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Based on review of nursing services, pharmacy services, personnel files, observation of the physical environment and staff interview, the hospital failed to ensure that all services furnished in these areas complied with all applicable conditions of participation. The facility did not have a current pharmacy contract, did not employ an executive nurse, did not have evidence of current nursing licenses for registered nurses, did not provide orientation to all employees and did provide a physical environment that met the life safety code (LSC) requirements. The total facility census at the time of the survey was zero.

Findings include:

Review of personnel files, the facility's pharmacy contract and staff interview found that the hospital failed to ensure that all services furnished in the areas of nursing and pharmacy services complied with all applicable conditions of participation.

Please see details at A83.

Based on review of the personnel records and staff interview the facility failed to maintain an executive nurse to provide nursing leadership and failed to ensure all nurses maintained a current nursing license. The total facility census at the time of the survey was zero.

Findings include:

The facility failed to maintain a director of nursing to provide nursing leadership.

Please see A386 for additional details.

The facility failed to ensure that 4 of 7 registered nurses (Staff # 10, 11, 23 and 24)considered to be the hospital's nursing pool have evidence of a current nursing license.

Please see A394 for additional details.

This deficiency substantiates an allegation contained in Complaint OH00054715.

Based on observation, review of personnel records and staff interview the facility failed to be in compliance with the existing 2000 life safety code at the time of the 04/12/10-04/14/10 recertification and Complaint investigation OH00054715. The total facility census during the survey was zero.

Findings include:

The 2000 LSC existing code was not met as evidenced by the following deficient areas cited:
K-27 Gaps > 1/8 inch between smoke doors in closed position.
K-38 Unsafe exit discharges at three exits.
K-50 Missed fire drills.
K-54 No sensitivity testing of smoke detectors.
K-56 Not performing quarterly sprinkler tests.
K-144 No weekly generator inspections.
K-154 No fire watch plan for the sprinkler system.

Please see A710 for details relating to the life safety code requirements which were not met.

Based on review of personnel files, review of contracts and interview of staff, the hospital failed to ensure that the Certified Nurse Practitioner (CNP) had a current contract and a current agreement with a physician that was credentialed at the hospital for oversight and supervision. The total facility census at the time of the survey was zero.

Findings include:

During review of the personnel files and review of the contracts, it was noted that the current contract for the CNP ran from 04/13/09 thru 01/13/10. There was no documented evidence in either the CNP's personnel file or in the "contracts" book showing that the contract had been renewed.
The personnel file for the CNP contained evidence of a gerontologist providing oversight and supervision to the CNP, but there was no documented evidence of a physician providing the oversight and supervision for the psychiatric adolescent population that the CNP was working with at the hospital.
Interview with Staff G on Tuesday, 04/13/10, in the morning, revealed that Staff G was not aware of being the person that had oversight or supervision for the CNP while the CNP was practicing at the hospital working with psychiatric adolescents.

This deficiency substantiates the allegation in complaint number OH00054715.

Based on review of nursing services, pharmacy services, personnel files, observations of the physical environment and staff interview, the hospital failed to ensure that all services furnished complied with all applicable conditions of participation. The facility does not currently have a pharmacy contract and review of the personnel files of staff #s 1-27 found that the facility failed to ensure that nursing licenses were current and that all employees received orientation. Observation of the physical environment found multiple life safety code (LSC) violations. The facility census during the survey was zero.

Findings include:

Per review of nursing services, there is no executive nurse employed by the hospital as of 04/14/10. Per interview with Staff B, the executive secretary, on 04/13/10 at 4:45 PM, there are currently seven registered nurses (Staff # 9, 10, 11, 12, 23, 24, and 25) considered to be necessary staff on an as needed basis (PRN). These seven staff indicated to Staff A, the executive director, that each would be available for individual shifts if needed and if available per interview on 04/14/10 at 10:45 AM. Additionally, 4 of 7 registered nurses (Staff # 10, 11, 23 and 24) did not have documented evidence of a current nursing license in their personnel files reviewed on 04/14/10. Each license had expired on 08/31/09 even though each of the four were approved to work between 08/31/09-10/16/09 when the last patient was discharged. Hospital orientation was not provided to 7 of 7 registered nurses (Staff # 9, 10, 11, 12, 23, 24, and 25) as determined by documentation in their personnel records and per interview with Staff A on 04/14/10 at 1:45 PM.

Please see A385, A386, A394 and A397.

Per interview with Staff A on 04/12/10 at 11:15 AM, the hospital currently has no contracted pharmacy company. The previous company had been sold and the current owner is not interested in providing pharmacy service to the hospital. Per observation on 04/13/10 at 10:45 AM, there is no medication storage even though a bottle of milk of magnesia and a bottle of Mylanta opened in 2009, according to the label, were located on the counter in the nurses station on the west wing. The nurses station is open to the patient hallway. These findings were verified by Staff H on 04/13/10 at the time of the tour. A request was made to Staff A and Staff B on 04/12/10 to review the drug formulary. As of 12:30 PM on 04/14/10 this information had not been found.

Please see findings at A491, A492, A493 and A511.

Per the life safety code (LSC) findings on 04/13/10, the hospital does not meet the existing 2000 life safety code in seven areas.

Please see A710.

This deficiency substantiates allegations contained in Complaint OH00054715.

Based on observation and staff interview, the hospital failed to ensure that information in regard to the complaint hotline of the State Regulatory Agency was available and posted. The total facility census at the time of the survey was zero.

Findings include:

During tour of the nursing unit area on Monday, 04/12/10, in the afternoon, of the nursing unit area,the main entry area, the admissions area and the dining room area, it was noted there was no posted information in regard to the State Hotline number for complaints. A re-tour of the areas on Wednesday, 04/14/10, at approximately 11:50 AM with Staff A, again revealed that there was no posted information in regard to the State Hotline number for complaints. Staff A confirmed that there was no posted information for the State Hotline number for complaints.

Based on review of personnel files, the in-service manual and staff interview, the hospital failed to ensure that staff were trained in the proper application of restraint and seclusion techniques for 21 patients that were admitted to the hospital from April of 2009 thru October of 2009. The total facility census at the time of this survey was zero.

Findings include:

During review of personnel files it was noted that 17 of the 27 staff reviewed (Staff # 4-7, 9-13, 16, 18, 21-25, and 27) did not have documented evidence of having had an orientation after being hired and prior to working with patients. Review of the 10 staff that had an orientation (Staff # 1-3, 8, 14, 15, 17, 19, 20 and 26) revealed that the subjects covered did not include restraints or seclusion. When asked about further information in regard to orientation and restraints, Staff A brought in a manual of in-service information on Wednesday, 04/14/10 around 1:45 PM, that included only the subject and the signatures of those that attended. The last documented in-service for restraint application was noted to have been done in December of 2008, with 9 staff members attending. Of the 9 staff that attended that in-service, not one is currently on staff at the hospital.

Review of the hospital's restraint and seclusion policy and procedure Number 2004 stated that "during hospital orientation, the initial seclusion and restraint competency is completed and then revisited at 90 days and 1 year reviews. All behavioral health unit staff will be Therapeutic Assault Prevention System (TAPS) certified within 90 of employment and have 1st. aid training.

During interview with Staff A the morning of 04/14/10, Staff A stated that all staff are trained in TAPS - Therapeutic Assault Prevention System. During review of the personnel files, it was noted that 10 out of the 27 staff reviewed (Staff # 7-10, 12, 13, 18, 21, 22 and 23) which included RNs, LPNs, and Psychiatric Technicians, did not have the TAPS training.
During an interview with Staff A the afternoon of Wednesday, 04/14/10, revealed that orientation information was all in the personnel files and a list of all in-services was in the manual.


This deficiency substantiates the allegations in complaint number OH00054713.

Based on review of personnel files and staff interview, the hospital failed to ensure that staff had the education and training and demonstrated knowledge based on the needs of their patient population in the use of first aid techniques and cardiopulmonary resuscitation (CPR) with periodic recertification. This included 17 out of 27 staff reviewed (Staff # 5-8, 10-12, 14-15, 17-19, 21, and 23-26) for cardiopulmonary resuscitation and 10 of 27 staff reviewed (Staff # 7-10, 12, 13, 18, 21, 22 and 23) for Therapeutic Assault Prevention System (TAPS) which is a specialized technique to help patients de-escalate their behavior. Eight of the 14 Psychiatric Technicians (Staff # 13-18, 21 and 26) did not have a current certificate for First Aid training. The total facility census at the time of this survey was zero.

Findings include:

During review of the personnel files on Tuesday, 04/13/10 and Wednesday, 04/14/10, it was noted that 17 out of 27 staff reviewed (Staff # 5-8, 10-12, 14-15, 17-19, 21, and 23-26) did not have a current CPR credentials. When asked on Wednesday afternoon 04/14/10 if there was any further information in regard to areas of staff training, Staff A stated that all training was in the personnel files of the individual staff. At approximately 1:45 PM, Staff A brought in a manual that contained all classes given to staff along with sign-in sheets. Review of this manual revealed that the number of staff that did not have their current CPR remained the same.

During this same review it was noted that 10 out of the 27 staff reviewed (Staff # 7-10, 12, 13, 18, 21, 22 and 23) did not have training in the TAPS. Review of the manual with training given to staff confirmed that the same 10 staff (Staff # 7-10, 12, 13, 18, 21, 22 and 23) did not have the TAPS training.

During review of the personnel files on Tuesday and Wednesday of the survey, it was noted that some individuals had first aid training while others did not. Eight of the 14 Psychiatric Technicians (Staff # 13-18, 21 and 26) did not have a current certificate for First Aid training.

This deficiency substantiates the allegations in complaint number OH00054715.

Based on staff interview and review of personnel records, the hospital failed to maintain a director of nursing. The total facility census at the time of the survey was zero.

Findings include:

Per interview with Staff A on 04/12/10 at 11:15 AM, the hospital is in the process of interviewing for an executive nurse/director of nursing. Currently the hospital maintains a pool of registered nurses and licensed practical nurses to be used on an "as needed basis" (PRN), but lacks a registered nurse in the leadership role. Per interview with Staff B on 04/13/10 at 4:45 PM, there are seven PRN registered nurses currently on the hospital personnel roster. The hospital discharged the last two patients on 10/16/09.

Review of personnel records on 04/13/10 and 04/14/10 revealed no full time registered nurses. These findings were confirmed by Staff A on 04/14/10 at 10:15 AM.

This deficiency substantiates an allegation contained in Complaint OH00054715.

Based on personnel record review and staff interview, 4 of 7 registered nurses (Staff #10, 11, 23 and 24) considered to be the hospital's nursing pool do not have evidence of current licensure. The total facility census at the time of the survey was zero.

Findings include:

Per review of the personnel records of Staff #10, 11, 23 and 24 on 04/14/10, none of these four registered nurses had evidence of a current nursing license. Per interview with Staff A at 10:35 AM on 04/14/10, the procedure to ensure hospital nursing personnel have current licensure is for human resources to check upon hire. Per interview with Staff A on 04/14/10 at 10:45 AM, all of the four nurses without evidence of current licensure " could have called upon to work between 08/31/09-10/16/09". State licenses of registered nurses are valid for a two year period and were required to be renewed by 08/31/09 for the period thru 08/31/11.

This deficeincy substantiates an allegation contained in Complaint OH00054715.

Based on medical record review of closed records and staff interview, 1 of 10 patient records reviewed (Patient #4) did not have evidence that the registered nurse supervised the nursing care of each patient. The total facility census during the survey was zero.

Findings include:

Per medical record review on 04/12/10, Patient 4 was admitted to the hospital on 05/15/09 at 09:45 AM with diagnoses including bipolar disorder, depression, attention deficit hyperactivity (ADHD) and insulin dependent diabetes mellitus. This 13 year old was 5'7" and weighed 135 pounds at admission. Humalog insulin was ordered as directed per "clinic". The medical record contained a document that addressed insulin coverage for the amount of carbohydrates eaten along with sliding scale blood sugars which were completed four times daily. A long acting insulin (Lantus) order was also included on a daily basis and was given in the evening. Recorded blood sugars ranged from 96-423 mg/dl for the first blood sugar of the day between 07:00 AM-08:00 AM on 05/16/09-05/19/09. Normal blood sugar level are 70-100 mg/dl. Blood sugars measured prior to lunch from 05/15/09-05/19/09 measured 197-410 mg/dl. On 05/16/09 there was a medical order written by the nurse practitioner for a dietary consult. No dietary order was documented. No documentation that the dietary consult had been completed was found. Staff H verified on 04/13/10 at 11:20 AM that the dietary consult was not completed and that no diet order was found. Having worked with Patient 4, Staff H stated he/she had never seen insulin coverage based on carbohydrates prior to providing nursing care to Patient 4. Documentation in the medical record reflected nutritional intake for 05/15/09, 05/16/09 and 05/19/09. No documentation was found for nutritional intake (including number of carbohydrates) to support the administration of the amount of Humalog insulin given. A nurse no longer employed at the hospital failed to administer Humalog insulin to cover the carbohydrates for Patient 4's breakfast on 05/17/09 due to the order not being "clear". This was confirmed by Staff H on 04/13/10 at 11:20 AM.

Based on review of personnel files, the in-service manual and staff interview, the hospital failed to ensure that staff had specialized training, qualifications and competency in the caring for patient needs. There were 21 patients that were admitted to the hospital from April of 2009 thru October of 2009. The total facility census during the survey was zero.

Findings include:

During review of personnel files it was noted that 17 of the 27 staff reviewed (Staff # 4-7, 9-13, 16, 18, 21-25, and 27) did not have documented evidence of having had an orientation. When asked about further information in regard to orientation, Staff A brought in a manual of in-service information on Wednesday, 04/14/10 around 1:45 PM, that included only the subject and the signatures of those that attended.

During interview with Staff A the morning of 04/14/10, Staff A stated that all staff are trained in TAPS - Therapeutic Assault Prevention System. During review of the personnel files, it was noted that 10 out of the 27 staff reviewed (Staff # 1-3, 8, 14, 15, 17, 19, 20 and 26) did not have the TAPS training. Staff included 7 RN's, 4 LPN's working as Psychiatric Technicians and 10 Psychiatric Technicians.

During interview with Staff A the afternoon of Wednesday, 04/14/10, revealed that orientation information was all in the personnel files and a list of all in-services was in the manual.

During review of the personnel files on Tuesday and Wednesday of the survey, it was noted that some individuals had first aid training while others did not. Eight of the 14 Psychiatric Technicians (Staff # 13-18, 21 and 26) were noted not to have a current certificate for First Aid training.

This deficiency substantiates the allegations in complaint number OH00054715.

Based on review of 10 closed medical records, review of the policies and procedures and staff interview, the hospital failed to ensure that there were proper discharge summaries with outcomes of the hospitalization, disposition of care and provision for follow up care for 10 out of 10 records reviewed. (Patient #s 1-10) The total facility census during the survey was zero.

Findings include:

During review of closed medical records for Patients #1-10 on Monday, 04/12/10 and Tuesday, 04/13/10, it was noted that there were no discharge summaries written by the physician or other qualified practitioner that had taken care of the patient. The discharge summaries were noted to be written by a Registered Nurse (RN) and by the Licensed Independent Social Worker (LISW). There was no documented evidence that the physician had delegated this specific task to the RN or the LISW, nor were any of the discharge summaries co-authenticated by the physician. This was shared with Staff A and Staff B on Wednesday, 04/14/10.

During review of the closed medical records, it was noted that one of the discharged patient's follow-up visits was not made by the hospital but stated that the parent should call and make an appointment the following morning. Interview of Staff G revealed that the follow-up visit appointment was never made by the parent. This information was shared with Staff G and H on Tuesday, 04/13/10 and with Staff A and B on Wednesday, 04/14/10.

Based on closed medical record review and staff interview, the hospital failed to ensure that the medical records were completed in 30 days following the patients discharge. This included patients 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 who had been discharge from April of 2009 thru October of 2009. There were a total of 25 discharges from all of the timeframes the hospital was open from 2008 thru 2009. The total facility census during the survey was zero.

Findings include:

During review of the 10 closed records (Patients #1-10), it was noted that a Registered Nurse (RN) and the LISW were the persons completing a discharge summary on the patients. None of the discharge summaries of the 10 closed records that were reviewed showed documentation that the physician had co-authenticated the discharge summaries, leaving the medical record incomplete. This information was shared with Staff A and B on Wednesday, 04/14/10.

Based on observation, review of documentation and staff interview the facility failed to have a current contract with a pharmacy to provide pharmaceutical services, did not have the capability to store medications, did not have a pharmacist responsible for developing, supervising and coordinating the activities of the pharmacy service, and no capability for pharmacy emergency services. These findings were verified by Staff A, the executive director on 04/12/10 at 11:15 AM. The total facility census during the survey was zero.

Findings include:

Based on observation, review of current contracts and staff interview, there is no current drug storage in this facility which meets accepted professional standards nor does the facility have a current pharmacy contract to provide pharmacy services.

Please refer to A491 for further details.

Based on staff interview and review of current hospital contracts, the hospital failed to maintain a contract to ensure an adequate number of personnel to provide pharmacy services, including emergency services.

Please refer to A492 for further details.

Based on staff interview and review of current hospital contracts, the hospital failed to maintain a contract to ensure an adequate number of personnel to provide pharmacy services, including emergency services.

Please refer to A493 for further details.

Based on observation, review of current contracts and staff interview, there is no current drug storage in this facility which meets accepted professional standards. The total facility census during the survey was zero.

Findings include:

Per observation on 04/13/10 at 11:00 AM while accompanied by Staff H, a registered nurse, the west wing nurses station was observed. Staff H confirmed there was no area for drug storage and a bottle of milk of magnesia and a bottle of Mylanta were observed on the nurses station counter. The nurses station is open to the hallway. Per interview with Staff H, when the hospital had patients, there was a big medication cart which contained all medications. This had been removed by the previous pharmaceutical company earlier in the year (2010), according to Staff A on 04/12/10 at 11:15 AM.

Per review of current hospital contracts on 04/13/10, there is no current contract with a pharmaceutical company to provide pharmacy services. This was confirmed by Staff A on 04/12/10 at 11:15 AM.

This substantiates an allegation contained in Complaint OH00054715.

Based on staff interview and review of current hospital contracts, there is no pharmacist responsible for developing, supervising, and coordinating pharmacy activities. The total facility census during the survey was zero.

Findings include:

Per interview with Staff A, the executive director on 04/12/10 at 11:15 AM, the hospital has no current contract with a pharmaceutical company. Review of the contract book revealed the previous contract expired on 04/12/10. Per interview with Staff A on 04/12/10, the previous company with whom the hospital had a contract had been sold and the new owner was not interested in providing service to the hospital. No separate contract was found for a consulting pharmacist.

This deficiency substantiates an allegation contained in Complaint OH00054715.

Based on staff interview and review of current hospital contracts, the hospital failed to maintain a contract to ensure an adequate number of personnel to provide pharmacy services, including emergency services. the total facilty census during the survey was zero.

Findings include:

Per interview with Staff A on 04/12/10 at 11:15 AM, the hospital does not have a current contract for pharmacy services. Review of current hospital contracts verified there is no pharmacy contract. Per interview with Staff A, the hospital which has been closed since late October 2009 plans to re-open as of 06/01/10 when it will begin to admit psychiatric patients.

This allegation substantiates an allegation contained in Complaint OH00054715.

Based on review of medication errors, staff interview and performance improvement meeting minutes, the drug administration errors were not discussed at the performance improvement committee. The total facilty census during the survey was zero.

Findings include:

Medication error documentation was located for the surveyor on 04/14/10 at 1:50 PM after being requested on 04/12/10, 04/13/10 and 04/14/10. Not mentioned in the performance improvement meeting minutes, the previous executive nurse had a file containing the individual medications on her desk. From 05/01/09-08/23/09, sixteen patients were hospitalized and five medication errors occurred. These errors ranged from failure to fax two PRN medications to the pharmacy properly resulting in the medications not being delivered for two days involving Patient #1, involved 4 nurses on 05/05/09 and 05/06/09, and failure to administer the correct dose of Patient 1's antipsychotic medication between 05/01/09-05/05/09.

Patient #1 had been admitted to the hospital on 04/30/09 with diagnoses including depression and eating disorder. A nurse no longer employed at the hospital failed to administer Humalog insulin to cover the carbohydrates for Patient 4's breakfast on 05/17/09 due to the order not being "clear". Another RN no longer employed by the hospital failed to administer two doses of antipsychotic to Patient #9 on 05/26/09 and 05/27/09 when the patient had been admitted with schizo-affective disorder and depression. Staff A confirmed the only information she could locate regarding the medication errors was presented to the surveyor on 04/14/10 at 1:50 PM.

Based on review of documentation presented by the hospital and staff interview, the hospital failed to ensure that there was a formulary system that was established by the medical staff. the total facility census during the survey was zero.

Findings include:

During review of the documentation presented by the hospital on all days of the survey, it was noted that there was no drug formulary available. Interview with Staff A on Tuesday and Wednesday of the survey revealed and confirmed that there was no drug formulary available. Staff A stated during entrance conference on Monday morning of the survey that the pharmaceutical company that was under contract had come and removed all medications and medication carts sometime earlier in the year (2010). This was confirmed as well by Staff B at the same time, 04/12/10 at approximately 11:50 AM.

Based on observation and staff interview in this psychiatric hospital with a capacity of 12, the 2000 LSC existing code was not met as evidenced by the following deficient areas cited. The total facility census during the survey was zero.

Findings include:

The following findings were observed on 04/12/10 during a tour of the facility while accompanied by Staff E, the environmental director who verified all of the findings. Please see the Life Safety Code survey for more details.

K-27 Gaps > 1/8 inch between smoke doors in closed position.
K-38 Unsafe exit discharges at three exits.
K-50 Missed fire drills.
K-54 No sensitivity testing of smoke detectors.
K-56 Not performing quarterly sprinkler tests.
K-144 No weekly generator inspections.
K-154 No fire watch plan for the sprinkler system.

This deficiency substantiates an allegation in Complaint OH00054715.

Based on staff interviews and personnel records, there is no current designated infection control officer in the hospital. Additionally, prior meetings of the infection control committee were not held according to policy. The total facility census during the survey was zero.

Findings include:

Per interview with Staff A on 04/12/10, there is a staff registered nurse who has been working on infection control policies and procedures. Currently, Staff #24, works PRN. Per interview with Staff #24 on 04/13/10 at 10:45 AM, he/she is not the "official" infection control officer.

Per review of infection control meeting minutes and infection control policies on 04/13/10, the policy at #3008, page 5 states, "infection control committee will meet bi-monthly and as needed." The last infection control meeting conducted was on 08/17/09. The hospital was officially open for business until 10/31/09 per interview with Staff D on 04/12/10 at 12:10 PM.

This deficiency substantiates an allegation contained in OH00054715.