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Based on record reviews and interviews, the hospital failed to ensure all patients were admitted to the hospital only on the recommendation of a licensed practitioner. This deficient practice was evidenced by failing to consult a provider to make a final decision for admission or denial for 1 (#1) of 3 (#1, #2, #3) patient records reviewed.

Findings:

Review of the hospital's policy titled "301 Admissions & Exclusionary Criteria" revised 08/2023, revealed in part, Referrals for Admission: 2.) All admissions to the facility are screened by the Admissions Department and Director of Nursing for clinical appropriateness. The on-call physician / practitioner is contacted by the admissions personnel or RN Charge Nurse, depending on the time of the referral, for admission approval and admit orders.

Review of Patient #1's medical record revealed an admission date of 06/07/2024. Review of the admit orders dated 06/07/2024 at 12:00 p.m. revealed the admission diagnosis was blank, the VORB practitioner line was blank, date of order and time were blank, the nurse signature line was blank, and the licensed practitioner's signature line was blank with no date or time. Review of the close observation (Q15 Min Checks) not dated revealed in part, 12:15 p.m. admit and 2:15 p.m. discharge. There was a note at the bottom of this observation sheet stating Patient #1 was in intake room for the hour he was here. Review of the multidisciplinary note dated 06/07/2024 at 12:15 p.m. revealed in part, Patient #1 arrived via ambulance.

In an interview on 07/11/2024 at 10:14 a.m. S1DON stated either himself or the charge RN accepts patients for evaluations for admission. S1DON stated if the patient meets the admission criteria, then that patient comes to the hospital for an evaluation. S1DON stated then the nursing assessment process starts. S1DON stated then the physician is contacted for admission of the patient. S1DON stated once Patient #1 arrived at this hospital that was when the psychiatrist was contacted to accept Patient #1 for admission.

In a phone interview on 07/11/2024 at 1:15 p.m. S2Psych stated generally they call and run information by the staff of the hospital and they accept the patient. S2Psych stated obviously Patient #1 should not have been accepted here. S2Psych stated he was contacted about Patient #1 after Patient #1 arrived to this hospital.

In an interview on 07/15/2024 at 1:39 p.m. S1DON stated Patient #1 should have been wheeled on the stretcher to the seclusion room with enough staff to secure Patient #1 in restraints to get Patient #1 off the EMS stretcher. S1DON verified Patient #1 would have been safer at Mercy Behavioral Hospital than being transferred back to Hospital 'A' emergency department. After reviewing the admission criteria policy, S1DON verified that Patient #1 did meet admission criteria and did not meet any exclusionary criteria.

In a phone interview on 07/15/2024 at 3:10 p.m. S3UR stated she notified S1DON. S3UR stated S1DON made the decision to accept Patient #1 into this hospital.

Based on record reviews and interviews, the hospital failed to ensure patients received care in a safe setting. This deficient practice was evidenced by:

1.) failing to accompany a discharged patient to his/her car as per hospital policy and allowing the patient to walk to a nearby gas station to wait on a ride for 1 (#2) of 3 (#1, #2, #3) patient records reviewed; and

2.) failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients for ligature risks and safety risks.

Findings:

1.) Failing to accompany a discharged patient to his/her car as per hospital policy and allowing the patient to walk to a nearby gas station to wait on a ride for 1 (#2) of 3 (#1, #2, #3) patient records reviewed.

Review of the hospital's policy titled "311 Patient Discharges" revised 06/2024, revealed in part, the patient must be accompanied by a nursing staff member or a designee to his/her car.

Review of Patient #2's medical record revealed an admission and discharge date of 06/07/2024. Review of the physician's orders revealed an order dated 06/07/2024 at 2:30 p.m. Per S2Psych Okay to discharge patient once job is confirmed telephone order read back S2Psych / S4RN. Further review of Patient #2's medical record revealed a nurse's note dated 06/07/2024 at 5:00 p.m. Job confirmed and patient signed non SI contract. S2Psych notified. Patient requested to walk and meet his ride at the gas station. Patient discharged at 5:50 p.m.

In an interview on 07/11/2024 at 10:55 a.m. S4RN stated Patient #2 called his ride to come get him. S4RN stated Patient #2 told her he didn't want to wait on his ride. S4RN stated she told Patient #2 that he could walk to the gas station to wait for his ride.

In an interview on 07/15/2024 at 2:10 p.m. S1DON verified Patient #2 was not accompanied by a hospital staff member and was allowed to walk to a nearby gas station.

2.) Failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients for ligature risks and safety risks.

Review of the hospital's policy titled "908 Contraband & Restricted Articles" revised 06/2024, revealed in part, To ensure a safe environment and to provide a monitoring system for patients who are utilizing sharps or items designated as contraband. Items considered to be restricted:
Knives (all types); Glass, mirrors and metal picture frames; Plastics (plastic garbage bags & plastic utensils); Ceramics, pottery, cosmetics with sharp attachments; Scissors, razor blades, nail files, metal combs; Coat hangers; Personal hairdryers, curling irons; Electric razors with cord attachments; Tape players with recording devices and record players; All medications; Other potentially sharp objects; Lighters, matches; Cameras; Clothing items deemed potentially dangerous such as belts, cords, and long shoelaces; Cell phones

Observation on 07/10/2024 at 10:15 a.m. - 11:13 a.m. of the inpatient unit accompanied by S1DON revealed the following:

Room 'g': there was a plastic spoon on the nightstand
Room 'b': there was a plastic cracker packaging on the nightstand

In an interview during the observation S1DON verified the above stated findings. S1DON stated the above stated items should not be in patient rooms.

Based on record reviews and interviews, the hospital failed to ensure the use of restraints was in accordance with the order of a physician or other licensed independent practitioner who was responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This deficient practice was evidenced by failing to obtain a physician's order for the use of restraints for 1 (#1) of 3 (#1, #2, #3) patients reviewed.

Findings:

Review of Patient #1's medical record revealed an admission date of 06/07/2024. Review of the multidisciplinary note dated 06/07/2024 at 12:15 p.m. revealed in part, S4RN called all staff for help due to the patient being in 4 point restraints and still launching his upper body off the stretcher. After attempting to calm the patient down, S2Psych was notified of patient arrival and current situation. PRN orders was given at this time. Haldol 15mg IM, Ativan 4mg IM, and Benadryl 50mg IM. Patient #1 remained on stretcher in 4 point restraint due to patient being extremely combative with EMT and staff. IM injection was given at 12:25 p.m. by LPN. We again attempted to calm patient down and waited on injection to take effect approximately 40 minutes (injection was ineffective). EMTs could not release patient out restraints due to patient trying to flip stretcher.

In an interview on 07/10/2024 at 12:27 p.m. S1DON stated Patient #1 was in soft restraints and stretcher belts were in place upon arrival. S1DON stated Patient #1 was not released from the soft restraints or taken off the stretcher at this hospital.

In an interview on 07/11/2024 at 10:31 a.m. S4RN stated EMS asked her if she had more staff to help with Patient #1. S4RN stated EMS told her that Patient #1 was very combative and had already head-butted the EMT girl. S4RN stated EMS brought Patient #1 into the hospital via stretcher. S4RN stated Patient #1 was very combative, trying to flip the stretcher. S4RN stated Patient #1 was in 4 point restraints.

In an interview on 07/15/2024 at 1:39 p.m. S1DON verified there was no documentation of an order for restraints in Patient #1's medical record.

Based on record reviews and interview, the hospital failed to ensure medical records contained accurate information related to patient name and date of birth for 1 (#2) of 3 (#1, #2, #3) patients reviewed.

Findings:

Review of the hospital's policy titled "1102 Authentication of Medical Records" revised 06/2024, revealed in part, It is the responsibility of the Coordinator of the Health Information Management Department to assure authenticity and integrity of the medical record of discharged patients within 30 days post-discharge. Medical records are completed within 30 days post-discharge and that medical records are accurate for clients assessed, cared for, treated, or served.

Review of Patient #2's medical record revealed an admission date of 06/07/2024 and a discharge date of 06/07/2024. Review of the face sheet revealed Patient #2's date of birth was 09/20/2000. Further review revealed the patient labels that were on majority of the pages of Patient #2's medical record revealed Patient #2's date of birth as 06/26/1992. Review of Patient #2's psychiatric evaluation dated 06/07/2024 revealed Patient #2's last name was incorrect. Further review revealed Patient #2's date of birth as 09/01/2000.

In an interview on 07/10/2024 at 3:21 p.m. S1DON verified Patient #2's name and date of birth was correct on the face sheet. S1DON verified Patient #2's date of birth was incorrect on the patient labels that were on majority of the pages of Patient #2's medical record. S1DON verified Patient #2's last name and date of birth were incorrect on Patient #2's psychiatric evaluation.

Based on record reviews and interviews, the hospital failed to ensure that all orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner for 2 (#1, #2) of 3 (#1, #2, #3) patient records reviewed.

Findings:

Review of the hospital's Medical Staff Bylaws & Rules and Regulations revealed in part, all orders for treatment shall be in writing. A verbal order shall be considered to be in writing if dictated to a licensed professional nurse functioning within his sphere of competency and signed by the responsible practitioner. The appropriately authorized person receiving dictation shall sign all orders dictated over the telephone with the name of the Practitioner dictating per his approval. The responsible Practitioner shall authenticate such orders within ten (10) days, and failure to do so shall be brought to the attention of the Medical Executive Committee for appropriate action.

Review of the hospital's policy titled "402 Medication & Treatment Orders" adopted date 05/2024, revealed in part, Verbal/Telephone Orders: The prescribing practitioner must date, time, and authenticate the verbal order within ten (10) days as designated by state law.

Patient #1
Review of Patient #1's medical record revealed an admission date of 06/07/2024. Review of the admit orders dated 06/07/2024 at 12:00 p.m. revealed the admit orders were not signed by the licensed practitioner. Further review of Patient #1's medical record revealed an order for Haldol 15mg IM, Ativan 4mg IM, Benadryl 50mg IM Q4h PRN for agitation/psychosis telephone order read back S2Psych / S4RN. This order was not signed by S2Psych.

In an interview on 07/10/2024 at 1:40 p.m. S1DON verified the telephone order for the PRN medication that was administered to Patient #1 was not signed by the physician.

In an interview on 07/10/2024 at 1:58 p.m. S1DON verified the physician has 10 days to sign orders.

In an interview on 07/15/2024 at 1:39 p.m. S1DON verified there were no documented signatures on the admission orders.

Patient #2
Review of Patient #2's medical record revealed an admission date of 06/07/2024. Review of the admit orders dated 06/07/2024 1:30 p.m. revealed the admit orders were not signed by the licensed practitioner. Further review of Patient #2's medical record revealed an order dated 06/07/2024 at 1:50 p.m. New Admit with OPC/FVA hx of bipolar. This order was not signed by the licensed practitioner. Order dated 06/07/2024 at 2:30 p.m. Per S2Psych Okay to discharge patient once job is confirmed. Telephone order read back S2Psych / S4RN. This order was not signed by S2Psych.

In an interview on 07/10/2024 at 3:21 p.m. S1DON verified the physician orders in Patient #2's medical record were not signed by the physician.

Based on observation and interview, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors.

Findings:

Observation on 07/10/2024 at 10:15 a.m. - 11:13 a.m. of the inpatient unit accompanied by S1DON revealed the following:

Dayroom A: there were 4 floor tiles broken in the middle of the room
Male Shower Room: there were 2 tiles missing from the baseboard
Room 'f': there was peeling paint on the wall near the head of the patient bed

In an interview during the observation S1DON verified the above stated findings.

Based on observation, record review, and interview, the infection control officer failed to ensure the hospital's system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel was implemented. This deficient practice was evidenced by failing to maintain a sanitary environment.

Findings:

Review of the hospital's policy titled "515 Environmental Services" revised 06/2024, revealed in part, To control the spread of infection within the hospital, the hospital will maintain a thoroughly clean and safe environment. All patient and non-patient rooms shall be thoroughly cleaned and disinfected, keeping in mind Standard Precautions and Infection Control.

Observation on 07/10/2024 at 10:15 a.m. - 11:13 a.m. of the inpatient unit accompanied by S1DON revealed the following:

Dayroom A: there was popcorn on the floor next to a chair and other debris in multiple areas on the floor
Dayroom B: there was a wet puddle of liquid on the table and the floor and debris in multiple areas on the floor
Room 'a': small area of liquid on the floor
Room 'b': multiple rust areas and rusted screws to the cover of the air conditioner
Room 'c': there was a dead bug located under the patient mattress of side B and a live bug located under the patient mattress of side A
Room "d': rust areas to the cover of the air conditioner
Room 'e': rust areas to the cover of the air conditioner
Room 'f': there was a dead bug located under the patient mattress of side B

In an interview during the observation S1DON verified the above stated findings.

Based on record review and interview, the hospital failed to ensure an admitting diagnosis was made on every patient at the time of admission, and include the diagnosis of intercurrent diseases as well as the psychiatric diagnosis. This deficient practice was evidenced by failing to document an admitting diagnosis on every patient at the time of admission for 1 (#1) of 3 (#1, #2, #3) patients reviewed.

Findings:

Review of Patient #1's medical record revealed an admission date of 06/07/2024. Review of the admit orders dated 06/07/2024 at 12:00 p.m. failed to reveal an admission diagnosis.

In an interview on 07/10/2024 at 1:40 p.m. S1DON verified the admission diagnosis on the admission orders was blank. S1DON stated "they did not put one."