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Based on observation, interview and record review the hospital failed to ensure that a safe environment was provided for 10 of 20 patients (Patient #6, #7, #8, #9, #14, #31, #32, #39, #40 and Patient #44), and

1) Patient #14, a 10 year old pediatric patient, was assaulted by (Patient #39, a 14 year old adolescent) and (Patient #40, a 16 year old adolescent). Patient #14 was sent to the acute care hospital for a head injury.

2) Patient rounds records did not accurately document the behavior/location and/or were left incomplete for 8 of 20 patients (Patient #6, #7, #8, #9, #14, #31, #32, and Patient #44)

3) An oxygen tank identified and documented by staff as being full was empty and oxygen was not available in case of an emergency.

4) Four electrical cords, a plastic trash bag, and a substance (Sani Wipes) that required poison control interventions in case of ingestion were in close proximity and easily accessible to patients eating their lunch meal on 04/21/15.

(refer to A144)

Based on record review and interview, the hospital's performance improvement:

1) failed to track adverse patient events for 4 of 4 patients (Patient #14, #39, #40 and Patient #47).

Patient #39 and #40 adolescents assaulted Patient #14, a pediatric patient.

Patient #47 threw a lit cigarette at a patient,

2) failed to investigate why more than 20 patient's urine specimens were left on the hospital adolescent unit for an unknown time without timely processing by the lab.

Refer to A0286

Based on observation, interview and record review, the hospital failed to ensure nursing services was effectively supervised to ensure that the care needs patients were met.

1) Registered nurses failed to assess and reassess patients with medical needs. (Patient #14) was sent to the medical hospital and upon return was not assessed.

2) Patient #41 fell on his left wrist/hand and no assessment was completed after the event was reported to the nurse on 04/20/15. Patient #41 did not receive treatment for a fracture until 04/24/15.

3) Nurse staffing on the adolescent unit and adult unit on 03/22/15 and 04/20/15 were not adequate to ensure patient safety and care provision. Patient #14, a pediatric patient was assaulted by a 14 and 16 year old adolescent patients. One technician was in charge of the 14 patients. The adult psychiatric unit had a total of 16 patients with one technician. One of the sixteen patients was on (HLO) hightened level of observation every five minute checks and the technician was responsible for all 16 patients observation rounds.

(refer to 0392 and 0395)

Based on record review, observation and interview, the facility failed to:

I. Provide Master Treatment, including alternative interventions, for one (1) of two (2) active sample patients (B7) on the Geriatric Unit, and 1 active sample patient (F19) on the Chronic Adult Psychiatric Unit. Although the treatment plan for each patient included multiple group therapies, both patients were not cognitively capable at times of attending the groups listed on their unit's schedules. The patients regularly and repeatedly did not attend the groups. Both patients spent many hours without any structured activities in his/her rooms or wandering around the units. Patient non-participation in assigned treatment modalities negates the clinical effectiveness of the patients' treatment goals and objectives, potentially delaying their improvement. (Refer to B125I)


II. Provide placement of hospitalized patients into milieus that contain (1) patients not yet hospitalized or (2) research patients hospitalized and possibly not receiving necessary medications. The potential for physical harm to the acutely ill patients is quite high.

1. The Adolescent Unit provides care to youngsters who are APOWW (apprehended by police officer without a warrant). These persons may or may not be determined to require hospitalization within 24 hours of their arrival. Staff on the unit estimate that about half of the APOWW persons are sent out after their evaluations. Thus, throughout the day seriously mentally ill persons may be sharing meals, groups etc. with persons not seen as mentally ill. The potential for harm to the acutely ill patients is therefore quite high.

There may also occur APOWW persons who are adults. Administrator estimates that 10% to 20% of these persons are assessed as not requiring acute care hospitalization yet are present throughout their stay with acutely mentally ill patients. There is a likelihood that other patients may be victimized by these persons who are not patients.


2. Patients hospitalized with other patients who are not on medications and who might require medications to modify their symptoms.

There is a research program present at the facility called Pillar Research Program. The nature of this research program is to assess patient responses to double blind medication interventions. The patients are typically hospitalized on the Lewis 1 Unit amid acutely ill mental patients, but, on occasion, may be placed on the Bloss Unit (Adult Intensive Care). Again the nursing staff and pharmacy staff do not know who is or is not receiving medications aimed at lessening their symptomatology. The potential for assaults, property destruction, and other behavioral issues is present and there is a likelihood of victimization of patients not in this research program. (Refer to B125II)

Based on record review, observation and interview, the facility failed to provide adequate numbers of registered nurses and mental health workers on the Dual/Psychiatric Adult units to create and maintain a therapeutic milieu.

Per the Nursing Director, in an interview on 4/20/15, around 9:30 a.m., the Dual/Psychiatric Unit was considered one unit with Dual patients on one side of a locked unit and Psychiatric patients on the other side of a locked unit. A Nursing station was located between these two units. In actuality, patients from one side did not mingle with patients on the other side. The two sides operated as separate units. Each side had its own groups and assigned staff. The total number of staff assigned to these units was split between the two sides, creating an inadequate number to meet all patients' needs.

This inadequate staffing results in the likelihood of unsafe patient care and failure of the professional nurses to adequately provide direction and supervision of non-professional personnel (Licensed practical nurses and mental health workers) in the provision of patient care (refer to B150).

Based on observation, interview and record review, the hospital failed to ensure that a safe environment was provided for 10 of 20 patients (Patient #6, #7, #8, #9, #14, #31, #32, #39, #40 and Patient #44).

1) Patient #14, a 10 year old pediatric patient was assaulted by (Patient #39, a 14 year old adolescent) and (Patient #40, a 16 year old adolescent). Patient #14 was sent to the acute care hospital for a head injury.

2) Patient rounds records did not accurately document the behavior/location and/or were left incomplete for 8 of 20 patients (Patient #6, #7, #8, #9, #14, #31, #32, and Patient #44)

3) An oxygen tank identified and documented by staff as being full was empty and oxygen was not available in case of an emergency.

4) Four electrical cords, a plastic trash bag, and a substance (saniwipes) that required poison control interventions in case of ingestion were in close proximity and easily accessible to patients eating their lunch meal on 04/21/15.


Findings included:


1) Patient #14's Integrated Assessment dated 03/08/15, timed at 0100, showed, "10 year old female in foster care...anger issues with Mother and Dad...reports she sometimes does not use coping skills...history of mood disorder, anxiety...history of cutting self mutilation..."

The Group Notes dated 03/21/15, timed at 1100, showed, "Attentive...hears other patients being mean...says she is afraid of another patient..."

The Multidisciplinary Progress Notes dated 03/22/15, timed at 2000, showed, "Female peer slapped patient in the face, she (Patient #14) fell to the floor, when she stood up the female patient with another female peer jumped her (Patient #14) and hit her (Patient #14) on the floor...neuro checks started...called Dr...send to ER (emergency room) for medical clearance of any injuries... Social Worker guardian called and notified...stated he will press charges for assault against the two female patients...gave report to (hospital)...2015...transport arrives to take patient to hospital..."

The Multidisciplinary Progress Notes dated 03/22/15 (03/23/15) timed at 0330 showed, "Hospital called to give report...patient on way back to unit with minor injury to head...suggests Ibuprofen for headache..."

On 04/23/15, at 0844, Personnel #33 was interviewed. Personnel #33 was asked if she had reviewed the assault incident involving Patient #14 and the resulting injuries suffered on 03/22/15, and whether the assault was investigated. Personnel #33 stated she was unaware of the assault and stated she picked up the reports.

On 04/23/15, at 0915, Personnel #2 was interviewed. The surveyor asked Personnel #2 if an investigation had been completed in regard to the assault incident involving Patient #14 and the injuries suffered at the hands of Patient #39 and Patient #40. Personnel #2 stated that the event had not been investigated and was unaware a pediatric patient was assaulted. Personnel #2 was asked if she had any documentation on the two adolescents who assaulted Patient #14. Personnel #2 said she did not know who the two patients were.

On 04/24/15, a confidential Interview was conducted. The interviewee stated that the adolescent girls and pediatric patients are housed together. The interviewee said that the documentation in the medical record did not accurately reflect what happened. The interviewee stated that Patient #14 was slapped in the face which caused (Patient #14) to fall and hit her head on the door. The two girls then attacked Patient #14 while she was on the floor. The interviewee stated that the girls were separated, and while walking in front of the nursing station one of the two girls slapped Patient #14 again. The interviewee said there was only one technician for 14 patients.

Patient #39's Integrated Assessment dated 03/16/15, timed at 22:02, showed, "14 year old...urges for self-injury...history of PTSD (post traumatic stress disorder), Bipolar...family conflict...hitting, slapping."

The 03/22/15, Multidisciplinary Progress Note timed at 23:50, showed, "Met with patient...agitated, aggressive/combative around unit...re-directable...will continue to monitor." No details were documented regarding the assault on (Patient #14).

Patient #40's Integrated Assessment dated 03/21/15, timed at 15:30, showed, "16 year old accompanied by police...increased appetite due to pregnancy...involved in human trafficking (witness)...runaway...three months pregnant...wanted to hurt herself...admit for safety."

The Multidisciplinary Progress Note dated 03/22/15, timed at 23:00, showed, "Met with patient...agitated, behavioral aggression, combative period, yelling, cursing...fighting with peers...redirected, q15 (every fifteen minute) for safety." No details were documented regarding the assault on (Patient #14).

Hospital Policy TMHS.NURS.067 dated 02/2015, and titled Patient Rights and Responsibility noted that "without limitations patient shall be entitled to care in a safe and sanitary setting."


2) A. Patient #14's Multidisciplinary Progress Notes dated 03/22/15, timed at 2000, showed, "Female peer slapped patient in the face, she (Patient #14) fell to the floor, when she stood up the female with another female peer jumped her (Patient #14) and hit her on the floor...neuro checks started...called Dr...send to ER (emergency room) for medical clearance of any injuries... Social Worker guardian called and notified...stated he will press charges for assault against the two female patients...gave report to (hospital)...2015...transport arrives to take patient to hospital..."

Patient #14's Precaution Checklist (close observation, 15 minute checks for assault) dated 03/22/15 (the day of assault), timed from 2045 through 2345 revealed the following documentation:

The precaution checklist timed from 2045 through 2100 showed, "Quiet in patient room."

The precaution checklist timed from 2115 through 2145 showed, "Interacting socially in the large lounge."

The precaution checklist timed from 2200 through 2345 showed, "Sleeping in patient room."

The above precaution checklist did not accurately document the location/behavior of the patient as (Patient #14) was transferred to the medical hospital on 03/22/15 at 2015.

On 04/30/15, at 1450, Personnel #37 was interviewed. Personnel #37 reviewed (Patient #14's) medical record and verified the rounds records were not accurate.



B. Patient #31's Notification of Emergency Detention dated 04/24/15, timed at 0855, showed, "Stating he wanted to kill himself...anger problems."

The APOWW Pre-Assessment Screening dated 04/22/15 (04/24/15) timed at 2200, showed, "Patient arrived on unit at 2055."

The Precaution Checklist for 04/25/15, showed, "Discharged 0030." No precaution checklist was found for 04/24/15 from 2055 to 2345.

On 05/01/15, at approximately 1000, Patient #31's medical record was reviewed with Personnel #3. Personnel #3 verified the rounds records were not completed for 04/24/15.



C. Patient #32's Notification of Emergency Detention dated 04/24/15, showed, "Patient #32 was becoming violent with neighbors and stated he wanted to die...would make police kill him..."

The 04/24/15, Precaution Checklist showed, "1600 to 1645" was left blank with no documentation regarding behavior/location.

On 05/01/15, at approximately 1015, Patient #32's medical record was reviewed with Personnel #3. Personnel #3 verified the rounds records were not completed for 04/24/15.


The policy and procedure entitled, "Patient Observation/Levels of Observation" with a current effective date of 03/2015, showed, "Purpose to ensure patient safety...to provide a process for observing and documenting patient location and behavior...document patient location and behavior when the observation occurs on the patient observation form...while monitoring hallways and patient care areas ensure patients are not entering rooms not assigned to them...not in rooms or areas that are designated "off limits" areas to patients...not left in "Treatment Areas" without direct staff supervision...levels of observation...all in-patient admissions as well as APOWWs will be on close observation with a minimum of observation to be completed every 15 minutes (give or take 5 minutes)...documentation of patient's behavior will be documented on the patient observation form...(Patient Observation Checklist)....Heightened Level of Observation (HLO) 5 minute close observation...where a patient is visualized and monitored for safety at least every five minutes..."



D. Patient #44 nursing documentation dated 04/19/15, showed that the patient had eloped at 1400, and returned to the unit at 14:30. Patient #44's 15 minute precaution checklist dated 04/19/15 showed that the patient was 'sleeping in [the] large lounge" between 14:00 and 1430. Personnel #3 and Personnel #14 acknowledged the above findings on 04/28/15 at approximately 15:30.



E. Patients #6's, #7's, #8's, and #9's behavior and location were observed documented on 04/20/15, at 1315, on the patient's precaution checklists. The time slots for 1245, 1300 and 1315 were left blank. One mental health technician was in charge of 16 patients including (Patient #50) who was on every five-minute (HLO) (high level observation) checks.

Patient #6's Physician's Preadmission examination orders dated 04/19/15, placed the patient under an order of protective custody for safety on 04/09/15. The patient's precaution checklist dated 04/20/15, showed the patient was on close observation and 15 minute checks.


Patient #7's Physician's Orders dated 04/18/15, placed the patient on suicide precautions. The patient's precaution checklist dated 04/20/15 showed that Patient #7 was on fifteen minute checks for suicide.


Patient #8's Physician Orders dated 03/26/15, ordered the patient to be on suicide precautions. Patient #8's precaution checklist dated 04/20/15 noted the patient was on close observation for suicide precautions.


Patient #9's Admission Physician Orders dated 04/14/15, the patient was ordered to be on 15 minute checks and suicide precautions. The patient's precaution checklist dated 04/20/15 noted the patient was on 15 minute checks.


Patient #50's Preadmission Examination Orders dated 04/17/15, showed the patient's admission diagnosis of Major Depressive Disorder, Recurrent,with psychotic features. Patient #50 was placed on suicide precautions. The Physician Daily Progress Note dated 04/20/15, at 1230, showed the patient heard voices telling the patient to kill herself, was suicidal, had scratched herself the previous day and "could not promise no harm." The physician placed the patient on high level of observation.


During an interview on 04/20/15, at 1345, Personnel #3 acknowledged that the above findings and stated the 15-minute observation checklists "should not be behind."

On 04/23/15, (confidential interview) Personnel #17 acknowledged that the unit did not have enough staff.



3) Observations on 04/20/15, at 1020, in the Trauma Unit Exam Room showed an oxygen tank placed in an area identified as storage for full oxygen tank was sealed with plastic. Personnel #4 stated it was full. Upon surveyor request, Personnel #6 opened the seal, tested the tank and stated, "It registers empty."

Personnel #2 stated during an interview on 04/20/15, at 1225, that nurses "were trained to turn on the oxygen to make sure the tanks are full. It is on their [the nurses'] competency checklist."

Personnel #3 was interviewed on 04/20/15, at 1235, and asked how nurses knew an oxygen tank was full. Personnel #3 replied that if the plastic seal was on the tank "it should be full."



4) Observations on 04/21/15, at 12 noon, in the hospital's dining room showed nine adolescent patients eating lunch. In close proximity and accessible to the patients, an unlocked door led to a room identified by Personnel #12 as staff dining room. The staff dining room contained the following items: a large plastic bag in a trash can, four electrical cords of about three feet of length each connecting steam tables with their electric outlets, and a container of 100 count saniwipes which carried the warning to call poison control in case of ingestion.

Personnel #12 acknowledged the above observations on 04/21/15, at approximately 1210.

Based on record review and interview, the hospital's performance improvement was unaware of and failed to:

1) Track adverse patient events for 4 of 4 patients (Patients #14, #39, #40 and Patient #47).

Patient #39 and Patient #40, adolescents, assaulted Patient #14, a pediatric patient.

Patient #47) threw a lit cigarette at a patient

2) Investigate why more than 20 patients' urine specimens were left in the adolescent unit's refrigerator for an unknown length of time without timely processing by the lab technician.


Findings included:


1) Patient #14's Multidisciplinary Progress Notes dated 03/22/15, timed at 2000, showed, "Female peer slapped patient in the face, she (Patient #14) fell to the floor, when she (Patient #14) stood up the female with another female peer jumped her (Patient #14) and hit her on the floor...neuro checks started...called Dr...send to ER (emergency room) for medical clearance of any injuries... Social Worker guardian called and notified...stated he will press charges for assault against the two female patients...gave report to (hospital)...2015...transport arrives to take patient to hospital..."

On 04/23/15, at 0844, Personnel #33 was interviewed. Personnel #33 was asked if she had reviewed the assault incident involving Patient #14 and the injuries suffered on 03/22/15, and whether the assault was investigated. Personnel #33 stated that she was unaware of the assault and stated that she just picked up the reports. Personnel #33 denied an investigation of the incident which involved Patient #14 being slapped.

On 04/23/15, at 0915, Personnel #2 was interviewed. The surveyor asked Personnel #2 if an investigation had been completed in regard to the assault of Patient #14 who suffered at the hands of a Patient #39 and Patient #40. Personnel #2 stated that the event had not been investigated and was unaware a pediatric patient was assaulted. Personnel #2 was asked if she had any documentation on the two adolescents who assaulted Patient #14. Personnel #2 said she did not know who the two patients were.

On 04/24/15, a confidential Interview was conducted. The interviewee stated that the adolescent girls and pediatric patients are housed together. The interviewee said that the documentation in the medical record did not accurately reflect what happened. The interviewee stated that Patient #14 was slapped in the face which caused Patient #14 to fall and hit her head on the door. The two girls then attacked Patient #14 while she was on the floor. The interviewee stated that the girls were separated and while walking in front of the nursing station, one of the two girls slapped Patient #14 again. The interviewee said there was only one technician for 14 patients.


Patient #39's Multidisciplinary Progress Notes dated 03/22/15, timed at 2350, showed, "Met with patient...agitated, aggressive/combative around unit...re-directable...will continue to monitor." No details were documented regarding the assault on Patient #14.


Patient #40's Multidisciplinary Progress Notes dated 03/22/15, timed at 2300, showed, "Met with patient...agitated, behavioral aggression, combative period, yelling, cursing...fighting with peers...redirected, q15 (every fifteen minute) for safety." No details were documented regarding the assault on (Patient #14).


Patient #47's Multidisciplinary Progress Notes dated 04/19/15, at 1320, showed that Patient #47 had "thoughts of harming self and others....became very anxious, agitated, and threatening other patients on the unit because he threw a lit cigarette at a patient in the smoke room..."

On 04/23/15, at 1450, Hospital Personnel #2 denied an investigation of the incident was done because "the nurse decided that it did not need to be investigated since nobody got hurt." Personnel #2 stated an investigation would be initiated.


2) On 04/23/15, at 1040, the surveyor observed 22 urine collection cups with yellow liquid in the refrigerator located at the hospital's Burkett I Treatment Room. Personnel #46 acknowledged that there were no accompanying lab requisition sheets with the specimen cups "because the computer was down last night and the lab person did not pick up the urine this morning because they did not have paper work."Personnel #46 stated one of the specimens was provided by (Patient #40) who was discharged.

On 04/23/15, at 1315, Personnel #2 denied having received notification that 22 specimen cups had not been picked up by the lab technician.

Record review of the hospital's performance improvement documentation showed every second hospital incident in 02/2015 was documented as physical confrontation. Personnel #14 acknowledged the data on 04/23/15, at 0920.

Personnel #2 was asked about an improvement plan for physical confrontation and stated on 04/23/15 at 0930 that "a PI [performance improvement] team is being developed."

Based on observations, interviews and record review, the hospital failed to ensure that nursing services had an adequate number of nursing personnel to provide care/supervision
for 2 of 4 units (Adolescent/Child Unit and Adult Psych Unit ) in that:

1) 1 of 1 patient (Patient #14), a 10 year old pediatric patient, was assaulted by Patient #39, a 14 year old adolescent, and Patient #40, a 16 year old adolescent. Patient #14 was sent to the acute care hospital for a head injury, and

2) 4 of 4 patients (Patients #6, #7, #8, and Patient #9) on the hospital's Adult Psych Unit did not have their behaviors and locations documented on their precaution sheets for 45 minutes on 04/20/15. One technician was in charge of 15 patients on 15 minute precautions and one acutely suicidal patient (Patient #50) on high level of observation (5 minute checks).


Findings included:


1) On 03/22/15, Patient #14, a 10 year old pediatric patient, was assaulted by Patient #39, a 14 year old adolescent patient, and Patient #40, a 16 year old adolescent patient. Patient #14 was sent to the medical hospital for a head injury.

The daily patient checklist dated 03/22/15, for adolescent/child (girls) unit revealed, 14 total patients listed on the daily patient checklist. Three of the fourteen patients were APOWW's (apprehension by peace officer without warrant). One MHT was assigned to all 14 patients. One nurse was assigned for the adolescent/girls unit. Fourteen patients were on close observations (15 minute checks), seven patients were on assault precautions, two patients were on (SAO) sexually acting out precautions and six patients on suicide precautions.

On 04/24/15, a confidential Interview was conducted. The interviewee stated that the adolescent girls and pediatric patients are housed on the same unit. The interviewee stated that there was only one MHT (mental health technician) for 14 adolescent/children and one nurse on 03/22/15. The interviewee stated that this included any APOWW's on the unit. The interviewee stated the staffing is unsafe.


2) Patients #6's, #7's, #8's, and #9's behavior and location were observed documented on 04/20/15, at 1315, on the patient's precaution checklists. The time slots for 1245, 1300 and 1315 were left blank. One mental health technician was in charge of 16 patients including (Patient #50) who was on every five-minute observation checks.

Patient #6's checklist dated 04/20/15, showed that the patient was on close observation and 15 minute checks.

Patient #7's precaution checklist dated 04/20/15, showed that Patient #7 was on suicide precautions.

Patient #8's precaution checklist dated 04/20/15, noted that the patient was on close observation for suicide.

Patient #9's precaution checklist dated 04/20/15, noted that the patient was on 15 minute checks.

Patient #50 was on high level of observation (every 5 minutes) for previous self-harming behavior.


During an interview on 04/20/15, at 1345, Personnel #3 acknowledged the above findings and stated the 15-minute observation checklists "should not be behind."

On 04/23/15 (confidential interview) Personnel #17 acknowledged that the unit did not have enough staff.

The hospital policy entitled, "Staffing Plan" with an effective date of 02/2015 showed, "To provide the appropriate number of staff necessary to provide patient care...staffing assignments based on the programmatic and acuity needs..."

Based on observation, interview and record review the hospital failed to ensure a Registered Nurse (RN) evaluated/re-assessed the care needs for:

1) 3 of 3 patients (Patient #14, #39 and Patient #40) who were in a physical altercation. The RN did not complete neuro-checks, vital signs upon Patient #14's, a 10 year old child, return from the medical hospital. The RN failed to document that Patient #39, a 14 year old adolescent, and Patient #40, a 16 year old adolescent were involved in the assault on Patient #14. No details regarding the event, skin assessment, vital signs were documented for Patient #39 and Patient #40.

2) 1 of 1 patient (Patient #41) sustained a fractured left wrist on 04/20/15. Although the technician reported the event to the RN, the RN did not document an initial assessment and/or ongoing assessment of the site until after the patient returned from the ER (emergency room) on 04/24/15 at 2330.

Findings included:


1) Patient #14's Integrated Assessment dated 03/08/15, timed at 0100, showed, "10 year old female in foster care...anger issues with Mother and Dad...reports she sometimes does not use coping skills...history of mood disorder, anxiety...history of cutting self mutilation..."

The Group Notes dated 03/21/15, timed at 1100, showed, "Attentive...hears other patients being mean...says she is afraid of another patient..."

The Multidisciplinary Progress Notes dated 03/22/1,5 timed at 2000, showed, "Female peer slapped patient in the face, she (Patient #14) fell to the floor, when she stood up the female with another female peer jumped her (Patient #14) and hit her on the floor...neuro checks started...called Dr...send to ER (emergency room) for medical clearance of any injuries... Social Worker guardian called and notified...stated he will press charges for assault against the two female patients...gave report to (hospital)...2015...transport arrives to take patient to hospital..."

The Multidisciplinary Progress Notes dated 03/22/15 (03/23/15) timed at 0330, showed, "Hospital called to give report...patient on way back to unit with minor injury to head...suggests Ibuprofen for headache..." No neuro-checks, vital signs and/or re-assessment was documented for the 10 year old child.

The acute carel hospital discharge instructions dated 03/23/15, with a print timed at 0405, showed, "Head Injury (Child: No Wake-Up)...your child has had a mild head injury...sometimes symptoms of a more serious problem (bruising or bleeding in the brain) may appear later...during next 24 hours watch for warning signs...home care...next 24 hours someone must stay with your child to check for signs below...if there is swelling of the face, scalp, apply an ice pack for 20 minutes every 1-2 hours until swelling starts to go down...do not use aspirin or ibuprofen after a head injury...you may use Tylenol...for next 24 hours do not give medicines that might make your child sleepy...no strenuous activities..."

On 04/23/15, at 1321, Personnel #3 was interviewed. Personnel #3 reviewed Patient #14's medical record. Personnel #3 verified no vital signs, assessment, neuro-checks were completed for (Patient #14) upon return from the hospital.


Patient #39's Integrated Assessment dated 03/16/15, timed at 2202, showed, "14 year old...urges for self-injury...history of PTSD (post traumatic stress disorder), Bipolar...family conflict...hitting, slapping."

The 03/22/15, Multidisciplinary Progress Note timed at 2350, showed, "Met with patient...agitated, aggressive/combative around unit...re-directable...will continue to monitor." No vital signs, assessment and/or details were documented for (Patient #39).

On 04/23/15, at 1330, Personnel #3 was interviewed. Personnel #3 reviewed Patient #39's medical record. Personnel #3 verified no vital signs and assessment was completed for Patient #39.


Patient #40's Integrated Assessment dated 03/21/15, timed at 1530, showed, "16 year old accompanied by police...increased appetite due to pregnancy...involved in human trafficking (witness)...runaway...three months pregnant...wanted to hurt herself...admit for safety."

The Multidisciplinary Progress Note dated 03/22/15, timed at 2300, showed, "Met with patient...agitated, behavioral aggression, combative period, yelling, cursing...fighting with peers...redirected, q15 (every fifteen minute) for safety." No vital signs, assessment was documented for (Patient #40).

On 04/23/15, at 1345, Personnel #3 was interviewed. Personnel #3 reviewed Patient #40's medical record. Personnel #3 verified no vital signs and assessment was completed for Patient #40.


2) Patient #41's Integrated Assessment dated 04/03/15, timed 1530, showed, "13 year old male...suicidal thoughts...drug use...threatened to kill himself at school...wants to beat up people...abusive towards mom."

The 04/20/15, Precaution Checklist showed, "1600 to 1645...interacting socially outside."

The 04/20/15, Multidisciplinary Progress Note timed at 1900, showed, "Presents with bright affect...will continue to monitor." No nursing documentation in regard to Patient #41's left wrist injury.

The 04/20/15, Physician's Orders timed at 2300, showed, "Consult Dr...to rule out left hand fracture..."

The 04/21/15, Physician's Orders timed at 0935, showed, "X-Ray left wrist...Ibuprofen 400 mg (milligrams) po (by mouth) TID (three times a day) as needed for left wrist pain."

The 04/21/15, Consultation timed at 1400, showed, "I fell on it yesterday playing football...swelling left wrist...increased pain to palpation...decreased range of motion secondary to pain."

The 04/22/15, Multidisciplinary Progress Note timed at 2100, showed, "Compliance with medications...attempted to call the labs for x-ray results...x-ray did not answer will give report to morning nurses...will monitor for changes in mood and behavior."

The Faxed Radiology Report dated 04/23/15, timed at 2327, showed, "There is acute impacted fracture involving left distal radius with mild displacement...there is associated tissue swelling..."

The Multidisciplinary Progress Notes dated 04/23/15, timed at 1700, showed, "Denies depression...will continue to monitor for changes in mood and behavior." No nursing documentation regarding the condition of the left wrist including vital signs.

The 04/24/15, Consultation showed, "ED (emergency department) for fracture stabilization."

The 04/24/15, Multidisciplinary Progress Note timed at 1800 showed, "MD ordered patient to be transferred to ER (emergency room)...patient transferred to hospital..."

The 04/24/15, Multidisciplinary Progress Notes timed at 2330, showed, "Patient returned from hospital...with splint to left forearm...no signs and symptoms of compartment syndrome...HS (hour of sleep) medications and went to bed." No vital signs were documented and no further treatment orders were documented upon Patient #41's return.

The medical hospital instructions dated 04/24/15, showed, "Fracture forearm...keep arm elevated, apply ice pack over injured area for 20 minutes every 1-2 hours the first day...continue with ice packs 3-4 times a day for the next two days...keep cast/splint dry...follow-up with your doctor in one week...to be sure the bone is healing properly...fracture of radius and ulna, left, closed, initial encounter."

On 04/28/15, at 1550, Personnel #40 was interviewed. Personnel #40 was asked how Patient #41 sustained a fractured left wrist. Personnel #40 stated that on the afternoon of 04/20/15, Patient #41 was outside playing football and he fell on his left arm/wrist. Personnel #40 stated that he reported the event to the nurse upon return to the unit.

On 04/30/15, at approximately 1000, Personnel #47 was interviewed. Personnel #47 was asked to review Patient #41's medical record. Personnel #47 stated that she remembered the day shift nurse reported that the patient had hurt his wrist/hand. Personnel #47 was asked if she assessed Patient #41's wrist/hand. Personnel #47 said that was all she remembered.

On 04/30/15, at 1110, Personnel #3 was interviewed. Personnel #3 was asked to review Patient #41's medical record. Personnel #3 said that she could find nothing about nursing assessing the condition of the patient's hand after he fell on it.

The Hospital Policy entitled "Assessment and Reassessment of Patients" dated 02/2015, noted the procedure that "the registered nurse will assess each patient at a minimum every shift and more often as deemed necessary. Assessment will include their mental and physical status...more frequent assessments of patients may be needed when the patient is having a physical problem..."

Based on observation and interview the hospital failed to:

1) ensure that a clean and sanitary environment was maintained for 4 of 4 units (Geriatric,Trauma, Lewis I, and Burkett II Units)

2) ensure that direct care staff for 1 of 1 unit (Geriatric Unit) practiced good infection control procedures during patient care for 3 of 3 patients (Patient #2, #3 and Patient #5)

3) ensure that specimens collected from patients were processed timely for lab analysis for 2 of 2 units (Bloss and Burkett I units). A frozen specimen was found labeled with the name of a patient who had been discharged fourteen days prior to the beginning of the survey.


This practice placed patients at risk of acquiring infections.


Findings included:


The following environmental observations were made on the Geriatric and Trauma Unit:

1) On 04/20/15, at 0915, observation rounds were conducted with Personnel #4 on the Geriatric Unit. The equipment storage room contained a plastic cart. Seven plastic bins were observed with various condiments located inside. The interior surface of the bins were soiled with debris and dirt.

The pink lemonade dispenser nozzle was soiled and the inside surface of the lid was soiled with an unknown brown residue. Personnel #4 was asked when was the last time the container was cleaned. Personnel #4 said that she did not know, it may have been used yesterday. Sitting on top of the same container was a metal scoop wrapped in a wet paper towel. Upon removal of the paper towel pink debris was observed on the paper towel. Personnel #4 said the unit must use the scoop for stirring.

On 04/20/15, at 0947, the storage closet on the Geriatric Unit was observed. A 5-shelf metal unit was observed with paper scrubs. The scrubs were not covered. The floor of the room was soiled and dusty. The above observation was verified by Personnel #4.

On 04/20/15, at 1015, the Trauma Unit dining room was observed. The bottom shelf of the beverage counter had a soiled wash cloth which was observed sitting on the shelf. Personnel #4 verified the above observations.

On 04/20/15, at 1030, the following observations were made in the Trauma Unit's Exam Room. The refrigerator was observed with a wet and soiled paper towel. The refrigerator's freezer compartment was covered in thick ice. A dusty and grimey plastic tray was observed on top of the refrigerator. A dead black bug was observed in front of the biohazard trash can. The Exam table had a cracked vinyl cover.

Personnel #4 acknowledged the above findings at that time and agreed that the exam table's cracked vinyl cover was difficult to sanitize.

On 04/20/15, at approximately 1050, Personnel #44 was observed with a housekeeping cart that contained a toilet brush. Personnel #44 was asked and agreed she used the brush in every bathroom. Personnel #44 was asked how often the brush was changed and stated that the last one was exchanged two months ago.

On 04/20/15, at 1112, a dust covered blood pressure cuff was observed on top of the eye wash station in the Lewis I Exam Room. The unit's storage room had an open bag on the floor containing 23 rolls of toilet paper.

On 04/20/15, at 1345, in the hospital's Burkett II unit's storage room, one bin with obstetric towelettes had debris and particles on the bottom. Three other bins were observed with particles as well. Personnel #3 acknowledged the bins were dirty.



2) The following direct care observations were made on the Geriatric Unit on 04/20/15 timed from 0945 to 0950:

On 04/20/15, at 0945, Personnel #5 assisted Patient #3 to the bathroom. Personnel #5 wore a disposable pair of blue gloves and in her left hand was a chart and clipboard. After Patient #3 was finished in the bathroom Personnel #5 exited the bathroom with a white rolled up brief in her left hand with the same disposable blue gloves on. Personnel #5 squeezed the item in her gloved hand against the chart. Personnel #5 was observed looking for a paper bag in the corner of the room. No paper bag was present. Personnel #5 proceeded to remove the disposable blue gloves and place the wet garment inside the gloves. Patient #3 said, "Oh I had a good bowel movement." Personnel #5 proceeded to take Patient #3 to the day area without washing her hands.


On 04/20/15, at 0950, Personnel #7 was observed wearing a pair of blue disposable gloves. Personnel #7 was observed assisting Patient #2 to the couch holding the patient under the arms. Personnel #7 proceeded to walk over to Patient #5 still wearing the blue disposable gloves. Personnel #7 put her gloved hand under Patient #5's arms and assisted her to the wheelchair. Personnel #7 took Patient #5 to her room. Personnel #7 removed the pillowcase from the pillow on the bed and left the room with the soiled pillowcase in her gloved hand. Personnel #7 walked to the storage room and removed a clean pillowcase from the linen cart with the same soiled gloves on. Personnel #7 placed the soiled pillowcase under her arm and then proceeded to take the soiled pillowcase to the soiled laundry cart. Personnel #7 with the same soiled gloves on took the clean pillowcase and put it on Patient #5's pillow. Personnel #7 proceeded to place (Patient #5) in bed with the same blue disposable gloves on. Personnel #7 did not wash her hands between patient care.


On 04/20/15 at 0957 Personnel #4 acknowledged the above surveyor observations.



3) On 04/21/15, at 1500, the hospital's Bloss Unit Treatment Room's refrigerator contained a urine collection cup with frozen yellow liquid in it. Personnel #45 acknowledged that it was Patient #48's urine sample and stated that Patient #48 was "no longer here [at the hospital]." Additional observations included a blood pressure Dynamap machine which stored an open container filled with probe covers. Personnel #45 identified the probe covers as being used and discarded them in the trash. A nebulizer machine for breathing treatments was observed uncovered and with an open bag of oxygen tubing. Personnel #45 stated she thought the tubing was used and disposed of it in the trash. A blue tub with four transport jackets had dirt particles and a dead moth on the bottom.

Record review of Patient #48's medical record noted an admission date of 03/23/15 at 1100. Admitting diagnoses included Schizophrenia. Admission labs were ordered and included a urine analysis. Physician's orders dated 04/06/15 noted the patient was discharged.

On 04/23/15, at 1040, the surveyor observed 22 urine collection cups with yellow liquid in the refrigerator located at the hospital's Burkett I Treatment Room. Personnel #46 acknowledged that there were no accompanying lab requisition sheets with the specimen cups "because the computer was down last night and the lab person did not pick up the urine this morning because they did not have paper work." Personnel #46 stated one of the specimens was provided by Patient #40 who was discharged.

Record review of Patient #49's medical record reflected the patient was admitted per APOWW (Apprehended by a Peace Officer Without a Warrant) on 04/21/15, at 1617, for daily thoughts of suicide. Admitting diagnoses dated 04/22/14, at 0304, included Major Depression, mild. Patient #40's precaution checklist dated 04/22/15, at 1015, showed that the patient was discharged.

On 04/23/15, at 1315, Personnel #2 denied having received notification that 22 specimen cups were in the adolescent unit refrigerator and had not been picked up by the lab.

On 04/21/15, at 1010, Personnel #12 was interviewed. Personnel #12 stated all staff members received training in infection control and were aware they were to wash hands before and after taking care of patients. Personnel #12 stated she caught "about 40 percent of infections in the hospital" and was "worried" about "missing some of them."

Documented incidents of infections increased from 113 in the third quarter of 2014 to 136 in the fourth quarter of 2014.

The hospital's 2015 Infection Control Plan noted the purpose to "...minimize the risk of infection...anticipating the infections that occur...planning for control of infections."

Based on interview and record reviews, the hospital failed to ensure 1 of 1 patient (Patient #41's) discharge plan included and addressed discharge planning/instructions which addressed Patient #41's left wrist fracture sustained while inpatient.

Findings included:

Patient #41's Integrated Assessment dated 04/03/15, timed at 1530, showed, "13 year old male...anger management, suicidal thoughts...drug use...threatened to kill himself at school...wants to beat up people...abusive towards mom."

The 04/20/15, Multidisciplinary Progress Note timed at 1500, showed, "Bright affect...denies anger...good for today...will continue to monitor."

The 04/20/15, Precaution Checklist showed, "1600 to 1645...interacting socially outside."

The 04/21/15, Consultation timed at 1400, showed, "I fell on it yesterday playing football...swelling left wrist...increased pain to palpation...decreased range of motion secondary to pain."

The Radiology Report faxed report dated 04/23/15, timed at 2327, showed, "There is acute impacted fracture involving left distal radius with mild displacement...there is associated tissue swelling..."

The 04/24/15, Consultation showed, "ED (emergency department) for fracture stabilization."

The 04/24/15, Multidisciplinary Progress Notes timed at 2330, showed, "Patient returned from hospital...with splint to left forearm...no signs and symptoms of compartment syndrome...HS (hour of sleep) medications and went to bed." No vital signs were documented and no further treatment orders were documented upon Patient #41's return.

The medical hospital instructions dated 04/24/15, showed, "Fracture forearm...keep arm elevated, apply ice pack over injured area for 20 minutes every 1-2 hours the first day...continue with ice packs 3-4 times a day for the next two days...keep cast/splint dry...follow-up with your doctor in one week...to be sure the bone is healing properly...fracture of radius and ulna, left, closed, initial encounter."

The hospital discharge instructions Form #3122-A dated 04/27/15, showed, "Diet as tolerated, physical activity as tolerated...follow-up medical care instructions...with your primary care physician, whenever necessary..."

The hospital discharge instructions Form #3122-C dated 04/28/15, showed, "Community Resources...crisis...suicide booklet." No documentation was found with instructions for (Patient #41's) fractured left wrist."

The Multidisciplinary Progress Notes dated 04/28/25, timed at 1500, showed, "Has a bright affect...appropriate behavior...denies pain...discharged home with mom."

On 04/30/15, at 1110, Personnel #3 was interviewed. Personnel #3 was asked to review (Patient #41's) medical record. Personnel #3 said she could find nothing about left wrist fracture addressed in the discharge instructions.

The policy and procedure entitled, "Discharge Aftercare Planning" with an effective date of 02/2015, showed, "Discharge and aftercare planning begins upon admission...is continually reassessed, updated and documented to meet the patient/family needs throughout the patient's length of stay..."

Based on medical record review and staff interview, it was determined that for eight (8) of ten (10) active patients (Patients A5, B7, B8, D1, D2, E1, E2 and F19), the facility failed to ensure that the Psychosocial Assessments provided a description of the specific and individualized role of the social work staff in treatment and discharge planning for these patients. The absence of this information prevents the treatment team from addressing critical patient needs during the course of hospitalization and formulating the patients' discharge plans, ensuring safe re-entry into the community.

Findings include:

A .Medical Record Review:

1. Patient A5: The Psychosocial Assessment, dated 4/12/15, had as the social services interventions - "group therapy, D/C (? discontinue) case mgmt (? management), planning." There was no description of the type of group therapy that was going to be provided or on what the discharge planning would focus.

2. Patient B7: The Psychosocial Assessment, dated 3/15/15, had as the social services interventions - "group therapy to stabilize changes in mood and behaviors; aftercare." There was no description of the patient's specific discharge planning needs.

3. Patient B8: The Psychosocial Assessment, dated 3/3/15, had as the social services to be provided - "group, individual and family therapy to stabilize changes in mood and behavior and aftercare planning". There was no patient specific description of what the focus for family therapy would be or the specific anticipated discharge planning efforts would be.

4. Patient D1: The Psychosocial Assessment, dated 4/93/15, had as a description of the role of the social work staff - "discharge planning, group therapy and individual therapy, supportive services." No patient specific focus was provided.

5. Patient D2: The Psychosocial Assessment, dated 4/12/15, had as social services role - "group therapy, family therapy, D/C planning." No patient specific focus was described.

6. Patient E1: The Psychosocial Assessment, dated 4/15/15, had as the role for social services - "Social work, group therapy, discharge planning." No patient specific focus was provided.

7. Patient E2: The Psychosocial Assessment, dated 4/8/15, had as the role of the social work staff - "group therapy, psycho-education, case management, D/C planning." No patient specific focus for these efforts was provided.

8. Patient F19: The Psychosocial Assessment, dated 4/10/15, had as the role for social service efforts - "Social work, group therapy, discharge planning." No patient specific focus for these efforts was described.



B. Staff Interview:

On 4/21/15, at 10:00 a.m., the Director of Social Services was interviewed. She was shown the findings described in Section A above. The Director agreed that these statements of the role or efforts of the social services staff were not individualized or patient specific.

Based on medical record review and staff interview, it was determined that the facility failed to ensure that for three (3) of ten (10) active patients (Patient A5, D1, and E2), their Master Treatment Plans contained the interventions that would be utilized by the psychiatrist and/or the nursing staff. This failure results in an inability of the patient or the other members of the treatment team to know what modalities or interventions would be attempted by these disciplines during hospitalization.

Findings include:

A. Medical Record Review:

1. Patient A5: The Master Treatment Plan, dated 4/10/15, failed to include a description of the psychiatrist's interventions.

2. Patient D1: The Master Treatment Plan, dated 4/6/15, failed to include a description of the interventions of the psychiatrist and the responsible nursing staff.

3. Patient E2: The Master Treatment Plan, dated 4/8/15, failed to include a description of the interventions of the psychiatrist and the responsible nursing staff.



B. Staff Interview:

On 4/21/15, at approximately 9:30 a.m., the clinical director was interviewed. The findings described in Section A. above were discussed. He agreed that Treatment Plans should include the interventions of the various members of the treatment team.

I. Based on record review, observation and interview, the facility failed to provide active treatment, including alternative interventions, for one (1) of two (2) active sample patients (B7) on the Geriatric Unit, and 1 active sample patient (F19) on the Chronic Adult Psychiatric Unit. Although the treatment plan for each patient included multiple groups, both patients were not always cognitively capable of attending the groups listed on the unit's activity schedule. The patients regularly and repeatedly did not attend the groups. Both patients spent many hours, without any structured activities, in their rooms or wandering around hallways on their specific units. Patient non-participation in assigned treatment modalities negates the clinical effectiveness of the patients' treatment goals and objectives, potentially delaying their improvement.

Findings include:

A. Patient B7

1. Patient B7 was admitted on 3/25/15. According to the Psychiatric Evaluation, dated 3/25/15, it stated "Patient brought in from NH (nursing home) last night. Here 3/12/15 - 3/20/15 and D/C (discharged) to nursing home. There was wandering of patient reported and patient was easily agitated. Patient became combative with staff trying to draw blood. Reportedly slept very little while there "---" disorganized, distrustful of caregiver "---" judgment poor."

2. Patient B7 was observed lying on bed with eyes closed on 4/20/15 around 12:25p.m. while most of patients were in dayroom eating lunch. When asked why B7 was not out eating lunch, MHT#1 stated, "[S/he] seldom comes out of [his/her] room. [S/he] just lies on his/her bed all day." When asked how [s/he] gets [his /her] meals, MHT#1 stated, "[Name of patient] just eats in [his/he] r room."

3. On B7's Master Treatment Plan, dated 3/25/15, an identified problem was "aggressive acting out behavior requiring the use of seclusion/restraint." The listed intervention included "1:1 [one to one] with patient to explore triggers for aggressive feelings and behavior, patient to attend psycho-education groups on anger management, patient to attend activity therapy groups to provide skills in coping, anger management, conflict resolution, patient to attend goal setting to assist patient in setting production goals." For the problem of "out of contact with reality," some of the listed interventions were: "Goals and wrap-up group" to assist patient in setting productive goals, psycho-education groups on memory processing, safety & [and] trust, getting needs met, process groups to provide the opportunity to express thoughts feelings, activity therapy groups to provide patient skills in order to increase reality orientation, and individual/family therapy involving all his discharge planning.
There were no updates on B7's treatment plan to address the patient's inability and/or unwillingness to consistently participate in the therapy groups offered

4. In an interview on 4/15 around 12:15 p.m., RN #1 was asked for a copy of patient B7's activity schedule. RN #1 stated, "We just have a unit schedule. All patients on the unit are expected to attend the groups listed on the schedule." When asked if patient B7 attended any groups, RN #1 stated, "[Name of patient] stays in his/her room most of the time. We do try to encourage all patients to go to the groups, but we can't force them."

5. A review of the progress notes of groups offered by social work staff revealed that between 4/13/15 and 4/19/15, patient B7 did not participate or attend 10 of 14 groups offered. These groups were: "Process/Education Group" at 11:00 a.m. and 2:00 p.m. on 4/1315 and 4/15/15; same group on 4/16/15 at 2:00 p.m., on 4/17/15 at 11:00 a.m.; both groups on 4/15/15 at 11:00 a.m. and 2:00 p.m., and on 4/17/15 at 11:00 a.m. and 2:00 p.m.
On 4/17/15, patient was documented at 2:00 p.m. as attending the "Process/Education Group", but patient's round's sheet stated "Patient sat near group with eyes closed. Pt [patient] then came to group. Pt irritable."

During the period of 4/13/15 and 4/19/15, patient B7 was documented on the "Daily Therapy Documentation" sheet as not attending four (4) of the seven (7) Recreation Therapy groups offered 7 days per week on the unit between the hours of 7:45 a.m. to 10:45 a.m. The dates were 4/13/15, 4/14/15, 4/15/15 and 4/18/15. There was no documentation in the Master Treatment Plan on whether the patient attended this group on 4/16, 4/17 and 4/19.

6. In an interview with patient B7 on 4/20/15, at 1:00 p.m., [s/he] was asked what [s/he] did all day. [S/he] stated, "I stay in my room most of the day."

7. In an interview on 4/20/15, at 1:55 p.m., MD #1 was asked if he was aware of patient B7's isolation in [his/her] room most of the day. MD #1 stated "[Name of patient] is significantly impaired. At one time [name of patient] would not sleep. I'm working with [his/her] medication. [Name of patient] does isolate self in room. I'm looking into a placement for [him/her]."



B. Patient F19

1. Patient F19 was admitted on 4/9/15. According to the Psychiatric Evaluation, dated 4/9/15, it stated that "Patient answered door with butcher knife in hand at private resident. Talking nonsense, irrelevant responses to the TBL (Timberlawn Bloss) [The patient's unit]. APOWW [apprehended by police without a warrant]." (In Texas a patient can be put in a facility for up to 48 hours for evaluation for treatment. Patient has the option of signing self into the facility if a physician feels patient needs treatment or physician can apply for a court order if patient opposes.) The evaluation goes on to say that patient still "talking in word salad stage of communication "----" unable to assess - appears to talk disorganized, unable to assess due to pt [patient] talking nonsense."

2. Patient F19 was observed wandering up and down the hallway on 4/20/15, at 11:50 a.m., while a process therapy group was being held in the lounge. When asked if patient F19 was supposed to be in that group, RN #2 said, "All the patients are expected to attend all the groups on the unit, but [name of patient] just wanders the hallway most of the time." Census on this unit was 24 at the time. Only 15 patients were at the Process group. Six (6) of the nine (9) patients not at the group were observed in their beds with eyes closed.

3. On patient F19's Master Treatment Plan, dated 4/9/15, an identified problem was "out of contact with reality." The listed interventions included: "1:1 patient education regarding effects, benefits and side effects of Haldol, goals and wrap-up group to assist patient in setting productive goals, psycho-education to assist patient in setting productive goals, psycho-education groups on reality testing, grounding techniques to develop self-care skills, process groups to provide patient opportunity to express thoughts and feelings, activity therapy groups to provide patient skills in grounding, 1:1 patient education regarding illness to promo 1:1 patient education regarding illness to promote self-care and prevent relapse, and medication education groups to increase understanding of effects and side effects of prescribed medications."

For the problem of "aggression toward others," some of the interventions groups were: "1:1 patient education regarding effects, benefits and side effects of Haldol, goals and wrap-up group to assist patient in setting productive goals, psycho-education groups on boundaries of anger management, impulse control to develop self-control skills, process groups to provide patient opportunity to express thoughts and feelings, activity therapy groups to provide patient skills in anger management, and 1:1 patient education regarding illness to provide self-control and prevent relapse." There was no documentation on the Master Treatment plan to address the patient's inability or unwillingness to attend these groups and any alternative measures that could be implemented to suit patient's needs and ability at present state of mind.

4. A review of the progress notes of groups offered by social work staff revealed that between 4/13/15 and 4/19/15, 14 groups conducted by social work staff on process and/or education were offered at 11:00 a.m. and 1:15 p.m. during the 7 day period. The patient was documented on 4/13/15, at 11:00 a.m., as "Quiet- non-participation" and at 1:15p.m. as "observed wandering the hallway, did not attend group." On 4/14/15, at 11:: 00a.m., group - "wandered aimlessly around the unit and through group area. Pt. appeared to be R1S, [responding to internal stimuli]." At 1:15p.m. - "Pt. in and out of group area, again wandering aimlessly throughout unit." On 4/15/15, at 11:00 a.m., - "Pt. wandered around unit and through group area. Pt appeared to be R1S, talking to self. " At 1:15 p.m., "Pt. again wandering aimlessly around unit, this time talking loudly to himself and disrupting group multiple times." On 4/16/15, at 11:00 a.m. and 1:15 p.m. groups - "Pt. was verbally encouraged to attend group, but refused. On 4/17/15, at 11:00 a.m. - "Pt. came at end of group, sat in chair. No verbal participation in group." At 1:15 p.m. group - "walking around. Handout given. Handout left in room." 4/18/15, at 11:00 a.m. - "Pt. wandering around the unit aimlessly and appeared to be R1S." At 1:15p.m. group - "pt remained in room." On 4/19/15, at 11:00 a.m. group - "Pt. paced around the unit and in and out of group and up and down hallway. Pt. appeared to be R1S, talking to self." At 1:15p.m. group - "Pt. remained in room initially, was again observed to be pacing the hallway during group. Pt. then returned to room and appeared to be asleep."

During the period of 4/13/15 and 4/19/15, patient F19 was documented on the "Daily Activity Therapy Documentation" sheet as not attending four (4) of the five (5) Recreation Therapy Groups offered Monday through Friday on the unit from 3:00 p.m. to 4:00 p.m. The dates of the groups not attended were 4/13/15 - 4/16/15. There was no documentation in the chart of an Activity Therapy Group on 4/19/15.



II. Based on record review, observation and interview, the facility failed to provide placement of hospitalized patients into milieus that contain (1) patients not yet hospitalized or (2) research patients hospitalized and possibly not receiving necessary medications. There is a likelihood of physical harm to the acutely ill patients.

Findings include:

A Record Review

1. The Adolescent Unit provides care to youngsters who are APOWW (apprehended by police officer without a warrant). These persons may or may not be determined to require hospitalization within 24 hours of their arrival. Staff on the unit estimate that about half of the APOWW persons are sent out after their evaluations. Thus throughout the day seriously mentally ill persons may be sharing meals, groups etc. with persons not seen as mentally ill. This arrangement presents a likelihood of harm to the acutely ill patients.

APOWW persons who are adults may also be present. The Administrator estimates that 10% to 20% of these persons are assessed as not requiring acute care hospitalization yet are present throughout their stay with acutely mentally ill patients. There is a likelihood that patients may be victimized by these persons who are not patients.


2. Patients hospitalized with other patients who are not on medications and who might require medications to modify their symptoms.

There is a research program present at the facility called Pillar Research Program. The nature of this research program is to assess patient responses to double blind medication interventions. The patients are typically hospitalized on the Lewis 1 Unit amid acutely ill mental patients but on occasion may be placed on the Bloss Unit (Adult Intensive Care) Again the nursing staff and pharmacy staff do not know who is or is not receiving medications aimed at lessening their symptomatology. There is a likelihood of assaults, property destruction, and other behavioral issues and there is a likelihood of victimization of patients not in this research program.


B. Staff Interview

On 4/22/15, at 3:40 p.m., the facility's administrator was interviewed concerning these placements of acutely mentally ill patients with persons who do not warrant hospitalization or are not receiving medications that might benefit them. She acknowledged that these situations are occurring.

Based on medical record review and staff interview, it was determined that for two (2) of five (5) Discharge Summaries (Patient G2 and Patient G3), the facility failed to ensure that a statement about the clinical status of the patient at the time of discharge was present. This failure results in no information to the next treatment provider about what condition the patient was presenting when the decision to discharge was made.

Findings include:

A. Medical Record Review:

1. Patient G2: The Discharge Summary, dated 4/5/15, did not contain any information about the patient's clinical status at the time of discharge.

2. Patient G3: The Discharge Summary, dated 3/13/15, did not contain any information about the patient's clinical status at the time of discharge.


B. Staff Interview:

On 4/21/15, at approximately 9:30 a.m., the Clinical Director was told of the findings described in Section A above. He agreed that this information should be present in a patient's Discharge Summary.

Based on medical record review, and staff and patient interviews, it was determined that the clinical director failed to adequately supervise and evaluate the care provided to patients at the facility. Specifically, the Medical Director failed to assure that:

1. The Treatment Plans contained interventions by all members of the treatment team. For details see B122.

2. Patients who were too cognitively impaired to consistently attend groups were provided alternative treatment methods of care which were addressed on their Master Treatment Plans. (For details see B125I)

3. Treatment of patients at the facility included

a) Active medical treatment being provided during hospitalization,

b) Acutely mentally ill patients were not co-mingled with persons not assessed as requiring hospitalization, and

c) Acutely mentally ill patients were not co-mingled with research patients who possibly were on placebo medication in double blind studies. For specific details see B125II.

4. Discharge Summaries contained a description of the patient's clinical status at the time of discharge. For details see B133.

Based on review and interview, the Nursing Director failed to adequately supervise and evaluate the quality of nursing care provided to patients. Specifically, the Nursing Director failed to:

1. Ensure that for two (2) of ten (10) active patients (Patient D1, and E2) their Master Treatment Plans contained the interventions that would be utilized by the nursing staff. This failure results in an inability of the patient or the other members of the treatment team to know what modalities or interventions would be attempted by these disciplines during hospitalization.

Findings include:

A. Medical Record Review:

1. PatientD1: The Master Treatment Plan, dated 4/6/15, failed to include a description of the interventions of the responsible nursing staff.

2. Patient E2: The Master Treatment Plan, dated 4/8/15, failed to include a description of the interventions of the responsible nursing staff.


B In an interview on 4/21/15, at 3:45 p.m., the lack of nursing interventions on some of the active sample patients' Master Treatment Plans was discussed with the Nursing Director. She did not dispute the findings.


2. Assure that adequate number of registered nurses and mental health technicians were assigned to the Dual/Adult Psychiatric Units at all times in order to create and maintain a therapeutic milieu.

Per the Nursing Director, in an interview on 4/20/15, around 9:30a.m., the Dual/Psychiatric Adult Unit was considered one unit with Dual patients on one side of a locked unit and Adult Psychiatric patients on the other side of a locked unit. A nursing station was located between these two units. In actuality, patients from one side did not mingle with patients from the other side. The two sides operated as separate units. Each side had its own groups and assigned staff. The total staff assigned to these units was split between the two sides, creating an inadequate number to meet all the patients' needs. This inadequate staffing results in the likelihood of unsafe conditions and failure of the professional nursing staff to provide direction and supervision of non-professional nursing personnel (licensed practical nurses and mental health workers) in the provision of nursing care. (Refer to B150)

Based on record review, observation and interview, the facility failed to provide adequate numbers of registered nurses and mental health workers on the Dual/Psychiatric Adult units at all times to create and maintain a therapeutic milieu.

Based on review and interview, the Nursing Director failed to assure that adequate number of registered nurses and mental health technicians were assigned to the Dual/Adult Psychiatric Units at all times in order to create and maintain a therapeutic milieu.

Per the Nursing Director, in an interview on 4/20/15, around 9:30 a.m., the Dual/Psychiatric Adult Unit was considered one unit with Dual patients on one side of a locked unit and Adult Psychiatric patients on the other side of a locked unit. A nursing station was located between these two units. In actuality, patients from one side from a locked unit did not mingle with patients from the other side. Each side had its own groups and staff. The total staff assigned to these units was split between the two sides, creating an inadequate number to meet all the patients' needs. There is a likelihood of unsafe conditions due to inadequate staffing and failure of the professional nursing staff to provide direction and supervision of non-professional nursing personnel (licensed practical nurses and mental health workers) in the provision of nursing care.

Findings include:

A. Record Review

1. RN and LVN (licensed vocational nurses, also called licensed practical nurses) staff work twelve hour shifts. MHW(Mental Health Workers) work 8 hour shifts. A review of 8 days of nurse staffing on the Dual/Psychiatric Adult Units for the period of 4/2/15 - 4/8/15 and 4/17/15 - 4/20/15 showed the following deficiency:

7 of the 8 day shifts had 1 RN and 1 LPN on duty.
2 of 8 night shifts had this staffing.
1 day shift of 8 and 5 of 8 night shifts had 2 RNs and 2 MHTs.

The total bed capacity for both units was 33. However, when 1 RN and 1 LVN are scheduled, one unit does not have a professional nurse. In this situation, the one RN has to cover both sides in providing treatment or documentation only the professional nurse can provide per facility policy. On the shift with 2 RNs and 2 MHTs, the staffing was 1 RN and 1 MHT for each side for about 16 -17 patients assigned to each unit.


2. The Nursing Needs Assessment sheet, dated 4/20/15, had a total census of 27. Average daily census was 29.

4 patients required diabetic checks,
2 were on seizure precautions,
14 on detox protocol,
4 patients were potentially assaultive (has occasionally demonstrated during hospitalization), 10 were low risk suicidal (has occasionally demonstrated during hospitalization),
4 patients were on assault precaution,
1 on elopement precaution,
1 patient under constant/line of sight supervision (was actually a every 5 min observation) and 26 were on every 15 - 30 minute supervision checks.


3. On 4/20/15, the "Precaution Checklist for 5 Minute Observation" for patient E2 was checked by a surveyor around 2:20 p.m. The sheet showed no documentation of E2 for about 35 minutes. This patient had been put on q 5 minute checks because [s/he] had threaten to harm [his/herself].



B. Staff Interview

1. On 4/20/15, around 1:30 p.m., the Director of Nursing was interviewed. The focus then was why her name appears as the responsible person on the treatment plan of active sample patient D2. She reported that she covered in treatment team meetings because the nurse (Unit Berkett 1 Adolescent) was too busy to attend, thus indicating a possible lack of sufficient staff on other units.


2. In an interview with Licensed Practical Nurse (LPN) #1 on 4/21/15 at 1:30 p.m., s/he was asked about the nurse staffing pattern on the unit for the day. LPN #1 stated that the total census for 4/21/15, was 33 - 16 Dual patients and 17 Adult Psychiatric patients. LPN #1 stated that there was 1 RN who covered the Psychiatric Adult Unit and s/he (the LPN) covered the Dual Unit. Three mental health workers were assigned for the day shift - 1 MHT on each side and 1 float. The float answered phones, covered the other technicians for breaks, lunch and doing patient round.


3. In an interview on 4/21/15 at 2:00 p.m. with RN #3, [s/he] was asked if [s/he] felt 1 RN and 1 LPN was adequate staffing for both units. RN #3 stated it was difficult to get all the work done for both sides with that number of staff. RN #3 stated that there had been an admission. "RNs have to do the Nursing Assessments on all patients and admit any new patients. LPNs do not do these functions."

4. In an interview with MHT #1 on 4/21/15, at 2:10 p.m., [s/he] was asked how 1 technician can provide rounds every 5 minutes for 1 patient and 15 minutes checks for about 16 -17 other patients. MHT #1 stated "It's extremely difficult. Patients are very needy. They want something to drink or towels, or time for doing their laundry. We also do vital signs." When asked how [s/he] can do all that and keep an eye on patient E1 who required checks every 5 minutes, MHT #1 stated, "I try to keep patient E1 in the dayroom so [s/he]'s in line of sight at all times." However MHT #1 admitted that a technician can get busy doing things for other patients and get behind in checking the patient every 5 minutes as evident in what happened on 4/20/15.

5. In an interview on 4/21/15, at 3:40 p.m. with the Director of Nursing, the shortage of staff on the Dual/Adult Psychiatric Units was discussed. She was told of the potential harm for patients, such as E1, who was suicidal (patient had expressed desire to harm self on 4/20/15, around 1:15p.m. per LPN #1. The Nursing Director did not dispute the findings.

Based on record review and interview, it was determined that the Director of Social Work failed to adequately monitor and evaluate the quality of social services provided to patients. Specifically, for eight (8) of ten (10) active patients (Patients A5, B7, B8, D1, D2, E1, E2 and F19), the Social Work Director failed to ensure that the Psychosocial Assessments provided a description of the specific and individualized role of the social work staff in treatment and discharge planning for these patients. The absence of this information prevents the treatment team from addressing critical patient needs during the course of hospitalization and formulating the patients' discharge plans, ensuring safe re-entry into the community.

Findings include:

A .Medical Record Review:

1. Patient A5: The Psychosocial Assessment, dated 4/12/15, had as the social services interventions- "group therapy, D/C (? discontinue) case mgmt (? management), planning." There was no description of the type of group therapy that was going to be provided or on what the discharge planning would focus.

2. Patient B7: The Psychosocial Assessment, dated 3/15/15, had as the social services interventions - "group therapy to stabilize changes in mood and behaviors; aftercare." There was no description of the patient's specific discharge planning needs.

3. Patient B8: The Psychosocial Assessment, dated 3/3/15, had as the social services to be provided - "group, individual and family therapy to stabilize changes in mood and behavior and aftercare planning". There was no patient specific description of what the focus for family therapy would be or the specific anticipated discharge planning efforts would be.

4. Patient D1: The Psychosocial Assessment, dated 4/93/15, had as a description of the role of the social work staff - "discharge planning, group therapy and individual therapy, supportive services." No patient specific focus was provided.

5. Patient D2: The Psychosocial Assessment, dated 4/12/15, had as social services role - "group therapy, family therapy, D/C planning." No patient specific focus was described.

6. Patient E1: The Psychosocial Assessment, dated 4/15/15, had as the role for social services - "Social work, group therapy, discharge planning." No patient specific focus was provided.

7. Patient E2: The Psychosocial Assessment, dated 4/8/15, had as the role of the social work staff - "group therapy, psycho-education, case management, D/C planning." No patient specific focus for these efforts was provided.

8. Patient F19: The Psychosocial Assessment, dated 4/10/15, had as the role for social service efforts - "Social work, group therapy, discharge planning." No patient specific focus for these efforts was described.



B. Staff Interview:

On 4/21/15, at 10:00 a.m., the Director of Social Services was interviewed. She was shown the findings described in Section A. above. The Director agreed that these statements of the role or efforts of the social services staff were not individualized or patient specific.