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.

BELMONT BEHAVIORAL HOSPITAL 4200 MONUMENT AVENUE PHILADELPHIA, PA 19131 Nov. 6, 2017
VIOLATION: BLOOD TRANSFUSIONS AND IV MEDICATIONS Tag No: A0409
Based on review of policy and procedures, observation and interview with staff (EMP) it was determined the facility failed to ensure safe administration practices for IV (intravascular) medications.

Findings include:
Review on November 8, 2017, of facility policy " The Role of Nursing in Medication Administration," dated July 2015, revealed no provisions for the administration of IV medications.
Observation on November 8, 2017, at 10:05 AM of procedure room 2 revealed OTH2 administer an IV medication into an IV access port and not disinfect the IV access prior to the administration of medication. Further observation revealed OTH2 obtained a second syringe of medication and injected the medication into the IV access port without disinfecting port prior to administration of the medication.
Interview on November 8, 2017, at 10:16 AM with OTH2 confirmed they did not disinfect the IV access port prior to the administration of medication.
VIOLATION: PATIENT RIGHTS: EXERCISE OF RIGHTS Tag No: A0129
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations, review of medical records (MR), facility documents and interview with staff (EMP), it was determined that the facility failed to ensure that the exercise of patients' rights requirements were met by not returning patients' belonging upon discharge for four (4) out of four (4) medical records reviewed (MR29-MR32) and failed to follow their own policy to secure patients' belongings by not completing the Belongings Inventory Record appropriately for four (4) out of four (4) medical records reviewed (MR29-MR32).

Observation on November 6, 2017 at approximately 10:45 AM of facility's 1 Center unit, revealed closet in kitchen storing a brown paper bag with personal items belonging to patients related to MR29 and MR32. Further review revealed patient related to MR29 discharged on [DATE] and patient related to MR32 discharged on [DATE].

Observation on November 6, 2017 at approximately 11:15 AM of facility's 1 South Expansion Unit, revealed seclusion room bathroom storing three (3) black duffel bags belonging to patient related to MR31 and three (3) duffel bags belonging to patient related to MR30.

Review on November 6, 2017 of facility's policy, "... PRS Rights and Responsibilities," dated November 1, 2015, revealed, " ... IV. Procedure: PRS Rights: ... 12. ... PRSs are offered a secure place to store valuables and personal effects ... ."

Review on November 8, 2017 of facility's policy, "Lost Belongings," dated October 1, 2016, revealed, " ... V. Procedure: New Admissions will have all belongings logged at intake using the Belongings Inventory Record Sheet."

Review on November 8, 2017 of facility's, " ... Belongings Inventory Record," dated September 17, 2017 related to patient in MR29, revealed form incomplete. Further revealed, patient signature missing at admission and "at discharge," acknowledgement of receipt of belongings not completed.

Review on November 8, 2017 of facility's, " ... Belongings Inventory Record," dated September 20, 2017 related to patient in MR30, revealed form incomplete. Further revealed, "at discharge," acknowledgement of receipt of belongings not completed.

Review on November 8, 2017 of facility's, " ... Belongings Inventory Record," dated September 17, 2017 related to patient in MR31, revealed form incomplete. Further revealed, patient signature missing at admission and "at discharge," acknowledgement of receipt of belongings not completed.

Request was made on November 7, 2017 at approximately 10:00 AM of EMP17 for Belongings Inventory Record for patient related to MR32. None provided.

Interview with EMP5 on November 6, 2017 at approximately 12:15 PM confirmed unit observations of patient items found for patients related to MR29-MR32.

Interview with EMP1 on November 8, 2017 at approximately 11:00 AM confirmed the patient Belongings Inventory Record was not completed properly for patients related to MR29-MR32.
VIOLATION: PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION Tag No: A0133
Based on a review of facility policy, review of medical record (MR), and interview with staff (EMP), it was determined that the facility failed to promptly notify a physician of patients' choice of his or her admission to the hospital for two (2) of ten (10) medical records reviewed. (MR36 and MR38).

Findings include:

Review on November 9, 2017, of facility policy, "PRS Rights and Responsibilities," dated November 1, 2015, revealed, "... IV. Procedure: ... PRS Rights: 8. ... a. PRS have the right to have ... a physician of their choice promptly notified of admission to the hospital... . It is the responsibility of the admission nurse and the attending physician to assure this communication is carried out and documented in the medical record in these instances."

Review on November 9, 2017, of MR36 and MR38, revealed no documented evidence that patients' physician of choice were promptly notified of patients' admission to hospital.

Interview on November 9, 2017 with EMP22 at 9:30 AM confirmed MR36 and MR38 had no documented evidence of patients' physician of choice being promptly notified of admission to the hospital.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on review of facility policies and procedures, and medical records (MR), and interviews with staff (EMP), it was determined the facility failed to provide a safe setting for one (1) of twenty five (25) medical records reviewed. (MR25).

Findings include:

Review on November 7, 2017, of facility policy "Suicide Risk Assessment", dated May 2017, revealed "The psychiatrist shall order the appropriate level of observation based on results of the suicide risk assessment ..."

Review on November 7, 2017, of MR25's "Adult Psychiatry Physician Admission Orders" dated April 28, 2017, revealed the psychiatrist did not document the "Observations:" and "Special Precautions:" sections. Further review of MR25 revealed this patient was pronounced on April 29, 2017.

Interview with EMP17, on November 7, 2017, at 10:43 AM, confirmed the psychiatrist did not document the "Observations:" and "Special Precautions:" sections in MR25.






Based on review of facility policy and procedures, facility document, and interview with staff (EMP), it was determined the facility failed to ensure Person Receiving Services (PRS) Room and Environmental Safety Rounds documentation by Behavioral Health Associate (BHA) staff was maintained for all units within the facility.
Review on November 9, 2017, of facility policy, "PRS Room and Environmental Safety Rounds" dated April 24, 2017, revealed "... II. Purpose: To provide guidelines for ensuring a safety and therapeutic environment by accounting for all PRS, evaluating therapeutic and physical environment and observing safety measures ... III. Policy: PRS Room and Environmental Safety Rounds are to be made on each unit on all PRS during all shifts. The Behavioral Health Associate (BHA) responsible for conducting the PRS Room and Environmental Safety Rounds will be identified using the Nursing Assignment Sheet ... IV. Definition: PRS Room and Environmental Safety Rounds identifies PRS rooms an all PRS accessible areas as areas that should be monitored during this rounding process. The identified areas will be assessed for environmental hazards such as malfunctioning or missing hardware, broken tiles, ... PRS rooms, bathrooms, etc ... V. Procedure ... 3. Rounds will be documented on the PRS Room and Environmental Safety Rounds Form and stored in a binder on each unit. 4. All environmental or physical plant concerns identified during the process will submitted via a Work Order ..."
Review on November 9, 2017, of facility policy, "RN Rounding" dated April 24, 2017, revealed "... V. The RN will check all BHA rounds sheets for completeness twice each shift. If there are any environmental concerns or property damage observed, the RN will complete an electronic Work Order and submit to Plant Operations for replacement or repair ..."
A request was made to EMP1 and EMP17 on November 8, 2017, at 9:15AM for the Person Receiving Services and Environmental Safety Rounds BHA documentation for all behavioral units within the facility. None was provided.
Interview on November 8, 2017, with EMP17 at 1:42PM confirmed no documented evidence of the Rounding sheets as specified above, for all units. Further interview confirmed "we do them for all the units, but we shred them every month ..."
_____________
Based on review of facility policy and procedures, facility document, and interview with staff (EMP), it was determined the facility failed to ensure that the Environmental of Care (EOC) Committee met monthly.
Review on November 8, 2017, of facility policy, "Facility Safety Committee" dated January 1, 2017, revealed "... 2.0 Procedure: The Risk Manager and HR Manager will appoint staff to participate in the Facility Safety Committee with the objectives to discuss and process ideas for resolution. This committee will meet monthly to discuss, implement and monitor issues surrounding patient, visitor and employee safety ... Minutes will be kept and maintained in hard copy version by the Risk Manager ..."
Review on November 8, 2017, of facility document, "PRS Safety and Facility and Environment Committee" Meeting minutes between December 20, 2016 and October 21, 2017, revealed no documented evidence of EOC meeting for the month of April, May, June, and July 2017.
Interview on November 8, 2017, with EMP1 at 2:14PM confirmed no documented evidence of EOC Committee Meeting minutes on the specified dates above.
_____________
Based on review of facility policy and procedures, facility document and interview with staff (EMP), it was determined the facility failed to ensure Plant Operations Environmental of Care rounding was conducted monthly.
Review on November 9, 2017, of Plant Operations "Facility Rounding" Binder revealed facility document "... Patient Room Door Inspection Process ... Room # ... Doors ... Door Knobs ... Finger Guards" Further review revealed no documented evidence of facility monthly rounding conducted between January 2017 to May 29, 2017.
A request was made to EMP23 on November 9, 2017, at 11:45AM for Plant Operations Environmental of Care Rounding Policy. None was provided.
Interview on November 9, 2017, with EMP23 at 11:45AM confirmed "... there is no policy for rounding or anything that states what they look for ..."
Interview on November 9, 2017, with EMP1 at 12:00PM confirmed no documented evidence of Plant Operations facility monthly rounding conducted between January 2017 and May 29, 2017.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on review of facility documents, observations, review of facility policies and procedures, review of facility documents, review of medical records (MR) and interview with staff (EMP), it was determined the Governing Body failed to ensure compliance with the Compliance with Laws Condition of Participation (A-0200), Patient Rights Condition of Participation (A-0115), and failed ensure compliance with the Physical Environment Condition of Participation to ensure a safe Physical Environment was provided to all patients that resulted in a suicide death of one patient (A-0700).

Findings include:

Review of facility document "Governing Board Bylaws", dated June 29, 2015, revealed "The Governing Body is ultimately accountable for the safety and quality of care, treatment, and services provided by the Facility."

Cross Reference:
482.13 - Patient Rights
482.41 - Physical Environment


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Based on review of facility policies and procedures, facility documents, and interview with staff (EMP), it was determined the facility failed to have an effective governing body by not conforming to all State laws:

Belmont Behavioral Hospital was not in compliance with the following State law:

Medical Care Availability and Reduction of Error (MCARE) Act, Act of Mar. 20, 2002, P.L. 154, No. 13 40, An Act Reforming the law on medical professional liability; providing for patient safety and reporting; establishing the Patient Safety Authority and the Patient Safety Trust Fund; abrogating regulations; providing for medical professional liability informed consent, damages, expert qualifications, limitations of actions and medical records; establishing the Interbranch Commission on Venue; providing for medical professional liability insurance; establishing the Medical Care Availability and Reduction of Error Fund; providing for medical professional liability claims; establishing the Joint Underwriting Association; regulating medical professional liability insurance; providing for medical licensure regulation; providing for administration; imposing penalties; and making repeals.

This is not met as evidenced by:

Based on review of facility policies and procedures, facility documents, and interview with staff (EMP), it was determined that the facility failed to ensure that a designated Patient Safety Officer attended the Patient Safety Committee, failed to ensure that two (2) designated community members attended the Patient Safety Committee, and failed to ensure that a distinct, separate Patient Safety Committee meeting, was held on a monthly basis.

Findings include:

Review on November 7, 2017, of the facility document, "Belmont Behavioral Hospital Safety Management Plan 2017", revealed "II. Scope: The Safety Management Plan describes the programs used to design, implement and monitor a program to manage safety for PRS's (Patient's Receiving Services), staff and visitors and to assure compliance with applicable codes and regulations ... To ensure that all of Belmont's interests and needs are considered when implementing the Safety program committee membership includes representation from all campuses, and property management staff ... The PRS and EOC Committee coordinates processes within the Environment of Care (EC) standard. Membership on the committee includes representatives from administration, clinical services, and support services. The PRS Safety and EOC Committee meets monthly to receive reports and conduct a timely review of safety issues."

Review on November 7, 2017, of the facility document, "Governing Board Bylaws Belmont Behavioral Hospital, LLC", revealed "2.3 CEO ... The CEO's duties include, but are not limited to the following ... (d) ensuring the Facility complies with all federal, state, and local laws to which it is subject, including all applicable licensure laws and regulations."

Review on November 7, 2017, of the facility documents, "Belmont Behavioral Hospital LLC PRS Safety and Facility Environmental Committee Meeting Minutes", dated, "9/26/2017", "8/15/2017", "3/21/2017", "2/21/2017", "1/17/2017", "11/15/2016", "9/20/2016", and "10/18/2016" revealed no documented evidence that a easily identifiable, designated Patient Safety Officer attended the PRS Safety and Facility Environmental Committee meetings. Further review of the meeting minutes revealed no documented evidence that two (2) designated community members attended the PRS Safety and Facility Environmental Committee meetings.

Interview with EMP17, on November 8, 2017, between approximately 10:15 A.M. and 1:00 P.M., confirmed that the PRS Safety and Facility Environmental Committee Meeting is the facilities designated Patient Safety Committee. Further interview with EMP17 confirmed that a designated Patient Safety Officer and two (2) designated community members "did not" attend the PRS Safety and Facility Environmental Committee Meetings, dated, "9/26/2017", "8/15/2017", "3/21/2017", "2/21/2017", "1/17/2017", "11/15/2016", "9/20/2016", and "10/18/2016". Further interview with EMP17 confirmed that the facility "did not" have a Patient Safety Committee meeting for the months of April, May, June, and July of 2017, due to the investigation of two (2) patient deaths within the facility during the month of April 2017.
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the CEO failed to ensure implementation of facility policy's for the management and care for inpatients receiving Electroconvulsive Therapy (ECT) and failed to ensure the policy for the reconciliation of controlled substances was followed.

Findings include:

Review on November 7, 2017, of the facility document, "Governing Board Bylaws Belmont Behavioral Hospital, LLC", revealed "Article 2 General Provisions 2.1 Facility Management ... The Governing body is ultimately accountable for the safety and quality of care, treatment, and services provided by the Facility ... 2.3 CEO. The CEO is responsible for the overall management of the facility. The Governing Board has delegated to the CEO broad authority and responsibility ... The CEO ' s duties include, but are not limited to the following: ... (f) ensuring the Facility has appropriate policies in place to define the goals and scope of services provided by the Facility and to guide and support the care and treatment provided by the facility; ... (h) requiring that patients with comparable needs will receive the same standard of care, treatment and services ant the Facility by ensuring that the Facility plans, designs, and monitors care, treatment, and services so they are consistent with the Facility ' s mission, vision, and goals and ensuring the planning for care, treatment, and services address the following: (i) the needs and expectations of clients and , as appropriate, families and referral sources; (ii) staff needs ... "

Interview on November 7, 2017 with EMP26 confirmed [they] were the CEO of Belmont Behavioral Hospital, Llc.
_____________
Based on review of facility policy, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure facility policy was followed for the care and treatment of inpatients and outpatients receiving Electroconvulsive Therapy (ECT) for two (2) of two (2) medical records reviewed. (MR3 and MR5).
Review on November 8, 2017, of facility policy " Inpatient Electroconvulsive Therapy, procedure number 270.00 " revealed " Purpose: to identify the responsibilities of nursing staff for the preparation, treatment and post-treatment care of the Person Receiving Services (PRS) receiving Electroconvulsive Therapy (ECT) ... C. Pre-procedure: 1. The ECT RN will: ... e. As soon as the ECT treatment is completed, the ECT RN monitors the PRS ' s vital signs until the vital signs are stable, and the PRS is awaken ... "
Observation on November 8, 2017, at 9:45 AM of the patient in MR3 revealed MR3 was admitted to the ECT suite to receive an ECT procedure. At the time of the observation there was one RN (EMP13), one behavioral health assistant (EMP15), one physician (OTH1) and CRNA (OTH2). Further observation between 9:45 AM and 10:15 AM revealed MR3 was sleeping and had a pulse oximeter monitoring device that was displaying heart rate. There were no ECT staff in the bay with MR3. Continued observation revealed at 10:05 AM EMP15 entered the bay and assisted the patient to a wheelchair and the patient left the ECT suite accompanied by a guardian.
Observation on November 8, 2017, at 9:45 AM of MR5 revealed MR5 was admitted to the ECT suite to receive an ECT procedure. At the time of the observation there was one RN (EMP13), one behavioral health assistant (EMP16), one physician (OTH1) and CRNA (OTH2). Further observation from 9:45 AM to 10:15 AM revealed the ECT procedure was completed and EMP13 took one set of vital signs at 9:48. Further observation revealed MR5 was sleeping and had a pulse oximeter monitoring device that was displaying heart rate. There were no ECT staff in the bay with MR3. Continued observation revealed at 10:05 AM EMP16 entered the bay and escorted the patient out of the suite.
Interview on November 8, 2017, at 10:15 AM with EMP16 confirmed no further vital signs were taken for the patient in MR5.
Interview on November 8, 2017, at 10:20 AM with EMP15 confirmed no further vital signs were taken for the patient in MR3.
Interview on November 8, 2017, at 10:30 AM confirmed vital signs for MR3 and MR5 were monitored by a pulse oximeter device (measures heart rate and blood oxygen saturation). Further interview with EMP13 confirmed the pulse oximeter would alarm if the patient had a problem and staff were nearby to respond in the event of an emergency.
_____________
Based on review of facility policy, observation and interview with staff (EMP) it was determined the facility failed to ensure the implantation of the facility ' s policy for the handling of controlled substances.
Findings include:
Review on November 7, 2017, of facility policy " Controlled Substance Order and Reconciliation, policy number PHR-129 " dated July 2017, revealed " 1.0 Statement of Purpose: A system is in place to monitor and reconcile control drug records to identify diversion and theft in a proper manner ... 2.0 Statement of Policy Control drug records will be audited by the pharmacy and nursing to ensure safe and lawful handling of controlled drugs ... 4.0 Procedure: ... Controlled drugs are secured under a two lock security measure ... "
Review on November 7, 2017, of facility policy " Controlled Medication " dated July 2017, revealed " 1.0 Statement of Purpose: The Facility will establish standard procedures with controlled medication to ensure safe and appropriate use ... 4.5 Controlled Substance Drugs Dispensed ... This applies to all Schedules II-IV ... The nurse who receives these materials shall verify and ... palace them immediately in the designated locked drawer ... 4.5.4 ... Nursing is responsible for maintaining proper records ... "
1.Observation on November 7, 2017, at 11:50 AM of the ECT suite revealed a metal cart used in the storage of medication. Further observation revealed the first drawer of the medication cart was unlocked and contained 3 closed multi-dose vials of methohexital sodium 500 mg/vial (Brevital, Schedule IV controlled medication) for injection and one opened vial of methohexital sodium for injection.
Interview on November 7, 2017, at 11:55 AM with EMP13 confirmed the methohexital sodium was not secured with a two-lock security measure.
2.Review on November 7, 2017, at 12:00 PM of the " Brevital Log Sheet " dated November 6, 2017, revealed " 4 vials [200 mg]. " Further review revealed the log sheet was used to document the total number of vials delivered to the ECT suite from the pharmacy. The document was signed by EMP13 and EMP11.
Review on November 9, 2017, of facility document " Brevital Log Sheet " dated November 6, 2017, revealed the name of 10 patients and a number assigned to each name. Further review revealed " use 870mg-87.0ml and 130mg-13,0 ml waste. " The document was signed by EMP13 and EMP11. Further review revealed no documented evidence how many vials of methohexital sodium were used and how vials remained in the drawer.
Review on November 9, 2017, of facility document " Brevital Log Sheet " dated November 8, 2017, revealed the names of 10 patients and a number assigned to each name. Further review revealed " used 800mg-80.0ml and 700mg-70.0 ml waste. The document was signed by EMP13 and EMP11. Further review revealed no documented evidence how many vials of methohexital sodium were used and how vials remained in the drawer.
Interview on November 9, 2017, with EMP13 at 11:00 AM confirmed the number next to each patient ' s name indicated the dosage of medication the patient received during the procedure. Further interview confirmed the " used and waste " notation indicated the number of total milligrams of the medication that was administered to patients and the total amount of milligrams wasted at the end of the day. Continued interview with EMP13 confirmed the reconciliation of narcotics in the ECT suite did not follow the facility policy and that " it was always done this way. "
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to protect and promote the rights of each patient and provide care in a safe setting; by failing to ensure the grievance process is analyzed and reviewed through the hospital's QAPI process (A0119); by failing to provide a written notice of grievance decision in a timely manner as specified in facility policy (A0123); by failing to ensure the exercise of patients' right to have belongings secured and returned to them at discharge for four (4) of four (4) medical records reviewed (A0129); by failing to promptly notify patients' physician of admission to facility (A0133); by failing to ensure care in a safe setting (A0144); by failing to ensure confidentiality of Records (A0147); and by failing to complete restraint documentation for one (1) of five (5) medical records reviewed (A0188).

Cross reference:
482.13(a)(2) Patient Rights: Review of Grievances
482.13(a)(2)(iii) Patient Rights: Notice of Grievance Decision
482.13(b) Patient Rights: Exercise of Rights
482.13(b)(4) Patient Rights: Admission Status Notification
482.13(c)(2) Patient Rights: Care in a Safe Setting
482.13(d)(1) Patient Rights: Confidentiality of Records
482.13(e)(16)(v): Restraint or Seclusion
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
Based on review of facility policy and procedures, review of medical records (MR), and interview with staff (EMP), it was determine the facility failed to ensure accurate emergency care documentation for two (2) of three (3) medical emergency records reviewed. (MR1 and MR25).

Findings include:

Review on November 7, 2017, of facility policy "Code 99," revised April 20, 2016, revealed " ... B. Responsibilities of Nurse Manager/Supervisor: ... 2. Record code proceedings (on Code 99 information sheet-see attached) ... A 5. Monitor vital signs ... D. Document For Transfer: ... 5. a. The code 99 recorder documents the code including all pertinent information up to and including PRSs [person receiving services] disposition on transfer.

Review of provider documentation for MR1 dated April 24, 2017, at 4:19 AM revealed " ... Pt was found on floor, skin was cool to touch, No heart rate or vent was auscultated ... No breathing was present. No femoral pulses were present. No radial pulses were present ... ".

Review on November 8, 2017, of MR1's "Medical Code Activity Record" dated April 24, 2017, revealed the following: " ... 03:10 - no BP, pulse 250, O2 sat 82%, ... 03:15 no BP, pulse 223, O2 sat 89% 03:20 no BP no pulse, O2 sat none, 03:21 BP 137/92, no documentation indicated for pulse ... ".

Further review of MR1's "Medical Code Activity Record" dated April 24, 2017, revealed documentation the PRS was transferred to an ED.

Review of the "Discharge Summary" for MR1 dated May 9, 2017, revealed " ... patient's body was released to the coroner."

Interview with EMP17 on November 7, 8, 2017, at 2:00 PM confirmed the vital sign documentation for MR1, and the PRS in MR1 was not taken to an ED.

Review on November 8, 2017, of MR25, revealed this patient had a medical emergency on April 29, 2017. There was no documented evidence a Code 99 was completed for this medical emergency.

Interview with EMP24 on November 9, 2017, at 9:20 AM, confirmed there was no documented evidence a Code 99 was completed for this medical emergency and that one should have been completed per facility policy.
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on a review of the facility documents and interview with staff (EMP), it was determined that the facility failed to ensure their grievance process was analyzed and reviewed through the hospital's QAPI (Quality Assurance Performance Improvement) process.

Review of the facility's policy, "Complaint and Grievances," dated January 12, 2016, revealed " ... II. Purpose: To establish consistent guidelines for addressing PRS/family concerns/complaints/grievances in a timely manner and as an important part of providing quality care and safe treatment for our PRS."

Review on November 7, 2017 of the facility's policy, "Belmont Behavioral Hospital 2017 Performance Improvement Plan," revealed, no documented evidence of utilization of quality indicators to track, analyze, and review the performance of facility's grievance process.

Review on November 7, 2017 of facility's document, "Belmont Behavioral Hospital Quality Management/HIM Committee Meeting Minutes," dated "10.26.16", "3/23/17", "2/23/17", "05.25.17", "06.22.17", "7.27.17", and "08.31.17" revealed no documented evidence that facility's grievance process was reviewed.

Review on November 7, 2017, of the facility documents, "Belmont Behavioral Hospital LLC PRS Safety and Facility Environmental Committee Meeting Minutes", dated, "9/26/2017", "8/15/2017", "3/21/2017", "2/21/2017", "1/17/2017", "11/15/2016", "9/20/2016", and "10/18/2016" revealed no documented evidence that facility's grievance process was reviewed.

Interview with EMP1 and EMP3 on November 8, 2017 between 11:00 AM and 11:30 AM confirmed the facility's grievance was not reviewed and analyzed through facility's QAPI program.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on a review of medical records (MR), facility documents and interview with staff (EMP), it was determined in its resolution of the grievance that the facility failed to provide patients a written notice of its decision for two (2) of eighteen (18) medical records reviewed (MR22 and MR24) and failed to provide a written notice of decision within an appropriate time frame as specified per facility policy for eighteen (18) of eighteen (18) medical records reviewed (MR11-MR21, MR23, MR25-MR28).

Review on November 7, 2017, of facility's policy, "... Complaint and Grievance," dated January 12, 2016, revealed, "... C. Patient Advocate will: ... The Care Advocate will attempt to respond in writing to all grievances within seven (7) calendar days of receipt of the grievance. ... if a written response cannot be made within seven (7) calendar days, the Care Advocate will inform the PRS or his/her representative that the organization is still working to resolve the grievance and that a written response will be made within thirty (30) calendar days of receipt of grievance."

Review of MR11 grievance documentation, "Person Receiving Services (PRS) Communication Form, dated May 3, 2017, revealed, a written notice of decision was provided on May 26, 2017. Further revealed this letter was not provided within seven (7) calendar days and there was no documented reason for it to be provided after seven (7) calendar days.

Review of MR12 grievance documentation, "Person Receiving Services (PRS) Communication Form, dated May 4, 2017, revealed, a written notice of decision was provided on May 26, 2017. Further revealed this letter was not provided within seven (7) calendar days and there was no documented reason for it to be provided after seven (7) calendar days.

Review of MR13 grievance documentation, "Person Receiving Services (PRS) Communication Form, dated April 12, 2017, revealed, a written notice of decision was provided on May 11, 2017. Further revealed this letter was not provided within seven (7) calendar days and there was no documented reason for it to be provided after seven (7) calendar days.

Review of MR14 grievance documentation, "Person Receiving Services (PRS) Communication Form, dated June 20, 2017, revealed, a written notice of decision was provided on July 10, 2017. Further revealed this letter was not provided within seven (7) calendar days and there was no documented reason for it to be provided after seven (7) calendar days.

Review of MR15 grievance documentation, "Person Receiving Services (PRS) Communication Form, dated June 20, 2017, revealed, a written notice of decision was provided on July 10, 2017. Further revealed this letter was not provided within seven (7) calendar days and there was no documented reason for it to be provided after seven (7) calendar days.

Review of MR16 grievance documentation, "Person Receiving Services (PRS) Communication Form, dated June 20, 2017, revealed, a written notice of decision was provided on July 10, 2017. Further revealed this letter was not provided within seven (7) calendar days and there was no documented reason for it to be provided after seven (7) calendar days.

Review of MR17 grievance documentation, "Person Receiving Services (PRS) Communication Form, dated June 20, 2017, revealed, a written notice of decision was provided on July 10, 2017. Further revealed this letter was not provided within seven (7) calendar days and there was no documented reason for it to be provided after seven (7) calendar days.

Review of MR18 grievance documentation, "Person Receiving Services (PRS) Communication Form, dated June 21, 2017, revealed, a written notice of decision was provided on July 10, 2017. Further revealed this letter was not provided within seven (7) calendar days and there was no documented reason for it to be provided after seven (7) calendar days.

Review of MR19 grievance documentation, "Person Receiving Services (PRS) Communication Form, dated June 22, 2017, revealed, a written notice of decision was provided on July 10, 2017. Further revealed this letter was not provided within seven (7) calendar days and there was no documented reason for it to be provided after seven (7) calendar days.

Review of MR20 grievance documentation, "Person Receiving Services (PRS) Communication Form, dated June 29, 2017, revealed, a written notice of decision was provided on July 10, 2017. Further revealed this letter was not provided within seven (7) calendar days and there was no documented reason for it to be provided after seven (7) calendar days.

Review of MR15 grievance documentation, "Person Receiving Services (PRS) Communication Form, dated June 20, 2017, revealed, a written notice of decision was provided to you on July 10, 2017. Further revealed this letter was not provided within seven (7) calendar days and there was no documented reason for it to be provided after seven (7) calendar days.

Review of MR22 grievance documentation, "Person Receiving Services (PRS) Communication Form, dated July 18, 2017, revealed, a written notice of decision was not provided.

Review of MR23 grievance documentation, "Person Receiving Services (PRS) Communication Form, dated August 8, 2017, revealed, a written notice of decision was provided to you on October 5, 2017. Further revealed this letter was not provided within seven (7) calendar days and there was no documented reason for it to be provided after seven (7) calendar days.

Review of MR24 grievance documentation, "Person Receiving Services (PRS) Communication Form, dated August 27, 2017, revealed, a written notice of decision was not provided.

Review of MR25 grievance documentation, "Person Receiving Services (PRS) Communication Form, dated September 10, 2017, revealed, a written notice of decision was provided to you on October 5, 2017. Further revealed this letter was not provided within seven (7) calendar days and there was no documented reason for it to be provided after seven (7) calendar days.

Review of MR26 grievance documentation, "Person Receiving Services (PRS) Communication Form, dated September 22, 2017, revealed, a written notice of decision was provided to you on October 5, 2017. Further revealed this letter was not provided within seven (7) calendar days and there was no documented reason for it to be provided after seven (7) calendar days.

Review of MR27 grievance documentation, "Person Receiving Services (PRS) Communication Form, dated September 26, 2017, revealed, a written notice of decision was provided to you on October 5, 2017. Further revealed this letter was not provided within seven (7) calendar days and there was no documented reason for it to be provided after seven (7) calendar days.

Review of MR28 grievance documentation, "Person Receiving Services (PRS) Communication Form, dated October 23, 2017, revealed, a written notice of decision was provided to you on November 3, 2017. Further revealed this letter was not provided within seven (7) calendar days and there was no documented reason for it to be provided after seven (7) calendar days.
VIOLATION: PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS Tag No: A0147
Based on review of facility documents and interview with staff it was determined the facility failed to ensure the confidentiality of patient's medical record (MR) was provided for ten (10) of ten (10) medical records reviewed. (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10)

Findings include:

A request was made on November 7, 2017, at 2:00 PM to EMP6 for a policy regarding the confidentiality of patient medical records. None provided.

A request was made on November 8, 2017, at 9:30 AM to EMP4 for a policy regarding the confidentiality of patient medical records. None provided.

Observation on November 6, 2017, at 1:00 PM of 2 Center Unit revealed a wire basket that contained documents related to patient care and response to treatment, was located at the nurse's station in a public corridor that did not provide unauthorized access to the documents. Continued observation revealed the basket contained 166 pages of patient related documents that were to be filed in the patient's medical record. Continued observation revealed the documents were dated from August 17, 2017, to November 5, 2017.

Interview on November 6, 2017, at 2:00 PM with EMP7, confirmed the patient related documents were placed in an unsecured area that did not protect patient information from unauthorized access. Further interview with EMP7 confirmed the documents were to be filed in the patient's medical record when the patient chart was returned to the unit.
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VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0188
Based on review of facility policy and procedures, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure restraint documentation was completed per facility policy for one (1) of five (5) medical records reviewed for restraint documentation. (MR1).

Findings include:

Review on November 8, 2017, of facility policy " Emergency Safety Interventions," revised August 1, 2016, revealed " ... IV. Procedure ... F. Removal of Restraints: 1. The Registered Nurse and physician will: a. Assure the PRS [person receiving service] is released from restraints when release criteria are met ... ".

Review on November 8, 2017, of the "Restraint/Seclusion Episode Record" for MR1 revealed the patient was placed in four point restraints on April 23, 2017, at 14:15 [2:15 PM] and was released at 15:15 [3:15 PM].

Further review of "Restraint/Seclusion Episode Record" for MR1 dated April 23, 2017, revealed no documentation in the section identified for "Discontinuation Criteria Met." Continued review of the "Rounds Record" for MR1 dated April 23, 2017, revealed the patient was documented as "C=Angry" at the time of release from restraints at 15:15.

Interview with EMP17 on November 8, 2017 at 1:20 PM confirmed there was no documentation for "Discontinuation Criteria Met" for MR1 and the Rounds Record documented the patient was "Angry" at the time of release.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on review of policy and procedures, observation and interview with staff (EMP) determined the facility failed to ensure aseptic techniques were followed during the preparation of a sterile compound and failed to ensure safe medication practices when using a multi-dose vial.
Findings include:
Review on November 8, 2017, of facility policy " The Role of Nursing in Medication Administration," dated July 2015, revealed no provisions for the compounding of immediate-use medications and no provision for safe methods of an IV (intravascular) medication when accessing a multidose medication vial.
Observation on November 8, 2017, of the ECT (Electroconvulsive Therapy) procedure area at 9:43 AM revealed 3 procedure bays numbered bay 1, bay 2, and bay 3 and a documentation area within the procedure area. There were patients occupying bay 3 and bay 2.
1.Observation on November 8, 2017, at 9:50 AM of the documentation area in the procedure area revealed a multi-dose vial of the medication methohexital sodium (preservative-free barbiturate) 500mg/vial for injection, with a 10cc syringe protruding from the access port of the vial and a multi-dose vial of the medication Labetalol Hydrochloride (medication for lowering blood pressure) 200mg/40ml were opened and sitting on the counter. Further observation revealed EMP13 was in the procedure area and withdrew medication into the existing syringe protruding from the bottle labeled methohexital sodium.
2.Observation on November 8, 2017, at 10:15 AM of the ECT (Electroconvulsive Therapy) procedure area at 10:15 AM revealed EMP13 was in the procedure area, and used a syringe to withdraw medication from a vial labeled Esmolol. EMP13 obtained a second syringe and withdrew medication from the same vial of Esmolol without disinfecting the top of the vial prior to inserting the syringe.
Interview on November 8, 2017, at 10:20 AM with EMP13 confirmed the medications were prepared in the procedure are of the ECT room. Further interview confirmed the existing syringe protruding from the methohexital sodium vial was used to add a diluent to the medication to alter the concertation of the medication prescribed by the physician. Continued interview with EMP13 confirmed they did not disinfect the access port of the methohexital medication vial or the Esmolol medication vial prior to accessing the ports.
VIOLATION: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Tag No: A0308
Based on review of facility policies and procedures, facility documents, and interviews with staff (EMP), it was determined the facility failed to ensure that the QAPI program involves the review of all hospital departments and services, including those services furnished under contract, for Anesthesia, Laboratory, Radiology, and Sterilization Services.

Findings include:

Review on November 7, 2017, of the facility document, "Governing Board Bylaws Belmont Behavioral Hospital, LLC", revealed "Article 2 General Provisions 2.1 Facility Management ... The Governing body is ultimately accountable for the safety and quality of care, treatment, and services provided by the Facility ... For this purpose, the Company has delegated to the Governing Body the authority to receive and evaluate periodic reports from the Medical Staff and its Officers, to make decisions regarding Medical Staff appointment and Clinical privileges, to oversee quality assessment and improvement ... 2.3 CEO ... The CEO's duties include, but are not limited to the following ... (i) periodically evaluating any contracted care and services to determine whether they are being provided in accordance with the terms of the applicable contracts and consistent with the level of safety and quality the Facility expects; (j) supporting the facility's quality assessment and improvement program ... (k) implementing processes that measure and assess the performance improvement and safety improvement activities of the Facility and its programs."

Review on November 7, 2017, of the facility document, "Belmont Behavioral Hospital 2017 Performance Improvement Plan", revealed "2.0 Purpose The performance improvement program is designated to provide a coordinated, objective and systematic approach to organizational-wide performance ... 3.0 Goals and Objectives ... The program promotes an organization-wide commitment to continually meet and/or exceed standards in the delivery of quality health care and services ... 5.0 Organization ... 5.8 Organization Departments/Services All departments, services and programs participate in the performance improvement and process improvement program."

Review on November 7, 2017, of the facility document, "Belmont Behavioral Hospital Performance Improvement Plan 2017", revealed specific quality, performance indicators for "Department ... Admissions ... CES (Clinical Education Services) ... Dietary ... Human Resources ... Infection Control ... Nursing ... Pharmacy ... Environmental Services ... Plant Operations ... Social Services." Further review of the performance improvement plan revealed no documented evidence of assigned, specific quality indicators and/or data elements for contracted services including Radiology, Laboratory, Anesthesia, and Sterilization Services.

Review on November 7, 2017, of the facility documents, "Contracts" binder, revealed active contracts for clinical services including "Radiology Services", "Laboratory Services", "Anesthesia Services", and "Sterilization Services" (Sterilization of mouth-guards utilized during ECT).

Review on November 7, 2017, of the facility documents, "Belmont Behavioral Hospital Quality Management/HIM Committee Meeting Minutes", dated "10.26.16", "3/23/17", "2/23/17", "05.25.17", "06.22.17", "7.27.17", and "08.31.17" revealed no documented evidence of the ongoing monitoring, review, and analysis of specific quality indicators and/or data elements for contracted services including Radiology, Laboratory, Anesthesia, and Sterilization Services.

Interview with EMP17, on November 8, 2017, between approximately 10:15 A.M. and 1:00 P.M., confirmed that the facility "does" have active contracts for Radiology, Laboratory, Anesthesia, and Sterilization Services. Further interview with EMP17 confirmed the facility "does not" have documented evidence within the 2017 Performance Improvement Plan for assigned, specific quality indicators and/or data elements related to contracted services, including Radiology, Laboratory, Anesthesia, and Sterilization Services. Further interview with EMP17 confirmed that the Belmont Behavioral Hospital Quality Management/HIM Committee Meeting Minutes, dated "10.26.16", "3/23/17", "2/23/17", "05.25.17", "06.22.17", "7.27.17", and "08.31.17", "did not" contain documented evidence of the ongoing monitoring, review, and analysis of specific quality indicators and/or data elements for contracted services including Radiology, Laboratory, Anesthesia, and Sterilization Services.
VIOLATION: MEDICAL STAFF BYLAWS Tag No: A0353
Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to ensure their Medical Staff Bylaws were reviewed according to their own bylaws and failed to ensure the the Medical Staff Bylaws contained an accurate Table of Contents.

Findings include:

Review on November 9, 2017, of facility document "Medical Staff Bylaws," reviewed August 17, 2015, revealed " ... Article 14 General Provisions 14.1 Medical Staff Rules & Regulations and Policies 14.1.1 ... The Rules and Regulations shall be reviewed at least every two (2) years ... ". Further review of the "Medical Staff Bylaws" revealed the "Table of Contents" section page numbers did not accurately correlate with the actual page contents of the Bylaws.

Interview with EMP24 on November 9, 2017, at 12:30 PM confirmed the "Medical Staff Bylaws" were not reviewed at least every two years and the "Table of Contents" was not accurate.
VIOLATION: AUTOPSIES Tag No: A0364
Based on review of medical records (MR) and interview with staff (EMP), it was determined the facility failed to have documentation of an autopsy report in the case of an unusual death for one (1) of two (2) medical records reviewed. (MR1).

Findings include:

On November 8, 2017, request was made to EMP1 for Autopsy policy and procedures and for autopsy report and disposition of the body for MR1. None was provided.

Review on November 9, 2017, of "Disposition of Body Form," undated, revealed information that included: " ... Medical Examiner Release, Tissue/Organ Donation, Identification/Transport of Body to Morgue, Release of Body ... ".

Review of MR1 on November 7, 2017, revealed the patient was found hanging from a loopable point on a bathroom anti-ligature door and was pronounced dead on April 24, 2017. Further review of MR1 revealed no documented evidence of a "Disposition of Body Form" or an autopsy report.

Interview with EMP3 on November 7, 2017, at 12:00 PM confirmed a "Disposition of Body Form," was not completed for MR1.

Interview with EMP24 on November 9, 2017, at 12:30 confirmed the facility had not requested an autopsy report for MR1.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on review of facility policy and procedures, facility documents, observation, and interview with staff (EMP), it was determined the facility failed to ensure a sufficient number of nursing staff were available to meet the nursing needs of the patients at the facility.

Findings include:

Review on November 8, 2017, of facility document " Belmont ECT Treatment Log " dated November 8, 2017, revealed one physician, one CRNA, one RN and two behavioral health assistants were scheduled to work in the ECT suit. Further review revealed a total of 12 appointments were scheduled for the day.

Review on November 8, 2017, of facility policy " Electroconvulsive Therapy (ECT) " dated March 7, 2017, revealed " ... IV. Procedure ... C. ECT Team-At BBH (Belmont Behavioral Hospital) ECT is administered by a team consisting of a board-certified psychiatrist ...a nurse anesthetist, a registered nurse and behavioral health assistants ... 3. Procedures for Post ECT Therapy: After treatment, the PRS (Patient Receiving Services) is carefully observed on a one to one basis until awake, the vital signs are stable, and PRS is able to walk ... Inpatient Electro-Convulsive Therapy, " dated March 7, 2017, revealed " ... IV. Procedure; ... C. Pre-Procedure. The ECT RN will: ... e. As soon as ECT treatment is completed, the ECT RN monitors the PRS ' s vital signs until the vital signs are stable, and the PRS is awaken ... h. The RN will document and relay pertinent information to the family/escort or unit staff as necessary ... "

Observation on November 8, 2017, at approximately 9:45 AM one R.N., one CRNA, one physician and two BHA. These individuals staffed the pre-operative area, post-operative area and the procedure room. There was one patient in the post-procedure area with an escort, one patient in the procedure area with the physician, CRNA and one RN, and no patients or staff in the post-procedure area. The pre-procedure and post-procedure area and procedure area was staffed with a total of one R.N.

Observation in the post-procedure area for Bay 1 from 9:30 AM to 10:02 AM revealed PT1 ' s procedure was completed at 9:30 AM and was recovering. Further observation revealed non-licensed staff, EMP15 and PT1 ' s escort in Bay 1 trying to awaken the patient for discharge. PT1 appeared sedated and unable to walk. PT1 vital signs were not checked and not evaluated by the physician prior to discharge during the observation. EMP15 with the assistance of PT1 ' s escort assisted PT1 into a wheelchair and left the suite. Continued observation revealed licensed staff, EMP13, OTH1 and OTH2 performing an ECT procedure in Bay 2 for PT2. There was no patient in Bay 3.

Observation of Bay 2 in the procedure area on November 8, 2017, at approximately 9:53 AM to 10:12 AM of Bay 2 revealed PT2 had completed their ECT procedure and was sleeping in bed. EMP13 checked vital signs immediately after the procedure and left Bay 2. OTH2 completed documentation for the procedure and left Bay 2. OTH1 also completed documentation and left Bay 2. PT2 was monitored electronically with a pulse oximeter that displayed the patient ' s heart rate. Non-licensed staff, EMP16, entered Bay 2 asked the patient how they were feeling and prepared the patient for discharge. During this observation, the RN and the physician did not further evaluate the patient prior to discharge. EMP16, assisted the patient into a wheelchair and left the suite

Observation of Bay 1 on November 8, from 10:08 AM to 10:29 AM revealed PT3 was escorted into Bay 1. Further observation revealed EMP13 checked the patient ' s vital signs and left Bay 1 to prepare medications that would be administered during the procedure. Non-licensed staff, EMP15, finished preparing the patient for ECT. OTH1, OTH2 and EMP13 entered Bay 1 and became the procedure. After the procedure was completed OTH1 and OTH2 completed documentation and EMP13 left Bay 1. PT3 was electronically monitored by a pulse oximeter that displayed the patient ' s heart rate. The patient was sleeping. EMP15 entered the room and asked the patient if they were ready to be discharged to which PT3 responded yes. PT3 was assisted to a wheel chair and left the suite. During this observation PT3 was evaluated by the physician or RN prior to discharge.

Interview on November 8, 2017, at 10:05 AM with EMP15 confirmed patients are monitored electronically after the procedure and the audible alarm from the pulse oximeter notifies staff if there is a problem.

Interview on November 8, 2017, at 10:10 AM with OTH2 confirmed Bay 1, Bay 2 and Bay 3 are visible from the back of the procedure area and staff were walking about the area frequently to observe patients. Further interview with OTH2 confirmed the pulse oximeter would alarm if there was a problem with a patient and staff would respond.

Interview on November 8, 2017, at 10:30 AM with EMP13 confirmed they did not monitor the patient on a one to one basis. EMP13 confirmed that this is the routine procedure for the ECT suite.
VIOLATION: PHARMACY ADMINISTRATION Tag No: A0491
Based on review of facility policy and procedures, review of facility documents and interview with staff (OTH), it was determined the facility failed to ensure that monthly inspections of the medication storage areas were conducted.

Findings include:

Review on November 9, 2017, of facility policy and procedures "Emergency Medications," dated July 20, 2015, revealed " ... 4.6 During monthly medication storage area inspections, the Pharmacy will check par levels and expiration dates."

Review on November 9, 2017, of facility documents "Nursing Unit Inspection Form" revealed it included Pharmacy inspections for the following : Patient Medications and Floors stock ... Emergency Drug Kit or First Aid Kit ... Controlled Substances ... Accucheck controls ... sanitary conditions ... ".

Further review of the "Nursing Unit Inspection Forms," revealed no documented evidence that Pharmacy inspections were conducted on the nursing units in February, May, July and September 2017.

Interview with OTH1 on November 9, 2017, at 10:30 AM confirmed there was no documented evidence that Pharmacy inspections were conducted on the nursing units for February, May, July and September 2017.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on review of facility policy and procedures, facility document, observation, and interview with staff (EMP), it was determined the facility failed to ensure a safe environment was provided for patients admitted to the adolescent and adult Behavioral Health Units.

Findings include:

Review on November 7, 2017, of facility policy, "Safety Management Plan" dated 2017, revealed "... III. Fundamentals: ... C. ... Regular evaluation of the environment for work practices and hazards is required to maintain a current relevant safety program. The program should change as needed to respond to identified risks, hazards and regulatory compliance issues ... Risk assessments are conducted of the buildings, grounds, equipment, staff activity, care of Person Receiving Services (PRS), and work environment ... V. Organization and Responsibility: ... The PRS and Environmental of Care (EOC) Committee meets monthly to receive reports and conduct a timely review of safety issues ... Safety Risk Assessment ... The organization conducts or reviews periodic risk assessments to evaluate the potential of adverse impacts of buildings ... equipment ... and internal physical systems on the safety and health of PRSs, staff, ... Risks are also identified from internal sources such as ongoing monitoring of the environment ... results of proactive risk assessments of high risk processes ... Some examples of risks associated with the physical environment include those that might be contributed to suicide or acts of violence ... The goal of performing risk assessments is to reduce the likelihood of future incidents or other negative experiences that have the potential to result in injury, an accident ... "

Review on November 7, 2017, of facility document, "Environmental Risk Assessment" dated December 2016, revealed "... Environmental of Care (EOC) Item ... Door handle, hinge, and locks ... Ligature/security risk - could be used as a suicide hanging point ... Mitigation of Issue - locks and hinge doors on patient room doors free of anchor points ... crescent or open spin anti-ligature handles ... Further Action Required Y... Schedule installation of full mortise hinges on all doors with Tip-it top to reduce ligature risk ... Time Frame for Action or Completion - 120 days contracted services required to meet completion time frame April 1, 2017... Platform Beds ... Open portals in bed frame present possible ligature point ... Secure red oak trim to cover all openings ... Schedule installation of trim to eliminate ligature risk ... Time Frame for Action or Completion - 120 Days, April 2017... Toilets ... Ligature Risk ... Mitigation of Issue - Toilets are floor mounted with exposed piping that could serve as an anchor point for hanging. Water supply pipe protrudes from the wall behind and beneath toilet ... Further Action Required Y ... Ongoing campus expansion includes installation of ligature resistant toilets ... "

Review on November 7, 2017, of facility document, "... EOC Proactive Risk Assessment Acute Inpatient" dated 2017, revealed "... to replace the door hinges in PRS bedrooms with an approved alternative anti-ligature hinge. Physical Plant modification ... will be developed focusing on a few units at a time until all unit changes are made. August 2017 ... Tentative Physical Plant Hardware Completion Date; 12/15/2017..."

Review on November 7-9, 2017, of facility documents, dated September 20, 2016, November 15, 2016, January 17, 2017, February 21, 2017, and August 15, 2017, revealed environmental safety concerns were discussed that included, but not limited to, loopable bed restraints and hinged doors.

Observation tour of Two South - Adolescent Unit on November 6, 2017 at 10:25 AM confirmed a 24 bed unit. Further review of the unit revealed the following environmental safety concerns:

Room 269: non-safety screws throughout room, toilet not encased, ceiling light at entrance not flushed mounted.

Room 267: Shower soap dispenser was lightweight plastic, toilet was loopable in design (not enclosed), two patient beds had multiple loopable slots utilized for restraint tie points.

Room 266: three loopable restraint beds, non-safety screws throughout room, toilet not encased, toilet plumbing not encased, all beds with restraint holes, plastic soap dispenser located at sink and shower, ceiling lights not flushed mounted.

Room 263: Shower soap dispenser was lightweight plastic, toilet was loopable in design (not enclosed), two patient beds had multiple loopable slots utilized for restraint tie points.

Room 262: one loopable restraint bed, non-safety screws throughout room, toilet not encased, toilet plumbing not encased, plastic soap dispenser located at sink and shower, ceiling lights not flushed mounted.

Room 261: Shower soap dispenser was lightweight plastic, toilet was loopable in design (not enclosed), three patient beds had multiple loopable slots utilized for restraint tie points.

Room 260: three loopable restraint beds, non-safety screws throughout room, plastic soap dispenser located at sink and shower, ceiling lights not flushed mounted.

E 208: plastic soap dispenser in shower

E 210: plastic soap dispenser in shower

E 212: plastic soap dispenser in shower

Observation tour of Two East - Adult Unit on November 6, 2017 at 10:45 AM confirmed a 23 bed unit. Further review of the unit revealed the following environmental safety concerns:

Snack Room: 3 pin hinge loopable door, sink with loopable faucets, handles and on/off stick

Room 222: one loopable restraint bed, non-safety screws throughout room, toilet not encased, toilet plumbing not encased, plastic soap dispenser located at sink and shower, ceiling lights not flushed mounted, 3 pin hinge loopable door

Room 223: Toilet was loopable in design (not enclosed), three patient beds had multiple loopable slots utilized for restraint tie points, desk was loopable in design (not flush against wall), room door hinge was loopable in design (three hinge points that were not continuous and were not enclosed).

Room 221: Shower soap dispenser was lightweight plastic, two patient beds had multiple loopable slots utilized for restraint tie points.

Room 219: Toilet was loopable in design (not enclosed), two patient beds had multiple loopable slots utilized for restraint tie points, room door hinge was loopable in design (three hinge points that were not continuous and were not enclosed).

Room 211: Shower soap dispenser was lightweight plastic.

Room 209: Shower soap dispenser was lightweight plastic.

Room 207: One patient beds had multiple loopable slots utilized for restraint tie points.

Room 206: three beds in room, one loopable restraint bed, non-safety screws throughout room, toilet not encased, toilet plumbing not encased, ceiling lights not flushed mounted, 3 pin hinge loopable door.

Room 203: Toilet was loopable in design (not enclosed), two patient beds had multiple loopable slots utilized for restraint tie points, room door hinge was loopable in design (three hinge points that were not continuous and were not enclosed).

Room 201: Toilet was loopable in design (not enclosed), three patient beds had multiple loopable slots utilized for restraint tie points, room door hinge was loopable in design (three hinge points that were not continuous and were not enclosed), shower soap dispenser was lightweight plastic.

Room 200: Toilet was loopable in design (not enclosed), three patient beds had multiple loopable slots utilized for restraint tie points, room door hinge was loopable in design (three hinge points that were not continuous and were not enclosed), shower soap dispenser was lightweight plastic.

Observation tour of Three Center - Adolescent Unit on November 6, 2017 at 10:45 AM confirmed a 24 bed unit. Further review of the unit revealed the following environmental safety concerns:

Room 321: three beds in room, two loopable restraint beds, toilet not encased, toilet plumbing not encased, plastic soap dispenser, ceiling lights not flushed mounted, 3 pin hinge loopable door, loopable desk, non-safety screws at window latch.

Room 322: Toilet was loopable in design (not enclosed), one patient beds had multiple loopable slots utilized for restraint tie points, shower soap dispenser was lightweight plastic.

Room 323: two loopable restraint beds, toilet not encased, toilet plumbing not encased, plastic soap dispenser, 3 pin hinge loopable door, loopable desk, non-safety screws at window latch.

Room 325: two loopable restraint beds, plastic soap dispenser, non-safety screws at window latch.

Room 326: Toilet was loopable in design (not enclosed), three patient beds had multiple loopable slots utilized for restraint tie points, room door hinge was loopable in design (three hinge points that were not continuous and were not enclosed), shower and sink soap dispensers were lightweight plastic.

Room 328: Toilet was loopable in design (not enclosed), three patient beds had multiple loopable slots utilized for restraint tie points, shower and sink soap dispensers were lightweight plastic, desk was loopable in design (not flush against wall).

Room 331: three loopable restraint beds, toilet not encased, toilet plumbing not encased, plastic soap dispenser, non-safety screws at window latch.

Room 333: three loopable restraint beds, plastic soap dispenser, non-safety screws at window latch.

Room 339: Three patient beds had multiple loopable slots utilized for restraint tie points, room door hinge was loopable in design (three hinge points that were not continuous and were not enclosed).

Observation tour of Three South - Adult Unit on November 6, 2017 between 10:30 AM and 11:45 AM confirmed a 18 bed unit. Further review of the unit revealed the following environmental safety concerns:

Group Day Room (M343): loopable door handle, television loopable, a vent with mesh.

Hallway: Loopable exit sign, loopable hinges on fire doors, loopable magnetic door latch/rod, AC vent in main hallway loopable, Ceiling AC vent in main hallway loopable, end of hall has loopable fire door latch/arm, kitchen group room door handle loopable, pantry closet handle loopable, storage closet handle and hinges loopable, washing machine room handle loopable.

Room 345: two (2) beds with loopable bed slats, desks and wardrobes creates a gap between furniture and wall, two (2) wall discs with non-safety screws, on door hinges to bathroom and room entrance there are non-safety screws, the light fixture in bedroom and bathroom not flushed.

Room 347: two (2) beds with loopable bed slats, desks and wardrobes creates a gap between furniture and wall, two (2) wall discs with non-safety screws, on door hinges to bathroom and room entrance there are non-safety screws, the light fixture in bedroom and bathroom not flushed.

Room 351 (Utility Closet Door): loopable handle, loopable hinges on outside of door.

Room 353(Staff bathroom): Door handle loopable.

Room 357 (Utility closet): loopable door handle and hinges.

Room 359 (Group room): loopable closet door handle, loopable door arms, hinges, window shades.

Room 360: three (3) beds with slats, furniture gap

Room 346: three (3) beds with slats, furniture gap

Room 344: three (3) beds with slats, furniture gap

Room 342: two (2) beds with loopable bed slats, desks and wardrobes creates a gap between furniture and wall, two (2) wall discs with non-safety screws, on door hinges to bathroom and room entrance there are non-safety screws, the light fixture in bathroom not flushed, bathroom rod breakaway.

Room 361: three (3) beds with loopable bed slats, two (2) wall discs with non-safety screws, on door hinges to bathroom and room entrance there are non-safety screws, the light fixture in bedroom and bathroom not flushed, entry door hinges loopable, toilet loopable, shower rod breakaway.

Observation tour of Three South West - Older Adult Unit on November 6, 2017 approximately between 10:30 AM and 11:45 AM confirmed a 10 bed unit. Further review of the unit revealed the following environmental safety concerns:

Room 363 (chart room): loopable door handle.

Kitchen/Group Area: loopable pantry door handle, refrigerator door handle loopable.

Interview Room: door handle loopable.

Hallway: loopable AC unit, end of hall exit signs loopable, exit door handles loopable, linen door handle loopable, washer/dryer door handle loopable.

Room 367: two (2) beds with slats, bathroom light fixture not flushed, non-safety screws on door, toilet plumbing loopable.

Room 369: two (2) beds, non-safety screws, ceiling light fixture not flushed, furniture creating gap, two (2) wall discs with non-safety screws.

Room 368: two (2) loopable geri-beds.

Room 366: two (2) loopable geri-beds.

Day room: loopable door hinges on TV cabinet, door hinges on storage cabinet, AC system loopable.

Room 362: desk creates a gap, the bathroom issues same as noted in other rooms.

Observation tour of Three East - Adult Unit on November 6, 2017 between 10:30 AM and 11:45 AM confirmed a 17 bed unit. Further review of the unit revealed the following environmental safety concerns:

Hallway: at entrance loopable door arm, staff bathroom with loopable door handle, Linen Room door handle loopable with loopable hinges, chart room door handle loopable, Nursing locker room door handle loopable, time clock loopable, cubby area not continuously visible, laundry room door handle and vent loopable.

Room 319: Furniture creating a gap, three (3) beds with slats, non-safety screws at bathroom entrance, hallway exit loopable.

Room 312 (Pantry door): exterior and interior door handle loopable,

Room 309 (Utility Closet): door handle loopable

Room 307 (interview room): door handle loopable.

Room 304: door hinges, three (3) beds with slats, 2 wall disc with non-safety screws, light fixture.

Room 302: door hinges, three (3) beds with slats, furniture creating gaps

Room 303: door hinges, two (2) beds with slats

Room 300: door hinges, three (3) beds with slats, furniture creating gaps, non-safety screws.

Room 301: four (4) lock hinge screws, two (2) non-safety screws in door, two (2) beds with slats, loopable exit sign at end of hall.

Interview on November 6, 2017, with EMP5 and EMP19, between approximately 10:15 A.M. and 11:45 A.M., confirmed the above findings.
Interview on November 9, 2017, with EMP1 at 2:14PM confirmed the facility was aware of the environmental safety concerns identified in the facility documents, and the Environment Risk Assessments.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on review of facility policy and procedures, review of medical record (MR), and interview with staff (EMP), it was determined the facility failed to ensure a patient death was reported to the FDA and the manufacturer within ten (10) working days of becoming aware that the device caused or contributed to the incident for one (1) of one (1) medical records reviewed. (MR1).

Findings include:

On November 9, 2017, surveyor requested facility policy for equipment malfunction and for any reports of equipment malfunctioning in MR1. No reports were provided.

Review of facility's draft policy and procedures "Medical Device Reporting/Recalls," dated November 9, 2017, revealed " ... The Risk Manager shall be responsible for submitting appropriate reports to the FDA and/or the medical device manufacturer in accordance with federal law and regulations. The law requires the following: Patient deaths must be reported to the FDA and the manufacturer within 10 working days of becoming aware that the device caused or contributed to the incident ... ".

Review of MR1 revealed a failure of a bathroom anti ligature safety door that had a bent piece(s) of the anti ligature hinge area which created a loopable point where a patient was found hanging by staff and pronounced dead.

Interview with EMP 3 on November 9, 2017, at 11:45 AM confirmed the draft "Medical Device Reporting/Recalls" policy and procedure was created during the survey and there were no reports for the equipment malfunction in MR1 to the FDA or manufacturer.