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Based on record review, observation, and interview, the hospital failed to meet the requirements of the Condition of Participation for Patient Rights as evidenced by:

1) The hospital failed to ensure patients received care in a safe setting. This deficient practice is evidenced by failing to ensure patient observations by staff were conducted at line of sight for 1 (#2) psychiatric patient and every 15 minutes for 13 (#1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14) psychiatric patients as ordered by the psychiatrist for 14 patients observed on a hospital-provided video recording (see findings A-0144).

2) Failing to ensure the psychiatric unit was maintained to ensure opportunities were not afforded for patients to injure themselves or others (see findings A-0144).


An Immediate Jeopardy situation was identified on 8/27/17 at 4:51 p.m. and reported to S2CCO and S3PsychMgr. The Immediate Jeopardy situation was a result of the hospital failing to ensure all patients were monitored as ordered by physicians, including a patient, who had a physician's order to be kept on line of sight precautions at all times. In addition, the hospital failed to ensure the environment was free from ligature risks. The failure to monitor patients as ordered and to provide a safe environment placed patients at risk for harm to self and others.


On 8/29/17 at 1:20 p.m., S5MHT's assigned patient observation sheets were reviewed and were noted to be missing entries from 12: 45 p.m. - 1:15 p.m. S5MHT indicated she was currently catching up with the entries at the time of the observation. All 7 of S5MHT's assigned patients were level 1- q 15 minute observation level.

On 8/29/17 at 4:40 p.m., S34Consultant and S3PsychMgr were notified of the observation conducted on 8/29/17 at 1:20 p.m. of S5MHT's assigned patient observation sheets. They were informed the observation sheets were reviewed and were noted to be missing entries from 12:45 p.m. - 1:15 p.m. S34Consultant and S3PsychMgr were notified S5MHT's observation sheets still being incomplete/not documented in real time despite having been educated on the need for accuracy (S5MHT had been involved in the situation that had resulted in calling of the IJ and had been re-educated) was also a contributing factor in the survey team being unable to lift the immediacy of the IJ situation.

Review on 08/31/17 at 9:10 a.m. of the RN audit tool used as documentation of the direct observation of the MHTs assuring adherence to the frequency/intensity of observations of patients as ordered by the physician revealed S14RN had not documented a direct observation at 8:00 a.m.

Observation on 08/31/17 at 9:25 a.m. on the psychiatric unit revealed S18MHT was assigned the observation of 7 patients. Review of the observation sheets provided by S18MHT revealed the observation sheets for Patients #1 and #2 had no documented evidence of observations at 9:15 a.m.

In an interview on 08/31/17 at 9:25 a.m., S18MHT indicated he had not documented observations at 9:15 a.m. for Patients #1 and #2, because group had just finished, and he was assisting with giving ice to the patients. When asked by the surveyor what was supposed to happen if he could not perform an observation at the required time, S18MHT indicated he was supposed to have another MHT make the observation and document the observation. When the surveyor asked S18MHT why this procedure had not been done, he indicated "I have no idea."

In an interview on 08/31/17 at 9:45 a.m., S14RN indicated she had made the observation of the MHTs' documentation but had not completed the RN audit tool at 8:00 a.m., because she was involved with discharging a patient. She further indicated the MHT observation sheets are prepared by the MHT on the night shift. She further indicated when she makes her observations every 2 hours, she checks the patient's level of observation for accuracy and that the MHT is documenting observations in real time. When informed that Patient #2's MHT observation sheet had his level of observation as Level 2SP (which means monitoring on a constant basis one-to-one). S14RN immediately went onto the psychiatric unit with the surveyor present to view Patient #2's MHT observation sheet. At 9:50 a.m. with S14RN present, S18MHT was asked by the surveyor what type of observation was a patient on Level 2SP to have. S18MHT indicated it meant suicide precautions, and the patient should be at arm's length. S18MHT confirmed he had been observing Patient #2 every 15 minutes and had not maintained one-to-one observation of Patient #2. During the interview, S14RN confirmed the MHT observation sheet had the incorrect observation level, she had not seen that the level of observation was incorrect, and S18MHT had not questioned her about Patient #2's observation level.

On 8/31/17 at 10:48 a.m. a meeting was held with S34Consultant. She was informed of the above referenced observations and was notified the immediacy of the IJ situation could not be lifted.

Observation on 08/31/17 at 3:35 p.m. revealed S18MHT was standing in the hall outside the shower room located next to Room "k". Continuous observation revealed S18MHT remained standing in the hall outside the shower room at 3:40 p.m. Continuous observation from 3:35 p.m. through 3:50 p.m. revealed S18MHT was not observed to walk down the hall to observe Patient #6 who was in Room "g" which was located on the opposite end of the hall from where S18MHT had been standing.

Review of Patient #6's MHT observation record provided by S18MHT on 08/31/17 at 3:50 p.m. revealed S18MHT documented that Patient #6 was delusional and laying in bed at 3:45 p.m.

In an interview on 08/31/17 at 3:50 p.m., the surveyor asked S18MHT if he had observed Patient #6 at 3:45 p.m., and he indicated that he had. When the surveyor informed S18MHT that she had begun observing him at 3:35 p.m. and continuously observed him through 3:50 p.m. and had never observed him walking down the hall to Room "g", he indicated "I knew the patient was in his room, and I had to watch the patient in the shower."

The Hospital Administrative staff (S1Adm, S2CCO, S3PsychMgr, and S34Consultant) was informed, at the time of the survey exit, that the plan of lifting had not been accepted due to the above-listed observations (at 9:25 a.m. and 3:35 p.m. on 08/31/17) and interviews (9:25 a.m., 9:45 a.m., and 3:50 p.m. on 08/31/17) made that reflected continuation of the identified issues that led to the Immediate Jeopardy being called. The Immediate Jeopardy situation remained in place at the time of survey exit on 8/31/17 at 7:20 p.m.




30984

Based on record reviews and interview, the hospital failed to ensure the governing body reappointed medical staff members after considering the recommendation of the existing members of the medical staff as evidenced by failure to have documented evidence that the governing body reappointed 1 (S8MD) of 6 (S8MD, S16PA-C, S20MedDir, S22MD, S25MD, S29Psychologist) physician/allied health professional/ psychologist credentialing files reviewed for reappointment.

Findings:

Review of the Medical Staff By-laws, presented as the current by-laws by S2CCO, revealed that an application for reappointment shall be completed every 2 years on the appropriate form provided by the hospital by each applicant. Each application for reappointment must contain a request for specific clinical privileges desired by the applicant. Once review and analysis of the data is completed, the Medical Executive Committee will recommend to grant. limit, or deny a requested privilege and will forward to the Governing Body for approval. Once the decision to grant, limit, or deny a requested privilege, or an existing privilege for renewal is made, the practitioner will be notified within 30 days regarding the granting decision, after approval by the medical staff.

Review of S8MD's credentialing file revealed he appointment was effective 10/21/14 to 10/21/16. Further review revealed an application for reappointment was completed on 05/19/16, and the Medical Executive Committee approved his privileges on 07/06/16. There was no documented evidence that his reappointment and privileges were approved by the Governing Body.

Review of Governing Body meeting minutes of 02/22/17 and 05/25/17, presented by S2CCO when a request was made for verification that S8MD had been reappointed to the medical staff, revealed no documented evidence that S8MD was reappointed at either meeting.

In a telephone interview on 08/31/17 at 3:15 p.m., S30Credentialing indicated she prepares credentialing documents, and the governing body meets by telephone to review and approve. The surveyor informed S30Credentialing that there's no evidence in S8MD's credentialing file that he was reappointed by the board. She indicated that she would fax the information that shows he was reappointed.

Review of the information faxed by S30Credentialing revealed no documented evidence of bard approval of S8MD's reappointment.

As of 08/31/17 at 7:15 p.m. prior to the exit conference, no documented evidence was provided of S8MD being approved for reappointment by the Governing Body.

Based on observations, record reviews, and interviews, the hospital failed to ensure patients received care in a safe setting. This deficient practice is evidenced by:

1) failing to ensure patient observations by staff were conducted at line of sight for 1 (#2) psychiatric patient and every 15 minutes for 13 (#1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14) psychiatric patients as ordered by the psychiatrist for 14 patients observed on a hospital-provided video recording; and

2) failing to ensure the psychiatric unit was maintained to ensure opportunities were not afforded for patients to injure themselves or others.

Findings:

1) Failing to ensure patient observations by staff were conducted as ordered by the psychiatrist.

Review of the hospital policy titled Observation revealed in part:

F. Level I: Consists of fifteen (15) minute checks by a staff member.

1. The patient is monitored every 15 minutes during the day and night.

2. The patient's behavior is documented on the monitoring log.

3. The watch will be continued until the Physician discontinues it.

G. Special Precautions I: Consists of constant visual monitoring by a staff member.

1. The patient is to remain visible to a staff member at all times during the day and the night.

2. The patient is placed in a room close to the nurse's station.

3. The patient's behavior is documented every fifteen (15) minutes on the monitoring log.

4. The staff observations will be continued until discontinued by the physician.

Review of Patient #2's medical record revealed he had been admitted on 8/25/17 with diagnoses including Major Depressive Disorder, recurrent and severe. Patient #2's Physician's Emergency Certificate dated 8/24/17 at 8:10 p.m. listed him as having suicidal ideations, being dangerous to himself and others, and being gravely disabled. Review of Physician's orders dated 8/24/17 revealed an order for Special Precautions (to remain in line of sight of a staff member).

Review of Patients #1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14's medical records revealed they were ordered to be on level 1 precautions (q 15 minute observations).

An observation was made on 8/28/17 beginning at 10:40 a.m. with S3PsychMgr of a video recording of the psychiatric unit from 12:45 a.m. until 5:00 a.m. on 8/28/17. S9RN, S10LPN, S4MHT and S5MHT were observed to be the only staff members working that morning. The recording included views of the nurses' station, the "long" hall containing rooms "a" through "k" and the "short" hall containing rooms "l" through "p". Patient #2 was in room "k" and the door was visibly closed during the entire observation (4 hours and 15 minutes).

Review of the video recording revealed the "short" and "long" halls were in an L shaped formation. S5MHT was observed remaining in her chair at the corner of the halls from 12:45 a.m. until 5:00 a.m. with the exception of standing up only once at 1:23 a.m. and walking into the seclusion room behind her and then returning to her chair. From her vantage point in the chair, she was unable to see patients in their rooms or Patient #9 sleeping in the seclusion room.

Review of the video recording revealed S4MHT was seated approximately midway down the "short" hall. He was observed walking down the entire length of both halls at 1:54 a.m. (1 hour and 9 minutes into observation), but it was unclear if he made any observations of the patients although he did not open the door to Patient #2's room. S4MHT then returned to his chair. At 3:08 a.m. (1 hour and 14 minutes later) he got out of his chair but did not round on the patients. At 3:40 a.m. (32 minutes later), he went to the end of the "short" hall and obtained a basket of clothes. He then took the basket to the end of the "long" hall and then returned to the nurse's station and talked to S9RN and S10LPN for 41 minutes until he returned to his chair at 4:05 a.m. At 4:46 a.m. (41 minutes later), he went to the nurse's station and got some water for Patient #13 and then returned to his chair. The observation of the film was stopped at 5:00 a.m.

Review of the video recording revealed S9RN and S10LPN never left the nurses station until S10LPN walked down the "short" hall at 5:00 a.m.

Review of the hospital's Observation Flow Sheets for the morning of 8/28/17 revealed there were boxes in 15 minute intervals to be initialed indicating the location, behavior and activity of the individual patients as observed by the staff. Further review revealed the top of the documents had a section to indicate if the patients' observation levels were level 1 (q 15 minutes), SP 1 (line of sight), SP 2 (one to one) or fall precautions. Review revealed none of the 14 current patient's observation levels had been selected at the top of the pages.

Review of the hospital's Observation Flow Sheets for the patients S4MHT was responsible for revealed he had initialed in 15 minute increments that he had observed Patient #2, Patient #4, Patient #5, Patient #6, Patient #7, and Patient #8 every 15 minutes from 12:45 a.m. until 5:00 a.m. on the "long" hall (although he had only walked down the hall twice in the 4 hours and 15 minutes observed on the video). He also documented that he had observed Patient #3 every 15 minutes during the same time frame on the "short" hall.

Review of the hospital's Observation Flow Sheets for the patients S5MHT was responsible for revealed she initialed that she had observed Patient #1, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13 and Patient #14 every 15 minutes from 12:45 a.m. until 5:00 a.m. although she had only left her chair once to walk into the seclusion room behind her chair at 1:23 a.m. where Patient #9 was sleeping.

In an interview on 8/28/17 at 11:25 a.m. with S3PsychMgr, he verified the above mentioned findings from the video recording. He said the fact that the MHTs did not have Patient #2 in their line of sight or did not make observations on the other patients every 15 minutes was inexcusable.

In an interview on 8/28/17 at 2:30 p.m. with S5MHT, she said she had worked last night at the hospital on the psychiatric unit from 8/27/17 until the morning of 8/28/17. S5MHT said she usually went down the hall and looked at the patients every 30-45 minutes at night because she did not want to wake the patients up constantly. S5MHT said she was supposed to be observing the patients "to see if they were still alive and okay". S5MHT said she could not see the patients in their rooms from where she was sitting on the morning of 8/28/17. S5MHT said after 1:00 a.m. she did not see the patients in their beds. S5MHT verified she would not have known if anyone was in their rooms hurting themselves. S5MHT also said she was not aware Patient #2 was on special precautions on 8/28/17.

In an interview on 8/28/17 at 2:46 p.m. with S9RN, he said he worked last night (8/27/17 through 8/28/17) and was the RN in charge of the psychiatric unit. He said he was not aware Patient #2 was on special precautions. S9RN said the MHTs should monitor the patient every 15 minutes by observing them to make sure they are safe and he would normally round himself every 2 hours but he was busy on a project. S9RN said last night he might have rounded once or twice. He said he would glance at the techs when he walked around to see if they were doing their jobs and he would sign off at the end of shift to acknowledge if the observation sheet were completed. S9RN said the patients could leave their doors to their rooms open or closed.

In an interview on 8/29/17 at 10:48 a.m. with S4MHT, he said he was working on the morning of 8/28/17 on the psychiatric unit of the hospital. S4MHT said he was supposed to view the patients every 15 minutes but he did not. S4MHT said generally when the patients were sleeping it would wake them up to check on them. He said he did not know Patient #2 was on special precautions and verified he had not opened the door to Patient #2's room from 12:45 a.m. until 5:00 a.m.

In an interview on 8/29/17 at 1:30 p.m. with S8MD, he said he was the psychiatrist of the psychiatric unit at the hospital. S8MD said Patient #2 had an order, from him, since admission on 8/25/17 to be on special precautions because he was suicidal. He said his expectation was that Patient #2 was kept in line of sight at all times for safety. He also said the other patients in the hospital had to be observed for safety at a minimum of every 15 minutes.



2) Failing to ensure the psychiatric unit was maintained to ensure opportunities were not afforded for patients to injure themselves or others.

In an observation on 8/28/17 at 8:00 a.m. in the psychiatric unit, the following safety problems were identified:

a) Air conditioning grates in patient rooms were spaced far enough apart to allow ligature points.

b) Sinks in patient rooms had faucets and knobs that protruded allowing ligature points.

c) Access to fluorescent bulbs in light fixtures above the beds.

d) Door handles not of the safety type.

e) Door to "Contraband" room unlocked. The room contained patient belongings, Clorox bleach times two bottles, Disinfectant, Rubbing Alcohol, Razors, and an unsecured breaker panel.

f) 4 portable air conditioners and portable fans in the patient hallway with electrical cords approximately 5 feet long.

g) door to shower room was unlocked allowing unauthorized access to grab bars with a gap between the wall, soap dish with bar, door knobs that were not ligature proof, 3 hinges with spaces between, gooseneck faucet on the sink, exposed plumbing under the sink, and air conditioner vent with large gaps in the grates.

h) Electrical cords hanging from a television in the day room.

i) One of the Plexiglas windows in room 60 was separating from the frame and could be pushed posing a risk for elopement or accept contraband.

j) a plastic garbage bag was observed in the trash can in the group/commons area room.


The above referenced findings were verified during the observation with S2CCO.



30984

Based on record review and interview, the hospital failed to maintain documented evidence of staff education, training, and demonstrated knowledge based on the specific needs of the patient population by failing to maintain documentation of staff training in the use of nonphysical intervention skills for 4 (S3PsychMgr, S10LPN, S13MusicTher, S18MHT) of 10 (S2CCO, S3PsychMgr, S6RN, S7LPN, S9RN, S10LPN, S13MusicTher, S14RN, S17MHT, S18MHT) psychiatric unit personnel records reviewed for MOAB (Management of Aggressive Behavior) training.

Findings:

Review of S10LPN's personnel file revealed no documented evidence of current MOAB training for de-escalation of the psychiatric patients.

In an interview on 8/31/17 at 5:11 p.m. with S19AsstPsychMgr, he confirmed S10LPN did not have documentation of current MOAB training.

Review of the personnel files of S3PsychMgr, S13MusicTher, and S18MHT revealed no documented evidence of current MOAB training.

In an interview on 08/31/17 at 4:50 p.m., S19AsstPsychMgr indicated S13MusicTher is a music intern. He further indicated the hospital keeps minimal personnel files on interns, and they aren't required to have the same orientation as the hospital's employees. He confirmed that S13MusicTher didn't receive MOAB training.

In an interview on 8/28/17 at 8:15 a.m. with S6RN-psychiatric unit nurse, she reported the psychiatric unit staff were trained in MOAB for de-escalation of the psychiatric patients.





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30984

Based on record review, observation, and interview, the hospital failed to ensure patient safety issues were identified, analyzed, measured, addressed, and tracked, through the hospital wide QAPI program, for all patients. This deficient practice was evidenced by failure of the hospital to identify patients on psychiatric unit, admitted for being a danger to themselves or others, were not being observed/monitored as ordered per physician's order for 14 (#1-#14) of 14 current inpatients observed (from 12:45 a.m. - 5:00 a.m. on 8/27/17) via hospital provided video recording. The observations were determined to be an Immediate Jeopardy situation on 8/28/17 at 4:51 p.m.

Findings:

Review of Patient #2's medical record revealed he had been admitted on 8/25/17 with diagnosis including Major Depressive Disorder, recurrent and severe. Patient #2's Physician's Emergency Certificate dated 8/24/17 at 8:10 p.m. listed him as having suicidal ideations, being dangerous to himself and others, and being gravely disabled. Review of Physician's orders dated 8/24/17 revealed an order for Special Precautions (to remain in line of sight of a staff member).

Review of Patients #1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14's medical records revealed the patients were ordered to be on level 1 precautions (q 15 minute observations).

An observation was made on 8/28/17 beginning at 10:40 a.m. with S3PsychMgr of a video recording of the psychiatric unit from 12:45 a.m. until 5:00 a.m. on 8/28/17. S9RN, S10LPN, S4MHT and S5MHT were observed to be the only staff members working that morning. The recording included views of the nurses' station, the "long" hall containing rooms "a" through "k" and the "short" hall containing rooms "l" through "p". Patient #2 was in room "k" and the door was visibly closed during the entire observation (4 hours and 15 minutes).

Review of the video recording revealed the "short" and "long" halls were in an L shaped formation. S5MHT was observed remaining in her chair at the corner of the halls from 12:45 a.m. until 5:00 a.m. with the exception of standing up only once at 1:23 a.m. and walking into the seclusion room behind her and then returning to her chair. From her vantage point in the chair, she was unable to see patients in their rooms or Patient #9 sleeping in the seclusion room.

Review of the video recording revealed S4MHT was seated approximately midway down the "short" hall. He was observed walking down the entire length of both halls at 1:54 a.m. (1 hour and 9 minutes into observation), but it was unclear if he made any observations of the patients although he did not open the door to Patient #2's room. S4MHT then returned to his chair. At 3:08 a.m. (1 hour and 14 minutes later) he got out of his chair but did not round on the patients. At 3:40 a.m. (32 minutes later), he went to the end of the "short" hall and obtained a basket of clothes. He then took the basket to the end of the "long" hall and then returned to the nurse's station and talked to S9RN and S10LPN for 41 minutes until he returned to his chair at 4:05 a.m. At 4:46 a.m. (41 minutes later), he went to the nurse's station and got some water for Patient #13 and then returned to his chair. The observation of the video was stopped at 5:00 a.m.

Review of the video recording revealed S9RN and S10LPN never left the nurses station until S10LPN walked down the "short" hall at 5:00 a.m.

Review of the hospital's Observation Flow Sheets for the morning of 8/28/17 revealed there were boxes in 15 minute intervals to be initialed indicating the location, behavior and activity of the individual patients as observed by the staff. Further review revealed the top of the documents had a section to indicate if the patients' observation levels were level 1 (q 15 minutes), SP 1 (line of sight), SP 2 (one to one) or fall precautions. Review revealed none of the 14 current patient's observation levels had been selected at the top of the pages.

Review of the hospital's Observation Flow Sheets for the patients S4MHT was responsible for revealed he had initialed in 15 minute increments that he had observed Patient #2, Patient #4, Patient #5, Patient #6, Patient #7, and Patient #8 every 15 minutes from 12:45 a.m. until 5:00 a.m. on the "long" hall (although he had only walked down the hall twice in the 4 hours and 15 minutes observed on the video). He also documented that he had observed Patient #3 every 15 minutes during the same time frame on the "short" hall.

Review of the hospital's Observation Flow Sheets for the patients S5MHT was responsible for revealed she initialed that she had observed Patient #1, Patient #9, Patient #10, Patient #11, Patient #12, Patient #13 and Patient #14 every 15 minutes from 12:45 a.m. until 5:00 a.m. although she had only left her chair once to walk into the seclusion room behind her chair at 1:23 a.m. where Patient #9 was sleeping.

In an interview on 8/28/17 at 11:25 a.m. with S3PsychMgr, he verified the above mentioned findings from the video recording. He said the fact that the MHTs did not have Patient #2 in their line of sight and did not make observations on the other patients every 15 minutes was inexcusable.

Review of the hospital wide QAPI program revealed no documented evidence that failure of the staff to observe/monitor psychiatric unit patients, admitted for being a danger to themselves or others, as ordered per physician's orders was identified as a patient safety issue that should have been addressed through the hospital wide QAPI program.

In an interview on 8/31/17 at 6:15 p.m. with S2CCO, she confirmed the above referenced findings regarding patient monitoring not being conducted as ordered had not been identified as a patient safety issue. S2CCO agreed the above referenced issues with patient monitoring not being conducted as ordered per physician order should have been addressed through the hospital wide QAPI program.

Based on record review and interview, the hospital's governing body failed to ensure that the hospital wide QAPI program reflected the complexity of the hospital's organization and services. This deficient practice was evidenced by the hospital's failure to include all direct and contracted services in the hospital's QAPI program.

Findings:


Review of the hospital's contracted services revealed contracts for language line services, linen services, and blood bank services.

Review of the QAPI data provided by the hospital revealed no indicators for dietary services (direct service), language line services, linen services, and blood bank services.

In an interview on 8/31/17 at 6:10 p.m. with S2CCO she confirmed the hospital's QAPI program did not have indicators for dietary services (direct service), language line services, linen services, and blood bank services.

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care for each patient as evidenced by:

1) The RN failing to ensure the MHT observation record was complete by failure to have documented evidence of the patient's level of observation for 14 (#1-#14) of 14 patient records reviewed for documentation of the MHT observation record from a total sample of 30 patient records.

2) The RN failing to ensure the observation record was documented on every 15 minutes by the MHT to ensure patient safety for 7 (#2, #6, #7, #8, #12, #13, #14) of 7 patients reviewed (assigned to S17MHT) out of a total of 14 (#1-#14) patient observation records reviewed.

3) The RN failing to conduct accurate nutritional screens of patients upon admission for 6 (#1, #8, #9, #10, #11, #14) of 8 (#1, #3, #4, #8, #9, #10, #11, #14) patient records reviewed for nutritional screens by the RN from a total sample of 30 patient records.

4) The RN failing to assess a patient with an initial pulse of 132 as documented by the MHT and notify the physician if found to be accurate after assessment for 1 (#3) of 1 patient record reviewed with abnormal vital signs from a total sample of 30 patient records.

5) The RN failing to ensure Accuchecks were done as ordered by the physician for 1 (#3) of 1 patient record reviewed with orders for Accuchecks from a total sample of 30 patient records.

6) The RN failing to clarify physician admit orders when complete physician orders that included level of observation, frequency of vital sign assessments, activity level, when weight was to be assessed, and smoking privileges were not included in the orders for 1 (#11) of 4 (#3, #4, #11, #14) patient records reviewed for complete physician orders from a total sample of 30 patient records.

7) The RN failing to document a complete admit assessment for 1 (#4) of 4 (#3, #4, #11, #14) patient records reviewed for admit assessments from a total sample of 30 patient records.

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Findings:

1) The RN failing to ensure the MHT observation record was complete:

Review of Patients #1, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14's medical records revealed the patients were ordered to be on level 1 precautions (q 15 minute observations).

Review of Patient #2's medical record revealed the patient had orders for special precautions (which is line of sight).

Review of Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14's observation records, dated 8/27/17 from 6:45 a.m. through 6:30 p.m. on 8/28/17 revealed level of precautions was left blank on all of the observation records.

In an interview on 8/28/17 at 10:40 a.m. with S3PsychMgr, he confirmed Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14's observation records, dated 8/27/17 from 6:45 a.m. through 6:30 p.m. on 8/28/17 did not have documentation of level of precautions.


2) The RN failing to ensure the observation record was documented on every 15 minutes by the MHT to ensure patient safety:

Review on 8/28/17 at 8:00 a.m. of the Hospital's Observation Flowsheet for Patients #2, #6, #7, #8, #12, #13, and #14 revealed the observation levels had not been selected, and the 6:45 a.m. through 8:00 a.m. observations had not been documented.

In an interview on 8/28/17 at 8:00 a.m. with S17MHT, he said there were no patients on special precautions. He verified he had not documented 15 minute assessments on any of his assigned patients since 6:45 a.m. but he should have. He also verified he was responsible for Patient #2 (ordered to be on line of sight since 8/25/17).


3) The RN failing to conduct accurate nutritional screens of patients upon admission:

A review of the policy titled "Nutrition Screening", as provided by S2CCO as the most current, revealed in part: A Registered Nurse will screen all patients upon admission to identify patients who are at potential nutritional risk and/or may require further assessment by the Registered Dietitian.

Patient #1
Review of Patient #1's medical record revealed an admission date of 08/11/17 with admission diagnoses including Diabetes mellitus Type II. Further review of the patient's medical record revealed the patient was receiving sliding scale insulin based upon capillary blood glucose results. A review of the Initial Nursing Assessment performed by S6RN revealed in part: The section labeled, "Risk Criteria of one or more indicates a need for a RD consult". The risk criteria identified under this section revealed a check of one or more criteria indicated the need for an RD consult. Further review revealed Diabetes Mellitus was one of the criteria which would have resulted in the need for an RD consult if chosen and the Diabetes Mellitus was left blank.

Patient #8
Review of Patient #8's medical record revealed an admission date of 8/18/17 with admission diagnoses including Hyperlipidemia. A review of the Initial Nursing Assessment performed by S6RN revealed in part: The section labeled, "Risk Criteria of one or more indicates a need for a RD consult". The risk criteria identified under this section revealed a check of one or more criteria indicated the need for an RD consult. Further review revealed hyperlipidemia was one of the criteria which would have resulted in the need for an RD consult if chosen and hyperlipidemia was left blank.

In an interview on 8/28/17 at 3:00 p.m. with S6RN, she confirmed the choices referenced above (Diabetes Mellitus and Hyperlipidemia), if chosen, would have flagged a patient for an RD consult. She also confirmed the choices referenced above for Patient #1 (Diabetes Mellitus) and Patient #8 (Hyperlipidemia) had been left blank.

Patient #9
Review of Patient #9's History and Physical dated 8/22/17 at 1:31 p.m. revealed diagnosis including Gastroesophageal Reflux Disease (GERD).

Review of the Multidisciplinary Nursing Assessment dated 8/21/17 at 5:00 p.m. revealed a total score of 0 for the risk factors. The nurse failed to score 2 points for Patient #9's GERD which would have triggered an assessment by the dietician within 72 hours.

Review on 8/29/17 at 9:15 a.m. of Patient #9's medical record revealed no dietary assessment had been performed.

In an interview on 8/29/17 at 1:15 p.m., S2CCO verified a dietary assessment had not been performed on Patient #9.

Patient #10
A review of Patient #10's medical record revealed in part: The patient was admitted on 08/25/17 to the hospital's psychiatric unit for S8MD with an admit diagnosis of schizophrenia-affective disorder and bipolar disorder and required stabilization. A review of the medical history and physical revealed the patient had hyperlipidemia, hypertension, and diabetes and that the patient had been non-compliant with all medications. The review revealed the medical assessment and plan was to perform accu-checks prior to meals with monitoring and administration of insulin as needed for diabetes so his blood sugars can return to normal values; monitor blood pressure and administer blood pressure medicine to treat hypertension associated with diabetes; and administer Crestor 20 mg daily for treatment and control of hyperlipidemia. A review of the physician orders revealed that daily medicines had been ordered for diabetes, hypertension, and hyperlipidemia with an order for staff to supervise oral medicine administration to ensue the patient takes and swallows his medicines, due the patient's history of medicine non-compliance. A review of the Initial Nursing Assessment performed by S14RN revealed in part: The section labeled, "Risk Criteria of one or more indicates a need for a RD consult". The risk criteria under this section included in part: hyperlipidemia, diabetes uncontrolled, and patient needs diabetic education. The section revealed that no risk criteria were checked off by S14RN as requiring a RD consult. A review of the Nutrition Screening section labeled, "Request a Dietary/Nutritional Consult" for all patients with a score of at least one indicator on the Risk Criteria revealed that S14RN had checked that the patient's Risk Level was "No Risk" and that the patient did not require a RD consult.

In an interview on 08/31/17 at 11:00 a.m. with S14RN, Patient #10's medical record was reviewed with her. S14RN indicated that she completed the patient's Nutritional Assessment. She indicated that in the risk criteria section under the RN Nutrition Assessment, she should have checked off hyperlipidemia, diabetes uncontrolled, and patient needs diabetic education. S14RN indicated, " I guess I missed it". S14RN further indicated that Patient #10 should have required a further assessment by a RD and a request for a Dietary/Nutritional Consult should have been checked.

Patient #11
Review of Patient #11's medical record revealed he was admitted on 08/22/17. Review of his nursing admit assessment conducted on 08/22/17 at 10:00 p.m. revealed a medical history of GERD and Hyperlipidemia. Review of his nutritional screen completed during the admission assessment revealed Patient #11 was scored as "no risk". There was no documented evidence that the admitting RN checked "GI (gastrointestinal) disorder" on the nutritional screen which would have resulted in Patient #11 having a low risk and requiring an assessment by the dietitian within 72 hours.

Patient #14
Review of Patient #14's nursing admit assessment conducted on 08/15/17 at 6:45 p.m. revealed she was lactose intolerant. Review of the nutritional screen conducted during the admit assessment revealed Patient #14 was scored as low risk (which required an assessment by the dietitian within 72 hours). Further review revealed no documented evidence that "food allergies" was checked which would have increased the total score to 5, which was a moderate risk and required an assessment by the dietitian within 48 hours.

In an interview on -8/29/17 at 1:10 p.m., S2CCO confirmed that the nutritional assessments conducted by the RN for Patients #11 and #14 were not accurate.


4) The RN failing to assess a patient with an initial pulse of 132 as documented by the MHT and notify the physician if found to be accurate after assessment:

Review of Patient #3's "Graphic Sheet" and "Nursing 24-Hour BH (behavioral health) Assessment Page 1" revealed on 08/27/17 at 6:00 p.m. his pulse was 132. Further review of the "Graphic Sheet" revealed an entry dated "8/27/17 re(check mark) 96" with no documented evidence of the time that the pulse was rechecked. Review of the nursing documentation for 08/27/17 revealed no documented evidence that the MHT notified the nurse of the initial pulse of 132, that Patient #3's pulse was assessed by a nurse, and that the physician was notified if the pulse was found to be elevated/

In an interview on 08/28/17 at 11:20 a.m., S7LPN reviewed Patient #3's medical record and revealed the pulse was taken by a MHT on 08/27/17. She confirmed there was no documented evidence that the MHT notified the RN and that Patient #3 was assessed by a RN to determine if the pulse was actually 132. She confirmed the record had no evidence of the time that the pulse was documented as rechecked by the MHT.


5) The RN failing to ensure Accuchecks were done as ordered by the physician:

Review of Patient #3's physician order dated 08/17/17 at 9:25 p.m. revealed an order to check his blood sugar BID for 3 days and to discontinue if normal.

Review of Patient #3's "Diabetic record revealed his blood sugar was checked BID on 08/18/17 and 08/19/17. There was no documented evidence his blood sugar was assessed BID for 3 days as ordered.

In an interview on 08/29/17 at 1:10 p.m., S2CCO confirmed Patient #3's blood sugar was not assessed for 3 days as ordered by the physician.


6) The RN failing to clarify physician admit orders when complete physician orders that included level of observation, frequency of vital sign assessments, activity level, when weight was to be assessed, and smoking privileges were not included in the orders:

Review of Patient #11's "Psychiatric Admit Orders" documented as a telephone order with no documented evidence of the date and time the order was received revealed no documented evidence that the following orders were included: observation level; frequency of vital signs; activity level; frequency of assessing weight; whether smoking privileges were ordered; whether blood sugar checks were to be done on admit; assessments/consults such as psychiatric consult, nursing assessment, psychosocial assessment, nutrition consult, other consult. There was no documented evidence that a clarification order was obtained that addressed these missing items on the original order.

In an interview on 08/29/17 at 1:10 p.m., S2CCO confirmed Patient #11's admit orders were incomplete, the orders did not have the date and time that the telephone order was received, and a clarification order was not documented.


7) The RN failing to document a complete admit assessment:

Review of Patient #4's medical record revealed he was admitted on 08/15/17. Review of his nursing admit assessment revealed no documented evidence of the following information: date and time assessment was done; employment/school information; contact person's phone number; chief complaint; general appearance; assessment of immunization status, genitourinary system, musculoskeletal system, neurological system, general disease, endocrine system; sleep; sexual activity; eating/appetite; weight and height; recent weight ;loss/gain; risk criteria for need for a RD consult; significant medical history; infection prevention and control considerations; patient treatment barriers; family treatment barriers; substance abuse history; pain assessment; medication information; restraint/seclusion risk assessment; risk for falls assessment; complete Folstein Mini-Mental Exam; nutritional screen.

In an interview on 08/29/17 at 1:10 p.m., S2CCO confirmed Patient #4's nursing admit assessment was not complete.



30172




30364




30984

Based on record review and interview, the hospital failed to ensure that the nursing staff developed and kept current a nursing care plan for each patient as evidenced by failure to have nursing care plans that included the psychiatric problem with the identified behaviors defined for which the patient was being treated, goals that were measurable, and the nursing interventions for 5 (#3, #4, #10, #11, #14) of 5 patient records reviewed for nursing care plans from a total sample of 30 patient records.

Findings:

Review of the policy titled "Treatment Planning", presented as a current policy by S2CCO, revealed that each discipline will complete their assessments, report their findings, and state their recommendations for the Master Treatment Plan for each patient. Initial treatment plans are completed within 24 hours of admission by the physician and admitting nurse. The Master Treatment Plan will contain behavioral objectives written in measurable terms and include target dates.

A review of the policy titled "Plan of Care", as provided by S2CCO as the most current, revealed in part: After a thorough nursing assessment is done, care plans are initiated by the RN. The care plan will identify the main problems or potential problem areas that are patient specific including interventions and measurable goals. All interventions should be patient specific. The patient care plan will be personalized to meet individual patient care needs.

Patient #3
Review of Patient #3's medical record revealed he was admitted on 08/17/17 with an admit diagnosis of Chronic Paranoid Schizophrenia, Depressed. Further review revealed a diagnosis of Crohn's disease and a suspicion of C Diff.

Review of Patient #3's treatment plan for Psychosis revealed the long term goal was for the patient to exhibit a reduction or absence of psychotic symptoms and return to a higher level of functioning. There was no documented evidence that the goal was written in measurable terms in order to determine when the goal would be met. Review of the long term goal for the treatment plan for Mood Instability revealed the patient would exhibit a reduction of mood instability and return to a higher level of functioning. There was no documented evidence that the goal was written in measurable terms in order to determine when the goal would be met.

There was no documented evidence that Patient #3 had a care plan developed for Crohn's disease and for suspicion of C Diff once a physician's order was received on 08/23/17 to collect a stool specimen for C Diff.

Patient #4
Review of Patient #4's treatment plan for Psychosis revealed the long term goal was for the patient to exhibit a reduction or absence of psychotic symptoms and return to a higher level of functioning. There was no documented evidence that the goal was written in measurable terms in order to determine when the goal would be met. Review of the long term goal for the treatment plan for Substance Use revealed it was written as patient will display an understanding of detrimental effects of chemical use, return to previous level of functioning, and consider treatment options available in the community for ongoing treatment upon discharge. There was no documented evidence that the goal was written in measurable terms in order to determine when the goal would be met.

Patient #10
A review of Patient #10's medical record revealed in part: The patient was admitted on 08/25/17 to the hospital's psychiatric unit for S8MD with an admit diagnosis of schizophrenia-affective disorder and bipolar disorder and required stabilization. A review of the medical history and physical revealed the patient had Hyperlipidemia, Hypertension, and Diabetes and that the patient had been non-compliant with all medications. A review of the patient's Master Treatment Plan/Care Plan revealed a patient problem of "Mood Instability" with no behavioral problems defined or identified and no nursing interventions identified on the Master Treatment Plan/Care Plan. A further review revealed a patient problem of "Psychosis" with no behavioral problems defined or identified.

Patient #11
Review of Patient #11's treatment plan for Psychosis revealed the long term goal was for the patient to exhibit a reduction or absence of psychotic symptoms and return to a higher level of functioning. There was no documented evidence that the goal was written in measurable terms in order to determine when the goal would be met. Review of the long term goal for the treatment plan for Hypertension revealed it was written as patient's blood pressure will be stable by discharge with no documented evidence of what was a "stable" blood pressure for Patient #11. Review of the treatment plan for GERD revealed the long term goal was written as patient will indicate awareness of importance to maintain optimal health status related to GERD. There was no documented evidence that the goal was written in measurable terms in order to determine when the goal would be met. Review of the treatment plan for Hyperlipidemia revealed the long term goal was written as patient will verbalize an understanding of the importance of compliance with the medical regimen. There was no documented evidence that the goal was written in measurable terms in order to determine when the goal would be met. The long term goal for the treatment plan for medication non-compliance was written as patient will be compliant with medication as ordered. There was no documented evidence that the goal was written in measurable terms in order to determine when the goal would be met.

Patient #14
Review of Patient #14's treatment plan for Depressed Mood revealed the long term goal was written as patient will demonstrate renewed feelings of self-worth, increased social interaction, and hopefulness of future and will verbalize a decrease in depressive symptoms. There was no documented evidence that the goal was written in measurable terms in order to determine when the goal would be met. Review of the long term goal for the treatment plan for Hypertension revealed it was written as patient's blood pressure will be stable by discharge with no documented evidence of what was a "stable" blood pressure for Patient #14. Review of the long term goal for the treatment plan for Hypothyroidism revealed it was written as patient will be stable by discharge with no documented evidence of how stability would be determined.

In an interview on 08/29/17 at 1:10 p.m., the above-listed patients' treatment plan findings were reviewed with S2CCO. She confirmed that the goals were not written in measurable terms.




30172

Based on record review and interview, the hospital failed to ensure a Registered Nurse assigned the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available. This deficient practice was evidenced by:

1) failure of the hospital to ensure nursing staff maintained current certification in BLS for 5 (S6RN, S7LPN, S10LPN, S17MHT, S18MHT) of 5 personnel records reviewed and failure of the hospital to ensure nursing staff maintained current certification in ACLS for 5 (S6RN, S7LPN, S9RN, S10LPN, S14RN) of 6 (S2CCO,S6RN, S7LPN, S9RN, S10LPN, S14RN) nursing personnel records reviewed.;

2) failure to have documented evidence of orientation and competency evaluations for 1 (S18MHT) of 8 (S2CCO, S6RN, S7LPN, S9RN, S10LPN, S14RN, S17MHT, S18MHT) nursing personnel files reviewed for orientation and competency evaluations.

Findings:

1) Failure of the hospital to ensure nursing staff maintained current certification in BLS and ACLS

A review of hospital policy titled, "Rapid Response Code Blue", as provided by S2CCO as the most current revealed in part:

Code Blue:
1. Staff identifying a patient in arrest will call a "Code Blue" by performing the following: a. contact nurses' station by nurse call button at bedside by pressing emergency button or pulling out of wall may call verbally for "help".

D. Initiate BLS (Basic Life Support) and Initiate ACLS (Advanced Cardiac Life Support) protocol per current AHA (American Heart Association) guidelines. E. RN or LPN/LVN will notify primary MD to provide report of patient's status.; RN/Case Manager will notify patient's family of patient's condition.

H. The crash cart should be cleaned, replenished, and locked as soon as possible.

Once the code or critical event is over a debriefing will be done by the Charge Nurse. The completed post Code Blue debriefing form will be forwarded to the Quality Improvement Department for review and follow-up. The hospital debriefing will include
a. equipment and supplies adequate,
b. emergency drugs in date range,
c. Infection Control practices maintained during code,
d. safety precautions maintained,
e. code record complete,
f. ACLS protocols followed,
g. prompt arrival of code team,
h. code team members performance,
i. any concerns identified during the code.

Review of the personnel files for S6RN, S7LPN, S10LPN, S17MHT, and S18MHT revealed no documented evidence of current BLS certification.

A review of the personnel files for S6RN, S7LPN, S9RN, S10LPN, S14RN revealed no documented evidence of current ACLS certification

In an interview on 08/31/17 at 5:11 p.m. with S19AsstPsychMgr, he confirmed S6RN and S10LPN had no documented evidence of current ACLS or BLS certification in their personnel files.

In an interview on 08/31/17 at 4:58 p.m. with S2CCO she reported RN's and LPN's on the medical unit were required to be ACLS and BLS certified, and RNs and LPNs on the psychiatric unit were only required to be BLS certified.

In an interview on 08/31/17 at 11:30 a.m. with S2CCO she indicated that she was the Chief Clinical Officer for the hospital. S2CCO indicated that the hospital had closed the acute care area on 07/31/17 when the last acute care patient was discharged. She indicated the hospital was currently only accepting patients into the psychiatric area. S2CCO indicated that her psychiatric nurses were not required to be ACLS certified because the acute care nurses were ACLS certified and were always present in the acute care area until 07/31/17. The psychiatric nurses (S2CCO, S6RN, S7LPN, S9RN, S10LPN, S14RN) were only required to have BLS. The "Rapid Response Code Blue" policy was reviewed with S2CCO. She indicated that the psychiatric nurses would have to be ACLS certified.

In an interview on 08/31/17 at 7:10 p.m., S3PsychMgr was informed by the surveyor that S18MHT had no documented evidence in his personnel file of CPR certification. S3PsychMgr offered no explanation for S18MHT not having evidence that he had current certification in CPR.


2) Failure to have documented evidence of orientation and competency evaluations:

Review of S18MHT's personnel file revealed he was hired on 05/28/17. Further review revealed no documented evidence of orientation and competency evaluations prior to him providing direct care to patients on the psychiatric unit..

In an interview on 08/31/17 at 7:10 p.m., S3PsychMgr was informed by the surveyor that S18MHT had no documented evidence in his personnel file of orientation and competency evaluations. S3PsychMgr offered no explanation for S18MHT not having evidence that he had been oriented and evaluated for competency.



30172






30984

Based on record reviews and interviews, the hospital failed to ensure that drugs and biologicals were administered as ordered by the physician as evidenced by failure to have documented evidence that medications were administered as ordered by the physician for 1 (#14) of 4 (#3, #4, #11, #14) patient records reviewed for medication administration from a total sample of 30 patient records.

Findings:

Patient #14
Review of Patient #14's physician orders revealed an order on 08/15/17 at 9:20 p.m. for Lisinopril 20 mg by mouth daily. Further review revealed an order on 08/17/17 at 9:10 p.m. to hold Lisinopril if the systolic blood pressure is less than 100 and to notify the physician.

Review of Patient #14's MAR revealed Lisinopril 20 mg was held at 9:00 a.m. on 08/17/17 when her blood pressure was 102/51. There was no documented evidence that the RN notified the physician that Lisinopril was being held and obtained an order to do so, when Patient #3's blood pressure did not meet the criteria for the medication to be held.

In an interview on 08/29/17 at 1:10 p.m., S2CCO confirmed Patient #14's blood pressure did not warrant Lisinopril to be held at 9:00 a.m. on 08/17/17.



30172

Based on record reviews and interviews, the hospital failed to ensure medical records were accurately written and documented timely as evidenced by:

1) Failing to have a psychosocial assessment completed in accordance with hospital policy for 1 (#3) of 4 (#3, #4, #11, #14) patient records reviewed for completion of the psychosocial assessment from a total sample of 30 patient records.

2) Failing to ensure the psychiatric evaluation was complete within 60 hours of admission and included the method that was used to determine the patient's insight, memory, and judgement for 5 (#1, #3, #4, #11, #14) of 7 (#1, #2, #3, #4, #5, #11, #14) patient records reviewed for completion of the psychiatric evaluation from a total sample of 30 patient records.

3) Failing to ensure the activity therapy assessment was conducted in accordance with hospital policy and completely documented for 2 (#3, #11) of 4 (#3, #4, #11, #14) patient records reviewed for activity therapy assessments from a total sample of 30 patient records.

Findings:

1) Failing to have a psychosocial assessment completed in accordance with hospital policy:
Review of the policy titled "Assessments", presented as a current policy by S2CCO, revealed that social histories (psychosocial assessment) shall be completed within 3 days after admission.

Review of Patient #3's medical record revealed he was admitted on 08/17/17. Review of his "Psychosocial History" revealed it was documented and signed by S12SW on 08/18/17 at 4:00 p.m. There was no documented evidence that the psychosocial assessment revealed what parts of the assessment were completed by chart review and what was added when S12SW met with Patient #3 on 08/23/17 at 1:00 p.m.

Review of Patient #3's "Social Services Progress Notes" revealed an entry on 08/18/17 at 4:00 p.m. by S12SW that she attempted to meet with Patient #3 to complete the psychosocial assessment, but Patient #3 was meeting with the psychiatrist. Further review revealed documentation by S12SW that she would use information from the chart to complete "as much as possible" and attempt to meet again with the patient at another time. Further review revealed an entry on 08/23/17 at 1:00 p.m. (6 days after admit) by S12SW that she met with Patient #3 to get missing information for the psychosocial assessment.

In an interview on 08/31/17 at 9:10 a.m., S12SW indicated "a lot of patients aren't willing or healthy enough to do the psychosocial assessment" on her first attempt, and she has to do it later. She further indicated Patient #3 stayed in his room on 08/18/17 most of the day, and that was the only day in the required 72 hour window required for the assessment to be conducted in accordance with policy that she worked. After reviewing Patient #3's chart, S12SW indicated he came out his room on 08/18/17 twice to attend group. She further indicated the only documentation she had to use from the chart to complete the assessment on 08/18/17 was the screening tool. She indicated most of the assessment would have been blank including the following information: affect; perceptions; thought content; suicidal ideations; homicidal ideations; sleep problems; appetite problems; current relationships/living situation and environment; education/education needs/goals; military service history; financial resources/issues; cultural/ethnic issues; severe grief/loss issues; current and past legal issues; recreation/leisure activities; patient strengths/resources; other problems. S12SW confirmed she completed the psychosocial assessment on 08/23/17, which was more than 72 hours after admission..


2) Failing to ensure the psychiatric evaluation was complete within 60 hours of admission and included the method that was used to determine the patient's insight, memory, and judgement:
Review of the policy titled "Assessments", presented as a current policy by S2CCO, revealed the psychiatric evaluation shall be completed within 60 hours of admission. There was no documented evidence that the policy addressed the content of the psychiatric evaluation.

Review of the Medical Staff By-laws and Medical Staff Rules and Regulations revealed no documented evidence that psychiatric evaluation content was addressed in the by-laws or the rules and regulations.

Patient #1
Review of Patient #1's medical record revealed he was admitted on 08/11/17. Review of his hand-written psychiatric evaluation documented by S8MD on 08/11/17 at 5:05 p.m. revealed the following sections had no documentation: Legal status, Chief Complaint, History of present illness, Mental status, Impact of symptoms on functioning, Estimate of intellectual function, Orientation, Memory, Patient's strengths, Patient's weaknesses/deficits/barriers to discharge and justification for 24 hour inpatient care.

Review of Patient #1's typed psychiatric evaluation revealed it was dictated on 08/24/17 at 3:52 p.m. and transcribed on 08/26/17 at 9:41 p.m. (13 days after admission). The signed copy of the dictated Psychiatric evaluation was not placed on the chart until 8/29/17 (18 days after admission).


Patient #3
Review of Patient #3's medical record revealed he was admitted on 08/17/17. Review of his hand-written psychiatric evaluation documented by S8MD on 08/18/17 at 4:37 p.m. revealed the following sections had no documentation: legal status; current medications; past fly., educational, vocational, occupational, and social history; fly. history of mental illness; pt.'s educational level; work history; mental status; estimate of intellectual function, orientation, & memory; patient's strengths; patient's weaknesses/deficits/barriers to discharge; justification for 24 hour inpatient care; treatment recommendation/plan of care; estimated length of stay.

Review of Patient #3's typed psychiatric evaluation revealed it was dictated on 08/17/17 at 6:59 p.m. and transcribed on 08/23/17 at 8:31 a.m. (6 days after admission).

There was no documented evidence in Patient #3's medical record of a completed psychiatric evaluation within 60 hours of admission.

Patient #4
Review of Patient #4's psychiatric evaluation conducted by S16PA-C on 08/17/17 at 1:58 p.m. revealed Patient #4's insight and judgement were poor, and his memory was not impaired. There was no documented evidence of the method that was used to determine his insight, memory, and judgement

Patient #11
Review of Patient #11's medical record revealed he was admitted on 08/22/17. Review of his psychiatric evaluation documented by S16PA-C on 08/24/17 at 1:13 p.m. revealed the following evaluations: judgement: poor; insight: poor; memory: memory intact. There was no documented evidence of the method that was used to determine his insight, memory, and judgement

Patient #14
Review of Patient #14's psychiatric evaluation conducted by S16PA-C on 08/17/17 at 3:46 p.m. revealed that her memory was not impaired, and her insight and judgement were poor. There was no documented evidence of the method that was used to determine her insight, memory, and judgement

In an interview on 08/29/17 at 1:25 p.m., S8MD indicated he usually writes the essential information on the psychiatric evaluation. He further indicated he has found that there's been a delay in dictation, and the medical records department isn't copying and getting the information to him timely for signature. He confirmed the completed psychiatric evaluation wasn't in Patient #3's medical record within 60 hours of admission. He further confirmed there should be documentation of the description of how memory, judgement, and insight were determined.

3) Failing to ensure the activity therapy assessment was conducted in accordance with hospital policy and completely documented:
Review of the policy titled "Assessments", presented as a current policy by S2CCO, revealed that the activity therapy assessment shall be completed within 3 days after admission.

Patient #3
Review of Patient #3's medical record revealed he was admitted on 08/17/17. Review of his activity therapy assessment revealed it was conducted on 08/25/17, 8 days after admission, rather than within 3 days after admission as required by policy.

Patient #11
Review of patient #11's Activity Therapist assessment conducted on 08/24/17 revealed no documented evidence that the following sections of the assessment were addressed: personal information; interpersonal and intrapersonal information; what are some things Patient #11 wants to work on while admitted; informants.

In an interview on 08/29/17 at 1:10 p.m., S2CCO confirmed the above findings.




30984

Based on record review and interview, the hospital failed to ensure all patient medical record entries were legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided as evidenced by failure of a physician order being signed by the physician responsible for 6 (#10, #21, #22, #25, #26, #28) of 30 patient records reviewed for signing, dating and timing of physician orders from a total sample of 30 patients.

Findings:

A review of the hospital policy titled, "Authentication" as provided by S2CCO as the most current, revealed in part: Every medical record entry must be dated, timed, author identified, and when required authenticated. All orders, including verbal orders, must be timed, dated, and authenticated by the ordering practitioner or another practitioner who is responsible for the care of the patient and is authorized to write orders.

Review of the Medical Staff Rules and Regulations, presented as the current rules and regulations by S2CCO, revealed that all verbal/telephone orders must be signed by the physician giving the order within 10 days.

A review of the hospital policy titled, "Authentication" as provided by S2CCO as the most current, revealed in part: Every medical record entry must be dated, timed, author identified, and when required authenticated. All orders, including verbal orders, must be timed, dated, and authenticated by the ordering practitioner or another practitioner who is responsible for the care of the patient and is authorized to write orders.

Patient #10
A review of Patient #10's medical record revealed in part: The patient was admitted on 08/25/17 to the hospital's psychiatric unit with an admit diagnosis of schizophrenia-affective disorder and bipolar disorder and required stabilization.

Review of Patient #10's physician orders revealed an order by S8MD, dated 08/28/17 at 5:00 p.m., that was not signed by the physician. Further review of the physician's order revealed that S7LPN had "noted" the order on 08/28/17 at 6:16 p.m.

In an interview on 08/29/17 at 10:50 a.m. with S7LPN, she reviewed the unsigned physician order written on 08/28/17 at 5:00 p.m. and indicated that she "noted" the order and had not realized the physician had not authenticated the order. S7LPN said the responsible physician, S8MD, must have forgot to authenticate the order.

Patient #21
Review of Patient #21's medical record revealed an admission date of 06/13/17 and a discharge date of 07/07/17
at 9:00 a.m. Further review revealed a verbal order for discharge written as RBVO (read back verbal order) by the nurse that was not signed, dated, or timed by the MD as of 08/29/17 (date of record review).

Patient #22
Review of Patient #22's medical record revealed a telephone order taken on 05/30/17 at 12:10 p.m. that had never been cosigned by the physician.

Review of Patient #22's medical record revealed a telephone order taken on 06/16/17 (untimed) that had never been cosigned by the physician.

Patient #25
Review of Patient #25's physician orders revealed a telephone order was received on 03/31/17 at 9:00 a.m., and the telephone order was dated, timed, and authenticated by the physician on 04/17/17, 17 days after it was given. Further review revealed a v.o. was received on 03/31/17 at 9:40 a.m., the v.o. was dated, timed, and authenticated by the physician on 04/11/17, 11 days after it was given.

Patient #26
Review of Patient #26's physician orders revealed a v.o. was received on 04/02/17 at 12:30 p.m., and the v.o. was dated, timed, and authenticated on 04/13/17, 11 days after it was received.

In an interview on 08/31/17 at 1:30 p.m., S11HIM indicated she reviewed the medical records to see that they were complete within 30 days from discharge. She further indicated verbal/telephone orders had to be signed within 7 days. She further indicated that by the time she reviewed charts for being completed in 30 days after discharge, some of the verbal/telephone orders may not have been signed within 7 days (rules and regulations allow 10 days).

Patient #28
Review of Patient #28's medical record revealed an admission date of 05/24/17 and a discharge date of 05/28/17. Further review revealed discharge orders written on 07/03/17 had not been not signed by the discharging MD as of 8/29/17.

In an interview on 8/29/17 at 4:26 p.m. with S11HIM, she confirmed Patient #28's discharge orders had not been signed by the discharging MD as of 8/29/17 (date of medical record review).




30984

Based on record reviews and interview, the hospital failed to ensure verbal/telephone orders were dated, timed, and authenticated in accordance with State law, including hospital policies and medical staff by-laws, rules, and regulations as evidenced by failure to have verbal/telephone orders authenticated by the practitioner within 10 days of the verbal/telephone order being given for 4 (#21, #22, #25, #26) of 6 (#10, #20, #21, #22, #25, #26) patient records reviewed for authentication of verbal/telephone orders from a total sample of 30 patient records.

Findings:

Review of the Medical Staff Rules and Regulations, presented as the current rules and regulations by S2CCO, revealed that all verbal/telephone orders must be signed by the physician giving the order within 10 days.

A review of the hospital policy titled, "Authentication" as provided by S2CCO as the most current, revealed in part: Every medical record entry must be dated, timed, author identified, and when required authenticated. All orders, including verbal orders, must be timed, dated, and authenticated by the ordering practitioner or another practitioner who is responsible for the care of the patient and is authorized to write orders.

Patient #21
Review of Patient #21's medical record revealed an admission date of 06/13/17 and a discharge date of 07/07/17 at 9:00 a.m. Further review revealed a verbal order for discharge written as RBVO (read back verbal order) by the nurse that was not signed, dated, or timed by the MD as of 08/29/17 (date of record review).

Patient #22
Review of Patient #22's medical record revealed a telephone order taken on 05/30/17 at 12:10 p.m. that had never been cosigned by the physician.

Review of Patient #22's medical record revealed a telephone order taken on 06/16/17 (untimed) that had never been cosigned by the physician.

Patient #25
Review of Patient #25's physician orders revealed a telephone order was received on 03/31/17 at 9:00 a.m., and the telephone order was dated, timed, and authenticated by the physician on 04/17/17, 17 days after it was given. Further review revealed a v.o. was received on 03/31/17 at 9:40 a.m., the v.o. was dated, timed, and authenticated by the physician on 04/11/17, 11 days after it was given.

Patient #26
Review of Patient #26's physician orders revealed a v.o. was received on 04/02/17 at 12:30 p.m., and the v.o. was dated, timed, and authenticated on 04/13/17, 11 days after it was received.

In an interview on 08/31/17 at 1:30 p.m., S11HIM indicated she reviewed the medical records to see that they were complete within 30 days from discharge. She further indicated verbal/telephone orders had to be signed within 7 days. She further indicated that by the time she reviewed charts for being completed in 30 days after discharge, some of the verbal/telephone orders may not have been signed within 7 days (rules and regulations allow 10 days).




30172




30984

Based on record review and interview, the hospital failed to ensure discharge summaries containing the outcome of the hospitalization, disposition of case and provisions for follow-up care were documented within 30 days of discharge for 4 (#17, #20, #21, #22) of 10 discharged patients' records reviewed for discharge summaries out of a total sample of 30 medical records reviewed.

Findings:

Review of the policy titled "Medical Record", presented as a current policy by S2CCO, revealed that when treatment is concluded, the psychiatrist will complete the discharge summary within 30 days of discharge. There was no documented evidence that the policy addressed medical records of patients cared for in the long term acute care setting.

Patient #17
Review of Patient #17's medical record revealed she had been discharged from the hospital on 5/19/17. Further review revealed there was no discharge summary in the medical record.

In an interview on 8/29/17 at 2:45 p.m. with S2CCO, she verified there was not a discharge summary in the medical record.


Patient #20
Review of Patient #20's medical record revealed an order on 06/22/17 at 9:30 a.m. to send him to the emergency room for acute abdominal pain and possible paracentesis. Further review revealed no documented evidence that Patient #20 returned to the hospital after the emergency evaluation, and there was no documented evidence that a discharge summary had been completed.

In an interview on 08/29/17 at 2:44 p.m., S2CCO confirmed a discharge summary had not been completed within 30 days of discharge for Patient #20 who was transferred to an acute care hospital on 06/22/17.


Patient #21
Review of Patient #21's medical record revealed he had been discharged from the hospital on 7/7/17. Further review revealed the patient did not have a discharge summary in his medical record as of 8/29/17 (date of the record review).

In an interview on 8/29/17 at 3:49 p.m. with S2CCO, she verified Patient #21 did not have a discharge summary in his medical record.


Patient #22
Review of Patient #22's medical record revealed he had been discharged from the hospital on 6/25/17. Further review revealed he did not have a discharge summary in his medical record.

In an interview on 8/29/17 at 3:50 p.m. with S2CCO, she verified Patient #22 did not have a discharge summary in his medical record.


In an interiew on 08/31/17 at 1:00 p.m. with S11HIM she indicated that she was responsible for the Medical Records Department. She indicated that all patient medical records are required to be completed by the physician within 30 days after discharge according to hospital policy and Medical Staff Rules and Regulations.



30172




30364




30984

Based on record review, observation, and interview the hospital failed to provide pharmaceutical services that met the needs of the patient during emergencies as evidenced by failing to maintain adequate emergency drugs and pharmaceuticals on site for patient emergencies.

Findings:

According to the American Heart Association, each ACLS algorithm utilizes a number of primary ACLS drugs. The following drugs are used on various ACLS Algorithms: Ventricular Fibrillation/Tachycardia: Epinepherine, Amioderone, Lidocaine, Magnesium; Asystole/PEA (primary arrhythmic event): Epinepherine; Bradycardia: Atropine, Epinephrine, Dopamine; Tachycardia: Adenosine, Diltiazem, Beta Blockers, Amioderone, Digoxin, Verapamil, Magnesium; Acute Coronary Syndromes: Oxygen, Aspirin, Nitroglycerin, Morphine, Fibrinolytic Therapy, Heparin, Beta Blockers; Acute Stroke: tPA-tissue, plasminogen activator, Glucose (50% Dextrose), Labetalol, Nitroprusside, Nicardipine, and Aspirin.


A review of hospital policy titled, "Rapid Response Code Blue", as provided by S2CCO as the most current, revealed in part:

Code Blue:
1. Staff identifying a patient in arrest will call a "Code Blue" by performing the following:
A. contact nurses' station by nurse call button at bedside by pressing emergency button or pulling out of wall may call verbally for "help"......

D. Initiate BLS (Basic Life Support) and Initiate ACLS (Advanced Cardiac Life Support) protocol per current AHA (American Heart Association) guidelines. E. RN or LPN/LVN will notify primary MD to provide report of patient's status.; RN/Case Manager will notify patient's family of patient's condition.

H. The crash cart should be cleaned, replenished, and locked as soon as possible.

Once the code or critical event is over a debriefing will be done by the Charge Nurse. The completed post Code Blue debriefing form will be forwarded to the Quality Improvement Department for review and follow-up. The hospital debriefing will include:
a. equipment and supplies adequate,
b. emergency drugs in date range,
c. Infection Control practices maintained during code,
d. safety precautions maintained,
e. code record complete,
f. ACLS protocols followed,
g. prompt arrival of code team,
h. code team members performance,
i. any concerns identified during the code.


An observation on 08/31/17 of the hospital's crash cart (emergency cart) revealed a cardiac monitor and cardiac monitoring supplies on the top of the cart, but there were no drugs and/or pharmaceuticals for patient emergencies noted in the crash cart. The crash cart was empty of all drugs and pharmaceuticals. A review of the crash cart log binder revealed no daily or periodic checks had been performed on the crash cart since 07/31/17.

In an interview on 08/31/17 at 11:30 a.m. with S2CCO she indicated that she was the Chief Clinical Officer for the hospital. She indicated that the acute care area had a crash cart that contained the required ACLS drugs and/or pharmaceuticals for patient emergencies when they had acute patients. S2CCO indicated that the hospital had closed the acute care area on 07/31/17 when the last acute care patient was discharged. She indicated the hospital was currently only accepting patients into the psychiatric area. S2CCO indicated that her psychiatric nurses were not required to be ACLS certified because the acute care nurses were ACLS certified and were always present in the acute area until 07/31/17. She indicated that the hospital had the contract pharmacist empty the crash cart and return all the drugs and/or pharmaceuticals to the outside pharmacy's inventory since there were no ACLS certified nurses present after the acute care area closed on 07/31/17. S2CCO indicated the psychiatric nurses were only required to have BLS and BLS equipment was present in the psychiatric area. She indicated the psychiatric area's policy was to call 911 for patient emergencies and to initiate BLS protocols and indicated that the psychiatric area has some patient emergency medications, but not all the ones required for ACLS. S2CCO further indicated that the hospital still had a current contract in place with the contracted pharmacy. The "Rapid Response Code Blue" policy was reviewed with S2CCO. She indicated that the psychiatric nurses would have to be ACLS certified and a crash cart would have to be maintained by the hospital.




30984

Based on occurrence report reviews, record review, and staff interview, the hospital failed to ensure medication administration errors were documented in the patients' medical records and reported to the attending physician for 1 (#30) of 2 (#29, #30) medical records reviewed for known errors out of a total sample of 30 medical records.

Findings:

Review of a hospital incident report revealed Patient #30 had not received an ordered dose of Klonopin 1mg on 5/24/17 at 9:00 p.m.

Review of Patient #30's medical record revealed the scheduled dose of Klonopin 1mg at 9:00 p.m. on 5/24/17 had not been documented as having been given.

Review of Patient #30's medical record revealed no documentation of physician notification of the omission of the Klonopin on 5/24/17.

Based on record review and interview, the hospital failed to ensure policies and procedures were developed that provided for safety for affected patients and hospital personnel as evidenced by failure to include provisions for safety in its policy that included shielding for patients, personnel, and facilities, the manner of notifying others when portable x-rays were being taken, and determining whether female patients were pregnant prior to taking an x-ray.

Findings:

Review of the policy titled "Radiology Services", presented as a current policy by S2CCO, revealed no documented evidence that safety provisions for patients and personnel during portable x-ray procedures conducted by the contracted company were included in the policy.

In an interview on 08/31/17 at 12:00 p.m., S2CCO confirmed the radiology policy didn't include information related to safety for patients and personnel.

Based on record review and interview, the hospital failed to have documented evidence of current CLIA certification for the contracted laboratory services provided by Hospital A.

Findings:

Review of the contract with Hospital A, presented as a current contract by S2CCO, revealed Hospital A was providing laboratory services for the hospital.

In an interview on 08/31/17 at 12:00 p.m., S2CCO indicated she didn't have a current CLIA certificate for Hospital A.

Based on record review and interview, the hospital failed to develop policies and procedures that addressed the administration of potentially HIV (Human Immunodeficiency Virus) infectious blood or blood products, and the notification of the patient, legal representative, or relative within a specified time frame with documentation in the patient's medical record of such notification or attempts to give the required notification. The hospital's lab policy did not include procedures related to the administration of potentially HIV infectious blood or blood products.

Findings:

Review of the policy titled "General Lab Procedures", presented as a current policy by S2CCO, revealed no documented evidence that it addressed procedures related to the administration of potentially HIV infectious blood or blood products.

In an interview on 08/31/17 at 12:00 p.m., S2CCO confirmed the lab policy didn't include procedures related to the administration of potentially HIV infectious blood or blood products.

Based on record reviews and interview, the hospital failed to ensure the RD performed and documented nutritional assessments in accordance with hospital policy as evidenced by failing to have documented evidence of nutritional assessments performed by the RD for 4 (#3, #4, #11, #14) of 7 (#1, #3, #4, #9, #10, #11, #14) patient records reviewed for nutritional assessments by the RD from a total sample of 30 patient records.

Findings:

Review of the policy titled "Assessments", presented as a current policy by S2CCO, revealed that initial dietary information and nutritional needs shall be assessed during the nursing assessment. Any patient identified as high risk shall be reported to the RD for a dietary/nutritional assessment within 24 hours. If the patient is not identified as high risk, the dietary/nutritional assessment shall be completed within 72 hours of admission. Further review revealed all consults shall be initiated within 24 hours of a physician's order.

Review of the medical records of Patients #3, #4, #11, and #14 revealed no documented evidence that dietary/nutritional assessments had been completed and documented by the RD. Patients #3, #4, #11, and #14 had all been admitted more than 72 hours prior to the chart review by the surveyor. Further review revealed Patient #4 had an order at admit on 08/15/17 at 4:00 p.m. for a Nutrition Consult which required the consult to be done within 24 hours in accordance with hospital policy.

In an interview on 08/29/17 at 1:10 p.m., S2CCO confirmed the above-listed patients did not have a dietary/nutritional assessment performed and documented in their medical record by the RD.

Based on observation, record review, and interview, the hospital failed to ensure the infection control officer implemented measures for controlling infections and communicable diseases as evidenced by:

1) failing to place a patient with suspicion of C Diff on contact precautions in accordance with hospital policy for 2 (#3) of 2 patient records reviewed and one observation of a patient with suspicion of C Diff from a total sample of 30 patients,

2) failing to ensure that staff adhered to the MFU's EPA disinfection protocols when cleaning/disinfecting the patient multiple-use glucometer,

3) failing to ensure that staff adhered to acceptable hand hygiene and glove removal practices during patient care procedures,

4) failing to ensure S31NP cleaned her stethoscope after using it to auscultate a patient's lungs prior to using it for another patient as observed performing chest auscultations for Patients #2 and #14 on 08/31/17 at 3:40 p.m., and

5) failing to ensure employees and physicians were screened for TB in accordance with the OPH guidelines as evidenced by failure to have documented evidence of current TB testing or a completed questionnaire for 4 (S12SW, S13MusicTher, S18MHT, S32RecTher) of 10 (S2CCO, S6RN, S7LPN, S9RN, S10LPN, S12SW, S13MusicTher, S17MHT, S18MHT, S32RecTher) personnel files and 5 (S8MD, S16PA-C, S20MedDir, S25MD, S29Psychologist) of 5 physician/psychologist/physician's assistant credentialing files reviewed for TB screening.

Findings:

1) failing to place a patient with suspicion of C Diff on contact precautions in accordance with hospital policy

Patient #3
Observation on 08/28/17 at 2:00 p.m. revealed Patient #3 was seated amongst peers in the day room during an activity therapy group session. Continuous observation revealed Patient #3 left the day room and entered his bedroom. Observation revealed no evidence of a Contact Precaution-Enteric or Contact Precautions Plus sign posted on Patient #3's bedroom door.

Review of the hospital policy titled "Clostridium Difficile Guidelines, R.18.43", presented as a current policy by S2CCO, revealed that patients who have confirmed C Diff infection and patients with diarrhea who are suspected to have C Diff infection will be placed in Contact Precautions-Enteric. Patients requiring Contact Precautions-Enteric should be placed in a private room. The door of the room may remain open, and special air handling is not necessary. A Contact Precaution-Enteric or Contact Precautions Plus sign will be placed on the patient's door. Dedicate the use of equipment to avoid sharing with other patients. The patient should wash his/her hands with soap and water and dry thoroughly before leaving the room. The patient should wear a clean cover gown or be covered by a clean sheet or drape for transport to another department or area.

Review of Patient #3's physician orders revealed an order on 08/23/17 at 2:50 p.m. to check stool for C Diff if patient has watery stools.

Review of Patient #3's "Graphic Sheet" revealed he had a bowel movement on 08/23/17 and 2 bowel movements on 08/24/17. Review of the nurse notes for 08/23/17 and 08/24/17 revealed no documented evidence of whether the bowel movements were watery, and there was no documented evidence that a stool specimen had been collected to test for C Diff.

Review of Patient #3's nurse note for 08/27/17 at 8:36 a.m. revealed he complained of diarrhea, and he was instructed that a stool specimen was needed. Further review revealed a collection device was given to Patient #3 at this time. Review of the lab requisition revealed a stool specimen was collected for C Diff on 08/27/17 at 10:00 a.m.

Review of the entire medical record revealed no documented evidence that Patient #3 was placed on Contact Precautions-Enteric on 08/23/17 when a suspicion of C Diff was discovered and maintained on these precautions until a negative C Diff result was obtained.

In an interview on 08/28/17 at 10:20 a.m. with S6RN and S7LPN, S6RN indicated Patient #3 had an order for a stool specimen for Crohn's disease. S7LPN indicated the order was for a stool specimen for C Diff. S7LPN presented a copy of a lab requisition that revealed a stool specimen for C Diff had been collected on 08/27/17. When the surveyor asked if Patient #3 had been placed on contact precautions for suspicion of C Diff, S6RN indicated if the test for C Diff is positive, then when they get the result, "we'll initiate precautions."

In an interview on 08/28/17 at 10:55 a.m., S2CCO, who is the Infection Control Officer for the hospital, confirmed that Patient #3 was not currently on Contact Precautions-Enteric as required by hospital policy for suspicion of C Diff. She offered no explanation for why Contact Precautions-Enteric had not been initiated on 08/23/17 when the order was received to obtain a stool specimen for C Diff.


Patient #22
Review of Patient #22's medical record revealed a physician's order to collect a stool for C Diff on 6/4/17 at 6:40 a.m. (never collected). Further review revealed no documentation that Patient #22 had been placed into isolation as a precaution until the patient's culture results were received.

In an interview on 8/29/17 at 3:50 p.m. with S2CCO, she verified Patient #22 was not placed into isolation precautions.



2) failing to ensure that staff adhered to the MFU's EPA disinfection protocols when cleaning/disinfecting the patient multiple-use glucometer,

A review of the MFU on the disinfecting of the glucometer after patient use revealed in part: The glucometer should be cleaned and disinfected with an EPA disinfectant approved by the manufacturer.

A review of the hospital policy titled "Cleaning of Non-Critical, Reusable Patient Care Equipment", as provided by S2CCO as the most current, revealed in part: Patient care equipment should be disinfected before use with another patient or before placed in storage, to include glucometers.

In an observation on 08/31/17 at 11:45 a.m. of S21LPN disinfecting the glucometer after patient use, she was observed disinfecting the glucometer with an alcohol pad only.

In an interview on 08/31/17 at 11:55 a.m. with S21LPN she indicated that she always cleaned the glucometer after use with alcohol. She indicated that she was not aware of the MFU cleaning instructions or the hospital's policy on the cleaning of the glucometer and would have to look it up, but her routine was to use alcohol.

In an interview on 08/31/17 at 3:50 p.m. with S2CCO she indicated that she was the Infection Control Officer. She was made aware of the observation of the glucometer cleaning by staff. S2CCO indicated that staff did not follow the MFU policy and the hospital's policy on glucometer cleaning after patient use.



3) failing to ensure that staff adhered to acceptable hand hygiene and glove removal practices during patient care procedures

An observation was made on 08/31/17 at 11:45 a.m. of S21LPN performing an accu-check on a patient. She was observed using the same gloves while simultaneously going back and forth from dirty tasks to clean tasks and was not observed changing her soiled gloves when moving from a dirty task to a clean task.

In an interview on 08/31/17 at 3:50 p.m. with S2CCO she indicated that she was the Infection Control Officer. She was made aware of the above observation during a patient accu-check procedure. She indicated the staff did not follow the hospital's infection control policy for changing gloves when moving from a dirty task to a clean task.



4) failing to ensure S31NP cleaned her stethoscope after using it to auscultate a patient's lungs prior to using it for another patient as observed performing chest auscultations for Patients #2 and #14 on 08/31/17 at 3:40 p.m.:
Observation on 08/31/17 at 3:40 p.m. revealed S31NP entered Patient #2's room, cleaned the stethoscope's ear buds with alcohol, and auscultated the patient's lungs. She then hung the stethoscope around her neck without cleaning the stethoscope bell. Continuous observation revealed S31NP then entered Patient #14's room and auscultated her lungs with the same contaminated stethoscope used to auscultate the lungs of Patient #2. She then placed the stethoscope around her neck and proceeded down the hall without cleaning the stethoscope bell.

Review of CDC's "Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008" revealed that non-critical medical devices (such as stethoscopes) were to be cleaned with an EPA-registered hospital disinfectant using the label's safety precautions and use directions. Review of Table 1 revealed low-level non-critical items that come in contact with intact skin can also be cleaned with Ethyl or isopropyl alcohol (70-90%).

In an interview on 08/31/17 at 3:45 p.m., when informed of the above observations of her not cleaning the stethoscope between patient use, S31NP asked "is that a standard of care? She indicated she usually cleans the stethoscope with alcohol wipes, but she didn't have any with her at the time.



5) Failing to ensure employees and physicians were screened for TB in accordance with the OPH guidelines:

Review of "Title 51 Public Health - Sanitary Code Chapter 5. Health Examinations for Employees, Volunteers and Patients at Certain Medical and Residential Facilities" revealed that all persons prior to or at the time of employment at any medical or 24-hour residential facility requiring licensing by LDH shall be free of TB in a communicable state as evidenced by either:

1) a negative purified protein derivative (PPD) skin test for TB, five tuberculin unit strength, given by the Mantoux method or blood assay for Mycobacterium tuberculosis approved by the United States Food and Drug Administration (FDA);

2) a normal chest x-ray, if the skin test or a blood assay is positive; or

3) a statement from a licensed physician certifying that the individual is non-infectious if the x-ray is other than normal.

In order to remain employed, the employee, who has a negative purified protein derivative skin test for tuberculosis, five tuberculin unit strength, given by the Mantoux method, or a negative result of a blood assay for Mycobacterium tuberculosis approved by the United States Food and Drug Administration, shall be rescreened annually by one of the following methods: purified protein derivative skin test for tuberculosis, five tuberculin unit strength, given by the Mantoux method, or a blood assay for Mycobacterium tuberculosis approved by the United States Food and Drug Administration remains negative, or a completed questionnaire asking of the person pertinent questions related to active tuberculosis symptoms, including, but not limited to: do you have a productive cough that has lasted at least 3 weeks? (Yes or No), are you coughing up blood (hemoptysis)? (Yes or No), have you had an unexplained weight loss recently? (Yes or No), have you had fever, chills, or night sweats for 3 or more days? (Yes or No).

Any employee converting from a negative to a positive purified protein derivative skin test for tuberculosis, five tuberculin unit strength, given by the Mantoux method or a blood assay for Mycobacterium tuberculosis approved by the United States Food and Drug Administration or having indicated symptoms of active tuberculosis revealed by the completed questionnaire, which indicates the person may have tuberculosis in a communicable state shall be referred to a physician and followed. All initial screening test results and all follow-up screening test results shall be kept in each employee's or volunteer's health record.

Review of the policy titled "TB Screening", presented as a current policy by S2CCO, revealed new personnel without history of a positive skin test will receive one skin test on hire if they can provide documentation of a prior negative test performed within the last 12 months. If no documentation can be provided, a two-step skin test will be performed. Further review revealed every year the employee will complete the signs and symptoms questionnaire only, unless he/she develops symptoms of active infection, which would require referral to a physician or OPH. At the time of reappointment, every two years, all licensed independent practitioners must have a current symptom screening questionnaire completed as part of the application process.

Review of S18MHT's personnel file revealed he was hired on 05/28/17. Further review revealed no documented evidence of a negative TB test result.

Review of the personnel and/or credentialing files of S12SW, S13MusicTher, S32RecTher, S8MD, S16PA-C, S20MedDir, S25MD, and S29Psychologist revealed no documented evidence of a TB screening questionnaire that had been documented within the last year.

In an interview on 08/31/17 at 4:50 p.m., S19AsstPsychMgr indicated that they don't require TB testing of physicians. He further indicated if a TB screening questionnaire was documented, it would be in the employee's personnel file.



30172





30364

Based on record review and interview, the hospital failed to maintain documented evidence of training of nursing personnel assigned to perform specific respiratory procedures. This deficient practice was evidenced by failure of the hospital to maintain documented evidence of respiratory service training for 5 (S6RN, S7LPN, S9RN, S10LPN, S14RN) of 6 (S2CCO, S6RN, S7LPN, S9RN, S10LPN, S14RN) nursing personnel records reviewed.

Findings:

Review of the hospital policy titled, Respiratory Care - Scope of Services, Policy number: IV.S.19.00, revealed in part: In LTACs (long-term acute care hospital) who do not accept complex respiratory patients, there will be a Respiratory Therapist available to work as needed, based on patient acuity and respiratory needs, and nurses will be trained and competent to provide basic respiratory treatments.

Review of the personnel records for S6RN, S7LPN, S9RN, S10LPN, and S14RN revealed no documented evidence of respiratory service training.

In an interview on 08/29/17 at 1:30 p.m. with S2CCO, she confirmed the hospital's nursing staff performed all of the hospital's respiratory care services.

In an interview on 8/31/17 at 5:30 p.m. with S19AsstPsychMgr, he confirmed documentation of nursing staff respiratory service training should have been maintained in the nursing staff personnel files. S19AsstPsychMgr confirmed documentation of nursing staff respiratory service training was not present in the nursing personnel records referenced above.