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Based on observation, record review and interview the hospital failed to meet the requirements to be in compliance with the Condition of Participation for Nursing as evidenced by:

1. Failing to ensure the R.N. instructed and/or informed in shift change report the Mental Health Technicians, who are responsible for monitoring psychiatric patients, when a patient was to be on suicide precautions for 1 of 6 sampled patients on suicide precautions out of a total sample of 11 (Patient #3); Failing to ensure an RN performed and documented on admission and on every shift a suicide assessment of each patient according to hospital policy for 4 of 6 sampled patients on suicide precautions out of a total sample of 11 (Patient #1, #3, #7, #9); failing to ensure that a complete nursing suicidal assessment was performed during the admission process and daily per hospital policy and procedure which included the need for close or 1:1 observation for 1 of 6 sampled residents on suicide precautions out of a total sample of 11 (Patient #3). The failure of these findings resulted in a patient who had been admitted for severe depression and suicidal ideations to strangle himself (Patient #3) which resulted in the patient's death. (See findings at Tag A0395).

2. Failing to establish an accurate initial plan of care and treatment plan for Patient # 3 who was admitted for suicidal ideations by identifying the patient's main problem on the plan of care as "pressre sores" rather than suicidal ideations. The medical record failed to indicate that upon admit patient #3 had any skin breakdowns. Patient #3 committed suicide on the second day of hospitalization. (See findings at Tag A0396)

3. Failure to ensure all nursing staff were knowledgeable and determined competent in the use of all emergency equipment, ambu bag, and changing of cylinder heads on oxygen tanks in the event a patient requires assisted ventilation or oxygen during an emergency as evidenced by 4 of 4 RNs observed unable to perform changing the cylinder heads on the oxygen tank. (S17, S18, S19, S20). (See findings at Tag A0397).

Based on record review and interview the hospital failed to ensure that the medical staff rules and regulations were followed for admission as evidenced by allowing a nurse practitioner to admit and treat a patient without any documented evidence the patient was under the care of a physician for 1 of 11 sampled medical records (Patient #10) Findings:

Review of the medical record revealed Patient #10 had been admitted to the hospital on 05/03/10 for Depression through the use of telephone orders at 1945 (5:45pm). Further review of the Admission Orders revealed no documented evidence who had given the orders to admit the patient. Review of orders received from 05/04/10 through 05/11/10, the day of discharge revealed the following: 05/04/10 at 0845 (8:45am) Acute hepatitis panel ordered by NP S25; 05/04/10 at 3:20pm Implement Abstinence Symptoms Evaluation written as a verbal order from MD S23 by NP S26; 05/04/10 at 5:25pm D/C previous Abstinence Symptoms Evaluation written as a verbal order from MD S23 by NP S26; 05/07/10 at 1630 (4:30pm) Seroquel 25mg po (by mouth) every AM (Morning) and Seroquel 100mg po every HS (Hour of Sleep) written by NP S27; 05/10/10 at 1635 (4:353pm) Trazodone 50mg po HS tonight X1 (times 1) written as a verbal order from MD S23 by NP S26; and 05/11/10 at 0921 (9:21am) Discharge orders written by NP S27. Further review of the orders revealed no documented evidence the physician MD S23 had authenticated any of his verbal orders .

Review of the Medical Staff Rules and Regulations (no date of implementation or revision) revealed,..... " 1. An admit psychiatric evaluation must be written by the admitting psychiatrist within sixty (60) hours of patient's admission.... a) The attending medical physician shall see the patient within 24 hours of admission. This will be documented in the progress notes".

Review of the Psychiatric Assessment for Patient #10 dated 05/04/10 revealed it had been written and signed by NP S26. Further review revealed no documented evidence the physician reviewed and/or signed the assessment.

Review of the Physician Progress Notes for Patient #10 dated 05/06/10, 05/07/10 and 05/08/10 (date of discharge) revealed no documented evidence the physician had participated in the treatment of Patient #10 as evidenced by all progress notes being written and signed by a nurse practitioner.

Review of the Daily Nursing Assessment form for Patient #10 in the space provided for documentation of physician visits and the time to be completed by the nursing staff revealed the following: 05/04/10, 05/05/10, 05/09/10, 05/10/10 and 05/11/10 no documented evidence the physician or the nurse practitioner had seen the patient as evidenced by a blank in the space provided for the name of the physician who visited and the time of the visit.

Review of the Clinical Summary/Master Treatment Plan for Patient #10 dated 05/04/10 revealed no documentation the physician had reviewed the plan as evidenced by a blank in the space provided for the physician's signature.

In a face to face interview on 05/18/10 at 3:15pm MD S23 after review of Patient #10's medical record verified there was no documented evidence that he had seen the patient.

Based on record review and interview the hospital failed to ensure a physician was on call at all times by assigning nurse practitioner to cover call for both the psychiatric and medical staff physicians. Findings:

The hospital Administrator was unable to submit a call schedule for the physicians and informed the survey team she would have to get it from the physician's office because it would be quicker than trying to find it. When submitted, it was for the Internal Medicine group only.

Review of the Call Schedule for Internal Medicine MD S29 for the time period of 03/15/10 through 05/24/10 revealed the following:
Monday 5:00pm through Tuesday 6:00am - MD S29
Tuesday 5:00pm through Wednesday 6:00am - NP (Nurse Practitioner) S30
Wednesday - 5:00pm through Thursday 6:00am - NP S31
Thursday - 5:00pm through Friday 6:00am - NP S25
Friday - 5:00pm through Monday 6:00am - MD S32

In a face to face interview on 05/19/10 at 1:40pm S2 RN DON (Director of Nursing) verified the Nurse Practitioners take call for the physicians and indicated the MD should be on call.

In a face to face interview on 05/19/10 at 2:00pm NP S24 indicated she had been a nurse practitioner for over 7 years and has taught at the college level and is knowledgeable concerning her scope of practice. Further she indicated under Louisiana Law she is permitted to independently perform History & Physicals, perform psychiatric evaluations and take call. S24 informed the surveyors she works at several large hospitals in the city and has never once been told this cannot be done. Further she is not aware of any regulation by CMS prohibiting nurse practitioners from taking call for physicians.

Review of the Medical Staff By-Laws (no date of implementation or revision documented) revealed... in Section 2. Qualifications of Membership b. Nurse Practitioners and Physician Assistants licensed in the State of Louisiana and demonstrated competency may treat patients in the hospital under the supervision of a privileged physician. Further review of the bylaws revealed no documented evidence the issue of physician call had been addressed.

Review of the Medical Staff Rules and Regulations (no date of implementation or revision documented) revealed no documented evidence the issue of physician call had been addressed.

Based on record review and interview the hospital failed to ensure care in a safe setting by:
1) Failing to ensure equipment was available in the hospital in order for staff to implement the hospital policy titled, " Code Blue Response " in emergencies by having no AED (automated external defibrillator) in the hospital.
2) Failing to ensure plastic bags were not accessible to patients which might be used for harming themselves or others by means of suffocation.
3) Failing to ensure the bathroom plumbing was designed in a manner that did not allow for the possibility of hanging oneself as evidenced by protruding shower heads and toilet pipes. Findings:

1) Failing to ensure equipment was available in the hospital in order for staff to implement the hospital policy titled, " Code Blue Response " in emergencies by having no AED (automated external defibrillator) in the hospital.
Observations on 5/17/2010 at 9:30 a.m. revealed no Automated External Defibrillator to be located in the hospital. These findings was confirmed by Hospital Administrator S1.

Review of the hospital policy titled, " Code Blue Response (approved 1/09) " presented by the hospital as their current policy revealed in part, " If pulse is absent, places patient on cardiac board and begins artificial circulation in addition to rescue breathing. Follow AED policy. Applies AED pads and allows AED to check cardiac rhythm. Follows AED prompt for shock and continue CPR. . . "

During a face to face interview on 5/18/2010 at 8:00 a.m., Director of Nursing S2 and Hospital Administrator S1 confirmed the hospital did not have an AED (Automated External Defibrillator). S2 indicated she had been aware that the hospital ' s Code Blue policy specified the use of an AED in response to codes (cardio-pulmonary resuscitation efforts); however, she since the hospital did not own an AED she had intended on removing that statement from the policy but had failed to do so.


2) Failing to ensure plastic bags were not accessible to patients which might be used for harming themselves or others by means of suffocation.
Observations on 5/18/2010 at 2:20 p.m. revealed the Day Room to contain 5 patients with no staff in attendance. Further observations revealed two garbage cans lined with plastic bags to be located in the room, one large and one small. Hospital Administrator S1 confirmed the findings and indicated there should be no plastic bags lining the garbage cans because they could be used by patients to inflict harm.

3)Failing to ensure the bathroom plumbing was designed in a manner that did not allow for the possibility of hanging oneself as evidenced by protruding shower heads and toilet pipes. Findings:
Observations were made on 5/18/2010 at 2:00 p.m. of Room A. Observations revealed a protruding shower head. The shower head had a pipe measuring 1 ? inches from the wall at a 90 degree angle. At the end of the 1 ? inches the shower head angled downward and measured 5 inches. These measurements were taken by the hospital administrator. Further observations revealed shower heads in Rooms B, C, D, F, G, H, I, J, and K to be the same 1 ? inches protruding and angling for another 5 inches. Observations revealed the shower head in Room E to be protruding 3 ? inches at a 90 degree angle and then angling down for another 4 ? inches. Observations revealed the toilets in each patient room have exposed pipes that extended at a 90 degree angle from the wall measuring 4 inches at a height of 25 inches. These findings were confirmed by the hospital ' s administrator who indicated the shower heads had not changed since the facility was opened.

Based on observation and record review the hospital failed to follow their Medical Staff Rules and Regulations by allowing Nurse Practitioners to perform history and physicals (Patient #7, and psychiatric admit assessments for 4 of 11 sampled patients (Patient #1, #7, #9, #10). Findings:

Patient #1
Review of the History & Physical for Patient #1 dated 05/01/10 revealed it had been performed by Nurse Practitioner S25. Further review of the medical record revealed no documented evidence the H&P had been reviewed by the physician or that an entry had been written in the progress notes concerning the H&P as specified in the Medical Staff Rules and Regulations.

Patient #7
Review of the History and Physical for Patient #7 performed by NP (Nurse Practitioner) S30 revealed no documented evidence the H&P had been reviewed by the attending internal medicine physician S29. Further review of the medical record for Patient #7 revealed no documented evidence of a notation in the Progress Notes made by S29 as required by the Medical Staff Rules and Regulations.

Patient #9
Review of the History and Physical for Patient #9 performed by NP (Nurse Practitioner) S30 revealed no documented evidence the H&P had been reviewed by the attending internal medicine physician S29. Further review of the medical record for Patient #9 revealed no documented evidence of a notation in the Progress Notes made by S29 as required by the Medical Staff Rules and Regulations.

Patient #10
Review of the History and Physical for Patient #10 performed by NP (Nurse Practitioner) S25 revealed no documented evidence the H&P had been reviewed by the attending internal medicine physician S29. Further review of the medical record for Patient #9 revealed no documented evidence of a notation in the Progress Notes made by S29 as required by the Medical Staff Rules and Regulations.

Review of the Medical Staff Rules and Regulation (no date of implementation or revision) revealed on page 24 2. a)..... "The attending medical physician shall see the patient within 24 hours of admission. This will be documented in the progress notes. Documentation will include notation of physical examination".

In a face to face interview on 05/18/10 at 3:30pm S1 the Administrator indicated the Medical Director had spoken told her the Medical Staff Rules and Regulations had been revised under the previous S34 the previous Administrator; however the hospital could not submit a copy of the new revision or indicate in the Governing Body Meeting Minutes the approval of the changes.

Patient #10
Review of the Psychiatric Assessment for Patient #10 dated 05/04/10 at 2:00pm revealed the assessment had been performed, dictated and signed by Nurse Practitioner S26. Further review of the medical record revealed no documented evidence the psychiatrist had performed a psychiatric evaluation as specified in the Medical Staff Rules and Regulations.

Review of the Medical Staff Rules and Regulation (no date of implementation or revision) revealed on page 23 1. ..... "An admit psychiatric evaluation must be written by the admitting psychiatrist within sixty (60) hours of patient's admission....". Further review of the Rules and Regulations revealed no documentation allowing delegation of this duty to a practitioner.

In a face to face interview on 05/19/10 at 2:00pm NP S24 indicated she had been a nurse practitioner for over 7 years and has taught at the college level and is knowledgeable concerning her scope of practice. Further she indicated under Louisiana Law she is permitted to independently perform History & Physicals, perform psychiatric evaluations and take call. S24 informed the surveyors she works at several large hospitals in the city and has never once been told this cannot be done. Further she is not aware of any regulation by CMS prohibiting nurse practitioners from taking call for physicians. When asked by the surveyor if she had read the Medical Staff Rules and Regulations of the Hospital she responded no.

Based on record review and interview the hospital failed to ensure staffing was based on acuity using the Three Level Classification System outlined in the hospital policy titled, "Patient Classification System" for the dates of 5/2/10 through 5/17/10 (15 of 15 days reviewed). Findings:

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."

During a face to face interview on 5/18/2010 at 8:50 a.m., Director of Nursing S2 indicated she had not used the formula specified in hospital policy to determine the number of staff needed on each unit based on acuity. S2 indicated she used an old formula from the hospital ' s previous owners to determine staffing needs and computed the figures in her head and not on paper. S2 indicated she had no documentation to reveal how she determined the staffing needs of each unit. S2 further indicated she had not required charge nurses to follow the policy requiring them to classify patients on the unit every morning according to acuity level. Director of Nursing S2 indicated she had done a post incident review with staff after a patient had attempted suicide on the unit on 5/09/2010 (Patient #3). S2 further indicated the staff on duty the day of the incident indicated the acuity was very high; however, they had never called to request additional staff.

Review of the form titled, "A Framework for a Root Cause Analysis and Action Plan in Response to a Sentinel Event " presented by the Director of Nursing S2 as a " work in progress" revealed in part, " The acuity level was high in that there were 15 patients, several of which were highly agitated. The MHTs were on the hall monitoring patients. "

During a face to face interview on 5/18/2010 at 2:25 p.m., Registered Nurse (RN) S28 indicated he worked on the Geriatric Unit on 5/09/2010 from 7:00 a.m. until 7:00 p.m. S28 further indicated the census was 11 and he had 1 Registered Nurse, 1 Licensed Practical Nurse, 1 male Mental Health Tech, and 1 female Mental Health Tech on duty until 1:30 p.m. when one of his female techs was scheduled to leave. RN S28 indicated he pulled Mental Health Tech S13 to his unit because she had been assigned to the front desk. RN S28 indicated he had not known that S13 had been pulled to the Adult Unit to work; however, when he called the unit and told them he needed her to work Geriatrics due to having no female technician on the unit; they had complained that they were too busy. S28 indicated S13 did work the Geriatric Unit from 1:00 p.m. until 3:00 p.m. when she had to cover the front desk during visiting hours.

Review of hospital staffing on the Adult Acute Unit of the hospital for the date of 5/09/2010 7 a.m. - 7 p.m. shift revealed the following: (Census 15: 6 patients identified as suicide precautions: #1, #2, #3, #7, #8, and #9, 1 patient sent to a local hospital for a CT scan: #9, 1 patient identified as requiring frequent redirection for verbal altercations, #8):
One Registered Nurse (S11) from 7:00 a.m. until 7:00 p.m.,
One Licensed Practical Nurse (S12) from 7:00 a.m. until 7:00 p.m.,
Three Mental Health Techs from 7:00 a.m. until 12:00 noon (S13, S16, S38)
Four Mental Health Techs from 12:00 p.m. until 1:00 p.m. (S13, S16, S37, S38)
Three Mental Health Techs from 1:00 p.m. until 3:00 p.m. (S14, S37, S38 )
Two Mental Health Techs from 3:00 p.m. until 4:00 p.m. (S14, S37)
Three Mental Health Techs from 4:00 p.m. until 5:00 p.m. (S14, S16, S37)
Four Mental Health Techs from 5:00 p.m. until 7:00 p.m. (S13, S14, S16, S37).

Review of the entire staffing data presented by the hospital as all inclusive for the date of 5/19/2010 revealed no documented evidence of determining the number of staff needed using the acuity rating system as described in the hospital policy titled, " Patient Classification System " . 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 Practical Nurses, and 2 Mental Health Technicians.

During a face to face interview on 5/18/2010 at 8:50 a.m., Director of Nursing S2 indicated that although staffing had been split on 5/09/2010, she had reviewed it as part of critical incident review and found the staffing to be adequate. S2 could produce no documented evidence of using the hospital ' s Classification Level for assessing acuity and then determining staffing needs based on the determined acuity as per hospital policy. S2 indicated she had made attempts to get additional coverage for the Mental Health Staff; however, employees were not answering her calls. S2 indicated she discovered in her interviews with staff (no documented evidence) that the adult acute unit had been busy on the day of the incident (5/09/2010) due to one patient being sent out for a CT scan (#9) and another patient (#8) that was repeatedly involved in verbal altercations; however, no one had ever called requesting additional staff and all staff indicated they were able to meet the needs of the patients.

Review of patient medical records and nurse staffing revealed the following time line on the Adult Acute Unit dated 5/09/2010:
One Registered Nurse (S11) from 7:00 a.m. until 7:00 p.m.,
One Licensed Practical Nurse (S12) from 7:00 a.m. until 7:00 p.m.,
Three Mental Health Techs from 7:00 a.m. until 12:00 noon (S13, S16, S38)

Patient #3: 0800 (8:00 a.m.) repetitively requesting to use the phone requiring redirection. Remains on behavior/SP (behavior and suicide precautions).

Patient #3: 0930 (9:30 a.m.): (Physician S5) visited. New orders noted. Pacing in hallway and repetitively asking to use the phone.

Patient #8: " 1105 (11:05 a.m.) yelling cursing & agitated & upset (with) peer requiring redirection. "

Patient #9: " 1107 (11:07 a.m.) transported to (Hospital B) for CT scan of head, accompanied by (MHT S16).

Four Mental Health Techs from 12:00 p.m. until 1:00 p.m. (S13, S16, S37, S38)

Three Mental Health Techs from 1:00 p.m. until 3:00 p.m. (S14, S37, S38 )

Patient #3: 1300 (1:00 p.m.) Refused lunch- calmer (at) present p (after) receiving meds (medications). Will continue to monitor.

Patient #9: 1445 (2:45 p.m.) returned from (Hospital B) via (local ambulance company) stretcher. Condition stable. . . "

Patient #8: " 1443 (2:43 p.m.) was cleaning table in dining area and threw away peer ' s snack that was left on table. Peer called him a ' queer ' yelling, screaming, cursing & threatening. Peer requiring redirection. (Physician S5) notified. New orders noted. Geodon 20 mg (milligrams) given IM (intramuscularly). . . "

Two Mental Health Techs from 3:00 p.m. until 4:00 p.m. (S14, S37)

Patient #3: 1540 (3:40 p.m.) used phone to call someone (with) assistance. Remains calmer (and) easier to redirect. Remains on SP.

Three Mental Health Techs from 4:00 p.m. until 5:00 p.m. (S14, S16, S37)

Patient #3: 1600 (4:00 p.m.) Roommate came to nurse ' s station stating someone was laying on the floor in his bathroom not moving, Pt. was laying on floor face down in his bathroom. Resps (respirations) shallow. Noticed gown tied tightly around pt ' s neck when turned pt. over in supine position c (with) moderate amt (amount) clotted blood noticed R (right) nostril & on shirt. Gown untied from around pt ' s neck p (after) several attempts by writer and (S16 MHT/ Mental Health Tech). 911 called per (Licensed Practical Nurse S12) LPN. CPR (Cardio Pulmonary Resuscitation) initiated due to shallow resp. (respirations) face cyanotic and gradually began to turn pink (with) CPR. VS (vital signs) attempted to take B/P (blood pressure) and P (pulse) but unable to obtain. (S28) RN on unit to assist (with) CPR. Pt. being ambued (and) O2 (oxygen) @ (at) 15 liters/min (minute) O2 tank. EMS (Emergency Medical Services) arrived and put pt. on monitor (before) transferring pt from bathroom to his room. HR (heart rate) 130. Accucheck BG (blood glucose) 340. Intubated per EMS at 1610 (4:10 p.m.). Placement checked and in stomach - IV (intravenous line) started per EMS & pt. re-intubated. (Physician S5) notified of suicide attempt and pt. status. New order noted. BR police (Baton Rouge police) x2 here and given statement regarding suicide attempt. BR police interviewed (staff) pt. ' s roommate, stated to secure room as crime scent until he calls to release room. (at) 1630 (4:30 p.m.) pt. left unit via stretcher accompanied by EMS. "

Four Mental Health Techs from 5:00 p.m. until 7:00 p.m. (S13, S14, S16, S37).

Based on record review and interview the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient by failing to: 1) to ensure Mental Health Technicians responsible for monitoring patients every 15 minutes were informed in report at the change of shift that a patient was to be on suicide precautions for 1 of 6 sampled patients on suicide precautions out of a total sample of 11 (Patient #3); 2) ensure patients on suicide precautions were assessed every shift as per hospital policy for 4 of 6 sampled patients on suicide precautions out of a total sample of 11 (Patient #1, #3, #7, #9); 3) ensure that a complete nursing suicide assessment was performed during the admission assessment for 1 of 6 sampled patients on suicide precautions out of a total sample of 11 (Patient #3); 4) notify the physician of low blood sugar levels that were obtained when Accu checks were performed for 1 of 1 sampled patients with diabetes (#8); and 5) obtain a baseline neurocheck after a head injury for 1 of 1 patients sustaining an injury after a fall (#9) out of 11 total sampled patients. Findings:

1) Failure to ensure Mental Health Technicians responsible for monitoring patients every 15 minutes were informed in report at the change of shift that a patient was to be on suicide precautions
Review of Patient #3's medical record revealed the patient was admitted to the hospital on 5/08/09 with admission orders received at 8:45 p.m. for the patient to be placed on suicide precautions. Review of Patient #3 ' s Observation flow sheet dated 5/09/2010 revealed no documented evidence identifying Patient #3 as being on Suicide Precautions.

During a face to face interview on 5/18/2010 at 11:35 a.m., Mental Health Technician S14 indicated he was not told in shift report that Patient #3 was on suicide precautions and the observation flow sheet had not been coded with any precautions. S14 indicated if he had known the patient was on suicide precautions he would have watched him for changes and would have made an effort to get the patient to socialize more. S14 indicated Close Observations, which all patients are on, ensures that the patient ' s are observed every 15 minutes and all rooms are kept free from sharps.

During a face to face interview on 5/18/2010 at 10:00, Registered Nurse S11 indicated she was the nurse that worked the 7 a.m. - 7 p.m. shift on 5/09/2010 when Patient #3 had to be transferred to another facility post suicide attempt. S11 confirmed there was no documented evidence indicating Patient #3 was on Suicide Precautions on the Observation Flow sheet for 5/09/2010. S11 indicated there was a board in the Nursing Station that identified the patient as being on Suicide Precautions.


2) Failure to ensure patients on suicide precautions were assessed every shift as per hospital policy
Review of Patient #1's medical record revealed the patient was admitted to the hospital on 4/30/2010 with physician's orders timed 1705 (5:05 p.m.) identifying the patient as Precaution: SP (Suicide Precaution), Activity As tolerated. Further review of Nursing shift assessments (12 hour day shift and 12 hour night shift) for the dates of 5/08/10 or 5/09/10 revealed no documented evidence of a nursing suicide assessment.

Review of Patient #3's medical record revealed the patient was admitted to the hospital on 5/08/2010 with physician ' s orders timed 2130 (9:30 p.m.) identifying the patient as Precaution: SP (Suicide Precaution) Activity As tolerated. Further review of Nursing shift assessments for the day shift of 05/09/2010 revealed no documented evidence of a nursing suicide assessment. Further review revealed Patient #3 was found at 1600 (4:00 p.m.) documented as pt. (patient) was laying on floor face down in his bathroom. Resps (respirations) shallow. Noticed gown tied tightly around pt's neck. . . "

During a face to face interview on 5/18/2010 at 10:00, Registered Nurse S11 indicated she was the nurse that worked the 7 a.m. - 7 p.m. shift on 5/09/2010 when Patient #3 had to be transferred to another facility post suicide attempt. S11 confirmed there was no documented evidence of a suicide assessment performed on Patient #3 on the 7 a.m. - 7 p.m. shift of 5/09/2010.

Review of Patient #7's medical record revealed the patient was admitted to the hospital on 5/04/2010 with physician ' s orders timed 2310 (11:10 p.m.) identifying the patient as Precaution: SP (Suicide Precaution) Activity (none listed). Further review of Nursing shift assessments for the 12 day shifts on 5/05/10, 5/08/10, 5/11/10 and the 12 hour night shifts on 5/05/10, 5/06/10, 5/08/10, 5/09/10, 5/10/10, and 5/11/10 revealed no documented evidence of a nursing suicide assessment.

Review of Patient #9's medical record revealed the patient was admitted to the hospital on 5/07/2010 with physician's orders timed 5:00 a.m. identifying the patient as Precaution: SP (Suicide Precaution). Activity: ad lib. Further review of Nursing shift assessments for the 12 hour day shift on 5/12/2010 and the 12 hour night shifts on 5/08/2010, 5/09/2010, 5/11/2010, and 5/12/2010 revealed no documented evidence of a suicide assessment.

Review of the hospital policy titled, "Special Precautions (1/09)" presented by the hospital as their current policy revealed in part, "Documentation shall include a suicide assessment every shift, patient response . . . "

3) Failure to ensure that a complete nursing suicide assessment was performed during the admission assessment for 1 of 6 sampled patients on suicide precautions out of a total sample of 11 (Patient #3).
Review of Patient #3's "Nursing Assessment" dated 5/08/2010 at 2045 (8:45 p.m.) revealed in part, "Reason for admission, chief complaint: I have not slept in a week because I'm like a petri dish, a science project. . . Suicidal Thoughts: Current "thoughts a lot lately". Plan: Yes. Method: Overdose, Hang Self. Additional: Drinking Crown. Does patient have means? (no documentation). Previous attempts? (no documentation). Patient's perception of strengths: "Don't really have any strengths".

During a face to face interview on 5/18/2010 at 1:05 p.m., Registered Nurse S15 indicated she was the nurse that did the initial assessment of Patient #3 at the time of his admission on 5/08/2010. S15 indicated Patient #3 had expressed to her how tired he was, due to not sleeping, when she was doing his initial assessment. S15 further indicated the patient told her he had made a previous suicide attempt but did not feel like talking about it. S15 indicated Patient #3 ' s most recent suicidal ideation included a plan to hang himself and or overdose by drinking "Crown". S15 indicated the patient readily signed a " No Harm" contract and verbalized a commitment to not harm himself. S15 indicated the patient's (#3) primary concern was that he needed sleep. S15 confirmed that she did not complete the section of the suicide assessment regarding, "Does patient have means?" S15 indicated Physician S5 also ordered standard Suicidal Precautions for Patient #3 which meant Close Observation with 15 minute observations. S15 indicated the physician did not order 1:1 (one to one) and she did not see any indication that the patient needed to be 1:1. S15 indicated she would have placed the patient on 1:1 herself if she had seen any indication that the patient intended to act on his suicidal ideation. S15 indicated she could tell the difference between a "weak" suicidal ideation versus a "strong" suicidal ideation. S15 could give no specific assessment findings to indicate when a patient would have a "weak" versus a "strong" suicidal ideation/plan. S15 indicated all patients are monitored to ensure they do not have sharp instruments or items that could be used to inflict harm. S15 confirmed that Patient #3 had attempted suicide with a torn gown tied tightly around his neck the day following her assessment, 5/09/2010.

4) notify the physician of low blood sugar levels
Review of Patient #8's Admission Reconciliation Orders dated 05/06/10 at 1800 (6:00 p.m.) revealed, in part, "Accu check AC & HS (before meals and at bedtime)". Further review revealed the following sliding scale ordered:
Regular Humulin Insulin SQ (subcutaneous)
160-220= give 3 units
221-280= give 6 units
281-340= give 9 units
341-400= give 12 units
401-460= give 15 units
460 & above= call physician.

Review of Patient #8's Accu Check record dated 05/07/10 at 15:30 (3:30 p.m.) revealed, "Accu check 43". Review of the nurse's notes dated 05/07/10 revealed no documented evidence the physician was notified of the patient's low blood sugar.

Review of Patient #8's Accu Check record dated 05/09/10 at 6:30 a.m. revealed, "Accu check 45". Further review revealed another blood sugar was obtained and was "165" (no time was documented when rechecked). Review of the nurse's notes dated 05/09/10 revealed, "Accu check =45, given milk an graham cracker snacks". There was no documented evidence the physician was notified of the patient's low blood sugar.

Review of Patient #8's Accu Check record dated 05/10/10 at 21:00 (9:00 p.m.) revealed, "Accu check 36". Further review revealed another blood sugar was obtained and was "77" (no time was documented when rechecked). Review of the nurse's notes dated 05/10/10 revealed no documented evidence the physician was notified of the patient's low blood sugar.

Review of Patient #8's Accu Check record dated 05/11/10 at 6:30 a.m. revealed, "Accu check 41". Further review revealed another blood sugar was obtained and was "134" (no time was documented when rechecked). Review of the nurse's notes dated 05/11/10 revealed no documented evidence the physician was notified of the patient's low blood sugar.

Review of Patient #8's Nurse's Notes dated 05/11/10 at 1300 (1:00 p.m.) revealed, in part, "Accu check at 11:30 a.m. was 33 on recheck after snack blood sugar was 98. Staff will monitor and provide supportive care as needed". Review of the entire medical record revealed no documented evidence the physician was notified of the patient's low blood sugar level.

The following sliding scale was presented by S1, Administrator, as the hospital's current approved protocol:
Insulin Dependent Scale:
Regular Humulin Insulin SQ (subcutaneous)
160-220= give 3 units
221-280= give 6 units
281-340= give 9 units
341-400= give 12 units
401-460= give 15 units
460 & above= call physician.

Non-Insulin Dependent Scale:
160-220= give 2 units
221-280= give 4 units
281-340= give 6 units
341-400= give 8 units
401-460= give 10 units
460 & above= call physician.

In interview on 05/19/10 at 9:30 a.m. S1, administrator, confirmed that the hospitals current procedure for Accu checks did not include a protocol for notification of the physician for low blood sugar levels.


5) follow the hospital policy and procedure for obtaining a baseline neurocheck after a head injury
Review of the Incident Report dated 05/07/10 at 2130 (9:30pm) revealed Patient #9 had a fall which the patient described as a "convulsion from not getting her Xanax" and sustained a small raised area over the right eye and a slightly red right knee. Further review revealed MD S29's Nurse Practitioner had been notified and an ice pack was applied to the area and the patient would be monitored for pain and anxiety. The Incident Report listed under the section "Consequence" as 2. Minor: Minor injury or damage - minimal risk.

Review of the Nursing Notes dated 05/07/10 at 2120 (9:20pm) revealed an entry which describes the patient walking toward her room, going down on her knees and then hitting the floor. She was assisted by the staff to a chair and given her prescribed medication of Klonopin 1mg and Vistaril 50mg by mouth with water and had no difficulty in swallowing. Additional entries into the nursing notes were as follows: 2200 (11:00pm) resting in bed, respiration unlabored, not crying or anxious, has no complaint of pain, has ice pack to right eye, states OK; 2400 (12 midnight) asleep, awakens easily; 05/08/10 0200 (2:00am) oxygen saturation 98%, asleep, awakens easily; 0400 (4:00am) awakens, no complaints voiced, respirations unlabored and anxiety noted and 0600 (6:00am) asleep, awakens easily, area over right eye not red, still raised, denies any problems, states not anxious and rested.
Further review of the nursing notes dated 05/07/10 through 05/08/10 revealed no documented evidence the patient had been assesses for motor strength, pupils, pulses and the medical record failed to contain a Neurological Assessment Checklist.

In a face to face interview on 05/19/10 at 1:40pm the Risk Management RN S6 indicated it is her responsibility to review all incident reports to make sure everything had been done appropriately. Further she indicated she felt the patient had been adequately assessed after her fall because the nurse checked on her every couple of hours during the night and she could be easily aroused. When asked what was the outcome of the patient S6 indicated the patient began to experience headaches and two days later was transferred to the hospital for a CT of the head where she was diagnosed with a head contusion.

Review of policy # AS-11 titled "Neurological Assessment" date of approval 01/09 and submitted by the hospital as the one currently in use revealed a neurological assessment is indicated after any head injury. Further review revealed the nurse is responsible to assess the patient's level of consciousness, motor strength, pupils, pulses and record on the Neurological Assessment Checklist. In addition observation of the patient's overall appearance, actions, behavior, and speech should be documented in the progress notes.

Based on record review and interview the hospital failed to ensure Patient #3's initial treatment plan of care identified suicidal ideations as the patient's primary problem and primary reason for admission to the hospital for 1 of 6 sampled patients with suicidal ideations out of a total sample of 11 (Patient #3). Findings:

Review of Patient #3's "Nursing Assessment" dated 5/08/2010 at 2045 (8:45 p.m.) revealed in part, " Reason for admission, chief complaint: I have not slept in a week because I'm like a petri dish, a science project. . . Suicidal Thoughts: Current " thoughts a lot lately". Plan: Yes. Method: Overdose, Hang Self. Additional: Drinking Crown. Does patient have means? (no response). Previous attempts? (no response). Patient ' s perception of strengths: "Don't really have any strengths".

Physician's verbal orders dated 5/08/2010 at 2045 (8:45 p.m.) revealed in part, "SP (Suicide Precaution) and BX (Behavior Precautions). Activity: Ad Lib".

Review of the entire medical record revealed no documented evidence of a Treatment Plan to include no documented identification of Suicidal Ideation on a Treatment Plan for Patient #3.

During a face to face interview on 5/18/2010 at 1:05 p.m., Registered Nurse S15 indicated she was the nurse that did the initial assessment of Patient #3 at the time of his admission on 5/08/2010. S15 indicated Patient #3 had expressed to her how tired he was, due to not sleeping, when she was doing his initial assessment. S15 further indicated the patient told her he had made a previous suicide attempt but did not feel like talking about it. S15 indicated Patient #3's most recent suicidal ideation included a plan to hang himself and or overdose by drinking "Crown". S15 indicated the patient's (#3) primary concern was that he needed sleep. S15 indicated Physician S5 also ordered standard Suicidal Precautions for Patient #3 which meant Close Observation with 15 minute observations. S15 indicated she did not place suicidal ideations on a treatment plan for Patient #3. S15 indicated she did a pressure sore assessment on Patient #3 which met the requirements of initiating the care plan.

Review of a hospital memo dated May 20, 2009 revealed in part, "Nurses please make sure to address an individual treatment plan with each patient upon admission. The nurse that admits the patient should ideally initiate the plan. . . The admit nurse should gather treatment plans that should be addressed immediately. . . Document all groups. . . Be sure to follow the schedule that has been provided".

Based on record review and interview the hospital failed to ensure nursing staff were determined competent and knowledgeable in the use of emergency equipment as evidenced by:

1) Failure to ensure all nursing staff were knowledgeable in the use of ambu bag in the event emergency assisted ventilation is needed for a patient for 3 of 4 nurses reviewed for use of an ambu (S17, S18, S19).
2) Failure to ensure all nursing staff were knowledgeable in the changing of cylinder heads on oxygen tanks in the event a tank becomes empty and a new tank is needed for use with patients in need of oxygen for 4 of 4 nurses observed for the ability to change cylinder heads on oxygen tanks (S17, S18, S19, S20) Findings:


1) Failure to ensure all nursing staff were knowledgeable in the use of ambu bag in the event emergency assisted ventilation is needed for a patient for 3 of 4 nurses reviewed for use of an ambu (S17, S18, S19).
Observations and interviews were conducted on 5/19/10 at 2:20 p.m. with Registered Nurse S17 and Licensed Practical Nurse S18 (nursing staff on duty on the Adult Acute Unit for 7 a.m. - 7 p.m. on 5/19/2010. Observations and interviews were conducted on 5/19/2010 at 2:30 p.m. with Licensed Practical Nurse S19. Registered Nurse S17 and Licensed Practical Nurse S18 indicated in the event that they needed to resuscitate a patient they would use 2 liters of oxygen to the ambu bag in case the patient might turn out to have COPD (Chronic Obstructive Pulmonary Disease). LPN S19 indicated she would use 10 liters of oxygen to the ambu if resuscitation were needed.

Director of Nursing (S2) was present during these interviews and indicated 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) Failure to ensure all nursing staff were knowledgeable in the changing of cylinder heads on oxygen tanks in the event a tank becomes empty and a new tank is needed for use with patients in need of oxygen for 4 of 4 nurses observed for the ability to change cylinder heads on oxygen tanks (S17, S18, S19, S20).

Observations and interviews were conducted on 5/19/10 at 2:20 p.m. with Registered Nurse S17 and Licensed Practical Nurse S18 (nursing staff on duty on the Adult Acute Unit for 7 a.m. - 7 p.m. on 5/19/2010). Observations and interviews were conducted on 5/19/2010 at 2:30 p.m. with Registered Nurse S20 and Licensed Practical Nurse S19 (nursing staff on duty on the Geriatric Unit for 7 a.m. - 7: p.m. on 5/19/2010). All four nurses observed were unable to change the e-cylinder head to a new oxygen tank and indicated verbally that they did not know how. Director of Nursing (S2) was present during these interviews and indicated all staff should be able to change cylinder heads in the event that one tank was to run out of oxygen and they were to need another tank. 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 changing of cylinder heads on oxygen tanks. S2 further indicated oxygen cannot be delivered from an oxygen tank without a cylinder head.

Based on record review and interview the hospital failed to ensure all psychiatric evaluations were completed within 60 hours of admission for 1 of 11 sampled patients (Patient #1). Findings:

Review of the medical record for Patient #10 revealed he had been admitted to the hospital on 04/30/10 at 1705 (5:05pm). Review of the Psychiatric Evaluation for Patient #1 revealed it had been performed om 05/03/10 at 5:15pm which was 72 hours after the patient had been admitted.

Review of the Medical Staff By-Laws (no date implemented or revised) and submitted by the hospital as the ones currently in use revealed.... "1. An admit psychiatric evaluation must be written by the admitting psychiatrist within sixty (60) hours of patient's admission...".

In a face to face interview on 05/18/20 at 3:15pm Psychiatrist S23 indicated a psychiatric evaluation must be done within 60 hours of admission.

Based on record review and interview the hospital failed to ensure Patient #3's initial treatment plan identified suicidal ideations as the patient's primary problem and primary reason for admission to the hospital for 1 of 6 sampled patients with suicidal ideations out of a total sample of 11 (Patient #3). Findings:

Review of Patient #3's "Nursing Assessment" dated 5/08/2010 at 2045 (8:45 p.m.) revealed in part, " Reason for admission, chief complaint: I have not slept in a week because I'm like a petri dish, a science project. . . Suicidal Thoughts: Current " thoughts a lot lately". Plan: Yes. Method: Overdose, Hang Self. Additional: Drinking Crown. Does patient have means? (no response). Previous attempts? (no response). Patient ' s perception of strengths: " Don ' t really have any strengths".

Physician's verbal orders dated 5/08/2010 at 2045 (8:45 p.m.) revealed in part, "SP (Suicide Precaution) and BX (Behavior Precautions). Activity: Ad Lib".

Review of the entire medical record revealed no documented evidence of a Treatment Plan to include no documented identification of Suicidal Ideation on a Treatment Plan for Patient #3.

During a face to face interview on 5/18/2010 at 1:05 p.m., Registered Nurse S15 indicated she was the nurse that did the initial assessment of Patient #3 at the time of his admission on 5/08/2010. S15 indicated Patient #3 had expressed to her how tired he was, due to not sleeping, when she was doing his initial assessment. S15 further indicated the patient told her he had made a previous suicide attempt but did not feel like talking about it. S15 indicated Patient #3's most recent suicidal ideation included a plan to hang himself and or overdose by drinking "Crown". S15 indicated the patient's (#3) primary concern was that he needed sleep. S15 indicated Physician S5 also ordered standard Suicidal Precautions for Patient #3 which meant Close Observation with 15 minute observations. S15 indicated she did not place suicidal ideations on a treatment plan for Patient #3. S15 indicated she did a pressure sore assessment on Patient #3 which met the requirements of initiating the care plan.

Review of a hospital memo dated May 20, 2009 revealed in part, "Nurses please make sure to address an individual treatment plan with each patient upon admission. The nurse that admits the patient should ideally initiate the plan. . . The admit nurse should gather treatment plans that should be addressed immediately. . . Document all groups. . . Be sure to follow the schedule that has been provided".

Based on record review and interview the hospital failed to ensure the focus of the individual's treatment modalities related to suicidal ideations which was the patient's primary reason for admission for 4 of 6 suicidal patients of the 11 sampled records. (Patient #1, #7, #9, #10) Findings:

Patient #1
Review of the Clinical Summary and Master Treatment Plan dated 05/03/10 revealed Patient #1 had been admitted to the hospital for bipolar disorder, poly-substance abuse with an estimated length of stay of 0-7 days for medication management to stabilize mood, affect and behavior.

Review of the group sessions scheduled for and attended by Patient #1 during her hospitalization 04/30/10 through 05/13/10 revealed the following:05/01/10 positive feedbck; 05/02/10 decrease stress, anxiety; 05/03/10 mental illness; 05/04/10 life stresses; 05/05/10 socialization; 05/06/10 self esteem; 05/07/10 process; 05/10/10 social skills (twice); 05/11/10 anger management (twice); 05/14/10 anger management. The other 32 scheduled groups were community, acitivity and leisure. According to the treatment plan medication management had been a main focus for Patient #1; however there was no documented evidence in the group therapy notes or the Multidisciplinary Educational Record for Patient #1 that any kind of instruction had been given to the patient concerning medication, reason and importance for taking medications, or side affects.

Patient #7
Review of the Clinical Summary and Master Treatment Plan dated 05/05/10 revealed Patient #7 had been admitted to the hospital for suicidal depression and paranoia with an estimated length of stay of 12-14 days for medication compliance and group therapy to stabilize mood, affect and behavior. Further review revealed the treatment plan had been signed by the social woker the registered and the patient. There was no documented evidence the psychiatrist had signed the treatment plan as evidenced by a blank in the space provided for his/her signature.

Review of the treatment plan dated 05/05/10 and signed by the NP S34 revealed the estmated length of stay for Patient #7 was 12-14 days in order to stabile target symptoms related to psychosis with medication management, encourage adherence to medication treatment. Further review revealed there was no written evidence to indicate what those target symptoms were or the exact treatment milieu that was to be used.

Review of the group sessions scheduled for and attended by Patient #7 during her hospitalization 05/04/10 through 05/11/10 revealed the following: 05/05/10 triggers, coping skills; 05/06/10 stress management, self esteem; 05/07/10 process; and 05/10/10 social skills. Further review revealed Patient #7 refused to participate in 6 of the 19 group sessions for community, creative expression, and activity. Further there was no documented evidence the patient had been offered any alternatives.

According to the treatment plan medication management had been a main focus for patient #7; however there was no documented evidence in the group therapy notes or the Multidisciplinary Educational Record for Patient #10 that any kind of instruction had been given to the patient concerning medication, reason and importaance for taking medications, or side affects.


Patient #9
Review of the Clinical Summary and Master Treatment Plan dated 05/07/10 revealed Patient #9 had been admitted to the hospital for depression and suicidal ideation with an estimated length of stay as 0-7 days for medication management and group therapy to control and stabilize symptoms. Further review revealed the plan had been signed by the psychiatrist, social worker, registered nurse, patient and recreational therapist.

Review of the psychiatric evaluation performed by MD S5 on Patient #9 revealed the treatment plan as suicide precautions, medication management, milieu treatment for 3-5 days. There was no documented evidence this information had been discussed with the entire treatment team.

Review of the group sessions scheduled for and attended by Patient #9 during her hospitalization 05/04/10 through 05/11/10 revealed the following: 05/10/10 social stress; 05/11/10 anger management (twice); 05/12/10 anger management (twice); and 05/13/10 grief and loss (twice). Further review revealed Patient #9 refused to participate in 5 of the 17 group sessions for community, creative expression, and activity. Further there was no documented evidence the patient had been offered any alternatives.


Patient #10
Review of the Clinical Summary and Master Treatment Plan dated 05/04/10 revealed Patient #10 had been admitted to the hospital for Major depression Disorder and alcohol abuse with an estimated length of stay as 0-14 days for medication management to stabilize mood, affect and behavior. Further review revealed the form had been signed by the Social worker, Registered Nurse, patient #10 and Recreational therapist. There was no documented evidence the physician had reviewed the plan as evidenced by a blank in the space titled MD signature.

Review of the dictated form titled "Master Treatment Plan" revealed a statement indicated the case of Patient #10 had been discussed with the entire treatment team and the problems and goals had been identified and types of services formulated. Further review revealed the patient would be educated on his illness with an emphasis on medication compliance, improved coping skills, and more effective problem solving skills. The form was signed by NP (Nurse Practitioner S26; however there was a blank in the space for the signature of the physician. Further review revealed there was no written evidence to indicate the entire treatment team was required to sign this document.

Review of the group sessions scheduled for and attended by Patient #10 during his hospitalization 05/04/10 through 05/11/10 revealed the following: 05/04/10 life stesses; 05/05/10 coping skills and socialization; 05/06/10 stress management and self esteem; 05/10/10 social skills (twice); 05/07/10 process; and 05/11/10 anger management. The other 18 scheduled groups were community, acitivity and leisure. According to the treatment plan medication management had been a main focus for patient #10; however there was no documented evidence in the group therapy notes or the Multidisciplinary Educational Record for Patient #10 that any kind of instruction had been given to the patient concerning medication, reason and importance for taking medications, or side affects.

Based on record review and interview the hospital failed to ensure therapeutic programs were provided to 5 of 5 sampled patients resulting in 102 missed group therapy sessions which had the potential to affect all hospitalized patients on both the adult and geri-psych units. (Patients #2, #8, #9, R1, R3) Finding:

Patient #2
Review of the Multidisciplinary Group Notes dated 0504/10 through 05/12/10 revealed Patient #2 had not attended the following scheduled group sessions: Community Meeting/Goal Setting on 05/07/10; Recreational Therapy Group on 05/09/10; Social Work Group on 05/07/10; Recreational Group on 05/09/10; Social Work/Process Group on 05/08/10 and 05/09/10; Nursing Group on 05/05/10, 05/06/10, 05/07/10 and 05/11/10; Social Work/Didactic Group on 05/08/10 and 05/09/10; Nursing/Medication Education/Diagnosis Group on 05/08/10 and 05/09/10; and Wrap-Up Group on 05/05/10, 05/06/10, 05/11/10 and 05/12/10.

Patient #9
Review of the Multidisciplinary Group Notes dated 0507/10 through 05/13/10 revealed Patient #9 had not attended the following scheduled group sessions: Recreational Therapy Group on 05/09/10; Social Work/ Process Group on 05/08/10 and 05/09/10; Recreational Group 0n 05/12/10; Nursing Group on 05/10/10, 05/11/10 and 05/12/10; Social Work/Didactic Group on 05/08/10 and 05/09/10; Nursing/Medication Education/Diagnosis Group on 05/08/10 and 05/09/10; on Wrap-Up Group 05/08/10, 05/10/10, 05/10/10, and 05/11/10.

Patient #8
Review of the Multidisciplinary Group Notes dated 0507/10 through 05/13/10 revealed Patient #8 had not attended the following scheduled group sessions: Community Meeting/Goal Setting on 05/07/10; Recreational Therapy Group on 05/09/10; Social Work /Process Group on 05/08/10 and 05/09/10; Nursing Group on 05/07/10, 05/11/10, 05/12/10 and 05/13/10; Social Work/Didactic Group on 05/08/10 and 05/09/10; Nursing/Medication Education/Diagnosis Group on 05/08/10; Wrap-Up Group on 05/10/10, 05/11/10, 05/12/10 and 05/13/10.

Patient R1
Review of the Multidisciplinary Group Notes dated 05/06/10 through 05/14/10 revealed Patient #R1 had not attended the following scheduled group sessions: Community Meeting/Goal Setting on 05/12/10 and 05/13/10; Recreational Therapy Group on 05/08/10; Social Work Group on 05/07/10; Recreational Group on 05/12/10; Nursing Group on 05/07/10, 05/10/10, 05/11/10, 05/12/10 and 05/13/10; Social Work/Didactic Group on 05/08/10 and 05/09/10; Social Work/Process Group on 05/08/10 and 05/09/10; Nursing/Medication Education/Diagnosis Group on 05/08/10; and Wrap-Up Group on 05/08/10, 05/10/10, 05/11/10, 05/12/10 and 05/13/10.

Patient R3
Review of the Multidisciplinary Group Notes dated 04/30/10 through 05/11/10 revealed Patient #R3 had not attended the following scheduled group sessions: Community Meeting/Goal Setting on 05/07/10; Recreational Therapy on 05/04/10; Recreational Therapy Group 05/01/10 and 05/09/10; Social Work Group on 05/07/10; Social Work/Process Group on 05/08/10 and 05/09/10; Nursing Group on 05/02/10, 05/03/10, 05/04/10, 05/05/10, 05/06/10, and 05/07/10; Social Work/Didactic Group on 05/08/10 and 05/09/10; Nursing/Medication/Education/ Diagnosis Group on 05/01/10, 05/08/10 and 05/09/10; Wrap-Up Group on 05/02/10, 05/03/10, 05/04/10, 05/05/10, 05/06/10 and 05/10/10.

Review of the List of RN Night Duties submitted by S2 RN Director of Nursing (DON) revealed the wrap-up groups held to discuss the problems which interfered with the goals accomplished earlier in the day were the responsibility of the registered nurses scheduled on the night shift. Further the nurses were instructed they did not have to document in the Multidisciplinary Group notes, " unless the day nurse was unable to complete a group due to increased admits " .

Review of the "Schedule of Activities" submitted by S1, the Administrator as the one currently in use and the one posted at the nurses' station and in the patient handbook revealed the following:
Monday through Friday
8:15am - 8:45am Community Meeting/Goal Setting
9:30am - 10:30am recreation Therapy
11:15am - 12noon Social Work Group
1:30pm - 2:30pm Social Work Group
2:45pm - 3:30pm Recreational Group
4:00pm - 4:45pm Nursing Group
8:30pm - 9:00pm Wrap-up Group
Saturday and Sunday
7:45am - 8:15am Community Meeting/Goal Setting
8:15am - 9:00am Recreational Therapy/Exercise Group
10:00am - 10:45am Recreational Group Therapy
11:00am - 12noon Social work/Process Group
12:45pm - 1:30pm Social Work/Didactic Group
1:40pm - 2:30pm Nursing/Medication Education/Diagnosis
8:30pm - 9:00pm Wrap-up Group

In a face to face interview on 0518/10 at 11:05am Licensed Practical Nurse (LPN) S12 indicated the activity schedule on the weekends was more relaxed and not as regimented. Further S12 indicated the patients were given more choices with most of them preferring to watch television.

In a face to face interview on 05/19/10 at 10:25am Social Worker S22 indicated he was hired to work Monday through Friday. Further he indicated the hospital had hired another social worker; however she left because she said the job was too much. S22 indicated he does not know what goes on during the weekend and we would have to speak with the director who is on vacation at the present time.

In a telephone interview on 05/19/10 at 1:40pm S21 the Director of Social Services indicated S33 the prior Administrator was an LCSW (Licensed Clinical Social Worker) and was the head of the Social Service Department. S21 indicated when she was hired; S33 was performing the duties of the weekend social worker. Further S21 indicated she does not work weekends.

In a face to face interview on 05/19/10 at 2:00pm RN S6, Utilization Review after reviewing the medical records of Patient #2, #8, #9, R1 and R3 verified the following: Patient #2 had 19 missed groups from 05/04/10 through 05/12/10; Patient #8 had 19 missed groups from 05/06/10 through 05/14/10; Patient #9 had 15 missed groups from 05/07/10 through 05/13/10; R1 had 21 missed groups from 05/06/10 through 05/14/10; and R3 had 28 missed groups from 04/30/10 through 05/11/10.

Based on record review and interview the hospital failed to ensure the Recreational Therapy, Social Work, and Nursing departments identified and tracked quality indicators regarding the provision of group therapy as outlined in the hospital's activity schedule resulting in a failure to ensure patient ' s received all the therapy services planned during their hospital admission. Findings:

Review of scheduled activities and patients' medical records (#R1, #R3, #2, #8, and #9) were performed with Registered Nurse S6 on 5/19/2010 at 2:00 p.m. This review revealed: Patient #R1 had inconsistent documentation that group therapy was being provided at scheduled times resulting in 21 missed groups from 5/06/2010 through 5/14/2010, Patient #R3 had inconsistent documentation that group therapy was being provided at scheduled times resulting in 28 missed groups from the dates of 4/30/10 through 5/11/2010, Patient #2 had inconsistent documentation that group therapy was being provided at scheduled times resulting in 19 missed groups from the dates of 5/04/2010 through 5/12/2010, Patient #8 had inconsistent documentation that group therapy was being provided at scheduled times resulting in 19 missed groups from 5/06/2010 through 5/14/2010, and Patient #9 had inconsistent documentation that group therapy was being provided at scheduled times resulting in 15 missed groups from 5/07/2010 through 5/13/2010. This finding was confirmed by RN S6 at the time of review who indicated the Activity Schedule should be followed as written with documentation of attendance and participation in the patient's medical record.

Review of a hospital memo dated May 20, 2009 revealed in part, "Document all groups. . . Be sure to follow the schedule that has been provided. "

During a face to face interview on 5/18/2010 at 3:30 p.m., Hospital Administrator S1 and Recreational Therapy Specialist S34 indicated there had been no quality indicators in the hospital regarding provision of group therapy as indicated on the Patient's Activity Schedule.

Based on record review and interview the hospital failed to follow their policy and procedure for root cause analysis for sentinel events as evidenced by failure to perform a complete and thorough investigation as evidenced by the lack of documentation of the date, time and content of interviews, analysis of process failures, or corrective actions taken for 1 of 1 sentinel events reviewed (Patient #3). Findings:

Review of the "Code Blue" form dated/timed 05/09/10 at 1600 (4:00pm) revealed Patient #3 had suffered a cardiac arrest and CPR (Cardiopulmonary Resuscitation) had been initiated via the use of an ambu bag. Further it indicated Patient #3's roommate alerted staff who found Patient #3 on his bathroom floor with pieces of a gown tied around his neck. Staff called 911 at 1606 (4:06pm) and another RN from geri-psych. EMS arrived at approximately 1613 (4:13pm) and intubated the patient. Patient #3 was transported to Hospital "A". Patient had a pulse, but was not breathing on departure. Further review revealed the report had been signed by S2 DON (Director of Nursing) at 2130 (9:30pm) which was 5 hours and 15 minutes after the event took place.

Review of the Code Blue Response Evaluation Form revealed the following information: date of incident as 05/09/10 the patient identified by first name only (Patient #3) the first names of the staff who responded to the emergency as RN S11, MHT S14, MHT S16, and RN S28; was the patient assessed for respirations, heartbeat, code blue called, time called time 911 called, notification of MD, administrator, DON, family, Clinical Director, report to EMS, incident report completed, transfer form completed with all pertinent documentation and debriefing with staff.

Review of the Incident Report dated/timed 05/09/10 at 1600 (4:00pm) revealed the following information: Name of patient involved - Patient #3; Location - adult unit in Room "A"; person reporting the incident as RN S11; person witnessing the incident as LPN S12; attending MD notified yes at 05/09/10 at 1610 (4:10pm); listed as a fall - patient found on floor with the contributing factor as # 7 Other Attempted strangulation; initiated CPR; Other: Pt. (patient) attempted suicide by strangulation with a patient gown; Action: CPR initiated, EMS called, Pt. transported to Hospital "A" , MD S5 notified, S1 Administrator notified, and S2 DON notified. Further review revealed it was completed and signed by S2 DON on 05/09/10 at 2045 (8:45pm) 4 hours and 45 minutes after the incident happened.

Review of the Incident Investigation report submitted by the hospital as the one performed for the incident concerning Patient #3 on 05/09/10 revealed no documented evidence to identify the report as being the one for Patient #3 as evidenced by the Incident number being left blank. Further review revealed the incident had been classified as a near death event with contributing causes documented as 16. Plan of treatment not communicated to patient and 21. Discharge planning not provided/documented. Prevention strategies include enforcement of policies and procedures and make a change so that only 1 gown per patient in Room.

Review of the additional documentation submitted to the survey team by S2 the DON revealed the following: a brief written handwritten description of the incident which included the position of the patient when found, initiation of CPR, notification of 911, check of heart rate, Accucheck, arrival of EMS, initiation of the IV, intubation, transfer of patient and arrival of the police. Further review revealed no documentation of the date/time or the name and/or signature of the person who wrote it.

Review of the handwritten documentation submitted by S2 DON as the official documentation of the interviews of all staff members present on the unit at the time of the incident revealed no documentation of the date, time, name or title of person interviewed. Further review revealed entries on the paper were made in no particular order and had not been made in complete sentences.

Review of the Root Cause Analysis submitted to the survey team which S2 the DON which she indicated was required as a Joint Commission Hospital revealed no documented evidence an investigation had been conducted which had included a environmental check of the Patient #3's room and bathroom (which when observed revealed a shower head with a protruding pipe of 11/2 inches in length), staffing pattern for the date and time of the incident, dated/timed and signed statements from all staff on duty, equipment check (policy and procedure stated the hospital was to use an AED and none could be found, MHT needed assistance opening the oxygen tank), review of the assessment process as well as the levels of observation currently practiced in the hospital, what was happening on the unit at the time of the incident (two documented fights between patients) and the compliance with the weekend therapeutic group activity schedule.

In a face to face interview on 05/19/10 at 1610 (4:10pm) S2 DON indicated she has not completed the investigation into the incident concerning Patient #3. Further she indicated she did interview the staff however S2 did not write anything down. S2 indicated she had never completed a root cause analysis before and would need help.