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.

ACCESS HOSPITAL DAYTON, LLC 2611 WAYNE AVENUE DAYTON, OH 45420 Jan. 15, 2020
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, staff interview and record review it was determined the facility failed to protect and promote patient rights by the failure to obtain informed consent prior to the administration of psychotropic medications (A131) and the failure to ensure all patients receive care in a safe setting (A144). The systemic effect of these practices resulted in the facility's inability to ensure the safety of all patients admitted to the inpatient psychiatric facility. The facility census was 36 patients.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview it was determined the facility failed to ensure the patient's right to informed consent was obtained prior to the administration of psychotropic medications. This affected one (Patient #1) of ten medical records reviewed. The active census was 36.

Findings include:

Review of the Informed Consent For Treatment Policy No. ADM-200.26 ( Revised 02/01/2019) states it is the responsibility of all Licensed Independent Practitioner (LIP) to explain the rationale for prescribing medications and other forms of treatment to the patient, along with information concerning side effects and treatment alternatives. LIP are expected to document the provision of this information to the patient in the clinical record and evidence of the patient's consent to treatment.

Review of the medical record for Patient #1 revealed the patient was voluntarily admitted on [DATE] for depression, anxiety, and substance abuse. Review of the physician's orders and the medication administration record from 11/17/9 through 11/23/19 revealed the following psychotropic medications were ordered and administered.

1. Seroquel 100 mg by mouth twice daily ordered on [DATE]

2. Seroquel 600 mg by mouth at night ordered on [DATE]

3. Remeron 15 mg by mouth at night as needed ordered on [DATE]

4. Vistaril Pamoate 25 mg by mouth every four hours as needed ordered on [DATE]

5. Zyprexa 5 mg by mouth for times daily as needed ordered on [DATE]

6. Geodon 20 mg by mouth every morning ordered on [DATE]

7. Geodon 20 mg by mouth twice daily with meals 11/19/19

8. Geodon 80 mg by mouth twice daily ordered 11/20/19

9. Geodon 40 mg by mouth every night ordered 11/21/19

10. Geodon 40 mg by mouth twice daily with meals ordered 11/21/19

Staff F confirmed on 01/13/2020 at 1:46 PM no informed consent for psychotropic medications was obtained prior to administration of the medications.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation of the psychiatric inpatient unit (s), record review and staff interview it was determined the facility failed to ensure the safety of Patient #1 by increasing the level of monitoring for patients verbalizing suicide ideation and inventoring patient belonging's for contraband on admission. In addition, the facility failed to ensure a safe environment for care regarding safety hazards on the inpatient psychiatric units. This finding has the potential to affect all patients receiving care in this facility. A total of ten medical records were reviewed. The active census was 36.

Findings include:


Observation of the acute and dual diagnosis units on 01/15/2020 noted moveable furniture on the units that can be used to barricade and/or be used as a weapon against patients or staff. Staff I confirmed the following items on the units as moveable/and or not secured. Unit 52 has twenty-five moveable patients beds and fourteen dressers. Unit 53 had twenty-one moveable patient beds, two dressers, twelve tables in the dining area with thirty-four chairs.

Observation of the staff identification badges were noted to have a draw string that could potentially be used for strangulation of staff and/or other patients.

Review of the medical record for Patient #1 revealed the patient was voluntarily admitted on [DATE] for depression, anxiety, and substance abuse. Diagnoses included bipolar disorder with current episode manic without psychotic features, anxiety disorder, post traumatic stress disorder, and cannabis use. The patient verbalized depression and sadness, increased anxiety, not sleeping well and mood swings with anger. Review of the initial psychiatric evaluation on 11/18/19 noted the patient denied suicidal ideation. The psychiatrist ordered 15 minute safety checks at this time.

Review of the evening nurse shift assessment on 11/22/19 at 8:30 PM noted Patient #1 was observed sitting on the bed reading a bible. At 12:45 AM Patient #1 entered the nurses station demanding scissors and verbalized wanting to kill his/her self by cutting tongue off. At 1:37 AM the nurse noted blood on the patient's left wrist and forehead from self-injurious behaviors (unknown how patient self-injured). At 1:45 AM the nurse observed the patient biting the tops of his/her hands, at 1:47 AM the nurse was preparing for a restraint, and at 1:49 AM the mental health technician called a code blue. Patient #1 was reported as cyanotic with pages of the bible in mouth with jaws clenched tightly. A code blue was initiated until emergency medical services arrived. Patient #1 was transferred to a local hospital and later expired.

Per Staff F on 01/13/2020 at 9:38 AM. the patient's level of monitoring was not increased when the patient verbalized suicidal ideation.

A review of the internal investigation documents that were provided by the facility noted the witness statements were dated 12/23/19 and each staff member noted on 11/23/19 the patient was shoving pages of a bible down his/her throat. Staff F stated the witness statements were reviewed and based off of video footage reviewed by the facility.

A request was made for the original written witness statements dated 11/23/19 which were provided. Review of the original witness statements for the internal investigation that occurred on 11/23/19 noted staff reported the patient had contraband items that included crayons and hygiene products and was shoving the items down the throat. In comparison of the 11/23/19 and 12/23/19 statements the contraband items available to the patient was left out of the 12/23/19 witness statements.

During a follow up interview on 01/17/20, Staff G confirmed the contraband items in the original 11/23/19 witness statements was not included in the revised witness statements dated 12/23/19.

Review of the Admission/inventory process revealed all belongings will be inventoried on admission. The medical record for Patient #1 lacked evidence the patient's belongings were inventoried upon admission as required. per policy.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on interview and record review it was determined the facility failed to ensure nursing staff increased the level of monitoring for suicidal patients, failed to ensure psychiatric nursing admission assessments and suicidal risk assessments were completed by a registered nurse, failed to ensure ongoing assessment was documented for a code blue medical emergency and failed to ensure nursing monitored blood glucose levels for diabetic patients. (A395) The cumulative effects of these systemic practices resulted in the facility's inability to ensure effective nursing practice to meet patient needs and promote patient safety. The facility census was 36 patients.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview it was determined the facility failed to ensure nursing staff increased the level of monitoring for suicidal patients, failed to ensure psychiatric nursing admission assessments and iniitial suicide risk assessments were completed by a registered nurse, failed to ensure nursing staff completed the code blue emergency medical documentation, failed to ensure nursing monitored blood glucose levels for diabetic patients. This affected seven ( Patient's #1, #3, #4, #5, #7, #9, #10) of ten medical records reviewed. The active census was 36.

Findings include:

Review of the Nursing Admission Assessment policy number NUR-7:003, last revised on 02/01/2019 revealed the purpose of this policy is ensure that a nursing assessment is completed by a registered nurse on each patient at the time of admission and no later than 24 hours to ensure that accurate and consistent information is gathered.

1. Review of the medical record for Patient #1 revealed the patient was voluntarily admitted to the inpatient psychiatric hospital on 11//17/19 for diagnoses to include depression, anxiety, and substance abuse, and type 2 diabetes. On 11/23/19 the patient reported suicidal ideation to the registered nurse and the level of monitoring was not increased to ensure the safety of the patient. The patient later began ingesting pages of a bible which resulted in airway obstruction and a code blue was initiated. The medical record lacked evidence of nursing documentation of the patient's medical condition such as vital signs for the code blue emergency. On admission the medical record noted a blood glucose level of 384 on 11/17/19 and none thereafter. In addition, the medical record lacked a nursing progress note for the morning of 11/18/19.

These findings were confirmed with Staff F on 01/13/2020 at 9:38 AM.

2. Review of the medical record for Patient #4 revealed the admitted was on 12/10/19. The initial nursing assessment dated [DATE] revealed the diagnoses was including unspecified bipolar, related mood disorder, and Methamphetamine use disorder. The patient was pink slipped to the hospital and was identified as being suicidal and then discharged on [DATE]. Further review of the medical lacked documented evidence of an initial nursing assessment or an initial suicidal risk assessment.

This finding was confirmed with Staff F on 01/10/2020 at 4:00 PM.

The following medical records lacked evidence a registered nurse performed the initial nursing assessment.

3. Review of the medical record for Patient #3 revealed the admitted was on 01/04/2020. The initial nursing assessment dated [DATE] revealed the diagnoses was including bipolar, depression, anxiety, substance abuse, and was previously hospitalized for mental health condition. Further review of the initial nursing assessment revealed the assessment was completed by a licensed practical nurse (LPN) and not a registered nurse (RN).

This finding was confirmed with Staff F on 01/10/2020 at 4:00 PM.

4. Review of the medical record for Patient #5 revealed the admitted was on 11/17/19. The initial nursing assessment dated [DATE] revealed the diagnosis was including increased aggression resulting from vascular dementia. Further review of the initial nursing assessment revealed the assessment was completed by an LPN and not and RN.

This finding was confirmed with Staff F on 01/10/20 at 4:00 PM.

5. Review of the medical record for Patient #7 revealed the admitted was on 12/18/19. The initial nursing assessment dated [DATE] revealed the diagnosis was including suicidal ideation and wanted to kill himself and was considered high risk for suicide. Other diagnoses are including bipolar, schizoaffective and paranoia. Further review of the initial nursing assessment revealed the assessment was completed by an LPN and not an RN.

This finding was confirmed with Staff F on 01/10/20 at 4:00 PM.

6. Review of the medical record for Patient #9 revealed the admitted was on 12/30/19. The initial nursing assessment dated [DATE] revealed the diagnoses was including suicidal ideation, homicidal ideation, lack of sleep, excessive worrying, lack of interest, schizophrenia, agitation, hypersomnia, aggressiveness physically, verbally and sexually, auditory hallucination, memory loss, speech changes, wandering stress, emotional abuse, marital problems, in law problems, dementia, uncontrolled depression, uncontrolled anxiety, weight and appetite changes, hopelessness and emotional distress. Further review of the initial nursing assessment revealed the assessment was completed by an LPN and not an RN.

This finding was confirmed with Staff F on 01/10/20 at 4:00 PM.

7. Review of the medical record for Patient #10 revealed the admitted was on 08/07/19. The initial nursing assessment dated [DATE] revealed the diagnoses was including mood disturbances, agitation, aggressiveness physically and verbally, abnormal behaviors, stress and psychiatric illness, suicidal and homicidal ideation. Further review of the initial nursing assessment revealed the assessment was completed by an LPN and not an RN.

This finding was confirmed with Staff F on 01/10/20 at 4:00 PM.
VIOLATION: CONTENT OF RECORD - DISCHARGE SUMMARY Tag No: A0468
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview it was determined the facility failed to ensure a discharge summary was completed following a patient death. This affected one ( Patient #1) of ten medical records reviewed. The active census was 36.

Findings include:

Review of the Discharge Summary Policy and Procedure number CLI-022 ( Revised 02/01/2019) states it is the policy of the hospital to complete a discharge summary for each patient discharge. It is the responsibility of the physician to complete the discharge summary.


Review of the medical record for Patient #1 revealed the patient was voluntarily admitted to the inpatient psychiatric hospital on 11//17/19 for diagnoses to include depression, anxiety, and substance abuse. The patient was transferred to a local hospital on [DATE] for presence of a foreign object in the airway. The facility was notified on 11/23/19 the patient had expired at the hospital. The medical record lacked evidence a discharge summary was completed as per policy.

This finding was confirmed with Staff F on 01/13/2020 at 1:46 PM.