HospitalInspections.org

Based on record reviews and interviews, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services as evidenced by:

1) Failing to ensure the registered nurse (RN) supervised and evaluated the nursing care for each patient as evidenced by:
a) Failure to ensure physician orders were implemented for capillary blood glucose checks for 4 (#2, #3, #9, #10) of 7 current patients' medical records reviewed with orders for capillary blood glucose (CBG) checks from a total of 29 sampled patients;
b) Failure to assess patients' vital signs as ordered for 4 (#3, #4, #5, #6) of 7 (#1 - #6, #9) current patients' records reviewed for assessment of vital signs from a total of 29 sampled patients;
c) Failure to ensure the mental health techs (MHTs) were informed of each assigned patients' precautions for 3 (#1, #3, #5) of 7 (#1 - #6, #9) current patients' records reviewed for patients being observed according to special precautions by MHTs from a total of 29 sampled patients;
d) Failure to assess patients according to the Clinical Opiate Withdrawal Scale (COW) or the Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA-A) as ordered by the physician for 2 (#4, #5) of 2 current patients' medical records reviewed with physician orders for COW and/or CIWA-A assessments from a total of 29 sampled patients; and
e) Failure to assess a patient's oxygen saturation according to the patient's treatment plan for 2 (#2, #6) of 3 patients' records (#2, #6, #24) (Patients #2 and #6 were current patients) reviewed with respiratory medications/orders from a total of 29 sampled patients (see findings in tag A0395);

2) Failing to ensure that drugs were administered as ordered by the physician and in accordance with hospital policy as evidenced by:
a) Failure to administer patients' medications as ordered by the physician and according to hospital policy for 8 (#2, #3, #4, #5, #6, #9, #10, #12) active patient s' records of 10 (#1-#6, #9, #10, #12, #17) patients' records reviewed for medication administration from a total of 29 sampled patients; and
b) Failure to ensure each patient's medication order included the indication for use and the specific route of administration as required by hospital policy for 5 (#1, #3, #4, #5, #6) active patients' records of 10 (#1-#6, #9, #10, #12, #17) patients' records reviewed for completeness of the medication order from a total of 29 sampled patients (see findings in tag A0405).

There were 66 medication errors identified by the surveyors that had not been identified by the hospital for 8 (#2, #3, #4, #5, #6, #9, #10, #12) active patients' records reviewed for medication administration compliance from a total of 29 sampled patients over a 10 day period (05/11/14 through 05/20/14); and


3) Failure to implement an effective policy/procedure relative to the identification of medication errors. This resulted in the hospital's failure to ensure that medication administration errors were reported to the physician and tracked through the hospital's quality assessment and performance improvement program (QAPI). The hospital did not have a system in place to identify medication administration errors and relied on the nurse administering medications to complete a medication variance report. (see findings in tag A0410).

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Radiologic Services as evidenced by:

1) Failing ensure there was a qualified full-time, part-time, or consulting radiologist who supervised the radiology services who was a member of the medical staff. The hospital did not have a radiologist credentialed and privileged as a member of the medical staff to supervise the radiology services provided in the hospital and to interpret the x-rays performed (see findings in tag A0546) and

2) Failing ensure policies and procedures were developed that addressed proper safety precautions against radiation hazards that included adequate shielding for patients and personnel and the method used to identify pregnant patients (see findings in tag A0536).

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Respiratory Services as evidenced by:

1) Failing to have a Director of Respiratory Services who is a physician with knowledge, experience, and capabilities to supervise and administer respiratory services (see findings in tag A1153);

2) Failing to have qualified staff who were trained and evaluated for competency to provide the physician-ordered respiratory services (see findings in tag A1154);

3) Failing to have written policies and procedures developed and approved by the medical staff for the delivery of respiratory services (see findings in tag A1152);

4) Failing to have written Policies and Procedures developed and approved by the medical staff defining the scope of respiratory therapy services and the supervision required for the delivery of respiratory therapy services provided to patients at the hospital (see findings in tag A1160); and

5) Failing to administer respiratory therapy services as ordered by the physician for 3 (#2, #6, #24) of 4 (#2, #6, #9, #24) patients' records reviewed for respiratory services out of a total sample of 29 patients (see findings in tag A1163).

Based on record reviews and interviews, the hospital failed to meet all special provisions applying to psychiatric hospitals as evidenced by:

Failing to meet the requirements for the Condition of Participation for the Special Medical Records Requirements For Psychiatric Hospitals (see findings in tag B0103).

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Special Medical Record Requirements for Psychiatric Hospitals as evidenced by:

1) Failing to ensure that each patient received a psychiatric evaluation as evidenced by having a policy that allowed a psychiatric evaluation update to be conducted if the previous psychiatric evaluation had been completed in the last 30 days. 1 (#1) of 6 current patients' (#1 - #6) records reviewed for a psychiatric evaluation performed within 60 hours of admission from a total of 16 current patients' records reviewed (total of 29 sampled patients) revealed a psychiatric evaluation update had been conducted rather than a psychiatric evaluation (see findings in tag B0110);

2) Failing to ensure that each patient received a psychiatric evaluation that estimated his/her intellectual functioning, memory functioning, and orientation in a sufficiently descriptive manner to establish a diagnosis and objective baseline for future comparison as required by hospital policy. The psychiatric evaluations failed to have intellectual functioning, memory functioning, and/or orientation documented in a descriptive manner as evidenced by having check marks placed in the space provided for description rather than descriptive terms for 3 (#1, #3, #5) of 6 current patients' (#1 - #6) psychiatric evaluations reviewed for intellectual functioning, memory functioning, and orientation from a total of 16 current patients' records reviewed (total of 29 sampled patients) (see findings in tag B0116);

3) Failing to ensure that each patient had an individual comprehensive treatment plan as evidenced by failing to include medical diagnoses for which the patient was being treated for 3 (#3, #9, #10) of 8 (#1-#6, #9, #10) current patients' records reviewed for treatment plans from a total of 16 current patients' records reviewed (total sample of 29 patients) (see findings in tag B0118);

4) Failing to ensure that the nursing staff documented in the patients' records the specific treatment utilized for each patient as stated in the goals for the patient as evidenced by having no documented evidence that pain (#5) and oxygen saturation (#6) was assessed and documented according to the stated goals for 2 (#5, #6) of 8 (#1-#6, #9, #10) current patients' records reviewed for treatment plans from a total of 16 current patients' records reviewed (total sample of 29 patients) (see findings in tag B0122); and

5) Failing to ensure that progress notes were recorded by all disciplines involved in active treatment of the patients as evidenced by failing to have documented evidence of progress notes for therapeutic recreational therapy groups conducted for 2 (#5, #6) of 3 (#4, #5, #6) current patients' records reviewed for therapeutic recreational therapy progress notes from a total of 16 current patients' records reviewed (total sample of 29 patients) (see findings in tag B0129).

Based on record review and interview, the hospital failed to ensure they provided for capital expenditures for at least a 3-year period including the year in which the operating budget is applicable. The hospital did not have a capital expenditure budget beyond 12/31/14. Findings:

Review of the "Capital Expenditure Budget" presented by S1Administrator revealed it was for the period ending 12/31/14. There was no documented evidence of capital expenditures for at least a 3-year period.

In an interview on 05/20/14 at 3:30 p.m., S1Administrator indicated that he didn't have a 3-year capital expenditure plan for the hospital.

Based on interview, the hospital failed to ensure the services performed under contract were provided in a safe and effective manner as evidenced by having no documented evidence that all services provided by contract had been evaluated for safety and efficiency.
Findings:

In an interview on 05/23/14 at 10:10 a.m., S2DON (Director of Nursing) indicated that she reviewed the contract information and not all contracted services had been evaluated to determine that the services were being provided in a safe and efficient manner. She further indicated that she couldn't explain why it wasn't done, because S1Administrator was responsible for doing evaluations, and he was currently on vacation and not available to explain.

Based on observations and interviews, the hospital failed to ensure that patients received care in a safe setting as evidenced by:
1) Having Styrofoam cups and plastic forks in plastic bags in an unlocked cart in the patient day room;
2) Allowing Patient #1, who was a 29 year old male admitted on 05/18/14 with diagnoses of Bipolar I Current Depression, Hypertension, and Polysubstance Abuse and presented stating that "I would've hurt myself if I couldn't get back in" (the hospital), to remain unattended by staff in the dining room which had a locked exit door with an exposed hinge that presented a ligature risk and a box containing 29 short, sharpened pencils;
3) Having the patient restraint/seclusion room with a vinyl mattress covering that zips around the mattress and could provide a means of suffocation; the restraint bathroom had a shower head that protruded 6 to 7 inches from the wall and had a foldable shower seat, both which could provide a ligature risk;
4) Having crank-type beds in Rooms a and b that could present a ligature risk; each of the 2 beds in Room b had sharp-edged metal protruding in 2 areas of each side of the beds that had been used for siderails previously;
5) Having all patient room doors and patient bathroom doors with exposed hinges and non-ligature handles that could present a ligature risk; having all sink guards in patient bathrooms connected with non-tamper-proof screws; having all mattress covers made of vinyl with a zipper surrounding the mattress that could present a means of suffocation;
6) Having an assistive shower seat in Room e, a sharp-edged sink guard in Room f and g, and a 7 foot plastic hose extending from the shower wall to a hand-held shower in Room g; and
7) Having 42 areas with broken wooden slats with sharp edges or splintered fence areas on the wooden fence surrounding the outdoor patient area. Record review revealed that Patient #25 had injured his head on 03/20/14 when his head hit the fence while playing kickball.

Findings:

1) Having Styrofoam cups and plastic forks in plastic bags in an unlocked cart in the patient day room:
Observation on 05/19/14 at 1:50 p.m. revealed a cart that held the ice maker in the patient's day room. Further observation revealed a compartment of the cart was unlocked and contained plastic bags with Styrofoam cups and plastic forks that was accessible to patients in the day room. S1Administrator confirmed during the observation that that the plastic bags and plastic forks could be used to injure oneself or others.

2) Allowing Patient #1, who was a 29 year old male admitted on 05/18/14 with diagnoses of Bipolar I Current Depression, Hypertension, and Polysubstance Abuse and presented stating that "I would've hurt myself if I couldn't get back in" (the hospital), to remain unattended by staff in the dining room which had a locked exit door with an exposed hinge that presented a ligature risk and a box containing 29 short, sharpened pencils:
Observation on 05/19/14 at 2:00 p.m. revealed Patient #1 was seated at a table in the dining room with no staff present for observation. Further observation revealed there was a box of 29 short, sharpened pencils on the ledge of the window that could provide a means of injury to a suicidal patient. Further observation revealed a locked exit door with an exposed hinge that presented a ligature risk.

Review of Patient #1's medical record revealed that he was a 29 year old male admitted on 05/18/14 with diagnoses of Bipolar I Current Depression, Hypertension, and Polysubstance Abuse and presented stating that "I would've hurt myself if I couldn't get back in" (the hospital). Review of his admit nursing assessment performed on 05/18/14 at 5:00 p.m. revealed he was assessed to be a medium suicide risk. His Psychiatric Evaluation performed by S3Medical Director on 05/19/14 at 11:10 a.m. revealed that Patient #1 had suicidal ideations.

In an interview on 05/19/14 at 2:10 p.m., S1Administrator confirmed the safety risks identified and confirmed that Patient #1 should not have been allowed to be unattended in the dining room.

3) Having the patient restraint/seclusion room with a vinyl mattress covering that zips around the mattress and could provide a means of suffocation; the restraint bathroom had a shower head that protruded 6 to 7 inches from the wall and had a foldable shower seat, both which could provide a ligature risk:
Observation of the restraint/seclusion room on 05/19/14 at 2:20 p.m. revealed the mattress on the bed had a vinyl covering that zipped around the mattress. Further observation revealed the bathroom adjacent to the restraint/seclusion room had a shower head that protruded 6 to 7 inches from the wall and had a foldable shower seat, both which could provide a ligature risk. These observations were confirmed by S1Administrator.

4) Having crank-type beds in Rooms a and b that could present a ligature risk; each of the 2 beds in Room b had sharp-edged metal protruding in 2 areas of each side of the beds that had been used for siderails previously:
Observation of Room a and b on 05/19/14 at 2:35 p.m. revealed each room had 2 crank-type beds that could present a ligature risk. The beds in Room b had sharp-edged metal protruding in 2 areas of each side of the beds that had been used for siderails previously that could present a risk for injury. These observations were confirmed by S1Administrator.

5) Having all patient room doors and patient bathroom doors with exposed hinges and non-ligature handles that could present a ligature risk; having all sink guards in patient bathrooms connected with non-tamper-proof screws; having all mattress covers made of vinyl with a zipper surrounding the mattress that could present a means of suffocation:
Observation of all patient rooms and bathrooms on 05/19/14 at 2:35 p.m. revealed the patient room doors and patient bathroom doors had exposed hinges and non-ligature handles that could present a ligature risk. Further observation revealed that all sink guards (used to secure the sink plumbing) in patient bathrooms had been connected with non-tamper-proof screws. Further observation revealed all mattresses were covered a vinyl mattress cover that zipped around the mattress and could be used for suffocation if unzipped. These observations were confirmed by S6Assistant Director of Environmental Care.

6) Having an assistive shower seat in Room e, a sharp-edged sink guard in Room f and g, and a 7 foot plastic hose extending from the shower wall to a hand-held shower in Room g:
Observations on 05/19/14 at 2:50 p.m. revealed Room e had an assistive shower seat that presented multiple ligature risks. Further observation revealed a sharp-edged sink guard in Rooms f and g and a 7 foot plastic hose extending from the shower wall to a hand-held shower in Room g that presented a ligature risk. These observations were confirmed by S6Assistant Director of Environmental Care and S2DON (Director of Nursing).

7) Having 42 areas with broken wooden slats with sharp edges or splintered fence areas on the wooden fence surrounding the outdoor patient area; record review revealed that Patient #25 had injured his head when his head hit the fence while playing kickball:
Observation on 05/19/14 at 3:10 p.m. revealed a wooden fence surrounding the perimeter of the outdoor area used by the patients. Further observation revealed at least 42 areas that had broken wooden slats with sharp edges or splintered fencing that left sharp, jagged edges that could injure a patient. This observation was confirmed by S2DON and S6Assistant Director of Environmental Care.

Review of the Incident Report Form dated 03/20/14 at 4:14 p.m. revealed Patient #25 was playing kickball and "the Right side of his head hit the fence." It further stated Patient #25 had scratches and bruises. There was no documented evidence that the outdoor fence was inspected after the injury to determine if structural damage could have caused some of Patient #25's scratches and bruises.

Based on record reviews and interview, the hospital failed to ensure that the quality assessment and performance improvement (QAPI) program measured, analyzed, and tracked quality indicators and other aspects of performance that assess processes of care, hospital services, and operations. The hospital failed to include all departments and contracted services in its QAPI data tracking and analysis.
Findings:

Review of the Governing Body By-laws, presented as the current by-laws by S2DON (Director of Nursing), revealed that the Chief Executive Officer was responsible for implementing processes that measure and assess the performance improvement and safety improvement activities of the hospital and its programs including processes that continually monitor the effectiveness of the performance improvement and safety improvement activities, assess and implement improvements for these activities, and assess the adequacy of the human, information, physical, and financial resources allocated to support performance improvement and safety improvement activities.

Review of the "Performance Improvement Committee Meeting Minutes for 03/06/14 and 03/26/14 revealed no documented evidence that data was collected, measured, analyzed, and tracked for all services provided by the hospital either directly or by contract including
pharmacy services provided by the contracted pharmacist, radiological services, laboratory services, dietary services, physical environment safety issues, respiratory services, and contracted linen and biohazardous waste services.

In an interview on 05/23/14 at 12:40 p.m., S2DON indicated that the staff member responsible for QAPI was not available for interview. She confirmed that not all services provided directly or by contract by the hospital were included in the QAPI program.

Based on interview, the hospital failed to ensure that it conducted performance improvement projects as part of its quality assessment and performance improvement program. The hospital could provide no documented evidence of a completed performance improvement project that it had conducted as well as an ongoing project.
Findings:

In an interview on 05/23/14 at 12:40 p.m., S2Director of Nursing confirmed that the hospital had not conducted any performance improvement projects and did not have an ongoing project in place at the present time.

Based on record reviews and interviews, the hospital failed to ensure that the Medical Staff enforced its By-laws as evidenced by failing to implement the by-laws for suspension of physicians with incomplete medical records 30 days after discharge. Patients' medical records were not completed within 30 days after discharge for 3 (#15, #17, #23) of 4 (#14, #15, #17, #23) patient records reviewed for discharge summaries from a total of 13 closed medical records reviewed from a total sample of 29 patients. The hospital's delinquency rate for medical record completion went from 13% (percent) in March 2014 to 59% in April 2014.
Findings:

Review of the Medical Staff By-laws, presented S2DON as the current by-laws, revealed that the attending medical staff member will be responsible for the preparation of a complete and legible medical record for each patient that includes a discharge summary. A discharge summary shall be written or dictated on all medical records of all patients within 30 days of discharge. An attending medical staff member will be considered delinquent in completion of his medical records if the records are not completed, written, or dictated within this time period. An attending medical staff member will automatically be suspended in the form of withdrawal of his admitting privileges 5 days after he is given a warning of delinquency for failure to complete medical records. A notice of delinquency will be given if the records are not completed within 30 days after discharge of the patient, the suspension shall continue until the medical records are completed. If the medical record is incomplete 5 days after the warning is given, a written notice shall be sent to the attending medical staff member notifying him/her that his/her admitting or other privileges shall be suspended immediately and that he/she shall remain suspended until all of his/her delinquent records have been completed. The Admitting Office shall be notified of this action by the RHIA. Reinstatement of privileges will be automatic upon completion of records, and the Admitting Office shall be notified. The Health Information Management Department will be responsible for analyzing medical records for the purpose of administering this rule.

Patient #15 Review of Patient #15 ' s medical record revealed she was a 26-year-old female admitted to the hospital on 04/04/14 with the diagnoses of Recurring Depression, Severe; Obsessive Compulsive Disorder; Hypertension; Thyroid Disease; and Sleep Apnea. Further review revealed Patient #15 was discharged from the hospital on 04/16/14 at 3:54 p.m. to an acute care hospital.
Review of Patient #15 ' s complete medical record revealed the medical record did not contain a discharge summary from the physician.

In an interview on 05/23/14 at 11:25 a.m., S16RHIA verified that a discharge summary had not been completed by the physician for Patient #15.

Patient #17 Review of Patient #17's medical record revealed he was a 26 year old male admitted on 03/11/14 with diagnoses of Bipolar Disorder, Manic Severe with Psychosis, Opiate Dependence, and Cannibas Dependence. He was discharged on 03/21/14. Further review revealed no documented evidence that a discharge summary had been dictated and signed as of 05/22/14.

Patient #23 Review of Patient #23's medical record revealed she was a 52 year old female admitted on 04/18/14 and discharged on 04/28/14. Further review revealed no documented evidence that a discharge summary had been written or dictated within 30 days of discharge.

In an interview on 05/22/14 at 12:00 p.m., S16RHIA (Registered Health Information Administrator) indicated the delinquency rate had gone from 13% in March 2013 (5% for the first quarter of 2014) to 59% for April 2014 due to incomplete discharge summaries. She further indicated that the physicians do not dictate their own discharge summaries. She further indicated that this responsibility had been delegated by the physicians to Case Management nurses. She indicated that the discharge summaries were incomplete, because the Case Management department was presently short-staffed and could not get to the discharge summaries. S16RHIA indicated that she had not sent any letters and no physician had been suspended as required by the hospital's Medical Staff By-laws.

Based on record reviews and interviews, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care for each patient as evidenced by:
1) Failing to ensure physician orders were implemented for capillary blood glucose checks for 4 (#2, #3, #9, #10) of 7 current patients' medical records reviewed with orders for capillary blood glucose (CBG) checks from a total of 29 sampled patients;
2) Failing to ensure physician's orders were implemented for obtaining an x-ray for 2 (#23, #24 - both closed medical records) of 4 patients' medical records reviewed with physician orders for x-rays (#11, #17, #23, #24) from a total of 29 sampled patients;
3) Failing to assess patients' vital signs as ordered for 4 (#3, #4, #5, #6) of 7 (#1 - #6, #9) current patients' records reviewed for assessment of vital signs from a total of 29 sampled patients;
4) Failing to ensure the mental health techs (MHTs) were informed of each assigned patients' precautions for 3 (#1, #3, #5) of 7 (#1 - #6, #9) current patients' records reviewed for patients being observed according to special precautions by MHTs from a total of 29 sampled patients;
5) Failing to assess patients according to the Clinical Opiate Withdrawal Scale (COW) or the Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA-A) as ordered by the physician for 2 (#4, #5) of 2 current patients' medical records reviewed with physician orders for COW and/or CIWA-A assessments from a total of 29 sampled patients;
6) Failing to assess a patient's oxygen saturation according to the patient's treatment plan for 2 (#2, #6) of 3 patients' records (#2, #6, #24) Patients #2 and #6 were current patients) reviewed with respiratory medications/orders from a total of 29 sampled patients;
7) Failing to assess a patient with physician orders for a chest x-ray and Albuterol administration for 1 (#24) (closed medical record) of 1 patient record reviewed with physician orders for a chest x-ray and administration of Albuterol from a total of 29 sampled patients;
8) Failing to obtain a report from the Emergency Department (ED) upon the patient's return from the ED and obtain physician orders for further treatment for 2 (#17, #29) of 2 patients' records reviewed who were sent to the ED for emergency treatment from a total of 29 sampled patients; and
9) Failing to assess a patient's neurological status for 1 (#25) of 2 (#25, #29) (closed medical records) patients' records reviewed who sustained injuries while in the hospital from a total sample of 29 patients.
Findings:

1) Failing to ensure physician orders were implemented for capillary blood glucose checks:
Patient #2 Review of Patient #2's medical record revealed he was a 47-year old male admitted to the Hospital on 05/17/14 at 3:30 p.m. with diagnoses of Major Depression, Suicide Attempt, Hypertension, and Diabetes Mellitus.
Review of the document "Regular Insulin Sliding Scale" revealed CBG levels were ordered by the physician on 05/17/14 at 7:20 p.m. to be done before meals and at bedtime. Review of the Medication Administration Record (MAR) and Diabetic flow sheet revealed no CBGs were done at bedtime on 05/17/13 and on 05/18/14 and 05/19/14 before breakfast.
In an interview on 05/20/13 at 11:30 a.m., S2DON confirmed there were no CBGs performed on Patient #2 on the above mentioned dates and times, and there should have been CBGs performed as ordered by the physician.

Patient #3
Review of Patient #3's medical record revealed she was a 50 year old female admitted on 05/18/14 with a diagnosis of Bipolar Manic. Review of her Psychiatric Evaluation performed on 05/19/14 revealed she also was diagnosed with Diabetes Mellitus Type 2.

Review of Patient #3's Physician's orders revealed an order on 05/19/14 at 7:00 a.m. to check her fasting CBG every morning for 3 days.

Review of Patient #3's "Initial Blank MAR" (medication administration record) revealed the hand-written entry of fasting CBG every morning for 3 days with a note (start 5/20/14." Review of the MAR and the "Diabetic Flow Sheet" revealed Patient #3's CBG was first assessed on 05/20/14/ Review of her "Daily Nursing Assessment" dated 05/19/14 for the day shift revealed no documented evidence of the reason her CBG was not assessed on 05/19/14 as ordered by the physician (no documentation that she had already eaten at 7:00 a.m.).

In an interview on 05/20/14 at 1:45 p.m., S2Director of Nursing (DON) indicated that she wasn't sure what time breakfast was served at the hospital. She further indicated that Patient #3's CBG should have been assessed on 05/19/14 when it was ordered, unless Patient #3 had already eaten. She further indicated that if Patient #3 had eaten, the nurse should have documented this in Patient #3's medical record and reported the delay to the physician.

Patient #9 Review of Patient #9's medical record revealed she was a 26-year-old female admitted to the hospital on 05/15/14 at 9:06 p.m. with diagnoses of Bipolar Disorder, Suicidal Ideations, Aggressive Behaviors, Diabetes Mellitus, Hypothyroidism, and High Cholesterol.
Review of the document "Regular Insulin Sliding Scale" revealed CBG levels were ordered by the physician on 05/15/14 at 9:06 p.m. for CBG levels to be done before meals and at bedtime. Review of the MAR and Diabetic flow sheet revealed no CBG was done on 05/17/13 at bedtime.
In an interview on 05/20/13 at 11:30 a.m., S2DON confirmed there was no CBG performed on Patient #9 on the above mentioned date and time, and there should have been a CBG performed as ordered by the physician.
Patient #10 Review of Patient #10's medical record revealed he was a 52-year-old male admitted to the hospital on 05/12/14 with diagnoses of Major Depressive Disorder without Psychosis, Anxiety Disorder, Hypertension, Diabetes Mellitus, and Chronic Pain.
Review of the document "Regular Insulin Sliding Scale" revealed CBG levels were ordered by the physician on 05/12/14 at 5:30 p.m. for CBG levels to be done before meals and at bedtime. Review of the MAR and Diabetic Flow Sheet revealed no CBG was done on 05/13/14 at bedtime.
In an interview on 05/20/13 at 11:30 a.m., S2DON confirmed there was no CBG performed on Patient #10 on the above mentioned date and time, and there should have been a CBG performed as ordered by the physician.

2) Failing to ensure physician's orders were implemented for obtaining an x-ray:
Review of the policy titled "X-Rays" (only one policy related to radiological services), policy number CTS-057 and revised April 2013, revealed the nurse was to obtain the order for x-ray, complete the x-ray request form, inform the contract service provider of the x-ray request, explain the purpose of the x-ray to the patient, and the x-ray was to be performed in the patient's room with staff present while protecting patient privacy.

Patient #23
Review of Patient #23's medical record revealed she was a 52 year old female admitted on 04/18/14 and discharged on 04/28/14. Review of her Physician's Orders revealed an order on 04/19/14 at 7:30 p.m. for a chest x-ray in the morning.

Review of Patient #23's chest x-ray report revealed the x-ray was performed on 04/21/14 rather than 04/20/14 as ordered by the physician.

Patient #24
Review of Patient #24's medical record revealed she was a 55 year old female admitted on 04/28/14 and discharged on 05/02/14. Review of her Physician's Orders revealed an order on 04/29/14 at 7:00 a.m. to obtain a chest x-ray today.

Review of Patient #24's entire medical record revealed no documented evidence that a chest x-ray was performed on 04/29/14 as ordered, and there was no documented evidence of a chest x-ray report.

In an interview on 05/23/14 at 8:30 a.m., S2DON indicated she couldn't explain why Patient #23's chest x-ray was not done on 04/29/14 as ordered and why no chest x-ray was performed as ordered for Patient #24.

3) Failing to assess patients' vital signs as ordered:
Patient #3
Review of Patient #3's medical record revealed she was a 50 year old female admitted on 05/18/14 with a diagnosis of Bipolar Manic. Review of her Psychiatric Evaluation performed on 05/19/14 revealed she also was diagnosed with Diabetes Mellitus Type 2.

Review of Patient #3's physician's admit orders dated 05/18/14 at 2:15 p.m. revealed an order for routine vital signs which consisted on 4 times a day while awake for 24 hours, the twice a day for 3 days, and then daily.

Review of Patient #3's graphic sheet revealed her vital signs were assessed on 05/18/14 at 4:00 p.m. There was no documented evidence that her vital signs were assessed at 8:00 p.m. which was the next scheduled time for assessment.

Patient #4
Review of Patient #4's medical record revealed he was a 31 year old male admitted on 05/16/14 with diagnoses of Mood Disorder and Severe Opiate Dependence.

Review of Patient #4's Physician's Orders revealed the following orders for vital signs related to detox using the COW Scale and the administration of Clonidine:
05/16/14 at 4:47 a.m. (telephone order): Clonidine 0.1 mg (milligrams) by mouth every 6 hours for 72 hours; hold if systolic blood pressure is less than 100, diastolic blood pressure is less than 60, or pulse is less than 60;
05/16/14 at 7:30 a.m. - Detox/COW scale: every 4 hours while awake for 48 hours, then twice a day for 3 days, then daily;
05/16/14 at 1:00 p.m. - Clonidine 0.1 mg by mouth every 8 hours as needed for systolic blood pressure greater than 160 or diastolic blood pressure greater than 100; Clonidine 0.2 mg by mouth every 8 hours as needed for systolic blood pressure greater than 190 or diastolic blood pressure greater than 115.
Further review of the physician's orders from 05/16/14 at 4:47 a.m. through 05/19/14 at 8:54 a.m. revealed no documented evidence that a physician's order was received to cancel any of the above-listed orders.

Review of Patient #4's graphic sheet revealed his vital signs were assessed on 05/16/14 at 8:00 a.m., 4:00 p.m., and 8:00 p.m. and on 05/17/14, 05/18/14 and 05/19/14 at 8:00 a.m. and 8:00 p.m. There was no documented evidence that Patient #4's vital signs were assessed as ordered every 4 hours while awake for 48 hours and every 8 hours to determine if the Clonidine that was ordered to be given as needed in relation to his blood pressure was needed. Review of the MARs revealed no documented evidence of the blood pressure results when Clonidine was administered on 05/16/14 at 9:00 a.m., 3:00 p.m., 9:00 p.m., on 05/17/14 at 9:00 p.m., on 05/18/14 at 9:00 a.m., 9:00 p.m., and 3:00 a.m. on 05/19/14, and on 05/19/14 at 9:00 a.m.

Patient #5
Review of Patient #5's medical record revealed he was a 29 year old male admitted on 05/16/14 with diagnoses of Psychosis and Polysubstance Dependence.

Review of Patient #5's physician orders revealed an admit order for vital signs per the Detox/COW scale which consisted of every 4 hours while awake for 48 hours, then twice a day for 3 days, then daily.

Review of Patient #5's graphic sheet revealed his vital signs were assessed on 05/16/14 at 4:00 p.m. and not again until 8:00 a.m. on 05/17/14. There was no documented evidence that his vital signs were assessed on 05/16/14 at 8:00 p.m. or that he was asleep when the 8:00 p.m. vital signs were taken.

Patient #6
Review of Patient #6's medical record revealed he was a 28 year old male admitted on 05/16/14 with diagnoses of Mood Disorder, Bipolar Disorder mixed with Psychosis, history of Opiate Abuse, Anxiety, Thyroid Disease, and Asthma.

Review of Patient #6's physician's admit orders revealed an order for vital signs to be assessed 4 times a day while awake for 24 hours, then twice a day for 3 days, then daily.

Review of Patient #6's graphic sheet revealed his vital signs were assessed on 05/16/14 at 8:00 a.m., 4:00 p.m., and 8:00 p.m. There was no documented evidence that his vital signs were assessed at 12:00 p.m.

In an interview on 05/20/14 at 1:45 p.m., S2DON confirmed Patients' #3, #4, #5, and #6 vital signs were not assessed as ordered by the physician or as required by hospital policy.

4) Failing to ensure the mental health techs (MHTs) were informed of each assigned patients' precautions:
Review of the hospital policy titled "Precautions Levels and Record", policy number RC-006, revised March 2013, and contained in the hospital's policy and procedure manual presented as the hospital's current policies and procedures by S2DON, revealed whenever a patient is on a precaution, the patient's every 15 minute observation sheet will be flagged to alert the MHT of the special precaution.

Review of the physician's admit orders for Patients #1, #3, and #5 revealed an order for "Suicide/Self Harm" precautions.

Review of the "q 15 (every 15 minutes) Minute Observation Check Sheet" for Patients #1, #3, and #5 revealed no documented evidence that the precaution for self harm had been circled or highlighted to designate that the patient was to be observed for self harm.

In an interview on 05/20/14 at 1:45 p.m., S2DON indicated that the charge RN was supposed to designate what type of precaution was ordered for each patient on the patient's observation sheet used by the MHTs to document their (MHTs) every 15 minutes observations.

5) Failing to assess patients according to the COW or the CIWA-A scales as ordered by the physician:
Review of the hospital policy titled "Protocols for Detoxification", policy number CTS-088, revised March 2013, and contained in the hospital's policy and procedure manual presented as the hospital's current policies and procedures by S2DON, revealed the nurses are responsible to administer the detoxification/withdrawal medications per physician's order, monitor the patient's vital signs, notify the physician of the patient's response to medications, and record medication and subsequent patient response in the patient's medical record. Further review revealed that the nurse was to check the patient's vital signs and use the CWIA and COW scale prior to administration of each dose and prn (as needed) for alcohol and/or drug withdrawal.

Patient #4
Review of Patient #4's medical record revealed he was a 31 year old male admitted on 05/16/14 with diagnoses of Mood Disorder and Severe Opiate Dependence.

Review of Patient #4's physician admit orders dated 05/16/14 at 7:30 a.m. revealed an order to obtain vital signs according to the Detox/COW scale which consisted of every 4 hours while awake for 48 hours, then twice a day for 3 days, then daily. Further review of the physician's orders revealed an order on 05/16/14 at 4:47 a.m. (received by telephone order) for S22Psychiatrist's Opiate Detox Orders which included Clonidine 0.1 mg every 6 hours for 72 hours; hold if systolic blood pressure is less than 100, diastolic blood pressure is less than 60, or pulse is less than 60. Further review revealed an order on 05/19/14 at 9:00 a.m. for Ultram Detox Protocol which consisted of Ultram 50 mg by mouth 4 times a day for 1 day, Ultram 50 mg 3 times a day by mouth for 1 day, Ultram 50 mg 2 times a day by mouth for 1 day, and Ultram 50 mg 1 time a day by mouth for 1 day, then discontinue.

Review of Patient #4's MARs and COW scales revealed the following times that the COW scale was not documented as ordered:
05/16/14 - prior to administering Clonidine at 3:00 p.m.;
05/17/14 - prior to administration of Clonidine at 9:00 a.m. and 3:00 p.m., 1:00 p.m., 5:00 p.m.;
05/18/14 - prior to administration of Clonidine at 3:00 p.m., 9:00 p.m., and at 3:00 a.m. on 05/19/14;
05/19/14 - prior to administration of Ultram at 1:00 p.m. and 5:00 p.m.; and
05/20/14 - prior to administration of Ultram at 1:00 p.m.

Patient #5
Review of Patient #5's medical record revealed he was a 29 year old male admitted on 05/16/14 with diagnoses of Psychosis and Polysubstance Dependence.

Review of Patient #5's physician's admit orders revealed an order on 05/16/14 at 3:30 p.m. to assess vital signs using the Detox/COW scale which consisted of every 4 hours while awake for 48 hours, then twice a day for 3 days, and then daily. Review of the physician's orders revealed an order on 05/16/14 at 3:30 p.m. for Ultram Detox Protocol which included Ultram 50 mg at 5:00 p.m. on 05/16/14, Ultram 50 mg at 9:00 p.m. on 05/16/14, Ultram 50 mg by mouth 4 times a day for 1 day beginning 05/17/14 at 9:00 a.m., then Ultram 50 mg by mouth 3 times a day for 1 day, then Ultram 50 mg by mouth 2 times a day for 1 day, then Ultram 50 mg by mouth once a day for 1 day, then discontinue.

Review of Patient #5's entire medical record revealed no documented evidence of any COW scale assessment. Patient #5 received Ultram 50 mg by mouth at 5:00 p.m. and 9:00 p.m. on 05/16/14, at 9:00 p.m. on 05/17/14, at 1:00 p.m. on 05/18/14, and at 9:00 a.m. on 05/19/14.

In an interview on 05/20/14 at 1:45 p.m., S2DON confirmed the above-listed COW scale assessments were not done for Patients #4 and #5. She indicated that the RN should be using the scale to assess for detox symptoms with each ordered vital signs assessments. She offered no explanation for the COW scale assessments not being performed by the RNs prior to administration of ordered detox medications as required by hospital policy.

6) Failing to assess a patient's oxygen saturation according to the patient's treatment plan:
Patient #2 Review of Patient #2's medical record revealed he was a 47-year old male admitted to the Hospital on 05/17/14 at 3:30 p.m. with diagnoses of Major Depression, Suicide Attempt, Hypertension, Chronic Obstructive Pulmonary Disease, and Diabetes Mellitus.
Review of Patient #2's physician orders revealed he had oxygen ordered at 2 L (liters) per nasal cannula at night only and PRN (as needed). Review of Patient #2's care plan revealed, as a Long-Term Goal, Patient #2 was to maintain his oxygen saturation level at 90 percent or above.
Review of Patient #2's medical record revealed no documentation in the medical record that Patient #2's oxygen saturation levels was assessed while he was in the hospital.
In an interview on 05/20/14 at 11:35 a.m., S2Director of Nursing confirmed there was no documentation in the entire medical record that indicated Patient #2's oxygen saturation status was assessed while he was in the hospital, and that Patient #2 should have had his oxygen saturation level monitored, assessed, and documented during his hospital stay.
In an interview on 05/2014 at 1: 42 p.m., S12RN (Registered Nurse) verified and confirmed there was no documentation in the medical record that Patient #2's oxygen saturation status was monitored and assessed during his hospital stay, and that Patient #2 should have had his oxygen saturation level monitored and documented during his hospital stay.

Patient #6
Review of Patient #6's medical record revealed he was a 28 year old male admitted on 05/16/14 with diagnoses of Mood Disorder, Bipolar Disorder mixed with Psychosis, history of Opiate Abuse, Anxiety, Thyroid Disease, and Asthma.

Review of Patient #6's physician's orders revealed an order on 05/16/14 at 1:00 p.m. for Albuterol HFA 2 puffs every 6 hours as needed for wheezing/shortness of breath (SOB) and Flovent Diskus 100 mcg (microgram) 2 puffs twice a day.

Review of Patient #6's treatment plan for "Impaired Gas Exchange", initiated on 05/17/14, revealed the long term goal was that Patient #6 would maintain an oxygen saturation at 90% (per cent) or above, and the intervention was that the RN would monitor his oxygen saturation every shift.

Review of Patient #6's entire medical record revealed no documented evidence that his oxygen saturation was ever assessed according to his treatment plan.

In an interview on 05/20/14 at 1:30 p.m., S2DON confirmed there was no documentation of Patient #6's oxygen saturation being monitored by the RN.

7) Failing to assess a patient with physician orders for a chest x-ray and Albuterol administration:
Review of Patient #24's medical record revealed she was a 55 year old female admitted on 04/28/14 and discharged on 05/02/14. Review of her physician orders dated 04/29/14 at 7:00 a.m. revealed an order for Albuterol nebulizer treatment now and then every 6 hours as needed for wheezing/SOB, Prednisone 20 mg one tablet by mouth daily for 3 days, and to obtain a chest x-ray today.

Review of Patient #24's MARs and nursing daily assessments revealed no documented evidence of an assessment by a RN of the events that warranted the order for the nebulizer treatment, an order for Prednisone, and the chest x-ray. Further review revealed no documented evidence that the nebulizer treatment was administered or that the chest x-ray was performed.

In an interview on 05/23/14 at 8:30 a.m., S2DON indicated there should have been an assessment of Patient #24 by a RN on 04/29/14. She could offer no explanation for the chest x-ray not being done and the nebulizer treatment not being administered as ordered.

8) Failing to obtain a report from the Emergency Department (ED) upon the patient's return from the ED and obtain physician orders for further treatment:
Patient #17
Review of Patient #17's medical record revealed he was a 26 year old male admitted on 03/11/14 with diagnoses of Bipolar Disorder, Manic Severe with Psychosis, Opiate Dependence, and Cannibas Dependence. He was discharged on 03/21/14.

Review of Patient #17's physician's orders revealed an order on 03/12/14 at 11:37 p.m. to send him to the ED for a possible asthmatic attack. Further review revealed an order on 03/13/14 at 2:10 a.m. for a medical consult post ED visit for asthma.

Review of Patient #17's "Multidisciplinary Notes" revealed that Patient #17 was sent to the ED on 03/12/14 (documented as 03/12/14 but should be 03/13/14) at 12:15 a.m. and returned on 03/13/14 at 1:58 a.m. There was no documented evidence that the RN obtained a report of the findings from the ED visit for Patient #17's possible asthma attack. There was no documented evidence of physician orders for treatment upon Patient #17's return from his ED visit.

In an interview on 05/23/14 at 8:30 a.m., S2DON offered no explanation for Patient #17's medical record not having evidence of a report from his ED visit on 03/13/14 and not having physician orders for treatment upon his return from the ED.

Patient #29 Patient #29 was a 72 year-old male admitted to the hospital on 05/01/14 with diagnoses of Major Depressive Disorder with Psychoses, Anxiety, Dementia, Seizure Disorder, Hypertension, and Chronic Back Pain.
Review of Patient #29's medical record revealed he had an unobserved fall at his room doorway on 05/05/14 at 5:15 p.m. The patient was sent to the Emergency Department for evaluation and treatment on 05/05/14, and he returned to the hospital on 05/06/14 at 2:10 a.m.
Review of the physician's orders for Patient #29 upon return from the Emergency Department to the hospital on 05/06/14 at 2:30 a.m. revealed the following telephone order from Patient #29's physician: "Medical consult after fall, altered mental status/after ER (emergency room) evaluation."

Review of the "Multidisciplinary Notes" dated 05/06/14 at 2:10 a.m. revealed Patient #29 returned from the Emergency Department to the hospital. There was no documented evidence in the notes that the nurse received a report of the findings from the Emergency Department regarding Patient #29's condition, and there was no physician's orders for Patient #29 which was specific to Patient #29's diagnoses and current condition.

In an interview on 05/23/14 at 10:45 a.m., S2Director of Nursing reviewed Patient #29's medical record and agreed there were no physician orders written for Patient #29 which were specific to Patient #29's diagnoses and current condition once he returned to the hospital from his Emergency Department visit.

9) Failing to assess a patient's neurological status after sustaining a head injury:
Patient #25 was a 29-year-old male admitted to the hospital on 03/16/14 with the diagnoses of Major Depressive Disorder, Suicide Attempt, and Alcohol Abuse.

Review of the policy "Neurological Assessment," No: CTS-30 presented by S2Director of Nursing as the current policy, revealed in part, "Neurological assessment is performed after (but not limited to) the following changes in patient condition: level of consciousness, motor strength, pupils, speech, and gait. Neurological assessment is indicated after any head injury."

Review of the Incident Report Form dated 03/20/14 at 4:14 p.m. revealed Patient #25 was playing kickball and "the Right side of his head hit the fence." It further stated Patient #25 had scratches and bruises, but Patient #25 stated he was okay.
Review of Patient #25's medical record revealed there was no neurological assessment performed by the nurse after Patient #25's injury to his head as indicated in the policy "Neurological Assessment. "
In an interview on 05/23/14 at 11:15 a.m., S2Director of Nursing reviewed Patient #25's medical record and confirmed there was no neurological assessment performed by the nursing staff after Patient #25 hit his head on the fence, and there should have been neurological assessments performed on Patient #25 after his head injury.


31048

Based on record reviews and interviews, the hospital failed to ensure that the registered nurse (RN) assigned the nursing care of each patient to nurses who had been evaluated for competency as evidenced by having no documented evidence of orientation to specific nursing duties and competency evaluations for 3 (S9, S10, S18) of 4 (S2, S9, S10, S18) RNs' personnel files reviewed from a total of 6 employed RNs and 2 (S11, S17) of 2 LPNs' (licensed practical nurses) personnel files reviewed from a total of 8 employed LPNs. Findings:

Review of the policies presented by S2Director of Nursing (DON) when policies relative to employee orientation and competency evaluations included policies titled "Employment", "Certifications & (and) Licensure", and "Performance Evaluation". Review of the three policies revealed no documented evidence that orientation to the specific nursing duties and evaluation of nurses' competencies were addressed.

Review of the personnel files of S9RN, S10RN, S11LPN, and S17LPN revealed no documented evidence that orientation to the specific nursing duties was conducted, and there was no documented evidence that an evaluation of competency was performed for each of them. Further review revealed no documented evidence of orientation to and competency of performing respiratory therapy treatments was conducted for S9RN, S10RN, S11LPN, and S17LPN.

In an interview on 05/23/14 at 12:10 p.m., S2DON confirmed that she didn't have any orientation or competency evaluations for the nursing staff other than what's in their personnel files. When informed that there was no evidence of orientation to nursing duties including respiratory services, no competency evaluations, and no performance evaluations as required by hospital policy, S2DON offered no explanation. She confirmed that the hospital did not have a respiratory therapist on staff or contracted, and the nursing staff was performing the respiratory treatments when ordered.

Review of the personnel file of S18Case Manager revealed no documented evidence that it was in her job description to dictate discharge summaries for physicians, that she had received orientation and training to dictate discharge summaries from a physician, and that she had been evaluated for competency in discharge summary dictation. Review of 13 closed medical records (#7, #8, #14-#17, #23-#29) revealed that S18Case Manager had dictated the discharge summaries for Patients #14 and #23.

In an interview on 05/22/14 at 2:55 p.m., S18Case Manager indicated that she didn't remember being evaluated for competency and was never trained by a physician on the components of a discharge summary and how to dictate a one.

Based on record reviews and interviews, the hospital failed to ensure that drugs were administered as ordered by the physician and in accordance with hospital policy.
1) The hospital failed to administer patients' medications as ordered by the physician and according to hospital policy for 9 (#2, #3, #4, #5, #6, #9, #10, #12, #17) of 10 (#1-#6, #9, #10, #12, #17) patients' records reviewed for medication administration from a total of 29 sampled patients.
2) The hospital failed to ensure each patient's medication order included the indication for use and the specific route of administration as required by hospital policy for 5 (#1, #3, #4, #5, #6) of 10 (#1-#6, #9, #10, #12, #17) patients' records reviewed for completeness of the medication order from a total of 29 sampled patients.
There was a total of 67 medication errors identified by the surveyors that had not been identified by the hospital for 8 (#2, #3, #4, #5, #6, #9, #10, #12) active patients' records and 1 closed medical record (#17) reviewed for medication administration compliance from a total of 29 sampled patients over a 10 day period (05/11/14 through 05/20/14).
Findings:

1) The hospital failed to administer patients' medications as ordered by the physician and according to hospital policy:
Review of the hospital policy titled "Medication Administration: General Guidelines", policy number MM-010, revised April 2013, and contained in the hospital's policy and procedure manual presented as the hospital's current policies and procedures by S2DON (Director of Nursing), revealed that medications are not given without a physician's/Licensed Independent Practitioner's (LIP) order. Further review revealed that medications ordered for a specific time are given promptly, never more than one hour before or after the time ordered. All medications administered are documented on the Medication Administration Record (MAR) immediately after they are given. If a medication is held for therapeutic reasons in conjunction with a physician's/LIP's order, the nurse is to document on the progress note and on the MAR the reason for holding the medication and notification of the physician/LIP.

Review of the hospital policy titled "Medication Administration Times", policy number MM-001, revised April 2013, and contained in the hospital's policy and procedure manual presented as the hospital's current policies and procedures by S2DON, revealed that a stat dose was to be administered within 30 minutes of the order, and a new dose was to be administered within 60 minutes of the order. Review of the entire policy revealed that the time interval for administering a medication ordered "now" was not addressed.

Review of the hospital policy titled "Protocols for Detoxification", policy number CTS-088, revised March 2013, and contained in the hospital's policy and procedure manual presented as the hospital's current policies and procedures by S2DON, revealed the nurses are responsible to administer the detoxification/withdrawal medications per physician's order, monitor the patient's vital signs, notify the physician of the patient's response to medications, and record medication and subsequent patient response in the patient's medical record. Further review revealed that the nurse was to check the patient's vital signs and use the CWIA and COW scale prior to administration of each dose and prn (as needed) for alcohol and/or drug withdrawal.

Patient #2 Review of Patient #2's medical record revealed he was a 47-year old male admitted to the Hospital on 05/17/14 at 3:30 p.m. with diagnoses of Major Depression, Suicide Attempt, Hypertension, Chronic Obstructive Pulmonary Disease, and Diabetes Mellitus.
Review of Patient #2's Insulin Sliding Scale orders revealed, in part, insulin was to be given according to the following scale:
CBG: 150 - 200, give 2 units (of insulin)
CBG: 201 - 250, give 4 units
CBG: 251 - 300, give 6 units
CBG: 301 - 350, give 8 units
CBG: 351 - 400, give 10 units
Review of Patient #2's Medication Administration Record (MAR) and Diabetic Flow Sheet revealed the following dosages of insulin were not given according to the physician orders:
05/18/14 at 11:30 a.m., CBG reading of 177, no insulin given
05/18/14 at 4:30 p.m., CBG reading of 179, no insulin given
05/18/14 at 9:00 p.m., CBG reading of 168, no insulin given
In an interview on 05/20/14 at 11:35 a.m., S2DON confirmed that Patient #2 did not receive his insulin as described above, and Patient #2 should have received the insulin as indicated according to the physician's orders.
Review of Patient #2's physician orders dated 05/17/14 at 6:14 p.m. for medications revealed the following medications were ordered: Tramadol 50 mg (milligrams), two tablets by mouth four times a day (at 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m.); Depakote 500 mg (one-half tablet) by mouth daily (at 9:00 a.m.), and Xanax 0.5 mg by mouth three times per day (at 9:00 a.m., 1:00 p.m., and 9:00 p.m.)
Review of Patient #2's Medication Administration Record (MAR) revealed the following medications were not given as ordered:
On 05/17/14, the Tramadol medication dose due at 9:00 p.m.; on 05/18/14, the Depakote medication dose due for 9:00 a.m.; and on 05/18/14, the Xanax medication dose due at 9:00 p.m.
Review of Patient #2's physician orders dated 05/17/14 at 7:20 p.m. for medications revealed the following medications were ordered: Onglyza 5 mg by mouth daily (at 9:00 a.m.); Flomax, 0.4 mg by mouth daily (at 9:00 a.m.); Spiriva, one puff (inhalation) by mouth daily (at 9:00 a.m.).
Review of Patient #2's MAR revealed the following medications were not given as ordered:
On 05/18/14, the Onglyza medication dose due for 9:00 a.m.; on 05/18/14, the Flomax medication dose due for 9:00 a.m.; and on 05/18/14, the Spiriva medication dose due for 9:00 a.m.
In an interview on 05/20/14 at 10:45 a.m., S2Director Of Nursing (S2DON) indicated the normal procedure for the nurse to follow when a medication(s) was ordered, and the medication was not given, the nurse was to circle the time the medication was due on the MAR, initial it, and put the reason on the MAR it was not given. S2DON verified and confirmed the above medications as listed and described on 05/17/18 and 05/18/14 were not documented as given to Patient #2. S2DON also confirmed there was no evidence in Patient #2's medical record that the medication was given, and there was no documented evidence as to why the medication doses were not given as ordered by the physician. S2DON also verified there was no documentation in the medical record the physician was notified of the missed medication doses.

Patient #3
Review of Patient #3's medical record revealed she was a 50 year old female admitted on 05/18/14 with a diagnosis of Bipolar Manic. Review of her Psychiatric Evaluation performed on 05/19/14 revealed she also was diagnosed with Diabetes Mellitus Type 2.

Review of Patient #3's physician orders revealed an order dated 05/19/14 at 7:00 a.m. for Ditropan 5 mg by mouth twice a day.

Review of Patient #3's MAR revealed a notation at the 9:00 a.m. dose "unavailable" with the time circled. The first dose of Ditropan was not administered until 9:00 p.m., 14 hours after the order was received. Review of the "Daily Nursing Assessment" for 05/19/14 revealed no documented evidence for the reason the medication was unavailable, that the pharmacist was contacted to obtain the medication, or that the physician was notified as required by hospital policy.

In an interview on 05/20/14 at 11:30 a.m., S2DON indicated that unavailable when documented on the patient's MAR usually meant that the medication was not "in house". She further indicated there was no excuse for Patient #3 not receiving her Ditropan for 14 hours, because the nurse should have called the pharmacist to bring it. She further indicated that the time should have been circled, because the medication wasn't administered within the 1 hour window, and the physician should have been notified.

Patient #4
Review of Patient #4's medical record revealed he was a 31 year old male admitted on 05/16/14 with diagnoses of Mood Disorder and Severe Opiate Dependence.

Review of Patient #4's physician admit orders dated 05/16/14 at 7:30 a.m. revealed an order to obtain vital signs according to the Detox/COW scale which consisted of every 4 hours while awake for 48 hours, then twice a day for 3 days, then daily. Further review of the physician's orders revealed an order on 05/16/14 at 4:47 a.m. (received by telephone order) for S22Psychiatrist's Opiate Detox Orders which included Clonidine 0.1 mg every 6 hours for 72 hours; hold if systolic blood pressure is less than 100, diastolic blood pressure is less than 60, or pulse is less than 60. Further review revealed an order on 05/19/14 at 9:00 a.m. for Ultram Detox Protocol which consisted of Ultram 50 mg by mouth 4 times a day for 1 day, Ultram 50 mg 3 times a day by mouth for 1 day, Ultram 50 mg 2 times a day by mouth for 1 day, and Ultram 50 mg 1 time a day by mouth for 1 day, then discontinue.

Review of Patient #4's MARs and COW scales revealed the following times that Patient #4's vital signs were not assessed per policy prior to the administration of Clonidine and Ultram:
05/16/14 - prior to administering Clonidine at 9:00 a.m., 3:00 p.m., and 9:00 p.m.;
05/17/14 - prior to administration of Clonidine at 9:00 a.m. and 9:00 p.m.;
05/18/14 - prior to administration of Clonidine at 9:00 a.m., and 9:00 p.m., and at 3:00 a.m. on 05/19/14;
05/19/14 - prior to administration of Clonidine and Ultram at 9:00 a.m. and Ultram at 1:00 p.m., and 5:00 p.m.; and
05/20/14 - prior to administration of Ultram at 9:00 a.m. and 1:00 p.m.

Patient #5
Review of Patient #5's medical record revealed he was a 29 year old male admitted on 05/16/14 with diagnoses of Psychosis and Polysubstance Dependence.

Review of Patient #5's physician's admit orders revealed an order on 05/16/14 at 3:30 p.m. to assess vital signs using the Detox/COW scale which consisted of every 4 hours while awake for 48 hours, then twice a day for 3 days, and then daily. Review of the physician's orders revealed an order on 05/16/14 at 3:30 p.m. for Ultram Detox Protocol which included Ultram 50 mg at 5:00 p.m. on 05/16/14, Ultram 50 mg at 9:00 p.m. on 05/16/14, Ultram 50 mg by mouth 4 times a day for 1 day beginning 05/17/14 at 9:00 a.m., then Ultram 50 mg by mouth 3 times a day for 1 day, then Ultram 50 mg by mouth 2 times a day for 1 day, then Ultram 50 mg by mouth once a day for 1 day, then discontinue, and Clonidine 0.05 mg by mouth four times a day for 5 days.

Review of Patient #5's entire medical record revealed Patient #5 received Ultram 50 mg by mouth at 5:00 p.m. and 9:00 p.m. on 05/16/14 with no documented evidence of his vital signs, at 9:00 p.m. on 05/17/14 with no documented evidence of his vital signs, at 1:00 p.m. on 05/18/14 with no documented evidence of his vital signs, and at 9:00 a.m. on 05/19/14 with no documented evidence of his heart rate. Further review revealed Patient #5 refused Ultram at 9:00 a.m. and 1:00 p.m. on 05/17/14 with no documented evidence that the physician was notified until after the 1:00 p.m. dose was refused. Further review revealed he continued to refuse his Ultram at 9:00 a.m. and 9:00 p.m. on 05/18/14 with no documented evidence that the physician was notified. There was no documented evidence that the 9:00 p.m. dose on 05/19/14 was administered. Review of Patient #5's MARs revealed Clonidine 0.05 mg Clonidine was listed to be administered twice a day rather than 4 times a day as ordered, thus having 6 doses missed from the time it was ordered on 05/16/14 at 3:30 p.m. through the 9:00 p.m. dose on 05/19/14. Further review revealed Patient #5 refused his Clonidine on 05/16/14 at 5:00 p.m. and 9:00 p.m. with no documented evidence that the physician was notified. Further review revealed no documented evidence that Patient #5's vital signs were assessed prior to administration of Clonidine as required by hospital policy on 9:00 a.m. and 9:00 p.m. on 05/17/14 and at 9:00 p.m. on 05/18/14. Further review revealed Clonidine was held at 9:00 a.m. due to Patient #5's blood pressure being 100/60. There was no documented evidence of a physician's order with parameters for holding Clonidine, and there was no documented evidence that the physician was notified.

In an interview on 05/20/14 at 1:45 p.m., S2DON confirmed vital signs were not assessed prior to administration of Ultram and Clonidine (detox medications) for Patients #4 and #5 as required by the hospital's policy. She offered no explanation for this not being done and confirmed that she does not perform chart audits to assure compliance with medication administration according to physician orders and hospital policy.

Patient #6
Review of Patient #6's medical record revealed he was a 28 year old male admitted on 05/16/14 with diagnoses of Mood Disorder, Bipolar Disorder mixed with Psychosis, history of Opiate Abuse, Anxiety, Thyroid Disease, and Asthma.

Review of Patient #6's physician's orders revealed an order on 05/16/14 at 10:55 a.m. for Depakote 500 mg by mouth every a.m. and give first dose now.

Review of Patient #6's MAR revealed he received his Depakote that was ordered to be given now at 10:55 a.m. at 2:00 p.m., 3 hours and 5 minutes after the now order was received.

In an interview on 05/20/14 at 1:30 p.m., S2DON indicated Patient #6's medical record was taken by the physician before the nurse saw the order for Depakote. She further indicated that they have had this problem occur before and do not have a system in place to avoid reoccurrences.

Patient #9 Review of Patient #9's medical record revealed she was a 26-year-old female admitted to the hospital on 05/15/14 at 9:06 p.m. with diagnoses of Bipolar Disorder, Suicidal Ideations, Aggressive Behaviors, Diabetes Mellitus, Hypothyroidism, and High Cholesterol.
Review of Patient #9's Insulin Sliding Scale orders revealed, in part, insulin was to be given according to the following scale:
CBG: 150 - 200, give 2 units (of insulin)
CBG: 201 - 250, give 4 units
CBG: 251 - 300, give 6 units
CBG: 301 - 350, give 8 units
CBG: 351 - 400, give 10 units
Review of Patient #9's MAR and Diabetic Flow Sheet revealed the following doses of insulin were not given as ordered by the physician.
05/17/14 at 6:30 a.m., CBG reading of 150, no insulin given
05/18/14 at 9:00 p.m., CBG reading of 189, no insulin given
In an interview on 05/20/14 at 10:45 a.m., S2DON indicated the normal procedure for the nurse to follow when a medication(s) were ordered, and the medication was not given, the nurse was to circle the time the medication was due on the MAR, initial it, and put the reason on the MAR it was not given. S2DON verified and confirmed the above medications as listed and described on 05/17/18 and 05/18/14 were not documented as given to Patient #9. S2DON also confirmed there was no evidence in Patient #9's medical record that the medication was given and no documentation as to why the medication doses were not given as ordered by the physician. S2DON also verified there was no documentation in the medical record the physician was notified of the missed medication doses.

Patient #10 Patient #10 was a 52-year-old male admitted to the hospital on 05/12/14 with diagnoses of Major Depressive Disorder without Psychosis, Anxiety Disorder, Hypertension, Diabetes Mellitus and Chronic Pain.
Review of Patient #10's Insulin Sliding Scale orders revealed, in part, insulin was to be given according to the following scale:
CBG: 150 - 200, give 2 units (of insulin)
CBG: 201 - 250, give 4 units
CBG: 251 - 300, give 6 units
CBG: 301 - 350, give 8 units
CBG: 351 - 400, give 10 units
Review of Patient #10's MAR and Diabetic Flow Sheet revealed the following doses of insulin were not given as ordered by the physician.
05/17/14 at 9:00 p.m., CBG reading of 156, no insulin given
05/18/14 at 9:00 p.m., CBG reading of 181, no insulin given
In an interview on 05/20/14 at 10:45 a.m., S2DON indicated the normal procedure for the nurse to follow when a medication(s) were ordered, and the medication was not given, the nurse was to circle the time the medication was due on the MAR, initial it, and put the reason on the MAR it was not given. S2DON verified and confirmed the above medications as listed and described on 05/17/18 and 05/18/14 were not documented as given to Patient #10. S2DON also confirmed there was no evidence in Patient #10's medical record that the medication was given and no documentation as to why the medication doses were not given as ordered by the physician. S2DON also verified there was no documentation in the medical record the physician was notified of the missed medication doses.

Patient #12
Review of Patient #12's medical record revealed he was a 67-year-old male admitted to the hospital on 04/28/14 with diagnoses of Bipolar Disorder, Depressed with Psychosis, Diabetes Mellitus Type 2, Hypertension, Hypothyroidism, and a history of a Cerebral Vascular Accident (stroke).
Review of Patient #12's Insulin Sliding Scale orders revealed, in part, insulin was to be given according to the following scale:
CBG: 150 - 200, give 2 units (of insulin)
CBG: 201 - 250, give 4 units
CBG: 251 - 300, give 6 units
CBG: 301 - 350, give 8 units
CBG: 351 - 400, give 10 units
Review of Patient #12's MAR and Diabetic Flow Sheet revealed the following dosage of insulin was not given according to the physician orders:
05/11/14 at 6:30 a.m., CBG reading of 156, no insulin given
In an interview on 05/20/14 at 10:45 a.m., S2DON indicated the normal procedure for the nurse to follow when a medication(s) were ordered, and the medication was not given, the nurse was to circle the time the medication was due on the MAR, initial it, and put the reason on the MAR it was not given. S2DON verified and confirmed the above medication as listed and described on 05/11/14 was not documented as given to Patient #12. S2DON also confirmed there was no evidence in Patient #12's medical record that the medication was given and no documentation as to why the medication dose was not given as ordered by the physician. S2DON also verified there was no documentation in the medical record the physician was notified of the missed medication dose.

Patient #17
Review of Patient #17's medical record revealed he was a 26 year old male admitted on 03/11/14 with diagnoses of Bipolar Disorder, Manic Severe with Psychosis, Opiate Dependence, and Cannibas Dependence. He was discharged on 03/21/14.

Review of Patient #17's physician's orders revealed an order on 03/11/14 at 7:00 a.m. for Albuterol nebulizer treatment now then every 6 hours as needed for wheezing.

Review of Patient #17's MAR revealed his Albuterol treatment was administered at 9:00 a.m. on 03/11/14, 2 hours after it was ordered to be given now.

In an interview on 05/23/14 at 8:30 a.m., S2DON could offer no explanation for Patient #17's Albuterol treatment being administered 2 hours after the physician had ordered it to be given now at 7:00 a.m.

2) The hospital failed to ensure each patient's medication order included the indication for use and the specific route of administration as required by hospital policy:
Review of the hospital policy titled "Medication Management", policy number MM-012, revised April 2013, and contained in the hospital's policy and procedure manual presented as the hospital's current policies and procedures by S2DON, revealed that the required elements of a complete medication order are as follows: patient name and location; time and date of order; drug name; strength/dose; dosage form if necessary; route of administration; frequency of administration; directions for use; prescriber's signature. Further review revealed that the indication for use is documented for each medication ordered. When medication orders are incomplete, illegible, or unclear, the order will be clarified with the prescriber before the medication is dispensed or administered, and medication clarifications will be documented in the patient's permanent medical record.

Patient #1
Review of Patient #1's medical record revealed he was a 29 year old male admitted on 05/18/14 with diagnoses of Bipolar I Current Depression, Hypertension, and Polysubstance Abuse.

Review of Patient #1's physician's admit orders dated 05/18/14 at 5:00 p.m. revealed the following medication orders with no specific route of administration ordered:
Dulcolax 10 mg by mouth or suppository twice a day for constipation;
Vistaril 100 mg by mouth or intramuscularly every 4 hours as needed for anxiety;
Zyprexa 10 mg by mouth or intramuscularly every 2 hours as needed for agitation;
Ativan 2 mg by mouth or intramuscularly every 4 hours as needed for agitation/anxiety.

Patient #3
Review of Patient #3's medical record revealed she was a 50 year old female admitted on 05/18/14 with a diagnosis of Bipolar Manic. Review of her Psychiatric Evaluation performed on 05/19/14 revealed she also was diagnosed with Diabetes Mellitus Type 2.

Review of Patient #3's physician's admit orders dated 05/18/14 at 2:15 p.m. revealed the following medication orders with no specific route of administration ordered:
Dulcolax 10 mg by mouth or suppository twice a day for constipation;
Vistaril 100 mg by mouth or intramuscularly every 4 hours as needed for anxiety;
Zyprexa 10 mg by mouth or intramuscularly every 2 hours as needed for agitation;
Ativan 2 mg by mouth or intramuscularly every 4 hours as needed for agitation/anxiety.

Patient #4
Review of Patient #4's medical record revealed he was a 31 year old male admitted on 05/16/14 with diagnoses of Mood Disorder and Severe Opiate Dependence.

Review of Patient #4's physician's admit orders dated 05/16/14 at 7:30 a.m. revealed the following medication orders with no specific route of administration ordered:
Dulcolax 10 mg by mouth or suppository twice a day for constipation;
Vistaril 50 mg by mouth or intramuscularly every 4 hours as needed for anxiety.

Patient #5
Review of Patient #5's medical record revealed he was a 29 year old male admitted on 05/16/14 with diagnoses of Psychosis and Polysubstance Dependence.

Review of Patient #5's physician's admit orders dated 05/16/14 at 3:30 p.m. revealed the following medication orders with no specific route of administration ordered:
Dulcolax 10 mg by mouth or suppository twice a day for constipation;
Vistaril 100 mg by mouth or intramuscularly every 4 hours as needed for anxiety;
Zyprexa 10 mg by mouth or intramuscularly every 2 hours as needed for agitation;
Ativan 2 mg by mouth or intramuscularly every 4 hours as needed for agitation/anxiety.

Patient #6
Review of Patient #6's medical record revealed he was a 28 year old male admitted on 05/16/14 with diagnoses of Mood Disorder, Bipolar Disorder mixed with Psychosis, history of Opiate Abuse, Anxiety, Thyroid Disease, and Asthma.

Review of Patient #6's physician's admit orders dated 05/16/14 at 7:30 a.m. revealed the following medication orders with no specific route of administration ordered:
Dulcolax 10 mg by mouth or suppository twice a day for constipation;
Vistaril 50 mg by mouth or intramuscularly every 4 hours as needed for anxiety.

In an interview on 05/23/14 at 12:10 p.m., S2DON confirmed the above physician orders did not have a specific route of administration ordered. She indicated that the night nurse is supposed to do medication chart audits. She further indicated that she does not audit charts for compliance with physician's medication orders. She confirmed that the above medication orders should have had a clarification order received from the prescribing physician and that no medication variances had been completed for these variances.




31048

Based on record reviews and interviews, the hospital failed to implement an effective policy/procedure relative to the identification of medication errors. This resulted in the hospital's failure to ensure that medication administration errors were reported to the physician and tracked through the hospital's quality assessment and performance improvement program (QAPI). The hospital did not have a system in place to identify medication administration errors and relied on the nurse administering medications to complete a medication variance report. There were 66 medication errors identified by the surveyors that had not been identified by the hospital for 8 (#2, #3, #4, #5, #6, #9, #10, #12) active patients' records reviewed for medication administration compliance from a total of 29 sampled patients over a 10 day period (05/11/14 through 05/20/14). Findings:

Review of the hospital's policy titled "Medication Errors/Variances," policy number MM-011, revised April 2013, and contained in the hospital's policy and procedure manual presented as the hospital's current policies and procedures by S2DON (Director of Nursing), revealed that the policy stated that the nurse would monitor the patient for adverse reactions to the medication error and included the process of notifying the physician, documentation requirements, and incorporating the data into the quality improvement data to observe for any trends or patterns. The policy did not identify what the hospital considered as a medication error.

Review of 10 active patients' medical records (#1-#6, #9, #10, #12) for medication administration compliance and accurate and complete physician's medication orders according to hospital policy revealed 9 active patients' records (#1, #2, #3, #4, #5, #6, #9, #10, #12) had errors in administration according to physician orders or had incomplete physician orders for medications as required by hospital policy for a period of 10 days reviewed (05/11/14 through 05/20/14). There were 66 medication errors in either administration or for having an incomplete physician order without a clarification order being obtained that were identified by the surveyors that had not been identified by the hospital.

In an interview on 05/23/14 at 12:10 p.m., S2DON confirmed the above-listed patient records had medication errors in administration or had incomplete physician orders. She indicated that the night nurse is supposed to do medication chart audits. She further indicated that she does not audit charts for compliance with physician's medication orders. She confirmed that the medication orders should have had a clarification order received from the prescribing physician when the order used a range in route of administration or or did not have an indication for use when a medication was ordered as needed. She confirmed that no medication variances had been completed for the variances identified by the surveyors.

Based on observations, record reviews, and interviews, the hospital failed to ensure:
1) Patients' medical records were maintained in a manner to assure they were protected from potential water damage in the event that the hospital's sprinkler system was activated. Patients' medical records contained in the locked storage room were stored on approximately 50 storage shelves with no enclosure to protect them from water damage and in 5 cardboard boxes stacked on the floor; and
2) The Medical Staff By-laws were implemented relative to suspension of physicians with incomplete medical records 30 days after discharge. Patients' medical records were not completed within 30 days after discharge for 3 (#15, #17, #23) of 4 (#14, #15, #17, #23) patient records reviewed for discharge summaries from a total of 13 closed medical records reviewed from a total sample of 29 patients. The hospital's delinquency rate for medical record completion went from 13% (per cent) in March 2014 to 59% in April 2014.
Findings:

1) Patients' medical records were maintained in a manner to assure they were protected from potential water damage in the event that the hospital's sprinkler system was activated:
Observation of the locked storage room where patients' closed medical records were stored on 05/19/14 at 1:30 p.m. with S1Administrator and S5Medical Record Coordinator present revealed the records were stored on approximately 50 shelves of lockable units with fold-down doors that were kept open and provided the potential for the records to be damaged by water if the hospital's sprinkler system became activated. Further observation revealed 5 cardboard boxes stacked on the floor that contained patients' medical records that were also accessible to potential water damage.

In an interview at the time of the observation on 05/19/14 at 1:30 p.m., S5Medical Record Coordinator indicated the 5 boxes of medical records were requested charts from the off-site storage unit and were waiting to be returned to the off-site storage unit. S5Medical Record Coordinator and S1Administrator confirmed the medical records in the cardboard boxes and on the open shelves in the locked storage room were accessible to potential water damage if the hospital's sprinkler system became activated.

2) The Medical Staff By-laws were implemented relative to suspension of physicians with incomplete medical records 30 days after discharge:
Review of the Medical Staff By-laws, presented S2DON as the current by-laws, revealed that the attending medical staff member will be responsible for the preparation of a complete and legible medical record for each patient that includes a discharge summary. Further review revealed that the attending medical staff member or designee shall complete the medical record at the time of the patient's discharge, including a discharge summary. If the discharge summary cannot be dictated at the time of discharge, a final progress note must be written in the medical record, including a final diagnosis if it is not recorded on the face sheet. A discharge summary shall be written or dictated on all medical records of all patients within 30 days of discharge. An attending medical staff member will be considered delinquent in completion of his medical records if the records are not completed, written, or dictated within this time period. An attending medical staff member will automatically be suspended in the form of withdrawal of his admitting privileges 5 days after he is given a warning of delinquency for failure to complete medical records. A notice of delinquency will be given if the records are not completed within 30 days after discharge of the patient, the suspension shall continue until the medical records are completed. If the medical record is incomplete 5 days after the warning is given, a written notice shall be sent to the attending medical staff member notifying him/her that his/her admitting or other privileges shall be suspended immediately and that he/she shall remain suspended until all of his/her delinquent records have been completed. The Admitting Office shall be notified of this action by the RHIA. Reinstatement of privileges will be automatic upon completion of records, and the Admitting Office shall be notified. The Health Information Management Department will be responsible for analyzing medical records for the purpose of administering this rule.

Patient #15 Review of Patient #15 ' s medical record revealed she was a 26-year-old female admitted to the hospital on 04/04/14 with the diagnoses of Recurring Depression, Severe; Obsessive Compulsive Disorder; Hypertension; Thyroid Disease; and Sleep Apnea. Further review revealed Patient #15 was discharged from the hospital on 04/16/14 at 3:54 p.m. to an acute care hospital.
Review of Patient #15 ' s complete medical record revealed the medical record did not contain a discharge summary from the physician.

In an interview on 05/23/14 at 11:25 a.m., S16RHIA verified that a discharge summary had not been completed by the physician for Patient #15.

Patient #17 Review of Patient #17's medical record revealed he was a 26 year old male admitted on 03/11/14 with diagnoses of Bipolar Disorder, Manic Severe with Psychosis, Opiate Dependence, and Cannibas Dependence. He was discharged on 03/21/14. Further review revealed no documented evidence that a discharge summary had been dictated and signed as of 05/22/14.

Patient #23 Review of Patient #23's medical record revealed she was a 52 year old female admitted on 04/18/14 and discharged on 04/28/14. Further review revealed no documented evidence that a discharge summary had been written or dictated within 30 days of discharge.

In an interview on 05/22/14 at 12:00 p.m., S16RHIA (Registered Health Information Administrator) indicated the delinquency rate had gone from 13% in March 2013 (5% for the first quarter of 2014) to 59% for April 2014 due to incomplete discharge summaries. She further indicated that the physicians do not dictate their own discharge summaries. She further indicated that this responsibility had been delegated by the physicians to Case Management nurses. She indicated that the discharge summaries were incomplete, because the Case Management department was presently short-staffed and could not get to the discharge summaries. S16RHIA indicated that she had not sent any letters and no physician had been suspended as required by the hospital's Medical Staff By-laws.

In an interview on 05/22/14 at 2:55 p.m. with S2DON (Director of Nursing), S16RHIA, S4Director of Clinical Services, and S18Case Manager present, S4Director of Clinical Services indicated that the physician reviews and signs the discharge summaries after they have been dictated by the nurse and transcribed. S18Case Manager indicated that she's short one position in her department, so she has been the only nurse dictating discharge summaries since January 2014. She further indicated that she had not been trained by a physician to prepare and dictate discharge summaries and had not been evaluated for competency in performing this duty. S2DON confirmed that the Medical Staff By-laws and Governing Body By-laws did not state that dictating discharge summaries could be delegated by the physician to a nurse.

Based on record reviews and interviews, the hospital failed to ensure that patients' discharge summaries were written or dictated by the attending medical staff member with admitting privileges who admitted the patient. The hospital allowed patients' discharge summaries to be dictated by RNs (registered nurses) for 1 (#14) of 4 (#14, #15, #17, #23) patient records reviewed for discharge summaries from a total of 13 closed medical records reviewed from a total sample of 29 patients.
Findings:

Review of the Medical Staff By-laws, presented S2DON as the current by-laws, revealed that the attending medical staff member will be responsible for the preparation of a complete and legible medical record for each patient that includes a discharge summary. Further review revealed that the attending medical staff member or designee shall complete the medical record at the time of the patient's discharge, including a discharge summary. If the discharge summary cannot be dictated at the time of discharge, a final progress note must be written in the medical record, including a final diagnosis if it is not recorded on the face sheet.

Patient #14 Review of Patient #14 ' s medical record revealed she was a 98-year-old female admitted to the hospital under the services of S19Medical Director on 03/10/14 at 1:00 p.m. with the diagnosis of Unspecified Psychosis, Hypertension, and Hypercholesterolemia. Further review revealed the patient was discharged from the hospital to an acute care facility on the same day of admission.
Review of the document entitled " Physician ' s Discharge Summary " revealed Patient #14 ' s Discharge Summary was dictated by S18Case Manager for S19Medical Director on 04/10/14 at 5:07 p.m.

In an interview on 05/22/14 at 12:00 p.m., S16RHIA (Registered Health Information Administrator) indicated the physicians do not dictate their own discharge summaries. She further indicated that this responsibility had been delegated by the physicians to Case Management nurses.

In an interview on 05/22/14 at 2:55 p.m. with S2DON (Director of Nursing), S16RHIA, S4Director of Clinical Services, and S18Case Manager present, S4Director of Clinical Services indicated that the physician reviews and signs the discharge summaries after they have been dictated by the nurse and transcribed. S18Case Manager indicated that she's short one position in her department, so she has been the only nurse dictating discharge summaries since January 2014. She further indicated that she had not been trained by a physician to prepare and dictate discharge summaries and had not been evaluated for competency in performing this duty. S2DON confirmed that the Medical Staff By-laws and Governing Body By-laws did not state that dictating discharge summaries could be delegated by the physician to a nurse.

Based on interviews and record reviews the hospital failed to ensure that drugs were distributed in accordance with applicable standards of practice as evidenced by:
1) Failure of pharmacists to review active patient medical records on a monthly basis according to the hospital's Pharmacy Services Agreement contract;
2) Failure of the pharmacist to review and assure that each patient's medication order included the indication for use and the specific route of administration as required by hospital policy for 5 (#1, #3, #4, #5, #6) of 10 (#1-#6, #9, #10, #12, #17) patients' records reviewed for completeness of the medication order from a total of 29 sampled patients.
Findings:

1) Failure of pharmacists to review active patient medical records on a monthly basis according to the hospital's Pharmacy Services Agreement contract:
A review of the "Pharmacy Services Agreement" contract as provided by S2DON (Director of Nursing) as the most current, revealed in part: under the responsibilities of the contracted Pharmacist: to provide consulting services on a monthly basis to include review of active patient medical records.

A review of the hospital's policy, entitled, " Director of Pharmacy: Qualifications and Responsibility" as provided by S2DON as the most current, revealed in part: the Director of the Pharmacy shall be responsible for all activities related to the pharmacy and ensuring that the pharmacy met the requirements of the Board of Pharmacy and that the pharmacy was conducted in accordance with accepted professional standards.

In an interview on 05/22/14 at 4:30 p.m. with S21RPh (Registered Pharmacist), he indicated that the hospital had a Pharmacy Services Agreement contract with his pharmacy and that he was the Director of the Pharmacy Department for his pharmacy and for the hospital. S21RPh was asked about the monthly medical record reviews for the provider by the Pharmacy Department. S21RPh indicated that he was not aware that the Pharmacy Department had to do monthly medical record reviews. S21RPh further indicated that he had been the Pharmacy Director for about a year, and the Pharmacy Department had not performed any medical record reviews during that time.

2) Failure of the pharmacist to review and assure that each patient's medication order included the indication for use and/or the specific route of administration as required by hospital policy:
Review of the hospital policy titled "Medication Management", policy number MM-012, revised April 2013, and contained in the hospital's policy and procedure manual presented as the hospital's current policies and procedures by S2DON, revealed that the required elements of a complete medication order are as follows: patient name and location; time and date of order; drug name; strength/dose; dosage form if necessary; route of administration; frequency of administration; directions for use; prescriber's signature. Further review revealed that the indication for use is documented for each medication ordered. When medication orders are incomplete, illegible, or unclear, the order will be clarified with the prescriber before the medication is dispensed or administered, and medication clarifications will be documented in the patient's permanent medical record.

Patient #1
Review of Patient 31's medical record revealed he was a 29 year old male admitted on 05/18/14 with diagnoses of Bipolar I Current Depression, Hypertension, and Polysubstance Abuse.

Review of Patient #1's physician's admit orders dated 05/18/14 at 5:00 p.m. revealed the following medication orders with no specific route of administration ordered:
Dulcolax 10 mg by mouth or suppository twice a day for constipation;
Vistaril 100 mg by mouth or intramuscularly every 4 hours as needed for anxiety;
Zyprexa 10 mg by mouth or intramuscularly every 2 hours as needed for agitation;
Ativan 2 mg by mouth or intramuscularly every 4 hours as needed for agitation/anxiety.

Patient #3
Review of Patient #3's medical record revealed she was a 50 year old female admitted on 05/18/14 with a diagnosis of Bipolar Manic. Review of her Psychiatric Evaluation performed on 05/19/14 revealed she also was diagnosed with Diabetes Mellitus Type 2.

Review of Patient #3's physician's admit orders dated 05/18/14 at 2:15 p.m. revealed the following medication orders with no specific route of administration ordered:
Dulcolax 10 mg by mouth or suppository twice a day for constipation;
Vistaril 100 mg by mouth or intramuscularly every 4 hours as needed for anxiety;
Zyprexa 10 mg by mouth or intramuscularly every 2 hours as needed for agitation;
Ativan 2 mg by mouth or intramuscularly every 4 hours as needed for agitation/anxiety.

Patient #4
Review of Patient #4's medical record revealed he was a 31 year old male admitted on 05/16/14 with diagnoses of Mood Disorder and Severe Opiate Dependence.

Review of Patient #4's physician's admit orders dated 05/16/14 at 7:30 a.m. revealed the following medication orders with no specific route of administration ordered:
Dulcolax 10 mg by mouth or suppository twice a day for constipation;
Vistaril 50 mg by mouth or intramuscularly every 4 hours as needed for anxiety.

Patient #5
Review of Patient #5's medical record revealed he was a 29 year old male admitted on 05/16/14 with diagnoses of Psychosis and Polysubstance Dependence.

Review of Patient #5's physician's admit orders dated 05/16/14 at 3:30 p.m. revealed the following medication orders with no specific route of administration ordered:
Dulcolax 10 mg by mouth or suppository twice a day for constipation;
Vistaril 100 mg by mouth or intramuscularly every 4 hours as needed for anxiety;
Zyprexa 10 mg by mouth or intramuscularly every 2 hours as needed for agitation;
Ativan 2 mg by mouth or intramuscularly every 4 hours as needed for agitation/anxiety.

Patient #6
Review of Patient #6's medical record revealed he was a 28 year old male admitted on 05/16/14 with diagnoses of Mood Disorder, Bipolar Disorder mixed with Psychosis, history of Opiate Abuse, Anxiety, Thyroid Disease, and Asthma.

Review of Patient #6's physician's admit orders dated 05/16/14 at 7:30 a.m. revealed the following medication orders with no specific route of administration ordered:
Dulcolax 10 mg by mouth or suppository twice a day for constipation;
Vistaril 50 mg by mouth or intramuscularly every 4 hours as needed for anxiety.

In a phone interview on 05/23/14 at 10:45 a.m. with S21RPh, he was asked about the pharmacists' review of patient medication orders when patient medication was ordered as IM (intramuscular) or P.O. (by mouth) and if the pharmacists clarified the "route" orders with the prescribing physician as to the specific route prior to authorizing the administration of the medication by the nursing staff. S21RPh indicated that if the patient's order was written by a qualified licensed practitioner with prescriptive authority that the pharmacists in his department did not question or clarify with the physicians to specify a specific route. S21RPh indicated that the decision to give the medications when ordered as IM or P.O. would be left to the nurses' judgement as to which route the medication would be given to the patient. S21RPh was asked about PRN (as needed) medications and the pharmacy's process when patient PRN medication orders required further clarification by the prescribing physician as to the appropriate range and indicators for use. S21RPh indicated that a computerized message would be sent to the nursing staff through the Medication Dispensing System that further clarification by the prescribing physician was needed for the appropriate range and indicators for use. S21RPh indicated that the Pharmacy Department had been receiving poor responses by the nursing staff over the past year and in the last 2-3 months email notifications (after 24 hours of no response by the nursing staff) have been sent to S2DON. S21RPh indicated that the problem was still a Pharmacy Department concern.

In an interview on 05/23/14 at 12:15 p.m. with S2DON she indicated that the contracted Pharmacy Services reported to her. The "Pharmacy Services Agreement" contract was reviewed with S2DON, and she was made aware that the pharmacists had not been performing monthly medical record reviews as per the contract. S2DON indicated that she was not aware that the pharmacists had not been performing monthly medical record reviews. S2DON was made aware that the pharmacists were not reviewing or clarifying patient medication orders when the medication was ordered as IM or P.O. by the prescribing physician as to a specific route prior to authorizing the administration of the medication to the patient by the nursing staff. S2DON was further made aware that S21RPh indicated that the decision to give the medications when ordered as an IM or a P.O. were left to the nurses judgement as to which route the medication would be given to the patient. S2DON indicated that this was not a nurse's decision. S2DON was asked about the PRN medications and the pharmacy's process when patient PRN medications were ordered and further clarification by the prescribing physicians were required as to the appropriate range and indicators for use and that the pharmacists had been receiving poor responses to the computerized messages by the nursing staff over the past year. S2DON indicated that she was aware of this pharmacy issue. S2DON was asked if in the last 2-3 months if email notifications (after 24 hours of no response by the nursing staff) had been sent to her (S2DON) by S21RPh regarding this pharmacy concern. S2DON indicated that she had received 1 (one) email notification by S21RPh. S2DON indicated that she and S21RPh were still working on this pharmacy issue.

Based on record reviews and interview, the hospital failed to ensure policies and procedures were developed that addressed proper safety precautions against radiation hazards that included adequate shielding for patients and personnel and the method used to identify pregnant patients.
Findings:

Review of the policies contained in the hospital's policy and procedure manual presented as the hospital's current policies and procedures by S2DON (Director of Nursing) revealed no documented evidence of a policy and procedure that addressed proper safety precautions against radiation hazards that included adequate shielding for patients and personnel and the method used to identify pregnant patients.

Review of the policy titled "X-Rays" (only one policy related to radiological services), policy number CTS-057 and revised April 2013, revealed the nurse was to obtain the order for x-ray, complete the x-ray request form, inform the contract service provider of the x-ray request, explain the purpose of the x-ray to the patient, and the x-ray was to be performed in the patient's room with staff present while protecting patient privacy. There was no documented evidence that proper safety precautions against radiation hazards that included adequate shielding for patients and personnel and the method used to identify pregnant patients was addressed in the policy.

Review of 29 patients' medical records revealed that Patients #11, #17, #23, and #24 had an x-ray during their hospital stay at the hospital by the contracted service provider (Patient #11 was a current patient, and Patients #17, #23, and #24 were closed medical records).

In an interview on 05/23/14 at 8:30 a.m., S2DON confirmed that the hospital's x-ray policy did not contain proper safety precautions against radiation hazards that included adequate shielding for patients and personnel and the method used to identify pregnant patients.

Based on record reviews and interviews, the hospital failed to ensure there was a qualified full-time, part-time, or consulting radiologist who supervised the radiology services who was a member of the medical staff. The hospital did not have a radiologist credentialed and privileged as a member of the medical staff to supervise the radiology services provided in the hospital and to interpret the x-rays performed.
Findings:

Review of the list of Psychiatric Staff and Medical Staff presented by S2Director of Nursing (DON) as the current list of credentialed medical staff members revealed no documented evidence that a radiologist was a member of the medical staff.

Review of 3 of 3 x-ray reports (#11, #17, #23) for 4 patients who had x-rays ordered (#11, #17, #23, #24) revealed the x-rays were interpreted by S13Radiologist, S14Radiologist, and S15Radiologist who were not credentialed and privileged as members of the medical staff.

In the entrance conference on 05/19/14 at 12:35 p.m., S1Administrator indicated that the hospital did not have a radiologist credentialed and privileged on its medical staff. He further indicated that x-rays were performed in the hospital by Company A.

In an interview on 05/23/14 at 8:30 a.m., S2DON confirmed that Patients #11, #17, #23 and #24 had x-rays performed at the hospital by Company A. She also confirmed that there was no radiologist credentialed and privileged as a member of the medical staff.

Based on observation, record review, and interview, the hospital failed to ensure the Dietary Manager assured safety practices for food handling was implemented as evidenced by: 1) Having food products without an expiration date available for use and 2) Having wet serving pans stored stacked inside one another before they were completely dried. Findings:
Review of the policy entitled Non-Perishable Food Expiration, Number DM-08a, revealed, in part, "All food items purchased from approved vendors will have an expiration date on individual items or on the manufacturer's box in which they were delivered. Boxes that contain items that are not individually dated cannot be split and sold by individual pieces. The Dietary Manager will purchase food products from approved food service vendor in boxes or cases that indicate expiration dates. Items that are not dated within the box will be dated for expiration date that is located on original box. At no time should any boxes be split and food items sold individually by food service vendor if manufacturer does not have expiration date on each piece in box or case. Small food items such as PC condiments may be placed in a canister or Ziploc bag with expiration date labeled on containers."
1) Having food products without an expiration date available for use:
Observation on 05/20/14 at 8:45 a.m. of items in the refrigerator revealed: a gallon of Classic Sysco Liberty Extra Heavy Mayonnaise dated as received on 09/18/13 with no open date or expiration date recorded on the item; a gallon of Marzetti Golden Italian Dressing dated as received on 04/16/14 and opened on 04/20/14 with no expiration date recorded on the item; a gallon of Classic Sysco Ranch Dressing dated as received on 04/16/14 with no open date or expiration date documented on the item; one clear gallon-sized storage bag with 14 individual packets of Philadelphia Cream Cheese dated as received on 09/25/13 with no expiration date on the14 individual packets or the bag which contained the items.
In an interview on 05/20/14 at 9:45 a.m., S7Dietary Manager verified the items described above did not have expiration dates, and the items should not have been accepted, used, or stored without an expiration date on the individual containers.
1) Having wet serving pans stored stacked inside one another before they were completely dried: Observation on 05/20/14 at 9:15 a.m. revealed metal serving pans (2 four-inch deep; 2 two-inch deep; one 2-inch, half-size pan; 1 four-inch, one-half size pan) stored stacked inside one another with the interiors of the serving pans still wet while stored in this manner.
In an interview on 05/20/14 at 9:45 a.m., S7Dietary Manager verified the metal serving pans described above were stacked inside one another while the items were still wet. S7Dietary Manager confirmed the items should not be stored in such a manner unless the items are completely dried.

Based on record review and interview, the hospital failed to have written policies and procedures to address the scope and complexity of therapeutic respiratory services offered by the hospital. Findings:
Review of the Policies and Procedures Manual provided by S2Director of Nursing as the current policy and procedure manual revealed there was no documented evidence that policies were developed that addressed the scope and complexity of therapeutic respiratory services offered by the hospital. The only policy and procedure related to respiratory care services was a policy titled "Oxygen Therapy," and there was no documented evidence that policies and procedures had been developed for the nebulizer treatments and respiratory medications that were being administered by the nursing staff.
In an interview on 05/20/14 at 11:35 a.m., S2Director of Nursing indicated the hospital did not have a Respiratory Department, and there were no written policies and procedures regarding the scope and complexity of the respiratory care services provided at the hospital.

Based on record review (current medical staff roster with specialities identified) and interview, the hospital failed to credential and appoint a Director of Respiratory Services who was a physician with knowledge, experience, and capabilities to supervise and administer the respiratory services. Findings:
Review of the current Physician Roster provided by S2Director of Nursing as the current physician roster revealed no qualified physician was identified as Director of Respiratory Services.
In an interview on 05/20/14 at 11:35 a.m., S2Director of Nursing indicated the hospital did not have a Respiratory Therapy Services Department, nor did the hospital have a physician approved by the Medical Staff as Director of Respiratory Therapy Services. S2Director of Nursing further indicated she was not aware that the hospital needed to have a qualified physician as Director over Respiratory Therapy Services provided by the hospital.

Based on record review and interview, the hospital failed to have qualified staff who were trained and evaluated for competency to provide respiratory therapy services. Findings:
Review of the personnel files of S9RN, S10RN, S11LPN, and S17LPN revealed no documented evidence that orientation to and competency of performing respiratory therapy treatments was conducted for S9RN, S10RN, S11LPN, and S17LPN.
In an interview on 05/20/14 at 11:35 a.m., S2Director of Nursing (S2DON) indicated there were no respiratory therapists on staff or under a contract at the hospital to provide respiratory treatments, services, and training. S2DON indicated the respiratory therapy treatments ordered by physicians are administered by the medication nurses, who are typically Licensed Practical Nurses (LPNs). S2DON also indicated she was not sure if the nurses were trained by proficient respiratory therapists personnel to administer respiratory therapy treatments. S2DON further indicated the nurses did not have any competencies assessed and evaluations performed for administering respiratory treatments to patients.

Based on record review and interview, the hospital failed to have written Policies and Procedures developed and approved by the medical staff defining the scope of respiratory therapy services and the supervision required for the delivery of respiratory therapy services provided to patients at the hospital. Findings:
Review of the Medical Staff Rules and regulations, presented by S2Director of Nursing as the current Rules and regulations, revealed no documented evidence that respiratory services was addressed.
Review of the Policies and Procedures Manual provided by S2Director of Nursing as the current policy and procedure manual revealed, in part, no written policy and procedure addressing respiratory therapy services offered by the hospital.
In an interview on 05/20/14 at 11:35 a.m., S2Director of Nursing indicated the hospital did not have a Respiratory Department, and there were no policies and procedures approved by the medical staff regarding respiratory therapy services provided at the hospital.

Based on record review and interview, the hospital failed to administer respiratory therapy services as ordered by the physician for 3 (#2, #6, #24) of 4 (#2, #6, #9, #24) patients' records reviewed for respiratory services out of a total sample of 29 patients. Findings:
Patient #2 Patient #2 was a 47-year old male admitted to the Hospital on 05/17/14 at 3:30 p.m. with diagnoses of Major Depression, Suicide Attempt, Hypertension, and Diabetes Mellitus.
Review of Patient #2's physician orders revealed he had oxygen ordered at 2 L (liters) per nasal cannula at night only and PRN (as needed).
Review of Patient #2's medical record revealed there was no documentation that Patient #2 had been provided his oxygen at night as ordered. Further review of the entire medical record revealed no documentation that Patient #2 had ever worn his oxygen during his hospital stay.
In an interview on 05/20/14 at 1:30 p.m., Patient #2 indicated he had not worn his oxygen at night or any other time since his admission to the hospital. He also indicated he remembered a pulse oximetry reading had been done on him once, or maybe twice, during his hospital stay.
In an interview on 05/20/14 at 11:35 a.m., S2Director of Nursing (DON) confirmed there was no documentation in Patient #2's entire medical record that indicated the patient's oxygen status, pulse oximetry readings, or why Patient #2 had not been wearing his oxygen at night.
In an interview on 05/2014 at 1: 42 p.m., S12RN (Registered Nurse) verified and confirmed there was no documentation in the medical record that Patient #2 had been wearing the oxygen at night as prescribed by the physician or that Patient #2 had refused to wear the oxygen. S12RN also verified there were no pulse oximetry readings documented in Patient #2's medical record.

Patient #6
Review of Patient #6's medical record revealed he was a 28 year old male admitted on 05/16/14 with diagnoses of Mood Disorder, Bipolar Disorder mixed with Psychosis, history of Opiate Abuse, Anxiety, Thyroid Disease, and Asthma.

Review of Patient #6's physician's orders revealed an order on 05/16/14 at 1:00 p.m. for Albuterol HFA 2 puffs every 6 hours as needed for wheezing/shortness of breath (SOB) and Flovent Diskus 100 mcg (microgram) 2 puffs twice a day.

Review of Patient #6's treatment plan for "Impaired Gas Exchange", initiated on 05/17/14, revealed the long term goal was that Patient #6 would maintain an oxygen saturation at 90% (per cent) or above, and the intervention was that the RN would monitor his oxygen saturation every shift.

Review of Patient #6's entire medical record revealed no documented evidence that his oxygen saturation was ever assessed according to his treatment plan.

In an interview on 05/20/14 at 1:30 p.m., S2DON confirmed there was no documentation of Patient #6's oxygen saturation being monitored by the RN.

Patient #24 Review of Patient #24's medical record revealed she was a 55 year old female admitted on 04/28/14 and discharged on 05/02/14. Review of her physician orders dated 04/29/14 at 7:00 a.m. revealed an order for Albuterol nebulizer treatment now and then every 6 hours as needed for wheezing/SOB, Prednisone 20 mg one tablet by mouth daily for 3 days, and to obtain a chest x-ray today.

Review of Patient #24's MARs and nursing daily assessments revealed no documented evidence that the nebulizer treatment was administered as ordered.

In an interview on 05/23/14 at 8:30 a.m., S2DON could offer no explanation for the nebulizer treatment not being administered as ordered.

Based on record reviews and interviews, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services, Radiologic Services and Respiratory Care Services.

Based on record reviews and interviews, the hospital failed to ensure that each patient received a psychiatric evaluation as evidenced by having a policy that allowed a psychiatric evaluation update to be conducted if the previous psychiatric evaluation had been completed in the last 30 days. 1 (#1) of 6 current patients' (#1 - #6) records reviewed for a psychiatric evaluation performed within 60 hours of admission from a total of 16 current patients' records reviewed (total of 29 sampled patients) revealed a psychiatric evaluation update had been conducted rather than a psychiatric evaluation.
Findings:

Review of the hospital policy titled "Psychiatric Evaluations", policy number CTS-020, revised March 2011, and presented as a current policy by S2DON (Director of Nursing), revealed that a comprehensive Psychiatric Evaluation is conducted and documented in the medical record by an Active Staff Psychiatrist / Licensed Independent Practitioner / Credentialed Designee within 24 hours following an inpatient admission. Further review revealed that a Psychiatric Evaluation Update is conducted as appropriate if a previous psychiatric evaluation had been completed in the last 30 days.

Review of the hospital's "Psychiatric Evaluation - Update" revealed the following areas for assessment that were included in the "Psychiatric Evaluation" were not listed on the update to be assessed:
Past Psychiatric History including the course and results of treatment;
Substance Abuse History and Treatment;
Developmental History;
Past Medical History;
Review of Systems/Symptoms;
Past psychiatric medications and response;
Allergies;
Family psychiatric history / chemical dependency history;
Social history.

Review of Patient #1's medical record revealed he was a 29 year old male admitted on 05/18/14 with diagnoses of Bipolar I Current Depression, Hypertension, and Polysubstance Abuse. Further review revealed a "Psychiatric Evaluation - Update" was conducted on 05/19/14 at 11:00 a.m. by S3Medical Director.

In an interview on 05/22/14 at 8:50 a.m., S3Medical Director confirmed that it was the hospital policy to allow a psychiatric evaluation update to be done if a psychiatric evaluation had been conducted within the last 30 days.

Based on record reviews and interview, the hospital failed to ensure that each patient received a psychiatric evaluation that estimated his/her intellectual functioning, memory functioning, and orientation in a sufficiently descriptive manner to establish a diagnosis and objective baseline for future comparison as required by hospital policy. The psychiatric evaluations failed to have intellectual functioning, memory functioning, and/or orientation documented in a descriptive manner as evidenced by having check marks placed in the space provided for description rather than descriptive terms for 3 (#1, #3, #5) of 6 current patients' (#1 - #6) psychiatric evaluations reviewed for intellectual functioning, memory functioning, and orientation from a total of 16 current patients' records reviewed (total of 29 sampled patients).
Findings:

Review of the hospital policy titled "Psychiatric Evaluations", policy number CTS-020, revised March 2011, and presented as a current policy by S2DON (Director of Nursing), revealed that a comprehensive Psychiatric Evaluation is conducted and documented in the medical record by an Active Staff Psychiatrist / Licensed Independent Practitioner / Credentialed Designee within 24 hours following an inpatient admission. Further review revealed that the psychiatrist performs a systematic mental status examination emphasizing immediate recall, recent and remote memory appropriate to age, and documents tests' performance to assess cognitive functioning, memory, and estimated intellectual functioning in a sufficiently descriptive manner to establish diagnosis and an objective baseline for future comparison.

Patient #1
Review of Patient #1's medical record revealed he was a 29 year old male admitted on 05/18/14 with diagnoses of Bipolar I Current Depression, Hypertension, and Polysubstance Abuse.

Review of Patient #1's "Psychiatric Evaluation - Update" conducted on 05/19/14 at 11:00 a.m. by S3Medical Director revealed a check mark was placed in the space next to "Memory: Immediate ___ Recent ___ Remote ___" rather than stated in descriptive terms to be used for future comparison.

Patient #3
Review of Patient #3's medical record revealed she was a 50 year old female admitted on 05/18/14 with a diagnosis of Bipolar Manic.

Review of Patient #3's Psychiatric Evaluation performed on 05/19/14 at 9:40 a.m. by S3Medical Director revealed his (S3Medical Director) documentation of Patient #3's cognitive exam included check marks in the spaces for immediate, recent, and remote memory, and check marks in the spaces for general fund of knowledge, attention/concentration, and calculations/abstraction. There was no documented evidence that Patient #3's intellectual functioning, memory functioning, and orientation was stated in a sufficiently descriptive manner to establish a diagnosis and objective baseline for future comparison as required by hospital policy.

Patient #5
Review of Patient #5's medical record revealed he was a 29 year old male admitted on 05/16/14 with diagnoses of Psychosis and Polysubstance Dependence.

Review of Patient #5's Psychiatric Evaluation performed on 05/17/14 at 8:00 a.m. by S3Medical Director revealed his (S3Medical Director) documentation of Patient #5's cognitive exam included check marks in the spaces for immediate, recent, and remote memory, and check marks in the spaces for general fund of knowledge, attention/concentration, and calculations/abstraction. There was no documented evidence that Patient #5's intellectual functioning, memory functioning, and orientation was stated in a sufficiently descriptive manner to establish a diagnosis and objective baseline for future comparison as required by hospital policy.

In an interview on 05/22/14 at 8:50 a.m., S3Medical Director indicated that the check marks he places for intellectual functioning, memory functioning, and orientation means "unremarkable." When informed that the hospital policy stated that this information needed to be stated in descriptive terms, S3Medical Director answered, "they have to change the form."

Based on record reviews and interview, the hospital failed to ensure that each patient received a psychiatric evaluation that included an inventory of the patient's assets in a descriptive manner and not an interpretive fashion for 1 (#1) 6 current patients' (#1 - #6) psychiatric evaluations reviewed for assets stated in a descriptive manner from a total of 16 current patients' records reviewed (total of 29 sampled patients).
Findings:

Review of the hospital policy titled "Psychiatric Evaluations", policy number CTS-020, revised March 2011, and presented as a current policy by S2DON (Director of Nursing), revealed that a comprehensive Psychiatric Evaluation is conducted and documented in the medical record by an Active Staff Psychiatrist / Licensed Independent Practitioner / Credentialed Designee within 24 hours following an inpatient admission. Further review revealed that the psychiatrist identifies specific patient strengths and assets to enable the multidisciplinary treatment team to choose treatment modalities that best utilize these identified strengths and assets in the patient's treatment.

Review of Patient #1's medical record revealed he was a 29 year old male admitted on 05/18/14 with diagnoses of Bipolar I Current Depression, Hypertension, and Polysubstance Abuse.

Review of Patient #1's "Psychiatric Evaluation - Update" conducted on 05/19/14 at 11:00 a.m. by S3Medical Director revealed S3Medical Director's assessment of Patient #1's assets was left blank with no description of assets to be used by the multidisciplinary treatment team to choose treatment modalities for Patient #1.

In an interview on 05/22/14 at 8:50 a.m., S3Medical Director indicated that Patient #1 did not have any assets. He further indicated if he assessed that Patient #1 had no assets, he should have documented this fact in his psychiatric evaluation and not left the space blank.

Based on record reviews and interviews, the hospital failed to ensure that each patient had an individual comprehensive treatment plan as evidenced by failing to include medical diagnoses for which the patient was being treated for 3 (#3, #9, #10) of 8 (#1-#6, #9, #10) current patients' records reviewed for treatment plans from a total of 16 current patients' records reviewed from a total sample of 29 patients.
Findings:

Review of the hospital's policy titled "Treatment Planning, policy number RC-017, revised March 2013, and presented by S2DON (Director of Nursing) as a current policy, revealed the multidisciplinary treatment team, under the direct supervision of the attending physician/Licensed Independent Practitioner shall develop an integrated, written, comprehensive treatment plan with specific goals and objectives necessary to address deficits identified in the assessment process. Further review revealed the treatment plan was to be patient-specific, individualized, and included defined problems and needs based on assessed needs, strengths and limits/weaknesses, frequency of care, and treatment and services.

Patient #3
Review of Patient #3's medical record revealed she was a 50 year old female admitted on 05/18/14 with a diagnosis of Bipolar Manic. Review of her Psychiatric Evaluation performed on 05/19/14 revealed she also was diagnosed with Diabetes Mellitus Type 2.

Review of Patient #3's Physician's orders revealed an order on 05/19/14 at 7:00 a.m. to check her fasting CBG every morning for 3 days.

Review of Patient #3's treatment plan revealed no documented evidence that her treatment included a plan for managing her Diabetes Mellitus.

In an interview on 05/20/14 at 1:45 p.m., S2DON confirmed that Patient #3 should have had her treatment plan revised to include her medical diagnosis of Diabetes Mellitus.

Patient #9 Review of Patient #9's medical record revealed she was a 26-year-old female admitted to the hospital on 05/15/14 at 9:06 p.m. with the documented diagnoses of Bipolar Disorder, Suicidal Ideations, Aggressive Behaviors, Diabetes Mellitus, Hypothyroidism, and High Cholesterol.
Review of Patient #9's medication orders dated 05/16/14 revealed Patient #9 had orders for medications prescribed for patients with impaired respiratory function. The medication orders included: Advair Diskus 250/50 mg (milligrams), one inhalation (puff) every day; Singulair, 10 mg by mouth every night at bedtime; and an order for Proventil HFA inhaler, two puffs every six hours as needed for shortness of breath.
Review of Patient #9's medical record revealed Patient #9 did not have a treatment plan for the medical diagnosis for which she was being treated such as impaired or altered respiratory function, impaired gas exchange, or shortness of breath.
In an interview on 05/23/14 at 11:15 a.m., S2Director of Nursing verified that Patient #9 was receiving medications for altered respiratory function and did not have a care plan addressing this problem, and Patient #9 should have had a care plan addressing altered respiratory function.
Patient #10 Review of Patient #10's medical record revealed he was a 52-year-old male admitted to the hospital on 05/12/14 with diagnoses of Major Depressive Disorder without Psychosis, Anxiety Disorder, Hypertension, Diabetes Mellitus and Chronic Pain.
Review of Patient #10's medical record revealed Patient #10 was receiving CBG (capillary blood glucose) level monitoring before meals and at bedtime and was on sliding scale insulin for his diagnosis of diabetes. Further review revealed Patient #10 did not have a treatment plan in his medical record addressing his medical diagnosis of Diabetes Mellitus.
In an interview on 05/23/14 at 11:15 a.m., S2Director of Nursing confirmed Patient #10 was receiving medications for his diagnosis of Diabetes. S2Director of Nursing verified Patient #10 did not have a care plan addressing his diagnosis of Diabetes Mellitus, and Patient #10 should have had a care plan addressing Diabetes Mellitus.

Based on record reviews and interview, the hospital failed to ensure that the nursing staff documented in the patients' records the specific treatment utilized for each patient as stated in the goals for the patient as evidenced by having no documented evidence that pain (#5) and oxygen saturation (#6) was assessed and documented according to the stated goals for 2 (#5, #6) of 8 (#1-#6, #9, #10) current patients' records reviewed for treatment plans from a total of 16 current patients' records reviewed from a total sample of 29 patients.
Findings:

Review of the hospital's policy titled "Treatment Planning, policy number RC-017, revised March 2013, and presented by S2DON (Director of Nursing) as a current policy, revealed the multidisciplinary treatment team, under the direct supervision of the attending physician/Licensed Independent Practitioner shall develop an integrated, written, comprehensive treatment plan with specific goals and objectives necessary to address deficits identified in the assessment process. Further review revealed the treatment plan was to be patient-specific, individualized, and included defined problems and needs based on assessed needs, strengths and limits/weaknesses, frequency of care, and treatment and services. Further review revealed that the nurse was to include all interventions on the treatment plan.

Patient #5
Review of Patient #5's medical record revealed he was a 29 year old male admitted on 05/16/14 with diagnoses of Psychosis and Polysubstance Dependence.

Review of Patient #5's treatment plan for "Altered Comfort" revealed a short-term goal was that Patient #5 would verbalize his pain on a scale of 1 to 10 with 10 being the most intense to the nursing staff daily. Review of Patient #5's nursing documentation (medication administration records and nursing flow sheets) revealed no documented evidence that the nurses were documenting Patient #5's pain according to the pain scale.

In an interview on 05/20/14 at 1:45 p.m., S2DON indicated the nurses should have been assessing Patient #5's pain by using the numerical pain scale and documenting it in his medical record as stated in the goals of his treatment plan.

Patient #6
Review of Patient #6's medical record revealed he was a 28 year old male admitted on 05/16/14 with diagnoses of Mood Disorder, Bipolar Disorder mixed with Psychosis, history of Opiate Abuse, Anxiety, Thyroid Disease, and Asthma.

Review of Patient #6's treatment plan for "Impaired Gas Exchange" revealed that the long term goal was that Patient #6 would maintain an oxygen saturation at 90% (per cent) or above.

Review of Patient #6's entire medical record revealed no documented evidence that his oxygen saturation was ever assessed according to his treatment plan.

In an interview on 05/20/14 at 1:30 p.m., S2DON confirmed there was no documentation of Patient #6's oxygen saturation being monitored by the RN.

Based on record reviews and interview, the hospital failed to ensure that progress notes were recorded by all disciplines involved in active treatment of the patients as evidenced by failing to have documented evidence of progress notes for therapeutic recreational therapy groups conducted for 2 (#5, #6) of 3 (#4, #5, #6) current patients' records reviewed for therapeutic recreational therapy progress notes from a total of 16 current patients' records reviewed from a total sample of 29 patients.
Findings:

Patient #5
Review of Patient #5's medical record revealed he was a 29 year old male admitted on 05/16/14 with diagnoses of Psychosis and Polysubstance Dependence. Further review revealed he had a therapeutic recreational therapy assessment conducted by S8TRS (Therapeutic Recreational Specialist) on 05/17/14. Review of his medical record revealed no documented evidence of any progress notes completed for recreational therapy groups.

Patient #6
Review of Patient #6's medical record revealed he was a 28 year old male admitted on 05/16/14 with diagnoses of Mood Disorder, Bipolar Disorder mixed with Psychosis, history of Opiate Abuse, Anxiety, Thyroid Disease, and Asthma.

Review of Patient #6's medical record revealed he had a recreational therapy assessment conducted by S8TRS on 05/16/14 at 2:15 p.m. Further review revealed no documented evidence of any progress notes completed for recreational therapy groups.

In an interview on 05/20/14 at 2:50 p.m., S8TRS indicated that since Optima Specialty Hospital "has merged with Hospital A, he does his part of the treatment plan which is the intervention." He confirmed that he does not set goals any longer since they have merged. He indicated that he does daily therapy sessions, but he doesn't document a progress note daily when this is done. He confirmed that he did not progress notes to present for therapy that he conducted for Patients #5 and #6.

Based on interview the hospital failed to ensure the hospital had a psychologist available to provide psychological services to meet the needs of its patients.
Findings:

In an interview on 05/19/14 at 12:35 p.m., S1Administrator indicated that the hospital did not have a psychologist on staff or contracted to provide psychological services to meet the needs of its patients.