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.

APOLLO BEHAVIORAL HEALTH HOSPITAL, L L C 7414 SUMRALL DRIVE, SUITE C BATON ROUGE, LA Aug. 26, 2013
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure that patient care was assigned to nursing personnel who had been evaluated for competency to perform the duties assigned to them for 4 of 5 RNs' (registered nurse) personnel files reviewed from a total of 18 employed RNs (S5, S6, S8, S19) and 3 of 3 MHTs' personnel files reviewed from a total of 24 employed MHTs (S7, S15, S18). Findings:

Review of the hospital policy titled "Selection and Hiring of Personnel", policy number 9.1, approved 05/12, and presented by S2DON (Director of Nursing) as the policy for hiring requirements and competency evaluations of staff, revealed that the hospital will administer and grade the appropriate competency test(s), verify current licensure, and check OIG (Office of the Inspector General) sanction list and federal debarment list. Only candidates who satisfactorily meet all hospital employment requirements may be offered a position within the company. Further review revealed that the new hire would be scheduled for the next available orientation which would become the employee's official hire date. Applicants will be required to complete a skills assessment and competency evaluation relevant to the responsibilities of the job description. Each new employee must participate in an orientation program which will include a general orientation component as well as a clinical component specifically geared to their job description and role of the new employee within the hospital structure. The employee's performance will be evaluated at the end of the 3 month probationary period.

Review of the RN "Job Description" revealed the RN was to maintain professional licensure/certification as well as CPR (cardiopulmonary resuscitation) and CPI (crisis prevent intervention). Further review revealed that the education/experience requirements included 10 hours of CEU's (continuing education units) in 2-year increments that relate to mental health.

Review of the "Nurses Orientation / Annual Competency / Skills Checklist" revealed that the new employee was to review the checklist and complete the self-assessment section. Further review revealed that the key to the self-assessment was as follows: circle (1) if you can do the skill independently; circle (2) if you need to practice the skill and then perform it under supervision; circle (3) if you need to learn the skill, practice it, and perform it under supervision. Further review revealed the checklist had a column titled "Discusses / Class" with no area for evaluation of the employee's performance of the skill.

S5RN
Review of S5RN's personnel file revealed she was hired on 05/14/13. Further review revealed no documented evidence of a "Nurses Orientation / Annual Competency / Skills Checklist" in her file and no competency assessments for the use of and application of restraints, suicide/violence/elopement risk assessments, the grievance procedure, and observations of competency in performing the duties of the RN in a psychiatric setting. S5RN had no documented evidence of CPI certification and 10 hours of CEUs related to mental health as required by her job description.

S6RN
Review of S6RN's personnel file revealed she was hired on 03/14/13. Review of S6RN's "Nurses Orientation / Annual Competency / Skills Checklist" revealed she circled a 2 (meaning she needed to practice the skill and then perform it under supervision) for the hospital's fire plan, the hospital's disaster plan, restraints, organ donation policy and procedure, applying restraints and removing restraints, and seclusion and restraint policy and procedure. There was no documented evidence that S6RN received education on the identified areas for which she needed practice and a follow-up evaluation of her competency. There was no documented evidence that S6RN was observed performing the skills listed on the competency checklist and an assessment of her competency to perform the skills had been completed.

S8RN
Review of S8RN's personnel file revealed she was hired on 02/06/13. Review of S8RN's "Nurses Orientation / Annual Competency / Skills Checklist" revealed she assessed herself as not competent with the hospital's disaster plan, LOPA (Louisiana Organ Procurement Agency), and ordering stock medication. Further review revealed no documented evidence that education was provided to S8RN on the identified areas for which she did not feel competent to perform and that a competency evaluation had been performed after the education. Further review revealed no documented evidence that S8RN was observed performing the skills listed on the competency checklist and an assessment of her competency to perform the skills had been completed. There was no documented evidence of 10 hours of CEUs related to mental health as required by her job description.

S19RN
Review of S19RN's personnel file revealed she was hired on 08/07/13. Review of her "Nurses Orientation / Annual Competency / Skills Checklist" revealed all areas were documented as assessed by S2DON on the day she was hired. There was no documented evidence that S19RN was observed performing the skills listed on the competency checklist and an assessment of her competency to perform the skills had been completed.

Review of the MHT's "Job Description" revealed some of the essential job functions and duties included assisting in the provision of maintaining a safe and therapeutic milieu by monitoring compliance with hospital rules, providing assistant with security and supportive man-power by assisting in the control of patients exhibiting unacceptable behavior and documenting patient's observed behaviors and vital signs. The minimum experience requirements included 3 years in a healthcare setting required with at least 1 year of mental health experience preferred.

S7MHT
Review of S7MHT's personnel file revealed she was hired on 05/15/13. Review of her application and resume revealed no documented evidence of 3 years experience in a healthcare setting. Review of her "Mental Health Tech Yearly Competency Checklist" revealed that she circled a (2) in the following areas (indicating that she needed to practice the skill and then perform it under supervision): obtaining sputum and stool specimens; obtaining height, weight, and vital signs within 15 minutes of admission; use and care of the electronic thermometer, portable vital sign monitor, Hoyer lift, and Geri-chair; limit setting; therapeutic milieu; legal status; community group meeting; interdisciplinary treatment plan. There was no documented evidence that S7MHT received education on the topics that she identified as needing more practice and performance under supervision with a follow-up of an observed assessment of her competency to perform these skills. There was no documented evidence that S7MHT was observed performing the skills listed on the competency checklist and an assessment of her competency to perform the skills had been completed.

S15MHT
Review of S15MHT's personnel file revealed he was hired on 05/15/13. Review of S15MHT's background check report revealed the results were received by the hospital on [DATE], the day after S15MHT was hired. Further review of the report revealed that he was arrested and charged on 05/06/96 and paid a fine for theft over $500.00, was arrested and charged with simple battery on 12/01/97 and 02/11/98 with no documented evidence of the outcome of the charges, and arrested and charged with issuing worthless checks on 09/01/99 with no documented evidence of the outcome of the charges.

Review of S15MHT's "Mental Health Tech Yearly Competency Checklist" revealed that he circled a (2) in the following areas (indicating that she needed to practice the skill and then perform it under supervision): obtaining supplies; oral hygiene; PM care; changing and straightening linen; giving and removing bedpans/urinals; assisting patients to and from the bathroom; safekeeping of personal belongings; ensuring a safe bed position; transporting patients by wheelchair or stretcher; assisting patients in moving/sitting/ambulating if needed; sharps policy; handling and disposing of sharps; red-bagging procedure; cleaning body fluid spills; documenting intake and output; communicating intake and output to the nurse; obtaining urine, sputum, stool, and 24 hour urine specimens; labeling specimens; taking specimens to the lab; checking for proper admit papers; obtaining height, weight, and vital signs within 15 minutes of admission; orientation of the patient to the hospital; transferring calls; use of the electronic thermometer and portable vital sign monitor; identifying the location of emergency equipment; Dr. Strong Code (patient out of control); seclusion/restraint policy and procedure; applying restraints; removing restraints; seclusion/restraint documentation; psychiatric orders of major depression, care of a dependent patient, care of a suicidal patient, and special precautions documentation for visual contact, close observation, and one-to-one. Further review revealed S15MHT circled a (3) (indicating that he needed to learn the skill, practice it, and perform it under supervision) for stating his role in a Code Blue. The date in the "discussed/class" column was 05/22/13 for all skills listed and initialed by S2DON. There was no documented evidence that S15MHT received education in the areas he listed as needing to practice the skill or learn the skill with a follow-up evaluation of his competency to perform the skill without supervision. There was no documented evidence that S15MHT was observed performing the skills listed on the competency checklist and an assessment of his competency to perform the skills had been completed.

S18MHT
Review of S18MHT's personnel file revealed that she was hired on 09/04/12. Review of her "Mental Health Tech Yearly Competency Checklist" revealed the column labeled as "Do you feel competent?" with a column labeled "Yes" and a column labeled "No" had no documented evidence that S18MHT had answered whether she felt competent to perform the skills listed. Further review revealed no documented evidence that S18MHT was observed performing the skills listed on the competency checklist and an assessment of her competency to perform the skills had been completed.

In a face-to-face interview on 08/26/13 at 2:50 p.m., S2DON confirmed that there was no documented observations of any of the above-listed nurses and MHTs performing the required skills/job duties. She indicated that she needed to revise the competency evaluation tool.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure patient medications were administered according to physician orders and hospital policies for 9 of 11 sampled patients (#1, #2, #5, #6, #7, #8, #9, #10, #11). This resulted in 113 medication errors being identified during the survey that had not been identified by the hospital. Findings:

Review of the hospital policy titled "Medication Administration", policy number 12.3, approved 05/12, and presented by S2DON (Director of Nursing) as a current policy, revealed that the medication order should contain the quantity of the dose, the route of administration, the time, and be legible. Further review revealed that the doctor who wrote the order was to be called when in doubt about any medication order. Further review revealed that an occurrence report was to be completed for all medication errors, including but not limited to, omissions, wrong medication administered, incorrect dose administered, transcription errors, and adverse reactions. Further review revealed the physician was to be notified when there was a medication error.

Review of the hospital policy titled "Patient Records of Medication at Admission and Discharge", policy number 12.2, approved 05/12, and presented by S2DON as a current policy, revealed that a "Medication Reconciliation Sheet" must be completed and signed by the charge nurse prior to the patient arrival. Once this form is completed, the charge nurse was to ask the patient review it, sign it, and date it. The admitting physician must sign the "Medication Reconciliation Sheet" within 48 hours authenticating it with the date and time. Further review revealed the "Medication Reconciliation Sheet" will include all home medications as well as those medications prescribed from the referring agency. Review of the procedure revealed that the nurse was to contact the physician for orders to continue, discontinue, or change the patient's current medications.

Review of the hospital policy titled "Administration of Medication Using Medication Administration Record (MAR) System", policy number 12.1, approved 05/12, and presented as a current policy by S2DON, revealed that some of the reasons for putting a note regarding medications into the nurse's notes included medication refusal, medication omission, and when PRN (as needed) medication was administered. Further review revealed that if medication was refused or omitted for any reason, the nurse should circle the time the medication should have been given and document the reason the medication was not given on the back of the MAR. Further review revealed that to ensure accuracy the MAR should be checked against the physician's orders once every 24 hours. The policy revealed that blank spaces on the MAR indicated a medication error. Documentation of the effectiveness of the PRN medications in the nurse's notes and on the back of the MAR was required by hospital policy.

Review of the hospital policy titled "Medication Errors", policy number 12.29, approved 05/12, and presented as a current policy by S2DON, revealed that the types of medication errors included wrong dose, wrong route, wrong time, omission (not administered before the next scheduled dose due), and an unordered dose. When a medication error occurred the following should occur: 1) notify the physician and evaluate the patient; 2) perform any necessary clinical interventions to reduce the negative effects of the identified error; 3) record the medication that was given in the medical record; 4) record the observed and assessed outcome of the patient in the medical record; 5) record notification of the physician in the medical record along with any orders given; 6) record any actions and clinical interventions taken and the patient's response; 7) report the error in detail on a medication inadvertent incident report.

Review of the hospital policy titled "Nursing Service and Pharmacy Interaction", policy number 12.7, approved 05/12, and presented as a current policy by S2DON, revealed that after pharmacy hours the order was to be transcribed, the needed medication was to be removed from stock, the transaction documented on a stock sign-out sheet noting which medication was taken, the number or amount, as well as the strength and form, and the sheet was to be faxed to the pharmacy. Further review revealed that if medications were needed before the scheduled refill time of the pharmacy, the medication was to be requested from pharmacy.

Review of the hospital policy titled "Standard Hours for Routine Medications", policy number 12.6, approved 05/12, and presented as a current policy by S2DON, revealed that medications ordered to be given TID (three times a day) were to be administered at 8:00 a.m., 2:00 p.m., and 8:00 p.m. Further review revealed that this standard would be effective unless the hours of administration of the medication was specified by the physician.

Patient #1
Review of Patient #1's medical record revealed she was a [AGE] year old female admitted on [DATE] and discharged on [DATE]. Further review revealed her admitting diagnosis was Suicidal Ideation. She had a PEC (Physician Emergency Certificate) signed on 06/09/13 at 12:10 a.m. secondary to being suicidal (history of depression complaining of a suicide attempt by taking 1 Phenergan tablet, 6 Xanax tablets, 2 Lortab tablets, and 3 Neurontin tablets) and a danger to herself. Her CEC (Coroner's Emergency Certificate) was signed on 06/10/13 at 5:58 p.m. secondary to Patient #1 being gravely disabled.

Review of the entire medical record revealed no documented evidence that a "Medication Reconciliation Sheet" was completed at the time of Patient #1's admission. Further review revealed 2 sheets of paper with a list of medications written with the dose and frequency of administration, one sheet had 12 medications listed and one sheet had 18 medications listed.

Review of Patient #1's "Physician Admit Orders & (and) Problem List" dated 06/09/13 at 12:45 p.m. revealed an order for a Multivitamin by mouth daily and Gabapentin 300 mg by mouth TID. Review of the MAR revealed a note on 06/10/13 in the space for 8:00 a.m. that Patient #1 refused the Multivitamin, and there was no documented evidence that the physician was notified that the medication was refused. Further review revealed the 8:00 a.m. time was circled on 06/11/13 for the Multivitamin with no documented evidence of the reason the drug was not given and that the physician was notified. Further review revealed no documented evidence that Gabapentin 300 mg was given at the hospital-scheduled time of 2:00 p.m. (for TID orders), and there was no documented evidence of the reason the medication was omitted and that the physician was notified.

Review of Patient #1's "Physician Orders" revealed a telephone order received from S11Physician (Internal Medicine) by S5RN (registered nurse) on 06/10/13 at 8:00 a.m. to give Lortab 7.5 mg (milligrams) by mouth now. Review of the MAR revealed S5RN administered Lortab 7.5 mg orally at 9:55 a.m., 1 hour and 55 minutes after the "now" medication was ordered. Further review of the MAR and the nurse's notes revealed no documented evidence of the reason for the PRN medication and that the effectiveness of the medication was assessed by the RN.

In a face-to-face interview on 08/20/13 at 4:20 p.m., S5RN indicated she had written the 18 medications that was on the chart. After reviewing Patient #1's medical record, S5RN indicated that she did not document that she reported Patient #1's home medications to the physician and whether he wanted to order them or defer the decision to S11Physician (Internal Medicine). When asked if she should have reported the significant medications such as Levothyroxine ([DIAGNOSES REDACTED]), Metoprolol (used to treat hypertension), and Diltiazem (used to treat hypertension) to the physician upon admit, S5RN answered "ideally yes but."

In a face-to-face interview on 08/22/13 at 2:50 p.m., S10RN indicated the hospital has a medication reconciliation sheet, but not everyone uses it. She further indicated that the day shift usually wrote the order to continue home medications. She further indicated that the medical doctor (not psychiatrist) would review the patient's home medications and would tell the nurse which medications to order. When asked about her getting the order to continue Patient #1's home medications, S10RN indicated that she remembered that Patient #1 kept coming to the nursing station and asking for her medications. She further indicated that when she saw the hand-written list of home medications, she called S11Physician to get orders to begin her home medications.

Patient #2
Review of Patient #2's medical record revealed she was a [AGE] year old female admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED].

Review of Patient #2's "Physician Orders" revealed an order on 08/20/13 at 10:18 a.m. to give Lortab TID at 7:00 a.m., 12:00 p.m., and 5:00 p.m. (scheduled dose). Review of the MAR revealed the Lortab time of administration was written for 8:00 a.m., 2:00 p.m., and 8:00 p.m., the hospital's scheduled TID times rather than the specific time ordered by the physician. Lortab was administered on 08/20/13 at 2:05 p.m. and 8:40 p.m. and on 08/21/13 at 9:00 a.m. rather than at times ordered by the physician.

Review of Patient #2's "Physician Orders" revealed an order written by S9Medical Director (Psychiatrist) on 08/20/13 at 1:30 p.m. to increase Klonopin 2 mg one at bedtime, Seroquel 25 mg one at bedtime, discontinue Klonopin 1 mg at bedtime, and Pamelor 25 mg one at bedtime. There was no documented evidence of the route of administration included in the order, and there was no documented evidence that the medication order was clarified by the nurse. Review of the MAR revealed Klonopin 2 mg and Seroquel 25 mg were administered orally on 08/20/13 at 8:40 p.m., and Pamelor 25 mg was unavailable and not given at bedtime on 08/20/13. There was no documented evidence that S9Medical Director was notified that Pamelor was not administered as ordered.

Patient #5
Review of Patient #5's medical record revealed she was a [AGE] year old female admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED].m. secondary to being a danger to herself and gravely disabled.

Review of Patient #5's "Physician Orders" revealed an order written by S9Medical Director on 08/17/13 at 7:50 a.m. for Lexapro 10 mg one every morning, Seroquel 25 mg one at bedtime, and Trazodone 50 mg one at bedtime. There was no documented evidence that the route of administration was ordered, and there was no documented evidence that the nurse got a clarification order before administering the medications. Review of Patient #5's MARs revealed she received Lexapro 10 mg orally on 08/17/13 at 9:48 a.m. and at 8:00 a.m. on 08/18/13, 08/19/13, and 08/20/13. She received Seroquel 25 mg by mouth at 8:00 p.m. on 08/17/13, at 8:10 p.m. on 08/18/13, at 8:30 p.m. on 08/19/13, and at 10:30 p.m. on 08/20/13 (2 hours and 30 minutes after the scheduled time). Patient #5 received Trazodone at 8:00 p.m. on 08/17/13, at 8:10 p.m. on 08/18/13, at 8:30 p.m. on 08/19/13, and at 10:30 p.m. on 08/20/13 (2 hours and 30 minutes after the scheduled time).

Patient #6
Review of Patient #6's medical record revealed he was a [AGE] year old male admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]. He was CEC'd on 08/16/13 at 2:50 p.m. secondary to being a danger to himself and gravely disabled.

Review of Patient #6's "Physician Orders" revealed a telephone order received from S13Physician by S14RN on 08/16/13 at 2:57 a.m. to perform glucose accuchecks before meals and at bedtime, and administer Regular Insulin according to S13Physician's sliding scale standing orders. Review of the "Standing Orders" revealed the following: "Insulin Regular Sliding Scale: (Check the appropriate box for dosage) 60-150=(equals)0 u (units); 151-200=2u; 201-250=4u; 251-300=6u; 301-350=8u; 351-400=10u; > (greater than) 400 call MD (medical doctor)." Further review revealed no documented evidence that any of the boxes were checked to designate the appropriate dosage. Review of Patient #6's MARs revealed he refused the sliding scale regular Insulin on 08/20/13 at 11:30 a.m. (glucose 157), at 4:30 p.m. (glucose 182), and at 8:00 p.m. (glucose 189) and on 08/21/13 at 6:30 a.m. (glucose 170). There was no documented evidence that the physician was notified of Patient #6's refusal to have his sliding scale insulin injections.

Review of Patient #6's "Physician Orders" revealed the following written order by S9Medical Director on 08/16/13 at 11:30 a.m.: Librium 100 mg by mouth 1st dose; Librium 50 mg every 6 hours PRN up to 6 doses; Librium 25 mg every 6 hours PRN up to 6 doses; check vital signs before PRN doses; start Seroquel 25 mg at bedtime; Trazodone 50 mg at bedtime; Wellbutrin SR 150 mg one BID (twice a day)." There was no documented evidence of the route of administration for Librium 50 mg and 25 mg, how the nurse was to determine whether to give 50 mg or 25 mg, the justification (symptoms) for the PRN medication, and the route of administration for Seroquel, Trazodone, and Wellbutrin. There was no documented evidence that a nurse clarified the physician's order before administering any of the above ordered medications.

Review of Patient #6's MARs revealed the following medications were administered at the documented times:
Librium 50 mg by mouth on 08/17/13 at 8:30 a.m., 2:30 p.m., and 8:45 p.m.; on 08/18/13 at 2:26 p.m. and 9:00 p.m.; on 08/19/13 at 8:25 a.m. and 3:23 p.m. (total of 7 doses when up to 6 doses was ordered); there was no documented evidence of Patient #6's vital signs prior to the administration of Librium as ordered;
Librium 25 mg administered by mouth on 08/19/13 at 9:00 p.m. and on 08/20/13 at 10:30 p.m.; there was no documented evidence of Patient #6's vital signs prior to the administration of Librium as ordered;
Seroquel 25 mg by mouth at bedtime on 08/16/13, 08/17/13, 08/18/13, 08/19/13, and 08/20/13;
Trazodone 50 mg administered at bedtime on 08/16/13, 08/17/13, 08/18/13, 08/19/13, and 08/20/13;
Wellbutrin SR 150 mg administered at 8:00 a.m. on 08/17/13, 08/18/13, 08/19/13, 08/20/13, 08/21/13 and at bedtime on 08/16/13, 08/18/13, 08/19/13, and 08/20/13; there was no documented evidence that Patient #6 received Wellbutrin SR 150 mg at bedtime on 08/17/13.

Review of Patient #6's "Physician Orders" revealed an order on 08/18/13 at 11:30 a.m. to administer Metformin 250 mg by mouth every morning. Review of his MAR revealed Metformin 250 mg was administered on 08/18/13 at 8:00 a.m. prior to the order being received.

Patient #7
Review of Patient #7's medical record revealed that she was a [AGE] year old female admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED].m. secondary to being gravely disabled.

Review of Patient #7's "Physician Orders" revealed the following orders:
08/13/13 at 3:15 p.m. - Lexapro 20 mg one each morning, Xanax 0.5 mg 1 twice a day, Seroquel 25 mg one at bedtime - ordered by S9Medical Director with no documented evidence of the route of administration and no documented evidence of a clarification order obtained by the nurses before administering these medications;
08/16/13 at 11:00 a.m. - start Xanax 0.5 mg one twice a day, continue Seroquel 25 mg one at bedtime - ordered by S9Medical Director with no documented evidence of the route of administration and no documented evidence of a clarification order obtained by the nurses before administering these medications;
08/17/13 at 4:52 a.m. telephone order to give Xanax 1 mg by mouth now and to change Xanax dose to Xanax 1 mg by mouth twice a day;
08/17/13 at 10:35 a.m. - increase Seroquel to 50 mg one at bedtime - ordered by S9Medical Director with no documented evidence of the route of administration and no documented evidence of a clarification order obtained by the nurses before administering these medications.

Review of Patient #7's MARs revealed the following medications administered:
Xanax 0.5 mg given orally on 08/13/13 and 08/14/13 at 8:00 p.m. with no physician orders for the route that the medication was to be given;
Seroquel 25 mg given orally on 08/13/13 and 08/14/13 at 8:00 p.m. with no physician orders for the route that the medication was to be given;
Xanax 0.5 mg given orally on 08/16/13 at 1:00 p.m. and 8:00 p.m. with no physician orders for the route that the medication was to be given;
Seroquel 25 mg given orally on 08/16/13 at 8:00 p.m. with no physician orders for the route that the medication was to be given;
Xanax 1 mg given orally at 8:00 a.m. on 08/17/13 and 08/20/13 and at 8:00 p.m. on 08/17/13 and 08/18/13 and at 8:30 p.m. on 08/19/13 and 08/20/13 with no physician orders for the route that the medication was to be given;
Seroquel 50 mg given orally at 8:00 p.m. on 08/17/13 and 08/18/13 and at 8:30 p.m. on 08/19/13 and 08/20/13 with no physician orders for the route that the medication was to be given.
Further review of the MARs revealed Patient #7 refused Lexapro 20 mg at 8:00 a.m. on 08/14/13, Xanax 0.5 mg at 8:00 a.m. on 08/14/13, Xanax 1 mg ordered now on 08/17/13 at 4:52 a.m., and Xanax 1 mg at 8:00 a.m. on 08/18/13 and 08/19/13 without the physician being notified of the patient's refusal.

Patient #8
Review of Patient #8's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED].m. secondary to being a danger to himself.

Review of Patient #8's "Physician Admit Orders & Problem List" dated 08/19/13 at 10:50 p.m. revealed an order for a Multivitamin by mouth daily. Review of his "Physician Orders" revealed an order written by S9Medical Director on 08/20/13 at 11:20 a.m. for Effexor XR 37.5 mg one every morning. There was no documented evidence of the route of administration, and there was no clarification order by the nurse before the medication was administered.

Review of Patient #8's MAR revealed the time for the Multivitamin and Effexor XR was circled (indicating they were not given) on 08/20/13 with no documented evidence on the back of the MAR of the reason the medications were not given as required by hospital policy. Further review revealed Effexor XR 37.5 mg was given orally at 8:00 a.m. on 08/20/13, 08/21/13, and 08/22/13 with no physician orders for the route that the medication was to be given.

Patient #9
Review of Patient #9's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED].m. secondary to being a danger to self.

Review of Patient #9's "Physician Admit Orders & Problem List" dated 08/19/13 at 2:50 a.m. revealed an order for Lunesta 2 mg by mouth at bedtime. Review of his "Physician Orders" revealed an order with no documented evidence of the physician's signature who wrote the order or the time and date that the order was written. The order was to give Seroquel 25 mg one at bedtime, Trazodone 75 mg one at bedtime, Zoloft 100 mg one every morning, and Ambien 10 mg at bedtime PRN for sleep with no documented evidence of the route that the medications were to be administered. Further review revealed no documented evidence of a clarification order obtained by the nurse before these medications were administered.

Review of Patient #9's MARs revealed he refused Lunesta 2 mg at 8:00 p.m. on 08/21/13 without the physician being notified. Further review revealed Patient #9 received Seroquel 25 mg orally at 9:00 p.m. on 08/20/13 and at 8:00 p.m. on 08/21/13, Trazodone 75 mg orally at 9:00 p.m. on 08/20/13 and at 8:00 p.m. on 08/21/13, and Zoloft at 9:00 a.m. on 08/21/13 with no physician orders for the route that the medication was to be given.

Patient #10
Review of Patient #10's medical record revealed she was a [AGE] year old female admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED].m. secondary to being suicidal, gravely disabled, and a danger to herself.

Review of Patient #10's "Physician Orders" revealed an order written by S9Medical Director on 06/05/13 at 7:00 p.m. for Prozac 20 mg one each morning for 2 days then increase to 20 mg two each morning, Effexor XR 75 mg one every morning, Topamax 25 mg one twice a day for 2 days then 50 mg one twice a day. There was no documented evidence that the route of administration was ordered by S9Medical Director, and there was no documented evidence of a clarification order obtained by the nurses before these medications were administered.

Review of Patient #10's MARs revealed the following medications were administered without a physician's order for the route of administration:
Prozac 20 mg orally at 8:00 a.m. on 06/06/13 and 06/07/13;
Prozac 20 mg two capsules given orally in the morning on 06/08/13, 06/09/13, and 06/10/13;
Effexor XR 75 mg given orally in the morning on 06/06/13, 06/07/13, 06/08/13, 06/09/13, and 06/10/13;
Topamax 25 mg one given orally at 8:00 a.m. on 06/06/13 and at 8:00 p.m. on 06/06/13 and 06/07/13;
Topamax 50 mg one given orally in the morning and evening on 06/08/13 and 06/09/13.

Patient #11
Review of Patient #11's medical record revealed she was a [AGE] year old female admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]'d on 02/06/13 at 11:48 a.m. secondary to being gravely disabled.

Review of Patient #11's "Physician Orders" revealed an order written by S9Medical Director on 02/05/13 at 5:30 p.m. for Seroquel 25 mg one at bedtime, Thorazine 10 mg one at bedtime, and Trazodone 50 mg one at bedtime. Further review revealed no documented evidence that the route of administration was ordered by S9Medical Director, and there was no documented evidence of a clarification order obtained by the nurses before these medications were administered.

Review of Patient #11's MAR revealed she received Seroquel 25 mg and Trazodone 50 mg orally at 8:00 p.m. on 02/05/13 with no physician orders for the route that the medication was to be given.

In a face-to-face interview on 08/26/13 at 2:50 p.m., S2DON confirmed the medication order for Patient #9 was incomplete. She indicated that the nurses were supposed to check the patient's vital signs before administering Librium. She further indicated that all medication orders were supposed to include the route of administration, and when it was written by the physician, the nurse was supposed to obtain a clarification order before administering the medication. S2DON indicated that she had an in-service with the nurses at which time they were told if a medication was not available, the nurse was to call the pharmacist to get it or to check with the physician for a substitution. She further indicated that the nurses were told that they should never document that that a medication was not available. S2DON confirmed that medication variance reports were not completed on the above identified medication errors. She indicated that she did chart audits, but no documentation of chart audit results were presented during the survey.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observations, record reviews, and interviews, the hospital failed to ensure the infection control officer implemented measures to prevent and control infections and communicable diseases as evidenced by failure to maintain a sanitary hospital environment. Findings:

Review of the hospital policy titled "Sanitation", policy number 6.4, approved 05/12, and presented as a current policy by S2Director of Nursing (DON), revealed that the Safety Officer/Activity Director will ensure that the hospital follows all sanitation codes by conducting periodic inspections of the hospital. Sanitation practices regarding the regular cleaning and sanitizing of bathrooms and all living areas, furniture fixtures, and equipment will be governing strictly by policies and procedures established within the Housekeeping Department of Company A. Apollo Behavioral Health Hospital is responsible for periodic cleaning and maintaining the medical equipment.

Review of the hospital policy titled "Sterile Supplies and equipment", policy number 6.5, approved 05/12, and presented as a current policy by S2DON, revealed that the DON or her designee was responsible for the implementation of procedures in the hospital. Further review revealed the DON would ensure compliance with hospital regulations regarding the following:
1) receipt, cleaning, disinfecting, and preparation of reusable supplies;
2) assembly, wrapping, identification, storage, and distribution of supplies;
3) monitoring and inventory control of the shelf life and expiration date of supplies, as well as the removal from use of expired supplies;
4) acquisition of supplies;
5) cleaning and sanitizing of all work spaces;
6) regular inspection of the areas pertaining to the use and storage of sterile supplies.

Review of the "Support Services Agreement" between the hospital and Company A revealed that Company A would provide the following housekeeping and cleaning services within the hospital on a daily basis: rubbish removal; dusting of furniture, fixtures and equipment; dry mopping or wet mopping of uncarpeted floors; vacuuming of carpeted floors; washing and cleaning of bathroom fixtures and water fountains; wet mopping of bathroom floors; and filling of toilet tissue holders, soap dispensers, and towel dispensers. Company A would provide housekeeping and cleaning services within all common areas of the hospital.

Observation on 08/20/13 at 11:10 a.m. of the supply storage area, with S2DON present, revealed the following used single-patient items on the shelf ready for re-use:
10 (of 16 available) 8 fluid ounces Shampoo and Body Wash with faded and crumpled wrappings and dried contents around the cap of the container;
2 ounces of used Fixodent Food Seal with squeezed areas on the tube and placed in the cardboard container;
Equate 100% (per cent) pure petroleum jelly with 2/3 of the contents missing;
1 open box (40 count) of Kleenex;
1 used can of 14 ounces Shave Cream.
Further observation revealed 1 box (50 count) of 1/8 inch by 3 inch Steri-Strips had expired 09/12.
S2DON confirmed the above observations during the tour.

Observation of the seclusion/restraint room on 08/20/13 at 11:40 a.m. with S2DON present revealed 1 restraint and the strap attached to the bed had dried brown substance on it. Further observation revealed the wall and floor tile in the corner of the room near the soiled restraint had a dried brown substance on them. During the observation S2DON indicated she didn't know what the substance was. Observation revealed the container of hand sanitizer was empty.

In a face-to-face interview in the seclusion/restraint room on 08/20/13 at 11:45 a.m., S2DON wiped the mattress of the restraint bed that resulted in the towel being light beige in color after wiping the mattress. Further observation revealed the towel was brownish-yellow in color when S2DON wiped the soiled wall. S2DON indicated the hospital's housekeeping service was contracted with Company A who was responsible to clean the seclusion/restraint room after use. She further indicated if Company A's staff wasn't present (worked 7 days a week from 7:00 a.m. to 6:00 p.m.), the hospital staff was responsible for cleaning soiled surfaces.

Observation in the room with a label of "Quiet Activity Room" on 08/20/13 at 11:50 a.m. revealed 3 wheelchairs that were either soiled, had tape applied to the leather, rusted metal wheels, and/or a hole on the arm cushion. Further observation revealed the treatment bed had stains on the mattress.

In a face-to-face interview on 08/20/13 at 11:50 a.m., S1Administrator indicated the "Quiet Activity Room" was currently being used for storage. He further indicated 2 of the 3 wheelchairs and the treatment bed had just been obtained from an outpatient facility and had not been checked or cleaned yet. He indicated that a sign should have been placed to ensure that staff knew not to use the dirty equipment. He further indicated that Company A had not been informed of the need to clean this equipment as of the time of this observation and interview.

In a face-to-face interview on 08/20/13 at 2:00 p.m., S4Human Resource Coordinator indicated that she was responsible to place orders and stock the storage room. She further indicated that the shampoo had recently come in damaged by some of the tops of the containers being open. She indicated that cleaned the tops of the containers that were still closed and placed them on the shelf. S4Human Resource Coordinator indicated she didn't send the damaged supplies back but only called to report the damage. She further indicated the company was supposed to send her replacements.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observations, record reviews, and interviews, the hospital failed to meet the requirements for the Condition of Participation for Nursing Services as evidenced by:

1) Failing to ensure patient medications were administered according to physician orders and hospital policies for 9 of 11 sampled patients (#1, #2, #5, #6, #7, #8, #9, #10, #11). This resulted in 113 medication errors being identified during the survey that had not been identified by the hospital. (See findings in tag A0405)

2) Failing to ensure the registered nurse (RN) supervised and evaluated the nursing care of each patient.

a) The RN failed to ensure that patients were observed by the mental health tech (MHT) according to physician's orders and hospital policy for 1 of 1 patient with physician orders for visual contact (#3) from a sample of 11 patients and for 1of 11 sampled patients (#5) and 1 of 5 random patients (R4) with physician orders for suicide precautions.

b) The RN failed to obtain a clarification order when a patient's level of observation was not ordered for a patient upon admit for 3 of 11 sampled patients (#2, #4, #9).

c) The RN failed to assess a patient's blood glucose by performing Accuchecks (test to assess a patient's blood glucose by a finger-stick) as ordered by the physician for 2 of 2 patients with orders for Accuchecks from a sample of 11 patients (#2, #7).

d) The RN failed to assess a patient with complaints of dizziness for 1 of 1 patient observed who reported being dizzy to the MHT and then to the RN from a sample of 11 patients (#3).

e) The RN failed to notify the physician after assessing a patient's suicide risk to be over the score of 12 (a score greater than 12 should be considered for increased acuity level or additional precautions) for 2 of 11 sampled patients (#5, #6).

f) The RN failed to assess the effectiveness of PRN (as needed) medications as required by hospital policy for 4 of 11 sampled patients (#1, #2, #6, #7).
(See findings in tag A0395)

3) Failing to ensure that patient care was assigned to nursing personnel who had been evaluated for competency to perform the duties assigned to them for 4 of 5 RNs' (registered nurse) personnel files reviewed from a total of 18 employed RNs (S5, S6, S8, S19) and 3 of 3 MHTs' personnel files reviewed from a total of 24 employed MHTs (S7, S15, S18).
(See findings in tag A0397)
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, record reviews, and interviews, the hospital failed to ensure that nursing services had an adequate number of MHTs (mental health techs) to provide patient observations as ordered by the physician and to meet the hospital's staffing plan policy for MHT-to-patient ratio for 2 of 23 days that staffing assignments were reviewed in August 2013. Findings:

Review of the hospital's policy titled "Assignment of Patient Care", policy number 3.2, approved 05/12, and presented as the current policy for staffing by S2DON (Director of Nursing), revealed that the charge nurse was responsible for determining the patient assignments based on the needs of the patients as determined by the nurse in order to provide continuity of care. Further review revealed that patient assignments could be revised as a change in the patient's status occurs. In the event that staffing needs changed based on acuity levels and patients' needs, the charge nurse could call in added staff. Review of the entire policy revealed no documented evidence of how the nurse would determine patient acuity to know when to call in additional staff.

Review of the hospital policy titled "Suicide Precautions", policy number 16.3, approved 05/12, and presented by S2DON (Director of Nursing) as a current policy, revealed that visual contact observation was ordered when the patient was assessed to be more capable of implementing suicide. Nursing interventions for visual contact observation required that the patient be within the staff member's visual field at all times, placed in a multiple patient room, be accompanied to the bathroom, have daily room searches, and have staff accompaniment for medical emergencies.

Review of the hospital's "Staffing Plan" submitted by S2DON revealed the MHT-to-patient ratio on the day shift (7:00 a.m. to 7:00 p.m.) for a census of 15 to 18 patients was 1 MHT to 5-6 patients (3 MHTs).

Review of the "MHT Daily Assignment" for the day shift for 08/20/13 and 08/21/13 revealed each day had 2 MHTs assigned to observe 8 patients, each with 2 more patients that the staffing plan allowed.

Review of Patient #3's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of Schizoaffective Disorder Bipolar Type. He had a Physician Emergency Certificate (PEC) signed on 08/15/13 at 9:45 p.m. secondary to being suicidal, dangerous to self, and gravely disabled. He had a Coroner's Emergency Certificate (CEC) signed on 08/16/13 at 2:45 p.m. secondary to being a danger to self and gravely disabled. Review of his "Physician Admit Orders & Problem List" revealed VC and CO were circled and SP (suicide precautions) was written in the space for "Precaution." Review of Patient #3's physician orders from admit to the time of the observations on 08/21/13 revealed no documented evidence of a physician's order to discontinue Patient #3's visual contact observation

Observation on 08/21/13 at 11:45 a.m. of the whiteboard located in the nursing station that was used to list patients by room number with their admitted , date of PEC and CEC, diagnosis, and level of observation revealed that Patient #3 was on visual contact and suicide precautions and Patients #5 and R4 were on close observation and suicide precautions.

In a face-to-face interview on 08/21/13 at 11:45 a.m., S6RN was asked what "VC" meant under the level of observation. She answered "I don't know." After reviewing Patient #3's medical record, S6RN indicated "VC" meant visual contact.

In a face-to-face interview on 08/21/13 at 10:55 a.m., S7MHT, while standing in the hall that contained the patients' rooms, indicated she was assigned the observation of 8 patients, one of whom was Patient #3. She further indicated that Patient #3 was in a group at this time that was being led by the Certified Therapeutic Recreational Specialist.

Observation on 08/21/13 at 11:02 a.m. revealed that Patient #3 walked to the nursing station and requested his insulin injection. Further observation revealed that Patient #3 was alone, and there was no evidence of a MHT present with him. S7MHT was observed at this time walking down the hall in the opposite direction of the nursing station with her back to Patient #3.

Observation on 08/21/13 at 11:04 a.m. revealed Patient #3 walked into Room "a" (his bed was the first bed near the door upon entering the room) and remained in the room for 2 minutes without a staff member having Patient #3 within their visual field as required by hospital policy.

Observation on 08/21/13 at 11:06 a.m. revealed Patient #3 exited Room "a" and ambulated in the hall toward the nursing station. S7MHT came out of a room, spoke with Patient #3, turned her back to Patient #3, and began to walk toward the nursing station while Patient #3 walked in the opposite direction toward Room "a".

Observation on 08/21/13 at 1:00 p.m. revealed Patient #3 was lying in his bed in Room "a" with the door closed leaving a 4 inch crack that allowed one to see Patient #3 in his bed. There was no staff member at this time who had Patient #3 within their visual field as required by hospital policy.

In a face-to-face interview on 08/21/13 at 1:12 p.m., S7MHT showed Patient #3's observation sheet to the surveyor and indicated that the observation sheet listed Patient #3 as being on close observation and not visual contact. She indicated that S6RN told her earlier today that Patient #3 was under visual contact. She further indicated that she had been observing a patient during her shower and couldn't leave the patient unattended, then had to watch another patient while the patient was on the phone, and S15MHT was outside with other patients while they were on a smoke break. S7MHT asked the surveyor how she could observe a patient who was supposed to be under visual contact while being assigned to watch 7 other patients.

In a face-to-face interview on 08/26/13 at 2:50 p.m., S2DON confirmed that 1 MHT assigned to observe 8 patients did not meet the hospital's staffing plan. When asked how the nurse determined that an increase in staff was needed, S2DON indicated they look at situations where the patient may be more aggressive, a patient may need 1:1 (1 staff to 1 patient) monitoring, there may be medical needs, or the patient may need assistance with performing activities of daily living. She indicated that there was no tool to use to measure patient acuity, and it was determined by the nurse's judgment.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, record reviews, and interviews, the hospital failed to ensure that the registered nurse (RN) supervised and evaluated the nursing care of each patient as evidenced by:

1) The RN failed to ensure that patients were observed by the mental health tech (MHT) according to physician's orders and hospital policy for 1 of 1 patient with physician orders for visual contact (#3) from a sample of 11 patients and for 1of 11 sampled patients (#5) and 1 of 5 random patients (R4) with physician orders for suicide precautions.

2) The RN failed to obtain a clarification order when a patient's level of observation was not ordered for a patient upon admit for 3 of 11 sampled patients (#2, #4, #9).

3) The RN failed to assess a patient's blood glucose by performing Accuchecks (test to assess a patient's blood glucose by a finger-stick) as ordered by the physician for 2 of 2 patients with orders for accu-checks from a sample of 11 patients (#2, #7).

4) The RN failed to assess a patient with complaints of dizziness for 1 of 1 patient observed who reported being dizzy to the MHT and then to the RN from a sample of 11 patients (#3).

5) The RN failed to notify the physician after assessing a patient's suicide risk to be over the score of 12 (a score greater than 12 should be considered for increased acuity level or additional precautions) for 2 of 11 sampled patients (#5, #6).

6) The RN failed to assess the effectiveness of PRN (as needed) medications as required by hospital policy for 4 of 11 sampled patients (#1, #2, #6, #7).

7) The RN failed to ensure abnormal lab specimens results were reported timely to the physician for 1 of 11 sampled patients reviewed with orders for labs (#3).

8) The RN failed to assess a patient's vital signs prior to administering Librium as ordered by the physician for 1 of 1 patient's record reviewed with orders for Librium from a sample of 11 patients (#6).

9) The RN failed to obtain an order for elopement precautions when the patient was assessed as an elopement risk for 1 of 1 patient's record reviewed who was assessed as an elopement risk from a sample of 11 patients (#11). This resulted in Patient #11 being able to elope when outside the hospital on a smoke break.
Findings:

1) The RN failed to ensure that patients were observed by the MHT according to physician's orders and hospital policy:

Review of the hospital policy titled "Suicide Precautions", policy number 16.3, approved 05/12, and presented by S2DON (Director of Nursing) as a current policy, revealed that an order for suicide precautions will be written by the attending psychiatrist and will include the degree of staff supervision and patient restriction.

Further review revealed that discontinuation of suicide precautions would occur only by physician order. Close observations for suicide precautions were to be re-evaluated and renewed daily with a psychiatrist's order.

Review of the policy revealed that guidelines for suicide assessment included 3 levels of observation: close observation, visual contact, and one-to-one (1:1) constant observation.

Close observation was ordered when the patient was assessed to be in minimal danger of implementing suicide. Nursing interventions for close observation required the patient to be checked every 15 minutes with frequent verbal contact during waking hours and 1:1 staff accompaniment for any necessary out-of-hospital activity.

Visual contact observation was ordered when the patient was assessed to be more capable of implementing suicide. Nursing interventions for visual contact observation required that the patient be within the staff member's visual field at all times, placed in a multiple patient room, be accompanied to the bathroom, have daily room searches, and have staff accompaniment for medical emergencies.

Review of the entire policy revealed no documented evidence whether a patient on suicide precautions could remain in their room with the door closed.

Review of the "Physician Admit Orders & (and) Problem List" revealed that the orders included "Precaution: 1:1 VC (visual contact) CO (close observation) Q15 (every 15 minutes) (circle one)."

Patient #3
Review of Patient #3's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of Schizoaffective Disorder Bipolar Type. He had a Physician Emergency Certificate (PEC) signed on 08/15/13 at 9:45 p.m. secondary to being suicidal, dangerous to self, and gravely disabled. He had a Coroner's Emergency Certificate (CEC) signed on 08/16/13 at 2:45 p.m. secondary to being a danger to self and gravely disabled. Review of his "Physician Admit Orders & Problem List" revealed VC and CO were circled and SP (suicide precautions) was written in the space for "Precaution." Review of Patient #3's physician orders from admit to the time of the observations on 08/21/13 revealed no documented evidence of a physician's order to discontinue Patient #3's visual contact observation

Observation on 08/21/13 at 11:45 a.m. of the whiteboard located in the nursing station that was used to list patients by room number with their admitted , date of PEC and CEC, diagnosis, and level of observation revealed that Patient #3 was on visual contact and suicide precautions and Patients #5 and R4 were on close observation and suicide precautions.

In a face-to-face interview on 08/21/13 at 11:45 a.m., S6RN was asked what "VC" meant under the level of observation. She answered "I don't know." After reviewing Patient #3's medical record, S6RN indicated "VC" meant visual contact.

In a face-to-face interview on 08/21/13 at 10:55 a.m., S7MHT, while standing in the hall that contained the patients' rooms, indicated she was assigned the observation of 8 patients, one of whom was Patient #3. She further indicated that Patient #3 was in a group at this time that was being led by the Certified Therapeutic Recreational Specialist.

Observation on 08/21/13 at 11:02 a.m. revealed that Patient #3 walked to the nursing station and requested his insulin injection. Further observation revealed that Patient #3 was alone, and there was no evidence of a MHT present with him. S7MHT was observed at this time walking down the hall in the opposite direction of the nursing station with her back to Patient #3.

Observation on 08/21/13 at 11:04 a.m. revealed Patient #3 walked into Room "a" (his bed was the first bed near the door upon entering the room) and remained in the room for 2 minutes without a staff member having Patient #3 within their visual field as required by hospital policy.

Observation on 08/21/13 at 11:06 a.m. revealed Patient #3 exited Room "a" and ambulated in the hall toward the nursing station. S7MHT came out of a room, spoke with Patient #3, turned her back to Patient #3, and began to walk toward the nursing station while Patient #3 walked in the opposite direction toward Room "a".

Observation on 08/21/13 at 1:00 p.m. revealed Patient #3 was lying in his bed in Room "a" with the door closed leaving a 4 inch crack that allowed one to see Patient #3 in his bed. There was no staff member at this time who had Patient #3 within their visual field as required by hospital policy.

In a face-to-face interview on 08/21/13 at 1:12 p.m., S7MHT showed Patient #3's observation sheet to the surveyor and indicated that the observation sheet listed Patient #3 as being on close observation and not visual contact. She indicated that S6RN told her earlier today that Patient #3 was under visual contact. She further indicated that she had been observing a patient during her shower and couldn't leave the patient unattended, then had to watch another patient while the patient was on the phone, and S15MHT was outside with other patients while they were on a smoke break. S7MHT asked the surveyor how she could observe a patient who was supposed to be under visual contact while being assigned to watch 7 other patients.

Patient #5
Review of Patient #5's medical record revealed she was a [AGE] year old female admitted on [DATE] with a diagnosis of depression with Suicide Ideations. Further review revealed she was PEC'd on 08/16/13 at 6:15 p.m. secondary to being suicidal and a danger to herself. She was CEC'd on 08/19/13 at 7:10 a.m. secondary to being a danger to herself and gravely disabled. Review of Patient #5's "Physician Admit Orders & Problem List" revealed she had orders to be on close observation every 15 minutes and suicide precautions.

Patient R4
Review of Patient R4's medical record revealed she was a [AGE] year old female admitted on [DATE] at 7:45 a.m. with diagnoses of Anxiety and Impulse Control Disorder. She was PEC'd on 08/17/13 at 12:45 a.m. secondary to being suicidal and a danger to self. She was CEC'd on 08/19/13 at 7:05 a.m. secondary to being a danger to self and gravely disabled. Review of her "Physician Admit Orders & Problem List" revealed she had orders for close observation and suicide precautions.

In a face-to-face interview on 08/21/13 at 2:30 p.m., S7MHT indicated that patients were only allowed in their room with the door closed if they were not suicidal and not on suicide precautions.

Observation on 08/22/13 at 9:50 a.m. revealed Patient R4 (who was on suicide precautions) was in her room (Room "b") with the light off and the door closed with a 3 inch crack in it (her bed was the bed near the window which did not allow her to be seen through the crack in the door). Further observation revealed Patient #5 (who was on suicide precautions) was in Room "c" with the door closed.

In a face-to-face interview on 08/22/13 at 10:00 a.m., S2DON indicated that patients who have orders for suicide precautions can be in their room, but the door is usually left open so the patient can be observed during every 15 minutes rounds by the MHTs. She further indicated that the suicide precautions policy did not address whether the patients' doors could be closed if they were on suicide precautions, but it was hospital protocol to keep the room doors open. During the interview S2DON was requested to accompany the surveyor down the hall to have the above observation confirmed, and S2DON indicated that she would be there in a moment.

In a face-to-face interview on 08/22/13 at 10:03 a.m., S7MHT confirmed that Patient #5 was in her room with the door closed, and Patient R4 was in her room with a 3 inch crack in the door.

In a face-to-face interview on 08/22/13 at 11:05 a.m., S2DON entered Room "d" with the surveyor. S2DON took a bed sheet, tied one end around the handle of the door to the bathroom, draped the bed sheet over the top of the door, and was able to pull the bed sheet without it releasing from the door knob. She indicated that it was possible for a patient to hang himself/herself using the bed sheet if left unattended in the patient's room.

In a face-to-face interview on 08/26/13 at 2:50 p.m., S2DON indicated that there was no means of determining that the MHTs observed patients as ordered by the physician and according to hospital policy other than by visually observing the MHTs. She further indicated the MHTs' patient observation sheets did not have a place for the RN to sign that they had reviewed it, and there was no hospital policy that required this to be done.

2) The RN failed to obtain a clarification order when a patient's level of observation was not ordered for a patient upon admit:

Review of the "Physician Admit Orders & Problem List" revealed that the orders included "Precaution: 1:1 VC CO Q15 (circle one)."

Patient #2
Review of Patient #2's medical record revealed she was a [AGE] year old female admitted on [DATE] with diagnoses of Depression and Drug Overdose. She was PEC'd on 08/19/13 at 3:36 a.m. secondary to being suicidal, a danger to herself, and attempting suicide by taking 10 Ativan 1 mg tablets. Review of her "Physician Admit Orders & Problem List" revealed no documented evidence that her observation level was ordered by the physician, and there was no documented evidence of a clarification order by the nurse designating what Patient #2's observation level should be.

Patient #4
Review of Patient #4's medical record revealed she was a [AGE] year old female admitted on [DATE] with diagnoses of Depression and Suicidal Ideations. She was PEC'd on 08/20/13 at 3:30 p.m. secondary to being suicidal, a danger to self, and gravely disabled. Review of her "Physician Admit Orders & Problem List" revealed no documented evidence that her observation level was ordered by the physician, and there was no documented evidence of a clarification order by the nurse designating what Patient #4's observation level should be.

Patient #9
Review of Patient #9's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of Suicide Attempt. He was PEC'd on 08/18/13 at 5:00 p.m. secondary to being suicidal and a danger to self. He was CEC'd on 08/19/13 at 7:10 a.m. secondary to being a danger to self. Review of his "Physician Admit Orders & Problem List" revealed no documented evidence that his observation level was ordered by the physician, and there was no documented evidence of a clarification order by the nurse designating what Patient #9's observation level should be.

In a face-to-face interview on 08/26/13 at 2:50 p.m., S2DON confirmed the above patients did not have an observation level ordered by the physician. When asked if this meant that the RN determined the level of observation for Patients #1, #4, and #9, S2DON answered "No, the nurse calls the physician." She confirmed there was no documented evidence of a verbal, telephone, or clarification order by the nurse from the physician for the observation level of these patients.

3) The RN failed to assess a patient's blood glucose by performing accu-checks as ordered by the physician:

Review of the hospital policy titled "Standard Hours for Routine Medications", policy number 12.6, approved 05/12, and presented as a current policy by S2DON, revealed that medications ordered to be given BID were administered at 8:00 a.m. and 8:00 p.m. Further review revealed before meal times were 7:00 a.m., 11:00 a.m., and 4:00 p.m., and at bedtime orders were to be given at 8:00 p.m. There was no policy presented that gave a different time related to performing Accuchecks.

Patient #2
Review of Patient #2's medical record revealed she was a [AGE] year old female admitted on [DATE] with diagnoses of Depression and Drug Overdose. She was PEC'd on 08/19/13 at 3:36 a.m. secondary to being suicidal, a danger to herself, and attempting suicide by taking 10 Ativan 1 mg tablets.

Review of Patient #2's "Physician Orders" revealed an order on 08/20/13 at 10:18 a.m. to perform Accuchecks ac and hs (before meals and at bedtime) for 24 hours and to call if the capillary blood glucose was less than 70 or greater than 200.

Review of Patient #2's MAR (medication administration record), "Graphic Flowchart", "Daily Nurse Flow Sheet", and "Multidisciplinary Progress Notes revealed no documented evidence that her blood glucose was assessed by the RN as ordered on [DATE] at 11:00 a.m. and 8:00 p.m. and on 08/21/13 at 7:00 a.m.

In a face-to-face interview on 08/20/13 at 4:20 p.m., S5RN indicated that she would begin checking Patient #2's blood glucose this evening, because she "missed it at noon I got distracted." She confirmed that Patient #2's blood glucose should have been assessed at 11:30 a.m.

Patient #7
Review of Patient #7's medical record revealed that she was a [AGE] year old female admitted on [DATE] with a diagnosis of Psychosis. She was PEC'd on 08/12/13 at 10:45 p.m. secondary to being a danger to herself and gravely disabled. She was CEC'd on 08/15/13 at 2:20 p.m. secondary to being gravely disabled.

Review of Patient #7's "Physician Orders" revealed an order on 08/16/13 at 11:30 a.m. to perform Accuchecks BID (twice a day) for 48 hours.

Review of Patient #7's MAR revealed her blood glucose was assessed by the RN on 08/17/13 at 8:00 p.m. and at 6:30 a.m. and 4:30 p.m. on 08/18/13. There was no documented evidence that her blood glucose was assessed at 8:00 p.m. on 08/16/13 and at 8:00 a.m. on 08/17/13 and that it was assessed for 48 hours as ordered by the physician.

In a face-to-face interview on 08/26/13 at 2:50 p.m., S2DON offered no explanation for Patient #7's blood glucose not being assessed as ordered by the physician.

4) The RN failed to assess a patient with complaints of dizziness:
Review of the hospital policy titled "Patient Centered Interdisciplinary Assessment", policy number 2.3, approved 05/12, and presented as the policy by S2DON when the policy for RN assessments was requested, revealed that the policy addressed the RN's assessment at the time of admission and did not address when the RN was to assess the patient after admission.

Review of Patient #3's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of Schizoaffective Disorder Bipolar Type. He had a PEC signed on 08/15/13 at 9:45 p.m. secondary to being suicidal, dangerous to self, and gravely disabled. He had a CEC signed on 08/16/13 at 2:45 p.m. secondary to being a danger to self and gravely disabled.

Observation on 08/21/13 at 11:02 a.m. revealed that Patient #3 approached the nurse in the nursing station requesting his insulin injection. Further observation revealed S8RN administered insulin subcutaneously to Patient #3.

Observation on 08/21/13 at 11:06 a.m. revealed S8RN approached Patient #3 while he was in the hall and asked him if he was "light-headed" (told him that the MHT had reported that Patient #3 had complained of being light-headed). After Patient #3 told S8RN that he was light-headed, S8RN instructed Patient #3 to drink some water. Continuous observation revealed that S8RN never performed a physical assessment of Patient #3 including assessment of his vital signs after he reported being light-headed.

In a face-to-face interview on 08/21/13 at 2:35 p.m., S8RN indicated that she looked at Patient #3 in the eyes and saw he wasn't sweaty or flushed. She further indicated that she knew Patient #3 and with 6 units of Insulin being administered prior to him complaining of dizziness, she didn't think the insulin was a problem. She confirmed that she did not assess his vital signs.

In a face-to-face interview on 08/26/13 at 2:50 p.m., S2DON confirmed that the hospital did not have a policy that addressed the RN's assessment of patients other than at the time of admit.

5) The RN failed to notify the physician after assessing a patient's suicide risk to be over the score of 12 (a score greater than 12 should be considered for increased acuity level or additional precautions):

Review of the "Suicide Risk Assessment" form revealed columns labeled Lower Risk, Mild Risk, Moderate Risk, and Serious Risk. There were 12 items listed to be assessed as risk factors. Further review revealed the following notation: "Scores over 12 should be considered for increased acuity level or additional precautions. Assess for appropriate level of care. Further assessment of risk for self-harm is indicate."

Patient #5
Review of Patient #5's medical record revealed she was a [AGE] year old female admitted on [DATE] with a diagnosis of depression with Suicide Ideations. Further review revealed she was PEC'd on 08/16/13 at 6:15 p.m. secondary to being suicidal and a danger to herself. She was CEC'd on 08/19/13 at 7:10 a.m. secondary to being a danger to herself and gravely disabled.

Review of Patient #5's "Suicide Risk Assessment" performed by S14RN on 08/17/13 at 1:39 a.m. revealed a score of 15. Further review revealed S14RN documented that Patient #5 reported that she drinks a lot of alcohol and used Heroin intravenously for the first time 4 days ago and had attempted suicide 3 weeks ago by drinking "a bunch of bleach." There was no documented evidence that S14RN reported her assessment to S9Medical Director to determine if an increased acuity level or additional precautions were needed.

Patient #6
Review of Patient #6's medical record revealed he was a [AGE] year old male admitted on [DATE] with diagnoses of Depression with Suicide Ideations and Uncontrolled Diabetes Mellitus. Review of his PEC signed on 08/15/13 at 7:30 p.m. revealed Patient #6 was suicidal and a danger to himself. He was CEC'd on 08/16/13 at 2:50 p.m. secondary to being a danger to himself and gravely disabled.

Review of Patient #6's "Suicide Risk Assessment" performed by S14RN on 08/16/13 at 2:42 a.m. revealed a score of 19. There was no documented evidence that S14RN reported her assessment to S9Medical Director to determine if an increased acuity level or additional precautions were needed.

In a face-to-face interview on 08/22/13 at 4:30 p.m., S14RN indicated she asked the patient the questions that are on the suicide risk assessment form. She further indicated her assessment of the patient's lethality and intent of the suicide attempt is based on the answer given by the patient and is not her assessment. She indicated that she speaks with the MHT and talks with the patient during her assessment to decide if the patient is at risk and needs 1:1 observation. She further indicated that she documents her call to the physician by calling for orders and placing the patient on suicide precautions, but she doesn't document what she reports to the physician. S14RN indicated she didn't document her conversation with the physician regarding Patient #6's assessment, but she didn't think he required 1:1 observation.

In a face-to-face interview on 08/22/13 at 1:00 p.m., S9Medical Director indicated that the suicide assessment performed by the nurse should be based on what the patient reports as well as the nurse's observations to verify what is being reported by the patient. He further indicated that there should be documentation of the nurse's report to him when a patient's suicide risk assessment score is greater than 12.

In a face-to-face interview on 08/26/13 at 2:50 p.m., S2DON indicated that the suicide risk assessment tool didn't indicate that the physician needed to be called for a score above 12, but she would have to look at the hospital's policy. S2DON was informed during the interview that a request was made for the hospital's suicide risk assessment, and no policy had been presented as of the time of this interview.

In a face-to-face interview on 08/26/13 at 4:25 p.m., S2DON indicated that the hospital did not have a policy for the patient's suicide risk assessment performed by the RN.

6) The RN failed to assess the effectiveness of PRN medications as required by hospital policy:

Review of the hospital policy titled "Administration of Medication Using Medication Administration Record (MAR) System", policy number 12.1, approved 05/12, and presented as a current policy by S2DON, revealed that the effectiveness of the PRN medications in the nurse's notes and on the back of the MAR was required by hospital policy. Further review revealed no documented evidence that the policy addressed the amount of time after the medication was administered that the effectiveness of the medication had to be assessed.

Patient #1
Review of Patient #1's medical record revealed she was a [AGE] year old female admitted on [DATE] and discharged on [DATE]. Further review revealed her admitting diagnosis was Suicidal Ideation. She had a PEC signed on 06/09/13 at 12:10 a.m. secondary to being suicidal (history of depression complaining of a suicide attempt by taking 1 Phenergan tablet, 6 Xanax tablets, 2 Lortab tablets, and 3 Neurontin tablets) and a danger to herself. Her CEC was signed on 06/10/13 at 5:58 p.m. secondary to Patient #1 being gravely disabled.

Review of Patient #1's "Physician Orders" revealed an order on 06/10/13 at 8:00 a.m. for Lortab 7.5 mg by mouth now and every 6 hours PRN pain. Review of her MAR revealed that Lortab 7.5 mg was given orally on 06/10/13 at 9:55 a.m. and 9:14 p.m. with no documented evidence that the effectiveness of the medication was assessed by the RN.

Patient #2
Review of Patient #2's medical record revealed she was a [AGE] year old female admitted on [DATE] with diagnoses of Depression and Drug Overdose. She was PEC'd on 08/19/13 at 3:36 a.m. secondary to being suicidal, a danger to herself, and attempting suicide by taking 10 Ativan 1 mg tablets.

Review of Patient #2's "Physician Orders" revealed an order on 08/19/13 at 3:15 p.m. for Lortab 10 mg orally TID PRN pain. Review of her MAR revealed Patient #2 received Lortab 10 mg orally on 08/20/13 at 8:20 a.m. with no documented evidence that the effectiveness of the medication was assessed by the RN.

Patient #6
Review of Patient #6's medical record revealed he was a [AGE] year old male admitted on [DATE] with diagnoses of Depression with Suicide Ideations and Uncontrolled Diabetes Mellitus. Review of his PEC signed on 08/15/13 at 7:30 p.m. revealed Patient #6 was suicidal and a danger to himself. He was CEC'd on 08/16/13 at 2:50 p.m. secondary to being a danger to himself and gravely disabled.

Review of Patient #6's "Physician Admit Orders & Problem List" dated 08/16/13 at 12:48 a.m. revealed an order for Antacid 30 ml (milliliters) by mouth every 6 hours PRN complaints of gastric distress. Review of his "Physician Orders" revealed an order dated 08/18/13 at 9:20 p.m. for Benadryl 25 mg by mouth every 6 hours PRN allergies/itching. Review of Patient #6's MAR revealed he received Antacid 30 ml by mouth on 08/18/13 at 9:23 p.m. and on 08/21/13 at 12:05 p.m. with no documented evidence that the effectiveness of the medication for each administration was assessed by the RN. Further review revealed he received Benadryl 25 mg orally on 08/18/13 at 9:23 p.m. with no documented evidence that the effectiveness of the medication was assessed by the RN.

Patient #7
Review of Patient #7's medical record revealed that she was a [AGE] year old female admitted on [DATE] with a diagnosis of Psychosis. She was PEC'd on 08/12/13 at 10:45 p.m. secondary to being a danger to herself and gravely disabled. She was CEC'd on 08/15/13 at 2:20 p.m. secondary to being gravely disabled.

Review of Patient #7's "Physician Orders" revealed an order on 08/15/13 at 10:48 p.m. for Ambien 5 mg by mouth at bedtime PRN (no documented evidence of the indication for use). Review of her MAR revealed Ambien 5 mg was given orally on 08/15/13 at 10:50 p.m. with no documented evidence that the effectiveness of the medication was assessed by the RN.

In a face-to-face interview on 08/26/13 at 2:50 p.m., S2DON indicated the hospital policy for assessing the effectiveness of medications did not address the time interval after the medication was administered that the nurse had to assess its effectiveness. She further indicated that it "usually is 30 minutes to 1 hour depending on the medication." She confirmed that the above PRN medications were not assessed for effectiveness by the nurse.

7) The RN failed to ensure abnormal lab specimen results were reported timely to the physician:
Review of Patient #3's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of Schizoaffective Disorder Bipolar Type. He had a PEC signed on 08/15/13 at 9:45 p.m. secondary to being suicidal, dangerous to self, and gravely disabled. He had a CEC signed on 08/16/13 at 2:45 p.m. secondary to being a danger to self and gravely disabled.

Review of Patient #3's "Physician Admit Orders & Problem List" dated 08/16/13 at 12:09 a.m. revealed orders for a Hemoglobin A1C and a Valproic Acid (Depakote) level to be drawn.

Review of Patient #3's lab results revealed blood was collected for both tests on 08/16/13 at 6:30 a.m. Review of the Hemoglobin A1C result revealed the result was 7.5 H (high) (normal value 3.8 - 7.0), the result was printed on 08/16/13 at 10:46 a.m., and the abnormal value was reported to the nurse practitioner by S6RN on 08/16/13 at 4:30 p.m., 5 hours and 44 minutes after the result was received. Review of the Valproic Acid result revealed the result was 32.8 L (low) (normal value 50.0 - 100.0), the result was printed on 08/16/13 at 11:06 a.m., and the abnormal value was reported to S9Medical Director on 08/16/13 at 5:00 p.m., 5 hours and 54 minutes after the result was received.

In a face-to-face interview on 08/26/13 at 2:50 p.m., S2DON indicated the accuracy of the time that the results were printed depended on which printer was used to print lab results. She further indicated the printer in the nursing station sometimes has the wrong time. She further indicated if S1Administrator is made aware of the time being off, he would make the necessary adjustments to the printer.

8) The RN failed to assess a patient's vital signs prior to administering Librium as ordered by the physician:

Review of Patient #6's medical record revealed he was a [AGE] year old male admitted on [DATE] with diagnoses of Depression with Suicide Ideations and Uncontrolled Diabetes Mellitus. Review of his PEC signed on 08/15/13 at 7:30 p.m. revealed Patient #6 was suicidal and a danger to himself. He was CEC'd on 08/16/13 at 2:50 p.m. secondary to being a danger to himself and gravely disabled.

Review of Patient #6's "Physician Orders" revealed the following written order by S9Medical Director on 08/16/13 at 11:30 a.m.: Librium 100 mg by mouth 1st dose; Librium 50 mg every 6 hours PRN up to 6 doses; Librium 25 mg every 6 hours PRN up to 6 doses; check vital signs before PRN doses. There was no documented evidence of the route of administration for Librium 50 mg and 25 mg, how the nurse was to determine whether to give 50 mg or 25 mg, and the justification (symptoms) for the PRN medication.

Review of Patient #6's MARs revealed Librium 50 mg was administered orally on 08/17/13 at 8:30 a.m., 2:30 p.m., and 8:45 p.m., on 08/18/13 at 2:26 p.m. and 9:00 p.m., and on 08/19/13 at 8:25 a.m. and 3:23 p.m. (total of 7 doses when up to 6 doses was ordered). Further review revealed there was no documented evidence of Patient #6's vital signs prior to the administration of Librium as ordered. Librium 25 mg was administered by mouth on 08/19/13 at 9:00 p.m. and on 08/20/13 at 10:30 p.m., there was no documented evidence of Patient #6's vital signs prior to the administration of Librium as ordered.

In a face-to-face interview on 08/26/13 at 2:50 p.m., S2DON indicated that the physician orders for Patient #6 as well as the hospital's Librium protocol required that the patient's vital signs be assessed before administering Librium. After reviewing Patient #6's medical record, she confirmed that his vital signs were not documented when he was administered Librium.

9) The RN failed to obtain an order for elopement precautions when Patient #11 was assessed as an elopement risk which resulted in Patient #11 being able to elope when outside the hospital on a smoke break:

Review of the hospital policy titled "Elopement Precautions", policy number 8.31, approved 05/12, and presented as the current policy by S1Administrator, revealed that the attending psychiatrist would be notified when a patient presents as an elopement risk, and all personnel would be informed and alerted. Elopement precautions will be ordered by the attending psychiatrist and maintained until the patient is assessed to be no longer at risk. Further review revealed that the patient would be restricted to the hospital, and the frequency of observation would be ordered by the attending psychiatrist. Elopement precautions were to be evaluated and renewed daily with a psychiatrist's order.

Review of Patient #11's medical record revealed she was a [AGE] year old female admitted on [DATE] with diagnoses of Suicidal Ideations, Drug Abuse, and Depression. She was PEC'd on 02/04/13 at 10:00 p.m. secondary to threatening to jump off a bridge, being suicidal, and a danger to herself. She was CEC'd on 02/06/13 at 11:48 a.m. secondary to being gravely disabled. Review of her "Physician Admit Orders & Problem List" dated 02/05/13 at 1:50 p.m. revealed that S9Medical Director ordered her to be on close observation. There was no documented evidence that she was ordered to be on suicide or elopement precautions upon admit and at any time during her hospital stay.

Review of Patient #11's "Multidisciplinary Progress Notes" revealed the following documentation:
02/05/13 at 7:25 p.m. by S16RN - "Pt. (patient) walked up to the door and pushed on it and say the following: "when does this get opened when you are going
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure that the nursing staff developed and kept current a nursing care plan for each patient as evidenced by not including patients' medical problems in their treatment plan, not updating the treatment plan in response to patient assessments, and not stating goals in a manner that can be measured to determine when the patient has met the goal or that the intervention needs to be changed for 6 of 7 patients' records reviewed for nursing care planning from a total sample of 11 patients (#1, #2, #4, #5, #6, #11). Findings:

Review of the hospital policy titled "Conducting Treatment Team Staffing and Master Treatment Plan Reviews", policy number 3.3, approved 05/12, and presented as a current policy by S2DON, revealed that each patient admitted to the hospital was to have an individualized master treatment plan, and the plan was to be updated on a regular basis to guarantee that the patient's progress was monitored throughout the treatment process and that all problems identified were addressed. Changes to the plan were to be made when roadblocks were encountered during the week that prevented the patient from realizing his/her treatment goals, when medical problems were encountered or resolved, and when new treatment issues arose.

Patient #1
Review of Patient #1's medical record revealed she was a [AGE] year old female admitted on [DATE] and discharged on [DATE]. Further review revealed her admitting diagnosis was Suicidal Ideation. She had a PEC signed on 06/09/13 at 12:10 a.m. secondary to being suicidal (history of depression complaining of a suicide attempt by taking 1 Phenergan tablet, 6 Xanax tablets, 2 Lortab tablets, and 3 Neurontin tablets) and a danger to herself. Her CEC was signed on 06/10/13 at 5:58 p.m. secondary to Patient #1 being gravely disabled.

Review of Patient #1's "Psychiatric Evaluation" performed on 06/10/13 at 6:30 p.m. revealed her medical history included Fibromyalgia, Hypertension, and Upper and Lower Back Pain.

Review of Patient #1's admit "Nursing Assessment" performed by S5RN on 06/09/13 at 5:00 p.m. revealed that Patient #1's physical illnesses/disabilities included Gastropareses, Back Pain, and Lupus.

Review of Patient #1's "Daily Nurse's Flow Sheet" revealed that S5RN documented on 06/10/13 at 7:30 a.m. that Patient #1 complained of back pain that radiated to her legs and arms. A physician's order was obtained by S5RN for Lortab 7.5 mg by mouth now and every 6 hours as needed for pain.

Review of Patient #1's "Initial Treatment Plan" initiated by S5RN on 06/09/13 revealed the problems identified and care planned were Suicidal Thoughts and Depression. There was no documented evidence that Patient #1 had a plan of care developed and implemented upon admit for back pain, and it was not revised when complaints of back pain were reported and an order was received for Lortab. Further review revealed the long term goal was that Patient #1 would be able to cope and develop increased skills to handle her life and kids effectively. There was no documented evidence of the manner in which this goal would be measured in order to determine when Patient #1 met this goal. The short term goal developed was that Patient #1 would remain free from harm and discontinue having suicidal ideations throughout her stay and beyond. There was no documented evidence of the manner in which this goal would be measured in order to determine when Patient #1 met this goal.

Patient #2
Review of Patient #2's medical record revealed she was a [AGE] year old female admitted on [DATE] with diagnoses of Depression and Drug Overdose. She was PEC'd on 08/19/13 at 3:36 a.m. secondary to being suicidal, a danger to herself, and attempting suicide by taking 10 Ativan 1 mg tablets.

Review of Patient #2's "History & (and) Physical" performed by S12NP (nurse practitioner) on 08/20/13 at 9:30 a.m. revealed medical diagnoses of Hypokalemia, Hypoglycemic Episode, Hip Pain, and a history of Fibromyalgia.

Review of Patient #2's "Physician Orders" revealed an order on 08/20/13 at 10:18 a.m. to give Lortab TID at 7:00 a.m., 12:00 p.m., and 5:00 p.m. (scheduled dose) and to perform Accuchecks ac and hs (before meals and at bedtime) for 24 hours and to call if the capillary blood glucose was less than 70 or greater than 200.

Review of Patient #2's "Initial Treatment Plan" initiated by S5RN on 08/19/13 at 2:50 p.m. revealed the identified problem was suicidal ideation. There was no documented evidence that her medical problems of Hypoglycemic Episode, Hip Pain, and Fibromyalgia for which nursing interventions were ordered was included in Patient #2's nursing care plan. Further review revealed short term goal was to improve mood, increase coping skills, and alleviate depression. There was no documented evidence of the manner in which this goal would be measured in order to determine when Patient #2 met this goal. Her long term goal was to increase coping skills and improve mood to eliminate thoughts of suicide and increase quality of life. There was no documented evidence of the manner in which this goal would be measured in order to determine when Patient #2 met this goal.

Patient #4
Review of Patient #4's medical record revealed she was a [AGE] year old female admitted on [DATE] with diagnoses of Depression and Suicidal Ideations. She was PEC'd on 08/20/13 at 3:30 p.m. secondary to being suicidal, a danger to self, and gravely disabled.

Review of Patient #4's treatment plan revealed one problem identified was Depression with Suicide Ideation. The goal stated was that Patient #4 would remain free from self-injury and report an increased sense of control over her current situation. There was no documented evidence of the manner in which this goal would be measured in order to determine when Patient #4 met this goal. Further review revealed the problem of risk for airway narrowing and swelling related to a history of asthma had the goal stated as Patient #4 would be free from respiratory distress. There was no documented evidence of the manner in which this goal would be measured in order to determine when Patient #4 met this goal.

Patient #5
Review of Patient #5's medical record revealed she was a [AGE] year old female admitted on [DATE] with a diagnosis of depression with Suicide Ideations. Further review revealed she was PEC'd on 08/16/13 at 6:15 p.m. secondary to being suicidal and a danger to herself. She was CEC'd on 08/19/13 at 7:10 a.m. secondary to being a danger to herself and gravely disabled.

Review of Patient #5's care plan revealed the problems identified were depressed mood with suicidal ideations and urinary tract infection. Further review revealed the goal for depression was that Patient #5's mood would improve, and she would be free of suicidal ideations. There was no documented evidence of the manner in which this goal would be measured in order to determine when her mood would be considered improved. The goal for urinary tract infection was that Patient #5 would be free of infection with no documentation evidence how the nursing staff would determine that she was free of infection.

Review of Patient #5's "Treatment Plan Review and Update" documented on 08/20/13 at 2:40 p.m. revealed no documented evidence of Patient #5's mood, orientation, and thought content as evidenced by these sections being blank without any selection choice being circled.

Patient #6
Review of Patient #6's medical record revealed he was a [AGE] year old male admitted on [DATE] with diagnoses of Depression with Suicide Ideations and Uncontrolled Diabetes Mellitus. Review of his PEC signed on 08/15/13 at 7:30 p.m. revealed Patient #6 was suicidal and a danger to himself. He was CEC'd on 08/16/13 at 2:50 p.m. secondary to being a danger to himself and gravely disabled.

Review of Patient #6's "Physician Orders" revealed a telephone order received from S13Physician by S14RN on 08/16/13 at 2:57 a.m. to perform glucose Accuchecks before meals and at bedtime, and administer Regular Insulin according to S13Physician's sliding scale standing orders. Review of Patient #6's MARs revealed he refused the sliding scale regular Insulin on 08/20/13 at 11:30 a.m. (glucose 157). There was no documented evidence that the physician was notified of Patient #6's refusal to have his sliding scale insulin injection.

Review of Patient #6's nursing care plan revealed his identified problems were depressed mood, suicidal ideations, and diabetes mellitus. Further review revealed the goal for depressed mood was that Patient #6's mood would improve, and the goal for suicidal ideation was that he would be free of suicidal ideation. There was no documented evidence of the manner in which these goals would be measured in order to determine when Patient #6 met the goals. The goal for diabetes was that Patient #6's blood glucose will be within normal limits with no documented evidence of what was considered a normal blood glucose for Patient #6.

Review of Patient #6's "Treatment Plan Review and Update" documented on 08/20/13 at 2:35 p.m. by S5RN revealed that Patient #6 was medication compliant with no documented evidence that a discussion was held related to Patient #6 refusing sliding scale insulin earlier in the day of the treatment plan meeting. Further review revealed no documented evidence of Patient #6's mood, orientation, and thought content as evidenced by these sections being blank without any selection choice being circled.

Patient #11
Review of Patient #11's medical record revealed she was a [AGE] year old female admitted on [DATE] with diagnoses of Suicidal Ideations, Drug Abuse, and Depression. She was PEC'd on 02/04/13 at 10:00 p.m. secondary to threatening to jump off a bridge, being suicidal, and a danger to herself. She was CEC'd on 02/06/13 at 11:48 a.m. secondary to being gravely disabled.

Review of Patient #11's "Multidisciplinary Progress Notes" revealed the following documentation:
02/05/13 at 7:25 p.m. by S16RN - "Pt. (patient) walked up to the door and pushed on it and say the following: "when does this get opened when you are going home?" Pt. redirected about the door. Pt. will be monitored on SP (suicide precautions), EP (elopement precautions), and CO for safety." There was no documented evidence that S16RN reported her assessment of Patient #11 as an elopement risk to S9Medical Director and obtained an order for elopement precautions as required by hospital policy.
02/06/13 at 12:13 p.m. by S17RN - "Pt. remains on SP CO and EP. Safety measures in place..."
02/16/13 at 6:57 p.m. by S17RN - "Patient was on evening smoke break between 5:30 p.m. - 5:45 p.m. pt. got on railing then jumped the brown fence on the patio then went through the gated fence and eloped. MHT preceding around the building to try to recover patient but she was already headed down (name of street where hospital is located)..."

Review of Patient #11's "Master Treatment Plan" revealed her identified problem was Psychosis with Suicidal Ideations. Further review revealed the goals established for this problem included the following: patient will demonstrate the ability to manage issues/symptoms by discharge; patient will exhibit a decrease in delusions and hallucinations and engage in appropriate behavior by discharge; patient will be free from thoughts of self-harm; patient will report feeling more positive about self and others; patient will have no sign of paranoid thoughts and will focus on gaining sobriety and begin the process. There was no documented evidence of the manner in which these goals would be measured in order to determine when Patient #11 would meet her goals. Further review revealed no documented evidence that S16RN and S17RN revised Patient #11's care plan when they assessed her to be at risk for elopement.

In a face-to-face interview on 08/26/13 at 2:50 p.m., S2DON (Director of Nursing) confirmed that the patients' goals were not written in a way that allowed them to be measured. When informed that chart reviews revealed that medical problems had not been included in the nursing care plans and that the care plan updates did not include accurate information, S2DON offered no comment or explanation.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observations, record reviews, and interviews, the hospital failed to meet the requirement for the Condition of Participation for Patient Rights as evidenced by:

1) Failing to ensure that patients received care in a safe setting.

a) The mental health techs (MHTs) failed to observe patients according to physician orders and hospital policy for 1 of 1 patient with physician orders for visual contact (#3) from a sample of 11 patients and for 1of 11 sampled patients (#5) and 1 of 5 random patients (R4) with physician orders for suicide precautions. (See findings in tag A-0144)

b) The hospital failed to maintain bathroom fixtures, ceiling vents, lights, floor drains, ceiling-mounted sprinklers, door knobs to patient bathrooms, plastic garbage liners, and the fire extinguisher covering in a manner to prevent a safety risk for psychiatric patients.(See findings in tag A-0144)

c) The hospital had a wooden ramp in the outdoor patio area with splinters, unattached protruding boards, weather-decayed railing with a deep crater with an exposed nail sticking out the rail, cracked/broken patio table and benches, and multiple items that could be used as projectiles to danger oneself or others.
(See findings in tag A-0144)
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on record reviews and interviews, the hospital failed to ensure that each patient was informed of all patients' rights including those that are required under state regulations prior to furnishing care for 11 of 11 sampled patients (#1 - #11). Findings:

Review of the hospital's "Patient Rights" contained in the "Patient Handbook" presented to patients at admission revealed the following patient rights required by state regulations were not included in the hospital's "Patient Rights":

1) The right to receive treatment and medical services without discrimination based on race, age, religion, national origin, sex, sexual preferences, handicap, diagnosis, ability to pay or source of payment;

2) The right to be informed of the names and functions of all physicians and other health care professionals who are providing direct care to the patient; these people shall identify themselves by introduction and/or by wearing a name tag;

3) The right to receive, as soon as possible, the services of a translator or interpreter to facilitate communication between the patient and the hospital's health care personnel;

4) The right to be included in experimental research only when he or she gives informed, written consent, or when a guardian provides such consent for an incompetent patient; the patient may refuse to participate in experimental research;

5) The right to be informed if the hospital has authorized other health care and/or educational institutions to participate in the patient's treatment, the right to know the identity and function of these institutions, and may refuse to allow their participation in his/her treatment;

6) The right to be informed by the attending physician and other providers of health care services about any continuing health care requirements after his/her discharge from the hospital and receive assistance in arranging for required follow-up care after discharge;

7) The right to examine and receive an explanation of the patient's hospital bill regardless of source of payment, and may receive upon request, information relating to financial assistance through the hospital;

8) The right to be informed of his/her responsibility to comply with hospital rules and be respectful of other patients;

9) The right to be transferred to another facility only with a full explanation of the reason for the transfer, provisions for continuing care, and acceptance by the receiving institution except in emergencies;

10) The right to be informed of patient rights provided in the Louisiana Mental Health Law.

In a face-to-face interview on 08/26/13 at 2:50 p.m., S2Director of Nursing (DON) indicated that she thought the hospital was in compliance with informing patients of their rights. After reviewing the "Patient Handbook," S2DON confirmed that no information was provided to patients regarding the patient rights provided in the Louisiana Mental Health Law.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on record reviews and interviews, the hospital failed to develop a process for the investigation of grievances, failed to document a patient's grievance on a grievance form as required by hospital policy, and failed to keep accurate information of grievances filed for 1 of 1 patient grievance reviewed from a total of 3 grievances submitted in July 2013 (#1). Findings:

Review of the hospital policy titled "Resolution of Complaints/Grievances", policy number 1.36, revised and approved 11/14/12, and presented as the current grievance policy by S1Administrator, revealed the Governing Body is ultimately responsible for the effective operation of the grievance process. Further review revealed that unresolved complaints requiring Administrative intervention should be brought to the attention of the Director of Nursing or Administrator. The complaint, its resolution and verbal or written response to the complainant will be documented on a grievance form for tracking purposes. The final decision for disposition of any incident rests with the Hospital Administrator, the designated agent for the Governing Body. Further review of the policy revealed no documented evidence of the process for investigation of grievances and the process for tracking grievances.

Review of the "Complaint Log" for July 2013, contained in the grievance manual presented by S1Administrator when a list of grievances was requested, revealed a list of 2 complaints. The grievance submitted by Patient #1 was not listed on the log.

Review of the letter sent by S1Administrator to Patient #1's mother dated 07/20/13, presented during the survey by S1Administrator, revealed that there was an investigation of her concerns, policies and patient charts were reviewed, and staff were interviewed. There was no documented evidence presented by the hospital of a completed grievance form related to the issues expressed by Patient #1's mother in the letter dated 07/03/13.

In a face-to-face interview on 08/26/13 at 4:00 p.m., S1Administrator indicated that S2DON (Director of Nursing) had written a letter to Patient #1, and he didn't know why the information on the grievance wasn't in the grievance binder.

In a face-to-face interview on 08/26/13 at 4:50 p.m., S1Administrator confirmed he had no documentation of the investigation of Patient #1's grievance to present.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, record reviews, and interviews, the hospital failed to ensure that patients received care in a safe setting as evidenced by:

1) Failing to ensure that mental health techs (MHTs) observed patients according to physician orders and hospital policy for 1 of 1 patient with physician orders for visual contact (#3) from a sample of 11 patients and for 1of 11 sampled patients (#5) and 1 of 5 random patients (R4) with physician orders for suicide precautions;

2) Having bathroom fixtures, ceiling vents, lights, floor drains, ceiling-mounted sprinklers, door knobs to patient bathrooms, plastic garbage liners, and the fire extinguisher covering that could provide a safety risk for psychiatric patients;

3) Having a wooden ramp in the outdoor patio area with splinters, unattached protruding boards, weather-decayed railing with a deep crater with an exposed nail sticking out the rail, cracked/broken patio table and benches, and multiple items that could be used as projectiles to danger oneself or others.
Findings:

1) Failing to ensure that mental health techs (MHTs) observed patients according to physician orders and hospital policy:

Review of the hospital policy titled "Suicide Precautions", policy number 16.3, approved 05/12, and presented by S2DON (Director of Nursing) as a current policy, revealed that an order for suicide precautions will be written by the attending psychiatrist and will include the degree of staff supervision and patient restriction.

Further review revealed that discontinuation of suicide precautions would occur only by physician order. Close observations for suicide precautions were to be re-evaluated and renewed daily with a psychiatrist's order.

Review of the policy revealed that guidelines for suicide assessment included 3 levels of observation: close observation, visual contact, and one-to-one (1:1) constant observation. Close observation was ordered when the patient was assessed to be in minimal danger of implementing suicide.

Nursing interventions for close observation required the patient to be checked every 15 minutes with frequent verbal contact during waking hours and 1:1 staff accompaniment for any necessary out-of-hospital activity. Visual contact observation was ordered when the patient was assessed to be more capable of implementing suicide. Nursing interventions for visual contact observation required that the patient be within the staff member's visual field at all times, placed in a multiple patient room, be accompanied to the bathroom, have daily room searches, and have staff accompaniment for medical emergencies.

Review of the entire policy revealed no documented evidence whether a patient on suicide precautions could remain in their room with the door closed.

Review of the "Physician Admit Orders & (and) Problem List" revealed that the orders included "Precaution: 1:1 VC (visual contact) CO (close observation) Q15 (every 15 minutes) (circle one)."

Patient #3
Review of Patient #3's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of Schizoaffective Disorder, Bipolar Type.

He had a Physician Emergency Certificate (PEC) signed on 08/15/13 at 9:45 p.m. secondary to being suicidal, dangerous to self, and gravely disabled.

He had a Coroner's Emergency Certificate (CEC) signed on 08/16/13 at 2:45 p.m. secondary to being a danger to self and gravely disabled.

Review of his "Physician Admit Orders & Problem List" revealed VC and CO were circled and SP (suicide precautions) was written in the space for "Precaution." Review of Patient #3's physician orders from admit to the time of the observations on 08/21/13 revealed no documented evidence of a physician's order to discontinue Patient #3's visual contact observation

Observation on 08/21/13 at 11:45 a.m. of the whiteboard located in the nursing station that was used to list patients by room number with their admitted , date of PEC and CEC, diagnosis, and level of observation revealed that Patient #3 was on visual contact and suicide precautions and Patients #5 and R4 were on close observation and suicide precautions.

In a face-to-face interview on 08/21/13 at 11:45 a.m., S6RN was asked what "VC" meant under the level of observation. She answered "I don't know." After reviewing Patient #3's medical record, S6RN indicated "VC" meant visual contact.

In a face-to-face interview on 08/21/13 at 10:55 a.m., S7MHT, while standing in the hall that contained the patients' rooms, indicated she was assigned the observation of 8 patients, one of whom was Patient #3. She further indicated that Patient #3 was in a group at this time that was being led by the Certified Therapeutic Recreational Specialist.

Observation on 08/21/13 at 11:02 a.m. revealed that Patient #3 walked to the nursing station and requested his insulin injection. Further observation revealed that Patient #3 was alone, and there was no evidence of a MHT present with him. S7MHT was observed at this time walking down the hall in the opposite direction of the nursing station with her back to Patient #3.

Observation on 08/21/13 at 11:04 a.m. revealed Patient #3 walked into Room "a" (his bed was the first bed near the door upon entering the room) and remained in the room for 2 minutes without a staff member having Patient #3 within their visual field as required by hospital policy.

Observation on 08/21/13 at 11:06 a.m. revealed Patient #3 exited Room "a" and ambulated in the hall toward the nursing station. S7MHT came out of a room, spoke with Patient #3, turned her back to Patient #3, and began to walk toward the nursing station while Patient #3 walked in the opposite direction toward Room "a".

Observation on 08/21/13 at 1:00 p.m. revealed Patient #3 was lying in his bed in Room "a" with the door closed leaving a 4 inch crack that allowed one to see Patient #3 in his bed. There was no staff member at this time who had Patient #3 within their visual field as required by hospital policy.

In a face-to-face interview on 08/21/13 at 1:12 p.m., S7MHT showed Patient #3's observation sheet to the surveyor and indicated that the observation sheet listed Patient #3 as being on close observation and not visual contact. She indicated that S6RN told her earlier today that Patient #3 was under visual contact. She further indicated that she had been observing a patient during her shower and couldn't leave the patient unattended, then had to watch another patient while the patient was on the phone, and S15MHT was outside with other patients while they were on a smoke break. S7MHT asked the surveyor how she could observe a patient who was supposed to be under visual contact while being assigned to watch 7 other patients.

Patient #5
Review of Patient #5's medical record revealed she was a [AGE] year old female admitted on [DATE] with a diagnosis of depression with Suicide Ideations. Further review revealed she was PEC'd on 08/16/13 at 6:15 p.m. secondary to being suicidal and a danger to herself. She was CEC'd on 08/19/13 at 7:10 a.m. secondary to being a danger to herself and gravely disabled. Review of Patient #5's "Physician Admit Orders & Problem List" revealed she had orders to be on close observation every 15 minutes and suicide precautions.

Patient R4
Review of Patient R4's medical record revealed she was a [AGE] year old female admitted on [DATE] at 7:45 a.m. with diagnoses of Anxiety and Impulse Control Disorder. She was PEC'd on 08/17/13 at 12:45 a.m. secondary to being suicidal and a danger to self. She was CEC'd on 08/19/13 at 7:05 a.m. secondary to being a danger to self and gravely disabled. Review of her "Physician Admit Orders & Problem List" revealed she had orders for close observation and suicide precautions.

In a face-to-face interview on 08/21/13 at 2:30 p.m., S7MHT indicated that patients were only allowed in their room with the door closed if they were not suicidal and not on suicide precautions.

Observation on 08/22/13 at 9:50 a.m. revealed Patient R4 (who was on suicide precautions) was in her room (Room "b") with the light off and the door closed with a 3 inch crack in it (her bed was the bed near the window which did not allow her to be seen through the crack in the door). Further observation revealed Patient #5 (who was on suicide precautions) was in Room "c" with the door closed.

In a face-to-face interview on 08/22/13 at 10:00 a.m., S2DON indicated that patients who have orders for suicide precautions can be in their room, but the door is usually left open so the patient can be observed during every 15 minutes rounds by the MHTs. She further indicated that the suicide precautions policy did not address whether the patients' doors could be closed if they were on suicide precautions, but it was hospital protocol to keep the room doors open. During the interview S2DON was requested to accompany the surveyor down the hall to have the above observation confirmed, and S2DON indicated that she would be there in a moment.

In a face-to-face interview on 08/22/13 at 10:03 a.m., S7MHT confirmed that Patient #5 was in her room with the door closed, and Patient R4 was in her room with a 3 inch crack in the door.

In a face-to-face interview on 08/22/13 at 11:05 a.m., S2DON entered Room "d" with the surveyor. S2DON took a bed sheet, tied one end around the handle of the door to the bathroom, draped the bed sheet over the top of the door, and was able to pull the bed sheet without it releasing from the door knob. She indicated that it was possible for a patient to hang himself/herself using the bed sheet if left unattended in the patient's room.

In a face-to-face interview on 08/26/13 at 2:50 p.m., S2DON indicated that there was no means of determining that the MHTs observed patients as ordered by the physician and according to hospital policy other than by visually observing the MHTs. She further indicated the MHTs' patient observation sheets did not have a place for the RN to sign that they had reviewed it, and there was no hospital policy that required this to be done.

2) Having bathroom fixtures, ceiling vents, lights, floor drains, ceiling-mounted sprinklers, plastic garbage liners, and the fire extinguisher covering that could provide a safety risk for psychiatric patients:

Review of the hospital policy titled "Suicide Precautions", policy number 16.3, approved 05/12, and presented by S2DON (Director of Nursing) as a current policy, revealed that close observation required the patient to be checked every 15 minutes with frequent verbal contact during waking hours and 1:1 staff accompaniment for any necessary out-of-hospital activity. Visual contact observation required that the patient be within the staff member's visual field at all times and be accompanied to the bathroom. 1:1 constant observation required the patient to be within arm's length of a staff member 24 hours a day.

Observation of the patient shower room on 08/20/13 at 11:20 a.m. revealed the following safety risks to patients:

a) 2 loose handrails that were able to be pulled from the wall when testing for stability;

b) Shower heads attached to the shower stall that protruded approximately 12 inches to which towels, linens, or clothing could be attached as a means of hanging;

c) Ceiling vent over the first shower stall had open areas with visible wiring;

d) Fluorescent light had a removable covering that provided access to the fluorescent glass bulbs;

e) Floor drain in the last shower stall had a sinking area from the shower floor to the drain that could provide a fall hazard; floor drain in the middle shower stall had a crack in the seal with an open area;

f) The toilet had a removable lid and had screws attached that were not tamper proof;

g) The sprinkler heads were exposed and offered the opportunity to have a towel, bed linen, or clothing tied to it to be used as a means of hanging; there was a movable chair in the shower room.

Observation on 08/20/13 at 11:20 a.m. of the "Shower Observation Rules for MHTs/Nurses" posted on the wall upon entering the patient shower room revealed that there was to be male-to-male and female-to-female observation only.

Further review revealed that if a patient was on one-to-one (1:1) observation, the staff member needed to be in constant observation of the patient in the shower, the patient could pull the shower curtain, and the staff member needed to have some conversation with the patient "every couple of minutes." If the patient was on close observation the staff member needed to stay inside the shower room at the door behind a curtain and needed to have some conversation with the patient "every couple of minutes." If the patient was on every 15 minutes checks the staff member could stay outside the shower room and "peek in and check on patient every 15 minutes." There was no description how the patient on visual contact would be observed.

In a face-to-face interview on 08/20/13 at 11:20 a.m., S2DON (Director of Nursing) indicated that patients were allowed to be behind the shower curtain with a staff member standing at the door behind a second shower curtain to allow for patient privacy. She offered no explanation when asked how a patient with physician orders to be on 1:1 constant observation or visual contact could be within sight of a staff member when the patient was behind a shower curtain.

In a face-to-face interview on 08/20/13 at 11:35 a.m., S1Administrator indicated the fire sprinkler regulations were for patient sleeping areas only.

Observation of the bathroom in the seclusion room on 08/20/13 at 11:40 a.m. with S2DON present revealed a plastic garbage liner in the trash can.

Observation of the compartment containing the fire extinguisher in the hall across from the seclusion room on 08/20/13 at 11:45 a.m. revealed the plastic covering was loose, and the top portion of the plastic covering was cracked that provided a sharp edge. Further observation revealed the trash can in the activity room used by patients had a plastic liner. These observations were confirmed by S2DON who was present during the tour.

Observation of the dining/noisy activity room on 08/20/13 at 12:00 p.m. revealed 2 garbage cans with plastic liners. This observation was confirmed by S2DON who was present at the time of the observation.

In a face-to-face interview on 08/22/13 at 11:05 a.m., S2DON entered Room "d" with the surveyor. S2DON took a bed sheet, tied one end around the handle of the door to the bathroom, draped the bed sheet over the top of the door, and was able to pull the bed sheet without it releasing from the door knob. She indicated that it was possible for a patient to hang himself/herself using the bed sheet if left unattended in the patient's room.

3) Having a wooden ramp in the outdoor patio area with splinters, unattached protruding boards, weather-decayed railing with a deep crater with an exposed nail sticking out the rail, cracked/broken patio table and benches, and multiple items that could be used as projectiles to danger oneself or others:

Observation on 08/20/13 at 12:10 p.m., with S1Administrator present, of the outdoor patio area used by patients for smoke breaks revealed the following safety risks:

a) A wooden wheelchair-accessible ramp was located at the end of the concrete slab that was at the back exit door of the hospital. The ramp led to a locked portable building. The ramp had wood splinters protruding from multiple areas. One area of the ramp's hand rail was weather-decayed and had a nail protruding from the wood. Part of the bottom rail of the ramp was unattached and protruding into the path where patients could walk.

b) The wooden 8 foot fence surrounding the outside area had a 9 inch by 4 inch oval-shaped opening that had splintered wood around the edges. There were 5 movable chairs located around the perimeter of the fence.

c) A large (approximately 8 inches round) heavy metal disc laying on the patio concrete that could be used as a projectile or used to hit someone or oneself.

d) An umbrella holder that was unsecured and could be lifted and thrown or used to hit someone.

e) A plastic patio table with attached benches had cracks in the table top and the bench that left sharp edges.

In a face-to-face interview on 08/20/13 at 12:10 p.m., S1Administrator indicated that the MHTs did safety rounds every morning. He further indicated that he was the safety officer, and his focus was on non-monitored areas of the hospital. A request was made during the interview to see the hospital's policy on safety rounds. When asked if any patients had ever eloped from the patio area, S1Administrator indicated that Patient #11 had eloped by climbing on the ramp's hand rail and jumped the 8 foot wooden fence. When asked what interventions had been implemented to prevent a future elopement, S1Administrator indicated that he had asked the landlord to raise the height of the fence. He confirmed that this request had not been done as of the time of this interview and observation.

In a face-to-face interview on 08/23/13 at 9:30 a.m., S1Administrator presented the "Maintenance Work Order Form" dated 02/11/13 at 1:16 p.m. requesting that the fence height be increased due to a patient elopement. The areas of the form for work performed, supplies required, anticipated project completion date, status of work, and signature of the person completing the work were blank (evidenced by no writing in any of the spaces). S1Administrator presented the "Life Safety Management" policy as the policy requested related to safety rounds. Review of the policy revealed that it focused entirely on fire safety, other than a statement of "Weekly Unit Safety Check rounds by Safety officer or designee" as the means of maintaining a safe patient care and working environment.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on observation of hospital-provided video surveillance, record reviews, and interviews, the hospital failed to ensure patients were free from all forms of abuse. The hospital failed to ensure staff followed hospital policy for reporting observed patient abuse and patients' reports of verbal abuse for 1 of 1 random patient's observation of abuse and report of verbal abuse from a sample of 11 patients and 5 random patients (R1). Findings:

Review of the hospital policy titled "Patient Abuse and/or Neglect", policy number 2.7, approved 05/12, and presented as the current policy on abuse by S2DON (Director of Nursing), revealed that Class III abuse means any use of verbal or other communication to curse, vilify (to make malicious or abusive statements about someone), or degrade a patient or threaten a patient with physical or emotional harm, or any act which vilifies, degrades, or threatens a patient with physical or emotional harm. Further review revealed that when an incident arises that constitutes possible neglect and/or abuse by a staff member, the following procedure is to be followed:

1) A staff person witnessing or suspecting patient abuse or neglect must report the incident to the DON, and failure to do so may result in termination;

2) The DON will inform the Medical Director and the Administrator;

3) The involved staff person may be suspended pending further investigation;

4) The DON will investigate the incident with the persons involved documenting facts surrounding the abuse or neglect, and an occurrence report will be forwarded to appropriate parties;

5) Incidents of patient abuse and neglect will be reported as defined by state law and hospital policy.

Disciplinary action will be based on a review of the hospital's investigation and/or findings of the investigation conducted by an outside agency. Each employee who has cause to believe that a patient has been or may be adversely affected by abuse or neglect must report the incident promptly to the Administrator or his/her designee. Upon receipt of verbal or written complaint of the alleged patient abuse or neglect, the charge nurse must contact the Administrator, the Physician, and the DON. Within 24 hours after notification the physician is to contact the patient's guardian, if incompetent, interview the patient, staff, and alleged perpetrator, and document the information on the chart. Upon receipt of an occurrence report or complaint of patient abuse or neglect, the Administrator must promptly and objectively investigate the incident by interviewing staff, the alleged perpetrator, and the victim, review documentation, medical records, patient records, and the hospital report, and obtain written statements from witnesses and the alleged perpetrator. The Administrator must report alleged or suspected cases of patient abuse or neglect in accordance with any appropriate laws.

Attached to the hospital policy titled "Patient Abuse and/or Neglect" that was presented by S2DON was a "memorandum" dated 10/27/10 from the Department of Health and Hospitals Health Standards Section. The memorandum stated that all hospital self-reports of allegations of abuse and/or neglect must be submitted to the Department by fax within 24 hours of the facility having knowledge of the allegation. Also attached to the policy was a copy of the Louisiana Revised Statutes Title 40.Public Health and Safety Chapter 11. State Department of Health and Hospitals "2009.20. Duty to make complaints; penalty; immunity... B. (1) Any person who is engaged in the practice of medicine, social services, facility administration, psychological or psychiatric services; or any registered nurse, licensed practical nurse, nurse's aide, home-and community-based service provider employee or worker, personal care attendant, respite worker, physician's assistant, physical therapist, or any other direct caregiver having knowledge that a consumer's physical or mental health or welfare has been or may be further adversely affected by abuse, neglect, or exploitation shall, within twenty-four hours, submit a report to the department or inform the unit of local law enforcement agency of such abuse or neglect."

Review of the hospital policy titled "Selection and Hiring of Personnel", policy number 9.1, approved 05/12, and presented by S2DON as the policy for hiring requirements and competency evaluations of staff, revealed that the hospital prohibits any personnel from engaging in unlawful practices or any form of harassment involving patients, families or co-workers.

Review of the hospital policy titled "Resolution of Complaints/Grievances", policy number 1.36, revised and approved 11/14/12, and presented as the current grievance policy by S1Administrator, revealed that abuse and neglect of the patient was one example of a grievance.

Review of the grievance binder presented by S1Administrator revealed a grievance was written by Patient R1 on 06/21/13 (should have been dated 08/21/13) at 3:30 p.m. Further review revealed that Patient R1 reported that S15MHT had made inappropriate comments to her, and it made her feel uncomfortable. Further review revealed "other actions taken" included that camera films were reviewed, witness statements were taken, and S15MHT was suspended pending the completion of the investigation. The report was signed by S3Risk Manager, Patient R1, and S1Administrator on 06/21/13 (should have been dated 08/21/13) at 5:30 p.m.

Review of all documentation presented by S1Administrator related to the investigation of the abuse of Patient R1 by S15MHT revealed no documented evidence that the witnessed observations and reports of abuse were reported immediately to S1Administrator as required by hospital policy.

In a face-to-face interview on 08/23/13 at 1:30 p.m., S1Administrator indicated that the grievance report submitted by Patient R1 was dated incorrectly by Patient R1, S3Risk Manager, and himself. He further indicated that the date was actually 08/21/13. When asked why he had not notified the surveyors that an allegation of abuse had been reported while the surveyors were conducting the survey, S1Administrator indicated that he wasn't aware that he had to report this allegation to the surveyors and had faxed the "Hospital Abuse / Neglect Initial Report" to the Department of Health and Hospitals (DHH) on 08/22/13 at 5:06 p.m. He confirmed that he was made aware of the allegation on 08/21/13 at 3:30 p.m., and his report to DHH was made more than 1 hour and 36 minutes later than 24 hours after being made aware of the allegation. S1Administrator indicated that after Patient R1 made the report to him on 08/21/13 about 3:25 p.m., he spoke with S20MHT and Patient R5, reviewed the hospital's video surveillance, and suspended S15MHT. He further indicated that he had to interview S15MHT and planned to terminate him and educate the staff on the policy for verbal sexual abuse.

In a face-to-face interview on 08/23/13 at 2:10 p.m., S20MHT indicated that she witnessed the incident of abuse on 08/20/13 regarding S15MHT that was reported by Patient R1 on 08/21/13. She indicated that she was inside the shower room when Patient R1 was getting out the shower and was standing about 3 feet from Patient R1. She further indicated that S15MHT knocked on the door, looked inside the shower room, and asked "who is that?" when he saw Patient R1. S20MHT indicated that Patient R1 was dressed at this time, but her hair was wet and hanging down. She further indicated that S15MHT said "uh, that's Patient R1, she looks different." S20MHT indicated that after S15MHT made the comment she could tell that Patient R1 was uncomfortable. She further indicated that the comment was made in a way that would make a person uncomfortable, and that it made her (S20MHT) feel uncomfortable. S20MHT indicated that what she felt made Patient R1 uncomfortable was that earlier before the shower, Patient R1 and her roommate called S20MHT to their room and reported that S15MHT kept "barging in our room, we could be changing, he doesn't knock." S20MHT indicated that after the report of S15MHT barging in Patient R1's room, she (S20MHT) spoke with S15MHT and told him he needed to knock before entering the female patients' room. S20MHT indicated that S15MHT walked past her and "barged in their room (Patient R1's and her roommate) without knocking." S20MHT indicated that on 08/21/13 reported to her that S15MHT had told her that she was "sexy", and he had made inappropriate comments before, such as asking her "do you know how to suck on (word not stated) till the white stuff comes out?" S20MHT indicated that she didn't report Patient R1's allegations of abuse to the RN but did report it to other MHTs. When asked who her supervisor was, S20MHT answered "it depends, S2DON." She indicated that "everybody knew S15MHT was confrontational and patients didn't like him." S20MHT indicated she knew these incidents were abuse "because it's sexual harassment." She further indicated that the hospital policy required physical, emotional, and verbal abuse be reported to the nurse on duty, the nurse would bring it to S2DON's or S1Administrator's attention, but the MHTs can't go above the nurses to S2DON and S1Administrator.

In a face-to-face interview on 08/23/13 at 3:05 p.m., S18MHT indicated she had never witnessed any abusive treatment of patients by MHTs. She further indicated that patients have voiced complaints about abuse and inappropriate gestures. She indicated that Patient R1 indicated that S15MHT had made inappropriate gestures, and she (S18MHT) told Patient R1 to file a grievance and gave her the form to use. She further indicated that Patient R5 told her that S15MHT had made the comments "pretty girls gone wild" when she wore shorts one day.

In a face-to-face interview on 08/23/13 at 3:15 p.m., S7MHT indicated that Patient R1 was talking about the incident regarding S15MHT in the day room on 08/21/13. She further indicated that Patient R1 said that S15MHT had touched her hair and said she was pretty, and that the day before S15MHT had burst into her room.

Observation of hospital-provided video surveillance for 08/20/13 on 08/23/13 at 4:15 p.m. revealed the following observations:

A.M.:
9:32:16 Patient R1 in Room "d"
9:36:26 S15MHT enters Room "d" (door open) without knocking on door
9:38:48 S15MHT exits Room "d"
9:39:40 Patient R1 exits Room "d"

P.M.:
3:11:00 Patient R1 entered Room "d"
3:13:50 Patient R1 exits Room "d"
3:23:52 S15MHT enters Room "d" without knocking
3:29:13 S15MHT exited Room "d"
3:37:49 Roommate of Patient R1 exits Room "d"
4:14:21 Patient R1 walking toward shower room with S20MHT
4:15:53 Patient R1 enters shower room with S20MHT
4:45:18 S15MHT goes to shower escorting a patient
4:47:17 S15MHT leaves shower area
4:47:21 S15MHT steps back toward shower door and is out of view of camera
4:48:58 Patient R1 exits shower room
4:49:11 S15MHT in camera view leaving shower area
4:49:19 Patient R1 walking down hall with S15MHT walking behind her
4:49:42 Patient R1 enters Room "d"

In a face-to-face interview on 08/26/13 at 4:00 p.m., S1Administrator indicated he had never been told anything by any staff member regarding patient complaints about S15MHT. He further indicated that until a patient reports it as a problem to the MHT, it is only viewed as the patient having a discussion with the MHT. He indicated that he knew there was a problem that nursing was not taking ownership of the patient unit.
VIOLATION: MEDICAL STAFF CREDENTIALING Tag No: A0341
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the medical staff failed to follow its Medical Staff Bylaws for credentialing and privileging physicians and allied health professionals (AHP). The medical staff failed to re-credential physicians and AHPs after the first year of staff membership, ensure physicians' and AHPs licenses were current, check the National Practitioner Data Bank prior to Medical Staff and Governing Body approval, obtain 2 references prior to Medical Staff and Governing Body approval, and/or have physicians and AHPs request and have privileges approved prior to being approved for membership as required by the Medical Staff Bylaws for 2 of 2 physicians' files reviewed from a total of 2 credentialed physicians (S9, S13) and 1 of 1 nurse practitioner's file reviewed from a total of 2 credentialed nurse practitioners (S12). Findings:

Review of the hospital's Medical Staff Bylaws, approved on 05/11/12, revised on 08/10/12, and presented as the current Medical Staff Bylaws by S4Human Resource Coordinator, revealed the following information and processes:

1) The governing body shall act on appointments and reappointments after there has been recommendations from the Medical Staff.

2) Initial appointments shall be made for a period extending to the end of the current medical staff year of the hospital. Reappointments shall be for a period of 2 years.

3) Appointment to the Medical Staff shall confer only such clinical privileges as have been granted by the Governing Body.

4) Request to perform specific patient care services from AHPs shall be processed in the same manner specified as any other person holding a professional license on staff.

5) The AHP may participate directly in the medical management of patients under the supervision of a physician who has been afforded privileges to provide such care and has the ultimate responsibility for the patient's care.

6) All initial appointments shall be provisional until the end of the Medical Staff year, and failure to advance as an appointee from provisional to regular staff status shall be deemed as a termination of Medical Staff appointments.

7) All applications for appointment shall be in writing and signed by the applicant. The name of at least 2 persons who can provide adequate references must be given.

8) The completed application with all the required attachments shall be submitted to the Administrator who will transmit the packet to the Medical Staff for evaluation.

9) The applicant shall provide current copies of licenses issued by the Louisiana State Board of medical Examiners, Federal Drug Enforcement Agency (DEA) Certificate, and Louisiana Controlled Dangerous Substance (CDS) Certificate.

10) The Medical Staff, through the Administrator will forward the completed application, a report of the investigation, and its recommendation to the Governing Body who will make the final decision regarding Medical Staff membership.

11) At least 30 days prior to final scheduled governing body meeting in the Medical Staff year, the Medical Staff shall review all pertinent information available on each practitioner scheduled for reappraisal to determine its recommendations for reappointments to the Medical Staff and granting clinical privileges for the ensuing period.

12) Every practitioner practicing at the hospital shall be entitled to exercise only those clinical privileges specifically granted to him by the governing body. Every initial application for staff appointment must contain a request for the specific clinical privileges desired by the applicant.

S9Medical Director
Review of S9Medical Director's credentialing file revealed he was approved by the Governing Body on 05/10/12. Further review revealed the line reading "Chairperson, Medical Professional Staff" was signed by S1Administrator on 05/10/12, and S1Administrator is not a physician.

Review of S9Medical Director's references revealed 3 references were received on 07/23/12, 2 months and 13 days after S9Medical Director had been approved for appointment by the Governing Body of the hospital. Further review revealed the National Practitioner Data Bank (NPDB) query was processed on 08/08/12, 2 months and 19 days after he had been approved for appointment.

Review of his file revealed he was reappointed on 07/12/13 with his medical license in his file having expired on [DATE] and his CDS certificate having expired on [DATE]. There was no documented evidence that S9Medical Director requested specific privileges and had approval to perform the privileges at the time of his initial appointment and upon his reappointment on 07/12/13.

S13Physician
Review of S13Physician's credentialing file revealed that he was approved for Medical Staff membership on 07/11/13. There was no documented evidence that he requested specific privileges that were reviewed and approved by the Medical Staff prior to being approved for Medical Staff membership by the Governing Body.

S12Nurse Practitioner (NP)
Review of S12NP's credentialing file revealed he was approved by the Governing Body for membership as an AHP on 07/11/13. There was no documented evidence that he requested specific privileges that were reviewed and approved by the Medical Staff prior to being approved for Medical Staff membership by the Governing Body.

In a face-to-face interview on 08/26/13 at 4:00 p.m., S1Administrator indicated that he had reviewed S9Medical Director's credentialing file and signed as the Medical Staff Chairperson, because S9Medical Director was the first physician at the hospital. He further indicated there was no other physician to review and approve his professional background. S1Administrator indicated that he was the person responsible for reviewing the medical staff's credentialing files before they are sent to the Governing Body for approval.

In a face-to-face interview on 08/26/13 at 4:50 p.m., S1Administrator confirmed there were no privileges requested and approved, because they used the physician's and AHP's application as evidence of their experience and privileges. He confirmed the late references and expired licenses for S9Medical Director.