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.

SEASIDE BEHAVIORAL CENTER 4201 WOODLAND DRIVE NEW ORLEANS, LA Dec. 8, 2011
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observation and interview, the hospital failed to ensure all equipment was maintained in a manner to ensure an acceptable level of safety and quality. This was evidenced by the presence of a 4 inch ice buildup in the medication room refrigerator. Ten (10) vials of Insulin were noted to be immediately under this 4 inch layer of ice.
Observations of the medication room refrigerator on 12/07/11 at 9:45 a.m. revealed a 4 inch layer of ice on the upper section of the refrigerator. Ten (10) vials of Insulin were noted to be immediately under this 4 inch layer of ice. Findings:

The Director of Nursing was interviewed at the time of this observation. The Director of Nursing confirmed the 4 inch layer of ice on the upper section of the refrigerator and reported the refrigerator needed to be defrosted. When asked if there was a schedule for defrosting the refrigerators, the Director of Nursing indicated that she was not aware of a schedule to defrost the refrigerator. The Director of Nursing indicated that the refrigerator should be defrosted as needed. The Director of Nursing reported that defrosting is needed.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review and interview the hospital failed to ensure the Condition of Patient Rights was met by failure to ensure patients received care in a safe setting as evidenced by:
1) failing to ensure interventions were put into place to protect vulnerable psychiatric patients located in the geriatric facility from inappropriate sexual comments and touching by a hypersexual demented patient for 1 of 1 hypersexual patients reviewed out of a total sample of 21 (Patient #14)
See findings cited at A0144.
VIOLATION: MEDICAL STAFF - APPOINTMENTS Tag No: A0046
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, the hospital's governing body failed to ensure all members of the medical staff had completed the credentialing and appointment process by failing to ensure the appointment of licensed practitioners to the hospital's medical staff and by failing to verify the current licensure status of members of the hospital's medical staff. Findings were noted in the credentialing files for 2 of 5 practitioners reviewed (S19 and S20). Findings:

Review of the credentialing file of S19 (Family Nurse Practitioner) on 12/07/11 revealed no evidence to indicate S19 had completed the hospital's credentialing and appointment process as there was no documentation to indicate the governing body appointed S19 to the hospital's medical staff.

Review of the credentialing file of S20 (Medical Doctor) on 12/07/11 revealed S20's medical license expired on [DATE]. There was no documentation to indicate that a verification was completed to ensure S20's medical license was current.

Review of the Medical Staff Bylaws revealed that all members of the medical staff will be appointed by the governing body.

The hospital's Administrator (S1) was interviewed on 12/07/11 at 3:30 p.m. S1 reviewed the credentialing files of S19 and S20. S1 confirmed there was no evidence to indicate current governing body appointment to the medical staff for S19 and confirmed there was no evidence to indicate current licensure for S20.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure patients received care in a safe setting by failing to ensure interventions were put into place to protect vulnerable psychiatric patients located in the geriatric facility from inappropriate sexual comments and touching by a hypersexual demented patient for 1 of 1 hypersexual patients reviewed out of a total sample of 21 (Patient #14). Findings:
Patient #14: The Medical Record for Patient #14 was reviewed. Patient #14, [AGE], was admitted on [DATE] with diagnoses the included Dementia with Behavior Disturbance and Psychosis. Review of Patient #14's Physician Progress Notes revealed the following:
11/25/2011 dictated 11/25/2011 at 1557 (3:37 p.m.): "He (#14) has been getting aggressive and manipulative and sexually inappropriate in the nursing home. He has talked about having sex, etc. with other patients and the staff. He still wanders in his conversations. He began to get abusive earlier towards staff."
11/26/2011 dictated at 1346 (1:46 p.m.): "The patient (#14) actually has visual hallucinations including saying hello to other residents and he tried to beat other residents also. . . The patient also at times becomes sexually inappropriate. The patient has a history of wandering from one room to other room."
11/27/2011 dictated at 1257 (12:57 p.m.): "The patient (#14) is roaming around the building, screaming out here and there. The patient also still sexually inappropriately (inappropriate) with the staff and making comments on the staff. The patient is wandering into other resident's room and grabs them inappropriately."
11/30/2011 dictated at 2157 (9:57 p.m.): "The patient (#14) remains rather hypersexual. He continues to make remarks about female genitalia, wanting to have sex with them, wanting to see their privates. etc. He walks into various patient's rooms and makes inappropriate remarks. He is difficult to redirect."
12/01/2011 dictated at 1458 (2:58 p.m.): "The patient (#14) remains rather hypersexual and continues to make remarks about the female patients and wants to hold the female staff. The patient walks into various patients' rooms and makes inappropriate remarks."
12/02/2011 dictated at 1052 (10:52 a.m.): "The patient (#14) still is aggressive, agitated, and sexually inappropriate. He continues to approach various staff members asking them to take clothes off and have sex with them. He touches other patients. He is inappropriate, impulsive, labile, and gets agitated when the staff tries to redirect him."
12/05/2011 dictated at 1856 (6:56 p.m.): "He (#14) walks into various patients' room. He is sexually very inappropriate. He has actually touched the other patient, tries to have ____ sex, etc. (blank was never filled in). He is very difficult to redirect."
Review of Patient #14's "Daily Treatment Plan update and Team Progress Notes" revealed the following:
11/27/2011 at 11:49 a.m.: "The pt (patient #14) made a sexually inappropriate comment to therapist, "I want you for lunch." Pt. also made a sexual advance to a pt.(no documented description and no documented identify of the victim). Pt. was observed sitting on sofa (with) no diaper on. Asked pt. to put his legs down. Pt. did comply."
12/01/2011 at 9:50 a.m.: "The pt (#14) was wandering down the hall going into other pt's room. Therapist asked pt. to go to dayroom. Pt. walked up to therapist and grabbed her breast. . . Pt. wanted to hit staff when redirected." 1612 (4:12 p.m.) "making sexual comments, take off your clothes so I can rape you." 1830 (6:30 p.m.) "remained hypersexual, attempting to grab nurse breast."
12/02/2011 at 1900 (7:00 p.m.): "Inappropriately speaking to staff, getting aggressive occasionally. Needs constant redirection. . . Pt. (#14) becoming aggressive (with) other patients. Swung at one pt. Admin (administered) Ativan . . ."
12/05/2011 at 1112 (11:12 a.m.): "Prior to group, pt. (#14) was cursing this writer, put his arm around my waist and stated that he was going to rape me. . ."
12/06/2011 at 1245 (12:45 p.m.): "During range of motion exercise, pt. (#14) asked peer sitting next to him if he could touch her breast and then stuck his hand under her bottom. Pt was separated from peer."
12/07/2011 at 1527 (3:27 p.m.): "Pt (#14) attended group session. Pt was observed rubbing a peer's back. Pt was asked to keep his hands to himself and that his behavior was inappropriate. Pt removed his hands from peer's back then yelled loudly with pressured speech 'She wants me to rub her back'. Pt was reminded to keep his hands to himself."
Review of Patient #14's Initial Multidisciplinary Treatment Plan revealed Problem #5 as being "Sexually inappropriate (no documented date)". Further review revealed Interventions to include medication management by the physician, group by Activity Therapist and Social Worker, and Nursing staff to "monitor behavior around others, teach appropriate socialization skills, and provide safe structured environment." Review of Patient #14's entire medical record revealed no documented evidence of revisions to the treatment plan when redirection failed to ensure the safety of other patients in regards to verbal sexual remarks and physical touching.
Observations were made of Patient #14 where the hypersexual male patient was found to be seated by the side of female patients on 12/07/2011 at 11:40 a.m., 12:15 p.m., and 4:20 p.m. and on 12/08/2011 at 10:50 a.m. and 11:00 a.m. Observations on 12/08/2011 at 8:00 a.m. revealed Patient #14 to be absent from the Group Room where other patients were located. When asked where Patient #14 was located, the therapy staff and a nurse aide went from room to room searching for Patient #14. Patient #14 was located in the bathroom of Patient #1. Patient #1 was not in the room. Further Patient #R1 was observed to have a physical response to Patient #14 on 12/07/2011 at 11:40 a.m. where Patient #R1 was noted to have pulled her body back- away from Patient #14 who was seated next to her in the group room.
During a face to face interview on 12/07/2011 at 12:00 p.m., Patient #R1 ([AGE] year old female admitted on [DATE] with diagnoses that included Major Depressive Disorder/ identified by Director of Nursing as cognitively intact) indicated Patient #14 had asked if he could suck her nipples on 12/07/2011 at 11:40 a.m. #R1 indicated she had told Patient #14 to stop. #R1 further indicated Patient #14 had made inappropriate sexual remarks to her on a daily basis and had touched her on the leg moving his hand to her behind on one occasion. #R1 indicated she had also witnessed Patient #14 rubbing the legs of older female patients in Geri Chairs on 3 - 4 separate occasions. #R1 indicated the staff allowed Patient #14 to sit near female patients. #R1 indicated she was not afraid of Patient #14 because she could stand up for herself even though #14 would sometimes get "mean". #R1 indicated she (#R1) did not think the older patients in Geri Chairs would have been able to stand up for themselves the way that she (#R1) had.
During a face to face interview on 12/08/2011 at 3:00 p.m., Licensed Practical Counselor S14 indicated Patient #14 had been allowed to sit where he wanted. S14 stated Patient #14 had been allowed to sit next to female patients. S14 indicated she (S14) had never known any patient to be as hypersexual as Patient #14. S14 indicated Patient #14 had been moved away from female patients after incidents had been observed but there had been no seating arrangements made to prevent or decrease the opportunity for sexual acting out with female patients.
During a face to face interview on 12/08/2011 at 3:15 p.m., Music Therapist S16 indicated she had been present when Patient #14 had touched Patient #R1 on the behind. S16 indicated she separated the two patients after the incident but had not updated the treatment plan to reflect the hospital's policy. S16 further indicated she believed Patient #14 should have been made a 1:1. S16 indicated she had mentioned 1:1 to someone on the team; however, she (S16) did not recall who it had been. S16 indicated Patient #14 had been "too much to handle."
During a face to face interview on 12/08/2011 at 9:15 a.m., Director of Nursing S2 indicated she had mentioned to the Medical Director that Patient #14 might benefit from being placed on 1:1; however, the physician indicated the patient did not need observation of that intensive a level. S2 indicated Medical Director S17 wanted the patient to be on Strict Visual Contact; however, the hospital only had two levels of observations which included every 15 minutes or 1:1. S2 indicated the decision had been made to keep the patient on q 15 minute observations. S2 confirmed there had been no changes made to Patient #14's treatment plan when re-direction had failed to work. S2 indicated the hospital had a policy to address Inappropriate Sexual Behavior which should have been implemented but had not been.
During a telephone interview on 12/08/2011 at 3:30 p.m., Medical Director S17 indicated he had not felt that Patient #14 warranted 1:1 staffing because it would be too restrictive and the Nursing Home would not be able to provide 1:1 when the patient was discharged from the hospital. S17 further indicated he needed to observe Patient #14's interactions with others in order to determine the effectiveness of medication adjustments. S17 indicated the policy for Sexual Inappropriateness probably should have been discussed in regards to patient #14.
Review of the hospital policy titled, "Hypersexual Precautions, developed 5/01/2011" presented by the hospital as current revealed in part, "Direct supervision is to be provided for patients that are determined to be hypersexual and/or who make inappropriate sexual gestures, make inappropriate sexual comments, or perseverant on the subject of sex. close observation, monitoring the patient every 15 minutes, is the minimum requirement for patients of this nature. The charge nurse can obtain an order from the physician for 1 to 1 observation if necessary. Order for hypersexual precautions is obtained by physician. Hypersexual Precautions are as follows: Contact with the opposite sex is to be limited. Obtain an order from the physician for a 5 foot restriction from the opposite sex. Encourage staff of the same sex to assist the patient when possible. . . No peer or staff member of the opposite sex is to be alone in a room with the patient. . . Patient will not be allowed to sit next to the opposite sex at meals or during groups. . . If patient displays inappropriate behavior in the group setting and cannot be redirected, the patient will be asked to leave or will be escorted out of the group. . . patients are not allowed to visit in each other's rooms at any time. . . The charge nurse must be notified immediately of any inappropriate comments, gestures, touching, etc. made towards another patient or staff member. . ."
Review of the hospital policy titled, "Treatment Planning, effective date 5/01/2011" presented by the hospital as current revealed in part, "Treatment Team meetings are held at least weekly in order to monitor patient's progress, summarize, and revise the plan as needed. However, the treatment plan may be altered at any time a patient's status indicates."
VIOLATION: PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS Tag No: A0147
Based on record review and interview the hospital failed to ensure the patient's right to confidentiality of his or her clinical records by having the patient sign blank release of information forms for 1 of 21 sampled patients (#9). Findings:

Review of Patient #9's medical record revealed a signed blank "Authorization to Release or Obtain Health Information". The form was signed by the patient (#9) on 11/03/2011. Further review revealed the sections to indicated whether information was to be released or obtained and the name of the facility and/or person to whom the information would be released or obtained to be blank.

During a face to face interview on 12/08/2011 at 9:15 a.m., Director of Nursing S2 indicated there should never be a signature of a patient obtained on a blank Authorization to Release or Obtain information because it could later be filled out without the patient's knowledge and would not safeguard the patient's confidentiality.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure allegations of abuse were reported through the hospital's Incident Reporting System and investigated as per hospital policy for 2 of 3 allegations of abuse reviewed out of a total patient sample of 21 (Patient #1, #21) and failed to promptly investigate sperm in the urinalysis of a [AGE] year old female for 1 of 1 patient to have sperm noted on their urinalysis out of a total sample of 21 (#16). Findings:

Patient #1 Review of the medical record for Patient #1 revealed a [AGE] year old male admitted on [DATE] for increasing agitation and aggressive behavior. Further review revealed Patient #1 had a history of chronic myelocytic [DIAGNOSES REDACTED], Diabetes Mellitus, CVA (Cerebral Vascular Accident) and chronic gastrointestinal problems. Review of the Nurses' Progress Notes for Patient #1 dated/timed 12/01/11 at 1855 (6:55pm) revealed, "Pt. (Patient) was by the nurses' station trying to get attention of a female staff psych tech, very intrusive and crossing the boundary of another male pt. who was talking to staff that this pt. grabbed the hand of another male pt. so he was ht on his left eye, MD S17 notified. No apparent injury noted."

Review of the Patient/Visitor Incident Report for Patient #1 dated/timed 12/01/11 at 1825 (6:25pm) revealed in part...... "Pt. (#1) was by the nurses' station trying to get the attention of a female psych tech being so intrusive and crossing the boundary by another patient (#14) who was conversing with this psych tech. Patient #1 grabbed the hand of pt. (#14) so was hit on left eye. A little redness noted". Further review of the report revealed no documented evidence the information contained in the report was reviewed by the Department Head or the Risk/Safety Manager or the incident was further investigated.

In a face to face interview on 12/08/2011 at 1:10 p.m., Director of Nursing S2 indicated there had been no further investigation of the incident and verified the incident had not been signed as reviewed by the Department Head and Risk Manager.

Patient #21
Review of Patient #21's 11/24/2010 Incident Report revealed in part, "Client was repeatedly at nursing station (with) various requests for assistance. Med Tech (Medical Technician) S18 redirected patient. Pt (patient) voiced delusional belief that he (#21) was being attacked and began assaulting the staff member by hitting and kicking and he (#21) threw ice water on the staff member."

During a face to face interview on 12/08/2011 at 8:05 a.m., Registered Nurse S4 indicated Patient #21 had been alone in his room on 11/22/2010 when she (S4) heard him yell out in his room. S4 indicated that she (S4) and a Mental Health Tech (no recall of who the Tech was) had responded immediately. S4 indicated Patient #21 had apparently fallen against the door frame and had a superficial laceration to his face. S4 indicated first aide had been administered and neuro checks were performed. S4 indicated there had been no change in the patient's mental status. S4 further indicated the patient's physician had been notified. S4 indicated there had been no discoloration of the patient's eye and there had been no abrasion on the patient's elbow the night the patient fell against the door (11/22/2010).. S4 confirmed there was no documented evidence located in the medical record of a skin assessment for Patient #22 at Seaside Behavioral Hospital prior to the incident (admitted on [DATE]). S4 further indicated Patient #21 had appeared with a black eye several days later and repeatedly claimed that Mental Health Technician S18 had beaten him. S4 indicated she (S4) had not been directly approached by Patient #21 with claims of abuse but had overheard Patient #21 telling various Mental Health Technicians that Mental Health Technician S18 had beaten him. S4 indicated she had completed an incident report on the night Patient #21 had fallen against the door frame; however, had never written an incident report about claims by Patient #21 that Mental Health Technician #S18 had beaten him.

During a telephone interview on 12/08/2011 at 1:50 p.m., Registered Nurse S10 indicated she (S10) had no recall of Patient #21 and would not be able to provide any information about the incident that she (S10) had documented on 11/24/2010.

Mental Health Technician S18 was no longer employed by the hospital and not available for interview. Mental Health Technician S18 had been involuntarily terminated on 6/28/2011 for being confrontational with a Charge Nurse, yelling at two female patients, and sleeping while on duty.

During a face to face interview on 12/08/2011 at 1:10 p.m., Director of Nursing S2 indicated there had been no incident report made regarding Patient #21's allegations of abuse during his 2010 admission to the hospital and no investigation had been done. S2 confirmed Mental Health Technician S18 had been involuntarily terminated for being confrontational with a charge nurse, yelling at patients, and sleeping on the job. S2 indicated that it was very likely that Patient #21 had injured himself when he fell ; however, Registered Nurse S4 should have completed an incident report when Patient #21 claimed that he (#21) had been abused by staff and an investigation should have been done.

Patient #16:
Review of the medical record for Patient #16 revealed the [AGE] year old female patient was admitted on [DATE] with diagnoses that included [DIAGNOSES REDACTED]"Sperm cells rare". Further review revealed illegible initials signed on the report with no date/time. Review of a Physician's Progress note by Medical Director S17 dated 9/22/2011 (no documented time) revealed in part, "Urinalysis indicated rare bacteria and traces of mucus." Review of the entire progress note revealed no documented evidence of noting the presence of sperm in the urine. Review of Physician Progress notes dated 9/26/2011 (4 days after urinalysis results were faxed to the hospital revealing the presence of sperm) at 1622 (4:22 p.m.) revealed in part, "She had urinalysis on 9/22/2011, which showed rare sperm cells. It is unclear whether this is contamination or some other problem, but it has been reported and will be followed up on."

Review of email from Hospital A (contracted lab) dated 12/07/2011 at 12:28 p.m. revealed in part, "A urinalysis was performed on 9/22/11 and the microscopic was reported with rare sperm cells (Patient #16). On 9/26 (four days after faxed results), the lab was contacted by Seaside questioning the result of rare sperm cell. The technologist reviewed the result and determined that the computer generated image was an artifact. . ."

During a face to face interview on 12/08/2011 at 9:15 a.m., Director of Nursing S2 indicated the urinalysis report for Patient #16 indicating the presence of sperm should have been investigated promptly; at the time of the fax, rather than 4 days later.

Review of the hospital policy titled, " Suspected Abuse and Neglect, effective date 5/01/2011" presented by the hospital as current revealed in part, "All instances of suspected or identified abuse or neglect within the program will be immediately reported to the Medical Director and the DON (Director of Nursing). An investigation will begin immediately and, at the discretion of the DON and CEO (Chief Executive Officer), the responsible staff member may be placed on suspension pending the findings of the investigation. The patient/client involved will be protected from any potential repercussion by reassignment, referral to another facility, or some other mutually agreeable arrangement. Within 72 hours of the initiation of an investigation a decision and the corresponding report will be completed. All offending staff members will be terminated, reported to the appropriate state agency, and all those directly involved will be contacted regarding the findings and resulting actions taken."

Review of the hospital policy titled, "Adverse Event/Incident Reports, effective date 5/01/2011" presented by the hospital as current revealed in part, "It is the policy of the Psychiatric service to assure the reporting of all significant events/occurrences in order to maintain a safe environment for all clients, staff, and visitors. The information reported is used to evaluate and identify risk areas so as to assure resolution and prevention of potential problem areas. Whenever this is a significant occurrence the staff member involved in identifying the event will complete an Incident Report form. The Program Nurse will be notified of any physical mishap to assess the appropriate action to be taken and disposition. Any incident involving a patient/client will be documented in the progress notes of that individual including; patient condition and the action taken. The Quality Manager will assist the program in investigating the incident, trending similar incidents and problem correction."
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure allegations of abuse were reported through the hospital's Incident Reporting System and investigated as per hospital policy for 2 of 3 allegations of abuse reviewed out of a total patient sample of 21 (Patient #1, #21) and failed to promptly investigate sperm in the urinalysis of a [AGE] year old female for 1 of 1 patient to have sperm noted on their urinalysis out of a total sample of 21 (#16). Findings:

Patient #1 Review of the medical record for Patient #1 revealed a [AGE] year old male admitted on [DATE] for increasing agitation and aggressive behavior. Further review revealed Patient #1 had a history of chronic myelocytic [DIAGNOSES REDACTED], Diabetes Mellitus, CVA (Cerebral Vascular Accident) and chronic gastrointestinal problems. Review of the Nurses' Progress Notes for Patient #1 dated/timed 12/01/11 at 1855 (6:55pm) revealed, "Pt. (Patient) was by the nurses' station trying to get attention of a female staff psych tech, very intrusive and crossing the boundary of another male pt. who was talking to staff that this pt. grabbed the hand of another male pt. so he was ht on his left eye, MD S17 notified. No apparent injury noted."

Review of the Patient/Visitor Incident Report for Patient #1 dated/timed 12/01/11 at 1825 (6:25pm) revealed in part...... "Pt. (#1) was by the nurses' station trying to get the attention of a female psych tech being so intrusive and crossing the boundary by another patient (#14) who was conversing with this psych tech. Patient #1 grabbed the hand of pt. (#14) so was hit on left eye. A little redness noted". Further review of the report revealed no documented evidence the information contained in the report was reviewed by the Department Head or the Risk/Safety Manager or the incident was further investigated.

In a face to face interview on 12/08/2011 at 1:10 p.m., Director of Nursing S2 indicated there had been no further investigation of the incident and verified the incident had not been signed as reviewed by the Department Head and Risk Manager.

Patient #21
Review of Patient #21's 11/24/2010 Incident Report revealed in part, "Client was repeatedly at nursing station (with) various requests for assistance. Med Tech (Medical Technician) S18 redirected patient. Pt (patient) voiced delusional belief that he (#21) was being attacked and began assaulting the staff member by hitting and kicking and he (#21) threw ice water on the staff member."

During a face to face interview on 12/08/2011 at 8:05 a.m., Registered Nurse S4 indicated Patient #21 had been alone in his room on 11/22/2010 when she (S4) heard him yell out in his room. S4 indicated that she (S4) and a Mental Health Tech (no recall of who the Tech was) had responded immediately. S4 indicated Patient #21 had apparently fallen against the door frame and had a superficial laceration to his face. S4 indicated first aide had been administered and neuro checks were performed. S4 indicated there had been no change in the patient's mental status. S4 further indicated the patient's physician had been notified. S4 indicated there had been no discoloration of the patient's eye and there had been no abrasion on the patient's elbow the night the patient fell against the door (11/22/2010).. S4 confirmed there was no documented evidence located in the medical record of a skin assessment for Patient #22 at Seaside Behavioral Hospital prior to the incident (admitted on [DATE]). S4 further indicated Patient #21 had appeared with a black eye several days later and repeatedly claimed that Mental Health Technician S18 had beaten him. S4 indicated she (S4) had not been directly approached by Patient #21 with claims of abuse but had overheard Patient #21 telling various Mental Health Technicians that Mental Health Technician S18 had beaten him. S4 indicated she had completed an incident report on the night Patient #21 had fallen against the door frame; however, had never written an incident report about claims by Patient #21 that Mental Health Technician #S18 had beaten him.

During a telephone interview on 12/08/2011 at 1:50 p.m., Registered Nurse S10 indicated she (S10) had no recall of Patient #21 and would not be able to provide any information about the incident that she (S10) had documented on 11/24/2010.

Mental Health Technician S18 was no longer employed by the hospital and not available for interview. Mental Health Technician S18 had been involuntarily terminated on 6/28/2011 for being confrontational with a Charge Nurse, yelling at two female patients, and sleeping while on duty.

During a face to face interview on 12/08/2011 at 1:10 p.m., Director of Nursing S2 indicated there had been no incident report made regarding Patient #21's allegations of abuse during his 2010 admission to the hospital and no investigation had been done. S2 confirmed Mental Health Technician S18 had been involuntarily terminated for being confrontational with a charge nurse, yelling at patients, and sleeping on the job. S2 indicated that it was very likely that Patient #21 had injured himself when he fell ; however, Registered Nurse S4 should have completed an incident report when Patient #21 claimed that he (#21) had been abused by staff and an investigation should have been done.

Patient #16:
Review of the medical record for Patient #16 revealed the [AGE] year old female patient was admitted on [DATE] with diagnoses that included [DIAGNOSES REDACTED]"Sperm cells rare". Further review revealed illegible initials signed on the report with no date/time. Review of a Physician's Progress note by Medical Director S17 dated 9/22/2011 (no documented time) revealed in part, "Urinalysis indicated rare bacteria and traces of mucus." Review of the entire progress note revealed no documented evidence of noting the presence of sperm in the urine. Review of Physician Progress notes dated 9/26/2011 (4 days after urinalysis results were faxed to the hospital revealing the presence of sperm) at 1622 (4:22 p.m.) revealed in part, "She had urinalysis on 9/22/2011, which showed rare sperm cells. It is unclear whether this is contamination or some other problem, but it has been reported and will be followed up on."

Review of email from Hospital A (contracted lab) dated 12/07/2011 at 12:28 p.m. revealed in part, "A urinalysis was performed on 9/22/11 and the microscopic was reported with rare sperm cells (Patient #16). On 9/26 (four days after faxed results), the lab was contacted by Seaside questioning the result of rare sperm cell. The technologist reviewed the result and determined that the computer generated image was an artifact. . ."

During a face to face interview on 12/08/2011 at 9:15 a.m., Director of Nursing S2 indicated the urinalysis report for Patient #16 indicating the presence of sperm should have been investigated promptly; at the time of the fax, rather than 4 days later.

Review of the hospital policy titled, " Suspected Abuse and Neglect, effective date 5/01/2011" presented by the hospital as current revealed in part, "All instances of suspected or identified abuse or neglect within the program will be immediately reported to the Medical Director and the DON (Director of Nursing). An investigation will begin immediately and, at the discretion of the DON and CEO (Chief Executive Officer), the responsible staff member may be placed on suspension pending the findings of the investigation. The patient/client involved will be protected from any potential repercussion by reassignment, referral to another facility, or some other mutually agreeable arrangement. Within 72 hours of the initiation of an investigation a decision and the corresponding report will be completed. All offending staff members will be terminated, reported to the appropriate state agency, and all those directly involved will be contacted regarding the findings and resulting actions taken."

Review of the hospital policy titled, "Adverse Event/Incident Reports, effective date 5/01/2011" presented by the hospital as current revealed in part, "It is the policy of the Psychiatric service to assure the reporting of all significant events/occurrences in order to maintain a safe environment for all clients, staff, and visitors. The information reported is used to evaluate and identify risk areas so as to assure resolution and prevention of potential problem areas. Whenever this is a significant occurrence the staff member involved in identifying the event will complete an Incident Report form. The Program Nurse will be notified of any physical mishap to assess the appropriate action to be taken and disposition. Any incident involving a patient/client will be documented in the progress notes of that individual including; patient condition and the action taken. The Quality Manager will assist the program in investigating the incident, trending similar incidents and problem correction."
VIOLATION: MEDICAL STAFF BYLAWS Tag No: A0353
Based on observation, interview and record review, the hospital failed to ensure the enforcement of the Medical Staff Bylaws and the Medical Staff Rules & Regulations. This was evidenced by 1) the hospital's failure to ensure medical records were completed by the member of the medical staff within 30 days of a patient's discharge from the hospital; 2) the hospital's failure to ensure the enforcement of the rules and regulations relating to delinquent medical records; and 3) the hospital's failure to ensure the delineation of privileging was completed for 2 of 5 members of the medical staff whose credentialing file was reviewed for the delineation of privileging. Findings:

Observations in the medical records department on 12/08/11 at 9:40 a.m. revealed a filing cabinet that contained over 50 medical records. The Medical Records Management Representative (S7) was interviewed at the time of this observation (12/08/11 at 9:40 a.m.) When asked about the hospital's medical record delinquency rate or the number of delinquent medical records, S7 reported that he was unable to determine the number of delinquent medical records. S7 indicated that the hospital was not monitoring and/or tracking the number of delinquent medical records. In addition, S7 indicated that the hospital was not tracking the members of the medical staff who have delinquent medical records. A focused review of the medical records in the filing cabinet was performed in an effort to determine if the medical records were completed within 30 days of discharge. Twelve (12) medical records in this filing cabinet (Seven medical records for S20 and five medical records for S22) were noted to be delinquent for greater than 30 days which would be greater than 60 days of the patient's discharge from the hospital. S7 confirmed the 12 medical records were not completed within 60 days of the patient's discharge from the hospital.

The Medical Staff Rules & Regulations were reviewed. The Rules & Regulations documents the following under the section of inpatient medical records: "If the record remains incomplete thirty (30) days after discharge, the CEO or designee shall notify the responsible staff member that his/her name will be placed on the "No Admit" list fifteen (15) days from the date of notice" and "If the record still remains incomplete fifteen (15) days after the physician is placed on the "No Admit" list, suspension of Medical staff privileges may occur. If the physician is responsible for the care of patients in the Hospital at the time of suspension, the physician shall continue to be responsible for the patient until discharge; however, no new patients may be admitted ".

The Administrator (S1) was interviewed on 12/08/11 at 10:50 a.m. When asked if S20 and/or S22 were notified of their delinquent medical records, S1 indicated that he could not provide any evidence to indicate that S20 or S22 were notified of their delinquent medical records. When asked if S20 and/or S22 had been placed on the "No Admit" list as a result of the delinquent medical records, S1 reported that S20 and S22 were not placed on the "No Admit" list. When asked if S20 and/or S22's privileges were suspended as a result of the delinquent medical records, S1 indicated that S20 and S22's privileges have not been suspended. S1 confirmed that the hospital is not following the rules & regulations in relation to delinquent medical records.

Review of the credentialing file of S20 (Medical Doctor) on 12/07/11 revealed no evidence to indicate that the Medical Director had approved the delineation of privileges for S20.

Review of the credentialing file of S21 (Advanced Practice Registered Nurse) on 12/07/11 revealed no evidence to indicate that the Medical Director had approved the delineation of privileges for S21.

The hospital's Administrator (S1) was interviewed on 12/07/11 at 3:30 p.m. S1 reviewed the credentialing files of S20 and S21. S1 confirmed there was no evidence to indicate that the Medical Director had approved the delineation of privileges for S20 or S21.
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 RN supervision of care as evidenced by: 1) failing to notify the physician of a significant change in condition when a patient was found to be hypotensive and unresponsive for 1 of 1 patients reviewed with altered level of conscious out of a total sample of 21 (#10); 2) failing to notify the physician of a significant change in condition when a patient was found to be hypoglycemic with a blood glucose of 34 mg/dl (milligrams/deciliter) for 1 out 21 sample patients.(Patient #7); 3) failing to assess three (3) patients with blood sugars less than 70 for symptoms of [DIAGNOSES REDACTED]#2, #3); and 4) failing to clarify a physician's order for lab (Digoxin level) for a patient that had the lab drawn three days after ordered (ordered on [DATE] and drawn on 11/28/2011) when the patient's heart rate had been running less than 60 on more than one occasion (#2) for 1 of 21 sampled patients (#2). Findings:

1) failing to notify the physician of a significant change in condition when a patient was found to be hypotensive and unresponsive for 1 of 1 patients reviewed with altered level of conscious out of a total sample of 22 (#10).

Review of Patient #10's medical record revealed the patient was admitted on [DATE] with diagnoses that included [DIAGNOSES REDACTED].m.) revealed in part, "Unable to rouse pt. (patient) by stating name numerous times and shaking pt. Unresponsive. HR (heart rate) weak, rise and fall of chest noted. Pt unresponsive to sternal rub. VS (Vital Signs) 70/50, HR 72, PO2% (oxygen saturation) 97%, blood sugar 137. After approximately 5 minutes was able to awaken pt. she said she felt well, very sleepy. Began respiratory tx, pt. appeared more alert. Post tx. VS 123/74, HR 75, PO2% 97%, Resp 14, pt. still quite drowsy but more easily aroused. will continue to monitor closely." Review of the entire medical record revealed no documented evidence that Patient #11's physician was notified of the unresponsive episode with a significant drop in blood pressure.

During a telephone interview on 12/08/2011 at 2:10 p.m., Registered Nurse S12 confirmed that she was the nurse providing care to Patient #10 on the day that the patient became unresponsive (12/02/2011). S12 indicated she had not called nor notified the patient's physician of the incident.

During a face to face interview on 12/08/2011 at 9:15 a.m., Director of Nursing S2 indicated a physician should always be notified of a significant change in condition. S2 indicated Patient #10's physician should have been notified when the patient became unresponsive to a sternal rub with a weak heart rate and blood pressure of 70/50.


2) Failing to notify the physician of a patient's 34 glucose.

Review of Patient #7's medical record revealed the patient was admitted on [DATE] for Schizophrenia and dementia with Psychosis. Review of the Physician Orders dated 11/29/11 revealed she had an order for Gluctorol 12.5 mg (milligram) po (by mouth) BID (twice a day), Lantus 18 units SQ (subcutaneous) q (every) 12 hours and accucheck's q am.

Review of the Diabetic Record revealed a late entry for 12/05/11 at 2100 (9 p.m.) for a glucose of 34 and a glucose recheck at 2230 (10:30 p.m.) of 92 by S4RN.

Review of the Nurse's Assessment for 12/05/11 revealed Patient #7 had refused her dinner.

Review of the Daily Treatment Plan Update and Team Progress Note for 1900 to 0700 (7 p.m. to 7 a.m. ) revealed, "Pt. (patient) found lying in bed with eyes closed, respiration even and unlabored. Refused HS (bedtime) snack, but given juice and glucerna. Compliant with medication crushed and given in juice. Refused to get out of bed. Will continue to monitor and provide safe and therapeutic environment." There was no documentation the physician was notified of the 34 mg/dl blood glucose, a stat blood glucose was not done as per policy, and the interventions for the [DIAGNOSES REDACTED] was not documented..

An interview was conducted with S4RN on 12/08/11 at 8:05 a.m. She reported the patient had no symptoms of [DIAGNOSES REDACTED]. When she rechecked her glucose, it was 92. When questioned if she should have called the physician she stated she should have,but she did not call the physician.

An interview was conducted with S2DON on 12/08/11 at 9:15 a.m. She reported with Patient #7's glucose of 34 mg/dl a stat glucose should have been done, the physician should have be notified, and the interventions documented.

3) failing to assess three (3) patients with blood sugars less than 70 for symptoms of [DIAGNOSES REDACTED]#2, #3).

Patient #1
Review of the medical record for Patient #1 revealed a [AGE] year old male admitted on [DATE] for increasing agitation and aggressive behavior. Further review revealed Patient #1 had a history of chronic myelocytic [DIAGNOSES REDACTED], Diabetes Mellitus, CVA (Cerebral Vascular Accident) and chronic gastrointestinal problems.

Review of the MAR (Medication Administration Record) for Patient #1 dated 11/30/11 revealed a blood sugar of 52 at 2100 (9:00pm). Further review of the medical record revealed no documented evidence Patient #1 had been assessed for symptoms of [DIAGNOSES REDACTED]

Review of the MAR (Medication Administration Record) for Patient #1 dated 12/01/11 revealed a blood sugar of 57 at 0600 (6:00am) at which time #1 received juice. Further review of the medical record revealed no documented evidence Patient #1 had been assessed for symptom of [DIAGNOSES REDACTED], the amount or type of juice given or a re-assessment of the blood sugar after the juice had been given.

In a face to face interview on 12/08 /11 at 9:15am RN S2 Director of Nursing indicated an assessment should have been performed on Patient #1 to determine if was symptomatic, interventions performed and re-assessment of the blood sugar after the interventions. Further S2 indicated this information should have been documented in the Nurse ' s Notes.

Patient #2:
Review of Patient #2's medical record revealed the patient was admitted on [DATE] with diagnoses that included [DIAGNOSES REDACTED]. Review revealed Patient #2's accucheck was repeated at 0245 (2:45 a.m.) with a reading of 52, and again at 0300 (3:00 a.m.) where the reading was listed as 42 and the patient was administered Ensure (no amount listed) and the rest of the candy bar. Patient #2's Nurse Practitioner was notified at 0320 (50 minutes after accucheck discovered to be 34) and an order for Glucogon 1 cc (cubic centimeter) was ordered and administered. Patient #2's accucheck was then repeated at 0350 (3:50 a.m.) and found to be 133. Review of Patient #2's entire medical record revealed no documented evidence of any attempt to draw a stat glucose at the time the patient was found to have an accucheck of 34.

During a face to face interview on 12/08/2011 at 9:15 a.m., Director of Nursing S2 indicated the nursing staff should have attempted to draw a stat glucose as per hospital policy when Patient #2's accucheck was 34. S2 further indicated if the nursing staff had difficulty obtaining the stat glucose, they should have continued with treatment as per the hospital policy and documented the unsuccessful attempt to draw labs.


Patient #3:
Review of Patient #3's medical record revealed the patient was admitted on [DATE] with diagnoses that included [DIAGNOSES REDACTED]<60 give Glucogon 1 mg (milligrams) IM (Intramuscular) recheck 5 minutes. . ." Further review revealed Patient #3's accucheck reading on 11/24/2011 at 0600 (6:00 a.m.) to be 55 with OJ (Orange Juice) noted as given. Review of the entire medical record revealed no documented evidence that Glucogon was administered as per physician's orders. Further review revealed no documented assessment of Patient #3's accucheck after administration of Orange Juice at 0600 until reassessed at 1130 (11:30 a.m./five and one half hours after the reading of 55).

During a face to face interview on 12/08/2011 at 9:15 a.m., Director of Nursing S2 indicated the nursing staff should have followed physician's orders and hospital policy when #3's accucheck was less than 60 on 11/24/2011 at 0600 (6:00 a.m.). S2 indicated the nurse should have rechecked the patient's glucose within 20 minutes of treatment and the nurse should have administered Glucogon as ordered by the physician.

Review of the hospital policy titled, "[DIAGNOSES REDACTED] and Hyperglycemia Protocols, developed 5/01/2011" presented by the hospital as current revealed in part, "Mild [DIAGNOSES REDACTED]: blood glucose < (less than) 70 mg/dl.(milligrams per deciliter), May not demonstrate symptoms or may exhibit pallor, diaphoresis, tachycardia, palpitations, hunger, or paresthesias. Patient remains alert. Moderate [DIAGNOSES REDACTED]: blood glucose <60 mg/dl. May not demonstrate symptoms or may exhibit headache, mood change, decreased attentiveness, drowsiness, impairment of motor function, confusion or inappropriate behavior., Severe [DIAGNOSES REDACTED]: blood glucose <40 mg/dl. May have significant neurological impairment and unable to initiate self treatment. May have seizures. May be unresponsive and/or unconscious with ongoing pulse and respirations. Request a stat lab blood glucose if BBG (blood glucose) is <50 mg/dl. Do not delay treatment if lab cannot draw blood within 5 minutes. Treat the patient having a blood glucose <70 mg/dl as follows: Conscious Patient. Give 15 Gms carbohydrate PO (by mouth). 4 oz (ounces) orange juice or 4 oz of apple or grape juice can be given or 5 oz non-dietetic carbonated beverage or Insta-Glucose. Repeat Accucheck or ISTAT in 20 minutes. Give additional 15 Gms (Grams) carbohydrates if blood glucose is <80 mg/dl. Repeat Accucheck or ISTAT in 20 minutes. Notify physician if blood glucose is still less than 80 mg/dl. Unconscious or NPO (nothing by mouth) Patient. Administer a 25 cc bolus of 50% Glucose IV (intravenously). Repeat Accucheck or ISTAT in 10 minutes. Bolus additional 25 cc or 50% Glucose IV if blood glucose is less than 50 mg/dl. Notify Physician or patient's status. Unconscious or NPO patient (without IV) Give Glucogon 1 mg. subcutaneously. Establish and IV line.. . Begin treatment listed under Conscious Patient if patient is responsive and able to swallow.. . ."

4) failing to clarify a physician's order for lab (Digoxin level) for a patient that had the lab drawn three days after ordered (ordered on [DATE] and drawn on 11/28/2011) when the patient's heart rate had been running less than 60 on more than one occasion (#2) for 1 of 21 sampled patients.

Review of Patient #2's medical record revealed the patient was admitted on [DATE] with diagnoses that included [DIAGNOSES REDACTED]#2's graphic sheet revealed the following: 11/19/2011 at 4:00 p.m. pulse 55, 11/20/2011 at 4:00 p.m. pulse 51, and 11/21/2011 at 6:00 a.m. pulse 56. Review of Patient #2's physician orders dated 11/25/2011 at 3:00 p.m. revealed an order for blood Digoxin level. Further review of Patient #2's medical record revealed the Digoxin level was drawn on 11/28/2011 at 6:00 a.m. (3 days after the routine lab was ordered).

During a face to face interview on 12/08/2011 at 9:15 a.m., Director of Nursing S2 indicated the contract for lab is a 24 hour per day 7 day per week contract. S2 indicated Hospital A (contracted lab) provides the service of drawing routine labs Monday through Friday. S2 indicated that any other routine labs were to be drawn by Seaside Behavioral Hospital nursing staff. S2 indicated the nursing staff should have called Patient #2's physician to clarify the patient's order for routine Digoxin level to see if the physician wanted nursing staff to draw the lab on the 11/26/2011 or wait until that Monday for the contracted lab to draw the blood work.

Review of the hospital policy titled, "Clinical Laboratory Test, effective date 5/01/2011" revealed in part, "The currently contracted lab will perform all ordered procedures on Psychiatric Service patients unless special arrangement is required and the appropriate orders given. . . When lab function is to be performed, Nursing. . . Performs lab service. . . The lab specimen will be transported to the lab either by internal transport system, or from the freestanding behavioral health unit, by the transportation service that runs twice daily. . Lab Service is on the unit every day Monday - Friday for routine labs.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure physician's orders for the plan of care were implemented as evidenced by: 1) failing to ensure Glucogon was administered for a blood sugar of <60 for 1 of 1 patients with orders for Glucogon (#3); 2) failing to ensure standing blood pressures were performed on patients identified as high risk for falls for 3 of 3 patients with orders for fall precautions (#1, #6, #18) out of a total of 21 sampled patients; 3) failing to ensure an RPR was done as ordered by the physician for 1 out 21 sampled patients (#4); 4) failing to notify the physician that a urine specimen came back contaminated for 1 out of 21 sample patients (#7) and 5) failing to ensure seizure precautions were implemented according to policy and procedure and as ordered by the physician for a patient with a history of seizures for 1 of 1 patients with seizure precautions ordered (#6) out of a total of 21 sampled medical records. Findings:

1) failing to ensure Glucogon was administered for a blood sugar of <60
Review of Patient #3's medical record revealed the patient was admitted on [DATE] with diagnoses that included [DIAGNOSES REDACTED]<60 give Glucogon 1 mg (milligrams) IM (Intramuscular) recheck 5 minutes. . ." Further review revealed Patient #3's accucheck reading on 11/24/2011 at 0600 (6:00 a.m.) to be 55 with OJ (Orange Juice) noted as given. Review of the entire medical record revealed no documented evidence that Glucogon was administered as per physician's orders.

During a face to face interview on 12/08/2011 at 9:15 a.m., Director of Nursing S2 indicated the nursing staff should have followed physician's orders for Glucogon when Patient #3's accucheck was less than 60 on 11/24/2011 at 0600 (6:00 a.m.)


2) failing to ensure standing blood pressures were performed on patients identified as high risk for falls
Patient #1
Review of the medical record for Patient #1 revealed a [AGE] year old male admitted via PEC (Physician's Emergency Certificate) to the hospital on [DATE] for increasing agitation and aggressive behavior while in residence at a nursing home. Further review revealed Patient #1 had a history of chronic myelocytic [DIAGNOSES REDACTED], Diabetes Mellitus, CVA (Cerebral Vascular Accident) and chronic gastrointestinal problems.

Review of the Physician's Admit Orders dated/timed 11/09/11 at 1445 (2:45pm) for Patient #1 revealed an order for fall precautions and assistance with activity.

Review of the Graphic sheet for Patient #1 dated 11/09/11 through 12/06/11 revealed no documented evidence orthostatic blood pressures were taken every four hours per hospital policy.

Patient #6
Review of the medical record for Patient #6 revealed a [AGE] year old male admitted on [DATE] for depression, ETOH (Alcohol) dependence, cocaine dependence, with a history of alcohol abuse, depression and crack cocaine use. Further review revealed Patient #6 had a medical history of [DIAGNOSES REDACTED]

Review of the Physician's Admit Orders dated/timed 11/26/11 at 2355 (11:55 pm) for Patient #6 revealed an order for fall precautions.

Review of the Graphic sheet for Patient #6 dated 11/2611 through 12/06/11 revealed no documented evidence standing blood pressures were taken every four hours per hospital policy.

Patient #18
Review of Patient #18's medical record revealed she was admitted on [DATE] for Dementia with behavioral disturbances.

Review of her Physicians' Admit Orders and Preliminary Treatment Plan dated 09/20/11 revealed she was on fall precautions.

Review of the graphic sheet for Patient #18 revealed no standing blood pressures from 09/20/11 to 09/30/11.

An interview was conducted with S5LPN on 12/08/11 at 8:15 a.m. She stated they only do sitting and standing blood pressure on patients when ordered by the physician, not when on fall precautions.

An interview was conducted with S4RN on 12/08/11 at 8 a.m. She reported only sitting and standing blood pressure done on patient's if there was an order by the doctor.

Review of the hospital's policy for Falls, with a policy number of PP-54, revealed in part,"...7. Fall precaution will include...b. sitting and standing blood pressure checks twice daily..."

3) failing to ensure a RPR was done as ordered by the physician.
Review of the medical record for Patient #4 revealed she was admitted on [DATE] for diagnosis of [DIAGNOSES REDACTED]

Review of her Physicians' Admit Orders and Preliminary Treatment Plan dated 11/30/11 revealed an order for lab work for RPR (Rapid Plasma Reagin). Review of the medical record revealed no results for the RPR lab work ordered on admission.

An interview was conducted with S2DON (Director of Nurses) on 12/06/11 at 10 a.m. She reported that the RPR lab work had not be done and had been an overlooked by the lab. She went on to report the Quality Assurance Nurse and night nurses doing the 24 hour chart check should had identified the lab work was not done.

4) failing to notify the physician of a contaminated urine specimen.

Review of the medical record for Patient #7 revealed she was admitted on [DATE] with the diagnosis of [DIAGNOSES REDACTED]

Review of the Physicians' Admit Orders and Preliminary Treatment Plan dated 11-29-11 revealed an order for an urinalysis and urine culture and sensitivity. Review of the Urinalysis dated 12/01/11 revealed a cath urine specimen had many bacteria in sample and Augmentin 875 mg (milligram) po (by mouth) BID(twice a day) was ordered. Review of the final urine culture dated 12/03/11 revealed three or more organism. Indicates specimen contamination. Review of the Daily Treatment Plan Update and Team Progress Note revealed no documentation the physician was notified of the contaminated urine culture and sensitivity.

An interview was conducted with S2 Director of Nurses on 12/06/11 at 8:30 a.m. She reported that their was no documentation the physician was notified of the result of the contaminated sample. She went on to report the physician should have been notified.


5) failing to ensure seizure precautions were implemented according to policy and procedure and as ordered by the physician for a patient with a history of seizures
Patient #6
Review of the medical record for Patient #6 revealed a [AGE] year old male admitted on [DATE] for depression, ETOH (Alcohol) dependence, cocaine dependence, with a history of alcohol abuse, depression and crack cocaine use. Further review revealed Patient #6 had a medical history of [DIAGNOSES REDACTED]

Review of the Physician's Admit Orders dated/timed 12/02/11 at 2215 (10:15pm) revealed an order for Seizure and Withdrawal Precautions.

Review of the Master Treatment Plan dated 12/02/11 for Patient #6 revealed no documented evidence seizures and withdrawals were identified as medical problems. Further review revealed no documented evidence seizure precautions were implemented.

In a face to face interview on 12/08/11 at 8:35 am RN S4 indicated interventions implemented for seizure precautions used is to communicate the fact the patient has a seizure disorder. Further S4 indicated she was not aware of the hospital's Seizure precaution policy requiring oxygen, padded siderails, airway, etc..

Review of Policy No. NS-054 titled Seizure Precautions" developed 05/01/2011 and submitted as the one currently in use revealed ...... "Seizure precautions will be set up for patients diagnosed with [DIAGNOSES REDACTED].
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on record review and interview the hospital failed to ensure Registered Nurses and Licensed Practical Nurses were evaluated as competent in Urinary Catheterizations prior to being assigned to catheterize patients or after having an increase in contaminated urinalysis for patients in the hospital. Findings:
Review of the Medical Executive Committee meeting minutes for November 30, 2011 meeting revealed in part, " The Medical Executive Committee has approved changing the standard Admit Orders to include a UA (urinalysis) on every patient. After UA results are obtained, the physician will decide if further testing is needed. Due to the increased number in contaminated specimens, (Culture and Sensitivities) will be removed from the Admit Orders sheet. (Director of Nursing) will train the nursing staff of these changes. . . "
Review of a sign in sheet for "Urine Culture Collection and Transport" presented by Hospital A (contracted lab service) on 8/31/2011 revealed 10 signatures of nursing staff in attendance: 1 identified as Registered Nurse, 1 identified as Licensed Practical Nurse, the remaining 8 had no title with their signature.
Review of a list of nursing staff currently employed by the hospital at the time of the survey revealed the hospital had 24 Registered Nurses on staff and 11 Licensed Practical Nurses.
Review of forms used to evaluate the competency of nursing staff (Registered Nurses and Licensed Practical Nurses) revealed no documented evidence of competency evaluation in urinary catheterization.
During a face to face interview on 12/08/2011 at 11:10 a.m., Quality Assurance Officer S27 indicated the hospital had an increase in contaminated urinalysis after switching contracted companies. S27 indicated Hospital A had provided an inservice training in regards to urine collection and transport for the hospital. S27 confirmed that not all nursing staff had attended the inservice training. S27 indicated there had been notes placed throughout the hospital for nursing staff to review regarding the education presented by Hospital A. S27 further indicated she had observed one Registered Nurse perform a catheterization but no others. S27 indicated there had never been an evaluation of competency for nursing staff at the facility in regards to urinary catheterizations.
VIOLATION: WRITTEN MEDICAL ODERS FOR DRUGS Tag No: A0406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure all physican orders were clarified as evidenced by; 1) failure to obtain complete orders for sliding scale insulin to include treatment of hypo and hyperglycemia (#1); 2) failure to obtain drug name, exact strength or concentration, dose, frequency, and route, and specific instructions for treatment of symptoms of [DIAGNOSES REDACTED]#12). Findings:



1) failure to obtain complete orders for sliding scale insulin to include treatment of hypo and hyperglycemia
Review of the medical record for Patient #1 revealed a [AGE] year old male admitted on [DATE] for increasing agitation and aggressive behavior. Further review revealed Patient #1 had a history of chronic myelocytic [DIAGNOSES REDACTED], Diabetes Mellitus, CVA (Cerebral Vascular Accident) and chronic gastrointestinal problems.

Review of the Physician's Verbal Admission Orders for Patient #1 dated/timed 11/09/11 1445 (2:45pm) revealed a a Novolog sliding scale as follows: <70 = 0 units; 70-150 = 0 units; 151-200 = 1 unit; 201-250 = 2 units; 251-400 = 6 units. Further review revealed no documented evidence of the physician had been notified for clarification of the orders to include treatment and/or interventions for [DIAGNOSES REDACTED] or hyperglycemia.

In a face to face interview on 12/08 /11 at 9:15am RN S2 Director of Nursing indicated each physician writes his own orders for sliding scale insulin and verified the hospital does not use standing orders for sliding scale insulin. Further S2 indicated the nurse should have called the physician for what to do when the blood sugar was below 70 and above 400.



2) failure to obtain drug name, exact strength or concentration, dose, frequency, and route, and specific instructions for use for used for symptoms of [DIAGNOSES REDACTED]
Review of the medical record for Patient #6 revealed a [AGE] year old male admitted on [DATE] for depression, ETOH (Alcohol) dependence, cocaine dependence, with a history of alsohol abuse, depression and crack cocaine use. Further review revealed Patient #6 had a medical history of [DIAGNOSES REDACTED]

Review of the Physician's Orders for Patient #6 dated/timed 12/03/11 at 11:50am revealed..... "4. Any meds (medication) for withdrawal symptoms per Psych". Furthe rreview of the medical record revealed no documented evidence the order was clarified by the nursing staff.

In a face to face interview on 12/08 /11 at 9:15am RN S2 Director of Nursing indicated the nurse taking off the order should have called the physician for clarification of the order.

3) failure to clarify parameters regarding when a prn (as needed) medication (Ativan) was to be administered by mouth (PO) versus Intramuscularly (IM) for 1 of 21 sampled patients (#12).

Review of Patient #12's medical record revealed the patient was admitted on [DATE] with diagnoses that included [DIAGNOSES REDACTED]'s orders dated 12/03/2011 at 0200 (2:00 a.m.) revealed an order for "Ativan 1 mg (milligrams) IM (Intramuscular) or PO (by mouth) every 6 hours prn (as needed) anxiety. Review of the entire medical record revealed no documented parameters to indicate when the patient should be administered the medication by mouth versus when the patient should receive the medication Intramuscularly.

During a face to face interview on 12/08/2011 at 9:15 a.m., Director of Nursing S2 confirmed the above findings. Futher S2 indicated the nursing staff should have clarified the order to specify the parameters for PO administration versus IM administration.



MEDICATION ADMINISTRATION POLICY
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on observation, interview and record review, the hospital failed to ensure that medical records were completed within 30 days after discharge from the hospital and failed to ensure the effective implementation of a system that provides for the monitoring and tracking of delinquent medical records. Delinquent medical records were identified for Patient's #R2 through R13. Findings:

Observations in the medical records department on 12/08/11 at 9:40 a.m. revealed a filing cabinet that contained over 50 medical records. The Medical Records Management Representative (S7) was interviewed at the time of this observation (12/08/11 at 9:40 a.m.) When asked about the hospital's medical record delinquency rate or the number of delinquent medical records, S7 reported that he was unable to determine the number of delinquent medical records. S7 indicated that the hospital was not monitoring and/or tracking the number of delinquent medical records. In addition, S7 indicated that the hospital was not tracking the members of the medical staff who have delinquent medical records. A focused review of the medical records in the filing cabinet was performed in an effort to determine if the medical records were completed within 30 days of discharge. Twelve (12) medical records in this filing cabinet were noted to be delinquent for greater than 30 days which would be greater than 60 days of the patient's discharge from the hospital. Delinquencies included but not limited to orders and evaluations that were not authenticated by the physician. S7 confirmed the 12 medical records were not completed within 60 days of the patient's discharge from the hospital.

Patient #R2 was discharged from the hospital on [DATE].
Patient #R3 was discharged from the hospital on [DATE].
Patient #R4 was discharged from the hospital on [DATE].
Patient #R5 was discharged from the hospital on [DATE].
Patient #R6 was discharged from the hospital on [DATE].
Patient #R7 was discharged from the hospital on [DATE].
Patient #R8 was discharged from the hospital on [DATE].
Patient #R9 was discharged from the hospital on [DATE].
Patient #R10 was discharged from the hospital on [DATE].
Patient #R11 was discharged from the hospital on [DATE].
Patient #R12 was discharged from the hospital on [DATE].
Patient #R13 was discharged from the hospital on [DATE].
VIOLATION: DELIVERY OF DRUGS Tag No: A0500
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview the hospital failed to ensure all medications were available for administration to patients as ordered by the physician as evidenced by documentation of "not available" in the MAR (Medication Administration Record) for 1 of 1 patient (#2, #6) out of a total 21 sampled medical records. Findings:

Patient #2: Review of the medical record for Patient #2 revealed a [AGE] year old male admitted on [DATE] for Schizophrenia. Further review revealed the patient's admission orders were written 11/14/2011 at 1335 (1:35 p.m.) which included an order for Tamulosin 0.4 milligrams every evening, Propylthiour 50 milligrams 4 tablets three times daily, Lovaza 1 gram two capsules two times daily, and Colace 100 milligrams two times daily.

Review of Patient #2's Medication Administration Record revealed a circle indicating medication had not been given by 11/14/2011 9:00 p.m. dosage of Tamulosin, Propylthiourl, Lovaza, and Colace. Further review revealed the medications had been administered at 2300 (11:00 p.m.)- two hours after the scheduled time of 9:00 p.m.

During a face to face interview on 12/08/2011 at 9:15 .M., Director of Nursing S2 indicated the probable cause for medications not be administered on the day of admission would be unavailability of the medications due to the delivery being late. S2 indicated the hospital's policy at the time of the survey allowed a 1/2 hour Lag time which was defined as 30 minutes before or after the scheduled time.

Patient #6: Review of the medical record for Patient #6 revealed a [AGE] year old male admitted on [DATE] for depression, ETOH (Alcohol) dependence, cocaine dependence, with a history of alcohol abuse, depression and crack cocaine use. Further review revealed Patient #6 had a medical history of rhinitis, seizures, malnutrition and BPH (Benign Prostate Hypertrophy).

Review of the Physician's Orders for Patient #6 dated/timed 12/03/11 at 11:50am revealed an order for to restart Rapalfo 8mg po and for B-Complex Vitamins i (one) po (by mouth) every day.

Review of the MAR for Patient #6 dated 12/03/11 revealed a circle around the time of 0900 ((:00am) by Rapalfo 8mg po and for B-Complex Vitamins i (one) po (by mouth) every day with a circle around the time of 0900 ((:00am) and documented "unavailable on the unit".

In a face to face interview on 12/07/11 at 2:00pm RN 2 Director of Nursing indicated there was no reason for the nurse to document any medication not being available. Further she indicated the pharmacist can be called 24/7 and the drugs can be obtained even if they have to go to a local pharmacy.

Review of the hospital policy titled, "Start time for Medication, #NS-033, developed 5/01/2011" presented by the hospital as current revealed in part, "Medications that are not ordered stat should be given within the time frame specified by the physician: Routine Schedules BID (two times per day, 9a and 2100 (9:00 a.m. and 9:00 p.m.), HS (bedtime) 2100 (9:00 p.m.), QD (every day) 9a every day (9:00 a.m.), tid (three times a day) 9a, 1300p, and 2100 p (9:00 a.m., 1:00 p.m., and 9:00 p.m.). . . . Lag time 1/2 hour."