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.

RED RIVER BEHAVIORAL HEALTH SYSTEM 1451 44TH AVENUE S GRAND FORKS, ND 58201 July 9, 2015
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, record review, policy and procedure review, and staff interview, the Hospital failed to protect and promote each patient's rights by failure to ensure care in a safe setting (Refer to A144); failure to provide care with privacy and dignity (Refer to A143); failure to ensure staff used restraints and/or seclusion in accordance with a physician's order (Refer to A168); failure to ensure completion/documentation of the one-hour face-to-face medical and behavioral evaluation following a restraint or seclusion (Refer to A184); failure to document the date and time of the patient's response to restraint or seclusion (Refer to A188); and failure to ensure registered nurses performing one-hour face-to-face evaluations of restrained/secluded patients received the appropriate training (Refer to A205). This placed all patients in serious and immediate jeopardy for harm.
The survey team determined an Immediate Jeopardy situation existed on July 9, 2015 at 11:04 a.m. related to suicide attempts by two inpatients. At 11:35 a.m., the survey team notified administrative staff members (#1, #2, #3, and #4) of the Immediate Jeopardy situation. The Hospital provided the following plan of correction on 07/09/15: staff removed door closures within the direct patient care areas; the Hospital assigned staff to monitor the fire doors on the geriatric unit until the Hospital can replace the hinges with a one-piece anti-ligature hinge; staff removed bed rails from the geriatric units and the low stimulation rooms; the Hospital restricted use of Room #448 until the Hospital can complete repairs scheduled for July 10, 2015; staff assessed and secured the locked areas of the low stimulation rooms; the Hospital educated staff on the security of the low stimulation rooms; the Hospital developed a policy pertaining to processing of orders for more restrictive patient checks and/or precautions; the Hospital re-educated staff on current policy for room checks and environmental safety rounds; a physician re-assessed the patients with suicidal precautions and determined the 15 minute checks were appropriate; the Hospital educated all staff currently providing care to patients; the Hospital will educate all staff not currently providing patient care before they work their next shift; the Hospital will hold an all staff meeting on July 14, 2015 to review all the information. The survey team verified implementation of the Hospital's plan and determined the Hospital abated the Immediate Jeopardy situation on 07/09/15 at 4:50 p.m. Condition level noncompliance continued post abatement.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on observation and staff interview, the Hospital failed to provide privacy and dignity for 3 of 11 sampled inpatients (Patient #6, #14, and #15) observed during medication administration, glucose monitoring, and personal cares. Failure to provide care in a dignified manner infringes on the patients' rights.

Findings include:

- Observation on 07/07/15 at 2:40 p.m. showed a nurse (#5) administered medication to a patient (#6) in a group therapy room with two other patients and a therapist present. During the observation, the patient requested a pain medication. The nurse discussed the medication information and availability during the group session.





- During an observation on 07/07/15 at 4:45 p.m., a nurse (#22) tested Patient #14 and #15's blood glucose in the lounge area where seven other patients and three staff played ball toss. The nurse (#22) failed to encourage/assist the patients to a private area before testing their blood glucose.

- During an observation on 07/08/15 at 7:45 a.m., a nurse (#23) assisted Patient #14 to the bathroom. The patient stood from her wheelchair and pulled her pants down, exposing her buttocks. Both the patient's bathroom door and the door to the corridor remained open while the patient used the bathroom, exposing the patient to those passing by in the corridor.

Upon request, the Hospital did not provide a policy regarding patients' rights to dignity and privacy.

During an interview on 07/09/15 at 1:10 p.m., an administrative nurse (#3) stated staff should test patient's blood glucose in a private area.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, record review, policy review, and staff interview, the Hospital failed to ensure care in a safe setting for 2 of 2 sampled patients in closed records (Patient #23 and #24) who attempted suicide while receiving care and treatment at the Hospital; for 3 of 3 patients (Patients #11, #25, and #27) when staff did not search their rooms according to facility policy; for 4 of 4 patients (Patients #1, #9, #10 and #11) the Hospital roomed in low stimulation (stim) rooms instead of on the patient units without proper monitoring, safety, and security in these areas; for 1 of 1 sampled patient in a closed record (Patient #26) identified as commingled with adolescent patients; for 3 of 4 units (geriatric, 500 unit, and 600 unit), 2 of 2 low stim areas, and 2 of 2 community restrooms observed (on geriatric unit and 600 unit) not free of safety hazards; and for 1 of 1 sampled patient in a closed record (Patient #25) who staff secluded in an area not designated for seclusion. Failure to provide care and treatment in a safe setting places patients at serious risk for injury.


Findings include:

Review of the facility policy "Patient Searches" occurred on 07/09/15. The policy, dated 10/08/14, stated: "Purpose: To establish a routine for patient searches upon admission and during hospitalization to maintain a safe and secure environment. . . . RESTRICTED ITEMS: . . . * Clothing with strings - staff must remove the strings. * Shoes with laces/strings - if patient is assessed as an acute safety risk . . . A room search will be facilitated once every day shift and once every pm [evening] for every patient room. . . . Results of room searches are documented on the Room Search Log . . . staff must be prepared for any patient's acting out behaviors."

Review of the facility policy "Patient Safety Checks" occurred on 07/09/15. The policy, dated 10/08/14, stated, ". . . each patient is monitored for safety. Patient Safety Checks are done to ensure the safety of patients and staff, maintain the location of all patients in the hospital and ensure that all patients are being monitored. . . . Definitions A. 15 Minute Safety Checks . . . are done on every inpatient . . . B. 5 Minute Safety Checks . . . done on patients whose high risk behaviors, symptoms, or outlying information puts them at risk for acute harm to self or others. Patients are in line of sight with staff at all times with the exception of bathroom use. C. 1:1 Safety Checks . . . Patients are in line of sight with staff at all times. . . . i.e. sleeping, bathroom use. . . ."

- Review of Patient #24's medical record occurred on July 7-9, 2015. Diagnoses included major depression, attention deficit hyperactivity disorder (ADHD), and trauma issues. The patient's admission occurred on 04/09/15. The physician admission orders included an order for suicide precautions and standard, 15 minute safety checks.

A discharge summary, dated 04/21/15, identified the hospital admitted Patient #24 for "increasing suicidal thoughts for the past few days. . . . The patient had stated she was going to strangle herself and that she 'has nothing to live for.' . . ."

The record included the following progress notes regarding the patient's suicidal ideation and events regarding two suicide attempts on 04/10/15:
* 04/09/15 at 1:55 p.m., Patient (pt) #24 informed a mental health technician (MHT) of plans to "hurt myself" and "no coping skills would work." The MHT informed a registered nurse (RN) the patient indicated on a scale of 1-10 "A ten" for the likelihood of hurting herself. An "Occupational Therapy Evaluation" form, handwritten by Patient #24 on 04/09/15, showed the patient wrote the reason for hospitalization as "because: I want to die." A "REPORT SHEET," dated 04/09/15, showed during the day shift (7:00 a.m. to 3:00 p.m.), Patient #24 told "staff that she is 'going to hurt myself"' and on the evening shift (3 p.m. to 11 p.m.) "reported to staff that she currently had suicidal ideation." The report sheet indicated the patient was on five minute checks on 04/09/15.

* 04/10/15 at 1:30 p.m., "Asked to come and see pt in her room by her roommate, stating she was 'in the bathroom and needed a nurse.' This nurse went down to room to [check] on pt. Pt reports she had just drank one bottle of liquid lotion soap (2 fl. oz [fluid ounces]) and one bottle of moisturizing lotion (4 fl. oz) and possibly a small amount of roll-on deodorant. Updated medical MD [medical doctor], poison control called. Update psych MD [psychiatrist] also & administration." Review of safety check monitoring forms showed the patient was on 15 minute safety checks until 12:15 p.m. and then on five minute safety checks.

* 04/10/15 at 1:45 p.m., "Charge RN notified this writer that pt self-reported 'I drank my shampoo, soap, and hand-lotion.' Pt reported to this writer, 'I thought it would kill me;' 'I just want to die, and now I want to die even more.' . . . Staff (this writer) conducted emergency room check of bathroom et [and] room. No contraband found. Staff utilized 1:1 monitoring of pt for safety . . . Pt noted to staff that it was hard to breathe, et that she asked previous MHT staff to talk, but was told to 'go to bed.' . . . Monitor SI [suicidal ideation]."

* 04/10/15 at 6:00 p.m., "Roommate again up to desk, requesting nurse reporting [sic] pt is 'purple.' To pt room for assessment. Pt leaning against wall, non-responsive cyanotic in color. Leather slipper lace around pt neck, fastened in a tie. Abruptly removed leather shoe lace from neck. . . . petechia [sic] to neck and outer face . . . room search completed. body search done and 1:1 staff started. . . . will cont [continue] [with] 1:1 monitoring."

* 04/10/15 at 10:17 p.m. a shift note regarding the 6 p.m. suicide attempt stated, "Writer was making the rounds and doing safety checks when pt's roommate told writer that pt was purple and in the bathroom. Writer ran to the bathroom to find the pt sitting against the wall and entire neck and face were purple. Pt was non-responsive. Writer did not initially see a lace of a slipper tied very tightly around pt's neck and immediately got the nurse. . . . Pt is now one on one. . . ." Review of report sheet showed the patient's suicide attempt occurred with a "moccasin leather string," and the attempted suicide by strangulation occurred "during quiet time." The safety check monitoring forms showed the patient was on five minute safety checks. Following the 1:30 p.m. incident, the medical record identified staff utilized 1:1 monitoring.

* 04/11/15 at 5:08 a.m., a progress note showed the night shift monitored the patient every 15 minutes and did not continue the five minute nor 1:1 monitoring.
* 04/11/15 at 10:00 p.m. ". . . Pt told staff that the soap was in her garbage from the previous day from when she drank the soap. She also told that the string from her shoes were just there but she did not make a plan to drink the soap or tie the string around her neck. . . ."

Physician's orders included a late entry verbal order written by a nurse from the child psychiatrist, dated 04/11/15 at 8:45 a.m., stating, "Do additional room search; Do patient search; 1:1 safety checks; Pt to wear scrubs."

A "MEDICAL PROGRESS NOTE," dated 04/10/15 (untimed), stated, ". . . patient seen emergently during medical rounding secondary to attempted suicide via strangulation. . . ." The progress notes lacked information regarding frequency of staff monitoring after the strangulation attempt. A "MEDICAL PROGRESS NOTE," dated 04/11/15 at 5:09 p.m., stated, ". . . Petechiae are improving on neck, cheeks, and forehead. . . . Attempted suicide follow-up. PLAN: . . . The patient continues to be one-to-one."

A "RN Daily Assessment/Mental Status" form, dated 04/10/15 (untimed), stated the patient had petechia [sic] bilaterally on the face and lacked additional information regarding the suicide gesture/attempt and evidence of on-going monitoring in the hours following.

On the afternoon of 07/06/15, an administrative staff member (#3) stated the hospital kept all patient Activities of Daily Living (ADL) supplies (personal items) locked in lockers (in the patients' rooms); only direct care staff have the keys to these lockers and if opened, staff must be present.

During interview on 07/08/15 between 4:30 p.m. and 5:30 p.m., an administrative staff member (#3) stated the patient had access to the ADL supplies as a parent brought in the patient's own supplies, and staff threw those given to her on admission in the garbage. Regarding the strangulation attempt, the staff member stated the Hospital allowed patients to have shoes with laces; however, the shoes must always be on their feet or the hospital required staff to lock up the shoes. The staff member stated staff monitor patients' shoes with every 15 minute check and in group therapy.

During interview on 07/08/15 at 5:30 p.m., an administrative staff member (#3) stated nurses give report based on written provider orders to direct care staff; and since the provider did not write an order for the 1:1's until the day after the strangulation incident, the nursing staff failed to inform the MHTs until the following day. When asked how MHTs and CNAs have awareness of the plans of care, Staff Member #3 stated the MHTs and CNAs have access to the patients' charts.

The Hospital failed to take a proactive approach of removing all potential environmental hazards, including ADL supplies and the leather shoe lace; failed to recognize the shoe lace on the patient's neck with the first observation and respond accordingly to remove the lace; failed to provide closer monitoring after the initial attempt; and failed to provide closer monitoring (1:1) of the patient after the strangulation attempt until the provider wrote orders eight hours after the incident. This resulted in avoidable significant risk of harm to Patient #24.

- Review of Patient #23's medical record occurred on July 7-9, 2015. Diagnoses included disruptive mood dysregulation disorder and conduct disorder. The patient's admission to the facility occurred on 03/16/15. The physician admission orders included an order for suicide precautions and standard, 15 minute safety checks. Review of safety check monitoring forms showed the patient on 15 minute safety checks until midnight on 03/19/15 and then on five minute safety checks.

A discharge summary, dated 03/26/15, stated Patient #23, "was admitted after making threats to slit his wrist or hang himself. The patient made statements that I am going to 'kill myself' . . . has a history of suicide attempts and has been making statements such as 'I don't want to be here anymore and I just want to end it off.' [sic] . . . On 03/20/1 [sic], an order was written to place the patient on one-to-one with staff present at all times due to attempting to hang himself for the patient's safety . . . patient denied suicidal ideation early on hospitalization but attempted a suicide gesture by hanging a bed sheet to the top hinge of his bedroom door and wrapping around his neck. . . . The patient was placed on one-to-one safety checks and monitored for 24 hours. . . ."

Included in the record, an "RN Daily Assessment/Mental Status," dated 03/19/15 at 11:25 p.m. lacked information regarding the suicide gesture/attempt and evidence of on-going monitoring in the hours following.

The record included the following nursing progress notes written by MHT staff regarding the patient's suicide attempt:
* 03/20/15 at 12:18 a.m., "Pt was observed outside the classroom with a bed sheet tied to the top hinge and the other end around his neck. Pt was standing - on the floor with no imminent danger. Writer and other staff tried to talk pt out of his pending decision but did not listen. Code 99 [used to call for staff assistance] was ordered. Pt threatened to 'drop on the count of 3' if we did not tell him what a code 99 was. Pt refused redirection and proceeded to drop from the hinge. Writer and other staff immediately untied the sheet from the hinge and lowered pt to the ground. Bed sheet was then removed from around neck . . ."
* 03/20/15 at 3:00 a.m.; ". . . being monitored 1:1 in pt room . . ."
* 03/20/15 at 5:30 a.m., ". . . pt observed [every] 5 min [minutes] . . ."
* 03/20/15 at 1:29 p.m.; progress note indicated staff monitoring the patient 1:1 and the patient responded negatively to the staff member informing him to "leave bathroom door open while pt used bathroom."

A physician's order, on 03/20/15 at 6:00 a.m., stated, "1:1 acuity (with staff at all times) due to attempting to hang self. Patient safety;" and an order for a "Soft tissue" x-ray of the neck.

A medical progress note, dated 03/21/15, stated, ". . . Nursing reports that this patient tied the bed linen around his neck and attempted to strangulate himself. Prior to any loss of consciousness, the patient was assisted and the linen was taken away. . . ." A medical progress note, dated 03/22/15, stated, ". . . This patient had a soft tissue of the neck x-ray done . . . IMPRESSION: 1. Status post self-strangulation with bed linen. 2. Neck contusion . . ."

Review of the incident report stated the incident occurred on 03/19/15 at 10 p.m.; occurred in the adolescent unit hallway; "Pt was found in the adolescent hallway with his bed sheets strapped around his neck and tied to one of the door's hinge. Pt refused to take down the bed sheets and stated 'I want to kill my self, I don't care.'"

During interviews on 07/07/15 at 2:00 p.m. and 3:00 p.m., an administrative staff member (#3) stated the incident with Patient #23 was attention getting behavior and occurred from a door hinge located outside of the group room in the adolescent wing. The Hospital closed the unit now due to renovation, and since the incident staff removed the hinge. The staff member stated the room is located in a hallway where view by facility staff could occur (versus around a corner of the hallway).

During interview on 07/09/15 at 8:05 a.m., a supervisory nurse (#4) stated when a nurse determines a change occurred with a patient, the nurse notifies the physician and communicates this through report sheets. The nurse stated the physician determines when a change in frequency of monitoring a patient should occur, i.e. 1:1, five minute, or 15 minute checks.

The Hospital failed to take a proactive approach of removing all potential environmental hazards; failed to respond appropriately and promptly remove a sheet tied around Patient #23's neck prior to the patient dropping to the floor during the suicide attempt; failed to include a physical assessment and ongoing assessment by professional nursing staff following the suicide attempt; failed to provide close monitoring (1:1) of the patient after the incident until the provider wrote orders eight hours after the incident. This resulted in a potentially avoidable significant risk of harm for Patient #23.

- Review of Patient #11's medical record occurred on July 7-8, 2015. A MHT shift review sheet, dated 07/04/15 at 5:00 p.m., stated the staff member did not complete a room search due to low staffing.

- Review of Patient #25's medical record occurred on July 7-8, 2015. A MHT review sheet, dated 05/30/15 at 11:00 p.m., stated the staff member did not complete a room search and documented, "No time for room checks."

- An incident report, dated 03/29/15 at 1:30 p.m., for Patient #27, stated while the nurse assessed the patient's skin, the nurse asked the patient "what she had harmed herself with. Pt stated 'something I brought with me but I lost.' Staff went through belongings found underwire broken in 1/2 with sharp edges" and "object brought in with her. . . ." Facility review of the incident identified the potential contributing factor as "Lack of monitoring." The facility did not document the severity of the incident (on scale of A to I) and failed to determine and implement an "Action Plan to Prevent Reoccurrence."

- On 07/06/15 at 1:50 p.m. four administrative staff members (#1, #2, #3 and #4) informed the survey team of the patient census and reported the location of current patients (adults and geriatrics) in two of four nursing units and two patients (one child and one adolescent) in one of two low stimulation (stim) areas. An administrative staff member (#3) stated staffing depends on the acuity level of patients and how many units the facility has open. The staff member stated staff keep the low stim unit unlocked and a group room is available in each low stim unit for programming.

Observation on 07/06/15 at 5:05 p.m., identified Patient #11 (a child) and Patient #10 (an adolescent) roomed/boarded in rooms in the low stim unit located on the left side of the nurses' station. A staff member (#8) reprimanded Patient #11 upon entering the group/activity room where Patient #10 worked on an activity. The staff member (#8) stated children and adolescents cannot be in the same area of the low stim unit even for meals. During this time, the staff member (#8) supervised Patient #10 and another unidentified staff member entered the unit from a side door and sat with Patient #11 in a different room throughout the meal. Observation showed the low stim door unlocked with access to the adjacent adult unit. Observation at 5:30 p.m., showed Patient #11 entered the adjacent adult unit, an unidentified staff member followed the patient, and two or three adult patients were present in the same area of the hallway.

Review of Patient #11's medical record occurred on July 6-7, 2015. A nursing progress note, dated 07/06/15 at 6:45 p.m., stated "Pt was trying to shut the doors to low stim so they lock; staff redirected and prompted pt multiple times to stop playing with the doors."

- Review of Patient #26's medical record occurred on July 7-9, 2015. Diagnoses included disruptive mood dysregulation, ADHD, and history of head banging. The record identified Patient #26 as seven years old. A progress note, dated 04/03/15 at 1:06 p.m., stated, "Pt came up to staff before lunch and told staff that Pt was not afraid [sic] of two male adolescents. Staff asked patient who [sic] pt was afraid of . . . continue to monitor fearful behaviors towards peers."

On 07/07/15 at 7:50 a.m., observation showed two patients in one of the low stim areas. Patient #9 (an adolescent) boarded in one room and Patient #1 (an adult) boarded in a different room. Patient #1 stated she exited the low stim area through the back door into an empty patient unit and described the surroundings in that unit. At 8:30 a.m., the back door to the low stim unit remained unlocked and failed to latch with a gentle closure.

On 07/07/15 at 8:05 a.m., Patient #10 and Patient #11 roomed in the other low stim area. Observation showed the area had access to an empty patient unit through an unlatched back door. A staff member (#6) identified the door as locked. Two staff members (#6 and #7) supervised each patient separately in this area. Staff member #6 reported working at the facility for six months and this was the third day in the low stim unit. Staff member #7 reported working at the facility since the beginning of March and this was the first day in the low stim unit. Both staff reported the Hospital hired them as certified nursing assistants (CNAs). Staff Member #7 reported the Hospital had not provided MHT training. At 9:00 a.m., the door remained unlocked.

During interview, on 07/07/15 at 3:25 p.m., an administrative staff member (#4) stated if the Hospital census increased the Hospital would open and staff separate units for the children and adolescents, and the Hospital would not utilize the low stim area for boarding. When asked regarding the protocol for staff requiring emergency assistance in the low stim area, the staff member stated the Hospital instructs staff in those locations to leave for help. The staff member identified the use of visual and audio monitoring in the low stim area. During observation on all days of survey, there was no evidence of staff observing the visual monitoring equipment or listening to the audio monitoring equipment for the low stim areas.

- During all days of survey, observation of the Hospital identified the following potentially unsafe areas:
* In the geriatric unit - two double doors attached to the wall with adjustable door closures propped open. The door closure created an open space with a gap large enough to use a device and/or clothing for looping.
* In both low stim units - doors when opened had a space/gap large enough to use a device and/or clothing for looping. During observation on the morning of 07/07/15, two patients roomed in the low stim area (Rooms 448 and 449) without staff present.
* In a low stim unit - an exit door failed to latch after passing through; this door allowed entrance into the locked geriatric unit.
* In both low stim units - back doors not latched. During observation on the morning of 07/07/15, two patients roomed in the low stim area (Rooms 448 and 449) without staff present.
* In two closed units (500 unit rooms and 600 unit rooms) - door closures with gaps between the door and the closures.
* In the community restrooms of the 600 unit and the geriatric unit - horizontal grab bars with open spaces behind the toilet and on the left side of the toilet.
* In the low stim unit - on the morning of 07/09/15, exposed wires hanging from the ceiling in Room 448
* In the geriatric unit - side rails on patients' beds with open spaces of 8 inches by 11 inches and two beds with metal side rails
* In the low stim unit - one bed with a side rail in Room 448
The presence of side rails on beds may pose a safety risk including entrapment and strangulation.
- Review of the facility policy "Restraint and Seclusion" occurred on 07/06/15. The policy, dated 08/13/14, stated, ". . . Seclusion or physical/chemical restraint are allowed to be used in an emergency situation in which there is imminent danger to the patient . . . Use only appropriate rooms and ensure the patient is free from potentially hazardous objects . . ."

Review of Patient #25's medical record occurred on July 7-9, 2015. The record identified a seclusion intervention occurred on 05/25/15 in a low stim room and showed the patient hit the window with a shoe. Observation on all days of survey showed a large window in each low stim room and no windows in the seclusion rooms. Utilizing a low stim room for seclusion poses a safety hazard.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on record review and policy review, the Hospital failed to ensure staff used restraints and/or seclusion in accordance with a physician's order for 3 of 3 sampled patients (Patient #21, #25, and #26) reviewed in closed records for the use of restraint and/or seclusion procedures. Failure to obtain a physician's order has the potential to violate the patient's right to be free of restraints.

Findings include:

Review of the facility policy "Restraint and Seclusion" occurred on 07/06/15. The policy, dated 08/13/14, stated, ". . . Seclusion or physical/chemical restraint are allowed to be used . . . in accordance with the order of the attending or on-call physician . . . Physicians are responsible for supplying the initial order . . ." Review of the facility form for documentation of physician orders regarding the use of restraint and seclusion stated, "Time Secluded/Restrained (Check each that apply)."

- Review of Patient #26's medical record occurred on July 7-9, 2015. Diagnoses included disruptive mood dysregulation, attention deficit hyperactivity disorder (ADHD), and history of head banging.

Review of the physician orders below showed verbal orders (co-signed by the physician) failed to identify the specific intervention (restraint and/or seclusion) and/or staff failed to obtain an order for all restraint or seclusion procedures:
* 04/10/15 at 12:40 p.m.: the order failed to identify if staff could use a restraint or seclusion intervention. The progress notes identified staff utilized a restraint and seclusion intervention. The progress notes stated, "assisted to low stim [stimulation] area into seclusion room . . ."
*04/13/15 at 10:30 p.m.: "(D) [Data] Around 5:20 p.m. pt [patient] was found in his room sitting in the corner of his room hitting his head against the wall. . . . staff yelled for help from nurse et [and] put pt [patient] in CPI [Crisis Prevention Intervention] hold. . . ."
* 04/16/15 at 11:45 p.m.: stated staff "therapeutically carried" Patient #26 to their room. The record lacked a physician's order for the intervention.

- Review of Patient #25's medical record occurred on July 7-9, 2015. Diagnoses included bipolar I disorder, disruptive mood dysregulation, ADHD, post traumatic stress disorder (PTSD), conduct disorder, and history of head banging.

Review of the record showed facility staff failed to identify in a verbal order (co-signed by the physician) the specific intervention (restraint and/or seclusion) and/or failed to get an order for the following restraint procedure:
* 05/24/15 at 10:45 p.m.: ". . . Staff et RN [registered nurse] assisted pt to low stimulation unit as he kicked et fought all the way. . . ." The record lacked evidence of a physician's order for the restraint intervention.
* 06/04/15 at 6:36 p.m.; ". . . therapeutically restrained et [and] assisted back to seclusion room. . . ." The record lacked evidence of a physician's order for the restraint intervention.





- Review of Patient #21's closed medical record occurred on July 8-9, 2015. Diagnoses included disruptive behavior disorder, reactive attachment disorder, and precautions for aggression, elopement, and self harm.

The following physician orders failed to identify the intervention used (restraint or seclusion):
* 11/24/14 at 1:15 p.m.: the progress notes identified staff utilized seclusion.
* 11/24/14 at 3:15 p.m.: the progress notes identified staff utilized seclusion.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0184
Based on policy review and record review the Hospital failed to ensure the completion/documentation in the patient's medical record of the one-hour face-to-face medical and behavioral evaluation following a restraint or seclusion intervention for 1 of 3 sampled patients (Patient #25) reviewed in a closed record. Failure to ensure complete documentation of the one-hour face-to-face evaluation following a restraint or seclusion intervention limits the Hospital's ability to ensure the patient's safety and well-being.

Findings include:

Review of the facility policy "Restraint and Seclusion" occurred on 07/06/15. This policy, dated 08/13/14, stated, ". . . Seclusion or physical/chemical restraint are allowed to be used in an emergency situation . . . A trained . . . registered nurses (RN) may . . . evaluate a patient within 1 hour after initiation if a restraint or seclusion is used. . . ." The nurse completes the physical and psychological assessment to determine the patient's condition following the restraint and/or seclusion intervention.

- Review of Patient #25's medical record occurred on July 7-9, 2015. Diagnoses included bipolar I disorder, disruptive mood dysregulation, attention deficit hyperactivity disorder (ADHD), post traumatic stress disorder, conduct disorder, and history of head banging.

Review of a documented restraint and/or seclusion intervention identified nursing staff failed to complete or document the one-hour face-to-face medical and behavioral evaluation:
* 05/24/15 at 6:50 p.m. a seclusion intervention occurred. The nurse failed to complete and/or document the review of systems assessment including an assessment of the patient's neurological, cardiovascular, pulmonary, muscular skeletal, skin integrity, and gastrointestinal systems.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0188
Based on policy and record review, the Hospital failed to document the date and time staff discussed a restraint and/or seclusion event afterwards with the patient and the patient's response (debriefing) for 3 of 3 sampled patients (Patients #21, #25, and #26) who experienced a restraint and/or seclusion intervention. Failure to document the date and time of restraint/seclusion debriefings limits the Hospital's ability to ensure staff performs debriefings within 24 hours of the event according to policy.

Findings include:

Review of the facility policy "Restraint and Seclusion" occurred on 07/06/15. The policy, dated 08/13/14, stated: ". . . D. Releasing the patient and integrating them back into the milieu . . . 3. Debrief the patient regarding the event (using the debriefing form). This is to be done by a registered nurse or designee and can include staff involved, members of the treatment team, families, etc. Debriefing will be done as soon as possible but no longer than 24 hours after the episode. During the debriefing the patient and staff shall discuss: a. identification of what led to the event and what could have been handled differently. b. which alternatives were used and why they were not effective c. how the patient's physical well-being, psychological comfort and right to privacy was addressed d. whether any trauma resulted from the incident . . ."

Review of the following restraint and/or seclusion interventions indicated staff failed to include the date and time of debriefing after the event:

- Patient #25 on 05/24/15, 05/25/15, 06/02/15, and 06/04/15.

- Patient #21 on 11/15/14, twice on 11/24/14, 11/26/14, and 11/28/14.

- Patient #26 on 04/04/15, 04/09/15, 04/10/15, and 04/11/15.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0205
Based on policy review, record review, and staff interview, the Hospital failed to ensure registered nurses (RNs) performing one-hour face-to-face evaluations of restrained/secluded patients received the appropriate training for 6 of 6 RNs' (#3, #4, #10, #11, #12, and #13) files reviewed. Failure to ensure RNs have the appropriate training to perform the one-hour face-to-face evaluations limits the Hospital's ability to ensure the safety of restrained/secluded patients.

Findings include:

Review of the policy "5200_5039.0 Restraint and Seclusion" occurred on 07/08/15. This policy, effective 08/13/14, stated, ". . . 6.0 Procedures . . . Initiating and Ordering Restraint or Seclusion: . . . 2. . . . Trained RN, NP [nurse practitioner], PA [physician's assistant] Interventions at time of 1 hour face-to-face evaluation: 1) Conduct an assessment and document all findings and interventions. 2) Perform a face to face observation of the patient's condition. . . ."

Review of the policy "5200_5043.0 Staff Education and Training for Use of Restraint and Seclusion" occurred on 07/08/15. This policy, effective 08/13/14, failed to include education and training requirements for RNs performing the one-hour face-to-face evaluations of restrained/secluded patients.

Reviewed on July 8-9, 2015, the 2014-2015 training records of the following RNs failed to include training documentation associated with the one-hour face-to-face monitoring of the physical and psychological well-being of restrained/secluded patients including respiratory and circulatory status, skin integrity, and vital signs: RNs #3, #4, #10, #11, #12, and #13.

During an interview on 07/08/15 at 5:35 p.m., an administrative nursing personnel (#3) confirmed the training records for the RNs performing the one-hour face-to-face evaluations of restrained/secluded patients did not include assessment of respiratory and circulatory status, skin integrity, and vital signs.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, record review, policy and procedure review, professional literature/reference review, incident and accident report review, quality assurance meeting minutes review, and staff interview, the Hospital failed to assess for signs and symptoms of pain and implement effective interventions, failed to evaluate the safe use of side rails, failed to assess each patient individually prior to utilizing side rails, failed to consider side rails as a potential fall and entrapment hazard, failed to provide education to the patient and responsible party regarding the hazards of side rail use, failed to ensure appropriate use of assistive devices to prevent accidents, failed to implement interventions to aid in the healing of pressure ulcers, failed to ensure nursing supervision and evaluation of care occurred for patient events identified in incident reports, implement an action plan in relation to these incidents, and ensure the completion of an assessment occurred (Refer to A395); failed to ensure the development and revision of the "Master Treatment Plan" (plan of care regarding psychiatric issues), and/or nursing care plan to provide direction for individualized patient care based on the assessment of the patient's behavioral/nursing care needs (Refer to A396); and failed to ensure physician ordered medications were available to patients in a timely manner, nurses accurately administered patient medications as ordered and/or documented medications administered on the medication administration record (Refer to A405). Failure of nursing staff to adequately take care of the needs of the patients places all patients at risk of pain, harm, and injury and may decrease their quality of life.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

PAIN MANAGEMENT

1. Based on record review, facility policy review, and staff interview, the Hospital failed to ensure a Registered Nurse (RN) supervised and evaluated the nursing care for each patient to assess for signs and symptoms of pain and implement effective interventions for 3 of 20 active patient records (Patient #6, #7 and #13) and for 1 of 10 closed patient records (Patient #28) reviewed. Failure to address patients' pain decreases their quality of life and well-being and contributes to behaviors and insomnia.

Findings include:

Review of the facility policy titled "Pain Assessment and Management" occurred on 07/07/15. This policy, dated 08/13/14, stated, ". . . The self-report of pain by a patient is considered sufficient evidence to establish pain as a problem/need/nursing diagnosis . . . If a patient reports the presence of pain, a more detailed history of the acute pain will be taken and may include the following data: *Location . . . *Duration . . . *Description *Intensity Rating . . . *Current medications for pain and what works best . . . *Patient's emotional and behavioral expressions of pain . . . Nursing is responsible to obtain initial assessment and reassessments of pain and for documenting results of action taken for pain management . . . Patient Education . . . *The patient's right to controlled pain. . . ."

- Review of Patient #6's medical record occurred on 07/07/15. Diagnoses included a left foot surgery in April 2015, depression, and anxiety. A physician's admission order, dated 07/06/15 at 10:05 p.m., stated to continue oxycodone 5/325 milligrams (mg) every 6 hours PRN (as needed) for pain.

Observation during medication pass on 07/07/15 at 2:40 p.m., showed Patient #6 requested a pain medication from the nurse (#5). The nurse explained to the patient that nursing staff failed to order the medication that morning and the pharmacy would deliver the medication about 5:00 p.m. Interview with the nurse (#5), after the above interaction, identified the patient recently had foot surgery, wore a brace, and used oxycodone PRN for pain.

The nurse failed to assess the patient's pain, offer an alternative for pain management, and correctly process the order for Patient #6's PRN pain medication. The Hospital received the patient's pain medication from the pharmacy approximately 19 hours after the order.

- Review of Patient #7's medical record occurred on 07/07/15. Diagnoses included osteoporosis psychosis, and suicidal ideation with a plan. A physician's admission order, dated 07/07/15 at 12:50 a.m., stated to continue Morphine (MS Contin) 30 mg tablet by mouth three times daily for pain and Morphine 15 mg by mouth every four hours PRN for pain. The patient's medical record lacked evidence staff documented the pain assessment/need. The Hospital received the patient's scheduled and PRN pain medication from the pharmacy approximately 16 hours after the order.

Observation on 07/07/15 at 3:00 p.m., showed Patient #7 at the nurses' station requesting scheduled pain medication. An unidentified staff nurse explained the pharmacy would deliver the medication around 5:00 p.m.

During an interview on 07/07/15 at 5:00 p.m., a nursing staff member (#9) stated nursing staff failed to process the orders correctly which made the medications unavailable to the patients until after 5:00 p.m. on 07/07/15. Staff failed to have the physician sign a prescription form for the narcotics and fax the form to the pharmacy for either the noon or 5:00 p.m. deliveries.

Observation on 07/07/15 at 5:05 p.m. identified Patient #7 at the door of the work station visibly agitated and asking the nurse for Morphine. Patient #7 stated, "You have been [expletive] telling me it [Morphine] is coming since noon. I'm going through withdrawals. I could take better care of myself at home!"

During an interview on 07/08/15 at 9:45 a.m., a administrative nurse (#3) verified the above process for ordering narcotics. The nurse stated the pharmacy would deliver between scheduled times or staff could notify her (Nurse #3) to pick-up medications. Staff failed to contact the nurse (#3) regarding the patients need for pain medications on 07/07/15.

- Review of Patient #13's medical record occurred on all days of survey and identified the Hospital admitted the patient on 06/16/15. Diagnoses included dementia with behaviors and depression.

Observation on 07/07/15 at 9:40 a.m. showed three certified nursing assistants (CNAs) (#14, #16, and #21) in Patient #13's room to assist him with transfers, toilet use, and personal cares. Patient #13 grimaced and stated, "Ow!" twice during the transfer. Review of Patient #13's Nursing Progress Notes and PRN Medication Administration Record (MAR) lacked a timely pain assessment and interventions to address the patient's discomfort.

Review of Patient #13's Nursing Progress Notes identified the following:
*07/06/15 at 5:15 a.m. - ". . . Pt [patient] up upon arrival in wheelchair. Pt cooperative with cares but yelling out slightly during cares due to soreness. but other than that, cooperative with cares. . . ."
*07/06/15 at 6:00 p.m. - ". . . Pt was observed to be cooperative [with] cares although did yell out [and] c/o [complain of] hip pain during repositioning . . . Assisted pt to toilet [and] reposition . . . Resistive to allow staff to reposition. When up in dayroom Pt is boundary intrusive wheeling self into peers. Touching peers . . . Redirects provided . . . Continue to monitor. . . ."
*07/07/15 at 6:30 a.m. - ". . . Pt cooperative w/ [with] cares . . . Pt in pain when repositioning . . . assisted pt when need [sic] . . . Pt constant motion. Confused. Several attempts to stand. . . ."

Review of Patient #13's physician's orders identified no scheduled pain medications and acetaminophen 325 mg by mouth every six hours PRN for pain or fever, ordered on [DATE]. Since admission, staff administered PRN acetaminophen on 07/05/15 at 6:00 a.m. for an increased temperature of 99.7 degrees Fahrenheit (F) and on 07/07/15 at 2:00 p.m. for right leg pain (more than four hours after the patient expressed pain during cares/transfer at 9:40 a.m.). The MAR lacked evidence staff assessed and treated Patient #13's sign/symptoms of pain identified in the Nursing Progress Notes on 07/06/15 at 5:15 a.m., 07/06/15 at 6:00 p.m., 07/07/15 at 6:30 a.m., and observed by CNAs on 07/07/15 at 9:40 a.m.

- Review of Patient #28's medical record occurred on July 8-9, 2015 and identified the Hospital admitted the patient on 05/14/14. Diagnoses included chronic pain, osteoarthritis, history of leg and pelvic fractures, recurrent left hip dislocation, atypical psychosis, and a Stage 4 pressure ulcer (first noted on 05/16/14).

Patient #28's scheduled pain medications included hydrocodone/acetaminophen three times daily and Lidoderm patches on for 12 hours a day. PRN pain medications included Tylenol 650 mg by mouth every four hours.

Review of a Psychiatric Progress Note, dated 07/08/14, stated, ". . . Acknowledges pain but then can't tell me where she hurts. . . ."

Patient #28's Nursing Progress Notes identified the following:
*05/19/14 untimed - ". . . pt crying [and] screaming out a lot during the day. sat quietly in chair . . . staff assisted [with] cares . . . pt was loud . . . encourage pt to stay quiet."
*05/21/14 at 6:40 a.m. - ". . . awoke [and] yelled at random times throughout the night, but slept well for the most part . . . redirection for the yelling behavior . . ."
*05/30/14 at 6:00 a.m. - ". . . Pt was hitting out, loud, yelling during cares. Pt was redirected . . ."
*05/30/14 untimed - ". . . pt was yelling swearing loudly all day . . . bed early still yelling for help . . . encourage pt to be quiet, telling her friends are sleeping."
*05/31/14 untimed - ". . . Pt was combative with cares Pt was yelling all day . . ."
*06/09/14 at 6:00 p.m. - ".. . Pt was yelling [and] screaming . . . staff assisted pt [with] cares. Staff would check on pt. when was heard yelling . . ."
*06/11/14 at 7:00 a.m. -". . . pt kept yelling all noc. [night] pt refused any snacks and fluids. pt was yelling during cares and would screamed [sic] when turned over. pt did not sleep well . . . kept yelling most of the night and doing [sic] the morning . . ."
*06/12/14 at 7:00 p.m. - ". . . she was yelling most of the day and didn't eat her meals very well . . . pt was yelling all day . . ."
*06/13/14 at 6:30 p.m. ". . . Pt yelling out during AM [morning] cares. Pt. yelling in day room . . ."
*06/14/14, untimed - ". . . Pt yelling and screaming in room [and] day room - does not appear to have any stimulus for yelling episodes . . ."
*06/22/14 at 7:00 p.m. - ". . . Pt was grinding teeth and yelling out throughout the day . . . Pt was redirectable at times . . ."
*06/23/14 at 7:00 p.m. - ". . . Pt was yelling out all day . . . Pt was friendly but yelled at the staff when tried helping changing [sic] her . . ."
*06/26/14 at 7:00 p.m. - ". . . Pt yelled out throughout the day . . . Pt was redirectable . . ."
*07/01/14 at 7:00 p.m. - ". . . pt was yelling out after lunch. pt kept to self. cooperative [with] cares . . . pt continued to yell out . . ."
*07/02/14 at 7:00 p.m. - ". . . Pt yelled out a couple times after lunch . . . Attempted to redirect . . . pt. continued to yell out in day room . . ."
*07/03/14, untimed - ". . . pt would yell out when being turned during cares . . ."
*07/17/14 at 6:30 p.m. - ". . . pt slept most of the day. She would whine a lot . . ."
*07/18/14 at 6:30 p.m. - ". . . Yelling out at times . . ."
*07/19/14 at 6:45 p.m. - ". . . In the afternoon pt. started to yell continuously . . . Staff assisted as needed and provided redirection . . . Pt was non-compliant . . ."
*07/20/14 at 6:40 a.m. - ". . . yelling out throughout the noc . . ."
*07/21/14 at 6:50 p.m. - ". . . Pt was fidgeting and yelling throughout shift . . . Pt was cooperative with staff, but remained restless and continued to yell . . ."
*07/22/14 at 7:05 a.m. - ". . . pt was cooperative with staff, but tired and was yelling . . ."
*07/22/14 at 6:50 p.m. - ". . . pt was in pain it seemed during cares . . . staff moderated [sic] pt PRN . . ."
*07/23/14, untimed - ". . . pt would yell during cares . . ."
*07/23/14 at 7:00 p.m. - ". . . Pt was cooperative [with] AM cares but yelling out at times . . ."
*07/24/14 at 6:20 a.m. - ". . . pt was yelling during cares . . ."
*07/24/14 at 6:00 p.m. - ". . . Pt would scream out in pain during a.m. cares . . . Provided reassurance [and] redirection . . .@ [at] times does yell out not redirectable . . ."
*07/25/14 at 7:00 p.m. - ". . . Pt yelled out during cares and while in the dayroom . . . Pt was nonredirectable from yelling . . ."
*07/26/14 at 6:30 a.m. - ". . . Pt tired, screaming during HS [bedtime] cares . . ."
*07/26/14 at 6:00 p.m. - ". . . Pt was cooperative [with] a.m. cares did yell out when completing peri-cares . . . Brought to dayroom where she was [with] peers. Did yell out @ [at] random moments . . . Nurse notified to assess for PRN medication . . ."
*07/29/14 at 6:30 p.m. - ". . . Pt would yell out @ times . . . staff would then attempt to provide redirection by interacting [with] pt . . . Pt was not redirectable continued to yell out . . ."
*07/31/14 at 6:35 a.m. - ". . . Pt slept through night occasionally yelling out . . . staff assisted [with] cares and helped pt into bed repositioning patient as needed throughout the night . . ."
*07/31/14 at 7:00 p.m. - ". . . Cries out in pain during peri cares . . ."
*08/12/14 at 7:10 a.m. - ". . . Pt yelled on [and] off through out [sic] the NOC shift . . ."
*08/29/14 at 7:00 p.m. - ". . . Pt was quiet [and] tired most of shift, yelling out occasionally . . . Pt was reposition [sic] when agitated . . . Pt calmed . . . continue to monitor agitation, reps [reposition]."
*09/09/14 at 7:30 a.m. - ". . . Pt did seem to yell out in some pain . . . continue to advise staff to keep off coccyx [and] rotate frequently . . ."
*09/10/14 at 6:45 a.m. - ". . . Pt was crying during cares but cooperative . . ."

Patient #28's Nursing Progress Notes, RN Daily Assessments, and MAR lacked evidence staff assessed and treated Patient #28's sign/symptoms of pain (yelling, agitation, etc).

During an interview on 07/09/15 at 1:10 p.m., an administrative nurse (#3) stated staff should consider pain as a causative factor for patients exhibiting behaviors such as yelling/agitation. The nurse (#3) stated she expected staff to assess and implement interventions in a timely manner when patients experienced signs and symptoms of pain.





SIDE RAILS

2. Based on observation, record review, policy review, professional literature review, and staff interview, the Hospital failed to evaluate the safe use of side rails, failed to assess each patient individually prior to utilizing side rails, failed to consider side rails as a potential fall and entrapment hazard, and failed to provide education to the patient and responsible party regarding the hazards of side rail use for 6 of 8 active geriatric patients (Patient #2, #12, #13, 16, #17, and #18) and 2 low stimulation rooms (Room #448 and #449) observed with elevated side rails and 1 of 1 closed geriatric record (#29) of a patient who fell from bed with the side rails elevated. Failure to assess and evaluate the use of side rails has the potential to restrict a patient's movement, and may be a potential entrapment and fall hazard which places patients at risk of injury.

Findings include:

The Hospital Bed Safety Workgroup (HBSW) publication titled, "Clinical Guidance for the Assessment and Implementation of Bed Rails in Hospitals, Long Term Care Facilities, and Home Care Settings, dated April 2003, stated, ". . . bed rails may pose increased risk to patient safety. . . . evidence indicates that half-rails pose a risk of entrapment . . . as well as falls that occur when patients climb over the rails or footboards when the rails are in use. . . . CMS [Centers for Medicare and Medicaid Services] issued guidance in June 2000 . . . One section of the guidance states, 'It is important to note that side rails present an inherent safety risk, particularly when the patient is elderly or disoriented. Even when a side rail is not intentionally used as a restraint, patients may become trapped between the mattress or bed frame and the side rail. Disoriented patients may view a raised side rail as a barrier to climb over, may slide between raised, segmented side rails, or may scoot to the end of the bed to get around a raised side rail. When attempting to exit the bed . . . the patient is at risk for entrapment, entanglement, or falling from a greater height posed by the raised side rail, with a possibility for sustaining greater injury or death than if he/she had fallen from the height of a lowered bed without raised siderails. . . . The population at risk for entrapment are patients who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain . . . 1. Regardless of the purpose for which bed rails are being used or considered, a decision to utilize . . . those in current use should occur within the framework of an individual patient assessment. . . . 3. Use of bed rails should be based on patients' assessed medical needs and should be documented clearly . . . The patient's chart should include a risk-benefit assessment that identifies why other care interventions are not appropriate or not effective if they were previously attempted . . . The care plan should include educating the patient about possible bed rail danger to enable the patient to make an informed decision . . . If a bed rail has been determined to be necessary, steps should be taken to reduce the known risks associated with its use. . . . Assessment of risk should be part of the individual patient's assessment, and steps to address the risk should be incorporated into the patient's care plan. . . ."

The HBSW publication titled, "A Guide to Bed Safety - Bed Rails in Hospitals, Nursing Homes and Home Health Care: The Facts", revised April 2010, stated, ". . . Potential risks of bed rails may include: Strangling, suffocating, bodily injury or death when patients or part of their body are caught between rails or between the bed rails and mattress. More serious injuries from falls when patients climb over rails. Skin bruising, cuts, and scrapes. Inducing agitated behavior when bed rails are used as a restraint. . . . Preventing patients, who are able to get out of bed, from performing routine activities . . . Most patients can be in bed safely without bed rails. Consider the following: Use beds that can be raised and lowered close to the floor . . . Keep the bed in the lowest position with wheels locked. When the patient is at risk of falling out of bed, place mats next to the bed . . . Monitor patients frequently. Anticipate the reasons patients get out of bed . . . meet these needs . . . When bed rails are used, perform an on-going assessment of the patient's physical and mental status; closely monitor high-risk patients. . . . Reassess the need for using bed rails on a frequent, regular basis."

Review of the Hospital policy titled, "Falls Prevention and Reporting" occurred on 07/09/15. This policy, dated 08/13/14, stated, "1.0 Purpose: Upon admission . . . patients are assured of assessment of their risk for falls; safeguarding of the environment to prevent falls . . . 6.0 Procedures: On admission all patients . . . will have an admission assessment by the RN [registered nurse]. . . . "

- Review of Patient #29's closed medical record occurred on July 8-9, 2015, and identified the Hospital admitted the patient on 11/11/14. Medical diagnoses included major neurocognitive disorder due to Alzheimer's disease with behavioral disturbance and aggression. Patient #29's admission nursing assessment identified the patient had a shuffled gait, a fall one week prior to admit, dizziness, weakness, and at high risk for falls.

Resident #29's Nursing Progress Note identified the following:
01/01/15 at 7:00 p.m. - ". . . Exit seeking and constant motion at times. . . . "
01/01/15 at 10:00 p.m. - "Pt [patient] found by Nurse Aide, 'Pt's bed alarm went off and when we were on our way to the room, we heard him fall.' Writer found pt laying on his left side on floor. Pt had a laceration to his left eye brow that was approximately 1 inch long. Pt had a laceration to his left elbow that was approximately 1 inch long. . . . Pt complaining of pain in his left hip. Pt screams, stating 'it hurts' when he tries to move the left leg. Pt is unable to put weight on the left leg when staff attempted to stand him. This writer assessed pt's left limb and it was warm and inflamed. [Name of physician] was notified . . . ordered to send pt to . . . ER [emergency room ] for further evaluation. . . ."

The "Patient Incident Report" regarding the above fall, signed by the nursing supervisor on 01/05/15, identified Patient #29 was sent to the emergency room for left hip fracture. The report identified two side rails were in use at the time of the fall from the bed and the bed was in the high position.

Patient #29's medical record lacked an individualized assessment of risk and safety for the use of side rails, lacked evidence of patient or responsible party education regarding the hazards of side rail use, and lacked a care plan for the side rails.

- Random observations from July 07-09, 2015, identified various adult and adolescent patients admitted with suicide precautions occupied the low stimulation rooms #448 and #449, which contain beds with one-third side rails visible from the rooms' doors.

- Observation on the morning of 07/08/15, while Patient #2 rested in bed, identified one elevated one-third rail on the bed.

Review of Patient #2's medical record occurred on all days of survey and identified the Hospital admitted the patient on 06/17/15. Diagnoses included Parkinson's disease, Alzheimer's dementia, and aggression. The admission nursing assessment identified the patient at high risk for falls. The patient's most recent fall occurred on 06/23/15.

Patient #2's record lacked an individualized assessment of risk and safety for the use of side rails, lacked evidence of patient or responsible party education regarding the hazards of side rail use, and lacked a care plan for the side rails.

- Observation on the morning of 07/08/15, while Patient #12 rested in bed, identified two elevated one-third rails on the bed.

Review of Patient #12's medical record occurred on all days of survey and identified the Hospital admitted the patient on 06/26/15. Diagnoses included Alzheimer's dementia with behaviors, anxiety, and agitation. The admission nursing assessment identified the patient at high risk for falls.

Patient #12's record lacked an individualized assessment of risk and safety for the use of side rails, lacked evidence of patient or responsible party education regarding the hazards of side rail use, and lacked a care plan for the side rails.

- Observation on the morning of 07/08/15, while Patient #13 rested in bed, identified one elevated one-third rail on the bed.

Review of Patient #13's medical record occurred on all days of survey and identified the Hospital admitted the patient on 06/16/15. Diagnoses included dementia with behaviors. The admission nursing assessment identified the patient at high risk for falls.

Patient #13's record lacked an individualized assessment of risk and safety for the use of side rails, lacked evidence of patient or responsible party education regarding the hazards of side rail use, and lacked a care plan for the side rails.

- Observation on 07/08/15 at 7:40 a.m. showed Patient #16 in bed with a one-third side rail in the up position on the exit side of the bed.

Review of Patient #16's medical record occurred on all days of survey and identified the Hospital admitted the patient on 06/26/15. Diagnoses included agitation and aggression. Patient #16's nursing admission assessment identified the patient at high risk for falls.

Patient #16's record lacked an individualized assessment of risk and safety for the use of side rails, lacked evidence of patient or responsible party education regarding the hazards of side rail use, and lacked a care plan for the side rails.

- Observation on 07/07/15 from 8:00 a.m. to 10:15 a.m. and on 07/08/15 at 7:40 a.m. showed Patient #17 in bed with a one-third side rail in the up position on the exit side of the bed.

Review of Patient #17's medical record occurred on all days of survey and identified the Hospital admitted the patient on 06/22/15. Diagnoses included vascular and Alzheimer's dementia. Patient #17's admission nursing assessment identified the patient at high risk for falls.

Patient #17's record lacked an individualized assessment of risk and safety for the use of side rails, lacked evidence of patient or responsible party education regarding the hazards of side rail use, and lacked a care plan for the side rails.

- Observation on 07/07/15 from 7:55 a.m. to 10:30 a.m. showed Patient #18 in bed with a one-third side rail in the up position on the exit side of the bed.

Review of Patient #18's medical record occurred on all days of survey and identified the Hospital admitted the patient on 07/03/15. Diagnoses included hospitalization due to laceration from a recent fall at a nursing home, abnormal gait, and weakness. Patient #18's admission nursing assessment identified the patient at high risk for falls.

Patient #18's record lacked an individualized assessment of risk and safety for the use of side rails, lacked evidence of patient or responsible party education regarding the hazards of side rail use, and lacked a care plan for the side rails.

An interview with two certified nursing assistants (CNAs) (#14 and #21) regarding side rails occurred on 07/07/15 at 2:46 p.m. Both CNAs stated they "use side rails on patients that need help getting out of bed" and they "put the side rails up so they [the patients] don't fall out of bed." The CNAs stated they use the side rails on Patients #17, #16 ("he should have them up") and #18 ("he gets out of bed, but we put them up").

During an interview on 07/07/15 at 5:30 p.m., an administrative nurse (#4) stated side rails existed only on the beds on the geriatric unit (contrary to observations in the low stimulation rooms). The nurse (#4) confirmed nursing staff does not perform an assessment for risk factors or safety for utilization of side rails. The staff member (#4) confirmed staff had not educated patients or families on the risks of using side rails.




GAIT BELTS/TRANSFERS

3. Based on observation, policy review, and staff interview, the Hospital failed to ensure appropriate use of assistive devices to prevent accidents for 5 of 6 patients (Patient #2, #12, #13, #14, and #16) who required staff assistance for transfers. Failure of staff to correctly use a gait belt and to ensure staff transferred patients by the safest means possible placed patients at risk for pain, falls and/or injury.

Findings include:

Review of the facility policy titled "Lifting" occurred on 07/09/15. This policy, dated 10/08/14, stated, ". . . Procedure . . . 9. When lifting/transferring patients, use of gait belt is required. If the patient is unable to bear weight or is difficult to transfer/lift; use of a mechanical lift should be utilized."

- Observation on 07/07/15 at 8:00 a.m. showed three certified nursing assistants (CNAs) (#14, #15, and #16) in Patient #2's room to assist with transferring and morning cares. Without using a gait belt, two CNAs (#15 and #16) lifted under the patient's arms to assist him to stand from the bed to finish dressing. When staff completed cares, two CNAs (#14 and #16) lifted under the patient's arms to transfer him from the bed to a wheelchair.

- Observation on 07/07/15 at 8:30 a.m. showed three CNAs (#15, #16, and #21) assisted Patient #12 with toileting. Two CNAs (#15 and #16) assisted Patient #12 to a standing position by lifting under the patient's arms, while the third CNA (#21) provided perineal cares. The CNAs (#15 and #16) pivot transferred Patient #12 to a wheelchair by lifting under the patient's arms. Patient #12 stood up from the wheelchair and started walking into the room to the bed alone. The CNAs (#15 and #21) held under Patient #12's arms while she walked. At 8:45 a.m., two CNAs (#16 and #21) assisted Patient #12 to a sitting position in bed by pulling up under her arms. The CNAs (#16 and #21) then lifted under the patient's arms to pivot transfer her to the wheelchair. The CNAs failed to use a gait belt on Patient #12.

- Observation on 07/07/15 at 8:40 a.m. showed a nurse (#5) and a CNA (#20) transferred Patient #16 from the wheelchair to the bed and back to the wheelchair without using a gait belt. The patient was unable to pivot or bear much weight and both staff lifted up on each of the patient's arms during each transfer.

- Observation on 07/07/15 at 9:06 a.m. showed two CNAs (#16 and #21) assisted Patient #2 on the toilet without using a gait belt. The CNAs (#16 and #21) lifted under the patient's arms when transferring back to the wheelchair.

- Observation on 07/07/15 at 9:40 a.m. showed three CNAs (#14, #16, and #21) in Patient #13's room to assist with transferring, toileting, and personal cares. Without using a gait belt, two CNAs (#16 and #21) lifted under the patient's arms to transfer the patient from the bed to the wheelchair. Once in the wheelchair, the CNAs (#16 and #21) assisted the patient into the bathroom and made three attempts to transfer him onto the toilet due to the patient's inability to bear weight. On the fourth attempt, three CNAs (#14, #16, and #21) transferred the patient without a gait belt, bearing almost all weight and making a visible physical effort. Patient #13 grimaced and stated, "Ow!" during the transfer. While the patient remained on the toilet, a CNA (#15) entered the patient's room and handed a gait belt to all three CNAs (#14, #16, and #21). A CNA (#16) loosely applied a gait belt around the patient and then two CNAs (#14 and #16) transferred the patient from the toilet to the wheelchair. During the transfer, the CNAs (#14 and #16) held on to the loose gait belt with one hand and each lifted under the patient's arms with their other hands. Observation showed staff bore most of the patient's weight. The patient stated "Ow!" and staff also verbalized pain during the transfer. All three CNAs (#14, #16, and #21) verbalized the difficulty in transferring Patient #13 and stated they "really have to lift" and it "hurts our backs." When asked how staff transferred patients who are unable to bear much weight, the staff stated they get more staff to help lift the patient. The staff members stated the facility does not have a sit-to-stand mechanical lift, only a full-body lift. To use the full-body lift on patients, the staff stated they get the nurse to do an assessment and then obtain a physician's order for the lift.

- Observation on 07/07/15 at 1:15 p.m. showed Patient #13 on the floor in the lounge area. A CNA (#20) stated the patient slipped out while self-propelling in a wheelchair. Observation showed a gait belt on the back of the patient's wheelchair. Two CNAs (#16 and #20) lifted Patient #13 from the floor by pulling under the patient's arms. Patient #13 made a groaning sound as the CNAs lifted him up to the wheelchair. The CNAs failed to use a gait belt on Patient #13.

- Observation on 07/08/15 at 7:45 a.m. showed a nurse (#23) assisted Patient #14 to transfer from the bed to the wheelchair without using a gait belt. The nurse (#23) lifted under the patient's left arm during the transfer. After Patient #14 finished toileting, she stumbled back into the wheelchair and the wheelchair rolled back. The nurse (#23) failed to lock the brakes on the patient's wheelchair when providing assistance.

During an interview on 07/09/15 at 1:10 p.m., an administrative nurse (#3) stated staff should use a gait belt when assisting patients with transfers and should avoid lifting on patients' arms.

PRESSURE ULCERS

4. Based on observation, record review, policy review, professional reference review, and staff interview, the Hospital failed to implement interventions to aid in the healing of pressure ulcers for 1 of 1 active patient (Patient #13) and 1 of 1 closed patient record (Patient #28) reviewed with a pressure ulcer. Failure to adequately assess skin breakdown, coordinate with nutritional services for reassessment/revised interventions, and provide pressure-relieving devices in a timely manner, may result in patients experiencing delayed healing and worsened pressure ulcers.

Findings include:

The facility lacked a nursing policy on the assessment and management of pressure ulcers.

A professional reference guide titled "Quick Reference Guide for Clinicians, Number 15, Pressure Ulcer Treatment" compiled by the U.S. [United States] Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, dated December 1994, stated, ". . . Assessment is the starting point in preparing to treat or manage an individual with a pressure ulcer . . . Initial assessment. Assess the pressure ulcer(s) initially for location, stage, size (length, width, and depth), sinus tracts, undermining, tunneling, exudate, necrotic tissue, and the presence or absence of granulation tissue and epithelialization . . . Reassessment. Reassess pressure ulcers at least weekly . . ."

Review of the facility policy titled "Nutritional Supplements" occurred on 07/09/15. This policy, dated 08/13/14, stated, ". . . the Registered Dietitian if deems appropriate can recommend nutritional supplements i.e. Ensure, Boost, Enlive, Propass and/or Magic Cup. Risk factors to include but not limited to . . . pressure ulcers . . . are identified on the Dietary Screening that warrant such nutritional supplements to be ordered . . . Dietician to complete Dietary Screening and Nutritional Consult. RN to complete the Dietary Screening in absence of the Dietitian. Medical staff order recommended supplements and/or dietary needs of the patient as per Dietitian recommendations . . . A dietary consult may be ordered at anytime throughout a patient's stay when a dietary concern has been identified."

Review of Patient #13's medical record occurred on all days of survey and identified the Hospital admitted the patient on 06/16/15. Diagnoses included dementia an
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on policy review and record review, the Hospital failed to ensure the development and revision of the "Master Treatment Plan" (plan of care regarding psychiatric issues), and/or nursing care plan to provide direction for individualized patient care based on the assessment of the patient's behavioral/nursing care needs for 2 of 2 sampled patients (Patients #23 and #24) reviewed in closed records who attempted suicide within the facility and 2 of 2 sampled patients (Patient #25 and #26) reviewed in closed records who experienced restraint or seclusion. Failure to develop, review, and revise the plan of care limits the Hospital's ability to ensure continuity of care and provide methods and approaches for implementation by staff.

Findings include:

Review of the "Nursing Care Plan" policy occurred on 07/07/15. This policy, dated 08/13/14, stated, "Purpose: A patient care plan is developed for each patient . . . to: 1. provide direction for individualized care of the patient. 2. provide continuity of care. 3. provide direction for documented [sic] on the patients progress notes. 4. serve as a guide for assigning staff to care for the patient. . . . must be developed and implemented based on the patients needs. . . . must be kept current. . . . must address patient needs, including the methods and approaches to be implemented and modifications necessary to ensure that the patient attains or maintains the highest practicable level of functioning. . . . goals must be identified, measurable, and made known to all appropriate personnel. . . ."

- Review of Patient #24's medical record occurred on July 7-9, 2015. The patient's "Master Treatment Plan Update" form, dated 04/10/15 (time not specified), stated, "pt [patient] [changed] to 1:1, additional rm [room] search done. Patient search completed & pt put into scrubs." The "Master Treatment Plan," dated 04/20/15, identified a goal of "suicidal ideation. Pt will [decrease] thoughts of suicidal ideation to [none] per day" with interventions of "Pt will meet with MD [medical doctor] daily to discuss medication effectiveness side effects and compliance related to suicide ideation." The plan lacked individualized interventions regarding Patient #24's recent suicide attempts which occurred within the facility, as well as specific interventions other than medication administration for care provided by direct care staff.

- Review of Patient #23's medical record occurred on July 7-9, 2015. The patient's "Master Treatment Plan," dated 03/19/15, included a narrative note of "Pt admitted . . . due to making statements that 'I am going to kill myself.' Pt made statements [with] plan to slit wrists or hang himself. . . ." The plan identified the patient on 15 minute precautions (standard for all patients admitted to the Hospital) for suicide and self-harm. The plan showed no goals or interventions in relation to suicide and self-harm precautions.

Patient #23's "Master Treatment Plan Update," dated 03/20/15, stated "Pt. placed on 1:1 Acuity d/t [due to] attempting to hang self." The medical record identified this attempt occurred on 03/19/15 and the plan update identified a change in monitoring to 1:1.

The treatment plan, dated 03/23/15, identified a short term goal of "Suicidal ideation; Pt will [decrease] suicidal ideation to [none] per shift" with an intervention of "Pt will be encouraged to attend/participate in OT [occupational therapy] group M-F [Monday through Friday] to ID [identify]/utilize 1-2 (+) [positive] coping skills to utilize @ [at] onset of suicidal ideation; Pt will be encouraged to report any suicidal ideation to staff to [decrease] attempts." The plan lacked individualized goals and interventions regarding Patient #23's recent suicide attempt which occurred within the facility.

- Review of Patient #26's medical record occurred on July 7-9, 2015. Diagnoses included disruptive mood dysregulation, attention deficit hyperactivity disorder (ADHD), and history of head banging.

Progress notes identified the patient displayed times of non-responsiveness on 04/04/15 and 04/09/15 and incidences of head banging. The "Master Treatment Plan," dated 04/13/15, included a narrative progress update of ". . . has had significant outburst and has self harmed in the past reporting period. . . . Seclusion et [and] restraint utilized on 4/9/11[15] and 4/10/11 [15]. The plan identified a short term goal for "self harm . . . head banging daily" with an intervention of "Staff to redirect/provide a safe environment for pt when he is engaged in episodes of self harm i.e. head banging." The plan did not identify measures to prevent the head banging and failed to define what "redirect" measures direct care staff could implement. The plan also identified a short term goal of decreasing the patient's aggressive behaviors of yelling, punching and biting with interventions of "Physician to assess pt's meds [medications] daily for side effects/effectiveness; staff to redirect pt during aggressive outbursts daily." The plan failed to define how to "redirect" the patient during these episodes. The short term goal and/or interventions failed to include measures for staff implementation in order to decrease the episodes of seclusion and restraint.

- Review of Patient #25's medical record occurred on July 07-09, 2015. Diagnoses included bipolar I disorder, disruptive mood dysregulation, ADHD, post traumatic stress disorder (PTSD), conduct disorder, and history of head banging.
Progress notes identified the patient restrained and/or secluded on six occasions between 05/24/15 and 06/04/15. The "Master Treatment Plan," dated 05/26/15, included a short term goal of reducing verbal and physical aggression with an intervention of "Pt will meet with MD daily to discuss and assess medication effectiveness, side effects and compliance related to aggression. Patient will be restrained or secluded as necessary to protect self and others." Another short term goal included reducing self harm behaviors with interventions of "Pt will notify nursing staff and accept gentle redirection upon triggers for self harm. Pt will be encouraged to attend OT group . . ." The plan failed to identify individualized specific coping skills for direct care staff to utilize outside of the OT group meetings to address the patient aggression other than with the use of restraint or seclusion.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on observation, record review, policy and procedure review, and staff interview, the Hospital failed to ensure physician ordered medications were available to patients in a timely manner, nurses accurately administered patient medications as ordered and/or documented medications administered on the medication administration record (MAR) for 7 of 16 active patient records (Patient #1, #4, #6, #7, #14, #17, and #20) and 3 of 10 closed patient records (Patient #25, #26, and #29) reviewed for medications administered. Failure of nursing staff to process physicians' orders resulted in a delay of patients receiving their medications which included pain medications, electrolyte (potassium chloride) replacement, a diuretic, and psychotropic medications. Failure of nurses to accurately administer physician ordered medications, follow hospital policy, and correctly document on the MAR resulted in medication errors and placed all patients at risk for harm due to medication errors.

Findings include:

Review of the facility's policy titled "Medication Administration, Monitoring and Documentation" occurred on 07/08/15. This policy, dated 08/13/14, stated, ". . . When administering medication, licensed staff will follow the six rights of medication administration which are as follows: . . . 6. Right documentation . . . Licensed Nurses - Responsible for administering/documenting all medications safely and accurately . . . Documentation on medication administration will be done immediately following the patient receiving the medication . . . The PRN [as needed]results will be documented on the same sheet. . . ."

Review of the facility policy titled, "Medication Administration, Monitoring and Documentation" occurred on 07/09/15. This policy, dated 08/13/14, stated, ". . . A. Medication Administration . . . 4. . . . An insulin pen/syringe will be primed (2 units) for the patient prior to administration . . ."

MEDICATIONS INCORRECTLY ADMINISTERED

- Review of Patient #14's medical record occurred on all days of survey and identified the Hospital admitted the patient on 07/01/15. Diagnoses included insulin-dependent diabetes.

Review of the patient's MAR on 07/07/15 at 5:00 p.m. identified the following NovoLog Flexpen sliding scale (accuchecks four times daily):
*0-150 mg/dL (milligrams per deciliter) = 0 units
*151-200 = 3 units
*201-250 = 6 units
*251-300 = 9 units
*301-350 = 14 units
*351-400 = 18 units
*400 and above = 20 units and call the physician

Observation on 07/07/15 at 5:05 p.m. showed a nurse (#22) dialed Patient #14's NovoLog Flexpen to administer nine units of insulin for a blood glucose of 207. Prior to administering the insulin to the patient, the surveyor alerted the nurse (#22) on the incorrect dose dialed on the insulin pen. The nurse (#22) then redialed the pen and administered the correct dose (according to the MAR) of six units of insulin to the patient. The nurse failed to prime the needle on the pen with two units of insulin prior to dialing in the dose and administering the insulin.

During an interview on 07/09/15 at 1:10 p.m., an administrative nurse (#3) stated staff should prime insulin pens with two units of insulin prior to administration.

Review of Patient #14's admission orders, dated 07/01/15, stated, ". . . cont. [continue] novolog flexpen . . . use sliding scale before meals and at HS [bedtime] (up to 20 units if BS [blood sugar] over 400) . . ." The physician's orders lacked a specific order for the patient's sliding scale NovoLog Flexpen insulin.

During an interview on 07/07/15 at 5:45 p.m., a nurse (#24) confirmed Patient #14's medical record lacked an order for the sliding scale NovoLog insulin and stated the facility transcribed the sliding scale used at the facility the patient resided prior to admission. The nurse (#24) stated the physician should write specific orders for sliding scale insulin at the time of admission.

A physician's order, dated 07/07/15 at 6:34 p.m., increased the amount of NovoLog Flexpen insulin the patient should receive for each blood glucose parameter as follows:
*0-150 = 0 units
*151-200 = 4 units
*201-250 = 8 units
*251-300 = 12 units
*301-350 = 16 units
*351-400 = 20 units
*400 and above = 24 units and call the physician

- Observation on 07/07/15 at 8:15 a.m. showed a nurse (#22) looking for an inhaler medication (Combivent) for Patient #20. Another nurse (#5) opened the medication cart and found the inhaler for Patient #20. Without looking at the medication administration record, the nurse (#5) took the inhaler into Patient #20's room and gave it to the patient. The patient took two puffs of the inhaler. Review showed the first nurse (#22) signed the medication administration record for the inhaler medication (Combivent). The physician's order for Patient #20 stated Combivent one spray, not two, as given by the nurse.





LACK OF DOCUMENTATION/FOLLOW-UP

- Review of Patient #1's active medical record occurred on July 6-9, 2015. The hospital admitted Patient #1 on 07/01/15. Diagnoses included psychosis unspecified and extreme paranoia. A physician's verbal order, dated 07/02/15 at 11:45 a.m., showed Benadryl 50 mg intramuscular (IM) with Haldol 5 mg IM with Ativan 2 mg IM every 6 hours PRN for acute aggression. Review of the patient's July 2015 MAR identified no time or nurse's initials for the administration of the above order. The licensed social worker's progress notes, dated 07/02/15 at 2:30 p.m., stated, ". . . Pt [patient] had IM prior to conversation with swk [social worker] so at end of conversation pt was very tired and going to lay down for awhile. . . ." The nursing progress notes, dated 07/02/15 at 11:45 a.m., stated, ". . . Pt making threats . . . not redirectable . . . MD [physician] gave orders for B52 [Benadryl, Haldol, Ativan combination] for acute aggression . . . Pt given IM. . . ."

During interview on 07/09/15 at 2:10 p.m., an administrative nurse (#3) stated the nurse responsible for administering the B52 failed to document the injection on the 07/02/15 MAR. The administrative nurse (#3) then told the nurse to document the administration and follow-up time for the injection on the 07/02/15 MAR, label it as a "late entry," and initial the entry. The nurse (#3) stated the follow-up time should be within one hour after administering a PRN medication.

Review of Patient #1's MAR, dated 07/02/15 and updated on 07/08/15, showed the nurse documented the injection time as 3:00 p.m. and the follow-up time as 5:10 p.m. The nurse failed to label it as a "late entry." These documented times fail to coincide with the social worker's and nurse's progress note and the physician's verbal order. The nurse failed to perform the follow-up within one hour after administering the PRN medication/injection.

AVAILABILITY OF MEDICATIONS

- Observation during medication pass on 07/07/15 at 2:40 p.m., showed Patient #6 requested a pain medication from a nurse (#5). The nurse explained to the patient staff failed to order the medication that morning, and the pharmacy would deliver the medication about 5:00 p.m. During an interview on 07/07/15 after the observation, this nurse identified the patient recently had foot surgery, wore a brace, and used oxycodone as needed for pain.

Review of Patient #6's medical record occurred on 07/07/15 and identified an admission order, dated 07/06/15 at 10:05 p.m., to continue oxycodone 5/325 mg every 6 hours PRN for pain. Approximately 19 hours after the order, the pharmacy delivered the patient's pain medication to the facility. Staff documented "unavailable" on the 07/07/15 MAR for the patient's Provigal 200 mg daily for daytime fatigue ordered on admission.

- Observation on 07/07/15 at 3:00 p.m., showed Patient #7 requested her scheduled pain medication from staff at the nurses' station.

Review of Patient #7's medical record identified a physician's telephone admission order, dated 07/07/15 at 12:50 a.m., to continue Morphine (MS Contin) 30 mg tablet by mouth three times daily for pain and Morphine 15 mg by mouth every four hours PRN for pain. Nursing staff documented on the 07/07/15 MAR at 8:30 a.m. and 2:30 p.m. "Unavailable waiting on pharmacy." Staff administered the MS Contin one time on 07/07/15 at 5:20 p.m. Approximately 16 hours after the order, the pharmacy delivered the patient's scheduled and PRN medication. Staff also documented "unavailable" on the 07/07/15 MAR for the potassium chloride 20 milliequivalents (mEq) daily ordered for a deficiency on admission.

During an interview on 07/07/15 at 5:00 p.m., a nursing staff member (#9) stated nursing staff failed to correctly process the orders making the medications unavailable to the patients until after 5:00 p.m. on 07/07/15. Staff failed to have the physician sign a prescription form for the narcotics and fax the form to the pharmacy for either the noon or 5:00 p.m. deliveries.

During an interview on 07/08/15 at 9:45 a.m., an administrative nurse (#3) verified the above process for ordering medications. The nurse stated the pharmacy will deliver between scheduled times or she could go and pick-up medications. Staff failed to contact this administrative nurse regarding the needed medications on 07/07/15.

- Review of Patient #17's medical record occurred on all days of survey and identified the Hospital admitted the patient on 06/22/15. The medical record identified a physician's order on 06/22/15 for Metolazone (a diuretic medication) 2.5 mg every day for edema. The MAR showed Patient #17 did not receive the medication on 06/24/15, 07/07/15, and 07/08/15 due to medication "unavailable."

- Review of Patient #25's medical record occurred on July 7-9, 2015. Diagnoses included bipolar I disorder, disruptive mood dysregulation, attention deficit hyperactivity disorder (ADHD), post traumatic stress disorder (PTSD), conduct disorder, and history of head banging. Review of the MAR identified a physician's order on 05/25/15 for Thorazine (antipsychotic medication) 75 mg by mouth three times a day. A comment on the MAR stated, "Gave 50 mg d/t [due to] stock" for the first dose scheduled at 8:00 p.m. on 05/25/15.

- Review of Patient #26's medical record occurred on July 7-9, 2015. Diagnoses included disruptive mood dysregulation, ADHD, and history of head banging. Review of the MAR identified an order, dated 03/03/15, for Adderall (used to treat ADHD) 5 mg two times a day. The MAR showed the medication not available and nursing staff failed to administer the evening dose on 04/01/15 and the twice daily doses on April 12 -13, 2015. The MAR identified a physician order, dated 04/17/15, for Vyvanse (stimulant medication, may use for treatment of ADHD) 40 mg once daily at 7:00 a.m. The MAR showed the medication not given April 17-20 (four days) and nursing staff documented the medication as unavailable. An entry on the MAR showed an order on 04/17/15 for Risperdal (an antipsychotic medication) one mg twice a day. The notation in the "Comments" column stated the nurse administered a half dose (0.5 mg) for the scheduled dose at 8:00 p.m.
A psychiatric progress note, dated 04/17/15, stated, ". . . Medications: Risperdal 0.5 mg twice a day for mood, Adderall 5 mg twice b.i.d (two times a day) for ADHD . . . Overall he seems worse the last couple days. This does not seem to be correlating with anything. 2. I will discuss the case with [another psychiatrist] and we will look at a change in his mood stabilizer." Failure to ensure the availability and administer medications as ordered may result and/or adversely alter the patient's treatment including changes in medication orders.

- Review of Patient #29's closed medical record occurred on July 8-9, 2015 and identified the Hospital admitted the patient on 11/11/14. Medical diagnoses included major neurocognitive disorder due to Alzheimer's disease with behavioral disturbance and major depression. The medical record identified physician's orders for Tegretol 200 mg twice a day for mood, Sertraline 100 mg daily for depression, and Risperidone for agitation. The MAR showed Patient #29 did not receive Tegretol on 12/08/14, Sertraline on 11/12/15, and Risperidone on 11/12/14 due to medication "unavailable."





An interview with a charge nurse (#24) regarding unavailable medications occurred on 07/07/15 at 9:30 a.m. The nurse (#24) stated the pharmacy makes two deliveries to the hospital during the day, at 12:00 noon and at 5:00 p.m. She stated a pharmacist is always available on call if a patient needed an important medication. When asked about the missing doses found in the medical records, the nurse stated it is up to the nurse passing medications to notify the charge nurse to get the medication.

SIGNING OFF MEDICATIONS BEFORE GIVING and A NURSE PREPARING MEDICATIONS WITH ANOTHER NURSE ADMINISTERING THEM:

- Observation of medication pass, on 07/07/15 at 8:10 a.m., showed a nurse (#22) prepared medications for patients from the medication cart in the medication room. The nurse (#22) placed the medications into a medication cup and wrote the patient's name on the cup. The nurse signed the medication administration record and then gave the medication cup to another nurse (#5) to administer to the patient. The nurse (#22) stated that if the other nurse (#5) tells him/her the patient did not take the medication, he/she will circle his/her initial on the medication administration record and explain that the patient did not take the medication.

During an interview on 07/09/15 at 1:15 p.m., an administrative nurse (#3) stated the nurse preparing the medications should administer the medications to the patient.

SIGNING MEDICATION ADMINISTRATION RECORD BEFORE ADMINISTERING MEDICATIONS

- Observation on 07/07/15 at 2:35 p.m. and 2:40 p.m. showed a nurse (#5) signed the medication administration record (MAR) before administering medication to two patients (#4 and #6).
VIOLATION: COMPETENT DIETARY STAFF Tag No: A0622
Based on observation, policy review, record review, and staff interview, the Hospital failed to ensure the competency of dietary staff in their assigned duties for 1 of 1 dietary staff member (#25) observed. Failure to have knowledge of food allergies, failure to provide ordered therapeutic diets, and failure to ensure the correct concentration of sanitizing solutions has the potential to result in patient injury/harm.

Findings include:

Review of the Hospital policy titled "Use and Sanitation of Dining Services Equipment and Supplies" occurred on 07/09/15. This policy, dated 08/13/14, stated, "1.0 Purpose: To emphasize that the equipment and supplies in the dining services department are used with care; to provide safe, sanitary food service that meets state and federal regulations. . . . 4.0 . . . e. Sanitation of dishes is completed in a 3 sink compartment (Wash, Rinse and Sanitize Procedure) in the designated area. Instructions are located above sink area and are as followed (sic): . . . 4. To sanitize the washed and rinsed items . . . If you use a chemical sanitizer, the sanitizer must be mixed at the proper concentration (follow the manufacturer's directions to assure the proper concentration). . . ."

- Observation of a dietary staff member (#25) preparing the three compartment sink for washing dishes occurred on 07/06/15 at 5:30 p.m. The staff member (#25) filled the third compartment of the sink approximately one-third full of hot water and then pressed the dispenser above the sink for the quaternary sanitizer solution. The staff member held the dispenser while the sanitizer dispersed into the water. When asked how staff measure the sanitizer, the staff member stated, "You put in as much as you think is right." The staff member stated the facility had not provided training on how to check the concentration of the sanitizer solution. Observation showed a roll of sanitizer test strips on the shelf with an expiration date of August 2014 and several areas of discoloration on the roll itself, which may cause inaccurate test results.

During interview on the afternoon of 07/09/15, the director of dietary services (#4) confirmed staff should correctly measure and test the concentration of the sanitizing solution.

- Observation of a dietary staff member (#25) dishing food from the steam table to patient plates occurred on 07/06/15 at 4:55 p.m. When asked about therapeutic diets, the staff member stated "right now everyone is on the same regular diet." The staff member stated that nursing has only informed her of one child who was diabetic.

- Review of Patient #14's medical record occurred on all days of survey, and identified the Hospital admitted the patient on 07/01/15. The dietary progress notes, dated 07/02/15, stated, ". . . Pt [patient] has type 2 diabetes and Accucheck QID [four times a day]. Her resting b.s. [blood sugar] yesterday was 178. . . . Pt has eaten 1 meal . . . so far and ate 100% of it. I recommend a diabetic diet for patient. . . ."

- Review of Patient #16's medical record occurred on all days of survey and identified the Hospital admitted the patient on 06/26/15. A dietary progress notes, dated 07/02/15, stated, ". . . has difficulty chewing and swallowing. . . I recommend switching to mechanical soft diet to help pt be able to eat food effectively . . ."

- Review of Patient #18 medical record occurred on all days of survey. The dietary progress notes, dated 07/06/15, stated, ". . . Pt intake of regular food is low. I recommend pt diet change to mechanical soft to help increase intake and pt agreed to this."

An interview with a dietary staff member (#25) and the consulting dietitian (#26) occurred on 07/09/15 at 10:30 a.m. When asked how she is aware of food allergies and therapeutic diets, the staff member stated "the nurses will tell me." The staff member stated a nurse told her Patient #6 is allergic to nuts. The staff member confirmed she was not aware of any current therapeutic diets or mechanically altered diets. The consultant dietitian (#26) stated the Hospital process is to have nursing staff provide dietary with a daily diet sheet, which lists therapeutic diets and allergies. The dietary staff member (#25) confirmed nursing staff had not provided this list for her. Upon request, the consultant dietitian (#26) asked nursing staff to print the diet sheet. This list, dated 07/09/15, identified two patients on a diabetic diet, two patients on a mechanical soft diet, one patient on a lactose free diet, one patient needing "cut meat" and one patient on a low sodium diet.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, policy and procedure review, and staff interview, the Hospital failed to follow professional standards of care regarding infection control practices during observations of patient care on 2 of 4 days of survey (July 7-8, 2015). Failure to follow established infection control practices may allow transmission of organisms and pathogens from patient to staff, to other patients, or to visitors; and from one environment to another.

Findings include:

Review of the facility policy titled "Barrier Protection" occurred on 07/09/15. This policy, revised 05/15/15, stated, ". . . Gloves used in patient's care should be worn only for contact with the patient. Once used, gloves must be discarded before leaving the patient's room . . ."

Review of the facility's policy titled "Gloving: Sterile and Non-Sterile" occurred on 07/09/15. This policy, dated 08/13/15, stated, "NON-STERILE: 1. Wash hands thoroughly . . . slip fingers into openings . . . GLOVE REMOVAL: 1. Remove the glove . . . 4. Wash hands. . . ."

Review of the facility's policy titled "Hand Hygiene" occurred on 07/09/15. This policy, dated 08/13/15, stated, ". . . Hand hygiene is considered the most important single procedure for preventing healthcare associated infections . . . Procedures A. Indication for Handwashing and Hand Antisepsis: When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either non-antimicrobial soap and water or antimicrobial soap and water. *If hands are not visibly soiled, you may use alcohol-based hand rub for routinely decontaminating hands. *Decontaminate hands before having direct contact with patients . . . *Decontaminate hands after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled. *Decontaminate hands if moving from a contaminated-body site to a clean-body site patient care. *Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. *Decontaminate hands after removing gloves. . . ."

Review of the facility policy titled "Cleaning of Glucometer" occurred on 07/09/15. This policy, revised 05/15/15, stated, ". . . Procedure
1. Wipe surface of machine with Cavi Wipe prior to use.
2. Wipe surface of machine with Cavi Wipe after use.
3. Once you have completed the cleaning process, store in the med room . . ."

HAND HYGIENE, GLOVE USAGE, HANDLING SOILED LINEN

- On 07/07/15 at 8:00 a.m., observation showed three certified nursing assistants (CNAs) (#14, #15, and #16) entered Patient #2's room, and without performing hand hygiene, donned gloves and all assisted to cleanse the resident's body prior to dressing. A CNA (#14) completed perineal care, and without changing her gloves and performing hand hygiene, proceeded to assist the other two CNAs with dressing, combed the patient's hair, and transferred him to his wheelchair. A second CNA (#15) disposed of the soiled brief, changed gloves without performing hand hygiene, then rinsed out the patient's washbasin. Without placing the patient's soiled clothing in a bag and wearing the same gloves, the CNA (#15) exited the room holding the patient's clothing. The CNA (#15) returned, stated she needed to assist another patient, removed her gloves in Patient #2's room, and then exited the room without performing hand hygiene. After assisting the patient to transfer to a wheelchair and wearing the same gloves used during perineal care, a CNA (#14) assisted Patient #2 out of the room to the lounge area. The CNA (#14) removed her gloves at the work station and without performing hand hygiene, began charting.

- On the morning of 07/07/15, at the time staff assisted Patient #2 at 8:00 a.m. (as described above), the CNA (#15) who exited the room with Patient #2's soiled clothing, returned with the patient's roommate, Patient #16. Without performing hand hygiene, the CNA (#15) entered, donned gloves, and gave Patient #16 a drink of water. Without performing hand hygiene, a third CNA (#16) assisting in the prior observation, changed her gloves and went from cleansing and transferring Patient #2, to assisting the CNA (#15) to stand Patient #16. After assisting Patient #16, both CNAs (#15 and #16) removed their gloves and without performing hand hygiene, exited the patient's room.

- During an observation on 07/07/15 at 8:25 a.m., two laboratory staff members (#17 and #18) entered Patient #16's room, and without performing hand hygiene, donned gloves, and attempted two venipunctures (one on each arm). After the unsuccessful attempts, both staff members (#17 and #18) removed their gloves and, without performing hand hygiene, exited the patient's room.

- During an observation on 07/07/15 at 8:40 a.m., a nurse (#5) and a CNA (#20) entered Patient #16's room and donned gloves without performing hand hygiene. The staff members transferred the patient from a wheelchair to the bed and the nurse (#5) applied cream to Patient #16's groin. The staff members transferred the patient back to the wheelchair. Without performing hand hygiene, both staff members removed their gloves and exited the patient's room. The nurse (#5) went to the work station to get another patient's dentures.

- During an observation on 07/07/15 at 8:42 a.m., two laboratory staff members (#17 and #19) entered Patient #16's room and donned gloves without performing hand hygiene. One staff member (#17) used a tissue and wiped the patient's runny nose. Without performing hand hygiene, the staff member changed her gloves, and assisted the second staff member (#19) with the lab draw. The patient became combative, so the staff member (#17) removed her gloves, exited the room to find a CNA, and then quickly returned. The staff member (#17) failed to perform hand hygiene prior to exiting and reentering the patient's room. The CNA (#14) failed to perform hand hygiene upon entering the patient's room. Both staff members (#14 and #17) donned gloves and positioned Patient #16 as the laboratory staff member (#19) obtained a blood sample from the patient's finger. Without performing hand hygiene, all three staff members (#14, #17, and #19) removed their gloves and exited the patient's room.

- Observation on 07/07/15 at 8:45 a.m. showed two CNAs (#16 and #21) entered Patient #12's room. The CNAs placed Patient #12's shoes on her feet and transferred the patient from the bed to a wheelchair. One CNA (#16) combed the patient's hair and the other CNA (#21) placed dentures in the patient's mouth. Both CNAs failed to perform hand hygiene upon entering the room and failed to perform hand hygiene after completing cares and leaving the room.

- During an observation on 07/07/15 at 9:06 a.m., two CNAs (#16 and #21) assisted Patient #2 to the bathroom. Without performing hand hygiene, the CNAs (#16 and #21) donned gloves upon entering the resident's room. A CNA (#16) completed perineal care and without performing hand hygiene, transferred the patient back to a wheelchair. Both CNAs (#16 and #21) removed their gloves and exited the room without performing hand hygiene.

- During an observation on 07/07/15 at 9:40 a.m., three CNAs (#14, #16, and #21) entered Patient #13's room to assist with morning cares. Two CNAs (#16 and #21) failed to perform hand hygiene prior to entering the patient's room. All three CNAs donned gloves and assisted in cleansing the patient. While wearing the same gloves, a CNA (#16) proceeded to brush the patient's dentures and swab his mouth. A CNA (#21) removed Patient #13's brief, wet with urine, and completed perineal cares. The CNA (#21) cleansed visible stool from the patient's buttocks. After transferring the patient to a wheelchair, a CNA (#14) removed her gloves, and without performing hand hygiene, exited the patient's room and assisted the patient to the dining room. After completing perineal care and assisting with the transfer, the CNA (#21) removed her gloves, exited the room, and used hand sanitizer as she walked down the corridor. During this observation, two CNAs (#14 and #21) both exited and re-entered the room on two occasions without performing hand hygiene and changing their gloves. The CNAs (#14 and #21) wore the same pair of gloves worn during cares throughout the observation, including upon exiting and reentering the patient's room. The third CNA (#16) stayed in the patient's room and made the bed, put away supplies, exited the patient's room, wearing the same gloves used during cares. This CNA (#16) walked down the corridor to the soiled utility room, came out wearing the same gloves, and walked to the work station. At this point, the CNA (#16) removed her gloves and completed hand hygiene; the first time during the entire observation.

- Observation on 07/07/15 at 10:15 a.m. showed three CNAs (#15, #16, and #21) assisting Patient #17 in the bathroom. One CNA (#16) provided perineal cares and the two other CNAs (#15 and #21) assisted with lifting the patient to a standing position and pivoting the patient into the wheelchair. All three CNAs wore gloves. The CNA (#15) who assisted with lifting the patient removed her gloves, left the room, and used a key to enter the kitchen/dining area. The CNA (#15) then washed her hands in the kitchen sink. The CNA (#16) who provided perineal cares removed her gloves, donned new gloves from her pocket, then applied foot pedals on Patient #17's wheelchair. Both CNAs (#16 and #21) then removed their gloves and left the room. The CNAs failed to perform hand hygiene after performing perineal cares and/or before leaving the patient's room.

- During a random observation on 07/08/15 at 7:40 a.m., two CNAs (#7 and #20) walked out of a patient's room, into another patient's room, and down the corridor into a third patient's room while wearing the same pair of gloves.

DISINFECTING GLUCOMETERS

- During an observation on 07/07/15 at 4:45 p.m., a nurse (#22) donned gloves without performing hand hygiene, tested Patient #15's blood glucose, and disinfected the glucometer. Without performing hand hygiene, the nurse (#22) changed gloves, tested Patient #14's blood glucose, removed the gloves and entered the medication room. The nurse (#22) failed to perform hand hygiene and disinfect the glucometer after testing Patient #14's blood glucose. The staff member (#22) stated, "he [another staff member] will do it [disinfect the glucometer] before the next accucheck done" and indicated he only disinfected the glucometer between consecutive patients.

- During an observation on 07/08/15 at 7:45 a.m., a nurse (#23) walked down the corridor, wearing gloves, and entered Patient #14's room. Without performing hand hygiene upon entering the room and changing gloves, the nurse tested the patient's blood glucose with a glucometer. After testing the patient's blood sugar, the nurse (#23) removed her gloves, used hand sanitizer, placed the glucometer on the counter in the medication room, and began charting and preparing another patient's medications. The nurse (#23) failed to disinfect the glucometer after testing Patient #14's blood glucose.

MEDICATION PASS HAND HYGIENE

- Observation on 07/07/15 at 8:10 a.m. showed a nursing staff member (#22) preparing medications for Patient #12. The nurse (#22) touched each of the medications with bare hands and fingers as he removed the pills from the cartridges and medication bottles.

- Observation on 07/07/15 at 8:15 a.m. showed a nursing staff member (#5), wearing gloves, applied Nystatin powder to Patient #16's scrotal area and Calmoseptine cream to the patient's rectal area. The staff member (#5) removed the gloves, picked up the patient's medication tray, and left the room to return to the medication room. Without performing hand hygiene, the staff member (#5) then picked up Patient #20's inhaler and brought it to the patient's room. After Patient #20 used the inhaler, the staff member returned to the medication room, crushed Patient #12's medications, mixed the medications with pudding and brought them on a tray to Patient #12's room. The staff member (#5) failed to perform hand hygiene between any of these activities.

- Observation during medication pass on 07/07/15 at 2:35 p.m., showed a nurse (#5) failed to perform any hand hygiene before and after administering medications to two different patients.

- During an observation on 07/07/15 at 5:05 p.m., a nurse (#22) administered insulin to Patient #14. The nurse (#22) failed to perform hand hygiene prior to and after insulin administration.





STORAGE OF PATIENTS' PERSONAL ITEMS

Random observations on July 7-8, 2015 at various times showed the following items on the floor in the low stimulation rooms occupied by patients:
* Styrofoam water cups with straws
* Various personal toiletry items such as soap, shampoo, toothpaste, and toothbrush
* Clothes and/or pajamas

During an interview on 07/08/15 at 2:00 p.m., an administrative infection control nurse (#4) stated:
* Bottles of hand sanitizer are provided for staff to carry in their pockets or staff may use foam dispensers located in the hallways or the hand washing sinks in the nurses' station.
* Staff should use hand sanitizer before going into patient rooms, during and after patient cares, before leaving a patient's room, and before and after glove use.
* Nurses should perform hand hygiene before and after patient contact during medication administration.
* Nurses should use the individually wrapped Cavi Wipes on the glucometer before and after patient use and nightly when performing glucometer control checks.
* Hand hygiene audits are performed approximately 20 times per month by this nurse and another registered nurse. The criteria included hand hygiene before and after leaving a patient room, before and after touching the patient or objects in the room, before providing treatment/cares to patient, before handling food, and after handling food.
* The facility's goal for staff correctly performing hand hygiene audits is a minimum of 95%. April 2015 had 83% accuracy and May 2015 had 95% accuracy.
* The Infection Control hand hygiene audits failed to include laboratory staff performing patient blood draws.