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 June 22, 2017
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on policy and procedure review, medical record review, and staff interview the facility failed to authenticate progress notes in the medical record for 1 out of 6 sampled medical records (Patient #3).

The findings include:

Review on 06/22/2017 of the policy titled "Documentation Requirements in the Medical Record" last revised 04/2016 revealed "All entries in the medical record are to be dated, timed, and signed including credentials by the person documenting the entry, using the actual date of documentation." Continued review under "Progress Notes" revealed " ...1. The Progress Notes are integrated and each discipline documents in chronological order, events as they occur. All hospital staff Progress Notes will include the full name, credentials of the author, date and time of the entry ..."

Review of Patient #3's medical record revealed multiple emails about Patient #3's discharge plan from Therapist #1, Case Manger #1 to Patient #3's mother and Insurance Representative #1. Review of an email dated 06/08/2017 at 0908 revealed there was no credentials next to Therapist #1's name. Review of an email dated 06/07/2017 at 1241 revealed there was no credentials next to Therapist #1's name Review of an email dated 06/06/2017 at 2046 revealed there was no credentials next to Therapist #1's name. Review of email from Case Manger #1 dated 05/30/2017 at 1023 revealed there was no credentials next to Case Manger #1's name. Review of email revealed no date or time of email. Review of email dated 04/06/2017 at 1504 revealed there was no credentials next to Case Manager #1's name.

Interview on 06/22/2017 with Director of Social Services #1 revealed email may be used as progress notes if they were printed out and placed in the medical record, a progress note was 'best practice' however email was acceptable.

Interview on 06/22/2017 at 1504 with HIM (Health Information Management) Director #1 revealed if clinical staff used emails as progress notes they still have to have credentials on them. Further interview revealed HIM staff review medical charts content and if "keep in record" is written on an email then the email was identified as pertinent and kept with the record. If HIM staff determine the email was not pertinent then the email was removed from the record and destroyed. Continued interview revealed that if clinical staff used email as replacement for progress notes, they had to be compliant with policy. Further interview revealed that was not something specifically addressed in their policy, therefore HIM Director #1 revealed she would reach out to corporate to assist in the use of emails as alternatives to progress notes.
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
Based on policy and procedure review, medical record review, and staff interview the facility staff failed to ensure medication orders were complete in 3 out of 6 sampled patients (Patient #1, #8, and #11).

The findings include:

Review on 06/22/2017 of policy and procedure titled "Medication Administration and Records" revealed "...Medication orders at a minimum must include the following elements: legible name, military time preferred, date, drug name (generic or brand name), Dosage strength (metric nomenclature only), directions for use, route of administration, and indication for use for all PRN orders. Written indication for use for routine orders is preferred during order entry but is not required. The indication for use may be recorded somewhere in the patient medical record as an alternative."

1. Review on 06/21/2017 of Patient #8's medical record revealed physician medication orders with no indication for use. Review revealed on 06/06/2017 at 1450 Thorazine (medication to help with mental illness) 50mg IM x1 now and Benadryl (medication to reduce side effects of other medications) 50mg IM x1 now ordered with no indication for use documented. On 06/08/2017 at 2232 revealed Thorazine 50mg IM x1 now and Benadryl 50mg IM x1 now ordered with no indication for use documented. On 06/10/2017 at 1215 revealed Thorazine 50mg PO x1 now and Benadryl 50mg PO x1 now ordered with no indication for use documented. On 06/10/2017 at 1840 Zyprexa (medication to help with mental illness) 10mg PO x1 ordered with no indication for use documented. On 06/11/2017 at 0900 revealed Zyprexa 10mg PO x1 now and Benadryl 50mg PO x1 now ordered with no indication for use documented. On 06/11/2017 at 1823 revealed Zyprexa 10mg IM now x1 ordered with no indication for use documented. On 06/13/2017 at 1855 revealed Zyprexa 10mg IM x1 now and Benadryl 50mg IM x1 now ordered with no indication for use documented. On 06/20/2017 at 1850 revealed Zyprexa 10mg IM x1 now and Benadryl 50mg IM x1 now ordered with no indication for use documented. Review of the MAR (medication administration record) revealed the above medication were all given to Patient #8. Continued review of Patient #8's MAR failed to reveal documented indication for use of Benadryl, Thorazine, and Zyprexa for the above orders.

Interview on 06/21/2017 at 1600 with Administrative Staff (AS) #1 revealed employees were expected to have an indication for use for medication orders.

Interview on 06/22/2017 at 1533 with Medical Doctor (MD) #1 revealed when an order was written there "should be an indication for use."

2. Review on 06/22/2017 of Patient #11's medical record revealed physician medication orders with no indication for use documented. Review revealed on 06/20/2017 at 1501 revealed Zyprexa 20mg IM x1 now ordered with no indication for use documented. Review of Patient #11's MAR revealed the medication was given to Patient #11. Continued review of Patient #11's MAR failed to reveal documented indication for use of Zyprexa.

Interview on 06/21/2017 at 1600 with AS #1 revealed employees were expected to have an indication for use for medication orders.

Interview on 06/22/2017 at 1533 with MD #1 revealed when an order was written there "should be an indication for use."

3. Review on 06/22/2017 of Patient #1's medical record revealed physician medication orders with no indication for use documented. Review revealed on 04/04/2017 at 1400 revealed Melatonin (medication to help with sleep) 6mg PO QHS (at bedtime) ordered with no indication for use documented. Review of Patient #1's MAR revealed the medication was given to Patient #1. Continued review of Patient #1's MAR failed to reveal documented indication for use of Melatonin.

Interview on 06/21/2017 at 1600 with AS #1 revealed employees were expected to have an indication for use for medication orders.

Interview on 06/22/2017 at 1533 with MD #1 revealed when an order was written there "should be an indication for use."
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on policy and procedure review, observation, review of the "Special Intervention" log, staff interviews, and review of a work order and service call receipt, the facility staff failed to ensure the latching mechanism for the seclusion room doors functioned as intended at the Children's Campus on 3 of 4 doors observed.

The findings include:

Review revealed no policy available for the maintenance of the mechanical function of the opening mechanism for the four doors in the seclusion area of the Children's Campus.

Observation on 06/21/2017 at 1000 of the two seclusion suites in the Children's Campus revealed each suite on the South and the North wing held two seclusion rooms. Observation revealed one seclusion room door on the North wing had an opening mechanism that remained latched in the locked position when the door handle was released. Continued observation revealed both seclusion room doors on the South wing had opening mechanisms which remained latched in the locked position when the handle was released.

Review on 06/21/2017 of a "Special Intervention" log which included physical restraints and seclusions performed at the Children's Campus revealed three incidents of seclusion occurred on 01/09/201/, 01/15/2017 and 01/20/17 for "patient out of control" in the past six months.

Interview on 06/21/2017 at 1245 with AS #2 revealed three of four seclusion rooms had an opening mechanism that did not work as it was intended. Interview revealed the opening mechanism was supposed to return to the unlatched position when the handle was released allowing the door to open freely. Interview revealed RN #3 had not been made aware by the staff that the latching mechanism was not working as intended, and had not inspected for door function during previous EOC (Environmental rounds) Interview revealed a work order would be placed to assess the function of all opening mechanisms not the seclusion room doors. Further interview revealed the seclusion rooms had not been used since January 2017.

Interview on 06/21/17 at 1300 with AS #1 revealed there was no manufacturer information available for review related to the locking mechanisms on the seclusion room doors. Continued interview revealed the doors were to be replaced with the facility's next phase of renovation and the doors would be repaired in the interim. The interview confirmed the seclusion room door latching mechanism was not working as intended.

Review revealed a work order dated 06/21/2017 at 2116 stated "Please check locks on all seclusion room doors to make sure they do not lock without a staff person constantly holding them. Some were locking without "push back" from the handle."

Review of an invoice dated 06/22/17 revealed an "emergency road trip" by a locksmith for "Emergency service called in by (name) reporting the door in the confinement area trident multi point lock system chassis is broken on right side parts are on order to repair three doors once parts are received."
VIOLATION: CONTENT OF RECORD Tag No: A0449
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure review, medical record review, and staff interviews the facility failed to provide a complete discharge plan for 1 out of 6 discharge records reviewed (Patient #7).
The findings include:

Review on 06/20/2017 of the policy titled "Discharge Planning" last revised 04/2017 revealed " ...The Therapist/Case Manger is the responsible party for initiating, planning, and working with the patient, the family, the Treatment Team members, and outside resources to develop the Discharge Plan. The Therapist/Case Manager discuses aftercare with the patient and guardian(s). The Therapist/Case Manger schedules or facilitates the patient/parent scheduling after care appointments for patients needing an outpatient level of care and works with outside agencies and government agencies for patients needing referral to a group home or residential level of care. The Therapist/Case Manger is responsible for working with the patient, family members, and case managers for placement of patients in setting other than home ..."

Review on 06/22/2017 of Patient #7 medical record revealed a [AGE] year old male admitted on [DATE] with major depression. Patient #7 was discharged on [DATE] to a PRTF (Psychiatric Residential Treatment Facility). Review of "Social Services Progress Note" dated 04/05/2017 at 1230 signed by Therapist #2 revealed "Family Session With Patient, Patient's Mother, And hospital Therapist ...Patient And Patient's Mother Agreed To Move Forward With The plan that the patient will be transferred from the hospital to a long term residential treatment program. Patient does not have a scheduled discharge date as the patient is at risk of harming himself and others." Review failed to reveal any other notes about conversations with Patient #7's mother regarding discharge. Review of Patient #7's "Aftercare/Crisis Plan and Discharge Instructions" dated 04/27/2017 revealed "Transported by (transport security company) to (PRTF). Review failed to reveal documentation that Patient #7's guardian was notified of discharge instructions, aftercare and crisis plan. Nursing note dated 04/27/2017 at 1430 by RN #1 revealed " ...Pt. (patient) discharged to (transport security company) for transport to (PRTF). D/C (discharge) paperwork given to deputies. Pt. remained safe during admission." Review failed to reveal documentation that Patient #7's guardian was notified of Patient #7's discharge instructions and the PRTF Patient #7 would be discharged to.

Interview on 06/22/2017 at 1236 with Director of Social Services #1 revealed as soon as the facility found out about discharge they would notify the family. Continued interview revealed that communications with families should be documented in the medical record. Review of Patient #7's medical record with Director of Social Services #1 failed to reveal documentation about notification of the family about where the patient would be discharged to, their discharge summary, or aftercare/crisis plans.