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.

FRIENDS HOSPITAL 4641 ROOSEVELT BOULEVARD PHILADELPHIA, PA April 20, 2018
VIOLATION: NURSING SERVICES Tag No: A0385
Based on review of facility policies and procedures, review of facility documents, observation, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure Nursing Services were provided in a safe and effective manner; by failing to ensure that Nursing Administration ensured a safe clinical setting on the inpatient Nursing units (A-0386); by failing to ensure that Registered Nurses effectively supervised and evaluated direct patient care (A-0395); by failing to ensure verbal orders were implemented and documented correctly (A-0408); and by failing to ensure that medications were administered and documented correctly (A-405).

Cross Reference:
482.23(a) Nursing Services: Organization of Nursing Services
482.23(b)(3) Nursing Services: RN Supervision of Nursing Care
482.23(c)(3)(ii) Nursing Services: Accepting Verbal Orders for Drugs
482.23(c)(1) Nursing Services: Administration of Drugs
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policies and procedures, facility documents, observation, review of medical records (MR), and interview with staff (EMP), it was determined that the facilities Nursing Administration failed to provide a clinically sound, safe, and secure environment, within the inpatient Nursing units, for four of eleven transfer medical records reviewed (MR1, MR2, MR13, and MR16), and one of one open medical record reviewed (MR27).

Findings include:

Review on April 18, 2018, of the facility policy, "Bill of Rights", dated, "11/2016", revealed "You have a right to be treated with dignity and respect ..."

Review on April 18, 2018, of the facility policy, "Plan for Provision of Patient Care and Service", dated, "11/2016", revealed "... Philosophy and Values In keeping with its Quaker heritage, Friends Hospital's services are based on respect for the dignity and worth of every individual. Protection of individual rights and freedom from unnecessary restriction are guiding principles in patient care. Care planned and provided through a patient-focused customer satisfaction model that emphasizes individualized services appropriate to the needs and expectations of each patient ... patient service includes recognition of health and strength, as well as, illness, and encompasses patient education and advocacy along with care and treatment ... Standards of Patient Care Friends Hospital patients can expect: To be treated with compassion, respect, and dignity at all times. To be cared for in an environment that provides for comfort, safety, and preservation of confidentiality. To receive appropriate, individualized assessment and treatment, delivered in accordance with currently recognized professional standards ... In order to maintain these standards, the Hospital is committed to: Establishment of appropriate policies, procedures, and protocols to guide aspects of patient care and treatment. Development of systems for service delivery which provide for interdisciplinary collaboration and coordination, to ensure continuity and seamless delivery of care to the greatest extent possible ..."

Review on April 18, 2018, of the facility policy, "Adverse Events", dated, "12/2017", revealed "... Definitions An Adverse Event is any happening or omission including incidents, Sentinel events, Serious Events and Infrastructure Failures, which is not consistent with the routine operation of the facility or the routine care of a particular patient, and any event or situation that harmed or could have harmed a person. For example: Patient care Bodily injury ... Hazardous Conditions ... Assault ... Policy 1. All staff is responsible for reporting Adverse Events in accordance with this policy ... Procedures 1. Immediate handling of an Event: a. The person responsible for the area or, in his/her absence, the Administrator on duty (AOD) will assess the situation and, as appropriate: i. Provide care or summon help for any injured person. ii. Take any necessary steps to prevent further risk to people or the environment ..."

Review on April 18, 2018, of the facility policy, "Assault Precautions", dated, "05/2017" , revealed "Purpose ... At all times, the principles of Recovery and Trauma Informed Care will be followed as precautions are assessed. It is well demonstrated that creating a safe, trustworthy, choice oriented, collaborative and empowering process from admission to treatment, minimizes the reoccurrence's of trauma and assaultive behaviors ... Staff members trained and competent in HWC (restrain training course) and verbal de-escalation techniques will be able to: 3. Ensure the patient and staff injuries are prevented or kept to a minimum during assaultive crisis. 4. Ensure proper monitoring of the patient during the recovery phase of an assaultive crisis. 5. Ensure the assaultive/homicidal behavior and interventions properly documented in the patient's record and notification plans and duty to warn implemented ... Procedure ... 6. Potential interventions for a patient on assault/homicide precautions include, but are not limited to (see De-escalation of Patients in Crisis Policy) ... Monitor high risk times: group activities, courtyard breaks, meals, anytime the staff attention may be diverted ... Separation from identified at risk peers ..."

Review on April 18, 2018,, of the facility policy, "Level of Observation", dated, "02/2017", revealed "Policy It is the policy of Friends Hospital to uphold the right of our patients to receive care in a safe and therapeutic environment ... Staff members assigned to each patient will provide monitoring, precautions, oversight and interventions to provide for their safety and security ... Levels of Observation 1. Q 15 Minute Observations ... D. Perform rounds at staggered intervals and in a varying pattern or sequence throughout the unit to minimize planned acting out opportunities ... F. While monitoring hallways and patient care areas ensure patients are ... Not left in Treatment Areas without direct staff supervision ... "

Review on April 18, 2018, of the facility policy, "Code Grey Psychiatric Emergency", dated, "10/2017", revealed "Policy: Code Gray Emergencies are paged to call additional staff to the area of need in order to aid in de-escalation, assist with patients on the unit that are not involved in the crisis or to assist with restrictive interventions as needed. Handle with Care techniques are utilized to address psychiatric emergencies. Patients experiencing a psychiatric emergency will be immediately assessed, provided appropriate emergency treatment and if needed, referred to the most appropriate facility. Since Friends Hospital admits and treats patients evaluated to be in danger to self and others it must be anticipated that patient emergencies and crises may occur, and must be identified and responded to as early as possible. All staff members' are expected to be alert for situations that are emergencies or have potential to develop into emergencies and immediately take the actions necessary to manage the situation in accordance with the approved procedure's. Psychiatric Emergency management is the responsibility of all clinical disciplines. The response to an emergency/crisis must take the highest priority and must be active, rapid, and based n a team approach. Purpose: This policy is intended to provide a systematic, efficient, and uniform response to a psychiatric emergency in order to maintain a safe and therapeutic hospital environment. This is designed to ensure a safe environment for patients, visitors, and staff ... Definitions ... Psychiatric Emergency: Any situation where a patient's behavior may result in a life threatening or psychologically damaging consequence to an individual(s), if not promptly addressed. Examples of such behavior include ... assault or attempted assault, excessive agitation or loss of control, threat of violence or harm to individual(s) ... Procedures ... 5. The other employees not assigned a role should focus on ensuring the safety and security of the other patients by removing them from the area and providing redirection ... 7. Debriefings are done after each drill with Charge Nurse and/or designee. When areas for improvement are identified, these are corrected immediately with staff education ..."

Review on April 18, 2018, of the facility policy, "De-Escalation of Patient in Crisis", dated, "04/2018", revealed "Purpose: To provide a safe environment for patients at risk for losing control ... Policy ... Certain basic assumptions are necessary in effecting these policies. 1. All staff who accept employment at Friends Hospital also accept an obligation to intervene, prevent, and control assaultive and disruptive behavior ... Procedure: 1. Any staff member in the vicinity can institute a Psychiatric Emergency by dialing "77". 2. All staff assigned to respond to the emergency pager should proceed with speed, to the point of crisis ..."

Review on April 18, 2018, of the facility policy, "Code Blue Emergency Response Procedure", dated, "01/2017", revealed "Purpose: To ensure appropriate medical response and stabilization are provided to the individual in need. Policy: The Code Blue medical response team will assist staff members in assessing and stabilizing the patient's condition ... Life threatening medical emergencies will be appropriately managed and the individual will be transferred to an acute care medical hospital. The Friends Hospital Staff will assess and provide treatment within the scope of practice for Friends Hospital ... Definitions of Medical Emergency A medical emergency is defined as a life threatening condition for which the person requires immediate life support measures and transfer to an acute care hospital. Criteria: The Code Blue may be activated when any or all of the following exist but not limited to ... D. Significant blood loss ... H. Acute changes in Systolic Blood Pressure < 90 mmHg in association with dizziness, light headedness or syncope ... L. Acute Significant Bleeding ... M. Changes in Level of Consciousness N. Difficulty speaking with no previous history ... Procedure ... B. Medical Management ... 7. The nurse will ensure appropriate care is rendered: i. Obtain vital signs (pulse, respirations, BP) ii. Pulse Oximeter iii. Blood Glucose Measurement iv. Electrocardiogram (ECG for patient units) v. Oxygen by nasal cannula at 2L/min or non-re-breather mask at 15 L/min vi. BLS as necessary 8. RN will ensure that the transfer form is completed ... C. After Medical Emergency is Over ... 2. The nurse will insure the completion of the Medical Emergency Flow Sheet 3. RN will complete comprehensive progress note that will include: i. Assessment data and interventions leading up to emergency situation ii. Interventions sued during medical emergency iii. Time of event iv. Notification of resident physician or n call attending psychiatrist ... "

Review on April 18, 2018, of the facility policy, "Code Blue and Transfer to emergency room and Return of Individual to the Inpatient Unit", dated, "04/2018", revealed "Purpose: To ensure appropriate medical response to emergent medical issues which require evaluation in an acute medical care facility. Policy: Urgent/Emergent medical issues are identified and managed within the scope of practice of Friends Hospital and those medical conditions that require more intensive and intervention are transferred to the appropriate facility from an inpatient unit. Definitions: 1. Emergency: An emergency service is one that is provided after sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the individual's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. Procedure: 1. Upon identification of actual or potential urgent/emergent medical issues, the RN will provide appropriate care and the physician will be contacted immediately. A. The RN will conduct an assessment and provide first aid or emergency BLS while awaiting MD assessment. B. Emergency medical equipment will be brought to the scene and a Code Blue is called if the situation requires emergency care. 2. The RN will delegate to staff the need to call a code if the situation is emergent. 3. When the decision to transfer is made, the RN will obtain an order from the Physician to facilitate the transfer process: A. If the medical condition is not life threatening, transport vendor will be called. B. If the medical condition is determined to be life threatening, the staff will call "77", Code Blue, the operator will call 9-1-1. 4. The RN will delegate to the appropriate staff: A. Monitoring of the individual and preparation of the transfer ... 5. The physician will call the emergency room to inform the ER staff of the transfer ... "

Review on April 19, 2018, of the facility policy, "Clinical Assessment", dated, "01/2017", revealed "... Policy The medical record is a legal document, an accounting record, and the blueprint for treatment during hospitalization . The patient's chart is the sole document of the patient's critical problems and the criteria for inpatient level of care. Therefore, a problem-oriented record that clearly identifies the required treatment should be the emphasis for all disciplines' documentation ... M. Progress Notes Integrated progress notes are vital in conveying the course of treatment additional data obtained beyond the initial assessment and specific services and consultations rendered. Notes should be written at the time of service delivery ... They should be legible and reflect time, date and signature with credentials ..."

Review on April 19, 2018, of the facility policy, "Documentation: Nursing", dated, "04/2018", revealed "Purpose: To provide standards and guidelines for documentation in the patient record in order to maintain a clear and concise record of nursing care in the hospital. Policy: It is the policy of Friends Hospital to ensure Nursing Staff (RN, LPN, and MHT) are competent in chart documentation. The nursing staff will document the patient's behavior and response to the interventions used as designated in the Multidisciplinary Treatment Team, as well as all other relevant information ... Procedure ... D. A nursing progress note is to be done once per shift on each patient by the RN, LPN, or MHT. Each note must describe the patient s behavior, the intervention(s) used, and the patient's response to the intervention(s) ..."

Review on April 20, 2018, of the facility policy, "Vital Signs", dated, "04/2017", revealed "Purpose: To ensure accurate physical monitoring of vital statistics of health status. Policy: Vital statistics (temperature, pulse, respirations, blood pressure, and weight) are patient indicators which assist in the maintenance of physical homeostasis. Vital signs are initiated with patient presentations for admission and are regularly reassessed throughout the hospital stay according to established procedures. Procedure ... 5. Routine vitals on the inpatient units are performed twice daily for the first three days of inpatient stay, and then once daily until discharged ... 8. Additional monitoring may be ordered at physician or nurses discretion based on physical acuity of the patient ... 11. Vital signs on the inpatient unit recorded on the Vital Signs Flow sheet by shift. 12. The MHT reports any abnormal vital sign readings to the nurse, who informs the physician of any atypical values immediately. The nurse, as well if he/she is performing the vital signs, informs the physician of any abnormal value immediately. The nurse will have the patient's current medications and medical diagnosis's readily available to provide this information to the physicians. The nurse, while waiting for the physician's response, will increase the monitoring of the vital signs until the physician provides orders. See the chart which is on every unit as a reference. Vital Sign Reference Guide ... Blood Pressure ... Low 100/60 mmHg or lower ... 13. The nurse enters the vital signs into EMAR on the HSC system ... Obtaining Blood Pressure ... m. Notify the physician immediately for blood pressure systolic/diastolic reading as specified on Vital signs Reference Guide ... "

Review on April 18, 2018, of the facility document, "2018 Performance Improvement and Patient Safety Plan", dated, "2018", revealed "... Purpose ... Under this plan, our organization seeks to ... d. Provide a culture where care is delivered in a safe environment and quality of care is measured, monitored, and continuously improved ..."

Review on April 18, 2018, of the facility document, "Job Description/Evaluation, Position Title: Assistant Director of Nursing", dated, no date provided, revealed "... Job Summary: reports to the Director of Nursing and is accountable for nursing care in the inpatient areas ... Job Responsibilities ... 4.0 Engages in leadership responsibilities by providing information, support and education which promote professionalism. 4.1 Ensures that the nursing functions of the Inpatient, Admission and Evaluation Services are carried out ... 4.5 Assists Director of Nursing with ensuring total compliance with the standards of JCAHO, other accrediting bodies/agencies, Federal, State and City authorities in regard to the provision of patient care and other requirements affecting the Clinical areas supervised. 4.5.1 Ensures compliance with applicable Federal, State and local laws and regulations on the part of persons under supervision ... 4.8 Interprets clinical and managerial issues to interdepartmental and interagency colleagues and groups; serves as an advocate for staff, patients and quality patient care ... 5.5 Assists with aspects of Performance Improvement for the Clinical services Department ... 5.5.3 Investigates specific problems of clinical practice and uses the results to improve clinical performance and patient care ... 6.0 Participates in centralized Nursing Services department professional activities, including education, performance improvement, peer review, and committee work, in order to maintain professional standards. 6.1 Ensures establishment of programs designed to impart knowledge, achieve high ethical standards, create a patient care climate in keeping with the mission and philosophy of Friends Hospital ..."

Review on April 18, 2018, of the facility document, "Performance Evaluation Form, Position Title: Chief Nursing Officer", dated, "10/14", revealed "B. Position Specific Performance 1. Management and Supervision: Assure that Nurse managers and direct reports establish appropriate standards of safety, quality of care, and quality/performance improvement mechanisms to achieve smooth operations and optimal efficiency ... 3. Regulatory Requirements: Maintains all accreditations and clarifies licensing and accreditation standards (during accreditation survey years and announced surveys) for Nursing Services ... Assure compliance with all regulatory agencies and hospital polices ..."

Review on April 18, 2018, of the facility document, "Job Description, Performance & Competency Evaluation, Job Title: Nurse Manager", dated, "2/2013", revealed "Primary Function: Clinical Nurse Building manager maintains oversight of unit based Clinical service lines in identified building in order to ensure quality, integrity, and excellence of treatment delivered ..."

Review on April 18, 2018, of the facility document, "Job Description, Position Title: Registered Nurse", dated, "12/12", revealed "Position Summary: Provides direct patient care as prescribed by the physician and treatment team. Provide medical management and assessment of patients. Ensure environmental safety and crisis management for the patient population ... document patient care, ensure that date is accurate ... B. Position Specific Performance Criteria/Essential Job Functions 1. Nursing Assessment ... Assesses and documents findings when patient condition changes and communicates changes in patient status to the physician and treatment team. 2. Nursing Documentation. Documents patient progress clearly, accurately, legibly, and concisely per hospital policy ... Ensures that occurrences are thoroughly documented ... 4. Medication Administration/Medical Management. Administers medications according to department procedure, including obtaining vital signs and lab work, within assessment guidelines and parameters ... 6. Crisis Intervention. Provides appropriate intervention in psychiatric and medical crisis situations. Directs crisis response by using sound judgement and timely intervention. Completes necessary documentation and obtains orders within prescribed timelines. Ensures that patient & staff safety is maintained throughout any special treatment procedures ..."

Review on April 18, 2018, of the facility document, "Job Description, Position Title: Mental Health Technician", dated, "12/17", revealed "Position Summary: assists in the direct care & management of patients across all age ranges with medical & behavioral issues as directed by the treatment team ... B. Position Specific Performance Criteria/Essential Job Functions 1. Patient Supervision. Provides age and developmentally appropriate, hands-on supervision, crisis intervention, therapeutic interactions and behavior management as directed in the treatment plan and program guidelines ... 2. Documentation. Accurately, legibly, and thoroughly documents patient behaviors, activities, and progress on a daily basis. Records complete and accurate behavioral data in the prescribed format ... 5. Crisis Intervention. Provides appropriate intervention in psychiatric and medical crisis situations by anticipating and responding quickly to escalating behaviors, utilizing de-escalation techniques to diffuse the situation, correctly prioritizing safety concerns ..."

Review on April 18, 2018, of the facility document, "Code Gray Log" , dated, "3/31/18", revealed a Code Grey was called on "BN2", on "3/31/18", at "1539" and a second Code Gray was called at "1541".

Review on April 16, 2018, of MR1, revealed the patient was admitted as an inpatient to the BN2 Unit, on March 24, 2018. Further review of MR1 revealed a Nursing Progress Note, dated "3/31/18", at "2030". Further review of the progress noted revealed "[patient name] was in a altercation [letter c, line over it, meaning the word with] a peer. Patient was punched by peers. Patient had abrasions on his face and swelling of the right eye. [patient name] was kicked by peers. VS are 92/53, 138, resp 24, pulse ox 97. Patient was evaluated by the ROC (resident on call) and sent to the hospital." Further review of the progress note reveals no documented evidence of the specific time when the altercation(s) took place, how many individuals were involved as well as where the events took place, and no documented evidence of the patient's specific injuries and/or specific first aid/medical care provided to the patient post-altercation. Further review of the progress note revealed no documented evidence that the patient was isolated from the individuals who were involved in the altercation(s) and that the patient was kept safe, secure, and protected from future assaults/physical abuse. Further review of the progress noted revealed no documented evidence that a Code Grey and/or Code Blue was initiated by the RN. Further review of MR1 revealed an Integrated Progress Note, dated "3/31/18", at "1748", by the "NSG Supervisor". Further review of the supervisor note revealed "Arrived to unit at approximately 1543 after code grey called by unit due to physical assault on pt [patient full name] where two peers physically attacked him. He was kicked + punched in face + body multiple times by both peers per patient report. Staff intervened after 1st altercation, where patient ran down hall. Per staff, both aggressors seemed to be calm, but quickly pushed past staff in attempt to continue assault. Pt. states he was kicked + hit multiple times again in hallway until staff was able to intervene. On arrival, Pt was in room [letter c, line over it, meaning the word with] ROC, nurse + 2 MHT's. I arrived to pt's room where he was being assessed by ROC + unit nurse. Neuro checks were being done, vital signs completed 92/53, p 138, R 20, Pulse ox - 97% on RA. Pt was immediately given ice + pressure applied to stop bleeding. Neuro checks were within normal limits. Pt was awake, alert + oriented x 3. 911 had already been activated per ROC. Nursing Supervisor + resident at bedside [letter c, line over it = to with] pt until 911 arrived." Further review of MR1 revealed an Integrated Progress Note, dated 3/31/18, at 15:40 pm, by the Resident on Call (ROC). Further review of the physician note revealed "ROC on call was notified that patient was assaulted by two patients on the unit in the lounge area. Pt was taken down to the floor and the other two patients punched his face with hands and feet. Pt received injury over his right eye and substantial nose bleed. Upon arrival at 3:50 pm on the unit the pt is in distress seated on his bed with ice pack to his face. Pt had swelling over the right eye, mild swelling on the right side of the nose and laceration of the lower lip. Pt complained of mild headache pain 6/10 on the eye and nose, denies blurry vision, nausea, vomiting diarrhea, [illegible word] or abdominal pain. Per nursing staff there was substantial bleeding from his nose after the incident. [illegible word] Pt is mild distress seated on bed holding ice to the eye." Further review of the Resident on Call note revealed no documented evidence that the patient was isolated from the individuals who were involved in the altercation(s) and that the patient was kept safe, secure, and protected from future assaults/physical abuse. Further review of MR1 revealed a Inpatient Transfer Form, dated 3/31/18, at 1605. Further review of the transfer form revealed "Reason for transfer: Very shaky. [patient name] was punched, hit by 2 peers. Had cut over face. Nose bleeding. Right eye very swollen = bloodshot. Very shaky. Kicked many times. " Further review of the transfer form revealed no documented evidence of the specific time of the transfer or how the patient was transported (i.e. EMS personnel or facility-based transport).

Interview with EMP4 and EMP5, on April 18, 2018, between approximately 7:46 A.M. and 8:19 A.M., confirmed that the facility currently has a video recording of the assault on the patient listed within MR1 and that they both "did" review the video. Further interview with EMP4 and EMP5 confirmed that assault occurred on the Bonsall North Two (BN2) Unit, on March 31, 2018, between approximately "3:30 to 3:45" , which was at the "change of shift" report by Nursing personnel. Further interview with EMP4 and EMP5 confirmed that at change of shift the nurses give report at the "nurse's station", which is "not near the lounge". Further interview with EMP4 and EMP5 confirmed that during shift report the Mental Health Technicians are "monitoring the hallways" and exchanging report. Further interview with EMP4 and EMP5 confirmed that the patient in MR1 was assaulted "twice" on March 31, 2018. Further interview with EMP4 and EMP5 confirmed that the first assault on the patient occurred in the "lounge". Further interview with EMP4 and EMP5 confirmed that the patient was "sitting on the floor in the lounge playing cards" and that "three patients" entered the lounge, "closed the lounge door", and "two" of the three patients began "kicking and punching" the patient in MR1, "repeatedly", to the "head" and "body area". Further interview with EMP4 and EMP5 confirmed that the facility staff intervened within approximately "15-20 seconds" and that the patient in MR1 "ran out" of the lounge area. Further interview with EMP4 and EMP5 confirmed that there "is not" documented evidence that the patient in MR1 was provided first-aid after the first assault and/or that the patient in MR1 was placed in a safe/secure environment/area for their protection from further assaultive behavior from the other patients involved in the assault. Further interview with EMP4 and EMP5 confirmed that a "second" assault on the patient within MR1, occurred on the BN2 hallway, within "a minute" from the first assault event in the lounge. Further interview with EMP4 and EMP5 confirmed that the patient in MR1 was "walking away from the lounge", in a common hallway, when the two patient's who completed the first assault, assaulted the patient again at the very end of the hallway. Further interview with EMP4 and EMP5 confirmed that the patient in MR1 was "kicked and punched", "repeatedly", to the "head" and "body area". Further interview with EMP4 and EMP5 confirmed that the facility staff intervened "immediately". Further interview with EMP4 and EMP5 confirmed that there "is not" documented evidence that the patient in MR1 was provided first-aid after the second assault and/or that the patient in MR1 was placed in a safe/secure environment/area for their protection from further assaultive behavior from the other patients involved in the assault. Further interview with EMP4 and EMP5 confirmed that the nurses note, documented on March 31, 2018, at 2030, "was not complete" and "was not reflective" of what transpired during either of the assault events. Further interview with EMP4 and EMP5 confirmed that a Police Report "was not" initiated by the facility as the "parents" of the patient in MR1 "had already" initiated a report once the patient was in the "ER" of the receiving hospital, post-transfer.

Interview with EMP20, on April 19, 2018, between 1:52 P.M. and 2:00 P.M., confirmed that the Nursing Supervisor note, documented on "3/31/18", at "1748", was "not accurate". Further interview with EMP20 confirmed that the Nursing Supervisor "did not" arrive to the unit and find the patient within MR1 in their room, post-assault. Further interview with EMP20 confirmed that the Nursing Supervisor arrived to the unit, post-Code Grey announcement, and immediately began assisting the unit staff by cleaning "up all the blood at the end of the hallway before Housekeeping arrived". Further interview with EMP20 confirmed that they "did not" know if the patient was provided immediate first-aid or other Nursing interventions, post-assault number one and/or number two. Further interview with EMP20 confirmed that they "did not" know if the patient was placed in a safe/secure environment/area for their protection from further assaultive behavior from the other patients involved in the assault, post-assault number one and/or number two.

Review on April 19, 2018, of MR2, revealed the patient was admitted to the facility on on [DATE]. Further review of MR2 revealed a Nursing Progress Note, dated "02/11/18" at "1400". Further review of the progress note revealed "Patient asleep in common area. During medication administration, [patient] stated 'I don't remember how' when asked to take pills in a medicine cup. Patient also required reminders to swallow. Patient unable to answer questions because she is heavily sedated. Patient was able to shower with help of MHT. Patient was asleep and barely [sic] rousable in the dayroom." Further review of MR2 revealed no documented evidence that a Code Blue was initiated when the patient was "heavily sedated", no documented evidence that the patient was provided basic nursing interventions while they were "heavily sedated", and/or no documented evidence that a physician was notified of the patients "heavily sedated" condition. Further review of MR2 revealed an Inpatient Transfer Form, dated, no date and/or time recorded by the RN. Further review of the transfer form revealed "reason for transfer: Rule out CVA. Pt is 34 yo female with AMS since 1 wk, Hx of fall & head contusion 4 days ago, since 2 days ago c/o weakness on left side of body, confusion, (increased, reflective by up arrow) drooling, [sic] confusion. AAO x 2. Vitals abnormal BP (elevated, reflective by up arrow) 158/98 mmHg. Further review of the transfer form revealed "Relative/Guardian Notified By" section was left blank with no entry documented. Further review of the transfer from revealed "Current Vital Signs" section with the "Resp", "Blood Sugar" and "Accu [sic] Chek" sections all left blank with no entries documented. Further review of the transfer form revealed the "Unit", "Telephone number", "RN Signature", "Print Name", and "Date and Time" sections were all left blank with no entries documented.

Interview with EMP5 and EMP19, on April 19, 2018, between 10:38 A.M. and 10:46 A.M., confirmed that MR2 "did not" contain documented evidence that a Code Blue was initiated when they were "heavily sedated", no documented evidence that the patient was provided basic nursing interventions while they were "heavily sedated", and/or no documented evidence that a physician was notified of the patients "heavily sedated" condition.

Review on April 19, 2019, of MR13, revealed the patient was admitted to the facility on on [DATE]. Further review of MR13 revealed a Nursing Progress Note written on "3/25/2018" at "13:35". Furt
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policies and procedures, facility documents, observation, review of medical records (MR), and interview with staff (EMP), it was determined that the facilities Registered Nurses failed to supervise, evaluate, and/or accurately document clinical events, to ensure the safe and effective delivery of patient care, for four of eleven patient transfer medical records reviewed (MR1, MR2, MR13, and MR16), and one of one open medical record reviewed (MR27).

Findings include:

Review on April 18, 2018, of the facility policy, "Bill of Rights", dated, "11/2016", revealed "You have a right to be treated with dignity and respect ..."

Review on April 18, 2018, of the facility policy, "Plan for Provision of Patient Care and Service", dated, "11/2016", revealed "... Philosophy and Values In keeping with its Quaker heritage, Friends Hospital's services are based on respect for the dignity and worth of every individual. Protection of individual rights and freedom from unnecessary restriction are guiding principles in patient care. Care planned and provided through a patient-focused customer satisfaction model that emphasizes individualized services appropriate to the needs and expectations of each patient ... patient service includes recognition of health and strength, as well as, illness, and encompasses patient education and advocacy along with care and treatment ... Standards of Patient Care Friends Hospital patients can expect: To be treated with compassion, respect, and dignity at all times. To be cared for in an environment that provides for comfort, safety, and preservation of confidentiality. To receive appropriate, individualized assessment and treatment, delivered in accordance with currently recognized professional standards ... In order to maintain these standards, the Hospital is committed to: Establishment of appropriate policies, procedures, and protocols to guide aspects of patient care and treatment. Development of systems for service delivery which provide for interdisciplinary collaboration and coordination, to ensure continuity and seamless delivery of care to the greatest extent possible ..."

Review on April 18, 2018, of the facility policy, "Adverse Events", dated, "12/2017", revealed "... Definitions An Adverse Event is any happening or omission including incidents, Sentinel events, Serious Events and Infrastructure Failures, which is not consistent with the routine operation of the facility or the routine care of a particular patient, and any event or situation that harmed or could have harmed a person. For example: Patient care Bodily injury ... Hazardous Conditions ... Assault ... Policy 1. All staff is responsible for reporting Adverse Events in accordance with this policy ... Procedures 1. Immediate handling of an Event: a. The person responsible for the area or, in his/her absence, the Administrator on duty (AOD) will assess the situation and, as appropriate: i. Provide care or summon help for any injured person. ii. Take any necessary steps to prevent further risk to people or the environment ..."

Review on April 18, 2018, of the facility policy, "Assault Precautions", dated, "05/2017" , revealed "Purpose ... At all times, the principles of Recovery and Trauma Informed Care will be followed as precautions are assessed. It is well demonstrated that creating a safe, trustworthy, choice oriented, collaborative and empowering process from admission to treatment, minimizes the reoccurrence's of trauma and assaultive behaviors ... Staff members trained and competent in HWC (restrain training course) and verbal de-escalation techniques will be able to: 3. Ensure the patient and staff injuries are prevented or kept to a minimum during assaultive crisis. 4. Ensure proper monitoring of the patient during the recovery phase of an assaultive crisis. 5. Ensure the assaultive/homicidal behavior and interventions properly documented in the patient's record and notification plans and duty to warn implemented ... Procedure ... 6. Potential interventions for a patient on assault/homicide precautions include, but are not limited to (see De-escalation of Patients in Crisis Policy) ... Monitor high risk times: group activities, courtyard breaks, meals, anytime the staff attention may be diverted ... Separation from identified at risk peers ..."

Review on April 18, 2018,, of the facility policy, "Level of Observation", dated, "02/2017", revealed "Policy It is the policy of Friends Hospital to uphold the right of our patients to receive care in a safe and therapeutic environment ... Staff members assigned to each patient will provide monitoring, precautions, oversight and interventions to provide for their safety and security ... Levels of Observation 1. Q 15 Minute Observations ... D. Perform rounds at staggered intervals and in a varying pattern or sequence throughout the unit to minimize planned acting out opportunities ... F. While monitoring hallways and patient care areas ensure patients are ... Not left in Treatment Areas without direct staff supervision ... "

Review on April 18, 2018, of the facility policy, "Code Grey Psychiatric Emergency", dated, "10/2017", revealed "Policy: Code Gray Emergencies are paged to call additional staff to the area of need in order to aid in de-escalation, assist with patients on the unit that are not involved in the crisis or to assist with restrictive interventions as needed. Handle with Care techniques are utilized to address psychiatric emergencies. Patients experiencing a psychiatric emergency will be immediately assessed, provided appropriate emergency treatment and if needed, referred to the most appropriate facility. Since Friends Hospital admits and treats patients evaluated to be in danger to self and others it must be anticipated that patient emergencies and crises may occur, and must be identified and responded to as early as possible. All staff members' are expected to be alert for situations that are emergencies or have potential to develop into emergencies and immediately take the actions necessary to manage the situation in accordance with the approved procedure's. Psychiatric Emergency management is the responsibility of all clinical disciplines. The response to an emergency/crisis must take the highest priority and must be active, rapid, and based n a team approach. Purpose: This policy is intended to provide a systematic, efficient, and uniform response to a psychiatric emergency in order to maintain a safe and therapeutic hospital environment. This is designed to ensure a safe environment for patients, visitors, and staff ... Definitions ... Psychiatric Emergency: Any situation where a patient's behavior may result in a life threatening or psychologically damaging consequence to an individual(s), if not promptly addressed. Examples of such behavior include ... assault or attempted assault, excessive agitation or loss of control, threat of violence or harm to individual(s) ... Procedures ... 5. The other employees not assigned a role should focus on ensuring the safety and security of the other patients by removing them from the area and providing redirection ... 7. Debriefings are done after each drill with Charge Nurse and/or designee. When areas for improvement are identified, these are corrected immediately with staff education ..."

Review on April 18, 2018, of the facility policy, "De-Escalation of Patient in Crisis", dated, "04/2018", revealed "Purpose: To provide a safe environment for patients at risk for losing control ... Policy ... Certain basic assumptions are necessary in effecting these policies. 1. All staff who accept employment at Friends Hospital also accept an obligation to intervene, prevent, and control assaultive and disruptive behavior ... Procedure: 1. Any staff member in the vicinity can institute a Psychiatric Emergency by dialing "77". 2. All staff assigned to respond to the emergency pager should proceed with speed, to the point of crisis ..."

Review on April 18, 2018, of the facility policy, "Code Blue Emergency Response Procedure", dated, "01/2017", revealed "Purpose: To ensure appropriate medical response and stabilization are provided to the individual in need. Policy: The Code Blue medical response team will assist staff members in assessing and stabilizing the patient's condition ... Life threatening medical emergencies will be appropriately managed and the individual will be transferred to an acute care medical hospital. The Friends Hospital Staff will assess and provide treatment within the scope of practice for Friends Hospital ... Definitions of Medical Emergency A medical emergency is defined as a life threatening condition for which the person requires immediate life support measures and transfer to an acute care hospital. Criteria: The Code Blue may be activated when any or all of the following exist but not limited to ... D. Significant blood loss ... H. Acute changes in Systolic Blood Pressure < 90 mmHg in association with dizziness, light headedness or syncope ... L. Acute Significant Bleeding ... M. Changes in Level of Consciousness N. Difficulty speaking with no previous history ... Procedure ... B. Medical Management ... 7. The nurse will ensure appropriate care is rendered: i. Obtain vital signs (pulse, respirations, BP) ii. Pulse Oximeter iii. Blood Glucose Measurement iv. Electrocardiogram (ECG for patient units) v. Oxygen by nasal cannula at 2L/min or non-re-breather mask at 15 L/min vi. BLS as necessary 8. RN will ensure that the transfer form is completed ... C. After Medical Emergency is Over ... 2. The nurse will insure the completion of the Medical Emergency Flow Sheet 3. RN will complete comprehensive progress note that will include: i. Assessment data and interventions leading up to emergency situation ii. Interventions sued during medical emergency iii. Time of event iv. Notification of resident physician or n call attending psychiatrist ... "

Review on April 18, 2018, of the facility policy, "Code Blue and Transfer to emergency room and Return of Individual to the Inpatient Unit", dated, "04/2018", revealed "Purpose: To ensure appropriate medical response to emergent medical issues which require evaluation in an acute medical care facility. Policy: Urgent/Emergent medical issues are identified and managed within the scope of practice of Friends Hospital and those medical conditions that require more intensive and intervention are transferred to the appropriate facility from an inpatient unit. Definitions: 1. Emergency: An emergency service is one that is provided after sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the individual's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. Procedure: 1. Upon identification of actual or potential urgent/emergent medical issues, the RN will provide appropriate care and the physician will be contacted immediately. A. The RN will conduct an assessment and provide first aid or emergency BLS while awaiting MD assessment. B. Emergency medical equipment will be brought to the scene and a Code Blue is called if the situation requires emergency care. 2. The RN will delegate to staff the need to call a code if the situation is emergent. 3. When the decision to transfer is made, the RN will obtain an order from the Physician to facilitate the transfer process: A. If the medical condition is not life threatening, transport vendor will be called. B. If the medical condition is determined to be life threatening, the staff will call "77", Code Blue, the operator will call 9-1-1. 4. The RN will delegate to the appropriate staff: A. Monitoring of the individual and preparation of the transfer ... 5. The physician will call the emergency room to inform the ER staff of the transfer ... "

Review on April 19, 2018, of the facility policy, "Clinical Assessment", dated, "01/2017", revealed "... Policy The medical record is a legal document, an accounting record, and the blueprint for treatment during hospitalization . The patient's chart is the sole document of the patient's critical problems and the criteria for inpatient level of care. Therefore, a problem-oriented record that clearly identifies the required treatment should be the emphasis for all disciplines' documentation ... M. Progress Notes Integrated progress notes are vital in conveying the course of treatment additional data obtained beyond the initial assessment and specific services and consultations rendered. Notes should be written at the time of service delivery ... They should be legible and reflect time, date and signature with credentials ..."

Review on April 19, 2018, of the facility policy, "Documentation: Nursing", dated, "04/2018", revealed "Purpose: To provide standards and guidelines for documentation in the patient record in order to maintain a clear and concise record of nursing care in the hospital. Policy: It is the policy of Friends Hospital to ensure Nursing Staff (RN, LPN, and MHT) are competent in chart documentation. The nursing staff will document the patient's behavior and response to the interventions used as designated in the Multidisciplinary Treatment Team, as well as all other relevant information ... Procedure ... D. A nursing progress note is to be done once per shift on each patient by the RN, LPN, or MHT. Each note must describe the patient s behavior, the intervention(s) used, and the patient's response to the intervention(s) ..."

Review on April 20, 2018, of the facility policy, "Vital Signs", dated, "04/2017", revealed "Purpose: To ensure accurate physical monitoring of vital statistics of health status. Policy: Vital statistics (temperature, pulse, respirations, blood pressure, and weight) are patient indicators which assist in the maintenance of physical homeostasis. Vital signs are initiated with patient presentations for admission and are regularly reassessed throughout the hospital stay according to established procedures. Procedure ... 5. Routine vitals on the inpatient units are performed twice daily for the first three days of inpatient stay, and then once daily until discharged ... 8. Additional monitoring may be ordered at physician or nurses discretion based on physical acuity of the patient ... 11. Vital signs on the inpatient unit recorded on the Vital Signs Flow sheet by shift. 12. The MHT reports any abnormal vital sign readings to the nurse, who informs the physician of any atypical values immediately. The nurse, as well if he/she is performing the vital signs, informs the physician of any abnormal value immediately. The nurse will have the patient's current medications and medical diagnosis's readily available to provide this information to the physicians. The nurse, while waiting for the physician's response, will increase the monitoring of the vital signs until the physician provides orders. See the chart which is on every unit as a reference. Vital Sign Reference Guide ... Blood Pressure ... Low 100/60 mmHg or lower ... 13. The nurse enters the vital signs into EMAR on the HSC system ... Obtaining Blood Pressure ... m. Notify the physician immediately for blood pressure systolic/diastolic reading as specified on Vital signs Reference Guide ... "

Review on April 18, 2018, of the facility document, "2018 Performance Improvement and Patient Safety Plan", dated, "2018", revealed "... Purpose ... Under this plan, our organization seeks to ... d. Provide a culture where care is delivered in a safe environment and quality of care is measured, monitored, and continuously improved ..."

Review on April 18, 2018, of the facility document, "Job Description/Evaluation, Position Title: Assistant Director of Nursing", dated, no date provided, revealed "... Job Summary: reports to the Director of Nursing and is accountable for nursing care in the inpatient areas ... Job Responsibilities ... 4.0 Engages in leadership responsibilities by providing information, support and education which promote professionalism. 4.1 Ensures that the nursing functions of the Inpatient, Admission and Evaluation Services are carried out ... 4.5 Assists Director of Nursing with ensuring total compliance with the standards of JCAHO, other accrediting bodies/agencies, Federal, State and City authorities in regard to the provision of patient care and other requirements affecting the Clinical areas supervised. 4.5.1 Ensures compliance with applicable Federal, State and local laws and regulations on the part of persons under supervision ... 4.8 Interprets clinical and managerial issues to interdepartmental and interagency colleagues and groups; serves as an advocate for staff, patients and quality patient care ... 5.5 Assists with aspects of Performance Improvement for the Clinical services Department ... 5.5.3 Investigates specific problems of clinical practice and uses the results to improve clinical performance and patient care ... 6.0 Participates in centralized Nursing Services department professional activities, including education, performance improvement, peer review, and committee work, in order to maintain professional standards. 6.1 Ensures establishment of programs designed to impart knowledge, achieve high ethical standards, create a patient care climate in keeping with the mission and philosophy of Friends Hospital ..."

Review on April 18, 2018, of the facility document, "Performance Evaluation Form, Position Title: Chief Nursing Officer", dated, "10/14", revealed "B. Position Specific Performance 1. Management and Supervision: Assure that Nurse managers and direct reports establish appropriate standards of safety, quality of care, and quality/performance improvement mechanisms to achieve smooth operations and optimal efficiency ... 3. Regulatory Requirements: Maintains all accreditations and clarifies licensing and accreditation standards (during accreditation survey years and announced surveys) for Nursing Services ... Assure compliance with all regulatory agencies and hospital polices ..."

Review on April 18, 2018, of the facility document, "Job Description, Performance & Competency Evaluation, Job Title: Nurse Manager", dated, "2/2013", revealed "Primary Function: Clinical Nurse Building manager maintains oversight of unit based Clinical service lines in identified building in order to ensure quality, integrity, and excellence of treatment delivered ..."

Review on April 18, 2018, of the facility document, "Job Description, Position Title: Registered Nurse", dated, "12/12", revealed "Position Summary: Provides direct patient care as prescribed by the physician and treatment team. Provide medical management and assessment of patients. Ensure environmental safety and crisis management for the patient population ... document patient care, ensure that date is accurate ... B. Position Specific Performance Criteria/Essential Job Functions 1. Nursing Assessment ... Assesses and documents findings when patient condition changes and communicates changes in patient status to the physician and treatment team. 2. Nursing Documentation. Documents patient progress clearly, accurately, legibly, and concisely per hospital policy ... Ensures that occurrences are thoroughly documented ... 4. Medication Administration/Medical Management. Administers medications according to department procedure, including obtaining vital signs and lab work, within assessment guidelines and parameters ... 6. Crisis Intervention. Provides appropriate intervention in psychiatric and medical crisis situations. Directs crisis response by using sound judgement and timely intervention. Completes necessary documentation and obtains orders within prescribed timelines. Ensures that patient & staff safety is maintained throughout any special treatment procedures ..."

Review on April 18, 2018, of the facility document, "Job Description, Position Title: Mental Health Technician", dated, "12/17", revealed "Position Summary: assists in the direct care & management of patients across all age ranges with medical & behavioral issues as directed by the treatment team ... B. Position Specific Performance Criteria/Essential Job Functions 1. Patient Supervision. Provides age and developmentally appropriate, hands-on supervision, crisis intervention, therapeutic interactions and behavior management as directed in the treatment plan and program guidelines ... 2. Documentation. Accurately, legibly, and thoroughly documents patient behaviors, activities, and progress on a daily basis. Records complete and accurate behavioral data in the prescribed format ... 5. Crisis Intervention. Provides appropriate intervention in psychiatric and medical crisis situations by anticipating and responding quickly to escalating behaviors, utilizing de-escalation techniques to diffuse the situation, correctly prioritizing safety concerns ..."

Review on April 18, 2018, of the facility document, "Code Gray Log" , dated, "3/31/18", revealed a Code Grey was called on "BN2", on "3/31/18", at "1539" and a second Code Gray was called at "1541".

Review on April 16, 2018, of MR1, revealed the patient was admitted as an inpatient to the BN2 Unit, on March 24, 2018. Further review of MR1 revealed a Nursing Progress Note, dated "3/31/18", at "2030". Further review of the progress noted revealed "[patient name] was in a altercation [letter c, line over it, meaning the word with] a peer. Patient was punched by peers. Patient had abrasions on his face and swelling of the right eye. [patient name] was kicked by peers. VS are 92/53, 138, resp 24, pulse ox 97. Patient was evaluated by the ROC (resident on call) and sent to the hospital." Further review of the progress note reveals no documented evidence of the specific time when the altercation(s) took place, how many individuals were involved as well as where the events took place, and no documented evidence of the patient's specific injuries and/or specific first aid/medical care provided to the patient post-altercation. Further review of the progress note revealed no documented evidence that the patient was isolated from the individuals who were involved in the altercation(s) and that the patient was kept safe, secure, and protected from future assaults/physical abuse. Further review of the progress noted revealed no documented evidence that a Code Grey and/or Code Blue was initiated by the RN. Further review of MR1 revealed an Integrated Progress Note, dated "3/31/18", at "1748", by the "NSG Supervisor". Further review of the supervisor note revealed "Arrived to unit at approximately 1543 after code grey called by unit due to physical assault on pt [patient full name] where two peers physically attacked him. He was kicked + punched in face + body multiple times by both peers per patient report. Staff intervened after 1st altercation, where patient ran down hall. Per staff, both aggressors seemed to be calm, but quickly pushed past staff in attempt to continue assault. Pt. states he was kicked + hit multiple times again in hallway until staff was able to intervene. On arrival, Pt was in room [letter c, line over it, meaning the word with] ROC, nurse + 2 MHT's. I arrived to pt's room where he was being assessed by ROC + unit nurse. Neuro checks were being done, vital signs completed 92/53, p 138, R 20, Pulse ox - 97% on RA. Pt was immediately given ice + pressure applied to stop bleeding. Neuro checks were within normal limits. Pt was awake, alert + oriented x 3. 911 had already been activated per ROC. Nursing Supervisor + resident at bedside [letter c, line over it = to with] pt until 911 arrived." Further review of MR1 revealed an Integrated Progress Note, dated 3/31/18, at 15:40 pm, by the Resident on Call (ROC). Further review of the physician note revealed "ROC on call was notified that patient was assaulted by two patients on the unit in the lounge area. Pt was taken down to the floor and the other two patients punched his face with hands and feet. Pt received injury over his right eye and substantial nose bleed. Upon arrival at 3:50 pm on the unit the pt is in distress seated on his bed with ice pack to his face. Pt had swelling over the right eye, mild swelling on the right side of the nose and laceration of the lower lip. Pt complained of mild headache pain 6/10 on the eye and nose, denies blurry vision, nausea, vomiting diarrhea, [illegible word] or abdominal pain. Per nursing staff there was substantial bleeding from his nose after the incident. [illegible word] Pt is mild distress seated on bed holding ice to the eye." Further review of the Resident on Call note revealed no documented evidence that the patient was isolated from the individuals who were involved in the altercation(s) and that the patient was kept safe, secure, and protected from future assaults/physical abuse. Further review of MR1 revealed a Inpatient Transfer Form, dated 3/31/18, at 1605. Further review of the transfer form revealed "Reason for transfer: Very shaky. [patient name] was punched, hit by 2 peers. Had cut over face. Nose bleeding. Right eye very swollen = bloodshot. Very shaky. Kicked many times. " Further review of the transfer form revealed no documented evidence of the specific time of the transfer or how the patient was transported (i.e. EMS personnel or facility-based transport).

Interview with EMP4 and EMP5, on April 18, 2018, between approximately 7:46 A.M. and 8:19 A.M., confirmed that the facility currently has a video recording of the assault on the patient listed within MR1 and that they both "did" review the video. Further interview with EMP4 and EMP5 confirmed that assault occurred on the Bonsall North Two (BN2) Unit, on March 31, 2018, between approximately "3:30 to 3:45" , which was at the "change of shift" report by Nursing personnel. Further interview with EMP4 and EMP5 confirmed that at change of shift the nurses give report at the "nurse's station", which is "not near the lounge". Further interview with EMP4 and EMP5 confirmed that during shift report the Mental Health Technicians are "monitoring the hallways" and exchanging report. Further interview with EMP4 and EMP5 confirmed that the patient in MR1 was assaulted "twice" on March 31, 2018. Further interview with EMP4 and EMP5 confirmed that the first assault on the patient occurred in the "lounge". Further interview with EMP4 and EMP5 confirmed that the patient was "sitting on the floor in the lounge playing cards" and that "three patients" entered the lounge, "closed the lounge door", and "two" of the three patients began "kicking and punching" the patient in MR1, "repeatedly", to the "head" and "body area". Further interview with EMP4 and EMP5 confirmed that the facility staff intervened within approximately "15-20 seconds" and that the patient in MR1 "ran out" of the lounge area. Further interview with EMP4 and EMP5 confirmed that there "is not" documented evidence that the patient in MR1 was provided first-aid after the first assault and/or that the patient in MR1 was placed in a safe/secure environment/area for their protection from further assaultive behavior from the other patients involved in the assault. Further interview with EMP4 and EMP5 confirmed that a "second" assault on the patient within MR1, occurred on the BN2 hallway, within "a minute" from the first assault event in the lounge. Further interview with EMP4 and EMP5 confirmed that the patient in MR1 was "walking away from the lounge", in a common hallway, when the two patient's who completed the first assault, assaulted the patient again at the very end of the hallway. Further interview with EMP4 and EMP5 confirmed that the patient in MR1 was "kicked and punched", "repeatedly", to the "head" and "body area". Further interview with EMP4 and EMP5 confirmed that the facility staff intervened "immediately". Further interview with EMP4 and EMP5 confirmed that there "is not" documented evidence that the patient in MR1 was provided first-aid after the second assault and/or that the patient in MR1 was placed in a safe/secure environment/area for their protection from further assaultive behavior from the other patients involved in the assault. Further interview with EMP4 and EMP5 confirmed that the nurses note, documented on March 31, 2018, at 2030, "was not complete" and "was not reflective" of what transpired during either of the assault events. Further interview with EMP4 and EMP5 confirmed that a Police Report "was not" initiated by the facility as the "parents" of the patient in MR1 "had already" initiated a report once the patient was in the "ER" of the receiving hospital, post-transfer.

Interview with EMP20, on April 19, 2018, between 1:52 P.M. and 2:00 P.M., confirmed that the Nursing Supervisor note, documented on "3/31/18", at "1748", was "not accurate". Further interview with EMP20 confirmed that the Nursing Supervisor "did not" arrive to the unit and find the patient within MR1 in their room, post-assault. Further interview with EMP20 confirmed that the Nursing Supervisor arrived to the unit, post-Code Grey announcement, and immediately began assisting the unit staff by cleaning "up all the blood at the end of the hallway before Housekeeping arrived". Further interview with EMP20 confirmed that they "did not" know if the patient was provided immediate first-aid or other Nursing interventions, post-assault number one and/or number two. Further interview with EMP20 confirmed that they "did not" know if the patient was placed in a safe/secure environment/area for their protection from further assaultive behavior from the other patients involved in the assault, post-assault number one and/or number two.

Review on April 19, 2018, of MR2, revealed the patient was admitted to the facility on on [DATE]. Further review of MR2 revealed a Nursing Progress Note, dated "02/11/18" at "1400". Further review of the progress note revealed "Patient asleep in common area. During medication administration, [patient] stated 'I don't remember how' when asked to take pills in a medicine cup. Patient also required reminders to swallow. Patient unable to answer questions because she is heavily sedated. Patient was able to shower with help of MHT. Patient was asleep and barely [sic] rousable in the dayroom." Further review of MR2 revealed no documented evidence that a Code Blue was initiated when the patient was "heavily sedated", no documented evidence that the patient was provided basic nursing interventions while they were "heavily sedated", and/or no documented evidence that a physician was notified of the patients "heavily sedated" condition. Further review of MR2 revealed an Inpatient Transfer Form, dated, no date and/or time recorded by the RN. Further review of the transfer form revealed "reason for transfer: Rule out CVA. Pt is 34 yo female with AMS since 1 wk, Hx of fall & head contusion 4 days ago, since 2 days ago c/o weakness on left side of body, confusion, (increased, reflective by up arrow) drooling, [sic] confusion. AAO x 2. Vitals abnormal BP (elevated, reflective by up arrow) 158/98 mmHg. Further review of the transfer form revealed "Relative/Guardian Notified By" section was left blank with no entry documented. Further review of the transfer from revealed "Current Vital Signs" section with the "Resp", "Blood Sugar" and "Accu [sic] Chek" sections all left blank with no entries documented. Further review of the transfer form revealed the "Unit", "Telephone number", "RN Signature", "Print Name", and "Date and Time" sections were all left blank with no entries documented.

Interview with EMP5 and EMP19, on April 19, 2018, between 10:38 A.M. and 10:46 A.M., confirmed that MR2 "did not" contain documented evidence that a Code Blue was initiated when they were "heavily sedated", no documented evidence that the patient was provided basic nursing interventions while they were "heavily sedated", and/or no documented evidence that a physician was notified of the patients "heavily sedated" condition.

Review on April 19, 2019, of MR13, revealed the patient was admitted to the facility on on [DATE]. Further review of MR13 revealed a Nursing Progress Note writte
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policies and procedures, review of facility documents, review of medical records (MR), and interview with staff (EMP), it was determined that the facilities Nursing Services failed to accurately record required, medication administration documentation for ten of twenty-one medical records reviewed (MR2, MR3, MR4, MR7, MR8, MR9, MR17, MR18, MR19, and MR21 ).

Findings include:

Review on April 18, 2018, of the facility policy, "Medication Administration", dated, "07/2017", revealed "Purpose: To insure that medications will be safely and efficiently administered to the correct patient in the prescribed manner at the designated time ... Procedure ...b. When administering the medication(s) the nurse must ... 7. Documentation of PRN medications including the rationale/reason for administering and patient's response are documented in the patient's medical record via the EMAR ... 8. Document refusals or nurse holds on medication due to lab results, side effects, etc. in the EMAR and notify physician ..."

Review on April 18, 2018, of the facility document, "Job Description, Position Title: Registered Nurse", dated, "12/12", revealed "Position Summary: Provides direct patient care as prescribed by the physician and treatment team. Provide medical management and assessment of patients ... B. Position Specific Performance Criteria/Essential Job Functions 1. Nursing Assessment ... Assesses and documents findings when patient condition changes and communicates changes in patient status to the physician and treatment team. 2. Nursing Documentation. Documents patient progress clearly, accurately, legibly, and concisely per hospital policy ... Ensures that occurrences are thoroughly documented ... 4. Medication Administration/Medical Management. Administers medications according to department procedure, including obtaining vital signs and lab work, within assessment guidelines and parameters ..."

Review on April 20, 2018, of MR2, revealed the patient was admitted to the facility on on [DATE]. Further review of MR2 revealed the patient was ordered "risperidone (psychiatric medication), 1.0 mg, by mouth, every twelve hours." Further review of MR2 revealed the patient "refused" the dose due on February 13, 2018, at 9:00 P.M. Further review of MR2 revealed no documented evidence that the physician was notified of the patient's refusal to take the medication.

Review on April 20, 2018, of MR3, revealed the patient was admitted to the facility on on [DATE]. Further review of MR3 revealed the patient was ordered "phenobarbital (withdrawal medication), 32.4 milligrams, by mouth, every six hours, times four doses." Further review of MR3 revealed the patient "refused" the medication on February 11, 2018, at 0:00 A.M. Further review of MR3 revealed no documented evidence that the physician was notified of the patient's refusal to take the medication.

Review on April 19, 2018, of MR4, revealed the patient was admitted to the facility on on [DATE]. Further review of MR4 revealed the patient was ordered "carbidopa-levodopa 25 (Parkinson's medication), 1 tablet, by mouth, every twelve hours." Further review of MR4 revealed the patient "refused" the medication on February 28, 2018, at 9:00 P.M. and on March 1, 2018, at 9:00 P.M. Further review of MR4 revealed no documented evidence that the physician was notified of the patient's refusals to take either of the medications.

Review on April 20, 2018, of MR7, revealed the patient was admitted to the facility on on [DATE]. Further review of MR7 revealed the patient was ordered "risperidone (psychiatric medication), 0.25 mg, by mouth, twice a day at 0900 and at bedtime." Further review of MR7 revealed the patient "refused" the dose due on November 3, 2017, at 9:00 A.M. and refused the 9:00 P.M. dose as well. Further review of MR7 revealed no documented evidence that the physician was notified of the patient's refusals to take either dose of medication.

Review on April 20, 2018, of MR8, revealed the patient was admitted to the facility on on [DATE]. Further review of MR8 revealed the patient was ordered "divalproex sodium (psychiatric medication), 500 milligrams, by mouth, twice a day and at bedtime." Further review of MR8 revealed the patient "refused" the dose on March 13, 2018, at 9:00 P.M. Further review of MR8 revealed the patient was also documented as "sleeping, unable to wake up" at 9:00 P.M. as well. Further review of MR8 revealed no documented evidence that the physician was notified of the patient's refusal to take the medication or that the patient was "unable to wake up."

Review on April 19, 2018, of MR9, revealed the patient was admitted to the facility on on [DATE]. Further review of MR9 revealed the patient was ordered "gabapentin (nerve pain medication), 100 milligrams, by mouth, three times daily." Further review of MR9 revealed the patient "refused" the dose on February 6, 2018, at 9:00 A.M. and 1:00 P.M. Further review of MR9 reviewed no documented evidence that the physician was notified of the patient's refusals of either dose of medication. Further review of MR9 revealed the patient was ordered "imipramine (psychiatric medication), 150 milligrams, by mouth, at bedtime." Further review of MR9 revealed the patient "refused" the dose on February 7, 2018, at 9:00 P.M. Further review of MR9 revealed no documented evidence that the physician was notified of the patient's refusal to take the medication.

Review on April 20, 2018, of MR17, revealed the patient was admitted to the facility on on [DATE]. Further review of MR17 revealed the patient was ordered "PRN (as needed) hydroxyzine pamoate (Vistaril, anxiety medication), 50 milligrams, by mouth, every six hours." Further review of MR17 revealed the patient was administered a PRN dose of medication on March 12, 2018, at 12:32 P.M. Further review of MR17 revealed no documented evidence that the effectiveness of the medication was recorded, post-administration.

Review on April 20, 2018, of MR18, revealed the patient was admitted to the facility on on [DATE]. Further review of MR18 revealed the patient was ordered "ziprasidone (Geodon, antipsychotic mediation), 20 milligrams, twice a day, by mouth, at 0900 and at bedtime." Further review of MR18 revealed the patient "refused" the dose due on March 7, 2018, at 9:00 A.M. Further review of MR18 revealed no documented evidence that the physician was notified of the patient's refusal to take the medication.

Review on April 20, 2018, of MR19, revealed the patient was admitted to the facility on on [DATE]. Further review of MR19 revealed the patient was ordered "Atenolol (cardiac medication) 12.5 milligrams, by mouth, daily." Further review of MR19 revealed the patient "refused" the dose due on November 5, 2017, at 9:00 A.M. Further review of MR19 revealed no documented evidence that the physician was notified of the patient's refusal to take the medication.

Review on April 20, 2018, of MR21, revealed the patient was admitted to the facility on on [DATE]. Further review of MR21 revealed the patient was ordered "hydrochlorothiazide (cardiac medication) 12.5 milligrams, by mouth, daily." Further review of MR21 revealed the patient "refused" the dose due on January 22, 2018, at 9:00 A.M. Further review of MR21 revealed no documented evidence that the physician was notified of the patient's refusal to take the medication. Further review of MR21 revealed the patient was ordered "Olanzapine (Zyprexa, psychiatric medication), 10 milligrams, by mouth, twice a day at 0900 and at bedtime." Further review of MR21 revealed the patient "refused" the dose on January 26, 2018, at 9:00 A.M. Further review of MR21 revealed no documented evidence that the physician was notified of the patient's refusal to take the medication. Further review of MR21 revealed the patient was ordered "PRN (as needed) hydroxyzine pamoate (Vistaril, anxiety medication), 100 mg, by mouth, every six hours." Further review of MR21 revealed the patient was administered a dose of the PRN medication on January 31, 2018, at 4:18 P.M. Further review of MR21 revealed no documented evidence that the effectiveness of the medication was recorded, post-administration.

Interview with EMP5 and EMP6, on April 20, 2018, between approximately 07:33 A.M. and 8:54 A.M., confirmed that MR2, MR3, MR4, MR7, MR8, MR9, MR18, MR19, and MR21 "did not" contain documented evidence that the RN notified the physician of the patient medication refusals. Further interview with EMP5 and EMP6 confirmed that MR17 and MR21 "did not" contain documented evidence that the effectiveness of a PRN medication was documented post-administration.

Repeat deficiency:
M02G11, dated August 9, 2017
VIOLATION: GOVERNING BODY Tag No: A0043
Based on review of facility policies and procedures, review of facility documents, observation, review of medical records (MR), and interview with staff (EMP), it was determined that the facilities Governing Body failed to maintain a safe, therapeutic clinical environment that protects the rights of each patient; by failing to ensure that informed consent was obtained prior to video recording of direct-patient care (A-0131); by failing to promptly notify a physician of the patients' choice, of his or her admission, to the facility (A-0133); by failing to protect patient's personal privacy (A-0143); by failing to ensure patient care was provided in a safe setting (A-0144); by failing to ensure that chemical restraints were not utilized (A-160); by failing to ensure that least restrictive restraints were utilized (A-0165); by failing to ensure that the patient's written plan of care was updated, post-application of a physical hold/restraint (A-0166); by failing to ensure that Nursing Administration maintained a safe, clinically sound environment for direct patient care on all inpatient Nursing units (A-0386); by failing to ensure that Registered Nurses effectively supervised direct patient care on all inpatient Nursing units (A-0395); by failing to ensure verbal orders were implemented and documented correctly (A-0408); and by failing to ensure that medications were administered and documented correctly (A-405).

Findings include:

Review on April 18, 2018, of the facility policy, "Bill of Rights", dated, "11/2016", revealed "You have a right to be treated with dignity and respect ..."

Review on April 18, 2018, of the facility policy, "Plan for Provision of Patient Care and Service", dated, "11/2016", revealed "... Philosophy and Values In keeping with its Quaker heritage, Friends Hospital's services are based on respect for the dignity and worth of every individual. Protection of individual rights and freedom from unnecessary restriction are guiding principles in patient care. Care planned and provided through a patient-focused customer satisfaction model that emphasizes individualized services appropriate to the needs and expectations of each patient ... patient service includes recognition of health and strength, as well as, illness, and encompasses patient education and advocacy along with care and treatment ... Standards of Patient Care Friends Hospital patients can expect: To be treated with compassion, respect, and dignity at all times. To be cared for in an environment that provides for comfort, safety, and preservation of confidentiality. To receive appropriate, individualized assessment and treatment, delivered in accordance with currently recognized professional standards ... In order to maintain these standards, the Hospital is committed to: Establishment of appropriate policies, procedures, and protocols to guide aspects of patient care and treatment. Development of systems for service delivery which provide for interdisciplinary collaboration and coordination, to ensure continuity and seamless delivery of care to the greatest extent possible ..."

Review on April 18, 2018, of the facility document, "2018 Performance Improvement and Patient Safety Plan", dated, "2018", revealed "... Purpose ... Under this plan, our organization seeks to ... d. Provide a culture where care is delivered in a safe environment and quality of care is measured, monitored, and continuously improved ..."

Review on April 18, 2018, of the facility document, "Amended and Restated Bylaws of the Board of Governors", dated, "October 17, 2017", revealed "... Article IV. Purpose of the Hospital The Board shall be accountable for the safety and quality of care, treatment and services of the Hospital ... Article V. Duties and Responsibilities The principle duties and responsibilities of the Board shall be to ... 4. Promote continuous quality improvement through monitoring of professional services provided by the Medical Staff, allied health professional and other health care providers who provide services at the Hospital ... 7. Advise on reasonable steps needed to ensure that the Hospital conforms with all applicable Federal, State, and local laws and regulations and all applicable accreditation standards ...Article XI. Quality of Professional Services 1. Board of Governors' Responsibilities. a. The board shall review and evaluate activities of the Medical Staff and other professional staffs in the Hospital on a continuing basis to assess, preserve, and continuously improve the quality and efficiency of patient care in the Hospital ..."

Review on April 18, 2018, of the facility document, "Job Description: CEO", dated, no date provided, revealed "... Position Summary: Manages the day-to-day operations ... Essential Job Duties ... 4. Develops and provides quality programs and services to the community ..."

Cross Reference:
482.13 Patient Rights
482.13(b)(2) Patient Rights: Informed Consent
482.13(b)(4) Patient Rights: Admission Status Notification
482.13(c)(1) Patient Rights: Personal Privacy
482.13(e)(2) Patient Rights: Care in a Safe Setting
482.13(e)(1)(i)(B) Patient Rights: Chemical Restraints
482.13(e)(3) Patient Rights: Less Restrictive Alternative
482.13(e)(4)(i) Patient Rights: Restraint Plan of Care
482.23 Nursing Services
482.23(a) Nursing Services: Organization of Nursing Services
482.23(b)(3) Nursing Services: RN Supervision of Nursing Care
482.23(c)(3)(ii) Nursing Services: Accepting Verbal Orders for Drugs
482.23(c)(1) Nursing Services: Administration of Drugs

Repeat Deficiencies:
482.13(b)(4) Patient Rights, M02G11, dated August 9, 2017
482.23(c)(1) Nursing Services, M02G11, dated August 9, 2017
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of facility policies and procedures, review of facility documents, observation, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to protect and promote the rights of each patient; by failing to ensure that informed consent was obtained prior to the video recording of direct-patient care (A-0131); by failing to promptly notify a physician of the patients' choice, of his or her admission, to the facility (A-0133); by failing to provide patient's with personal privacy (A-0143); by failing to ensure patient care was provided in a safe setting (A-0144): by failing to ensure that chemical restraints were not utilized (A-160): by failing to ensure that least restrictive physical hold/restraint was utilized (A-0165); and by failing to ensure that the patient's written plan of care was updated, post-application of a physical hold/restraint (A-0166).

Cross Reference:
482.13(b)(2) Patient Rights: Informed Consent
482.13(b)(4) Patient Rights: Admission Status Notification
482.13(c)(1) Patient Rights: Personal Privacy
482.13(e)(2) Patient Rights: Care in a Safe Setting
482.13(e)(1)(i)(B) Patient Rights: Chemical Restraints
482.13(e)(3) Patient Rights: Less Restrictive Alternative
482.13(e)(4)(i) Patient Rights: Restraint Plan of Care
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on review of facility policies and procedures, review of facility documents, observation, review of medical records (MR), and interview with staff (EMP), it was determined that the facility failed to ensure that informed consent was obtained, prior to the video recording of direct-patient care activities, for one of one complaint medical record reviewed (MR1).

Findings include:

Review on April 18, 2018, of the facility policy, "Facility Surveillance Video Camera Recording", dated "12/2017", revealed "... Purpose: To provide direction for retention of video surveillance recordings in the facility, as well as for the destruction of same. Procedure: A. Storage time for video surveillance footage should not exceed 30 days. B. DVR's should be maintained in a secure location ... C. Ability to copy/burn camera surveillance recorded images is limited ... F. Video footage from surveillance cameras at a facility should be maintained and copied to a DVD, flash drive or other appropriate storage device under the following circumstances ... I. No taped video footage of an alleged incident/event is to be maintained at the facility for any purpose ..."

Review on April 18, 2018, of the facility policy, "Confidentiality, Access and Release of Patient Information", dated, "03/2018", revealed "Purpose: To provide a structure for management of patient health information that protects the privacy of that information ... Policy 1. General Information The health information record will be maintained by Friends Hospital in accordance with legal and regulatory requirements to uphold the confidentiality of patient-released information and to protect patient's right to privacy in the collection and disclosure of that information ..."

Review on April 18, 2018, of the facility document, "Conditions of Admission", dated, "10/5/14", revealed "... 2. Consent for Admission ... I consent to FH's (Friends Hospital) use of surveillance equipment for monitoring of patient's safety in public areas ..."

Review on April 20, 2018, of the facility documents, "Patient Safety Council Report Meeting Minutes", dated, "July 20, 2017", "August 17, 2017", and "September 21, 2017", revealed documented evidence that "camera recordings" were reviewed in both "concurrent" as well as "historical" reviews.

Review on April 18, 2018, of the facility document, "Job Description, Performance & Competency Evaluation, Job Title: Nurse Manager", dated, "2/2013", revealed "Primary Function: Clinical Nurse Building manager maintains oversight of unit based Clinical service lines in identified building in order to ensure quality, integrity, and excellence of treatment delivered ... A. Job Specific Competencies ... Video surveillance ..."

Observational tour of the Bonsall North Two (BN2) Inpatient Unit, conducted on April 16, 2018, between approximately 10:10 A.M. and 11:30 A.M., with EMP2 and EMP3, revealed multiple, ceiling mounted, camera surveillance units, dispersed throughout patient care areas including the common hallways, main patient lounge, and the axillary patient lounge. Further observation of the BN2 Unit revealed no evidence of any viewing monitors for the staff to review the camera feeds and monitor patient safety.

Interview with EMP3, on April 16, 2018, at 10:24 A.M., confirmed that "all" patient care units throughout the facility, and "all patients and staff" on those units, are under constant camera surveillance. Further interview with EMP3 confirmed that "no units" contain any viewing monitors for the staff to review the camera feeds and monitor patient safety.

Review on April 16, 2018, of MR1, revealed the patient was admitted as an inpatient to the BN2 Unit, on March 24, 2018. Further review of MR1 revealed a Consent for Admission form, signed by the patient, and dated "3/24/18". Further review of MR1 revealed no documented evidence, of any other consent forms, granting the facility the permission to video record the daily activities of the patient during their respective hospitalization .

Interview with EMP1, on April 19, 2018, at 8:47 A.M. confirmed the facility "does" utilize camera surveillance equipment throughout the facility, including on all patient care units, to monitor "patient safety". Further interview with EMP1 confirmed that the camera feeds "are not" monitored by the Nursing Staff on the patient care units and "are not" centrally monitored by any type of Security Staff. Further interview with EMP1 confirmed that the patient care units "do contain" unmonitored areas due to the lack of camera surveillance coverage. Further interview with EMP1 confirmed that "all" of the the surveillance camera's "are" recorded, including "all" surveillance views on the patient care units, and that recorded images "are reviewed" without the explicit consent of the patient and/or their respective family member(s). Further interview with EMP1 confirmed that the Consent for Admission "does not" contain verbiage allowing for the recording of camera surveillance equipment images and/or the recording of actual patient care activities. Further interview with EMP1 confirmed that the patient in MR1 "did" sign a Consent for Admission. Further interview with EMP1 confirmed that the activities of the patient in MR1, including the assault on that patient on March 31, 2018, were recorded and utilized by the administrative staff for viewing purposes of an unusual incident within the facility.

Interview with EMP1, on April 19, 2018, at 12:35 P.M., confirmed that patients who refuse to sign and/or patients who are unable to sign the Consent for Admission, "are not" excluded from the camera surveillance system and that their respective activities "are still" recorded throughout their hospital stay without their explicit consent and/or knowledge.

Interview with EMP9, on April 20, 2018, at 9:47 A.M. confirmed the facility "does" utilize camera surveillance equipment throughout the facility, including on all patient care units, to monitor "patient safety". Further interview with EMP9 confirmed that the camera feeds "are not" monitored by the Nursing Staff on the patient care units and "are not" centrally monitored by any type of Security Staff. Further interview with EMP9 confirmed that the surveillance camera's "are" recorded, including all surveillance views on the patient care units, and that recorded images "are reviewed" without the explicit consent of the patient and/or their respective family member(s). Further interview with EMP9 confirmed that select, facility administration members utilize the recorded camera images for review of specific patient safety events as well as to review the activity of the facility staff. Further interview with EMP9 confirmed that recorded events "are" discussed within the facilities Patient Safety Committee. Further interview with EMP9 confirmed that the facility Consent for Admission "does not" contain verbiage allowing for the recording of camera surveillance equipment. Further interview with EMP9 confirmed that patients who refuse to sign and/or patients who are unable to sign the Consent for Admission, "are not" excluded from the camera surveillance system and that their respective activities "are still" recorded throughout their hospital stay without their explicit consent and/or knowledge. Further interview with EMP9 confirmed that the activities of the patient in MR1, including the assault on that patient on March 31, 2018, were recorded and utilized by the administrative staff for viewing purposes of an unusual incident within the facility.
VIOLATION: PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION Tag No: A0133
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of facility policies and procedures, review of medical records (MR), and interview with staff (EMP), it was determined that the facility failed to promptly notify a physician of the patients' choice, of his or her admission to the hospital, for twenty-one of twenty seven medical records reviewed (MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR19, MR20, and MR21).

Findings include:

Review on April 18, 2018, of the facility policy, "Coordination of Care: Medical/Primary Care Physicians", dated, "12/2016", revealed "Friends Hospital follows best practice standards of care by obtaining pertinent clinical patient information from providers/facilities in order to facilitate the coordination of high quality, and continued effective care for ongoing medical/psychiatric treatment ... Procedure 1. The assessment clinician in the Admissions [sic] Dept will identify, on admission, the medical or Primary care Physician, ongoing treatment provider(s) actively treating the patient in the community ... 7. Discharge planning requires the PCP and treatment provider(s) involvement to ensure that continuation of coordinated care and update of pertinent d/c recommendations is maintained ..."

Review on April 19, 2018, of MR1, revealed the patient was admitted to the facility on on [DATE]. Further review of MR1 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Review on April 19, 2018, of MR2, revealed the patient was admitted to the facility on on [DATE]. Further review of MR2 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Review on April 19, 2018, of MR3, revealed the patient was admitted to the facility on on [DATE]. Further review of MR3 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Review on April 19, 2018, of MR4, revealed the patient was admitted to the facility on on [DATE]. Further review of MR4 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Review on April 19, 2018, of MR5, revealed the patient was admitted to the facility on on [DATE]. Further review of MR5 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Review on April 19, 2018, of MR6, revealed the patient was admitted to the facility on on [DATE]. Further review of MR6 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Review on April 19, 2018, of MR7, revealed the patient was admitted to the facility on on November10, 2017. Further review of MR7 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Review on April 19, 2018, of MR8, revealed the patient was admitted to the facility on on [DATE]. Further review of MR8 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Review on April 19, 2018, of MR9, revealed the patient was admitted to the facility on on [DATE]. Further review of MR9 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Review on April 19, 2018, of MR10, revealed the patient was admitted to the facility on on [DATE]. Further review of MR10 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Review on April 19, 2018, of MR11, revealed the patient was admitted to the facility on on [DATE]. Further review of MR11 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Review on April 19, 2018, of MR12, revealed the patient was admitted to the facility on on [DATE]. Further review of MR12 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Review on April 19, 2018, of MR13, revealed the patient was admitted to the facility on on [DATE]. Further review of MR13 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Review on April 19, 2018, of MR14, revealed the patient was admitted to the facility on on [DATE]. Further review of MR14 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Review on April 19, 2018, of MR15, revealed the patient was admitted to the facility on on [DATE]. Further review of MR15 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Review on April 19, 2018, of MR16, revealed the patient was admitted to the facility on on [DATE]. Further review of MR16 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Review on April 19, 2018, of MR17, revealed the patient was admitted to the facility on on [DATE]. Further review of MR17 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Review on April 19, 2018, of MR18, revealed the patient was admitted to the facility on on [DATE]. Further review of MR18 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Review on April 19, 2018, of MR19, revealed the patient was admitted to the facility on on [DATE]. Further review of MR19 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Review on April 19, 2018, of MR20, revealed the patient was admitted to the facility on on [DATE]. Further review of MR20 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Review on April 19, 2018, of MR21, revealed the patient was admitted to the facility on on [DATE]. Further review of MR21 revealed no documented evidence that the patients' physician of choice was promptly notified of the patients' admission to the facility.

Interview with EMP5 and EMP19, on April 19, 2018, between approximately 10:04 A.M. and 1:25 P.M., confirmed that MR1, MR2, MR3, MR4, MR5, MR6, MR7, MR8, MR9, MR10, MR11, MR12, MR13, MR14, MR15, MR16, MR17, MR18, MR19, MR 20, and MR21 "do not" contain documented evidence that the patient's primary care physician (PCP) were notified promptly of their respective admission to the facility.

Repeat Deficiency:
M02G11, dated August 9, 2017
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on review of facility policies and procedures, review of facility documents, observation, review of medical records (MR), and interview with staff (EMP), it was determined that the facility failed to ensure the patient's right to privacy, by using camera surveillance equipment to record clinical care activities, on inpatient Nursing units, for one of one complaint medical record reviewed (MR1).

Findings include:

Review on April 18, 2018, of the facility policy, "Facility Surveillance Video Camera Recording", dated "12/2017", revealed "... Purpose: To provide direction for retention of video surveillance recordings in the facility, as well as for the destruction of same. Procedure: A. Storage time for video surveillance footage should not exceed 30 days. B. DVR's should be maintained in a secure location ... C. Ability to copy/burn camera surveillance recorded images is limited ... F. Video footage from surveillance cameras at a facility should be maintained and copied to a DVD, flash drive or other appropriate storage device under the following circumstances ... I. No taped video footage of an alleged incident/event is to be maintained at the facility for any purpose ..."

Review on April 18, 2018, of the facility policy, "Confidentiality, Access and Release of Patient Information", dated, "03/2018", revealed "Purpose: To provide a structure for management of patient health information that protects the privacy of that information ... Policy 1. General Information The health information record will be maintained by Friends Hospital in accordance with legal and regulatory requirements to uphold the confidentiality of patient-released information and to protect patient's right to privacy in the collection and disclosure of that information ..."

Review on April 18, 2018, of the facility document, "Conditions of Admission", dated, "10/5/14", revealed "... 2. Consent for Admission ... I consent to FH's (Friends Hospital) use of surveillance equipment for monitoring of patient's safety in public area ..."

Review on April 20, 2018, of the facility documents, "Patient Safety Council Report Meeting Minutes", dated, "July 20, 2017", "August 17, 2017", and "September 21, 2017", revealed documented evidence that "camera recordings" were reviewed in both "concurrent" as well as "historical" reviews.

Review on April 18, 2018, of the facility document, "Job Description, Performance & Competency Evaluation, Job Title: Nurse Manager", dated, "2/2013", revealed "Primary Function: Clinical Nurse Building manager maintains oversight of unit based Clinical service lines in identified building in order to ensure quality, integrity, and excellence of treatment delivered ... A. Job Specific Competencies ... Video surveillance ..."

Observational tour of the Bonsall North Two (BN2) Inpatient Unit, conducted on April 16, 2018, between approximately 10:10 A.M. and 11:30 A.M. with EMP2 and EMP3, revealed multiple, ceiling mounted, camera surveillance units, dispersed throughout patient care areas including the common hallways, main patient lounge, and axillary patient lounge. Further observation of the BN2 Unit revealed no evidence of any viewing monitors for the staff to review the camera feeds and monitor patient safety.

Interview with EMP3, on April 16, 2018, at 10:24 A.M., confirmed that "all" patient care units throughout the facility, and "all patients and staff" on those units, are under constant camera surveillance. Further interview with EMP3 confirmed that "no units" contain any viewing monitors for the staff to review the camera feeds and monitor patient safety.

Review on April 16, 2018, of MR1, revealed the patient was admitted as an inpatient to the BN2 Unit, on March 24, 2018. Further review of MR1 revealed a Consent for Admission form, signed by the patient, and dated "3/24/18". Further review of MR1 revealed no documented evidence, of any other consent forms, granting the facility the permission to video record the daily activities of the patient during their respective hospitalization .

Interview with EMP1, on April 19, 2018, at 8:47 A.M. confirmed the facility "does" utilize camera surveillance equipment throughout the facility, including on all patient care units, to monitor "patient safety". Further interview with EMP1 confirmed that the camera feeds "are not" monitored by the Nursing Staff on the patient care units and "are not" centrally monitored by any type of Security Staff. Further interview with EMP1 confirmed that the patient care units "do contain" unmonitored areas due to the lack of camera surveillance coverage. Further interview with EMP1 confirmed that "all" of the the surveillance camera's "are" recorded, including "all" surveillance views on the patient care units, and that recorded images "are reviewed" without the explicit consent of the patient and/or their respective family member(s). Further interview with EMP1 confirmed that the Consent for Admission "does not" contain verbiage allowing for the recording of camera surveillance equipment. Further interview with EMP1 confirmed that the patient in MR1 "did" sign a Consent for Admission. Further interview with EMP1 confirmed that the activities of the patient in MR1, including the assault on that patient on March 31, 2018, were recorded and utilized by the administrative staff for viewing purposes of an incident within the facility.

Interview with EMP1, on April 19, 2018, at 12:35 P.M., confirmed that patients who refuse to sign and/or patients who are unable to sign the Consent for Admission, "are not" excluded from the camera surveillance system and that their respective activities "are still" recorded throughout their hospital stay without their explicit consent and/or knowledge. Further interview with EMP1 confirmed that the patient's right to privacy "is not" being protected due to the numerous camera recording systems, throughout the entire facility, capturing direct patient care activities.

Interview with EMP9, on April 20, 2018, at 9:47 A.M. confirmed the facility "does" utilize camera surveillance equipment throughout the facility, including on all patient care units, to monitor "patient safety". Further interview with EMP9 confirmed that the camera feeds "are not" monitored by the Nursing Staff on the patient care units and "are not" centrally monitored by any type of Security Staff. Further interview with EMP9 confirmed that the surveillance camera's "are" recorded, including all surveillance views on the patient care units, and that recorded images "are reviewed" without the explicit consent of the patient and/or their respective family member(s). Further interview with EMP9 confirmed that select, facility administration members utilize the recorded camera images for review of specific patient safety events as well as to review the activity of the facility staff. Further interview with EMP9 confirmed that recorded events "are" discussed within the facilities Patient Safety Committee. Further interview with EMP9 confirmed that the facility Consent for Admission "does not" contain verbiage allowing for the recording of camera surveillance equipment. Further interview with EMP9 confirmed that patients who refuse to sign and/or patients who are unable to sign the Consent for Admission, "are not" excluded from the camera surveillance system and that their respective activities "are still" recorded throughout their hospital stay without their explicit consent and/or knowledge. Further interview with EMP9 confirmed that the activities of the patient in MR1, including the assault on that patient on March 31, 2018, were recorded and utilized by the administrative staff for viewing purposes of an unusual incident within the facility.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policies and procedures, facility documents, observation, review of medical records (MR), and interview with staff (EMP), it was determined that the facility failed to provide a safe clinical setting for four of eleven transfer medical records reviewed (MR1, MR2, MR13, and MR16), and one of one open medical record reviewed (MR27).

Findings include:

Review on April 18, 2018, of the facility policy, "Bill of Rights", dated, "11/2016", revealed "You have a right to be treated with dignity and respect ..."

Review on April 18, 2018, of the facility policy, "Plan for Provision of Patient Care and Service", dated, "11/2016", revealed "... Philosophy and Values In keeping with its Quaker heritage, Friends Hospital's services are based on respect for the dignity and worth of every individual. Protection of individual rights and freedom from unnecessary restriction are guiding principles in patient care. Care planned and provided through a patient-focused customer satisfaction model that emphasizes individualized services appropriate to the needs and expectations of each patient ... patient service includes recognition of health and strength, as well as, illness, and encompasses patient education and advocacy along with care and treatment ... Standards of Patient Care Friends Hospital patients can expect: To be treated with compassion, respect, and dignity at all times. To be cared for in an environment that provides for comfort, safety, and preservation of confidentiality. To receive appropriate, individualized assessment and treatment, delivered in accordance with currently recognized professional standards ... In order to maintain these standards, the Hospital is committed to: Establishment of appropriate policies, procedures, and protocols to guide aspects of patient care and treatment. Development of systems for service delivery which provide for interdisciplinary collaboration and coordination, to ensure continuity and seamless delivery of care to the greatest extent possible ..."

Review on April 18, 2018, of the facility policy, "Adverse Events", dated, "12/2017", revealed "... Definitions An Adverse Event is any happening or omission including incidents, Sentinel events, Serious Events and Infrastructure Failures, which is not consistent with the routine operation of the facility or the routine care of a particular patient, and any event or situation that harmed or could have harmed a person. For example: Patient care Bodily injury ... Hazardous Conditions ... Assault ... Policy 1. All staff is responsible for reporting Adverse Events in accordance with this policy ... Procedures 1. Immediate handling of an Event: a. The person responsible for the area or, in his/her absence, the Administrator on duty (AOD) will assess the situation and, as appropriate: i. Provide care or summon help for any injured person. ii. Take any necessary steps to prevent further risk to people or the environment ..."

Review on April 18, 2018, of the facility policy, "Assault Precautions", dated, "05/2017" , revealed "Purpose ... At all times, the principles of Recovery and Trauma Informed Care will be followed as precautions are assessed. It is well demonstrated that creating a safe, trustworthy, choice oriented, collaborative and empowering process from admission to treatment, minimizes the reoccurrence's of trauma and assaultive behaviors ... Staff members trained and competent in HWC (restrain training course) and verbal de-escalation techniques will be able to: 3. Ensure the patient and staff injuries are prevented or kept to a minimum during assaultive crisis. 4. Ensure proper monitoring of the patient during the recovery phase of an assaultive crisis. 5. Ensure the assaultive/homicidal behavior and interventions properly documented in the patient's record and notification plans and duty to warn implemented ... Procedure ... 6. Potential interventions for a patient on assault/homicide precautions include, but are not limited to (see De-escalation of Patients in Crisis Policy) ... Monitor high risk times: group activities, courtyard breaks, meals, anytime the staff attention may be diverted ... Separation from identified at risk peers ..."

Review on April 18, 2018,, of the facility policy, "Level of Observation", dated, "02/2017", revealed "Policy It is the policy of Friends Hospital to uphold the right of our patients to receive care in a safe and therapeutic environment ... Staff members assigned to each patient will provide monitoring, precautions, oversight and interventions to provide for their safety and security ... Levels of Observation 1. Q 15 Minute Observations ... D. Perform rounds at staggered intervals and in a varying pattern or sequence throughout the unit to minimize planned acting out opportunities ... F. While monitoring hallways and patient care areas ensure patients are ... Not left in Treatment Areas without direct staff supervision ... "

Review on April 18, 2018, of the facility policy, "Code Grey Psychiatric Emergency", dated, "10/2017", revealed "Policy: Code Gray Emergencies are paged to call additional staff to the area of need in order to aid in de-escalation, assist with patients on the unit that are not involved in the crisis or to assist with restrictive interventions as needed. Handle with Care techniques are utilized to address psychiatric emergencies. Patients experiencing a psychiatric emergency will be immediately assessed, provided appropriate emergency treatment and if needed, referred to the most appropriate facility. Since Friends Hospital admits and treats patients evaluated to be in danger to self and others it must be anticipated that patient emergencies and crises may occur, and must be identified and responded to as early as possible. All staff members' are expected to be alert for situations that are emergencies or have potential to develop into emergencies and immediately take the actions necessary to manage the situation in accordance with the approved procedure's. Psychiatric Emergency management is the responsibility of all clinical disciplines. The response to an emergency/crisis must take the highest priority and must be active, rapid, and based n a team approach. Purpose: This policy is intended to provide a systematic, efficient, and uniform response to a psychiatric emergency in order to maintain a safe and therapeutic hospital environment. This is designed to ensure a safe environment for patients, visitors, and staff ... Definitions ... Psychiatric Emergency: Any situation where a patient's behavior may result in a life threatening or psychologically damaging consequence to an individual(s), if not promptly addressed. Examples of such behavior include ... assault or attempted assault, excessive agitation or loss of control, threat of violence or harm to individual(s) ... Procedures ... 5. The other employees not assigned a role should focus on ensuring the safety and security of the other patients by removing them from the area and providing redirection ... 7. Debriefings are done after each drill with Charge Nurse and/or designee. When areas for improvement are identified, these are corrected immediately with staff education ..."

Review on April 18, 2018, of the facility policy, "De-Escalation of Patient in Crisis", dated, "04/2018", revealed "Purpose: To provide a safe environment for patients at risk for losing control ... Policy ... Certain basic assumptions are necessary in effecting these policies. 1. All staff who accept employment at Friends Hospital also accept an obligation to intervene, prevent, and control assaultive and disruptive behavior ... Procedure: 1. Any staff member in the vicinity can institute a Psychiatric Emergency by dialing "77". 2. All staff assigned to respond to the emergency pager should proceed with speed, to the point of crisis ..."

Review on April 18, 2018, of the facility policy, "Code Blue Emergency Response Procedure", dated, "01/2017", revealed "Purpose: To ensure appropriate medical response and stabilization are provided to the individual in need. Policy: The Code Blue medical response team will assist staff members in assessing and stabilizing the patient's condition ... Life threatening medical emergencies will be appropriately managed and the individual will be transferred to an acute care medical hospital. The Friends Hospital Staff will assess and provide treatment within the scope of practice for Friends Hospital ... Definitions of Medical Emergency A medical emergency is defined as a life threatening condition for which the person requires immediate life support measures and transfer to an acute care hospital. Criteria: The Code Blue may be activated when any or all of the following exist but not limited to ... D. Significant blood loss ... H. Acute changes in Systolic Blood Pressure < 90 mmHg in association with dizziness, light headedness or syncope ... L. Acute Significant Bleeding ... M. Changes in Level of Consciousness N. Difficulty speaking with no previous history ... Procedure ... B. Medical Management ... 7. The nurse will ensure appropriate care is rendered: i. Obtain vital signs (pulse, respirations, BP) ii. Pulse Oximeter iii. Blood Glucose Measurement iv. Electrocardiogram (ECG for patient units) v. Oxygen by nasal cannula at 2L/min or non-re-breather mask at 15 L/min vi. BLS as necessary 8. RN will ensure that the transfer form is completed ... C. After Medical Emergency is Over ... 2. The nurse will insure the completion of the Medical Emergency Flow Sheet 3. RN will complete comprehensive progress note that will include: i. Assessment data and interventions leading up to emergency situation ii. Interventions sued during medical emergency iii. Time of event iv. Notification of resident physician or n call attending psychiatrist ... "

Review on April 18, 2018, of the facility policy, "Code Blue and Transfer to emergency room and Return of Individual to the Inpatient Unit", dated, "04/2018", revealed "Purpose: To ensure appropriate medical response to emergent medical issues which require evaluation in an acute medical care facility. Policy: Urgent/Emergent medical issues are identified and managed within the scope of practice of Friends Hospital and those medical conditions that require more intensive and intervention are transferred to the appropriate facility from an inpatient unit. Definitions: 1. Emergency: An emergency service is one that is provided after sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the individual's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. Procedure: 1. Upon identification of actual or potential urgent/emergent medical issues, the RN will provide appropriate care and the physician will be contacted immediately. A. The RN will conduct an assessment and provide first aid or emergency BLS while awaiting MD assessment. B. Emergency medical equipment will be brought to the scene and a Code Blue is called if the situation requires emergency care. 2. The RN will delegate to staff the need to call a code if the situation is emergent. 3. When the decision to transfer is made, the RN will obtain an order from the Physician to facilitate the transfer process: A. If the medical condition is not life threatening, transport vendor will be called. B. If the medical condition is determined to be life threatening, the staff will call "77", Code Blue, the operator will call 9-1-1. 4. The RN will delegate to the appropriate staff: A. Monitoring of the individual and preparation of the transfer ... 5. The physician will call the emergency room to inform the ER staff of the transfer ... "

Review on April 19, 2018, of the facility policy, "Clinical Assessment", dated, "01/2017", revealed "... Policy The medical record is a legal document, an accounting record, and the blueprint for treatment during hospitalization . The patient's chart is the sole document of the patient's critical problems and the criteria for inpatient level of care. Therefore, a problem-oriented record that clearly identifies the required treatment should be the emphasis for all disciplines' documentation ... M. Progress Notes Integrated progress notes are vital in conveying the course of treatment additional data obtained beyond the initial assessment and specific services and consultations rendered. Notes should be written at the time of service delivery ... They should be legible and reflect time, date and signature with credentials ..."

Review on April 19, 2018, of the facility policy, "Documentation: Nursing", dated, "04/2018", revealed "Purpose: To provide standards and guidelines for documentation in the patient record in order to maintain a clear and concise record of nursing care in the hospital. Policy: It is the policy of Friends Hospital to ensure Nursing Staff (RN, LPN, and MHT) are competent in chart documentation. The nursing staff will document the patient's behavior and response to the interventions used as designated in the Multidisciplinary Treatment Team, as well as all other relevant information ... Procedure ... D. A nursing progress note is to be done once per shift on each patient by the RN, LPN, or MHT. Each note must describe the patient s behavior, the intervention(s) used, and the patient's response to the intervention(s) ..."

Review on April 20, 2018, of the facility policy, "Vital Signs", dated, "04/2017", revealed "Purpose: To ensure accurate physical monitoring of vital statistics of health status. Policy: Vital statistics (temperature, pulse, respirations, blood pressure, and weight) are patient indicators which assist in the maintenance of physical homeostasis. Vital signs are initiated with patient presentations for admission and are regularly reassessed throughout the hospital stay according to established procedures. Procedure ... 5. Routine vitals on the inpatient units are performed twice daily for the first three days of inpatient stay, and then once daily until discharged ... 8. Additional monitoring may be ordered at physician or nurses discretion based on physical acuity of the patient ... 11. Vital signs on the inpatient unit recorded on the Vital Signs Flow sheet by shift. 12. The MHT reports any abnormal vital sign readings to the nurse, who informs the physician of any atypical values immediately. The nurse, as well if he/she is performing the vital signs, informs the physician of any abnormal value immediately. The nurse will have the patient's current medications and medical diagnosis's readily available to provide this information to the physicians. The nurse, while waiting for the physician's response, will increase the monitoring of the vital signs until the physician provides orders. See the chart which is on every unit as a reference. Vital Sign Reference Guide ... Blood Pressure ... Low 100/60 mmHg or lower ... 13. The nurse enters the vital signs into EMAR on the HSC system ... Obtaining Blood Pressure ... m. Notify the physician immediately for blood pressure systolic/diastolic reading as specified on Vital signs Reference Guide ... "

Review on April 18, 2018, of the facility document, "2018 Performance Improvement and Patient Safety Plan", dated, "2018", revealed "... Purpose ... Under this plan, our organization seeks to ... d. Provide a culture where care is delivered in a safe environment and quality of care is measured, monitored, and continuously improved ..."

Review on April 18, 2018, of the facility document, "Amended and Restated Bylaws of the Board of Governors", dated, "October 17, 2017", revealed "... Article IV. Purpose of the Hospital The Board shall be accountable for the safety and quality of care, treatment and services of the Hospital ... Article V. Duties and Responsibilities The principle duties and responsibilities of the Board shall be to ... 4. Promote continuous quality improvement through monitoring of professional services provided by the Medical Staff, allied health professional and other health care providers who provide services at the Hospital ... 7. Advise on reasonable steps needed to ensure that the Hospital conforms with all applicable Federal, State, and local laws and regulations and all applicable accreditation standards ...Article XI. Quality of Professional Services 1. Board of Governors' Responsibilities. a. The board shall review and evaluate activities of the Medical Staff and other professional staffs in the Hospital on a continuing basis to assess, preserve, and continuously improve the quality and efficiency of patient care in the Hospital ..."

Review on April 18, 2018, of the facility document, "Job Description: CEO", dated, no date provided, revealed "... Position Summary: Manages the day-to-day operations ... Essential Job Duties ... 4. Develops and provides quality programs and services to the community ..."

Review on April 18, 2018, of the facility document, "Job Description/Evaluation, Position Title: Assistant Director of Nursing", dated, no date provided, revealed "... Job Summary: reports to the Director of Nursing and is accountable for nursing care in the inpatient areas ... Job Responsibilities ... 4.0 Engages in leadership responsibilities by providing information, support and education which promote professionalism. 4.1 Ensures that the nursing functions of the Inpatient, Admission and Evaluation Services are carried out ... 4.5 Assists Director of Nursing with ensuring total compliance with the standards of JCAHO, other accrediting bodies/agencies, Federal, State and City authorities in regard to the provision of patient care and other requirements affecting the Clinical areas supervised. 4.5.1 Ensures compliance with applicable Federal, State and local laws and regulations on the part of persons under supervision ... 4.8 Interprets clinical and managerial issues to interdepartmental and interagency colleagues and groups; serves as an advocate for staff, patients and quality patient care ... 5.5 Assists with aspects of Performance Improvement for the Clinical services Department ... 5.5.3 Investigates specific problems of clinical practice and uses the results to improve clinical performance and patient care ... 6.0 Participates in centralized Nursing Services department professional activities, including education, performance improvement, peer review, and committee work, in order to maintain professional standards. 6.1 Ensures establishment of programs designed to impart knowledge, achieve high ethical standards, create a patient care climate in keeping with the mission and philosophy of Friends Hospital ..."

Review on April 18, 2018, of the facility document, "Performance Evaluation Form, Position Title: Chief Nursing Officer", dated, "10/14", revealed "B. Position Specific Performance 1. Management and Supervision: Assure that Nurse managers and direct reports establish appropriate standards of safety, quality of care, and quality/performance improvement mechanisms to achieve smooth operations and optimal efficiency ... 3. Regulatory Requirements: Maintains all accreditations and clarifies licensing and accreditation standards (during accreditation survey years and announced surveys) for Nursing Services ... Assure compliance with all regulatory agencies and hospital polices ..."

Review on April 18, 2018, of the facility document, "Job Description, Performance & Competency Evaluation, Job Title: Nurse Manager", dated, "2/2013", revealed "Primary Function: Clinical Nurse Building manager maintains oversight of unit based Clinical service lines in identified building in order to ensure quality, integrity, and excellence of treatment delivered ..."

Review on April 18, 2018, of the facility document, "Job Description, Position Title: Registered Nurse", dated, "12/12", revealed "Position Summary: Provides direct patient care as prescribed by the physician and treatment team. Provide medical management and assessment of patients. Ensure environmental safety and crisis management for the patient population ... document patient care, ensure that date is accurate ... B. Position Specific Performance Criteria/Essential Job Functions 1. Nursing Assessment ... Assesses and documents findings when patient condition changes and communicates changes in patient status to the physician and treatment team. 2. Nursing Documentation. Documents patient progress clearly, accurately, legibly, and concisely per hospital policy ... Ensures that occurrences are thoroughly documented ... 4. Medication Administration/Medical Management. Administers medications according to department procedure, including obtaining vital signs and lab work, within assessment guidelines and parameters ... 6. Crisis Intervention. Provides appropriate intervention in psychiatric and medical crisis situations. Directs crisis response by using sound judgement and timely intervention. Completes necessary documentation and obtains orders within prescribed timelines. Ensures that patient & staff safety is maintained throughout any special treatment procedures ..."

Review on April 18, 2018, of the facility document, "Job Description, Position Title: Mental Health Technician", dated, "12/17", revealed "Position Summary: assists in the direct care & management of patients across all age ranges with medical & behavioral issues as directed by the treatment team ... B. Position Specific Performance Criteria/Essential Job Functions 1. Patient Supervision. Provides age and developmentally appropriate, hands-on supervision, crisis intervention, therapeutic interactions and behavior management as directed in the treatment plan and program guidelines ... 2. Documentation. Accurately, legibly, and thoroughly documents patient behaviors, activities, and progress on a daily basis. Records complete and accurate behavioral data in the prescribed format ... 5. Crisis Intervention. Provides appropriate intervention in psychiatric and medical crisis situations by anticipating and responding quickly to escalating behaviors, utilizing de-escalation techniques to diffuse the situation, correctly prioritizing safety concerns ..."

Review on April 18, 2018, of the facility document, "Code Gray Log" , dated, "3/31/18", revealed a Code Grey was called on "BN2", on "3/31/18", at "1539" and a second Code Gray was called at "1541".

Review on April 16, 2018, of MR1, revealed the patient was admitted as an inpatient to the BN2 Unit, on March 24, 2018. Further review of MR1 revealed a Nursing Progress Note, dated "3/31/18", at "2030". Further review of the progress noted revealed "[patient name] was in a altercation [letter c, line over it, meaning the word with] a peer. Patient was punched by peers. Patient had abrasions on his face and swelling of the right eye. [patient name] was kicked by peers. VS are 92/53, 138, resp 24, pulse ox 97. Patient was evaluated by the ROC (resident on call) and sent to the hospital." Further review of the progress note reveals no documented evidence of the specific time when the altercation(s) took place, how many individuals were involved as well as where the events took place, and no documented evidence of the patient's specific injuries and/or specific first aid/medical care provided to the patient post-altercation. Further review of the progress note revealed no documented evidence that the patient was isolated from the individuals who were involved in the altercation(s) and that the patient was kept safe, secure, and protected from future assaults/physical abuse. Further review of the progress noted revealed no documented evidence that a Code Grey and/or Code Blue was initiated by the RN. Further review of MR1 revealed an Integrated Progress Note, dated "3/31/18", at "1748", by the "NSG Supervisor". Further review of the supervisor note revealed "Arrived to unit at approximately 1543 after code grey called by unit due to physical assault on pt [patient full name] where two peers physically attacked him. He was kicked + punched in face + body multiple times by both peers per patient report. Staff intervened after 1st altercation, where patient ran down hall. Per staff, both aggressors seemed to be calm, but quickly pushed past staff in attempt to continue assault. Pt. states he was kicked + hit multiple times again in hallway until staff was able to intervene. On arrival, Pt was in room [letter c, line over it, meaning the word with] ROC, nurse + 2 MHT's. I arrived to pt's room where he was being assessed by ROC + unit nurse. Neuro checks were being done, vital signs completed 92/53, p 138, R 20, Pulse ox - 97% on RA. Pt was immediately given ice + pressure applied to stop bleeding. Neuro checks were within normal limits. Pt was awake, alert + oriented x 3. 911 had already been activated per ROC. Nursing Supervisor + resident at bedside [letter c, line over it = to with] pt until 911 arrived." Further review of MR1 revealed an Integrated Progress Note, dated 3/31/18, at 15:40 pm, by the Resident on Call (ROC). Further review of the physician note revealed "ROC on call was notified that patient was assaulted by two patients on the unit in the lounge area. Pt was taken down to the floor and the other two patients punched his face with hands and feet. Pt received injury over his right eye and substantial nose bleed. Upon arrival at 3:50 pm on the unit the pt is in distress seated on his bed with ice pack to his face. Pt had swelling over the right eye, mild swelling on the right side of the nose and laceration of the lower lip. Pt complained of mild headache pain 6/10 on the eye and nose, denies blurry vision, nausea, vomiting diarrhea, [illegible word] or abdominal pain. Per nursing staff there was substantial bleeding from his nose after the incident. [illegible word] Pt is mild distress seated on bed holding ice to the eye." Further review of the Resident on Call note revealed no documented evidence that the patient was isolated from the individuals who were involved in the altercation(s) and that the patient was kept safe, secure, and protected from future assaults/physical abuse. Further review of MR1 revealed a Inpatient Transfer Form, dated 3/31/18, at 1605. Further review of the transfer form revealed "Reason for transfer: Very shaky. [patient name] was punched, hit by 2 peers. Had cut over face. Nose bleeding. Right eye very swollen = bloodshot. Very shaky. Kicked many times." Further review of the transfer form revealed no documented evidence of the specific time of the transfer or how the patient was transported (i.e. EMS personnel or facility-based transport).

Interview with EMP4 and EMP5, on April 18, 2018, between approximately 7:46 A.M. and 8:19 A.M., confirmed that the facility currently has a video recording of the assault on the patient listed within MR1 and that they both "did" review the video. Further interview with EMP4 and EMP5 confirmed that assault occurred on the Bonsall North Two (BN2) Unit, on March 31, 2018, between approximately "3:30 to 3:45" , which was at the "change of shift" report by Nursing personnel. Further interview with EMP4 and EMP5 confirmed that at change of shift the nurses give report at the "nurse's station", which is "not near the lounge". Further interview with EMP4 and EMP5 confirmed that during shift report the Mental Health Technicians are "monitoring the hallways" and exchanging report. Further interview with EMP4 and EMP5 confirmed that the patient in MR1 was assaulted "twice" on March 31, 2018. Further interview with EMP4 and EMP5 confirmed that the first assault on the patient occurred in the "lounge". Further interview with EMP4 and EMP5 confirmed that the patient was "sitting on the floor in the lounge playing cards" and that "three patients" entered the lounge, "closed the lounge door", and "two" of the three patients began "kicking and punching" the patient in MR1, "repeatedly", to the "head" and "body area". Further interview with EMP4 and EMP5 confirmed that the facility staff intervened within approximately "15-20 seconds" and that the patient in MR1 "ran out" of the lounge area. Further interview with EMP4 and EMP5 confirmed that there "is not" documented evidence that the patient in MR1 was provided first-aid after the first assault and/or that the patient in MR1 was placed in a safe/secure environment/area for their protection from further assaultive behavior from the other patients involved in the assault. Further interview with EMP4 and EMP5 confirmed that a "second" assault on the patient within MR1, occurred on the BN2 hallway, within "a minute" from the first assault event in the lounge. Further interview with EMP4 and EMP5 confirmed that the patient in MR1 was "walking away from the lounge", in a common hallway, when the two patient's who completed the first assault, assaulted the patient again at the very end of the hallway. Further interview with EMP4 and EMP5 confirmed that the patient in MR1 was "kicked and punched", "repeatedly", to the "head" and "body area". Further interview with EMP4 and EMP5 confirmed that the facility staff intervened "immediately". Further interview with EMP4 and EMP5 confirmed that there "is not" documented evidence that the patient in MR1 was provided first-aid after the second assault and/or that the patient in MR1 was placed in a safe/secure environment/area for their protection from further assaultive behavior from the other patients involved in the assault. Further interview with EMP4 and EMP5 confirmed that the nurses note, documented on March 31, 2018, at 2030, "was not complete" and "was not reflective" of what transpired during either of the assault events. Further interview with EMP4 and EMP5 confirmed that a Police Report "was not" initiated by the facility as the "parents" of the patient in MR1 "had already" initiated a report once the patient was in the "ER" of the receiving hospital, post-transfer.

Interview with EMP20, on April 19, 2018, between 1:52 P.M. and 2:00 P.M., confirmed that the Nursing Supervisor note, documented on "3/31/18", at "1748", was "not accurate". Further interview with EMP20 confirmed that the Nursing Supervisor "did not" arrive to the unit and find the patient within MR1 in their room, post-assault. Further interview with EMP20 confirmed that the Nursing Supervisor arrived to the unit, post-Code Grey announcement, and immediately began assisting the unit staff by cleaning "up all the blood at the end of the hallway before Housekeeping arrived". Further interview with EMP20 confirmed that they "did not" know if the patient was provided immediate first-aid or other Nursing interventions, post-assault number one and/or number two. Further interview with EMP20 confirmed that they "did not" know if the patient was placed in a safe/secure environment/area for their protection from further assaultive behavior from the other patients involved in the assault, post-assault number one and/or number two.

Review on April 19, 2018, of MR2, revealed the patient was admitted to the facility on on [DATE]. Further review of MR2 revealed a Nursing Progress Note, dated "02/11/18" at "1400". Further review of the progress note revealed "Patient asleep in common area. During medication administration, [patient] stated 'I don't remember how' when asked to take pills in a medicine cup. Patient also required reminders to swallow. Patient unable to answer questions because she is heavily sedated. Patient was able to shower with help of MHT. Patient was asleep and barely [sic] rousable in the dayroom." Further review of MR2 revealed no documented evidence that a Code Blue was initiated when the patient was "heavily sedated", no documented evidence that the patient was provided basic nursing interventions while they were "heavily sedated", and/or no documented evidence that a physician was notified of the patients "heavily sedated" condition. Further review of MR2 revealed an Inpatient Transfer Form, dated, no date and/or time recorded by the RN. Further review of the transfer form revealed "reason for transfer: Rule out CVA. Pt is 34 yo female with AMS since 1 wk, Hx of fall & head contusion
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0160
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy and procedures, review of medical records (MR), and interview with staff (EMP), it was determined that the facility failed to ensure that chemical restraints were not utilized, for one of ten restraint medical records reviewed (MR16).

Findings include:

Review on April 18, 2018, of the facility policy, "Restraints & Physical Holds", dated, "12/2016", revealed "Policy ... Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient or others from harm ... Definitions ... Medication (Chemical) Restraint ... Use of a drug or medication may be considered a chemical restraint if it is not being used as a standard treatment for the patient's medical or psychiatric condition, and results in restricting the patient's freedom of movement, including sedation ... 13. Documentation of use of restraint: The use of restraint will be thoroughly documented in the patient's medical record. Documentation related to restraint includes ... 2. The initial assessment of the patient related to restraint use. 3. Documentation of each episode of restraint includes: 1. The circumstances that led to the use of restraint. 1. Specific behaviors. 2. Detailed description of events leading up to the incident and other pertinent information ... 11. Continuous monitoring of patient and care provided ..."

Review on April 19, 2018, of MR16, revealed the patient was admitted to the facility on on [DATE]. Further review of MR16 revealed a Nursing Progress Note written on "10/21/17" at "7-3p". Further review of the progress note revealed "Pt was visible, disorganized, responds to [sic] internal stimuli. Pt was witnessed coming out into milieu naked frequently @ 1100. Pt swung on male peer and was punched in head and face causing hematoma and laceration beneath [encircled R symbol meaning right] eye. First aid was given by writer. Pt (individual assaulted) was administered IM (intramuscular injection) Benadryl/Haldol/Ativan (psychiatric medications). Meds were effective within 1 hr. @ 1420 patient was attacked by male peer [patient initials]. Pt was placed on 1:1 and examined by Dr. [physician name]. Received orders to transfer patient to [hospital name] ER for tx of laceration + hematoma." Further review of MR16 revealed no documented evidence that a Code Grey and/or Code Blue was initiated, post-assault number one and/or assault number two. Further review of MR16 revealed no documented evidence of specific aggressive, psychiatric behaviors, requiring the patient listed within MR16 to receive a chemical restraint, after the first assault event at "1100" on "10/21/17". Further review of MR16 revealed no documented evidence of any attempts by the facility staff to utilize least restrictive, restraint alternatives, and determine their ineffectiveness, prior to the use of a chemical restraint (intramuscular injection).

Interview with EMP5 and EMP19, on April 19, 2018, between 12:45 P.M. and 1:00 P.M., confirmed that MR16 "did not" contain documented evidence that a Code Blue and/or Code Grey were initiated post-assault. Further interview with EMP5 and EMP19 confirmed MR16 "did not" contain documented evidence that the patient within MR16 was placed in a safe/secure environment/area, for their protection from further assaultive behavior from the other patient involved in the assault, post-assault number one and/or number two. Further interview with EMP5 and EMP19 confirmed that MR16 "did not" contain documented evidence of any acute aggressive/psychiatric behaviors that required the patient within MR16 to receive a chemical restraint, post the first assault event at "1100" on "10/21/17". Further interview with EMP5 and EMP19 confirmed that MR16 "did not" contain documented evidence of any attempts by the facility staff to utilize least restrictive, restraint alternatives, and determine their ineffectiveness, prior to the use of a chemical restraint (intramuscular injection). Further interview with EMP5 and EMP19 confirmed that MR16 "did not" contain documented evidence that the patient was provided with any initial and/or ongoing monitoring of their neurological status post-assault.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0165
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policies and procedures, medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure that restraint documentation was accurate and complete, as required by facility policy, for two of ten restraint medical records reviewed (MR8 and MR9).

Findings include:

Review on April 18, 2018, of the facility policy, "Restraints & Physical Holds", dated, "12/2016", revealed "Policy ... Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient or others from harm ... Definitions ... Physical Restraints: The application of any manual method that immobilizes or reduces the ability of the patient to move his or her arms, legs, body, or head freely (also named therapeutic hold, protective hold, or manual restraint) ... Procedure ... 4. Restraint Application and Assessment/Monitoring during the Use of Restraints: 1. If physical restraint is indicated, at least 2 staff must participate in the physical hold application ... 13. Documentation of use of restraint: The use of restraint will be thoroughly documented in the patient's medical record. Documentation related to restraint includes ... 8. Check of appropriate restraint application ..."

Review on April 19, 2018, of MR8, revealed the patient was admitted to the facility on on [DATE]. Further review of MR8 revealed the patient was placed in a physical hold on March 12, 2018, at 11:54 A.M. Further review of MR8 revealed a Restraint/Seclusion Nursing Flow Sheet, Standards for Documentation. Further review of the flow sheet revealed "I. Type of Hold" section, with check boxes for "Arms", "Legs", "Both" listed. Further review of MR8 revealed no documented evidence that the type of hold utilized was selected on the flow sheet.

Interview with EMP5 and EMP19, on April 19, 2018, at 1:11 P.M., confirmed that MR8 "did not" contain documented evidence of what specific type of physical hold was utilized on the patient and that the type of hold was the least restrictive modality.

Review on April 19, 2018, of MR9, revealed the patient was admitted to the facility on on [DATE]. Further review of MR9 revealed the patient was placed in a physical hold on February 8, 2018, at 02:22 A.M. Further review of MR9 revealed a Restraint/Seclusion Nursing Flow Sheet, Standards for Documentation. Further review of the flow sheet revealed a section to document "Staff Involved in Hold". Further review of MR9 revealed no documented evidence that any staff names were entered into the "Staff Involved in Hold" section.

Interview with EMP5 and EMP19, on April 19, 2018, at 1:10 P.M., confirmed that MR9 "did not" contain documented evidence of the specific staff members involved in the application of a physical hold on the patient.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policy and procedures, review of medical records (MR), and interview with staff (EMP), it was determined that the facility failed to ensure that the patients plan of care was modified, in writing, post-application of a physical hold/restraint, for two of ten restraint medical records reviewed (MR20 and MR21).

Findings include:

Review on April 18, 2018, of the facility policy, "Restraints & Physical Holds", dated, "12/2016", revealed "Policy ... Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient or others from harm ... Definitions ... Physical Restraints: The application of any manual method that immobilizes or reduces the ability of the patient to move his or her arms, legs, body, or head freely (also named therapeutic hold, protective hold, or manual restraint) ... Procedure ... 4. Restraint Application and Assessment/Monitoring during the Use of Restraints: 1. If physical restraint is indicated, at least 2 staff must participate in the physical hold application ... 11. Treatment Plan Review/Revision: When the patient has presented behavior that is dangerous to themselves of others so that restraint were indicated, a review and modification of the treatment plan is indicated ... 13. Documentation of use of restraint: The use of restraint will be thoroughly documented in the patient's medical record. Documentation related to restraint includes ... 15. Treatment plan review/revision following the episode of restraint will include treatment interventions to prevent future use ..."

Review on April 19, 2018, of MR20, revealed the patient was admitted to the facility on on [DATE]. Further review of MR20 revealed the patient was placed in a physical hold/restraint on March 9, 2018. Further review of MR20 revealed no documented evidence that the patient's written plan of care was updated, post-application of a physical hold/restraint.

Interview with EMP5, on April 19, 2018, at 2:48 P.M., confirmed that MR20 "did not" contain documented evidence that the patient's written plan of care was updated, post-application of a physical hold/restraint.

Review on April 19, 2018, of MR21, revealed the patient was admitted to the facility on on [DATE]. Further review of MR21 revealed the patient was placed in a physical hold/restraint on January 30, 2018. Further review of MR21 revealed no documented evidence that the patient's written plan of care was updated, post-application of a physical hold/restraint.

Interview with EMP5, on April 19, 2018, at 2:49 P.M., confirmed that MR21 "did not" contain documented evidence that the patient's written plan of care was updated, post-application of a physical hold/restraint.
VIOLATION: VERBAL ORDERS Tag No: A0408
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of facility policies and procedures, review of medical records (MR), and interview with staff (EMP), it was determined that the facility failed to ensure verbal orders were implemented and documented correctly for one of ten transfer medical records reviewed (MR7).

Findings include:

Review on April 18, 2018, of the facility policy, "Verbal Orders", dated, "03/2018", revealed "Purpose: To establish a consistent, safe method for giving and receiving verbal orders ensuring patient safety. Policy ... Verbal Orders may only be taken under the following circumstances: An unexpected occurrence demanding immediate action, in which any delay in action would lead to harm to the patient, other patients, or the staff, or adversely affect the condition of the patient potentially leading to a serious event ... Procedure ... If the healthcare provider does not have direct access to a computer he/she may write the verbal order on a physician order sheet preferably using the verbal order format sticker ... g. Verbal orders must be countersigned, dated, and signed by an ordering practitioner ... and if applicable on the paper order in the patient's chart as soon as possible, but no later than 24 hours ..."

Review on April 19, 2018, of MR7, revealed the patient was admitted to the facility on on [DATE]. Further review of MR7 revealed the patient had a Physicians Order sheet filled out, manually, with a "Verbal Order" documented on "12/9/17 0635". Further review of the manually written verbal order revealed "verbal order, Hold AM dose of [unable to determine medication due to illegible writing] 25 mg" with a "Read Back" box checked, and an "RN Sign" line containing a signature, and a "MD Sign" line containing no documented signature.

Interview with EMP5 and EMP19, on April 19, 2018, at 10:05 A.M., confirmed that a verbal order "was" manually transcribed into MR7, by a Registered Nurse, on "12/9/17", at "0635". Further interview with EMP5 and EMP19 confirmed that a facility-approved, verbal order sticker "was not" utilized for the documentation of the verbal order. Further interview with EMP5 and EMP19 confirmed that the verbal order "was not" properly authenticated by a physician and "was not" properly timed to reflect completion within 24 hours of the date the verbal order was transcribed.