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.

HOLLY HILL MENTAL HEALTH SERVICES 3019 FALSTAFF RD RALEIGH, NC 27610 May 12, 2016
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on review of policies, review of manufacturer's recommendations for glucometer, observations during nursing unit tours, and staff interviews, the hospital's nursing staff failed to maintain the facility in a manner to promote safety by failing to record dates opened and expired on glucometer control bottles for 6 out of 10 opened bottles.

The findings include:

Review of Policy titled, "Glucometer," with review date of 11/15, revealed "....10. Glucose Control Solution is utilized with each new bottle of test strips for machine calibration and once a day per manufacturer's instructions.....Upon opening a new bottle of the Glucose Control Solution, the date shall be written on the bottle. The Glucose Control Solution will expire 90 days after being opened."

Review of Manufacturer's Guidelines titled "EvenCare G2, Glucose Control Solutions" revealed "....TO PERFORM A TEST WITH CONTROL SOLUTIONS FOLLOW THESE STEPS: 1. Newly opened bottles of control solutions must be marked on the space provided on the control solutions label with the date that it was opened. Check the expiration date of the control solutions to make sure they have not expired. Discard any unused control solutions 90 days after opening or after expiration date....."

1. Observation on nursing unit #1 on 05/10/2016 at 1515 revealed four (4) opened glucose control solution bottles with no dates the bottles were opened written on the bottles.

Interview with LPN #1 on 05/10/2016 at 1540 revealed the glucometer was used earlier the same day to obtain bedside glucose's of patient (Patient #10). Further interview revealed the staff member was unsure of the dates that the bottles were opened and stated the dates should have been written on the bottles.

Interview with AS #1 (administrative staff) on 05/10/2016 at 1540 revealed the glucose control solutions should have open and expiration dates written on the bottles.

2. Observation on 05/11/2016 at 1000 of Nursing unit #2 revealed a box of opened glucose control solutions containing two (2) bottles with no dates the bottles were opened written on the bottles.

Interview with AS #2 on 05/11/2016 at 1000 revealed the glucose control bottles should have open dates written on bottles.

NC 450
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy review, medical record review and staff interview, the licensed staff failed to ensure vitals signs were obtained per physician's orders and hospital policy for 5 of 15 patients (#1, #8, #9, #6 and #7).

Findings include:

Review of the hospital's policy titled "VITAL SIGNS / WEIGHT", last date reviewed "7/15", revealed "It is the policy of (facility name) to monitor vital signs (Clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions.) and weight on all patients in a manner which provides ongoing data regarding their physical condition. 1. Vital signs will be performed at least daily . . . . 2. Vital signs will be recorded in the medical record. . . . 4. Physicians requesting vital signs be taken more often that (than) once a day will specify by written order. . . . "

1. Open medical record review on 05/10/2016 of Patient #1 revealed a [AGE] year old male admitted to the facility on [DATE] with a diagnosis of Major Depression, recurrent severe, with Suicidal Ideations (thinking about, considering, or planning suicide). Review of Patient #1's "PHYSICIAN'S ORDERS (Admission)", dated 04/10/2016 at 1726, revealed an order for daily vital signs. Review of Patient #1's "Vital Signs" record revealed the patient's temperature was not recorded on 04/13/2016 at 2200, 04/14/2016 at 0700 and 2200, 04/15/2016 at 0700. Further record review revealed Patient #1's temperature was not recorded on 04/16/2016 at 0600, 04/17/2016 at 0700, 04/18/2016 at 0700; on 04/19/2016, 04/21/2016, and 04/26/2016 no vital signs time or temperature was documented. Continued vital signs documentation review revealed no temperature or respirations recorded for Patient #1 on 04/27/2016, no time or temperature on 05/06/2016, no temperature on 05/08/2016 at 0700 or 2200, and no temperature or pain documentation on 05/09/2016 at 0700. Review of Nursing Flow Sheets for Patient #1 revealed nursing staff documented completion of "Vital sign flowsheet reviewed q (every) day" on 04/13/2016, 04/14/2016, 04/15/2016, 04/16/2016, 04/17/2016, 04/18/2016, 04/19/2016, 04/21/2016, and 04/26/2016.

Interview with an Assistant Nursing Director (AS #2) of the facility, on 05/12/2015 at 1035, revealed " My expectation is that staff do vital signs according to orders." AS #2 reported nursing staff should look at the vital signs sheet and verify vital signs are complete. AS #2 stated it is "Nursing responsibility to supervise the MHTs (Mental Health Technicians) to make sure their duties are complete. If something is missing, identify missing components and get them corrected. "





2. Closed medical record review of Patient #7 revealed a [AGE] year-old male that was admitted on [DATE] at 1131 with a diagnosis of Major Depression Disorder Severe without Psychotic Features and Alcohol Use - Severe and discharged on [DATE] at 1000. Review of physician's orders revealed a telephone order dated 04/18/2016 at 1300 for a standing alcohol detox protocol for "...Vital Signs: Detox (q (every) 4 hours for 3 days then Q12H (every 12 hours) until discharge..." Review of "Vital Signs" record revealed no available documentation of vital signs (Temperature, Heart Rate, Respiratory Rate and Blood Pressure) documented on 04/18/2016 at 1531, on 04/19/2016 at 0331, 1131 and 1531, on 04/20/2016 at 1131 and 1531, on 04/24/2016 at 2200, on 04/25/2016 at 2200, on 04/26/2016, 04/27/2016, 04/28/2016, 04/29/2016, 04/30/2016, 05/01/2016 and 05/02/2016. Further review of "Vital Signs" sheet revealed no available documentation of a Temperature documented on 04/18/2016 at 1131, 1931 and 2331, on 04/19/2016 at 1931, on 04/20/2016 at 0331, 0731 and 2331, on 04/21/2016 at 0331, 0731 and 2200, on 04/22/2016 at 2200, on 04/23/2016 at 0700 and 2200 and on 04/24/2016 at 0700.
Interview with an Assistant Nursing Director (AS #2) of the facility, on 05/12/2015 at 1035, revealed " My expectation is that staff do vital signs according to orders." AS #2 reported nursing staff should look at the vital signs sheet and verify vital signs are complete. AS #2 stated it is "Nursing responsibility to supervise the MHTs (Mental Health Technicians) to make sure their duties are complete. If something is missing, identify missing components and get them corrected. "

3. Closed medical record review of Patient #9 revealed a [AGE] year-old female that was admitted on [DATE] at 1859 with a diagnosis of Schizoaffective disorder, bipolar type and discharged on [DATE] at 1330. Review of physician orders dated 04/04/2016 at 2105 revealed an order for Vital Signs daily. Review of "Vital Signs" record revealed no available documentation of vital signs (Temperature, Heart Rate, Respiratory Rate and Blood Pressure) documented on 04/04/2016, 04/05/2016 and 04/26/2016. Further review of physician's orders revealed an order dated 04/06/2016 at 9 a.m. for "1. Vital Signs qid (four times a day)...3. Notify MD if resting pulse is 120 or more..." Review of "Vital Signs" record revealed no available documentation of vital signs (Temperature, Heart Rate, Respiratory Rate and Blood Pressure) documented on 04/06/2016 at 1800 and 2200. Further review of "Vital Signs" sheet revealed no available documentation of a Temperature documented on 04/17/2016 at 2200, on 04/19/2016 at 0600, 1800 and 2200, on 04/20/16 at 0600, 0900, 1800 and 2200, on 04/23/2016 at 2200 and on 04/24/2016 at 0600.
Interview with an Assistant Nursing Director (AS #2) of the facility, on 05/12/2015 at 1035, revealed " My expectation is that staff do vital signs according to orders." AS #2 reported nursing staff should look at the vital signs sheet and verify vital signs are complete. AS #2 stated it is " Nursing responsibility to supervise the MHTs (Mental Health Technicians) to make sure their duties are complete. If something is missing, identify missing components and get them corrected. "

4. Closed medical record review of Patient #8 revealed a [AGE] year-old male that was admitted on [DATE] at 0235 with a diagnosis of Schizophrenia unspecified and discharged on [DATE] at 1100. Review of physician's orders dated 04/03/2016 (not timed) revealed a standing alcohol detox protocol for "...Vital Signs: Detox (q (every) 4 hours for 3 days then Q12H (every 12 hours) until discharge..." Review of "Vital Signs" record revealed no available documentation of vital signs (Temperature, Heart Rate, Respiratory Rate and Blood Pressure) documented on 04/03/2016 at 0635, 1435 and 1835, on 04/05/2016 at 1435, 1835 and 2235, and on 04/06/2016 at 0235, 0600, and 1800. Further review of "Vital Signs" sheet revealed no available documentation of a Temperature documented on 04/03/2016 at 0235 and 1035 and on 04/04/2016 at 0235.
Interview with an Assistant Nursing Director (AS #2) of the facility, on 05/12/2015 at 1035, revealed " My expectation is that staff do vital signs according to orders." AS #2 reported nursing staff should look at the vital signs sheet and verify vital signs are complete. AS #2 stated it is " Nursing responsibility to supervise the MHTs (Mental Health Technicians) to make sure their duties are complete. If something is missing, identify missing components and get them corrected. "

5. Closed medical record review of Patient #6 revealed a [AGE] year-old male that was admitted on [DATE] at 1254 with a diagnosis of Major Depression Disorder and discharged on [DATE] at 1000. Review of physician orders revealed a telephone order dated 04/18/2016 at 1515 for Vital Signs daily. Review of "Vital Signs" record revealed no available documentation of vital signs (Temperature, Heart Rate, Respiratory Rate and Blood Pressure) documented on 04/18/2016, 04/22/2016, 04/24/2016, 04/25/2016, 04/30/2016 and 05/02/2016. Further review of "Vital Signs" sheet revealed no available documentation of a Temperature documented on 04/23/2016 at 2000.

Interview with an Assistant Nursing Director (AS #2) of the facility, on 05/12/2015 at 1035, revealed " My expectation is that staff do vital signs according to orders." AS #2 reported nursing staff should look at the vital signs sheet and verify vital signs are complete. AS #2 stated it is "Nursing responsibility to supervise the MHTs (Mental Health Technicians) to make sure their duties are complete. If something is missing, identify missing components and get them corrected. "