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 Nov. 8, 2013
VIOLATION: OPO AGREEMENT Tag No: A0886
Based on policy review, interview, and donor network agreement, the facility failed to ensure that all deaths were reported to the donor network as required.

Findings include:

A review of the organ and tissue donations policy #OF-MOI-10 dated 12/12 revealed on page two all deaths would be referred as indicated by the client or next of kin, to donate organs /or tissues to the Nevada Donor Network (NDN) for donor evaluations.

A review of the agreement with the Nevada Donor Network (NDN) dated 9/21/12, under the title of Hospital Services Responsibilities, stated in part, "2. Refer all deaths to NDN in a timely manner according to clinical triggers".

An interview with the facility administrator revealed there were no reported deaths in the facility in the last year.
VIOLATION: CONTRACTED SERVICES Tag No: A0084
Based on observation, interview and document review, the facility failed to ensure the nursing contract service was educated in the prevention of medication error and the dietary contract service maintained kitchen equipment and followed facility infection control policies.

1. Contracted Nursing Services.

On 11/7/13 in the morning, the Director of Pharmacy provided the Pharmacy and Therapeutics Committee Meeting Minutes for the past nine months. The Director of Pharmacy also provided a copy of the aggregate medication variances for July 2013 through October 2013. The tally of medication variances for the month of October 2013 was reported to be partially completed and completion was not required until the second week in November.

The Director of Pharmacy reported there was an increase in transcription errors and it was believed the increase was caused by contract registry nurses. The Director of Pharmacy reported the Nursing Department was going to provide the names of contracted registered nurse staff to determine the number and type of errors caused by contracted nurses.

Review of the medication variances revealed the following transcription errors over the past four months:

July 2013 - 5 errors
August - 4 errors
September - 3 errors
October - 12 errors

Review of the Pharmacy and Therapeutics Committee Minutes for 10/8/13 revealed the medication variances report was presented to the committee and the nursing department was to provide a list of contract registry nurses to the Director of Pharmacy. The list of contracted nurses involved in medication errors was to facilitate a focused in-servicing on preventing medication variances.

On 11/7/13 in the morning, the Director of Nursing (DON) was aware of the increase in transcription errors and believed they were caused by the contracted registry nursing staff. The DON confirmed nurses were counseled and actions were taken to correct the nurse at the time of the medication error or as soon as possible after occurrence. The DON confirmed counseling and correction were documented and nurses were not allowed to return to work at the facility if they did not improve. The DON reported the contracted agencies were sending new nursing graduates to the facility and the nurses did not have much experience in the transcription of physician orders.

The DON reported the facility planned to provide training for the contract nurses in an effort to reduce errors. The DON reported the training was to begin on 11/12/13, thirty-three days after the problem was identified in the Pharmacy and Therapeutics Committee Minutes of 10/8/13.

The DON denied she had an analysis of the errors made by the contracted registry nursing staff and denied the problem and the correction were part of the Quality Assurance Performance Improvement Program (QAPI). The DON reported there was not enough time since the discovery of the problem to include it in the QAPI program.

Review of the policy entitled "Medication Variances" effective date 10/12 revealed "The variance data shall be compiled and aggregated quarterly. The Pharmacy and Therapeutics (P&T) Team shall review all the Medication Variance reports and provide comments and recommendations to the Medical Staff and Leadership Teams regarding: 1. The medication variance surveillance process 2. Evaluation of (name of facility)'s medication management system to identify risk points and areas to improve safety."





2. Contracted Food Services.

On 11/5/13 in the morning, a tour of the facility's kitchen was conducted with Employee #30, the contracted Director of Food and Nutritional Services. During the course of the tour, the following was observed:

1. A ceiling tile between the manual and automatic wash areas dripped water on the floor. The contractor's Executive Chef indicated the dripping was due to condensation, which occurred when operating the automatic washer. An evaporator fan was possibly inoperable.

On 11/05/13, the facility's "Master Contract Log Summary Sheet" was reviewed. The document indicated the designated contract monitor for the contracted food service, an Administrative Services Officer III (Employee #8). Employee #8 was interviewed on 11/05/13 at 1:30 PM. The Administrative Services Officer III indicated the contractor failed to notify the facility about the exhaust fan and ceiling tiles.

On 9/25/13 at 1:00 PM, a facility work order showed a request for replacement of two ceiling tiles in the same area.

On 11/5/13 in the afternoon, the facility's Maintenance Director acknowledged the facility was responsible for replacing the ceiling tiles and the evaporator fan and failed to show documented evidence the ceiling tiles were addressed.

2. The kitchen's ice machine was dispensing a glacier-like blob of ice into the pocket of loose ice cubes in the machine, requiring an employee to break up the ice with an elongated, shovel-like tool.

On 11/5/13 at 11:45 AM, the Maintenance Director indicated the aforementioned description of the glacier-like blob of ice did not sound normal, and the kitchen contractor was responsible for the ice machine maintenance.

Invoices dated 3/22/13 and 8/12/13 indicated the kitchen contractor paid for servicing the kitchen's ice machine.

On 11/5/13 at 3:15 PM, a refrigeration contractor indicated the ice bin deflector was backwards in the machine, causing ice formation on the insulation side of the deflector. The resulting new ice cubes formed after the repair appeared more clear. The contractor mentioned a more sturdy flap with new screws should be installed, since the old flap was slightly bowed with a screw missing in the center.

3. The kitchen had two Salvajor scrap collectors: one on the manual wash counter and another adjacent to the automatic wash. The electrical spinning components were inoperable in each scrap collector.

On 11/5/13 in the morning, the kitchen contractor's Director of Food and Nutritional Services, Executive Chef, and a food service worker indicated the scrap collectors did not spin electrically and had not for years. They indicated the facility was aware of the inoperable scrap collectors.

On 11/5/13 at 11:45 AM, the Maintenance Director indicated the facility was never informed about the scrap collectors, and the staff did not repair anything without work orders. The Maintenance Director acknowledged a need to inspect the kitchen periodically to ensure equipment was maintained whether the facility or the kitchen contractor was responsible for a specific issue. The Maintenance Director indicated rounding probably should be done, but nobody told him.

According to the facility's policy Contract Services (OF-LDR-03) dated 3/2012, "...Definition: ...D. Contract Monitor: A [facility] employee, usually a program or department head, responsible for contractor compliance during the term of the contract..."

On 11/5/13 at 1:30 PM, the Administrative Services Officer III indicated there was no discussion about the scrap collectors not working.

There was no documented evidence anyone reported the inoperable scrap collectors or that they were ever serviced.

According to the facility's contract with the kitchen contractor # dated 7/1/2010, the facility failed to appoint a field contract monitor in writing, as the entry was left blank. Page 7 of the contract indicated the vendor performed the following tasks... under section 3.4.10 "...Maintenance and repair of all kitchen areas used by the vendor..., and Maintenance, repair and replacement of all equipment and fixtures used by the vendor..."
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview with staff members, clinical record review, and document review, the facility did not thoroughly and appropriately investigate grievances according to established facility policy for 3 of 50 sampled Patients (Patient #47, Patient #48, & Patient #49).

Findings include:

The facility's policy, titled, "Consumer/Family Complaints and Grievances" Number PF-RRE-03, and dated 06/2013, stated in part, "...Consumers filing grievances shall be informed of the steps taken on behalf of the grievant to investigate the complaint during the process and for level 1 grievances shall be notified in writing the results of the grievance process within 10 business days of submitting the grievance, this written notice will conclude the grievance process".

Patient #47:

Patient #47 was admitted to the facility on [DATE], on a "Legal 2000" (involuntary hold), after attempting to shock self with a defibrillator at the airport. The patient was diagnosed with bipolar I with psychosis.

On 07/16/2013, Patient #47 filed a "Complaint-Concerns Form" with the facility which alleged on 07/02/2013, "...I (Patient #47) went to the counter to ask for my scheduled medication for anxiety and breathing relief. I was told that the nurse was busy and to wait. At 7:30 after experiencing a panic attack and symptoms of stressors or stress related tension. I went back to the counter and told the staff that was there that I had been awake since 5:30 A.M. and waiting for two hours for relief for my anxiety and now my stress level was at a ten. I went to sit down at the brown table to wait for staff or nurse. The tech came over to the table and grabbed me, knocking me and the journal to the floor and grab (sic) my leg pulling me across the carpet that burned off my skin".

The nursing documentation indicated the incident occurred on 07/03/2013. The time stamp on the grievance indicated the facility received the document on 07/16/2013.

Patient #47's assessment, dated 05/27/2013, indicated that her skin was intact and she did not have any injuries.

On 07/03/2013 at 3:08 PM, Patient #47's physician wrote "(Patient) evaluated post seclusion injury (illegible) stable (with) (right) posterior abrasion". The physician ordered Ultram 50 milligrams to be given by mouth every eight hours if needed for pain.

On 07/03/2013 at 3:14 PM, Patient #47's nurse documented, "(Patient) complained of right side back sharp pain rated 6/10 and reported that she obtained an abrasion on her back when she was carried to seclusion room yesterday at (7:00 AM)... MD assess (patient) and ordered pain (medication as needed)".

On 07/03/2013, Patient #47's nurse documented in the clinical record, "0720 (7:20 AM) Patient yelling loudly, cursing, demanding to get her scheduled medication early. Patient verbally threatening bodily harm to staff and physically gesturing with clenched fist and exaggerated (sic) hand and arm movements, as well as noted escalation of pressured speech. Patient refused redirection to quiet room, tried 1:1 with patient. Patient presented as a danger to others and to self as peers/patients were disturbed by her assaultive behavior. Patient given one minute manual hold to quiet room, 0732 (7:32 AM) ... "

On 07/29/2013, the Nurse Manager for Patient #47's unit documented on the grievance investigation, "On 7/4/13 (Patient #47) filed a complaint alleging she was 'grabbed, knocked down, and then dragged across the carpet by her leg burning off her skin'. (Patient #47) further alleges the assault occurred in the dayroom area of Inpatient Unit D1B @ 0730 (7:30 AM) and a (Mental Health Technician) was the assailant. Unfortunately, I was unable to interview (Patient #47) prior to her discharge from (name of) hospital on [DATE] regarding her allegations. However, I did review the patient's chart, nursing notes and documentation for several days prior to and after her alleged attack. I was unable to find any type of documentation substantiating (Patient #47's) allegation. Additionally, I interviewed the Day shift staff on Inpatient Unit D1B and no one was able to provide any information regarding (Patient #47's) allegations. The most common refrain from staff was, 'That did not happen'. However, I did note an MD order written by (name of the physician deleted) (medical MD) on 7/4/13 for Triple Antibiotic Ointment to be applied to (Patient #47's) back (three times a day for 3 days and then twice a day for 3 days) related to an abrasion. During most of her treatment at (name of) Hospital, (Patient #47) suffered from delusional thoughts and was not clear in her thinking. (Patient #47) primary psychiatrist, Day shift D1B staff, and myself (Employee #28, a licensed nurse), that this alleged attack did not take place as (Patient #47) has described. In retrospect, (Patient #47) did not mention the alleged attack again prior to her discharge. (Patient #47) was discharged from (name of) hospital on [DATE] to (name of group home) with medications. All documentation related to this incident has been completed and closure is recommended."

A letter dated 07/30/2013 to Patient #47 was addressed to unit D1B at (name of) Hospital, was signed by the Recovery Services Coordinator (a licensed social worker). The letter stated "I am writing to inform you that I have received your Complaint, dated 07/04/13, and the investigation did not substantiate your complaints. F (sic) you wish to appeal this, please feel free to contact me."

The investigation was not completed within the time frame specified for a grievance Level 1 (10 days), per facility policy.

Patient #49:

Patient #49 was admitted to the facility on [DATE], with depression.

Patient #49 completed a "Compliment - Concerns Form" on 06/18/2013, alleging Patient #49 had been sexually harassed by a Mental Health Technician because the patient was inappropriately questioned about her bra. The Patient also alleged "My friend on the unit has a second degree burn that has gone untreated for two days."

On 07/19/2013, the Nurse Manager of the unit (Employee #31, a licensed nurse), documented, "Upon admission to the unit, she was extremely angry, defiant, uncooperative, arguementive (sic), demanding, and entitled. She would not listen to explainantions (sic) or abide by the unit rules. She was questioned about her bra since underwire bras are not allowed in the patients (sic) possession by a female (Mental Health Technician). She became agitated and (the Mental Health Technician) attempted to de-escalate the situation. Patient had no insight to her illness and refused all medications and remained uncooperative. She denied having suicide ideations or audio/visual hallucinations. Patient was discharged on [DATE] to the (name of shelter) and refused all discharge medications and after care plan instructions. All activities related to this incident have been completed. Closure recommended".

On 11/08/2013 at 4:00 PM, the facility's Patient Safety Officer (Employee #4) acknowledged the allegation Patient #49's "friend" had an untreated burn was not addressed in the investigation.





Patient #48

On 7/8/13, Patient #48 completed a grievance requesting a discharge from services.

On 7/18/13, Patient #48 completed a second grievance requesting a discharge from services.

On 7/26/13, Patient #48 was discharged to a group home.

On 8/2/13, a date stamp indicated recovery services received the first and second grievances.

On 8/7/13, the complaint-concerns forms for each grievance showed the Recovery Services Coordinator received and reviewed the grievances.

According to the facility's policy "Consumer/Family Complaints and Grievances" (PF-RRE-03) dated 6/2013, "...H....2. All grievances shall be reviewed by the Recovery Services Coordinator within two business days of receipt..."

An undated memo attached to one of the grievances indicated the grievances were sent from medical records to the Recovery Services Coordinator after culling from the chart after discharge. The Recovery Services Coordinator indicated to "please remind all units that these [grievances] do not belong in charts. Must be sent to me..."

On 11/8/13 at 3:40 PM, the Administrator indicated it appeared an employee(s) did not turn in the grievances.

According to the facility's policy "Consumer/Family Complaints and Grievances" (PF-RRE-03) dated 6/2013, "...IV. Procedure...B.2...b. All employees shall attempt to connect the grievant with the employee responsible for resolving the concern..."
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on policy review, record review and interview, the facility failed to provide a patient with written notice of the grievance decision, including the name of a contact person, the steps taken to investigate, the results of the grievance, and the completion date for 1 unsampled patient.

Findings include:

According to the facility's policy under part I Responsibility, pages 4-5, Consumer/Family Complaints and Grievances (PF-RRE-03) dated 6/2013, "...1. Any employee receiving a complaint from the Recovery Services Coordinator shall review, resolve, make necessary program/process/procedure changes, document such changes, provide a copy of the resolution to the grievant, and return to the Recovery Services Coordinator within five business days...J. Review and Analysis: 1. The Recovery Services Coordinator shall review all complaints and ensure follow up is documented..."

A review of grievance forms documented on 8/8/13, a Nurse Manager (Employee #18) closed two grievances without demonstrating the chart was reviewed for pertinent information related to the complainant's concern about an earlier discharge.

On 11/8/13 in the afternoon, a review of a grievance, date stamped 8/2/13, lacked a written response to the complainant with the steps taken to investigate, the results of the grievance, the name of a contact person, and the completion date.

On 11/8/13 at 4:15 PM, the Administrator indicated there was no follow up letter sent to the complainant regarding the steps taken to investigate, the results of two grievances, the name of a contact person, and the completion date.
VIOLATION: QAPI Tag No: A0263
Based on observation, interview and document review, the facility failed to ensure repeat issues and knowledge of medication errors without immediate corrective actions were addressed (A0084); failed to manage contracted temporary nursing staff (A0084, A0308 and A3095); failed to ensure on-going continuous performance improvement projects regarding infection control (A0308); failed to ensure on-going continuous performance improvement projects regarding pharmacy services (A0308); and failed to ensure compliance with monitoring of contracted kitchen and dietary services (A0084 and A0308).

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver statutorily mandated care to the patients.
VIOLATION: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Tag No: A0308
Based on observation, interview, and document review, the facility did not ensure the Quality Assessment and Performance Improvement Program addressed services provided by contracted resources.

Findings include:

On 11/06/2013, the facility's policy, titled "Performance Improvement Plan", dated 06/26/2013, was reviewed. The policy stated in part, "It is the policy of (name of facility) to implement and evaluate:...The processes to design, measure, assess, improve, and maintain the performance of (name of facility)'s management, clinical and support services...The purpose of the Performance Improvement Program at (name of facility) is to monitor and assist (name of facility)'s Governing Body, Leaders and the (name of facility)'s organization to meet its client quality of care, safety, treatment and service responsibilities..."

On 11/06/2013 at 3:00 PM, the facility's Administrator stated the facility had not brought forward the oversight of contracted services to the Performance Improvement Committee. The Administrator indicated that within the State system the designated compliance monitor was responsible to monitor the scope of work for specific contracts. The Administrator further acknowledged the facility was ultimately responsible for oversight of the contracted work.






Contracted Nursing Services.

On 11/7/13 in the morning, the Director of Pharmacy provided the Pharmacy and Therapeutics Committee Meeting Minutes for the past nine months. The Director of Pharmacy also provided a copy of the aggregate medication variances for July 2013 through October 2013.

The Director of Pharmacy reported there was an increase in transcription errors and it was believed the increase was caused by contract registry nurses. The Director of Pharmacy reported the Nursing Department was going to provide the names of contracted registered nurse staff to determine the number and type of errors caused by contracted nurses.

Review of the medication variances revealed the following transcription errors over the past four months:

July 2013 - 5 errors
August - 4 errors
September - 3 errors
October - 12 errors

Review of the Pharmacy and Therapeutics Committee Minutes for 10/8/13 revealed the medication variances report was presented to the committee and the nursing department was to provide a list of contract registry nurses to the Director of Pharmacy. The list of contracted nurses involved in medication errors was to facilitate a focused in-servicing on preventing medication variances.

On 11/7/13 in the morning, the Director of Nursing (DON) was aware of the increase in transcription errors and believed they were caused by the contracted registry nursing staff. The DON confirmed nurses were counseled and actions were taken to correct the nurse at the time of the medication error or as soon as possible after occurrence. The DON confirmed counseling and correction were documented and nurses were not allowed to return to work at the facility if they did not improve. The DON reported the contracted agencies were sending new nursing graduates to the facility and the nurses did not have much experience in the transcription of physician orders.

The DON reported the facility planned to provide training for the contract nurses in an effort to reduce errors. The DON reported the training was to begin on 11/12/13, thirty-three days after the problem was identified in the Pharmacy and Therapeutics Committee Minutes of 10/8/13.

The DON denied she had an analysis of the errors made by the contracted registry nursing staff and denied the problem and the correction were part of the Quality Assurance Performance Improvement Program (QAPI). The DON reported there was not enough time since the discovery of the problem to include it in the QAPI program.

Review of the policy entitled "Medication Variances" effective date 10/12 revealed "The variance data shall be compiled and aggregated quarterly. The Pharmacy and Therapeutics (P&T) Team shall review all the Medication Variance reports and provide comments and recommendations to the Medical Staff and Leadership Teams regarding: 1. The medication variance surveillance process 2. Evaluation of (name of facility)'s medication management system to identify risk points and areas to improve safety."

Infection Control

On 11/6/13, the Infection Control Coordinator, Employee #5, was interviewed. The Director reported the Infection Control Program was integrated into the hospital QAPI program but did not have a current QAPI project.

Pharmacy

On 11/6/13, the Director of Pharmacy, Employee #35, was interviewed. The Director of Pharmacy reported the Pharmacy Department was integrated into the QAPI program but did not have a current QAPI project. The Director did report the pharmacy the facility was monitoring medication variances and planned to initiate an electronic record to reduce transcription errors.





Contracted Food Services.

On 11/5/13 in the morning, a tour of the facility's kitchen was conducted with Employee #30, the contracted Director of Food and Nutritional Services. During the course of the tour, the following was observed:

1. A ceiling tile between the manual and automatic wash areas dripped water on the floor. The contractor's Executive Chef indicated the dripping was due to condensation, which occurred when operating the automatic washer. An evaporator fan was possibly inoperable.

On 11/05/13, the facility's "Master Contract Log Summary Sheet" was reviewed. The document indicated the designated contract monitor for the contracted food service, an Administrative Services Officer III (Employee #8). Employee #8 was interviewed on 11/05/13 at 1:30 PM. The Administrative Services Officer III indicated the contractor failed to notify the facility about the exhaust fan and ceiling tiles.

On 9/25/13 at 1:00 PM, a facility work order showed a request for replacement of two ceiling tiles in the same area.

On 11/5/13 in the afternoon, the facility's Maintenance Director acknowledged the facility was responsible for replacing the ceiling tiles and the evaporator fan and failed to show documented evidence the ceiling tiles were addressed.

2. The kitchen's ice machine was dispensing a glacier-like blob of ice into the pocket of loose ice cubes in the machine, requiring an employee to break up the ice with an elongated, shovel-like tool.

On 11/5/13 at 11:45 AM, the Maintenance Director indicated the aforementioned description of the glacier-like blob of ice did not sound normal, and the kitchen contractor was responsible for the ice machine maintenance.

Invoices dated 3/22/13 and 8/12/13 indicated the kitchen contractor paid for servicing the kitchen's ice machine.

On 11/5/13 at 3:15 PM, a refrigeration contractor indicated the ice bin deflector was backwards in the machine, causing ice formation on the insulation side of the deflector. The resulting new ice cubes formed after the repair appeared more clear. The contractor mentioned a more sturdy flap with new screws should be installed, since the old flap was slightly bowed with a screw missing in the center.

3. The kitchen had two Salvajor scrap collectors: one on the manual wash counter and another adjacent to the automatic wash. The electrical spinning components were inoperable in each scrap collector.

On 11/5/13 in the morning, the kitchen contractor's Director of Food and Nutritional Services, Executive Chef, and a food service worker indicated the scrap collectors did not spin electrically and had not for years. They indicated the facility was aware of the inoperable scrap collectors.

On 11/5/13 at 11:45 AM, the Maintenance Director indicated the facility was never informed about the scrap collectors, and the staff did not repair anything without work orders. The Maintenance Director acknowledged a need to inspect the kitchen periodically to ensure equipment was maintained whether the facility or the kitchen contractor was responsible for a specific issue. The Maintenance Director indicated rounding probably should be done, but nobody told him.

According to the facility's policy Contract Services (OF-LDR-03) dated 3/2012, "...Definition: ...D. Contract Monitor: A [facility] employee, usually a program or department head, responsible for contractor compliance during the term of the contract..."

On 11/5/13 at 1:30 PM, the Administrative Services Officer III indicated there was no discussion about the scrap collectors not working.

There was no documented evidence anyone reported the inoperable scrap collectors or that they were ever serviced.

According to the facility's contract with the kitchen contractor # dated 7/1/2010, the facility failed to appoint a field contract monitor in writing, as the entry was left blank. Page 7 of the contract indicated the vendor performed the following tasks... under section 3.4.10 "...Maintenance and repair of all kitchen areas used by the vendor..., and Maintenance, repair and replacement of all equipment and fixtures used by the vendor..."
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review and staff interview, the facility failed to obtain a physician ordered medication for 1 of 50 patients (Patient #39).

Findings include:

Patient #39:

Patient #39 was admitted on [DATE] at 2:35 AM, with diagnoses including mood disorder, mental retardation, bedwetting, and seizure disorder. Review of the physician orders revealed the patient was ordered DDAVP (Desmopressin) intranasal and by mouth for diabetes insipidus on 11/1/13 and again on 11/2/13.

On 11/6/13, medication pass on Unit E was observed. While preparing to administer medications to Patient #39, the nurse discovered DDAVP 20 mcg (micrograms) intranasal was not available for administration. According to the medication administration record, the nursing staff documented the patient was without the intranasal drug on 11/2/13, 11/3/13, 11/4/13, and 11/5/13.

The physician had also written an order for DDAVP 0.1 milligrams (mg) po (orally) every 12 hours. The oral dosage was available on the morning of 11/6/13 but had not been available for administration on 11/2/13, 11/3/13, 11/4/13 and 11/5/13 according to nursing documentation.

Registered Nurse #24, who was administering medications, was interviewed on the morning of 11/6/13 and did not know why the intranasal DDAVP was not available for administration. The nurse contacted the pharmacy and reported she was told the drug was non-formulary so there was a delay in obtaining the drug. The nurse reported she was told the weekend further delayed the delivery of the medication.

Record review revealed the physician completed a Medical Consultation Form on 11/1/13 indicating the non-formulary medication, DDAVP 20 mcg and 0.1 mg, was ordered for enuresis and the form was labeled as scanned. The form indicated three working days should be allowed for inpatient non formulary drugs. On 11/2/13 a second Medical Consultation Form was completed by the physician indicating 0.1 mg dosage of DDAVP was needed, but the frequency of administration was changed to hour of sleep. Nursing progress notes dated 11/2/13, revealed the form was scanned to pharmacy. The pharmacist signed the form on 11/4/13.

On 11/5/13 a third Medical Consultation Form requesting the non-formulary DDAVP 20 mcg intranasal was requested by the physician. The form indicated the drug was needed for diabetes insipidus. On 11/6/13 at 10:00 AM, two more Medical Consultation Forms were completed by the medical physician requesting both DDAVP in the intranasal form and oral forms of the drugs and indicated a change in the frequency of dosage.

On 11/6/13in the afternoon, the Pharmacy Director and a Pharmacist were interviewed regarding the delay of the medication. The Director of Pharmacy reported non-formulary requests were usually filled in one day. The Director indicated the drug orders for DDAVP remained unclear, six days after the original order was written. The pharmacist, Employee #33, reported she was aware of the non formulary request. The pharmacist reported she attempted to contact the medical physician on 11/5/13 for order clarification but was unsuccessful. The pharmacist reported she left voice mail requesting the physician contact her but he did not call her back.

The DDAVP for intranasal administration continued to be unavailable to the nursing staff as of the morning of 11/7/13.

Review of the policy entitled "Hospital Formulary and Non Formulary" effective date 12/11 revealed the results of the pharmacy consultation form would be provided in three business days after it was received.
VIOLATION: UNUSABLE DRUGS NOT USED Tag No: A0505
Based on observation, interview and policy review, the facility failed to dispose of an opened/dated vial of medication after 28 days.

Findings include:

On 11/6/13 at 2:15 PM, a 50 milligram/milliliter vial of Haldol was observed in a drawer of a medication cart in the medication room at the Charleston clinic.

The vial had lot number 79 and was to expire 11/14. The vial's open date was 10/4/13.

The Clinical Psychiatric Nurse Supervisor indicated the facility's policy was to discard opened vials after 28 days.

According to the facility's policy Multiple Dose Vials Dating (PF-CC-24) dated 10/2013, "...IV. Procedures: A. Upon the initial withdrawal of medication from a multiple dose vial, the vial shall have an auxiliary label affixed thereon indicating the date of expiration [10/4/13], which shall be twenty-eight (28) days there from, and will be initialed by the person performing this procedure. B. Once entered, the vial shall be used within twenty-eight (28) days or within the manufacturer's expiration date on the vial, whichever is lesser...E. Vials that are outdated as in procedure (B) above shall be returned to the pharmacy for proper disposal, and replacement if necessary..."
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on observation, interview and document review, the facility failed to ensure infection control policies were followed related to the ice machines in the main kitchen and cafe kitchen.

Findings include:

1. On 11/5/13 in the morning, the kitchen's ice machine was dispensing a glacier-like blob of ice into the pocket of loose ice cubes in the machine, requiring an employee to break up the ice with an elongated, shovel-like tool. The employee opened and closed the lid on the ice machine several times without hand-sanitizing or wearing gloves.

On 11/5/13 at 3:15 PM, a refrigeration contractor was observed handling ice machine parts and opening/closing the lid of the ice machine without wearing gloves.

According to the facility's policy Infection Control of Ice Machine (#OF-SP-01) dated 4/2013, "...IV. Procedure...B. Employees must wash and glove hands before scooping, bagging, or otherwise touching the ice..." The part handled by the refrigeration contractor came into direct contact with ice.

2. The caf kitchen's ice machine was streaked with what appeared to be "calcium deposits" around its perimeter.

On 11/5/13 at 11:45 AM, the facility's Maintenance Director indicated the facility was responsible for cleaning the outside perimeter of the ice machines.

According to the facility's policy Infection Control of Ice Machine (OF-SP-01) dated 4/2013, "...IV. Procedure...F...2. Housekeeping shall maintain the exterior components of the individual units [ice machines]..."

On 11/5/13 at 1:30 PM, an Administrative Services Officer III indicated ice machines were wiped and cleaned daily.

On 11/5/13 at 1:30 PM, the Maintenance Director indicated there was no documented evidence of cleaning rounds for the ice machines, and someone was already sent to clean the perimeter of the caf kitchen's ice machine.

On 11/5/13 at 3:30 PM, the caf kitchen's ice machine showed the same streaking it had earlier in the morning.
VIOLATION: QUALIFIED EMERGENCY SERVICES PERSONNEL Tag No: A1112
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, document review, and interview, the facility failed to ensure medical records were accurately created and maintained including failure to ensure Legal 2000 (Nevada Process of Civil Commitment) paperwork was completed correctly; and failure to complete COBRA (Consolidated Ominbus Reconciliation Act) transfer forms for 3 of xx sampled patients (Patient #16, Patient #24, and Patient #25).

Findings include:

The facility policy titled Involuntary Admissions effective date 3/12 documented:
- "IV. G. Discontinuing Legal 2000R: The discontinuance of a Legal 2000R by any SNAMHS physician requires face to face assessment/evaluation of the individual with alleged mental illness. The written justification for this action shall be fully addressed in the patient's chart, including the determination that the patient is no longer a danger to self and/or others."

Patient #16

Patient #16 presented to the Outpatient (OP) Clinic on 10/23/13, with complaints of depression and thoughts of suicide. The patient was placed on a Legal 2000 and admitted to the Psychiatric Observation Unit (POU).

The Legal 2000 form was completed by the physician The form specified the reason the patient was being admitted to the facility was for depression and was suicidal. The facility's Medical Doctor medically cleared the patient on 10/23/13 at 3:45 PM.

Patient #16's medical record revealed the patient was observed and monitored overnight. The patient was discharged home on 10/24/13 with referrals for outpatient follow up for depressive disorder.

The Legal 2000 form contained a section titled "Discharge" which was to be completed by the physician prior to the patient's discharge. The discharge section indicated - "I have personally observed and examined this allegedly mentally ill person and have concluded that (s)he is not or no longer a danger to self or others as a result of mental illness. My opinions are based on the following facts:_______".

The discharge section of the Legal 2000 form was not completed or signed by a physician.

Patient #24

Patient #24 (MDS) dated [DATE] with complaints of severe depression and suicidal thoughts. The patient was evaluated by the nurse and psychiatrist. The patient was placed on a Legal 2000 and admitted to the Psychiatric Observation Unit.

The Legal 2000 form was completed by the physician. The form specified the reason the patient was being admitted to the facility was for worsening depression and suicudal ideations. The facility's Medical Doctor medically cleared the patient on 11/7/13 at 1:50 PM.

Patient #24's medical record revealed the patient was observed and monitored overnight. The patient was discharged home on 11/8/13 with referrals for outpatient follow up for major depression.

The Legal 2000 form contained a section titled "Discharge" which was to be completed by the physician prior to the patient's discharge. The discharge section indicated - "I have personally observed and examined this allegedly mentally ill person and have concluded that (s)he is not or no longer a danger to self or others as a result of mental illness. My opinions are based on the following facts:_______".

The discharge section of the Legal 2000 form was not completed or signed by a physician.

There was no documented evidence of a face-to-face assessment/evaluation by a physician. There was no documented evidence the patient was no longer a danger to himself and/or others.

Patient #25

Patient #25 presented to the Outpatient Clinic on 11/7/13 with complaints of suicidal ideations. The patient was evaluated by the nurse and psychiatrist. The patient was placed on a Legal 2000 and admitted to the Psychiatric Observation Unit.

The Legal 2000 form was completed by the physician and documented the patient attempted to run into traffic. The form specified the reason the patient was being admitted to the facility was for depression and suiciadal ideations. The facility's Medical Doctor medically cleared the patient on 11/7/13 at 2:00 PM.

Patient #25's medical record revealed the patient was discharged home on 11/10/13 with referrals for outpatient follow up for mood disorders

The Legal 2000 form contained a section titled "Discharge" which was to be completed by the physician prior to the patient's discharge. The discharge section indicated - "I have personally observed and examined this allegedly mentally ill person and have concluded that (s)he is not or no longer a danger to self or others as a result of mental illness. My opinions are based on the following facts:_______".

The discharge section of the Legal 2000 form was not completed or signed by a physician.

On 11/12/13 at 3:00 PM, the Hospital Administrator (Adm) verbalized when someone showed up requesting services after the clinic was closed and there was a determination the patient was a Legal 2000, there was no requirement for the nurse to complete a transfer form, as the person was not an admission to the facility.

The Adm added, the determination as to which the facility the patient was referred to was totally the decision of the EMS (Emergency Medical Staff). There was no communication between the staff at facility and the receiving facility.