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.

SALT LAKE BEHAVIORAL HEALTH 3802 SOUTH 700 EAST SALT LAKE CITY, UT 84106 July 3, 2012
VIOLATION: UTILIZATION REVIEW COMMITTEE Tag No: A0654
Based on Utilization Review (UR) meeting minutes, attendance logs and interview, it was determined the facility did not have two or more practitioners functioning as part of the UR committee.

Findings include:

On 6/28/2012 at 10:30 AM, a review of the UR rolls and minutes dated 11/22/2011, 12/20/2011, 1/31/2012, 2/23/2012, 3/21/2012, 4/17/2012 and 5/31/2012 was reviewed. There was no documentation that any physicians had attended or participated in any of the above UR meetings as required.

On 06/28/2012 at 11:00 AM, the facility's Adminisrative Assistant (AA) was interviewed. The AA confirmed that there was no physician participation in the above listed UR meetings.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**






Based on interview and record review, it was determined that the hospital had not set priorities for its performance improvement activities that focused on high-risk or problem-prone areas and affect health outcomes, patient safety and quality of care.

Findings include:

1. On 6/28/2012, an interview was held with the facility Risk Management Director (RMD) .

The RMD stated that the projects that were in place were tracking of medication errors and lost patient articles. He stated that when he started employment at the hospital there was a limited Quality Improvement program (QI). He stated that he spent most of his time tracking lost patients' items. He stated that only recently has he been able to put a system in place to focus on more important issues. The RMD stated that in January, the QI committee had identified that suicide risk assessments were not being completed on admission and there was also a problem with discharge. He stated that at each QI meeting the issue had been discussed but no follow through.

The RMD stated that as of 6/27/2012, he had formulated a quality plan to track clinical assessments, history and physicals, psychiatric evaluations and suicide risk assessments. The RMD stated that he had developed a chart review system that identified where the deficit areas are and a way to ensure that all necessary concerns are addressed and all areas of the patients' charts are completed. In addition, he stated that there is a component to the plan that calls for discharge charts to be reviewed to ensure that each patient had appropriate follow up care after discharge.
This was implemented after the facility was informed of the finding of Immediate Jeopardy.

2. A review of the plan and the audits was completed on 7/2/2012.

The QI committee meeting minutes for 3/27/12 were reviewed. In section 6 "Outside Agency Compliance" the following was documented: "...Dept. of Health is going to move forward with finding that SLBH is out of Compliance (at a Condition level) re: both Pt's (patient) Rights & Discharge Planning...." There was no documentation found that the facility addressed these problem prone areas. It was documented that "all SLBH staff" were responsible.

3. In January of 2012 a patient was admitted to the facility with suicidal ideation with a plan. Within 72 hours of discharge, the patient carried out her plan of suicide by a self inflicted gun shot wound. The facility was aware in January of 2012 that they had a discharge planning problem. In March of 2012, during an abbreviated survey, the facility was found out of compliance at a Condition level pertaining to "Discharges". No documentation for follow up training of staff pertaining to discharge planning was found.

4. In March of 2012, during an abbreviated survey, the facility was found out of compliance at a Condition level pertaining to "Patient Rights." There was no documentation of a discussion nor follow-up training pertaining to patient rights for facility staff.

5. Patient 4 (B tag-F1) was admitted on [DATE] to the facility.

a. The Suicide Risk assessment dated [DATE] indicated that this patient was seen as a "high risk for suicide/self-harm."

b. The Master Treatment Plan dated June 15, 2012 did not identify suicide risk as a problem to address with treatment interventions.

c. In an interview on June 26, 2012 at 11:00 AM, the Unit Manager of the Crisis Stabilization Unit (CSU) was asked if patient 4 (F1) was on suicidal precautions. The Unit Manager answered "no", and stated that since patient 4 (F1) was on the CSU, which "had more staff than other units," that was sufficient. As to why patient 4's (F1) Master Treatment Plan problem list did not contain suicide precautions or interventions, the Unit Manager stated that the CSU "had more staff than other units."

d. Patient 4 (F1) spent most of the day within the Adult Psychiatric Unit (APU), as observed on June 25, 2012. Patient 4 (F1) was observed in two group activities; the first was between 11:30 AM and 12:30 PM and the other group was between 1:30 PM and 2:00 PM. The APU has an "L-shaped" design, and some areas on the unit are not easily visible to the staff from the centrally located nursing station. Therefore, the patient was not on a status equivalent to observation for suicide precautions during the time on the APU.
VIOLATION: QAPI Tag No: A0263
Based on interview and record review, it was determined that the hospital failed to have systems in place to ensure that all patient conditions were identified and carried over into the patient treatment plan. (Refer to Tag B103)

Findings include:

1. It was determined that the hospital failed to track an adverse event that resulted in a finding of "Immediate Jeopardy". (Refer to tag A 267)

2. It was determined that the hospital failed to set priorities for its performance improvement activities that focused on high-risk or problem-prone areas. (Refer to tag A 266)




3. It was determined that the governing body failed to ensure quality psychiatric care in a safe setting. Specifically, the governing body failed to ensure that the recommendation, as result of the Root Cause Analysis, were initiated and carried out. These failures placed current patients at risk for continued suicide risk potential. As a result of these failures and current risks to patient safety an IMMEDIATE JEOPARDY was identified. (Refer to tag A-311)
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**






Based on interview and record review, it was determined that the hospital failed to track an adverse event that resulted in a finding of "Immediate Jeopardy".

Findings include:

An interview was held with the hospital Risk Management Director (RMD) on 6/28/2012. The RMD stated that when the hospital was informed of an incident that occurred in January of 2012, a Root Cause Analysis (RCA) was done and a plan was devised. He stated, unfortunately, the plan was never fully implemented.

A review of the Performance Improvement (PI) Committee Meeting minutes was completed on 6/28/2012. The review revealed the following:

January 24, 2012

Bullet 6, "Suicide Risk Assessment-please remind nurses to complete on admission for EVERY patient and therapists to complete upon discharge for EVERY patient."

February 14, 2012

Bullet 2, "Suicide Risk Assessment-please remind nurses to complete on admission for EVERY patient and therapists to complete upon discharge for EVERY patient."

Bullet 4, "Chart review- 'Patient' - reviewed in detail this patient's chart. She successfully completed suicide 3 days following discharge from 'hospital'. Reviewed the whole process from assessment admission, treatment planning to discharge, identifying what was done correctly and what was not, with specific areas being highlighted and suggested for training on each of the units."

March 27, 2012

5. Patient Safety/Risk Management

"RCA follow-up, ongoing need for improved documentation and understanding of process. Training this month on documentation for all staff."

April 24, 2012

2. Miscellaneous Business

...."Tx (treatment) team meetings need to include a quick chart review to ensure essential consents, assessments and Tx plans are current. Program Directors will ensure that individual charts are reviewed in Tx Team meeting."

May 16, 2012

3. "...starting audit on all new charts having any deficiencies immediately followed up on. Areas to audit are Psych Evals, H&P (history and physical) and Clinical assessments to make sure that are complete and timely. Incident report to be completed if information is missing from chart..."

There was no documentation found that assessed the process of care for patients with a diagnosis of suicidal ideation. There was no documentation found that tracked if patients had suicidal ideation, or if it carried over to the treatment plan, and there was no information to show that staff members were made aware if suicidal ideation was identified.

In addition, patient 4 (B tag- F1) was admitted to the facility on [DATE] expressing suicidal ideations; however, suicidal ideation was not documented on the Master Treatment Plan as a problem. Failure to note suicide intent as a problem on the Master Treatment Plan, in order to provide appropriate suicide interventions, places patients at risk for not having significant psychiatric problems adequately addressed.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**






Based on interview and record review, it was determined that the hospital failed to track an adverse event that resulted in a finding of "Immediate Jeopardy".

Findings include:

An interview was held with the hospital Risk Management Director (RMD) on 6/28/2012. The RMD stated that when the hospital was informed of an incident that occurred in January of 2012, a Root Cause Analysis (RCA) was done and a plan was devised. He stated, unfortunately, the plan was never fully implemented.

A review of the Performance Improvement (PI) Committee Meeting minutes was completed on 6/28/2012. The review revealed the following:

January 24, 2012

Bullet 6, "Suicide Risk Assessment-please remind nurses to complete on admission for EVERY patient and therapists to complete upon discharge for EVERY patient."

February 14, 2012

Bullet 2, "Suicide Risk Assessment-please remind nurses to complete on admission for EVERY patient and therapists to complete upon discharge for EVERY patient."

Bullet 4, "Chart review- 'Patient' - reviewed in detail this patient's chart. She successfully completed suicide 3 days following discharge from 'hospital'. Reviewed the whole process from assessment admission, treatment planning to discharge, identifying what was done correctly and what was not, with specific areas being highlighted and suggested for training on each of the units."

March 27, 2012

5. Patient Safety/Risk Management

"RCA follow-up, ongoing need for improved documentation and understanding of process. Training this month on documentation for all staff."

April 24, 2012

2. Miscellaneous Business

...."Tx (treatment) team meetings need to include a quick chart review to ensure essential consents, assessments and Tx plans are current. Program Directors will ensure that individual charts are reviewed in Tx Team meeting."

May 16, 2012

3. "...starting audit on all new charts having any deficiencies immediately followed up on. Areas to audit are Psych Evals, H&P (history and physical) and Clinical assessments to make sure that are complete and timely. Incident report to be completed if information is missing from chart..."

There was no documentation found that assessed the process of care for patients with a diagnosis of suicidal ideation. There was no documentation found that tracked if patients had suicidal ideation, or if it carried over to the treatment plan, and there was no information to show that staff members were made aware if suicidal ideation was identified.

In addition, patient 4 (B tag- F1) was admitted to the facility on [DATE] expressing suicidal ideations; however, suicidal ideation was not documented on the Master Treatment Plan as a problem. Failure to note suicide intent as a problem on the Master Treatment Plan, in order to provide appropriate suicide interventions, places patients at risk for not having significant psychiatric problems adequately addressed.
VIOLATION: GOVERNING BODY Tag No: A0043
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, it was determined that Salt Lake Behavioral Hospital's governing body failed to ensure the hospital operated in a manner in which all Medicare Conditions of Participation, for hospitals, were met and did not carry out all the functions required of the governing body by regulation. The governing body failed to ensure that the hospital met all Conditions of Participation:
(1) for Psychiatric Hospitals - FED - 5.01;
a. Spec Medical Records Reqs for Psych Hospitals (B-103 482.61)
b. Spec Staff Requirements for Psych Hospitals (B-136 482.62)
and
(2) for Acute Care Hospital - FED A 19.05.
a. Patient Rights (A-115 482.13)
b. Quality Assessment and Performance Improvement Program (A-263 482.21)

Findings include:

The facility did not ensure the safety, appropriate treatment nor appropriate discharge for a patient verbalizing suicidal ideation with a plan. Within 72 hours of discharge, the patient carried out her plan of suicide by a self inflicted gun shot wound. Additionally, an active patient in the hospital during the survey was found to have suicidal ideation that had not been documented on his/her treatment plan.

1. The facility failed to ensure that patients, (1 of 1 death records reviewed [I1] and 1 of 11 active sample patients [F1]), who were experiencing suicidal thinking and/or behaviors were provided active treatment while hospitalized . Patient I1 expressed suicidal intent to multiple staff members upon admission to the facility. Patient I1 was never placed on suicide precautions and never had suicidal thinking addressed in the Master Treatment Plan as a problem. Patient I1 died of a self inflicted gunshot wound shortly after discharge. Similarly, Patient F1 was admitted to the facility on [DATE] expressing suicidal ideations and did not have active treatment of the suicidal thoughts addressed by treatment providers nor was the suicide potential documented on the Master Treatment Plan as a problem or intervention. (Refer to B118 and B125)

This situation led to a status of IMMEDIATE JEOPARDY; the facility was notified on 6/26/12 at 4:00 PM Mountain Time. (Refer to tag B- 103)

2. The facility failed to ensure that Clinical Directors implemented policy/procedure changes and staff training that was recommended in a Root Cause Analysis (RCA) initiated after the suicide death of a patient (I1) shortly after discharge in February of this year. The RCA was completed in February 2012 and identified several areas of concern related to failures by specific disciplines in the assessment and treatment of the patient. These included: physicians failed to supervise the development of a Master Treatment Plan that identified suicidal ideation as a problem; nursing staff failed to complete suicide risk assessments; and, social work staff failed to provide adequate discharge planning. The RCA recommended staff training to improve care in the identified areas. The Medical Director (refer to B144), Chief Nursing Officer (refer to B148) and the Director of Social Work (refer to B152) all failed to implement RCA recommendations to assure patient safety. These failures place current patients at risk for continued suicide risk potential. As a result of these failures and current risk to patient safety an IMMEDIATE JEOPARDY was identified and related to facility administration on 6/26/12 at 4PM Mountain Time. (Refer to B 136)

3. The governing body failed to ensure that the hospital's medical staff had taken responsibility for the quality of medical care provided to the patients by the hospital. After the above mentioned incident, the governing body, the medical staff and the admintsration failed to respond the findings of the RCA and did not provide appropriate training and monitoring of training. (Refer to tags B 103 and A 115)

4. The governing body failed to ensure that the hospital had systems in place to ensure that all patients' psychiatric conditions were identified and carried over into the patient treatment plan. (Refer to Tags B103, A-263)
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on governing body meeting minutes and a Root Cause Analysis (RCA), it was determined that the governing body failed to ensure quality psychiatric care in a safe setting. Specifically, the governing body failed to ensure that the recommendation as result of the RCA were initiated and carried out. These failures placed current patients at risk for continued suicide risk potential. As a result of these failures and current risks to patient safety an IMMEDIATE JEOPARDY was identified.

Findings include:

The RCA was completed after a suicidal patient shot and killed herself within 72 hours of being discharged from the facility. Shortly after a discharge in February of 2012, an RCA was completed and identified several areas of concern.

Review of the RCA evidenced that there were three "Risk Reduction Strategies" that were to be implemented: "(1)"Provide training on assessing suicidal potential." (2) "Provide information on the patient with a dual diagnosis including focusing on staff 's attitude toward these patients." (3) "Provide direction, in-service and follow-up on how to write appropriate treatment plans."

A review of the Governing Body Meeting Minutes from April 25, 2012 and an Ad Hoc meeting dated 6/5/12 were reviewed. The meeting minutes revealed no evidence that the RCA was discussed or followed up on amongst the members, nor was there any evidence in the meeting minutes that the three "Risk Reduction Strategies" were acted upon, discussed, or followed through, by the Governing Body. It was documented, however, that the CEO of the facility was present for the RCA meeting in 2/2012.

In addition, patient 4 (B tag-F1) was admitted to the facility on [DATE] expressing suicidal ideations and did not have suicide potential documented on the Master Treatment Plan as a problem. Failure to note suicide intent as a problem on the Master Treatment Plan, in order to provide appropriate suicide interventions, places patients at risk for not having significant psychiatric problems adequately addressed.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on interview and review of medical executive meeting minutes, governing body meeting minutes and a Root Cause Analysis (RCA), it was determined that the medical staff and governing body failed to ensure quality psychiatric care in a safe setting. Specifically, the medical staff and governing body failed to ensure that the recommendations, as a result of a RCA, were initiated and carried out. These failures placed current patients at risk for continued suicide potential and failed to contribute to a safe setting.

Findings include:

The RCA was completed after a suicidal patient shot and killed herself within 72 hours of being discharged from the facility. Shortly after a discharge in February of 2012, an RCA was completed and identified several areas of concern.

Review of the RCA evidenced that there were three "Risk Reduction Strategies" that were to be implemented: "(1)"Provide training on assessing suicidal potential." (2) "Provide information on the patient with a dual diagnosis including focusing on staff 's attitude toward these patients." (3) "Provide direction, in-service and follow-up on how to write appropriate treatment plans."

It was documented in the Medical Staff Meeting for February of 2012 under performance improvement that there was a discussion of the "RCA". Review of Medical Staff meeting minutes for March, April, and May of 2012 revealed no evidence that the RCA was discussed or followed up on amongst the members, nor was there any evidence in the meeting minutes that the three "Risk Reduction Strategies" were acted upon, discussed, or followed through, by the medical staff .

An interview was conducted with the Medical Director (MD) on 6/26/12 at 11:00 AM. The MD stated there were patient care issues which needed to be addressed by the medical staff. He stated he was a member of the RCA Committee. He was unaware if any new policy and procedure formats for discharge summaries that had been implemented by hospital administration. When asked if policies and procedures had been enacted by him, he stated that was not his area, but someone else's in the facility. He stated the whole administrative process had changed after the RCA finding, and he was unable to refer to any documentation of policy changes. He stated,"I don't know if there are policies and procedures to show changes." He confirmed that there was no documentation that the medical staff had been trained and supervised related to any changes recommended by the RCA.

A review of the Governing Body Meeting Minutes from April 25, 2012 and an Ad Hoc meeting dated 6/5/12 were reviewed. The meeting minutes revealed no evidence that the RCA was discussed or followed up on amongst the members, nor was there any evidence in the meeting minutes that the three "Risk Reduction Strategies" were acted upon, discussed, or followed through, by the Governing Body.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview, review of medical staff meeting minutes and governing body meeting minutes it was determined that the facility failed to protect and promote the safety of each of its patients.

Findings include:

The facility failed to ensure that Clinical Directors implemented policy/procedure changes and staff training that was recommended in a Root Cause Analysis (RCA) initiated after the suicide death of a patient (I1) shortly after discharge in February of this year. The RCA was completed in February 2012 and identified several areas of concern related to failures by specific disciplines in the assessment and treatment of the patient. These included: physicians failed to supervise the development of a Master Treatment Plan that identified suicidal ideation as a problem; nursing staff failed to complete suicide risk assessments; and social work staff failed to provide adequate discharge planning. The RCA recommended staff training to improve care in the identified areas. The Medical Director (refer to B144), Chief Nursing Officer (refer to B148) and the Director of Social Work (refer to B152) all failed to implement RCA recommendations to assure patient safety. These failures place current patients at risk for continued suicide risk potential. As a result of these failures and current risk to patient safety an IMMEDIATE JEOPARDY was identified and related to facility administration on 6/26/12 at 4PM Mountain Time. (Refer to B 136)