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.

EL PASO BEHAVIORAL HEALTH SYSTEM 1900 DENVER AVE EL PASO, TX Oct. 17, 2012
VIOLATION: GOVERNING BODY Tag No: A0043
Based on a review of facility policies, procedures and documents, patient records and staff interviews, it was determined that the governing body failed in its responsibility to ensure that services were provided to patients in a safe setting that permitted the hospital to comply with all applicable conditions of participation and standards.

Findings included:

Review of 2 of 2 patient records of patients with special observation/monitoring ordered revealed that they were not monitored. Treatment plans did not address patient precautions/observation status, and were not updated with a change in a patient ' s condition. Patients on voluntary status requesting to leave the facility were not assisted in completing the process to request discharge, and the facility did not follow their grievance policy for a patient expressing a desire to file a complaint. Nurses and nursing staff neglected to monitor a patient on Line of Sight precautions as ordered, creating an unsafe environment in which a patient committed suicide.
Cross refer:
CFR 482.13
CFR 482.23
VIOLATION: CONTRACTED SERVICES Tag No: A0083
Based on direct observation, record review, and interviews, it was determined that the governing body failed in its responsibility to ensure that services provided were in compliance with all applicable conditions of participation and standards.

Findings included:

Review of facility policy entitled " Opiate Detoxification " stated in part, " Vital Signs-Take and record TPR and B/P every 4 hours for the first 72 hours, then every shift for 72 hours, then daily thereafter. "

Patient # 9 was on Opiate Detoxification Protocol initiated on 07/28/12 at 1330. A review of the Vital Signs, Blood Sugar and Meals Record for Patient # 9 revealed that vital signs were only recorded for the following dates: 07/28/12 at 1330, 07/29/12 at 0600, 07/30/12 at 0600, 07/31/12 at 0600, and 08/01/12 at 0600. On 08/02/12 vitals were recorded in the medical consult. On 08/03/12 vitals were recorded as a late entry related to a post fall assessment.

Patient # 9 did not have vitals monitor every 4 hour for 72 hours per physician order and facility policy.


Review of facility policy entitled, " Medical Emergencies " stated in part, " 1. The staff person witnessing or receiving an initial report of a major illness, accident, or injury on site requiring emergency response will activate the emergency by calling a " Code Blue " over the enunciator system...
7. An incident report will be completed documenting details of any event. "

A review of facility provided documentation and review of patient # 9's complete medical record revealed no incident report was completed detailing the code blue and subsequent patient death.

Review of facility policy entitled, " CPR Code Blue " stated in part,
" 3. Additional University Behavioral Health of El Paso member has the responsibility for the following:
C. Taking and recording of vital signs.
D. After paramedics arrive:
1. Document in the medical record utilizing the code blue response form ...
4. Notify patient ' s family of emergency.
Documentation of the Code Blue will include:
A. Time of cardiac and/or respiratory arrest.
B. How arrest was recognized
C. Time CPR started and by whom
D. Emergency medical interventions
E. Time medical control relinquished to paramedic team
F. Disposition of patient (if transferred following patient transfer policy) "

A review of Patient # 9's complete medical record revealed vital signs were not recorded during the Code Blue on 08/04/12. No code blue response form was present in the medical record. There was no documented notification of the patient ' s family of the medical emergency. The documentation in the medial record did not include the time CPR was started, by whom, and the time medical control was relinquished to paramedic team.
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of medical records, facility policies and documents, and staff interviews, the facility failed to promote and protect patient rights:

a)that patients received care in a safe setting:
1) a patient was not monitored at the level ordered by the physician.
2) a patient was not assessed by a nurse performing rounds every 2 hours per facility policy.

b) that voluntary status patients' requests for discharge were not addressed properly per Patient Bill of Rights and facility based policy. Cross refer to A0116.

c) that informed consent was obtained for the administration of psychoactive medication. Cross refer to A0131.

d) that patient grievances were properly addressed per facility policy. Cross refer to A0118.

An Immediate Jeopardy exists in that the facility failed to ensure the right for all patients served or seeking services at the facility to receive care in a safe setting as evidenced by
failing to monitor a patient per policy or physician order, creating an unsafe environment in which a patient committed suicide.

Findings were:

Review of 2 of 2 patient records of patients with special observation/monitoring ordered revealed that they were not monitored. An [AGE] year old High School student (on the adult unit due to age) that was not monitored as ordered (line of sight) committed suicide while on inpatient status at the facility. Treatment plans did not address patient precautions/observation status, and were not updated with a change in a patient ' s condition.
Cross refer: CFR 482.13(c)(2)

Review of 2 of 2 patient records revealed documentation that 2 patients on voluntary status requested to leave the hospital, yet there was no documented evidence the patients were assisted in completing the process for a voluntary patient to request discharge.
Cross refer: CFR 482.13(a)

Review of 1 of 1 patient record of patients expressing a desire to file a complaint revealed that the facility failed to ensure that the established process for a patient grievance was followed and the patient was informed of whom to contact to file a grievance.
Cross refer: CFR 482.13(a)(2)

Review of 2 of 9 patient records revealed that the facility failed to ensure that informed consent was obtained for the administration of psychoactive medication.
Cross refer: 482.13(b)(2)
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0116
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of facility policies, documentation, and interview, it was determined that the facility failed to ensure that the notice of rights requirement were met.

Findings Included:

Review of the facility document, " Patient ' s Bill of Rights " stated, in part,
"Voluntary Patients-Special Rights
1. You have the right to request discharge from the hospital. If you want to leave, you need to say so in writing or tell a staff person. If you tell a staff person you want to leave, the staff person must write it down for you.2. You have the right to be discharged from the hospital within four (4) hours of requesting discharged . There are only three (3) reasons why you would not be allowed to go:? First, if you change your mind and want to stay at the hospital, you can sign a paper that says
you do not wish to leave, or you can tell a staff member that you don ' t want to leave, and the
staff member has to write it down for you.? Second, if you are under [AGE] years old ...? Third, you may be detained longer than four (4) hours if your doctor has reason to believe that
you might meet the criteria for court-ordered mental health services or emergency detention
because:o You are likely to cause serious harm to yourself;o You are likely to cause serious harm to others;OrYour condition will continue to deteriorate and you are unable to make an informed decision as to whether or not to stay for treatment. If your doctor thinks you may meet the criteria for court-ordered mental health services or emergency detention, he/she must examine you in person within 24 hours of your filing the discharge request. You must be allowed to leave the hospital upon completion of the in-personexamination unless your doctor confirmed that you meet the criteria for court-ordered mental health services and files an application for court-ordered mental health services and files an application for court-ordered services. The application asks a judge to issue a court order requiring you to stay at the facility for services. The order will only be issued if the judge decides that either:? You are likely to cause serious harm to yourself;? You are likely to cause serious harm to others; or? Your condition will continue to deteriorate and you are unable to make an informed decision as to whether or not to stay for treatment.Even if an application for court-ordered services is filed, you cannot be detained at the hospital beyond 4:00 pm of the first business day following the in-person examination unless the court-order for services is obtained. "

Per documentation, both Patient # 1 and Patient # 2 made 1 statements indicating their desire to leave the facility and/or be discharged . Both Patient # 1 and Patient # 2 were on voluntary status while inpatient.

Nursing Shift Assessment and Progress Notes for Patient # 1 on 10/8/12 at 21:07 pmstated, " Pt agitated, appears irritable c/o wanting to leave " I don ' t feel comfortable here. I want to go somewhere I know the people. " Pt tried to elope pt broke off the lever which locks bathroom window in pt bathroom. Pt unable to lift window, window has screws that keep it in place. Supervisor notified, maintenance notified of damage towindow. Pt given 30 mg Zydis, 2 mg Ativan PO for disruptive behavior. " The Nursing Shift Assessment and Progress Note for Patient # 1 on 10/10/12 at 08:30am stated, " States he feels anxious and wants to leave the hospital. "
Physician Progress Note for Patient # 1 dated 10/10/12 stated, " As per staff, he refused to eat stating that the food here is not convenient for him, so he eats a lot of snacks. No suicidal or homicidal ideation was voiced by the patient. No auditory or visual hallucination was reported. His judgment and insight were fair as the patient was stating that he wants to go home or to be transferred to Las Cruces, so he can make it easy for him (sic) mom to visit with him. "

Nursing Shift Assessment Progress Note for Patient # 2 dated 10/06/12 at 2142 stated in part, " ...Pt. also verbalized AMA but did not ask for paperwork ... "

There was no documentation in the medical records of Patient #1 and # 2 that the patients were assisted in requesting discharge, which is a right of patients on voluntary status. There was not written request for discharge in the patients medical records. There was no Request for Release from a Voluntary Admission in either patients' medical record. There is no documentation in the medical record that once the patients stated they wanted to leave, they were instructed to request the discharge in writing nor assisted by staff to make this request in writing. There is no documentation that the physician was notified of the patients' request for discharge. The medical record contained no documentation that the patients changed their mind about wanting to leave the hospital and/or signed a paper stating they did not wish to leave. Neither patient was discharged within 4 hours of requesting discharge, nor is there documentation that the physician determined they met the criteria for court-ordered mental health services or filed an application for court-ordered mental health services.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on a review of facility policies, documentation, and interview, it was determined that the facility failed to ensure that established processed for patient grievance were followed and patient were informed of whom to contact to file a grievance.

Findings Included:

Review of the facility document, " Patient ' s Bill of Rights " stated, in part, " ...is the responsibility of this hospital, under law, to make sure you have been informed of your rights. But just giving you thisinformation does not mean your [ri]ghts have been protected. This hospital is required to respect and provide for your rights in order to maintain licensure and to conduct business in this state. Your Right to Make a Complaint You have the right to make a complaint and to be told how to contact people who can help you...
36. You have the right to complain directly to any agency including those listed on front of this form. You have the right to make a complaint and receive a fair response within a reasonable amount of time ... "
Review of facility policy entitled, " Patient & Family Grievances/The Role of the Patient Advocate " (date issued 11/2008) stated, in part,
" 2.0 It is the responsibility of each staff member to respond promptly to any concern or grievance voiced by patient and their families no matter how trivial the complaint may appear to be. The staff member receiving the complaint should notify his/her supervisor when the issues cannot be immediately resolved.
3.0 When a patient voices a grievance, the patient may be encouraged to discuss the grievance with their physician or unit nursing staff. The unit manager or house supervisor may be involved if necessary ...
4.0 If the grievance issue cannot be resolved at this level (or if the patient contacts the patient advocate directly), the patient should have access to the following persons to facilitate resolution of the grievance.
? Patient Advocate
? Director of Clinical Services
? Medical Director (when the issues involves a physician) and/or CEO
At each level of this process the facility staff should listen to the patient ' s grievance, consider the circumstances and context of the grievance, assure the patient that their concerns will be investigated and see further information and input as needed. The facility staff person should express concern and empathy for the patient ' s condition and assure him/her that immediate attention will be given to the problem ...
8.0 The grievance and problem resolution/follow up should be documented. This documentation should include:
? name of voicing a grievance/how to contact
? patient name
? nature of Complaint
? pertinent Investigation Information
? resolution of Grievance/Follow Up
? signature of Staff Person addressing grievance ... "

Review of facility policy entitled, " Patient Rights and Responsibilities " (date issued 11/2008) stated, in part, " University Behavioral Health of El Paso ' s policy is to preserve the patient ' s basic human rights during hospitalization , ...
2.0 Purpose
To provide a guideline of how to maintain a patient ' s basic human right while hospitalized ...
F. Grievance: The patients are entitled to information about the hospital ' s mechanisms for the initiation, review and resolution of a patient complaint. The patient has the right to complain without fear of repercussions. "

Nursing Shift Assessment Progress Note for Patient #2 dated 10/06/12 at 2142 stated in part, " ...Pt. requested a change of physician, then wanted to lodge a complaint against certain staff members ... "

There was no documentation that the Patient # 2's request to make complaints against staff member was addressed. There was no documentation that the patient was assisted with or informed of the process for making a grievance. There was no documented grievance or complaint filed by the patient. There was no documented grievance and problem resolution/follow up to the patient complaint per policy.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on a review of facility policies, documentation, and interview, it was determined that the facility failed to ensure that informed consent was obtained for the administration of psychoactive medication.

Findings were:

Review of facility policy entitled, " Informed Consent " (date issued 11/2008) stated, in part,
" 2. The nursing staff as directed by the physician shall be responsible for obtaining signed consent for: a) Administration of Psychopharmacological Medication (see Informed Consent for Medication Administration Policy). " Review of facility policy entitled, " Informed Consent for Medication Administration " (date issued 11/2008), stated, in part,
" Informed consent for the administration of psychoactive medication shall be required for allpatients, voluntary or involuntary. Such consent must be written and made a part of the medical record ...Informed consent for the administration of psychoactive medication will be evidenced by a copy of the Consent for Treatment with Psychoactive Medication form executed by the patient ...This executed form will establish a rebuttal presumption of valid consent and will be retrained (sic) in the medical record. "

A review of the 9 medical records revealed 2 patients (Patient #1 and 8) that lacked proper documentation of psychoactive mediation consents. A review of the medical record for Patient # 1 revealed no psychoactive medication consent forms completed for the following medications: Lithium, Risperdal, and Seroquel, which were administered routinely at the facility. A review of the medical record for Patient # 8 revealed no psychoactive medication consent forms completed for the following medications: Klonopin, Risperdal, and Zoloft, which were administered routinely at the facility.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of patient records, facility policies, and staff interviews, the facility failed to ensure a safe setting for patients as treatment plans did not include current conditions, treatment plans were not updated with a changed in patient's condition, treatment plans did not reflect patient's Line of Sight observation level, suicide precautions or seizure precautions, and nursing staff neglected to monitor patients as ordered, creating an unsafe environment in which a patient committed suicide.

Findings were:

Review of facility policy entitled, " Observation Levels " (date issued 11/2008) stated, in part,
" 10. The need for special observation should be addressed in the patient ' s treatment plan. "

Review of the facility document, " Patient ' s Bill of Rights " stated, in part, " [It] is the responsibility of this hospital, under law, to make sure you have been informed of your rights. But just giving you this information does not mean your [ri]ghts have been protected. This hospital is required to respect and provide for your rights in order to maintain licensure and to conduct business in this state.
...2. You have the right to a clean and humane environment in which you are protected from harm, have privacy with regard to personal needs, and are treated with respect and dignity.
...5. You have the right to be free from mistreatment, abuse, neglect, and exploitation.
...26. You have the right to a treatment plan that is individualized for your stay in the hospital.

Review of facility policy entitled, " Observation Levels " (date issued 11/2008) stated, in part,
" 2. An order for the appropriate level of observation and type of precaution should be documented in the physician ' s order section of the medical record, and the charge nurse or designee should initiate the Patient Rounds Sheet ...Initiation of precautions should be documented in the physician orders ...
5. A physician order is required to decrease or discontinue a special precaution level ...
7. Special Precaution Levels and protocol guidelines that may be ordered include: ...
B. Constant Observation (Line of Sight) Guidelines for implementation of this level of precaution include, but are not limited to, the following: ...
(2) The patient should be within visual range of the assigned staff at all times ...
(4). During times for personal hygiene, toileting and other self-care needs, the staff should be in visual and hearing range of the bathroom door. When necessary, arrangements should be made for same sex staff to accompany the patient during times of personal hygiene, toileting and other self-care needs ...
(8). A Patient Rounds Sheet, which reflects the patient ' s location and observed behaviors every 5 minutes, is maintained. "

Review of the " Patient Rounds Adolescent, Senior Adult, Rehab and Adult Units " form stated the requirement for, " Environment of care rounds to be completed every 4 hours " and " RN rounds q2 hrs throughout hospital. "

Review of facility policy entitled, Re-Assessment of Patients stated, in part, " 1. Reassessment is conducted by a Registered Nurse every shift at a minimum. Additionally, reassessment occurs in the following circumstances:
A. Change in the patient ' s condition.
B. Physical complaint.
2. R.N. findings from the reassessment are documented in the patient ' s chart.
3. The attending physician reassesses at the time of each daily patient visit. The reassessment is documented in the patient ' s chart.
4. As indicated by the patient ' s condition, length of stay and level of care, the treatment team reassesses the patient in relation to progress toward treatment plan goal. These reassessments are documented on the Interdisciplinary Treatment Plan Update form.

Review of medical records for 2 out of 2 patients on precautions revealed no documented evidence that patients were monitored for suicide precautions or other precautions at the level ordered by the physician.

Review of the record for Patient #1 revealed he was found on 10/10/12 at 14:00 pm in his patient bathroom on the unit, by another patient and a staff member, alone with a sheet around his neck, hanging from the bathroom door. Review of facility documents indicated the patient suicided.

Review of the Initial Treatment Plan for Patient #1, dated 10/8/12 at 10:10 pm stated, Initial Problems to be addressed: 1. Safety: " Pt. verbally threatens with taking his life " . There was no documentation in the initial treatment plan to reflect the patient ' s Line of Sight Precautions. " There was no documentation in the treatment plan of the patient ' s recent head injury which had been documented on the Clinical Assessment completed 10/8/12 at 16:00 pm. The treatment plan was not updated to reflect the patient ' s attempt to leave the facility by breaking the lock in his patient bathroom on 10/8/12 to try to escape through the window.

Review of the record for Patient #1 revealed the following:
Admitting orders on 10/8/12 at 1615 included: " Admit to inpatient ...Line of sight (for safety). "
There was no documented evidence of an order throughout Patient #1 ' s stay to discontinue the suicide precautions.
On the " Patient Rounds Adolescent, Senior Adult, Rehab and Adult Units " observation form, the space for " Precaution: Suicide " was not checked for the following dates: 10/8/12, 10/9/12, and 10/10/12, providing no documented evidence that the staff was aware or that the patient was monitored specifically for Line of Sight Suicide Precautions as ordered.
There was no documented evidence in the record for Patient #1 that he was monitored for Line of Sight Precautions within visual range of the assigned staff at all times per physician order and facility policy.
There was no documented evidence in the record for Patient #1 of a " Patient Rounds Sheet " reflecting the patient ' s location and observed every 5 minutes as required by policy for Line of Sight Precautions.
There was no documentation by nursing on the " Nursing Shift Assessment and Progress Note " reflecting the status of Patient #1 on Line of Sight Suicide Precautions for the following dates: 10/8/12, 10/9/12, and 10/10/12.

Review of the " Patient Rounds Adolescent, Senior Adult, Rehab and Adult Units " form for Patient #1 stated, " Environment of care rounds to be completed every 4 hours. "
? The Patient Rounds form for 10/8/12 did not have a completed signature key. Initials documented on the form for 22:15 pm, 22:30 pm, 22:45pm, EOC (rounds), 23:00 pm, 23:15 pm were not included in the signature key and the signature block was left blank, so there was no means of determining what staff member documented during those times.
? The Patient Rounds form for 10/9/12 was incomplete as Environment of Care rounds were not documented at 15:00 pm; the space for 15:00 pm was left blank.
? The Patient Rounds form for 10/10/12 was incomplete as Environment of Care rounds were not documented at 12:00 pm; the space for 12:00 pm was left blank, indicating that Environment of Care rounds were not completed prior to the suicidal death of Patient #1 on the unit at 14:00 pm. Patient #1 had been an [AGE] year old high school student hospitalized after an overdose of Klonopin and " suicidal ideation and aggressive, unpredictable behavior " as noted in the clinical assessment, completed on 10/8/12 at 1600.

Review of the " Patient Rounds Adolescent, Senior Adult, Rehab and Adult Units " form for Patient #1 stated, " RN rounds q2 hrs throughout hospital. "
On 10/10/12, the space for the RN to document every two hour rounds for 1200 was left blank, with no initial by an RN.
There was documentation of RN rounds at 08:00 am and 10:00 am, but no RN rounds documented after 10:00 am.
There were no RN rounds documented at 12:00 pm and at 14:00 PM; the death of Patient #1 was discovered at 1400.
The only documentation on the Patient Rounds sheet after 10:00 am was completed by a Mental Health Tech, Staff #6.
There was no documented evidence of patient rounding or that the patient was seen by an RN after 10:00 am, on 10/10/12, before the suicidal death on the unit of Patient #1 was discovered at 14:00 pm despite the patient ' s " Line of Sight " precautions status, statements indicating he wished to leave the facility by trying to break through a bathroom window, and his actual attempt to leave the facility on 10/8/12.

Review of the record for Patient #8 revealed the following:
Admitting orders at 0450 on 7/29/12 that included: " Admit to inpatient PICU ...Suicide precautions/Q15 minutes and Seizure Precautions " .
There was no documented evidence during the patient ' s stay of an order to discontinue the suicide precautions or the seizure precautions. On the " Patient Rounds Adolescent, Senior Adult, Rehab and Adult Units " observation form for Patient #8, the space for " Precaution Suicide " was not checked for the following dates: 7/29/12, 7/30/12, 7/31/12, 8/1/12, and 8/2/12, providing no documented evidence that the staff was aware or that the patient was monitored specifically for Suicide Precautions as ordered.

Review of the Initial Treatment Plan for Patient #8, dated 7/29/12 at 9:30 am stated, Initial Problems to be addressed: 1. Safety: " ...attempted to overdose on Dilantin " . There was no documentation in the initial treatment plan to reflect the patient ' s suicide or seizure precautions. The treatment plan was not updated to reflect physical changes in condition and treatment which were documented on 7/31/12 including bronchitis with wheezing, and urinary tract symptoms, including burning, difficulty voiding, and elevated temperature.

Review of the record for Patient #2 revealed no evidence of a documented reassessment by a registered nurse after a change in condition. Nursing Shift Assessment Progress Note dated 10/10/12 contains the following nurses note:
At 0930, " In pt room to assess pt. Alert but disoriented to time only. Flat affect and blunted. Denies feeling suicidal or homicidal. Cooperative with medication regimen and treatment plan. Will cont to monitor. "

Patient #2 and a staff member discovered Patient #1 on 10/10/12 at 14:00 pm in the bathroom shared by Patient #1 and Patient #2 on the unit. Patient #1 was alone with a sheet around his neck, hanging from the bathroom door. Review of facility documents indicated Patient #1 suicided. There was no documented evidence of a nursing assessment or progress note for Patient #2 which included a description or evaluation of Patient #2 ' s emotional state after witnessing the discovery of his roommate ' s body post suicide. The only nursing note in the record occurred 7 hours after the event at 21:00 pm after Patient #2 witnessed and discovered his roommate ' s body post suicide. At 21:00 pm, an RN documented, " Patient sleeping in dayroom across from nursing station to provide comfort and allow closer observation. Still upset and intermittently anxious related to events earlier in the day involving his roommate. States does not want to go back to that room. "

A review of Physician Progress Notes for Patient #2 revealed the following note on 10/10/12 at 16:00 pm, 2 hours after Patient #2 and a staff member discovered the suicided body of his roommate: " I saw Mr. Tymon today for a follow up visit. He presents less pressured in his speech with less intensity in his flight of ideas, is a little bit easy to understand what he is saying, although at times he continues to become disorganized and derails. He is also a bit labile, stared to feel sad and became tearful with remembering a painful memory. Reports that he however is sleeping better ... "
There is no documentation in the follow up visit physician notes addressing the traumatic event of Patient #2 witnessing the discovery of his roommate ' s body post suicide which occurred just two hours previously.

There was no documented evidence in the physician note which included a description or evaluation of Patient #2 ' s emotional state related to witnessing the discovery of his roommate ' s body post suicide.

Review of Interdisciplinary Treatment Plan -Review/Update forms for Patient #2 revealed the most recent update occurred on 10/15/12. " Problem #1 " stated, " medication complaint-eating and sleeping-well " . " Problem # EPS " stated, " variable-mediation helping to curtail side effects " . No other problems listed. The previous Interdisciplinary Treatment Plan -Review/Update form was dated 10/08/12. There was no documented evidence that the treatment plan address the traumatic event of Patient #2 witnessing the discovery of his roommate ' s body post suicide which occurred on 10/10/12.
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Review of facility policy, " Patient Assessment Nursing Flow Sheet " , stated, in part, " The MHT and LVN will be documenting each shift the following patient activities on the patient rounds form:
...4.0 The MHT and LVN will document each shift the progress the patient is making toward the patient ' s treatment plan. All documentation in the progress notes will be narrative including the following information:
? Subjective and Objective data of the patient ' s behavior
? Interventions utilized for the patient
? Patient ' s response to the interventions.

Review of the record for Patient #1, Patient #2 and Patient #8 revealed no narrative progress note documentation each shift by MHT or LVNs, including " Subjective and Objective data of the patient ' s behavior, Interventions utilized for the patient, and Patient ' s response to the interventions. "

In an interview with Staff #2 on 10/16/12 at 2:00 pm in the conference room regarding a policy about expectations of RNs during rounding and documenting on patient rounds, Staff #2 stated the facility did not have a specific policy on RN rounding and did not provide a specific policy. Staff #2 provided a memo document on UBH letterhead dated 7/18/11 which had been distributed to all nurses, and was also currently being given to all new nurses during their orientation to the facility and a copy of the memo was included as part of the nursing orientation materials. Staff #2 stated that the memo included the expectations for RN rounding for all nurses and that staff are supposed to follow the instructions in this memo, which is RN rounds " every two hours to be sure everyone is where they ' re supposed to be and everyone is okay. The RNs see the patients every 2 hours. " The memo document stated, " To: All Nursing Staff From: [name] CNO Date: July 18, 2011 Re: RN Rounds on All Units Due to our recent Sentinel Events, it has become necessary to document RN rounds throughout the shift. On the Military Units, an RN must make rounds every hour and document those rounds on the patient observation record. On all other units the expectation is RN rounds every two (2) hours. You need to document as you make rounds to avoid inaccuracy and the possibility of fraud ...please utilize the special patient rounds forms with RN rounds highlighted according to program. Mental Health Techs need to assist in ensuring that the RN makes rounds at these times. This measure is needed to ensure RN accountability and patient safety. "

The above findings were confirmed in an interview with administrative staff in the conference room the afternoon of 10/16/12.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on a review of patient records, facility policies, and staff interviews, the facility failed to ensure a safe setting for patients as nursing staff neglected to monitor patients as ordered, including a patient on ' Line of Sight " monitoring who suicided in the facility; Code Blue documentation was not properly completed; treatment plans did not include current conditions; nursing documentation was incomplete; medications were administered without informed consent and were administered without documentation on the MAR; and physicians were not notified of a change in a patient ' s condition.

Findings were:

Review of medical records for 2 of 2 patients on special observation monitoring revealed that assigned staff did not monitor patients as ordered and did not document on patients per policy. Cross refer: CFR 482.23(b)(5)

Review of medical records, facility policies and documentation, and staff interviews, revealed that nursing care for patients was not properly supervised, implemented and evaluated for each patient based on their presentation and assessment as nursing care was not documented as given in patient records, and nurses neglected to ensure that patients on special observation precautions were monitored, creating an unsafe environment in which a patient suicided. Cross refer: CFR 482.23(b)(3)
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of facility policies and documentation, patient records, and staff interviews, the facility failed to ensure that nursing care for patients was properly supervised, implemented and evaluated for each patient based on their presentation and assessment as nurses neglected to ensure that patients on special observation precautions were monitored, and nursing care was not documented as given in patient records.

Findings included:

A review of Patient # 9's complete medical record revealed that vital signs were not recorded during the Code Blue on 08/04/12. No code blue response form was present in the medical record. There was no documented notification of the patient ' s family of the medical emergency. The documentation in the medial record did not include the time CPR was started, by whom, and the time medical control was relinquished to paramedic team.

Review of the medical record for Patient #1 revealed a Physician Progress Note dated 10/10/12 " As per staff, he refused to eat stating that the food here is not convenient for him, so he eats a lot of snacks. " Nursing Shift Assessment and Progress note on 10/10/12 at 08:30 am stated, " Continues with poor appetite. Enc. to attend meal times and to eat meals and snacks. "

Review of facility policy, " Patient Assessment Nursing Flow Sheet " , stated, in part, " The MHT and LVN will be documenting each shift the following patient activities on the patient rounds form: Diet: Note percentage of meals eaten "

In an interview with Staff #2 on 10/16/12 at 10:50 am conference room, she stated that, " Meals are documented on the Q sheet " indicating the " Patient Rounds Adolescent, Senior Adult, Rehab and Adult Units " form.

Review of the " Patient Rounds Adolescent, Senior Adult, Rehab and Adult Units " form for Patient #1 revealed the form was incomplete as there was no documentation to reflect the percent of meal consumed by Patient #1 for dinner on 10/8/12 and 10/9/12, as the space provided was left blank.

Review of the record for 2 of 2 patients, Patient #1 and Patient #8, revealed the Nursing Admission Assessment section entitled, " Nursing Admission Treatment Summary " with instructions to " Include limitations in self-care, needs, impaired functioning, coping, predisposing factors, primary stressors, active medical problems, safety and treatment recommendations " ) revealed no documentation of the suicide precautions of Patient #1 and the suicide and seizure precautions for Patient #8.

The Review of the record for Patient #1 indicted Nursing Shift Assessment and Progress Note for 10/10/12 in the column for " 7am-3pm or 7am-7pm " included RN documentation of " c/o headache " and documented treatment as " Tylenol PRN " . Review of the Medication Administration Record contained no documentation or initials indicating administration of Tylenol/Acetaminophen.

Review of the facility policy entitled, " Recording in Patient ' s MAR " (date issued 11/2008, date revised 12/2009) stated, in part, " Medication administered (including medication administer in error), adverse drug reactions, and omitted doses shall be documented in the patient ' s record.
1. Properly record every dose of every medication administered into the patient ' s record after administration,
2. Clearly enter or identify the time of administration and the person administering each dose ...
3. Indicate PRN and no-recurring dose on the appropriate form. Explain (in the nurse ' s notes) the reason for each PRN, non-recurring or omitting dose (including refused doses). Note the patient ' s response to PRN medication. "

There was no documentation on the " Nursing Shift Assessment and Progress Note " reflecting the status of Patient #8 on Suicide Precautions for the following dates: 7/30/12, 7/31/12, 8/1/12, and 8/2/12 and there was no on the " Nursing Shift Assessment and Progress Note " reflecting the status of Patient #1 on Line of Sight Suicide Precautions for the following dates: 10/8/12, 10/9/12, and 10/10/12.

Review of the record for Patient #1 revealed the following:
Admitting orders on 10/8/12 at 1615 included: " Admit to inpatient ...Line of sight (for safety). "
There was no documented evidence of an order throughout Patient #1 ' s stay to discontinue the suicide precautions.
On the " Patient Rounds Adolescent, Senior Adult, Rehab and Adult Units " observation form, the space for " Precaution: Suicide " was not checked for the following dates: 10/8/12, 10/9/12, and 10/10/12, providing no documented evidence that the staff was aware or that the patient was monitored specifically for Line of Sight Suicide Precautions as ordered.
There was no documented evidence in the record for Patient #1 that he was monitored for Line of Sight Precautions within visual range of the assigned staff at all times per physician order and facility policy.
There was no documented evidence in the record for Patient #1 of a " Patient Rounds Sheet " reflecting the patient ' s location and observed every 5 minutes as required by policy for Line of Sight Precautions.

Review of the " Patient Rounds Adolescent, Senior Adult, Rehab and Adult Units " form for Patient #1 stated, " Environment of care rounds to be completed every 4 hours. "
? The Patient Rounds form for 10/8/12 did not have a completed signature key. Initials documented on the form for 22:15 pm, 22:30 pm, 22:45pm, EOC (rounds), 23:00 pm, 23:15 pm were not included in the signature key and the signature block was left blank, so there was no means of determining who documented during those times.
? The Patient Rounds form for 10/9/12 was incomplete as Environment of Care rounds were not documented at 15:00 pm; the space for 15:00 pm was left blank.
? The Patient Rounds form for 10/10/12 was incomplete as Environment of Care rounds were not documented at 12:00 pm; the space for 12:00 pm was left blank, indicating that Environment of Care rounds were not completed prior to the suicidal death of Patient #1 on the unit at 14:00 pm.

Review of the " Patient Rounds Adolescent, Senior Adult, Rehab and Adult Units " form for Patient #1 stated, " RN rounds q2 hrs throughout hospital. "
On 10/10/12, the space for the RN to document every two hour rounds for 1200 was left blank, with no initial by the RN.
There was documentation of RN rounds at 08:00 am and 10:00 am, but no RN rounds documented after 10:00 am.
There were no RN rounds documented at 12:00 pm and at 14:00 PM; the death of Patient #1 was discovered at 1400.
The only documentation on the Patient Rounds sheet after 10:00 am was completed by a Mental Health Tech, Staff #6.
There was no documented evidence of patient rounding or that the patient was seen by an RN after 10:00 am, on 10/10/12, before the suicidal death on the unit of Patient #1 at 14:00 pm despite the patient ' s " Line of Sight " precautions status, statements indicating he wished to leave the facility, and his actual attempt to leave the facility on 10/8/12.

Review of the record for Patient #1, an [AGE] year old high school student, revealed he was found on 10/10/12 at 14:00 pm in his bathroom alone with a sheet around his neck, hanging from the bathroom door by another patient and staff member. Review of facility documents indicated the patient suicided.

Review of the record for Patient #8 revealed the following:
Admitting orders at 0450 on 7/29/12 that included: " Admit to inpatient PICU ...Suicide precautions/Q15 minutes and Seizure Precautions " .
There was no documented evidence during the patient ' s stay of an order to discontinue the suicide precautions or the seizure precautions. On the " Patient Rounds Adolescent, Senior Adult, Rehab and Adult Units " observation form for Patient #8, the space for " Precaution Suicide " was not checked for the following dates: 7/29/12, 7/30/12, 7/31/12, 8/1/12, and 8/2/12, providing no documented evidence that the staff was aware or that the patient was monitored specifically for Suicide Precautions as ordered.
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Review of the record for Patient #8 revealed that on 7/30/12 at 0325, a nursing note documented " Pt awake and c/o difficulty voiding, burning and very little urine. Temp 100.9. Given Motrin 800 mg po. " There was no documented evidence in the nurse ' s progress note that the nurse notified the doctor. On 7/30/12 at 0435, the nurse documented, " Temp 99.9 "

Review of facility policy entitled, Re-Assessment of Patients stated, in part, " 1. Reassessment is conducted by a Registered Nurse every shift at a minimum. Additionally, reassessment occurs in the following circumstances:
A. Change in the patient ' s condition.
B. Physical complaint.
2. R.N. findings from the reassessment are documented in the patient ' s chart.
3. The attending physician reassesses at the time of each daily patient visit. The reassessment is documented in the patient ' s chart.
4. As indicated by the patient ' s condition, length of stay and level of care, the treatment team reassesses the patient in relation to progress toward treatment plan goal. These reassessments are documented on the Interdisciplinary Treatment Plan Update form.

Review of the record for Patient #2 revealed no evidence of a documented reassessment by a registered nurse after a change in condition. Nursing Shift Assessment Progress Note dated 10/10/12 contains the following nurses note:
At 0930, " In pt room to assess pt. Alert but disoriented to time only. Flat affect and blunted. Denies feeling suicidal or homicidal. Cooperative with medication regimen and treatment plan. Will cont to monitor. "

Patient #2 and a staff member discovered Patient #1 on 10/10/12 at 14:00 pm in the bathroom shared by Patient #1 and Patient #2 on the unit. Patient #1 was alone with a sheet around his neck, hanging from the bathroom door. Review of facility documents indicated Patient #1 suicided. There was no documented evidence of a nursing assessment or progress note for Patient #2 which included a description or evaluation of Patient #2 ' s emotional state after witnessing the discovery of his roommate ' s body post suicide. The only nursing note in the record occurred 7 hours after the event at 21:00 pm after Patient #2 witnessed and discovered his roommate ' s body post suicide. At 21:00 pm, an RN documented, " Patient sleeping in dayroom across from nursing station to provide comfort and allow closer observation. Still upset and intermittently anxious related to events earlier in the day involving his roommate. States does not want to go back to that room. "

The above findings were confirmed in an interview with administrative staff in the conference room the afternoon of 10/16/12.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of medical records and facility policies, the facility failed to ensure that nursing care was assigned in accordance with identified individual patient needs.

Findings were:

Review of the medical records for 2 of 2 patients on special precautions revealed that staff assigned to patients did not monitor the patients according to physician orders for precautions and in accordance with facility policies and procedures.

Review of facility policy entitled, " Observation Levels " (date issued 11/2008) stated, in part,
" 2. An order for the appropriate level of observation and type of precaution should be documented in the physician ' s order section of the medical record, and the charge nurse or designee should initiate the Patient Rounds Sheet ...Initiation of precautions should be documented in the physician orders ...
5. A physician order is required to decrease or discontinue a special precaution level ...
7. Special Precaution Levels and protocol guidelines that may be ordered include: ...
B. Constant Observation (Line of Sight) Guidelines for implementation of this level of precaution include, but are not limited to, the following: ...
(2) The patient should be within visual range of the assigned staff at all times ...
(4). During times for personal hygiene, toileting and other self-care needs, the staff should be in visual and hearing range of the bathroom door. When necessary, arrangements should be made for same sex staff to accompany the patient during times of personal hygiene, toileting and other self-care needs ...
(8). A Patient Rounds Sheet, which reflects the patient ' s location and observed behaviors every 5 minutes, is maintained. "

Review of medical records for 2 out of 2 patients on precautions revealed no documented evidence that patients were monitored for suicide precautions or other precautions at the level ordered by the physician.

Review of the record for Patient #1 revealed the following:
Admitting orders on 10/8/12 at 1615 included: " Admit to inpatient ...Line of sight (for safety). "
There was no documented evidence of an order throughout Patient #1 ' s stay to discontinue the suicide precautions.
On the " Patient Rounds Adolescent, Senior Adult, Rehab and Adult Units " observation form, the space for " Precaution: Suicide " was not checked for the following dates: 10/8/12, 10/9/12, and 10/10/12, providing no documented evidence that the staff was aware or that the patient was monitored specifically for Line of Sight Suicide Precautions as ordered.
There was no documented evidence in the record for Patient #1 that he was monitored for Line of Sight Precautions within visual range of the assigned staff at all times per physician order and facility policy.
There was no documented evidence in the record for Patient #1 of a " Patient Rounds Sheet " reflecting the patient ' s location and observed every 5 minutes as required by policy for Line of Sight Precautions.

Review of the record for Patient #1, an [AGE] year old high school student, revealed he was found on 10/10/12 at 14:00 pm in his bathroom alone with a sheet around his neck, hanging from the bathroom door by another patient and staff. Review of facility documents indicated the patient suicided.

Review of the record for Patient #8 revealed admitting orders at 0450 on 7/29/12 that included:
Admit to inpatient PICU ...
Suicide precautions/Q15 minutes and Seizure Precautions
There was no documented evidence during the patient ' s stay of an order to discontinue the suicide precautions or the seizure precautions. On the " Patient Rounds Adolescent, Senior Adult, Rehab and Adult Units " observation form for Patient #8, the space for " Precaution Suicide " was not checked for the following dates: 7/29/12, 7/30/12, 7/31/12, 8/1/12, and 8/2/12, providing no evidence that the staff was aware or that the patient was monitored specifically for Suicide Precautions as ordered.

Review of facility policy, " Patient Assessment Nursing Flow Sheet " , stated, in part, " The MHT and LVN will be documenting each shift the following patient activities on the patient rounds form:
...4.0 The MHT and LVN will document each shift the progress the patient is making toward the patient ' s treatment plan. All documentation in the progress notes will be narrative including the following information:
? Subjective and Objective data of the patient ' s behavior
? Interventions utilized for the patient
? Patient ' s response to the interventions.

Review of the record for Patient #1, Patient #2 and Patient #8 revealed no narrative progress note documentation each shift by MHT or LVNs, including " Subjective and Objective data of the patient ' s behavior, Interventions utilized for the patient, and Patient ' s response to the interventions. "

The above findings were confirmed in an interview with administrative staff in the conference room the afternoon of 10/16/12.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of medical records, facility policies, and staff interviews, the facility failed to ensure that medical records were legible, complete, dated, timed and authenticated consistent with hospital policies and procedures.

Findings were:

Review of the medical record for Patient #1 revealed a verbal order on 10/9/12 at 10:45 am for Ativan IM, Zydis S/L, Geodon IM and Ativan po was not signed by the physician until 10/15/12 at 11:25 am, more than 48 hours after written.

Review of the medical record for Patient #8 revealed a verbal order on 8/2/12 at 0115 for Albuterol inhaler that was not signed by the physician until 9/5/12 at 16:00 pm, more than 48 hours after written.

Review of facility policy entitled, " Verbal or Telephone Orders " stated, in part, " When receiving a telephone/verbal order for a patient, the nurse will write the order(s) down in the medical record ...4. The physician giving the telephone or verbal order must sign the order as authentication no later than 48 hours after issuing the order. "
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Review of the " Patient Rounds Adolescent, Senior Adult, Rehab and Adult Units " form for Patient #1 for 10/8/12, 10/9/12, and 10/10/12, revealed no documented evidence of the patient ' s elimination (voiding or bowel movements) or hygiene, including when activities of daily living were addressed.

Review of facility policy, " Patient Assessment Nursing Flow Sheet " , stated, in part, " The MHT and LVN will be documenting each shift the following patient activities on the patient rounds form:
? Diet: Note percentage of meals eaten
? Elimination: Indicate if patient is voiding and/or reports BM.
? Hygiene: Indicate when each ADL is addressed.
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Review of the record for Patient #8 revealed The Nursing Admission Assessment Nutrition Screen included a 2 point score for " Active GI Problems: GERD, Persistent Diarrhea, Vomiting " however the nurse documented " 0 " total points on the Nutrition Screen (including " 0 " points for " GERD " ) despite Patient #8 ' s documented diagnosis of GERD on 7/29/12 at 0900.

Review of the record for Patient #8 revealed The Clinical assessment dated [DATE] at 0700 documented the following Suicide Risk Factors, indicated by check marks: presence of Medical Procedure or Pain; Presence of Suicidal Ideation; Presence of: Mood Disorder, Domestic Violence, Verbal abuse, Anxiety, Hopelessness ... " Pt. attempted suicide yesterday by overdose on pills. Pt. still hopeless, helpless but agrees to seek help ...had means " In response to " Rank below your conclusion regarding this patient ' s SUICIDAL risk and make any comments: " Staff #10 failed to complete required documentation, as she checked the box " Imminent Risk (requires response) " however there was no documented evidence of the required response or further documentation.

Review of the record for Patient #8 revealed that on 7/30/12 at 0325, a nursing note documented " Pt awake and c/o difficulty voiding, burning and very little urine. Temp 100.9. Given Motrin 800 mg po. " There was no documented evidence in the nurse ' s progress note that the nurse notified the doctor. On 7/30/12 at 0435, the nurse documented, " Temp 99.9 "

Review of facility policy entitled, Re-Assessment of Patients stated, in part, " 1. Reassessment is conducted by a Registered Nurse every shift at a minimum. Additionally, reassessment occurs in the following circumstances:
A. Change in the patient ' s condition.
B. Physical complaint.
2. R.N. findings from the reassessment are documented in the patient ' s chart.
3. The attending physician reassesses at the time of each daily patient visit. The reassessment is documented in the patient ' s chart.
4. As indicated by the patient ' s condition, length of stay and level of care, the treatment team reassesses the patient in relation to progress toward treatment plan goal. These reassessments are documented on the Interdisciplinary Treatment Plan Update form.

Review of facility policy entitled, " Documentation in the Patient ' s Medical Record " (date issued 11/2008) stated, in part,
" Chart Notes-
(Acceptable) All contacts with the patient must be documented with a signature, date, and time.
(Unacceptable) Not documenting patient care; delaying all entries until the end of the day ...
Dating Chart Notes-
(Acceptable) Date all noted/pages with month, day, year, and time.
(Unacceptable) Not dating every separate entry ...
Identifying Information-
(Acceptable) Each page in the medical record, including outside reports, must have the patient ' s name, DOB, and MR #
(Unacceptable) Missing identifying information on any page of the medical record ...
Forms-
(Acceptable) All blanks on forms should be completed (unknown, negative, not obtained, N/A, ECT.) All forms used in the medical record must be approved.
(Unacceptable) Leaving blanks on forms empty. Using unapproved forms in the medical record ...
Using All Lines-
(Acceptable) Never leave blank areas in the medical record. Begin current documentation immediately following the last entry. If lines are inadvertently left blank a line should be immediately marked through the unused lines to indicate no entry will be made.
(Unacceptable) Leaving blanks between visits, entries, notes, ECT ...
Legibility-
(Acceptable) Attempt to write legibly. Medical records should be made in a clear and concise manner. "

Review of the record for Patient #1 revealed the following:
? An incomplete Staff Signature as only one person, Staff # 10 had completed the form, which required the following: printed name, signature, title, and initial. There was no means of determining the position, title, or credentials of staff signing and initialing on the " Patient Rounds Adolescent, Senior Adult, Rehab and Adult Units " and other documents in the patient ' s medical record.
? History and Physical Examination form was incomplete with no patient label or identifying information (patient ' s name, date of birth, medical record number) on 7 of 7 pages and the form contained blank areas, including Psychologic, Females/Males, Immunizations, and Cranial Nerves I and II.
? Patient Home Medications form did not contain patient date of birth or medical record number and was not timed.
? Physician ' s Order form did not contain patient date of birth or medical record number.
? Code Blue Record form was incomplete as there was no patient label in the space indicated, date of birth or medical record number.
? Physician ' s Admitting Note only had patient first name; no last name, date of birth or medical record number, and was not dated or timed.
? Clinical Assessment - Part 1 form did not have a patient label in the space indicated on the first page, and no patient name, date of birth or medical record number on pages 2-7. On page 6 of 7, the form stated SUMMARY EVALUATION OF RISK OF SUICIDE / HOMICIDE / ASSAULTIVE BEHAVIOR: Rank below your conclusion regarding this patient ' s SUICIDAL risk and make any comments: [box marked for:] Imminent Risk (requires response). Rank below your conclusion regarding this patient ' s HOMICIDAL/ASSAULTIVE RISK AND MAKE ANY COMMENTS: [box marked for:] Imminent Risk (requires response) " There was no response documented in the required spaces as indicated.
? Level of Care Recommendations were left blank in the space for signatures or other indication in " CASE REVIEWED WITH PHYSICIAN (if applicable) and " Nurse accepting patient on the unit " and date and time.(if applicable).
? Triage form did not have a label in the space indicated on the first or second page.
? Clinical Assessment (Therapist) - Part 2 contained blank spaces.
? Nursing Admission Assessment did not have a patient label in the space indicated and there was no patient name, date of birth and medical record number on pages 2-8; spaces on the form were left blank.
? Nursing Admission Treatment Summary included approximately 1/3 of the note that was illegibly written. The note was reviewed with Staff #2 and Staff #3 the afternoon of 10/16/12 who confirmed that much of the note (total 9 lines of narrative) was illegible.
? Initial Treatment Plan did not have a patient label in the space indicated and there was no patient name, date of birth and medical record number.
? Braden Scale for Predicting Pressure Sore Risk did not have a patient label in the space indicated and there was no patient name, date of birth and medical record number.
? Nursing Fall Reassessment Tool did not have a patient label in the space indicated and there was no patient name, date of birth and medical record number.

Review of the record for Patient #8 revealed:
? History and Physical Examination did not have a patient label in the space indicated and there was no patient name, date of birth and medical record number. Cranial Nerves I, II, XIII were not documented as assessed.
? Patient Home Medications did not have a patient label in the space indicated and there was no date of birth and medical record number; there was no time documented.
? Physician ' s Progress Notes 7/30/12 and 7/31/12 did not have a patient label in the space indicated and there was no name, date of birth and medical record number on the page.
? Clinical Assessment - Part 1 form did not have a patient label in the space indicated and there was no medical record number. On page 6 of 7, the form stated SUMMARY EVALUATION OF RISK OF SUICIDE / HOMICIDE / ASSAULTIVE BEHAVIOR: Rank below your conclusion regarding this patient ' s SUICIDAL risk and make any comments: [box marked for:] Imminent Risk (requires response). " There was no response documented in the required spaces as indicated.
? Clinical Assessment (Therapist) - Part 2 contained blank spaces.
? Group Therapy Progress Note was not completed as assessment boxes for participation, attention, attitude, affect, mood, though process, appearance, risk assessment, and stage of change were left blank.
? Progress Note for 08/02 did not have a patient label in the space indicated and there was no date of birth and medical record number; there was no time documented.
? Medication Administration Record had handwritten errors that were written over resulting in confusing or illegible documentation.
? Memorandum of Transfer from another hospital to University Behavioral Health: the portion entitled " Section B (To be filled out at receiving hospital) " was left blank.

The above findings were confirmed in an interview with administrative staff in the conference room the afternoon of 10/16/12.
VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
Based on a review of records and interview, the facility failed to ensure that medical records contained information, including vital signs and assessments, necessary to monitor patient conditions.

Findings were:

A review of 9 medical records revealed 1 patient ' s (Patient # 9) vitals were not monitored as ordered.

Patient # 9 was on Opiate Detoxification Protocol initiated on 07/28/12 at 1330 which included the following vital sign order, " Vital signs q 4 hours x 72 hours, then Vital signs qshift (sic) X 72 hours, then Vital signs daily thereafter " .

A review of the Vital Signs, Blood Sugar and Meals Record for Patient # 9 revealed that vital signs were only recorded for the following dates: 07/28/12 at 1330, 07/29/12 at 0600, 07/30/12 at 0600, 07/31/12 at 0600, and 08/01/12 at 0600. On 08/02/12 vitals were recorded in the medical consult. On 08/03/12 vitals were recorded as a late entry related to a post fall assessment. Patient # 9 did not have vitals monitor every 4 hour for 72 hours per physician order.

Review of facility policy, " Patient Assessment Nursing Flow Sheet " , stated, in part, " The MHT and LVN will be documenting each shift the following patient activities on the patient rounds form: Diet: Note percentage of meals eaten " .
In an interview with Staff #2 on 10/16/12 at 10:50 am conference room, she stated that, " Meals are documented on the Q sheet " indicating the " Patient Rounds Adolescent, Senior Adult, Rehab and Adult Units " form.

Review of the medical record for Patient #1 revealed a Physician Progress Note dated 10/10/12 " As per staff, he refused to eat stating that the food here is not convenient for him, so he eats a lot of snacks. " Nursing Shift Assessment and Progress note on 10/10/12 at 08:30 am stated, " Continues with poor appetite. Enc. to attend meal times and to eat meals and snacks. " Patient #1 ' s record did not indicate the percentage of meals eaten for dinner on 10/8/12 and 10/9/12.

A review of Patient # 9's complete medical record revealed that vital signs were not recorded during the Code Blue on 08/04/12. No code blue response form was present in the medical record. There was no documented notification of the patient ' s family of the medical emergency. The documentation in the medial record did not include the time CPR was started, by whom, and the time medical control was relinquished to paramedic team.

Per facility provided documentation stated that Patient # 2 witnessed the nurse's discovery of Patient # 1 ' s suicide. Nursing and physician documentation in the medical record contained no description or evaluation of the patient ' s emotional state after witnessing the discovery of his roommate ' s body post suicide.
[can we pump up patient #2 ' s trauma, his own history? Can we do anything with patient #2 ' s rights?

Review of the record for Patient #1 revealed no documented evidence of a physician ' s progress note, discharge summary, or other documentation related to the patient ' s suicide by hanging at the hospital.

The above findings were confirmed in an interview with administrative staff in the conference room the afternoon of 10/16/12.