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Based upon record review and interview, the Governing Body failed to;





1.) ensure compliance with the medical staff bylaws related to medical executive committee meetings. Medical executive meetings were being held as "ad hoc" (an unplanned meeting to address one specific purpose) meetings without a quorum present for the meetings.

Refer to Tag A0353



PATIENT RIGHTS

2.) A. follow its own policy and procedures to ensure Least restrictive measures are to be attempted prior to giving a chemical restraint and documented, a face to face is done within 1 hour and a restraint and seclusion packet was initiated and chemical restraints are not ordered as a PRN (as needed).
B. ensure telephone orders are taken and transcribed correctly to prevent a medication error that can result in patient harm.
C. ensure the physician is aware of patient allergies before ordering and administering medications.

The condition and deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Refer to TAG A0144



NURSING SERVICES

3.) ensure compliance with the medical staff bylaws related to medical executive committee meetings. Medical executive meetings were being held as "ad hoc" (an unplanned meeting to address one specific purpose) meetings without a quorum present for the meetings.

Refer to Tag A0353


4.) manage the operation of nursing service by providing nursing staff with unapproved policies to operate by.

Refer to TAG A0386


5.) have the appropriate number of Registered Nurses (RNs) and Mental Health Technicians (MHTs) on duty to provide the needed care.

Refer to TAG A0392


6.) ensure nursing care plans, as part of the Interdisciplinary Treatment Plan, were complete, updated, or kept current as new problems develop in 5 (Patient #'s 4, 5, 7, 13, and 14) of 6 charts reviewed (Patient #'s 4, 5, 6, 7, 13, and 14).

Refer to TAG A0396


PHYSICAL ENVIROMENT
7.) A. ensure routine maintenance and preventive maintenance was completed to ensure patient safety.
B. to conduct ongoing maintenance inspections that identified equipment and areas in need of repair.
C. ensure the preventive maintenance and condition of the plant was incorporated in the Quality Assurance Performance Improvement (QAPI) plan.

Refer to Tag A0701


8.) A. ensure adequate lighting in patient care areas and medication preparation rooms.

B. ensure maintenance and acceptable cleaning standards were met to prevent water leakage in patient care areas and air conditioning units were free of mildew, mold, and promoted patient comfort.

Refer to Tag A0726

The condition and deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.




INFECTION CONTROL
9.) A. ensure all areas of the hospital were clean and sanitary. The infection control program failed to include appropriate monitoring of housekeeping, maintenance, and other areas to ensure a sanitary environment was maintained.
Refer to TAG A0747
The condition and deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.


10.) ensure the person (staff #4) designated as infection control nurse was qualified through education, training, experience, or certification. The facility failed to ensure the infection control nurse had an adequate amount of time and resources allotted to fulfill her job duties related to infection control.

Refer to Tag A0748


11.) ensure infection control policies were specific to the services provided by the facility. The infection control officer failed to ensure maintenance of a sanitary hospital environment, conduct ongoing active surveillance of risks associated with infection on a regular basis, and monitoring compliance with infection control policies and procedures.

Refer to Tag A0749

Based on review of records, policy and procedures, and interviews the facility failed to:


1. A. notify patients of the correct contact information of the Quality Improvement Organization (QIO) prior to admission and discharge, preventing patients from being able to contact the QIO with complaints.

B. obtain a patient signature on the Patient Bill of Rights and Consent for Treatment for patients that were confused, or court committed. The facility failed to have written explanation on why there was no signature and no explanation of a later attempt to obtain a signature in 3 (#8,10, and 11) of 3 charts reviewed.

Refer to TAG A0117



2. A. allow patients to resolve complaints at the time of the complaint.
B. ensure patients had the correct information to seek review of the QIO for quality of care issues, coverage decisions, and to appeal a premature discharge.
Refer to TAG A0118



3.) A. ensure the patient was given the name of the hospital contact person, steps to investigate the grievance, results of the process and date of the grievance completion.
B. to ensure a complaint was handled immediately to resolve the patients problem or need and prevent the grievance process in 3(#28, 30 and 36) out of 3 patient grievances.


Refer to TAG A0123



4. A. follow its own policy and procedures to ensure least restrictive measures are to be attempted prior to giving a chemical restraint and documented, a face to face assessment is done within 1 hour and a restraint and seclusion packet was initiated and chemical restraints are not ordered as a PRN (as needed).
B. ensure telephone orders are taken and transcribed correctly to prevent a medication error that can result in patient harm.
C. ensure the physician is aware of patient allergies before ordering and administering medications in 2 (#10 and #12) of 3 (#8, 10, and 12) charts reviewed.

The condition and deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.


Refer to TAG A0144

Based on medical chart review, policies, and interviews, the facility failed to:

1. manage the operation of nursing service by providing nursing staff with approved policies to operate by.


Refer to TAG A0386


2. have the appropriate number of Registered Nurses (RNs) and Mental Health Technicians (MHTs) on duty to provide the needed care.

Refer to TAG A0392


3. ensure nursing care plans as part of the Interdisciplinary Treatment Team are incomplete, not updated, or kept current as new problems develop in 5 (Patient #'s 4, 5, 7, 13, and 14) of 6 charts reviewed (Patient #'s 4, 5, 6, 7, 13, and 14).

Refer to TAG A0396

Based on observation, review of maintenance logs, safety committee meeting minutes, and interviews the facility failed to:


1.
A. ensure routine maintenance and preventive maintenance was completed to ensure patient safety.
B. to conduct ongoing maintenance inspections that identified equipment and areas in need of repair.
C. ensure the preventive maintenance and condition of the plant was incorporated in the Quality Assurance Performance Improvement (QAPI) plan.

Refer to Tag A0701


2.

A. ensure adequate lighting in patient care areas and medication preparation rooms.

B. ensure maintenance and acceptable cleaning standards were met to prevent water leakage in patient care areas and air conditioning units were free of mildew, mold, and promoted patient comfort.

The condition and deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Refer to Tag A0726

Based on observation, record review and interview the facility failed to:


A. ensure all areas of the hospital were clean and sanitary. The infection control program failed to include appropriate monitoring of housekeeping, maintenance, and other areas to ensure a sanitary environment was maintained.

A tour of the facility was conducted on 5/3/2016 with staff #'s 1, 2, 4, 6, and 29. The following infection control issues were found in the following areas:
The condition and deficient practices were identified under the following Conditions of Participation and were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

1. The patient bathrooms in the admissions area:

A. The men's room was soiled around base of toilet with hair, dirt, and urine. The sink was soiled with hair and hard water stains. The ceiling tiles were soiled with water stains. The wall paper was ripped on the walls exposing sheet rock. The air vent was coated heavily in dust, the floor was soiled in hair and dirt.

B. The women's bathroom was soiled on the floor around the toilet base with hair and dirt. The toilet seat was soiled with dried urine. The toilet paper holder was broken and soiled with dust. The sink was dirty with residue, hard water stains and hair.

2. The disaster supplies room had patient supplies in cardboard shipping boxes and the boxes were stored on the floor without a barrier.

3. Staff #19's therapist office and patient meeting room had dirt and dust on the floor, bugs in the windowsills and storage boxes on the floor.

4. The "Bubble Room" was a large room with a cabinet and sink on one end and a door on the back wall leading out to the outside patient smoking area. A wall of glass blocks was on the front wall. The bubble room floor was soiled with dirt, dust and hair. The door frame to the bubble room had a buildup of dust and dirt all around the frame and on the glass. The threshold was soiled with dried up dirt and dust that had built up in the corners. The threshold to the outside door was soiled with dust, dirt and bugs. The threshold door frames were missing paint. The rugs were soiled with grass, dirt and dead bugs. The countertops were covered in a thick dust and hair. The sink was soiled with dried liquids and hard water deposits. The vents in the room were heavily soiled with dust and a black substance. The large block glass wall was covered in cob webs, with dead bugs, in both upper corners.

5. The patient gym area had the following;
A. The door leading into the gym from the hallway was wooden. The wooden door was damaged and had exposed wood. Two other metal doors leading to the outside from the gym were missing paint on the doors and frames of the thresholds. The threshold frames were rusted on the bottom and covered in a thick buildup of dirt and bugs. The floor of the gym was missing paint and was soiled with leaves, dirt, dust, hair, and bugs all around the gym floor. The gym had two water fountains. The fountains had dried brown stains in and around the metal fountains. The fountains had hard water stains and trash in the drains. A rubber mat, approximately 12x12, was found by the storage room on the floor. The mat was soiled with dirt and bugs. The vents around the gym were covered in a heavy thick dust and dirt. The patients did not have a table available to put their drinks or snacks on and had been instructed to put their drinks and food on the lid of a large trash can. A patient also had put their jacket on the lid. The trash can and lid was soiled with dried liquids, food particles, hair, and dust. The short wall of the gym had a climbing wall. The apparatus to climb on was removed from the wall leaving multiple large holes in the cinder block. The holes were filled with dirt, dust and bugs. The lenses on the florescent light fixtures were soiled with many bugs.

B. The ladies bathroom had holes in the walls exposing sheet rock. The vents were covered in dust and hair. The stall door was cracked at the top. The toilet was soiled with dried urine and hair. The floor was soiled around the base of toilet with hair and dirt. The floor grout was covered in a black substance. The men's bathroom floor was soiled with a black substance on the grout, hair, dirt and dead bugs. The back of the wall behind the toilet had a large patch on the sheet rock but was not sealed with paint. The toilet was soiled on the lid and seat with dried urine and hair. The back of the urinal had a mucous like substance growing mold. The florescent light fixtures were missing bulbs and the lens was soiled with dead bugs.

C. The gym storage room was full of broken gym equipment, air conditioner filters, shipping boxes on the floor, and a broken computer with monitor. The floor was soiled with dust and dead bugs.


6. The Men's bathroom in the hallway between the gym and unit 4 was used by patients. The toilets in the stalls would not flush. The urinal flushed slowly and required two flushes to flush completely. The floor in the bathroom was soiled with dust and a black substance on the grout. The mirror was soiled with a white substance and sink faucet had a buildup of hard water minerals. The bathroom door was damaged exposing bare wood.

7. The ceiling in the hallway before unit 4 had 4 cylinder lights not burning and two of the lights had no bulbs. The fixtures had cob webs draped over the light fixtures.

8. Staff #20's therapist office and patient meeting room had a small refrigerator on the floor. The refrigerator had dust and hair on the top. The wall next to the door had a large patch to the sheet rock but had not been sealed with paint. The vents in the ceiling were soiled with dust and a black substance. The door to the room was scratched and damaged exposing bare wood.

9. Staff #31's therapist office and patient meeting room had a cracked window. The window sills were soiled with dust and bugs. The floor was soiled with dust and bugs. The drop down ceilings were soiled with water stains, and mildew around the vent. The vent was soiled with dust and mildew. The florescent light fixture lenses were soiled with dust and dead bugs. Blankets were found on the cabinet exposed to dust and hair. There was no way to tell if it was clean or soiled blankets. The cabinet had 38 empty cardboard shipping boxes sitting on top.

10. A storage room referred to as the HRR room was found unlocked. The room had patient equipment, patient room curtains stacked uncovered on a desk, a broken fax machine, a dietary warming cart, and video equipment to watch the medication rooms. The room had another door that led to a large closet. The closet door was also unlocked and had multiple boxes sitting on the floor stacked to the ceiling. The room was dusty and had dirty air vents.

11. The following items were found on unit 4:
A.) The doors to the unit were soiled and dusty. The material on three couches and several chairs was torn. The couch arms were broken and torn.

B.) The solarium had dirt and dust on the books. The paint on the walls was scratched and missing paint exposing bare wall. The vent in the ceiling was covered in dust and mildew. The floor was soiled with buildup of dirt, dust, hair, dried food particles, and dead bugs.

C.) The day room had a snack table with a large plastic water cooler sitting on the table. The table was dusty and soiled with dried liquids. The plastic container holding the condiments was soiled with dried food particles, dust, and dried liquids. The water cooler was soiled with mildew on the top of the jug and on the water spout. The patient properties closet had the patient's clothes and properties sitting on the bare floor. The floor was dusty and soiled. The report room had soiled vents in the ceilings and the door frames were missing paint.

D.) The patient bathroom next to the nurse's station had soiled floors. The floor was dusty and had urine and hair build up in the corners and base of the toilet. The toilet was full of urine the toilet bowl and seat was soiled with feces, hair, and dried urine. Dried urine had dripped down the sides of the bowl and pooled on the floor. The metal railing in the bathroom was covered in a sticky dusty substance. Feces smears and hair were on the wall and railing next to the toilet. The floor grout was covered in a black sticky substance. The air vent was soiled with dust and a mildew substance.

E.) The "Quiet Room" floor was soiled with dust and hair.

F.) The emergency treatment room had floors soiled with dust and dirt. The emergency crash cart was sitting next to the bio hazard trash. The shift nurse had stored her purse in the cabinet next to patient medical supplies. The exam bed was soiled with dust and hair. The cabinets holding medical supplies was dusty with dead bugs. Dirty Linen was found on the floor. The air vent covers were soiled with dust and dirt.

G.) the storage room next to the quiet room was filled with patient equipment such as: wheel chairs, walkers, bedside commodes, chairs, and fans. Staff #2 and #6 confirmed it was a room for clean patient equipment. The room was dirty and dusty. There was no equipment covered. Staff #2 could not state what equipment was clean and confirmed the area was dirty.

H.) Unit 4 nutrition room's microwave was soiled with dried food particles and liquids. The inside was rusted and had burn marks inside. The counter top was soiled with food particles, dust, and dead bugs. Plastic crate containers, holding bags of chips, were mildewed on the bottom. A refrigerator held patient snacks and juices. The top of the refrigerator was sticky, dusty, and soiled with dead bugs. The refrigerator door gasket was torn and mildewed. The refrigerator door was soiled with dried, dripping liquids, dirt, and hair. An opened bottle of salad dressing and coffee creamer were found in the refrigerator with no dates.

I.) The washer and dryer area on unit 4 was soiled with dust, dirt, and hair on the outside of the units, on the inside lid of the washer, around the floor, and in the back of the units.

J.) Unit 4 supply room floors were found soiled with dried liquid stains, dust, and dirt. The sink was soiled with dried liquids. The counter tops were soiled with dust and dried bugs. The wall paper was ripped, exposing sheet rock.

K.) Unit 4 biohazard room had patient plastic laundry baskets sitting on the soiled floor next to biohazard waste. The laundry baskets were being taken in and out of the room for patients to put their laundry in. A large trash can in the biohazard room was labeled "laundry". Staff# 6 was not aware that linen could not be placed in the same room with biohazard trash.

L.) Patient room number 406 on unit 4 was confirmed by staff as a "terminal clean room " (Terminal cleaning is a cleaning method used in healthcare environments to control the spread of infections). According to the Association for the Healthcare Environment's (AHE's) Practice Guidance for Healthcare Environmental Cleaning, terminal or discharge cleaning refers to "the comprehensive, deep cleaning of a patient room at the time of discharge from a health care setting or upon termination of transmission-based precaution policies in place at a given facility. This is meant to render the area safe and ready for the next patient.The environmental infection prevention strategy must include at a minimum: cleaning and disinfection of surfaces touched by patients, health care providers and visitors; cleaning of environmental surfaces and visibly soiled surfaces, followed by disinfection in accordance with the facility's discharge procedures."

The floor of room 406 was soiled with dust, dried food particles, dirt, hair, and dried bugs on the floor and windowsill. There were multiple holes in the walls exposing the sheet rock. The patient clothes dresser was soiled with dust and hair. The door to the patient room was soiled with a white dripping liquid on the windows and dust on the door frames and hinges. The threshold to the bathroom was soiled with a buildup of dust, dirt, and hair. The frame to the door was missing paint. The bathroom had floor tiles missing and was soiled with black mildew, dust, and hair. There were cobwebs with dead bugs under the sink. The toilet was soiled with dried urine and hair. There was a large amount of rust around the toilet. The metal railing around the toilet was soiled with dust and hair. A chewed up wad of gum was sitting inside the railing. The shower tiles needed to be chalked in multiple places to avoid mildew growth.

An interview with staff #32 on 5/3/16 confirmed room 406 was considered a terminally clean room and was available for a new patient admission. Staff #32 confirmed that the Mental Health Technicians (MHT) cleaned the rooms when housekeeping was unable to clean or after 3:00PM when housekeeping goes off duty. Staff #32 confirmed the MHT usually just cleaned off the bed and changed the linen after a patient was discharged. Staff #6 confirmed the MHT's had no training to terminally clean a room.

Room 405 had damaged ceiling tiles stained from water damage.

Review of the EOC/Safety Committee Meetings for April 2016 revealed a roofing company came out in December of 2015 to repair the roof on unit 405. The report stated "It still leaks." The report stated, "1/18/18 rented wet/dry vac to clean the carpet in the lobby." There is no other information that the facility had attempted to fix the roof from leaking. Staff #6 confirmed the roof continued to leak.

M.) Unit 4 nursing medication room had Dutch doors. Dutch doors, also called double-hung doors or half doors, are divided in half horizontally so the bottom half can remain shut while the top half opens. A shelf is on the top of the bottom door. The wooden shelf was scratched up and missing paint. The nurse was observed checking a patient's blood sugar level with a glucometer on the wooden shelf. The patient's finger was pricked and blood was obtained. The shelf nor the glucometer was cleaned after use. The glucometer was placed back in the bin with clean supplies. Patients were viewed leaning on the shelf and medications were passed to patients on the shelf without cleaning between patients.

The medication refrigerator was found sitting on the floor of the medication room. The floor was soiled with dirt, dust and hair. There were dried liquids spilled on the floor, walls, and trash can. The inside of the refrigerator held patient medications and insulin bottles. A wad of hair and dirt was found in the bottom of the refrigerator and on the insulin bottles.

Clean plastic drinking cups for patients were found stacked next to the sink and wall. This sink was used by the nurse for hand washing. Each time hands were washed the dirty water was slung onto the drinking cups being given to patients during medication administration.

A sharps container was found on the wall in the medication room. A sharps container is a container that is filled with used medical needles (and other sharp medical instruments, such as needles or IV catheter). The facility used the "single use" which are disposed of with the waste inside. The nurse's clean stethoscopes, used on patients, were found draped over the container.

The countertops in the med room were soiled with dust and hair. The containers holding the patient medications were soiled with dust.


12. The following items were found in the Dietary Department:

A. The doors to the entrance were missing paint from the threshold. The windows were open into the dining room and the windowsills were soiled with dirt and dead bugs. Thirteen chairs were found torn or broken in the dining room. The 4 way plug by cups in the dining room was soiled with dried liquids and dirt. The stainless steel supply cart was soiled with a greasy substance, dirt, and dust. The threshold leading to the hallway was soiled with dirt and buildup of food particles.

B. The refrigerator threshold was soiled with a buildup of dirt and rust. The gasket to the door was not sealing properly. The fan covers for the condenser inside the refrigerator were soiled with a thick buildup of dust and dirt. The condenser was dripping on the cucumber bin below. The ceiling of the refrigerator had rusted areas. The quick access doors to the refrigerator did not seal properly due to broken gaskets. Greasy build up on handles to refrigerator.

C. The freezer door did not seal properly due to broken door gaskets. The freezer had a buildup of condensation and large icicles were hanging from the ceiling. The freezer had multiple corrugated shipping boxes. The floor had a large buildup of ice.

D. The fryer had very dark grease with multiple food particles and a soured smell. The ice machine was dusty on the outside. Mildew and hard water stains were found on the inside of the machine. The ice scoop was soiled. The UV lights above all the thresholds were not working. The UV lights help to prevent flying bugs in the food preparation area. The menu book was soiled with a greasy substance and food particles. There was mildew in the coffee maker. The bins for utensils and condiments were soiled with dust and food particles. The mixer, confirmed as clean, was soiled with a greasy substance and food particles. The kitchen floor was covered in a heavy greasy substance. The grout in the tiles was covered in a black substance.

E. The commercial trash bins outside and grease trap were open and exposed to elements, animals, and people.

F. Outside on the loading dock four large bins of laundry was found uncovered and not bagged. Soiled laundry was left to the outside elements, animals, and people. Laundry was also found in biohazard rooms, and uncovered in the linen rooms. The laundry carts were covered around the sides but had no tops to prevent dust and dirt build up on clean laundry. The floor in the main laundry area (maintenance hall) was soiled with dust, dirt, and hair. Laundry was being delivered to the facility on 5/3/16. The cart was brought in with bagged laundry except for a large bundle of kitchen towels. The towels were uncovered on top. The towels had been soiled with a black dirty substance when transferred from the laundry truck. The surveyor questioned staff #6 about the soiled towels. Staff #6 was asked by the surveyor if they were going to return the soiled towels. Staff #6 stated, "No, they are just kitchen towels."

13. The following items were found on patient unit 3:

A. The unit medication room did not have opening dates on the glucometer calibration chemicals or glucometer strips.

B. Patient room number 307 on unit 3 was confirmed by staff as a "terminal clean room". The base of the bed was wooden and not sealed. A mattress was torn and there were plastic wrappers and trash found under the mattress. The bathroom floor was soiled with dust, dirt, and hair. The bathroom mirror was soiled and the toilet was soiled with dust and hair.

C. The floor in Unit 3 Solarium was soiled with dirt and hair. Buildup of dirt was noted around thresholds and corners. The windows were broken.

D. The patient snack and food area on unit 3 had broken cabinet doors, soiled countertops with dust, and dead bugs. The floor was soiled with dust and dirt. There were cleaning products stored with the food products.

E. In the Recreation Room Storage a live lizard was found crawling around on the floor. Corrugated boxes were found stacked on the floor.


14. The following items were found on patient unit 2:

A. Twelve patient rooms had window air conditioning units for heating and cooling. In room 211 the AC had been set for cool, however, heat was blowing out of the unit. The front of the unit was removed and the filter to the unit was covered in a heavy dust. The coils to the unit were covered in dust and a dark mildewed substance. The vents were mildewed and dirty.


B. The screens were missing on the patient windows on unit 2. The windows were able to be opened 10-12 inches. The windowsills in all of the patient rooms and bathrooms were soiled with dust, build-up of dirt, and dead bugs.


C. The nutrition room had cleaning supplies stored with patient food. Dust and dirt found on top of the refrigerator, the counter tops and floor. Employees had stored their personal food with patient food.


D. The nurse's station had two torn chairs. The counter tops and floors were soiled with dried liquids, dirt, and dust.


E. In the Dr. office/exam room there were no dates on when the disaster container was last checked. The container was soiled with dust and hair. The AC filters were soiled with a heavy dust and coils had mildewed. The floor was soiled with dust and hair.


F. Medication room had Glucometers with no opening dates on the test strips or the control solutions. The medication refrigerator was soiled on the outside and inside with dust. The floor and countertops were soiled and dirty with dust and dirt build up in the corners and threshold.

Staff #6, #2, and #29 confirmed the above findings.


ensure the person (staff #4) designated as infection control nurse was qualified through education, training, experience, or certification. The facility failed to ensure the infection control nurse had an adequate amount of time and resources allotted to fulfill her job duties related to infection control.

Refer to Tag A0748


ensure infection control policies were specific to the services provided by the facility. The infection control officer failed to ensure maintenance of a sanitary hospital environment, conduct ongoing active surveillance of risks associated with infection on a regular basis, and monitoring compliance with infection control policies and procedures.

Refer to Tag A0749

Based on review of records and interview, the hospital failed to

A. notify patients of the correct contact information of the Quality Improvement Organization (QIO) prior to admission and discharge, preventing patients from being able to contact the QIO with complaints.



Review of the Important Message from Medicare (IM) showed that FMQAI was listed as the QIO. The QIO for Texas for the past two years has been KEPRO. Prior to KEPRO, it was TMF. The phone number for the QIO was listed as a toll free number. Staff #9 and Staff #15, both, attempted to call that number and verified it was a sales call number for a home medical security system.

Staff #9 verified his department delivered the IM upon admission and he did not know the QIO was incorrect. Staff #15 verified her department delivered the second copy of the IM and she did not know the QIO was incorrect.




32143


B. obtain a patient signature on the Patient Bill of Rights and Consent for Treatment for patients that were confused, or court committed. The facility failed to have written explanation on why there was no signature and no explanation of a later attempt to obtain a signature in 3(#8,10, and 11) of 3 charts reviewed.


1. Review of patient #8's chart revealed the patient was admitted on 3/21/16 as a involuntary patient. Patient #8 was admitted under an Emergency Detention Warrant (EDW). Review of the chart revealed the physician pre-admission exam on 3/21/16 stated the patient was "psychotic".

Review of the consents revealed no patient signatures. All the consents had "EDW" on all of the signature lines. Patient #8 did not sign a consent for treatment. Patient Handbook consent form had no checks that the information was even given or if it was given at a later time. A form "An Important Message From Medicare About Your Rights" was found signed by the patient on 4/4/16. The form had the wrong name of the QIO and wrong telephone number. There were no other consents found signed at a later date.


2. Review of patient #10's chart revealed the patient was admitted on 4/9/16 as a involuntary patient. Patient 10 was admitted under an Emergency Detention Warrant (EDW). Review of the chart revealed the psychiatric evaluation on 4/10/16 stated the patient was "poor historian due to psychosis."

Review of the consents revealed no patient signatures. All the consents had "EDW" on all of the signature lines. Patient #10 did not sign a consent for treatment. Patient Handbook consent form had no information it was given at a later time. A form "An Important Message From Medicare About Your Rights" was found signed by the patient on 4/19/16. The form had the wrong name of the QIO and wrong telephone number. There were no other consents found signed at a later date.


3. Review of patient #11's chart revealed the patient was admitted on 3/26/16 as a involuntary patient. Patient #11 was admitted under an Emergency Detention Warrant (EDW). Review of the chart revealed the psychiatric evaluation on 3/26/16 stated the patient was "poor historian due to acute psychosis."

Review of the consents revealed no patient signatures. All the consents had "EDW" on all of the signature lines. Patient #11 did not sign a consent for treatment. Patient Handbook consent form had no information if it was given at a later time. A form "An Important Message From Medicare About Your Rights" was found signed by the patient on 4/19/16. The form had the wrong name of the QIO and wrong telephone number. There were no other consents found signed at a later date.


An interview was conducted with staff #2 on 5/5/2016. Staff #2 reported that she could not explain why there was no documentation of patient acceptance of Patient Bill of Rights. Staff #2 stated, "I don't know why they didn't sign. They should have."

Based on review of complaints and grievances, policy and procedures, and interviews, the facility failed to;

A. allow patients to resolve complaints at the time of the complaint.

B. ensure patients had the correct information to seek review of the QIO for quality of care issues, coverage decisions, and to appeal a premature discharge.

Review of the "Complaints/ Grievances, Patient" policy and procedure page 3 of 10 revealed, "A written complaint is always considered a GRIEVANCE."

On all patient units, wooden boxes were found on the wall, by the nurses station that said, "complaints". On unit 4, the box labeled complaints, was marked through with a pen and now read the word "grievances." Staff #2 confirmed the patients were instructed to place a written complaint in the complaint/ grievance box and a staff member would address it the next day. There was no evidence found or offered that patients were given an opportunity to resolve their complaints immediately without it going into a grievance process.



36827

Review of the Important Message from Medicare (IM) showed that FMQAI was listed as the Quality Improvement Organization (QIO). The QIO for Texas for the past two years has been KEPRO. Prior to KEPRO, it was TMF. The phone number for the QIO was listed as a toll free number. Staff #9 and Staff #15, both, attempted to call that number and verified it was a sales call number for a home medical security system.

Staff #9 verified his department delivered the IM upon admission and he did not know the QIO was incorrect. Staff #15 verified her department delivered the second copy of the IM and she did not know the QIO was incorrect.

Based on review of complaints and grievances, policy and procedures, and interviews, the facility failed to

A. ensure the patient was given the name of the hospital contact person, steps to investigate the grievance, results of the process and date of the grievance completion.

B. to ensure a complaint was handled immediately to resolve the patients problem or need and prevent the grievance process in 3 (#28, 30 and 36) out of 3 patient grievances.

Review of the "Complaints/ Grievances, Patient" policy and procedure page 3 of 10 revealed, "A written complaint is always considered a GRIEVANCE."

Review of written complaint/grievance book revealed patient #28 submitted a grievance on 4/11/2016. The "Client Grievance Form" had the patients name at the top and the date 4/11/16. The next line stated, "Grievance (may add additional sheet of information if desired)," the patient had written, "Tech has trashed my bed 3 days in a row, he laughs you off when asked to do something, he argues with other patients, he blows everyone off. If asked a question he just turns and walks off." The next line on the form stated, "Employee receiving Grievance" and names an employee, written by the patient.

The following information was blank on the form;
"Date: _________ individual making the grievance was notified of which staff member was assigned to investigate the grievance.
Signature: _________ Date Received: __________ Time received: _________ response due date (within 3 days of receipt)
Investigation &response/resolution: __________ "

The next line stated "I am satisfied with the resolution of my grievance." The patient signature was there and the date 4/13/16. Below the patient signature was another signature line stating, "Copy of this grievance & resolution given to the patient: (within 1 business day of resolution)" was blank. There was no name of the hospital contact person or how to get in touch with them, the steps of the investigation, the results of the grievance, or the date of completion.

A form letter was attached to the back of the grievance that stated, "Employee complaint received out of the grievance box on 4/12/16. Investigation: Attempted to visit with Patient #28 on 4/12/16. Patient was unavailable. Visited with patient #28 on 4/13/16. Patient didn't talk about the grievance. He just stated that somebody needs to do something. Patient #28 is aware that his concern I (SIC) being followed up on. Administrator is aware. DON is aware and to follow up. Patient signed that he is satisfied. Date: 4/13/16 and staff #34's signature. " There was nothing found on a follow up by the DON.

The patient advocate wrote that the "Employee complaint" was received out of the grievance box on 4/12/16. This was a patient complaint not an employee complaint. On all units, wooden boxes were found on the wall, by the nurses station that said "Complaints" . On unit 4, the box labeled complaints, was marked through with a pen and now read the word " "Grievances".

Staff #34 documented the patient never talked about his grievance but staff #34 documented patient #28 was aware his concern was being followed up on. There was no information that the patient's grievance was ever discussed. There was no further follow up of an investigation of the grievance nor patient notification of a resolution. There was no documentation of the patients' physician, nursing staff, or the therapist in the resolution.

Review of the "Complaints/Grievances, Patient" policy and procedure page 6 of 10 revealed, "2. Grievances and complaints processing procedures are as follows:

B. All grievances shall first be filed with a Longview Behavioral Hospital staff member by completing a "Patient Grievance" form. The staff member shall give the patient a receipt of the filed grievance and log the grievance. The grievance shall be forwarded to the Patient Advocate/designee, who will conduct an internal investigation and render an initial determination and resolution within 2 days of receipt of the complaint in writing. The Patient Advocate/designee shall include the patient physician, nursing staff, or the therapist in the resolution."
There was no log that stated the staff assisted the patient or was given a receipt. Staff #2 confirmed that the wooden box was for patient complaints and grievances. Staff #2 reported the patients come here and put their information in the box.

Review of written complaint/grievance book revealed patient #30 submitted a grievance on 3/05/2016. Patient #30 wrote, "I was a client in room #202 with (roommate name). I walked in and the light was off. Staff member (female staff name) was sitting in a lg chair pt (roommate name) had his private part out and got upset when I walked in. We had words they moved me. Not professional at any cost about 6:43PM."

Review of the Grievance form had no name of the employee receiving the grievance, who was assigned to the investigation, or the investigation, response/resolution. At the bottom of the form the patient had initialed the box "I am not satisfied with the resolution of my complaint and wish to appeal to the administrator." Patient #30 wrote on the bottom of the grievance form, "Still not professional a (illegible) I'm concerned staff and clients are not suppose to be involved."

An attached letter stating Grievance Resolution stated, "Employee complaint received out of the grievance box on 3/7/16. Investigation: Risk Management spoke with patient #30 on 3/7/16. Patient stated that he and another patient had a dispute and staff moved him to another room and he wasn't satisfied with that. Patient stated that staff shouldn't have been involved. It was explained to the patient the protocol concerning when patients have a verbal dispute. Patient verbalized understanding. Patient signed that he is not satisfied but doesn't wish to pursue his grievance any further. Issue resolved."

The patient had written that he was not satisfied and requested an appeal. The issue was not resolved. The patient advocate never mentioned the patients ' true complaint that the male roommate and female employee may have been involved in unprofessional sexual conduct. There was no evidence of the Risk Manager involvement. An email was behind the complaint that was written by staff #28. The email addresses patient #30 complaining about missing belongings to the administrator. There was no mention of the above grievance. There was no further follow up of an investigation of the grievance nor patient notification of a resolution. There was no documentation of the patients' physician, nursing staff, or the therapist in the resolution.

Review of written grievance book revealed patient #36 submitted a grievance on 4/7/2016. The "Client Grievance Form" stated, "(Nurses name) she is just really rude to me for no reason. I asked for a throat longnes (SIC) at 10:55 and after 11:15 I ask again. Finally rec'd one at 11:30. She is just rude and hateful to me and she appears lazy." There was no information found that patient was informed on who was assigned to the investigation, nor a signature that a response would be within 3 days of receipt. In the investigation & response/resolution section. Someone with a different hand writing wrote, "Pt very rude- You can fucking wait until later." Was only asking for pill. Pt reports (illegible) herself." There was no signature or date ofhis writer.

An attached form "Grievance Resolution" stated, "Employee complaint received out of the grievance box on 4/5/16. Investigation: Administrator visited with patient # 36. Patient signed that she was satisfied. DON is aware and to follow up." The form was signed by staff #34 on 4/11/16 (6 days after the grievance was written). There was no information found that the administrator talked with the patient. There was no information that the DON followed up on the grievance.

An interview was conducted on 5/4/16, with staff #34, on the complaint and grievance process. Staff #34 was not able to explain reason for incomplete grievances, lack of follow up, or failure to follow policy and procedures. Staff #34 reported that she was a Mental Health Technician and was pulled from patient care to do grievances and complaints about two years ago. Staff #34 stated that Staff #3 trained her. Staff #3 reported on 5/4/16 that she follows up behind staff #34. Staff #3 reported she makes sure when a patient has been discharged, and the grievance was not completed, a letter is sent by certified mail to ensure the patient knows the results. Patient #3 was unable to bring evidence for that claim.

An interview with staff #2 was conducted on 5/4/16. Staff #2 was asked her process in the grievance process. Staff #2 was mentioned in several grievances to "follow up" on the issues. Staff # 2 reported that any follow up she does should be attached to the grievance. Staff #2 was informed that multiple grievances reported that she would follow up. Staff #2 reported that she cannot always get to all of them.

Review of written complaint/grievance book revealed patient #34 submitted a grievance on 3/17/2016. The patient wrote, "This is the second notice I have put in on staff #35. She is a very rude person. She no reason to be working in the inviroment (SIC). She said she worked in a prison. And for sure acts that way. I feel very mistreated by her. Review of the Grievance form had no name of the employee receiving the grievance, the date patient #34 was informed on who was assigned to the investigation, or the investigation, response/resolution. At the bottom of the form was the following information with no name to identify writer on the patient grievance form;
"3-18-16 left message via voicemail to return call.
3-21-16 called via phone no answer.
3-22-16 no answer "
An attached note "Grievance Resolution" stated, "Employee complaint received out of the box on 3/18/16. Investigation: DON and administrator are aware of multiple complaints on this employee. There was an attempt to speak with patient #34 had already discharged. Risk Manager has made several attempts to reach patient via phone and left a voicemail and patient did not return phone call therefore we are unable to make patient aware that her concerns has been followed up and speak with patient.(SIC)"

This was not an employee complaint but a patient complaint. Review of the Grievance form had no name of the employee receiving the grievance, the date patient #34 was informed on who was assigned to the investigation, or the investigation, response/resolution. There was no attempt to contact the patient by mail.

Based on chart reviews, policy and procedures, and interviews the facility failed to:

A. follow its own policy and procedures to ensure least restrictive measures were attempted prior to giving a chemical restraint and documented, chemical restraints were not ordered as a PRN (as needed), and a face to face was done within 1 hour of the restraint being initiated. Policy for Restraint and Seclusion and the policy for "Psychiatric Emergencies" provided conflicting processes for dealing with patient needing interventions for behaviors.

B. ensure telephone orders were taken and transcribed correctly to prevent a medication error that can result in patient harm.

C. ensure the physician is aware of patient allergies before ordering and administering medications in 2 (#10 and #12) of 3 (#8,10, and 12) charts reviewed.

The condition and deficient practices were identified under the following Conditions of Participation and were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.


1. Review of patient #10's chart revealed patient #10 was admitted under an Emergency Detention Warrant (EDW) on 4/9/16 with a diagnosis of Schizophrenia, disorganized type.

Review of patient #10's nurse's notes on 4/13/16 at 9:00AM patient #10 was in "her room, not answering questions, reaches out for the nurse's hand and walks around the room hitting the walls." Patient #10 was on a 1:1 for safety. There were no other interventions documented. At 1:00PM patient #10 was lying on the floor in the dayroom and assisted to standing position by staff. Nurse documented, "Pt. begins running and chasing a peer then goes to nurses station and begins hitting counter with a book. Pt showing signs of increased agitation. Pt hitting at staff. MD on unit. New orders to come. Will continue to monitor." There were no other documented interventions found.

Review of physician orders, written by the physician, dated 4-13-16 at 1:25PM stated, "Haldol 10mg IM NOW assaultive behavior (pt after other pt) and BID/severe agitation." Physician ordered a medication IM twice a day for chemical restraint. Review of the physicians progress note for 4/13/16 had no mention of the Haldol IM order or any other alternatives attempted.

Review of the policy and procedure, "Seclusion and Restraint " page 6 of 8 under H. Chemical restraint,

" 2. Chemical restraint is any psychoactive medication used for behavioral issues that is not a scheduled part of the patient's medical or psychiatric regimen.

3. Least restrictive measures are to be attempted prior to giving a chemical restraint and documented.

4. When a chemical restraint is ordered the patient must have a face to face within an hour as specified in the policy in item A.

5. Seclusion and restraint packet will be initiated as described in the policy under F. Observation and Documentation that is applicable to chemical restraint."


Review of patient #10's nurses notes on 4/13/16 at 1:50PM (50 minutes after patient #10's outburst) The nurse documented, "Pt. given Haldol 10mg IM in R arm pt tolerated well. No distress noted. Pt seated in chair. Peers removed from area. Will continue to monitor." There was no documentation where the patient was seated and what happened to the other patients. There was no documentation of the patient's behavior before the medication was administered. There was no documentation of least restrictive measures, a face to face performed, vital signs or assessment, or a restraint/seclusion packet initiated.


Review of the MHT's 5 minute observation sheet on 4/13/16 at 1:45PM patient #10 was outside on a smoke break with the staff, at 1:50PM at nurses station with staff, and at 2:00PM patient is in her room resting until 7:20PM. There is no mention of vital signs taken until 7:25PM.


Review of the patient's medication assessment record (MAR) for the Haldol IM order was written, "Haldol 10mg IM NOW (pt after other pt assaultive behavior) and BID,PRN for severe agitation." The nurse had transcribed an order incorrectly. The order said BID (twice a day). The physicians order did not read PRN (as needed). The BID and PRN for severe agitation was then marked through with no date or signature. On the MAR by the order on 4/13/16 initials were written and the comment "11:00 right deltoid." The order was written at 1:25PM and in the nurses notes administered at 1:50PM. There was no name or discipline written on the MAR to identify those initials or credentials.


Review of patient #10's nurse's notes on 4/13/16 at 1:58 Pt slid (SIC) out of chair at nurses station eased to floor by staff. Pt then helped to room by MHT's. Provided wc (SIC) in pts room. Pt seated comfortably. Will monitor 1:1 for safety." There was no nursing documentation on why the patient was not allowed to lie down in the bed or if patient #10 was safely secured in the wheel chair. There also was no documentation of less restrictive interventions prior to the chemical restraint.


Review of the physician orders dated 4/13/16 at 3:10PM revealed the nurse wrote a clarification order that read, "Haldol IM BID PRN severe agitation." There was no dose written on the order. A chemical restraint was ordered as a PRN.


Review of the treatment plan revealed the medication Haldol 10 mg IM now and BID was written on 4/13/16. There was no explanation for the medication, interventions, short term, or long term goals applied to the treatment plan.


An interview was conducted with staff #2 and staff #6 on 5/3/16. During a tour the staff #6 was asked what the seclusion room was used for. Staff # 6 reported that the room was not used. Staff #6 was unable to answer the question. Staff #2 was asked the same question. Staff #2 also replied the room is never used. When asked where the patients go for quiet time or seclusion, staff #2 answered in their rooms. Staff #2 and #6 were asked if they could explain the difference between quiet time and seclusion and neither staff member could give an appropriate explanation. Staff #6 reported she was unaware. Staff #2 and staff #6 have been the two people responsible for training staff on restraint and seclusion.



2.) Review of patient #12's chart revealed the patient was admitted on 3/11/16 for a diagnosis of schizoaffective disorder. Review of the physician admission orders dated 3/11/16, the patient was admitted voluntary and signed by physician on 3/12/16. Review of the physician orders on 3/15/16 at 11:30AM revealed an order to start the Order of Protective Custody (OPC) process that would change the patient to involuntary.


Review of patient #12's nurse's notes on 3/15/16 at 8:00PM revealed the patient was yelling and agitated. "Med nurse called MD and new orders were received House supervisor notified of issue." Review of the telephone physician order dated 3/15/16 at 8:15PM, "Ativan 1mg IM x 1 dose now/agitation. There was no nursing documentation in the nurse's notes that the Ativan was ordered or given. Review of the MAR revealed an order for IM Ativan was noted on 3/15/16 as a one dose now order. Initials were written on the MAR and stated, "2030 (8:30PM) L arm" There was no name or discipline documented on the MAR to identify the staff member administering the medication. There was no documentation of least restrictive measures, a face to face performed, vital signs or assessment, or a restraint/seclusion packet initiated. There was no nursing documentation noted on the patient until 10:00PM. The nurse documented, "pt calm and resting with eyes closed. Continue to monitor."


Review of the telephone physician order dated 3/15/16 at 9:50PM, "If patient continues aggression/agitation may give Ativan 1 mg IM prn x 1 dose. Call MD with results." The order for a chemical restraint was written PRN.


Review of patient #12's nurse's notes on 3/17/16 at 3:00AM revealed the patient was running up and down the hallway screaming wanting to go to the hospital because she is "having 8 babies." Patient #12 refused to calm down upon redirection and refused po medications. Nurse called the physician for orders.


Review of the telephone physician orders on 3/17/16 at 3:19AM revealed an order for, " Haldol 10mg IM and Ativan 2mg IM x 1 dose now for psychosis/agitation." Review of the patient's initial physician orders on 3/11/16 revealed the patient was allergic to Haldol.


Review of patient #12's MAR revealed the medication was administered at 3:20AM and only initials were on the MAR. There was no names or discipline in who administered this medication. Nurses' name and discipline, on nursing notes, were illegible. There was no documentation found in the patients chart for a face to face performed or a restraint/seclusion packet initiated. Nurse documented at 3:40AM that the nurse realized the patient was allergic to Haldol and called the physician to report the medication error. MD advised to monitor patient and get vital signs every hour. There was no incident report for this patient medication error. There was no incident report found for patient #12's medication error.


An interview with staff #2 was conducted on 5/6/2016. Staff #2 stated that staff #6 would no longer be involved in staff training for behavioral emergencies, seclusion, and restraint. Staff #2 reported that she would be taking on that responsibility. Staff #2 reported staff #6 needed the time to concentrate on infection control. Staff #2 reported that she felt confident that the nurses understood the chemical restraint process and would go back over the procedures for quiet time and seclusion to ensure patient safety.


Review of the facility's policy and procedure " Psychiatric Emergencies" stated, "POLICY: To ensure safety to patients and staff when responding to a psychiatric emergency involving an assaultive patient." On page 2 of 2,


"#4 The designated staff member in charge of the emergency will direct staff as to assignments ( show of force, keeping bystanders away, etc.)


A. A staff member will attempt to deescalate the patient through appropriate verbal interventions.


B. Patients will not be physically restrained in any fashion.

5. In the case of further threat or harm, or staff are unable to verbally de-escalate the emergency, 911 will be called to obtain further assistance from law enforcement personnel."

Based upon record review and interview, the medical staff failed to ensure compliance with the medical staff bylaws related to medical executive committee meetings. Medical executive meetings were being held as "ad hoc" (an unplanned meeting to address one specific purpose) meetings without a quorum present for the meetings.


Review of the "Medical Staff Bylaws Article 1 - Definitions" revealed:

"1.19 Voting Member of the Medical Staff is a qualified physician of the Medical Staff
1.20 Quorum of qualified medical staff members is considered to be greater than 50% of qualified active medical staff members eligible to vote."


Review of the "Medical Staff Bylaws Article 10 - Committees of the Medical Staff - 10.1 Medical Executive Committee (MEC) 10.1.1 Composition" revealed the following:


"All qualified active medical staff physicians are automatically appointed to the MEC. Ex-officio members are the Administrator or designee and Director of Nursing, who do not hold voting privileges. At a minimum, the MEC shall consist of the Medical Director, another physician with an active status, and the Administrator, who in an emergency situation, may be required to act on behalf of the Medical Staff. If immediate action is required in order to support quality of care and/or patient safety, all medical staff members will be immediately notified and given the opportunity to review, comment and adjust the action at the next available Medical Staff Meeting."


Review of medical executive committee meeting minutes from January, 2016 - April, 2016 revealed 12 "ad hoc" meetings were held on the following dates:


1/13/16 - Medical Director only medical staff present - Approval of Psychosocial Update Form (non-emergent)


1/26/16 - Medical Director only medical staff present - Approval of 2015 Utilization Review Annual Evaluation and 2016 Scope of Services (non-emergent)


2/2/16 - Medical Director only medical staff present - Approval of Amendment to Bylaws regarding time frame for completing Psychological Evaluation. Also approval of policy and form for personal belongings in the Partial Hospitalization Program (non-emergent)


2/10/16 - Medical Director only medical staff present - Approval of Nursing Form for One Hour Face to Face Assessment following Restraint (non-emergent)


2/11/16 - Medical Director and Staff #25 present - Approval of 3 Social Services Policies and Table of Content Revision (non-emergent)


2/18/16 - Medical Director only medical staff present - Credentialing for 17 medical staff members - privileges granted (non-emergent)


2/24/16 - Medical Director only medical staff present - Granted privileges for Psychiatric Nurse Practitioner to complete Psychiatric evaluations. Approved "Patient Compliment" Form. Administratively closed 32 open patient charts due to an inactive MD. (non-emergent)


2/25/16 - Medical Director only medical staff present - Informational meeting about Sentinel Event that occurred on this date. (Emergent)


2/29/16 - Medical Director only medical staff present - Accepted and approved Nursing Policy Revisions related to the Sentinel Event (Emergent)


3/9/16 (day after regular Med Exec) - Medical Director and Staff #25 present - Approval of Inclement Weather Policy for Partial Hospitalization Program. (non-emergent)


3/14/16 - Medical Director only medical staff present - Accepted and approved Paid Time Off Policy (non-emergent)


4/1/16 - Medical Director and Staff #25 present - Approval of Suicide/Harm Assessment Form and Summer Menu (non-emergent)


4/8/16 - Medical Director only medical staff present - Approval of 3 Nursing Forms (non-emergent)


4/20/16 - Medical Director and Staff #25 present - Approval of HR Revised Policy for Applicant Drug Screens (non-emergent)


None of the ad hoc meetings had a quorum present. There were 2 "ad hoc" meetings conducted that would be considered emergent, but the Medical Director was the only medical staff present.


Three (3) regularly scheduled Medical Executive Committee meetings were held during this same time period. Medical Executive Committee meeting dates were conducted on February 9, 2016, without a quorum; March 8, 2016, without a quorum; April 13, 2016, without a quorum.


An interview was conducted with the Administrator on 5/5/16 at 4:30 pm. The Administrator confirmed the "ad hoc" meetings were being held without a quorum present.

Based on review of policies and interviews, the director of nursing failed to manage the operation of nursing service by providing nursing staff with unapproved policies to operate by.

On 5-4-2016, Staff #2 provided a binder of Nursing Policy and Procedure. The binder contained multiple versions of the following policies:

NUR-7:002A Initial Screening and Criteria for Admission
NUR-7:002B Nursing Assessment and Admission Policy
NUR-7:037C Observation of Patients
NUR-7:042 Patient Assessment and Reassessment
NUR-7:055 Close Observation of Detoxification Patients
NUR-7:073 Detoxification from Alcohol-General Principles
NUR-7:077 Detoxification of Benzodiazepines
NUR-7:081 Detoxification from Opiates-General Principles
NUR-7:135 Designated Safety Rooms


Staff #2 verified that all of the Nursing Policy and Procedures binders in the Nursing Stations were set up this way. Staff #2 stated that the policies in all of the binders were printed front and back in book-form. In order to keep from having to reprint the entire binder, Staff #2 inserted the new policies in the front of the binders and educated staff where to find the new policies. Staff #2 verified that the new policies were the policies that nursing staff were supposed to be using.


The new policies did not have any signature verification that they had been approved by Governing Body (GB). When questioned, Staff #2 stated she thought they had been approved by GB. The policies could not be found to be approved in the GB meeting minutes. Staff #1 and Staff #3 both stated that they had been through GB and must have been left off of the typed minutes. However, neither Staff #1 nor Staff #3 provided the agenda where the policies were to be discussed at the meeting.


Staff #2 was requested to research the Nursing Policies and provide copies of only those policies that could be shown to have been approved by GB. The policies provided on 5/2/16 contained the original versions of the above listed policies. The new versions had not been approved but were in use.

Based on review of records and interview, the hospital failed to have the appropriate number of Registered Nurses (RNs) and Mental Health Technicians (MHTs) on duty to provide the needed care.

Review of April staffing sheets showed that the hospital failed to staff the appropriate number of RNs and MHTs on the following days:


4/2/16, Unit 2 was short one MHT needed to monitor a patient undergoing detoxification.


4/13/16, Unit 3 was short one MHT. With a census of 15, they required 3 MHTs but only had 2.


4/15/16, Unit 2's census was 21. They should have had 3 MHTs plus the increased staff to monitor detoxification patients. They only had 2 MHTs.


4/15/16, Unit 3 census was 15. They should have had 3 MHTs plus increased staff to monitor patients requiring one-to-one monitoring. They only had 2 MHTs.


4/17/16, The schedule shows that 2 patients were on one-to-one monitoring but does not indicate which unit they are on or show staff assigned to them. There were not enough MHTs listed on the staffing sheets to cover this increased need.


4/25/16, Unit 4 did not have an RN staffed for dayshift.


On 5/5/16 a review of the policy titled "Nurse Staffing Plan and Nurse Staffing Committee" revealed that the plan had been approved on 11/10/15 for the 2016 calendar year. The staffing grid that was included in the policy was titled "2015 Nursing Staffing Grid". The hospital had submitted a Plan of Correction from the previous survey in 2016 that increased staffing based on census of patients undergoing detoxification. The policy and nursing grid were not updated to include the new staffing requirements.


On 5/5/16 an interview was conducted with Staff #2. Staff #2 confirmed that the policy had not been revised. Staff #2 stated that the scheduler and House Supervisors knew the new requirement and knew to staff accordingly. Staff #2 stated they have meetings twice daily called "flash" meetings where they discuss the need for increased staffing. Staff #2 advised that Staff #33 prepared the daily staffing sheets.


An interview was conducted with Staff #33 on 5/5/16. Staff #33 confirmed that she does not have a written policy to go by telling her how to adjust the staffing for increased census of patients undergoing detoxification or how to increase staff for increased acuity such as one-to-one monitoring. The Staffing Grid for Detoxification Patients was described as follows: one nurse is added to the existing grid per 10 patients undergoing detoxification. One Mental Health Technician (MHT) is added to the existing grid for every two patients who are undergoing detoxification protocols. Staff #2 confirmed this is how they are staffing.

Based on review of record, nursing care plans as part of the Interdisciplinary Treatment Team are incomplete, not updated, or kept current as new problems develop in 5 (Patient #'s 4, 5, 7, 13, and 14) of 6 charts reviewed (Patient #'s 4, 5, 6, 7, 13, and 14).


Review of Patient #4's records showed that the patient developed scratches to both shins and Triple Antibiotic Ointment and wound care orders were given on 4-27-2016. This new problem with medication and treatment was not added to the nursing plan of care in the Interdisciplinary Treatment Team record. The patient required a dietary consult due to a change in appetite related to drug use. Orders for supplemental nutrition (Ensure) were received on 4-22-2016 but the problem was not added to the nursing plan of care in the Interdisciplinary Treatment Team record.


Review of Patient #5's records showed that the patient had a history of gastric bypass. The history and physical examination completed on 4-27-2016 identified that the patient complained of nausea that was ongoing, related to the gastric bypass. The physician prescribed Zofran and noted that the patient had never taken Zofran before. This problem was not added to the nursing plan of care in the Interdisciplinary Treatment Team record. The patient fell and hit her head on 5-4-2016. She complained of continued headache and was transferred to the local emergency room. She was transferred back with discharge instructions for headache and syncope. The nursing plan of care in the Interdisciplinary Treatment Team record was not updated.


Review of Patient #7's records showed that on 3-18-16, the patient complained of difficulty sleeping and was ordered medication to help sleep. She received this medication at bedtime each night until discharge. This new problem with medication and treatment was not added to the nursing plan of care in the Interdisciplinary Treatment Team record.


Review of Patient #13's records showed that the patient was admitted for alcohol detoxification. This medical problem with treatment was not added to the nursing plan of care in the Interdisciplinary Treatment Team record.


Review of Patient #14's records showed that on 4-6-2016 the patient developed athlete's foot and was prescribed medication. This medical problem with treatment was not added to the nursing plan of care in the Interdisciplinary Treatment Team record. Review of Patient #14's records showed that the patient was admitted with orders for opiate detoxification. This medical problem with treatment was not added to the nursing plan of care in the Interdisciplinary Treatment Team record.

Based on observation and interview, the hospital failed to protect the confidentiality of patient information and medical records.


On 5/4/16 a tour of the facility was conducted with administrative staff. During a tour of Staff #31's office and group therapy room, boxes of records containing patient information were found in unlocked cabinets that patients had access to. These records dated as far back as October/November 2013 and included the daily census of all hospital patients. The daily census listed the patient Name, Medical Record Number, Account Number, Age, Unit Assigned, Room Assigned, Physician Assigned, Insurance Provider, Admit Date, Referral Source, and number of benefit days available for Medicare patients. A message slip with a former patient's name and phone number was sitting on Staff #31's desk in plain sight of any patients attending groups.


Interview with Staff #1 during the tour confirmed that this was not a designated storage area for patient information and the papers needed to be shredded.


A tour of the Unit 4 Patient Exam Room revealed a consent for Human Immunodeficiency Virus (HIV) testing with a patient's name on it in an unsecured drawer. Staff #32 stated she did not know why it was in there.

Based on review of records and interview, the hospital failed to review admissions for appropriateness of admission as outlined in the Utilization Review Plan and Utilization Review Policies and Procedures. The hospital failed to perform Continued Stay Reviews for Medicare patients in the same manner as they did for other payer sources.


Review of the 2016 Utilization Review (UR) Plan and Policies was conducted. The 2016 UR Plan stated, "(the hospital's) UR plan provides for review of all patients without regard to payment source, to determine the medical necessity and appropriateness of their admission, continued stay, and to assure early discharge planning."


"Continued Stay Reviews. The purpose of the Continued Stay Review is to assure that patients are obtaining timely and effective treatment according to their diagnosis and to determine when the patient has reached maximum benefit of hospitalization. The Continued Stay Review process has been integrated into the treatment team reviews."


Utilization Review Policy UR: 1 under section II d. Utilization Review stated, "Within 72 hours of admission, the client record shall be reviewed to determine that the documentation in the client record supports the admission in accordance with the criteria associated with assigned level of care. If the documentation fails to support the admission, the Director of Social Services shall contact the assigned primary therapist to advise them that the admission cannot be justified without additional documentation. If the primary therapist or other clinical staff member cannot provide the documentation, the Director of Social services shall be contacted to provide justification for any temporary continued stay. If the Director of Social Services cannot provide documented justification but judges the admission as necessary, the Utilization Review specialist shall be contacted to make a determination. If the UR specialist fails to justify the admission, the client shall be transferred to a more appropriate level or type of care."


An interview was conducted with Staff #22 on 5/5/16 at 9:45 AM in Staff #22's office. Staff #22 stated she obtained pre-certification of commercial insurance by reviewing the admission information for appropriateness of admission (Admission Review). Staff #22 stated she reviewed the chart on regular intervals determined by the insurance company for appropriateness of continued stay to get more authorized days approved (Continued Stay Review.)


When Staff #22 was asked if she reviewed Medicare patients, she stated no. She explained that, for Medicare patients, she helped with the extended stay and short stay reviews. She pulled the patient charts from Medical Records storage of Medicare patients who were discharged in 5 days or less for review by the UR Committee. She also pulled the charts from medical records of Medicare patients who stayed more than 30 days for review by the UR Committee.


Staff #22 stated the only time she reviewed Medicare patients was when they ran out of their Lifetime Psychiatric days. They were unfunded and she reviewed them at least once a week, "sometimes more", to see "why the doctor was still keeping them." (Medicare recipients are allotted 190 inpatient psychiatric days during their lifetime. Once used, Medicare does not pay for inpatient psychiatric admissions). When Staff #22 was asked why she only reviewed the charts for Medicare patients when their Medicare days ran out, she replied, "Because we don't get paid for them."


An interview was conducted with Staff #9 on 5/5/16 at 11:00 AM in the Conference Room. Staff #9 stated there was not a formal process for completing a UR admission review within 72 hours of admission. Staff #9 stated she was aware there was a UR plan and she attended UR Committee meetings. Staff #9 stated her role in the meeting was to review the charts of patients who had been in the hospital less than 5 days or greater than 30 days for appropriateness of treatment. Staff #9 stated she was not aware of any other responsibilities assigned to her in the UR policies. When the UR policies were reviewed with Staff #9, she confirmed that the procedures for the 72 hour review were not being completed as listed in Utilization Review Policy UR: 1, under section II d: Utilization Review.

Based on record review and observation the facility failed to;

A. ensure routine maintenance and preventive maintenance was completed to ensure patient safety.
B. to conduct ongoing maintenance inspections that identified equipment and areas in need of repair.
C. ensure the preventive maintenance and condition of the plant was incorporated in the Quality Assurance Performance Improvement (QAPI) plan.

A tour of the facility was conducted on 5/3/2016 with staff #'s 1, 2, 4, 6, and 29. The following patient safety issues were found in the following areas:

An interview on 5/3/16 was conducted with staff #6 concerning ongoing maintenance inspections and how needed repairs were identified and reported. Staff #6 reported that monthly inspections and rounds were done to identify issues. The staff could also place a work order for items that were in need of repair. Staff #6 brought his monthly rounding sheets "Multidisciplinary Rounding Sheets" for review. Review of the "Multidisciplinary Rounding Sheets" revealed from January- April 2016 there was no names on the rounding sheets. There was no way to identify who had done the rounds. The sheets had a check list and a yes or no column to determine if the are was in compliance or not. The sheets were blank in the following departments for inspection from January -April 2016;
* Emergency Room
* Medication Rooms
*Kitchen
*HIPPA
*Refrigerators
*Infection Control
* Personal Protective Equipment
Staff #6 was not able to give an explanation of the blank sections. Staff #6 stated it was the responsibility of the staff to tell him if something was broken. Staff #6 reported that he had reported to issues to the administration but was told to wait on any repairs.
Review of a work order for 1/31/16 revealed the nurse placed the order. The order read, "Looks like a broken piece from the AC/Heat unit vent. in room 203. The work action stated, "do not affect the unit." An observation of the unit on 5/16/16 revealed the front cover of the AC unit was still broken and could be removed by the patient. The patient could have used the cover to harm themselves or others.
An interview with staff #6 on 5/4/16 revealed there was no information sent to QAPI regarding the preventive maintenance issues. Staff # 6 stated if there is problems we just try to fix it if we can."

Based on observation, review of Multidisciplinary Rounding Sheets, EOC/Safety Committee Meeting Minutes and interviews the facility failed to:

A. ensure adequate lighting in patient care areas and medication preparation rooms.

B. ensure maintenance and acceptable cleaning standards were met to prevent water leakage in patient care areas and air conditioning units were free of mildew, mold, and promoted patient comfort.

The condition and deficient practices were identified under the following Conditions of Participation and were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.


A tour of the facility was conducted on 5/3/2016 with staff #'s 1, 2, 4, 6, and 29. The following patient safety issues were found in the following areas:

1. The patient had to go up three steps to reach the bathrooms from the admission area; there was no railing for patient balance and safety. The lighting was inadequate; light bulbs were out in the fixtures for both bathrooms.

2. In the hallway between units three and four three florescent bulbs in the ceiling light fixtures were observed to be out and not secured in the hallway between units three and four.
3. The "Bubble Room" was a large room with a cabinet and sink on one end and a door on the back wall leading out to the outside patient smoking area. A wall of glass blocks was on the front wall. The florescent light fixtures were missing bulbs and was not adequately lighted. The room had cylinder light fixtures, two of the cylinders had no light bulbs.

4. The ceiling to the gym in the entry way had drop down ceilings. The ceiling had florescent light fixtures that were missing bulbs or the bulbs were not working. The men's and ladies bathrooms had florescent light fixtures that were missing bulbs and dimly lighted.

5. The men's bathroom in the hallway between the gym and unit 4 had florescent light fixtures that were not burning and was very dark over the toilet area.

6. The following items were found on unit 4:

A.) The lighting in the entry hall before entering unit four was burned out and had no covers on the recessed light cans.

C.) The dayroom had multiple lights not burning causing a safety hazard.

The patient bathroom next to the nurse's station and the emergency treatment room had air vents that were soiled with dust and a mildew substance.

E.) The lights in the environmental closet were out causing difficulty to see chemicals and or ability to read a MSDS (Material Safety Data Sheet) book.

F.) The florescent light fixture in the unit 4 medication room had bulbs out and only one bulb was on. The lighting in the medication room was very dim. Staff #32 confirmed it was difficult to see the medications and had almost made mistakes because it was so dim.

Room 405 had damaged ceiling tiles stained from water damage.

Review of the EOC/Safety Committee Meetings for April 2016 revealed a roofing company came out in December of 2015 to repair the roof on unit 405. The report stated "It still leaks." The report stated, "1/18/18 rented wet/dry vac to clean the carpet in the lobby." There is no other information that the facility had attempted to fix the roof from leaking. Staff #6 confirmed the roof continued to leak.

7. The following items were found on unit 3:

A.) Multiple lights were out in the dayroom causing the area to be dimly lighted and a fall hazard for impaired patients.


8. The following items were found on unit 2:

A.) Twelve patient rooms had window air conditioning units for heating and cooling. In room 211 the unit but had been set on AC for cool, however, heat was blowing out of the unit. The front of the unit was removed and the filter to the unit was covered in a heavy dust. The coils in rooms 211, 204, 206 and the exam room AC unit filter and coils were covered in dust and a dark mildewed substance. The vents were mildewed and dirty.

The gutters on the building were filled with dirt and debris. The gutters had foliage growing out of them.

Staff #'s 2, 4, 6, and 29 confirmed the above findings.

Staff #6 was unable to provide a routine and preventive maintenance schedule. There was no documentation to determine ongoing maintenance inspections were performed and that necessary repairs were completed.

Based upon record review and interview, the facility failed to ensure the person (staff #4) designated as infection control nurse was qualified through education, training, experience, or certification. The facility failed to ensure the infection control nurse had an adequate amount of time and resources allotted to fulfill her job duties related to infection control.

An interview was conducted with Staff #4 on 5/3/16 at approximately 11:30 am in the conference room. Staff #4 stated she was the infection control nurse and her other job duties were employee health monitoring and facility educator. Staff #4 stated she was allotted 5 hours weekly/20 hours monthly for infection control duties. Staff #4 stated random environmental rounds were made of the facility and they were really hard to make happen because of being unable to coordinate schedules with the Maintenance Director (Staff #6). Staff #4 also reported there was no established schedule for environmental rounds. Staff #4 stated that when rounds were conducted, the findings were provided to the Quality Committee and then they would be reported in the Quality Report. Staff #4 was asked if there was any follow through with deficient findings that needed to be corrected. Staff #4 reported she did no follow up on the findings, she just reported to the Quality Committee and assumed they ensured corrective action was taken.

An interview was conducted with the Quality Director on 5/4/16 at approximately 9:45 am. in the conference room regarding corrective action taken for deficient findings from the environmental/infection control rounds. The Quality Director reported that the Administrator and Maintenance Director had a spreadsheet with all the findings, who was responsible to correct the findings, date and initial when done. The Quality Director was asked to provide the spreadsheet for review but none was offered.
On 5/5/16 in the conference room during the afternoon, the Quality Director reported she did not bring the spreadsheet for review because there had been no follow-up documented on the spreadsheet that the corrective action had been accomplished.

Review of the facility floor plan revealed patient care areas consisting of 3 inpatient units and 1 unit utilized for a partial hospitalization program. There was an admissions unit where patients remained during the admissions process, a full service kitchen and dining room. There were multiple rooms throughout the facility that were identified as "Therapist Office" that contained a staff desk in a corner with the remainder of the room set up as a classroom with patient desks. During a tour of the facility, Staff #1 confirmed the "Therapist Office's" identified throughout the facility were utilized as group therapy rooms.

Review of "infection control rounds" documents dated from 1/27/16 - 4/27/16 revealed the following:

1/27/16 - Unit 1 - Partial Hospitalization Program - Women's Community Restroom - 8 deficient findings requiring corrective action

3/2/16 - Unit 3 - Acute Adult Psychiatric Unit - 11 deficient findings requiring corrective action

3/2/16 - Unit 4 - Dual Diagnosis Adult Unit - 26 deficient findings requiring corrective action

3/2/16 - Dietary Department including Dining Area, Kitchen, Walk in Fridge & Freezer, Dry Storage Room - 47 deficient findings requiring corrective action

4/27/16 - Kitchen Only - 8 deficient findings requiring corrective action

There was no documentation that corrective action had been taken for any of these areas reviewed. During the dates from 1/27/16 - 4/27/16 (3 months), Unit 2, an adult dual diagnosis unit, patient care areas identified as group therapy rooms, and the admissions unit were not inspected for infection control or environmental concerns during this time frame.


Review of the policy and procedure #INF - 1:001 titled "Infection Prevention and Control Plan & Program" revealed the following:

"IX. The Role of the Infection Control Nurse:
A. It has been determined by the Infection Control Committee and authrorized by the Governing Body for the Infection Control Nurse to practice a minimum of 20 hours /month.

B. The Infection Control Nurse is given the authority by the Governing Body to act in their behalf in taking the necessary steps to prevent and control the spread of infection.

C. Responsibilities:
1. Detects and records hospital acquired infection on a systematic and ongoing basis.
2. Summarizes monthly infection reports for review with PI Committee.
3. Advises nursing staff about the hospital's policy on Isolation and disposition of patient admitted with infection.
4. Collects and analyzes data.
5. Monitors and evaluates infection control activiites within the hospital."

The Infection Control Program contained no other duties, responsibilities, or training/certification requirements for the position of Infection Control Nurse.

Review of Staff #4's personnel record revealed she had a job description with a position title "Registered Nurse/Charge Nurse/Infection Control Nurse" signed on 11/19/14. Staff #4 also had a current job description for Infection Control Coordinator/Clinical Nurse Educator signed on 10/12/15. Also found in the personnel file was a certificate for attending a conference held in January 2015 provided by the Texas Society of Infection Control and Prevention titled "Essentials of Infection Control and Prevention" and a certificate for a workshop titled "Infection Control in Long-term Care".

An interview was conducted with Staff #4 on 5/3/2016 at 4:30 pm in the conference room. Staff #4 reported she did not have any certification to oversee the infection control program. Staff #4 reported that the previous infection control nurse had been a resource but what she had been taught had been more emphasis on employee health and surveillance of hospital acquired infections and there had not been enough time allotted and emphasis placed on the sanitary and safe work environment.

Based upon record review and interview, the infection control officer failed to ensure infection control policies were specific to the services provided by the facility. The infection control officer failed to ensure maintenance of a sanitary hospital environment, conduct ongoing active surveillance of risks associated with infection on a regular basis, and monitoring compliance with infection control policies and procedures.

Review of the policy #INF - 1:0001 titled "Infection Prevention and Control Program" revealed the Infection Control Plan was reflective of a program in an acute care facility with strong emphasis on identifying risk for acquiring and transmitting infections. The plan had strong emphasis on the Infection Control Nurse's duties related to monitoring, surveillance, and reporting of infections identified on admission and hospital acquired infections. The plan did not address the maintaining of a sanitary environment at all. The plan was written to address the infection control issues found in an acute care hospital and was not written to address the infection control needs of this psychiatric facility.


An interview was conducted with Staff #4 on 5/3/16 at approximately 11:30 am in the conference room. Staff #4 stated she was the infection control nurse and her other job duties were employee health monitoring and facility educator. Staff #4 stated she was allotted 5 hours weekly/20 hours monthly for infection control duties. Staff #4 stated random environmental rounds were made of the facility and they were really hard to make happen because of being unable to coordinate schedules with the Maintenance Director (Staff #6). Staff #4 also reported there was no established schedule for environmental rounds. Staff #4 stated that when rounds were conducted, the findings were provided to the Quality Committee and then they would be reported in the Quality Report. Staff #4 was asked if there was any follow through with deficient findings that needed to be corrected. Staff #4 reported she did no follow up on the findings, she just reported to the Quality Committee and assumed they ensured corrective action was taken.

An interview was conducted with the Quality Director on 5/4/16 at approximately 9:45 am. in the conference room regarding corrective action taken for deficient findings from the environmental/infection control rounds. The Quality Director reported that the Administrator and Maintenance Director had a spreadsheet with all the findings, who was responsible to correct the findings, date and initial when done. The Quality Director was asked to provide the spreadsheet for review but none was offered.
On 5/5/16 in the conference room during the afternoon, the Quality Director reported she did not bring the spreadsheet for review because there had been no follow-up documented on the spreadsheet that the corrective action had been accomplished.

Review of the facility floor plan revealed patient care areas consisting of 3 inpatient units and 1 unit utilized for a partial hospitalization program. There was an admissions unit where patients remained during the admissions process, a full service kitchen and dining room. There were multiple rooms throughout the facility that were identified as "Therapist Office" that contained a staff desk in a corner with the remainder of the room set up as a classroom with patient desks. During a tour of the facility, Staff #1 confirmed the "Therapist Office's" identified throughout the facility were utilized as group therapy rooms.

Review of "infection control rounds" documents dated from 1/27/16 - 4/27/16 revealed the following:

1/27/16 - Unit 1 - Partial Hospitalization Program - Women's Community Restroom - 8 deficient findings requiring corrective action

3/2/16 - Unit 3 - Acute Adult Psychiatric Unit - 11 deficient findings requiring corrective action

3/2/16 - Unit 4 - Dual Diagnosis Adult Unit - 26 deficient findings requiring corrective action

3/2/16 - Dietary Department including Dining Area, Kitchen, Walk in Fridge & Freezer, Dry Storage Room - 47 deficient findings requiring corrective action

4/27/16 - Kitchen Only - 8 deficient findings requiring corrective action

There was no documentation that corrective action had been taken for any of these areas reviewed. During the dates from 1/27/16 - 4/27/16 (3 months), Unit 2, an adult dual diagnosis unit, patient care areas identified as group therapy rooms, and the admissions unit were not inspected for infection control or environmental concerns during this time frame.

A telephone conference was conducted with Staff #3 and Staff #4 on 5/13/16 at 11:30 am. Staff #4 stated that the infection control plan had been written by an acute care Infection Control Consultant. Staff #4 reported with the Consultant's expertise, she felt the plan was appropriate and therefore the emphasis on infections was the focus of the infection control program.

Based on review of records, the hospital failed to provide treatment plans that were individualized to patient needs and kept current in 5 (Patient #'s 4, 5, 7, 13, and 14) of 6 charts reviewed (Patient #'s 4, 5, 6, 7, 13, and 14).

Review of Patient #4's chart showed that the patient had received treatment at Facility #3 for approximately 6 weeks. Patient #4 had been discharged as stable per Staff #27. Patient #4 was picked up at Facility #3 by hospital staff to continue substance abuse treatment per Staff #27. Per Staff #25 on the Psychiatric Evaluation completed on 4-22-2016, the Assessment/Problem list was Depression, Cocaine dependence, and Methamphetamine dependence.

Review of Master Treatment Plan problem list developed on 4-22-2016 showed that Mood Instability was identified as problem #1 and Chemical Dependency was listed as problem #2. Two other problems were listed but not numbered, Chronic Pain and Insomnia.

· The treatment plan for problem #1, mood instability, did not address depression that was identified as the first problem on the Psychiatric Evaluation problem list. The treatment plan for mood instability has a space title "Related to & Evidenced By (Situation Content & Behavioral Statements by Patient). This space could have been used to personalize the plan to the patient's situation but was left blank. The only long-term goal for Mood Instability was for the patient to be able to communicate logically and clearly. Short term goals selected were preprinted and had blanks to individualize the number of symptoms or changes the patient was to list, identify and/or verbalize. These were left blank and not individualized for this patient.
· The treatment plan for problem #2, chemical dependency, listed did not address cocaine as a problem, only "Meth". The treatment plan for Chemical Dependency - Treatment has a space title "Related to & Evidenced By (Situation Content & Behavioral Statements by Patient). This space could have been used to personalize the plan to the patient's situation but was left blank.
· The treatment plan for the problem listed as Chronic Pain was titled Alteration in Comfort - Pain. The section titled "Related To: (Check those that apply)" had the box "Other" checked. Instead of individualizing the plan by identifying the reason the patient was in pain or the source of pain, the blank was completed as, "Pt (patient) statement" and the "As evidenced by" box that was checked was "Communication of pain description." Under the Long Term Goal Section, there was a blank to individualize the target pain level on a pain scale that was left blank and not individualized for this patient. Under the Long Term Goal Section, there was a blank to individualize alternative methods for pain management that was checked. The blank space used to individualize the treatment plan and identify the specific alternative pain relief methods was left blank and not individualized for this patient.
· The treatment plan for problem listed as Insomnia was titled Sleep Difficulty. The section titled "Related To: (Check those that apply)" had the box "Other" checked. Instead of individualizing the plan by identifying the reason the patient was in pain or the source of pain, the blank was completed as, "Pt (patient) statement". The Long Term Goal was preprinted and did not offer an option to write in an individualized goal. The Long Term Goal for Sleep Difficulty listed as the only option is "Patient wall maintain a normal body temperature of 98.7 degrees Fahrenheit for a minimum of ___ days." The Long Term Goal did not relate to sleep difficulty and was not individualized for this patient. The Plan and Outcome section, as well as the Nursing Intervention section did not relate to the Long Term Goal and also had blanks that were not filled in to individualize the plan for this patient.

Review of Patient #5's chart showed that the Assessment / Problems listed on the Psychiatric Evaluation completed on 4-27-2016 were #1 Addiction and #2 Manic. The History and Physical completed on 4-27-2016 identified the patient complained of nausea related to Gastric Bypass and Neuropathy. The patient was transferred to a local emergency room on 5-5-2016 for headaches after a fall. Patient was transferred back with instructions for headache and syncope.

Review of the Master Treatment Plan Problem List for Patient #5 showed it contained the problems "M1 Alt Comfort", "M2 Fall Risk", "P1 Chemical Dependency", and "P2 Mood Instability". The problem list did not address the nausea due to gastric bypass or headaches related to a fall. Treatment plans were not initated for these two problems.

Review of Patient #7's records showed that on 3-18-16, the patient complained of difficulty sleeping and was ordered medication to help sleep. She received this medication at bedtime each night until discharge. This new problem with medication and treatment was not added to the Master Problem List and a treatment plan was not initiated.

Review of Patient #13's records showed that the patient was admitted for alcohol detoxification. The alcohol detoxification protocol was ordered. No treatment plan was initiated for alcohol detoxification.

Review of Patient #14's records showed that the patient was admitted with orders for opiate detoxification. The opiate detoxification protocol was ordered. No treatment plan was initiated for opiate detoxification. Review of Patient #14's records showed that on 4-6-2016 the patient developed athlete's foot and was prescribed medication. This new problem with medication and treatment was not added to the Master Problem List and a treatment plan was not initiated. The treatment plan for problem listed as M2 Insomnia was titled Sleep Difficulty. The Long Term Goal was preprinted and did not offer an option to write in an individualized goal. The preprinted Long Term Goal for Sleep Difficulty listed as the only option is "Patient wall maintain a normal body temperature of 98.7 degrees Fahrenheit for a minimum of __ days." This goal, as the only long term goal available for choice, was selected and the blank was filled in with the number 7. The Long Term Goal did not relate to sleep difficulty and was not individualized for this patient. The Plan and Outcome section, as well as the Nursing Intervention section did not relate to or explain how to achieve the Long Term Goal.