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Based on observation, interview, review of hospital and patient documentation and the deficient practices cited in the SOD (Statement of Deficiencies), the hospital failed to have an effective governing body that was legally responsible for the conduct of the hospital and insured that the facility operated in accordance with the Medicare Conditions of Participation.

Findings included:

The hospital failed to have an Institutional Plan and Budget which included a capital expense budget for a 3-year period. (Please refer to A 73).

The hospital failed to ensure that contracted services were provided in a safe and effective manner. (Please refer to A 84 and A 749 example #3).

The hospital failed to ensure that the hospital carried out its functions in a manner that protected and promoted each patient's rights. (Please refer to A 115).

The hospital failed to ensure that its QAPI (Quality Assurance Performance Improvement) Program measured, analyzed and tracked quality indicators that included adverse patient events, and all hospital-wide services including contracted services and operations. (Please refer to A 263).

The hospital failed to ensure that the hospital provided an organized nursing service that ensured adequate delivery of nursing care to all patients. (Please refer to A 385).

The hospital failed to ensure that the requirements for organ, tissue, and eye procurement were met. (Please refer to A 884.)

Based on observation, record review, staff interview, and the deficiencies cited in the area of Patient Rights, the hospital failed to protect and promote each patient's rights.

Findings included:

1. The hospital failed to promptly investigate and resolve a patient grievance, per hospital policy, for non-sampled patient (NS #A) who alleged inappropriate care and treatment while a patient at the hospital. (Please refer to A 118).

2. The hospital failed to allow Patient #17 to make informed decisions regarding treatment with antipsychotic medication. (Please refer to A 131).

3. The hospital failed to provide personal privacy during staff interviews with two sampled and one non-sampled patients during confidential discussions regarding patient care. The hospital also failed to ensure patients were afforded the opportunity for privacy during personal care. (Please refer to A 143).

4. The hospital failed to provide a safe setting for all patients. (Please refer to A 144).

5. The hospital failed to ensure that its policy for screening potential employees for prior criminal offense was conducted prior to hire. (Please refer to A 145).

6. The hospital failed to review and revise care plans for patients who required restraints. (Please refer to A 166).

7. The hospital failed to ensure that a physician's order was obtained when a physical restraint was ordered. (Please refer to A 168).

8. The hospital failed to prohibit the use of PRN (as needed) orders for the use of mechanical restraints. (Please refer to A 169).

9. The hospital failed to ensure that when restraint or seclusion was used for the management of violent or self-destructive behaviors, that the patient was seen face to face by the physician, or other licensed practitioner, within one hour after the initiation of the intervention. (Please refer to A 178 and A 179).

Based on documentation review, observation and staff interview, the hospital failed to develop an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program that reflected the complexity of the hospital's organization and services including contracted services.

Finding include:

1. At the time of survey, the Conditions for Governing Body, Rights, Nursing and Organ, Tissue and Eye Procurement were found not met. The Hospital's Quality Assurance Program failed to identify and address significant findings to improve health outcomes. (Please refer to A 43; A 115; A 385; A 884).

2. The hospital failed to ensure that its QAPI (Quality Assurance Performance Improvement) Program Scope included quality assurance and performance improvement evaluations for services provided by outside contracted services including laboratory, pharmacy, radiology and organ, tissue and eye procurement agency. There was no mechanism in place to insure that these services were provided in a safe and effective manner. (Please refer to A 264; A 283)

3. The hospital failed to ensure that its QAPI (Quality Assurance Performance Improvement) Program measured, analyzed and tracked quality indicators that included findings from adverse patient events. (Please refer to A 267).

Based on record reviews, observations and interviews the Hospital failed to provide an organized nursing service that ensured adequate delivery of nursing care to patients.

1. The Hospital failed to provide adequate numbers of licensed registered nurses to 1 of 2 hospital units (the Inn unit) to ensure the immediate availability of a registered nurse to provide safe, active care and treatment.(Please refer to A 392).

2. The Hospital failed to provide 24 hour nursing services furnished or supervised by a registered nurse, and have a licensed practical nurse or registered nurse on duty at all times for 1 of 2 units (the Inn unit).(Please refer to A 393).

3. The Hospital nursing service failed to ensure the emergency equipment was ready for immediate use. (Please refer to A 395).

4. The Hospital nursing service failed to ensure that adequate nursing care plans were developed and implemented for patients. (Please refer to A 396).

5. The Hospital nursing service failed to ensure that the Registered Nurse assigned and directed the care provided by the nursing assistants. (Please refer to A 397).

Based on review of hospital documents and staff interview, the hospital failed to ensure that the organ, tissue, and eye procurement requirements were met.

Findings include:

During an interview with the Administrator on 2/8/12 at 1:30 P.M., the Administrator said that the hospital had not:
- educated staff regarding the policies and procedures related to organ procurement,
- developed a process to inform families of their options regarding organ donation,
- assigned anyone at the hospital to be a representative or designated requestor to initiate the request to a family for organ donation when appropriate,
- educated staff on donation issues.

(Please refer to A 886, A 888, A 889 and A 891).

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

I. Revise the Master Treatment Plans of 3 of 8 active sample patients (A1, A5, A11) and 1 non-sample discharged patient (E1) (reviewed for use of mechanical restraint and for suicide attempt while hospitalized). Previously selected modalities were unsuccessful, but changes to the plan were not made. This resulted in patients being hospitalized without the opportunity to receive interventions to meet identified treatment needs, thereby delaying their improvement. (Refer to B118)

II. Develop Master Treatment Plans (MTPs) for 8 of 8 active sample patients (A1, A5, A9, A10, A11, B1, B2 and B3) which included individualized interventions with specific purpose and focus. Many of the interventions on the MTPs were stated as patient expectations rather than staff actions, were patient goals, or were lists of generic staff functions/tasks. Failure to clearly describe specific modalities on patients' MTPs hampers staff's ability to provide treatment based on individual patient needs. (Refer to B122).

III. Ensure that individualized psychiatric care was provided for 2 of 8 active sample patients (Patients A5 and A9). These patients were hospitalized without the provision of alternative treatment modalities for their special needs to move them to a higher level of functioning and a less restrictive environment. This failure results in patients remaining hospitalized without all interventions for recovery being provided in a timely fashion, potentially delaying their improvement.(Refer to B125-I)

IV. Provide ongoing active treatment by qualified clinical staff for patients in 1 of 2 certified wards (The Unit). The majority of activities 7 days weekly were leisure-oriented, rather than therapeutic treatment activities based on individualized needs of the patient population. This failure results in lack of active treatment for all 11 patients on this ward. (Refer to B125-II.)

IV. Ensure that staff reinforce the importance of and responsibility for patients' attendance and participation in assigned treatment, and provided structured alternative treatment as needed in 1 of 2 certified wards (The Unit), affecting 4 of 5 active sample patients on The Unit during the survey (A1, A5, A9 and A10). This failure results in patients lying/sleeping in bed, sitting around and idly walking about the ward. (Refer to B125-III)

Based on interview and document review, the facility failed to assure that the Medical Director and the Director of Nursing monitored active treatment and took corrective actions. Specifically,

I. The Medical Director failed to:

A. Ensure that staff had the modality of seclusion available as a less restrictive intervention for external control of violence during emergency situations. Because seclusion is not available, staff must always resort to the use of either mechanical and/or physical restraints when a patient's behavior is a danger to self and/or others. This failure results in the need to utilize more restrictive interventions (i.e. mechanical and chemical restraints) when a patient's behavior is a danger to self and/or others. (Refer to B144 Part I.)

B. Ensure that patients received appropriate treatment as specified in individualized Master Treatment Plans that identified specific behaviorally expressed problems and individualized interventions, and that appropriate modifications were made to reflect changing patients treatment needs. (Refer to B144 Part II)

C. Ensure that patients received adequate therapeutic treatment in 1 of 2 certified wards (The Unit) (Refer to B144 Part V.)

II. The Director of Nursing failed to:

A. Assure adequate staffing (numbers of qualified nursing personnel) to provide a safe environment for the patient population. Specifically, on 1 of 2 certified wards (The Inn) the DON failed to ensure the availability of a Registered Nurse (RN) to the certified unit on all work shifts, and to provide sufficient numbers of total nursing personnel on this ward (The Inn) based on the acuity of patients. Failure to assure adequate staffing is a safety risk for all patients on the unit, and hampers staff's ability to provide quality nursing care (Refer to B150.)

B. Ensure that staff have available seclusion rooms for external control of violence during emergency situations in 1 of 2 wards (The Unit). The facility does not support the use of seclusion even though it may be the option of choice to assist the patient to control aggressive behavior. This failure results in the need to utilize more restrictive interventions (i.e. mechanical and chemical restraints) when a patients' behavior is a danger to self or others. (Refer to B148 Section IV.)

C. Ensure that individualized nursing interventions were included in treatment plans, and that appropriate changes were made to reflect changes in patient's treatment needs (Refer to B148 Section II)

D. Ensure that nursing staff reinforced the importance of and the responsibility for patient attendance and participation in available treatment, and provided structured alternative treatment as needed for patients on 1 of 2 certified wards (The Unit) (Refer to B148 Section III.)

E. Ensure proper, safe storage of narcotics on 1 of 2 certified wards (The Unit). This failure to secure controlled medications can result in potential untoward use. (Refer to B148, Section V)

Based on record review and staff interview, the hospital failed to ensure that SW#1 was licensed as required.

Findings included:

Review of personnel records on 2/9/12 at 8:00 A.M., indicated that Social Worker #1 (SW)#1 was hired as a social worker (SW) by the hospital in 11/2011. Per SW#1's resume, the SW received a Master's of Social Work degree in 2010. There was no evidence that the SW was certified as a licensed social worker, per state licensure requirements.

Interview with the Director of Nursing on 2/9/12 at 9:30 A.M. acknowledged the hospital employed SW#1 without insuring the employee met the required social worker licensure requirements.

Please refer to A 818.

Based on record review and interview, the hospital failed to have an institutional plan and budget that included a 3-year capital expenditure plan.

Findings included:

The hospital Administrator provided the survey team with a copy of the hospital's institutional plan and budget. The plan included a capital expense budget which identified capital expenditures for the years 2010 and 2011.

The hospital's capital expense plan for 2012 was incomplete. Capital expenditure information for 2012 was only available through February 8, 2012. It did not include any projected capital expenditures for 2/9/12 through 12/31/2012.

During interview with the Administrator on 2/9/12 at 11:00 A.M., the Administrator said that the 3-year capital expenditure plan only included capital expenditures through 2/8/12.

Based on document review and staff interview, the hospital failed to ensure that a Governing Body or other individual or individuals, was appointed to ensure that laboratory, pharmacy and radiology services performed under contract were provided in a safe and effective manner.

Findings included:

1. The hospital's PI/QA (Performance Improvement/Quality Assurance) Committee meeting minutes for 7/2011 through 12/2011 were reviewed on 2/9/12 at 2:45 P.M. Review of the meeting minutes revealed that there was no record, or documented evidence that quality assurance activities included the hospital's contracted services to ensure that these services were provided in a safe and effective manner.

The QA/PI (Quality Assurance/Performance Improvement) Director and the DON (Director of Nurses) were interviewed on 2/9/12 at 2:45 P.M., regarding the process for evaluating services provided to the hospital by outside contractors.

Both the QA/PI Director and DON said that they were not aware of the hospital's process for evaluating the services contracted by outside vendors.

On interview with the Adminstrator on 2/9/12 at 3:30 P.M., the administrator told the surveyor that that there was no evaluation available for each of the hospital's contracted services. Additionally, the Administrator said that no one within the hospital has been appointed to oversee evaluation of each contracted service provided to the hospital.

2. On 2/6/12 at 10:40 A.M., during the initial tour of The Unit, a laboratory worker contracted by the hospital to provide laboratory services, was observed processing a tube of blood with a centrifuge.

The laboratory worker was observed in the open area across from the nurses station using a centrifuge to spin down a vial of blood that had been drawn from a patient. The centrifuge was observed being used directly on top of a wooden table with no protective barrier covering it. No cleaning of the table was observed after the laboratory worker had completed the blood processing.

The wooden table where the laboratory worker had processed the blood was observed during all days of the survey being used by The Unit staff, patients, and visitors for various therapeutic activities.

Nurse #1 said during interview on 2/6/12 at 10:40 A.M., that it was the accepted practice of the laboratory workers, to routinely process blood specimens on the wooden table in the open area across from the nurses station on The Unit.

The DON (Director of Nurses) and QA Director were interviewed on 2/9/12 at 2:45 P.M., regarding the observation of the laboratory technician processing blood on The Unit. They both said that blood processing should not occur on the table in The Unit common area used by patients, staff, and visitors.

Please refer to A-0264 and A-0749

Based on record review and staff interviews, the hospital failed to ensure prompt resolution of a grievance for 1 non-sampled patient (NS#A).

Findings include:

Patient NS#A had diagnoses including alcohol dependence and mood disorder. The patient had 3 admissions to the hospital during 2010 as follows: 4/13/10 - 4/16/10, 7/15/10 - 7/20/10 and 10/20/10 - 10/22/10.

The hospital received a letter/complaint to the hospital's owner/Chief Executive Officer from an attorney for NS#A dated 1/10/11, that alleged the following regarding the patient's last admission to the hospital:

- The patient was originally admitted to The Unit. The patient was told there were no beds at The Inn (non-medical unit), but was promised a move to The Inn when a bed became available.

- On admission, the patient was not given a breathalyzer test. Without any determination of blood-alcohol levels, the patient was then heavily medicated for the next three days. The medication the patient was given caused hallucinations. After the patient complained about the effects of the medication, the dosages were neither modified nor was the medication changed.

- The patient suffers from debilitating arthritis and was not given arthritis medication for days. On the day of admission, the patient was to attend a patient meeting at The Inn and instead of transporting the patient to the meeting, the staff forced the patient to walk through the woods in the dark, even though the patient was heavily medicated and had trouble walking due to arthritis.

- The conditions in the medical unit during October 2010 were substandard and unsanitary; the unit and the patient's room were dirty with trash on the floor and no pillowcases for the patient's pillow.

The only response from the hospital to these grievances was a letter dated 1/24/11 from the hospital's Administrator to the patient's attorney that stated the following: As far as the issue of the patient's care during the October stay, the patient never brought to our attention any of the issues mentioned in your letter, such as "overmedication, lack of cleanliness or transfer to The Inn." The review of the chart and our inquiry with the staff did not suggest that the patient ever brought these issues to our attention. Had the patient done so, we would have certainly looked into the complaint. Also, in October when the patient met with the Human Rights Officer, the patient never mentioned any of these issues and did not appear to be overmedicated. The patient only stayed 2 days and then decided to leave. The medical record indicates that orders for the patient's transfer to the Inn were issued by the attending physician and had the patient stayed, the patient would have been transferred to The Inn.

No other information was available regarding the hospital's investigation of these grievances.

The hospital's policy regarding grievances stated the following:

Upon receipt of a complaint, or at any time the Person in Charge becomes aware of any condition or incident which he or she believes to be dangerous, illegal or inhumane, he or she shall: 1) Undertake any necessary fact-finding; 2) Give a written decision to the parties within ten days containing findings of fact and conclusions and any actions to be taken.

According the the hospital's policies, the Person in Charge of investigating and responding to grievances was the Human Rights Officer.

On 2/8/12 at 1:45 P.M., during interview, the Human Rights Officer said that a written investigation could not be found to address the above complaints made by NS#A patient's lawyer. He said he remembered looking into some of these allegations but could not find a copy of an investigation.

Based on review of documentation and interviews, the Hospital failed to ensure that Patient #17 and his or her representative (as allowed under State Law) has the right to make informed decisions regarding his or her care.

Findings include:

Patient #17 was admitted on 12/3/2011 with diagnosis including epilepsy and alcohol withdrawal.

Record review on 2/8/12 at 11:45 A.M., revealed that the patient was receiving Seroquel (antipsychotic) on an ongoing basis. The hospital required patients to consent to the use of antipsychotics. An Informed Consent For Treatment With Anti-Psychotic Medications form, for the use of Seroquel, was found in the medical record but was not signed by the patient.

Based on observation and staff interview, the Hospital failed to ensure privacy in care for two of 30 sampled patients (#16 and #30) and one Non-Sampled Patient (NS#B). Additionally, patients were not afforded privacy screens in two, three and four bed patient rooms in both the Hospital and Inn Units.

Findings included:

1. Observation of the common room area in front of the Unit nursing station on 2/6/12 between 3:45 P.M. and 4:05 P.M., revealed a Registered Nurse (RN) (who had earlier identified herself to the surveyor as an orientee) seated at a table conducting an admission assessment with Patient #16. The conversation between the RN and Patient #16 was loud enough that two other patients, four other Hospital staff behind the nursing station and two surveyors could hear the conversation. Discussion between the RN and the newly admitted Patient (#16) consisted of review of hospital consents for privacy, treatments, pelvic and rectal examinations, as well as a suicide risk assessment.

Interview with Hospital Nurse #1 on 2/7/12 at 10:30 A.M. acknowledged the RN orientee did not provide the patient with privacy during the discussion of admission procedures and personal issues.

2. Observation of the common room area in front of The Unit nursing station, on 2/9/12 between 12:00 P.M. and 12:10 P.M., revealed Nurse Practitioner #1 (NP#1) and Counselor #1 seated with a newly admitted Patient (NS#B). These staff were conducting a nursing admission assessment. The conversation between the two staff members and NS#B was easily overheard by two staff members behind the Nursing Station, two patients adjacent to the nursing station, and two surveyors seated at another table in the common room.

Interviews with NP#1 on 2/9/12 at 12:20 P.M., and Counselor #1 on 2/9/12 at 12:25 P.M., acknowledged staff did not afford NS#B privacy when conducting the nursing assessment.


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3. During the initial tour of The Inn on 2/6/12, and a subsequent tour on 2/8/12, there were no privacy screens available on the first floor in Rooms #1, #2, #3, #4 (2-bed rooms).

During interview on 2/8/12 at 11:50 A.M., the Director of Maintenance said that there were no privacy screens available for patients in the building.

4. Patient #30 was observed on 2/9/12 at 12:12 P.M., being interviewed by Counselor #1, in the patient common area across from The Unit nurses station. Another patient, Patient #29 and MHA #1 (mental health assistant), were sitting at a table directly across from Counselor #1 and Patient #30, in the same common area.

Counselor #1 was observed discussing details of Patient #30's upcoming discharge from the hospital. The conversation between Counselor #1 and Patient #30 could easily be heard by Patient #29, MHA #1, or, any other patient, staff member, or visitor who were in the adjacent area at the time.

Nurse #1 was at the nurses' station of The Unit at the time Counselor #1 was observed discussing Patient #30's discharge plans. Nurse #1 said that Counselor #1 should have discussed Patient #30's discharge plans in an area that protected the patient's privacy. Nurse #1 informed the surveyor that there were private areas on The Unit that Counselor #1 could have used to discuss the patient's confidential information.

Based on observations on 2/6/12, 2/7/12 and 2/8/12 on one of the two hospital units, The Inn, the hospital failed to ensure a safe environment was provided for all patients.

Findings included:

1. Observation of the first floor of The Inn, during the initial tour on 2/6/12 at 11:00 A.M., revealed the following:

a. In Room #1, a removable metal rod was observed in the clothes closet. The ends of the rod had sharp metal edges if the rubber caps to the rods were removed by a patient. Also, if a patient became aggressive, the rod could be used as a weapon to harm themselves and/or another person.

b. In Room #2, sharp edges were observed on a radiator which was not firmly attached to the wall.

c. In Rooms #1, #2, #3 and #4, there was no call bell system available for the patients to contact the nursing station which was located on the second floor.

2. Observation of the first floor of The Inn on 2/8/12 at 11:15 A.M., revealed the following:

a. In the entrance hallway, approximately 12 feet of the radiator was observed to be loose and not firmly attached to the wall. Sharp edges were observed on the section of the radiator next to the exit door.

b. Door closures were observed on the doors to the Gold Room, Living Room, the Green Room and Rooms #1, #2, #3 and #4. The door closures, which were accessible to all patients, presented a hanging risk from the metal extended door closures that swung into these rooms.


08949



3. During a tour of The Inn on 2/7/12 at 9:45 A.M., and a subsequent tour on 2/8/12 at 11:30 A.M., patient environmental safety concerns were observed in areas that had been designated for treatment of patients. The observed environmental safety concerns particular to the potential for strangulation or hanging, included: exposed pipes used for the sprinkler system hung along the ceiling throughout the entire first and second floor areas, including patient bedrooms and common areas, and, on the first floor, a long wooden board attached to the wall near the ceiling containing multiple large wooden pegs sticking out of it for hanging coats. Another room had a private pay phone booth. The cord on the telephone was approximately 30 inches in length, presenting a ligature or strangulation risk. Thin telephone cord wire was also observed running along the exposed pipe on the second floor across from Room #8 and #9.


















07338

Based on record review and staff interview, the hospital failed to ensure that 30 of 30 patients were free from the risk of abuse by ensuring that, prior to hire, all staff were screened with a CORI [Criminal Offender Record Information] check.

Findings include:

Review of the hospital's procedure for Hiring of Personnel indicated the following procedure must be followed: "Before making a commitment to a prospective employee, consultant, or volunteer to work, the CORI check will be conducted."

1. Review of the employee information for the Director of Food Service, Dietary Employee #2, Dietary Employee #3 and Dietary Employee #4 indicated that a CORI check was not completed prior to hire.

During an interview on 2/9/12 at 11:35 A.M., Business Office Employee #1
said that CORIs are not done on Administration and dietary staff.

2. Review of the employee information for the Consultant Dietitian indicated that a CORI check was not obtained prior to hire.

During an interview on 2/9/12 at 11:40 A.M., Business Office Employee #1 said that CORIs are not completed on any consultant. Business Office Employee #1 also said that the Dietitian and all of the physicians were considered consultants.

Based on record review and staff interview, the hospital failed to develop, review, and revise the care plan for 3 of 4 restrained patients (#23, #26 and #27) in a total sample of 30 patients.

Findings include:

1. Patient #26 had diagnoses of alcohol dependence, alcohol-induced mood disorder, gout, rectal bleeding and prostate cancer.

The patient had a nursing care plan dated 6/3/11 and a treatment plan dated 6/6/11.

The patient was restrained with a physical hold and a 4-point mechanical restraint on 6/6/11 for behavior that was a danger to self and others. Neither the care plan nor the treatment plan were updated to include the use of restraints.

During interview on 2/9/12 at 11:05 A.M., the Director of Nurses said that the care plan should include the use of restraints.

2. Patient #23 had diagnoses of alcohol dependence and mood disorder.
The patient was restrained in a physical hold on 10/24/11 at 8:20 A.M. The treatment plan dated 10/24/11 did not include the use of restraints.

During interview on 2/9/12 at 11:05 A.M., the Director of Nurses said that the care plan should include the use of restraints.


08949


3. For Patient #27, the hospital failed to update the care plan to include the use of restraints.

Patient #27 was admitted to the facility on 5/27/11, with diagnoses including alcohol dependence and bipolar disorder.

Record review on 2/9/12 indicated the patient had a nursing and treatment plan dated 5/27/11. On 6/2/11 at 2:15 P.M., Patient #27 was restrained in a physical hold for 3 minutes after Patient #27 punched a wall three times and physically pushed a staff member.

Further record review indicated that neither the nursing care plan or the treatment plan were updated to include the use of restraints.

On 2/9/12 at 10:55 A.M., the Director of Nurses said the patients' care plans were not updated to include the use of restraints.

Based on record review, and staff interview, the hospital failed to ensure that physical restraints were implemented only when ordered by the physician for 1 of 4 restrained (Patient #27) sampled patients in a total sample of 30.

Findings include:

For Patient #27, the hospital failed to ensure a physician's order was obtained when a physical restraint was implemented.

Record review on 2/9/12 indicated that on 6/2/11 at 2:15 P.M., Patient #27 was restrained in a physical hold for 3 minutes after Patient #27 punched a wall three times and physically pushed a staff member.

Review of the 6/11 physician's orders indicated that there was no physician's order on 6/2/11 for a physical restraint. Review of the hospital's Emergency Restraint or Seclusion Form indicated that the physician saw the patient on 6/2/11. However, the physician did not document the time he/she saw the patient.

On 2/9/12 at 10:55 A.M., the Director of Nurses said she could not find a physician's order for the physical restraint on 6/2/11 as required.

Based on record review and staff interview, the hospital failed to prohibit the use of PRN (as needed) orders for the use of mechanical restraints for 1 of 4 restrained patients (#23) in a sample of 30 patients.

Findings include:

Record review on 2/9/12, indicated that on 10/24/11, Patient #23 was restrained in a physical hold for 3 minutes after throwing a chair down a hall and flipping over a table in the dining room.

Record review revealed that the patient had an order for, "Place on 1:1 and move to comfort room for observation and safety. Use mechanical restraints if the patient is a danger to self or others."

The hospital is prohibited from using an order that specifies "if the patient is a danger to self or others." As required, the hospital should have obtained an order that addressed one specific time period and a new order would be needed for another incident requiring restraint.

During interview on 2/9/12, at 11:00 A.M., the Director of Nurses stated that restraint orders should not be written PRN.

Based on record review and staff interview, the hospital failed to ensure that in cases when physical restraints were used for the management of violent or self destructive behaviors that jeopardized the immediate safety of the patient or others, that the patient was seen face to face, within one hour after the initiation of the interventions by either a physician or other authorized trained practitioner for 2 of 4 sampled, restrained patients (Patients #26 and #27) in a total sample of 30 patients.

Findings include:

1. For Patient #27, the hospital failed to ensure the patient was examined by a physician within one hour following the initiation of a restraint.

Record review on 2/9/12 indicated that on 6/2/11 at 2:15 P.M., Patient #27 was restrained in a physical hold for 3 minutes after Patient #27 punched a wall three times and physically pushed a staff member.

Review of the hospital's Emergency Restraint or Seclusion Form indicated that the physician saw the patient on 6/2/11. However, the physician did not document the time he/she saw the patient and as a result, it cannot be determined when the physician saw the patient.

Review of hospital's policy for Restraint and Seclusion Policy indicated that the patient be examined as soon as possible, but no later than one hour following the initiation of the restraint

On 2/9/12 at 10:55 A.M., the Director of Nurses said there was no documentation by the physician that he/she saw the patient within an hour as required.



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2. Record review on 2/9/12 indicated that on 6/6/11 at 2:20 A.M., Patient #26 was placed in a physical hold and then restrained in 4-point mechanical restraints. The patient was asked to remove the belt and attempted to charge at the mental health assistant with belt raised at neck level to wrap around the mental health assistant. The patient was then restrained in a physical hold by staff and resisted the hold and was then placed in 4-point mechanical restraints.

The patient was not seen face to face by the physician until 5:30 A. M. on 6/6/11, which was 3 hours and 10 minutes after the initiation of the restraint.

On 2/9/12 at 10:55 A.M., the Director of Nurses stated that patients were to be seen by physicians, face to face within one hour of being restrained.

Please refer to A 0179.

Based on record review and staff interview, the hospital failed to ensure that following the initiation of physical restraints, patients were seen face to face within one hour, to evaluate the patients' immediate situation, the patients' reaction to the intervention, the patients' medical and behavioral condition and the need to continue or terminate the restraints for 4 of 4 restrained, sampled patients (Patient #22, #23, #26 and #27) in a total sample of 30 patient records reviewed.

Findings include:

1. For Patient #22, the facility failed to ensure the physician documented his/her evaluation after examining Patient #22.

Record review on 2/9/12 indicated that on 3/30/11 at 12:05 A.M., Patient #22 was placed in a 4-point mechanical restraint after Patient #22 kicked in a large window in the hospital's dayroom.

Review of the hospital's Emergency Restraint or Seclusion Form indicated that the physician saw the patient on 3/20/11 at 12:30 A.M. Further review of the hospital's emergency restraint form indicated that at 1:30 A.M., an hour and 25 minutes later, the patient was released from the restraints.

Review of hospital's policy for Restraint and Seclusion Policy indicated that the patient be examined as soon as possible, but no later than one hour following the initiation of the restraint

Although the physician saw Patient #22 within the hour of the application of the restraint, there was no documentation by the physician regarding his/her examination of the patient.

On 2/9/12 at 10:45 A.M., the Director of Nurses said there was no documentation by the physician that he/she examined the patient as required.

2. For Patient #27, the facility failed to ensure the physician documented his/her evaluation after examining Patient #27.

Record review on 2/9/12 indicated that on 6/2/11 at 2:15 P.M., Patient #27 was restrained in a physical hold for 3 minutes after Patient #27 punched a wall three times and physically pushed a staff member.

Review of the hospital's Emergency Restraint or Seclusion Form indicated that the physician saw the patient on 6/2/11. However, the physician did not document the time he/she saw the patient and as a result, it can not be determined when the physician saw the patient. In addition, there was no documentation by the physician regarding his/her examination of the patient.

On 2/9/12 at 10:55 A.M., the Director of Nurses said there was no documentation by the physician that he/she examined the patient as required.



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3. Record review on 2/9/12 indicated that on 10/24/11 at 8:45 A.M., Patient #23 was placed in a physical hold for 3 minutes. The patient had thrown a chair down the hall and flipped over a table in the dining room prior to the physical hold.

Although the physician signed the Emergency Restraint or Seclusion Form at 8:45 A.M. on 10/24/11, within one hour of the application of the restraint, there was no documentation by the physician regarding his/her evaluation/examination of the patient.

On 2/9/12 at 10:55 A.M., the Director of Nurses said there was no documentation by the physician that he/she evaluated the patient as required.

4. Record review on 2/9/12 indicated that on 6/6/11 at 2:20 A.M., Patient #26 was placed in a physical hold and then restrained in a 4-point mechanical restraint. The patient was asked to remove the belt and attempted to charge at the mental health assistant with belt raised at neck level to wrap around the mental health assistant. The patient was then restrained in a physical hold by staff and resisted the hold and was then placed in 4-point mechanical restraint.

The patient was not seen face to face by the physician until 5:30 A.M. on 6/6/11, which is 3 hours and 10 minutes after the initiation of the restraint.

On 2/9/12 at 10:55 A.M., the Director of Nurses said there was no documentation by the physician that he/she evaluated the patient as required.

Based on document review and interview with the Administrator, the facility failed to ensure that the Hospital's Quality Assurance Performance Improvement Program included services arranged by the hospital with outside contractors.

Findings included:

The hospital's PI/QA (Performance Improvement/Quality Assurance) Committee meeting minutes for 7/2011 through 12/2011, were reviewed on 2/9/12 at 2:45 P.M. Those in attendance at the monthly meetings included, the Administrator, the Director of Medical Records, the Human Rights Officer, the Director of Nursing, the PI/QA Director, and other hospital staff.

Additional review of the meeting minutes revealed that there was no record, or documented evidence to support quality assurance activities in regards to the hospital's contracted services.

The PI/QA Director and the Director of Nurses said during interview on 2/9/12 at 2:45 P.M., that contracted services were not included in the hospital's PI/QA Program.

Based on record review and staff interview, the hospital failed to ensure that the medical bylaw was adhered to that required a medical history and physical examination was completed, no more than 30 days before, or 24 hours after admission, for 11 patients (#s 1, 2, 3, 4, 5, 6, 10, 11, 14, 18 and 21) of a total sample of 30.

Findings included:

Please refer to A 458.

Based on document review and staff interview, the facility failed to ensure that adequate numbers of qualified nursing personnel were present to provide safe, active treatment and care to the patients on one (The Inn unit) of two inpatient hospital units.

Findings included:

The Inn is a locked patient unit housed in a three-story, wood-framed building, that has a total of 10 certified beds on the first floor, and 29 non-certified beds on the second and third floors combined. The third floor of The Inn was closed for renovation during the survey. The Inn provides active medical, substance abuse (drugs and alcohol), psychiatric, and crisis intervention treatment to the patients that reside there. Patients treated at The Inn are in varied stages of detoxification and most carry psychiatric diagnoses, including depression, and present with a risk of self-harm.

Staffing schedules provided by the Director of Nursing on 2/6/12, for the period of 1/31/12 through 2/6/12, revealed that only 1 RN (Registered Nurse) was assigned to all evening and night shift tours of duty (14 total shifts) at The Inn. The first-floor certified unit was observed to have a census of between 3 - 4 patients during the survey from 2/6/12 to 2/9/12. The second floor, non-certified unit, had an average census of between 14 - 16 patients during the survey. Although an additional RN was assigned to The Inn from 4:00 P.M. to 8:00 P.M., on 6 of 7 evening shifts, this RN was subject to being called to the other certified unit (The Unit), located across the campus. Additionally, although there were two RNs assigned to work the day shift on The Inn, either of these RNs could be called to The Unit to assist with admissions and/or other RN duties.

During the tour of The Inn on 2/7/12 at 12:00 Noon, surveyors observed that there was only one nurses station for all of the patients residing at The Inn. During interview with Nurse #4 on 2/7/12 at 12:00 Noon, Nurse #4 said that the nurses station situated on the second floor served all of the patients at The Inn. Nurse #4 said that nurses on duty periodically go down to the first floor (the certified section of the Inn) to observe and talk to patients about their treatment. However, she said that most of the time, nurses remain at the second floor nurses station. Additionally, Nurse #4 acknowledged that there was no call system in the building, and no way other than calling out for help (from either floor), that a patient could alert the nurse in the event of an emergency.

During interview with the DON (Director of Nursing) on 2/9/12 at 2:30 P.M., the DON said that the nurse on duty at The Inn would not be able to respond to patient emergencies that occurred simultaneously on different floors of The Inn.

Based on review of nursing time schedules and staff interview, the Hospital failed to ensure that 24-hour nursing services were furnished for one of two nursing units (The Inn), and that a Registered Nurse or licensed practical nurse was on duty at all times to furnish care or supervise other nursing staff furnishing care to patients on that unit.

Findings included:

The Inn is a locked patient unit housed in a three-story, wood-framed building, that has a total of 10 certified beds on the first floor, and 29 non-certified beds on the second and third floors combined. The third floor of The Inn was closed for renovation during the survey. The Inn provides active medical, substance abuse (drugs and alcohol), psychiatric, and crisis intervention treatment to the patients that reside there. Patients treated at The Inn are in varied stages of detoxification and most carry psychiatric diagnoses, including depression, and present with a risk of self-harm.

Staffing schedules provided by the Director of Nursing on 2/6/12, for the period of 1/31/12 through 2/6/12, revealed that only 1 RN (Registered Nurse) was assigned to all evening and night shift tours of duty (14 total shifts) at The Inn. The first-floor certified unit was observed to have a census of between 3-4 patients during the survey from 2/6/12 to 2/9/12. The second floor, non-certified unit, had an average census of between 14-16 patients during the survey. Although an additional RN was assigned to The Inn from 4:00 P.M. to 8:00 P.M., on 6 of 7 evening shifts, this RN was subject to being called to the other certified unit (The Unit), located across the campus. Additionally, although there were two RNs assigned to work the day shift on The Inn, either of these RNs could be called to The Unit to assist with admissions and/or other RN duties.

During the tour of The Inn on 2/7/12 at 12:00 Noon, surveyors observed that there was only one nurses station located on the second floor, non-certified unit. During interview on 2/7/12 at 12:00 Noon, Nurse #4 said that the nurses station situated on the second floor served all of the patients at The Inn. Nurse #4 said that nurses on duty periodically go from the second floor nurses station to the first floor, to observe and talk to patients about their treatment. However, she said that most of the time, nurses remain at the second floor nurses station where they are providing care to patients on the non-certified floors of the Inn. Additionally, Nurse #4 acknowledged that there was no call system in the building, and no way other than calling out for help (from any floor), that a patient could alert the nurse in the event of an emergency.

During interview with the DON on 2/9/12 at 2:30 P.M., the DON said that the nurse on duty at The Inn would not be able to respond to patient emergencies that occurred simultaneously on different floors of The Inn. She also said that there may be a delay in the nurse being notified in the event of a patient emergency.

Based on observation and interview, the Hospital failed to ensure that the registered nurse supervising the care and services provided to the patients on The Inn unit maintained the emergency equipment required to provide immediate emergent care.

Findings included:

During a tour of The Inn on 2/7/12 at 12:00 Noon, observation of the unit's emergency medical equipment at the nurses station was conducted with Nurse #3. The Inn's emergency medical equipment consisted of a cloth bag containing various dressing materials, bandages, chemical cold packs, an oxygen face mask with tubing, a blood pressure cuff, and a stethoscope. The Inn also had a green emergency oxygen tank able to deliver 25 liters/minute of oxygen.

During interview, Nurse #3 said that The Inn did not have an AED (Automated External Defibrillator) available in the event of a a cardiopulmonary emergency. She also confirmed that there was no Ambu Bag available in the event of a medical emergency.

During further interview with Nurse #3, Nurse #3 said that the hospital had not provided any inservice education on mock codes (emergency medical response) in the two years she had worked at the hospital . Nurse #8 said that she had worked at the hospital five years and could not remember receiving any emergency medical response or mock code training. Nurse #3 and Nurse #7 said they did not know who the hospital staff educator was.

Interview with the Director of Nursing on 2/9/12 at 2:45 P.M. acknowledged that The Inn did not have an AED or an Ambu Bag, and that 2 of 3 nurses working at The Inn on 2/7/12 on the day shift, had not received any inservice training on emergency medical response or mock codes.

Based on record review and staff interview, the hospital failed to develop, review, revise and/or implement the care plans for 10 sampled patients (#1, #2, #5, #6, #11, #14, #21, #22, #26, and #30) in a total sample of 30 patients.

Findings included:

1. Patient #26 had diagnoses of alcohol dependence, alcohol-induced mood disorder, gout, rectal bleeding and prostate cancer.

The patient had a nursing care plan dated 6/3/11 and a treatment plan dated 6/6/11. Neither plan addressed the following care areas:

a) The patient was admitted on two medications for gout. Gout was not identified as a problem area on the nursing or treatment plan.

b) The patient had a fall on 6/6/11. The hospital conducted an updated fall assessment but did not update the care plan or treatment plan to address the prevention of further falls.

During interview on 2/9/12 at 11:05 A.M., the Director of Nurses stated that the care plan should include all the patient care areas

2. For Patient #5, the hospital failed to implement the plan of care which indicated the patient receive Carnation Instant Breakfast (nutritional supplement) three times a day.

Record review on 2/6/12 indicated that on 1/27/12, the patient's physician ordered Carnation Instant Breakfast three times a day. Review of the patient's Medication Administration Records (MAR) indicated the physician's order for the nutritional supplement did not appear on the 1/27/12 through 2/6/12 MAR.

On 2/7/12 at 9:55 A.M., Nurse #4 said the hospital did not document a physician's order for nutritional supplements on the MAR. Nurse #4 said she would not know if the patient was to receive the supplement unless she was the nurse who took the order from the physician or if the patient asked for the supplement. Nurse #4 also said because the nutritional supplements are not on the MAR, the hospital failed to implement the plan of care. Nurse #4 said the kitchen was responsible for providing the supplement, but not responsible for documenting when the patient accepted the supplement.

3. For Patient #22, the hospital failed to implement the medical plan of care which indicated that the patient's vital signs be obtained four times a day daily for three days.

Record review on 2/9/12 indicated the patient had a physician's order, dated 3/26/11, which read vital signs four times daily for three days and then two times daily for three days. According to the 3/11 MAR, vital signs were not obtained on 3/27/11 at 1:00 P.M., 6:00 P.M., and at bedtime per the medical plan of care.

On 2/9/12 at 10:45 A.M., the Director of Nurses said there was no documentation to indicate the vital signs were obtained as per the plan of care.

4. For Patient #6, the hospital failed to implement the medical plan of care which indicated that the patient's vital signs would be obtained four times a day for three days.

Record review on 2/7/12 indicated the patient had a physician's order dated 1/31/12, which read, " Vital signs four times daily for three days." According to the 2/12 MAR , vital signs were not obtained on 2/1/12 at 7:00 A.M., 1:00 P.M., and at bedtime as per the medical plan of care.

On 2/7/12 at 11:00 A.M., Nurse #4 said the vital signs were not obtained as per the medical plan of care.

5. For Patient #1, medical record review on 2/7/12 at 8:30 A.M. revealed that the patient had diagnoses that included neuropathy, problems with joint and leg pain, and head trauma, and that the patient was at high risk for falls with a score of 15. (Per hospital Fall Risk Assessment policy, a score of 10 or more required the patient be "placed on Fall Risk Precautions".) The facility failed to develop an individualized care plan with interventions related to the management of pain and the prevention of falls.

Interview with Nurse #1 on 2/7/12 at 10:30 A.M., acknowledged the only care plans were for the patient's detoxification and mood stabilization.

6. Review of the medical record for Patient #2 on 2/6/12 at 1:30 P.M. indicated the patient had diagnoses that included alcohol abuse, COPD (Chronic Obstructive Pulmonary Disease), hyperlipidemia, and chronic bronchitis. The facility failed to develop a care plan to address and manage the increased risk factors of the patient's high cholesterol levels associated with alcohol abuse. Also, the patient's care plan did not address the patient's respiratory difficulties and chronic bronchitis.

During interview on 2/7/12 at 1:30 P.M., Counselor #1 said the only patient care plans were for detoxification and mood stabilization.

7. Review of the medical record for Patient #11 on 2/7/12 at 9:00 A.M. indicated the patient had diagnoses that included pacemaker, hepatic encephalopathy, acute pancreatitis, and DVT (Deep Vein Thrombosis.) Pre-admission hospital ER (Emergency Room) records dated 2/2/12 indicated the patient was administered anticoagulant medications and required a low fat diet to treat pancreatitis. There was no evidence that the facility developed an individualized care plan to monitor the patient's pacemaker, anticoagulant therapy and dietary restrictions.

Interview with the registered dietitian on 2/7/12 at 3:00 P.M., acknowledged there was no care plan for the patient's diet, pacemaker and anticoagulant therapy.

8. Review of Patient #14's medical record on 2/6/12 at 4:15 P.M. indicated the patient was at high risk for falls with a score of 12. The facility failed to develop an individualized care plan with interventions related to the prevention of falls.

Interview with Nurse #1 on 2/7/12 at 10:30 A.M., acknowledged the only care plans were for the patient's detoxification and mood stabilization.

9. Review of the medical record for Patient #21 on 2/8/12 at 9:00 A.M. indicated the patient had diagnoses that included chronic pain. Pre-admission ER (Emergency Room) records of 2/5/12 indicated the patient had severe pain of the right hand and hip, and expressed hostile and threatening behavior when in the ER to self and others. There was no evidence that the facility developed individualized care plans to manage the resident's chronic pain issues or potential threatening behavior.

Interview with Nurse #7 on 2/8/12 at 11:00 A.M., acknowledged there was no patient care plan addressing the patient's pain and behavioral issues.

10. Review of the medical record for Patient #30 on 2/9/12 at 1:00 P.M. indicated the patient had diagnoses that included back injury and pain. Pre-admission ER records dated 2/5/12 indicated the patient had severe pain of the right hand and hip, and also that the patient expressed hostile and threatening behavior when in the ER to self and others. There was no evidence that the facility developed care plans to manage the resident's chronic pain issues or potential threatening behavior.

Interview with Counselor #1 on 2/9/12 at 12:25 P.M., acknowledged there was no individualized care plan to address the patient's chronic pain and potential for threatening behavior.

Based on document review and staff interview, the Hospital failed to ensure that a registered nurse was assigned to the nursing care of each patient and that care by other unlicensed nursing personnel was supervised in accordance with the patient's needs, for each of the patients on The Inn unit.

Findings included:

The Inn is a locked patient unit housed in a three-story, wood-framed building, that has a total of 10 certified beds on the first floor, and 29 non-certified beds on the second and third floors combined. The third floor of The Inn was closed for renovation during the survey. The Inn provides active medical, substance abuse (drugs and alcohol), psychiatric, and crisis intervention treatment to the patients that reside there. Patients treated at The Inn are in varied stages of detoxification and most carry psychiatric diagnoses, including depression, and present with a risk of self-harm.

Staffing schedules provided by the Director of Nursing on 2/6/12, for the period of 1/31/12 through 2/6/12, revealed that only 1 RN (Registered Nurse) was assigned to all evening and night shift tours of duty (14 total shifts) at The Inn. The first-floor certified unit was observed to have a census of between 3-4 patients during the survey from 2/6/12 to 2/9/12. The second floor, non-certified unit, had an average census of between 14-16 patients during the survey. Although an additional RN was assigned to The Inn from 4:00 P.M. to 8:00 P.M., on 6 of 7 evening shifts, this RN was subject to being called to the other certified unit (The Unit), located across the campus. Additionally, although there were two RNs assigned to work the day shift on The Inn, either of these RNs could be called to The Unit to assist with admissions and/or other RN duties.

During the tour of The Inn on 2/7/12 at 12:00 Noon, surveyors observed that there was only one nurses station for all of the patients residing at The Inn. Interview with Nurse #4 on 2/7/12 at 12:00 Noon, said that the nurses station situated on the second floor served all of the patients at The Inn. Nurse #4 said that nurses on duty periodically go down to the first floor to observe and talk to patients about their treatment. However, she said that most of the time, nurses remain at the second floor nurses station. This situation left the care and supervision of patients to unlicensed MHAs (Mental Health Assistants) for unspecified periods of time.

Additionally, Nurse #4 acknowledged that there was no call system in the building, and no way other than calling out for help (from either floor), that a patient could alert the nurse in the event of an emergency.

Interview with the Director of Nursing on 2/9/12 at 2:30 P.M., said that the nurse on duty at The Inn would not be able to respond to patient emergencies, and not always be present to supervise the care provided by unlicensed MHAs.

Based on documentation review and staff interview, the hospital failed to ensure that a physician's order for a prn (as needed) blood pressure medication included specific instructions for when the medication should be administered for 5 sampled patients (Patient #5, #10, #14, #19, #30) in a total of 30 patients.

Findings include:

1. For Patient #5, the hospital failed to ensure that a physician's order for Clonidine (blood pressure medication) contained specific instructions for use.

Record review on 2/6/12 indicated that the patient had a physician's order dated 1/22/11 which read," Clonidine 0.1 milligrams (mg) prn (as needed) for increased vital signs, bid (twice a day)." The physician's order failed to indicate specific instructions and/or parameters as to what constitutes increased vital signs and when to administer the medication.

On 2/6/12 at 1:55 P.M., Nurse #4 said the hospital did not have a policy for the use of Clonidine. Nurse #4 said the medication was used for patients with "high anxiety" and that she would administer the medication when a patient had a systolic blood pressure of 150 or higher.


2. For patient #19, the facility failed to provide clear parameters for use of the medication Clonidine.

Record review on 2/8/12 at 3:30 P.M., indicated that a physician order was written for Clonidine 0.1 mg every 8 hours as needed for blood pressure greater than 140/90 or withdrawal from opiates.

The physician's order lacked specificity as to whether the medication was to be given for specific elevated systolic or diastolic blood pressure. There was no definition as to what defined withdrawal from opiates and no specific direction as to blood pressure when only one of the parameters are exceeded.


3. For Patient #30. the Hospital failed to ensure that a physician's order for Clonidine contained specific instructions for use.

Record review on 2/9/12 at 12:00 P.M. indicated the patient had a physician's order, dated 2/8/12, for "Clonidine 0.1 mg. PO (by mouth) every 4 hours for blood pressure (BP) >150/100 (times 5 days)". A 2/8/12 plan of care for BP stated that BP shall be within normal limits had the approaches of "monitor VS (Vital Signs) daily" and "Medicate A/O" (as ordered.)

Interdisciplinary Progress Notes of 2/8/12 at 8:30 P.M. -12:00 A.M. indicated the patient's vital signs were BP of 154/94. Review of the PRN Medications Administration Record indicated no administration on 2/8/12 for the prn Clonidine.

Upon surveyor inquiry with Nurse Practitioner #1 [NP#1] on 2/9/12 at 1:30 P.M. regarding the parameters of Clonidine prn medication, NP #1 said that it was difficult to know when to administer this medication for Patient #30. NP #1 said that probably the medication was not administered by staff, because the diastolic reading of 94 was below the 100 diastolic level. When asked hypothetically if the BP reading was 160/99, the NP #1 said the medication would be administered, because this reading was nearer to a diastolic reading of 100. NP #1 agreed that the physician should have been called to clarify BP parameters for the use of Clonidine prn.


4. Patient #10 was admitted with diagnoses which included alcohol dependence, depressive disorder, and history of gastric ulcer.

Record review on 2/7/12, indicated a physician order written 1/30/12, for the medication Clonidine 0.1 milligram by mouth now, and every 6 hours PRN (as needed) for increased blood pressure. The physician's order did not include blood pressure or pulse parameters for nurses to follow when administering the PRN Clonidine. Additionally, the physician's order failed to document what parameters of vital signs should trigger the nurse to notify the physician.

Review of "Nurses PRN Notes" on 2/7/12, indicated that Clonidine 0.1 milligrams had been administered on nine different occasions from 1/30/12 to 2/6/12. Further record review noted that multiple different measures of the patient's blood pressure, and/or pulse, were documented as the "REASON" for administering the PRN Clonidine.

For example:

- On 1/31/12 at 9:20 (A.M./P.M. not documented) Clonidine 0.1 mg. p.o. (by mouth) prn was administered. No blood pressure or pulse was recorded.

- On 2/2/12 at 6:30 P.M., Clonidine 0.1 mg. was administered. No blood pressure or pulse was documented.

- On 2/3/12 at 7:00 A.M., Clonidine 0.1 mg. was administered. The nurse documented an increased BP (blood pressure) of 142/73, and a pulse of 101.

- On 2/3/12 at 1:30, Clonidine 0.1 mg. prn was administered. The nurse documented a blood pressure of 147/97 and a pulse of 118.

- On 2/3/12 at 8:30 P.M., Clonidine 0.1 mg. prn was administered. No reason for administering the drug was noted. No blood pressure or pulse was documented.

- On 2/4/12 at 7:00 A.M., Clonidine 0.1 mg. prn was administered. The nurse documented a blood pressure of 129/81, and a pulse of 144.

Nurse #1 was interviewed on 2/7/12 at 4:50 P.M. The nurse said that the physician's order for Clonidine for this patient was ambiguous. She said that she wished the physicians would give clear parameters of blood pressure and pulse when writing orders for PRN Clonidine, so that the nurses did not have to decide on their own when to administer or not administer the medication. Nurse #1 also acknowledged the documented disparities in blood pressure and pulse, when each nurse administered the PRN Clonidine to the patient.


5. Patient #14's medical record was reviewed on 2/6/12 at 4:15 P.M.

The Hospital failed to ensure that a Physician's order for PRN (as needed) Clonidine administration was written clearly and was followed.

Record review on 2/6/12 at 4:15 P.M. indicated the patient had a physician's order, dated 2/1/12, for "Clonidine 0.1 mg. PO (by mouth) every 4 hours PRN for blood pressure (BP) >(greater than) 150/100 (times 5 days)".

Review of the Medication Administration Record (MAR) for 2/2/12 indicated that Clonidine 0.1 mg. was administered at 6:00 P.M. following a BP reading of 143/95. The MAR for 2/3/12 indicated that the prn Clonidine was administered at 7:30 P.M for a BP reading of 144/89. The MAR for 2/5/12 indicated that the prn Clonidine was administered at 9:00 P.M for a BP reading of 128/84. The prn Clonidine was not administered as ordered by the physician.

Upon surveyor inquiry with Nurse #7 on 2/8/12 at 12:00 P.M. regarding the BP parameters for the administration of the prn Clonidine, Nurse #7 said it appeared that the medication was given without regard to BP parameters. The nurse acknowledged that the physician needed to be notified to also clarify the BP parameters for when the prn Clonidine was to be administered.

Based on observation and staff interviews, the hospital failed to ensure the security of medical records from unauthorized staff/persons and failed to properly maintain medical records in locations that were protected from fire and water damage.

Findings included:

1. Security:

Observation of the three closed medical records rooms on the first floor of the Administration Building on 2/6/12, from 12:00 P.M. to 12:30 P.M. and on 2/7/12, from approximately 12:25 P.M. to 12:45 P.M., revealed no medical record staff or other authorized personnel monitoring the closed record rooms (for closed records within the last 5 years). These rooms were unlocked and left open during staff lunch breaks. Medical records were filed in rows (on end) on long metal book shelves within easy access to any unauthorized staff or persons who entered the rooms. Visitors and other office staff were observed during the above times, and throughout the day, seated, standing, or walking in the waiting room area, around the corner from the nearby record room corridor.

Per interview with the Medical Records Director on 2/9/12 at 10:15 A.M., maintenance personnel have routine access to the 2nd floor storage area in the maintenance department's barn, where medical records closed over 5 years are stored in numerous cardboard boxes.

2. Closed Record Maintenance:

Observation of the closed record rooms in the Hospital's Administration Building, on all days of survey, throughout the day and on 2/7/12 at 1:45 P.M. with the Medical Records Director, revealed no fire prevention device or sprinkler system in the closed record rooms. The Director stated that there was no way to effectively protect closed records if a fire occurred when administrative staff were unavailable (such as nights, weekends and holidays.)

Observation on 2/8/12 at 9:50 A.M., of the closed medical records storage area (those records more than 5 years old), revealed hundreds of cardboard boxes stacked and lining the perimeter of the barn loft in the maintenance department building. This completely wooden structure, over 200 years old, had no fire prevention devices or fire sprinklers in it. These cardboard boxes were stored with other flammable material and maintenance supplies (cloth drops and other paper products, etc). There was no evidence that the records were protected from water damage if the wooden roof leaked.

Interviews with the Medical Records Director on 2/9/12 at 10:15 A.M. and the hospital's owner at 1:40 P.M., said that the hospital was not providing security and/or proper storage of closed medical records in either the Administration Building or the barn.

:

Based on record review and staff interview, the hospital failed to ensure that for 2 patients (#8 and #10), of a total sample of 30, that the Interdisciplinary Treatment Plan & Review Update was completed by each discipline of the IDT (Interdisciplinary Team) per hospital policy.

Findings included:

1. Patient #10 was admitted with diagnoses which included alcohol dependence, depressive disorder, and history of gastric ulcer.

Record review on 2/7/12, indicated that as part of the patient's treatment, an Interdisciplinary Treatment Plan Review & Update was periodically conducted to discuss the patient's progress toward meeting the established goals. Members of the interdisciplinary team required to attend these meetings, included the psychiatrist, and representatives from nursing, social service, therapeutic activities, and counseling.

Review of the Interdisciplinary Treatment Plan and the Review & Update meeting, held on 2/6/12, indicated that a representative from each discipline was not present at the meeting.

The meeting held to discuss Patient #10's goals of mood stabilization and safe detoxification was attended by social service, nursing, and therapeutic activities. The psychiatrist and a representative from the substance abuse counseling department, were not present at the meeting per hospital policy.

During interview on 2/7/12 at 4:50 P.M., Nurse #1 said that all members of the Interdisciplinary Team are required to attend the Treatment Plan Review & Update meetings.



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2. For Patient #8 the facility failed to complete and update the Interdisciplinary Treatment Plan Review

Patient #8 was admitted with diagnoses which included schizoaffective disorder and bipolar disorder.

Record review on 2/8/12 at 10:05 A.M., indicated that as part of the patient's treatment, an Interdisciplinary Treatment Plan Review & Update was periodically conducted to discuss the patient's progress toward meeting the established goals. Members of the interdisciplinary team required to attend these meetings, included the psychiatrist, and representatives from nursing, social service, therapeutic activities, and counseling.

The meeting held on 1/31/12 to discuss Patient #8's goals of mood stabilization and safe detoxification was only attended by social service, nursing, and therapeutic activities and counseling. The psychiatrist was not present at the meeting

The meeting held on 2/7/12 to discuss Patient #8's goals of mood stabilization and safe detoxification was only attended by therapeutic activities. Psychiatry, social work, nursing were not present at the meeting.

During interview on 2/8/12 at 10:05 A.M., with Mental Health Assistant #1 said that the Interdisciplinary Treatment Plan Review & Update's should be completed the day they are dated.

Based on record review and staff interviews, the Hospital failed to ensure that 12 Patients (#s 1, 2, 5, 6, 8, 11, 14, 16, 19, 21, 24 and 25 ) out of a sample of 30 records, had medical record entries that were dated, timed, and signed by the person responsible for providing and entering the service provided.

Findings included:

Interviews with The Unit's Nurse #1 on 2/7/12 at 10:30 A.M., the Medical Records Director at 2:30 P.M., and Nurse #2 at 3:30 P.M. said the facility policy required all medical record entries be signed and dated. Staff acknowledged that not all patient record entries contained the time of entry.

1. For Patient #1, medical record review on 2/6/12 indicated the patient's history and physical was not in the record, and when received by the surveyor from staff on 2/7/12 at 10:45 A.M. was not dated, timed and signed by the admitting Physician. The patient's pain assessment related to a diagnosis of "head trauma, pain in legs, joints-neuropathy" was blank, as well as the evidence sections, long and short term goals, interventions, target dates, date resolved, and signature on the Medical Problems/Pain form.

2. For Patient #2, medical record review on 2/6/12 indicated the patient's history and physical was not in the record. When the surveyor received the record from the staff on 2/7/12 at 10:45 A.M., the record was not dated, timed, or signed by the admitting physician.

3. For Patient #11, medical record review on 2/7/12 indicated the patient's history and physical was not in the record, and when received by the surveyor from staff on 2/7/12 at 10:45 A.M. was not dated, timed, or signed by the admitting physician. Additionally, the 2/2/12 Physician's Order Form was not signed or timed by the physician. The 2/6/12 Psychosocial Assessment was blank for the following sections: Family History, Developmental History, and Education History. There were no social service progress notes in the record, even though the patient's social worker had recorded other information in the patient's psychosocial assessment.

4. For Patient #14, medical record review on 2/6/12 indicated the patient's history and physical was not in the record. When on 2/7/12 at 10:45 A.M. the record was received by the surveyor, the record was not dated, timed, or signed, by the admitting physician. Additionally, the 2/1/12 psychosocial assessment was blank for all sections, as well as a referred to "Psychosocial Update" form.

5. For Patient #21, medical record review on 2/8/12 indicated the patient's history and physical was not dated, timed, or signed by the admitting physician. Additionally, hospital emergency room records, prior to admission, indicated the patient was allergic to penicillin (PCN) V, saccharin, aspartame, red dye, phenylalanine (an amino acid in food/drink), and peanut-containing drug products. The history and physical, admitting physician orders, and the nursing assessment did not include the patient's allergies to saccharin, aspartame, red dye, and phenylalanine.


00420

6. For Patient #5, the hospital failed to ensure that the patient's history and physical examination was signed by the physician who examined the patient.

Record review on 2/6/12 indicated that Patient #5 was admitted to the facility on 1/23/12. On 1/23/12, a history and physical examination was completed. As of 2/8/12, (16 days after the patient's admission date), the examination had not been signed by the physician who had examined the patient.

On 2/8/12 at 2:00 P.M., the Medical Records Director said the patient's history and physical examination was not signed by the physician who examined the patient.


7. For Patient #6, the hospital failed to ensure that the patient's history and physical examination was signed by the physician who examined the patient.

Record review on 2/7/12, indicated Patient #6 was admitted to the facility on 1/31/12. As of 2/8/12 (eight days after the patient's admission), the examination had not been signed by the physician who had examined the patient.

On 2/8/12 at 2:00 P.M., the Medical Records Director said the patient's history and physical examination was not signed by the physician who examined the patient.


8. For Patient #8, the facility failed to ensure that the history and physical was signed by the physician who completed the examination. Patient #8 was admitted to the facility on 12/19/11.

Review of the medical record on 2/7/12 at 4:15 P.M. indicated that a history, physical and psychiatric evaluation were contained as part of the record. There is no evidence that the document had been signed by the physician who completed the examination.


9. For Patient #24, the facility failed to ensure that the history and physical was signed by the physician who completed the examination.

Patient #24 was admitted to the facility on 2/5/12.

Review of the medical record on 2/9/12 at 9:10 A.M. revealed that a history, physical and psychiatric evaluation were contained as part of the record. There was no evidence that the document had been signed by the physician who completed the examination.


10. For Patient #25, the facility failed to ensure that the history and physical was signed by the physician who completed the examination.

Patient #25 was admitted to the facility on 2/7/11.

Review of the medical record on 2/9/12 at 9:50 A.M. revealed that a history, physical and psychiatric evaluation were contained as part of the record. Further review of the document revealed that the evaluation was dictated by one physician, but was read and signed by a second physician.


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11. Patient #19 was admitted on 2/6/12 with diagnoses which included history of epilepsy and opiate dependence.

Record review on 2/8/12 at 10:30 A.M., revealed that the admission history and physical exam was not signed as completed by the physician.


12. Patient #16 was admitted on 2/6/2012 with diagnosis including bipolar disorder and alcohol detoxification.

Record review on 2/7/12 at 3:35 P.M., indicated that the Treatment Agreement and Responsibilities was not signed as complete.

Nurse #1 said on 2/6/12 at 4 :00 P.M., that the Treatment Agreement and Responsibilities document was incomplete.

Please refer to A 458.

Based on record review and staff interviews, the Hospital failed to ensure that 11 patients (#s 1, 2, 3, 4, 5, 6, 10, 11, 14, 18 and 21) out of a sample of 30 records, had medical history and physical examination (H&P) documented in the patient record no more than 24 hours after admission.

Findings include:

Nurse #1 on 2/7/12 at 10:30 A.M., the Medical Records Director at 2:30 P.M., and Nurse #2 at 3:30 P.M. said during interviews that the facility policy required H&P documentation to be in the patient's record within 24 hours after admission. The nurse also said that H&Ps were not placed in patient records due to computer program glitches which occurred over the last 2 to 4 weeks.

1. For Patient #1, who was admitted to the hospital 2/3/12, the medical record review of 2/6/12 indicated the patient's H&P was not in the record.


2. For Patient #2, who was admitted to the hospital 2/1/12, the medical record review of 2/6/12 indicated the patient's H&P was not in the record.


3. For Patient #11, who was admitted to the hospital 2/2/12, the medical record review of 2/7/12 indicated the patient's H&P was not in the record.


4. For Patient #14, who was admitted to the hospital 2/1/12, the medical record review of 2/6/12 indicated the patient's H&P was not in the record.


5. For Patient #21, who was admitted to the hospital 2/5/12, the medical record review of 2/8/12 indicated the patient's H&P was not in the record until 2/7/12 (more than 24 hours after admission.)



08949


6. For Patient #5, the hospital failed to ensure that the patient's H & P was placed in the patient's medical record within 24 hours of admission.

Record review on 2/6/12 indicated that Patient #5 was admitted to the facility on 1/23/12. As of 2/8/12, (16 days after the patient's admission date), a H & P was not in the patient's medical record.

On 2/8/12 at 2:00 P.M., the Medical Records Director said the patient's H & P was not in the medical record, but she could "print it out".


7. For Patient #6, the hospital failed to ensure that the patient's H & Physical was placed in the patient's medical record within 24 hours of admission.

Record review on 2/7/12 indicated Patient #6 was admitted to the facility on 1/31/12. As of 2/8/12 (eight days after the patient's admission), a H & P was not the patient's medical record.

On 2/8/12 at 2:00 P.M., the Medical Records Director said the patient's H & P was not in the medical record, but she could "print it out".



00368

8. Patient #3 was admitted on 1/25/12 with diagnoses including hard of hearing, back pain, opiate, heroin and alcohol dependency. Record review on 2/6/12 indicated that the patient did not have a current H & P in the clinical record.


9. Patient #4 was admitted on 1/31/12 with diagnoses including back pain, alcohol dependency, anxiety, depression and bipolar disorder. Record review on 2/6/12 indicated that the patient did not have a current H & P in the clinical record.


10. Patient #10 was admitted with diagnoses which included alcohol dependence, depressive disorder, and history of gastric ulcer.

Record review on 2/7/12 indicated that the patient was admitted on 1/27/12. A history and physical form was noted in the chart on 2/7/12, however, it was found to be blank.

Interview with Nurse #1 on 2/7/12 at 4:50 P.M., acknowledged that the patient did not have a current medical history and physical examination in the clinical record.


11. Patient # 18 was admitted on 2/6/12 with diagnosis including bipolar disorder and substance abuse. Record review on 2/8/12 at 11:00 A.M. , indicated that the patient did not have a current H & P form in the clinical record. The patient had been admitted on multiple occasions at the hospital. The unsigned H & P examination form that was in the patients current admission record was dated 10/12/2008. This physical exam was written from a previous admission.

Based on observation and interview, the hospital failed to ensure that policies and procedures were followed to ensure the security of all drugs and biologicals.

Findings included:

Nurse #4 was interviewed on 2/7/12 at 12 Noon in the medication room on The Inn.. During interview, Nurse #4 said that only the oncoming nurse signed to confirm the accuracy of the controlled medications contained in the medication cart. She said that this had been a long-standing practice on The Inn.

Observation of the Narcotic Control Register on 2/7/12 at 12 Noon, confirmed that only one nurse documented, and affixed his/her signature to the narcotic register, when the narcotic count was done.

The DON (Director of Nurses) was interviewed on 2/9/12 at 2:30 P.M., regarding the practice being conducted by nurses on The Inn during the narcotic count. The DON said that the narcotic count should always be conducted by two nurses. She also said that both nurses should sign the narcotic register, and that their signatures attested to the accuracy of the count.

Based on observation and interview, the hospital failed to ensure that that the Schedule IV controlled substance Lorazepam was kept locked and stored within a secure area as required.

Findings included:

A tour of The Inn was conducted on 2/7/12 at 12 Noon. During the tour, it was observed that the Schedule IV antianxiety medication, Lorazepam 2 milligram injectable solution, was stored in a small metal box in an unlocked refrigerator in the second floor nurses station. The small metal box was noted to be locked, but the metal box was not secured within the refrigerator. However, it could easily be removed from the refrigerator according to Nurse 4 who was interviewed at that time

Interview with Nurse 4 on 2/7/12 at 12 Noon, stated that the small metal box containing Lorazepam 2 mg injectable narcotic was always stored in the unlocked refrigerator at the nurses station on the second floor of The Inn. Nurse 4 said she realized that the metal box containing the injectable Lorazepam 2 mg was not properly secured. She also said that other staff besides nursing, were permitted access to the medication room where the box containing the Lorazepam was stored in the unsecured refrigerator.

Interview with the Director of Nurses on 2/9/12 at 2:45 P.M., said that all narcotic medications should be kept locked and stored within a secured area.

Based on observation, staff interview, and monitoring of food temperatures via a test tray, the hospital failed to ensure that the food service operation provided hot food for the 18 patients who resided on The Unit. Findings include:

During observation of the noon meal on 2/6/12, meals for the patients who resided on The Unit, were packaged in the kitchen. The kitchen is located in The Inn. The food, for each patient, was placed in a 3 compartment Styrofoam container. The Styrofoam containers were stacked in soft-sided insulated containers. The insulated containers were carried, along with the other food for the meal (i.e. soup, dessert, bread, milk, etc.), to a waiting automobile and driven up the hill to The Unit which is situated approximately 300-400 yards away from The Inn. After the food arrived at The Unit, the dietary staff member carried the food through two sets of locked doors to the nourishment kitchen. The food was then distributed by The Unit staff.

On 2/7/12 at noon, a test tray was obtained. Observation revealed that prior to the food being served in the central kitchen which was located in The Inn, the temperature of the food items were above 160 degrees Fahrenheit.

The food arrived at The Unit at 11:40 A.M. and was delivered to the patients within 10 minutes. A test tray was taken and was tasted by the Surveyor and Dietary Employee #1. The results of the test tray were as follows:

*roast turkey with gravy - 115 degrees Fahrenheit - tasted lukewarm
*squash - 116 degrees degrees Fahrenheit - tasted lukewarm
*stuffing - 117 degrees Fahrenheit - tasted lukewarm, however, the edges of the stuffing tasted cold.

During interview on 2/7/12 at 12:30 P.M., with the Food Service Director, he said that in the winter months it is difficult to transport the food to The Unit and maintain palatable temperatures.

Based on record review and staff interview, the hospital failed to have the practitioner responsible for the care of the patients order therapeutic diets for 2 of 30 patients (#9 and #11), in a total sample of 30, whose medical diagnoses indicated the need for therapeutic diets.

Findings included:

1. For Patient #9, with a diagnosis of NIDDM (non-insulin dependent diabetes), the facility failed to prescribe a therapeutic diet.

Patient #9 was admitted to the facility on 11/16/82, with diagnoses including NIDDM.

On 2/6/12 at 4:10 P.M., review of the medical record indicated that the resident received Glyburide (a medication used to lower glucose levels in patients with NIDDM). For the time period 1/25/12 to 2/5/12, the patient had capillary blood glucose levels that ranged from 55 mg/dl (milligrams /deciliter) to 308 mg/dl. The resident did not have a signed dietary order for a therapeutic diet to be provided by the kitchen.

Review on 2/7/12 at 10:40 A.M. of the Interdisciplinary Treatment Plan Review & Update indicated that the Dietitian documented the resident was to receive a 1600 calorie, carbohydrate controlled diet.

During an interview on 2/8/12 at 10:30 A.M., the Director of Food Service and Nurse #6 said that the kitchen was providing a NAS (no added salt) diet for the patient and that a diabetic diet had not been ordered.


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2. For Patient #11, the hospital failed to ensure that the patient received a low fat diet.

For Patient #11, medical record review on 2/7/12 at 9:00 A.M., indicated the patient was admitted to the hospital on 2/2/12 and had diagnoses that included pacemaker, hepatic encephalopathy, acute pancreatitis, and DVT (Deep Vein Thrombosis.)

Pre-admission hospital ER (Emergency Room) records dated 2/2/12 indicated the patient required a low fat diet to treat pancreatitis. There was no evidence that the facility and/or physician addressed/or prescribed a low fat diet for the patient.

Review of the Nutritional Assessment/Consult notes dated 2/6/12 recommended a "low fat diet to help in past treatment of pancreatitis."

Interview with the Dietitian, on 2/7/12 at 3:00 P.M., acknowledged the patient was discharged on 2/7/12 without any physician's orders or implementation of the patient's therapeutic diet while in the hospital.

Based on record review and staff interview, the hospital failed to ensure that for 1 (#5) of a total sample of 30 residents, that a nutritional supplement ordered by a physician, was provided in accordance with the patient's nutritional care plan.

Findings included:

For Patient #5, the hospital failed to implement the plan of care which indicated the patient receive Carnation Instant Breakfast (nutritional supplement) three times a day.

Record review on 2/6/12 indicated that on 1/27/12, the patient's physician ordered Carnation Instant Breakfast three times a day. Review of the patient's Medication Administration Records (MAR) indicated the physician's order for the nutritional supplement did not appear on the 1/27/12 through 2/6/12 MARs.

On 2/7/12 at 9:55 A.M., Nurse #4 said the hospital did not document a physician's order for nutritional supplements on the MARs. Nurse #4 said she would not know to give the supplement to the patient because it had not been transcribed onto the MAR. Nurse #4 also said because the nutritional supplement was not on the MARs, the hospital failed to implement the plan of care. Nurse #4 said the kitchen was responsible for providing the supplement, but not responsible for its administration or documenting when the patient accepted the supplement.

Based on document review and staff interview, the hospital failed to ensure that a current therapeutic diet manual approved by the Dietitian and medical staff was readily available to all medical, nursing, and food service personnel.

Findings included:

Review of the diet manual used by the hospital indicated that the manual was published in 2003 (9 years old). During an interview with the Director of Food Service and the Registered Dietitian on 2/6/12 at 2:00 P.M., they said that the diet manual was published in 2003 and was not current because it was more than 5 years old.

Based on observation, record review and interview, the Hospital failed to ensure that staff consistently implemented infection prevention and control protocols.

Findings include:

1. The hospital failed to minimize the risk of cross contamination during fingerstick blood sugar (FSBS) testing procedures.
On 8/26/2010, the Centers for Disease Control (CDC) issued requirements for Infection Prevention during Blood Glucose Monitoring and Insulin Administration, supported by the Food and Drug Administration (FDA), that state fingerstick devices should never be used for more than one person. Whenever possible, point of care (POC) blood testing devices, such as blood glucose meter and PT/INR anticoagulation meter, should be used only on one patient and not shared. If dedicating POC blood testing devices to a single patient is not possible, the devices should be properly cleaned and disinfected after every use as described in the device labeling. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared.
Observation on 2/8/12, at 3:30 P.M. at The Inn revealed that the facility was utilizing an Assure 4 glucose meter testing device. Nurse #4 was asked to review the use of this device, including how many patients currently receive blood glucose testing. Nurse #4 said that 2 patients at The Inn were currently being tested, once in the morning and again in the afternoon. When asked how the glucose meter is cleaned between use, the nurse pointed to an alcohol swab. Nurse #4 said the machine is wiped down with the swab between use.
Observation on The Unit on 2/8/2012 at 3:45 P.M., revealed that this unit was also using the Assure 4 glucose fingerstick testing device. Nurse #8 was asked to review use of the fingerstick device. Nurse # 8 said that she cleans the device between use with an alcohol swab, though at present, The Unit did not have any patients who required use of this device.
At 4:15 P.M., the Director of Nursing was asked how the machine is cleansed. She said that as far as she knew, the machine was cleaned with an alcohol swab between patients.
The manufacturer's instructions for disinfection of the Assure 4 glucose meter is as follows: "To disinfect the meter, dilute 1 mL of household bleach (5-6% sodium hypochlorite solution) in 9 mL of water. This is a 1:10 dilution. The final concentration is 0.5-0.6% sodium hypochlorite... In accordance to CDC guidelines, we recommend that the Assure 4 meter be cleaned between resident tests in a multi-resident setting.
The Hospital failed to properly disinfect the glucometers.

2. For 3 of 4 dietary department employees, the facility failed to ensure that PPD tests (a test for Tuberculosis) was conducted prior to employment.

Review of hospital's documentation indicated that "If you have received a PPD in the last 12 months, you are required to produce proof of a negative result upon employment with Baldpate Hospital."

Review of the employee records for the dietary employees on 2/9/12, indicated that the Food Service Director, Dietary Employee #2 and Dietary Employee #4 did not have proof of a PPD test prior to employment.

During an interview with Business Office Person #2 on 2/9/12 at 10:15 A.M., Business Office Person #2 said that the Director of Nurses is responsible for the PPD's. Upon subsequent interview on 2/9/12 at 10:20 A.M., the Director of Nurses said that the management of the hospital is so flat that each department is responsible for itself. When asked how, without the assistance of nursing, the dietary department would be able to perform PPD testing, the Director of Nurses was unable to answer

3. On 2/6/12 at 10:40 A.M., during the initial tour of The Unit, a laboratory worker contracted by the hospital to provide laboratory services, was observed processing a tube of blood with a centrifuge.

The laboratory worker was observed in the open area across from the nurses station, using a centrifuge to spin down a vial of blood that had been drawn from a patient. The centrifuge was observed being used directly on top of a wooden table with no protective barrier covering it. No cleaning of the table was observed after the laboratory worker had completed the blood processing.

The wooden table where the laboratory worker had processed the blood was observed during all days of the survey being used by The Unit staff, patients, and visitors for various therapeutic activities.

Nurse #1 said during interview on 2/6/12 at 10:40 A.M., that it was the accepted practice of the laboratory workers to routinely process blood specimens on the wooden table in the open area across from the nurses station on The Unit.

Based on record review and staff interview, the hospital failed to ensure that a social worker who participated in the development of discharge plans was qualified with the appropriate licensure requirements.

Findings included:

Review of personnel records for Social Worker (SW) #1 on 2/9/12 at 8:00 A.M. indicated that this person was hired as a SW by the hospital in 11/2011. Per SW #1's resume, the SW received a Master's of Social Work degree in 2010. However, there was no evidence that the SW was certified as a licensed social worker, per state licensure requirements.

Interview with the Director of Nurses on 2/9/12 at 9:30 A.M. acknowledged the hospital employed SW #1 to participate in counseling and discharge planning for patients without the required SW licensure requirements.

Based on staff interview, the hospital failed to reassess its discharge planning process on an ongoing basis.

Findings included:

A review of the hospital's Discharge Planning Policy did not include a process to reassess discharge planning services.

During interview on 2/7/12 at 1:30 P.M., the Administrator and Social Worker #1 said that the hospital did not not have a process in place to reassess discharge planning on an ongoing basis. The Administrator said that the Quality Assurance Program did not include a review of discharge plans to ensure they are responsive to a patients' discharge needs.

Based on staff interview, the hospital failed to educate the staff regarding policies and procedures related to the the written agreement with an Organ Procurement Organization (OPO), designated under 42 CFR Part 486.

Findings include:

During an interview with the hospital Administrator on 2/8/12 at 1:30 P.M., the Administrator said that the hospital had an agreement with an OPO. The Administrator further said that although the agreement was present, the hospital staff were not educated regarding the policies and procedures related to organ procurement.

Based on staff interview, the hospital failed to provide a mechanism to ensure that 30 of 30 families of potential donors would be informed of their option to donate organs, tissues or eyes.

Findings include:

During an interview with the hospital Administrator on 2/8/12 at 1:30 P.M., the Administrator said that the hospital did not have any patients who expired at the facility. The administrator further said that he did not feel that the patients would be appropriate for donation via the organ procurement program, and that there was no mechanism to inform families of their options.

Based on staff interview, the hospital did not have a designated requestor or an individual who had completed a course approved by the Organ Procurement Organization for approaching potential donor families or patients and requesting organ or tissue donation.

Findings include:

During an interview with the Administrator on 2/8/12 at 1:30 P.M., the Administrator said that no staff at the hospital had been assigned to be a representative or designated requestor to initiate the request to a family for organ procurement when appropriate. The Administrator further said that due to the type of patients this hospital serves, there is no need to address organ procurement responsibilities.

Based on review of staff education training programs and staff interviews, the hospital failed to educate staff on donation issues.

Findings include:

1. During an interview with the hospital Administrator on 2/8/12 at 1:30 P.M., the Administrator said that there was no staff person appointed to educate staff regarding organ procurement issues.

2. During interviews on 2/8/12 at 1:58 P.M. with Nurse #3 and Nurse #6 (who were working in The Inn) and at 2:17 P.M. with Nurse #7 (who was working in The Unit), the nurses said that they had never been educated regarding organ procurement and had no knowledge what to do regarding organ donation if someone expired.

Revise the Master Treatment Plans of 3 of 8 active sample patients (A1, A5, A11) and 1 non-sample discharged patient (E1) (reviewed for use of mechanical restraint and for suicide attempt while hospitalized.) Previously selected modalities were unsuccessful, but changes to the plan were not made. This resulted in patients being hospitalized without the opportunity to receive interventions to meet identified treatment needs, thereby delaying their improvement.

Findings include:

A. Patient A5

The patient was admitted on 1/26/2012 for "depression and alcohol dependence." A review of his/her participation in the available groups provided on The Unit as recorded in the Group Evaluation Forms (which describe patient participation or absence) disclosed that as of 2/8/12 at 1:00PM s/he had refused to attend 23 of the available 35 groups, or approximately 66% that had been offered. As of 2/9/12, Patient A5's failure to participate in his/her current treatment had not been addressed in the treatment plan.

On 2/8/2012 at 4:00 p.m., the Director of Nursing was asked to examine Patient A5's Treatment Plan. She stated, "They are not mentioning that [the patient] is not going to groups. I am not seeing what I would like to see." She agreed that no new interventions or modifications to the Treatment Plan were present to reflect the lack of success with the current modalities.

B. Patient A9

The patient was admitted on 1/31/12 with diagnoses of Polysubstance dependence and Bipolar Disorder. Review of Patient A9's participation as recorded in the Group Evaluation Forms revealed that as of 2/8/12 Patient A9 had refused 14 of the 20 assigned groups (70%) since admission. Patient A9 was in bed during 10 of the 14 assigned treatment activities that she refused. As of 2/8/12, Patient A9's treatment plan had not been revised to address his/her refusal to participate in the majority of his/her assigned treatment.

During interview on 2/9/12 at 4:15p.m., after reviewing Patient A9's treatment plan, the Director of Nursing verified the team's failure to address patient's treatment refusals.

C. Patient A11

The patient was admitted on 12/19/11 with diagnosis of Psychotic Disorder, NOS. After alleging rape by a staff member (found unsubstantiated by police) on 1/1/12, according to the physician's order of that date Patient A11 was placed on 1:1 supervision to ensure safety and make patient more comfortable as the patient continually made paranoid statements. After a decrease in paranoid statements, the 1:1 supervision was discontinued on 1/14/12. After a statement made to a male patient that he was the "Lipstick Serial Killer," a nursing progress note (1/9/12) stated, "Pt [Patient] placed on 1:1 per MD orders. Pt [Patient] states that (s/he) feels as though (s/he) was attacked last night". As of 2/9/11 at 9:30a.m., Patient A11's treatment plan had not been revised to address this issue.

On 2/9/2012 at 9:25a.m., after reviewing Patient A11's treatment plan, the Director of Nursing acknowledged that there were no new interventions or modifications of the treatment plan to address the patient's behavior with specific interventions to care for this patient in the clinical area.

D. Non-sample (discharged) Patient E1

1. The patient, admitted to the facility on 10/22/11, had required physical restraint on 10/24/12. On 10/27/12, the Incident Report of that date described that Patient E1 was found by staff in the bathroom "...sitting on floor with shirt loosely tied around his neck" and stating "If I don't get more meds I am going to kill myself."

2. Review on 2/8/12 of the Treatment Plan of Patient E1, who had been discharged 11/03/11, revealed that the patient behaviors which resulted in the use of restraint and the patient's threat to commit suicide had not been addressed prior to discharge.

3. In an interview on 2/8/2012 at 1:10p.m. the Acting Clinical Director said that he was familiar with the case of Patient E1. When asked if the Treatment Plan (which he examined during the interview) had been modified to reflect the events above, he acknowledged that nothing was changed in the Plan.

Based on record review and staff interview, the facility failed to develop Master Treatment Plans that clearly identified the problems of 8 of 8 active sample patients (A1, A5, A9, A10, A11, B1, B2 and B3). The problems on the MTPs were stated as unclear diagnostic statements rather than patient behaviors to be reduced or resolved. This failure results in lack of specific direction for staff in meeting patients' individual needs.

Findings include:

A. Record Review

1. Patient A1: The Master Treatment Plan dated 2/1/2012 stated, "Detoxification/Psychiatric" as the identified problem.

2. Patient A5: The Master Treatment Plan dated 1/27/2012 stated, "Detoxification/Psychiatric" as the identified problem.

3. Patient A9: The Master Treatment Plan dated 1/31/2012 stated, "Detox and Psychiatric" as the identified problem.

4. Patient A10: The Master Treatment Plan dated 2/6/2012 stated, "Psych/Detox" as the identified problem.

5. Patient A11: The Master Treatment Plan dated 12/20/2011 stated, "Psychiatric" as the identified problem.

6. Patient B1: The Master Treatment Plan dated 2/06/2012 stated, "Detox/Psychiatric" as the identified problem.

7. Patient B2: The Master Treatment Plan dated 1/24/2012 stated, "Detoxification/Psychiatric" as the identified problem.

8. Patient B3: The Master Treatment Plan dated 1/26/2012 stated, "Detoxification/Psychiatric" as the identified problem.

B. Staff Interview:

In an interview on 2/9/2012 at 9:30a.m. after examining the findings for Patients A5 and A10, the Director of Psychology/Administrator agreed that the problems for focus of treatment were not individualized and were not expressed behaviorally on the patients' Master Treatment Plans.

Based on record review and staff interview it was determined that the facility failed to develop Master Treatment Plans (MTP) for 8 of 8 active sample patients (A1, A5, A9, A10, A11, B1, B2 and B3) that included individualized treatment interventions with a specific purpose and focus. Many of the interventions on the MTPs were stated as patient expectations rather than staff actions; were patient goals; were lists of generic discipline functions/tasks; or were absent for several disciplines. Failure to clearly describe specific modalities on patients' MTPs can hamper staff's ability to provide treatment based on individual patient needs.

Findings include:

A. Record Review

1. Patient A1

a. On the Master Treatment Plan dated 2/1/12), for the Problem, "Detoxification," there was no psychiatrist intervention to address medication use to support safe detoxification. The nursing interventions, stated as goals for the patient, were "P.S. (person served) will comply c/ [with] detox [detoxification] protocol per MD orders"; "P.S. will comply c/ VS (vital signs) protocol" and "P.S. will identify 2 coping skills that promote sobriety." Additional nursing interventions were generic functions: "Evaluate for signs and symptoms of detox"; "Medicate as ordered by MD" and "Encourage groups and socialization." Counselor interventions, stated as patient goals, were "(Patient) will develop alternative socialization skills and will develop alt. [alternative] coping skills" and "(Patient) Will be able to list individual relapse triggers and will develop a relapse prevention plan."

b. For the Problem, stated by the patient as "I want to feel better and less stressed," there was no psychiatrist intervention to identify the type of medication to treat patient's mood disorder. The nursing interventions were generic, rather than individualized interventions such as "Encourage social improvement"; "Provide medication education" and "Medicate P.S. A/O [sic]. Offer PRN's [sic] as needed." (The Director of Nursing on 2/9/12 at 10:00AM was asked what "A/O" meant. She replied that she did not know.) Counselor interventions were stated as patient goals: "P.S. will improve self-expression + [and] self-esteem skills" and "P.S. will increase development of appropriate emotional coping skills."

c. For the Problem, "Safe detox [detoxification], generic nursing interventions were listed as " Medicate as ordered by the MD" and "Encourage groups and socialization."

2. Patient A5

On the Treatment Plan dated 1/27/12, generic nursing interventions listed were "Monitor VS 4x/day" and "Medicate A/O [sic]."

3. Patient A9

a. On the Master Treatment Plan dated 1/31/12, for the Problem "Detox. Safely," non-specific psychiatrist intervention was stated as "MD will prescribe detox medications to aid patient ' s mood improvement and safety, monitor for side effects and adjust if necessary." The nursing interventions were "Medicate A/O per MD protocol"; "PS follow V.S. protocol A/O" and "P.S. will identify 2 coping skills that promote sobriety."
Generic nursing interventions were listed as "Medicate," "Group participation," and "Teach health coping skills."

b. For the Problem identified as "Mood Improvement," the psychiatrist intervention was "MD will prescribe medications to aid in patient's mood improvement and stabilization, monitor for side effects and adjust, if necessary." The nursing interventions were "Encourage social involvement"; "Provide medication education" and "Medicate P.S. A/O. Offer prn's [sic] as needed."


4. Patient A10

The Master Treatment Plan dated 2/6/2012, stated for the Problem identified as "Improve Mood" that nursing staff will "Person served will report SI(suicidal ideation)" and "destalt" [sic] and "Will comply with medication A/O and report efficacy." For the problem identified as "Detox and Sobriety," the interventions by nursing staff were "Person served will comply with vitals each shift" and "take medication A/O per Dr and report efficacy." All of these listed interventions are staff goals for the patient, not actual staff interventions.

5. Patient A11

a. On the Master Treatment Plan dated 12/20/11, for the Problem identified as "Psychiatric," the psychiatrist intervention was stated as "MD will monitor pt. mental status, and effectiveness and any adverse side effects of medication." The nursing interventions, stated as patient goals, were: "Person served will report S.I. destalt [sic]" and "Will comply with med A/O and report efficacy."

b. For the Problem identified as "Improve thought processes (deescalate)," generic nursing interventions were stated as "Medicate pt [patient] per M.D.," "Encourage pt to take meds [medications]" and "Enc [Encourage] pt to follow Tx [treatment] plan."

6. Patient B1

a. The Master Treatment Plan dated 2/6/2012 had no interventions listed for the discipline of psychiatry.

b. For the Problem, "Detox [detoxification] safety," generic nursing interventions were listed as "Monitor VS [Vital Signs]," "Medicate per MD order," and "...develop new coping skills by d/c (discharge)."

7. Patient B2.

a. The Master Treatment Plan dated 1/24/2012 stated for the problem identified as "Sobriety" that the psychiatrist intervention was "MD will educate pt (patient) on the negative consequences of substance abuse." The nursing interventions, stated as goals for the patient, were "PS will comply with detox protocol per MD orders" and "PS will ID (identify) 2 coping skills to maintain sobriety."

b. For the problem identified as "Mood improvement" the psychiatrist intervention was "MD will prescribe mood stabilizing medications as indicated from daily assessment of pt mental status." The nursing interventions, stated as goals for the patient, were "PS will report S.I., H.I. (homicidal ideation), A.H. (auditory hallucinations, VH (visual hallucinations) to staff"; "PS will eat 3 meals daily" and "PS will sleep 6-8 hours nightly."

8. Patient B3

a. On the Master Treatment Plan dated 1/26/2012, for the problem identified as "Detox Safely," the generic intervention for the psychiatrist was "MD will prescribe detox medications to aid in patient's comfort and safety, monitor for side effects and adjust if necessary." The nursing interventions, stated as goals for the patient, were "PS will comply c/detox protocol per MD orders"; "PS will comply c/ [with] vital signs protocol" and "PS will ID 2 coping skills to maintain sobriety."

b. For the problem identified as "Psychiatric," the generic intervention for the psychiatrist was " MD will prescribe medications to aid patient's mood improvement and stabilization, monitor for side effects and adjust if necessary." The nursing interventions, stated as goals for the patient, were "PS will report SI. HI, AH, VH to staff"; "PS will eat 3 meals per day" and "PS will sleep 6-8 hours nightly."

B. Interview

In an interview on 2/9/2012 at 9:30a.m. after a discussion of the findings listed in Section A above and examination of the findings for Patients A5 and A10, the Director of Psychology/Administrator agreed that the treatment modalities were not individualized.

Based on observation, interview and record review, it was determined that the facility failed to:

I. Ensure that active individualized psychiatric care was provided for 2 of 8 active sample patients (A5 and A9). These patients were hospitalized without the provision of alternative treatment modalities for their special needs to move them to a higher level of functioning and a less restrictive environment. This failure results in patients remaining hospitalized without all interventions for recovery being provided in a timely fashion, potentially delaying their improvement.

II. Provide ongoing active treatment for patients in 1 of 2 certified wards (The Unit). The majority of activities 7 days weekly were leisure-oriented, rather than therapeutic treatment activities based on individualized needs of the patient population. This failure resulted in lack of active treatment for all patients in this ward.

III. Ensure that staff reinforced the importance of and responsibility for patients' attendance and participation in available activities, and provided structured alternative treatment as needed on 1 of 2 certified wards (The Unit), affecting 4 of 5 active sample patients on The Unit during the survey (A1, A5, A9 and A10). This failure resulted in patients lying/sleeping in bed, sitting around and idly walking about the ward.

Findings include:

I. Failure to ensure active individualized treatment:

A. Patient A5.

1. The patient was admitted on 1/26/12 for "depression and alcohol dependence."

2. Review of the Group Evaluation Form, which describes this patient's participation or absence in treatment sessions that had been selected for him/her by the Treatment Team, revealed that as of 2/8/2012 at 1PM, the patient had refused to attend 23 of 35 groups (66%) that had been offered.

2. In an interview on 2/7/2012 at 10:30AM, Patient A5 was asked to describe his/her hospital stay. S/he stated, "I never go to the Arts and Crafts groups." S/he had refused to go to 2 scheduled groups earlier that day. S/he reported that s/he had attended a discharge planning group led by Activity staff.

3. On 2/8/2012 at 4p.m., after examining Patient A5's treatment plan, the Director of Nursing (DON) stated, "They (referring to staff members) are not mentioning that (Patient A5) is not going to groups. I am not seeing what I would like to see." The DON acknowledged that no new interventions or modifications had been added to the treatment plan to reflect the lack of success with the current modalities.

B. Patient A9

1. According to the Psychiatric Evaluation (dated 1/31/12), the patient was admitted on 1/31/12 with diagnoses of Polysubstance dependence and Bipolar Disorder.

2. Review of the unit Group Evaluation Form, which lists assigned treatment groups, revealed that as of 2/8/12, Patient A9 had refused 14 of 20 assigned groups (70 %) since admission. The form stated that Patient A9 was in bed during 10 of the 14 assigned treatment activities that s/he refused.

3. In an interview on 2/8/12 at 11:15a.m., when discussing Patient A9's treatment, RN 4 stated, "[Patient A9] has attended few groups even though [s/he] seems to have the best of intentions."

4. Review of Patient A9's treatment plan revealed that as of 2/8/12, the patient's plan had not been revised to address refusal of treatment.

II. Failure to provide an active treatment program:

A. Review of the treatment/programming schedule revealed that for 1 of 2 certified wards (The Unit), the majority of treatment 7 days per week was leisure-oriented, rather than therapeutic treatment activities based on the individual needs of the patient population (11-14 patients during the survey dates). The majority of these groups/activities were conducted by Recreation Technicians (Recreational Therapy Aides) or Health Care Technicians.

B. In an interview on 2/7/2012 at 10:30AM, Patient A5 was asked to describe his/her hospital stay. When asked to describe Unit treatment modalities on Saturday and Sunday s/he replied, "You pretty much have free time. If they (i.e. hospital staff) see you sitting in your room they come in and ask if they can help you with anything."S/he continued "It's laid back on Saturday and Sunday."

C. In an interview on 2/8/12 at 2:50p.m., the Director of Therapeutic Activities reported that all but 4-5 groups/treatment activities provided on The Unit, were conducted by Recreation Technicians or Mental Health Technicians. He reported that the majority of the group/activities are recreation and leisure activities and that the Recreation Technicians' presentations are guided by "literature about the topic." He reported that he was a MHT and that all groups are run by technicians, other than 2-3 which are conducted by the Certified Occupational Therapist Consultant.

III. Failure to reinforce the importance of and responsibility for patient attendance and participation in assigned treatment:

A. On 2/7/12, a treatment activity (Arts and Crafts led by a Recreation Technician), which all patients on The Unit were expected to attend ,was scheduled to be held from 10:30a.m. to 11:30a.m. Observations revealed that at 10:35a.m.(time group was to begin,) nursing staff was serving coffee to the patients. The group began around 10:40a.m. Prior to the group at 10:35a.m., staff was seen asking each patient, "Would you like to go to the arts and crafts group?" If the patient refused, the only response from the staff member was "We're going to have a good group today."

B. Observations of the The Unit on 2/7/12 at 11:05a.m. revealed that only 3 (including 1 of 5 active sample patients) of the 14 patients on the Unit attended the arts and crafts session. The observations also revealed the following:

1. Non-sample A7 was using the telephone.
2. Non-sample Patient A6 shaved and then took a shower.
3. Active sample Patient A1 was seen by the physician and then went to bed rather than going to the group. When asked (at 11:15a.m.) why s/he did not attend the group after being seen by the physician, s/he responded. "I did not know it was going on. I would have gone to it."
4. Active sample Patient A5 was chatting in the dayroom with non-sample Patient A13. Patient A5 was later seen at the nursing station, chatting with a MHT.
5. Active sample Patient A9 was asleep in bed.
6. Active sample Patient A10 was seen by the physician and then refused to attend the group.
7. Four additional patients including non-sample Patients A8 and A14, were sitting in the dayroom, chatting or sitting alone.

C. Interviews

1. In an interview on 2/7/12 at 11:05a.m., MHT 7 reported that all patients were supposed to have attended the Arts and Crafts program at 10:30a.m. S/he added, "If they refuse to attend the scheduled program, we can't make them go." When asked if s/he is supposed to do anything with the patients who refuse to attend the scheduled treatment activities, s/he responded, "We're just supposed to supervise them and do their monitoring checks."

2. In an interview on 2/7/12 at 11:55a.m., after a discussion of the findings in "B" above, RN3 reported that patients should not have been allowed use of the phone and bathing and shaving during group time. RN3 stated that the approach to patients about groups did not reflect staff's expectations about the patients' responsibility for treatment participation. RN3 also acknowledged that alternative treatment should be provided for patients who refuse to participate in scheduled groups/activities, and this treatment should be based on individual patient needs.

3. In an interview on 2/8/12 at 11:15a.m., RN 9 reported that all patients in The Unit are expected to attend all scheduled groups/activities. S/he added, "The only exception is the first day (of hospitalization) when they are usually acutely ill (physically)."

Based on observation, Record Review, and patient and staff interviews, it was determined the Clinical Director failed to:

I. Ensure that staff have available the treatment modality of Seclusion to use for external control of violence during emergency situations. Because seclusion is not available, staff must always resort to the use of either mechanical and/or physical restraints. This failure results in the need to utilize more restrictive interventions (i.e. mechanical and chemical restraints) when a patient's behavior is a danger to self and/or others.

Findings include:

A. During observation with RN3 on "The Unit" on 2/6/12 at 11:45a.m., observations were made of 2 rooms which were equipped with mirrors to allow staff outside the room to see into all parts of the room, which would usually be seen in rooms set aside for use during a patient seclusion. At the time of the observation, one of these rooms was set up as a "comfort room," with a chair, floor mat, etc., which would not be found in a room used for the purpose of seclusion. The other room was being used for patients that staff assessed as needing close monitoring, quiet, etc., but which also was not set up to be used for seclusion. During the observation, when asked about the rooms, RN 3 stated, "We do not use seclusion."

B. On 2/7/12 at 12:15p.m. the Director of Nursing was interviewed about the availability of seclusion at the facility. After reviewing the Nursing Policy and Procedure for use of restrictive measures with the surveyor, the DON acknowledged that there was no clear description of how "seclusion" would be implemented with current approved protocols. She further verified what RN3 had told the surveyors on 2/6/12 (i.e. seclusion is not used at the facility).

C. Review of the policy, "Nursing Protocol Restraint and Seclusion Policy," revised September 2011, revealed that seclusion is defined in the policy with protocol for its use integrated with that for the use of restraints. There is no specific procedure for the use of seclusion with patients.

II. Revise the Master Treatment Plans of 3 of 8 active sample patients (A1, A5, A11) and 1 non-sample discharged patient (E1) (reviewed for use of mechanical restraint and for suicide attempt while hospitalized.) Previously selected modalities were unsuccessful, but changes to the plan were not made. This resulted in patients being hospitalized without the opportunity to receive interventions to meet identified treatment needs, thereby delaying their improvement. (Refer to B118.)

III. Ensure that the Master Treatment Plans for 8 of 8 active patients A1, A5, A9, A10, A11, B1, B2 and B3) and 1 discharged patient (Patient E1) identified patient specific and behaviorally expressed Problems. These failures result in staff being unable to focus on patient specific issues. (Refer to B119).

IV. Ensure that the Master Treatment Plans for 8 of 8 active patients ( A1, A5, A9, A10, A11, B1, B2 and B3) contained individualized interventions, not generic discipline tasks, and that there were psychiatrist interventions for all patients. These failures result in the absence of a description of what staff are using as interventions to modify patient behavior. (Refer to B122)

V. Ensure that active treatment was occurring on a daily basis. This failure results in patient complaints of no active treatment especially on weekends on "the Unit" and the possible extension of hospital stays. (Refer to B125-II).

Based on observation, interview and record review, it was determined that the Director of Nursing failed to:

I. Assure adequate staffing (numbers of qualified nursing personnel) to provide safe, active treatment for the patient population. Specifically, on 1 of 2 certified wards (The Inn) the DON failed to ensure 1) the availability of a Registered Nurse (RN) on all work shift, and 2) provide sufficient numbers of total nursing personnel on the certified unit (The Inn) based on the acuity of patients. Failure to assure adequate staffing is a safety risk for all patients on the unit, and hampers staff's ability to provide quality nursing care. (Refer to B150)

II. Assure that the Master Treatment Plans of 8 of 8 active sample patients (A1, A5, A9, A10, A11, B1, B2 and B3) included individualized nursing interventions to address the patients' specific treatment needs. Many of the nursing interventions were routine, generic nursing functions. For some patients, the listed nursing interventions were stated as patient goals or staff goals for patient participation in treatment. The absence of individualized nursing interventions on patients' treatment plans hampers staff's ability to provide individualized nursing care to patients.

Findings include:

A. Record Review

1. Patient A1

a. On the Master Treatment Plan dated 2/1/12 for the problem, "Detoxification," nursing interventions were stated as patient goals: "P.S. (person served) will comply c/[with] detox [detoxification] protocol per MD orders"; "P.S. will comply c/VS (vital signs) protocol" and "P.S.will identify 2 coping skills that promote sobriety/" Additional nursing interventions were generic tasks: "Evaluate for signs and symptoms of detox [detoxification]"; "Medicate as ordered by MD" and "Encourage groups and socialization."

b. For the problem stated by the patient "I want to feel better and less stressed," the listed nursing interventions were generic tasks rather than individualized interventions. These were: "Encourage social improvement," "Provide medication education," and "Medicate P.S. A/O [sic]. Offer PRN's (sic) as needed."

c. For the problem, "Safe detox [detoxification] dated 2/1/12, generic nursing interventions were listed as "Medicate as ordered by the MD" and "Encourage groups and socialization."

2. Patient A5

On the Master Treatment Plan dated 1/26/2012 the Nursing interventions listed were "Monitor VS 4x/day" and "Medicate A/O [sic]." The Director of Nursing on 2/9/2012 at 10:00 AM was asked what "A/O" meant. She replied that she did not know.

3. Patient A9

On the Master Treatment Plan dated 2/1/2012, for the issue "Detox. [detoxification] safely," a generic nursing intervention was "Medicate A/O per MD protocol." Patient goals were listed as nursing interventions; they were "P.S. follow V.S. protocol A/O," and "P.S. will identify 2 coping skills that promote sobriety."

For the issue identified as "Mood Improvement," generic nursing interventions were "Encourage social involvement" and "Provide medication education" and "Medicate P.S. A/O. Offer prn's [sic] as needed."

4. Patient A10

On the Master Treatment Plan dated 2/6/2012, for the issue identified as "Improve Mood," the generic nursing intervention was "Will comply with medication A/O and report efficacy." For the problem identified as "Detox and Sobriety" patient goals were listed as nursing interventions; they were as "Person served will comply with vitals each shift" and "take medication A/O per Dr and report efficacy."

5. Patient A11

a. On the Master Treatment Plan dated 12/20/2011, for the issue identified as "Psychiatric," a patient goal was listed as a nursing intervention; it was "Will comply with med A/O and report efficacy." Generic nursing interventions were stated as "Medicate pt [patient] per M.D.," "Encourage pt to take meds [medications]" and "Enc [Encourage] pt to follow Tx [treatment] plan."

6. Patient B1

For the problem, "Detox [detoxification] safety," generic nursing interventions were listed as "Monitor VS [Vital Signs]" and "Medicate per MD order."

7. Patient B2

On the Master Treatment Plan dated 1/24/2012, for the issue identified as "Sobriety," the following patient goals were incorrectly listed as nursing interventions: "PS will comply with detox protocol per MD orders" and "PS will ID (identify) 2 coping skills to maintain sobriety. "For the issue identified as "Mood improvement," the following patient goal was incorrectly listed as a nursing intervention: "PS will eat 3 meals daily."

8. Patient B3

On the Master Treatment Plan dated 1/26/2012, for the issue identified as "Detox Safely," the following patient goals were listed as nursing interventions: "PS will comply c/detox protocol per MD orders"; "PS will comply c/ [with] vital signs protocol" and "PS will ID 2 coping skills to maintain sobriety." For the issue identified as "Psychiatric," the following patient goal was listed as a nursing intervention: "PS will eat 3 meals per day."

B. Interview

In an interview on 2/8/12 at 4:30p.m., the Director of Nursing acknowledged that the nursing interventions on the patients' treatment plans were generic nursing tasks, rather than individualized interventions for the patients.


III. Ensure that nursing staff reinforce the importance of and responsibility of patients' attendance and participation in available activities and provided structured alternative treatment as needed in 1 of 2 certified wards (The Unit), affecting 4 of 5 active sample patients on this ward during the survey (A1, A5, A9 and A10). This failure resulted in patients lying/sleeping in bed, sitting around and idling walking about the ward. (Refer to B125-III)

IV. Ensure that staff have available seclusion rooms for external control of violence during emergency situations in 1 of 2 wards (The Unit). The facility does not support the use of seclusion even though it may be the option of choice to assist the patient to control aggressive behavior. This failure results in the need to utilize more restrictive interventions (i.e. mechanical and chemical restraints) when a patients' behavior is a danger to self or others.

Findings include:

A. During observations with RN3 on "The Unit" on 2/6/12 at 11:45a.m., observations were made of 2 rooms equipped with mirrors; such rooms would usually be set up with such mirrors when the room is used to seclude a patient if needed. At the time of the observation, neither room was available to be used for seclusion: one of these rooms was set up as a "comfort room" with a chair, floor mat, etc.; the other room was being used for patients that staff assessed as needing close monitoring, quiet, etc. When asked about this, RN 3 stated, "We do not use seclusion."

B. In an interview on 2/7/12 at 12:15p.m., when asked about the availability of seclusion rooms at the facility, the Director of Nursing stated. "Seclusion is primarily a definition in the Nursing Policy and Procedure for use of restrictive measures." After reviewing the policy with the surveyor, the DON acknowledged that there was no clear description of how seclusion would be accomplished. She further verified what RN3 had told the surveyors on 2/6/12 (i.e., seclusion is not used at the facility).

C. Review of the policy, "Nursing Protocol Restraint and Seclusion Policy," revised September 2011, revealed that seclusion is defined in the policy with protocol for its use integrated with that for the use of restraints. There is no specific procedure for the use of seclusion with patients.

V. Ensure proper, safe storage of narcotics on 1 of 2 certified wards (The Unit). This failure to secure controlled medications can result in potential untoward use.

Findings include:

On 2/6/12 at 2:35p.m., during a review of the medication room in the nurses' station on the second floor of "The Inn" (where the patients on the first floor certified Distinct Part come to receive medications), it was observed that the narcotics drawer was unlocked and open. RN 5 had left the narcotics drawer unlocked and went to the adjoining room for approximately 3 minutes, leaving the narcotic drawer unlocked while 2 surveyors were in the room.

During an interview, RN5 reported that she is the only staff member with a key (pointing to keys on a neck strap).

Based on interview and document review, the facility failed to ensure adequate numbers of qualified nursing personnel to provide a safe, therapeutic environment for the patient population. Specifically, the facility failed to:

I. Ensure the availability of a Registered Nurse (RN) on each ward on all work shifts (days, evenings, nights). There were insufficient numbers of RNs deployed to 1 of the 2 certified wards (The Inn) for all evening and night tours of duty for the reviewed dates of January 31, 2012 through February 6, 2012. The RN does not go to the first floor (certified) except to make rounds; otherwise the RN remains in an office on the second floor (non-certified ward). This staffing pattern results in lack of professional nursing staff to provide needed assessments of patients, and to provide direction and supervision for the non-professional nursing staff.

II. Ensure sufficient numbers of total nursing staff (MHTs) on 1 of 2 wards (The Inn), based on the acuity of the patients for all work shifts (days, evenings, nights). RNs remained on the non-certified area except for making rounds on the certified ward, leaving the MHT(s) assigned to the certified unit without regular RN supervision. This staffing pattern resulted in safety risks for patients.

Findings include:

I. Insufficient numbers of Registered Nurses

A. "The Inn" is a 3 story building without an elevator. It has 10 certified beds on the first floor, and a total of 29 non-certified beds on the second and third floors (19 beds on the 2nd floor; 10 beds on the 3rd floor). The third floor is currently closed for renovations with a target date of April 2012 for completion. The first floor of The Inn (certified ward) provides crisis stabilization, evaluation and treatment for acutely ill patients. Some of the patients served on the first floor are in varied stages of detoxification (drugs and/or alcohol) in addition to presenting symptoms related to psychiatric illnesses. Most of the patients are experiencing depression, some with potential for self-harm.

B. In an interview on 2/6/12 at 1:45p.m., RN 4 stated that the Registered Nurse(s) remain on the second floor of the build, only going to first floor (certified ward) to make rounds and talk to each "Medicare patient" at least 4 times during a 24 hour period (usually on the day and evening shifts). RN4 also stated that the RN is supposed to "touch base and talk to them (certified patients)." In addition, RN4 reported, "There is usually only 1 RN working (in The Inn) on the evenings and nights."

C. In an interview on 2/8/12 at 9:50a.m., the Director of Nursing (DON) reported that the RN(s) assigned to The Inn work as a team from the office on the second floor of the building. She reported that an RN is supposed to "go down to the first floor to observe and talk to the certified patients and are responsible for writing notes on these patients." The DON acknowledged that an RN on the non-certified wards, s/he would not be able to attend to the patients on the certified ward if there was an emergency with a patient on both floors simultaneously.

D. Analysis of staffing forms provided by the Director of Nursing for the dates January 31 through February 6, 2012 revealed that only 1 Registered Nurse was assigned to all evening and night work shifts (14 of 14 work shifts) for a total patient census of 19-24, Two to four of these patients were being served on the certified ward (first floor). Although there was an additional RN assigned to The Inn from 4p.m. to 8p.m. on 6 of 7 of the evening shifts, this additional RN also provided back-up for the other certified ward (The Unit) which is physically located about .2 mile across campus. In addition, even though there are 2 RNs assigned on the day shifts in The Inn building, one of these RNs could be called to The Unit to assist with RN tasks, such as admissions.

On 2/8/12 at 9:50a.m., the staffing forms were compared to actual staffing sheets with the Director of Nursing. The staffing forms completed by the DON did reflect the staffing sheets.

II. Insufficient numbers of nursing staff (MHTs)

A. The Inn is a 3 story building without an elevator. There are 10 certified beds on the first floor, and a total of 29 non-certified beds on the second and third floors (19 and 10 respectively).The third floor is currently closed for renovations with a target date of April 2012 for completion. The first floor of The Inn (certified ward) provides crisis stabilization, evaluation and treatment for acutely ill patients. Some of the patients served on this ward are in varies stages of detoxification (drugs and/or alcohol) in addition to symptoms related to psychiatric diseases. Most of the patients are experiencing depression, some with potential for self-harm.

B. In an interview on 2/6/12 at 1:45p.m., RN 4 stated that the Registered Nurse(s) do not go on to the first floor (certified ward) except to make rounds and talk to each "Medicare patient" at least 4 times during a 24 hour period (usually on the day and evening shifts), but stay in an office upstairs on the non-certified ward. RN4 also stated that the RN is supposed to "touch base and talk to them (certified patients)." In addition, RN4 reported, "There is usually only 1 RN working (in The Inn) on the evenings and nights."

C. In an interview on 2/8/12 at 9:50a.m., the Director of Nursing (DON) reported that the RN(s) assigned to The Inn work as a team from the office on the second floor of the building. She reported that an RN is supposed to "go down to the first floor to observe and talk to the certified patients and are responsible for writing notes on these patients." The DON acknowledged that an RN who was on one of the upper floors of the building (non-certified wards) would not be able to attend to the patients on the certified ward if there was an emergency with a patient on both floors simultaneously.

D. In an interview on 2/6/12 at 1:45p.m., RN4 stated that usually one Mental Health Technician (MHT) is assigned to monitor patients on each floor, to conduct the 30 minute safety checks, and to make rounds. RN4 stated that at least one of the three MHTs should remain on the first floor, but said that when patients are quiet/asleep, the MHT might go upstairs to do assigned charting in the second floor office.

E. Analysis of staffing forms provided by the Director of Nursing for the dates of January 31, 2012 through February 6, 2012 revealed that only 3 Mental Health Technicians were assigned to all night tours of duty (7 of 7 work shifts) for a total patient census of 19-24. Two to four of these patients were housed on the certified ward (first floor). In addition, on the dates of 2/4/12 and 2/5/12, there were only 3 MHT working in the building from 10p.m. until 12a.m. (midnight).

F. On 2/8/12 at 9:50a.m., the staffing forms were compared to actual staffing sheets with the Director of Nursing. The staffing forms completed by the DON did reflect the staffing sheets.

Based on document review and staff interview, the hospital failed to ensure that its QAPI (Quality Assurance Performance Improvement) Program Scope included quality assurance and performance improvement evaluations for services provided by outside contractors.

Findings included:

The QA/PI (Quality Assurance/Performance Improvement) Director and the DON (Director of Nurses) were interviewed on 2/9/12 at 2:45 P.M., regarding the process for evaluating services provided to the hospital by outside contractors.

QAPI meeting minutes were provided by the hospital QA Director on 2/9/12 at 2:45 P.M. Review of the minutes with the QA Director and DON, revealed no evidence that the hospital's laboratory contracted service had been evaluated by the Administrator, CEO, or other hospital staff who attended the monthly QAPI meetings.

Both the QA Director and DON stated that they were not aware of the hospital's process for evaluating the services contracted by outside vendors.

Interview with the Adminstrator on 2/9/12 at 3:30 P.M., acknowledged that the hospital contracted such services as laboratory, pharmacy and radiology services. He said that there was no evaluation available for each contracted service provided to the hospital. Additionally, the Administrator said that no one within the hospital was appointed to oversee evaluation of each contracted service provided to the hospital.

Based on record review and staff interview, the hospital failed to ensure, that for 1, non-sampled patient (NS #A) of a total of 30 sampled patients, that the hospital QAPI Program measured, analyzed, and tracked quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital services, and operations.

Findings included:

Non-sampled #A alleged improper medical care, treatment, and an unclean/ unsafe, environment during multiple admissions to the hospital in 2010. The hospital's QAPI Program failed to evaluate the grievances filed by the patient in order to improve patient health outcomes.

Please refer to A-0118.