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.

OCEANS BEHAVIORAL HOSPITAL OF KATY 455 PARK GROVE LANE KATY, TX Sept. 21, 2018
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observation, interview & record review, the governing body failed to discharge its oversight responsibility in ensuring :

Protection of Patient Rights:

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

1) Safe environment: hazards that could be used for self-harm were identified in 4 patients' rooms / or on their person. Three (3) of the 4 patients were currently placed on suicide precautions. Cross refer A-0144

2) Patient # 1's right to be free from abuse and neglect. The facility failed to investigate a documented allegation of staff abuse made by Patient # 1.
Cross refer A-0145

3) An effective process to inform patients about the hospital's patient advocacy for two of two patients (Patient #13, Patient #15).

Cross refer A-0118

1) Patients' right to safety requirements were being met. Eight (8) of 8 direct patient care staff were unable to verbalize or demonstrate the use of the facility overhead paging system to announce emergency situations per facility policy and procedure.

Cross refer A-0142

1) Six (6) of 8 patients' right to access their personal property and have their property safeguarded. The facility failed to :

a. allow Patient # 2 access to his hearing aids during his entire admission; limiting his ability to participate in treatment and interact with staff and other patients.

b. Accurately complete the "Inventory of Patient Possession" form for 5 of six (6) current sampled patients .

Cross refer A-0129

Provision of Nursing Services:

Based on record review and interview, nursing staff failed to administer medication per physician order and professional standards of practice. Nursing administered medication incorrectly to lower Patient #22's blood pressure (BP) five (5) times. Patient fell due to an episode of hypotension (low blood pressure) on 8-24-18. He was transported to an acute hospital ER. Patient # 22 sustained a facial fracture.

Cross refer: A-0405

Based on observation, interview, and record review, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for 4 of 4 patients. Nursing failed to assess and intervene:

a.) In a diabetic patient's foot problem that potentially could lead to serious complications including amputation. (Patient # 15)
b.) To ease the patient's constipatory state( Patient # 17).
c.) To prevent further deterioration of the patient's kidney failure ( Patient #12) .
d.) To inform Nurse Practitioner (NP) of an elevated kidney function lab test. Patient # 3 was transferred the next day to an acute care hospital for possible dehydration based on the NP noting the lab test result

Cross refer A-0395

Based on record review and interview, the hospital failed to ensure that nursing staff developed, and kept current, a care plan for four of four patients (Patient #12, #17, #15, #23).

1) Patient #12 : The nursing care plan did not reflect the patient's insufficient kidney function or specified close observation of the patient's urinary status and fluid intake.

2) Patient #17 : The nursing care plan did not reflect the patient's condition or interventions to ease the lack of bowel movements.

3) Patient #15 :The nursing care plan did not address the diabetic patient's skin condition.

4) Patient #23 :The nursing care plan did not reflect fall prevention measures until after the patient sustained a fall two (2) days after admission. He was assessed as a moderate risk upon admission.

Cross refer A-0396
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review, observation, and interview, the hospital failed to ensure :

1) Four of four patients' right to receive care in a safe environment. Hazards that could be used for self-harm were identified in their rooms/ on their person. Three (3) of the 4 patients were currently placed on suicide precautions (Patient # 12, #16, #25, #26).

Cross refer A-144

2) Ensure Patient # 1's right to be free from abuse and neglect. The facility failed to investigate a documented allegation of staff abuse made by Patient # 1.

Cross refer A-145

3) An effective process to inform patients about the hospital's patient advocacy for two of two patients (Patient #13, Patient #15).

Cross refer A-118

4) Patients' right to safety requirements were being met. Eight (8) of 8 direct patient care staff were unable to verbalize or demonstrate the use of the facility overhead paging system to announce emergency situations per facility policy and procedure.

Cross refer A-142

5) Six (6) of 8 patients' right to access their personal property and have their property safeguarded. The facility failed to:

a. Ensure Patient # 2 had access to his hearing aids during his entire admission; limiting his ability to participate in treatment and interact with staff and other patients.

b. Accurately complete the "Inventory of Patient Possession" form for 5 of six (6) current sampled patients .

Cross refer A-129
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, interview, and observation, the hospital failed to establish an effective process to inform patients about the hospital's patient advocacy for two of two patients (Patient #13, Patient #15). There was no visual reinforcement of initially provided advocacy information for Patient #13 and Patient #15 whose sensorium and cognitive status on admission were poor and/or gravely impaired.


1) Patient #13 was noted with poor insight and judgement and psychosis at the time of her admission when staff explained the hospital's patient advocacy program to her. Seven days into her hospital stay, Patient #13 had concerns regarding her food tolerances and a kitchen-refused food item request. Patient #13 was unaware of the hospital's patient advocacy program.

2) Patient #15 was noted to be very limited in judgement upon admission. The patient suffered from psychosis and was cognitively impaired. During her hospitalization , the patient felt threatened by a hospital staff member and was unable to identify a patient advocate to voice her concerns.


Findings included

1) Patient #13 was observed in her room on 09/11/18 at approximately 1020. The patient complained that she "could not hold food down" and complained of lower abdominal pain. She stated, "I am very hungry," and had unsuccessfully requested a grilled cheese sandwich. Patient #13 denied knowledge of the patient advocate and did not know the staff member to whom she could file a complaint.

Patient #13's Preadmission Evaluation/Management document dated 09/04/18 at 1937 reflected the patient's "poor" insight and judgment. The patient was assessed to have "psychotic thoughts."

2) Patient #15 was observed in the South Side Day Area on 09/11/18 at 1112. The patient stated to the surveyor that she felt "threatened by the cleaning lady." Patient #15 denied knowledge of the patient advocacy and denied knowing which staff member to contact for a complaint.

Patient #15's Admit Nursing assessment dated [DATE] at 1730 reflected the patient's "unreliable insight/ judgement."

Physician Psychiatric Evaluation dated 08/30/18 at 1025 reflected the patient had "tangential thoughts" and "limited insight." Her judgement was "gravely impaired." The document reflected the patient had psychosis and cognitive impairment.

Physician Progress Notes dated 08/31/18 at 1027, 09/02/18 at 1210, 09/03/18 at 1015, 09/04/18 at 1216,09/05/16 at 1020, 09/06/18 at 1130, 09/07/18 at 1301, 09/08/18 at 1500, 09/09/18 at 1701, 09/10/18 at 0957, and 09/11/18 at 1133, reflected the patient had "poor insight."

Observations in the hospital South Side Day Area on 09/11/18 at 2115 reflected a bulletin board with patient rights information. The name of the patient advocate, CEO #1, was ripped off and a patient advocate was not identified.

CNO #2 acknowledged the above finding at that time and stated, "Somebody ripped the name of the patient advocate off." The surveyor asked CNO #2 how patients would know which staff member to contact for complaints and grievances. CNO #2 stated that it was "explained to them [the patients] on admission."
VIOLATION: PATIENT RIGHTS: EXERCISE OF RIGHTS Tag No: A0129
Based on observation, interview, and record review, the facility failed to ensure 6 of 8 patients' right to access their personal property and have their property safeguarded (Patient# 2, 3, 33, 34, 36, 40).

The facility failed to:

a. Ensure Patient # 2 had access to his hearing aids during his entire admission; limiting his ability to participate in treatment and interact with staff and other patients.

b. Accurately complete the "Inventory of Patient Possession" form for 5 of six (6) current sampled patients (ID # 3, # 33, # 34, # 36, # 40).

Findings included:

TX 462

Record review of facility policy titled "Personal Belongings" dated 1/11/2016 stated:" The patient has the right to keep and use personal clothes and possessions as directed by hospital policy."

Patient # 2:

Review of Complaint intake TX 462, it read:" ...Patient # 2 had his hearing aid and glasses locked up, reducing (patient's) ability to interact and participate in treatment ...."

Record review on 9/13/2018 of Patient (ID #2) "Inventory of Possessions" document, dated 10/29/17, revealed his hearing aid was locked in the medication room on admission 10/29/2017 and was not returned to the patient until 11/16/2017 at discharge.

Interview on 9/13/2018 at 1115 with, RN (Staff ID #11) he stated: "Patients need their classes and hearing aids to participate in group activities. Patient belongings are documented on the inventory sheet."




Record review on 9/14/18 of several current patients' "Inventory of Patient Possession" forms revealed the following:

a. Patients ID # 33, #36: patient belonging form was completely blank except for patient name label.

b. Patient ID # 2: patient belonging form showed documentation her eye glasses were in the facility Possession Storage room. Observation of the storage room on 09-14-18 at 10 a. m. failed to reveal Patient # 2's eyeglasses were stored there.

c. Patient ID # 40: patient belongings form had multiple items listed (socks, pants, sweater, glasses, etc..). The form lacked documentation to indicate the date items were secured and the location of the items.

d .Patient # 34: her belongings inventory form was completely bank, except for her name; however, she had belongings stored in the facility storage room:

Observation on 9/14/18 at 10:00 of Patient Possessions storage room revealed a brown colored large paper envelope that was stapled shut and had the name of Patient #34 written on the envelope. The envelope was opened to reveal the contents; a medium sized purse that contained personal belongings, including make-up, hair brush, keys, and various papers and paper receipts.


In an interview at the time of observation, with Staff #29, (responsible for patient possessions storage room), she stated that Patient #34's Inventory of Possessions document should have been completed to show that there was a purse along with a list of its contents.
VIOLATION: PATIENT RIGHTS: PRIVACY AND SAFETY Tag No: A0142
Based on observation,interview,and record review,the facility failed to ensure all patients' right to safety requirements being met.

Eight (8) of 8 direct patient care staff were unable to verbalize or demonstrate the use of the facility overhead paging system to announce emergency situations per facility policy and procedure. (Staff 10, #16, & #17,#21, #22, #23, #24, & #33)

Finding include:

Record review on 09-13-18 of facility policy titled "Paging System", policy # EOC-47, stated: " ...PURPOSE: To inform staff of how facility-wide emergency situations (or other non-emergencies) are to be communicated. Policy: This facility uses a paging system to alert staff to emergency situations ... .....PROCEDURE: All staff/... Announce 'visitor on unit' before non-employees are permitted beyond reception area....As situation warrants, pages: Code Red (for fire), Code Blue (medical emergency) Code Green (psychiatric emergency) Green File (possible assistance needed with potential crisis situation-page personnel by name) Code Gray (Inclement Weather, tornadoes, and hurricanes) Code Yellow (Disaster/Mass Casualty) Code Black (Bomb Threat) Code White (Security Alert/Violence/Hostage) Code Orange (Hazardous Materials)...".

During interviews on 9/13/18 between 10:20 am and 10:40 am with Mental Health Tech (MHT) staff #21, #22, #23, #24, & #33, none were able to verbalize or demonstrate the use of the overhead paging system to announce emergencies. MHT Staff #22 and MHT Staff #24 both stated that the nurses were familiar with the use of the emergency paging system.

During interviews on 9/13/18 between 10:40 am and 10:55 am with Registered Nurse (RN) staff #10, #16, & #17, none were able to verbalize or demonstrate how to use of the facility's overhead paging system to announce emergencies.

In an interview on 9/13/18 at 10:25, RN Staff #16 stated that staff get training on the use and coding system used during orientation, but could not recall the number to dial on the phone to use the overhead paging system.

Record review on 09/13/18 of staff HR files regarding new staff orientation, failed to reveal specific check-off lists addressing the use of the overhead paging system for use to announce a 'code' [a code is one of several types of the various emergency situations which might occur in the facility].
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 hospital failed to ensure the right to receive care in a safe setting for four of four patients (Patients #12, #16, #25, #26).

Three (3) of the 4 patients were currently placed on suicide precautions.

Findings include:

Observation on 09-11-18 at 10:15 a.m. revealed a large, dry-erase "whiteboard" located on the wall behind the main nurse's station. Current patient names were listed on the board, along with other information that included precaution levels. Interview at the time of observation with Charge Nurse #11 he said the information on the board was current and it was updated at least once per shift; usually twice. Further review of the whiteboard revealed five (5) patients were currently placed on suicide precautions: Patients #4, # 7, # 12, # 26, and # 30.

Observation on 09-11-18 at 10:20 a.m. of these five (5) patients' rooms revealed the following hazardous items that could be used for self-harm :

Patient # 26:

Two(2) pencils; a long scarf; and a full length curtain on the floor.

Record review of Patient # 26's "Psychiatric Evaluation," dated 8-29-18, read: " ...[AGE]-year-old ...female with history of major depressive disorder and anxiety bought here after attempting suicide by strangulation ..."

Interview at time of observation with MHT # 40, he stated these items were hazards and should not be in the room of a patient on suicide precautions.

Review of the patient's "Admit Orders/Initial Plan of Care," dated 08-28-18, revealed she had been placed on "Suicide Precautions." As of 09-11-18, this order had not been discontinued; and Patient # 26 was listed on the unit updated whiteboard as currently on "suicide precautions".

Patient # 12:

A zippered bag of colored markers & roll-on antiperspirant deodorant.

Interview at time of observation with MHT # 40, he stated the markers were hazards and should not be in the room of a patient on suicide precautions

Additional observation in Patient #12's room on 09/11/18 at approximately 1000 reflected a roll-on perspirant labeled "contact poison control right away if ingested."

CNO #2 witnessed and acknowledged the findings at that time.

Record Review of Patient #12's Psychiatric Evaluation, dated 09/08/18 at 0900 reflected the patient's "depression worsen due to health issues..." and "...anxiety and feeling of sadness of health condition..." Admitting diagnoses included Major Depressive Disorder, Recurrent, Severe.

Physician Progress Note reflecting the date of service to be 09/11/18, dated 09/12/18 at 1100 reflected that Patient #12 "is trying to minimize her symptoms...still depressed and disorganized...I believe patient is imminent danger to self...keeping the patient's safety into consideration, we will continue to monitor her to evaluate suicidal ideation..."

Review of Patient # 12's Observation Check sheet, dated 09-11-18, documented she was on suicide precautions.

Patient # 25:

One (1) pair of latex gloves found in the pocket of the patient's pants located in a laundry basket.

Record Review of Patient #25's Psychiatric Evaluation, dated 09/01/18 read:"...[AGE] year old male who presents with present problem of increase suicidal ideation with plan to cut throat with knife with intent to kill himself..."

Review of the patient's "Admit Orders/Initial Plan of Care," dated 08-31-18, revealed he had been placed on "Suicide Precautions." As of 09-11-18, this order had not been discontinued; and Patient # 25 was listed on the unit updated whiteboard as currently on "suicide precautions".





Patient # 16:

Patient #16 had been admitted with agitation and aggression. The physician assessed him to have poor impulse control and unpredictable behavior, and recommended staff to monitor him closely for safety. The patient had access to a latex glove that could potentially be used aiding ligature or choking during a self-harm attempt, or potentially be used during an attempt to harm others.

Observations in the hospital's day area in front of the nurses' station on 09/11/18 at 2125 reflected Patient #16 who walked down the hallway. A blue glove was observed tied to the left side of the patient's pants.

Mental Health Technician (MHT) #26 was surveyor asked about Patient #16's possession of a glove. MHT #26 stated, 'That's how we hold his pants up" and showed the surveyor how the glove was tied through several belt loops.

Patient #16's Preadmission Evaluation/ Management dated 09/05/18 at 1501 reflected the patient had been admitted with agitation and aggression. The patient was noted with "poor impulse control with increased periods of unpredictable behavior."

Physician Progress Note with the date of service of 09/11/18 reflected the physician request for "staff members to monitor him closely in order to ensure patient's safety."

Daily Nurse Note dated 09/11/18 for the 0700 to 1900 shift reflected the patient was "depressed" and "agitated...can become combative..." The patient was on assault precaution.

Record review of facility policy titled "Room Checks", dated 01-11-16, read: "...Purpose: To implement a system to check for any potentially dangerous articles...and assure safe patient environment.,... Procedure: Nursing Staff Member: using a checklist as a guide, conducts room checks, observing for contraband and safety factors in each patient room...Potentially dangerous articles and contraband noticed during these room checks will be removed.."
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to ensure a patient's right to be free from abuse and neglect.

The facility failed to investigate a documented allegation of staff abuse by patient # 1.

[Citing patient # 1]

Findings include:

TX 856

Review of intake TX 856 revealed " ...patient # 1 alleged "night staff roughed me up, my ribs still hurt. Intake further stated:" ...patient # 1 verbalized the incident to staff and nothing was done ..."

Record review on 09-12-18 of patient #1's clinical record revealed the patient was an [AGE]-year-old male admitted involuntarily to the facility on [DATE] with an admitting diagnosis of Bipolar Disorder, unspecified.

Further record review revealed a nursing note dated 3/13/18 at 8:20 am that read: " ...Pt (patient) came to the nurse told nurse he had been beaten up last night by one of our staff ...."

Progress notes dated 3/13/18 at 11:37 am authored by MD #32 stated " .... Spoke with pt. He states he was roughed up last night by a black male. States he was hit on both flank areas ...he does complain of feeling pain to both areas ..."
Record review of facility's Incident Report Log 2018 (year to date) failed to reveal a documented incident related to patient #1's allegation of physical abuse on 03/13/18.

In an interview on 9/13/18 at 9:30 am with Director of Nurses (DON) #2, she stated there should have been an Incident Report generated along with an investigation into patient #1's allegation of physical abuse. She was unable to locate an investigation of the alleged abuse by staff of patient # 1.

In an interview on 9/13/18 at 9:45 am, Assistant Director of Nurses (ACNO), he stated that there should always be an Incident Report and investigation conducted whenever a patient makes an allegation of physical abuse.

Record review of facility policy titled "Patient Incident & Occurrence Reporting," dated 01-11-19, read: " ...Policy: Facility staff will report all patient occurrences through the use of the facility's incident report form ...A patient incident or occurrence is anything that is out of the expected norm for the patient ...Procedure: All Staff: If one had witnessed an incident or is informed an incident has occurred, completes the incident report; routes form to PI coordinator ...or in some cases immediate supervisor ...The Administrator will be notified of any Sentinel Event or unanticipated outcome ...PI Coordinator will conference with personnel and parties involved ...cosigns report and investigation form ...recommends corrective action and follows-up with appropriate Department Manager for implementation and follow-through for immediate safety measures ..."

Review of facility policy titled "Patient Rights," dated 01-11-16, read: " ...Patient Client Rights: The right to a humane treatment environment that ensures protection from harm ..."
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, interview, and record review, the facility failed to ensure:

1) A registered nurse supervised and evaluated the nursing care for 4 of 4 patients (Patient #15, #17, #12, and # 3).

a. Nursing staff failed to assess, document, and intervene in the diabetic patient's foot problem that potentially could lead to serious complications including amputation. (patient # 15)

b.Nursing failed to assesses, document and intervene to ease the patient's constipatory state( Patient # 17).

c. Nursing staff failed to evaluate and supervise the care for Patient #12 to prevent further deterioration of the patient's kidney failure.

d. Nursing failed to inform Nurse Practitioner (NP) of an elevated creatinine level. Patient # 3 was transferred the next day to an acute care hospital for possible dehydration based on the NP noting the creatinine level result.

Cross refer A-0395

Based on record review and interview, the hospital failed to ensure that nursing staff developed, and kept current, a care plan for four of four patients (Patient #12, #17, #15, #23).

1) Patient #12 : The nursing care plan did not reflect the patient insufficient kidney function or specified close observation of the patient's urinary status and fluid intake.

2) Patient #17 : The nursing care plan did not reflect the patient's condition or interventions to ease the lack of bowel movements.

3) Patient #15 :The nursing care plan did not address the diabetic patient's skin condition.

4) Patient #23 :The nursing care plan did not reflect fall prevention measures until after the patient sustained a fall two (2) days after admission. He was assessed as a moderate risk upon admission.

Cross refer A-0396

Based on record review and interview, nursing staff failed to administer medication per physician order and professional standards of practice.

Nursing administered medication to lower Patient #22's blood pressure (BP) five (5) times. Four (4) of the 5 times, the patient's BP was less than the medication order parameters; and one time when no blood pressure was taken.

Patient fell due to an episode of hypotension (low blood pressure) on 8-24-18. He was transported to an acute hospital ER. Patient # 22 sustained a facial fracture.

Cross refer: A-0405
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and record review, the hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for 4 of 4 patients (Patient #15, #17, #12, and # 3).

1) Patient #15 had been admitted with medical diagnoses that included Diabetes Mellitus. More than two weeks into her hospitalization , the patient was surveyor observed with a black discolored toe on her right foot and red indentations from ill-fitting shoes on all of the patient's toes. Nursing staff failed to assess, document, and intervene in the diabetic patient's foot problem that potentially could lead to serious complications including amputation.

2) Patient #17 was admitted with medical diagnoses that included Constipation. The patient did not have a bowel movement for 84 hours of her hospital stay. Nursing failed to assess, document and intervene to ease the patient's constipatory state.

3) Nursing staff failed to evaluate and supervise the care for Patient #12 to prevent further deterioration of the patient's kidney failure. Patient #12 was admitted with advanced chronic kidney disease. Three days into her stay, the patient had a critical change in kidney function and needed to drink at least two liters of fluids a day. Five days after her admission, the patient had insufficient kidney function requiring close supervision of the patient's fluid intake and urination. Although the patient's fluid intake was less than the physician-ordered amount, nursing noted that her fluid intake was adequate.

4) Patient # 3 was admitted on 08-10-18 from a nursing home for delusional thoughts, increased aggression, and paranoid behaviors. She refused food, fluid and medications due to thoughts that "staff was poisoning her." Nursing failed to inform Nurse Practitioner (NP) of an elevated creatinine level. Patient was transferred the next day to an acute care hospital for possible dehydration based on the NP noting the creatinine level result.

Findings included:

1) Record review of Patient #15's Intake assessment dated [DATE] at 1525 reflected the patient had medical diagnoses that included Diabetes Mellitus.

Skin Assessment and Wound Care documentation dated 08/29/18 at 1750 reflected the patient's left big toe and the second toe had "toe nail overgrowth."

The Daily Nurse Note dated 09/09/18 at 1510 noted "see skin assessment." Skin Assessment and Wound Care documentation dated 09/09/18 at 1040 did not reflect a reassessment of the patient's feet. The diagram of the patient's feet to document findings was left blank.

Patient #15 stated on 09/13/18 at 1135 that she "had not seen the podiatrist in two years...are you going to take my foot off now?"

Patient #15 was observed on 09/13/18 at 1135 with a very thick and yellow discolored nail on her left big toe. The nail of the second toe on the patient's left foot was black. Red indentations were noted on each toe on Patient #15's left foot. The toes on the patient's right foot were very long and in need of trimming.

RN #25 witnessed and acknowledged the above findings at that time and stated Patient #15's shoes did not fit well.


Nursing documentation dated 09/10/18 through 09/13/18 did not reflect an assessment of Patient #15's black discolored second toe on the left foot.

The American Diabetes Association warned that "People with diabetes can develop many different foot problems. Even ordinary problems can get worse and lead to serious complications...[and] may lead to amputation. Most amputations are preventable with regular care and proper footwear..." (http://www.diabetes.org/living-with-diabetes/complications/foot-complications/)


2. Patient #17's Physician Preadmission Evaluation dated 09/06/18 at 1803 reflected the [AGE] year old patient had multiple medical diagnoses that included Constipation.

Graphic Flow Sheets dated 09/07/18 (1900-0700 shift), 09/08/18 (0700-1900 shift and 1900-0700 shift), 09/09/18 (0700-1900 shift and 1900-0700 shift), 09/10/18 (0700-1900 shift and 1900-0700 shift) did not reflect the patient had a bowel movement.

Daily Nurses Notes dated 09/07/18 through 09/10/18 did not reflect the patient's lack of bowel movement.

During an interview on 09/13/18 at 1029, RN #25 was asked regarding nursing documentation of the patient's lack of bowel movement and intervention. RN #25 stated she did not see any.




3. Patient #12 History and Physical examination documentation dated 09/05/18 at 1131 reflected the patient had Chronic Kidney Disease, Stage 4.

Patient #12's Nursing Notes dated 09/08/18 reflected the the patient's critical lab result "of BUN of 65."

Physician orders dated 09/08/18 at 1245 reflected an order for Patient #12 to drink 2000 cc of fluid on 09/08/18 and 09/09/18.

Graphic Flow Sheet dated 09/08/18 reflected the patient drank 960 cc. The Graphic Flow Sheet dated 09/09/18 reflected the patient intake of 1680 cc.


Physician Progress Note dated 09/11/18 at 0926 reflected the assessment that the patient had Uremia (kidney insufficiency) and the plan to increase the patient's fluid intake to avoid nephrotoxicity (kidney damage).

Patient #12's Physician Orders dated 09/11/18 at 0927 reflected an order to "increase [the patient's] fluid intake to 2500 cc/day and [keep] strict I & O [Intake and Output]."


Patient # 12's Daily I&&O Sheet dated 09/11/18 reflected the patient had 400 cc of water, 480 cc of ice tea, 480 cc of lemonade. The patient's total fluid intake had not been calculated. There was no documentation of the patient's output. The night shift documentation reflected the patient drank 320 cc of water and urinated 400 cc during that shift. The 24-hour total intake and output documentation space was left blank.

Daily I&O documentation dated 09/12/18 reflected the patient drank 1820 cc. The document did not reflect how much the patient had urinated.

Daily Nurse Notes dated 09/11/18 and 09/12/18 did not reflect the patient's kidney function but noted the patient had "adequate intake."

During an interview on 09/13/18 at approximately 1210, RN #25 acknowledged the findings.





4) Record review of Patient # 3 's Intake assessment dated [DATE] at 1650 revealed the patient was admitted for delusional thoughts, increased aggression, and paranoid behaviors.

Nurses's Note dated 08/10/18 at 1950 read :"...due to paranoid delusions believes staff is poisoning her. patient refused to eat or take medication...".

Review of laboratory results, dated 08-11-18 (1415) revealed a creatinine level of 3.26 mg/dl ( reference range : 0.5 - 0.9). This result had the following handwritten notation at the bottom of the lab results : "8-11-18, 2 initials, noted 1647 ".

[A high serum creatinine level is an indicator of poor kidney function...can be elevated with dehydration, low blood volume... or due to certain medications: Mayo Clinic reference].

Further review of the nursing documentation failed to reveal this abnormal creatinine lab result was communicated to the physician or NP.

Review of nursing note, dated 08-12-18 (0840) it read: "Patient up ad lib, confused and disorganized on unit. NP did review of systems and noted creatine 3.6 high. Stated we need to transfer pt. to hospital..."

Record review of physician order, dated 08-12-18 ( 1115) read: "transfer to ER..crea (creatinine) 3.26...?? (sic) severe dehydration.. decreased po (by mouth) intake, refusing meds & fluids.."

Interview on 09-12-18 (1245) with Charge RN # 11 , he stated " The nurse who noted the creatinine level should definitely have called the NP with the abnormal result." He went on to say that he discovered this issue soon after it happened and spoke with the nurse involved.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to ensure that nursing staff developed, and kept current, a care plan for four of four patients (Patient #12, #17, #15, #23).

1) Patient #12 was admitted with advanced chronic kidney disease. Three days into her stay, the patient had a critical change in kidney function and required close nursing observation. The nursing care plan did not reflect the patient insufficient kidney function or specified close observation of the patient's urinary status and fluid intake.

2) Patient #17 was admitted with medical diagnoses that included Constipation. The patient did not have a bowel movement for seven consecutive 12-hour nursing shifts. The nursing care plan did not reflect the patient's condition or interventions to ease the lack of bowel movements.

3) Patient #15 had been admitted with medical diagnoses that included Diabetes Mellitus. The patient developed sores on her left foot during the hospital stay and was noted with a black discolored toe. The nursing care plan did not address the diabetic patient's skin condition.

4) Patient #23 was admitted with medical diagnosis of bronchitis and expiratory wheezing. He was assessed as "moderate risk " for falls on admission. The nursing care plan did not reflect fall prevention measures until after the patient sustained a fall two(2) days after admission.

Findings included:



1) Patient #12 History and Physical examination documentation dated 09/05/18 at 1131 reflected the patient had Chronic Kidney Disease, Stage 4.

Patient #12's Nursing Notes dated 09/08/18 reflected the patient's critical lab result "of BUN of 65."

Physician orders dated 09/08/18 at 1245 reflected an order for Patient #12 to drink 2000 cc of fluid on 09/08/18 and 09/09/18.

Physician Progress Note dated 09/11/18 at 0926 reflected the assessment that the patient had Uremia (kidney insufficiency) and the plan to increase the patient's fluid intake to avoid nephrotoxicity (kidney damage).

Patient #12's Physician Orders dated 09/11/18 at 0927 reflected an order to "increase [the patient's] fluid intake to 2500 cc/day and [keep] strict I & O [Intake and Output]."


Patient #12's Multidisciplinary Integrated Treatment Plan and Problem List dated 09/04/18 did not reflect the patient's kidney dysfunction. There was no evidence of planned nursing interventions.

Daily Nurse Notes dated 09/11/18 and 09/12/18 did not reflect interventions to increase the patient's fluid intake and measure the patient's urinary output.

During an interview on 09/13/18 at approximately 1029, RN #25 acknowledged the findings.


2) Patient #17's Physician Preadmission Evaluation dated 09/06/18 at 1803 reflected the [AGE] year old patient had multiple medical diagnoses that included Constipation.

Graphic Flow Sheets dated 09/07/18 (1900-0700 shift), 09/08/18 (0700-1900 shift and 1900-0700 shift), 09/09/18 (0700-1900 shift and 1900-0700 shift), 09/10/18 (0700-1900 shift and 1900-0700 shift) did not reflect the patient had a bowel movement.

Daily Nurses Notes dated 09/07/18 through 09/10/18 did not reflect interventions to address the patient's lack of bowel movement.

Patient #17's Multidisciplinary Integrated Treatment Plan dated 09/06/18 and 09/07/18 did not reflect interventions for constipation.

During an interview on 09/13/18 at 1029, RN #25 acknowledged the above findings.

3) Record review of Patient #15's Intake assessment dated [DATE] at 1525 reflected the patient had medical diagnoses that included Diabetes Mellitus.

Skin Assessment and Wound Care documentation dated 08/29/18 at 1750 reflected the patient's left big toe and the second toe had "toe nail overgrowth."

Patient #15 stated on 09/13/18 at 1135 that she "had not seen the podiatrist in two years...are you going to take my foot off now?"

Patient #15 was observed on 09/13/18 at 1135 with a very thick and yellow discolored nail on her left big toe. The nail of the second toe on the patient's left foot was black. Red indentations were noted on each toe on Patient #15's left foot. The toes on the patient's right foot were very long and in need of trimming.

Patient #15's Multidisciplinary Integrated Treatment Plan dated 08/29/18 did not address the diabetic patient's foot problems.

During an interview on 09/13/18 at approximately 1120, RN #25 acknowledged the above findings.

The American Diabetes Association warned that "People with diabetes can develop many different foot problems. Even ordinary problems can get worse and lead to serious complications...[and] may lead to amputation. Most amputations are preventable with regular care and proper footwear..." (http://www.diabetes.org/living-with-diabetes/complications/foot-complications/)




4) Record review of Patient #23's Intake assessment dated ,d+[DATE] revealed the patient had Bipolar disorder and medical diagnoses that included Bronchitis.

Record review of Patient #23's nursing admission assessment, dated 05-13-18 revealed he was assessed as a moderate fall risk (score 11).

Review of facility fall data and variances for 2018 revealed Patient #23 fell on [DATE] at 1115. He was transported to an acute care hospital for care and treatment.

Review of Patient #23's Multidisciplinary Integrated Treatment Plan dated 08/13/18 revealed "high risk for falls" was not addressed on his care plan until after he fell .

During an interview on 09/14/18 at approximately 1120, DON # 2 stated "fall risk" should have been addressed on patient # 23's care plan upon admission because he was assessed as a moderate fall risk.

Review of facility policy titled "Fall Assessment/Re-Assessment, dated 01-11-18, read: "...Procedure...patients will be scored as follows: 0-6 : Low Risk; 7-17 Moderate Risk ( initiate Fall Precautions) ...Charge RN/Primary RN: ..fall Precautions for Moderate Risk:...Fall risk identified on treatment plan and at shift change.."
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interview, nursing staff failed to administer medication per physician order and professional standards of practice.

Nursing administered medication to lower Patient #22's blood pressure (BP) five (5) times. Four (4) of the 5 times, the patient's BP was less than the medication order parameters; and one time when no blood pressure was taken.

Patient fell due to an episode of hypotension (low blood pressure) on 8-24-18. He was transported to an acute hospital ER. Patient # 22 sustained a facial fracture.

Findings include:

Review of facility policy titled " Medications", dated 01-11-16, it read:" ...Medication Administration...Before administering a medication...the qualified individual does the following:...verifies the medication selected for administration is correct one based on the medication order, prescriber instructions...verifies there are no contraindications for administering the medication..."

Patient # 22

Record review of Patient # 22's clinical record revealed he was an [AGE]-year-old male admitted to the facility on on [DATE] for aggression and inappropriate sexual behaviors. He was assessed as high risk for falls upon admission.

Review of physician orders dated 08-14-18, read:" Lisinopril 10 mg by mouth daily, Hold if blood pressure less than 120/70"

Record review of the daily Medication Administration Records(MAR) and Graphic Flowsheets for Patient # 22 for August, 2018 revealed the following recorded for Patient # 22:

On 08-14-18 at 7:00 a.m. patient's blood pressure was recorded as 107/53. The medication to lower blood pressure, Lisinopril 10 mg, was administered at 9 a.m. despite the blood pressure being lower than 120/70 per physician order parameters.

On 08-17-18 at 7:33 a.m. patient's blood pressure was recorded as 102/ 63. Lisinopril 10 mg, was administered at 9 a.m. despite the blood pressure being lower than 120/70 per physician order parameters.

On 08-18-18 at 7:00 a.m. patient's blood pressure was recorded as 109/55. Lisinopril 10 mg. was administered at 9 a.m. despite the blood pressure being lower than 120/70 per physician order parameters.

08-23-18 at 7:15 a.m. patient's blood pressure was recorded as 119/68. Lisinopril 10 mg. was administered at 9 a.m. despite the blood pressure being lower than 120 /70 per physician order parameters.

On 08-24-18 it was documented "patient refused" the morning vital signs. Lisinopril 10 mg was administered at 9 a.m. without a recorded blood pressure.

Patient #2 fell on [DATE] at 9:20 a.m. due to an episode of low blood pressure.

Interview on 09-14-18 at 10:30 a.m. with Director of Nurses (DON) #2 she stated Patient # 2 had been taken outside by a tech on 08-24-18 at 9:20 a.m. to get some fresh air.

Review of the incident report for Patient # 2's fall with the DON revealed the patient tried to stand up, leaned on a table and fell , landing on his right side. His blood pressure was taken right after the fall and was recorded as 75/41. The DON said the antihypertensive medication given could have contributed to the patient's fall.

DON # 2 went on to say, Patient # 2 was immediately transported by ambulance to a local hospital ER. He sustained a facial fracture and did not return to the facility.

Physician order dated 08-24-18 (9:32 a.m.): "transport pt to ...ER status post fall -hypotension ( low blood pressure) ".

Continued interview with DON # 2 she stated the nurses should check the blood pressures prior to giving antihypertensive medications; especially if there are parameters in the medication order. She went on to say the techs give the vital sign sheets to the Physician Assistant and also inform the nurses if the vital signs are abnormal.

DON # 2 reviewed the MARS for Patient # 2 for August 14,17,18,23,24, 2018 and stated the Lisinopril should not have been given based on the blood pressures recorded; or not recorded / taken on 08-24-18 prior to the fall.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview it was determined that the facility failed to ensure that medical record entries were authenticated, identified and legible in three (3) out of three (3) medical records reviewed.

Findings included:

Record review on 9/11/2018 for Patient (ID #2) revealed illegible signatures for the following documents;
The Inventory of Patient Possessions Sheet dated 10/29/2017
The Incident Report dated 11/10/2017
The Close Observation Sheet dated 11/11/17.
The intake assessment dated [DATE] had no time of assessment or
signature.

Record review on 9/11/2018 for Patient (ID # 4) revealed illegible signatures for the following documents:
Incidents report dated 8/31/2018.
A neurology flow sheet that was not dated with initials and no signature;
Nurses process notes dated 8/13/2018 at 2200 had no nurses signature.

Record review on 9/11/2018 for Patient (ID #27) revealed illegible signatures for the following documents:
Initial assessment dated [DATE] and
The daily nurse's notes

Interview on 9/13/2018 with staff (ID #4) Director of Health Information Management revealed she has a list with everyone's signature, but sometimes she has to ask the others to identify the signature.

Record review of facility's "Documentation Policy" dated 10/01/2016 stated: Documentation must be legible.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on record review, interview, and observation, the hospital failed to develop an effective system to identify and mitigate potential sources of infections and maintain a sanitary hospital environment for 32 of 32 patients.

1) Restrooms in both the North and South Side Day Areas were left unflushed and malodorous. Bolts to anchor toilets into the ground were uncovered and/or rusty in at least five patient rooms. Dusty vents were observed in a patient room and in an all-patient accessible bathroom. In addition, at least one bathroom wall had paint peeling off and offered a non-functional soap dispenser. A patient-used wheel chair was visibly soiled.

2) Clean and dirty equipment was not separated according to hospital policy. A mud-splattered wheel-chair was stored with clean utilities.

3) Although identified as activity on the patients' schedule, hand hygiene was not completed prior to patients eating their meals and left one patient with dried blood on his hand until surveyor intervention. Staff was unaware of national hand-hygiene guidelines.

4) Facility's Patient Possessions storage room was disorganized, and dirty. Patients' possessions scattered on the visibly dirty floor, on shelving, with various patients' personal belongings piled on top of each other, increasing the chance of cross-contamination. The room also had a strong malodorous smell of urine in the room.

Findings included:

Observational rounds with CEO #1 and/or CNO #2 were conducted on 09/11/18 between 0920 and 1155 on the Inpatient Unit North and South wings. Administrative staff identified 32 patients on the hospital inpatient unit on 09/11/18. Observations reflected the following.

1) The patient bathroom in the North Side Day Area was observed on 09/11/18 at 0920. The bathroom toilet was not flushed and contained urine. The wall paint peeled off on at least one wall, the vent was covered with dust, and the soap dispenser was nonfunctional. The patient bathroom in the South Side Day Area was noted to have an unflushed toilet on 09/11/18 at approximately 1055.

The CD player close to the big television in the North Side Day Area was dusty.

The North Side Laundry Room was observed on 09/11/18 at 0930. It had two brown slippers and one sandal without owners' identification.

Patient bathrooms in Room 1603 and Room 1609 were observed with unflushed toilets on 09/11/18 at approximately 0940.

Uncovered and/or rusty bolts to fasten toilet bowls to the floor were observed in Patient Rooms 1605, 1609, 1604, and 1704.

Patient Room 1606 was observed with a broken door stopper, a loose floor board, a dusty vent in the bathroom, and uncovered bolts that fastened the toilet to the floor.

A blood-tinged alcohol prep was observed on the floor of Room 1702 on 09/11/18 at approximately 1005. CNO #2 acknowledged the finding at that time.

Patient #13 was observed in her room on 09/11/18 at approximately 1020. The patient's wheel-chair had dusty and grimy spokes. Patient #13 stated at that time, "It is filthy." Per surveyor request, CNO #2 wiped the spokes with a clean paper towel. The paper returned dark discolored. CNO #2 acknowledged at that time, "It is dirty."

The patient bathroom in the South Side Day Area was malodorous. The odor appeared to come from a green blanket that was tossed on a trash can.

2) The Clean Utility Room was observed on 09/11/18 at 1045. It contained a walker with a ripped seat that left it not unable to be sanitized. A wheel chair was observed with mud-splattered spokes and wheels. CNO #2 acknowledged that it "needs to be cleaned." CNO #2 identified the wheel chair to belong to Patient #14.

Hospital Policy titled Separation of Clean and Dirty Supplies (Policy Number IC-05.04) mandated the procedure to separate "the clean and dirty utility areas...into two different rooms" and any supplies "...used on or by a patient are considered dirty/soiled."

3) Multiple patients were observed in the South Side Day Area on 09/11/18 at 1132 waiting for their lunch meal. The publicly posted Program Schedule designated the time between 1130 and 1145 to be used as "Hand Hygiene/Preparation for Lunch." Patient #16 was observed with an area of dried blood between thumb and pointer finger of his right hand. The patient frequently tugged on the skin in that area. Staff served several patients their lunch meal at that time. No staff member cleaned Patient #16's hands. On 09/11/18 at about 1140, staff moved Patient #16 to the North Side Day Area and placed him at a table. Staff did not clean the patient's hands. On 09/11/18 at approximately 1150, CNO #2 acknowledged the dried blood.

During a brief interview on 09/11/18 at approximately 1155, RN #10 denied knowledge of professional hand hygiene guidelines provided by the national Centers for Disease Control.

RN #25 was interviewed on 09/13/18 at 0950 and asked about the hospital's hand hygiene compliance. RN #25 stated it was "poor."


The national Centers for Disease Control and Prevention (CDC) noted that "practicing hand hygiene is a simple yet effective way to prevent infections" and strongly recommended hand hygiene before meals (https://www.cdc.gov/handhygiene/providers/index.html).





4. ) Observation on 9/14/18 at 10:00 am of facility's Patient Possessions storage room revealed it to be cluttered and disorganized. There were clothes, shoes, and other patients' possessions scattered on the visibly dirty floor, in back of shelves, and on full shelves with various patients' personal belongings piled on top of each other, increasing the chance of cross-contamination. Most belongings were clothes, were not completely separated from other patients' belongings, and were in direct contact with other patients' personal belongings. The room also had a strong malodorous smell of urine in the room.

In an interview on 9/14/18 at 10:05 with Staff #29, she stated she was in charge of the Patient Possessions storage room. She added that all the loose clothing items scattered on the floor were donated cloths used for needy patients, and should have been kept in a cardboard box on the floor. She also stated that patients' clothes should be stored in plastic bags or in one of the facility's bags to keep them clean and to prevent contamination. She added that the urine smell was coming from the clothes that new patients wore when they were first admitted to the facility, and were not washed. The dirty clothes were in contact with other patients' possessions.