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.

BROOKHAVEN HOSPITAL, INC 201 SOUTH GARNETT ROAD TULSA, OK March 15, 2018
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review, interview, and observation the hospital failed to ensure:

I. the Governing Body reviewed and resolved grievances or was responsible for implementing and maintaining an effective grievance process.This failed practice had the potential for grievance activities to neither be conducted nor evaluated comprehensively by a specific grievance committee. (Refer to Tag A-0119)

II. the medical record contained sufficient documentation of a basic physical nursing assessment performed by nursing staff to monitor for changes in clinical condition. These failed practice had the potential to affect the physical safety and well-being for 21 (Patient #1-21) out of 21 patients and increased risk of medical changes going unnoticed for all patients. (Refer to Tag A-0449)

III. 15 minute checks were performed to determine the location and clinical status of patients. This failed practice resulted in the delay of medical interventions for one (Patient #10) of two patients' medical records reviewed, and affect the physical safety and well-being of all patients. (Refer to Tag A-0395).

IV. the safety and well-being of a patient (Patient #12) who reported allegations of physical abuse by another patient. This failed practice increased risk for alleged abuse to continue for one (Patient #12) of 21 patients. (Refer to Tag A-0144)

V. patient #22 was wearing an identification wrist bracelet during his/her entire hospitalization . This failed practice had the potential to increase the risk that patients would be misidentified prior to medication administration, assessments, and treatments or medical history would be assigned to the wrong patient. (Refer to Tag A-0144)

VI. the seclusion room door had a locking mechanism that complied with national standards. This failed practice had the potential for difficult extraction of a patient from the seclusion room during an emergency. (Refer to Tag A-0144), and

VII. staff and patients were safe and protected from harm due to contraband. This failed practice had the potential to cause harm to all patients admitted to the Behavioral Health Unit. (Refer to Tag A-0144)
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on record review and interview, the Governing Body failed to review and resolve grievance or designate a persone responsible for implementing and maintaining an effective grievance process.

This failed practice had the potential for grievance activities to not be conducted or evaluated comprehensively by a specific grievance committee, which would cause the Governing Body to be unaware of care issues and hospital performance concerns.

Findings:
A review of policy titled, "Patient Grievances (07/99)" documented the Grievance Report should be reviewed by the patient's therapist, program director, and hospital administrator. The policy also documented the report would be reviewed by the Performance Improvement Council, if the grievance was not resolved, the Ethic Committee and Chief Executive Officer would review the issues. The policy failed to designate someone responsible for resolving grievances.

A review of policy titled, "Handling, Resolution, and Dissemination of Information from Patient Grievances (12/17)" documented how grievances would be routed whether resolved or not resolved. The policy documented the Facility Compliance Officer would review, analyze, trend, and report results to the Ethics and Performance Improvement Committees. The policy failed to designate someone the responsibility of resolving grievances.

A review of policy titled, "Resolution Procedure for Recurrent Complaints (07/03)" documented it was required for all grievances to be routed to the Facility Compliance Officer who was responsible for tracking resolutions and overview of the process. The policy documented reports would be incorporated into the Performance Improvement Committee process. The policy failed to define who was assigned the responsibility for resolving grievances.

The following documents titled, "Performance Improvement Committee (date 03/16)", "Duties of the Privacy Officer (04/03)", and "Protection of Patient Privacy (03/13)" was provided by Staff A as evidence of the Governing Body's delegation of duties in writing to the grievance committee. The three policies failed to clearly designate who was responsible for review and resolution of the grievance process.

A review of the document titled, "Professional Staff By-laws (date 01/18)" in section two "Committee" failed to designate the staff who was responsible for the grievance program.

On 03/15/18 at 9:46 am, a review of four grievances from 2018, documented proposed action plans, but failed to show all actions taken. The proposed actions incuded, but were not limited to:"Process in therapy", "Need Staff HH to use appropriate tone for adults, not children", "will discuss customer satisfaction with nurse" and "therapist to discuss with recreation therapist ...".

On 03/15/18 at 9:46 am, Staff A stated it was tough to show he/she had followed through on the grievance form. Staff A stated the Performance Improvement and Ethics Committee had participated in the grievance process.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on record review, interview and observation the hospital failed to ensure:

I. the medical record contained sufficient documentation of a basic physical nursing assessment performed by nursing staff to monitor for changes in clinical condition. This failed practice had the potential to result in delay in patient care decisions for one patient. (Patient #10) and potential increased risk for the delay in care decisions for all patients. (Refer to Tag A-0449)

II. 15 minute checks were performed to determine the location and clinical status of the patient. This failed practice resulted in the delay of medical interventions for one (#10) of two patients medical records reviewed and affect the physical safety and well-being of all patients. (Refer to Tag A-0395).

III. the safety and well-being of a patient (Patient #12) who reported allegations of physical abuse by another patient. This failed practice increased risk for alleged abuse to continue for one (Patient #12) of 21 patients. (See findings below)

IV. patient # 22 was wearing an identification wrist bracelet during his/her entire hospitalization . This failed practice had the potential to increase the risk patients would be misidentified prior to medication administration, assessments, treatments,or their medical history would be assigned to the wrong patient.

VI. the seclusion room door had a locking mechanism that complied with national standards. This failed practice had the potential for difficult extraction of a patient from the seclusion room during an emergency, and

VII. staff demonstrated consistent safety procedures regarding inspection and confiscation of contraband during the admission process and throughout patient stay on the Behavioral Health Unit. This failed practice had the potential to create harm and safety risks to all patients admitted to the Behavioral Health Unit.


Findings:

I. Nursing Assessment Documentation

Refer to Tag A-0449

II. Fifteen Minute Checks

Refer to Tag A-0395

III. Allegation of Abuse

A document titled "Patient's Bill of Rights" showed patients have the right not to be abused verbally, sexually or physically.

A hospital policy titled "Variance Reporting" showed reports were forwarded to the Risk Manager for review and then sent to the Chief Executive Officer.

A hospital policy titled "Protocol for Alleged Abuse Investigations" showed staff must secure the safety and well-being of the patient including relocation of the patient as required. Investigation would include assessment of patient's psychological and physical condition and statements from any involved staff and/or other patients. A preliminary report would be sent to the chief executive officer (CEO), including an analysis of the alleged situation to support the response (if any).

A hospital document titled "Variance Report (dated 01/09/18)" for incident on 01/08/18 showed Patient #12 reported his/her roommate requested the patient to touch his/her private areas and the Administrator on Call (AOC) was notified. No other actions were identified.

A hospital documented titled "Variance Report January 1, 2018 - January 31, 2018" showed Patient #12 "accused" another patient "touching his/her breasts and genitals" and was "not clear on explanation". Outcome was identified as AOC notified, patient had history of false allegations and issues would be addressed through therapy. No evidence hospital staff or the roommate were interviewed or Patient #12 was removed from the room to ensure his/her safety and well-being.

On 03/15/18 at 11:35 am, Staff A stated Staff E (DON) reviewed the allegation of abuse with the charge nurse who reported it. Staff A stated Staff E would not sign the report unless he/she had spoken with the charge nurse and followed up with the therapist. Staff A stated he/she was aware Patient #12 was prone to delusions and allegations of sexual abuse. Staff A stated it was determined to let the therapist address the issues in therapy. Staff A stated neither Patient #12 nor the patient's roommate were relocated to another room.

IV. Patient Identification

On 03/15/18 at 12:05 pm, Patient #22 stated upon admission he/she had an identification bracelet placed on his wrist, but he/she had lost it in the prior week.

On 03/15/18 at 12:05 pm, the surveyor observed Patient #22 pacing in the Behavioral Health Unit hallway without an identification bracelet.

On 03/15/18 at 12:08 pm, Staff W stated Patient #22 should have a patient identification wrist band. Staff W stated he/she was from another unit and was assigned to the Behavioral Health Unit for lunch coverage. Staff W stated he/she did not know the patient's name, asked the patient his name, created an identification wrist band, and placed the band on the patient's wrist.

V. Seclusion Door

A review of National Fire Protection Association (NFPA) 101, 2012 Edition, Chapter 19, Section 19.2.2.2.5.1, and 19.2.2.2.6 showed egress doors shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times.

On 03/15/18 at 12:20 pm, the surveyor observed the Behavioral Health Unit's seclusion room door included two sliding bolt latches and locking mechanism, not engineered from the manufacturer, in which one would turn a crank to move a wooden board into brackets and thus barricade the door.

On 03/15/18 at 1:00 pm, Staff G stated the Behavior Health Unit seclusion room door had been modified and the locking mechanisms and a barricade bar was added to ensure patients could not force through the door.


VI. Contraband

A variance on 01/17/18 showed a patient admitted to smoking a cigarette in room and staff confiscated a cigarette lighter.

A variance on 02/21/18 showed two patients were smoking in a bathroom and the staff confiscated a cigarette lighter.

Review of a document, "Framework for a Root Cause Analysis and Action Plan in Response to a Sentinel Event" showed on 06/05/17 a patient turned in an angled box knife blade to a therapist. When the patient was admitted on [DATE] he had five similar blades in his wallet. The document showed the Mental Health Tech (MHT) had to answer the phone during the patient's check in process "which would have given the patient time without supervision".

On 03/14/18 at 2:30 pm, Staff U stated patients were "wanded" (metal detector) on admission, taken to the intake room where staff took their possessions. He/she also stated after visitation, patients' pockets were checked but they were not "wanded". He/she stated "patients are slick and can take things like cigarette lighters".

On 03/15/18 at 11:00 am, Staff F stated patients were "wanded" in admissions and that once on the unit staff looked for "dangerous" items.

On 03/15/18 at 11:30 am, Staff J stated that on admission patients were "wanded", their possessions were taken, and rooms were checked. He/she stated after they had visitors patients were not "wanded" but their pockets were checked.

On 03/15/18 at 11:30 am, Staff J stated that staff checked for contraband after visitation, "but not very thorough", visitors were not checked for contraband, and staff "only" searched patient rooms "as needed".
VIOLATION: QAPI Tag No: A0263
Based on record review and interview the hospital failed to:

I. address the lack of surveillance, tracking, and trending performed by the ICO (Infection Control Officer).

II. Based on record review and interview the hospital failed to assess, analyze, track, and implement measurable action plans for quality indicators to improve the safety and quality of care and to monitor the effectiveness. (Refer to Tag A-0273)

III. Based on record review and interview the hospital failed to track, analyze, measure, and implement measurable action plans for high risk, high volume areas. The program failed to set benchmarks and evaluate outcomes for sustainability. (Refer to Tag A-0283)

IV. Based on record review and interview the hospital failed to establish a quality improvement program that utilized a process to thoroughly investigate, analyze causes, and implement preventative action plans for adverse events and measure outcomes for effectiveness for four of four events. (Refer to Tag A-0286)

V. Based on record review and interview the Governing Body and leadership staff failed to assume full responsibility for establishing an ongoing quality improvement program that identified, analyzed, tracked, and implemented measurable action plans for quality indicators and adverse events to improve the safety and quality of care. The program failed to evaluate and set benchmarks to determine effectiveness for sustainability. (Refer to Tag A-0309)

These failed practices had the potential to affect the safety and health of all patients receiving care due to the hospital's failure to analyze, track and implement measurable actions plans to improve patient safety, quality of care and patient outcomes.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on record review and interview the hospital failed to identify, analyze, track, and implement measurable action plans for quality indicators to improve the safety and quality of care and to monitor the effectiveness.

This failed practice had the potential to affect the safety and health of all patients receiving care due to the hospital's failure to identify, analyze, track and implement measurable action plans to improve patient safety, quality of care and patient outcomes.

Findings:

Review of a document "Professional Staff Bylaws (dated 01/25/18)" showed the Professional Staff shall serve as the committee of the whole ...for Pharmacy and Therapeutics, Nursing/Infection Control, Environment of Care/Risk Management, Rights and Ethics, Quality Improvement ...It shall make recommendations to the Governing Body ...It shall satisfy the Governing Board as to the quality of health care rendered to patients in the hospital as outlined in the Performance Improvement Plan ...meets monthly.

On 03/14/18 surveyors requested the hospital's Performance Improvement Plan (PIC) and none was provided.

Review of a policy titled "Performance Improvement Committee (03/16)" documented the finding and recommendations from the PIC would be reported to the Professional Staff by the Chairperson of the PIC on a quarterly basis, and annually to the Governance Board for review and approval.

Review of a document titled "Board of Directors Meeting Minutes" dated 01/30/18 showed a discussion of the following:

I. Medication Errors:
a. Nursing report provided statistics for November with no analysis, action plan(s) or benchmark.
b. Document titled "Medication Errors & Patient Errors" dated 12/17 provided statistics, trends and an action plan that was neither measurable nor identified staff responsible for implemention of the actions.

II. Restraints and Seclusion:
a. Nursing report provided statistics for November with no analysis, action plan(s) or benchmark.
b. Document titled "Restraint & Seclusion Data" dated 12/17 provided statistics, analysis, no benchmarks for number of occurrences, and no measurable action plans which identified responsible staff for implemention of the actions.

III. Falls:
a. Nursing report provided statistics for November with no analysis, action plan(s) or benchmark.
b. Untitled document dated 12/17 for falls provided statistics, analysis, trends and an action plan that was not measurable and failed to identify staff responsible for implementation of the actions.

IV. Infection Control:
a. Nursing report provided statistics for November with no analysis, action plan(s) or benchmark.
b. Document titled "Infection Control" dated 12/17 provided statistics with no analysis, benchmark or measurable action plan(s) with identified responsible staff for implemention of the actions.

On 03/14/18 at 9:13 am, Staff A stated quality improvement information was routed to the Quality Improvement Committee, the Professional Staff Committee, and the Board of Directors.

03/14/18 at 1:10 pm, Staff E stated review of falls showed the main source of falls were on the NRI (Neuroscience Rehabilitation Institute) unit. Staff E stated after review of the infection control data he/she had determined dermatological infections such as atheletes' foot and pneumonia were the main sources of infection.

03/15/18 at 9:40 am, Staff E stated "I'm tracking what the CNO before me was tracking." Staff E stated "usually" from November through February there was a "cyclic trend" with UTIs (urinary tract infections).

On 03/15/18 at 9:46 am, Staff A stated it was tough to show he/she had followed through on the grievance form. Staff A stated the Performance Improvement and Ethics Committee had participated in the grievance process.

On 03/15/18 at 11:09 am, Staff E stated the use of medications for chemical restraints was not recorded on the seclusion/restraint log. Staff E stated medications used for chemical restraints "could be" recorded on the "Restraint/Seclusion RN/LIP Assessment" form under "medications given". Staff E stated all patients who had CPI(Crisis Prevention Intervention) initiated went on the log whether or not a restraint was used. Staff E stated the hospital was not reviewing the form for chemical restraint use. Staff E stated chemical restraints were not evaluated, tracked, analyzed or trended.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on record review and interview the hospital failed to track, analyze, measure, and implement measurable action plans for high risk, high volume areas.

This failure to identify risks, quality improvement opportunities, and implement action plans to improve patient outcomes

Findings:

Review of document titled "Board of Directors Meeting Minutes" dated 01/30/18 contained minutes from "Performance Improvement Committee" dated 01/25/18 and "Professional Staff Committee" dated 01/25/18 which showed a discussion of the following:

I. Falls
a. Nursing report provided statistics for November with no analysis, action plans or benchmark.
b. Untitled document dated 12/17 for falls provided statistics, analysis, trends and an action plan that was not measurable and did not identify staff responsible for implemention of actions.

II. Restraints/Seclusion
a. Nursing report provided statistics for November with no analysis, action plans or benchmark.
b. Document titled "Restraint & Seclusion Data" dated 12/17 provided statistics, analysis, no benchmarks for number of occurrences, and no measurable action plans which identified staff responsible for implementing those actions.

Review of a hospital policy titled "Use of Medications as Chemical Restraints" showed medications used for restraint were reviewed quarterly by the Facility Compliance Officer and reported in the seclusion/restrictive practices log. Seclusion and physical restraint were "highly monitored". There was no evidence the use of chemical restraints were monitored.

Review of a hospital document titled "CPI (Crisis Prevention Intervention)-RT (Restraint) Log" showed a list of patients who had CPI initiated and if physical restraint, seclusion or both were required. The log did not include patients who required the use of chemical restraints.

Review of a hospital document titled "Performance Improvement Committee Minutes" from 09/26/17 to 02/22/18 showed no evidence of discussion of chemical restraint usage.

On 03/14/18 at 9:13 am, Staff A stated quality improvement information was routed to the Quality Improvement Committee, the Professional Staff Committee, and the Board of Directors.

03/14/18 at 1:10 pm, Staff E stated after review of falls the main source of falls were on the NRI (Neuroscience Rehabilitation Institute) unit. Staff E stated review of the infection control data he/she had determined dermatological infections such as atheletes' foot and pneumonia were the main sources of infection. Staff E stated all patients who had the CPI initiated went on the log whether a restraint was used or not.

03/15/18 at 9:40 am, Staff E stated "I'm tracking what the CNO before me was tracking." Staff E stated usually from November through February there was a cyclic trend with UTIs (urinary tract infections).

On 03/15/18 at 9:46 am, Staff A stated it was tough to show he/she followed through on the grievance form. Staff A stated the Performance Improvement and Ethics Committee participated in the grievance process.

On 03/15/18 at 11:09 am, Staff E stated the use of medications for chemical restraints were not recorded on the seclusion/restraint log. Staff E stated medications used for chemical restraints "could be" recorded on the "Restraint/Seclusion RN/LIP Assessment" form under medications given. Staff E stated all patients who had the CPI initiated were included on the log whether or not a restraint was used. Staff E stated the hospital had not reviewed the form for chemical restraint use. Staff E stated chemical restraints were not evaluated, tracked, analyzed or trended.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on record review and interview the hospital failed to establish a quality improvement program that utilized a process to thoroughly investigate, analyze causes, or implement preventative action plans for adverse events and did not measure outcomes for effectiveness for (four of four events).

This failed practice had the potential to affect the safety and health of all patients receiving care due to the hospital's failure to analyze, track and implement measurable actions plans to improve patient safety, quality of care, and patient outcomes.

Findings:

Review of a document titled "Federal Guidelines for Opioid Treatment Programs" showed programs should have in place policies that address events that include "full documentation", including documentation of the event, investigation, and review of the situation surrounding the event. Determine corrective action and implementation of those actions in a timely and appropriate manner and perform ongoing monitoring to ensure actions are effective.

Review of a hospital policy titled "Sentinel Event Response" showed the CEO was responsible for designating an investigation team that included members from nursing leadership, physician staff and senior administrative team. The Root Cause Analysis (RCA) would examine issues that contributed to the cause of the event and determine methods to reduce or prevent recurrence. Hospital leadership would be responsible for implementing identified actions for improvement and monitoring subsequent changes on an ongoing basis. At the conclusion of the investigation and RCA, a report would be presented to Professional Staff, Performance Improvement Committee, and Board of Directors.

Review of a hospital policy titled "Sentinel Events - Additional Reporting Requirements" showed a written report would be prepared by the DON that provided a chronology of events, results of the investigation and disposition. The CEO and Director of Administrative Services would receive copies of the report. After receipt of "written report by a designated administrator, (reference policy "Sentinel Event Response") a Root Cause Analysis (RCA) would be initiated". Recommendations for improvement and the RCA would be reported to the Performance Improvement Council (PIC), CEO and Risk Management Committee for further recommendations and implementation.

Review of a document titled "RCA2 Improving Root Case Analysis and Actions to Prevent Harm" by the National Patient Safety Foundation dated 01/16 showed there are multiple contributing factors to adverse events due to the complexity of healthcare processes and once identified and addressed it may lead to improved patient safety. When utilizing an RCA the analysis would not be complete when a single contributing factor had been found, but to strive to identify multiple contributing factors. Actions would be identified along a hierarchy to prevent the re-occurence of the event. Weaker actions such as training and policy changes would not be used alone as they may not provide sustained improvement for patient safety. The actions must be measured to determine the effectiveness of each action.

Review of a hospital document titled "Performance Improvement Committee Minutes" from 09/26/17 to 02/22/18 showed the following:
*On 10/26/17 minutes identified two adverse events and identification of action plans. In the column "outcomes" it was noted as "completed". There was no evidence these action plans had measurable outcomes to ensure sustained improvement.
*On 11/30/17 minutes identified two adverse events. One event had identified an action plan with no measurable outcomes and the other had just initiated the RCA process.
*On 12/21/17 minutes identified an action plan for the RCA initiated at the meeting on 11/30/17. There was no evidence the action plan had measurable outcomes to ensure sustained improvement.

Review of four hospital documents identified as "RCA" investigations (three patient events including Patient #10, and one staff event) showed there was no evidence of the following:
*Written report of the chronology of events included results of the initial investigation that initiated the RCA per hospital policy.
*Identification and analysis of all possible contributing factors to the adverse event.
*Identified measurable actions to determine the effectiveness of each action.
*Documentation specific to each action item to show evidence of the implementation and/or completion of the item.
*Documentation of meeting minutes, medical record review (patient events) and interviews.

Review of a hospital document titled "Performance Improvement Committee Minutes" from 09/26/17 to 02/22/18 showed the following:
*On 10/26/17 minutes identified two adverse events with identified action plans. In the column "outcomes" it was noted as "completed". There was no evidence the action plans had measurable outcomes to ensure sustained improvement.
*On 11/30/17 minutes identified two adverse events. One event had an action plan identified with no measurable outcomes and the other had only initiated the RCA process.
*On 12/21/17 minutes identified an action plan for the RCA initiated at the meeting on 11/30/17. There was no evidence these action plans had measurable outcomes to ensure sustained improvement.

On 03/13/18 at 12:39 pm, Staff E stated he/she could not remember if he/she initiated an RCA for the unexpected death of Patient #10.

On 03/14/18 at 9:18 am, Staff E stated he/she was responsible for performing the investigation involving an adverse event on 02/11/18. Staff E stated he/she reviewed the chart and had a discussion with Staff B (CEO) and Staff K (internal medicine physician). Staff E stated they initiated the RCA and training in relation to the RCA on 02/11/18, the day Patient #10 expired.

On 03/14/18 at 1:10 pm, Staff F stated a RCA would be similar regardless of the incident. Staff F stated Staff K reviewed the medical record that morning and wrote a note in the patient's chart and Staff K talked with the staff the day of the event. Staff F stated "when requested" a physician could do an independent review of the patient's chart during an investigation. Staff F stated Staff E, Staff K and Staff B had conversations regarding the event and practices, but there were no official minutes of those conversations. Staff F stated Staff E looked at the lapses in processes on the day of the patient death and was not able to identify any environmental lapses or a fall for Patient #10.

On 03/14/18 at 1:29 pm, Staff E stated Patient #10 was not on any new medications the day prior to his/her death. Staff E stated there were no discussion that Patient #10 had developed a rash. Staff B, Staff K and myself "discussed Patient #10 that morning and I do remember now that he/she did receive one dose of Benadryl for a rash." Staff E stated Patient #10 was admitted for opiate withdrawal and had been started on Suboxone but did not recall when it was started. Staff E stated staff received training on the use of Suboxone but there would be no record of training in staff files. Staff E stated he/she was not aware Patient #10 had complaints of dizziness and an increased heart rate of 120 the day prior to his/her death. Staff E stated he/she does remember Patient #10 had complaints of a headache. Staff E stated the result of the RCA for Patient #10 was to provide staff education on 15 minute checks.

On 03/14/18 at 1:48 pm, Staff K (internal medicine physician) stated Patient #10 had been started on Suboxone for opiate withdrawal the evening of 02/09/18, had developed a rash the evening prior to his/her death and he/she had ordered Benadryl. Staff K stated PSC discussed the event "minorly" (sic). Staff K stated he/she had reviewed the chart.

On 03/14/18 at 2:17 pm, Staff B stated the RCA process "does not take a short amount of time". Staff B stated there had been meetings where the progress of the RCA had been discussed. Staff B stated at the meetings it had been discussed whether it had been a training or documentation issue that had lead to the event. Staff B stated "we just threw people at the process". Staff B stated there had been some meetings and reviews conducted.
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
Based on record review and interview the Governing Body and leadership staff failed to assume responsibility for establishing an ongoing quality improvement program that analyzed, tracked, and implemented measurable action plans for quality indicators and adverse events to improve the safety and quality of care. These failed practices had the potential for delayed patient care decisions for one patient (Patient #10) and potential harm for all behavioral health patients admitted to the hospital.

Findings:

Review of document "Professional Staff Bylaws (dated 1/25/18)" showed the professional staff shall serve as the committee of the whole ...for Pharmacy and Therapeutics, Nursing/Infection Control, Environment of Care/Risk Management, Rights and Ethics, Quality Improvement ...It shall make recommendations to the Governing Body ...It shall satisfy the Governing Board as to the quality of health care rendered to the patients in the hospital as outlined in the Performance Improvement Plan ...meets monthly."

On 03/14/18 surveyors requested the hospital's Performance Improvement Plan and none was provided.

Review of a policy titled "Performance Improvement Committee (03/16)" documented findings and recommendations from the PIC will be reported to the Professional Staff by the PIC Chairperson on a quarterly basis, and annually to the Governance Board for review and approval

Review of a document titled "Board of Directors Meeting Minutes" dated 01/30/18 showed a discussion of the following:
I. Medication Errors:
a. Nursing report provided statistics for November with no analysis, action plans or benchmark.
b. document titled "Medication Errors & Patient Errors" dated 12/17 provided statistics, trends and an action plan that was not measurable and did not identify staff responsible for implementing actions.
II. Restraints and Seclusion:
a. Nursing report provided statistics for November with no analysis, action plans or benchmark.
b. Document titled "Restraint & Seclusion Data" dated 12/17 provided statistics and analysis,with no benchmarks for number of occurrences or measurable action plans and failed to identify staff responsible for implemention.
III. Falls:
a. Nursing report provided statistics for November with no analysis, action plans or benchmark.
b. Untitled document dated 12/17 for falls provided statistics, analysis, and trends with no measurable action plan and failed to identify staff responsible for implemention of actions.
IV. Infection Control:
a. Nursing report provided statistics for November with no analysis, action plans or benchmark.
b. Document titled "Infection Control" dated 12/17 provided statistics, no analysis, benchmark or measurable action plans and failed to indentify staff responsible for implementing those actions.

On 03/14/18 at 9:13 am, Staff A stated quality improvement information was routed to the Quality Improvement Committee, Professional Staff Committee, and to the Board of Directors.

On 03/13/18 at 12:39 pm, Staff E stated he/she could not remember if he/she initiated an RCA for the unexpected death of Patient #10.

On 03/14/18 at 9:18 am, Staff E stated he/she was responsible for performing the investigation involving an adverse event on 02/11/18. Staff E stated he/she reviewed the chart and had a discussion with Staff B (CEO) and Staff K (internal medicine physician). Staff E stated they initiated the RCA and training on 02/11/18 the day Patient #10 expired.

03/14/18 at 1:10 pm, Staff E stated review of falls showed the main source of falls were on the NRI (Neuroscience Rehabilitation Institute) unit. Staff E stated after review of the infection control data he/she had determined dermatological infections such as atheletes' foot and pneumonia were the main sources of infection. Staff E stated all patients who have CPI initiated go on the log whether or not a restraint is used.

On 03/14/18 at 2:17 pm, Staff B stated the RCA "does not take a short amount of time". Staff B stated Staff E had conducted meetings where the progress of the RCA had been discussed such as "was this a training or documentation issue". Staff B stated "we just threw people at the process". Staff B stated there were some meetings and reviews conducted.

03/15/18 at 9:40 am, Staff E stated "I'm tracking what the CNO before me was tracking." Staff E stated usually from November through February there was a cyclic trend with UTIs (urinary tract infections).

On 03/15/18 at 9:46 am, Staff A stated it was "tough to show" if he/she followed had through on the grievance form. Staff A stated the Performance Improvement and Ethics Committee participated in the grievance process.

On 03/15/18 at 11:09 am, Staff E stated the use of medications for chemical restraints was not recorded on the seclusion/restraint log. Staff E stated medications used for chemical restraints "could be" recorded on the "Restraint/Seclusion RN/LIP Assessment" form under medications given. Staff E stated all patients who had CPI initiated went on the log whether or not a restraint was used. Staff E stated the hospital had not reviewed the form for chemical restraint use. Staff E stated chemical restraints were not evaluated, tracked, analyzed or trended.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on record review and interview the hospital failed to ensure:

I. patients were assessed for the severity, location, quality of pain, and notification of the physician was made for one (Patient #10) of 21 patients. This failed practice resulted in the potential for delayed recognition of changes in clinical condition for one (Patient #10) of 21 patients and increased risk for delayed recognition for changes in clinical condition for all patients. (Refer to Tag A-0395)

II. ensure vital signs for all behavioral health patients were completed per physician orders, hospital policies, and protocols. This failed practice resulted in the lack of timely recognition of clinical deterioration for one patient (Patient #10), and had the potential for changes of condition to not be identitfied for a second patient (Patient #2) evaluated for vital sign monitoring out of a total sampling of 21 patients, and all patients admitted for drug and alcohol withdraw. (Refer to Tag A-0395)

III. 15 minute checks were performed to determine the location and clinical status of the patient. This failed practice resulted in the delay of medical interventions for one (Patient #10) of 21 patients whose records were reviwed and had the potential for delayed medical interventions for all patients. (Refer to Tag A-0395)

IV. ensure nursing personnel demonstrated competency in caring for patients with nasogastric tubes. This failed practice had the potential to cause harm to patients admitted to the Behavioral Health Unit with eating disorder diagnoses and physician orders for nasogastric feeding. (Refer to Tag A-0397)
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview the Registered Nurse (RN) failed to:

I. ensure patient's pain was assessed for severity, location, quality, and notification of the physician was made for one (Patient #10) of 21 patients. This failed practice resulted in the potential for delayed recognition of changes in clinical condition for one (Patient #10) of 21 patients and increased risk of delayed recognition of changes in condition for all patients.

II. ensure vital signs for all behavioral health patients were completed per physician orders, hospital policies, and protocols. This failed practice resulted in the lack of timely recognition of clinical deterioration for one patient (Patient #10), and had the potential for changes of condition to not be identitfied for a second patient (Patient #2) evaluated for vital sign monitoring out of a total sampling of 21 patients, and all patients admitted for drug and alcohol withdraw. (Refer to Tag A-0395)

III. ensure 15 minute checks were performed to determine the location and clinical status of the patient for one (Patient #10) of 21 patient records reviewed. This failed practice resulted in the delay of medical interventions for one (Patient #10) of 21 patient records reviewed had the potential to effect the physical safety and well being of all patients.

Findings:


I. Pain Assessments

Review of hospital document titled "Patient's Bill of Rights" showed patients who were experiencing pain had the right to have their pain assessed and receive treatment or referral when appropriate.

A review of hospital policy titled "Documentation Frequency" showed when there was a significant event or medical issue nursing staff would describe in a progress note.

Review of hospital policy titled "Staff Assignments and Duties: Registered Nurse/Licensed Practical Nurse" showed nursing staff were responsible for the assessment of patient symptoms and clinical needs each shift.

Patient #10 was a [AGE] year old patient admitted on [DATE] for schizoaffective disorder, opiate dependence, posttraumatic stress disorder, seizure disorder and chronic pain. Review of the patient's medical record showed:

*On 02/08/18 reported complaints of back pain and requested Ibuprofen 800mg and Flexeril 10mg. The patient's severity and quality of pain were not assessed by nursing staff. There was no evidence in the medication administration record (MAR) the patient received these medications.

On 03/15/18 at 12:55 pm, Staff E stated he/she would assess pain using a numeric pain scale (1 = no pain to 10 = worst pain) and have the patient describe the pain. Staff E stated the hospital had a pain sheet but it was not used very often. Staff E stated he/she would let the patient know what they had ordered for pain and provide it. Staff E stated he/she would then go back later and ask the patient to rate their pain.

II. Vital Signs (VS)

A review of policy, titled "Vital Signs (date 03/17)" showed full set of vital signs (blood pressure, pulse, temperature, respirations) would be obtained and recorded upon admission. The policy showed blood pressure and pulse would be obtained daily at 8:00 pm and recorded. The physican might order increased frequency, specific times, and/or respirations and/or temperature if tracking a specific disease process.

A review of the medical record for Patient #10 showed he/she was admitted for the treatment for opiate/opioid addiction on 02/07/18 and showed the following:
* On 02/07/18 at 10:55 pm, "Physician Standing Admission Orders" were signed and included "Vital Signs Daily per Protocol".
* On 02/08/18 at 8:20 pm, "Opiate/Opioid Withdrawal Management MAT (medication assisted treatment) Induction Orders" were signed and documented "VS (including temperature) BID [twice daily] and addititonally at nursing discretion".
*On 02/08/18 at 6:00 am and 8:00 pm BP and P were recorded; no temperatures were recorded. (Protocol listed twice daily including temperature).
*On 02/09/18 at 6:00 am and 8:00 pm BP and P were recorded; no temperatures were recorded. (Protocol listed twice daily including temperature).
*On 02/10/18 at 6:00 am and 8:00 pm BP and P were recorded; no temperatures were recorded. On 7am-7pm shift (no specific time cited), Staff EE documented Patient #10 was irritable, complained of dizziness, "BP was stable- [no] orthostatic changes" (no evidence of orthostatic evaluation of VS noted),and pulse was 120. At 10:05 pm, Patient #10 presented to nursing desk and stated "I have a migraine", VS were not recorded. (Protocol listed twice daily and PRN including temperature).
*On 02/11/18 at 6:35 am, Patient #10 expired.

A review of the medical record for Patient #2 showed he/she was admitted for the treatment for alcohol use on 03/01/18 and showed the following:
* On 03/01/18 at 3:00 pm, "Physician Standing Admission Orders" were signed and included "Vial Signs Daily per Protocol"
* On 03/01/18 at 3:00 pm, "Alcohol / Sedative Hyponotic Detox Orders" were signed and included "VS 3 times daily PRN [as needed] for 72 hours.
* On 03/01/18 at 2:10 pm Blood pressure (BP), pulse (P), respiration, and temperature were recorded. (Protocol listed three times daily)
* On 03/02/18 at 8:00 pm, BP and P were recorded. (Protocol listed three times daily)
*On 03/03/18 at 6:00 am, 1:00 pm, and 8:00 pm, BP and P were recorded.
*On 03/04/18 at 6:00 am and 1:00 pm BP and P were recorded.

On 03/13/18 at 2:15 pm, Staff L stated the nurses determined the frequency of vital signs based on physician's order and a frequency decided by the nurse. Staff L stated vital signs mainly consisted on BP and P.

On 03/14/18 at 3:22 pm, Staff N stated the physician would write the original order for vital signs, and the nurses would write the frequency for the mental health technician to perform vital signs on a white board at the nursing station. Staff N stated many vital signs were ordered three times a day.

On 03/15/18 at 11:49 pm, Staff O stated the frequency of vital signs were on a white board at the nursing station. Staff O said the frequency would change based on the patient's taking BP medication or experiencing drug withdrawal.

III. 15 Minute Checks

Surveyors requested a policy or procedure for hospital's 15 minute patient checks on 03/13/18 at 9:00 am and a second request was made on 3/14/18 at 9:18 am. At the time of exit surveyors were not provided a policy or procedure for the hospital's 15 minute patient checks.

Review of hospital document titled "BH (behavioral health unit) 15 Minute Check Sheet NOC (night) Shift" showed Q 15 minute intervals for 11:00 pm to 6:45 am. The check sheet codes were used only to identify patient location. Code number 2 identifies "patient sleeping". The 15 Minute Check Sheet did not provide codes for a patient's clinical status or appearance such as respirations, mood or position.

Patient #10 was a [AGE] year old patient admitted on [DATE] for schizoaffective disorder, opiate dependence, posttraumatic stress disorder, seizure disorder and chronic pain. Review of the patient's medical record showed:

*On 02/07/18 from 8:45 pm to 02/10/18 at 10:45 pm, there was no documentation of 15 minute checks. Patient was last coded 1 "patient in room awake" at 10:45 pm. There was no evidence of a 15 minute check sheet for night shift from 02/10/18 11:00 pm to 02/11/18 7:00 am during the time the patient was reported in his/her room sleeping by nursing and administrative staff prior to being discovered by a MHT at approximately 6:30 am in the morning he/she expired.
*On 02/10/18 11:05 pm, Staff N documented in a statement during 15 minute checks patient was on right side covered up with a blanket.
*On 02/11/18 at 6:05 am, Staff CC documented on a progress note the patient was found cyanotic in a "tightly-fixed" in semi-fetal position and unable to lay flat to perform CPR.

On 03/14/18 at 1:29 pm, Staff E (DON) stated if the patient was noted by the MHT on the 15 minute check sheet to be "patient room asleep" that was assumed the patient was breathing.

On 03/14/18 at 3:10 pm, Staff N stated the MHTs use the 15 minute check sheets to document their checks. Staff N stated there is not a place to document if the patient is breathing on the check sheet.

On 03/15/18 at 8:47 am, Staff J stated 15 minute checks are performed on all patients. Staff J stated the procedure was to use a flashlight and go to the patient's door, shine the light onto the patient, not at the patient's face and look to see if there was a rise and fall of the patient's chest. Staff J stated the MHT would document on the check sheet. Staff J stated he/she was not aware of any recent training or changes to the 15 minute patient safety checks. Staff J stated if he/she could not determine if the patient was breathing he/she would go into the room, make sure, and if the patient was not breathing he/she would notify another staff member to call 911 and start CPR (cardiopulmonary resuscitation).

On 03/15/18 at 9:10 am, Staff I stated when he/she performed the 15 minute checks he/she would use a flashlight and she if the chest was rising and if not would go in the room. Staff I stated he/she would be suspicious if the patient remained in the same position each time. Staff I stated if the patient had the covers over their head he/she would pull the covers back to make sure the patient was breathing, even it meant disturbing the patient. Staff I stated if the patient was on their side it would be impossible to see if they were breathing from the door and he/she would need to go into to the room. Staff I stated Staff E "may have" come to a meeting a couple of weeks ago and spoke about 15 minute checks.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
0397

Based on record review and interview the director of nursing services and the hospital failed to ensure nursing personnel demonstrated competency in caring for patients with nasogastric tubes.

This failed practice had the potential to harm patients admitted to the Behavioral Health Unit with eating disorder diagnoses and physician orders for nasogastric feeding.

Findings:

Air instillation and auscultation are inaccurate methods for validating the position of a nasogastric tube. This may result in pulmonary or pleural effusion, pneumothorax or pulmonary abscess. Misplacement is often not suspected unless a radiograph is obtained. (Journal of Parental Nutrition 2011)

A policy, "Staff Development and Training", showed the Director of Nursing was responsible for assessing the educational needs of staff members. It also showed he/she would plan educational presentations to meet those needs.

A policy, "Clinical Competencies for Registered Nurses" showed categories of required competencies, including non-specific assessments, with competency and return demonstration obtained via review of assessments, nursing treatment plans and documentation of patient needs. It failed to show frequency requirements beyond orientation or list specific skills for which competencies would be validated.

A nursing policy, "Nasogastric Tube Insertion" showed auscultation of 10-15 cc of air was the process for verification of correct placement.

On 03/14/18 at 11:40 am, Staff L stated patients admitted to the Behavioral Health Unit with eating disorders frequently required nasogastric tube feedings. He/she stated some physicians ordered chest x-rays to confirm nasogastric tube placement and auscultation of air with a stethoscope was used for placement confirmation if x-ray was not ordered. Staff L stated he/she had not demonstrated competency for nursing skills at the facility and was not aware auscultation of air for confirmation of nasogastric tube was not current standard of practice.

On 03/15/18 at 9:40 am, Staff E stated he/she was not aware auscultation of air for confirmation of nasogastric tube placement was not current standard of practice.
VIOLATION: CONTENT OF RECORD Tag No: A0449
Based on record review and interview the hospital failed to ensure medical record contained sufficient documentation of a basic physical nursing assessment performed by nursing staff to monitor for changes in clinical condition. This failed practice resulted in delayed medical interventions for one patient (Patient #10)of 21 and the potential for delayed care for all patients.

Findings:

Review of a hospital policy titled "Supplemental Assessments" showed assessment on a more "detailed basis" would be performed when there was a change in condition.

Review of a hospital policy titled "Ongoing Assessments" showed nursing staff would notify the physician immediately for "critical assessment" which would include but not be limited to cardio-pulmonary distress, pain and skin integrity.

Review of a hospital policy titled "Documentation Frequency" showed when there was a significant event or medical issue nursing staff would describe in a progress note.

Review of hospital policy titled "Staff Assignments and Duties: Registered Nurse/Licensed Practical Nurse" showed nursing staff were responsible for the assessment of patient symptoms and clinical needs each shift. There was no evidence the policy identified a frequency for a basic nursing physical assessment to meet the needs of the patient.

21 (Patient #1-21) of 21 medical records reviewed showed no evidence of documentation of a basic physical nursing assessment after the patient's initial admission assessment.

On 03/15/18 10:20 am, Staff H stated at least once a shift nurses "should" perform a nursing assessment. Staff H stated "should" look at the patient and perform a physical assessment. Staff H stated if a patient had a rash he/she would assess how it looked, determine if it had fluid in it, was the shape of it uniform, and notify the physician. Staff H stated the nursing shift note did not have a place for documenting a basic nursing assessment since it was a psych unit.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on record review and interview the hospital failed to ensure:

I. Standing Orders had a date, time and signature by the ordering physician.
II. Orders were timed and dated.
III. Provider signatures were legible.
IV. Nurses and MHTs documented a time when progress notes were entered.
V. An actual time was associated with the nurses and MHT shift assessment notes.

This failed practice had the potential for 14 (Patient #1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 12, 13, 14, and 15) of 14 behavioral health patients to have incomplete or inaccurate documentation and communication between healthcare providers as the medical record provides a sequential record of patient care promoting patient safety through timely assessments, interventions and ensuring quality patient care.

Findings:

Review of hospital policy titled "Chart Analysis" showed physician progress notes and orders, must be signed, dated and timed. Legibility was not addressed in the policy.

Review of hospital policy titled "Authentication of Medical Records" showed written signatures must be legible and dated.

Review of hospital document titled "BH Nursing Shift Note" showed a 7:00 am to 7:00 pm, and 7:00 pm to 7:00 am, time period for a shift assessment including a signature with date and time completed.

Review of hospital document titled "BH MHT (Mental Health Technician) Shift Note" showed a 7:00 am to 3:00 pm, 3:00 pm to 11:00 pm, and 11:00 pm to 7:00 am, time periods for a shift assessment and a space for a signature with date and time completed.

Patient #1 was a [AGE] year old patient admitted for major depressive disorder with suicidal ideation. Review of the medical record on 03/14/18 showed:
*Internal Medical Consultation dated 03/09/18 had no signature, date or time.
* Standing Admission Orders initiated by nursing staff on 03/09/18 at 4:10 pm showed no physician signed, dated or timed these orders.
* An untitled nine page admission assessment document dated 03/09/18 had no signature, date or time by the psychiatrist or physician.
* Medication Consent Form dated 03/09/18 had no physician signature.
* New Patient Checklist had not been completed by the MHT on admission.

Patient #2 was a [AGE] year old male admitted for alcohol use, chemical dependency and detoxification. Review of the medical record showed:
*No date and time documented for order on 03/08/18.

Patient # 10 was a [AGE] year old patient admitted for schizoaffective disorder, opiate dependence, post traumatic stress disorder, seizure disorder and chronic pain. Review of the medical record showed:
*No time documented for nursing notes on 02/08/18, 02/09/18 and 02/10/18.
*On 02/08/18 it was documented the patient reported complaints of back pain and requested Ibuprofen 800mg and Flexeril 10mg. The MAR contained no documentation medications were given.

Patient #11 was a [AGE] year old patient admitted for amphetamine abuse/dependence, posttraumatic stress disorder, schizoaffective disorder, and panic disorder with agoraphobia. Review of medical record showed:
*Signatures on the Social Work Discharge-Transition Plan were not legible
*Physician signature on the "Justification for Multiple Antipsychotic Medications Physician Form", Psychiatric Discharge Summary and Comprehensive Initial Psychiatric Evaluation were not legible
* No times documented for nursing notes on 12/27/17, 12/29/17, 01/01/18 - 01/07/18
* No times documented for MHT notes on 12/27/17 - 12/29/17, 12/31/17 - 01/05/18, 01/07/18 - 01/08/18

Patient #13 was a [AGE] year old patient admitted with a traumatic brain injury, cognitive disorder and behavioral disturbance. Review of medical record showed:
*No time documented for nursing notes from 12/30/17 to 01/02/18.
*No time documented for MHT notes from 12/30/17 to 01/01/18.

Patient #14 was a [AGE] year old patient admitted with a traumatic brain injury, cognitive disorder, epilepsy, intermittent explosive disorder, psychosis, severe borderline personality and major depressive disorder. Review of medical record showed:
*No time documented for nursing notes on 02/01/18 for the 7:00 am to 7:00 pm, and 7:00 pm to 7:00 am shifts.

Patient # 15 was a [AGE] year old patient admitted for bipolar disorder manic phase, panic disorder with agoraphobia, and generalized anxiety. Review of the medical record on 03/14/18 showed:
*Standing Admission Orders initiated by nursing staff on 03/08/18 at 9:00 pm did not contain a physicians signature or date and time of order.
*Physician orders for 03/09/18 through 03/11/18 were not legible and there was no identifiable ordering physician signature.

14 (Patient #1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 12, 13, 14, and 15) of 14 behavioral health patient records showed no evidence of an actual time when the nursing shift assessments were performed. The records showed a time period for a shift of either 7:00 am to 7:00 pm, or 7:00 pm to 7:00 am.

14 (Patient #1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 12, 13, 14, and 15) of 14 behavioral health patient records showed no evidence of an actual time when the elements of the MHT assessments were performed. The records showed a time period for a shift of either 7:00 am to 3:00 pm, 3:00 pm to 11:00 pm or 11:00 pm to 7:00 am.

On 03/13/18 at 2:15 pm, Staff L stated the nursing shift assessment was an accumulation of what occurred throughout the day. Staff L stated the date/time and signature was not the time the assessment was performed, it was usually when he/she would document near the end of shift.

On 03/15/18 at 12:59 pm, Staff E stated nurse progress notes "should have" a time to identify when the event had occurred. Staff E stated signatures "should be" legible.
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
A person or persons must be designated as infection control officer or officers to develop and implement policies governing control of infections and communicable diseases ...

Based on record review and interview, the hospital failed to ensure the designated infection control officer was qualified through education, training, experience, or certification as evidenced by

Findings:

Review of a document titled "Infection Control Officer" (no date), showed the hospital would designate an ICO (Infection Control Officer) to develop and implement hospital wide policies governing the control of infections and communicable diseases among all departments, employees, and patients.

Review of a document titled "Infection Control Officer" (ICO) showed the hospital's ICO would show certification in the area of infection prevention and control and also maintain ongoing education annually. Record of educational certificates/continuing education units (CEU) obtained for infection control programs would be filed in the ICO's personnel file. Educational certificates would constitute a specific annual competency for the ICO.


A review of Staff E personnel file showed one document certifying Staff #E completed 0.50 credit hours of "Orientation: Infection Control Basics" on 9/20/17.

On 03/15/18 at 10:00 am, Staff E stated he/she tracked the same data the previous chief nursing officer had tracked. Employee E stated he/she was not aware of how/why the data had been chosen.

On 03/15/18 at 10:00 am, Staff E stated a monthly report of antibiotic use from the pharmacy was utilized to track infections. He/she stated this information was referred to the Performance Improvement Committee and the Professional Staff Committee. There was no documentation provided to show utilization of the tracked information.

On 03/15/18 at 12:50 pm, Staff E stated he/she had completed a thirty minute course titled "Orientation: Infection Control Basics" on 9/20/17. He/she stated the course was the total of infection control education received since beginning of employment at the hospital. He/she stated that he/she had information from the Centers for Disease Control (CDC) website, "a book about infection control", and also utilized "Infection Control Today" and the "American Journal of Infection Control".
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on record review and interview, the hospital failed to ensure the designated infection control officer had a system in place to prevent the spread of infections for patients and staff.

This failed practice resulted in a lack of quality improvement initiatives for infection control to include surveillance and equipment disinfection which had the potential to increase the risk of infection for all patients admitted to the facility.

Findings:

I. Surveillance

Review of a document "Plan for Infection Control Committee" showed to minimize or reduce the risk of spreading infections was the hospital's goal.

Review of a document "Infection Control Officer" showed the Infection Control Officer (ICO) was responsible for the development of programs and systems which would include surveillance, prevention and control of infectious processes.

Review of a document "Infection Control" showed the collected information was shared with the Professional Staff and Performance Improvement Committees.

Review of a document "Infection Control" from 8/17 to 1/18 showed statistical information, but failed to identify problem areas or measure progress of prevention efforts to reduce or eliminate Healthcare Acquired Infections.

The documents provided failed to show the data was utilized to monitor the effectiveness of the Infection Control Program. No other documents were provided during the survey.

On 3/15 /18 at 9:40 am, Staff E stated he/she tracked the same data as the previous Chief Nursing Officer.

On 03/15/18 at 10:00 am, Staff E stated a monthly report of antibiotic use from the pharmacy was utilized to track infections. Staff E stated this information was presented to the Performance Improvement and Professional Staff Committees.

II. Equipment disinfection

A review of a document titled, "Plan for Infection Control Services" showed surveillance would be conducted to assess the potential for the spread of infections associated with the use of medical supplies and devices.


Blood pressure cuffs:

A review of a document titled, "CDC (Centers for Disease Control and Prevention) Guideline for Disinfection and Sterilization in Healthcare Facilities (2008)" showed noncritical surfaces, such as blood pressure cuffs should be disinfected with an EPA-registered disinfectant unless the item is visibly contaminated with blood.

On 03/14/18 at 12:30 pm, Staff J stated blood pressure cuffs were cleaned daily by staff.

On 03/14/18 at 1:30 pm, Staff N stated blood pressure cuffs were not disposable and "we don't" wipe the cuffs between patients.

On 03/15/18 at 10:00 am, Staff E stated he/she tracked the same infection control data the previous chief nursing officer had tracked. Staff E stated he/she was not aware of how/why the data had been chosen.

On 03/13/18 at 2:00 pm, the surveyor observed Staff O obtain blood pressure on two consecutive patients with a re-usable blood pressure cuff, staff did not disinfect or clean the equipment before or after use.

Glucometers:

Review of a document "Contour Next EZ User Guide", which accompanied the device, showed the "over the counter" device was manufactured for self-testing by persons with diabetes at home, was for single-patient use only, and should not be shared. All parts of the kit were to be "considered biohazardous" and could "potentially transmit infectious diseases".

Review of a document, "Injection Safety", showed if blood glucose meters must be shared the device should be cleaned and disinfected after every use, to prevent carry-over of blood and infectious agents (Centers for Disease Control and Prevention, 2012).

Review of a document, "Injection Safety", showed a risk of blood glucose testing was exposure to bloodborne viruses through contaminated equipment and supplies if devices used for testing (e.g. blood glucose meters) were shared (Centers for Disease Control and Prevention, 2012).

A review of nursing personnel files showed zero of five (Staff E, H, L, Q, and U) staff had demonstrated competencies for use of the glucometer.

On 3/15/18 at 10:19 am, Staff Q stated the protocol was for each glucometer to be cleaned at night.

On 3/15/18 at 10:19 am, Staff Q stated he/she had not demonstrated competencies for use of the glucometer.

On 3/14/18 at 11:30 am, the surveyor observed a "Contour Next EZ" device utilized by nursing staff to obtain multiple patient's blood glucose levels.
VIOLATION: WRITTEN POLICIES AND PROCEDURES Tag No: A0885
Based on record review and interview, the hospital failed to ensure the Organ Donation policy was consistent with their Transplant Donor Services agreement, to include, but not limited to: hospital's responsibilities, definitions of imminent death, timely notification, and tissue, and staff training.

This failed practice resulted in the death of one patient (Patient #10), not being reported to the Transplant Donor Services.

Findings:
A review of policy titled, "Organ Donation (dated 09/00) documented the Director of Nursing (DON) would be responsible for the organ donation process. The policy failed to define imminent death, timely notification, tissue and staff training expectations.

On 03/14/18 at 9:45 am, Staff E stated the hospital did not have an agreement with Transplant Donation Services.

On 03/14/18 at 9:45 am, Staff E stated Lifeshare Donation Services was not contacted of the death of Patient #10.

On 03/19/18 at 1:00 pm, Staff A provided a copy of the Organ Donation policy and agreement.
VIOLATION: OPO AGREEMENT Tag No: A0886
Based on record review and interview, the hospital failed to ensure Transplant Donor Services agreement included definitions of imminent death and timely notification.

This failed practice resulted in one patient (Patient #10) not being reported to the Transplant Donor Services upon his death.

Findings:
A review of agreement titled, "Agreement between Lifeshare Transplant Donor Service of Oklahoma, Inc. and Brookhaven Hospital (dated 2014 with perpetual renewal) documented the Director of Nursing (DON) would be responsible for the organ donation process. The agreement failed to define agreement included definitions of imminent death and timely notification.

On 03/14/18 at 9:45 am, DON, Staff E stated the hospital did not have an agreement with Transplant Donation Services. On 03/19/18 at 1:00 pm, Staff A provided a copy of the Organ Donation policy and agreement.

On 03/14/18 at 9:45 am, DON, Staff E stated Lifeshare Donation Services was not contacted of the death of Patient #10.
VIOLATION: STAFF EDUCATION Tag No: A0891
Based on record review and interview, the hospital failed to ensure staff were trained regarding organ procurement, to include, but not limited, to : consent process, role of the designated requestor, and role of the organ procurement organization.

This failed practice resulted in the death of one patient (Patient #10) not being reported to the Transplant Donor Services.

Findings:
A review of policy titled, "Organ Donation (dated 09/00) documented the Director of Nursing (DON) would be responsible for the organ donation process. The policy failed to address staff training expectations.

A review of eight (Staff H, I, J, L, N, P, U, and V) of eight personnel files showed no competency for the organ procurement process.

On 03/14/18 at 9:45 am, Staff E stated the hospital had not provided organ procurement training to the staff.

On 03/15/18 at 10:19 am, Staff O stated he/she had not received training the regarding organ procurement process.

On 03/14/18 at 9:45 am, Staff E stated Lifeshare Donation Services was not notified of the death of Patient #10.