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Based on review of documentation and interview it was determined that the facility failed to ensure that patient #1 was provided with an environment which promoted personal privacy and dignity.

Findings were:
Patient #1 was placed in a diaper even though nursing staff documented that the patient was continent. Review of Multi-Disciplinary Note for 01/03/18 at 0630 from Nursing stated: "Pt has been under direct line of sight observation and has asked to go to bathroom at least 4 times he was placed in a diaper for safety and his mattress has remained on the floor. He has refused to use the diaper and he has remained dry despite repeatedly asking to go to the bathroom. He has not gotten up either." Patient #1 was listed as being a fall risk under the area on the note where the treatment plan problem # is documented.

Review of Daily Care Monitoring Flow Sheet for 1/3/18 from midnight to 0700 revealed that patient #1 had what appeared to be 2 marks next to the continent bladder area.

Review of facility policy entitled: Patient Rights, effective date of 5/1/2017 stated: "This facility fully supports, endorses and enforces the rights of patients. This facility informs each patient, patient's guardian, and/or patient's family when appropriate, of the patient's rights, in advance of furnishing or discontinuing care whenever possible. Patient rights include all federal and state requirements." Under the Procedure section of the Policy was: "b. The right to treatment in the least restrictive environment that is humane treatment environment that ensures protection form harm, provides privacy to as great degree as possible with regards to personal needs." "h. The right to receive care in a safe setting." "i. the right to be free from all forms of abuse or harassment." "o. The right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff."

In an interview with the Director of Nursing on 01/24/2018 the above findings were confirmed.

Based on review of documentation and interview it was determined that the facility failed to ensure that the patient received care in a safe setting.

Findings were:
Patient #1, an inpatient who was on 1:1 observation sustained an injury to his left ring finger while hospitalized at the facility. Although the patient was on 1:1 observation the facility was unable to determine how the patient had sustained the injury. Patient #1 was admitted to the facility on 12/23/2017 and was placed on 1:1 observation per physician order on 1/4/2018 at 1100 hours. Prior to being placed on 1:1 observation for safety, patient #1 had fallen on 4 separate occasions as evidenced by facility incident reports.

Incident report, dated 12/30/2017 at 0115 hours stated: "Pt states he "slipped off of bed." Found pt on floor, on his knees." "No apparent injuries at this time." The form documented that the physician had been notified.

Incident Report, dated 01/02/2018 at 0920 hours stated: "Patient had unwitnessed fall in bathroom. Patient was escorted to bathroom. Patient then yelled out for help. Min assist X2 to stand. Patient was noted sitting on bathroom floor." No injuries were noted and the physician was documented as being notified.

Incident Report, dated 01/03/2018 at 0158 hours stated: "Patient had witnessed fall earlier in shift where he slid his back down bathroom door then laid on the floor then screamed help, help, help. At 0158 pt unwitnessed got out of bed went to bathroom then screamed help help help, found lying on stomach at bathroom door." Patient #1 denied any pain after the incident.

Incident Report, dated 01/04/2018 at 0530 hours stated: "Patient fell out of bed and hit corner of left eye on wheelchair next to his bed. Laceration cleaned and dressed. No LOC, GCS 14, Pt confused about what happened. Place mattress on mattress on floor for safety." Patient #1 had the laceration cleaned, triple antibiotic ointment was applied as well as a nonstick dressing applied. The physician was documented as being notified.

Review of Daily Nurse Assessment & Progress Note for 1/7/18 for the 0700-1900 shift. Review of page two of the assessment revealed an anatomical drawing which documented that patient #1 had a left ring finger bruise. On page three he was documented as being a high fall risk. On page four staff documented that he was a fall risk and currently was on 1:1 for safety and there was the comment: "Pt. educated that he must remain with staff at all times for safety."

Review of Daily Nurse Assessment & Progress Note for 1/8/18 for the 0700-1900 shift. Review of page two of the assessment revealed an anatomical drawing which documented that patient #1 had "4th finger left hand swollen with purplish bruise pt cannot remember what happened to his finger." On page three he was documented as being a high fall risk.

Review of facility Policy entitled: Levels of Observation, effective date of 5/1/2017 stated under the Procedures section: "b. One to one (1:1) observation: constant visual observation of a patient within arm's length, unless a different distance is specified by physician's order." Page two of the policy stated: "b. One-to-One (1-1) Observation i. 1:1 is the highest level of monitoring, where a staff member stays within arm's length of a patient at all times. 1. A shorter or farther distance may be specifically ordered by the physician if clinically appropriate. ii. During sleep, the staff member may monitor the patient from the doorway, as long as the face, hands, and chest of the patient can be visualized. Iii. When 1:1 is ordered, it must be specifically addressed in the treatment plan, including a plan to graduate to routine observations at the earliest opportunity." Page three stated: "viii. The need for 1:1 observation must be reviewed every twenty four (24) hours during the daily treatment team meetings. On weekends, the nurse should review the need to continue 1:1 individually with the physician."

In an interview with the Director of Nursing on 01/24/2018 the above findings were confirmed.

Based on review of documentation and interview it was determined that the facility failed to ensure that physician orders were dated and timed and verbal orders were only used for clinical emergencies as per facility policy.

Findings were:
1.) Physician orders were not dated and timed. Review of the medical record of patient #1 revealed physician orders not dated or timed to include:

Physician telephone order dated 12/23/17 at 0125, signed by physician but not dated or timed.
Physician telephone order dated 12/29 at 1357, signed by physician but not dated or timed.
Physician telephone order dated 1/4/18 at 0925, signed by physician but not dated or timed.

2.) Verbal Orders were used in situations other than a clinical emergency.
Physician order dated 12/24/17 at 230pm stated: "D/C COQ10"
Physician order dated 12/26/17 at 1800 stated UA C&S

The bottom of the Physician Orders sheets stated: "All orders written by the physician must include a date, time and signature." Also found was the statement: "All orders written by the RN as a telephone order from the physician must include the patient's name, the prescriber's name, date, and time of the order, "read back and verified" (RBV), the RN's signature, and be signed, and timed by the physician within 48 hours."

Policy entitled: Physician Orders, effective date of 2/1/2017 stated: "3. Elements of a complete physician order for any care, treatment, or services in the hospital include: a. Date and time of the order, b. Content of the order, c. Indications for any order antibiotic, pain medication, or as needed (prn) medication, if applicable, d. Signature of the ordering physician." "7. Verbal orders are prohibited except in the case of a clinical emergency. Telephone orders are permissible during times in which the provider is not on site at the hospital." "8. All telephone and verbal orders must be read back to the physician and verified for accuracy. The nurse shall write "RBV" on all telephone and verbal orders to signify this action. No order shall be acted upon until it is completely verified with the physician." "20. All verbal and telephone orders must be authenticated within two (2) working days. Authenticating the order requires signature, date, and time the order. He or she may also print his/her name if the signature is illegible."

In an interview with the Director of Nursing on 01/24/2018 the above findings were confirmed.

Based on review of documentation it was determined that the facility failed to ensure that the the master treatment plan for patient #1 was completed within the time frame specified by the facility's own policy.

Findings were:
The initial master treatment plan for patient #1 was not completed with the time frame specified by the tacitly's own policy.

Patient #1 was admitted to the hospital on 12/23/2017. Review of the Inpatient Master Treatment Plan revealed that it had been initiated on 12/23/2017 at 0335 hours. Page two of the plan listed five separate problems to include: 1) risk for self-harm, 2) depression, 3) impaired skin integrity, 4) fall risk, 5) pain. Page three of the plan documented the treatment team signatures. All members of the treatment team to include the patient, nursing, social work, and the physician had signed on 1/4/18 at approximately 1100 hours. This was 12 days after patient #1's admission.

Policy entitled: Interdisciplinary Treatment Planning (ITP) Documentation, effective date of 2/1/2017 stated: "II. The comprehensive interdisciplinary treatment plan (ITP) a. The ITP is initiated, developed, and documented treatment team meetings and is based upon the patient's identified needs and goals for treatment. The initial treatment team meeting should occur within twenty-four (24) hours of admission but no later than seventy-two (72) hours after admission. See ITP Team Meetings Policy." Page two of the policy stated: "iv. Problem List: 4. The problem list should be reviewed daily and updated every seven (7) days and as needed with each treatment plan review, or following any qualifying event. See ITP Team meeting Policy." "6. The status of all problems must be documented at discharge."

Based on review of documentation and interview it was determined that the facility failed to ensure that the treatment plan for patient #1 was promptly reviewed after there hospital documentation of the need for a review.

Findings were:
Patient #1 was a fall risk. He was admitted to the hospital on 12/23/2017 and from the date of admission to the morning of 1/04/2018 there were 4 separate incident reports completed documenting that patient #1 had fallen.

Incident Report, dated 12/30/2017 at 0115 hours stated: "Pt states he "slipped off of bed." Found pt on floor, on his knees." "No apparent injuries at this time." The form documented that the physician had been notified.

Incident Report, dated 01/02/2018 at 0920 hours stated: "Patient had unwitnessed fall in bathroom. Patient was escorted to bathroom. Patient then yelled out for help. Min assist X2 to stand. Patient was noted sitting on bathroom floor." No injuries were noted and the physician was documented as being notified.

Incident Report, dated 01/03/2018 at 0158 hours stated: "Patient had witnessed fall earlier in shift where he slid his back down bathroom door then laid on the floor then screamed help, help, help. At 0158 pt unwitnessed got out of bed went to bathroom then screamed help help help, found lying on stomach at bathroom door." Mr. Dunk denied any pain after the incident.

Incident Report, dated 01/04/2018 at 0530 hours stated: "Patient fell out of bed and hit corner of left eye on wheelchair next to his bed. Laceration cleaned and dressed. No LOC, GCS 14, Pt confused about what happened. Place mattress on mattress on floor for safety." Mr. Dunk had the laceration cleaned, triple antibiotic ointment was applied as well as a nonstick dressing applied. The physician was documented as being notified.

Examination of the Treatment Plan Review, dated 1/4/2018 at approximately 1100 hours revealed that it had been signed by the patient, nursing, social work, and the physician. The summary of ongoing issues stated: "Continues to admit feelings of wishing he was dead. States yesterday that was all he thought about. Depression remains at issue. Possibly causing falls in an effort to self harm." The Treatment and Discharge Planning Changes section listed for Modality or Intervention Changes: "Patient placed on 1:1 for safety." Page two listed Problems #1 and #2 but problems #3, #4, and #5 were not found. No other documentation was found by or provided to the surveyor indicating that there had been an earlier treatment team plan review to address the issue of patient #1 having multiple incident reports dut to falling.

Review of facility policy entitled: Interdisciplinary Treatment Team Meetings, effective date of 5/01/2017 stated on page two: "Per the Interdisciplinary Treatment Planning (ITP) Policy, all patients shall have an ITP initiated and reviewed by the team within 72 hours of admission. Although every patient shall be reviewed every day in the treatment team meeting, all patients shall have a formal Treatment Team Review every seven (7) days and/or within 24 hours of any qualifying event, whichever is sooner. Examples of qualifying events include, but are not limited to: i. Any fall regardless of injury."

During an interview with the Director of Nursing on 01/24/2018 the above findings were confirmed.

Based on review of documentation and interview it was determined that the facility failed to ensure that the treatment plan was complete.

Findings were:
The treatment plan identified problems and treatment plan reviews were found to be incomplete as it they did not address all the identified problems.

1.) The initial treatment plan for patient #1 listed 5 problems. Problem #1 was Risk for Self Harm, this problem had been established on 12/23/17 with a target date of 12/29/17 for the short term goals. The area on the plan where the short term goals for this problem were to be documented as: "Date Met, Revised or Discontinued (M, R, D) was to be documented was blank.

Problem #2 was Depression, this problem had been established on 12/23/17 with a target date of 12/29/17 and 1/3/18 for the short term goals. The area on the plan where the short term goals for this problem were to be documented as: "Date Met, Revised or Discontinued (M, R, D) was to be documented was blank.

Problem #3 was Impaired Skin Integrity, this problem had been established on 12/23/17 with a target date of 12/29/17 for the short term goals. The area on the plan where the short term goals for this problem were to be documented as: "Date Met, Revised or Discontinued (M, R, D) was to be documented was blank.

Problem #4 was Fall Risk, this problem had been established on 12/23/17 with a target date of 12/29/17 for the short term goals. The area on the plan where the short term goals for this problem were to be documented as: "Date Met, Revised or Discontinued (M, R, D) was to be documented was blank.

Problem #5 was Pain, this problem had been established on 12/23/17 with a target date of 12/27/17 for the short term goals. The area on the plan where the short term goals for this problem were to be documented as: "Date Met, Revised or Discontinued (M, R, D) was to be documented was blank.

Review of treatment plan review, dated 1/4/2018 at approximately 1100 hours revealed that it had been signed by the patient, nursing, social work, and the physician. The summary of ongoing issues stated: "Continues to admit feelings of wishing he was dead. States yesterday that was all he thought about. Depression remains at issue. Possibly causing falls in an effort to self harm." The Treatment and Discharge Planning Changes section listed for Modality or Intervention Changes: "Patient placed on 1:1 for safety." Page two listed Problems #1 and #2 but problems #3, #4, and #5 were not found by or provided to the surveyor for review.

Review of treatment plan review, dated 1/11/2018 at approximately 1130 hours revealed that it had been signed by the patient, nursing, social work, and the physician. The summary of ongoing issues stated: "Continues to make improvement. Cont to stay in room @ times, not engaging in milieu. Pt agreed to do so remainder of stay. Motivated for treatment and to go home. Dene (sic) SI." The Treatment and Discharge Planning Changes section listed for Modality or Intervention Changes: "1:1 on 1/4/18" Page two listed Problems #1 and #2 but problems #3, #4, and #5 were not found by or provided to the surveyor for review.

Review of facility policy entitled: "Medical Record Documentation" with an effective date of 2/1/2017 stated: "It is the policy of the facility that medical records are adequately maintained in order to provide documentary evidence of the course of the patient's medical evaluation, treatment and change in condition."

In an interview with the Director of Nursing on 01/24/2018 the above finding were confirmed.