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.

PERIMETER BEHAVIORAL HOSPITAL OF SPRINGFIELD 2828 N NATIONAL SPRINGFIELD, MO 65803 Sept. 12, 2019
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interview, record review and review of Revised Statutes of Missouri (RSMO), the Governing Body failed to:
- Ensure the Governing Body was responsible for monitoring to ensure the contracted services provided for the facility were safe and effective. (A-0045)
- Ensure that four medical staff providers (Staff W, X, Y and Z) out of four medical staff provider's records reviewed, had approved and current privileges to provide medical care at the facility. (A-0050)
- Ensure the Chief Executive Officer (CEO) was responsible for management of the entire facility including accountability for the effective oversight of the staff to comply with the requirements under the Conditions of Participation for Patient Rights and the Governing Body. (A-0057)
- Have an institutional plan and budget prepared under the direction of the Governing Body and by a committee consisting of representatives of the Governing Body, the administrative staff, and the medical staff of the facility. (A-0077)


This resulted in the facility to be out of compliance with 42 CFR 482.12 Condition of Participation: Governing Body. The facility census was 11.
VIOLATION: MEDICAL STAFF Tag No: A0045
Based on review of Revised Statutes of Missouri (RSMO), record review and interview the facility failed to ensure the Governing Body was responsible to ensure the contracted services provided for the facility were safe and effective. This failure had the potential to affect the quality of care and safety of all patients. The facility census was 11.

Findings included:

Review of the RSMO Chapter 334 Section 334.036 stated that:
- An assistant physician collaborative practice arrangement shall limit the assistant physician to providing only primary care services and only in medically underserved rural or urban areas of this state or in any pilot project areas established in which assistant physicians may practice.
- An assistant physician shall be considered a physician assistant (PA) for purposes of regulations of the Centers for Medicare and Medicaid Services (CMS).
- An assistant physician shall clearly identify himself or herself as an assistant physician and shall be permitted to use the terms "doctor", "Dr.", or "doc".
- The collaborating physician is responsible at all times for the oversight of the activities of and accepts responsibility for primary care services rendered by the assistant physician.

Review of the RSMO Chapter 334 Section 334.037 stated that:
- There shall be a description of the time and manner of the collaborating physician's review of the assistant physician's delivery of health care services.
- The description shall include provisions that the assistant physician shall submit a minimum of 10 percent of the charts documenting the assistant physician's delivery of health care services to the collaborating physician, or any other physician designated in the collaborative practice arrangement, every fourteen days.
- All collaborating physicians and assistant physicians in collaborative practice arrangements shall wear identification badges while acting within the scope of their collaborative practice arrangement.
- The identification badges shall prominently display the licensure status of such collaborating physicians and assistant physicians.

Review of the credentialing file for Staff Y, Physician Assistant (PA), showed a valid Certificate/License from the Missouri State Board of Registration as an Assistant Physician and had an Assistant Physician collaborative agreement with Staff Z, Physician.

Review of electronic mail (email) sent from Staff JJ, Quality Director, to Staff Y, PA, on 06/26/19, showed that Staff JJ asked "what do I need to list as your professional title, Medical Doctor (MD), Doctor of osteopathic Medicine (DO), or how should it be listed." Staff Y responded, "list me as MD."

Review of the Governing Body Board Meeting minutes, dated 07/25/19, showed that Staff Y and Staff Z were credentialed.

Review of the collaborative agreement between Staff Y and Staff Z, dated 05/13/19, showed that the collaborator will review a minimum of 10 percent of the Assistant Physician's charts each month via the Electronic Medical Record (EMR). (RSMO requires 10 percent every 14 days)

During an interview on 09/11/19 at 9:52 AM, Staff Y, PA, stated that:
- He was hired in 05/2019, and subcontracted with Staff Z, Physician, to perform History and
Physicals (H&Ps) on patients every day.
- He did not medically clear patients for admissions.
- He would on occasion write medical orders for the patients.

Review of the credentialing file for Staff Z, Physician, showed no collaborating agreement between Staff Y and Staff Z. Staff Z had a valid certificate/license from the Missouri State Board of Registration as a Doctor of Osteopathic Medicine (DO).

During an interview on 09/11/19 at 2:50 PM, Staff Z, Physician, stated that:
- He was hired in 05/2019, and had not been in the facility since 06/2019.
- Staff Y had graduated from medical school and was waiting for his residency.
- He did not document any reviews of Staff Y's H&Ps.

During an interview on 09/11/19 at 10:15 AM, Staff G, CEO, stated the following:
- He understood that Staff Y was an Assistant Physician, which was new to him, and indicated that he was a Medical Doctor;
- Staff Y had been appointed and credentialed from the previous Medical Director; and
- He was unaware of requirements of RSMO chapter 334.

During an interview on 09/12/19 at 8:45 AM, Staff JJ, Quality Director, stated that Staff Y had performed 245 H&Ps since hire date in 05/2019. The facility did not have any documentation that Staff Z (collaborating physician) had reviewed any health care services provided by Staff Y, PA.
VIOLATION: MEDICAL STAFF - SELECTION CRITERIA Tag No: A0050
Based on interview, record review and review of the Revised Statutes of Missouri (RSMO), the facility failed to ensure that four medical staff providers (StaffW, X, Y and Z) out of four medical staff provider's records reviewed, had approved and current privileges to provide medical care at the facility. This failure had the potential to affect the quality of care and safety of all patients. The facility census was 11.

Findings included:

Review of the facility's document titled, "Medical Staff By-Laws," dated 2019, showed the following:
- Clinical privileges means the specific permission granted to a practitioner by the Board, based on staff recommendations in accordance with these bylaws, rules and regulations, to provide medical or other patient care services in the facility whether in person or through the use of any medium (including an electronic medium.)
- Privileges shall relate to standards of patient care, patient welfare, and the objectives of the facility or the character or competency of the individual practitioner.
- A practitioner shall be entitled to exercise only those clinical privileges specifically granted to him by the Board.
- Each application and reapplication must include a completed form specifically delineating the clinical privileges desired by the applicant.

Review of the facility's undated document titled, "Privileges in Psychiatry Medicine," showed that the form was a request by the medical staff that included:
- An area to check whether the provider was active, consulting, or telemedicine service.
- An area to list specific privileges that were not included in the core privileges; and
- List of basic privileges.

Review of the RSMO Chapter 334 Section 334.036 stated that an assistant physician shall be considered a physician assistant (PA) for purposes of regulations of the Centers for Medicare and Medicaid Services (CMS).

Review of the credentialing file for Staff W, Nurse Practitioner, showed no documented specific clinical privileges that were requested and approved. The credentialing file also showed no documented date or signatures that the Medical Staff recommended, or the Governing Body approved, her specific clinical privileges.

During an interview on 09/11/19 at 9:50 AM, Staff W, Nurse Practitioner, stated that:
- She had been working and providing care to patients for three weeks;
- She had not had any orientation to the facility; and
- She felt overwhelmed because she did not know where everything was in the facility.

Review of the credentialing file for Staff X, Medical Director, showed no documented specific clinical privileges that were requested and approved. The credentialing file also showed no documented date or signatures that the Medical Staff recommended, or the Governing Body approved, his specific clinical privileges.

During an interview on 09/11/19 at 2:40 PM, Staff X, Medical Director, stated that he had been interim Medical Director since 08/2019. He had been on call every day and responsible for the intake area. He was contracted to provide Psychiatric care and was not to be responsible for medical care of the patients.

Review of the credentialing file for Staff Y, PA, showed a valid Certificate/License from the Missouri State Board of Registration as an Assistant Physician. The credentialing file showed no documented specific clinical privileges that were requested and approved. The credentialing file also showed no documented date or signatures that the Medical Staff recommended, or the Governing Body approved, his specific clinical privileges.

During an interview on 09/11/19 at 9:52 PM, Staff Y, PA, stated that he was hired in 05/2019, and subcontracted with Staff Z, Physician, to perform History and Physicals (H&Ps) on patients every day. Staff Y agreed to only perform H&Ps, but would occasionally get called to give orders on patients.

Review of the credentialing file for Staff Z, Physician, showed no documented specific clinical privileges that were requested and approved. The credentialing file also showed no documented date or signatures that the Medical Staff recommended, or the Governing Body approved, his specific clinical privileges.

During an interview on 09/11/19 at 2:50 PM, Staff Z, Physician, stated that he was hired in 05/2019, had not been in the facility since 06/2019, and did not document any reviews of Staff Y's H&Ps.

During an interview on 09/10/19 at 10:30 AM, Staff K, Medical Executive of Credentialing, stated that Staff W, X, Y, and Z did not have requested specific privileges in their credentialing files and/or acknowledgment that the medical staff providers had the education, training, current experience and/or demonstrated performance approved by the Board.

During an interview on 09/11/19 at 10:15 AM, Staff G, CEO, stated the following:
- He was not involved in Staff W, X, Y and Z appointments or credentialing;
- They had been appointed and credentialed from the previous Medical Director; and
- He was surprised to hear that physician's did not have specific privileges.
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
Based on observation, interview, and record review, the Governing Body failed to ensure the Chief Executive Officer (CEO) was responsible for management of the entire facility including accountability for the effective oversight of the staff to comply with the requirements under the Conditions of Participation: (COP) Patient Rights; and the COP: Governing Body. This failure had the potential to affect the quality of care and safety of all patients. The facility census was 11.

Findings included:

Review of the facility's Medical Staff Bylaws, dated 2019, showed that the CEO was defined to mean the person appointed by the Governing Board to act on its behalf in the overall administration of the facility, or his/her designee.

Review of Staff G's, CEO, job description showed a duty that under the direction of the Governing Body, he was to manage and direct the organization toward its primary objectives.

The CEO failed to ensure compliance with the following:

COP: Patient Rights (refer to A-115)
- Post or display signs to inform the public of the usage of Physician Assistants (PA's) in patient care areas. (refer to A-0131)
- Ensure patients were informed of their right to formulate an Advanced Directive (AD, a legal document where the patient can direct their medical care wishes should the patient become unable to make their own decisions). (refer to A-0132)
- Properly conduct an abuse investigation for two patients (#29 and #30) of two patients reviewed and failed to develop a written policy or procedure to adequately investigate allegations of abuse. (refer to A-0145)
- Provide evidence they utilized the least restrictive restraint/seclusion (any involuntary confinement of a patient alone in a room where he/she was physically prevented from leaving) for two separate restraint/seclusion episodes. (refer to A-0165)
- Ensure a restraint/seclusion order was signed in a timely manner for one restraint/seclusion episode. (refer to A-0168)
- Provide evidence they monitored a patient while in seclusion for two separate seclusion episodes. (refer to A-0175)
- Provide evidence they conducted the one-hour face to face assessment, within one hour after a patient was in seclusion for two separate seclusion episodes. (refer to A-0178)
- Ensure that four medical staff and seven nursing staff completed restraint and first aid training. (refer to A-0206)

COP: Governing Body (refer to A-0043)
- Ensure the Governing Body was responsible to ensure the contracted services provided for the facility were safe and effective. (refer to A-0045)
- Ensure that four medical staff providers (Staff W, X, Y and Z) out of four medical staff provider's records reviewed, had approved and current privileges to provide medical care at the facility. (refer to A-0050)
- Ensure the CEO to comply with the requirements under the Conditions of Participation for Patient's Rights and the Governing Body. (refer to A-0057)
- Have an institutional plan and budget prepared under the direction of the Governing Body and by a committee consisting of representatives of the Governing Body, the administrative staff, and the medical staff of the facility. (refer to A-0077)

During an interview on 09/11/19 at 10:15 AM, Staff G, CEO, stated he agreed with the surveyors' findings and the facility had room for improvements.
VIOLATION: INSTITUTIONAL PLAN AND BUDGET Tag No: A0077
Based on interview and record review, the facility failed to have an institutional plan and budget prepared under the direction of the Governing Body and by a committee consisting of representatives of the Governing Body, the administrative staff and the medical staff of the facility. This failure had the potential to affect the quality of care and safety of all patients. The facility census was 11.

Findings included:

Review of the facility's provided document titled, "Town Hall Meeting," dated 07/31/19, showed that the facility was not closing.

Even though requested, the facility failed to provide a three year institutional plan and budget.

Review of the Staff G's, Chief Executive Officer (CEO), job description showed his duties included, in coordination with the governing body, to participate in the development of strategic plans, budgets, resource allocations, operational plans, and policies of the hospital.

During an interview on 09/11/19 at 10:15 AM, Staff G, CEO, stated that he had spoken with Staff BB, Governing Body Board Member, on a conference call with Staff JJ, Quality Director, and staff BB stated that the facility did not have a three year institutional plan and budget.

During an interview on 09/11/19 at 10:20 AM, Staff JJ, Quality Director, stated on the conference call, Staff BB, Governing Body Board Member, stated that the facility did not have a three year institutional plan and budget.
VIOLATION: LICENSURE OF NURSING STAFF Tag No: A0394
Based on interview, record review and job description review the facility failed to ensure one (Staff P) of four Registered Nurses (RNs) reviewed provided evidence of his current licensure. This had the potential to allow unlicensed, or ineligible personnel to function, inappropriately, caring for vulnerable patients. The facility census was 11.

Findings included:

Review of an undated facility's job description titled, "Position Description, Department: Nursing, Job Title: Registered Nurse," showed the following:
- The RN maintains regulatory requirements.
- Has a current license as an RN in the State of Missouri or compact state.
- Complies with all organizational policies regarding ethical business practices.

Review of Staff P's personnel file on 09/12/19, showed no evidence of a current RN license.

During an interview on 09/12/19, at 3:15 PM, Staff HH, Human Resources Coordinator, reviewed Staff P's files and confirmed there was no evidence of a current RN license.

As of of 09/17/19 at 2:36 PM, the facility failed to provide evidence of Staff P's RN licensure.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview, record review, policy review and review of the Revised Statutes of Missouri (RSMO), the facility failed to:
- Post or display signs to inform the public of the usage of Physician Assistants (PA's) in patient care areas. (refer to A-0131)
- Ensure patients were informed of their right to formulate an Advanced Directive (AD, a legal document where the patient can direct their medical care wishes should the patient become unable to make their own decisions). (refer to A-0132)
- Properly conduct an abuse investigation for two patients (#29 and #30) of two patients reviewed and failed to develop a written policy or procedure to adequately investigate allegations of abuse. (refer to A-0145)
- Provide evidence they utilized the least restrictive restraint/seclusion (any involuntary confinement of a patient alone in a room where he/she was physically prevented from leaving) for two separate restraint/seclusion episodes. (refer to A-0165)
- Ensure a restraint/seclusion order was signed in a timely manner for one restraint/seclusion episode. (refer to A-0168)
- Provide evidence they monitored a patient while in seclusion for two separate seclusion episodes. (refer to A-0175)
- Provide evidence they conducted the one-hour face to face assessment, within one hour after a patient was in seclusion for two separate seclusion episodes. (refer to A-0178)
- Ensure that four medical staff and seven nursing staff completed restraint and first aid training. (refer to A-0206)

These failures created an unsafe environment and had the potential to place all patients admitted to the facility at risk for their safety. The cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.13, Condition of Particiapation: Patient's Rights. The facility census was 11.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on observation, interview, record review, and review of Revised Statutes of Missouri (RSMO), the facility failed to post or display signs to inform the public of the usage of Physician Assistants (PA) in patient care areas. This failure had the potential to affect the quality of care and safety of all patients. The facility census was 11.

Findings included:

Review of the RSMO Chapter 334 Section 334.036 stated that an assistant physician shall be considered a physician assistant, (PA) for purposes of regulations of the Centers for Medicare and Medicaid Services (CMS).

Review of the RSMO Chapter 334 Section 334.037 stated that there shall be posted at every office where the assistant physician was authorized to prescribe, in collaboration with a physician, a prominently displayed disclosure statement informing patients that they may be seen by an assistant physician and have the right to see the collaborating physician.

Review of the credentialing file for Staff Y, Physician Assistant (PA), showed a valid Certificate/License from the Missouri State Board of Registration as an Assistant Physician.

During an interview on 09/11/19 at 9:52 AM, Staff Y, PA, stated that he was hired in 05/2019, and subcontracted with Staff Z, Physician, to perform History and Physicals (H&Ps) on patients every day.

Observation on 09/12/19 at 9:45 AM, in all patient care areas showed no signage informing patients or visitors that PAs were utilized.

During an interview on 09/12/19 at 10:00 AM, Staff G, CEO, stated that:
- The facility utilized the services of PAs;
- There were no signs in the patient care areas informing patients that PAs were utilized;
- He was unaware of the requirements under RSMO chapter 334.
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
Based on interview, record review and policy review, the facility failed to ensure patients were informed of their rights to formulate an Advanced Directive (AD, a legal document where the patient can direct their medical care wishes should the patient become unable to make their own decisions) for 18 patients (#1, #2, #6, #7, #8, #11, #12, #13, #14, #15, #18, #19, #20, #21, #22, #23, #24, and #28) of 22 patient records reviewed. The facility census was 11.

Findings included:

Review of the facility's policy titled, "Advanced Directives," revised 01/31/19, showed the following directions:
- Staff were to provide an atmosphere of respect and caring and ensure that each competent patient's ability and right to participate in medical decision making was maximized and not compromised as a result of admission for care.
- Patients would be encouraged to communicate their desires in regard to advance directives to their significant others, to allow for guidance of significant others and healthcare providers in following the patient's wishes should the patient become incapacitated, rendering them unable to make decisions.
- An inquiry would be made by the intake department during the admissions process of the patient, or if the patient was incapacitated, to the patient's representative, as to whether or not the patient had completed an advance directive.
- As part of the admission process the patient/significant other would be provided with an information packet outlining the individual's right to make decisions concerning medical care.
- Assessment and referral department staff would document in the medical record whether the patient had completed an advance directive and that information concerning advance directives had been given to the patient/significant other during the admission process.
- In order to ensure that an opportunity for patient participation in medical decision making was maximized, and that care provided was consistent with patient values and directives, educational information about advance directives would be provided. Springfield Behavioral Hospital's policies, mission, and value statements regarding advance directives and withholding of life-sustaining measures would be provided to the medical, allied health professional and hospital staff on a periodic basis and as necessary.

Review of Patients #1, #2, #6, #7, #8, #11, #12, #13, #14, #15, #18, #19, #20, #21, #22, #23, #24 and #28's medical records, showed that the patients had not formulated an AD. There was no evidence that the patients, and/or their guardian, were provided with information related to formulating an AD upon admission.

During an interview on 09/12/19, at approximately 10:40 AM, Staff A, Licensed Clinical Social Worker (LCSW)/Assessment and Referral Director, stated the following:
- Intake staff would asks patients about their AD.
- If a patient told them they did not have an AD, the intake staff would not ask any more questions.
- If the boxes were not marked beside a question in the paper medical record, that would indicate that the question had not been asked.
- Something should be marked beside each question on the AD form in the paper medical record.
- Her expectation would be for staff to fill out each form in its entirety.

During an interview on 09/12/19 at 10:20 AM, Staff D, Registered Nurse, RN stated that:
- When completing an intake she would ask the patient or their guardian about their medical and psychiatric AD.
- When no box was marked beside a question she stated it was probably an oversight on the part of the intake person.
- The expectation was that all forms were to be completed in their entirety.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview, record review and policy review, the facility failed to immediately and properly conduct an abuse investigation for two patients (#29 and #30) of two patients reviewed. The facility also failed to develop a written procedure or policy to adequately investigate allegations of abuse, neglect or mistreatment to include methods to protect patients from abuse during investigations of allegations. This failed practice had the potential to expose all patients in the facility to continued abuse or neglect by staff members. The facility census was 11.

Findings included:

Although requested, the hospital did not provide an abuse and neglect policy. There were no documents provided to show that the hospital had an effective abuse prevention program in place that contained the following components:
- Prevention; There should be adequate staff on duty to care for the individual needs of all patients.
- Screening; Persons with a record of abuse or neglect should not be hired or retained as
employees.
- Identification; Hospitals should create and maintain a proactive approach to identify events and occurrences that may constitute or contribute to abuse and neglect.
- Training; During new hire orientation and through an ongoing training, all employees will be provided with information regarding abuse and neglect and reporting requirements.
- Protection; The hospital must protect patients from abuse during investigations of any allegations of abuse, neglect or harassment.
- Investigate; The hospital will investigate thoroughly, and in a timely manner, all allegations of abuse, neglect or mistreatment.
- Report/Respond- Ensure that any incidents of abuse, neglect or harassment are reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with applicable local, State, or Federal law.

CMS defines verbal abuse as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms.

Record review of Patient #29's History and Physical (H&P) dated 05/23/19, showed the following:
- A [AGE] year old female admitted on [DATE] with chief complaint of depression, back pain and neck pain;
- History of physical abuse, self-harm, gastro-esophageal reflux disease (GERD, a digestive disease in which stomach acid or bile irritates the food pipe lining) and migraine headaches;
- Recent history of hallucinations (seeing or hearing things which are not there), fatigue and poor appetite;
- Denied any suicidal thoughts or self-harm;
- Admitting diagnosis was Major Depressive Disorder (persistent depressed mood or loss of interest in activities, causing significant impairment in daily life).

Record review of Patient #30's H&P dated 08/01/19, showed the following:
- A [AGE] year old female admitted on [DATE] with chief complaint of major depression, anxiety and suicidal ideation;
- History of suicide attempt, headaches;
- Recent history of pregnancy-21 weeks, poor appetite;
- Denied any self-harm or homicidal thoughts;
- Suicide precautions psychiatric consult.
- Admitting diagnosis was Major Depressive Disorder.

Record review of personnel file for Staff P, Registered Nurse (RN), Alleged Perpetrator (AP) showed that:
- On 06/02/19, Patient #29 reported that Staff P entered her room and pulled the blankets off her to wake her up. Patient #29 reported not being fully dressed and had to grab the blanket to keep herself covered.
- On 06/03/19, Staff JJ, Quality Director, gave Staff P a coaching memo which educated him not to wake patients up in this manner and that going forward he would need to have a female escort with him when entering female patient rooms.
- On 06/12/19, an unidentified adolescent male patient reported to Staff J, DON that Staff P said to him, "Why are you being a dick?"
- On 06/12/19, Staff J, DON gave Staff P an informal written warning and moved him from the adolescent unit to the adult unit.
- On 08/05/19, Patient #30, a pregnant female on the adult unit, reported to a therapist, that she experienced cramping, had requested Tylenol from Staff P and that he responded by saying, "You shouldn't have gotten knocked-up."
- On 08/06/19, Staff J, DON documented that during a conversation with Patient #30 she changed her story and stated Staff P said "that's what happens when you get knocked-up". Staff J documented that she would follow up with Staff P regarding the incident, however, no further investigation regarding this incident was found.

During a phone interview on 9/11/19 at 5:20 PM, Staff P, RN (AP), stated:
- The incident with Patient #29 never happened.
- He could not recall if an investigation was completed but did state he received coaching regarding the incident and did sign a paper regarding that coaching.
- He recalled the incident on 06/12/19 with the adolescent male patient but could not remember the patient's name.
- Staff J, DON only spoke with him and the unidentified patient, and that he was "cleared because it was the patient's word against mine".
- The DON moved him to the adult unit and hasn't worked on the adolescent unit since that date.
- That Patient #30 "incredibly misquoted" him. Patient was pregnant and having some ligament pain and he told her "that's what happens when you get knocked up".
- Staff J, DON spoke with him regarding Patient #30 and re-assigned him a different patient but did not remove him from the unit.

During an interview on 09/12/19 at 10:13 AM, Staff D, RN, stated:
- She has never witnessed Staff P say anything inappropriate to any patient.
- She does not recall ever witnessing any staff to patient abuse during her employment.
- She does not recall ever seeing a policy specific to abuse and neglect.
- She would report any possible abuse to the DON or to Human Resources and she felt they "may investigate if they thought it was important enough".

During an interview on 09/12/19 at 10:43 AM Staff E, RN stated:
- She has never witnessed any staff to patient abuse.
- She would report suspected abuse to the House Manager, DON or CEO.
- She's not aware of an abuse and neglect policy but felt that if she were to report any questionable incident it would be investigated.

During an interview on 09/12/19 at 9:56 AM Staff HH, Human Resources Coordinator, stated:
- That abuse could be considered anything physical, sexual or verbal including; calling names or haranguing (a lengthy and aggressive speech) patients.
- Staff are trained to identify abuse and to report it to their supervisor or any member of administration.
- She's not aware of a written policy on how to investigate potential abuse.
- The DON would be responsible for initiating an investigation.
- The DON would decide if an incident progresses forward for discipline.
- If an incident did progress forward the DON would inform Staff JJ, Quality Director, and then it would be reported to her if there were any disciplinary actions that needed to be taken.
- She and Staff J were going to meet regarding the incident with Staff P and Patient #30 but it "just hadn't happened yet".

During an interview on 09/11/19 at 3:00 PM, Staff GG, House Supervisor, Nurse Educator, Infection Control RN, stated:
- That it is never ok to call a patient a name.
- She would expect staff to report suspected abuse.
- Her expectation would be that if abuse was reported it would be investigated.
- She would pull the nurse from the floor until the investigation was completed.

During an interview on 09/11/19 at 4:05 PM, Staff J, DON, stated that:
- Verbal abuse would be cussing, derogatory name calling or possibly inappropriate tone.
- Staff know to fill out an incident report and give it to the charge nurse or the house supervisor.
- The charge nurse or house supervisor would contact her if they felt it was something that needed her attention.
- If she was unavailable the incident reports could be given to the Quality Director or Human Resources.
- She did not consider incident between Staff P and Patient #29 abuse and he received a coaching memo because "it was a teachable moment".
- She did not consider the incident with the unidentified male abuse because the patient was not directly called a "dick" but rather just formed it as the question "Why are you being a dick?"
- She decided to move Staff P from the adolescent unit to the adult unit because he "just works better with adults".
- She did not consider the incident between Staff P and Patient #30 abuse, although she acknowledged that Patient #30 stated it hurt her feelings.
- She does not keep investigation timelines.
- Unable to recall how she determined the incidents she looked into were unsubstantiated because she "failed to write down her investigation".
- She would keep a folder of each investigation.
- Staff P, RN, does not have a documented improvement plan but she "personally monitors him".
- Staff P has continued to work on the adult unit since the incident with Patient #30.
- Staff P is now training in the intake department and acknowledged that he will be working with adolescents.

During an interview on 09/11/19 at 4:42 PM, Staff LL, Corporate Vice President of Nursing, stated:
- She would expect more detailed documentation on an investigation.
- She saw room for improvement with the facility's investigations.

Facility failed to recognize, protect and investigate the possible abuse of Patient #29, which allowed Staff P, RN, to continue working, which resulted in the verbal abuse of two additional patients, Patient #30 and one unidentified patient.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0165
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and policy review the facility failed to provide evidence they utilized the least restrictive restraint/seclusion (any involuntary physical or confinement of a patient alone in a room where he/she is physically prevented from leaving) for two separate restraint/seclusion episodes, prior to placing one discharged (Patient #19) of two current and one discharged patients in restraint/seclusion. The facility identified 10 restraint episodes, involving two patients, from 06/01/19 through 08/09/19, three of which involved Patient #19. This had the potential to affect all restrained patients, causing them undue stress and/or harm by restricting their movement any more than necessary. The facility census was 11.

Findings included:

Review of the facility's policy titled, "Restraints or Seclusion Use," revised 01/31/19 showed:
- It was the intent to support the limited use of restraints and seclusion.
- The guidelines support use of the least restrictive restraint.
- A "light" physical escort,"timeout," engaging in one-on-one conversation, and increased level of observation could be considered lessor restrictive alternatives to seclusion.
- Seclusion is any involuntary confinement of a patient alone in a room where he/she is physically prevented from leaving.

Review of the facility's Seclusion/Restraint Logs for the months of 06/01/19 through 08/09/19 showed Patient #19 was admitted on [DATE] and had three restraint episodes, one on 08/07/19, one on 08/09/19, and one on 08/12/19.

Review of Patient #19's restraint documentation showed orders for seclusion on 08/09/19 from 7:45 PM through 8:30 PM, and on 08/12/19 from 7:00 PM through 7:30 PM.

Review of the entire medical record showed no evidence of an assessment for, or application of, a lessor restrictive method prior to initiating the seclusion.

During an interview on 09/11/19 at 3:45 PM Staff J, DON, confirmed lessor restrictive restraint documentation was not in the patient's record.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and policy review the facility failed to ensure a restraint/seclusion (any involuntary confinement of a patient alone in a room where he/she is physically prevented from leaving) order was signed in a timely manner for one restraint/seclusion episode for one discharged (Patient #19) of two current and one discharged patients reviewed in restraint/seclusion. The facility identified 10 restraint episodes, involving two patients, from 06/01/19 through 08/09/19, three of which involved Patient #19. This had the potential to affect all restrained patients, potentially causing them to be restrained without physician's. The facility census was 11.

Findings included:

Review of the facility's policy titled, "Restraints or Seclusion Use," revised 01/31/19 showed restraint/seclusion shall be used in emergency situations only and requires an order from a physician. The physician shall authenticate the telephone/verbal order within 24 hours.

Review of the facility's Seclusion/Restraint Logs for the months of 06/01/19 through 08/09/19 showed Patient #19 was admitted on [DATE] and had three restraint/seclusion episode on 08/07/19 related to yelling, hitting, and damaging the environment.

Review of the physician's order for the restraint/seclusion dated 08/07/19 showed the patient was to be in seclusion starting at 9:50 PM. This physician's order was not signed until 09/03/19, or 27 days later.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and policy review the facility failed to provide evidence they monitored a patient while in seclusion (any involuntary confinement of a patient alone in a room where he/she is physically prevented from leaving) for two separate seclusion episodes, prior to placing one discharged (Patient #19) of two current and one discharged patients in restraint/seclusion. The facility identified 10 restraint/seclusion episodes, involving two patients, from 06/01/19 through 08/09/19, three of which involved Patient #19. This had the potential to affect all restrained/secluded patients, potentially allowing them to sustain harm while restrained/secluded. The facility census was 11.

Findings included:

Review of the facility's policy titled, "Restraints or Seclusion Use," revised 01/31/19 showed:
- A staff member shall maintain continuous face to face observation of an individual in seclusion or restraint.
- The patient shall be assessed every fifteen minutes to include signs of injury, circulation and skin integrity, mental status, level of distress, and readiness for discontinuation of restraint/seclusion.
- Hydration as necessary, and range of motion at a minimum of every hour.

Review of the facility's Seclusion/Restraint Logs for the months of 06/01/19 through 08/09/19 showed Patient #19 was admitted on [DATE] and had three restraint episodes, one on 08/07/19, one on 08/09/19, and one on 08/12/19.

Review of Patient #19's restraint documentation showed orders for seclusion on 08/09/19 from 7:45 PM through 8:30 PM, and on 08/12/19 from 7:00 PM through 7:30 PM.

Review of the entire medical record showed no evidence of continuous face to face observation or assessment every fifteen minutes for Patient #19, for either restraint episode.

During an interview on 09/11/19 at 3:45 PM Staff J, DON, confirmed the observations and assessments for the restraint/seclusion episodes were not in the patient's record.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review and policy review the facility failed to provide evidence they conducted the one-hour face to face assessment, within one hour after a discharged patient (#19) was in seclusion (any involuntary confinement of a patient alone in a room where he/she is physically prevented from leaving) for two separate seclusion episodes, of two current and one discharged patients in restraint/seclusion. The facility identified 10 restraint/seclusion episodes, involving two patients, from 06/01/19 through 08/09/19, three of which involved Patient #19. This had the potential to affect all restrained/secluded patients, potentially causing them to remain restrained/secluded longer than necessary, or by a ineffective method. The facility census was 11.

Findings included:

Review of the facility's policy titled, "Restraints or Seclusion Use," revised 01/31/19 showed:
- The patient shall be evaluated, in person, by a physician, or authorized/trained nurse within one hour of the initiation of restraint/seclusion.
- The evaluation will be documented in the medical record.
- Ways to help the patient regain control, make necessary revisions and if necessary, provide a new order.

Review of the facility's Seclusion/Restraint Logs for the months of 06/01/19 through 08/09/19 showed Patient #19 was admitted on [DATE] and had three restraint episodes, one on 08/07/19, one on 08/09/19, and one on 08/12/19.

Review of Patient #19's restraint documentation showed orders for seclusion on 08/09/19 from 7:45 PM through 8:30 PM, and on 08/12/19 from 7:00 PM through 7:30 PM.

Review of the entire medical record showed no evidence of the one-hour face to face assessment for Patient #19, for either restraint episode.

During an interview on 09/11/19 at 3:45 PM Staff J, DON, confirmed the one-hour face to face assessments for Patient #19 were not in the patient's record.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0206
Based on interview, record review and policy review, the facility failed to ensure that four Medical Staff (W, X, Y, and Z) of four Medical Staff reviewed, and seven nursing staff (P, C, A, I, S, U, and V) of seven nursing staff reviewed, had evidence of competency in restraint (application of mechanical restraining devices or manual restraints which were used to limit the physical mobility of a patient), first aid (techniques used to address common emergencies that can occur from the use of restraint and seclusion) and restraint training. The lack of this training before hire and periodically had the potential to affect the care and safety of all patients in this facility. The facility census was 11.

Findings included:

Record review of the facility's policy titled, "Restraints or Seclusion Use," Revised 01/31/19, showed that:
-Medical Staff, direct care staff, and Registered Nurses (RNs)/Physician Assistants (PAs) were orientated to the standards for the use of restraint/seclusion.
- Direct care staff and PAs were required to attend aggression management training and show evidence of competency related to participating in application of restraints, or the monitoring, and assessment of a patient in restraints or seclusion.
- Physicians and other Licensed Independent Practitioners (LIPs) authorized to order restraint or seclusion must have a working knowledge of the facility's policy regarding the use of restraint/seclusion.
- All records documenting completion of training and competency demonstration will be maintained in staff personnel files or credentialing files.

Review of the credentialing files for Staff W, Nurse Practitioner, Staff X, Medical Director, Staff Y, PA, and Staff Z, Physician, showed no documented competency demonstration and/or completion of restraint training.

During an interview on 09/11/19 at 9:50 AM, Staff W, Nurse Practitioner, stated that she had been working and providing care to patients for three weeks and had not received any orientation to the facility.

During an interview on 09/11/19 at 2:40 PM, Staff X, Medical Director, stated that he had been interim Medical Director since 08/2019. He had not had any restraint training and he did not need the training because he had been a Psychiatric Physician for over 30 years.

During an interview on 09/11/19 at 9:52 AM, Staff Y, PA, stated that he did not need the restraint training because he was a medical physician and restraints would be for behavioral.

During an interview on 09/11/19 at 2:50 PM, Staff Z, Physician, stated that he was hired in 05/2019, and had not been in the facility since 06/2019.

Review of seven personnel/educational files (P, C, A, I, S, U, and V) showed no documented evidence or completion of first aid training specific to the identified population and types of restraints used in the facility.

During an interview on 09/11/19 at 3:15 PM, Staff R, Nurse Educator, stated that she was unaware of any first aid training, related to restraint use, ever having been provided to the nursing staff.

During an interview on 09/11/19 at 3:45 PM, Staff J, DON, stated that she was unaware of any specific first aid training provided to the nursing staff.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on interview, personnel file review and job description review the facility failed to ensure the following:
- Two Registered Nurses (RNs, Staff S and U) had their Basic Life Support (BLS, emergency care to keep blood/oxygen flowing when the heart stops) as required by their job descriptions.
- Two RNs (Staff A and U) had annual restraint (any involuntary physical or environmental confinement of a patient alone in a room where he/she is physically prevented from moving/leaving) training as required by facility policy.
- Five RNs (Staff P, I, S, A, and U) had restraint first aid training as required by regulation.
- Two Behavioral Health Technicians (BHTs, staff trained to assist doctors and nurses in the care of patients with behavioral problems) (Staff C and V) had first aid training as required by regulation.
- One RN (Staff S) had Crisis Prevention Intervention (CPI, a type of training whereby staff use physical holds which restrict a persons movement) training as required by job description.
A total of five RNs and two BHTs personnel files were reviewed. This had the potential to affect all patients admitted by allowing potentially untrained staff to care for vulnerable patients. The facility census was 11.

Findings included:

Review of an undated facility's job description titled, "Position Description, Department: Nursing, Job Title: Registered Nurse," showed the following:
- The RN maintains regulatory requirements.
- The RN performs all aspects of patient in an environment that optimizes patient safety and reduces the likelihood of medical/health care errors.
- The RN has a current BLS certificate.
- The RN has a current CPI certificate.

Review of an undated facility's job description titled, "Position Description, Department: Nursing, Job Title: Psychiatric Technician," showed the following:
- The technician (tech) assists with restraining a patient, placing a patient in seclusion.
- The tech performs all aspects of patient in an environment that optimizes patient safety and reduces the likelihood of medical/health care errors.
- The tech completes annual educational requirements.
- The tech maintains regulatory requirements.
- The tech has a current BLS certificate.
- The tech has a current CPI certificate.

During an interview on 09/12/19 at 11:25 AM, Staff HH, Human Resources Coordinator, stated that restraint training was required in nursing orientation and annually thereafter.

Review of the facility's policy titled, "Restraints or Seclusion Use, " revised 01/31/19, showed:
- All clinical staff will receive restraint/seclusion training prior to patient intervention.
- Cardiopulmonary Resuscitation/BLS (CPR, emergency life-saving procedure that is done when someone's breathing or heartbeat has stopped) is a requirement of all clinical staff.
- First Aid is a requirement of all clinical staff.
- CPI is a requirement of all clinical staff.

Review of personnel and educational files on 09/12/19 showed two full-time RNs, Staffs S and U failed to have their current BLS certificates.

Review of personnel and educational files on 09/12/19 showed one full-time RN, Staff A, and one as needed (PRN) RN, Staff U, failed to have annual restraint training.

During an interview on 09/11/19 at 3:15 PM, Staff R, Nurse Educator, stated that she was unaware of any specific first aid training based on the facility's assessment and use of restraints.

Review of personnel and educational files on 09/12/19 showed four full-time RNs (Staffs P, I, S, and A), one PRN RN (Staff U), and two full-time BHTs (Staffs C and V) failed to have restraint first aid training.

During an interview on 09/11/19 at 9:45 AM, Staff L, Director of Plant Operations, stated that CPI was required of all staff upon hire with a refresher course and full course review every other year.

Review of personnel and educational files on 09/12/19 showed one full-time RN (Staff S) failed to have CPI training.
VIOLATION: USE OF VERBAL ORDERS Tag No: A0407
Based on interview, record review and policy review the facility failed to keep telephone and/or verbal physician's orders to a minimum for ten current (#1, #2, #8, #11, #12, #15, #16, #17, #18, and #21) and seven discharged patients (#5, #10, #13, #20, #23, #24, and #28) of 21 total reviewed. This failure had the potential to cause transcription and/or communication errors leading to the wrong orders being applied by staff. The facility census was 11.

Findings included:

Review of the facility's policy titled, "Verbal-Telephone-Written Orders," revised 01/31/19 showed no direction to utilize verbal/telephone orders as infrequently as possible.

Review of current Patient #1's physician's orders dated 09/03/19, showed two of three orders (all admission orders and Catapres 0.1 milligrams (mg, a measure of dosage strength) every morning-a medication for high blood pressure) were received via telephone.

Review of current Patient #2's physician's orders dated 09/07/19, showed all admission orders were received via telephone.

Review of current Patient #8's physician orders showed the following:
- 09/05/19, an order to discontinue line of sight precautions received via telephone.
- 09/06/19, Haldol 5mg (an antipsychotic) intramuscular (IM, administered into a muscle) and Ativan (a sedative) 2mg IM for increased aggression was received via telephone.
- 09/07/19, an order to discontinue Haldol IM and start Haldol 5mg po (by mouth) was received via telephone.
- 09/07/19, an order Haldol 2mg IM and Ativan 2mg IM for increased aggression was received via telephone.
- 09/07/19, an order to discontinue Haldol po and start Zyprexa (an antipsychotic) 5mg tablet was received via telephone.
- 09/07/19, an order for a one time dose of Zyprexa Zydis (disintegrating tablet) 5mg was received via telephone.

Review of current Patient #11's physician's orders dated 09/09/19, showed all admission orders and an order for Nix lice treatment were received via telephone.

Review of current Patient #12's physician orders showed the following:
- 09/05/19, an order for Tegretol (an anticonvulsant) 25mg order was increased to 50mg via telephone.
- 09/06/19, the patient's pending discharge was cancelled per physician via telephone order.
- 09/07/19, the patient was sent to another hospital emergency department for an x-ray of left wrist, arm and forearm via telephone order.

Review of current Patient #15's physician's orders dated 08/29/19 and 09/05/19, showed Lexapro 10 mg (an antidepressant) and Tegretol 50 mg (an anticonvulsant) were received via telephone.

Review of current Patient #16's physician's orders dated 09/02/19, showed Keppra 500 mg (an antiseizure) was received via telephone.

Review of current Patient #17's physician's orders dated 09/10/19, showed Fluoxetine HCL 40 mg (an antidepressant) was received via telephone.

Review of current Patient #18's physician's orders dated 09/07/19, showed two of two orders, for admission and five continued home medications, were received via telephone.

Review of current Patient #21's physician's orders dated 09/09/19, showed all admission orders were received via telephone.

Review of discharged Patient #5's physician's orders dated 07/22/19, showed two of three (admission orders and Haldol 0.5 mg [an antipsychotic medication], a urinalysis, Vitamin D, B12 and folic acid levels to be drawn) orders were received via telephone. One of two orders dated 07/23/19, for Haldol 2 mg and Ativan 1 mg (an antianxiety medication), were received via telephone.

Review of discharged Patient #10's physician's orders showed four medication changes and one cancelled discharge via telephone order.

Review of discharged Patient #13's physician's orders showed admission orders on 07/12/19, an order to discontinue one to one (1:1, continuous visual contact with close physical proximity) observation, order for urinalysis (a test of urine to determine if an infection is present) and three medication changes were received via telephone.

Review of discharged Patient #20's physician's orders dated 07/27/19, showed all admission orders were received via telephone. Orders dated 07/29/19, showed the patient was sent to another hospital emergency department for evaluation via telephone order.

Review of discharged Patient #23's physician's orders dated 08/20/19, showed that:
- All the orders to admit the patient to the adolescent unit were received via telephone.
- An Albuterol inhaler (a bronchodilator medication used to relax muscles in the airways and increase airflow to the lungs) two puffs every four hours as needed was ordered via telephone.
- Haldol (a medication used to treat severe behavior problems in children) 1 mg by mouth could be given for agitation, and they could give it intramuscular (IM, an injection given in the muscle) if the patient refused to take the medication by mouth was given via telephone.

Review of discharged Patient #24's physician's orders showed that:
- On 08/02/19 all orders to admit the patient to psychiatric services were received via telephone.
- On 08/05/19 there was a telephone order to decrease Lyrica (a medication used to treat nerve pain and seizures) to 25 mg daily at bedtime.
- On 08/05/19 Magnesium Oxide (a mineral supplement used to treat or prevent low levels of magnesium in the blood) 400 mg by mouth twice a day was ordered via telephone.
- On 08/09/19 Zyprexa (a medication used to treat the symptoms of psychotic conditions and symptoms of mood disorders such as bipolar disorder in adults and children at least 13 years and older 5 mg tablets by mouth at bedtime was ordered via telephone.
- On 08/09/19 Zyprexa 2.5 mg tablets by mouth every morning for severe depression (extreme sadness that doesn ' t go away) and anxiety (overwhelming fear or worry) was ordered by telephone.
- On 08/17/19) all Zyprexa orders were discontinued by telephone.
- On 08/17/19 an order for Patient #24 to start Zyprexa 5 mg three times a day for mood was received via telephone order.

Review of discharged Patient #28's physician's orders showed that:
- All admission orders for Patient #28 to the Psychiatric Unit were given via telephone on 08/06/19.
- On 08/09/19 Mirtazapine (a medication used to treat depression) 15 mg tablet by mouth at bedtime was ordered via telephone.
- On 08/09/19 Travoprost Ophthalmic solution (a medication used to treat glaucoma [a group of eye conditions that can cause blindness] and hypertension [high pressure in the eye] in the eye) 0.004% one drop in both eyes daily at bedtime for glaucoma was given via telephone.
- On 08/09/19 a telephone order was given to obtain blood tests including a complete blood count (CBC, a blood test performed to determine inflammation or infection), comprehensive metabolic panel (CMP, a lab test that gives a healthcare provider important information about the current status of a person ' s kidneys, liver, electrolyte and acid base balance as well as levels of blood sugar and blood proteins), Hemoglobin A1C (the average level of blood sugar over the past two to three months), red blood cell-Magnesium (RBC-Mag, a test that measures the amount of magnesium in the red blood cells), Vitamin D level, Vitamin B-12 level and a Vitamin B-6 level.
- On 08/14/19 Zyprexa 2.5 mg IM at that time for sleep and agitation was ordered via telephone.
- On 08/14/19 Seroquel (an antipsychotic medication used to treat schizophrenia, bipolar disorder, and depression) 50 mg by mouth to be given at that time and then repeated in one hour if no relief from agitation (excessive motor activity associated with a feeling of inner tension) and mania (a period of time when a person cannot sleep for days, feels elevated and grandiose, and is easily distracted) was given via telephone.