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31048

Based on record reviews and interviews, the hospital failed to ensure the requirements for the Condition of Participation for Governing Body were met as evidenced by:

1) failing to ensure the chief executive officer (CEO) appointed by the governing body was responsible for managing the hospital as evidenced by failing to ensure the hospital was in compliance with the Conditions of Participation of Medical Record Services (see findings in A-0057 and A-0431).

2) failing to ensure the hospital was in compliance with the Conditions of Participation of Infection Control (see findings in A-0747).


30172

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation for Medical Record Services as evidenced by:

Failing to implement its Medical Staff By-laws and Rules and Regulations for delinquent medical records as evidenced by

1) having 403 delinquent medical records not completed within 30 days after discharge administratively closed on 06/16/15 by the Governing Board, and

2) failing to suspend the physician(s) admitting privileges as required by the Medical Staff By-laws and Rules and Regulations (see findings in A-0438).

Based on observations, interviews and record reviews, the hospital failed to ensure the requirements for the Condition of Participation for Infection Control were met as evidenced by:
1. Failing to ensure the Infection Control Program maintained an effective system for identifying, reporting, investigating, and controlling of infections and communicable diseases of patients and personnel. (see findings at A-0749)
2. Failing of the Administrator, the Medical Staff, and the DON (Director of Nursing) to monitor adherence of the hospital's Infection Control Program's Plan by failing to ensure that the Infection Control Program and the Infection Control Committee adhered to the surveillance monitoring activities set forth in the Infection Control Plan/Program as evidenced by incomplete surveillance monitoring activity documentation. (see findings at A-0756)

Based on record reviews and interviews, the hospital failed to ensure the chief executive officer (CEO) appointed by the governing body was responsible for managing the hospital as evidenced by failing to ensure the hospital was in compliance with the Conditions of Participation of Medical Record Services. The hospital failed to ensure the implementation of its Medical Staff By-laws and Rules and Regulations for delinquent medical records as evidenced by having 403 delinquent medical records not completed within 30 days after discharge administratively closed on 06/16/15 by the Governing Board, and failing to suspend the physician(s) admitting privileges as required by the Medical Staff By-laws and Rules and Regulations.

Findings:

Review of the "Governing Body Bylaws" presented by S1Administrator revealed the governing body would appoint a CEO as its direct executive representative in the management of the hospital. Further review revealed the authority and duties of the CEO included, in part,
1) carrying out all policies as established by the hospital;
2) negotiating and finalizing professional, consultant, and service contracts in accordance with corporate policy; and
3) being responsible for assuring that the hospital is in conformity with the requirements of planning, regulatory, and inspecting agencies.

Review of the hospital's "Rules and Regulations For The Professional Medical Staff," presented as the current rules and regulations by S1Administrator, revealed the following, in part: "Section 2. Admission and Discharge of Patients, b. Only appropriately licensed of the medical staff shall be responsible for the medical care and treatment of each patient in the hospital, for the prompt completeness and accuracy of the medical record.... 3. Medical Records, a. The attending physician shall be responsible for the preparation of a complete and legible medical record for each patient; d. All clinical entries in the patient's medical record shall be accurately dated, timed and authenticated. Authentication means to establish authorship by written signature of identifiable initials; j. A medical record shall not be permanently filed until it is completed by the responsible physician or is ordered filed by the medical record director; m. Each medical record shall be completed within 30 days after the discharge of the patient or the record becomes delinquent. On a continuous basis, the medical record director shall review incomplete records. At this time, any physician who has any delinquent charts shall be so notified by phone. If the records are still incomplete two weeks after being notified, he shall automatically suffer suspension of admitting privileges. He shall be notified of such suspension in writing by the medical record director. Privileges may be restored by the Chief Medical Officer when he has been notified by the medical record (department) that the delinquent records have been completed."

Further review of the Rules and Regulations for the Professional Medical Staff revealed no documented evidence of a procedure to administratively close incomplete medical records.

Review of a Policy and Procedure entitled, "Authentication Process for Medical Records" with a revision date of 03/15, revealed, in part: "Purpose, To comply with the standards of JCAHO (The Joint Commission)/CMS (Centers for Medicare and Medicaid Services), patient records will be completed within 30 days post-discharge. . . .D. Quantitative Analysis, 3. The Medical Records Coordinator files medical record in incomplete file area for up to 30 days to allow staff to complete all deficiencies. E. Notification to Staff of Deficient Charts, 1. The Medical Records Coordinator notifies staff of deficient charts. 2. The Clinical Staff checks closed medical records in incomplete file area and completes any identified deficiencies indicated. 3. The Medical Record Coordinator files completed, closed medical record in permanent file area."

Review of a Policy and Procedure entitled, "Discharge Summary" with a revision date of 06/15 revealed, in part: "Procedure, D. The facility will complete all necessary audits to determine the completeness of the patient's clinical record within thirty (30) days of the discharge date. Procedure for Closure of Patient Medical Record, Health Information Staff: 1. After all attempts to contact the physician and/or staff to arrange for completion of the medical record has failed (if contacting the physician is applicable), the patient's name, admit, discharge date and medical record number is submitted for approval to the Governing Body. Health Information Management Coordinator: HIM (Health Information Management) submits the chart(s) in need of closure at the next Governing Body for approval to be filed as incomplete. Governing Body: Signs approval of closure. Health Information Staff: Files the chart in the permanent file section of the Health Information Department."

In an interview on 07/08/15 at 1:15 p.m., S9MR (Coordinator) indicated the 59 identified deficient medical records from the survey on 05/21/15 were "administratively closed." When asked what administratively closed meant, she replied administratively closed meant that the medical records were beyond the 30 day deadline for completion of the medical records, so the records were presented to the Governing Board to be administratively closed, meaning no further attempts to get the medical record completed after the 30-day deadline would be made. Once the medical records were administratively closed, the records could be forwarded to permanent storage. She further indicated at the time of the 05/21/15 survey, the 59 records were on a list awaiting approval from the Governing Board to be administratively closed, and after the 05/21/15 survey, her previous supervisor (who is no longer employed at the hospital) went into the medical record system and identified all medical records that were delinquent since the hospital opened, and she printed the list (which consisted of 403 records) to present to the Governing Board for approval to have them administratively closed. S9MR confirmed she was not aware of any physicians who had privileges suspended for delinquent medical records since she has been employed at the hospital.

Review of the list provided by S9MR presented to the Governing Board on 06/16/15, revealed a total of 403 (number of medical records verified by S9MR) delinquent medical records identified for administrative closure starting with the date of 11/14/13. Review of the current log for delinquent medical records began with the date of 05/07/15.

Review of the Governing Board Committee Meeting Minutes dated 06/16/15 revealed, the following, in part: "5) Medical Records; i. Delinquent charts and charts that are 30 days old have been administratively closed. Please refer to Medical records for the list. MR0001 to MR00339." There was no documentation or evidence to indicate that any of the physicians with delinquent medical records were suspended as indicated in the Medical Staff By-laws and Rules and Regulations.

Review of the current "Medical Record Delinquent Detail Report" revealed there were 4 medical records that were delinquent beyond the 30 day deadline from a total of 31 medical records. Further review revealed one medical record was delinquent by 3 days; two by 6 days; and one at 37 days.

In an interview on 07/09/15 at 12:20 p.m., S1Administrator indicated the data for delinquent medical records was forwarded to the PI (Performance Improvement) committee monthly. S1Administrator indicated the previous employee in charge of the medical record department provided incorrect data on the medical record delinquency issues/rates. S1Administrator confirmed the list of the 403 delinquent medical records provided to the surveyor on 07/09/15 by S9MR, was the list of medical records presented to the Governing Board on 06/16/15 for administrative closure due to the medical records being delinquent beyond 30 days. When S1Administrator was asked if he was aware that the procedure in place at the hospital for administratively closing medical records was not correct, he indicated he followed the recommendations of a previous assistant administrator who informed him this was the correct procedure for charts that were not completed within 30 days. S1Administrator confirmed no physicians had privileges suspended at the hospital due to delinquent medical records.


31048

Based on record review, observation and interview, the hospital failed to ensure care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for patients admitted for acute inpatient psychiatric services and by failing to ensure that the patient medication cart left in the hallway during a patient accu-check was locked prior to entering the patient's room. Findings:

Review of the hospital policy titled, Program Safety/Security revealed in part the following: It is the policy of the Hospital to equip, operate, maintain and monitor the environment to ensure safety and security for all patients, personnel and visitors. 1) Glass objects, weight-bearing bars, removable ceilings, firearms, explosives and any potential weapons will be prohibited in the Hospital. 4) All medication will be kept in the locked medication room. 16) Staff will review the unit environment regularly and report any safety issues to Director of EOC (Environment of Care)/Safety....

An observation was conducted on 07/06/15 at 3:40 p.m. to 4:30 p.m. of the inpatient unit with S2DON (Director of Nursing). The patient shower room was observed to have 2 shower stalls. The shower stall on the right side of the room was observed to have a shower head attached to an approximately 5 foot long shower hose (hand held shower head). S2DON confirmed the observation and removed the shower hose and stated it was supposed to be locked in a cabinet when not in use. Also observed in this shower stall was a round knob that was loosely attached to the wall and had a piece of black tape over the base of the knob and the wall. S2DON confirmed the observation.

An observation of the bathroom doors in all 6 patients' rooms revealed the bathroom doors had 3 door hinges set apart widely enough to allow for potential ligature. S2DON confirmed the space between the door hinges could be used as potential ligature points.

An observation of the patient beds in all 6 rooms revealed all 12 in-patient beds had metal springs that were removable. S2DON confirmed all the beds were the same and confirmed the springs could potentially be removed by patients and used as weapons. S2DON confirmed the hospital did not have a policy to address mitigation of the risk of using beds with removable metal springs.

An observation of room "A" and room "B" revealed each room had an electrical outlet. The outlets were observed to have red switch plates and have a white plastic cover that was easily opened, allowing access to the outlet. S2DON stated the only patient rooms that had electrical outlets were room "A" and room "B." S2DON confirmed the electrical outlets were accessible to the patients and stated she did not know if the outlets were ground fault circuit interrupted (GFCI) outlets.

In an interview on 07/09/15 at 9:10 a.m., S31Maintenance was asked if the electrical outlets in room "A" and room "B" were GFCI outlets. He stated after a hurricane the patients needed oxygen and they put in emergency outlets in these two rooms. After observing the outlet in room "A," he stated the outlet was not GFCI and the white plastic case covering the outlet was supposed to be zip tied where patients would not have access to the outlet.

An observation on 07/07/15 at 4:30 p.m. was made of S13LPN (Licensed Practical Nurse)performing an accu-check on Patient #3 in his room. S13LPN was observed using the top of the nurse's medication cart as her work surface. S13LPN was observed bringing the accu-check supplies and the glucometer into the patient's room and performed the accu-check test on Patient #3 by the patient's bedside. S13LPN left the nurse's medication cart in the hallway outside of the patient's door. An observation of the nurse's medication cart revealed the cart was not locked and contained several patient medications drawers with patient medications in the medication cart drawers. S13LPN remained in Patient #3's room for 10 minutes and was observed to have her back to the medication cart that was located in the hallway. A further observation revealed several patients in the hallway by Patient #3's door. An MHT (Mental Health Technician) was observed intermittently in the hallway doing observation checks on the patients, and a MHT was not observed to be in constant site of the patients in the hallway.
In an interview on 07/07/15 at 4:50 p.m. with S13LPN, she was asked about the nurse's medication cart left in the hallway unlocked with potential access of the medication cart to other patients in the hallway. S13LPN indicated that she used the top of the medication cart as her work surface when she performed patient accu-checks. S13LPN indicated that she did not think about locking the medication cart.



30172

Based on record review and staff interview, the hospital failed to ensure the QAPI (Quality Assessment Performance Improvement) program included an effective system to identify medication errors as evidenced by the current practices of self-reporting and 24 hour chart audits failed to identify a medication error. Findings:

Review of the QAPI program Quality Monitoring and Evaluation Indicator for Medication Variances revealed the data would be collected from 100% of medication variances documented.

In an interview on 07/09/15 at 10:20 a.m., S4QA (Quality Assurance) stated he has only been looking for medication variances to determine if there are any medication errors. He confirmed the 24 hour chart check is to review charts for medication errors. He stated there had been no medication variances for the month of June, 2015, and none had been reported so far in July.

On 07/09/15 the medical record of Patient #10 was reviewed and revealed a medication error occurred on 07/07/15 when Thiamine and Folate were not transcribed to the MAR (Medication Administration Record) and the medication was not administered to the patient until 2 days after the medication was prescribed.

In an interview on 07/09/15 at 12:58 p.m., S2DON reviewed the medical record for Patient #10 and confirmed the Thiamine and Folate were not transcribed to the MAR for 07/07/15, and the medications were not given to the patient that day. She confirmed the 24 hour chart check was not done and should have been. She stated the medication error would have been found if the nurse had completed the chart audit. She confirmed this was a medication error, and it had not been identified through the hospital's current process of identification of medication errors.

Based on record review and staff interview, the hospital failed to ensure the reasons for conducting the identified projects were documented and implemented. Findings:

Review of the QAPI (Quality Assessment Performance Improvement) program documents revealed quality indicators for Effectiveness of Fall Reduction Program, Medication Variance, Basic Disinfection, and Hand Hygiene. There was no documented evidence in the QAPI program documents that these quality indicators were the hospital's QAPI projects.

Review of the Performance Improvement Committee meeting minutes dated 06/08/15 revealed the new QAPI program was introduced. The minutes revealed the new monitors (quality indicators) were discussed. There was no documented evidence that the PI (Performance Improvement) projects were identified or discussed.

Review of the Performance Improvement Program Master List of Indicators revealed the annual Performance Improvement Projects were as follows: At Risk for Falls - Effectiveness of Monitoring, Significant Reduction of Medication Variances, and Effectiveness of Infection Control Surveillance. There was no documented evidence of why these projects were chosen.

In an interview on 07/07/15 at 2:30 p.m., S4QA (Quality Assurance) stated falls and medication variances were the PI projects. When documentation of the projects was requested for review, he was unable to provide any documentation. He confirmed there was no documentation of why the projects were chosen. He confirmed the only documentation related to the projects was the quality indicator methodology. S4QA confirmed he had not collected any data on medication variances or falls yet. S4QA also stated he was told that "State" (surveyors) was coming, and he needed to collect some data. He further stated he had to re-write some of the audits due to not collecting in the information in accordance with methodology.

Based on record review and staff interviews, the hospital failed to ensure an effective system was in place to ensure that each physician/practitioner providing services in the hospital was credentialed in accordance with the Medical Staff By-laws as evidenced by failing to ensure clinical privileges were reviewed by the medical staff prior to recommending appointment to the medical staff for 3 (S29Physician, S28Physician, S30APRN) of 8 credentialing files reviewed (S12Physician, S18APRN, S21Radiologist, S26Medical Director, S27Physician, S28Physician, S29Physician, S30APRN). Findings:

Review of the Medical Staff By-laws, provided by S2DON (Director of Nursing) as current, revealed in part the following: Section 1. Application for Appointment. The application shall require detailed information concerning the applicant's education, training, and professional experience and qualifications. The application shall contain a specific request for staff category assignment and clinical privileges. The completed application shall be submitted to the Administrator. After collecting the references and other materials deemed pertinent, the application and all supporting materials shall be transmitted to the Chief Medical Officer and the Medical Executive Committee for evaluation. All recommendations to appoint must also specifically recommend the clinical privileges to be granted....Temporary clinical privileges may be granted for a period of three months or 90 days at the discretion of the Administrator and the discretion of the Chief Medical Officer.
Review of the Medical Staff Rules & Regulations revealed the following: Section 8. Medical. All medical privileges shall be reviewed by the Chief Medical Officer as applied for by the members of the medical staff. These privileges shall only be granted with the approval of the Chief Medical Officer.

S29Physician
Review of the credentialing file for S29Physician revealed a letter dated 11/11/14 signed by S1Administrator indicating the hospital had granted S29Physician temporary privileges for 90 days. The file also revealed another letter dated 12/12/14 signed by S1Administrator indicating the Governing Board appointed S29Physician to the medical staff from 12/12/14 to 12/11/16 as an active member with a specialty in Family Medicine. Review of the Delineation of Privileges dated and signed by S29Physician on 06/04/14 revealed S29Physician requested medical and general psychiatry privileges by checking all available medical and psychiatric options. The staff category was not checked (Honorary, Active, Consulting). The form provided a space to check approved and a space to check denied by each privilege listed. The approved/denied spaces were left blank. The signature and date line for the medical director signature was left blank. There was no documented evidence in the credentialing file that the chief medical officer had reviewed and approved/denied the requested privileges. Further review of the credentialing file revealed no documented evidence of any Continuing Medical Education (CME).

In an interview on 07/07/15 at 3:00 p.m., S1Administrator confirmed the delineation of privileges was not signed by the medical director/chief medical officer, and the requested privileges were not documented as approved or denied. S1Administrator confirmed there was no documentation of the applicant's CME in the file.


S28Physician
Review of the credentialing file for S28Physician revealed the physician's specialty was psychiatry. The file revealed a letter dated 12/12/14 signed by S1Administrator indicating the Governing Board appointed S28Physician to the medical staff from 12/12/14 to 12/11/16 as an active member with a specialty in Psychiatry. Review of the Delineation of Privileges dated and signed by S28Physician on 05/01/14 revealed S28Physician requested only consulting privileges under General Psychiatry. The staff category was checked as Consulting. The form provided a space to check approved and a space to check denied by each privilege listed. The approved/denied spaces were left blank. The signature and date line for the medical director signature was left blank. There was no documented evidence in the credentialing file that the chief medical officer had reviewed and approved/denied the requested privileges.


S30APRN (Advanced Practice Registered Nurse)
Review of the credentialing file for S30APRN revealed a letter dated 12/12/14 signed by S1Administrator indicating the Governing Board appointed S30APRN to the medical staff from 12/12/14 to 12/11/16 as an active member with a specialty in Psychiatry. Review of the Delineation of Privileges dated and signed by S30APRN on 09/02/14 revealed S30APRN requested medical and general psychiatry privileges by checking all available medical and psychiatric options. The staff category was checked Active. The form provided a space to check approved and a space to check denied by each privilege listed. The approved/denied spaces were left blank. The signature and date line for the medical director signature was left blank. There was no documented evidence in the credentialing file that the chief medical officer had reviewed and approved/denied the requested privileges.

Based on record reviews, observations, and interviews, the hospital failed to ensure a registered nurse (RN) supervised and evaluated the nursing care of each patient as evidenced by:
1) failing to assess a patient's blood pressure (BP) and pulse prior to administration of antihypertensive medications as required by hospital policy for 1 (#3) of 2 (#3, #10) current inpatient records reviewed for nursing assessments from a sample of 12 patients, and;
2) failing to accurately perform a 24 hour chart check by the RN for 1 (#4) of 1 patient reviewed for 24 hour chart checks. Findings:


1) Failing to assess a patient's blood pressure and pulse prior to administration of antihypertensive medications as required by hospital policy:

Review of the hospital policy titled, Medication Administration, number MM-05 with a reviewed/revised date of March 2015, revealed in part the following: h. Assess and document vital signs and blood sugar values as ordered or indicated prior to the administration of medication. 3. Blood pressure will be obtained and recorded on the MAR (Medication Administration Record) prior to each dose of antihypertensive medication for three days, then every AM (morning) for one week and weekly thereafter, unless otherwise ordered by the licensed prescriber. Notify the licensed prescriber before administering the medication in the event that the BP is below 90/60 or if there is any significant change in blood pressure.

Patient #3

Review of the medical record for Patient #3 revealed the patient was a 67 year old male admitted to the hospital on 07/05/15 with diagnoses of Bipolar Disorder, Major Depressive Affective Disorder with Psychotic Behavior, Dementia with Behavioral Disturbances, and Cocaine Abuse. The patient's medical diagnoses included Chronic Obstructive Pulmonary Disease, Hypertension, Diabetes Mellitus, and Chronic Pain.

Review of the physician's orders dated 07/05/15 at 7:30 a.m. revealed an order for the following Blood Pressure medications:
Clonidine 0.1 mg (milligrams) by mouth 3 times a day
Lisinopril 40 mg by mouth 1 time a day.

Review of the MARs dated 07/05/15 and 07/06/15, and the Graphics Sheet (containing the patient's vital signs), revealed no documented evidence that the nurse assessed the patient's blood pressure and pulse prior to administering the Clonidine and the Lisinopril. Review of the MAR dated 07/07/15 revealed the MAR was pre-printed and contained instructions to record the apical pulse prior to administration of the Clonidine and to check the blood pressure prior to administration of the Lisinopril.

In an interview on 07/08/15 at 2:20 p.m., S2DON (Director of Nursing) reviewed the medical record for Patient #3. She confirmed the nurse failed to document the patient's blood pressure and pulse prior to administering the Clonidine and the Lisinopril for first 2 days the patient was admitted. She stated the nurse should not need a prompt to assess the patient's vital signs before administering medications that affect the blood pressure and pulse.


2) failing to accurately perform a 24 hour chart check by the RN for 1 (#4) of 1 patient reviewed for 24 hour chart checks.

Patient #4
The patient was admitted to the hospital on 07/03/15 with a diagnosis of attempted overdose. Patient #4's initial RN assessment was performed by S17RN on 07/03/15. A review of the Advance Directive Acknowledgement sheet signed by Patient #4 and witnessed by S17RN revealed an incomplete form. The Advance Directive Acknowledgement sheet section labeled, "Please complete the following questions below" : Are you currently an Organ Donor, Have you executed a DNR (Do Not Resuscitate)previously, and Do you wish for a Physician to evaluate and implement a DNR now - was not completed and was left blank. The Advance Directive Acknowledgement sheet section labeled, "Please check one of the following Statements": I have executed an Advance Directive, I have NOT executed an Advance Directive, I have executed a Psychiatric Advance Directive, I have NOT executed a Psychiatric Advance Directive - was not completed and was left blank. A review of Patient #4's "Integrated Treatment Plan - Potential for self-harm" initiated by S17RN revealed the identified problems checked off were: a history of severe depression, self-destructive behavior, and anxiety. The section underneath revealed the RN was to check off how the above problems were "evidenced by." A review of this section revealed no "evidenced by" behaviors were checked off by S17RN. A further review of Patient #4's medical record revealed that a 24 hour chart check audit was documented as being performed on 07/04/15 and 07/05/15 by S17RN.
In an interview on 07/07/15 at 1:30 p.m. with S17RN, she was made aware of the incomplete documentation in Patient #4's medical record and that she, S17RN, was documented as performing the 24 hour chart check audit on 07/04/15 and 07/05/15. S17RN indicated that she discussed the Advance Directive Acknowledgement sheet with Patient #4 and indicated that she must have forgotten to mark it. S17RN indicated that the RNs at night were responsible for the 24 hour medical record chart checks by checking each medical record for completeness and accuracy. S17RN indicated that she performed the 24 hour chart check on Patient #4's medical record on 07/04/15 and again on 07/05/15 and indicated that she must have missed the incomplete documentation.


30172

Based on record review and staff interview, the hospital failed to ensure drugs and biologicals were administered in accordance with physician orders and hospital policy for 1 (#10) of 8 (#1-#4 and #9-#12) current sampled patients reviewed for medication administration.

Findings:

Review of the hospital policy titled, Medication Administration, number MM-05 with a reviewed/revised date of March 2015, revealed in part the following: Medications are administered to patients by qualified personnel in compliance with federal and state laws and standards of professional practice. All medications require an order which is written on the physician's order form and must contain the name of the medication....Document the administration of medication on MAR (Medication Administration Record). All new orders are faxed to the pharmacy and are verified every 24 hours by night shift licensed nurses to ensure accurate transcription to MAR. All medication errors require the completion of a Medication Error Report and proper notification in accordance with established hospital guidelines.


Patient #10
Review of the medical record for Patient #10 revealed the patient was a 46 year old male admitted to the hospital on 07/04/15 at 9:45 p.m. with diagnoses of Schizophrenia and Alcohol Use Disorder. The patient's medical diagnoses included Hypertension, Diabetes Mellitus, Cirrhosis, Hepatitis-C, Seizure Disorder, Hypothyroidism and Alcoholism.

Review of the physician's orders dated 07/06/15 at 3:30 p.m. revealed an order for Thiamine 100 mg (milligrams) by mouth every morning, and Folate 2 mg by mouth every morning.

Review of the MAR dated 07/07/15 revealed no documented evidence that the Thiamine and Folate were transcribed to the MAR or administered to the patient. Review of the MAR dated 07/08/15 revealed both medications were transcribed and administered to the patient on 07/08/15, two days after prescribed by the physician.

Review of the Chart Audit form on Patient #10's record revealed that no 24 chart audit had been documented since 07/07/15. Review of the 07/07/15 audit revealed the MAR was correct to the orders.

In an interview on 07/09/15 at 12:58 p.m., S2DON (Director of Nursing) reviewed the medical record for Patient #10 and confirmed the Thiamine and Folate were not transcribed to the MAR for 07/07/15, and the medications were not given to the patient that day. She confirmed the 24 hour chart check was not done and should have been. She stated the medication error would have been found if the nurse had completed the chart audit. She confirmed this was a medication error, and it had not been identified through the hospital's current process of identification of medication errors.

Based on record reviews and interviews, the hospital failed to implement its Medical Staff By-laws and Rules and Regulations for delinquent medical records as evidenced by the Governing Board administratively closing 403 delinquent medical records that were not completed within 30 days after discharge between the period of November of 2013 and May of 2015 and the physician(s) with delinquent medical records not being suspended of admitting privileges as required by the Medical Staff By-laws and Rules and Regulations

Findings:

Review of the hospital's "Rules and Regulations For The Professional Medical Staff," presented as the current rules and regulations by S1Administrator, revealed the following, in part: "Section 2. Admission and Discharge of Patients, b. Only appropriately licensed of the medical staff shall be responsible for the medical care and treatment of each patient in the hospital, for the prompt completeness and accuracy of the medical record.... 3. Medical Records, a. The attending physician shall be responsible for the preparation of a complete and legible medical record for each patient; d. All clinical entries in the patient's medical record shall be accurately dated, timed and authenticated. Authentication means to establish authorship by written signature of identifiable initials; j. A medical record shall not be permanently filed until it is completed by the responsible physician or is ordered filed by the medical record director; m. Each medical record shall be completed within 30 days after the discharge of the patient or the record becomes delinquent. On a continuous basis, the medical record director shall review incomplete records. At this time, any physician who has any delinquent charts shall be so notified by phone. If the records are still incomplete two weeks after being notified, he shall automatically suffer suspension of admitting privileges. He shall be notified of such suspension in writing by the medical record director. Privileges may be restored by the Chief Medical Officer when he has been notified by the medical record (department) that the delinquent records have been completed."

Further review of the Rules and Regulations for the Professional Medical Staff revealed no documented evidence of a procedure to administratively close incomplete medical records.

Review of a Policy and Procedure entitled, "Authentication Process for Medical Records" with a revision date of 03/15, revealed, in part: "Purpose, To comply with the standards of JCAHO (The Joint Commission)/CMS (Centers for Medicare and Medicaid Services), patient records will be completed within 30 days post-discharge. . . .D. Quantitative Analysis, 3. The Medical Records Coordinator files medical record in incomplete file area for up to 30 days to allow staff to complete all deficiencies. E. Notification to Staff of Deficient Charts, 1. The Medical Records Coordinator notifies staff of deficient charts. 2. The Clinical Staff checks closed medical records in incomplete file area and completes any identified deficiencies indicated. 3. The Medical Record Coordinator files completed, closed medical record in permanent file area."

Review of a Policy and Procedure entitled, "Discharge Summary" with a revision date of 06/15 revealed, in part: "Procedure, D. The facility will complete all necessary audits to determine the completeness of the patient's clinical record within thirty (30) days of the discharge date. Procedure for Closure of Patient Medical Record, Health Information Staff: 1. After all attempts to contact the physician and/or staff to arrange for completion of the medical record has failed (if contacting the physician is applicable), the patient's name, admit, discharge date and medical record number is submitted for approval to the Governing Body. Health Information Management Coordinator: HIM (Health Information Management) submits the chart(s) in need of closure at the next Governing Body for approval to be filed as incomplete. Governing Body: Signs approval of closure. Health Information Staff: Files the chart in the permanent file section of the Health Information Department."

In an interview on 07/08/15 at 1:15 p.m., S9MR (Coordinator) indicated the 59 identified deficient medical records from the survey on 05/21/15 were "administratively closed." When asked what administratively closed meant, she replied administratively closed meant that the medical records were beyond the 30 day deadline for completion of the medical records, so the records were presented to the Governing Board to be administratively closed, meaning no further attempts to get the medical record completed after the 30-day deadline would be made. Once the medical records were administratively closed, the records could be forwarded to permanent storage. She further indicated at the time of the 05/21/15 survey, the 59 records were on a list awaiting approval from the Governing Board to be administratively closed, and after the 05/21/15 survey, her previous supervisor (who is no longer employed at the hospital) went into the medical record system and identified all medical records that were delinquent since the hospital opened, and she printed the list (which consisted of 403 records) to present to the Governing Board for approval to have them administratively closed. S9MR confirmed she was not aware of any physicians who had privileges suspended for delinquent medical records since she has been employed at the hospital.

Review of the list provided by S9MR presented to the Governing Board on 06/16/15, revealed a total of 403 (number of medical records verified by S9MR) delinquent medical records identified for administrative closure starting with the date of 11/14/13. Review of the current log for delinquent medical records began with the date of 05/07/15.

Review of the Governing Board Committee Meeting Minutes dated 06/16/15 revealed, the following, in part: "5) Medical Records; i. Delinquent charts and charts that are 30 days old have been administratively closed. Please refer to Medical records for the list. MR0001 to MR00339." There was no documentation or evidence to indicate that any of the physicians with delinquent medical records were suspended as indicated in the Medical Staff By-laws and Rules and Regulations.

Review of the current "Medical Record Delinquent Detail Report" revealed there were 4 medical records that were delinquent beyond the 30 day deadline from a total of 31 medical records. Further review revealed one medical record was delinquent by 3 days; two by 6 days; and one at 37 days.

In an interview on 07/09/15 at 12:20 p.m., S1Administrator indicated the data for delinquent medical records was forwarded to the PI (Performance Improvement) committee monthly. S1Administrator indicated the previous employee in charge of the medical record department provided incorrect data on the medical record delinquency issues/rates. S1Administrator confirmed the list of the 403 delinquent medical records provided to the surveyor on 07/09/15 by S9MR, was the list of medical records presented to the Governing Board on 06/16/15 for administrative closure due to the medical records being delinquent beyond 30 days. When S1Administrator was asked if he was aware that the procedure in place at the hospital for administratively closing medical records was not correct, he indicated he followed the recommendations of a previous assistant administrator who informed him this was the correct procedure for charts that were not completed within 30 days. S1Administrator confirmed no physicians had privileges suspended at the hospital due to delinquent medical records.

Review of an electronic mail document dated 06/04/15 addressed to S10RHIA (Registered Health Information Administrator) revealed the following, in part: "Attached is my response to Survey (05/21/15). Reviewed and discussed with S9MR and S1Administrator. In reviewing the survey report, A-0438, page 62, states 'Review of the Medical Staff By-laws and Rules and Regulations revealed no documented evidence of a procedure to administratively close incomplete medical records.' In review of the Medical Records Policy and Procedures, I do not see a policy on Administratively Closing a delinquent medical record greater than 30 days post discharge. This needs to be addressed in order to develop a plan of correction. Recommended a policy and procedure on administratively closing chart."

In an interview on 07/07/15 at 2:45 p.m., S10RHIA indicated she was not aware the Governing Board had approved to administratively close 403 delinquent medical records. She also indicated she discussed with S9MR and S1Administrator the process currently practiced at the hospital for administratively closing medical records after a 30 day deadline was not correct, and medical records should only be administratively closed after all attempts had been made to obtain the required documentation to complete the medical record regardless of how long it took to complete the medical record. She further indicated she informed S9MR and S1Administrator if the person(s) who were needed to complete the medical record were no longer available to come to the hospital to complete the medical record, for whatever reason, then it would be appropriate to administratively close a medical record.

Based on record review and interview, the hospital failed to ensure medical records contained a completed and authenticated medical history and physical examination (H&P)within 24 hours of admission for 2 (#2, #10) of 8 (#1-#4 and #9-#12) medical records reviewed in a total sample of 12 as evidenced by:
1) the medical history and physical for 1 (#2) was not authenticated by the licensed practitioner, and;
2) the medical history and physical for 1 (#10) was not completed and available on the medical record within 24 hours of admission. Findings:

Review of the hospital's "Rules and Regulations For The Professional Medical Staff," presented as the current rules and regulations by S1Administrator, revealed the following, in part: "Section 2. Admission and Discharge of Patients, b. Only appropriately licensed of the medical staff shall be responsible for the medical care and treatment of each patient in the hospital, for the prompt completeness and accuracy of the medical record.... 3. Medical Records, a. The attending physician shall be responsible for the preparation of a complete and legible medical record for each patient; b. A complete admission history and physical examination shall be recorded within 24 (twenty-four) hours of patient's admission... d. All clinical entries in the patient's medical record shall be accurately dated, timed and authenticated. Authentication means to establish authorship by written signature of identifiable initials."

1) the medical history and physical for 1 (#2) was not authenticated by the licensed practitioner

Patient #2
A review of the medical record for Patient #2 revealed she was a 48-year-old female admitted to the hospital on 06/30/15 at 5:30 p.m. Diagnoses included Depression, Anxiety, Suicidal Ideations, Hypertension, and Gastroesophageal Reflux Disease (GERD).

Review of Patient #2's medical H&P revealed the H&P was not signed by the physician.

In an interview on 07/07/15 at 12:20 p.m., S2DON (Director of Nursing) confirmed Patient #2's H&P was not signed by the physician and should have been signed by the physician.


2) the medical history and physical for 1 (#10) was not completed and available on the medical record within 24 hours of admission.

Patient #10
Review of the medical record for Patient #10 revealed the patient was a 46 year old male admitted to the hospital on 07/04/15 at 9:45 p.m. with diagnoses of Schizophrenia and Alcohol Use Disorder. The patient's medical diagnoses included Hypertension, Diabetes Mellitus, Cirrhosis, Hepatitis-C, Seizure Disorder, Hypothyroidism and Alcoholism.
Review of the record revealed an H&P was documented by S12Physician on 07/06/15 at 8:30 a.m., over 34 hours after admission.
In an interview on 07/09/15 at 12:58 p.m., S2DON reviewed the record for Patient#10 and confirmed the H&P was not done by S12Physician within 24 hours of admission.

Based on observations, interviews, and record reviews, the hospital failed to ensure that the Dietary Services Department assured dietary competency for the MHTs (Mental Health Technicians) who were assigned dietary assignments as evidenced by no documented in-services or skills competency checklist in 4 of 4 MHTs (S6MHT, S8MHT, S24MHT, S25MHT) employee files reviewed for dietary competency, and the hospital failed to ensure that the Dietary Service Department developed and implemented guidelines for acceptable hygiene practices for the food service personnel or guidelines to address kitchen sanitation and safety precautions as evidenced by no documented policy(s) in place.
Findings:
A review of the hospital's Policy and Procedure Manual on the hospital's internet, as indicated by S1Administrator as the most current and complete, revealed a policy entitled, "Dietary Services." The "Dietary Services" policy revealed in part: The patient's meals will be provided by the contracted Dietary Service. The nursing staff will check the trays to assure delivery of the appropriate diets to each patient. The nursing staff will measure the temperatures of "test food trays" to assure appropriate temperatures. A further review of the hospital's Policy and Procedure Manual on the hospital's internet revealed no Dietary Service policy that addressed guidelines for acceptable hygiene practices for the food service personnel or guidelines to address kitchen sanitation and safety precautions.
An observation on 07/06/15 at 4:00 p.m. with S3ADON, in the patient dining room/kitchen area of the patient refrigerator revealed the following: over 30 juices (4 ounce) that were available for patient use that had no expiration dates on them and over 30 individual butter and jelly containers that had no expiration dates on them.
In an interview on 07/06/15 at 4:05 p.m. with S3ADON (Assistant Director of Nursing), she indicated that she was the Infection Control Officer and the Dietary Manager. S3ADON was asked about the over 30 juices (4-ounce) that were available for patient use that had no expiration dates on them and the over 30 individual butter and jelly containers that had no expiration dates on them. S3ADON indicated that the staff, MHTs (Mental Health Technicians) would save the unused individual butters and jellies from the patient trays in case a patient wanted extra butter or jelly. S3ADON further indicated that she was not aware that the juices and the individual butters and jellies did not have expiration dates on them.
An observation on 07/09/15 at 11:30 a.m. of the patient lunch meal, revealed that the hospital's MHTs received the patient lunch meals from the contracted Dietary Service and distributed the meals to the patients in the patient dining/kitchen area. The MHTs were observed obtaining juice and milk containers from the patient refrigerator located in the patient dining/kitchen area and distributing them to the patients.
In an interview on 07/09/15 at 1:50 p.m. with S6MHT, he indicated that the MHTs were responsible for distributing the patient meal trays and distributing the patient juice and milks containers. S6MHT further indicated that the MHTs checked the patient's meal tray dietary card to assure each patient received the correct meal tray. S6MHT was asked if he was in-serviced on acceptable dietary hygiene practices and kitchen sanitation. S6MHT indicated that he remembered being told to make sure the patients washed their hands before eating and to provide the patients with plastic utensils. S6MHT was not sure about a formal in-service or a skills competency checklist for the MHTs dietary assignments.
In a review of the employee files for 4 of 4 MHTs (S6MHT, S8MHT, S24MHT, S25MHT), there was no documented evidence of a dietary skills competency checklists regarding the MHTs dietary assignments.
In an interview on 07/09/15 at 2:30 p.m. with S3ADON, she indicated that she was the Infection Control Officer and the Dietary Manager for the hospital. S3ADON was asked about the MHTs dietary assignments and their skills competency checklist. S3ADON indicated that the MHTs were responsible for distributing the patient meal trays and assuring the patients received the correct meal tray, as well as, distributing the patient beverage selections for each meal. S3ADON indicated that she had not developed or implemented a skills competency checklist for the MHTs regarding their dietary assignments nor was there a dietary skills competency checklist in place. S3ADON was asked for the Dietary Service policy(s) that addressed guidelines for acceptable hygiene practices for the food service personnel or guidelines to address kitchen sanitation and safety precautions. S3ADON indicated that there were no Dietary Service policy(s) that addressed guidelines for acceptable hygiene practices for the food service personnel or guidelines to address kitchen sanitation and safety precautions.

Based on record review and interview, the hospital failed to ensure the Utilization Review Committee members consisted of at least two (2) members who were doctors of medicine or osteopathy. Findings:
Interview on 07/8/15 at 9:10 a.m. with S4QA (Quality Assurance) revealed that he had only been over UR (Utilization Review) since 06/01/15. He further stated that there were no UR minutes available. The previous staff member over UR no longer worked at the hospital, and all minutes were on the computer that was password locked. S4QA later gave surveyor copies of the PIC (Performance Improvement Committee) meeting minutes dated 06/08/15, and stated that the PIC members were the same members for the UR Committee.
Interview on 07/09/2015 at 12:45 p.m. with S2DON verified that there was no hospital policy for Utilization Review. S2DON stated that the hospital followed "Plan For Utilization Review" according to 42 CFR 482.30 CoP: Utilization Review, III. Utilization Committee, A. Membership. The UR Committee must consist of two or more practitioners...C. Conflict of Interest, No member of the Committee may participate in the review of any case being reviewed if he/she has been or currently is directly responsible for the care or treatment provided.
Interview on 07/08/15 at 10:00 a.m. with S1Administrator confirmed the PIC Committee members were the same members for the UR Committee and consisted of: S1Administrator, S18APRN (Advanced Practice Registered Nurse), S2DON (Director of Nursing), S4QA, S9MR (Medical Records Coordinator), and S3ADON (Assistant Director of Nursing). S1Administrator verified that the UR Committee did not include 2 members who were doctors of medicine or osteopathy.

Based on record review and staff interview, the hospital failed to ensure the Utilization Review (UR) committee carried out its responsibilities to monitor the medical necessity for Medicare and Medicaid patients. This deficient practice was evidenced by the UR committee failing to review admission records for May and June of 2015. Findings:

Interview on 07/08/15 at 9:10 a.m. with S4QA (Quality Assurance), revealed that he had only been over UR since 06/01/15. S4QA further stated that there were no UR minutes available. The staff member previously over UR no longer worked at the hospital, and all minutes were on the computer that was password locked. S4QA later gave surveyor a binder that contained UR documents for the months of January 2015, February 2015, March 2015, and April 2015. S4QA confirmed that there was no documentation for May 2015 and June 2015. S4QA presented surveyor with the PIC meeting minutes dated 06/03/15 which had UR under the agenda items for the meeting, but there was no documentation in the space.
Interview on 07/08/15 at 10:00 a.m. with S1Administrator confirmed that there had been no UR documentation for review of services for May 2015 and June 2015.

Based on observation, record review and staff interview, the hospital failed to ensure supplies and patient equipment were maintained to ensure an acceptable level of safety and quality as evidenced by:
1) Failing to ensure expired sterile supplies were removed and not available for use, and;
2) Failing to ensure a system was in place to ensure all patient care equipment was inspected and tested for performance and safety.

Findings:

1) Failing to ensure expired sterile supplies were removed and not available for use:

Review of the hospital policy titled, Expiration and Rotation of Supplies and Medications, reviewed and revised March, 2015, revealed in part the following: All supplies and medications will be rotated and monitored for expiration dates. Items are to be discarded when the date shown on packaging is reached....On a continual basis the IC (Infection Control) Nurse will do visual checks in the storage and supply areas.

On 07/06/15 at 4:10 p.m., an observation was made of the emergency (crash) cart for the in-patient unit. Three (3) naso-pharyngeal suction kits were observed on the crash cart. All 3 suction kits had an expiration date of April, 2015. S2DON (Director of Nursing) was present for the observation and confirmed the suction kits had expired in April and should have been removed from the cart so they were not available for patient use. S2DON confirmed these were the only suction kits available in the hospital.

On 07/06/15 at 4:30 p.m., an observation was made of the hospital's supply room with S2DON. Three (3) Foley Catheter drainage bags were observed to have expiration dates of May, 2014. One (1) Foley Catheter insertion tray was observed to have an expiration date of January, 2014. S2DON confirmed the Foley Catheter supplies were expired and should have been removed from the supply room so they were not available for patient use.


2) Failing to ensure a system was in place to ensure all patient care equipment was inspected and tested for performance and safety:

Review of the hospital's policy and procedure manual revealed no documentation of a policy related to bio-medical inspection of patient care equipment.

Review of the hospital's contract binder revealed no documented evidence of a written agreement for bio-medical inspection of patient care equipment.

On 07/06/15 at 4:10 p.m., an observation was made of the emergency (crash) cart for the in-patient unit with S2DON. A suction machine was observed on top of the crash cart. There was no evidence on the suction machine of a bio-medical inspection, nor was there any evidence of any type of inspection done on this suction machine. An AED (Automatic External Defibrillator) was observed on top of the crash cart. There was no evidence on the AED of a bio-medical inspection, nor was there any evidence of any type of inspection done on the AED. Also observed in this room (treatment/exam room) was a standing electronic blood pressure/thermometer. In the basket of the blood pressure machine was another hand -held digital thermometer. S2DON stated the thermometer that was in the standing blood pressure machine did not work, so the staff used the hand-held digital thermometer to assess the patients' temperature. Observation of the electric blood pressure machine and the hand-held digital thermometer revealed no evidence of a bio-medical inspection or any other type of inspection. S2DON confirmed there was no evidence of bio-medical inspections this patient care equipment and stated she did not know how the hospital ensure the patient care equipment was inspected.

On 07/06/15 at 4:30 p.m., an observation was made of the hospital's supply room with S2DON. 1 Hoyer Lift, 2 oxygen concentrators and 1 suction machine were observed in the supply room. There was no evidence any type of inspection of this patient care equipment for safety and quality. An observation of 1 of the oxygen concentrators revealed an inspection sticker that indicated the equipment was due for inspection in 2005. S2DON confirmed the observations. The hospital's documentation of bio-medical inspection of patient care equipment was requested for review, along with any policies & procedures.

In an interview on 07/08/15 at 12:30 p.m. S1Administrator stated the hospital's patient care equipment was all leased. The hospital's documentation of bio-medical inspection of patient care equipment was requested for review. He stated, " They came yesterday. " Documentation of any bio-medical inspections done prior to yesterday were requested for review.

In an interview on 07/09/15 at 10:20 a.m., S2DON stated she was unable to find any policies or procedures related to bio-medical inspection of patient care equipment.

On 07/09/15 at 5:00 p.m., at the end of the survey, there was no documentation of bio-medical inspections of patient care equipment provided for review.

Based on observations, interviews, and record reviews, the hospital failed to ensure the Infection Control Program maintained an effective system for identifying, reporting, investigating, and controlling of infections and communicable diseases of patients and personnel, as evidenced by:
1) failing to ensure environmental cleaning of patient rooms followed hospital policy and acceptable infection control practices,
2) failing to ensure that staff followed hospital policy for accu-check testing,
3) failing to ensure that staff followed acceptable standards of infection control practices for wound care,
4) failing to ensure that dietary food items for patient use were identified with expiration dates,
5) failing to ensure that patient supplies available for patient use were labeled and dated when opened and that single use only items were discarded when opened, and
6) failing to ensure that the Infection Control Program and the Infection Control Committee adhered to the surveillance monitoring activities set forth in the Infection Control Plan/Program as evidenced by incomplete surveillance monitoring activity documentation
Findings:
1) failing to ensure environmental cleaning of patient rooms followed hospital policy and acceptable infection control practices
A review of the hospital's Policy and Procedure Manual on the hospital's internet, as indicated by S1Administrator, as the most current and complete, revealed a policy titled, "Housekeeping Cleaning Schedule." A review of the "Housekeeping Cleaning Schedule" policy revealed a list of various housekeeping tasks and the frequency of when each housekeeping/environmental cleaning task would be performed. A further review of the hospital's Policy and Procedure Manual on the hospital's internet revealed no policies describing the cleaning protocols to be followed by housekeeping during the environmental cleaning by the housekeeping staff.
An observation on 07/07/15 from 10:30 a.m. to 11:00 a.m. was made of S14Hker (Housekeeper) performing terminal cleaning of a patient room after the patient was discharged from the room. S14Hker was observed spraying the disinfectant cleaner over the entire bed, mattress, night stand, and cabinet. The disinfectant spray was noted to settle onto the floor and the floor was very slippery when the surveyor walked to the other side of the room. S14Hker was observed using a pink patient wash basin that she filled with water from the patient's bathroom sink faucet, and she was observed using the water in the basin to rinse all the sprayed items with the water and a clean rag that she had previously sprayed with the disinfectant. After rinsing all the above items, she cleaned the toilet bowl with "comet" cleaner and a non-disposable toilet brush. S14Hker then sprayed the toilet itself and rinsed and dried it. S14Hker was next observed using a paper towel to wipe dry the bed and furniture (previously sprayed), and then she returned to the bathroom to spray, rinse and dry the bathroom sink and vanity. S14Hker then mopped the bedroom floor. S14Hker was further observed frequently empting the water from the pink patient wash basin into the patient's bathroom toilet, cleaning the basin and filling it up with more water several times as she moved from area to area in the patient's room. S14Hker was observed obtaining various supplies from her housekeeping cart which she locked and unlocked each time she went into it. S14Hker was observed getting the keys from her pocket to lock and unlock the housekeeping cart each time. S14Hker was not observed changing her gloves during this entire process.
In an interview on 07/07/15 at 11:00 a.m. with S14Hker, she indicated that she was a contracted employee, and she had been the housekeeper for the hospital for over a year. The manufacturer's instructions on the EPA disinfectant used by S14Hker, was reviewed with S14Hker. The manufacturer's instructions revealed the following: spray area to be disinfected with the EPA disinfectant and allow 3 minutes of contact time. Areas disinfected can be wiped with a soft dry cloth after 3 minutes if still visibly wet. In a kitchen area, the areas treated with the EPA disinfectant can be rinsed as needed and dried after 3 minutes of contact time. S14Hker indicated that she uses a lot of spray and she liked to rinse the areas with a wet rag before drying. S14Hker was asked about her other housekeeping practices: the use of the pink patient wash basin; going back and forth from bedroom to bathroom when cleaning; using "comet" cleaner in the bathroom toilet bowl with a non-disposable toilet brush; and not changing her gloves between clean and dirty tasks. S14Hker indicated that her supervisor at the contract agency gives her the pink patient wash basin to use on her cart and that she (S14Hker) uses it for all the patient rooms until it gets "old" and then she replaces it. S14Hker indicated that she changes her gloves between patient rooms and that she usually cleaned the patient bathrooms last, but she had forgot to clean the bathroom sink, so she went back to do the sink. S14Hker was asked if the "comet" and the use of a non-disposable toilet brush were approved by the Infection Control nurse. S14Hker indicated that she was not sure. S14Hker was asked if she followed written infection control housekeeper protocols for the cleaning of patient rooms. S14Hker indicated that she follows the same cleaning routine, and that she thought her supervisor at the contract agency had a written policy. S14Hker indicated that she was not aware of one at the hospital. S14Hker further indicated that she was instructed to always keep her housekeeping cart locked when unattended, but she locks it each time as an extra precaution even though it was not unattended and in the patient room with her and there were no patients present. S14Hker indicated that she had recently had an infection control in-service with one of the infection control nurses and one of them went over housekeeper cleaning protocols with her. S14Hker further indicated that she did not remember if one of the nurses observed her doing housekeeping cleaning of a patient room.
In an interview on 07/07/15 at 2:30 p.m. with S3ADON (Assistant Director of Nursing) and S11CIC (Certified Infection Control Officer), they were made aware of the S14Hker practices. S11CIC indicated that she reviewed acceptable infection control practices with S14Hker. S11CIC indicated that S3ADON was to monitor S14Hker for non-compliance.

2) failing to ensure that staff followed hospital policy for accu-check testing
A review of the hospital policy, entitled, "Disinfection of the Glucometer" dated June 2015, revealed in part: The glucometer is disinfected prior to use, between each patient use, and prior to storage in the medication room to prevent cross contamination. Obtain glucometer and gather all testing supplies. Place supplies and glucometer on a clean surface where testing will occur. Wipe glucometer and work surface by saturating it with the approved disinfectant wipe. Leave the glucometer on the clean surface until Kill Time (one minute) is reached. After testing is complete, the glucometer and the work surface are cleaned and saturated again with the approved disinfectant wipe, allowing the disinfectant to remain on the surfaces until Kill Time (one minute) is reached.
An observation on 07/07/15 at 4:30 p.m. was made of S13LPN (Licensed Practical Nurse)performing an accu-check on Patient #3 with a multiple use hand-held glucometer. S13LPN was not observed wiping the work surface prior to placing the glucometer on it. S13LPN was observed donning small disposable gloves that tore several times before the patient's testing began, and she had to repeat the gloving process each time. S13LPN was not observed wiping the work surface with the approved disinfectant wipe after the testing was completed.
In an interview on 07/07/15 at 4:50 p.m. with S13LPN, she was asked about the glucometer policy. S13LPN indicated that she was not aware that she had to disinfect the work surface area if she used a paper towel on the work surface. S13LPN indicated that the small gloves were too small and they tore frequently. S13LPN further indicated that the hospital did not have medium gloves available, and the large gloves were too big for her hands and would fall off.
An observation on 07/08/15 at 10:50 a.m. was made of S20LPN performing an accu-check on Patient #3 with a multiple use hand-held glucometer. S20LPN was observed using a hallway table furniture top as her work surface. S20LPN was not observed wiping the work surface prior to placing the glucometer on it. S20LPN was not observed disinfecting the glucometer prior to use as per hospital policy. S20LPN was observed donning small disposable gloves that tore prior to the patient's accu-check testing, and she had to repeat the gloving process. S20LPN was not observed wiping the work surface with the approved disinfectant wipe after the testing was completed.
In an interview on 07/08/15 at 11:00 a.m. with S20LPN, the hospital's glucometer policy was reviewed with her. S20LPN indicated that she was not aware that the policy indicated that she had to disinfect the glucometer before use or that she had to disinfect the work surface area. S20LPN indicated that she probably should not have used a furniture table top in the hallway as her work surface. S20LPN indicated that the small gloves were too small, and they tore frequently. S20LPN further indicated that the hospital did not have medium gloves available, and the large gloves were too big for her hands and would fall off.

3) failing to ensure that staff followed acceptable standards of infection control practices for wound care
An observation on 07/08/15 at 10:10 a.m. was made of S20LPN performing wound care on Patient #2. Patient #2 had a self-inflicted wound on her left wrist with sutures. Daily wound care was ordered by the physician. S20LPN was observed donning small disposable gloves that tore prior to the wound care beginning and twice during wound care, and she (S20LPN) had to repeat the gloving process each time. S20LPN was not observed changing her soiled gloves after she cleansed the wound and prior to applying a new sterile dressing onto the wound site. During re-dressing of the patient's wound, S20LPN was observed using the sterile packaged kerlix roll that she had previously dropped on the floor. S20LPN was not observed washing/sanitizing her hands immediately after removing her gloves when the wound care was completed. S20LPN returned the wound care supply container back to the nurse's desk and put it away before washing her hands.
In an interview on 07/08/15 at 11:00 a.m. with S20LPN, S20LPN was asked about her wound care protocols. S20LPN indicated that she should have washed/sanitized her hands after cleansing the patient's wound and prior to applying a new sterile dressing. S20LPN indicated that she probably should not have used the sterile packaged kerlix roll after it dropped onto the floor and should have gotten another one to use for Patient #2's wound care. S20LPN indicated that the hospital did not have medium gloves available, and the large gloves were too big for her hands and would fall off.
In an interview on 07/08/15 at 12:30 p.m. with S3ADON and S11CIC, they were made aware of the accu-check and the wound care infection control breaches identified upon observations. S11CIC indicated that she in-serviced all the staff on acceptable infection control practices. S11CIC indicated that S3ADON was to monitor staff through surveillance monitoring for non-compliance and infection control breaches.

4) failing to ensure that dietary food items for patient use were identified with expiration dates
An observation on 07/06/15 at 4:00 p.m. with S3ADON in the patient dining room/kitchen area of the patient refrigerator revealed the following: over 30 juices (4-ounce) that were available for patient use that had no expiration date on them and over 30 individual butter and jelly containers that had no expiration dates on them.
In an interview on 07/06/15 at 4:05 p.m. with S3ADON, she indicated that she was the Infection Control Officer and the Dietary Manager. S3ADON was asked about the over 30 juices (4-ounce) that were available for patient use that had no expiration date on them and the over 30 individual butter and jelly containers that had no expiration dates on them. S3ADON indicated that the staff, MHTs (Mental Health Technicians), would save the unused individual butters and jellies from the patient trays in case a patient wanted extra butter or jelly. S3ADON further indicated that she was not aware that the juices and the individual butters and jellies did not have expiration dates on them.

5) failing to ensure that patient supplies available for patient use were labeled and dated when opened and that single use only items were discarded when opened
An observation on 07/06/15 at 3:30 p.m. of the wound care supply container in the nurse's Medication Room revealed the following: an 8 ounce bottle of betadine solution that was opened and not labeled or dated; a bottle of 2-inch iodoform gauze labeled as single patient use only that had been opened and was available in the wound care supply container; and a 16 ounce bottle of lubricating skin lotion that was opened and not labeled or dated. An observation of the medication cart in the nurse's Medication Room revealed a 10 ml (milliliter) bottle of sterile water, for single patient use, that had been opened and was available on the medication cart.
In an interview on 07/06/15 at 3:45 p.m. with S5LPN, she was asked about the 10 ml bottle of sterile water, for single patient use, which had been opened and was available on the medication cart. S5LPN indicated that she used the 10 ml bottle of sterile water to dilute a patient's medication earlier that morning and saved it since she did not use all 10 ml. S5LPN indicated that she did not notice that it was for single use only.
In an interview on 07/06/15 at 3:50 p.m. with S3ADON, she was asked about the 10 ml bottle of sterile water, for single patient use, that had been opened and was available on the medication cart and about the opened and unlabeled supplies available for patient use in the wound care supply container. S3ADON indicated that this was not acceptable infection control practices.

6) failing to ensure that the Infection Control Program and the Infection Control Committee adhered to the surveillance monitoring activities set forth in the Infection Control Plan/Program as evidenced by incomplete surveillance monitoring activity documentation
A review of the Governing Body (GB) meeting minutes dated 06/01/15 and provided by S1Administrator, revealed in part: The GB reviewed and approved the Infection Control Policy/Plan. S3ADON was approved as the designated Infection Control Officer. The GB appointed an Infection Control Committee that included S1Administrator, S2DON, and S3ADON as members.
A review of the Infection Control Program's surveillance monitoring activities and data collection, provided by S3ADON as the complete surveillance monitoring activities and data collection from 06/01/15 to present, revealed in part:
The Basic Disinfection Monitoring Audit Tool had 8 (eight) indicators to be observed. The dates of observations were 06/20/15, 06/22/15, 06/27/15 and 06/29/15. There were only 3 (three) staff that were observed in those 4 (four) days, and they were observed in only 2 - 4 of the indicators. The other indicators were blank.
The Hand Hygiene Monitoring Audit Tool had 11 (eleven) indicators to be observed. The dates of observations were 06/20/15, 06/22/15, 06/25/15 and 06/27/15. There were 4 (four) staff that were observed on 06/20/15 and 06/22/15; 1 (one) staff on 06/25/15; and 3 (three) staff on 06/27/15. There was no documented evidence of physicians or contract staff observations. Only 1 (one) of the Hand Hygiene Monitoring Audit Tools, dated 06/20/15, had a mark by all of the indicators for each staff observed. Many indicators on the Hand Hygiene Monitoring Audit Tool sheets were blank for several of the indicators.
The EOC (Environment of Care) Inspection Monitoring Audit Tool had 22 (twenty-two) indicators to be observed. The dates of observations were 06/20/15 and 06/22/15. There were no indicators on the EOC Audit Tool that indicated that housekeeping cleaning infection control practices were being monitored as recommended by S11CIC (Certified Infection Control Officer).
In an interview on 07/08/15 at 9:30 a.m. with S11CIC, she indicated that she was the Infection Control Consultant for the hospital, and that she signed her contract with the hospital on 06/05/15. S11CIC indicated that she was to assist the hospital and the Infection Control Officer, S3ADON (Assistant Director of Nursing) with the hospital's infection control issues and to educate S3ADON in infection control. S11CIC was asked about the in-services that she conducted with the staff and the contract housekeeper regarding acceptable infection control practices. S11CIC indicated that she conducted several meetings with S1Administrator, S2DON, and S3ADON regarding the hospital's identified infection control breaches following the DHH (Department of Health and Hospitals) survey to include in part: risk assessments, hand hygiene compliance, isolation precautions, evaluations and approval of appropriate disinfectants and appropriate disinfectant practices, and inconsistent infection control monitoring. S11CIC indicated that she conducted various in-services with all the staff, S14Hker, and the housekeeping contract supervisor. S11CIC further indicated that she monitored S14Hker during her patient room cleaning practices and addressed her infection control practices. S11CIC indicated that her recommendations to S1Administrator, S2DON and S3ADON included in part: ongoing monitoring of the identified infection control breaches for compliance, facility surveillance through environmental rounds, continued monitoring of the disinfection practices of the contract housekeepers, monitoring of the facility daily by the Infection Control Officer (S3ADON) to identify corrective actions needed and high risk areas.
In an interview on 07/09/15 at 11:00 a.m. with S3ADON she indicated that she was the designated Infection Control Officer and that the hospital also had contracted with an Infection Control Consultant, S11CIC. S3ADON was asked about the time she spent in the hospital doing infection control activities. S3ADON indicated that she was designated as the Infection Control Officer on 06/01/15 by the Governing Body and the Infection Control Consultant's first day was on 06/08/15. S3ADON indicated that she was still on the nursing staffing schedule sheets and was assigned patient care 2-3 days a week after 06/01/15. S3ADON indicated that she performed infection control activities on the days when she was not assigned patient care. S3ADON was asked for her Infection Control activities from 06/01/15 to present, to include her surveillance monitoring activities, her data collection, and her Infection Control Committee meeting minutes. S3ADON presented The Basic Disinfection Monitoring Audit Tool, The Hand Hygiene Monitoring Audit Tool, and The EOC Inspection Monitoring Audit Tool reports which were reviewed with S3ADON. S3ADON was asked about the 3 (three) Audit Tool's and the indicators that were blank. S3ADON indicated that if she was unable to observe an opportunity on the day she was assigned infection control activities that she left the indicators blank. S3ADON further indicated that she has had no Infection Control Committee meetings or minutes and that the Infection Control Committee had not presented any Infection Control Reports to the Governing Body.
In an interview on 07/09/15 at 11:30 a.m. with S1Administrator, S2DON, and S3ADON, S1Administrator indicated that he was a member of the hospital's Governing Body. The Infection Control Program's incomplete surveillance monitoring activities for the month of June, 2015 and July, 2015 were reviewed. S1Administrator indicated that the hospital had been in chaos since the prior DHH survey, and the hospital was having difficulty overcoming obstacles. S1Administrator indicated that the Infection Control Program was functioning through January, 2015. S1Administrator indicated that prior Infection Control officers (since January 2015) were not "doing their job." S1Administrator further indicated that the Governing Body did not realize the "fallout" until early May, 2015, that the Infection Control Department was not performing its duties.

25119

Based on record review, and interview the hospital failed to ensure the discharge plan evaluation was initiated upon admission per hospital policy for 6 of 6 (#1, #5, #6, #7, #8, #9) records reviewed for discharge planning out of a total sample of 12 (#1-#12). Findings:
Review of the hospital policy titled Discharge Planning, August 2013, revealed in part: Policy: It is the policy at Kalio Behavioral Hospital that discharge planning begins upon admission to any program. Tentative discharge plans are established and reviewed and modified or performed throughout treatment. Procedure: -At the time of admission, risks for discharge are identified. -Treatment team updates/post discharge plans are updated as assessments are completed and treatment progresses.
1. Record review on 07/07/2015 revealed Patient #1 was an active patient and was admitted to the hospital on 06/27/2015 with an admitting diagnosis of Schizophrenia. Other diagnoses included Hypertension, Hepatitis C, and Ca (Cancer) of Lung.
Review of the Psychiatric Evaluation dated 06/28/15 revealed a section titled, Tentative Discharge Plan/Criteria, with check-off boxes labeled: sustained absence of SI/HI (Suicidal Ideations/Homicidal Ideations), improved mood, and accepting need for treatment, and did not include a complete evaluation to assess the patient's capacity for self-care or environmental factors.
Review of the Multidisciplinary Integrated Treatment Plan dated for 07/02/15 revealed a section titled, Tentative Discharge Plan and Discharge Criteria, were blank.

2. Record review on 07/07/15 revealed Patient #5 was admitted to the hospital on 06/08/15 with an admitting diagnosis of Bipolar/Depression and discharged on 06/18/15. Other diagnoses included Psychosis.
Review of the Psychiatric Evaluation dated 06/09/15 revealed a section titled, Tentative Discharge Plan/Criteria, with check-off boxes labeled: sustained absence of SI/HI, improved mood, and accepting need for treatment, and did not include a complete evaluation to assess the patient's capacity for self-care or environmental factors.
Review of the Multidisciplinary Integrated Treatment Plan dated for 06/10/15 revealed a section titled, Tentative Discharge Plan and Discharge Criteria, were blank.

3. Record review on 07/07/2015 revealed Patient #6 was admitted to the hospital on 04/14/15 with an admitting diagnosis of Bipolar and severe Psychosis and was discharged on 04/20/15.
Review of the Psychiatric Evaluation dated 04/15/15 revealed a section titled, Tentative Discharge Plan/Criteria, with check-off boxes labeled: sustained absence of SI/HI, improved mood, and accepting need for treatment, and did not include a complete evaluation to assess the patient's capacity for self-care or environmental factors.
Review of the Multidisciplinary Integrated Treatment Plan dated for 04/17/15 revealed a section titled, Tentative Discharge Plan and Discharge Criteria, were blank.

4. Record review on 07/07/2015 revealed Patient #7 was admitted to the hospital on 05/27/15 with an admitting diagnosis of Bipolar, Depression, and Psychosis and was discharged on 06/18/15.
Review of the Psychiatric Evaluation dated 05/28/15 revealed a section titled, Tentative Discharge Plan/Criteria, with check-off boxes labeled: sustained absence of SI/HI, improved mood, and accepting need for treatment, and did not include a complete evaluation to assess the patient's capacity for self-care or environmental factors.
Review of the Multidisciplinary Integrated Treatment Plan dated for 05/29/15 revealed a section titled, Tentative Discharge Plan and Discharge Criteria, were blank.

5. Record review on 07/07/15 revealed Patient #8 was admitted to the hospital on 04/28/15 with an admitting diagnosis of Senile Dementia with Behavioral Disturbances and discharged on 05/08/15.
Review of the Psychiatric Evaluation dated 04/30/15 revealed a section titled, Tentative Discharge Plan/Criteria, with check-off boxes labeled: sustained absence of SI/HI, improved mood, and accepting need for treatment, and did not include a complete evaluation to assess the patient's capacity for self-care or environmental factors.
Review of the Multidisciplinary Integrated Treatment Plan dated for 04/30/15 revealed a section titled, Tentative Discharge Plan and Discharge Criteria, were blank.

6. Record review on 070/7/15 revealed Patient #9 was an active patient and was admitted to the hospital on 07/02/15 with an admitting diagnosis of Bipolar, Manic, moderate.
Review of the Psychiatric Evaluation dated 07/03/15 revealed a section titled, Tentative Discharge Plan/Criteria, with check-off boxes labeled: sustained absence of SI/HI, improved mood, and accepting need for treatment, and did not include a complete evaluation to assess the patient's capacity for self-care or environmental factors.
Review of the Multidisciplinary Integrated Treatment Plan dated for 07/02/15 revealed a section titled, Tentative Discharge Plan and Discharge Criteria, were blank.
Interview on 07/07/15 at 10:00 a.m. with S7D/C (Discharge) Planner revealed that this was only her second day as D/C Planner. She further stated that she was not sure what forms or what the process was for D/C Planning at the hospital.

Interview on 07/08/15 at 3:25 p.m. with S9MR (Medical Records Coordinator) revealed the discharge records (#5, #6, #7, #8) were completed charts. S9MR stated that the only documents she was aware of in the record for discharge planning were the Discharge Physicians Orders, Discharge Medicine Sheet, and the Discharge Summary.

Interview on 07/09/15 at 9:30 a.m. with S2DON (Director of Nursing) verified that the D/C Planning process should begin on admission. She further stated that she was not familiar with the forms or the documentation for D/C Planning in the medical records because she had only been at the hospital a couple of weeks.

Interview on 07/09/15 at 10:15 a.m. with S22LCSW (Licensed Clinical Social Worker) revealed the D/C Planning process begins on admission. The patient information is obtained on admission where the patient is to be discharged and documented on the Psychosocial Assessment which is a check-off list. S22LCSW further stated that he writes a summary note on discharge on the discharge summary.

25119

Based on record review, and interview the hospital failed to ensure each patient received a discharge planning evaluation in the medical record to guide the development of the patient's discharge plan for 4 of 4 (#1, #9, #3, #10) active records reviewed for Discharge Planning out of a total of 8 active patient records reviewed. Findings:
Review of the hospital policy titled Discharge Planning, August 2013, revealed in part: Policy: It is the policy at Kalio Behavioral Hospital that discharge planning begins upon admission to any program. Tentative discharge plans are established and reviewed and modified or performed throughout treatment. Procedure: -At the time of admission, risks for discharge are identified. -Treatment team updates/post discharge plans are updated as assessments are completed and treatment progresses.

1. Record review on 07/07/15 revealed Patient #1 was admitted to the hospital on 06/27/15 with an admitting diagnosis of Schizophrenia. Other diagnoses included Hypertension, Hepatitis C, and Ca (Cancer) of Lung.
Review of the Psychiatric Evaluation dated 06/28/15 revealed a section titled, Tentative Discharge Plan/Criteria, with check-off boxes labeled: sustained absence of SI/HI (Suicidal Ideations/Homicidal Ideations), improved mood, and accepting need for treatment, and did not include a complete evaluation to assess the patient's capacity for self-care or environmental factors.
Review of the Multidisciplinary Integrated Treatment Plan dated for 07/02/15 revealed a section titled, Tentative Discharge Plan and Discharge Criteria, were blank.

2. Record review on 07/07/15 revealed Patient #9 was admitted to the hospital on 07/02/15 with an admitting diagnosis of Bipolar, Manic moderate.
Review of the Psychiatric Evaluation dated 07/03/15 revealed a section titled, Tentative Discharge Plan/Criteria, with check-off boxes labeled: sustained absence of SI/HI, improved mood, and accepting need for treatment, and did not include a complete evaluation to assess the patient's capacity for self-care or environmental factors.
Review of the Multidisciplinary Integrated Treatment Plan dated for 07/02/2015 revealed section titled Tentative Discharge Plan and Discharge Criteria were blank.
Interview on 07/07/15 at 10:00 a.m. with S7D/C (Discharge) Planner revealed that this was only her second day as D/C Planner. She further stated that she was not sure what forms or what the process was for D/C Planning at the hospital.
Interview on 07/09/15 at 9:30 a.m. with S2DON (Director of Nursing) verified that the D/C Planning process should begin on admission. She further stated that she was not familiar with the forms or the documentation for D/C Planning in the medical records because she had only been at the hospital a couple of weeks.
Interview on 07/09/15 at 10:15 a.m. with S22LCSW (Licensed Clinical Social Worker) revealed the D/C Planning process begins on admission. The patient information is obtained on admission where the patient is to be discharged and documented on the Psychosocial Assessment which is a check-off list. S22LCSW further stated that he writes a summary note on discharge on the discharge summary.

3. Review of the medical record for Patient #3 revealed the patient was a 67 year old male re-admitted to the hospital on 07/05/15 with a diagnosis of Bipolar Disorder. Review of the psychiatric evaluation dated 07/06/15 revealed the patient's diagnoses were Major Depressive Affective Disorder with Psychotic Behavior, Dementia with Behavioral Disturbances, and Cocaine Abuse. The record revealed the patient was admitted under a PEC (Physician Emergency Certificate) dated 07/05/15 for Suicidal, Dangerous to Self, and Unable to Seek Voluntary Admission. The record revealed the patient was previously admitted to this hospital from 06/10/15 to 06/18/15 with a diagnosis of Major Depression, Recurrent, Severe with Psychosis and he was admitted under a PEC for suicidal and dangerous to self.
The Intake assessment documented on 07/05/15 at 7:30 a.m. revealed Out Patient treatment failed and the patient wanted to be admitted to a nursing home.
Review of the Psychosocial Assessment dated 07/07/15 at 8:00 a.m. revealed the Discharge criteria was left blank. The only documentation related to discharge planning was, "possible nursing home."
Review of the patient's Treatment Plan revealed the sections for Discharge Criteria and Tentative Discharge Plan were left blank. Review of the Treatment Plan Review and Update with Physician Certification (Documentation of multidisciplinary team meeting) revealed the Discharge Criteria and Discharge Planning sections were left blank.

In an interview on 07/08/15 at 1:00 p.m. S7D/C (Discharge) Planner (LPN) confirmed that she was the discharge planning nurse and stated she started on Monday, and this was her second day. She stated she had not received any orientation or training since employed here relative to discharge planning. After reviewing the medical record for Patient #3, she confirmed there was no documentation of any discharge planning. She stated she spoke with the patient on Monday and he wants to go to a nursing home. She stated he abuses drugs and gets back into that after being discharged. She stated from her experience he was not a candidate for nursing home placement but that was his request and she would try. S7D/C Planner confirmed this patient needed a discharge plan and stated she was still trying to learn the forms here. She stated every patient gets a discharge plan.


In an interview on 07/08/15 at 2:21 p.m. S2DON reviewed the medical record for Patient #3 for discharge planning. She confirmed there was no documentation of discharge planning on the record. She stated the Treatment Plan Review and Update with Physician Certification was not completed at the team meeting, and it should have been. S2DON confirmed the social worker did not complete the section for discharge planning.


4. Review of the medical record for Patient #10 revealed the patient was a 46 year old male admitted to the hospital on 07/04/15 at 9:45 pm with a diagnosis of Schizophrenia and Alcohol Use Disorder. The patient's medical diagnoses included Hypertension, Diabetes Mellitus, Cirrhosis, Hepatitis C, Seizure Disorder, Hypothyroidism and Alcoholism. The patient was admitted under a PEC dated 07/04/15 for suicidal, dangerous to self, and unwilling to seek voluntary admission.
Review of the Intake Assessment, dated 07/04/15 revealed Out Patient treatment failed.
Review of the Treatment Plan revealed no documented evidence of discharge planning. The Multidisciplinary Notes dated 07/07/15 revealed the social worker contacted the patient's sister regarding group home placement. There was no other documentation of discharge planning in the patient's record.

In an interview on 07/09/15 at 12:58 p.m., S2DON reviewed the medical record for Patient #10 and confirmed the Treatment plan did not include any discharge planning and the intake assessment did not include any discharge planning. She stated the discharge forms are not done until the patient is discharged. She stated they do not have a process to document a discharge plan that she was aware of. She stated S7D/C Planner was not here today as she was working out her 2 week notice at her former employer. S2DON stated she did not know if she had a binder of documentation in her office of any planning she had done, but stated it should be documented on the patient's record so staff could have access to what she had done. She stated Patient #10 was very paranoid and does not want to go back to his apartment because there are too many people. S2DON stated he said this on admission. S2DON stated she knew S7D/C Planner had made some calls but it was not documented and she did not know where she was in this process.

Based on record review and staff interview, the hospital failed to ensure the discharge planning process was reassessed on an on-going basis as evidenced by failing to track re-admissions and failing to evaluate readmissions for potential problems due to discharge planning. Findings:

Review of the active medical record for Patient #3 revealed the patient was a 67 year old male readmitted to the hospital on 07/05/15 under a PEC (Physician Emergency Certificate) for suicidal, dangerous to self, and unable to seek voluntary admission. Review of the record revealed the patient was previously admitted to the hospital on 06/10/15 to 06/18/15 also under a PEC for suicidal. Review of the intake assessment revealed outpatient treatment had failed.

Review of the QAPI (Quality Assessment Performance Improvement) Quality Monitoring and Evaluation Indicators revealed the only indicator related to discharge planning was the Post Discharge Continuing Care Plan. Review of the methodology for monitoring the indicator revealed the following performance measures were going to be monitored: Discharge medications, next level of care, principal discharge diagnosis, and reason for hospitalization. There was no documented evidence that readmissions were tracked or evaluated in the QAPI program.


Interview on 07/07/15 at 10:00 a.m. with S7D/C (Discharge) Planner revealed that this was only her second day as D/C Planner. She further stated that she was not sure what forms or what the process was for D/C Planning at the hospital. S7D/C Planner also stated that she did not know what the hospital was reviewing in the QAPI process for discharge planning.

In an interview on 07/08/15 at 2:30 p.m. with S4QA (Quality Assurance), he confirmed the only discharge planning monitoring was the post discharge continuing care plan. S4QA provided a patient record for review and indicated his data collection was done from a review of the forms that are done on discharge. S4QA indicated the forms he reviews are the Physician's Discharge Orders, Discharge Medication Reconciliation, Continuing Care Plan, and the Discharge Social Services Treatment Summary. S4QA confirmed there was no process in place for evaluation of readmissions.


25119

Based on interviews and record reviews the hospital failed to ensure that the patient's psychiatric evaluations included a descriptive inventory of the patients assets as evidenced by no documented evidence of a descriptive asset inventory in 4 of 4 (Patient #3, Patient #4, Patient #10, Patient #11) active patient's psychiatric evaluations reviewed out of a total census of 8 active patients.
Findings:
Review of the hospital policy titled, "Treatment Planning, number PC-29" with a reviewed/revised date of March, 2015, revealed in part the following: Admitting Psychiatrist: Performs a full Psychiatric Evaluation within 60 hours of admission which includes problems, strengths, weaknesses, diagnosis, interventions and plans.

Review of the Medical Staff Bylaws, Rules & Regulations revealed no provisions related to psychiatric evaluations.

Patient #3
Review of the medical record for Patient #3 revealed the patient was a 67 year old male admitted to the hospital on 07/05/15 with a diagnosis of Bipolar Disorder. Review of the psychiatric evaluation dated 07/06/15 and documented by S18APRN (Advanced Practice Registered Nurse) revealed the patient's diagnoses were Major Depressive Affective Disorder with Psychotic Behavior, Dementia with Behavioral Disturbances, and Cocaine Abuse. Further review of the psychiatric evaluation revealed no documented evidence of an assessment of the patient's assets and strengths that could be used to develop the treatment plan.
Review of the patient's Multi-Disciplinary Integrated Treatment Plan revealed the section for Patient Strengths and Assets was left blank.
In an interview on 07/08/15 at 2:21 p.m. S2DON (Director of Nursing) reviewed the medical record for Patient #3 and confirmed there was no documented evidence of the patient's strengths in the psychiatric evaluation or the treatment plan.

Patient #10
Review of the medical record for Patient #10 revealed the patient was a 46 year old male admitted to the hospital on 07/04/15 at 9:45 p.m. with diagnoses of Schizophrenia and Alcohol Use Disorder. The patient's medical diagnoses included Hypertension, Diabetes Mellitus, Cirrhosis, Hepatitis-C, Seizure Disorder, Hypothyroidism and Alcoholism.
Review of the Psychiatric Evaluation dated 07/06/15 at 3:36 p.m. and documented by S18APRN revealed no documented evidence of an assessment of the patient's assets and strengths that could be used to develop the treatment plan. Review of the Treatment Plan revealed the section for the patient's strengths and assets was left blank.
In an interview on 07/09/15 at 12:58 p.m., S2DON reviewed the record for Patient#10 and confirmed the Psychiatric Evaluation and the Treatment Plan had no documentation of the patient's strengths and assets.

Patient #4
Patient #4 was admitted to the hospital on 07/03/15 with a diagnosis of attempted overdose. A review of Patient #4's Psychiatric Evaluation performed by S18APRN(Advanced Practice Registered Nurse), dated 7/06/15 and authenticated by S18APRN on 7/06/15, revealed no documented evidence that S18APRN had included a descriptive inventory of the patient's assets.
Patient #11
Patient #11 was admitted to the hospital on 07/05/15 with a diagnosis of Manic Severe Psychotic Disorder. A review of Patient #11's Psychiatric Evaluation performed by S18APRN, dated 7/06/15 and authenticated by S18APRN on 7/06/15, revealed no documented evidence that S18APRN had included a descriptive inventory of the patient's assets.
In a phone interview on 07/07/15 at 2:30 p.m. with S18APRN, she indicated that she was the Psychiatric Nurse Practitioner for the hospital and that she performed the psychiatric evaluations for Patient #4 and Patient #11. S18APRN was asked about the assessment and documentation of Patient #4 and Patient #11's descriptive inventory of their assets (strengths and weaknesses) on the psychiatric evaluations performed by S18APRN on Patient #4 and Patient #11. S18APRN indicated that the psychiatric evaluation format she utilized was an electronic format and that it did not include a section for patient assets. S18APRN further indicated that the electronic psychiatric evaluation format she used did not have a "prompt" that allowed her to add options. S18APRN indicated that she did not evaluate or include a descriptive inventory of the patient's assets for Patient #4 or Patient #11 in their respective psychiatric evaluations.


17091

Based on record reviews and interviews, the hospital failed to ensure that each patient's treatment plan was based on an inventory of the patient's strengths and disabilities that is derived from information contained in the psychiatric evaluation and assessments collected by the total treatment team for 4 (#2, #3, #10, #12) of 8 (#1-#4, #9-#12) active patient records reviewed for treatment plan development from a total sample of 12 patients.
Findings:

Review of the hospital's policy titled Treatment Planning, reviewed/revised March, 2015, revealed in part the following: Admitting Psychiatrist performs a full psychiatric evaluation within 60 hours of admission which includes problems, strengths, weaknesses, diagnosis, interventions, and plans. Therapist/Social Worker within 3 days of admission identifies strengths, weaknesses, discharge plans....Psychiatrist holds a Formal Treatment Planning Meeting within 5 days of admission to finalize development of MDTP (Multi-Disciplinary Treatment Plan).

Patient #2
A review of the medical record for Patient #2 revealed she was a 48-year-old female admitted to the hospital on 06/30/15 at 5:30 p.m. Diagnoses included Depression, Anxiety, Suicidal Ideations, Hypertension, and Gastroesophageal Reflux Disease (GERD).

Review of the Patient #2's Multi-Disciplinary Integrated Treatment Plan revealed the section for Liabilities was left blank. The Treatment Plan revealed the section for Patient Strengths and Assets was left blank. Review of the treatment plan revealed the treatment planning meeting was conducted on 07/01/15 at 8:00 a.m.
In an interview on 07/09/15 at 3:30 p.m., S2DON (Director of Nursing) reviewed the medical record for Patient #2 and confirmed there was no documented evidence of the patient's strengths and disabilities in the treatment plan. She confirmed the section for the patient's strengths and disabilities was left blank. She confirmed the treatment plan was not completed at the team meeting on 07/01/15 and should have been.


Patient #3
Review of the medical record for Patient #3 revealed the patient was a 67 year old male admitted to the hospital on 07/05/15 with a diagnosis of Bipolar Disorder. Review of the psychiatric evaluation dated 07/06/15 revealed the patient's diagnoses were Major Depressive Affective Disorder with Psychotic Behavior, Dementia with Behavioral Disturbances, and Cocaine Abuse. The record revealed the patient was admitted under a PEC (Physician Emergency Certificate) dated 07/05/15 for Suicidal, Dangerous to Self, and Unable to Seek Voluntary Admission.
Review of the patient's Multi-Disciplinary Integrated Treatment Plan revealed the section for Liabilities was left blank. The Treatment Plan revealed the section for Patient Strengths and Assets was left blank. Review of the treatment plan revealed the treatment planning meeting was conducted on 07/07/15 at 10:50 a.m.

In an interview on 07/08/15 at 2:21 p.m. S2DON (Director of Nursing) reviewed the medical record for Patient #3 and confirmed there was no documented evidence of the patient's strengths and disabilities in the treatment plan. She confirmed the section for the patient's strengths and disabilities was left blank. She confirmed the treatment plan was not completed at the team meeting on 07/07/15 and should have been.

Patient #10
Review of the medical record for Patient #10 revealed the patient was a 46 year old male admitted to the hospital on 07/04/15 at 9:45 p.m. with diagnoses of Schizophrenia and Alcohol Use Disorder. The patient's medical diagnoses included Hypertension, Diabetes Mellitus, Cirrhosis, Hepatitis-C, Seizure Disorder, Hypothyroidism and Alcoholism.
The record revealed the patient was admitted under a PEC dated 07/04/15 for Suicidal, Dangerous to Self, and Unwilling to Seek Voluntary Admission.
Review of the patient's Multi-Disciplinary Integrated Treatment Plan revealed the section for Liabilities was left blank. The Treatment Plan revealed the section for Patient Strengths and Assets was left blank. Review of the treatment plan revealed the treatment planning meeting was conducted on 07/07/15 at 10:25 a.m.

In an interview on 07/09/15 at 12:58 p.m., S2DON reviewed record for Patient#10 and confirmed the Treatment Plan and confirmed there was no documented evidence of the patient's strengths and disabilities in the treatment plan. She confirmed the section for the patient's strengths and disabilities was left blank. She confirmed the treatment plan was not completed at the team meeting on 07/07/15 and should have been.

Patient #12
A review of the medical record for Patient #12 revealed he was a 60-year-old male admitted to the hospital on 06/30/15. Diagnoses included Schizoaffective Disorder, Bipolar Type; Hypertension; Type II Diabetes Mellitus; and Osteoarthritis.
Review of the Patient #12's Multi-Disciplinary Integrated Treatment Plan revealed the section for Liabilities was left blank. The Treatment Plan revealed the section for Patient Strengths and Assets was left blank. Review of the treatment plan revealed the treatment planning meeting was conducted on 07/03/15 at 8:12 a.m.

In an interview on 07/09/15 at 3:30 p.m., S2DON (Director of Nursing) reviewed the medical record for Patient #12 and confirmed there was no documented evidence of the patient's strengths and disabilities in the treatment plan. She confirmed the section for the patient's strengths and disabilities was left blank. She confirmed the treatment plan was not completed at the team meeting on 07/03/15 and should have been.



31048

Based on interviews and record reviews the Administrator, the Medical Staff, and the DON (Director of Nursing) failed to monitor adherence of the hospital's Infection Control Program's Plan by failing to ensure that the Infection Control Program and the Infection Control Committee adhered to the surveillance monitoring activities set forth in the Infection Control Plan/Program as evidenced by incomplete surveillance monitoring activity documentation.

Findings:
A review of the Governing Body (GB) meeting minutes dated 06/01/15 and provided by S1Administrator, revealed in part: The GB reviewed and approved the Infection Control Policy/Plan. S3ADON (Assistant Director of Nursing) was approved as the designated Infection Control Officer. The GB appointed an Infection Control Committee that included: S1Administrator, S2DON, and S3ADON as members.
A review of the Infection Control Program's surveillance monitoring activities and data collection, provided by S3ADON as the complete surveillance monitoring activities and data collection from 06/01/15 to present, revealed in part:
The Basic Disinfection Monitoring Audit Tool had 8 (eight) indicators to be observed. The dates of observations were 6/20/15, 6/22/15, 6/27/15 and 6/29/15. There were only 3 (three) staff that were observed in those 4 (four) days and they were observed in only 2 - 4 of the indicators. The other indicators were blank.
The Hand Hygiene Monitoring Audit Tool had 11 (eleven) indicators to be observed. The dates of observations were 6/20/15, 6/22/15, 6/25/15 and 6/27/15. There were 4 (four) staff that were observed on 6/20/15 and 6/22/15; 1 (one) staff on 6/25/15; and 3 (three) staff on 6/27/15. There was no documented evidence of physicians or contract staff observations. Only 1 (one) of the Hand Hygiene Monitoring Audit Tools, dated 6/20/15, had a mark by all of the indicators for each staff observed. Many indicators on the Hand Hygiene Monitoring Audit Tool sheets were blank for several of the indicators.
The EOC (Environment of Care) Inspection Monitoring Audit Tool had 22 (twenty-two) indicators to be observed. The dates of observations were 6/20/15 and 6/22/15. There were no indicators on the EOC Audit Tool that indicated that housekeeping cleaning infection control practices were being monitored as recommended by S11CIC (Certified Infection Control Officer).
In an interview on 7/08/15 at 9:30 a.m. with S11CIC, she indicated that she was the Infection Control Consultant for the hospital, and that she signed her contract with the hospital on 6/05/15. S11CIC indicated that she was to assist the hospital and the Infection Control Officer, S3ADON with the hospital's infection control issues and to educate S3ADON in infection control. S11CIC was asked about the in-services that she conducted with the staff and the contract housekeeper regarding acceptable infection control practices. S11CIC indicated that she conducted several meetings with S1Administrator, S2DON and S3ADON regarding the hospital's identified infection control breaches following the DHH (Department of Health and Hospitals) survey to include in part: risk assessments, hand hygiene compliance, isolation precautions, evaluations and approval of appropriate disinfectants and appropriate disinfectant practices, and inconsistent infection control monitoring. S11CIC indicated that she conducted various in-services with all the staff, S14Hker, and the housekeeping contract supervisor. S11CIC further indicated that she monitored S14Hker during her patient room cleaning practices and addressed her infection control practices. S11CIC indicated that her recommendations to S1Administrator, S2DON and S3ADON included in part: ongoing monitoring of the identified infection control breaches for compliance, facility surveillance through environmental rounds, continued monitoring of the disinfection practices of the contract housekeepers, monitoring of the facility daily by the Infection Control Officer (S3ADON) to identify corrective actions needed and high risk areas.
In an interview on 7/09/15 at 11:00 a.m. with S3ADON she indicated that she was the designated Infection Control Officer and that the hospital also had contracted with an Infection Control Consultant, S11CIC. S3ADON was asked about the time she spent in the hospital doing infection control activities. S3ADON indicated that she was designated as the Infection Control Officer on 6/01/15 by the Governing Body and the Infection Control Consultant ' s first day was on 6/08/15. S3ADON indicated that she was still on the nursing staffing schedule sheets and was assigned patient care 2-3 days a week after 6/01/15. S3ADON indicated that she performed infection control activities on the days when she was not assigned patient care. S3ADON was asked for her Infection Control activities from 6/01/15 to present, to include her surveillance monitoring activities, her data collection, and her Infection Control Committee meeting minutes. S3ADON presented The Basic Disinfection Monitoring Audit Tool, The Hand Hygiene Monitoring Audit Tool, and The EOC Inspection Monitoring Audit Tool reports which were reviewed with S3ADON. S3ADON was asked about the 3 (three) Audit Tool ' s and the indicators that were blank. S3ADON indicated that if she was unable to observe an opportunity on the day she was assigned infection control activities that she left the indicators blank. S3ADON further indicated that she has had no Infection Control Committee meetings or minutes and that the Infection Control Committee had not presented any Infection Control Reports to the Governing Body.
In an interview on 7/09/15 at 11:30 a.m. with S1Administrator, S2DON and S3ADON, S1Administrator indicated that he was a member of the hospital ' s Governing Body. The Infection Control Program ' s incomplete surveillance monitoring activities for the month of June 2015 and July 2015 were reviewed. S1Administrator indicated that the hospital had been in chaos since the prior DHH survey and the hospital was having difficulty overcoming obstacles. S1Administrator indicated that the Infection Control Program was functioning through January 2015. S1Administrator indicated that prior Infection Control officers (since January 2015) were not " doing their job " . S1Administrator further indicated that the Governing Body did not realize the " fallout " until early May 2015 that the Infection Control Department was not performing its duties.