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Based on observations, interviews and record review, the Dallas and Arlington facility failed to ensure a safe setting for patients and staff in that,

1) (Dallas Facility) seclusion room doors on the patient units were able to be locked by anyone, including patients, allowing for potential seclusion or hostage situation;

(refer to A0144)

2) (Dallas facility) sink faucets, shower heads, and door hinges presented ligature risks; emergency call lights did not function; PVC pipe was left lying in the patient outside recreational area; and patients were not monitored at the level of monitoring ordered by the physician.

(refer to A0144)

3) (Arlington facility) two patients on the hospital's intensive psychiatric care unit (Patient #21 and Patient #12) had injured body parts covered with long elastic wraps with the potential for self-harm and ligature. The patients were not placed under special observation until after surveyor observation on 08/18/15.

(refer to A0144)

4) (Arlington facility) items potentially usable in patient self-harm were identified easily accessible to patients and included electrical cords, plastic items, exposed glass light bulbs and electric wiring.

(refer to A0144)

5) (Arlington facility) a badge-access only outside door was left open for easy access to the otherwise locked patient dining area.

(refer to A0144)

6) (Dallas facility) fire extinguisher inspection tags were outdated and exit signs not lighted for the PHP (partial hospital program) hallway, second floor east stairwell and the third floor west stairwell. The second floor visitor quiet room celing tile was water damaged. Water damage was observed underneath a cabinet sink.

(refer to A0144)

Based on observation, review of documentation and interviews, the facility failed to ensure that nurisng services was adequately supervised by an RN (Registered Nurse) in that,

1) (Dallas facility) 1 of 1 patient (Patient #25) was not reasessed by a registered nurse at least every 12 hours. This presents a risk that patients will not receive necessary care as their needs have not been assessed;

(Refer to 0395)

2) (Dallas facility) RN's (Registered Nurses) were not assigned to the adult and/or adolescent units every shift for the months of 07/2015 and 08/2015 and current inpatients were not assessed/evaluated by an RN;

(Refer to 0395)

3) 1 of 1 patient (Patient #12) at the (Arlington facility) medical treatment for a fractured finger was delayed three days after x-ray results dated 08/14/15 were received. Registered nurses failed to evaluate and/or assess Patient #12's fractured 5th finger on the right hand.

(Refer to 0395)

Based on a review of documentation, interviews, and observation, the Dallas facility failed to ensure that the patient right to make informed decisions regarding medications was provided as medications were administered to 5 of 5 patients (Patient #24, #25, #26, #28 and Patient #29) without medication education or informed consent.

Findings included:

Review of the medical record for the following patients revealed that psychotropic medications had been administered without documented evidence of informed consent as required by facility policy and state regulation.

Patient #24 received Trazadone on 06/10/15 at 2100, yet the psychotropic medication consent form for Trazadone was not signed until 06/14/15. This was confirmed with the facility administrator the afternoon of 8/19/15 in the facility conference room.

Patient #25 received Trazadone on 08/11/15 at 2100. Review of the medical record revealed no documented evidence of a psychotropic medication consent form. This was confirmed with the facility administrator the afternoon of 08/19/15 in the facility conference room.

Patient #26 received Effexor on 08/6/15 at 0900, Paxil on 08/5/15 at 0900, Melatonin on 08/6/15 at 2100, and Vistaril on 08/10/15 at 0900. Review of the medical record revealed no documented evidence of a psychotropic medication consent form for the above medications. This was confirmed with the facility administrator the afternoon of 08/19/15 in the facility conference room.

Patient #28 received Neurontin on 08/17/15, Vistaril on 08/18/15, and Lithium on 08/18/15. Review of the medical record revealed no documented evidence of a psychotropic medication consent form. This was confirmed with Personnel #49, LVN the afternoon of 08/19/15 on the patient unit.

Patient #29 received Celexa, Risperdal, Trazadone, Vistaril on 08/7/15 at 2100. Review of the medical record revealed no documented evidence of a psychotropic medication consent form. This was confirmed with Personnel #49, LVN (Licensed Vocational Nurse) the afternoon of 08/19/15 on the patient unit.

The above findings were confirmed in an interview the afternoon of 08/19/15 with the Dallas facility administrator in the facility conference room.

Review of facility policy, "Psychoactive Medication: Administration," issued 09/8/2014, stated, in part, "Psychoactive medications are administered with the patient's informed consent...2...Prior to the administration of any psychoactive medication, medication education and informed medication consent must be obtained for each individual medication, not by medication class. Informed consent will be documented in the medical record of the patient...B. Medication information and explanations will include notification of the right to withdraw consent at any time. 3. The first dose(s) of the prescribed psychoactive medication(s) is given after the appropriate information/education has been performed and the appropriate consent has been obtained."

Review of hospital policy titled "Informed Consent for Psychoactive Medications" stated in part "...Psychoactive medications are administered with the patient's informed consent and/or the informed consent of the patient's legally authorized representative (LAR). Informed medication consent must be obtained for each individual medication, not by medication class ....6. The licensed nurse responsible for transcribing the medication order or reviewing/signing the transcribed order will be responsible for completing the appropriate information and Consent for Medication forms...B...Notation of medication consents for psychoactive medications that have been obtained will be in patient's permanent medical record..."

Based on observation, record reviews and interviews, the Dallas facility failed to ensure that a patient has the right to personal privacy.

Findings included:

A tour of the Dallas facility was conducted the afternoon of 08/17/15 accompanied by the facility administrator. The outside recreational area used by patients was visible to a person standing outside the facility near the entrance to the Partial Hospitalization Program through the floor to ceiling windows in the hallway. The outside recreational area was used by psychiatric patients, including minors. This presents a risk for the right to privacy to be violated.

Review of the "Basic Rights for All Patients" in the handbook, "Patient's Bill of Rights" stated, in part,
"3. You have the right to a clean and humane environment in which you are protected from harm, have privacy with regard to personal needs, and are treated with respect and dignity."

The above finding was confirmed in an interview with the Dallas facility administrator the afternoon of 08/17/15 during the tour of the facility.

Based on observations, interviews and record reviews, the Dallas and Arlington facility failed to ensure a safe setting for patients and staff in that,

1) (Dallas Facility) seclusion room doors on the patient units were able to be locked by anyone, including patients, allowing for potential seclusion or hostage situation;

2) (Dallas facility) sink faucets, shower heads, and door hinges presented ligature risks; emergency call lights did not function; PVC pipe was left lying in the patient outside recreational area; and patients were not monitored at the level of monitoring ordered by the physician;

3) (Arlington facility) two patients on the hospital's intensive psychiatric care unit (Patient #21 and Patient #12) had injured body parts covered with long elastic wraps with the potential for self-harm and ligature. The patients were not placed under special observation until after surveyor observation on 08/18/15;

4) (Arlington facility) items potentially usable in patient self-harm were identified easily accessible to patients and included electrical cords, plastic items, exposed glass light bulbs and electric wiring;

5) (Arlington facility) a badge-access only outside door was left open for easy access to the otherwise locked patient dining area;

6) (Dallas facility) fire extinguisher inspection tags were outdated and exit signs not lighted for the PHP (partial hospital program) hallway, second floor east stairwell and the third floor west stairwell. The second floor visitor quiet room celing tile was water damaged. Water damage was observed underneath a cabinet sink.

Findings included:

1) A tour of the Dallas facility was conducted the afternoon of 08/17/15 accompanied by the facility administrator and the following was observed:

Observation of 5 out of 5 seclusion rooms at the Dallas facility on the active units revealed that each seclusion room door had a lock that did not require a key on the outside of the door. The seclusion room was unsecured. The door could be locked or unlocked by anyone, including a patient. This presents a risk that a patient outside the seclusion room could seclude another patient by allowing a patient to enter the unlocked seclusion room and closing and locking the door after the patient entered the room. This also presents a risk that a patient could seclude or confine a staff member in the seclusion room, allowing a hostage situation.

2) The sink faucet in the patient bathrooms, available for patient use, were outfitted with a faucet which presented a ligature risk as a patient could secure a ligature to the faucet. These faucets were observed on the second floor in the 2 seclusion room bathrooms, in patient rooms 246 and 248, on the third floor in the 2 seclusion room bathrooms.

On the morning of 08/18/15, faucets with a ligature risk were observed in patient rooms 141, 144, and 149. The faucets were observed and confirmed with the facility administrator during the tours on 8/17/15 and 08/18/15. In the seclusion rooms on the second and third floor, the emergency call lights and alarms were tested. There was no response by nursing staff in the nurse's station. There was no audible alarm at the nurse's station on 3 attempts. This presents a risk that nursing staff may not be aware of an emergency situation in the seclusion room.

During a tour of the Dallas facility the morning of 08/18/15, the external door near the geriatric nurse's station had a large overhead hinge that presented a ligature risk. In the geriatric patient bathing room, the shower head and the faucet presented a ligature risk as a ligature could be secured to the shower head or faucet. In the outside recreation area used by patients, there was approximately 18 feet of PVC pipe which had been pulled out of the ground and was lying on the ground.

Review of the "Basic Rights for All Patients" in the handbook, "Patient's Bill of Rights" stated, in part,
"3. You have the right to a clean and humane environment in which you are protected from harm, have privacy with regard to personal needs, and are treated with respect and dignity."

The above findings were confirmed by the facility administrator during the tours of the facility on 08/17/15 and 08/18/15.

Review of the medical record for Patient #26 revealed no documented evidence that he was monitored every 15 minutes as ordered for the following times on 08/7/15 as the times were left blank:
0800, 0815, 0830, 0845, 0900, 0915, 0930, 0945, 1000, 1015, 1030, 1045, 1100, 1115, 1130, 1145, 1200, 1215, 1230, 1245, 1300, 1315, 1330, 1345, 1400, 1415, 1430, 1445. Per the observation patient rounding checklist, patient #26 was not monitored for approximately 8 hours on 8/7/15.

Review of the medical record for Patient #23 revealed no documented evidence that she was monitored every 15 minutes as ordered at 0600 and 0615 on 3/19/15 as the times were left blank. Per the observation patient rounding checklist, Patient #23 was not monitored for approximately 30 minutes on 3/19/15.

Review of facility policy, "Precautions: Level System: Adult Inpatient Program" issued 8/11/2014, stated, in part,
"It is the policy of Sundance Hospital to provide a safe and secure environment for patients during their hospitalization. At the time a patient is admitted, Sundance Hospital shall assign and implement precaution monitoring typically every 15 minutes, based on the patient's needs, and for safety monitoring during their inpatient hospitalization...
10. Staff making rounds shall observe patients' activity, behavior, whereabouts and document observations as indicated...
13. Staff making rounds document rounds on the approved patient monitoring rounds form."

Review of facility policy, "Medical Record: Content" with an issue date of 8/11/2014, stated, in part,
"Each inpatient at Sundance Hospital shall have a Medical record. The medical record shall include, but not be limited to...
11. Documentation of the monitoring of the patient by the staff members responsible for such monitoring, including observations of the patient at pre-determined intervals."

The above findings were confirmed in an interview with the Dallas facility administrator the afternoon of 08/19/15 in the facility conference room.


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3) Patient #21 was observed in the hospital's dining area on 08/18/15 at approximately 1145 with his right arm wrapped in an elastic bandage (ace wrap).

Physician Orders dated 08/18/15 at 1330 noted to place Patient #21 "on LOS [line of sight observation] for pt [patient] safety."

Patient #21's Physician's Orders and Preliminary Plan of Care dated 08/16/15 at 1410 reflected the level of observation to be every 15 minutes.

Patient #21's Integrative Psychiatric Assessment dated 08/16/15 at 1422 reflected the patient was "erratic" and "paranoid." He was assessed to be a "high risk" for suicide and self harm.

Patient #21's rounding check list dated 08/16/15 through 08/18/15 revealed the patient's precaution level of observation was left blank.

Personnel #30 stated during an interview on 08/18/15 at approximately 1616 that Patient #21 had been admitted with the ace wrap on his arm "over the week-end [08/15/15 to 08/16/15] and was not on LOS (line of sight observation) yesterday [08/17/15]."

Patient #21 agreed on 08/18/15 at 1630 that he had received the injury on his right arm prior to his hospital admission and had not been on special staff observation the previous day (08/17/15).


On 08/18/15 at approximately 1150 Patient #12 was observed in the patient dining room. Patient #12 had a long elastic wrap covering a white splint to the right hand/wrist.

The Behavioral Health Integrated Psychiatric Assessment dated 08/10/15 timed at 1140 reflected, "Patient transferred from...hospital...patient is suicidal and homicidal ideation's with plan to shoot herself...history of suicidal ideations...attempt 2X (two times) OD (overdose)...poisoning and hanging self."

Patient #12's Restraint/Seclusion order/record dated 08/13/15 timed at 1220 reflected, "Patient states hit wall several days ago and right pinky finger hurts..."

Patient #12's 08/13/15 physician's orders and directions timed at 1620 reflected, "x-ray of right 5th digit due to pain and swelling..."

Patient #12's 08/14/15 Right Hand x-ray results timed at 2037 reflected, "Two views of right hand dated 08/14/15, 1900 hours demonstrate a nondisplaced fracture in the 5th metacarpal neck with minimal anterior angulation...soft tissue swelling is present..."

Patient #12's physician orders and directions dated 08/16/15 timed at 1200 reflected, "Please transfer to ER...when able."

Patient #12's 08/17/15 nursing shift assessment and progress note not timed reflected, "Patient off unit to....hospital ER (emergency room) for right hand...at 1515...patient back on unit with wrap/splint on right hand says she has pain...at 2100...continues on Q15 (every fifteen minute) checks..."

Patient #12's physician orders and directions dated 08/18/15 timed at 1330 reflected, "Place patient on los (line of sight) for patient safety..." The LOS was initiated after the surveyors observation on 08/18/15 at 1150.

On 08/18/15 at 1535 Personnel #1 was interviewed. Personnel #1 stated he thought the nurses put Patient #12 on line of sight when she returned from the hospital on 08/17/15 due to having the elastic wrap. Personnel #1 verified the line of sight observation was ordered after the surveyor's observation on 08/18/15 at 1150.

On 08/18/15 at 1610 Personnel #30 was interviewed. Personnel #30 was asked to review Patient #12's medical record. Personnel #30 stated Patient #12 should of been placed on line of sight upon return from the medical hospital on 08/17/15. Personnel #30 stated obtaining an order for line of sight was missed.

4) Observations in the hospital's dining room on 08/17/15 at 1206 reflected two electrical cords connecting the drink vending machine with the wall plug were visible and accessible to ten patients eating their lunch meal at that time.

A phone holder plate made of black plastic with sharp edges and easy-to-break-off pieces was observed on the hospital's pediatric unit in close proximity to two male adolescent patients on 08/17/15 at 1210.

On the female pediatric unit, an approximately two-feet-long cable connecting the television set with its power supply was visible and easily accessible to the patients as observed on 08/17/15 at 1225. Personnel #1 acknowledged the finding at that time.

Safety round documentation completed by administrative staff was dated 08/10/15, 08/11/15, 08/13/15, 08/15/15, and 08/17/15 did not identify the cable as a safety risk.

A large plastic trash bag was observed in the bathroom adjacent to the lobby on 08/17/15 at 1645 and on 08/18/15 at 0844. Personnel #1 and #4 acknowledged on 08/18/15 at 0850 that the plastic bag was a potential ligature risk for patients who used the lobby bathroom prior to their hospital admission procedure.

Inside the locked patient care area, a large black plastic trash bag was observed in the patient accessible bathroom on 08/18/15 at 1000. Personnel #24 acknowledged the finding at that time.

Uncovered light fixtures providing patients access to glass light bulbs and electric wiring were observed in patient rooms #300 and #315 on 08/18/15 at 1325. The unit was used for treating PICU (Psychiatric Intensive Care Unit) patients at that time.

Easily removable loose light switch plates were observed with the potential for patient exposure to electrical wiring were observed in patient rooms #314 and #315 on 08/18/15 at 1325. Personnel #24 acknowledged the above findings.

5) On 08/18/15 at 1530 the badge-activated back door with access from the parking lot to the locked patient dining area was observed ajar and easily opened from the outside. Personnel #53 stated on 08/18/15 at 1532 that the door "should not be open."

The hospital policy and procedure entitled, "Precaution/Patient Monitoring with an issue date of 11/2010 reflected, "It is the policy of Sundance Hospital...to provide a safe and secure environment for patients...monitors and modifies the patient care environment so as to protect inpatients by providing furnishings that do not present safety hazards...objects that are identified as hazardous to the patient shall be secured or removed from the environment...hospital shall assign and implement precautions monitoring based on the patient's needs, and for safety monitoring during their inpatient hospitalization...patients on line of sight monitoring shall stay in the visual view or in the line of sight of staff at all times..."



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6) During a tour of the Dallas facility the afternoon of 08/17/15, the following was observed:

Six fire extinguishers throughout the hospital had punched inspection tags of 07/2014. Two exit signs were not lighted above the exit doors on the Partial Hospital Program(PHP) hallway, one exit sign was not lighted above the second floor exit door by the east stairwell, and one exit sign was not lighted above the third floor exit door by the west stairwell. A water leak stain on the ceiling and water damaged cabinet floor under the sink was observed in a second floor visitor quiet room.

The fire extinguishers with expired inspection stickers and the unlighted exit lights above exit doors could cause potential patient harm as a result of malfunctioning fire extinguishers and possible delayed facility evacuation of patients during either a fire or other emergency situation. The unrepaired water damage could possibly result in development of mold and possible respiratory health issues of patients.

Based on review of documentation and interview, the Dallas facility failed to ensure that treatment plans were modified after patient restraint or seclusion. for 2 of 2 patients (Patient #23 and Patient #24).

Findings included:

1) Review of the medical record for Patient #23 revealed the following:

Patient #23 was restrained on 03/20/15. The order stated, "Treatment plan modification indicated:" and the box was checked for "Yes." There was no documented evidence that the treatment plan was modified.

Patient #23 was restrained on 03/21/15. The order stated, "Treatment plan modification indicated:" and the box was checked for "Yes." There was no documented evidence that the treatment plan was modified; there was a blank form for a treatment plan modification in the medical record with the restraint packet labeled "Problem: Emergency Behavior Management" however this form was left blank.

Patient #23 was restrained on 03/22/15. The order stated, "Treatment plan modification indicated:" and the box was checked for "Yes." There was no documented evidence that the treatment plan was modified; there was a blank form for a treatment plan modification in the medical record with the restraint packet labeled "Problem: Emergency Behavior Management" however this form was left blank.

2) Review of the medical record for Patient #24 revealed that the patient debriefing was not completed. There was a form in the medical record entitled, "Patient Debriefing" but the form was blank.

Review of facility policy, "Emergency Behavioral Interventions: Use of Seclusion/Restraints" issued 08/11/2014, stated, in part, "15...The use of seclusion or restraint must be in accordance with a written modification to the patient's plan of care. This will be evidenced by the physician orders..."

Review of facility policy, "Emergency Behavioral Interventions: Use of Seclusion/Restraints" issued 08/11/2014, stated, in part, "STAFF ACTIONS TO BE TAKEN FOLLOWING/AFTER THE RELEASE OF A PATIENT FROM RESTRAINT OR SECLUSION
2. As soon as possible after an episode of restraint or seclusion, available staff members involved in the episode, supervisory staff, the patient, the LAR, and (with the consent of the individual) family members must meet to discuss the episode. The purpose of the debriefing is to:
A. Identify what led to the episode and what could have been handled differently;
B. Identify strategies to prevent future restraint or seclusion, taking into consideration suggestions from the individual and the individual's advanced directive, if any;
C. Ascertain whether the individual's physical well-being, psychological comfort, and right to privacy were addressed;
D. Counsel the individual in relation to any trauma that may have resulted from the episode;
E. When indicated, identify appropriate modifications to the individual's treatment plan; and
F. When clinically indicated or upon request of individuals who witnessed the restraint, persons who witnessed the restraint also shall be debriefed..."

Review of facility policy, "Emergency Behavioral Interventions: Seclusion/Restraint Observation Record/Documentation" issued 8/11/2014, stated, in part,
"9. PROGRESS NOTE REQUIREMENTS...
D. The staff will take and document appropriate actions to facilitate the individual's re-entry into the social milieu following release from restraint or seclusion. These actions include:
(1) providing the patient an opportunity to discuss/debrief the experience privately within twenty-four (24) hours following release...
10. The patient and staff participate in debriefing about the seclusion event. The debriefing occurs as soon as possible, but no longer than 24 hours after the event. The debriefing is documented on the Seclusion/Code Debriefing Form."

The above findings were confirmed in an interview with the Dallas facility administrator the afternoon of 08/19/15 in the facility conference room.

Based on review of documentation and interviews, the Dallas facility failed to implement restraint and/or seclusion in accordance with hospital policy and state law for 1 of 1 patient (Patient #23). The facility failed to ensure that restraint or seclusion was implemented in a safe manner (Patient #23) was not observed continuously by a staff member while in seclusion for over an hour. The facility failed to ensure that documentation was completed for episodes of restraint and seclusion, as (Patient #23) was not observed face-to-face while in seclusion or restraint and no documented evidence that (Patient #23) was monitored every 5 minutes for the first 15 minutes while in restraint and seclusion. No physician order for seclusion and no documentation which indicated bathroom privileges or an opportunity to drink water or other appropriate liquids every 2 hours was provided.

Findings included:

Review of the medical record for Patient #23 revealed that she was secluded on 03/21/15 from 1350 until 1455. The Sundance Hospital Adult Inpatient Seclusion / Restraint Observation Record associated with this event was left blank. There was no documented evidence that Patient #23 was maintained with continuous face-to-face observation while she was in seclusion.

Review of facility policy, "Emergency Behavioral Interventions: Seclusion/Restraint Observation Record/Documentation" issued 8/11/2014, stated, in part, "The Seclusion/Restraint event is documented in each case of patient seclusion and/or restraint...
Seclusion/Restraint Observation Record...
A. Patients in seclusion are observed continuously by 1:1 observation for the first hour, thereafter the patient may be observed either by 1:1 visualization or by closed circuit T.V. monitor. Monitored by continuous face-to-face (1:1) observation shall be by a same gender staff member unless the individual's history indicates this is contraindicated. In such cases, contraindications are documented and observations are done by opposite sex staff member. Documentation is completed q (5) five minutes for the Initial (15) fifteen minutes, then q (15) fifteen minutes thereafter."

Review of 25 Texas Administrative Code Chapter 415.266a)(1-3) stated, in part,
"(a) Observation...(3) A staff member shall maintain continuous face-to-face observation of an individual in seclusion for at least one hour. After one hour, the staff member may monitor the individual continuously using simultaneous video and audio equipment in close proximity to the individual."

Review of the medical record for Patient #23 revealed the following restraint and seclusion episodes on 03/19/15:

Review of the Sundance Hospital Adult Inpatient Seclusion/Restraint Observation Record for Patient #23 revealed no documented evidence that Patient #23 was maintained with continuous face-to-face observation while she was restrained from 1120 until 1150. This presents a risk for injury for a patient in restraint for emergency behaviors without observation.

Patient #23 began a second episode of restraint and seclusion on 03/19/15 at 1155. There was no new observation form associated with this episode as a form from a previous episode was used. The documentation for the episode beginning at 1155 did not reflect observations every 5 minutes for the initial 15 minutes per policy.

Patient #23 began another episode of restraint and seclusion at 1420. There was no new observation form associate with this episode as a form from a previous episode was used. There was no documentation to reflect observations every 5 minutes for the initial 15 minutes per policy, as the documentation reflected observation at 1415, 1430, 1445 and 1500, every fifteen minutes until 1700.

Patient #23 was secluded on 03/19/15 from 1425 until 1700 for a duration of 2 hours and 35 minutes. There was no documented evidence that Patient #23 was offered or provided bathroom privileges or an opportunity to drink water or other appropriate liquids every 2 hours. There was no documented evidence of an RN assessment a minimum of every 2 hours to supervise the observation and care provided by other assigned staff and to assess and document specific behaviors that the patient was exhibiting and the rationale to continue the seclusion. There was no documented evidence that Patient #23 was assessed by an RN during the 2 hour and 35 minute seclusion on 3/19/15.

On 03/19/15, Patient #23 was secluded from 2255 until 2315. The patient was released from seclusion at 2315. A separate episode of seclusion began at 2330, however there was no physician order for the second episode of seclusion that began at 2330. Review of the Seclusion/Restraint Observation Record revealed that observation began for Patient #23 at 2255. At 2315, documentation on the Observation Record indicated "Release Criteria Met." There was no separate documentation for the 2330 episode of seclusion. Consequently, Patient #23 was secluded without an order on 03/19/15 at 2330.

Review of facility policy, "Emergency Behavioral Interventions: Seclusion/Restraint Observation Record/Documentation" issued 8/11/2014, stated, in part,
"The Seclusion/Restraint event is documented in each case of patient seclusion and/or restraint...the RN shall be responsible for nursing assessments at a minimum of every 2 hours...and for supervising the observation and care provided by other assigned staff...
1. Seclusion/Restraint Observation Record is initiated within five (5) minutes of the patient being placed in seclusion by the RN or the patient being placed in a physical hold/restraint...
Seclusion/Restraint Observation Record:
B. Every two (2) hours, document utilizing the specified codes (right side of sheet) that bathroom breaks and fluids were offered and either accepted or refused.
C. Every two (2) hours, an assessment by the RN is to be completed for continued stay in seclusion and/or restraint. Document specific behaviors that patient is exhibiting and rational for continuation..."

The above findings were confirmed in an interview with the Dallas facility administrator the afternoon of 08/19/15 in the facility conference room.

Based on a review of documentation and interviews, the Dallas facility failed to ensure that each episode of restraint and seclusion for 1 of 1 patient (Patient #23) was ordered by a physician and that physician orders for restraint and seclusion included all required components, including specific behaviors constituting the behavioral emergency.

Findings included:

Review of the medical record for Patient #23 revealed the following:

Patient #23 was restrained on 03/29/15 from approximately 1448 to 1458 and secluded from 1458 until 1556. There was no physician signature on the order for restraint. The physician order did not describe the specific behaviors which constituted the behavioral emergency which resulted in the need for restraint. The line for "Specific Behavior Exhibited" was left blank on the order form.

Patient #23 was secluded on 03/21/15 from 1350 to 1455, initiated by a registered nurse. There was no physician name for the physician who gave a telephone or verbal order for the seclusion and no date and time for the verbal order. The place on the order form for TORB [telephone order read back] Psychiatrist, Date, and Time was left blank. There was no documented evidence that a physician ordered this seclusion; however a physician did sign the order 24 hours later, on 03/22/15 at 1355.

Patient #23 was secluded without an order on 03/19/15 at 2330.
On 03/19/15, Patient #23 was secluded the following times:
Seclusion 2255 - 2315
Seclusion 2330 - 0010
The patient was released from seclusion at 2315. A separate episode of seclusion began at 2330, however there was no physician order for the second episode of seclusion that began at 2330. Review of the Seclusion/Restraint Observation Record revealed that observation began for Patient #23 at 2255. At 2315, documentation on the Observation Record indicated "Release Criteria Met." There was no separate documentation for the 2330 episode of seclusion. Consequently, Patient #23 was secluded without an order on 03/19/15 at 2330.

Review of facility policy, "Emergency Behavioral Interventions: Seclusion/Restraint Observation Record/Documentation" issued 8/11/2014, stated, in part,
"The Seclusion/Restraint event is documented in each case of patient seclusion and/or restraint...
(4) Trial releases may not be utilized."

Review of facility policy, "Emergency Behavioral Interventions: Use of Seclusion/Restraints" issued 08/11/2014, stated, in part,
"4. A time-limited physician order is required for the use of seclusion and/or restraint....Patients shall be released from seclusion and/or restraint as soon as the criteria for release have been met...
6. When restraint or seclusion is the appropriate intervention, staff members should use it for the shortest period necessary and should terminate it as soon as the individual demonstrates the release behaviors specified by the physician.
7. A physician must order each use of restraint or seclusion...
PHYSICIAN ORDER
1. A physician order from a member of the Hospital's medical staff is required for seclusion and/or restraint use as an emergency behavior management technique at Sundance Hospital. The physician's order for restraint or seclusion must:
C. Describe the specific behaviors which constituted the emergency which resulted in the need for restraint or seclusion;
E. Be signed, timed, and dated by the physician or the registered nurse who accepted the prescribing physician's telephone order.
2. Because use of seclusion and restraint is limited to behavioral emergencies, and the physician may not be immediately available, a qualified registered nurse (RN) is authorized by Sundance Hospital to assess the situation and initiate seclusion and/or restraint as necessary for the safety of the patient and/or others.
A. The order from the physician must be obtained no longer than one (1) hour after the initiation of seclusion or restraint. If restraint or seclusion was ordered by telephone, the ordering physician must personally sign, time, and date the telephone order within 24 hours of the time the order was originally issued...PRN or standing orders for seclusion or restraint are not acceptable or allowed...
9. A physician's order is required for the use of emergency seclusion. It is obtained as soon as possible and within no more than one (1) hour of the patient being placed in seclusion. The attending or covering physician is contacted for the order..."

The above findings were confirmed in an interview with the Dallas facility administrator the afternoon of 08/19/15 in the facility conference room.

Based on review of documentation and interview, the Dallas facility failed to ensure that physician orders for restraint or seclusion for 1 of 1 patient (Patient #23) were time limited, as physician orders for seclusion did not specify a time limitation for the order.

Findings included:

Review of the medical record for Patient #23 revealed the following:

Patient #23 was secluded on 03/20/15 from 2330 to 2340. The order for seclusion did not specify a period of time for the order, not to exceed four hours.

Patient #23 was secluded on 03/20/15 from 2045 to 2105. The order for seclusion did not specify a period of time for the order, not to exceed four hours.

Patient #23 was secluded on 03/20/15 from 1340 to 1505. The order for seclusion did not specify a period of time for the order, not to exceed four hours. The order did not indicate the time the patient was in a physical restraint, the time out of the restraint, the time in for seclusion, and the time out of seclusion as the space on the order for that information was left blank.

Review of facility policy, "Emergency Behavioral Interventions: Seclusion/Restraint Observation Record/Documentation" issued 08/11/2014, stated, in part,
"4. The following criteria will be followed regarding obtaining physician orders for seclusion and/or restraint:
Restraint by Personal Hold shall not exceed 15 minutes total time (No renewal order allowed past 15 minutes)
Seclusion shall:
· Not exceed 1 hour for children < 9 years of age
· Not exceed 2 hours for children/adolescents 9-17 years of age
· Not exceed 4 hours for patients >17 years of age"

Review of facility policy, "Emergency Behavioral Interventions: Use of Seclusion/Restraints" issued 08/11/2014, stated, in part,
"4. A time-limited physician order is required for the use of seclusion and/or restraint...
TIME LIMITATION ON AN ORDER FOR SECLUSION AND/OR RESTRANT
(Initiated In Response to a Behavioral Emergency)
1. Original order. A physician may order restraint or seclusion for a period of time not to exceed:
A. 15 minutes for physical (personal) restraint;
B. One hour for mechanical restraint or seclusion for individuals under the age of 9;
C. Two hours for mechanical restraint or seclusion for individuals ages 9-17; and
D. Four hours for mechanical restraint or seclusion for individuals age 18 and older."

The above findings were confirmed in an interview with the Dallas facility administrator the afternoon of 08/19/15 in the facility conference room.

Based on a review of documentation and interview, the Dallas facility failed to ensure 1 of 1 patient (Patient #23) who was restrained and/or secluded was assessed every 2 hours by an RN and offered or provided bathroom privileges and an opportunity to drink water or other appropriate liquids.

Findings included:

Review of the medical record for Patient #23 revealed the following:


Patient #23 was secluded on 03/19/15 from 1425 until 1700 for a duration of 2 hours and 35 minutes. There was no documented evidence that Patient #23 was offered or provided bathroom privileges or an opportunity to drink water or other appropriate liquids every 2 hours. There was no documented evidence of an RN assessment a minimum of every 2 hours to supervise the observation and care provided by other assigned staff and to assess and document specific behaviors that the patient was exhibiting and the rationale to continue the seclusion.

There was no documented evidence that Patient #23 was assessed by an RN during the 2 hour and 35 minute seclusion on 03/19/15.

Review of facility policy, "Emergency Behavioral Interventions: Seclusion/Restraint Observation Record/Documentation" issued 08/11/2014, stated, in part,
"The Seclusion/Restraint event is documented in each case of patient seclusion and/or restraint...The RN shall be responsible for nursing assessments at a minimum of every 2 hours...and for supervising the observation and care provided by other assigned staff...
1. Seclusion/Restraint Observation Record is initiated within five (5) minutes of the patient being placed in seclusion by the RN or the patient being placed in a physical hold/restraint ...
Seclusion/Restraint Observation Record:
B. Every two (2) hours, document utilizing the specified codes (right side of sheet) that bathroom breaks and fluids were offered and either accepted or refused.
C. Every two (2) hours, an assessment by the RN is to be completed for continued stay in seclusion and/or restraint. Document specific behaviors that patient is exhibiting and rational for continuation."

The above findings were confirmed in an interview with the Dallas facility administrator the afternoon of 08/19/15 in the facility conference room.

Based on a review of documentation and interview, the Dallas facility failed to conduct appropriate face-to-face evaluations for 2 of 2 patient (Patient #23 and Patient #24) after being released from restraint or seclusion, face-to-face evaluations were being completed by registered nurses despite the facility policy requiring the face-to-face to be conducted by physicians or advance practice nurses appointed to the medical staff and privileged to practice in the facility. The face-to-face evaluations conducted by registered nurses were conducted by the same nurse who initiated the restraint or seclusion.

Findings included:

Review of the medical record for Patient #23 revealed the following:

Patient #23 was restrained on 03/29/15 from 1448 to 1458 and secluded from 1458 until 1556. There was no documented evidence in the medical record that a face-to-face evaluation was conducted. There was a face-to-face evaluation form in the medical record related to this restraint; however the form was blank and not completed.

Patient #23 was restrained on 03/22/15 from 4:45 pm to 4:55 pm. There was no documented evidence in the medical record that a face-to-face evaluation conducted. There was a face-to-face evaluation form in the medical record related to this restraint; however the form was blank and not completed.

Patient #23 was secluded on 03/21/15 from 1350 to 1455. There was no documented evidence in the medical record that a face-to-face evaluation conducted. There was a face-to-face evaluation form in the medical record related to this restraint; however the form was blank and not completed.

Patient #23 was secluded on 03/20/15 from 2330 to 2340. The RN who conducted the face-to-face evaluation was the same RN who initiated the seclusion.

Patient #23 was secluded on 03/20/15 from 2045 to 2105. The RN who conducted the face-to-face evaluation was the same RN who initiated the seclusion.

Patient #23 was restrained and secluded on 03/20/15 from 1340 to 1505. There was no documented evidence in the medical record that a face-to-face evaluation was conducted. There was a face-to-face evaluation form in the medical record related to this restraint; however the form was blank and not completed.

Patient #23 was secluded on 03/19/15 from 2255 to 2315. There was no documented evidence in the medical record that a face-to-face evaluation was conducted.

Patient #23 was secluded on 03/19/15 at the following times where the RN who conducted the face-to-face evaluation was the same RN who initiated the seclusion:
1155 - 1255
1420 - 1700
1850 - 2045
2330 - 0010
1137 - 1150

Review of the medical record for Patient #24 revealed that the RN who conducted the face-to-face evaluation was the same RN who initiated the seclusion on 06/15/15 at 1235.

Review of the personnel records for RNs performing face-to-face evaluations after restraint and seclusion (Personnel #41, #42, #43, and Patient #44), revealed no documented evidence of specific training or competence demonstration in assessing medical and psychiatric stability to qualify them to conduct a face-to-face evaluation of the individual within one hour following the initiation of restraint or seclusion to personally verify the need for restraint or seclusion.

Review of facility policy, "Emergency Behavioral Interventions: Use of Seclusion/Restraints" issued 08/11/2014, stated, in part,
"8. Face-to-Face Evaluation. A physician must conduct a face-to-face evaluation of the individual following the initiation of restraint or seclusion to personally verify the need for restraint or seclusion and to approve its continuation, if indicated. The face-to-face evaluation must be conducted within one hour following the initiation of restraint or seclusion...
A. A physician may delegate this face-to-face evaluation to a staff person who is under the clinical supervision of a physician appointed to the medical staff and who is privileged to practice in the facility; and who is a physician assistant or an advanced practice nurse appointed to the medical staff and privileged to practice in the facility.
B. The physician, who delegates the face-to-face evaluation that is to be completed within one hour following the initiation of restraint or seclusion, must ensure that a physician performs a follow-up evaluation of the patient face-to- face. This face-to-face follow-up evaluation of the patient shall be conducted by either the attending physician or by another physician appointed to the facility medical staff as soon as possible, and not later than 24 hours following the initiation of the restraint or seclusion...
FACE-TO-FACE EVALUATION
1. A physician must conduct a face-to-face evaluation of the individual following the initiation of restraint or seclusion to personally verify the need for restraint or seclusion and to approve its continuation, if indicated.
A. The face-to-face evaluation must be conducted within one (1) hour following the initiation of restraint or seclusion.
2. A physician may delegate the face-to-face evaluation to a staff person:
A. Who is under the clinical supervision of a physician appointed to the medical staff and who is privileged to practice in the facility; and
B. Who is a physician assistant or an advanced practice nurse appointed to the medical staff and privileged to practice in the facility.
3. The physician, who delegates the face-to-face evaluation that is to be completed within one hour following the initiation of restraint or seclusion, must ensure that a physician performs a follow-up evaluation of the patient face-to-face. This face-to-face follow-up evaluation of the patient shall be conducted by either the attending physician or by another physician appointed to the facility medical staff as soon as possible, and not later than 24 hours following the initiation of the restraint or seclusion...
5. Documentation of the one (1) hour face to face will be a permanent part of the patient's medical record...
OBSERVATION, MONITORING AND CARE ...
5. Physician Assessment (Face-to-Face Evaluation) of the patient.
A. The face-to-face evaluation must be conducted within one (1) hour following the initiation of restraint or seclusion...
D. An authorized designee may complete the required face to face evaluation as defined by this policy and regulatory statutes."

The above findings were confirmed in an interview with the Dallas facility administrator the afternoon of 8/19/15 in the facility conference room.

Based on a review of documentation and interviews, the Dallas facility failed to ensure that each episode of restraint and seclusion was ordered by a physician and the facility failed to ensure that physician orders for restraint and seclusion included all required components, including specific behaviors constituting the behavioral emergency for 1 of 1 patient (Patient #23).

Findings included:

Review of the medical record for Patient #23 revealed the following:

Patient #23 was restrained on 03/29/15 from approximately 1448 to 1458 and secluded from 1458 until 1556. There was no physician signature on the order for restraint. The physician order did not describe the specific behaviors which constituted the behavioral emergency which resulted in the need for restraint. The line for "Specific Behavior Exhibited" was left blank on the order form.

Review of facility policy, "Emergency Behavioral Interventions: Use of Seclusion/Restraints" issued 8/11/2014, stated, in part,
"PHYSICIAN ORDER
1. A physician order from a member of the Hospital's medical staff is required for seclusion and/or restraint use as an emergency behavior management technique at Sundance Hospital. The physician's order for restraint or seclusion must:...
C. Describe the specific behaviors which constituted the emergency which resulted in the need for restraint or seclusion."

The above findings were confirmed in an interview with the Dallas facility administrator the afternoon of 08/19/15 in the facility conference room.

Based on a review of documentation and interview at the Dallas facility, face-to-face evaluations after patient restraint or seclusion for 2 of 2 patients (Patient #23 and Patient #24) were being conducted by 4 of 4 Registered Nurses, (Personnel #41, #42, #43 and Personnel #44) with no documented evidence of having completed specific training or competence demonstration in assessing medical and psychiatric stability as required by state law to qualify them to conduct a face-to-face evaluation of the individual within one hour following the initiation of restraint or seclusion to personally verify the need for restraint or seclusion.

Findings included:

Review of the medical record for Patient #23 revealed the following:

Patient #23 was secluded on 03/20/15 from 2330 to 2340. An RN without specific training or competence demonstration conducted the face-to-face evaluation.

Patient #23 was secluded on 03/20/15 from 2045 to 2105. An RN without specific training or competence demonstration conducted the face-to-face evaluation.

Patient #23 was secluded on 03/19/15 at the following times where an RN conducted the face-to-face evaluation despite lack of qualifications or training:
1155 - 1255
1420 - 1700
1850 - 2045
2330 - 0010
1137 - 1150

Review of the medical record for Patient #24 revealed that an RN without specific training or competence demonstration conducted the face-to-face evaluation for a seclusion episode which occurred on 06/15/15 at 1235.

Review of the personnel records for RNs performing face-to-face evaluations after restraint and seclusion (Personnel #41, #42, #43, and #44), revealed no documented evidence of specific training or competence demonstration in assessing medical and psychiatric stability to qualify them to conduct a face-to-face evaluation of the individual within one hour following the initiation of restraint or seclusion to personally verify the need for restraint or seclusion.

Review of facility policy, "Emergency Behavioral Interventions: Use of Seclusion/Restraints" issued 08/11/2014, stated, in part,
"8. Face-to-Face Evaluation. A physician must conduct a face-to-face evaluation of the individual following the initiation of restraint or seclusion to personally verify the need for restraint or seclusion and to approve its continuation, if indicated. The face-to-face evaluation must be conducted within one hour following the initiation of restraint or seclusion.
A. A physician may delegate this face-to-face evaluation to a staff person who is under the clinical supervision of a physician appointed to the medical staff and who is privileged to practice in the facility; and who is a physician assistant or an advanced practice nurse appointed to the medical staff and privileged to practice in the facility.
B. The physician, who delegates the face-to-face evaluation that is to be completed within one hour following the initiation of restraint or seclusion, must ensure that a physician performs a follow-up evaluation of the patient face-to- face. This face-to-face follow-up evaluation of the patient shall be conducted by either the attending physician or by another physician appointed to the facility medical staff as soon as possible, and not later than 24 hours following the initiation of the restraint or seclusion..."

Review of 25 Texas Administrative Code, Chapter 415.260(c)(1) revealed the following requirement:
"(c) Face-to-face evaluation. A physician, physician assistant as provided in paragraph (3) of this subsection, or a registered nurse who is trained and has demonstrated competence in assessing medical and psychiatric stability, other than the registered nurse who initiated the use of restraint or seclusion, shall conduct a face-to-face evaluation of the individual within one hour following the initiation of restraint or seclusion to personally verify the need for restraint or seclusion."

The above findings were confirmed in an interview with the Dallas facility administrator the afternoon of 08/19/15 in the facility conference room.

Based on observation, review of documentation and interviews, the facility failed to ensure that,

1) (Dallas facility) 1 of 1 patient (Patient #25) was not reasessed by a registered nurse at least every 12 hours. This presents a risk that patients will not receive necessary care as their needs have not been assessed;

2) (Dallas facility) RN's (Registered Nurses) were not assigned to the adult and/or adolescent units every shift for the months of 07/2015 and 08/2015 and current inpatients were not assessed/evaluated by an RN;

3) 1 of 1 patient (Patient #12) at the (Arlington facility) medical treatment for a fractured finger was delayed three days after x-ray results dated 08/14/15 were received. Registered nurses failed to evaluate and/or assess Patient #12's fractured 5th finger on the right hand.

Findings included:

1) Review of the record for Patient #25 revealed that the patient was admitted on 08/12/15 and discharged on 08/15/15. There was no documented evidence in the medical record of a nursing reassessment for the 7 am - 7 pm shift on 8/14/15 and for the 7 pm - 7 am shift on 8/14/15.

Review of facility policy, "Assessment and Reassessments of Patients, issued 8/11/2014, stated, in part, "(3) The RN Nursing Admission Assessment is completed within eight (8) hours of admission. (25 TAC 411.473 e.)...
Nursing Reassessments. An RN will reassess the patient based on the patient's needs, but at least every 12 hours after the initial comprehensive nursing assessment has been completed. (25 TAC 411.473 f.).
Assessment and reassessment patient information are documented in the patient's medical record and are permanent parts of the patient's medical record."


The above findings were confirmed in an interview the afternoon of 08/18/15 with the Dallas facility administrator in the facility conference room.



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2) During the hospital rounds on 08/19/15 on the Children/Adolescent unit at approximately 0930 observation revealed only one licensed vocational nurse (LVN) Personnel #51 on the unit. There was no RN present or assigned to the unit for supervision of nursing services. No registered nurse on the hospital unit could result in patient harm as a result of lack of supervision of nursing staff to ensure complete patient treatment.

On 08/19/15 at approximately 0930 hospital (LVN) Personnel #51 stated during an in-person interview "I'm the only nurse on the unit today. Most of the days I work here, I'm alone." Personnel #51 stated she works 12 hour shifts.

Hospital staffing schedules revealed the Children/Adolescent unit was staffed with only 1 licensed vocational nurse (LVN), Personnel #51 for the day shift on 08/19/15.

Review of hospital staffing schedules revealed the Adult unit was staffed with only 1 licensed vocational nurse (LVN) for 3 day shifts and 11 night shifts for 07/2015. The Adult unit was staffed with only 1 LVN for 2 days shifts and 6 night shifts on 08/1/15-08/19/15. There was no RN assigned to the unit for the shifts.

Review of hospital staffing schedules revealed the Children/Adolescent unit was staffed with only 1 licensed vocational nurse (LVN) for 27 day shifts and 30 night shifts for 07/2015. The Children/Adolescent unit was staffed with only 1 licensed vocational nurse (LVN) for 14 day shifts and 6 night shifts on 08/1/15-08/19/15.

Review of hospital policy titled "Services: Nursing" stated in part "...The RN will supervise and evaluate nursing care for each patient; and assign the nursing care to other nursing personnel in accordance with patient needs and staff qualifications and competency..."



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3) On 08/18/15 at approximately 1150 Patient #12 was observed in the patient dining room. Patient #12 had a long elastic wrap covering a white splint to the right hand/wrist.

The Behavioral Health Integrated Psychiatric Assessment dated 08/10/15 timed at 1140 reflected, "Patient transferred from...hospital...patient is suicidal and homicidial ideations with plan to shoot herself...history of suicidal ideations...attempt 2X (two times) OD (overdose)...poisoning and hanging self."

Patient #12's Restraint/Seclusion order/record dated 08/13/15 timed at 1220 reflected, "Patient states hit wall several days ago and right pinky finger hurts..." No nursing assessment of Patient #12's pinky finger was documented.

Patient #12's 08/13/15 physician's orders and directions timed at 1620 reflected, "x-ray of right 5th digit due to pain and swelling..."

Patient #12's 08/14/15 Right Hand x-ray results timed at 2037 reflected, "Two views of right hand dated 08/14/15 at 1900 hours demonstrate a nondisplaced fracture in the 5th metacarpal neck with minimal anterior angulation...soft tissue swelling is present..."

Patient #12's 08/15/15 and 08/16/15 nursing shift assessment and progress note revealed no documentation which indicated an assessment was completed for Patient #12's right fifth finger fracture.

Patient #12's physician orders and directions dated 08/16/15 timed at 1200 reflected, "Please transfer to ER...when able."

Patient #12's 08/17/15 nursing shift assessment and progress note not timed reflected, "Patient off unit to....hospital ER (emergency room) for right hand...at 1515...patient back on unit with wrap/splint on right hand says she has pain...at 2100...continues on Q15 (every fifteen minute) checks..." No documentation was found which indicated the nurse assessed Patient #12's right hand upon return from the hospital.

Patient #12's medical hospital discharge instructions dated 08/17/15 reflected, "Discharge instructions for a boxers fracture...ice bag, pillow...keep elevated, apply ice to affected area for 15-20 minutes, four times a day for several days...inspect skin around the cast or strapping daily...you will need to wear cast or keep finger (s) taped for 3-6 weeks...call doctor...swelling, pain, pale and/or blue fingers...numbeness or tingling..." No orders were found which addressed the medical hospital discharge instructions.

On 08/18/15 at 1535 Personnel #1 was interviewed. Personnel #1 was asked why it took so long for Patient #12 to be seen in the ER (emergency room) after the x-ray results for 08/14/15 were completed. Personnel #1 did not offer an explanation. Personnel #1 stated no documentation was found in the nursing notes which indicated Patient #12's fractured finger was assessed every shift and upon return 08/17/15 from the medical hospital.

On 08/18/15 at 1610 Personnel #30 was interviewed. Personnel #30 was asked to review Patient #12's medical record. Personnel #30 stated Patient #12's treatment for a fractured finger was delayed several days. Personnel #30 stated the x-ray results were completed 08/14/15 and Patient #12 did not go to the hospital until 08/17/15 for treatment.

Based on observation, interviews and record review, the hospital Dietary Director at the Dallas facility failed to adequately manage the daily operations of the dietary department in that,

1) The facility did not consistently implement first in and first out rotation system for all food items. Multiple food items were stored without dates in storage racks, refrigerator, and the pantry. The food items were available for patient use.

2) The facility did not comply with food service sanitation requirements as there was excessive dust on horizontal surfaces and grease build up on the grill, oven, and stove.

Findings included:

During a tour of the dietary department on 08/18/15 between 1425 and 1610 accompanied by hospital interim CEO (Personnel #7), dietary manager (Personnel #52), and system plant operational manager (Personnel #48) the following items were observed:

Multiple food items were observed without in and out dates: Storage racks; 24 loaves of bread, 7 packages of hamburger buns, refrigerator; 2 gallons of Mayonnaise, 2 gallons of orange juice, 6 3-liter bottles of ice tea. Pantry; 15 boxes of salt, 1 gallon bottle of Vanilla, 2 gallon bottles of red wine vinegar, 6 packages of pasta, 12 packages of gravy mix, 1 package of corn meal, 21 gelatin dessert packages, 6 pudding pie packages, 1 bottle of coffee creamer, 1 bottle of liquid butter.

The following opened items were stored without opened dates in: Refrigerator 1 gallon of green olives, 1 gallon of coleslaw dressing. Pantry; 1 large container of Kuiona, 1 package of corn meal and 1 box of oatmeal.

Observation of the dining room revealed excessive dust on the horizontal surfaces of the salad bar plastic covering, and the plastic cover over the warming trays. Excessive dust was observed in and hanging from the vents above the warming tray and serving area. Excessive dust was observed on the horizontal levels of the dishwasher. There was a buildup of old grease on the bottom oven racks. The grill had excessive old grease buildup on the sides and back and excessive burnt crumbs under the front of the grill racks. Excessive grease buildup was observed on the back bottom of stove burners.

Review of hospital policy titled "Director of Food and Nutritional Services/Job Description" stated in part "The director has the responsibility and authority for ensuring that...Satisfying meals are planned, prepared and served under high standards of sanitation and safety for patients and hospital personnel...Operates a department which meets or exceeds the standards set forth by federal, state and local regulatory agencies...""

On 08/18/15 at approximately 1445 during an in-person interview with hospital dietary manager Personnel #52. Personnel #52 stated she had reported to maintenance several times that the vents needed cleaning. When asked how often the oven and grill was cleaned, Personnel #52 stated "I clean the oven every week and clean the grill every month." Personnel #7, Personnel #52, and Personnel #48 confirmed the above findings in the dietary and dining room areas.

Based on a review of documents and interviews, the Dallas facility failed to conduct fire drills to ensure the safety of patients and employees. Not conducting fire drills puts the patients, employees and others at the facility at risk for not knowing how to respond in an emergency.

Findings included:

Review of facility policy entitled, "Fire Drill Policy (1038)", issued 09/15/2014, stated, in part, "All staff are required to participate in fire drills. Fire drills will be conducted periodically to assure patient and employee safety...Fire drills shall be conducted once per shift per quarter in each building defined as a healthcare occupancy minimum 12 per year...All least 50% of the drills conducted quarterly will be unannounced...All fire drills will be critiqued to the extend necessary to ensure that the hospital's fire plan aspects have been met."

Review of the fire drill documentation provided to the surveyor by Personnel #48, Plant Operations Manager on 8/18/15 revealed the following:

There were no drills documented for the 1st shift since the facility opened in January, 2015. There was 1 incident documented of a patient pulling the pull box by the stairwell on 04/11/15. There was no staff roster to indicate that staff participated. There was no critique of the drill or participant's discussion and review, evaluation, or whether follow up was required.
·
For the 2nd shift, there was only one drill documented on 03/26/15 with an attendance roster of staff participating and documented critique and evaluation. There were 3 incidents documented of the pull station being pulled on 01/9/15, 05/31/15, and 06/30/15, however there was no staff roster to indicate that staff participated in any of these events as a drill. There was no critique of the drill or participant's discussion and review, evaluation, or whether follow up was required.

In an interview the afternoon of 08/19/15 in the facility conference room, the Dallas Facility Administrator confirmed the above findings that fire drills had not been conducted once per shift per quarter to assure patient and employee safety.

Based on observation and interviews with staff, the Dallas facility failed to ensure hospital waste was properly managed and removed from the hospital property as 1 of 1 garbage dumpster was observed on multiple days of the survey with overflowing full garbage bags with open lids which could result in rodent activity and possible spread of disease.

Findings included:

During the Dallas hospital tour on the afternoon of 08/17/15, and the morning of 08/18/15 the hospital dumpster in the back of the facility was observed with overflowing full garbage bags and open lids.

During an in-person interview with the System Plant Ops Manager, Personnel #48 on the morning of 08/18/15, when asked about the overflowing trash dumpster, Personnel #48 stated "We are on a 1 day a week pick up. They pick up the trash on Wednesdays." Personnel #48 stated he was working on getting a request to the city to pick up the trash more days a week.

Based on interview and review of documentation, the Dallas facility failed to ensure that the person designated as the Infection Control Director (Personnel #40) was qualified to perform the duties of Infection control Director as the Infection Control Director had no training in Infection Control.

Findings included:

Review of personnel records for Personnel #40, Infection Control Director, revealed no documented evidence of training or other qualification in Infection Control.

Review of the Sundance Hospital Infection Control/Prevention Manual, approved on 02/24/15, stated, in part, "Responsibilities of the Infection Control Nurse (ICN) include...Assuming responsibility for self-education by reviewing current literature, attending workshops, seminars and formal courses."

Review of facility policy, "Infection Control Program Purpose" dated 9/8/2014, stated, in part, "1. The Infection Control Nurse or appointed designee will be responsible for the Infection Control Program at Sundance Hospital."

Review of the job description provided to the surveyors for Personnel #40, signed by Personnel #40 on 08/10/15 stated, in part, "The ADON will also serve as the infection control nurse and is responsible for coordinating the activities of the Facility's infection control program, by assuming direct responsibility for infection surveillance, infection control reporting, and provision of infection control technical support and education for the facility staff." The requirements for Infection Control include, but are not limited to, "II. Carry out periodic inspections to ensure that procedures for the control of infections are being followed correctly. III. Collect and maintain statistical data in regards to the identification and control of infections. IV. Coordinate closely with all departments to obtain information regarding patients and staff with suspected infections and ensuring control procedures are in place and adhered to...VI. Initiate discussion regarding possible epidemiological causes of illnesses, specifically the determination of nosocomial versus community acquired infections. VII. Contribute significantly to any interventions or recommendations made by the committee in response to the discussion about an illness...IV. Conduct periodic inspections to ensure that procedures for the control of infections are implemented and adhered to. Infection Control Reporting. I. Identify objectives for infection control monitoring, data collection and reporting. II. Prepare monthly reports to the Safety/Risk Management Committee, Infection Control Committee, Medical Staff Committee, and Nursing Administration Committee that includes data on infection rates by nursing units, site, and pathogen...VII Develop and implement continuously improved patient care procedures and control mechanisms relating to infectious diseases...IV. Evaluate and document the effectiveness of infection control activities. Infection Control Education and Consultation I. Participate in infection control education of all employees during orientation and annually thereafter, including classes in infection control practices and employee health. II. Act as a consultant in infection control for the Nursing Department by assisting with assessing patient infection control problems...IV. Coordinate with the Infection Control Committee to update and revise facility infection control policies, procedures and practices...VI Continuously monitor all infections, and investigate and report on unusual events. VII. Ensure the infection control procedures meet JCAHO, county and state guidelines. VIII. Organize Infection Control Committee meetings and maintain all meeting minutes."

In an interview with Personnel #7, Chief Executive Officer of the Dallas Hospital on the afternoon of 08/19/15 in the facility conference room, she stated that Personnel #40 had no training or other qualifications in infection control. Personnel #7 confirmed that Personnel #40 had no prior experience as an Infection Control Director. Personnel #7 stated that Personnel #40 would be attending Infection Control training in the near future.

Based on observation, interviews, and record review, the hospital's infection control officer or officers failed to develop an efficient system for identifying, reporting, and investigating potential sources of infections and potential communicable diseases in patients and personnel at the hospital's Arlington location in that,

1) The hospital environment was conducive to the spread of infections and food born illnesses and included soiled work surfaces, food items in close proximity to cleaning solutions, opened, unlabeled, and expired food items, and out of safety range food temperatures;

2) 5 of 6 current employees (Personnel #12, #54, #55, #57, and Personnel #58 did not have Tuberculosis screening completed within the last 12 months.

Findings included:

1) Observations on 08/17/15 at 1206 reflected ten patients ate their lunch meal in the patient dining area. In close proximity, a wall-mounted temperature control device did not have a cover and contained dust from sheet rock. The temperature read 85 degrees Fahrenheit. A glue trap was observed on the floor half-way behind the drink vending machine with a red M&M like candy next to it. Personnel #48 acknowledged the findings.

On 08/18/15 between 1011 and approximately 1150 the surveyors and Personnel #24 conducted a tour in the patient dining, food storage, and preparation areas. The condiment bins in the patient dining area had debris on the bottom. Multiple Styrofoam cups were uncovered on top of a soiled surface. The floor in front of the patient accessible coffee machine was sticky and had some debris on it. Employee #24 stated it needed "thorough cleaning."

The food preparation area reflected a red sanitation bucket with liquid next to six red bell peppers, a bag of bagels, and an open cup filled with an orange liquid which was identified by Personnel #18 as his personal drink. Personnel #18 acknowledged that his personal drink was in the refrigerator designated for patient coffee and tea. There was no documentation that the refrigerator temperature had been taken that morning.

The door to the supply room in the back of the kitchen was observed propped open with a Carbon Dioxide tank. One rolled up apron was observed on the floor, a second one was on a tea dispenser. A dust bin filled with debris was observed about one half inch away from the spigot of a container labeled "ice tea." Personnel #18 stated the ice tea container "should not be there [and] should have been picked up a long time ago."

A large pan was observed on the drying rack with water in it. Two pans on the drying rack were observed stacked wet. An unlabeled green and clear container with a coffee-creamer like substance was observed next to a sanitation pail on the shelf above the sink in the food preparation area. Personnel #18 acknowledged the unlabeled container.

Fourteen cartons of chocolate milk with an expiration date of 08/16/15 were observed ready to be served to patients. Personnel #18 acknowledged the finding and removed the cartons.

Unlabeled food items included a plastic bag of meat in the freezer. Food items observed in open and/or unlabeled containers in the kitchen's dry storage area included broken pretzel- like pieces, long spaghetti-type noodles, gingerbread streusel topping, and a cream-colored substance identified by Personnel #18 as "food thickener."

Storage bins with flour, sugar, rice, and potatoes in the dry goods storage area had debris on the top. A metal bowl was observed inside the flour bin. A six-pound-six-ounce can of tomatoes was dented. Personnel #18 removed the can.

A red potato was on the floor of the dirty dish area next to a container filled with a dark pink liquid labeled "sanitizer."

On 08/18/15 at 1145 Personnel #27 was observed taking food temperatures at the patient self-serve salad bar in the dining area. Personnel #27 stated the temperature "should be 38 [degrees Fahrenheit]." Personnel #27 took the following temperatures: shredded cheese (50.9 degrees), creamy broccoli salad (48 degrees), fruit salad (50.1 degrees), green melons (56 degrees), chicken salad (50 degrees). Temperature reading of the salad dressings included ranch (45.5 degrees), honey mustard (53.9 degrees) and Italian (54.1 degrees). Personnel #18 stated there was no ice underneath the salad bar food items because it was cooled electrically. The ambient air temperature in the dining room was 86 degrees Fahrenheit at that time.

The ambient air temperature in the dining room was 94 degrees Fahrenheit on 08/18/15 at 1630. This finding was witnessed at that time by Personnel #1.

An interview with Personnel #24 on 08/18/15 at approximately 12 noon reflected that infection control surveillance was done in chart review and unit surveillance. Personnel #24 stated the last infection control visit to the Arlington site was 05/18/15.

Record review of the infection control provider activity log noted the latest entry was dated 05/18/15.

The Infection Control Plan 2015 undated and unsigned, noted the policy to "maintain an infection control program to prevent, identify, and control any infection which may affect patients, personnel, or visitors by reviewing...and promoting screening, preventive, and corrective programs designed to minimize infectious processes."


2) Personnel #1 stated during an interview on 08/19/15 at 1401 that Personnel #54's last TB screening was completed in 09/2013, Personnel #55 was last screened for TB in 01/2014, and Personnel #58's last screening was in 06/2014.

Record review of employee files of Personnel #12 and #57 reflected no evidence of tuberculosis screening.

The Infection Control Report dated 05/18/15 reflected "TB [tuberculosis] compliance will be monitored for all employees."

Based on a review of documentation and interviews, the Dallas facility failed to ensure that initial treatment plans developed within 24 hours were based on the findings of the physical examination and the psychiatric evaluation; the facility failed to ensure that a list of all diagnoses to be treated at the hospital were included in the initial treatment plan; the facility failed to ensure that the initial treatment plan contained a list of the problems and needs to be addressed during a patient's hospitalization; the facility failed to ensure that initial treatment plans contained a description of all treatment interventions, including medications prescribed; the facility failed to ensure that initial treatment plans contained identification of the level of monitoring assigned to the patient; the facility failed to ensure that treatment plans contained a description of the clinical criteria for the patient to be discharged; and the facility failed to ensure that treatment plans contained a description of the recommended services and supports needed by the patient after discharge. These findings could result in inadequate care of the patient's physical and psychiatric needs.

Findings included:

Review of facility policy, "Treatment Plan: Interdisciplinary Treatment Planning/Master Treatment Plan" issued 8/11/2014, stated, in part,
"1. An initial interdisciplinary treatment team planning session will take place at the first scheduled treatment team meeting session after the patient's admission. Subsequent interdisciplinary treatment team meetings will be held to update and modify the individual treatment plan of each patient as warranted.
2. In collaboration with the patient and/or the patient's legally authorized representative (LAR), the inpatient treatment team staff shall begin to develop and implement a written treatment plan within 24 hours after the patient's admission. If the patient is unable or unwilling to collaborate with the hospital, the circumstances of such inability or unwillingness shall be documented in the patient's medical record.
3. The treatment plan shall be based on the findings of: the physical examination, the psychiatric evaluation; the intake assessment, and the comprehensive nursing admission assessment.
4. The treatment plan shall contain:
A. A list of diagnoses for the patient with notation as to which diagnoses will be treated at the hospital including:
(1) At least one mental illness diagnosis;
(2) Any substance use disorder diagnoses; and
(3) Any non-psychiatric conditions:
B. A list of problems and needs that are to be addressed during the patient's hospitalization;
C. A description of treatment interventions intended to address the patient's problems and needs, including the medication(s) prescribed and the symptoms each medication is intended to address...
E. Identification of the level of monitoring assigned to the patient; and...
5. Within 72 hours of the patient's admission the inpatient staff shall:
E. Add to the treatment plan...
(5) A description of the clinical criteria for the patient to be discharged; and
(6) A description of the recommended services and supports needed by the patient after discharge."

Review of facility policy, "History and Physical Examination" issued 8/11/2014, stated, in part,"1. A completed history and physical (H&P) examination is completed within twenty-four (24) hours of admission."

Review of the medical record for Patient #23 revealed the initial treatment plan was written on 03/18/15. The plan did not incorporate the findings of the History and Physical Examination (conducted on 03/19/15 at 1300) and the Psychiatric Evaluation (conducted on 03/19/15).

Review of the medical record for Patient #23 revealed that the initial treatment plan did not contain at least one mental illness diagnosis and did not contain non-psychiatric conditions. The Psychiatric Evaluation and the History and Physical Examination both stated that the patient had been raped two days before admission, including "polymyalgia s/p assault/rape", however this was not included on the initial treatment plan. The Initial Nursing Assessment Skin assessment indicated that Patient #23 had 8 bruises over her body, yet this was not included on the initial treatment plan.

Review of the initial treatment plan for Patient #23 revealed that there was no list of problems and needs that were to be addressed during the patient's hospitalization. The History and Physical Examination stated that the patient had been raped two days before admission, including Axis III diagnosis of "polymyalgia s/p assault/rape," however this was not included on the initial treatment plan. The Initial Nursing Assessment Skin assessment indicated that Patient #23 had 8 bruises over her body, yet this was not included on the initial treatment plan. The Psychiatric Evaluation for Patient #23 included a diagnosis of Bipolar I disorder, current episode manic, severe, which was not included in the initial treatment plan as a problem to be addressed during the patient's hospitalization.

Review of the medical record for Patient #23 revealed no documented evidence of treatment interventions to address the patient's problems and needs on the initial treatment plan. Medications prescribed at admission for Patient #23 included Ambien for sleep, Lithium ER for mood, Seroquel for sleep/mood, and Trileptal for mood. These medications were not included on the initial treatment plan.

Review of the medical record for Patient #24 revealed the initial treatment plan was written on 06/10/15 at 0220. The plan did not incorporate the findings of the History and Physical Examination (conducted on 06/10/15 at 1310) and the Psychiatric Evaluation (conducted on 06/11/15 at 1630).

Review of the medical record for Patient #24 revealed that the initial treatment plan did not contain non-psychiatric conditions, including lower extremity bruising noted on the initial nursing assessment.

Review of the medical record for Patient #24 revealed that medication prescribed at admission for Patient #24, Lexapro, was not included on the initial treatment plan.

Review of the medical record for Patient #25 revealed the initial treatment plan was written on 08/12/15 at 0030. The plan did not incorporate the findings of the History and Physical Examination (conducted on 08/12/15 at 1310) and the Psychiatric Evaluation (conducted on 06/11/15 at 1630).

Review of the medical record for Patient #25 revealed that medication prescribed at admission for Patient #25, Depakote, was not included on the initial treatment plan.

Review of the medical record for Patient #25 revealed no documented evidence in the treatment plan of a description of the clinical criteria for the patient to be discharged.

Review of the medical record for Patient #25 revealed no documented evidence in the treatment plan of a description of the recommended services and supports needed by the patient after discharge.

Review of the medical record for Patient #26 revealed the initial treatment plan was written on 08/4/15 at 0700. The plan did not incorporate the findings of the History and Physical Examination (conducted on 08/5/15 at 1300) and the Psychiatric Evaluation (conducted on 08/5/15).

Review of the medical record for Patient #26 revealed that medication prescribed at admission for Patient #26, Effexor, Klonopin, Paxil, and Seroquel were not included on the initial treatment plan.

Review of the medical record for Patient #28 revealed the initial treatment plan was written on 08/18/15 at 0130. The plan did not incorporate the findings of the History and Physical Examination (conducted on 08/18/15 at 1350) and the Psychiatric Evaluation (conducted on 08/18/15).

Review of the medical record for Patient #28 revealed that medication prescribed at admission for Patient #28, Ambien, Lithium and Neurontin were not included on the initial treatment plan.

Review of the medical record for Patient #29 revealed that he was admitted on 08/16/15. There was no documented evidence in the medical record of an initial treatment plan for Patient #29. The form entitled, "Sundance Hospital Initial Treatment Plan" was included in the medical record; however the form was completely blank.

Review of the medical records for Patients #23, 24, 25, 26, 28 revealed no documented evidence of the level of monitoring assigned.

The above findings were confirmed in an interview the afternoon of 08/18/15 with the Dallas facility administrator in the facility conference room.

Based on a review of documentation and interview, the Dallas facility failed to ensure that 2 of 2 patients (Patient #24 and Patient #25) who had been discharged had a discharge summary.

Findings included:

Review of the record for Patient #24, discharged on 06/16/15, revealed no documented evidence of a completed discharge summary. The discharge summary form in the medical record was blank and not completed.

Review of the record for Patient #25, discharged on 08/15/15, revealed no documented evidence of a completed discharge summary. The discharge summary form in the medical record was blank and not completed.

The above findings were confirmed in an interview with the Dallas facility administrator the afternoon of 08/19/15 in the facility conference room.

Based on record review and interviews, the Dallas facility failed to have an effective DON (Director of Nurses) that developed and implemented a written staffing plan that described the number of Registered Nurses (RNs), Licensed Vocational Nurses (LVNs), and Unlicensed Assistive Personnel (UAPs) on each unit for each shift. The interim Director of Nursing (DON), Personnel #40, was not effective because of having to work on the units as the charge nurse due to the shortage of nurses at the Dallas facility. This resulted in an ineffective nursing services program.
Findings Included:
Review of the hospital policy titled "Staffing: Nursing Plan" stated in part "The Chief Nursing Officer (CNO) and the Chief Executive Officer for the Hospital are responsible for determining the types and number of nursing personnel and staff necessary to provide patient care for all areas of the hospital...The staffing plan for Nursing Services is designed to comply with all standards of the Texas Nurse Practice Act and Nursing Peer Review Act of the Texas Board of Nurse Examiners...2. There is an adequate number of RNs, LVNs and other personnel to provide safe nursing care to the patients..."

Review of hospital staffing guidelines titled "Inpatient Behavior Health Services Department Staffing Pattern Guidelines" stated in part "To adequately provide the above services to the patient population, the Inpatient Behavior Health Services Department follows the staffing patterns noted below for startup operational services..." The chart stated in part for the "Day Shift Monday - Friday 0645 to 1515, Required Staff (Core Staff ) 1-RN and 1-MHT; Evening Shift Monday-Friday 1445-2315, Required Staff (Core Staff ) 1-RN, 1-2 -MHTs; Night Shift Monday - Friday 2245-0715, Required Staff (Core Staff ) 1-RN, 2-MHTs, Day Shift Saturday-Sunday 0700-1915, Required Staff (Core Staff ) 1-RN, 1-2 MHTs; Night Shift Saturday-Sunday 1845-0715, Required Staff (Core Staff ) 1-RN, 2 MHTs" This document was signed by the members of the governing body on 2/24/15.

During an interview with the Interim Director of Nursing (DON), Personnel #40 on 8/18/15 at approximately 1630, Personnel #40 stated "I'm supposed to work the 7-3 shift. I started the first week of August. I stepped up to take the DON position but I haven't been able to do that job because I've been working on the units."

Based on observation, record review, and interviews the Dallas facility hospital failed to develop a nurse staffing plan based on the characteristics of patients, including the intensity of the patient's emotional, mental, and medical needs. The Interim Director of Nursing (DON), Personnel #40 was not effective because of having to work on the units as the charge nurse due to the shortage of nurses at the Dallas facility. The lack of an effective nursing services program could potentially result in inadequate care of patients as a result of insufficient nurse staffing on units and possible medication administration delays and medication errors for patients. Unlocked medication refrigerators that contained vials of controlled substances could result in potential controlled substances diversions. Absence of nurse initials for medications scheduled for 0900 for 12 of 18 patients could cause possible medication errors to patients. The facility failed to ensure safe temperature monitoring of patient food and nutrition refrigerators on 2 of 2 patient units which could cause potential food borne illnesses to patients.

Findings included:

During hospital rounds on the Children/Adolescent unit on 08/18/15 at approximately 1640 accompanied by interim Director of Nursing (DON), Personnel #40, the surveyor observed an unlocked medication refrigerator in the medication room that contained nine vials of Lorazepam (controlled substance). Personnel #40 locked the medication refrigerator after a narcotic count was performed between the surveyor and Personnel #40. Personnel #40 verified the medication refrigerator that contained controlled substances was unlocked.

During hospital rounds on the Adult unit on 08/19/15 at approximately 1005 accompanied by the Interim Director of Nursing (DON), Personnel # #40 and Interim Chief Executive Officer (CEO), Personnel #7 the surveyor observed an unlocked medication refrigerator in the medication room that contained eight vials of Lorazepam (controlled substance). Also, observed in the medication refrigerator were two prefilled syringes with no medication name and no dosage. Personnel #40 locked the medication refrigerator after a narcotic count was performed between the surveyor and Personnel #40. Surveyor and Personnel #7 observed Personnel #40 wasting the medication in the 2 prefilled syringes in the sink. Personnel #40 locked the medication refrigerator after a narcotic count was performed between the surveyor and Personnel #40.

During an in-person interview with Personnel #40 on 08/19/15 at approximately 1005 when asked what was in the pre-filled syringes, Personnel #40 stated "I don't know." Personnel #40 and Personnel #7 verified the above findings. During an in-person interview with the hospital Pharmacist, Personnel #10 on 08/19/15 at approximately 1150, when asked if she knew anything about the 2 prefilled syringes in the medication refrigerator on the Adult unit, Personnel #10 stated "I remember being there when the nurse pulled the medicine. A patient was getting out of control. I told them if they didn't give the medicine they had to waste it."

During hospital rounds on the Adult unit on 08/19/15 at approximately 1430 record review of individual patient Medication Administration Records (MARs) revealed no nurse initials for medications scheduled for 0900 for the following 12 patients: #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, and #42.

During an in-person interview with Personnel #49 on 8/19/15 at approximately 1440 when asked if the 0900 medications were given to the patients Staff #49 stated "Yes. I gave the morning meds." Personnel #49 verified the absence of her initials on the above patients' MARs for the 0900 medications.

During a tour of the Dallas facility on 08/17/15 at approximately 1330 accompanied by the interim Chief Executive Officer, CEO, observation revealed a refrigerator on the second floor with a packaged ham sandwich labeled 08/16/15 available for patient use.


Review of the second floor food refrigerator log revealed temperatures had not been recorded for the dates of 8/9/15, 8/10/15, 8/12/15, 8/15/15, and 8/17/15. Observation of the patient food refrigerator on the third floor revealed temperatures had not been recorded for dates of 8/14/15 and 8/15/15. The interim Chief Executive Officer, CEO, Personnel #7 verified the above findings.

Review of the hospital policy titled "Staffing: Nursing Plan" stated in part "The Chief Nursing Officer (CNO) and the Chief Executive Officer for the Hospital are responsible for determining the types and number of nursing personnel and staff necessary to provide patient care for all areas of the hospital...The CNO assures that there is adequate orientation, supervision and evaluation of clinical activities of the nonemployee nursing personnel utilized by the hospital as well as all hospital nursing staff..."

Review of hospital policy titled "Medication Administration" stated in part "Medication Administration Record (MAR)...Nurses will document medications that are administered to patients on the MAR, and note their administration by their initial at the time of administration. Signatures shall validate the initial of the nurse on the MAR..."

Review of hospital policy titled "Medication Administration Record (MAR)" stated in part "Documenting Medication Given: Medication documentation is recorded on the Medication Administration (MAR) for patients receiving medications on an Inpatient Nursing Unit. 1) The nurse will initial each medication given on the MAR..."

Review of hospital policy titled "Medications: Notification, Verification and Error Prevention" noted in part "J. When medications are drawn up in syringe and not given immediately, the syringe is labeled with: patient name, medication name, strength, amount (if not apparent from the container), expiration date when not used within 24 hours, expiration time when expiration occurs in less than 24 hours, date prepared...(compounded intravenous admixtures and parental nutrition formulas)..."

Review of facility policy titled "Refrigerator Temperature Monitoring" stated in part "To ensure safe storage for laboratory specimens, food and nutrition products, and medications on the patient care units. All refrigerators will be checked twice daily to ensure that the temperature remains at a consistently safe level...2. Food storage refrigerators: A. The Day Shift and Night Shift Mental Health Technicians will check the refrigerators twice daily, and record the temperature on the Temperature Log..."