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.

HIGHLAND RIDGE HOSPITAL 7309 SOUTH 180 WEST MIDVALE, UT 84047 Jan. 8, 2019
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interview and record review, it was determined that the hospital failed to ensure that its governing body was effective and responsible for the conduct of the hospital.

Additionally, the governing body did not ensure hospital staff members and records were kept separate from another provider located within the hospital.

Findings include:

1. The hospital failed to promote and protect each patients' rights. (Refer to tag A-0115)

2. The hospital failed to ensure that all licensed nurses, certified nursing assistants, and behavioral health assistants had licensure and training prior to providing care to the patients. (Refer to tag A-0385)

3. The hospital failed to ensure it had a medical records service that had administrative responsibility for medical records. (Refer to tag A-0431)

4. The hospital failed to ensure the building and facility equipment were maintained in a routine, clean, and sanitary condition to assure patient safety and well-being. (Refer to tag A-0700)

5. The hospital failed to have an active program for the prevention, control, and investigation of infections and communicable diseases. (Refer to tag A-0747)

6. The hospital failed to have a discharge planning process that applied to all patients. (Refer to tag A-0799)

7. On 12/11/18, upon a tour of the hospital, it was determined that a separately licensed Residential Treatment Center (RTC) was located within the hospital.

On 12/13/18 at 11:45 AM, an observation was made of a hospital nurse and hospital technician leaving their assigned unit to respond to a "Doctor Strong" code in the RTC.

On 12/13/18, an interview was conducted with the hospital director of nursing (DON). The DON stated a "Doctor Strong" was called when a patient was a danger to themselves and/or others and additional staff members were needed to assist in de-escalation. The DON stated the RTC unit was staffed separately from the hospital and when staff were working as an employee of the hospital they were not to leave the hospital to provide care in the RTC.

Upon review of the hospital quality assurance and performance improvement meeting minutes, governing body meeting minutes, and medical executive meeting minutes, it was determined RTC information was discussed in each meeting.

On 1/8/19 at approximately 11:30 AM, the Division President of the hospital confirmed the RTC was a separately licensed provider and hospital documentation should not include RTC information.

8. The facility failed to meet all requirments for Emergency Preparedness. (Refer to tag E-004 on the Life Safety Code Defficiency Report).
VIOLATION: VENTILATION, LIGHT, TEMPERATURE CONTROLS Tag No: A0726
Based on observation and interview, it was determined that the hospital did not ensure that food products were stored properly.

Findings include:

On 12/11/18 at 1:45 PM, a tour of the food storage area was completed. The following items were noted:

1. There was no documented expiration date or use by date on each of the canned goods.

2. There was no documented expiration date or use by date on the boxed cake mixes and brownie mixes.

3. A plastic bag of yellow powdery substance was noted to have been opened and resealed with tape. No open date was noted on the package, nor was there any identification as to what the substance was.

4. An opened plastic bag of brownie mix that had been taped closed, had a date of 10/30/18.

An interview was conducted with the dietary manager (DM) at that time. The DM stated that he did not know if the date on the opened brownie mix was the open date or discard by date. The DM further stated that he did not realize the food items did not have an expiration date or use by date documented on the packaging.
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on interview and record review, it was determined that the hospital failed to develop and maintain an active program for the prevention, control, and investigation of infections and communicable diseases.

Findings include:

1. On 1/7/19, a request for the hospital water management plan and the policies and procedures for the prevention of Legionella and other opportunitistic pathogens in building water systems was made.

At that time the director of nursing (DON) stated that the hospital was not required to have a Legionella water plan. Clarification was given to the DON concerning the requirement. The DON stated there may be something in a binder in the plant manager's office.

On 1/7/19 at 11:00 AM, an interview was conducted with the infection control nurse (ICN). The ICN stated that she was aware of the signs and symptoms of Legionella but did not know what the hospital program was. The ICN stated that she was told by someone that Legionella was not an issue in the state of Utah.

On 1/7/19 at 11:15 AM, the DON stated that she had found a document from a water management company but did not know if that was a contract with the company or just a bid.

On 1/8/19, the DON provided a copy of the corporate water management plan with an issue date of 12/18.

A review of the was plan was completed. The plan indicated, "It is the policy of the hospital that water and air systems will be maintained to prevent illnesses to patients, staff and visitors." The purpose of the of the policy indicated, " To protect the health and safety of residents, visitors, and associates from Legionnaires' disease with prevention and early recognition, by formulation this water management plan to help identify and control hazardous conditions that support the growth and spread of bacterial organisms, such as Legionella."

Further review of the policy revealed, no documented date of approval of the policy.

No documentation was provided to indicate that the hospital had a functioning water management program and policies and procedures for the prevention of Legionella and other opportunitistic pathogens for the building water system that contained the following required elements:

a. Description of the plumbing system using text and flow diagrams.
b. Identified areas where Legionella and other opportunitistic pathogens could growth and spread.
c. Established ways to intervene when control limits are not met.
d. Documentation to ensure the program is running as designed and effective.
e. Documentation of all communication and activities.
f. Description of the building, location, age, and uses.
g. Team members' roles and responsibilities.
h. Control measures and control points
i. Documentation of sampling procedure, specimen transport and the laboratory performing testing (methods and procedure).
j. Documentation for training for staff responsible for implementing and monitoring the plan.

2. The hospital failed to ensure that the infection control officer was qualified through ongoing education, training, experience, or certification to oversee the infection control program. (Refer to tag A-0749)

3. The infection control officer failed to develop a system for identifying, reporting, investigating, and controlling infections and communicable disease of patients and personnel. (Refer to tag A-0747)

4. The chief executive officer, the medical staff, and the director of nursing failed to ensure that the hospital-wide quality assessment and performance improvement (QAPI) program addressed problems identified by the infection control officer and did not ensure there was implementation of successful corrective action plans in affected problem areas. (Refer to tag A-0756)
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview and record review, it was determined that the hospital failed to promote and protect each patients' rights.

Findings include:

1. The hospital did not follow the plan of care that was developed with input from the patient and family. (Refer to tag A-0130)

2. It was determined that the hospital did not obtain a signature for the use of restraints from the ordering physician within 24 hours of the telephone order being written. (Refer to tag A-0168)

3. The hospital did not consult the attending physician after the order of a restraint. (Refer to tag A-0170)

4. The hospital did not document the description of the patient's behavior and the intervention used when restraining a patient. (Refer to tag A-0185)

5. The hospital did not document the patient's response and the impact of the restraint interventions. (Refer to tag A-0188)

6. The hospital did not ensure that all staff providing care to patients had been trained and demonstrated competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion. (Refer to tag A-0196)

7. The hospital did not ensure that all patient care staff had the required training in first aid techniques and cardiopulmonary certification. (Refer to tag A-0206)
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, it was determined that the hospital did not follow the plan of care that was developed with input from the patient and family for one of 14 sampled patients. (Patient identifier: 2 )

Findings include:

1. On 12/11/18, a request was made to view the hospital complaint and grievance log. A review of the log revealed 4 grievances had been filed within the last 3 months.

The Director of Risk Management (DRM) provided a grievance communication form that had not been added to the list. The grievance was filed by the mother of patient 2 on 11/27/18.

A review of the form revealed the mother was concerned about the lack of individual therapy, the safety plan was poor and the patient had been admitted to another facility after discharge from the hospital for further care. The mother also had concerns about the poor communication with the providers at the hospital.

During a telephone call made by the surveyor to patient 2's mother, the mother stated that her child had not received the therapy that he was to receive based on his plan of care and the admission paperwork. The mother also stated that the patient and family had not received a safety plan at discharge. The mother stated that the patient was currently receiving therapy at another hospital.

2. On 12/12/18, patient 2's medical record was reviewed.

Patient 2 was admitted on [DATE], with diagnoses of depression and suicide ideation.

A review of the psychiatric evaluation dated 11/14/18, noted that the initial plan of care was for patient 2 to receive "therapy and also with parents".

A review of the hospital psychosocial assessment indicated that the necessary steps for discharge included to develop coping skills, and family meeting, and safety planning. The social work role in the treatment would be discharge planning, safety plan development, and group therapy.

A review of the care plan revealed patient 2 was to complete a safety plan before discharge. Further review of the plan of care revealed an intervention for the therapist to provide individual and group counseling daily.

No documentation could be located in patient 2's medical record to indicate that he had received individual therapy nor was there documentation that indicated that the family had received counseling.

3. On 12/11/18, a review of the adolescent unit patient handbook was completed. Documentation in the handbook indicated that patients would receive individual and family therapy. The handbook also revealed the following:
a. "Dear Parent/Guardian,... Here is what to expect over the next couple of days:...
WITHIN 24 hours: You will receive a call from your child's psychiatrist to provide a status on your child's wellbeing...

WITHIN 48 hours: A therapist will contact you to discuss your child's treatment plan and the expectations while the patient is attending our program. The therapist will schedule a family therapy session with you...

DAYS 3-4: You will attend a family session with your child's therapist...

DAYS 5-8: Your child's therapist will set an additional family session prior to the patient's exit to discuss treatment progress, recommendations, and a safe discharge plan..."

4. On 12/11/18 at 2:30 PM, an interview was conducted with nurse practitioner (NP) 2. NP 2 stated that he would meet with a patient mostly for medication management. NP 2 stated that a therapist was required to meet with the each patient's family, and hold at least one family meeting, and more if possible. NP 2 stated that he normally did not do individual or family therapy. NP 2 stated there was not enough time to do so.

5. On 12/11/18 at 3:00 PM, an interview was conducted with licensed clinical social worker (LCSW) 1. LCSW 1 stated each therapist had a case load of patients, who they, "try and check in with" every other day, "because there is not enough staff to do every day." LCSW 1 stated he did not complete individual therapy notes, "because we are short". LCSW 1 further stated if he talked one on one with a patient he would document it on a group therapy note, "Because I don't have time to document."

Note: No documentation could be located in patient 2's medical record to indicate that he had received individual therapy nor was there documentation that indicated that the family had received counseling.

6. On 12/12/18, an interview was conducted with the hospital administrator. The administrator stated the hospital worked on a group therapy model and did not provide individual therapy.

7. A review of the crisis safety plan for patient 2, at the time of discharge, was completed. A review of the plan revealed the following:

a. "Recognizing my warning signs and use coping skills to keep myself safe and healthy."

b. "Triggers and Stressors: Behaviors, situations and circumstances that put me at emotional risk."
1. "When people say faggot or gay"

c. "Warning signs: (Blank)"

d. "Things to do... My goals for health behavior:
1. "talk about my feelings and wants more"

e. "Support System...Who can I call?"
1. "mom"
2. "dad"
3. "sister"
4. "brother"
5. "National Suicide Prevention Lifeline" (input by the hospital)

f. "Firearms Safety Plan"
1. Do I have firearms? No "

The patient had signed the form - no date was documented.

There was no documentation of a guardian/family signature or date.

There was no documentation of a therapist signature, date, or time. The section "copy was provided to the patient, guardian/family/support person" was left blank.

8. On 12/13/18, at approximately 10:00 AM, an interview was conducted with LCSW 2. LCSW 2 stated that therapy provided at the hospital was usually group based because they had no time to really address the individual issues appropriately.

LCSW 2 reviewed the crisis safety plan for patient 2. LCSW 2 stated that based on what patient 2 had written on the crisis safety plan, the patient would not have been eligible for discharge. The LCSW stated there were many questions and "red flags" with the information documented. The LCSW stated that the discharge would not have been a safe discharge. The LCSW further stated that the discharge paperwork was inadequate.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, it was determined that the hospital did not obtain a signature for the use of restraints from the ordering physician within 24 hours of the telephone order being written for one of 14 sampled patients. (Patient identifier: 14.)

Findings include:

Patient 14 was admitted on [DATE], with a diagnosis of depression with suicide ideation.

On 12/11/18, patient 14's medical record was reviewed.

A review of the physician orders revealed a telephone order dated 12/8/18, for "Physical hold for Safety". The order was taken by a registered nurse on 12/8/18 at 7:30 PM. The order had not been signed by the ordering physician.

Further review of the medical record revealed a "Seclusion/Restraint Practitioner Order" for patient 14. The order was for "physical restraint" due to the patient being a "threat to immediate physical safety of others". The duration of the restraint ordered was for "Restraint 2 hours age 9-17". Criteria for release was "No longer an immediate physical threat to others". The order had not been signed, dated, or timed by the practitioner.

A review of the hosptial "Seclusion and Restraint Policy" revealed the following: "A physician's order shall be obtained and if ordered by telephone the ordering physician must personally sign, time and date the telephone order within 24 hours of the time the order was originally issued."

On 12/12/18 at 12:40 PM, an interview was conducted with the director of nursing (DON). The DON stated that she had only been employed for eight days and did not know what the hospital policy was for signing telephone orders for restraints. The DON stated that the order probably should have been signed within 24 hours.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0170
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, it was determined that the hospital did not consult the attending physician after an order for the use of restraints for one of 14 sampled patients. (Patient identifier: 14.)

Findings include:

Patient 14 was admitted on [DATE], with a diagnosis of depression with suicide ideation.

On 12/11/18, patient 14's medical record was reviewed.

A review of the physician orders revealed a telephone order dated 12/8/18, for "Physical hold for Safety". The order had not been signed by the ordering physician.

Further review of the medical records revealed no documentation that the attending physician had been informed of the restraint of patient 14, as required.

A review of the hospital policy on seclusion and restraint was completed. No documentation could be located to indicate that the attending physician needed to be consulted after restraints had been used on a patient, if the attending physician didn't order the retsraint, in accordance with federal regulations.

On 12/12/18 at 12:40 PM, an interview was conducted with the director of nursing (DON). The DON stated that she had only been employed for eight days and did not know the hospital policy for restraints.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on interview and review of facility records, it was determined the hospital did not ensure the facility equipment was maintained in a manner to assure patient safety and well-being. Specifically, the hospital did not adequately maintain all equipment to ensure safety and quality. The hospital did not maintain equipment inventory lists or preventive maintenance logs and documentation for equipment.

Findings include:

During the entrance conference on 12/11/18, the Director of Nursing (DON) and the Chief Executive Officer (CEO) stated the facility operations manager had left employment with the hospital the week before survey. They stated that a maintenance technician would be available to answer questions regarding the facility's physical environment and maintenance.

In an interview on 12/12/18 at 10:00 AM, the maintenance tech was asked for an equipment inventory list and a maintenance log showing preventive maintenance records for all hospital equipment. The maintenance tech stated he did not have a list for the medical equipment, such as crash carts and vital sign carts, because these would be part of the DONs responsibility, and that he would try to find an inventory list for the other hospital equipment.

Surveyors requested the medical equipment inventory list and maintenance log from the DON. The medical inventory list was provided along with logs for the automated external defibrillator (AED) checks, glucometer testing, and refrigerator temperature logs. The AED logs were complete, but the glucometer testing log and refrigerator temperature logs showed only information collected through November 2018, with no information logged for December 2018. Additionally, there was no information provided for other equipment checks or equipment maintenance on the medical inventory list. In an interview on 12/13/18 at 9:37 AM, the DON stated she did not have any additional logs besides what had been provided to surveyors.

On 12/12/18 at 2:45 PM, the hospital CEO and DON introduced surveyors to the operations manager of their sister facility (owned by the same entity in the local area). The operations manager provided answers to surveyors' questions regarding hospital equipment and maintenance. He also provided information regarding emergency power, lighting, gas, and water. The CEO and DON were asked for a full inventory list of hospital equipment and maintenance logs at this time. Items provided included: generator inspection logs, fire alarm logs, sprinkler inspection logs, and a bid for heating, ventilation, and air conditioning (HVAC) which listed the components of the HVAC system (motor, fan motor, compressor, blower, exhaust fan). However, a full inventory list of hospital equipment was not provided to surveyors.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0185
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, it was determined that the hospital did not document the description of the behaviors and intervention used when restraining a patient for one of 14 sampled residents. (Patient identifier: 14.)

Findings include:

Patient 14, a 13 year old, was admitted on [DATE], with a diagnosis of depression with suicide ideation.

On 12/11/18, patient 14's medical record was reviewed.

A review of the record revealed patient 14 was physically restrained on 12/8/18 at 7:30 PM.

A review of the "seclusion/restraint progress note RN (Registered Nurse)/Practitioner" dated 12/8/18 at 9:00 PM, revealed "patient had refused a complete body search, Staff attempted to negotiate with patient. Staff explained multiple times why the search is done. Patient continued to refuse to complete body search. Staff compromised with patient and told him he needed to just pull down his underwear to his knees, squat and cough. Patient continued to refuse. Additional staff was called into the exam room. 2 male and 2 female staff members present. 2 staff assisted patient while the 3rd staff member checked between his thighs. Once completed staff let patient get fully dressed. Patients (sic) mother was contacted and informed of the event and why the body search is completed prior to patients walking into units".

A review of the seclusion/restraint flowsheet was completed. No documentation was noted under the behavior section and the intervention section of the flowsheet. No documentation was located to indicate which staff had participated in the restraint process other than the nurse filling out the form.

On 12/12/18 at 12:40 PM, an interview was conducted with the director of nursing (DON). The DON stated the forms should have included the patient's behaviors and interventions.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0188
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview and record review, it was determined that the hospital did not document the patient's response and the impact of the restraint interventions for one of 14 sampled patients. (Patient identifier: 14.)

Findings include:

Patient 14, a 13 year old, was admitted on [DATE], with a diagnosis of depression with suicide ideation.

On 12/11/18, patient 14's medical record was reviewed.

A review of the record revealed patient 14 was physically restrained on 12/8/18 at 7:30 PM.

A review of the "seclusion/restraint progress note RN (Registered Nurse)/Practitioner" dated 12/8/18 at 9:00 PM, revealed "patient had refused a complete body search, Staff attempted to negotiate with patient. Staff explained multiple times why the search is done. Patient continued to refuse to complete body search. Staff compromised with patient and told him he needed to just pull down his underwear to his knees, squat and cough. Patient continued to refuse. Additional staff was called into the exam room. 2 male and 2 female staff members present. 2 staff assisted patient while the 3rd staff member checked between his thighs. Once completed staff let patient get fully dressed. Patients (sic) mother was contacted and informed of the event and why the body search is completed prior to patients walking into units".

A review of the medical record revealed no documentation concerning patient 14's response to the restraint intervention. No documentation could be located in the medical record concerning the impact the restraint intervention had upon patient 14.

A review of the "Seclusion/Restraint Patient Debriefing" form for patient 14, revealed the form was blank. None of the sections had been completed.

A review of the hospital "Seclusion and Restraint" policy was completed. The policy indicated the following:

"Following every seclusion or restraint episode, the staff will have two debriefings. The patients, and family if possible and appropriate, participate in one meeting. The staff will also debrief separately. The purpose of debriefing is to: identify what led to the incident and what could have been handled differently, ascertain that the patient's physical and well-being, psychological comfort, and the right to privacy were addressed; and counsel the patient for any trauma that may have resulted from the incident. "

No documentation could be located in patient 14's medical record to indicate that any debriefing had occurred.

On 12/12/18 at 12:40 PM, an interview was conducted with the director of nursing (DON). The DON stated that a debriefing with the patient and family should have occurred and been documented in patient 14's medical record.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0196
Based on interview and record review, it was determined that the hospital did not ensure that all staff providing care to patients had been trained and demonstrated competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion. Specifically, there was no evidence provided for 3 of 8 hospital employees and 16 of 16 contract employees to demonstarte that they received the required nonviolent crisis prevention training (CPI) restraint training. (Employees: 3, 7, and 8.) (Contract employees: 9,10,11,12,13,14,15,16,17,18,19,20,21,22,23 and 24.)

Findings include:
1. During entrance conference on 12/11/18, a list of current and contract employees was requested. Eight employee records and 16 contract employee records were chosen for review.

2. A review of the hospital employee records revealed employees 3, 7, and 8 did not have documented evidence that they had completed or were current on the required CPI restraint training.

3. On 12/13/18 at 10:40 AM, an interview was conducted with the director of nursing (DON).
The DON stated that employees 7 and 8 had current CPI training but could not provide documented evidence.

4. A review of the contract employee records revealed 16 of 16 contract employee records had no documented evidence that the contract employees had completed the required CPI restraint training.

5. Surveyors requested and received the hospital's policy and procedure for Training and Development. The policy stated that for orientation, "All newly hired employees must complete the designated new employee orientation within two (2) weeks of beginning work." The policy stated one of the required training's to be completed within the first two weeks was the CPI training.

6. On 12/11/18 at 12:27 PM, an interview was conducted with the director of human resources (DHR). The DHR stated her predecessor had "eliminated" files prior to her taking the position. The DHR further stated when she took over the position she realized she did not have any information for the agency staff, but that she had started to gather information from the agencies. The DHR stated she was still in the process of gathering the necessary information for agency staff personnel files. The DHR stated, "We know we need to audit and make changes."

7. On 12/11/18 at 9:45 AM, an interview was conducted with CE 10, who was an agency staff member, on the adolescent unit. CE 10 stated she had not received any orientation or training from the hospital. CE 10 stated she had not received training on the use of de-escalation or restraints, but that she had experience with them at a previous job. CE 10 stated she had not heard of the de-escalation/restraint program which was utilized by the hospital. CE 10 stated she believed another technician determined she was competent to provide care to patients, because she watched her provide care during part of one of her shifts. CE 10 stated she had already been working on the floor with patients when the other technician came to observe her performing patient care.

On 12/11/18 at 11:55 AM, an interview was conducted with CE 14, who was contracted through an agency to work at the hospital. CE 14 stated she had been working at the hospital for 2-3 weeks. She stated that on the first day she came to the hospital she had seen the agency coordinator and been given a badge and keys. She stated she did not receive an orientation to the hospital or training specific to the hospital. CE 14 also stated the other technicians oriented her to the patients on the unit and she had been assigned to 1:1 patient care in which she was responsible for continually watching one patient. She stated no restraint or behavioral intervention training had been provided. During the 1:1 patient care assignment, the patient became agitated and the nurse on duty came in and took over the care of the patient.

On 12/11/18 at 11:46 AM, an interview was conducted with CE 21, who was contracted through an agency to work at this hospital. CE 21 stated she had received restraint training during her work at a different hospital, but that she had not received an orientation to this hospital or training specific to this hospital when she began working at this hospital "several weeks ago."

On 12/12/18 at 11:51 AM, an interview was conducted with CE 20, an agency nurse. CE 20 stated she had not received orientation or training to the hospital because she was an agency nurse and was, "expected to jump in."

On 12/12/18 at 11:55 AM, an interview was conducted with CE 24, an agency nurse. CE 24 stated this was third shift working at the hospital. CE 24 stated the only orientation/training she received was regarding the medication pass times, this is the medication cart, and how to login into the medication cart. CE 24 stated she was not sure which de-escalation and restraint program the hospital used, but that she did want training on both. CE 24 further stated she had been on the unit when the de-escalation of a patient was necessary, but "I was not able to help aides because I have not had training on de-escalation."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0206
Based on interview and record review, it was determined that the hospital did not ensure that all patient care staff had the required training in cardiopulmonary certification (CPR). (Employee identifiers: 4, and 8.) (Contract employees (CE) 11, 13, 14, 15, 17, 19, and 22).

Findings include:

During the entrance conference 12/11/18, a list of hospital and contract employees were requested. A sample of hospital employees and contracted employee records were chosen for review.

1. A review of the employee records revealed hospital employees 4 and 8 had no documented evidence that they had a current CPR certification.

2. A review of the contract employee records revealed that CE 11, 14, 15 and 17 employee records contained no evidence that they had a current CPR certification.

3. CE employee 13, 18, and 22's personnel records contained a photocopy of the required CPR certification. The photocopies were too dark to read the dates. The surveyor was unable to determine if the certifications were current.

At that time, an interview was conducted with the director of nursing (DON). The DON stated she was not able to determine if the certifications were current.

4. During the survey process the DON made multiple attempts to get the required information from the staffing agencies the hospital had contracted with to provide nursing personnel.

5. On 12/11/18 at 12:27 PM, an interview was conducted with the director of human resources (DHR). The DHR stated her predecessor had "eliminated" files prior to her taking the position. The DHR further stated when she took over the position she realized she did not have any information for the agency staff, but that she had started to gather information from the agencies. The DHR stated, "We know we need to audit and make changes."

6. A review of the hospital policy for training and development indicated that "All new hired employees must complete the designated new employee orientation within two weeks of beginning work."

One of the items to be completed was "CPR".
VIOLATION: QAPI Tag No: A0263
Based on observation, interview, and record review, it was determined that the hospital failed to develop and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance program.

Findings include:

1. The hospital failed to promote and protect each patients' rights. (Refer to tag A-0115)

2. The hospital failed to ensure that all licensed nurses, certified nursing assistants, and behavioral health assistants had licensure and training prior to providing care to the patients. (Refer to tag A-0385)

3. The hospital failed to ensure it had a medical records service that had administrative responsibility for medical records. (Refer to tag A-0431)

4. The hospital failed to ensure the building and facility equipment were maintained in a routine, clean, and sanitary condition to assure patient safety and well-being. (Refer to tag A-0700)

5. The hospital failed to develop and maintain an active program for the prevention, control, and investigation of infections and communicable diseases. (Refer to tag A-0747)

6. The hospital failed to have a discharge planning process that applied to all patients. (Refer to tag A-0799)

7. A review of the hospital Quality committee meeting minutes revealed several of the areas listed above were topics of discussion. However, the committee did not identify any of the topics as areas that required further development of a QAPI plan for sustained improvement.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on interview and record review, it was determined that the hospital failed to ensure that all licensed nurses, certified nursing assistants and behavioral health assistants had licensure and training prior to providing care to the patients.

Findings include:

1. The hospital did not ensure that all hospital nursing personnel had the proper licensure, certifications, and competency to meet the needs of the patients for 8 of 8 sampled employees. (Refer to tag A-0397)

2. The hospital did not ensure that all non-employee licensed nurses had the required training and orientation to provide care to the patients for 8 of 8 contracted licensed nurses. (Refer to tag A-0398)

3. The hospital did not ensure medications were prepared and administered in accordance with the orders of the practitioner responsible for patients care. (Refer to tag A-0405)

4. Furthermore, a review of the non-licensed contract employee records were reviewed for the contract certified nursing assistant (CNA) employees. (Contract employee (CE) 9,10,12,14, 19, 21, 22, and 23.)

During the entrance conference on 12/11/18, a list of contract employees was requested.

On 12/11/18, the Director of Nursing (DON), provided a list of all contracted employees based on the last 3 months of nursing schedule. Eight contracted non-licensed employee records were chosen for review. At that time, a request was made for start dates of all contracted employees. Multiple requests were made for the start dates of the contracted employees throughout the survey process. The DON could not provide a start date for any of the contracted employees.

On 12/13/18, the DON stated that the only way the hospital knew what date the contracted employees had started to work at the hospital was to go by the nursing schedule.

a. The hospital had no documented employee record for CE 14.

b. CEs 9 and 21 had no documented orientation to the hospital and their roles and responsibilities.

c. CEs 9, 10,12,19, 21, 22, and 23, had no documented evidence that they had completed the required nonviolent crisis prevention training (CPI).

d. CEs 19 and 22, personnel records contained photocopies of the required Cardio-pulmonary resuscitation (CPR) certification. However, the photocopies were too dark to read the dates. The surveyor unable to determine of the certification was current.

At that time an interview was conducted with the DON. The DON stated she was not able to determine if the certifications were current.

e. CE10 had no documented evidence of a current CNA certification or competency.

f. During the survey process, the DON made multiple attempts to get the required information from the staffing agencies the hospital had contracted with to provide nursing personnel.

On 12/11/18 at 12:27 PM, an interview was conducted with the director of human resources (DHR). The DHR stated her predecessor had "eliminated" files prior to her taking the position. The DHR further stated when she took over the position she realized she did not have any information for the agency staff, but that she had started to gather information from the agencies. The DHR stated she was still in the process of gathering the necessary information for agency staff personnel files. The DHR stated, "We know we need to audit and make changes."






g. On 12/11/18 at 9:45 AM, an interview was conducted with CE 10, who was an agency staff member, on the adolescent unit. CE 10 stated she had not received any orientation or training from the hospital. CE 10 stated she had not received training on the use of de-escalation or restraints, but that she had experience with them at a previous job. CE 10 stated she had not heard of the de-escalation/restraint program which was utilized by the hospital. CE 10 stated she believed another technician determined she was competent to provide care to patients, because she watched her provide care during part of one of her shifts. CE 10 stated she had already been working on the floor with patients when the other technician came to observe her performing patient care.







On 12/11/18 at 11:55 AM, an interview was conducted with CE 14, who was contracted through an agency to work at the hospital. CE 14 stated she had been working at the hospital for 2-3 weeks. She stated that on the first day she came to the hospital she had seen the agency coordinator and been given a badge and keys. She stated she did not receive an orientation to the hospital or training specific to the hospital. CE 14 also stated the other technicians oriented her to the patients on the unit and she had been assigned to 1:1 patient care in which she was responsible for continually watching one patient. She stated no restraint or behavioral intervention training had been provided. During the 1:1 patient care assignment, the patient became agitated and the nurse on duty came in and took over the care of the patient.

On 12/11/18 at 11:46 AM, an interview was conducted with CE 21, who was contracted through an agency to work at this hospital. CE 21 stated she had received restraint training during her work at a different hospital, but that she had not received an orientation to this hospital or training specific to this hospital when she began working at this hospital "several weeks ago."
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, it was determined that the hospital did not ensure that all hospital nursing personnel had the proper licensure, certifications, and competency to meet the needs of the patients for 8 of 8 employee records reviewed. (Employee identifiers: 1, 2, 3, 4, 5, 6, 7,and 8.)

Findings include:

During the entrance conference on 12/11/18, a list of current employees was requested. Eight employee records were chosen for review.

1. Employee 1 was hired as a behavior health associate 1 (BHA1) on 11/26/18. A review of the personnel record revealed that employee 1 had partially completed the orientation skills checklist.

2. Employee 2 was hired as a licensed practical nurse (LPN) on 8/14/17. A review of the personnel record revealed no documented evidence that employee 2 had been oriented to her position.

3. Employee 3 was hired as a registered nurse (RN) on 9/24/18. A review of the personnel record revealed no documented evidence that employee 3 had been oriented to her position. There was no documented evidence that employee 3 had the required nonviolent crisis prevention training (CPI).

4. Employee 4 was hired as a BHA1 on 11/26/18. A review of the personnel record revealed no documented evidence of orientation to her position and no CPR training.

5. Employee 5 was hired as a RN on 1/8/18. A review of the personnel record revealed documentation that employee 5 had completed the orientation requirements on 3/16/18, 3 months after being hired. The orientation checklist indicated that the form was to be completed within 30 days of hire.

6. Employee 6 was hired as a LPN on 9/24/18. A review of the personnel record revealed no documentation that employee 6 had been oriented to her position.

7. Employee 7 was hired as a certified nursing assistant (CNA) on 6/5/17. A review of the employee record revealed employee 7 had completed the orientation on 8/14/17, 2 months after being hired. The CPI training had expired in 6/2018.

On 12/13/18, the DON stated that employee 7 had taken her CPI and the current expiration date was 5/2019. The DON did not provide documented evidence during the survey process.

8. Employee 8 was hired as a CNA on 6/5/17. A review of the employee personnel record revealed employee 8 had completed her orientation on 8/10/17, 2 months after being hired. Her CPI training had expired on [DATE] and there was no documentation of employee 8 having a CPR certification.

On 12/13/18, the DON stated that employee 8 had a current CPI with an expiration date of 7/9/19. The DON did not provide documented evidence at that time. The DON further stated that employee 8 had a current CPR certification. The DON stated the employee had the current card but had not provided a copy to the hospital.





9. On 12/11/18 at 12:27 PM, an interview was conducted with the director of human resources (DHR). The DHR stated her predecessor had "eliminated" files prior to her taking the position. The DHR further stated when she took over the position she realized she did not have any information for the agency staff, but that she had started to gather information from the agencies. The DHR stated she was still in the process of gathering the necessary information for agency staff personnel files. The DHR stated that employees 3 and 6 were hired when no one was in her position so she did not have a file for them yet. The DHR further stated she could not find a file for employee 5. The DHR then stated for employees 1 and 4, all that was in their files were their resume's and background checks. The DHR stated, "We know we need to audit and make changes."
VIOLATION: SUPERVISION OF CONTRACT STAFF Tag No: A0398
Based on interview and record review, it was determined that the hospital did not ensure that all non-employee licensed nurses had the required training and orientation to provide care to the patients. (Contracted employee (CE) identifiers: 11,13, 15, 16, 17, 18, 20, and 24.)

Findings include:

During the entrance conference on 12/11/18, a list of contract employees was requested.

1. On 12/11/18, the Director of Nursing (DON), provided a list of all contracted employees based on the last 3 months of nursing schedule. Eight contracted licensed employee records were chosen for review. At that time a request was made for the start dates of all contracted licensed employees. Multiple requests were made for the start dates throughout the survey process. The DON could not provide a start date for any of the contracted employees.

On 12/13/18, the DON stated that the only way the hospital knew what date the contracted employees had started to work at the hospital was to go by the nursing schedule.

2. The hospital had no documented employee records for CE 11, and CE 15, both registered nurses (RN).

3. CEs 13, 16, and 24, RNs, had no documented orientation to the hospital and their roles and responsibilities.

4. CEs 13, 16, 17, 18, and 24, RNs, and 20, an Licensed Practical Nurse (LPN) had no documented evidence that they had completed the required nonviolent crisis prevention training (CPI).

5. CE 13's personnel record contained a photocopy of the required Cardio-pulmonary resuscitation (CPR) certification. The photocopy was too dark to read the dates. The surveyor was unable to determine of the certification was current.

At that time an interview was conducted with the DON, the DON stated she was not able to determine if the certification was current.

6. During the survey process the DON made multiple attempts to get the required information from the staffing agencies the hospital had contracted with to provide nursing personnel.

On 12/11/18 at 12:27 PM, an interview was conducted with the director of human resources (DHR). The DHR stated her predecessor had "eliminated" files prior to her taking the position. The DHR further stated when she took over the position she realized she did not have any information for the agency staff, but that she had started to gather information from the agencies. The DHR stated she was still in the process of gathering the necessary information for agency staff personnel files. The DHR stated, "We know we need to audit and make changes."






7. On 12/12/18 at 11:51 AM, an interview was conducted with CE 20, an agency nurse. CE 20 stated she had not received orientation or training to the hospital because she was an agency nurse and was, "expected to jump in."

On 12/12/18 at 11:55 AM, an interview was conducted with CE 24, an agency nurse. CE 24 stated this was third shift working at the hospital. CE 24 stated the only orientation/training she received was regarding the medication pass times, this is the medication cart, and how to login into the medication cart. CE 24 stated she was not sure which de-escalation and restraint program the hospital used, but that she did want training on both. CE 24 further stated she had been on the unit when the de-escalation of a patient was necessary, but "I was not able to help aides because I have not had training on de-escalation."
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review it was determined that the hospital did not ensure medications were prepared and administered in accordance with the orders of the practitioner responsible for the patient's care. (Patient identifiers: 1, 2, 9, and 12.)

Findings include:

1. Patient 1 was admitted on [DATE] at approximately 4:00 AM, with a diagnosis of suicidal ideation.

A review of patient 1's medical record was completed on 12/13/18.

A medication reconciliation form signed and dated 11/2/18, at 4:45 PM, by a nurse practitioner (NP), revealed patient 1 was to continue the following home medications:

a. Wellbutrin 300 milligrams (mg) daily
b. Metformin 500 mg daily with dinner
c. Ampicillin 500 mg at bedtime
d. Trazadone 125 mg at bedtime
e. Melatonin 5 mg at bedtime

A physician order signed and dated by an NP on 11/2/18 at 5:00 PM, revealed the following information: "Depression - Prozac 40 mg po (by mouth) daily. PTSD (Post Traumatic Stress Disorder) - Prazosin 2 mg po daily. Progesterone 200 mg po daily (all ok w/ [with] parents)".

Patient 1's Medication Administration Record (MAR) was reviewed and revealed she received no ordered mediations on 11/2/18. The MAR also revealed the following information:

1. Patient 1 received her first medication on 11/3/18 at 11:00 AM (approximately 31 hours after her admission, and 16 hours after the physician's orders were signed).

2. Patient 1 did not receive her ordered Metformin, Prazosin, or Progesterone until 11/4/18 (two days after her admission, and physician signed order).

No information could be found in patient 1's medical record to indicate why the medications were not given as ordered, or that the physician was notified of the missed doses.

On 12/13/18 at 11:36 AM, an interview was conducted with the hospital director of nursing (DON). The DON stated she could not find documentation as to why patient 1 did not receive her medications as ordered.






2. An interview was conducted with Patient 9, on 12/11/18 at 10:30 AM. Patient 9 stated that ,on 12/9/18, his medications had been inadvertently switched with Patient 12's medications.

Review of Patient 9's medical record revealed the following:

Patient 9 was admitted to the hospital with diagnoses of Bipolar I and Psychosis on 11/28/18. Medications included: Gabapentin 600 mg, Cymbalta 90 mg, Wellbutrin 100 mg, Subutex 8mg, Depakote 250 mg, Protonix 40 mg. It was not clear from the MAR which medications the patient had received or not on 12/9/18. There was a line through the initials for the Gabapentin administration for the medication administration on 12/9/18 and the word "error" written. Otherwise, the MAR indicated medications were given as ordered.

Review of Patient 12's medical record revealed the following:

Patient 12 was admitted to the hospital with diagnoses of Schizophrenia and Acute Psychosis on 11/27/18. Medications included: Mirapex 0.5 mg, Mobic 15mg, Claritin 10 mg, Gabapentin 300 mg, Risperdal 1mg, Cymbalta 30 mg, Depakote 500 mg, Cogentin 1 mg, Wellbutrin XR (extended release) 150 mg, and Protonix 40 mg. It was not clear from the MAR which medications the patient had received or not on 12/9/18. The MAR for Patient 12 had lines through some areas and the words "not given" written. The patient's medical record documented a note from the patient's physician on 12/10/18, "Tired, laying in bed, got another pt's (patient's) med by mistake. Vitals stable. Still (illegible writing). Not ready to DC (discharge) yet."

An interview was conducted with the DON on 12/12/18 at 8:40 AM. The DON stated the medical records did not contain information regarding the medication error because the assessment forms available at the nurses station were being printed from copies of the original forms, but the copies did not always have the back of the form printed. The DON stated that the various versions of the forms meant that a place to document additional information was not available on the forms.

The adverse event log provided to surveyors on 12/11/18 did not originally contain any events from December 2018. When asked about this, the DON stated she would try to get an up-to date log from the Risk Manager. Another section of the log was provided to surveyors on 12/12/18 and included both patients involved in the medication error.

Additionally, on 12/12/18, the DON brought surveyors papers with the title "Progress Notes" for Patients 9 and 12. She stated they had been placed on the counter in the nurse's station due to not having forms for progress notes in the patients' charts. The progress note for Patient 9 stated he was given another patients medications and then he "asked for his Subutex and nurse realized he had received the wrong medication." The progress note stated the physician was called and notified; the physician asked the nurse about the narcotics administered, and asked the nurse to assess and evaluate the patient." The progress note for Patient 12 stated he was given another patient's medications and that the physician had been called.

Surveyors requested and received the hospital's policy and procedure for Medication Administration. The policy stated, "14.0 The five (5) rights of medication administration will be followed: 13.1 the right amount of; 13.2 the right medicine to; 13.3 the right patient at; 13.4 the right time by; 13.5 the right route."
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0431
Based on interview and record review, it was determined that the hospital failed to ensure it had a medical records service that had administrative responsibility for medical records.

Findings include:

The hospital did not ensure that medical records were properly filed and accessible. (Refer to tag A-0438)
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
Based on interview and record review, it was determined the hospital did not ensure that medical records were properly filed and accessible.

Findings include:

A complaint survey was conducted from 12/11/18 through 12/13/18, and 1/7/19 through 1/8/19.

Throughout the survey hospital staff provided the team with incomplete patient medical records. When survey staff asked for missing paperwork staff stated that there could be more information in medical records, but that they would have to "dig" through all of the files and stacks of paperwork to try and obtain them. On several occasions the survey team had to wait for extended periods of time, even several hours, to receive requested information, if it was able to be located at all.

On 12/13/18 at 11:36 AM, an interview was conducted with the hospital Director of Nursing (DON). The DON apologized to the survey team for the wait time on requested paperwork. The DON further stated the medical records office had stacks and stacks of papers they were having to go through to attempt and find the requested items. The DON then stated on one of the stacks of papers in the medical records office she found a note which stated, "Records doesn't' file loose papers!"
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on observation, interview, and review of facility records, it was determined the hospital failed to ensure the building and facility equipment were maintained in a routine, clean, and sanitary condition to assure patient safety and well-being.

Findings include:

1. The hospital failed to ensure adequate cleaning and repair of patient and staff areas in order to provide a clean and sanitary environment. The deficient practice had the potential to impact patient well-being and safety. (Refer to tag A-0701)

2. The hospital failed to adequately maintain all equipment to ensure safety and quality. The hospital did not maintain equipment inventory lists or preventive maintenance schedules and documentation for equipment. (Refer to tag A-0724)

3. The hospital failed to ensure that food products were stored properly. (Refer to tag A-0726)

4. The Hospital failed to ensure that all Life Safety Code (LSC) requirments were met. (Refer to tags K-0211, K0531, K0712, K0916 and K0918 on the LSC Defficiency Report)
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on direct observation and interview, it was determined the hospital did not ensure the building was maintained in a clean and sanitary condition to assure patient safety and well-being.

Findings include:

1. On 12/11/18 at 9:40 AM, a tour of the detox, acute care, and sub-acute care units of the hospital was completed. The following items were noted:

A. Walls in the detox unit hallway and patient rooms had areas where paint had chipped away from the wall in various areas and sizes (some areas were one inch in length, other areas had 5-7 inch long areas of exposed plaster). The day room where patient group therapy meetings were held in the detox unit had a strip of the wall (approximately 2 1/2 feet in length with paint peeled from the wall exposing the plaster).

B. Hallway floors in the detox unit and sub-acute unit were dusty with swept piles of dirt and debris in some corners.

C. A wall in the acute care unit had a patched hole approximately 9 inches in diameter, which had not been repainted.

D. The hallways in both the acute care and sub-acute care units also had areas of paint chipped away, with exposed plaster that prohibited the cleaning/disinfection of the walls in order to ensure a sanitary environment..

E. In the nurses station for the detox and acute units, there were rips in the chair surfaces that prohibited the cleaning/disinfection of the chairs in order to ensure a sanitary environment.

2. In an interview with Registered Nurse (RN) 1 on 12/11/18 at 10:10 AM, RN 1 stated the maintenance and housekeeping crews tried to keep up with the cleaning and repairing needs of the hospital, but that perhaps there needs to be more staff in order to make sure things get done.

3. In an interview with Technician 2 on 12/11/18, at approximately 10:00 AM, Technician 2 stated that she felt there was a need for more housekeeping staff because she had noticed dusty areas and because occasionally patients would complain that they felt the hospital was dirty.






4. Observations were made of the elevator throughout the survey process. Each time the floor of the elevator was dusty and had debris in the corners of the elevator floor.

5. On 12/11/18 at 9:30 AM, a tour of the adolescent unit was completed. The hallway walls were observed to have patched areas that were in several different phases of repair. The paint on the walls was chipped and marred. The hallway and patient room floors were dusty, with particles of dirt and paper throughout.

6. Observations of patient rooms 210 and 211 were completed. The room temperature was stifling hot and uncomfortable. The shower drain in both rooms 210 and 211 were missing the drain covers which posed a trip hazard.

7. Observations were made of the overflow adolescent hall. The patient rooms were extremely cold in temperature. The classroom on the overflow hall was extremely cold in temperature. The vent was blowing extremely cold air.

At that time an interview was conducted with the Chief Operations Officer (COO). The COO stated that the overflow hall was used only at night. Some of the adolescent patients would sleep on that side of the unit. The COO stated that patient rooms seemed too hot on the adolescent hall and too cold on the overflow hall.

8. On 12/12/18 at 9:45 AM, an interview was conducted with the maintenance technician (MT). The MT stated that he was constantly patching and repairing the walls in the hospital. The MT stated that he had an estimate for the patching and painting of the walls in the hospital and he hoped they would start in the next week. A review of the estimate revealed the estimate was for only the day room on the residential treatment center, not for the hospital.

The MT further stated that there had been issues with the heating and cooling system in the past. The MT stated that he would have to call to get someone out to look at the system again.

When asked about the housekeeping for hospital, the MT stated the hospital only had one full time housekeeper and one part time housekeeper. The hospital was unable to hire more housekeepers until after they hired a permanent plant manager.
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on interview and record review , it was determined that the hospital did not ensure that the infection control officer was qualified through ongoing education, training, experience, or certification to oversee the infection control program.

Findings include:

On 1/7/19, at 11:00 am, an interview was conducted with the infection control nurse (ICN).

The ICN stated that she had been the ICN for the hospital for about 5 years. The ICN stated that she stopped being the ICN in August of last year. During the transition to the new leadership team, no one replaced her in the role of ICN. The ICN stated that the current administrator asked her to continue being the ICN sometime in December 2018. The ICN stated that she had no formal training in infection control, only on the job training.

The ICN stated that she has taken some continuing education courses and had been a member of the local chapter of the Association for Professionals in Infection Control (APIC). The ICN stated that she just submitted the receipts for the training to finance for reimbursement. She had not provided copies of her completed training to the hospital.

The ICN stated that she would conduct monthly surveillance for hand hygiene and antibiotic stewardship. She did not track vaccinations for patients or employees. She was not the employee nurse. She stated that she did not know who tracked immunizations. The ICN stated she did set the goals for flu vaccinations for employees. The ICN stated that she provided infection control education during new employee orientation and during staff meetings. The ICN stated that she was aware of the signs and symptoms of Legionella but did not know what the hospital plan was for Legionella prevention was but was told that it was not a problem in the state.

The ICN stated that she collected the surveillance data along with her monthly environment of care data and would send it to the director of nursing (DON). The DON would then present the information at the quality meeting. The ICN stated that she did not attend the quality meeting. The ICN stated that if there were any concerns it would be addressed in the monthly safety and infection control meeting.

On 1/7/19, documentation of the qualifications, education, and training records for the ICN was requested. The DON provided certificates that the ICN had found of her completed education and training.

A review of the documentation revealed a certificate of completion of a Basic Statistics for Infection Preventionists course issued on 10/25/17, and a certificate of completion for participating in an education activity entitled: "What's in Your Toolbox? Come Sharpen Your Saw", provided by APIC Utah. The certificate was dated 4/23/15-4/24/15.

A copy of a receipt, dated 12/26/18, for payment of an APIC membership for the ICN was also provided at that time.

No other documentation was provided to indicate that the ICN had the qualifications, education and continued training to oversee the infection control program.

On 1/7/19 and 1/8/19 the infection control meeting minutes were requested. The DON stated that the safety and infection control meeting was held at the end of the quality meeting. The DON stated that the minutes of the meeting were included in the quality meeting minutes. A review of the quality meeting minutes revealed a summary of the data collected by the ICN nurse. No other documentation was provided to indicate that the ICN had developed and implemented policies and procedures and measures to prevent infection.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, interview and record review, it was determined that the infection control officer did not develop a system for identifying, reporting, investigating, and controlling infections and communicable disease of patients and personnel. Specifically, the infection control officer did not develop and implement policies and procedures that were centered on maintaining a sanitary physical environment related to ventilation and water quality control issues, including measures taken to maintain a safe environment during internal or external construction/renovation. Furthermore, the infection control officer did not evaluate the infection control program regularly and revise it, when indicated.

Findings include:

1. On 1/7/19, a request for the hospital water management plan and the policies and procedures for the prevention of Legionella and other opportunitistic pathogens in building water systems was made.

At that time the director of nursing (DON) stated that the hospital was not required to have a Legionella water plan. Clarification was given to the DON concerning the requirement. The DON stated there may be something in a binder in the plant manager's office.

On 1/7/19 at 11:00 AM, an interview was conducted with the infection control nurse (ICN). The ICN stated that she was aware of the signs and symptoms of Legionella but did not know what the hospital program was. The ICN stated that she was told by someone that Legionella was not an issue in the state of Utah.

On 1/7/19 at 11:15 AM, the DON stated that she had found a document from a water management company but did not know if that was a contract with the company or just a bid.

On 1/8/19, the DON provided a copy of the corporate water management plan with an issue date of 12/18.

A review of the plan was completed. The plan indicated "It is the policy of the hospital that water and air systems will be maintained to prevent illnesses to patients, staff and visitors." The purpose of the of the policy indicated, " To protect the health and safety of residents, visitors, and associates from Legionnaires' disease with prevention and early recognition, by formulation this water management plan to help identify and control hazardous conditions that support the growth and spread of bacterial organisms, such as Legionella."

Further review of the policy revealed, no documented date of approval of the policy.

No documentation was provided to indicate that the hospital had a functioning water management program and the policies and procedures for the prevention of Legionella and other opportunitistic pathogens in building water system.

2. During the survey process, the hospital was in the middle of renovations of the main hallway of the hospital. Several observations were made of the the hallway floor. The floor covering had been removed to the concrete. The floor was observed to be covered in a layer of dust and small particles of debris were found throughout the hallway. Observations of the offices and intake rooms along the hallway were noted to have thick layers of dust on the flooring and the furniture in each of the rooms.

A copy of the Infection Prevention and Control plan was requested on 1/7/19.

On 1/8/19, the DON provided a copy of the Infection Prevention and Control Plan/Risk Assessment with a preliminary formulation date of 9/2017 and a revised date of January 2019.

A review of the infection plan revealed infection prevention and control risk assessment for 2017 and 2018. A review of the 2018 risk assessment revealed a section labeled "Construction". The comment in the section indicated that when construction happened the infection control officer would be responsible for determining the number and placement of handwashing stations and hand sanitizers and to place appropriate barriers and HVAC (heating ventilation and air conditioning) precautions. Additional risks would be monitored and issues identified would be addressed immediately. No documentation was provided to indicate that the hospital was monitoring the construction areas for infection control risks.

A review of the quality committee meeting minutes and the infection control meeting minutes revealed no documentation concerning construction and infection control risks related to construction.

3. A review of the monthly infection control report revealed a high incidence of hospital acquired infections (HAI) especially, urinary tract infections (UTI).

A review of the quality meeting minutes for February 2018 was completed. Documented in the infection control section was "UTIs were the main HAI again this month. Staff unable to collect samples in time for CAI (community acquired infections)". No documentation was located in the minutes concerning a follow up plan to decrease the rate of UTIs.

A review of the quality committee meeting minutes for March 2018 was completed. Documented in the infection control section was "UTIs were again the HAI this month". No documentation was located in the minutes concerning a follow-up plan to decrease the rate of UTIs.

A review of the quality committee meeting minutes for October 2018 was completed. Documented in the infection control section was "UTIs were the main HAI again this month. Continue using UA (urinalysis) dipsticks to catch UTIs early".

A review of the November 2018 quality committee meeting minutes revealed no documentation concerning infection control.

A review of the process improvement projects binder, revealed no action plans for decreasing HAIs or UTI rates.

A review of the Infection Prevention and Control Plan/Risk Assessment revealed the mission statement: " Infection Prevention and Control is the department with expertise in infection prevention and control, and our mission is to continually decrease all occurrences of healthcare-associated infections (HAIS) among the hospital patients and Health Care Workers (HCWs) while striving for zero HAIs".

No documentation was provided to indicate that the hospital had developed and implemented a plan to decrease and prevent further UTIs and HAIs.
VIOLATION: LEADERSHIP RESPONSIBILITIES Tag No: A0756
Based on observation interview and record review, it was determined that the chief executive officer, the medical officer and the director of nursing failed to ensure that the hospital-wide quality assessment and performance improvement (QAPI) program addressed infection control problems and were responsible for the implementation of successful corrective actions in the problem areas.

Findings include:

1. The chief executive officer, the medical staff and the nursing director failed ensure the hospital had a functioning water management program and policies and procedures for the prevention of Legionella and other opportunitistic pathogens for the building water system. (Refer to tag A-0747)

2. The chief executive officer, the medical staff and the nursing director failed ensure the infection control officer was qualified through ongoing education, training, experience, or certification to oversee the infection control program. (Refer to tag A-749)

3. The chief executive officer, the medical staff and the nursing director failed ensure the hospital had maintained a safe, sanitary physical environment during construction /renovation of the hospital. (Refer to tag A-749)

4. The chief executive officer, the medical staff and the nursing director failed ensure the hospital developed and implemented, and maintained a plan for the reduction of hospital acquired infections. (Refer to tag A-0749)
VIOLATION: DISCHARGE PLANNING Tag No: A0799
Based on interview and record review, it was determined the hospital failed to have a discharge planning process that applied to all patients.

Findings include:

The hospital failed to reassess the patient's discharge needs and the appropriateness of the discharge plan. (Refer to tag A-0821)
VIOLATION: REASSESSMENT OF A DISCHARGE PLAN Tag No: A0821
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, it was determined that the hospital did not reassess the patient's discharge needs and the appropriateness of the discharge plan for one of 14 sampled patients. (Patient identifier:2)

Findings include:

1. On 12/11/18, a request was made to view the hospital complaint and grievance log. A review of the log revealed 4 grievances had been filed within the last 3 months.

The Director of Risk Management (DRM) provided a grievance communication form that had not been added to the list. The grievance was filed by the mother of patient 2 on 11/27/18.

A review of the form revealed the mother was concerned about the lack of individual therapy, the safety plan was poor and the patient had been admitted to another facility after discharge from the hospital for further care. The mother also had concerns about the poor communication with the providers at the hospital.

During a telephone call made by the surveyor to patient's 2 mother, the mother stated that her child had not received the therapy that he was to receive based on his plan of care and the admission paperwork. The mother also stated that the patient and family had not received a safety plan at discharge. The mother stated that the patient was currently receiving therapy at another hospital.

2. On 12/12/18, patient 2's medical record was reviewed.

Patient 2 was admitted on [DATE] and discharged on [DATE], with diagnoses of depression and suicide ideation.

3. A review of the psychiatric evaluation dated 11/14/18, noted that the initial plan of care was for patient 2 to receive "therapy and also with parents".

A review of the hospital psychosocial assessment indicated that the necessary steps for discharge included to develop coping skills, a family meeting, and safety planning. The social work role in the treatment would be discharge planning, safety plan development, and group therapy.

A review of the care plan revealed patient 2 was to complete a safety plan before discharge. Further review of the plan of care revealed an intervention for the therapist to provide individual and group counseling daily.

No documentation could be located in patient 2's medical record to indicate that he had received individual therapy nor was there documentation that indicated that the family had received counseling.

On 12/11/18, a review of the adolescent unit patient handbook was completed. Documentation in the handbook indicated that patients would receive individual and family therapy. The handbook also revealed the following:
a. "Dear Parent/Guardian,... Here is what to expect over the next couple of days:...
WITHIN 24 hours: You will receive a call from your child's psychiatrist to provide a status on your child's wellbeing...

WITHIN 48 hours: A therapist will contact you to discuss your child's treatment plan and the expectations while the patient is attending our program. The therapist will schedule a family therapy session with you...

DAYS 3-4: You will attend a family session with your child's therapist...

DAYS 5-8: Your child's therapist will set an additional family session prior to the patient's exit to discuss treatment progress, recommendations, and a safe discharge plan..."

On 12/11/18 at 2:30 PM, an interview was conducted with nurse practitioner (NP) 2. NP 2 stated that he would meet with a patient mostly for medication management. NP 2 stated that a therapist was required to meet with the family and hold at least one family meeting, and more if possible. NP 2 stated that he normally did not do individual or family therapy. NP 2 stated that there was not enough time to do so.

Note: No documentation could be located to indicate that a therapist had met with patient 2's family or that a meeting was held during patient 2's stay in the hospital.

4. On 12/13/18, at approximately 10:00 AM, an interview was conducted with licensed clinical social worker (LCSW) 2. LCSW 2 stated that each patient had a log sheet title "Special Services Discharge Planning Log". LCSW 2 stated each time the social services worker would make telephone calls, have meetings, or doing anything related to discharge planning for the patient, they were to document it on the log sheet. If a conversation was made, further information was to be documented on a separate progress note.

Note: During the review of patient 2's medical record no documentation could be located to indicate that patient 2 had a social services discharge planning log. No documentation could be located to indicate that discharge planning had occurred for patient 2.

5. A review of the crisis safety plan for patient 2 at the time of discharge was completed. A review of the plan revealed the following:

a. "Recognizing my warning signs and use coping skills to keep myself safe and healthy."

b. "Triggers and Stressors: Behaviors, situations and circumstances that put me at emotional risk."
1. "When people say faggot or gay"

c. "Warning signs: (Blank)"

d. "Things to do... My goals for health behavior:"
1. "talk about my feelings and wants more"

e. "Support System...Who can I call?"
1. "mom"
2. "dad"
3. "sister"
4. "brother"
5. "National Suicide Prevention Lifeline" (input by the hospital)

f. "Firearms Safety Plan"
1. Do I have firearms? No"

The patient had signed the form, no date was documented.

There was no documentation of a guardian/family signature or date.

There was no documentation of a therapist signature, date, or time. The section "copy was provided to the patient, guardian/family/support person" was left blank.

On 12/13/18, at approximately 10:00 AM, an interview was conducted with LCSW 2. LCSW 2 stated that therapy provided at the hospital was usually group based because they had no time to really address the individual issues appropriately.

LCSW 2 reviewed the crisis safety plan for patient 2. LCSW 2 stated that based on what patient had written on the crisis safety plan, the patient would not have been eligible for discharge. LCSW 2 stated there were many questions and "red flags" with the information documented. The LCSW stated that the discharge would not have been a safe discharge. The LCSW further stated that the discharge paperwork was inadequate.

6. A review of the "Discharge Plan and Home Medications" form was completed. In the section titled "Scheduled Aftercare Appointments" the following was documented, "parents will call for appt (appointment)".

During the interview with LCSW 2, LCSW 2 stated that it was a requirement that the LCSW make the follow-up appointment with the outside agency to ensure that the patient had follow-up after care once they were discharged from the hospital.