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 HEALTH SYSTEM 4363 CONVENTION STREET BATON ROUGE, LA 70806 Jan. 17, 2013
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observations, record reviews, and interviews, the hospital failed to meet the Condition of Participation for Patient Rights as evidenced by:
Failing to ensure patients received care in a safe setting. The hospital failed to ensure that the clinical staff were trained and competent to provide care to psychiatric patients with the potential for behavioral problems as evidenced by:

1) 2 MHT's (Mental Health Technician), who were not trained and competent in crisis prevention and intervention, attempted to restrain a combative elderly psychiatric patient which resulted in the patient falling and sustained a laceration to the head requiring 3 sutures for 1 of 10 sampled patients (#7);

2) The hospital failed to provide competency evaluations for employees, formalized orientation for new employees, training in crisis prevention and intervention for 35 of 40 direct care staff and current training in cardiopulmonary resuscitation for 20 of 40 direct care staff; and

3) The hospital failed to ensure that 4 patients with physician orders for line of sight (LOS) observations were in sight of the MHT on 01/16/13 during observations from 1:25 p.m. to 1:40 p.m. (#1, R1, R2, R3) (see findings in tag A0144).
On 1/17/13 at 11:10 a.m., Administrator S1 was notified of an immediate jeopardy situation. The immediate jeopardy situation was:
The hospital failed to ensure that the clinical staff were trained and competent to provide care to psychiatric patients with the potential for behavioral problems. This was evidenced by two Mental Health Technicians (MHT) who were not trained in crisis prevention and intervention who attempted to restrain a combative patient which resulted in the patient falling and sustained a laceration to the scalp that required three stitches. The facility failed to investigate the cause of the incident and failed to make changes to prevent further incidents from occurring.

The Immediate Jeopardy situation continues as evidenced by having 35 of the 40 direct care clinical staff not having training and competency evaluation in crisis prevention intervention. Review of the staff assignment sheet for the day and night shifts dated 1/17/13 revealed that none of the registered nurses, licensed practical nurses, or mental health technicians have current crisis prevention intervention training. This has the potential to affect 19 current psychiatric patients at the hospital.
On 1/17/13 at 2:00 p.m. the survey team exited the hospital with no plan of removal in place.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on observations, records review and staff interviews, the hospital failed to ensure that patients received care in a safe setting. The hospital failed to ensure that the clinical staff were trained and competent to provide care for psychiatric patients with the potential for behavioral problems. This was evidenced by:

1) 2 MHT's (Mental Health Technician) who were not trained and competent in crisis prevention and intervention attempted to restrain a combative elderly psychiatric patient which resulted in the patient falling and sustained a laceration to the head that required 3 sutures for 1 of 10 sampled patients (#7);

2) The hospital failed to provide competency evaluations for employees, formalized orientation for new employees, training in crisis prevention and intervention for 35 of 40 direct care staff and current training in cardiopulmonary resuscitation for 20 of 40 direct care staff; and
3) The hospital failed to ensure that 4 patients with physician orders for line of sight (LOS) observations were in sight of the MHT on 01/16/13 during observations from 1:25 p.m. to 1:40 p.m. (#1, R1, R2, R3).
Findings:

1) Review of the hospital policy titled, Incident/Accident Reporting, number 9.26, provided by Administrator S1 as current, revealed in part the following: 1. The hospital will maintain a system for generating incident/accident reports and follow-up corrective action, if applicable.... 1. The employee will report any accident, incident, and/or injury immediately to the DON/Administrator or the Director of Human Resources. DON/Administrator will complete an Employee Incident/Accident Report, review and sign the form, request any necessary follow-up from appropriate personnel and initiate incident report follow-up form as required.

Patient #7

Review of the patient's medical record revealed that the patient was an [AGE] year old male who was admitted on [DATE] from a nursing home where he was combative with the staff and resistant to care. The patient's diagnoses included Psychosis and Dementia.

Review of the Nurse's Daily Shift Assessments dated/timed 11/17/12 at 12:00 p.m. revealed that the patient became combative toward the staff, hitting and kicking at the MHT. While charging toward the MHT, the patient was swinging his arm to hit the MHT, and lost his balance and fell . Further review of the nurse's notes (11/17/12 - 11/25/12) revealed the patient continued to be combative with ADL (Activities of Daily Living)/hygiene care.

Review of the Nurse's Daily Shift Assessments dated/timed 11/26/12 at 9:30 p.m. revealed the patient became combative during ADL care, "broke away" from 2 MHT's, threw himself against the headboard of the bed, sustaining a laceration to the corner of his right eye. The note further revealed LPN S21 noted "moderate amount of bleeding", cleaned the wound with normal saline, and applied steri strips. There was no documented evidence of any assessment of the wound. Further review of the nurse's notes revealed on 11/27/12 at 10:15 a.m., the patient was transported to an emergency room for evaluation of the wound and the patient received 3 sutures to the wound over his right eye.

Review of the Patient/Visitor Incident Report Form for Patient #7 dated 11/26/12 revealed the following: S11 and S9 were doing ADL's with patient when he broke away from MHT holding him and flung himself hitting head against headboard. The form was signed by RN (Registered Nurse) S5 and the Director of Nursing (DON) S3. There was no documented evidence of an investigation of the incident.

Review of the physician's orders dated 11/26/12 revealed the only physician order related to patient's fall on 11/26/12 was for neuro checks every 2 hours for 12 hours. Further review of the physician's orders revealed the patient was ordered on 1:1 observation status on 11/17/12 at 1:55 p.m.

Review of the personnel record for S11 revealed that S11 was employed on 08/17/12 as a MHT. Review of the application for employment revealed no documented evidence of any experience in a health care setting. There was no documented evidence of any training, competency evaluations, or CPI (Crisis Prevention Intervention) certification.

Review of the personnel record for S9 revealed that S9 was employed on 01/31/12 as a MHT. There was no documented evidence of any training, competency evaluations, or CPI (Crisis Prevention Intervention) certification.

In an interview on 01/16/13 at 9:30 a.m. with S11, he verified that he was assigned to Patient #7 on 11/26/12 for the 7:00 p.m. to 7:00 a.m. shift. He stated that he had assisted the patient into bed and was trying to change the patient's pull up. S11 stated that the patient became anxious, began resisting the pull up change, and became agitated. S11 stated the patient threw his slippers at S11 and started yelling and swinging his arms at him. He stated that he was trying to hold the patient with his hands. S11 stated that S9 came to assist him when he heard the patient yelling. S11 stated that he held the patient's feet and S9 held the patient's hands while the patient was lying in bed. He stated Patient #7 was able to get loose from him and S9, and got out of bed on the opposite side of the bed from him and S9. S11 stated that the patient got out of the bed, stood up, lost his balance and fell to the floor, hitting his head on the headboard. S11 stated that the patient hit his head on the right side over the eyebrow and cut his head. S11 stated that S5 and another nurse (did not remember name) looked at the patient's wound and put a band-aid on it. S11 stated the wound continued to bleed, "small drops" during the night and he had to keep blotting the area. He stated the nurse told him to watch it and blot the blood from the area. S11 stated that the only person who asked him about the incident was S5. S11 stated that he did not know how to do this job and had not received any training since he had been employed. S11 stated that he did not know how to handle patients when they became aggressive and combative and stated, "I just tell them to calm down and stay back." S11 verified that he had not received any training in Crisis Prevention Intervention (CPI). S11 verified that he had no previous experience or training as a MHT.

In an interview on 01/16/13 at 10:00 a.m. with S9, he confirmed that he remembered Patient #7 and confirmed he was working the 7:00 p.m. to 7:00 a.m. shift on 11/26/12. He stated that the patient was combative at times. When asked to relay the circumstance of the incident when the patient hit his head, S9 stated he was not sure if he and S11 went together to the patient's room, or if S9 arrived later. S9 stated that the patient started "fighting and we tried to hold him down." S9 verified that the patient was lying in bed and stated that the patient hit his head on the head board when he was trying to get up. S9 verified that the patient sustained a laceration to his head when he hit the head board of the bed. S9 further stated that he did not remember who was assigned to Patient #7. When asked if he had received any training since employed at the hospital, S9 stated no. He stated he had a 3-4 hour orientation, but no other training. He stated that he had CPI training in the past at another hospital, but it had expired.

In an interview on 01/16/13 at 10:05 a.m. with S5, she confirmed that she was the RN Charge Nurse on 11/26/12 and recalled the incident with Patient #7. She stated that she remembered S9 coming to get her and she assessed the patient's injury. S5 stated, "What I saw-he did not need to go to the doctor." S5 stated the physician told her to "Steri-strip it" and she did. S5 verified that she did not document an assessment of the patient after the injury and there were no physician's orders to apply steri-strips to the wound. S5 verified that the patient was transferred to the emergency room the next day for sutures. S5 verified that she had no experience in evaluating wounds and what required sutures. S5 stated that she had only received a general orientation and had a preceptor for 4 days. S5 stated that she had no previous work experience with psychiatric patients.

In an interview on 01/16/13 at 4:15 p.m. S3 verified that there was no investigation of the circumstances of Patient #7's incident on 11/26/12. She verified that S11 had informed her they were trying to hold the patient down during ADL care, the patient got loose from them, fell and hit his head. S3 confirmed that there was no investigation of the incident. After reviewing the patient's record, she verified that there was no assessment of the patient's wound and the patient was not transferred to the emergency room until the next day, over 12 hours after the injury. S3 confirmed that there was no training done for the staff after this incident, there was no change in any policies/procedures, and there was no corrective action implemented.










2) The hospital failed to provide competency evaluations for employees, formalized orientation for new employees, training in crisis prevention and intervention for 35 of 40 direct care staff and current training in cardiopulmonary resuscitation for 20 of 40 direct care staff.

Review of the hospital policy titled "Educational Development," policy number 9.13 and presented by Administrator S1 as the current policy for job requirements related to education, revealed that the hospital required each employee involved in providing direct patient care to have CPI (crisis prevention intervention) certification and CPR (cardiopulmonary resuscitation) certification.

Review of "The Training Process" from the CPI 2012 Curriculum, provided by S1 as the hospital's current curriculum for CPI training, revealed in part the following: ....It is recommended that all participants review course content every six months to refresh their skills. At a minimum, formal refresher courses should be completed once per year.

A review was made of a list provided by the facility on 1/16/13 of employees who were Crisis Prevention Institute (CPI) trained to effectively handle patients in a crisis situation. The Administrator S1 verified the list was current and accurate. 35 of the 40 direct care staff listed did not have current CPI training. Review of the list revealed the following:
8 RN's -5 did not have training, 1 had expired training, and 2 were current
12 LPN's - 6 did not have training, 5 had expired training, and 1 was current
19 MHT's - 12 did not have training, 5 had expired training, and 2 were current
1 CNA - 1 did not have training
A review was made of a list provided by the facility on 1/16/13 of employees who were Cardio Pulmonary Resuscitation (CPR) certified. S1 verified that the list was current and accurate. Only 20 of the 40 direct care staff listed had a current CPR card. Review of the list revealed the following:
8 RN's- 1 did not have a CPR card, 1 had an expired card and 6 had current cards
12 LPN's- 6 did not have a CPR card, 3 had expired cards and 3 had current cards
19 MHT's- 6 did not have a CPR card, 2 had expired cards and 11 had current card
CNA- 1 did not have a card
A review was made of a list provided by the facility on 1/16/13 of employees who had attended the annual education fair provided by the facility in December 2012. S1 verified that the list was accurate for the employees in December 2012. 29 of the 46 direct care staff listed did not attend the fair. Review of the list revealed the following:
9 RN's- 2 attended
12 LPN's- 4 attended
25 MHT's- 11 attended
In an interview on 1/16/13 at 1:37 p.m. with S15, she stated that the lists provided of employees TB skin test results, CPR expiration dates, CPI training and skills fair attendance were current and accurate.
Review of the December 11, 2012 Competency Fair material presented by S2 revealed that the only competency testing provided for staff was for EKG training and Pharmacy for Nursing staff. Further review revealed a two page handout was provided on instructions for Seclusion and Restraint, but no demonstrations or competencies were offered by the hospital. The handout said in part:
The hospital utilizes NON-Violent Crisis Intervention (NVPCI) as the training of choice to promote care, welfare, safety, and security. This training provides education to staff to assist in de-escalation techniques, learn contributing factors, understand the cycle of escalation, and demonstrate safe and appropriate physical interventions for use in crisis situations.
Further review revealed no NVPCI training was offered at the competency fair.
An interview was conducted on 1/15/13 at 12:56 p.m. with S10. S10 stated she had been employed at the hospital since August, 2011. S10 said this was the first mental health technician job she has ever had and she had not even worked as an aide at another facility. S10 said her training at the hospital consisted of following another technician for 1 week. S10 also said she had not done any written or formal training until December, 2012 during the hospital training fair which did not cover everything the MHT's do at the hospital. S10 said she does vital signs on patients, but was not trained or checked for competency at the hospital.

In an interview on 1/15/13 at 3:28 p.m. with S2, she stated that staff was not taught respiratory functions, how to properly take vital signs or shown proper restraint application during the skills fair in December, 2012. S2 said the only teaching boards at the fair were on Electrocardiograms (EKG) and some medication instruction for nurses. S2 stated that there were no documented competencies on staff or a generalized hospital orientation when staff were hired. S2 said if a person was hired at the beginning of a calendar year, they may work the whole year without formalized training.
In an interview on 1/16/13 at 9:15 a.m. with S5, she said on 11/30/13 she heard a MHT yell and saw Patient #2 on the floor in the hall. S5 said Patient #2's oxygen saturations were in the 70's or 80's, so she had a MHT get the oxygen (O2) tank from the nurse's station. She said she could not find the key to turn the oxygen on, so someone ran and found a key for her. Then, S5 said she placed a nasal cannula on Patient #2 and turned the oxygen as high as it would go which was 10 L/min (liters/minute). S5 said the O2 should not have been higher than 6 liters/minute, but Patient #2's oxygen saturations were low and she just wanted to get them in the 90's. S5 then said that the hospital did not provide respiratory training for her. S5 said thatshe had some orientation about hospital sick days, attendance and personnel type information, but not clinical skills or patient care. S5 said she had a preceptor for 4 days when she started, but did not feel like she was adequately trained. S5 said that she did not have any competencies until the December, 2012 skills fair, but that the training was limited.
In an interview on 1/17/13 at 10:00 a.m. with S1, he stated that S15, S3, and himself were responsible to ensure the clinical staff at the hospital had education in patient care and verification of competency. S1 said that all direct care clinical staff was responsible for having CPI training and CPR training. S1 said that the competencies and training were just not done and he had no explanation as to why they were not done.
In an interview on 1/17/13 at 10:15 a.m. with S15, she stated that Administration, Human Resources, and Nursing Administration were all responsible for ensuring the competencies and training of staff were completed. S15 said that she should have kept up with the training better than she had done. S15 also said that she was trying to obtain her current CPR instructor status, so no CPR training had been done for the staff. S15 also verified that there should have been competency verifications for new employees, but none had been completed.
In an interview on 1/17/13 at 1:30 p.m. with S3, she said that the staff was not being properly trained and she knew the employees were behind in CPR, Crisis Intervention, TB (Tuberculosis) testing, and training. S3 said that she had not been keeping up with the training. S3 said she had been trying to get some people to work the floor for her so she could catch up with her DON duties and some things just fell through the cracks.

3) The hospital failed to ensure that 4 patients with physician orders for line of sight (LOS) observations were in sight of the MHT on 01/16/13 during observations:
Review of the hospital policy titled "Patient Observation," policy number 8.8 and presented by S1 as the current policy, revealed that visual contact meant 24 hours constant observation of the patient within visual sight of the staff member.

Observation on 01/16/13 at 1:25 p.m. revealed S10 standing at the end of Hall "a" with a chair positioned outside Room "j" with the door partially closed. Continuous observation revealed S10 walked to the door of Room "j" and opened the door more to revealed Patient #1 lying in the bed.

In a face-to-face interview on 01/16/13 at 1:25pm, MHT S10 indicated that she was observing Patient #1 for another MHT who also had patients in rooms on Hall "b". She further indicated that Patient #1 was on LOS observation. MHT S10 confirmed that while she was at the end of the hall and while she was seated in the chair outside Room "j" with the door partially closed, she (MHT S10) did not have Patient #1 in her line of sight at all times as ordered by the physician.

In a face-to-face interview on 01/15/13 at 1:00 p.m., S10 indicated that she had been hired in 08/12, and this was her first job in a mental health facility. She further indicated that she shadowed another MHT for about a week when she was hired. S10 indicated that she had no hospital orientation, had not been evaluated by anyone for competency, and was not CPI certified. She further indicated that there were times that she was assigned patients on LOS along with other patients who required every 15 minute checks, and she was unable to keep the patients on LOS in her view at all times.

Observation on 01/16/13 at 1:30 p.m. through 1:40 p.m. on Hall "b" revealed S12 seated in a chair outside Room "h" with the door to Room "h" partially closed and not allowing visibility of Patient R2 who had physician orders to remain on LOS. Further observation revealed Patient R1's room door (Room "g" and next door to Room "h") was closed with a small crack that did not allow visibility of Patient R1 (physician orders for LOS). Further observation revealed S12 was the only MHT at the time on Hall "b". Patient R3 was in Room "i" (located across the hall from Room "g") and had physician orders for LOS observation. Continuous observation revealed Patients R1, R2, and R3 were not in constant LOS of S12 from 1:30 p.m. to 1:40 p.m.

In a face-to-face interview on 01/16/13 at 1:30 p.m., S12 indicated that Patient R1 was in her room. When the door to Room "g" was opened, Patient R1 walked from behind the door to the open doorway. S12 indicated that she could not see Patients R1 and R2 where S12 was seated in Hall "b". She further indicated that she was observing 9 patients, 3 of whom were on LOS observation, while the other MHT was at lunch. She further indicated that when the other MHT returned, S12 was assigned the observation of 4 patients. S12 indicated that she "was peeping at everybody right now" when asked which MHT was observing Patient R3 who had physician orders to be on LOS. S12 confirmed that she did not have Patient R3 in her view at all times during the time of this observation.

In a face-to-face interview on 01/15/13 at 2:25 p.m., S3 indicated that the hospital did not have a policy regarding the number of patients that could be observed by a MHT. She further indicated that a MHT could not observe several patients who were on LOS observation at the same time.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0196
Based on records review and interviews, the hospital failed to ensure that all staff who had direct patient contact had training and demonstrated competence in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion. This was evident in 3 of 3 registered nurses' (RN's) personnel files reviewed from a total of 8 employed RN's, 1 of 1 licensed practical nurse's (LPN) personnel file reviewed from a total of 11 employed LPNs, and 9 of 9 mental health technician's (MHTs) personnel files reviewed from a total of 25 employed MHTs. Findings:

Review of the hospital policy titled "Seclusion & (and) Restraint for Behavioral Management", policy number 3.1 and presented by S1 as the current restraint and seclusion policy" revealed that all staff who have direct patient contact must have ongoing education and training in the proper and safe use of seclusion and restraint application and techniques and alternative methods for handling behavior, symptoms, and situations requiring seclusion or restraint.

Review of the list of employees who had attended the annual education fair in December 2012, provided by S1 who confirmed that the list was current and accurate, revealed that 29 of 46 direct care staff had not attended the education fair.
Review of the December 11, 2012 Competency Fair material presented by S2 revealed a two page handout was provided on instructions for Seclusion and Restraint, but no application demonstrations or competency evaluations were performed.

S9
Review of the personnel record for S9 revealed that S9 was employed on 01/31/12 as a MHT. There was no documented evidence of any orientation, training, and competency evaluations on the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion.

In a face-to-face interview on 01/17/13 at 10:00 a.m., S9 stated that he had been employed at the hospital for almost 1 year. When asked what training he had received from the hospital, he stated, none. S9 stated that he went to a general orientation for 3-4 hours and that was all the training he had received. He stated he had taken CPI training in the past, but it had expired.

S10
Review of MHT S10's personnel file revealed that she was hired on 08/10/12 and had no prior direct patient care experience in a health care facility. Further review revealed no documented evidence of any orientation, training, and competency evaluations on the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion.

S11
Review of the personnel record for S11 revealed that S11 was employed on 08/17/12 as a MHT. Review of the application for employment revealed no documented evidence of any experience in a health care setting. Further review revealed no documented evidence of any orientation, training, and competency evaluations on the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion.

In a face-to-face interview on 01/16/13 at 9:10am, S11 indicated that he had worked at the hospital since 08/12, and this job was his first job in health care and working with psychiatric patients. He further indicated that his orientation consisted of being told and shown what to do regarding taking vital signs and doing admits and discharges by another MHT. S11 indicated that he was assigned 1 patient on his first day of work and 3 patients on his second day while he worked with another MHT. He further indicated that he had no formal hospital orientation and had never been evaluated for competency regarding restraints and seclusion.

S12
Review of the personnel record for S12 revealed that S12 was employed on 07/26/12 as a MHT. Further review revealed no documented evidence of any orientation, training, and competency evaluations on the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion.

S16
Review of S16's personnel file revealed that she was hired on 12/20/12. Further review revealed no documented evidence of any orientation, training, and competency evaluations on the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion.

S17
Review of S17's personnel file revealed that he was hired on 12/18/12 and had no prior health care experience. Further review revealed no documented evidence of any orientation, training, and competency evaluations on the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion.

S18
Review of S18's personnel file revealed that she was hired on 12/17/12. Further review revealed no documented evidence of any orientation, training, and competency evaluations on the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion.

S19
Review of the personnel record for S19 revealed that S19 was employed on 08/15/12 as a MHT. Further review revealed no documented evidence of any orientation, training, and competency evaluations on the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion.

S20
Review of the personnel record for S20 revealed that S20 was employed on 08/09/12 as a MHT. Review of the application for employment revealed no documented evidence of any experience in a health care setting. Further review revealed no documented evidence of any orientation, training, and competency evaluations on the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion.

S3
Review of S3's personnel file revealed she was hired on 04/01/11. Further review revealed no documented evidence of an annual evaluation that included a competency evaluation as required by hospital policy. Further review revealed no documented evidence of training on and competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion.

S5
Review of S5's personnel file revealed that she was hired on 01/23/12 and had no prior psychiatric nursing experience. Further review revealed no documented evidence of any orientation, training, and competency evaluations on the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion.

S7
Review of S7's personnel file revealed that she was hired on 07/12/12 and had no prior health care experience. Further review revealed no documented evidence of any orientation, training, and competency evaluations on the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion.

In a face-to-face interview on 01/16/13 at 10:25am, S7 indicated that she was hired in 12/11, and this was her first nursing job upon graduation from nursing school. She further indicated that she had never been evaluated for competency.

S8
Review of S8's personnel file revealed that she was hired on 01/03/12 and had no prior hospital or psychiatric experience. Further review revealed no documented evidence of any orientation, training, and competency evaluations on the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion.

In a face-to-face interview on 01/15/13 at 2:25pm, S3 indicated that she could not remember when the last hospital orientation was held. She further indicated that it had been more than 6 months since she had seen a competency checklist for any employee. S3 could offer no explanation for the clinical staff not being trained, oriented, and evaluated for competency on the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0200
Based on interview and record review, the hospital failed to ensure that all direct care staff had education, training, and demonstrated competence in the use of nonphysical intervention skills as evidenced by 35 of 40 direct care staff not having current crisis prevention training.
Findings:

Review of the hospital policy titled "Educational Development", policy number 9.13 and presented by S1 as the current policy for job requirements related to education, revealed that the hospital required each employee involved in providing direct patient care to have CPI (crisis prevention intervention) certification.

Review of "The Training Process" from the CPI 2012 Curriculum, provided by Administrator S1 as the hospital's current curriculum for CPI training, revealed in part the following: ....It is recommended that all participants review course content every six months to refresh their skills. At a minimum, formal refresher courses should be completed once per year.

Review of the December 11, 2012 Competency Fair material presented by S2 revealed the only competency testing provided for staff was EKG training and Pharmacy for Nursing staff. Further review revealed a two page handout was provided with instructions for Seclusion and Restraint, but no demonstrations or competency evaluations were conducted by the hospital. The handout said in part:
The hospital utilizes NON-Violent Crisis Intervention (NVPCI) as the training of choice to promote care, welfare, safety, and security. This training provides education to staff to assist in de-escalation techniques, learn contributing factors, understand the cycle of escalation, and demonstrate safe and appropriate physical interventions for use in crisis situations.
Further review revealed no NVPCI training was offered at the competency fair.
A review was made of a list provided by the facility on 01/16/13 of employees who were Crisis Prevention Institute (CPI) trained to effectively handle patients in a crisis situation. S1 verified the list was current and accurate. 35 of the 40 direct care staff listed did not have current CPI training. Review of the list revealed the following:
8 RN's -5 did not have training, 1 had expired training, and 2 were current
12 LPN's - 6 did not have training, 5 had expired training, and 1 was current
19 MHT's - 12 did not have training, 5 had expired training, and 2 were current
1 CNA - 1 did not have training
In an interview on 01/17/13 at 10:00 a.m. with S1, he stated S15, S3, and himself were responsible to ensure the clinical staff at the hospital had education in patient care and verification of competency. S1 said all direct care clinical staff were responsible for having CPI training and CPR training. S1 said the competencies and training were just not done, and he had no explanation as to why they were not done.
In an interview on 01/17/13 at 1:30 p.m. with S3, she said that the staff was not being properly trained, and she knew some of the employees were behind in crisis intervention training. S3 said she had not been keeping up with the training. S3 said she had been trying to get some people to work the floor for her, so she could catch up with her DON duties, and some things just fell through the cracks.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0206
Based on record reviews and interviews, the hospital failed to ensure that all employees providing direct patient care were trained and currently certified in the use of cardiopulmonary resuscitation (CPR) according to hospital policy for 20 of 40 direct care staff employed by the hospital. Findings:





Review of the hospital policy titled "Educational Development", policy number 9.13 and presented by S1 as the current policy for job requirements related to education, revealed that the hospital required all employees involved in providing direct patient care to have CPR (cardiopulmonary resuscitation) certification.

A review was made of a list provided by the facility on 01/16/13 of employees who were Cardiopulmonary Resuscitation (CPR) certified. S1 verified the list was current and accurate. Further review revealed that 20 of the 40 direct care staff listed did not have a current CPR card. Review of the list revealed the following:
8 RN's- 1 did not have a CPR card, 1 had an expired card and 6 had current cards
12 LPN's- 6 did not have a CPR card, 3 had expired cards and 3 had current cards
19 MHT's- 6 did not have a CPR card, 2 had expired cards and 11 had current cards
CNA- 1 did not have a card
In an interview on 01/16/13 at 1:37 p.m. with S15, she stated the lists provided of employees CPR expiration dates were current and accurate.
In an interview on 01/17/13 at 10:00 a.m. with S1, he stated that S15, S3, and himself were responsible to ensure the clinical staff at the hospital had education in patient care and verification of competency. S1 said that all direct care clinical staff were responsible for having CPR training. S1 said that the competencies and training were just not done, and he had no explanation as to why they were not done.
In an interview on 01/17/13 at 10:15 a.m. with S15, she stated Administration, Human Resources, and Nursing Administration were all responsible for ensuring the competencies and training of staff were completed. S15 said that she should have kept up with the training better than she had done. S15 also said that she was trying to obtain her current CPR instructor status, so no CPR training had been done for the staff.
In an interview on 01/17/13 at 1:30 p.m. with S3, she said that the staff was not being properly trained, and she knew the employees were behind in CPR. S3 said that she had not been keeping up with the training. S3 said that she had been trying to get some people to work the floor for her, so she could catch up with her DON duties, and some things just fell through the cracks.
VIOLATION: QAPI Tag No: A0263
Based on interviews and records review, the hospital failed to meet the Condition of Participation for Quality Assessment and Performance Improvement (QAPI) as evidenced by:

1) The hospital failed to maintain an effective, ongoing, hospital-wide, data-driven assessment and performance improvement program by not having any QAPI team meetings in 2012-2013 and not tracking and trending high-risk or problem-prone areas (see Tags A0283, A0297).

2) The hospital failed to ensure that the hospital's governing body was responsible and accountable for ensuring that an ongoing program for quality improvement was maintained (see tag A0309).
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interviews and records review, the hospital failed to set priorities for its performance improvement activities that focused on high-risk, high-volume, or problem-prone areas. This resulted in 22 medication errors noted during chart reviews that were not identified by the hospital for 4 of 10 sampled patients (#1, #3, #6, #7) and had the potential to affect 22 of 22 current patients at the facility.
Findings:

Review of the hospital's Quality Assurance/Performance Improvement binder (QA/PI) for 2012-2013 revealed no ongoing measuring, assessing, and sustaining the hospitals' performance. Further review revealed the number of incident reports for each month had been separated into the number of falls, medication errors, and miscellaneous events, but no details of each occurrence were listed, tracked or trended.

In an interview on 01/15/13 at 10:42 a.m. with S1, he said that the last Quality Assurance (QA) meeting was before last year. S1 said that the QA committee had collected some minimal data, but no tracking or trending had been done with the data. S1 said that the QA committee had not had a meeting in 2012 or 2013.

In an interview on 01/16/13 at 2:17 p.m. with S1, he stated that he had no answer as to why the hospital was not tracking or trending problems identified at the hospital.

In an interview on 01/17/13 at 1:10 p.m. with S2, she stated the Hospital Quality Assurance Program had no Quality Indicators and no Performance Improvement projects.

Patient #1
Review of the medical record for Patient #1 revealed the patient was a [AGE] year old female admitted on [DATE] under a PEC (Physician Emergency Certificate) for dangerous to others and unwilling to seek voluntary admission. The patient's diagnoses included Bipolar, Schizoaffective Disorder-acute exacerbation, Hypertension, and Diabetes Mellitus.

Review of the admission physician's orders dated/timed 01/09/13 at 9:15 a.m. revealed the following order: Start Klonopin 0.5 mg. PO TID (by mouth, three times a day). First dose 1500 (3:00 p.m.) today.

Review of the Medication Administration Record (MAR) dated 01/07/13 through 01/10/13 revealed Klonopin 0.5 mg. was administered on 01/09/13 at 9:30 a.m., 3:00 p.m., and at 9:00 p.m.

In a face-to-face interview on 01/16/13 at 4:15 p.m. S3 verified that the Klonopin was ordered by the physician to begin at 3:00 p.m. on 01/09/13. She verified an additional dose was administered at 9:30 a.m. on 01/09/13 and would be considered a medication error.

Patient #3
Review of Patient #3's medical record revealed that he was a [AGE] year old male admitted on [DATE] with the diagnoses of Psychosis, Dementia, Hypertension, Diabetes Mellitus, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Benign Prostatic Hypertrophy, and Edema.

Review of Patient #3's "Admit/Discharge Medication Reconciliation and Order Sheet" revealed that S7 transcribed the medications on the form on 01/12/13 at 7:35 a.m. Further review revealed that all medications were to be continued except Haldol. Further review revealed that a notation of "TORB x 2 Psychiatrist S23" (telephone read back times 2) with no documented evidence of the author of the notation and the date and time that the order was received. Further review revealed that the practitioner signed the medication orders on 01/12/13 at 6:00 p.m. (therefore no physician orders for medication until 01/12/13 at 6:00 p.m.).

Review of Patient #3's "Physician Admit Orders & (and) Problem List" dated 01/12/13 at 6:55 a.m. revealed an order to perform fingerstick blood sugar testing on admit and daily before meals and at bedtime and to call the physician if blood sugar was less than 60 or greater than 400. Further review revealed that "N/A (not applicable) at this time" was written across the section that addressed the amount of Regular Insulin to be administered per sliding scale. There was no physician order given for Regular Insulin to be administered.

Review of Patient #3's "Medication/Treatment Administration Record" (MAR) revealed that he received the following medications prior to the medication list being signed by the practitioner:

Altace 2.5 mg (milligrams) capsule, Flomax 0.4 mg capsule, Atenolol 25 mg tablet, Exelon 1.5 mg capsule, Haldol 2 mg tablet, Humalog 100/ml (milliliter) 10 units subcutaneously, Multivitamin and Mineral Supplement, Aspirin 81 mg enteric-coated, Lasix 40 mg tablet, Paxil 10 mg tablet, Metamucil 520 mg capsule, and Seroquel 25 mg tablet at 11:35 a.m.;
Haldol 2 mg tablet at 3:00 p.m.

Further review revealed that Patient #3 was administered Haldol 2 mg by mouth on 01/12/13 at 11:35 a.m., 3:00 p.m., and 9:00 p.m. and on 01/13/13 at 9:00 a.m., 3:00 p.m., and 9:00 p.m. with no physician orders to administer it.

Review of Patient #3's "Diabetic Flow Sheet" revealed that S7 administered Regular Insulin 6 units subcutaneously on 01/12/13 at 9:30 a.m. with no physician order for the insulin to be administered.

In a face-to-face interview on 01/16/13 at 10:25 a.m., S7 indicated that there was a question about the sliding scale for Patient #3 from his referring hospital's record. She further indicated that she had called the hospital to ask if Patient #3 had been on sliding scale, and the referring hospital staff indicated that the sliding scale had been discontinued. S7 confirmed that she administered the Regular Insulin, and there was no physician order for it to be given. After review of Patient #3's "Admit/Discharge Medication Reconciliation and Order Sheet", S7 confirmed that there was no date and time for the telephone order and giving medications prior to the practitioner's signing the "Admit/Discharge Medication Reconciliation and Order Sheet" would constitute giving medications without a physician's order.

Patient #6
Review of the patient's medical record revealed the patient was an [AGE] year old male admitted on [DATE] with a diagnosis of Major Depressive Disorder with Psychosis. The record also revealed the patient was admitted from a nursing home where he attempted to choke a staff member.

Review of the physician's orders dated/timed 01/02/13 at 5:30 p.m. revealed an order for Exelon patch 4.6 mg. apply Q day (every day). Further review of the physician's orders dated/timed 01/03/13 at 5:30 p.m. revealed an order for B12 1000 mcg. IM (injection) today then every week for 4 weeks, then every month.

Review of the MAR dated 01/02/13 through 01/03/13 revealed the Exelon patch was not administered until 9:00 a.m. on 01/03/13 ( 1 day after the order). Review of the MAR dated 01/04/13 to 01/10/13 revealed the B12 injection was administered on 01/04/13 at 6:45 a.m. (1 day after the order).

In a face-to-face interview on 01/16/13 at 4:15 p.m. S3 verified the Exelon was not administered as ordered and should have been given on 01/02/13. S3 verified the B12 injection was not administered as ordered and should have been administered on 01/03/13. S3 verified both late administrations were medication errors and there was no reason the medication could not have been obtained and administered on the day they were ordered.

Patient #7
Review of the patient's medical record revealed the patient was an [AGE] year old male who was admitted on [DATE] from a nursing home where he was combative with staff and resistant to care. The patient's diagnoses included Psychosis and Dementia.

Review of the physician's orders dated/timed 11/17/12 at 1:55 p.m. revealed an order for Geodon 20 mg. IM (injection) every 8 hours.

Review of the MAR dated 11/16/12 to 11/22/12 revealed the Geodon was administered on 11/17/12 at 3:00 p.m., but the 11:00 p.m. dose was circled. The MAR also revealed a dose was administered at 3:00 a.m. The scheduled times on the MAR for the Geodon were 7:00 a.m., 3:00 p.m., and 11:00 p.m.

Review of the Nurse's Daily Shift Assessments dated 11/17/12 revealed the following entries:

10:00 p.m. Patient in bed eyes closed. Patient restless in bed....

11:00 p.m. Patient's Geodon injection held because patient in bed, eyes closed.

12:30 a.m. Patient in bed awake, restless. MHT (Mental Health Tech) stated he has been awake for 1 1/2 hours....

2:00 a.m. ....Patient becoming increasingly excited. 1:1 continues.

3:00 a.m. Patient needed brief changed. 4 techs (MHT) used to ensure safety of MHT's. Patient combative, loud, and angry. Earlier scheduled dose of Geodon administered late at this time IM in left thigh....

In a face-to-face interview on 01/16/13 at 4:15 p.m. S3 verified that there was no physician's order to hold the 11:00 p.m. dose of Geodon. S3 stated that the medication was not ordered as needed and the RN should have notified the physician before holding a dose and administering a late dose of the Geodon. S3 verified this would be considered a medication error.
VIOLATION: QAPI PERFORMANCE IMPROVEMENT PROJECTS Tag No: A0297
Based on interview and records review, the hospital failed to ensure performance improvement projects were conducted as part of its quality assessment and performance improvement program. This deficient practice had the potential to affect 22 of 22 current patients at the facility.

Findings:
Review of the Performance Improvement Binder for 2012 and 2013 presented by S1 revealed no documented evidence of performance improvement projects being conducted by the hospital.

In an interview on 1/15/13 at 10:42 a.m. with S1, he said that since the last Quality Assurance (QA) meeting several months ago, the QA committee had collected some data, but nothing had been done with the data. He said the QA committee has not had a meeting in 2012 or 2013.

In an interview on 1/15/13 at 10:45 a.m., S2 said that the QA committee consisted of herself, S1, and S3.

In an interview on 1/17/13 at 10:00 a.m. with S1, he verified that no Performance Improvement (PI) projects were being done by the hospital. S1 also stated the hospital had no polices on PI projects or QA.

In an interview on 1/17/13 at 1:10 p.m. with S2, she stated the Hospital Quality Assurance Program had no Quality Indicators and no Performance Improvement projects.
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
Based on records review and interviews, the hospital failed to ensure that the hospital's governing body was responsible and accountable for ensuring that an ongoing program for quality improvement was maintained.

Findings:

Review of the hospital's Quality Assurance/Performance Improvement binder (QA/PI) for 2012-2013 revealed no ongoing measuring, assessing, and sustaining the hospitals performance.

In an interview on 01/15/13 at 10:42 a.m. with S1, he said that the last Quality Assurance (QA) meeting was before last year. S1 said the QA committee has collected data, but no tracking or trending had been done with the data. S1 said the QA committee has not had a meeting in 2012 or 2013.

In an interview on 01/16/13 at 11:16 with S23, he stated he was on the governing body. S23 said he was on the QA committee as far as he knew, but did not remember attending a QA meeting at the hospital.

In an interview on 01/16/13 at 2:17 p.m. with S1, he stated that the governing body meetings were conducted 4 times per year. After review of the minutes provided, S1 said that the last regularly scheduled meeting was held on 08/28/12. S1 said that the minutes listed the board had reviewed and approved the QAPI reports, but he said they were the outpatient reports, not the in-patient reports. S1 said the governing body was aware the hospital was not tracking and trending problems for QAPI. When asked why the hospital was not tracking or trending problems identified at the hospital, S1 said he had no answer.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observations, records review, and interviews, the hospital failed to meet the requirements for the Condition of Participation for Nursing Services as evidenced by:

1) The hospital failed to ensure there was adequate numbers of MHT's (mental health technicians) to provide observations of patients with physician orders for line of sight observation on 19 shifts from 01/07/13 to 01/16/13 (see findings in tag A0392);

2) The hospital failed to ensure that a registered nurse (RN) supervised and evaluated the nursing care of each patient.

a) The RN failed to develop and implement a system to ensure that each patient was assessed by an RN at least every 24 hours and with a change in condition as required by the Louisiana State Board of Registered Nurses for 8 of 10 sampled patients (#1,#3, #4, #5, #6, #7, #8, #10).

b) The RN failed to ensure the patients' level of observation was maintained as ordered by the physician by the MHT's (mental health technicians) for 6 of 10 sampled patients and 3 random patients (#1, #3, #4, #5, #8, #10, R1,R2, R3).

c) The RN failed to develop and implement a system for obtaining admit orders from the psychiatrist as evidenced by nurses texting patients' medication lists obtained from the referring facility to the psychiatrist on their personal cell phones (see findings in tag A0395);

3) Th ehospital failed to ensure that the RN assigned patient care to nursing personnel who had training, orientation, and competency evaluations according to hospital policy and job descriptions for of 3 of 3 RN's personnel files reviewed from a total of 8 employed RN's (S3, S5, S7), 1 of 1 LPN's (licensed practical nurse) personnel file reviewed from a total of 11 employed LPN's (S8), and 9 of 9 MHT's (mental health technician) personnel files reviewed from a total of 25 employed MHT's (S9, S10, S11, S12, S16, S17, S18, S19, S20). Of a total of 40 clinical staff, 35 clinical staff were not certified in CPI, 20 were not certified in CPR, and 29 had not attended the annual skills fair held in December 2012. This resulted in 4 patients with physician orders for line of sight (LOS) observations not being in sight of the MHT on 01/16/13 during observations from 1:25 p.m. to 1:40 p.m. (#1, R1, R2, R3) (see findings in tag A0397); and

4) the hospital failed to ensure that all drugs and biologicals were administered according to physician orders and acceptable standards of practice for 4 of 10 sampled patients (#1, #3, #6, #7). This resulted in 22 medication errors noted during chart reviews that were not identified by the hospital for the 4 patients (see findings in tag A0405).
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on observations, record reviews, and interviews, the hospital failed to ensure that there was adequate numbers of MHTs (mental health technicians) to provide observations of patients with physician orders for line of sight observation on 19 shifts from 01/07/13 to 01/16/13. Findings:

Review of the hospital policy titled "Patient Observation", policy number 8.8 and presented by S1 as the current policy, revealed that visual contact meant 24 hours constant observation of the patient within visual sight of the staff member.

Observation on 01/16/13 at 1:25 p.m. revealed S10 standing at the end of Hall "a" with a chair positioned outside Room "j" with the door partially closed. Continuous observation revealed S10 walked to the door of Room "j" and opened the door more to revealed Patient #1 lying in the bed.

In a face-to-face interview on 01/16/13 at 1:25pm, S10 indicated that she was observing Patient #1 for another MHT who also had patients in rooms on Hall "b". She further indicated that Patient #1 was on LOS observation. S10 confirmed that while she was at the end of the hall and while she was seated in the chair outside Room "j" with the door partially closed, S10 did not have Patient #1 in her line of sight at all times as ordered by the physician.

In a face-to-face interview on 01/15/13 at 1:00 p.m., S10 indicated that she had been hired in 08/12, and this was her first job in a mental health facility. She further indicated that she shadowed another MHT for about a week when she was hired. S10 indicated that she had no hospital orientation, had not been evaluated by anyone for competency, and was not CPI certified. She further indicated there were times that she was assigned patients on LOS along with other patients who required every 15 minute checks, and she was unable to keep the patients on LOS in her view at all times.

Observation on 01/16/13 at 1:30 p.m. through 1:40 p.m. on Hall "b" revealed S12 seated in a chair outside Room "h" with the door to Room "h" partially closed and not allowing visibility of Patient R2 who had physician orders to remain on LOS. Further observation revealed Patient R1's room door (Room "g" and next door to Room "h") was closed with a small crack that did not allow visibility of Patient R1 (physician orders for LOS). Further observation revealed S12 was the only MHT at the time on Hall "b". Patient R3 was in Room "i" (located across the hall from Room "g") and had physician orders for LOS observation. Continuous observation revealed Patients R1, R2, and R3 were not in constant LOS of MHT S12 from 1:30 p.m. to 1:40 p.m.

In a face-to-face interview on 01/16/13 at 1:30 p.m., S12 indicated that Patient R1 was in her room. When the door to Room "g" was opened, Patient R1 walked from behind the door to the open doorway. S12 indicated that she could not see Patients R1 and R2 where S12 was seated in Hall "b". She further indicated that she was observing 9 patients, 3 of whom were on LOS observation, while the other MHT was at lunch. She further indicated that when the other MHT returned, S12 was assigned the observation of 4 patients. S12 indicated that she "was peeping at everybody right now" when asked which MHT was observing Patient R3 who had physician orders to be on LOS. S12 confirmed that she did not have Patient R3 in her view at all times during the time of this observation.

In a face-to-face interview on 01/15/13 at 2:25 p.m., S3 indicated that the hospital did not have a policy regarding the number of patients that could be observed by a MHT and the number of LOS patients that a MHT could observe at one time. She further indicated that a MHT could not observe several patients who were on LOS observation at the same time.

Review of the "Daily Assignment Sheet" presented by S3 from 01/07/13 through 01/15/13 revealed that MHTs had as many as 4 patients with orders for line of sight observations and 4 patients who were on Q 15 minutes observation. The average staffing of MHTs was 1 MHT with 1 patient on LOS and 5 patients on Q 15 minutes observations.

Review of the "MHT Duties: revised 12-7-12", presented as a handout during the education fair and presnted to the surveyors by S2, revealed the MHT had the following duties in addition to their scheduled patient observations:

1) Baths to be done on all shifts

2) Oral care in the morning and at night

3) Wash patients' clothes

4) Perform safety checks for contraband, perform vital signs, obtain weight and height, and complete the patient's belongings sheet on each admit

5) On weekends, holidays, and at supper time, put dinner trays in the oven about 2 hours prior to the scheduled meal time; on Monday through Friday heat the meals for supper; prepare meals, check meals against MHT Report Sheet; set out utensils, napkins, and drinks prior to meals being passed out; feed patients who need help; pass out snacks; encourage fluids

6) take vital signs 4 times a day for the first 24 hours of admission and twice a day afterwards

7) Weigh all patients at admit and every Sunday morning

8) Night MHT to check 5 refrigerator temperatures

9) Clean the ice scoop daily; rotate milk and juices; unload cold supplies

10) Clean the staff lounge and Biohazard Room every Friday night

11) Clean the oven and microwave on Friday night

12) Clean all refrigerators and the Biohazard Room on Sunday night

13) Clean and organize the patients' belongings room on Saturday night

14) Clean and organize the laundry room on Tuesday night

15) Check each chart every night and stuff with Physician's Orders and Physician Progress Notes; make new group notes for the next day; make Daily Nursing Assessment sheets for the next day; make MHT 15 minutes check sheets and Meal Percentage sheets; file group notes from the previous day in the charts

16) At least 2 MHTs to take patients on smoke breaks.

In a face-to-face interview on 01/16/13 at 8:40 a.m., S3 indicated that the hospital did not have any system in place to determine the number of patients that a MHT could observe at any one time. She further indicated that she tried to staff a MHT with patients whose rooms were on the same hall and tried not to schedule a MHT with several patients wheelchair-bound who required a lot of assistance with their ADLs (activities of daily living).

In a face-to-face interview on 01/16/13 at 9:10 a.m., S11 indicated that he had worked at the hospital since 08/12, and this job was his first job in health care and working with psychiatric patients. He further indicated that his orientation consisted of being told and shown what to do regarding taking vital signs and doing admits and discharges by another MHT. S11 indicated that he was assigned 1 patient on his first day of work and 3 patients on his second day while he worked with another MHT. S11 indicated that when he was assigned the observation of a female patient, he did not enter their room. He further indicated that he would leave the room door open, so he could see the patient, and the female patient would close the bathroom when she entered the bathroom. He confirmed that a female patient was not in his line of sight when they went to the bathroom.

In a face-to-face interview on 01/16/13 at 9:40 a.m., S5 indicated that sometimes she watched a patient who was on LOS for a MHT when they went to check on their other patients who had Q 15 minutes observations. She further indicated that she couldn't say the this occurred at all times. S5 indicated, when asking about the review of the staffing assignment sheets, "you can see we need another tech (MHT)". When asked if she ever requested another MHT, S5 indicated that when she had received approval for another MHT, she couldn't always get a MHT to answer their phone. She further indicated that at times her request was denied with a response of "you have 15 patients you don't need another tech". S5 indicated that this response was usually from S1 or S2. S5 indicated that it was not possible for a MHT to effectively observe 2 to 3 patients who were on LOS and several other patients on Q 15 minutes observations. After review of the staffing of MHTs on the night shift of 01/08/12 (1 MHT with 3 patients on LOS and 4 patients on Q 15 minutes and 1 MHT with 4 patients on LOS and 4 patients on Q 15 minutes), S5 indicated that it was not possible to observe the patients as ordered by the physician and per hospital policy.

In a face-to-face interview on 01/16/13 at 10:00 a.m., S9 indicated that he worked the night shift of 01/08/13. He further indicated that he was assigned 4 patients on LOS and 4 patients on Q 15 minutes observations. He further indicated that 2 patients on LOS were in the same room, another male patient on LOS was a "couple of doors down" from the 2 patients who were in the same room, and the fourth LOS patient was a female in the room across the hall from the one male patient. S9 indicated that LOS meant that the patient had to be in your vision at all times. He further indicated that he had to keep moving to observe all 4 patients on LOS, so he had at least 2 of the patients in his LOS at all times but not all 4 at all times. S9 indicated that it was impossible to observe 4 patients on LOS and keep all of them within his sight at all times. S9 indicated that when he was doing the Q 15 minutes checks on the other 4 assigned patients, he did not have any of the LOS patients within his sight.

In a face-to-face interview on 01/16/13 at 10:25 a.m., S7 indicated that she couldn't explain how a MHT could observe 3 to 4 patients who were on LOS plus other patients with Q 15 minutes observations. She further indicated that a patient who wanders and was on LOS would require the MHT to follow the wandering patient, and thus the MHT couldn't observe the other LOS patients. S7 indicated that although this was impossible to be done, that's how the MHTs were scheduled and assigned.

In a face-to-face interview on 01/16/13 at 11:16 a.m., S23 indicated that he was not aware that his patients who had orders for LOS observation were not being observed by a MHT having the patient in his/her LOS at all times.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on observations, records review and interviews, the hospital failed to ensure that a registered nurse (RN) supervised and evaluated the nursing care of each patient.

1) The RN failed to develop and implement a system to ensure that each patient was assessed by an RN at least every 24 hours and with a change in condition as required by the Louisiana State Board of Registered Nurses for 8 of 10 sampled patients (#1,#3, #4, #5, #6, #7, #8, #10).

2) The RN failed to ensure the patients' level of observation was maintained as ordered by the physician by the MHT's (mental health technicians) for 6 of 10 sampled patients and 3 random patients (#1, #3, #4, #5, #8, #10, R1,R2, R3).

3) The RN failed to develop and implement a system for obtaining admit orders from the psychiatrist as evidenced by nurses texting patients' medication lists obtained from the referring facility to the psychiatrist on their personal cell phones.

4) The RN failed to ensure that the patients' physician's orders were implemented for assessment of vital signs, labs, and EKG's (electrocardiograms) for 5 of 10 sampled patients (#3, #4, #5, #8, #9).

Findings:

1) Develop and implement a system to ensure that each patient was assessed by an RN at least every 24 hours and with a change in condition:

Review of the "Declaratory Statement On The Role And Scope Of Practice Of Registered Nurses Delegating Intravenous Therapy Interventions" according to the Louisiana State Board Of Nursing's rules and regulations regarding nursing practice, LAC 46:XLVII.3701-3703, specifically the delegation of nursing interventions and managing and supervising the practice of nursing, revealed that RN's may delegate select nursing interventions provided the patient was assessed by an RN every 24 hours. Further review revealed that the RN may delegate to an LPN the major part of the nursing care needed by individuals in stable nursing situations, when the following three conditions prevail at the same time in a given situation:

(a) nursing care ordered and directed by RN/MD (medical doctor) requires abilities based on a relatively fixed and limited body of scientific fact and can be performed by following a defined nursing procedure with minimal alteration, and responses of the individual to the nursing care are predictable;

(b) change in the patient's clinical condition is predictable; and

(c) medical and nursing orders are not subject to continuous change or complex modification.

Patient #1
On 01/14/13 at 10:25 a.m., Patient #1 was observed reclined in a geri chair in the activity room with her eyes closed. The patient was observed to have a bruise to her left eyebrow area with steri-strips noted over a linear wound. The patient opened her eyes and stated she fell last night.

Review of the medical record for Patient #1 revealed that the patient was a [AGE] year old female admitted on [DATE] under a PEC (Physician Emergency Certificate) for dangerous to others and unwilling to seek voluntary admission. The patient's diagnoses included [DIAGNOSES REDACTED]

Review of the physician's orders dated/timed 01/06/13 at 9:00 p.m. revealed an order for Ativan 2 mg. IM (Injection), Haldol 5 mg. IM, and Benadryl 50 mg. IM for severe anxiety every 6 hours PRN (As needed). The order included to administer all 3 medications together.

Review of the Medication Administration Record (MAR) revealed the patient received an injection of Ativan 2 mg. IM, Haldol 5 mg. IM, and Benadryl 50 mg. IM on 01/08/13 at 4:15 p.m. Further review of the MAR revealed S22 documented the reason for the medication was increased agitation, cursing and yelling.

Review of the Nurse's Daily Shift Assessments form dated 01/08/13 revealed no documented evidence of the patient's behavior warranting the PRN medication, and there was no documented evidence of an assessment by the RN of the change in the patient's behavior requiring the use of an injection of Ativan, Haldol, and Benadryl.

Review of the Observation Checklist dated 01/08/13 revealed from 3:15 p.m. to 4:45 p.m. the patient was in the lounge, watching television, and was cooperative.

S3 was interviewed on 01/17/13 at 4:15 p.m.. After reviewing the patient's medical record, she verified that there was no assessment of the patient's behavior by an RN. S3 stated that the RN should have assessed the patient's change in condition prior to the administration of the medication.

Patient #3
Review of Patient #3's medical record revealed that he was a [AGE] year old male admitted on [DATE] with the diagnoses of [DIAGNOSES REDACTED]

Review of Patient #3's "Nurse's Daily Shift Assessments" dated 01/14/13 at 12:30 p.m. revealed that Patient #3 approached the nursing station and complained of chest pain rated 6 of 10 (10 being the worst pain) as documented by S25. Further review revealed S25 informed the physician at 12:30 p.m., orders were received, and S25 documented that Nitrostat 0.4 sublingual was administered by S24. Review of the nursing documentation for Patient #3 for 01/14/13 from 12:30 p.m. through 6:00 p.m. revealed no documented evidence of an assessment by an RN of the patient's complaints of chest pain which was a change in condition for Patient #3.

In a face-to-face interview on 01/14/13 at 4:00 p.m., S3 indicated that she had assessed Patient #3 when he complained of chest pain but had not charted her assessment yet (3 hours and 30 minutes after the complaint had been voiced).

Review of Patient #3's "Nurse's Daily Shift Assessments" dated 01/14/13 on 01/15/13 revealed no documented evidence that S3 had documented a nursing assessment of Patient #3 after he had complained of chest pain. Further review revealed no documented evidence of an RN assessment of Patient #3 on 01/14/13 from 9:00 a.m. until an assessment was documented by S6 at 8:35 p.m.

In a face-to-face interview on 01/15/13 at 2:25 p.m., S3 confirmed that she had not documented an assessment of Patient #3 after he had complained of and received treatment for chest pain.

Patient #4
Review of Patient #4's medical record revealed that she was a [AGE] year old female admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]

Review of Patient #4's "Nurse's Daily Shift Assessments" dated 01/11/13, 01/12/13, 01/13/12, and 01/14/13 revealed no documented evidence that Patient #4 was assessed by an RN at least every 24 hours on 01/12/13 and 01/14/13 as required by the Louisiana State Board of Registered Nurses.

Patient #5
Review of Patient #5's medical record revealed that she was a [AGE] year old female admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]

Review of Patient #5's "Nurse's Daily Shift Assessments" dated 01/08/13 through 01/13/13 revealed no documented evidence of an RN assessment at least every 24 hours as required by the Louisiana State Board of Registered Nurses on 01/08/13, 01/10/13, 01/11/13, and 01/12/13.

In a face-to-face interview on 01/16/13 at 10:25 a.m., S7 indicated that she didn't "always" document her patient assessments. She further indicated that at one time it was the practice to have an RN on the shift following a shift covered by an LPN to ensure that the RN assessed the patient every 24 hours, but she didn't know why this practice was not being carried out at this time.

Patient #6
On 01/14/13 at 10:25 a.m., Patient #6 was observed sitting on the couch in the Activity Room with his head tilted down and his eyes closed.

Review of the patient's medical record revealed the patient was an [AGE] year old male admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]

Review of the Nurse's Daily Shift Assessments revealed there was no documented evidence of an RN assessment on the following days: 01/02/13, 01/03/13, 01/06/13, 01/08/13, 01/10/13, 01/11/13, 01/12/13, and 01/13/13.

Patient #7
Review of the patient's medical record revealed the patient was an [AGE] year old male who was admitted on [DATE] from a nursing home where he was combative with staff and resistant to care. The patient's diagnoses included [DIAGNOSES REDACTED]

Review of the Nurse's Daily Shift Assessments dated/timed 11/17/12 at 12:00 p.m. revealed the patient became combative toward the staff, hitting and kicking at the MHT. While charging toward the MHT, the patient was swinging his arm to hit the MHT, and lost his balance and fell . Further review of the nurse's notes (11/17/12 - 11/25/12) revealed that the patient continued to be combative with ADL/hygiene care. The nursing assessment of the patient before and after the fall was documented by S27. There was no documented evidence of an assessment by the RN.

Review of the Nurse's Daily Shift Assessments dated/timed 11/26/12 at 9:30 p.m. revealed that the patient became combative during ADL care, "broke away" from 2 MHT's, threw himself against the headboard of the bed, and sustained a laceration to the corner of his right eye. The note further revealed that S21 noted "moderate amount of bleeding", cleaned the wound with normal saline, and applied steri strips. There was no documented evidence of any assessment of the wound. There was no documented evidence of an assessment of the patient after the fall by an RN. Further review of the nurse's notes revealed on 11/27/12 at 10:15 a.m., the patient was transported to an emergency room for evaluation of the wound and the patient received 3 sutures to the wound over his right eye.

Further review of the Nurse's Daily Shift Assessments revealed there was no documented evidence of an assessment of the patient by the RN on the following dates: 11/20/12, 11/21/12, 11/26/12, 11/28/12, and 11/29/12.

S5 was interviewed on 01/16/13 at 10:05 a.m..She confirmed that she was the RN Charge Nurse on 11/26/12 and recalled the incident with Patient #7. She stated that she remembered S9 came to get her and she assessed the patient's injury. S5 verified that she had not documented an assessment of the patient after the patient sustained the laceration over his right eye. S5 stated that she co-signed some of the Nurse's Daily Shift Assessments, and stated that by co-signing the note she was indicating she had reviewed the note and agreed with the LPN documentation. S5 verified she did not do an assessment of the patient when she co-signed a note.

In an interview on 01/16/13 at 4:15 p.m., S3 verified that there was no RN assessment of Patient #7 after the patient sustained a fall with an injury on 11/26/12. She verified that there was also no RN assessment of the patient after the first fall the patient sustained on 11/17/12. After reviewing the patient's record, S3 verified there were no RN assessments documented on 11/20/12, 11/21/12, 11/26/12, 11/28/12, and 11/29/12.

Patient #8
Review of Patient #8's medical record revealed that she was a [AGE] year old female admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]

Review of Patient #8's "Nurse's Daily Shift Assessments" dated 01/10/13, 01/11/13, and 01/12/13 revealed no documented evidence that Patient #8 was assessed by an RN on 01/11/13.

In a face-to-face interview on 01/17/13 at 1:05 p.m., S3 indicated that the hospital did not have policies and procedures for RN assessment of patients that addressed the frequency that an RN was to assess a patient and that an RN assessment was required with any change in a patient's condition.

Patient #10
Review of the patient's medical record revealed the patient was a [AGE] year old male admitted on [DATE] under a PEC (Physician Emergency Certificate) for dangerous to self, gravely disabled, and unable to seek voluntary admission. The patient's diagnoses included [DIAGNOSES REDACTED]

Review of the Nurse's Daily Shift assessments revealed there was no documented evidence of an RN assessment on 01/14/13 and 01/15/13.

In a face-to-face interview on 01/16/13 at 8:20 a.m., S8 stated that when the RN co-signed the Nurse's Daily Shift Assessments it indicated the RN had read the note. S8 stated that if the RN needed to add to the note, she could.

In a face-to-face interview on 01/16/13 at 4:30 p.m., S3 verified that Patient #6 and #10 had no documented evidence of an RN assessment at least once every 24 hours for the above dates.

2) Patients' level of observation was maintained as ordered by the physician by the MHT's:

Review of the hospital policy titled "Patient Observation," policy number 8.8 and presented by S1 as the current policy, revealed that visual contact meant 24 hours constant observation of the patient within visual sight of the staff member.

Observation on 01/16/13 at 1:25 p.m. revealed that S10 standing at the end of Hall "a" with a chair positioned outside Room "j" with the door partially closed. Continuous observation revealed S10 walked to the door of Room "j" and opened the door more to revealed Patient #1 lying in the bed.

In a face-to-face interview on 01/16/13 at 1:25pm, S10 indicated that she was observing Patient #1 for another MHT who also had patients in rooms on Hall "b". She further indicated that Patient #1 was on LOS (line of sight) observation. S10 confirmed that while she was at the end of the hall and while she was seated in the chair outside Room "j" with the door partially closed, S10 did not have Patient #1 in her line of sight at all times as ordered by the physician.

In a face-to-face interview on 01/15/13 at 1:00 p.m., S10 indicated that she had been hired in 08/12, and this was her first job in a mental health facility. She further indicated that she shadowed another MHT for about a week when she was hired. S10 indicated that she had no hospital orientation, had not been evaluated by anyone for competency, and was not CPI certified. She further indicated that there were times that she was assigned patients on LOS along with other patients who required every 15 minute checks, and she was unable to keep the patients on LOS in her view at all times.

Observation on 01/16/13 at 1:30 p.m. through 1:40 p.m. on Hall "b" revealed that S12 was seated in a chair outside Room "h" with the door to Room "h" partially closed and not allowing visibility of Patient R2 who had physician orders to remain on LOS. Further observation revealed Patient R1's room door (Room "g" and next door to Room "h") was closed with a small crack that did not allow visibility of Patient R1 (physician orders for LOS). Further observation revealed that S12 was the only MHT at the time on Hall "b". Patient R3 was in Room "i" (located across the hall from Room "g") and had physician orders for LOS observation. Continuous observation revealed Patients R1, R2, and R3 were not in constant LOS of S12 from 1:30 p.m. to 1:40 p.m.

In a face-to-face interview on 01/16/13 at 1:30 p.m., S12 indicated that Patient R1 was in her room. When the door to Room "g" was opened, Patient R1 walked from behind the door to the open doorway. S12 indicated that she could not see Patients R1 and R2 where she was seated in Hall "b". She further indicated that she was observing 9 patients, 3 of whom were on LOS observation, while the other MHT was at lunch. She further indicated that when the other MHT returned, S12 was assigned the observation of 4 patients. S12 indicated that she "was peeping at everybody right now" when asked which MHT was observing Patient R3 who had physician orders to be on LOS. S12 confirmed that she did not have Patient R3 in her view at all times during the time of this observation.

In a face-to-face interview on 01/15/13 at 2:25 p.m., S3 indicated that the hospital did not have a policy regarding the number of patients that could be observed by a MHT. She further indicated that a MHT could not observe several patients who were on LOS observation at the same time.

Review of the pre-printed "Physician Admit Orders & (and) Problem List" used for all admits revealed a choice of a close observation bed and a general population bed. Further review revealed that if the patient was in a close observation bed, line of sight must be initiated, and the choice of precautions included 1:1 (1 patient to 1 MHT), LOS, suicide precautions, homicidal precautions, elopement precautions, behaviors, falls, and seizures.

Patient #1
Review of the medical record for Patient #1 revealed the patient was a [AGE] year old female admitted on [DATE] under a PEC (Physician Emergency Certificate) for dangerous to others and unwilling to seek voluntary admission. The patient's diagnoses included [DIAGNOSES REDACTED]

Review of the admission physician's orders dated/timed 01/06/13 at 9:00 p.m. revealed an order for every 15 minute observation. Further review of the physician's orders revealed Line of Sight (LOS) observation was ordered on [DATE] at 8:40 p.m. There was no documented evidence of any further physician's orders to change the LOS observation status.

Review of the Observational Checklist forms dated 01/06/13 to 01/07/13, and 01/09/13 to 01/13/13 revealed no documented evidence of the observation level the patient was on. Review of the Observational Checklist dated 01/11/13 revealed no documented evidence the observation level was changed from every 15 minutes to LOS.

In a face-to-face interview on 01/16/13 at 4:15 p.m., S3 verified the MHT had not documented the observation level of the patient on the above Observational Checklists. S3 verified there was no documented evidence in the MHT documentation that the observation level was changed to LOS on 01/11/13.

Patient #3
Review of Patient #3's medical record revealed that he was a [AGE] year old male admitted on [DATE] with the diagnoses of [DIAGNOSES REDACTED]

Review of Patient #3's physician orders at admit on 01/12/13 at 6:55 a.m. revealed an order for a "close observation bed" and precautions including LOS, behaviors, and falls.

Review of Patient #3's "Observational Checklist" dated 01/12/13 and 01/13/12 revealed that Patient #3's observation level was every 15 minutes with no documented evidence that Patient #3 was being observed within the line of sight of the MHT.

In a face-to-face interview on 01/14/13 at 4:20 p.m., S13 indicated that Patient #3 was to be in LOS only when he was on oxygen.

Patient #4
Review of Patient #4's medical record revealed that she was a [AGE] year old female admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]

Review of Patient #4's physician orders for admitted d 01/10/13 at 12:00 p.m. revealed an order for a general observation bed (which required every 15 minute observations by the MHT) and precautions for behaviors.

Review of Patient #4's "Observational Checklist" dated 01/10/13, 01/12/13, and 01/13/13 revealed no documented evidence of the observation level and the precautions for behaviors.

Patient #5
Review of Patient #5's medical record revealed that she was a [AGE] year old female admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]

Review of Patient #5's physician orders at admitted d 01/07/13 at 5:10 p.m. revealed an order for a close observation bed with precautions of line of sight, behaviors, and seizures. Further review revealed an order dated 01/08/13 at 8:00 p.m. to move Patient #5 from close observation to a general population bed, and continue every 15 minutes observations by the MHT.

Review of Patient #5's "Observational Checklist" dated 01/07/13 revealed no documented evidence of the observation level and precautions of LOS, behaviors, and seizures. Review of the "Observational Checklist" dated 01/08/13 revealed that the observation level was every 15 minutes, which did not begin until 8:00 p.m. There was no documented evidence that a change in observation level had occurred at 8:00 p.m., and that Patient #5 was being observed for behavior and seizure precautions. Review of the "Observational Checklist" dated 01/11/13 and 01/13/13 revealed no documented evidence of the level of observation and the precautions for behaviors and seizures.

Patient #8
Review of Patient #8's medical record revealed that she was a [AGE] year old female admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]

Review of Patient #8's physician orders at admit revealed that he was in a close observation bed, and his precautions included suicide precautions and behaviors.

Review of Patient #8's "Observational Checklist" revealed the following:

01/09/13 and 01/10/13 - observation level checked was every 15 minutes rather than LOS as ordered; no documented evidence of suicide precautions and behaviors checked;

01/11/13 - LOS and behaviors checked with no documented evidence that Patient #8 was being observed for suicide precautions;

01/12/13 - no documented evidence of the observation level and precautions of suicide and behaviors;

01/13/13 and 01/14/13 - every 15 minutes observation was checked rather than LOS as ordered; no documented evidence that Patient #8 was being observed for suicide precautions and behaviors.

Patient #10
On 01/16/13 at 1:25 p.m., Patient #10 was observed to be in his room with the door partially closed. There was no MHT observed monitoring the patient within Line of Sight. At 1:50 p.m., the patient remained in his room with the door partially shut. 2 MHT's were observed seated on the hall, but neither MHT were in Line of Sight of Patient #10.

Review of the patient's medical record revealed that the patient was a [AGE] year old male admitted on [DATE] under a PEC (Physician Emergency Certificate) for dangerous to self, gravely disabled, and unable to seek voluntary admission. The patient's diagnoses included [DIAGNOSES REDACTED]

Review of the admission physician's orders dated/timed 01/08/13 at 10:00 p.m. revealed an order for Line of Sight (LOS) observation. There was no documented evidence of any further physician's orders to change the LOS observation status.

Review of the Observational Checklist forms dated 01/09/13, 01/11/13, 01/14/13, and 01/15/13, revealed that the observation level was every 15 minutes. Review of the Observational Checklist forms dated 01/10/13, 01/12/13, and 01/13/12 revealed no documented evidence of the observation level the patient was on. There was no documented evidence that LOS observation was provided for Patient #10.

Review of the Nurse's Daily Shift Assessments dated 01/09/13 to 01/15/13 revealed no documented evidence the patient was on LOS observation.

In a face-to-face interview on 01/16/13 at 4:30 p.m. S3 verified LOS observation was ordered on admission and should have been since the patient was new to the hospital and the staff did not know him. She verified there were no physician's orders to change the LOS observation status. After reviewing the Observational Checklists and Nurse's Daily Shift Assessments, she verified there was no documented evidence the LOS observation was provided for Patient #10.

In a face-to-face interview on 01/15/13 at 1:00 p.m., S10 indicated that the MHT completed the level of observation on the "Observational Checklist". She further indicated that if a patient's level of observation changed during the shift, the nurse would tell the MHT. S10 indicated that MHTs "don't have anywhere to document on the paperwork" when a level of observation changes. She further indicated that there have been times that she had patients on LOS and other patients on every 15 minutes observations, and she could not keep the patient in continuous line of sight at all times.

In a face-to-face interview on 01/15/13 at 2:25 p.m., S3 indicated that the MHT assignments were made by the charge RN from the previous shift. She further indicated that the RN did not document anything on the "Observational Checklist" (meaning the observation level and precautions). S3 confirmed that it was difficult to perform LOS observations when a MHT was assigned 3 patients who were on LOS, because a MHT could not watch several patients at the same time while observing a patient on LOS.

In a face-to-face interview on 01/16/13 at 9:10 a.m., S11 indicated that when he was assigned a female patient who was on LOS, he did not go into the bathroom with the patient, and the patient closed the door to the bathroom. S11 confirmed that allowing a patient to go to the bathroom unattended while on LOS did not meet the physician orders to keep the patient on LOS at all times.

In a face-to-face interview on 01/16/13 at 10:00 a.m., S9 indicated that on the night shift of 01/08/13, he was assigned 8 patients to observe, 4 of whom were on LOS. He further indicated that he had to keep moving to observe all of his patients, so he had at least 2 of the LOS patients in his line of sight at all times. S9 indicated that he did not have all 4 within LOS at all times because "it was impossible." S9 indicated that when he was assigned a female who was on LOS, he never went into a female's room at all. He further indicated that he would allow male patients to go to the bathroom and leave a crack in the door, so he could at least see the patient's legs.

3) Develop and implement a system for obtaining admit orders from the psychiatrist:

In an interview on 1/15/13 at 2:32 p.m. with S3, she that S23 was notified of new patient's home medications by the nurses taking a picture of the list with their personal cell phones and texting it to him. S3 said although the hospital had no policy on texting medication lists to the physicians, she had told other nurses to text a picture of the medication list to S23.

In an interview on 1/16/13 at 9:15 a.m. with S5, she said that when a new patient arrived at the hospital, she would sometimes send a picture text of the patient's medication list to S23 from her personal phone.
In an interview on 1/16/13at 11:16 a.m. with S23, he said that when new patients were admitted to the facility, he would receive a phone call from the nursing staff. He then said that if he did not answer his phone, the nurses would text him a photograph of the patient's current medication list for him to review. S23 verified the hospital had no policy on sending photographs of medication lists on personal phones.

4) Patients' physician's orders were implemented for assessment of vital signs, labs, and EKG's:

Review of the hospital policy titled "EKG", submitted by S1 as the current policy, revealed that the EKG's were performed by the Respiratory Care Practitioners in the Respiratory Therapy Department. Further review revealed that the EKG was performed when ordered by the physician and completed in the following priority: a) Stat orders, b) Critically ill patients, c) Pre-operative care patients, d) Routine EKG's, and e) next day pre-op patients. Further review revealed no documented evidence that the time interval between receiving the order and performing the test had been addressed in the policy. There was no respiratory therapy department in the hospital, and the hospital did not care for critically ill patients and patients having surgery.

Review of the hospital policy titled "Pathology and Laboratory Service", policy number 5.17 and presented by Administrator S1 as the current policy, revealed that it was the hospital's policy that all patients admitted have the routine laboratory tests that were ordered by the physician. Further review revealed that the RN documented the order and requisitioned the lab test by phone to Hospital A's laboratory. Further review revealed that Hospital A's lab personnel would come to Seaside Health System and collect the lab sample from the patient and transport it to Hospital A's lab. The lab results would be faxed to Seaside Health System by Hospital A's lab. Review of the policy revealed no documented evidence that the time interval between receiving the order and performing the test had been addressed in the policy.

Patient #3
Review of Patient #3's medical record revealed that he was a [AGE] year old male admitted on [DATE] with the diagnoses of [DIAGNOSES REDACTED]

Review of Patient #3's "Physician Admit Orders & Problem List" dated 01/12/13 at 6:55 a.m. revealed an order for the following diagnostic tests: Vitamin B12, RPR (rapid plasma reagin) with reflex, Pre-albumin, Folate, and HgbA1C (hemoglobin A1C).

Review of Patient #3's "Laboratory Report" revealed that the diagnostic tests's specimen was collected on 01/14/13, 2 days after admission. Review of the entire medical record revealed no documented evidence of a reason that the lab specimen was not collected on the day of admission or the following morning.

In a face-to-face interview on 01/15/13 at 2:25 p.m., S3 indicated that Patient #3 had refused his blood to be drawn, but his refusal was not documented in his medical record.

Patient #4
Review of Patient #4's medical record revealed that she was a [AGE] year old female admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]

Review of Patient #4's "Physician Admit Orders & Problem List" dated 01/10/13 at 12:00 p.m. revealed an order to obtain vital signs QID (four times a day) for the first 24 hours and then BID (twice a day). Further review revealed the QID times listed on the orders were 6:00 a.m., 11:00 a.m., 5:00 p.m., and 9:00 p.m., and the BID times listed were 6:00 a.m. and 5:00 p.m.

Review of Patient #4's "Vital Sign Record" revealed her vital signs were taken on 01/10/13 at 1:45 p.m. (at admit) and at 5:00 p.m. and on 01/11/13 at 6:00 a.m. and 5:00 p.m. There was no documented evidence that Patient #4's vital signs were assessed at 9:00 p.m. on 01/10/13 as ordered.

Patient #5
Review of Patient #5's medical record revealed that she was a [AGE] year old female admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]

Review of Patient #5's "Physician Admit Orders & Problem List" dated 01/07/13 at 5:10pm revealed an order for an EKG and vital signs QID for the first 24 hours and then BID.

Review of Patient #5's medical revealed that an EKG was performed on 01/11/13 at 4:08 p.m., 4 days after having been ordered. Review of the entire medical record revealed no documented evidence of a reason for the delay in obtaining the EKG and that the physician was notified of the delay.

Review of Patient #5's "Vital Sign Record" revealed that her vital signs were taken on 01/07/13 at 5:10 p.m. (at admit), rechecked manually at 5:20 p.m. Further review revealed no documented evidence that Patient #5's vital signs were assessed at 9:00 p.m. as ordered by the physician.

In a face-to-face interview on 01/15/13 at 2:25 p.m., S3 indicated that there was no valid reason for Patient #5's EKG not to be done timely.

Patient #8
Review of Patient #8's medical record revealed that she was a [AGE] year old female admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]

Review of Patient #8's "Physician Admit Orders & Problem List" dated 01/09/13 at 8:30 a.m. revealed an order for vital signs QID for the first 24 hours then BID. Review of the "Physicians Orders" dated 01/10/13 at 10:00 a.m. revealed an order for a Dilantin level, Keppra level, and Depakene level in the morning.

Review of Patient #8's "Vital Sign Record" revealed that her vital signs were taken on 01/09/13 at 11:00 a.m. and 5:00 p.m. There was no documented evidence that Patient #8's vital signs were assessed at 9:00 p.m. as ordered b
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on observations, records review and interviews, the hospital failed to ensure that the nursing staff developed and kept current a nursing care plan for each patient. The nursing staff failed to develop a nursing care plan for fall prevention and failed to update/revise the nursing care plan after the patient sustained a fall for 2 of 3 current sampled patients reviewed for falls from a total sample of 10 (#1, #6).

Findings:

Review of the hospital policy titled, Treatment Plans, number 1.37, reviewed date of August 2011, and provided as current policy by Administrator S1, revealed in part the following: Each patient will have an individualized treatment plan that is based upon the assessments of the patient's clinical needs and is reviewed regularly and revised if needed during the course of treatment.... The Master Treatment Plan is based on an assessment of the patient's presenting problems, physical health, emotional and behavioral problems, cognitive functioning, family, and social functioning....

Patient #1
On 01/14/13 at 10:25 a.m., Patient #1 was observed reclined in a geri chair in the activity room with her eyes closed. The patient was observed to have a bruise to her left eyebrow area with steri-strips noted over a linear wound. The patient opened her eyes and stated she fell last night.

Review of the medical record for Patient #1 revealed that the patient was a [AGE] year old female admitted on [DATE] under a PEC (Physician Emergency Certificate) for being dangerous to others and unwilling to seek voluntary admission. The patient's diagnoses included Bipolar, Schizoaffective Disorder-acute exacerbation, Hypertension, and Diabetes Mellitus.

Review of the initial nursing assessment dated /timed 01/06/13 at 11:45 p.m. revealed a fall risk assessment of "Low Risk". Review of the At Risk For Fall score sheet dated 01/06/13 revealed the patient was scored at "8" (6-12 moderate risk-initiate fall precautions).

Review of the Nurse's Daily Shift Assessments dated/timed 01/09/13 at 4:15 p.m. revealed Patient #1 fell over, out of her wheel chair, hitting her forehead on the ground. Further review of the Nurse's Daily Shift Assessments dated/timed 01/11/13 at 7:50 p.m. revealed that the patient was found on the floor by MHT and sustained a laceration and swelling to the left eyebrow.

Review of the initial treatment plan/care plan dated 01/07/13 and the Master Treatment Plan dated 01/09/13 revealed no documented evidence that fall prevention was identified as a problem, and there was no identified interventions. There was no documented evidence the treatment plan/care plan was updated with new interventions after the patient sustained a fall.

In a face-to-face interview on 01/16/13 at 8:30 a.m., S6 verified that she was familiar with Patient #1 and recalled the patient's fall on 01/11/12. S6 stated that the patient was only able to bear weight to transfer and was not able to walk. S6 verified that the patient was using a wheel chair on admission and had continued to use a wheel chair or a geri chair during her current hospitalization . After reviewing the patient's treatment plans, S6 verified that the patient's fall risk and subsequent falls were not included on the treatment plans.

In a face-to-face interview on 01/16/13 at 4:15 p.m., S3 verified that she was working as the charge RN on the unit when the patient fell on [DATE]. After reviewing the treatment plans, she verified the patient's fall risk was not included in the initial treatment plan, but stated it should have been. S3 verified that the patient was at risk for falls, and a separate form for the problem of safety should have been added to the treatment plan. S3 verified that the treatment plan should have been revised after each fall, but was not.

Patient #6
On 01/14/13 at 10:25 a.m., Patient #6 was observed sitting on the couch in the Activity Room with his head tilted down and his eyes closed.

Review of the patient's medical record revealed the patient was an [AGE] year old male admitted on [DATE] with a diagnosis of Major Depressive Disorder with Psychosis. The record also revealed the patient was admitted from a nursing home where he attempted to choke a staff member.

Review of the initial nursing assessment dated /timed 12/31/12 at 4:45 p.m. revealed the patient was assessed as a moderate fall risk by S3.

Review of the Nurse's Daily Shift Assessments dated/timed 01/01/13 at 7:43 p.m. revealed the patient was assisted back into a chair and sustained a skin tear to his left upper arm. Review of the Patient/Visitor Incident Report Form dated/timed 01/01/13 at 7:43 p.m. revealed the patient attempted to stand from a chair, became weak or lost his balance, fell back to his chair, and rolled onto the floor, hitting his left arm and elbow on the floor.

Review of the initial treatment plan/care plan dated 01/03/13 and the Master Treatment Plan dated 01/07/13 revealed no documented evidence that fall prevention was identified as a problem, and there were no identified interventions. There was no documented evidence the treatment plan/care plan was updated with new interventions after the patient sustained a fall on 01/01/13.

In a face-to-face interview on 01/16/13 at 8:40 a.m., S6 verified that she was familiar with Patient #6 and recalled the patient's fall on 01/01/12. S6 stated that the treatment plan should be updated with fall precautions and stated any fall should be added to the treatment plan with updated interventions. After reviewing the treatment plan for Patient #6, S6 verified that there was no problem identified for fall risk, and there were no interventions identified to prevent falls. S6 verified that the treatment plan was not updated after the patient sustained a fall on 01/01/13.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on observations, records review and interviews, the hospital failed to ensure that the registered nurse (RN) assigned patient care to nursing personnel who had training, orientation, and competency evaluations according to hospital policy and job descriptions for of 3 of 3 RN's personnel files reviewed from a total of 8 employed RN's (S3, S5, S7), 1 of 1 LPN's (licensed practical nurse) personnel file reviewed from a total of 11 employed LPN's (S8), and 9 of 9 MHT's (mental health technician) personnel files reviewed from a total of 25 employed MHT's (S9, S10, S11, S12, S16, S17, S18, S19, S20). Of a total of 40 clinical staff, 35 clinical staff were not certified in CPI, 20 were not certified in CPR, and 29 had not attended the annual skills fair held in December 2012. This resulted in 4 patients with physician orders for line of sight (LOS) observations not being in sight of the MHT on 01/16/13 during observations from 1:25 p.m. to 1:40 p.m. (#1, R1, R2, R3). Findings:

Review of the hospital policy titled "Staff Orientation", policy number 4.2 and presented by S1 as the current policy for staff orientation, revealed that the employee's direct supervisor (Director of Nursing or Administrator) was responsible for orientation activities. Further review revealed that orientation of all full-time and part-time staff would include the items outlined on the "Staff Skills Checklist".

Review of the "Competency Skills Checklist" for RN's, LPN's, and MHT's revealed a list of specific job skills for each discipline that had to be evaluated by the Supervisor or designated mentor within 60 days of employment. The methods of evaluation included observation, written test, oral evaluation or supervision, skills test, evaluation of an academic transcript or workshop evaluations, quality management monitors, and pre-employment interview. The coding system included a number 1 for proficient-competent, 2 for limited experience, and 3 for needs instruction.

Review of the hospital policy titled "Educational Development", policy number 9.13 and presented by S1 as the current policy for job requirements related to education, revealed that the hospital required each employee to complete the following programs upon hire and annually thereafter: universal precautions and infection control, safety, fire safety, ergonomics, emergency preparedness, bloodborne pathogens, hazard communication/material safety date sheets, TB (tuberculosis)/respiratory, and HIPAA (health information and portability act). Further review revealed that all employees involved in providing direct patient care were expected to have CPR (cardiopulmonary resuscitation) certification and CPI (crisis prevention intervention) certification.

Review of the hospital's policy titled "Competency Assessment," policy number 9.8 and presented by S1 as the current policy for staff competency evaluations, revealed that the competency of all hospital employees would be assessed during orientation, periodically throughout the year, and during annual performance evaluations.

Further review revealed that the supervisor of all clinical employees was responsible for the periodic evaluation of each employee's competence in the provision of patient care and services according to hospital policies and procedures, federal and state regulations, and accepted standards of practice.

Further review revealed that each employee was to have an annual performance evaluation, at which time the employee's competence in performing the duties delineated in their respective job description would be evaluated.

Review of the RN's job description, provided by S15, revealed that the qualifications included a minimum of 3 years in a mental health setting and experience in an inpatient setting was preferred and current CPR and CPI certification were required.

Review of the MHT's job description, provided by S15, revealed that the qualifications included one year in a health care setting was required, at least 6 months' mental health experience was preferred, and certified nursing assistant was preferred.

Review of the hospital policy titled "Patient Observation", policy number 8.8 and presented by S1 as the current policy, revealed that visual contact meant 24 hours constant observation of the patient within visual sight of the staff member.

Observation on 01/16/13 at 1:25 p.m. revealed that S10 standing at the end of Hall "a" with a chair positioned outside Room "j" with the door partially closed. Continuous observation revealed S10 walked to the door of Room "j" and opened the door more to revealed Patient #1 lying in the bed.

In a face-to-face interview on 01/16/13 at 1:25pm, S10 indicated that she was observing Patient #1 for another MHT who also had patients in rooms on Hall "b". She further indicated that Patient #1 was on LOS observation. S10 confirmed that while she was at the end of the hall and while she was seated in the chair outside Room "j" with the door partially closed, S10 did not have Patient #1 in her line of sight at all times as ordered by the physician.

In a face-to-face interview on 01/15/13 at 1:00 p.m., S10 indicated that she had been hired in 08/12, and this was her first job in a mental health facility. She further indicated that she shadowed another MHT for about a week when she was hired. S10 indicated that she had no hospital orientation, had not been evaluated by anyone for competency, and was not CPI certified. She further indicated that there were times that she was assigned patients on LOS along with other patients who required every 15 minute checks, and she was unable to keep the patients on LOS in her view at all times.

Observation on 01/16/13 at 1:30 p.m. through 1:40 p.m. on Hall "b" revealed S12 seated in a chair outside Room "h" with the door to Room "h" partially closed and not allowing visibility of Patient R2 who had physician orders to remain on LOS. Further observation revealed Patient R1's room door (Room "g" and next door to Room "h") was closed with a small crack that did not allow visibility of Patient R1 (physician orders for LOS). Further observation revealed S12 was the only MHT at the time on Hall "b". Patient R3 was in Room "i" (located across the hall from Room "g") and had physician orders for LOS observation. Continuous observation revealed Patients R1, R2, and R3 were not in constant LOS of S12 from 1:30 p.m. to 1:40 p.m.

In a face-to-face interview on 01/16/13 at 1:30 p.m., S12 indicated Patient R1 was in her room. When the door to Room "g" was opened, Patient R1 walked from behind the door to the open doorway. S12 indicated she could not see Patients R1 and R2 where she was seated in Hall "b". She further indicated that she was observing 9 patients, 3 of whom were on LOS observation, while the other MHT was at lunch. She further indicated that when the other MHT returned, S12 was assigned the observation of 4 patients. S12 indicated that she "was peeping at everybody right now" when asked which MHT was observing Patient R3 who had physician orders to be on LOS. S12 confirmed that she did not have Patient R3 in her view at all times during the time of this observation.

In a face-to-face interview on 01/15/13 at 2:25 p.m., S3 indicated that the hospital did not have a policy regarding the number of patients that could be observed by a MHT. She further indicated that a MHT could not observe several patients who were on LOS observation at the same time.

Review of the list of employees who had attended the annual education fair in December 2012, provided by S1 who confirmed that the list was current and accurate, revealed that 29 of 46 direct care staff had not attended the education fair.
Review of the December 11, 2012 Competency Fair material presented by S2 revealed that the only competency testing provided for staff was EKG training, and the nursing staff had competency testing for Pharmacy. Further review revealed a two page handout was provided on instructions for Seclusion and Restraint, but no application demonstrations or competency evaluations were performed. Review of the handout provided to staff in attendance revealed that the hospital used NON-Violent Crisis Intervention (NVPCI) as the training of choice to promote care, welfare, safety, and security. This training provided education to staff to assist in de-escalation techniques, learn contributing factors, understand the cycle of escalation, and demonstrate safe and appropriate physical interventions for use in crisis situations. Further review revealed no documented evidence that NVPCI training was offered during the annual education fair.

S9
Review of the personnel record for S9 revealed that S9 was employed on 01/31/12 as a MHT. There was no documented evidence of any orientation, training, competency evaluations, or CPI (Crisis Prevention Intervention) certification.

In a face-to-face interview on 01/17/13 at 10:00 a.m., S9 stated that he had been employed at the hospital for almost 1 year. When asked what training he had received from the hospital, he stated, none. S9 stated that he went to a general orientation for 3-4 hours and that was all the training he had received. He stated he had taken CPI training in the past, but it had expired.

S10
Review of S10's personnel file revealed that she was hired on 08/10/12 and had no prior direct patient care experience in a health care facility. Further review revealed no documented evidence of CPI certification, orientation or training, and a competency evaluation. Further review revealed no documented evidence that S10 had received education upon hire of the hospital's policies and procedures regarding universal precautions and infection control, safety, fire safety, ergonomics, emergency preparedness, bloodborne pathogens, hazard communication/material safety date sheets, TB/respiratory, and HIPAA.

S11
Review of the personnel record for S11 revealed that S11 was employed on 08/17/12 as a MHT. Review of the application for employment revealed no documented evidence of any experience in a health care setting. There was no documented evidence of any orientation, training, competency evaluations, or CPI certification.

In a face-to-face interview on 01/16/13 at 9:10am, S11 indicated that he had worked at the hospital since 08/12, and this job was his first job in health care and working with psychiatric patients. He further indicated that his orientation consisted of being told and shown what to do regarding taking vital signs and doing admits and discharges by another MHT. S11 indicated that he was assigned 1 patient on his first day of work and 3 patients on his second day while he worked with another MHT. He further indicated that he had no formal hospital orientation and had never been evaluated for competency.

S12
Review of the personnel record for S12 revealed that S12 was employed on 07/26/12 as a MHT. There was no documented evidence of any orientation, training, competency evaluations, or CPI certification.

S16
Review of S16's personnel file revealed that she was hired on 12/20/12. Further review revealed no documented evidence of orientation, training, competency evaluation, CPI certification, and CPR certification. Review of the "MHT Schedule" for 11/26/12 through 01/20/13, presented by S2, revealed that S16 worked on 12/29/12, 12/31/12, and 01/17/13. Further review revealed no documented evidence that S16 had received education upon hire of the hospital's policies and procedures regarding universal precautions and infection control, safety, fire safety, ergonomics, emergency preparedness, bloodborne pathogens, hazard communication/material safety date sheets, TB/respiratory, and HIPAA.

S17
Review of S17's personnel file revealed that he was hired on 12/18/12 and had no prior health care experience. Further review revealed no documented evidence of orientation, training, competency evaluation, and CPI certification. Further review revealed no documented evidence that S17 had received education upon hire of the hospital's policies and procedures regarding universal precautions and infection control, safety, fire safety, ergonomics, emergency preparedness, bloodborne pathogens, hazard communication/material safety date sheets, TB/respiratory, and HIPAA. Review of the "MHT Schedule" for 11/26/12 through 01/20/13, presented by S2, revealed that S17 worked on 12/23/12, 12/31/12, 01/01/13, 01/09/13, 01/13/13, 01/14/13, and 01/16/13.

S18
Review of S18's personnel file revealed that she was hired on 12/17/12. Further review revealed no documented evidence of orientation, training, competency evaluation, and CPI certification. Further review revealed no documented evidence that S18 had received education upon hire of the hospital's policies and procedures regarding universal precautions and infection control, safety, fire safety, ergonomics, emergency preparedness, bloodborne pathogens, hazard communication/material safety date sheets, TB/respiratory, and HIPAA. Review of the "MHT Schedule" for 11/26/12 through 01/20/13, presented by S2, revealed that S18 worked on 12/18/12, 12/19/12, 12/24/12, 01/04/13, and 01/09/13.

S19
Review of the personnel record for S19 revealed that S19 was employed on 08/15/12 as a MHT. There was no documented evidence of any orientation, training, competency evaluations, or CPI certification. Review of the application for employment revealed the only health care related work experience S19 had was 1 year and 8 months in an assisted living facility.

S20
Review of the personnel record for S20 revealed that S20 was employed on 08/09/12 as a MHT. Review of the application for employment revealed no documented evidence of any experience in a health care setting. There was no documented evidence of any orientation, training, competency evaluations, or CPI certification.

S3
Review of S3's personnel file revealed she was hired on 04/01/11. Further review revealed no documented evidence of an annual evaluation that included a competency evaluation as required by hospital policy. Further review revealed no documented evidence of training on and competency in the application of restraints. Further review revealed no documented evidence that S3 had received education annually of the hospital's policies and procedures regarding universal precautions and infection control, safety, fire safety, ergonomics, emergency preparedness, bloodborne pathogens, hazard communication/material safety date sheets, TB/respiratory, and HIPAA as required by hospital policy.

S5
Review of S5's personnel file revealed that she was hired on 01/23/12 and had no prior psychiatric nursing experience. Further review revealed no documented evidence of orientation, training, competency evaluation, CPI certification, training on and competency in the application of restraints, and education upon hire of the hospital's policies and procedures regarding universal precautions and infection control, safety, fire safety, ergonomics, emergency preparedness, bloodborne pathogens, hazard communication/material safety date sheets, TB/respiratory, and HIPAA as required by hospital policy.

S7
Review of S7's personnel file revealed that she was hired on 07/12/12 and had no prior health care experience. Further review revealed no documented evidence of CPR certification, orientation, training, competency evaluation, CPI certification, training on and competency in the application of restraints, and education upon hire of the hospital's policies and procedures regarding universal precautions and infection control, safety, fire safety, ergonomics, emergency preparedness, bloodborne pathogens, hazard communication/material safety date sheets, TB/respiratory, and HIPAA as required by hospital policy.

In a face-to-face interview on 01/16/13 at 10:25am, S7 indicated she was hired in 12/11, and this was her first nursing job upon graduation from nursing school. She further indicated that she had never been evaluated for competency. S7 indicated that she was not certified in CPI, and upon hire she did not know how to deal with aggressive patients and patients with behavioral problems. She further indicated that her comfort level was obtained on-the-job by observing her co-workers.

S8
Review of S8's personnel file revealed that she was hired on 01/03/12 and had no prior hospital or psychiatric experience. Further review revealed no documented evidence of orientation, training, competency evaluation, training on and competency in the application of restraints, and education upon hire of the hospital's policies and procedures regarding universal precautions and infection control, safety, fire safety, ergonomics, emergency preparedness, bloodborne pathogens, hazard communication/material safety date sheets, TB/respiratory, and HIPAA as required by hospital policy.

In a face-to-face interview on 01/15/13 at 2:25pm, S3 indicated that she could not remember when the last hospital orientation was held. She further indicated that it had been more than 6 months since she had seen a competency checklist for any employee.

In a face-to-face interview on 01/17/13 at 10:05 a.m., S1 indicated that he, S15, and S3 were responsible for hiring employees and were all responsible for hiring MHT's with no prior health care experience. He confirmed that all staff who provided direct patient care were required to be certified in CPR and CPI.

In a face-to-face interview on 01/17/13 at 10:10 a.m., S15 indicated taht she, S1 and S3 were responsible for the training and competency of the nursing personnel. When asked about the number of clinical staff who were not certified in CPI, S15 indicated "that's something we should have kept up with better". S15 indicated that they had not been able to get a CPR class scheduled, because she was not aware of a CPR instructor to do the class. When asked about hiring a MHT without prior health care experience, S15 indicated that S11 was hired based on a recommendation from a staff member who knew him. She confirmed that the MHT job description required one year of health care experience.

In a face-to-face interview on 01/17/13 at 1:05 p.m., S3 indicated that she had not been keeping up with the required CPI and CPR certifications of staff, because it was difficult to get someone to work her scheduled shifts on the floor to free her to do the DON duties.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on records review and interviews, the hospital failed to ensure that all drugs and biologicals were administered according to physician orders and acceptable standards of practice for 4 of 10 sampled patients (#1, #3, #6, #7). This resulted in 22 medication errors noted during chart reviews that were not identified by the hospital for the 4 patients.

Findings:

Review of the hospital's policies and procedures provided by S3 revealed no documented evidence of a policy that addressed Medication Administration.

Patient #1
Review of the medical record for Patient #1 revealed the patient was a [AGE] year old female admitted on [DATE] under a PEC (Physician Emergency Certificate) for dangerous to others and unwilling to seek voluntary admission. The patient's diagnoses included Bipolar, Schizoaffective Disorder-acute exacerbation, Hypertension, and Diabetes Mellitus.

Review of the admission physician's orders dated/timed 01/09/13 at 9:15 a.m. revealed the following order: Start Klonopin 0.5 mg. PO TID (by mouth, three times a day). First dose 1500 (3:00 p.m.) today.

Review of the Medication Administration Record (MAR) dated 01/07/13 through 01/10/13 revealed that Klonopin 0.5 mg. was administered on 01/09/13 at 9:30 a.m., 3:00 p.m., and at 9:00 p.m.

In a face-to-face interview on 01/16/13 at 4:15 p.m., S3 verified that the Klonopin was ordered by the physician to begin at 3:00 p.m. on 01/09/13. She verified that an additional dose was administered at 9:30 a.m. on 01/09/13 and would be considered a medication error.

Patient #3
Review of Patient #3's medical record revealed that he was a [AGE] year old male admitted on [DATE] with the diagnoses of Psychosis, Dementia, Hypertension, Diabetes Mellitus, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Benign Prostatic Hypertrophy, and Edema.

Review of Patient #3's "Admit/Discharge Medication Reconciliation and Order Sheet" revealed that S7 transcribed the medications on the form on 01/12/13 at 7:35 a.m. Further review revealed that all medications were to be continued except Haldol. Further review revealed that a notation of "TORB x 2 Psychiatrist S23" (telephone read back times 2) with no documented evidence of the author of the notation and the date and time that the order was received. Further review revealed that the practitioner signed the medication orders on 01/12/13 at 6:00 p.m. (therefore no physician orders for medication until 01/12/13 at 6:00 p.m.).

Review of Patient #3's "Physician Admit Orders & (and) Problem List" dated 01/12/13 at 6:55 a.m. revealed an order to perform fingerstick blood sugar testing on admit and daily before meals and at bedtime and to call the physician if blood sugar was less than 60 or greater than 400. Further review revealed that "N/A (not applicable) at this time" was written across the section that addressed the amount of Regular Insulin to be administered per sliding scale. There was no physician order given for Regular Insulin to be administered.

Review of Patient #3's "Medication/Treatment Administration Record" (MAR) revealed that he received the following medications prior to the medication list being signed by the practitioner:

Altace 2.5 mg (milligrams) capsule,
Flomax 0.4 mg capsule,
Atenolol 25 mg tablet,
Exelon 1.5 mg capsule,
Haldol 2 mg tablet,
Humalog 100/ml (milliliter) 10 units subcutaneously,
Multivitamin and Mineral Supplement,
Aspirin 81 mg enteric-coated,
Lasix 40 mg tablet,
Paxil 10 mg tablet,
Metamucil 520 mg capsule, and
Seroquel 25 mg tablet at 11:35 a.m.;
Haldol 2 mg tablet at 3:00 p.m.

Further review revealed that Patient #3 was administered Haldol 2 mg by mouth on 01/12/13 at 11:35 a.m., 3:00 p.m., and 9:00 p.m. and on 01/13/13 at 9:00 a.m., 3:00 p.m., and 9:00 p.m. with no physician orders to administer it.

Review of Patient #3's "Diabetic Flow Sheet" revealed that S7 administered Regular Insulin 6 units subcutaneously on 01/12/13 at 9:30 a.m. with no physician order for the insulin to be administered.

In a face-to-face interview on 01/16/13 at 10:25 a.m., S7 indicated that there was a question about the sliding scale for Patient #3 from his referring hospital's record. She further indicated that she had called the hospital to ask if Patient #3 had been on sliding scale, and the referring hospital staff indicated that the sliding scale had been discontinued. S7 confirmed that she administered the Regular Insulin, and there was no physician order for it to be given. After review of Patient #3's "Admit/Discharge Medication Reconciliation and Order Sheet", S7 confirmed that there was no date and time for the telephone order and giving medications prior to the practitioner's signing the "Admit/Discharge Medication Reconciliation and Order Sheet" would constitute giving medications without a physician's order.

Patient #6
Review of the patient's medical record revealed the patient was an [AGE] year old male admitted on [DATE] with a diagnosis of Major Depressive Disorder with Psychosis. The record also revealed the patient was admitted from a nursing home where he attempted to choke a staff member.

Review of the physician's orders dated/timed 01/02/13 at 5:30 p.m. revealed an order for Exelon patch 4.6 mg. apply Q day (every day). Further review of the physician's orders dated/timed 01/03/13 at 5:30 p.m. revealed an order for B12 1000 mcg. IM (injection) today then every week for 4 weeks, then every month.

Review of the MAR dated 01/02/13 through 01/03/13 revealed the Exelon patch was not administered until 9:00 a.m. on 01/03/13 ( 1 day after the order).

Review of the MAR dated 01/04/13 to 01/10/13 revealed the B12 injection was administered on 01/04/13 at 6:45 a.m. (1 day after the order).

In a face-to-face interview on 01/16/13 at 4:15 p.m., S3 verified that the Exelon was not administered as ordered and should have been given on 01/02/13. S3 verified that the B12 injection was not administered as ordered and should have been administered on 01/03/13. S3 verified both late administrations were medication errors and there was no reason the medication could not have been obtained and administered on the day they were ordered.

Patient #7
Review of the patient's medical record revealed the patient was an [AGE] year old male who was admitted on [DATE] from a nursing home where he was combative with staff and resistant to care. The patient's diagnoses included Psychosis and Dementia.

Review of the physician's orders dated/timed 11/17/12 at 1:55 p.m. revealed an order for Geodon 20 mg. IM (injection) every 8 hours.

Review of the MAR dated 11/16/12 to 11/22/12 revealed the Geodon was administered on 11/17/12 at 3:00 p.m., but the 11:00 p.m. dose was circled. The MAR also revealed a dose was administered at 3:00 a.m. The scheduled times on the MAR for the Geodon were 7:00 a.m., 3:00 p.m., and 11:00 p.m.

Review of the Nurse's Daily Shift Assessments dated 11/17/12 revealed the following entries:

10:00 p.m. Patient in bed eyes closed. Patient restless in bed....

11:00 p.m. Patient's Geodon injection held because patient in bed, eyes closed.

12:30 a.m. Patient in bed awake, restless. MHT (Mental Health Tech) stated he has been awake for 1 1/2 hours....

2:00 a.m. ....Patient becoming increasingly excited. 1:1 continues.

3:00 a.m. Patient needed brief changed. 4 techs (MHT) used to ensure safety of MHT's. Patient combative, loud, and angry. Earlier scheduled dose of Geodon administered late at this time IM in left thigh....

In a face-to-face interview on 01/16/13 at 4:15 p.m., S3 verified that there was no physician's order to hold the 11:00 p.m. dose of Geodon. S3 stated that the medication was not ordered as needed and the RN should have notified the physician before holding a dose and administering a late dose of the Geodon. S3 verified that this would be considered a medication error.