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.

TWO RIVERS BEHAVIORAL HEALTH SYSTEM 5121 RAYTOWN ROAD KANSAS CITY, MO 64133 Aug. 16, 2018
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview, record review, policy review, and video review the facility failed to:
Ensure patients admitted with diagnosis of suicidal ideation, history of suicidal ideation or attempts to harm self or others were provided care in a safe setting for six patients (#10, #30, #6, #7, #28, and #29) of six patient's reviewed in the Assessment and Referral Center (ARC, specialty area of the facility that performs assessments prior to admission).
Ensure patient and staff safety when doors to the nurse's station (a non psych safe area) were left open and one suicidal patient (#14) entered the nurse's station unsupervised.
Ensure contraband (harmful material) room checks were completed appropriately, doors made with non psych safe screws (potentially used for cutting), leaving a pack of pens (potentially used for cutting or stabbing) unattended in the dayroom, leaving a charging cord (potentially used for strangulation) for one patient's (#22) ankle monitor unattended in an open psychiatric dayroom, allowing access to contraband for all other patients on the unit.

These deficient practices resulted in the facility's non-compliance with specific requirements found under the Condition of Participation: Patient Rights. The facility census was 19.

The severity and cumulative effect of these systemic practices had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ).

On 08/15/18, after the survey team informed the facility of the IJ, the staff created educational tools and began educating all staff and put into place interventions to protect the patients.

As of 08/16/18, at the time of survey exit, the facility had provided an immediate action plan sufficient to remove the IJ by implementing the following:
- Increased staffing the ARC so that additional staff member was assigned to the secured Intake Area waiting room for all shifts.
- An RN or PST will greet individuals in the main lobby upon arrival for appointment or transfer.
- Revised admission process to include:
a. Patients identified as moderate risk of suicide/homicide/elopement then monitoring will be increased to 10 minute intervals.
b. Patients identified as high risk of suicide/homicide/elopement will immediately be placed on a 1:1 status, changed into facility provided garments, shoes removed, admission paperwork completed and escorted to the assigned unit.
c. Direct transfers of patients from another facility will be taken directly to the inpatient unit and the admission process will be completed there.
- All nurses in the ARC will be supervised by the Director of Nursing.
- All staff educated completed prior to their next shift.
- The DON will perform real-time monitoring and audits for all high risk patients for 30 days, then decrease to three times per week for 60 days and then three times per month for the next six months.
- The Director of Risk Management/Performance Improvement changed the process so that the lobby bathroom doors must remain locked and will be unlocked only by staff.
- The initial safety screen policy was revised to include securing belongings and wanding with a metal detector of all patient/visitors that are allowed into the secured intake area.
- All intake staff education completed prior to their next shift.
- The Director of Risk Management will audit compliance by reviewing camera surveillance daily for 30 days, then one day's visitors per week for 60 days and then once per month for the next six months.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review the facility failed to:
Ensure patients admitted with diagnosis of suicidal ideation, history of suicidal ideation or attempts to harm self or others were provided care in a safe setting for six patients (#6, #7, #10, #28, #29. #30) of six patient's reviewed in the Assessment and Referral Center (ARC, specialty area of the facility that performs assessments prior to admission).
Ensure patient and staff safety when doors to the nurse's station (a non psych safe area) were left open and one suicidal patient (#14) entered the nurse's station unsupervised.
Ensure contraband (harmful material) room checks were completed appropriately, doors made with non psych safe screws (potentially used for cutting), leaving a pack of pens (potentially used for cutting or stabbing) unattended in the dayroom, leaving a charging cord (potentially used for strangulation) for one patient's (#22) ankle monitor unattended in an open psychiatric dayroom, allowing access to contraband for all other patients on the unit.
This had the potential to affect any patient that entered and/or admitted to the facility. The facility census was 19.

Findings included:

Review of the facility's policy titled, "Admission Procedure for Acute Services," revised 04/2018, showed that:
- It was the policy of the facility to utilize a standard procedure in the assessment/admission of patients that reinforces safety, quality care, and efficiency in communication with other team members.
- When an individual presents to the facility for an evaluation, the receptionist will begin a patient observation rounds sheet with 15 minute safety checks.
- The intake specialist will assess behaviors/patient condition that may warrant immediate attention/interventions.
- The intake specialist will make the necessary provision to ensure patient and staff safety during the assessment/admission process.

Review of the facility's document titled, "Intake assessment," showed an assessment was performed on an individual based on a series of question that included suicidal risk factors and suicide protective factors. Any yes answer was scored using a numbered system. The total number of yes answers were added together to determine the risk level and was defined with interventions as:
-Low risk, continue to monitor and assess suicidality each shift;
-Moderate risk, continue to monitor on suicidal precautions, complete suicide assessment each shift , notify physician if this was a change in condition; and
-High risk, continue to monitor on suicidal precautions, complete suicide assessment each shift, close observation by staff to monitor for suicidal behaviors/indicators, notify physician, consider one to one (direct line of sight).

Observation on 08/14/18 at 1:04 PM, in the main lobby, showed Patient #10 entered the facility, in her street clothes (potential to hide contraband,) accompanied by Emergency Medical Services (EMS). The receptionist initiated patient observation/precaution rounds (document used by staff to show visual accountability of the patients.) Patient #10 asked the receptionist to use the restroom, entered the restroom, and was not in sight of any staff.

During an interview on 08/14/18 at 1:05 PM, Staff Z, EMS, stated that Patient #10 was from another facility as a direct admit (transfer from another facility with physician to physician acceptance) for a suicidal (thoughts to kill self) with recent suicide attempt prior to arrival to this facility.

During an interview on 08/14/18 at 1:15 PM, Staff AA, Receptionist, stated that the receptionist started patient observation/precaution rounds every 15 minutes on all patients that entered the facility. The receptionist did not have a standing order or protocols to follow for the levels of observations and were not directed to what level of observations were on the patients. She was unaware that Patient #10 was suicidal, and acknowledged that the patient was out of her sight.

Observation on 08/15/18 at 1030 AM in the main lobby bathroom, showed the following unsafe environment for psychiatric patients diagnosed as suicidal:
- Two bathroom stalls with hinges (potentially used for ligatures);
- Tampon machine with sharp corners (potential for self-harm);
- Two removable metal bins in the stalls (potential for self-harm); and
- Hand dryer with a grill (potentially used for a ligature).

Review of the patient observation/precaution rounds initiated by Staff AA for Patient #10, showed monitoring levels with 15 minute checks, and no precaution type (self-harm, suicide, assaultive, homicidal, etc.) level indicated.

Observation on 08/14/18 at 1:38 PM, in ARC, showed Patient #10, in her street clothes, alone, unsupervised in the waiting room. In the adjacent room, view by opening a door through the waiting room was a Registered Nurse (RN) and the ARC Director, no other patient was in the ARC at this time.

Review of Patient #10's intake assessment, dated 08/14/18, showed that she was a direct admission, suicidal with recent attempt prior to arrival. The risk assessment was determined that she was a high suicidal risk. The patient observation showed 15 minute rounds for 2 hours and 46 minutes in the ARC. The patient remained in her street clothes until 3:48 PM (2 hours and 44 minutes after arrival.) The medical record did not contain any documentation for increased level of observation, notification of a physician or physician orders for increased level of observation.

During an interview on 08/14/18 at 1:40 PM, Staff JJ, Registered Nurse (RN), stated that direct admissions and new patients all go through the ARC. All patients in the ARC were on 15 minute patient observation/precaution rounds and the precaution level was done by the admitting nurse on the unit after the patient leaves the ARC. She acknowledged that Patient #10 could not be seen unless the door was opened to the waiting room. There was a video monitor that could be viewed in the assessment area of the waiting room. There was no staff assigned view the monitor continuously. Staff JJ also stated that there were times when the patients in ARC were not observed.

During an interview on 08/14/18 at 1:40 PM, Staff OO, RN, stated that patients that were in the ARC remain in their street clothes until the ARC staff performs the skin assessment. On admission, the ARC staff do not search for contraband (belts, shoestrings, etc., items that could be used for self-harm,) the staff has the patients "just to show inside of their pockets."

During an interview on 08/14/18 at 10:36 AM, Staff M, Assessment and Referral Center Director, stated that the individuals that were in the ARC were not considered patients. The ARC staff do not call physicians or obtain orders for level of observation. The intake assessments were done to assess what coverage was available for treatment.

Even though Patient #10 was a scheduled appointment and the facility was aware of the patient's history of suicidal attempt, the facility failed to provide increased level of observation. This failed practice has the potential to affect all patients with suicide risk that enter the facility.

Review of Patient #30's intake assessment, dated 06/27/18,showed that he was suicidal, behavior was "out of control", angry, and manic (change in person's mood accompanied by high energy levels).The risk assessment was determined that he was a high suicidal risk. The patient observation showed 15 minute rounds initiated at 7:25 PM with no precaution type, for 3 hours and 37 minutes in the ARC. The patient remained in his street clothes. The patient attempted to elope from the facility, injured his hand requiring more than first aid, and was transported to another facility for treatment. The patient returned to the facility on [DATE] at 2:22 AM, where the patient successfully eloped (left without permission, or acknowledgment from the facility's staff) from the facility at approximately 2:32 AM. The medical record did not contain any documentation for increased level of observation, notification of a physician or physician orders for increased level of observation.

During an interview on 08/14/18 at 4:00 PM, Staff KK, Licensed Professional Counselor (LPC), stated that he remembered Patient #30 and the events on 06/27/18. Patient #30 attempted to elope from the facility through the lobby, and was stopped by staff. The ARC staff continued to do patient observation/precaution rounds every 15 minutes. Staff KK acknowledged that there were times when the patients in the ARC were not observed or supervised.

During an interview on 08/14/18 at 4:00 PM, Staff K, LPC, stated that she remembered Patient #30 and the events on 06/28/18. Patient #30 returned from another facility for treatment of his hand. She was performing a skin assessment on another patient and was not observing Patient #30. The patient successfully eloped from the facility. Staff K acknowledged that there were times when the patients in the ARC were not observed or supervised.

Even though the facility was aware of Patient #30's attempt to elope from the facility, the facility failed to increase the level of observation, which resulted in the patient's successful elopement from the facility.

Review of Patient #6's intake assessment, dated 08/13/18, showed that she was suicidal with a plan to cut herself and end her life. The risk assessment was determined that she was a high suicidal risk. The patient observation initiated at 8:18 AM, showed 15 minute rounds for 2 hours and 22 minutes in the ARC. The patient remained in her street clothes until 10:40 AM (2 hours and 22 minutes.) The medical record did not contain any documentation for increased level of observation, notification of a physician or physician orders for increased level of observation.

Review of Patient #7's intake assessment, dated 08/13/18, showed that he was a direct admission, (transfer from another facility with physician to physician acceptance) suicidal, assaultive behavior, and homicidal. The risk assessment was determined that he was a high suicidal risk. The patient observation initiated at 11:39 AM, showed 15 minute rounds for 2 hours and 6 minutes in the ARC. The patient remained in his street clothes until 1:31 PM (2 hours and 2 minutes.) The medical record did not contain any documentation for increased level of observation, notification of a physician or physician orders for increased level of observation.

Review of Patient #28's intake assessment, dated 07/15/18, showed that he arrived with Law Enforcement (LE), suicidal with elopement prior to arrival from LE. The risk assessment was determined that he was a high suicidal risk. The patient observation initiated at 00:08 AM, showed 15 minute rounds for 2 hours and 58 minutes in the ARC. The patient remained in his street clothes until 3:11 AM (3 hour and 3 minutes.) The medical record did not contain any documentation for increased level of observation, notification of a physician or physician orders for increased level of observation.

Review of Patient #29's intake assessment, dated 06/14/18, showed that she was a direct admission, suicidal attempt with knife, violent with property destruction. The risk assessment was determined that she was a high suicidal risk. The patient observation initiated at 7:21 AM, showed 15 minute rounds for 3 hours and 6 minutes in the ARC. The patient remained in her street clothes until 9:30 AM (2 hours and 9 minutes.) The medical record did not contain any documentation for increased level of observation, notification of a physician or physician orders for increased level of observation.

Even though the ARC staff assessment showed the patients at high risk level for self harm, the staff failed to implement immediate intervention to provide safety to the patients.

During an interview on 08/15/18 at 1:30 PM Staff J, Chief Executive Officer (CEO), stated that it was the facility's staffs responsibility to provide safety to the patients.

Review of the facility's policy titled, "Identification of Contraband," revised 08/2018, showed that it was the policy to provide a safe and secure environment for patients, visitors and staff and to withhold items that may be considered dangerous if present on the units. The following items are considered to be contraband for patients on all units and these items will be sent home or securely stored during a patient's stay in the hospital:
- Alcohol based substances, hand sanitizer
- Any metal items
- Pens/pencils/paperclips/keys
- Books (including soft cover, hard cover, notebooks, coloring books, etc)
- Cords/string/ribbon/paracord items
- Pagers/camera/phones
- Electronics (including batteries of all types)

Even though requested, the facility failed to provide a policy regarding patient movement between Module A and B on the Adult Psychiatric floor, for group therapy and sleeping room access.

Observation on 08/13/18 at 3:00 PM on the Adolescent Psychiatric Unit, the Adult Psychiatric Unit Module A (Focused group for patients that were bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), schizophrenic (a disorder that affects a person's ability to think, feel and behave clearly), psychotic (a mental disorder characterized by a disconnection from reality) and/or alcohol/substance abuse withdrawal) and Adult Psychiatric Unit Module B Nurse's station, showed the following:
- The newly built half doors that separated the patient area from the nurse's station were made with non-psych safe screws.
- The doors had slide locks on the inside of the door, but were not locked and/or not able to be locked.
- At times the doors were left wide open which had the potential for patients to access a non-psych safe area.

During an interview on 08/13/18 at 3:30 PM, Staff H, Lead Patient Safety Tech (PST), stated that the adult patients on Module A attended group therapy sessions on Module B and on occasion they were escorted through the nurses station. Patients usually go through the secured locked doors at the entrance to the unit. The doors were unlocked automatically through a button pressed at the nurse's station and patients were watched as they walked through the hallway and passed through the door to Module A or B.

Review of Patient #14's Psychiatric Evaluation dated 08/08/2018 showed that he was a [AGE] year old male admitted to the facility for hearing voices and attempted suicide by overdose.

Observation on 08/14/18 at 10:00 AM in the Adult Unit Nurse's Station showed Patient #14 walk through the unlocked half door from Module B and was standing in the nurse's station unsupervised.
Contraband items located in the nurses station included pens, paper clips, patient charts, phones, computer screens, two metal three hole punch devices, can of alcohol foam hand sanitizer, and a set of three thermostat keys.

During an interview on 08/14/18 at 2:00PM, Patient #14 stated that he was in room 215, which was on Module A of the Adult Unit. He stated that he attended group sessions on Module B and sometimes staff walked him through the nurse's station to attend group.

Observation on 08/15/18 at 9:00 AM on the Adult Unit Module B Dayroom showed a pack of 18 gel pens and one ink pen laying on the table unsupervised. Patients were seen going in and out of the room and Staff A, PST, did not notice that the pens were on the table.

During an interview on 08/15/18 at 9:30 AM, Staff A, PST, stated that pens should not be left out in the dayroom unless a staff member was supervising and observing the activity.

During an interview on 08/13/18 at 2:55PM, Staff A, Patient Safety Tech, stated that:
- The techs are the staff responsible for completing contraband checks on each unit;
- Contraband checks are completed on each shift, or twice daily, at random times;
- The purpose is to make sure that patients have not obtained or hidden any contraband (items that can be used to injure self or others).

Review of facility's Patient Observation Rounds sheet directed staff to monitor suicidal patients for contraband, razors, cords, etc.

Review of facility document titled, Confidential Information (Incident Report), dated 07/16/2018, showed that a staff member found a 13 foot charging cable, for an ankle monitor, unattended in the group room of a psychiatric unit.

Review of Patient #11's medical record, showed:
- That she was admitted to the facility on [DATE] with a history of a recent intentional overdose, suicidal ideations, and a plan;
- Diagnosis for this admission included, major depressive disorder, alcohol dependency, and sedative, hypnotic, or anxiolytic abuse;
- Recent arrest for third incident of Driving under the Influence (DUI), and was required to wear an ankle monitor;
- A physician's order dated 07/16/18 at 2:15 PM, allowing patient to use charging cord for ankle bracelet monitoring device only in the presence of staff.

Review of Patient #11's Medical Device Observation Rounds sheets showed:
- Direction for staff to monitor patient's ankle monitor unit every 15 minutes while wearing;
- Direction for staff to monitor patient's charging cord every 5 minutes while in use;
- That on 07/16/18 the charging cord was last observed at 10:51 AM in the Group Room, with no further observation until 2:20 PM in the Dayroom.

During an interview on 08/15/18 at 10:15 AM, Staff T, Director of Nursing (DON), stated that the nurse's station on every unit is a non-psych safe area and her expectation of staff was to keep the half doors locked at all times and patients should never be escorted through or allowed in the nurse's station. The doors should have psych safe screws. Pens should not be lying around and should be accounted for.

These failures had the potential to place all patients and staff in danger when contraband was left unattended and patients were allowed access to the nurse's station.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0431
Based on staff interviews, review of medical records and review of policies and procedures, the facility failed to ensure that a safe and effective medical record service was provided. The facility failed to:
- Ensure that patient medical record entries were accurately written and complete for four discharged patients (#12, #22, #23 and #26) of four reviewed. (refer to A438)
- Provide physican orders for one electrocardiograms (EKG, measures the heart's electrical activity) of one discharged patient (#22) and one four point manual hold restraint order for one discharged patient (#12). (refer to A457)
- Ensure discharge summaries were completed for 280 of 280 discharges reviewed. (refer to A468)
- Implement accurate and timely interventions that corresponded to the documented suicide risk assessment for six patients (#6, #7, #10, #28, #29 and #30) of six suicidal patients records reviewed. (refer to A467)
- Complete physician signatures and/or deficiencies within thirty days for 187 patient discharges of 187 reviewed. (refer to A454)

The cumulative effect of these systemic failures resulted in the facilities inability to ensure the provision of quality medical record services.
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to have accurately written and promptly completed medical records for four discharged patients (#12, #22, #23, #26) of four discharged patients whose charts were reviewed. The facility census was 19.

Findings included:

Review of facility's policy titled Restraint and Seclusion, dated 3/2018, directed staff to document the following in the patient's medical record for each episode of restraint or seclusion:
- Less restrictive interventions attempted;
- The circumstances that led to the use of the restraint or seclusion;
- Specific behaviors that led to the episode;
- Detailed description of the events leading up to the incident and other pertinent information;
- The rationale for use of restraint or seclusion;
- Notifications, including the child or adolescent's family, the attending physician, and any consultations;
- Written physician orders including each renewal order;
- Behavioral criteria for discontinuation of restraint or seclusion including informing of the patient;
- The initial face-to-face and subsequent re-evaluations of the patient;
- Initiation of the restraint or seclusion treatment plan addendum;
- Monitoring of the patient's status;
- Continuous monitoring of patient and care provided including the patient's response to restraint or seclusion;
- Debriefing of the patient and staff;
- Any injuries sustained and treatment received for these injuries; and
- Time of termination of restraint or seclusion.

Review of the facility's Restraint/Seclusion packet (total of 8 pages) showed that it contains the following documentation:
- Physician's Order;
- Restraint/Seclusion Nursing Documentation (two pages);
- Restraint and/or Seclusion Patient Status Flow Sheet; and a
- Post Restraint Staff Debriefing.

Review of Patient #22's medical record showed that:
- She was admitted to the facility on [DATE] for Unspecified Depressive Disorder;
- She was placed in a therapeutic hold a total of 12 times per order review;
- A total of six separate hold order (06/15/18 at 4:45PM, 06/15/18 at 6:10PM, 06/16/18 at 4:37 PM, 06/16/18 at 5:00PM, 06/17/18 at 4:18PM, and 06/17/18 at 7:03PM) with no correlating incident reports.

Review of Patient #23's medical record showed that:
- A [AGE] year old male was admitted on [DATE] for Disruptive Mood Dysregulation Disorder (DMDD) and Attention-deficit/hyperactivity disorder (ADHD);
- He was placed in therapeutic holds on four separate occasions;
- Multiple time discrepancies for the 08/08/18 incident, order written for hold with time of 16:08;
- Nursing documentation showed that hold was initiated at 14:08 and ended at 14:16;
- The restraint flowsheet started the checks at 16:08 and ended at 16:14;
- The corresponding incident report showed that the hold was initiated at 12:08 and ended at 14:16;
- According to documentation the hold for 08/08/18 started at three different times, 12:08, 14:08, and 16:08.

Review of facility's Incident Report, dated 08/09/18, and showed that Patient #23 was placed in a therapeutic hold on 08/09/18 at 14:08, which ended at 14:16. No order, nursing documentation, or restraint flow sheet was located for that date.

Review of Patient # 26's medical record showed that a [AGE] year old male was admitted on [DATE] with DMDD. Inconsistent times were noted on an Electrocardiogram (EKG) that had a handwritten date of 06/24/18 and the machine time stamp of Jan/01/2001, the EKG was ordered on [DATE].

Review of Patient # 12's medical record showed that a nine year old female was admitted on [DATE] with DMDD. Inconsistent times were noted on two EKG's that had a handwritten dates of 06/05/18 on both, and the machine time stamp of Jan/01/2001, with no orders on the chart to complete the EKG's.

During an interview on 08/14/2018 at 9:10AM, Staff W, RN, stated that every hold gets an order and an incident report should be completed in the computer.

During an interview on 08/13/2018 at 3:50PM, Staff D, Registered Nurse (RN), Director of Utilization Review, stated that any time a restraint or hold is used, the staff and patients are debriefed, and an incident report is filed for every incident/hold.

During an interview on 08/16/2018 at 9:15AM, Staff T, Director of Nursing (DON), stated that:
- Every Restraint/Seclusion packet that is completed should have correct date, time, technique, and requirements for release accurately documented;
- The expectation for staff would be that there would be no holes or missing information from the documentation;
- She was unable to locate an order, nursing documentation, or a restraint flow sheet for Patient #22's four point hold on 06/16/18 from 6:10PM to 6:30PM.

During an interview on 08/16/18 at 10:20AM, Staff L, RN, Nurse Manager, stated that the expectation for staff would be for them to document appropriately, including date, time, techniques for de-escalation, requirements for patient release, and the length of each and every hold utilized on a patient.

During an interview on 08/15/18 at 11:00 AM, Staff EE, Director of Health Information Management (HIM) stated that medical record services did not audit nursing or clinical staff's documentation for completion of the medical record.
VIOLATION: CONTENT OF RECORD Tag No: A0449
Based on interview and record review the facility failed to ensure the content of the medical record contained correct consultation with physician information for one patient (#10) of six patients reviewed. This had the potential to affect any patient in the Assessment and Referral Center (ARC, specialty area of the facility that performs assessments prior to admission). The facility census was 19.

Findings included:

Review of the facility's policy titled, "Admission Procedure for Acute Services," revised 04/2018, showed that upon completion of the assessment, the intake specialist will contact the licensed practitioner, who is a member of the hospital medical staff, to review the intake assessment information obtained from the patient and/or individuals accompanying the patient. This review may be conducted with the licensed practitioner in person or via telephone.

Review of Patient #10's intake assessment, dated 08/14/18 at 2:23 PM, showed that she was a direct admission, (transfer from another facility with physician to physician acceptance) suicidal with recent attempt prior to arrival. The medical clearance history showed that the patient reported that she had a urinary tract infection (UTI, infection of the bladder) and the admitting nurse was to follow up. The transfer facility's urinary laboratory findings showed four plus bacteria (normal value was no bacteria, acute psychotic relapse can be related to an elevated level of bacteria.) The recommended care was to be admitted to the adult inpatient unit. The consultation with the physician was dated and timed for 08/14/18 at 1:32 AM. (Approximately 12 hours before the ARC staff completed the assessment)

During an interview on 08/15/18 at 9:00 AM, Staff OO, Registered Nurse (RN) stated that the purpose of the consultation was to review with the physician the assessment performed by the ARC staff. With Direct admissions, the physician was only called once, and that time would be entered into the medical record even if it was 12 hours before the assessment was actually performed.

Review of Patient #10's inpatient admission assessment, dated 08/14/18 at 4:00 PM, showed no documentation that addressed Patient #10's UTI for treatment.

During an interview on 08/15/18 at 10:00 AM, Staff T, Nursing Director, stated that she did not have authority over the RNs in ARC. She preferred that only one assessment would be performed and a consultation with the physician at the time of the assessment be done to prevent missed information and treatment as with Patient #10's UTI.

During an interview on 08/15/18 at 11:00 AM, Staff EE, Director of Health Information Management (HIM) stated that medical record services did not audit nursing or clinical staff's documentation for completion of the medical record.
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
Based on interview and record review the facility failed to have physician signatures and/or deficiencies (any documents that required a physician's signature) completed within thirty days of the patient's discharge for 187 of 187 discharges reviewed. The facility census was 19.

Findings included:

Review of the facility's policy titled, "Medical Record Delinquency Reporting" revised 11/2016, showed direction for staff to complete patient medical records within thirty days from the patient's discharge per state and hospital policy.

Review of the facility's notice, dated 08/09/18, showed that Staff S, Physician, had 75 medical records that lacked physician signatures and/or deficiencies which were more than 30 days delinquent from the patient's discharge.

Review of the facility's notice, dated 08/09/18, showed that Staff II, Physician, had 40 medical records that lacked physician signatures and/or deficiencies which were more than 30 days delinquent from the patient's discharge.

Review of the facility's notice, dated 08/09/18, showed that Staff G, Physician, had 37 medical records that lacked physician signatures and/or deficiencies which were more than 30 days delinquent from the patient's discharge.

Review of the facility's notice, dated 08/09/18, showed that Staff HH, Physician, had 21 medical records that lacked physician signatures and/or deficiencies which were more than 30 days delinquent from the patient's discharge.

Review of the facility's notice, dated 08/09/18, showed that Staff GG, Physician, had 14 medical records that lacked physician signatures and/or deficiencies which were more than 30 days delinquent from the patient's discharge.

During an interview on 08/15/18 at 11:00 AM, Staff EE, Director of Health Information Management (HIM) stated that patient's medical records should be completed within thirty days of the patient's discharge from the facility.

During an interview on 08/15/18 at 1:30 PM Staff J, Chief Executive Officer (CEO), stated that it was a challenge to get the physicians to complete the medical record.
VIOLATION: VERBAL ORDERS AUTHENTICATED BASED ON LAW Tag No: A0457
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, record review, and policy review, the facility failed to obtain a physician's order for a four point manual hold restraint for one discharged patient (Patient #22), and failed to follow their Electrocardiogram (EKG) policy upon admission for one discharged patient (Patient #12), whom they completed two EKGs on without a physician's order. The facility census was 19.

Review of the facility's policy titled, Restraint and Seclusion, dated 03/2018, showed:
- Protective hold, therapeutic holds, and manual holds are all terms for restraint.
- Protective hold is defined as a type of physical restraint involving the application of physical force, restricting free movement of the whole body or a portion of the body in order to control physical activity.
- Hands on interventions are only permitted under emergency circumstances (when a patient displays violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others).
- Restraint or seclusion requires a physician's order.
- Documentation of each episode of restraint or seclusion includes:
a. Less restrictive interventions attempted;
b. The circumstances that led to the use of the restraint or seclusion;
c. Specific behaviors that led to episode;
d. Detailed description of events leading up to the incident and other pertinent information;
e. The rationale for use of the restraint or seclusion;
f. Notifications, including the child or adolescent's family, the attending physician (if not the ordering physician), and any consultations;
g. Written physician orders including each renewal order;
h. Behavioral criteria for discontinuation of restraint or seclusion including informing of the patient;
i. The initial face to face and subsequent re-evaluation of the patient;
j. Initiation of the restraint or seclusion treatment plan addendum;
k. Monitoring of the patient's status;
l. Continuous monitoring of patient and care provided including the patient's response to restraint or seclusion;
m. Debriefing of the patient and staff;
n. Any injuries sustained and treatment received for these injuries; and
o. Time of termination of restraint or seclusion.

Review of the facility's Restraint/Seclusion packet (total of 8 pages) showed that it contains the following documentation:
- Physician's Order;
- Restraint/Seclusion Nursing Documentation (two pages);
- Restraint and/or Seclusion Patient Status Flow Sheet; and a
- Post Restraint Staff Debriefing.

Review of Incident Report related to Patient #22 showed that she was placed in a four point restraint/hold on 06/16/18 at 6:10PM, and held till 6:30PM.

Record review of Patient #22's medical record showed that:
- A [AGE] year old female was admitted on [DATE] on a 96 Hour Imminent Harm Hold for Suicidal Attempt, and history of Depression, Bipolar Disorder, Schizoaffective Disorder, Histrionic Personality Disorder, and PTSD;
- She was placed in a physical hold twelve times according to order review;
- No order was found for four point restraint/hold dated 06/16/18.

During an interview and chart review of Patient #22's medical record on 08/16/2018 at 9:15AM, Staff T, Director of Nursing (DON), was unable to locate an order, nursing documentation, or a restraint flow sheet for Patient #22's four point hold on 06/16/18 from 6:10PM to 6:30PM.

During an interview on 08/13/2018 at 2:55PM, Staff A, Patient Safety Tech (PST), stated that staff only uses physical holds, no restraints, but a physician's order is required to use a hold of any type.

During an interview on 08/13/2018 at 3:50PM, Staff D, Registered Nurse (RN), Director of Utilization Review, stated that any time a restraint or hold is used, the staff and patients are debriefed, and an incident report is filed for every incident/hold.

During an interview on 08/14/2018 at 9:10AM, Staff W, RN, stated that every hold gets an order and an incident report should be completed in the computer.

During an interview on 08/14/2018 at 09:25AM, Staff L, RN, Nurse Manager, stated that 100% of all holds or seclusions are audited and each episode should have a staff debriefing.

During an interview on 08/16/2018 at 9:15AM, Staff T, Director of Nursing (DON), stated that:
- For any hold that is utilized, there must be a physician's order;
- A Restraint/Seclusion packet should be completed;
- An incident report should be completed for each hold, or incident; and
- She and Staff L, RN, Nurse Manager, decided to audit 100% of all holds/seclusions beginning 07/24/2018 due to staff failure to follow policy for proper documentation, including orders, specific behaviors, and criteria for release.

Record review of Patient #12's medical record showed that:
- A nine year old female was admitted on [DATE] at 6:45AM for Disruptive Mood Dysregulation Disorder (DMDD), and history of angry/destructive behaviors including assault of a foster sibling, and homicidal threats;
- There were two separate EKG's completed with hand written dates of 06/05/18on both;
- There was not an EKG order marked on the admission order sheet dated 06/02/2018; and
- The printed Admission Order sheet directs staff to complete an EKG on any child/adolescent; any adult patient taking methadone, or with history of cardiac disease, or [AGE] or older.

During an interview on 08/15/2018 at 09:55AM, Staff L, RN, Nurse Manager, stated that the policy is that each pre-adolescent, adolescent, and any adult over the age of 50, should have an Electrocardiogram (EKG) completed on the admitting unit, and it should be ordered on the admission orders.
VIOLATION: CONTENT OF RECORD - DISCHARGE SUMMARY Tag No: A0468
Based on interview and record review the facility failed to ensure patient medical records discharge summaries were completed within thirty days of the patient's discharge for 280 of 280 discharges reviewed. The facility census was 19.

Findings included:

Review of the facility's policy titled, "Medical Record Delinquency Reporting" revised 11/2016, showed direction for staff to complete patient medical records with a discharge summary within thirty days from the patient's discharge per state and hospital policy.

Review of the facility's notice, dated 08/09/18, showed that Staff S, Physician, had 160 discharge summaries that were more than 30 days delinquent from the patient's discharge. The delinquent discharge summaries dated from 03/07/18 through 07/05/18.

Review of the facility's notice, dated 08/09/18, showed that Staff II, Physician, had 73 discharge summaries that were more than 30 days delinquent from the patient's discharge. The delinquent discharge summaries dated from 10/06/17 through 07/09/18.

Review of the facility's notice, dated 08/09/18, showed that Staff G, Physician, had 33 discharge summaries that were more than 30 days delinquent from the patient's discharge. The delinquent discharge summaries dated from 08/24/17 through 07/09/18.

Review of the facility's notice, dated 08/09/18, showed that Staff HH, Physician, had 14 discharge summaries that were more than 30 days delinquent from the patient's discharge. The delinquent discharge summaries dated from 10/26/17 through 06/25/18.

During an interview on 08/15/18 at 11:00 AM, Staff EE, Director of Health Information Management (HIM) stated that patient's medical records should be completed with a discharge summary within thirty days of the patient's discharge from the facility.

During an interview on 08/15/18 at 1:30 PM Staff J, Chief Executive Officer (CEO), stated that it was a challenge to get the physicians to complete the medical record.