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Based on observation, record review, and interview the hospital failed to ensure the hospital's policy for keeping patient's valuables safe was followed for 1 Random Patient out of a total sample of 2 random patients and 4 sampled patients that were present in the hospital and reviewed for safe handling of valuables (Patient #R44). Findings:

A tour was conducted of the Adult and Geriatric Unit at Focus Behavioral Hospital on 4/14/2010 at 10:00 a.m. Observations during this tour revealed items located on a shelf in the medication room on the Geriatric Unit which contained one wallet with three credit cards identified as belonging to Patient #R44. The Director of Nursing S2 indicated any patient valuables such as cell phones, money, credit cards, or jewelry should have been locked in the valuables lock box located in the medication room.

During an interview on 4/14/2010 at 10:00 a.m., Registered Nurse S3 indicated credit cards should be labeled with the patient's name and then locked in the valuables lock box located in the medication room.

Review of the hospital policy titled, "Search of Patient Property, NO: TX-Spec-20" presented by the hospital as their current policy revealed in part, "Valuables or cash greater than $10 (ten dollars) will be maintained in safe."

Based on record review and interview, the hospital failed to ensure that the training/orientation program included the training and competency evaluations of personnel working on the acute care psychiatric unit regarding the appropriate and safe use and application of restraints. Findings:

The Personnel Records of S6 (Licensed Practical Nurse), S8 (Mental Health Technician), S9 (Mental Health Technician), S10 (Mental Health Technician), S11 (Licensed Practical Nurse), and S12 (Registered Nurse) were reviewed. The hospital's policy/procedure titled "Orientation; Nursing Staff" was reviewed. The policy/procedure indicates that the responsibility of the Director of Nursing includes "assesses competence of job-specific skills by use of competency skills checklist. Provides an on-the-job orientation for the new employee under the supervision of a designated mentor. Reviews 1 on 1 with new employee learning needs and provides ongoing training". This review revealed the following:

? S6 (Licensed Practical Nurse). Date of Hire was 7/01/09. The "Initial Skills Competencies/Checklist" was incomplete as there was no documented evidence to indicate that an assessment was conducted by the Director of Nursing and/or designee to determine S6's ability to perform job-specific skills in a safe and competent manner prior to the job-specific patient care assignment. In addition, there was no documentation to indicate that S6 received training on the appropriate and safe use of restraints and no documentation to indicate that a competency evaluation was done relating to S6's ability to utilize restraints in a safe and appropriate manner.
? S8 (Mental Health Technician). Date of Hire was 4/06/10. The "Initial Skills Competencies/Checklist" was incomplete as there was no documented evidence to indicate that an assessment was conducted by the Director of Nursing and/or designee to determine S8's ability to perform job-specific skills in a safe and competent manner prior to the job-specific patient care assignment. In addition, there was no documentation to indicate that S8 received training on the appropriate and safe use of restraints and no documentation to indicate that a competency evaluation was done relating to S8's ability to utilize restraints in a safe and appropriate manner.
? S9 (Mental Health Technician). Date of Hire was 7/14/09. The "Initial Skills Competencies/Checklist" was incomplete as there was no documented evidence to indicate that an assessment was conducted by the Director of Nursing and/or designee to determine S9's ability to perform job-specific skills in a safe and competent manner prior to the job-specific patient care assignment. In addition, there was no documentation to indicate that S9 received training on the appropriate and safe use of restraints and no documentation to indicate that a competency evaluation was done relating to S9's ability to utilize restraints in a safe and appropriate manner.
? S10 (Mental Health Technician). Date of Hire was 3/14/09. The "Initial Skills Competencies/Checklist" was incomplete as there was no documented evidence to indicate that an assessment was conducted by the Director of Nursing and/or designee to determine S10's ability to perform job-specific skills in a safe and competent manner prior to the job-specific patient care assignment. In addition, there was no documentation to indicate that S10 received training on the appropriate and safe use of restraints and no documentation to indicate that a competency evaluation was done relating to S10's ability to utilize restraints in a safe and appropriate manner.
? S11 (Licensed Practical Nurse). Date of Hire was 6/24/09. The "Initial Skills Competencies/Checklist" was incomplete as there was no documented evidence to indicate that an assessment was conducted by the Director of Nursing and/or designee to determine S11's ability to perform job-specific skills in a safe and competent manner prior to the job-specific patient care assignment. In addition, there was no documentation to indicate that S11 received training on the appropriate and safe use of restraints and no documentation to indicate that a competency evaluation was done relating to S11's ability to utilize restraints in a safe and appropriate manner.
? S12 (Registered Nurse). Date of Hire was 3/06/09. The "Initial Skills Competencies/Checklist" was incomplete as there was no documented evidence to indicate that an assessment was conducted by the Director of Nursing and/or designee to determine S12's ability to perform job-specific skills in a safe and competent manner prior to the job-specific patient care assignment. In addition, there was no documentation to indicate that S12 received training on the appropriate and safe use of restraints and no documentation to indicate that a competency evaluation was done relating to S12's ability to utilize restraints in a safe and appropriate manner.

Based on record review, interview and observation, the registered nurse failed to ensure the supervision and evaluation of care by failing to ensure that the nursing training/orientation program included the training and competency evaluations of personnel working on the acute care psychiatric unit prior to the assignment of patient care duties. Findings:

The Personnel Records of S6 (Licensed Practical Nurse), S8 (Mental Health Technician), S9 (Mental Health Technician), S10 (Mental Health Technician), S11 (Licensed Practical Nurse), and S12 (Registered Nurse) were reviewed. The hospital's policy/procedure titled "Orientation; Nursing Staff" was reviewed. The policy/procedure indicates that the responsibility of the Director of Nursing includes "assesses competence of job-specific skills by use of competency skills checklist. Provides an on-the-job orientation for the new employee under the supervision of a designated mentor. Reviews 1 on 1 with new employee learning needs and provides ongoing training". This review revealed the following:

? S6 (Licensed Practical Nurse). Date of Hire was 7/01/09. The "Initial Skills Competencies/Checklist" was incomplete as there was no documented evidence to indicate that an assessment was conducted by the Director of Nursing and/or designee to determine S6's ability to perform job-specific skills in a safe and competent manner prior to the job-specific patient care assignment.
? S8 (Mental Health Technician). Date of Hire was 4/06/10. The "Initial Skills Competencies/Checklist" was incomplete as there was no documented evidence to indicate that an assessment was conducted by the Director of Nursing and/or designee to determine S8's ability to perform job-specific skills in a safe and competent manner prior to the job-specific patient care assignment.
? S9 (Mental Health Technician). Date of Hire was 7/14/09. The "Initial Skills Competencies/Checklist" was incomplete as there was no documented evidence to indicate that an assessment was conducted by the Director of Nursing and/or designee to determine S9's ability to perform job-specific skills in a safe and competent manner prior to the job-specific patient care assignment.
? S10 (Mental Health Technician). Date of Hire was 3/14/09. The "Initial Skills Competencies/Checklist" was incomplete as there was no documented evidence to indicate that an assessment was conducted by the Director of Nursing and/or designee to determine S10's ability to perform job-specific skills in a safe and competent manner prior to the job-specific patient care assignment.
? S11 (Licensed Practical Nurse). Date of Hire was 6/24/09. The "Initial Skills Competencies/Checklist" was incomplete as there was no documented evidence to indicate that an assessment was conducted by the Director of Nursing and/or designee to determine S11's ability to perform job-specific skills in a safe and competent manner prior to the job-specific patient care assignment.
? S12 (Registered Nurse). Date of Hire was 3/06/09. The "Initial Skills Competencies/Checklist" was incomplete as there was no documented evidence to indicate that an assessment was conducted by the Director of Nursing and/or designee to determine S12's ability to perform job-specific skills in a safe and competent manner prior to the job-specific patient care assignment.

Observations on 4/15/10 at 2:55 p.m. revealed S19 (Registered Nurse) attempting to locate supplies for the Geriatric Unit's suction machine. S19 indicated she was not able to find the supplies and would need the assistance of other staff. S19 contacted S14 (Registered Nurse) for assistance. S14 appeared with connecting tubing and a Yanker suction. S19 viewed the supplies and then stated she did not know how to connect the tubing to the suction machine and would need the assistance of S14 in connecting the tubing. S14 returned to the unit and connected tubing to the suction container. S14 then turned on the machine and discovered it was not suctioning. S14 admitted that she was accustomed to using wall suction and was not sure how to connect the tubing on a portable suction machine. S14 made another attempt at reconnecting the tubing and the suction worked.

Based on record review and interview, the hospital failed to ensure the implementation of policies/procedures relating to controlled drugs by failing to ensure that the narcotics record was signed by the oncoming and the outgoing nurse at shift change. Findings:

The narcotic records for March of 2010 and April of 2010 was reviewed. The hospital ' s policy/procedure titled " Medication Administration " was reviewed. The policy/procedure documents that an accurate record of all narcotics used must be made on the form provided with indelible ink, and a narcotic check is to be taken and reported with the change of all shifts. These must be signed by oncoming and outgoing nurses. Review of the narcotic records for March and April of 2010 revealed that the narcotic records were not signed by the oncoming and outgoing nurses on 3/01/10, 3/02/10, 3/03/10, 3/06/10, 3/09/10, 3/12/10, 3/13/10, 3/14/10, 3/20/10, 3/27/10, 4/01/10, 4/06/10 and 4/08/10. In an interview with the Director of Nursing on 4/15/10 at 9:50 a.m., the Director of Nursing confirmed that the narcotic sheets were not signed by the oncoming and outgoing nurses on the above documented days. The Director of Nursing reported that the nurses did not follow the hospital ' s policy/procedure relating to the narcotic records on those days.

Based on record review and interview, the hospital failed to set priorities for its performance improvement activities by failing to ensure that the QAPI (Quality Assurance Performance Improvement) program included data relating to high-risk, high-volume, and/or problem prone areas including the accuracy of the hospital's medication error rate and the effectiveness of the hospital's orientation/training program. Findings:

Review of the medical records of Patient #2, Patient #3, Patient #4, and Patient #8 revealed that medication errors occurred while providing care to the patients.

The hospital's Quality Assurance Performance Improvement (QAPI) data (plan and meeting minutes for the most recent meeting) was reviewed. There was no documentation to indicate that the QAPI data included the identification of a breakdown in the hospital's identification of medication errors that occurred while providing patient care. This was evidenced by the hospital's failure to ensure that an effective system was in place to capture the medication omissions that occurred with Patient #2 (Gabitrol omission), Patient #3 (Paxil omission), Patient #4 (Florinef omission), and Patient #8 (Lactulose delay) as there were no medication variance reports completed on these errors and they were not reported to the QA Director. This resulted in inaccurate data being reported through the QAPI activities in relation to the hospital's medication error rate.

The hospital's QA Director was interviewed on 4/16/10 at 11:10 p.m. The QA Director confirmed that there was no documentation to indicate that the medication errors for Patient #2, Patient #3, Patient #4, and Patient #8 had been identified and reported as medication errors so that the information could be included in the hospital's medication error rate.


Review of the Personnel Records of S6 (Licensed Practical Nurse), S8 (Mental Health Technician), S9 (Mental Health Technician), S10 (Mental Health Technician), S11 (Licensed Practical Nurse), and S12 (Registered Nurse) revealed no documentation to indicate that the training/orientation program included competency evaluations of personnel to ensure that the employee had the knowledge and ability to perform job related tasks in a safe and effective manner prior to the employee being assigned a job specific task.

The hospital's policy/procedure titled "Orientation; Nursing Staff" was reviewed. The policy/procedure indicates that the responsibility of the Director of Nursing includes "assesses competence of job-specific skills by use of competency skills checklist. Provides an on-the-job orientation for the new employee under the supervision of a designated mentor. Reviews 1 on 1 with new employee learning needs and provides ongoing training".

The hospital's Quality Assurance Performance Improvement (QAPI) data (plan and meeting minutes for the most recent meeting) was reviewed. There was no documentation to indicate that the QAPI data included the identification of a breakdown in the hospital's orientation/training program as evidenced by failing to ensure that competency evaluations were done on personnel in an effort to assess an individual's ability to perform job-specific skills in a safe and competent manner prior to the job-specific patient care assignment.

The hospital's QA Director was interviewed on 4/16/10 at 11:10 p.m. The QA Director confirmed that there was no documentation to indicate that QAPI data included information relating to the hospital's failure to ensure that competency evaluations were done on employees prior to the assignment of patient care duties.

Based on record review and interview, the hospital failed to ensure that drugs and biologicals were administered in accordance with the orders of the licensed practitioner for 4 of 9 sampled patients (Patient #2, Patient #3, Patient #4 & Patient #8). Findings:

Patient #2: Medical record review revealed that Patient #2 was admitted to the hospital on 4/04/10. Review of the record revealed orders dated 4/05/10 at 4:10 p.m. to "Begin Gabitrol 4mg BID". Review of the medication administration record revealed that the 4mg of Gabitrol was not administered to the patient until 9:00 a.m. on 4/06/10 resulting in the omission of the p.m. dose on 4/05/10. S6 (Licensed Practical Nurse) was interviewed on 4/14/10 at 10:30 a.m. S6 reported that she was the medication nurse and confirmed that there was no documentation in the medical record to indicate that the p.m. dose of Gabitrol was administered as ordered on 4/05/10. S6 reviewed the medical record and reported that there was no documentation to indicate a reason for the medication omission and no documentation to indicate that the physician had been informed of the omitted dose of Gabitrol on 4/05/10.

Patient #3: Medical record review revealed that Patient #3 was admitted to the hospital on 4/09/10. Review of the record revealed orders dated 4/09/10 at 7:30 p.m. for "Paxil 30mg q AM". Further review of the record revealed orders dated 4/10/10 at 3:25 p.m. for "May give Paxil 30mg first dose now". Review of the medication administration record revealed that the initial 30mg of Paxil was not administered to the patient until 3:25 p.m. on 4/10/10 resulting in the omission of the a.m. dose on 4/10/10. Documentation on the medication administration record revealed that the Paxil was not given on the a.m. on 4/10/10 due to not being available from pharmacy. S3 (Licensed Practical Nurse) was interviewed on 4/14/10 at 11:30 a.m. S3 reported that there are sometimes problems getting medications in from pharmacy for the first dose administration. S3 reported that there was no documentation to indicate that the a.m. dose of Paxil was administered as ordered on 4/10/10. S3 reported that there was no documentation to indicate that the pharmacy had been notified in the a.m. on 4/10/10 that the Paxil was not available for administration.

Patient #4: Medical record review revealed that Patient #4 was admitted to the hospital on 3/29/10. Review of the record revealed orders dated 3/31/10 at 2:30 p.m. for Una-Boots to the bilateral lower extremities with instructions to change every 3 days. Review of the medication administration record revealed that the Una Boots were not available on 4/01/10. Further review revealed orders dated 4/01/10 at 11:30 a.m. for 0.2mg of Florinef to be administered BID. Review of the medication administration record revealed that the p.m. dose of the 0.2mg of Florinef was not administered to the patient on 4/01/10. Documentation on the medication administration record revealed that the Florinef was not given on the p.m. on 4/01/10 due to not being available from pharmacy.

Patient #8: Medical record review revealed that Patient #8 was admitted to the hospital on 3/29/10. Review of the record revealed orders dated 3/29/10 for 30 ml of Lactulose to be administered daily. Review of the medication administration record revealed that the Lactulose was scheduled to be administered daily at 9:00 a.m. beginning on 3/30/10. Further review of the medication administration record revealed that the Lactulose was not administered at 9:00 a.m. on 3/30/10 due to not being available from pharmacy. Documentation revealed that the pharmacy was notified of the unavailability of the Lactulose and the first dose was administered at 11:40 a.m. on 3/30/10.

The hospital's policy/procedure titled "Medication Administration" was reviewed. The policy/procedure documents the principles of medication administration include observing the "five rights" in giving medications: "The right patient, the right medicine, the right time, the right dose, and the right method of administration".

In an interview with S5 (Registered Nurse) and S6 (Licensed Practical Nurse) on 4/14/10 at 10:40 a.m., S5 & S6 reported that there are times when medications are unavailable for administration in the hospital. S5 & S6 reported that the unavailability usually occurs with the first dose administration when the medicine is not in the stock supply and pharmacy has not yet delivered the medicine to the hospital. S5 & S6 reported that pharmacy will deliver the medicine once notified of the unavailable status. S5 & S6 reported that pharmacy deliveries are made 3 times daily on average.