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.

CYPRESS GROVE BEHAVIORAL HEALTH, LLC 4673 EUGENE WARE ROAD BASTROP, LA 71220 March 26, 2015
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**







Based on record review and interview the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient as evidenced by:
1. Psychological and Intelligent testing (ordered by a physician) failing to be conducted prior to the patient being discharged for 1 out 1 ( Patient # 7) patient reviewed for testing being completed prior to discharge out of a sample of 9 patients.
2. Failure to obtain readmission orders for 1 of 1 (Patient #5) patients readmitted to the hospital after being discharged due to elopement from the hospital out of a sample of 9 patients.
3. Failure to conduct/document observations of a patient as ordered by the physician for 1 patient (Patient #4) reviewed for observation documentation out of a sample of 9.

Findings:

1. Psychological and Intelligent testing (ordered by a physician) failing to be conducted prior to the patient being discharged for 1 out 1 ( Patient # 7) patient reviewed for testing being completed prior to discharge out of a sample of 9 patients.

Patient #7
Patient #7 was a 7 year old male patient admitted on [DATE] for sucidial and homicidal ideation.

Review of his Physician Orders dated 3/17/15 revealed an order for Psychological and IQ (Intelligent) testing ordered by S12MD.

Review of the medical record for Patient #7 revealed no indication the Psychological and IQ testing was conducted prior to the patient being discharged on [DATE].

An inteview was conducted with S2Administrator on 3/25/15 at 10:00 a.m. She reported she was not notified the testing was ordered on Patient #7 and it was not conducted prior to the patient being discharged .

2. Failure to obtain readmission orders for 1 of 1 (Patient #5) patients readmitted to the hospital after being discharged from the hospital due to elopement from the hospital out of a sample of 9 patients.

Patient #5
Patient #5 was a [AGE]-year-old male admitted on [DATE] under a Physician's Emergency Certificate (PEC) and Coroner's Emergency Certificate (CEC) with diagnoses which included Major Depressive Disorder, Recurrent, Severe without Psychosis, and Oppositional Defiant Disorder. Review of his Psychiatric Evaluation revealed Patient #5's estimated length of stay was 10-14 days. Further review revealed a Voluntary Admission Consent was signed by Patient #5's state-appointed legal guardian on 01/28/15.
A review of Patient #5's medical record revealed Patient #5 eloped from the hospital on [DATE] at approximately 8:00 p.m. Further review revealed discharge orders were written on 03/04/15 at 8:00 p.m. which stated, "Discharge 24 hours after elopement related to patient still at large." Review of the nurse's notes dated 03/04/15 at 9:32 p.m. by S5RN revealed "(Patient #5's name) eloped from facility at approximately 8:00 p.m. on 03/03/15. He is discharged at this time related to remaining at large."
Review of Patient #5's medical record revealed Patient #5 was returned to the hospital on [DATE] at approximately 8:45 a.m. Further review of all physician orders revealed no readmission orders were written for Patient #5 once he was returned to the hospital on [DATE].
In an interview on 03/26/15 at 10:53 a.m., S34EMR (Electronic Medical Records Coordinator) confirmed there were no physician orders for readmission to the hospital written in the paper medical record or the electronic medical record for readmission of Patient #5 on 03/05/15.
In an interview on 03/26/15 at 10:59 a.m., S3DON/ICO (Director of Nursing, Infection Control Officer) indicated the process for receiving a patient back at the hospital after an elopement was to contact the physician for readmission orders once the patient was returned to the hospital, especially if the physician had written an order to discharge the patient. S3DON/ICO confirmed she was not aware of any policies and procedures addressing physician orders for readmitting patients once they were discharged from the hospital due to elopement and then returned to the hospital. S3DON/ICO confirmed there should have been physician orders for readmission of Patient #5 to the hospital because Patient #5 had been discharged from the hospital on [DATE].
3. Failure to conduct/document observations of a patient as ordered by the physician for 1(Patient #4) out of a sample of 9.

Review of the record for Patient #4 revealed an admitted [DATE] with diagnoses including Bipolar Disorder and Mood Disorder. Review of the admit physician orders revealed the patient was to be in line of sight observations from 7A-9P and every 15 minute observations from 9P-7A. Review of the Close Observation form dated 01/09/15 revealed no documented evidence that the patient was observed from 1:30 p.m. until 3:00 p.m.

On 03/25/15 at 2:30 p.m., interview with S33 MHT revealed she worked with the patient the day of 01/09/15, but was pulled to another area at 1:30 p.m. due to short staffing. S33 MHT revealed that she could not remember who took her place, but confirmed there was no documented evidence that the patient was observed from 1:30 p.m. until 3:00 p.m.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observation and interview, the hospital failed to ensure supplies were maintained to provide an acceptable level of safety and quality for patients as evidenced by expired laboratory blood tubes available for patient use in the hospital laboratory rooms.
Findings:

An observation with S3 DON on 3/24/15 at 1:40 p.m. in the laboratory room of the boys dorm revealed the following laboratory blood tubes were expired and available for patient use:

40 red top laboratory blood tubes with an expiration date of 01/2015.
40 purple top laboratory blood tubes with an expiration date of 11/2012.
2 blue top laboratory blood tubes with an expiration date of 12/2013.

An observation with S3 DON on 3/24/15 at 2:20 p.m. in the laboratory room of the girls dorm revealed the following laboratory blood tubes were expired and available for patient use:

21 blue top laboratory blood tubes with an expiration date of 01/2015.

In an interview on 3/24/15 at 2:30 p.m., S3 DON confirmed the above referenced blood tubes were expired and were available for patient use. S3 DON further confirmed the expired laboratory blood tubes should not have been available for patient use.
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on personnel record review and interview, the hospital failed to ensure the designated Infection Control Officer was qualified through education, training, experience or certification as evidenced by appointing an Infection Control Officer with no specialized infection control education/experience/training or certification other than standard infection control knowledge obtained through routine nursing care.
Findings:
Review of S3DON/ICO's current resume (located in her personnel record) revealed she had no specialized infection control education/experience/training or certification.
In an interview on 3/26/15 at 9:12 a.m. with S3DON/ICO, she confirmed she had no specialized infection control education/experience/training or certification other than standard knowledge obtained through routine nursing care.
VIOLATION: RESPIRATORY CARE PERSONNEL POLICIES Tag No: A1161
Based on record review and interview, the hospital failed to ensure personnel were qualified to perform specific respiratory care procedures as evidenced by failure to maintain current documented skills competency evaluations on staff responsible for provision of respiratory care services for 6 (S3DON/ICO, S4ADON, S14LPN, S22RN, S25RN,S35RN) of 6(S3DON/ICO, S4ADON, S14LPN, S22RN, S25RN,S35RN) personnel records reviewed for skills competency evaluations.
Findings:
Review of the personnel files for S3DON/ICO, S4ADON, S14LPN, S22RN, S25RN and S35RN revealed no documented evidence of current skills competency evaluations (based upon return demonstration of the skill) for the following respiratory therapy services provided by hospital staff provided : nebulizer therapy, oxygen therapy, pulse oximetry, metered dose inhaler and manual ventilation.
In an interview on 3/26/15 at 11:00 a.m. with S24HumanResources Manager, she confirmed there were no current documented skills competency evaluations for the above referenced staff in their personnel files.
In an interview on 3/26/15 at 11:10 a.m. with S3DON/ICO she confirmed there were no current documented skills competency evaluations for the above referenced staff.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record reviews, observations and interviews, the hospital failed to meet the requirements of the Condition of Participation for Patient Right's as evidenced by:
1) Failing to follow physician orders for "Line of Sight" levels on the male side of the dormitory when the male and female dormitories were combined, which resulted in the elopement of 1 (#5) male patient. (See findings Tag A-0144).
2) Failing to ensure patients were observed according to documented level of observation and hospital policy for 15 current patients (#1, #2, #3, #R2 - #R13) on line of sight precautions in the Girl's Dormitory Unit (See findings Tag A-0144).

3) Failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for acute care psychiatric patients admitted for being a danger to self or others (See finding A-0144).
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**






Based on record reviews, observations and interviews, the hospital failed to ensure that patients received care in a safe setting as evidenced by:
1) Failing to follow physician orders for "Line of Sight" levels on the male side of the dormitory when the male and female dormitories were combined, which resulted in the elopement of 1 (#5) male patient.
2) Failing to ensure patients were observed according to documented level of observation and hospital policy for 15 (#1, #2, #3, #R2 - #R13) current patients on line of sight precautions in the Girl's Dormitory Unit;
3) Failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for acute care psychiatric patients admitted for being a danger to self or others;
4) Failing to ensure the front entrance gate to the secured grounds was locked at all times.
Findings:
Review of the Policy Number 2015, entitled "Patient Observation Levels" with an Effective Date of 07/05 and a Revised Date of 12/14, presented by S2Adm (Administrator) as the current policy, revealed the following:
"Purpose: To ensure a safe environment for patients and to establish specific guidelines for staff observation of these patients."
Procedure: Level of observation will be ordered by the physician, but nursing personnel will implement suicide precautions if indicated while awaiting the order.
The levels are as follows: Every 15 Minute Observation: This is moderately restrictive toward the patient and involves continuous monitoring every 15 minutes. Nursing Personnel must maintain a continuous log which indicates the patient's location every 15 minutes. The RN assesses and documents the patient's thoughts and behaviors each shift including level of suicidal thought. Line of Sight Observation: This is very restrictive toward the patient and involves continuous visual monitoring at all times. Staff must be within visual contact at all times with the exception of toileting and showering during which times staff shall be present outside a door left ajar but remain in audible contact with the patient. A staff member may observe more than one patient on line of sight observation only while those patients remain in an area for scheduled activity (i.e. group therapy, dining, outside break or 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 line of sight to other staff member(s) so that there is continuous observation of all patients on line of sight. Nursing personnel must maintain a continuous log which indicates the patient's location every 15 minutes. The RN assesses and documents the patient's thoughts and behaviors each shift including level of suicidal thought. Patients on this level are considered high-risk and documentation must reflect the need for continued line of sight or improvement in behaviors and thoughts, which allows the patient to be re-categorized to a lower level of observation. One to One Observation at All Times: This is the most restrictive toward the patient and involves continuous monitoring and physical proximity to the patient at all times. Staff must be within arm's reach at all times including toileting and showering. Nursing personnel must maintain a continuous log which indicated the patient's location every 15 minutes. The RN assesses and documents the patients' thoughts and behaviors throughout each shift. Patients on this level are considered highest risk and documentation must reflect the need for continued 1-to-1 or improvement in behaviors and thoughts, which allows the patient to be re-categorized to a lower level of observation."

1) Failing to follow physician orders for "Line of Sight" observation levels on the male side of the dormitory when the male and female dormitories were combined, which resulted in the elopement of 1 (#5) male patient.
Patient #5
Patient #5 was a [AGE]-year-old male admitted on [DATE] under a Physician's Emergency Certificate (PEC) and Coroner's Emergency Certificate (CEC) with diagnoses which included Major Depressive Disorder, Recurrent, Severe Without Psychosis, and Oppositional Defiant Disorder. Review of his Psychiatric Evaluation revealed Patient #5's estimated length of stay was 10-14 days. Further review revealed a Voluntary Consent for Treatment signed by Patient #5's state-appointed legal guardian on 01/28/15.
A review of the document entitled "Child Welfare Child Placement Agreement," completed and dated by Patient #5's legal guardian (appointed by the state court system approximately 2 years ago) revealed documentation under the section "Child's Initial Screening and Special Care Provisions" that Patient #5 "is very manipulative and not easily redirected. He can be destructive and runs away." Further review reveled Patient #5 needed "close supervision."
A review of the Nursing Personnel Staffing Sheet for the date of 03/03/15, when the female and male patients were combined together in the female dormitory, revealed the following:
Evening Shift (3:00 p.m.-11:00 p.m.): A total census of 19 patients with one patient (female) on a 1:1 (one-to-one) level of observation; 4 MHTs, 1 RN (Registered Nurse), and 1 LPN (Licensed Practical Nurse) were staffed in the dormitory. There were no male patients who were on suicide precautions.
A review of the Payroll Summary Sheet for 03/03/15 revealed S8MHT was the male MHT assigned to work in the dormitory for the shift documented as 2:45 p.m. to 11:15 p.m, and there were 3 female MHTs assigned for the 2:45 p.m. to 11:15 p.m. shift.
A review of the census/staffing sheet for 03/03/15 for the 3:00 p.m.-11:00 p.m. shift revealed a total of 7 male patients ranging in ages from 12 years to 17 years of age. All male patients' observation levels were documented as Line of Sight (LOS) during the hours of 7:00 a.m. until bedtime (around 9:00 p.m.) and Every 15 Minute Observation once the patients were in bed from about 9:00 p.m. until about 7:00 a.m. the following morning.
In an interview on 03/26/15 at 11:00 a.m., S8MHT indicated he was the only male MHT on the 3:00 p.m.-11:00 p.m. shift on 03/03/15 when the male and female dormitories were combined. He indicated he had concerns that evening regarding the staffing because one of the male patients had been attempting to get the attention of a female patient while the male and female patients were all in the Day Room together. S8MHT indicated at approximately 7:40 p.m., Patient #5 had asked him to go to the bathroom down the boys' hall. S8MHT indicated he allowed Patient #5 to go down the hall to the bathroom without S8MHT maintaining Line of Site observation because he did not want to leave the rest of the males unsupervised in the Day Room where the female patients were recreating with the male patients. S8MHT indicated he stood in the doorway between the male hall and the Day Room so he could maintain line of sight down the hall and in the Day Room at the same time. S8MHT indicated at about 7:45 or 7:50, he could hear the toilet paper spool rolling. At that time, S8MHT asked Patient #5 if he was okay, and Patient #5 responded verbally to S8MHT. At approximately 7:55 p.m., S8MHT indicated he could hear the water running in the bathroom where Patient #5 was located, but did not physically observe Patient #5. S8MHT stated at approximately 8:00 p.m., he called out to Patient #5 and asked him if he was about finished because the nurse was calling him for administration of medications, and Patient #5 responded, "yes sir." At approximately 8:05 p.m., S8MHT walked into Patient #5's room to get Patient #5 to go to the nurse's station to take his medication, and it was at that time S8MHT observed Patient #5 had eloped from the bathroom through the bathroom window, and the entire plexi-glass to the bathroom window had been removed and was lying on the ground outside. Patient #5 was later found by the police and returned to the facility approximately 48 hours later.
In an interview on 03/26/15 at 12:00 p.m., S2Adm (Administrator) confirmed the physician orders for maintaining Line of Sight observation was not followed by S8MHT.

2) Failing to ensure patients were observed according to documented level of observation and hospital policy for 15 (#1, #2, #3, #R2 - #R13) current patients on line of sight precautions in the Girl's Dormitory Unit;
Review of the Girls ' Dormitory Patient "Cheat Sheet", dated 3/23/15, (presented as current by S4ADON/Unit Charge Nurse), revealed the census of the unit was 15. Further review revealed 13 of the 15 patients on the unit were documented as having suicidal ideations.
Review of the 24 hour assignment sheet, dated 3/23/15, (presented as current by S4ADON/Unit Charge Nurse) for 3pm -11pm shift revealed all 15 of the current patients were ordered to be on a line of sight observation level with documentation to be done every 15 minutes.
On 3/23/15 at 3:35 p.m. an observation was made, upon entry to the unit, of a group of adolescent female patients seated at a large table, in the commons area, watching television. S4ADON/Unit Charge Nurse was seated in the nurses' station and noted to not be observing the adolescent female patients seated at the large table and S14LPN was standing in the medication room which opens off of the nurses' station and was also noted to not be observing the adolescent female patients seated at the large table. Neither staff member was noted to be directly observing (maintaining continuous line of sight) the girls seated at the table. No other staff members were noted, at that time, to be maintaining continuous direct line of sight observation of the patients seated at the table in the commons area.
In an interview on 3/25/15 at 4:00 p.m. with S4ADON/Unit Charge Nurse, she indicated the current census of the unit was 15 (8 patients housed on 1 hall and 7 patients housed on another hall). She said the unit was currently staffed with 1 RN (S4ADON), 1 LPN (S14LPN) and 3 Mental Health Technicians (MHT ' s). S4ADON indicated all of the patients on the unit were line of sight with q 15 minute checks. She said, " most all of the patients on the unit are on suicidal ideation precautions " . She explained the MHTs were currently off of the unit washing patient laundry. She also indicated all of the patients on the unit were kept in the commons area during the time interval after all groups had ended and prior to dinner so that the MHTs could wash patient laundry. S4ADON confirmed she and S14LPN had assumed responsibility for continuous line of sight supervision of the unit ' s 15 patients in the absence of the MHTs.
In an interview on 3/25/15 at 9:05 a.m. with S20MHT, she confirmed the MHTs washed patient laundry. She also confirmed during the MHTs absence from the unit, the nurses on duty were to assume continuous line of sight supervision and q 15 minute checks for all patients on that level of supervision.

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

Ligature/Safety risks identified in the male dormitory:
Observations on 03/23/15 at 3:30 p.m. during a tour of the male dormitory with S5RN (Registered Nurse) revealed the following safety risks:
Doors: All doors, including the exterior and interior doors in the patients' rooms had right-to-left lever-type handles on the inside and outside of the doors (ligature risk). All of the doors in the unit had regular door hinges with regular screws (not tamper resistant) which created a ligature risk. The metal plates on the doors and door frames for the latching mechanism had regular screws. The hall doors leading out of the halls (exit to the outside and exit to the Day Room) had large hinges located at the top of the doors with approximately 12-inch metal bars extending out from the side of the door (ligature risk).

Bathrooms: The shower rooms and the individual patient-room bathrooms had exposed plumbing behind the toilets (ligature risk). The showers and tubs had lever-type water/temperature control handles, and the tubs had extended faucets protruding out from the tub's surface where the faucet was mounted (ligature risk).

Bathroom Sinks: The bathroom sinks had circular-type faucet handles which extended approximately 3 inches above the surface where the handles were mounted onto the sink (ligature risk). The sinks also had faucets which extended out approximately 4 inches from the surface of the sink where the faucet was mounted (ligature risk).

Bathroom Mirrors: All of the bathroom mirrors were secured with regular screws into the concrete cinder block walls.

Shelving: All of the shelving units in the bedrooms were put together with regular screws. The wall art, made of a canvas-type material, was screwed into the walls (which were concrete cinder-block walls) with regular type screws.

Beds: All of the beds were twin-sized beds constructed with metal framing which were exposed (ligature risk).

Fire Extinguishers: There were two fire extinguishers located on the "Big Boy Hall." Both of the housing units for the fire extinguishers had loose plexis-glass in the door of the housing unit. On the Little Boy Hall, one fire extinguisher housing unit had a loose plexis-glass in the door of the housing unit.

In an interview on 3/23/15 at 4:00 p.m., S5RN agreed that the above referenced environmental issues were potential ligature and/or safety risks for the patients in the male dormitory.

Ligature/Safety risks identified in the female dormitory:

On 3/23/15 at 3:35 p.m. the following observations were made of the Girl ' s Dormitory (Dormitory B)
a. A single glass window pane (bottom pane = of the window [30 inches x 35 inches]) in the shower room was partially detached from the window frame (approximately 3 inches), opening to the outside.
b. 2 beds, on metal frame legs (approximately 8 inches off of the ground-potential ligature point) dressed with linens (pillowcases, sheets and blankets): all rooms
c. In-room bathrooms with sinks. The sinks had faucet handles which protruded approximately 3 inches above the level of the sink basin creating a potential ligature point: all rooms
d. Lever type door handles attached in a fashion which created a potential ligature point on all doors, both room entry doors and in-room bathroom doors: all rooms
e. Interior door hinges: 3 hinges spaced widely enough apart to facilitate potential ligature point on both room entry doors and in-room bathroom doors: all rooms
f. Metal plate of the locking mechanism on the door frames secured with screws that were not tamper proof: all rooms
g. Toilet with exposed pipes and a flanged handle for flushing-potential ligature point: handicapped accessible patient room
h. Metal plate over locking mechanism on door was secured with screws that were not tamper proof. The plate was visibly loosened and moveable: Room #3.

Review of the Girls ' Dormitory Patient "Cheat Sheet", dated 3/23/15 (presented as current by S4ADON), revealed the current census of the unit was 15. Further review revealed 13 of the 15 patients on the unit had suicidal ideations.
Review of the 24 hour assignment sheet, dated 3/23/15 (presented as current by S4ADON), for 3pm -11pm shift revealed all 15 of the current patients were on line of sight observation with q (every) 15 minute checks.
In an interview on 3/23/15 at 4:00 p.m. with S4ADON, she indicated patients were not allowed to go to their rooms unattended during the dayshift. She explained patients who were line of sight during the day were converted to every 15 minute checks on the night shift. She agreed the 15 minute observations/room checks performed during the nightshift created a window of time where the patients were not directly visualized by staff. S4ADON agreed the above referenced in-room findings were unsafe and posed potential ligature risk. She also confirmed she had no knowledge of the window pane that was partially detached from the window in the shower room of the girls ' dormitory.
In an interview on 3/23/15 at 4:40 p.m. with S13Maintenance he confirmed the door hinges, faucets, exposed toilet plumbing pipes in the handicapped bathroom, and the door handles located throughout the girls ' dormitory were potential ligature points. He also confirmed the screws used in the metal plates of the locking mechanism on the doors were not tamper proof. He also confirmed he had no knowledge of the window pane that was partially detached from the window in the shower room of the girls ' dormitory.
In an interview on 3/25/15 at 9:05 a.m. with S20MHT, she confirmed line of sight patient observation was continuous during the day and converted to every 15 minute checks at night. She also confirmed patients were escorted to the bathroom during the day, but had access to their in room bathrooms, unattended by staff, during the night.
4) Failing to ensure the front entrance gate to the secured grounds was locked at all times.
Observations on 03/25/15 at 12:50 p.m and 2:30p.m.. revealed the front gates were held together with a chain and a manual lock, which was not locked.
In an interview on 03/25/15 at 9:15 a.m., S9LPN (Licensed Practical Nurse) indicated the front gate electronic locking mechanism had been broken for a few months. The front gate, which secured the grounds of the hospital facility, normally had an electronic releasing/locking control mechanism whereby the staff could remotely activate the gate to open or close with a device. S9LPN also indicated patients were aware that the gate locking mechanism had been broken. S9LPN indicated the female patients had a clear view of the front gate entrance from their dormitory, and staff in the female dormitory had witnessed the female patients pointing and talking about the gate situation among them. S9LPN also indicated a male patient had eloped from the gym on through the front gate while it was unlocked.
Review of the Patient/Visitor Variance Report dated 2/1/15 revealed in part, Patient #9 was in the gym with a MHT and other big boys pt (patients) when he left the gym without permission. After having another MHT supervise the other patients, the MHT went to find the patient and was unable to locate the patient. The sheriff office was called and the patient was found walking down the road away from the hospital. Further review of the Patient/Visitor Variance Report revealed this was the only occurance documented in the last year of a patient eloping through the front gate.
An interview was conducted with S2Administrator on 3/25/15 at 9:00 a.m. She reported after the Patient #9 eloped the MHT was disciplined for being the only MHT with the boys while they were in the gym. She further reported whenever the patients are brought to the gym, a minimum of two MHTs are to be with the patients.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on record review and staff interview, the hospital failed to ensure the QAPI (Quality Assurance Performance Improvement) program set priorities for performance improvement projects that focused on high-risk, high volume, or problem-prone activities as evidenced by no Performance Improvement Projects being conducted in the hospital. Findings:

Review of the hospital Quality Assurance information provided by S2Administrator revealed no evidence of a Performance Improvement Project being conducted in the hospital.

An interview was conducted with S2Administrator on 3/25/15 at 4 p.m. She reported the hospital was not conducting any performance improvement projects currently.
VIOLATION: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Tag No: A0308
Based on record review and staff interview, the governing body failed to ensure that the hospital's QAPI (Quality Assessment Performance Improvement) program reflected the hospital's organization and services as evidenced by not having all hospital departments and services, including those services furnished under contract, involved in the QAPI Program. The governing body failed to ensure the QAPI program included monitoring of pharmacy services, respiratory, radiology, psychology and emergency medical services.
Findings:

Review of the hospital's QAPI information revealed no information was obtained and/or was included from the following contracted services in the QAPI information: pharmacy services, radiology, psychology and emergency medical services.

An interview was conducted with S2Administrator on 3/26/15 at 10:00 a.m. She reported the contracted services for pharmacy, radiology, psychology and emergency medical services were not included in the QAPI program for the hospital.
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
Based on record review and staff interview, the Governing Body failed to determine the number of distinct improvement projects the hospital would conduct annually as evidenced by no performance improvement projects conducted in the last year or currently being conducted. Findings:

Review of the hospital Quality Assurance information provided by S2Administrator revealed no evidence of a Performance Improvement Project being conducted in the hospital.

Review of the Governing Body meeting minutes for 2015 revealed no indication Performance Improvements Projects were discussed in the Governing Body meeting by the Governing Body.

An interview was conducted with S2Administrator on 3/25/15 at 4:00 p.m. She reported the hospital was not conducting any performance improvement projects.
VIOLATION: MEDICAL STAFF CREDENTIALING Tag No: A0341
Based on review of the medical staff bylaws and credentialing files and interviews, the hospital failed to ensure that each physician/practitioner providing services in the hospital was credentialed in accordance with the medical staff bylaws for 4 of 4 credentialing files reviewed (S9 Family Nurse Practitioner, S10 Psychologist, S12 Psychiatric Medical Director, S26 Psychiatrist).
Findings:

Review of the medical staff bylaws (approved 01/17/14), section 7.1-3, revealed in part that all initial appointments to the medical staff shall be for a period of one year. A provisional period for initial appointment shall extend for no more than twelve months. If an initial appointee fails within that period to furnish the required certifications, his staff membership particular privileges, as applicable shall automatically terminate.

Review of the credentialing files for S9 Family Nurse Practitioner, S12 Psychiatric Medical Director and S26 Psychiatrist revealed that they were initially appointed to the medical staff with privileges granted in 2013. Further review of the files revealed no documented evidence that the hospital reexamined the credentials of the practitioners or reappointed them for medical staff membership/privileges within 12 months after their initial appointments, as stated in the medical bylaws.

Review of the file for S10 Psychologist revealed no documented evidence that his credentials had been examined. There was no documented evidence in the file that S10 had been ever appointed to the medical staff with privileges granted. Further review of the file revealed that S10 Psychologist began providing services at the hospital in 2013.

On 03/26/15 at 10:10 a.m., interview with S23 Credentialing Consultant confirmed that S9 Family Nurse Practitioner, S12 Psychiatric Medical Director and S26 Psychiatrist had not been recredentialed and reappointed for medical staff membership/privileges since 2013. S23 revealed that she was unaware of the medical staff bylaws which stated that initial appointments lasted one year. Further interview with S23 revealed that the hospital does not credential any of the contracted practitioners, such as S10 Psychologist.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on record review and interview, the hospital failed to ensure the patient's medical records were completed consistent with hospital policies and procedures as evidenced by the deficiency rate for incomplete medical records were 64 % in December 2014, 66% in January of 2015 and 57% in February of 2015. Findings:

Review of the hospital's policy on Management of Information Plan , Reference #9001, revealed in part, Timeliness of information is felt to be of paramount importance.

Review of the hospital's Medical Staff By-laws revealed in part, the attending physician shall be held responsible for the preparation of a complete medical record for each patient. A chart shall not be considered "delinquent" until thirty (30) days following discharge. All medical records shall be completed by the attending physician within thirty (30) days of discharge.

Review of the hospital deficiency rate, presented to the surveyor by S30Medical Records Clerk, revealed the medical record deficiency rate was 64 % in December 2014, 66% in January of 2015 and 57% in February of 2015.

An interview was conducted with S30Medical Records Clerk on 3/25/15 at 2:00 p.m. She reported it was her responsibility to audit the medical records for deficiencies. She further reported due to a physician's nurse practitioner being unavailable to sign medical records, the hospital's deficiency rate has increased.

An interview was conducted with S2Administrator on 3/25/15 on 3 p.m. She reported she was aware of the hospital's high medical record deficiency rate and planned to put a plan of correction in place to correct the issues.
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
Based on record review and interview, the hospital failed to ensure that all orders, including verbal orders, were dated, timed and authenticated promptly by the ordering practitioner for 4 of 4 records reviewed (#3, #4, #5, #8) out of a sample of 9.
Findings:

Review of a policy entitled "Physician Orders," Reference #9023, Effective 01/11/15 and Revised 03/14, presented by S2Adm (Administrator) as current, revealed: "Purpose: To identify the requirements of a physician's order. Policy: All physicians' orders will have an original signature and date. The exception is when the orders state it is a copied standing order. If this is the case, the original order that was copied will be on the chart with an original signature and date. Procedure: Physician Orders should include but are not limited to, the following items: 1. Admission and type of observation/precautions (constant, close, one to one, etc), 2. Restraints seclusion, etc., 3. Standing and Stat orders for psychiatric and non-psychiatric medications. 4. Laboratory and other diagnostic testing, and 5. Vital signs and diet orders.

1. Review of the record for Patient #3 revealed admission orders which were obtained from a telephone order dated 03/19/15. Further review revealed the order was authenticated, but not dated or timed.

2. Review of the record for Patient #4 revealed admission orders, which were obtained from a telephone order dated 01/03/15. The patient was discharged home on 01/10/15. As of 03/26/15, the telephone order had not been authenticated, dated or timed by the physician.

3. Review of the record for Patient #4 revealed readmission orders, which were obtained from a telephone order dated 01/20/15. Further review revealed the order was authenticated, but not dated or timed.

4. Review of the record for Patient #5 revealed a verbal order dated 03/03/15 and timed 7:20 a.m. stated "Refer to Podiatrist for Right great toe wound treatment" from S9FNP; a verbal order dated 03/06/15 at 10:00 a.m."give Phenergan 25 m.g. (milligram) one by mouth every six hours as needed for nausea" from S9FNP. Further review revealed S9FNP had signed the verbal order, but had not documented the date and time the verbal order was signed.

5. Review of the record for patient #8 revealed admission orders which were obtained from a verbal order dated 01/04/15. Further review revealed the order was authenticated, but not dated or timed.
VIOLATION: PHARMACEUTICAL SERVICES Tag No: A0490
Based on record reviews and interviews, the hospital failed to meet the requirements of the Condition of Participation for Pharmaceutical Services as evidenced by:

1. Failing to ensure a full time, part-time or consulting pharmacist was responsible for developing, supervising, and coordinating all of the pharmacy services and by failing to appoint a designated pharmacist to serve as Director of Pharmaceutical Services
(See Findings in A-0492).

2. Failing to ensure errors in medication administration were documented in the medical record for 2 of 2 patients (#R2,#3) reviewed for medication errors out of a total sample of 10 (#1-#9,#R2) patients reviewed and by failing to ensure errors in medication administration were tracked each month for analysis and identification of trends (See Findings in A-0508).
VIOLATION: PHARMACIST RESPONSIBILITIES Tag No: A0492
Based on record review and interview, the hospital failed to ensure a full time, part-time or consulting pharmacist was responsible for developing, supervising, and coordinating all of the pharmacy services as evidenced by failing to appoint a designated pharmacist to serve as Director of Pharmaceutical Services.

Findings:

Review of the hospital 's contracts revealed no documented evidence of a contract with a designated pharmacist to serve as Director of Pharmaceutical Services for the hospital.

Review of the hospital 's personnel files revealed no documented evidence of an appointed Director of Pharmaceutical Services.

In an interview on 3/25/15 at 4:34 p.m. with S2Administrator, she confirmed there was no designated pharmacist appointed by the Governing Body to serve as Director of Pharmaceutical Services for the Hospital.
VIOLATION: UNUSABLE DRUGS NOT USED Tag No: A0505
Based on observation and interview the hospital failed to ensure unusable medications were not available for patient use as evidenced by having expired medications, unlabeled multi-dose medications (not dated and timed when opened) and used single dose medication vials available for patient use in the Girl's Dormitory Medication Cart.
Findings:
During the initial tour of the Girls' Dormitory on 3/23/15 at 4:45 p.m. the following items were found in the unit's medication cart:
2 uncapped, used vials of single use Sterile Water (for Intravenous Use);
1 single use packet of used Triple Antibiotic Ointment, folded closed with a paperclip;
1 opened tube of Triple Antibiotic Ointment (multiple use) not labeled with date or time of opening;
1 opened bottle of stock Robafen Cough Syrup -473 milliliters (ml), not labeled with date or time of opening;
1 opened bottle of Q-Tussin Cough Syrup- 118 ml, not labeled with date or time of opening;
1 opened bottle of Ibuprofen 200 milligram tablets (500 count) not labeled with date or time of opening;
1 box of Albuterol Sulfate, Inhalation Solution, expired 2/2015
In an interview on 3/23/15 at 4:45 p.m. with S14LPN (assigned medication nurse) he confirmed the above referenced single use medications should have been discarded after one use. He also confirmed the multiple dose medications should have been labeled with a date and time of opening. S14LPN indicated the expired medications should have been removed from the cart prior to expiration. S14LPN said oral solutions were kept for 30 days after opening and bottles of medications were kept for 3 months. He agreed the staff would be unable to determine when to discard the stock bottles (tablets and oral solutions) if they were not dated and timed when opened.
VIOLATION: REPORTING ADVERSE EVENTS Tag No: A0508
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the hospital failed to ensure:
1) errors in medication administration were documented in the medical record for 2 of 2 patients (#R2,#3) reviewed for medication errors out of a total sample of 10 (#1-#9,#R2) patients reviewed.
2) errors in medication administration were tracked each month for analysis and identification of trends.

Findings:

Review of the hospital's policy titled Medication Administration and MD (Medical Doctor) Orders for Medications, Reference #: MM107, revised 3/2013, revealed in part:
Purpose:
To provide guidelines for the hospital's nursing staff to determine the required elements of medication orders, and those that are acceptable to help reduce the incidence of medication errors.
Policy:
Medications will be administered only upon the order of a physician/licensed independent practitioner who is a member of the medical staff and has been granted clinical privileges to write such orders. The orders are written under the guidelines of his/her respective scopes of practice by a physician.
Errors in administration of medication will be reported immediately to the attending physician, and a medication Variance Form will be sent to the Director of Nurses. The actual medication administered will be documented in the medical record.

Review of the hospital ' s incident reports revealed the following medication error documentation:

Patient #R2:

Review of the medication error incident report for Patient #R2, dated 3/7/15, revealed the following, in part: Gave her (Patient #R2) Geodon 80 milligrams (mg) with bedtime medications without realizing she had gotten it from previous nurse, so patient received Geodon 160 mg within 2 hours.

Review of Patient #R2's medical record revealed no documentation of the medication error in the patient's medical record. Further review revealed no documentation of the nurse ' s actions following the incident.

In an interview on 3/27/15 at 12:30 p.m. with S3DON/ICO she explained the patient ' s nurse had informed the registered nurse (RN) on duty, called the patient's MD, and had notified S2Adm (Administrator) of the medication error. She said the nurse had also completed an incident report. S3DON/ICO indicated it was not the hospital ' s practice to document medication errors in the patients ' medical record and confirmed there was no documentation of the incident in Patient #R2 ' s medical record.

Patient #3

Review of the medical record for Patient #3 revealed an admitted [DATE] with diagnoses including suicidal ideations, mood disorder and psychosis. Review of the patient's physician orders dated 03/21/15 at 11:00 a.m. revealed orders to increase Risperdal to 1 mg (milligram) every night at bedtime.

Review of the patient's medication administration record (MAR) for 03/21/15 revealed that Risperdal 1mg was to be administered at 9 p.m. Further review of the MAR revealed that Risperdal was not administered at 9:00 p.m. and the nurse documented "no consent".

On 03/26/15 at 11:30 a.m., interview with S3 DON revealed that the patient's nurse must have failed to obtain a consent from the family to increase the dosage of the patient's medication. S3 DON further confirmed that there was no documented evidence that the nurse attempted to notify the family to obtain consent for the medication prior to the first dose.

Further review of the patient's MAR revealed that Risperdal 1mg was to be administered at 9:00 p.m. on 03/25/15. Documentation revealed the nurse did not administer the medication because it was unavailable.

Interview with S3 DON on 03/26/15 at 11:45 a.m. revealed that the medication should have been available to administer to the patient.


2) Failed to ensure errors in medication administration were tracked each month for analysis and identification of trends.

Review of the hospital ' s medication safety events (adverse event/medication error) binder revealed the hospital performed monthly tracking of medication errors/adverse events. Further review revealed no documented evidence of adverse event/medication error tracking for January 2015 and February 2015.

In an interview on 3/26/15 at 11:21 a.m. with S3DON/ICO she confirmed the DON was responsible for tracking medication errors and adverse events. S3DON/ICO also confirmed the hospital had no documented evidence of adverse event/medication error tracking for January 2015 and February 2015.
VIOLATION: RADIOLOGIC SERVICES Tag No: A0528
Based on record reviews and interviews, the hospital failed to meet the requirements of the Condition of Participation for Radiological Services as evidenced by:
1. Failing to ensure there was a radiologist, who was a member of the medical staff, supervised the radiology services and interpreted the radiological tests on either a full-time, part-time or consulting basis (See Findings in A-0546).
VIOLATION: RADIOLOGIST RESPONSIBIITIES Tag No: A0546
Based on staff interview, the hospital failed to ensure there was a radiologist, who was a member of the medical staff, supervised the radiology services and interpreted the radiological tests on either a full-time, part-time or consulting basis.
Findings:

On 03/24/15 at 10:45 a.m., interview with S2 Administrator revealed that the hospital did not have a radiologist who was a member of the medical staff and who supervised the radiology services for the hospital.
VIOLATION: DIRECTOR OF DIETARY SERVICES Tag No: A0620
Based on observation, record review and interview, the hospital failed to ensure that dietetic services were currently under the direction of a qualified dietary manager.
Findings:

On 03/24/15 at 9:25 a.m., interview with S27 Dietary Manager revealed that she was over the dietetic services at the hospital. S27 stated that she had previously been a cook at the hospital, but had been promoted to the dietary manager in August 2014. S27 revealed that she had not completed the courses needed to become a certified dietary manager, and had just began taking the online classes in February 2015. Further interview with S27 revealed S28 Registered Dietician performed consultant work at the hospital every two weeks, but does not assist S27 with any training related to dietetic services. S27 stated S28 Registered Dietician mainly reviews charts when she comes to the hospital.

Observation of the three-compartment sink in the kitchen revealed that it was in use, with several dishes in the sinks. At that time, the surveyor asked S29 Dietary Worker to check the sanitizer solution in the sink and she was unsure how to perform the test. At that time, the surveyor asked S27 Dietary Manager to perform the testing of the sanitizer solution and she stated that she was unsure how to correctly perform the test and read the results.

Review of the personnel file for S27 Dietary Manager revealed no documented evidence that she had completed any educational training related to the dietary manager certification.

On 03/25/15 at 4:00 p.m., interview with S2 Administrator confirmed that S27 Dietary Manager had not completed her training in dietary management. Further interview with S2 Administrator revealed that S27 was promoted to dietary manager in August 2014 and was supposed to begin her training classes then, but she was unaware that S27 had not started them until last month.
VIOLATION: QUALIFIED DIETITIAN Tag No: A0621
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to have evidence the consultant Registered Dietician was qualified.
Findings:

Review of the hospital's contract book revealed a contract with S28 Registered Dietician to be a consultant for dietary services. Further review revealed a copy of S28's license, which expired on [DATE].

On 03/25/15 at 2:15 p.m., interview with S24 Human Resources Manager revealed the hospital did not have a personnel file on S28 Registered Dietician because she was a contracted employee. S24 further stated that all information on the contracted employees should be in the contract books.

On 03/25/15 at 4:00 p.m., interview with S2 Administrator confirmed that S28 Registered Dietician had a contract with the hospital for consulting. S2 Administrator further confirmed that she was unaware that S28's license had expired and there was no documented evidence to show that she was qualified.
VIOLATION: THERAPEUTIC DIET MANUAL Tag No: A0631
Based on review of the diet manual and interview, the hospital failed to have a current therapeutic diet manual that was approved by the dietician and medical staff.
Findings:

On 03/24/15 at 9:25 a.m., review of the therapeutic diet manual in the kitchen revealed it was dated as being approved by the medical staff in 2005. Further review of the manual revealed that it did not have the current hospital's name on it. At that time an interview with S27 Dietary Manager revealed she did not use the manual because it was outdated.
VIOLATION: UTILIZATION REVIEW COMMITTEE Tag No: A0654
Based on record review and interviews, the hospital failed to have two or more practitioners on the Utilization Committee to carry out the Utilization Review (UR) functions, who were not professionally involved in the care of the patients whose case was being reviewed. Findings:

Review of the hospital's policy for Utilization Management Plan, Reference #2064, revealed in part, the medical director and at least one additional physician shall be members of the Utilization Management Review Committee.

An interview was conducted with S31UR Manager on 3/25/15 at 9:15 a.m. She reported S12MD and S26MD are the two physicians on the Utilization Review Committee. She further reported the physicians review only their own patients' medical records.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, record review and interview, the hospital failed to ensure an effective system for identification, reporting, investigating and controlling of infections and communicable diseases of patients and personnel as evidenced by:
1. Failing to train hospital personnel on types of isolation precautions and personal protective equipment (PPE) necessary for staff use when caring for patients in different types of isolation for 8 (S3DON/ICO, S4ADON, S14LPN, S15MHT, S17MHT, S21Housekeeping, S22RN, S25RN) of 8 personnel records reviewed;
2. Failing to ensure personnel skills competency evaluations were performed annually for donning/doffing PPE for all types of isolation and respiratory mask fit testing for 8 (S3DON/ICO, S4ADON, S14LPN, S15MHT, S17MHT, S21Housekeeping, S22RN, S25RN) of 8 personnel records reviewed for documented annual skills competency;
3. Failing to ensure policies and procedures were developed to minimize the risk of development and transmission of multi drug resistant organisms (MDROs) within the hospital; 4. Failing to disinfect the glucose meter, after use, per hospital policy;
5. .Failing to ensure the Girls' Dormitory medication cart was maintained in sanitary condition.

Findings:

1) Failing to train hospital personnel on types of isolation precautions and personal protective equipment (PPE) necessary for staff use when caring for patients in different types of isolation:

Review of the personnel records for S3DON/ICO, S4ADON, S14LPN, S15MHT, S17MHT, S21Housekeeping,S22RN and S25RN revealed no documented evidence of current training of hospital personnel on the types of isolation precautions and the PPE necessary for staff use when caring for patients in different types of isolation.

In an interview on 3/26/15 at 11:22 a.m. with S3DON/ICO, she confirmed hospital personnel had not been trained on different types of isolation precautions. She also confirmed the staff had not been trained on the PPE necessary for staff use when caring for patients in different types of isolation.

2) Failing to ensure personnel skills competency evaluations were performed annually for donning/doffing PPE for all types of isolation and respiratory mask fit testing:

Review of the personal records for the following hospital staff : S3DON/ICO, S4ADON, S14LPN, S15MHT, S17MHT, S21Housekeeping, S22RN and S25RN revealed no documented evidence of current annual skills competency for donning/doffing PPE for all types of isolation and respiratory mask fit testing.

In an interview on 3/26/15 at 11:22 a.m. with S3DON/ICO, she confirmed hospital personnel had no documented evidence of current annual skills competency for donning/doffing PPE for all types of isolation and respiratory mask fit testing.

3) Failing to ensure policies and procedures were developed to minimize the risk of development and transmission of multi drug resistant organisms (MDROs) within the hospital:

Review of the hospital's infection control policies and procedures revealed no policies and procedures had been developed to minimize the risk of development and transmission of multi drug resistant organisms (MDROs) within the hospital.

In an interview on 3/26/15 at 11:20 a.m. with S3DON/ICO, she confirmed the hospital had not developed policies and procedures to minimize the risk of development and transmission of multi drug resistant organisms (MDROs) within the hospital.

4) Failing to disinfect the glucose meter, after use, per hospital policy:

Review of the policy titled Glucose Monitoring System, revised 12/2014, presented as the current method of disinfection for glucometers utilized by the hospital revealed the following, in part:
Cleaning the meter:
a.Clean the meter with a moist lint free tissue with a mild detergent or EPA- registered disinfecting solution (1 part bleach mixed with 9 parts water). DO NOT USE ALCOHOL. (Capitalized in the policy).

In an interview on 3/23/15 at 4:45p.m.with S14LPN, he indicated the hospital 's glucose meters were cleaned with alcohol after and in-between patient use.

In an interview on 3/24/15 at 3:02 p.m. with S2Administrator, she confirmed the hospital continued to use the disinfection method addressed in the hospital policy titled: Glucose Monitoring System, revised 12/2014, as the current method of disinfection for glucose meters utilized by the hospital.

In an interview with S3DON/ICO on 3/26/15 at 10:00 a.m., she confirmed the glucose meters should not be cleaned with alcohol. She also confirmed the hospital 's policy was to clean the glucose meter with a bleach solution.

5) Failing to ensure the Girls' Dormitory medication cart was maintained in sanitary condition:

During the initial tour of the Girls' Dormitory on 3/23/15 at 4:45 p.m. the following food items were found in the top drawer of the unit 's medication cart:
1 tub of Honey Mustard sauce from a fast food restaurant,
1 packet of jelly,
4 packets of salt and pepper and
3 packs of saltine crackers.

In an interview on 3/23/15 at 4:45 p.m. with S14LPN (assigned medication nurse) he confirmed the above referenced food items should not be found in the medication cart.
VIOLATION: REASSESSMENT OF DISCHARGE PLANNING PROCESS Tag No: A0843
Based on record review and interview, the hospital failed to reassess its discharge planning process on an on-going basis as evidenced by not tracking the hospital's readmissions.
Findings:

Review of the hospital's discharge planning policy, revised 12/2014, revealed that it did not address tracking of readmissions as part of its review of the discharge planning process.

On 03/25/15 at 9:30 a.m., interview with S32LPN/Discharge Planner revealed she was responsible for the discharge planning of all patients. S32 further revealed she did not track the readmissions to determine the effectiveness of the prior discharge plans.

On 03/25/15 at 1:30 p.m., interview with S31 LPN/Utilization Review revealed she gets the number of total number of readmissions from S30 Medical Records Clerk to put on the performance indicators, but no tracking is performed.

On 03/25/15 at 2:05 p.m., interview with S2 Administrator confirmed the hospital did not track its readmissions to determine whether the readmissions were potentially due to problems in discharge planning or the implementation of the discharge plans.
VIOLATION: DIRECTOR OF RESPIRATORY SERVICES Tag No: A1153
Based on record review and interview, the hospital failed to ensure Respiratory Care Services were under the direction of a doctor of medicine or osteopathy on a full time or part time basis as evidenced by failure of the Governing Body to appoint a physician as Director of Respiratory Services.

Findings:
Review of the key personnel list revealed no documented evidence of a Medical Director of Respiratory Care Services.
In an interview on 3/24/15 at 10:00 a.m., with S2Adm (Administrator), she confirmed the hospital ' s Governing Body had not appointed a Medical Director of Respiratory services because it was a contracted, as needed service.