HospitalInspections.org

Based on observations and interview the hospital failed to maintain a safe environment as evidenced by: 1) failing to ensure chemicals on the Children/Adolescent's unit were stored in a closet that was locked at all times; 2) allowing a broken, hard plastic lid to a linen cart with jagged, hard, pointed, sharp edges to be accessible to the patients utilizing the dayroom of the Children/Adolescent's Unit; 3) failing to maintain window frames and jams resulting in flaking and peeling paint; 4) failing to inspect air-conditioning vents resulting in paper and rags being inserted preventing air flow. Findings:

1) Failing to ensure chemicals on the Children/Adolescent's unit stored in a secured area were locked at all times:
Environmental observations were made on 02/22/12 at 10:50 a.m. with RN S28 Nurse Manager of the Child/Adolescent Unit, S33 Maintenance, and RN S34 Risk Manager. While on the Children/Adolescent Unit, a room labeled "Environmental Services" that contained eye wash equipment and chemicals was found to be unlocked and unsupervised at the time. The following chemicals were found on the bottom shelf of an open cabinet in the room: 2 containers of urine odor eliminator, 1 can of oven cleaner, 3 spray cans of insect killer, 1 gallon of disinfectant, 1 gallon of Febreze, and 1 gallon of floor cleaner.

On 02/22/12 the total census on the children's/adolescent unit was 13. There were (1) 8 year old, (1)12 year old, (1) 13 year old, (2) 14 year olds, (3)15 year olds, (1) 16 year old, and (4) 17 year olds residing on the children/adolescent unit.

An interview was conducted with S33 Maintenance on 02/22/12 at 10:50 a.m. He reported the door was to be locked at all times since there were chemicals in the room.

2) Allowing a broken hard plastic lid to a linen cart with jagged, hard, pointed, sharp edges to be accessible to the patients utilizing the dayroom of the Children/Adolescent's Unit:
Observation on 02/22/12 at 10:50 a.m. of the common area/dayroom revealed a dirty linen cart with a hard white plastic lid. Further observation revealed the lid had numerous pieces broken leaving the remainder of the lid with jagged, hard, pointed sharp edges. The finding was confirmed with S33 Maintenance.

3) Failing to maintain window frames and jams resulting in flaking and peeling paint:
Observation on 02/22/12 at at 11:00am of Room "a" revealed the window sill was rusted and flaking. Further review revealed the paint surrounding the window was bubbled and in some places was also flaking. The window pane had a deep approximately seven inch scratch which was almost completely through the thickness of the window pane.

In a face-to-face interview on 02/22/12 at 11:00am, S33 Maintenance Director indicated he performed monthly inspections of the environment; however windows are not part of the check.

4) Failing to inspect air-conditioning vents resulting in paper and rags being inserted preventing air flow:
On 02/22/12 at 11:40 a.m., observation on the Dual Diagnoses Unit revealed paper, cardboard and/or washcloths had been placed behind the plastic vent covers of the air conditioner unit preventing the flow of air. S33 Maintenance verified that patients slide things under the vent cover to block the air.

Based on record review and interview the hospital failed to ensure adverse patient events were documented and their cause analyzed for 3 of 24 sampled patients (#3, #6, #14). Findings:

Patient #3
Review of Patient #3's "Psychiatric Admission Summary" revealed he was a 9 year old male admitted on 11/08/11 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems. Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/08/11 at 12:05pm due to Patient #3 being homicidal and dangerous to others. A Coroner's Emergency Certificate (CEC) was signed on 11/09/11 at 1:31pm due to Patient #3 being dangerous to others.

Review of Patient #3's "Multidisciplinary Progress Notes" revealed the following entry on 11/10/11 at 11:00pm by Psychiatric Counselor (PC) S31: "...Pt (patient) became upset when sent to bed early for cursing at peers. Pt wrapped a shirt around his neck & (and) said "I want to kill myself". RN notified Psychiatrist S8 & pt was placed on SVC (strict visual contact). (1) Staff provided support, guidance, & encouragement. (o) Pt not compliant (with) unit rules & structure. Pt needs redirection from staff. (P) continue to monitor & follow tx (treatment) plan". Further review revealed no documented evidence of an assessment by the RN of the patient's change in condition that included a suicide attempt. Review of the "Patient Monitor Record" documented by PC S31 and dated 11/10/11 revealed Patient #3 was asleep in Module C (children's unit) at 11:00pm.

Review of the hospital's incident report log revealed no documented evidence that an incident report had been completed in relation to Patient #3's suicide attempt and suicide threat.

In a face-to-face interview on 02/27/12 at 11:15am, RN Manager of the Child/Adolescent Unit S28 indicated Patient #3 should have been assessed by the RN on 11/10/11 when she notified Psychiatrist S8 of the above report from PC S31. S28 further indicated an incident report should have been completed by the RN. S28 further indicated PC S31 documented her note for the entire shift at 11:00pm, and there was not the specific time that the event with Patient #3 had occurred, which resulted in the observation record and the progress notes information not matching.

Review of Patient #3's "Progress Notes" dated 11/12/11 at 10:50 (no documented evidence whether it was am or pm) revealed documentation by PC S42 of "...He began attention seeking and pulling a towel around his neck. He started cursing and disrespecting staff...". Further review revealed no documented evidence that this was reported to the RN, and there was no documented evidence of a RN's assessment of Patient #3's suicide attempt. Review of Patient #3's "Patient Monitor Record" dated 11/12/11 revealed from 10:45am through 11:00am, Patient #3 was cooperative in Module C, and from 10:45pm through 11:00pm he was sleeping in the quiet room.

Review of the hospital's incident report log revealed no documented evidence that an incident report had been completed.

In a face-to-face interview on 02/27/12 at 11:15am, RN Manager of the Child/Adolescent Unit S28 indicated Patient #3 should have been assessed by the RN, and an incident report was required to be completed when patients made suicide attempts or threats.

In a face-to-face interview on 02/27/12 at 11:50am, RN Manager of the Child/Adolescent Unit S28 indicated the RN should document an assessment of the patient behaviors that warranted the need for prn medication.

In a face-to-face interview on 02/27/12 at 2:20pm, RN Risk Manager S34 indicated incident reports were to be reviewed by the supervisor and signed on the day the report was written, and she (S34) was to review and sign the report by the following day.

Patient #6
Patient #6 was an 11 year old boy admitted to the hospital on 11/30/11 by Coroner's Emergency Certificate for hearing voices telling him to kill his school mates and himself. He attempted to put his head through a glass door because the voice told him to do it.

Review of the Progress Notes dated 12/02/11 at 9:20 p.m. revealed, "Pt (patient) became agitated, banging on walls, cursing, and tying his sheets around his neck. Pt made verbal threats to kill staff".

Review of the Incident and Accident reports for December 2011 revealed no documented evidence of an incident and accident report related to the patient attempting to tie sheets around his neck.

An interview was conducted with S 28 Nurse Manager on 02/27/12 at 11:10 a.m. She reported that an incident report should had been filled out related to the patient attempting to tie a sheet around his neck on the unit.

Patient #14
Review of Patient #14's medical record revealed he was admitted on 01/25/12 with the diagnoses of Depressive Disorder, Post Traumatic Stress Disorder, Physical Abuse, Sexual Abuse, and Disruptive Behavior Disorder. Further review revealed a PEC was completed on 01/25/12 at 4:30pm due to Patient #14 being suicidal, homicidal, violent, dangerous to self and others, and gravely disabled. A CEC was signed on 01/27/12 at 11:20am due to Patient #14 being dangerous to self and others and gravely disabled.

Review of Patient #14's "Multidisciplinary Progress Notes" dated 01/29/12 revealed an entry at 2:30pm by PC S36 of "...being physically aggressive punching a male child on the face over a movie. Pt was stopped by a female PC & was put in his room by other nursing staff who came to assist. Doctor was called by nurse & she told PCs that if pt stays in his room & he is able to calm himself down he will be okay no shot but a Vistaril by mouth... pt was put on early bedtime & no privileges. Monitor pt behavior encourage pt to follow his treatment plan...". Further review revealed no documented evidence of an assessment of Patient #14 by a RN and the report of the RN's phone call to the physician.

Review of the hospital's incident report log revealed no documented evidence that an incident report was completed related to Patient #14 striking another patient in the face.

In a face-to-face interview on 02/27/12 at 11:05am, PC S36 indicated she reported that Patient #14 had struck another peer in the face on 01/29/12 to the charge nurse, but she doesn't remember which nurse she told. S36 further indicated that she didn't know if an incident report had been completed at the time of the incident.

Review of Patient #14's "Multidisciplinary Progress Notes" dated 02/02/12 revealed a shift entry by PC S20 of "...appeared to have a limited affect. He could not participate in the activities & group because his behavior was out of control. He stated that he will do what he want. x 2 in the quiet room for his inappropriate behaviors...". Further review revealed no documented evidence that a RN assessed Patient #14's behaviors when he was "out of control" that warranted him to be placed in the quiet room twice by PC S20.

In a face-to-face interview on 02/27/12 at 9:02am, PC S20 indicated she placed a child in the seclusion room and left the door open when she documents that they are in the quiet room. S20 further indicated she kept the patient from exiting the room until they've "done their little time out". S20 further indicated she decides when the patient can come out of the seclusion/quiet room. When asked if she's familiar with the seclusion policy, S20 indicated that she was and reviewed it every 2 to 3 weeks. After being told that the hospital policy considered it to be seclusion when a patient was not allowed to leave a room, S20 reconfirmed that she kept patients from leaving the seclusion room when she placed them there for time-out until she determined that the patient could leave.

Review of Patient #14's "Reassessment/Progress Note dated 02/15/12 revealed documentation written across the front of the page with no documented evidence of the date, time, and name and title of the person who made the notation. Further review revealed the documentation included "Vistaril 25 mg p.o. (by mouth) at 4PM - agitated angry hostile threatening". Review of the PRN MAR revealed Vistaril 25 mg was given by mouth on 02/15/12 at 10:00pm. Review of the "Multidisciplinary Progress Notes" dated 02/15/12 revealed no documented evidence of an assessment by the RN of the behaviors exhibited by Patient #14 that warranted the need for prn medication at 4:00pm and 10:00pm.

In a face-to-face interview on 02/27/12 at 11:15am with RN Manager of the Child/Adolescent Unit S28 and RN Manager S11 present, S28 indicated an incident report should have been completed if the other patient was injured (relating to the above incident of 01/29/12). S11 indicated an incident report needed to be completed at the time even if the other patient was not injured. S28 indicated the RN should have performed and documented an assessment of Patient #14's behaviors. RN Manager S11 confirmed that an incident report had not been completed when Patient #14 struck another patient in the face on 01/29/12.

Review of the hospital policy titled "Healthcare Peer Review (HPR) Occurrence Reporting System", reviewed 08/11, revised 05/05, and contained in the policy manual submitted by Administrator S1 as current, revealed, in part, "...Occurrence (Incident Type): that which is not consistent with the routine care of a patient and/or the desired operations of the facility. ...Serious Injuries/Events constitute any of the following outcomes as a result of healthcare intervention but may not be limited to this list: ...Suicidal gestures or attempt, Injury/Physical harm to patients, staff or third parties... Violence...". Further review revealed the incident report was to be completed at the time of the event, signed by the individual preparing the report, reviewed by the charge nurse on duty at the time of the event for completeness and to assure the medical record documentation was appropriate and appropriate actions/interventions had been taken.




26351

Based on record review and interview the hospital failed to enforce its bylaws. The medical staff did not implement its rules and regulations for suspension and disciplinary action of physicians who failed to complete medical records within 30 days after discharge. Findings:

Review of the Medical Staff Rules and Regulations revealed in part,"....On the thirtieth (30th) day after discharge, if the record is incomplete, the Medical Director, the Chief Executive officer, and the Chairman of the Medical Executive Committee will be notified to consider suspension of privileges or other appropriate disciplinary action. Suspension of clinical privileges will usually apply to future cases only. When privileges are suspended, the practitioner must complete all incomplete records before his/her privileges will be reinstated. A record is not complete until all material has been dictated, transcribed, and signed...".

Review of the Physician Delinquency rate for January 2012 revealed the total rate was 39% and the delinquent rate for the year 2011 was 42%.

Review of the Physician Delinquency rate per physician revealed:
S 8 MD had 6 charts over 30 days delinquent, 1 chart over 60 days delinquent, and 1 chart over 90 days delinquent.
S 19 MD had 7 charts over 30 days delinquent, 6 charts over 60 days delinquent, and 4 charts over 90 days delinquent.
S 40 MD had 2 charts over 30 days delinquent and 4 charts over 90 days delinquent.
S 41 MD had 1 chart over 30 days delinquent and 2 charts over 90 days delinquent.
S 39 MD had 1 chart over 30 days delinquent.
S 38 MD had 1 chart over 234 days delinquent.

An interview was conducted with S30 RHIA (Registered Health Information Administrator) on 02/24/12 at 9:25 a.m. She reported that the delinquency rate for medical records was 39% for January. She reported the system in place to notify the doctors of delinquent charts was to e-mail them once a week and "cc" S1 Administrator and S18 Medical Director. S30 stated she had been at the hospital about 4 years, and none of the physicians' privileges had been suspended for delinquent medical records.

An interview was conducted with S18 MD on 02/27/12 at 2 p.m. He stated he was the Medical Director of the hospital, and once a month in the Medical Executive Committee the delinquent rate per physician is presented to him. He further reported he speaks to the physicians and reminds them about their delinquent records. He also stated there was no disciplinary actions or suspension of privileges related to delinquent records, because he did not see the need for it.

Based on record review and interviews, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care for each patient as evidenced by: 1) failing to develop and implement a system for performance of a medical assessment for all psychiatric patients as evidenced by the family of a patient (#20) identifying an injury to her left wrist, not identified by hospital staff, which resulted in a visit to the emergency room and the diagnosis of a fractured wrist for 1 of 1 patients with an injury not identified by hospital staff out of a toal sample of 24 patients; 2) failing to perform patient assessments at a minimum of every 24 hours as required by hospital policy for 3 of 24 sampled patients (#4, #11, #12); 3) failing to perform patient assessments when there was a change in the patient's condition for 5 of 24 sampled patients (#3, #14, #15, #20, #24); 4) failure to reassess patients after prn (as needed) medications were administered to determine if the intervention was effective for 4 of 24 sampled patients (#3, #13, #14, #20); 5) failing to assess the patients' vital signs according to hospital policy for 3 of 3 sampled patients (#3, #12, #14); 6) delegating the assessment and documentation of patient behaviors to unlicensed psychiatric counselors for 3 of 24 sampled patients (#3, #13, #14) and 7) delegating unlicensed psychiatric counselors who had no documented evidence of training or assessment of competency to conduct nursing groups for 6 of 24 sampled patients (#3, #4, #5, #12, #13, #14). Findings:

1) Failing to develop and implement a system for performance of a medical assessment for all psychiatric patients:
Patient #20
Review of the medical record for Patient #20 revealed a 54 year old female admitted to the hospital on 10/29/11 under a formal voluntary admission for opiate dependency with a history of fibromyalgia.

Review of the Multidisciplinary Reassessment/Progress Note dated 11/02/11 (no time documented) revealed the family members of Patient #20 reported to the staff that she (#20) may have an injured left hand. Further review of the notes revealed the charge nurse determined Patient #20's left hand did not appear to be injured and offered her an ice pack. There was no documented evidence that the physician was notified.

Review of the Physician's Orders dated/timed 11/03/11 at 9:00am revealed an order for Patient #20 to be sent to an urgent care facility for an x-ray. Review of the radiology report dated 11/03/11 revealed Patient #20 had an impacted fracture distal radius extending into the articular surface.

Review of the medical record revealed the next entry was made into the progress notes on 11/03/11 at 4p-11p with no documented evidence Patient #20 had been x-rayed or the results of the x-ray. Further there was no documented evidence the left hand of Patient #20 was assessed. On 11/04/11 at 11:25am an entry written by the nurse revealed.... "Pt. (Patient) returned from ortho f/u (follow-up) with cast on left wrist. + (positive) capillary refill, 2 sec to left finger, no acute complaints of left arm/hand". Patient #20 was discharged at 2:30pm.

In a face to face interview on 02/24/12 at 3:30pm RN S2 Director of Nursing verfied medical assessments are not performed daily on patients.

2) Failure to perform patient assessments at a minimum of every 24 hours:
Patient #4
Review of the patient's clinical record revealed the patient was an 8 year old male admitted to the facility on 11/15/11 as a PEC for violent behavior. The record revealed the patient was discharged on 11/18/11.

Review of the Reassessment/Progress Notes revealed no documentation of a nursing assessment on 11/17/12.

In a face to face interview on 02/27/12 at 12:05 p.m., RN Manager of the Child/Adolescent Unit S28 reviewed the patient's record and verified there was no nursing assessment documented on 11/17/12. S28 verified that nurse was required to reassess the patient at least every 24 hours.

Patient #11
Review of the patient's clinical record revealed that the patient was a 15 year old female admitted to the facility on 12/30/11 by PEC (Physician Emergency Commitment) for suicidal ideations.

Review of the Reassessment/Progress Notes revealed no documentation of a nursing assessment on 01/01/12 and 01/03/12. Review of the notes revealed that the Patient Reassessment checklist was checked on 01/01/12, but the only signature on the form was by a PC (Psychiatric Counselor). Review of the Reassessment/Progress note revealed that the Patient Reassessment section was left blank. Review of the Multidisciplinary Progress note section revealed that the patient was discharged to home at 4:15 p.m. Review of the Multidisciplinary Progress Note section revealed no documented evidence of an assessment by the nurse on these 2 days.

In a face to face interview on 02/27/12 at 12:05 p.m., RN Manager of the Child/Adolescent Unit S28 reviewed the patient's record and verified that the nurse had not signed the Patient Reassessment on 01/01/12, and verified the only signature on the form was the PC signature. S28 verified she was unable to confirm the RN Review of the radiology report dated 11/03/11 revealed Patient #20 had an impacted fracture distal radius extending into the articular surface.
d th
Rof the patient's clinical record revealed the patient was a 50 year old female admitted to the facility on 01/03/12. The Master Treatment Plan revealed the patient's diagnoses were as follows: Stimulant Dependant and withdrawal, Opiate Dependant in remission, Suborned withdrawal, Cannabis Dependant, and Nicotine Dependant. The Criteria for Discharge was safe detoxify.

Review of the Reassessment/Progress Notes revealed no documentation of a nursing assessment on the following dates: 01/06/12, 01/07/12, and 01/08/12. Review of the notes revealIIed that the Patient Reassessment checklist was left blank. Review of the Multidisciplinary Progress Note section revealed no documented evidence of an assessment by the nurse on these 3 days.

On 02/27/12 at 12:20 p.m. a face to face interview was conducted with the Nurse Manager of the Adult Unit, S 11 RN. After reviewing the patient's record, she verified that no nursing assessments had been done for 01/06/12, 01/07/12, and 01/08/12. She verified that the Patient Reassessment section was left blank, and there were no assessments documented by the nurse in the Multidisciplinary Progress Note section. S 11 RN verified that the facility's policy was for the RN (Registered Nurse) to assess the patient at least every 24 hours.

In a face-to-face interview on 02/27/12 at 11:15am, RN Manager of the Child/Adolescent Unit S28 indicated the day RN and the evening RN share the duty of performing the daily nursing assessments of patients on the Child/Adolescent Unit. S28 further indicated the hospital policy required each patient to be assessed by the RN at a minimum of every 24 hours. S28 confirmed the nursing assessments were not timed when they were performed, and thus she couldn't be sure that the assessment was performed within the 24 hour time interval as required by policy.

Review of the hospital policy titled "Assessment And Reassessment Of Patients", contained in the manual presented by Administrator S1 as the current policies and reviewed 10/10 and revised 01/10, revealed, in part, "...The Nursing Assessment is a vital component of the admission procedure... Reassessment is also a vital component of the patient's plan of care. Reassessment occurs on a daily basis and is addressed in the Reassessment Progress Note... 11. Nursing reassessment done every 24 hours, including mental status and medical issues".

3) Failure to perform patient assessments when there was a change in the patient's condition: Patient #3
Review of Patient #3's "Psychiatric Admission Summary" revealed he was a 9 year old male admitted on 11/08/11 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems. Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/08/11 at 12:05pm due to Patient #3 being homicidal and dangerous to others. A Coroner's Emergency Certificate (CEC) was signed on 11/09/11 at 1:31pm due to Patient #3 being dangerous to others.

Review of Patient #3's "Multidisciplinary Progress Notes" revealed the following entry on 11/10/11 at 11:00pm by Psychiatric Counselor (PC) S31: "...Pt (patient) became upset when sent to bed early for cursing at peers. Pt wrapped a shirt around his neck & (and) said "I want to kill myself". RN notified Psychiatrist S8 & pt was placed on SVC (strict visual contact). (1) Staff provided support, guidance, & encouragement. (o) Pt not compliant (with) unit rules & structure. Pt needs redirection from staff. (P) continue to monitor & follow tx (treatment) plan". Further review revealed no documented evidence of an assessment by the RN of the patient's change in condition that included a suicide attempt. Review of the "Patient Monitor Record" documented by PC S31 and dated 11/10/11 revealed Patient #3 was asleep in Module C (children's unit) at 11:00pm.

Review of the hospital's incident report log revealed no documented evidence that an incident report had been completed in relation to Patient #3's suicide attempt and suicide threat.

In a face-to-face interview on 02/27/12 at 11:15am, RN Manager of the Child/Adolescent Unit S28 indicated Patient #3 should have been assessed by the RN on 11/10/11 when she notified Psychiatrist S8 of the above report from PC S31. S28 further indicated an incident report should have been completed by the RN. S28 further indicated PC S31 documented her note for the entire shift at 11:00pm, and there was not the specific time that the event with Patient #3 had occurred, which resulted in the observation record and the progress notes information not matching.

Review of Patient #3's "Progress Notes" dated 11/12/11 at 10:50 (no documented evidence whether it was am or pm) revealed documentation by PC S42 of "...He began attention seeking and pulling a towel around his neck. He started cursing and disrespecting staff...". Further review revealed no documented evidence that this was reported to the RN, and there was no documented evidence of a RN's assessment of Patient #3's suicide attempt. Review of Patient #3's "Patient Monitor Record" dated 11/12/11 revealed from 10:45am through 11:00am, Patient #3 was cooperative in Module C, and from 10:45pm through 11:00pm he was sleeping in the quiet room.

Review of the hospital's incident report log revealed no documented evidence that an incident report had been completed.

In a face-to-face interview on 02/27/12 at 11:15am, RN Manager of the Child/Adolescent Unit S28 indicated Patient #3 should have been assessed by the RN, and an incident report was required to be completed when patients made suicide attempts or threats.

In a face-to-face interview on 02/27/12 at 11:50am, RN Manager of the Child/Adolescent Unit S28 indicated the RN should document an assessment of the patient behaviors that warranted the need for prn medication.

In a face-to-face interview on 02/27/12 at 2:20pm, RN Risk Manager S34 indicated incident reports were to be reviewed by the supervisor and signed on the day the report was written, and she (S34) was to review and sign the report by the following day.

Patient #14
Review of Patient #14's medical record revealed he was admitted on 01/25/12 with the diagnoses of Depressive Disorder, Post Traumatic Stress Disorder, Physical Abuse, Sexual Abuse, and Disruptive Behavior Disorder. Further review revealed a PEC was completed on 01/25/12 at 4:30pm due to Patient #14 being suicidal, homicidal, violent, dangerous to self and others, and gravely disabled. A CEC was signed on 01/27/12 at 11:20am due to Patient #14 being dangerous to self and others and gravely disabled.

Review of Patient #14's "Multidisciplinary Progress Notes" dated 01/29/12 revealed an entry at 2:30pm by PC S36 of "...being physically aggressive punching a male child on the face over a movie. Pt was stopped by a female PC & was put in his room by other nursing staff who came to assist. Doctor was called by nurse & she told PCs that if pt stays in his room & he is able to calm himself down he will be okay no shot but a Vistaril by mouth... pt was put on early bedtime & no privileges. Monitor pt behavior encourage pt to follow his treatment plan...". Further review revealed no documented evidence of an assessment of Patient #14 by a RN and the report of the RN's phone call to the physician.

Review of the hospital's incident report log revealed no documented evidence that an incident report was completed related to Patient #14 striking another patient in the face.

In a face-to-face interview on 02/27/12 at 11:05am, PC S36 indicated she reported that Patient #14 had struck another peer in the face on 01/29/12 to the charge nurse, but she doesn't remember which nurse she told. S36 further indicated that she didn't know if an incident report had been completed at the time of the incident.

Review of Patient #14's "Multidisciplinary Progress Notes" dated 02/02/12 revealed a shift entry by PC S20 of "...appeared to have a limited affect. He could not participate in the activities & group because his behavior was out of control. He stated that he will do what he want. x 2 in the quiet room for his inappropriate behaviors...". Further review revealed no documented evidence that a RN assessed Patient #14's behaviors when he was "out of control" that warranted him to be placed in the quiet room twice by PC S20.

In a face-to-face interview on 02/27/12 at 9:02am, PC S20 indicated she placed a child in the seclusion room and left the door open when she documents that they are in the quiet room. S20 further indicated she kept the patient from exiting the room until they've "done their little time out". S20 further indicated she decides when the patient can come out of the seclusion/quiet room. When asked if she's familiar with the seclusion policy, S20 indicated that she was and reviewed it every 2 to 3 weeks. After being told that the hospital policy considered it to be seclusion when a patient was not allowed to leave a room, S20 reconfirmed that she kept patients from leaving the seclusion room when she placed them there for time-out until she determined that the patient could leave.

Review of Patient #14's "Reassessment/Progress Note dated 02/15/12 revealed documentation written across the front of the page with no documented evidence of the date, time, and name and title of the person who made the notation. Further review revealed the documentation included "Vistaril 25 mg p.o. (by mouth) at 4PM - agitated angry hostile threatening". Review of the PRN MAR revealed Vistaril 25 mg was given by mouth on 02/15/12 at 10:00pm. Review of the "Multidisciplinary Progress Notes" dated 02/15/12 revealed no documented evidence of an assessment by the RN of the behaviors exhibited by Patient #14 that warranted the need for prn medication at 4:00pm and 10:00pm.

In a face-to-face interview on 02/27/12 at 11:15am with RN Manager of the Child/Adolescent Unit S28 and RN Manager S11 present, S28 indicated an incident report should have been completed if the other patient was injured (relating to the above incident of 01/29/12). S11 indicated an incident report needed to be completed at the time even if the other patient was not injured. S28 indicated the RN should have performed and documented an assessment of Patient #14's behaviors. RN Manager S11 confirmed that an incident report had not been completed when Patient #14 struck another patient in the face on 01/29/12.

Review of the " Psychiatric Admission Summary " dated 01/18/12 for Patient #15 revealed a 16 year old male admitted to the hospital under a PEC (Physician ' s Emergency Certificate) for suicidal ideation - thoughts of cutting or burning himself. Further review revealed Patient #15 had become increasingly frustrated due to having a new social worker and not knowing where he would be living. Patient #15 is in the custody of the State.

Review of the Multidisciplinary Progress Notes dated 02/10/12 3-11 shift revealed Patient #15 was involved in a take-down for oppositional behavior and was sent to the Emergency Department at Hospital " b " .

Review of the medical record from the Emergency Department of Hospital " b " revealed Patient #15 sustained a fractured right humerus, placed in a sling, prescribed pain medication and instructed to follow-up with an orthopedist.

Review of the Multidisciplinary Progress Notes for Patient #15 dated 02/11/12 at 1:50am revealed the patient returned from the Emergency Room of Hospital " b " and went to sleep. Further review revealed no documented evidence the registered nurse assessed the patient ' s arm.

Review of the Multidisciplinary Progress Notes for Patient #15 dated 02/12/12 through 02/14/12 at 4:51am revealed no documented evidence the patient ' s arm was assessed even though documentation indicated he (#15) was experiencing increasing pain which was not released by Tylenol. Further review revealed after the assessment performed on 02/14/12 at 4:51am indicating Patient #15 ' s arm was swollen, there was no documented evidence another assessment of the arm was performed by the registered nurse 02/16/12 at 8:50am. The assessment performed revealed Patient #15 ' s fingers were now swollen and he was being encouraged to place a rolled washcloth in hand to assist in exercising his fingers.
According to the Multidisciplinary Progress Notes for Patient #15 dated 02/16/12 at 8:50am through 02/23/12 reviewed no documented evidence the registered nurse assessed the broken right arm of Patient #15.

Patient #20
Review of the medical record for Patient #20 revealed a 54 year old female admitted to the hospital on 10/29/11 under a formal voluntary admission for opiate dependency with a history of fibromyalgia.

Review of the Multidisciplinary Reassessment/Progress Note dated 11/02/11 (no time documented) revealed the family members of Patient #20 reported to the staff that she (#20) may have an injured left hand. Further review of the notes revealed the charge nurse determined Patient #20's left hand did not appear to be injured and offered her an ice pack. There was no documented evidence that the physician was notified.

Review of the Physician's Orders dated/timed 11/03/11 at 9:00am revealed an order for Patient #20 to be sent to an urgent care facility for an x-ray.

Review of the radiology report dated 11/03/11 revealed Patient #20 had an impacted fracture distal radius extending into the articular surface.

Review of the medical record revealed the next entry was made into the progress notes on 11/03/11 at 4p-11p with no documented evidence Patient #20 had been x-rayed or the results of the x-ray. Further there was no documented evidence the left hand of Patient #20 was assessed. On 11/04/11 at 11:25am an entry written by the nurse revealed.... "Pt. (Patient) returned from ortho f/u (follow-up) with cast on left wrist. + (positive) capillary refill, 2 sec to left finger, no acute complaints of left arm/hand". Patient #20 was discharged at 2:30pm.

In a face to face interview on 02/24/12 at 3:30pm RN S34 Risk Manager verified the nurse failed to document in the chart; however she offered that when questioned in regards to the Incident Report additional details were forthcoming.

Patient #24
Review of the medical record for Patient #24 revealed a 32 year old female admitted to the hospital on 09/05/11 at 4:30pm under a PEC (Physician's Emergency Certificate) for severe depression and paranoid thoughts. Further review revealed Patient #24 had a history of being sexually abused. Review of the Physicians' Admit Orders dated 09/05/11 at 4:40pm revealed Patient #24 was placed on close observation (observation every 15 minutes).

Review of the Reassessment/Progress Notes dated/timed 09/05/11 at 9:30pm revealed that while on staff PC (psychiatric counselor rounds) Patient #24 was found in her bathroom hitting her head against the corner of the wall. According to the entry dated/timed 09/05/11 at 9:30am in the Progress Notes revealed the patient sustained a large bump approximate size of a 50 cent piece with a superficial cut. Further review of the medical record revealed no documented evidence the physician was notified, vital signs were taken, a neuro assessment performed or if treatment was provided for the cut.

Review of the hospital policy titled "Assessment And Reassessment Of Patients", contained in the manual presented by Administrator S1 as the current policies and reviewed 10/10 and revised 01/10, revealed, in part, "...The Nursing Assessment is a vital component of the admission procedure... Reassessment is also a vital component of the patient's plan of care. Reassessment occurs on a daily basis and is addressed in the Reassessment Progress Note... A significant change in the patient condition or diagnosis results in reassessment. ... 11. Any significant change in the patient condition or diagnosis requires reassessment. Nursing reassessment done every 24 hours, including mental status and medical issues".

Review of the hospital policy titled "Healthcare Peer Review (HPR) Occurrence Reporting System", reviewed 08/11, revised 05/05, and contained in the policy manual submitted by Administrator S1 as current, revealed, in part, "...Occurrence (Incident Type): that which is not consistent with the routine care of a patient and/or the desired operations of the facility. ...Serious Injuries/Events constitute any of the following outcomes as a result of healthcare intervention but may not be limited to this list: ...Suicidal gestures or attempt, Injury/Physical harm to patients, staff or third parties... Violence...". Further review revealed the incident report was to be completed at the time of the event, signed by the individual preparing the report, reviewed by the charge nurse on duty at the time of the event for completeness and to assure the medical record documentation was appropriate and appropriate actions/interventions had been taken.

Review of the hospital policy titled "Restraint And Seclusion", reviewed 01/12, revised 01/09, and contained in the policy manual submitted by Administrator S1 as current, revealed, in part, "...Seclusion: The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. If a patient is restricted to a room alone and staff are physically intervening to prevent the patient from leaving the room or giving the perception that threatens the patient with physical intervention if the patient attempts to leave the room, the room is considered locked, whether or not the door is actually locked or not. ... Time Out/Time Away: A procedure used to assist the individual to regain emotional and behavioral control by moving the individual to a quiet area or encouraging the individual to move to a quiet area. In time out, the patient consents to being alone in a designated area for an agreed upon timeframe from which the patient is not physically prevented from leaving...".

4) Failure to reassess patients after prn (as needed) medications were administered to determine if the intervention was effective:
Patient #3
Review of Patient #3's "Psychiatric Admission Summary" revealed he was admitted on 11/08/11 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems. Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/08/11 at 12:05pm due to Patient #3 being homicidal and dangerous to others. A Coroner's Emergency Certificate (CEC) was signed on 11/09/11 at 1:31pm due to Patient #3 being dangerous to others.

Review of Patient #3's "Physician's Orders" revealed a telephone order was received from Psychiatrist S8 by RN S32 on 11/08/11 at 2:30pm for Vistaril 25 mg (milligrams) by mouth every 6 hours as needed for agitation and Vistaril 25 mg IM (intramuscular) every 6 hours as needed if refuses by mouth and/or aggression. Further review revealed a verbal order was received by RN S25 (with no documented evidence of the name of the physician who gave the verbal order) on 11/12/11 at 9:00pm for Thorazine 50 mg IM one dose now.

Review of Patient #3's "PRN/Pain Medication Administration Record (MAR) and the progress notes for 11/12/11 revealed Patient #3 received Vistaril 25 mg IM at 7:15pm and Thorazine 50 mg IM at 9:00pm each administered by RN S25. Further review of the MAR revealed RN S25 documented the response for both the Vistaril and Thorazine as "2", which according to policy means results in 1 hour to 2 hours. Review of the progress notes revealed no documented evidence of an assessment by RN S25 of what the results/effectiveness were from the administration of Thorazine at 9:00pm.

Patient #13
Review of Patient #13's "Psychiatric Admission Summary" revealed he was admitted on 02/14/12 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Disruptive Behavior Disorder, Parent-Child Relational Conflict, and Mild Mental Retardation. Further review of his medical record revealed a PEC was completed on 02/11/12 at 455 (no documented evidence whether the time was am or pm) due to Patient #13 being violent and dangerous to self. A CEC was signed on 02/14/12 at 1415 (2:15pm) due to Patient #13 being violent, dangerous to self, dangerous to others, and gravely disabled.

Review of Patient #13's "Physician's Orders" revealed a telephone order received from Psychiatrist S8 on 02/14/12 at 10:30am for Vistaril 25 mg by mouth every 6 hours as needed for agitation and Vistaril 25 mg IM every 6 hours as needed for severe agitation or if refuses by mouth medication. Further review revealed a telephone order from S8 on 02/16/12 at 10:05pm for Thorazine 50 mg IM every 6 hours as needed for aggression and give the first dose now.

Review of Patient #13's "Multidisciplinary Progress Notes" dated 02/15/16 at 4:25pm revealed he received Vistaril 25 mg IM after he became angry, scratched two staff nurses, and attempted to bite another nurse. Review of the progress notes and MARs revealed no documented evidence that Patient #13 was reassessed for the effectiveness of the prn medication administered.

Review of Patient #13's "Progress Notes" dated 02/16/12 revealed he was administered Vistaril 25 mg IM for aggression at 9:45pm by RN S10 and Thorazine 50 mg IM at 10:15pm by RN S10 for aggression. Review of the PRN MAR revealed S10 documented that the Vistaril was administered at 9:45am rather than 9:45pm, and there was no documented evidence of the response. Further review of the progress notes and the MARs revealed no documented evidence that RN S10 assessed Patient #13 for the effectiveness of the Thorazine administered at 10:15pm.

Review of Patient #13's "Multidisciplinary Progress Notes" dated 02/18/12 revealed he received Vistaril 25 mg IM at 12:30pm administered by RN S45 when he began kicking at staff and stating he was going to kill himself. Further review revealed S45 administered Thorazine 50 mg IM at 2:00pm when Patient #13 began kicking, hitting, head butting, and scratching staff. Review of the PRN MAR and nurse's notes revealed no documented evidence that RN S45 assessed Patient #13 for the effectiveness of the Vistaril and Thorazine administered.

Review of Patient #13's "Multidisciplinary Progress Notes" dated 02/19/12 revealed he received Thorazine 50 mg IM at 1:05pm administered by RN S45 when he was threatening to stab peers with the head of a pencil and kicking at staff. Review of the PRN MAR and the nurse's notes revealed no documented evidence that RN S45 assessed Patient #13 for the effectiveness of the Thorazine that was administered.

In a face-to-face interview on 02/27/12 at 1:45pm, RN S10 confirmed that she did not document a reassessment of Patient #13 for the effectiveness of Thorazine administered on 02/16/12 at 10:15pm.

Patient #14
Review of Patient #14's medical record revealed he was admitted on 01/25/12 with the diagnoses of Depressive Disorder, Post Traumatic Stress Disorder, Physical Abuse, Sexual Abuse, and Disruptive Behavior Disorder. Further review revealed a PEC was completed on 01/25/12 at 4:30pm due to Patient #14 being suicidal, homicidal, violent, dangerous to self and others, and gravely disabled. A CEC was signed on 01/27/12 at 11:20am due to Patient #14 being dangerous to self and others and gravely disabled.

Review of Patient #14's "Reassessment/Progress Note" dated 02/15/12 revealed documentation written across the front of the page with no documented evidence of the date, time, and name and title of the person who made the notation. Further review revealed the documentation included "Vistaril 25 mg p.o. (by mouth) at 4PM - agitated angry hostile threatening". Review of the PRN MAR revealed Vistaril 25 mg was given by mouth on 02/15/12 at 10:00pm. Review of the "Multidisciplinary Progress Notes" and the PRN MAR dated 02/15/12 revealed no documented evidence of a reassessment by the RN of the effectiveness of the Vistaril administered at 4:00pm and 10:00pm.

In a face-to-face interview on 02/27/12 at 11:50am, RN Manager of the Child/Adolescent Unit S28 indicated the RN documents a reassessment after the administration of prn medications by using the number system on the MAR. S28 confirmed that the number system only tells the amount of time taken for a response but does not indicate the type of response, such as whether the medication was effective or not effective.

Patient #19
Review of Patient #19's medical record revealed a 26 year old female admitted to the hospital on 02/15/12 under a formal voluntary admission for opiate and benzo dependency.

Review of the Physician's Orders for Patient #19 dated/timed 02/15/12 at 5:00pm revealed orders for the following: Phenergan 50mg po (by mouth) Q-6 (every six) hours prn (as needed for nausea and vomiting; Phenergan 50mg IM (Intramuscular) Q-6 (every six) hours prn (as needed for nausea and vomiting if unable to take po); Immodium caps ii po Q-6 hours prn diarrhea; Sandostatin 100 mcg Subcutaneous Q-4 hours prn nausea, vomiting or diarrhea; Zanaflex 8mg po Q-4 hours prn muscle spasms, muscle or joint aches;

Review of the MAR (Medication Administration Record) revealed Patient #19 received the following prn medications:
Phenergan 50mg po (by mouth) on 02/16/12 at 8:30 (am/pm not documented); 02/13/12 at 9:30 (am/pm not documented); 02/19/12 at 5:00am; 02/20/12 at 9:48pm; 02/21/12 at 9:05pm; Phenergan 50mg IM (Intramuscular) 02/19/12 at 9:30 (am/pm not documented).
Immodium caps ii po 02/16/at 6:00pm; 02/17/12 at 10:30am and 9:50 (am/pm not documented); 02/19/12 at 10:00pm; 02/20/12 at 5:50am and 9:49pm; 02/21/12 at 10:30pm; 02/22/12 at 5:45am.
Zanaflex 8mg po on 02/15/12 at 6:55pm; 02/22/12 at 9:09pm; 02/22/12 at 8:00p; 02/23/12 at 6:00am.
Immodium Capsules ii po on 02/16/12 at 6:00pm; 02/17/12 at 10:30am and 9:50pm; 02/19/12 at 10pm; 02/20/12 at 9:49pm; and 02/21/12 at 10:30pm.
Sandostatin 100mcg subcutaneous on 02/21/12 at 6:30am; 02/22/12 at 8:15pm; and 02/23/12 at 8:00am.
Zanaflex 8mg po on 02/15/12 at 6:00pm; 02/22/12 at 10;30am and 8:00pm; and 02/23/12 at 6:04am.
Review of the MAR and Reassessment/Progress Notes for Patient #19 revealed no documented evidence assessments were performed after administration of prn medication for the effectiveness of the medication for nausea, vomiting, diarrhea or muscle cramping.

Further review of the MAR for Patient #19 revealed Catapres 0.1mg 1mg on 02/17/12 at 10:30am; 02/18/12 at 7:30 (am/pm not documented); 02/19/12 at 10:00pm; 02/20/12 at 9:42pm.

Review of the MAR for Patient #19 for 02/17/12 through 02/22/12 revealed no documented evidence vital signs were recorded for the indication of the administration of Catapres.
Review of the Detoxification Flowsheet for Patient #19 revealed the following:
02/17/12 10:00am Pulse 100 and Blood Pressure 123/104. Vital signs assessed 6 hours later. 02/18/12 6:00am Pulse 101 and Blood Pressure 95/91. Vital signs assessed 4 hours later. 02/19/12 10:00pm Pulse 107 Blood Pressure 151/105. Vital signs assessed 8 hours later.

Patient #20
Review of the medical record for Patient #20 revealed a 54 year old female admitted to the hospital on 10/29/11 under a formal voluntary

Based on observation, record review, and interview, the hospital failed to ensure the nursing staff developed and kept current a nursing care plan for each patient as evidenced by: 1) failing to follow physician's orders for observation of a patient for 8 of 24 sampled patients (#1, #3, #4, #6, #8, #11, #21, #24); 2) failing to update the treatment plan after a change in a patient's condition for 2 of 2 patient with a change in condition out of a total of 24 sampled patients (#3, #13); 3) failing to evaluate the patient's treatment plan to determine if the patient had met his/her goal by the target date established and whether the plan needed to be revised for 1of 24 sampled patients (#14); and 4) failing to follow physician orders for vital signs on patients experiencing drug withdrawal for 3 of 3 drug dependent patients (#19, #20, #23) out of a total sample of 24 patients. Findings:

1) Failing to follow physician's orders for observation of a patient:
Patient #1
Review of the medical record for Patient #1 revealed she was a 17 year old female admitted on 10/29/11 for mood disorder with suicidal ideations.

Review of the medical record for Patient #1 revealed a physician's order on admission (10/29/11) for MVO/CO (moderate visual contact/close observation) as the observation status. Review of the Patient Monitor Record for 10/29/11 revealed no observation indicated on the form. Review of the Patient Monitor Record for 10/30/11 revealed her observation status was documented as CO (close observation). Review of the Patient Monitor Record for 10/31/11 revealed her observation status was documented as CO (close observation). Review of the Patient Monitor Record for 11/1/11 revealed her observation status was documented as CO (close observation). Patient #1 was discharged on 11/1/11.

An interview was conducted with S 11 Nurse Manager and S 28 Nurse Manager on 02/27/12 at 11:10 a.m. They confirmed there was no physician order for close observation status, only MVO/CO. The wrong observation status was documented or not documented the patient's entire hospitalization.

Patient #3
Review of Patient #3's "Psychiatric Admission Summary" revealed he was admitted on 11/08/11 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems. Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/08/11 at 12:05pm due to Patient #3 being homicidal and dangerous to others. A Coroner's Emergency Certificate (CEC) was signed on 11/09/11 at 1:31pm due to Patient #3 being dangerous to others.

Review of Patient #3's admit orders revealed his ordered observation status was MVC/CO (modified visual observation/close observation). Further review revealed a telephone order on 11/10/11 at 8:30pm from Psychiatrist S8 to place him on SVC (strict visual contact). Review of Patient #3's "Reassessment/Progress Note" dated 11/10/11 revealed he was on SVC. Review of the "Patient Monitor Record" dated 11/10/11 revealed no documented evidence of a change from MVC/CO to SVC at 8:30pm as ordered by the physician. Review of the "Reassessment/Progress Note" dated 11/11/11 and 11/12/11 revealed Patient #3's observation level was CO when SVC was still in effect from the order on 11/10/11. The "Patient Monitor Record" dated 11/11/11 revealed his observation status was MVC/CO rather than SVC as ordered.

Review of Patient #3's "Physician's Orders" revealed an order was written by Psychiatrist S8 on 11/12/11 at 11:20am to discontinue SVC and start MVC/CO. Further review revealed an order was written by RN S25 on 11/12/11 at 7:18pm (with no documented evidence whether the order was received verbally or by telephone and which physician gave the order) for SVC. Review of Patient #3's "Reassessment/Progress Note" dated 11/12/11 revealed his observation status was documented as CO, rather than MVC/CO as ordered at 11:20am. Review of the "Multidisciplinary Progress Notes" dated 11/12/11 and written by PC (psychiatric counselor) S20 for the 7:00am to 3:30pm shift revealed "...He is now off of SVC status & (and) on CO status...". Review of the "Patient Monitor Record" dated 11/12/11 revealed Patient #3 was on SVC status with no documented evidence that his observation status was changed to MVC/CO at 11:20am and then changed to SVC at 7:18pm.

Review of Patient #3's "Physician's Orders revealed a telephone order on 11/14/11 at 3:50pm from Psychiatrist S8 to discontinue SVC and start MVC/CO. Review of the "Reassessment/Progress Note" and the "Patient Monitor Record" dated 11/15/11 and 11/16/11 revealed Patient #3 was placed on CO rather than MVC/CO as ordered.

Review of Patient #3's "Master Treatment Plan" revealed no documented evidence that his treatment plan was updated when his behaviors warranted a change in his observation status.

In a face-to-face interview on 02/27/12 at 11:50am, RN Manager S11 indicated the psychiatric counselor completes the observation form, and the RN signs the form assuring that it is correct. S11 further indicated a physician's order was needed to change a patient's observation level.

Patient #4
Review of the medical record for Patient #4 revealed an 8 year old male admitted to the hospital on 11/15/11 at 8:30 p.m. under a PEC (Physician Emergency Certificate) for suicidal ideations, Psychosis, and Major Depressive Disorder. Review of the Physician's Admission Orders dated 11/15/11 at 8:30 p.m. revealed Patient #4 was placed on MVC/CO (Modified Visual contact/Close Observation). Review of the physician's orders revealed no documented evidence that the MVC/CO observation status was changed during the patient's hospital stay. The record revealed the patient was discharged on 11/18/11.

Review of the Multidisciplinary Assessment dated 11/15/11, revealed that the Initial Treatment Plan identified safety as a patient problem and an intervention for this problem was MVC/CO.

Review of the Patient Monitoring Records for Patient #4 revealed on 11/15/11 the observation status was left blank and did not indicate the level of observation provided to the patient.

Review of the Reassessment/Progress Notes for Patient #4 revealed that on 11/16/11 the RN checked CO under the patient safety section. On 11/17/11 there was no assessment of the observation status documented by the RN. On 11/18/11 the RN checked MVO/CO as the observation status and indicated in the progress notes that the patient was discharged to home at 1:00 p.m. on 01/18/11.

In a face to face interview on 02/27/12 at 12:05 p.m. with the RN Manager of the Adolescent Unit, S28, she reviewed the patient's record and verified that the observation status ordered by the physician on admit was for MVC/CO, and there were no physician's orders to change the observation status. S28 verified the Patient Monitoring Records did not indicate the level of observation ordered by the physician on 11/15/11. S28 verified there was no observation status documented by the RN on 11/17/11.

Patient #6
Patient #6 was a 11 year old boy admitted to the hospital on 11/30/11 by Coroner's Emergency Certificate for hearing voices telling him to kill his school mates and himself. He attempted to put his head through a glass door because the voice told him to do it.

Review of the the Admission Orders dated 11/30/11 revealed a physician order for MVC/CO observation status. Review of the Patient Monitor Record date 11/30/11 revealed no observation status was indicated.

An interview was conducted with S 11 Nurse Manager and S 28 Nurse Manager on 2/27/11 at 11:10 a.m. They reported if an observation status was not marked the observation status was close observation (CO), not MVC/CO as ordered by the physician.

Patient #8
Review of the medical record of Patient #8 revealed a 13 year old male admitted to the hospital under a PEC (Physician's Emergency Certificate) for pulling a knife on his mother's boyfriend. Review of the Physician's Admit Orders dated/timed 12/13/11 at 1:25am revealed an order for an observation status of MVC/CO (Modified Visual Contact/Close Observation). Further review of the Physician's Orders from 12/13/11 through discharge 12/19/11 revealed no documented evidence for orders to change the observation status.

Review of the Patient Monitor Record for Patient #8 dated 12/13/11 through 12/19/11 revealed the status of CO (Close Observation) was checked off . Further review of the form revealed no documented evidence Patient #8 was observed under modified visual contact.

Review of the Multidisciplinary Progress Note dated 12/13/11 through 12/19/11 revealed no documented evidence Patient #8 was observed under modified visual contact as ordered by the physician.

Patient #11
Review of the medical record for Patient #11 revealed a 14 year old female admitted to the hospital on 12/30/11 at 11:55 a.m. under a PEC (Physician's Emergency Certificate) for suicidal ideations and Major Depressive Disorder. Review of the Physician's Admission Orders dated 12/30/11 at 11:55 a.m. revealed Patient #11 was placed on MVC/CO (Modified Visual contact/Close Observation). Review of the physician's orders revealed no documented evidence that the MVC/CO observation status was changed during the patient's hospital stay. The record revealed the patient was discharged on 01/03/12.

Review of the Multidisciplinary Assessment dated 12/30/11, revealed that the Initial Treatment Plan was left blank. There was no documented evidence of the patient's educational needs, the patient's stated goals for treatment, and there were no identified problems and interventions. The form was signed by the RN and dated/timed 12/30/11 at 3:30 p.m. Review of the Master Treatment Plan revealed no documented evidence of the observation status of the patient.

Review of the Patient Monitoring Records for Patient #11 revealed the following observation status:
12/30/11 - Status: SVC (Strict Visual Contact)
12/31/11 - Status: CO (Close Observation)
01/01/12 - Status: CO
01/03/12 - Status: CO

Review of the Reassessment/Progress Notes for Patient #11 revealed that on 12/31/11 the RN checked MVC/CO under the patient safety section. On 01/01/12 and 01/02/12, C/O (Close Observation) was checked by the RN. Review of the progress notes revealed no documented evidence that the observation status was addressed.

In a face to face interview on 02/27/12 at 12:05 p.m. with the RN Manager of the Adolescent Unit, S28, she reviewed the patient's record and verified that the RN had failed to document the initial treatment plan. S28 confirmed the observation status ordered by the physician on admit was for MVC/CO, and there were no physician's orders to change the observation status. S28 verified the Patient Monitoring Records did not indicate the level of observation ordered by the physician.

Patient #21
Patient #21 was admitted to the hospital on 2/20/12 for Schizoaffective disorder and suicidal ideations.

Review of her Physician's Admission Orders dated 2/20/12 revealed her physician ordered an observation status of SVC (strict visual contact) and next to the observation status was handwritten the word suicidal.

Review of an undated Patient Monitor Record in the patient's medical record revealed the patient was on observation level CO (close observation).

An interview was conducted with S 11 Nurse Manager on 2/23/12 at 10:45 a.m. She reported the undated Patient Monitor Record was for 2/20/12 from 6:45 p.m. to 7:15 a.m. on 2/21/12. She further reported the patient was supposed to be on SVC observation level not CO as documented on the Patient Monitor Record.

Patient #24
Review of the medical record for Patient #24 revealed a 32 year old female admitted to the hospital on 09/05/11 at 4:30pm under a PEC (Physician's Emergency Certificate) for severe depression and paranoid thoughts. Further review revealed Patient #24 had a history of being sexually abused. Review of the Physicians' Admit Orders dated 09/05/11 at 4:30pm revealed Patient #24 was placed on close observation (observation every 15 minutes).

Review of the Nurse's Progress Notes dated/timed 09/05/11 at 9:30pm revealed that while on staff PC (psychiatric counselor rounds) Patient #24 was found in her bathroom hitting her head against the corner of the wall. According to the Physician's Orders dated/timed 09/05/11 at 9:30pm orders for SVC (Strict Visual Contract) to prevent patient from harming herself was ordered. The order was changed to MVC/CO (Modified Visual Contact/Close Observation) on 09/06/11 at 2:10pm.

Review of the Patient Monitoring Record for Patient #24 dated 9/5/11 at 9:30pm through 09/06/11 at 2:00pm revealed no documented evidenced the patient had been placed on SVC as evidenced by no change made to the observation status. Further review of the Nursing Progress Notes dated 09/05/11 at 9:30pm through 09/06/11 at 2:00pm revealed one entry at the time the order was documented in the progress notes concerning the patient being placed on SVC, one by the PC (psychiatric counselor) when the patient came out of her room (no specific time documented only that it occurred during the 3p-11p shift) and that the patient was observed sleeping at 5:05am by a nurse.

Review of the Nurse's Progress Notes dated/timed 09/06/11 at 2100 (9:00pm) revealed Patient #24 was found lying in a fetal position in the shower with the water running. Patient #24 was describes as despondent with her eyes closed tight and expressed to staff she was having flashbacks of waking up next to her father in bed. According to the Physician's Orders dated/times 09/06/11 at 2145 (9:45pm) Patient #24 was placed on SVC until 2:45pm on 09/07/11 at which time observation changed to MVC/CO.

Review of the Patient Monitoring Record for Patient #24 dated 09/06/11 revealed under the section titled "Status" an X was placed in the box next to SVC and a line through SVC; a large check mark over MVC/CO but without any mark in the box and then handwritten SVC with a big X with changed to MVC/CO. Further review revealed no documented evidence of who had completed the status section or the handwritten entries.

Review of the Nursing Progress Notes dated 09/06/11 at 2245 (10:45pm) revealed an entry by the nurse indicating Patient #24 was on SVC. Further review revealed no further entries until 9:15am on 09/07/11 which did not address monitoring of the patient.

2) Failing to update the treatment plan after a change in a patient's condition:
Patient #3
Review of Patient #3's "Psychiatric Admission Summary" revealed he was admitted on 11/08/11 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems. Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/08/11 at 12:05pm due to Patient #3 being homicidal and dangerous to others. A Coroner's Emergency Certificate (CEC) was signed on 11/09/11 at 1:31pm due to Patient #3 being dangerous to others.

Review of Patient #3's "Multidisciplinary Progress Notes" revealed the following entry on 11/10/11 at 11:00pm by Psychiatric Counselor (PC) S31: "...Pt (patient) became upset when sent to bed early for cursing at peers. Pt wrapped a shirt around his neck & (and) said "I want to kill myself".

Review of Patient #3's "Master Treatment Plan" revealed no documented evidence his treatment was updated with interventions and goals for a suicide attempt and threat that occurred on 11/10/11.

In a face-to-face interview on 02/27/12 at 11:50am, RN S28 indicated Patient #3's treatment plan should have been updated when he attempted suicide by wrapping a sheet around his neck.

Patient #13
Review of Patient #13's "Psychiatric Admission Summary" revealed he was a 12 year old male admitted on 02/14/12 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Disruptive Behavior Disorder, Parent-Child Relational Conflict, and Mild Mental Retardation. Further review of his medical record revealed a PEC was completed on 02/11/12 at 455 (no documented evidence whether the time was am or pm) due to Patient #13 being violent and dangerous to self. A CEC was signed on 02/14/12 at 1415 (2:15pm) due to Patient #13 being violent, dangerous to self, dangerous to others, and gravely disabled.

Review of Patient #13's "Master Treatment Plan" dated 02/17/12 (developed 13 days after his admission) revealed his problems identified were mood lability with suicidal/homicidal ideations, family conflict, and behaviors resulting in danger to self or others.

Review of Patient #13's "Multidisciplinary Notes" dated 02/21/12 at 10:00pm revealed RN S32 documented "redirected many times for pulling his pants below his buttocks & (and) showing his underwear...".

Observation on 02/23/12 at 10:35am revealed Patient #13 attended a group session led by MSW (medical social worker) S26. Observation revealed Patient #13 continued to move from chair to chair in the room and pulled his pants leg up to show his underwear. During the observation S26 had to instruct Patient #13 to put his pants leg down.

Review of Patient #13's medical record revealed he was placed in seclusion on 02/15/12 at 4:15pm due to him jumping on tables, running, throwing toys at staff, attempting to scratch and bite staff, kicking, and head-butting. Further review revealed Patient #13 was placed in seclusion on 02/21/12 at 8:45pm due to being extremely oppositional and defiant and refusing all redirections. Further review revealed he was placed in seclusion on 02/23/12 at 3:15pm due to screaming and kicking, biting, punching, and scratching staff.

Review of Patient #13's "Master Treatment Plan" revealed no documented evidence his plan was updated to include sexually inappropriate behaviors and the continued need for seclusion. Further review revealed his "Mood Lability", "Behaviors resulting in danger to self or others", and "Family Conflict short term goals were to be accomplished by day 2, day 3, and day 5 of treatment. There was no documented evidence whether the goals had been accomplished or whether they had been revised by 39 days after admit.

In a face-to-face interview on 02/27/12 at 11:15am, RN Manager of the Child/Adolescent Unit S28 confirmed that Patient #13's treatment plan was not revised to include sexually inappropriate behavior. S28 indicated the behavior wasn't present when the care plan was developed. In the same interview, RN Manager S11 indicated the patient's care plan can be revised as needed and did not have to be done at the weekly treatment team meeting.

3) Failing to evaluate the patient's treatment plan to determine if the patient had met his/her goal by the target date established and whether the plan needed to be revised:
Patient #14
Review of Patient #14's medical record revealed he was an 8 year old male admitted on 01/25/12 with the diagnoses of Depressive Disorder, Post Traumatic Stress Disorder, Physical Abuse, Sexual Abuse, and Disruptive Behavior Disorder. Further review revealed a PEC was completed on 01/25/12 at 4:30pm due to Patient #14 being suicidal, homicidal, violent, dangerous to self and others, and gravely disabled. A CEC was signed on 01/27/12 at 11:20am due to Patient #14 being dangerous to self and others and gravely disabled.

Review of Patient #14's "Master Treatment Plan" dated 01/29/12 revealed his problems identified were mood lability and ineffective coping. Further review revealed the short term goals for each problem were to be met by day 2 and day 3. There was no documented evidence whether the goals were met or whether the goals were revised.

Review of Patient #14's "Treatment Plan Update Patient Reassessment" dated 02/04/12 revealed the progress since last review for mood lability was that the patient "is attacking roommate", and the short term goal was that the patient "will work on anger management with staff". Further review revealed the progress since the last review for ineffective coping was "trashes room when not given his way". The short term goal for ineffective coping was that the patient "will work on impulse control with staff". Further review revealed no documented evidence that the question of whether each problem had been resolved was answered as evidenced by absence of a check mark in the box labeled yes and no. Further review revealed no documented evidence that the question of whether the problems were resolved had been answered. There was no documented evidence of the interventions that would be used to accomplish the goals and the specific staff member responsible for the intervention.

Review of Patient #14's "Treatment Plan Update Patient Reassessment" dated 02/11/12 revealed the progress since last review for mood lability was that the patient "is arguing (with) peers, trying to intimidate peers". The short term goal was that the patient "will (decrease) aggressiveness & (decrease) argumentativeness". Further review revealed the progress since the last review for ineffective coping was the patient "is oppositional, more focused on peers behavior than his". The short term goal for ineffective coping was that the patient "will focus on his behavior not the behavior of peers, will follow milieu & staff direction". Further review revealed no documented evidence whether the problems had resolved or if problems had been added. There was no documented evidence of the interventions that would be used to accomplish the goals and the specific staff member responsible for the intervention.

Review of Patient #14's "Treatment Plan Update Patient Reassessment" dated 02/18/12 revealed the progress since last review for mood lability was that the patient was "(increasingly) hyper, had (increased) difficulty settling down for bed, bath", and the short term goal was that the patient "will calm down & be ready for bed, (no) talking, 2 days". Further review revealed the progress since the last review for ineffective coping was the patient "requires constant redirection 2 x (times) in time out chair, hyper & loud". The short term goal was that the patient "will follow direction on 1st request, (no) time out chair for 1 day". There was no documented evidence of the interventions that would be used to accomplish the goals and the specific staff member responsible for the intervention. Further review revealed no documented evidence whether Patient #14 met the goals by day 1 and day 2 (when record reviewed 5 days after the plan was developed) or if the plan had to be revised.

In a face-to-face interview on 02/27/12 at 9:00am with Administrator S1, Director of Nursing S2 and Corporate Director Clinical Services S46 , neither S1, S2, nor S46 could offer an explanation for the patients' treatment plans not being updated with the patients' changes in condition or when the interventions were not effective in meeting the patients' goals.

In a face-to-face interview on 02/27/12 at 11:15am, RN Manager of the Child/Adolescent Unit S28 confirmed Patient #14's treatment plan was not updated during the treatment team meetings. S28 further indicated the physician made changes to the plan, but the RN did not update it with interventions and goals.

Review of the policy titled "Multidisciplinary Master Treatment Plan/Treatment Plan Update/Patient Reassessment", last reviewed 2011 and submitted as the one currently in use, revealed, in part, "...Procedure: 4. Specific goals and measurable objectives or outcomes, interventions planned, recommendations, frequency or treatment procedures and the person, by name and title, responsible are to be documented by the discipline responsible as determined by the treatment plan...Procedure: 7. The master treatment plan shall be updated frequently as clinically indicated, and at least as often as every 7 days...".

4) Failing to follow physician orders for vital signs on patients experiencing drug withdrawal:
Patient #19
Review of Patient #19's medical record revealed a 26 year old female admitted to the hospital on 02/15/12 under a formal voluntary admission to the Dual Diagnosis Unit for opiate and benzo dependency.

Review of the Physician's Admit Orders for Patient #19 dated/timed 02/15/12 at 5:00pm revealed an order for vital signs Q (every) 4 hours X (times) 72 hours and prn (as needed), then bid (twice a day) if stable.

Review of the Detoxification Flowsheet revealed Patient #19 was assessed for vital signs on admit at 3:50 (am/pm not documented); however according to the nurse's admit note the time was 3:50pm. Further review revealed no documented evidence Patient #19 was assessed for vital signs at 8:00pm, 12:00am, and 4:00am on 02/15/16. Review of the vital signs for 02/16/12 and 02/17/12 revealed vial signs were assessed from from 6:00am through 8:00pm and not every four hours as ordered.

Patient #20
Review of the medical for Patient #20 revealed a 54 year old female admitted to the hospital on 10/29/11 under a formal voluntary admission for opiate dependency. Review of the Physician's Admit Orders dated/timed 10/29/11 at 5:00pm revealed an order for vital signs Q (every) 4 hours X (times) 72 hours and prn (as needed), then bid (twice a day) if stable.

Review of the Detoxification Flowsheet for Patient #20 revealed vital signs were assessed as follows: 10/29/11 at 5:55pm, 8:00pm; 10/30/11 at 6:00am, 10:00am, 4:00pm; 10/31/11 6 (no am/pm documented) and 4:00pm; 11/01/11 at 6 (no am/pm documented), 10:00am, 4:00pm and 8:00pm. Further review of the medical record revealed no documented evidence vital signs were taken every four hours as ordered.

Patient #23
Review of the patient's clinical record revealed the patient was admitted to the facility on 02/07/12 and was currently a patient on the Dual Diagnosis Unit. The Master Treatment Plan revealed the patient's diagnoses were Alcohol Dependency, Anxiety/Depression.

Review of the physician's orders dated 02/07/12 revealed the following order: Vital signs Q (Every) 4 hours and PRN (As needed) for 72 hours PRN then BID (Twice a day) if stable.

Review of the Detoxification Flow Sheets revealed the following:
Vital Signs Q 4 hours and PRN X 72 hours
02/07/12 - 7:50 p.m. Temperature: 99.1, Pulse 107, Respiration: 18, Blood Pressure: 130/92
There was no documented evidence of any other vital signs done for Patient #23 until 02/08/12 at 6 a.m.

02/08/12 - Vital signs were documented at 6 a.m., 10 a.m., 4 p.m. (6 hours), and 8 p.m. There was no documented evidence of any vital signs taken after 8 p.m. on 02/08/12.

02/09/12 - Vital signs were documented at 6 a.m., 10 a.m., 4 p.m. (6 hours), and 8 p.m. There was no documented evidence of any vital signs taken after 8 p.m. on 02/09/12.

In a face to face interview on 02/27/12 at 12:25 p.m., the RN Nurse Manager of the Adult Unit, S11 reviewed the clinical record for Patient #23. S11 verified that the physician had ordered vital signs to be monitored every 4 hours for 72 hours on 02/07/12. S11 verified the only vital signs documented on 02/07/12 were at 7:50 p.m. S11 verified that on 02/08/12 and 02/09/12, there were no vital signs taken after 8:00 p.m.




26351




17091




25065

Based on record review and interview, the hospital failed to ensure a registered nurse (RN) assigned the nursing care of each patient to other nursing personnel according to the needs of the patient and the qualifications and competence of the available nursing staff. The RN delegated the conductance of group sessions to psychiatric counselors (PC) who had not received training and had not been assessed for competency to conduct group sessions for 3 of 3 PCs' personnel files reviewed from a total of 47 PCs employed (S15, S20, S31). The hospital could provide no documented evidence that a RN made staff assignments on the 11:00pm to 7:00am shift on the child/adolescent unit. Findings:

1) Group sessions by PCs who had not received training and had not been assessed for competency to conduct group sessions:
Review of the personnel records for PCs S15, S20, and S31 revealed no documented evidence of any training or competency assessment on conductance of group therapy.

In a face to face interview on 02/27/12 at 12:00 p.m. with the Director of Nursing, S2DON, she stated they did not have documentation of training or competency assessment for PCs on conducting group therapy.

In a face to face interview on 02/27/12 at 3:00 p.m. with the RN Manager of the Adult Unit, S 11 RN was asked what training and competency assessment was done to ensure the PC staff were competent in conducting group therapy. S 11 RN stated she included an evaluation of the PC's group conductance in their annual evaluation, but stated this was not done until the PC had been employed one year. S 11 RN verified there was no documentation of training or any competency assessment done for the conductance of group therapy for the PC staff.

Patient #2
Review of Patient #2's "Psychiatric Admission Summary" revealed he was admitted on 11/02/11 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Combined Type Disruptive Behavior Disorder, and Rule out Oppositional Defiant Disorder. Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/01/11 at 1:40pm due to Patient #2 being homicidal and dangerous to others. A Coroner's Emergency Certificate (CEC) was signed on 11/01/11 at 1:43pm (1342) due to Patient #2 being dangerous to others.

Review of Patient #2's "Group Note" dated 11/03/11 at 1900 (7:00pm), 11/03/11 at 1:00pm, 11/04/11 at 8:15pm, 11/06/11 at 8:30am, 11/06/11 at 1600 (4:00pm), 11/07/11 at 9:00am, and 11/07/11 at 7:30pm revealed these were nursing groups conducted by PCs who had no documented evidence of training and and assessment of competency to conduct groups. Further review revealed education groups were conducted by PCs who had no documented evidence of training and /or assessment of competency to conduct groups on 11/03/11 at 1900 (7:00pm), 11/03/11 at 1:00pm, 11/04/11 at 8:15pm, 11/06/11 at 8:30am, 11/06/11 at 1600 (4:00pm), 11/07/11 at 9:00am, and 11/07/11 at 7:30pm. Further review revealed a process group titled "are you growing worries " , " expressing anger " , " respect " , " anger-dousing " , " doing something nice for someone else " , and/or " responsibility " were conducted by a PC who had no documented evidence of training and/or assessment of competency to conduct groups on 11/03/11 at 1900 (7:00pm), 11/03/11 at 1:00pm, 11/04/11 at 8:15pm, 11/06/11 at 8:30am, 11/06/11 at 1600 (4:00pm), 11/07/11 at 9:00am, and/or 11/07/11 at 7:30pm.

Patient #3
Review of Patient #3's "Psychiatric Admission Summary" revealed he was a 9 year old male admitted on 11/08/11 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems. Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/08/11 at 12:05pm due to Patient #3 being homicidal and dangerous to others. A Coroner's Emergency Certificate (CEC) was signed on 11/09/11 at 1:31pm due to Patient #3 being dangerous to others.

Review of Patient #3's "Group Note" dated 11/08/11 at 1600 (4:00pm), 11/09/11 at 9:00am, 11/09/11 at 1800 (6:00pm), 11/11/11 at 5:00pm, 11/12/11 at 7:45pm, 11/13/11 at 8:00pm, and 11/15/11 at 7:00pm revealed these were nursing groups conducted by PCs who had no documented evidence of training and and assessment of competency to conduct groups. Further review revealed education groups were conducted by PCs who had no documented evidence of training and and assessment of competency to conduct groups on 11/11/11 at 9:30am, 11/12/11 at 10:30am, 11/13/11 at 11:00 (no documented evidence whether am or pm), 11/14/11 at 9:30 (no documented evidence whether am or pm), 11/15/11 at 9:30 (no documented evidence whether am or pm), and 11/16/11 at 9:30 (no documented evidence whether am or pm). Further review revealed a process group titled "focusing on own treatment" was conducted by a PC who had no documented evidence of training and and assessment of competency to conduct groups on 11/10/11 at 7:00pm.

Patient #4
Review of the patient's clinical record revealed the patient was an 8 year old male admitted to the facility on 11/15/11 as a PEC for violent behavior. The patient's diagnoses included Psychoses, Major Depression, Suicidal Ideations. The record revealed the patient was discharged on 11/18/11.

Review of Patient #4's "Group Note" dated 11/16/11 at 7:45 p.m. and 11/17/11 at 8:00 p.m. revealed these were nursing groups conducted by PCs who had no documented evidence of training and assessment of competency to conduct groups. Further review of the Group Notes revealed that Education Groups on Coping Skills, Responsibility, and Anger-Dousing were conducted by PCs who had no documented evidence of training and competency assessment to conduct group therapy.

Patient #5
Review of Patient #5's "Psychiatric Admission Summary" revealed a 16 year old female admitted to the hospital on 11/23/11 under a PEC (Physician's Emergency Certificate) for suicidal thoughts and behavioral problems at home Further review of the medical record revealed the diagnoses of Major Depressive Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems and Cannabis Abuse.

Review of the Group Note for Patient #5 dated 11/24/11 at 1600 (4:00pm) revealed the nursing group with the subject of coping skills for the purpose of patient education. Further review revealed Patient #24 was observed as an active participant with appropriate behavior and response. In addition a handwritten note stated the patient "did not participate, sleepy". The group and the observations were performed by PC S15 a psychiatric counselor with no documented evidence of training or assessed competency to perform group.

Patient #12
Review of the patient's clinical record revealed the patient was a 50 year old female admitted to the facility on 01/03/12. The Master Treatment Plan revealed the patient's diagnoses were as follows: Stimulant Dependant and withdrawal, Opiate Dependant in remission, Suboxone withdrawal, Cannabis Dependant, and Nicotine Dependant. The Criteria for Discharge was safe detox.

Review of Patient #12's "Group Note" dated 12/30/11 at 7:30 p.m., 12/31/11 at 10:15 a.m., 01/01/12 at 12:00 p.m., 01/02/12 at 12:00 p.m. and 5:00 p.m. revealed these were nursing groups conducted by PCs who had no documented evidence of training and assessment of competency to conduct groups. Further review of the Group Notes revealed that Education Groups on Coping Skills, were conducted on 12/31/11 and 01/03/12 by PCs who had no documented evidence of training and competency assessment to conduct group therapy.

Patient #13
Review of Patient #13's "Psychiatric Admission Summary" revealed he was a 12 year old male admitted on 02/14/12 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Disruptive Behavior Disorder, Parent-Child Relational Conflict, and Mild Mental Retardation. Further review of his medical record revealed a PEC was completed on 02/11/12 at 455 (no documented evidence whether the time was am or pm) due to Patient #13 being violent and dangerous to self. A CEC was signed on 02/14/12 at 1415 (2:15pm) due to Patient #13 being violent, dangerous to self, dangerous to others, and gravely disabled.

Review of Patient #13's "Group Note" dated 02/18/12 at 7:00pm and 02/19/12 at 7:45 (no evidence whether am or pm) revealed these were nursing groups conducted by PCs who had no documented evidence of training and and assessment of competency to conduct groups.
Further review revealed education groups were conducted by PCs who had no documented evidence of training and and assessment of competency to conduct groups on 02/15/12 at 10:10 (no evidence whether am or pm), 02/17/12 at 7:00 (no evidence whether am or pm), 02/18/12 at 9:00am, 02/18/12 at 10:30am, 02/21/12 at 9:30am, and 02/22/12 at 10:00am.

Patient #14
Review of Patient #14's medical record revealed he was an 8 year old male admitted on 01/25/12 with the diagnoses of Depressive Disorder, Post Traumatic Stress Disorder, Physical Abuse, Sexual Abuse, and Disruptive Behavior Disorder. Further review revealed a PEC was completed on 01/25/12 at 4:30pm due to Patient #14 being suicidal, homicidal, violent, dangerous to self and others, and gravely disabled. A CEC was signed on 01/27/12 at 11:20am due to Patient #14 being dangerous to self and others and gravely disabled.

Review of Patient #14's "Group Note" dated 01/26/12 at 9:00am, 01/29/12 at 7:00pm, 02/01/12 at 8:15pm, 02/02/12 at 8:15 (no evidence whether am or pm), 02/05/12 at 8:15pm, 02/04/12 at 8:00pm, 02/05/12 at 8:15 (no evidence whether am or pm), 02/08/12 at 6:45pm, 02/09/12, 02/11/12 at 8:45am, 02/13/12 at 8:00pm, 02/14/12 at 8:00pm, 02/18/12 at 7:00pm, 02/19/12 at 7:45pm, and 02/23/12 at 7:45pm revealed these were nursing groups conducted by PCs who had no documented evidence of training and and assessment of competency to conduct groups.
Further review revealed education groups were conducted by PCs who had no documented evidence of training and and assessment of competency to conduct groups on 01/26/12, 01/27/12, 01/28/12 at 9:15am, 01/31/12 at 8:00 (no evidence whether am or pm and did not document whether group was education or nursing), 01/30/12 at 6:00 (no evidence whether am or pm), 01/30/12 at 9:30 (no evidence whether am or pm), 02/01/12 at 10:00 (no evidence whether am or pm), 02/02/12 at 10:00 (no evidence whether am or pm), 02/03/12 at 1545 (3:45pm), 02/03/12 at 9:30 (no evidence whether am or pm), 02/04/12, 02/05/12 at 10:00 (no evidence whether am or pm), 02/06/12 at 6:00 (no evidence whether am or pm), 02/06/12 at 9:30 (no evidence whether am or pm), 02/07/12 at 5:00pm, 02/07/12 at 9:30 (no evidence whether am or pm), 02/08/12 at 9:30 (no evidence whether am or pm), 02/09/12 at 4:00pm, 02/10/12, 02/12/12 at 3:30pm, 02/13/12, 02/15/12, 02/17/12 at 7:00 (no evidence whether am or pm), 02/17/12 at 10:00 (no evidence whether am or pm), 02/18 (no year documented) at 9:00 (no evidence whether am or pm), 02/19/12 at 10:00 (no evidence whether am or pm), 02/21/12 at 9:30 (no evidence whether am or pm), and 02/22/12 at 10:00 (no evidence whether am or pm).
Further review revealed process groups were conducted by PCs who had no documented evidence of training and assessment of competency to conduct groups on 01/28/12 at 4:00pm and 02/11/12 at 5:00pm.

Patient #15
Review of the medical record for Patient #15 revealed a 16 year old male admitted to the hospital under a PEC (Physician ' s Emergency Certificate) for suicidal ideation - thoughts of cutting or burning himself.

Review of the "Group Notes" for Patient #15 revealed the following groups were performed by
by PCs who had no documented evidence of training and/or assessment of competency to conduct groups: 01/18/12 12:00pm Self-Expression and 8:00pm Wrap-up; 01/19/12 12:00pm Attitude Adjustment and 4:00pm Unit Handbook for Adolescents; 01/20/12 12:00pm Team Building and 4:00pm Goals; 01/21/12 12:00pm Behavioral Treatment Focus and 8:00pm Wrap-up; 01/22/11 8:00pm Wrap-up; 01/23/12 9:00am Treatment Focus; 12:00pm Self-Assessment and 7:00pm Wrap-up/Boundaries; 01/14/12 9:00am Healthy and Health Coping Skills, 3:50pm Peer Pressure; 01/25/12 12:00pm Attitude and Self-Awareness and 7:00pm Wrap-up; 01/26/12 4:00pm Life Skills; 01/27/12 12:00pm Self Expressions and 7:30pm Wrap-up; 01/28/12 12:00pm Anger Management and 3:45pm Coping with Everyday Life; 01/29/12 12:00pm Attitude Adjustment and 7:30pm Goals; 01/30/12 12:00pm Positive Attitudes and 4:00pm Positive Goals; 01/31/12 9:00am Dealing with Conflict and 3:45pm Coping; 02/01/12 12:00pm Self Expression and 8:00pm Wrap-up; 02/02/12 12:00pm Coping Skills and 8:30pm Wrap-up; 02/03/12 12:00pm Self Image and 7:00pm Goals; 02/04/12 12:00pm Goals and 4:00pm The Brain; 02/05/12 12:00pm Emotions; 02/06/12 9:00am Goals and Thinking Errors, 12:00pm Taking Responsibility for What You Feel and 7:20pm Goals; 02/07/12 4:00pm Positive Goals; 02/08/12 12:00pm Coping Skills and 9:00 (am/pm not documented) Goals; 02/09/12 9:00 (am/pm not documented) Goals and 12:00pm Individual Needs; 02/10/12 9:00am Feeling and Emotions and 8:00pm Wrap-up; 02/11/12 3:50pm Unit Rules and Safety; 02/12/12 4:00pm Self-Image; 02/13/12 12:00pm Attitude Tune Up and 4:00pm Goals Check-In; 02/14/12 9:00 (am/pm not documented) Unit Behavioral Guidelines and 4:30pm Goals; 02/15/12 12:00pm Enhancing Social Skills; 02/16/12 12:00pm Development of Interpersonal Skills and 4:40pm Goals; 02/17/12 9:00am Boundaries and Conflicts and 4:30pm Goals; 02/18/12; 02/18/12 8:00pm Wrap-Up; 02/20/12 12:00pm Self-Expression and 4:30pm Goals; 02/21/12 8:00pm Wrap-Up; 02/22/12 12:30pm Self-Expressions and 8:30pm Stay on Task.

Patient #17
Review of Patient #17's "Psychiatric Admission Summary" revealed he was admitted on 02/18/12 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, Parachild Relational Problems (PCRP), Physical and Sexual Abuse, victim, and Asthma. Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 02/17/12 at 5:15pm (1715) due to Patient #17 being dangerous to self and others. A Formal Voluntary Admission (FVC) was signed on 02/20/12. .

Review of Patient #17's "Group Note" dated 02/22/12 at 1230pm, 02/22/12 at 8:30pm, 02/21/12 at 12:00pm, 02/21/12 at 8:00pm, 02/20/12 at 12:00pm, and 02/19/12 at 12:00pm revealed these were nursing groups conducted by PCs who had no documented evidence of training and/or assessment of competency to conduct groups. Further review revealed education groups were conducted by PCs who had no documented evidence of training and /or assessment of competency to conduct groups on 02/22/12 at 1230pm, 02/22/12 at 8:30pm, 02/21/12 at 12:00pm, 02/21/12 at 8:00pm, 02/20/12 at 12:00pm, and 02/19/12 at 12:00pm. Further review revealed a process group titled "self expressions " , " stay on task " , " self awareness " , " wrap up " , " self expressions " , and " attitude " were conducted by a PC who had no documented evidence of training and/or assessment of competency to conduct groups on 02/22/12 at 1230pm, 02/22/12 at 8:30pm, 02/21/12 at 12:00pm, 02/21/12 at 8:00pm, 02/20/12 at 12:00pm, and 02/19/12 at 12:00pm.

In a face-to-face interview on 02/27/12 at 2:20pm, MSW (medical social worker) S26 indicated the social workers were responsible for conducting process groups which focused on patient feelings. S26 further indicated she was not involved in educating or training PCs to conduct groups.

2) Staff assignments for the 11:00pm-7:00am shift on the child/adolescent unit:
Review of the "Staff Assignment Sheet" for the child/adolescent unit revealed no documented evidence of staff assignment sheets for the 11:00pm to 7:00am shift.

In a face-to-face interview on 02/27/12 at 2:30pm, RN Manager S11 confirmed there were no staff assignment sheets completed for 11:00pm to 7:00am shift on the child/adolescent unit. S11 further confirmed without an assignment sheet, there was no way to determine that the psychiatric counselors (PC) had been assigned by a RN according to the patients' needs and the PCs' qualifications and competence.

In a face-to-face interview on 02/27/12 at 3:30pm, Director of Nursing S2 confirmed the staff assignments for child/adolescent unit were not by the RN on the night shift. S2 indicated "for the most part the patients are sleeping".

Based on record review and interviews, the hospital failed to ensure: 1) medications were administered as ordered by the physician for 2 of 24 sampled patients (#3, #13) and 2) patients were monitored following the administration of the first dose of newly prescribed medications according to hospital policy for 2 of 24 sampled patients (#3, #5). Findings:

1) Medications administered as ordered by the physician:
Patient #3
Review of Patient #3's "Psychiatric Admission Summary" revealed he was admitted on 11/08/11 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems. Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/08/11 at 12:05pm due to Patient #3 being homicidal and dangerous to others. A Coroner's Emergency Certificate (CEC) was signed on 11/09/11 at 1:31pm due to Patient #3 being dangerous to others.

Review of Patient #3's "Physician's Orders" revealed an order on 11/11/11 at 1330 (1:30pm) for Prozac 10 mg (milligrams) by mouth at bedtime each day.

Review of Patient #3's "Routine Medication Administration Record" (MAR) and the nurses' notes for 11/13/11 revealed no documented evidence that Prozac was administered to Patient #3 at bedtime on 11/13/11.

In a face-to-face interview on 02/27/12 at 11:15am, S28, RN (registered nurse) Manager of the Child/Adolescent Unit, confirmed there was no documented evidence that Prozac was administered to Patient #3 on 11/13/11.

Patient #13
Review of Patient #13's "Psychiatric Admission Summary" revealed he was admitted on 02/14/12 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Disruptive Behavior Disorder, Parent-Child Relational Conflict, and Mild Mental Retardation. Further review of his medical record revealed a PEC was completed on 02/11/12 at 455 (no documented evidence whether the time was am or pm) due to Patient #13 being violent and dangerous to self. A CEC was signed on 02/14/12 at 1415 (2:15pm) due to Patient #13 being violent, dangerous to self, dangerous to others, and gravely disabled.

Review of Patient #13's "Physician's Orders" revealed an order was written by Psychiatrist S8 on 02/17/12 at 11:45am for Celexa 20 mg by mouth, 1 now and every morning.

Review of Patient #13's "Routine Medication Administration Record" revealed Celexa that was ordered to be given at 11:45am was administered at 2:00pm, 2 hours and 15 minutes after it had been ordered.

In a face-to-face interview on 02/27/12 at 11:15am, S28, RN Manager of the Child/Adolescent Unit, confirmed the hospital did not have a policy that designated the amount of time after an order was received for a stat or "now" medication that the medication should be administered.

Review of the hospital policy titled "Medication And Pharmacy Function: Medication Management", contained in the policy manual submitted by Administrator S1 as the current policies, reviewed 01/12, and revised 01/10, revealed, in part, "... 7. Individual Medication Administration Records (MARs) ... E. If for some reason the medication is not given, the nurse circles his/her initials for that dose and indicate why medication was not given. An explanation should be put in patient's chart on nurse's notes why not given...".

2) Patients monitored after the first dose of newly prescribed medication:
Patient #3
Review of Patient #3's "Psychiatric Admission Summary" revealed he was admitted on 11/08/11 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems.

Review of Patient #3's "Physician's Orders" revealed an order on 11/11/11 at 1330 (1:30pm) for Prozac 10 mg by mouth at bedtime each day.

Review of Patient #3's medical record revealed the form titled "Patient's Response To The First Dose Of A Medicine" with the date of 11/11/11, the time of 9:00 (no documented evidence of am or pm), and the medication Prozac 10 mg documented. Further review revealed the following information required was not answered as evidenced by a blank line: patient follow-up date and time; questions to be asked 4 to 12 hours after administration - any side effects, comments whether effective, non-effective, unable to determine; staff signature.

Patient #5
Review of Patient #5's "Psychiatric Admission Summary" revealed she was admitted on 11/23/11 under a PEC (Physician's Emergency Certificate) with the diagnoses of Major Depressive Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems and Cannabis Abuse.

Review of Patient #5's "Physician's Orders" revealed an order on 11/27/11 for Prozac 10 mg by mouth every am (morning).

Review of Patient #5's medical record revealed the form titled "Patient's Response To The First Dose Of A Medicine" with the date of 11/27/11, the time of 11:45am, and the medication Prozac 10 mg documented. Further review revealed the following information required was not answered as evidenced by a blank line: patient follow-up date and time; questions to be asked 4 to 12 hours after administration - any side effects, comments whether effective, non-effective, unable to determine; staff signature.

In a face-to-face interview on 02/22/12 at 3:00pm RN S2 Director of Nursing verified the form should have been completed by the nursing staff. Further S2 indicated the form had been created in response to another survey requiring that all patients were re-assessed after administration of first-dose medications.

Review of the hospital policy titled "Medication And Pharmacy Function: Medication Management", contained in the policy manual submitted by Administrator S1 as the current policies, revealed, in part, "... 9. First Dose Monitoring A. The Registered Nurse will monitor the patient following the administration of the first dose of any newly prescribed medication. The nurse will report any possible side effects or reactions immediately to the prescribing physician. The physician will then immediately evaluate the patient to determine appropriate action...".

20177




25065




26351


Based on record review and interview the hospital failed to ensure each patient's medical record was accurately written and promptly completed. The delinquency rate for 2011 was 42%, and the delinquency rate as of January 2012 was 39%. Physician-ordered observation levels were not accurately documented in the medical record for 6 of 24 sampled records (#1, #4, #6, #8, #11, #21). Documented observations were not consistent with the behaviors documented in the progress notes for 3 of 24 sampled patients (#3, #13, #14, #15). White correction liquid (white out) was used in a medical record for 1 of 24 sampled medical records (#6). Findings:

1) Delinquency rate:
Review of the Physician Delinquency rate for January 2012 revealed the total rate was 39%, and the delinquency rate for the year 2011 was 42%.

Review of the Physician Delinquency rate per physician revealed:
S 8 MD had 6 charts over 30 days delinquent, 1 chart over 60 days delinquent, and 1 chart over 90 days delinquent.
S 19 MD had 7 charts over 30 days delinquent, 6 charts over 60 days delinquent, and 4 charts over 90 days delinquent.
S 40 MD had 2 charts over 30 days delinquent and 4 charts over 90 days delinquent.
S 41 MD had 1 chart over 30 days delinquent and 2 charts over 90 days delinquent.
S 39 MD had 1 chart over 30 days delinquent.
S 38 MD had 1 chart over 234 days delinquent.

An interview was conducted with S30 RHIA (Registered Health Information Administrator) on 02/24/12 at 9:25 a.m. She reported that the delinquency rate for medical records was 39% for January. She reported the system in place to notify the doctors of delinquent charts was to e-mail them once a week and "cc" S1Administrator and S 18 Medical Director. She stated she had been at the hospital about 4 years and none of the physicians' privileges had been suspended for delinquent medical records.

An interview was conducted with S 18 MD on 02/27/12 at 2 p.m. He stated he was the Medical Director of the hospital, and once a month in the Medical Executive Committee the delinquent rate per physician is presented to him. He further reported he speaks to the physicians and reminds them about their delinquent records. He also stated there was no disciplinary actions or suspension of privileges related to delinquent records because he did not see the need for it.

Review of the Medical Staff Rules and Regulations revealed in part, "....On the thirtieth (30th) day after discharge, if the record is incomplete, the Medical Director, the Chief Executive officer, and the Chairman of the Medical Executive Committee will be notified to consider suspension of privileges or other appropriate disciplinary action. Suspension of clinical privileges will usually apply to future cases only. When privileges are suspended, the practitioner must complete all incomplete records before his/her privileges will be reinstated. A record is not complete until all material has been dictated, transcribed, and signed...".

2) Physician-ordered observation levels were not accurately recorded in the medical record:
Patient #1
Review of the medical record for Patient #1 revealed she was a 17 year old female admitted on 10/29/11 for mood disorder with suicidal ideations.

Review of the medical record for Patient #1 revealed a physician's order on admission (10/29/11) for MVO/CO (moderate visual contact/close observation) as the observation status. Review of the Patient Monitor Record for 10/29/11 revealed no observation indicated on the form. Review of the Patient Monitor Record for 10/30/11 revealed her observation status was documented as CO (close observation). Review of the Patient Monitor Record for 10/31/11 revealed her observation status was documented as CO (close observation). Review of the Patient Monitor Record for 11/1/11 revealed her observation status was documented as CO (close observation). Patient #1 was discharged on 11/1/11.

An interview was conducted with S 11 Nurse Manager and S 28 Nurse Manager on 02/27/12 at 11:10 a.m. They confirmed there was no physician order for close observation status, only MVO/CO. The wrong observation status was documented or not documented the patient's entire hospitalization.

Patient #4
Review of the medical record for Patient #4 revealed an 8 year old male admitted to the hospital on 11/15/11 at 8:30 p.m. under a PEC (Physician Emergency Certificate) for suicidal ideations, Psychosis, and Major Depressive Disorder. Review of the Physician's Admission Orders dated 11/15/11 at 8:30 p.m. revealed Patient #4 was placed on MVC/CO (Modified Visual contact/Close Observation). Review of the physician's orders revealed no documented evidence that the MVC/CO observation status was changed during the patient's hospital stay. The record revealed the patient was discharged on 11/18/11.

Review of the Multidisciplinary Assessment dated 11/15/11, revealed that the Initial Treatment Plan identified safety as a patient problem and an intervention for this problem was MVC/CO.

Review of the Patient Monitoring Records for Patient #4 revealed on 11/15/11 the observation status was left blank and did not indicate the level of observation provided to the patient.

Review of the Reassessment/Progress Notes for Patient #4 revealed that on 11/16/11 the RN checked CO under the patient safety section. On 11/17/11 there was no assessment of the observation status documented by the RN. On 11/18/11 the RN checked MVO/CO as the observation status and indicated in the progress notes that the patient was discharged to home at 1:00 p.m. on 01/18/11.

In a face--o face interview on 02/27/12 at 12:05 p.m. with the RN Manager of the Adolescent Unit S28, she reviewed the patient's record and verified that the observation status ordered by the physician on admit was for MVC/CO, and there were no physician's orders to change the observation status. S28 verified the Patient Monitoring Records did not indicate the level of observation ordered by the physician on 11/15/11. S28 verified there was no observation status documented by the RN on 11/17/11.

Patient #6
Patient #6 was a 11 year old boy admitted to the hospital on 11/30/11 by Coroner's Emergency Certificate for hearing voices telling him to kill his school mates and himself. He attempted to put his head through a glass door because the voice told him to do it.

Review of the the Admission Orders dated 11/30/11 revealed a physician order for MVC/CO observation status. Review of the Patient Monitor Record date 11/30/11 revealed no observation status was indicated.

An interview was conducted with S11 Nurse Manager and S28 Nurse Manager on 02/27/11 at 11:10 a.m. They reported if an observation status was not marked, the observation status was close observation (CO), not MVC/CO as ordered by the physician.

Patient #8
Review of the medical record of Patient #8 revealed a a 13 year old male admitted to the hospital under a PEC (Physician's Emergency Certificate) for pulling a knife on his mother's boyfriend. Review of the Physician's Admit Orders dated/times 12/13/11 at 1:25am revealed an order for an observation status of MVC/CO (Modified Visual Contact/Close Observation).

Review of the Patient Monitor Record for Patient #8 dated 12/13/11 revealed the following: 3:00pm through 3:45pm Patient #8 was in his room displaying cooperative behavior; 4:15pm through 8:00pm was in his dayroom displaying cooperative behavior which was recorded by the psychiatric counselor.

Review of the Multidisciplinary Progress Notes for Patient #8, dated/timed 12/13/11 at 3:05pm by S47 PC (Psychiatric Counselor), revealed "...Patient is all over the place, picking in the bottom of the wall digging out the grout, eating black pepper, poor boundaries with his peers, sitting too close or getting in their face, needs to be re-directed...".

Review of the Patient Monitor Record dated 12/15/11 from 7:30am through 12/16/11 at 7:15am revealed Patient #8's behavior to be CP (cooperative).

Review of the Multidisciplinary Progress Notes for Patient #8 dated/timed 12/15/11 at 3:00pm revealed ..... "Patient seemed impulsive and was often noted pacing and saying sexual comments to peers and making jumpy furtive (flurtive) gestures. Pt. presented an incongruent affect and isolated himself from peers at times. Pt. was compliant at times with re-direction but was argumentative at times.

Review of the Patient Monitor Record dated 12/16/11 from 7:30am through 12/17/11 at 7:15am revealed Patient #8's behavior to be CP (cooperative).

Review of the Multidisciplinary Progress Notes for Patient #8 dated/timed 12/16/11 at 3:00pm revealed "...Pt. pressures with a bizarre affect, after that he was quiet, isolative, often made bizarre remarks and seemed confused at times. 2010 (8:10pm) Pt. was hyperactive and hyperverbal. Pt. talked about bathing babies. Pt. also stated he wanted a women's bra...".

Review of the Patient Monitor Record dated 12/17/11 from 7:30am through 12/18/11 at 7:15am revealed Patient #8's behavior to be CP (cooperative).

Review of the Multidisciplinary Progress Notes for Patient #8 dated/timed 12/17/11 at 2:00pm revealed "...Pt. was sociable with peers, but re-directed for hyperactive bx (behavior)". 6:15pm Pt. was hyperactive and needed constant redirection. Pt horseplayed with peers and almost started a fight...".

Review of the Patient Monitor Record dated 12/18/11 from 7:30am through 12/19/11 at 7:15am revealed Patient #8's behavior to be CP (cooperative).

Review of the Multidisciplinary Progress Notes for Patient #8 dated/timed 12/18/11 at 11:15am revealed "...Hyperactive, hyperverbal, boundary issues. Appears anxious i..e. legs shaking, pacing, etc... 9:30pm Pt was hyperactive and required redirection by staff for poor boundaries with female peers...".

Patient #11
Review of the medical record for Patient #11 revealed a 14 year old female admitted to the hospital on 12/30/11 at 11:55 a.m. under a PEC (Physician's Emergency Certificate) for suicidal ideations and Major Depressive Disorder. Review of the Physician's Admission Orders dated 12/30/11 at 11:55 a.m. revealed Patient #11 was placed on MVC/CO (Modified Visual contact/Close Observation). Review of the physician's orders revealed no documented evidence that the MVC/CO observation status was changed during the patient's hospital stay. The record revealed the patient was discharged on 01/03/12.

Review of the Multidisciplinary Assessment dated 12/30/11 revealed that the Initial Treatment Plan was left blank. Review of the Master Treatment Plan revealed no documented evidence of the observation status of the patient.

Review of the Patient Monitoring Records for Patient #11 revealed the following observation status:
12/30/11 - Status: SVC (Strict Visual Contact)
12/31/11 - Status: CO (Close Observation)
01/01/12 - Status: CO
01/03/12 - Status: CO

Review of the Reassessment/Progress Notes for Patient #11 revealed that on 12/31/11 the RN checked MVC/CO under the patient safety section. On 01/01/12 and 01/02/12, C/O (Close Observation) was checked by the RN. Review of the progress notes revealed no documented evidence that the observation status was addressed.

In a face-to-face interview on 02/27/12 at 12:05 p.m. with the RN Manager of the Adolescent Unit S28, she reviewed the patient's record and verified that the RN had failed to document the initial treatment plan. S28 confirmed the observation status ordered by the physician on admit was for MVC/CO, and there were no physician's orders to change the observation status. S28 verified the Patient Monitoring Records did not indicate the level of observation ordered by the physician.

Patient #21
Patient #21 was admitted to the hospital on 02/20/12 for Schizoaffective disorder and suicidal ideations.

Review of her Physician's Admission Orders dated 02/20/12 revealed her physician ordered an observation status of SVC (strict visual contact) and next to the observation status was handwritten the word suicidal.
Review of an undated Patient Monitor Record in the patient's medical record revealed the patient was on observation level CO (close observation).

An interview was conducted with S 11 Nurse Manager on 02/23/12 at 10:45 a.m. She reported the undated Patient Monitor Record was for 02/20/12 from 6:45 p.m. to 7:15 a.m. on 02/21/12. She further reported the patient was supposed to be on SVC observation level not CO as documented on the Patient Monitor Record.

3) Documented observations were consistent with the behaviors documented in the progress notes:
Patient #3
Review of Patient #3's "Psychiatric Admission Summary" revealed he was a 9 year old male admitted on 11/08/11 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems. Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/08/11 at 12:05pm due to Patient #3 being homicidal and dangerous to others. A Coroner's Emergency Certificate (CEC) was signed on 11/09/11 at 1:31pm due to Patient #3 being dangerous to others.

Review of Patient #3's "Multidisciplinary Progress Notes" revealed the following entry on 11/10/11 at 11:00pm by Psychiatric Counselor (PC) S31: "...Pt (patient) became upset when sent to bed early for cursing at peers. Pt wrapped a shirt around his neck & (and) said "I want to kill myself". RN notified Psychiatrist S8 & pt was placed on SVC (strict visual contact). (1) Staff provided support, guidance, & encouragement. (o) Pt not compliant (with) unit rules & structure. Pt needs redirection from staff. (P) continue to monitor & follow tx (treatment) plan". Review of the "Patient Monitor Record" documented by PC S31 and dated 11/10/11 revealed Patient #3 was asleep in Module C (children's unit) at 11:00pm.

Review of Patient #3's "Progress Notes" dated 11/12/11 at 10:50 (no documented evidence whether it was am or pm) revealed documentation by PC S42 of "...He began attention seeking and pulling a towel around his neck. He started cursing and disrespecting staff...". Review of Patient #3's "Patient Monitor Record" dated 11/12/11 revealed from 10:45am through 11:00am, Patient #3 was cooperative in Module C, and from 10:45pm through 11:00pm he was sleeping in the quiet room.

Patient #13
Review of Patient #13's "Psychiatric Admission Summary" revealed he was a 12 year old male admitted on 02/14/12 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Disruptive Behavior Disorder, Parent-Child Relational Conflict, and Mild Mental Retardation. Further review of his medical record revealed a PEC was completed on 02/11/12 at 455 (no documented evidence whether the time was am or pm) due to Patient #13 being violent and dangerous to self. A CEC was signed on 02/14/12 at 1415 (2:15pm) due to Patient #13 being violent, dangerous to self, dangerous to others, and gravely disabled.

Review of Patient #13's "Multidisciplinary Progress Notes" dated 02/18/12 revealed he received Vistaril 25 mg IM at 12:30pm administered by RN S45 when he began kicking at staff and stating he was going to kill himself. Further review revealed S45 administered Thorazine 50 mg IM at 2:00pm when Patient #13 began kicking, hitting, head butting, and scratching staff. Review of Patient #13's "Patient Monitor Record" dated 02/18/12 revealed he was cooperative on the child's unit at 12:30pm through 3:15pm when his progress note revealed Patient #13 was medicated for aggression at 12:30pm and 2:00pm.

Review of Patient #13's "Multidisciplinary Progress Notes" dated 02/19/12 revealed he received Thorazine 50 mg IM at 1:05pm administered by RN S45 when he was threatening to stab peers with the head of a pencil and kicking at staff. Review of Patient #13's "Patient Monitor Record" dated 02/19/12 revealed he was cooperative on the child's unit at 1:00pm through 2:15pm when his progress note revealed Patient #13 was medicated for threatening to stab peers with the head of a pencil and kicking at staff at 1:05pm.

Patient #14
Review of Patient #14's medical record revealed he was admitted on 01/25/12 with the diagnoses of Depressive Disorder, Post Traumatic Stress Disorder, Physical Abuse, Sexual Abuse, and Disruptive Behavior Disorder. Further review revealed a PEC was completed on 01/25/12 at 4:30pm due to Patient #14 being suicidal, homicidal, violent, dangerous to self and others, and gravely disabled. A CEC was signed on 01/27/12 at 11:20am due to Patient #14 being dangerous to self and others and gravely disabled.

Review of Patient #14's "Multidisciplinary Progress Notes" dated 01/29/12 revealed an entry at 2:30pm by PC S36 of "...being physically aggressive punching a male child on the face over a movie. Pt was stopped by a female PC & was put in his room by other nursing staff who came to assist. Doctor was called by nurse & she told PCs that if pt stays in his room & he is able to calm himself down he will be okay no shot but a Vistaril by mouth... pt was put on early bedtime & no privileges. Monitor pt behavior encourage pt to follow his treatment plan...". Review of the "Patient Monitor Record" dated 01/29/12 revealed Patient #14 was cooperative in the day area at 2:30pm when his progress note revealed that he was being physically aggressive.

Review of Patient #14's "Reassessment/Progress Note dated 02/15/12 revealed documentation written across the front of the page with no documented evidence of the date, time, and name and title of the person who made the notation. Further review revealed the documentation included "Vistaril 25 mg p.o. (by mouth) at 4PM - agitated angry hostile threatening". Review of the PRN MAR revealed Vistaril 25 mg was given by mouth on 02/15/12 at 10:00pm. Review of the "Multidisciplinary Progress Notes" dated 02/15/12 revealed no documented evidence of an assessment by the RN of the behaviors exhibited by Patient #14 that warranted the need for prn medication at 4:00pm and 10:00pm. Review of the "Patient Monitor Record" dated 02/15/12 revealed Patient #14 was cooperative in his room at 4:00pm and awake in his room at 10:00pm when at 4:00pm his progress notes revealed he was administered Vistaril for agitation and no assessment was performed when he was administered Vistaril at 10:00pm.

In a face-to-face interview on 02/27/12 at 11:15am, RN Manager of the Child/Adolescent Unit S28 indicated if the psychiatric counselor documented her note for the entire shift, and the specific time that an event occurred was not documented, it could result in the observation record and the progress notes information not matching.

Patient #15
Review of the " Psychiatric Admission Summary " dated 01/18/12 for Patient #15 revealed a 16 year old male admitted to the hospital under a PEC (Physician ' s Emergency Certificate) for suicidal ideation - thoughts of cutting or burning himself. Further review revealed Patient #15 had become increasingly frustrated due to having a new social worker and not knowing where he would be living. Patient #15 is in the custody of the State.

Review of the Multidisciplinary Progress Notes for Patient #15 dated 02/10/12 (3-11 shift) revealed the patient became defiant and refused to go to his room. He remained in the Day Room after refusing to go into seclusion. Additional staff was called for assistance and a " take-down " of Patient #15 occurred.

Review of the Patient Monitor Record dated 02/10/12 revealed Patient #15 was assessed as displaying cooperative behavior from 9:00am through 9:15am when he left with the staff on an outing.

In a face to face interview on 02/24/12 at 2:50pm RN S34 Risk Manager reviewed the chart and verified the Patient Monitor Notes documented by the Psychiatric Counselor were not accurate.

4) White correction liquid used:
Review of the medical record for Patient #6 revealed the Patient Monitor Record dated 12/3/12 had white correction liquid (white out) used to remove documentation.

An interview was conducted with S 11 Nurse Manager and S 28 Nurse Manager on 02/27/12 at 11:10 a.m. They reported white correction liquid (white out) should never be used in the medical record.

Based on observations, record review, and interview, the hospital failed to have a system in place to maintain an account of and reconcile expired scheduled drugs kept in the pharmacy. Findings:

An observation was made on 02/23/12 at 2 p.m. with S2 DON (director of nursing) and S27 Pharmacy Tech in the pharmacy . Observation revealed expired medication being haphazardly stacked in a cabinet under the sink in the pharmacy. The cabinet had no lock and was not secured. When S27 Pharmacy Tech was questioned if there were narcotics in with the expired medications under the sink, he stated yes.

An interview was conducted with S44 Pharmacist on 02/23/12 at 2:15 p.m. She stated she was the pharmacist filling in for the regular pharmacist on leave. She stated she was unaware there were narcotics under the pharmacy's sink that were unsecured.

The following controlled substances were found in the unlocked cabinet under the sink:
Acetaminophen and Codeine 300 mg (milligrams)/ 30 mg- 30 tablets
Valium 5 mgs - 5
Chlordiazepoxide 10 mg- 25 tablets
Vyvanse- 2 tablets
Ativan vials 2mg/ml (milliliter)- 21 vials

An interview was conducted with S2 DON on 02/24/12 at 1:45 p.m. She reported there was no system in place to maintain and to routinely reconcile expired scheduled drugs currently, and the policy was being revised.

An interview was conducted with S35 Executive Director of contract company "a" on 02/27/12 at 10:10 a.m. He reported the current pharmacist was on leave, and he was unaware that narcotics were under the sink in the pharmacy and were unsecured. He further reported before Joint Commission surveyed the hospital, he had cleaned out all medication under the pharmacy's sink.

Review of the hospital's current policy titled Controlled Substances, Policy #77, revealed in part, "...It is the policy of the hospital to maintain proper distribution and administration of controlled substances to include adequate documentation and record keeping...All inventories and records of controlled substances in Schedule II must be maintained separately from all other records of controlled substances in Schedules III, IV and V ...Controlled substance drugs are stored in a locked, secure place within the drug storage room. Schedules III, IV, and V are stored in a locked cabinet separately from other drugs. Schedule II medications are stored in a double locked cabinet..."

Based on observation, record review, and interview, the hospital failed to secure expired scheduled II, III, and IV drugs in the pharmacy. Findings:

An observation was made on 02/23/12 at 2 p.m. with S2 DON (director of nursing) and S27 Pharmacy Tech in the pharmacy. Observation revealed expired medication being haphazardly stacked in a cabinet under the sink in the pharmacy. The cabinet had no lock and was not secured. When S27 Pharmacy Tech was questioned if there were narcotics in with the expired medications under the sink, he stated yes. The following controlled substances were found in the unlocked cabinet under the sink:
Acetaminophen and Codeine 300 mg (milligrams)/ 30 mg- 30 tablets
Valium 5 mgs - 5
Chlordiazepoxide 10 mg- 25 tablets
Vyvanse- 2 tablets
Ativan vials 2mg/ml (milliliter)- 21 vials

An interview was conducted with S 35 Executive Director of contract company "a" on 02/27/12 at 10:10 a.m. He reported the current pharmacist was on leave, and he was unaware that narcotics were under the sink in the pharmacy unsecured. He further reported before Joint Commission surveyed the hospital, he had cleaned out all medication under the pharmacy's sink.

Review of the hospital's current policy titled Controlled Substances, Policy #77, revealed in part, "...It is the policy of the hospital to maintain proper distribution and administration of controlled substances to include adequate documentation and record keeping...All inventories and records of controlled substances in Schedule II must be maintained separately from all other records of controlled substances in Schedules III, IV and V ...Controlled substance drugs are stored in a locked, secure place within the drug storage room. Schedules III, IV, and V are stored in a locked cabinet separately from other drugs. Schedule II medications are stored in a double locked cabinet..."

Based on observations, record reviews, and staff interviews, the hospital failed to ensure that the food and dietetic services organization requirements and policies were met as evidenced by: 1) failing to ensure the guidelines for kitchen sanitation was followed as per the "Food Storage Function: Infection Control" policy by having caked black, brown, orange, gray and/or white substances/debris on the ice machine, large metal panel, five (5) cooking sheets, five (5) large sheet pans, food scale, six (6) large dry food containers, a large white lid, clear dinner roll lid, two (2) spice containers, seasonings (Tony Chachere, Oregano, Sage, Whole Dill Weed, Basil, Cinnamon, Caribbean Jerk), deep fat fryer, grill, stove, two (2) convention ovens, five (5) pots, four (4) frying pans, two (2) large strainers, faucet, walk-in cooler, four (4) plastic curtains hanging in the walk way of the cooler, the freezer door located inside the walk-in cooler, and a clip board in the clean kitchen area; 2) failing to ensure there were food temperatures recorded for all meals prior to serving the food to the patients from 11/24/11 through 02/23/12 as per the Dietary Manager S43 and Registered Dietician S17; and 3) failing to follow the food temperature guidelines for hot food to be served at 140 degrees from 01/03/12 through 02/22/12 as per the "Food Storage Function: Infection Control", policy. Findings:

1)
During a tour of the kitchen conducted on 02/23/12 from 8:25 a.m. through 11:30 a.m. with S 43 Dietary Manager and S2DON (Director of Nursing), there was an ice machine observed with three (3) grooved areas on the front of the machine. Further observation revealed there was a whitish piece of plastic with jagged edges extending from the grooved areas approximately one-quarter inch. The jazzed edges on the piece of plastic inside the grooved areas on the machine were grayish in color. Further observation revealed there was a white, brown, and black substance/debris observed under the lid of the ice machine. On the front panel of the ice machine was whitish/brownish debris noted. There was a large metal panel and four (4) cooking sheets stacked on top of the ice machine. Further observation revealed the large metal panel and four cookie sheets were noted cached with a grayish substance/debris. To the left of the ice machine was a rack with five (5) large sheet pans noted in its slots. Further observation revealed the five (5) large sheet pans were cached with a black substance. Next to the rack of sheet pans was a food scale sitting located on the countertop. Further observation revealed the front panel and both sides of the scale were covered with a brownish/orangish substance. There were a total of six (6) large stacked dry food containers noted below the cooks prep area with brown rice, white rice (empty container), corn meal and/or yellow corn meal. Further observation revealed the top and sides of these six (6) stacked containers was cached with a grayish/whitish substances. To the right of these six (6) stacked containers was a large white lid noted with a whitish/orange debris. At 9:55 a.m., there was a clear dinner roll lid noted covered with brown debris located next to stacked dinner rolls on top of the cook's prep area. At 9:59 a.m., there were two (2) spice storage bins observed under the cook's prep area. Further observation revealed the two (2) spice storage bins had a whitish, orange, grayish, red, black and brown substance in the bottom of the containers. There was an orange substance observed on the Tony Chachere seasoning's lid, a brown/black substance on the Oregano seasoning's lid, a gray substance on the Sage seasoning's lid, a grayish/white substance on the Whole Dill Weed seasoning's lid, a brown/reddish substance on the Basil seasoning's lid, a whitish substance on the Cinnamon seasoning's lid, and a whitish/gray substance on the Caribbean Jerk seasoning's lid. At 10:00 a.m., the deep fat fryer was observed with two (2) side panels. Further observation revealed these two (2) side panels of the fryer were covered with a cached brown, white, and gray substances. At 10:07 a.m., the grill was observed with orange cached debris on the side panels. Further observation revealed the grill's edges were covered with a cached orange/brown substance. There was a one (1) inch by half-inch (1/2) piece of orange, brown, and black debris noted on the right side panel of the grill. The DON (S2) peeled the piece of debris from the side panel at this time and discarded it in the trash. At 10:08 a.m., the six (6) burner stove was observed with a cached white, orange, brown, and black substance on the surface between the burners. Further observation revealed the front and back two (2) left burner's on the stove was noted with small black pieces of chipped debris. At 10:15 a.m., there were two (2) convention ovens observed. Further observation of the ovens revealed the front bottom panel areas were cached with a black substance. The black handles on the stoves had a whitish, orange, and brown substance and debris noted on top of them. There were three (3) knobs (power, temperature, and timer) on the stoves that were covered with white debris and cached with a grayish substance. At 10:20 a.m., there were a total of five (5) pots and four (4) frying pans observed cached with a brownish/black substances. There were two (2) large metal strainers had the bottom inner rings that were covered with an orange debris. At 10:20 a.m., the double sink area used to prep vegetables was observed with a facet. Further observation revealed the facet did not have a plate that covered the back area of the facet. The faucet's connecting device (screws) were exposed and covered with orange, green, and white substance. The right facet handle was observed covered with a whitish substance. At 10:25 a.m., the bottom panels of the walk-in cooler was observed with an orange substance on both panels. The four (4) plastic curtains hanging in the walk way of the cooler was observed covered with a whitish substance. The bottom of the freezer door located inside the walk-in cooler was observed with a cached orange substance. At 10:35 a.m., a clip board with a menu for that week was observed on the countertop in the cook's prep area. Further observation revealed the clip on the clip board and the area behind the clip was cached with black debris. S2DON put the clip board in the trash can at this time.

In an interview on 02/23/12 from 8:25 a.m. through 11:30 a.m., S2DON and S 43 Dietary Manager confirmed all the above findings during the tour of the kitchen.

Review of the policy titled, "Food Storage Function: Infection Control", with no policy number, page 1 of 1, last reviewed date of 9/11, last revised date of 1/11, presented as the hospital's current "Food Temperature" policy indicated the kitchen will be kept clean at all times.

Review of the "Food Storage Function: Infection Control", with no policy number, pages 1 to 3, last reviewed date of 2/11, last revised date of 1/10, with no effective date, presented as the hospital's current "Food Storage/Equipment" policy indicated all foods, non-food items and supplies, related to and used in food preparations shall be stored in such a manner to prevent bacteriological contamination. The dry food storage area must be clean. The containers for dry food item storage must be used for bulk materials such as flour, sugar, mixes, dry lentils, pasta, and etc. The containers should be fabricated so that residue may be completely removed by normal cleaning methods, and have tight lids. Food not subject to further washing or cooking before serving shall be stored in such a manner as to be protected against contamination from food requiring washing or cooking.

2)
During the hot/cold food temperature checks of a test tray by S 17 Registered Dietician on 02/23/12 at 12:25 p.m., the mixed vegetable temperature was one hundred ten (110) degrees Fahrenheit.

In an interview on 02/23/12 at 12:25 p.m., S 17 Registered Dietician and S2DON confirmed the mixed vegetables were a hot food that should be served to the patients a temperature of 140 degrees Fahrenheit.

Review of the policy titled, "Food Storage Function: Infection Control", with no policy number, page 1 of 1, last reviewed date of 9/11, last revised date of 1/11, presented as the hospital's current "Food Temperature" policy indicated the sanitation in storage for hot foods shall leave the kitchen or steam table at or above 140 degrees Fahrenheit.

Review of the "Dietary Manual " revealed there was no policy regarding the temperatures of the food were to be checked and recorded on the "Patient Service Log-Checklist" prior to serving the food to the patients presented during the survey conducted from 02/22/12 through 02/27/12.

Review of the "Patient Service Log-Checklists" revealed there was no food temperatures recorded for the hot/cold food served to the patients during breakfast, dinner and/or lunch on 02/21/12, 01/01/12, 12/25/11, and 11/24/11.

Further review of the "Patient Service Log-Checklists" revealed there was no food temperatures recorded for the hot/cold food served to the patients during dinner on 02/14/12, 02/05/12, 02/04/12, 02/02/12, 01/29/12, 01/28/12, 01/23/12, 01/20/12, 01/19/12, 01/15/12, 01/14/12, 01/12/12, 01/11/12, 01/10/12, 01/09/12, 01/08/12, 01/07/12, 01/06/12, 01/04/12 and 01/02/12.

There was no food temperatures recorded on the "Patient Service Log-Checklists" for the hot/cold food served to the patients during lunch on 01/06/12.

Further review of the "Patient Service Log-Checklist" revealed there was no food temperatures recorded for the hot/cold food served to the patients during breakfast on 02/23/12, 01/13/12 and 01/06/12.

There was no food temperature recorded on the "Patient Service Log-Checklist" for the hot food temperature of the french toast served to the patients for breakfast on 02/08/12 or 01/04/12, the English muffin on 01/31/12 or 01/10/12, and/or bacon on 02/17/12.

In interviews conducted on 02/23/12 from 08:30 a.m. through 09:45 a.m., S 17 Registered Dietician and S 43 Dietary Manager both indicated all food temperatures must be checked and recorded on the "Patient Service Log-Checklist" prior to serving the food to the patients as per protocol. The Registered Dietician (S17) and Dietary Manager (S43) both confirmed there were no food temperatures checked and/or recorded for the food served to the patients in the hospital from 11/24/11 through 02/23/12 as indicated in the above findings as per policy. S17 and S43 both indicated all cooks are expected to check and record the food temperature of the hot/cold food prior to serving the patients the meals (breakfast, lunch, dinner) on the "Patient Service Log-Checklist" as per policy. Both S17 and S43 denied knowledge there were no food temperatures recorded for the food served to the patients from 11/24/11 through 02/23/12 as per policy.

3)
Review of the "Patient Service Log-Checklists" for the hot foods served to the patients revealed the following food temperatures:
The French toast was ninety (90) degrees Fahrenheit on 02/22/12 and 01/25/12, was seventy (70) degrees Fahrenheit on 01/29/12, was one hundred thirty (130) degrees Fahrenheit on 01/15/12;
The Biscuit was eighty (80) degrees Fahrenheit on 02/20/12 and 01/23/12, was fifty (50) degrees Fahrenheit on 02/10/12, was sixty (60) degrees Fahrenheit on 02/03/12, 01/28/12, 01/27/12, and 01/20/12;
The Bacon was 60 degrees Fahrenheit on 02/10/12, 02/06/12, and 01/10/12, was 90 degrees Fahrenheit on 02/07/12, 01/27/12, and 01/20/12, was 80 degrees Fahrenheit on 02/03/12, 01/24/12, 01/17/12 and 01/03/12, and one hundred (100) degrees Fahrenheit on 01/31/12;
The Pancake was 90 degrees Fahrenheit on 02/16/12, and 01/19/12, and was 60 degrees Fahrenheit on 02/02/12 and 01/05/12; and
The English muffin was 80 degrees Fahrenheit on 02/14/12, 01/09/12, and 01/03/12, was 90 degrees Fahrenheit on 02/07/12, and was 60 degrees Fahrenheit on 01/24/12, and 01/17/12.

In interviews conducted on 02/23/12 from 08:30 a.m. through 09:45 a.m., S 17 Registered Dietician and S 43 Dietary Manager both confirmed the hot food temperatures served to the patients from 01/02/12 through 02/23/12 were not 140 degrees Fahrenheit as per policy. Both S17 Registered Dietician and S 45 Dietary Manager indicated all hot food served to the patients must be 140 degrees Fahrenheit as per policy. S17 and S43 expected the hot food temperatures of less than 140 degrees Fahrenheit to be reheated and the food temperature rechecked prior to serving the food to the patients. Both S17 and S43 confirmed there was no documented evidence the hot food temperatures from 01/02/12 through 02/23/12 were reheated, rechecked and recorded on the "Patient Service Log". S 17 Registered Dietician and S 43 Dietary Manager both indicated no hot food with a temperature of less than 140 degrees Fahrenheit should be served to the patients as per policy.

Review of the policy titled, "Food Storage Function: Infection Control", with no policy number, page 1 of 1, last reviewed date of 9/11, last revised date of 1/11, presented as the hospital's current "Food Temperature" policy, indicated the hot foods shall leave the kitchen or steam table at or above 140 degrees Fahrenheit.

Based on observations, record reviews, and staff interviews, the hospital failed to ensure the condition of the food and dietetic services was maintained in a sanitary environment as per the "Food Storage Function: Infection Control" policies as evidenced by having: caked black, brown, orange, gray and/or white substances/debris on the ice machine, large metal panel, five (5) cooking sheets, five (5) large sheet pans, food scale, six (6) large dry food containers, a large white lid, clear dinner roll lid, two (2) spice containers, seasonings (Tony Chachere, Oregano, Sage, Whole Dill Weed, Basil, Cinnamon, Caribbean Jerk), deep fat fryer, grill, stove, two (2) convention ovens, five (5) pots, four (4) frying pans, two (2) large strainers, faucet, walk-in cooler, four (4) plastic curtains hanging in the walk way of the cooler, the freezer door located inside the walk-in cooler, clip board in the clean kitchen area; 2) failing to ensure there were food temperatures recorded for all meals prior to serving the food to the patients from 02/23/12 through 11/24/11 as per the Dietary Manager, S43 and Registered Dietician, S17; and 3) failing to follow the food temperature guidelines for hot food to be served at 140 degrees from 01/03/12 through 02/22/12 as per the "Food Storage Function: Infection Control", policy. Findings:

During a tour of the kitchen conducted on 02/23/12 from 8:25 a.m. through 11:30 a.m. with S 43 Dietary Manager and S2DON (Director of Nursing), there was an ice machine observed with three (3) grooved areas on the front of the machine. Further observation revealed there was a whitish piece of plastic with jagged edges extending from the grooved areas approximately one-quarter inch. he jazzed edges on the piece of plastic inside the grooved areas on the machine were grayish in color. Further observation revealed there was a white, brown, and black substance/debris observed under the lid of the ice machine. On the front panel of the ice machine was whitish/brownish debris noted. There was a large metal panel and four (4) cooking sheets stacked on top of the ice machine. Further observation revealed the large metal panel and four cookie sheets were noted cached with a grayish substance/debris. To the left of the ice machine was a rack with five (5) large sheet pans noted in its slots. Further observation revealed the five (5) large sheet pans were cached with a black substance. Next to the rack of sheet pans was a food scale sitting located on the countertop. Further observation revealed the front panel and both sides of the scale were covered with a brownish/orangish substance. There were a total of six (6) large stacked dry food containers noted below the cooks prep area with brown rice, white rice (empty container), corn meal and/or yellow corn meal. Further observation revealed the top and sides of these six (6) stacked containers was cached with a grayish/whitish substances. To the right of these six (6) stacked containers was a large white lid noted with a whitish/orange debris. At 9:55 a.m., was a clear dinner roll lid noted covered with brown debris located next to stacked dinner rolls on top of the cook's prep area. At 9:59 a.m., there were two (2) spice storage bins observed under the cook's prep area. Further observation revealed the two (2) spice storage bins had a whitish, orange, grayish, red, black and brown substance in the bottom of the containers. There was an orange substance observed on the Tony Chachere seasoning's lid, a brown/black substance on the Oregano seasoning's lid, a gray substance on the Sage seasoning's lid, a grayish/white substance on the Whole Dill Weed seasoning's lid, a brown/reddish substance on the Basil seasoning's lid, a whitish substance on the Cinnamon seasoning's lid, and a whitish/gray substance on the Caribbean Jerk seasoning's lid. At 10:00 a.m., the deep fat fryer was observed with two (2) side panels. Further observation revealed these two (2) side panels of the fryer were covered with a cached brown, white, and gray substances. At 10:07 a.m., the grill was observed with orange cached debris on the side panels. Further observation revealed the grill's edges were covered with a cached orange/brown substance. There was a one (1) inch by half-inch (1/2) piece of orange, brown, and black debris noted on the right side panel of the grill. The DON (S2) peeled the piece of debris from the side panel at this time and discarded it in the trash. At 10:08 a.m., the six (6) burner stove was observed with a cached white, orange, brown, and black substance on the surface between the burners. Further observation revealed the front and back two (2) left burner's on the stove was noted with small black pieces of chipped debris. At 10:15 a.m., there were two (2) convention ovens observed. Further observation of the ovens revealed the front bottom panel areas were cached with a black substance. The black handles on the stoves had a whitish, orange, and brown substance and debris noted on top of them. There were three (3) knobs (power, temperature, and timer) on the stoves that were covered with white debris and cached with a grayish substance. At 10:20 a.m., there were a total of five (5) pots and four (4) frying pans observed cached with a brownish/black substances. There were two (2) large metal strainers had the bottom inner rings that were covered with an orange debris. At 10:20 a.m., the double sink area used to prep vegetables was observed with a faucet. Further observation revealed the facet did not have a plate that covered the back area of the facet. The faucet's connecting device (screws) were exposed and covered with orange, green, and white substance. The right facet handle was observed covered with a whitish substance. At 10:25 a.m., the bottom panels of the walk-in cooler was observed with an orange substance on both panels. The four (4) plastic curtains hanging in the walk way of the cooler was observed covered with a whitish substance. The bottom of the freezer door located inside the walk-in cooler was observed with a cached orange substance. At 10:35 a.m., a clip board with a menu for that week was observed on the countertop in the cook's prep area. Further observation revealed the clip on the clip board and the area behind the clip was cached with black debris. S2DON put the clip board in the trash can at this time.

In an interview on 02/23/12 from 8:25 a.m. through 11:30 a.m., S2DON and S 43 Dietary Manager confirmed all the above findings during the tour of the kitchen.

Review of the policy titled, "Food Storage Function: Infection Control", with no policy number, page 1 of 1, last reviewed date of 9/11, last revised date of 1/11, presented as the hospital's current "Food Storage/Temperature" policy indicated the kitchen will be kept clean at all times.

Review of the "Food Storage Function: Infection Control", with no policy number, pages 1 to 3, last reviewed date of 2/11, last revised date of 1/10, with no effective date, presented as the hospital's current "Food Storage/Equipment" policy indicated all foods, non-food items and supplies, related to and used in food preparations shall be stored in such a manner to prevent bacteriological contamination. The dry food storage area must be clean. The containers for dry food item storage must be used for bulk materials such as flour, sugar, mixes, dry lentils, pasta, and etc. The containers should be fabricated so that residue may be completely removed by normal cleaning methods, and have tight lids. Food not subject to further washing or cooking before serving shall be stored in such a manner as to be protected against contamination from food requiring washing or cooking.

Based on observation, record review and interview the hospital failed develop and implement a system for identifying and controlling infections as evidenced by: 1) failing to identify the source of the organism(s) for infections resulting in the inability to implement appropriate isolation precautions and 2) failing to maintain a sanitary environment as evidenced by performance of Environment/Safety rounds which did not include sanitary issues. Findings:

1) failing to identify the source of the organism(s) for infections resulting in the inability to implement appropriate isolation precautions:
Review of the "Patient Inspection Report" completed by the staff nurse and submitted to the Infection Control Nurse revealed the form contained the following information: a list of signs and symptoms of infections and the type (location) of the infection, date the infection developed, and the date of the report.

Review of the form titled "Anti Infective Report" revealed a print out derived from the orders entered into the computer from the physician's orders. Further review revealed the information contained in the report was as follows: patient's name, antibiotic orders, name of physician. Further review revealed no documented evidence of the name of the organism responsible for the infection.

In a face to face interview on 02/27/12 at 11:00am the Infection Control Officer, RN S11, indicated she relies on the nursing staff to complete the "Patient Infection Report" and S11 indicated she does not have the information on the organism causing the infection because the only cultures done are for MRSA (Mothballing Resistant Staph Aureus) at the time of admit. S11 indicated because cultures are not routinely ordered, the hospital would not be able to identify trends or implement isolation precautions other than for MRSA.

2) Failing to maintain a sanitary environment as evidenced by performance of Environment/Safety rounds which did not include sanitary issues:
On 02/22/12 at 10:15 a.m. during a tour of Building 4 where the Eating Disorder Program was housed, an observation was made in the kitchen area where patients prepared their meals. The cabinet containing the sink was observed to have a 2-3 inch wide space between the end of the flooring (Tile) and the cabinet extending 2-3 feet in length (Length of the cabinet). In this 2-3 inch space dirt, debris, and pieces of paper were noted. Between the refrigerator and the dishwasher another area was observed to have no flooring covering the area. In this space (approximately 6 inches by 2 feet) dirt and debris had collected. The beige accordion door separating the kitchenette in the Eating Disorder Unit and the common area had splattered dried liquid marks on the door. The microwave in the kitchenette had food splattered on the inside of the microwave.
S34 Risk Manager was present for this observation and verified that these areas had a collection of dirt and debris. S34 Risk Manager stated, "It should not look like that."

Also observed in the kitchen area was a toaster used by the patients. In the bottom of the toaster a large accumulation of bread crumbs and a brown substance was noted. S34 Risk Manager was present and verified the observations.

On 02/22/12 at 10:55 a.m., during a tour of Building 2 - Children's Unit, a wheeled cart with 3 shelves was observed on the unit. The top shelf of the cart was observed to have an insulated bag. The second and third shelves were observed to have a black substance on the shelves. S28 RN Unit Manager was present for the observation and verified the black substance on the shelves. When asked who was responsible for cleaning the carts, S28 stated, "Whoever can".

Also observed in Building 2 at 11:15 a.m., in the observation area of the Adolescent unit was the following: a large amount of an unknown gray substance that appeared to be a large accumulation of dust, was noted along the base of a chair. Upon lifting the chair, this substance was noted to be a strip of carpet attached to the base of the chair. This strip of carpet was observed to be frayed and coming off of the base of the chair. Carpet strips were observed to be applied to the base of the sofas and chairs in this area. These carpet strips were fraying and coming off the base of the chairs and sofas. On the Children/Adolescent Unit there was a splattered dried brown substance half way up one wall. The beige accordion door separating the visiting area and the common area had large dark beige stains on the door S34 Risk Manager was present for this observation and verified carpet strips had been applied to the base of the chairs and sofas and this carpet was fraying and coming off the base of the furniture.

On 02/22/12 at 11:30 a.m., observations of the physical environment in Building 6 - Adult Unit was revealed the doorway leading to an outside are, adjacent to the medication room had no threshold between the bottom of the door and the floor. A 1/2 -1 inch space was observed between the bottom of the door and the floor, allowing insects, debris, or air to enter from the outside. S33 Maintenance Director was present for the observation and verified there was no threshold in place for this door.

On 02/22/12 at 11:40 a.m., a tour of the Dual Diagnoses Unit was conducted with S33 Maintenance Director and S34 Risk Manager. In the kitchen area a toaster was observed to have a large amount of a brown substance in the bottom of the toaster. Observation of the vents in patient bathrooms revealed paper/cardboard had been placed behind the plastic vent covers. S33 Maintenance stated that patients slide things under the vent cover to block the air.

An environmental tour was conducted on 02/22/12 on the Eating Disorder Unit at 10:15 a.m. A three shelf open cart was located next to the nurses' station. The bottom shelf of the cart had dark brownish-black substance over 1/2 of the shelf. The second shelf had a small amount of the brownish-black substance. The top shelf had an insulated square container on top. When questioned what the insulated container was on the top shelf, S 34 Risk Manager stated it keeps the patient's food warm while being transported. The cart is used to transport the patient's food from the kitchen to the unit. She confirmed the cart was dirty and needed to be cleaned.

The beige accordion door separating the kitchenette in the Eating Disorder Unit and the common area had splattered dried liquid marks on the door. The microwave in the kitchenette had food splattered on the inside of the microwave.

Review of the form titled "Environmental Rounds" used by the hospital monthly to monitor the environment of the hospital revealed no evidence the cleanliness of the facility was monitored.

In a face to face interview on 02/22/12 at 11:15am S33 Eminence Director confirmed cleanliness issues were not included on the environmental rounds form.











17091






20177

Based on record review and interview, the hospital failed to ensure the short-term and long range goals included specific dates for expected achievement and were written as observable, measurable patient behaviors to be achieved for 5 of 24 sampled patients (#3, #4, #11, #13, #14). Findings:

Patient #3
Review of Patient #3's "Psychiatric Admission Summary" revealed he was a 9 year old male admitted on 11/08/11 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems. Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/08/11 at 12:05pm due to Patient #3 being homicidal and dangerous to others. A Coroner's Emergency Certificate (CEC) was signed on 11/09/11 at 1:31pm due to Patient #3 being dangerous to others.

Review of Patient #3's "Master Treatment Plan" dated 11/08/11 revealed his problems identified were mood lability with threats to harm others and oppositional and defiant behavior.

Review of the short-term goals for oppositional behavior revealed Patient #3 would identify 3 triggers to defiant/uncooperative behavior and identify 3 alternative behaviors to function appropriately with staff and peers. Further review revealed no documented evidence of a specific date for expected achievement of the goals. Further review revealed the goals were not written as observable, measurable patient behaviors. Review of the long range goal revealed Patient #3 was to "develop positive social behaviors and coping skills to manage uncomfortable feelings". There was no documented evidence of the measure to be used by staff to determine when the goal would be met.

Review of the short-term goal for mood lability revealed Patient #3 would identify 3 triggers to angry outbursts and identify 3 positive coping skills to manage angry feelings. Further review revealed no documented evidence of a specific date for expected achievement of the goals. Further review revealed the goals were not written as observable, measurable patient behaviors. Review of the long range goal revealed Patient #3 was to "develop positive coping skills to deal (with) feelings". There was no documented evidence of the measure to be used by staff to determine when the goal would be met.

Patient #4
Review of the patient's clinical record revealed the patient was an 8 year old male admitted to the facility on 11/15/11 with diagnoses of Psychoses, Major Depressive Disorder, and Suicidal Ideations (SI). Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/15/11 at 12:19 p.m. due to Patient #4 having violent behavior for the past 3 weeks. The record revealed the patient was discharged on 11/18/11.

Review of Patient #4's "Master Treatment Plan" dated 11/18/11 revealed his problems identified were mood liability with anger and suicidal ideations and family conflict.

Review of the short-term goals for family conflict revealed Patient #4 would "Identify 5 things at home that make him sad/mad, List 3-5 compromises to consider". Further review revealed no documented evidence of a specific date for expected achievement of the goals. Further review revealed the goals were not written as observable, measurable patient behaviors. Review of the long range goal revealed Patient #4 was to "Complete family session". There was no documented evidence of the measure to be used by staff to determine when the goal would be met.

Review of the short-term goal for mood liability revealed Patient #4 would "Identify 5 things that make him mad/sad, Identify 5 people to call when upset, List 3 coping skills". Further review revealed no documented evidence of a specific date for expected achievement of the goals. Further review revealed the goals were not written as observable, measurable patient behaviors. Review of the long range goal revealed Patient #4 was to "Stabilize mood/Deny SI (suicidal ideations)". There was no documented evidence of the measure to be used by staff to determine when the goal would be met.

Patient #11
Review of the patient's clinical record revealed that the patient was a 15 year old female admitted to the facility on 12/30/11 with diagnoses of Major Depressive Disorder and Suicidal Ideations. The record revealed the patient was PEC'd on 12/30/11 at 9:15 a.m. for suicidal ideations. The patient was discharged from the facility on 01/03/12.

Review of Patient #11's "Master Treatment Plan" dated 01/02/12 revealed the patient's problems identified were mood liability with SI and family conflict.

Review of the short-term goals for family conflict revealed Patient #11 would "Identify 5 things at home that upset her, List 3-5 compromises to consider". Further review revealed no documented evidence of a specific date for expected achievement of the goals. Further review revealed the goals were not written as observable, measurable patient behaviors. Review of the long range goal revealed Patient #11 was to "Complete family session". There was no documented evidence of the measure to be used by staff to determine when the goal would be met.

Review of the short-term goal for mood liability revealed Patient #11 would "Identify 5 things that make her sad/upset, Identify 5 people to call when upset, List 3 coping skills". Further review revealed no documented evidence of a specific date for expected achievement of the goals. Further review revealed the goals were not written as observable, measurable patient behaviors. Review of the long range goal revealed Patient #11 was to "Stabilize mood/Deny SI". There was no documented evidence of the measure to be used by staff to determine when the goal would be met.

Patient #13
Review of Patient #13's "Psychiatric Admission Summary" revealed he was a 12 year old male admitted on 02/14/12 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Disruptive Behavior Disorder, Parent-Child Relational Conflict, and Mild Mental Retardation. Further review of his medical record revealed a PEC was completed on 02/11/12 at 455 (no documented evidence whether the time was am or pm) due to Patient #13 being violent and dangerous to self. A CEC was signed on 02/14/12 at 1415 (2:15pm) due to Patient #13 being violent, dangerous to self, dangerous to others, and gravely disabled.

Review of Patient #13's "Master Treatment Plan" dated 02/17/12 (developed 13 days after his admission) revealed his problems identified were mood lability with suicidal/homicidal ideations, family conflict, and behaviors resulting in danger to self or others.

Review of the short-term goal for mood lability revealed Patient #13 would identify 5 things that make him upset by day 2 and identify 5 people to talk to when upset by day 3. Further review revealed no documented evidence whether Patient #3 had met these goals by day 2 and day 3 or whether the goals had to be revised. Further review revealed the goals were not written as observable, measurable patient behaviors. Review of the long range goal revealed Patient #13 was to stabilize mood and deny suicidal and homicidal ideations. There was no documented evidence of the measure to be used by staff to determine when the goal would be met.

Review of the short-term goal for behaviors resulting in danger to self or others revealed Patient #13 was to identify 3 triggers to his anger within 5 days of admit and identify 3 positive coping skills to use when feeling angry within 5 days of admit. Further review revealed the expected achievement date for the goals was 5 days after admit, and the treatment plan was developed on 02/17/12, 13 days after his admit date. Further review revealed the goals were not written as observable, measurable patient behaviors.

Patient #14
Review of Patient #14's medical record revealed he was an 8 year old male admitted on 01/25/12 with the diagnoses of Depressive Disorder, Post Traumatic Stress Disorder, Physical Abuse, Sexual Abuse, and Disruptive Behavior Disorder. Further review revealed a PEC was completed on 01/25/12 at 4:30pm due to Patient #14 being suicidal, homicidal, violent, dangerous to self and others, and gravely disabled. A CEC was signed on 01/27/12 at 11:20am due to Patient #14 being dangerous to self and others and gravely disabled.

Review of Patient #14's "Master Treatment Plan" dated 01/29/12 revealed his problems identified were mood lability and ineffective coping.

Review of the short-term goal for mood lability revealed Patient #14 was to identify 5 triggers to angry outbursts by day 2 and identify 5 coping skills to use when angry by day 3. Further review revealed the expected achievement date for the goals was 2 and 3 days after admit, and the treatment plan was developed on 01/29/12, 4 days after his admit date. Further review revealed the goals were not written as observable, measurable patient behaviors. Review of the long range goal revealed Patient #14 was to demonstrate a decrease in the number of outbursts 48 hours prior to discharge. There was no documented evidence of the measure to be used by staff to determine when the goal would be met.

Review of the short-term goals for ineffective coping revealed Patient #14 was to identify 3 coping skills to assist with focus on progress in process group by day 2. Further review revealed the expected achievement date for the goals was 2 days after admit, and the treatment plan was developed on 01/29/12, 4 days after his admit date. Further review revealed the goals were not written as observable, measurable patient behaviors. Review of the long range goal revealed Patient #14 was to learn 5 coping skills before discharge. There was no documented evidence of the measure to be used by staff to determine when the goal would be met.

Review of Patient #14's "Treatment Plan Update Patient Reassessment" dated 02/04/12 revealed the progress made since the last review of problem 1 (mood lability) was that Patient #14 was attacking his roommate. Further review revealed the short-term goal was for Patient #14 to work on anger management with staff. Further review revealed the goal was not written as observable, measurable patient behaviors, did not include an expected date of achievement, and there were no interventions documented. Further review revealed the progress made since the last review of problem 2 (ineffective coping) was that Patient #14 was trashing his room when he was not given his way. The short-term goal was that he would work on impulse control with the staff. Further review revealed the goal was not written as observable, measurable patient behaviors and did not include an expected date of achievement.

Review of Patient #14's "Treatment Plan Update Patient Reassessment" dated 02/11/12 revealed the progress made since the last review of problem 1 (mood lability) was that Patient #14 was arguing with peers and trying to intimidate peers. Further review revealed the short-term goal was for Patient #14 to decrease aggressiveness and argumentativeness. Further review revealed the goal was not written as observable, measurable patient behaviors, did not include an expected date of achievement, and there were no interventions documented. Further review revealed the progress made since the last review of problem 2 (ineffective coping) was that Patient #14 was oppositional and more focused on his peers' behavior than his own. The short-term goal was that Patient #14 would focus on his behavior and follow milieu and staff directions. Further review revealed the goal was not written as observable, measurable patient behaviors and did not include an expected date of achievement.

Review of Patient #14's "Treatment Plan Update Patient Reassessment" dated 02/18/12 revealed the progress made since the last review of problem 1 (mood lability) was that Patient #14 was demonstrating increased hyperactivity and had increased difficulty settling down for bedtime and his bath. The short-term goal was that Patient #14 would calm down and be ready for bed with no talking in 2 days. Further review revealed the goal was not written as observable, measurable patient behaviors.

In a face-to-face interview on 02/27/12 at 9:00am with Administrator S1, Director of Nursing S2 and Corporate Director Clinical Services S46 , neither S1, S2, nor S46 could offer an explanation for the patients' treatment plans not having specific dates for expected achievement of short-term and long range goals and for not being written as observable, measurable patient behaviors to be achieved.

Review of the policy titled "Multidisciplinary Master Treatment Plan/Treatment Plan Update/Patient Reassessment", last reviewed 2011 and submitted as the one currently in use, revealed, in part, "...Procedure: 4. Specific goals and measurable objectives or outcomes, interventions planned, recommendations, frequency or treatment procedures and the person, by name and title, responsible are to be documented by the discipline responsible as determined by the treatment plan...".




17091

25065


Based on record review and interview, the hospital failed to ensure the written treatment plan included the specific treatment interventions to be used for each patient for 5 of 24 sampled patients (#3, #4, #11, #13, #20). Findings:

Review of the hospital's "Problem Description" for "Mood Liability" revealed a blank for the patient's name, the problem number, the behavioral observations, and the long term goal. Further review revealed a column labeled "objective/short-term goal", a column labeled interventions/frequency, and a column labeled "staff responsible". Review of the "interventions/frequency" revealed the following pre-printed interventions: "(Identify main interventions used with individual patient during treatment.) (box to be checked) Individual MD (physician) sessions ___ per week. Activity Therapy (___/1 hr(hour)/daily) to develop techniques (box to be checked) journaling (box to be checked) art (box to be checked) exercise (box to be checked) music (box to be checked) other ___ to decrease target symptoms. (Box to be checked) Process group (___ x/1 hr/daily) to assist with (box to be checked) reorientation (box to be checked) grounding (box to be checked) redirection (box to be checked) other ___. (box to be checked) Milieu therapy daily to assist in obtaining increased levels within level system to learn (box to be checked) responsibility (box to be checked) motivation (box to be checked) other ___. (box to be checked) Evaluate patient daily for evidence of decreased: (box to be checked) racing thoughts (box to be checked) energy (box to be checked) impulsiveness, or increased: (box to be checked) sleep (box to be checked) appetite (box to be checked) concentration. Other:".

Review of the hospital's "Problem Description" for "Oppositional Behavior" revealed a blank for the patient's name, the problem number, the behavioral observations, and the long term goal. Further review revealed a column labeled "objective/short-term goal", a column labeled interventions/frequency, and a column labeled "staff responsible". Review of the "interventions/frequency" revealed the following pre-printed interventions: "(Identify main interventions used with individual patient during treatment.) (box to be checked) Individual MD sessions ___ x/week, focusing on ___ (box to be checked) Milieu therapy daily to assist in obtaining increased levels within level system to learn responsibility motivation. (box to be checked) Activity Therapy (___/1hr/weekly) to provide format for non-verbal expression of feelings and to aide in development of coping skills (box to be checked) journaling (box to be checked) exercise (box to be checked) affirmations (box to be checked) self talk (box to be checked) music/art (box to be checked) other ___ (box to be checked) Process group (___/1hr/weekly) to aide in identifying triggers to oppositional behavior. Other:".

Review of the hospital's "Problem Description" for "Family Conflict" revealed a blank for the patient's name, the problem number, the behavioral observations, and the long term goal. Further review revealed a column labeled "objective/short-term goal", a column labeled interventions/frequency, and a column labeled "staff responsible". Review of the "interventions/frequency" revealed the following pre-printed interventions: "(Identify main interventions with individual patient during treatment) (box to be checked) Evaluate patient's strengths, coping skills, and current support system on admission. (box to be checked) Process group (___/1hr/daily) to assist in identifying family issues (box to be checked) closed communication (box to be checked) substance abuse (box to be checked) abuse (specify) ___ (box to be checked) boundaries (box to be checked) other ___ (box to be checked) Activity Therapy (___/1hr/daily) to help find coping skills to address family conflicts (box to be checked) journaling) (box to be checked) exercise (box to be checked) walking away (box to be checked) music (box to be checked) art (box to be checked) other ___ (box to be checked) Family sessions (___/1hr/weekly) to open communication and process inconsistencies (box to be checked) limit setting (box to be checked) Clarification of roles (box to be checked) boundary setting (box to be checked) communication ties (box to be checked) other Other:".

Patient #3
Review of Patient #3's "Psychiatric Admission Summary" revealed he was a 9 year old male admitted on 11/08/11 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems. Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/08/11 at 12:05pm due to Patient #3 being homicidal and dangerous to others. A Coroner's Emergency Certificate (CEC) was signed on 11/09/11 at 1:31pm due to Patient #3 being dangerous to others.

Review of Patient #3's "Master Treatment Plan" dated 11/08/11 revealed his problems identified were mood liability with threats to harm others and oppositional and defiant behavior. Review of the interventions and frequency to be used for "Mood Liability" and "Oppositional Behavior" revealed no documented evidence that any intervention and frequency had been selected as evidenced by the boxes not checked and the blanks not filled in with a number.

Patient #4
Review of the patient's clinical record revealed the patient was an 8 year old male admitted to the facility on 11/15/11 with diagnoses of Psychoses, Major Depressive Disorder, and Suicidal Ideations (SI). Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/15/11 at 12:19 p.m. due to Patient #4 having violent behavior for the past 3 weeks. The record revealed the patient was discharged on 11/18/11.

Review of Patient #4's "Master Treatment Plan" dated 11/18/11 revealed his problems identified were mood liability with anger/suicidal ideations, and family conflict. Review of the interventions and frequency to be used for "Mood Liability" and "Family Conflict" revealed no documented evidence that any intervention and frequency had been selected as evidenced by the boxes not checked and the blanks not filled in with a number.

Patient #11
Review of the patient's clinical record revealed that the patient was a 15 year old female admitted to the facility on 12/30/11 with diagnoses of Major Depressive Disorder and Suicidal Ideations. The record revealed the patient was PEC'd on 12/30/11 at 9:15 a.m. for suicidal ideations. The patient was discharged from the facility on 01/03/12.

Review of Patient #11's "Master Treatment Plan" dated 01/02/12 revealed the patient's problems identified were mood liability with SI (suicidal ideation) and family conflict. Review of the interventions and frequency to be used for "Mood Liability" and "Family Conflict" revealed no documented evidence that any intervention and frequency had been selected as evidenced by the boxes not checked and the blanks not filled in with a number.

Patient #13
Review of Patient #13's "Psychiatric Admission Summary" revealed he was a 12 year old male admitted on 02/14/12 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Disruptive Behavior Disorder, Parent-Child Relational Conflict, and Mild Mental Retardation. Further review of his medical record revealed a PEC was completed on 02/11/12 at 455 (no documented evidence whether the time was am or pm) due to Patient #13 being violent and dangerous to self. A CEC was signed on 02/14/12 at 1415 (2:15pm) due to Patient #13 being violent, dangerous to self, dangerous to others, and gravely disabled.

Review of Patient #13's "Master Treatment Plan" dated 02/17/12 (developed 13 days after his admission) revealed his problems identified were mood liability with suicidal/homicidal ideations, family conflict, and behaviors resulting in danger to self or others. Review of the "interventions/frequency" to be used for "Mood Liability" and "Family Conflict" revealed a number was written in the blank for the frequency. Further review revealed there was no documented evidence that a box had been checked to designate which intervention was to be used and what the focus was to be.

Patient #20
Review of the medical record for Patient #20 revealed a 54 year old female admitted to the hospital on 10/29/11 under a formal voluntary admission for opiate dependency with a history of fibromyalgia.

Review of the Problem Description for abuse of opiates for Patient #20 revealed in the column for interventions and frequency the following: a check in the box indicating administer and monitor patient daily on effects of medications as ordered; however all boxes next to the medications were left blank.

Review of the Physician's Orders for Patient #20 revealed the following medications were ordered: 10/29/11 at 5:00pm Zanaflex 8mg po (by mouth) Q-4 (every four) hours prn (as needed) for muscle spasms, muscle or joint aches, Subutex 2mg SL (sublingual) q2H (every two hours) prn for s/s (signs and symptoms) of opiate withdrawal, Sandostatin 100 mcg Sub cut. (subcutaneous) Q-4 hours prn for nausea, vomiting or diarrhea, Phenergan 50mg po Q-6 hours prn nausea and vomiting and Catapres 0.1mg po q-2 hours prn pulse over 90 s/s of opiate withdrawal.

Review of the MAR (Medication Admission Record) revealed Patient #20 received the following medications:
Subutex 2mg Q 2 hours - 10/29/11 at 6:00pm, 8:00pm, 10:00pm; 10/30/11 at 9:25am and 5:45pm
Zanaflex 8mg po Q-4 hours - 11/01/11 at 9:15am and 10:15pm
Catapres 0.1mg po q-2 hours - 11/01/11 7:15am and 10:25am
Further review of the medical record revealed no documented evidence Patient #20 was monitored for the effects of the drugs.

In a face-to-face interview on 02/27/12 at 9:00am with Administrator S1, Director of Nursing S2 and Corporate Director Clinical Services S46 , neither S1, S2, nor S46 could offer an explanation for the patients' treatment plans not having the specific treatment interventions selected.

Review of the policy titled "Multidisciplinary Master Treatment Plan/Treatment Plan Update/Patient Reassessment", last reviewed 2011 and submitted as the one currently in use, revealed, in part, "...Procedure: 4. Specific goals and measurable objectives or outcomes, interventions planned, recommendations, frequency or treatment procedures and the person, by name and title, responsible are to be documented by the discipline responsible as determined by the treatment plan...".





17091

Based on record review and interview the hospital failed to ensure the written treatment plan included the responsibilities of each member of the treatment team for 5 of 24 sampled patients (#3, #4, #11, #13, #14). Findings:

Review of the pre-printed forms used by the hospital to identify problems revealed the following: Top section of the page- Name of patient; Problem #; Problem (pre-printed diagnosis i.e. Depression); Behavioral Observations; and Long Term Goal. The rest of the page is divided into three columns: Column 1 for Short-Term Goals; Column 2 pre-printed interventions; and Column 3 the staff responsible.

Patient #3
Review of Patient #3's "Psychiatric Admission Summary" revealed he was a 9 year old male admitted on 11/08/11 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems. Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/08/11 at 12:05pm due to Patient #3 being homicidal and dangerous to others. A Coroner's Emergency Certificate (CEC) was signed on 11/09/11 at 1:31pm due to Patient #3 being dangerous to others.

Review of Patient #3's "Master Treatment Plan" dated 11/08/11 revealed his problems identified were mood lability with threats to harm others and oppositional and defiant behavior. Review of the interventions and frequency to be used for "Mood Lability" and "Oppositional Behavior" revealed no documented evidence that any intervention and frequency had been selected as evidenced by the boxes not checked and the blanks not filled in with a number. Further review revealed the column for "staff responsible" had the name of the psychiatrist, a registered nurse, a licensed medical social worker, and a psychiatric counselor with no documented evidence for which intervention each staff member was responsible.

Patient #4
Review of the patient's clinical record revealed the patient was an 8 year old male admitted to the facility on 11/15/11 with diagnoses of Psychoses, Major Depressive Disorder, and Suicidal Ideations (SI). Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/15/11 at 12:19 p.m. due to Patient #4 having violent behavior for the past 3 weeks. The record revealed the patient was discharged on 11/18/11.

Review of Patient #4's "Master Treatment Plan" dated 11/18/11 revealed his problems identified were mood liability with anger/suicidal ideations, and family conflict. Review of the interventions and frequency to be used for "Mood Liability" and "Family Conflict" revealed no documented evidence that any intervention and frequency had been selected as evidenced by the boxes not checked and the blanks not filled in with a number. Further review revealed the column for "staff responsible" had the name of the psychiatrist, a registered nurse, a licensed medical social worker, and a psychiatric counselor with no documented evidence for which intervention each staff member was responsible.

Patient #11
Review of the patient's clinical record revealed that the patient was a 15 year old female admitted to the facility on 12/30/11 with diagnoses of Major Depressive Disorder and Suicidal Ideations. The record revealed the patient was PEC'd on 12/30/11 at 9:15 a.m. for suicidal ideations. The patient was discharged from the facility on 01/03/12.

Review of Patient #11's "Master Treatment Plan" dated 01/02/12 revealed the patient's problems identified were mood liability with SI, and family conflict. Review of the interventions and frequency to be used for "Mood Liability" and "Family Conflict" revealed no documented evidence that any intervention and frequency had been selected as evidenced by the boxes not checked and the blanks not filled in with a number. Further review revealed the column for "staff responsible" had the name of the psychiatrist, a registered nurse, a licensed medical social worker, and a psychiatric counselor with no documented evidence for which intervention each staff member was responsible.

Patient #13
Review of Patient #13's "Psychiatric Admission Summary" revealed he was a 12 year old male admitted on 02/14/12 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Disruptive Behavior Disorder, Parent-Child Relational Conflict, and Mild Mental Retardation. Further review of his medical record revealed a PEC was completed on 02/11/12 at 455 (no documented evidence whether the time was am or pm) due to Patient #13 being violent and dangerous to self. A CEC was signed on 02/14/12 at 1415 (2:15pm) due to Patient #13 being violent, dangerous to self, dangerous to others, and gravely disabled.

Review of Patient #13's "Master Treatment Plan" dated 02/17/12 (developed 13 days after his admission) revealed his problems identified were mood lability with suicidal/homicidal ideations, family conflict, and behaviors resulting in danger to self or others. Review of the "interventions/frequency" to be used for "Mood Lability" and "Family Conflict" revealed a number was written in the blank for the frequency. Further review revealed there was no documented evidence that a box had been checked to designate which intervention was to be used and what the focus was to be. Further review revealed the name of the psychiatrist, the social worker, and "staff" was listed under "staff responsible". There was no documented evidence of a registered nurse named as staff who would be responsible for Patient #13's treatment plan. Further review revealed there was no documented evidence for which intervention each staff member was responsible.

Patient #14
Review of Patient #14's medical record revealed he was an 8 year old male admitted on 01/25/12 with the diagnoses of Depressive Disorder, Post Traumatic Stress Disorder, Physical Abuse, Sexual Abuse, and Disruptive Behavior Disorder. Further review revealed a PEC was completed on 01/25/12 at 4:30pm due to Patient #14 being suicidal, homicidal, violent, dangerous to self and others, and gravely disabled. A CEC was signed on 01/27/12 at 11:20am due to Patient #14 being dangerous to self and others and gravely disabled.

Review of Patient #14's "Master Treatment Plan" dated 01/29/12 revealed his problems identified were mood lability and ineffective coping. Review of the "Problem Description" for mood lability and ineffective coping revealed there was no documented evidence for which intervention each staff member was responsible.

In a face-to-face interview on 02/27/12 at 9:00am with Administrator S1, Director of Nursing S2 and Corporate Director Clinical Services S46 , neither S1, S2, nor S46 could offer an explanation for the patients' treatment plans not including the responsibilities of each member of the treatment team.

Review of the policy titled "Multidisciplinary Master Treatment Plan/Treatment Plan Update/Patient Reassessment", last reviewed 2011 and submitted as the one currently in use, revealed, in part, "...Procedure: 4. Specific goals and measurable objectives or outcomes, interventions planned, recommendations, frequency or treatment procedures and the person, by name and title, responsible are to be documented by the discipline responsible as determined by the treatment plan...".



25065




17091

Based on record review and interview the hospital failed to ensure the patient's problems/needs, interventions, progress, and responses to treatment were assessed and documented by the nurse as evidenced by allowing, via policy and procedure, the delegation to the Psychiatric Counselor (Mental Health Technician) the assessment and documentation of the appearance of the patient, order changes, reasons for changes, reactions to changes, progress toward or away from treatment plan, and the patient's general mood and reactions for 9 of 24 sampled medical records (#3, #5, #8, #10, #14, #15, #19, #20, #24). Findings:

Patient #3
Review of Patient #3's "Psychiatric Admission Summary" revealed he was a 9 year old male admitted on 11/08/11 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems. Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/08/11 at 12:05pm due to Patient #3 being homicidal and dangerous to others. A Coroner's Emergency Certificate (CEC) was signed on 11/09/11 at 1:31pm due to Patient #3 being dangerous to others.

Review of the Reassessment/Progress Note for Patient #3 dated 11/11/11, 11/13/11, and 11/15/11 revealed no documented evidence the patient's progress was assessed by the registered nurse.

Patient #5
Review of Patient #5's "Psychiatric Admission Summary" revealed a 16 year old female admitted to the hospital on 11/23/11 under a PEC (Physician's Emergency Certificate) for suicidal thoughts and behavioral problems at home Further review of the medical record revealed the diagnoses of Major Depressive Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems and Cannabis Abuse.

Review of the Reassessment/Progress Note for Patient #5 dated 11/24/11, 11/25/11, 11/26/11, 11/27/11 and 11/28/11 revealed no documented evidence the patient's progress was assessed by the registered nurse.

Patient #8
Review of Patient #8's medical record revealed a 13 year old male admitted under a CEC (Coroner's Emergency Certificate) on 12/13/11 for uncontrollable anger. Further review revealed Patient #8 pulled a knife on his mother and became violent with property.

Review of the Reassessment/Progress Note for Patient #8 dated 12/13/11 3p-11p shift, 12/15/11, and 12/17/11 revealed no documented evidence a progress note had been written by the registered nurse.

Patient #10
Review of Patient #10's medical record revealed a 47 year old female admitted under a formal voluntary admit on 12/19/11 for sexual trauma. Further review revealed Patient #10 was placed under MVC/CO (Modified Visual Contact/Close Contact) per physician's orders.

Review of the Reassessment/Progress Note for Patient #10 dated 12/20/11, 12/21/11 3p-11p shift, 12/22/11 7a-3p and 3p-11p shifts, 12/24/11 7a-3p shift, 12/25/11, 12/26/11, 12/28/11 3p-11p and 11p-7a shifts, 12/29/11 7a-3p shift, 12/20/11 7a-3p and 30-11p shifts, and 11/28/11 revealed no documented evidence a progress note had been written by the registered nurse.

Patient #14
Review of Patient #14's medical record revealed he was an 8 year old male admitted on 01/25/12 with the diagnoses of Depressive Disorder, Post Traumatic Stress Disorder, Physical Abuse, Sexual Abuse, and Disruptive Behavior Disorder. Further review revealed a PEC was completed on 01/25/12 at 4:30pm due to Patient #14 being suicidal, homicidal, violent, dangerous to self and others, and gravely disabled. A CEC was signed on 01/27/12 at 11:20am due to Patient #14 being dangerous to self and others and gravely disabled.

Review of the Reassessment/Progress Note for Patient #14 dated 02/08/12, 02/12/12, 02/14/12, and 02/16/12 revealed no documented evidence a progress note had been written by the registered nurse.

Patient #15
Review of Patient #15's medical record revealed a 16 year old male admitted to the hospital on 01/16/12 under a PEC (Physician's Emergency Certificate) for suicidal ideation and wanting to burn himself with a lighter.

Review of the Reassessment/Progress Note for Patient #15 dated 01/21/12, 01/22/12, 01/23/12 01/26/12 7a-3p shift, 01/29/12 3p-11p shift, 01/30/12 7a-3p and 11p-7a shifts, 01/31/12, 02/01/12 3p-11p and 11-7a, 02/09/12, 02/11/12 3p-11p shift, 02/13/12 11p-7a shift, 02/15/12 3p-11p and 11p-7a shift, 02/16/12 3p-11p shift, 02/17/12 11p-7a, 02/17/12 3p-11p, 02/18/12, 02/19/12 11p-7a and 3p-11p, 02/20/12 3p-11p, 02/21/11 7a-3p and 3p-11p, and 02/22/12 7a-3p revealed no documented evidence a progress note had been written by the registered nurse.

Patient #19
Review of Patient #19's medical record revealed a 26 year old female admitted to the hospital on 02/15/12 under a formal voluntary admission for opiate and benzo dependency.

Review of the Reassessment/Progress Note for Patient #19 dated 02/17/11, 02/18/12, 02/19/12 3p-11p shift, 02/20/12 7a-3p shift, 02/22/12 7a-3p and 3p-11p shifts revealed no documented evidence a progress note had been written by the registered nurse.

Patient #20
Review of the Patient #20's medical record revealed a 54 year old female admitted under a formal voluntary admission to the hospital on 10/29/11 for opiate dependency and withdrawal.

Review of the Reassessment/Progress Note for Patient #20 dated 10/31/11 7a-3p shift, 11/01/11 7a-3p shift, 11/03/11 3p-11p and 11p-7a shifts revealed no documented evidence a progress note had been written by the registered nurse.

Patient #24
Review of Patient #24's medical record revealed a 34 year old female admitted to the hospital on 09/05/11 under a PEC (Physician's Emergency Certificate) for positive paranoid thoughts and major depression.

Review of the Reassessment/Progress Note for Patient #24 dated 09/06/11 3p-11p shift and 09/09/11 11p-7a shift revealed no documented evidence a progress note had been written by the registered nurse.

In a face-to-face interview on 02/24/12 at 1:30pm, RN S2 DON (Director of Nursing) verified psychiatric counselors are allowed by the hospital to document in the patient's progress notes. Further she was not aware of any regulations requiring the nurse to document the progress of the patient. After review of several of the cited medical records, S2 verified in some cases the only documentation by the RN was the Patient re-assessment performed once every 24 hours.

Review of the policy titled "Patient Progress Notes" last reviewed in 2011 and submitted as the one currently in use revealed...."Procedure: C. Each patient must be charted on each shift. Charting progress notes is the responsibility of the staff nurses and psychiatric councilors on the day and evening shifts and on the night shift. Patient progress notes should be documented in the BIOP (Behavior-Intervention-Outcome-Plan) format. The following should be included in the patient progress notes: 1. Appearance of patient when staff arrives on program, including status regimen (i.e., SVC [Strict Visual Contact], full restraints, on pass, etc). 2. Any order changes, the reason for the change, and the patient's reaction to the change. 3. Techniques used by staff to accomplish goals on treatment plan. 4. Statement of progress toward or away from treatment plan goals. 5. Patient's behavior or general topic of verbalization in group psychotherapy. 6. Patient's general mood and reactions. 7. Any minor or major happenings during the shift, either to the patient or in the milieu that affects the patient's therapy. 8. At least once per shift on day and evening shift, a BIOP note should be charted. Note should address at least one or more treatment plan problems".

Based on record review and interview, the hospital failed to ensure each patient's progress notes contained recommendations for revisions in the treatment plan. Patients' treatment plans were not revised when there was a change in the patient's condition for 3 of 24 sampled patients (#3, #6, #13). Findings:

Patient #3
Review of Patient #3's "Psychiatric Admission Summary" revealed he was admitted on 11/08/11 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems. Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/08/11 at 12:05pm due to Patient #3 being homicidal and dangerous to others. A Coroner's Emergency Certificate (CEC) was signed on 11/09/11 at 1:31pm due to Patient #3 being dangerous to others.

Review of Patient #3's "Multidisciplinary Progress Notes" revealed the following entry on 11/10/11 at 11:00pm by Psychiatric Counselor (PC) S31: "...Pt (patient) became upset when sent to bed early for cursing at peers. Pt wrapped a shirt around his neck & (and) said "I want to kill myself".

Review of Patient #3's "Master Treatment Plan" revealed no documented evidence his treatment was updated with interventions and goals for a suicide attempt and threat that occurred on 11/10/11.

In a face-to-face interview on 02/27/12 at 11:50am, RN S28 indicated Patient #3's treatment plan should have been updated when he attempted suicide by wrapping a sheet around his neck.

Patient #6
Patient #6 was a 11 year old boy admitted to the hospital on 11/30/11 by Coroner's Emergency Certificate for hearing voices telling him to kill his school mates and himself. He attempted to put his head through a glass door because the voice told him to do it.

Review of the Progress Notes dated 12/2/12 at 9:20 p.m. revealed, "Pt (patient) became agitated, banging on walls, cursing, and tying his sheets around his neck. Pt made verbal threats to kill staff."

Review of the Master Treatment Plan for Patient #6 revealed his Diagnoses are as follows:
Axis I: Depressive d/o(disorder) NOS (nonspecific) ADHD (Attention Deficit Hyperactivity Disorder), Combined type, r/o (rule out) Psychosis, NOS Disruptive Behavior d/o, NOS

His problems are listed as mood lability and family conflict. Problem #1 is listed as mood lability. His short term goals are: identify 3 challenges to deal with when he hears voices telling him to things within 5 days of admit. His other short term goal is to identify 5 coping skills to use when hearing the voices within 5 days of admit. Problem #2 is listed as family conflict. His short term goals are to identify 2 major problems he is having at home within 5 days of admit and to identify 2 ways he can help to increase communication within 5 days of admit.

With review of the Master Treatment Plan and the 2 problems identified, there was no documentation of the episode of the patient tying sheets around his neck on 12/2/11 while in the hospital. The episode was not addressed or included in the treatment plan.

An interview was conducted with S 28 RN manager and S 11 RN Manager on 02/27/12 at 11:15 a.m. They stated the episode of the patient tying his sheets around his neck was not addressed in the Treatment Plan and should have been addressed. The patient was discharged on 12/8/11 from the hospital.

Patient #13
Review of Patient #13's "Psychiatric Admission Summary" revealed he was a 12 year old male admitted on 02/14/12 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Disruptive Behavior Disorder, Parent-Child Relational Conflict, and Mild Mental Retardation. Further review of his medical record revealed a PEC was completed on 02/11/12 at 455 (no documented evidence whether the time was am or pm) due to Patient #13 being violent and dangerous to self. A CEC was signed on 02/14/12 at 1415 (2:15pm) due to Patient #13 being violent, dangerous to self, dangerous to others, and gravely disabled.

Review of Patient #13's "Master Treatment Plan" dated 02/17/12 (developed 13 days after his admission) revealed his problems identified were mood lability with suicidal/homicidal ideations, family conflict, and behaviors resulting in danger to self or others.

Review of Patient #13's "Multidisciplinary Notes" dated 02/21/12 at 10:00pm revealed RN S32 documented "redirected many times for pulling his pants below his buttocks & (and) showing his underwear...".

Observation on 02/23/12 at 10:35am revealed Patient #13 attended a group session led by MSW (medical social worker) S26. Observation revealed Patient #13 continued to move from chair to chair in the room and pulled his pants leg up to show his underwear. During the observation S26 had to instruct Patient #13 to put his pants leg down.

Review of Patient #13's medical record revealed he was placed in seclusion on 02/15/12 at 4:15pm due to him jumping on tables, running, throwing toys at staff, attempting to scratch and bite staff, kicking, and head-butting. Further review revealed Patient #13 was placed in seclusion on 02/21/12 at 8:45pm due to being extremely oppositional and defiant and refusing all redirections. Further review revealed he was placed in seclusion on 02/23/12 at 3:15pm due to screaming and kicking, biting, punching, and scratching staff.

Review of Patient #13's "Master Treatment Plan" revealed no documented evidence his plan was updated to include sexually inappropriate behaviors and the continued need for seclusion. Further review revealed his "Mood Lability", "Behaviors resulting in danger to self or others", and "Family Conflict short term goals were to be accomplished by day 2, day 3, and day 5 of treatment. There was no documented evidence whether the goals had been accomplished or whether they had been revised by 39 days after admit.

In a face-to-face interview on 02/27/12 at 11:15am, RN Manager of the Child/Adolescent Unit S28 confirmed that Patient #13's treatment plan was not revised to include sexually inappropriate behavior. S28 indicated the behavior wasn't present when the care plan was developed. In the same interview, RN Manager S11 indicated the patient's care plan can be revised as needed and did not have to be done at the weekly treatment team meeting.

Review of the policy titled "Multidisciplinary Master Treatment Plan/Treatment Plan Update/Patient Reassessment", last reviewed 2011 and submitted as the one currently in use, revealed, in part, "...Procedure: 4. Specific goals and measurable objectives or outcomes, interventions planned, recommendations, frequency or treatment procedures and the person, by name and title, responsible are to be documented by the discipline responsible as determined by the treatment plan...Procedure: 7. The master treatment plan shall be updated frequently as clinically indicated, and at least as often as every 7 days.....".





26351

Based on record review and staff interview, the facility failed to ensure that each patient who was discharged had a discharge summary that was accurate and dictated within 30 days of discharge for 2 (#4, #9) of 14 sampled discharged records reviewed out of a total sample of 24. Findings:

Review of the policy and procedure titled, "Analyzing Records-Discharge Summary", with no policy number, page 1 of 2, last revised date of 10/11, presented as the hospital's current policy, revealed the following:
"Policy: Verifies that patient record contains all pertinent information and if complete.
Procedure:
Responsibility: Attending Physician
Action: Dictates discharge summary within 30 days of patient's discharge.
B. Clinical Resume - The discharge summary includes a clinical resume that summarizes the following: Initial Assessment/Diagnosis, Clinical course of hospitalization, Final Assessment/Diagnosis, Condition on Discharge, Prognosis, Aftercare Planning/Recommendations/ Medications, Living arrangements, Diet, Level of physical activity".

Patient #4
Review of the patient's clinical record revealed the patient was an 8 year old male admitted to the facility on 11/15/11 as a PEC (Physician Emergency Commitment) for violent behavior. The record revealed the patient was discharged to home on 11/18/11. Review of the Psychiatric Evaluation revealed the patient's diagnosis was Major Depressive Disorder with Anxious Features.

Review of the record revealed there was no documented evidence of a discharge summary.

On 02/27/12 at 12:20 p.m., a face to face interview was conducted with the Director of Nursing, S2RN. After reviewing the patient's record, she verified there was no discharge summary on the record. S2 verified that the patient was discharged on 11/18/11 and the discharge summary should be on the record by this date (101 days after the patient's discharge). S2 verified the hospital's policy of dictating the discharge summary within 30 days of discharge.

Patient #9
Review of the patient's clinical record revealed the patient was a 31 year old female admitted to the facility on 12/19/11 as a formal voluntary admission for Bi-Polar Depression (Per Physician's Admission Orders). Review of the record revealed that the patient was discharged from the inpatient facility on 12/23/11.

Review of the Psychiatric Discharge Summary, dictated on 02/22/12 at 12:00 p.m. (66 days after discharge) revealed the following:
"Date of Admission: 01/03/12
Date of Discharge: 01/09/12
History of Present Illness: The patient is a 31-year old Caucasian female with bipolar disorder, on lithium, who was PEC'd to River Oaks Hospital on 01/01/12 secondary to depressed mood with suicidal ideation and feelings of hopelessness and helplessness....."

Further review of the record revealed no documented evidence of a discharge summary that addressed the patient's inpatient stay. There was also no documented evidence of a PEC.

On 12/27/12 at 12:00 p.m., a face to face interview was conducted with the Director of Nursing, S2RN. After reviewing the patient's record, she verified the discharge summary had not been dictated within 30 days of the patient's discharge. S2RN verified that there was no evidence of a PEC on the record and stated that the record indicated that the patient was a voluntary admission. She verified the discharge summary did not reflect the patient's inpatient admission. S2RN verified that discharge summary on the patient's record was not an accurate recapitulation of the patient's hospitalization.

Based on record review and interviews, the hospital failed to ensure: 1) medications were administered as ordered by the physician for 2 of 24 sampled patients (#3, #13) and 2) patients were monitored following the administration of the first dose of newly prescribed medications according to hospital policy for 2 of 24 sampled patients (#3, #5). Findings:

1) Medications administered as ordered by the physician:
Patient #3
Review of Patient #3's "Psychiatric Admission Summary" revealed he was admitted on 11/08/11 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems. Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/08/11 at 12:05pm due to Patient #3 being homicidal and dangerous to others. A Coroner's Emergency Certificate (CEC) was signed on 11/09/11 at 1:31pm due to Patient #3 being dangerous to others.

Review of Patient #3's "Physician's Orders" revealed an order on 11/11/11 at 1330 (1:30pm) for Prozac 10 mg (milligrams) by mouth at bedtime each day.

Review of Patient #3's "Routine Medication Administration Record" (MAR) and the nurses' notes for 11/13/11 revealed no documented evidence that Prozac was administered to Patient #3 at bedtime on 11/13/11.

In a face-to-face interview on 02/27/12 at 11:15am, S28, RN (registered nurse) Manager of the Child/Adolescent Unit, confirmed there was no documented evidence that Prozac was administered to Patient #3 on 11/13/11.

Patient #13
Review of Patient #13's "Psychiatric Admission Summary" revealed he was admitted on 02/14/12 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Disruptive Behavior Disorder, Parent-Child Relational Conflict, and Mild Mental Retardation. Further review of his medical record revealed a PEC was completed on 02/11/12 at 455 (no documented evidence whether the time was am or pm) due to Patient #13 being violent and dangerous to self. A CEC was signed on 02/14/12 at 1415 (2:15pm) due to Patient #13 being violent, dangerous to self, dangerous to others, and gravely disabled.

Review of Patient #13's "Physician's Orders" revealed an order was written by Psychiatrist S8 on 02/17/12 at 11:45am for Celexa 20 mg by mouth, 1 now and every morning.

Review of Patient #13's "Routine Medication Administration Record" revealed Celexa that was ordered to be given at 11:45am was administered at 2:00pm, 2 hours and 15 minutes after it had been ordered.

In a face-to-face interview on 02/27/12 at 11:15am, S28, RN Manager of the Child/Adolescent Unit, confirmed the hospital did not have a policy that designated the amount of time after an order was received for a stat or "now" medication that the medication should be administered.

Review of the hospital policy titled "Medication And Pharmacy Function: Medication Management", contained in the policy manual submitted by Administrator S1 as the current policies, reviewed 01/12, and revised 01/10, revealed, in part, "... 7. Individual Medication Administration Records (MARs) ... E. If for some reason the medication is not given, the nurse circles his/her initials for that dose and indicate why medication was not given. An explanation should be put in patient's chart on nurse's notes why not given...".

2) Patients monitored after the first dose of newly prescribed medication:
Patient #3
Review of Patient #3's "Psychiatric Admission Summary" revealed he was admitted on 11/08/11 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems.

Review of Patient #3's "Physician's Orders" revealed an order on 11/11/11 at 1330 (1:30pm) for Prozac 10 mg by mouth at bedtime each day.

Review of Patient #3's medical record revealed the form titled "Patient's Response To The First Dose Of A Medicine" with the date of 11/11/11, the time of 9:00 (no documented evidence of am or pm), and the medication Prozac 10 mg documented. Further review revealed the following information required was not answered as evidenced by a blank line: patient follow-up date and time; questions to be asked 4 to 12 hours after administration - any side effects, comments whether effective, non-effective, unable to determine; staff signature.

Patient #5
Review of Patient #5's "Psychiatric Admission Summary" revealed she was admitted on 11/23/11 under a PEC (Physician's Emergency Certificate) with the diagnoses of Major Depressive Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems and Cannabis Abuse.

Review of Patient #5's "Physician's Orders" revealed an order on 11/27/11 for Prozac 10 mg by mouth every am (morning).

Review of Patient #5's medical record revealed the form titled "Patient's Response To The First Dose Of A Medicine" with the date of 11/27/11, the time of 11:45am, and the medication Prozac 10 mg documented. Further review revealed the following information required was not answered as evidenced by a blank line: patient follow-up date and time; questions to be asked 4 to 12 hours after administration - any side effects, comments whether effective, non-effective, unable to determine; staff signature.

In a face-to-face interview on 02/22/12 at 3:00pm RN S2 Director of Nursing verified the form should have been completed by the nursing staff. Further S2 indicated the form had been created in response to another survey requiring that all patients were re-assessed after administration of first-dose medications.

Review of the hospital policy titled "Medication And Pharmacy Function: Medication Management", contained in the policy manual submitted by Administrator S1 as the current policies, revealed, in part, "... 9. First Dose Monitoring A. The Registered Nurse will monitor the patient following the administration of the first dose of any newly prescribed medication. The nurse will report any possible side effects or reactions immediately to the prescribing physician. The physician will then immediately evaluate the patient to determine appropriate action...".

Based on record review and interviews, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care for each patient as evidenced by: 1) failing to develop and implement a system for performance of a medical assessment for all psychiatric patients as evidenced by the family of a patient (#20) identifying an injury to her left wrist, not identified by hospital staff, which resulted in a visit to the emergency room and the diagnosis of a fractured wrist for 1 of 1 patients with an injury not identified by hospital staff out of a toal sample of 24 patients; 2) failing to perform patient assessments at a minimum of every 24 hours as required by hospital policy for 3 of 24 sampled patients (#4, #11, #12); 3) failing to perform patient assessments when there was a change in the patient's condition for 5 of 24 sampled patients (#3, #14, #15, #20, #24); 4) failure to reassess patients after prn (as needed) medications were administered to determine if the intervention was effective for 4 of 24 sampled patients (#3, #13, #14, #20); 5) failing to assess the patients' vital signs according to hospital policy for 3 of 3 sampled patients (#3, #12, #14); 6) delegating the assessment and documentation of patient behaviors to unlicensed psychiatric counselors for 3 of 24 sampled patients (#3, #13, #14) and 7) delegating unlicensed psychiatric counselors who had no documented evidence of training or assessment of competency to conduct nursing groups for 6 of 24 sampled patients (#3, #4, #5, #12, #13, #14). Findings:

1) Failing to develop and implement a system for performance of a medical assessment for all psychiatric patients:
Patient #20
Review of the medical record for Patient #20 revealed a 54 year old female admitted to the hospital on 10/29/11 under a formal voluntary admission for opiate dependency with a history of fibromyalgia.

Review of the Multidisciplinary Reassessment/Progress Note dated 11/02/11 (no time documented) revealed the family members of Patient #20 reported to the staff that she (#20) may have an injured left hand. Further review of the notes revealed the charge nurse determined Patient #20's left hand did not appear to be injured and offered her an ice pack. There was no documented evidence that the physician was notified.

Review of the Physician's Orders dated/timed 11/03/11 at 9:00am revealed an order for Patient #20 to be sent to an urgent care facility for an x-ray. Review of the radiology report dated 11/03/11 revealed Patient #20 had an impacted fracture distal radius extending into the articular surface.

Review of the medical record revealed the next entry was made into the progress notes on 11/03/11 at 4p-11p with no documented evidence Patient #20 had been x-rayed or the results of the x-ray. Further there was no documented evidence the left hand of Patient #20 was assessed. On 11/04/11 at 11:25am an entry written by the nurse revealed.... "Pt. (Patient) returned from ortho f/u (follow-up) with cast on left wrist. + (positive) capillary refill, 2 sec to left finger, no acute complaints of left arm/hand". Patient #20 was discharged at 2:30pm.

In a face to face interview on 02/24/12 at 3:30pm RN S2 Director of Nursing verfied medical assessments are not performed daily on patients.

2) Failure to perform patient assessments at a minimum of every 24 hours:
Patient #4
Review of the patient's clinical record revealed the patient was an 8 year old male admitted to the facility on 11/15/11 as a PEC for violent behavior. The record revealed the patient was discharged on 11/18/11.

Review of the Reassessment/Progress Notes revealed no documentation of a nursing assessment on 11/17/12.

In a face to face interview on 02/27/12 at 12:05 p.m., RN Manager of the Child/Adolescent Unit S28 reviewed the patient's record and verified there was no nursing assessment documented on 11/17/12. S28 verified that nurse was required to reassess the patient at least every 24 hours.

Patient #11
Review of the patient's clinical record revealed that the patient was a 15 year old female admitted to the facility on 12/30/11 by PEC (Physician Emergency Commitment) for suicidal ideations.

Review of the Reassessment/Progress Notes revealed no documentation of a nursing assessment on 01/01/12 and 01/03/12. Review of the notes revealed that the Patient Reassessment checklist was checked on 01/01/12, but the only signature on the form was by a PC (Psychiatric Counselor). Review of the Reassessment/Progress note revealed that the Patient Reassessment section was left blank. Review of the Multidisciplinary Progress note section revealed that the patient was discharged to home at 4:15 p.m. Review of the Multidisciplinary Progress Note section revealed no documented evidence of an assessment by the nurse on these 2 days.

In a face to face interview on 02/27/12 at 12:05 p.m., RN Manager of the Child/Adolescent Unit S28 reviewed the patient's record and verified that the nurse had not signed the Patient Reassessment on 01/01/12, and verified the only signature on the form was the PC signature. S28 verified she was unable to confirm the RN Review of the radiology report dated 11/03/11 revealed Patient #20 had an impacted fracture distal radius extending into the articular surface.
d th
Rof the patient's clinical record revealed the patient was a 50 year old female admitted to the facility on 01/03/12. The Master Treatment Plan revealed the patient's diagnoses were as follows: Stimulant Dependant and withdrawal, Opiate Dependant in remission, Suborned withdrawal, Cannabis Dependant, and Nicotine Dependant. The Criteria for Discharge was safe detoxify.

Review of the Reassessment/Progress Notes revealed no documentation of a nursing assessment on the following dates: 01/06/12, 01/07/12, and 01/08/12. Review of the notes revealIIed that the Patient Reassessment checklist was left blank. Review of the Multidisciplinary Progress Note section revealed no documented evidence of an assessment by the nurse on these 3 days.

On 02/27/12 at 12:20 p.m. a face to face interview was conducted with the Nurse Manager of the Adult Unit, S 11 RN. After reviewing the patient's record, she verified that no nursing assessments had been done for 01/06/12, 01/07/12, and 01/08/12. She verified that the Patient Reassessment section was left blank, and there were no assessments documented by the nurse in the Multidisciplinary Progress Note section. S 11 RN verified that the facility's policy was for the RN (Registered Nurse) to assess the patient at least every 24 hours.

In a face-to-face interview on 02/27/12 at 11:15am, RN Manager of the Child/Adolescent Unit S28 indicated the day RN and the evening RN share the duty of performing the daily nursing assessments of patients on the Child/Adolescent Unit. S28 further indicated the hospital policy required each patient to be assessed by the RN at a minimum of every 24 hours. S28 confirmed the nursing assessments were not timed when they were performed, and thus she couldn't be sure that the assessment was performed within the 24 hour time interval as required by policy.

Review of the hospital policy titled "Assessment And Reassessment Of Patients", contained in the manual presented by Administrator S1 as the current policies and reviewed 10/10 and revised 01/10, revealed, in part, "...The Nursing Assessment is a vital component of the admission procedure... Reassessment is also a vital component of the patient's plan of care. Reassessment occurs on a daily basis and is addressed in the Reassessment Progress Note... 11. Nursing reassessment done every 24 hours, including mental status and medical issues".

3) Failure to perform patient assessments when there was a change in the patient's condition: Patient #3
Review of Patient #3's "Psychiatric Admission Summary" revealed he was a 9 year old male admitted on 11/08/11 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems. Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was complet

Based on record review and interview the hospital failed to ensure adverse patient events were documented and their cause analyzed for 3 of 24 sampled patients (#3, #6, #14). Findings:

Patient #3
Review of Patient #3's "Psychiatric Admission Summary" revealed he was a 9 year old male admitted on 11/08/11 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems. Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/08/11 at 12:05pm due to Patient #3 being homicidal and dangerous to others. A Coroner's Emergency Certificate (CEC) was signed on 11/09/11 at 1:31pm due to Patient #3 being dangerous to others.

Review of Patient #3's "Multidisciplinary Progress Notes" revealed the following entry on 11/10/11 at 11:00pm by Psychiatric Counselor (PC) S31: "...Pt (patient) became upset when sent to bed early for cursing at peers. Pt wrapped a shirt around his neck & (and) said "I want to kill myself". RN notified Psychiatrist S8 & pt was placed on SVC (strict visual contact). (1) Staff provided support, guidance, & encouragement. (o) Pt not compliant (with) unit rules & structure. Pt needs redirection from staff. (P) continue to monitor & follow tx (treatment) plan". Further review revealed no documented evidence of an assessment by the RN of the patient's change in condition that included a suicide attempt. Review of the "Patient Monitor Record" documented by PC S31 and dated 11/10/11 revealed Patient #3 was asleep in Module C (children's unit) at 11:00pm.

Review of the hospital's incident report log revealed no documented evidence that an incident report had been completed in relation to Patient #3's suicide attempt and suicide threat.

In a face-to-face interview on 02/27/12 at 11:15am, RN Manager of the Child/Adolescent Unit S28 indicated Patient #3 should have been assessed by the RN on 11/10/11 when she notified Psychiatrist S8 of the above report from PC S31. S28 further indicated an incident report should have been completed by the RN. S28 further indicated PC S31 documented her note for the entire shift at 11:00pm, and there was not the specific time that the event with Patient #3 had occurred, which resulted in the observation record and the progress notes information not matching.

Review of Patient #3's "Progress Notes" dated 11/12/11 at 10:50 (no documented evidence whether it was am or pm) revealed documentation by PC S42 of "...He began attention seeking and pulling a towel around his neck. He started cursing and disrespecting staff...". Further review revealed no documented evidence that this was reported to the RN, and there was no documented evidence of a RN's assessment of Patient #3's suicide attempt. Review of Patient #3's "Patient Monitor Record" dated 11/12/11 revealed from 10:45am through 11:00am, Patient #3 was cooperative in Module C, and from 10:45pm through 11:00pm he was sleeping in the quiet room.

Review of the hospital's incident report log revealed no documented evidence that an incident report had been completed.

In a face-to-face interview on 02/27/12 at 11:15am, RN Manager of the Child/Adolescent Unit S28 indicated Patient #3 should have been assessed by the RN, and an incident report was required to be completed when patients made suicide attempts or threats.

In a face-to-face interview on 02/27/12 at 11:50am, RN Manager of the Child/Adolescent Unit S28 indicated the RN should document an assessment of the patient behaviors that warranted the need for prn medication.

In a face-to-face interview on 02/27/12 at 2:20pm, RN Risk Manager S34 indicated incident reports were to be reviewed by the supervisor and signed on the day the report was written, and she (S34) was to review and sign the report by the following day.

Patient #6
Patient #6 was an 11 year old boy admitted to the hospital on 11/30/11 by Coroner's Emergency Certificate for hearing voices telling him to kill his school mates and himself. He attempted to put his head through a glass door because the voice told him to do it.

Review of the Progress Notes dated 12/02/11 at 9:20 p.m. revealed, "Pt (patient) became agitated, banging on walls, cursing, and tying his sheets around his neck. Pt made verbal threats to kill staff".

Review of the Incident and Accident reports for December 2011 revealed no documented evidence of an incident and accident report related to the patient attempting to tie sheets around his neck.

An interview was conducted with S 28 Nurse Manager on 02/27/12 at 11:10 a.m. She reported that an incident report should had been filled out related to the patient attempting to tie a sheet around his neck on the unit.

Patient #14
Review of Patient #14's medical record revealed he was admitted on 01/25/12 with the diagnoses of Depressive Disorder, Post Traumatic Stress Disorder, Physical Abuse, Sexual Abuse, and Disruptive Behavior Disorder. Further review revealed a PEC was completed on 01/25/12 at 4:30pm due to Patient #14 being suicidal, homicidal, violent, dangerous to self and others, and gravely disabled. A CEC was signed on 01/27/12 at 11:20am due to Patient #14 being dangerous to self and others and gravely disabled.

Review of Patient #14's "Multidisciplinary Progress Notes" dated 01/29/12 revealed an entry at 2:30pm by PC S36 of "...being physically aggressive punching a male child on the face over a movie. Pt was stopped by a female PC & was put in his room by other nursing staff who came to assist. Doctor was called by nurse & she told PCs that if pt stays in his room & he is able to calm himself down he will be okay no shot but a Vistaril by mouth... pt was put on early bedtime & no privileges. Monitor pt behavior encourage pt to follow his treatment plan...". Further review revealed no documented evidence of an assessment of Patient #14 by a RN and the report of the RN's phone call to the physician.

Review of the hospital's incident report log revealed no documented evidence that an incident report was completed related to Patient #14 striking another patient in the face.

In a face-to-face interview on 02/27/12 at 11:05am, PC S36 indicated she reported that Patient #14 had struck another peer in the face on 01/29/12 to the charge nurse, but she doesn't remember which nurse she told. S36 further indicated that she didn't know if an incident report had been completed at the time of the incident.

Review of Patient #14's "Multidisciplinary Progress Notes" dated 02/02/12 revealed a shift entry by PC S20 of "...appeared to have a limited affect. He could not participate in the activities & group because his behavior was out of control. He stated that he will do what he want. x 2 in the quiet room for his inappropriate behaviors...". Further review revealed no documented evidence that a RN assessed Patient #14's behaviors when he was "out of control" that warranted him to be placed in the quiet room twice by PC S20.

In a face-to-face interview on 02/27/12 at 9:02am, PC S20 indicated she placed a child in the seclusion room and left the door open when she documents that they are in the quiet room. S20 further indicated she kept the patient from exiting the room until they've "done their little time out". S20 further indicated she decides when the patient can come out of the seclusion/quiet room. When asked if she's familiar with the seclusion policy, S20 indicated that she was and reviewed it every 2 to 3 weeks. After being told that the hospital policy considered it to be seclusion when a patient was not allowed to leave a room, S20 reconfirmed that she kept patients from leaving the seclusion room when she placed them there for time-out until she determined that the patient could leave.

Review of Patient #14's "Reassessment/Progress Note dated 02/15/12 revealed documentation written across the front of the page with no documented evidence of the date, time, and name and title of the person who made the notation. Further review revealed the documentation included "Vistaril 25 mg p.o. (by mouth) at 4PM - agitated angry hostile threatening". Review of the

20177




25065




26351


Based on record review and interview the hospital failed to ensure each patient's medical record was accurately written and promptly completed. The delinquency rate for 2011 was 42%, and the delinquency rate as of January 2012 was 39%. Physician-ordered observation levels were not accurately documented in the medical record for 6 of 24 sampled records (#1, #4, #6, #8, #11, #21). Documented observations were not consistent with the behaviors documented in the progress notes for 3 of 24 sampled patients (#3, #13, #14, #15). White correction liquid (white out) was used in a medical record for 1 of 24 sampled medical records (#6). Findings:

1) Delinquency rate:
Review of the Physician Delinquency rate for January 2012 revealed the total rate was 39%, and the delinquency rate for the year 2011 was 42%.

Review of the Physician Delinquency rate per physician revealed:
S 8 MD had 6 charts over 30 days delinquent, 1 chart over 60 days delinquent, and 1 chart over 90 days delinquent.
S 19 MD had 7 charts over 30 days delinquent, 6 charts over 60 days delinquent, and 4 charts over 90 days delinquent.
S 40 MD had 2 charts over 30 days delinquent and 4 charts over 90 days delinquent.
S 41 MD had 1 chart over 30 days delinquent and 2 charts over 90 days delinquent.
S 39 MD had 1 chart over 30 days delinquent.
S 38 MD had 1 chart over 234 days delinquent.

An interview was conducted with S30 RHIA (Registered Health Information Administrator) on 02/24/12 at 9:25 a.m. She reported that the delinquency rate for medical records was 39% for January. She reported the system in place to notify the doctors of delinquent charts was to e-mail them once a week and "cc" S1Administrator and S 18 Medical Director. She stated she had been at the hospital about 4 years and none of the physicians' privileges had been suspended for delinquent medical records.

An interview was conducted with S 18 MD on 02/27/12 at 2 p.m. He stated he was the Medical Director of the hospital, and once a month in the Medical Executive Committee the delinquent rate per physician is presented to him. He further reported he speaks to the physicians and reminds them about their delinquent records. He also stated there was no disciplinary actions or suspension of privileges related to delinquent records because he did not see the need for it.

Review of the Medical Staff Rules and Regulations revealed in part, "....On the thirtieth (30th) day after discharge, if the record is incomplete, the Medical Director, the Chief Executive officer, and the Chairman of the Medical Executive Committee will be notified to consider suspension of privileges or other appropriate disciplinary action. Suspension of clinical privileges will usually apply to future cases only. When privileges are suspended, the practitioner must complete all incomplete records before his/her privileges will be reinstated. A record is not complete until all material has been dictated, transcribed, and signed...".

2) Physician-ordered observation levels were not accurately recorded in the medical record:
Patient #1
Review of the medical record for Patient #1 revealed she was a 17 year old female admitted on 10/29/11 for mood disorder with suicidal ideations.

Review of the medical record for Patient #1 revealed a physician's order on admission (10/29/11) for MVO/CO (moderate visual contact/close observation) as the observation status. Review of the Patient Monitor Record for 10/29/11 revealed no observation indicated on the form. Review of the Patient Monitor Record for 10/30/11 revealed her observation status was documented as CO (close observation). Review of the Patient Monitor Record for 10/31/11 revealed her observation status was documented as CO (close observation). Review of the Patient Monitor Record for 11/1/11 revealed her observation status was documented as CO (close observation). Patient #1 was discharged on 11/1/11.

An interview was conducted with S 11 Nurse Manager and S 28 Nurse Manager on 02/27/12 at 11:10 a.m. They confirmed there was no physician order for close observation status, only MVO/CO. The wrong observation status was documented or not documented the patient's entire hospitalization.

Patient #4
Review of the medical record for Patient #4 revealed an 8 year old male admitted to the hospital on 11/15/11 at 8:30 p.m. under a PEC (Physician Emergency Certificate) for suicidal ideations, Psychosis, and Major Depressive Disorder. Review of the Physician's Admission Orders dated 11/15/11 at 8:30 p.m. revealed Patient #4 was placed on MVC/CO (Modified Visual contact/Close Observation). Review of the physician's orders revealed no documented evidence that the MVC/CO observation status was changed during the patient's hospital stay. The record revealed the patient was discharged on 11/18/11.

Review of the Multidisciplinary Assessment dated 11/15/11, revealed that the Initial Treatment Plan identified safety as a patient problem and an intervention for this problem was MVC/CO.

Review of the Patient Monitoring Records for Patient #4 revealed on 11/15/11 the observation status was left blank and did not indicate the level of observation provided to the patient.

Review of the Reassessment/Progress Notes for Patient #4 revealed that on 11/16/11 the RN checked CO under the patient safety section. On 11/17/11 there was no assessment of the observation status documented by the RN. On 11/18/11 the RN checked MVO/CO as the observation status and indicated in the progress notes that the patient was discharged to home at 1:00 p.m. on 01/18/11.

In a face--o face interview on 02/27/12 at 12:05 p.m. with the RN Manager of the Adolescent Unit S28, she reviewed the patient's record and verified that the observation status ordered by the physician on admit was for MVC/CO, and there were no physician's orders to change the observation status. S28 verified the Patient Monitoring Records did not indicate the level of observation ordered by the physician on 11/15/11. S28 verified there was no observation status documented by the RN on 11/17/11.

Patient #6
Patient #6 was a 11 year old boy admitted to the hospital on 11/30/11 by Coroner's Emergency Certificate for hearing voices telling him to kill his school mates and himself. He attempted to put his head through a glass door because the voice told him to do it.

Review of the the Admission Orders dated 11/30/11 revealed a physician order for MVC/CO observation status. Review of the Patient Monitor Record date 11/30/11 revealed no observation status was indicated.

An interview was conducted with S11 Nurse Manager and S28 Nurse Manager on 02/27/11 at 11:10 a.m. They reported if an observation status was not marked, the observation status was close observation (CO), not MVC/CO as ordered by the physician.

Patient #8
Review of the medical record of Patient #8 revealed a a 13 year old male admitted to the hospital under a PEC (Physician's Emergency Certificate) for pulling a knife on his mother's boyfriend. Review of the Physician's Admit Orders dated/times 12/13/11 at 1:25am revealed an order for an observation status of MVC/CO (Modified Visual Contact/Close Observation).

Review of the Patient Monitor Record for Patient #8 dated 12/13/11 revealed the following: 3:00pm through 3:45pm Patient #8 was in his room displaying cooperative behavior; 4:15pm through 8:00pm was in his dayroom displaying cooperative behavior which was recorded by the psychiatric counselor.

Review of the Multidisciplinary Progress Notes for Patient #8, dated/timed 12/13/11 at 3:05pm by S47 PC (Psychiatric Counselor), revealed "...Patient is all over the place, picking in the bottom of the wall digging out the grout, eating black pepper, poor boundaries with his peers, sitting too close or getting in their face, needs to be re-directed...".

Review of the Patient Monitor Record dated 12/15/11 from 7:30am through 12/16/11 at 7:15am revealed Patient #8's behavior to be CP (cooperative).

Review of the Multidisciplinary Progress Notes for Patient #8 dated/timed 12/15/11 at 3:00pm revealed ..... "Patient seemed impulsive and was often noted pac

Based on observations, record reviews, and staff interviews, the hospital failed to ensure that the food and dietetic services organization requirements and policies were met as evidenced by: 1) failing to ensure the guidelines for kitchen sanitation was followed as per the "Food Storage Function: Infection Control" policy by having caked black, brown, orange, gray and/or white substances/debris on the ice machine, large metal panel, five (5) cooking sheets, five (5) large sheet pans, food scale, six (6) large dry food containers, a large white lid, clear dinner roll lid, two (2) spice containers, seasonings (Tony Chachere, Oregano, Sage, Whole Dill Weed, Basil, Cinnamon, Caribbean Jerk), deep fat fryer, grill, stove, two (2) convention ovens, five (5) pots, four (4) frying pans, two (2) large strainers, faucet, walk-in cooler, four (4) plastic curtains hanging in the walk way of the cooler, the freezer door located inside the walk-in cooler, and a clip board in the clean kitchen area; 2) failing to ensure there were food temperatures recorded for all meals prior to serving the food to the patients from 11/24/11 through 02/23/12 as per the Dietary Manager S43 and Registered Dietician S17; and 3) failing to follow the food temperature guidelines for hot food to be served at 140 degrees from 01/03/12 through 02/22/12 as per the "Food Storage Function: Infection Control", policy. Findings:

1)
During a tour of the kitchen conducted on 02/23/12 from 8:25 a.m. through 11:30 a.m. with S 43 Dietary Manager and S2DON (Director of Nursing), there was an ice machine observed with three (3) grooved areas on the front of the machine. Further observation revealed there was a whitish piece of plastic with jagged edges extending from the grooved areas approximately one-quarter inch. The jazzed edges on the piece of plastic inside the grooved areas on the machine were grayish in color. Further observation revealed there was a white, brown, and black substance/debris observed under the lid of the ice machine. On the front panel of the ice machine was whitish/brownish debris noted. There was a large metal panel and four (4) cooking sheets stacked on top of the ice machine. Further observation revealed the large metal panel and four cookie sheets were noted cached with a grayish substance/debris. To the left of the ice machine was a rack with five (5) large sheet pans noted in its slots. Further observation revealed the five (5) large sheet pans were cached with a black substance. Next to the rack of sheet pans was a food scale sitting located on the countertop. Further observation revealed the front panel and both sides of the scale were covered with a brownish/orangish substance. There were a total of six (6) large stacked dry food containers noted below the cooks prep area with brown rice, white rice (empty container), corn meal and/or yellow corn meal. Further observation revealed the top and sides of these six (6) stacked containers was cached with a grayish/whitish substances. To the right of these six (6) stacked containers was a large white lid noted with a whitish/orange debris. At 9:55 a.m., there was a clear dinner roll lid noted covered with brown debris located next to stacked dinner rolls on top of the cook's prep area. At 9:59 a.m., there were two (2) spice storage bins observed under the cook's prep area. Further observation revealed the two (2) spice storage bins had a whitish, orange, grayish, red, black and brown substance in the bottom of the containers. There was an orange substance observed on the Tony Chachere seasoning's lid, a brown/black substance on the Oregano seasoning's lid, a gray substance on the Sage seasoning's lid, a grayish/white substance on the Whole Dill Weed seasoning's lid, a brown/reddish substance on the Basil seasoning's lid, a whitish substance on the Cinnamon seasoning's lid, and a whitish/gray substance on the Caribbean Jerk seasoning's lid. At 10:00 a.m., the deep fat fryer was observed with two (2) side panels. Further observation revealed these two (2) side panels of the fryer were covered with a cached brown, white, and gray substances. At 10:07 a.m., the grill was observed with orange cached debris on the side panels. Further observation revealed the grill's edges were covered with a cached orange/brown substance. There was a one (1) inch by half-inch (1/2) piece of orange, brown, and black debris noted on the right side panel of the grill. The DON (S2) peeled the piece of debris from the side panel at this time and discarded it in the trash. At 10:08 a.m., the six (6) burner stove was observed with a cached white, orange, brown, and black substance on the surface between the burners. Further observation revealed the front and back two (2) left burner's on the stove was noted with small black pieces of chipped debris. At 10:15 a.m., there were two (2) convention ovens observed. Further observation of the ovens revealed the front bottom panel areas were cached with a black substance. The black handles on the stoves had a whitish, orange, and brown substance and debris noted on top of them. There were three (3) knobs (power, temperature, and timer) on the stoves that were covered with white debris and cached with a grayish substance. At 10:20 a.m., there were a total of five (5) pots and four (4) frying pans observed cached with a brownish/black substances. There were two (2) large metal strainers had the bottom inner rings that were covered with an orange debris. At 10:20 a.m., the double sink area used to prep vegetables was observed with a facet. Further observation revealed the facet did not have a plate that covered the back area of the facet. The faucet's connecting device (screws) were exposed and covered with orange, green, and white substance. The right facet handle was observed covered with a whitish substance. At 10:25 a.m., the bottom panels of the walk-in cooler was observed with an orange substance on both panels. The four (4) plastic curtains hanging in the walk way of the cooler was observed covered with a whitish substance. The bottom of the freezer door located inside the walk-in cooler was observed with a cached orange substance. At 10:35 a.m., a clip board with a menu for that week was observed on the countertop in the cook's prep area. Further observation revealed the clip on the clip board and the area behind the clip was cached with black debris. S2DON put the clip board in the trash can at this time.

In an interview on 02/23/12 from 8:25 a.m. through 11:30 a.m., S2DON and S 43 Dietary Manager confirmed all the above findings during the tour of the kitchen.

Review of the policy titled, "Food Storage Function: Infection Control", with no policy number, page 1 of 1, last reviewed date of 9/11, last revised date of 1/11, presented as the hospital's current "Food Temperature" policy indicated the kitchen will be kept clean at all times.

Review of the "Food Storage Function: Infection Control", with no policy number, pages 1 to 3, last reviewed date of 2/11, last revised date of 1/10, with no effective date, presented as the hospital's current "Food Storage/Equipment" policy indicated all foods, non-food items and supplies, related to and used in food preparations shall be stored in such a manner to prevent bacteriological contamination. The dry food storage area must be clean. The containers for dry food item storage must be used for bulk materials such as flour, sugar, mixes, dry lentils, pasta, and etc. The containers should be fabricated so that residue may be completely removed by normal cleaning methods, and have tight lids. Food not subject to further washing or cooking before serving shall be stored in such a manner as to be protected against contamination from food requiring washing or cooking.

2)
During the hot/cold food temperature checks of a test tray by S 17 Registered Dietician on 02/23/12 at 12:25 p.m., the mixed vegetable temperature was one hundred ten (110) degrees Fahrenheit.

In an interview on 02/23/12 at 12:25 p.m., S 17 Registered Dietician and S2DON confirmed the mixed vegetables were a hot food that should be served to th

Based on observation, record review, and interview, the hospital failed to ensure the nursing staff developed and kept current a nursing care plan for each patient as evidenced by: 1) failing to follow physician's orders for observation of a patient for 8 of 24 sampled patients (#1, #3, #4, #6, #8, #11, #21, #24); 2) failing to update the treatment plan after a change in a patient's condition for 2 of 2 patient with a change in condition out of a total of 24 sampled patients (#3, #13); 3) failing to evaluate the patient's treatment plan to determine if the patient had met his/her goal by the target date established and whether the plan needed to be revised for 1of 24 sampled patients (#14); and 4) failing to follow physician orders for vital signs on patients experiencing drug withdrawal for 3 of 3 drug dependent patients (#19, #20, #23) out of a total sample of 24 patients. Findings:

1) Failing to follow physician's orders for observation of a patient:
Patient #1
Review of the medical record for Patient #1 revealed she was a 17 year old female admitted on 10/29/11 for mood disorder with suicidal ideations.

Review of the medical record for Patient #1 revealed a physician's order on admission (10/29/11) for MVO/CO (moderate visual contact/close observation) as the observation status. Review of the Patient Monitor Record for 10/29/11 revealed no observation indicated on the form. Review of the Patient Monitor Record for 10/30/11 revealed her observation status was documented as CO (close observation). Review of the Patient Monitor Record for 10/31/11 revealed her observation status was documented as CO (close observation). Review of the Patient Monitor Record for 11/1/11 revealed her observation status was documented as CO (close observation). Patient #1 was discharged on 11/1/11.

An interview was conducted with S 11 Nurse Manager and S 28 Nurse Manager on 02/27/12 at 11:10 a.m. They confirmed there was no physician order for close observation status, only MVO/CO. The wrong observation status was documented or not documented the patient's entire hospitalization.

Patient #3
Review of Patient #3's "Psychiatric Admission Summary" revealed he was admitted on 11/08/11 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems. Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/08/11 at 12:05pm due to Patient #3 being homicidal and dangerous to others. A Coroner's Emergency Certificate (CEC) was signed on 11/09/11 at 1:31pm due to Patient #3 being dangerous to others.

Review of Patient #3's admit orders revealed his ordered observation status was MVC/CO (modified visual observation/close observation). Further review revealed a telephone order on 11/10/11 at 8:30pm from Psychiatrist S8 to place him on SVC (strict visual contact). Review of Patient #3's "Reassessment/Progress Note" dated 11/10/11 revealed he was on SVC. Review of the "Patient Monitor Record" dated 11/10/11 revealed no documented evidence of a change from MVC/CO to SVC at 8:30pm as ordered by the physician. Review of the "Reassessment/Progress Note" dated 11/11/11 and 11/12/11 revealed Patient #3's observation level was CO when SVC was still in effect from the order on 11/10/11. The "Patient Monitor Record" dated 11/11/11 revealed his observation status was MVC/CO rather than SVC as ordered.

Review of Patient #3's "Physician's Orders" revealed an order was written by Psychiatrist S8 on 11/12/11 at 11:20am to discontinue SVC and start MVC/CO. Further review revealed an order was written by RN S25 on 11/12/11 at 7:18pm (with no documented evidence whether the order was received verbally or by telephone and which physician gave the order) for SVC. Review of Patient #3's "Reassessment/Progress Note" dated 11/12/11 revealed his observation status was documented as CO, rather than MVC/CO as ordered at 11:20am. Review of the "Multidisciplinary Progress Notes" dated 11/12/11 and written by PC (psychiatric counselor) S20 for the 7:00am to 3:30pm shift revealed "...He is now off of SVC status & (and) on CO status...". Review of the "Patient Monitor Record" dated 11/12/11 revealed Patient #3 was on SVC status with no documented evidence that his observation status was changed to MVC/CO at 11:20am and then changed to SVC at 7:18pm.

Review of Patient #3's "Physician's Orders revealed a telephone order on 11/14/11 at 3:50pm from Psychiatrist S8 to discontinue SVC and start MVC/CO. Review of the "Reassessment/Progress Note" and the "Patient Monitor Record" dated 11/15/11 and 11/16/11 revealed Patient #3 was placed on CO rather than MVC/CO as ordered.

Review of Patient #3's "Master Treatment Plan" revealed no documented evidence that his treatment plan was updated when his behaviors warranted a change in his observation status.

In a face-to-face interview on 02/27/12 at 11:50am, RN Manager S11 indicated the psychiatric counselor completes the observation form, and the RN signs the form assuring that it is correct. S11 further indicated a physician's order was needed to change a patient's observation level.

Patient #4
Review of the medical record for Patient #4 revealed an 8 year old male admitted to the hospital on 11/15/11 at 8:30 p.m. under a PEC (Physician Emergency Certificate) for suicidal ideations, Psychosis, and Major Depressive Disorder. Review of the Physician's Admission Orders dated 11/15/11 at 8:30 p.m. revealed Patient #4 was placed on MVC/CO (Modified Visual contact/Close Observation). Review of the physician's orders revealed no documented evidence that the MVC/CO observation status was changed during the patient's hospital stay. The record revealed the patient was discharged on 11/18/11.

Review of the Multidisciplinary Assessment dated 11/15/11, revealed that the Initial Treatment Plan identified safety as a patient problem and an intervention for this problem was MVC/CO.

Review of the Patient Monitoring Records for Patient #4 revealed on 11/15/11 the observation status was left blank and did not indicate the level of observation provided to the patient.

Review of the Reassessment/Progress Notes for Patient #4 revealed that on 11/16/11 the RN checked CO under the patient safety section. On 11/17/11 there was no assessment of the observation status documented by the RN. On 11/18/11 the RN checked MVO/CO as the observation status and indicated in the progress notes that the patient was discharged to home at 1:00 p.m. on 01/18/11.

In a face to face interview on 02/27/12 at 12:05 p.m. with the RN Manager of the Adolescent Unit, S28, she reviewed the patient's record and verified that the observation status ordered by the physician on admit was for MVC/CO, and there were no physician's orders to change the observation status. S28 verified the Patient Monitoring Records did not indicate the level of observation ordered by the physician on 11/15/11. S28 verified there was no observation status documented by the RN on 11/17/11.

Patient #6
Patient #6 was a 11 year old boy admitted to the hospital on 11/30/11 by Coroner's Emergency Certificate for hearing voices telling him to kill his school mates and himself. He attempted to put his head through a glass door because the voice told him to do it.

Review of the the Admission Orders dated 11/30/11 revealed a physician order for MVC/CO observation status. Review of the Patient Monitor Record date 11/30/11 revealed no observation status was indicated.

An interview was conducted with S 11 Nurse Manager and S 28 Nurse Manager on 2/27/11 at 11:10 a.m. They reported if an observation status was not marked the observation status was close observation (CO), not MVC/CO as ordered by the physician.

Patient #8
Review of the medical record of Patient #8 revealed a 13 year old male admitted to the hospital under a PEC (Physician's Emergency Certificate) for pulling a knife on his mother's boyfriend. Review of the Physician's Admit Orders dated/timed 12/13/11 at 1:25am revealed an order for an observation status of MVC/CO (Modified Visual Contact/Close Observation). Fur

Based on observation, record review and interview the hospital failed develop and implement a system for identifying and controlling infections as evidenced by: 1) failing to identify the source of the organism(s) for infections resulting in the inability to implement appropriate isolation precautions and 2) failing to maintain a sanitary environment as evidenced by performance of Environment/Safety rounds which did not include sanitary issues. Findings:

1) failing to identify the source of the organism(s) for infections resulting in the inability to implement appropriate isolation precautions:
Review of the "Patient Inspection Report" completed by the staff nurse and submitted to the Infection Control Nurse revealed the form contained the following information: a list of signs and symptoms of infections and the type (location) of the infection, date the infection developed, and the date of the report.

Review of the form titled "Anti Infective Report" revealed a print out derived from the orders entered into the computer from the physician's orders. Further review revealed the information contained in the report was as follows: patient's name, antibiotic orders, name of physician. Further review revealed no documented evidence of the name of the organism responsible for the infection.

In a face to face interview on 02/27/12 at 11:00am the Infection Control Officer, RN S11, indicated she relies on the nursing staff to complete the "Patient Infection Report" and S11 indicated she does not have the information on the organism causing the infection because the only cultures done are for MRSA (Mothballing Resistant Staph Aureus) at the time of admit. S11 indicated because cultures are not routinely ordered, the hospital would not be able to identify trends or implement isolation precautions other than for MRSA.

2) Failing to maintain a sanitary environment as evidenced by performance of Environment/Safety rounds which did not include sanitary issues:
On 02/22/12 at 10:15 a.m. during a tour of Building 4 where the Eating Disorder Program was housed, an observation was made in the kitchen area where patients prepared their meals. The cabinet containing the sink was observed to have a 2-3 inch wide space between the end of the flooring (Tile) and the cabinet extending 2-3 feet in length (Length of the cabinet). In this 2-3 inch space dirt, debris, and pieces of paper were noted. Between the refrigerator and the dishwasher another area was observed to have no flooring covering the area. In this space (approximately 6 inches by 2 feet) dirt and debris had collected. The beige accordion door separating the kitchenette in the Eating Disorder Unit and the common area had splattered dried liquid marks on the door. The microwave in the kitchenette had food splattered on the inside of the microwave.
S34 Risk Manager was present for this observation and verified that these areas had a collection of dirt and debris. S34 Risk Manager stated, "It should not look like that."

Also observed in the kitchen area was a toaster used by the patients. In the bottom of the toaster a large accumulation of bread crumbs and a brown substance was noted. S34 Risk Manager was present and verified the observations.

On 02/22/12 at 10:55 a.m., during a tour of Building 2 - Children's Unit, a wheeled cart with 3 shelves was observed on the unit. The top shelf of the cart was observed to have an insulated bag. The second and third shelves were observed to have a black substance on the shelves. S28 RN Unit Manager was present for the observation and verified the black substance on the shelves. When asked who was responsible for cleaning the carts, S28 stated, "Whoever can".

Also observed in Building 2 at 11:15 a.m., in the observation area of the Adolescent unit was the following: a large amount of an unknown gray substance that appeared to be a large accumulation of dust, was noted along the base of a chair. Upon lifting the chair, this substance was noted to be a strip of carpet attached to the base of the chair. This strip of carpet was observed to be frayed and coming off of the base of the chair. Carpet strips were observed to be applied to the base of the sofas and chairs in this area. These carpet strips were fraying and coming off the base of the chairs and sofas. On the Children/Adolescent Unit there was a splattered dried brown substance half way up one wall. The beige accordion door separating the visiting area and the common area had large dark beige stains on the door S34 Risk Manager was present for this observation and verified carpet strips had been applied to the base of the chairs and sofas and this carpet was fraying and coming off the base of the furniture.

On 02/22/12 at 11:30 a.m., observations of the physical environment in Building 6 - Adult Unit was revealed the doorway leading to an outside are, adjacent to the medication room had no threshold between the bottom of the door and the floor. A 1/2 -1 inch space was observed between the bottom of the door and the floor, allowing insects, debris, or air to enter from the outside. S33 Maintenance Director was present for the observation and verified there was no threshold in place for this door.

On 02/22/12 at 11:40 a.m., a tour of the Dual Diagnoses Unit was conducted with S33 Maintenance Director and S34 Risk Manager. In the kitchen area a toaster was observed to have a large amount of a brown substance in the bottom of the toaster. Observation of the vents in patient bathrooms revealed paper/cardboard had been placed behind the plastic vent covers. S33 Maintenance stated that patients slide things under the vent cover to block the air.

An environmental tour was conducted on 02/22/12 on the Eating Disorder Unit at 10:15 a.m. A three shelf open cart was located next to the nurses' station. The bottom shelf of the cart had dark brownish-black substance over 1/2 of the shelf. The second shelf had a small amount of the brownish-black substance. The top shelf had an insulated square container on top. When questioned what the insulated container was on the top shelf, S 34 Risk Manager stated it keeps the patient's food warm while being transported. The cart is used to transport the patient's food from the kitchen to the unit. She confirmed the cart was dirty and needed to be cleaned.

The beige accordion door separating the kitchenette in the Eating Disorder Unit and the common area had splattered dried liquid marks on the door. The microwave in the kitchenette had food splattered on the inside of the microwave.

Review of the form titled "Environmental Rounds" used by the hospital monthly to monitor the environment of the hospital revealed no evidence the cleanliness of the facility was monitored.

In a face to face interview on 02/22/12 at 11:15am S33 Eminence Director confirmed cleanliness issues were not included on the environmental rounds form.











17091






20177

Based on record review and interview, the hospital failed to ensure a registered nurse (RN) assigned the nursing care of each patient to other nursing personnel according to the needs of the patient and the qualifications and competence of the available nursing staff. The RN delegated the conductance of group sessions to psychiatric counselors (PC) who had not received training and had not been assessed for competency to conduct group sessions for 3 of 3 PCs' personnel files reviewed from a total of 47 PCs employed (S15, S20, S31). The hospital could provide no documented evidence that a RN made staff assignments on the 11:00pm to 7:00am shift on the child/adolescent unit. Findings:

1) Group sessions by PCs who had not received training and had not been assessed for competency to conduct group sessions:
Review of the personnel records for PCs S15, S20, and S31 revealed no documented evidence of any training or competency assessment on conductance of group therapy.

In a face to face interview on 02/27/12 at 12:00 p.m. with the Director of Nursing, S2DON, she stated they did not have documentation of training or competency assessment for PCs on conducting group therapy.

In a face to face interview on 02/27/12 at 3:00 p.m. with the RN Manager of the Adult Unit, S 11 RN was asked what training and competency assessment was done to ensure the PC staff were competent in conducting group therapy. S 11 RN stated she included an evaluation of the PC's group conductance in their annual evaluation, but stated this was not done until the PC had been employed one year. S 11 RN verified there was no documentation of training or any competency assessment done for the conductance of group therapy for the PC staff.

Patient #2
Review of Patient #2's "Psychiatric Admission Summary" revealed he was admitted on 11/02/11 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Combined Type Disruptive Behavior Disorder, and Rule out Oppositional Defiant Disorder. Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/01/11 at 1:40pm due to Patient #2 being homicidal and dangerous to others. A Coroner's Emergency Certificate (CEC) was signed on 11/01/11 at 1:43pm (1342) due to Patient #2 being dangerous to others.

Review of Patient #2's "Group Note" dated 11/03/11 at 1900 (7:00pm), 11/03/11 at 1:00pm, 11/04/11 at 8:15pm, 11/06/11 at 8:30am, 11/06/11 at 1600 (4:00pm), 11/07/11 at 9:00am, and 11/07/11 at 7:30pm revealed these were nursing groups conducted by PCs who had no documented evidence of training and and assessment of competency to conduct groups. Further review revealed education groups were conducted by PCs who had no documented evidence of training and /or assessment of competency to conduct groups on 11/03/11 at 1900 (7:00pm), 11/03/11 at 1:00pm, 11/04/11 at 8:15pm, 11/06/11 at 8:30am, 11/06/11 at 1600 (4:00pm), 11/07/11 at 9:00am, and 11/07/11 at 7:30pm. Further review revealed a process group titled "are you growing worries " , " expressing anger " , " respect " , " anger-dousing " , " doing something nice for someone else " , and/or " responsibility " were conducted by a PC who had no documented evidence of training and/or assessment of competency to conduct groups on 11/03/11 at 1900 (7:00pm), 11/03/11 at 1:00pm, 11/04/11 at 8:15pm, 11/06/11 at 8:30am, 11/06/11 at 1600 (4:00pm), 11/07/11 at 9:00am, and/or 11/07/11 at 7:30pm.

Patient #3
Review of Patient #3's "Psychiatric Admission Summary" revealed he was a 9 year old male admitted on 11/08/11 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems. Further review of his medical record revealed a Physician's Emergency Certificate (PEC) was completed on 11/08/11 at 12:05pm due to Patient #3 being homicidal and dangerous to others. A Coroner's Emergency Certificate (CEC) was signed on 11/09/11 at 1:31pm due to Patient #3 being dangerous to others.

Review of Patient #3's "Group Note" dated 11/08/11 at 1600 (4:00pm), 11/09/11 at 9:00am, 11/09/11 at 1800 (6:00pm), 11/11/11 at 5:00pm, 11/12/11 at 7:45pm, 11/13/11 at 8:00pm, and 11/15/11 at 7:00pm revealed these were nursing groups conducted by PCs who had no documented evidence of training and and assessment of competency to conduct groups. Further review revealed education groups were conducted by PCs who had no documented evidence of training and and assessment of competency to conduct groups on 11/11/11 at 9:30am, 11/12/11 at 10:30am, 11/13/11 at 11:00 (no documented evidence whether am or pm), 11/14/11 at 9:30 (no documented evidence whether am or pm), 11/15/11 at 9:30 (no documented evidence whether am or pm), and 11/16/11 at 9:30 (no documented evidence whether am or pm). Further review revealed a process group titled "focusing on own treatment" was conducted by a PC who had no documented evidence of training and and assessment of competency to conduct groups on 11/10/11 at 7:00pm.

Patient #4
Review of the patient's clinical record revealed the patient was an 8 year old male admitted to the facility on 11/15/11 as a PEC for violent behavior. The patient's diagnoses included Psychoses, Major Depression, Suicidal Ideations. The record revealed the patient was discharged on 11/18/11.

Review of Patient #4's "Group Note" dated 11/16/11 at 7:45 p.m. and 11/17/11 at 8:00 p.m. revealed these were nursing groups conducted by PCs who had no documented evidence of training and assessment of competency to conduct groups. Further review of the Group Notes revealed that Education Groups on Coping Skills, Responsibility, and Anger-Dousing were conducted by PCs who had no documented evidence of training and competency assessment to conduct group therapy.

Patient #5
Review of Patient #5's "Psychiatric Admission Summary" revealed a 16 year old female admitted to the hospital on 11/23/11 under a PEC (Physician's Emergency Certificate) for suicidal thoughts and behavioral problems at home Further review of the medical record revealed the diagnoses of Major Depressive Disorder, Oppositional Defiant Disorder, and Parent-Child Relational Problems and Cannabis Abuse.

Review of the Group Note for Patient #5 dated 11/24/11 at 1600 (4:00pm) revealed the nursing group with the subject of coping skills for the purpose of patient education. Further review revealed Patient #24 was observed as an active participant with appropriate behavior and response. In addition a handwritten note stated the patient "did not participate, sleepy". The group and the observations were performed by PC S15 a psychiatric counselor with no documented evidence of training or assessed competency to perform group.

Patient #12
Review of the patient's clinical record revealed the patient was a 50 year old female admitted to the facility on 01/03/12. The Master Treatment Plan revealed the patient's diagnoses were as follows: Stimulant Dependant and withdrawal, Opiate Dependant in remission, Suboxone withdrawal, Cannabis Dependant, and Nicotine Dependant. The Criteria for Discharge was safe detox.

Review of Patient #12's "Group Note" dated 12/30/11 at 7:30 p.m., 12/31/11 at 10:15 a.m., 01/01/12 at 12:00 p.m., 01/02/12 at 12:00 p.m. and 5:00 p.m. revealed these were nursing groups conducted by PCs who had no documented evidence of training and assessment of competency to conduct groups. Further review of the Group Notes revealed that Education Groups on Coping Skills, were conducted on 12/31/11 and 01/03/12 by PCs who had no documented evidence of training and competency assessment to conduct group therapy.

Patient #13
Review of Patient #13's "Psychiatric Admission Summary" revealed he was a 12 year old male admitted on 02/14/12 with the diagnoses of Mood Disorder, Attention Deficit Hyperactivity Disorder, Disruptive Behavior Disorder, Parent-Child Relational Conflict, and Mild Mental Retardation. Further review of his medical record revealed a PEC was completed on 02/11/12 at 455 (no documented evidence whether the time was am or pm) due to Patient #13 being violent and dangerous to self. A CE