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.

THOMAS MEMORIAL HOSPITAL 4605 MACCORKLE AVENUE SW SOUTH CHARLESTON, WV 25309 Feb. 26, 2020
VIOLATION: CONTENT OF RECORD - CONSULTS Tag No: A0464
Based on record review and staff interviews it was determined the Medical Director of the Emergency Department (ED) failed to ensure physician #2 completed a discharge summary for one (1) of three (3) psychiatric medical records reviewed (patient #9). This resulted in patient #9's medical record to not have a discharge summary and has the potential for all patients to have an incomplete medical record.

1. Review of the medical record for patient #9 on the identifier list is a forty-five (45) year old male who was brought to the hospital by ambulance at the request of law enforcement for violent and bizarre behavior on 01/06/20 at 1:54 p.m. The patient had a medical screening at 2:13 p.m. and was deemed to be a harm to self and others and placed on one (1) on one (1) (1:1) and at 4:00 p.m. the patient was ordered four (4) point restraints due to violent behavior. The patient was awaiting a mental hygiene court hearing for placement into a psychiatric hospital. Physician #1 completed hand off to physician #2 on 01/06/20 at 7:00 p.m. Physician #2 has no documentation in the medical record from 01/06/20 at 7:00 p.m. through the patient's discharge on 01/07/20 at 8:28 a.m.

2. An interview was conducted on 02/26/20 at 12:35 p.m. with the Chief Medical Officer. When asked what his expectation of assessments by a physician in the ED were when a patient is in restraints and on 1:1 he stated in part: "I would expect an assessment completed upon the start of shift and while in restraints, the patient would need to be seen every hour and documented on." When asked if the physician should have continued to visit the patient and document through discharge he stated in part, "Yes, that is expected by the ED physician." It should be noted a review of the medical staff by-laws was conducted and the by-laws do not have any documentation on a physician assessment. During the interview he was given access to the medical record and reviewed the medical record. He concurred physician #2 did not complete any documentation on a psychiatric patient for thirteen (13) hours and twenty-eight (28) minutes.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observations, document review and staff interviews it was determined the facility failed to facilitate the ability to call a code blue in all their radiology suites and failed to ensure every patient area had a call light. This failure has the potential to place all patients receiving radiology services in the radiology imaging and radiology therapy departments at risk for serious harm or death.

Findings include:

1. A tour was conducted of the diagnostic radiology department on 2/24/20 at 2:10 p.m. The Director of Radiology and the Director of Critical Care Services accompanied the State surveyor on this tour. During the tour the surveyor noted all rooms lacked code blue buttons. In room #4 there was an intercom on the wall. Staff activated the intercom twice with no response.

2. A tour was conducted of the diagnostic radiology department on 2/26/20 at 8:45 a.m. The Director of Critical Care Services accompanied the State surveyor on this tour. Rooms #1, 2 and 4 had no call bells, no phones and no code button. A tour was conducted immediately of the radiology therapy department with the Director of Critical Care Services. Exam #2 had no phone, no call bell and no code button. Two (2) out of two (2) dressing rooms with solid doors had no call bell.

3. A review of document titled "Code Response and Emergency Cart Inspection & Restocking," revision date October 2019, states in part: "Purpose: To establish a procedure for responding to victims of cardiopulmonary arrest on the Saint Francis and Thomas Memorial Hospital campuses in order to facilitate the patient's survival ...Scope and Responsibility ...Hospital leadership will ensure that appropriate emergency response equipment ...will be stocked throughout the facility in order to facilitate rapid response to 'Code Blue' and 'Code Pink' calls."

4. An interview was conducted with the Director of Clinical Care Services and the Director of Radiology during the tour on 2/24/20 at 2:10 p.m. They stated the code buttons were not included in the redesign of the imaging suites.

5. An interview was conducted with the Charge Nurse of the radiology imaging department on 2/26/20 at 8:45 a.m. She revealed the Charge Nurse is the only staff carrying a portable phone.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
A. Based on a tour, document review and staff interviews it was revealed the facility failed to provide a sanitary environment to avoid the transmission of infectious and communicable diseases. This failure was identified in the main facility and three (3) outpatient service units. This failure has the potential to adversely affect all patients.

Findings include:

1. A tour of the facility was conducted on 2/24/20 at 11:00 a.m. The Interim Chief Nursing Officer (CNO) accompanied the surveyors on the tour. The fifth floor clean equipment supply room had three (3) blood pressure cuffs, two (2) respiratory monitors and a fan not marked as clean. The fourth floor clean equipment room had two (2) blood pressure cuffs not marked as clean. The anteroom, which joined two negative pressure rooms, had clean supplies and a ladder present in the room. During the tour the CNO concurred the equipment stored in the clean equipment rooms was not marked as clean and a ladder was stored in the anteroom with clean supplies.

2. A tour of the Outpatient Physical Therapy (PT) department was conducted on 2/24/20 at 2:30 p.m. The Director of the PT and the senior PT technician accompanied the surveyor on the tour. When asked if the Thera Bands are cleaned between patients, the PT technician stated the bands are never cleaned between patients. He stated the bands are reused. When asked if the cloth gait belts are cleaned between patients, the PT technician stated, "No." The clean storage room had boxes and paper on the floor and a dolly transporter was located in the clean supply room. During the tour the Director of PT concurred with the findings.

3. A tour of the Surgical Associates was conducted on 2/24/20 at 3:05 p.m. The Clinical Manager accompanied the surveyors on the tour. The biohazard room had biohazard bags and housekeeping supplies stored in the room. During the tour the Clinical Manager concurred with the findings.

4. A tour of the Medical Associates was conducted on 2/25/20 at 7:45 a.m. The Clinical Manager accompanied the surveyor on the tour. The Vice President (VP) of Thomas Health Physician Services joined the surveyor on the tour. The centrifuge being used for patient services had no maintenance sticker. The biohazard closet had biohazard bags for patient rooms and stored sharps containers. During the tour the VP of Thomas Health Physician Services concurred with the findings.

5. A tour of the Magnetic Resonance Imaging (MRI) department was conducted on 2/25/20 at approximately 8:15 a.m. The Director of Medical Imaging and the MRI lead technician accompanied the surveyor on the tour. The clean supply room had a snow shovel with cobwebs and a box of florescent lights stored in the clean supply room. During the tour the Director of Medical Imaging concurred with the findings.

6. A tour of the operating room (OR) was conducted on 2/25/20 at 12:45 p.m. The Executive Director of OR Services, the Director of the Endoscopy (Endo) Services and the Clinical Manager of the Recovery Room accompanied the surveyor on the tour. During the observation of the set up of the OR suite for a procedure, the scrub nurses grabbed the trash bin on multiple occasions to move it to another location in the OR room while opening sterile equipment and packages. No hand sanitizer was used after grabbing the trash bin before opening other supplies. On the supply cart one (1) package of soiled four (4) by four (4) gauzes was for patient use. The suture supply cart located at the end of the OR table had dust on all boxes of sutures. The computer area in the OR suite had dust on the computer and surrounding area. During the tour of the set up of the OR suite the Executive Director of OR removed the stained gauzes. The endoscopy suite clean scope room had two scopes with a white substance located on the scopes and the scopes were for patient use. The Director of Endo stated it appears to be glue on the scopes in the clean scope room. The biohazard room in recovery had new trash bags and biohazard bags stored in the biohazard room. During the tour of OR services the Executive Director of OR services stated the staff of OR services has dedicated shoes for OR services. She confirmed they wear their shoes throughout the hospital and do not wear shoe covers over their dedicated shoes. She stated it is their policy they can wear their shoes throughout the hospital but not outside the hospital.

7. A review of the guidelines titled 2017 Edition GUIDELINES FOR PERIOPERATIVE PRACTICE, AORN stated in part: "Perioperative personnel should wear clean shoes that are dedicated for use within the perioperative area."

8. An interview was conducted with the Infection Control Officer on 2/26/20 at 1:20 p.m. She concurred no clean supplies can be stored in the biohazard room, only clean supplies are to be kept in the clean supply room, no staff should touch a garbage bin unless they use hand sanitizer after touching the bin and OR staff should cover their dedicated shoes with shoes covers or change their shoes before leaving the OR. She stated they follow the Association of PeriOperative Registered Nurses (AORN).
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review, staff interviews and policy review it was determined the hospital failed to ensure patient care was provided in a safe setting. (See tag A 144, A 147 and A 154). This failure has the potential to lead to poor patient outcomes and possible death.

An Immediate Jeopardy was cited on 2/26/20 at 10:40 a.m. due to the compromise in patient safety.

A. An Immediate Jeopardy (IJ) to Patient Right's (care in a safe setting, confidentiality and restraints) was called on 2/26/20 at 10:40 a.m. due to the hospital staff not following hospital policy in regards to the psychiatric patient and having the ability to call a code blue in all their radiological suites.

B. Noncompliance: Patient #9 was kept in restraints while sleeping and was discontinued without a physician's order.

A juvenile psychiatric patient (patient #10) was left in a room in the emergency room (ER) with a parent when the patient was ordered one (1) on one (1) (1:1) supervision by the physician. The hospital policy states that they are to be supervised by hospital staff.

Patient #20 was ordered 1:1 supervision with no 1:1 supervision documented.

In medical imaging are rooms one (1) and two (2) with no code button or no phone. Room four (4) has no phone and no code button, intercom was present but staff did not respond. In radiation therapy exam room two (2) no phone and no code button was present.

C. Immediacy: The likelihood of a serious adverse outcome is death may occur if the psychiatric patient is not monitored appropriately and if code blue buttons are not available in all areas of the radiological suites.

D. An immediate Plan of Correction was received and sent to the State agency program manager. It was accepted and the facility abated the IJ on 2/26/20 at 3:50 p.m.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on medical record review, observation, document review and staff interviews it was determined the Director of the Emergency Department (ED) failed to ensure psychiatric patients who require one (1) on one (1) (1:1) observation (patient #10 and #20) for their safety were completed in two (2) of three (3) psychiatric medical records reviewed. This failure has the potential for all patients who come to the hospital for a psychotic episode or suicidal ideation to cause harm to themselves or others.

Findings include:

1. Review of the medical record for patient #10 revealed a fourteen (14) year old patient who was brought to the ED on 02/24/20 at 2:51 p.m. for suicidal ideations with a plan. A medical screening was completed at 2:58 p.m. and the patient was placed on suicide precautions. The patient's grandmother completed the 1:1 observation. The patient remained on 1:1 until her discharge on 02/25/20 at 11:25 p.m. when she was admitted to a psychiatric hospital.

2. Observation on 02/25/20 at 10:15 a.m. in the presence of the Director of the ED revealed patient #10 in the ED room thirteen (13) being observed by her grandmother who was asleep during observation. No hospital staff was present in the patient's room.

3. Review of the medical record for patient #20 revealed a forty-one (41) year old female who was brought to the hospital on [DATE] at 5:04 p.m. for suicidal ideations. A medical screening was completed at 5:04 p.m. An order for 1:1 was ordered on [DATE] at 5:30 p.m. A nursing note on 12/08/19 at 7:15 p.m. states in part: "No staff available for 1:1 at this time." The patient was discharged and transferred to a psychiatric hospital on [DATE] at 5:53 a.m. No documentation of 1:1 completed.

4. Review of the policy titled "One on One Monitoring & Documentation," last revision date of 06/2018, states in part: "One on one Monitoring is required for suicidal patients ...System wide Interdepartmental-Applies to inpatient and ER settings. This policy applies to nursing supervision, all nurses, nursing assistants, nurse externs, patient care techs, mental health techs, patient transporters, unit clerks, housekeeping staff and any other staff appointed by supervision ...Using the "Patient Observation-One-on-One Monitoring Form" (Computer or on downtime form) ... An order for one-on-one can only be discontinued by a physician."

5. An interview was conducted with the Director of the ED and the ED Clinical Coordinator on 02/26/20 at 9:10 a.m. and they concurred with the above findings.

B. Based on record review, policy review and staff interviews it was determined the Director of the ED failed to ensure that a physician's order was received prior to discontinuing 1:1 for a psychiatric patient for one (1) of three (3) psychiatric medical records reviewed (patient #9). This failure has the potential for all patients ordered 1:1 observation by a physician to be able to cause harm to themselves or others.

Findings include:

1. Review of the medical record for patient #9 on the identifier list is a forty-five (45) year old male who was brought to the hospital by an ambulance at the request of law enforcement for violent and bizarre behavior on 01/06/20 at 1:54 p.m. The patient had a medical screening at 2:13 p.m. and was deemed to be a harm to self and others. An order for 1:1 was ordered and the patient was placed on 1:1. Registered Nurse (RN) #1 discontinued 1:1 without a physician's order on 01/07/20 at 3:10 a.m.

2. Review of the policy titled "One on One Monitoring & Documentation," with a last revision day of 06/2018, states in part: "An order for one-on-one can only be discontinued by a physician."

3. An interview was conducted with the Director of the ED and the ED Clinical Coordinator on 02/26/20 at 9:10 a.m. and they concurred with the above findings.

C. Based on record review and staff interviews it was determined the Medical Director of the ED failed to ensure all patients in the ED for psychiatric care received medical care for the patient's entire hospital stay for one (1) of three (3) psychiatric medical records reviewed (patient #9). This failure has the potential for the patient to remain in a psychiatric crisis of psychosis and cause harm to self or others.

Findings include:

1. Review of the medical record for Patient #9 on the identifier list is a forty-five (45) year old male who was brought to the hospital by an ambulance at the request of law enforcement for violent and bizarre behavior on 01/06/20 at 1:54 p.m. The patient had a medical screening at 2:13 p.m. and was deemed to be a harm to self and others and placed on 1:1 and at 4:00 p.m. the patient was ordered four (4) point restraints due to violent behavior. The patient was awaiting a mental hygiene court hearing for placement into a psychiatric hospital. Physician #1 completed hand off to physician #2 on 01/06/20 at 7:00 p.m.. Physician #2 has no documentation in the medical record from 01/06/20 at 7:00 p.m. through the patient's discharge on 01/07/20 at 8:28 a.m.

2. An interview was conducted on 02/26/20 at 12:35 p.m. with the Chief Medical Officer. When asked what his expectation of assessments by a physician in the ED were when a patient is in restraints and on 1:1 he stated in part: "I would expect an assessment completed upon the start of shift and while in restraints, the patient would need to be seen every hour and documented on." When asked if the physician should have continued to visit the patient and document through discharge he stated in part, "Yes, that is expected by the ED physician." It should be noted a review of the medical staff by-laws was conducted and the by-laws do not have any documentation on a physician assessment. During the interview he was given access to the medical record and reviewed the medical record. He concurred physician #2 did not complete any documentation on a psychiatric patient for thirteen (13) hours and twenty-eight (28) minutes.

D. Based on observations, interviews and document review it was determined the facility failed to maintain a sanitary environment in the dietary department. This failure has the potential to place all patients at risk for harm due to food-borne illness and infection.

Findings include:

1. A tour was conducted of the dietary department on 2/25/20 at 10:45 a.m. Two (2) refrigerators contained uncovered fresh salad, pears, applesauce and gelatin. While serving food on the tray line the cook (wearing disposable gloves) used a sanitizing cloth to wipe down surface areas, wiped her hands on her apron and then placed her hands on top of the plates before putting food on them.

2. A tour was conducted of the dietary department on 2/26/20 at 9:05 a.m. with the Director of Critical Care Services and the Dietary Director. Two (2) refrigerators contained uncovered fresh salad, peaches and pears.

3. During an interview with the Dietary Director on 2/26/20 at 9:05 a.m. he acknowledged the above. The Dietary Director stated the facility adheres to the Kanawha County Health Department rules and regulations.

4. A review of document titled "Kanawha-Charleston Health Department," with no issue date, states in part: "All foods must be stored at least six inches off the floor. Stored foods should always be kept covered. The only exception is foods that are cooling, which should be left uncovered in the refrigerator until cooled."

E. Based on observations, interviews and document reviews it was determined the facility failed to facilitate the ability to call a code blue in all their radiology suites. It was determined the facility failed to ensure every patient area had a call light. This failure has the potential to place all patients receiving radiology services in the radiology imaging and radiology therapy departments at risk for serious harm or death.

Findings include:

1. A tour was conducted of the diagnostic radiology department on 2/24/20 at 2:10 p.m. The Director of Radiology and the Director of Critical Care Services accompanied the State surveyor on this tour. During the tour the surveyor noted all rooms lacked code blue buttons. In room #4 there was an intercom on the wall. Staff activated the intercom twice with no response.

2. A tour was conducted of the diagnostic radiology department on 2/26/20 at 8:45 a.m. The Director of Critical Care Services accompanied the State surveyor on this tour. Rooms #1, 2 and 4 had no call bells, no phones and no code buttons. A tour was conducted immediately of the radiology therapy department with the Director of Critical Care Services. Exam #2 had no phone, no call bell and no code button. Two (2) out of two (2) dressing rooms with solid doors had no call bell.

3. An interview was conducted with the Director of Clinical Care Services and the Director of Radiology during the tour on 2/24/20 at 2:10 p.m. They stated the code buttons were not included in the redesign of the imaging suites.

4. An interview was conducted with the Charge Nurse of the radiology imaging department on 2/26/20 at 8:45 a.m. She revealed the Charge Nurse is the only staff carrying a portable phone.

5. A review of document titled "Code Response and Emergency Cart Inspection & Restocking," revision date October 2019, states in part: "Purpose: To establish a procedure for responding to victims of cardiopulmonary arrest on the Saint Francis and Thomas Memorial Hospital campuses in order to facilitate the patient's survival ...Scope and Responsibility ...Hospital leadership will ensure that appropriate emergency response equipment ...will be stocked throughout the facility in order to facilitate rapid response to 'Code Blue' and 'Code Pink' calls."
VIOLATION: PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS Tag No: A0147
Based on record review and staff interviews it was determined the Director of the Emergency Department (ED) failed to ensure that Registered Nurse (RN) #1 maintained confidentiality of the patient's medical care in one (1) of three (3) psychiatric medical records reviewed (patient #9). This failure has the potential for all patients who seek care in the ED to have a breach of their medical information.

Findings include:

1. Review of the medical record for patient #9 on the identifier list is a forty-five (45) year old male who was brought to the hospital by ambulance at the request of law enforcement for violent and bizarre behavior on 01/06/20 at 1:54 p.m. The patient had a medical screening at 2:13 p.m. and was deemed to be a harm to self and others and placed on one (1) on one (1) (1:1) and at 4:00 p.m. the patient was ordered four (4) point restraints due to violent behavior. The patient was awaiting a mental hygiene court hearing for placement into a psychiatric hospital. RN #1 documented an addendum in the medical record on 01/07/20 at 2:57 a.m. that states in part: "Spoke with (states name) this is his boss that is one of his closest friends. The patient calls him and wants staff to talk to him and tell him what is going on ... Explained to (states name of boss) that the patient exhibited extreme behavior yesterday that he thought he was someone else and wanted to hurt other people. Explained that we are trying to do what is best for the patient and other people and keep everyone safe. Informed him that we cannot let him leave d/t (due to) court order and that he can be there for the hearing in the morning at the courthouse." The patient was discharged to police custody for a mental hygiene hearing on 01/07/20 at 8:28 a.m.

2. Numerous requests were made for a policy for confidentially of patient information and at the time of exit no policy had been received by this surveyor.

3. An interview was conducted on 02/26/20 at 12:35 p.m. with the Chief Medical Officer. When asked if a psychiatric patient who is awaiting a mental hygiene court hearing would have capacity he stated in part: "The patient would be considered to lack capacity until the hearing has taken place."
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
A. Based on record review, policy review and staff interviews it was determined the Director of the Emergency Department (ED) failed to ensure that patients remained free from restraints in one (1) of one (1) restraint records reviewed (patient #9). This failure led to patient #9 being in four (4) point restraints for four (4) hours and thirty (30) minutes after his violent behavior had ceased and has the potential for all patients who require restraints to be left in restraints when they are no longer required for patient's or other's safety.

Findings include:

1. Review of the medical record for patient #9 on the identifier list is a forty-five (45) year old male who was brought to the hospital by ambulance at the request of law enforcement for violent and bizarre behavior on 01/06/20 at 1:54 p.m. The patient had a medical screening at 2:13 p.m. and was deemed to be a harm to self and others and placed on one (1) on one (1) (1:1) and at 3:42 p.m. the patient was ordered four (4) point restraints due to violent behavior. A 1:1 document was completed by patient care technician #1 and revealed from "3:40 p.m. to 3:45 p.m. patient acting out. 4:00 p.m. restraints applied. 4:15 p.m. talking to nurse. 4:30 p.m. to 5:30 p.m. patient sleeping. 5:45 p.m. sitting up partially in bed. 6:00 p.m. said he needed to go pee/fell back asleep. 6:15 p.m. moving in bed. 6:30 p.m. nurse in room to draw blood. 6:45 p.m. to 7:15 p.m. patient sleeping. 7:30 p.m. patient used urinal, complained of burning. 7:45 p.m. to 8:00 p.m. lying awake in room. 8:15 p.m. patient eating. 8:30 p.m. lying awake. 8:45 p.m. sleeping. 9:00 p.m. to 10:00 p.m. patient sleeping. 10:00 p.m. sleeping/woke to use urinal. 10:15 p.m. lying in bed. 10:30 p.m. to 12:15 a.m. patient sleeping." Registered Nurse (RN) #1's documentation from "3:45 to 5:00 p.m. has no documentation of patient's behavior. 5:00 p.m. to 5:45 p.m. patient sleeping. 6:00 p.m. no documentation of patient's behavior. 6:15 p.m. to 7:45 p.m. patient sleeping. 8:00 p.m. patient voiding in urinal, removed right wrist restraint momentarily while patient eats, one-on-one observation continues. Patient cooperative so far. 8:30 p.m. restraints discontinued; no behavior documented."

2. Review of the policy titled "Restraints and Seclusion Use," last revision date of 09/2018, states in part: "Evaluate the patient in person within one hour of the initiation of restraint or seclusions for patients of all ages. At the time of the in-person evaluation, the LIP will: Evaluate and document the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion ...Written, telephone, electronic or verbal orders for initial use of restraint or seclusion are time limited. 4 hours for patients ages 18 and older."

3. An interview was conducted with the Director of the ED and the ED Clinical Coordinator on 02/26/20 at 9:10 a.m. and they concurred with the above findings.

B. Based on record review, policy review and staff interviews it was determined the Director of the ED failed to ensure a physician's orders for restraints were followed in one (1) of one (1) psychiatric medical records with restraint orders (patient #9). The failure allowed the patient to remain in restraints without the patient exhibiting violent behavior and to continue restraints thirty (30) minutes after restraints should have been released.

Findings include:

1. Review of the medical record for patient #9 on the identifier list is a forty-five (45) year old male who was brought to the hospital by ambulance at the request of law enforcement for violent and bizarre behavior on 01/06/20 at 1:54 p.m. The patient had a medical screening at 2:13 p.m. and was deemed to be a harm to self and others and placed on one (1) on one (1) (1:1) and at 3:42 p.m. the patient was ordered four (4) point restraints due to violent behavior. A 1:1 document was completed by patient care technician #1 and revealed "from 3:40 p.m. to 3:45 p.m. patient acting out. 4:00 p.m. restraints applied. 4:15 p.m. talking to nurse. 4:30 p.m. to 5:30 p.m. patient sleeping. 5:45 p.m. sitting up partially in bed. 6:00 p.m. said he needed to go to the pee/fell back asleep. 6:15 p.m. moving in bed. 6:30 p.m. nurse in room to draw blood. 6:45 p.m. to 7:15 p.m. patient sleeping. 7:30 p.m. patient used urinal, complained of burning. 7:45 p.m. and 8:00 p.m. lying awake in room. 8:15 p.m. patient eating. 8:30 p.m. lying awake. 8:45 p.m. sleeping. 9:00 p.m. to 10:00 p.m. patient sleeping. 10:00 p.m. sleeping/woke to use urinal. 10:15 p.m. lying in bed. 10:30 p.m. to 12:15 a.m. patient sleeping." Registered Nurse (RN) #1's documentation from 3:45 p.m. to 5:00 p.m. has no documentation of patient's behavior. 5:00 p.m. to 5:45 p.m. patient sleeping. 6:00 p.m. no documentation of patient's behavior. 6:15 p.m. to 7:45 p.m. patient sleeping. 8:00 p.m. patient voiding in urinal, removed right wrist restraint momentarily while patient eats, one-on-one observation continues. Patient cooperative so far. 8:30 p.m. restraints discontinued; no behavior documented."

2. Review of the policy titled "Restraints and Seclusion Use," last revision date of 09/2018, states in part: "Written, telephone, electronic or verbal orders for initial use of restraint or seclusion are time limited. 4 hours for patients ages 18 and older."

3. An interview was conducted with the Director of the ED and the ED Clinical Coordinator on 02/26/20 at 9:10 a.m. and they concurred with the above findings.
VIOLATION: MEDICAL STAFF Tag No: A0338
Based on record review and staff interviews it was determined the Medical Director of the Emergency Department (ED) failed to ensure that all medical staff followed the care of each patient during the entirety of their emergency room visit in one (1) of three (3) psychiatric patients receiving services of the ED (patient # 9) (See Tag A 347). This failure has the potential to delay possible life-saving measures in the event of a change in the condition of the psychiatric patient may.
VIOLATION: MEDICAL STAFF ACCOUNTABILITY Tag No: A0347
Based on record review and staff interviews it was determined the Medical Director of the Emergency Department (ED) failed to ensure all patients in the ED for psychiatric care received medical care for the patient's entire hospital stay for one (1) of three (3) psychiatric medical records reviewed (patient #9). This failure resulted in the patient not having medical care by a physician and has the potential for the patient to remain in a psychiatric crisis of psychosis and cause harm to self or others.

Findings include:

1. Review of the medical record for patient #9 on the identifier list is a forty-five (45) year old male who was brought to the hospital by ambulance at the request of law enforcement for violent and bizarre behavior on 01/06/20 at 1:54 p.m. The patient had a medical screening at 2:13 p.m. and was deemed to be a harm to self and others and placed on one (1) on one (1) (1:1) and at 4:00 p.m. the patient was ordered four (4) point restraints due to violent behavior. The patient was awaiting a mental hygiene court hearing for placement into a psychiatric hospital. Physician #1 completed hand off to physician #2 on 01/06/20 at 7:00 p.m. Physician #2 has no documentation in the medical record from 01/06/20 at 7:00 p.m. through the patient's discharge on 01/07/20 at 8:28 a.m.

2. An interview was conducted on 02/26/20 at 12:35 p.m. with the Chief Medical Officer. When asked what his expectation of assessments by a physician in the ED were when a patient is in restraints and on 1:1 he stated in part: "I would expect an assessment completed upon the start of shift and while in restraints, the patient would need to be seen every hour and documented on." When asked if the physician should have continued to visit the patient and document through discharge he stated in part, "Yes, that is expected by the ED physician." It should be noted a review of the medical staff by-laws was conducted and the by-laws do not have any documentation on a physician assessment. During the interview he was given access to the medical record and reviewed the medical record. He concurred physician #2 did not complete any documentation on a psychiatric patient for thirteen (13) hours and twenty-eight (28) minutes.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on record review, document review and staff interviews it was determined the Director of Nursing failed to ensure staff in the emergency room is following physician's orders and hospital policy in three (3) of thirty (30) records reviewed (patient # 9, 10 and 20). This failure has the potential to lead to adverse outcomes or possible death of the psychiatric patient receiving the services of the emergency department (See Tag A 395)
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on record review, policy review and staff interviews it was determined the Director of Nursing failed to supervise and evaluate the nursing care of one (1) of two (2) psychiatric medical records reviewed (patient #10 and 20). This failure created an adverse impact on the care and condition of patient #10 and #20 and the potential to have an adverse impact of the care and conditions of all patients.

Findings include:

1. Review of the medical record for patient #10 revealed a fourteen (14) year old patient who was brought to the emergency department (ED) on 02/24/20 at 2:51 p.m. for suicidal ideations with a plan. A medical screening was completed at 2:58 p.m. and the patient was placed on suicide precautions. The patient's grandmother completed the one (1) on one (1) (1:1) observation. The patient remained on 1:1 until her discharge on 02/25/20 at 11:25 p.m. when she was admitted to a psychiatric hospital.

2. Observation on 02/24/20 at 02/25/20 at 10:15 a.m. in the presence of the Director of the ED revealed patient #10 in the ED room thirteen (13) being observed by her grandmother who was asleep during observation. No hospital staff was present in the patient's room.

3. Review of the medical record for patient #20 revealed a forty-one (41) year old female who was brought to the hospital on [DATE] at 5:04 p.m. for suicidal ideations. A medical screening was completed at 5:04 p.m. An order for 1:1 was ordered on [DATE] at 5:30 p.m. A nursing note on 12/08/19 at 7:15 p.m. states in part: "No staff available for 1:1 at this time." The patient was discharged and transferred to a psychiatric hospital on [DATE] at 5:53 a.m. No documentation of 1:1 completed.

4. Review of the policy titled "One on One Monitoring & Documentation," with a last revision day of 06/2018, states in part: "One on one Monitoring is required for suicidal patients ...System wide Interdepartmental-Applies to inpatient and ER settings. This policy applies to nursing supervision, all nurses, nursing assistants, nurse externs, patient care techs, mental health techs, patient transporters, unit clerks, housekeeping staff and any other staff appointed by supervision ...Using the "Patient Observation-One-on-One Monitoring Form" (Computer or on downtime form) ... An order for one-on-one can only be discontinued by a physician."

5. An interview was conducted with the Director of the ED and the ED Clinical Coordinator on 02/26/20 at 9:10 a.m. and they concurred with the above findings.

B. Based on record review, policy review and staff interviews it was determined the Director of the ED failed to ensure that a physician's order was received prior to discontinuing 1:1 for a psychiatric patient for one (1) of three (3) psychiatric medical records reviewed (patient #9). This failure has the potential for all patients ordered 1:1 observation by a physician to be able to cause harm to themselves or others.

Findings include:

1. Review of the medical record for patient #9 on the identifier list is a forty-five (45) year old male who was brought to the hospital by ambulance at the request of law enforcement for violent and bizarre behavior on 01/06/20 at 1:54 p.m. The patient had a medical screening at 2:13 p.m. and was deemed to be a harm to self and others. An order for 1:1 was ordered and the patient was placed on 1:1. Registered Nurse (RN) #1 discontinued 1:1 without a physician's order on 01/07/20 at 3:10 a.m.

2. Review of the policy titled "One on One Monitoring & Documentation," last revision date of 06/2018, states in part: "An order for one-on-one can only be discontinued by a physician."

3. An interview was conducted with the Director of the ED and the ED Clinical Coordinator on 02/26/20 at 9:10 a.m. and they concurred with the above findings.

C. Based on record review, policy review and staff interviews it was determined the Director of the ED failed to ensure that a physician's order was received prior to discontinuing 1:1 for a psychiatric patient for one (1) of three (3) psychiatric medical records reviewed. (patient #9). This failure has the potential for all patients ordered 1:1 observation by a physician to be able to cause harm to themselves or others.

Findings include:

1. Review of the medical record for patient #9 on the identifier list is a forty-five (45) year old male who was brought to the hospital by ambulance at the request of law enforcement for violent and bizarre behavior on 01/06/20 at 1:54 p.m. The patient had a medical screening at 2:13 p.m. and was deemed to be a harm to self and others. An order for 1:1 was ordered and the patient was placed on 1:1. RN #1 discontinued 1:1 without a physician's order on 01/07/20 at 3:10 a.m.

2. Review of the policy titled "One on One Monitoring & Documentation," last revision date of 06/2018, states in part: "An order for one-on-one can only be discontinued by a physician."

3. An interview was conducted with the Director of the ED and the ED Clinical Coordinator on 02/26/20 at 9:10 a.m. and they concurred with the above findings.

D. Based on record review, policy review and staff interviews it was determined the Director of the ED failed to ensure a physician's orders for restraints were followed in one (1) of one (1) psychiatric medical records with restraint orders (patient #9). The failure allowed the patient to be remain in restraints without the patient exhibiting violent behavior and to continue restraints thirty (30) minutes after restraints should have been released.

Findings include:


2. Review of the policy titled "Restraints and Seclusion Use," last revision date of 09/2018, states in part: "Written, telephone, electronic or verbal orders for initial use of restraint or seclusion are time limited. 4 hours for patients ages 18 and older."

3. An interview was conducted with the Director of the ED and the ED Clinical Coordinator on 02/26/20 at 9:10 a.m. and they concurred with the above findings.

E. Based on document review and staff interviews it was determined RN #1 discharged a psychiatric patient without a physician's order for discharge. This failure allowed a psychiatric patient to be discharged from the hospital without an order and without the physician's knowledge and has the potential for all psychiatric patients to be discharged without an order and may cause harm to themselves or others.

Findings include:

1. Review of the medical record for patient #9 on the identifier list is a forty-five (45) year old male who was brought to the hospital by ambulance at the request of law enforcement for violent and bizarre behavior on 01/06/20 at 1:54 p.m. The patient had a medical screening at 2:13 p.m. and was deemed to be a harm to self and others and placed on one (1) on one (1) (1:1) and at 4:00 p.m. the patient was ordered four (4) point restraints due to violent behavior. The patient was awaiting a mental hygiene court hearing for placement into a psychiatric hospital. RN #1 documented an addendum in the medical record on 01/07/20 at 2:57 a.m. that states in part: "Spoke with (states name) this is his boss that is one of his closest friends. The patient calls him and wants staff to talk to him and tell him what is going on ... Explained to (states name of boss) that the patient exhibited extreme behavior yesterday that he thought he was someone else and wanted to hurt other people. Explained that we are trying to do what is best for the patient and other people and keep everyone safe. Informed him that we cannot let him leave d/t (due to) court order and that he can be there for the hearing in the morning at the courthouse." The patient was discharged to police custody for a mental hygiene hearing on 01/07/20 at 8:28 a.m.

2. Review of the medical staff by-laws revealed a physician's order is required for discharge.

3. An interview was conducted with the Director of the ED and the ED Clinical Coordinator on 02/26/20 at 9:10 a.m. and they concurred with the above findings.

F. Based on record review and staff interviews it was determined the Director of the Emergency Department (ED) failed to ensure that Registered Nurse (RN) #1 maintained confidentiality of the patient's medical care in one (1) of three (3) psychiatric medical records reviewed (patient #9). This failure has the potential for all patients who seek care in the ED to have a breach of their medical information.

Findings include:

1. Review of the medical record for patient #9 on the identifier list is a forty-five (45) year old male who was brought to the hospital by ambulance at the request of law enforcement for violent and bizarre behavior on 01/06/20 at 1:54 p.m. The patient had a medical screening at 2:13 p.m. and was deemed to be a harm to self and others and placed on one (1) on one (1) (1:1) and at 4:00 p.m. the patient was ordered four (4) point restraints due to violent behavior. The patient was awaiting a mental hygiene court hearing for placement into a psychiatric hospital. RN #1 documented an addendum in the medical record on 01/07/20 at 2:57 a.m. that states in part: "Spoke with (states name) this is his boss that is one of his closest friends. The patient calls him and wants staff to talk to him and tell him what is going on ... Explained to (states name of boss) that the patient exhibited extreme behavior yesterday that he thought he was someone else and wanted to hurt other people. Explained that we are trying to do what is best for the patient and other people and keep everyone safe. Informed him that we cannot let him leave d/t (due to) court order and that he can be there for the hearing in the morning at the courthouse." The patient was discharged to police custody for a mental hygiene hearing on 01/07/20 at 8:28 a.m.

2. Numerous requests were made for a policy for confidentially of patient information and at the time of exit no policy had been received by this surveyor.

3. An interview was conducted on 02/26/20 at 12:35 p.m. with the Chief Medical Officer. When asked if a psychiatric patient who is awaiting a mental hygiene court hearing would have capacity he stated in part: "The patient would be considered to lack capacity until the hearing has taken place." The Chief Medical Officer reviewed the chart and concurred RN #1 should not have discussed medical care with the patient's boss because at the time the patient would not have capacity
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0431
Based on document review and staff interviews it was determined the hospital failed to ensure that the medical record was completed with a discharge summary in one (1) of three (3) psychiatric medical records reviewed (patient # 9) (See Tag A 464). This failure led to the incomplete medical record of patient #9.