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.

SUMNER COMMUNITY HOSPITAL 1323 NORTH A STREET WELLINGTON, KS 67152 July 27, 2017
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and policy review the Hospital failed to document the provision of patient rights to 2 of 10 medical records reviewed (Patient #7 and #10). Failure to inform patients of their rights prior to treatment places all patients at risk of not knowing and acting on all rights.

Findings include:

- Patient #7's medical record review on 7/27/2017 revealed an admission date of [DATE] at 9:22 AM. There is no evidence the patient received information regarding the Patient Bill of Rights.

- Patient #10's medical record review on 7/27/2017 revealed an admission date of [DATE] at 1:45 PM. There is no evidence the patient received information regarding the Patient Bill of Rights.

Program Director RN Staff A confirmed receipt of patient rights documentation was absent from the records.

The facility did not provide a policy regarding patient rights.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation and interview, the Behavioral Health Unit (BHU) failed to provide a safe environment by removing or locking items from patient access that could be used as weapons, failed to ensure all electrical conduits were covered, and failed to accurately document and perform individual patient checks every 15 minutes for three of ten patients reviewed (Patient #1, #4, #5), and failed to install video monitoring on the unit. Failure to provide a safe environment places all patients and employees at risk of harming themselves or others and possible death.


Findings Include:

- Review of Patient #1's medical record on 7/27/2017 revealed the Documentation on the 15 Minute Checks/1-1 Observation Check Sheet initiated 7/18/17 at 11:30 PM by the unit CNA staff revealed on 07/19/17 at 11:30 AM and 11:45 AM, CNA Staff D documented Patient #1 was in the hallway, walking. Documentation performed by CNA Staff D from 12:00 PM through 2:15 PM on 7/19/17 revealed the patient was off the Unit, walking. Review of surveillance revealed the patient leaving the hospital at 11:19 AM on 7/19/2017. CNA staff incorrectly documented 15 minute checks on Patient #1 when the patient was not even physically present in the BHU.

Review of Patient #4's medical record on 7/27/2017 revealed the 15 Minute Checks/1-1 Observation Check Sheet dated 7/11/2017 were not documented for the time period 11:30 PM (7/10/2017) through 4:45 PM (7/11/2017) (~17 hours).

Review of Patient #5's medical record on 7/27/2017 revealed documentation of the 15 Minute Checks/1-1 Observation Check Sheet dated 7/16/2017 no frequency of observation was noted but documentation revealed the patient was considered an elopement risk.

Program Director RN Staff A confirmed the incomplete, inaccurate documentation and the expectation of the staff was to follow the policy.

Policy titled, "Observation Levels" directed, " ...Three levels of staff monitoring are provided: Standard Observation (assess and document at 15 minute intervals), Line of Sight (assess and document at 15 minute intervals), and One to one (staff member constantly with the patient not less than arm's length away and documents at 15 minute intervals) ... ...During waking hours, observations should include, "checking in" with the patient verbally to ensure their safety and well-being and identify needs for further assessment or intervention ... ...Standard Observation ... the staff member will observe and check in with the patient at least every 15 minutes and document the patient's location and status at each interval ...Assigned staff will make direct visual contact with patients and confirm they are in no danger or distress ..."

Policy titled, "Elopement Prevention" directed, "Increased staff monitoring more frequent than every 15 minutes, line of sight or one to one is instituted when a patient attempts to leave the unit without proper authorization or when there is clinical indication the patient will attempt to leave ..."

Policy titled, "Nursing Rounds" directed, "The Charge Nurse is responsible for assigning nursing staff to make unit/patient rounds in order to account for all patients' whereabouts and ensure a safe environment ...Rounds are made a minimum of every fifteen minutes ... ...The assigned staff member(s) personally locates each patient listed (unless on pass or off unit for testing), and documents the rounds exact time, patient's location, and behavior on the Observation Sheet under the appropriate column ..."

- Review of document "Pro-Active Risk Assessment Form" performed April 26, 2017 by Program Director RN Staff A and Risk Assessor Staff R revealed the absence of video cameras in day area, hallway, and seclusion.

Program Director RN Staff A confirmed on 7/25/2017 at 4:40 PM the policy titled, "Video Safety Monitor Audit" dated 5/1/2017, was not enforced because video surveillance equipment was not installed on the unit.



- Observation in the day room of the BHU on 7/27/2017 at 10:45 AM revealed 2 unlocked cabinets above the sink. Both cabinets stored multiple cans of soup. Unsuccessful attempts by Certified Nurses Aide (CNA) Staff B and CNA Staff P to lock the cabinets were observed.

Maintenance Staff O was notified the locks were not working and CNA Staff P removed the food products from the cabinets.

Observation in the day room of the BHU on 7/27/2017 revealed two unlocked drawers containing plastic forks and knives. No locks were evident on the drawers.

CNA Staff B removed the plastic ware.



- Observation in the day room of the BHU on 7/27/2017 revealed a microwave on a shelf above the counter top. The microwave was easily moved.

Maintenance Staff O confirmed the microwave could be picked up and arranged to have it anchored in place.

- Observation in the day room bathroom of the BHU on 7/27/2017 revealed an open conduit in the shower with wires sticking through.

Maintenance Staff O confirmed the opening and covered it with metal plating and tamper resistant screws.


Program Director RN Staff A confirmed the document "Environmental Rounds Checklist" was to be performed at the start of every shift by the RN to assess for patient safety concerns.


Policy titled, "Environmental Safety Checks" directed, " ...The purpose is to ensure a safe physical environment for patients, staff, and visitors ... ...Following inspection of patient rooms, common community patient areas, group/conference rooms, and hall exits are inspected ... ...major structural damage of unknown origin or potentially hazardous conditions shall be reported to the designated nurse.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on personnel record review and policy review, the Behavioral Health Unit (BHU) failed to contact state registries to conduct back ground checks for all personnel providing direct care to BHU patients in two of eight personnel files reviewed (Staff B and G). Failure to perform background checks on all personnel places all patients at increased risk of abuse, neglect, or mistreatment by personnel.

Findings Include:


- Certified Nurses Aide (CNA) Staff B's employee file reviewed on 7/26/2017 at 9:00AM, hired 6/9/2017, revealed no evidence of state registry or criminal background check.

- Registered Nurse (RN) Staff G's employee file reviewed on 5/23/2017 at 9:40 AM, hired 5/30/2017, revealed no evidence of state registry or criminal background check.

Interview with Human Resource Director Staff Q on 7/26/2017 at 3:00 PM acknowledged state registries have not been contacted for all new personnel hired. Those personnel were just missed.

Policy titled, "Initial Selection & Employment & Probation," reviewed on 7/26/2017 directed, " ...KBI Criminal History Investigation Authorization: Consent form authorizing the Kansas Bureau of Investigation to provide [hospital] with information about an applicant's criminal history ..."
VIOLATION: MEDICAL STAFF RESPONSIBILITIES Tag No: A0359
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, interview, and policy review, the Behavioral Health Unit (BHU) failed to document in a timely fashion an admission history and physical for one of ten medical records reviewed (Patient #7). Failure to perform a timely history and physical places all patients at risk for inappropriate medical care.

Findings Include:

- Review of Patient #7's medical record on 7/27/2017 revealed the patient was admitted [DATE] with a diagnosis of dementia (a group of thinking and social symptoms that interferes with daily functioning), aggression, and confusion. Physician Staff L performed a history and physical 7/25/2017.

Program Director RN Staff A confirmed the history and physical was performed 5 days post admission.

Policy review on 7/27/2017AM revealed facility failed to provide a policy for a time frame the history and physical is to be completed.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review and interview, the Behavioral Health Unit (BHU) failed to administer medications as ordered for two of ten medical records reviewed (Patient #6 and #7). Failure to administer medications as ordered places patients at risk of insufficient treatment, delayed improvement, and delayed dismissal.

Findings include:

- Review of Patient #6's medical record on 7/27/2017 revealed the patient was admitted on [DATE] with a diagnosis of anxiety, aggression, and delusional dementia (a group of thinking and social symptoms that interferes with daily functioning). The medication Risperdal (medication used to treat schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and irritability), ordered by Physician Staff K on 7/20/2017 was not administered as ordered at 1:00 PM on 7/26/2017. The medical record lacked documentation of a reason for the missed medication or notification to the physician.

Review of Patient #7's medical record on 7/27/2017 revealed the patient was admitted on [DATE] with a diagnosis of dementia, aggression, and confusion. The medication Seroquel (antipsychotic used to treat schizophrenia, bipolar disorder, and depression), ordered by Physician Staff K was not administered as ordered at 9:00 PM on 7/24/2017. The medical record lacked documentation of a reason for the missed medication or notification to the physician.

Program Director RN Staff A acknowledged the missed medications.

Policy review on 7/27/2017 revealed the facility failed to provide a policy for medication administration.
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
Based on medical record review, interview and policy review the Behavioral Health Unit (BHU), failed to ensure physician signature on all orders, verbal and written in ten of ten medical records reviewed (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10). Failure of the BHU to ensure all orders are signed by the ordering provider put all patients at risk of receiving wrong treatments, medication errors, and sub-standard care.

Findings Include:

- Review of Patient #1's medical record on 7/27/2017 revealed the document "Physician Admission Orders" was not initiated with a date or signed by the admitting Physician, Staff K or staff nurse.

Review of Patient #2's medical record on 7/27/2017 revealed orders initiated on 7/12/17, 7/15/17, and 7/19/17 were not dated and signed by the ordering Physician, Staff K. The initial Physician Certification dated 7/8/2017 was incomplete lacking the treatment needed, estimation of the number of days for inpatient treatment, and post hospitalization plan. The document had been signed by Physician, Staff K on 7/8/2017.

- Observation of medical record #3 on 7/27/2017 revealed orders written on 7/10/17 and 7/17/17 were not dated and signed by the ordering Physician Staff K.

Review of Patient #4's medical record on 7/27/2017 revealed orders written on 7/9/2017, 7/11/2017, 7/21/2017, 7/23/2017, 7/24/2017, and 7/25/2017 were not dated and signed by the ordering Physician, Staff K.

Review of Patient #5's medical record on 7/27/2017 revealed orders written from 7/7/2017 through 7/24/2017, a total of 35 medications, were not dated and signed by the ordering Physician, Staff K.

Review of Patient #6's medical record on 7/27/2017 revealed orders written on 7/20/2017 were not dated and signed by the ordering Physician, Staff K.

Review of Patient #7's medical record revealed orders written 7/20/2017 through 7/24/2017, a total of 24 medications, were not dated and signed by the ordering Physician, Staff K.

Review of Patient #8's medical record revealed orders written 7/17/2017 through 7/26/2017, a total of 16 medications, were not dated and signed by the ordering Physician, Staff K. The initial Physician Certification dated 7/18/2017 and signed by Physician Staff K was incomplete lacking the treatment needed, estimation of the number of days for inpatient treatment, and post hospitalization plan.

Review of Patient #9's medical record revealed orders written 7/19/2017 through 7/24/2017, a total of 16 medications, were not dated and signed by the ordering Physician, Staff K.

Review of Patient #10's medical record revealed orders written 7/20/2017 through 7/24/2017, a total of 16 medications, not dated and signed by the ordering Physician, Staff K.

Program Director RN Staff A confirmed the unsigned orders and incomplete treatment plans.

Policy titled, "Verbal/Telephone Orders" directed, " ...All verbal and telephone orders must be authenticated and countersigned by the prescriber or other responsible practitioner per Medical Staff rules and regulations within 48 hours unless state law is more restrictive. Authentication must include signature, date, and time of authentication ..."

Policy titled, "Treatment Planning Process" directed, " ...Key elements essential to all stages of treatment planning include the following: ...Treatment plans specify the frequency of each treatment intervention/procedure and name the disciplines and persons responsible for interventions ...Treatment plans specify criteria for discharge ..."
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation of personnel health review and policy review, the Behavioral Health Unit (BHU) failed to perform TB testing upon hire for one of eight personnel records reviewed (Staff C) and failed to perform an initial health assessment in two of eight personnel records reviewed (Staff C and A). Failure to perform health testing and assessment of all hired personnel places all patients and personnel at risk for exposure to infectious diseases.

Findings Include:

- Observation of Licensed Practical Nurse (LPN), Staff C's personnel file on 7/26/2017 at 9:00 AM revealed LPN Staff C's hire date was 7/7/2017. The personnel file lacked evidence of Tuberculosis (TB) testing and an Initial Health Assessment performed prior to her/his hire date.

Review of the Program Director's, Registered Nurse (RN), Staff A's personnel file on 7/26/2017 at 8:50 AM revealed her/his hire date was 7/5/2016. The personnel file lacked evidence of Initial Medical Exam performed prior to her/his hire date.

Program Director RN Staff A confirmed TB Testing and Initial Health Assessment documents were not present in the noted personnel files.

Policy review on 7/26/2017 revealed the facility failed to provide a policy for personnel health requirements prior to hire.