in another building from where the patients are housed) or handles visitation. She indicated that she had spoken with S1Administrator about the MHTs leaving patients unsupervised to wash clothes, S1Administrator said she would check into it.

In a face-to-face interview on 12/18/13 at 10:50 a.m., S18MHT indicated she didn't think a MHT should have 9 patients and have to leave patients to go to another building to wash clothes. She further indicated some of her patients were on line of sight (LOS) when this occurred, but she didn't leave her patients unattended since she was relieved by the LPN. S18MHT indicated she sometimes was assigned 3 female patients and 4 male patients who located on 2 separate halls, so she had to ask one of the male MHTs to monitor the boys while she watched the girls. When asked how the patients' observation records were completed when she had patients on 2 halls, S18MHT answered that she may walk to the door of the boy's hall to complete her documentation. She confirmed that she does not visually see the patient when she does this. When asked how she handles having male and female patients who are on LOS, she indicated that the male MHT walked the hall. When asked how she maintained LOS in this instance, S18MHT answered that she couldn't see all the assigned patients on LOS at the same time.

In a face-to-face interview on 12/18/13 at 11:50 a.m., S1Administrator indicated the hospital policy stated that the MHT's staff ratio was 2 MHTs to 12 patients. When asked if the ratio meant that 1 MHT could be assigned 6 patients, S1Administrator answered "yes".

In a face-to-face interview on 12/18/13 at 2:15 p.m., S22MHT indicated she worked the night shift (11:00 p.m. to 7:00 a.m.) on 12/07/13 and was assigned 8 patients, 5 patients on 1 hall and 3 patients on another hall. She further indicated that all her assigned patients were on LOS (LOS on the assignment sheet). When asked how she maintained LOS observations with patients on 2 separate halls, she answered "a lot of walking". She indicated that S32MHT watched her (S22MHT) 5 patients along with her (S32MHT) 9 patients when she (S22MHT) left to check the 3 patients on the other hall. S22MHT indicated that LOS meant that she had to physically see the patient at all times. She confirmed that she and S32MHT could not see each patient continuously on the night of 12/07/13. S22MHT indicated that she and S33MHT alternated doing laundry on the night shift of 12/07/13 which meant she was gone from the building where her patients were housed every other 30 minutes from 11:45 p.m. to 5:00 a.m., leaving 2 MHTs with 22 patients during those times. S22MHT confirmed that she documented the observation sheets every 15 minutes but did not make rounds every 15 minutes. She indicated that the nurses usually stay in the nursing station. She further indicated that the RN went down one of the halls to which she was assigned twice during her shift on 12/07/13 while she was present.

In a face-to-face interview on 12/19/13 at 9:00 a.m. with S1Administrator and S2DON present, S2DON confirmed that patients with physician orders for LOS observation who are on 2 separate halls cannot be observed by the same MHT. She indicated that what is supposed to happen is if one MHT has patients on LOS, another MHT should be available to do every 15 minutes observations. S2DON indicated she reviews the staffing assignments for the day and evening shifts. She further indicated that on 12/07/13 she saw that the observation levels were written wrong on the staffing assignment sheet, but she didn't catch that MHTs had more than 6 patients and that MHTs had patients on LOS who were located on 2 separate halls.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on observations, record reviews, and interviews, the RN (Registered Nurse) failed to effectively supervise and evaluate the nursing care of each patient. This was evidenced by:

1) Failing to ensure the consistent implementation of physician orders for 1 of 7 current sampled patients (#6) and 4 of 10 current random sampled patients (R3, R4, R8, and R10) ordered to be on a LOS (Line of Sight) status and

2) Failing to obtain a physician order for the patents level of observation upon admit for 3 of 10 current random sampled patients (R5, R6, and R7).
Findings:

1) Failing to ensure the consistent implementation of physician orders for LOS:
Review of the hospital policy titled "Patient Observation Levels", policy number 2015, revised 02/10, and presented as a current policy by S1Administrator, revealed that the levels of observation were every 15 minutes, line of sight (LOS), and 1-to-1 observation at all times. Further review revealed that LOS required the staff to be within visual contact at all times with the exception of toileting and showering during which times staff shall be present outside the door left ajar but remain in audible contact with the patient. A staff member may observe more than one patient on line of sight only while those patients remain in an area for scheduled activity. If a staff member is observing more than one patient and one or more of the patients go to separate areas, the staff must transfer responsibility for LOS to other staff members, so there is continuous observation of all patients on LOS.

Observation on 12/18/13 at 3:45 p.m. revealed 9 current patients walking outside as they returned to the building that housed the patients with one therapist and 2 MHTs in attendance. Further observation revealed Patient R3 was walking at the back of the line with the backs of the therapist and the 2 MHTs to Patient R3 who was ordered to be on LOS.

Review of Patient R3's "Admission Physician Orders" dated 12/17/13 at 11:20 p.m. revealed her ordered observation level was line of sight from 7:00 a.m. to 9:00 p.m. and every 15 minutes from 9:00 p.m. to 7:00 a.m.

Observation on 12/18/13 at 4:00 p.m. revealed current Patient R4 was walking outside toward the building that housed the patients with S11Therapist walking ahead of Patient R4 with her (S11Therapist) back to Patient R4. Patient R4 was ordered to have LOS observation from 7:00 a.m. to 9:00 p.m.

Review of Patient R4's "Admission Physician Orders" dated 12/17/13 at 5:05 a.m. revealed her ordered observation level was line of sight from 7:00 a.m. to 9:00 p.m. and every 15 minutes from 9:00 p.m. to 7:00 a.m.

In a face-to-face interview on 12/18/13 at 4:25 p.m. S1Administrator and S2DON (Director of Nursing) confirmed the breaches in LOS observations of Patients R3 and R4.

Observation on 12/18/13 at 3:55 p. m. revealed S24MHT and 4 current patients (#6, R5, R6, R8) were walking across the lawn with S24MHT walking ahead of the patients. The 4 patients (#6, R5, R6, R8) were walking in a row and at no time did S24MHT turn around to check on the patients.

Review of Patient #6's medical record revealed he was ordered to be on LOS from 7:00 a.m. to 9:00 p.m.

Review of Patient R8's medical record revealed Patient R8 had a physician's order to be on continuous LOS.

In a face-to-face interview on 12/18/13 at 3:58 p.m., S1Administrator and S2DON indicated S24 MHT and the patients were returning from the Education Building and Patient #6's, Patient R8's, and Patient R10's level of observation was LOS at the time of the observation. S1Administrator and S2DON confirmed that S24MHT should have maintained LOS during the return back to the unit and did not.

Observation on 12/18/13 at 4:05 p.m. in the dayroom revealed S18MHT was seated at a table in front of the nurses' station with Patient R9 and Patient R10. S18MHT walked across the room with her back to Patient R9 and Patient R10 and sat with her back to Patient R9 and Patient R10 at a table located near the restraint room where 5 female patients were seated. S2DON approached S18MHT after approximately 3 minutes at which time S18MHT returned to the table where Patient R9 and Patient R10 were still seated unsupervised.

Review of Patient R10's medical record revealed Patient R10 had a physician's order to be on LOS from 7:00 a.m. to 9:00 p.m.

In a face-to-face interview on 12/18/13 at 4:12 p.m., S18MHT indicated Patient R9 and R10 were assigned to her, and both were on LOS (there were no physician orders for the observation level of Patient R9). According to S18MHT, when she walked over to be seated at the next table, Patient R9 and Patient R10 was not in line of sight and should have been.

In a face-to-face interview on 12/18/13 at 4:30 p.m., S1Administrator and S2DON indicated that all patients currently admitted to the hospital are on a LOS observation level during the day and every 15 minutes at night.

2) Failing to obtain a physician order for the patients level of observation upon admit.

Review of physician admission orders presented by S1Administrator and S2DON on 12/18/13 at 4:32 p.m. revealed no documented evidence of a level of observation ordered upon admit for current Patients R5, R6, and R7.

In a face-to-face interview on 12/18/13 at 4:10 p.m., S1Administrator confirmed that Patients R5, R6, and R7 did not have a level of observation ordered by the physician at admit. She further indicated there was no documented evidence that the RN obtained a clarification order to determine the level of observation that these patients should have been placed on.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on record reviews and interviews, the hospital failed to ensure that the RN (registered nurse) assigned the nursing care of each patient to other nursing personnel according to the patients' needs and the qualifications and competence of the available nursing staff. The nursing staff were trained in nonviolent crisis intervention strategies (NVCI) used to deal with patients exhibiting aggressive behaviors by a MHT (mental health technician) (S20) who did not have evidence of current training as an educator of the program for 15 of 17 personnel files reviewed for training in crisis prevention intervention strategies (S1, S2, S3, S7, S9, S10, S11, S12, S13, S14, S18, S21, S22, S25, S31).
Findings:

Review of S20MHT's personnel file revealed a certificate acknowledging that she completed the requirements for the "Nonviolent Crisis Intervention Instructor Certification Program" on 01/06/10. There was no documented evidence in her file that she was currently certified as an instructor of the program.

Review of the following staff members' personnel files revealed they were instructed by S20MHT on NVCI on the following dates:
S1Administrator - 02/05/13
S2DON (Director of Nursing) - 11/25/13
S3Medical record Clerk - 07/16/13
S7Discharge Planner - 11/13/12
S9Therapist Intern - 10/22/13
S10RN - 10/22/13
S11Therapist - 11/13/12
S12RN - 04/12/13
S13LPN (licensed practical nurse) - 11/29/13
S14Counselor Intern - 05/08/13
S18MHT - 04/12/13
S21RN - 05/21/13
S22MHT - 11/25/13
S25RN - 10/22/13
S31RN - 11/25/13

In a face-to-face interview on 12/18/13 at 4:25 p.m., S1Administrator indicated S20MHT's training as an instructor expired in 2011. She further indicated the hospital had developed their own nonviolent crisis intervention course. She could produce no evidence of training received by S20MHT to qualify her as an instructor of a nonviolent crisis intervention course. S1Administrator confirmed that she did not have documented evidence of training in providing nonviolent intervention strategies for the above-listed employees providing care to current patients by a qualified and competent instructor.

Review of R2's admission orders written on 12/9/13 at 2350 revealed R2's observation level was, day (7 a.m.-9 p.m. ) line of sight & night (9 p.m.-7 a.m.) q 15 ( every 15 minutes).

Review of the Interdisciplinary Flowsheet dated & timed 12/11/13 at 0900 by S31 RN(no longer on staff) indicated that R2 was pushed out of a chair, kicked in the head by "an aggressive pt. (patient ) on the unit." S31 RN documented that a MHT(Mental Health Technician) grabbed pt.(patient) by the chest removing other pt.(patient) from this pt.(R2). According to S31 RN who documented an assessment of R2 immediately after the incident there was "bruising to left upper forehead area, raised area to back of head and a small cut in the mouth with bleeding controlled." S31 RN documented on 12/11/13 at 0915 orders were written for X-ray CT (computed tomography) of head.

Review of R2's record revealed his observation level was LOS line of sight on 12/11/13 on the date of the incident. Review of the close observation sheet by the MHT for 12/11/13 revealed observation checked every 15 minutes with initial of the MHT. Further review of the close observation sheet revealed at 0900 (time of the incident) R2 was in the dayroom with documented observation every 15 minutes.

In a face-to-face interview on 12/18/13 at 10:35 a.m., S2 DON (Director of Nursing) indicated R2's observation level at the time of the incident was line of sight.

In a face-to-face interview on 12/18/13 at 2:15 p.m., S22MHT indicated she was the only MHT in the room with 5 young patients and 5 older male patients when Patient #7 physically attacked Patient R2. She further indicated she was assigned the observation of the 5 young patients, and the MHT assigned to the 5 older male patients was in another building doing laundry. S22MHT indicated a counselor was seated at the table with Patient R2 while Patient #7 sat alone at another table across the room. She further indicated after she heard a noise, she turned and saw Patient #7 punching Patient R2. By the time she reached the 2 patients a few moments after seeing them in the altercation, She surrounded her arms around Patient #7's chest to remove him from Patient R2. When asked what the counselor seated at the table with Patient R2 when the altercation began did when the altercation began, S22MHT answered "she was frozen". When asked where the nurse was at the time of the altercation, S22MHT answered that she (S31RN who is no longer employed) was "frozen".

In a face-to-face interview on 12/19/13 at 9:00 a.m. with S1Administrator and S2DON present, S2DON indicated Patient #7 was not being monitored appropriately when the altercation took place. S1Administrator indicated Patient #7 had an altercation the previous day that was not documented or reported by S31RN until this altercation occurred, and that is the reason S31RN no longer works at the hospital. She further indicated that the counselor seated at the table with Patient R2 told her she didn't intervene, because she didn't think she was the one to step in at the moment. S1Administrator further indicated that she (S1Administrator) actually thinks the counselor was in shock, because she had never witnessed an event such as this. S1Administrator indicated that she thought it all related back to the staff not being trained effectively on crisis prevention strategies.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, record reviews, and interviews, the hospital failed to ensure:
1) Medications were prepared in a clean and orderly area as evidenced by having medications stored in cabinets that contained medical equipment, having a centrifuge (used to spin blood specimens before transporting to the lab) on the work counter in the medication room, and having staff's personal belongings on the work counter of the medication room;
2) Medications that were expired or unusable were not available for use as evidenced by having expired medications stored with medications available for use, having multi-dose vials of medications with no date and initials of the person who opened the vial to determine when the medication had been opened, and multi-dose vials dated when opened that had dates to discard that were prior to the date of observation (12/16/13) available to be used for patient administration; and
3) Medications were administered as ordered by the physician or Licensed Independent Practitioner who is a member of the medical staff and has been granted clinical privileges to write such orders as required by hospital policy for 3 of 7 patients' medical records reviewed for medication administration from a total of 7 sampled patients (#1, #3, #4).
Findings:

1) Medications were not prepared in a clean and orderly area:
Review of the hospital policy titled "Medication Storage And Disposal", policy number MM104, revised 01/10, and presented as a current policy by S1Administrator, revealed that all medications are stored under proper conditions of sanitation and temperature, according to the manufacturer's recommendations and the Pharmacy's instructions to ensure their integrity, stability, and effectiveness.

Observation of the Medication Room on 12/16/13 from 9:25 a.m. through 10:10 a.m. with S2DON (Director of Nursing) present revealed the following:
a) A cabinet containing medications had notebook binders, multiple blood pressure cuffs, a bag with 5 boxes of thermometer probe covers, and lice spray also in the cabinet;
b) A second cabinet with medical supplies stored that included an open bag of bacteriology Culture Collection and Transport Systems (50 swabs) that expired 05/21/13, a second bag of the same items that expired 10/04/13, and an open box of Fingerstix Lancets that expired 03/13;
c) Drawer 1 of the medication cart had 2 Contour glucometers with test strips that had been opened and not dated when opened and 6 bottles of Contour Control Solution (2 low, 2 high, 2 normal) that should have been discarded 11/15/13 according to the label on the containers mixed with medications;
d) The counter in the Medication Room located next to the handwashing sink had a Hamilton Bell centrifuge (used to spin blood specimens before sending them to be tested ), a staff member's cup of fluids, and a staff member's personal bag/tote on the counter.

In a face-to-face interview on 12/16/13 at 9:45 a.m., S2DON indicated the literature for the Contour Control Solution and test strips state that they should be discarded when expired or 6 months after they are opened.

In a face-to-face interview on 12/16/13 at 10:10 a.m., S2DON confirmed that medical supplies were stored with medications. She further confirmed that the room was cluttered, and the dirty area with the centrifuge should not be near the clean area used for preparing medications.

2) Medications that were expired or unusable were not available for use:
Review of the hospital policy titled "Medication Storage And Disposal", policy number MM104, revised 01/10, and presented as a current policy by S1Administrator, revealed that vials that are opened are labeled per nursing to include the date, time, and initial of the nurse who opened the vial, and medications are checked for expiration dates on a regular basis by nursing. There was no documented evidence that the policy addressed the time frame that medication could be used once the vial was opened before discarding it.

Observation of the Medication Room on 12/16/13 from 9:25 a.m. through 10:10 a.m. with S2DON present revealed the following:
a) A cabinet with 2 opened boxes of 1 pound Epsom Salt (Magnesium Sulfate Saline laxative), unable to read the expiration on either box and neither box was dated and initialed when opened; one 500 ml (milliliter) Antiseptic Mouth Rinse that had been opened and available for re-use; 1 opened 4 pound box of Epsom Salt not dated and initialed when opened;
b) The second drawer of the medication cart had Mupirocin Ointment and Furoate Cream 0.1% (per cent) each with a label for patients who had been discharged ;
c) Drawer 1 of the medication cart had 1 opened 10 ml single dose Sterile Water for Injection, 2 tubes of 0.35 ounces Carmex and 1 tube of 0.25 ounces of Orajel that had been used.

In a face-to-face interview on 12/16/13 at 9:25 a.m., S2DON indicated the Epsom Salt should have been discarded after being open for 28 days. She further indicated that the mouth rinse should have been dated and initialed when opened.

In a face-to-face interview on 12/16/13 at 9:45 a.m., S2DON indicated medications for patients who have been discharged should not be stored in the medication cart and available for use. She further indicated the sterile water should have been discarded, and the Carmex and Orajel should have been labeled for a specific patient.

3) Medications were administered as ordered by the physician or Licensed Independent Practitioner who is a member of the medical staff and has been granted clinical privileges to write such orders as required by hospital policy:
Review of the hospital policy titled "Medication Administration And MD (medical doctor) Orders For Medications", policy number MM107, revised 03/13, and presented as a current policy by S1Administrator, revealed that medications will be administered only upon the order of a physician or Licensed Independent Practitioner who is a member of the medical staff and has been granted clinical privileges to write such orders. Further review revealed that all medication orders are to be timed and dated by the authorized person writing the order.

Patient #1
Review of Patient #1's medical record revealed she was a [AGE] year old female admitted on [DATE] at 4:30 p.m. with diagnoses of Major Depression with Psychosis, Possible PTSD (Post Traumatic Stress Disorder), Suicidal and Homicidal Threats, and Encopresis.

Review of Patient #1's "Physician Orders" revealed an order on 12/11/13 written by S6Medical Director with no documented evidence of the time the order was written for Risperdal 0.5 mg (milligrams) every night at bedtime from today. Review of the MAR (medication administration record) revealed Risperdal was first administered at 9:00 p.m. on 12/13/13 (2 nights after the order was written with 2 missed doses).

Patient #3
Review of Patient #3's medical record revealed he was a [AGE] year old male admitted on [DATE] at 9:45 a.m. with diagnoses of Attention Deficit Hyperactive Disorder (ADHD), Bipolar Disorder, Oppositional Defiant Disorder, and Major Depression.

Review of Patient #3's "Physician Orders" revealed an order on 11/22/13 written by S6Medical Director with no documented evidence of the time the order was written for Risperdal 1 mg by mouth at bedtime for psychosis. Review of the MAR revealed no documented evidence that Patient #3 received Risperdal at bedtime on 11/22/13 as ordered.

Patient #4
Review of Patient #4's medical record revealed she was a [AGE] year old female admitted on [DATE] with a diagnoses of Depressive Disorder, Mood Disorder, History of ADHD, and Suicide Attempt by overdose with Adderall.

Review of Patient #4's "Physician Orders" revealed an order on 12/06/13 written by S6Medical Director with no documented evidence of the time the order was written for Concerta 18 mg by mouth from tomorrow for ADHD. Review of the MAR revealed no documented evidence the medication was administered as ordered on [DATE] as the MAR had "N/A" (not available) written in the space for 9:00 a.m.

In a face-to-face interview on 12/19/13 at 9:00 a.m., S2DON indicated when S6Medical Director writes "from today" he means after today. She confirmed that Patient #1 missed 2 doses of Risperdal, and there was no clarification order obtained by the nurse to confirm that he wanted the medication to begin the next day. She confirmed that Patient #3's Risperdal was not documented as administered on 11/22/13 as ordered. S2DON indicated "N/A" on the MAR means not available. She indicated that Patient #4 not receiving Concerta on 12/07/13 would depend on what time the physician wrote the order. She further indicated if the order was written late in the day and the order was faxed to the pharmacy at that time, the medication may not have been available. She indicated the medication may not have arrived until the next evening, because the pharmacy makes one delivery a day late in the day.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0431
Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation for Medical Record Services as evidenced by:

1) Failing to ensure there was adequate trained staff to assure the prompt completion and filing of patient records. There were 254 completed patients' medical records in the medical record closet waiting to be filed and 120 delinquent medical records with the longest date of 03/19/13. The medical record clerk (S3) had no documented evidence of training and an evaluation of competency to perform the assigned duties in the medical record department (see findings in tag A0432);

2) Failing to ensure that patients' medical records were filed in a manner that provided protection from fire and water damage. There was no sprinkler system in place to protect the closed patient records from fire, and patient records were stacked on the floor in the medical record closet that provided an opportunity for water damage if there was a breach in the hospital's plumbing system (see findings in tag A0438); and

3) Failing to ensure that unauthorized individuals cannot gain access to patient records as evidenced by having the door to the Medical Record room open with a table and rolling cart containing more than 100 patients' medical records, the door to the hall leading to the medical record closet unlocked, and the door to the medical record closet that contained discharged patients' medical records open with no staff member in the room. The Medical Record room was accessible to the lobby of the hospital where staff and visitors entered the building (see findings in tag A0441).
VIOLATION: ORGANIZATION AND STAFFING Tag No: A0432
Based on observations, record reviews, and interviews, the hospital failed to ensure there was adequate trained staff to assure the prompt completion and filing of patient records. There were 254 completed patients' medical records in the medical record closet waiting to be filed and 120 delinquent medical records with the longest date of 03/19/13. The medical record clerk (S3) had no documented evidence of training and an evaluation of competency to perform the assigned duties in the medical record department.
Findings:

Review of the "Medical Staff Bylaws", presented by S1Administrator as the current bylaws, revealed that all medical records shall be completed by the attending physician within 30 days of discharge.

Observation in the conference room on 12/16/13 at 8:50 a.m. revealed 100 plus patient records stacked on the table. At the time of this observation S3Medical Record Clerk indicated the patient records were in need of nursing staff signatures. She confirmed that most of the records were incomplete and thus delinquent.

Observation in the Medical Records room on 12/16/13 at 10:55 a.m. revealed a table and a rolling cart with 125 patients' medical records. Observation at this time of the medical record closet where patients' medical records are stored revealed 12 wooden shelves containing patients' medical records. There were 254 patients' medical records stacked on the shelves that needed to be filed.

Review of a list of delinquent records provided by S3Medical record Clerk revealed a total of 120 patients' medical records that were delinquent with the longest date being 03/19/13.

Review of S3Medical Record Clerk's personnel file revealed she transferred from the position of Receptionist to Medical Records Clerk on 11/26/13. Further review revealed no documented evidence that S3Medical records Clerk received orientation to the job duties of Medical record Clerk, and there was no documented evidence that she had been evaluated to determine that she was competent to perform the assigned duties of her job.

In a face-to-face interview on 12/16/13 at 10:55 a.m., S3Medical Record Clerk indicated she was the only medical record staff other than the contracted coder.

In a face-to-face interview on 12/16/13 at 11:00 a.m., S1Administrator confirmed that S3Medical Record Clerk was the only staff responsible for the medical record department. She further indicated S4Contracted RHIT (Registered Health Information Technician) provided oversight of S3Medical record Clerk. S1Administrator indicated both S3Medical Record Clerk and S4Contracted RHIT were new to the department as a result of the former staff not fulfilling the duties required in the department such as filing and working delinquent charts.

In a face-to-face interview on 12/19/13 at 9:00 a.m., S1Administrator indicated that she could not present any evidence that S3Medical Records Clerk had been oriented to her new position and had been evaluated for competency in performing the duties assigned to her.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on observations, record reviews, and interviews, the hospital failed to ensure that patients' medical records were filed in a manner that provided protection from fire and water damage. There was no sprinkler system in place to protect the closed patient records from fire, and patient records were stacked on the floor in the medical record closet that provided an opportunity for water damage if there was a breach in the hospital's plumbing system.
Findings:

Review of the hospital policy titled "Management Of Information Plan", policy number 9001, revised 01/10, and presented as a current policy by S1Administrator, revealed that information management policies and procedures outline the mechanisms undertaken by the hospital to protect and safeguard data against loss, destruction, and tampering. Further review revealed that measures outlined in related information management policies and procedures include protection of data and records from fire and water damage or destruction. S1Administrator did not present any additional policy that addressed the specific measures taken to protect patient medical records from fire damage by the end of the survey on 12/19/13.

Observation in the conference room on 12/16/13 at 8:50 a.m. revealed 100 plus patient records stacked on the table. Further observation revealed no visible sprinkler system in place to protect the medical records from potential fire damage.

Observation in the Medical Records room on 12/16/13 at 10:55 a.m. revealed a table and a rolling cart with 125 patients' medical records. Observation at this time of the medical record closet where patients' medical records are stored revealed 12 open wooden shelves containing patients' medical records. Further observation revealed 21 patient records were stacked on the floor. There was no visible sprinkler system in the closet that could provide protection of the records from water damage. There was no means of protecting the records stacked on the floor from damage from water if there was a breach in the hospital's plumbing.

In a face-to-face interview on 12/19/13 at 9:00 a.m., S1Administrator indicated there was a fire extinguisher available outside the Medical Record room, and she didn't know if the hospital was constructed with fire walls as a protection of the patients' medical records stored in the Medical Record room and closet. She further indicated that the fire extinguisher would not be a sufficient means of protecting the medical records from fire. She confirmed that the records stored on the floor in the closet provided a means of damage in the event a plumbing problem occurred, and the records should not have been stacked on the floor.
VIOLATION: CONFIDENTIALITY OF MEDICAL RECORDS Tag No: A0441
Based on observation and interview the hospital failed to ensure that unauthorized individuals cannot gain access to patient records as evidenced by having the door to the Medical Record room open with a table and rolling cart containing more than 100 patients' medical records, the door to the hall leading to the medical record closet unlocked, and the door to the medical record closet that contained discharged patients' medical records open with no staff member in the room. The Medical Record room was accessible to the lobby of the hospital where staff and visitors entered the building.
Findings:

Observation of the Medical Record room on 12/16/13 at 2:45 p.m. revealed the door to the Medical Record room was open with no staff present at the time of the observation. Further observation revealed a table and rolling cart containing more than 100 patients' medical records was located in the Medical record room. Further observation revealed the door to the hall leading to the medical record closet was unlocked, and the door to the medical record closet that contained discharged patients' medical records was open.

In a face-to-face interview on 12/16/13 at 2:45 p.m., S1Administrator confirmed the above observation. She indicated that the room should not be left unattended with the door open and unlocked.
VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews the hospital failed to ensure that each patient's record contained radiology reports as evidenced by failure to have a copy of the radiology report for a CT (computed tomography) Scan of the head on the medical record for 1 of 1 patient's record reviewed who had an injury that required a CT from a total of 7 sampled patients and 10 sampled random patients (R2).
Findings:

Review of the hospital policy titled "Management Of Information Plan", policy number 9001, revised 01/10, and presented as a current policy by S1Administrator, revealed that necessary elements of the patient record include reports of any diagnostic and therapeutic procedures, such as Radiology and Nuclear Medicine examinations or treatment.

Review of the medical record for Patient R2 revealed an order for CT Scan of the Head written on 12/11/13 at 9:15 a.m. by S16 APRN (Advanced Practice Registered Nurse). Documentation revealed Patient R2 was transported to a local hospital ED (Emergency Department) for treatment and evaluation, and a CT Scan was performed. Documentation revealed no indication that the results of the the CT-Scan had been reviewed by Patient R2's attending physician, Psychiatrist, or by S16 APRN.

In a face-to-face interview on 12/18/13 at 10:25 a.m., S3Medical Record Clerk indicated there was no documented evidence that a copy of the results of the CT Scan was placed in Patient R2's medical record. S3Medical Records Clerk requested that a copy of the CT Scan results be faxed to the hospital after the surveyor requested a copy for review.

In a face-to-face interview on 12/18/13 at 10:35 a.m., S2 DON (Director of Nursing) indicated Patient R2 was discharged on [DATE], and a copy of the CT results should have been placed in Patient R2's medical record for review.