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Based on observation, interview, record review and policy review, the facility failed to provide a safe environment for patients on unit Four South. The facility failed to ensure staff completed patient safety rounds for 14 patients (#5, #17, #20, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, and #38) of 19 current patients. The facility also failed to ensure that three wall mounted frames in the patient intake rooms (rooms where individuals were assessed for need of psychiatric admission) were securely fastened with tamper proof screws. This failure gave the patients unmonitored time to potentially harm themselves or others. The facility census was 84.

Findings included:

1. Record review of facility's policy titled, "Observation and Patient Monitoring", revised 05/09/13, showed the following direction for staff:
-Fifteen minutes checks were standard precautions for all patients in the acute care units.
-Complete 15 minute checks on Precautions Check Sheets.
-Visually monitor patients randomly within 15 minute intervals and document check in real time.
-Document at least four checks every hour with no time lapse of greater than 20 minutes within the hour.
-Document checks on the Precautions Check Sheet form every 15 minutes and include the location of the patient.
-Increase monitoring of patients with Suicide precautions (to prevent harm to self) and to keep patients within line of sight observation at all times, including bathroom and shower usage.
-Increase monitoring of patients with Assault precautions (to prevent harm to others) and observe for escalation, aggressive body language, and appropriate boundaries with other patients and staff.
-Increase monitoring of patients with Elopement precautions (to prevent leaving the facility without permission) and monitor patients for behaviors such as, watching door, layering clothing, etc.

2. Observation and concurrent record review of patient 15 Minute Precaution Check and Point Sheet forms on 06/03/13 at 3:30 PM, failed to show documentation of two 15 minute checks for 14 (#5, #17, #20, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, and #38) of 19 current patients on unit Four South. This occurred during the day to evening shift change, from 3:00 PM to 3:30 PM. Two of the patients (#20 and #35) were on line of sight (staff to keep patients within their sight at all times) with suicide, assault, and elopement precautions, during the time of the missing 15-minutes checks.

3. During an interview on 06/03/13 at 3:30 PM, Staff E, Registered Nurse (RN) and Nurse Manager, stated that staff were expected to observe and complete patient 15 Minute Precaution Check and Point Sheet forms randomly every 15 minutes and an interval was not to exceed 20 minutes. Staff E also stated that staff was expected to complete the documentation at the time of the observation and the failure of staff to document two fifteen minute checks for 14 patients was not good.

4. During an interview on 06/03/13 at 3:40 PM, Staff F, BHT (Behavioral Health Technician), stated that she got off orientation last Friday and that she was required to complete checks every 15 minutes and document with behavior and location. She stated that she was required to complete documentation within a few minutes of the check.

5. During an interview on 06/04/13 at 9:45 AM, Staff P, BHT, stated that he kept the precaution sheets with him for the patients he was assigned to keep documentation current. He also stated that Patient's #20 and #35 were on line of sight observation for Suicide precautions.

6. During an interview on 06/04/13 at 10:35 AM, Staff Q, PST (Patient Safety Technician), stated that staff were assigned to observe patients every 15 minutes and expected to document at the time of the observation. He also stated that he would definitely see a potential safety risk if two 15 minutes checks are not completed on a patient, and that two checks not completed for 14 of 19 patients yesterday was definitely a safety risk. He stated that someone should have paid attention and gotten help from other staff.

7. During an interview on 06/04/13 at 1:30 PM, Staff I, Director of Nursing, stated that typically day staff conducts 15 minute checks until shift change report is complete and then transfers assignment to the evening shift. She stated she did not know why they had not been completed as required on 06/03/13.

8. During an interview on 06/05/13 at 10:15 AM, Staff I, Director of Nursing, stated she completed an investigation and found that Staff FF, BHT, was responsible to complete rounds on the day shift on 06/03/13. She stated that Staff FF failed to complete rounds until the evening shift arrived and received report, and also failed to transfer the documents directly to evening staff following shift change report.

9. Observation on 06/04/13 at 3:30 PM of the intake area showed there were three intake assessment rooms. Each room had a black plastic frame mounted on the wall with non-tamper proof screws. The black frame was approximately eight and one-half inches by 11 inches. The frame stuck out from the wall approximately one-half inch. A screw in the middle, of two shorter sides of the frame held it to the wall. A patient could easily pry their fingers behind the frame and would be able to pull it off the wall. This would allow a patient to break the frame causing sharp edges and use the frame or the screws to harm themselves or others. Staff C, Chief Operating Officer (COO) was present during the observation.

10. During an interview on 06/05/13 at 2:30 PM Staff T, Admission Coordinator, stated that patients were alone at times in the intake rooms and were observed every five minutes. She stated that the black plastic frames could be easily torn off the wall and used as a weapon to harm themselves or others during the five minutes between patient observations.

11. During an interview on 06/05/13 at 3:10 and 3:15 PM Staff C, stated that a patient could take the frame and screws from the wall and use them for a weapon to harm themselves or others. There was no policy for maintaining psychiatric safe surroundings.








29117

Based on interview and record review the facility failed to modify six of 12 patients' care plans to reflect the use of restraint and/or seclusion (Patients #2, #16, #9, #35, #49, and #5). This had the potential to affect all patients with episodes of restraint/seclusion. The facility census was 84.

Findings included:

1. Record review of a facility policy titled, "Seclusion/Restraint Procedure," revised 08/21/12, showed the the qualified Registered Nurse (RN) was to document changes to the treatment plan/Individual Crisis Management Plan (ICMP).

2. During interviews on 06/05/13 at 8:45 AM and 9:05 AM, RN, Staff I, Director of Nurses, stated that staff were to update the treatment plan and ICMP with each restraint/seclusion episode. The treatment plans were to be individualized to reflect any interventions identified during the debriefing sessions in an attempt to prevent future episodes. Staff I confirmed the treatment plans failed to identify an actual restraint/seclusion episode with specific goals and interventions identified in the debriefing sessions.

3. Record review of Patient #2's History and Physical (H & P), dated 05/26/13, showed he was admitted on that date with diagnoses of an unstable mood and aggression.

Record review of a Seclusion/Restraint Order, dated 05/31/13, showed Patient #2 was secluded for 15 minutes related to escalation and threatening to poke his own eye out.

Record review of a treatment plan update form, dated 05/31/13 showed the patient got very aggressive after talking with his mother on the phone.

Record review of the patient's treatment/ICMP showed no reference to the aggression after speaking with his mother on the phone, which could have been a future indicator of behaviors, and helpful in the plan.

Record review of a Seclusion/Restraint Order, dated 06/02/13, showed Patient #2 was physically restrained and secluded for one hour and twenty minutes related to hitting peers and staff.

Further review of the patient's treatment/ICMP, dated 05/26/13, showed no evidence of any restraint/seclusion episode with an obtainable goal.

4. Record review of Patient #16's H & P, dated 04/27/13, showed he was admitted on 04/26/13 with a diagnosis of bipolar disease (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks).

Record review of Patient #16's Seclusion/Restraint Orders showed the following:
-He was secluded on 05/05/13 for one-hour six minutes related to throwing things,cursing and hitting staff.
-He was physically restrained on 05/28/13 for nine minutes related to throwing chairs and threatening to hit peers.
-He was physically restrained on 05/31/13 for two minutes related to attempting to scratch and kick staff.
-He was secluded on 05/31/13 for 16 minutes related to throwing chairs and shoving staff.

Record review of the patient's treatment/ICMP, dated 04/27/13, on 06/04/13, showed no evidence of any of the above restraint/seclusion episodes, with an obtainable goal.

5. Record review of Patient #9's psychiatric evaluation, dated 05/17/13, showed he was admitted on 05/11/13 with a diagnosis of major depressive disorder (a mood disorder where feelings of sadness, loss, anger, or frustration interfere with everyday life for weeks or longer).

Record review of the Seclusion/Restraint Order, dated 05/18/13, showed Patient #9 was secluded for one hour related to throwing chairs across the hall when asked to come out of time-out.

Record review of the Seclusion/Restraint Order, dated 05/21/13, showed Patient #9 was physically restrained for 20 minutes related to punching self in the eye with a closed fist, banging his head on the wall, punching staff, and kicking staff.

Record review of the patient's treatment/ICMP, dated 05/11/13, showed no evidence of any restraint/seclusion episodes with an obtainable goal.

6. Record review of Patient #35's psychiatric evaluation, dated 05/28/13, showed she was admitted on the same date with a primary diagnosis of Bipolar disorder most recent manic type with psychotic features (characterized by false ideas about what is taking place or who one is).

Record review of Patient #35's Seclusion/Restraint Order, dated 05/30/13, showed patient was secluded for one hour and 45 minutes for physical aggression toward staff.

Review of the Patient #35's Treatment Plan/ICMP showed no evidence of any restraint/seclusion episode with an obtainable goal.

7. Record review of Patient #49's psychiatric evaluation, dated 05/15/13, showed she was admitted on the 05/13/13 with a primary diagnosis of Bipolar disorder.

Record review of Patient #49's Seclusion/Restraint Order, dated 05/29/13, showed patient was physically restrained for 18 minutes for threats of harm and attempt to assault peer.

Review of the Patient #49's Treatment Plan/ICMP showed no evidence of any restraint/seclusion episode with an obtainable goal.

8. Record review of Patient #5's psychiatric evaluation, dated 0/15/13, showed she was admitted on the 05/13/13 with a primary diagnosis of Bipolar disorder, and Oppositional defiant disorder (a childhood disorder characterized by an ongoing pattern of anger-guided disobedience, hostility, and defiant behavior toward authority figures which goes beyond the bounds of normal childhood behavior)

Record review of Patient #5's Seclusion/Restraint Order, dated 06/01/13, showed patient was physically restrained for 25 minutes for assaultive behavior towards staff.

Review of the Patient #5's Treatment Plan/ ICMP showed no evidence of any restraint/seclusion episode with an obtainable goal.





29117




31891

Based on interview and record review the facility failed to conduct a thorough one-hour face-to-face assessment, that included a medical/physical assessment, after a restraint/seclusion episode for six patients (#2, #9, #16, #35, #49, and #5) of six reviewed. This had the potential to affect all patients that had episodes of behavioral restraint/seclusion. The facility census was 84.

Findings included:

1. Record review of a facility policy titled, "Seclusion/Restraint Procedure," revised 08/21/12, showed the following:
-The Physician/Qualified Registered Nurse (RN)/Licensed Independent Practitioner (LIP) will complete a face-to-face evaluation within one hour of the use of any restraint.
-Document the assessment and rationale for ending the procedure.
-Document the evaluation of the patient's physical and psychological well-being.

The facility policy failed to address all the required elements of the one-hour face-to-face assessment, including the patient's response to the restraint/seclusion episode, the rationale for continued use, and lessor restrictive methods attempted.

2. During an interview on 06/05/13 at 9:05 AM, RN, Staff I, Director of Nurses, stated that nursing supervisors, charge nurses and herself were trained to do the one-hour face-to-face assessment. Staff I confirmed the one-hour face-to-face assessment failed to include all required elements by the qualified assessor, including a medical/physical evaluation after the restraint/seclusion episode.

3. Record review of Patient #2's History and Physical (H & P), dated 05/26/13, showed he was admitted on that date with diagnoses of an unstable mood and aggression.

Record review of a Seclusion/Restraint Order, dated 05/31/13, showed Patient #2 was secluded for 15-minutes related to escalation and threatening to poke his own eye out. The qualified RN completing the one-hour face-to-face assessment failed to conduct a medical/physical evaluation of the patient.

Record review of a Seclusion/Restraint Order, dated 06/02/13, showed Patient #2 was physically restrained and secluded for one-hour twenty minutes related to hitting peers and staff. The qualified RN completing the one-hour face-to-face assessment failed to conduct a medical/physical evaluation of the patient.

4. Record review of Patient #16's H & P, dated 04/27/13, showed he was admitted on 04/26/13 with a diagnosis of bipolar disease (characterized by elevated and low moods).

Record review of Patient #16's Seclusion/Restraint Orders showed the following:
-He was secluded on 05/05/13 for one hour and six minutes related to throwing things,cursing and hitting staff.
-He was physically restrained on 05/28/13 for nine minutes related to throwing chairs and threatening to hit peers.
-He was physically restrained on 05/31/13 for two minutes related to attempting to scratch and kick staff.
-He was secluded on 05/31/13 for 16 minutes related to throwing chairs and shoving staff.
-The qualified RN completing the one-hour face-to-face assessment failed to conduct a medical/physical evaluation of the patient after each restraint/seclusion episode.

5. Record review of Patient #9's psychiatric evaluations, dated 05/17/13, showed he was admitted on 05/11/13 with a diagnosis of major depressive disorder (a mood disorder where feelings of sadness, loss, anger, or frustration interfere with everyday life for weeks or longer).

Record review of the Seclusion/Restraint Order, dated 05/18/13, showed Patient #9 was secluded for one hour related to throwing chairs across the hall when asked to come out of time-out. The qualified RN completing the one-hour face-to-face assessment failed to conduct a medical/physical evaluation of the patient.

Record review of the Seclusion/Restraint Order, dated 05/21/13, showed Patient #9 was physically restrained for 20 minutes related to punching self in the eye with a closed fist, banging his head on the wall, punching staff, and kicking staff. The qualified RN completing the one-hour face-to-face assessment failed to conduct a medical/physical evaluation of the patient.

6. Record review of Patient #35's psychiatric evaluation, dated 05/28/13, showed she was admitted on the same date with a primary diagnosis of Bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks).

Record review of Patient #35's Seclusion/Restraint Order, dated 05/30/13, showed patient was secluded for one hour and 45 minutes due to physical aggression toward staff. The qualified RN completing the one-hour face-to-face assessment failed to conduct a medical/physical evaluation of the patient.

7. Record review of Patient #49's psychiatric evaluation, dated 05/15/13, showed she was admitted on the 05/13/13 with a primary diagnosis of Bipolar disorder.

Record review of Patient #49's Seclusion/Restraint Order, dated 05/29/13, showed patient was physically restrained for 18 minutes due to threats of harm and attempt to assault peer. The qualified RN completing the one-hour face-to-face assessment failed to conduct a medical/physical evaluation of the patient.

8. Record review of Patient #5's psychiatric evaluation, dated 0/15/13, showed she was admitted on the 05/13/13 with a primary diagnosis of Bipolar disorder, and Oppositional defiant disorder (a childhood disorder characterized by an ongoing pattern of anger-guided disobedience, hostility, and defiant behavior toward authority figures which goes beyond the bounds of normal childhood behavior)

Record review of Patient #5's Seclusion/Restraint Order, dated 06/01/13, showed patient was physically restrained for 25 minutes for assaultive behavior towards staff. The qualified RN completing the one-hour face-to-face assessment failed to conduct a medical/physical evaluation of the patient.





29117












31891

Based on interview and record review the facility failed to include the patient's response to restraint/seclusion episodes during the one-hour face-to-face assessment for six patients (#2, #16, #9, #35, #49, and #5) of six patients reviewed with behavioral restraints. This had the potential to affect all patients restrained or secluded in the facility. The facility census was 84.

Findings included:

1. Record review of a facility policy titled, "Seclusion/Restraint Procedure," revised 08/21/12, showed the following:
-The Physician/Qualified Registered Nurse (RN)/Licensed Independent Practitioner (LIP) will complete a face-to-face evaluation within one hour of the use of any restraint.
-Document the assessment and rationale for ending the procedure.
-Document the evaluation of the patient's physical and psychological well-being.
-The facility policy failed to address all the required elements of the one-hour face-to-face assessment, including the patient's response to the restraint/seclusion episode, the rationale for continued use, and lessor restrictive methods attempted.

2. During an interview on 06/05/13 at 9:05 AM, RN, Staff I, Director of Nurses, stated that nursing supervisors, charge nurses and herself were trained to do the one-hour face-to-face assessment. Staff I confirmed the one-hour face-to-face assessment failed to include all required elements by the qualified assessor, including the response to the episode.

3. Record review of Patient #2's History and Physical (H & P), dated 05/26/13, showed he was admitted on that date with diagnoses of an unstable mood and aggression.

Record review of a Seclusion/Restraint Order, dated 05/31/13, showed Patient #2 was secluded for 15 minutes related to escalation and threatening to poke his own eye out. The qualified RN completing the one-hour face-to-face assessment failed to document the patient's response to the seclusion.

Record review of a Seclusion/Restraint Order, dated 06/02/13, showed Patient #2 was physically restrained and secluded for one hour and 20 minutes related to hitting peers and staff. The qualified RN completing the one-hour face-to-face assessment failed to document the patient's response to the restraint/seclusion.

4. Record review of Patient #16's H & P, dated 04/27/13, showed he was admitted on 04/26/13 with a diagnosis of bipolar disease (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks).

Record review of Patient #16's Seclusion/Restraint Orders showed the following:
-He was secluded on 05/05/13 for one hour and six minutes related to throwing things,cursing and hitting staff.
-He was physically restrained on 05/28/13 for nine minutes related to throwing chairs and threatening to hit peers.
-He was physically restrained on 05/31/13 for two minutes related to attempting to scratch and kick staff.
-He was secluded on 05/31/13 for 16 minutes related to throwing chairs and shoving staff.
-The qualified RN completing the one-hour face-to-face assessment failed to document the patient's response to the restraint/seclusion episodes.

5. Record review of Patient #9's psychiatric evaluation, dated 05/17/13, showed he was admitted on 05/11/13 with a diagnosis of major depressive disorder (a mood disorder where feelings of sadness, loss, anger, or frustration interfere with everyday life for weeks or longer).

Record review of the Seclusion/Restraint Order, dated 05/18/13, showed Patient #9 was secluded for one hour related to throwing chairs across the hall when asked to come out of time-out. The qualified RN completing the one-hour face-to-face assessment failed to document the patient's response to the seclusion.

Record review of the Seclusion/Restraint Order, dated 05/21/13, showed Patient #9 was physically restrained for 20 minutes related to punching self in the eye with a closed fist, banging his head on the wall, punching staff, and kicking staff. The qualified RN completing the one-hour face-to-face assessment failed to document the patient's response to the restraint.

6. Record review of Patient #35's psychiatric evaluation, dated 05/28/13, showed she was admitted on the same date with a primary diagnosis of Bipolar disorder (a brain disorder that causes unusual shifts in mood, energy, activity levels, and the ability to carry out day-to-day tasks).

Record review of Patient #35's Seclusion/Restraint Order, dated 05/30/13, showed patient was secluded for one hour and 45 minutes due to physical aggression toward staff. The qualified RN completing the one-hour face-to-face assessment failed to document the patient's response to the seclusion.

7. Record review of Patient #49's psychiatric evaluation, dated 05/15/13, showed she was admitted on the 05/13/13 with a primary diagnosis of Bipolar disorder.

Record review of Patient #49's Seclusion/Restraint Order, dated 05/29/13, showed patient was physically restrained for 18 minutes due to threats of harm and attempt to assault peer. The qualified RN completing the one-hour face-to-face assessment failed to document the patient's response to the physical restraint.

8. Record review of Patient #5's psychiatric evaluation, dated 0/15/13, showed she was admitted on the 05/13/13 with a primary diagnosis of Bipolar disorder, and Oppositional defiant disorder (a childhood disorder characterized by an ongoing pattern of anger-guided disobedience, hostility, and defiant behavior toward authority figures which goes beyond the bounds of normal childhood behavior)

Record review of Patient #5's Seclusion/Restraint Order, dated 06/01/13, showed patient was physically restrained for 25 minutes for assaultive behavior towards staff. The qualified RN completing the one-hour face-to-face assessment failed to document the patient's response to the physical restraint.




29117




31891

Based on interview and record review the facility failed to periodically, and thoroughly, train the designated staff to do a one-hour face-to-face assessment, that included all required elements, for three of three staff (AA, Z, and E) indicated as qualified to do the one-hour face-to-face assessment. This had the potential to affect all patients that are secluded or restrained related to a behavior. The facility census was 84.

Findings included:

1. Even though requested, no policy regarding this requirement was provided.

2. During an interview on 06/05/13 at 9:05 AM, Staff I, Registered Nurse (RN), Director of Nurses, stated that nursing supervisors, charge nurses and herself were trained to conduct a one-hour face-to-face assessment. Staff I confirmed the one-hour face-to-face assessment failed to include all required elements by the qualified assessor. This included the response to the restraint episode, the medical/physical assessment after the episode, and rationale for continued use of a restraint.

3. Record review of randomly chosen staff, who were identified as qualified to do the one-hour face-to-face assessment, showed the following:
-RN Supervisor, Staff AA, was hired on 07/15/97 and had one-hour face-to-face training on 10/08/07.
-RN Supervisor, Staff Z, was hired on 12/06/10 and had one-hour face-to-face training on 01/24/12.
-RN Manager, Staff E, was hired on 04/29/97 and had one-hour face-to-face training on 01/10/08.

4. During an interview on 06/06/13 at 10:04 AM, Staff EE, Director of Inservice Education, stated that the one-hour face-to-face training will be completed on an annual basis, after completion upon hire, an annually thereafter beginning in October, 2013. Staff EE stated that she was currently working on establishing this training to begin in October, 2013. Staff EE stated that she did not know about the training requirements for staff prior to her hire (within the last 12 months). Staff EE confirmed there was no evidence of annual training for Staff AA, Staff Z, and or Staff E.

5. Record review of four one-hour face-to-face assessments, showed the qualified RNs failed to address all elements required.

Staff failed to demonstrate competency while conducting the one-hour face-to-face assessments. Staff also failed to show evidence of a periodic training program regarding the one-hour face-to-face assessment procedure.

Based on interview and policy review the facility failed to incorporate radiology and laboratory services into the hospital-wide Quality Assessment Performance Improvement (QAPI). This had the potential to affect all patients receiving care in the facility. The facility census was 84.

Findings included:

1. Record review of the facility policy titled, "Performance Improvement Plan (PIP)," revised 02/21/12, showed the following:
-The facility emphasizes a "system and process" approach to evaluate and continuously improve the quality of services provided within the organization.
-The Governing Body is responsible ensuring an effective system;
-The hospital used the following process model for collecting and analyzing information throughout the organization
a. Plan the improvement;
b. Do improvement;
c. Check the results;
d. Act to continue improving the process.
-The functions included monitoring compliance with regulatory and health care standards and identifying opportunities for improvement.
-Each manager was responsible for an ongoing and systematic plan to monitor and evaluate PI activities within their respective departments.
-Each manager forwards to their administrative leader, progress reports toward their department's PI goals. Quarterly reports would be reviewed by the manager's administrative supervisor, the Manager of Performance Improvement/Risk Management, and their respective Medical Coordinators for Clinical Departments.

2. During an interview on 06/05/13 at 2:52 PM Staff U, Infection Prevention and Employee Health and Lab Liaison, stated that the facility did not have ongoing QAPI for Laboratory services.

3. During an interview on 06/06/13 at 9:00 AM Staff Y, Performance Improvement, Risk Management Director, stated that there were not any QAPI for the radiology and laboratory services. The facility had not had any complaints about the two services so they failed to perform ongoing hospital-wide QAPI.

Based on observation, interview, and policy review the facility failed to monitor a high risk and problem prone area for potential safety hazards by having four steel window grates, one concrete block and an extension ladder available in the patient's outdoor courtyard. The facility census was 84.

Findings included:

1. Record review of the facility's policy titled, "Performance Improvement Plan (PIP)", revised 02/21/12 showed that one of the Performance Improvement Review Board (PIRB) functions was to maintain a safety/security program that continually assess and minimizes the risks of situations that posed threats to life, health, and/or property, and monitor and evaluate safety and security practices within the organization.

2. Observation and concurrent interview on 6/05/13 at 11:10 AM, of the patient's outdoor courtyard (or south playground), near the entrance of the gymnasium, showed potential safety hazards:
-Four steel metal grates on the ground next to window wells (concrete areas that provides access to windows that are below the surface of the ground),
-One concrete block, approximately 16 inches long by eight inches wide by six inches high, and
-One extension ladder, approximately 12 feet in length, hanging from hooks, on an exterior wall of the storage building near the entrance to the gymnasium, and was not locked. (This ladder could have been easily moved off of the hooks and utilized for climbing over a facility perimeter fence).
Staff V, Certified Recreation Therapy Specialist (CTRS), Director of Rehabilitation Services, stated that he conducted safety rounds of activity areas, but it did not include the areas in the outdoor courtyard where the potential safety hazards were identified.

3. During an interview on 06/06/13 at 9:45 AM with observation of outdoor courtyard area, Staff DD, Plant Operations Director and Safety Officer, stated that:
-He did not know why the steel grates were removed from the window wells and left on the ground.
-Each grate was approximately 40 pounds in weight.
-He did not know why a concrete block was in a patient care area.
-He had not identified these potential hazards on safety rounds, including the extension ladder that was not secured from patient access.
-The failure to replace the metal grates and remove other hazards was an oversight.
-Recreation staff conducted safety rounds of indoor and outdoor recreation areas and he thought they conducted rounds of the entire area.

Based on interview, record review, and policy review the facility failed to ensure the medical records were completed within 30 days of the patient discharge for five (#39, #40, #43, #44, and #45) of twelve discharged patient medical records reviewed. This had the potential to affect all patients' records in the facility. The facility census was 84.

Findings included:

1. Record review of the facility document titled, "Medical Staff Rules and Regulations," revised on 12/11, showed direction for facility physicians to have the discharge summary reviewed and signed within seven days of its availability. If the discharge summary was not signed within seven days, the Director of Medical Records/Designee will notify the physician. If the discharge summary is not signed within 48 hours(after notified by medical records), the Administrator will send a letter to the physician indicating that admitting privileges will be suspended in 48 hours if the discharge summary is not signed.

Record review of the facility policy titled, "Discharge Summaries, Completion Of," revised on 10/18/11 showed facility direction for physicians to dictate and transcribe within 30 days of discharge. The physician was directed to review, sign, date, and time dictated summaries.

2. Record review of Patient #39's Discharge Summary showed he was discharged on 04/29/13 and the Discharge Summary was signed on 06/04/13. The physician failed to complete the medical record by not completing the Discharge Summary within 30 days.

3. Record review of Patient #40's Discharge Summary showed he was discharged on 09/06/12 and the Discharge Summary was signed on 06/30/13. Patient #40 had a second admission and was discharged on 04/10/13 and the Discharge Summary was signed on 05/31/13. The physician failed to complete the medical records by not completing the Discharge Summaries within 30 days.

4. Record review of Patient #43's Discharge Summary showed he was discharged on 11/21/12 and the Discharge Summary was signed on 01/09/13. Patient #43 had a second admission and was discharged on 04/02/13 and the Discharge Summary was signed on 05/28/13. The physician failed to complete the medical records by not completing the Discharge Summaries within 30 days.

5. Record review of Patient #44's Discharge Summary showed he was discharged on 04/03/13 and the Discharge Summary was signed on 05/16/13. The physician failed to complete the medical record by not completing the Discharge Summary within 30 days.

6. Record review of Patient #45's Discharge Summary showed he was discharged on 04/23/13 and the Discharge Summary was signed on 05/29/13. The physician failed to complete the medical record by not completing the Discharge Summary within 30 days.

7. During an interview on 06/05/13 at 1:00 PM Staff R, Health Information Management (HIM) Manager, stated that she confirmed each of the above discharge summaries were not completed within 30 days.

Based on interview, record review, and policy review the facility failed to have a current contract with an Organ Procurement Organization (OPO). This had the potential to affect any deceased patient in the facility. The facility census was 84.

Findings included:

1. Record review of the facility policy titled, "Anatomical Gift Donation and Recovery," reviewed [facility review] 12/09/11, directed the facility to maintain a current agreement with the local OPO.

Record review of the undated facility document titled, "Organ and Tissue Recovery Agreement," showed the agreement's effective date was 02/02/08 and was for a period of one year.

2. During an interview on 06/06/13 at 8:30 AM Staff C, Chief Operating Officer (COO), stated that he was not sure who was responsible for maintaining the contract for OPO, but agreed that the contract was terminated after one year.