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.

PSYCHIATRIC INSTITUTE OF WASHINGTON DC 4228 WISCONSIN AVENUE, NW WASHINGTON, DC 20016 Jan. 15, 2020
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observations, record and policy review, and staff interviews, the governing body failed to establish an effective monitoring mechanism to ensure the adequate oversight of the hospital, as evidenced by the Chief Executive's Officer's failure to:

Comply with the Condition of Participation for the provision of nursing services; as a result, placed the health and safety of recipients of care at risk for serious harm. Subsequently, the state agency identified an Immediate Jeopardy relative to the provision of nursing services, requiring the need for immediate corrective action.

Findings included...

The noncompliance requiring immediate corrective action is as follows:

Failure to...

A. Ensure the medical staff is accountable to the governing body for the quality of care provided to patients (See A-049) and

B. Ensure nursing services provide care in accordance with physician orders, to include medication administration and wound dressing changes (A-395).

The cumulative effect of these systemic deficient practices resulted in the governing body's failure to comply with the conditions of participation for the Governing Body.
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
Based on a closed medical record review, hospital policy review, and staff interview, the medical staff failed to provide necessary care and services for a patient that was admitted with a lower extremity wound that medical staff assessed as gangrenous, discolored with drainage and infected, in one of one patient records reviewed (Patient #1).

Findings included ...

Review of the hospital policy titled, "Admission, Continued Stay and Discharge Criteria for Inpatient," dated 08/17, shows; "The (inpatient) individual has developed symptoms...that require this intensity of service for safe and effective treatment. Acute Exclusionary Criteria: 1.0 Significant medical condition which cannot besafely treated in a psychiatric hospital setting, e.g.; medically unstable...requiring medical or surgical intervention which cannot be provided in a psychiatric hospital...1.8 'Stage 3 or 4 Decubitus Ulcers or stasis ulcers', 1.12 Any acute medical condition which would otherwise require an inpatient medical hospitalization if the patient were not otherwise psychiatrically impaired".

Review of the hospital policy titled, "[hospital named] Contracted Medical Provider (CMP) HCS Medical Consults", dated 03/07/19, shows: "The contracted medical provider and/or an advanced license practitioner will evaluate all [hospital named] patients for whom consults have been placed in the HCS [electronic medical record]. The MHG (Medical Home Group) PROVIDER will document his/her recommendation in the [electronic medical record] and place a copy of the patient evaluation in the patient's chart...The MHG PROVIDER will write orders for medications, lab test and/or any other treatments necessary. The MHG PROVIDER will communicate directly to the Psychiatrist any pertinent information immediately...consults will be addressed at the discretion of the MHG on-call Provider and completed within twenty-four (24) hours. The MHG PROVIDER will confer with the attending psychiatrist and get their authentications for the recommended treatment plan. The MHG PROVIDER will place any needed orders in the [ electronic medical record] for the patient".

The surveyor conducted a closed medical record review on 01/14/2020 at 1:30 PM, for Patient #1. Employee #2, Nurse Practitioner, conducted an admission History and Physical (H&P), on Patient #1, on 11/19/19 at approximately 4:45 PM. The patient's diagnoses included: Hypertension, Diabetes Mellitus and and Opioid Addiction. Employee #2 documented that Patient #1 had a left lower leg bandage dressing on at the time of them medical examination; and documented, "Will follow up later" [regarding the left lower leg bandage].

The initial admission nursing assessment completed on 11/19/19 at 5:54 PM, by Employee #4, Registered Nurse (RN), showed documentation on the Skin Integrity Exam; "Description of Marks/Scars/Wounds/Tattoos, etc, identified: #1 thru 3, Scars. Wound on left leg and arthritis, wound on left leg". The attending physician, Employee #1, ordered "Medical Consult Other: New patient admitted with a wound on her left lower foot", on 11/19/19 at 11:00 PM.

Review of the wound care consult, completed by, Employee #2, Nurse Practitioner on 11/25/19 [no time indicated], showed the patient as having an "open wound: 9 centimeters (cm), by 7cm and 3 small wounds on the area, appears slightly infected, slight drainage noted. Noted gangrene and discoloration from knee down".

There was a six day delay for the wound consult for Patient#2's left lower leg wound.

A physician order dated 11/20/19 at 1:00 PM directed for Patient #1 to have a dressing change [to the left leg wound] "apply 1 (one) application of isdosorb gel (gel used for wound debridement) daily."

A review of the nursing progress notes showed no evidence of the physician being notified for clarification regarding the wound care, as it relates to the cleansing, prior to application of the prescribed treatment. Additionally, there was no evidence on the Medication Administration Record to reflect that the nursing staff completed Patient #1's dressing changes in accordance with the physician's orders.

Further review of the medical record, revealed a physician order dated 11/26/19 at 2:00 PM, showed an order for Patient #1 to receive Clindamycin 300 milligrams by mouth, every eight hours for 10 days. The staff nurse documented in the Medication Administration Record as being administered on 11/26/19 at 4:31 PM, and 11/27/19 at 1:23 AM.

The nursing staff failed to administer 28 doses of Clindamycin, and there was no documented evidence of notification to the physician regarding the missed medications.

A review of the nursing Initial Care Plan, dated 11/19/19 at 6:30 PM, lacked evidence that Patient #1's diagnoses of Diabetes and Alteration in Skin integrity were identified, as part of the medical treatment plan with goals and nursing interventions.

The surveyor conducted a face to face interview with Employee #2, Nurse Practitioner, on 01/14/2020 at approximately 1:45 PM, regarding Patient #1's wound. When queried, about her assessment of the left lower leg wound on admission, she stated, "The patient was refusing everything. I only work two days a week, and I was planning to follow up with her the next time I was here."

The surveyor queried Employee #2, if she had informed anyone of Patient #1's left lower leg wound that was covered with a bandage. She stated "I called the Unit nurse who was receiving the patient".

The surveyor queried Employee #2 regarding wound parameters for admission to the facility, She stated "I have never seen wound parameters for admission to the hospital". When queried about reporting the findings of her 11/25/19 wound consultation with Employee #1, She stated "I work as an independent contractor, and the referring [attending] physician is responsible to look up my consult findings on the computer after I have completed my assessment. I am not required to contact the referring physician after my assessment."

The surveyor conducted a face to face interview with the attending physician Employee #1, on 01/14/2020 at 1:00 PM, who stated, "I ordered a medical consult for Patient #1 on 11/19 at 9:00 PM for a left lower leg wound evaluation. I ordered the consult as a result of information I received from the nurse on the admitting unit, conducting an admission skin assessment. However, I was not aware of the results of the wound consult on 11/25/19, the patient should have been transferred to an emergency room for further medical assessment with the wound consult evaluation findings."

The practice lacked evidence that medical staff failed to follow hospital policy for a medical finding of a stage IV wound, with gangrene and drainage, with discoloration from the knee down, requiring further medical evaluation and transfer to a higher level of care. Attending physician, Employee #1, failed to review the consult findings, resulting in the patient remaining in the hospital with a wound that required further medical evaluation from a higher level of care.

The medical team failed to adhere to the hospital's exclusionary policy as it relates to abstaining from the admittance of a patient with an advanced wound.

The surveyor conducted a face to face interview with Employee's # 7, Chief Medical Officer, #5, Quality, and #6, Chief Nursing Officer, on 01/15/2020 at approximately 1:15 PM. The surveyor reviewed the findings for Patient #1, and queried the Employee's about the admission criteria for a patient with a stage IV wound, documented as draining, with gangrene and infected, is considered acceptable for Acute Inpatient Admission at PIW.

All Employee's acknowledged the findings, stating that a patient would not be admitted as the hospital is not equipped for the medical requirements needed for a patient with the findings stated. Per interview with hospital leadership, it is not customary to manage [advanced} wounds such as Patient #1's at the (psychiatric) hospital. The normal course of action would require transfer to an acute care hospital for wound management and stabilization.
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**







Based on medical record review, hospital policy review, and staff interview, the hospital staff failed to complete consents for the administration of psychotropic and non-psychotropic medications, in four of six patient records reviewed (Patients #2, 40, 39, and 38).

Findings included ...

The surveyor reviewed hospital policy titled, "Patient Rights and Responsibilities," dated 08/17, shows the patient has the "right to give or not give consent for the treatment of your medical or physical problems, to take or refuse to take medications..."

A. The physician admitted Patient #2 with diagnoses to include Status Post Gastric Ulcer and Alcohol Abuse.

B. Review of the medical record for Patient # 40, on 01/09/2020 at approximately 12:15 PM with Employee # 16, Nurse Manager, showed the patient was admitted on [DATE] with findings of Asthma, Depression, Alcohol, and Heroin use disorder, and suicidal ideation.

C. Review of the medical record for Patient # 39 on 01/09/2020 at 11:45 AM with Employee # 16, Nurse Manager, showed the patient was admitted on [DATE] with diagnoses to include Heroin Use Disorder.

D. Review of the medical record for Patient # 38, on 01/09/2020 at approximately 11:15 AM with Employee # 16, Nurse Manager, showed the patient was admitted on [DATE] with a diagnosis of alcohol and heroin use disorder, seeking detoxification

Review of the hospital consent form for administration of psychotropic and non-psychotropic medications showed, "You or your child will be receiving the medications (s) checked above and explained below."

Further review of the medical records showed the consent forms for the administration of psychotropic medications and non-psychotropic for Patients #2, #40, #39, and #38 were blank.

The practice lacked evidence that the hospital staff failed to completed the informed consent for Psychotropic and Non-Psychotropic medications in accordance with the hospital policy. Additionally, there were

Employees #4, Registered Nurse and Employee #16, Nurse Manager, confirmed the findings at the time of the medical record review.
VIOLATION: PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS Tag No: A0146
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


2. Based on medical record review, policy review and staff interview, nursing staff failed to develop an individualized care plan to address the needs of a patient with a history of elopement, three patients with a history of substance in four of four records reviewed (Patients #27, #38, #40, and #39).

Findings included...

Record review of the hospital policy titled, "Inpatient Documentation Requirements," dated 08/17, showed that the nursing staff will complete the initial nursing treatment plan within four hours of admission and document the initial plan for nursing care of each patient admitted to the hospital, to include both psychiatric and medical concerns.

Record review of the hospital policy titled, "Continuous Nursing Assessment," dated 08/17, showed that the "nursing staff develops the initial treatment plan to identify issues and guide treatment ...specific to the individual patient's health care needs."

The physician admitted Patient #27 with diagnoses to include Unspecified Schizophrenia Spectrum Disorder,
Review of the medical record revealed on the physician's history and physical, that patient had a history of elopement.

A. According to the physician's orders dated 10/31/19 at 2:00 PM, directed the patient to be placed on elopement precautions.

Further review of the medical record showed that nursing staff did not develop a plan of care, with goals and intervention, to address the patient's history of elopement.

The surveyor conducted a face-to-face interview on 01/09/2020, at approximately 2:00 PM, with Employee #6, Chief Nursing Officer, regarding the development of a care plan related to elopement. She acknowledged the findings at the time of the record review.


B. A review of the medical record for Patient # 38 on 01/09/2020 at approximately 11:15 AM with Employee # 16 Nurse Manager, showed the patient was admitted on [DATE], with a diagnosis of alcohol and heroin use disorder, seeking detoxification. Review of the Initial Nursing Treatment Plan, dated 01/07/20, showed Substance Abuse as blank.

The practice lacked evidence that the nursing staff identified substance abuse as a nursing treatment plan for Patient #38, who was admitted for alcohol and heroin abuse.

At the time of the medical record review, Employee #16 confirmed the findings.

C. Review of the medical record for Patient # 40 on 01/09/2020 at approximately 12:15 PM, with Employee # 16 Nurse Manager, showed the patient was admitted on [DATE] with diagnoses to include Asthma, Depression, Alcohol, Heroin use disorder, and Suicidal Ideation.

Review of the Initial Nursing Treatment Plan, dated 01/07/2020, failed to identify: Substance Abuse, as part of the nursing treatment plan.

The practice lacked evidence that the nursing staff identified Suicidal/Self-Injurious, Mood Disturbance, and Substance Abuse, as part of the nursing treatment plan.

Employee # 16 confirmed the findings at the time of the medical record review.

D. Review of the medical record for Patient # 39 on 01/09/2020 at 11:45 AM with Employee # 16, Nurse Manager, showed the patient was admitted on [DATE] with Heroin use disorder. Review of the Initial Nursing Treatment Plan showed Substance Abuse as blank.

The practice lacked evidence that the nursing staff identified Substance Abuse, as part of the nursing treatment plan.

Employee # 16 confirmed the findings at the time of the medical record review.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observations, record and policy review, and staff interviews, nursing services failed to provide care in accordance with physician orders, to include medication administration and wound dressing changes.

Findings included...

Failure to comply with the Condition of Participation for the provision of nursing services; as a result, placed the health and safety of a patient at risk for serious harm.

Subsequently, the state agency identified an Immediate Jeopardy relative to the provision of nursing services, requiring the need for immediate corrective action.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


1. Based on medical record review and staff interview, the nursing staff failed to follow the physician's order relative to elopement monitoring, for one patient with a history of elopement (Patient #27).

Finding included...

The physician admitted Patient #27 with diagnoses to include Unspecified Schizophrenia Spectrum Disorder, with a History of Elopement.

Physician orders dated 10/31/19 at 2:00 PM, directed patient to be on elopement precautions, with Q [every] 15 minutes level of observations.

A review of the monitoring observation flowsheets dated 10/31/19 through 11/14/19, revealed the box for elopement behavior/activity was not checked for monitoring.

The medical record lacked documented evidence that Patient #27 was monitored in accordance with physician's orders.

The surveyor conducted a face-to-face interview with Employee #6, Chief Nursing Officer (CNO), on 1/9/2020 at approximately 4:00 PM, regarding the aforementioned findings. She confirmed the findings at the time of the chart review.

2. Based on record review and staff interview, the psychiatrist failed to write orders for an antibiotic and non-steroidal anti-inflammatory medication, recommended by the medical team, in a timely manner, for a patient diagnosed with Gingivitis (Patient #22).

Findings included...

The physician admitted Patient #22 on 12/07/19 with diagnoses to include Depression and Bipolar Disorder.

Review of the medical record showed a physician note, indicating that the medical team saw the patient on 12/12/19 for complaint of painful gums. On exam, the patient was diagnosed as having Gingivitis, with recommendations for Amoxicillin 500mg (milligrams) po [by mouth] every 8 hours for 5 days and Motrin 600mg by mouth every 6 hours for 3 days with food.

A review of the medical record lacked evidence that a physician order was written to administer the antibiotic and the anti-inflammatory medications.

Further review of the electronic Medication Administration Record lacked documented evidence of the patient receiving the medications as recommended.

The medical record lacked documented evidence that the psychiatrist followed up and wrote orders to administer Patient #22's medications for Gingivitis as recommended by the medical team. There was a delay of 29 days before patient received his medications. There was no adverse outcomes.

The surveyor conducted a face-to-face interview with Employee #29, Nurse Manager and Employee # 34, Psychiatrist, on 01/09/2020 at approximately 1:00 PM, regarding the aforementioned finding. Employee #29 stated that a new process was implemented, and the psychiatrist was to write the order, not the medical team. Employee #34 stated that he recalled writing the order; and the patient received the medication. However, after reviewing the medical record, he acknowledged that the order was not written and the patient did not receive the medication as recommended by the medical physician.










3. Based on closed medical record review, and staff interview, the nursing staff failed to provide care as directed by a physician, including medication administration and wound dressing changes, for one patient, Patient #1.

Findings included ...

The surveyor conducted a closed medical record review on 01/14/2020 at 1:30 PM. Review of daily shift nursing documentation, and physician orders dated 11/26/19 at 2:00 PM, showed an order for Clindamycin 300 milligrams by mouth, every eight hours for 10 days. The medication was documented in the Medication AdministratioRecord (MAR) as administered on 11/26/19 at 4:31 PM, and 11/27/19 at 1:23 AM. The nursing staff failed to administer 28 doses of Clindamycin.

Review of the physician MAR orders dated 11/20/19 at 1:00 PM for a dressing change [to the left leg wound] directed: "apply 1 application of isdosorb get daily". There was no clarification for the dressing change order, such as cleaning of the wound, in the nursing care documentation. There was no evidence of skin/wound care documentation on the nursing daily shift assessment/progress notes. There was no evidence in the MAR that the nursing staff completed dressing changes as ordered on [DATE].

The practice lacked evidence that the nursing staff administered medications and performed daily wound assessments and/or dressing changes in accordance with the physician order.

The surveyor conducted a face to face interview on 01/15/2020 at approximately 1:00 PM with Employees #5, Quality, and 6, Chief Nursing Officer, who acknowledged the findings.


4. Based on medical record review, hospital policy review, and staff confirmation, the nursing staff failed to clarify the parameters for administration of an anti-hypertensive medications for one of five medical records reviewed (Patient # 16).

Findings included...

The surveyor conducted a medical record review on 01/07/2020 at approximately 11:45 AM, with Employees # 6, Chief Nursing Officer, and 12, Program Director, for Patient # 16. The patient was admitted on [DATE] with diagnoses to include Hypertension.

According to a history and physical dated 12/16/19, Employee #2, Nurse Practitioner, documented under the plan "monitor blood pressure, (bp), closely, call medical staff on call for bp greater than 140/90".

Employee # 35, Attending Physician/Psychiatrist, reviewed the history and physical and counter signed it on 12/19/19 at 3:30 PM.

A review of the electronic medication administration record (eMAR), revealed the registered administered Norvasc 10 milligram (mg) po (by mouth), and Metoprolol 50 mg po daily for blood pressure management.

Review of blood pressure measurements above 140 systolic, was noted on the following dates: 12/23/19, and 1/02/2020 through 01/07/2020.

There was no evidence that the nursing staff notified the medical staff regarding the elevated systolic blood pressure readings. Additionally, the nursing staff failed to clarify the parameters for the administration of the anti-hypertensive medications for Patient #16.

The surveyor conducted a face to face interview on 01/08/2020 at 11:58 AM, with Employee # 35, Attending Physician, regarding the elevated blood pressure measurements, and the recommendations for blood pressure monitoring, as signed off on 12/18/19. When queried about the recommendations from the NP (Nurse Practitioner) for bp monitoring, Employee # 35 stated: "It is the responsibility of the Internet Technology (IT) department, and they should be working with the medical director to ensure indications for bp medications are printed on the Medical Administration Record (MAR), for staff to follow directions, we are working on that".

At the time of the interview with Employee # 35, Attending Physician, confirmed the finding.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


1. Based on medical record review, policy review and staff interview, hospital staff failed to complete the Master Treatment Plan (MTP) within 72 hours of admission for five of five records reviewed (Patients #20, #21, #22, #23, and #24).

Findings included ...

Record review of the hospital policy titled, "Multidisciplinary Treatment Planning", dated 07/19, and showed that the "Treatment Team Members" will complete the Master Treatment Plan (MTP) within 72 hours of admission.

A. The physician admitted Patient #20 on 12/14/19 with diagnoses to include Bipolar and Unspecified Depression.
The medical record lacked a Master Treatment Plan within 72 hours of the patient's admission.

B. The physician admitted Patient #21 on 1/4/2020 with diagnosis to include Unspecified Depression Disorder.
The medical record lacked a Master Treatment Plan within 72 hours of the patient's admission.

C. The physician admitted Patient #22 on 12/7/19 with diagnosis to include Depression, Bipolar Disorder, and Post Traumatic Stress Syndrome.

The medical record lacked a Master Treatment Plan within 72 hours of the patient's admission.

D. The physician admitted Patient #23 on 12/07/19 with diagnosis to include Major Depressive Disorder, Epilepsy, Attention Deficit Hyperactivity Disorder and history of inappropriate sexual behavior.

The medical record lacked a Master Treatment Plan within 72 hours of the patient's admission.

E. The physician admitted Patient #24 on 01/06/2020 with diagnosis to include Major Depressive Disorder, Sedative/Hypnotic Use Disorder.

The medical record lacked a Master Treatment Plan within 72 hours of the patient's admission.

There was no evidence that the treatment team members completed a Master Treatment Plan for Patients #20, #21, 22, #23, and #24 in accordance with hospital policy.

The surveyor conducted a face-to-face interview with Employees #29, Nurse Manager, #28, Charge Nurse, and Employee #27, Clinical Coordinator, on 01/09/2020 at approximately 3:00 PM, regarding the aforementioned findings. Employee #27 stated the assigned clinical coordinator had resigned. The unit is being covered by different coordinators, which has caused the delay in initiating the master treatment plans for patients, within 72 hours. All confirmed the findings at the time of the medical record reviews.

2. Based on medical record review, policy review and staff interview, nursing staff failed to develop an individualized care plan to address the needs of a patient with a history of elopement, three patients with a history of substance in four of four records reviewed (Patients #27, #38, #40, and #39).

Findings included...

Record review of the hospital policy titled, "Inpatient Documentation Requirements," dated 08/17, showed that the nursing staff will complete the initial nursing treatment plan within four hours of admission and document the initial plan for nursing care of each patient admitted to the hospital, to include both psychiatric and medical concerns.

Record review of the hospital policy titled, "Continuous Nursing Assessment," dated 08/17, showed that the "nursing staff develops the initial treatment plan to identify issues and guide treatment ...specific to the individual patient's health care needs."

The physician admitted Patient #27 with diagnoses to include Unspecified Schizophrenia Spectrum Disorder,
Review of the medical record revealed on the physician's history and physical, that patient had a history of elopement.

A. According to the physician's orders dated 10/31/19 at 2:00 PM, directed the patient to be placed on elopement precautions.

Further review of the medical record showed that nursing staff did not develop a plan of care, with goals and intervention, to address the patient's history of elopement.

The surveyor conducted a face-to-face interview on 01/09/2020, at approximately 2:00 PM, with Employee #6, Chief Nursing Officer, regarding the development of a care plan related to elopement. She acknowledged the findings at the time of the record review.


B. A review of the medical record for Patient # 38 on 01/09/2020 at approximately 11:15 AM with Employee # 16 Nurse Manager, showed the patient was admitted on [DATE], with a diagnosis of alcohol and heroin use disorder, seeking detoxification. Review of the Initial Nursing Treatment Plan, dated 01/07/20, showed Substance Abuse as blank.

The practice lacked evidence that the nursing staff identified substance abuse as a nursing treatment plan for Patient #38, who was admitted for alcohol and heroin abuse.

At the time of the medical record review, Employee #16 confirmed the findings.

C. Review of the medical record for Patient # 40 on 01/09/2020 at approximately 12:15 PM, with Employee # 16 Nurse Manager, showed the patient was admitted on [DATE] with diagnoses to include Asthma, Depression, Alcohol, Heroin use disorder, and Suicidal Ideation.

Review of the Initial Nursing Treatment Plan, dated 01/07/2020, failed to identify: Substance Abuse, as part of the nursing treatment plan.

The practice lacked evidence that the nursing staff identified Suicidal/Self-Injurious, Mood Disturbance, and Substance Abuse, as part of the nursing treatment plan.

Employee # 16 confirmed the findings at the time of the medical record review.

D. Review of the medical record for Patient # 39 on 01/09/2020 at 11:45 AM with Employee # 16, Nurse Manager, showed the patient was admitted on [DATE] with Heroin use disorder. Review of the Initial Nursing Treatment Plan showed Substance Abuse as blank.

The practice lacked evidence that the nursing staff identified Substance Abuse, as part of the nursing treatment plan.

Employee # 16 confirmed the findings at the time of the medical record review.
VIOLATION: PHARMACY DRUG RECORDS Tag No: A0494
Based on a review of hospital documents to include floor stock, Schedule II, III, IV, and V Controlled Substance Transactions by patient report, physicians' orders, and the Medication Administration Record [MAR] and staff confirmation, the hospital staff failed to properly document the administration or handling of controlled substances, in four of sixteen records reviewed (Patients #10, #50, #53, #54).

Findings included ...

On 01/08/20, the surveyor reviewed the event report for floor stock controlled substances schedule II-V, a seventy-two (72) for Patient Care Units: 1, 2, 3, 4, 5 and 8. All patients were randomly selected for this audit. The survey of records was started on 01/08/2020 at approximately 11:00 and was completed on 01/09/2020, at approximately 11:00.

On 01/02/2020, at 10:01AM, the physician ordered Concerta 72 mg (milligram), every morning for Attention-Deficit/Hyperactivity Disorder (ADHD), for Patient #10, on Unit 8. On 1/2/2020, at 08:44, one dose was removed and not administered to the patient. However, the medication was returned at 16:00 to Unit #7, over 8 hours later.

On 01/01/2020, at 16:44, the physician ordered Lorazepam 2 milligrams intramuscularly (IM) once for agitation for Patient #50, on Unit 1. On 01/01/2020, at 17:00, one dose was removed and administered at 01:02. The dose was administered over eight hours later.

On 12/26/19, at 13:00, the physician ordered Methadone 90 mg, by mouth once daily, for Patient #53, on Unit 4. On 12/26/19, 90 mg of Methadone was removed; however, the nursing staff failed to document the time of removal.

On 01/02/2020, at10:10, the physician ordered Lorazepam 2 mg intramuscularly (IM) once for anxiety for Patient #54, on Unit 3. On 01/02/2020, at 10:10, one dose was removed; however, there was not documentation of administration or dispositioning of the controlled substance.


Employee #9, Director of Pharmacy acknowledged the findings.
VIOLATION: ORGANIZATION Tag No: A0619
Based on observations and during the survey, it was determined that dietary services were not adequate, to ensure that foods are prepared and served in a safe and sanitary manner. These findings were observed and acknowledged in the presence of Employee # 11, Director of Dietary services on 01/07/2020.

Findings included ...

1. Cutting boards used in the cooks preparation area of the main kitchen, were worn and had deep groove in the board surfaces in the following instances: 3 Green, 1 Brown and 1 Red.

2. Ceiling tile grids exhaust and air supply vents, were soiled with dust in the main kitchen over the cooking areas.

3. During a Test Tray observation on Unit APS 3, on 01/09/2020, patients hot food temperatures were below 140 degrees Fahrenheit, in the following instances: Cardiac Diet-Turkey Meatball 107 degrees Fahrenheit, Chicken Breast 107 degrees Fahrenheit; Noodles 107 degrees Fahrenheit; Vegetable Blend 109 degrees Fahrenheit. ADA (American Diabetic Association) Diet-Meatballs 118 degrees Fahrenheit and Vegetable Blend 107 degrees Fahrenheit.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observations during the survey, it was determined that housekeeping and maintenance services were not adequate; to ensure that the facility is maintained in a safe and sanitary manner. These findings were observed in the presence of Employee # 10, Director of Facilities, on 01/07/2020.

Findings included ...

1. The following findings were observed during a tour of the 3rd Floor, at 3:35 PM, on 1/07/2020 in the presence of Employee #10.

A. The lower shower walls were soiled and a penetration was observed between the wall and floor surfaces in Rooms 302 and 306.

B. The interior surfaces of the overhead lamp was soiled, in Room 306.

C. Window sill surfaces were cracked, and a -inch space was present between the window sill, and the frames, in Rooms 303, 305, 330, and the Kitchen.

D. The base surfaces of the toilet was soiled and in need of re -caulking; shower curtain hooks were disconnected from the track; and walls and baseboard surfaces were damaged in Room 302.

E. The Linen Closet and Washer areas, on the ICU Unit lacked signage on the exterior walls.

F. A one-half inch gap was observed between the window sill, and the frame; the interior surface of the exhaust vent were soiled with dust in Room 300.

G. A three fourth inch space was observed between the window sill and window frame surfaces in the Kitchen and Day Room.

H. Floor and wall surfaces were marred in the Kitchen.

I. Several small penetrations were observed in wall surfaces in the Medication Room.

J. Exhaust vent surfaces were rusty and wall surfaces were marred, in the Housekeeping Closet on Unit 2.

K. Wall surfaces were marred and damaged with graffiti in the Seclusion Room.

L. Shower wall surfaces were damaged above baseboard surfaces, shower curtains were soiled on the lower surfaces and the hot water was inoperable in Room 331.

M. A one-half gap was observed between the frame and window sill. The hot water temperature was 73 degrees Fahrenheit, below the required minimal temperature of 105 degrees Fahrenheit. A small penetration was observed between the shower floor and wall, and the caulking around the base of the toilet was soiled in Room 330.

2. The following findings were observed during a tour of the 4th floor, on 01/08/2020 at 9:25 AM, in the presence of Employees # 10, Director of Facilities and #13, Program Director.

A. Floor surfaces were marred, window sill surfaces were rusty, and exhaust vents were dusty in the Day Room.

B. Graffiti was noted on window sills; a penetration was observed between the shower walls and floor surfaces in Room 405.

C. A baseboard was not secured near the toilet in the shower area, in Room 404.

D. Floor tiles were missing at the entrance, and door jambs were rusty on the lower surfaces at the entrance to the bathroom, and baseboards were not secured to the wall surfaces in Room 402.

E. The linen closet in the hallway lacks signage to identify the room's usage.

F. Baseboards, walls, and the laminate counter top in the rear of the washer and dryer was damaged, and the room lacked signage to identify its usage.

G. Floor surfaces were marred; sofa seat and back surfaces were worn and torn and wall surfaces were damaged near the window, in the 4th Floor Day Room.

H. Floor surfaces were marred, baseboards were missing along the north wall in the Kitchen.

I. The exhaust vent was soiled on the interior and exterior surfaces in the toilet room, and wall surfaces and doorjambs were stained and marred, in the Nurses Station Charting Area.

J. Toilet door surfaces were marred. The hot water temperature was measured and determined to be 57 degrees Fahrenheit, below the required minimal temperature of 105 degrees Fahrenheit, in Room 431.

K. The housekeeping closet lacked signage, to identify the room's usage.

L. The Laundry Room near Room 434, lacked signage on the exterior wall to identify its usage.

M. Baseboard surfaces were stained, and shower floors and walls were damaged in Room 435.

N. Wall surfaces were marred in the 4th Floor Kitchen, near the refrigerator.

O. The Medication Treat Room, lacks signage on the exterior walls, and splatters were observed on the ceiling speaker.

3. The following findings were observed during a tour of the 5th Floor, at 9:30 AM on 01/08/2020, in the Presence of Employees #10, #13, and #14, Program Director.

A. Floor surfaces were marred, and ceiling tiles were not secured into grids, in the Day Room.

B. The threshold was missing at the entrance to the shower/toilet area, the shower and wall were in need of repair, and the hot water temperature was 83 degrees Fahrenheit, below the minimum recommended temperature of 105 degrees Fahrenheit, in Room 509.

C. The bathroom door jamb was rusty on the lower surfaces; baseboard surfaces were not secured; the seat cover was not secured to the toilet. The hot water temperature was measured and determined to be 62 degrees Fahrenheit, below the minimum required temperature of 105 degrees in Room 507.

D. Window sill surfaces were in need of re-caulking, graffiti was on wall surfaces, floor surfaces were marred. Hot water temperature were measured and determined to be 85 degrees Fahrenheit, below the minimum required temperature of 105 degrees Fahrenheit, and the exhaust vent cover was rusty in in Room 505.

E. Signage was not posted outside of the Linen Room, to identify the usage; a large opening approximately 3 feet by 3 feet were observed in the rear of the washer and dryer.

F. Window sill surfaces were in need of re-caulking; baseboards were separated in front of sink cabinets in the 5th Floor Kitchen.

G. Wall and door surfaces were marred and damaged in the in the Medication Room.

4. The following findings were observed on the 5th Floor, at 2:00 PM on 01/08/2020 in the presence of Employees # 10 and #14.

A. The overhead lamp covers were stained; the exhaust vent cover was soiled with dust, in the toilet area in the 5th Floor Nurses Station.

B. Hallway floors were soiled on the perimeter of the outer Nurses Station.

C. Floor tile surfaces were stained, in the hallway, and on the exterior of the outer Nurses Station.

D. Floor tiles at the entrance to the bathroom were damaged. The hot water temperature was 71 degrees Fahrenheit, below the required minimum temperature of 105 degrees Fahrenheit in Room 534.

E. Sprinkler lacks a cover, door surfaces were marred, and the escutcheon ring cover was missing, creating a penetration in the ceiling surfaces in the Seclusion Room.

F. Wall surfaces were marred and marks was on the exterior of the ceiling lamp cover in Room 537.

5. The following findings were observed during a tour of the Unit 4 Nurses Station, at 3:45 PM on 01/08/2020 in the presence of Employees # 10 and 13.

A. Multiple electrical and computer wires were comingled on the counter and floor surfaces; and printer paper were on the floor in Nurses Stations Units 1, 4, 5 and 8. These observations were made in the presence of Employee #10 between 9:30 AM and 10:00 AM on 01/09/2020.

6. A multiple outlet strip was on the floor, instead of mounted on the wall, and floor surfaces were stained in the Nurses Station, on Unit 5. These observations were made in the presence of Employee #10 at 9:55 AM on 01/09/2020.

7. A multiple outlet strip was on the floor, instead of mounted on the wall in the Medication Room, and the hot water temperature at the sink in the bathroom, was 75 degrees Fahrenheit, below the required minimum temperature of 105 degrees Fahrenheit. These observations were made on Unit 7, in the presence of Employee #10 at 10:15 AM on 01/09/2020.

8. Staff personal book bags were located on the floor under the counter in the Nurses Station on Unit 2. This finding was observed in the presence of Employee #10 at 10:40 AM on 01/09/2020.

9. Paper bags were improperly stored on the floor, under the counter in the ante-area of the Unit 3 Nurses Station. This observation occurred at 11:05 AM on 01/09/2020, in the presence of Employee #10.





Based on observation, hospital policy review, and staff interview, the hospital staff failed to secure soiled linen as required by hospital policy, in one of one observations.

Findings included ...

The surveyor reviewed the hospital policy titled, "Handling and Transport Used Linen", dated 09/19, which shows "Keep linen hamper covered until hamper is full".

Review of the hospital's training manual, titled, "The Employee Training Topic: Ligature Risks and Mitigating Strategies," showed to reduce the risk of self- injurious behavior and increase safety in patient care areas, under access to linen: "for safety, we must limit patient's access to linen. This includes towels, blankets, and sheets. Having free access to linen can pose a safety concern as patients can use linen to strangulate, injure themselves or others."

The surveyor conducted a tour of Unit 2 Intensive Care Unit (ICU) on 01/07/2020, at approximately 11:30 AM, with Employees # 6, Chief Nursing Officer (CNO), and #12, Program Director. The surveyor observed a half-filled linen cart, unattended, unsecured, and without a covering in a hallway. The surveyor queried the Employees regarding the uncovered, unsecure, unattended dirty linen cart. Employee # 12 responded that the cart should be covered, and not left in the hallway alone, and normally is kept in the locked laundry room.

The practice lacked evidence that the hospital staff followed hospital policy and Employee Training, relative to used linen, regarding ligature risks and mitigating strategies.

Employees # 6 and 12 confirmed the findings at the time of the observations.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
1. Based on observations and review of the generator logs during the survey, the facility documentation failed to show that the emergency generator was tested , serviced and exercised as required.

Findings included...

Diesel generator sets in service shall be in service shall be exercised, at least once monthly, for a period of 30 minutes, under operating temperature conditions, at not less than 30 percent of the nameplate load.

During a review of the emergency generator logs, it was determined that the Emergency Generator, was not exercised for 30 minutes each month, under load as required. The logs indicate that the generator was exercise three-tenths (.3) of an hour 18 minutes; instead of the required, five-tenths (.5) of an hour, 30 minutes under load. The odometer readings from the logbook, verify that the Emergency Generator Log, was not exercised for a full 30 Minutes at 10:30 , 01/04/19 and 12/06/19. NFPA 110, Standard for Emergency and Standby Power Systems; Sections 8.4.2, and 8.4.2.3.

Employee #10, Director of Facilities, on 01/15/2020 at approximately 11:30 AM confirmed the findings at the time of the review of the generator logs.







2. Based on observation, hospital policy review, and staff confirmation, the hospital staff failed to ensure the emergency medical equipment was readily available for use in an emergency, in two of three observations.

Findings included ...

A review of the hospital's policy number NSG.165, titled "Emergency Medical Equipment", dated 03/01/19, showed that the Registered Nurse on the night tour, (7 PM- 7 PM) tour is responsible for completing the Daily Emergency Equipment Checklist. Responsibilities include checking for the presence of a breakaway lock. If the lock is broken or missing, the 7 PM- 7AM nurse shall check the cart to confirm that all the equipment is present, clean, and not outdated. In addition, the nursing supervisor shall be contacted for replacement.

During a tour of the Clinical Admission Center (CAC) Unit on 01/10/2020 at approximately 3:21 PM, in the presence of Employee # 8, Director of Admissions, the surveyor requested to see the contents of a locked closet located in the hallway of the unit.

The surveyor observed inside the locked closet an emergency code cart without a breakaway lock, and the drawers were partly open and unsecure.

Review of the 'Emergency Equipment Daily Checklist' dated for the month of January 2020, showed nursing staff initials for 01/10/2020, indicating that the breakaway locks were intact and the cart was readily available for emergency use.

The practice lacked evidence that the staff followed the hospital's policy for management of the emergency medical equipment.

The surveyor conducted a face-to-face interview with Employee #8, Director of Admissions, on 01/10/2020, at approximately 2:00 PM, regarding the aforementioned findings. She provided supportive documentation that showed the cart was last used on 01/08/2020 at 4:21 PM.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
1. Based on medical record review, policy review, and staff interview, hospital staff failed to follow through on admission tuberculosis screening forms to prevent the spread of infection in four of five medical record reviews (Patients #13, #17, #19 and #33).

Findings included ...

Record review of the hospital policy titled, "Tuberculosis Control Within the Hospital," dated 09/17, showed that on admission, The Clinical Assessment Center staff use a "Tuberculosis Screening" form for identification of potential TB infection. "It is the attending physician's responsibility to refer the patient accordingly. Criteria for referral to a local medical hospital or private physician (a) 4 or more yes responses with a history of TB or exposure to TB, (b) 4 or more yes responses with a high risk for TB, (c) 5 or more yes responses without a history of tuberculosis or exposure tuberculosis. Notify the Nursing Supervisor and the Infection Control Nurse. It is the responsibility of the Infection Control Nurse to follow up on this person for possible exposure of tuberculosis to the staff ..."

A. The physician admitted Patient #13 with diagnoses to include Hypertension, Diabetes, and Schizophrenia.

A review of the medical record revealed a Tuberculosis Screening form [undated], with Patient #13's identification label in the upper right hand corner. The form lacked documented evidence that the nursing staff completed the form.

B. The physician admitted Patient #17 with diagnoses to include Depression, Type II Diabetes, and Vitamin D Deficiency.

A review of the medical record revealed a Tuberculosis Screening form [undated] lacked documented evidence that nursing staff completed the form.

C. The physician admitted Patient #19 with diagnoses to include Unspecified Psychotic Disorder. A review of the medical record revealed a Tuberculosis Screening form dated 09/19 at 10:30 PM, lacked documented evidence that nursing staff completed the form.

The practice lacked evidence that the nursing staff followed hospital policy, related to minimizing the risk of infections for Patients #13, #17, and #19.

The surveyor conducted a face-to-face interview on 01/08/2020 at approximately 10:30 AM with Employees#12, Program Manager and Employee #16, Charge Nurse regarding the aforementioned findings. Both confirmed the findings at the time of the medical record review.


D. Review of Patient #33's medical record 01/14/2020 at approximately 11:49 AM showed it did not contain documented evidence of a tuberculosis screening, nor a tuberculosis skin test.

The surveyor requested the patient's tuberculosis information from a previous hospital encounter, but the patient's last medical record did not contain up to date information per Employee #5, Director Quality.

The practice lacked evidence that the medical and clinical staff followed the hospitals Tuberculosis control policy.

The surveyor reviewed the findings with Employee #5, who confirmed the findings at the time of the medical record review.

A review of the Infection Control Program lacked evidence that practices were followed as stipulated in the hospital's policy for monitoring the completion of patients' tuberculosis screening form(s) upon at admission.

Findings were confirmed with Employee #18, Infection Preventionist.







2. Based on observation, policy review, and staff interviews, the hospital staff failed to follow acceptable standards as to prevent the spread of infection, relative to the storage of linen in two of two observations.

Findings included...

Review of the hospital's policy, Number INF.048, titled, "Transport of Clean Linen", revised 08/16, and showed that staff will check clean linen carts to make sure that linen are properly covered.

The surveyor conducted a tour of Unit 6 on 01/07/2020 at approximately 10:45 AM, in the presence of Employees #13, the Program Director and #23, a Registered Nurse. The surveyor observed a linen cart with clean linen, partially covered, in the nursing station, opposite Room #438. Employee #23 immediately covered the cart.

On 01/07/2020 at 2:30 PM, in the presence of Employees #13, and #23, the surveyor observed the same linen cart with clean linens in the nursing station, partially covered.

In response to the surveyor's query regarding the storage of the linen carts. Employee #23, stated that Unit 6 does not have a particular area that is designated for storage of the clean linen carts.

The practice lacked evidence that the staff followed hospital policy for the storage of clean linen.

Employees #13 and 23, confirmed the findings at the time of the observations.