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.

FREEDOM BEHAVIORAL HOSPITAL OF TOPEKA, LLC 1334 SW BUCHANAN STREET TOPEKA, KS 66604 April 30, 2019
VIOLATION: MEDICAL STAFF RESPONSIBILITIES Tag No: A0358
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on staff interview, record review, document and policies and procedures review the hospital failed to ensure the medical staff Bylaws included a requirement for a History and Physical (H&P) to be documented in the medical record less than 30 days before admission or within 24 hours after admission.

This deficient practice has the potential to cause a disruption in the continuity of care for 11 of 20 patients (Patients 2, 3, 5, 9-11, 14-15, and 18-20) admitted between 09/01/18 to 04/22/19 which could lead to poor patient outcomes.

Findings Include:

Document review of the hospital's "Medical and Professional Staff Organization Bylaws," adopted on 12/12/16, showed the hospital failed to include a provision requiring H&Ps to be completed and documented in the medical record less than 30 days prior to admission or within 24 hours after admission.

Patient 2's medical record review showed he was admitted on [DATE] and a H&P transcription was not completed for placement in the medical record until 04/01/19 which is greater than 24-hours after admission.

Patient 3's medical record review showed he was admitted on [DATE] and a H&P transcription was not completed for placement in the medical record until 03/28/19 which is greater than 24-hours after admission.

Patient 5's medical record review showed he was admitted on [DATE] and a H&P was signed and dated 09/28/18 which is greater than 24-hours after admission.

Patient 9's medical record review showed he was admitted on [DATE] and a H&P transcription was not completed for placement in the medical record until 02/10/19 which is greater than 24-hours after admission.

Patient 10's medical record review showed he was admitted on [DATE] and a H&P transcription was not completed for placement in the medical record until 03/24/19 which is greater than 24-hours after admission.

Patient 11's medical record review showed he was admitted on [DATE] and a H&P transcription was not completed for placement in the medical record until 04/10/19 which is greater than 24-hours after admission.

Patient 14's medical record review showed he was admitted on [DATE] and a H&P transcription was not completed for placement in the medical record until 04/22/19 which is greater than 24-hours after admission.

Patient 15's medical record review showed he was admitted on [DATE] and a H&P transcription was not completed for placement in the medical record until 04/22/19 which is greater than 24-hours after admission.

Patient 18's medical record review showed he was admitted on [DATE] and a H&P transcription was not completed for placement in the medical record until 04/22/19 which is greater than 24-hours after admission.

Patient 19's medical record review showed he was admitted on [DATE] and a H&P transcription was not completed for placement in the medical record until 04/18/19 which is greater than 24-hours after admission.

Patient 20's medical record review showed he was admitted on [DATE] and a H&P transcription was not completed for placement in the medical record until 04/12/19 at 11:23 AM which is greater than 24-hours after admission.

During an interview on 04/30/19 at 1:15 PM, Staff R, Medical Records, stated the expectation is that the providers must complete the history and physicals within 24-hours of the patient's admission. Staff R further stated that the providers complete the H&P and then it is sent for dictation prior to being placed into the medical record.
VIOLATION: LICENSURE OF PERSONNEL Tag No: A0023
Based on personnel file review, staff interview, and job description review, the hospital failed to ensure five of ten personnel had current Basic Life Support (BLS) certificates (Staff J, K, N, O, and Q). This deficient practice has the potential to place patients at risk for receiving ineffective cardiopulmonary resuscitation (CPR).

Findings Include:

Review of hospital documents titled "Job Description" with revision date of 10/01/17 showed: "Job Title: Director of Nursing" (DON) "Certifications, Licenses and/or Registrations Required: Cardiopulmonary Resuscitation (CPR)." "Job Title: Registered Nurses" (RN) "Certifications, Licenses and/or Registrations Required: Cardiopulmonary Resuscitation (CPR)." "Job Title: Licensed Practical Nurses" (LPN) "Certifications, Licenses and/or Registrations Required: Cardiopulmonary Resuscitation (CPR)." "Job Title: Mental Health Technician" (MHT) "Certifications, Licenses and/or Registrations Required: Cardiopulmonary Resuscitation (CPR)."

Review of Staff J, RN's personnel file showed no evidence of BLS certification.

Review of Staff K, RN, interim DON's personnel file showed an expired BLS certification.

Review of Staff N, MHT's personnel file showed no evidence of BLS certification.

Review of Staff O, MHT's personnel file showed her BLS certification expired 07/2018.

Review of Staff Q, MHT's personnel file showed no evidence of BLS certification.

During an interview on 04/30/19 at 9:00 AM, Staff S, Human Resource Director (HR) stated that staff should not be allowed to work on the floor if they do not have their CPR completed. She stated that they should not be working without it and that some staff have told her they have it and will email it to me, but she has not received them.

During an interview on 04/30/19 at 10:15 AM Staff B, Chief Executive Officer stated that he wasn't aware of Staff not having current CPR certification and he had not restricted any staff from working because of it.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observation, staff interview, document and record review, the hospital's Governing Body failed to ensure the hospital's operation was conducted in an effective, safe, and organized manner by: 1. Failing to ensure the physical environment was safe for the care and treatment of patients; 2. Failing to incorporate risk assessment findings from 07/2018 into the quality assessment and performance improvement (QAPI) program so it reflected the safety of all patients; 3. Failing to ensure medical staff bylaws include all required elements; 4. Failing to ensure the hospital had an ongoing infection control program; 5. Failing to ensure hospital personnel were trained, and had documentation of required health information; and 6. Failing to ensure the hospital was in compliance with 42 CFR 482.60, Condition of Participation: Special Provisions Applying to Psychiatric Hospitals, 42 CFR 482.61, Condition of Participation: Special Medical Record Requirements for Psychiatric Hospitals and 42 CFR 482.62, Condition of Participation: Special Staff Requirements for Psychiatric Hospitals.

These deficient practices have the potential to cause patients to receive care in an unsafe environment which could lead to patient harm.

Finding Include:

The hospital failed to ensure all personnel had current Basic Life Support (BLS) certification. (Refer to A-0023).

The hospital failed to maintain an environment free from ligature (hanging) hazards, for patients assessed at risk for harm to self or others. The hospital has a current census of seventeen, and of those, five have been assessed at risk for suicide (Patients 3, 13, 14, 16, and 17). Specifically, three patients assessed at risk for suicide were left unattended (Patients 3, 13, and 16), nine patients assessed as having assaultive/aggressive precautions had access to items that could be used to harm self or others (Patients 3, 11, 12, 13, 14, 16, 17, 18, and 19), eight of ten patients assessed as a suicide risk or placed on assaultive/violence precautions (Patients 6, 11, 14, 16, 17, 18, 19, and 20) did not have fifteen minute checks completed as ordered, and five of five patients with suicide precautions did not have their suicide precaution orders renewed or discontinued during their stay (Patients 3, 13, 14, 16, and 17). (Refer to A-0144).

The hospital failed to ensure development of an effective Quality Assessment Performance Improvement Plan that identifies high risk, high-volume problem prone areas including identified ligature risked and infection control practices specifically by not including ligature risks identified in a risk assessment and infection control issues in its ongoing quality improvement program (Refer to A-0283).

The hospital's Governing Body failed to ensure quality assessment and performance improvement efforts addressed priorities for improved quality of care and patient safety by not including ligature risked identified in a risk assessment and infection control issues in its ongoing quality improvement program. (Refer to A-0309).

The hospital failed to ensure the medical staff Bylaws included a requirement for a History and Physical (H&P) to be documented in the medical record less than 30 days before admission or within 24 hours after admission. (Refer to A-0358).

The hospital failed to ensure expired supplies were removed from patient use, failed to ensure that staff members (Staff J, RN) properly donned personal protective equipment (PPE) when providing wound care for one of one patients (Patient 25) and when passing medications for seven of seven patients (Patient 16, 17, 18, 22, 25, 26, and 27), failed to ensure one of one flushable basins and three of three observed air vents were clean, failed to ensure initial health examinations were completed for four of ten personnel records reviewed (Staff I, J, L, and Q), failed to ensure periodic health evaluations were completed for four of ten personnel records reviewed (Staff C, K, O, and P) , failed to ensure tuberculin (TB) skin tests or chest x-rays were completed for four of ten personnel records reviewed (Staff I, J, L, and Q) during new hire orientation; failed to ensure a TB test was provided annually for one of ten personnel files reviewed (Staff K); and failed to ensure immunization history for eight of ten personnel records reviewed (Staff C, I, J, K, L, M, N, and Q). (Refer to A-0749).


The facility failed to ensure the availability of a physician to provide psychiatric treatment and ensure oversight of the treatment and care of geriatric patients 50 years and older at the frequency, level, and intensity necessary for psychiatric hospitalization . Specifically, there was no physician on-site to provide, direct, review, and supervision psychiatric treatment. Instead, the only physician contact with patients for psychiatric care was via electronic telecommunication (a telemedicine process) once a week for approximately five to ten minutes per patient. Without consistent on-site supervision and direction of each patient's treatment, the patients' recovery may be compromised, potentially delaying their timely discharge. (Refer to B-0099)


The facility failed to ensure an adequate number of clinical staff to complete comprehensive assessments, provide ongoing active treatment, and document progress for the geriatric patient population served. In addition, Directors of Services failed to assure all care was appropriately completed and documented. Specifically, the facility failed to:

I. Provide an onsite physician responsible for psychiatric care and treatment of acutely ill geriatric patients and provide consistent oversight and supervision of psychiatric treatment on a regular basis. Instead, a psychiatrist saw patients for approximately five to ten minutes once per week via electronic telecommunication (a telemedicine process). This failure potentially delays the treatment of acutely mentally ill geriatric patients with appropriate psychiatric treatment and psychotropic medications. (Refer to B-0142).

II. Employ a Director of Nursing (DON) with a Master's Degree in Psychiatric Nursing, or alternatively assure the DON had necessary consultation with a qualified Psychiatric nurse or ongoing training. The DON did not have documented evidence of supervisory consultation from a nurse with a Master's degree in Psychiatric/Mental Health Nursing nor alternatively, did she have ongoing training in psychiatric/mental health nursing. This failure results in the facility not having a qualified nursing director to manage and monitor psychiatric/mental health nursing care of the patients. (Refer to B-0147).

III. Ensure that nurses documented verbal orders accurately on the form titled "Admit Orders / Preliminary Plan of Care." Specifically, telephone orders were recorded as being ordered by the psychiatrist when they were orders received from the APRN for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15). This deficient practice results in the lack of appropriate monitoring of medication orders resulting in falsified medical documentation. (Refer to B-0148).

IV. Provide an adequate number of Registered Nurses (RNs) to implement active treatment interventions, supervise paraprofessional staff, and monitor patients. The facility's staffing of RNs results in the lack of active treatment provided by registered nurses and limited direction and supervision of paraprofessional staff in the provision of psychiatric nursing care. (Refer to B-0150).

V. Ensure the availability of services by a licensed psychologist for the geriatric patients in its care. This deficiency potentially results in patients not receiving the full array of diagnostic and intervention services when needed, and patients' needs not being met in a timely manner. (Refer to B-0151).

VI. Employ a sufficient number of qualified therapeutic rehabilitation (TR) staff to plan and implement a structured therapeutic rehabilitation program especially after hours and on weekends for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15). This failure results in patients not receiving active treatment at the intensity and frequency necessary for psychiatric hospital treatment, potentially delaying recovery. (Refer to B-0158).

The facility failed to:

I. Ensure that the psychosocial assessment contained a comprehensive statement of conclusions and recommendations that included the social evaluation of psychiatric issues, anticipated role of the social worker in treatment during hospitalization , and projected steps in discharge planning for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A14). This failure hampers the ability of the treatment team to formulate appropriate social service interventions for patients. (Refer to B-0108)

II. Ensure that a neurological examination was completed for three (3) of nine (9) active sample patients (A1, A2, and A13.) For an additional three (3) active sample patients (A6, A9, and A15), the neurological document failed to include any information to verify the specific testing performed. This failure to document a neurological examination with specific testing compromises the identification of pathology for geriatric patients, which may be pertinent to their current mental illness and compromises future comparative re-examination to assess the patient's response to treatment interventions. (Refer to B-0109)

III. Ensure that psychiatric evaluations were performed by a physician and contained all the necessary information to justify the patients' diagnoses and planned treatment for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15). Instead, psychiatric evaluations for these patients were completed by an Advanced Practice Registered Nurse without comprehensive information and documented physician review. The failure to have the psychiatric evaluation completed with detailed information and provided under the direction of a physician potentially compromises the formulation of an accurate diagnostic view of the patient, thereby limiting the team's ability to develop a meaningful plan of care to meet the patient's individual psychiatric needs. (Refer to B-0110)

IV. Ensure that the psychiatric evaluations for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15) included comprehensive information regarding an estimate of intellectual functioning, memory functioning, and orientation. Lack of this necessary clinical information can negatively affect decision-making on the need of geriatric patients for further evaluation. (Refer to B-0116)

V. Include an inventory of each patient's personal assets such as accomplishments, skills, or interests written in descriptive and non-interpretative fashion for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15). This deficiency results in a lack of necessary information to guide in developing a plan of treatment for the patient. (Refer to B-0117)

VI. Develop and document comprehensive Master Treatment Plans (MTPs) for nine (9) of nine (9) sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15). Instead, MTPs were completed separately by each discipline using a preprinted document with treatment goals and interventions assigned by discipline. The physician and APRN were not involved in the development of the Master Treatment Plan. These deficient practices reflect a failure of collaborative input by all team members resulting in the potential to compromise patients' opportunity to receive appropriate treatment measures. (Refer to B-0118-I)

VII. Provide comprehensive Master Treatment Plans (MTPs) that were individualized and included all required components for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15). The MTPs were missing the following components:

A. Behaviorally descriptive strength statements and disability statements (called problems by the facility) to be used as the basis for developing treatment plans. (Refer to B-0119).

B. Observable and measurable goals based on each patient's presenting psychiatric symptoms and needs. (Refer to B-0121)

C. Individualized active treatment interventions with a method of delivery, frequency of contact and focus of treatment based on each patient's presenting psychiatric symptoms and needs. (Refer to B-0122).

D. Both the name and discipline of the staff responsible and accountable for each of the interventions identified in the Master Treatment Plan. (Refer to B-0123)

Failure to develop Master Treatment Plans with all the required components hampers the staff's ability to provide coordinated interdisciplinary care, potentially resulting in patient's treatment needs not being met.

VIII. Ensure that the physician responsible for psychiatric treatment wrote progress notes as stipulated by facility policy for nine (9) of nine (9) active sample patients (A1, A2, A3, A6, A8, A9, A10, A13, and A15) and five (5) non-sample active patients selected for review of physician progress notes (A4, A7, A11, A12, and A16). Instead, the APRN recorded and signed progress noted without documented physician review. These notes failed to include the progress or lack of progress related to the presenting psychiatric symptoms and rationale for medication orders and changes. The absence of comprehensive documentation of each patient's progress prevented an up to date picture of pertinent changes in the patient's psychiatric condition or response to changes in the medication. (Refer to B-0126)

IX. Ensure that discharge summaries were completed according to the facility's policy in providing timely discharge summary for three (3) of five (5) sampled discharged patients (D1, D3, and D4). This deficiency results in a failure to communicate in a timely manner psychiatric assessments and discharge plans to providers providing follow-up care. (Refer to B-0133)
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, staff interview and document review the hospital failed to maintain an environment free from ligature (hanging) hazards, for patients assessed at risk for harm to self or others. The hospital has a current census of seventeen, and of those, five have been assessed at risk for suicide. Specifically, three patients assessed at risk for suicide were left unattended (Patients 3, 13, and 16), nine patients assessed as having assaultive/aggressive precautions had access to items that could be used to harm self or others (Patients 3, 11, 12, 13, 14, 16, 17, 18, and 19), eight of ten patients assessed as a suicide risk or placed on assaultive/violence precautions (Patients 6, 11, 14, 16, 17, 18, 19, and 20) did not have fifteen minute checks completed as ordered, and five of five patients with suicide precautions did not have their suicide precaution orders renewed or discontinued during their stay (Patients 3, 13, 14, 16, and 17).

Refer to A-0144 for further details.

Findings Include:

Review of an undated document titled, "Patient Handbook" showed: ..."The hospital program has been set up to provide a safe environment where you can heal from recent life events and recover from your symptoms. Keeping the program safe and comfortable requires a cooperative relationship between all staff and patients on the program." Review of the Patient Rights contained in the handbook showed: ..."As a patient you have the right to:" ..."Be treated with consideration, dignity, and respect with care provided in a safe environment free from any form of abuse, neglect, exploitation, or harassment."

Review of a hospital policy titled, "Risk Assessment Program" effective 09/2016 and revised 09/2016, showed: "The performance improvement program for the Safety/Environment of Care Committee is designed to monitor the level of safety compliance at the hospital, and to identify any situations that detract from the goal of providing a safe and secure environment for patients, employees, medical staff and visitors. Any risks that are identified through proactive risk assessments, environmental tours, performance measure monitoring, etc., will be evaluated, and have procedures and controls put into place to reduce to the lowest possible point the adverse impact on the safety and health of patients, personnel, medical staff, and visitors of the hospital. For those cases, where appropriate and deemed necessary, the failure mode effects and analysis process will be undertaken."

Review of a hospital notebook labeled "Risk assessment 07/2018" on 04/30/19 at 9:00 AM showed the hospital conducted a facility wide risk assessment and identified ligature risks that included door hinges, TV mount and TV, "all chairs and tables are free moving and lightweight enough to be used as a weapon", glass mirrors, and door handles.

During an interview on 04/30/19 at 12:15 PM, Staff A, Registered Nurse (RN) Director of Nursing (DON), stated that she didn't know why the Governing Body didn't initiate a plan to fix the ligature risks. She stated that she still wondered how the hospital opened with those in place. When asked about the Risk Assessment 2018 notebook she stated that she thought a guy from corporate did that risk assessment in July of 2018, but I don't recall the issues being brought up during the Governing Body meetings.

Observations made during the hospital tour on 04/22/19 between 10:45 AM until 11:50 AM showed multiple ligature risks and items accessible to patients that could be used for self-harm or harm to others. These ligature risks and items accessible to patients could be used for self-harm or harm to others include the following:

Door handles of the Entrance/Exit Double Doors, have open push arms not flush with the glass doors, hinges at the top of both doors near the walls. A patient could loop a cord or other similar item around these door handles to hang themselves.

Six exit signs with large round lights on each side. A patient could loop a cord or other similar item around these exit signs to hang themselves.

Two sets double fire doors have elbow hinges at the top of both doors near the walls leaving a gap in the hinge, at the top backside of both fire doors, there are magnets that protrude out, the handles on the back side of the door are not flush with the door, latch bars that are not flush and runs vertically on each door and has a flat surface that protrudes out at the top of the door. A patient could loop a cord or other similar item around the elbow hinges, magnets, handles, and latch bars of the fire doors to hang themselves.

Eight locked doors with exterior hinges that protrude out. A patient could loop a cord or other similar item around the exterior hinges of these locked doors to hang themselves.

A water fountain with spout. A patient could loop a cord or other similar item around the spout of the water fountain to hang themselves.

Four chairs located in the hallway and 12 chairs in the dining room that are light enough to be picked up and thrown. A patient could use these chairs as a weapon to assault other patients, staff, or visitors.

Blunt solid wood handle on fire extinguisher box. A patient could loop a cord or other similar item around the wood handle to hang themselves.

An exit door at the east end of the hall between patient rooms 111 and 112 has a push arm that is not flush with the door. A patient could loop a cord or other similar item around the push arm of the exit door to hang themselves.

The top casing of the fire doors in the north hall by the nurse's station has a bar that protrudes out. A patient could loop a cord or other similar item around the bar of the fire door to hang themselves.

The shower room has two square light switch boxes, a locked, plastic storage cabinet with a break in the plastic that could be used to harm self, and a large metal cabinet with a square top. The tub has Hot and Cold-water handles, faucet and hand bar, a square wall mounted timer and laundry basket with metal wire framing and soap dispenser and paper towel dispensers. A patient could loop a cord or other similar item around the light switch boxes, the top of the large metal cabinet, the tub's hot and cold fixtures, the tub's faucet, tub's hand bar, the timer, the laundry baskets's metal frame, the soap dispenser, and the paper towel dispenser of the shower room to hang themselves. A patient could also use the break in the locked, plastic storage cabinet to cut themselves.

Observation in the dining room showed four tables light enough to be picked up and thrown, a wall mounted television, square ice machine, soap dispenser hanging on the wall, faucets, and the lower cabinets had five looping handles. A patient could loop a cord or other similar item around the wall mount of the TV, the ice machine, the soap dispenser, and the handles of the lower cabinets to hang themselves. A patient could use the tables as a weapon to assault other patients, staff, or visitors.

Eight of nine patient bathrooms had paper towel and soap dispensers hanging on the walls. A patient could loop a cord or other similar item around the paper towel and soap dispensers of these bathrooms to hang themselves.

Patient rooms 101, 107A, 107B, 110B, and 112A all had broken metal bells with sharp edges attached to the bedside tables that creates a self-injury hazard. A patient could use the sharp metal edges to cut themselves.


Review of a hospital policy titled, "Suicide Precautions," effective 09/2016 and revised 12/2016, showed, "To ensure a safe environment for potentially self-destructive patients and to establish specific guidelines for staff observation of these patients." ... "All patients placed on suicide precautions will be assigned an acuity level based upon the severity of the suicidal thoughts, plan or behavior." The levels are as follows: "Every 15-minute observation, Line of sight observation and one-to-one observation at all times.

Review of a hospital policy titled, "Assessment for Suicidal Ideation," effective 09/2016 and revised 12/2016, showed: "To ensure safety, prevent injury and maintain a therapeutic relationship with all patients." "Upon admission to the facility, every patient will be evaluated for suicidal ideation." ..."All patients admitted to the program following any suicide attempt will be considered high-risk, kept on suicide precautions and assessed every 24 hours." ..."This is an ongoing assessment since patients in a behavioral health setting may regress at any time. Orders for suicide precautions will be renewed every 24 hours and discontinued only by order of the physician."

Review of current medical records for Patient 3, 13, 14, 16 and 17, who were placed on suicide precautions, lacked evidence of renewed or discontinued suicide precautions orders throughout their hospital stay.

Failure of the hospital to follow their policy to assess a patient's risk for suicide every twenty four hours and for the physician to write continued orders for suicide precautions or discontinue suicide precautions has the potential for a patient, whose suicidal thoughts may have increased and who may need closer observation including either "line of sight" or 1:1 observation, instead of 15 minute observations, to have an opportunity to injure themselves.


During an observation in the dining room, on 04/22/19 at 1:18 PM, four patients (Patients 3, 13, 16 and an unidentified female patient) were sitting in chairs unattended by any hospital staff. At 1:26 PM (about 8 minutes later), Patient 15 approached in the hall just outside of the dining room followed by unidentified MHT staff, the unidentified MHT staff asked Staff N, MHT if he could help in the dining room. Staff N went into the dining room with the patients and escorted them out.

Review of the records for Patient 3, 13, and 16 showed the hospital had placed them on suicide and assaultive/aggressive precautions. The dining room had tables and chairs that were lightweight and could be used by one of the patients as a weapon to injure another patient, staff member, or visitor. The dining room also contained items that one of the patients could have used to hang themselves by looping a cord or other similar item around it including the wall mount of the TV, the ice machine, the soap dispenser, and the handles of the lower cabinets. Staff left patients (suicidal/assaultive/aggressive) unattended in the dining room for about 8 minutes in an environment that included hanging risks and items that could be used to harm others. This situation placed patients at risk for harming themselves or others.

During an interview on 04/22/19 at 11:25 Staff A, RN DON stated that it is the expectation that staff should never leave patients alone in the shower room, group activity room or the dining room.


Review of Patient 3's current medical record on 04/24/19 showed she was admitted on [DATE] with a diagnosis of delusional disorder and anxiety, the psychiatric diagnosis showed major depressive disorder and schizoaffective disorder. Review of the psychiatric evaluation dated 03/28/19 showed the chief complaint of paranoid/somatic delusions with physical aggression. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." Review of the admission orders dated 03/26/19 showed she was placed on Assaultive/Violence and Suicide Precaution, Level 1, every 15-minute observation. The record lacked the required every 24 hour assessment and evidence of renewed or discontinued suicide precaution orders throughout their hospital stay

During an interview on 04/22/19 at 1:20 PM, in the dining room, Patient 3 stated that she goes to the bathroom by herself and staff do not go with her. Even though eight of the nine patient bathrooms had paper towel and soap dispensers that a patient could use to loop a cord or other similar item around to hang themselves, the patient reports that staff allow her to go to the bathroom unattended, thus giving the patient opportunity to injure herself.


Review of Patient 6's discharged medical record showed a picture of Patient 6 at admission, sitting in a chair with a sling on her left arm with straps that extend from her left elbow and shoulder area up around both sides of her neck. Patient 6 was admitted on [DATE] with a diagnosis of severe Major Depressive disorder. Review of the psychiatric evaluation dated 10/19/18 showed she was admitted because she attempted to wrap a cord around her neck as a suicidal gesture. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." Review of the Nursing Admission assessment dated [DATE] showed, ..."Assistive Devices: ...other LUE (left upper extremity) sling. The Suicide Risk Level Screen showed that she was a high risk for suicide. The document comments regarding risk level and precautions showed: Pt. attempted suicide in last 72 hours by trying to use cords and gait belt and took a bottle of pills when she was younger.

Even though the hospital assessed her as a high risk for suicide and that she attempted suicide by trying to use cords and a gait belt to hang herself, the staff left her with an arm sling which had long straps that could easily be used to hang herself.

The admission orders showed: "Precautions: Suicide", with "Observation: every (Q) 15 minutes and 1:1" both marked. A physician's order dated 10/20/18 showed, "Change Pt (patient) order to now, line of sight only, for hx (history) of suicidal ideation and intent. Review of the "Close Observation" forms dated 10/19/18 through 11/02/18 showed the following:

Level 1 - observation every 15-minutes: 10/21/18, 10/22/18, 10/28/18, 10/29/18, 10/30/18, 11/01/19 and 11/02/19.
Level II - Line of Sight: 10/19/18 and 10/25/18.
Level III - One to One: 10/20/18 and 10/21/18.
"Close Observation" forms with no level of observation mark: 10/23/18, 10/24/18, 10/26/18, 10/27/18 and 10/31/18.

Review of the "Close Observation" forms dated 10/19/18 through 11/02/18 showed missed 15-minute observations on 10/29/18 beginning at 4:30 AM, she was observed in her room awake, the next observation was documented at 5:15 AM in her room asleep, forty-five minutes later. She was observed in the day room on 10/29/18 at 2:30 PM and the next observation was at 3:00 PM in the day room, thirty minutes later. On 10/30/18 at 6:15 AM, she was observed in her room awake, the next documented observation was at 7:00 AM, in her room awake, thirty minutes later. On 10/31/18 at 1:45 PM she was observed in the day room, the next documents observation was at 3:00 PM in the day room, one hour and fifteen minutes later. Hospital staff failed to conduct line of sight observations of Patient 6 on ten of twelve days even though there was no physician's order to stop the line of site observations ordered on [DATE]. The staff's failure to observe the patient with "line of sight" placed this suicidal patient at risk for harming herself.


Review of Patient 11's discharged medical record on 04/26/19 showed he was admitted on [DATE] with a diagnosis of delusion disorder and anxiety. Review of the psychiatric evaluation dated 04/09/19 showed the chief complaint of physical aggression. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." The admission orders dated 04/08/19 showed he was placed on Assaultive/Violence precautions with every 15-minute observation. Review of the "Close Observation" form dated 04/11/19 showed missed 15-minute observations beginning at 5:00 PM, he was observed in the day room, the next observation was documented at 7:19 PM when he was in the hall, two hours and 19 minutes later. The staff's failure to observe this assaultive/violent patient every 15 minutes placed the other patients at risk of being harmed by Patient 11.


Review of Patient 13's current medical record showed he was admitted on [DATE] with a diagnosis of Major depressive disorder and delusional disorder. Review of the psychiatric evaluation dated 04/13/19 showed a chief complaint of suicidal ideation with no plan. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." The admission orders dated 04/12/19 showed he was placed on Assaultive/Violence and Suicide Precaution Level 1, every 15 minutes observation. The record lacked the required every 24 hour assessment and evidence of renewed or discontinued suicide precaution orders throughout their hospital stay.


Review of Patient 14's current medical record on 04/30/19 showed she was admitted on [DATE] with a diagnosis of delusional disorder and schizophrenia. Review of the psychiatric evaluation dated 04/19/19 showed a chief complaint of delusions. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." The admission orders showed she was placed on Assaultive/Violence and Suicide precaution, Level 1, every 15 minutes observation. Review of the "Close Observation" form dated 04/23/19 showed missed 15-minute observations beginning at 5:45 PM when she was in her room sleeping, the next observation documented was at 7:19 PM, one hour and 34 minutes later. Review of the "Close Observation" form dated 04/26/19 showed missed 15-minute observations beginning at 1:06 PM when she was observed in her room awake, the next documented 15-minute observation was at 1:43 PM when she was observed in the hall 37 minutes later. The staff's failure to perform 15 minute checks of this assaultive/violent/suicidal patient places Patient 14 at risk for injuring himself or others.


Review of Patient 16's current medical record showed he was admitted on [DATE] with a diagnosis of Major Depressive Disorder, Alzheimer and anxiety. Review of the psychiatric evaluation dated 04/22/19 showed a chief complaint of suicide attempt by hanging times two on 04/21/19. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." The admission orders dated 04/21/19 showed he was placed on Assaultive/Violence and Suicide Precaution Level 1, every 15 minutes observation. Review of the "Close Observation" form dated 04/24/19 showed missed 15-minute observations beginning at 6:45 PM, when he was observed in his room awake, the next observation documented was at 7:45 PM when he was in the hall, one hour later. The staff failed to complete every 15 minute checks for an hour, giving the patient opportunity to harm himself or others. The record lacked the required every 24 hour assessment and evidence of renewed or discontinued suicide precaution orders throughout their hospital stay.

During an interview on 04/22/19, at 1:18 PM, in the dining room, Patient 16 stated that it was a nice day and he got good care. He stated he didn't know why he was here. Observation showed that he had on a long sleeve brown sweater. Patient 16 had attempted suicide by using shirt sleeves on 04/21/19. The hospital allowed the patient to wear an article of clothing that he could use to hang himself.

During an interview on 04/22/19 at 3:15 PM, Staff I, RN, stated that all patients are on 15-minute observation and more often if needed, she stated that even though not all patients are assessed as suicidal, they might not tell you and you may not know, so they are all on 15-minute checks. She stated that Patient 16 was admitted last night, 04/21/19, after attempting suicide twice that day, she stated that he used his sleeves once and a mini blind cord the second time. She stated that he has Alzheimer and does not remember attempting suicide.


Review of Patient 17's current medical record on 04/22/19 showed he was admitted on [DATE] with a diagnosis of delusional disorder and schizoaffective disorder. Review of the psychiatric evaluation dated 04/19/19 showed a chief complaint of refusing medications and physical aggression. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." The close observation forms dated 04/18/19 through 04/24/19 showed he was on Assaultive/Violence and Suicide precautions, Level 1, Observation every 15-minutes. Review of the "Close Observation" forms dated 04/24/18 showed missed 15-minute observations beginning at 6:45 PM when he was observed sleeping in his room and was next observed awake in his room at 7:30 PM, 45 minutes later. On 04/25/19 at 3:15 AM Patient 17 was observed asleep in his room and next observed at 4:00 AM, 45 minutes later. The staff's failure to perform 15 minute checks of this assaultive/violent/suicidal patient places Patient 17 at risk for injuring himself or others.


Review of Patient 18's current medical record on 04/27/19 showed she was admitted on [DATE] with a diagnosis of delusional disorder and schizophrenia. Review of the psychiatric evaluation dated 04/09/19 showed a chief complaint of delusions and physical aggression. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." The undated admission orders showed she was placed on Assaultive/Violence precautions and Observation every 15-minutes. Review of three undated "Close Observation" forms showed missed 15-minute observations beginning at 4:15 AM and the next observation was documented at 4:45 AM, 30 minutes later. The staff's failure to observe this assaultive/violent patient every 15 minutes placed the other patients at risk of being harmed by Patient 18.


Review of Patient 19's current medical record on 04/27/19 showed he was admitted on [DATE] with a diagnosis of delusional disorder and anxiety. Review of the psychiatric evaluation dated 04/18/19 showed a chief complaint of physical aggression. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation. The admission orders dated 04/16/18 showed he was placed on Assaultive/Violence precautions with every 15-minute observation. Review of a "Close Observation" form dated 04/23/19 showed missed observations beginning at 5:45 PM when he was in the day room and the next observation was at 7:19 PM in the hall, one hour and 19 minutes later. The staff's failure to observe this assaultive/violent patient every 15 minutes placed the other patients at risk of being harmed by Patient 19.


Review of Patient 20's current medical record on 04/27/19, showed he was admitted on [DATE], with a diagnosis of delusional disorder and anxiety. Review of the psychiatric evaluation dated 04/11/19, showed a chief complaint of physical aggression and paranoia. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." The admission orders dated 04/10/19, showed he was placed on Assaultive/Violence precautions and Observation every 15-minutes. Review of a "Close Observation" form dated 04/11/19, showed missed observations beginning at 6:45 PM when he was in his room sleeping and the next documented observation was at 7:19 PM when he was in the hall, 34 minutes later. Review of a "Close Observation" form dated 04/24/19, showed missed observations when he was observed in the day room a 6:45 PM, the next observation documented was at 7:45 PM, one hour later. The staff's failure to observe this assaultive/violent patient every 15 minutes placed the other patients at risk of being harmed by Patient 20.

During an interview on 04/24/19 at 3:15 PM, Staff K, Interim DON, stated that the CNA/MHT is supposed to do 15-minute checks and then the nurse is supposed to do a walk around every hour. There shouldn't be any times that are not documented with a location and a signature.
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
Based on staff interview and document review the facility failed to ensure they investigated and responded to patient grievances in a timely manner for three of five grievances (Patients 21, 22, and 23) dated from 04/2018 to 04/2019.

This deficient practice had the likelihood to cause patient concerns to be unresolved.

Findings Include:

Document review of hospital policy titled, "Complaint and Grievance Procedures for Inpatient Mental Health" revised on 12/16 showed, "This facility shall respond to any such concern in a reasonable, consistent and timely fashion". The policy showed staff are to notify the patient and the patient's family/legally responsible person by written notice of the grievance determination.

Patient 21's complaint & grievance form completed on 02/12/19 showed the patient reported that night shift staff was abusive to him and hurt his neck, he stated they talk about him and are disrespectful.

The complaint & grievance form lacked evidence the hospital investigated the grievance.


Patient 22's complaint & grievance form completed on 08/09/18 showed the patient reported he was discharged without his teeth.

The complaint & grievance form lacked evidence the hospital investigated the grievance


Patient 23's complaint & grievance form completed on 04/17/18 showed the patient reported a staff member was "very nasty and rude" and delayed smoke break because she was asked many times.

The complaint & grievance form lacked evidence the hospital investigated the grievance


During an interview on 04/20/19 at 10:15 AM, Staff B, CEO, stated that he did not know why Patient 21, 22, and 23's complaint & grievance forms were not complete and stated that a patient's reported concern is only a grievance if it takes longer than 24-hours to resolve.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on document review and staff interview the hospital failed to provide written notification to complainants in response to grievances for thee of five grievances (Patients 21, 22, and 23) reviewed from 04/2018 to 04/2019.


Failure of the hospital to provide written notice of the outcome of their grievance investigation, and steps taken on behalf of the patient or the patient's family to investigate the grievance violates their right to be informed of how the hospital investigated and resolved the grievance.

Findings Include:

Document review of hospital policy titled, "Complaint and Grievance Procedures for Inpatient Mental Health" revised on 12/16 showed, "This facility shall respond to any such concern in a reasonable, consistent and timely fashion". The policy showed staff are to notify the patient and the patient's family/legally responsible person by written notice of the grievance determination.

Patient 21's complaint & grievance form completed on 02/12/19 showed the patient reported that night shift staff was abusive to him and hurt his neck, he stated they talk about him and are disrespectful. The date of resolution was not documented.

The complaint & grievance form lacked evidence the hospital provided written notification of the resolution to the patient and the patient's family/legally responsible person.

Patient 22's complaint & grievance form completed on 08/09/18 showed the patient reported he was discharged without his teeth. The date of resolution was not documented.

The complaint & grievance form lacked evidence the hospital provided written notification of the resolution to the patient and the patient's family/legally responsible person.

Patient 23's complaint & grievance form completed on 04/17/18 showed the patient reported a staff member was "very nasty and rude" and delayed the smoke break because she was asked many times. The date of resolution was not documented.

The complaint & grievance form lacked evidence the hospital provided written notification of the resolution to the patient and the patient's family/legally responsible person.

During an interview on 04/20/19 at 10:15 AM, Staff B, CEO, stated that he did not know why Patient 21, 22, and 23 did not receive a letter indicating the resolution of their concerns and stated that a patient's reported concern is only a grievance if it takes longer than 24-hours to resolve. Staff B stated that if they resolved it in less than 24-hours they do not have to send a letter. Staff B did stated he did not have any additional documentation showing when or if Patient 21, 22, or 23's grievances had been resolved.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, staff interview and document review the hospital failed to ensure five of seventeen current patients assessed at risk for suicide (Patients 3, 13, 14, 16 and 17) and one of ten discharged patient records reviewed at risk for suicide (Patient 6) were safe from ligature (hanging) hazards and items likely to cause harm, failed to follow procedure by leaving three of five patients (Patient 3, 13, and 16) assessed at risk for suicide unattended by staff in the dining room; failed to ensure nine patients assessed as having aggressive behaviors and placed on Assaultive/Aggressive precautions (Patients 3, 11, 12, 13, 14, 16, 17, 18, and 19) did not have access to items that could be used to cause harm to self or others, failed to observe eight of eleven patients (Patient 6, 11, 14, 16, 17, 18, 19, and 20) placed on Suicidal precautions and Assaultive/Violence precautions every 15-minutes as ordered and failed to renew or discontinue suicide precaution orders for five of five current patients (Patients 3, 13, 14, 16 and 17) assessed at risk for suicide on admission.

An Immediate Jeopardy (IJ - represents a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death.) was identified on 04/23/19 at 9:00 AM as a result of the hospital's failure to ensure all patients were cared for in a safe setting and free from ligature (hanging) hazards and items likely to cause harm to self and others.

The hospital submitted a plan of removal on 04/25/19 and was it accepted at 4:41 PM before exiting the survey.

The plan of removal included: Leadership will educate all Charge Nursing staff about each identified ligature risk area. Training acknowledgement forms will be completed prior to start of check shift. ...Charge Nursing staff will educate all licensed practical nurses (LPNs) and mental health technicians (MHT) staff on all identified ligature risk areas. At 6:45 PM on 04/24/19 Charge Nurse will train the oncoming charge nurse and nursing staff on ligature risks. This will continue each shift at 6:45 AM and 6:45 PM until all staff shifts have cycled through. Charge nurse will supervise the rotation of all staff throughout the building with special attention to all areas of ligature risks that have been identified. This will be done by 1 MHT positioned in each hallway in order for all areas to be covered as patient coverage is warranted. The 1 MHT's responsibilities will be to monitor ligature risk areas. If the MHT gets called away from the hallway the MHT will notify the charge nurse or LPN one of them will cover until the MHT can return. All employed employees will be trained by their next shift. All contract employees will be trained before they work their next shift. Staff will be re-educated about Freedom Policy to never have a patient be unattended in the dining room/noisy activity room. The charge nurse will monitor this on the cameras to ensure compliance. If the charge nurse has to step away the LPN will monitor the cameras. All LPN's and RN's will be trained prior to their next shift worked by leadership or trained charge nurse. All nursing staff will be trained by their next shift. MHT's will walk the hallways to do random 15-minute room checks on all patients in their rooms. These checks will be randomized and documented on the 15 minutes or less chart check. All patients will be monitored in high risk areas the same way unless ordered by the physician. Training will begin at 6:45 PM on 04/24/19 by Chief Executive Officer (CEO). All patients will be on line of sight while in the shower area until immediate ligature risks are resolved.

Findings Include:

Review of an undated document titled, "Patient Handbook" showed: ..."The hospital program has been set up to provide a safe environment where you can heal from recent life events and recover from your symptoms. Keeping the program safe and comfortable requires a cooperative relationship between all staff and patients on the program." Review of the Patient Rights contained in the handbook showed: ..."As a patient you have the right to:" ..."Be treated with consideration, dignity, and respect with care provided in a safe environment free from any form of abuse, neglect, exploitation, or harassment."

Review of a hospital policy titled, "Risk Assessment Program" effective 09/2016 and revised 09/2016, showed: "The performance improvement program for the Safety/Environment of Care Committee is designed to monitor the level of safety compliance at the hospital, and to identify any situations that detract from the goal of providing a safe and secure environment for patients, employees, medical staff and visitors. Any risks that are identified through proactive risk assessments, environmental tours, performance measure monitoring, etc., will be evaluated, and have procedures and controls put into place to reduce to the lowest possible point the adverse impact on the safety and health of patients, personnel, medical staff, and visitors of the hospital. For those cases, where appropriate and deemed necessary, the failure mode effects and analysis process will be undertaken."

Review of a hospital notebook labeled "Risk assessment 07/2018" on 04/30/19 at 9:00 AM showed the hospital conducted a facility wide risk assessment and identified ligature risks that included door hinges, TV mount and TV, "all chairs and tables are free moving and lightweight enough to be used as a weapon", glass mirrors, and door handles.

During an interview on 04/30/19 at 12:15 PM, Staff A, Registered Nurse (RN) Director of Nursing (DON), stated that she didn't know why the Governing Body didn't initiate a plan to fix the ligature risks. She stated that she still wondered how the hospital opened with those in place. When asked about the Risk Assessment 2018 notebook she stated that she thought a guy from corporate did that risk assessment in July of 2018, but I don't recall the issues being brought up during the Governing Body meetings.

Observations made during the hospital tour on 04/22/19 between 10:45 AM until 11:50 AM showed multiple ligature risks and items accessible to patients that could be used for self-harm or harm to others. These ligature risks and items accessible to patients could be used for self-harm or harm to others include the following:

Door handles of the Entrance/Exit Double Doors, have open push arms not flush with the glass doors, hinges at the top of both doors near the walls. A patient could loop a cord or other similar item around these door handles to hang themselves.

Six exit signs with large round lights on each side. A patient could loop a cord or other similar item around these exit signs to hang themselves.

Two sets double fire doors have elbow hinges at the top of both doors near the walls leaving a gap in the hinge, at the top backside of both fire doors, there are magnets that protrude out, the handles on the back side of the door are not flush with the door, latch bars that are not flush and runs vertically on each door and has a flat surface that protrudes out at the top of the door. A patient could loop a cord or other similar item around the elbow hinges, magnets, handles, and latch bars of the fire doors to hang themselves.

Eight locked doors with exterior hinges that protrude out. A patient could loop a cord or other similar item around the exterior hinges of these locked doors to hang themselves.

A water fountain with spout. A patient could loop a cord or other similar item around the spout of the water fountain to hang themselves.

Four chairs located in the hallway and 12 chairs in the dining room that are light enough to be picked up and thrown. A patient could use these chairs as a weapon to assault other patients, staff, or visitors.

Blunt solid wood handle on fire extinguisher box. A patient could loop a cord or other similar item around the wood handle to hang themselves.

An exit door at the east end of the hall between patient rooms 111 and 112 has a push arm that is not flush with the door. A patient could loop a cord or other similar item around the push arm of the exit door to hang themselves.

The top casing of the fire doors in the north hall by the nurse's station has a bar that protrudes out. A patient could loop a cord or other similar item around the bar of the fire door to hang themselves.

The shower room has two square light switch boxes, a locked, plastic storage cabinet with a break in the plastic that could be used to harm self, and a large metal cabinet with a square top. The tub has Hot and Cold-water handles, faucet and hand bar, a square wall mounted timer and laundry basket with metal wire framing and soap dispenser and paper towel dispensers. A patient could loop a cord or other similar item around the light switch boxes, the top of the large metal cabinet, the tub's hot and cold fixtures, the tub's faucet, tub's hand bar, the timer, the laundry baskets's metal frame, the soap dispenser, and the paper towel dispenser of the shower room to hang themselves. A patient could also use the break in the locked, plastic storage cabinet to cut themselves.

Observation in the dining room showed four tables light enough to be picked up and thrown, a wall mounted television, square ice machine, soap dispenser hanging on the wall, faucets, and the lower cabinets had five looping handles. A patient could loop a cord or other similar item around the wall mount of the TV, the ice machine, the soap dispenser, and the handles of the lower cabinets to hang themselves. A patient could use the tables as a weapon to assault other patients, staff, or visitors.

Eight of nine patient bathrooms had paper towel and soap dispensers hanging on the walls. A patient could loop a cord or other similar item around the paper towel and soap dispensers of these bathrooms to hang themselves.

Patient rooms 101, 107A, 107B, 110B, and 112A all had broken metal bells with sharp edges attached to the bedside tables that creates a self-injury hazard. A patient could use the sharp metal edges to cut themselves.


Review of a hospital policy titled, "Suicide Precautions," effective 09/2016 and revised 12/2016, showed, "To ensure a safe environment for potentially self-destructive patients and to establish specific guidelines for staff observation of these patients." ... "All patients placed on suicide precautions will be assigned an acuity level based upon the severity of the suicidal thoughts, plan or behavior." The levels are as follows: "Every 15-minute observation, Line of sight observation and one-to-one observation at all times.

Review of a hospital policy titled, "Assessment for Suicidal Ideation," effective 09/2016 and revised 12/2016, showed: "To ensure safety, prevent injury and maintain a therapeutic relationship with all patients." "Upon admission to the facility, every patient will be evaluated for suicidal ideation." ..."All patients admitted to the program following any suicide attempt will be considered high-risk, kept on suicide precautions and assessed every 24 hours." ..."This is an ongoing assessment since patients in a behavioral health setting may regress at any time. Orders for suicide precautions will be renewed every 24 hours and discontinued only by order of the physician."

Review of current medical records for Patient 3, 13, 14, 16 and 17, who were placed on suicide precautions, lacked evidence of renewed or discontinued suicide precautions orders throughout their hospital stay.

Failure of the hospital to follow their policy to assess a patient's risk for suicide every twenty four hours and for the physician to write continued orders for suicide precautions or discontinue suicide precautions has the potential for a patient, whose suicidal thoughts have increased and who may need closer observation including either "line of sight" or 1:1 observation, instead of 15 minute observations, to have a greater opportunity to injure themselves.


During an observation in the dining room, on 04/22/19 at 1:18 PM, showed four patients (Patients 3, 13, 16 and an unidentified female patient) sitting in chairs unattended by staff. At 1:26 PM, Patient 15 approached in the hall just outside of the dining room followed by unidentified MHT staff, the unidentified MHT staff asked Staff N, MHT if he could help in the dining room. Staff N went into the dining room with the patients and escorted them out.

Review of the records for Patient 3, 13, and 16 showed the hospital had placed them on suicide and assaultive/aggressive precautions. The dining room had tables and chairs that were lightweight and could be used by one of the patients as a weapon to injure another patient, staff member, or visitor. The dining room also contained items that one of the patients could have used to hang themselves by looping a cord or other similar item around it including the wall mount of the TV, the ice machine, the soap dispenser, and the handles of the lower cabinets. Staff left patients (suicidal/assaultive/aggressive) unattended in the dining room for about 8 minutes in an environment that included hanging risks and items that could be used to harm others. This situation placed patients at risk for harming themselves or others.

During an interview on 04/22/19 at 11:25 Staff A, RN DON stated that it is the expectation that staff should never leave patients alone in the shower room, group activity room or the dining room.


Review of Patient 3's current medical record on 04/24/19 showed she was admitted on [DATE] with a diagnosis of delusional disorder and anxiety, the psychiatric diagnosis showed major depressive disorder and schizoaffective disorder. Review of the psychiatric evaluation dated 03/28/19 showed the chief complaint of paranoid/somatic delusions with physical aggression. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." Review of the admission orders dated 03/26/19 showed she was placed on Assaultive/Violence and Suicide Precaution, Level 1, every 15-minute observation.

During an interview on 04/22/19 at 1:20 PM, in the dining room, Patient 3, who was placed on suicide precautions, stated that she goes to the bathroom by herself and staff do not go with her. Even though eight of the nine patient bathrooms had paper towel and soap dispensers that a patient could use to loop a cord or other similar item around to hang themselves, the patient reports that staff allow her to go to the bathroom unattended, thus giving the patient an opportunity to injure herself.


Review of Patient 6's discharged medical record showed a picture of Patient 6 at admission, sitting in a chair with a sling on her left arm with straps that extend from her left elbow and shoulder area up around both sides of her neck. Patient 6 was admitted on [DATE] with a diagnosis of severe Major Depressive disorder. Review of the psychiatric evaluation dated 10/19/18 showed she was admitted because she attempted to wrap a cord around her neck as a suicidal gesture. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." Review of the Nursing Admission assessment dated [DATE] showed, ..."Assistive Devices: ...other LUE (left upper extremity) sling. The Suicide Risk Level Screen showed that she was a high risk for suicide. The document comments regarding risk level and precautions showed: Pt. attempted suicide in last 72 hours by trying to use cords and gait belt and took a bottle of pills when she was younger.

Even though the hospital assessed her as a high risk for suicide and that she attempted suicide by trying to use cords and a gait belt to hang herself, the staff left her with an arm sling which had long straps that could easily be used to hang herself.

The admission orders showed: "Precautions: Suicide", with "Observation: every (Q) 15 minutes and 1:1" both marked. A physician's order dated 10/20/18 showed, "Change Pt (patient) order to now, line of sight only, for hx (history) of suicidal ideation and intent. Review of the "Close Observation" forms dated 10/19/18 through 11/02/18 showed the following:

Level 1 - observation every 15-minutes: 10/21/18, 10/22/18, 10/28/18, 10/29/18, 10/30/18, 11/01/19 and 11/02/19.
Level II - Line of Sight: 10/19/18 and 10/25/18.
Level III - One to One: 10/20/18 and 10/21/18.
"Close Observation" forms with no level of observation mark: 10/23/18, 10/24/18, 10/26/18, 10/27/18 and 10/31/18.

Review of the "Close Observation" forms dated 10/19/18 through 11/02/18 showed missed 15-minute observations on 10/29/18 beginning at 4:30 AM, she was observed in her room awake, the next observation was documented at 5:15 AM in her room asleep, forty-five minutes later. She was observed in the day room on 10/29/18 at 2:30 PM and the next observation was at 3:00 PM in the day room, thirty minutes later. On 10/30/18 at 6:15 AM, she was observed in her room awake, the next documented observation was at 7:00 AM, in her room awake, thirty minutes later. On 10/31/18 at 1:45 PM she was observed in the day room, the next documents observation was at 3:00 PM in the day room, one hour and fifteen minutes later. Hospital staff failed to conduct line of sight observations of Patient 6 on ten of twelve days even though there was no physician's order to stop the line of site observations ordered on [DATE]. The staff's failure to observe the patient with line of site placed this suicidal patient at risk for harming themselves.


Review of Patient 11's discharged medical record on 04/26/19 showed he was admitted on [DATE] with a diagnosis of delusion disorder and anxiety. Review of the psychiatric evaluation dated 04/09/19 showed the chief complaint of physical aggression. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." The admission orders dated 04/08/19 showed he was placed on Assaultive/Violence precautions with every 15-minute observation. Review of the "Close Observation" form dated 04/11/19 showed missed 15-minute observations beginning at 5:00 PM, he was observed in the day room, the next observation was documented at 7:19 PM when he was in the hall, two hours and 19 minutes later. The staff's failure to observe this assaultive/violent patient every 15 minutes placed the other patients at risk of being harmed by Patient 11.


Review of Patient 13's current medical record showed he was admitted on [DATE] with a diagnosis of Major depressive disorder and delusional disorder. Review of the psychiatric evaluation dated 04/13/19 showed a chief complaint of suicidal ideation with no plan. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." The admission orders dated 04/12/19 showed he was placed on Assaultive/Violence and Suicide Precaution Level 1, every 15 minutes observation. The record lacked the required every 24 hour assessment and evidence of renewed or discontinued suicide precaution orders throughout their hospital stay.


Review of Patient 14's current medical record on 04/30/19 showed she was admitted on [DATE] with a diagnosis of delusional disorder and schizophrenia. Review of the psychiatric evaluation dated 04/19/19 showed a chief complaint of delusions. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." The admission orders showed she was placed on Assaultive/Violence and Suicide precaution, Level 1, every 15 minutes observation. Review of the "Close Observation" form dated 04/23/19 showed missed 15-minute observations beginning at 5:45 PM when she was in her room sleeping, the next observation documented was at 7:19 PM, one hour and 34 minutes later. Review of the "Close Observation" form dated 04/26/19 showed missed 15-minute observations beginning at 1:06 PM when she was observed in her room awake, the next documented 15-minute observation was at 1:43 PM when she was observed in the hall 37 minutes later. The staff's failure to perform 15 minute checks of this assaultive/violent/suicidal patient places Patient 14 at risk for injuring himself or others.


Review of Patient 16's current medical record showed he was admitted on [DATE] with a diagnosis of Major Depressive Disorder, Alzheimer and anxiety. Review of the psychiatric evaluation dated 04/22/19 showed a chief complaint of suicide attempt by hanging times two on 04/21/19. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." The admission orders dated 04/21/19 showed he was placed on Assaultive/Violence and Suicide Precaution Level 1, every 15 minutes observation. Review of the "Close Observation" form dated 04/24/19 showed missed 15-minute observations beginning at 6:45 PM, when he was observed in his room awake, the next observation documented was at 7:45 PM when he was in the hall, one hour later. The staff's failure to perform 15 minute checks of this assaultive/violent/suicidal patient places Patient 16 at risk for injuring himself or others.

During an interview on 04/22/19, at 1:18 PM, in the dining room, Patient 16 stated that it was a nice day and he got good care. He stated he didn't know why he was here. Observation showed that he had on a long sleeve brown sweater. Patient 16 had attempted suicide by using shirt sleeves on 04/21/19. The hospital allowed the patient to wear an article of clothing that he could use to hang himself.

During an interview on 04/22/19 at 3:15 PM, Staff I, RN, stated that all patients are on 15-minute observation and more often if needed, she stated that even though not all patients are assessed as suicidal, they might not tell you and you may not know, so they are all on 15-minute checks. She stated that Patient 16 was admitted last night, 04/21/19, after attempting suicide twice that day, she stated that he used his sleeves once and a mini blind cord the second time. She stated that he has Alzheimer and does not remember attempting suicide.


Review of Patient 17's current medical record on 04/22/19 showed he was admitted on [DATE] with a diagnosis of delusional disorder and schizoaffective disorder. Review of the psychiatric evaluation dated 04/19/19 showed a chief complaint of refusing medications and physical aggression. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." The close observation forms dated 04/18/19 through 04/24/19 showed he was on Assaultive/Violence and Suicide precautions, Level 1, Observation every 15-minutes. Review of the "Close Observation" forms dated 04/24/18 showed missed 15-minute observations beginning at 6:45 PM when he was observed sleeping in his room and was next observed awake in his room at 7:30 PM, 45 minutes later. On 04/25/19 at 3:15 AM Patient 17 was observed asleep in his room and next observed at 4:00 AM, 45 minutes later. The staff's failure to perform 15 minute checks of this assaultive/violent/suicidal patient places Patient 17 at risk for injuring himself or others.


Review of Patient 18's current medical record on 04/27/19 showed she was admitted on [DATE] with a diagnosis of delusional disorder and schizophrenia. Review of the psychiatric evaluation dated 04/09/19 showed a chief complaint of delusions and physical aggression. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." The undated admission orders showed she was placed on Assaultive/Violence precautions and Observation every 15-minutes. Review of three undated "Close Observation" forms showed missed 15-minute observations beginning at 4:15 AM and the next observation was documented at 4:45 AM, 30 minutes later. The staff's failure to observe this assaultive/violent patient every 15 minutes placed the other patients at risk of being harmed by Patient 18.


Review of Patient 19's current medical record on 04/27/19 showed he was admitted on [DATE] with a diagnosis of delusional disorder and anxiety. Review of the psychiatric evaluation dated 04/18/19 showed a chief complaint of physical aggression. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation. The admission orders dated 04/16/18 showed he was placed on Assaultive/Violence precautions with every 15-minute observation. Review of a "Close Observation" form dated 04/23/19 showed missed observations beginning at 5:45 PM when he was in the day room and the next observation was at 7:19 PM in the hall, one hour and 19 minutes later. The staff's failure to observe this assaultive/violent patient every 15 minutes placed the other patients at risk of being harmed by Patient 19.


Review of Patient 20's current medical record on 04/27/19, showed he was admitted on [DATE], with a diagnosis of delusional disorder and anxiety. Review of the psychiatric evaluation dated 04/11/19, showed a chief complaint of physical aggression and paranoia. Justification for 24-hour care showed: "Patient is potentially or actively dangerous to self, others, or property with need for controlled environment and requires 24-hour medical supervision due to acute decompensation." The admission orders dated 04/10/19, showed he was placed on Assaultive/Violence precautions and Observation every 15-minutes. Review of a "Close Observation" form dated 04/11/19, showed missed observations beginning at 6:45 PM when he was in his room sleeping and the next documented observation was at 7:19 PM when he was in the hall, 34 minutes later. Review of a "Close Observation" form dated 04/24/19, showed missed observations when he was observed in the day room a 6:45 PM, the next observation documented was at 7:45 PM, one hour later. The staff's failure to observe this assaultive/violent patient every 15 minutes placed the other patients at risk of being harmed by Patient 20.

During an interview on 04/24/19 at 3:15 PM, Staff K, Interim DON, stated that the CNA/MHT is supposed to do 15-minute checks and then the nurse is supposed to do a walk around every hour. There shouldn't be any times that are not documented with a location and a signature.
VIOLATION: QAPI Tag No: A0263
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, document review and staff interview the hospital failed to ensure development of an effective Quality Assessment Performance Improvement Plan that identifies high risk, high-volume problem prone areas including identified ligature risked and infection control practices.

This systemic failure has the potential to adversely affect all patient by putting them at risk for infections, self-harm and harm to others.

Findings Include:

Review of a hospital policy titled, "Risk Assessment Program" effective 09/2016 and revised 09/2016, showed: "The performance improvement program for the Safety/Environment of Care Committee is designed to monitor the level of safety compliance at the hospital, and to identify any situations that detract from the goal of providing a safe and secure environment for patients, employees, medical staff and visitors. Any risks that are identified through proactive risk assessments, environmental tours, performance measure monitoring, etc., will be evaluated, and have procedures and controls put into place to reduce to the lowest possible point the adverse impact on the safety and health of patients, personnel, medical staff, and visitors of the hospital. For those cases, where appropriate and deemed necessary, the failure mode effects and analysis process will be undertaken."

Review of a hospital notebook labeled "Risk Assessment 07/2018" on 04/30/19 at 9:00 AM showed the hospital conducted a facility wide risk assessment and identified ligature risks that included door hinges, TV mount and TV, "all chairs and tables are free moving and lightweight enough to be used as a weapon", glass mirrors, and door handles.

During an interview on 04/30/19 at 12:15 PM, Staff A, Registered Nurse (RN) Director of Nursing (DON), stated that she didn't know why the Governing Body didn't initiate a plan to fix the ligature risks. She stated that she still wondered how the hospital opened with those in place. When asked about the Risk Assessment 2018 notebook she stated that she thought a guy from corporate did that risk assessment in July of 2018, but I don't recall the issues being brought up during the Governing Body meetings.

Review of a hospital document titled "Black-Ops Operations and Quality, Total Quality Management System" (BTQM)" Black-Ops TQM Systems Plan" dated April 2019 showed: "Operations, quality and performance management is the practice of actively using hospital data to improve the health of patients, who require care and treatment services. A Total Quality Management (TQM) system is defined by the activities and methods that help the hospital meet its goals in the most effective and efficient manner possible. In order to achieve desired patient outcomes, the hospital focuses on improving the safety, quality and efficiency of the services, care and treatment provided. The best way to achieve desired patient outcomes is by measuring the performance of processes that support the services, and then using that data to make improvements."

Review of the plans Annual Performance Improvement Projects does not include the identified ligature risks that included door hinges, TV mount and TV, "all chairs and tables are free moving and lightweight enough to be used as a weapon", glass mirrors, and door handles found on the facility wide risk assessment dated ,d+[DATE].

Review of the Quality Assessment Performance Improvement Meeting minutes dated 10/25/18, 11/15/18, 12/21/18, 01/18/19, 02/14/19, and 03/15/19 showed no discussion of the identified ligature risks in the hospital.

Document review of the hospitals policy titled, "Infection Prevention and Control Program" showed, "The facilities Infection Prevention and Control Plan ensures that this organization develops, implements and maintains and active, organization-wide program for the prevention, control and investigation of infections and communicable diseases in order to reduce the risks of endemic and epidemic infections in patients, visitors and healthcare workers, and to optimize use of resources".

Review of the hospital's "Infection Control" Binder on 04/30/2019 showed the infection control officer, Director of Nursing (DON), failed to complete employee health program information which was to include immunization and exposure information, Behavioral Health Facility Surveillance information which was to include information on Hospital Acquired Infections and Community Acquired Infections, employee education including hand hygiene, isolation precautions, prevention of urinary tract infections, cleaning techniques and other infection control education offerings, the Antibiotic and Organism Yearly Summary, the QAPI monitoring for basic disinfection, hand hygiene, patient identifiers, and the Infection control tracking reports for February 2019, March 2019, and April 2019.

Review of the hospitals QAPI report on 04/30/19 showed during the 02/14/19 and 03/15/19 meetings no infection control information was reported.

During an interview on 04/30/2019 at 12:00 PM, Staff A, DON, stated the she quit working at the hospital in February 2019 and Staff K, RN, was to be her replacement. Staff A stated that Staff K was also supposed to take over the infection control officer duties. Staff A stated, "I don't know why there is no documentation for February, March, and April". Staff A stated, "It is too much for someone to be the DON and the infection control officer".
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, document review and staff interview the hospital quality assessment performance improvement program failed to identify, act, and focus on identified high risk, high-volume problem prone areas by not including ligature risked identified in a risk assessment and infection control. This deficient practice has the potential to adversely affect all patient by putting them at risk for infections, self-harm and harm to others because of missed opportunities for improvement and change in care practices.

Findings Include:

Review of a hospital policy titled, "Risk Assessment Program" effective 09/2016 and revised 09/2016, showed: "The performance improvement program for the Safety/Environment of Care Committee is designed to monitor the level of safety compliance at the hospital, and to identify any situations that detract from the goal of providing a safe and secure environment for patients, employees, medical staff and visitors. Any risks that are identified through proactive risk assessments, environmental tours, performance measure monitoring, etc., will be evaluated, and have procedures and controls put into place to reduce to the lowest possible point the adverse impact on the safety and health of patients, personnel, medical staff, and visitors of the hospital. For those cases, where appropriate and deemed necessary, the failure mode effects and analysis process will be undertaken."

Review of a hospital notebook labeled "Risk Assessment 07/2018" on 04/30/19 at 9:00 AM showed the hospital conducted a facility wide risk assessment and identified ligature risks that included door hinges, TV mount and TV, "all chairs and tables are free moving and lightweight enough to be used as a weapon", glass mirrors, and door handles.

During an interview on 04/30/19 at 12:15 PM, Staff A, Registered Nurse (RN) Director of Nursing (DON), stated that she didn't know why the Governing Body didn't initiate a plan to fix the ligature risks. She stated that she still wondered how the hospital opened with those in place. When asked about the Risk Assessment 2018 notebook she stated that she thought a guy from corporate did that risk assessment in July of 2018, but I don't recall the issues being brought up during the Governing Body meetings.

Review of a hospital document titled "Black-Ops Operations and Quality, Total Quality Management System" (BTQM)" Black-Ops TQM Systems Plan" dated April 2019 showed: "Operations, quality and performance management is the practice of actively using hospital data to improve the health of patients, who require care and treatment services. A Total Quality Management (TQM) system is defined by the activities and methods that help the hospital meet its goals in the most effective and efficient manner possible. In order to achieve desired patient outcomes, the hospital focuses on improving the safety, quality and efficiency of the services, care and treatment provided. The best way to achieve desired patient outcomes is by measuring the performance of processes that support the services, and then using that data to make improvements."

Review of the plans Annual Performance Improvement Projects does not include the identified ligature risks that included door hinges, TV mount and TV, "all chairs and tables are free moving and lightweight enough to be used as a weapon", glass mirrors, and door handles found on the facility wide risk assessment dated ,d+[DATE].

Review of the Quality Assessment Performance Improvement Meeting minutes dated 10/25/18, 11/15/18, 12/21/18, 01/18/19, 02/14/19, and 03/15/19 showed no discussion of the identified ligature risks in the hospital.

Document review of the hospitals policy titled, "Infection Prevention and Control Program" showed, "The facilities Infection Prevention and Control Plan ensures that this organization develops, implements and maintains and active, organization-wide program for the prevention, control and investigation of infections and communicable diseases in order to reduce the risks of endemic and epidemic infections in patients, visitors and healthcare workers, and to optimize use of resources".

Review of the hospital's "Infection Control" Binder on 04/30/2019 showed the infection control officer, Director of Nursing (DON), failed to complete employee health program information which was to include immunization and exposure information, Behavioral Health Facility Surveillance information which was to include information on Hospital Acquired Infections and Community Acquired Infections, employee education including hand hygiene, isolation precautions, prevention of urinary tract infections, cleaning techniques and other infection control education offerings, the Antibiotic and Organism Yearly Summary, the QAPI monitoring for basic disinfection, hand hygiene, patient identifiers, and the Infection control tracking reports for February 2019, March 2019, and April 2019.

Review of the hospitals QAPI report on 04/30/19 showed during the 02/14/19 and 03/15/19 meetings no infection control information was reported.

During an interview on 04/30/2019 at 12:00 PM, Staff A, DON, stated the she quit working at the hospital in February 2019 and Staff K, RN, was to be her replacement. Staff A stated that Staff K was also supposed to take over the infection control officer duties. Staff A stated, "I don't know why there is no documentation for February, March, and April". Staff A stated, "It is too much for someone to be the DON and the infection control officer".
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
Based on observation, document review and staff interview the hospital's Governing Body failed to ensure quality assessment and performance improvement efforts addressed priorities for improved quality of care and patient safety by not including ligature risked identified in a risk assessment and infection control in ongoing quality improvement program. This deficient practice has the potential to place all patients at risk for infections, self-harm and harm to others because of missed opportunities for improvement and change in care practices.

Findings Include:

Review of a hospital document titled "Black-Ops Operations and Quality, Total Quality Management System" (BTQM)" Black-Ops TQM Systems Plan" dated April 2019 showed: "Operations, quality and performance management is the practice of actively using hospital data to improve the health of patients, who require care and treatment services. A Total Quality Management (TQM) system is defined by the activities and methods that help the hospital meet its goals in the most effective and efficient manner possible. In order to achieve desired patient outcomes, the hospital focuses on improving the safety, quality and efficiency of the services, care and treatment provided. The best way to achieve desired patient outcomes is by measuring the performance of processes that support the services, and then using that data to make improvements."

Review of a hospital policy titled, "Risk Assessment Program" effective 09/2016 and revised 09/2016, showed: "The performance improvement program for the Safety/Environment of Care Committee is designed to monitor the level of safety compliance at the hospital, and to identify any situations that detract from the goal of providing a safe and secure environment for patients, employees, medical staff and visitors. Any risks that are identified through proactive risk assessments, environmental tours, performance measure monitoring, etc., will be evaluated, and have procedures and controls put into place to reduce to the lowest possible point the adverse impact on the safety and health of patients, personnel, medical staff, and visitors of the hospital. For those cases, where appropriate and deemed necessary, the failure mode effects and analysis process will be undertaken."

Review of a hospital notebook labeled "Risk Assessment 07/2018" on 04/30/19 at 9:00 AM showed the hospital conducted a facility wide risk assessment and identified ligature risks that included door hinges, TV mount and TV, "all chairs and tables are free moving and lightweight enough to be used as a weapon", glass mirrors, and door handles.

Observations made during the hospital tour on 04/22/19 between 10:45 AM until 11:50 AM showed multiple ligature risks and items accessible to patients that could be used for self-harm or harm to others. These ligature risks and items accessible to patients could be used for self-harm or harm to others include the following:

Door handles of the Entrance/Exit Double Doors, have open push arms not flush with the glass doors, hinges at the top of both doors near the walls. A patient could loop a cord or other similar item around these door handles to hang themselves.

Six exit signs with large round lights on each side. A patient could loop a cord or other similar item around these exit signs to hang themselves.

Two sets double fire doors have elbow hinges at the top of both doors near the walls leaving a gap in the hinge, at the top backside of both fire doors, there are magnets that protrude out, the handles on the back side of the door are not flush with the door, latch bars that are not flush and runs vertically on each door and has a flat surface that protrudes out at the top of the door. A patient could loop a cord or other similar item around the elbow hinges, magnets, handles, and latch bars of the fire doors to hang themselves.

Eight locked doors with exterior hinges that protrude out. A patient could loop a cord or other similar item around the exterior hinges of these locked doors to hang themselves.

A water fountain with spout. A patient could loop a cord or other similar item around the spout of the water fountain to hang themselves.

Four chairs located in the hallway and 12 chairs in the dining room that are light enough to be picked up and thrown. A patient could use these chairs as a weapon to assault other patients, staff, or visitors.

Blunt solid wood handle on fire extinguisher box. A patient could loop a cord or other similar item around the wood handle to hang themselves.

An exit door at the east end of the hall between patient rooms 111 and 112 has a push arm that is not flush with the door. A patient could loop a cord or other similar item around the push arm of the exit door to hang themselves.

The top casing of the fire doors in the north hall by the nurse's station has a bar that protrudes out. A patient could loop a cord or other similar item around the bar of the fire door to hang themselves.

The shower room has two square light switch boxes, a locked, plastic storage cabinet with a break in the plastic that could be used to harm self, and a large metal cabinet with a square top. The tub has Hot and Cold-water handles, faucet and hand bar, a square wall mounted timer and laundry basket with metal wire framing and soap dispenser and paper towel dispensers. A patient could loop a cord or other similar item around the light switch boxes, the top of the large metal cabinet, the tub's hot and cold fixtures, the tub's faucet, tub's hand bar, the timer, the laundry baskets's metal frame, the soap dispenser, and the paper towel dispenser of the shower room to hang themselves. A patient could also use the break in the locked, plastic storage cabinet to cut themselves.

Observation in the dining room showed four tables light enough to be picked up and thrown, a wall mounted television, square ice machine, soap dispenser hanging on the wall, faucets, and the lower cabinets had five looping handles. A patient could loop a cord or other similar item around the wall mount of the TV, the ice machine, the soap dispenser, and the handles of the lower cabinets to hang themselves. A patient could use the tables as a weapon to assault other patients, staff, or visitors.

Eight of nine patient bathrooms had paper towel and soap dispensers hanging on the walls. A patient could loop a cord or other similar item around the paper towel and soap dispensers of these bathrooms to hang themselves.

Patient rooms 101, 107A, 107B, 110B, and 112A all had broken metal bells with sharp edges attached to the bedside tables that creates a self-injury hazard. A patient could use the sharp metal edges to cut themselves.

During an interview on 04/30/19 at 12:15 PM, Staff A, Registered Nurse (RN) Director of Nursing (DON), stated that she didn't know why the Governing Body didn't initiate a plan to fix the ligature risks. She stated that she still wondered how the hospital opened with those in place. When asked about the Risk Assessment 2018 notebook she stated that she thought a guy from corporate did that risk assessment in July of 2018, but I don't recall the issues being brought up during the Governing Body meetings.


Document review of the hospitals policy titled, "Infection Prevention and Control Program" showed, "The facilities Infection Prevention and Control Plan ensures that this organization develops, implements and maintains and active, organization-wide program for the prevention, control and investigation of infections and communicable diseases in order to reduce the risks of endemic and epidemic infections in patients, visitors and healthcare workers, and to optimize use of resources".

Review of the hospital's "Infection Control" Binder on 04/30/2019 showed the infection control officer, Director of Nursing (DON), failed to complete employee health program information which was to include immunization and exposure information, Behavioral Health Facility Surveillance information which was to include information on Hospital Acquired Infections and Community Acquired Infections, employee education including hand hygiene, isolation precautions, prevention of urinary tract infections, cleaning techniques and other infection control education offerings, the Antibiotic and Organism Yearly Summary, the QAPI monitoring for basic disinfection, hand hygiene, patient identifiers, and the Infection control tracking reports for February 2019, March 2019, and April 2019.

Observation on 04/22/19 at 10:45 AM showed a room labeled Oxygen Room which revealed an open Yankauer suction tip (airway suction device) connected to suction tubing, expired culture swabs, expired Foley catheter (devise used to remove urine from the bladder) insertion tray, fabric gait belts, a flushable basin with a greenish substance staining the basins bottom and there was no personal protective equipment (PPE), i.e. gowns, gloves, masks or goggles at the basin for staff use near the basin. There were also numerous air vents located in patient rooms and storage rooms that showed a buildup of dust/dirt.

Observation on 04/29/19 at 2:45 PM in the dining room showed Staff J, RN passing medications. Staff J put on gloves without washing her hands, poured water in a small cup, removed medications from a bin in the medication cart, she went to Patient 16, gave him the medication, took the cup back, opened the medication cart drawer, threw the cup away and removed her gloves, she then put on another pair of gloves without washing her hands. Patient 18 then came to the cart, Staff J pour water, removed medication from a bin in the medication cart, handed the medication and water to Patient 18, Staff J removed her gloves, put on a new pair without washing her hands and was going to give Patient 22 his medication but had to return to the medication room for additional medications. She removed the gloves and did not wash her hands. On her way to the medication room Staff J was approached by Staff Q, MHT, who had Patient 25 with her. Staff Q pointed out areas on Patient 25's arms that were actively bleeding. Staff J, RN touched both of Patient 25's arms, without washing her hands, to examine the areas that were bleeding. Staff J then went into the medication room, collected skin cleansing solution, non-adhesive bandages, gauze, wrap and tape from a cabinet just inside the door without washing her hands. Staff J did not wash her hands prior to putting on gloves, she then cleaned the wounds with the cleansing solution and gauze, removed her gloves, did not wash hands or put on gloves to apply the bandages to Patient 25's arms.

Review of the hospitals QAPI report on 04/30/19 showed during the 02/14/19 and 03/15/19 meetings no infection control information was reported.

During an interview on 04/30/2019 at 12:00 PM, Staff A, DON, "I don't know why there is no documentation for February, March, and April."
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on interview, record review and policy review the hospital failed to ensure nursing staff develops, and keeps current, a nursing care plan for 10 of 14 patients (Patients 1, 2, 3, 4, 5, 6, 7, 10, 13, and 14). The hospital's failure to ensure nursing staff develops, and keeps current, a nursing care plan for each patient has the potential for patients to fail to have accurate assessments and interventions to meet their health care and recovery needs resulting in falls, harm, injury, poor discharge planning and poor health outcomes.

Findings Include:

Document review of the Hospital's policy titled, "Plan of Care," dated 11/16, showed ...every patient shall have an individualized comprehensive plan of care ...the needs, strengths, preferences and goals of the patient are identified based on the screening and assessment, and are used in the plan for care, treatment of services ...the plan for care includes goals expressed in a manner that captures the patient's words or ideas, build on the patient's strengths, and supports the transition to community integration as a need during assessment ...objectives include identified steps to achieve goals, are sufficiently specific to assess the progress of the individual served, are in terms that provide indices of progress ...goals and objectives will be reevaluated and as necessary, revised based on changes in the patient's condition, problems, needs and responses to care, treatment and services.

Document review of the Master Treatment Plan of Care showed:

Patient 1's treatment team goals were to verbalize need to request assistance to prevent falls within seven days, demonstrate proper transfer techniques within seven days, and demonstrate use of call bell within seven days.
Review of medical record failed to show the nursing staff assessed and documented progress toward the goals and intervention. Final documentation failed to show if the goals were met upon discharge.

Patient 2's treatment team goals were to verbalize need to request assistance to prevent falls within seven days, demonstrate proper transfer techniques within seven days, and demonstrate use of call bell within seven days.

Review of medical record failed to show the nursing staff assessed and documented progress toward the goals and intervention. Final documentation shows the goals were deferred.

Patient 3's treatment team goals were to demonstrate proper transfer techniques within seven days and demonstrate use of call bell within seven days.

Review of medical record failed to show the nursing staff assessed and documented progress toward the goals and intervention. Final documentation shows the goals were deferred.

Patient 4's treatment team goal was to have no falls as evidenced by providing insight on fall precautions by 12/02/19.

Review of medical record failed to show the nursing staff assessed and documented progress toward the goals and intervention. Final documentation failed to show if the goals were met upon discharge.

Patient 5's treatment team care plan showed falls were listed as a problem upon admission 11/26/19. The facility failed to provide the goals and resolution of goals upon record request.

Patient 6's treatment team goal was patient will remain free from falls or injury while inpatient for seven days. Final documentation failed to show if the goals were met upon discharge.

Patient 7's treatment team goals were to verbalize need to request assistance to prevent falls within seven days, demonstrate proper transfer techniques within seven days, demonstrate use of call bell within seven days, and patient will have no falls during hospital stay for 12 days.
Review of medical record failed to show the nursing staff assessed and documented progress toward the goals and intervention. Final documentation showed the goals were resolved on 10/22/19.

Patient 10's treatment team care plan showed falls were not addressed or included on the care plan after the initial fall assessment upon admission showing she was a fall risk.

Patient 13's treatment team goals failed to be provided by the facility. Her score upon admission showed she was a fall risk.

Patient 14's treatment team goals were to verbalize need to request assistance to prevent falls within seven days and demonstrate use of call bell within seven days.
Review of medical record failed to show the nursing staff assessed and documented progress toward the goals and intervention.

During an interview on 12/23/19 at 4:42 PM, Staff B, Director of Nursing (DON) verified the treatment plans of care failed to be completed on all the patients and the resolutions were not always marked appropriately.
VIOLATION: USE OF VERBAL ORDERS Tag No: A0407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on medical record review, policy review and staff interview the hospital failed to ensure that verbal orders were used infrequently for 20 of 20 (Patient 1-20) medical records reviewed.

This deficient practice has the potential to cause a miscommunication which could lead to patient harm.

Finding Include:

Document review of the hospital's policy titled, "Verbal and Written Orders" revised on 11/16 showed, "verbal/telephone orders shall be used infrequently".

Review of Patient 1's discharged medical record on 04/23/19 showed they were admitted on [DATE] and discharged on [DATE]. Review of documents titled, "Physician's Orders" and "Admit Orders/ Preliminary Plan of Care" showed a total of 16 orders with 12 of them documented as verbal orders. (75% of the orders were verbal).

Review of Patient 2's discharged medical record on 04/26/19 showed they were admitted on [DATE] and discharged on [DATE]. Review of documents titled, "Physician's Orders" and "Admit Orders/ Preliminary Plan of Care" showed a total of 11 orders with seven of them documented as verbal orders. (63% of the orders were verbal).

Review of Patient 3's current medical record on 04/24/19 showed they were admitted on [DATE]. Review of documents titled, "Physician's Orders" and "Admit Orders/ Preliminary Plan of Care" showed a total of 21 orders with 17 of them documented as verbal orders. (81% of the orders were verbal).

Review of Patient 4's discharged medical record on 04/23/19 showed they were admitted on [DATE] and discharged on [DATE]. Review of documents titled, "Physician's Orders" and "Admit Orders/ Preliminary Plan of Care" showed a total of 19 orders with 12 of them documented as verbal orders. (63% of the orders were verbal).

Review of Patient 5's discharged medical record on 04/26/19 showed they were admitted on [DATE] and discharged on [DATE]. Review of documents titled, "Physician's Orders" " and "Admit Orders/ Preliminary Plan of Care" showed a total of four orders with all four of them documented as verbal orders. (100% of the orders were verbal).

Review of Patient 6's discharged medical record on 04/24/19 showed they were admitted on [DATE] and discharged on [DATE]. Review of documents titled, "Physician's Orders" and "Admit Orders/ Preliminary Plan of Care" showed a total of 11 orders with seven of them documented as verbal orders. (64% of the orders were verbal).

Review of Patient 7's discharged medical record on 04/26/19 showed they were admitted on [DATE] and discharged on [DATE]. Review of documents titled, "Physician's Orders" and "Admit Orders/ Preliminary Plan of Care" showed a total of three orders with two of them documented as verbal orders. (66% of the orders were verbal).

Review of Patient 8's discharged medical record on 04/24/19 showed they were admitted on [DATE] and discharged on [DATE]. Review of documents titled, "Physician's Orders" and "Admit Orders/ Preliminary Plan of Care" showed a total of nine orders with eight of them documented as verbal orders. (89% of the orders were verbal).

Review of Patient 9's discharged medical record on 04/26/19 showed they were admitted on [DATE] and discharged on [DATE]. Review of documents titled, " Physician's Orders" and "Admit Orders/Preliminary Plan of Care, showed a total of nine orders with six documented as verbal orders. (66% of the orders were verbal).

Review of Patient 10's discharged medical record on 04/29/19 showed they were admitted on [DATE] and discharged on [DATE]. Review of documents titled, "Physician's Orders" and "Admit Orders/ Preliminary Plan of Care" showed a total of seven orders with five of them documented as verbal orders. (71% of the orders were verbal).

Review of Patient 11's discharged medical record on 04/26/19 showed they were admitted on [DATE] and discharged on [DATE]. Review of documents titled, "Physician's Orders" and "Admit Orders/Preliminary Plan of Care" showed a total of seven orders with five documented as verbal orders. (71% of the orders were verbal).

Review of Patient 12's current medical record on 04/27/19 showed they were admitted on [DATE]. Review of documents titled, "Physician's Orders" and "Admit Orders/Preliminary Plan of Care" showed a total of eight orders with four documented as verbal orders. (50% of the orders were verbal).

Review of Patient 13's current medical record on 04/30/19 showed they were admitted on [DATE]. Review of documents titled, "Physician's Orders" and "Admit Orders/ Preliminary Plan of Care" showed a total of ten orders with nine of them documented as verbal orders. (90% of the orders were verbal).

Review of Patient 14's current medical record on 04/30/19 showed they were admitted on [DATE]. Review of documents titled, "Physician's Orders" and "Admit Orders/ Preliminary Plan of Care" showed a total of nine orders with six of them documented as verbal orders. (67% of the orders were verbal).

Review of Patient 15's current medical record on 04/27/19 showed they were admitted on [DATE]. Review of documents titled, "Physician's Orders" and "Admit Orders/Preliminary Plan of Care" showed a total of five orders with five documented as verbal orders. (100% of the orders were verbal).

Review of Patient 18's current medical record on 04/27/19 showed they were admitted on [DATE]. Review of documents titled, "Physician's Orders" and "Admit Orders/Preliminary Plan of Care" showed a total of 15 orders with eight documented as verbal orders. (53% of the orders were verbal).

Review of Patient 19's current medical record on 04/27/19 showed they were admitted on [DATE]. Review of documents titled, "Physician's Orders" and "Admit Orders/Preliminary Plan of Care" showed a total of four orders with three documented as verbal orders. (75% of the orders were verbal).

Review of Patient 20's current medical record on 04/27/19 showed they were admitted on [DATE]. Review of documents titled, "Admit Orders/Preliminary Plan of Care" showed a total of 11 orders with eight documented as verbal orders. (72% of the orders were verbal).

During an interview on 04/30/19 at 12:00 PM, Staff A, Director of Nursing (DON), stated, "The providers use a lot of verbal orders". Staff A stated that she believed that The Joint Commission required them to use verbal orders 10% or less. Staff A stated that she doesn't know if anyone had told the providers to limit their use of verbal orders.

During an interview on 04/29/19 at 3:15 PM, Staff D, Advanced Practice Registered Nurse (APRN), stated, "I try to write most of my orders when I am here to reduce verbal orders and I make the nurse read it back to me". Staff D stated that Staff E, Physician, has more verbal orders because he is here through telemedicine and Staff F, Physician, does give a lot of verbal orders as well.

During an interview on 04/30/19 at 1:15 PM, Staff R, Medical Records, stated, "I didn't know there should be a limit on verbal orders. I have not spoken to the providers about it".
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview, record review, document and policies and procedures review the hospital failed to ensure verbal orders were completed timely for nine of 10 discharged patients (Patients 1, 2, 4-8, 10, and 11) sampled medical records between 09/01/18 to 04/22/19.

Failure to review, sign, and date verbal orders promptly has the potential to cause errors to remain unidentified which could lead to patient harm.

Findings Include:

Document review of hospital policy titled, "Verbal and Written Orders," revised on 11/16, showed, "Verbal orders, including telephone orders, should include the date and signature of the person recording them. The prescribing or covering practitioner should authenticate the order within 72-hours of the patient's discharge or 30-days, whichever occurs first. Records of patient's discharged should be completed within 30-days following discharge.


Review of Patient 1's discharged medical record on 04/23/19 showed she was admitted on [DATE] and discharged on [DATE] and the following:

Staff F, Physician gave verbal orders on 09/02/18 for Progesterone (a hormone supplement) with no substitutions. Staff F failed to time and date the order as of 04/23/19 (230 days after discharge).

Staff F, Physician gave a clarification order for Flonase (a nasal spray used to treat allergy symptoms) on 09/02/18 and an order to discontinue loratadine (an allergy medication) and to start Zyrtec (an allergy medication). Staff F signed the order on 09/19/18 which is 14 days after discharge. Staff F failed to ensure verbal orders
Staff U, Physician gave verbal orders on 09/01/19 for admission and preliminary plan of care. Staff U failed to time and date the order as of 04/23/19 (230 days after discharge).


Review of Patient 2's discharged medical record on 04/22/19 showed he was admitted on [DATE] and discharged on [DATE] showed the following:

Staff H, Advanced Practice Registered Nurse (APRN) gave a verbal order on 04/10/19 to discharge Patient 2 on 04/10/19. The order remained unsigned as of 04/22/19 (11 days after discharge).

Staff E, Physician gave a verbal order on 04/11/19 to discharge Patient 2 on 04/11/19. The order remained unsigned as of 04/22/19 (11 days after discharge).

Staff F, Physician gave a verbal order on 04/10/19 requesting a nursing home placement for Patient 2 on 04/10/19. The order remained unsigned as of 04/22/19 (11 days after discharge).

Staff F, Physician gave a verbal order on 04/03/19 for Flomax (a medication used to treat an enlarges prostate). The order remained unsigned as of 04/22/19 (11 days after discharge).

Staff F, Physician gave a verbal order on 03/28/19 medically clearing Patient 2 for admission. The order remained unsigned as of 04/22/19 (11 days after discharge).


Review of Patient 2's, "Reconcile Home Medication and Physician Order Form," showed Staff H gave a verbal order on 03/28/19 to discontinue the following medications: Hydroxyzine (used to treat itching caused by allergies), Lexapro (used to treat depression and anxiety), and Seroquel (used to treat symptoms of schizophrenia), Alirocumab (used to treat high cholesterol). The order remained unsigned as of 04/22/19 (11 days after discharge).

Review of Patient 2's, "Admit Orders/Preliminary Plan of Care," showed Staff E gave a verbal order for the prescribed plan of care on 03/28/19. Staff E failed to sign the verbal order as of 04/22/19 (11 days after discharge).


Review of Patient 4's discharged medical record on 04/23/19 showed she was admitted on [DATE] and discharged on [DATE] and the following:

Staff F, Physician gave a verbal order on 03/02/19 to medically clear Patient 4 for admission. Staff F failed to sign the verbal order as of 04/23/19. (14 days after discharge).

Staff F, Physician gave a verbal order on 03/16/19 for Lisinopril (a blood pressure medication). Staff Failed to sign the verbal order as of 04/23/19. (14 days after discharge).

Staff E, Physician gave a verbal order on 03/12/19 for Patient 4's discharge. Staff E failed to sign the verbal order as of 04/23/19 (14 days after discharge).

Staff F, Physician gave a verbal order on 03/08/19 for Diflucan (a medication used to treat yeast infections). Staff F failed to sign the verbal order as of 04/23/19. (14 days after discharge).

Staff F, Physician gave a verbal order on 03/06/19 for a culture of an abdominal wound. Staff F failed to sign the verbal order as of 04/23/19. (14 days after discharge).

Staff F, Physician gave a verbal order on 03/16/19 to discontinue Lisinopril (a medication used to treat high blood pressure). Staff F failed to sign verbal orders order as of 04/23/19. (14 days after discharge).

Staff F, Physician gave a verbal order on 04/09/19 to discharge Patient 4. Staff F failed to sign the order as of 04/23/19. (14 days after discharge).

Staff E, Physician gave a verbal order on 04/09/19 to discharge Patient 4. Staff F failed to sign the order as of 04/23/19. (14 days after discharge).


Review of Patient 5's discharged medical record on 04/22/19 showed he was admitted on [DATE] and discharged on [DATE] and the following:

Staff F, Physician gave a verbal order on date? for Aspirin 81 milligrams daily. The order was signed and dated on 10/31/18. (23 days after discharge).


Review of Patient 6's discharged medical record on 04/22/19 showed she was admitted on [DATE] and discharged on [DATE] and the following:

Staff F, Physician gave a verbal order on 10/29/18 for a nicotine patch for Patient 6. Staff F signed the order on 12/12/18. (40 days after discharge).

Staff F, Physician gave a verbal order on 10/30/18 to hold the medication Humalog (insulin used to treat diabetes) on 10/28/18 only. Staff F signed the order on 12/12/18. (40 days after discharge).

Staff F, Physician gave a verbal order on 10/31/18 to give 8 units of Humalog with 16 units as a one-time dose. Staff F signed the order on 12/12/18. (40 days after discharge).


Review of Patient 7's discharged medical record on 04/22/19 showed she was admitted on [DATE] and discharged on [DATE] and the following:

Staff F, Physician, gave a verbal order for no medication substitutions for Sodium Bicarbonate (a medication used to reduce heartburn). Staff F failed to time and date the order as of 04/22/19. (143 days after discharge).


Review of Patient 8's discharged medical record on 04/22/19 showed she was admitted on [DATE] and discharged on [DATE] and the following:

Staff F, Physician gave a verbal order on 08/10/19 for performing a straight catheterization to obtain a urine sample on Patient 8. Staff F signed the verbal order on 09/19/18. (31 days after discharge).


Review of Patient 10's discharged medical record on 04/22/19 showed he was admitted on [DATE] and discharged on [DATE] and the following:

Unidentified Staff on 04/07/19 gave a verbal order for Patient 10's discharge. Unidentified Staff failed to sign the verbal order as of 04/22/19. (12 days after discharge).

Staff H, Advanced Practice Registered Nurse (APRN) gave a verbal order on 04/10/19 to discharge Patient 10. Staff H failed to sign the verbal order as of 04/22/19. (12 days after discharge).

Staff E, Physician gave a verbal order on 03/22/19 to admit Patient 10. Staff H, APRN signed the verbal order and failed to time and date the order as of 04/22/19. (12 days after discharge). Staff E failed to sign the order as of 04/22/19. (12 days after discharge).

Staff F, Physician gave a verbal order on 04/05/19 for laboratory studies. Staff F failed to sign and date the order as of 04/22/19. (12 days after discharge).

Staff H, Advanced Practice Registered Nurse (APRN) gave a verbal order on 03/31/19 to increase Risperdal (a medication used to treat mood disorders). Staff H failed to sign the verbal order as of 04/22/19. (12 days after discharge).


Review of Patient 11's discharged medical record on 04/22/19 showed he was admitted on [DATE] and discharged on [DATE] and the following:

Staff E, Physician gave a verbal order for Patient 11 to be discharged on [DATE]. Staff E failed to sign the order as of 04/22/19. (6 days after discharge).

Staff H, Advanced Practice Registered Nurse (APRN) gave a verbal order on 04/10/19 to discontinue two medications, Anbesol (a medication used to treat tooth pain) and Linagliptin (a medication used to treat diabetes) and add two medications, Januvia (a medication used to treat diabetes) and Isosorbide (a medication used to prevent chest pain). Staff H failed to sign the verbal order as of 04/22/19. (6 days after discharge).

Staff E, Physician gave a verbal order for Patient 11's discharge on 04/16/19. Staff E failed to sign the order as of 04/22/19. (6 days after discharge).

During an interview on 04/30/19 at 1:15 PM, Staff A, CEO, stated, "In our policies the providers are required to sign orders within 72 hours after discharge or 30-days whichever comes first".
VIOLATION: CONTENT OF RECORD Tag No: A0458
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on staff interview, record review, document and policies and procedures review the hospital failed to ensure providers completed a medical history and physical examination (H&P) and placed it in the medical record within 24 hours after admission for 11 of 20 sampled patients (Patient 2, 3, 5, 9-11, 14-15, and 18-20) admitted between 09/01/18 to 04/22/19.

This deficient practice has the potential to cause a disruption in the continuity of care which could lead to poor patient outcomes.

Findings Include:

Document review of hospital's policy titled, "Medical Record Content Policy," revised on 12/16, showed providers are to perform a physical health examination within 24-hours of admission or sooner as appropriate to the physical health needs of the patient.

Document review of the hospital's "Medical and Professional Staff Organization Bylaws," adopted on 12/12/16, showed the hospital failed to include a provision requiring H&P's to be completed and documented in the medical record less than 30 days prior to admission or within 24 hours after admission.

Patient 2's medical record review showed he was admitted on [DATE] and a H&P transcription was not completed for placement in the medical record until 04/01/19 which is greater than 24-hours after admission.

Patient 3's medical record review showed he was admitted on [DATE] and a H&P transcription was not completed for placement in the medical record until 03/28/19 which is greater than 24-hours after admission.

Patient 5's medical record review showed he was admitted on [DATE] and a H&P was signed and dated 09/28/18 which is greater than 24-hours after admission.

Patient 9's medical record review showed he was admitted on [DATE] and a H&P transcription was not completed for placement in the medical record until 02/10/19 which is greater than 24-hours after admission.

Patient 10's medical record review showed he was admitted on [DATE] and a H&P transcription was not completed for placement in the medical record until 03/24/19 which is greater than 24-hours after admission.

Patient 11's medical record review showed he was admitted on [DATE] and a H&P transcription was not completed for placement in the medical record until 04/10/19 which is greater than 24-hours after admission.

Patient 14's medical record review showed he was admitted on [DATE] and a H&P transcription was not completed for placement in the medical record until 04/22/19 which is greater than 24-hours after admission.

Patient 15's medical record review showed he was admitted on [DATE] and a H&P transcription was not completed for placement in the medical record until 04/22/19 which is greater than 24-hours after admission.

Patient 18's medical record review showed he was admitted on [DATE] and a H&P transcription was not completed for placement in the medical record until 04/22/19 which is greater than 24-hours after admission.

Patient 19's medical record review showed he was admitted on [DATE] and a H&P transcription was not completed for placement in the medical record until 04/18/19 which is greater than 24-hours after admission.

Patient 20's medical record review showed he was admitted on [DATE] and a H&P transcription was not completed for placement in the medical record until 04/12/19 at 11:23 AM which is greater than 24-hours after admission.

During an interview on 04/30/19 at 1:15 PM, Staff R, Medical Records, stated the expectation is that the providers must complete the history and physical within 24-hours of the patient's admission. Staff R further stated that the providers complete the H&P and then it is sent for dictation prior to being placed into the medical record.
VIOLATION: CONTENT OF RECORD - DISCHARGE DIAGNOSIS Tag No: A0469
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on staff interview, record review, document and policies and procedures review the hospital failed to ensure to complete medical records within 30 days following discharge for five of 10 discharged patients (Patients 1, and 6-9) sampled medical records between 09/01/18 to 04/22/19.

This deficient practice has the potential to cause a lack of continuity of care for patients discharged from the hospital.


Findings Include:

Document review of the hospital's "Medical and Professional Staff Organization Bylaws," adopted on 12/12/16, showed, "Practitioners must complete their patients' medical records within 30-days of each patients discharge." Medical Records Manager shall notify the practitioner of the delinquency and they will have five days to complete the medical record or they will be automatically suspended.

Document review of hospital policy titled, "Verbal and Written Orders," revised on 11/16, showed, "Verbal orders, including telephone orders, should include the date and signature of the person recording them. The prescribing or covering practitioner should authenticate the order within 72-hours of the patient's discharge or 30-days, whichever occurs first. Records of patient's discharged should be completed within 30-days following discharge".

Review of Patient 1's discharged medical record on 04/23/19 showed she was admitted on [DATE] and discharged on [DATE] and the following:

Staff F, Physician gave verbal orders on 09/02/18 for Progesterone (a hormone supplement) with no substitutions. Staff F failed to time and date the order within 30-days after discharge.

Staff U, Physician gave verbal orders on 09/01/19 for admission and preliminary plan of care. Staff U failed to time and date the order within 30-days after discharge.


Review of Patient 6's discharged medical record on 04/22/19 showed she was admitted on [DATE] and discharged on [DATE] and the following:

Staff F, Physician gave a verbal order on 10/29/18 for a nicotine patch for Patient 6. Staff F signed the order on 12/12/18. (40 days after discharge).

Staff F, Physician gave a verbal order on 10/30/18 to hold the medication Humalog (insulin used to treat diabetes) on 10/28/18 only. Staff F signed the order on 12/12/18. (40 days after discharge).

Staff F, Physician gave a verbal order on 10/31/18 to give 8 units of Humalog with 16 units as a one-time dose. Staff F signed the order on 12/12/18. (40 days after discharge).


Review of Patient 7's discharged medical record on 04/22/19 showed she was admitted on [DATE] and discharged on [DATE] and the following:

Staff F, Physician gave a verbal order on 11/08/18 for no medication substitutions for Sodium Bicarbonate (a medication used to reduce heartburn). Staff F failed to time and date the order within 30-days after discharge. (143 days).


Review of Patient 8's discharged medical record on 04/22/19 showed she was admitted on [DATE] and discharged on [DATE] and the following:

Staff F, Physician gave a verbal order on 08//10/19 for performing a straight catheterization to obtain a urine sample on Patient 8. Staff F signed the verbal order on 09/19/18. (31 days after discharge).


Review of Patient 9's discharged medical record on 04/22/19 showed he was admitted on [DATE] and discharged on [DATE] and the following:

Staff H, Advanced Practice Registered Nurse (APRN), gave a verbal order on 02/14/19 to discontinue memantine (a medication used to treat moderate to severe confusion). Staff H failed to time and date the order within 30-days after discharge. (60 days).

Staff H, APRN, gave a verbal order on 02/08/19 for acetaminophen (Tylenol, a medication used to treat pain) and Florinef (a medication used to treat conditions where the body does not produce enough steroids). Staff H failed to time and date the order within 30-days after discharge. (60 days).


During an interview on 04/30/19 at 1:15 PM, Staff R, Medical Records, stated, "In our policies the providers should be suspended if they haven't signed their orders within 30 days. We haven't enforced that here, but we may have to start doing that".
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, staff interview, and review of the hospital policies and procedures the hospital failed to ensure expired supplies were removed from patient use, failed to ensure that staff members (Staff J, RN) properly donned personal protective equipment (PPE) when providing wound care for one of one patients (Patient 25) and when passing medications for seven of seven patients (Patient 16, 17, 18, 22, 25, 26, and 27), failed to ensure one of one flushable basins and three of three observed air vents were clean, failed to ensure initial health examinations were completed for four of ten personnel records reviewed (Staff I, J, L, and Q), failed to ensure periodic health evaluations were completed for four of ten personnel records reviewed (Staff C, K, O, and P) , failed to ensure tuberculin (TB) skin tests or chest x-rays were completed for four of ten personnel records reviewed (Staff I, J, L, and Q) during new hire orientation; failed to ensure a TB test was provided annually for one of ten personnel files reviewed (Staff K); and failed to ensure immunization history for eight of ten personnel records reviewed (Staff C, I, J, K, L, M, N, and Q).

These deficient practices place all patients and staff at risk of infection, illness, and communicable diseases.

Findings Include:


Document review of the hospitals policy titled, "Infection Prevention and Control Program" showed, "The facilities Infection Prevention and Control Plan ensures that this organization develops, implements and maintains and active, organization-wide program for the prevention, control and investigation of infections and communicable diseases in order to reduce the risks of endemic and epidemic infections in patients, visitors and healthcare workers, and to optimize use of resources".

Review of the hospital's "Infection Control" Binder on 04/30/2019 showed the infection control officer, Director of Nursing (DON), failed to complete employee health program information which was to include immunization and exposure information, Behavioral Health Facility Surveillance information which was to include information on Hospital Acquired Infections and Community Acquired Infections, employee education including hand hygiene, isolation precautions, prevention of urinary tract infections, cleaning techniques and other infection control education offerings, the Antibiotic and Organism Yearly Summary, the QAPI monitoring for basic disinfection, hand hygiene, patient identifiers, and the Infection control tracking reports for February 2019, March 2019, and April 2019.
Review of the hospitals QAPI report on 04/30/19 showed during the 02/14/19 and 03/15/19 meetings no infection control information was reported.


Document review of the hospital's policies and procedures on 04/30/19 showed the hospital failed to provide a policy that directed staff to dispose of expired supplies.

Observation on 04/22/19 at 10:45 AM showed a room labeled Oxygen Room which revealed the following:

1. One open Yankauer (airway suction device) with packaging that states it is a single use sterile item. The Yankauer was open and connected to suction tubing which made it no longer sterile and unable to verify if had been used.

During an interview on 04/22/19 at 10:45 AM, Staff A, DON, stated, "I don't know why someone would have done that. Maybe they thought they were supposed to".

2. One StartSwab II (a culture swab) with an expiration date of 02/01/19

3. One Foley catheter tray (a device used to remove urine from the bladder) with an expiration date of 02/2018.

4. Three fabric gait belts with obvious signs of dirt and wear.

During an interview on 04/22/19 at 10:45 AM, Staff A, DON, stated, "I don't know why those are even up there. Yes, staff must have used those, and they should have thrown them away. We do not launder them we use them on a specific patient and throw them away when they are discharged ".


5. One flushable basin with a greenish substance staining the basins bottom, and there was no PPE, i.e. gowns, gloves, masks or goggles at the basin for staff use.

During an interview on 04/22/19 at 10:45 AM Staff B, CEO, stated that he did not know what the greenish substance in the basin was and stated, "I think the housekeepers are responsible for cleaning that, but I am not sure."


6. Air vent located directly outside the Oxygen Room showed to have a buildup of dust/dirt.

During an interview on 04/22/19 at 11:00 AM, Staff A, DON, stated, "that really looks bad and should have been cleaned". Staff A stated that Staff T, Environmental of Care (EOC) Director, is responsible for providing oversight of the housekeeping staff.


Observation on 04/22/19 at 11:00 AM showed a room identified as the Seclusion Room with an air vent containing a buildup of dust/dirt.

Observation on 04/22/19 at 11:15 AM showed a room identified as the Shower Room with an air vent containing a buildup of dust/dirt.

During an interview on 04/30/19 at 8:15 AM Staff T, EOC Director, stated that he does two environmental rounds per day to make sure things are clean. Staff T stated that he just seen the greenish growth in the bottom of the flushable basin the other day and did not know what it was. Staff T stated that the housekeepers should have been cleaning that along with the mental health technicians who use also use the basin. Staff T stated that he had noticed that the vents thought out the hospital were dirty and "he needed to get on that".


Document review of a hospital policy titled, "Hand Hygiene - CDC Guidelines" dated effective 09/2016 and revised 11/2016 showed: "To provide guidelines for effective hand hygiene, in order to prevent the transmission of bacteria, germs and infections." ..."All staff will use the hand-hygiene techniques, as set forth in the following procedure." ..."Before each patient encounter" ..."After coming in contact with patient intact skin, i.e., taking a patient's blood pressure, pulse, lifting/moving the patient." ..."Always after removing gloves or facemasks." ..."Always follow standard precautions." ...Gloves are to be worn when contact with blood, bodily fluids, mucous membranes, dressings, non-intact skin, etc., is anticipated."

Observation on 04/29/19 at 2:45 PM in the dining room showed Staff J, RN passing medications. Staff J put on gloves without washing her hands, poured water in a small cup, removed medications from a bin in the medication cart, she went to Patient 16, gave him the medication, took the cup back, opened the medication cart drawer, threw the cup away and removed her gloves, she then put on another pair of gloves without washing her hands. Patient 18 then came to the cart, Staff J pour water, removed medication from a bin in the medication cart, handed the medication and water to Patient 18, Staff J removed her gloves, put on a new pair without washing her hands and was going to give Patient 22 his medication but had to return to the medication room for additional medications. She removed the gloves and did not wash her hands. On her way to the medication room Staff J was approached by Staff Q, MHT, who had Patient 25 with her. Staff Q pointed out areas on Patient 25's arms that were actively bleeding. Staff J, RN touched both of Patient 25's arms, without washing her hands, to examine the areas that were bleeding. Staff J then went into the medication room, collected skin cleansing solution, non-adhesive bandages, gauze, wrap and tape from a cabinet just inside the door without washing her hands. Staff J did not wash her hands prior to putting on gloves, she then cleaned the wounds with the cleansing solution and gauze, removed her gloves, did not wash hands or put on gloves to apply the bandages to Patient 25's arms.

During an interview on 04/29/19 at 3:10 PM, Staff J, RN stated that she thought the policy for hand hygiene was to wash between, before and after each patient and stated, "but I don't know their policy."

Continued observation showed that Staff J washed her hands in the dining room sink after she was asked about the hand hygiene policy. She then passed medications to Patients 17, 22, 25, 26 and 27 without washing her hands between each patient.

During an interview on 04/29/19 at 3:20 PM, Staff J, RN, was asked why she didn't perform hand hygiene between each patient she stated that she had not touched the pills with her hands.

During an interview on 04/30/19 at 12:15 PM, Staff A, DON stated that hand hygiene is required to be done between each patient when passing medications and between glove changes.

During an interview on 04/30/2019 at 12:00 PM, Staff A, DON, stated the she quit working at the hospital in February 2019 and Staff K, RN, was to be her replacement. Staff A stated that Staff K was also supposed to take over the infection control officer duties. Staff A stated, "I don't know why there is no documentation for February, March, and April". Staff A stated, "It is too much for someone to be the DON and the infection control officer".



Document review of the hospital's policies and procedures on 04/30/19 showed the hospital failed to provide a policy for initial and periodic health examinations.

Document review of the hospital's policies and procedures on 04/30/19 showed the hospital failed to provide a policy for immunization history of personnel.

Review of hospital documents titled "Job Description" with revision date of 10/01/17 showed: "Job Title: Director of Nursing" (DON) "The employee must provide documentation of a tuberculosis test during new hire orientation and annually thereafter." "Job Title: Registered Nurses" "The employee must provide documentation of a tuberculosis test during new hire orientation and annually thereafter." "Job Title: Licensed Practical Nurses," "The employee must provide documentation of a tuberculosis test during new hire orientation and annually thereafter." "Job Title: Mental Health Technician" "The employee must provide documentation of a tuberculosis test during new hire orientation and annually thereafter."

Review of Staff C, Mental Health Technician's (MHT) personnel file showed a hire date of 05/18/18. There was no evidence of periodic health examination or immunization history in the personnel file.

Review of Staff I, Registered Nurse's (RN) personnel file showed a hire date of 12/27/18. There was no evidence of an initial health examination, immunization history, or TB testing in the personnel file.

Review of Staff J, RN's personnel file showed a hire date of 04/19/19. There was no evidence of an initial health examination, immunization history, or TB (tuberculosis) testing in the personnel file.

Review of Staff K, RN, interim Director of Nursing's (DON) personnel file showed a hire date of 09/27/17. There was no evidence of a periodic health assessment, immunization history, or an annual TB test in the personnel file.

Review of Staff L, Licensed Practical Nurses (LPN) personnel file showed a hire date of 12/04/18. There was no evidence of an initial health examination, immunization history, or a TB test in the personnel file.

Review of Staff O, MHT's personnel file showed a hire date of 01/27/17. There was no evidence of a periodic health assessment or immunization history in the personnel file.

Review of Staff P, MHT's personnel file showed a hire date of 05/17/17. There was no evidence of a periodic health assessment or immunization history in the personnel file.

Review of Staff Q, MHT's personnel file showed a hire date of 04/09/19. There was no evidence of an initial health examination, immunization history, or TB test in the personnel file.

During an interview on 04/30/19 at 9:00 AM, Staff S, Human Resource Director (HR) stated that periodic health assessments are due annually.

During an interview on 04/30/19 at 9:00 AM, Staff S, Human Resource Director (HR) stated that staff need an initial health exam and immunizations record in their personnel file.

During an interview on 04/30/19 at 10:15 AM Staff B, Chief Executive Officer stated that he wasn't aware of the need for immunization records.