HospitalInspections.org

Based on observations, policy reviews, interviews and record reviews the facility:
- failed to ensure patients who filed a grievance received a timely response to the grievance (A0122)
- failed to provide a safe environment for all patients by:
- allowing plastic trash can liners which are accessable to patients (A0144)
- allowing non-tamper-proof screws in patient rooms (A0144)
- allowing non-suicide-resistant shower water control knobs and non-suicide-resistant plumbing in patient bathrooms (the configuration of the water control knobs and plumbing creates a looping hazard for all patients on the unit, A0144)
- not following the physican's order for line of site observation (A0144) and
- having television and audio visual equipment with lengthy cords accessable to patients (A0144)


The cumulative result of these findings resulted in noncompliance with the Condition of Participation: Patient Rights.

The facility had a census of 79.

Findings included:

Based on interview and record review facility staff failed to ensure one patient (Patient # 11) who filed a grievance, received timely response to the grievance. Three grievances were reviewed. The facility census was 79.

Findings included:

1. Record review of the facility policy titled Patient Grievances, policy #RR .003. revised and reviewed 02/03/09 directed, in part, the following:
-It is the responsibility of each staff member to respond in a timely manner to any concern or complaint voiced by patients and their families no matter how trivial the complaint may appear to be.
-A written complaint is always considered a grievance, whether from an inpatient, outpatient, released/discharged patient or their representative regarding the patient care provided, abuse or neglect, or the hospital's compliance with the CMS {Centers for Medicare/Medicaid Services} Conditions of Participation.
-Whenever the patient or the patient's representative requests their complaint be handled as a formal grievance pr when the patient requests a response from the hospital, then the complaint is a grievance and all the requirements apply.
-Grievances will be reviewed within 72 {seventy two} hours and patients will receive a response within seven (seven) days on average.
-The grievance and problem resolution/follow up must be documented.

2. Record review of Patient #11's face sheet revealed staff admitted the patient on 08/25/10 at 11:11 p.m.

Record review of the patient's admission history and physical dated 08/266/10 revealed the physician assessed the patient with diagnoses including tobacco abuse, marijuana abuse and major depression.

Record review of the patient's discharge summary dated 08/27/10 revealed the physician assessed diagnoses including depression and marijuana abuse and recommended follow-up care in the outpatient {clinic} program.

3. Record review of an amended copy of the facility grievance log (requested for dates 05/10 through present) revealed the following:
-Staff recorded an unnamed patient "voiced a concern" on 09/01/10 regarding being refused admission to an outpatient clinic program.
-The date the complaint/grievance was resolved was recorded as 09/21/10 (twenty days later).

Record review of documents provided by the Risk Manager/Performance Improvement (RM/PI) Co-ordinator, Staff N related to the unnamed patient on the grievance log revealed the following:
-An electronic mail message dated 09/02/10 from a previous manager of the outpatient clinic regarding Patient #11 delineating reasons the outpatient clinic could not provide follow up care for the patient.
-An electronic mail message (noted as printed on 09/20/10) from the hospital accreditation organization regarding a written grievance from Patient #11 to the organization and forwarded on to the facility for a response.
-A letter from the facility to Patient #11 dated 09/21/10 outlining the facility investigation undertaken in response to the grievance.

During an interview on 10/05/10 at 2:55 p.m. the RM/PI Co-ordinator, Staff N stated the following:
-Part of his/her job duties included management of patient complaints and grievances.
-The patient identified on the amended grievance log was Patient #11.
-Patient #11 filed a written complaint with a hospital accreditation organization so, he/she did not include it on the original (first) grievance log provided to the survey team.
-Patient #11 was discharged from inpatient care on 08/27/10 and directed by facility staff to go to the outpatient clinic for after care.
-The outpatient clinic had previously (up to 2008) treated the patient and found the patient to be non-compliant, diagnosed issues beyond the scope of service the clinic could provide and recommended care with other professionals/clinics.
-Inpatient staff who discharged Patient #11 on 08/27/10 committed a communication error through failing to talk with outpatient staff regarding the patient.
-A written communication from the hospital accreditation organization was received by the facility.
-Since Patient #11 did not send the letter of complaint to the facility, the RM/PI Co-ordinator felt he/she did not have to respond to the patient.
-Patient #11 had spoken on the telephone to the RM/PI Co-ordinator, Staff N and personally complained.
-The RM/PI Co-ordinator did not retain a log of telephoned complaints/grievances.
-The RM/PI Co-ordinator did not provide a written response to Patient #11's telephoned complaint.
-The RM/PI Co-ordinator wrote a letter to the patient dated 09/21/10 {twenty days after receipt of the original grievance} responding to the issues.

Based on policy review, observation, interview and record review the facility failed to ensure patients admitted with diagnosis of suicidal ideation, history of suicidal ideation or attempts to harm self or others were provided care in a safe setting for 15 of 15 current patients on the Children's unit, 19 of 19 current patients on the Acute Adolescent unit, 13 of 13 current patients on the Acute Adult unit, 32 of 32 current patients on the Adult unit and two (Patient #14 and #15) of two discharged patients reviewed for care in a safe setting. The facility had a census of 79.

Findings included:

1. Review of the facility's policy titled, "Precautionary Levels at CenterPointe Hospital", dated 01/22/09, provided the following guidance (in part):
"LOS (Line of Sight) The patient must be in sight of the staff at all times."
"SP2 (Suicide Precaution, Level 2) This is our most protective level of suicide watch. Patients are observed every 15 minutes."
"SP1 (Suicide Precaution, Level 1) Patients are observed every 15 minutes."
"AP1 (Assault Precautions, Level 1) This precaution is ordered for patients who have verbalized homicidal or aggressive feelings towards others; or have a history of these types of behaviors."
"AP2 (Assault Precautions, Level 2) This precaution is ordered for patients who have been recently assaultive, i.e., within the past three months, or actually demonstrate aggressive behaviors towards others."

Review of the facility's document titled, "Statement of Patient Rights", revised 06/15/10, provided the following (in part):
"As a patient at CenterPointe Hospital, you are granted the following rights:"
"To protective oversight while a patient at the hospital".
"To the extent that the facilities, equipment, and personnel are available, to psychiatric and medical care and treatment in accordance with the highest standards accepted in medical/psychiatric practice".


2. Observations on 10/04/10 at 10:26 a.m. on the Children's Unit revealed the following:
-Staff lined two large (approximately four foot tall) enclosed trash bins with plastic can liners. (Plastic liner was accessible by inserting a hand through the opening to discard trash).
-Staff stored a television and audio visual equipment with lengthy cords unprotected in a corner of the Major League Day Room. There was no line of sight from the hallway so unwitnessed access to the electrical cords was possible.

Observation on 10/04/10 at 2:35 p.m. revealed the Major League Day Room door was opened and patients and staff in the hallway.

3. Observations on 10/05/10 at 01:25 p.m. revealed the following:
-The bathroom off the Major League Day Room (shared with patient room #34) included a shower stall with separate hot and cold water handles extending approximately five inches off the wall and four feet off the floor. The same bathroom also included a commode with exposed plumbing pipes and a lever flush mechanism at least two feet off the ground.
-Patient rooms #36 and #38 shared a bathroom which included a shower stall with separate hot and cold water handles extending approximately five inches off the wall and four feet off the floor. The same bathroom also included a commode with exposed plumbing pipes and a lever flush mechanism at least two feet off the ground.-Patient room #37 and #39 shared a bathroom which included a shower stall with separate hot and cold water handles extending approximately five inches off the wall and four feet off the floor. The same bathroom also included a commode with exposed plumbing pipes and a lever flush mechanism at least two feet off the ground.-Patient room #33 and #35 shared a bathroom which included a shower stall with separate hot and cold water handles extending approximately five inches off the wall and four feet off the floor. The same bathroom also included a commode with exposed plumbing pipes and a lever flush mechanism at least two feet off the ground.
-Patient room #31 had a bathroom, not shared with other patient rooms. The bathroom included a shower stall with separate hot and cold water handles extending approximately five inches off the wall and four feet off the floor. The same bathroom also included a commode with a wall mounted push button flush mechanism.

The configuration of these water control handles, exposed plumbing and lever flush mechanisms create a looping hazard for all patients.

4. During an interview on 10/05/10 at 1:31 p.m. the Child/Adolescent Unit Manager, Staff B stated one of the other units in the facility had recently added some enclosed plumbing commodes but the facility had not installed any of those on this unit.

During an interview on 10/05/10 at 2:30 p.m. the Child/Adolescent Unit Manager, Staff B stated he/she recognized the electrical cords on the equipment were potential hazards.

5. During an interview on 10/06/10 at 08:06 a.m. the Housekeeping Supervisor stated the following:
-He/she had only been in position since 07/06/10.
-Plastic trash can liners were used in the large hallway receptacles.
-Paper bags were used as trash can liners in patient rooms for safety reasons.
-He/she did not know of a written policy directing housekeeping staff to use plastic or paper trash can liners in any specific areas of the building.


27724

6. Review of the facility's document of Acute Adult Census for 10/04/10 showed 13 of 13 patients on suicide precautions.

Observation on 10/04/10 at 2:30 p.m. on the Acute Adult unit in a patient room #46 showed an open shelf with patient belongings. The belongings included pants. During a concurrent interview, Charge Nurse, Staff E, stated that suicidal patients would be given paper scrubs to wear and that their pants, belt, and purse would be taken away. When asked what would prevent a suicidal patient from taking someone else's pants, Staff E stated that they have never had that happen. Further observation of patient room #46's bathroom showed a shower stall with the water control knobs and shower head surrounded by a large metal covering. The large metal covering was secured to the shower wall with two large Phillips head screws (not tamper-proof). The towel hooks were on a metal plate that was secured to the wall with six large Phillips head screws (not tamper-proof). The commode had exposed pipes (plumbing) approximately two feet off the ground. Staff E stated that they haven't had anyone try to hang themselves from the commode. Staff E stated that the doors were equipped with sensors above the doors to prevent patients from securing a loop for hanging and that the doors were also equipped with a hinge extending the height of the door to prevent patients from securing a loop for hanging. Staff E stated that tamper-proof screws were used to prevent patients from removing the screws.

Observation on 10/05/10 at 1:30 p.m. on the Acute Adult unit with Director of Nursing, Staff Q, showed the following:
- Patient room #43's bathroom showed a commode with exposed pipes (plumbing) approximately two feet off the ground. The shower stall had the water control knobs and shower head surrounded by a large metal covering. The large metal covering was secured to the shower wall with two large Phillips head screws (not tamper-proof). The towel hooks were on a metal plate that was secured to the wall with six large Phillips head screws (not tamper-proof).
- Patient room #45's bathroom showed a commode with exposed pipes (plumbing) approximately two feet off the ground. The shower stall had the water control knobs and shower head surrounded by a large metal covering. The large metal covering was secured to the shower wall with two large Phillips head screws (not tamper-proof). The towel hooks were on a metal plate that was secured to the wall with six large Phillips head screws (not tamper-proof). The overhead ceiling light was secured with Phillips head screws (not tamper-proof). Director of Nursing, Staff Q, confirmed that these Phillips head screws were not tamper-proof.
- Patient room #47 and #49 shared a bathroom, which included a commode with exposed pipes (plumbing) approximately two feet off the ground. The shower stall had the water control knobs and shower head surrounded by a large metal covering. The large metal covering was secured to the shower wall with two large Phillips head screws (not tamper-proof).
- Patient room #48's bathroom showed a commode with exposed pipes (plumbing) approximately two feet off the ground. The shower stall had the water control knobs and shower head surrounded by a large metal covering. The large metal covering was secured to the shower wall with two large Phillips head screws (not tamper-proof). The towel hooks were on a metal plate that was secured to the wall with six large Phillips head screws (not tamper-proof). The toilet paper holder was secured with two Phillips head screws (not tamper-proof).
- Day Room bathroom with an external lock on the door and unlocked by a staff member who stated the lock was installed approximately two weeks ago after an incident with two patients (Patient #14 and #15) who had sexual intercourse. The Day Room bathroom showed a commode with exposed pipes (plumbing) approximately two feet off the ground.
- Activity Room contained two large trash cans positioned around the corner of the room and was not within line of sight from the hallway. Both trash cans held a large plastic trash bag. The Activity Room bathroom showed a shower stall that had the water control knobs and shower head surrounded by a large metal covering. The large metal covering was secured to the shower wall with two large Phillips head screws (not tamper-proof). The towel hooks were on a metal plate that was secured to the wall with six large Phillips head screws (not tamper-proof).

The presence of exposed plumbing creates a looping hazard for patients at risk for suicide. The presence of plastic bags create choking hazards for patients at risk for suicide and the presence of and non-tamper-proof removable metal screws create hazards for patients at risk for self harm.

7. Review of the facility's document of Adult Census for 10/04/10 showed 32 of 32 patients on suicide precautions.

Observation on 10/05/10 at approximately 2:30 p.m. on the Adult unit with Nursing Supervisor, Staff R, showed the following:
- Patient room #66 and #68 shared a bathroom, which included a shower stall with separate hot and cold water handles extending approximately four inches off the wall and four feet off the floor. There was a commode with exposed pipes (plumbing) approximately two feet off the ground. The toilet paper holder was secured with two Phillips head screws (not tamper-proof) and one screw was partially unscrewed. This was confirmed by Staff R.
- Patient room #67 and #69 shared a bathroom, which included a shower stall with separate hot and cold water handles extending approximately four inches off the wall and four feet off the floor. The shower head was secured to the wall of the shower with four large Phillips head screws (not tamper proof). There was a commode with exposed pipes (plumbing) approximately two feet off the ground. The toilet paper holder was secured with two Phillips head screws (not tamper proof). The bathroom had two doors, leading to room #67 and #69. Both doors had a metal plate on the bathroom side, approximately 12 inches long, each secured by six Phillips head screws (not tamper proof). One door lock was secured with four Phillips head screws (not tamper proof). The air intake ventilation cover on the ceiling was missing one screw.
- Patient room #63 and #65 shared a bathroom, which included a commode with exposed pipes (plumbing) approximately two feet off the ground. The shower stall had the water control handles and shower head surrounded by a large metal covering. The large metal covering was secured to the shower wall with two large Phillips head screws (not tamper-proof). The bathroom had two doors, leading to room #63 and #65. Both doors had a metal plate on the bathroom side, approximately 12 inches long, each secured by six Phillips head screws (not tamper proof). The door lock to room #63 was secured with four Phillips head screws (not tamper proof). The door lock to room #65 was secured with two Phillips head screws (not tamper proof).
- Patient room #62 and #64 shared a bathroom, which included a commode with exposed pipes (plumbing) approximately two feet off the ground. The shower stall had the water control handles and shower head surrounded by a large metal covering. The large metal covering was secured to the shower wall with two large Phillips head screws (not tamper-proof). The bathroom had two doors, leading to room #62 and #64. Both doors had a metal plate on the bathroom side, approximately 12 inches long, each secured by six Phillips head screws (not tamper proof).

Further observation on 10/06/10 at 9:55 a.m. on the Adult unit with Nursing Supervisor, Staff R, showed the following:
- Patient room #57 and #59 shared a bathroom, which included a commode with one exposed pipe (plumbing) approximately two feet off the ground. The shower stall had separate hot and cold water handles extending approximately four inches off the wall and four feet off the floor. The bathroom had two doors, leading to room #57 and #59. Both doors had a metal plate on the bathroom side, approximately 12 inches long, each secured by six Phillips head screws (not tamper proof). Both doors had a lock secured with four Phillips head screws (not tamper proof). There was no sensor above the two bathroom doors to alert the staff if someone used the doors as devices for hanging. Both bathroom doors had standard door hinges that would permit securing a loop device for hanging.
- Patient room #56 and #58 shared a bathroom, which included a commode with one exposed pipe (plumbing) approximately two feet off the ground. The shower stall had separate hot and cold water handles extending approximately four inches off the wall and four feet off the floor. The bathroom had two doors, leading to room #56 and #58. Both doors had a metal plate on the bathroom side, approximately 12 inches long, each secured by six Phillips head screws (not tamper proof). Both doors had a lock secured with four Phillips head screws (not tamper proof). There was no sensor above the two bathroom doors to alert the staff if someone used the doors as devices for hanging. Both bathroom doors had standard door hinges that would permit securing a loop device for hanging.
- Patient room #53 and #55 shared a bathroom, which included a commode with one exposed pipe (plumbing) approximately two feet off the ground. The bathroom had two doors, leading to room #53 and #55. Both doors had a metal plate on the bathroom side, approximately 12 inches long, each secured by six Phillips head screws (not tamper proof). Both doors had a lock secured with four Phillips head screws (not tamper proof).
- Patient room #52 and #54 shared a bathroom, which included a commode with one exposed pipe (plumbing) approximately two feet off the ground. The shower stall had the water control handles and shower head surrounded by a large metal covering. The large metal covering was secured to the shower wall with two large Phillips head screws (not tamper-proof). Next to the shower was a wall-mounted handle secured to the wall with two large Phillips head screws (not tamper-proof). Along a wall in the bathroom was a long wall-mounted handle secured to the wall with six large Phillips head screws (not tamper-proof). The bathroom had two doors, leading to room #52 and #54. Both doors had a metal plate on the bathroom side, approximately 12 inches long, each secured by six Phillips head screws (not tamper proof). Both doors had a lock secured with four Phillips head screws (not tamper proof).

8. Review of the facility's document of the Acute Adolescent Census for 10/04/10 showed 16 of 19 patients on suicide precautions and the three patients not on suicide precautions are on assault precautions with homicidal or aggressive feelings towards others; or have a history of these types of behaviors.

9. Observation on 10/06/10 at 1:50 p.m. on the Acute Adolescent unit with the Chief Operating Officer/Chief Nursing Officer, Staff P, showed the following:
- Patient room #11's bathroom showed a commode with exposed pipes (plumbing) approximately two feet off the ground.
- Patient room #12's bathroom showed a commode with exposed pipes (plumbing) approximately two feet off the ground. Observation also showed a shower stall with regular shower water control knobs, which protrude from the wall approximately five inches and are approximately four feet off the floor.
- Patient dayroom #14's bathroom showed a commode with exposed pipes (plumbing) approximately two feet off the ground.
- Patient room #18's bathroom showed a commode with exposed pipes (plumbing) approximately two feet off the ground. Observation also showed a shower stall with regular shower water control knobs, which protrude from the wall approximately five inches and are approximately four feet off the floor.
- Patient dayroom #19's bathroom showed a commode with exposed pipes (plumbing) approximately two feet off the ground.

10. Review of discharged Patient #14's medical record on 10/05/10 at 8:15 a.m. showed he/she was admitted on 08/28/10 for Schizophrenia (severe brain disorder causing abnormal interpretation of reality) and a history of hyper-sexual behavior. A physician's order showed he/she was to be placed on LOS (line of sight [must be in sight of the staff at all times]) while awake. Admitting physician orders were for Suicide Precautions and Assault Precautions. Nursing notes from 09/02/10 at 10:25 p.m. showed that Patient #14 was told she would have to stay away from all (opposite sex) on the unit due to explicit sexual talk. He/she was then found in the Day Room bathroom with a patient of the opposite sex. Patient #14 had his/her clothes off and later admitted to having had sexual intercourse with the other patient. Nursing notes showed, "remains on SA (Suicide Precautions), AP (Assault Precautions), LOS (line of sight) while awake. (He/she) has been monitored for safety throughout the evening."

Review of discharged Patient #15's medical record on 10/05/10 at 10:15 a.m. showed he/she was admitted on 08/30/10 for Bipolar Disorder (severe mood swings), depression, and suicide ideations (thoughts of suicide). The admission psychiatric evaluation stated, "We will admit for safety, monitoring ..." Admitting physician orders were for Suicide Precautions and Assault Precautions. Nursing notes from 09/02/10 at 11:26 p.m. showed that Patient #15 was found in the Day Room bathroom with a patient of the opposite sex. Nursing notes from 09/03/10 at 1:36 a.m. showed, "Remains on every 15 min (minute) safety round checks". Nursing notes from 09/03/10 at 9:21 a.m. showed, "Pt (patient) upset that (opposite sex) peer (he/she) had sex with was transferred to the adult unit and not (him/her)". Nursing notes from 09/03/10 at 10:54 p.m. showed, "Pt (patient) report SI (suicidal ideations [thoughts of suicide]) thoughts 'I want to hang myself with a towel in my bathroom'."

During an interview on 10/05/10 at 11:50 a.m., Registered Nurse, Staff O, confirmed that he/she was on duty 09/02/10 on the Acute Adult unit where Patients #14 and #15 were. Staff O stated that Patient #14 was to remain in line of sight, which meant the patient was to remain within staff view. Staff O stated that there was a medical emergency with another patient and he/she didn't know how long Patients #14 and #15 were left unattended.

During an interview on 10/05/10 at 3:30 p.m., Mental Health Technician, Staff C, confirmed that he/she was on duty on 09/02/10 on the Acute Adult unit where Patients #14 and #15 were. Staff C stated that Patient #14 and Patient #15 took advantage of a medical emergency that was occurring on the unit with another patient. Staff C stated that he/she responded to the medical emergency and wasn't sure who watched the other patients.

During an interview on 10/05/10 at approximately 4:15 p.m., Mental Health Technician, Staff T, confirmed that he/she was on duty on 09/02/10 on the Acute Adult unit where Patients #14 and #15 were. Staff T stated that he/she found Patients #14 and #15 in the Day Room bathroom at the end of the shift as he/she was cleaning up and checked the bathroom. Staff T stated the he/she thought the line of sight responsibility was his/hers but had been called down to assist with another patient's medical emergency.

During an interview on 10/05/10 at 4:30 p.m., Mental Health Technician, Staff U, confirmed that he/she was on duty on 09/02/10 on the Acute Adult unit where Patients #14 and #15 were. Staff U stated that at the beginning of their shift on 09/02/10, their supervisor had told the technicians to keep a watch on Patient #14 and #15 because they had taken a liking to each other.


19957

Based on interview and record review facility nursing staff failed to ensure patient vital signs (temperature, pulse, respirations, and blood pressure measurements) were taken twice a day as ordered by the physician for two (Patient #6 and #8) of seven patients reviewed. The facility census was 79.

Findings included:

1. Record review of current Patient #6's admission history and physical revealed staff admitted the patient on 09/17/10 with chief complaints of medication not working, increased aggression, ran from school and wants to be hit by a car.

Record review of the patient's physician's orders dated 09/17/10 directed staff to admit the patient, provide laboratory testing, diet, activity and specific precautions and measure the patients vital signs twice a day.

Record review of the patient's Vital Signs form revealed on 09/19/10 staff recorded vital signs at 08:15 a.m. and failed to record a second set of values during the rest of the day.

2. Record review of current Patient #8's face sheet revealed staff admitted the patient on 09/21/10 with bipolar disorder.

Record review of the patient's physician's admission orders dated 09/21/10 directed staff to provide diet, activity, laboratory testing, specific precautions and privileges and measure the patients vital signs twice a day.

Record review of the patient's Vital Signs form revealed staff recorded vital signs at 4:00 p.m. and failed to record a second set of values during the day.

3. During an interview on 10/04/10 at 11:25 a.m. the Unit Manager, Staff B stated the Mental Health Technicians usually measure and record the patient vital signs and the Registered Nurse charge was responsible to oversee the vital signs were measured and recorded.

Based on record review, the facility failed to ensure physician orders were timed for five (Patient #5, #23, #14, #15 and #2) of nine records reviewed for physician orders. The facility census was 79.

Findings included:

1. Review of the facility's Amended and Restated Rules and Regulations of the Medical Staff reviewed and revised 10/15/09 directed, in part, the following:
-Section 7.4. 1 Orders must be written clearly and legibly and must be dated, timed and authenticated promptly by the ordering practitioner and include justification for the order.

2. Review of current Patient #5's medical record on 10/04/10 at 1:45 p.m. showed the following:
- A physician's order written 09/30/10 for:
"Repeat BMP (Basic Metabolic Panel [lab test]) AM (morning), no need to repeat CBC (Complete Blood Count [lab test])".
The order was not timed.
- An order written 10/01/10 for:
"Discontinue Celexa (anti-depressant);
Lithium (used to treat manic depressive disorder) 300 mg (milligrams) po (by mouth) BID (twice a day)."
These orders were not timed.

3. Review of current Patient #23's medical record on 10/05/10 at 2:15 p.m. showed the following:
- An order written on 10/03/10 for:
"ECT (Electroconvulsive Therapy [electric shock therapy]) on Monday October 4th 2010;
NPO (nothing to eat or drink) after midnight tonight".
These orders were not timed.

4. Review of discharged Patient #14's medical record on 10/05/10 at 8:15 a.m. showed the following:
- An order written on 08/30/10 for:
"Synthroid (thyroid hormone) 25 mcg (micrograms) po (by mouth) q (every) daily".
This order was not timed.
- An order written on 09/01/10 for:
"Nicotine Patch (patch placed on skin to help patient stop smoking) 21 mg (milligrams) q (every) 24 hours".
This order was not timed.
- An order written on 09/02/10 that is illegible to this surveyor. The order included two medications and was not timed.
- An order written on 09/05/10 for:
"D/C (discontinue) Nicotine Patch;
Claritin D 1 po (by mouth) bid (twice a day)".
These orders were not timed.
- An order written on 09/07/10 for:
"Flonase () nasal spray 1 spray each nostril bid".
This order was not timed.
- An order written on 09/13/10 that is illegible to this surveyor. The order included two medications and was not timed.

5. Review of discharged Patient #15's medical record on 10/05/10 at 10:15 a.m. showed the following:
- An order written on 09/01/10 for:
"Ibuprofen (anti-inflammatory medication) 600 mg (milligrams) po (by mouth) q (every) 6 hours prn (as needed)".
This order was not timed.


19957

6. Review of current Patient #2's medical record on 10/05/10 at 11:30 a.m. showed the following:
- Orders written on 09/24/20 for:
Amoxicillin 500 mg one po three times a day x 10 days for ear ache
Albuterol HFA MDI (metered-dose inhaler, used to prevent and treat wheezing, difficulty breathing and chest tightness) 2 puffs q 6 hours prn when difficulty breathing
- An order written on 09/26/10 for:
Tylenol 500 mg po q 4 hours prn for ear pain.
These orders were not timed by the physician.

Based on interview and record review facility staff failed to ensure physician's orders including verbal/telephone orders were dated and timed and authenticated within forty eight hours in six of nine (Patient #6, #20, #23, #14, #15 and #2) medical records reviewed for dated, timed and authenticated orders. The facility census was 79.

Findings included:

1. Record review of the facility Amended and Restated Rules and Regulations of the Medical Staff reviewed and revised 10/15/09 directed, in part, the following:
-Section 7.4. 1 Orders must be written clearly and legibly and must be dated, timed and authenticated promptly by the ordering practitioner and include justification for the order.
-Section 7.4.1 {further directed} An order shall be considered to be written if dictated in person to a licensed nurse and authenticated by the ordering practitioner, attending physician, or another responsible physician, such as covering, rounding, or co-attending within 24 {twenty four} hours (or such shorter time period as may be required by a Hospital program, policy, or law).

2. Record review of current Patient #6's admission history and physical revealed staff admitted the patient on 09/17/10 with chief complaints of medication not working, increased aggression, ran from school and wants to be hit by a car.

Record review of the patient's physician's orders dated 09/18/10 at 10:05 a.m. revealed
an unauthenticated verbal order for discontinuation of ward restriction.

During an interview on 10/04/10 at 11:25 a.m. the Unit Manager, Staff B reviewed the patient's physician's verbal order and stated the physician failed to authenticate the order.

3. Record review of current clinic Patient #20's admission progress notes dated 09/28/10 at 09:30 a.m. revealed the nurse assessed the patient was admitted for history of depression, alcohol and drug abuse and chronic back pain.

Record review of the patient's physician's orders dated 09/28/10 at 09:30 a.m. revealed an unauthenticated verbal order for admission to the outpatient program, licensed nurse may call pharmacy to refill current medications, licensed nurse may administer as needed Ibuprofen for pain and Maalox for dyspepsia, and urine drug screen on admission, weekly and randomly.

During an interview on 10/05/10 at 11:12 a.m. the Acting Clinic Manager, Staff F reviewed the patient's physician's verbal admission orders and stated the physician failed to authenticate the orders.









27724

4. Review of current Patient #23's medical record on 10/05/10 at 2:15 p.m. showed the following:
- Verbal orders written 09/23/10 at 12:02 p.m. for:
"Lexapro (anti-depressant) 10 mg (milligrams) po (by mouth) daily
Wellbutrin XL (anti-depressant) 150 mg po daily
Decrease Ritalin (used to treat attention deficit hyperactivity disorder) to 10 mg Q (every) a.m.
Vistaril (used to treat anxiety and alcohol withdrawal) 25 mg po Q 6 h (hours) prn (as needed) anxiety."
The orders were signed by a physician but the signature was not dated and timed.
- Verbal orders written 09/23/10 at 12:14 p.m. for:
"Lithium (used to treat manic-depressive disorder) level
Inderal (used to prevent migraine headaches) 10 mg (milligrams) po (by mouth) BID (twice a day)."
The orders were signed by a physician but the signature was not dated and timed.

5. Review of discharged Patient #14's medical record on 10/05/10 at 8:15 a.m. showed the following:
- Verbal order written 09/06/10 at 11:15 a.m. for:
"Discontinue po (by mouth) Risperdal (used to treat mental illness)
1:1 (one to one observation by staff member within an arms length of patient) X (times) 24 hours."
These orders were signed by a physician but the signature was not dated and timed.
- Verbal order written 09/10/10 at 1:00 p.m. for:
"Transfer pt (patient) to acute unit on LOS (line of sight [keep patient within sight of staff])."
The order was signed by a physician but the signature was not dated and timed.
- Verbal order written 09/13/10 at 9:50 p.m. for:
"LOS (line of sight) while awake."
The order was signed by a physician but the signature was not dated and timed.

6. Review of discharged Patient #15's medical record on 10/05/10 at 10:15 a.m. showed the following:
- Verbal order written 09/01/10 at 10.25 p.m. for:
"Klonopin (used to treat panic attacks) 0.5 mg (milligrams) po (by mouth) now."
The order was signed by a physician but the signature was not dated and timed.
- Verbal order written 09/02/10 at 9:30 p.m. for:
"Klonopin 0.5 mg po now."
The order was signed by a physician but the signature was not dated and timed.


19957

7. Review of current Patient #2's medical record on 10/05/10 at 11:30 a.m. showed the following:
Discontinue Tylenol 500 mg po every 4 hr (hours) prn for ear pain.
The telephone order is not signed by the physician.

Based on record review and interviews the facility failed to ensure discharge summaries are completed by a qualified practitioner who is knowledgabe about the patient's condition and care by allowing facility employees to write the discharge summary for eight patients (#12, #16, #17, #18, #24, #25, #26 and #27) of nine discharge summaries reviewed. The facility had a census of 79.

Findings included:

1. Record review of closed Patient #12's admission face sheet revealed staff admitted the patient on 08/23/10 at 10:35 p.m.

Review of Patient #12's admission psychiatry evaluation dated 08/24/10 at 08:00 a.m. revealed the physician assessed the patient with recent past admission to a residential care facility (since 03/10) for suicidal ideation with plan to cut throat, unresolved grief issues with death of both parents, superficial cuts to the extremities, suspiciousness, average intellect, poor insight/judgment and diagnosed mood disorder with moderate suicide risk.

Record review of the patient's discharge summary revealed the following:
-The patient was discharged on 08/31/10.
-The document was dictated and authenticated by a Licensed Clinical Social Worker (LCSW).
-The physician failed to authenticate the document.

Record review of the patient's progress notes, master treatment plan, Clinical Services Assessment/Family Contact dated 08/24/10, all Patient Group Participation Notes revealed the LCSW who dictated the discharge summary did not participate in documented inpatient care of the patient.

2. Closed record review on 10/05/10 of the discharge summary showed Patient #16 entered the intensive outpatient program (IOP) 09/13/10 for follow-up care for mood instability including depression and anxiety. The physician discharged the patient from IOP on 09/20/10. Review of the discharge summary dated 09/28/10 showed a facility employee, licensed professional counselor (LPC) Staff I dictated the discharge summary on 9/28/10. There is no physician's signature on the discharge summary.

3. Closed record review on 10/05/10 of discharge summary showed Patient #17 entered the IOP on 08/27/10 for continued care due to opiate dependence and signs of mood instability. The physician discharged Patient #17 on 09/14/10. Further review of the discharge summary showed a facility employee, licensed professional counselor (LPC) Staff I dictated the discharge summary on 9/28/10. There is no physician's signature on the discharge summary.

4. Closed record review on 10/05/10 of the discharge summary showed Patient #18 entered IOP 08/16/10 for continued care after an inpatient treatment for a suicide attempt. The physician discharged Patient #18 on 09/27/10. Further review of the discharge summary dated 09/28/10 showed a facility employee, licensed professional counselor (LPC) Staff I dictated the discharge summary. There is no physician's signature on the discharge summary.

During an interview on 10/05/10 at 10:15 a.m. Physician G said that in the outpatient program the physician does not sign the discharge summary.

During an interview on 10/05/10 at 11:10 a.m. IOP acting manager Staff F said that the LPC Staff I is employed by the hospital as a therapist and is not a member of a physician group practice.

5. Closed record review on 10/05/10 of the discharge summary showed Patient #24 entered the facility on 05/27/10 due to an increase in aggression and self-injurious gestures. The physician discharged Patient #24 on 06/11/10. Further review of the discharge summary dated 07/07/10 showed a facility employee, licensed clinical social worker (LCSW) Staff Y dictated the discharge summary.

6. Closed record review on 10/05/10 of the discharge summary showed Patient #25 entered the facility on 06/21/10 due to symptoms of depression, poor sleep, decreased appetite and decreased energy. The physician discharged Patient #25 on 06/24/10. Further review of the discharge summary dated 07/21/10 showed a facility employee, licensed clinical social worker (LCSW) Staff Y dictated the discharge summary.

7. Closed record review on 10/05/10 of the discharge summary showed Patient #26 entered the facility on 05/12/10 following a suicide attempt by trying to choke self with a chain. The physician discharged Patient #26 on 06/02/10. Further review of the discharge summary dated 06/29/10 showed a facility employee, licensed clinical social worker (LCSW) Staff Y dictated the discharge summary.

8. Closed record review on 10/05/10 of the discharge summary showed Patient #27 entered the facility on 07/08/10 due to symptoms of paranoia. The physician discharged Patient #27 on 07/19/10. Further review of the discharge summary dated 08/11/10 showed a licensed clinical social worker (LCSW), Staff Y dictated the discharge summary.

Review of the personnel record showed Staff Y is employed by the facility as a social worker and is not a member of a physician group practice.

Based on record review the facility failed to ensure discharge summaries are completed within 30 days following discharge for one patient (#12). Five records of patients discharged more than 30 days were reviewed.

Record review of closed Patient #12's admission face sheet revealed staff admitted the patient on 08/23/10 at 10:35 p.m.

Record review of the patient's admission psychiatry evaluation dated 08/24/10 at 08:00 a.m. revealed the physician assessed the patient with recent past admission to a residential care facility (since 03/10) for suicidal ideation with plan to cut throat, unresolved grief issues with death of both parents, superficial cuts to the extremities, suspiciousness, average intellect, poor insight/judgment and diagnosed mood disorder with moderate suicide risk.

Record review of the patient's discharge summary revealed the following:
-The patient was discharged on 08/31/10.
-The discharge summary was dictated on 10/04/10 {thirty three days after discharge}