HospitalInspections.org

Based on record review, observation and interview, the facility failed to:


A.) Follow its own policy and procedure to assist patients to exercise their rights in 2(#1and 9) of 2 pt. charts reviewed. The facility failed to complete a four-hour discharge notice when the voluntary patients requested to leave Against Medical Advice (AMA).

Refer to Tag A0129



B.) Prohibit the use of "as needed" (PRN) psychotropic medications for the use of restraint or seclusion found in 3(#2, #3 and #5) of 3 patient charts reviewed.

C.) Recognize chemical restraints/emergency behavioral medications (EBM) as restraints and failed to follow, track, or analyze data on the usage and effectiveness of psychotropic medications.

D.) Document in the patient medical record about the patient's behaviors, incidents, care received before and after a chemical restraint was administered, and the physician failed to document the use of chemical restraint in 1(5) of 3(#2, #3 and #5) patient charts reviewed.

E.) Follow policy and procedures for Restraint and Seclusion and Now Order for Emergency Administration of Psychoactive Medication. Restraint packets were not being completed or started for the administration of Chemical Restraints/EBM.

F.) Initiate or complete restraint packet, perform a face to face, or reassessments. There were chemical restraints administered with no de-escalation documented, an attempt to place the patient in restraints or 1:1 before medication in 3(#2, #3 and #5) of 3 patient charts reviewed. Nursing staff subjectively administered PRN psychotropic medications without a scope, scale, or standards for degrees of agitation, or aggression.

G.) provide a safe environment for the treatment of psychiatric patients on 1 unit (Unit 3) of 2 units observed (Unit 3 and Unit 4). The facility was aware that patients could easily access the nursing station by reaching over the half door and opening the door using the inside door handle. Despite having knowledge of this, the facility failed to identify and remove potential patient hazards from the nursing station. The facility staff failed to conduct and document 15-minute patient safety checks on patients as required.

The deficient practices identified above were determined to pose Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Refer to Tag A0144



H.)ensure all patients were provided with warm water for showers and daily care. 2 (Room's #308 and #306) out of 2 patient rooms were found to have no hot water in the bathrooms.

Refer to Tag A0145



I.) ensure that 4 out of 4 medical staff members' (Staff #15, Staff #22, Staff #23, and Staff #24) credential files reviewed had been appropriately credentialed and/or appointed to the Medical Staff in accordance with Medical Staff Bylaws.

Refer to Tag A0046



J.) have evidence of acuity levels being used for safe staffing matrix.
K.) identify nursing staff working in the facility from staffing agencies.
L.) have employee files, competencies, orientation to the facility, current licenses, education, training, or criminal backgrounds of agency nurses in 3(36, 37, and 38) of 3 agency nurse employee files.

Refer to Tag A0386


M.) Document in the patient medical record about the patient's behaviors, incidents, care received before and after a chemical restraint was administered, and the physician failed to document the use of chemical restraint in 1(5) of 3(#2, #3 and #5) patient charts reviewed.

N.) Follow policy and procedures for Restraint and Seclusion and Now Order for Emergency Administration of Psychoactive Medication. Restraint packets were not being completed or started for the administration of Chemical Restraints/EBM.

O.) initiate or complete restraint packet, perform a face to face, or reassessments. There were chemical restraints administered with no de-escalation documented, an attempt to place the patient in restraints or 1:1 before medication in 3(#2, #3 and #5) of 3 patient charts reviewed. Nursing staff subjectively administered PRN psychotropic medications without a scope, scale, or standards for degrees of agitation, or aggression.

Refer to Tag A0395


P.) administer medications in an appropriate time frame in 2 (#1 and #8) of 2 patient charts reviewed.

Refer to Tag A0405



Q.) establish a Utilization Review Committee of two or more practitioners that could carry out the review function and who were not professionally involved in the care of patients being reviewed.
Refer to Tag A0654

R.) establish objective continued stay criteria for inpatient psychiatric admissions for the Utilization Review Nurse to use in determining if the patient meets inpatient criteria or needs to be referred to the attending physician, Medical Director, or Utilization Review Committee for follow-up.
Refer to Tag A0655

S.) ensure that extended stay outliers were defined in a Utilization Review Plan and reviewed by the Utilization Review Committee.
Refer to Tag A0657




40989


T.) Based on document review and interview, the Governing Body failed to ensure that 31 of 32 Policies and Procedures were reviewed and/or revised annually according to the facility policy.

Review of Policy and Procedure GOV-1:002 with the latest review and approval date of 2/23/18 revealed the following:

" ...PROCEDURE:
1.Governing Body functions include:
A. Reviewing annually, or more frequently as events require:
o Policies and Procedures,
o Performance Improvement Activities,
o Management of Information functions,
o Safety and Infection Control,
o Monitoring and Evaluation Data,
o Written Plan for Clinical Services ..."

Review of the Policy and Procedures for the Food Services Department revealed the following: 8 (Policy #'s FOS-7:105, #1:1000, #2:005, #3:003, #3:004, #6:000, #6:005, and #6:019) of 9 policies have not been reviewed/revised since 12/1/09.
2 (Policy #'s FOS-#6:011 and #6:008) of 2 policies have no review or approval date.

An interview with Staff #3 was conducted on 3/19/2019 after 9:30 AM. Staff #3 was asked why the policies for the Food Service Department had not been reviewed or revised before the kitchen reopened in October.. Staff #3 stated she was not aware the policies had not been reviewed before the kitchen reopened. Staff #3 stated she was aware the policies were to be reviewed annually.

Review of Policy and Procedures for the Nursing Department revealed the following: 6 (Policy #'s NUR-7:064, NUR-7:011, NUR-7:130, NUR-7:084, NUR-7:042, and NUR-7:004) of 6 policies have not been reviewed/revised since 02/18.

Review of Policy and Procedures for the EOC-Safety Management Program revealed the following: 14 (Policy #'s SMP-4:000, SMP-4:001, SMP-4:002, SMP-4:003, SMP-4:004, SMP-4:005, SMP-4:006, SMP-4:007, SMP-4:008, SMP-4:009, SMP-4:010, SMP-4:011, SMP-4:012, SMP-4:013) of 14 policies have not been reviewed/revised since 1/10/18.

Review of Policy and Procedures for the Life Safety Management Program, Fire Drills #LSM-5:009 had not been reviewed/revised since 1/10/2018.

Based on record review, observation and interview the facility failed to:


A.) Follow its own policy and procedure to assist patients to exercise their rights in 2(#1and 9) out 2 pt. charts reviewed. The facility failed to complete a four-hour discharge notice when the voluntary patients requested to leave Against Medical Advice (AMA).

Refer to Tag A0129


B.) Prohibit the use of "as needed" (PRN) psychotropic medications for the use of restraint or seclusion found in 3(#2, #3 and #5) of 3 patient charts reviewed.

C.)Recognize chemical restraints/emergency behavioral medications (EBM) as restraints and failed to follow, track, or analyze data on the usage or how the effectiveness of psychotropic medications.

D.) Document in the patient medical record about the patient's behaviors, incidents, care received before and after a chemical restraint was administered, and the physician failed to document the use of chemical restraint in 1(5) of 3(#2, #3 and #5) patient charts reviewed.

E.) Follow policy and procedures for Restraint and Seclusion and Now Order for Emergency Administration of Psychoactive Medication. Restraint packets were not being completed or started for the administration of Chemical Restraints/EBM.

F.) Initiate or complete restraint packet, perform a face to face, or reassessments. There were chemical restraints administered with no de-escalation documented, an attempt to place the patient in restraints or 1:1 before medication in 3(#2, #3 and #5) of 3 patient charts reviewed. Nursing staff subjectively administered PRN psychotropic medications without a scope, scale, or standards for degrees of agitation, or aggression.

G.) Provide a safe environment for the treatment of psychiatric patients on 1 unit (Unit 3) out 2 units observed (Unit 3 and Unit 4). The facility was aware that patients could easily access the nursing station by reaching over the half door and opening the door using the inside door handle. Despite having knowledge of this, the facility failed to identify and remove potential patient hazards from the nursing station. The facility staff failed to conduct and document 15-minute patient safety checks on patients as required.

The deficient practices identified above were determined to pose Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Refer to Tag A0144

H.) ensure all patients were provided with warm water for showers and daily care. 2 (Room's #308 and #306) out of 2 patient rooms were found to have no hot water in the bathrooms.

Refer to Tag A0145

Based on review and interview the facility failed to:

A..) have evidence of acuity levels being used for safe staffing matrix.
B.) identify nursing staff working in the facility from staffing agencies.
C..) have employee files, competencies, orientation to the facility, current licenses, education, training, or criminal backgrounds of agency nurses in 3(36, 37, and 38) of 3 agency nurse employee files.

Refer to Tag A0386

D.) Document in the patient medical record about the patient's behaviors, incidents, care received before and after a chemical restraint was administered, and the physician failed to document the use of chemical restraint in 1(5) of 3(#2, #3 and #5) patient charts reviewed.

E.) Follow policy and procedures for Restraint and Seclusion and Now Order for Emergency Administration of Psychoactive Medication. Restraint packets were not being completed or started for the administration of Chemical Restraints/EBM.

F.) initiate or complete restraint packet, perform a face to face, or reassessments. There were chemical restraints administered with no de-escalation documented, an attempt to place the patient in restraints or 1:1 before medication in 3(#2, #3 and #5) of 3 patient charts reviewed. Nursing staff subjectively administered PRN psychotropic medications without a scope, scale, or standards for degrees of agitation, or aggression.



G. administer medications in an appropriate time frame in 2 (#1 and #8) of 2 patient charts reviewed.

Refer to Tag A0405

Based on review of records and interview, the facility failed to implement an effective utilization review plan. The facility was unable to provide a Utilization Review Plan for 2018 and 2019. The facility failed to:

A. establish a Utilization Review Committee of two or more practitioners that could carry out the review function and who were not professionally involved in the care of patients being reviewed.
Refer to Tag A0654

B. establish objective continued stay criteria for inpatient psychiatric admissions for the Utilization Review Nurse to use in determining if the patient meets inpatient criteria or needs to be referred to the attending physician, Medical Director, or Utilization Review Committee for follow-up.
Refer to Tag A0655

C. ensure that extended stay outliers were defined in a Utilization Review Plan and reviewed by the Utilization Review Committee.
Refer to Tag A0657

Based on review of records and interview, the Governing Body failed to ensure that 4 out of 4 medical staff members' (Staff #15, Staff #22, Staff #23, and Staff #24) credential files reviewed had been appropriately credentialed and/or appointed to the Medical Staff in accordance with Medical Staff Bylaws.

Findings for Staff #15 included:

A review of Medical Staff Bylaws and Medical Staff Credentialing was conducted on the morning of 3-19-2019.

Review of Staff #15's credential file showed that an application for Medical Staff membership was made in November of 2017. A letter from the Chief Executive Officer, dated 12/13/2017 stated the following:
"It is my privilege to notify you that upon recommendation of the Medical Executive Committee, the Board of Directors approved your appointment of Provisional Status to the Medical Staff at Magnolia Behavioral Hospital of East Texas for a period of one (1) year on December 13, 2017. Your appointment is to the Provisional category with privileges in Telemedicine and Psychiatry."

An agreement for services between Staff #15 and the Hospital, effective the "14th day of December 2017", was found in the credential chart and reviewed as follows:
"Medical Director & Professional Services Agreement
...
1. Qualifications of the Professional Services. To satisfy the Hospital's criteria for appointment and retention of the position of Professional Services, the Physician shall at all times during the term of this Agreement:

A ...
B. Retain membership in good standing on the Hospital's medical staff, with unrestricted clinical privileges in psychiatry in accordance with the Hospital's medical staff bylaws, rules, regulations and policies. Physician shall not be entitled to appointment, reappointment or any clinical privileges at Hospital by virtue of this Agreement."

Review of the Medical Staff Bylaws, adopted on 2/23/2018 was made as follows:
"3.4.1. Duration and Renewal of Initial and Modified Appointments. All provisional appointments, and modifications of appointments pursuant to Section 5.6, shall be for a period of one year. At the end of one year the physician/ARNP or Allied Therapist will transition and receive a letter from the hospital stating they have achieved Active status for period of one year.
...
3.5.2 Duration of Provisional Status. Provisional Status shall be for one year (1) year. If the Medical Executive Committee fails within that period to make the determination required in Section 3.5.1, his staff status or particular clinical privileges, as applicable, shall automatically terminate. The appointee so affected shall be given special notice of such termination and shall be entitled to procedural rights afforded in Article 8."

Review of Governing Body meeting minutes in February 2019. No evidence that Governing Body had approved Staff #15 to be appointed to Active status was present in the minutes. This indicated that Staff #15's staff status, per the bylaws, should have been automatically terminated. Staff #15 was still practicing in the hospital at the time of the survey.


Findings for Staff #22 included:

Review of Staff #22's credential file showed that an application to the Medical Staff had been made in February of 2018. A form for Delineation of Clinical Responsibilities was in the file and signed by the "Board of Directors:" on 3-2-2018 and stated "CLINICAL RESPONSIBILITIES GRANTED AND APPROVED."

No letter of appointment was found in the file to indicate the Status appointed to or duration of appointment. Per the medical staff bylaws, it should have been Provisional status good for one year then transitioned to Active status.

Review of the Medical Executive meeting minutes for 2019 and Governing Body meeting minutes for 2019, Staff #22's transition from Provisional status to Active status had not been submitted nor discussed. Per the bylaws, Staff #22 should have been automatically terminated. No evidence was presented that Staff #22 had been removed from the Medical Staff.


Findings for Staff #23 included:

Review of Staff #23's credential file showed that an application to the Medical Staff had been made in May of 2018. A form for Delineation of Clinical Responsibilities was in the file and signed by the Credentialing Committee on 5-1-2018. The Board of Directors signature was blank. The blocks for the applicant, Staff #23, to place her initials if requesting that particular Clinical Responsibility were all left blank, as if no Clinical Responsibilities were requested by Staff #23. All of the Clinical Responsibilities were checked off in the "Recommended" column for the Committee Recommendations section. A second form was in the file that had been faxed and returned. There appeared to be a signature in Board of Director's signature line with a date of 6/5/18. However, the copy was of such poor quality, it could not be determined if this was the same form with no Clinical Responsibilities being requested by Staff #23, or if it was a different form with Clinical Responsibilities requested by Staff #23 and granted by the Credentialing Committee and Board of Directors.

No letter of appointment was found in the file to indicate the Status appointed to, duration of appointment, or Clinical Responsibilities approved.

Findings for Staff #24 Included:

Review of Staff #24's credential file showed that an application to the Medical Staff had been made in December of 2016. A letter from the Administrator was dated January 9, 2016 (sic) and stated:
"It is my privilege to notify you that upon recommendation of the Medical Executive Committee, the Governing Board of Directors approved your appointment to Active Status of the Medical Staff at Magnolia Behavioral Hospital of East Texas for a period of one (1) year on December 15, 2016 (sic). Your appointment is to the Active category with privileges in Family Practitioner Services."

A form for Delineation of Clinical Responsibilities was in the file and signed by the "Board of Directors:" on 01-19-2017 and stated "CLINICAL RESPONSIBILITIES GRANTED AND APPROVED."

A second form for Delineation of Clinical Responsibilities was in the file and signed by the applicant, Staff #24, the Credentialing Committee and the Board of Directors on 8-2-2018 and stated "CLINICAL RESPONSIBILITIES GRANTED AND APPROVED.

No application for reappointment to medical staff was found in the credential file. No other letter of appointment was found in the file to indicate the Status appointed to, duration of appointment, or Clinical Responsibilities approved.

Review of Medical Staff Bylaws was as follows:

"5.5.1 Information Form For Reappointment. All appointments are subject to renewal not to exceed two years upon appointment by the Board to Medical Staff. The Director of Human Resources will notify appointees in a timely fashion that their appointments are subject to renewal and provide them with reappointment application. Each person who desires reappointment shall submit reappointment application to the Medical Staff Office in a timely manner so that the application can be processed pursuant to Section 5.5.8. Failure to so return the form shall be deemed a voluntary resignation from appointment/reappointment status and shall result in automatic termination of appointment/reappointment status together with all clinical privileges at the expiration of such person's current term. Such action shall not be deemed to be adverse to the applicant and, as such, the provisions of article 8 are not applicable."

On the morning of 3-19-2019, an interview was conducted with Staff #10. Staff #10 stated that the only thing she had been trained on for credentialing was "how to look up things" like licenses. Staff #10 stated that everything is forwarded to the corporate office and the corporate office takes care of all credentialing.

Based on recordreview, observation and interview the facility failed to follow its own policy and procedure to assist patients to exercise their rights in 2(#1and 9) of 2 pt. charts reviewed. The facility failed to complete a four-hour discharge notice when the voluntary patients requested to leave Against Medical Advice (AMA).

Review of Patient #1's "Daily Nursing Assessment" sheet dated 2/4/19 at 0815 (8:15AM) stated, "Pt. requested discharge. Stated he is only here for anti-depressant since he doesn't have a local doctor. Faxed H&P to pharmacy for medications. Pt. requesting to go home. Informed pt. he must be seen by the physician prior to any discharge planning. Pt. pacing back and forth, very much in control but obviously irritated/upset. Emotional support provided.
10:00AM- Pt going to group activities and is participating. Repeatedly asking when Dr. will be here. He denies any suicidal/homicidal ideation at this time.
12:00PM- Pt again requesting discharge, reeducated pt. in physician needing to evaluate him prior. Informed nurses that his wife will be here at 1330 to take him home. Pt continues pacing up and down hallway.
1400 (2:00PM)- Pt spoke with _____(psychiatrist) regarding his desire to be discharged. Dr. informed him he will evaluate his medical records and make a determination.
1500(3:00PM)- Nursing supervisor here to talk with pt. regarding his wishes.
1700 (5:00PM)- Nursing sup and CEO discussing pt status with him. Pt upon conclusion of meeting states he's staying 24 more hours. Will continue to monitor and assess."

Review of Patient #1's chart revealed there was no "Four -Hour Discharge" form on the patient's chart. Once a voluntary patient has made his or hers request to discharge from the facility, the facility should offer the patient a "Four Hour Discharge Notice (Against Medical Advice)" form.

Review of the facility's policy and procedure, "Against Medical Advice/Request for Discharge" stated, "POLICY:
Only voluntary patients may leave the Magnolia Behavioral Hospital of East Texas against the advice of their physician after a written request for discharge is filed with the facility administrator or the administrator's designee when:

The patient is in no clear danger to themselves or others.
The patient is able, as determined by the staff present, to provide for their basic needs. The patient has received an explanation of the risks involved.
The attending physician and appropriate patient representatives have been notified.
The Against Medical Advice Discharge Form has been completed.

The request must be signed, timed, and dated by the patient or a person legally responsible for the patient and must be made a part of the patient's clinical record.

If a patient informs an employee of, or person associated with, the facility, of the patient's desire to leave the facility, the employee or person shall, as soon, as possible, assist the patient, in creating, the written request and present it to the patient, for the patient's signature If a patient rescinds his/her Request to Leave Treatment and decides to stay, the physician shall be notified and a note documented in the patient's medical record.

PROCEDURE:
When the patient verbally requests or provides a written document that requests discharge, a progress note must be made in the chart, including date and time.

The AMA Intervention Summary Form shall be initiated by the charge nurse or house supervisor.

The facility shall, within one hour after a request for discharge is filed, notify the physician responsible for the patient's treatment.

All members of the treatment team are notified, patient will meet with the therapist in order to determine if a problem within the hospital exists and whether it can be remedied so that the patient's treatment may continue.

The notified physician shall discharge the patient before the end of the four-hour period unless

A physician who has reasonable cause to believe that a patient might meet the criteria for court-ordered mental health services or emergency detention shall examine the patient as soon as possible within 24 hours after the time the request for discharge is filed.

The physician shall discharge the patient on completion of the examination unless the physician determines that the person meets the criteria for court-ordered mental health services or emergency detention.

If the physician makes a determination that the patient meets the criteria for court-ordered mental health services or emergency detention, the physician shall, not later than 4 PM on the next succeeding business day after the date on which the examination occurs, either discharge the patient or file an application for court-ordered mental health services or emergency detention and obtain a written order for further detention.

The charge nurse/designee shall ensure that the AMA Discharge from is completed, signed by the patient and witnessed.

The charge nurse/designee will notify the psychiatrist of any/all medications being returned to the patient (those brought in at time of admission).

Before the patient leaves the facility, there shall be an explanation given to the patient or the patient's representative concerning the risks involved.

Should the patient or the patient's representative persist in a refusal to remain in the facility, a full assessment should be made on the patient's medical record. Such statement should include a description of the precipitation factors leading to the request and the fact that the patient or his/her representative persists in the refusal."


Review of Patient #1's chart revealed there was no physician progress noted conversation of discharge request. Review of the "Inpatient Psychiatric Evaluation" dated 2/4/19 at 1300 (1:00PM). The physician documented under Justification for inpatient care:
The patient is gravely disabled due to inability to care for self, hallucinations, delusions, agitation, anxiety, depression, or other factors resulting in loss of function."

The medical history section was left blank and the physician documented the patient was not presently homicidal or suicidal. The patient had clear speech and organized thoughts. Pt was oriented x4. A side note on page five stated, "Start OPC, request D/C and is high risk for suicide."

Review of the physician orders revealed a telephone order dated 2/4/19 at 1530 (3:30PM), "initiate OPC paperwork." There was no reason on the order to hold the patient and why the patient needed an OPC. There was no found documentation of OPC paperwork initiated.

Review of the physician progress note on 2/5/19 at 11:00AM revealed the patient was still requesting to be discharged and the physician documented, "D/C today AMA no OPC- does not meet criteria."

Review of Patient #1's chart revealed a Four- Hour discharge notice was found on the chart dated 2/5/19 at 11:45AM, 30 minutes after the physician had given an order for AMA discharge.

Review of Patient #1's chart revealed there was no nurse's notes found for 2/5/19. There was no evidence documented of the patients medical or mental condition at discharge, when the patient left the facility, with whom, or if the patient was discharged with any instructions. A form called "Aftercare Plan and Instructions" was found dated 2/5/19 at 11:55AM. The form had AMA checked and had written "pt left AMA." The patient, the RN and D/C planner had all signed it.

Review of the facility's log for "Leaving Against Medical Advice" did not have Patient #1's name on it.

Staff #1 reported the facility failed to offer the four- hour discharge form to the patient when he requested on 2/4/19. Staff #1 stated the CNO at the time had talked to the patient and did not do the four-hour discharge notice. Staff #1 stated, "He didn't think it was needed. He was not aware of the regulations when he was here."

During a tour of Unit 3 on the morning of 3/18/19 Patient #9 was standing at the nurses station asking if she could leave and go home. The patient stated to the nurse "I want to go home now" three times. The nurse told the patient to go sit down and she would be going to lunch soon. Review of #9's chart revealed she was a voluntary patient.

An interview was conducted with Staff # 20 RN on the morning of 3/18/19. The RN was asked if she had offered Patient #9 a four hour discharge notice. Staff #20 stated ," No." Staff #20 was asked why she would not give the patient the four hour discharge notice? Staff #20 was aware of the notice but not why, when or how to offer the notice. Staff #20 stated, "I never really knew when to give them the form and what to do afterwards. I have never done it before."

Based on record review, observation and interview, the facility failed to:

A.) Prohibit the use of "as needed" (PRN) psychotropic medications for the use of restraint or seclusion found in 3(#2, #3 and #5) of 3 patient charts reviewed.

B.) Recognize chemical restraints/emergency behavioral medications (EBM) as restraints and failed follow, track, or analyze data on the usage or how the effectiveness of psychotropic medications.

C.) Document in the patient medical record about the patient's behaviors, incidents, care received before and after a chemical restraint was administered, and the physician failed to document the use of chemical restraint in 1(5) of 3(#2, #3 and #5) patient charts reviewed.

D.) Follow policy and procedures for Restraint and Seclusion and Now Order for Emergency Administration of Psychoactive Medication. Restraint packets were not being completed or started for the administration of Chemical Restraints/EBM.

E.) Initiate or complete restraint packet, perform a face to face, or reassessments. There were chemical restraints administered with no de-escalation documented, an attempt to place the patient in restraints or 1:1 before medication in 3(#2, #3 and #5) of 3 patient charts reviewed. Nursing staff subjectively administered PRN psychotropic medications without a scope, scale, or standards for degrees of agitation, or aggression.


F.) Provide a safe environment for the treatment of psychiatric patients on 1 unit (Unit 3) out 2 units observed (Unit 3 and Unit 4). The facility was aware that patients could easily access the nursing station by reaching over the half door and opening the door using the inside door handle. Despite having knowledge of this, the facility failed to identify and remove potential patient hazards from the nursing station. The facility staff failed to conduct and document 15-minute patient safety checks on patients as required.

The deficient practices identified above were determined to pose Immediate Jeopardy to patient health and safety, and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.


Findings:

Review of Patient #5's chart revealed he was admitted to the facility on 2/12/19 at 21:05 (9:25PM). The patient was a 35-year-old male and was brought to the facility on a Peace Officers Warrant (POW). The officer documented, "Patient was just released from hospital on Feb 10, 2019. Patient is stating that there are people in his residence that is going to harm him. He stated he had run out of the house to keep from getting hurt. I located subject standing in the median of US Hwy 271. Patient's sister stated he has been running around the inside of the house fighting a war."
Review of the chart revealed the officer took him to the emergency room at a local hospital for a physician evaluation. Review of the physician notes from the ER on 2/12/19 stated, "Patient reports since being discharged yesterday on Zyprexa 5 mg, he reports he has had increase visual hallucinations thinking" People trying to harm me." He affirms cocaine and heroine abuse since being discharged. Per Tyler PD patient was found in the middle of HWY 271, POW has been obtained. Patient denies SI/HI. States he wants help."

Review of the Physician Preadmission Evaluation/ Management form revealed the physician saw Patient #5 on 2/12/19 at 4:43AM. The patient was admitted to the facility for Schizophrenia Paranoid Type. Patient was to be involuntary while pending involuntary commitment filing with court. He was ordered suicide precautions.
Review of the nurse's notes dated 2/13/19 at 2000 (8:00PM) A/Ox3 calm at times, anxious at times. Dr. ____ (Physician #15) called lt mes. No si/hi or (illegible word) present. No meds to give. Pt with steady gait non-aggressive behavior on unit (illegible word) in smoke breaks. Will continue to monitor. 2130 (9:30PM) Pt still anxious at unit 3 pts, new orders noted for anxiety per Dr. ___ (Physician #15), see orders." (SIC)
Review of the physician orders dated 2/13/19 at 2130 (9:30PM) revealed a telephone order for "Ativan 1 mg po q6 hours x2."

Review of the nurse's notes dated 2/13/18 at 2200(10:00PM) Pt appears to be less anxious. Pt stable on unit in chair. 2348 (11:48PM) Pt found hanging above nutrition room. Pt removed x4 -5 staff members without injury. T.O Dr.___ (Physician 15) for 50mg Benadryl Im x 1/Haldol x 10mg IM x 1 for aggression/agitation. IM shot to both delts without complication. Pt being (illegible word) by Tony RN for safety, will continue to monitor."

Review of Patient # 5's chart revealed there was no explanation of the "hanging" incident. An interview was conducted with Staff #1 on the afternoon of 3/19/19. Staff #1 stated Patient #5 had an incident report written on 2/13/19. Staff #1 stated the patient attempted to elope through the ceiling. The patient stepped on a chair and was able to access a crawl space in the ceiling and lifted himself into the ceiling. Staff was able to remove him without harm. Staff #1 stated the chair was removed to prevent that from happening again.

Review of the Physician Progress note dated 2/14/19 stated, "tried to elope last PM. was paranoid about someone hurting him so tried to elope. A little better now." (SIC) There was no documentation in the nurses notes that the patient tried to elope. There was no documentation found in the physician progress note about the use of a chemical restraint/EBM."

Review of the "Seclusion and Restraint Policy" revealed the following: "A. Restraint ....B.) Is a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition. Concerning Emergency Medication refer to policy Nur 7:112 Now Order for Emergency Administration of Psychoactive Medication.

PROCEDURE
1. Authorized physicians and licensed independent providers (LIPs) can issue a "Now" order to administer psychoactive medication to a patient without the patient's consent in an emergency situation to prevent the following:
a. Imminent probable death or substantial bodily harm to the patient because the patient is overtly or continually threatening or attempting to commit suicide or serious bodily harm.

b. Imminent physical or emotional harm to others because of threats, attempts or other acts that the patient overtly or continually makes or commits.

2. The "Now" order form is completed by the physician, LIP, or nurse in the case of a telephone order.

3. After administration of an emergency medication, the physician, LIP or nurse who did not administer emergency medication and has had proper training must conduct a one hour face to face evaluation.

a. Vital signs will be assessed within one hour of administration.

b. If multiple injections occur vital signs will be assessed every 30 minutes for 1 hour for each subsequent injection."


Review of Patient #5's chart revealed no documentation of de-escalation techniques used or least restrictive measures before using a chemical restraint. The nurse documented at 12:00AM and stated the patient was sleeping on the couch. There was no documentation of any vital signs within an hour of the medication.
There was no face to face performed.


Patient #2's chart revealed she was admitted on 12/2/18 with a diagnosis of schizophrenia. The patient was involuntary and had an Order of Protective Custody(OPC).

Review of patient #2's nurse's notes revealed on 12/4/18 at 3:50AM, Patient #2 walked up to the nurse's station demanding to call a physician. "Patient picked up phone and started banging it against the wall repeatly (sic). Staff intervene able to get phone from her. She then took hygiene bucket started hitting on countertop at nursing station repeatly (sic). Staff had intervene (sic) patient started yelling and screaming, threw cup of milk and snack across the room. Call placed to Dr.___ (Staff #15) with new order noted Haldol 5mg IM Q4hr PRN psychosis and Cogentin 2 mg IM Q4hr PRN for EPS. O400 (4:00AM) Code 10 called. Patient given Haldol 5 mg IM x1 dose and Cogentin 2 mg IM x 1 dose. She took both injections willingly without any problems." There was no documentation why a Code 10 was called if the patient was willing to take medication without intimidation or force." Interview with Staff #3 confirmed on 3/19/19 that a code 10 was called to alert other staff to assist with a patient that was "out of control" or need assistance with an "agitated or combative patient."

Review of Patient #2's chart revealed the patient did not have a face to face evaluation but did have the medication order written on a form called "Now Order for Involuntary Emergency Administration of Psychoactive Medication." This form was part of a restraint packet to assist the nurse in evaluation of the patient. The packet was incomplete. There were no vital signs or nursing assessment documented on the patient after the administration of IM psychotropic medications.

Review of patient #2's Nurses notes dated 12/4/18 revealed the patient was slamming doors, yelling and intrusive at 8:00AM.

A physician order dated 12/4/18 at 12:35PM was found written, by the physician, for "1.) Haldol 10mg IM NOW/ psychosis with Ativan 2 mg IM NOW x agitation. 2.) May repeat above in 4-8 hours (up to 2 times in 24 hours.)" There was no discontinue order written for the previous order of Haldol 5mg IM Q4hr PRN psychosis and Cogentin 2 mg IM Q4hr PRN for EPS on 2/4/19 at 3:50AM.

Review of the Medication Administration Record (MAR)on 12/4/18 revealed Patient #2 was administered the PRN order of Haldol 10mg IM with Ativan 2 mg IM at 12:35PM. There was no nursing documentation on why the patient received the medication. There was no restraint packet, face to face, or reassessment documented. There was no de-escalation documented or an attempt to place the patient in restraints or 1:1 before medication.

Review of patient #2's Nurses notes dated 12/4/18 stated, "2000 (8:00PM) Patient is yelling and screaming, very delusional, agitated and angry, tried redirect patient several times, unsuccessful. Continue to slam doors and slam stuff. Patient take shower curtain down wraps shower curtain around her waist. Patient yelling and screaming and cont to try to manipulate staff. Patient given Haldol 10mg IM x 1 dose for psychosis and Ativan 2 mg IM x 1 dose for agitation to (L) buttock using aseptic technique. Patient took the injections willingly without any problems(SIC). There was no restraint packet, face to face, or reassessment documented. There was no de-escalation documented or an attempt to place the patient in restraints or 1:1 before medication.

The physician order "Haldol 10mg IM NOW /Psychosis with Ativan 2 mg IM NOW x agitation, may repeat above order in 4-8- hours cap to 2 times in 24 hours." The medication was administered by the nurse on the following dates and times:
12/4/18 at 12:35PM, and 8:20PM.
12/05/18 at 9:40AM and 3:35PM.

Review of Patient #2's chart revealed a telephone order dated 12/6/18 at 1300 for "Haldol 10mg IM4H PRN and Ativan 2 mg IM Q4H PRN." There was no physician signature. There was no discontinuation of previous orders for Haldol IM and Ativan IM. There was no clear or updated orders for the administration of psychotropic medication administration.

Review of the MAR revealed the nursing staff administered these psychotropic medications without a scope, scale, or standards for degrees of agitation, or aggression as follows:
12/07/18 at 8:10AM, 12:45PM, and 10:40PM.
12/8/18 at 4:15AM, 8:10AM, 12:55PM, 16:35PM.
12/9/18 at 5:00AM, 9:55AM and 6:00AP.
12/10/18 at 4:30AM,9:40Am and 3:15PM.
12/11/18 at 1:00AM, 7:50AM, 1:40PM, and 9:15PM
12/12/18 at 4:20AM, 12:30PM.

On 12/15/18 an order for Geodon 20mg IM every 6 hrs. agitation PRN was administered on:
12/15/18 at 3:15PM.
12/17/18 at 6:50AM and 3:19PM.

An interview with Staff #20 RN was conducted on the morning of 3/19/19. Staff #20 confirmed she was not aware that a chemical/EBM restraint was the most restrictive restraint and that a chemical/EBM restraint could not be PRN. Staff #20 reported that her understanding of a chemical restraint, "Is when the patient refuses to take the shot and they have to be held down to give it."

An interview with Staff #8 RN was conducted on the afternoon of 3/19/19. Staff #8 confirmed he was not aware that a chemical/EBM restraint was the most restrictive restraint and that a chemical/EBM restraint could not be PRN. Staff #8 stated that he was not aware that the restraint packets needed to be done on chemical restraints. Staff #8 reported that he thought it was just for physical restraints. Staff #8 was unable to tell the surveyor how often the patient should be reassessed after an administration of a chemical restraint.

An interview with Staff #3 and #1 was conducted on the afternoon of 3/19/19. Staff #3 stated that the staff had training after 12/18 for restraints including chemical restraints. Staff #1 was instructed on the past and current findings. Staff #1 was unable to show the surveyor how the effectiveness of the training was reviewed, tracked, or analyzed. Staff #3 stated there was no PI processes in place to follow the chemical restraint usage or administration. The chemical restraints were not logged onto the restraint log. Staff #3 confirmed they were not addressing or recognizing the chemical restraints/EBM as restraints.



36827



:

The complete chart for Patient #3's admission from 1-30-2019 through 2-22-2019 was requested and provided by medical records. Review of Patient #3's chart revealed the following:

Patient #3 was a 34-year-old male brought to the facility on an Apprehension by a Peace Officer Without a Warrant (APOWW). This would allow a peace officer to emergently detain a person they believed was at risk of harm to themselves or others due to a mental health condition and transport them to a psychiatric hospital for evaluation. The APOWW was signed by the peace officer on 1-29-2019. An APOWW does not allow the facility to force the patient to take medication. Medication could only be given without consent in an emergent situation when determined by the physician that the patient was in imminent danger to self and/or others

The patient was evaluated by a physician on 1-30-2019 and an order was written as follows:
"LEGAL STATUS: Involuntary. Hold patient for involuntary admission while pending involuntary commitment filing with court."

The psychiatrist did not write an order to apply for an Order of Protective Custody (OPC) with provision to administer medications without patient consent until 2-4-2019. The request was filed on 2-5-2019 and granted on 2-12-2019.

On 1-31-2019 at 11:30 AM, Staff #15 (Psychiatrist) gave a verbal order that was written as follows:

"Haldol 10 mg IM Q4H PRN psychosis (Haldol antipsychotic medication, 10 milligrams, to be given as an injection into a muscle as needed for psychosis)
Ativan 2 mg IM Q4H PRN anxiety (Ativan antianxiety medication, 2 milligrams, to be given as an injection into a muscle as needed for anxiety)
Benadryl 50 mg IM Q4H PRN EPS (Benadryl antihistamine medication, 50 milligrams, to be given as an injection into a muscle as needed for extrapyramidal symptoms, a serious side-effect of antipsychotic medications that can include spasms and muscle contraction)
Repeat in 45 mins - 1 hour until asleep. Place in seclusion if needed (The order could be repeated by nursing staff every 45 minutes to an hour until the patient fell asleep. If the nursing staff needed, the physician gave permission for the staff to place the patient in seclusion.)"

Staff #15 signed the verbal order, as written, on 1-31-2019 at 4:00 PM.

Because the indication for use did not identify specific symptoms or behaviors, nursing staff were required to apply medical judgement as to when the symptoms of psychosis, anxiety, and EPS were severe enough to administer this combination of medications, which was outside of nursing scope of practice. The order to repeat the administration of medications until the patient is asleep showed that the intent was not to improve the patient's participation in the environment, but rather, to remove the patient from the environment. Removing the patient from the therapeutic environment using medication was a form of restraint.

Review of the Medication Administration Record (MAR) showed that the patient received injections of all three medications on 1-31-2019 at 1:45 PM and on 2-04-2019 at 6:45 PM.

Review of the chart did not include nursing notes or physician progress notes for those days to determine if the patient had been an imminent threat to himself or others. No signed consent for the medication or court order authorizing medications to be given was found for those days. No nursing assessment/reassessment was found in the chart to document the patient's condition and response to the medications given on those days. No information was found on the interdisciplinary treatment plan for the need of emergency behavioral medications or plan of care in response to needing the injections. No restraint or seclusion paperwork was found in the chart. A Social Services Progress Note for 2-5-2019 at 11:55 was found and read, "Met pt for TT. Pt had aggressive outburst on unit yesterday. Pt still refusing meds."



On the morning of 3-18-2018, a tour of Unit 3 was conducted. It was observed that no staff were in the nursing station and patients were standing by the nursing station, preparing to exit the unit to attend programming. The half-door entrance was observed to be locked from the outside. The surveyor was able to easily reach over the half-door entrance and use the inside handle to gain access to the nursing station.

The nursing station was configured with a half-wall and counter in a circular area to provide visibility to all areas of the unit. A machine used to provide breathing treatments to patients was observed just under the counter, but within arm's reach of patients. The breathing machine was observed to have a cord long enough to be used as a ligature by a psychiatric patient to harm themselves or others.

A drawer next to the entrance of the nursing station contained multiple items that could be used by a psychiatric patient to harm themselves or others. Items included a pointed cross-tip screwdriver, metal keys to unlock electrical outlets, metal keys to access medication cabinets in the medication room, ballpoint pens, glass tubes for collecting blood specimens, broken nail clippers, and a sharp, pointed staple remover.

Computer, copy machine, and telephone equipment cords presented ligature risks if a patient were to access the nursing station. Cords could be used by psychiatric patients to harm themselves or others.

An interview was conducted with Staff #32 at the time of the tour. Staff #32 stated that the breathing machine was only placed under the countertop when there was patient on the unit who was receiving breathing treatments. Staff #32 stated it would stay there until the patient was discharged. When Staff #32 was shown how easy it was for a patient to reach over the counter, pick up the light-weight machine, and the length of the cord available to be used as a ligature, Staff #32 responded, "What should we do with it? Maybe we should keep it locked in the med room (medication room)." Staff #32 stated the screwdriver was kept at the nursing station to disconnect the phone in the patient day room area if they had a patient that continuously call 911.

An interview was conducted with Staff #3 at the time of the tour. Staff #3 stated the hospital was aware of the problems with the patients being able to access the nursing station. Staff #3 stated the door handle on the door was not the correct type. However, the previous door handle kept jamming and that was the only door handle available. Staff #3 stated that there were plans to enclose the entire nursing station in with Plexiglas. When asked about the timeline for correction, Staff #3 stated she did not know when the project would be started. Staff #3 was asked about the hazards found in the nursing station. Staff #3 stated she had not been aware that there were hazards to patients in the nursing station.

While on Unit 3, all patients had left the unit to attend programming except 2, Patient #8 and Patient #11. Records indicated that Patient #8 had been admitted the previous day, 3-17-2019, and was on suicide precautions. Patient #8 was sitting in chair in a common area of the unit where he could be visualized by staff. Patient #11 was in his room (Room 302A) lying down. Records indicated that Patient #11 had been admitted that day, 3-18-2018, and was on suicide precautions. Two Mental Health Technicians (MHT), Staff #26 and Staff #33, remained on the unit to watch the patients, along with nurse Staff #32. Staff #26 was assigned to watch Patient #11 and Staff #33 was assigned to watch Patient #8. Staff #26 and Staff #33 were observed from 10:55 AM until 11:23 AM performing housekeeping duties, cleaning the unit. Staff #26 was finally observed going to Patient #11's room to check on him at 11:23 AM.

Staff #26 was asked to provide the forms for documenting 15-minute checks for Patients #8 and #11. Staff #26 had last documented on Patient #11 in the 10:45 AM box. Over 30 minutes had passed since the patient had been check on. The block for the nursing staff to document nursing rounds every 2 hours was also blank for the first two checks, 8:00 AM and 10:00 AM.

Patient #11's form was last documented by Staff #33 at 11:00 AM. The block for the nursing staff to document nursing rounds every 2 hours was also blank for the first two checks, 8:00 AM and 10:00 AM.

Staff #26 and Staff #33 were interviewed at the time of the observations. Staff #26 stated she had been asked to clean the unit along with Staff #33 and had lost track of time because she was focused on cleaning. Staff #33 stated he was continuously observing his patient in the common area and had not gotten around to documenting his observations for his last 15-minute check.

Review of Policy and Procedures, Title: Observation of Patients, Policy No.: NUR-7:037, Review and Approval 02/2018 was made as follows:

"Close Observation every 15 minutes

Guidelines for implementation of this level of precaution include but are not limited to the following:
The patient should only be allowed off the secure unit under direct staff supervision.

The patient may attend all therapies and activities conducted in secure areas of the facility with direct supervision of staff.

A patient Rounds Sheet reflects the patient's location and observed behaviors and is to be completed every 15 minutes. The registered nurse will assess the MHT q 15 minute observation status records every two hours by initialing. The RN must sign the MHY q 15 minute observation record every shift. This is done to discourage discrepancies on where and what the patients were doing."

Based on interview, record review, and observation the facility failed to ensure all patients were provided with warm water for showers and daily care. 2 (Room's #308 and #306) out of 2 patient rooms were found to have no hot water in the bathrooms.

An interview with Staff #5 was conducted on 3/19/2019 after 9:30 AM. Staff #5 was asked about work orders and if there was a time the facility did not have any hot water. Staff #5 replied, "We have never been without hot water."

Review of the Plant Operations work orders dated January 2019 through March 2019 did not reveal any reports or requests for hot water problems.

An interview was conducted on 3/20/2019 after 11:30 AM with Staff #27. Staff #27 was asked if there had been a time when the hot water was not working. Staff #27 replied, "We had some patient's say that the shower water would not get warm and it was always cold. I told them they just had to hold the hot water button down until it got warm." Staff #27 was asked if she had reported it to anyone and if the problem had been resolved? Staff #27 replied, "They were aware of the problem and told us it got fixed. I never went to check to see if the water would heat up."

An observation tour was conducted on Unit #3 on 3/20/2019 after 11:30AM with Staff #27. Observed in 2 (Patient room's #308 and #306) of 2 patient rooms and there was no hot water. The hot water was tested in Patient Room #308. This surveyor held the hot water button for greater than 3 minutes and the temperature of the water remained cold. The hot water sensor must be held down to increase the temperature of the water. The hot water was then tested in Patient Room #306. This surveyor held the hot water button for greater than 1 minute and the temperature of the water remained cold. Staff #27 confirmed the findings.

Based on review of records and interview, the facility failed to ensure performance improvement actions were identified, implemented, measured and tracked for all departments of the hospital except the Quality Department.

Findings included:

On the afternoon of 3-19-2019 an interview was conducted with Staff #1. Staff #1 had previously presented a document titled, "Magnolia Behavioral Hospital of East Texas Performance Improvement Plan 2019". Staff #1 confirmed during the interview that this was the Quality/Performance Improvement plan (QAPI) that she had been following in 2019. The plan presented did not have a signature/record page identifying who reviewed and approved the plan and when it had been approved by Governing Body. Staff #1 stated she did not know when it had been approved, but stated the Governing Body had recently meet in February.

Review of the QAPI minute meetings for 2018 showed that an Annual Plan was listed as "New Business" in the May 2018 and July 2018 meetings. There was no record of what year plan was discussed, what the content of the discussion was, or the outcome of the discussion. A QAPI meeting was held in October 2018. No records of discussion about an Annual Plan was evident.

Review of Governing Board Committee Meeting Minutes for February 22, 2019 along with the agenda and attachments of what was discussed at the meeting was presented by the hospital. While the meeting agenda that was attached included policies, forms, and plans to be reviewed and approved, the meeting minutes did not reflect that the Governing Board had reviewed the plans or voted to approve the plans. No such forms or plans were attached to the package to identify what may have been presented during the Governing Board meeting.

Review of the plan revealed under the heading "C. Purpose: ... A Four-Step Model will provide the opportunity for input from front line staff and patients as well as supervisors and administrators. ... The Performance Improvement Plan addresses the Performance Design, Performance Measurement, Performance Assessment, Performance Improvement approach for important patient care and organizational functions.

Under the Scope of Performance Improvement Activities, it stated, "A Priority Setting Grid will be utilized to select and assess Performance Improvement activities. The priority grid card will compile and evaluate impact areas for the Division on a point value system. The impact areas will include life threatening (10 points); Potential for life threatening (8 points); Safety (8 points); increased cost (5 points); Decreased Customer Satisfaction (5 points); Potential Liability (5 points); Impact Regulatory Compliance (8 points); Ethical Impact (2 points); and Public Relations (2 points);"

Staff #1 was asked to show how the Four-Step Model was used and present the Priority Setting Grid and priority grid cards. Staff #1 stated she did not have those and had not implemented the plan. Staff #1 stated the Process Improvement Team (PIT) team had not met in 2019. Staff #1 presented a form titled "Magnolia Behavioral Hospital Performance Improvement Goals and Objectives 2019, Department: Risk Management/Quality Improvement" with 4 goals for the Risk Management/Quality Improvement Department. This form listed Goal/Objective, Actions Necessary, Person(s) Responsible, Start Date, Targeted Completion Date, and Estimated Expense ($).

No other Performance Improvement Goals & Objectives 2019 forms were presented for the other departments. Staff #1 confirmed that she had not received any. Staff #1 had received a form titled "Nursing Action Plan 2.21.19" from the previous Director of Nursing with one "Clinical Measure for identified improvement:". Staff #1 confirmed that since the previous Director of Nursing's departure, no information had been submitted to her on the status of this action plan. Staff #1 did not know if the actions identified had ever been taken or were being monitored. Staff #3, in a separate interview on 3-19-2019 stated she was not aware of any current Process Improvement projects for the nursing department because she had only recently taken over as the Interim Director of Nursing.

Based on review and interview the facility failed to:
1.) have evidence of acuity levels being used for safe staffing matrix.
2.) identify nursing staff working in the facility from staffing agencies.
3.) have employee files, competencies, orientation to the facility, current licenses, education, training, or criminal backgrounds of agency nurses in 3(36, 37, and 38) of 3 agency nurse employee files.

Review of the staffing schedule and staffing sheets on 3/19/19 revealed the staffing office did not have an acuity level to use for increase or decrease in staff levels.

An interview was conducted in the afternoon of 3/19/19 with Staff #10 and 11. Staff #10 stated that she does the schedules and changes. Staff #10 stated that Staff #11 would be taking over the schedule full time. Upon review of the working schedule there was no documented evidence in how the patient acuity levels are measured or how to identify when a patient was on 1:1 or precautions that required special attention. Staff #10 stated that the Director of Nurses or the RN House Supervisor lets her know when more staff are required or if there is too much staff scheduled.

Review of the facility's Nursing Staffing Plan stated, "Adjustments to the core staffing levels are made on the basis of acuity for example, not limited to 1:1 ratios. Such adjustments for planned staffing are made several times daily and as needed by the Director of Nursing or his/her designee. After the staffing has been reviewed, the Daily Staffing Form is then posted in the mail room every day.

The staffing for each unit is based on several critical factors:
Patient characteristics and number of patients
Acuity level of the patients
Variability of patient care across the unit
Scope of services provided by each unit
Patient precautions
Behavioral issues
Patient admissions/discharges
Patient 1:1 observations
The anticipated admissions, discharges, and transfer
Nursing staff competency, experience, and other pertinent factors."

An interview with Staff #3 and #13 was conducted in the afternoon on 3/19/19. Staff #3 and #13 was asked what was the factors for the acuity levels and how it was used to make safe staffing levels. Staff #3 stated that she had just recently took the interim DON position. Staff #3 stated that she had put in a staffing coordinator position and would be working on changing the process. Staff #3 stated she was trying to streamline the process but was not able to give the surveyor specific acuity level factors or was able to show the surveyor what the nurse staffing plan stated.
Staff #13 was asked about the acuity levels and how they were used in staffing. Staff #13 stated she was not aware of the acuity levels. Staff #13 stated she just uses her judgement to determine if a nurse may need more help.
Staff #3 was asked if Agency nurses were used to compensate for nurse staffing. Staff #3 stated, "Yes, we do use agency nurses."

An interview was conducted on the afternoon of 3/19/19 with Staff #12. Staff #12 was asked for a list of contracted nursing employees that have recently worked. Staff #12 stated she did not have a list. Staff #12 stated she would have to call the agencies to send her a list of all the agency nurses that they send to the facility. Staff #12 was not able to provide employee files for agency nurses working in the facility. Staff #12 stated, "I just don't have them." There was no evidence of their orientation to the facility, current licenses, education, training, or criminal backgrounds.
Review of the #1 staffing agency invoice number ATIO10000133514 revealed 2 RN's Staff #36 and #37 had worked in the facility in the month of February. Staff #36 worked 2/2/19, 2/3/19, and 2/4/19 for 12 hour shifts. Staff #37 worked 2/3/19 for 12.75 hours.

Staff #12 was able to provide the surveyor with one nurse's employee file from #2 staffing agency. Staff #38 was an RN and has currently worked at the facility in February of 2019. Review of the employee's chart revealed the nurse's licenses had expired in 11/18.

Based on record review, observation and interview Nursing failed to:

A.) Document in the patient medical record about the patient's behaviors, incidents, care received before and after a chemical restraint was administered, and the physician failed to document the use of chemical restraint in 1(5) of 3(#2, #3 and #5) patient charts reviewed.

B.) Follow policy and procedures for Restraint and Seclusion and Now Order for Emergency Administration of Psychoactive Medication. Restraint packets were not being completed or started for the administration of Chemical Restraints/EBM.

C.) initiate or complete restraint packet, perform a face to face, or reassessments. There were chemical restraints administered with no de-escalation documented, an attempt to place the patient in restraints or 1:1 before medication in 3(#2, #3 and #5) of 3 patient charts reviewed. Nursing staff subjectively administered PRN psychotropic medications without a scope, scale, or standards for degrees of agitation, or aggression.


Findings:

Review of Patient #5's chart revealed he was admitted to the facility on 2/12/19 at 21:05 (9:25PM). The patient was a 35-year-old male and was brought to the facility on a Peace Officers Warrant (POW). The officer documented, "Patient was just released from hospital on Feb 10, 2019. Patient is stating that there are people in his residence that is going to harm him. He stated he had run out of the house to keep from getting hurt. I located subject standing in the median of US Hwy 271. Patients sister stated he has been running around the inside of the house fighting a war."
Review of the chart revealed the officer took him to the emergency room at a local hospital for a physician evaluation. Review of the physician notes from the ER on 2/12/19 stated, "Patient reports since being discharged yesterday on Zyprexa 5 mg, he reports he has had increase visual hallucinations, thinking People trying to harm me." He affirms cocaine and heroine abuse since being discharged. Per Tyler PD patient was found in the middle of HWY 271, POW has been obtained. Patient denies SI/HI. States he wants help."

Review of the Physician Preadmission Evaluation/ Management form revealed the physician saw Patient #5 on 2/12/19 at 4:43AM. The patient was admitted to the facility for Schizophrenia Paranoid Type. Patient was to be involuntary while pending involuntary commitment filing with court. He was ordered suicide precautions.
Review of the nurse's notes dated 2/13/18 at 2000 (8:00PM) A/Ox3 calm at times, anxious at times. Dr. ____ (Physician #15) called lt mes. No si/hi or (illegible word) present. No meds to give. Pt with steady gait non-aggressive behavior on unit (illegible word) in smoke breaks. Will continue to monitor. 2130 (9:30PM) Pt still anxious at unit 3 pts, new orders noted for anxiety per Dr. ___ (Physician #15), see orders." (SIC)
Review of the physician orders dated 2/13/19 at 2130 (9:30PM) revealed a telephone order for "Ativan 1 mg po q6 hours x2."

Review of the nurse's notes dated 2/13/18 at 2200(10:00PM) Pt appears to be less anxious. Pt stable on unit in chair. 2348 (11:48PM) Pt found hanging above nutrition room. Pt removed x4 -5 staff members without injury. T.O Dr.___ (Physician 15) for 50mg Benadryl Im x 1/Haldol x 10mg IM x 1 for aggression/agitation. IM shot to both delts without complication. Pt being (illegible word) by Tony RN for safety, will continue to monitor."

Review of Patient # 5's chart revealed there was no explanation of the "hanging" incident. An interview was conducted with Staff #1 on the afternoon of 3/19/19. Staff #1 stated Patient #5 had an incident report written on 2/13/19. Staff #1 stated the patient attempted to elope through the ceiling. The patient stepped on a chair and was able to access a crawl space in the ceiling and lifted himself into the ceiling. Staff was able to remove him without harm. Staff #1 stated the chair was removed to prevent that from happening again.

Review of the Physician Progress note dated 2/14/19 stated, "tried to elope last PM. was paranoid about someone hurting him so tried to elope. A little better now." (SIC) There was no documentation in the nurses notes that the patient tried to elope. There was no documentation found in the physician progress note about the use of a chemical restraint/EBM."

Review of the seclusion and restraint policy and procedure stated, "A. Restraint B.) Is a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition. Concerning Emergency Medication refer to policy Nur 7:112 Now Order for Emergency Administration of Psychoactive Medication.

PROCEDURE
1. Authorized physicians and licensed independent providers (LIPs) can issue a "Now" order to administer psychoactive medication to a patient without the patient's consent in an emergency situation to prevent the following:
a. Imminent probable death or substantial bodily harm to the patient because the patient is overtly or continually threatening or attempting to commit suicide or serious bodily harm.

b. Imminent physical or emotional harm to others because of threats, attempts or other acts that the patient overtly or continually makes or commits.

2. The "Now" order form is completed by the physician, LIP, or nurse in the case of a telephone order.

3. After administration of an emergency medication, the physician, LIP or nurse who did not administer emergency medication and has had proper training must conduct a one hour face to face evaluation.

a. Vital signs will be assessed within one hour of administration.

b. If multiple injections occur vital signs will be assessed every 30 minutes for 1 hour for each subsequent injection."


Review of Patient #5's chart revealed the following:

No documentation of de-escalation techniques used or least restrictive measures before using a chemical restraint.
The nurse documented at 12:00AM and stated the patient was sleeping on the couch. There was no documentation of any vital signs within an hour of the medication.
There was no face to face performed.



Patient #2

Patient #2's chart revealed she was admitted on 12/2/18 with a diagnosis of schizophrenia. The patient was involuntary and had an Order of Protective Custody(OPC).

Review of patient #2's nurse's notes revealed on 12/4/18 at 3:50AM reported that Patient #2 walked up to the nurse's station demanding to call a physician. "Patient picked up phone and started banging it against the wall repeatly (sic). Staff intervene able to get phone from her. She then took hygiene bucket started hitting on countertop at nursing station repeatly (sic). Staff had intervene (sic) patient started yelling and screaming, threw cup of milk and snack across the room. Call placed to Dr.___ (Staff #15) with new order noted Haldol 5mg IM Q4hr PRN psychosis and Cogentin 2 mg IM Q4hr PRN for EPS. O400 (4:00PM) Code 10 called. Patient given Haldol 5 mg IM x1 dose and Cogentin 2 mg IM x 1 dose. She took both injections willingly without any problems." There was no documentation why a Code 10 was called if the patient was willing to take medication without intimidation or force." Interview with Staff #3 confirmed on 3/19/19 that a code 10 was called to alert other staff to assist with a patient that was "out of control" or need assistance with an "agitated or combative patient."

Review of Patient #2's chart revealed the patient did not have a face to face evaluation but did have the medication order written on a form called "Now Order for Involuntary Emergency Administration of Psychoactive Medication." This form was part of a restraint packet to assist the nurse in evaluation of the patient. The packet was incomplete. There were no vital signs or nursing assessment documented on the patient after the administration of IM psychotropic medications.

Review of patient #2's Nurses notes dated 12/4/18 revealed the patient was slamming doors, yelling and intrusive at 8:00AM.

A physician order dated 12/4/18 at 12:35PM was found written, by the physician, for "1.) Haldol 10mg IM NOW/ psychosis with Ativan 2 mg IM NOW x agitation. 2.) May repeat above after in 4-8 hours (up to 2 times in 24 hours.)" There was no discontinue order written for the previous order of Haldol 5mg IM Q4hr PRN psychosis and Cogentin 2 mg IM Q4hr PRN for EPS on 2/4/19 at 3:50AM.

Review of the Medication Administration Record (MAR)on 12/4/18 revealed Patient #2 was administered the PRN order of Haldol 10mg IM with Ativan 2 mg IM at 12:35PM. There was no nursing documentation on why the patient received the medication. There was no restraint packet, face to face, or reassessment documented. There was no de-escalation documented or an attempt to place the patient in restraints or 1:1 before medication.

Review of patient #2's Nurses notes dated 12/4/18 stated, "2000 (8:00PM) Patient is yelling and screaming, very delusional, agitated and angry, tried redirect patient several times, unsuccessful. Continue to slam doors and slam stuff. Patient take shower curtain down wraps shower curtain around her waist. Patient yelling and screaming and cont to try to manipulate staff. Patient given Haldol 10mg IM x 1 dose for psychosis and Ativan 2 mg IM x 1 dose for agitation to (L) buttock using aseptic technique. Patient took the injections willingly without any problems(SIC). There was no restraint packet, face to face, or reassessment documented. There was no de-escalation documented or an attempt to place the patient in restraints or 1:1 before medication.

The physician order "Haldol 10mg IM NOW /Psychosis with Ativan 2 mg IM NOW x agitation, may repeat above order in 4-8- hours cap to 2 times in 24 hours." The medication was administered by the nurse on the following dates and times:
12/4/18 at 12:35PM, and 8:20PM.
12/05/18 at 9:40AM and 3:35PM.

Review of Patient #2's chart revealed a telephone order dated 12/6/18 at 1300 for "Haldol 10mg IM4H PRN and Ativan 2 mg IM Q4H PRN." There was no physician signature. There was no discontinuation of previous orders for Haldol IM and Ativan IM. There was no clear or updated orders for the administration of psychotropic medication administration.

Review of the MAR revealed the nursing staff administered these psychotropic medications without a scope, scale, or standards for degrees of agitation, or aggression as follows:
12/07/18 at 8:10AM, 12:45PM, and 10:40PM.
12/8/18 at 4:15AM, 8:10AM, 12:55PM, 16:35PM.
12/9/18 at 5:00AM, 9:55AM and 6:00AP.
12/10/18 at 4:30AM,9:40Am and 3:15PM.
12/11/18 at 1:00AM, 7:50AM, 1:40PM, and 9:15PM
12/12/18 at 4:20AM, 12:30PM.

On 12/15/18 an order for Geodon 20mg IM every 6 hrs. agitation PRN was administered on:
12/15/18 at 3:15PM.
12/17/18 at 6:50AM and 3:19PM.

An interview with Staff #20 RN was conducted on the morning of 3/19/19. Staff #20 confirmed she was not aware that a chemical/EBM restraint was the most restrictive restraint and that a chemical/EBM restraint could not be PRN. Staff #20 reported that her understanding of a chemical restraint, "Is when the patient refuses to take the shot and they have to be held down to give it."

An interview with Staff #8 RN was conducted on the afternoon of 3/19/19. Staff #8 confirmed he was not aware that a chemical/EBM restraint was the most restrictive restraint and that a chemical/EBM restraint could not be PRN. Staff #8 stated that he was not aware that the restraint packets needed to be done on chemical restraints. Staff #8 reported that he thought it was just for physical restraints. Staff #8 was unable to tell the surveyor how often the patient should be reassessed after an administration of a chemical restraint.

An interview with Staff #3 and #1 was conducted on the afternoon of 3/19/19. Staff #3 stated that the staff had training after 12/18 for restraints including chemical restraints. Staff #1 was instructed on the past and current findings. Staff #1 was unable to show the surveyor how the effectiveness of the training was reviewed, tracked, or analyzed. Staff #3 stated there was no PI processes in place to follow the chemical restraint usage or administration. The chemical restraints were not logged onto the restraint log. Staff #3 confirmed they were not addressing or recognizing the chemical restraints/EBM as restraints.



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The complete chart for Patient #3's admission from 1-30-2019 through 2-22-2019 was requested and provided by medical records. Review of Patient #3's chart revealed the following:

Patient #3 was a 34-year-old male brought to the facility on an Apprehension by a Peace Officer Without a Warrant (APOWW). This would allow a peace officer to emergently detain a person they believed was at risk of harm to themselves or others due to a mental health condition and transport them to a psychiatric hospital for evaluation. The APOWW was signed by the peace officer on 1-29-2019. An APOWW does not allow the facility to force the patient to take medication. Medication could only be given without consent in an emergent situation when determined by the physician that the patient was in imminent danger to self and/or others

The patient was evaluated by a physician on 1-30-2019 and an order was written as follows:
"LEGAL STATUS: Involuntary. Hold patient for involuntary admission while pending involuntary commitment filing with court."

The psychiatrist did not write an order to apply for an Order of Protective Custody (OPC) with permission administer medications without patient consent until 2-4-2019. The request was filed on 2-5-2019 and granted on 2-12-2019.

On 1-31-2019 at 11:30 AM, Staff #15 (Psychiatrist) gave a verbal order that was written as follows:

"Haldol 10 mg IM Q4H PRN psychosis (Haldol antipsychotic medication, 10 milligrams, to be given as an injection into a muscle as needed for psychosis)
Ativan 2 mg IM Q4H PRN anxiety (Ativan antianxiety medication, 2 milligrams, to be given as an injection into a muscle as needed for anxiety)
Benadryl 50 mg IM Q4H PRN EPS (Benadryl antihistamine medication, 50 milligrams, to be given as an injection into a muscle as needed for extrapyramidal symptoms, a serious side-effect of antipsychotic medications that can include spasms and muscle contraction)
Repeat in 45 mins - 1 hour until asleep. Place in seclusion if needed (The order could be repeated by nursing staff every 45 minutes to an hour until the patient fell asleep. If the nursing staff needed, the physician gave permission for the staff to place the patient in seclusion.)"

Staff #15 signed the verbal order, as written, on 1-31-2019 at 4:00 PM.

Because the indication for use did not identify specific symptoms or behaviors, nursing staff were required to apply medical judgement as to when the symptoms of psychosis, anxiety, and EPS were severe enough to administer this combination of medications, which was outside of nursing scope of practice. The order to repeat the administration of medications until the patient is asleep showed that the intent was not to improve the patient's participation in the environment, but rather, to removed the patient from the environment. Removing the patient from the therapeutic environment using medication was a form of restraint.

Review of the Medication Administration Record (MAR) showed that the patient received injections of all three medications on 1-31-2019 at 1:45 PM and on 2-04-2019 at 6:45 PM.

Review of the chart did not include nursing notes or physician progress notes for those days to determine if the patient had been an imminent threat to himself or others. No signed consent for the medication or court order authorizing medications to be given was found for those days. No nursing assessment/reassessment was found in the chart to document the patient's condition and response to the medications given on those days. No information was found on the interdisciplinary treatment plan for the need of emergency behavioral medications or plan of care in response to needing the injections. No restraint or seclusion paperwork was found in the chart. A Social Services Progress Note for 2-5-2019 at 11:55 was found and read, "Met pt for TT. Pt had aggressive outburst on unit yesterday. Pt still refusing meds."

Based on record review, observation, and interview, Nursing failed to administer medications in an appropriate time frame in 2 (#1 and #8) of 2 patient charts reviewed.

The facility has a medication dispensing station called "MedDISPENSE Station." It allows the pharmacy to fill up the electronic medication cabinet with the patient's medication and the nurse can pull and administer the drugs from the cabinet. The cabinet also had "emergency drawers" to store medications that are ordered after pharmacy hours. This would ensure medications would be available to patients until the pharmacy can stock the cabinet and patients can receive medications in a timely manner.

Review of patient #1's chart revealed the Medication Administration Record (MAR) was dated from 2/2/19 to 2/5/19. Physician orders revealed he was ordered Coreg 25mg twice a day with meals. The MAR revealed the Coreg was administered to the patient on 2/2/19 at 8:00AM and 1400 (2:00PM). Coreg is used for treating high blood pressure and congestive heart failure.

The pharmacy was asked to pull an audit sheet of Patient #1's medication administration from the cabinet and what time it was removed by the nurse. The report revealed the Coreg 25mg was not pulled from the cabinet until 4:32PM, 2 hours and 32 minutes after it was charted as administered.

A tour was conducted on unit 3 on 3/18/19 at 10:30AM. Review of the unit MAR was observed. Patient #8 was ordered Aricept on 3/17/19. The patients MAR had not been signed as given for the 8:00AM dose. Staff #17 RN was interviewed on 3/18/19 at 11:00AM. Staff #17 was asked about the missed medication she stated, "We just don't have it. Pharmacy has not brought it to us." Staff #17 was asked how long they had to administer the medication to be within the facilities time frames and Staff #17 stated, "We have an hour before and an hour after." Staff #17 was asked what needed to be done if the medication was out of the prescribed time frame. Staff #17 stated, "We just have to wait till the pharmacy fills it. This happens sometimes." There was no documentation that the pharmacy or physician had been notified. Staff #17 denied calling the physician and reported the pharmacy was aware. A policy and procedure was requested from the pharmacy concerning medication administration times. No such policy was offered after 3 separate request.

Based on review of records and interview, the facility failed to establish a Utilization Review Committee of two or more practitioners that could carry out the review function and who were not professionally involved in the care of patients being reviewed.

Findings included:

On the morning of 3-19-19, an interview was conducted with Staff #2, Utilization Review Registered Nurse. Staff #2 stated she had been performing the Utilization Review functions since August of 2018, approximately 7 months. Staff #2 was asked if there was a list of members of the committee. Staff #2 stated that she did not have a list of committee members and had not attended a Utilization Review Committee meeting.

Review of Utilization Review Committee meeting minutes provided by the facility showed that a meeting took place on July 27, 2018. Attached was a sign-in sheet, meeting minutes, and an agenda. The sign in sheet did not identify who was a committee member and who was a non-committee member in attendance. Only one physician had signed in, Staff #15. The typed meeting minutes did not identify who was a committee member and who was a non-committee member in attendance. The typed meeting minutes listed two physicians as attending, Staff #15 and Staff #34. The meeting was called to order at 1:40 PM central standard time, and adjourned at 1:56 PM central standard time. This was a total of 16 minutes to review and approve the previous meeting minutes, under the heading "Discussion" review 9 cases of patients being readmitted within 30 days of discharge, 12 cases of patient outliers who had stayed less than 3 days, review the payer mix (a breakdown of each insurance for April, May, and June), and review numbers of admissions, discharges, average length of stay and average daily census by month. Under the heading of "Decision" for all of the new business discussed, was "Charts provided see attachments". Attached was a sheet that was titled "Outliers". This sheet contained a summary of why the patient was admitted and why they discharged in less than 3 days. Staff #2 was asked about the Outlier sheet. Staff #2 stated that the summaries were typed up by the Utilization Review Nurse after the Nurse reviewed the chart to determine if the patient actually met criteria to be in the hospital and why they discharged early.

Minutes were provided to Utilization Review Committee meeting conducted on October 26, 2018. The forms provided did not indicate who was a committee member and who was a non-committee member in attendance. This meeting reviewed data from the third quarter of 2018, July/August/September. The meeting was called to order at 1:25 PM and adjourned at 1:57 PM. The only physician who signed the attendance sheet and was listed as an attendee on the meeting minutes was Staff #15. The same type of data was reviewed as the previous meeting, as well as a review of "Days Lost Due to Discharge". This was a review of days that had been prior authorized by insurance providers, but patients discharged before all of the authorized days had been used.

Staff #2 stated that a meeting for the 4th quarter of 2018 had not occurred and that she had not prepared the data for that meeting or started preparing data for a 1st quarter 2019 meeting.

Staff #2, when interviewed, stated that Staff #15 saw all patients Monday through Friday. Weekends were covered by different psychiatrists. This meant that Staff #15 would have been professionally involved in the care of the majority of patients reviewed unless the patient admitted and discharged from the hospital over the weekend and prior to Staff #15 seeing them.

Staff #2 was asked if there were any other physicians that reviewed cases for Utilization Review. Staff #2 indicated that the Utilization Review Nurses review the cases and send them to Staff #15 if there is a question.

A request was made for the Utilization Review Plan that had been in effect in 2018 and the current 2019 Utilization Review Plan. None was provided. Staff #2 stated that due to leadership turnover, some documents were now missing, including the Utilization Review Plan. Staff #2 stated that in February she had been made aware that no plan had been developed for 2019. Staff #2 stated this was the first time she had been aware that a plan was required and that she had just been performing the duties she had been trained on.

A Utilization Review policy was provided. Policy Title: Utilization Review, Number: UR:1, Review and Approval: 1/26/2018, was reviewed. The policy did not include who would be assigned as a member of the Utilization Review Committee, restrictions on physicians from reviewing cases that they had participated in the development of professional care, or the establishment of an independent Physician Advisor to review those cases that were required to be reviewed when the committee members could not review them due to involvement in developing professional care.

Based on review of records and interview, the facility failed to establish objective continued stay criteria for inpatient psychiatric admissions for the Utilization Review Nurse to use in determining if the patient meets inpatient criteria or needs to be referred to the attending physician, Medical Director, or Utilization Review Committee for follow-up.

Findings included:

A request was made on 3-18-2019 for the Utilization Review Plan that had been in effect in 2018 and the current 2019 Utilization Review Plan. None was provided. During interview on 3-19-2019, Staff #2 stated that due to leadership turnover, some documents were now missing, including the Utilization Review Plan. Staff #2 stated that in February she had been made aware that no plan had been developed for 2019. Staff #2 stated this was the first time she had been aware that a plan was required and that she had just been performing the duties she had been trained on.

A Utilization Review policy was provided. Policy Title: Utilization Review, Number: UR:1, Review and Approval: 1/26/2018, page 3 of 4, was reviewed as follows:

"g. Continued Stay Review - Continued Stay Review is to assure that patients are obtaining timely effective treatment according to their diagnosis and to determine when the patient has reached maximum benefit for hospitalization. If there is a question about a patient meeting continued stay criteria the following process is followed:

UR RN will refer the case to the attending physician. If unsuccessful with a resolution

The case is referred to the Medical Director and the UR Committee for resolution. "

Staff #2 was interviewed on 3-19-2019 and asked if the facility used a commercial decision support model that had pre-established continued stay criteria, a decision support model provided by third-party payers (insurance companies), or had the hospital developed their own decision support model that allowed a nurse to screen for medical necessity since a non-physician cannot make a determination that a patient does not meet criteria. Decision support models look at objective Severity of Illness (SI) indicators and Intensity of Services (IS) provided to recommend the appropriate level of care (LOC) such as inpatient hospitalization, partial hospitalization, intensive outpatient program, or outpatient therapy.

Staff #2 stated she just used the admission criteria outlined in Policy and Procedures Title: Criteria for Admission, Number: AD 1.02, Review and Approval: 01/26/2018 to conduct all reviews.

Review of above policy showed that there were specific criteria that could be applied for an admission review. However, as the patient's treatment progresses, no objective continued stay criteria could be found for the nurse to make a recommendation on the medical necessity of continued stay or to assist the nurse in determining "when the patient has reached maximum benefit for hospitalization" per the Utilization Review policy. The Utilization Review policy on page 2 of 4 also stated:

"b. The Utilization Review Plan including procedure, criteria, and effectiveness is monitored through regular reports for programmatic and administrative review.
i. Utilization Review
1. Criteria - MBH shall utilize the DSM-V to determine admission and continued stay"

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), stated on page 19 under "Use of the Manual":

" ...The primary purpose of DSM-5 is to assist trained clinicians in the diagnosis of their patients' mental disorders as a part of a case formulation assessment that leads to a fully informed treatment plan for each individual."

Review of the DSM- 5 showed that the manual was intended to be primarily used for the diagnosis of the mental illness and not a decision support model that recommended particular levels of care. The Utilization Review policy did not instruct the Utilization Review Registered Nurse on how to apply diagnostic information from the DSM-5 to SI indicators and IS provided in order to determine if the patient no longer meets criteria for the inpatient LOC and needs to be referred to the physician, Medical Director, or Utilization Review Committee.

Staff #2 stated that the Medicare and Medicaid patients are reviewed for continued stay and always meet criteria. When they have a commercial insurance that denies a continued stay then they appeal if the physician doesn't think the patient is ready for discharge.

Based on review of records and interview, the facility failed to ensure that extended stay outliers were defined in a Utilization Review Plan and reviewed by the Utilization Review Committee.

Findings included:

A request was made on 3-18-2019 for the Utilization Review Plan that had been in effect in 2018 and the current 2019 Utilization Review Plan. None was provided. During interview on 3-19-2019, Staff #2 stated that due to leadership turnover, some documents were now missing, including the Utilization Review Plan. Staff #2 stated that in February she had been made aware that no plan had been developed for 2019. Staff #2 stated this was the first time she had been aware that a plan was required and that she had just been performing the duties she had been trained on.

A Utilization Review policy was provided. Policy Title: Utilization Review, Number: UR:1, Review and Approval: 1/26/2018, page 3 of 4, was reviewed as follows:

"h. Length of Stay Norms - Each year, retrospective data shall be reviewed to determine the average length of stay for each level of care. In order to attain accurate norms, the data for clients who leave against medical advice or clients who transfer because of acute medical or psychiatric problems shall be extracted from the cumulative data."

The Utilization Review policy did not include the definition of an extended stay or the process and time-frame for review of extended stay outliers.

Staff #2 was interviewed and asked if she knew what the criteria for an extended stay outlier was. Staff #2 stated that anyone with a 30-day length of stay or greater was reviewed as an extended stay outlier. Staff #2 reported that she would review the charts and a write a summary of the care received during the stay to ensure the patient met criteria for the admission. Staff #2 stated she tracked the outliers and reported them to Quality.

Review of the Utilization Review Committee meeting minutes for the 3rd Quarter 2018 did not show a review of any length of stays 30 days or greater. Review of Quality Data for the period 3rd Quarter 2018 recorded 1 extended stay outlier for September that was not reviewed in the October 2018 meeting.

Quality data for the 4th Quarter 2018 report 2 extended stay outliers, 1 in October and 1 in December. However, review of the daily census reports showed that Patient # 16 had a 35-day length of stay and discharged October 22, 2018. Patient #17 had a 34-day length of stay and discharged November 16, 2018. Patient #18 had a 33-day length of stay and discharge on November 20, 2018. No patients with a 30-day length of stay or greater were discharged in December. The data reported to Quality was incorrect.
No Utilization Review Committee meeting was held for the 4th Quarter of 2018. No evidence was provided that a physician reviewer from the Utilization Review Committee had reviewed the 4th Quarter extended stay outliers.

Based on observation and interview, the facility failed to ensure expired supplies were not available for use for 2 areas (Unit 4 and Kitchen) of 3 areas (Kitchen, Unit 3, and Unit 4)

Findings included:

The facility was toured on the morning of 3-18-2019. A wall-mounted eyewash station was observed in the area by the dishwashing station. The eyewash solution bottle was observed to have expired on 01/2019.

Two large plastic bins were observed in a storage room outside of Unit 4. One plastic bin had a paper sheet attached that was title, "Disaster Cabinet Contents" with an inventory list. The other plastic bin had a label taped to it that said, "Disaster Box Unit 4". The contents of the box contained the following expired supplies:

Gauze 4X4 pads expired 2017-01
Oval eye pads expired 2018-10
4 each 30 milliliter tubes of sterile saline expired 2017-12

At the time of the observations, Staff #3 and Staff #5 were present and interviewed.

Staff #3 stated the plastic bins were the disaster supplies for Unit 4 but did not know why they were in the storage area outside of Unit 4. Staff #3 stated the bins were supposed to be in the Unit 4 treatment room.

Staff #5 stated the bins had been removed from Unit 4, "probably because the supplies were expired" and that they should have been replaced by another set of bins with the proper supplies.

A tour of Unit 4 revealed that there was not another set of bins containing disaster supplies on Unit 4.

A tour of Unit 4 treatment room revealed expired blood collection tubing available for use.
Grey top collection tube expired 2018-04
Red top collection tube expired 2018-10-31

Based on review, observation, and interviews, the facility failed to:
A.) ensure the infection control officer developed a system that maintained a clean and sanitary environment. The facility failed to maintain a sanitary hospital environment and mitigate risks of possible hospital acquired infections in 3 (Patient Rooms, Admissions, Training Room, ) of 3 departments.

B.) provide a sanitary environment in the dietary department in 2 (food storage and preparation areas) of 2 areas observed. Potential for cross-contamination due to unsanitary food storage, unsanitary cooking supply storage, unsanitary food service items (pots, pans, food processors, oven/stove, and food warmer) and poor general sanitation practices were found throughout the dietary department


A.)

Admissions Department:

The Patient admission area exam room was supposed to be clean and ready for a new patient. The biohazard trash was full and trash was also found in the open trash can.

The admissions bathroom was soiled and trash can was full. The toilet had not been cleaned and had hair and urine on it.


Training Room:

In a training room an open sharps container filled with needles was sitting on a table. Staff was not able to explain why the sharps container was there. Bread was found lying on the floor in the closet of the training room. Mouse droppings were found in the closet and around the eaten dried bread.


Patient Room 306:

Patient room 306 was found to have no shower curtain and the floor of the bathroom was full of water. The shower was mildewed on the floor and there was a build up of hair and dirt in the corners of the bathroom floor.


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B.)

Dietary:

A tour of the kitchen was performed on 3/18/2019 after 9:30 AM with staff #3 and staff #16. Findings were as follows:


1. Stored on the shelf for non-perishable items were two containers of grape jelly that had been opened and the manufactures instructions were to "refrigerate after opening." Staff #16 confirmed the findings.
2. On the clean food preparation table, there were multiple spices that were not dated with open date, expiration date, or contents.
3.The flooring inside the kitchen was covered with dirt and spilled liquid causing the floor to be sticky. The tile grout was heavily soiled and black in color.
4.Corrugated shipping boxes were on top of a counter used for food preparation. Shipping boxes found in the clean supply area can bring in outside contaminates. The likelihood for food borne illnesses can occur.
5. The wall behind the drying rack for clean dishes had a large brown/orange color stain that resembled rust.
6.The bottom shelf on the clean drying rack had no barrier to prevent contamination from the floor to the clean dishes. The likelihood for food borne illnesses can occur.
7. A 3 tier rolling cart stored in the kitchen was soiled with dirt and food particles. Staff #16 confirmed the findings.
8. The stored metal pans used for serving food were noted to be stacked together and wet. Moisture can create bacteria causing cross contamination of food and bacteria.
9. The bottom of the food preparation table was visibly soiled with dirt, spilled liquid, and black stains next to the clean pans. The likelihood for food borne illnesses can occur.
10. The icemaker was covered with dirt, dust, and spilled liquid on the outer surface.
11. On the floor between the wall and the icemaker a wet floor sign, a broken down corrugated box, and an open 5gallon bucket of an unidentified liquid. Shipping boxes found in the clean supply area can bring in outside contaminates. The likelihood for food borne illnesses can occur.
12. On the countertop next to the icemaker, was a food processor stored in a bin that is heavily soiled with dirt, liquid stains, and food crumbs.
13. The walk in refrigerator had corrugated boxes stored with food. Corrugated boxes may harbor dust, bacteria, and insects that may have entered the box during shipping increasing the likeliness for food borne illnesses.
14. The walk in refrigerator had a sealed bag of yellow contents that was dated but no item description written on the bag.
15. A vegetable wrapped in plastic was not dated or labeled and stored on a shelf in the walk in refrigerator.
16. An open container of juice was stored on the shelf in the refrigerator with no opened or expiration date.
17. The opening to the freezer was pulled back and placed on the top shelf. This action could prevent the freezer from maintaining the proper temperature to adequately store frozen food.
18. The floor in the freezer was soiled with dirt, food crumbs, and large pieces of ice.
19. There were corrugated boxes stored in the freezer next to, under, and over the food. Corrugated boxes may harbor dust, bacteria, and insects that may have entered the box during shipping increasing the likeliness for food borne illnesses.
20. The inside of the food warmer was soiled with a brown/black color on the bottom tray and the metal racks. Uncovered food was stored in the warmer.
21. The inside door and the frame of the oven was rusted and heavily soiled with food particles and grease. The metal hinges were noted to be rusted. The metal racks were covered with baked on food.
22. The top of the gas stove was dirty with food particles and a rusted surface. The rust and missing coating on the stove did not allow for proper cleaning. Inability to clean the stove properly creates a likelihood for a possible food borne illness.


An interview with Staff #16 was conducted on 3/18/2019 after 9:30 AM. Staff #16 was asked about his experience as a Dietary Director. Staff #16 stated he has worked many years in dietary but he did not have hospital dietary experience.




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23. A dirty trashcan was observed near the clean dish storage area and dishwashing area. Staff #16 confirmed that this was a clean area of the kitchen and that there was not a marked-off, identifiable dirty area of the kitchen.
24. A handwashing sink/eyewash station sink was observed to be near the entrance to the kitchen and by the dishwashing station. The sink was observed to have vegetable scraps in it and was heavily soiled with dirt build-up. Staff #16 confirmed this was not a food preparation area. The food scraps and dirty handwashing sink provided the opportunity for staff entering the kitchen not properly sanitize their hands before handling food and dishes.

Based on review of records, the facility failed to ensure the Psychiatric Evaluation was completed and/or countersigned by the physician in 1 (Patient #19) of 5 charts reviewed. The facility failed to ensure that the Psychiatric Nurse Practitioner was appropriately credentialed to complete the initial Psychiatric Evaluation.

Findings included:

Patient #19's chart was reviewed on 3-20-19. The patient had been involuntarily admitted on 3-15-19. Staff #23 completed the Inpatient Psychiatric Evaluation on 3-16-2019 at 11:00 AM. The physician's signature block was blank.


Review of Medical Staff Bylaws, Article 6, Determination of Privileges, stated:

"6.2 Delineation of Privileges in General.
6.2.1 Requests. Each application for appointment and reappointment must contain a request for the specific clinical privileges desired by the applicant. The process for the delineation of clinical privileges id described to each applicant. A request pursuant to Section 5.6 for the modification of privileges must be supported by documentation of training and/or experience supportive of the request."


Review of Staff #23's credential file showed no evidence of Staff #23 requesting the specific privilege of completing the Psychiatric Evaluation. No letter of appointment was found in the file to indicate Staff #23 had been appointed to the Medical Staff, the Status appointed to, the duration of appointment, or the Clinical Responsibilities (to include completing the Psychiatric Evaluations) approved.