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.

SONORA BEHAVIORAL HEALTH HOSPITAL 6050 NORTH CORONA ROAD TUCSON, AZ 85704 March 28, 2019
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on review of the facility process improvement program, infection control program, facility documents, and interviews, it was determined that the facility failed to measure, track and take actions to improve performance in accordance with the hospital's "Process Improvement Program."

Findings include:

The facility "Process Improvement Program" requires: "...The Program provides a system for the measurement and assessment of important processes or outcomes related to patient care...Data is systematically collected for both improvement priorities and continuing measurement of those processes having the greatest impact on patient care and clinical performance...Data is analyzed for improvement opportunities...Establish a baseline when a process is implemented or re-designed...Identify areas for improvement...Determine whether changes in a process have met objectives...Sustain improvement...The Quality Council is the steering committee for the Program and will: Establish policy and ensure implementation of process improvement activities...Design, maintain, support, and document evidence of an ongoing program to systematically measure, assess, and improve patient outcomes...Assure that appropriate actions are implemented to resolve identified problems or improve existing processes...."

The facility identified the following areas for improvement in October 2018:

-Staff complacent on performing skin assessments
-Staff complacent on inventorying patient belongings
-Staff not properly conducting observation rounding
-Staff needs training on incident reporting and seclusion/restraint training
-Staff not properly processing transports and securing belongings

The improvement plan that outlined recommended actions was implemented; however, there was no documentation of evaluation and follow up for the effectiveness of the actions.

Employees #4 and 43 confirmed that no follow up and evaluation occurred after the development of a plan to address improved performance of skin assessments, inventorying patient belongings, observation rounding, training on incident reporting and seclusion and restraint, and transporting and securing belongings.

Seclusion and Restraints

The occurrences of seclusion and restraints were documented in Quality Committee Meetings for the following months:

July 2018 - 10
August 2018 - 30
September 2018 - 27
October 2018 - 26
November 2018 - 25
December 2018 - 24

Employees #4 and 43 confirmed that the data reported to the quality committee had not been analyzed for trends and did not develop and implement a plan to alleviate the number of events. Additionally, they confirmed that 25% of staff had not had annual restraint training as documented in the December 2018 quality committee meeting.

Medication Variances

The occurrence of medication variances due to transcription errors and not verifying a patient's identity was unchanged for September, October, November, and December 2018, and for January and February 2019.

The performance improvement plans for September, October, and December 2018 included action to provide training to nurses on medication errors and the importance of noting and transcribing medication orders correctly. The improvement plan for December 2018, also documented implementation of spot medication pass competencies.

Employees #4 and 43 confirmed that data gathered was not being analyzed to identify causes, interventions were not specific and effective to prevent errors from occurring, and that no follow up or changes were implemented when an improvement in medication errors did not occur.

Infection control audits

The following data was documented in monthly infection control audits.

July 2018
20 hand hygiene observations were 100% compliant.

August 2018
20 hand hygiene observations were 100% compliant.

September 2018
30 hand hygiene observations were 100% compliant.

October 2018
90 hand hygiene observations were 100% compliant.

November 2018
90 hand hygiene observations were 100% compliant.

December 2018
90 hand hygiene observations were 100% compliant.

January 2019
90 hand hygiene observations were 100% compliant.

February 2019
90 hand hygiene observations were 100% compliant.

Additionally, there was conflicting documentation in the audits for October and November 2018 that included correction plans with contributing factors for staff not performing hand hygiene despite the documentation that there was a 100% compliance with hand hygiene. The problems identified for correction were staff getting distracted or forgetting to wash, the location of hand sanitizer, staff unable to perform hand hygiene due to holding supplies, and that staff did not believe there was a need to perform hand hygiene.

Employee #43 confirmed that the validity of the hand hygiene audit data was questionable. He/she stated that it was unlikely there was a 100% compliance rate with hand hygiene every month from July 2018 through February 2019. Additionally, Employee #43 confirmed that October and November 2018 audits contained documentation of performance improvement plans when none was needed if the hand hygiene compliance rate was 100%.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on clinical record reviews, document reviews and staff interviews, it was determined each patient's rights were not protected and promoted as evidenced by the hospital's failure to:

A-0130: ensure patient responsible family members/ guardians were notified and treatment plans updated to reflect the incident that triggered the Safety/Focus status. (Patients #10, #15, and #16) This deficient practice posed the risk of family members/guardians not being given the opportunity to participate and involved in treatment planning.

A-0144: ensure the staff member assigned to be the hospital Supervisor from 6 p.m. on 3/17/2019 to 6:30 a.m. on 3/18/2019 was familiar with the system requirement to ensure an emergency exit door that leads directly out to the parking lot closed and locked after exiting. Three adolescent patients were able to elope from the hospital for several hours before they were located. (Patients #11, #13, and #14.) This deficient practice posed the risk of harm to the unaccompanied patients outside of the hospital setting.

A-0145: ensure patients were free from abuse by hospital staff. (Patients #10, #12). This deficient practice violated the patients' right to a safe environment from physical and psychosocial harm to them.

A-0154: ensure patients were only restrained to ensure the immediate physical safety of the patient, a staff member or others. (Patients #2 and #16) This deficient practice poses the risk to patients of physical and/or psychological harm if restraints are used without appropriate justification.

A-0196: ensure all direct care staff received training on Verbal Intervention (De-escalation) and Physical Intervention (restraints) every year per their policy. Seven Behavioral Health Technicians (BHT) were beyond their 12-month window for retraining and five Registered Nurses (RN) were beyond their 12 month retraining window. This deficient practice posed the risk of patient harm if staff are not periodically trained using approved and safe techniques.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment that protects patient rights.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on review of the Governing Board Bylaws, review of clinical records, review of hospital policies and procedures, review of internal hospital documentation, and staff interviews, it was determined the governing body was not effective in carrying out the functions of the hospital to ensure compliance with the Conditions of Participation for Patient Rights (A-0115).

Findings include:

The Governing Body Bylaws included: "The Governing Body is ultimately accountable for the safety and quality of care, treatment, and services provided by the Facility. The primary function of the Governing Board is to assure that the Facility and its Medical Staff provide quality medical care that meets the needs of the community."

Cross refererence Tag A-0115 Patient Rights for specific details related to the hospitals failure to ensure that the Facility and its Medical Staff provided quality medical care that met the needs of its patients as evidenced by:

* medical staff failed to ensure patient responsible family members/ guardians were notified and treatment plans updated to reflect the incident that triggered the Safety/Focus status;

* the staff member assigned to be the hospital Supervisor from 6 p.m. on 3/17/2019 to 6:30 a.m. on 3/18/2019 was familiar with the system requirement to ensure an emergency exit door that leads directly out to the parking lot closed and locked after exiting;

* administration failed to ensure patients were free from abuse by hospital staff.

* medical staff and administrators failed to ensure patients were only restrained to ensure the immediate physical safety of the patient, a staff member or other;

* administration failed to ensure all direct care staff received training on Verbal Intervention (De-escalation) and Physical Intervention (restraints) every year per their policy. Seven Behavioral Health Technicians (BHT) were beyond their 12-month window for retraining and five Registered Nurses (RN) were beyond their 12 month retraining window;

Cross reference Tag A286 Patient Safety for specific details related to the facility's failure to ensure appropriate actions were implemented to resolve ongoing occurrences of medication administration errors within the facility, and their failure to analyze data for potential causes to implement a plan to decrease and /or correct the number and frequency of medication administtration errors from occurring.

Cross reference Tag A 395 RN Supervision of Nursing Care for specific details related to the facility's failure to ensure daily vital signs and pain assessments were performed as ordered by the physician and per facility policy for (14) of (19) patients (Patients #2, 3, 4, 5, 9, 10, 22, 23, 24, 25, 28, 30, 31, and 33). Failure to conduct ongoing physical assessment of patients in a psychiatric hospital may result in patient harm, if nurses do not recognize a change in their medical condition.ility's failure to ensure

Cross Reference Tag A 396 Nursing Care Plan for specific details related to the facility's failure to ensure master treatment plans were developed and completed for (17) of (24 ) patients (Patients #1, 2, 3, 4, 5, 6, 7, 9, 10, 23, 25, 26, 27, 28, 30, 31, and 33). Failure to complete a patient's care plan prevents the IDT (interdisciplinary team) from identifying needed services, developing goals for treatment, and evaluating the effectiveness of services delivered while a patient is receiving care during admission to the hospital.

The cumulative effect of this systemic problem resulted in the hospital's inability to provide quality care in a safe environment that promotes and protects the rights of each patient.
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
Based on clinical record reviews and staff interviews, it was determined for 3 of 3 focused reviews of adolescent patients placed on "Safety/Focus" status during their hospitalization ,(Patients #10, #15, and #16), the hospital failed to ensure patient responsible family members/ guardians were notified and treatment plans updated to reflect the incident that triggered the Safety/Focus status. This deficient practice posed the risk of family members/guardians not being given the opportunity to participate and involved in treatment planning.

Findings include:

The hospital's policy and procedure titled, "Patient Rights and Responsibilities," included the following: "Each patient has the right to...To participate or, if applicable, to have the patient's parent, guardian, custodian or agent participate in treatment decisions and in the development and periodic review and revision of the patient's written treatment plan."

Documentation in the hospital's "Child and Adolescent Bill of Rights" included: "5. You have the right to receive treatment that is not a punishment...14. If any of your rights are temporarity restricted, the reasons will be written in your chart. You will be told how long the restriction is to last, and it will be reviewed every seven days."

Documentation in the policy and procedure titled, "Treatment Planning," included: "12. Treatment Plan reviews and updates shall include the following steps...b. Modifications or additions made to goals and interventions, as appropriate, and whenever a significant event or change in condition arises. Such events include falls, seclusion or restraint, and or change in medical, cognitive or behavioral status that requires changes in the interventions.

Documentation in the clinical records of Patients #15 and #16 revealed they were placed on "Safety" and/or "Focus" status during their hospitalization because of certain problematic behaviors. Documentation in Staff #18's personnel record revealed he placed Patient #10 into scrubs and placed him on "safety" status after an altercation. There was no documentation in the clinical records that the individual treatment plans were updated to reflect the incident(s) that triggered placement on a specific status nor was there documentation that the responsible family member and/or guardian was notified.

Staff #11 and Staff #12 acknowledged during interviews that family members/guardians were not generally notified of a patient being placed on safety/focus status.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on clinical record reviews, personnel record review, and staff interviews, it was determined the hospital failed to ensure the staff member assigned to be the hospital Supervisor from 6 p.m. on 3/17/2019 to 6:30 a.m. on 3/18/2019 was familiar with the system requirement on opening and closing an emergency exit door that leads directly out to the parking lot. Three adolescent patients were able to elope from the hospital for several hours before they were located. (Patients #11, #13, and #14.) This deficient practice posed the risk of harm to the unaccompanied adolescent patients outside of the hospital setting.

Findings include:

Documentation in Patients #11, #13, and #14 clinical record dated 3/17/2019, revealed that on or around 7:30 a.m., they were not able to be located on the unit. Nursing documentation in Patient #11's clinical record included: "Door found ajar which required 2 fobs to open...Door guarded until maintenance arrived...." All three patients were located and returned to the facility within 24-hours.

Staff #3 reported during an interview that Staff #17 agreed to be the Supervisor during the night shift of 3/17/2019. Staff #3 acknowledged that the RN was a staff nurse and not hired in a Supervisor role. It was reported that Staff #17 exited from an emergency exit door that led to the parking lot and did not know that two separate fobs were required after exiting to ensure the door closed and locked. (A fob is a small electronic hardware security device with built in authentication used to control and secure access to computer systems.)

A review of Staff# 17's personnel record revealed a Job Description and completed competencies for the essential functions of a "Direct Care" RN. There was no job description or competencies for the role of "House" Supervisor.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on clinical record reviews, hospital policies and procedures and documentation reviews, and staff interviews, it was determined the hospital failed to ensure patients were free from abuse by hospital staff. (Patients #2, #10, and #12). This deficient practice violated the patients' right to a safe environment free from physical and psychosocial harm.

Findings include:

The hospital's policy and procedure titled, "Patient Rights and Responsibilities" (Policy Number: RI 01), included: Each patient has the right to: 1. To be treated with dignity, respect, and consideration...19. To be free from: a. Abuse.

The hospital's "Child and Adolescent Bill of Rights" included:
"1. You are to be treated by all staff with dignity and with respect...
5. You have the right to receive treatment that is not a punishment. Your treatment is based on trying to help you learn positive coping skills. Staff will work with you to keep you safe...
8. You have the right to tell any staff member that you have a complaint. You can write it down and give it to a staff member. You can also tell staff that you have better ideas on how to treat patients and you don't have to worry about the staff getting angry about it."

The hospital's policy and procedure titled, "Zero Tolerance" (Policy Number RM202), included:
"It is the policy of Sonora Behavioral Health to educate all facility staff including contracted individuals, agency employees and volunteers of Acadia Healthcare's Zero Tolerance policy."

The surveyors were provided with a copy of the Zero Tolerance training material. Zero Tolerance was defined as: "The policy and practice of not tolerating undesirable behavior...Acadia Healthcare does not tolerate any action which can be construed as abuse, neglect, or exploitation." The following definitions and examples of abuse were provided in the training document:

"Mental/Psychological
Acts that inflict emotional harm, invoke fear and/or humiliate, intimidate, degrade, demean or otherwise negatively impact the mental health or safety of an individual
-Derogatory, threatening, belittling, humiliating, or profane or obscene language toward a patient
-Physical intimidation

Physical Abuse
Acts of assault/battery
-Assaultive behavior physically
-Putting a patient in a seclusion or restraint (lack of freedom) without justification of imminent danger to self or others
-Pushing, hitting, slapping, or striking a patient

Verbal Abuse
The use of offensive and/or intimidating language that can provoke or upset an individual
-Cursing/verbally threatening a patient...."

Patient #2

Documentation in a hospital investigation report revealed that on approximately 1/31/2019 (no time documented), Patient #2 was reported to be "agitated and in a chair." The patient tried to stand up but was held down by his shoulders by the LPN assigned to the unit on the day shift (Staff #19). Staff #19 told the patient to ["profane language redacted"] and walked back behind the nurses station. The patient went to the nurses station with his hands up in the air in a fighting position and challenged Staff #19 to "come out." Staff #19 left the nurses station and took the patient "down to the ground" and told the patient: "'...this is not the streets, this is a hospital!'" There was no documentation of this incident in the patient's clinical record. Staff #19 remained on the unit and was assigned to the same unit the following day, 2/1/2019, and there was another altercation between Staff #19 and Patient #2 which resulted in injuries to Staff #19. There was no documentation in the hospital's investigation report of when the incident was reported to the Quality/Risk department. Staff #19 was terminated from employment on 2/8/2019 based on witness accounts of the incident as well as "other mitigating factors."

Patient #10

Patient #10 was an adolescent patient. The Registered Nurse (RN) assigned to the patient's unit on the day shift of 2/6/2019, (Staff # 23) documented an incident at 9 a.m. that occurred between the patient and the Licensed Practical Nurse (LPN) who was also assigned to the unit (Staff #18). Staff #23's documentation included: "(Patient #10) approached author, asked if author could pass meds due to (Staff #18) had 'attitude.' Staff #18 was asked about the med and he stated, 'You know your meds' and threw the med. Patient #10 got upset and said ['profane language redacted'] and Staff #18 came from Nursing Station and went hands on (with) pt. Author was able to deescalate the situation." There was no other documentation from the RN that described the "hands on." The RN documented at 9:35 a.m. that the patient: "...was able to use his coping skills and calm himself down."

The hospital's investigation of the incident revealed Patient #10 felt "unsafe" with Staff #18 giving him his medications because of Staff #18's "attitude." The patient questioned his medications because he did not recognize the pill in the cup. (The surveyor later confirmed there was a medication error involving Staff #18 and Patient #10 prior to this incident.) The RN (Staff #23) asked Staff #18 to verify the patient's medications and Staff #18 responded that the patient knew what his medications were and to "stop lying and [language redacted]." This upset the patient who responded verbally with foul language. Staff #18 was then witnessed by staff to come from behind the nurses station, grab the patient and hold him against the wall until staff told him to let go. Staff #18 then carried the patient, "feet in the air" into a patient room (not Patient #10's room) and continued to provoke him, however, Patient #10 remained calm and did not engage with Staff #18. Staff #18 was then provided with a 45-minute break to "cool off." He later requested to be transferred off of the adolescent units and be assigned to the adult units. His request was approved and arranged for the end of the week (according to documentation in the Coaching Form in the personnel record). Staff #18 was allowed to return to the same adolescent unit where the incident occurred because he "assured" nursing leadership that he was okay to finish out his shift. Documentation in Staff #18's personnel record revealed he was provided with "written coaching" by an Assistant Director of Nursing (Staff #12). Staff #12 documented Staff 18 placed the patient in scrubs and placed him on "safety," and Staff #18 was coached on ways to de-escalate himself and the patient and: "Alternatives to scrubs, safety."

Patient #12

Later that day, 2/6/2019, Staff #18 was involved in another incident with a different adolescent patient (Patient #12). Documentation at 6 p.m. in the clinical record by the RN (Staff #23) included the following: "Pt was on his way to dinner when (Staff #18) had words (with Patient #12) and the verbal altercation led to going hands on (with Patient #12). He stated that he said that (Staff #18) said 'you wanna go?' So according to staff he went hands on and slammed him against the wall and hit his head on the wall. (Patient #12) stated that he had punched the wall and floor. Sent out to (name of acute care hospital) for x-rays per (name of Nurse Practitioner)." The patient returned from the Emergency Department at approximately 11 p.m. The patient was assessed by the RN on duty at that time whose documentation dated 2/17/2019 at 12:55 a.m. included the following: "Pt has red area behind neck area, red mark on (R) wrist, (R) forearm. Pt's (R) hand has sore above ring finger, and (unable to read) finger...(R) wrist red horizontal line. Small bruise noted upper (R) forearm. (L) eye slight puffy below eye. No redness noted. Both shoulders have reddened area and (R) hip has reddened area. Pt c/o (complained of) headache 8/10. Pt stated 'the back of my head hurts.' Pt medicated with Tylenol...."

The hospital's investigation of the incident revealed Patient #12 was walking with other patients and staff to the dining room. A staff member who was present reported it appeared that the patient said something to Staff #18 who was in the Art Room. Staff #18 came out of the Art Room, followed the line and took the patient "down to the ground" and repeatedly "pushed" the patient's head into the ground and wall. Another staff member who was in the Art Room responded and pulled Staff #18 off the patient and told him to "go away." The patient was escorted back to the unit. He was described to be upset and punched the wall. The investigation report did not include when Staff #18 left the hospital. The hospital notified the Pima County Sheriff's Department the following day, 2/7/2019 and terminated his employment on 2/8/2019.

The first incident of "physically assaultive behavior" as defined in the Zero Tolerance training was on 1/31/2019 by Staff #19 to Patient #2. The employee was not terminated until 2/8/2019. The second incident of physically assaultive behavior by a staff member (Staff #23) to a Patient #10) (adolescent) was on the morning of 2/6/2019. The staff member was allowed to stay on the unit which placed other vulnerable adolescent patients at risk for harm from this staff member. The third incident of physically assaultive behavior was later that day by Staff #23 to Patient #12, which resulted in the adolescent patient being sent to an Emergency Department for evaluation including a CT scan of his head.

The hospital's corrective actions documented in their investigation reports as a result of the incidents involving Patients #2, #10, and #12 included eight mandatory Zero Tolerance/Code of Conduct organization wide trainings which were performed between 2/20/2019 (twenty days after the first incident) to 3/14/2019. Another corrective action included: "...implementing a plan to send all clinical staff through a Handle with Care refresher training."

Staff #4 reported the trainers went through the refresher course, and the hospital was in the process of scheduling the rest of the staff.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based on review of clinical records, review of hospital policies and procedures, and staff interviews, it was determined the facility failed to ensure patients were only restrained to ensure the immediate physical safety of the patient, a staff member or others (Patients #2 and #16), and failed to ensure policies and procedures included the practice of forcing patients to wear hospital issued scrubs when they were placed on "Safety/Focus status." (Patients #10 and #16). This deficient practice poses the risk to patients of physical and/or psychological harm if restraints are used without appropriate justification.

Findings include:

The hospital's policy and procedure titled, "Patient Rights and Responsibilities (Policy Number RI 01)" included: "Each patient has the right to...19. To be free from...Restraint or seclusion, of any form, used as a means of coercion, discipline, convenience, or retaliation."

The hospital's policy and procedure titled, "Restraint (Policy Number: PC 12)" included: A restraint is any manual method that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely....Restraint may only be used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member or others after less restrictive interventions are ineffective or ruled-out...Restraint is never used as a means of coercion, discipline, convenience or staff retaliation."

The hospital's policy and procedure titled, "Use of 1 to 1, Roommate Restriction and Unit Restriction Status," revealed a Registered Nurse could implement a unit restriction at any time if the patient's behavior met one of the criteria listed including danger to others or danger to self. The term "focus and safety" was used in this policy related to work packets to be completed and individualized programming for "severe focus and safety behaviors" The policy did not address that patients placed on Unit Restriction or "Safety/Focus Status" were required to change from their regular clothes into hospital issued scrubs. The policy did not address protocols if the patients refused to change into the scrubs.

Patient #2

Patient #2 was an adolescent patient. Documentation in a hospital investigation report revealed there was a altercation between Staff #18 and the patient that resulted in Staff #18 grabbing the patient and carrying him, "feet in the air" into a patient room and placing the patient into scrubs and "safety." Cross reference Tag A-145 for further details regarding the incident.

Patient #10

Patient #10 was restrained and placed into scrubs after a verbal altercation with a Licensed Practical Nurse (Staff #18). Cross reference Tag 145 for more details related to Patient #10.

Patient #16

Patient #16 was an adolescent. The RN assigned to the patient's unit on 11/27/2018 (Staff #20) documented that at 8:40 a.m. the patient was found with a sharp pencil and ink cartridge coaching two other patients on how to give her a tattoo. The RN documented that staff tried to get the patient to change out of her clothes into scrubs, however, the patient refused and started a "loud fight" with the staff. The staff called for Behavioral Health Technicians (BHT's) to come to the unit and help get the patient into her room where she "finally" changed herself into scrubs. Restraint documentation in the clinical record revealed the patient was held by her arms and taken to her room. A telephone order for the "physical restraint" was obtained at 10:15 a.m., over one and one-half hours after the restraint. The "Purpose" of the physical restraint documented in the order was "Threat to immediate physical safety of self...Threat to immediate physical safety of others." The RN who performed the one hour face-to-face assessment (Staff #23) documented in the Seclusion and Restraint One Hour Face To Face Assessment form the initiation of the restraint was for: "Pt found cutting herself." However, Staff #20, the RN who directed the staff to restrain the patient, documented the patient was telling two other patients how to give her a tattoo. Staff #23 documented in the face-to-face assessment that the patient was crying and stated she was "sad and upset." The patient also reported she was confused and unsure of who was in charge. The additional orders/direction from the physician included "Place on safety...."

Staff #11 and Staff #12 stated during interviews that they felt there was not a consistent understanding by staff and physicians for the practice of placing patients on safety/focus status. Interviews conducted with Staff #3 and #13 reported the practice is only used on the adolescent units. The surveyor asked if a patient would be restrained in order to place them into scrubs, and they responded, no.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0196
Based on document reviews and staff interviews, it was determined the hospital failed to ensure all direct care staff received training on Verbal Intervention (De-escalation) and Physical Intervention (restraints) every year per their policy. Seven Behavioral Health Technicians (BHT) were beyond their 12-month window for retraining and five Registered Nurses (RN) were beyond their 12 month retraining window. This deficient practice posed the risk of patient harm if staff are not periodically trained using approved and safe techniques.

Findings include:

The hospital's policy and procedure Titled "Restraint (Policy Number: PC 12) did not include requirements for training and periodic retraining of staff. However, interviews with Staff #5 and Staff #13 revealed the hospital required direct care staff to be trained at the time of hire and retrained on a yearly basis. A list of employees with documentation of De-escalation & Restraint certification revealed the following staff were outside of their 12 month renewal window:

Staff # (BHT) Last Completed Date
24 12/14/2017
25 12/14/2017
26 12/19/2017
27 12/22/2018
28 01/08/2018
29 02/23/2018
30 02/27/2018
31 03/14/2018
32 03/23/2018
33 12/09/2017
34 12/09/2017
(RN's)
35 12/15/2017
36 12/20/2017
37 01/09/2018
38 01/26/2018
39 01/26/2018
40 03/04/2018
41 03/09/2018
42 03/15/2018


A review of a sample of 11 Daily Staffing Reports between the period of 1/31/2019 to 3/18/2019 revealed all of the above employees except for Staff #28, #35, and #41 were scheduled during that time frame.

Staff #5 acknowledged on 3/27/2019 that the above employees did not have current De-Escalation & Restraints certification.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on review of facility documents, policy and procedure, and staff interviews, it was determined that the facility failed to ensure appropriate actions were implemented to resolve ongoing occurrences of medication administration errors within the facility. Failure to analyze data to develop and implement a plan to decrease and/or correct the number and frequency of medication administration errors increases unintended adverse events and increases the risk of patient harm.

Findings include:

The document titled "Process Improvement Program" requires: "...As pertinent to the Program, the Medical Executive Committee will: Adopt, subject to the approval of the Governing Board, a system designed to routinely collect and assess data related to important clinical and non-clinical processes and resulting patient outcomes...Recommend and implement appropriate actions and assess the effectiveness of such actions...Document the findings and results...Pursue improvement opportunities and document actions taken to correct identified problems and effectively improve patient care...."

The policy titled "Medication Administration and Records PHR-159" requires: "...Patient Identification: Any patient receiving a medication will be positively identified prior to drug administration...."

The policy titled "Medication Administration NR 08" requires: "...The process of the transcription acts as a review with both practitioner and nurse to insure (sic) the issues of accuracy and safety are taken into account prior to the patient being administered any medication. To ensure that medications are transcribed in a manner that provides for accuracy and patient safety...."

September 2018

Medication errors reported to the Quality Council Committee

-The RN did not verify a patient's identity and administered Prozac in error to the wrong patient.
-A patient was not given night dose of Morphine ER. The error was found when the patient reported the omission the following day.
-Klonopin was discontinued in a patient's MAR (medication administration record) without an order.
-Zyprexa Zydis given to a patient without and order.
-The RN did not verify a patient's identity and administered a medication not ordered to a patient.
-A medication was mislabeled by the pharmacy.
-A nurse found Trazadone, Haldol, and Geodon "stashed" in a drawer in the medication room.

The Quality Committee meeting minutes in September 2018 documented a focus of providing training to nurses on medication errors.

October 2018

Medication errors reported to the Quality Council Committee

-A patient was not given a night dose of Lithium because the order was not transcribed to the MAR.
-A patient was not given a dose of Viibryd because the order was not transcribed to the MAR.
-Humalog and Lantus was not given to a patient as ordered.
-A nurse discontinued an approved substitution for Sulindac without an order. The patient was not given 2 doses of naproxen (the ordered substitution) in error.
-A patient was not given a night dose of Seroquel because the order was not transcribed to the MAR.
-A patient was not given nightly medications because the orders were not transcribed to the MAR.

The Quality Committee meeting minutes in October 2018 documented a focus of providing training to nurses on medication errors.

November 2018

Medication errors reported to the Quality Council Committee

-A patient was given an incorrect dose of medication because the order was not transcribed correctly to the MAR.
-A patient was not given a morning dose of Concerta because the order was not transcribed to the MAR.
-A patient was not given morning medication because MAR was missing from the patient's chart.
-A patient was given an incorrect dose of Prolixin because the order was not transcribed correctly to the MAR.
-A patient was given an incorrect dose of Invega due to medication mislabeling.
-A patient was not given 2 doses of Lisinopril because the order was not transcribed to the MAR.
-A patient was given an incorrect dose of Seroquel because the order was not transcribed correctly to the MAR.

The Quality Committee meeting minutes for November 2018 was not provided to the surveyor.

December 2018

Medication errors reported to the Quality Council Committee

-A patient was not given a dose of Risperdal because the order was transcribed to another patient's MAR.
-A patient was given a dose of Risperdal instead of Zyprexa because the order was not transcribed correctly to the MAR.
-The RN did not verify a patient's identity and administered Subutex in error to the wrong patient.
-The RN administered an incorrect dose of Seroquel for 4 days because the wrong order was discontinued in the MAR.
-A patient was not given a dose of Prozac because the order was not transcribed to the MAR.
-A patient was not given a dose of Risperdal because the order was not transcribed to the MAR.
-A patient received an incorrect dose of Seroquel because the order was not transcribed correctly to the MAR.

The Quality Committee meeting minutes in December 2018 documented a focus of providing training to nurses on medication errors.

January 2019

Medication error reports provided to the surveyor

-A patient was given an incorrect dose of Seroquel because the order was not transcribed correctly to the MAR.
-A patient was not given a dose of Subutex because the order was transcribed to another patient's MAR.
-A patient was given a dose of Seroquel without an order.
-A patient was not given a dose of Abilify and Zyprexa because the order was not transcribed to the MAR.
-A patient was given a dose of Haldol without an order.

The Quality Committee meeting minutes in January 2019 documented no interventions to prevent medication errors.

February 2019

Medication error reports provided to the surveyor

-A patient was not given Omeprazole for 3 days because the order was transcribed to another patient's MAR.
-A patient was given a flu shot without consent.
-A patient was given a dose of Seroquel without an order.
-A patient was not given a dose of Zyprexa because the order was not transcribed to the MAR.
-A patient was not given 3 doses of Zyprexa and 3 doses of Zoloft because the order was not transcribed to the MAR.
-A patient was not given the correct dose of Risperdal and the correct dose of Lithium because the nurse did not fax the order to the pharmacy.
-A patient did not receive a medication because the order was not faxed to the pharmacy and was not transcribed to the patient's MAR.

The Quality Committee meeting minutes in February 2019 documented no interventions to prevent medication errors.

Employees #4 and 43 confirmed on 03/28/2019, that data collected for medication errors was not analyzed for potential causes and that no correction plan was developed and implemented to decrease the incidence and/or prevent medication errors from occurring.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of policy and procedure, medical records, and interview, it was determined that the facility failed to ensure daily vital signs and pain assessments were performed as ordered by the physician and per facility policy for (14) of (19) patients (Patients #2, 3, 4, 5, 9, 10, 22, 23, 24, 25, 28, 30, 31, and 33). Failure to conduct ongoing physical assessment of patients in a psychiatric hospital may result in patient harm, if nurses do not recognize a change in their medical condition.

Findings include:

The policy/procedure titled "Monitoring Vital Signs" requires: "...Patients are monitored upon admission, and as ordered by physician for blood pressure, heart rate, and respiration...."

The policy/procedure titled "Re-assessment of Patient Needs" requires: "...The Registered Nurse will complete and document a full re-assessment of the patient each shift. The re-assessment will address issues of patient management, symptoms changes and reductions...and any physical changes that may affect treatment and treatment outcomes...If information from the re-assessment renders information that has potential to immediately affect patient safety, wellness, or progress in treatment, the attending practitioner is consulted with immediately...Any issues related to pain are re-assessed every shift by the nurse on duty. The pain re-assessment is documented in the daily note...."

The medical record form "Graphics" included in the patients' medical records requires daily documentation of vital signs, percentage of meals eaten, personal hygiene, hours slept, and pain assessment.

During a review of medical records it was revealed that daily vital signs and pain assessments were not performed for (14) of (19) patients (Patients #2, 3, 4, 5, 9, 10, 22, 23, 24, 25, 28, 30, 31, and 33).

Patient #2

Patient #2 had a physician's order dated 01/30/2019, for daily vital signs and weekly weight assessment upon admission to the facility. Patient #2's weight was not recorded on the graphic sheet until 02/06/2019, eight days after admission. Vital signs were not recorded on 01/30/2019 and 01/31/2019. Percentage of meals eaten, personal hygiene, hours slept, and pain assessments were not documented during the patient's admission to the facility.

Employees #3 and 43 confirmed in interviews on 03/27/2019, that Patient #2 did not have daily vital signs and weekly weights documented per the physician's order and facility policy. Additionally, Employees #3 and 43 confirmed that Patient #2's medical record did not contain documentation of percentage of meals eaten, personal hygiene, hours slept, and pain assessments during his/her admission to the facility as required by facility procedure.

Patient #3

Patient #3 was transferred to a local emergency department for treatment of dehydration on 03/02/2019 at 1212. The patient returned to the facility on [DATE] at 2000. Documentation in the patient's medical record does not contain evidence of follow up vital signs or pain assessment upon the patient's return to the facility. Nursing notes dated 03/03/2019, contain documentation that Patient #3 was found down on a bathroom floor at 1700. The medical record contains no documentation of a nursing follow up assessment, vital signs, and/or pain assessment. Percentage of meals eaten, personal hygiene, hours slept, and pain assessments were not documented during the patient's admission to the facility.

Employees #3 and 43 confirmed in interviews on 03/27/2019, that Patient #3 was not reassessed upon return to the facility after being treated for dehydration on 03/02/2019 ,at a local emergency department. Additionally, they confirmed that Patient #3 was not reassessed after being found on a bathroom floor the following day on 03/03/2019. Employees #3 and 43 confirmed that Patient #3's medical record did not contain documentation of percentage of meals eaten, personal hygiene, hours slept, and pain assessments during his/her admission to the facility as required by facility procedure.

Patient #4

Patient #4 had a physician's order dated 01/24/2019 for daily vital signs and weekly weight assessment upon admission to the facility. Vital signs were not documented on 01/25/2019, 01/27/2019, 01/31/2019, and 02/01/2019. Percentage of meals eaten, personal hygiene, hours slept, and pain assessments were not documented during the patient's admission to the facility.

Employees #3 and 43 confirmed in interviews on 03/27/2019, that Patient #4 did not have daily vital signs documented per the physician's order and facility policy. Additionally, Employees #3 and 43 confirmed that Patient #4's medical record did not contain documentation of percentage of meals eaten, personal hygiene, hours slept, and pain assessments during his/her admission to the facility as required by facility procedure.

Patient #5

The patient's medical record did not document percentage of meals eaten, personal hygiene, hours slept, and pain assessments during the patient's admission to the facility.

Employees #3 and 43 confirmed in interviews on 03/27/2019, that Patient #5's medical record did not contain documentation of percentage of meals eaten, personal hygiene, hours slept, and pain assessments during his/her admission to the facility as required by facility procedure.

Patient #9

Patient #9 had a physician's order dated 02/04/2019 for daily vital signs and weekly weight assessment upon admission to the facility. Vital signs were not recorded on 02/06/2019, 02/07/2019, 02/08/2019, 02/09/2019, 02/10/2019, 02/11/2019, 02/14/2019, 02/15/2019, 02/16/2019, 02/17/2019, and 02/18/2019. Patient #9's weight was not documented in the medical record. Percentage of meals eaten, personal hygiene, hours slept, and pain assessments were not documented during the patient's admission to the facility.

Employees #3 and 43 confirmed in interviews on 03/27/2019, that Patient #9 did not have daily vital signs and weekly weights documented per the physician's order and facility policy. Additionally, Employees #3 and 43 confirmed that Patient #9's medical record did not contain documentation of percentage of meals eaten, personal hygiene, hours slept, and pain assessments during his/her admission to the facility as required by facility procedure.

Patient #10

Patient #10 had a physician's order dated 01/16/2019 for daily vital signs and weekly weight assessment upon admission to the facility. Vital signs were not recorded on 01/17/2019, 01/18/2019, 01/19/2019, 01/21/2019, 01/22/2019, 01/25/2019, and 01/27/2019. Patient #10's weight was documented once on the day of admission but was not reassessed during the admission. Percentage of meals eaten, personal hygiene, hours slept, and pain assessments were not documented during the patient's admission to the facility.

Employees #3 and 43 confirmed in interviews on 03/27/2019, that Patient #10 did not have daily vital signs and weekly weights documented per the physician's order and facility policy. Additionally, Employees #3 and 43 confirmed that Patient #10's medical record did not contain documentation of percentage of meals eaten, personal hygiene, hours slept, and pain assessments during his/her admission to the facility as required by facility procedure.

Patient #22

Patient #22 had a physician's order dated 09/06/2018 for daily vital signs and weekly weight assessment upon admission to the facility. Vital signs were not recorded on 09/09/2018, 09/10/2018, 09/11/2018, 09/12/2018, 09/13/2018, 09/14/2018, 09/15/2018, 09/16/2018, and 09/17/2018. Patient #10's weight was not documented. Percentage of meals eaten, personal hygiene, hours slept, and pain assessments were not documented during the patient's admission to the facility.

Employees #3 and 43 confirmed in interviews on 03/27/2019, that Patient #22 did not have daily vital signs and weekly weights documented per the physician's order and facility policy. Additionally, Employees #3 and 43 confirmed that Patient #22's medical record did not contain documentation of percentage of meals eaten, personal hygiene, hours slept, and pain assessments during his/her admission to the facility as required by facility procedure.

Patient #23

Patient #23 had a physician's order dated 03/22/2019 for daily vital signs and weekly weight assessment upon admission to the facility. Vital signs were taken on 03/22/2019, the day of admission at 2300. The medical record did not contain further documentation of vital signs as of the time the record was reviewed by surveyors on 03/27/2019. Percentage of meals eaten, personal hygiene, hours slept, and pain assessments were not documented during the patient's admission to the facility.

Employees #3 and 43 confirmed in interviews on 03/27/2019, that Patient #23 did not have daily vital signs documented per the physician's order and facility policy. Additionally, Employees #3 and 43 confirmed that Patient #23's medical record did not contain documentation of percentage of meals eaten, personal hygiene, hours slept, and pain assessments during his/her admission to the facility as required by facility procedure.

Patient #24

Patient #24 had a physician's order dated 03/22/2019 for daily vital signs and weekly weight assessment upon admission to the facility. Vital signs were not recorded on 03/26/2019. Vital signs taken on 03/25/2019 are documented; however, the time is illegible. The nursing note dated 03/25/2019 at 0455, documented that the patient was found passed out on his/her bathroom floor at 2315. No date was documented with the time that the patient was found on the floor. The medical record does not contain documentation that vital signs were performed and that Patient #24 was reassessed after being found on his/her bathroom floor.

Employees #3 and 43 confirmed in interviews on 03/27/2019, that Patient #24's medical record did not contain documentation of daily vital signs as ordered. Additionally, they confirmed that Patient #24's medical record did not contain evidence of follow up vital signs or reassessment by the nurse after the patient was found down on the floor.

Patient #25

Patient #25 had a physician's order dated 03/18/2019 for daily vital signs and weekly weight assessment upon admission to the facility. Vital signs were not documented on 03/19/2019, 03/20/2019, 03/21/2019, 03/25/2019, and 03/26/2019. The patient was still admitted at the facility on 03/27/2019 when the medical record was reviewed by surveyors. Percentage of meals eaten, personal hygiene, hours slept, and pain assessments were not documented during the patient's admission to the facility.

Employees #3 and 43 confirmed in interviews on 03/27/2019, that Patient #25 did not have daily vital signs documented per the physician's order and facility policy. Additionally, Employees #3 and 43 confirmed that Patient #25's medical record did not contain documentation of percentage of meals eaten, personal hygiene, hours slept, and pain assessments during his/her admission to the facility as required by facility procedure.

Patient #28

Patient #28 had a physician's order dated 03/20/2019 for daily vital signs and weekly weight assessment upon admission to the facility. The patient refused vital signs throughout the admission including the date the surveyors reviewed the medical record on 03/27/2019. Percentage of meals eaten, personal hygiene, hours slept, and pain assessments were not documented during the patient's admission to the facility.

Employees #3 and 43 confirmed in interviews on 03/27/2019, that while the patient had the right to refuse taking of vital signs the other elements of the nursing assessment including documentation of percentage of meals eaten, personal hygiene, hours slept, and pain assessments should have been documented in the patient's graphics form in the medical record.

Patient #30

Patient #30 had an admission order dated 03/21/2019 for daily vital signs and weekly weight assessment upon admission to the facility. Vital signs were not documented on 03/22/2019 and 03/23/2019. Percentage of meals eaten, personal hygiene, hours slept, and pain assessments were not documented during the patient's admission to the facility.

Employees #3 and 43 confirmed in interviews on 03/27/2019, that Patient #30 did not have daily vital signs documented per the physician's order and facility policy. Additionally, Employees #3 and 43 confirmed that Patient #30's medical record did not contain documentation of percentage of meals eaten, personal hygiene, hours slept, and pain assessments during his/her admission to the facility as required by facility procedure.

Patient #31

Patient #31 had an admission order dated 03/25/2019 for daily vital signs and weekly weight assessment upon admission to the facility. Vital signs were not documented as of 03/27/2019 when the surveyor reviewed the medical record. Percentage of meals eaten, personal hygiene, hours slept, and pain assessments were not documented during the patient's admission to the facility.

Employees #3 and 43 confirmed in interviews on 03/27/2019, that Patient #31 did not have daily vital signs documented per the physician's order and facility policy. Additionally, Employees #3 and 43 confirmed that Patient #31's medical record did not contain documentation of percentage of meals eaten, personal hygiene, hours slept, and pain assessments during his/her admission to the facility as required by facility procedure.

Patient #33

Patient #33 had an admission order dated 03/22/2019 for daily vital signs and weekly weight assessment upon admission to the facility. Page 1 of the graphics form documented vital signs; however, the entry was not dated. Included in the documents provided to the surveyor contained a sheet with vital sign entries; however, there were no patient identifiers on the document. Percentage of meals eaten, personal hygiene, hours slept, and pain assessments were not documented during the patient's admission to the facility.

Employees #3 and 43 confirmed in interviews on 03/27/2019, that Patient #33 did not have daily vital signs documented per the physician's order and facility policy. Additionally, Employees #3 and 43 confirmed that Patient #33's medical record did not contain documentation of percentage of meals eaten, personal hygiene, hours slept, and pain assessments during his/her admission to the facility as required by facility procedure.

They confirmed that patient identifiers including the patient's first and last name, date of birth, date of admission, and the attending physician were missing from documents provided to the surveyor.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of policy and procedure, medical records, and staff interview, it was determined that the facility failed to ensure master treatment plans were developed and completed for (17) of (24 ) patients (Patients #1, 2, 3, 4, 5, 6, 7, 9, 10, 23, 25, 26, 27, 28, 30, 31, and 33). Failure to complete a patient's care plan prevents the IDT (interdisciplinary team) from identifying needed services, developing goals for treatment, and evaluating the effectiveness of services delivered while a patient is receiving care during admission to the hospital.

Findings include:

The policy/procedure titled "Treatment Planning" requires: "...Each Patient admitted to the hospital shall have a written, individualized treatment plan...Ultimate responsibility for the development and implementation of the treatment plan serves as an organizational tool whereby the care rendered each patient is designed, implemented, assessed, and updated in an orderly and clinically sound manner...Within 72 hours of admission, members of the treatment team shall further develop the MASTER Treatment Plan that is based on a comprehensive assessment of the patient's presenting problems identified on the Master Problem List, physical health, emotional and behavioral needs. The team will consist of the practitioner, the nurse, the social worker, and representatives from other clinical disciplines, as appropriate...The Treatment Plan shall be reviewed and updated as frequently as clinically indicated by the patients (sic) anticipated length of stay and treatment issues, but at a minimum, the treatment plan is to be reviewed and updated at least weekly...reviews and updates shall include...progress toward goals and effectiveness of interventions for each open problem...Modifications or additions made to goals and interventions, as appropriate, and whenever a significant event or change in condition arises...."

Patient #1

Patient #1 was admitted to the facility 01/23/2019 through 01/31/2019. The Master Treatment Plan dated 01/25/2019, was not completed by the RN, MSW, Activities Therapist, and Physician. The RN and MSW signed the signature page acknowledging development of the treatment plan on 01/25/2019; however, the nursing services and social services sections were not completed. The Activities Therapist did not sign acknowledgment of care plan development, nor was the Activity /Recreational Therapy section completed. MD #4 approved an incomplete treatment plan on 01/30/2019, eight days after the patient's admission to the facility. Additionally, MD #4 did not complete the physician's section. The "Patient/Family/Legal Representative Involvement" section was not completed and signed by Patient #1 and/or his/her representative.

Employees #3 and 43 confirmed in interviews on 03/27/2019, that IDT did not develop a master treatment plan for Patient #1 as per facility policy and procedure, and within 72 hours of admission to the facility.

Patient #2

Patient #2 was admitted to the facility 01/30/2019 through 02/11/2019. The RN signed acknowledgement of participation in the master treatment plan on 02/08/2019, nine days after the patient was admitted to the facility. The nursing section of the treatment plan was missing. The activities therapist signed acknowledgment of participation in the master treatment plan on 02/06/2019, seven days after the patient was admitted to the facility. The activity therapy section of the treatment plan was not completed. The MD #5 approved an incomplete treatment plan on 02/08/2019, nine days after the patient was admitted to the facility and the physician's section page was missing. The "Patient/Family/Legal Representative Involvement" section was missing from the master treatment plan.

Employees #3 and 43 confirmed in interviews on 03/27/2019, that IDT did not develop a master treatment plan for Patient #2 as per facility policy and procedure, and within 72 hours of admission to the facility.

Patient #3

Patient #3 was admitted to the facility 02/26/2019 through 03/08/2019. Patient #3's treatment plan was not provided to the surveyor upon request.

Patient #4

Patient #4 was admitted to the facility 01/24/2019 through 02/01/2019. The RN did not sign acknowledgement of participation in the development of the master treatment plan. Nursing interventions were left blank in addition to the nursing section of the master treatment plan not completed. The social worker signed acknowledgment of participation in the master treatment plan on 01/25/2019; however, the social services section was not completed. The activities therapist signed acknowledgment of participation in the master treatment plan on 02/01/2019, eight days after the patient was admitted to the facility which was also on the date of discharge. The activities section of the treatment plan was not completed. MD #4 approved an incomplete treatment plan on 02/01/2019, eight days after the patient was admitted to the facility which was also on the date of discharge. Physician interventions and the physician's section of the treatment plan were both incomplete. The patient's representative signed acknowledgment that he/she received and was involved in the development of Patient #4's treatment plan on 01/31/2019, seven days after admission.

Employees #3 and 43 confirmed in interviews on 03/27/2019, that IDT did not develop a master treatment plan for Patient #4 as per facility policy and procedure, and within 72 hours of admission to the facility.

Patient #5

Patient #5 was admitted to the facility 01/28/2019 through 02/06/2019. The RN signed acknowledgment of participation in the development of the master treatment plan on 02/06/2019, nine days after the patient was admitted to the facility. The activities therapist did not participate in the development of the treatment plan. The social services, activities therapy, nursing, physician, and patient involvement sections of the treatment plan were not completed.

Employees #3 and 43 confirmed in interviews on 03/27/2019, that IDT did not develop a master treatment plan for Patient #5 as per facility policy and procedure, and within 72 hours of admission to the facility.

Patient #6

Patient #6 was admitted to the facility 02/13/2019 through 02/18/2019. MD #6 approved an incomplete treatment plan on 02/14/2019. Nursing, social services, and the activities therapist did not sign acknowledgment of participation in the treatment planning, nor were the sections for nursing, social services, and activities therapy completed.

Employees #3 and 43 confirmed in interviews on 03/27/2019, that IDT did not develop a master treatment plan for Patient #6 as per facility policy and procedure, and within 72 hours of admission to the facility.

Patient #7

Patient #7 was admitted to the facility 02/15/2019 through 02/19/2019. The treatment plan was not completed in any required sections by the IDT and all pages were blank. MD #4 approved an incomplete treatment plan on 02/26/2019, seven days after the patient was discharged from the facility.

Employees #3 and 43 confirmed in interviews on 03/27/2019, that IDT did not develop a master treatment plan for Patient #7 as per facility policy and procedure, and within 72 hours of admission to the facility.

Patient #9

Patient #9 was admitted to the facility 02/05/2019 through 02/19/2019. The RN signed acknowledgment of participation in the development of the master treatment plan on 02/05/2019. The nursing interventions and nursing services sections were left blank. MD #6 approved the treatment plan; however, the date of signature is illegible. Physician interventions and the physician's section of the treatment plan was left blank. Additionally, the initial treatment plan does not include the patient's time of admission and was left blank.

Employees #3 and 43 confirmed in interviews on 03/27/2019, that IDT did not develop a master treatment plan for Patient #9 as per facility policy and procedure, and within 72 hours of admission to the facility.

Patient #10

Patient #10 was admitted to the facility 01/16/2019 through 02/07/2019. The RN did not sign acknowledgment of participation in the development of the master treatment plan. Nursing intervention and nursing services sections were incomplete. Social services, activities therapy, nursing, and physicians sections of the treatment plan were not completed. MD #4 approved an incomplete treatment plan on 01/23/2019, seven days after the patient was admitted to the facility. The patient's psychiatric and medical diagnoses were not documented on the treatment plan.

Employees #3 and 43 confirmed in interviews on 03/27/2019, that IDT did not develop a master treatment plan for Patient #10 as per facility policy and procedure, and within 72 hours of admission to the facility.

Patient #23

Patient #23 was admitted to the facility on [DATE]. The social service, activities therapy, nursing, and physicians sections of the treatment plan were not completed.

Employees #3 and 43 confirmed in interviews on 03/27/2019, that IDT did not develop a master treatment plan for Patient #23 as per facility policy and procedure, and within 72 hours of admission to the facility.

Patient #25

Patient #25 was admitted to the facility 03/18/2019. Patient #25's treatment plan was not provided to the surveyor upon request.

Patient #26

Patient #26 was admitted to the facility on [DATE]. The RN signed acknowledgment of participation in the development of the master treatment plan on 03/27/2019, thirteen days after the patient was admitted to the facility. The activities therapist did not sign acknowledgement of development of the treatment plan. The social services, activities therapy, nursing, physician, and patient involvement sections of the treatment plan were not completed.

Employees #3 and 43 confirmed in interviews on 03/27/2019, that IDT did not develop a master treatment plan for Patient #26 as per facility policy and procedure, and within 72 hours of admission to the facility.

Patient #27

Patient #27 was admitted to the facility on [DATE]. The social services, activities therapy, nursing, physician, and patient involvement sections of the treatment plan were not completed.

Employees #3 and 43 confirmed in interviews on 03/27/2019, that IDT did not develop a master treatment plan for Patient #27 as per facility policy and procedure, and within 72 hours of admission to the facility.

Patient #28

Patient #28 was admitted to the facility on [DATE]. Patient #28's treatment plan was not provided to the surveyor upon request.

Patient #30

Patient #30 was admitted to the facility on [DATE]. Patient #30's initial nursing treatment plan was not completed, no goals were developed. Additionally, the patient's date and time of admission in the initial nursing treatment plan was left blank. The RN and activities therapist did not sign acknowledgement of participation in the development of the patient's master treatment plan. The social services, activities therapy, nursing, physician, and patient involvement sections of the treatment plan were not completed. Pages 1, 2, and 3 of the document did not contain any patient identifiers which included the patient's name, date of birth, admitted , and the attending physician.

Employees #3 and 43 confirmed in interviews on 03/27/2019, that IDT did not develop a master treatment plan for Patient #30 as per facility policy and procedure, and within 72 hours of admission to the facility.

Patient #31

Patient #31 was admitted to the facility on [DATE]. Patient #31's treatment plan was not provided to the surveyor upon request.

Patient #33

Patient #33 was admitted to the facility on [DATE]. Patient #33's treatment plan was approved by an unknown provider four days after the patient's admission. The provider's signature was illegible except for his/her credentials after the signature which indicated the provider was a nurse practitioner. The attending physician listed in the patient's record is an MD. Also, the initial treatment plan does not include the patient's time of admission, this area was left blank.

Employees #3 and 43 confirmed in interviews on 03/27/2019, that IDT did not develop a master treatment plan for Patient #33 as per facility policy and procedure, and within 72 hours of admission to the facility.