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Based on record review and interviews, the hospital failed to ensure a patient was free from all forms of neglect by failing to assess a patient for possible injury when she was found nude in a male patient ' s room and to perform an investigation to assure the appropriate corrective action occurred to prevent a reoccurrence of the incident for 1 of 1 patients reviewed for possible neglect from a total of 10 sampled patients (#FF5). Findings:

Review of Patient # FF5's medical record revealed she admitted on 09/09/10 at 1:25pm with a diagnosis of Psychosis.

Review of Patient # FF5's "Nurse's Daily Shift Assessments" revealed on 09/10/10 at 12:40am RN SFF17 documented "not in room at present, searched other residents rooms". At 12:42am on 09/10/10 RN SFF17 documented "found in other patient's room nude undressed. Escorted pt to time out. Will notify MD. No noted problems at present". At 12:50am RN SFF17 documented "notified MD. Pt on LOS (line of sight) in time out at present ...". Further review revealed no documented evidence of the location in the room of Patient # FF5 when found in the other patient's room, the location of the other patient in the room, and the activity of the patients upon the nurse's entrance to the room. Further review revealed no documented evidence of a RN's assessment for possible injury upon finding Patient # FF5 nude in another patient's room.

Review of the physician's orders revealed a telephone order received by RN SFF17 from Psychiatrist SFF18 on 09/10/10 at 12:50am for "ok for LOS (line of sight)". Further review revealed a telephone order received on 09/10/10 at 7:55am by RN SFF21 from Psychiatrist SFF18 to "please make pt a 1:1". Further review revealed Patient # FF5 remained on 1:1 observation until an order was received to discontinue 1:1 observation on 09/15/10 at 1:50pm. There was no documented evidence of an assessment of the need to continue 1:1 observation on 09/11/10, 09/13/10, 09/14/10, and 09/15/10 and an order every 24 hours to continue 1:1 observation as required by hospital policy.

In a face-to-face interview on 09/16/10 at 3:35pm, Director of Clinical Services confirmed RN SFF17's documentation did not include an appropriate assessment of the situation. She further confirmed there was no incident report submitted for the occurrence on 09/10/10 with Patient # FF5, and she (Director of Clinical Services) had not conducted an investigation after learning that Patient # FF5 had been found nude in a male patient's room.

In a telephone interview on 09/20/10 at 12:20pm, RN SFF17 indicated she worked the night shift of 09/09/10 from 7:00pm on 09/09/10 through 7:00am on 09/10/10 and was the nurse assigned to Patient # FF5. When asked why she had checked on Patient # FF5 2 minutes after she had just been in her room, SFF17 indicated when she returned to the nursing station, she thought she saw a shadow pass by down the hall, so she went to Patient # FF5's room to check. She further indicated she found Patient # FF5 in the male patient's room across the hall from # FF5's room. When asked where Patient # FF5 was located when she was found, RN SFF17 indicated "just what was written". When informed by the surveyor that there was no documented evidence where # FF5 was located when RN SFF17 entered the room, where the male patient was located, and what activity was occurring upon her entering the room, RN SFF17 indicated Patient # FF5 was standing at the door when SFF17 opened the door. She further indicated she did not see the male patient walk out the room, but Patient # FF5 was alone in the room when she entered. RN SFF17 could offer no explanation for her documentation revealing Patient # FF5 was in the male patient's room at 12:42pm and the mental health technician's documentation revealing Patient # FF5 was in the other patient's room at 12:30pm. RN SFF17 indicated Patient # FF5's plan of care was not revised by her, because Psychiatrist SFF18 indicated she would see the patient later. She further indicated "I'm not going to change it at the time the incident occurred".

In a face-to-face interview on 09/20/10 at 1:40pm, Psychiatrist SFF18 indicated she didn't think the hospital had line of sight as a type of observation, and she had ordered Patient # FF5 to be on 1:1 observation.

Review of the hospital policy titled "Patient Abuse and/or Neglect", originated June 2006 and submitted by the Administrator as their current policy for patient abuse and neglect, revealed, in part, "...To outline guidelines for staff regarding what constitutes abuse. To outline procedures regarding any incident of patient abuse and/or neglect by patients, staff, or others. ...Neglect: Neglect is the act or series of acts or omission of any employee, affiliated, or agent which causes or may have caused any physical or emotional injury to patient. Examples of neglect shall include, but are not limited to, failure to carry out a prescribed individual program plan or treatment plan; failure to provide a safe environment ...". Review of the entire policy revealed the entire policy was related to staff-to-patient occurrences and did not address patient-to-patient occurrences.

Review of the hospital policy titled "Sexual Acting Out Precautions", revised and effective 07/10 and submitted by the Administrator as the hospital ' s policy for dealing with sexually inappropriate behavior, revealed, in part, "...Purpose: To ensure the safety of all patients, guidelines are provided to consistently assess the sexually acting out patient(s) {i.e. (that is) patients who disrobe, are sexually preoccupied, engage in inappropriate touch, or make seductive remarks, etc. (and so on)} ... Procedure: Staff MD (medical doctor)/NP (nurse practitioner)/RN Assess patients to determine risk of acting out sexually as evidenced by one or more of the following: 1. Preoccupation with sexual thoughts 2. Verbalizes feelings of sexually acting out or making seductive remarks or gestures 3. Maintains insufficient boundaries with peers 4. Disrobing publicly on the unit ... RN/LPN/MHT (mental health technician) Take the following actions should sexual contact occur or be strongly suspected: - confront patient(s) of suspected behavior - encourage expression of feelings and restate limits - notify physician(s) for appropriate orders according to Hospital protocol which may include: gynecological consultation; ...complete Incident Report for each party involved; immediately evaluate and update treatment plan with interventions to prevent reoccurrence; institute sexual acting out precautions monitoring ...MD/NP or RN An order for precautions is written by the physician or a registered nurse as an independent nursing intervention, and the physician notified of the patient's behavior. A physician's order must be obtained within 24 hours of the nursing order. Sexual Acting Out Precautions MD/TX (treatment) Team Evaluations of sexual acting out precautions are reviewed daily by the physician and treatment team and reordered every 24 hours as needed. RN Documentation of the specific behavior necessitating precautions is made in the progress notes. ... Interventions used are reflected on the Master Treatment Plan (e.g 10-foot restriction from identified peer). ... RN/LPN/MHT Reinforce/teach about personal boundaries as frequently as needed. Minimum once every shift while awake, and document in progress note".

Review of the hospital policy titled "Patient Observation and Precaution Protocols", revised 07/01/10 and submitted by the Administrator as their current policy for observation precautions, revealed, in part, "...The level of observation and/or precautions needed may be ordered by the attending physician, nurse practitioner, or initiated by nursing staff. Should the nursing staff initiate any level of observation, rationale for this decision is recorded in the medical record and the patient's physician is notified as soon as possible. If the physician concurs, an order must be written. ... Observation Levels: 1. One-on-one - staff member is no more than an arm's length away from the patient at all times. 2. Q 15 (every 15 minutes) - staff member to personally view patient at least every 15 minutes ... One-to-one supervision is instituted when a patient is assessed to be a danger to self or others. An order for 1:1 is written by the physician or NP (nurse practitioner), or a registered nurse as an independent nursing intervention until a physician's order is obtained. A physician's order must be obtained within 24 hours of the nursing order. ...The registered nurse communicates the patient's status to all members of the treatment team. The treatment team assesses the patient every 24 hours to ensure that 1:1 staff supervision is necessary and, if so, the order is renewed. ... Interventions: ... 2. Initiate treatment plan to address reason for initiation of precautions/observation. ... Documentation: 1. Assessment findings 2. Precautions maintained, 3. Observation intervals and findings 4. Effectiveness of interventions 5. M.D./N.P. notification...".

Based on record review and interview, the hospital failed to ensure the contracted pharmacist assisted with the development and oversight of medication error reporting, participated in quality assurance activities related to medications, and ensured medications were delivered in time to be administered for the next scheduled dose as required by the pharmacy service agreement as evidenced by the facility continuing to utilize the nurse self-reporting method to identify medication errors which resulted in 18 unreported medication variances for 6 of 10 sampled patients (# FF3, # FF4, # FF5, # FF7, # FF8, # FF8). Findings:

Record reviews of physicians' orders and patient MARs (Medication Administration Records) for Patients # FF3, # FF4, # FF5, # FF7, # FF8, and # FF9 revealed a total of 18 unreported medication variances (See findings at Tag A0404).

Review of the Quality Assurance/Performance Improvement (QA/PI) data collected by SFF22 QA/PI Coordinator revealed no documented evidence the hospital had identified any medication variances since the last survey conducted on 08/12/10.

Review of the Medication Variance Reports sent from the contracted pharmacy Facility "A" Compliance Officer SFF16 revealed the following:
June 2010 - no medication variances
July 2010 - no medication variances
August 2010 - 17 medication variances (identified by the survey team on 08/12/10)
September 2010 - none up to present 09/20/10.

In a face-to-face interview on 09/16/10 at 2:00pm, SFF22, the QA/PI Coordinator, indicated the hospital is still relying on the nurses to self-report medication errors and at the present time have no reported medication variances. She further indicated chart audits are supposed to be performed by the nursing staff; however compliance has not been good.

In a face-to-face interview on 09/20/10 at 9:50am, SFF14 contracted pharmacist with Facility "A" indicated he comes to the hospital once a month and checks stock, expired medications, and refrigerator temperature checks. SFF14 verified he does not perform chart audits, and any medication variances identified via the chart comes from the facility. He further indicated the pharmacy has a compliance officer who handles the medication variances. When asked if at the end of the month the hospital does not submit any medication variances, does the compliance officer contact the hospital to verify no variances have occurred, SFF14 responded "no". SFF14 had no response when informed the surveyors had identified 18 unreported medication variances while performing chart audits for 6 of 10 patient records. The Pharmacist confirmed he is not involved in any QA/PI activities.

Review of the "Pharmacy Services Agreement" between Focus Behavioral Hospital and Facility "A" , effective 02/12/09 and submitted by the Administrator as the current service agreement with Facility "A", revealed, in part, "...5. Providing routine and timely service for the Facility in-patients 7 days per week and as necessary to meet patient needs. ...12. Pharmacy will participate in quality assurance activities related to medications, including pharmaceutical and therapeutic committees. ... 19. Assist with the development and oversight of medication error reporting ...".

Based on record review and interviews, the hospital failed to have a process in place for identification, investigation, and reporting of medication errors as evidenced by no documented evidence any medication variances had been identified for the month of September 2010 which resulted in 18 unreported medication variances to the physician, pharmacist, and QAPI (quality assurance performance improvement) department for 6 of 10 sampled patients (# FF3, # FF4, # FF5, # FF7, # FF8, # FF8). Findings:

Record reviews of physicians' orders and patient MARs (Medication Administration Records) for Patients # FF3, # FF4, # FF5, # FF7, # FF8, and # FF9 revealed a total of 18 unreported medication variances (See findings at Tag A0404).

Review of the Quality Assurance/Performance Improvement (QA/PI) data collected by SFF22 QA/PI Coordinator revealed no documented evidence the hospital had identified any medication variances since the last survey conducted on 08/12/10.

Review of the Medication Variance Reports sent from the contracted pharmacy Facility "A" Compliance Officer SFF16 revealed the following no medication variances had been identified thus far for the month of September.

Review of the hospital policy presented by the Administrator as their current policy for medication administration revealed no documented evidence of a definition of what constitutes a medication error. Further review revealed no documented evidence that the physician had to be notified of a medication error.

In a face-to-face interview on 09/16/10 at 2:00pm, SFF22, the QA/PI Coordinator, indicated the hospital is still relying on the nurses to self-report medication errors and at the present time have no reported medication variances. She further indicated chart audits are supposed to be performed by the nursing staff; however compliance has not been good.

In a face-to-face interview on 09/20/10 at 9:50am, SFF14 contracted pharmacist with Facility "A" indicated he comes to the hospital once a month and checks stock, expired medications, and refrigerator temperature checks. SFF14 verified he does not perform chart audits, and any medication variances identified via the chart comes from the facility. He further indicated the pharmacy has a compliance officer who handles the medication variances. When asked if at the end of the month the hospital does not submit any medication variances, does the compliance officer contact the hospital to verify no variances have occurred, SFF14 responded "no". SFF14 had no response when informed the surveyors had identified 18 unreported medication variances while performing chart audits for 6 of 10 patient records. The Pharmacist confirmed he is not involved in any QA/PI activities.

Review of the "Pharmacy Services Agreement" between Focus Behavioral Hospital and Facility "A", effective 02/12/09 and submitted by the Administrator as the current service agreement with Facility "A", revealed, in part, "...5. Providing routine and timely service for the Facility in-patients 7 days per week and as necessary to meet patient needs. ... 12. Pharmacy will participate in quality assurance activities related to medications, including pharmaceutical and therapeutic committees. ... 19. Assist with the development and oversight of medication error reporting ...".

Review of the one policy presented by the Administrator when asked for the hospital's medication administration policy revealed a policy titled "Pharmacy Services" which was originated in June 2006. Further review of the policy revealed, in part, "...4. All medication errors, patient's adverse reactions, and unusual occurrences will be fully documented in the patient's medical record. The pharmacist will be notified of all medication errors and patient's adverse reactions. ... 6. A medication variance report (MVR) will be completed for medication errors and all adverse reactions: a. he MVR will be faxed to the pharmacy once completed b. the Director of Nursing will review and evaluate each incident c. the medical consultant will review all MVRs".

Based on record review and interview the hospital failed to implement an effective process to identify and reduce medication variances as evidenced by continuing to utilize the nurse self-reporting method to identify medication errors resulting in 18 unreported medication variances, monitor patient Medication Administration Records for identification of unreported medication variances, and involve the contracted pharmacist in the process for medication variance identification and implementation of corrective action. Findings:

Record reviews of physicians' orders and patient MARs (Medication Administration Records) for Patients #FF3, #FF4, FF5, #FF7, #FF8, and #FF9 revealed a total of 18 unreported medication variances (See findings at Tag A404).

Review of the Quality Assurance/Performance Improvement (QA/PI) data collected by SFF22 QA/PI Coordinator revealed no documented evidence the hospital had identified any medication variances since the last survey conducted on 08/12/10.

Review of the Medication Variance Reports sent from the contracted pharmacy Facility "A" 's Compliance Officer SFF16 revealed the following:
June 2010 - no medication variances
July 2010 - no medication variances
August 2010 - 17 medication variances (identified by the survey team on 08/12/10)
September 2010 - none up to present 09/20/10

In a face to face interview on 09/16/10 at 2:00pm SFF22 the QA/PI Coordinator indicated the hospital is still relying on the nurses self-reporting and at the present time have no reported medication variances. Further she indicated chart audit are supposed to be performed by the nursing staff; however compliance has not been good.

In a face to face interview on 09/20/10 at 9:50am SFF14 contracted pharmacist with Facility "A" indicated he comes to the hospital once a month and checks stock, expired medications and refrigerator temperature checks. SFF14 verified he does not perform chart audits and any medication variances identified via the chart comes from the facility. Further the pharmacy has a compliance officer who handles the medication variances. When asked if at the end of the month the hospital does not submit any medication variances, does the compliance officer contact the hospital to verify no variances have occurred, SFF14 responded "no". Further SFF14 had no response when informed the surveyors had identified 18 unreported medication variances while performing chart audits for 6 of 10 patient records. The Pharmacist confirmed he is not involved in any QA/PI activities.