HospitalInspections.org

Based on record review and interview the hospital failed to meet the Condition of Participation of Governing Body as evidenced by the governing body allowing the hospital admission criteria to be changed from providing care and services to patients who require long term acute care services to only providing care and services to patients with mental conditions without prior notice or approval to the appropriate licensing and certification agencies. The hospital is certified to provide long term acute care services and is not certified as a psychiatric hospital.

Findings:

Review of the admission criteria, dated June 2009, that is currently in use at the hospital revealed the following: "Subject: Admission Criteria: Patient Rights/Organization Ethics. Policy: It is the policy of the Hospital to admit patients whose mental condition warrants acute, inpatient psychiatric care....Purpose. To establish the criteria for appropriate admission to the hospital. Procedure. 1) The Administrator/Director of Nursing or his/her designee will administratively screen patients for evidence of acceptable conditions of admission. This screening can occur concurrently or retrospectively. 2) All admissions require a written admission order by a psychiatrist with medical staff privileges. 3) Patients who show evidence of symptoms of acute psychiatric disorders will be accepted for admission if they are medically cleared. Such conditions include but are not limited to: a) Suicide attempt or risk. b) Homicide ideation, intent, or risk of violent/assaultive behavior as a result of a psychiatric disorder. c) Psychiatric symptoms such as hallucinations, delusions, catatonia, mania, depression which are severe enough to cause disordered/bizarre behavior or psychomotor agitation or retardation resulting in functional problems in daily living. d) Self-destructive or self-mutilative behavior. e) Memory impairment and/or disorientation that might endanger welfare of self or others. f) Inability to maintain adequate nutrition, severe enough to threaten life or vital body functions. g) Mental disorders not responding to outpatient therapy or non-compliance with outpatient therapy resulting in severe psychiatric symptoms. h) Patients with chronic, organic mental conditions who are also experiencing severe psychiatric symptoms such as psychosis or disordered/bizarre behavior. l) Patients who are deemed gravely disabled.

Contraindications to Admission. 1. Patients with a primary diagnosis of alcoholism or substance abuse. 2. Uncomplicated brain dysfunction/dementia or Alzheimer's type with no psychiatric symptomology.

Medical Clearance prior to admission. Patients must be medically stable prior to admission. The attending psychiatrist will evaluate the appropriateness of all potential patients. Patient's medical conditions must allow for the rigorous schedule of the program. Conditions that would prevent participation in group activity would prevent admission.

Conditions that may prevent medical clearance include but are not limited to the following: a) Patients requiring skilled and/or extensive nursing care; however, an exception could be made if the Director of Nurses and the Medical Director agree that staffing and the integrity of the program could handle the care; b) Patients immediately post-operative from major surgical procedures; c)patients with active communicable disease and infectious processes requiring isolation; d) patients in comas; e) Patients with acute head injuries (evaluated by case); f) patients with acute, bold, cardiac conditions; g) patients in acute renal crisis; and h) patients with recent extensive CVA's (cerebral vascular accidents) with diminished cognitive ability that would prohibit participate (sp?) in the therapeutic milieu. i) Patients with respiratory conditions that require management beyond supplemental oxygen and or nebulizer treatments. j) Patients requiring blood or blood product transfusions."


In a telephone interview at 8:40 a.m. on 06/16/10 with S3CEO, Acting Administrator and voting member of hospital "c"s Governing Body, she stated that hospital "c" had subleased the second floor from the licensed hospital, Promised Hospital of Gonzales on 03/22/10. She reported hospital "c" began functioning as a Psychiatric Hospital on 3/22/19. She indicated the admission criteria currently in use since June 2009 excludes the admission of those patients who would normally be admitted to a long term acute care hospital (LTAC). She stated that "it is not the intention nor will the hospital (hospital "c") admit regular LTAC patients". Hospital " c " subleased the second floor of the building that was leased to Promise Hospital of Gonzales. Hospital " c " has been operating under Promise Hospital of Gonzales ' state license number since 3/22/10. Promise Hospital of Gonzales is in the process of a CHOW. There is no documented evidence on the licensure renewal application submitted to state agency that it had a change in ownership, change in services (Psychiatric Services) and/or name change, (hospital " c " ). Promise Hospital of Gonzales is not licensed to provide Psychiatric Services with the state agency. Hospital " c " presented the surveyors on 06/16/10 at 9:30 a.m. a lease agreement between Hospital " c " and Promise Hospital of Gonzales. This agreement revealed Hospital " c " was subleasing the second floor of Promise Hospital of Gonzales on 3/22/10. Promise Hospital had leased the entire building from the Acension Parish Hospital District. Page 6 item #10 on this lease read, " ...Use of Premises. Sublessee may only use and occupy the Premises for the operation of a psychiatric hospital...".

Review of a lease agreement on 06/16/10 at 9:30 a.m. revealed that on 03/22/10 Seaside Health System subleased the second floor of Promise Hospital. Promise Hospital had a lease for the entire building from the Acension Parish Hospital District. Page 6 item #10 reads: "Use of Premises. Sublessee may only use and occupy the Premises for the operation of a psychiatric hospital....."

In an interview on 06/10/10 at 3:20 p.m. with S2Administrator he stated that the hospital has been actively marketing the hospital as a geriatric psychiatric hospital. He further stated that there are 2 employees visiting Emergency Rooms, Nursing Homes,Coroner's Office and IOP's. (Intensive Outpatient facilities) The Administrator provided a copy of a brochure titled "Seaside Health System" with the address listed as 615 East Worthey Street, Gonzales, Louisiana 70737. Review of the brochure revealed in part: "Seaside Health System specializes in the treatment of emotional and behavioral disturbances in the Older Adult population....."

Review of a Seaside Health System policy titled "Admission Criteria", policy number 1.5, no date adopted or last revised, reads in part: "Policy. It is the policy of the hospital to admit patients whose mental condition warrants acute, inpatient psychiatric care...."

Review of the medicare certification information for Promise Hospital of Gonzales revealed that the hospital has not been certified as a psychiatric hospital and still maintains certification as a long term acute care hospital.

Based on interview the hospital failed to meet the Condition of Participation of Patient Rights by:

1) failing to ensure that patients with psychiatric diagnoses who were being treated in the hospital were in a safe and controlled setting by failing to maintain constant monitoring of 4 Fire Exits which were unlocked allowing egress from the building without an alarming device to alert staff should a patient try to escape from the hospital. In addition, the hospital's elevator that comes to the patient floor and opens to the patient floor does not have a security device to control who enters and exits the 2nd floor where psychiatric patients are admitted. The failure to have security devices on the elevators resulted in Patient#7, who was on a CEC (Coronor's Emergency Certificate), eloping from the hospital on 5/22/10. During review of medical records of patients on the psychiatric area on the 2nd floor, 2 patients were noted to be under CEC (Coroner's Emergency Certification), 3 were under Judicial Order, and 5 were FVA (Formal Voluntary Admission) in a total census of 12.(see findings at A0144)

2) failing to ensure psychiatric patients, who were hospitalized with suicidal ideations and dementia, did not have access to 5 gallons of Clorox, 1 bottle of Virex, and 1 gallon of Vesphene in the housekeeping room; access to 3 - 4' electrical cords in the Staff Lounge, Quiet/Activity room, exam room, and consultation room; approximately 4' long metal hose and an E/Z lift (hoyer lift) with an approximately 3" cord in the shower room. (see findings at A0144)

Based in interview the hospital failed to meet the Condition of Participation for Quality Assurance/Performance Improvement by the failure of the hospital to focus on high risk, high volume, problem prone areas related to patient falls, failure to track and trand the number of falls that occurred in the hospital and develop a plan to prevent future falls. There were 13 incident reports documented of patient falls which occurred in April and May 2010 without any evidence that the hospital had incorporated this data into the hospital-wide quality assurance program.. (See findings at A267, A275, A276, A285, A287, A288, and A289.)

The hospital failed to ensure the patients right to receive care in a safe environment by:

1) failing to ensure constant monitoring of 4 Fire Exits which were unlocked allowing egress from the building without alarm and an elevator that comes to the patient floor and opens to the patient floor without security device to control who enters/exits the patient floor. 2 patients were under CEC (Coroner ' s Emergency Certification), 3 were under Judicial Order, and 5 were FVA (Formal Voluntary Admission). In an interview on 06/08/10 at 10:10 with S5RN, Charge Nurse, she stated that of the 12 patients in the hospital 4 were under suicide precautions and 3 were Demented. This has the potential to affect all patients in the hospital.

2) failing to ensure patients did not have access to chemicals/equipment that could cause harm. In an interview on 06/08/10 at 10:10 with S5RN, Charge Nurse, she stated that there were 4 suicidal patients and 3 Demented patients in a total census of 12 patients on the unit at the time the following observations were made on 06/08/10 at 9:50 a.m.:

a) The Staff Lounge door was open. Inside was a coffee pot with approximately 3 '
electrical cord and a Refrigerator with approximately 4 ' electrical cord. The Staff
restroom contained another coffee pot and crock pot both with approximately 3 '
electrical cords.

b) The patient scale by the nursing station had an electrical cord of approximately 3 '
length.

c) The Housekeeping room was open and contained 5 gallons of Clorox, 1 bottle of
Virex and 1 gallon of Vesphene. (disinfectant)

d) The Quiet/Activity room had 2 flat screen televisions on the wall with approximately 4
(') foot electrical cords.

e) The isolation room was unlocked and contained a telephone with cord approximately
3 foot long and a coiled cord for the handset.

f) The shower room was unlocked and the shower contained an approximately 4 ' long
metal hose and an E/Z lift (hoyer lift) with an approximately 3 ' cord.

g) The exam room was unlocked and contained 6 IV (intravenous pumps) with
approximately 4 ' electrical cords, a Pulse Oxygenation monitor with an
approximately 3 ' long electrical and finger probe cord and 4 Stryker evacuation
chairs with 2-3 3 " wide nylon straps approximately 3 ' long on each chair.

h) The Consultation room door was open and the room contained a telephone and fan
both having approximately 4 ' electrical cords.

i) The OT (occupational therapy) room was open and there was a 5 ' long 3 " wide
gait belt on a wheelchair near the door.

j) The medication room was unlocked with the Emergency stock medication box
unlocked and the medication cart was unlocked with all patient medicines inside.

In an interview on 06/08/10 at 10:10 a.m. with S5RN, Charge Nurse, all of the above findings were confirmed.

In an interview on 06/08/10 at 12:15 a.m. with S1DON all of the above findings were confirmed.

3) failing to ensure the safety of patients in a locked unit by failing to have adequate staff to monitor the unlocked Fire Exit doors and elevator. Findings:

In an interview on 06/08/10 at 12:15 a.m. with S1DON she stated that the 4 MHT's (mental health technicians) on duty cannot monitor the patients and the Fire Exits/Elevator simultaneously.

In an interview on 06/10/10 at 4:00 p.m. with S2Administrator and S3CEO both confirmed that the Fire Exits were not monitored from 05/25/10 when the State Fire Marshal ordered the doors unlocked through 06/09/10, the second day of the survey.

In an interview on 06/11/10 at 11:55 a.m. with S2Administrator he stated he was not aware of any incidents/elopements from any of the Fire doors or elevator.

Review of a hospital Patient/Visitor Incident Report Form for patient #7, dated 05/22/10 at 10:00 a.m. revealed the following note: "B. Type of Occurrence: Other: Elopement....A. Brief Factual Description: Elevator was locked and door open as usual. Door closed which got RN's attn. (attention) Looked at monitor , rear door, to find pt. (patient) Found on grounds. Called S?? (Ken) to assist getting back. Cooperative. Pt. pushed correct buttons that over rode locked elevator. Notified Admin. and DON." Patient #7 was under a PEC (Physician Emergency Certificate) on 05/20/10 at 9:30 a.m. and CEC (Coroner's Emergency Certificate) on 05/21/10 at 12:15 p.m.

In an interview on 06/11/10 at 1:17 p.m. with S2Administrator he stated that he was not made aware of the patient getting out of the building and he confirmed the attached "investigation" sheet was blank.

4) failing to ensure the hospital staff followed hospital policy and physician orders by failing to have documented evidence on 06/08/10 that q (every) 15 minute checks were done on 8 of 12 patients in a total hospital cencus of 12 with 12 of 12 patients to have q 15 minute checks per physician order/hospital policy. (#4, #6, #7, #R1, #R2, #R3, #R4, #R5) Findings:

Patient #4

Review of the Face Sheet and physician orders for patient #4 revealed the patient was admitted on 05/27/2010 at 1750 (5:50 p.m.) with no admission diagnosis. The reasons for admission on the physician's orders included Danger to self, gravely disabled, danger to self or others, altered thought processes: psychosis, hallucinations, delusions, impaired functioning: social, familial, occupational. Patient #4's legal status was documented as "Judicial."

Review of the q 15 minute observation sheet on 06/08/10 at 10:00 a.m. revealed no documented evidence the patient was directly observed every 15 minutes for 0900 (9:00 a.m.), 0915 (9:15 a.m.), 0930 (9:30 a.m.), 0945 (9:45 a.m.) and 1000 (10:00 a.m.).

In an interview on 06/08/10 at 12:15 p.m. with S1DON she confirmed the above findings.

Patient #6

Review of the Face Sheet and physician orders for patient #6 revealed the patient was admitted on 05/31/2010 at 2050 (8:50 p.m.) with an admission diagnosis of Major Depression and Bipolar. The reasons for admission on the physician's orders included danger to self, gravely disabled, altered thought processes: psychosis, hallucinations, Altered mood: depressed, manic, agitated, anxious. Patient #6's legal status was documented as "FVA." (Formal Voluntary Admission)

Review of the q 15 minute observation sheet on 06/08/10 at 10:00 a.m. revealed no documented evidence the patient was directly observed every 15 minutes for 0930 (9:30 a.m.) 0945 (9:45 a.m.) and 1000 (10:00 a.m.).

In an interview on 06/08/10 at 12:15 p.m. with S1DON she confirmed the above findings.

Patient #7

Review of the Face Sheet and physician orders for patient #7 revealed the patient was admitted on 05/20/2010 at 1230 (12:30 p.m.) with an admission diagnosis of Schizo (schizophrenia) - Paranoid Type and Dementia. The reasons for admission on the physician's orders included danger to others, danger to self or others (potential), altered thought processes: psychosis, hallucinations, Altered mood: depressed, manic, agitated, anxious. Patient #7's legal status was documented as "PEC." (Physician Emergency Certificate)

Review of the q 15 minute observation sheet on 06/08/10 at 10:00 a.m. revealed no documented evidence the patient was directly observed every 15 minutes for 0900 (9:00 a.m.), 0915 (9:15 a.m.), 0930 (9:30 a.m.) 0945 (9:45 a.m.) and 1000 (10:00 a.m.).

In an interview on 06/08/10 at 12:15 p.m. with S1DON she confirmed the above findings.

Patient #R1

Review of the Face Sheet and physician orders for patient #R1 revealed the patient was admitted on 06/07/2010 at 1830 (6:30 p.m.) with an admission diagnosis of Schizo (schizophrenia) - Bipolar Type. The reasons for admission on the physician's orders included gravely disabled, altered thought processes: psychosis, hallucinations, Altered mood: depressed, manic, agitated, anxious and impaired functioning: social, familial, occupational. Patient #R1's legal status was documented as "PEC/CEC." (Physician Emergency Certificate/Coroner's Emergency Certificate) The physician ordered Elopement Precautions.

Review of the q 15 minute observation sheet on 06/08/10 at 10:00 a.m. revealed no documented evidence the patient was directly observed every 15 minutes for 0930 (9:30 a.m.) 0945 (9:45 a.m.) and 1000 (10:00 a.m.).

In an interview on 06/08/10 at 12:15 p.m. with S1DON she confirmed the above findings.

Patient #R2

Review of the Face Sheet and physician orders for patient #R2 revealed the patient was admitted on 06/01/2010 at 1615 (4:15 p.m.) with an admission diagnosis of Psychosis NOS (not otherwise specified). The reasons for admission on the physician's orders included danger to others, danger to self or others (potential), altered thought processes: psychosis, hallucinations, Altered mood: depressed, manic, agitated, anxious and impaired functioning: social, familial, occupational. Patient #R2's legal status was documented as "FVA."

Review of the q 15 minute observation sheet on 06/08/10 at 10:00 a.m. revealed no documented evidence the patient was directly observed every 15 minutes for 0815 (8:15 a.m., 0830 (8:30 a.m.), 0900 (9:00 a.m.), 0915 (9:15 a.m.), 0930 (9:30 a.m.) 0945 (9:45 a.m.) and 1000 (10:00 a.m.).

In an interview on 06/08/10 at 12:15 p.m. with S1DON she confirmed the above findings.

Patient #R3

Review of the Face Sheet and physician orders for patient #R3 revealed the patient was admitted on 05/26/2010 at 2040 (8:40 p.m.) with an admission diagnosis of Hx (history of) Bipolar and Depression. The reasons for admission on the physician's orders included danger to self, gravely disabled, agitation, and altered thought processes: psychosis, hallucinations. Patient #R3's legal status was documented as "FVA."

Review of the q 15 minute observation sheet on 06/08/10 at 10:00 a.m. revealed no documented evidence the patient was directly observed every 15 minutes for 0815 (8:15 a.m., 0830 (8:30 a.m.), 0900 (9:00 a.m.), 0915 (9:15 a.m.), 0930 (9:30 a.m.) 0945 (9:45 a.m.) and 1000 (10:00 a.m.).

In an interview on 06/08/10 at 12:15 p.m. with S1DON she confirmed the above findings.

Patient #R4

Review of the Face Sheet and physician orders for patient #R4 revealed the patient was admitted on 05/13/2010 at 1545 (3:45 p.m.) with an admission diagnosis of Mental Disorder, Anxiety. The reasons for admission on the physician's orders included danger to others, gravely disabled, danger to self or others (potential), and altered mood: depressed, manic, agitated, anxious. Patient #R4's legal status was documented as "NCA." (non-contested admission)

Review of the q 15 minute observation sheet on 06/08/10 at 10:00 a.m. revealed no documented evidence the patient was directly observed every 15 minutes for 0900 (9:00 a.m.), 0915 (9:15 a.m.), 0930 (9:30 a.m.) 0945 (9:45 a.m.) and 1000 (10:00 a.m.).

In an interview on 06/08/10 at 12:15 p.m. with S1DON she confirmed the above findings.

Patient #R5

Review of the Face Sheet and physician orders for patient #R5 revealed the patient was admitted on 05/24/2010 at 2010 (8:10 p.m.) with an admission diagnosis of Alzheimer's. The reasons for admission on the physician's orders included gravely disabled, altered thought processes: psychosis, hallucinations. Patient #R5's legal status was documented as "PEC/CEC."

Review of the q 15 minute observation sheet on 06/08/10 at 10:00 a.m. revealed no documented evidence the patient was directly observed every 15 minutes for 0900 (9:00 a.m.), 0915 (9:15 a.m.), 0930 (9:30 a.m.) 0945 (9:45 a.m.) and 1000 (10:00 a.m.).

In an interview on 06/08/10 at 12:15 p.m. with S1DON she confirmed the above findings.

5) failing to ensure the hospital staff followed hospital policy and physician orders by failing to have documented evidence on 06/10/10 that q (every) 15 minute checks were done on 5 of 12 patients in a total hospital cencus of 12 with 12 of 12 patients to have q 15 minute checks per physician order/hospital policy. (#4, #6, #7, #R1, #R6) Findings:

Patient #4

Review of the Face Sheet and physician orders for patient #4 revealed the patient was admitted on 05/27/2010 at 1750 (5:50 p.m.) with no admission diagnosis. The reasons for admission on the physician's orders included Danger to self, gravely disabled, danger to self or others, altered thought processes: psychosis, hallucinations, delusions, impaired functioning: social, familial, occupational. Patient #4's legal status was documented as "Judicial."

Review of the q 15 minute observation sheet on 06/10/10 at 10:45 a.m. revealed no documented evidence the patient was directly observed every 15 minutes for 1000 (10:00 a.m.), 1015 (10:15 a.m.), 1030 (10:30 a.m.), and 1045 (10:45 a.m.).

In an interview on 06/10/10 at 10:45 p.m. with S6RN, Charge Nurse, she confirmed the above findings.

Patient #6

Review of the Face Sheet and physician orders for patient #6 revealed the patient was admitted on 05/31/2010 at 2050 (8:50 p.m.) with an admission diagnosis of Major Depression and Bipolar. The reasons for admission on the physician's orders included danger to self, gravely disabled, altered thought processes: psychosis, hallucinations, Altered mood: depressed, manic, agitated, anxious. Patient #6's legal status was documented as "FVA." (Formal Voluntary Admission)

Review of the q 15 minute observation sheet on 06/10/10 at 10:45 a.m. revealed no documented evidence the patient was directly observed every 15 minutes for 0945 (9:45 a.m.) and 1000 (10:00 a.m.) 1015 (10:15 a.m.), 1030 (10:30 a.m.), and 1045 (10:45 a.m.).

In an interview on 06/10/10 at 10:45 p.m. with S6RN, Charge Nurse, she confirmed the above findings.

Patient #7

Review of the Face Sheet and physician orders for patient #7 revealed the patient was admitted on 05/20/2010 at 1230 (12:30 p.m.) with an admission diagnosis of Schizo (schizophrenia) - Paranoid Type and Dementia. The reasons for admission on the physician's orders included danger to others, danger to self or others (potential), altered thought processes: psychosis, hallucinations, Altered mood: depressed, manic, agitated, anxious. Patient #7's legal status was documented as "PEC." (Physician Emergency Certificate)

Review of the q 15 minute observation sheet on 06/10/10 at 10:45 a.m. revealed no documented evidence the patient was directly observed every 15 minutes for 1000 (10:00 a.m.), 1015 (10:15 a.m.), 1030 (10:30 a.m.), and 1045 (10:45 a.m.).

In an interview on 06/10/10 at 10:45 p.m. with S6RN, Charge Nurse, she confirmed the above findings.

Patient #R1

Review of the Face Sheet and physician orders for patient #R1 revealed the patient was admitted on 06/07/2010 at 1830 (6:30 p.m.) with an admission diagnosis of Schizo (schizophrenia) - Bipolar Type. The reasons for admission on the physician's orders included gravely disabled, altered thought processes: psychosis, hallucinations, Altered mood: depressed, manic, agitated, anxious and impaired functioning: social, familial, occupational. Patient #R1's legal status was documented as "PEC/CEC." (Physician Emergency Certificate/Coroner's Emergency Certificate) The physician ordered Elopement Precautions.

Review of the q 15 minute observation sheet on 06/10/10 at 10:45 a.m. revealed no documented evidence the patient was directly observed every 15 minutes for 1000 (10:00 a.m.), 1015 (10:15 a.m.), 1030 (10:30 a.m.), and 1045 (10:45 a.m.).

In an interview on 06/10/10 at 10:45 p.m. with S6RN, Charge Nurse, she confirmed the above findings.

Patient #R6

Review of the Face Sheet and physician orders for patient #R6 revealed the patient was admitted on 06/02/2010 at 1520 (3:20 p.m.) with an admission diagnosis of Chronic Paranoid Schizophrenia. The reasons for admission on the physician's orders included gravely disabled, altered thought processes: psychosis, hallucinations, delusions, Altered mood: depressed, manic, agitated, anxious and impaired functioning: social, familial, occupational. Patient #R6's legal status was documented as "FVA."

Review of the q 15 minute observation sheet on 06/08/10 at 10:00 a.m. revealed no documented evidence the patient was directly observed every 15 minutes for 1000 (10:00 a.m.), 1015 (10:15 a.m.), 1030 (10:30 a.m.), and 1045 (10:45 a.m.).

In an interview on 06/10/10 at 10:45 p.m. with S6RN, Charge Nurse, she confirmed the above findings.

Review of a facility policy titled "Key Control", policy number 8.4, Section: Environment of Care, no date effective or revised, reads in part: "Purpose: To effectively operate a locked unit in a manner that maintains the safety of patients. Procedure: 2) The following areas will be provided with locks and keys: a) all exit doors; b) all Fire Escape doors;...k) medicine cabinet....."

Review of a facility policy titled "Locking Exits", policy number 8.5, Section: Environment of Care, no date adopted or revised, reads in part: "Policy: It is the policy of the Hospital to operate as a locked unit. Purpose: To maintain the safety, security, and confidentiality of the treatment environment. Procedure: 1) Exits to remain locked include: a) exterior or outside doors;....c) fire escape doors......."

Review of a Seaside Health System policy titled "Admission Criteria", policy number 1.5, no date adopted or last revised, reads in part: "Policy. It is the policy of the hospital to admit patients whose mental condition warrants acute, inpatient psychiatric care...."

Based on record reviews and interviews, the hospital failed to have adequate numbers of licensed registered nurses and other personnel to provide nursing care to all patients on the acute care unit as evidenced by not having one Medical Health Technician (MHT) available to provide one-on-one (1:1) supervision for:
a) 7 days to Random Patient #7 (R7) (5/18, 5/19, 5/20, 5/21, 5/24, 5/25, 5/26),
b) 2 days to Random Patient #9 (R9) (5/24, 5/25),
c) 3 days to Random Patient #10 (R10) on (5/24, 5/25, 5/26)
d) 8 days to Patient #3 (#3) (5/18, 5/19, 5/20, 5/21, 5/23, 5/24, 5/25, 5/26) for 3 out of 10 random sampled patients (R7, R9, R10) and 1 of 7 sampled patients (#3).
Findings:

Review of the daily "Assignment Sheets" revealed the charge nurse assigned and designated patients that the MHTs were to monitor during their shifts, (days or nights). Further review revealed the patient ' s observation status (one-on-one) was written on the MHT assignment sheets indicating what monitoring was required by the MHT for each designated patient on the sheet during their shifts.

Random Patient #7 (R7):
Review of the daily "Staffing Report" and "Patient Assignment Sheets " for the MHTs for 5/18, 5/19, 5/20, and 5/21 revealed there were a total of 6 MHTs scheduled to work these days, (3 day shift and 3 night shift). Further review revealed the charge nurses had assigned 1:1 supervision of R7 to the MHTs on 5/18, 5/19, 5/20 and 5/21. These assignment sheets read as follows:
S17MHT (day shift) was assigned four (4) patients including R7 ' s 1:1 supervision (5/18),
Two day MHTs (S14MHT) was assigned three (3) patients including R7 and (S11MHT)
(night) with (4) patients including R7 (5/19),
S14MHT (day) was assigned (3) patients including R7 (5/20),
S12MHT (night) was assigned (4) patients including R7 (5/20) and
S15MHT (day) was assigned (4) patients including R7 (5/21).

R7 was assigned by the charge nurse to be in line of sight and in arms reach (1:1 supervision) of the MHTs at all times on 5/18, 5/19, 5/20 and 5/21. R7 was being monitored by MHTs that had other patients on 5/18, 5/19, 5/20 and 5/21. There was documented evidence on the daily " Assignment Sheets " that R7 was monitor 1:1 by one MHT on 5/18, 5/19, 5/20 and 5/21 as assigned by the charge nurses on the sheets and as per policy.

On 5/24/10, the daily "Staffing Report" and "Patient Assignment Sheets" for the MHTs and the daily "Staffing Reports were reviewed. There were 3 MHTs scheduled to work the day shift and (5) MHTs scheduled to work the night shift. There were 3 patients (R7, #3, R9) assigned 1:1 supervision by the charge nurses on the assignment sheets. Further review revealed there were no daily "Patient Assignment Sheets" for the MHTs assignment on each patient or what each of the patient's observation status was. There was no documented evidence that any of the 1:1 patients (R7, #3, R9) were monitored by one MHT during the day shift. There was no documented evidence in the MHT daily " Assignment Sheets " that R7 was in line of sight and in arms reach of a MHT at all times during the day shift (7:00 a.m. to 7:00 p.m.) on 5/24. There was no domented evidence R7 was assigned to one designated MHT during the day shift on 5/24.

Further review of the daily "Staffing Report" and "Assignment Sheets" for MHTs on 5/25/10 revealed there were (3) MHTs scheduled to work the day shift and (5) MHTs scheduled to work the night shift. Further review revealed there were 4 patients, (R7, #3, R9, R10) assigned 1:1 supervision to the MHTs as per the assignment sheets on 5/25/10. The Assignment Sheets read as follows:
S9MHT (day) was assigned five (5) patients including R7 ' s 1:1 supervision on 5/25. There was documented evidence on the "Assignment Sheets " that R7 was in line of sight and in arms reach of the MHTs at all times during the day shift on 5/25. There was no documented evidence R7 was assigned to one designated MHT during the day shift on 5/25.

On 5/26/10, the daily "Staffing Report" and "Patient Assignment Sheets" for the MHTs were reviewed. Furthr review revealed there (3) MHTs scheduled to work each shift that day. There were 3 patients (R7, #3, R9) assigned by the charges nurses to be in line of sight and arms reach of the MHTs at all times (1:1 supervision). There should had been (4) patients, (R7, R9, R10, #3) assigned 1:1 supervision. The charge nurses omitted R10 from the daily "Patient Assignment Sheets" for one MHT to be assigned to monitor him. The "Assignment Sheets " read as follows:
S15MHT (day) was assigned nine (9) patients including (2) patients on 1:1 supervision both
at the same time, (R7 and R10).
There was no daily "Patient Assignment Sheets" that R7 was assigned for a MHT during the
night shift on 5/26.

There was no documented daily "Assignment Sheets" for 5/26/10 during the day or night shifts that R7 was in line of sight and in arms reach of the MHTs at all times.

Random Patient #9 (R9):
The daily "Staffing Report" and "Patient Assignment Sheets" for the MHTs on 5/24 and 5/25 revealed there were (3) MHTs scheduled to work (day shift) and (5) MHTs scheduled to work (night shift). There were 3 patients (R7, #3, R9) assigned 1:1 supervision on the assignment sheets for 5/24 and 5/25. These assignment sheets read as follows:
There was no documented evidence R9 was monitored 1:1 by the during the day shift (5/24),
S11MHT (night) was assigned seven (7) patients including R9 (5/24),
S11MHT (day) was assigned seven (7) patients including (2) patients to assigned 1:1 supervision, (R9 and R10) both at the same time on 5/25.

There were no documented daily "Patient Assignment Sheets " for R9 during the day shift on 5/24 and during the day shift on 5/25. Further review there was no documented evidence one MHT was assigned to monitored R9's 1:1 supervision as assigned by the charge nurses on 5/24 and 5/26.

Random Patient #10 (R10):
Review of the daily "Staffing Report" and "Patient Assignment Sheets" for the MHTs on 5/24/10 and 5/25/10 revealed there were (3) MHTs scheduled to work (day shift) and (5) MHTs scheduled to work (night shift). There were 3 patients (R7, #3, R9) assigned 1:1 supervision on these assignment sheets for 5/24. Further review revealed there were no documented evidence R10 was monitored by a designated MHT during the day shift on 5/24.

The daily "Staffing Report" and "Assignment Sheets" on 5/25/10 were reviewed. There were (3) MHTs scheduled to work the day shift and (5) MHTs to work the night shift. There were 4 patients, (R7, #3, R9, R10) assigned 1:1 supervision on these assignment sheets for 5/25. These sheets read as follows:
S11MHT (day) was assigned four (4) patients that included (2) patients assigned 1:1
supervision (R9, R10) to be monitored at the same time during the same shift.
S19MHT (night) was assigned to ten (10) patients including R10 ' s 1:1 supervision.
There was documented evidence one MHT was assigned R10's 1:1 supervision during the day and night shifts as assigned by the charge nurses on 5/25.

Review of the daily "Staffing Report" and "Patient Assignment Sheets" for the MHTs on 5/26/10 revealed there were (6) MHTs scheduled to work that day. There were 3 patients (R7, R9, #3) assigned 1:1 supervision to the designated MHTs on these sheets. There should had been (4) patients, (R7, R9, R10, #3) assigned 1:1 supervision. The charge nurses omitted R10 from the daily "Patient Assignment Sheets" for one MHT to be assigned to monitor him during the day and night shifts. These "Assignment Sheets " read as follows:
There were two (day) MHTs, (S15MHT) was assigned nine (9) patients including 2
both patients assigned 1:1 supervision, (R7 and R10) and (S16MHT) was assigned six
(6) patients including 2 patients, (R10 and #3) both assigned 1:1 supervision during the
same shift.
S8MHT (night) was assigned three (3) patients including R10's 1:1 supervision;
There was documented evidence R10 was monitored 1:1 by one desigated MHT during the day and night shifts on 5/26/10.

Patient #3:
Review of the medical record for #3 revealed there was a physician ' s order dated/timed 5/23/10 at 11:00 a.m. for a " 1:1 status ", which meant the patient was to be remain in line of sight and in arms reach of the MHT at all times.

Review of the daily "Staffing Report" and "Patient Assignment Sheets " for the MHTs revealed the charge nurses assigned 1:1 supervision by the MHTs for #3 on 5/23, 5/24, 5/25 and 5/26 . Further review revealed there were (4) MHTs scheduled to work day shift and (4) to work the night shifts on 5/23/10. There were 2 patients (R7, #3) assigned 1:1 supervision by the charge nurses on the assignment sheets for 5/23/10. These "Assignment Sheets" read,
There were 2 day MHTs (S17MHT and S20MHT) both had (6) patients each.
There was documented evidence #3 was assigned to one desigated MHT during the day shift from 11:00 am to 7:00pm as ordered by the attending physician at 11:00 am.

Further review of the daily "Staffing Report" and "Patient Assignment Sheets " for 5/24/10 revealed there were 3 MHTs scheduled to work the day shift. There were 3 patients (#3, R7, R9) assigned 1:1 supervision by the charge nurses on the MHT's assignment sheets. Further review revealed there were no "Patient Assignment Sheets" for the day shift MHTs. There was no documented evidence #3's 1:1 supervision was assigned to one MHT as assigned by the charge nurse during the day shift on 5/24/10.

The daily "Staffing Report" and "Patient Assignment Sheets " for 5/25/10 were reviewed. There were (3) MHTs scheduled to work the day shift and (5) MHTs scheduled to work the night shift. There were 4 patients, (R7, #3, R9, R10) assigned 1:1 supervision on the daily assignment sheets by the charge nurses on 5/25. These "Assignment Sheets " read as follows: S14MHT (day) assigned five (5) patients including # ' 3.
There was documented evidence #3 was designated to one MHT during the day shift as assigned by the charge nurse on 5/25/10.

Review of the daily "Staffing Report" and "Patient Assignment Sheets " for 5/26/10 revealed there were (6) MHTs scheduled to work each shift that day. There were 3 patients (#3, R7, R9) assigned 1:1 supervision by the charge nurses on the daily assignment sheets. R10's 1:1 supervision was omitted by the charge nurses on the daily "Patient Assignment Sheets " for 5/26. There should have been 4 patients (#3, R7, R9, R10) assigned 1:1 supervision by the charge nurse on 5/26. These "Assignment Sheets " read as follows:
S16MHT (day) was assigned (6) patients including 2 patients assigned both 1:1 supervision,
(#3 and R10) both at the same time. #3 was discharged from the hospital at 11:20 am.
There was documented evidence #3 was assigned to one MHT from 7:00 am to 11:20 am on 5/26.

The Interim DON (Director of Nursing) was interviewed on 6/11/10 from 2:00 p.m. to 2:30 p.m. She reviewed Random Patients' (R7's, R9's, R10's) "Patient Assignment Sheets" from 5/18/10 through 5/26/10 and Patient #3's medical record and "Patient Assignment Sheets" on 5/23, 5/24, 5/25, and 5/26. S1 verified R7, R9, R10 and #3 were on 1:1 supervision as indicated in the above findings from 5/18 through 5/26. She indicated 1:1 supervision requires that the patient be in line of site and in arms reach of the MHT at all times. She verified there was not enough staff members on the unit to ensure that the patients (R7, R9, R10, #3) remained in line of sight and in arms reach with staff members (MHTs) at all times as assigned by the charge nurses for the designated MHTs assigned 1:1 supervision for these patient's (R7's, R9's, R10's, #3's) as per the findings listed above from 5/18 to 5/26/10. She further reported there was 1:1 supervision ordered by the physician for #3 from 5/23 through 5/26. The DON reported #3's 1:1 supervision remains as ordered by the attending physician and/or when the patient is discharged from the hospital. She verified R10 there were (4) patients, (R7, R9, R10, #3) assigned 1:1 supervision on 5/26/10. She agreed the charge nurses omitted R10 from the daily "Patient Assignment Sheets" for one MHT to be assigned to monitor him during their designated shifts. She was unable to provide any explanations why #3, R7, R9, or R10 were not provided 1:1 supervision as indicated on the "Assignment Sheets " from 5/18 through 5/26 (refer to the above findings). She reported that she had just began her job duties as Interim DON last Thursday, 6/3/10. She further reported that she was unaware the MHTs were not providing the patients (R7, R9, R10, #3) 1:1 supervision as ordered by the charge nurses or the psychiatrist (#3). The DON indicated the charge nurses make a judgment call to put the patients on 1:1 observation (supervision). She continued the charge nurse determines whether or not the patients need increased observation status in various ways and gave the following examples: If the patient has an "unsteady gait, history of falls, or has fallen recently in the past 2 days. She indicated the charge nurse makes the judgment call to increase the patients' observation status to 1:1 supervision. She reported the 1:1 supervision is when the patient remains in line of sight and in arms reach of the MHT at all times-which is the first intervention implemented after a pattient has fallen as per the "Fall Prevention" policy. The DON verified #3 fell on 5/18, 5/22, 5/25, and 5/26 as per the Incident Reports. She indicated the charge nurse should have implemented the first intervention of the "Fall Prevention" policy for #3 to increase his observation status to be assigned 1:1 supervision. She further indicated the charge nurses make a judgment call to implement the "Fall Preventions" first intervention to increase the fall patient's observation status to 1:1 supervision until the nurse contacts the attending physcian to get an order to keep that patient on 1:1 supervision within 24 hours. She verified the charge nurses did not implement the first intervention of the "Fall Prevention" policy to increase #3's observation status after he fell on 5/18 and 5/22. She indicated it is up to the charge nurses to ensure that the MHT assigned to each patient follows the policy for 1:1 supervision to remain in line of sight and in arms reach of the MHT at all times.

In another interview with the Interim DON on 6/11/10 at 2:45 p.m., she indicated #3 would not had fallen on 5/25 at 7:20 p.m. (1920) or 5/26/10 at 6:05 a.m. if the MHTs (S7, S12, S14) had maintained the 1:1 supervision as ordered by the attending physician/psychiatrist from 5/23/10 at 11:00 a.m. to 5/26/10 until he was discharged from the hospital. She reported the MHTs (S7, S12, S14) broke the hospital's policy and definition for 1:1 supervision for #3 on 5/25 and 5/26 when the MHTs did not maintain #3's 1:1 supervision to remain in line of sight and in arms reach of the MHT at all times.

Review of the policy titled, " Close Observation " with hospital "c "s letterhead, Policy 8.22, pps 1 to 2, Originate: June 2009, with no revised or reviewed dates, presented as the hospital ' s current " Close Observation Policy " on 6/11/10 at 3:00p.m. read, " Policy-To provide and initiate constant observation for patients. Purpose: To provide guidelines for monitoring and assistin patients who pose a safety risk. Procedure: 1) Identify patients need of increased supervision and control. 4) Specify type and frequency of observation. B. Frequency-1:1 (Constant Observation): constant visual observation of the patient by an assigned staff member. Observation must be uninterrupted and no less than 6 feet of the patient " .

Based on record reviews and interviews, the hospital failed to ensure the registered nurse supervised and evaluated the nursing care for each patient as evidence by failing to ensure:
1) patients assigned one-on-one (1:1) supervision remained in line of sight and in arms reach of the MHTs at all times as per the policy by having a patient fall 2 times, (5/25 at 7:20 p.m. and 5/26 at 6:05 a.m.) during the 1:1 supervision by 2 MHTs, (S14 on 5/25, S12 on 5/26) that the 2 MHTs failed to follow the policy to keep the patient in line of sight and in arms reach of the MHTs at all times for 1 of 7 sampled patients (#3);
2) patients assigned 1:1 supervision had adequate numbers of MHTs available to provide the patients on the acute care unit to one designated MHT as evidenced by having MHTs assigned to the 1:1 supervised patients and to two of more patients for:
a) Random Patient #7, (R7) on (5/18, 5/19, 5/20, 5/21, 5/24, 5/25, 5/26),
b) Random Patient #9, (R9) on (5/24, 5/25),
c) Random Patient #10, (R10) on (5/24, 5/25, 5/26) for 3 of 10 random sampled patients
(R7, R9, R10) and
d) Patient #3, (#3) on (5/18, 5/19, 5/20, 5/21, 5/23, 5/24, 5/25, 5/26) for 1 of 7 sampled
patients; and
3) physician's orders for blood glucose monitoring, oral medication administrations, and
nebulizer treatments were administered to patient #3 by having: a) 3 missed blood glucose
readings, b) 42 missed oral medication administrations, c) 23 missed nebulizer treatments,
to patient #3 for 1 of 7 sampled patients.
FINDINGS:
1) Patient #3's falls, (5/25 at 7:20 a.m.) and (5/26 at 6:05 a.m.):

Patient #3' fall on 5/25/10 (7:20 am):
Review of the #3's medical record revealed he was admitted to the hospital on 5/15/10 at 2230 (10:30 p.m.) with a diagnosis of Alzheimers. Review of the Incident Reports documented on #3 revealed he had fallen on 5/18/10 at 1730 (5:30 p.m.). Further review revealed #3 fell a second time on 5/22/10 at 1230 (12:30 p.m.). There was a physician's order written dated/timed 5/23/10 at 11:00 a.m. for " 1:1 status ", which meant the patient was to remain in line of sight and in arms reach of the MHT at all times. Review of the "Close Observation" policy read, "...Close Observation: Staff checks on patient every fifteen (15) minutes. 1:1 (Constant Observation): constant visual observation of patient by assigned staff member. Observation must be uninterrupted and no less than 6 feet of the patient...".

Review of the Incident Reports revealed patient #3 had a third fall on 5/25/10 at 1920 (7:20 a.m.). Further review revealed S14MHT was in the process of swapping patient assignments in the hallway when she heard #3 fall in his room. #3's 1:1 supervision was not maintained by S14MHT as per policy when S14 left #3 alone in his room to swap patient assignments in the hallway.

Review of S14MHT's hand written statement of #3's fall on 5/25/10 read, " (S14MHT named herself) was on 1 on 1 with (#3 named) when call ...to hallway to ask if I would swap patient with (S7MHT named) ...when we were walking back to the room (#3 named) fell". Further review revealed S7MHT ' s hand written statement on #3 ' s fall on 5/25 read, " I (S7MHT named) was assigned to (R9 named) but told (S21RNnamed -the preceding DON) how he (R9) reacts toward me (S7), And she (S21) said Lets ask (S14MHT named) to switch patient, (S14MHT named) was taking care of (#3 named) across the hall, we (S7 and S14) were in the process of switching when we heard the patient (#3) hit floor " .

Review of S7MHT's handwritten statement of #3's fall on 5/25/10 read, "(S7MHT named herself) was assigned to R9 but told (S21RN-DON named) how he (R9) reacts toward me, And she (S21) said lets's ask (S14MHT named) to switch patient, (S14) was taking care of (Patient #3 named) across the hall, we were in the process of swithching when we heard the patient (#3) hit floor. We called for the nurse".

The Formal Counseling Agreement hand written by S21RN-the preceding DON was held with S7MHT and S23RN on 5/25/10 read, " (S7MHT named) was in the process of switching patient 1:1 assignments with the MHT across the hall. She delayed briefly to talk /c (with) me, (S21, the preceding DON) & (and) (S14MHT named) & (over) instructed her (S7MHT) and (S14MHT named) to assume their assignments. A few seconds passed & I re-instructed them (S7and S14) to assume their assignments. They took steps to go in their patients ' (R9 ' s, #3 ' s) rooms. By the time I sat down, I (S21RN preceding DON) was called & informed (#3 named) had fallen " .

Review of the daily "Staffing Report" for 5/25/10 from 7A to 7P (7:00 a.m. to 7:00 p.m.) revealed S25RN charge nurse and S14MHT were the staff scheduled to provide #3's nursing care during the day shift . S24RN charge nurse and S7MHT were the staff scheduled to provide #3's nursing care during the night shift from 7P to 7A (7:00 p.m. to 7:00 a.m.) on 5/25.

Review of S24RN's daily nursing documentation read, "#3 had a recent fall, had an unsteady gait, was at risk for falls, and was on 1:1 supervision". Further review revealed S24RN's documentation read, "Called to pt's (patient's) room, Pt. (patient) fell on floor & (and) hit head" at 1930 (7:30 p.m.)".

The daily "Patient Assignment Sheets " for each MHT are written and assigned by the charge nurses that designated which patients are assigned to each scheduled MHT to monitor during their shifts, (day and night). These sheets also include what each patient's observation status (1:1 supervision) is required by each MHT during their designated shifts.

Review of the daily "Patient Assignment Sheets " for the MHTS on 5/25/10 revealed S14MHT was the MHT assigned #3 ' s 1:1 supervision during her day shift. Further review revealed there were (3) MHTs scheduled to work the day shift and (5) MHTs scheduled to work the night shift. There were 4 patients, (R7, #3, R9, R10) assigned 1:1 supervision on by the charge nurses on the daily assignment sheets for 5/25. These assignment sheets read as follow:
S14MHT was assigned five (5) including #3's 1:1 supervision during her day shift.
S12MHT was assigned #3's 1:1 supervision during her night shift.

In interview with S14MHT on 6/11/10 from 1:30 p.m. to 1:50 p.m., she reviewed the daily Staffing Report (5/25), daily "Patient Assignment Sheets" for the MHTs (5/25), Incident Report (5/25), S14MHT ' s and S7MHT ' s Statements on #3 ' s fall (5/25), and Formal Counseling Agreement held by S21RN-the preceding DON with S7MHT and S23RN on 5/25/10. She verified that she provided #3 ' s 1:1 supervision during her day shift on 5/25. She confirmed S25RN charge nurse assigned her to monitor #3 ' s 1:1 supervision during her day shift. She verified she was assigned by S25RN to monitor five (5) patients including #3's 1:1 supervision all at the same time during her day shift on 5/25. S14 recalled from memory that #3 fell during shift change. She continued she (S14) and the night MHT, (S7) were in the hallway swapping patients as per the DON (S21RN-preceding DON). She indicated # S7MHT was re-assigned to monitor #3 ' s 1:1 supervsion during the night shift. S14MHT indicated #3 fell while S7MHT was in the hallway headed to his room to resume his 1:1 supervision as ordered by S25RN (day charge nurse) and S24RN (night charge nurse) She agreed that she left #3 alone in his room to swap patient assignments in the hallway. She provided the surveyor with the hospital's definition for 1:1. She indicated that 1:1 means that the MHT never leaves the patient and is to be with the patient at all times and in arms reach. She agreed she did not follow the definition of 1:1 supervision that she provided the surveyor and the 1:1 supervision policy to never leave #3 alone and remain in arms reach of the patient at all times when she left #3 and went into the hallway to swap patient assignments with S12MHT. She indicated #3 should not had fallen on 5/25. She further indicated the 1:1 supervision worked to prevent #3 from falling. S14MHT reported #3 fell (the third time) when we (S14 and S7) left him alone in the room to swap patient assignments in the hallway. S14MHT stated, I will never leave another patient on 1:1 supervision alone, again.

On 6/10/10 from 4:40 p.m. to 6:00 p.m., S7MHT was interviewed. She reviewed the " Patient Assignment Sheets " and Staffing Schedules (5/25), the Incident Report (5/25), S14MHT and S7MHTs ' Statements (5/25) and Formal Agreement held by S21 with S23RN and S7MHTS14MHT on 5/25. She verified she provided #3 ' s 1:1 supervision during her night shift on 5/25. She confirmed S24RN charge nurse assigned her to monitor R9 ' s 1:1 supervision, but she requested to assigned to another patient to monitor during her night shift. S7 recalled both her and S14 (day MHT) were in the hallway swapping patient assignments when they heard #3 fall. She indicated she was not assigned to a patient while getting her new patient assignment from S21RN -the preceding DON. She verified S14MHT was the MHT assigned to monitor #3 ' s 1:1 supervision during the day shift. She stated S14 was in the hallway out of #3 ' s sight and out of arms reach. She provided the surveyor with the policy ' s definition for 1:1 supervision. S7 indicated 1:1 supervision means the patient is to remain in line of sight and in arms reach of the MHT at all times. She further indicated S14MHT did not follow the policy to remain in line of sight and in arms reach of #3 at all times while she was in the hallway speaking to me, (S7) and S21RN(-the preceding DON). S7MHT indicated #3 was still assigned to S14MHT when they (S7 and S14) both heard him fall. She agreed #3 ' s 1:1 supervision worked to prevent him from falling. S7MHT indicated #3 should not had fallen if the 1:1 supervision was followed by the MHT (S14) to remain in line of sight and in arms reach of the patient at all times.

In an interview on 6/10/10 from 10:25 a.m. through 11:25 a.m., S25RN reviewed her documented daily Nursing Progress Notes (5/25), Staffing Schedules (5/25), daily " Patient Assignment Sheets " (5/25), Incident Report (5/25), S14 and S7MHT ' s Statements (5/25), Formal Counseling Agreement by S21 held with S23RN and S7MHT and #3 ' s medical record. She verified she was #3 ' s nurse and S14MHT was the MHT that she had assigned to monitor #3 ' s 1:1 supervision during her day shift. S25 agreed that she had assigned S14MHT to 5 patients including #3 ' s 1:1 supervision during her shift. She indicated there was no one MHT assigned to provide #3 ' s 1:1 supervision during her shift. She reported the hospital ' s policy for 1:1 supervision is for the patient to remain in line of sight and in arms reach of the MHT at all times. She further reported that only one MHT can be assigned to monitor patients on 1:1 supervision as per the policy. S25 indicated #3 fell during shift change. She continued shift change occurs 15 minutes prior to the shift starting and #3 fell after her shift at 1920 (7:20 p.m.). She reported that #3 fell on charge nurses (S24RN ' s) shift that began at 7P. She indicated S14MHT (day) and S7MHT (night) both left #3 alone in his room during shift change. She agreed the hospital ' s policy to remain with #3 at all times was not followed by both, (S14 and S7) during shift change. She reported 1:1 supervision worked to prevent #3 from falling. She indicated #3 should not have fallen if the 1:1 supervision was provided by the MHTs (S14 and S7) on 5/25/10.

On 6/10/10 from 10:15 a.m. to 12:20 p.m., S24RN was interviewed. She reviewed her documented nurses progress notes (5/25), incident reports (5/25 and 5/26) and #3's medical record. She verified she had provided #3's nursing care during her night shift from 7P to on 5/25 to 7A on 5/26. She confirmed S14MHT was the day MHT assigned by the charge registered nurse, (S25RN) to monitor #3's 1:1 supervision during the day shift from 7A to 7P. She verified S14MHT was assigned to monitor 5 patients including #3 ' s 1:1 supervision all at the same time during the day shift by S25RN. S24 verified #3 fell during the MHT's (S14 and S7) shift change (7:20 p.m.). She agreed she documented #3 ' s fall at 7:30 p.m. (1930) in her nurses progress notes on 5/25. She reviewed S14MHT's and S7MHT ' s hand written statements on #3 ' s fall at 7:20 a.m. on 5/25. She indicated S14MHT left #3 alone in his room during shift change. She reported #3 fall while S14MHT was in the hallway swapping patient assignments with S7MHT. She provided the surveyor with the definition for 1:1 supervision as per the hospital ' s policy. She indicated 1:1 meant that the patient was to remain in line of sight and in arms reach of the MHT at all times. She further indicated that only one MHT can be assigned to monitor patients with 1:1 supervision. She agreed that S14MHT did not follow the policy to remain in line of sight, in arms reach, or one MHT assigned to #3 at all times during the day shift on 5/25. S24RN reported #3 fell a third time. She indicated #3 should not had fallen if 1:1 supervision had been provided by the MHTs (S14, S7).

Patient #3's Fall on 5/26/10 (6:05 am): Findings:

Further review of #3's medical record revealed #3 was put on 1:1 supervision by the attending psychiatrist/practitioner on 5/23 at 11:00 a.m. after he fell the second time (5/22 at 12:30 p.m.) until he was discharged from the hospital on 5/26 at 11:20 a.m.. Further review revealed #3 fell a third time (5/25 at 7:20 p.m.) while he was on 1:1 supervision by the MHTs during their shifts.

Further review of the Incident Reports revealed patient #3 fell a fourth time, 5/26/10 at 0605 (6:05 a.m.). Further review revealed S24RN charge nurse reported the following occurrence, "Patient (#3) was in w/c (wheel chair) had a belt around him in his room. 1 (2) MHTs were in the room. they had just gotten him OOB (out of bed). Patient was reaching out and turned the w/c over on the floor. Patient has small cut to right upper lip and a skin tear to his right elbow". There were 2 witnesses, (S12MHT and S19MHT-had left the room) noted on the report. Further review revealed #3 had a physician's order for 1:1 prior to his fall incident on 5/26/10. The Formal Counseling Agreement was held with S24RN for S12MHT on 5/26/10. The Agreement read, "(S12MHT named) was doing 1:1 supervision on (patient #3 named) when he tilted his w/c & (and) fell busting his lip. (S12MHT named) admits she was making the patient's bed when he fell. She admits patient was in her presence but not in arms reach. 1:1 supervision requires the MHT be within arm ' s length of the patient at all times" that was no signed by the employee did not sign on the designated line on the form-this section was left blank on the form.

The daily "Assignment Sheets" for 5/25/10 were further reviewed. The assignment sheets revealed there were (3) MHTs scheduled to work the day shift and (5) MHTs scheduled to work the night shift. There were 4 patients, (R7, #3, R9, R10) assigned 1:1 supervision on the daily assignment sheets for 5/25. The " Assignment Sheets " read, S14MHT (day) was assigned to five (5) patients including # ' 3. There was documented evidence #3 remained in line of sight and in arms reach of the MHTs at all times as designated by the charge nurses on the daily assignment sheets on 5/25/10. Review of the daily "Assignment Sheets" for 5/25/10 revealed S24RN was the night charge nurse from 7:00 p.m. on 5/25 to 7:00 a.m. on 5/26/10 that provided #3's nursing care during her night shift. S12MHT was the night MHT assigned by S24RN charge nurse on the assignment sheets to monitor #3's 1:1 supervision during her night shift on 5/25/10.

Further review of the daily "Assignment Sheets" for 5/26/10 revealed there were (6) MHTs scheduled to work that day. There were 3 patients (#3, R7, R9) assigned 1:1 supervision by the charge nurses on the daily assignment sheets. There should have been 4 patients (#3, R7, R9, R10) assigned 1:1 supervision on these assignment sheets, R10 was omitted from being assigned 1:1 monitoring on the sheets. The " Assignment Sheets " read, S16MHT (day) was assigned to (6) patients which included 2 patients being monitored, 1:1, (#3 and R10) both at the same time until #3 was discharged at 11:00 a.m. from the hospital. There was documented evidence #3 remained in line of sight and in arms reach of the MHTs at all times until as designated by the charge nurses on the daily assignment sheets on 5/26/10 until he was discharged at 11:20 a.m. from the hospital.

Review of S24RN's Progress Notes documentation at 0605 (6:05 a.m.) on 5/26/10-the end of the night shift on 5/25/10 (7:00 p.m. to 7:00 a.m.) read, "Patient fell on floor after turning his w/c over in his room. 2 MHTs were in the room /c (with) him. Has small cut to rt (right) upper lip and a skin tear to rt elbow".

The Patient Assignment Sheets for S12MHT were reviewed for 5/25/10 (night shift). Further review revealed S12MHT was assigned by S24RN charge nurse to monitor #3's 1:1 supervision during her shift. S12MHT was assigned to monitor five (5) patients including #3's 1:1 supervision during her night shift on 5/25.

In interview on 6/10/10 at 1:55 p.m., S12MHT reviewed the " Patient Assignments Sheets " for 5/25 and 5/26, Incident Report (5/25, 5/26), S14 and S7MHT ' s Statements (5/25) and Formal Counseling Agreement by S21DON with S24RN and herself (S12) on 5/26/10. She reviewed the daily " Patient Assignment Sheets, Incident Report, Formal Counseling Agreement, S14 and S7MHT ' s Statements for 5/25/10. She verified #3 was on 1:1 supervision by S14MHT. She confirmed S14MHT was assigned to 5 patients including #3 ' s 1:1 supervision. She indicated S14MHT and S7MHT were in the hallway when they heard #3 hit the floor. She provided the surveyor the hospital ' s policy and definition for 1:1 supervision. She indicated 1:1 supervision means the MHT does not leave the patient at anytime. She continued only one MHT can be assigned to monitor patients on 1:1 supervision as per the policy. She further indicated S14MHT and S7MHT did not follow the policy to not leave #3 alone at anytime on 5/25. She verified #3 fell after S14 and S7 left him alone in his room. She reviewed the " Patient Assignment Sheets " for 5/25 7P to 7A shift. She verified she was the MHT assigned to monitor # 3's 1:1 supervision during her (night) shift from 7P on 5/25/10 through 7A on 5/26. S12 recalled from memory that #3 had fallen at the end of her shift on 5/26. She reviewed the Formal Counseling Agreement meeting done by S21RN and S24RN on 5/26. S12MHT read aloud, " (I, S12MHT named herself) was doing 1:1 supervision on (#3 named) when he tilted his w/c & fell busting his lips. (S12 named) admits she was making the patient ' s bed when he fell. She (S12) admits patient was in her presence but not in arms reach. 1:1 Supervision requires the MHT be within arms length of the patient at all times " . S12 agreed she was changing #3 ' s linen on his bed while she asked him to stay seated in his wheel chair. She recalled asking him to stay seated in his wheel chair at a minimum of 2 times. She indicated he (#3) does not listen. She recalled #3 was confused. She indicated #3 fell because he was out of my arms reach. S12 agreed she did not follow the policy to keep #3 in arms length at all times while she was fixing his bed.

During the same interview with S24RN on 6/10/10 from 10:15 am to 12:20 p.m., she verified she had provided #3's nursing care during her night shift on 5/25/10 7P (7:00 p.m.) to 7A (7:00 a.m.) on 5/26. She confirmed S12MHT was the MHT assigned by her to monitor #3's 1:1 supervision during her night shift from 7P on 5/25 to 7A on 5/26. She verified S12MHT was assigned to 5 patients including #3's 1:1 supervision during her night shift on 5/25. S24RN reviewed the Formal Counseling Meeting Agreement held by S21RN-the preceding DON with her (S24RN) and S12 MHT on 5/26. S24 read aloud, "(S12MHT named) admits making patient's bed when he (#3) fell. She (S12MHT) admits patient not in arms reach. 1:1 supervision requires MHT be within arm ' s length of the patient at all times". She agreed S12MHT did not follow the hospital's policy #3 to remain in arms reach of the MHT at all times. S24RN indicated #3 fell a third and fourth time because the MHTs, (S14MHT) left him alone in his room (5/25) and (S12MHT) making his bed (5/26) did not follow the hospital's policy for 1:1 supervision. S24RN reported #3 did not fall when the MHTs monitored him as per the policy for 1:1 supervision.

In interview with the Interim DON (S1) on 6/11/10 from 1:15 p.m. to 1:45 p.m., she reviewed #3's medical record, Incident Reports (5/18, 5/22, 5/25 and 5/26), and " Patient Assignment Sheets " (5/22, 5/23, 5/25, and 5/26). She verified #3 fell on (5/18 at 5:30 p.m.), second fall (5/22 at 12:30 p.m.), and third fall (5/25 at 7:20 p.m.), and fourth fall (5/26 at 6:05 a.m.). She confirmed #3 was on 1:1 supervision as ordered by the attending psychiatrist/practitioner from 5/23 at 11:00 a.m., 5/24 and until he was discharged from the hospital at 11:20 a.m. on 5/26. She indicated the physician wrote the order for 1:1 after #3 fell the second time (5/22 at 12:30 p.m.). She reviewed the MHT "Assignment Sheets" for 5/25, and 5/26. She confirmed S14MHT was assigned to monitor #3 ' s 1:1 supervision during the day shift. She verified S14MHT was assigned to 5 patients including #3 ' s 1:1 supervision on 5/25. She provided the surveyor with the policy for 1:1 supervision. She indicated 1:1 supervision policy is for the MHT to remain with the patient at all times; The MHT cannot have other patient assignments when monitoring the 1:1 patient; The MHT cannot take their eyes off of the patient at all; The MHT cannot fix patient ' s (#3 ' s) bed (S12MHT on 5/26 at 6:05 a.m.) while monitoring a 1:1 patient; " . She verified the 1:1 protocol was broke on 5/25 day shift with S14MHT and S7MHT while in the process of shift change. She indicated the MHTs, (S14 and S7) did not follow the 1:1 protocol to keep the patient in their sight at all times. The DON further indicated this was no excuse that the MHTs were in the process of shift change to break the 1:1 protocol. The Interim DON continued, the MHT are to stay with the patient at all times. The MHTs stop their 1:1 supervision after the oncoming MHT is at the patient ' s side and in line of sight. She reported #3 ' s 1:1 was working until the MHTs, (S14 and S7) left #3 alone in his room. She indicated #3 should not have fallen the third time (5/25 at 7:20 p.m.) during the MHTs shift change. The Interim DON confirmed S12MHT was assigned to monitor #3's 1:1 supervision during the night shift on 5/25. She verified S12MHT was the only MHT assigned to monitor #3. The Interim DON reviewed the Formal Counseling Meeting Agreement by S21RN, (the preceding DON) held with S24RN and S12 MHT on 5/26/10. The DON read aloud, "(S12MHT named) admits she was making the patient's bed when he (#3) fell. She (S12MHT) admits patient was in her presence but not in arms reach. 1:1 supervision requires the MHT be within arms length of the patient at all times". The Interim DON indicated S12MHT did not follow the hospital's policy to remain in line of sight and in arms reach of the patient at all times. She further indicated S12MHT was making or fixing #3 ' s bed. The DON continued, this is no reason to break the 1:1 protocol. She indicated the policy is that the MHT (S12) has no other assignments. She reported the MHT ' s main focus is to remain in line of sight of the patient at all times. She continued there are other MHTs designated/assigned to change, make and/or fix patients bed. She reported this is not the MHT ' s assignment while monitoring the 1:1 patient. She indicated #3 fell a third and fourth time as a result of the MHTs, (S14MHT) left #3 alone in his room, (S12MHT) was making #3 ' s bed. The Interim DON further indicated #3 did not fall when the MHTs followed the 1:1 protocol.

2) Adequate MHT staff:
Review of the daily "Assignment Sheets" revealed the charge nurses assign the patients to designated MHTs to monitor during their shifts, (days or nights). Further review revealed the patient ' s observation status (one-on-one) was written on the MHT's daily " Patient Assignment Sheets " indicating what monitoring was required for each patient assigned to the MHT during their shifts.

a) Random Patient #7 (R7):
Review of the " Assignment Sheets " for 5/18, 5/19, 5/20, and 5/21 revealed there were a total of 6 MHTs scheduled to work these days, (3 day shift MHTs and 3 night shift MHTs). Further review revealed the charge nurses had assigned 1:1 supervision of R7 to the MHTs on 5/18, 5/19, 5/20 and 5/21. These assignment sheets read as follows:
On 5/18/10, S17MHT (day shift) was assigned to four (4) patients including R7 ' s 1:1 supervision,
On 5/19/10, two day MHTs (S14MHT) was assigned to three (3) patients including R7 and (S11MHT) (night) with (4) patients including R7,
On 5/20/10, S14MHT (day) was assigned to (3) patients including R7,
On 5/20/10, S12MHT (night) was assigned to (4) patients including R7 and
On 5/21/10, S15MHT (day) was assigned to (4) patients including R7.

R7 was assigned by the charge nurse to be in line of sight and in arms reach (1:1 supervision) of the MHTs at all times on 5/18, 5/19, 5/20 and 5/21. R7 was being monitored by MHTs that had other patients on 5/18, 5/19, 5/20 and 5/21. There was documented evidence on the daily " Assignment Sheets " that R7 was in line of sight and in arms reach of the MHTs at all times on 5/18, 5/19, 5/20 and 5/21 as assigned/designated by the charge nurses on the sheets.

The daily "Assignment Sheets" on 5/24/10 revealed there were no MHTs scheduled to work the day shift. There were (5) MHTs scheduled to work the night shift. There were 3 patients (R7, #3, R9) assigned 1:1 supervision by the charge nurses on the assignment sheets. There was no documented evidence in the MHT daily " Assignment Sheets " that R7 was in line of sight and in arms reach of a MHT at all times during the day shift (7:00 a.m. to 7:00 p.m.) on 5/24.

Further review of the "Assignment Sheets" for 5/25/10 revealed there were (3) MHTs scheduled to work the day shift and (5) MHTs scheduled to work the night shift. Further review revealed there were 4 patients, (R7, #3, R9, R10) assigned 1:1 supervision to the MHTs as per the assignment sheets on 5/25/10. The Assignment Sheets read as follows: S9MHT (day) was assigned to five (5) patients including R7 ' s 1:1 supervision on 5/25. There was no documented evidence on the daily " Assignment Sheets " that R7 was in line of sight and in arms reach of the MHTs at all times on 5/25.

Review of the "Assignment Sheets" on 5/26/10 revealed there (6) MHTs scheduled to work that day. There were 3 patients (R7, #3, R9) assigned by the charges nurses to be in line of sight and arms reach of the MHTs at all times (1:1 supervision). Further review revealed there should had been (4) patients, (R7, R9, R10, #3) being monitored 1:1. There was no documentation on the assignment sheets of what R10 ' s observation status was for the MHTs to monitor during their shifts. The " Assignment Sheets " read as follows: S15MHT (day) was assigned to nine (9) patients including R7 ' s 1:1 supervision. S15MHT was monitoring (2) patients on 1:1 supervisions at the same time, (R7 and R10). There was no MHT assignment sheet for the night shift on 5/26. There was documented evidence on the daily " Assignment Sheets " for 5/26/10 that R7 was in line of sight and in arms reach of the MHTs at all times.

b) Random Patient #9 (R9):
The daily "Assignment Sheets" for 5/24/10 and 5/25/10 revealed there were (3) MHTs scheduled to work (day shift) and (5) MHTs scheduled to work (night shift). There were 3 patients (R7, #3, R9) assigned 1:1 supervision on the assignment sheets for 5/24 and 5/25. Review of the assignment sheets for 5/24 and 5/25 read as follows:
On 5/24/10, there was no documented evidence on the MHT assignment sheets that R9 was monitored 1:1 by the MHTs during the day shift on 5/24/10.
On 5/24/10, S11MHT (night) was assigned to seven (7) patients including R9,
On 5/25/10, S11MHT (day) was assigned to seven (7) patients including R9 and S11MHT was assigned to two (2) patients to monitor 1:1, (R9 and R10) both at the same time. There was documented evidence on the daily " Assignment Sheets " for 5/24 and 5/25 that R9 was in line of sight and in arms reach of the MHTs at all times.

c) Random Patient #10 (R10):
Review of the daily "Assignment Sheets" on 5/24/10 and 5/25/10 revealed there were (3) MHTs scheduled to work (day shift) and (5) MHTs scheduled to work (night shift). There were 3 patients (R7, #3, R9) assigned 1:1 supervision on the assignment sheets for 5/24. Further review of the Assignment Sheets for 5/24 revealed there was no documented evidence R10 was monitored by a MHT during the day shift.

The daily "Assignment Sheets" dated, 5/25/10 revealed there were (3) MHTs scheduled to work the day shift and (5) MHTs to work the night shift. There were 4 patients, (R7, #3, R9, R10) assigned 1:1 supervision on the assignment sheets for 5/25/10. S11MHT (day) was assigned to four (4) patients that included (2) patients, with 1:1 supervision (R9, R10) to be monitored at the same time during the same shift. S19MHT (night) was assigned to ten (10) patients including R10 ' s 1:1 supervision. There was documented evidence R10 was in line of sight and in arms reach of the MHTs at all times as designated by the charge nurses on the daily assignment sheets on 5/25.

Further review of the "Assignment Sheets" for 5/26/10 revealed there were (6) MHTs scheduled to work that day. Further review revealed there were 4 patients (R7, R9, R10, #3) assigned by the charge nurse to have 1:1 supervision monitoring by the MHTs. The " Assignment Sheets " read as follows, R10 was assigned to two (day) MHTs, (S15MHT) was assigned to nine (9) patients with 2 patients being 1:1 supervision, (R7 and R10) and (S16MHT) was assigned to six (6) patients with 2 patients, (R10 and #3) being monitored 1:1 supervision both at the same time during the same shift,
On 5/26/10, S8MHT (night) was assigned to three (3) patients including R10 ' s 1:1 supervision;

There was documented evidence R10 was in line of sight and in arms reach of the MHTs at all times as designated by the charge nurses on the daily assignment sheets on 5/26.

d) Patient #3:
Review of the medical record for #3 revealed there was a physician ' s order dated/timed 5/23/10 at 11:00 a.m. for a " 1:1 status ", which meant the patient was to be remain in line of sight and in arms reach of the MHT at all times.

Review of the daily "Assignment Sheets " for 5/23, 5/24, 5/25 and 5/26 revealed the charge nurses had assigned 1:1 supervision by the MHTs for #3. Further review revealed there were (4) MHTs scheduled to work day shift and (4) to work the night shifts on 5/23/10. There were 2 patients (R7, #3) assigned 1:1 supervision by the charge nurses on the assignment sheets, 5/23/10. The " Assignment Sheets " read, #3 was assigned to 2 (day) MHTs, (S17MHT and S20MHT) both had (6) patients each. There was documented evidence #3 remained in line of sight and in arms reach of the MHTs at all times as designated by the charge nurses on the daily assignment sheets on 5/23/10.

Further review of the "Assignment Sheets" dated, 5/24/10 revealed there were 3 MHTs designated/assigned to work the day shift. There were 3 patients (#3, R7, R9) assigned 1:1 supervision by the charge nurses on the MHT ' s assignment sheets. There were no documented evidence #3 ' s 1:1 supervision was monitored by the MHT as assigned by the charge nurses on the assignment sheet for the day shift on 5/24/10. There was documented evidence #3 remained in line of sight and in arms reach of the MHTs at all times as designated by the charge nurses on the daily assignment sheets on 5/24.

The daily "Assignment Sheets" for 5/25/10 revealed there were (3) MHTs scheduled to work the day shift and (5) MHTs scheduled to work the night shift. There were 4 patients, (R7, #3, R9, R10) assigned 1:1 supervision on the daily assignment sheets for 5/25. The " Assignment Sheets " read, S14MHT (day) was assigned to five (5) patients

Based on record reviews, observation and interviews, the hospital failed to meet the Condition of Participation in Pharmacy Services as evidenced by:

1) Failing to ensure the drugs and biologicals were stored and secured in a locked medication room per hospital policies and procedures when the door to the medication room was disabled from 5/25/10 to 6/8/10 without direct staff supervision of the medication room and medication cart located inside the room. During this time, there were 12 psychiatric patients hospitalized, including 4 suicidal patients and 3 dementia patients. (See deficiency cited at A0502)

2) Failing to have a system in place to identify medication errors and ensure that medication variance reports were completed according to hospital policies and procedures. Patient #3 was not administered 42 oral medications according to physician's ordersand 23 nebulizer treatments were not administered according to physician's orders, without evidence the hospital had identified these medication errors, completed a medication variance report, and reported the findings through the QA program. (See deficiencies cited at A0508).

Based on record reviews, observation and interviews, the pharmacy failed to ensure the drugs and biologicals were stored and secured in a locked medication room as per hospital policy and procedures when the door to the medication room was disabled from 5/25/10 to 6/8/10 without direct staff supervision of the medication room and medication cart located inside the room. During this time, there were 12 psychiatric patients, (#4, #5, #6, #7, R1, R2, R3, R4, R5, R6, R8, R9) hospitalized, including 4 suicidal patients and 3 dementi patients. Findings:

Review of the census on 6/8/10 revealed there were 12 psychiatric patients, (#4, #5, #6, #7, R1, R2, R3, R4, R5, R6, R8, R9) on the acute care unit. Further review revealed there were 4 patients were on suicidal watch and 3 demented patients.

Review of the State Fire Marshall's last inspection on 5/25/10 revealed the electronic system to lock the medication room's door was disabled.

A tour of the Medication Room was conducted on 6/8/10 from 10:05 a.m. to 10:15 a.m. revealed the medication room was unlocked for about 10 minutes with no nursing staff present. Further observation revealed there was a Medication Cart located in the unlocked room along with a brown bin located on the back wall in the room with Emergency Stock Medications noted in it.

At 10:15 a.m., S22LPN entered into the unlocked Medication Room. S22LPN verified the Medication Room, Medication Cart and Emergency Stock Medications were unlocked and unsecured from the 12 psychiatric patients, (#4, #5, #6, #7, R1, R2, R3, R4, R5, R6, R8, R9) hospitalized on the unit. S22 indicated the Medication Room's Door is locked by using an electronic key system in which the system was disabled one day last week. She reported there was no key in the nursing station or on the unit to lock the Medication Room. She indicated the Medication Room, Medication Cart and Emergency Stock Medications must be kept locked at all times as per hospital policy. S22 reported the hospital's policy to keep the medication room, medication cart and emergency stock medications was not followed by having the medication room, medication cart and emergency stock medications unlocked/unsecured in the medication room and accessible to all 12 shchiatric ric patients, (#4, #5, #6, #7, R1, R2, R3, R4, R5, R6, R8, R9) on the unit. She confirmed the unlocked medication's cart had two (2) drawers, (#1 and #2). Drawer #1 had 12 medications for #5, 10 medications for #7, 3 medications for R2, 20 medications for R3, 10 medications for R5, 9 medications for R8. Drawer #2 had 13 medications for #4, 12 medicaitons for #6, 6 medications for R1, 9 medications for R4, 6 medications for R6, 14 medications for R9. This was a total of about 124 medications in the unlocked/unsecured Medication Cart in the unlocked Medication Room that was accessible to the 12 patients, (#4, #5, #6, #7, R1, R2, R3, R4, R5, R6, R8, R9) on the unit. S22LPN reviewed the "Drug Formulary, Non-Narcotic, Emergency Cabinet" form, pages 1 to 2. She verified the emergency stock medications had approximately 934 medications accessible to the 12 patients, (#4, #5, #6, #7, R1, R2, R3, R4, R5, R6, R8, R9) on the unit.

In interview with the Administrator (S2) on 6/8/10 at 10:30 a.m., he verified the Medication Room was unlocked/unsecured. He was instructed that the medication room was observed by the surveyor for 10 minutes unlocked/unsecured with all medications available to the 12 patients, (#4, #5, #6, #7, R1, R2, R3, R4, R5, R6, R8, R9) on the unit. S2 indicated the medication room, medication cart, and emergency stock medications must be kept locked at all times as per the hospital's policy. The Administrator confirmed that all of the medications in the medication room, medication cart and stock medications were accessible to all 12 patients, (#4, #5, #6, #7, R1, R2, R3, R4, R5, R6, R8, R9) on the unit.

S5RN, Charge Nurse was interviewed on 6/8/10 at 10:35 a.m. and she verified the medication room, medication cart and emergency stock medications was unlocked/unsecured. S5RN denied knowledge the electronic key system to lock the medication room was disabled one day last week. S5 further denied there was no key in the nursing station and/or on the unit to lock the Medication Room. She indicated the medication room, medication cart, and emergency stock medications must be kept locked at all times as per the hosptial's policy. S5RN further indicated that no medication cart must be left unattended without being locked. S5 verified the medication cart contained all 12 patients, (#4, #5, #6, #7, R1, R2, R3, R4, R5, R6, R8, R9) medications of about 124. She reported the 124 patient's medications were accessible to all 12 patients, (#4, #5, #6, #7, R1, R2, R3, R4, R5, R6, R8, R9) on the unit. She denied knowledge of how many medications were contained in the emergency stock medicaiton's bin. She reviewed the "Drug Formulary Non-Narcotic" pages 1 to 2. She indicated the emergency stock medications contained about 934 medications in it. She further indicated the 934 medications were accessible to all 12 patients, (#4, #5, #6, #7, R1, R2, R3, R4, R5, R6, R8, R9) on the unit.

Review of the policy titled, "Medication Administration", Policy 12.14, with hospital "c"'s letterhead, pages to 4, with no effective, revised or reviewed dates and presented as the current Medication Administration policy read, "6. Keep medicine room door locked. Only hospital staff nurses are permitted to carry the key. 8. All areas where there are medications are to be locked when not in use to include the medication room and the medication cart. Principles of Medication Administration- Q. Do not leave medication cart unattended, unless it is locked and in the medication room".

Review of the policy titled, "Storage and Care of Medications", Policy 12.21, with hospital "c"'s letterhead, pages 1 of 2, with an originated date: June 200, with no revised or reviewed dates and presented as the current Medication Storage policy read, " (Hospital "c" named) secures medications within a locked Medication Room. Use it for this purpose. The medication room shall have the following sections, 1. Patient Medication Cart, 2. Emergency Drug Kit (Night Cabinet). Patient Medicaton Cart...4. The medicine cart must be locked when not in use... Emergency Drug Kit (Night Cabinet) 1. Must be locked in the medication room at all times...2.c) the cart will be available at all times to ensure that medications are more readily available for patient care. 3. A stock of medications will be maintained including a written record of what is available".

Based on record reviews and interview the pharmacy failed to have a system in place to identify medication errors and ensure that medication variance reports were completed according to hospital policies and procedures. Patient #3 was not administered 42 oral medications according to physician's ordersand 23 nebulizer treatments were not administered according to physician's orders, without evidence the hospital had identified these medication errors, completed a medication variance report, and reported the findings through the QA program. Findings:

Review of the incident reports for April and May 2010 revealed there were 13 documented patient falls.

There were 42 missed oral medication administrations and 23 missed nebulizer treatments for Patient #3 from 5/15/10 through 5/26/10. Further review revealed there was no documented evidence that the nursing staff filed medication variance reports and hospital occurrence reports for the 42 missed oral medication administrations and/or 23 missed breathing treatments for Patient #3 from 5/15 to 5/26 as per Pharmacy policy. There was no documentation of the tracking and trending for the 42 missed oral medications and/or the 23 missed nebulizer treatments for Patient #3 from 5/15/10 to 5/26/10.

In interview with S1RN, Interim DON on 6/11/10 from 12:00 p.m. to 12:30 p.m., she reviewed Patient #3 ' s medical record and MARs (5/15 to 5/26/10). She verified #3 was a diabetic. She agreed #3 had 42 missed oral medication administrations as indicated in the above findings. She confirmed #3 had 23 missed doses of nebulizer treatments as indicated in the above findings. She indicated all medications are to be administered as ordered by the prescribing physician. She further indicated all physicians ' orders are to followed including medication administrations and breathing treatments for continuity of care. S1RN agreed there were blank squares on MAR (5/15 to 5/26) indicating #3 was not administered the oral medications and/or breathing treatments. She indicated the " Medication Administrations MAR Systems " policy indicates that blank squares on the MAR are medication errors that should be reported immediately to the attending physician and pharmacist. S1 verified there was no documented evidence the nursing staff notified pharmacist of the 42 missed medication administrations and/or 23 missed breathing treatments for #3. S1 indicated the nursing staff did not follow the hospital's policy for " Missed Medication Administrations " to be reported to the pharmacist, immediately then fill out a medication variance report for the 42 missed medications and 23 missed breathing treatments. She verified there were no medication variance reports on the 42 missed oral medications or 23 missed breathing treatments. She denied knowledge of why the nursing staff failed to administer #3 the 42 oral medications and the 23 breathing treatments as ordered by the attending psychiatrist. She agreed the nursing staff did not follow the Medication Administration Policy that all physicians ' orders are to be followed. She denied knowledge of why the nursing staff did not fill out the medication variance reports on the 42 missed oral medications and 23 breathing treatments. She reported the nursing staff did not follow the " Medication's Administration " Policy that all physician's orders (oral medication administrations and breathing treatments) are to be followed. She did not know what the medication error rate was for the past six months. S1RN indicated that the medication error rate was inaccurate because pharmacy did not identify #3 had 42 missed oral medications and 23 missed breathing treatments during his hospital stay. She continued pharmacy did not have a system in place to identify that the nursing staff did not administer the oral medications and breathing treatments. She did not know how long it would take pharmacy to have identified that #3 had 42 missed medication administrations and 23 missed breathing treatments by nursing staff.
In an interview on 06/11/10 at 1:15 p.m. S4RN, QA/PI and S1DON confirmed there was no data collected to indicate the QA/PI department was tracking falls. S1DON indicated there was data collected on the 42 missed medication administrations or 23 missed nebulizer treatments. The DON further indicated these 65 missed medication administrations were medication errors. The DON stated all medication errors have to have a medication variance report filed. She verified there were no medication variance reports filed on the 65 missed medication administrations. She indicated the 65 missed medication administrations did not have an occurrence report filed. She further indicated the occurrence reports on the 65 missed medication administrations are reported to Risk Management. Risk Management in turns tracks and trends the 65 missed medication administrations. The DON indicated there is no system in place to track and trend the falls or the 65 missed medication administrations.

The policy titled, "Pharmacy Services " , Policy number" 5.17, with hospital "c"'s letterhead, pages 1 to 3, with no effective, revised or reviewed dates and presented as the current " Pharmacy Services " Policy was reviewed and read, " ...10. All medication errors, will be fully documented in the patient ' s medical record. A Hospital Occurrence Report (HOR) form must be filled out. (see 12.14, 12.3 and 12.31)..18. A HOR, in addition to the Medication Error Reporting Form will be completed for medication errors...:(12.14, 12.3, 12.31) ...c) the Administrator and Director of Nursing will review and evaluate each incident. d. Each incident will be reported to the Pharmacist for inclusion in the report to the Medical Staff (Pharmacy and Therapeutics) ... " .

Review of the policy titled, "Occurrence Reports " , Policy number" 8.6, with hospital "c"'s letterhead, pages 1 to 3, Originated: June 2009, with no effective, revised or reviewed dates and presented as the current " Occurrence Reports " policy read, " ...It is policy of the Hospital to document on a Hospital Occurrence Report the occurrence of any unusual event. Purpose-To maintain a record of the unusual occurrences and provide a mechanism for monitoring and minimizing risk in the Hospital. Procedure-1) Occurrences for which an HOR should be completed include, but are not limited to, the following (if doubt remains, the HOR should be completed " : ...d. Medication Errors- 1. Omissions ...7. Hospital occurrence reporting shall be sent to PI coordinator who will trend same process VIA the hospital PI committee structure ... " .

The policy titled, "Medication Administration" Policy number" 12.14, with hospital "c"'s letterhead, pages 1 to 4, with no effective, revised or reviewed dates and presented as the current Medication Administration policy was reviewed and read, "N. Medications are to be given and charted on the Medication Administration Record (MAR)".

Review of the policy titled, "Administration of Medications Using the MAR System" Policy number" 12.2, with hospital "c"'s letterhead, pages 1 to 4, with no effective, revised or reviewed dates and presented as the current Medication Administration Using the MAR policy read, "13. If patient is not available when medication is due the actual time the medication is given is to be written in the square with your initials. 22. To ensure complete accuracy, once ever(y) 24 hours the MAR should be checked against the doctor's orders. 24. Blank spaces on the MAR indicate a medication error; therefore, each nurse should check the forms before going off duty to make sure all squares are properly initiated. 25. No blanks are to be left when transcribing orders. 26. Remember to record all medication refusals, omissions, and PRNs in the nurses' notes as well as the MAR".

Based on interview the hospital failed to track adverse patient events as evidenced by the Quality Assurance/Performance Improvement (QA/PI) department having no data related to patient falls in the hospital. Findings:

Review of the incident reports for April and May 2010 revealed there were 13 documented patient falls.

In an interview on 06/11/10 at 1:15 p.m. S4RN, QA/PI and S1DON confirmed there was no data collected to indicate the QA/PI department was tracking falls.

Based on interview the hospital failed to use data collected to monitor patient safety as evidenced by the Quality Assurance/Performance Improvement (QA/PI) department having no data collected related to patient falls in the hospital. Findings:

Review of the incident reports for April and May 2010 revealed there were 13 documented patient falls.

In an interview on 06/11/10 at 1:15 p.m. S4RN, QA/PI and S1DON confirmed there was no data collected to indicate the QA/PI department was tracking falls.

Based on interview the hospital failed to collect data to identify opportunities for improvement and changes that will lead to improvement as evidenced by the Quality Assurance/Performance Improvement (QA/PI) department having no data collected related to patient falls in the hospital. Findings:

Review of the incident reports for April and May 2010 revealed there were 13 documented patient falls.

In an interview on 06/11/10 at 1:15 p.m. S4RN, QA/PI and S1DON confirmed there was no data collected to indicate the QA/PI department was tracking falls.

Based on interview the hospital failed to focus on high-risk, high-volume, or problem-prone areas that affect health outcomes and patient safety as evidenced by the Quality Assurance/Performance Improvement (QA/PI) department having no data collected related to patient falls in the hospital. Findings:

Review of the incident reports for April and May 2010 revealed there were 13 documented patient falls.

In an interview on 06/11/10 at 1:15 p.m. S4RN, QA/PI and S1DON confirmed there was no data collected to indicate the QA/PI department was tracking falls.

Based on interview the hospital failed to analyze the cause of adverse patient events (falls) as evidenced by the Quality Assurance/Performance Improvement (QA/PI) department having no data collected related to patient falls in the hospital. Findings:

Review of the incident reports for April and May 2010 revealed there were 13 documented patient falls.

In an interview on 06/11/10 at 1:15 p.m. S4RN, QA/PI and S1DON confirmed there was no data collected to indicate the QA/PI department was tracking falls.

Based on interview the hospital failed to implement preventive actions and mechanisms that include feedback and learning throughout the hospital related to patient falls as evidenced by the Quality Assurance/Performance Improvement (QA/PI) department having no data collected related to patient falls in the hospital. Findings:

Review of the incident reports for April and May 2010 revealed there were 13 documented patient falls.

In an interview on 06/11/10 at 1:15 p.m. S4RN, QA/PI and S1DON confirmed there was no data collected to indicate the QA/PI department was tracking falls.

Based on interview the hospital failed to take actions aimed at performance improvement related to patient falls as evidenced by the Quality Assurance/Performance Improvement (QA/PI) department having no data collected related to patient falls in the hospital. Findings:

Review of the incident reports for April and May 2010 revealed there were 13 documented patient falls.

In an interview on 06/11/10 at 1:15 p.m. S4RN, QA/PI and S1DON confirmed there was no data collected to indicate the QA/PI department was tracking falls.