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 9938 AIRLINE HWY BATON ROUGE, LA 70809 Nov. 9, 2017
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation and interview, the hospital failed to ensure the system for controlling infections and communicable diseases of patients and personnel was implemented as evidenced by failing to maintain a sanitary environment by having lab supplies and a centrifuge (used to spin blood specimens for testing and considered a dirty area) kept in the Central Supply Room that had patient care items (considered c a clean environment).
Findings:

Observation on 11/07/17 at 10:00 a.m. with S2DON present revealed the Central Supply Room had patient care items mixed with the lab supplies and the centrifuge used to spin blood (dirty and clean areas not separated). Further observation revealed a Blue Vacutainer Buff Na Citrate 0.109M, 3.2%: 13 expired 06/30/17 and 7 of the same Blue Vacutainers expired 04/30/17.

In an interview on 11/07/17 at 10:00 a.m., S2DON confirmed the dirty and clean areas should be separate. He confirmed the above-listed lab supplies were expired and available for use.
VIOLATION: CONTENT OF RECORD - DISCHARGE SUMMARY Tag No: A0468
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interview, the hospital failed to ensure the patients' medical records included a discharge summary developed by the physician or other qualified practitioner with admitting privileges who admitted the patient as evidenced by discharge summaries being dictated by S6QA and reviewed and signed by S3MD for 2 (#1, #3) of 3 discharged medical records reviewed for discharge summaries from a sample of 5 patients.
Findings:

Review of the policy titled "Discharge Summary", presented as a current policy, revealed that the attending nurse and Social Worker will complete the discharge instructions and aftercare discharge summary to be included in the patient's record. The physician may also write or dictate a separate discharge summary. Once the physician has reviewed the dictated discharge summary, it will be signed, dated, and timed on date of review.

Patient #1
Review of Patient #1's "Psychiatric Discharge Summary" revealed he was discharged on [DATE]. Further review revealed it was dictated by S6QA with no documented evidence of the date and time of the dictation. Further review revealed S3MD reviewed the dictation and signed it on 10/27/17 at 2:45 p.m. There was no documented evidence that S3MD prepared and/or dictated the discharge summary.

Patient #3
Review of Patient #3's "Psychiatric Discharge Summary" revealed he was discharged on [DATE]. Further review revealed it was dictated by S6QA with no documented evidence of the date and time of the dictation. Further review revealed S3MD reviewed the dictation and signed it on 10/24/17 at 3:00 p.m. There was no documented evidence that S3MD prepared and/or dictated the discharge summary.

In an interview on 11/08/17 at 10:15 a.m., S2DON offered no explanation when informed that the certification regulations require the discharge summary to be prepared/dictated by the physician and not a staff member without admitting privileges.

In an interview on 11/09/17 at 12:10 p.m., S6QA confirmed she dictated the discharge summaries for S3MD.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on record review and interview, the hospital failed to ensure its QAPI program included quality indicators to be measured, analyzed, and tracked to assess processes of care and hospital service and operations as evidenced by failure to have quality indicators developed for the contracted services providing linen services and lab services.
Findings:

Review of the QAPI meeting minutes for August, September, and October 2017 revealed no documented evidence that the contracted services of linen services and lab services were included in the data presented.

In an interview on 11/09/17 at 12:10 p.m., S6QA indicated linen services and lab services were provided by contract. She confirmed that no quality indicators had been developed to measure, analyze, and track the services provided by the contracted linen and lab companies.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on record reviews and interviews, the hospital failed to ensure adverse events were analyzed for cause and preventive actions were implemented as evidenced by failure to have documentation of a thorough review of 2 adverse events that occurred on 10/15/17 and 10/24/17 with implementation of preventive actions.
Findings:

Adverse event of 10/15/17
Review of documentation presented by S2DON revealed that Patient #3 was found unresponsive by S9MHT on 10/15/17 at 6:47 a.m. Further documentation revealed Patient #3 was observed to have no pulse and respirations, 911 was called, attempt to use an automated external defibrillator was made, and death was pronounced on 10/15/17 at 6:50 a.m.

Review of the final report submitted to LDH on 10/26/17 by S2DON revealed the report was a timeline of the documentation present in Patient #3's medical record. Witness statements were included from S8LPN, S9MHT, and S20MHT. There was no documented evidence of a witness statement from or documentation of an interview conducted by S2DON with S7RN, the charge RN on duty at the time of the event.

Review of Patient #3's medical record revealed sliding scale insulin was administered by S8LPN on 10/14/17 at 9:00 p.m. with no documented evidence of a physician's order for administration. Further review revealed no documented evidence of an assessment of Patient #3 when he was foubnd unresponsive, that CPR was initiated, a Resuscitation Record was completed, an order for discharge was documented by the physician, and that the RN documented Q 15 minute safety checks on 10/15/17 at 6:15 a.m., 6:30 a.m., and 6:45 a.m.

In an interview on 11/08/17 at 10:15 a.m., S2DON confirmed that sliding scale insulin was documented as given, and he didn't see a physician's order for it. He indicated he thought it was a documentation error. He confirmed that he did not identify this when he reviewed the medical record after Patient #3's adverse event. S2DON indicated he reviewed the video, but he focused on the time after 6:45 a.m. when the MHT entered the room. He further indicated video review revealed S9MHT did safety checks throughout the shift which means she was seen walking into Patient #3's room, but it was determined that the checks were ineffective based on the outcome. S2DON confirmed that he didn't identify during his review that S7RN had documented safety checks on 10/15/17 at 6:15 a.m., 6:30 a.m., and 6:45 a.m.

In a telephone interview on 11/09/17 at 9:00 a.m., S7RN indicated she was called to Patient #3's room by S9MHT who told her "he (Patient #3) was gone." S7RN indicated Patient #3's face was pale, his hands were mottled blue and purple (called dependent lividity by S7RN), he was cold to touch, had passed stool, and rigor mortis had set in (defined as stiff, rubbery). She further indicated she didn't start CPR, because he was found in rigor mortis. S7RN indicated "everything began about 6:50 a.m." When informed that the MHT observation record revealed that she had made safety rounds at 6:15 a.m., 6:30 a.m., and 6:45 a.m., S7RN indicated "it was an honest mistake", and she should not have documented the rounds, because she didn't make them. When asked by the surveyor why she had not documented her assessment of Patient #3 since CPR had not been initiated, S7RN indicated "I can't honestly tell you why I didn't put that in there."

Adverse event of 10/24/17
Review of documentation presented by S2DON revealed that Patient #1 came out his room in a rage and attacked a MHT in the hall and went into another patient's room and attacked a nurse and another patient. Further review revealed Patient #1 was brought to the floor by staff and eventually went "limp" and appeared to pass out. Further review revealed a Code Blue was called, and 911 was called. Patient #1 expired, and death was pronounced at 9:40 p.m.

Review of the final report submitted to LDH on 11/01/17 by S2DON revealed the report was a timeline of the documentation present in Patient #3's medical record. A witness statement was included from S15RN. There was no documented evidence of witness statements from or interviews by S2DON with all staff present during the event including S13MHT, S14RN, S16MHT, and S12MHT. Further review revealed plans for improvement included educating staff on CPI Team Control and Transport and risks of restraints.

Review of the documentation of the education in-service sign-in sheet revealed no documented evidence that S8LPN and S13MHT had attended the education.

In an interview on 11/08/17 at 11:15 a.m., S2DON indicated he met with the patient whose room Patient #1 entered, S14RN, and S13MHT but didn't document his interviews with them. he confirmed he got a witness statement only from S15RN and offered no explanation for not getting witness statements from all staff involved in the event.
VIOLATION: MEDICAL STAFF ACCOUNTABILITY Tag No: A0347
Based on record reviews and interviews, the hospital failed to ensure Louisiana Revised Statute 9:111 relating to pronouncement of death was followed by physicians as evidenced by the coroner pronouncing death after receipt of a telephone call from S7RN who reported the death of Patient #3 on 10/15/17 at 6:50 a.m..
Findings:

Review of the "Louisiana Revised Statute 9:111, 111. Definition of death" revealed a person will be considered dead if in the announced opinion of a physician, duly licensed in the state of Louisiana based on ordinary standards of approved medical practice, the person has experienced an irreversible cessation of spontaneous respiratory and circulatory functions. Death will have occurred at the time when the relevant functions ceased. Further review revealed the medical pronouncement of death by a coroner may also be based on personal observation, information, or statements obtained from coroner investigators or emergency medical technicians at the scene who are reporting from firsthand observation of the physical condition of the deceased . The time of death shall be reported as the time that the death was reported or discovered. The name of the personnel that the coroner is relying on shall be noted on the coroner's day record or protocol. There was no documented evidence that the law allowed the RN to report the firsthand observation of the physical condition of the deceased to the coroner.

Review of the policy titled "Death of a patient", presented as a current policy by S2DON, revealed that if a patient has a do not resuscitate order, the Medical Director, attending physician, or their designee may make the pronouncement of death when death occurs from natural causes. If the patient does not have a do not resuscitate order, the staff will initiate CPR, activate emergency medical services, begin basic life safety protocols, notify the attending physician and Administrator, and notify the next of kin or transfer. There was no documented evidence that pronouncement of death was addressed in situations when the patient does not have a do not resuscitate order.

Review of Patient #3's medical record revealed an entry documented by S7RN on 10/15/17 at 7:30 a.m. that the first responders were at the bedside of Patient #3. Further review revealed S7RN documented that she was notified by the MHT to come to Patient #3's room. S7RN documented that Patient #3 was lying in bed in a supine position, unresponsive, with no pulse, respirations, BP, and blood glucose reading. Another nurse entered the room and applied an automated external defibrillator with no results. S7RN documented that the medical doctor, psychiatrist, coroner, and administration were notified. Further review revealed an entry on 10/15/17 at 9:45 a.m. by S7RN that the coroner arrived, and the patient was pronounced dead at 6:50 a.m. by the coroner's office.

In a telephone interview on 11/09/17 at 9:00 a.m., S7RN indicated she was called to Patient #3's room by S9MHT who told her "he (Patient #3) was gone." S7RN indicated Patient #3's face was pale, his hands were mottled blue and purple (called dependent lividity by S7RN), he was cold to touch, had passed stool, and rigor mortis had set in (defined as stiff, rubbery). She further indicated she didn't start CPR, because he was found in rigor mortis. S7RN indicated "everything began about 6:50 a.m." She indicated she called the coroner by phone to report her findings, and the coroner pronounced death at that time. She further indicated she was aware she couldn't report her observations for the coroner to use to pronounce death, "but the coroner pronounced him, I didn't." S7RN confirmed the coroner pronounced death at 6:50 a.m. and didn't arrive at the hospital until 9:45 a.m. She confirmed a physician was not present in the hospital at 6:50 a.m. to pronounce death.

In an interview on 11/09/17 at 9:45 a.m. with S1ADM and S2DON present, S1ADM indicated S18Phys was notified of patient #3's death by phone, but he doesn't know who notified him. He further indicated S19NP was present at the hospital after Patient #3 had expired. S1ADM indicated when the coroner was leaving, S7RN asked the coroner the time of pronouncement of death, and the coroner answered "you all found him at 6:50 a.m., so that's the time of death."
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observations, record reviews, and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by:
1) Observation of Patient #4 (who was ordered to be on 1:1 observation on 11/05/17 at 1:00 p.m.) on 11/07/17 at 10:00 a.m. revealed Patient #4 was in the Seclusion Room with the door open, and S4MHT was coming from the bathroom that was around the corner in the anteroom of the Seclusion Room. Patient #4 was not within arm's length of S4MHT at the time of the observation as required by hospital policy.
2) Observation during the tour of the unit on 11/07/17 from 10:00 a.m. to 10:45 a.m. revealed all toilets in the patients' bathrooms and the toilet in the Seclusion Room had exposed plumbing that presented a risk for harm. Further observation revealed all toilet tissue dispensers in the patients' bathrooms and the Seclusion Room bathroom had a serrated, sharp edge that could produce a cut if a patient continuously rubbed against the edge of the dispenser. Further observation revealed the large trash can in the Dining/Noisy Activity Room had a plastic liner in the can and an additional plastic liner hanging from the handle of the trash can that could present a risk for suffocation.
3) The hospital policy for patient observation levels failed to clearly define visual observation and 1:1 observation by having contradictory statements in each definition.
Findings:

1) Observation of Patient #4 (who was ordered to be on 1:1 observation on 11/05/17 at 1:00 p.m.) on 11/07/17 at 10:00 a.m., with S2DON present, revealed Patient #4 was in the Seclusion Room with the door open, and S4MHT was coming from the bathroom that was around the corner in the anteroom of the Seclusion Room. Patient #4 was not within arm's length of S4MHT at the time of the observation as required by hospital policy:
Observation on 11/07/17 at 10:00 a.m. revealed Patient #4 was lying on the bed in the Seclusion Room with the door to the Seclusion Room open. Further observation revealed S4MHT was observed coming from the bathroom in the anteroom that was around the corner from the entrance to the Seclusion Room. Further observation revealed there was no other staff present in the Seclusion Room or the anteroom who had Patient #4 within sight or within arm's length.

Review of Patient #4's medical record revealed a verbal order on 11/05/17 at 1:00 p.m. to place Patient #4 on 1:1 until canceled.

Review of the policy titled "Patient Observation Levels", presented as a current policy by S2DON, revealed that 1:1 observation required staff to supervise the patient at all times at no further than an arm's length from the patient. One staff member must maintain the patient within visual contact at all times.

In an interview at the time of the observation on 11/07/17 at 10:00 a.m., S4MHT indicated S5MHT was in the room when she was cleaning the Seclusion Room bathroom.

In an interview on 11/07/17 at 10:00 a.m., S2DON indicated Patient #4 was in the Seclusion Room to provide low stimulation due to aggression. He further indicated Patient #4 was ordered to be on 1:1 but was not ordered to be in seclusion. S2DON confirmed no other staff member was present observing Patient #4 within arm's length and in visual contact at the time he and the surveyor entered the Seclusion Room and observed S4MHT coming around the corner from the anteroom bathroom.

2) Observation during the tour of the unit on 11/07/17 from 10:00 a.m. to 10:45 a.m. revealed all toilets in the patients' bathrooms and the toilet in the Seclusion Room had exposed plumbing that presented a risk for harm; all toilet tissue dispensers in the patients' bathrooms and the Seclusion Room bathroom had a serrated, sharp edge that could produce a cut if a patient continuously rubbed against the edge of the dispenser; the large trash can in the Dining/Noisy Activity Room had a plastic liner in the can and an additional plastic liner hanging from the handle of the trash can that could present a risk for suffocation:
Observation during the tour of the unit on 11/07/17 at 10:00 a.m. with S2DON present revealed the toilets in all patients' bathrooms and the toilet in the Seclusion Room had exposed plumbing which presented a risk for harm (a ligature risk). Further observation revealed the toilet tissue dispensers in the patients' bathrooms and the Seclusion Room bathroom had a serrated, sharp edge that could produce a cut if a patient continuously rubbed against the edge of the dispenser. Further observation revealed the large trash can in the Dining/Noisy Activity Room had a plastic liner in the can and an additional plastic liner hanging from the handle of the trash can that could present a risk for suffocation.

In an interview on 11/07/17 at 10:45 a.m. during the above observations, S2DON confirmed the findings.

3) The hospital policy for patient observation levels failed to clearly define visual observation and 1:1 observation by having contradictory statements in each definition:
Review of the policy titled "Patient Observation Levels", presented as a current policy by S2DON, revealed that visual observation required the patient to be maintained within visual contact of the staff at all times. If the patient is on close observation (no observation level of close observation), the staff member needs to stay inside the shower room at the door behind the curtain and must have some conversation with the patient every couple of minutes (doesn't address how visual contact will occur). The patient able to spend time alone in their rooms during the day at times when activities are not scheduled; however, this is contingent on the staff's assessment of the patient at the time (doesn't address how visual contact will be maintained). 1:1 observation required staff to supervise the patient at all times at no further than an arm's length from the patient and must maintain the patient within visual contact at all times. On the night shift, if two 1:1 observation patients are in the same room, one staff member may monitor the patients while they are in their room or sleeping (doesn't reflect that arm's length must be maintained). The patient is able to spend time in his/her room during the day at times when activities are not scheduled, but a staff member may sit in the doorway of the patient's room as long as the patient can be maintained in direct visual contact (doesn't address arm's length). If the patient is on 1:1, constant observation of the patient will occur while the patient is in the shower. The patient can close the shower curtain, and staff members must have some conversation with the patient every couple of minutes (doesn't address arm's length and visual contact). During visitation the staff member doesn't need to stay within arm's length of the patient and family group unless specifically ordered by the physician.

In an interview on 11/08/17 at 10:15 a.m., S2DON confirmed the above policy had contradictory information related to visual observation and 1:1 observation.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:
1) The RN failed to document an assessment of a patient when found unresponsive for 1 (#3) of 5 patient records reviewed for assessment by the RN from a sample of 5 patients.
2) The RN failed to notify the physician of a patient's elevated blood pressure for 1 (#1) of 1 patient record reviewed with elevated BPs from a sample of 5 patients.
3) The RN failed to document a code in accordance with hospital policy for 1 (#1) of 1 patient record reviewed who was coded from a sample of 5 patients.
Findings:

1) The RN failed to document an assessment of a patient when found unresponsive:
Review of the policy titled "Patient Centered Interdisciplinary Assessment", presented as a current policy by S2DON, revealed a RN will assess every patient every 4 hours and document results of the assessment on the nurses' observation note daily on every shift. Further review revealed no documented evidence that the policy addressed an assessment of the patient by the RN when there's a change in condition.

Review of Patient #3's "Multidisciplinary progress Notes" documented by S7RN on 10/15/17 at 7:30 a.m. revealed S7RN was called to the patient's room by the MHT. Further documentation revealed Patient #3 was lying in bed in a supine position unresponsive with no pulse, no respirations, no BP, and no blood glucose reading. An automatic external defibrillator was applied with no results. There was no documented evidence that CPR was initiated and an assessment of Patient #3 by S7RN as described in the interview below.

In a telephone interview on 11/09/17 at 9:00 a.m., S7RN indicated she was called to Patient #3's room by S9MHT who told her "he (Patient #3) was gone." S7RN indicated Patient #3's face was pale, his hands were mottled blue and purple (called dependent lividity by S7RN), he was cold to touch, had passed stool, and rigor mortis had set in (defined as stiff, rubbery). She further indicated she didn't start CPR, because he was found in rigor mortis. S7RN indicated "everything began about 6:50 a.m." When asked by the surveyor why she had not documented her assessment of Patient #3 since CPR had not been initiated, S7RN indicated "I can't honestly tell you why I didn't put that in there."

2) The RN failed to notify the physician of a patient's elevated blood pressure:
Review of the policy titled "Patient Centered Interdisciplinary Assessment", presented as a current policy by S2DON, revealed a RN will assess every patient every 4 hours and document results of the assessment on the nurses' observation note daily on every shift. Further review revealed no documented evidence that the policy addressed an assessment of the patient by the RN when there's a change in condition.

Review of Patient #1's "Multidisciplinary Progress Notes" documented by S17RN on 10/24/17 at 11:40 a.m. revealed his BP was 162/111. Further review revealed S17RN documented that S3MD was notified of Patient #1's arrival. There was no documented evidence that S17RN notified S3MD of Patient #1's elevated BP.

In an interview on 11/07/17 at 4:05 p.m., S17RN indicated she didn't notify S3MD of Patient #1's elevated BP when she notified him of Patient #1's arrival on the unit.

3) The RN failed to document a code in accordance with hospital policy:
Review of the hospital policy titled "Code Blue/Cardiopulmonary Arrest", presented as a current policy by S2DON, revealed that the first available nurse/employee arriving after CPR has been initiated should assure that the call for help has been activated. The third employee can assume the role of recorder and is responsible for documentation on the Resuscitation Record. The Resuscitation Record will be placed in the patient's medical record, and a copy will be provided to the DON.

Review of Patient #1's medical record revealed a Code Blue was called on 10/24/17 at 9:06 p.m. by S14RN. Further review revealed no documented evidence of a Resuscitation Record in Patient #1's medical record.

In an interview on 11/08/17 at 11:15 a.m., S2DON indicated the Resuscitation record was not documented for Patient #1 as required by hospital policy.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure the nursing staff developed and kept current an individualized nursing care plan for each patient as evidenced by failure to include medical problems of the patient for 1 (#3) of 5 patient records reviewed for a nursing care plan from a sample of 5 patients.
Findings:

Review of the policy titled "Treatment Plans", presented as a current policy by S2DON, revealed that each patient will have an individualized treatment plan that is based on the assessments of the patient's presenting problems, physical health, emotional and behavioral problems, cognitive functioning, and family and social functioning. An initial care plan/problem list will be developed within 24 hours of admission.

Review of Patient #3's history and physical conducted on 10/13/17 at 6:00 p.m. revealed he had a history of Hypertension, Seizure Disorder, [DIAGNOSES REDACTED], and Hepatitis. Review of his physician orders revealed he had medications ordered for detoxification and assessments ordered for alcohol and opiate withdrawal symptoms.

Review of Patient #3's "Initial Treatment Plan" developed by S7RN on 10/13/17 at 2:27 a.m. revealed the problems identified were threat to harm self, ineffective coping, and Psychosis. Further review revealed no documented evidence that the nursing care plan was revised after the history and physical was conducted to add the problems of alcohol and opiate detoxification, Hypertension, Seizure Disorder, [DIAGNOSES REDACTED], and Hepatitis.

In an interview on 11/08/17 at 10:15 a.m., S2DON confirmed Patient #3's nursing care plan did not include the medical problems for which Patient #3 was being treated.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on record reviews and interview, the hospital failed to ensure the RN assigned the nursing care of each patient to other nursing personnel in accordance with the specialized qualifications and competence of the available nursing staff. There was no documented evidence that staff had required certifications, were evaluated for competency, and/or were hired in accordance with experience requirements included in the job description for 5 (S2DON, S8LPN, S9MHT, S10RN, S16MHT) of 12 (S2DON, S7RN, S8LPN, S9MHT, S10RN, S11LPN, S12MHT, S13MHT, S14RN, S15RN, S16MHT, S17RN) personnel files reviewed for competency.
Findings:

Review of the policy titled "Selection and hiring of personnel", presented as a current policy by S2DON, revealed that the hospital will administer and grade the appropriate competency test(s). Applicants will be required to complete a skills assessment and competency evaluation relevant to the responsibilities of the job description.

S2DON
Review of S2DON's "Competency Skills Checklist" revealed no documented evidence that a mentor was assigned as evidenced by the space for the name being blank. Further review revealed his competency was evaluated on 11/01/17 by S1ADM who is not a physician or RN.

S8LPN
Review of S8LPN's personnel file revealed the multiple tests included in the file had no documented evidence that they had been reviewed and scored by a competent staff member. Further review revealed no documented evidence that a competency evaluation had been conducted for S8LPN.

S9MHT
Review of S9MHT's personnel file revealed she was hired on 09/01/17. Review of her job description revealed the minimum experience requirements for a MHT was three years in a healthcare setting required and at least one year mental health experience was preferred. Review of S9MHT's application and resume revealed no documented evidence that she had three years of experience in a healthcare setting. There was no documented evidence of current CPR certification. Review of S9MHT's "Competency Skills Checklist" signed by S2DON on 10/11/17 revealed a score of "2" (in need of training/supervision) in the areas of family therapy; principles of milieu therapy; basic knowledge of adult psychiatric illnesses; aware of special needs of psychiatric patients; aware of special needs of geriatric patients; aware of special needs of the chronically mentally ill; shaving - monitor and disposal of razors/log in and out sheet; assisting with the discharge planning process; patient belonging admit/discharge accountability. Further review revealed on 10/31/17 S2DON re-evaluated the above items and scored S9MHT as proficient with no documented evidence of training or supervision provided to address the areas designated as needing further training or supervision on 10/11/17. Of significance related to competency was that on 10/15/17 (prior to S9MHT being re-evaluated as proficient), Patient #3 was found unresponsive during S9MHT's rounds, and she confirmed that she had not performed rounds Q 15 minutes as ordered by the physician for 45 minutes prior to finding Patient #3 unresponsive.

S10RN
Review of S10RN's personnel file revealed no documented evidence of current CPR certification.

S16MHT
Review of S16MHT's personnel file revealed his competency was evaluated by another MHT rather than a RN on 10/28/17.

In an interview on 11/09/17 at 11:45 a.m., S2DON indicated competency is to be done within 3 months at the end of the employee's probationary period. He offered no explanation for the tests not being scored and for not having a competency evaluation before the employee provided unsupervised direct patient care. S2DON confirmed that the MHT should be evaluated by a RN. He indicated his supervisor is S1ADM who is not medical, so his (S2DON) competency should have been done by a competent RN or the psychiatrist. S2DON indicated he had no documentation of retraining and supervision provided to S9MHT. After reviewing S9MHT's application and resume, S2DON confirmed she did not meet the minimum experience requirements of an MHT.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on record reviews and interviews, the hospital failed to ensure drugs were administered in accordance with physician orders as evidenced by failure to have documented evidence of a physician order to administer medications (#1, #3) and failure to have a documented indication for use for medication ordered (#4) for 3 (#1, #3, #4) of 5 patient records reviewed for medication orders from a sample of 5 patients.
Findings:

Review of "Physician Standing Orders", presented as the current standing orders by S17RN, revealed the list of medications included Clonidine 0.1 mg po every 6 hours PRN systolic BP > 180 and/or Diastolic BP > 100.

Patient #1
Review of Patient #1's physician orders revealed an order on 10/24/17 at 3:18 p.m. for Clonidine 0.1 mg po every 6 hours PRN BP > 170/95. Further review revealed no documented evidence of a "Physician Standing Orders".

Review of Patient #1's "Daily Nursing Flow Sheet Addendum dated 10/24/17 for the day shift revealed a note at 11:40 a.m. by S17RN of a BP of 162/111 with Clonidine given at 11:58 a.m. Review of the MAR revealed "Clonidine 0.1 mg po Q 6 PRN BP > 170/95" was written under the "Medications" column. Further review revealed Clonidine was documented as given by S17RN at 12:00 p.m.

In an interview on 11/07/17 at 4:05 p.m., S17RN indicated she used the hospital's standing orders for Clonidine. After reviewing Patient #1's medical record, S17RN confirmed she didn't see the "Physician Standing Orders" in the record. She indicated there's a standing order sheet with PRN medications listed. S17RN indicated she was supposed to date, time, and sign the standing order sheet, send it to the pharmacist, and write the medication on the MAR. She further indicated she doesn't have to notify the physician before initiating a standing order. She further indicated if the BP was very elevated, or if it didn't come down after the PRN medication, she would notify the physician.

Patient #3
Review of Patient #3's physician orders revealed no documented evidence of an order for sliding scale insulin.

Review of Patient #3's "Daily Nursing Flow Sheet" for 10/14/17 of the night shift revealed a note at 9:00 p.m. by S8LPN and co-signed by S7RN that sliding scale insulin was given.

Review of Patient #3's MARs revealed no documented evidence that insulin was documented as administered on the night shift of 10/14/17.

In a telephone interview on 11/09/17 at 9:00 a.m., S7RN indicated she didn't know anything about a sliding scale order for Patient #3. When the surveyor read the documentation to S7RN, she indicated she didn't question the LPN about the documentation, because the LPN passed the medications, and she (S7RN) didn't know what medications Patient #3 was supposed to get. She confirmed that she was the charge nurse the night shift of 10/14/17.

Patient #4
Review of Patient #4's physician orders revealed an order written on 11/05/17 at 2:00 p.m. for Haldol 10 mg IM now, Ativan 2 mg IM now, and Haldol and Ativan 5 mg and 2 mg IM or po every 6 hours PRN. There was no documented evidence of the indication for use for any of the administrations and no documented evidence of how the nurse was to determine whether to give the PRN medication po or IM.

In an interview on 11/07/17 at 3:58 p.m., S2DON confirmed the physician's order did not include an indication for use. He confirmed that the indication for use should have been documented.
VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
Based on record reviews and interview, the hospital failed to ensure each patient's closed record had a discharge order properly authenticated by the physician as evidenced by failure to have documented evidence of an order for discharge for 2 (#1, #3) of 2 closed patient records reviewed from a sample of 5 patients.

Review of Patient #1's and Patient #3's medical records revealed no documented evidence that S3MD had documented a discharge order.

In an interview on 11/08/17 at 10:15 a.m., S2DON confirmed there was no discharge order written for Patient #1 and Patient #3.