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.

AURORA BEHAVIORAL HEALTHCARE-SANTA ROSA, LLC 1287 FULTON ROAD SANTA ROSA, CA 95401 Oct. 21, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview and record review, the hospital failed to ensure that each patient's rights were protected as evidenced by:

1. The hospital failed to document in the clinical record that 1 of 25 patients (Patient 5) and/or his patient representative was informed of his rights before receiving patient care. (Cross Reference A 117).


2. The hospital failed to ensure a patient was free from abuse for one of 25 patients (Patient 2). (Cross Reference A 145).

The cumulative effect of these systemic problems resulted in the hospitals' failure to meet statutorily mandated compliance with the Condition of Participation for Patient Rights.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on staff interview, clinical record review, and document review, the facility failed to document in the clinical record that 1 of 25 patients (Patient 5) and/or his patient representative was informed of his rights before receiving patient care. This had the potential to deny the patient his rights.

Findings:

Review of Patient 5's clinical record on 9/21/16 at 3:25 p.m., failed to find documentation that he or his patient representative had been informed of his rights.

During an interview and concurrent clinical record review on 9/21/16 at 4 p.m., Licensed Staff O was asked to find documentation verifying Patient 5 had been advised of his rights. Licensed Staff O stated: "I don't see it in here. It's usually in the legal section. I'm not sure why it's not in the chart. It's missing from this chart."

Review of the policy titled, "Content of the Patient Medical Record," dated 5/1/13, indicated: "The medical record will serve as a record of the services provided to the patient and will include...Signed copy of Patient Rights."
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review, the hospital failed to ensure a patient was free from abuse for one of 25 patients (Patient 2) when:

1. The hospital failed to follow the precautions policy when the hospital did not prevent Patient 1 from potentially having contact with Patient 2 during an investigation of allegations that Patient 1 and Patient 2 allegedly had sexual encounter causing the potential of subjecting Patient 2 to further abuse. Patient 2 was not protected from 8/5/16 through 8/9/16.

2. An allegation of sexual abuse was reported by Patient 2 on 8/5/16 and the hospital failed to report the allegations of sexual abuse to the administrator on call/leadership, law enforcement, the physician, child protective services (CPS) Patient 2's guardian until 8/9/16.

Findings:

1. On 8/12/16 the hospital reported to the Department an incident that on 8/7/16, an alleged sexual encounter occurred between two adolescent patients, Patient 1 and Patient 2 during 8/4/16 - 8/7/16.

During a review of the medical record for Patient 2, on 9/19/16, indicated Patient 2 was admitted on [DATE] with a diagnosis of psychosis, suicidal ideation and was considered a danger to herself.

Patient 1 was admitted to Room 507 and Patient 2 was admitted to Room 503 (separated by Room 505) on the Sierra Unit.

Review of the admission Nursing Admission Assessment document, dated 8/2/16, timed at 8:00 p.m., by the Admission Registered Nurse (RN), indicated on page 6 of 6 the patients risk status, Patient 2's Absence Without Official Leave (AWOL) score was 0 (0-5 low risk, no special AWOL precautions). The Danger To Others (DTO) Risk Assessment score was 5 (0-5 low risk, no special DTO precautions). The Sexual Acting Out Risk Assessment score was 5 (0-5 low risk, no special sexually acting out precautions). The vulnerability risk assessment score was 10 (10 plus high risk, place on vulnerability precautions).

During a review of the medical record for Patient 1, on 9/19/16, indicated Patient 1 was admitted on [DATE] with a diagnosis of psychotic disorder, polysubstance abuse and was considered a danger to others.

Review of the admission Nursing Admission Assessment document, not dated, timed or signed by an Admission Registered Nurse (RN), indicated on page 6 of 6 the patients risk status, Patient 1's Absence Without Official Leave (AWOL) score was 16 (10 plus denotes high risk, place on AWOL precautions). The Danger To Others Risk Assessment score was 18 (10 plus place on assault precautions). The Sexual Acting Out Risk Assessment score was 5 (0-5 low risk, no special sexually acting out precautions). The vulnerability risk assessment score was 5 (0-5 low risk, no special vulnerability precautions).

Review of the admission Intake Assessment document, dated 8/2/16 and timed 5:15 a.m., indicated Patient 1 had a history of elopement, was identified as a high risk for suicide, was identified as a high risk for homicidal behavior.

Review of the telephone Admission Orders (unsigned by the admitting physician until 8/15/16 at 4:51 p.m.) dated 8/1/16 and timed at 11:37 p.m., Patient 1's Observation Level Routine every 15 minute checks.

Review of the Patient Observation Record (a 24 hour record used by staff to document visual appearance/behavior) dated 8/2/16 indicated Patient 1's Physician Ordered Precautions documented "15 minute checks."
On 8/3/16 in addition to the "15 minute checks" additional precautions were documented, "Elopement" and "Assault."
On 8/4/16 in addition to the "15 minute checks" additional precautions were documented "Sexual." These precautions remained in effect through 8/9/16.

During a concurrent interview and record review on 9/20/16 at 4:30 p.m., with Non-licensed Staff C, she confirmed she was the author of a hand written unsigned note contained in the Progress Notes for Patient 1. The progress note was written on 8/5/16 at 9:00 p.m., whereby Non-licensed Staff C documented Patient 1 reported to her ...that he and Patient 2 "fxxxxx" [explanative] in the bathroom. Non-licensed Staff C reported this to the charge nurse and wrote an incident report. There was no entry documenting the physician was notified. There was no documentation Patient 1 was placed on 1 to 1 observation. There was no documentation Patient 1 was relocated to another patient room.

The next entry by Licensed Staff Q in the Progress Notes was dated 8/6/16 at 6:37 p.m., indicated "Pt stated he had "relations" with one of the female pts. Pt stated he always was in her room, but it was mutual. Pt stated female pt also initiated relations. Pt understood he should not be in other pts rooms. Will continue to monitor." There was no entry documenting the physician was notified. There was no documentation Patient 1 was placed on 1 to 1 observation. There was no documentation Patient 1 was relocated to another patient room.

During an interview on 9/21/16 at 11:10 a.m., with Physician C, she stated she became involved on 8/9/16 at the morning team meeting. She stopped the meeting and began the investigation. On 8/9/16 at 9:25 a.m., she ordered Patient 1 to be on 1:1 observation for remainder of hospitalization .

Review of the policy and procedure titled "PRECAUTIONS, Inpatient units" revised 4/10/14, indicated "...6. In the event of a consensual sexual encounter involving a patient: a. ensure safety of patients involved. b. Immediately report the alleged occurrence to the Charge Nurse who will inform the Nurse Manager/House Charge. Nurse Manager/House Charge will notify the AOC and Attending Physician. d. If indicated, the Attending Physician or RN House Charge will notify family members...d. Take appropriate precautions with all involved patients as appropriate..."

"7. In the event of a non-consensual sexual encounter involving a patient: a. RN House Charge/Nurse Manager will notify law enforcement b. Separate alleged perpetrator and victim immediately. c. Stay with the alleged victim to be supportive and to ensure safety...e. Maintain separation of alleged victim and perpetrator until legal authorities arrive..."

2. During an interview on 9/20/16 at 11:20 a.m., with Administrator Staff B, she stated it was on 8/9/16 she became aware of the alleged sexual encounter between two adolescent patients when the police arrived. She stated she had not been notified by the House Charge Registered Nurse (RN) or the unit's Nurse Manager. She stated an incident report was generated by Licensed Staff H on 8/7/16 and placed on the nurse managers' desk for investigation. The incident report was overlooked until 8/9/16.

During a review of the hospital's incident report, dated 8/5/16 and timed 9:00 p.m., indicated that Licensed Staff F was notified by Non-licensed Staff C who reported she was told by Patient 1 that he and Patient 2 (explanative "[fxxxxx] in the bathroom." Non-licensed Staff C reported this to her charge nurse Licensed Staff F on 8/5/16 at 9:00 p.m., and wrote an incident report. The incident report was reviewed by Administrative Staff A on 8/8/16 at 9:42 a.m.

Review of the Interdisciplinary Notes dated from 8/5/16 at 9:00 p.m., through 8/9/16 at 4:45 p.m., for Patient 1 indicated no documentation by Licensed Staff F, Licensed Staff H, Licensed Staff Q that Patient 1 was separated from Patient 2 or that the physician was notified.

Review of the Physician dictated Progress Note dated 8/6/16 for Patient 1, indicated no documentation by Physician A he was notified of the alleged sexual abuse.

Review of the Physician dictated Progress Note dated 8/7/16 for Patient 1, indicated no documentation by Physician A he was notified of the alleged sexual abuse.

Review of the Physician C dictated Progress Note dated 8/8/16 for Patient 1, indicated no documentation by Physician C she was notified of the alleged sexual abuse.

During an interview on 9/21/16 at 11:10 a.m., with Physician C, she stated she became involved on 8/9/16 at the morning team meeting. She stated the physician's rely on the verbal reports from the nursing staff at the morning team meetings. When she became aware of the incident, she stopped the meeting and began the investigation. On 8/9/16 at 9:25 a.m., she ordered Patient 1 to be on 1:1 observation for remainder of hospitalization .

During a review of the hospital's incident report (a second incident report), dated 8/7/16 and timed 2:00 p.m., indicated that Licensed Staff H was notified by Patient 2 who reported Patient 1 tried to have sex with her. The incident report was reviewed by Administrative Staff A on 8/8/16 at 3:15 p.m. and delegated to Licensed Staff I.

During an interview on 9/21/16 at 11:10 a.m., with Physician C, she stated she became involved on 8/9/16 at the morning team meeting. She stopped the meeting and began the investigation. On 8/9/16 at 9:25 a.m., she ordered Patient 1 to be on 1:1 observation for remainder of hospitalization . She contacted Patient 2's guardian. She contacted the police department and CPS was notified by the hospital.


Review of the policy and procedure titled "ABUSE REPORTING" revised 7/24/13, indicated "All incidents of suspected abuse will be reported ...This procedure applies to information staff acquire, either by patient report ...regarding suspected abuse. All staff is mandated to report anytime ... have knowledge regarding allegations of abuse ...of patients. "Staff" is including of senior leaders, administrative, clinical nursing, non-nursing clinical...The criteria for reporting child abuse could include ...a child reports abuse or neglect ...during hospitalization ...Staff should notify their supervisor and/or initiate a report ...If staff other than social services acquires the information ...notify their immediate supervisor ...or the House Supervisor ..."
During an interview on 9/20/16 at 2:15 p.m., Administrative Staff E stated she did not receive any telephone calls from the nursing supervisor while she was the administrator on call the weekend of 8/5/16 through 8/7/16.
Review of the policy and procedure titled "ADMINISTRATOR ON CALL" effective date 5/1/13 indicated "...The following provide guidelines for when to contact the Administrator-On-Call. The AOC may also be contacted at the discretion of Nursing Supervisor and/or other administrative staff ...d. Patient abuse resulting in patient injury (alleged, suspected, or known)..."
VIOLATION: QAPI Tag No: A0263
Based on interview, and document review, the hospital failed to ensure there was a hospital wide Quality Assurance Performance Improvement (QAPI) program as evidenced by:

1. The hospital failed to ensure an effective performance improvement program for identified hospital services that accurately reflected the depth and scope of departmental operations to ensure services furnished were evaluated on a routine basis to identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities.
(Cross Reference A 273).

2. The hospital failed to ensure an effective performance improvement program for identified hospital services that accurately reflected the depth and scope of departmental operations to ensure services furnished were reviewed on a routine basis to identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities.
(Cross Reference A 283).

3. The hospital failed to ensure an effective performance improvement program to analyze indicators that identify and reduce medical errors. (Cross Reference A 286).

4. The hospital failed to ensure that performance improvement activities 1) fully evaluated the depth and scope of the department and 2) demonstrated opportunities for improvement. Performance improvement activities that are limited to monitoring of quality indicators that demonstrated hospital compliance resulted in missed opportunities to identify areas of improvement. (Cross Reference A 297).

5. The hospital failed to provide adequate resources within the hospital's performance improvement department to adequately measure and assess identified risk issues to improve patient safety. (Cross Reference A 315).

The cumulative effect of these systemic problems resulted in the hospitals' failure to meet statutorily mandated compliance with the Condition of Participation for Quality Assurance Performance Improvement.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on administrative staff interview, and document review, the hospital failed to ensure an effective performance improvement program for identified hospital services that accurately reflected the depth and scope of departmental operations to ensure services furnished were evaluated on a routine basis to identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities.
Failure to develop a comprehensive program that identifies opportunities for improvement may result in compromised patient outcomes in relationship to the patience care services provided.

Findings:

On 9/21/16 beginning at 3:00 p.m., the hospital's performance improvement plan was reviewed with Administrative Staff B. She described a program that was implemented by the Performance Improvement Committee. It was noted that the program was limited to evaluating the "ORXY Performance Measures" (National Hospital Quality Measures) submitted by corporate to the accreditation organization. While the data was reviewed in the presence of Administrative Staff B, it was not possible to interpret the results as Administrative Staff B was unsure how to interpret the ORXY report. She stated the hospital also evaluated information that was as a result of the hospitals' patient satisfaction survey responses, but that the Performance Improvement Committee had not chosen performance improvement indicators from these two sources to demonstrate the hospital was able to improve health outcomes.

Review of the hospital document titled, "Performance Improvement Plan" dated 2015, indicated the scope of the plan was to evaluate data systematically collected for both improvement priorities and continuing measurement of those processes that have the greatest impact on patient care and clinical performance. There was no documentation that the hospital ensured a comprehensive performance improvement program, which demonstrated opportunities for improvement, in relationship to the provision of patient care services provided was implemented.
VIOLATION: QAPI PERFORMANCE IMPROVEMENT PROJECTS Tag No: A0297
Based on interview, and administrative document review, the hospital failed to ensure that performance improvement activities 1) fully evaluated the depth and scope of the department and 2) demonstrated opportunities for improvement. Performance improvement activities that are limited to monitoring of quality indicators that demonstrated hospital compliance resulted in missed opportunities to identify areas of improvement.

Findings:

On 9/21/16 beginning at 3:00 p.m., the hospital's performance improvement plan was reviewed with Administrative Staff B. She described a program that was implemented by the Performance Improvement Committee. It was noted that the program was limited to evaluating the "ORXY Performance Measures" (National Hospital Quality Measures) submitted by corporate to the accreditation organization. While the data was reviewed in the presence of Administrative Staff B, it was not possible to interpret the results as Administrative Staff B was unsure how to interpret the ORXY report. She stated the hospital also evaluated information that was as a result of the hospitals' patient satisfaction survey responses, but that the Performance Improvement Committee had not chosen performance improvement indicators from these two sources to demonstrate the hospital was able to improve health outcomes.

In an interview on 9/21/16 at 3:00 p.m., with Administrative Staff B, she was asked to describe the performance improvement activities for the hospital. She stated that her primary focus was patient satisfaction surveys. She stated the hospital performance improvement project for 2015 was the reduction of the use of restraints/seclusion. She further stated that while this was identified as a performance improvement project, there was no data analysis or rational for conducting the restraint/seclusion project. There was no documentation of measurable goals. There was no documentation to evaluate if the hospitals' annual project goals and/or progress were achieved or not achieved.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on administrative staff interview, and document review, the hospital failed to ensure an effective performance improvement program for identified hospital services that accurately reflected the depth and scope of departmental operations to ensure services furnished were reviewed on a routine basis to identify quality and performance problems, implement appropriate corrective or improvement activities, and to ensure the monitoring and sustainability of those corrective or improvement activities.
Failure to develop a comprehensive program that identifies opportunities for improvement may result in compromised patient outcomes in relationship to the patience care services provided.

Findings:

On 9/21/16 beginning at 3:00 p.m., the hospital's performance improvement plan was reviewed with Administrative Staff B. She described a program that was implemented by the Performance Improvement Committee. It was noted that the program was limited to evaluating the "ORXY Performance Measures" (National Hospital Quality Measures) submitted by corporate to the accreditation organization. While the data was reviewed in the presence of Administrative Staff B, it was not possible to interpret the results as Administrative Staff B was unsure how to interpret the ORXY report. She stated the hospital also evaluated information that was as a result of the hospitals' patient satisfaction survey responses, but that the Performance Improvement Committee had not chosen performance improvement indicators from these two sources to demonstrate the hospital was able to improve health outcomes. She stated while the hospital was evaluating restraints/seclusion and falls she was not able to produce the evaluation data, the hospital was not able to provide performance improvement actions aimed at improving care to patients in restraints/seclusion. Nor was the hospital able to provide performance improvement actions aimed at reducing falls. Nor was the hospital able to provide measures of success data to ensure improvements are sustained.

Review of the hospital document titled, "Performance Improvement Plan" dated 2015, indicated the scope of the plan was to evaluate data systematically collected for both improvement priorities and continuing measurement of those processes that have the greatest impact on patient care and clinical performance. There was no documentation that the hospital ensured a comprehensive performance improvement program, which demonstrated opportunities for improvement, in relationship to the provision of patient care services provided was implemented.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on administrative staff interview, and document review, the hospital failed to ensure an effective performance improvement program to analyze indicators that identify and reduce medical errors. Failure to develop a comprehensive program that identifies opportunities for improvement may result in compromised patient outcomes in relationship to the patience care services provided.

Findings:

On 9/21/16 beginning at 3:00 p.m., the hospital's performance improvement plan was reviewed with Administrative Staff B. She described a program that was implemented by the Performance Improvement Committee. It was noted that the program was limited to evaluating the "ORXY Performance Measures" (National Hospital Quality Measures) submitted by corporate to the accreditation organization. While the data was reviewed in the presence of Administrative Staff B, it was not possible to interpret the results as Administrative Staff B was unsure how to interpret the ORXY report. She stated the hospital also evaluated information that was as a result of the hospitals' patient satisfaction survey responses, but that the Performance Improvement Committee had not chosen performance improvement indicators from these two sources to demonstrate the hospital was able to improve health outcomes.

Review of the hospital document titled, "Performance Improvement Plan" dated 2015, indicated the scope of the plan was to evaluate data systematically collected for both improvement priorities and continuing measurement of those processes that have the greatest impact on patient care and clinical performance. There was no documentation that the hospital ensured a comprehensive performance improvement program, which demonstrated opportunities for improvement, in relationship to the provision of patient care services provided was implemented.

Review of the hospital document titled, "Risk Management Plan" dated 2015, indicated the scope of the plan was to identify actual or potential risks. Formal problem identification would be accomplished through regular review of internal data. Data obtained through participation in ORXY and the Perception of Care Projects and external monitoring systems may also be considered for problem identification. There was no documentation that the hospital ensured a comprehensive performance improvement program, which demonstrated opportunities for improvement, in relationship to the provision of patient care services provided was implemented.
There was no documentation that the hospital had identified through evaluation of the review of internal/external data clear measurable improvement indicators to be evaluated through out the year.
VIOLATION: PROVIDING ADEQUATE RESOURCES Tag No: A0315
Based on interview, and document review, the hospital failed to provide adequate resources within the hospital's performance improvement department to adequately measure and assess identified risk issues to improve patient safety. This failure has the potential for the hospital to not identify indicators to reduce medical errors and therefore would reduce risks to patients.

Findings:

During an interview on 9/21/16 at 3:00 p.m., with Administrative Staff B, stated she has been in the role of Director of Performance Improvement for approximately 11 months. Her duties as the Director of Performance Improvement included but not limited to the hospital coordinator for the accreditation organization, survey readiness, risk manager, patient complaint/grievance coordinator, patient satisfaction coordinator, and data abstractor. She was responsible for the incident report investigations and follow-up.

During the past 11 months she was assigned as the trainer for the staff coordinator position from approximately March 2016 through June 2016 (three months) and had trained three separate people for this position. She stated during these three months as the trainer for the staff coordinator position she was unable to completely concentrate her time fully as the Director of Performance Improvement. She stated the hospital did not provide her with additional staff support.

During a concurrent interview and review of the training certificates on 9/22/16 at 2:00 p.m., Administrative Staff J stated the only formal training provided for Administrative Staff B in the past 11 months as the Performance Improvement Director was on 6/28/16, the course concentrated on accreditation and survey process. He stated Administrative Staff B has had no formal training or mentoring as the Director of Performance Improvement. Administrative Staff B stated she has had no formal training or mentoring in assessing for the high risk, high volume problem prone areas, measuring/analyzing adverse events, performance improvement project selection, or evaluating improvement actions.

Review of the Performance Improvement Plan 2015, indicated on page four of four "...The Performance Improvement Committee is the steering committee for the Quality Management Program and Process Improvement Plan and is responsible to oversee and accomplish the following: 5.3.1 Establish policy, create and ensure organizational preparedness for quality management activities by providing resources and training for program implementation."
VIOLATION: MEDICAL STAFF PERIODIC APPRAISALS Tag No: A0340
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, and document review, the hospital failed to maintain two of two credential files to ensure privileges, competencies and qualifications were current and up to date. These failures of the appraisal by the medical staff to determine the suitability of continuing the medical staff membership or privileges of each individual practitioner, failure to determine an individual practitioner's clinical membership or privileges were continued, discontinued, revised, or otherwise changed has the potential for harm to a patient if the practitioner was not qualified.

Findings:

During an interview with the Medical Director on 9/20/16 at 1:15 p.m., he stated the medical staff office was currently short staffed and he was aware there would be inconstancies found in the credential files. He stated the hospital decided to have a sister facility in southern California complete the medical staff credential files and one of the two files chosen (Physician A) would be available via fax or overnight mail tomorrow. There was no current credential file on site for Physician A. Hospital staff were not aware of the privileges granted for Physician A.

During a concurrent interview and document review with the Medical Director on 9/20/16 at 3:35 p.m., he indicated the credential file for Physician A was reproduced via fax. Physician A's application for reappointment was present. The review of privileges requested by Physician A indicated he had selected to care for the adolescent patients only. He had not requested privileges to treat adults 18 or over. The Medical Director stated Physician A treated adult patients 18 or older, and this must be an oversight. Further review indicated the requested privileges were not granted as there were no indications the Medical Director or the governing body had granted the privileged requests. The medical license verifications through CA.Gov and the Office of Inspector General (OIG) were completed prior to the file review today on 9/20/16. There was no documentation of continuing medical education (CME) for Physician A. There was no documentation of active peer review. Physician A was not available for interview.

During a concurrent interview and document review with the Medical Director on 9/20/16 at 3:35 p.m., the credential file for Physician B was on site. Physician B's application dated 4/15/16 for reappointment was present. The reviews of privileges requested by Physician B were not selected by Physician B. The Medical Director stated Physician B treated all ages of patients admitted , and this must be an oversight. Further review indicated privileges were not granted as there was no indication the Medical Director or the governing body had granted privileges. The copy of the medical license on file expired on [DATE] and the copy of the Drug Enforcement Administration (DEA) certificate on file expired on [DATE]. Physician B was not available for interview. The Medical Director stated the hospital did not have a current quality assurance/performance improvement program in place to evaluate and authenticate the medical staff credential files.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on interview and record review, the hospital failed to provide an organized nursing service for two of 25 sampled patients (Patient 1 and Patient 2) as evidenced by:

1. The hospital failed to have a staffing system in place based on the number and acuity of patients. That patients would not receive nursing care based on their individual, sudden or emergent nursing/medical needs. (Cross Reference A 392).

2. The hospital failed to ensure licensed staff kept current the multidisciplinary treatment plan for a patient that required sexual precautions, and to include individual interventions for sexual precautions for Patient 1. (Cross Reference A 396).

The cumulative effect of these systemic problems resulted in the hospitals' failure to meet statutorily mandated compliance with the Condition of Participation for Nursing Services.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on staff interviews and document review, the facility failed to have a staffing system in place based on the number and acuity of patients. This had the potential that patients would not receive nursing care based on their individual, sudden or emergent nursing/medical needs.

Findings:

"Acuity can be defined as the measurement of the intensity of nursing care required by a patient. An acuity-based staffing system regulates the number of nurses on a shift according to the patients' needs, and not according to raw patient numbers." http://www.americansentinel.edu/blog/2014/02/05/using-patient-acuity-to-determine-nurse-staffing. Accessed 9/26/16.

During an interview on 9/19/16 at 11 a.m., Administrative Staff A stated the staffing ratios for Halls 2 and 5 are 1:4 (one nurse to four patients) and are 1:5 for Halls 3 and 4.

During an interview on 9/19/16 at 2:35 p.m., Licensed Staff I stated the facility used to have an acuity form used for staffing, "but at some point got rid of it" and now staff according to ratios.

During an interview on 9/20/16 at 9:10 a.m., the Staffing Coordinator was asked what components factor into making the staffing schedule. He stated acuity, whether a patient is on Line of Sight (LOS) precautions, on 1:1 observation (one staff member solely assigned to one patient), if staff members call off, staff qualifications, and education, i.e. an unlicensed Mental Health Worker (MHW) vs. a licensed nurse.

During an interview on 9/20/16 at 1 p.m., the Staffing Coordinator stated the staffing ratios for Halls 2 and 5 are 1:4 and 1:5 for Halls 3 and 4. He stated he does not staff according to acuity, but on the patient census.

During an interview and concurrent review of the 2016 Nursing Staffing Plan on 9/20/16 at 1:35 p.m., the Staffing Coordinator stated the 2016 Plan utilizes patient census and ratios rather than patient acuity.

During an interview and concurrent review of the 2016 Nursing Staffing Plan and 2015 Nursing Staffing and Acuity Plan on 9/20/16 at 1:42 p.m., Administrative Staff A was asked if use of the Staffing and Acuity form had been removed from the 2016 staffing plan. She stated, "Yes," and added staffing is "just done with ratios right now." When asked where the set ratios came from, Administrative Staff A stated it was the standard of practice at the facility before her employment and they were not based on any laws or regulations. Administrative Staff A stated the facility stopped utilizing the acuity staffing form because it was "too complicated and people weren't always doing them."

Review of the policy titled, "Plan for the Provision of Care," revised 5/22/14, indicated under the section, "Nursing Staffing:" "Adjustments to the core staffing levels are made on the basis of more severe acuity. Such adjustments for planned staffing are made daily by the Chief Nursing Officer or his/her designee based on the clinical services acuity guidelines."

Review of the policy titled, "Scheduling of Nursing Personnel," revised 11/12/14, indicated: "A daily schedule will be given to the Nurse Managers and House Charges for reference and for required adjustments to meet fluctuating patient acuity care needs."

Review and comparison of the "Nursing Staffing and Acuity Plan 2015," dated May 2015, and the "Nursing Staffing Plan 2016," dated June 2016 indicated the following differences:

1. Staffing Plan: Each plan included the statement: "Each unit has a pre-determined maximum patient to staff ration used as a guideline (Attachment A--Staffing Matrix). This staffing is established according to census, type of unit, and by shift." The 2015 Plan only continued on and also stated: "This guideline is adjusted according to each 'patient/acuity.' For each shift an Acuity Evaluation Form (Attachment B) is completed by the unit Registered Nurse to ensue prompt recognition of any change requiring additional intervention(s) by nursing staff. Unit RN, LVN/LPT and MHW FTE allocations are reviewed and revised, as appropriate, based on acuity contributory factors. The total number of staff is determined by totaling the acuity hours on the Acuity Evaluation form and the total on the Staffing Matrix."

2. Daily Staffing: The 2015 plan indicated: "The acuity evaluation form will be completed on each eight (8) hour shift, two (2) hours prior to the end of the shift. Staff category decisions should be based on tasks listed on the acuity level system form and should address as much behavioral, measurable and objective data as possible. The acuity report will be given to the CNO/NM/HC two (2) hours prior to the next shift for review. At this time any questions will be discussed with the unit charge nurse and staffing levels will be reconciled accordingly." This language was omitted in the 2016 Plan.

3. Staffing Variances: The 2015 plan indicated: "The acuity ratings are filed in the House Charge/Staffing office. Variations from staffing plans are documented with explanation and the Chief Nursing Officer is involved as needed." The 2016 Plan did not include this section or language.

4. Attachment A: The 2016 Plan included a chart which indicated: "Staffing ratios: maximum per staff member." The ratios listed were 1:5 for for Day and Evening shifts and 1:6 for the Night shift. The 2015 Plan did not include this chart. The 2015 Plan included a "Staffing and Acuity" worksheet.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review, the hospital failed to ensure licensed staff kept current the multidisciplinary treatment plan for a patient that required sexual precautions, and to include individual interventions for sexual precautions for one of 25 patients (Patient 1). These failures could result in a delay in treatment and security for both the patient and others.

Findings:

Review of the Discharge Summary dated 8/16/16 indicated Patient 1 was admitted on [DATE] with diagnoses Bipolar disorder, severe, manic with psychotic features. The Discharge Summary indicated during the hospitalization , a female adolescent patient alleged that there had been some sexual contact between Patient 1 and Patient 2.

Review of Patient 1's master treatment/care plan indicated there were no updates to the initial problems/goals of the master treatment/care plan which described interventions that were provided to the patient such as ensuring safety of patients involved, immediately report alleged occurrences to the charge nurse, monitor patient for attempts to sneak into other patient rooms. There were no specific sexual precautions identified for Patient 1 until 8/9/16.

During an interview on 9/20/16 at 1:45 p.m., Licensed Staff P stated that Patient 1 was problematic. Licensed Staff P stated that the nurse admitting the patient would complete a head to toe assessment of the patient when they arrive to the unit, looked at the orders and verified what is being done for the patient. Licensed Staff P stated that a treatment plan of care should have been updated on 8/3/16 when the physician order was received for the ten foot rule (a distance of ten feet between Patient 1 and other patients) to begin. The nurse needed to revise the care plan as needed.

On 9/20/16, review of the facility policy MULTIDISCIPLINARY TREATMENT PLANNING (MDTP), revised 7/28/16, indicated the purpose "to provide a process for implementation of comprehensive individualized treatment planning for every inpatient. The MDTP is reviewed and revised as needed...The plan shall be revised more frequently when the patient's status or acuity changes significantly (example if patient is secluded or restrained for very dangerous/violent behavior to self or others)...Each patient's MDTP is reviewed at least twice a week and more often as warranted. The Physician directs patient care planning."
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on interview, and document review, the hospital failed to authenticate a progress note on the INPATIENT INTERDISCIPLINARY NOTES for one of 25 patients (Patient 1). This failure of the progress notes not authenticated in the medical record that are not legible may be misread or misinterpreted and may lead to medical errors or other adverse patient events.

Findings:

During a concurrent interview with Administrative Staff B and review of the closed record on 9/20/16 at 11:20 a.m., the progress note in the "INPATIENT INTERDISCIPLINARY NOTES" for Patient 1 was reviewed for "8/5/16 at 2100." The entry on "8/5/16 at 2100" did not contain the signature of the author of the progress note. Administrative Staff B concurred and could not provide the author's name.

During a concurrent interview with Non Licensed Staff C and view of the progress note on 9/20/16 at 4:30 p.m., the progress note in the "INPATIENT INTERDISCIPLINARY NOTES" for Patient 1 was reviewed for "8/5/16 at 2100". She stated she was the author of the note. She stated she was advised by her charge nurse to document what Patient 1 had told her. She stated she did not know she needed to sign the note.

During an interview with Administrative Staff D on 9/21/16 at 3:00 p.m., she stated her department does not evaluate for the completeness of the medical records for the non-physician staff. Administrative Staff A and Administrative Staff B stated the hospital did not have a current quality assurance/performance improvement program in place to evaluate and authenticate the non-physician missing documentation once a patient has been discharged .

Review of the policy and procedure titled "DOCUMENTING NURSING CARE" effective date 5/1/13, indicated "...Narrative documentation in the progress note will include as appropriate, but not be limited to, the following: ...Signature and title."
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
Based on staff interview, clinical record review, and document review, the facility failed to ensure verbal physician orders were signed by the health provider in a timely manner four times for 2 of 25 patients (Patients 3 and 4). This had the potential for an incorrect order to be written and possible incorrect implementation which could negatively affect patients.

Findings:

During clinical record review on 9/21/16 at 1:08 p.m., Patient 4 had three physician orders which indicated:
1. A "VORB" (Verbal Order Read Back) order from Physician K dated 8/23/16: "D/C (discontinue) B Complex (vitamin B complex). Multivitamin w/o (without) minerals daily nutritional supplement." Following the order was: "MD ________ (signature blank) Date ________ (blank) and Time _________ (blank)."

2. An order which did not indicate whether it was a verbal or telephone order as indicated by the acronym VORB or TORB (Telephone Order Read Back) from Physician L indicated: "OK for pt (patient) to take morning dose of lopresso (sic) 50 mg (milligrams) and Zostril 10 mg for HTN (high blood pressure) now." Following the order was: "MD ________ (signature blank) Date ________ (blank) and Time _________ (blank)."

3. A VORB order from Physician B dated 9/4/16: "Pt (patient) may attend meals off unit." Following the order was: "MD ________ (signature blank) Date ________ (blank) and Time _________ (blank)."

During an interview and concurrent clinical record review on 9/21/16 at 1:18 p.m., Licensed Staff M was asked how long the physician had to sign a verbal order from the time it was received by the nurse. She stated: "Usually within 24 hours." Licensed Staff M acknowledged the three physician orders for Patient 4 had not been signed. When asked whose job it was to check to make sure verbal orders had been signed by the physician, Licensed Staff M stated there was a nurse who was responsible for this.

During clinical record review on 9/22/16 at 11 a.m., Patient 3 had a VORB physician order from Physician N dated 9/17/16 which indicated: "Initial ice pack for bruises (right) hand." Following the order was: "MD ________ (signature blank) Date ________ (blank) and Time _________ (blank)."

During an interview and concurrent clinical record review on 9/22/16 at 11:40 a.m., Licensed Staff I was asked how long the physician had to sign a verbal order from the time it was received by the nurse. She stated: "Within 24 hours. The next day." Licensed Staff I acknowledged Patient 3's physician order had not been signed.

Review of the policy titled, "Authentication--Physician Orders," dated 5/1/13, indicated: "Verbal or telephone orders shall be taken and recorded only by a staff member licensed to do so. These orders shall be co-signed within 24 hours by an authorizing person according to hospital policy."

Review of the policy titled, "Safe Medication Management Process," revised 7/30/14, indicated "VORB" was the acronym for "Verbal Order Read Back," and "TORB" was the acronym for "Telephone Order Read Back."