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Based on staff interviews and review of the Governing Body Meeting Minutes, Performance Improvement Meeting Minutes, Personnel Files, Credentialing Files , the hospital failed to meet the Condition of Participation for Governing Body as evidenced by:

1. Failure to ensure that the hospital implemented corrective action for not having the availability of medications and timeliness of delivery of medications in order for patients to receive all medications as ordered by physicians. (See findings A0310).

2. Failure to ensure that all physicians were re-appointed after the initial year of appointment according to the Medical Staff Bylaws for 3 of the 3 credentialed physicians (S9, S10, S11) and 4 of 4 nurse practitioners (NPs) reviewed from a total of 8 NPs (S12, S13, S14, S15) (See A0341).

3. Failure to provide the necessary financial funding to provide for drug screening and/or background checks, required by hospital policies and procedures, prior to employment for 6 of 7 nurses reviewed from a total of 34 nurses (S4, S19, S21, S22, S25, S33) and 6 of 6 mental health technicians (MHTs) reviewed from a total of 30 MHTs (S7, S20, S23, S29, S31, S32). Financial funding was also not provided for employees to attend nonviolent crisis intervention inservice (CPI) and CPR (cardiopulmonary resuscitation) resulting in expired CPI certification for 7 of 7 nurses reviewed for CPI certification from a total of 34 nurses (S2, S4, S19, S21, S22, S25, S33), 6 of 6 MHTs reviewed for CPI certification from a total of 30 MHTs (S7, S20, S23, S29, S31, S32), and expired CPR certification for 3 of 6 MHTs reviewed for CPR certification from a total of 30 MHTs (S7, S20, S32) (See A0073 and A0397).

Based on staff interviews and review of administrative records, governing board meeting minutes, performance improvement/quality assurance meeting minutes, medical records, intake logs, staffing patterns, policies and procedures, the hospital failed to meet the Condition of Participation for Quality Assessment and Performance Improvement as evidenced by:

1. Failure to have a system in place which monitored proactively all departments and patient care services of the hospital. The quality assurance data showed no evidence that data was collected or if data was collected that it was accurate as evidenced by the hospitals inability to evaluate patient care services for pharmacy, respiratory, radiology, infection control, nursing, risk management and medical records. There was no evidence the hospital implemented corrective action resulting in continued delinquency rate of medical records; unresolved problems for over a year with the pharmacy contract and unavailability of ordered medications. This was evident in 4 of 22 sampled patients not receiving their medications on time either due to unavailability or not being delivered on time (#3, #9, #10, #17) (refer to A0289).

2. Failure to ensure medication variances had been accurately tracked and the severity assessed as evidenced by failing to follow their policy and procedure for assignment of levels for medication variances and reporting of data analysis to the P&T (Pharmacy & Therapeutics) and PI (Performance Improvement) Committees and relying on self-reporting as the only means of identification of errors. The failure resulted in the hospital's inability to determine the actual number of inaccurate, untimely medications administered to their patients (refer to A0286).

20638

Based on staff interview and record review and interview, the hospital failed to meet the Condition of Participation for Medical Staff as evidence by:

1. The Medical Staff failed to ensure that members of the medical staff were reappointed according to the Medical Staff Bylaws by not examining the credentials of physicians and nurse practitioners after the initial year of appointment of 3 of 3 credentialed physicians (S9, S10, S11) and 4 of 4 nurse practitioners reviewed from a total of 8 credentialed nurse practitioners (S12, S13, S14, S15) (see findings in A0341).

2. The Medical staff failed to ensure the bylaws were enforced regarding suspension of physicians with delinquent medical records resulting in 42 medical records delinquent greater than 60 days with patient discharge dates from 02/16/10 through 04/21/10 and 58 medical records delinquent greater than 30 days with patient discharge dates from 04/22/10 through 05/11/10 (see findings in A0353).

3. The Medical Staff failed to ensure the procedure for requesting and granting of clinical privileges was followed according to the Medical Staff Bylaws as evidenced by: a) failing to have documented evidence of the Medical Director's approval of requested privileges for 3 of 3 physicians appointed to the medical staff (S9, S10, S11) and 3 of 4 nurse practitioners reviewed from a total of 8 nurse practitioners appointed to the medical staff (S12, S13, S15) and b) failing to have requested and approved clinical privileges prior to the expiration of medical staff appointment for 3 of 3 physicians appointed to the medical staff (S9, S10, S11) and 4 of 4 nurse practitioners reviewed from a total of 8 nurse practitioners appointed to the medical staff (S12, S13, S13, S14, S15) (see findings in A0363).


25065

Based on observations of the medical records department, staff interviews and review of medical record policy and procedures and medical records, the hospital failed to meet the Condition of Participation for Medical Records Services as evidenced by:

1. Failure to ensure polices and procedures were followed relative to the prompt completion of medical records resulting in 42 medical records being delinquent greater then 60 days with discharge dates from 02/16/10 through 04/21/10 (see findings at A0438).

2. Failure to ensure the medical records department had been allocated adequate space to house current medical records as evidenced by 76 unfiled medical records from the years 2009 through 2010 stored on open shelving and stacked on tables and left uncovered in a manner which allowed the records to remain exposed to the possibility of being damaged from water. The hospital is licensed for 28 beds. (see findings at A0438).

Based on staff interview and review of administrative records, polices and procedures, and infection control and quality assurance documentation, the hospital failed to meet the Condition of Participation for Infection Control as evidenced by:

1. Failure to ensure the Infection Control Officer had the qualifications as specified in their policy and procedure and job description for an Infection Control Officer. (See findings at A01748).

2. Failure to develop, implement, report and investigate sources of transmission of patients upon admit so as to be proactive in identifying and controlling infections and communicable diseases. The Infection Control Officer failed to be aware that the nursing assessment form regarding infections was not being completed on all patients upon admit (#11, #12, #18) (See findings at A0749).

3. Failing to ensure that all patients hospitalized with a known infection were assessed for the need for isolation. This was evidenced by the failure to monitor and document the findings in the infection control log involving 16 random patients for the month of May 2010. (See findings at A0749)

4. Failing to ensure the hospital's infection control program included current nationally recognized infection control practices or guidelines of the Centers for Disease Control (CDC) which included active surveillance of all health care workers in the hospital. The hospital failed to require all physicians and nurse practitioners to be verified as free from TB (tuberculosis), a communicable disease, prior to intial appointment to the medical staff and at least annually thereafter for 3 of 3 physicians (S9, S10, S11) and 4 of 4 Nurse Practitioners (S12, S13, S14, S15) out of a total of 8 reviewed personnel files for nurse practitioners. (See findings at 01749).

Based on record review and interview, the governing body failed to ensure medical staff appointments were approved after recommendation from the Medical Staff after the initial year of appointment according to the timeframe established in the Medical Staff Bylaws for 3 of the 3 credentialed physicians (S9, S10, S11) and 4 of 4 nurse practitioners (NPs) reviewed from a total of 8 NPs (S12, S13, S14, S15). Findings:

Review of the credentialing files of Physician S9, Psychiatrist S10, NP S12, NP S13, and NP S14 revealed they were initially appointed to the medical staff on 03/03/09. Further review revealed no documented evidence S9, S10, NP S12, NP S13, and NP S14 had been approved for reappointment after the end of the initial appointment year.

Review of the credentialing files of NP S11 and NP S15 revealed they were initially appointed to the medical staff on 04/08/09. Further review revealed no documented evidence S11 and S15 had been approved for reappointment after the end of the initial appointment year.

In a face-to-face interview on 06/22/10 at 9:30am, HR Director S16 indicated she was responsible for the credentialing process. She confirmed that no physicians and NPs have been reappointed to the medical staff, and their initial appointment has expired.

In a face-to-face interview on 06/22/10 at 11:25am, Chief Executive Officer S1 indicated she had instructed HR Director S16 to get the reappointments done in April 2010.

In a face-to-face interview on 06/23/10 at 10:10am, Psychiatrist S10, also the Medical Director and 20% (per cent) owner of the hospital, indicated he was aware that the medical staff appointments were expired, but he didn't know how long they had been expired.

Review of the Governing Body Bylaws dated 01/14/09 revealed, in part, "...The Board shall review recommendation from the Medical Staff concerning appointment, reappointment, and clinical privileges, and make final approval of each...".

Review of the Medical Staff Bylaws, with no documented evidence of the date of approval, revealed, in part, "... Initial appointments and reappointments to the Medical Staff shall be approved by the Governing Body. The Governing Body shall act on appointments, reappointments only after there has been recommendations from the Medical Staff... Initial appointments shall be made for a period one calendar year. Reappointments shall be for a period of two years. ...".

Based on observations, record review and interview, the hospital failed to ensure the practicing medical and psychiatric physicians had provided and/or updated their on-call lists for use by the nursing staff in the care of their patients. Findings:

Observation on 06/21/10 at 11:15am in the Ger-psych nursing station revealed a conversation between LPN (licensed practical nurse) S42 and RN (registered nurse) S22 concerning who was on-call for the medical physicians, since a new schedule for the week had not been sent. S22 then called NP (nurse practitioner) S45 to ask if he knew who was taking call. When S22 got off the phone, she told LPN S42 that someone from the medical team was on the adult unit and would be there shortly, and they could ask that person.

Review of the on-call list for medical physician S9 and his Nurse Practitioners which was posted in the Geri-psych unit on 06/21/10 at 11:00am revealed the schedule was dated for 06/14/20 thru 06/21/10; however it ended at 6:00am on Monday, 06/21/10.

In a face-to-face interview on 06/22/10 at 11:30am, LPN S42 indicated the psychiatrists never have used an on-call list because they are on-call 24/7 for their own individual practices. Further she indicated the medical physicians do use an on-call list, because physician S9 utilizes his Nurse Practitioners to take call.

Based on record review and interview, the hospital failed to ensure that the budget included all anticipated expenses by failing to include the expenses associated with the hiring of new personnel (background checks and drug screens) for 6 of 7 nurses reviewed from a total of 34 nurses (S4, S19, S21, S22, S25, S33) and 6 of 6 mental health technicians reviewed from a total of 30 mental health technicians (S7, S20, S23, S29, S31, S32). The hospital failed to ensure that the budget included all anticipated expenses associated with maintaining specific certifications for patient care (crisis prevention intervention and cardiopulmonary resusitation) resulting in the expiration of these certifications for 7 of 7 nurses reviewed from a total of 34 nurses (S2, S4, S19, S21, S22, S25, S33) and 6 of 6 mental health techs reviewed from a total of 30 mental health techs (S7, S20, S23, S29, S31, S32) for crisis prevention intervention. Expired cardiopulmonary resusitation certification for 3 of 6 mental health techs reviewed for cardiopulmonary resusitation certification from a total of 30 mental health techs (S7, S20, S32). This could potentially affect all patients admitted to the hospital.

FINDINGS:

Review of Policy and Procedure for orientation of nursing staff included crisis prevention intervention and cardiopulmonary resusitation. The policy further indicated that the director of nursing would ensure that nursing employees maintain competence in designated areas and participate in annual re-orientation.

In an interview with the director of nursing on 06/23/2010 at 10:15 a.m. she indicated that she was not aware that employees not current in crisis intervention prevention and cardiopulmonary resusitation.

Review of personnel files revealed that S4, S7, S19, S20, S21, S22, S23, S25, S29, S31, S32 and S33 did not indicate that pre-employment drug screens and background checks had been performed.

Review of personnel files revealed that S2, S4, S4, S7, S19, S20, S21, S22, S23, S25, S29, S31, S32 and S33 did not indicate that crisis prevention intervention had been provided or maintained.

Review of personnel files revealed that S7, S20 and S32 had expired cardiopulmonary resusitation certification.

Based on record review and interview, the hospital failed to evaluate contracted services via the Quality Assurance/Performance Improvement (QA/PI) program to ensure quality of care had been provided to their patients. Findings:

Review of the Performance and Safety Improvement Plan, dated 01/09 and submitted by the hospital as the one currently in use, revealed no documented evidence contracted services had been included in the QA/PI Plan.

Review of the QA/PI Meeting Minutes and performance data dated 03/09 through the present revealed no documented evidence respiratory, radiology, dietary, therapy, or pharmacy services had been evaluated through the use of collected data and a report sent to the Governing Body for review.

In a face-to-face interview on 06/23/10 at 11:00am S1 Chief Executive Officer indicated there had been several PI Coordinators in the short time the hospital had been opened, and she verified the entire program needs to be revised. Further S1 indicated she is not sure how or by whom contracts are being evaluated.

Based on record review and interview, the hospital failed to ensure patients were informed of their 19 mental health rights as well as their 22 patient rights granted by the Louisiana Hospital Licensing Standards (LAC 48:I.Chapter 93) for 22 of 22 sampled patients (#1, #2, #3, #4, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22). Findings:

Review of the "Patient Handbook" presented by Chief Executive Officer (CEO) S1 as the hospital's patient handbook that was presented to patients upon admission revealed the list of patient rights. Further review revealed the following patient rights: "A. The right to inspect and copy your protected health information... B. The right to request a restriction on uses and disclosures of your protected health information... C. The right to request to receive confidential communications from us by alternative means or at an alternative location... D. The right to have your physician amend your protected health information... E. The right to receive an accounting... F. The right to obtain a paper copy of this notice". Further review of the entire booklet revealed no documented evidence of the 19 mental health rights and the 22 patient rights granted by the Louisiana Hospital Licensing Standards.

In a face-to-face interview on 06/23/10 at 8:35am, CEO S1 indicated the 22 hospital licensing standards patient rights were posted on the unit, but the patient handbook which was presented to patients as notification of their rights did not include these 22 rights and all of the mental health rights.

Based on record review and interview, the hospital failed to ensure patients were informed in writing that the hospital was physician-owned for 22 of 22 sampled patients. This finding had the potential to affect all patients admitted to the hospital (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22). Findings:

Review of the medical records of Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, and #22 revealed no documented evidence that these patients were informed in writing that the hospital was physician-owned.

Review of the "Patient Handbook", submitted by Chief Executive Officer (CEO) S1 as the handbook presented to patients upon admission, revealed no documented evidence that physician ownership of the hospital was addressed.

In a face-to-face interview on 06/23/10 at 10:10am, Psychiatrist S10, who was also the Medical Director and 20% (per cent) owner of the hospital, confirmed he owned 20% of the hospital. When asked by the surveyor if he was aware that if he had ownership in the hospital he had to disclose his ownership to admitted patients, S10 indicated he saw that requirement at another hospital. He further indicated it had not been the practice at this hospital to inform their patients of his ownership. S10 could offer no explanation why this requirement was not being met.

Based on record review and interview, the hospital failed to ensure a patient's right to formulate an Advance Directive for 1 of 22 sampled patients by failing to determine Patient #4's formulated or executed advance directive on admission. Findings:

The medical record for Patient #4 was reviewed. Patient #4 was admitted on 06/09/10 with a diagnosis of Psychosis. Documentation on the Advance Directive Acknowledgement form revealed Patient #4 was confused and unable to sign acknowledgement of formulated or executed advance directives. The patient's husband was identified as the person of contact for emergencies and to take part in treatment. There was no documented evidence attempts were made to contact the patient's husband to identify if Patient #4 had a previously executed Advance Directive, There was no documented evidence attempts were made to readdress with the patient the acknowledgement of advance directives as of 06/21/10.

Patient #4 was interviewed on 06/21/10 at 11am. She was alert, and answered questions appropriately and voiced no complaints.

S1 Chief Executive Officer was interviewed face-to-face on 06/21/10 at 11:40am. She confirmed staff should have followed up on Patient #4's Advance directives. She stated, "I would think they would follow up every shift."

The hospital policy #RTS-07, approved 01/09 entitled "Advanced Directives", was reviewed. Documentation revealed, in part, "Procedure: Assessment Professional "During preadmission assessment process, asks patient (or patient's relative, if the patient is determined to be not competent) whether the patient has appointed a health care surrogate or executed a Living Will and whether any advance directives are still valid and up to date. If patient has executed an advance directive, information shall be placed in the patient's medical record where it is readily visible during patient's treatment stay. If information is not available requests that patient/family supply this information. Informs patient/family that facility cannot honor advance directive unless copy is on file at this facility and physician has written order. If the patient does not have a health care surrogate and has not issued advance directives, documents that the patient was presented with a copy of Advance Directive form with appendices: a. Notice to Patients Regarding Your Right to Make Advance Health Care Decision b. Living Will c. Durable Power of Attorney d. Written information about Advance Directives."

Based on observation, record review, and interview, the hospital failed to ensure the hospital environment was maintained to assure the safety and well-being of patients by having: 1) an unlocked door to the clean linen closet on the adult unit with carts containing gowns, sheets, and towels that could be used as a means of injury by patients; 2) the bathroom of the exam room on the adult unit with window blinds with hanging cords and a screenless window that was able to be opened that could allow escape/elopement of psychiatric patients; 3) five patient rooms with excess clothing and personal items not allowed by hospital policy (rooms "a", "b", "c", "e", "f"); 4) an uninhabited patient's bathroom with non-functioning lights (room "d"); 5) an eight foot wooden fence with seven chairs in the outdoor area of the adult unit which provided and continued to provide a means of patient elopement; and 6) an exam room window able to be fully opened that could allow escape/elopement of psychiatric patients. Findings:

1) Unlocked door to clean linen closet
Observation on the adult unit on 06/21/10 at 10:00am revealed the door to the clean linen room was unlocked. Further observation revealed 2 wire linen carts with stacked gowns, sheets, and towels.

In a face-to-face interview on 06/21/10 at 10:00am, Interim Director of Nursing (DON) S2 indicated the door should remain locked, because the sheets, towels, and patient gowns stored within could be used by patients as a means of injuring themselves or others.

2) Exam room bathroom with hanging cords on blinds and a window able to be opened from within the bathroom
Observation on the adult unit on 06/21/10 at 10:00am revealed the door to the examination room open. Further observation revealed the bathroom that could be entered once inside the exam room had an unlocked door. Further observation revealed a screenless window inside the bathroom that was able to be opened by the surveyor. This window opened to the outside and had no means to prevent someone from pushing on it to provide a means of escape/elopement to the outdoors. The blinds covering this window had hanging cords that are used to raise and lower the blind.

In a face-to-face interview on 06/21/10 at 10:00am, Interim DON S2 confirmed that the window could be used as a means of escape and the cord of the blind could be used as a means of injury by patients. She further indicated that some psychiatric patients were allowed to use the bathroom to provide urine samples while unsupervised by staff.

3) Excess clothing and personal items in patient rooms
Observation of patient rooms on the adult unit on 06/21/10 at 10:35am, with Interim DON S2 present, revealed the following findings:
Room "a" - 4 shirts and 3 pair of panties over the allowed amount by policy; 1 patient gown in the drawer;
Room "b" - approximately 2 foot long hair piece, 3 tubes of lipstick, 2 hair brushes, 1 toothbrush, 1 tube of toothpaste, 1.5 ounce half-full plastic bottle of baby lotion in the patient's bedside drawer;
Room "c" - 3 shirts and 1 pair of pants over the allowed amount per policy and a pair of panty hose on the shelf in the patient's room;
Room "e" - 2 patient gowns in the soiled linen basket on the patient's shelf;
Room "f" - 2 gowns, 4 towels, 2 washcloths on the shelf in the patient's room.

In a face-to-face interview on 06/21/10 at 10:35am, Interim DON S2 indicated hospital policy stated that patients were only allowed to keep 3 suits of clothing in their room. She further indicated that patient gowns, towels, and washcloths should not be in patient rooms, but they should be handed out when patients are ready to bathe. She further indicated not keeping linen in the patient rooms was a hospital practice, but she was not aware of such a policy.

In a face-to-face interview on 06/21/10 at 10:50am, Mental Health Tech S7 indicated it was his duty to perform routine checks and observations. He indicated he was not aware of a hospital policy regarding the number of gowns that could be given to patients, but he knew that patients were allowed to keep 3 suits of clothing in their rooms. S7 indicated he didn't check for the amount of clothing in patient rooms when he made rounds of the patient rooms.

Review of the hospital policy titled "Intake Screening and Admission Process", originated 01/09, revealed, in part, "...Explains and allows patient to have three sets of clothing per policy back to the unit. ... Assessment Professional ... Additional items (clothing ...) over the allotted amount will be listed by Admission personnel and stored in the belongings storage room until discharge. ... Admitting Nurse/MHT (mental health tech) ... Has patient's personal hygiene items stored at nursing station in secure area.

Review of the hospital policy titled "Body And Belongings Search", originated 01/09, revealed, in part, "... Admissions Personnel ... Notifies patient/family only 3 sets of clothing are allowed on the units. Instruct family members to take home contraband items and secure them when necessary. ... The charge nurse reserves the right to deem items contraband on a case-by-case bases...".

Review of the "Mental Health Technician Job Description" revealed, in part, "... Employee maintains safe and therapeutic environment/milieu through patient monitoring as designated by RN (registered nurse)/Physician. a. Continually monitors compliance with unit rules, conducts environmental safety checks/security rounds...".

4) Non-functioning lights in patient bathroom
Observation on 06/21/10 at 10:35am, with Interim DON S2 present, revealed Room "d" patient bathroom with 3 light switches on the right wall upon entering the bathroom. Further observation revealed no light came on when the switches were raised by the surveyor.

Observation on 06/23/10 at 9:10am, with Interim DON S2 present, revealed the bathroom light over the lavatory in Room "d" was not working when the switch was activated.

In a face-to-face interview on 06/23/10 at 9:10am, Interim DON S2 confirmed the light over the lavatory in the bathroom of Room "d" was not working.

5) Wooden fence in outdoor area
Observation on 06/21/10 at 10:25am of the outdoor area for the adult unit revealed an eight foot high wooden fence surrounding the outdoor area where patients were allowed for smoke breaks. Further observation revealed 7 moveable chairs were situated on the concrete floor in the center of the outdoor area.

In a face-to-face interview on 06/21/10 at 10:25am, Interim DON S2 confirmed that the presence of moveable chairs that could be placed next to the fence as a means of reaching to pull oneself up would allow a psychiatric patient a means of escape/elopement.

Review of the hospital's incident reports on 06/24/10 revealed Patient #R1 had eloped from the hospital on 02/18/10 at 1935 (7:35pm) by using a chair in the outdoor adult unit to jump the eight foot wooden fence.

6) Exam room window able to be fully opened from inside the exam room
Observations on 6/21/2010 at 10:10 a.m. revealed an open door from the hallway located across from the nursing station. This door allowed entrance into an exam room. Further observations revealed a screenless window located in the exam room that was able to be fully opened by the surveyor.

During a face-to-face interview on 6/21/2010 at 10:10 a.m. Interim Director of Nursing S2 indicated the door to the exam room should have been locked when not in use by staff.

Based on record review and interview, the hospital failed to ensure medication variances had been accurately tracked as evidenced by: 1) failing to follow their policy and procedure for assignment of levels for medication variances and reporting of data analysis to the P&T (Pharmacy & Therapeutics) and PI (Performance Improvement) Committees and 2) relying on self-reporting as the only means of identification of errors resulting in the hospital's inability to determine the actual number of inaccurate, untimely medications administered to their patients. Findings:

1) Failing to follow their policy and procedure for assignment of levels for medication variances and reporting of data analysis to the P&T and PI Committees
Review of the Performance Improvement Meeting Minutes dated 03/10/10 revealed no adverse drug reactions and only 3 transcription errors. Further review revealed no additional data to indicate the severity level of the medication variances, if an investigation had been conducted, corrective action taken, or the responsibility for monitoring assigned.

Review of the P&T Committee Meeting Minutes revealed the last documented meeting held was 04/16/2009.

Review of the policy titled "Medication Variance Corrective Action", dated 01/09 and submitted as the one currently in use, revealed the severity of medication variances would be classified on a scale with Level 0 - as the potential for error, Level 1 - no harm, Level 2 increased monitoring, Level 3 - increased monitoring with a change in vital signs, Level 4 need for treatment and additional hospital stay, Level 5 - permanent patient harm and Level 6 - death.
Further review revealed that aggregation and analysis of data would be reported to the PI and P&T Committees.

2) Relying on self reporting as the only means of identification of errors
Review of the incident/occurrence reports for the past six months submitted by the hospital to the survey team revealed no documented evidence of any medication variances.

Review of Patient #3's medical record revealed physician's orders dated 06/18/10 as follows: 1055 (10:55 a.m.) Risperdal consta 50 milligrams every 2 weeks - give first dose now. 1600 (4:00 p.m.) OK to give Risperdal Consta when arrives. Review of Patient #3's nursing notes dated 06/18/2010 at 1815 (6:15 p.m./6 hours and 20 minutes after ordered by the physician) revealed "Pt. received IM (intramuscular) dosage of Risperdal consta (with) sterile technique per Medicine nurse. . . tolerated injection well, (no) complaints voiced".

During a face-to-face interview on 06/21/2010 at 11:50 a.m., LPN (Licensed Practical Nurse) S4 indicated she had sent pharmacy a fax requesting Risperdal Consta when she received the order. S4 further indicated she called the pharmacy back every 30 minutes and they continued to tell her it would arrive with the next batch of medication. S4 indicated it did not arrive until 6:15 p.m. (6 hours and 20 minutes after ordered by the physician). S4 further indicated she did not do an occurrence report/incident report.

Review of the medical record for Patient #9 revealed she was admitted to the hospital for altered thought processes, schizophrenia and delusions on 06/15/10. Review of the Physicians' Orders dated 06/17/10 at 11:25am revealed an order for "second loading dose of Invega Sustena 156mg IM as soon as available".
Review of the MAR (Medication Administration Record) for Patient #9 revealed.... "Invega Sustena 156mg IM as soon as available, called pharmacy won't be available until 06/18/10".

Review of the medical record for Patient #10 revealed he had been admitted to the hospital on 06/16/10 for depression with a history of COPD (Chronic Obstructive Pulmonary Disease). Review of the Physicians' Orders for Admit revealed an order for Advair Diskus bid (twice a day) inhalant.
Review of the MAR for Patient #10 revealed Advair could not be administered because it was unavailable in the pharmacy. Further review of the MAR revealed no substitution had been made with a similar drug for the Advair which is used in the treatment of respiratory disease, and Patient #10 missed the dose on 06/16/10 at 2100 (9:00pm) and was administered the 06/17/10 0900 (9:00am) dose at 1400 (2:00pm) or 5 hours late.

Review of Patient #17's physician's orders dated 05/12/2010 at 1600 (4:00 p.m.) revealed an order for "Saphris 10 mg. (milligrams) PO (by mouth) bid (two times per day)". Review of Patient #17's Medication Administration Record revealed the next scheduled dosage of Saphris was due at 2100 (9:00 p.m./5 hours after the physician ordered the medication). Further review revealed Patient #17 did not receive the medication until 2315 (2 hours and 15 minutes after the scheduled dosage).

In a face-to-face interview on 6/22/2010 at 10:35 a.m., Interim Director of Nursing (DON) S2 indicated medication availability varies due to delivery times by the contracted pharmacy. S2 further indicated nursing staff have not made it a practice to complete occurrence reports for missed medications. In addition the interim DON S2 indicated chart audits are not being done to monitor for medication variances.

In a telephone interview on 6/24/2010 at 2:50 p.m., Pharmacy Compliance Officer S35 indicated she investigates all occurrence reports from the hospital; however, if no occurrence report is generated by the hospital she would not investigate.

Based on record review and interview, the hospital failed to implement their performance improvement plan by failing to conduct a performance improvement project. Findings:

Review of Policy #: LD 13 titled "Performance and Safety Improvement Plan", approved 03/09 and submitted as the one currently in use, revealed, in part, "... At least once every twelve months, a high risk process is selected for a pro-active risk assessment to either (1) correct process problems and reduce the likelihood of experiencing adverse events, or (2) evaluate processes to see how they could fail, to understand the consequences of such a failure, and to identify parts of the process that need improvement...".

Review of the data presented as Quality Assurance and Performance Improvement revealed no documented evidence an improvement project had been initiated.

Review of the Governing Board Meeting Minutes for 10/28/09, 04/07/09, 03/03/09 revealed no documented evidence improvement projects had been discussed. The hospital could not submit any documentation of meetings held in 2010.

In a face-to-face interview on 06/23/10 at 2:00pm, Chief Executive Officer S1 indicated the Performance Improvement Plan had already been implemented when she was hired two months ago. Further she indicated to her knowledge she is not aware of any ongoing projects for QA.

Based on record review and interview, the hospital failed to ensure the medical staff was re-appointed after the initial year of appointment according to the Medical Staff Bylaws by failing to examine the credentials of 3 of the 3 credentialed physicians (S9, S10, S11) and 4 of 4 nurse practitioners (NPs) reviewed from a total of 8 NPs (S12, S13, S14, S15) . Findings:

Physician S9
Review of S9's credentialing file revealed he was initially appointed to the medical staff on 03/03/09. Further review revealed a letter dated 04/28/10 was sent to S9 by S16, Human Resource Director (HR Director) regarding S9's medical staff reappointment. Further review revealed this letter was sent more than one month after S9's appointment had expired. There was no documented evidence S9 had submitted an application for reappointment to the medical staff.
Review of S9's credentialing file revealed his medical license had expired 04/30/09, his Controlled Dangerous Substance (CDS) license expired 10/01/09, and his National Practitioner Data Bank (NPDB) query was processed 05/06/09, more than 2 months after S9 had been appointed to the medical staff.

Psychiatrist S10
Review of S10's credentialing file revealed he was initially appointed to the medical staff on 03/03/09. Further review revealed a letter dated 04/28/10 was sent to S10 by S16, HR Director regarding S10's medical staff reappointment. Further review revealed this letter was sent more than one month after S10's appointment had expired. There was no documented evidence that S10 had been submitted for reappointment to the medical staff since his initial appointment.
Review of S10's credentialing file revealed the "Applicant's Consent And Release" signed by S10 with no documented evidence of the date it was signed. Further review revealed the "Application for Reappointment to the Medical Staff" was signed by S10 with no documented evidence of the date of his signature. Further review revealed no documented evidence of the date of S10's last complete physical examination and the date of S10's signature on the health status form.
Review of the NPDB query for S10 revealed it was processed on 05/06/09, more than 2 months after S10 had been appointed to the medical staff.

Psychiatrist S11
Review of S11's credentialing file revealed she was initially appointed to the medical staff on 04/08/09. Further review revealed a letter dated 04/28/10 was sent to S11 by S16, HR Director regarding S11's medical staff reappointment. Further review revealed this letter was sent more 20 days after S11's appointment had expired. There was no documented evidence of a reapplication for medical staff appointment submitted by S11.
Review of S11's credentialing file revealed her medical license had expired 08/31/09, her CDS license had expired 07/01/09, and her liability coverage had expired 02/01/10. Further review revealed the NPDB query was conducted on 05/06/09, which was after S11 had been appointed to the medical staff.

Nurse Practitioner S12
Review of S12's credentialing file revealed she was initially appointed to the medical staff on 03/03/09. Further review revealed a letter dated 04/28/10 was sent to S12 by S16, HR Director regarding S12's medical staff reappointment. This letter was sent more than one month after S12's appointment to the medical staff had expired. Review of the "Application for Reappointment to the Medical Staff" in S12's file revealed page 4, the health status, was signed by S12 with no documented evidence that the questions had been answered.
Review of S12's credentialing file revealed no documented evidence of a Registered Nurse license, the Advanced Practice Registered Nurse license had expired 01/31/10, the medical professional liability coverage had expired 09/27/09, and the NPDB query was conducted 05/06/09, more than 2 months after S12's initial appointment. Further review revealed the "Collaborative Practice Agreement" of S12 with Psychiatrist S10 was signed by S12 on 05/07/09 with no documented evidence of the date S10 had signed the agreement.

Nurse Practitioner S13
Review of S13's credentialing file revealed he was initially appointed to the medical staff on 03/03/09. Further review revealed a letter dated 04/28/10 was sent to S13 by S16, HR Director regarding S13's medical staff reappointment. This letter was sent more than one month after S13's appointment to the medical staff had expired. Further review revealed no documented evidence that an application for reappointment had been completed by S13.

Nurse Practitioner S14
Review of S14's credentialing file revealed he was initially appointed to the medical staff on 03/03/09. Further review revealed a letter dated 04/28/10 was sent to S14 by S16, HR Director regarding S14's medical staff reappointment. This letter was sent more than one month after S14's appointment to the medical staff had expired. Further review revealed no documented evidence that an application for reappointment had been completed by S14.
Review of S14's credentialing file revealed his CDS license had expired on 03/13/10, and his liability coverage had expired 11/01/09.

Nurse Practitioner S15
Review of S15's credentialing file revealed she was initially appointed to the medical staff on 04/08/09. Further review revealed a letter dated 04/28/10 was sent to S15 by S16, HR Director regarding S15's medical staff reappointment. This letter was sent 20 days after S15's appointment to the medical staff had expired. Further review revealed no documented evidence that an application for reappointment had been completed by S15.

In a face-to-face interview on 06/22/10 at 9:30am, HR Director S16 indicated she was responsible for the credentialing process. She confirmed that no physicians and NPs have been re-appointed to the medical staff, and their initial appointment has expired. She further indicated she thought the initial appointment had been for 2 years and then was told the initial appointment was for one year. She further indicated she "didn't know what credentialing was till I came here, still learning actually". When asked by the surveyor about the training she received, S16 indicated she had "just got thrown into it". She further indicated the former Performance Improvement Coordinator and former Administrator had taught some of what she knew. S16 indicated the physicians and NPs have to apply for reappointment after the first year of appointment.

In a face-to-face interview on 06/22/10 at 11:25am, Chief Executive Officer S1 indicated she had instructed HR Director S16 to get the re-appointments done in April 2010.

In a face-to-face interview on 06/23/10 at 10:10am, Psychiatrist S10, also the Medical Director and 20% (per cent) owner of the hospital, indicated he was aware that the medical staff appointments were expired, but he didn't know how long they had been expired.

Review of the Medical Staff Bylaws, with no documented evidence of the date of approval, revealed, in part, "... Section 2. Qualifications of Membership a. Only physicians licensed to practice in the State of Louisiana, who can document their background, experience, training and demonstrated competence, their adherence to the ethics of their profession, their good reputation, and their ability to work with others... shall be qualified for membership on the Medical Staff. ... Nurse Practitioners ... licensed in the State of Louisiana who can document their background, experience, training and demonstrated competence, their adherence to the ethics of their professional, their good reputation, ... under the supervision of a privileged physician, shall be qualified for membership on the Medical Staff. ... Initial appointments and re-appointments to the Medical Staff shall be approved by the Governing Body. The Governing Body shall act on appointments, re-appointments only after there has been recommendations from the Medical Staff... Initial appointments shall be made for a period one calendar year. Re-appointments shall be for a period of two years. ...The completed application with all required attachments shall be submitted to the Administrator. After collecting the references and other material deemed pertinent, the Administrator shall transmit the application and all supporting materials to the Medical Staff for evaluation. ... Also, in order to be qualified for staff membership, the individual must furnish a current certificate of malpractice insurance... The applicant shall also provide current copies of license issued by the Louisiana State Board of Medical Examiners, Federal DEA (drug enforcement administration) Certificate, and Louisiana Controlled Dangerous Substance Certificate... Reappointment Process a. At least 60 days prior to the expiration of the practitioner's membership and clinical privileges, the hospital shall provide the member with a reapplication form so that the applicant can update any information and submit it to the hospital for consideration of continued membership and clinical privileges. Upon receipt of the completed reapplication form, the hospital shall verification all applicable credentials and required information. ... The Medical Staff shall function as a committee of the whole... Credential function: To review applications for appointment and reappointment to all categories of the staff; to delineate the privileges to be extended to the applicant and make appropriate recommendations to the Governing Body ...".

Based on record review and interview, the hospital failed to ensure the medical staff enforced its bylaws regarding delinquent medical records which resulted in 42 medical records delinquent greater than 60 days with patient discharge dates from 02/16/10 through 04/21/10 and 58 medical records delinquent greater than 30 days with patient discharge dates from 04/22/10 through 05/11/10. Findings:

Review of a Medical Records data sheet titled, "FBH (Focus Behavioral Hospital/28 bed hospital) Charts Delinquent 60 days or more" revealed 42 medical records with patient discharge dates from 02/16/10 through 04/21/10.

Review of a Medical Records data sheet titled, "FBH Charts Delinquent 30 days or more" revealed 58 medical records with patient discharge dates from 04/22/10 through 05/11/10.

This finding was confirmed by Health Information Manager S5 who further indicated in an interview on /22/10 at 10:30 a.m. that all communication with physicians regarding the need to complete delinquent medical records had been done verbally. S5 indicated there had been no written notification. S5 indicated Medical Staff Bylaws regarding delinquent medical records had not been implemented and the two physicians (Psychiatrist S10, Psychiatrist S11) with delinquencies greater than 60 days had never been suspended.

This finding was also confirmed by Chief executive Officer S1 on 06/22/10 at 11:00 a.m. S1 further indicated she had never sent a letter to any physician regarding medical records delinquent for 30 days as indicated in the Medical Staff Bylaws.

During a face-to-face interview on 6/23/2010 at 10:15 a.m., Medical Director, Psychiatrist S10 indicated he had not enforced the Medical Staff bylaws regarding delinquent Medical Records.

Review of Medical Staff Bylaws, presented by the hospital as current, revealed in part, "Reasonable efforts by the Medical Record Department shall be made to obtain completed medical records from the physician within 15 days following discharge of the patient. The Medical Records Coordinator shall present a list of delinquent records at the quarterly Medical Staff meeting. If these efforts fail and records remain delinquent after (30) days following discharge, the physician will receive a warning letter from the Administrator allowing three (3) days for the completion of the delinquent records; and, if these measures are not successful, a temporary suspension letter will be sent by registered mail and the physician will remain suspended until such time as the records are completed."

Based on record review and interview, the hospital failed to ensure the procedure for requesting and granting of clinical privileges was followed according to the medical staff bylaws by: 1) failing to have documented evidence of the Medical Director's approval of requested privileges for 3 of 3 physicians appointed to the medical staff (S9, S10, S11) and 3 of 4 nurse practitioners (NPs) reviewed from a total of 8 NPs appointed to the medical staff (S12, S13, S15) and 2) failing to have requested and approved clinical privileges prior to the expiration of medical staff appointment for 3 of 3 physicians appointed to the medical staff (S9, S10, S11) and 4 of 4 NPs reviewed from a total of 8 NPs appointed to the medical staff (S12, S13, S14, S15). Findings:

1) Medical Director's approval of requested privileges:
Physician S9
Review of S9's credentialing file revealed he was appointed to the medical staff on 03/03/09. Review of the "Delineation Of Privileges" for Internal Medicine requested and signed by S9 on 08/26/08 revealed no documented evidence that the requested privileges were approved by the Medical Director.

Psychiatrist S10
Review of S10's credentialing file revealed he was appointed to the medical staff on 03/03/09. Review of the "Delineation Of Privileges: Psychiatry" revealed no documented evidence of the date the privileges were requested by S10 as well as no documented evidence of approval by another physician, as S10 was the Medical Director.

Psychiatrist S11
Review of S11's credentialing file revealed he was appointed to the medical staff on 04/08/09. Review of the "Delineation Of Privileges: Psychiatry" revealed no documented evidence of approval of the requested privileges by the Medical Director.

Nurse Practitioner S12
Review of S12's credentialing file revealed she was appointed to the medical staff on 03/03/09. Review of the "Delineation Of Privileges: Nurse Practitioner" revealed S12 requested privileges on 04/23/08. There was no documented evidence of approval of the requested privileges by the Medical Director.

Nurse Practitioner S13
Review of S13's credentialing file revealed he was appointed to the medical staff on 03/03/09. Review of the "Delineation Of Privileges: Nurse Practitioner" revealed S13 requested privileges on 02/18/09. There was no documented evidence of approval of the requested privileges by the Medical Director.

Nurse Practitioner S15
Review of S15's credentialing file revealed he was appointed to the medical staff on 04/08/09. Review of the "Delineation Of Privileges: Nurse Practitioner" revealed S15 requested privileges on 03/05/09. There was no documented evidence of approval of the requested privileges by the Medical Director.

2) Requested and approved clinical privileges prior to the expiration of the medical staff appointment:
Physician S9
Review of S9's credentialing file revealed no documented evidence an application of reappointment and request of clinical privileges had been submitted by S9. Further review revealed his initial appointment had expired on 03/02/10.

Psychiatrist S10
Review of S10's credentialing file revealed no documented evidence an application of reappointment and request of clinical privileges had been submitted by S10. Further review revealed his initial appointment had expired on 03/02/10.

Psychiatrist S11
Review of S11's credentialing file revealed no documented evidence an application of reappointment and request of clinical privileges had been submitted by S11. Further review revealed her initial appointment had expired on 04/07/10.

Nurse Practitioner S12
Review of S12's credentialing file revealed the "Delineation Of Privileges: Nurse Practitioner" form had been signed by S12, but there was no documented evidence of the date of signature and the privileges requested. There was no documented evidence that the requested privileges had been approved by the Medical Director. Further review revealed her initial appointment had expired on 03/02/10.

Nurse Practitioner S13
Review of S13's credentialing file revealed no documented evidence an application of reappointment and request of clinical privileges had been submitted by S13. Further review revealed his initial appointment had expired on 03/02/10.

Nurse Practitioner S14
Review of S14's credentialing file revealed no documented evidence an application of reappointment and request of clinical privileges had been submitted by S14. Further review revealed his initial appointment had expired on 03/02/10.

Nurse Practitioner S15
Review of S15's credentialing file revealed no documented evidence an application of reappointment and request of clinical privileges had been submitted by S15. Further review revealed his initial appointment had expired on 04/07/10.

In a face-to-face interview on 06/22/10 at 9:30am, HR Director S16 indicated she was responsible for the credentialing process. She confirmed that no physicians and NPs have been re-appointed to the medical staff, their clinical privileges had not been requested and approved, and their initial appointment has expired. She further indicated she thought the initial appointment had been for 2 years and then was told the initial appointment was for one year. She could offer no explanation for the request for privileges not being signed and approved by the Medical Director. She further indicated she "didn't know what credentialing was till I came here, still learning actually". When asked by the surveyor about the training she received, S16 indicated she had "just got thrown into it". She further indicated the former Performance Improvement Coordinator and former Administrator had taught some of what she knew. S16 indicated the physicians and NPs have to apply for reappointment after the first year of appointment.

In a face-to-face interview on 06/22/10 at 11:25am, Chief Executive Officer S1 indicated she had instructed HR Director S16 to get the re-appointments done in April 2010.

In a face-to-face interview on 06/23/10 at 10:10am, Psychiatrist S10, also the Medical Director and 20% (per cent) owner of the hospital, indicated he was aware that the medical staff appointments were expired, but he didn't know how long they had been expired.

Review of the Medical Staff Bylaws, with no documented evidence of the date of approval, revealed, in part, "... Initial appointments shall be made for a period one calendar year. Re-appointments shall be for a period of two years. ... All applications for appointment to the Medical Staff shall be in writing and shall be signed by the applicant. The delineation of privileges the person is requesting shall be specified and within the operational scope of the hospital. ... Reappointment Process a. At least 60 days prior to the expiration of the practitioner's membership and clinical privileges, the hospital shall provide the member with a reapplication form so that the applicant can update any information and submit it to the hospital for consideration of continued membership and clinical privileges. Upon receipt of the completed reapplication form, the hospital shall verification all applicable credentials and required information. ... Every practitioner practicing at this Hospital by virtue of Medical Staff membership or otherwise, shall, in connection with such practice, be entitled to exercise only those clinical privileges specifically granted to him/her by the Governing Body... The Medical Staff shall function as a committee of the whole... Credential function: To review applications for appointment and reappointment to all categories of the staff; to delineate the privileges to be extended to the applicant and make appropriate recommendations to the Governing Body ...".

Based on record review and interview, the hospital failed to ensure the Adult Acute Care (Psychiatric) Unit was adequately staffed for 1 of 15 days reviewed for staffing (06/22/10). Findings:

Review of the hospital's "Daily Hospital Census" for 06/22/10 revealed the census on the Adult Unit to be 13 with 5 new admissions.

Review of the hospital's "Daily Assignment Sheet" for the date of 06/22/10 from 7:00 p.m. through 7:00 a.m. revealed the "Adult Unit (Adult Acute Care Psychiatric Unit)" to be staffed with one Registered Nurse (RN), one Licensed Practical Nurse (LPN), and three Mental Health Technicians (MHT).

Patient #21:
Review of Patient #21's medical record revealed the patient was admitted to the hospital on 06/15/10 under a Physician's Emergency Certificate for "46 yo (year old) c (with) mental retardation. left psych hospital today and returned to group home. Became combative. Throwing things in home aggressive toward caregivers. Hitting head against wall. . .". Review of physician's orders for Patient #21 dated 06/17/10 at 2010 (8:10 p.m.) revealed an order for "1:1 observation".

Patient #22:
Review of Patient #22's medical record revealed the patient was admitted to the hospital on 06/22/10 at 11:12 a.m. under a Physician's Emergency Certificate for "Patient attempted suicide by taking 45 Seroquel pills". Review of physician's orders for Patient #22 dated 06/22/10 at 12:51 p.m. revealed an order for "Precaution: 1:1, SP (suicide precautions)".

Review of the hospital's "MHT Duties and Assignments" form for the 7:00 p.m. through the 7:00 a.m. shift on the Adult Acute Care Unit revealed there were two male Mental Health Technicians and 1 female Mental Health Technicians on duty which consisted of S29 (female MHT), S31 (male MHT), and S32 (male MHT). Further review revealed two patients (S21, S22) were identified as having physician's orders for 1:1 (one staff to monitor the one patient). Assignments were documented as follows:
MHT S29: 1:1 with Patient #21, Fill water pitcher (all techs), Take Vital Signs (all techs), Chart Meal and Snack (all techs), Wrap Up Group, Monitor Halls, ADLs (Activities of Daily Living/All techs), 15 minute checks (all techs), and Clean Refrigerator/ Record Temps.
MHT S31: 1:1 with Patient #22, Take Vital Signs, Smoke Breaks, Snacks/Coffee, Fill water Pitcher, Laundry, Chart Meals and Snacks, Security Rounds, Shave Male Patients, Empty Trash by end of shift, Monitor Halls, ADLs, 15 minute checks, Admission #3, and care of 6 other patients.
MHT S32: 1:1 with Patient #22, Pick up Keys, Take Vital Signs, Chart Vital Signs, Fill Water Pitcher, Chart Meals and Snacks, Stuff Charts, Make Sure front door is locked, Diet Sheets, Make Admit Packets, Update and Print Vital Signs and Patient Daily Record for morning, Monitor Halls, ADLs, 15 Minute Checks, Clean Dining and Nutrition Rooms, Admit #1, Admit #2, Biohazard Room Check, and care for 4 additional patients.

During a telephone interview on 06/23/10 at 2:30 p.m., MHT S29 indicated she had worked short-staffed on the 7 p.m. - 7 a.m. shift on 06/22/10. S29 indicated the unit was very busy with 2 patients on 1:1 observations in addition to two new admissions. S29 indicated staff had called other techs in an attempt to get someone to come in. S29 indicated no one would agree to come in with the exception of one MHT who told them she would come in if her husband showed up with their car; otherwise, she had no transportation. S29 indicated this MHT never showed up. S29 indicated there had been no calls made to inform the Director of Nursing or the Administrator of the staffing shortage on the Adult Unit. S29 indicated the Registered Nurse and MHT S32 were busy with the admissions of the two new patients which required assessments, paper work, and logging of property. S29 further indicated due to the shortage of staff, the other 11 patients (with the exclusion of the two new admissions) were placed in the Activity Group Room. S29 indicated she made observations on the two patients that were on 1:1 observations (Patient #21 and #22) in addition to 9 patients on routine observations requiring 15 minute checks. S29 indicated MHT S31 assisted by helping patients during phone time, smoke breaks, and personal needs such as bathroom request or water. S29 indicated patients with orders for 1:1 observations should be assigned solely to one Mental Health Technician; however, there had not been enough staff to provide the level of care as ordered by the patients' physician. S29 indicated around 10:00 p.m. Patient #21 was assisted by her (S29) with bedtime Activities of Daily Living while Patient #22 was placed in the Quiet Room near the nursing station which was enclosed with glass observation windows. S29 indicated when she completed assisting Patient #21 with her Activities of Daily Living in preparation for bed, she exchanged the two patients, leaving Patient #21 in the Quiet Room and then assisted Patient #22 with her bedtime activities. S29 indicated after all bedtime preparations were complete, Patient #22 was left to sleep in the Quiet Room on the sofa and Patient #21 was allowed to sleep in her room. S29 indicated she remained 1:1 with Patient #21 for the remainder of the night while Patient #22 was assigned to MHT S31 and S32.

During a telephone interview on 06/24/10 at 9:25 a.m., MHT S32 indicated the unit (Adult) had been short-staffed on 06/22/10 from 7 p.m. until 7 a.m. MHT S32 further indicated he helped the nursing staff with admission of the two new patients which required a lot of paper work and logging of patient's belongings. S32 indicated MHT S29 watched all the patients in the Activity Group Room during the initial three hours of the shift while he did the admissions and while S31 assisted with snacks, phone time, and smoke break. S32 further indicated when the admission work for the two new patients had been completed, the decision was made to place Patient #22 in the Quiet Room located near the nursing station rather than her room because the room had observation glass around it allowing the nursing staff to see into the room from the nurse's station. S32 indicated this allowed the Mental Health Tech to observe the hallway for activity from other patients while at the same time making observations of Patient #22 who was ordered to be on 1:1 observations.

During a telephone interview on 06/24/10 at 9:40 a.m., MHT S31 indicated he worked the night shift on 06/22/10 when the Adult Unit was understaffed. S31 indicated all staff were busy with new admissions and unit activities until around 10:00 p.m. S31 indicated S32 did the two new admissions, S29 watched all the patients including the two 1:1 patients in the Activity Group Room, and he (S31) assisted patients with personal needs such as using the telephone, receiving snacks, and smoke breaks. S31 indicated after all patients were ready for bed, they placed Patient #22 in the Quiet Room near the nursing station rather than in her room. S31 indicated he was able to observe Patient #22 through the door of the room and observe the hall for patient activity at the same time. S31 indicated he would have RN (Registered Nurse) S21 watch Patient #22 when he made 15 minute checks on the other patients, because she was able to observe Patient #22 in the Quiet Room through the glass observation windows from the nursing station.

During a face-to-face interview on 6/24/2010 at 8:40 a.m., Patient #22 indicated she had slept in the Quiet Room on the night of her admission to the hospital (06/20/10). Patient #22 indicated she preferred sleeping in the Patient Room assigned to her rather than the Quiet Room. Patient #22 indicated the Quiet Room had been too loud and too bright.

During a telephone interview on 06/24/10 at 1:20 p.m., RN S21 indicated she made attempts to get extra staff on 06/22/10 but had been unsuccessful. S21 indicated there had been one MHT that had told them she would agree to come in if she could find transportation, but she had never come in. S21 confirmed that she had not reported the staffing deficit to anyone in administration to include the Interim Director of Nursing (S2) and/or theChief executive officer (S1). S21 indicated Patient #22 had been placed in the Quiet Room on the night shift of 06/22/10 in order to be observed by herself (S21) in addition to observations by MHT S31. RN S21 indicated she observed the patient when S31 made his 15 minute observations. S21 indicated Patient #22 slept most of the night and had a blanket wrapped around her. S21 indicated Patient #22 made no complaints. S21 indicated the lights had been on in the nursing station but were off in the Quiet Room. S21 indicated there may have been communication between staff members conducted at the nursing station; however, it would have been minimal.

During a face-to-face interview on 6/24/2010 at 11:15 a.m., Interim Director of Nursing S2 and Chief executive Officer S1 indicated the hospital had not been staffing the hospital according to acuity as required in the policy titled, "Patient Classification System". S1 and S2 indicated it had been the intention of the hospital to institute a new policy regarding staffing; although, it had not yet been done. S1 and S2 indicated they used the staffing grid based on hospital/unit census to staff the unit; however, depended on nursing staff to alert them when the acuity level goes up and extra staff are needed. S1 and S2 indicated no one had informed them of staffing deficits on the night shift for 06/20/10. Both indicated they would have come in themselves had they known. Both indicated patients on 1:1 observations levels should have one staff assigned to the one patient.

Review of the hospital policy titled, "Patient Classification System (approved 1/09)", presented by the hospital as their current policy, revealed in part, "It is the policy to measure the acuity level of each patient every morning using the Patient Classification Form. Inpatient staffing utilizes an established staffing matrix for allocation of HPPD (Hours Per Patient Day). Adjustments are made daily to staffing matrix through coordination of the Staffing Coordinator and Director of Nursing for each unit's acuity. . . Once evaluation and level assignment is complete the Charge Nurse will add up the number of Level I's, Level II's, and Level III's. Adds the number of Level I's (3.50), Level II's (2.5), and Level III's (2.0) HPPD. Indicates the total number of points at the bottom of the patient Classification form and divides by eight to determine the staffing requirements. The staffing requirements established are for one session. (Example) Total Level value = 15.5. 15.5 (divided by) 8 = 1.9 Full time equivalent (FTE). Level I: Intensive Supervision: Requires one to one emotional support more than twice per shift. Requires substantial assistance with toileting and bathing. Verbalizes active suicidal ideation and/or has made a suicidal gesture. Psychotic symptoms, high risk potential for aggressive behavior or verbally aggressive. Verbalizes death wish. Have medical issues that need to be addressed during patient day. Requires medical interventions (vital signs, accucheck) more than two times per shift. High fall risk. Level II: Moderate Supervision: Requires one to one emotional support no more than two times per shift. Assistance with toileting and bathing. Needs reminders to meet scheduled activities. Verbalizes passive suicidal ideation. Emotionally labile. Mild confusion, demanding, manipulative behavior. Hallucinations or delusions may be present but do not require frequent interventions. Regular monitoring of vital signs, I&O (intake and output), Nurse monitoring related to seizure disorder, diabetes. Patient teaching required. Moderate risk for falls. Level III: Minimum Supervision: Minimal Supervisor Interventions needed per shift. Primary self care with ACL's. Independently meets group schedule. No self destructive ideation. Reality oriented. Coping effectively. Communicating openly. Medically stable. No medical concerns."

Review of the staffing requirements grid outlined in the hospital policy titled, "Staffing Plan" revealed the minimum number of staff based on patient census (not acuity) for a census of 13 - 20 was 1 Registered Nurse, 2 Licensed Vocational Nurses (LVN), and 2 Mental Health Technicians. Further review revealed a red line was drawn through 2 LVN for a census of 13 - 20 with a handwritten notation in red indicating 1 (LVN). Review also revealed a red line drawn through 2 MHT (Mental Health Technicians) for a census of 13 - 20 with a handwritten notation in red ink indicating 3 MHT.

Review of the hospital policy titled, "Therapeutic Monitor, # 35", presented by the hospital as their current policy, revealed in part, "The Patient Therapeutic Monitor shall ensure patient safety by providing continuous visual observation and appropriate therapeutic intervention. 1. To ensure overall patient safety. 3. To prevent self injurious behaviors, i.e., cutting or sticking self with objects. 4. To provide safety and security for those patients with severely altered mental states. 5. To provide observation that is more intensive to the medically comprised patients, over and above the parameters of the routine 15-minute checks. The patient Therapeutic Monitor will maintain constant observation of the patient at all times. The patient Therapeutic Monitor shall not leave the patient unattended, or move out of the visual contact without obtaining coverage of the patient. The patient Therapeutic Monitor will not leave for breaks or meals until relieved by the RN or designated replacement".

Based on record review and interview, the hospital failed to ensure a Registered Nurse supervised and evaluated the nursing care for each patient by:
1) failing to clarify incomplete orders for 4 of 4 incomplete orders (#14, #16, #17, #R7) reviewed out of a total sample of 22 with 7 random patients;
2) failing to ensure a Registered Nurse (RN) developed and implemented a system for assessing and reporting a change in patients' condition for 7 of 7 patients (#1, #2, #8, #11, #12, #17, #22) with changes in condition reviewed out of a total sample of 22;
3) failing to ensure patients on suicidal precautions were assessed on each shift as per hospital policy for 2 of 2 patients reviewed with suicidal precautions out of a total sample of 22 (#16, #22); and
4) failing to assess a patient after a fall with injury for 1 of 2 random patients reviewed for falls with injury from a total of 4 patients with falls (#R5). Findings:

1) Failing to clarify incomplete orders:
Patient #14:
Review of Patient #14's medical record revealed the patient was admitted to the hospital under a physician's emergency certificate on 06/02/10 for "multiple suicidal threats and statements. . . passive suicidal plans". Further review revealed physicians's orders dated 06/02/10 at 12:30 p.m. revealed the pre-printed section of admission orders titled "Precaution (Select at least one): 1:1 (1 to 1 observations), SP (Suicide Precautions), HP (Homicide Precautions)), EP(Extrapyramidal Precautions) , BX (Behavior Precautions), Falls, Sz (Seizure Precautions)" to be blank. Further review revealed no documented evidence to indicate Patient #14's physician was contacted for clarification of the incomplete order regarding the level of observation to be implemented for Patient 14. This finding was confirmed by Chief Executive Officer S1 on 06/21/10 at 3:15 p.m. who further indicated every patient admitted to the hospital should have at least one precaution level ordered by their physician.

Patient #16:
Review of Patient #16's medical record revealed the patient was admitted to the hospital on 06/03/10 with diagnoses that included Psychosis Not Otherwise Specified and Bipolar Disorder. Medical Record review revealed a physician's order dated 06/02/10 at 2345 (11:45 p.m.) for Ativan 2 mg. (milligrams) PO (by mouth)/IM (intramuscular) q8h (every eight hours) prn (as needed) severe anxiety or insomnia. Further review revealed no documented evidence of parameters to indicate when the medication was to be given by mouth and/or when the medication was to be given intramuscularly. This finding was confirmed by Chief Executive Officer S1 and Interim Director of Nursing S2.

Patient #17:
Review of Patient #17's medical record revealed the patient was admitted to the hospital on 02/11/10 with diagnoses that included Chronic Paranoid Schizophrenia and Bipolar Disorder. Medical Record review revealed a physician's order dated 02/13/10 at 0800 (8:00 a.m.) for Ativan 2 mg. i (one) PO or IM / Haldol 5 mg i (one) PO or IM/ may be given together prn for severe agitation q8h. Further review revealed no documented evidence of parameters to indicate when the medication was to be given by mouth and/or when the medication was to be given intramuscularly. This finding was confirmed by Chief Executive Officer S1 and Interim Director of Nursing S2. S1 further indicated the hospital did not have a policy addressing parameters for medications ordered PO/IM, and the physician should have ordered specific parameters outlining when he wanted the medication to be given by mouth and when he wanted it given Intramuscularly.

Patient #R7:
Review of Patient #R7's medical record revealed an order dated 06/09/10 at 9:42 a.m. for "Haldol 5 mg., Ativan 2 mg., Benadryl 50 mg. IM or PO q6hrs prn agitation". Further review revealed no documented evidence of parameters to indicate when the medication was to be given by mouth and/or when the medication was to be given intramuscularly.

2) Failing to ensure a RN developed and implemented a system for assessing and reporting a change in patients' condition
Patient #1:
Review of Patient #1's medical record revealed the patient was admitted to the hospital on 06/16/10 under a Physician's Emergency Certificate for "Paranoid, refusing to eat because she does not know the cooks, threatening to light a lighter in her mouth, threatening other patients, aggressive and hitting. . ." Further review revealed Patient #1's Nutritional Risk Assessment to state "pt. denies" with no check marks or documentation identifying the patient's paranoid behavior resulting in refusing to eat due to not knowing the cooks. Review of Patient #1's "Vital Sign Record" revealed the patient's weight to be 323 on 06/16/10. Further review revealed the patient's weight to be 318 on 06/20/10 (5 pound weight loss in 4 days). Review of Patient #1's "Nutrition: Document % of meals consumed" located on the "Daily Nursing Assessment" form revealed the following: 06/16/10 dinner 20%, 06/17/10 lunch 25 %, 06/18/10 lunch 25 %, 06/18/10 dinner 0 %, 06/19/10 lunch 0 %, 06/19/10 dinner 50 %, and 06/20/10 lunch 30 %.

During a face-to-face interview on 6/21/2010 at 10:50 a.m., Interim Director of Nursing S2 indicated nursing staff should have assessed Patient #1's refusal to eat, weight loss, and varying food consumption. S2 indicated the hospital's dietician should have been consulted, and the treatment plan should have addressed the patient's paranoia regarding food preparation and refusal to eat.

Patient #2:
Review of Patient #2's medical record revealed the patient was admitted to the hospital on 06/20/10 under a Physician's Emergency Certificate for "caught having sex by mother and then tried to kill herself". Review of Patient #2's vital sign record for the date of 06/20/10 revealed the patient was 4 feet 11 inches tall and weighed 75 pounds. Patient #2 was discharged the following day with no repeat weight.

During a face-to-face interview on 06/22/10 at 3:50 p.m., Registered Dietician S18 indicated the acceptable weight for a patient 4 feet 11 inches tall would be 95 pounds. S18 indicated at 75 pounds the patient would be extremely underweight - visible to human eye. S18 indicated the weight was most likely inaccurate; however, there had been no reassessment of the patient's weight by nursing staff, and she had never been contacted regarding the patient's extremely low BMI (Body Mass Index) of 16.1. S18 indicated if the weight had been accurate, the patient would have been little more than "bones".

Patient #8
Review of Patient #8's medical record revealed he was admitted under a PEC (Physician Emergency Certificate) on 06/17/10 with diagnoses of Psychosis, Chronic Paranoid Schizophrenia, Suicidal Ideation, and Depression.
Review of Patient #8's "Nursing Assessment" performed on 06/17/10, with no documented evidence of the time of the assessment, revealed a weight of 210 pounds.
Review of Patient #8's "Vital Sign Record" revealed his weight on 06/20/10 at 0600 (6:00am) was 180, which was a 30 pound weight loss in 3 days. Review of the entire medical record revealed no documented evidence Patient #8's weight loss was reported to the RN (registered nurse), the weight was reassessed, and the weight was reported to the physician.
In a face-to-face interview on 06/22/10 at 3:55pm, Registered Dietitian S18 indicated weight reporting was a problem at the hospital that needed to be addressed.

Patient #11
Review of Patient #11's medical record revealed she was admitted on 06/17/10 with a diagnosis of Suicide Attempt. Review of the "Nursing Assessment" completed on 06/17/10 at 2150 (9:50pm) by RN S21 revealed a weight of 135 pounds.
Review of Patient #11's "Vital Sign Record" revealed her weight on 06/20/10 at 0600 (6:00am) was 123 pounds, a loss of 12 pounds in 3 days. Review of the entire medical record revealed no documented evidence that the RN was notified, the weight was reassessed, and the physician was notified.

In a face-to-face interview on 06/21/10 at 1:25pm, Interim Director of Nursing (DON) S2 indicated the Mental health Tech (MHT) should have reported the weight loss to the RN to be reassessed.

In a face-to-face interview on 06/23/10 at 10:10am, Psychiatrist S10, who was also the Medical Director and 20% owner of the hospital, indicated, when asked about weight loss not being assessed and reported by the RNs, that weights weren't "accurate at any hospital I'm at". He further indicated the scale probably had not been calibrated.

Patient #12
Review of Patient #12's medical record revealed he was a formal voluntary admit on 06/16/10 with diagnoses of Bipolar Disorder with Psychosis and Substance Induced Psychotic Disorder.
Review of Patient #12's "Nursing Assessment" completed on 06/16/10 at 1300 (1:00pm) by RN S26. Further review revealed Patient #11 was assessed as denying suicidal thoughts.
Review of Patient #12's "Daily Nursing Assessment" for 06/19/10 revealed the following "Additional Nursing Notes", in part, "06/19/10 0840 (8:40am) ... Pt. (patient) states he's here for trying to commit suicide. States he's hearing voices telling him to kill himself. Pt. states also that he will going home alone. (signature of Licensed Practical Nurse [LPN] S43) 06/19/10 0930 (9:30am) Pt. participating in a.m. group session (signature of LPN S43). 06/19/10 1800 (6:00pm) Ate (sign indicating approximately) 100% (per cent) dinner. Appetite good. Interacting more with peers & (and) staff. Will continue to monitor (signature of RN S17)". Review of the entire medical record revealed no documented evidence of LPN S43 reporting Patient #12's suicidal thoughts to RN S17, a suicide assessment by RN S17, and the report of suicidal thoughts to Psychiatrist S10, Patient #12's admitting physician.

In a face-to-face interview on 06/21/10 at 2:45pm, Interim DON S2 confirmed there was no evidence that Patient #12's report of suicidal thoughts had been reported to a RN, that the physician was notified, and that any action had been taken. She further indicated the LPN should have reported this event to the RN who should have notified the physician.

In a face-to-face interview on 06/23/10 at 8:40am, Interim DON S2 indicated the hospital had no policy and procedure for reporting a change in the patient's condition.

Patient #17:
Review of Patient #17's medical record revealed the patient was admitted to the hospital on 05/10/10 under a Physician's Emergency Certificate for "auditory hallucinations, feels like hurting others, paranoia". Review of Patient #17's "Vital Sign Record" revealed Patient #17's weight was 223 on 05/10/10, 219 on 05/13/10 (4 pound weight loss in 3 days), and 170 on 05/16/10 (49 pound weight loss in 3 days).

During a face-to-face interview on 06/22/10 at 10:35 a.m., Interim Director of Nursing S2 indicated she had no explanation as to how a patient would lose 49 pounds in 3 days. S2 further indicated after reviewing Patient #17's medical record that there had been no assessment done by nursing staff to evaluate the patient's documented weight fluctuation. S2 indicated nursing staff should have noticed the weight changes and assessed the patient for nutritional problems, the scale to ensure it was calibrated, and the staff for competency in the use of scales to weigh patients.

Patient #22:
Review of Patient #22's medical record revealed the patient was admitted to the hospital with diagnoses that included Major Depression and Polysubstance Abuse on 06/22/10. Further review revealed the patient was admitted under a Physicians Emergency Certificate dated 06/20/10 at 7:45 p.m. for "attempted suicide by taking 45 Seroquel pills". Review of Physician's orders dated 06/22/10 at 12:31 p.m. revealed the patient was ordered 1:1 SP (Suicide Precautions). Review of Patient #22's Vital Sign Record revealed Patient #22's weight was 156 on 06/22/10. Further review revealed Patient #22's documented weight as 147 on 06/24/10 (9 pound weight loss in 2 days). Further review revealed no documented evidence of an assessment regarding the decrease in Patient #22's weight. This finding was confirmed by Interim Director of Nursing S2 on 06/24/10 at 8:20 a.m.
Further review of Patient #22's Vital Sign Record revealed the patient's heart rate was 122 on 06/24/10 at 6:00 a.m.

During a face-to-face interview on 06/24/10 at 8:40 a.m., Patient #22 confirmed that she had beaten her head against the wall a few hours prior to the interview. Patient #22 indicated she did this to distract herself from the chronic pain she experienced in her legs (fibromyalgia). Patient #22 indicated creating pain by beating her head against the wall helps decrease the pain in the rest of her body. Patient #22 indicated she also pulls her hair out to help with the pain and has bald spots as a result.

During a face-to-face interview on 06/24/10 at 1:10 p.m., Interim Director of Nursing S2 indicated she had been told by Mental Health Tech (MHT) S31 that Patient #22 had beaten her head against the wall earlier in the morning (06/23/10 night shift/ 7 p.m. - 7 a.m.).

During a telephone interview on 06/24/10 at 1:20 p.m., RN S21 confirmed that she had worked 7 p.m. - 6 a.m. on 06/23/10. S21 indicated she had never been informed by MHT S31 that Patient #22 had hit her head against the wall. S21 confirmed that she had not documented a suicide assessment of Patient #22 on the night shift of 06/23/10.

During a face-to-face interview on 06/24/10 at 1:50 p.m., RN S26 indicated she had come in at 6:00 a.m. to relieve RN S21 who had been approved to leave early. S26 indicated she had been told by MHT S31 that Patient #22 had beaten her head against the wall. S26 indicated she had not performed any post trauma assessment on Patient #22 after hearing that the patient had beaten her head against the wall and had not interviewed the patient to determine the rationale behind her behavior.

During a face-to-face interview on 06/24/10 at 2:00 p.m., RN S25 indicated she had taken over the care of Patient #22 at 7:00 a.m. on 06/24/10. RN S25 indicated no one had reported to her that Patient #22 had beaten her head against the wall on the night shift. RN S25 indicated she would not have known that Patient #22 had never been assessed after beating her head against the wall. S25 indicated she had not assessed Patient #22's head.

Review of the hospital policy titled, "Nutritional Screening, AS-05" presented by the hospital as their current policy revealed in part, "Patients suffering from a psychiatric disorder are at high risk for nutritional deficiencies. Patients are screened for nutrition intervention as a component of the nursing assessment procedure. The Patient Centered Interdisciplinary Assessment form is used by the admitting nurse to assess nutritional risk factors; any identification of a nutritional trigger noted during the assessment will be communicated to the physician for review and order for dietician consult. Reassessments are done throughout treatment. If the RN identifies triggers during the Nutritional Screen sections of the Nursing Assessment, orders a dietary consult and notifies the physician of the identified triggers and requests need for dietician consult. Identified triggers may include: 2. Patient's appropriate weight for height and frame, as established from American Dietary Association norms for sex and age. 3. Evaluation of appetite and food tolerance. 5. Review of history of eating disorders and medical diagnoses that could establish the need for review by registered dietician. Nursing Staff: Monitors inpatient's food intake at every meal and documents same on graphic sheet in the medical record. Weighs patient weekly or according to physician orders or dieticians recommendations. Reports to physician if patient. . . has any other special nutritional needs."

Review of the hospital policy titled, "Documentation, Nursing, NSG 02", presented by the hospital as their current policy, revealed in part, "Documentation: Documents in the integrated progress notes a minimum of once per shift or at the time any pertinent event occurs."

3) Failing to ensure patients on suicidal precautions were assessed on each shift as per hospital policy
Patient #16:
Review of Patient #16's medical record revealed the patient was admitted to the hospital with diagnoses that included Psychosis Not Otherwise Specified and Bipolar Disorder on 06/02/10. Further review revealed the patient was admitted under a Physician's Emergency Certificate for "manic behavior, suicidal ideation". Review of Patient #16's physician's orders dated 06/02/10 at 2345 (11:45 p.m.) revealed an order for "SP (Suicide Precautions). Review of the entire medical record revealed no documented evidence of a shift assessment for suicidal ideations for 06/04/10 night shift (7 p.m. until 7 a.m.) or 06/05/10 day shift (7 a.m. - 7 p.m.) as per hospital policy. This finding was confirmed by Interim Director of Nursing S2.

Patient #22:
Review of Patient #22's medical record revealed the patient was admitted to the hospital with diagnoses that included Major Depression and Polysubstance Abuse on 06/22/10. Further review revealed the patient was admitted under a Physician's Emergency Certificate dated 06/20/10 at 7:45 p.m. for "attempted suicide by taking 45 Seroquel pills". Review of Physician's orders dated 06/22/10 at 12:31 p.m. revealed the patient was ordered 1:1 SP (Suicide Precautions). Review of the entire medical record revealed no documented evidence of a shift assessment for suicidal ideations for 06/23/10 night shift (7 p.m. - 7 a.m.). This finding was confirmed by Interim Director of Nursing S2.

During a face-to-face interview on 06/21010 at 3:15 p.m., Chief Executive Officer S1 indicated it had been the intention of the hospital's administrative staff to implement a new Suicide Assessment form for nursing staff to utilize for shift assessments on patients with suicidal ideation; however, the hospital had not yet created or implemented the new procedure. S1 indicated all nursing staff should follow hospital policy and assess suicidality every shift on patients presenting with suicidal ideation.

Review of the hospital policy titled, "Special Precautions, 05", presented by the hospital as their current policy, revealed in part, "Documentation shall include a suicide assessment every shift, patient response, and the discontinuation of monitoring. . . Assess patient's condition regarding danger to self or others every shift".

4) Failing to assess a patient after a fall
Review of Patient R5's medical record revealed she was admitted on 05/07/10 at 0400 under PEC with diagnoses of Depression and Suicidal.
Review of R5's "Daily Nursing Assessment" for 05/07/10 revealed an entry at 2120 (9:20pm) by RN S49 of "@ (at) nsg (nursing) station asking for med (medication) nurse she turned & walked toward her room & went to her knees then to floor, assisted (arrow up) to chair via staff x 3 ... has small raised red area over eye & R (right) knee has red area ... " .
Review of the entire medical record revealed no documented evidence of a complete head to toe assessment that included a neuro assessment and vital signs and education on fall precautions.

In a face-to-face interview on 06/25/10 at 10:15am, Interim DON S2 reviewed the medical record of R5 and verified there was no documented evidence neurochecks had been performed. Further S2 indicated that even if the neuro checks had not been ordered, a prudent nurse would have assessed her patient.


25065

Based on record review and interview, the hospital failed to ensure staff developed and implemented a nursing care plan for each patient by:
1) failing to follow physician's orders for 1 of 22 sampled patients (#21) and 1 of 2 random patients reviewed for falls with head injury from a total of 4 patients reviewed for falls (R4);
2) failing to ensure treatment plans were updated with changes in condition for 4 of 22 sampled patients (#1, #8, #11, #21); and
3) failing to ensure treatment plans were initiated and/or updated to address the patient's medical needs for 4 of 22 sampled patients (#7, #8, #9, #10). Findings:

1) Failing to follow physician's orders
Patient #21:
Review of Patient #21's medical record revealed physician's orders dated 06/21/10 at 1846 (6:46 p.m.) that included an order for "Calorie Count". Review of Patient #21's Dietary Progress notes revealed the following (in part): 06/21/10 at 1735 (5:35 p.m.) Calorie count: List all food and beverage eaten c (with) quantity. . . 06/22/10 at 1630 (4:30 p.m.) "Calorie Count: Partial 6/22 intake inadequate/ grossly. Recommend nursing monitor fluid status, re-attempt pt. (patient) wt. (weight) 6/23 a.m. and encourage fluid and food throughout day. Continue with calorie count and daily weights." Further review of the entire medical record revealed no documented evidence that a calorie count had been done. This finding was confirmed by Registered Dietician S18 on 06/22/10 at 3:50 p.m. who further indicated staff had done Intake and Output regarding fluids but had failed to list the foods eaten with the amount as she had requested.

Patient R4
Review of Patient R4's medical record revealed she was a formal voluntary admission on 12/29/09 with a diagnosis of Psychosis. Further review revealed her physician orders included fall precautions and activity with supervision.
Review of the "Incident Report" completed on 01/03/10 by RN S48 revealed Patient #R4 on 01/03/10 at 10:10am was "found after falling out of bed while attempting to get up alone. S/R (siderails) (arrow up) x (times) 2" in the patient's bedroom. Further review revealed the outcome was "pt. has a bruise on left forehead & cheek. She also bit her tongue. BP (blood pressure) 130/76 HR (heart rate) 102" . Further review revealed the investigation/prevention strategies was documented as a "high risk patient".
Review of the "Daily Nursing Assessment" for 01/03/10 revealed an entry at 1010 (10:10am) by RN S48 of "after hearing a noise, pt. was found lying next to bed after trying to get up. Bp 130/76, HR 102. She has a bruise on her left forehead & cheek. She also bit her tongue. She was alert & no change in orientation or LOC (level of consciousness)".
Review of the physician's orders revealed an order for neuro checks every 4 hours for 24 hours received by RN S48 from Nurse Practitioner (N.P.) S50.
Review of the entire medical record revealed no documented evidence that neuro checks were performed as ordered by N.P. S50.

In a face-to-face interview on 06/25/10 at 10:15am, S2 Interim DON (Director of Nursing) reviewed the medical record of Patient R4 and verified there was no neurochecks documented as ordered by the physician.

2) Failing to ensure treatment plans were updated with changes in condition
Patient #1:
Review of Patient #1's medical record revealed the patient was admitted to the hospital on 06/16/10 under a Physician's Emergency Certificate for "Paranoid, refusing to eat because she does not know the cooks, threatening to light a lighter in her mouth, threatening other patients, aggressive and hitting. . ." Further review revealed Patient #1's Nutritional Risk Assessment to state "pt. denies" with no check marks or documentation identifying the patient's paranoid behavior resulting in refusing to eat due to not knowing the cooks. Review of Patient #1's "Vital Sign Record" revealed the patient's weight to be 323 on 06/16/10. Further review revealed the patient's weight to be 318 on 06/20/10 (5 pound weight loss in 4 days). Review of Patient #1's "Nutrition: Document % of meals consumed" located on the "Daily Nursing Assessment" form revealed the following: 06/16/2010 dinner 20%, 06/17/10 lunch 25 %, 06/18/10 lunch 25 %, 06/18/10 dinner 0 %, 06/19/10 lunch 0 %, 06/19/10 dinner 50 %, and 06/20/10 lunch 30 %.

During a face-to-face interview on 06/21/10 at 10:50 a.m., Interim Director of Nursing S2 indicated nursing staff should have assessed Patient #1's refusal to eat, weight loss, and varying food consumption. S2 indicated the hospital's dietician should have been consulted, and the treatment plan should have addressed the patient's paranoia regarding food preparation and refusal to eat.

Patient #8
Review of the medical record for Patient #8 revealed he was admitted to the hospital on 06/17/10 suicidal ideation with a history of hypertension (HTN). Review of the initial nursing assessment Patient #8 weighed 210 pounds.
Review of the Vital Sign Record Sheet for Patient #8 revealed a weight of 180 pounds on 06/20/10 which represented a 30 pound weight loss in three days. Further review revealed no documented evidence the patient had been reweighed.
Review of the Plan of Care/Treatment Plan for Patient #8 revealed no documented evidence the care plan had been revised to reflect the weight loss of the patient.

Patient #11:
Review of Patient #11's medical record revealed she was admitted on 06/17/10 with a diagnosis of Suicide Attempt. Review of the "Nursing Assessment" completed on 06/17/10 at 2150 (9:50pm) by RN S21 revealed a weight of 135 pounds.
Review of Patient #11's "Vital Sign Record" revealed her weight on 06/20/10 at 0600 (6:00am) was 123 pounds, a loss of 12 pounds in 3 days. Review of the entire medical record revealed no documented evidence that the RN was notified, the weight was reassessed, and the physician was notified. Further review revealed no documented evidence the patient's care plan had been updated with the change in the patient's condition.

In a face-to-face interview on 06/21/10 at 1:25pm, Interim Director of Nursing (DON) S2 indicated the Mental Health Tech (MHT) should have reported the weight loss to the RN to be reassessed. She confirmed the patient's care plan had not been updated to reflect Patient #11's change in condition.

Patient #21:
Review of Patient #21's medical record revealed nursing notes dated 06/06/10 at 0300 (3:00 a.m.) indicating "Pt. called out, as she usually does when ever she wants something and staff rush to her room and found pt. sitting on floor near her bed. Pt. assisted up, help to wheelchair and taken to bathroom. Pt. refused to use wheelchair to go to her bed. Denies any pain/discomfort. (Administrator) notified of incident". Further review revealed no documented evidence of "potential risk for falls" being identified on the Master Treatment Plan Problem List with no documented interventions. This finding was confirmed by Interim Director of Nursing S2 on 06/23/10 at 10:00 a.m.

3) Failing to ensure treatment plans were initiated and/or updated to address the patient's medical needs
Patient #7
Review of the medical record for Patient #7 revealed she was admitted to the hospital on 06/18/10 for schizophrenia exacerbation. Review of the Plan of Care/Treatment Plan for Problem #2 Impaired Health related to patient history of Diabetes as evidenced by weight gain revealed the nursing staff was to notify the physician if patient's "blood sugar remains too high or too low". Further review revealed no documented parameters on the Physicians' Orders or Plan of Care.

The hospital could not submit a Standing Order or a Policy and Procedure which would clarify "too low or too high" blood sugars and the appropriate intervention to be taken by the nursing staff.

Patient #8
Review of the medical record for Patient #8 revealed he was admitted to the hospital on 06/17/10 suicidal ideation with a history of hypertension (HTN).
Review of Problem #2 Ineffective Management of Blood Pressure as evidenced by elevated blood pressure revealed clinical intervention #2 was to monitor and record patient's blood pressure; however the frequency had been left blank. Further clinical intervention #3 was to notify the physician if blood pressure remains too low or too high.
Review of the Physicians' Orders for Patient #8 revealed no documented parameters as to when to notify the physician of blood pressure which would be considered too low or too high.

Patient #9
Review of the medical record for Patient #9 revealed she was admitted to the hospital on 06/15/10 with bizarre delusions and a history of anemia, diabetes, hypothyroidism and hypernatremia. Review of the Plan of Care/Treatment Plan for Problem #2 Impaired Health related to patient history of hypothyroidism as evidenced by poor diet and intolerance to cold revealed the following short term goals had been checked off (to be implemented) with the required information to complete the goals had been left blank: a) Patient will verbalize a ____% increase regarding insight hypothyroidism within ___ days. Problem #3 Impaired Health related to patient's history of Diabetes revealed the following short term goals had been checked off (to be implemented) with the required information to complete the goals had been left blank: a) patient will comply ____% with diabetic diet with _____ days; b) patient will comply ____% with diabetic medications/insulin within _____ days; c) patient will verbalize and demonstrate a ______% increase in insight regarding diabetes within ____ days. Further review revealed these goals were identified on 06/15/10 and were expected to be achieved by 06/20/10; however there was no documented evidence of the status of these goals as of the review on 06/21/10 by the surveyor.

Patient #10
Review of the medical record for Patient #10 revealed he was admitted to the hospital on 06/16/10 suicidal ideation with a history of hypertension (HTN). Review of the Plan of Care/Treatment Plan revealed Problem #2 Ineffective Management of Blood Pressure as evidenced by elevated blood pressure with the clinical intervention #2 was to monitor and record patient's blood pressure; however the frequency had been left blank. Further clinical intervention #3 was to notify if blood pressure remains too low or too high.
Review of the Physicians' Orders for Patient #10 revealed no documented parameters as to when to notify the physician of blood pressure which would be considered too low or too high.

The hospital could not submit a policy and procedure for blood pressure which included parameters/guidelines on when the physician should be notified about a patient's blood pressure.

In a face-to-face interview on 06/25/10 at 10:00am, S2 Interim DON indicated, to her knowledge, there was no policy for blood pressure parameters. Further she indicated she could not say for certain exactly what pressures would be considered too low or too high in order to notify the physician.



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25065

Based on observation, record review, and interview, the hospital failed to: 1) ensure nursing staff were determined competent and knowledgeable in the use of emergency equipment as evidenced by failure to ensure all nursing staff were knowledgeable in the use of the Ambu bag in the event emergency-assisted ventilation were to be needed for a patient for 1 of 4 nurses reviewed for use of an Ambu (S19); 2) follow hospital policy for drug screening and background checks prior to employment for 6 of 7 nurses reviewed from a total of 34 nurses (S4, S19, S21, S22, S25, S33) and 6 of 6 mental health technicians (MHTs) reviewed from a total of 30 MHTs (S7, S20, S23, S29, S31, S32); 3) ensure the nursing staff were determined competent and knowledgeable in nonviolent crisis intervention (CPI) and CPR (cardiopulmonary resuscitation) as evidenced by failure to have documented evidence of current CPI certification for 7 of 7 nurses reviewed for CPI certification from a total of 34 nurses (S2, S4, S19, S21, S22, S25, S33) and 6 of 6 MHTs reviewed for CPI certification from a total of 30 MHTs (S7, S20, S23, S29, S31, S32) and current CPR certification for 3 of 6 MHTs reviewed for CPR certification from a total of 30 MHTs (S7, S20, S32); and 4) ensure the nursing staff were determined competent and knowledgeable of their job functions prior to performing patient care for 5 of 7 nurses reviewed from a total of 34 nurses (S2, S4, S21, S22, S25) and 5 of 6 MHTs reviewed from a total of 30 MHTs (S7, S20, S23, S29, S31). Findings:

1) Competent in use of Ambu bag
Observations and interviews were conducted on 06/22/10 at 3:10 p.m. with Licensed Practical Nurse (LPN) S19. LPN S19 was observed changing the cylinder head on an oxygen tank (E cylinder). During a face-to-face interview at the time of the observation, LPN S19 indicated, in the event a patient would need to be ventilated with an Ambu bag during emergency resuscitation efforts, she would apply 2 liters of oxygen to the Ambu bag. After a few seconds, S19 changed her statement and indicated it would require 5 liters of oxygen flow to the Ambu bag.

Interim Director of Nursing (DON) S2 indicated in an interview on 06/22/10 at 3:25 p.m. that resuscitation with an Ambu required 15 liters of oxygen. S2 indicated this information had recently been reviewed in a hospital wide in-service (confirmed with education documentation review), and all staff should be knowledgeable in the use of an Ambu which included the need to connect to 15 liters of oxygen.

2) Drug screening and background checks
Review of the personnel files of Licensed Practical Nurse (LPN) S4, LPN S19, Registered Nurse (RN) S21, RN S25, LPN S33, MHT S23, MHT S31, and MHT S32 revealed no documented evidence that a drug screen had been performed as required for employment by hospital policy.

Review of LPN S4's personnel file revealed a hire date of 10/05/09. Further review revealed S4's background check was requested on 11/02/09 and completed 11/03/09, 29 days after hire.

Review of LPN S19's personnel file revealed a hire date of 04/09/09. Further review revealed S19's background check was requested on 04/21/09 and completed on 04/21/09, 12 days after her hire date.

Review of RN S21's personnel file revealed a hire date of 04/06/10. Further review revealed no documented evidence of a background check being requested and completed for S21.

Review of RN S22's personnel file revealed a hire date of 03/16/09. Further review revealed S22's background check was requested 03/18/09 and completed 03/26/09, 10 days after her date of hire.

Review of RN S25's personnel file revealed a hire date of 03/14/09. Further review revealed S25's background check was requested 05/20/09 and completed 05/21/09, more than 2 months after her hire date.

Review of LPN S33's personnel file revealed a hire date of 03/22/10. Further review revealed no documented evidence of a background check being requested and completed for S33.

Review of MHT S7's personnel file revealed a hire date of 03/10/10. Further review revealed S7's background check was not performed by Company A, the contracted research company.

Review of MHT S20's personnel file revealed a hire date of 08/25/09. Further review revealed S20's background check was requested 11/02/09 and completed 11/03/09, more than 1 month after S20's hire date.

Review of MHT S23's personnel file revealed a hire date of 04/06/10. Further review revealed no documented evidence of a background check being requested and completed for S23.

Review of MHT S29's personnel file revealed a hire date of 03/19/09. Further review revealed S29's background check was requested 03/19/09 and completed 03/26/09, 7 days after S29's hire date.

Review of MHT S31's personnel file revealed a hire date of 08/14/09. Further review revealed S31's background check was requested 11/02/09 and completed 11/03/09, more than 2 months after S31's hire date.

Review of MHT S32's personnel file revealed a hire date of 03/14/09. Further review revealed S32's background check was requested 04/20/09 and completed 04/21/09, more than 1 month after S32's hire date.

In a face-to-face interview on 06/22/10 at 4:25pm, Chief Executive Officer (CEO) S1, when informed of no evidence in the personnel files of background checks and drug screens, could offer no explanation for these not being performed.

In a face-to-face interview on 06/23/10 at 8:45am, Human Resources (HR) Director S16 indicated she was responsible for the employees' personnel files. She further indicated it was the responsibility of former DON (director of nursing) S40 to perform drug screens prior to an applicant being hired, but S40 didn't do them. S16 further indicated she reported this to the Administrator when it was not done. S16 indicated background checks were not performed, because the "corporate office quit paying the bill". She further indicated that some employees brought background check results from former employers or had them done on their own. S16 indicated this occurrence was reported to the Administrator.

In a face-to-face interview on 06/25/10 at 8:15am, CEO S1 presented the balance details revealing the balance due the research company was paid on 03/15/10. She indicated that she was told by HR Director S16 that S16 could not get a background check completed.

In a face-to-face interview on 06/25/10 at 8:25am, HR Director S16 indicated she had tried to do a background check 3 weeks ago and received an answer of "access denied". She further indicated she had no documented evidence that this search had been attempted. With CEO S1 present during this interview, neither S16 nor S1 could offer an explanation for a background check not being performed for RN S21 who was hired 04/06/10, LPN S33 who was hired 03/22/10, and MHT S23 who was hired 04/06/10, all after 03/15/10 when the research company balance showed $0.

Review of the hospital policy titled "Drug Free Workplace", approved 01/09, revealed, in part, "...All offers of employment will be conditional pending successful completion of a drug screen..."

Review of the hospital policy titled "Reference and Background Checks", approved 01/09, revealed, in part, "...Reference and Background Checks are to be conducted on all final applicants for employment before an offer is extended. ... Offers of employment are contingent on favorable references and background investigations. ... Background Checks for New Hires: Human Resources will utilize Company A to obtain the information and will advise the hiring manager of the eligibility for hire...".

3) CPI and CPR
Review of the personnel files of Interim DON S2, LPN S4, LPN S19, RN S21, RN S22, RN S25, LPN S33, MHT 7, MHT S20, MHT S23, MHT S29, MHT S31, and MHT S32 revealed no documented evidence of current certification/training in nonviolent crisis intervention.

Review of the personnel files of MHT S7, MHT S20, and MHT S32 revealed no documented evidence of current certification in CPR.

Review of the "Performance Improvement Corrective Action Plan for CPI Training ... 3/2010" signed by CEO S1, who signed as the Performance Coordinator, revealed, in part, "Area/Indicator of Concern (indicate dates) Employees need more training on Crisis Prevention Intervention; Recommended Action: Staff Training ... Responsibility ... responded that she will be willing to get certification if (name of hospital) would pay for it. Reported to HR Director S16 03/10/10; Improvement Expected By 2nd Quarter; Expected Date of resolution May 2010; Outcome: CPI Seminar to be held ... 03/29/10 - 04/01/10. Information regarding price/benefit submitted to Administrator 03/18/10".

In a face-to-face interview on 06/22/10 at 4:25pm, CEO S1 could offer no explanation for not having current CPR and CPI training for employees.

In a face-to-face interview on 06/23/10 at 8:45am, HR Director S16 indicated she was responsible for having current CPR and CPI certifications done, but the corporate office had not been reimbursing the training.

In a face-to-face interview on 06/23/10 at 10:10am, Psychiatrist S10, who was also the Medical Director and 20% (per cent) owner of the hospital indicated, when asked why the nursing staff were not current with CPR and CPI training, he was aware that the former Administrator had to use his personal funds to pay some vendors.

Review of the hospital policy titled "Orientation and Mandatory Annual Refresher Education", approved 01/09, revealed, in part, "...all employees are required to be certified (or recertified) in crisis prevention and intervention. All employees who have direct patient contact are also required to be certified in cardio-pulmonary resuscitation (CPR)...".

Review of the "Mental Health Technician Job Description", presented by HR Director S16 as the hospital's current MHT job description, revealed CPR and CPI were special skills and knowledge required for this position.

Review of the "Job Description - Licensed Practical Nurse", presented by HR Director S16 as the hospital's current LPN job description, revealed the LPN's professional development responsibilities included maintaining certification in CPR and CPI.

Review of the "Job Description - Registered Nurse", presented by HR Director S16 as the hospital's current RN job description, revealed the RN's professional development responsibilities included maintaining certification in CPR and CPI.

4) Competent and knowledgeable of job functions
Review of Interim DON S2's "Initial Skills Competencies/Checklist" revealed a self-assessment was completed by S2 with no documented evidence of the date of completion. Further review revealed no documented evidence of a preceptor's assessment of competency and the method of evaluation of competency. The form was signed by former DON S40 on 04/09/09.

Review of LPN S4's personnel file revealed a hire date of 10/05/09. Review of the "Initial Skills Competencies/Checklist" revealed a self-assessment was completed by S4 on 10/05/09. Further review revealed no documented evidence of a preceptor's assessment of competency and the method of evaluation of competency, The form was signed by former DON S40 on 11/19/09.

Review of RN S21's personnel file revealed a hire date of 04/06/10. Review of the "Review Assessment Drug Treatment of Mental Illness" revealed 2 questions with no documented evidence of an answer (the letter written was lined through) and no documented evidence that the test had been scored. Further review revealed instructions of "please read each question carefully and select the most appropriate answer. Note you must complete this test with a passing score of 80 or above. If you do not make a passing score, you will need to contact the Director to schedule a time to re-take the test".

Review of RN S22's prsonnel file revealed a hire date of 03/16/09. Review of the "Initial Skills Competencies/Checklist" revealed a self-assessment was completed by S22 with no documented evidence of the date it was completed. Further review revealed no documented evidence of a preceptor's assessment of competency, and the form was signed by former DON S40 on 04/09/09.

Review of RN S25's personnel file revealed a hire date of 03/14/09. Review of the "Initial Skills Competencies/Checklist" revealed a self-assessment was completed by S25 with no documented evidence of the date it was completed. Further review revealed no documented evidence of a preceptor's assessment of competency, and the form was signed by former DON S40 on 04/19/09.

Review of MHT S7's personnel file revealed a hire date of 03/10/10. Further review revealed no documented evidence of orientation and assessment of competency prior to assignment of patient care.

Review of MHT S20's personnel file revealed a hire date of 08/25/09. Review of the "Initial Skills Competencies/Checklist" revealed a self-assessment was completed by S20 with no documented evidence of the date it was completed. Further review revealed there was no documented evidence of a preceptor's assessment of some areas of the tasks/skills. Former DON S40 signed as the preceptor, and there was no documented evidence of a supervisor's signature.

Review of MHT S23's personnel file revealed a hire date of 04/06/10. Further review revealed no documented evidence an assessment of competency had been performed prior to S23 performing patient care.

Review of MHT S29's personnel file revealed a hire date of 03/19/09. Review of the "Initial Skills Competencies/Checklist" revealed a self-assessment was completed by S29 on 04/08/09. Further review revealed no documented evidence of an assessment of competency by a preceptor and the method of evaluation. The form was signed by S29 as the preceptor and by former DON S40 on 04/08/09.

Review of MHT S31's personnel file revealed a hire date of 08/14/09. Review of the "Initial Skills Competencies/Checklist" revealed a self-assessment was completed by S31 on 11/30/09. Further review revealed no documented evidence of an assessment of competency by a preceptor. The form was signed by former DON S40 on 11/30/09.

Review of the task/skill revealed tasks not related to duties of a MHT such as: admission interview/assessment; restraint/seclusion assessment; physical assessment; mental status assessment; risk assessments; AIMS (involuntary movement scale); Folstein Mini-Mental Status; admission order; medications/communicating to pharmacy; lab/radiology/communicating to lab; therapies/activities/diet; consults; initiation of the plan of care; medication variance/adverse drug reaction reports; written consent to release restraint/seclusion use; documentation of less restrictive measures attempted and patient's response to each; documentation of interventions to meet patient's needs for nutrition, hydration, toileting, circulation and psychological support.

In a face-to-face interview on 06/22/10 at 4:25pm, CEO S1 indicated former DON S40 didn't do any employee education and competency assessments.

Review of the hospital policy titled "Clinical Competency", approved 01/09, revealed, in part, "...It is the policy of the facility that clinical and nursing staff members will receive a comprehensive orientation at the onset of employment. This shall include a minimum of facility-wide and departmental and unit-based orientations. Clinical competency shall be determined by the clinical supervisor of the employee. ... Employee's Supervisor Administers clinical competency skills checklists; determines areas where employee is proficient; schedules inservices or supervisory sessions... monitors employee's proficiency improvement progress... Supervisor routes completed competency checklists to Human Resource personnel for filing...".


25065

Based on record review and interview, the hospital: 1) failed to ensure medical records were promptly completed resulting in 42 medical records greater then 60 days delinquent with discharge dates from 02/16/10 through 04/21/10; 2) failed to ensure the hospital had adequate space for filing medical records which resulted in 76 unfiled medical records from the years 2009 through 2010; 3) failed to ensure medical records were stored in a manner to prevent the possibility of damage from water; and 4) failed to ensure medical records were accurately written and promptly completed for 2 of 22 patients (#11, #12). Findings:


1) Failed to ensure medical records were promptly completed resulting in 42 medical records greater then 60 days delinquent with discharge dates from 02/16/10 through 04/21/10:

Review of a Medical Records data sheet titled, "FBH (Focus Behavioral Hospital/28 bed hospital) Delinquent 60 days or more" revealed 42 medical records with discharge dates from 02/16/10 through 04/21/10.

This finding was confirmed by Health Information Manager S5 who further indicated in an interview on 06/22/10 at 10:30 a.m. that all communication with physicians regarding the need to complete delinquent medical records had been done verbally. S5 indicated there had been no written notification. S5 indicated Medical Staff Bylaws regarding delinquent medical records had not been implemented, and the two physicians (Psychiatrist S10, Psychiatrist S11) with delinquencies greater than 60 days had never been suspended.

This finding was also confirmed by Chief Executive Officer S1 on 06/22/10 at 11:00 a.m. S1 further indicated she had never sent a letter to any physician regarding medical records delinquent for 30 days as indicated in the Medical Staff Bylaws.

Review of Medical Staff Bylaws, presented by the hospital as current, revealed in part, "Reasonable efforts by the Medical Record Department shall be made to obtain completed medical records from the physician within 15 days following discharge of the patient. The Medical Records Coordinator shall present a list of delinquent records at the quarterly Medical Staff meeting. If these efforts fail and records remain delinquent after (30) days following discharge, the physician will receive a warning letter from the Administrator allowing three (3) days for the completion of the delinquent records; and, if these measures are not successful, a temporary suspension letter will be sent by registered mail and the physician will remain suspended until such time as the records are completed."

2) Failed to ensure the hospital had adequate space for filing medical records which resulted in 76 unfiled medical records from the years 2009 through 2010:

Observations on 06/22/10 at 10:30 a.m. revealed 76 medical records located on two table top shelves in the Medical Records Department. One table top shelf contained 56 medical records from the year of 2009 and the other contained 20 medical records from the year 2010.

During a face-to-face interview on 06/22010 at 10:30 a.m., Health Information Manager S5 indicated the hospital had no additional space in the four filing cabinets located in the Medical Records Department; therefore, the 76 medical records found on table top shelves in the department could not been filed.

3) Failed to ensure medical records were stored in a manner to prevent the possibility of damage from water:

Observations on 06/21/10 at 10:30 a.m. revealed 3 storage cabinets located in the Medical Records Department to be open shelves with no means of covering the medical records when not in use. Further observations revealed sprinklers located on the ceiling in the Medical Records Department where the cabinets were located. These sprinklers had the potential of saturating all medical records stored on the 3 open shelved cabinets in the Medical Records Department in the event the sprinklers were activated.

This finding was confirmed by Health Information Manager S5 at the time of the observations (06/21/10 at 10:30 a.m.).

4) Failed to ensure medical records were accurately written and promptly completed:

Patient #11
Review of Patient #11's medical record revealed she was admitted on 06/17/10.
Review of the "Clinical Summary/Master Treatment Plan" revealed it was completed by Licensed Clinical Socail Worker (LCSW) S6 on 06/18/10 with no documented evidence of the time of completion. Further review revealed a statement above the signature of S6 that included "I have reviewed the following multidisciplinary assessments; Intake assessment, H&P (history and physical), psychiatric evaluation, nursing assessment, psychosocial assessment, Psychiatric testing, prior records, and the initial physician's orders. An integration of information and a master treatment plan has been formulated from all assessments". Further review of Patient #11's treatment revealed the Axis I, Axis II, Axis III, and Axis IV sections were blank; the barriers to treatment were blank; the problem list was blank; and there was no documented evidence the physician had signed the plan. Further review of Patient #11's medical record revealed the psychiatric evaluation was not on the medical record as of 06/21/10 at 11:40am when it was reviewed by the surveyor.
Review of Patient #11's "Nursing Assessment" completed by Registered Nurse (RN) S21 on 06/17/10 at 2150 (9:50pm) revealed no documented evidence that the assessment of educational needs had been completed.

Patient #12
Review of Patient #12's medical record revealed he was admitted on 06/16/10. Review of the "Patient Observation Record" for 06/19/10 and 06/20/10 revealed no documented evidence of the type of observation that was performed.
Review of Patient #12's EKG (electrocardiogram) report revealed no documented evidence of a hand-written date and time on the record. Further review revealed the computer written date and time documented was 01/01/70 at 00:00.
Review of Patient #12's "Nursing Assessment" completed by RN S26 on 06/16/10 at 1300 (1:00pm) revealed no documented evidence of the legal status of the patient.
Review of the "Activity Therapy Evaluation" completed by Certified Therapeutic Recreation Specialist S41 on 06/17/10 at 6:30pm revealed the name, admit date/time, evaluation date, patient number, diagnosis, date of birth, age, medical record number, and special diet were blank. Further review revealed a note of "refer to H&P (history and physical) for "condition affecting participation".
Review of Patient #12's "Clinical Summary/Master Treatment Plan" revealed it was completed by LCSW S6 on 06/16/10 with no documented evidence of the date of completion. Further review revealed barriers to treatment was blank, family involvement was blank, and estimated length of stay and anticipated discharge date were blank.

Patient #20
Review of the medical record for Patient #20 revealed he was a 54 year old male who had been admitted to the hospital on 05/29/10 for suicidal ideation and depression. Review of the EKG which had been ordered on admit revealed it had been performed on 01/01/1970. Further review revealed .... " Pediatric analysis: Normal sinus rhythm " .

In a face-to-face interview on 06/21/10 at 1:25pm, Interim DON S2 could offer no explanation for the incomplete documentation in the medical record.

In a face-to-face interview on 06/21/10 at 2:45pm, Interim DON S2 confirmed the EKG reports had the wrong date, year, and time.

Review of the Medical Staff Rules and Regulations revealed, in part, "...The psychiatrist medical doctor (M.D.) or doctor of osteopathy (D.O.) under whose care the patient was admitted shall be responsible for the preparation of a comprehensive, legible medical record for each patient treated...". Further review revealed no documented evidence that accuracy and completeness of documentation was addressed in the rules and regulations.







25065

Based on review of the medical records, Medical Staff Rules and Regulations and interview the hospital failed to ensure all progress notes had been dated and timed by the licensed practitioner making the entry for 1 of 21 sampled records (Patient #15). Findings:

Review of the Progress Notes for Patient #15 revealed progress notes dated 05/29/10 and 05/30/10 were not timed.

Review of the Progress Note for Patient #4 revealed the progress note dated 06/17/10 was not timed.

The Medical Staff Rules and Regulations were reviewed. Documentation revealed in part, "All clinical entries in the patient's medical record shall be accurately dated and authenticated within forty-eight hours.

Based on record review and interview, the hospital failed to follow its medical staff rules and regulations for authentication of verbal/telephone orders by failing to have verbal/telephone orders signed within 48 hours of giving the order for 5 of 22 sampled patients reviewed for verbal/telephone authentication from a total of 22 sampled patients (#9, #10, #11, #12, #19). Findings:

Patient #9
Review of the Physicians' Orders for Patient #9 revealed no date or time the physician signed the verbal order on the following dates and times: 06/15/10 at 1745 (5:45pm), 06/15/10 at 1830 (6:30pm), 06/17/10at 11:35am, and 07/17/10 1700 (5:00pm).

Patient #10
Review of Patient #10's Admit Orders dated 06/16/10 at 1630 (4:30pm) revealed no documented evidence how the nurse hd received the orders (verbal or telephone) and there was no documented evidence that the orders had been signed by Psychiatrist S10 as of 06/21/10. Review of the verbal orders dated/timed 06/17/10 at 900 (9:00am)given by physician S10 revealed no documented evidence the orders had been signed as of 06/21/10 and verbal orders dated/timed 06/17/10 at 1420 (2:20) pm revealed no documented evidence of the date and time the orders had been signed by physician S9.

Patient #11
Review of Patient #11's "Physician Admit Orders & (and) Problem List" received by telephone on 06/17/10 at 2010 (8:10pm) revealed no documented evidence that it had been signed by Psychiatrist S10 as of 06/21/10.

Patient #12
Review of Patient #12's "Physician Admit Orders & Problem List" received by telephone on 06/16/10 at 1300 (1:00pm) revealed no documented evidence of the date and time Psychiatrist S10 authenticated the telephone order.

Patient #19
Review of the medical record for Patient #19 revealed verbal orders dated 05/26/10 and 05/27/10. There was no documented evidence of a physician's signature as of 06/23/10.

In a face-to-face interview on 06/21/10 at 1:25pm, Interim Director of Nursing S2 confirmed the telephone orders had not been authenticated within 48 hours.

Review of the hospital's Medical Staff Rules and Regulations revealed, in part "A verbal order shall be considered to be in writing if dictated to a licensed professional nurse functioning within his/her sphere of competency and signed by the responsible practitioner. . . The responsible practitioner shall authenticate such orders within forty-eight hours, and failure to do so shall be brought to the attention of the Executive Committee for appropriate action."








25065

Based on record review and interview, the hospital failed to follow its policy for obtaining a properly executed informed consent by failing to obtain the signature of the patient and/or the patient's responsible party for 1 of 22 patients reviewed for completion of the informed consent from a total of 22 sampled patients (#4) Findings:

Patient #4
Review of Patient #4's medical record on 06/21/10 (12 days since admission) revealed an admit date of 06/09/10. Further review revealed no documented evidence of the patient's or representative's signature on the "Consents" (which included consent for treatment, authorization for disclosure, family/significant other acknowledgement of presence, receipt of patient rights, advance directive acknowledgement, notice of privacy practices, no harm contract, financial responsibility, medicare secondary payer que. Further documentation by the RN (registered nurse) revealed, "Pt (patient) unable to sign-pt with severe psychosis, delusional, loose thoughts, oriented to person, situation only."

Patient #4 was interviewed on 06/21/10 at 11am. She was alert, answered questions appropriately and voiced no complaints.

S1 Administrator was interviewed face-to-face on 06/21/10 at 11:40am. She confirmed staff should have followed up on Patient #4's consents. She stated, "I would think they would follow up every shift."

Review of the hospital policy titled, "Informed Consents, RTS 25", presented by the hospital as their current policy, revealed, in part, "It is the policy of Focus Behavioral Hospital is to consider and respect patient rights and need for relevant information through informed consent. Each patient has a right to clear information about his/her behavioral healtcare and possible treatment options."

Based on record review and interview, the hospital failed to ensure the patient's medical record contained reports of ordered laboratory tests for 1 of 22 sampled patients (#12). Findings:

Review of Patient #12's medical revealed an admit order on 06/16/10 at 1300 (1:00pm) that included an order for a urine drug screen.
Review of the entire medical record on 06/21/10 revealed no documented evidence of a drug screen result on the chart.

In a face-to-face interview on 06/21/10 at 2:45pm, Interim Director of Nursing S2 confirmed the drug screen results were not on Patient #12's medical record.

Review of the policies and procedures presented by Chief Executive Officer S1 for Lab Services revealed no documented evidence of a policy regarding the reporting and filing of lab reports (other than critical lab values) on the medical record.

Review of the Medical Staff Rules and Regulations revealed, in part, "...The psychiatrist medical doctor (M.D.) or doctor of osteopathy (D.O.) under whose care the patient was admitted shall be responsible for the preparation of a comprehensive, legible medical record for each patient treated. The contents shall be pertinent and current. The admitted patient's record shall include ... clinical laboratory ... reports...".

Based on record review and interview, the hospital failed to ensure medications were available for administration to patients as ordered by the physician for 4 of 22 sampled patients (#3, #9, #10, #17). Findings:

Review of the contract for Pharmacy services dated 12/02/09 revealed in Appendix A, "5. Providing routine and timely pharmacy service for the Facility in-patients 7 days per week and as necessary to meet patient needs".

Review of the Pharmacy Hours and Delivery Schedule submitted to the hospital by the contracted pharmacy revealed the following pharmacy hours: Monday - Friday 8:00am - 6:00pm. After hours, Weekends and Holidays - 24 hour On-Call Availability. Ordering of Medications: Routine Refills and New Medication Orders may be faxed during regular business hours. Emergency/Stat Orders/After hour orders - must be called to the pharmacy. Delivery Hours: Monday-Friday 3 (three) Scheduled deliveries will be made between approximately 10am-1:00pm, 2:00pm-5:00pm and 7:00pm-10:00pm. Saturday and Sunday 1 (one) Scheduled Delivery (no time documented). Emergency Deliveries on an as needed basis with an anticipated turn around time of 2 hours.

Review of the contract pharmacy policy # 2.01 dated 03/18/09 revealed.... "New medication orders received by Pharmacy will be available for administration on the day ordered by the physician and/or prior to the scheduled first dose".

Patient #3:
Review of Patient #3's medical record revealed physician's orders dated 06/18/10 as follows: 1055 (10:55 a.m.) Risperdal consta 50 milligrams every 2 weeks - give first dose now. 1600 (4:00 p.m.) OK to give Risperdal Consta when arrives. Review of Patient #3's nursing notes dated 06/18/10 at 1815 (6:15 p.m.), 6 hours and 20 minutes after ordered by the physician, revealed "Pt. received IM dosage of Risperdal consta (with) sterile technique per Medicine nurse. . . tolerated injection well, (no) complaints voiced".

During a face-to-face interview on 6/21/2010 at 11:50 a.m., LPN (Licensed Practical Nurse) S4 indicated she had sent pharmacy a fax requesting Risperdal Consta when she received the order. S4 further indicated she called the pharmacy back every 30 minutes, and they continued to tell her it would arrive with the next batch of medication. S4 indicated it did not arrive until 6:15 p.m. (6 hours and 20 minutes after ordered by the physician). S4 further indicated she did not do an occurrence report/incident report.

Patient #9
Review of the medical record for Patient #9 revealed she was admitted to the hospital for altered thought processes, schizophrenia and delusions on 06/15/10. Review of the Physicians' Orders dated 06/17/10 at 11:25am revealed an order for "second loading dose of Invega Sustena 156mg IM (Intramuscular) as soon as available".

Review of the MAR (Medication Administration Record for Patient #9 revealed.... "Invega Sustena 156mg IM as soon as available, called pharmacy won't be available until 06/18/10".

Patient #10
Review of the medical record for Patient #10 revealed he had been admitted to the hospital on 06/16/10 for depression with a history of COPD (Chronic Obstructive Pulmonary Disease). Review of the Review of the Physicians' Orders for Admit revealed an order for Advair Diskus bid (twice a day) inhalant.

Review of the MAR for Patient #10 revealed Advair could not be administered because it was unavailable in the pharmacy. Further review of the MAR revealed no substitution had been made for with a similar drug for the Advair which is used in the treatment of respiratory disease, and that Patient #10 missed the dose on 06/16/10 at 2100 (9:00pm) and was administered the 06/17/10 0900 (9:00am) dose at 1400 (2:00pm) or 5 hours late.

Patient #17:
Review of Patient #17's physician's orders dated 05/12/10 at 1600 (4:00 p.m.) revealed an order for "Saphris 10 mg. (milligrams) PO (by mouth) bid (two times per day)". Review of Patient #17's Medication Administration Record revealed the next scheduled dosage of Saphris was due at 2100 (9:00 p.m./5 hours after the physician ordered the medication). Further review revealed Patient #17 did not receive the medication until 2315 (2 hours and 15 minutes after the scheduled dosage).

During a face-to-face interview on 06/22/10 at 10:35 a.m., Director of Nursing S2 indicated medication availability varies due to delivery times by the contracted pharmacy. S2 further indicated nursing staff have not made it a practice to complete occurrence reports for missed medications.

During a telephone interview on 06/24/10 at 2:45 p.m., Pharmacy Director S34 indicated the pharmacy delivery times vary; however, typically they are scheduled for 10:00 a.m., 12:00 p.m., and between 6:00 and 7:00 p.m. for routine deliveries. S34 indicated stat orders are provided within 2 hours of receiving order. S34 indicated the Pharmacy's goal is to have medication available for the next scheduled dose when an order is received.

During a telephone interview on 06/24/10 at 2:50 p.m., Pharmacy Compliance Officer S35 indicated she investigates all occurrence reports from the hospital; however, if no occurrence report is generated by the hospital she would not investigate.

Based on interview, the hospital failed to ensure a radiologist was credentialed and appointed to the medical staff by having no documented evidence that a radiologist had been appointed to the medical staff. Findings:

In a face-to-face interview on 06/22/10 at 9:30am, Human Resource Director S16 indicated she was responsible for the credentialing process at the hospital. She confirmed that the hospital did not have a radiologist appointed to the medical staff.

In a face-to-face interview on 06/22/10 at 11:25am, Chief Executive Officer S1 confirmed the hospital did not have a radiologist appointed to the medical staff.

Based on record review and interview, the hospital failed to have a full time employee who served as the director of the food and dietetic services. Findings:

Review of the hospital employee personnel files revealed no documented evidence that a full time employee was designated as the director of food and dietetic services.

In interview on 06/21/10 at 2pm, S1 Chief Executive Officer verified there was no full time employee at the hospital designated as the director of food and dietetic services.

Based on record review and interview, the hospital failed to ensure two physicians were members of the Utilization Committee. Findings:

Review of the Utilization Review and Utilization Management UR/UM) Plan dated 04/0/09 revealed "... II. Structure: The UR/UM Committee shall consist of at least one physician who is a member of the medical staff ... The physician serves as the chairperson and physician reviewer...".

In a face-to-face on 06/22/10 at 2:50pm, S2 Interim DON (Director of Nursing) and the UR/UM Coordinator indicated physician S11 serves as the physician on the committee. Further she indicated she was not aware two physicians were required for the committee.

Based on record review and interview, the hospital failed to ensure professional services provided to the patients at the hospital were evaluated . Findings:

Review of the Utilization Review and Utilization Management (UR/UM) Plan dated 04/01/09 revealed no documented evidence the evaluation performed annually by the hospital would be based on the professional services provided to the patients, but rather the achievement of the UR/UM process.

In a face-to-face interview on 06/22/10 at 2:50pm, S2 Interim DON (Director of Nursing) and UR/UM Coordinator indicated the plan was already in place when she was hired for the position and verified she had not read the Federal regulations. Further she verified there had been no review of professional services performed by the UR/UM Committee.

Based on observation, record review, and interview, the hospital failed to ensure the hospital environment was maintained to assure the safety and well-being of patients by having: 1) an unlocked door to the clean linen closet on the adult unit with carts containing gowns, sheets, and towels that could be used as a means of injury by patients; 2) the bathroom of the exam room on the adult unit with window blinds with hanging cords and a screenless window that was able to be opened that could allow escape; 3) five patient rooms with excess clothing and personal items not allowed by hospital policy (rooms "a", "b", "c", "e", "f"); 4) an uninhabited patient's bathroom with non-functioning lights(room "d"); 5) an eight foot wooden fence with seven chairs in the outdoor area which provided and continued to provide a means of patient elopement; and 6) an exam room window able to be fully opened from inside the exam room. Findings:

1) Unlocked door to clean linen closet
Observation on the adult unit on 06/21/10 at 10:00am revealed the door to the clean linen room was unlocked. Further observation revealed 2 wire linen carts with stacked gowns, sheets, and towels.

In a face-to-face interview on 06/21/10 at 10:00am, Interim Director of Nursing (DON) S2 indicated the door should remain locked, because the sheets, towels, and patient gowns stored within could be used by patients as a means of injuring themselves or others.

2) Exam room bathroom with hanging cords on blinds and a window able to be opened from within the bathroom
Observation on the adult unit on 06/21/10 at 10:00am revealed the door to the examination room open. Further observation revealed the bathroom that could be entered once inside the exam room had an unlocked door. Further observation revealed a screenless window inside the bathroom that was able to be opened by the surveyor. This window opened to the outside and had no means to prevent someone from pushing on it to provide a means of escape to the outdoors. The blinds covering this window had hanging cords that are used to raise and lower the blind.

In a face-to-face interview on 06/21/10 at 10:00am, Interim DON S2 confirmed that the window could be used as a means of escape and the cord of the blind could be used as a means of injury by patients. She further that some patients were allowed to use the bathroom to provide urine samples while unsupervised by staff.

3) Excess clothing and personal items in patient rooms
Observation of patient rooms on the adult unit on 06/21/10 at 10:35am, with Interim DON S2 present, revealed the following findings:
Room "a" - 4 shirts and 3 pair of panties over the allowed amount by policy; 1 patient gown in the drawer;
Room "b" - approximately 2 foot long hair piece, 3 tubes of lipstick, 2 hair brushes, 1 toothbrush, 1 tube of toothpaste, 1.5 ounce half-full plastic bottle of baby lotion in the patient's bedside drawer;
Room "c" - 3 shirts and 1 pair of pants over the allowed amount per policy and a pair of panty hose on the shelf in the patient's room;
Room "e" - 2 patient gowns in the soiled linen basket on the patient's shelf;
Room "f" - 2 gowns, 4 towels, 2 washcloths on the shelf in the patient's room.

In a face-to-face interview on 06/21/10 at 10:35am, Interim DON S2 indicated hospital policy stated that patients were only allowed to keep 3 suits of clothing in their room. She further indicated that patient gowns, towels, and washcloths should not be in patient rooms, but they should be handed out when patients are ready to bathe. She further indicated this was a hospital practice, but she was not aware of such a policy.

In a face-to-face interview on 06/21/10 at 10:50am, Mental Health Tech S7 indicated it was his duty to perform routine checks and observations. He indicated he was not aware of a hospital policy regarding the number of gowns that could be given to patients, but he knew that patients were allowed to keep 3 suits of clothing in their rooms. S7 indicated he didn't check for the amount of clothing in patient rooms when he made rounds of the patient rooms.

Review of the hospital policy titled "Intake Screening and Admission Process", originated 01/09, revealed, in part, "...Explains and allows patient to have three sets of clothing per policy back to the unit. ... Assessment Professional ... Additional items (clothing ...) over the allotted amount will be listed by Admission personnel and stored in the belongings storage room until discharge. ... Admitting Nurse/MHT (mental health tech) ... Has patient's personal hygiene items stored at nursing station in secure area.

Review of the hospital policy titled "Body And Belongings Search", originated 01/09, revealed, in part, "... Admissions Personnel ... Notifies patient/family only 3 sets of clothing are allowed on the units. Instruct family members to take home contraband items and secure them when necessary. ... The charge nurse reserves the right to deem items contraband on a case-by-case bases...".

Review of the "Mental Health Technician Job Description" revealed, in part, "... Employee maintains safe and therapeutic environment/milieu through patient monitoring as designated by RN (registered nurse)/Physician. a. Continually monitors compliance with unit rules, conducts environmental safety checks/security rounds...".

4) Non-functioning lights in patient bathroom
Observation on 06/21/10 at 10:35am, with Interim DON S2 present, revealed the uninhabited Room "d" patient bathroom with 3 light switches on the right wall upon entering the bathroom. Further observation revealed no light came on when the switches were raised by the surveyor.

Observation on 06/23/10 at 9:10am, with Interim DON S2 present, revealed the bathroom light over the lavatory in Room "d" was not working when the switch was activated.

In a face-to-face interview on 06/23/10 at 9:10am, Interim DON S2 confirmed the light over the lavatory in the bathroom of Room "d" was not working.

5) Wooden fence in outdoor area
Observation on 06/21/10 at 10:25am of the outdoor area for the adult unit revealed an eight foot high wooden fence surrounding the outdoor area where patients were allowed for smoke breaks. Further observation revealed 7 moveable chairs were situated on the concrete floor in the center of the outdoor area.

In a face-to-face interview on 06/21/10 at 10:25am, Interim DON S2 confirmed that the presence of moveable chairs that could be placed next to the fence as a means of reaching to pull oneself up would allow a patient a means of escape/elopement.

Review of the hospital's incident reports on 06/24/10 revealed Patient #R1 had eloped from the hospital on 02/18/10 at 1935 (7:35pm) by using a chair in the outdoor adult unit to jump the eight foot wooden fence.

6) Exam room window able to be fully opened from inside the exam room
Observations on 06/21/10 at 10:10 a.m. revealed an open door from the hallway located across from the nursing station. This door allowed entrance into an exam room. Further observations revealed a screenless window located in the exam room that was able to be fully opened by the surveyor.

During a face-to-face interview on 06/21/10 at 10:10 a.m., Interim DON S2 indicated the door to the exam room should have been locked when not in use by staff.

Based on record review and interview, the hospital failed to follow their policy and procedures for Infection Control as evidenced by failing to appoint a Registered Nurse as the Infection Control Officer. Findings:

Review of policy no: IC-01 titled "Provision of Infection Control Care", date of approval 01/09 and submitted as the one currently in use and approved by the Governing Body, revealed, "...Qualifications of Staff - A. Qualification Required of Infection Control Nurse: a) Registered Nurse licensed in Louisiana...".

Review of the personnel file of LPN (Licensed Practical Nurse) S38, identified by the hospital as the Infection Control Nurse, revealed she had been hired as Infection Control Officer in 03/09 by former Director of Nursing (DON) S40 with no previous documented experience in infection control and with six continuing education contact hours received in 2003 from an inservice with the topic "Infectious Diseases: Challenges and the Future". Further review revealed no documented evidence of continuing education since 2003.

In a face-to-face interview on 06/22/10 at 9:45am, LPN S38 indicated she felt she was qualified to be the Infection Control Officer because of her experience and training; however when asked by the surveyor if she had ever served in the position of infection control at another facility her response was no. Further S38 indicated she had not been to any other inservices and did not attend any local APIC meeting. Further LPN S38, when describing her job duties, indicated she was not responsible for employee health, including annual TB (Tuberculosis) screening, because that was the duty of the DON; she only performed surveillance to make sure the facility had soap, water, paper towels, and that the sinks were clean, but she did not make observations of employees actually washing their hands; and she collected data on infections, but did not perform any trending.

Based on record review and interview, the hospital failed to ensure the Infection Control Plan had been implemented and monitored as evidenced by: 1) failing to screen all admits for infectious disease as evidenced by incomplete screening forms initiated on admit for 3 of 21 sampled patients (#11, #12, #18); 2) failing to monitor all patient infections for the causative pathogen and to determine patient infections as either nosocomial or community-acquired resulting in possible trends and/or clusters not being identified; 3) failing to ensure all staff (including physicians) were free of TB (tuberculosis); 4) failing to review employee sick leave reports in order to communicate possible trends and clusters to nursing service; 5) failing to implement and monitor surveillance activities for handwashing and fingernail compliance; and 6) failing to ensure temperature checks had been performed on a refrigerator used for patient nourishment. Findings:

1) Failing to screen all admits for infectious disease as evidenced by incomplete screening forms initiated on admit
Review of the Infection Control Plan, dated 01/09 and submitted as the one currently in use, revealed no documented evidence of an infection control screening for patients upon admit.

Review of the Infection Control Screening Form for Patients #11, #12 and #18 revealed no documented evidence a form had been initiated on the patients.

In a face-to-face interview on 06/22/10 at 9:45am, S38 Infection Control Officer indicated the nurses were responsible for completing the information on the Infectious Disease Screening form. Further she indicated she was not sure what the purpose of the form was, and that I would need to ask the DON (Director of Nursing).

In a face-to-face interview on 06/25/10 at 10:100am, S2 Interim DON indicated this form was something S40 the former DON had implemented. Further she indicated the staff had not been educated on the rationale for the form or what to do with the information once completed; therefore it was just left on the chart.

2) Failing to monitor all patient infections for the causative pathogen, determine patient infections were either nosocomial or community-acquired resulting in possible trends and/or clusters not being identified
Review of the Patient Infection Control Log dated May 2010 revealed 16 entries with the following breakdown of infections: 11 UTIs (Urinary Tract Infections), 1 STD (Sexually Transmitted Disease), 1 Toothache, and 2 URIs (Upper Respiratory Infections) and 1 r/o (rule out) Pneumonia. Further review revealed no identified pathogen(s) had been identified; however all patients had been placed on antibiotic therapy, and there was no documented evidence as to whether each infection had been determined to be community-acquired or nosocomial or had shown a trend or cluster. The Infection Control Log dated 05/10 revealed no documented evidence of monitoring by the Infection Control Officer. Further review revealed no documented evidence of anyone other than patients had been documented on the log.

Review of the form titled Adult and Geri-Psych Patient infections for May 2010 revealed there had been 1 nosocomial infection located on the geri-psych unit. Further review revealed no documented evidence of how this had been determined, since no pathogens had been listed on the reports. In addition, there was no documented evidence on how this patient might have acquired the nosocomial infection.

In a face-to-face interview on 06/22/10 at 9:45am, LPN (licensed practical nurse) S38 indicated she collected data on infections, but did not perform any trending. S38 indicated she gave the information on the logs to the former DON who compiled the information to submit to the PI Committee and to her knowledge the hospital did not have a problem with infections.

In a face-to-face interview on 06/25/10 at 10:00am, S2 Interim DON indicated, due to the lack of information, it would be very hard to determine whether or not the hospital had a problem with infections since so much information was missing.

3) Failing to ensure all staff (including physicians) were free of TB
Review of 3 of 3 physicians (S9, S10, S11) appointed to the medical staff and 4 of 4 nurse practitioners (NPs) from a total of 8 NPs (S12, S13, S14, S15) revealed no documented evidence that the physicians and NPs had been determined to be free of tuberculosis (TB).
In a face-to-face interview on 06/22/10 at 10:30am, Human Resource (HR) Director S16 indicated the hospital did not require TB testing for its physicians and nurse practitioners.

Review of Therapeutic Recreational Specialist S8's personnel file revealed her TB test was administered on 01/29/10 and read on 02/02/10. The result was read greater than 72 hours after the test was administered.

Review of Registered Nurse (RN) S21's personnel file revealed a hire date of 04/06/10. Further review revealed a chest x-ray result dated 09/08/09. There was no documented evidence of a TB questionnaire completed by S21.

Review of Mental Health Tech (MHT) S29's personnel file revealed no documented evidence of a TB result or a completed TB questionnaire.

In a face-to-face interview on 06/23/10 at 8:45am, Chief Executive Officer (CEO) S1 indicated the former Director of Nursing S40 was responsible for the administration of the TB test and the accuracy of the results obtained. She further indicated HR Director S16 was only responsible for filing the form in the personnel record.

Review of policy no: IC-09 titled "Tuberculosis Guidelines/Tuberculosis Control Plan, date of approval 01/09 and submitted as the one currently in use, revealed "...All qualified applicants for employment shall be screened for presence of infection with M. Tuberculosis using the Mantoux PPD skin test. The intervals for repeat PPD skin testing for employees with a negative skin test history will be annually, upon exposure, or development of signs and symptoms of TB. Employees with a history of a positive PPD test will fill out a TB screening questionnaire annually or development of signs and symptoms of TB...".

4) Failing to review employee sick leave reports in order to communicate possible trends and clusters to nursing service
Review of policy no: IC-03 titled "Routine Surveillance of Infections", date of approval 01/09 and submitted as the one currently in use, revealed "... Procedure: Employee Sick Leave Absence Reports reviewed by the Infection Control Nurse monthly. Nursing Service will be notified of possible clusters or trends...".

In a face-to-face interview on 06/22/10 at 9:45am, LPN S38 the Infection Control Officer indicated she was not responsible for reviewing this information, and that I should check with the Director of Nursing. Further she indicated she was not responsible for any Employee Health activities.

In a face-to-face interview on 06/22/10 at 3:00pm, Interim DON S2 indicated the Infection Control Officer is responsible for Employee Health. Further S2 indicated she could not find any review of of Employee Sick Leave Reports which might have been performed by the previous DON. S2 verified that in her present position as DON, she is not reviewing or documenting employee illness.

In a face-to-face interview on 06/23/10 at 3:20pm, after review of the Infection Control Policy and Procedure Manual, Chief Executive Officer S1 confirmed there was no policy for what should be done when an employee reports to duty sick. Further S1 indicated she had not been given any information concerning employee health reports by either LPN S38 or former DON S40.

5) Failing to implement and monitor surveillance activities for handwashing and fingernail compliance
Review of the Infection Control Plan, dated 01/09 and submitted by the hospital as the one currently in use, revealed no documented evidence handwashing surveillances are required to be performed.

In a face-to-face interview on 06/22/10 at 9:45am, LPN S38 indicated she only performed surveillance to make sure the facility had soap, water, paper towels and that the sinks were clean, but did not make observations of employees actually washing their hands.

Review of policy no: IC-14 titled "Fingernails", date of approval 01/09 and submitted as the policy currently in use, revealed that artificial nails were forbidden by nursing staff providing direct patient care, dietary, and housekeeping staff. Further the policy indicated the department directors, managers, and supervisors are responsible for monitoring and enforcing compliance.

In a face-to-face interview on 06/25/10 at 10:00am, Interim DON S2 indicated she was not aware the hospital had a policy that fake nails could not be worn. Further S2 indicated to her knowledge no surveillances had been done to monitor fingernails on the nursing units.

6) Failing to ensure temperature checks had been performed on a refrigerator used for patient nourishment
Observation on 06/21/10 at 10:00am revealed a refrigerator/freezer in the nourishment room of the adult unit with a "Temperature Recording Form" for the month of June 2010 posted on the door of the refrigerator. Review of the form revealed instructions of "Fahrenheit Refrigerator Temperature - Check once daily in the P.M.". Further review of the form revealed no documented evidence of the temperature result on 06/11/10, 06/12/10, 06/13/10, 06/19/10, and 06/20/10.

In a face-to-face interview on 06/21/10 at 10:00am, Interim Director of Nursing S2 indicated the temperatures should be checked daily.

Based on record review and interview, the hospital failed to ensure a complete and accurate record of infections had been documented as evidenced by failing to identify the pathogens via the lab report, failing to determine the infections to be nosocomial or community-acquired, and failing to include employees as well as admitted patients in the review of reportable infectious diseases. Findings:

Review of policy no: IC-21 titled "Infection Control Reporting", date of approval 01/09 and submitted by the hospital as the one currently in use, revealed "...When a patient is identified as having a possible infection process, the nurse will notify the MD (medical doctor). The Nursing Staff initiates the Surveillance of Patient Infections Worksheet when: 1. Notifies physician of symptomology and for possible infection and/or 2. A physician orders the following: a. Antibiotic; b. Culture; or c. Special infection precautions/antibiotic. 3. Communicates lab findings with MD. Routes Infection Control Report Sheet to the Infection Control Nurse...". Further review revealed it is the Infection Control Nurse's Responsibility to identify nosocomial infections, compile a monthly report and present it to the Performance Improvement (PI) Committee.

Review of the Patient Infection Control Log dated May 2010 revealed 16 entries with the following breakdown of infections: 11 UTIs (Urinary Tract Infections), 1 STD (Sexually Transmitted Disease), 1 Toothache, and 2 URIs (Upper Respiratory Infections) and 1 r/o (rule out) Pneumonia. Further review revealed no identified pathogen(s) had been identified; however all patients had been placed on antibiotic therapy and there was no documented evidence as to whether each infection had been determined to be community-acquired or nosocomial or had shown a trend or cluster. The Infection Control Log dated 05/10 revealed no documented evidence of monitoring by the Infection Control Officer. Further review revealed no documented evidence of anyone other than a patient had been documented on the log.

In a face to face interview on 06/22/10 at 9:45am LPN S38 indicated she documents the information on the infection contol log and then the former DON S40 would complete the information and do the trending and make the report to the committee in PI.

Based on record review and interview, the hospital failed to follow their policy and procedure for psychiatric evaluations by failing to complete the evaluation within 24 hours of admit for 4 of 22 sampled patients (#8, #9, #10, #11). Findings:

Patient #8
Review of the medical record for patient #8 revealed he was admitted to the hospital under a physician's emergency certificate on 06/17/10 for suicidal ideation and presented a potential harm to himself and others. Further review revealed no documented evidence a psychiatric evaluation had been performed on Patient #8 when the chart was reviewed by the surveyor on 06/21/10.

Patient #9
Review of the medical record for Patient #9 revealed she was admitted to the hospital under a physician's emergency certificate on 06/15/10 for a bipolar disorder with bizarre delusions. Further review revealed no documented evidence a psychiatric evaluation had been performed on Patient #9 when the chart was reviewed by the surveyor on 06/21/10.

Patient #10
Review of the medical record for patient #10 revealed he was admitted to the hospital under a coroner's emergency certificate on 06/16/10 for suicidal ideation and presented a potential harm to himself and others. Further review revealed no documented evidence a psychiatric evaluation had been performed on Patient #10 when the chart was reviewed by the surveyor on 06/21/10.
In a face to face interview on 06/21/10 at 11:00am LPN (licensed practical nurse) S42 verified there was no psychiatric evaluation on the chart for Patient #10. Further she indicated this is a frequent occurrence because Psychiatrist S10 does psychiatric evaluations on his computer and does not always print out a copy right away for placement on the chart.

Patient #11
Review of Patient #11's medical record revealed she was admitted on 06/17/10 after a suicide attempt. Further review of the medical record revealed no documented evidence a psychiatric evaluation had been performed on Patient #11 as evidenced by a blank psychiatric evaluation form found in the medical record on 06/21/10.
In a face-to-face interview on 06/21/10 at 11:40am, Interim Director of Nursing S2 verified there was no psychiatric evaluation on the chart of Patient #11 at the time of this interview.
In a face-to-face interview on 06/23/10 at 10:10am, when informed by the surveyor that the Psychiatric Evaluation for Patient #11 was not on the medical record after more than 72 hours from admission, Psychiatrist S10 indicated he was not compulsive with documentation. He further indicated he remembered that the medical student did the evaluation on the evening of 06/17/10, and he saw Patient #11 on the morning of 06/18/10.

Review of the hospital policy titled "Documentation Timeliness Guidelines", originated 01/09, revealed, in part, "...It is the policy that clinical personnel document specific data in the patient's medical record in a timely manner...".

Review of the "Clinical Documentation Reference Log", with no documented evidence of the date of origination or approval, revealed, in part, "...What: Psychiatric Evaluation When: within 24 hours of admission Who: Physician...".

Review of the Medical Staff Rules and Regulations revealed, in part, "...An admit psychiatric evaluation must written by the admitting psychiatrist or psychiatric nurse practitioner within sixty (60) hours of patient's admission...".

In a face-to-face interview on 06/23/10 at 10:10am, Psychiatrist/Medical Director S10 indicated he was lax concerning completing the psychiatric evaluations; hoevers he indicated he was not aware of the hospital policy that stated the evaluation had to be completed within 24 hours of admit.

In a face-to-face interview on 06/24/at 3:00pm S1 Chief Executive Officer indicated because she has been employed for a very short time as the administrator, she was not aware of the difference between the hospital policy and the Federal regulation which allows 60 hours for the completion of the psychiatric evaluation.




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Based on record review and interview, the hospital failed to ensure the treatment plan of the patient was under the direct supervison of the psychiatrist as evidenced by lack of documentation in the treatment plan that it had been reviewed by the physician or that any multidisciplinary team approach had been utilized in the care of the patient for 4 of 22 sampled patients (#8, #9, #10, #18). Findings:

Patient #8
Review of the medical record for Patient #8 revealed he was admitted to the hospital under a physician's emergency certificate on 06/17/10 for suicidal ideation with a history of hypertension. Review of the Clinical Summary/Master Treatment Plan dated 06/17/10 revealed the identified problems as a potential risk of harm to self and others and hypertension. Further review revealed Patient #8's estimated length of stay at the hospital was 7-10 days with an anticipated discharge date of 06/27/10. Discharge criteria included mood stabilization and medication compliance. The Treatment Plan was signed by the GSW (graduate social worker) and the Activity Therapist. There was no documented evidence the treatment plan was under the direction of a physician as evidenced by the blank in the space for his signature.

Patient #9
Review of the medical record for Patient #9 revealed she was admitted to the hospital under a physician's emergency certificate on 06/15/10 for a bipolar disorder with bizarre delusions. Review of the Clinical Summary/Master Treatment Plan dated 06/15/10 revealed the identified problems as alterations in thought processes related to delusions and the medical conditions of diabetes and hypothyroidism. Further review revealed the anticipated length of stay was 3-5 days with the anticipated discharge date of 06/20/10 and the criteria as stabilization of mood and medication compliance. The plan was signed by GSW S44, RN (registered nurse) S25 and Patient #9 indicating the following, " I have reviewed the following multidisciplinary assessments: Intake assessment, H&P, Psychiatric evaluation, nursing assessment, psychosocial assessment, Psychiatric testing, prior records, and the initial physician's orders. An integration of information and a master treatment plan has been formulated from all assessments". Further review of the Master Treatment Plan for Patient #9 revealed no documented evidence physician S10 had performed a psychiatric evaluation or directed the development of the treatment plan as evidenced by a blank in the space provided for his signature.

Patient #10
Review of the medical record for Patient #10 revealed he had been admitted to the hospital under a coroner's emergency certificate for suicidal ideation and was evaluated as a potential threat to himself as well as others. Review of the Clinical Summary/Master Treatment Plan dated 06/16/10 revealed, although the physician determined the patient to be a threat to himself and others and ordered Patient #10 to be placed on suicide precautions, the GSW who developed the treatment plan assessed his problem as alteration in mood related to depression with a potential risk for falls and a medical history of hypertension. Further review revealed Patient #10's estimated length of stay in the hospital was estimated at 7-10 days with an anticipated discharge date of 06/26/10. Discharge criteria included stabilization of mood and medication compliance. The treatment plan was signed by the GSW and Activity Therapist indicating the following, "I have reviewed the following multidisciplinary assessments: Intake assessment, H&P, Psychiatric evaluation, nursing assessment, psychosocial assessment, Psychiatric testing, prior records, and the initial physician ' s orders. An integration of information and a master treatment plan has been formulated from all assessments". Further review of the Master Treatment Plan for Patient #9 revealed no documented evidence physician S10 had performed a psychiatric evaluation or directed the development of the treatment plan as evidenced by a blank in the space provided for his signature.

Patient #18
Review of the medical record for Patient #18 revealed she was admitted to the hospital under a physician's emergency certificate on 06/10/10 for schizophrenia and delusions. Review of the Clinical Summary/Master Treatment Plan dated 06/10/10 revealed the identified problems as alterations in thought processes related to delusions and hallucinations. Further review revealed her mother was involved in her care and the estimated length of her hospital stay was 0-7 days with an anticipated discharge date of 06/17/10. Discharge criteria included medication management, group therapy to stabilize symptoms. Further review revealed the treatment plan was signed by the LCSW (licensed clinical social worker), the Activity therapist and Patient #18. There was no documented evidence the RN or the physician had directed the development of the treatment plan as evidenced by a blank in the space provided for her signature.

In a face to face interview on 06/23/10 at 10:25am S10 Medical Director indicated he is very lax about making sure documentation has been done. Further S10 acknowlwdged this was some of the same issues from a previous survey that had not been addressed.

Based on record review and interview, the hospital failed to ensure the the activity therapy program met the needs of the patients by failing to: 1) ensure the activity therapy assessment was performed within 72 hours of admission according to hospital policy for 2 of 22 sampled patients (#8, #11); 2) ensure the therapeutic recreation specialist developed a treatment plan starting within 72 hours of admission according to hospital policy for 3 of 22 sampled patients (#8, #11, #12); and 3) ensure the activity therapy assessments and development of treatment plans was performed by a licensed or certified recreational therapy specialist (S8). Findings:

1) Activity therapy assessment performed within 72 hours of admission:
Patient #8
Review of Patient #8's medical record revealed he was admitted on 06/17/10 with diagnoses of Psychosis and Chronic Paranoid Schizophrenia. Further review revealed no documented evidence an activity therapy assessment had been performed.

Patient #11
Review of Patient #11's medical record revealed she was admitted on 06/17/10 with diagnoses of Substance Abuse/Dependence, Rule Out Bipolar Disorder-Depressed Phase and Borderline Personality Disorder. Further review revealed no documented evidence an activity therapy assessment had been performed.

In a face-to-face interview on 06/21/10 at 11:50am, Therapeutic Recreation Specialist (TRS) S8 indicated she had been off since 06/15/10. She further indicated hospital policy required the assessment to be performed within 72 hours of admission. S8 indicated the assessments for Patients #8 and #11 should have been performed by the contracted Certified Therapeutic Recreation Specialist.

Review of the hospital policy titled "Activity Therapy Services", originated 01/09, revealed, in part, "...Procedure 1. An recreation therapy assessment will be completed on each patient within seventy-two (72) hours of admission.

2) Activity Therapy treatment plan started within 72 hours of admission:
Patient #8
Review of Patient #8's medical record revealed he was admitted on 06/17/10 with diagnoses of Psychosis and Chronic Paranoid Schizophrenia. Further review revealed no documented evidence of an activity therapy assessment and subsequent development of a treatment plan as of 06/21/10.

Patient #11
Review of Patient #11's medical record revealed she was admitted on 06/17/10 with diagnoses of Substance Abuse/Dependence, Rule Out Bipolar Disorder-Depressed Phase and Borderline Personality Disorder. Further review revealed no documented evidence of an activity therapy assessment and subsequent development of a treatment plan as of 06/21/10.

In a face-to-face interview on 06/21/10 at 11:50am, TRS S8 indicated she had been off since 06/15/10. She further indicated hospital policy required the assessment and initiation of the care plan to be performed within 72 hours of admission. S8 indicated the assessments and plan of care for Patients #8 and #11 should have been performed by the contracted Certified Therapeutic Recreation Specialist.

Patient #12
Review of Patient #12's medical record revealed he was admitted on 06/16/10 with diagnoses of Bipolar Disorder with Psychosis and Substance Induced Psychotic Disorder. Further review revealed S12's "Activity Therapy Evaluation" was performed on 06/17/10 at 6:30pm by Certified Therapeutic Recreational Therapist (CRTS) S41. Review of the "Multidisciplinary Group Notes" revealed no documented evidence that Patient #12 had participated in or been offered activity therapy on 06/17/10 through 06/20/10. Further review revealed no documented evidence of the development of a treatment plan as of 06/21/10.

In a face-to-face interview on 06/21/10 at 10:15am, TRS S8 confirmed the treatment plan for Patient #12 was not initiated as of the time of this interview. She indicated the treatment plan should be established within 72 hours of admission.

Review of the hospital policy titled "Activity Therapy Scheduling", originated 01/09, revealed, in part, "...A recreation Therapist will meet with every patient admitted to develop an individualized schedule of primary Recreation Therapy for that patient...".

Review of the hospital policy titled "Activity Therapy: Standards of Practice", originated 01/09, revealed, in part, "... Standard I: Assessment ... Through the use of the Activity therapy needs assessment and the patient self-evaluation process, an Activity therapist will complete an assessment within seventy-two hours (72) of admission, taking into account the social, behavioral, emotional and physical aspects of care. ... Standard II : Planning Activity therapy collaboration with other health professionals is following the process of assessment planning, implementing and evaluating patient care services ... Utilizing a problem-solving approach and based on the Activity therapy assessment, the Activity therapist prioritizes and develops a treatment plan with specific goals and interventions delineating Activity therapy actions unique to each patient's need. ... Assessment factors: ... Input and systematic review of the interdisciplinary treatment plan starting within 72 hours of admission and thereafter at least every 7 days of treatment...".

3) Activity therapy assessments and development of treatment plans performed by licensed or certified recreational therapy specialist:
Review of the employee roster presented by Chief Executive Officer (CEO) S1 as their current list of employees revealed S8 was the full-time Recreational Therapist. Review of S8's personnel file revealed no documented evidence that she was licensed or certified as a Therapeutic Recreational Specialist. Review of S8's job description revealed her job title was "Certified Recreation Therapy Specialist". Further review revealed the minimum education requirements were a Bachelor of Recreation Therapy or Music Therapy with Board Certification and/or state licensure.

In a face-to-face interview on 06/22/10 at 2:15pm, TRS S8 confirmed she is neither licensed nor certified as a CTRS. She indicated CTRS S41 was on contract, came twice a week, and signed behind S8. S8 confirmed that she did assessments and established activity therapy treatment plans.

In a face-to-face interview on 06/23/10 at 8:55am, CEO S1 confirmed she was aware that TRS S8 was not licensed or certified.

Review of the hospital policy titled "Activity Therapy Scheduling", originated 01/09, revealed, in part, "...A Recreation Therapist will meet with every patient admitted to develop an individualized schedule of primary Recreation Therapy for that patient...". Review of the policy revealed no documented evidence that the Recreational Therapist was required to be licensed or certified.

Review of the hospital policy titled "Activity Therapy: Standards of Practice", originated 01/09, revealed, in part, "... It is the policy of ... Hospital that all Activity Therapy services rendered will be consistent with Activity therapy standards. ... During orientation, the Activity Therapist(s) will receive a copy of the Activity therapy Standards of Practice...". Review of the policy revealed no documented evidence that the Recreational Therapist was required to be licensed or certified.

Based on record review and interview, the hospital failed to implement the Quality Assurance and Performance Improvment Plan to assess hospital services as evidenced by failing to assess the process for admission to the hospital which had been identified as an ongoing problem with non-compliance with Federal Regulations for EMTALA.

Review of the "Admission Criteria", no date of issue and submitted as the one currently in use by the hospital, revealed "... Intake personnel reviews pre-admission assessment data with physician who determines the appropriate level of care indicated....". Further review reveals there are 11 possible criteria to be utilized as follows: 1 concerning age had to be selected and 3 or more concerning psychiatric condition had to be selected to be considered eligibile for admit. Also included on the admit criteria form are 12 "exclusionary" criteria which indicate if the patient is identified as having one, he/she is not considered appropriate for admission "unless both the Medical Director and the Director of Nursing concur".

Review of the "Inquiry Call Form" completed by the intake person/nurse and used to determine appropriateness of admit revealed the hospital used four different forms. Further review of the intake forms dated 03/31/10 through 06/14/10 revealed 102 out of 143 intake inquiries had not been completed with the required information needed to determine eligibilty for admit as evidenced by the blank spaces left on the forms. In addition, there was no documented evidence the admission criteria or exclusionary criteria had been used to determine acceptance or denial for admission to the hospital on the inquiry form nor when a patient had been denied was there any documented evidence the physician or Director of Nursing had been notified so that they could "concur" as stated on the "Admissions Criteria".

Review of the Daily Assignment Sheets for the 7A-7P and 7P-7A dated 03/31/10 through 06/14/10 used to document unit staffing, census, and ordered one-to-one observations, call-ins and no-shows revealed 150 out of 150 had not been completed with the required information used to assist in the determination of the number of staff needed on the shift and the number of available beds on the unit.

In a face-to-face interview on 6/24/2010 at 11:15 a.m., Interim Director of Nursing S2 and Chief Executive Officer S1 indicated the hospital had not been staffing the hospital according to the policy titled, "Patient Classification System" according to acuity. S1 and S2 indicated it had been the intention of the hospital to institute a new policy regarding staffing; although, it had not yet been done. S1 and S2 indicated they used the staffing grid based on hospital/unit census to staff the unit; however, depended on nursing staff to alert them when the acuity level goes up and extra staff are needed. Further S2 verified the "Daily Assignment Sheets" used to document staffing, 1:1 observations, and census had not been kept up by the nursing staff and therefore were not accurate.

Review of the hospital policy titled, "Patient Classification System", approved 01/09 and submitted as the one currently in use, revealed in part, "It is the policy to measure the acuity level of each patient every morning using the Patient Classification Form. Inpatient staffing utilizes an established staffing matrix for allocation of HPPD (Hours Per Patient Day). Adjustments are made daily to staffing matrix through coordination of the Staffing Coordinator and Director of Nursing for each unit's acuity.

Review of the "Inquiry Call Forms" dated 03/31/10 through 06/14/10 of the denials for admission to the hospital were documented as follows: 65 denials were due to "no beds"(representative of 21of 76 days); 25 denials were due to "acuity"(representative of 11 of 76 days); 17 denials were due to "no staffing" (representative of 7of 76 days); 6 denials had no documented reason why the patients had been denied admit; 15 denials were due to either no female or no male beds; 2 denials were due to documented exclusionary criteria for denial used by the hospital; 1 denial was documented as no accepting psychiatrist"; 10 denials were due to "did not meet criteria" without any documented evidence of the exclusionary criteriay used by the hospital; and 2 recorded in the denial book were actually placed before the hospital could call back and accept or deny the patient.

Review of the Daily Hospital Census submitted by the hospital as accurate revealed the following days on which patients had been denied admit to the hospital and the number of available total beds: 04/01/10 (16/28); 04/02/10 (16/28); 04/04/10 (20/28); 04/05/10 (23/28); 04/06/10 (27/28); 04/07/10 (27/28); 04/08/10 (25/28); 04/09/10 (25/28); 04/10/11 (24/28); 04/11/10 (24/28); 04/12/10 (21/28); 04/13/10 (24/28); 04/14/10 (17/28); 04/19/10 (24/29); 04/26/10 (25/28); 04/27/10 (26/28); 05/11/10 925/28); and 05/11/10 (24/28).

Review of the staffing pattern for the admit process revealed the full time position of the "Intake Coordinator" has been vacant and is being presently filled by the interim DON who also functions as the Director of Nursing, Risk Manager and Utilization Review Nurse. During the PM hours, the RN from either the adult or geri-psych unit is assigned the duty of the intake person in addition to her regularly-assigned patient care duties.

Based on record review and interview, the hospital failed to ensure all adverse patient events had been analyzed for possible underlying causes as evidenced by: 1) failing to include the name of staff and patients present; the description of the placement of chairs in proximity to the fence in the outside smoke area; the ratio of patients to staff on break; the observation precautions ordered for each patient present; the knowledge and competency of staff present during the event and interviews with all staff involved in the incident of a patient's elopement (R1); 2) failing to include inspection of the bathroom environment for the presence of safety concerns, type of foot-wear patient had on, vital signs (patient was on new hypertension medication), or accucheck (patient was a diabetic) which may have contributed to the fall of a patient (R3); 3) failing to identify possible reasons for patient attempting to get up alone (need to use bathroom, confusion from mental status), use of siderails on the bed, staffing pattern, and environmental issues which could have contributed to the fall of the patient (R4); and 4) failing to perform a head to toe assessment that included a neuro assessment and vital signs to determine a medical reason of the fall for a patient (R5) for 4 of 4 sampled incident reports involving patient falls. Findings:

1) Patient R1
Review of Patient R1's medical record revealed he was admitted on 02/17/10 at 11:45am to the hospital under a Physician's Emergency Certificate with the diagnoses of Chronic Paranoid Schizophrenia and Bipolar Disorder.
Review of the "Incident Report" submitted by Registered Nurse (RN) S45 on 02/18/10 at 1935 (7:35pm) and signed by former Director of Nursing (DON) S40 on 02/19/10 at 0920 (9:20am) revealed Patient R1 stood on a chair located next to the fence surrounding the smoking area, climbed over the fence and eloped on 02/18/10 at 1935 (7:35pm). Further review revealed Mental Health Technician (MHT) S39 was reported unable to apprehend R1 and after a search the patient could not be located. Further review of the incident report revealed no documented evidence of an investigation of the incident had been performed to include, but limited to: the name of staff and patients present; the description of the placement of chairs in proximity to the fence in the outside smoke area; the ratio of patients to staff on break; the observation precautions ordered for each patient present; the knowledge and competency of staff present during the event; interviews with all staff involved.

2) Patient R3
Review of Patient #R3 ' s medical record revealed she was admitted on 03/29/10 as a formal voluntary admission with diagnoses of Depression, Hypertension, Diabetes, and Congestive Heart Failure. Review of R3's "Physician Admit Orders & (and) Problem List" revealed no documented evidence of the type of precaution to be observed; however her activity level was "as tolerated".
Review of the "Incident Report" submitted by RN S47, Charge Nurse, on 04/10/10 at 10:30am revealed Patient R3 reported she experienced a fall, which was unwitnessed, in her bathroom located on the geri-psych unit. Further review of the incident report revealed the contributing factors documented as physical condition and not using an assistive device properly or at all. R3 complained of a slight ache in her lower mid back and was assessed with no redness, bruising, or skin tears noted. The report also indicated there was a likelihood of the fall re-occurring. Review of the entire incident report revealed no documented evidence of the incident being investigated to include an inspection of the bathroom environment for the presence of safety concerns, type of foot-wear patient had on, vital signs (patient was on new hypertension medication), or accucheck (patient was a diabetic).

3) Patient R4
Review of Patient R4's medical record revealed she was a formal voluntary admission on 12/29/09 with a diagnosis of Psychosis. Further review revealed her physician orders included fall precautions and activity with supervision.
Review of the "Incident Report" completed on 01/03/10 by RN S48 revealed Patient R4 on 01/03/10 at 10:10am was found after falling out of bed while attempting to get up alone. Further review revealed the siderails on her bed were up X2 (times 2). According to the documentation on the report, R4 sustained a bruise on left forehead & cheek and bit her tongue. Further review revealed a BP (blood pressure) of 130/76 and HR (heart rate) of 102 and was considered a high risk patient.
Review of the incident report revealed no documented evidence of an investigation of the incident to include identifying the problem that caused the fall, evaluating the problem identified, and steps taken to ensure a safe environment for Patient #R4.

4) Patient R5
Review of Patient R5's medical record revealed she was admitted on 05/07/10 at 0400 under a physician's emergency certificate with the diagnoses of Depression and Suicidal Ideation.
Review of the incident report completed by RN S49 on 05/07/10 at 2120 (9:20pm) revealed R5 reported she had fallen on the adult unit "due to a convulsion because she had not received her Xanax. Further review revealed she sustained a raised red area over her right eye. Review of the investigation revealed no documented evidence of a complete head to toe assessment that included a neuro assessment and vital signs and education on fall precautions.

In a face-to-face interview on 06/25/10 at 10:15am, S2 Interim DON (Director of Nursing) indicated she was also considered the risk management person. S2 verified she had not been performing investigations of the incidents. Further she indicated when S2 had been assigned the job of risk management duties, she received no training and what she knows she learned on the job.

Based on record review and interview, the hospital failed to: 1) implement corrective action concerning identified deficiencies in documentation by the medical staff as evidenced by the continued delinquency rate of medical records; 2) implement corrective action on a safety issue concerning the fence and chairs in the smoking area identified as an elopement issue as evidenced by the patients still being able to move the chairs to the fence and the fence height remaining unchanged; and 3) implement corrective action of a problem identified and unresolved for over a year with the pharmacy contract and availability of ordered medications as evidenced by 4 of 22 sampled patients not receiving their medications on time either due to unavailability or not being delivered on time by the contracted pharmacy (#3, #9, #10, #17). Findings:

1) Implement corrective action concerning identified deficiencies in documentation by the medical staff as evidenced by the continued delinquency rate of medical record
Review of a Medical Records data sheet titled, "FBH (Focus Behavioral Hospital/28 bed hospital) report" revealed the delinquency rate was 46% in July 2009 and 42 medical records had discharge dates from 02/16/2010 through 04/21/2010.

Review of the Performance Improvement Committee Meeting Minutes dated 06/10/10, 05/14/10, 03/10/10, 12/02/09, 09/30/09, 08/26/09, 06/25/09, 04/27/09, 04/14/09, and 03/31/09 revealed the only documented evidence of recommendation for action was in the 03/10/10 meeting which stated the plan of action would be to place the issue on the agenda of the Medical Executive Committee. This action came after 8 months of physician delinquency of medical records.

Review of the Medical Executive Meeting Minutes dated 01/25/10, 10/26/09, 07/06/09, 05/06/09, and 04/14/09 revealed in the January 25, 2010 meeting, the physicians decided to delegate the duty of record completion to the nurse practitioners; however no one from the medical staff was assigned to monitor, and there was no documented evidence another Medical Executive Meeting had been held after January 25, 2010.

In a face-to-face interview on 06/22/10 at 10:30am, Health Information Manager S5 indicated there had been no written notification sent to the physicians who had delinquent records. S5 indicated Medical Staff Bylaws regarding delinquent medical records had not been implemented, and the two physicians (Psychiatrist S10, Psychiatrist S11) with delinquencies greater than 60 days had never been suspended.

In a face-to-face interview on 06/23/10 at 10:25am, Physician S10 Medical Director verified no corrective action as stated in the Medical Staff By-Laws had been taken to improve the delinquency rate of medical records.

2) Implement corrective action on a safety issue concerning the fence and chairs identified as an elopement issue in the smoking area
Review of the hospital's incident reports on 06/24/10 revealed Patient R1 had eloped from the hospital on 02/18/10 at 1935 (7:35pm) by using a chair in the outdoor adult unit to jump the eight foot wooden fence.

Review of the Performance Improvement Committee Meeting Minutes dated 03/10/10 revealed... "15. Elopement - patient jumped fence when outside to smoke. Police notified, DOCS (Director of Clinical Services), Administrator and family notified. Property search conducted. Unable to locate patient. Plan of action: Remove chairs from around fence. Contact a fence company for height adjustment". Further review revealed no documented evidence of the person assigned responsibility for making sure this action was done.

Observation on 06/21/10 at 10:25am of the outdoor area for the adult unit revealed an eight foot high wooden fence surrounding the outdoor area where patients were allowed for smoke breaks. Further observation revealed 7 moveable chairs were situated on the concrete floor in the center of the outdoor area.

In a face-to-face interview on 06/21/10 at 10:25am, Interim DON S2 confirmed that the presence of moveable chairs that could be placed next to the fence as a means of reaching to pull oneself up would allow a patient a means of escape/elopement. Further no changes had been or were in the process of being made to the height of the fence.

3) Implement corrective action of an identified problem with the pharmacy contract and availability of ordered medications
Review of the Performance Improvement Committee Meeting Minutes dated 03/31/09 revealed an identified problem with the turnaround time for medications which former DON (Director of Nursing) S40 said had already been discussed with the pharmacy. Further review revealed no documented evidence the medication turnaround time would be monitored.

Review of the Performance Improvement Committee Meeting Minutes dated 04/14/09 revealed the identified problem with the turnaround time for medications continued. Further review revealed the plan of action was that S40 was to meet with the pharmacist to discuss her concerns, and monthly reporting would include timeliness, accuracy and availability of pharmacy service.

Review of the Performance Improvement Committee Meeting Minutes dated 04/27/09 and 05/14/09 revealed medication administration, medication variances, or P&T (Pharmacy and Therapeutics) Committee Review was not on the agenda.

Review of the Performance Improvement Committee Meeting Minutes dated 06/25/09 revealed the identified problem with the turnaround time for medications continued. The Plan of Action was to "invite" the pharmacist to the P&T Committee Meetings and to continue P&T activities.

Review of the Performance Improvement Committee Meeting Minutes dated 08/26/09 revealed the section on the documented form used for the meeting minutes titled "timely delivery of meds" had been left blank.

Review of the Performance Improvement Committee Meeting Minutes dated 09/30/09 revealed no documented evidence, due to the change in the format of the performance improvement meeting, to reflect opportunities for improvement staff members had identified. Further review revealed timeliness of medications delivery had not been considered a problem by the staff.

Review of the Performance Improvement Committee Meeting Minutes dated 12/02/09 revealed one medication had not been delivered within the 3 hour time frame by the pharmacy. Further review revealed the plan of action was to discuss the late delivery with the contract pharmacist.

Review of the Performance Improvement Committee Meeting Minutes dated 03/10/10 (1 year after the problem with late delivery of medications had been identified) revealed the form titled "Performance Improvement Corrective Action Plan for P&T March 2010". Further review of the form revealed tracking of delivery times for medication faxed and called to pharmacy; recommended action: process change; responsibility DON; improvement expected immediately or the beginning of the 2nd quarter (April 2010); and expected date of resolution April 2010.

Review of the physicians' orders and MARs (Medication Administration Records) revealed continuing problems with pharmacy services as follows:

Patient #3:
Review of Patient #3's medical record revealed physician's orders dated 06/18/10 as follows: 1055 (10:55 a.m.) Risperdal Consta 50 milligrams every 2 weeks - give first dose now. 1600 (4:00 p.m.) OK to give Risperdal Consta when arrives. Review of Patient #3's nursing notes dated 06/18/2010 at 1815 (6:15 p.m./6 hours and 20 minutes after ordered by the physician) revealed "Pt. received IM (intramuscular) dosage of Risperdal Consta....".

In a face-to-face interview on 6/21/2010 at 11:50 a.m., LPN (Licensed Practical Nurse) S4 indicated she had sent pharmacy a fax requesting Risperdal Consta when she received the order. S4 further indicated she called the pharmacy back every 30 minutes, and they continued to tell her it would arrive with the next batch of medication. S4 indicated it did not arrive until 6:15 p.m. (6 hours and 20 minutes after ordered by the physician).

Patient #9
Review of the medical record for Patient #9 revealed she was admitted to the hospital for altered thought processes, schizophrenia and delusions on 06/15/10. Review of the Physicians' Orders dated 06/17/10 at 11:25am revealed an order for "second loading dose of Invega Sustena 156mg IM as soon as available". Review of the MAR for Patient #9 revealed.... "Invega Sustena 156mg IM as soon as available, called pharmacy won't be available until 06/18/10".

Patient #10
Review of the medical record for Patient #10 revealed he had been admitted to the hospital on 06/16/10 for depression with a history of COPD (Chronic Obstructive Pulmonary Disease). Review of the Physicians' Orders for Admit revealed an order for Advair Diskus bid (twice a day) inhalant, and Patient #10 missed the dose on 06/16/10 at 2100 (9:00pm) and was administered the 06/17/10 0900 (9:00am) dose at 1400 (2:00pm) or 5 hours late.

Patient #17:
Review of Patient #17's physician's orders dated 05/12/2010 at 1600 (4:00 p.m.) revealed an order for "Saphris 10 mg. (milligrams) PO (by mouth) bid (two times per day)". Review of Patient #17's Medication Administration Record revealed the next scheduled dosage of Saphris was due at 2100 (9:00 p.m.), 5 hours after the physician ordered the medication. Further review revealed Patient #17 did not receive the medication until 2315 (2 hours and 15 minutes after the scheduled dosage).

In a face-to-face interview on 6/22/2010 at 10:35 a.m., Interim Director of Nursing S2 indicated medication availability varies due to delivery times by the contracted pharmacy.

In a telephone interview on 6/24/2010 at 2:45 p.m., Pharmacy Director S34 indicated the pharmacy delivery times vary; however, typically they are scheduled for 10:00 a.m., 12:00 p.m., and between 6:00 and 7:00 p.m. for routine deliveries. S34 indicated stat orders are provided within 2 hours of receiving order. S34 indicated the Pharmacy's goal is to have medication available for the next scheduled dose when an order is received.

Based on record review and interview, the hospital failed to implement a Quality Assurance/Performance Improvement (QA/PI) program based on outcomes by which success could be measured. Findings:

Review of the Master PI Indicator Tracker for 2009 revealed indicators had been developed according to the following departments: Infection Surveillance, Prevention and Control; Employee Health; Utilization Review; Contractual Service Providers; Medical Records; Seclusion and Restraint Usage; Safety; Patient Satisfaction and Patient Grievances; Human Resources; Annual Policy and Procedures, Plans, Manuals; ORYX indicators; and Medication/Lab Reports. Further review of the report revealed only Utilization Review and Medical Records completed the report which would have provided measurement of outcomes.

Review of the reports contained in the QA/PI data collection were as follows: prioritization matrix, corrective action plan form, performance improvement monitoring report, summary of EOC (environmental of care) events, infection control report, medication error audit, and pharmacy monthly inspection reports. Further review revealed none of the data from the reports had been included in a form which would enable the hospital to measure improvement.

In a face-to-face interview on 06/24/10 at 2:00pm, S1 Chief Executive Officer (CEO) indicated when she was appointed as Administrator in April 2010, that left a void in the position of PI Coordinator. Further she indicated a nurse from corporate came to assist the hospital in that position. A permanent nurse has just been hired for the QA/PI Coordinator; however she will only be working 2 days a week until the end of summer. S1 indicated when she assumed the position of QA/PI, the former DON (director of nursing) S40 was in charge of the program. When the surveyor asked if she could explain what process had been implemented, S1 indicated there was no process because S40 kept on changing the forms and the way data had been collected.

Based on record review and interview, the Governing Board failed to ensure an ongoing program for quality assurance had been implemented as evidenced by: 1) failing to ensure corrective action had been taken for identified system failures for the admit process resulting in continued non-compliance with federal regulations for EMTALA; 2) failing to ensure the corrective action had been taken for identified system failures for obtaining medications resulting in unavailability of medications and untimeliness of delivery to the facility by the contracted pharmacy resulting in patients not receiving medications as ordered; 3) failing to ensure identified financial issues had been addressed resulting in background checks and drug screens not being performed on newly hired staff and the inability of the administration of the hospital to ensure all staff had been trained in crisis intervention. Findings:

1) Continued non-compliance with federal regulations for EMTALA
In a face-to-face interview on 06/23/10 at 11:00am, S1 Chief Executive Officer indicated S51, major owner and member of the Governing Board, came to the hospital in January 2010 and had a meeting with S10 physician concerning the finances of the hospital.

The hospital could not submit any documented meeting minutes for the Governing Board meeting which was reportedly held sometime in January 2010.

Review of the Performance Improvement Committee Meeting Minutes for 03/10/10 revealed no documented evidence the admission process had been discussed.

In a face-to-face interview on 06/23/10 at 11:00am, S1 Chief Executive Officer indicated she just hired a new PI (performance improvement) Coordinator; however she will be working only part time through the summer months. A member of the corporate team will assist in getting the QA/PI (quality assurance/performance improvement done. Further S1 verified the admit process had not been reviewed using the QA/PI process and she is aware that there are problems. Further she indicated the process for admitting patients had not been monitored since she had delegated that duty to the previous DON who now she is finding out had not performed her duties.

2) Unavailability of medications and untimeliness of delivery to the facility by the contracted pharmacy resulting in patients not receiving medications as ordered:
Review of the Performance Improvement Committee Meeting Minutes dated 03/31/09 revealed an identified problem with the turnaround time for medications which former DON (Director of Nursing) S40 said had already been discussed with the pharmacy. Further review revealed no documented evidence the medication turnaround time would be monitored.

Review of the Performance Improvement Committee Meeting Minutes dated 04/14/09 revealed the identified problem with the turnaround time for medications continued. Further review revealed the plan of action was that S40 was to meet with the pharmacist to discuss her concerns, and monthly reporting would include timeliness, accuracy and availability of pharmacy service.

Review of the Performance Improvement Committee Meeting Minutes dated 04/27/09 and 05/14/09 revealed medication administration, medication variances, or P&T (Pharmacy and Therapeutics) Committee Review was not on the agenda.

Review of the Performance Improvement Committee Meeting Minutes dated 06/25/09 revealed the identified problem with the turnaround time for medications continued. The Plan of Action was to "invite" the pharmacist to the P&T Committee Meetings and to continue P&T activities.

Review of the Performance Improvement Committee Meeting Minutes dated 08/26/09 revealed the section on the documented form used for the meeting minutes titled "timely delivery of meds" had been left blank.

Review of the Performance Improvement Committee Meeting Minutes dated 09/30/09 revealed no documented evidence, due to the change in the format of the performance improvement meeting, to reflect opportunities for improvement staff members had identified. Further review revealed timeliness of medications delivery had not been considered a problem by the staff.

Review of the Performance Improvement Committee Meeting Minutes dated 12/02/09 revealed one medication had not been delivered within the 3 hour time frame by the pharmacy. Further review revealed the plan of action was to discuss the late delivery with the contract pharmacist.

Review of the Performance Improvement Committee Meeting Minutes dated 03/10/10 (1 year after the problem with late delivery of medications had been identified) revealed the form titled "Performance Improvement Corrective Action Plan for P&T March 2010". Further review of the form revealed tracking of delivery times for medication faxed and called to pharmacy; recommended action: process change; responsibility DON; improvement expected immediately or the beginning of the 2nd quarter (April 2010); and expected date of resolution April 2010.

Review of the physicians' orders and MARs (Medication Administration Records) revealed continuing problems with pharmacy services as follows:

Patient #3:
Review of Patient #3's medical record revealed physician's orders dated 06/18/10 as follows: 1055 (10:55 a.m.) Risperdal Consta 50 milligrams every 2 weeks - give first dose now. 1600 (4:00 p.m.) OK to give Risperdal Consta when arrives. Review of Patient #3's nursing notes dated 06/18/10 at 1815 (6:15 p.m./6 hours and 20 minutes after ordered by the physician) revealed "Pt. received IM (intramuscular) dosage of Risperdal Consta....".

In a face-to-face interview on 6/21/2010 at 11:50 a.m., LPN (Licensed Practical Nurse) S4 indicated she had sent pharmacy a fax requesting Risperdal Consta when she received the order. S4 further indicated she called the pharmacy back every 30 minutes, and they continued to tell her it would arrive with the next batch of medication. S4 indicated it did not arrive until 6:15 p.m. (6 hours and 20 minutes after ordered by the physician).

Patient #9
Review of the medical record for Patient #9 revealed she was admitted to the hospital for altered thought processes, schizophrenia and delusions on 06/15/10. Review of the Physicians' Orders dated 06/17/10 at 11:25am revealed an order for "second loading dose of Invega Sustena 156mg IM as soon as available". Review of the MAR for Patient #9 revealed.... "Invega Sustena 156mg IM as soon as available, called pharmacy won't be available until 06/18/10".

Patient #10
Review of the medical record for Patient #10 revealed he had been admitted to the hospital on 06/16/10 for depression with a history of COPD (Chronic Obstructive Pulmonary Disease). Review of the Physicians' Orders for Admit revealed an order for Advair Diskus bid (twice a day) inhalant, and Patient #10 missed the dose on 06/16/10 at 2100 (9:00pm) and was administered the 06/17/10 0900 (9:00am) dose at 1400 (2:00pm) or 5 hours late.

Patient #17:
Review of Patient #17's physician's orders dated 05/12/10 at 1600 (4:00 p.m.) revealed an order for "Saphris 10 mg. (milligrams) PO (by mouth) bid (two times per day)". Review of Patient #17's Medication Administration Record revealed the next scheduled dosage of Saphris was due at 2100 (9:00 p.m.), 5 hours after the physician ordered the medication. Further review revealed Patient #17 did not receive the medication until 2315 (2 hours and 15 minutes after the scheduled dosage).

In a face-to-face interview on 6/22/10 at 10:35 a.m., Interim Director of Nursing S2 indicated medication availability varies due to delivery times by the contracted pharmacy.

In a telephone interview on 6/24/10 at 2:45 p.m., Pharmacy Director S34 indicated the pharmacy delivery times vary; however, typically they are scheduled for 10:00 a.m., 12:00 p.m., and between 6:00 and 7:00 p.m. for routine deliveries. S34 indicated stat orders are provided within 2 hours of receiving order. S34 indicated the Pharmacy's goal is to have medication available for the next scheduled dose when an order is received.

3) financial issues which resulted in background checks and drug screens not being performed on the staff hired by the hospital and the inability of the administration of the hospital to ensure all staff had been trained in crisis intervention:
Review of the Performance Improvement Committee Meeting Minutes dated 03/31/09, 04/14/09, 04/27/09, 06/25/09, 08/26/09, 09/30/10, 12/02/10, and 03/10/10 revealed no documented evidence the inability to obtain background checks and drug screens for new hired employees and crisis prevention training to the staff providing direct patient care had been perceived as a problem by the Human Resource Department, the Performance Improvement Committee or the Governing Board.

In a face-to-face interview on 06/22/10 at 4:25pm, Chief Executive Officer (CEO) S1, when informed of no evidence in the personnel files of background checks and drug screens, could offer no explanation for these not being performed.

In a face-to-face interview on 06/23/10 at 8:45am, Human Resources (HR) Director S16 indicated she was responsible for the employees' personnel files. She further indicated it was the responsibility of former DON (director of nursing) S40 to perform drug screens prior to an applicant being hired, but S40 didn't do them. S16 further indicated she reported this to the Administrator when it was not done. S16 indicated background checks were not performed, because the "corporate office quit paying the bill". She further indicated that some employees brought background check results from former employers or had them done on their own. S16 indicated this occurrence was reported to the Administrator.

In a face-to-face interview on 06/25/10 at 8:15am, CEO S1 presented the balance details revealing the balance due the research company was paid on 03/15/10. She indicated that she was told by HR Director S16 that S16 could not get a background check completed.

In a face-to-face interview on 06/25/10 at 8:25am, HR Director S16 indicated she had tried to do a background check 3 weeks ago and received an answer of "access denied". She further indicated she had no documented evidence that this search had been attempted. With CEO S1 present during this interview, neither S16 nor S1 could offer an explanation for a background check not being performed for RN S21 who was hired 04/06/10, LPN S33 who was hired 03/22/10, and MHT S23 who was hired 04/06/10, all after 03/15/10 when the research company balance showed $0.

Based on record review and interview, the hospital failed to ensure medications were administered as per physicians orders for 4 of 22 sampled patients (#3, #9, #10, #17). Findings:

Patient #3:
Review of Patient #3's medical record revealed physician's orders dated 06/18/10 as follows: 1055 (10:55 a.m.) Risperdal consta 50 milligrams every 2 weeks - give first dose now. 1600 (4:00 p.m.) OK to give Risperdal Consta when arrives. Review of Patient #3's nursing notes dated 06/18/10 at 1815 (6:15 p.m./6 hours and 20 minutes after ordered by the physician) revealed "Pt. received IM dosage of Risperdal consta (with) sterile technique per Medicine nurse. . . tolerated injection well, (no) complaints voiced".

During a face-to-face interview on 06/21/10 at 11:50 a.m., LPN (Licensed Practical Nurse) S4 indicated she had sent pharmacy a fax requesting Risperdal Consta when she received the order. S4 further indicated she called the pharmacy back every 30 minutes and they continued to tell her it would arrive with the next batch of medication. S4 indicated it did not arrive until 6:15 p.m. (6 hours and 20 minutes after ordered by the physician). S4 further indicated she did not do an occurrence report/incident report.

Patient #9
Review of the medical record for Patient #9 revealed she had been admitted to the hospital for altered thought processes, schizophrenia and delusions on 06/15/10. Review of the Physicians' Orders dated 06/17/10 at 11:25am revealed an order for "second loading dose of Invega Sustena 156mg IM (Intramuscular) as soon as available".

Review of the MAR (Medication Administration Record) for Patient #9 revealed.... "Invega Sustena 156mg IM as soon as available, called pharmacy won't be available until 06/18/10".

Patient #10
Review of the medical record for Patient #10 revealed he had been admitted to the hospital on 06/16/10 for depression with a history of COPD (Chronic Obstructive Pulmonary Disease). Review of the Review of the Physicians' Orders for Admit revealed an order for Advair Diskus bid (twice a day) inhalant.

Review of the MAR for Patient #10 revealed Advair could not be administered because it was unavailable in the pharmacy. Further review of the MAR revealed no substitution had been made for with a similar drug for the Advair which is used in the treatment of respiratory disease.

Patient #17:
Review of Patient #17's physician's orders dated 05/12/10 at 1600 (4:00 p.m.) revealed an order for "Saphris 10 mg. (milligrams) PO (by mouth) bid (two times per day)". Review of Patient #17's Medication Administration Record revealed the next scheduled dosage of Saphris was due at 2100 (9:00 p.m./5 hours after the physician ordered the medication). Further review revealed Patient #17 did not receive the medication until 2315 (2 hours and 15 minutes after the scheduled dosage).

During a face-to-face interview on 06/22/10 at 10:35 a.m., Interim Director of Nursing S2 indicated medication availability varies due to delivery times by the contracted pharmacy.

Review of the contract pharmacy policy # 2.01 dated 03/18/09 revealed.... "New medication orders received by Pharmacy will be available for administration on the day ordered by the physician and/or prior to the scheduled first dose".

During a face-to-face interview on 06/22/10 at 10:35 a.m., Interim Director of Nursing S2 indicated medication availability varies due to delivery times by the contracted pharmacy. S2 further indicated nursing staff have not made it a practice to complete occurrence reports for missed medications. S2 further indicated nursing staff should complete occurrence reports on missed medications in order for the root cause to be identified and corrective action to be taken as needed.

Review of the hospital policy titled, "Medication Variance Corrective Action, dated 01/09", presented by the hospital as their current policy, revealed in part, "It is the policy of Focus Behavioral Hospital to support staff in disclosure of Medication Variance and error reporting without fear of reprisal. . . Types of medication variances include, but are not limited to, the following: Omission of Medication - dose of medication not administered when it was ordered. . . When a medication variance level 1 or above occurs, the person who made the error, or if not available, the person who discovered the variance will . . Report all levels of medication incidents via incident reports".

Based on record review and interview, the hospital failed to ensure the Administrator, Medical Staff, or Director of Nursing monitored the Infection Control Program as evidenced by lack of discussion in Governing Body Meeting Minutes and Performance Improvement Meeting Minutes. Findings:

Review of the Governing Board Meeting Minutes revealed the following: 10/28/09 - no reports of influenza H1N1; 04/07/10 - no infection control information submitted, and 03/03/09 - no infection control information submitted; and the hospital could not submit any documentation of meetings held in 2010.

Review of the Medical Staff Meeting Minutes dated 01/25/10, 10/09/09, 07/06/09, 05/06/09, and 04/14/09 revealed no documented evidence of discussion of infection control data.

In a face-to-face interview on 06/25/10 at 10:10am, S1 Chief Executive Officer indicated she assumed the formed DON was performing her job duties and was not aware TB testing was not up-to-date, handwashing surveillances not performed, or investigations into the causes of infections had not been conducted.