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.

KAILO BEHAVIORAL HOSPITAL, L L C 3859 HWY 190 EUNICE, LA May 21, 2015
VIOLATION: QAPI Tag No: A0263
Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of participation of QAPI (quality assessment and performance improvement) as evidenced by:

1) Failing to measure, analyze, and track quality indicators and other aspects of performance that assess processes of care, hospital services, and operations as evidenced by failure to have documented evidence of collection of data, analysis, and tracking of quality indicators for the first quarter and the beginning of the second quarter of 2015 (see findings in tag A0273).

2) Failing to ensure quality assessment and performance improvement (QAPI) data collected was used to identify opportunities for improvement and changes that will lead to improvement. There were 7 opportunities for improvement identified during the survey that had not been identified, trended, tracked, and analyzed with corrective action implemented by the hospital (see findings in tag A0283).

3) Failing to ensure it tracked adverse patient events, analyzed their causes, and implemented preventive actions and mechanisms that include feedback and learning throughout the hospital as evidenced by having no documented evidence that 7 patient falls that occurred in April 2015 were tracked, analyzed, and preventive actions and were mechanisms implemented (see findings in tag A0286).

4) Failing to develop and implement a policy for conducting performance improvement projects as evidenced by having no documented evidence that the hospital's "Performance Improvement Plan" addressed performance improvement projects and not having conducted any performance improvement project (see findings in tag A0297).

5) The governing body failing to ensure an ongoing program for quality improvement and patient safety is implemented and maintained and determines the number of distinct improvement projects that will be conducted annually (see findings in tag A0309).

6) The governing body failing to provide adequate resources for measuring, assessing, improving, and sustaining the hospital's performance and reducing risk to patients as evidenced by having no person designated the responsibility for the quality assessment and performance improvement (QAPI) program after S12LPN (Licensed Practical Nurse) left employment on 02/13/15 (see findings in tag A0315).
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on record reviews and interviews, the hospital failed to measure, analyze, and track quality indicators and other aspects of performance that assess processes of care, hospital services, and operations as evidenced by failure to have documented evidence of collection of data, analysis, and tracking of quality indicators for the first quarter and the beginning of the second quarter of 2015.

Findings:

Review of the hospital's "Performance Improvement Plan", presented by S12LPN (Licensed Practical Nurse) as the current plan, revealed the program incorporates the functions of quality monitoring, evaluation, and improvement; utilization management; infection surveillance/prevention/control; safety and risk management of environment of care; information management; staff development; clinical competence; and grievance/ethical issues resolution.

Further review revealed final responsibility for performance improvement in the provision of quality services rests with the Chief Executive Officer (CEO). The CEO shall receive quarterly reports of ongoing monitoring and improvement activities, identified trends, and/or potential risk exposure concerns, accompanied by narrative interpretations, and a progress report or recommendations on problem solving and performance improvement.

The Director of Performance Improvement coordinates, assures the integration of, and monitors all activities of the program and provides regular and quarterly summary reports to the senior Administration person, senior management personnel, Medical and Professional Staff, and the governing board.

The Performance Improvement Committee meets at least monthly to review and analyze data for any patterns or trends or opportunities to improve performance, make recommendations for corrective actions, and to monitor effectiveness of corrective actions taken.

Review of "Performance Improvement Committee Meeting" minutes presented by S12LPN revealed a meeting was held on 01/14/15 to discuss monitoring for the month of December 2014. No documented evidence of monthly meetings for January, February, March, and April 2015 were presented as of the completion of the survey on 05/21/15 at 6:20 p.m.

No documented evidence of data collection, analysis, and trending of the hospital's quality indicators was presented for January, February, March, and April 2015.


In an interview on 05/20/15 at 11:20 a.m., S6LPN indicated she had recently been assigned responsibility for QAPI about 3 weeks ago by S1Admin (Administrator). She further indicated she told him she was willing to assist and take it on, but the whole program needed to revamped first. She further indicated she had not signed a job description for Director of Performance Improvement. S6LPN indicated the performance improvement program was "constricted, basically useless", had monitors that didn't capture what needed to be captured, and was very brief with no detail. S6LPN indicated the QAPI program was under the previous infection control nurse who was no longer here. She further indicated that since she was hired in October or November 2014, she had sat in one QAPI meeting, and nothing related to performance improvement was discussed. She indicated the meeting was more like a social gathering. S6LPN indicated she had no QAPI data or meeting minutes to present from the previous infection control nurse.

In an interview on 05/20/15 at 12:10 p.m., S12LPN joined a meeting in progress with S6LPN. S12LPN indicated she was responsible for QAPI before she left employment. She further indicated she just returned to work PRN (as needed). She presented a spread sheet dated 01/14/14 and said it should have been 01/14/15, since the meeting was held on 01/14/15. S12LPN indicated the data reviewed at this meeting was from the December 2014 monitoring. She further indicated when she left, all data was up-to-date and doesn't know "who messed with it." S12LPN indicated she found her agenda for February 2015 but doesn't know where the minutes are.

In an interview on 05/20/15 at 3:00 p.m., S12LPN indicated her last day of work was 02/13/15. She further indicated S6LPN "will have to find that stuff (referring to QAPI data) because I wasn't around." She confirmed she didn't have any further QAPI data to present other than the meeting minutes for January 2015.

In an interview on 05/21/15 at 8:05 a.m., S1Admin indicated S6LPN was in charge of QAPI.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on record reviews and interviews, the hospital failed to ensure quality assessment and performance improvement (QAPI) data collected was used to identify opportunities for improvement and changes that will lead to improvement. There were 7 opportunities for improvement identified during the survey that had not been identified, trended, tracked, and analyzed with corrective action implemented by the hospital.

Findings:

Review of the hospital's "Performance Improvement Plan", presented by S12LPN (Licensed Practical Nurse) as the current plan, revealed the program incorporates the functions of quality monitoring, evaluation, and improvement; utilization management; infection surveillance/prevention/control; safety and risk management of environment of care; information management; staff development; clinical competence; and grievance/ethical issues resolution.

Further review revealed final responsibility for performance improvement in the provision of quality services rests with the Chief Executive Officer (CEO). The Director of Performance Improvement coordinates, assures the integration of, and monitors all activities of the program and provides regular and quarterly summary reports to the senior Administration person, senior management personnel, Medical and Professional Staff, and the governing board.

The Performance Improvement Committee meets at least monthly to review and analyze data for any patterns or trends or opportunities to improve performance, make recommendations for corrective actions, and to monitor effectiveness of corrective actions taken.

Review of "Performance Improvement Committee Meeting" minutes presented by S12LPN revealed a meeting was held on 01/14/15 to discuss monitoring for the month of December 2014. No documented evidence of monthly meetings for January, February, March, and April 2015 were presented as of the completion of the survey on 05/21/15 at 6:20 p.m.

No documented evidence of data collection, analysis, and trending of the hospital's quality indicators was presented for January, February, March, and April 2015.

Review of the "PI (performance improvement) Reporting" for 2014 and January 2015 (data collection for December 2014) revealed hand hygiene was 88% (per cent) in November 2014 and 85% in January 2015 with no documented evidence that a corrective action plan was developed and implemented to address this identified opportunity for improvement.

Further review revealed biohazard waste through handled through contract with Nursing Home A was 75% in January 2015 with no documented evidence that corrective action or continued monitoring would occur. Further review revealed the contract pharmacy was at 83% in January 2015 with no documented evidence that corrective action or continued monitoring would occur.

Review of variance reports, presented by S2DON (Director of Nursing), revealed there was 7 patient falls from 04/06/15 through 04/27/15 with no documented evidence of tracking, trending, and corrective action initiated to address this opportunity for improvement.


During the survey the following opportunities for improvement were identified that had not been trended, tracked, analyzed, and had corrective action implemented:

1) Failing to ensure a registered nurse (RN) assigned the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff as evidenced by having no documented evidence of the qualifications of the individuals training the nursing staff in crisis prevention interventions (CPI) for 8 (S2, S5, S8, S9, S13, S14, S15, S26) of 9 (S2, S5, S8, S9, S13, S14, S15, S18, S26) nursing staff personnel files reviewed for competency from a total of 23 employed nursing personnel;

2) Failing to implement contact precautions as ordered by the physician, perform accurate skin assessments and wound care as ordered by the physician, and assess patients' blood pressure prior to administration of antihypertensive, antipsychotic, anti-anxiety, and antidepressant medications as required by hospital policy;

3) Failing to implement its Medical Staff By-laws and Rules and Regulations for delinquent medical records as evidenced by having 59 delinquent medical records not completed within 30 days after discharge of patients and the physician not being suspended of his admitting privileges as required by the Medical Staff By-laws and Rules and Regulations;

4) Failing to develop a system for coding and indexing medical records that allowed timely retrieval by diagnosis;

5) Failing to destroy medications in accordance with hospital policy and failing to develop a system for destruction of controlled substances when informed by S19RPh (Registered Pharmacist) with Pharmacy A and S20Contract RPh that they could no longer destroy controlled substances;

6) Failing to ensure a contract was signed for each lab providing services to the hospital as evidenced by no documented evidence of the contract with Lab B signed by Lab B's representative and having no documented evidence of a contract with Hospital A for performing critical lab tests in accordance with the hospital's lab policies;

7) Failing to implement a system for identifying, investigating, and controlling infections and communicable diseases of patients and personnel that resulted in an Immediate Jeopardy situation that was identified on 05/14/15 at 5:20 p.m.


In an interview on 05/20/15 at 11:20 a.m., S6LPN indicated she had recently been assigned responsibility for QAPI about 3 weeks ago by S1Admin (Administrator). She further indicated she told him she was willing to assist and take it on, but the whole program needed to revamped first. She further indicated she had not signed a job description for Director of Performance Improvement. S6LPN indicated the performance improvement program was "constricted, basically useless", had monitors that didn't capture what needed to be captured, and was very brief with no detail. S6LPN indicated the QAPI program was under the previous infection control nurse who was no longer here. She further indicated that since she was hired in October or November 2014, she had sat in one QAPI meeting, and nothing related to performance improvement was discussed. She indicated the meeting was more like a social gathering. S6LPN indicated she had no QAPI data or meeting minutes to present from the previous infection control nurse.

In an interview on 05/20/15 at 12:10 p.m., S12LPN joined a meeting in progress with S6LPN. S12LPN indicated she was responsible for QAPI before she left employment. She further indicated she just returned to work PRN (as needed). She presented a spread sheet dated 01/14/14 and said it should have been 01/14/15, since the meeting was held on 01/14/15. S12LPN indicated the data reviewed at this meeting was from the December 2014 monitoring. She further indicated when she left, all data was up-to-date and doesn't know "who messed with it." S12LPN indicated she found her agenda for February 2015 but doesn't know where the minutes are.

In an interview on 05/20/15 at 3:00 p.m., S12LPN indicated her last day of work was 02/13/15. She further indicated S6LPN "will have to find that stuff (referring to QAPI data) because I wasn't around." She confirmed she didn't have any further QAPI data to present other than the meeting minutes for January 2015.

In an interview on 05/21/15 at 8:05 a.m., S1Admin indicated S6LPN was in charge of QAPI.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on record reviews and interviews, the hospital failed to ensure it tracked adverse patient events, analyzed their causes, and implemented preventive actions and mechanisms that include feedback and learning throughout the hospital as evidenced by having no documented evidence that 7 patient falls that occurred in April 2015 were tracked, analyzed, and preventive actions and were mechanisms implemented.
Findings:

Review of the hospital's "Performance Improvement Plan", presented by S12LPN (Licensed Practical Nurse) as the current plan, revealed the program incorporates the functions of quality monitoring, evaluation, and improvement; utilization management; infection surveillance/prevention/control; safety and risk management of environment of care; information management; staff development; clinical competence; and grievance/ethical issues resolution.

Further review revealed final responsibility for performance improvement in the provision of quality services rests with the Chief Executive Officer (CEO). The Director of Performance Improvement coordinates, assures the integration of, and monitors all activities of the program and provides regular and quarterly summary reports to the senior Administration person, senior management personnel, Medical and Professional Staff, and the governing board.

The Performance Improvement Committee meets at least monthly to review and analyze data for any patterns or trends or opportunities to improve performance, make recommendations for corrective actions, and to monitor effectiveness of corrective actions taken.

Review of variance reports, presented by S2DON (Director of Nursing), revealed there was 7 patient falls from 04/06/15 through 04/27/15 with no documented evidence of tracking, trending, and corrective action initiated to address this opportunity for improvement.

In an interview on 05/21/15 at 4:15 p.m., S2DON confirmed that no analysis or corrective action had been implemented to address the 7 patient falls that occurred in April 2015.
VIOLATION: QAPI PERFORMANCE IMPROVEMENT PROJECTS Tag No: A0297
Based on record reviews and interview, the hospital failed to develop and implement a policy for conducting performance improvement projects as evidenced by having no documented evidence that the hospital's "Performance Improvement Plan" addressed performance improvement projects and not having conducted any performance improvement project.


Findings:

Review of the hospital's "Performance Improvement Plan", presented by S12LPN (Licensed Practical Nurse) as the current plan, revealed no documented evidence that performance improvement projects was addressed in the hospital.

In an interview on 05/21/15 at 12:50 p.m., S12LPN (Licensed Practical Nurse) confirmed the hospital's "Performance Improvement Plan" did not address performance improvement projects, and the hospital had never conducted a performance improvement project.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interview, the hospital failed to ensure the use of restraint was in accordance with the order of a physician as evidenced by failing to obtain and document a physician's order for restraints for 1 (#1) of 2 (#1, #4) discharged patient records reviewed of patients who had restraints applied from a sample of 6 patients.

Findings:

Review of the hospital policy titled "Seclusion & (and) Restraint", presented as a current policy by S2DON, revealed that the use of a restraint or seclusion must be in accordance with the order of a physician or design (licensed independent practitioner, a trained registered nurse or physician assistant) permitted by the state and hospital to order seclusion or restraint.

Review of the "Seclusion and Restraint Log" presented by S2DON revealed Patient #1 had a physical hold and chemical restraint implemented on 01/26/15, 01/27/15, and 01/30/15.

Review of Patient #1's medical record revealed he was a [AGE] year old male admitted on [DATE] and discharged on [DATE]. Further review revealed his diagnoses included [DIAGNOSES REDACTED][DIAGNOSES REDACTED].

Review of Patient #1's Discharge summary documented by S11Psychiatrist on 02/10/15 at 2:25 p.m. revealed the following documentation:

"On 01/26 the nursing staff reports Patient #1 required a physical restraint for twenty minutes, a chemical restraint as other interventions had failed including verbal de-escalation and redirection."

"On 01/27 the nursing staff reports Patient #1 required a physical restraint for fifteen minutes with a PRN (as needed) IM (intramuscular) injection."

"On 01/30 the nursing staff reports Patient #1 required a physical restraint for fifteen minutes, a chemical restraint as other interventions had failed including verbal de-escalation and redirection."


Review of Patient #1's physician orders revealed no documented evidence of physician orders for physical restraints or physical holds on 01/26/15, 01/27/15, and 01/30/15.


In an interview on 05/21/15 at 4:15 p.m., S2DON indicated she couldn't explain why a physician's order was not documented when Patient #1 had restraints. She confirmed that the nurse is supposed to obtain and document a physician's order.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on record reviews and interviews, the hospital failed to ensure the requirements for the Condition of Participation for Governing Body were met as evidenced by:

Failing to ensure the chief executive officer (CEO) appointed by the governing body was responsible for managing the hospital as evidenced by failing to ensure the hospital was in compliance with the Conditions of Participation of QAPI (quality assessment and performance improvement), Nursing Services, Medical Record Services, and Infection Control (see findings in tag A0057).
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
Based on record reviews and interviews, the hospital failed to ensure the chief executive officer (CEO) appointed by the governing body was responsible for managing the hospital as evidenced by failing to ensure the hospital was in compliance with the Conditions of Participation of QAPI (quality assessment and performance improvement), Nursing Services, Medical Record Services, and Infection Control.

Review of the "Governing Body Bylaws" presented by S1Admin (Administrator) revealed the governing body would appoint a CEO as its direct executive representative in the management of the hospital. Further review revealed the authority and duties of the CEO included, in part,

1) carrying out all policies as established by the hospital;

2) negotiating and finalizing professional, consultant, and service contracts in accordance with corporate policy; and

3) being responsible for assuring that the hospital is in conformity with the requirements of planning, regulatory, and inspecting agencies.


The hospital failed to meet the requirements of the Condition of Participation for QAPI as evidenced by:

1) Failing to measure, analyze, and track quality indicators and other aspects of performance that assess processes of care, hospital services, and operations as evidenced by failure to have documented evidence of collection of data, analysis, and tracking of quality indicators for the first quarter and the beginning of the second quarter of 2015;

2) Failing to ensure quality assessment and performance improvement (QAPI) data collected was used to identify opportunities for improvement and changes that will lead to improvement. There were 7 opportunities for improvement identified during the survey that had not been identified, trended, tracked, and analyzed with corrective action implemented by the hospital;

3) Failing to ensure it tracked adverse patient events, analyzed their causes, and implemented preventive actions and mechanisms that include feedback and learning throughout the hospital as evidenced by having no documented evidence that 7 patient falls that occurred in April 2015 were tracked, analyzed, and preventive actions and were mechanisms implemented;

4) Failing to develop and implement a policy for conducting performance improvement projects as evidenced by having no documented evidence that the hospital's "Performance Improvement Plan" addressed performance improvement projects and not having conducted any performance improvement project;

5) The governing body failing to ensure an ongoing program for quality improvement and patient safety is implemented and maintained and determines the number of distinct improvement projects that will be conducted annually; and

6) The governing body failing to provide adequate resources for measuring, assessing, improving, and sustaining the hospital's performance and reducing risk to patients as evidenced by having no person designated the responsibility for the quality assessment and performance improvement (QAPI) program after S12LPN (Licensed Practical Nurse) left employment on 02/13/15.


The hospital failed to meet the requirements for the Condition of Participation for Nursing Services as evidenced by:

1) Failing to ensure a registered nurse (RN) assigned the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff as evidenced by having no documented evidence of the qualifications of the individuals training the nursing staff in crisis prevention interventions (CPI) for 8 (S2, S5, S8, S9, S13, S14, S15, S26) of 9 (S2, S5, S8, S9, S13, S14, S15, S18, S26) nursing staff personnel files reviewed for competency from a total of 23 employed nursing personnel;

2) Failing to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:

a) Failing to implement physician orders for Contact Precautions for 1 (#3) of 1 current inpatient with physician orders for Contact Precautions from a total of 3 (#3, #5, #6) current inpatients and a sample of 6 patients;

b) Failing to ensure an accurate skin assessment was performed on admission as evidenced by the RN documenting Patient #3's integumentary system as "normal" on 05/12/15 at 2:10 p.m. and S10MD (Medical Doctor) documenting on 05/12/15 at 6:07 p.m. a diagnosis of Scabies for 1 (#3) of 6 (#1 - #6) patient records reviewed for skin assessments from a sample of 6 patients; and

c) Failing to assess a patient's blood pressure prior to administration of antihypertensive, antipsychotic, anti-anxiety, and antidepressant medications as required by hospital policy for 2 (#3, #6) of 3 (#3, #5, #6) current inpatient records reviewed for nursing assessments from a sample of 6 patients.


The hospital failed to meet the requirements for the Condition of Participation for Medical Record Services as evidenced by:

1) Failing to implement its Medical Staff By-laws and Rules and Regulations for delinquent medical records as evidenced by having 59 delinquent medical records not completed within 30 days after discharge and the physician not being suspended of his admitting privileges as required by the Medical Staff By-laws and Rules and Regulations for 1 (S11) of 2 credentialed psychiatrists; and

2) Failing to develop a system for coding and indexing medical records that allowed timely retrieval by diagnosis.


The hospital failed to meet the requirements for the Condition of Participation for Infection Control as evidenced by:

1) Failing to implement a system for identifying, investigating, and controlling infections and communicable diseases of patients and personnel that resulted in an Immediate Jeopardy (I.J.) situation that was identified on 05/14/15 at 5:20 p.m. The I.J. remained in place as of the conclusion of the survey on 05/21/15 at 6:20 p.m.

2) Failing to have updated infection control policies and procedures as evidenced by having no documented evidence that the hospital's infection control policies and procedures had been reviewed and revised as needed by the infection control officer since development of the policies on 08/01/13;

3) Failing to maintain a sanitary physical environment as evidenced by failure of staff to disinfect the chair, table, wall, and handrails touched by Patient #3 who was diagnosed with Scabies and had physician orders for Contact Precautions;

4) Failure to mitigate risks contributing to healthcare-associated infections as evidenced by:

a) Failure of staff to perform handwashing or to use alcohol-based hand sanitizer before and after patient contact and after removal of gloves as observed on 05/15/15 (several observations) and 05/18/15;

b) Failure to develop a system to identify patients known to be colonized or infected with a targeted MDRO (multi-drug resistant organism) and for notification of receiving healthcare facilities and personnel prior to transfer of such patient between facilities;

c) Failure to develop a policy to ensure that patients identified as colonized or infected with target MDROs are placed on Contact Precautions as evidenced by having the hospital's policy addressing only MRSA (Methicillin-resistant Staphylococcus aureus);

d) Failure to have alcohol-based hand rub readily accessible and placed in appropriate locations as evidenced by having wall-mounted alcohol-based hand rubs in the nursing station and physician's exam room and 2 partially-filled small containers on alcohol-based hand rub locked in a drawer in the dining room. There was no documented evidence that the hospital had developed a plan for alcohol-based hand rubs to be readily accessible to staff, since wall-mounted alcohol-based hand rubs were limited due to risk factors in the psychiatric hospital;

e) Failure to develop a plan to ensure PPE supplies used for Standard Precautions were available and located near the point of use as evidenced by having the gowns, gloves, mouth, eye, nose, and face protection stored in the physician's exam room which would not be accessible if the physician was examining a patient;

f) Failure to establish and follow a schedule for areas/equipment to be cleaned/serviced regularly, such as HVAC equipment and refrigerators;

g) Failure to ensure that reusable noncritical patient care devices, such as blood pressure cuffs and oximeter probes, are disinfected on a regular basis and when visibly soiled as evidenced by failure of staff to clean blood pressure cuffs between patient use;

h) Failure of staff to follow manufacturer's guidelines for cleaning point of care devices as evidenced by observation of S13LPN (Licensed Practical Nurse) cleaning the glucometer with a wet paper towel and soap rather than a disinfectant wipe; and

i) Failure to perform active surveillance of handwashing and use of PPE as evidenced by having no documented evidence of handwashing surveillance from 01/01/15 through 05/21/15.

5) Failing to ensure the designated infection control officer was qualified and maintained qualifications through education, training, and experience as evidenced by having no designated qualified infection control officer from 02/13/15 through the completion of the survey on 05/21/15. The infection control officer appointed on 05/20/15 had no documented evidence of ongoing education and training in infection control; and

6) Failing to ensure the chief executive officer, the medical staff, and the director of nursing assured the hospital-wide QAPI program addressed problems identified by the infection control officer and was responsible for the implementation of successful corrective action plans in affected problem areas as evidenced by failure to have documented evidence of the collection of, tracking, and analysis of infection control data with corrective action plans for identified problems from 01/01/15 through the time the survey was completed on 05/21/15 at 6:20 p.m.


In an interview on 05/18/15 at 11:05 a.m., S1Administrator confirmed he was currently the Administrator of the hospital and responsible for management of the hospital.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on record reviews and interview, the hospital failed to ensure a patient who filed a grievance was provided written notice of the hospital's decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion as evidenced by failure to have documented evidence that a resolution letter was sent for 1 (R1) of 1 patient grievance reviewed.

Findings:

Review of the "Grievance/Complaint Log", presented by S2DON (Director of Nursing), revealed there were 13 grievances logged for 2014 and 1 logged for 2015.

Review of the investigation of the grievance reported by Patient R1, presented by S12LPN (Licensed Practical Nurse), revealed that Patient R1 complained of "a tall skinny man grabbed his hair and slapped him." Further review revealed S12LPN interviewed Patient R1 twice and interviewed 2 mental health techs and the charge nurse.

Review of the documentation presented by S12LPN revealed no documented evidence that a resolution letter was prepared and sent to Patient R1 at the conclusion of the investigation as required by the Patient Rights certification standards.

In an interview on 05/21/15 at 8:50 a.m., S12LPN confirmed that a resolution letter had not been sent to Patient R1 upon completion of the investigation of his grievance.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0200
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to ensure the direct care staff were trained and evaluated for competency in the use of nonphysical intervention skills as evidenced by having no documented evidence of the qualifications of the individuals training the direct care staff in crisis prevention interventions (CPI) for 11 (S2, S5, S8, S9, S12, S13, S14, S15, S26, S27, S28) of 12 (S2, S5, S8, S9, S12, S13, S14, S15, S18, S26, S27, S28) direct care staff personnel files reviewed for competency from a total of 26 employed direct care personnel.

Findings:

Review of the personnel files of S5RN, S8MHT (Mental Health Tech), S9RN, S13LPN (Licensed Practical Nurse), S14RN, S15MHT, and S26MHT revealed their training and evaluation of competency for performing CPI was conducted by S2DON (Director of Nursing).

Review of S2DON's personnel file revealed her training and evaluation of competency for performing CPI was conducted by S25APRN (Advanced Practice registered Nurse) on 01/05/15.

Review of S12LPN's personnel file revealed her training and evaluation of competency for performing CPI was conducted by S25APRN on 01/06/14.

Review of S25APRN's credentialing file revealed her certification in "The Crisis Prevention Institute, Inc. and the International Association of Nonviolent Crisis Intervention Certified Instructors" program expired on [DATE]. Further review revealed she was trained in CPI by S2DON on 08/10/14.

In an interview on 05/20/15 at 4:30 p.m., S7HR Dir (Human Resource Director) confirmed that S2DON had been conducting CPI training and competency evaluations for the hospital's nursing personnel.

In an interview on 05/21/15 at 4:15 p.m., S2DON confirmed she had been trained in CPI by S25APRN, and she had trained S25APRN on 08/10/14. S2DON confirmed that she had conducted the CPI training for S5RN, S8MHT, S9RN, S13LPN, S14RN, S15MHT, and S26MHT. During the interview S2DON was asked to present evidence of S25APRN's qualifications as an instructor of CPI when she trained S2DON on 01/05/15.

No documented evidence of qualifications of S2DON and S25APRN as qualified instructors of CPI were presented as of the completion of the survey on 05/21/15 at 6:20 p.m.
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
Based on record reviews and interview, the governing body failed to ensure an ongoing program for quality improvement and patient safety is implemented and maintained and determines the number of distinct improvement projects that will be conducted annually.

Findings:

Review of the hospital's "Performance Improvement Plan", presented by S12LPN (Licensed Practical Nurse) as the current plan, revealed the program incorporates the functions of quality monitoring, evaluation, and improvement; utilization management; infection surveillance/prevention/control; safety and risk management of environment of care; information management; staff development; clinical competence; and grievance/ethical issues resolution.

Further review revealed final responsibility for performance improvement in the provision of quality services rests with the Chief Executive Officer (CEO). The Director of Performance Improvement coordinates, assures the integration of, and monitors all activities of the program and provides regular and quarterly summary reports to the senior Administration person, senior management personnel, Medical and Professional Staff, and the governing board.

The Performance Improvement Committee meets at least monthly to review and analyze data for any patterns or trends or opportunities to improve performance, make recommendations for corrective actions, and to monitor effectiveness of corrective actions taken.

Review of Governing Board meeting minutes for 08/06/14, 12/12/14, 02/11/15, 03/02/15, and 03/27/15 revealed no documented evidence that QAPI (quality assessment and performance improvement) reports were presented and discussed.

In an interview on 05/21/15 at 4:15 p.m., S2DON (Director of Nursing) confirmed the governing meeting minutes had no documented evidence that QAPI was discussed or presented (S2DON interviewed due to the absence of S1Administrator at the time of the interview).
VIOLATION: PROVIDING ADEQUATE RESOURCES Tag No: A0315
Based on record reviews and interviews, the governing body failed to provide adequate resources for measuring, assessing, improving, and sustaining the hospital's performance and reducing risk to patients as evidenced by having no person designated the responsibility for the quality assessment and performance improvement (QAPI) program after S12LPN (Licensed Practical Nurse) left employment on 02/13/15.


Findings:

Review of the hospital's "Performance Improvement Plan", presented by S12LPN (Licensed Practical Nurse) as the current plan, revealed the program incorporates the functions of quality monitoring, evaluation, and improvement; utilization management; infection surveillance/prevention/control; safety and risk management of environment of care; information management; staff development; clinical competence; and grievance/ethical issues resolution.

Further review revealed final responsibility for performance improvement in the provision of quality services rests with the Chief Executive Officer (CEO). The Director of Performance Improvement coordinates, assures the integration of, and monitors all activities of the program and provides regular and quarterly summary reports to the senior Administration person, senior management personnel, Medical and Professional Staff, and the governing board.

The Performance Improvement Committee meets at least monthly to review and analyze data for any patterns or trends or opportunities to improve performance, make recommendations for corrective actions, and to monitor effectiveness of corrective actions taken.

Review of "Performance Improvement Committee Meeting" minutes presented by S12LPN revealed a meeting was held on 01/14/15 to discuss monitoring for the month of December 2014. No documented evidence of monthly meetings for January, February, March, and April 2015 were presented as of the completion of the survey on 05/21/15 at 6:20 p.m.

No documented evidence of data collection, analysis, and trending of the hospital's quality indicators was presented for January, February, March, and April 2015.

In an interview on 05/20/15 at 11:20 a.m., S6LPN indicated she had recently been assigned responsibility for QAPI about 3 weeks ago by S1Admin (Administrator). She further indicated she told him she was willing to assist and take it on, but the whole program needed to revamped first. She further indicated she had not signed a job description for Director of Performance Improvement. S6LPN indicated the QAPI program was under the previous infection control nurse who was no longer here. S6LPN indicated she had no QAPI data or meeting minutes to present from the previous infection control nurse.

In an interview on 05/20/15 at 12:10 p.m., S12LPN joined a meeting in progress with S6LPN. S12LPN indicated she was responsible for QAPI before she left employment. She further indicated she just returned to work PRN (as needed). She presented a spread sheet dated 01/14/14 and said it should have been 01/14/15, since the meeting was held on 01/14/15. S12LPN indicated the data reviewed at this meeting was from the December 2014 monitoring. She further indicated when she left, all data was up-to-date and doesn't know "who messed with it." S12LPN indicated she found her agenda for February 2015 but doesn't know where the minutes are.

In an interview on 05/20/15 at 3:00 p.m., S12LPN indicated her last day of work was 02/13/15. She further indicated S6LPN "will have to find that stuff (referring to QAPI data) because I wasn't around." She confirmed she didn't have any further QAPI data to present other than the meeting minutes for January 2015.

In an interview on 05/21/15 at 8:05 a.m., S1Admin indicated S6LPN was in charge of QAPI. He had no explanation when informed that S6LPN indicated during her interview that she had not accepted responsibility as Director of Performance Improvement.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on record reviews, observations, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Nursing Services as evidenced by:

1) Failing to ensure a registered nurse (RN) assigned the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff as evidenced by having no documented evidence of the qualifications of the individuals training the nursing staff in crisis prevention interventions (CPI) for 8 (S2, S5, S8, S9, S13, S14, S15, S26) of 9 (S2, S5, S8, S9, S13, S14, S15, S18, S26) nursing staff personnel files reviewed for competency from a total of 23 employed nursing personnel (see findings in tag A0397).

2) Failing to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by:

a) Failing to implement physician orders for Contact Precautions for 1 (#3) of 1 current inpatient with physician orders for Contact Precautions from a total of 3 (#3, #5, #6) current inpatients and a sample of 6 patients.

b) Failing to ensure an accurate skin assessment was performed on admission as evidenced by the RN documenting Patient #3's integumentary system as "normal" on 05/12/15 at 2:10 p.m. and S10MD (Medical Doctor) documenting on 05/12/15 at 6:07 p.m. a diagnosis of Scabies for 1 (#3) of 6 (#1 - #6) patient records reviewed for skin assessments from a sample of 6 patients.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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

1) Failing to implement physician orders for Contact Precautions for 1 (#3) of 1 current inpatient with physician orders for contact Precautions from a total of 3 (#3, #5, #6) current inpatients and a total sample of 6 patients.

2) Failing to ensure an accurate skin assessment was performed on admission as evidenced by the RN documenting Patient #3's integumentary system as "normal" on 05/12/15 at 2:10 p.m. and S10MD (Medical Doctor) documenting on 05/12/15 at 6:07 p.m. a diagnosis of [DIAGNOSES REDACTED]#6) patient records reviewed for skin assessments from a sample of 6 patients.

3) Failing to assess a patient's blood pressure prior to administration of antihypertensive, antipsychotic, anti-anxiety, and antidepressant medications as required by hospital policy for 2 (#3, #6) of 3 (#3, #5, #6) current inpatient records reviewed for nursing assessments from a sample of 6 patients.

4) Failing to ensure a patient's CBG (capillary blood glucose) reading was documented on the MAR for 1 (#6) of 2 (#5, #6) current inpatients with sliding scale insulin orders from a total of 3 current inpatients (#3, #5, #6) and a total sample of 6 patients.

5) Failing to obtain and document a physician's order for restraints for 1 (#1) of 2 (#1, #4) discharged patient records reviewed of patients who had restraints applied from a sample of 6 patients.

6) Failing to ensure ordered labs were drawn timely with results documented on the chart (#1, #2) and labs were drawn only upon receipt of a physician's order (#1) for 2 (#1, #2) of 6 (#1 - #6) patient records reviewed for labs from a sample of 6 patients.

7) Failing to ensure the RN assessed a patient's wound and performed wound care in accordance with physician orders and hospital policy for 1 (#2) of 1 patient record reviewed with a wound from a sample of 6 patients.

Findings:

1) Failing to implement physician orders for Contact Precautions:

Review of the hospital titled "Management of Outbreaks (Lice/Scabies)", originated August 2013 and presented as a current policy by S2DON (Director of Nursing), revealed that the patient suspected of having Scabies would be immediately placed in Contact Isolation. The patient's room door will be kept closed. Transmission-based protocols (contact precautions) will be followed until completion of treatment and 8 hours thereafter. All contaminated towels/linen are to be handled with care with the employee using appropriate PPE such as gloves and gowns.

Review of the hospital policy titled "Transmission Based Precautions: Contact; Droplet; Airborne Precautions Protocol to Identify Pathogen/Organism/Infection", revised March 2015 and presented as a current policy by S2DON, revealed that Contact Precautions are added to "Standard Precautions" with patients known to have or suspected to have an organism and/or disease easily transmitted by direct or indirect contact. Protocol instructions for Contact Precautions included the following:

1) The patient will be assigned a private room.

2) A sign will be posted outside the door indicating Contact Precautions.

3) In addition to Standard Precautions, all employees are required to wear gloves prior to entering the patient's room and prior to having direct contact with the patient. A gown is worn if soiling of clothes is likely while providing care. Contaminated linen will be handled using appropriate PPE based on the level of saturation, then bagged and routed for industrial cleaning.

4) Door does not have to remain closed.

5) In the case of Scabies only disposable single patient vital sign equipment will be used.


Review of information provided on the CDC website related to crusted Scabies is as follows:

1) Remember that persons with crusted scabies are infested with very large numbers of mites; this increases the risk of transmission both from brief skin-to-skin contact and from contact with items such as bedding, clothing, furniture, rugs, carpeting, floors, and other fomites that can become contaminated with skin scales and crusts shed by a person with crusted scabies.

2) Use contact precautions with protective garments (e.g. gowns, disposable gloves, shoe covers, etc.) when providing care to any patient with crusted scabies until successfully treated; wash hands thoroughly after providing care to any patient.

3) Isolate patients with crusted scabies from other patients who do not have crusted scabies.

4) Maintain contact precautions until skin scrapings from a patient with crusted scabies are negative; persons with crusted scabies generally must be treated at least twice, a week apart; oral Ivermectin may be necessary for successful treatment.

5) Identify and treat all patients, staff, and visitors who may have been exposed to a patient with crusted scabies or to clothing, bedding, furniture or other items (fomites) used by such a patient; strongly consider treatment even in equivocal circumstances because controlling an outbreak involving crusted scabies can be very difficult and risk associated with treatment is relatively low.

6) Treat patients, staff, and household members at the same time to prevent reexposure and continued transmission.


Patient #3

Review of Patient #3's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]#3 had a rash noted on his hands and diagnoses of [DIAGNOSES REDACTED]

Review of Patient #3's physician orders revealed a telephone order received by S9RN from S10MD on 05/12/15 at 6:35 p.m. for Contact Precautions and no roommate.

Review of Patient #3's "Multidisciplinary Progress Note" documented on 05/12/15 at 2:10 p.m. by S9RN revealed Patient #3 was placed on fall, suicide, and choking precautions. There was no documented evidence that he was placed on Contact Precautions.

Observation on 05/14/15 at 9:25 a.m. during the hospital tour revealed no observation of any patient room with a sign designating Contact Precautions.

Observation on 05/14/15 at 2:34 p.m. revealed a hand-written sign for "Contact Precautions" on the door of Patient #3. There was no documented evidence that the sign indicated the type of PPE that was to be used.

Observation on 05/15/15 at 8:05 a.m. revealed a sign on Patient #3's door that read as "Stop Contact Precautions Use Bio-hazard Bags Proper Hand Hygiene." There was no documented evidence that the sign indicated the type of PPE that was to be used.


In an interview on 05/14/15 at 1:35 p.m., S2DON indicated Patient #3 was ordered to be on contact precautions due to having Scabies on a previous admission. She further indicated he is not confined to his room. She confirmed that Contact Precautions had not been implemented as ordered.

In an interview on 05/14/15 at 3:50 p.m., S5RN confirmed that she placed the Contact Precaution sign on Patient #3's door after the surveyor had arrived on the morning of 05/14/15.

Observation on 05/14/15 at 9:50 a.m. revealed S4Contract Housekeeper with Nursing Home A cleaning patient rooms no isolation gown over her scrubs as PPE for Contact Precautions.

Observation on 05/14/15 at 2:34 p.m. revealed Patient #3, who was ordered to be on Contact Precautions, was outside on the patio with 2 other patients and 2 staff members.

In an interview on 05/14/15 at 10:10 a.m., S4Contract Housekeeper with Nursing Home A indicated she doesn't usually clean in the hospital, but was assigned today. She further indicated the nursing staff didn't inform her whether any patients had infections that would require her to take special precautions when cleaning, and she didn't ask anyone for a report. She confirmed she didn't wear an isolation gown when she cleaned Patient #3's room.

In an interview on 05/15/15 at 9:45 a.m., S10MD confirmed Patient #3's Scabies is Crusted Scabies. He indicated Patient #3's hands are scarred and thick and scaly. S10MD indicated he did not do a scraping. He indicated he received a telephone call from a nurse at the hospital (don't remember name) on 05/13/15 telling him the hospital wasn't sure they could get Elmite timely, and without a scraping he/she thought the cost would be an issue. He indicated his change in treatment from 7 days to 2 days was based on his conversation with the nurse. He confirmed that treatment with the oral medication is part of the treatment, and Patient #3's treatment wouldn't be considered complete until the oral medication was finished. He indicated he didn't expect the patient to be confined to his room when he ordered contact precautions. He expected no intimate contact and no sharing of a room. He indicated that he shouldn't be allowed to sit on sofas or chairs with cushions, and surfaces that he touched should be cleaned. He indicated it would be advisable to treat everyone with symptoms as a precaution, or they could treat everyone who had been in contact with the patient, since no precautions had been taken.


Patient #1

Review of Patient #1's medical record revealed he was a [AGE] year old male admitted on [DATE] and discharged on [DATE]. Further review of his H&P documented by S10MD 01/26/15 at 6:33 p.m. revealed Patient #1 had Scabies. There was no documented evidence that Patient #1 was ordered to be on Contact Precautions.

Review of Patient #1's physician orders revealed an order on 01/29/15 at 9:00 a.m. to continue isolation for rash (no documented evidence of a previous physician order for isolation).
Review of Patient #1's nursing notes revealed no documented evidence that Patient #1 was on Contact Precautions until the nursing note of the day shift on 01/29/15. Further review of his nursing notes revealed the only notes with documentation of Contact Precautions being implemented from his admission on 01/26/15 through his discharge on 02/03/15 were entries made on 01/27/15 at 6:00 a.m., 01/29/15, 02/02/15, and 02/03/15.
In an interview on 05/18/15 at 11:25 a.m., S10MD indicated technically if medication was applied that night (of admission), it was o.k. He further indicated if itching continued in 2 weeks, he would re-treat the patient. He further indicated he typically wouldn't isolate for scabies, but everything patient came in contact with should have been cleaned. S10MD indicated he "probably should have put the first patient (Patient #1) in isolation, it would have been the most precautionary, but I don't usually do it."


2) Failing to ensure an accurate skin assessment was performed on admission:

Review of Patient #3's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]#3 had a rash noted on his hands and diagnoses of [DIAGNOSES REDACTED]

Review of Patient #3's "Comprehensive Integrated Assessment Nursing Assessment - Part 2", documented by S9RN on 05/12/15 at 2:10 p.m., revealed his integumentary system was documented as normal color and "recently treated for scabies." There was no documented evidence that a rash was noted on his hands as documented by S10MD approximately 4 hours later.

In an interview on 05/18/15 at 10:10 a.m., S9RN offered no explanation for no documentation of Patient #3's rash to his hands on her nursing admit assessment.


3) Failing to assess a patient's blood pressure prior to administration of antihypertensive, antipsychotic, anti-anxiety, and antidepressant medications as required by hospital policy:
Review of the hospital policy titled "Medication Administration", presented as a current policy by S2DON, revealed that blood pressure will be obtained and recorded on the MAR (Medication Administration Record) prior to each dose of antihypertensive medication for 3 days, then every morning for one week, and weekly thereafter unless otherwise ordered by the physician. The licensed prescriber is to be notified before administering medication in the event that the blood pressure is below 90/60 or if there is any significant change in blood pressure. Further review revealed the blood pressure will be monitored for patients receiving antipsychotic, anti-anxiety, and antidepressant medications prior to each dose for 3 days, then once weekly, and record on the MAR.


Patient #3

Review of Patient #3's medical record revealed he was a [AGE] year old male admitted on [DATE] with a diagnosis of [DIAGNOSES REDACTED]#3 had a rash noted on his hands and diagnoses of [DIAGNOSES REDACTED]

Review of Patient #3's physician orders revealed a telephone order received on 05/12/15 at 3:10 p.m. for Clonidine 0.2 mg (milligrams) by mouth now. Further review revealed an order written on 05/12/15 at 6:07 p.m. for Norvasc 5 mg by mouth every day. Further review revealed Patient #3 had Abilify ordered for psychosis.

Review of Patient #3's MARs revealed he was administered Clonidine 0.2 mg orally on 05/12/15 at 4:10 p.m. and Norvasc 5 mg orally at 8:30 a.m. on 05/13/15, 05/14/15, and 05/15/15 with no documented evidence of Patient #3's blood pressure on the MAR at the time of administration of the antihypertensive medications as required by hospital policy. Further review of the MARs revealed Patient #3 was administered Abilify 10 mg orally on 05/13/15, 05/14/15, and 05/15/15 at 8:30 a.m. with no documented evidence of Patient #3's blood pressure on the MAR at the time of administration as required by hospital policy.


Patient #6

Review of Patient #6's medical record revealed she was a [AGE] year old female admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]

Review of Patient #6's physician orders revealed an order for Cozaar 50 mg orally daily for Hypertension, Risperdal 1 mg orally every morning for Psychosis, Risperdal 2 mg orally at bedtime for Psychosis, Celexa 40 mg orally at bedtime for Depression, Klonopin 1 mg orally at bedtime for Anxiety, Benztropine 0.5 mg orally twice a day for Anxiety, Topamax 50 mg orally twice a day for Psychosis, and Ativan 0.5 mg orally every 8 hours as needed for Anxiety.

Review of Patient #3's MARs revealed she was administered Cozaar 50 mg orally at 8:30 a.m. on 05/19/15 with no documented evidence of her blood pressure. Further review revealed she was administered Topamax, Risperdal 2 mg, Celexa, Klonopin, and Benztropine at 11:00 p.m. on 05/18/15, Celexa at 11:30 a.m. on 05/19/15, Risperdal 1 mg and Benztropine at 8:30 a.m. on 05/19/15, and Benztropine at 8:00 p.m. on 05/19/15 with no documented evidence of her blood pressure on the MAR prior to administration of the medications as required by hospital policy.

In an interview on 05/21/15 at 4:15 p.m., S2DON indicated the policy that required the blood pressure to be documented on the MAR prior to the administration of antihypertensive, antipsychotic, anti-anxiety, and antidepressant medications needed to be revised. She confirmed Patient #3 and Patient #6 did not have documented blood pressures on their MARs when their medications were administered.


4) Failing to ensure a patient's CBG (capillary blood glucose) reading was documented on the MAR:

Review of Patient #6's medical record revealed she was a [AGE] year old female admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]

Review of Patient #6's physician orders revealed an order for "Insulin Sliding Scale Orders" with frequency of monitoring to be before meals and at bedtime.

Review of Patient #6's MAR revealed no documented evidence of her CBG reading on 05/19/15 at 9:00 p.m.

In an interview on 05/21/15 at 4;15 p.m., S2DON confirmed the CBG result was not documented on Patient #6's MAR.


5) Failing to obtain and document a physician's order for restraints:

Review of the hospital policy titled "Seclusion & (and) Restraint", presented as a current policy by S2DON, revealed that the use of a restraint or seclusion must be in accordance with the order of a physician or design (licensed independent practitioner, a trained registered nurse or physician assistant) permitted by the state and hospital to order seclusion or restraint.

Review of the "Seclusion and Restraint Log" presented by S2DON revealed Patient #1 had a physical hold and chemical restraint implemented on 01/26/15, 01/27/15, and 01/30/15.

Review of Patient #1's medical record revealed he was a [AGE] year old male admitted on [DATE] and discharged on [DATE]. Further review revealed his diagnoses included [DIAGNOSES REDACTED][DIAGNOSES REDACTED].

Review of Patient #1's Discharge summary documented by S11Psychiatrist on 02/10/15 at 2:25 p.m. revealed the following documentation:

"On 01/26 the nursing staff reports Patient #1 required a physical restraint for twenty minutes, a chemical restraint as other interventions had failed including verbal de-escalation and redirection."

"On 01/27 the nursing staff reports Patient #1 required a physical restraint for fifteen minutes with a PRN (as needed) IM (intramuscular) injection."

"On 01/30 the nursing staff reports Patient #1 required a physical restraint for fifteen minutes, a chemical restraint as other interventions had failed including verbal de-escalation and redirection."

Review of Patient #1's physician orders revealed no documented evidence of physician orders for physical restraints or physical holds on 01/26/15, 01/27/15, and 01/30/15.

In an interview on 05/21/15 at 4:15 p.m., S2DON indicated she couldn't explain why a physician's order was not documented when Patient #1 had restraints. She confirmed that the nurse is supposed to obtain and document a physician's order.


6) Failing to ensure ordered labs were drawn timely with results documented on the chart and labs were drawn only upon receipt of a physician's order:

Review of the hospital policy titled "Laboratory Services", presented as a current policy by S2DON, revealed that laboratory services are provided by Lab A for routine labwork and Lab C for critical tests.


Patient #1

Review of Patient #1's medical record revealed he was a [AGE] year old male admitted on [DATE] and discharged on [DATE]. Further review revealed his diagnoses included [DIAGNOSES REDACTED][DIAGNOSES REDACTED].

Review of Patient #1's admit orders revealed an order to draw a Thyroid Profile, a Lipid Profile, and a Depakote Level.

Review of Patient #1's lab results revealed the Depakote Level was not drawn until 02/01/15, 6 days after it was ordered (drawn by Lab A). The Thyroid Profile and Lipid Profile were drawn and resulted by Lab B.


Patient #2

Review of Patient #revealed she was admitted on [DATE] and discharged on [DATE]. Further review revealed her admit diagnosis was Chronic Paranoid Schizophrenia with Behavioral Disturbances.

Review of Patient #2's admit orders revealed orders to draw a CBC with diff (complete blood count with differential), CMP (comprehensive metabolic profile), RPR (Rapid Plasma Reagin), Thyroid profile, Lipid profile, Urine drug Screen, Urine Pregnancy Test, Urinalysis with culture and sensitivity if indicated, and Serum Osmolality.

Review of Patient #2's lab results from Lab A revealed no documented evidence that results of a Urine Drug Screen, Urine Pregnancy Test, and Urinalysis were reported.

In an interview on 05/21/15 at 4:15 p.m., S2DON could not explain why labs were not done timely and why some labs were drawn without a physician's order.


7) Failing to ensure the RN assessed a patient's wound and performed wound care in accordance with physician orders and hospital policy:

Review of the hospital policy titled "Skin Assessment and care", presented as the current policy by S2DON when the skin assessment and wound care policies were requested, revealed that every patient was to have their skin assessed upon admission, once per shift, with any change in skin integrity, and weekly. As part of the initial nursing assessment, photographs of skin integrity issues will be obtained and filed in the wound care book with associated documentation. The RN or designee is to photograph all wounds, cuts, bruises, rashes, and other skin integrity problems and place photographs in the wound care book by patient. The size, color, appearance, and location of the wound is to be documented on the wound care assessment. Document skin condition each shift on the nursing note. Perform a full skin assessment on every patient every Saturday, and document such assessment in the wound care/skin assessment book. Document wound care on the MAR as ordered by the physician. Maintain all photos and wound care documentation and skin assessment as a part of the permanent medical record upon discharge.

Review of Patient #2's medical record revealed she was admitted on [DATE] and discharged on [DATE]. Further review revealed her admit diagnosis was Chronic Paranoid Schizophrenia with Behavioral Disturbances.

Review of Patient #2's "Multidisciplinary Progress Note" documented 04/29/15 at 10:00 a.m. revealed Patient #2 had a pressure ulcer to the coccyx that measured 0.8 by 0.6 by 0.1 cm (centimeters). It was cleaned with soap and water and a Duoderm was applied.

Review of Patient #2's physician's orders revealed a telephone order on 04/29/15 at 10:00 a.m. to clean the wound to the coccyx every 48 hours with soap and water, rinse, pat dry, and apply Duoderm. Further review revealed the order included to perform wound assessment and measurement at the time of wound care every 48 hours.

Review of Patient #2's MARs and nurses' notes revealed no documented evidence that her wound was assessed with measurements every 48 hours as ordered (no measurement after initial measurement), and there was no documented evidence that wound care was performed on 05/03/15. Further review of the entire medical record revealed no documented evidence that photographs were taken as required by hospital policy.

In an interview on 05/18/15 at 10:05 a.m., S5RN indicated photographs of wounds are supposed to be taken every 2 days. She further indicated there's a form for pictures to be attached with a place for measurements. S5RN confirmed there were no photographs of Patient #2's coccyx pressure ulcer in her medical record.
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 an individualized nursing care plan for each patient as evidenced by having a delay in initiation of the nursing care plan (#3) and inaccurate assessment of goal achievement (#5) for 2 (#3, #5) of 3 (#3, #5, #6) current inpatient records reviewed for nursing care plans from a sample of 6 (#1 - #6).

Findings:

Review of the hospital policy titled "Nursing Services", presented as a current policy by S2DON (Director of Nursing), revealed that a nursing plan of care shall be developed based on identified nursing diagnoses and/or patient care needs and patient care standards, implemented in accordance with the Louisiana Nurse Practice Act, and shall be consistent with the plan of all other health care disciplines.


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 under PEC. Review of his History and Physical (H&P) documented by S10MD (Medical Doctor) on 05/12/15 at 6:07 p.m. revealed Patient #3 had a rash noted on his hands and diagnoses of Depression, Hypertension, GERD (Gastroesophageal Reflux Disease), Schizophrenia, & Scabies.

Review of Patient #3's physician orders revealed an order on 05/12/15 at 6:07 p.m. for Elmite cream and Ivermectin orally for treatment of Scabies and an order on 05/12/15 at 6:35 p.m. for Contact Precautions.

Review of Patient #3's "Integrated treatment Plan" revealed a nursing care plan for "Impaired Skin Integrity" was developed on 05/14/15, 2 days after Patient #3 was admitted and diagnosed with and treated for Scabies.


Patient #5

Review of patient #5's medical record revealed he was a [AGE] year old male admitted on [DATE] with diagnosis of Major Depression, recurrent, severe with Suicidal Ideation. Further review revealed additional diagnoses included Polysubstance Dependence (Cocaine, Opiates), Type II Diabetes Mellitus, and Hepatitis C. He was discharged on [DATE].

Review of his physician orders revealed an order for Accuchecks before meals and at bedtime with regular Insulin Sliding Scale.

Review of Patient #5's nursing care plan for "Alteration in Health Maintenance related to Blood Sugar" revealed his goal was to have improved blood sugars with no blood sugar greater than 140 for 3 consecutive days within 7 days. Further review revealed the goal was achieved on 05/16/15.

Review of Patient #5's MARs (Medication Administration Record) revealed his blood sugar on 05/13/15 at 9:00 p.m. was 154 and 168 on 05/14/15 at 9:00 p.m. Further review revealed Patient #5's goal for blood sugar not being greater than 140 for 3 consecutive days was not met.

In an interview on 05/21/15 at 4:15 p.m., S2DON offered no explanation for Patient #3's nursing care plan for skin integrity not being initiated timely and for the inaccuracy of Patient #5's goal achievement for blood sugars.
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 a registered nurse (RN) assigned the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff as evidenced by having no documented evidence of the qualifications of the individuals training the nursing staff in crisis prevention interventions (CPI) for 9 (S2, S5, S8, S9, S12, S13, S14, S15, S26) of 10 (S2, S5, S8, S9, S12, S13, S14, S15, S18, S26) nursing staff personnel files reviewed for competency from a total of 24 employed nursing personnel.

Findings:

Review of the personnel files of S5RN, S8MHT (Mental Health Tech), S9RN, S13LPN (Licensed Practical Nurse), S14RN, S15MHT, and S26MHT revealed their training and evaluation of competency for performing CPI was conducted by S2DON (Director of Nursing).

Review of S2DON's personnel file revealed her training and evaluation of competency for performing CPI was conducted by S25APRN (Advanced Practice registered Nurse) on 01/05/15.

Review of S12LPN's personnel file revealed her training and evaluation of competency for performing CPI was conducted by S25APRN on 01/06/14.

Review of S25APRN's credentialing file revealed her certification in "The Crisis Prevention Institute, Inc. and the International Association of Nonviolent Crisis Intervention Certified Instructors" program expired on [DATE]. Further review revealed she was trained in CPI by S2DON on 08/10/14.

In an interview on 05/20/15 at 4:30 p.m., S7HR Dir (Human Resource Director) confirmed that S2DON had been conducting CPI training and competency evaluations for the hospital's nursing personnel.

In an interview on 05/21/15 at 4:15 p.m., S2DON confirmed she had been trained in CPI by S25APRN, and she had trained S25APRN on 08/10/14. S2DON confirmed that she had conducted the CPI training for S5RN, S8MHT, S9RN, S13LPN, S14RN, S15MHT, and S26MHT. During the interview S2DON was asked to present evidence of S25APRN's qualifications as an instructor of CPI when she trained S2DON on 01/05/15.

No documented evidence of qualifications of S2DON and S25APRN as qualified instructors of CPI were presented as of the completion of the survey on 05/21/15 at 6:20 p.m.
VIOLATION: CONTENT OF RECORD Tag No: A0458
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interview, the hospital failed to ensure that all medical records had a medical history and physical examination (H&P) completed and documented no more than 30 days before or 24 hours after admission as evidenced by having 1 (#6) of 6 (#1 - #6) patient records reviewed for a completed and documented H&P within 24 hours of admission without an H&P.

Findings:

Review of the hospital's "Rules and Regulations For The Professional Medical Staff", presented as the current rules and regulations by S1Admin (Administrator), revealed that a complete admission history and physical examination shall be recorded within 24 hours of the patient's admission.

Review of patient #6's medical record revealed she was a [AGE] year old female admitted on [DATE] at 8:00 p.m. with diagnoses of Schizoaffective Disorder, Bipolar Type, currently depressed, Hypertension, and Hypercholesterolemia.

Review of Patient #6's entire medical record on 05/20/15 at 3:30 p.m., 43 and 1/2 hours after admit, revealed no documented evidence that an H&P had been completed and documented.

In an interview on 05/20/15 at 3:30 p.m., S9RN (Registered nurse) confirmed that an H&P had not been conducted by a physician for Patient #6.
VIOLATION: PHARMACY ADMINISTRATION Tag No: A0491
Based on record reviews, observation, and interviews, the hospital failed to ensure the pharmacy or drug storage area was administered in accordance with hospital policies and procedures and its contract with Pharmacy A as evidenced by failing to destroy medications in accordance with hospital policy and failing to develop a system for destruction of controlled substances when informed by S19RPh (Registered Pharmacist) with Pharmacy A and S20Contract RPh that they could no longer destroy controlled substances.

Findings:

Review of the hospital policy titled "Pharmacy Services", presented as a current policy by S2DON (Director of Nursing), revealed that the Director of Pharmacy is responsible for the removal of all recalled, expired, or damaged medications.

Review of the "Pharmacy Services Agreement" entered into on 08/16/13 with Pharmacy A, presented by S1Admin (Administrator), revealed that responsibilities of the pharmacy included the rendering of pharmacy services in accordance with any applicable requirements of Louisiana Board of Pharmacy guidelines; local, state, and federal laws and regulations; community standards of practice; and pharmacy's policies and procedures manual and hospital's policies and procedures manual and related policies and procedures.

Observation on 05/14/15 at 2:10 p.m. revealed a locked safe in a locked drawer of S2DON's desk that contained multiple controlled substances that were either expired or remained after a patient was discharged .

In an interview on 05/14/15 at 1:35 p.m., when asked how controlled medications are handled after discharge, S2DON indicated they are logged for donation purposes and locked in the medication room. When asked if she ever kept controlled substances in her office, S2DON indicated narcotics that are expired are kept double-locked in her desk drawer in her office until they can be destroyed. She further indicated S20Contract RPh said he couldn't destroy controlled substances anymore, and the hospital had not "figured a plan to destroy them." S2DON indicated she didn't feel comfortable destroying controlled substance without having a pharmacist present, so she's holding the ones she has in her desk drawer until the pharmacist comes to the hospital.

In a telephone interview on 05/21/15 at 8:40 a.m., S20Contract RPh indicated he was contracted by the hospital to conduct the monthly pharmacy inspections and perform chart audits. When asked about whether he destroys controlled substances, S20Contract RPH indicated he originally was given permission by the Louisiana Board of Pharmacy to destroy narcotics, but with changes to the new law in December 2014, narcotics have to be given to a collector or a third party to destroy. He further indicated he doesn't destroy any medications. When asked if it was acceptable standards of practice for the DON to store controlled substances in her desk drawer, he indicated it was alright, as long as the DON has the only key and keeps a log of what;s contained in the lock box. He further indicated if medications are sent to the hospital by Pharmacy A with a patient-specific label, the medication can be given to the patient at discharge, but most hospitals don't do that.

In a telephone interview on 05/21/15 at 8:55 a.m., S19RPh with Pharmacy A confirmed he is the designated pharmacist responsible for Kailo Behavioral Hospital. When asked if he destroys medications and controlled substances, he indicated "no", it's done at the hospital. He further indicated he didn't know how medications were being destroyed at the hospital. S19RPh with Pharmacy A indicated if there's an expired medication in the med-dispense system supplied by Pharmacy A, he can take it back, but he doesn't know how patient-specific medications sent to the hospital are destroyed. He further indicated he's responsible for getting ordered medications to the hospital and for getting medications into the med-dispense system. S19RPh with Pharmacy A indicated once a medication is in the patient's name, "it's out of our control." When asked if it's acceptable standard of practice to have controlled substances locked in the DON's desk drawer, he indicated that's the way a lot of facilities handle it. He further indicated if the physician doesn't want the patient to take his/her patient-specific medications home when they are discharged , the patient can destroy the medications while witnessed by the nurse.
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 drugs and biologicals were administered in accordance with the orders of the physician for 1 (#3) of 3 (#3, #5, #6) current inpatients and 1 (#2) of 3 (#1, #2, #4) closed medical records from a total sample of 6 patients.

Findings:

Review of the hospital policy titled "Medication Administration", presented as a current policy by S2DON (Director of Nursing), revealed that all medications required an order which is written on the physician's order form and must contain the name of the medication, dose, time to be administered, route, reason/indication the medication is prescribed, and the specific time the first dose is to be administered. Further review revealed no documented evidence of the time interval after receipt of the order for administration of medications ordered to be given "now."


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 under PEC. Review of his History and Physical (H&P) documented by S10MD (Medical Doctor) on 05/12/15 at 6:07 p.m. revealed Patient #3 had a rash noted on his hands and diagnoses of Depression, Hypertension, GERD (Gastroesophageal Reflux Disease), Schizophrenia, & Scabies.

Review of Patient #3's physician's orders revealed an order on 05/12/15 at 3:10 p.m. to administer Clonidine 0.2 mg orally now. Further review revealed an order on 01/12/15 at 6:07 p.m. for Elmite 5% (per cent) Cream to be applied every day for 7 days and Ivermectin 3 mg (milligram) tablet 5 by mouth on day 1, 2, 8, 9, and 15. Further review revealed a clarification telephone order from S10MD on 05/13/15 at 1:30 p.m. to administer Elmite 5% Cream for 2 days.

Review of Patient #3's MARs (Medication Administration Record) revealed he received Clonidine 0.2 mg orally on 05/12/15 at 4:10 p.m., 1 hour after it was ordered by the physician to be given now at 3:10 p.m. Further review of the MAR on 05/14/15 revealed Elmite Cream was not applied on 05/12/15 as ordered. Further review it was applied on 05/13/15 at 8:00 p.m. and on 05/14/15 at 8:00 p.m.

In an interview on 05/18/15 at 9:15 a.m., S14RN (Registered Nurse) indicated he applied Elmite Cream to Patient #3 on the night of 05/12/15, but he didn't document the administration. He confirmed that by failing to document the administration a medication error occurred, because Patient #3 had Elmite Cream applied for 3 days rather than 2 days as ordered by the physician.

In an interview on 05/21/15 at 4:15 p.m., S2DON confirmed the medication administration policy did not address the time interval for administering a medication ordered to be given "now" (after receipt of the order).


Patient #2

Review of Patient #revealed she was admitted on [DATE] and discharged on [DATE]. Further review revealed her admit diagnosis was Chronic Paranoid Schizophrenia with Behavioral Disturbances.

Review of Patient #2's physician orders revealed the following orders:

04/27/15 at 1:30 p.m. - Saphris 10 mg SL (sublingual) every night;

04/28/15 at 11:05 a.m. - Increase saphris to 5 mg SL every morning and 10 mg SL at bedtime;

05/01/15 at 9:40 a.m. - Increase Saphris to 10 mg SL twice a day.

Review of patient #2's MARs revealed she received Saphris 5 mg SL on 05/01/15 at 8:30 a.m. There was no documented evidence that an additional 5 mg SL was administered at 9:40 a.m. when the order was received to increase the dose to 10 mg SL twice a day.

In an interview on 05/21/15 at 4:15 p.m., S2DON indicated an additional Saphris should have been administered when the order was received to increase it.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0431
Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Medical Record Services as evidenced by:

1) Failing to implement its Medical Staff By-laws and Rules and Regulations for delinquent medical records as evidenced by having 59 delinquent medical records not completed within 30 days after discharge and the physician not being suspended of his admitting privileges as required by the Medical Staff By-laws and Rules and Regulations for 1 (S11) of 2 credentialed psychiatrists (see findings in tag A0438).

2) Failing to develop a system for coding and indexing medical records that allowed timely retrieval by diagnosis (see findings in tag A0440).
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews and interviews, the hospital failed to implement its Medical Staff By-laws and Rules and Regulations for delinquent medical records as evidenced by having 59 delinquent medical records not completed within 30 days after discharge and the physician not being suspended of his admitting privileges as required by the Medical Staff By-laws and Rules and Regulations for 1 (S11) of 2 credentialed psychiatrists.

Findings:

Review of the hospital's "Rules and Regulations For The Professional Medical Staff", presented as the current rules and regulations by S1Admin (Administrator), revealed that the attending physician shall be responsible for the preparation of a complete and legible medical record for each patient.

Further review revealed each medical record shall be completed within 30 days after the discharge of the patient or the record becomes delinquent. On a continuous basis, the medical record director shall review incomplete records. At this time, any physician who has any delinquent charts shall be so notified by phone. If the records are still incomplete two weeks after being notified, he shall automatically suffer suspension of admitting privileges. He shall be notified of such suspension in writing by the medical record director.

Review of the Medical Staff By-laws and Rules and regulations revealed no documented evidence of a procedure to administratively close incomplete medical records.

Review of a list of "Charts for Administrative Closure", presented by S3MR Coord (Medical Record Coordinator) on 05/14/15 at 4:15 p.m., revealed a list of 57 patients who had been discharged between 01/08/15 to 03/29/15. Further review revealed the column titled "Admitting Physician" contained 43 records for S11Psychiatrist and 14 records for S25APRN (Advanced Practice registered Nurse) (who has a collaborative practice agreement with S11Psychiatrist).

Review of the "Medical Record Delinquent Detail Report", presented by S3MR Coord on 05/14/15, revealed Patient R1 was discharged on [DATE] and was awaiting signatures of an LPN (Licensed Practical Nurse) on a MAR (Medication Administration Record) and S23MD (Medical Doctor) on his progress note. Further review revealed Patient R2 was discharged on [DATE] and was awaiting the signature of S10MD on a physician order.

In an interview on 05/14/15 at 10:45 a.m., S3MR Coord indicated she was hired on 02/17/15. She further indicated the Medical Record Department was "backed up" when she was hired, and some medical records were "administratively closed" by the hospital. When asked what she meant by "administratively closed", she indicated the charts were tagged, closed, and had to go before the Governing Body for approval. S3MR Coord indicated she didn't know how many charts were "administratively closed." She further indicated her supervisor S6LPN had a list, but she (S6LPN) was on vacation this week. S3MR Coord presented documents during the interview of incomplete charts. She indicated none of the charts were delinquent.

In an interview on 05/14/15 at 12:10 p.m., S3MR Coord presented documentation of medical records awaiting staff signatures. During the interview, review of the documentation revealed 5 patient records were delinquent, as the patient had been discharged greater than 30 days. Further review revealed 2 of the 5 records were awaiting the signature of S10MD. S3MR Coord indicated the medical records weren't considered delinquent, because the physician had signed them, and they were only awaiting signatures by staff members. S3MR Coord confirmed that she didn't know that any record incomplete, whether waiting for physicians' signatures or signatures of staff members, after 30 days was delinquent. She further indicated she didn't know it was delinquent if only staff signatures were needed.

In an interview on 05/14/15 at 2:10 p.m., S2DON (Director of Nursing) indicated she had texted S6LPN, S3MR Coord's supervisor, who was on vacation to ask about the "administratively closed" medical records. She further indicated S6LPN indicated she didn't know how many were closed, but they had not been "administratively closed". She further indicated that S6LPN indicated the records needed to be audited with a list submitted to the Medical Executive Committee (MEC) and Governing Body for approval before they could be "administratively closed."

In an interview on 05/18/15 at 10:55 a.m., S3MR Coord indicated she didn't notify S11Psychiatrist of his more recent medical records that were delinquent due to waiting for staff signatures. She further indicated she usually speaks verbally to S11Psychiatrist and doesn't have any documentation to present when she spoke with him. She further indicated she didn't have any documentation of her conversations with S25APRN, because S25APRN "just comes by and signs charts." S3MR Coord indicated that S11Psychiatrist had not been suspended since she's been hired on 02/17/15. She further indicated she had spoken with the former Administrator who had created a document to address suspension, but it was never used. She further indicated she had created a letter, but it was never used. S3MR Coord indicated she couldn't explain why the documented created by the former Administrator and the letter she created were never implemented.

In an interview on 05/21/15 at 11:40 a.m., S11Psychiatrist confirmed he is the hospital's medical Director. When asked about his delinquent medical records, he indicated that he signs everything that's brought to him when he's at the hospital. He further indicated he knew that at some point the hospital was trying to get orders signed. He further indicated that he was surprised that he had not been getting requests for signatures recently. S11Psychiatrist indicated he was surprised to hear that he's delinquent with medical records to the point of being suspended. he further indicated no one had informed him that he currently had delinquent medical records. S11Psychiatrist indicated he thought it had been about 3 months since the last MEC meeting, and MEC meetings were supposed to be held quarterly (Medical Staff By-laws revealed MEC meetings were to be held monthly).
VIOLATION: CODING AND INDEXING OF MEDICAL RECORDS Tag No: A0440
Based on interviews, the hospital failed to develop a system for coding and indexing medical records that allowed timely retrieval by diagnosis.

Findings:

In an interview on 05/14/15 at 1:35 p.m., S2DON (Director of Nursing) was asked if she could provide a list of patients treated in the last year who had wounds. She indicated she could not pull patients by diagnosis.

In an interview on 05/20/15 at 3:35 p.m., S3MR Coord (Medical Records Coordinator) confirmed the hospital did not have a system in place for coding and indexing medical records that allowed timely retrieval by diagnosis.
VIOLATION: ADEQUACY OF LABORATORY SERVICES Tag No: A0582
Based on record reviews and interviews, the hospital failed to ensure a contract was signed for each lab providing services to the hospital as evidenced by no documented evidence of the contract with Lab B signed by Lab B's representative and having no documented evidence of a contract with Hospital A for performing critical lab tests in accordance with the hospital's lab policies.

Findings:

Review of the hospital policy titled "Laboratory Services", presented as a current policy by S2DON (Director of Nursing), revealed that laboratory services are provided by Lab A for routine labwork and Lab C for critical tests.

Review of the contracts for lab services presented by S2DON revealed contracts were in place with Lab A, Lab B, and Hospital A. There was no documented evidence of a contract with Lab C which was to perform critical tests as per hospital policy.

Review of the contract with Lab B, effective 11/20/14, revealed no documented evidence that the contract had been signed by the representative of Lab B. Lab services were provided for Patient #1 by Lab B on 01/27/15.

In an interview on 05/21/15 at 4:15 p.m., S2DON (interviewed in the absence of S1Administrator) could offer no explanation for the contract with Lab B not being signed by the representative of Lab B and for not having a contract with Lab C. She confirmed that the lab services policy was not indicative of what was in place currently in regards to lab services being provided.
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on record reviews, observations, and interviews, the hospital failed to meet the requirements for the Condition of Participation of Infection Control as evidenced by:

1) Failing to implement a system for identifying, investigating, and controlling infections and communicable diseases of patients and personnel as evidenced by:

An Immediate Jeopardy situation was identified on 05/14/15 at 5:20 p.m. due to the hospital:

a) Delaying treatment by failing to implement physician orders for Patient #3 who was diagnosed with Scabies on 05/12/15 at 6:07 p.m. The hospital failed to administer physician-ordered Elmite Cream 5% until the night of 05/13/15, more than 24 hours after ordered (see findings at tag A0749).

b) Failing to implement Contact Precautions per hospital policy and MD orders as evidenced by observations of Patient #3 not being confined to his room, no identification of Contact Precautions and type of personal protective equipment (PPE) required to treat Patient #3, and no observation of staff and the contracted housekeeper donning PPE when providing care and cleaning the patient's room. Patient #3 was observed on 05/14/15 at 2:34 p.m. on the outside patio with 2 other patients and 2 staff members. This had the potential to affect the health of 3 other admitted patients, all staff of the hospital, and the residents and staff at the attached nursing home where the contracted housekeeper is employed (see findings at tag A0749).

The hospital presented a Corrective Action Plan to lift the Immediate Jeopardy on 05/18/15 at 1:15 p.m. Due to the Corrective Action Plan having no documented objective, specific plans for revision of hospital policies and procedures, development of the nurse-to-nurse report tool mentioned in the plan, development and implementation of PI (Performance Improvement) tracking monitors for communicable diseases and appropriate precautions, staff education, and a plan for how the infection control program would be managed until the hospital hired an experienced and qualified infection control officer, the Corrective Action Plan was not accepted.

The hospital presented a second Corrective Action Plan to lift the I.J. on 05/21/15 at 3:30 p.m. The plan did not include objective, specific plans for monitoring the screening of patients for infectious and communicable diseases, evidence of treatment of patients who had come in contact with Patient #3, evidence of staff and contracted staff assessment for symptoms of Scabies and refusal of treatment, how the infection control program would be managed until the re-hired infection control officer obtained recent training on infection control, and how the infection control activities would be coordinated into the QAPI (quality assessment and performance improvement) plan. The Corrective Action Plan was not accepted.

The I.J. remained in place as of the time of exit on 05/21/15 at 6:20 p.m.

c) Failing to have updated infection control policies and procedures as evidenced by having no documented evidence that the hospital's infection control policies and procedures had been reviewed and revised as needed by the infection control officer since development of the policies on 08/01/13 (see findings in tag A0749).

d) Failing to maintain a sanitary physical environment as evidenced by failure of staff to disinfect the chair, table, wall, and handrails touched by Patient #3 who was diagnosed with Scabies and had physician orders for Contact Precautions (see findings in tag A0749).

e) Failure to mitigate risks contributing to healthcare-associated infections as evidenced by:

i) Failure of staff to perform handwashing or to use alcohol-based hand sanitizer before and after patient contact and after removal of gloves as observed on 05/15/15 (several observations) and 05/18/15.

ii) Failure to develop a system to identify patients known to be colonized or infected with a targeted MDRO (multi-drug resistant organism) and for notification of receiving healthcare facilities and personnel prior to transfer of such patient between facilities.

iii) Failure to develop a policy to ensure that patients identified as colonized or infected with target MDROs are placed on Contact Precautions as evidenced by having the hospital's policy addressing only MRSA (Methicillin-resistant Staphylococcus aureus).

iv) Failure to have alcohol-based hand rub readily accessible and placed in appropriate locations as evidenced by having wall-mounted alcohol-based hand rubs in the nursing station and physician's exam room and 2 partially-filled small containers on alcohol-based hand rub locked in a drawer in the dining room. There was no documented evidence that the hospital had developed a plan for alcohol-based hand rubs to be readily accessible to staff, since wall-mounted alcohol-based hand rubs were limited due to risk factors in the psychiatric hospital.

v) Failure to develop a plan to ensure PPE supplies used for Standard Precautions were available and located near the point of use as evidenced by having the gowns, gloves, mouth, eye, nose, and face protection stored in the physician's exam room which would not be accessible if the physician was examining a patient.

vi) Failure to establish and follow a schedule for areas/equipment to be cleaned/serviced regularly, such as HVAC equipment and refrigerators

vii) Failure to ensure that reusable noncritical patient care devices, such as blood pressure cuffs and oximeter probes, are disinfected on a regular basis and when visibly soiled as evidenced by failure of staff to clean blood pressure cuffs between patient use.

viii) Failure of staff to follow manufacturer's guidelines for cleaning point of care devices as evidenced by observation of S13LPN (Licensed Practical Nurse) cleaning the glucometer with a wet paper towel and soap rather than a disinfectant wipe.

ix) Failure to perform active surveillance of handwashing and use of PPE as evidenced by having no documented evidence of handwashing surveillance from 01/01/15 through 05/21/15 (see findings in tag A0749).


2) Failing to ensure it designated a qualified and experienced infection control officer after the resignation of S12LPN (Licensed Practical Nurse) on 02/13/15. The hospital failed to have an infection control officer qualified through education, ongoing training, experience, or certification from 02/13/15 through the completion of the survey on 05/21/15 (see findings in tag A0748).


3) Failing to ensure the chief executive officer, the medical staff, and the director of nursing assured the hospital-wide QAPI program addressed problems identified by the infection control officer and was responsible for the implementation of successful corrective action plans in affected problem areas as evidenced by failure to have documented evidence of the collection of, tracking, and analysis of infection control data with corrective action plans for identified problems from 01/01/15 through the time the survey was completed on 05/21/15 at 6:20 p.m. (see findings in tag A0756).
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on record reviews and interviews, the hospital failed to ensure it designated a qualified and experienced infection control officer after the resignation of S12LPN (Licensed Practical Nurse) on 02/13/15. The hospital failed to have an infection control officer qualified through education, ongoing training, experience, or certification from 02/13/15 through the completion of the survey on 05/21/15.

Findings:

Review of the "Full Time Employees" list, presented by S2DON (Director of Nursing) when a list of all staff with job title and date of hire was requested, revealed no documented evidence of a staff member designated as the infection control officer. Further review revealed no documented evidence that S17LPN (Licensed Practical Nurse) was listed as an employee.

In an interview on 05/14/15 at 1:35 p.m., S2DON indicated S17LPN had been hired about the beginning of May as the infection control officer but had not finished her orientation or skills checklist yet. She further indicated S17LPN was currently on leave after having had an accident. S2DON confirmed S17LPN had no education, training, or experience in infection control.

In an interview on 05/20/15 at 11:20 a.m., S6LPN indicated S1Admin (Administrator) had asked her to be the infection control officer and asked her to sign a job description as such, "so he'd have it on paper." She further indicated didn't accept the job of infection control officer, because she knew "they wouldn't allow her to do what's necessary to comply."

In an interview on 05/20/15 at 3:00 p.m., S12LPN indicated her last day of work before returning on 05/20/15 was 02/13/15. She further indicated she was the infection control officer at the time of her resignation.

In an interview on 05/21/15 at 8:05 a.m., S1Admin indicated S12LPN is now the infection control officer as of 05/20/15. He further indicated she had been the previous infection control officer, and her personnel file wasn't terminated when she left in February.

In an interview on 05/21/15 at 12:50 p.m., S12LPN indicated she had prior infection control experience but had not received any additional training or education in infection control for the past 2 years.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record reviews, observations, and interviews, the hospital failed to implement a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel in accordance with hospital policies and procedures and CDC (Centers For Disease Control and Prevention) guidelines as evidenced by:

1) Delay in treatment by failing to implement physician orders for Patient #3 who was diagnosed with Scabies on 05/12/15 at 6:07 p.m. The hospital failed to administer physician-ordered Elmite Cream 5% until the night of 05/13/15, more than 24 hours after ordered.

2) Failing to implement Contact Precautions per hospital policy and MD orders as evidenced by observations of Patient #3 not being confined to his room, no identification of Contact Precautions and type of personal protective equipment (PPE) required to treat Patient #3, and no observation of staff and the contracted housekeeper donning PPE when providing care and cleaning the patient's room. Patient #3 was observed on 05/14/15 at 2:34 p.m. on the outside patio with 2 other patients and 2 staff members. This had the potential to affect the health of 3 other admitted patients, all staff of the hospital, and the residents and staff at the attached nursing home where the contracted housekeeper is employed.

3) Failing to ensure it designated a qualified and experienced infection control officer to implement its infection control program after the resignation of S12LPN (Licensed Practical Nurse) on 02/13/15. The hospital failed to have an infection control officer qualified through education, ongoing training, experience, or certification from 02/13/15 through the completion of the survey on 05/21/15.

4) Failing to have updated infection control policies and procedures as evidenced by having no documented evidence that the hospital's infection control policies and procedures had been reviewed and revised as needed by the infection control officer since development of the policies on 08/01/13.

5) Failing to maintain a sanitary physical environment as evidenced by:

a) Failure to obtain physician orders for Contact Precautions for 1 (#1) of 1 closed medical record reviewed with physician orders for Contact or Isolation Precautions from a sample of 6 (#1 - #6) patients.

b) Failure of staff to disinfect the chair, table, wall, and handrails touched by Patient #3 who was diagnosed with Scabies and had physician orders for Contact Precautions.

6) Failure to mitigate risks contributing to healthcare-associated infections as evidenced by:

a) Failure of staff to perform handwashing or to use alcohol-based hand sanitizer before and after patient contact and after removal of gloves as observed on 05/15/15 (several observations) and 05/18/15.

b) Failure to develop a system to identify patients known to be colonized or infected with a targeted MDRO (multi-drug resistant organism) and for notification of receiving healthcare facilities and personnel prior to transfer of such patient between facilities.

c) Failure to develop a policy to ensure that patients identified as colonized or infected with target MDROs are placed on Contact Precautions as evidenced by having the hospital's policy addressing only MRSA (Methicillin-resistant Staphylococcus aureus).

d) Failure to have alcohol-based hand rub readily accessible and placed in appropriate locations as evidenced by having wall-mounted alcohol-based hand rubs in the nursing station and physician's exam room and 2 partially-filled small containers on alcohol-based hand rub locked in a drawer in the dining room. There was no documented evidence that the hospital had developed a plan for alcohol-based hand rubs to be readily accessible to staff, since wall-mounted alcohol-based hand rubs were limited due to risk factors in the psychiatric hospital.

e) Failure to develop a plan to ensure PPE supplies used for Standard Precautions were available and located near the point of use as evidenced by having the gowns, gloves, mouth, eye, nose, and face protection stored in the physician's exam room which would not be accessible if the physician was examining a patient.

f) Failure to establish and follow a schedule for areas/equipment to be cleaned/serviced regularly, such as HVAC equipment and refrigerators

g) Failure to ensure that reusable noncritical patient care devices, such as blood pressure cuffs and oximeter probes, are disinfected on a regular basis and when visibly soiled as evidenced by failure of staff to clean blood pressure cuffs between patient use.

h) Failure of staff to follow manufacturer's guidelines for cleaning point of care devices as evidenced by observation of S13LPN (Licensed Practical Nurse) cleaning the glucometer with a wet paper towel and soap rather than a disinfectant wipe.

i) Failure to perform active surveillance of handwashing and use of PPE as evidenced by having no documented evidence of handwashing surveillance from 01/01/15 through 05/21/15.


Findings:

1) Delay in treatment by failing to implement physician orders for Patient #3 who was diagnosed with Scabies on 05/12/15 at 6:07 p.m.:

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 under PEC. Review of his History and Physical (H&P) documented by S10MD (Medical Doctor) on 05/12/15 at 6:07 p.m. revealed Patient #3 had a rash noted on his hands and diagnoses of Depression, Hypertension, GERD (Gastroesophageal Reflux Disease), Schizophrenia, & Scabies. Further review revealed S10MD's treatment plan included Elmite 5% (per cent) every day for 7 days and Ivermectin 0.2 mg/kg (milligrams per kilogram) by mouth on day 1, 2, 8, 9, and 15.

Review of Patient #3's physician orders revealed an order written by S10MD on 05/12/15 at 6:07 p.m. for Elmite 5% Cream apply for 7 days and Ivermectin 3 mg tablet, give 5 tablets, by mouth on day 1, 2, 8, 9, and 15. Further review revealed a clarification telephone order from S10MD on 05/13/15 at 1:30 p.m. to administer Elmite 5% Cream for 2 days.

Review of Patient #3's MAR (Medication Administration Record) revealed no documented evidence that Patient #3 was administered Elmite Cream 5% on 05/12/15. Further review revealed the first administration of Elmite Cream 5% was at 8:00 p.m. 05/13/15, more than 25 hours after the physician order was written.

Review of Patient #3's "Multidisciplinary Progress Note" on 05/18/15 revealed documentation by S14RN of "5/12/15 22:00 (10:00 p.m.) Nsg (nursing) Late Entry Late Entry Permethrin Crm (Cream) 5% administer as order to head to toe." There was no documented evidence of the date and time the late entry was documented by S14RN.

In an interview on 05/14/15 at 3:25 p.m., S5RN (Registered Nurse) confirmed Patient #3's MAR had no documentation that Elmite Cream was administered on the night of 05/12/15. She indicated that she spoke with the night nurse of 05/13/15 this morning during report, and S18RN (night nurse) indicated she had administered Elmite cream the previous night.

In an interview on 05/18/15 at 9:15 a.m., S14RN indicated he administered Elmite Cream to Patient #3 on the night of the 05/12/15 but didn't document it anywhere. He further indicated that night was his first time out of orientation, and he hadn't given medications in the LPN's role for about 7 years.


2) Failing to implement Contact Precautions as per hospital policy and MD orders:

Review of the hospital titled "Management of Outbreaks (Lice/Scabies)", originated August 2013 and presented as a current policy by S2DON, revealed that the patient suspected of having Scabies would be immediately placed in Contact Isolation. The patient's room door will be kept closed. Transmission-based protocols (contact precautions) will be followed until completion of treatment and 8 hours thereafter. All contaminated towels/linen are to be handled with care with the employee using appropriate PPE such as gloves and gowns.

Review of the hospital policy titled "Transmission Based Precautions: Contact; Droplet; Airborne Precautions Protocol to Identify Pathogen/Organism/Infection", revised March 2015 and presented as a current policy by S2DON, revealed that Contact Precautions are added to "Standard Precautions" with patients known to have or suspected to have an organism and/or disease easily transmitted by direct or indirect contact. Protocol instructions for Contact Precautions included the following:

1) The patient will be assigned a private room.

2) A sign will be posted outside the door indicating Contact Precautions.

3) In addition to Standard Precautions, all employees are required to wear gloves prior to entering the patient's room and prior to having direct contact with the patient. A gown is worn if soiling of clothes is likely while providing care. Contaminated linen will be handled using appropriate PPE based on the level of saturation, then bagged and routed for industrial cleaning.

4) Door does not have to remain closed.

5) In the case of Scabies only disposable single patient vital sign equipment will be used.


Review of information provided on the CDC website related to crusted Scabies is as follows:

1) Remember that persons with crusted scabies are infested with very large numbers of mites; this increases the risk of transmission both from brief skin-to-skin contact and from contact with items such as bedding, clothing, furniture, rugs, carpeting, floors, and other fomites that can become contaminated with skin scales and crusts shed by a person with crusted scabies.

2) Use contact precautions with protective garments (e.g. gowns, disposable gloves, shoe covers, etc.) when providing care to any patient with crusted scabies until successfully treated; wash hands thoroughly after providing care to any patient.

3) Isolate patients with crusted scabies from other patients who do not have crusted scabies.

4) Maintain contact precautions until skin scrapings from a patient with crusted scabies are negative; persons with crusted scabies generally must be treated at least twice, a week apart; oral Ivermectin may be necessary for successful treatment.

5) Identify and treat all patients, staff, and visitors who may have been exposed to a patient with crusted scabies or to clothing, bedding, furniture or other items (fomites) used by such a patient; strongly consider treatment even in equivocal circumstances because controlling an outbreak involving crusted scabies can be very difficult and risk associated with treatment is relatively low.

6) Treat patients, staff, and household members at the same time to prevent reexposure and continued transmission.


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 under PEC. Review of his History and Physical (H&P) documented by S10MD (Medical Doctor) on 05/12/15 at 6:07 p.m. revealed Patient #3 had a rash noted on his hands and diagnoses of Depression, Hypertension, GERD (Gastroesophageal Reflux Disease), Schizophrenia, & Scabies. Further review revealed S10MD's treatment plan included Elmite 5% (per cent) every day for 7 days and Ivermectin 0.2 mg/kg (milligrams per kilogram) by mouth on day 1, 2, 8, 9, and 15.

Review of Patient #3's physician orders revealed an order written by S10MD on 05/12/15 at 6:07 p.m. for Elmite 5% Cream apply for 7 days and Ivermectin 3 mg tablet, give 5 tablets, by mouth on day 1, 2, 8, 9, and 15. Further review revealed a clarification telephone order from S10MD on 05/13/15 at 1:30 p.m. to administer Elmite 5% Cream for 2 days. Further review revealed a telephone order received by S9RN (Registered Nurse) from S10MD on 05/12/15 at 6:35 p.m. for Contact Precautions and no roommate.

Review of Patient #3's "Multidisciplinary Progress Note" documented on 05/12/15 at 2:10 p.m. by S9RN revealed Patient #3 was placed on fall, suicide, and choking precautions. There was no documented evidence that he was placed on Contact Precautions.


Observation on 05/14/15 at 9:25 a.m. during the hospital tour revealed no observation of any patient room with a sign designating Contact Precautions.

Observation on 05/14/15 at 2:34 p.m. revealed a hand-written sign for "Contact Precautions" on the door of Patient #3. There was no documented evidence that the sign indicated the type of PPE that was to be used.

Observation on 05/15/15 at 8:05 a.m. revealed a sign on Patient #3's door that read as "Stop Contact Precautions Use Bio-hazard Bags Proper Hand Hygiene." There was no documented evidence that the sign indicated the type of PPE that was to be used.


In an interview on 05/14/15 at 1:35 p.m., S2DON indicated Patient #3 was ordered to be on contact precautions due to having Scabies on a previous admission. She further indicated he is not confined to his room.
In an interview on 05/14/15 at 3:50 p.m., S5RN confirmed that she placed the Contact Precaution sign on Patient #3's door after the surveyor had arrived on the morning of 05/14/15.

Observation on 05/14/15 at 9:50 a.m. revealed S4Contract Housekeeper with Nursing Home A cleaning patient rooms no isolation gown over her scrubs as PPE for Contact Precautions.
Observation on 05/14/15 at 2:34 p.m. revealed Patient #3, who was ordered to be on Contact Precautions, was outside on the patio with 2 other patients and 2 staff members.

In an interview on 05/14/15 at 10:10 a.m., S4Contract Housekeeper with Nursing Home A indicated she doesn't usually clean in the hospital, but was assigned today. She further indicated the nursing staff didn't inform her whether any patients had infections that would require her to take special precautions when cleaning, and she didn't ask anyone for a report. She confirmed she didn't wear an isolation gown when she cleaned Patient #3's room.
In an interview on 05/15/15 at 9:45 a.m., S10MD confirmed Patient #3's Scabies is Crusted Scabies. He indicated Patient #3's hands are scarred and thick and scaly. S10MD indicated he did not do a scraping. He indicated he received a telephone call from a nurse at the hospital (don't remember name) on 05/13/15 telling him the hospital wasn't sure they could get Elmite timely, and without a scraping he/she thought the cost would be an issue. He indicated his change in treatment from 7 days to 2 days was based on his conversation with the nurse. He confirmed that treatment with the oral medication is part of the treatment, and Patient #3's treatment wouldn't be considered complete until the oral medication was finished. He indicated he didn't expect the patient to be confined to his room when he ordered contact precautions. He expected no intimate contact and no sharing of a room. He indicated that he shouldn't be allowed to sit on sofas or chairs with cushions, and surfaces that he touched should be cleaned. He indicated it would be advisable to treat everyone with symptoms as a precaution, or they could treat everyone who had been in contact with the patient, since no precautions had been taken.

3) Failing to ensure it designated a qualified and experienced infection control officer to implement its infection control program after the resignation of S12LPN on 02/13/15: Review of the "Full Time Employees" list, presented by S2DON (Director of Nursing) when a list of all staff with job title and date of hire was requested, revealed no documented evidence of a staff member designated as the infection control officer. Further review revealed no documented evidence that S17LPN (Licensed Practical Nurse) was listed as an employee.

In an interview on 05/14/15 at 1:35 p.m., S2DON indicated S17LPN had been hired about the beginning of May as the infection control officer but had not finished her orientation or skills checklist yet. She further indicated S17LPN was currently on leave after having had an accident. S2DON confirmed S17LPN had no education, training, or experience in infection control.

In an interview on 05/20/15 at 11:20 a.m., S6LPN indicated S1Admin (Administrator) had asked her to be the infection control officer and asked her to sign a job description as such, "so he'd have it on paper." She further indicated didn't accept the job of infection control officer, because she knew "they wouldn't allow her to do what's necessary to comply."

In an interview on 05/20/15 at 3:00 p.m., S12LPN indicated her last day of work before returning on 05/20/15 was 02/13/15. She further indicated she was the infection control officer at the time of her resignation.

In an interview on 05/21/15 at 8:05 a.m., S1Admin indicated S12LPN is now the infection control officer as of 05/20/15. He further indicated she had been the previous infection control officer, and her personnel file wasn't terminated when she left in February.

In an interview on 05/21/15 at 12:50 p.m., S12LPN indicated she had prior infection control experience but had not received any additional training or education in infection control for the past 2 years.


4) Failing to have updated infection control policies and procedures:
Review of the "Infection Control P & P (Policies and Procedures)" manual, presented by S2DON revealed it was dated 08/01/13. Further review revealed no documented evidence that the policies and procedures had been reviewed and revised by the infection control officer since the policies and procedures were developed.

In an interview on 05/21/15 at 12:50 p.m., S12LPN (Licensed Practical Nurse) indicated she was the designated Infection Control Officer as of 05/20/15. She further indicated she had previously been the Infection Control Officer at the hospital from 12/23/13 until 02/13/15. She indicated that she had not revised any infection control policies since she had been hired in 2013. S12LPN indicated the infection control policies and procedures needed revisions, because the policies only relate to MRSA and should reference MRDOs.


5) Failing to maintain a sanitary physical environment as evidenced by:

5a) Failure to obtain physician orders for Contact Precautions:
Review of the hospital titled "Management of Outbreaks (Lice/Scabies)", originated August 2013 and presented as a current policy by S2DON, revealed that the patient suspected of having Scabies would be immediately placed in Contact Isolation. The patient's room door will be kept closed. Transmission-based protocols (contact precautions) will be followed until completion of treatment and 8 hours thereafter. All contaminated towels/linen are to be handled with care with the employee using appropriate PPE such as gloves and gowns.

Review of the CDC's "2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings" revealed the recommendation to don the indicated PPE upon entry into the patient's room for patients who are on Contact and/or Droplet Precautions since the nature of the interaction with the patient cannot be predicted with certainty and contaminated environmental surfaces are important sources for transmission of pathogens. Further review revealed mites from a Scabies-infested patient are transferred to the skin of a caregiver while he/she is having direct ungloved contact with the patient's skin.

Review of Patient #1's medical record revealed he was a [AGE] year old male admitted on [DATE] and discharged on [DATE]. Further review of his H&P documented by S10MD 01/26/15 at 6:33 p.m. revealed Patient #1had Scabies. There was no documented evidence that Patient #1 was ordered to be on Contact Precautions.

Review of Patient #1's physician orders revealed an order on 01/29/15 at 9:00 a.m. to continue isolation for rash (no documented evidence of a previous physician order for isolation).
Review of Patient #1's nursing notes revealed no documented evidence that Patient #1 was on Contact Precautions until the nursing note of the day shift on 01/29/15. Further review of his nursing notes revealed the only notes with documentation of Contact Precautions being implemented from his admission on 01/26/15 through his discharge on 02/03/15 were entries made on 01/27/15 at 6:00 a.m., 01/29/15, 02/02/15, and 02/03/15.
In an interview on 05/18/15 at 11:25 a.m., S10MD indicated technically if medication was applied that night (of admission), it was o.k. He further indicated if itching continued in 2 weeks, he would re-treat the patient. He further indicated he typically wouldn't isolate for scabies, but everything patient came in contact with should have been cleaned. S10MD indicated he "probably should have put the first patient (Patient #1) in isolation, it would have been the most precautionary, but I don't usually do it."

5b) Failure of staff to disinfect the chair, table, wall, and handrails touched by Patient #3 who was diagnosed with Scabies and had physician orders for Contact Precautions:

Review of information from the CDC related to Crusted Scabies revealed the following:

1) Remember that persons with crusted scabies are infested with very large numbers of mites; this increases the risk of transmission both from brief skin-to-skin contact and from contact with items such as bedding, clothing, furniture, rugs, carpeting, floors, and other fomites that can become contaminated with skin scales and crusts shed by a person with crusted scabies.

2) Attempt to ensure that all persons who receive treatment have the clothing and bedding they used anytime during the 3 days before treatment machine-washed and dried using the hot water and high heat cycles. Clean the room of patients with crusted scabies regularly to remove contaminating skin crusts and scales that can contain many mites.

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 under PEC. Review of his History and Physical (H&P) documented by S10MD (Medical Doctor) on 05/12/15 at 6:07 p.m. revealed Patient #3 had a rash noted on his hands and diagnoses of Depression, Hypertension, GERD (Gastroesophageal Reflux Disease), Schizophrenia, & Scabies. Further review revealed S10MD's treatment plan included Elmite 5% (per cent) every day for 7 days and Ivermectin 0.2 mg/kg (milligrams per kilogram) by mouth on day 1, 2, 8, 9, and 15.


Observation on 05/15/15 at 8:40 a.m. revealed Patient #3 leaving the Dining/Activity Room and opening the door to and entering his room.

Observation on 05/15/15 at 8:45 a.m. revealed S15MHT (Mental health tech) touching the door to Patient #3's room with ungloved hands. Further observation revealed S15MHT did not sanitize or hand wash after touching the door. Further observation revealed no one cleaned the chair and table that Patient #3 used in the Dining/Activity Room after he left.

Observation on 05/15/15 at 8:46 a.m. revealed Patient #3 exited his room and went to sit in the same chair in the Dining/Activity Room. He leaned on the wall and touched the handrail in the hall across from the nursing station. Observation revealed S15MHT told him "quit touching everything." Further observation revealed no one cleaned the wall or handrail that Patient #3 had touched.


In an interview on 05/15/15 at 9:45 a.m., S10MD confirmed Patient #3's Scabies is Crusted Scabies.

In an interview on 05/15/15 at 9:50 a.m., S15MHT confirmed he didn't wipe the wall and handrail that was touched by Patient #3 until approximately 10 minutes after, upon his return from a 10 minute smoke break with patients. He confirmed the chair and table that Patient #3 is assigned in the Dining/Activity Room hasn't been disinfected since breakfast. He further indicated it isn't disinfected each time after Patient #3 uses it. He confirmed that he touched the door handle to Patient #3's room with his bare hands after Patient #3 had touched it, and he (S15MHT) did not perform hand hygiene.


6) Failure to mitigate risks contributing to healthcare-associated infections as evidenced by:
6a) Failure of staff to perform handwashing or to use alcohol-based hand sanitizer before and after patient contact and after removal of gloves as observed on 05/15/15 (several observations) and 05/18/15:

Review of the hospital policy titled "Infection Control P&P", presented as the current infection control policies and procedures by S12LPN, revealed that personnel should wash their hands thoroughly and promptly between patients to reduce contamination. Further review revealed handwashing is also required after the use of restroom facilities, after break or lunch, after any nursing procedure, or any time the hands become soiled.

Review of the CDC's "Guideline for Hand hygiene in Health-Care Settings" revealed indications for handwashing and hand antisepsis included the following:

1) When hands are visibly dirty or contaminated with proteinaceous material or contaminated with blood or other body fluids;

2) If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands;

3) Decontaminate hands before having direct contact with patients;

4) Decontaminate hands after contact with a patient's intact skin, such as when taking a pulse or blood pressure and lifting a patient;

5) Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings;

6) Decontaminate hands after contact with inanimate objects including medical equipment in the immediate vicinity of the patient;

7) Decontaminate hands if moving from a contaminated body site to a clean body site during patient care;

8) Decontaminate hands after removing gloves.


Observation on 05/15/15 at 10:40 a.m. revealed S13LPN perform an Accucheck on Patient #5. While wearing contaminated gloves (after obtaining the blood specimen) S13LPN touched the test strip container to close it and placed it in the glucometer case. Further observation revealed S13LPN then removed her gloves and did not immediately perform hand hygiene. She then carried the glucometer in one hand and the sharps container in the other hand, unlocked and opened the Medication Room door, washed the glucometer with a wet paper towel with soap on it, rinsed the glucometer, and then washed her hands.

Observation on 05/18/15 at 8:20 a.m. revealed S2DON administering patients' medications. Further observation revealed S2DON touched the first patient's arm to check the armband and did not perform hand hygiene before continuing medication administration for the second patient. S2DON then touched Patient #3's hand to check his armband and administered his medications with no observation of S2DON performing hand hygiene after administering Patient #3's medications.


In an interview on 05/21/15 at 12:50 p.m., S12LPN indicated she was the designated Infection Control Officer. She confirmed the above situations required hand hygiene to be performed after removing gloves and between patient contact during medication administration. She confirmed that she had no documented evidence to present of hand hygiene surveillance for the current calendar year.


6b) Failure to develop a system to identify patients known to be colonized or infected with a targeted MDRO (multi-drug resistant organism) and for notification of receiving healthcare facilities and personnel prior to transfer of such patient between facilities:
Review of the hospital policy titled "Infection Control P&P", presented as the current infection control policies and procedures by S12LPN, revealed no documented evidence that a policy and procedure had been developed and implemented to identify patients known to be colonized or infected with a targeted MDRO and for notification of receiving healthcare facilities and personnel prior to transfer of such patient between facilities.

In an interview on 05/21/15 at 12:50 p.m., S12LPN indicated she was the designated Infection Control Officer. She further indicated the hospital did not have a policy and procedure or system in place to identify patients known to be colonized or infected with a targeted MDRO and for notification of receiving healthcare facilities and personnel prior to transfer of such patient between facilities.


6c) Failure to develop a policy to ensure that patients identified as colonized or infected with target MDROs are placed on Contact Precautions as evidenced by having the hospital's policy addressing only MRSA (Methicillin-resistant Staphylococcus aureus):
Review of the hospital policy titled "Infection Control P&P", presented as the current infection control policies and procedures by S12LPN, revealed no documented evidence that a policy and procedure had been developed and implemented to ensure that patients identified as colonized or infected with target MDROs are placed on Contact Precautions as evidenced by having the hospital's policy addressing only MRSA.

In an interview on 05/21/15 at 12:50 p.m., S12LPN indicated she was the designated Infection Control Officer. She further indicated the hospital's infection control policies and procedures needed revision, because the only MDRO addressed in its policies and procedures was MRSA.


6d) Failure to have alcohol-based hand rub readily accessible and placed in appropriate locations as evidenced by having wall-mounted alcohol-based hand rubs in the nursing station and physician's exam room and 2 partially-filled small containers on alcohol-based hand rub locked in a drawer in the dining room. There was no documented evidence that the hospital had developed a plan for alcohol-based hand rubs to be readily accessible to staff, since wall-mounted alcohol-based hand rubs were limited due to risk factors in the psychiatric hospital:

Observation on 05/14/15 at 9:55 a.m. revealed hand sanitizer was mounted on the wall in the physician exam room and inside the nursing station. Further observation revealed the Dining/Activity room had a locked drawer with 2 opened bottles of hand sanitizer. Further observation at 9:57 a.m. in the Storage Room revealed no observation of individual hand sanitizer.

In an interview on 05/21/15 at 12:50 p.m., S12LPN indicated she was the designated Infection Control Officer. She further indicated that hand sanitizer can't be mounted on the walls that are accessible to the psychiatric patients (due to safety issues). She further indicated that hand sanitizer is locked in a drawer in the Activity/Dining room for staff use. S12LPN confirmed the hospital did not have a system developed for easy accessibility of hand sanitizer by staff, since wall-mounted hand sanitizers were not able to be located throughout the hospital.


6e) Failure to develop a plan to ensure PPE supplies used for Standard Precautions were available and located near the point of use as evidenced by having the gowns, gloves, mouth, eye, nose, and face protection stored in the physician's exam room which would not be accessible if the physician was examining a patient:
Observation on 05/14/15 at 8:15 a.m. revealed a plastic rolling cart in the Physician Exam Room had red biohazard bags & bouffant hair covers, 1 open and 1 unopened bag of yellow isolation gowns, and one full box latex gloves. A second cart in the room had an opened and partially-filled box of face masks, 1 unopened box of gloves, and 1 opened bag of yellow isolation gowns.

In an interview on 05/21/15 at 12:50 p.m., S12LPN indicated she was the designated Infection Control Officer. When asked how the staff were to access PPE contained in the Physician Exam Room if PPE was needed when the physician was examining the patient, S12LPN indicated the staff was supposed to put a red biohazard bag in their pocket when they went to a patient's room who was on Contact Precautions. She confirmed the hospital did not have a system in place to assure that all staff had PPE easily accessible to them for use with a patient on Contact Precautions.


6f) Failure to establish and follow a schedule for areas/equipment to be cleaned/serviced regularly, such as HVAC equipment and refrigerators:
In an interview on 05/21/15 at 12:50 p.m., S12LPN indicated she was the designated Infection Control Officer. She further indicated she could not present any evidence that that the hospital's
VIOLATION: LEADERSHIP RESPONSIBILITIES Tag No: A0756
Based on record reviews and interview, the hospital failed to ensure the chief executive officer, the medical staff, and the director of nursing assured the hospital-wide quality assessment and performance improvement (QAPI) program addressed problems identified by the infection control officer and was responsible for the implementation of successful corrective action plans in affected problem areas as evidenced by failure to have documented evidence of the collection of, tracking, and analysis of infection control data with corrective action plans for identified problems. No documented evidence of QAPI or Infection Control meeting minutes were presented for the calendar year of 2015 as of the time the survey was completed on 05/21/15 at 6:20 p.m.

Findings:

Review of the hospital policy titled "Infection Control P & P", presented as a current policy by S12LPN (Licensed Practical Nurse), revealed that the Infection Control Program is reported on a monthly basis to Performance Improvement/Medical Staff Committee. Information in this report will include, but is not limited to, results related to surveillance, emerging pathogens, public health bulletins or issues, CDC (Centers for Disease Control and Prevention) recommendations or alerts, quality improvement issues, results of clinical care surveillance rounds, and special studies/reports.

Review of the hospital policy titled "Performance Improvement Plan", presented as a current policy by S2DON (Director of Nurses), revealed the program included infection surveillance/prevention/control. Further review revealed final responsibility for performance improvement in the provision of quality services rests with its Chief Executive Officer (CEO). The CEO will meet with the Senior Management Committee at least quarterly to review all reports concerned with the overall Performance Improvement activities. The Performance Improvement Committee meets at least monthly to review and analyze data from monthly Infection Surveillance, Prevention, and Control activities.

Review of Governing Body meeting minutes conducted on 08/06/14, 02/11/15, 03/02/15, and 03/27/15 revealed no documented evidence that Infection Control or QAPI was discussed during any of the meetings.

In an interview on 05/20/15 at 11:20 a.m., S6LPN indicated she had been employed in October/November 2014 as the Utilization review Nurse. She further indicated since then she had sat in one QAPI meeting and nothing related to PI (Performance Improvement) was discussed. She indicated it was more like a social meeting. S6LPN indicated she has no PI data or meeting minutes to present from the previous person doing PI (S12LPN); she can look for it, but nothing was given to her. She further indicated she had never signed a job description as being responsible for QAPI.

In an interview on 05/20/15 at 3:00 p.m., S12LPN indicated her last day of work was 02/13/15. She further indicated she didn't have any QAPI or Infection Control data or meeting minutes from 01/01/15 through 05/20/15 to present to the surveyor. When asked about the January 2015 data, she indicated her January monitors "were on my desk and I don't know what happened to them".