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.

SOUTHERN NEVADA ADULT MENTAL HEALTH SERVICES 6161 W CHARLESTON BLVD LAS VEGAS, NV 89146 July 26, 2013
VIOLATION: NURSING SERVICES Tag No: A0385
Based on interview, clinical record review, personnel file review and document review, the facility failed to ensure Nursing services provided patient care with delineation of responsibilities and accountablities as evidenced by:

Nursing staff failure to follow up on request for a physician consultation (A-395)

Certified nursing assistant performance evaluations were not completed by nursing staff (A-398).

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

Based on clinical record review, interview and document review, the facility failed to ensure the nursing staff followed up on a request for a gastrointestinal consultation for 1 of 47 sampled patients (Patient #1).

Findings include:

Patient #1 was admitted to the facility on [DATE] with diagnoses including Schizophrenia, Paranoid type and adult failure to thrive.

On 06/06/13 at 10:43 AM, a physician order documented right upper quadrant ultrasound related to increased liver function tests, rule out gallbladder.

On 06/06/13, a computerized tomography scan (CT scan) of the abdomen revealed gallbladder sludge.

On 06/08/13 at 7:30 AM, a physician order documented an order to please arrange for a GI (gastrointestinal) clinic (or surgical clinic) evaluation at (name of local clinic) for gallbladder sludge vs cholelithiasis, abdominal symptoms and pain. Social worker to please assist in any way possible.

On 06/11/13, a physician order documented to arrange for GI consult (previous order on 06/08/13).

The Inpatient Transportation Request form dated 06/12/13, documented an appointment on 07/23/13 at the local clinic. There was no documentation to indicate if this appointment was for a GI consult.

The Social Worker documented on the Treatment Plan the patient had an ultrasound on 06/06/13 due to experiencing symptoms related to the gallbladder. The ultrasound results recommended follow up. The patient had Medicaid benefits and was scheduled for outpatient primary care physician appointment at a local clinic on 07/23/13.

A review of the clinical record revealed the patient would eat and drink on some days, but the patient expressed complaints of nausea and a few episodes of vomiting. The dietitian was involved and the patient's diet was changed to low-fat. The physician had order intake and output to evaluate the patient's nutritional status.

The patient was discharged on [DATE], with a note to follow up with mental health services at (name of clinic). The patient was discharged home with family. There was no documentation reminding the patient of the physician appointment on 07/23/13 at the local clinic for follow up from the ultrasound.

On 06/18/13 at 11:00 AM, the Administrative Assistant indicated the "Inpatient Transportation Request" form was completed when an appointment was made. Medical consultation appointment could not be made on the weekends. The physician was not contacted with updates on the status of requested consultations, it was the responsibility of the physician to follow up.

On 06/08/13 at 11:25 AM, the Psychiatric Nurse III indicated there was no formal process to update the physicians on the status of requested consultations. All specialty consultations required a visit with the patient's primary care physician. Requests for consultations were arranged Monday through Friday and most consultation referrals were sent to a local clinic. If the physician felt an earlier evaluation was warranted, then the patient could be sent to the emergency department.

The facility's policy entitled "Client Rights and Responsibilities" dated 711 documented "...C.2 To medical, psychosocial and rehabilitative care, treatment and training including prompt and appropriate medical aliments for the prevention of any illness for disability. All of that care, treatment, and training must be consistent with standards of practice of the professions in the community..."
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interview, clinical record review and document review, the facility failed to ensure compliance with the following Conditions of Participation: Medical Staff (A-0338) and Nursing Services (A-0385).

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.
VIOLATION: SUPERVISION OF CONTRACT STAFF Tag No: A0398
Based on review of hospital personnel records and staff interview the facility failed to ensure:1) Evaluations were consistently done by a nurse for 7 of 26 agency (non-employee) Certified Nursing Assistants (CNA's); 2) Evaluations were completed for 2 of 26 agency CNA's; and 3) Evaluations were recent for 5 of 26 agency CNA's.

Findings include:

On 6/18/13 at 1:15 PM, the Director of Nursing (DON) indicated all agency CNA's used in the units work as CNA's and not mental health technicians (MHT's).

On 6/18/13 at 1:25 PM, a review of 26 personnel records for agency CNA's revealed the following:

- CNA #1 was last evaluated on 10/29/11, by a Mental Health Technician (MHT).
- CNA #2 was last evaluated on 11/9/11 by a MHT.
- CNA #3 was last evaluated on 10/31/11 by a MHT.
- CNA #4's personnel record lacked documented evidence of an evaluation.
- CNA #5's personnel record lacked documented evidence of an evaluation.

On 6/18/13 at 1:55 PM, information provided by the Staffing Coordinator revealed the following:

- CNA #1 worked on 6/17/13, and was scheduled to work on 6/18/13.
- CNA #2 last worked on 4/24/13.
- CNA #3 worked on 6/17/13, and was scheduled to work on 6/18/13.
- CNA #4's worked on 6/17/13, and was scheduled to work on 6/18/13.
- CNA #5's worked on 6/16/13.

On 6/18/13 at 2:46 PM, an Administrative Assistant explained evaluations for agency CNA's were done at a minimum quarterly or as needed.





On 6/18/13 at 1:25 PM, a review of 26 personnel records for agency CNA's revealed the following:

- Agency provided CNA #6 was last evaluated on 9/07, by a Mental Health Technician IV (MHT).
- Agency provided CNA #7 was last evaluated on 3/14/11 by a MHT.
- Agency provided CNA #8 was evaluated on 5/25/11 by a MHT III, an evaluation on 6/7/11 that was not signed by the evaluator, and last evaluated on 12/11/11 by a MHT III.

On 6/18/13 at 1:55 PM, information provided by the Staffing Coordinator revealed the following:

- CNA #6 worked on 5/22/13.
- CNA #7 last worked on 6/15/13.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review, interview and policy review the facility failed to ensure the Treatment and Medication Consent form was completed for 2 of 47 sampled patients (Patient #5, #2).

Findings include:

Patient #5 was admitted on [DATE], with diagnoses including schizophrenia paranoid type.

On 6/11/13 at 2:11 PM, review of Patient #5's clinical record revealed a psychiatrist's note dated 4/17/13. The psychiatrist note indicated the patient to continue the following medications:

- Haldol deconate 200 mg (milligrams) IM (intramuscular) q (every) 2 weeks.
- Prazosin 1 mg po (by mouth) qHS (every bedtime)
- Seroquel XR 200 mg po qAM (every morning)
- Seroquel 600 mg po qHS

The psychiatrist note documented, "Patient understands treatment plan, including potential risks of prescribed medications and agrees and gives verbal consent."

Further review of Patient #5 clinical record revealed a "Treatment and Medication Consent Form" for Haldol, Seroquel and Prazosin. The consent form was not signed by the patient or a legal guardian nor was the consent form dated. The form included an option to be checked if the patient had given verbal consent. This option was left blank. The consent form did not contain the physician's signature.

On 6/1/13 at 3:08 PM, the Outpatient Clinical Director explained the physician is responsible for ensuring the treatment medication consent is on the chart. The Clinical Director acknowledged the consent was not signed. The Clinical Director stated, "the client will be in on 6/12/13 and will sign the consent."

The facility policy entitled, Client Rights and Responsibilities effective date 07/11 indicated:

"... IV. Procedures: ... 2... a. Before instituting a plan of care, treatment (including medication) or training, or carrying out any necessary surgical procedure, expressed and informed consent must be obtained in writing from: i. The Client, if he/she is 18 years of age or over or legally emancipated and competent to give consent, and form his/her legal guardian, if any; ..."






Patient #2 was admitted on [DATE] to the facility's Psychiatric Observation Unit on a legal psychiatric hold due to hearing voices and physically threatening behavior. The patient's diagnoses included Autism Spectrum Disorder, Obsessive Compulsive Disorder, and Pervasive Developmental Disorder. Prior to admission the patient was residing in a group home. The patient had legal guardians which was known prior to admission and guardianship documents were included in the medical record.

A review of Patient #2's medical record revealed Haldol 5 Mg PO (by mouth), Ativan 2 Mg PO, and Benadryl 50 Mg PO were administered on 6/4/13 at 08:45 PM for agitation. The patient's medical record contained an unsigned "Treatment/Medication Consent" dated 6/4/13 identifying Haldol, Ativan, and Benadryl were administered. The patient had not signed the consent form, but had verbally and/or behaviorally indicated voluntary and informed consent to taking the psychotropic medications. On 6/5/13 at 5:30 PM, Klonopin 0.5 Mg PO was administered for anxiety. There was no consent in the patient's medical record. There was no documentation to support the facility contacted the legal guardians to obtain medication consent for administration.

The facility policy number PF-RRE-05, dated 4/0/13 entitled Medication: Informed Consent for Administration and Protocol for Involuntary Administration indicated:
"....1. Policy: A. Recognizing the therapeutic importance of mutual collaboration between physician and patient, as well as the potential for serious side effects caused by psychotropic medication, it shall be the practice of facility staff physicians to obtain informed consent prior to administering medication. IV. Procedures: A. Legally effective informed consent requires fulfillment of three basic requirements: 1. Competency to Grant Consent: An individual is considered legally competent to grant informed consent, unless a minor by age or otherwise adjudicated incompetent and lacking in legal capacity to knowingly grant consent. See NRS 433.033 and 433A.460. B. Appropriate significant persons to grant consent are: 2. The legal guardian of a patient who lacks the mental or legal capacity if said guardian has the proper legal authority. C. Documentation 2. The patients or guardian with the proper legal authority is encouraged to confirm in writing give their informed consent by signing the "Treatment/Medication Consent Form"."

On 6/5/13 at 10:50 AM, the physician ordered, "Guardian to sign all consents today."

On 6/11/13, the Utilization Review Nurse verified there were no signed medication consents and indicated the patient had given verbal permission for the 6/4/13 medication administration and obtaining consent from the legal guardians may not have been required.
VIOLATION: MEDICAL STAFF Tag No: A0338
Based on interview, clinical record review and document review, the facility failed to ensure the medical was accountable to the governing body for the quality of medical care provided to the patients (A-0347); and failed to ensure the medical staff must adopt and enforce bylaws to carry out its responsibilities (A-0353).

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.
VIOLATION: MEDICAL STAFF ACCOUNTABILITY Tag No: A0347
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review, interview and document review, the facility failed to ensure the medical staff communicated pertinent medical problems to appropriate medical staff and incorporated the pertinent medial problems into the treatment plan for 1 of 47 sampled patients (Patient #1); and failed to ensure 4 of 47 sampled patients (Patient's #31, 35, 36, and #37) were evaluated by a psychiatrist weekly.

Findings include:

1.) Patient #1 was admitted to the facility on [DATE] with diagnoses including Schizophrenia, Paranoid type and adult failure to thrive.

On 06/06/13 at 10:43 AM, a physician order documented right upper quadrant ultrasound related to increased liver function tests, rule out gallbladder.

On 06/06/13, a computerized tomography scan (CT scan) of the abdomen revealed gallbladder sludge.

On 06/08/13 at 7:30 AM, a physician order documented an order to please arrange for a GI (gastrointestinal) clinic (or surgical clinic) evaluation at (name of local clinic) for gallbladder sludge vs cholelithiasis, abdominal symptoms and pain. Social worker to please assist in any way possible.

On 06/11/13, a physician order documented to arrange for GI consult (previous order on 06/08/13).

The Inpatient Transporation Request form dated 06/12/13, documented an appointment on 07/23/13 at the local clinic. There was no documentation to indicate if this appointment was for a GI consult.

The Social Worker documented on the Treatment Plan the patient had an ultrasound on 06/06/13 due to experiencing symptoms related to the gallbladder. The ultrasound results recommended follow up. The patient had Medicaid benefits and was scheduled for outpatient primary care physician appointment at a local clinic on 07/23/13.

A review of the clinical record revealed the patient would eat and drink on some days, but the patient expressed complaints of nausea and a few episodes of vomiting. The dietitation was involved and the patient's diet was changed to low-fat. The physician had order intake and output to evaluate the patient's nutritional status.

The patient was discharged on [DATE], with a note to follow up with mental health services at (name of clinic). The patient was discharged home with family. There was no documentation reminding the patient of the physician appointment on 07/23/13 at the local clinic for follow up from the ultrasound.

On 06/18/13 at 11:00 AM, the Administrative Assistant indicated the "Inpatient Transportation Request" form was completed when an appointment was made. Medical consultation appointment could not be made on the weekends. The physician was not contacted with updates on the status of requested consultations, it was the responsiblity of the physician to follow up.

On 06/08/13 at 11:25 AM, the Psychiatric Nurse III indicated there was no formal process to update the physicians on the status of requested consultations. All specialty consultations required a visit with the patient's primary care physician. Requests for consultations were arranged Monday through Friday and most consultation referrals were sent to a local clinic. If the physician felt an earlier evaluation was warranted, then the paitent could be sent to the emergency department.

The facility's policy entitled "Client Rights and Responsibilities" dated 711 documented "...C.2 To medical, psychosocial and rehabilitative care, treatment and training including prompt and appropriate medical aliments for the prevention of any illness for disabiity. All of that care, treatment, and training must be consistent with standards of practice of the professions in the community..."

The Medical Staff Bylaws dated 04/18/13, documented "...F...All pertinent medical problems will be communicated to all appropriate medical staff and incorporated into the treatment plan.."

The clinical record lacked documented evidence the physician was aware of the delay in the patient receiving the GI consultation, as the appointment for 07/23/13 was with a primary care physician. There was no clear system in place to ensure consultations were done in a timely manner.

2.) Patient #31 was admitted on [DATE], on a legal hold due to suicidal ideation. The patient was evaluated by a psychiatrist on 05/05/13, the clinical impression was depressive disorder and polysubstance dependence.

The patient was admitted as an inpatient to Pod H on 05/07/13 at 7:33 PM. The patient was evaluated by a psychiatric advanced nurse practitioner on 5/9/13 at 12:45 PM, with a clinical impression of depressive disorder, polysubstance dependence, pathological gambling and personality disorder. The initial treatment plan included: Trazadone for insomnia, Prozac for depression, Abilify for mood, Vistaril for anxiety, Lisinopril for hypertension, Acyclovir for infection, Flexiril for muscle spasms and group attendance.

A review of the clinical record revealed the next entry from the psychiatrist was on 05/21/13 at 1:44 PM.

On 06/08/13 at 2:15 PM, the Psychiatric Medical Director indicated the psychiatrists should be evaluating the patients at minimum of twice a week. Once during the treatment team meeting and a face-to-face meeting with the patient. There should be at a minimum, a progress note in the clinical record from the psychiatrist weekly.

Patient #31's clinical record lacked a psychiatric progress note for the week of 05/13/13 through 05/19/13.

Patient #35 was admitted on [DATE] at 9:16 PM, on a legal psychiatric hold due to depression and suicidal ideation. The patient was evaluated by a psychiatrist on 05/09/13 at 2:46 PM, the clinical impression was bipolar disorder, mixed episode and alcohol abuse.

Tha patient was admitted as an inpatient to Pod H on 05/09/13 at 10:02 PM. The patient was evaluated by a psychiatrist on 05/11/13 at 5:37 PM, with a clinical impression of bipolar disorder and alcholol abuse. The initial treatment plan included: Depakote for mood, Seroquel XR for mood, monitor for mood symptoms and supportive, group and milleu therapy.

A review of the clinical revealed the next entry from the psychiatrist was 05/21/13 at 1:27 PM.

On 06/08/13 at 2:15 PM, the Psychiatric Medical Director indicated the psychiatrists should be evaluating the patients at minimum of twice a week. Once during the treatment team meeting and a face-to-face meeting with the patient. There should be at a minimum, a progress note in the clinical record from the psychiatrist weekly.

Patient #35's clinical record lacked a psychiatric progress note for the week of 05/13/13 through 05/19/13.

Patient #36 was admitted on [DATE] at 3:40 PM, on a legal psychiatric hold due to suicidal ideation. The patient was evaluated by a psychiatrist on 5/9/13 at 10:30 PM, the clinical impression was bipolar type I, most recent episode depressed.

The patient was admitted as an inpatient to Pod H on 05/10/13 at 5:47 AM. The patient was evaluated by a psychiatrist on 05/11/13 at 5:23 PM, with a clinical impression of bipolar type I, most recent episode depressed. The initial treatment plan included: discontinue Lithium, Lamictal for mood, Cymbalta for depression, Vistaril for anxiety, Ambien for insomnia, monitor for mood symptoms, and supportive, group amd milleu therapy.

The patient was evaluated by the internal medicine physician on 05/10/13 at 4:39 PM.

A review of the clinical record revealed the next entry from the psychiatrist was on 05/21/13 at 1:38 PM.

On 06/08/13 at 2:15 PM, the Psychiatric Medical Director indicated the psychiatrists should be evaluating the patients at minimum of twice a week. Once during the treatment team meeting and a face-to-face meeting with the patient. There should be at a minimum, a progress note in the clinical record from the psychiatrist weekly.

Patient #36's clinical record lacked a psychiatric progress note for the week of 05/13/13 through 05/19/13.

Patient #37 was admitted on [DATE] at 5:05 AM, on a legal psychiatric hold due to depression and suicidal ideation. The patient was evaluated by a psychiatrist and the clinical impression was major depressive disorder.

The patient was admitted as an inpatient to Pod H on 05/2/13 at 8:38 PM. The patient was evaluated by a psychiatric advanced practice nurse on 05/3/13 at 3:56 PM, with a clinical impression of major depressive disorder. The initial treatment plan included: Celexa for depression, Ambien for insomnia, Vistaril for anxiety, Risperidone for mood, the patient was to attend groups and routine observations.

The patient was evaluated by an internal medicine physician on 05/3/13 at 3:22 PM.

A review of the clinical record revealed the next entry from the psychiatrist was on 05/17/13 at 2:57 PM.

On 06/08/13 at 2:15 PM, the Psychiatric Medical Director indicated the psychiatrists should be evaluating the patients at minimum of twice a week. Once during the treatment team meeting and a face-to-face meeting with the patient. There should be at a minimum, a progress note in the clinical record from the psychiatrist weekly.

Patient #37's clinical record lacked a psychiatric progress note for the week of 05/6/13 through 05/12/13.

The Medical Staff Bylaws dated 04/18/13, documented "...I. Progress notation and treatment plan documentation shall be in compliance with...policies..."

On 06/19/13, the Psychiatric Medical Director indicated during the week of 5/8/13 through 5/16/13, one psychiatrist was moved from the H pod to the POU at assist with staffing.
VIOLATION: MEDICAL STAFF BYLAWS Tag No: A0353
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record review, interview and document review, the facility failed to ensure the medical staff communicated pertinent medical problems to appropriate medical staff and incorporated the pertinent medial problems into the treatment plan for 1 of 47 sampled patients (Patient #1); and failed to ensure 4 of 47 sampled patients (Patient's #31, 35, 36, and #37) were evaluated by a psychiatrist weekly.

Findings include:

1.) Patient #1 was admitted to the facility on [DATE] with diagnoses including Schizophrenia, Paranoid type and adult failure to thrive.

On 06/06/13 at 10:43 AM, a physician order documented right upper quadrant ultrasound related to increased liver function tests, rule out gallbladder.

On 06/06/13, a computerized tomography scan (CT scan) of the abdomen revealed gallbladder sludge.

On 06/08/13 at 7:30 AM, a physician order documented an order to please arrange for a GI (gastrointestinal) clinic (or surgical clinic) evaluation at (name of local clinic) for gallbladder sludge vs cholelithiasis, abdominal symptoms and pain. Social worker to please assist in any way possible.

On 06/11/13, a physician order documented to arrange for GI consult (previous order on 06/08/13).

The Inpatient Transporation Request form dated 06/12/13, documented an appointment on 07/23/13 at the local clinic. There was no documentation to indicate if this appointment was for a GI consult.

The Social Worker documented on the Treatment Plan the patient had an ultrasound on 06/06/13 due to experiencing symptoms related to the gallbladder. The ultrasound results recommended follow up. The patient had Medicaid benefits and was scheduled for outpatient primary care physician appointment at a local clinic on 07/23/13.

A review of the clinical record revealed the patient would eat and drink on some days, but the patient expressed complaints of nausea and a few episodes of vomiting. The dietitation was involved and the patient's diet was changed to low-fat. The physician had order intake and output to evaluate the patient's nutritional status.

The patient was discharged on [DATE], with a note to follow up with mental health services at (name of clinic). The patient was discharged home with family. There was no documentation reminding the patient of the physician appointment on 07/23/13 at the local clinic for follow up from the ultrasound.

On 06/18/13 at 11:00 AM, the Administrative Assistant indicated the "Inpatient Transportation Request" form was completed when an appointment was made. Medical consultation appointment could not be made on the weekends. The physician was not contacted with updates on the status of requested consultations, it was the responsiblity of the physician to follow up.

On 06/08/13 at 11:25 AM, the Psychiatric Nurse III indicated there was no formal process to update the physicians on the status of requested consultations. All specialty consultations required a visit with the patient's primary care physician. Requests for consultations were arranged Monday through Friday and most consultation referrals were sent to a local clinic. If the physician felt an earlier evaluation was warranted, then the paitent could be sent to the emergency department.

The facility's policy entitled "Client Rights and Responsibilities" dated 711 documented "...C.2 To medical, psychosocial and rehabilitative care, treatment and training including prompt and appropriate medical aliments for the prevention of any illness for disabiity. All of that care, treatment, and training must be consistent with standards of practice of the professions in the community..."

The Medical Staff Bylaws dated 04/18/13, documented "...F...All pertinent medical problems will be communicated to all appropriate medical staff and incorporated into the treatment plan.."

The clinical record lacked documented evidence the physician was aware of the delay in the patient receiving the GI consultation, as the appointment for 07/23/13 was with a primary care physician. There was no clear system in place to ensure consultations were done in a timely manner.

2.) Patient #31 was admitted on [DATE], on a legal hold due to suicidal ideation. The patient was evaluated by a psychiatrist on 05/05/13, the clinical impression was depressive disorder and polysubstance dependence.

The patient was admitted as an inpatient to Pod H on 05/07/13 at 7:33 PM. The patient was evaluated by a psychiatric advanced nurse practitioner on 5/9/13 at 12:45 PM, with a clinical impression of depressive disorder, polysubstance dependence, pathological gambling and personality disorder. The initial treatment plan included: Trazadone for insomnia, Prozac for depression, Abilify for mood, Vistaril for anxiety, Lisinopril for hypertension, Acyclovir for infection, Flexiril for muscle spasms and group attendance.

A review of the clinical record revealed the next entry from the psychiatrist was on 05/21/13 at 1:44 PM.

On 06/08/13 at 2:15 PM, the Psychiatric Medical Director indicated the psychiatrists should be evaluating the patients at minimum of twice a week. Once during the treatment team meeting and a face-to-face meeting with the patient. There should be at a minimum, a progress note in the clinical record from the psychiatrist weekly.

Patient #31's clinical record lacked a psychiatric progress note for the week of 05/13/13 through 05/19/13.

Patient #35 was admitted on [DATE] at 9:16 PM, on a legal psychiatric hold due to depression and suicidal ideation. The patient was evaluated by a psychiatrist on 05/09/13 at 2:46 PM, the clinical impression was bipolar disorder, mixed episode and alcohol abuse.

Tha patient was admitted as an inpatient to Pod H on 05/09/13 at 10:02 PM. The patient was evaluated by a psychiatrist on 05/11/13 at 5:37 PM, with a clinical impression of bipolar disorder and alcholol abuse. The initial treatment plan included: Depakote for mood, Seroquel XR for mood, monitor for mood symptoms and supportive, group and milleu therapy.

A review of the clinical revealed the next entry from the psychiatrist was 05/21/13 at 1:27 PM.

On 06/08/13 at 2:15 PM, the Psychiatric Medical Director indicated the psychiatrists should be evaluating the patients at minimum of twice a week. Once during the treatment team meeting and a face-to-face meeting with the patient. There should be at a minimum, a progress note in the clinical record from the psychiatrist weekly.

Patient #35's clinical record lacked a psychiatric progress note for the week of 05/13/13 through 05/19/13.

Patient #36 was admitted on [DATE] at 3:40 PM, on a legal psychiatric hold due to suicidal ideation. The patient was evaluated by a psychiatrist on 5/9/13 at 10:30 PM, the clinical impression was bipolar type I, most recent episode depressed.

The patient was admitted as an inpatient to Pod H on 05/10/13 at 5:47 AM. The patient was evaluated by a psychiatrist on 05/11/13 at 5:23 PM, with a clinical impression of bipolar type I, most recent episode depressed. The initial treatment plan included: discontinue Lithium, Lamictal for mood, Cymbalta for depression, Vistaril for anxiety, Ambien for insomnia, monitor for mood symptoms, and supportive, group amd milleu therapy.

The patient was evaluated by the internal medicine physician on 05/10/13 at 4:39 PM.

A review of the clinical record revealed the next entry from the psychiatrist was on 05/21/13 at 1:38 PM.

On 06/08/13 at 2:15 PM, the Psychiatric Medical Director indicated the psychiatrists should be evaluating the patients at minimum of twice a week. Once during the treatment team meeting and a face-to-face meeting with the patient. There should be at a minimum, a progress note in the clinical record from the psychiatrist weekly.

Patient #36's clinical record lacked a psychiatric progress note for the week of 05/13/13 through 05/19/13.

Patient #37 was admitted on [DATE] at 5:05 AM, on a legal psychiatric hold due to depression and suicidal ideation. The patient was evaluated by a psychiatrist and the clinical impression was major depressive disorder.

The patient was admitted as an inpatient to Pod H on 05/2/13 at 8:38 PM. The patient was evaluated by a psychiatric advanced practice nurse on 05/3/13 at 3:56 PM, with a clinical impression of major depressive disorder. The initial treatment plan included: Celexa for depression, Ambien for insomnia, Vistaril for anxiety, Risperidone for mood, the patient was to attend groups and routine observations.

The patient was evaluated by an internal medicine physician on 05/3/13 at 3:22 PM.

A review of the clinical record revealed the next entry from the psychiatrist was on 05/17/13 at 2:57 PM.

On 06/08/13 at 2:15 PM, the Psychiatric Medical Director indicated the psychiatrists should be evaluating the patients at minimum of twice a week. Once during the treatment team meeting and a face-to-face meeting with the patient. There should be at a minimum, a progress note in the clinical record from the psychiatrist weekly.

Patient #37's clinical record lacked a psychiatric progress note for the week of 05/6/13 through 05/12/13.

The Medical Staff Bylaws dated 04/18/13, documented "...I. Progress notation and treatment plan documentation shall be in compliance with...policies..."

On 06/19/13, the Psychiatric Medical Director indicated during the week of 5/8/13 through 5/16/13, one psychiatrist was moved from the H pod to the POU at assist with staffing.
VIOLATION: ALCOHOL-BASED HAND RUB DISPENSERS Tag No: A0716
Based on observation the facility failed to ensure that alcohol-based hand rub (ABHR) dispensers were properly located.

Findings include:

Alcohol-based handrub dispensers were observed to be installed over ignition sources in the following locations:

On 6/12/13 at 2:27 PM Rawson-Neal, E-Pod Nurses Station. An ABHR dispenser was installed over a public announcement, volume control switch.

On 6/13/13 at 9:40 AM Building 3A. An ABHR dispenser was installed over a duplex, electrical outlet in hallway near the Medication room.

On 6/13/13 at 11:05 AM Building 1. An ABHR dispenser was installed over a light switch in the Medication room. At 11:50 AM, ABHR installed over an electrical duplex outlet in the hallway near room 49.

On 6/13/13 at 4:30 PM at the East Las Vegas Clinic. An ABHR dispenser was installed over an electrical duplex outlet in the hallway near room 40.

On 6/14/13 at 7:20 AM in the Rawson-Neal's Section B, Conference room. An ABHR dispenser was installed over duplex light switches. The dispenser was moved during the survey.

On 6/14/13 at 9:25 AM in the Henderson Clinic. An ABHR dispenser was installed over a duplex light switch in the reception office. The dispenser was moved during the survey.
VIOLATION: FACILITIES Tag No: A0722
Based on observation, staff interview and review of maintenance request forms the facility failed to maintain carpet in a clean manner in one of three outpatient facilities, maintain the protective edge in one section of carpet in one of three patient units, failed to ensure walls in patient sleeping rooms were free of holes and damage in 3 of 20 patient rooms on the H unit.

Findings include:

On 6/12/13 the main entrance, patient lobby and hallways of the Outpatient Facility on East Sahara Avenue were observed. The carpet in the main entrance area and lobby of the outpatient facility was exceptionally stained and heavily soiled throughout. Staff accompanying the surveyors also observed the stains and indicated the carpets, although cleaned regularly, are continually stained.

On 6/14/13 observed the G Unit - B Side carpet area located close to the medication dispensing area of the unit. A portion of the protective strip between the carpet and non-carpeted area of flooring was missing. Observation of the male and female bathrooms revealed overhead lights were not illuminated in one of three toilet rooms and in the second shower room. The paint was observed to be scraped off the outer surface of the sheetrock. The lights were not illuminated in the female bathroom in two of three toilet rooms.

Review of the work order document revealed a submission date for repair or replacement of light bulbs was submitted in the morning on 6/13/13. Interview with the maintenance staff on 6/14/13, in the afternoon, revealed the lights were to be repaired the same day the work order is received.

On 6/18/13, observed patient rooms H118, H119, H120 in the H Unit - A side, the walls were in need of repair due to holes beneath the windows.

On 6/18/13 observed a full container of urine sitting on the bedside table in Patient Room H120A in the morning at approximately 9:00am. Staff indicated the urinal should have been emptied.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observation and staff interview the facility failed to ensure that open-element space heaters were prohibited from use on the campus.


Findings include:

On 6/13/13 at 11:17 AM a space heater was found in room R30, in Rawson-Neal's "Building 1". At 1:25 PM a space heater was discovered in room R3. The Facility Supervisor indicated that it was the facility's policy to prohibit the use of space heaters on the campus.