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Based on record review and interview the hospital failed to met the requirements of the Condition of Participation for Governing Body as evidenced by:

Failure to ensure a process was in place in order to provide the same standard of care and safety for psychiatric patients admitted to the medical unit for care as evidenced by failure to ensure a physician ordered an observation level for a patient admitted under a CEC (coroner's emergency certificate) resulting in the the patient's elopement (#7), failing to ensure all nursing staff was assessed for competency in the care and observation of the psychiatric patient admitted to the medical unit.(#4, #7) and failing to provide group therapy for patients with a psychiatric diagnosis for 2 of 2 (#4, #7) psychiatric patients admitted to the medical unit out of a total of 9 sampled patients (See findings at A0049).

Based on observation, record review and interview the hospital failed to meet the Condition of Participation for Patient Rights as evidenced by:

1) Failure to develop and implement a process for admission of patients with a primary psychiatric diagnosis to an unsecured medical unit to ensure the safety of both the psychiatric and medical patients housed on the medical unit. This was evidenced by failure to develop and implement policies and procedures related to safety, observation levels and competence of the staff assigned to the medical unit who were to care for psychiatric patients housed on the medical unit for 2 of 2 psychiatric patients on the medical unit (#4, #7) out of a total of 9 sampled patients . This resulted in the elopement of Patient (#7) who had been admitted under a CEC'd (coroner's emergency certificate) for paranoid, threatening behavior with possible homicidal ideation and who had been left unattended by the nursing staff. (See findings at A0144).

Based on record review and interview the hospital failed to ensure a process was in place in order to provide the same standard of care and safety for psychiatric patients admitted to the medical unit for care as evidenced by failure to ensure a physician ordered an observation level for a patient admitted under a CEC (coroner's emergency certificate) resulting in the the patient's elopement (#7), failing to ensure all nursing staff was assessed for competency in the care and observation of the psychiatric patient admitted to the medical unit.(#4, #7) and failing to provide group therapy for patients with a psychiatric diagnosis for 2 of 2 (#4, #7) psychiatric patients admitted to the medical unit out of a total of 9 sampled patients. Findings:

Patient #7
Review of the medical record for Patient #7 revealed a 44 year old female admitted on 12/21/11 under a Coroner's Emergency Certificate (CEC dated 12/18/12 with expiration in 14 days) for delusional, paranoid and threatening behavior and was being transferred to long term acute care for intravenous antibiotic therapy, wound care, dialysis and psych treatment.

Review of the Physician's Verbal Admit Orders for Patient #7 dated/timed 12/21/11 at 1630 (4:30pm) revealed she was admitted to the medical unit with no documented evidence orders were written for an observation level related to the CEC for threatening and violent behavior.

Observation of the medical unit on 01/20/12 at 11:00am revealed all rooms were equipped with electrical beds, windows which could be opened to allow an adult access to the outside of the building (located on a busy highway), long electrical cords used for equipment, plastic bags in waste receptacles and a pull cord for calling the nurse.

Review of the Nursing 24-Hour Assessment and Narrative Notes dated 12/21/11 through 12/26/11 revealed Patient #7 was being observed by staff every 1-2 hours and there was no documentation of her behavior. Review of the Narrative Notes dated 12/26/11 that at 2015 (8:15pm) Patient #7 was not in her room, the facility and surrounding area searched by staff; however she could not be found. Police returned Patient #7 to the hospital at 9:20pm later that evening. Further review of the medical record revealed Patient #7 was still under a CEC which was confirmed by S2 Director of Nursing.

Review of the "Daily Staffing Schedule" for the Medical Unit for 12/26/11, 12/27/11, 12/28/11and 12/29/11 revealed the following staff were assigned 1:1 monitoring of Patient #7: 12/28/11 morning shift- Housekeeper S18 and 12/29/11 morning shift- Housekeeper S18.

In a face to face interview on 01/20/12 at 2:00pm RN S2 Director of Nursing indicated the hospital recently started admitting patients with a primary psychiatric diagnosis to the medical unit and also those patients needing medical treatment which could not be provided on the psychiatric unit. S2 confirmed the medical unit was not a locked unit, the patient rooms on the medical unit where psychiatric patients are assigned were not the same as on the psychiatric unit. Further S2 indicated psychiatric patients were placed in rooms with electric beds, plastic bags in waste receptacles, windows which open to the outside and electrical cords. S2 indicated at the present time, the psychiatric patients placed on the medicine unit were not participating in group therapy.

In a face to face interview on 01/20/12 at 2:15pm S3 Director of the Behavioral Unit indicated that when a patient with a primary diagnosis which is psychiatric is admitted to the medical unit he (S3) does not supervise his/her care nor does the staff of the behavioral unit participate in his/her care.

In a face to face interview on 01/23/12 at 11:00am RN S5 Charge Nurse of the Medicine Unit indicated she had previous psychiatric experience and had worked on the psych unit at the hospital before transferring to the medicine unit. Further S5 indicated no special precautions were taken when a psych patient was admitted on the Medicine Unit concerning preparation of the room and verified observation documentation was not performed on the medicine unit.

In a face to face interview on 01/23/12 at 12:05pm RN S7 Charge Nurse of the Medicine Unit indicated patients under a CEC are sometimes placed on the medicine unit depending on their medical condition. S7 indicated Patient #7 was not placed on 1:1 observation when she was admitted because no one was aware at the time of her admission that she (#7) had been CEC' d. Further S7 indicated it was not until Patient #7 had eloped that the CEC was discovered and when she (#7) returned to the hospital she (#7) was then placed on 1:1 observation.


Patient #4
Review of Patient #4's medical record revealed the patient was admitted to the hospital on 1/10/2012 under a Physician's Emergency Certificate dated 1/10/2012 for being "Gravely Disabled (non compliant with medications, behaving bizarrely, extremely paranoid . . . screaming and hollering in progress)". Patient #4's diagnoses included Schizoaffective Disorder- Bipolar Type. Further review revealed #4's Nursing "Narrative Notes" dated 1/11/12 (2012) at 1515 (3:15 p.m.) indicating, "Requires 1:1 monitoring". Patient #4 was placed on the Medical Unit of the hospital. Review of nursing notes revealed documentation and/or check marks indicating Patient #4 was assigned 1:1 staffing from 1/10/2012 through 1/15/2012. Review of the entire medical record revealed no documented evidence to indicate the name and discipline of the staff monitoring Patient #4 on a 1:1 basis. Review of the entire medical record revealed no documented evidence of 15 minute observations for Patient #4.

Review of the "Daily Staffing Schedule" for January 10th, 11th, 12th, and 13th of 2012 revealed the following staff were assigned 1:1 monitoring (Patient #4):
1/10/2012 morning shift Respiratory Therapist S20
1/10/2012 night shift Respiratory Therapist S22
1/11/2012 morning shift Respiratory Therapist S29
1/11/2012 night shift Respiratory Therapist S28
1/12/2012 morning shift Respiratory Therapist S20
1/12/2012 night shift Respiratory Therapist S29
1/13/2012 morning shift Housekeeper S18.

Review of the hospital job descriptions for Respiratory Therapist and Housekeeping revealed no documented evidence indicating the duty of 1:1 observations of psychiatric patients was a required duty for Respiratory and/or Housekeeping.

Review of the Personnel files for Respiratory Therapist S20, Respiratory Therapist S22, Respiratory Therapist S29, Respiratory Therapist S28, and Housekeeper S18 revealed no additional Job Descriptions outside of their discipline.

During a face to face interview on 1/23/2012 at 10:40 a.m., Respiratory Therapist S15 indicated he(S15) had been assigned to sit with 1:1 psychiatric patients housed on the medical floor. S15 indicated he (S15) had some training in Behavior Management as part of the hospital's annual training; however, he (S15) did not know what was required for different levels of observation of psychiatric patients or policy requirements regarding securing the environment for psychiatric patients to ensure safety. S15 further indicated he (S15) had never completed an observation flow sheet when assigned to 1:1 monitoring of psychiatric patients on the medical floor.

During a face to face interview on 1/23/2012 at 11:50 a.m., Housekeeper S18 indicated she (S18) been assigned at times to sit with 1:1 psychiatric patients housed on the medical floor. S18 indicated there had been no other Housekeeper assigned to sit with 1:1 patients and she (S18) did not know why she (S18) had been assigned the task. S18 indicated the 1:1 psychiatric patient rooms on the Medical Unit were fully equipped with call lights on cords and plastic bags in garbage cans. S18 indicated she (S18) knew she (S18) was to keep the patients from getting out of the room and hurting themselves. S18 indicated she (S18) did not know anything about different levels of observation and had never documented on the patients that she (S18) had sat with. S18 indicated she(S18) had known that psychiatric patients housed on the psych unit could not have plastic bags in their garbage cans and that the rooms were scarcely equipped; however, when psychiatric patients were housed on the medical unit there had been no alterations made to the rooms. S18 indicated she had no knowledge of any policies regarding procedures for ensuring the environment of psychiatric patients housed on the medical unit were safe.

During a face to face interview on 1/23/2012 at 12:20 p.m., Respiratory Director S20 indicated there had been some material reviewed about patient behavior with a post test at the hospital's skills fair; however, there had been no specific psychiatric training, no review of policies regarding observation levels or environmental safety for psychiatric patients, and many of the Respiratory Therapists that had been assigned to observing 1:1 psychiatric patients had voiced that they were uncomfortable with the assignment, some being afraid of the patients.

Observations on 1/20/2012 at 8:45 a.m. revealed Patient #4 to be located in a private room on the Medical Unit of the hospital. Further review revealed #4's room to have a call light attached to a cord at the patient's bedside, plastic bags in the garbage can, a window that could be opened completely- allowing an adult patient the ability to climb out of the room, and blinds covering the window with a pull cord attached.

During a face to face interview on 1/20/2012 at 8:45 a.m., Registered Nurse S16 confirmed the above findings. S16 indicated it had not been the practice for nursing staff on the Medical Unit to make any revisions to patient's room environment in response to housing psychiatric patients on the unit. S16 indicated the reason Patient #4 had been placed on the Medical Unit, instead of Psychiatry, was due to using CPAP (Continuous Positive Airway Pressure) at night (plugged into red emergency outlet in patient's room). S16 indicated she (S16) had no knowledge of any policy and/or procedure for altering the environment of Medical Rooms to ensure the safety of psychiatric patients being housed on the unit. S16 further indicated she (S16) had never made any alterations to a Medical Room when a Psychiatric Patient had been placed there. S16 further indicated she (S16) was not aware of different levels of observation for Psychiatric Patients. S16 indicated there had never been a physician's order on Patient #4 to indicate the Level of Observation for the Patient. S16 indicated the practice on the Medical Unit for housing psychiatric patients had been to place them on 1:1 when they were under a PEC (Physician's Emergency Certificate) or CEC (Coroner's Emergency Certificate) and then treating them as any other medical patient after the PEC or CEC was completed. S16 indicated there had never been observation levels ordered for psychiatric patients housed on the Medical Unit to include no order for 1:1 observation.

During a face to face interview on 1/23/2012 at 1500 (3:00 p.m.), Director of Nursing S2 indicated there had never been any environmental alterations made to the rooms for psychiatric patients housed on the Medical Unit nor had that been identified as a problem. S2 further indicated the hospital had psychiatric policies (Behavioral Health Policies) regarding Special Precautions, Observation Levels, and Environmental Safety on the Psychiatric Unit of the hospital; however, there was no policy in regards to ensuring safety of psychiatric patients being housed on the medical unit.

Review of the hospital policy titled, "Behavioral Health: Special Precautions, BH-037" presented by the hospital as current revealed in part, "It is the policy of the Psychiatric Service that staff monitoring is instituted to prevent patients from harming themselves or others. Indications of suicidal intent, a desire to elope, or increasing agitation will be immediately evaluated by the staff member who becomes aware of them. In order to provide protection to psychiatric patients, two levels of staff monitoring are provided: Routine Precautions (monitoring every 15 minutes). Special Precautions (monitoring on a constant basis). A written physician's order is obtained for Special Precautions. . . The physician's order shall include the level of the monitoring (watch, close, constant) and the reason of the monitoring (suicidal risk, agitation, elopement risks). . . A physician order is necessary to discontinue or lower the level of staff monitoring. . . Routine Precautions: Consists of fifteen (15) minute checks by a staff member. The patient is placed under staff observation every fifteen minutes. . . The patient's behavior is documented every fifteen minutes on the monitoring log. The staff observation will be continued until discontinued by the Physician. Special Precautions: Consist of one to one staff contact with a patient. The Physician and treatment team determine the specific emergency needs of the patient. . ."

Review of the hospital policy titled, "Behavioral Health: Sharps, BH-036" presented by the hospital as current revealed in part, "Certain items which may be necessary for patient care or personal hygiene, may pose a danger to aggressive or confused patients. For patient safety these items will be identified as "Sharps" and will be kept by program staff except when in use and under direct staff supervision. These items include, but are not limited to : Safety razors, Glass container, Aerosol cans, Wire coat hangers, Solutions or creams that have potentially poisonous or harmful ingredients, Scissors, Metal nail files, Corded electric appliances, Plastic bags, Cleaning solutions, Matches and lighters.

Based on record review and interview the hospital failed to follow their policy on Grievances as evidenced by failing to respond to the complainant within 30 days with the results of the investigation for 1 of 1 grievances submitted by the hospital for the last 12 months. Findings:

Review of the Formal Patient/Family Grievance Log dated 02/16/11 revealed the husband of Random Patient R1 voiced his displeasure with his wife's hospital stay related to the care given by one particular CNA (certified nursing assistant). Further R1's husband indicated the CNA was rude, failed to bath his wife, change the sheets on the bed, or assist with feeding.

Review of the letter dated 02/21/11 to R1 acknowledged receipt of the grievance and that the hospital was looking into the matter. Further the letter stated the hospital would keep R1 informed of the progress and would forward those results in writing within 30 days of the original grievance receipt. Further review of the information submitted by S2 Director of Nursing concerning the grievance revealed no documented evidence a final letter was sent to R1.

In a face to face interview on 01/19/11 at 3:00pm S2 Director of Nursing verified only one letter was sent to the complainant.

Review of Policy Number III.A.1.11 titled "Patient/Family Grievance" last revised 10/19/11 and submitted as the one currently in use revealed..... B. Grievance 5. Once the Committee and the Corporate Director of Quality/Risk Management makes a final decision a written response will be provided the complainant within 5 working days. The written response will include the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance investigation process, as appropriate, and the date of completion. The response will not exceed 30 days from the original receipt of the grievance".

Based on observation, policy review, and interview, the hospital failed to ensure Patient's Rights were exercised for 1 of 7 psychiatric patients out of a sample of 9 patients as evidenced by not honoring the patient's rights for privacy by placing the patient's bed in the hallway at night next to the nurse's station in order to administer a CPAP treatment (#2). Findings:

Patient #2, a 40 year old male, was admitted to the Psychiatric Unit on 1/3/12 at 1615. Record review of Physician Admit Orders & Problem List dated 1/3/12 by S25 LPN and signed by the physician on 1/5/12 at 1405. Admit diagnoses included Pneumonia, Hyperkalemia (low potassium), CPS, HTN (Hypertension), Gout, and Hyperlipidemia. Additional physician orders written on the Physician's Order Sheet dated 1/3/12 by the physician included Aerosol treatments with Atrovent qid (four times a day). On 1/4/12, physician ordered a Sleep Study ASAP (as soon as possible.) On 1/6/12 at 1050 a.m., physician discontinued the Sleep Study ASAP order because patient was scheduled for a sleep study in a month. Physician then order the patient to be placed on BiPap at night. On 1/8/12, Physician's Order Sheet revealed an order for the C-Pap set at 10 centimeters of oxygen while sleeping.

Record review of Nurses Progress Notes written by RN S10 on 1/6/12 at 0830 revealed patient was a fall risk, so he was "moved to room within nurse's eye view--close to the nurses' station." S10 RN also documented at 1400 that respiratory services met with patient to set up C-Pap machine, but patient refused to wear the mask. On 1/6/12 at 2000, patient was again fitted with the C-Pap face mask to sleep with at night. Patient accepted the mask and continued to wear the mask each night. On 1/8/12 at 0700, S10 noted the patient was lying in his bed in a deep sleep. The C-PAP machine was set up to #8. At 0745, S10 noted that patient was having more difficulty in breathing. S10 documented that patient was still within "nurse station eye contact."

Record review of S9 RN's documentation on 1/9/12 and signed at 0600 revealed patient was still in the "hospital bed in hall." Nurses failed to document that the patient's C-PAP treatment were being given in the hallway next to the nurse's station from 1/9/12 0800 until patient was discharged 1/16/12 at 1500.

On 1/19/12 at 2:30 p.m. in a face-to-face interview with RN S3 Psychiatric Unit Director stated that if a patient needs treatment such as elevating the head of the bed, shortness of breath, aspiration, or intravenous therapy, then the patient needs to be admitted to the Medical Unit, not the Psychiatric Unit. S3 confirmed that patient #2 had sleep apnea , but did have his own personal C-PAP machine. S3 also stated he had informed the physician that the Psychiatric Unit does not provide a C-PAP, nor has the electrical outlets present in the patient's room to operate the machine. According to S3, the physician told him patient #2 needed to have a C-PAP machine delivering oxygen at night, so S3 agreed to have a regular hospital bed placed in the hallway outside the nurse's station so the C-PAP machine could be plugged into the electrical outlet.

Record review of the "Job Description--Registered Nurse--Behavioral Health" written 10/2010 (pg 3 of 6), IV Mission/Standards B. reads: "Observes confidentiality policy and HIPPA guidelines at all times. 1. Protects and honors patients and coworkers confidentiality. 2. Respects patients' and coworkers' right to privacy."

The hospital staff failed to follow their job description of protecting and honor patient #2's right to privacy.

20638

Based on record review and interview the hospital failed to develop and implement a process for admission of patients with a primary psychiatric diagnosis to an unsecured medical unit to ensure the safety of both the psychiatric and medical patients housed on the medical unit of the hospital for 2 of 2 psychiatric patients housed on the medical unit (#4, #7) resulting in the elopement of a patient (#7) who had been CEC'd (coroner's emergency certificate) for paranoid, threatening behavior with possible homicidal ideation out of a total of 9 sampled patients. Findings:

Patient #7
Review of the medical record for Patient #7 revealed a 44 year old female admitted on 12/21/11 under a Coroner's Emergency Certificate (CEC dated 12/18/12 with expiration in 14 days) for delusional, paranoid and threatening behavior. Review of the History & Physical dated 12/21/11 revealed Patient #7 was transferred from Hospital "a" where she had left AMA (against medical advise) twice and was being transferred to long term acute care for intravenous antibiotic therapy, wound care, dialysis and psych treatment.

Review of the Physician's Verbal Admit Orders for Patient #7 dated/timed 12/21/11 at 1630 (4:30pm) revealed she was admitted to the medical unit with no documented evidence orders were written for an observation level related to the CEC for threatening and violent behavior. According to the section titled "Other Orders" a consult for psych was ordered for non-compliance with treatment. Review of the medical record revealed the Psychiatric Consult was not performed until 12/27/11 which was 6 days after admit and the day after Patient #7's elopement.

Review of the Psychiatric Evaluation dated 12/27/11 revealed Patient #7 was transferred from Hospital "a" with a history of non-compliance with treatment and medication. Further review revealed Patient #7 was verbally abusive to staff at Hospital "a" and was PEC'd. R/O (rule out) psychosis vs (versus) paranoid disorder.

Observation of the medical unit on 01/20/12 at 11:00am revealed all rooms were equipped with electrical beds, windows which could be opened to allow an adult access to the outside of the building (located on a busy highway), long electrical cords used for equipment, plastic bags in waste receptacles and a pull cord for calling the nurse.

Review of the Nursing 24-Hour Assessment and Narrative Notes dated 12/21/11 through 12/26/11 revealed Patient #7 was being observed by staff every 1-2 hours and there was no documentation of Patient #7's behavior. Review of the Narrative Notes dated 12/26/11 revealed Patient #7 told RN S8 she wanted to leave the hospital to go home and pay her bills. RN S8 explained to Patient #7 this was not possible without an MD order and reported the incident to the charge nurse. Further review of the Nurses' Narrative Notes for 12/26/11 revealed ... ... 2015 (8:15pm) Patient not in room. Facility and surrounding area searched by staff. Patient not located. 2025 (8:25pm) Charge nurse notified the MD; 2040 (8:40pm) Police notified; 2120 (9:20pm) Patient found by the police and returned to the facility. Further review of the medical record revealed Patient #7 was still under a CEC which was confirmed by S2 Director of Nursing.

Review of the "Daily Staffing Schedule" for the Medical Unit for 12/26/11, 12/27/11, 12/28/11and 12/29/11 revealed the following staff were assigned 1:1 monitoring of Patient #7:
12/28/11 morning shift- Housekeeper S18
12/29/11 morning shift- Housekeeper S18

In a face to face interview on 01/20/12 at 2:00pm RN S2 Director of Nursing indicated the hospital recently started admitting patients with a primary psychiatric diagnosis to the medical unit and also those patients needing medical treatment which could not be provided on the psychiatric unit. S2 confirmed the medical unit was not a locked unit, the patient rooms on the medical unit where psychiatric patients are assigned were not the same as on the psychiatric unit. Further S2 indicated psychiatric patients were placed in rooms with electric beds, plastic bags in waste receptacles, windows which open to the outside and electrical cords. S2 indicated at the present time, the psychiatric patients placed on the medicine unit were not participating in group therapy.

In a face to face interview on 01/20/12 at 2:15pm S3 Director of the Behavioral Unit indicated that when a patient with a primary diagnosis which is psychiatric is admitted to the medical unit he (S3) does not supervise his/her care nor does the staff of the behavioral unit participate in his/her care.

In a face to face interview on 01/23/12 at 11:00am RN S5 Charge Nurse of the Medicine Unit indicated she had previous psychiatric experience and had worked on the psych unit at the hospital before transferring to the medicine unit. Further S5 indicated no special precautions were taken when a psych patient was admitted on the Medicine Unit concerning preparation of the room and verified observation documentation was not performed on the medicine unit.

In a face to face interview on 01/23/12 at 12:05pm RN S7 Charge Nurse of the Medicine Unit indicated patients under a CEC are sometimes placed on the medicine unit depending on their medical condition. S7 indicated Patient #7 was not placed on 1:1 observation when she was admitted because no one was aware at the time of her admission that she (#7) had been CEC' d. Further S7 indicated it was not until Patient #7 had eloped that the CEC was discovered and when she (#7) returned to the hospital she (#7) was then placed on 1:1 observation.


Patient #4
Review of Patient #4's medical record revealed the patient was admitted to the hospital on 1/10/2012 under a Physician's Emergency Certificate dated 1/10/2012 for being "Gravely Disabled (non compliant with medications, behaving bizarrely, extremely paranoid . . . screaming and hollering in progress)". Patient #4's diagnoses included Schizoaffective Disorder- Bipolar Type. Further review revealed #4's Nursing "Narrative Notes" dated 1/11/12 (2012) at 1515 (3:15 p.m.) indicating, "Requires 1:1 monitoring". Patient #4 was placed on the Medical Unit of the hospital. Review of nursing notes revealed documentation and/or check marks indicating Patient #4 was assigned 1:1 staffing from 1/10/2012 through 1/15/2012. Review of the entire medical record revealed no documented evidence to indicate the name and discipline of the staff monitoring Patient #4 on a 1:1 basis. Review of the entire medical record revealed no documented evidence of 15 minute observations for Patient #4.

Review of the "Daily Staffing Schedule" for January 10th, 11th, 12th, and 13th of 2012 revealed the following staff were assigned 1:1 monitoring (Patient #4):
1/10/2012 morning shift Respiratory Therapist S20
1/10/2012 night shift Respiratory Therapist S22
1/11/2012 morning shift Respiratory Therapist S29
1/11/2012 night shift Respiratory Therapist S28
1/12/2012 morning shift Respiratory Therapist S20
1/12/2012 night shift Respiratory Therapist S29
1/13/2012 morning shift Housekeeper S18.

Review of the hospital job descriptions for Respiratory Therapist and Housekeeping revealed no documented evidence indicating the duty of 1:1 observations of psychiatric patients was a required duty for Respiratory and/or Housekeeping.

Review of the Personnel files for Respiratory Therapist S20, Respiratory Therapist S22, Respiratory Therapist S29, Respiratory Therapist S28, and Housekeeper S18 revealed no additional Job Descriptions outside of their discipline.

During a face to face interview on 1/23/2012 at 10:40 a.m., Respiratory Therapist S15 indicated he(S15) had been assigned to sit with 1:1 psychiatric patients housed on the medical floor. S15 indicated he (S15) had some training in Behavior Management as part of the hospital's annual training; however, he (S15) did not know what was required for different levels of observation of psychiatric patients or policy requirements regarding securing the environment for psychiatric patients to ensure safety. S15 further indicated he (S15) had never completed an observation flow sheet when assigned to 1:1 monitoring of psychiatric patients on the medical floor.

During a face to face interview on 1/23/2012 at 11:50 a.m., Housekeeper S18 indicated she (S18) been assigned at times to sit with 1:1 psychiatric patients housed on the medical floor. S18 indicated there had been no other Housekeeper assigned to sit with 1:1 patients and she (S18) did not know why she (S18) had been assigned the task. S18 indicated the 1:1 psychiatric patient rooms on the Medical Unit were fully equipped with call lights on cords and plastic bags in garbage cans. S18 indicated she (S18) knew she (S18) was to keep the patients from getting out of the room and hurting themselves. S18 indicated she (S18) did not know anything about different levels of observation and had never documented on the patients that she (S18) had sat with. S18 indicated she(S18) had known that psychiatric patients housed on the psych unit could not have plastic bags in their garbage cans and that the rooms were scarcely equipped; however, when psychiatric patients were housed on the medical unit there had been no alterations made to the rooms. S18 indicated she had no knowledge of any policies regarding procedures for ensuring the environment of psychiatric patients housed on the medical unit were safe.

During a face to face interview on 1/23/2012 at 12:20 p.m., Respiratory Director S20 indicated there had been some material reviewed about patient behavior with a post test at the hospital's skills fair; however, there had been no specific psychiatric training, no review of policies regarding observation levels or environmental safety for psychiatric patients, and many of the Respiratory Therapists that had been assigned to observing 1:1 psychiatric patients had voiced that they were uncomfortable with the assignment, some being afraid of the patients.

Observations on 1/20/2012 at 8:45 a.m. revealed Patient #4 to be located in a private room on the Medical Unit of the hospital. Further review revealed #4's room to have a call light attached to a cord at the patient's bedside, plastic bags in the garbage can, a window that could be opened completely- allowing an adult patient the ability to climb out of the room, and blinds covering the window with a pull cord attached.

During a face to face interview on 1/20/2012 at 8:45 a.m., Registered Nurse S16 confirmed the above findings. S16 indicated it had not been the practice for nursing staff on the Medical Unit to make any revisions to patient's room environment in response to housing psychiatric patients on the unit. S16 indicated the reason Patient #4 had been placed on the Medical Unit, instead of Psychiatry, was due to using CPAP (Continuous Positive Airway Pressure) at night (plugged into red emergency outlet in patient's room). S16 indicated she (S16) had no knowledge of any policy and/or procedure for altering the environment of Medical Rooms to ensure the safety of psychiatric patients being housed on the unit. S16 further indicated she (S16) had never made any alterations to a Medical Room when a Psychiatric Patient had been placed there. S16 further indicated she (S16) was not aware of different levels of observation for Psychiatric Patients. S16 indicated there had never been a physician's order on Patient #4 to indicate the Level of Observation for the Patient. S16 indicated the practice on the Medical Unit for housing psychiatric patients had been to place them on 1:1 when they were under a PEC (Physician's Emergency Certificate) or CEC (Coroner's Emergency Certificate) and then treating them as any other medical patient after the PEC or CEC was completed. S16 indicated there had never been observation levels ordered for psychiatric patients housed on the Medical Unit to include no order for 1:1 observation.

During a face to face interview on 1/23/2012 at 1500 (3:00 p.m.), Director of Nursing S2 indicated there had never been any environmental alterations made to the rooms for psychiatric patients housed on the Medical Unit nor had that been identified as a problem. S2 further indicated the hospital had psychiatric policies (Behavioral Health Policies) regarding Special Precautions, Observation Levels, and Environmental Safety on the Psychiatric Unit of the hospital; however, there was no policy in regards to ensuring safety of psychiatric patients being housed on the medical unit.

Review of the hospital policy titled, "Behavioral Health: Special Precautions, BH-037" presented by the hospital as current revealed in part, "It is the policy of the Psychiatric Service that staff monitoring is instituted to prevent patients from harming themselves or others. Indications of suicidal intent, a desire to elope, or increasing agitation will be immediately evaluated by the staff member who becomes aware of them. In order to provide protection to psychiatric patients, two levels of staff monitoring are provided: Routine Precautions (monitoring every 15 minutes). Special Precautions (monitoring on a constant basis). A written physician's order is obtained for Special Precautions. . . The physician's order shall include the level of the monitoring (watch, close, constant) and the reason of the monitoring (suicidal risk, agitation, elopement risks). . . A physician order is necessary to discontinue or lower the level of staff monitoring. . . Routine Precautions: Consists of fifteen (15) minute checks by a staff member. The patient is placed under staff observation every fifteen minutes. . . The patient's behavior is documented every fifteen minutes on the monitoring log. The staff observation will be continued until discontinued by the Physician. Special Precautions: Consist of one to one staff contact with a patient. The Physician and treatment team determine the specific emergency needs of the patient. . ."

Review of the hospital policy titled, "Behavioral Health: Sharps, BH-036" presented by the hospital as current revealed in part, "Certain items which may be necessary for patient care or personal hygiene, may pose a danger to aggressive or confused patients. For patient safety these items will be identified as "Sharps" and will be kept by program staff except when in use and under direct staff supervision. These items include, but are not limited to : Safety razors, Glass container, Aerosol cans, Wire coat hangers, Solutions or creams that have potentially poisonous or harmful ingredients, Scissors, Metal nail files, Corded electric appliances, Plastic bags, Cleaning solutions, Matches and lighters.

20638

Based on record review and interview the hospital failed to ensure a Registered Nurse supervised and evaluated the care of each patient as evidenced by:
1) failure to ensure a full admission assessment was initiated within 2 hours of admission and completed within 24 hours after admission for 2 of 9 sampled patients (#1, #9).
2) failure to ensure a Registered Nurse assess a patient post ingestion of un-ordered home medications while on the Medical Unit of the hospital to determine if the patient was suicidal, abusing substances, or experiencing pain for 1 of 1 patients with ingestion of home medications while admitted to the hospital out of a total sample of 9 (#9).
3) failure to ensure a psychological assessment was performed on admit for a patient admitted under a CEC (coroner's emergency certificate) for delusional, paranoid and threatening behavior for 1 of 1 psychiatric patients admitted to the medical unit (#7) out of a total sample of 9 patients.
4) failing to reassess skin on each shift and daily for 1 of 9 sampled patients (#1).
5) failure to supervise the care of each patient to ensure skin protection protocol was being implemented by mental health technicians for 1 of 9 sampled patients (#1).
Findings:


1)
Patient #1:
Patient #1 was admitted to the Psychiatric Unit on 1/12/12 from a local nursing home, where she resides. Record review of the Transfer Summary from nursing home to hospital revealed patient #1 had an intact integumental system without excoriation. Under Nursing Care Status, patient was receiving health rehab services for MI/MR (Mental illness/Mental retardation) and was receiving preventative skin care. Under Problem, the potential for impaired skin integrity related to poor circulation and fragile skin was identified.

Record review of Nurses Progress Notes revealed initial assessment documented by S10 RN on 1/12/12 and timed 1800 did not include a skin assessment or preventive care to both feet due to patient's immobility, "poor circulation, and fragile skin."

During a face to face interview on 1/20/2012 at 0835 (8:35 a.m.) Registered Nurse S10 indicated full body assessments are done on all patients upon admission. There was no documentation that a full body assessment was done on patient #1.

Patient #9:
Review of Patient #9's (55 year old female) medical record revealed the patient was admitted to the hospital on 12/20/2011 with diagnoses that included Cellulitis Left Lower Extremity, Congestive Heart Failure, Atrial Fibrillation, Hemorrhagic Bullous Dermatitis, Rule out vasculitis, Rule out drug eruption, and Implantable cardioverter defibrillator placed in 2007.

Review of Patient #9's Nursing Admission Assessment dated 12/20/2011 at 1635 (4:35 p.m.) revealed in part, "Behavioral Disorders, mental, drug, ETOH (alcohol), S (Self)." Further review revealed no documented evidence as to whether the patient had a Mental Illness, Drug Abuse/Addiction, or Alcohol Abuse/Addiction.

During a face to face interview on 1/23/2011 at 12:00 p.m., Registered Nurse S7 indicated Patient #9 had a check mark on the Admission Assessment that indicated the Patient had a Behavioral Disorder which could have been mental, drug, or alcohol. S7 further indicated there should have been a narrative note indicating what the Behavioral Disorder was.

2) Review of Patient #9's (55 year old female) medical record revealed the patient was admitted to the hospital on 12/20/2011 with diagnoses that included Cellulitis Left Lower Extremity, Congestive Heart Failure, Atrial Fibrillation, Hemorrhagic Bullous Dermatitis, Rule out vasculitis, Rule out drug eruption, and Implantable cardioverter defibrillator placed in 2007.

Further review of Patient #9's medical record revealed the following:
12/22/11 (2011) a.m. (no documented time) OT (Occupational Therapy) pt (patient) lethargic this am (morning), having difficult(y) staying awake.
12/22/11 1430 (2:30 p.m.), Physician Progress Notes: pt. lethargic, can not stay awake to converse.
12/23/11 0000 (12 midnight): Narrative Notes (Nursing), Patient appears lethargic. Opens eyes to sound but immediately closes them back. will continue to monitor.
12/23/11 0100 (1:00 a.m.): Narrative Notes (Nursing), (Nurse Practitioner S6) informed of patient's non-compliance and drowsiness. due to the lethargicness (as written) of the patient, she requested we search patient's room for non-prescribed medications. numerous pills found in small bag. Also boxcutter and other items found. Items listed on belongings sheet and placed in lockbox.
12/23/11 (no documented time): Patient Valuable List: 8 1/2 pills identified as Skelaxin, 10 yellow pills -Tessalon, 10 whole pills identified as Lortab, 13 half white pills identified as Lortab, 1 white pill, 11 whole white pills identified as Ativan, 11 while off white pills identified as Ativan, 1 box cutter, 1 unidentified ivory piece, 1 unidentified plastic piece with resin inside, 2 bottles Nitrostat, 1 prescription bottle of Prednisone with 9 pills inside.
12/23/11 0100 (1:00 a.m.), Physician Progress Notes: Nurse reported (not) being able to wake pt. up. Responds to sternal rub only. Nothing given to pt. to make her this way. Knowing she would have to have taken something to put her in this state, we started looking around in room. Found sandwich baggie 1/2 full of different sizes and colored pills. Recognize most as Lortab and Ativan. . . Pt. being monitored very closely in case may need to push Narcan or code her. Also found were razor blade, box cutter, palm size stone, along (with) other items, also some unknown objects. the whole process was (with) nurse, charge nurse, and myself present (at) all times. I stayed on extra hour just to make sure pt. was going to revive. "
12/23/11 a.m. (no documented time) OT: pt. still lethargic. .
12/23/11 0620 (6:20 a.m.), Narrative Notes (Nursing): pt. is confused and thinks that bugs are crawling on the floor. . .
12/23/2011 1130 (11:30 a.m.), Narrative Notes (Nursing): spoke with (Nurse Practitioner S6) question was raised as to if pt (patient) would have 1:1 supervision. (S6) felt that pt. was remorseful and more compliant (with) POC (Plan of Care). She felt she no longer would require 1:1. (S6) had lengthy conversation (with) pt (patient) and husband regarding taking non-prescribed medication. Pt. thanked (S6) for 'saving her life.' Nurse noted to station herself outside of room in hall desk to keep an eye on pt."
12/23/11 1130 (11:30 a.m.), Physician Progress Notes: pt. remains 1:1, pt presents much better this a.m. (morning) color coming back, pt. moving around (and) responsive now. Explained what happened as she was upset to find her pills missing. I explained what happened (and) she said she understood and would have done the same thing. Thanks me for saving her life and caring."
(Review of Patient #9's entire medical record revealed no documented evidence of a physician's order for 1:1 observation or any other level of observation).
12/23/2011 6:30 p.m., Physician's orders: Psych Consult. . . (Review of Patient #9's entire medical record revealed no documented evidence of a Psychiatric Consult)
12/23/2011 9:05 ordered, 12/23/2011 1901 (7:01 p.m.) reported: Lab: Opiates: Positive.
12/25/2011 2030 (8:30 p.m.) Physician's orders: Nitro 0.4 SL (sublingual) x1 now.
12/25/2011 2030 Narrative Notes (Nursing): NitroStat 0.4 SL x1 now. Med given.
12/26/2011 0045 (12:45 a.m.). Narrative Notes (Nursing). Speech very slurred. within seconds, pt. went unresponsive and dilated to 5 mm (millimeters).
12/26/2011 0050 (12:50 a.m.): Narrative Notes (Nursing) (Local Ambulance Arrived)
12/26/2011 0100 (1:00 a.m.): Narrative Notes (Nursing) Narcan given x1
12/26/2011 0110 (1:10 a.m.) Narrative Notes (Nursing) left building via (Ambulance)
12/26/2011 0430 (4:30 a.m.) Narrative Notes (Nursing) called by charge nurse to inform me that husband returned to hospital for patient belongings. He was very irate and yelling 'Ya'll killed her'. Husband took every thing from room including trash in trash can."

During a face to face interview on 1/23/2012 at 11:00 a.m., Nurse Practitioner S6 indicated she had been present on the night Patient #9 had been discovered as unresponsive (12/23/2011 at 1:00 a.m.). S6 indicated the room had been searched and a bag full of pills had been discovered along with what appeared to be a pipe with brown colored resin present. S6 indicated she did not know what a crack pipe or crack looked like but the item found could have been something used for illicit drugs. S6 indicated she stayed with Patient #9 for several hours to ensure there was no need to push Narcan. S6 indicated the following morning Patient #9 and her husband were both very disturbed that the bag of medications had been taken from her. S6 indicated nursing staff had informed her that Patient #9 would never go to the bathroom without her purse present and would ask the staff to leave her alone for privacy while in the bathroom. S6 indicated she had thought the patient's remorse the following day (day after discovered ingestion of non-prescribed medications) meant the problem was resolved. S6 further indicated Patient #9 had told her that she liked to take Nitro-glycerine tablets because it dilated her vessels and made other medications work better and she felt "real good" when she took Nitro-glycerine with other medications. S6 indicated Patient #9 had been educated on the proper use of Nitro-glycerine.

Review of Patient #9's entire medical record revealed no documented evidence of a nursing assessment post ingestion of un-prescribed medications on 12/23/11 discovered at 0100 (1:00 a.m.) for Suicidal Ideation/Risk, Substance Abuse/Addiction/Withdrawal, or Pain Management Problems.

The following staff who were involved in the care of Patient #9 were interviewed:
Registered Nurse S16 on 1/20/2012 at 11:00 a.m.
Director of Nursing S2 on 1/20/2012 at 1:00 p.m.
Registered Nurse S5 on 1/23/2012 at 10:40 a.m.
Licensed Practical Nurse S19 on 1/23/2012 at 11:50 a.m.
S2, S5, S16, and S19 all confirmed there had never been a Suicidal Risk Assessment, Substance Abuse Risk Assessment, or Pain Assessment of Patient #9 post ingestion of un-subscribed medications on 12/23/2011 at 1:00 a.m. that resulted in the patient being unresponsive except to sternal rub.

Review of the hospital policy titled, "Nursing Documentation Guidelines, II-A.1.02" presented by the hospital as current revealed in part, "Initial head to toe nursing assessment is initiated within 2 hours of admission and completed within 24 hours after admission. Problems listed on the plan of care shall be referred to in the daily nursing documentation as needed. Changes in the patient status will result in a head to toe reassessment. the reassessment is to be documented in patient's daily record and communicated to the physician and other disciplines involved in the patient's care. . ."

3) Review of the medical record for Patient #7 revealed a 44 year old female admitted on 12/21/11 under a Coroner's Emergency Certificate (CEC) for delusional, paranoid and threatening behavior. Review of the Admission Assessment dated/timed 12/21/11 at 1815 (6:15pm) revealed no documented evidence a psychological assessment was performed on Patient #7.

In a face to face interview on 01/20/12 at 2:00pm RN S2 Director of Nursing indicated the hospital recently started admitting patients with a primary psychiatric diagnosis to the medical unit and not all of the nursing staff had experience in the care of the psychiatric patient. Further she indicated, because this practice is new, Patient #7 was assessed using a medical nursing admission assessment and not a psychiatric assessment.

In a face to face interview on 01/20/12 at 2:15pm S3 Director of the Behavioral Unit indicated that when a patient with a primary diagnosis which is psychiatric is admitted to the medical unit he (S3) does not supervise his/her care nor does the staff of the behavioral unit participate in his/her care. Further S3 verified all patients with who are admitted to the hospital under a PEC or CEC should have a psychiatric assessment performed.


4 and 5)
On 1/20/12, S10 RN signed the Nurses Progress Notes at 0830 indicating the time she assessed patient #1. In the Time space, S10 documented as an addendum: "Noted: Bruising to top of right thigh, top of left hand wrist, and right top of hand. Scabbed area inner left thigh."

On 1/23/12, in a face-to-face interview with S3 Unit Director of Psychiatric Unit at 2:10 p.m., he stated that if nurse's find bruises on a patient's body, they are to notify the physician and document in the nurses's progress notes. When shown the addendum from S10 RN dated 1/20/12 and timed at 0830, S3 stated that the nurse's had found these bruises prior to 1/20/12. S3 was unable to find documentation that the nurses' had found these bruises prior to 1/20/12 because the nurses had not conducted a skin assessment. S3 confirmed he did not receive an incident report regarding these bruises of unknown origin from any of the staff on the Psychiatric Unit and he did not investigate as to the causes of the bruising.

Patient #1 was admitted to the Psychiatric Unit on 1/12/12 from a local nursing home, where she resides. She had previously been on the Medical Unit for wound treatment of a stage IV wound of the right ankle. The wound had been debrided by the Wound Care physician on two separate occasions (8/29/11 and 9/1/11).

Record review of the Transfer Summary from nursing home to hospital revealed patient #1 had an intact integumental system without excoriation. Under Nursing Care Status, patient was receiving health rehab services for MI/MR (Mental illness/Mental retardation) and was receiving preventative skin care. Under Problem, the potential for impaired skin integrity related to poor circulation and fragile skin was identified.

Record review of hospital's History and Physical dated 1/12/12 revealed patient #1 had "no movement of lower legs noted" (pg 3 of 4).

Record review of Nurses Progress Notes revealed initial assessment documented by S10 RN on 1/12/12 and timed 1800 did not include a skin assessment or preventive care to both feet due to patient's immobility, "poor circulation, and fragile skin." Documentation in Nurses Progress Notes over a 24 hour period on 1/13/12, 1/14/12, 1/15/12, 1/16/12, 1/17/12, and 1/18/12 revealed no skin preventive care being provided.

On 1/19/12 at 11:20 a.m. in a face to face interview, S9 RN denied that patient #1 had any pressure sores. S9 RN was asked by the surveyor to conduct a skin assessment of patient #1's feet. Observation of patient #1's right heel revealed reddened areas on each side of the heel approximately the size of a dime. Patient #1's left heel revealed a dime-sized reddened area on the lateral side of the heel. S9 RN staged these three areas as Stage I pressure sores. Patient's edematous feet, which were covered with socks, had a depressed area around the top of the sock. S9 RN instructed S26 MHT to use a pillow under the patient's legs to prevent the feet from laying on the bed. S26 MHT placed a pillow under the patient's legs.

On 1/20/12 at 8:35 a.m., an observation revealed patient #1 with socks on and feet lying on the bed un-propped. Record review of the Daily Nursing Assessment documentation dated 1/19/12 revealed under Skin integrity, color: a check was marked next to WNL (within normal limits)" for both the 7a-7p and 7p-7a shift.

Also during this time, on 1/20/12, in a face to face interview with S10 RN, she stated that full body assessments are done on patients upon admission. If MHTs see problems with the patient's skin during bathing, they are to report this information to the nurse. When MHTs report changes to the patient's skin, the nurses go and reassess. S10 RN stated that changes to the patient's condition or treatment changes are placed on the Daily Record, which is the hospital's form of shift change report, or "hand-off" report. S10 RN stated she did not receive any report that patient #1 had any skin integrity conditions, nor preventive care was being done by propping the feet up with a pillow. S10 RN was asked by the surveyor to complete a skin assessment of patient #1's feet. Patient #1's right heel was reddened across the lower part of the heel; patient's left heel had no signs of redness.

On 1/23/12 at 10:15 a.m. patient #1 was observed lying asleep on her left side. She had pink heel protectors on her feet. In a face-to-face interview with S9 RN, she confirmed she had not documented the appearance of patient #1's heels on the daily nursing assessment sheet dated 1/19/12 because the assessment sheet did not have a place to document pressure sores. She also confirmed that she had not documented the assessment of patient #1's reddened heels on 1/19/12 after assessing her heels with surveyor, nor did she add it to the Hand-off communication form.

Record review of policy titled "Skin Care Protocol" reviewed on 11/09 (pg 1 of 4), under Policy, "All patients have an integumentary assessment completed upon admission and daily for their risk of developing skin breakdown according to overall physical condition, mental status, activity level, mobility level, nutrition/fluid intake and incontinence status." Under Procedure: "Braden Scale is completed at time of admission and daily. Each patient is assessed on the Braden Scale provided on the nursing admission assessment and daily nursing flowsheet."

Record review of the Position Description/Performance Evaluation for the job title of Registered Nurse, (pg 1 of 3) under Duties and Responsibilities: Demonstrates Competency in the Following Area: "Ability to perform a head-to-toe assessment on all patients and reassessments as per policy. This includes: pediatric, geriatric and the general patient population."

Record review of Policy titled "Pressure Ulcer Prevention" effective date 4/09, (pg 3 of 4) under Further description of a Stage I: "The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I...may indicate "at risk" persons ( a heralding sign of risk)."

Record review of Policy titled "Skin Tear Dressing and Stage I Pressure Ulcer Treatment Protocol" effective date 04/09 under Pressure Ulcer Treatment--Stage I; Treatment A: Redness due to Pressure: (1) Position patient off affected area. (4) Remove cause of pressure."

The hospital failed to honor patient #1's right to receive medically appropriate care given by competent personnel when the nursing personnel failed to follow the hospital's skin care protocol.




26313

Based on record review and interview the hospital failed to:
1) ensure nursing staff developed and/or revised the nursing care plan for each patient to include all problems and/or significant changes in a patient's condition for 4 of 9 sampled patients ( #1, #5, #7, #9).
2) implement the plan of care by failing to follow hospital policy regarding weighing of patients for 2 of 9 sampled patients (#3, #5). Findings:

1)
Patient #1:
Record review of patient #1's record revealed she was admitted to the Psychiatric Unit on 1/12/12 from a local nursing home, where she resides. Record review of hospital's History and Physical dated 1/12/12 revealed patient #1 had "no movement of lower legs noted" (pg 3 of 4).

Record review of Nurses Progress Notes revealed initial assessment documented by RN S10 on 1/12/12 and timed 1800 did not include a skin assessment or preventive care to both feet due to patient's immobility, "poor circulation, and fragile skin." Documentation in Nurses Progress Notes over a 24 hour period on 1/13/12, 1/14/12, 1/15/12, 1/16/12, 1/17/12, and 1/18/12 revealed no skin preventive care being provided.

On 1/19/12 at 11:20 a.m. in a face to face interview, RN S9 denied that patient #1 had any pressure sores. S9 was asked by the surveyor to conduct a skin assessment of patient #1's feet. Observation of patient #1's right heel revealed reddened areas on each side of the heel approximately the size of a dime. Patient #1's left heel revealed a dime-sized reddened area on the lateral side of the heel. S9 staged these three areas as Stage I pressure sores. Patient's edematous feet, which were covered with socks, had a depressed area around the top of the sock. S9 instructed MHT S26 to use a pillow under the patient's legs to prevent the feet from laying on the bed. S26 placed a pillow under the patient's legs, which elevated the feet off the bed.

On 1/20/12 at 8:35 a.m., an observation revealed patient #1 with socks on and feet lying on the bed unpropped.
Also during this time, on 1/20/12, at 0835 (8:35 a.m.) in a face to face interview with RN S10, she stated that full body assessments are done on patients upon admission. S10 stated that changes to the patient's condition or treatment changes are placed on the Daily Record, which is the hospital's form of shift change report, or "hand-off" report. S10 stated she did not receive any report that patient #1 had any skin integrity conditions, nor preventive care was being done by propping the feet up with a pillow. S10 was asked by the surveyor to complete a skin assessment of patient #1's feet. Patient #1's right heel was reddened across the lower part of the heel; patient's left heel had no signs of redness.

Record review of the Multidisciplinary Treatment Plan revealed skin protection protocol was not added to protect and prevent injuries to patient #1's skin. There was no documented evidence that the nursing staff included the skin care protocol in the plan of care and no documented evidence that interventions were being done consistently to prevent skin breakdown.

Patient #5:
Review of Patient #5's medical record revealed the patient was admitted to the hospital on 1/05/2012 with diagnoses that included Schizoaffective Disorder-Bipolar Type. Further review revealed Patient #5 had been engaged in Self Mutilation by "Scratching herself".

Review of Patient #5's entire Treatment Plan of Care revealed no documented evidence that the problem of Self Mutilation/Scratching herself had been identified. Further there was no documented evidence of Goals and/or Interventions for Self Mutilation/Scratching herself.

This finding was confirmed by Director of Nursing S2 in a face to face interview on 1/20/2012 at 1300.

Patient #7
Review of the medical record for Patient #7 revealed a 44 year old female admitted via CEC (Coroner ' s Emergency Certificate) for delusional, paranoid and threatening behavior on 12/21/11. Further review revealed Patient #7 had a history of ESRD (end stage renal disease), infected AV Shunt, and HTN (hypertension). Review of the History & Physical dated 12/21/11 revealed Patient #7 was transferred from Hospital " a " where she had left AMA (against medical advise) twice and was being transferred to long term acute care for intravenous antibiotic therapy, wound care, dialysis and psych treatment.

Review of the Interdisciplinary Plan of Care for Patient #7 revealed ... .... " 12/21/11 6. Altered Pain and Comfort " ( no documented evidence goals were established or interventions implemented); " 12/26/11 9. Fluid Volume Excess - Goals: Intake and Output (I&O) will be balanced and stable daily weight; Interventions: Weigh daily, access for edema, assess lung sounds, I&O, administer medications, monitor response and dialysis; Goal Met on 01/02/12. 13. High Risk for infection - Goal: Patient will be free from infection as evidenced by afebrile, normal WBC, inflammations, etc.; Interventions: vital signs as ordered and prn (as needed), observe and note condition of ______ (left blank) site q (every) shift, universal precautions, maintain aseptic technique in all procedures, proper handwashing, assess dressings, including IV sites for signs of infection, and administer antibiotics as ordered. Reviewed: 12/26/11. 01/06/12 and Goal Met: no documented evidence this was assessed at the time the patient left the hospital " .

Further review of the Plan of Care revealed no documented evidence Patient #7's threatening, violent behavior or non-compliance to treatment were addressed on admit or that the plan was updated after her (#7's) elopement from the hospital on 12/26/11.

Review of the Interdisciplinary Team Conference Assessment form dated 12/20/11, 01/06/12 and 01/12/12 revealed no documented evidence Patient #7's psychiatric problems were addressed.

Patient #9:
Review of Patient #9's (55 year old female) medical record revealed the patient was admitted to the hospital on 12/20/2011 with diagnoses that included Cellulitis Left Lower Extremity, Congestive Heart Failure, Atrial Fibrillation, Hemorrhagic Bullous Dermatitis, Rule out vasculitis, Rule out drug eruption, and Implantable cardioverter defibrillator placed in 2007.

Further review of Patient #9's medical record revealed the following:
12/22/11 (2011) a.m. (no documented time) OT (Occupational Therapy) pt (patient) lethargic this am (morning), having difficult(y) staying awake.
12/22/11 1430 (2:30 p.m.), Physician Progress Notes: pt. lethargic, can not stay awake to converse.
12/23/11 0000 (12 midnight): Narrative Notes (Nursing), Patient appears lethargic. Opens eyes to sound but immediately closes them back. will continue to monitor.
12/23/11 0100 (1:00 a.m.): Narrative Notes (Nursing), (Nurse Practitioner S6) informed of patient's non-compliance and drowsiness. due to the lethargicness (as written) of the patient, she requested we search patient's room for non-prescribed medications. numerous pills found in small bag. Also boxcutter and other items found. Items listed on belongings sheet and placed in lockbox.
12/23/11 (no documented time): Patient Valuable List: 8 1/2 pills identified as Skelaxin, 10 yellow pills -Tessalon, 10 whole pills identified as Lortab, 13 half white pills identified as Lortab, 1 white pill, 11 whole white pills identified as Ativan, 11 while off white pills identified as Ativan, 1 box cutter, 1 unidentified ivory piece, 1 unidentified plastic piece with resin inside, 2 bottles Nitrostat, 1 prescription bottle of Prednisone with 9 pills inside.
12/23/11 0100 (1:00 a.m.), Physician Progress Notes: Nurse reported (not) being able to wake pt. up. Responds to sternal rub only. Nothing given to pt. to make her this way. Knowing she would have to have taken something to put her in this state, we started looking around in room. Found sandwich baggie 1/2 full of different sizes and colored pills. Recognize most as Lortab and Ativan. . . Pt. being monitored very closely in case may need to push Narcan or code her. Also found were razor blade, box cutter, palm size stone, along (with) other items, also some unknown objects. the whole process was (with) nurse, charge nurse, and myself present (at) all times. I stayed on extra hour just to make sure pt. was going to revive. "
12/23/11 a.m. (no documented time) OT: pt. still lethargic. .
12/23/11 0620 (6:20 a.m.), Narrative Notes (Nursing): pt. is confused and thinks that bugs are crawling on the floor. . .
12/23/2011 1130 (11:30 a.m.), Narrative Notes (Nursing): spoke with (Nurse Practitioner S6) question was raised as to if pt (patient) would have 1:1 supervision. (S6) felt that pt. was remorseful and more compliant (with) POC (Plan of Care). She felt she no longer would require 1:1. (S6) had lengthy conversation (with) pt (patient) and husband regarding taking non-prescribed medication. Pt. thanked (S6) for 'saving her life.' Nurse noted to station herself outside of room in hall desk to keep an eye on pt."
12/23/11 1130 (11:30 a.m.), Physician Progress Notes: pt. remains 1:1, pt presents much better this a.m. (morning) color coming back, pt. moving around (and) responsive now. Explained what happened as she was upset to find her pills missing. I explained what happened (and) she said she understood and would have done the same thing. Thanks me for saving her life and caring."
(Review of Patient #9's entire medical record revealed no documented evidence of a physician's order for 1:1 observation or any other level of observation).
12/23/2011 6:30 p.m., Physician's orders: Psych Consult. . . (Review of Patient #9's entire medical record revealed no documented evidence of a Psychiatric Consult)
12/23/2011 9:05 ordered, 12/23/2011 1901 (7:01 p.m.) reported: Lab: Opiates: Positive.
12/25/2011 2030 (8:30 p.m.) Physician's orders: Nitro 0.4 SL (sublingual) x1 now.
12/25/2011 2030 Narrative Notes (Nursing): NitroStat 0.4 SL x1 now. Med given.
12/26/2011 0045 (12:45 a.m.). Narrative Notes (Nursing). Speech very slurred. within seconds, pt. went unresponsive and dilated to 5 mm (millimeters).
12/26/2011 0050 (12:50 a.m.): Narrative Notes (Nursing) (Local Ambulance Arrived)
12/26/2011 0100 (1:00 a.m.): Narrative Notes (Nursing) Narcan given x1
12/26/2011 0110 (1:10 a.m.) Narrative Notes (Nursing) left building via (Ambulance)
12/26/2011 0430 (4:30 a.m.) Narrative Notes (Nursing) called by charge nurse to inform me that husband returned to hospital for patient belongings. He was very irate and yelling 'Ya'll killed her'. Husband took every thing from room including trash in trash can."

Review of Patient #9's Plan of Care to include Nursing Diagnosis, Goals, and Interventions revealed the plan was created on 12/20/2011. Further review revealed no documented evidence of updating the plan of care for Patient #9 to ensure safety of the patient post ingestion of un-prescribed medications discovered on 12/23/2011 at 1:00 a.m. that resulted in the patient being responsive only to sternal rub.

During a face to face interview on 1/23/2012 at 11:00 a.m., Nurse Practitioner S6 indicated she had been present on the night Patient #9 had been discovered as unresponsive (12/23/2011 at 1:00 a.m.). S6 indicated the room had been searched and a bag full of pills had been discovered along with what appeared to be a pipe with brown colored resin present. S6 indicated she did not know what a crack pipe or crack looked like but the item found could have been something used for illicit drugs. S6 indicated she stayed with Patient #9 for several hours to ensure there was no need to push Narcan. S6 indicated the following morning Patient #9 and her husband were both very disturbed that the bag of medications had been taken from her. S6 indicated nursing staff had informed her that Patient #9 would never go to the bathroom without her purse present and would ask the staff to leave her alone for privacy while in the bathroom. S6 indicated she had thought the patient's remorse the following day (day after discovered ingestion of non-prescribed medications) meant the problem was resolved. S6 further indicated Patient #9 had told her that she liked to take Nitro-glycerine tablets because it dilated her vessels and made other medications work better and she felt "real good" when she took Nitro-glycerine with other medications. S6 indicated Patient #9 had been educated on the proper use of Nitro-glycerine.

Review of Patient #9's entire medical record revealed no documented evidence of updating/revising Patient #9's Plan of Care; post ingestion of un-prescribed medications on 12/23/11 discovered at 0100 (1:00 a.m.), to ensure the safety of Patient #9.

The following staff who were involved in the care of Patient #9 were interviewed:
Registered Nurse S16 on 1/20/2012 at 11:00 a.m.
Director of Nursing S2 on 1/20/2012 at 1:00 p.m.
Registered Nurse S5 on 1/23/2012 at 10:40 a.m.
Licensed Practical Nurse S19 on 1/23/2012 at 11:50 a.m.
S2, S5, S16, and S19 all confirmed there had never been a revision of Patient #9's Plan of Care post ingestion of Un-prescribed medications that resulted in being unresponsive other than to sternal rub on 12/23/2011.

Review of the hospital policy titled, "Patient Care Standards, II-C.3.00" presented by the hospital as current revealed in part, "Planning: An individual patient care plan will be developed within eight hours of admission. The patient care plan will be reviewed q (every) wee and updated as patient need arises. . ."

Review of the hospital policy titled, "Individual Plan of Care, II-A01.01" presented by the hospital as current revealed in part, "All patients will have an individualized plan of care that is individually tailored, integrated and coordinated by competent professionals through licensure, training, and experience. Each individualized treatment plan is developed through the initial evaluation and team conference process in coordination with the attending physician and treatment team. The individual treatment plan includes the following information presently behavioral: The individual's functional limitations and presenting need. The patient's stated goals. The type of treatment and/or services to be provided, and revised when appropriate. measurable goals with the anticipated time frames of accomplishing these goals. Objective measures to be used to assess progress and goal attainment. Assessment of integration of the individual into the community, including accessing communities' resources. Any barrier to learning or treatment. Patient skill and support requirements for living, learning, and working with optimal independence and choice. Identifies activities services and interventions the pt. will use to teach rehabilitation goals. . ."

2)
Review of the hospital policy titled, "Patient Weights, II-A.1.08" revealed in part, "Patients will be weighed on admission and weekly or following physician's orders by the attending nurse and/or certified nurse assistant . . .

Patient #3
Review of the medical record for Patient #3 revealed a 68 year old female admitted to the hospital on 12/22/11 for malnutrition and weakness. Further review revealed Patient #3 had a history of hypertension, anxiety, anemia, hypokalemia and smoking. Review of the Physician's Admit Orders dated/timed 12/22/11 at 2100 (9:00pm) revealed an order for Patient #3 to be weighed on admit and then weekly.

Review of the Patient Weight Log for Patient #3 revealed the following:
12/22/11 60.6 (pounds or kilograms not documented)
12/26/11 86.6 (pounds or kilograms not documented)
01/02/12 88.4 (pounds or kilograms not documented)
Further review revealed no documented evidence Patient #3 had been weighed again. She was discharged 01/13/12.

Patient #5:
Review of Patient #5's medical record revealed the patient was admitted to the hospital on 1/05/2012 with diagnoses that included Schizoaffective Disorder-Bipolar Type. Further review revealed Patient #5's Weight Log to indicate Frequency "Weekly". Documentation on the Weight Log for Patient #5 revealed a weight of 250 (pounds) on 1/05/2012. Patient #5 remained in the hospital at the time of the survey. Patient #5's medical record was reviewed on 1/19/2012. This review revealed no documented evidence of weekly weights post the initial weight recorded on 1/05/2012 (14 days post admission date).

During a face to face interview on 1/20/2012 at 9:05 a.m., Registered Nurse S14 indicated patients in the hospital should be weighed a minimum of one time per week and the weights should be documented in the medical record in order to monitor weight maintenance, loss, or gain. S14 further indicated there was no indication in the medical record for Patient #5 that any weights had been obtained after the initial admission weight.





20638










26313

Based on record review and interview the hospital failed to ensure patient care assignments for 1 to 1 nursing observations were made in accordance with employee's job descriptions and/or level of competence as evidenced by the assigning of Respiratory Therapists, CNAs (certified nursing assistants) from the medical unit and Housekeeping to sit with 1:1 psychiatric patients housed on the hospital's medical unit for 2 of 2 psychiatric patients housed on the Medical Unit reviewed for assignments of care (#4, #7) out of a total sample of 9 patients. Findings:

Review of Patient #4's medical record revealed the patient was admitted to the hospital on 1/10/2012 under a Physician's Emergency Certificate for being "Gravely Disabled (non compliant with medications, behaving bizarrely, extremely paranoid . . . screaming and hollering in progress)". Further review revealed #4's Nursing "Narrative Notes" dated 1/11/12 (2012) at 1515 (3:15 p.m.) indicating, "Requires 1:1 monitoring". Patient #4 was placed on the Medical Unit of the hospital.

Review of the "Daily Staffing Schedule" for January 10th, 11th, 12th, and 13th of 2012 revealed the following staff were assigned 1:1 monitoring (Patient #4):
1/10/2012 morning shift Respiratory Therapist S20
1/10/2012 night shift Respiratory Therapist S22
1/11/2012 morning shift Respiratory Therapist S29
1/11/2012 night shift Respiratory Therapist S28
1/12/2012 morning shift Respiratory Therapist S20
1/12/2012 night shift Respiratory Therapist S29
1/13/2012 morning shift Housekeeper S18.

Patient #7
Review of the medical record for Patient #7 revealed a 44 year old female admitted on 12/21/11 under a Coroner's Emergency Certificate (CEC) for delusional, paranoid and threatening behavior. Review of the Nurse's Narrative Notes dated 12/26/11 at 2140 (9:40pm) revealed Patient #7 was placed on 1:1 observation due to a successful elopement.

Review of the "Daily Staffing Schedule" for the Medical Unit for 12/26/11, 12/27/11, 12/28/11and 12/29/11 revealed the following staff were assigned 1:1 monitoring of Patient #7:
12/28/11 morning shift- Housekeeper S18
12/29/11 morning shift- Housekeeper S18

Review of the hospital job descriptions for Respiratory Therapist and Housekeeping revealed no documented evidence indicating the duty of 1:1 observations of psychiatric patients was a required duty for Respiratory and/or Housekeeping.

Review of the Personnel files for Respiratory Therapist S20, Respiratory Therapist S22, Respiratory Therapist S29, Respiratory Therapist S28, and Housekeeper S18 revealed no additional Job Descriptions outside of their discipline.

During a face to face interview on 1/23/2012 at 10:40 a.m., Respiratory Therapist S15 indicated he(S15) had been assigned to sit with 1:1 psychiatric patients housed on the medical floor. S15 indicated he (S15) had some training in Behavior Management as part of the hospital's annual training; however, he (S15) did not know what was required for different levels of observation of psychiatric patients or policy requirements regarding securing the environment for psychiatric patients to ensure safety. S15 further indicated he (S15) had never completed an observation flow sheet when assigned to 1:1 monitoring of psychiatric patients on the medical floor.

During a face to face interview on 1/23/2012 at 11:50 a.m., Housekeeper S18 indicated she (S18) been assigned at times to sit with 1:1 psychiatric patients housed on the medical floor. S18 indicated there had been no other Housekeeper assigned to sit with 1:1 patients and she (S18) did not know why she (S18) had been assigned the task. S18 indicated the 1:1 psychiatric patient rooms on the Medical Unit were fully equipped with call lights on cords and plastic bags in garbage cans. S18 indicated she (S18) knew she (S18) was to keep the patients from getting out of the room and hurting themselves. S18 indicated she (S18) did not know anything about different levels of observation and had never documented on the patients that she (S18) had sat with. S18 indicated she(S18) had known that psychiatric patients housed on the psych unit could not have plastic bags in their garbage cans and that the rooms were scarcely equipped; however, when psychiatric patients were housed on the medical unit there had been no alterations made to the rooms. S18 indicated she had no knowledge of any policies regarding procedures for ensuring the environment of psychiatric patients housed on the medical unit were safe.

During a face to face interview on 1/23/2012 at 12:20 p.m., Respiratory Director S20 indicated there had been some material reviewed about patient behavior with a post test at the hospital's skills fair; however, there had been no specific psychiatric training, no review of policies regarding observation levels or environmental safety for psychiatric patients, and many of the Respiratory Therapists that had been assigned to observing 1:1 psychiatric patients had voiced that they were uncomfortable with the assignment, some being afraid of the patients.

20638

Based on record review and interview the hospital failed to ensure a medical history and physical was completed, documented, and placed in the patient's chart within 24 hours of admission for 3 of 9 sampled patients (#3, #4, #7). Findings:

Patient #3
Review of the medical record for Patient #3 revealed a 68 year old female admitted to the hospital on 12/22/11 for debility due to malnutrition and weakness. Review of the H&P for Patient #3 revealed it was dictated on 12/23/11 and typed on 12/24/11 (48 hours after admission).

Patient #4
The medical record for Patient #4 was reviewed on 1/19/2012. Review of #4's medical record revealed the patient was admitted to the hospital on 1/10/2012 under a Physician's Emergency Certificate for being "Gravely Disabled (non compliant with medications, behaving bizarrely, extremely paranoid . . . screaming and hollering in progress)". Review of the entire medical record revealed no documented evidence of a History and Physical for Patient #4 (9 days after admission to the hospital).

Patient #7
Review of the medical record for Patient #7 revealed a 44 year old female admitted via CEC (Coroner ' s Emergency Certificate) for delusional, paranoid and threatening behavior on 12/21/11. Review of the History & Physical for Patient #7 revealed it was dictated on 12/22/11 by Nurse Practitioner S6 and typed on 12/23/11 (48 hours after admission).

During a face to face interview on 1/19/2012 at 9:15 a.m., Registered Nurse S14 confirmed the above findings. S14 indicated the History and Physical for Patient #4 had probably been dictated; however, it should have been placed in the Medical Record. S14 indicated there was no History and Physical present in the Medical Record for Patient #4.

Review of the hospital's "Medical Staff Bylaws and Rules and Regulations" presented by the hospital as current revealed in part, "A complete history and physical examination shall in all cases be recorded within twenty four hours of admission of the patient by a practitioner or an allied health professional who has been granted privileges to do so. . ."

Based on observation, record review, and interview the hospital failed to ensure Respiratory Services were provided under the orders of a physician as evidenced by a patient's use of CPAP (Continuous Positive Airway Pressure) without a physician's order for 1 of 9 sampled patients (#4). Findings:

Review of Patient #4's medical record revealed the patient was admitted to the hospital on 1/10/2012 under a Physician's Emergency Certificate for being "Gravely Disabled (non compliant with medications, behaving bizarrely, extremely paranoid . . . screaming and hollering in progress)". Patient #4's diagnoses included Schizoaffective Disorder- Bipolar Type. Patient #4 was placed on the Medical Unit of the hospital. Review of Patient #4's medical record revealed a physician's verbal order for CPAP at night dated 1/10/2012. The order had a line drawn through it and void written next to the order. Review of Patient #4's entire medical record revealed no documented evidence of an active order for CPAP.

Observations on 1/20/2012 at 8:45 a.m. revealed Patient #5 to be sitting in a chair in her room with a CPAP machine located on her bedside table. Registered Nurse S16 was present during the observation and indicated in a face to face interview the CPAP machine belonged to the patient and was being used at night by the patient. Registered Nurse S16 confirmed the physician order for CPAP written on 1/10/2012 had been voided. S16 reviewed the medical record for Patient #5 and indicated there was no physician's order for the use of CPAP at night. S16 indicated there should have been a physician's order for the use of CPAP and the use of home equipment.

During a face to face interview on 1/20/2012 at 8:05 a.m., Respiratory Therapists S15 indicated when a patient has equipment from home, such as Patient #5's CPAP, "we don't deal with it". S15 reviewed the medical record for Patient #5 and confirmed there was no order for the use of home equipment or for CPAP.

Review of the hospital policy titled, "RT (Respiratory Therapy) 12 hour Chart Check, RC. 1.07." revealed in part, "The Respiratory Therapist will review all respiratory therapy patient's chart every shift and at any time a new order is received."

Based on record review and interview the hospital failed to follow their policy and procedure for occurrences as evidenced by failing to investigate the elopement of a patient who was under a Coroner's Emergency Certificate (CEC) (#7), analyze possible causes and implement preventive actions. Findings:

Review of the medical record for Patient #7 revealed a 44 year old female admitted on 12/21/11under a Coroner's Emergency Certificate (CEC) for delusional, paranoid and threatening behavior. Review of the History & Physical dated 12/21/11 revealed Patient #7 was transferred from Hospital "a" where she had left AMA (against medical advise) twice and was being transferred to long term acute care for intravenous antibiotic therapy, wound care, dialysis and psych treatment.

Review of the Nursing 24-Hour Assessment and Narrative Notes dated 12/26/11 revealed at 2015 (8:15pm) Patient #7 was not in his room, the facility and surrounding area was searched by staff; however Patient #7 was not located. 2025 (8:25pm) Charge nurse notified the MD; 2040 (8:40pm) Police notified; 2120 (9:20pm) Patient found by the police and returned to the facility.

Review of the Occurrence Report for Patient #7 dated/timed 12/26/11 at 2015 (8:15pm) revealed the "Miscellaneous" category was completed and described the occurrence as "Pt. (patient) left building returned by police file# 2011-52076. MD, RN Supervisor and Daughter of patient notified. Outcome: No apparent injury. Risk Manager Review/Follow-up: Patient returned to facility by deputy. 1:1 supervision assigned to patient. Pt. still threatening to leave. Pt. to remain with 1:1 supervision until re-assessed by physician. 1:1 supervision assignments made".

The hospital could not submit any further investigation. This was verified by the Director of Nursing S2 who signed the Occurrence Report as the Risk Manager.

In a face to face interview on 01/22/12 at 2:15pm S3 Director of the Behavioral Unit indicated elopements had occurred in the hospital. When asked what action had been taken S3 indicated the elopements were included in the statistical data for AMA's (leaving Against Medical Advise).

In a face to face interview on 01/22/12 at 2:30pm RN S2 Director of Nurses indicated elopements were not a problem and had not been analyzed. After S2 reviewed the statistical data for AMA's for 2011, she indicated elopements had not been separated and had not been analyzed.

Review of Policy Number I-E.5.08 titled Occurrence Reports" last reviewed 04/09 and submitted as the one currently in use revealed........ "E. Completing the Form: 3. The Risk Manager will initiate an intensive analysis for those occurrences which may be more serious in nature".