HospitalInspections.org

Based on record review and interview the hospital failed to: 1) ensure security measures designed by the hospital to protect patient valuables from theft were implemented for 2 of 16 shifts reviewed for securing property (9/20/2011 7 p.m.- 7 a.m. and 9/21/2011 7 a.m. - 7 p.m.); 2) ensure the environment was free from hazardous objects that could be used as weapons or tools for self harm for 1 of 1 observation made for environmental safety (9/21/2011 from 10:30 a.m. through 11:05 a.m.); and 3) ensure the safety of patients in a case of possible abuse by failing to develop a policy and procedure for abuse and/or neglect which included the immediate removal of the alleged perpetrator from patient care which has the potential to affect all patients in the hospital. Findings:

1) ensure security measures designed by the hospital to protect patient valuables from theft were implemented
Review of the hospital Memo dated June 23, 2011, addressed to "All Medication Nurses" revealed in part, "Valuables will be documented on patient belonging sheet and given to administration to keep in safe located in administrator's office during business hours. . . After hours and weekends, belonging will be documented on pt (patient) valuable belongings Count form and placed in narcotic lock box by medication nurse only. At the end of each shift, each item will be accounted for and signatures of oncoming and off going medication staff will be documented. If any item is missing off the list, administration will be notified immediately and offgoing med nurse will be held accountable. The door to medication room is to remain closed at all times. The keys to medication room, med cart and narcotic box are to remain in medication nurse's possession at all times."

Review of the hospital policy titled, "Patient Valuables, #1.26" presented by the hospital as current revealed in part, "During non-regular hours, the valuables are received by Nursing Staff, and placed in a locked drawer in medicine room for safe keeping until the Administration offices are opened."

Review of the hospital's Patient Valuable Belonging Count for the dates of 9/13/2011 through 9/21/2011 revealed no documented evidence of a count with two staff on the date of 9/20 (2011) P.M. shift or for the next shift entry with no documented date (9/21/2011 7 a.m. - 7:00 p.m.).

During a face to face interview on 9/21/2011 at 11:20 a.m., Registered Nurse FS6 indicated the Licensed Practical Nurse (LPN) FS10 that had worked the night shift of 9/20/2011 from 7:00 p.m. through 9/21/2011 at 7:00 a.m. had left that morning without counting valuables. FS6 further indicated the LPN FS10 had placed to narcotic keys on the counter in the nursing station where all nursing staff had access which included non-licensed Mental Health Techs. FS6 indicated the LPN should have turned the keys over to another licensed professional. FS6 indicated LPN FS10 should have counted valuables with an oncoming nurse on 9/21/2011 at 7:00 a.m.

During a telephone interview on 9/23/2011 at 10:50 a.m., Licensed Practical Nurse (LPN) FS10 confirmed her failure to count valuables with another nurse x 2 shifts. FS10 indicated there had been no nurse to count valuables with her on 9/20/2011 at 7:00 p.m. when she (FS10) began her (FS10) shift. FS10 indicated she had been in a hurry on 9/21/2011 and had placed the narcotic keys on the counter in the nursing station even though she (FS10) knew that it was unacceptable practice. FS10 confirmed that she (FS10) had failed to count valuables with another nurse on 9/21/2011 at 7:00 a.m.

During a face to face interview on 9/23/2011 at 11:40 a.m., Clinical Coordinator S3 and Director of Nursing S2 indicated the medication nurse holding the narcotic keys at the change of shift was to count valuables with the oncoming nurse.

2) ensure the environment was free from hazardous objects that could be used as weapons or tools for self harm for 1 of 1 observation made for environmental safety
Environmental observations were made on 9/21/2011 from 10:30 a.m. through 11:05 a.m. Observations revealed:
9/21/2011 at 10:50 a.m., Room b contained one toothbrush
9/21/2011 at 10:55 a.m., Female Shower Room had three metal shower curtain rods. Surveyor was able to remove the longest shower rod and over lap it on the lips of the shower edge in the smaller shower stall where it could potentially be used for a weapon or to hang one self
9/21/2011 at 11:00 a.m., Room d contained one comb on top of drawer
9/21/2011 at 11:03 a.m., Room e contained one ink pen

Administrator S1 was present during environmental observations. During a face to face interview on 9/21/2011 at 11:03 a.m., Administrator S1 indicated there should be no combs or toothbrushes left available to patients in their rooms. Further S1 indicated at no time should a patient have access to an ink pen. S1 confirmed the finding of metal shower rods in the Female shower room that could possible be used as a weapon or to hang one self. S1 indicated the metal shower rods had been present since the facility opened.

Review of the hospital policy titled, "Contraband, #8.23" presented by the hospital as current revealed in part, "Contraband is not permitted in the therapeutic milieu of the Hospital. Exceptions are. . . Patient Personal Belongings and relate to personal grooming items utilized with supervision."

3) ensure the safety of patients in a case of possible abuse by failing to develop a policy and procedure for abuse and/or neglect which included the immediate removal of the alleged perpetrator from patient care which has the potential to affect all patients in the hospital.
Review of Policy 2.3 titled " Patient Abuse and/or Neglect " last revised 08/11and submitted as the one currently in use revealed .... "IV. Disciplinary Actions: Disciplinary actions shall be based on a review of the hospital ' s investigation and/or findings of the investigation conducted by an outside agency". Further review revealed no documented evidence the alleged abuser would be immediately removed from the patient care area.

Review of the "Abuse and Neglect Test" implemented in response to a suspected case of abuse in the hospital dated 04/06/11 revealed ten questions, none of which pertained to what is done to protect the patient(s) from continued abuse by removal of the suspected abuser from patient care.

In a face to face interview on 09/21/11 at 2:30pm RN FS2 DON (Director of Nursing) and RN FS3 Clinical Coordinator both indicated they felt that when the charge nurse notified the Administrator On-Call, he/she would remove the person who had allegedly abused a patient, would be removed at that time.



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

1) failing to ensure patients admitted with the diagnosis of suicidal ideations and with orders for suicidal precautions including observations every fifteen minutes were observed as ordered by having one patient left unmonitored in his room for 46 minutes (#F1) and one patient left unmonitored in her room for one hour (#F2); (See findings at Tag A0395);

2) failing to assess and take immediate action when a patient voiced threats to kill her mother on 09/20/11 and prior to being discharged to her mother's care on 09/22/11 (See findings at Tag A0395);

The hospital Administrator was notified on 09/23/11 at 5:00pm of an immediate jeopardy situation when the RN (Registered Nurse) failed to: 1) ensure patients on suicide precautions were monitored according to hospital policy and procedure. Observations on 09/21/11 by surveyors revealed a patient was not monitored from 10:47am through 11:47am; however the MHT (Mental Health Technician) assigned to the patient documented that he made observations every fifteen minutes. Another patient was not monitored as observed by surveyors from 11:01am through 11:47am; however the MHT assigned to the patient documented she made observations every fifteen minutes and 2) assess and take immediate action when a patient voiced threats to kill her mother on 09/20/11 and prior to being discharged to her mother's care on 09/22/11. Further the hospital had no policy and procedure in place for the assessment and interventions for a homicidal patient.

A plan of removal developed by FS1 Administrator and FS3 Clinical Coordinator was presented to the survey team on 09/26/11 at 10:30am. Review of the plan of removal revealed the development of a policy for Homicidal Assessment and Intervention which failed to include interventions to protect the safety of the person (whether it be someone outside of the hospital or a patient of the hospital) whom the patient verbalizes he/she intends to kill, approval by the Governing Body of the policy and procedure for Assessment of a Homicidal patient, or documentation of education of the staff concerning the new policy. Further review revealed corrective action for failure to observe patients as ordered by the MHTs (Mental Health Technicians) was to assign two (2) MHTs with the sole duty to monitor the patients every 15 or 30 minutes as ordered. The plan failed to provide details on how the staff would be educated on the change in duties, what RN would be responsible for hourly checks on observations, or how long video surveillance and unit spot auditing would be performed. Further the plan failed to address any corrective action concerning the falsification of records to ensure the practice would not continue.

A revised plan of removal developed by FS3 Clinical Coordinator and Consultant RN FS20 was presented to the survey team on 09/28/11 at 11:00am. A policy approved by the Governing Body on 09/26/11 at 1900 (7:00pm) for Homicidal Assessment included interventions to protect the safety of the person (whether it be someone outside of the hospital or a patient of the hospital) whom the patient verbalizes he/she intends to kill and a process for educating the staff before being assigned to patient care. Further, the two MHTs involved with falsification of records were re-educated and suspended from duty without pay for a period of two days.

However, after review of the medical record for Random Patient FR2 revealed a second incident of failure of the nursing staff to assess and re-assess a patient with symptoms of EPS (Extrapyramidal Symptoms). Concern remained over the care and safety of the patients in the hospital.

The immediate jeopardy remained in place at the time of the exit on 09/28/11 at 1:30pm.

3) failing to ensure the Registered Nurse assessed patients with symptoms of EPS (Extrapyramidal Symptoms) for 2 of 2 patients reviewed with symptoms of EPS out of a total sample of 11 sampled patients and 2 random sampled patients (Patient #F5, #FR2); (See findings at Tag A0395)





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Based on observation, record review, and interview the hospital failed to ensure a Registered Nurse supervised and evaluated the nursing care for each patient as evidenced by: 1) failing to ensure patients admitted with the diagnosis of suicidal ideations and with orders for suicidal precautions including observations every fifteen minutes were observed as ordered by having one patient left unmonitored in his room for a period of 46 minutes (#F1) and one patient left unmonitored in her room for one hour (#F2); 2) failing to assess and take immediate action when a patient voiced threats to kill her mother on 09/20/11 and prior to being discharged to her mother's care on 09/22/11; 3) failing to ensure the Registered Nurse assessed patients with symptoms of EPS (Extrapyramidal Symptoms) for 2 of 2 patients reviewed with symptoms of EPS requiring intervention out of a total sample of 11 sampled patients and 2 random sampled patients (#F5, #FR2); Fi

1) failing to ensure patients 2 of 2 admitted with the diagnosis of suicidal ideations and with orders for suicidal precautions including observations every fifteen minutes were observed to be left unmonitored in their rooms for a period of approximately one hour
Patient #F1
Review of the medical record for Patient #F1 revealed a 20 year old male admitted to the hospital on 08/16/11 per a PEC (Physician's Emergency Certificate) with the diagnosis of SI (Suicidal Ideation) and polysubstance abuse. Review of the Physician's Admit Orders dated 08/16/11 revealed Patient #F1 was ordered to be placed on suicide precautions (monitoring every 15 minutes).

Observations on 09/21/11 at 11:01am through 11:47am in the hallway outside of Patient #F1's room revealed he (#F1) remained in his room during this time with the door closed until 11:20am, when the housekeeper entered and exited the room and left the door with a small crack in it. Further observation revealed no staff member came to his room during the time period of 11:01am through 11:47am.

Review of the "Patient 15"(minute) &/or 30" Observation For AM Shift" dated 09/21/11 for Patient #F1 revealed the following: 11:00am 10/20/21/12 (Monitoring/Awake/Cooperative/ in Group; 11:15am 10/20/21 (Monitoring/Awake/Cooperative); 11:30am (Monitoring/Awake/Cooperative); 11:45am (Monitoring/Awake/Cooperative).

Mental Health Technician SF12 declined to return phone calls by the hospital per the Clinical Coordinator SF3 for an interview. Review of the "Employee Reprimand/Disciplinary Report" for MHT SF12 dated 09/27/11 revealed SF12 was suspended for two days without pay for not performing rounds on a patient and falsifying the observations in the medical record.

Review of Policy 10.5 titled "Entries into the Clinical Record" last revised 03/11 and submitted as the one currently in use revealed ...."Policy: 1. Documentation in the clinical record is detailed and accurate and reflects the care of services provided".

Patient #F2
Review of Patient #F2's medical record revealed she was admitted on 09/20/11 with a diagnosis of Major Depressive Disorder. Further review revealed Patient #F2's medical problems included Hypertension, Hyperlipidemia, Mitral Valve Prolapse, Anemia, and Osteoarthritis. Further review revealed she was PEC'd (physician's emergency certificate) on 09/20/11 secondary to being gravely disabled and unable to seek voluntary admission. Review of Patient #F2's "Physician Orders" revealed a telephone order received on 09/21/11 at 0100 (1:00am) by RN (registered nurse) FS14 from Medical Director FS17 for suicide precautions. Further review revealed no documented evidence of an order for the level of observation for Patient #F2.

Observation on 09/21/11 at 10:47am revealed Patient #F2 was lying in her bed near the window in room "a" with the door to the room with an opening that allowed one to view the patient lying in the bed near the window. Further observation revealed no staff member was present in the room or in the hall outside room "a".

Observation on 09/21/11 at 10:58am (with continuous observation since 10:47am) revealed a surveyor and Administrator FS1 entered room "a" to inspect the windows and closed the door upon exiting the room.

Continuous observation on 09/21/11 from 10:47am through 11:47am revealed Patient #F2 never left her room (room "a"), and no nurse or MHT (mental health tech) entered room "a" to observe Patient #F2 every 15 minutes as required for suicide precautions per hospital policy.
Review of Patient #F2's "Patient 15" (minutes) & (and)/or 30" Observation Form AM Shift" for 09/21/11 revealed no documented evidence of the type of observation ordered. Further review revealed MHT SF11 documented from 10:45am through 12:45pm that Patient #F2's staff intervention was monitoring, and her behaviors were asleep with respirations visible whi8le in her room.

In a telephone interview on 09/23/11 at 9:53am, MHT FS11 confirmed that he was the MHT assigned to observe Patient #F2 on 09/21/11. FS11 indicated Patient #F2 was lying in her bed most of that morning. He further indicated Patient #F2 did not attend group on the morning of 09/21/11, because she was in her room sleeping. FS11 indicated if a patient he was assigned to observe was in his/her room, he (FS11) would go to the room to observe the patient. When MHT FS11 was told that the continuous observation by the surveyor on 09/21/11 from 10:47am through 11:47am revealed no observation that he had checked on Patient #F2 while she was in her room, FS11 indicated he could not remember if he was maybe assisting the physician during that time. FS11 confirmed he did not transfer the observation of Patient #F2 to another MHT at any time. He could offer no explanation for not making observations every 15 minutes but documenting that he did observe Patient #F2 to be asleep in her room.

In a face-to-face interview on 09/23/11 at 11:05am, DON (director of nursing) FS2 and Clinical Coordinator FS3 could offer no explanation when told that continuous observations for one hour revealed no evidence that MHT FS11 made every 15 minutes observations but documented that they were done for Patient #F2.

2) failing to assess and take immediate action when a patient voiced threats to kill her mother on 09/20/11 and prior to being discharged to her mother's care on 09/22/11
The medical record of Patient #F6 was reviewed. Patient #F6 was admitted to the hospital on 9/15/2011 with diagnoses that included Major Depressive Disorder. Further review revealed a nursing note dated 9/20 (2011) with no documented time indicating "pt. (patient) with 1:1 present, overheard stating she (#F6) will kill her (#F6) mo (mother) after she (#F6) gets out. Physician (no documented name of physician) advised of statement.". Review of nursing notes dated 9/22/2011 at 1000 (10:00 a.m.) revealed in part "discharged c (with) mother". Review of Psychiatric Attending Progress Notes dated 9/22/2011 at 10:00 a.m. revealed in part, "document suicidality/homicidality here: 0 (none). Very much improved." Review of Patient #F6's entire medical record revealed no documented evidence of a homicidal assessment of Patient #F6's plan to kill her (#F6) mother when she (#F6) got out of the hospital and prior to being discharged to her (#F6) mother's care two days after making the statement.
Review of the hospital policy and procedure manual revealed no documented evidence of a policy regarding Homicidality to include assessment and/or security measures. This finding was confirmed in a face to face interview with Director of Nursing FS2 and Clinical Coordinator FS3 on 9/23/2011 at 12:40 p.m.
During a face to face interview on 9/23/2011 at 12:40 p.m., Licensed Master Social Worker FS23 indicated she (FS23) had never been informed that Patient #F6 had ever expressed Homicidal Ideations.
During a face to face interview on 9/23/2011 at 12:40 p.m., Director of Nursing FS2 indicated he (FS2) had been the nurse on duty when a Mental Health Tech had informed him (FS2) that Patient #F6 had stated she (#F6) planned on killing her mother when she (#F6) was discharged from the hospital. FS2 indicated he (FS2) had informed Psychiatrist FS17 of the statement. FS2 indicated he (FS2) had not performed any nursing assessment regarding Patient #F6's reported statement of planning to kill her (#F6) mother after she (#F6) was discharged.
During a face to face interview on 9/23/2011 at 1415 (2:15 p.m.), Medical Director Psychiatrist FS17 indicated he (FS17) would expect any patient who verbalizes homicidal ideation at St. James Behavioral Hospital to have an assessment to determine who the intended victim is, what the plan consists of, the lethality of the plan, and the patient's ability to carry out the plan. FS17 indicated there would be a duty to warn the intended victim of the threat. FS17 indicated he (FS17) had not been aware that the hospital had no policy regarding Homicidal Patients. FS17 indicated he (FS17) had not been informed of patient #F6's homicidal ideation until the day the patient (#F6) had been discharged.

3) failing to ensure the Registered Nurse assessed patients with symptoms of EPS
Patient #F5: The medical record for Patient F5 was reviewed. Patient #F5 was admitted to the hospital on 9/19/2011 with diagnoses that included Bipolar Disorder. Review of physician orders for Patient #F5 dated 9/19/ (2011) at 3:30 p.m. revealed in part, "Cogentin 2 mg (milligrams) IM (Intramuscular) STAT x1 (times one), Cogentin 1 mg PO (by mouth) bid (twice per day) EPS (Extrapyramidal Symptoms). Further review revealed a physician's order dated 9/19/(2011) at 6:15 p.m. that revealed in part, "Benadryl 50 mg (milligrams) IM STAT". Review of Psychiatric Attending Progress notes for Patient #F5 dated 9/20/2011 at 1300 (1:00 p.m.) revealed in part, "Bizarre. Had dystonic rx (reaction) c (with) Risperdal." Review of Patient #F5's Medication Administration Record revealed the patient (#F5) was administered Cogentin 2 mg (milligrams) IM stat at 1630 (4:30 p.m./ 1 hour after the verbal stat order). Further review revealed Patient #F5 was administered Benadryl 50 mg. IM at 1815 (6:15 p.m./same time as stat order). Review of Patient #F5's Medication Administration Record further revealed "1630 (4:30 p.m./ordered at 3:30 p.m.), Cogentin 2 mg IM/ EPS symptoms, Results/Response: neck 0 (not) as stiff, 1730 (5:30 p.m./1 hour after administration of Cogentin which was ordered at 3:30 p.m. and given at 4:30 p.m. as per medical record documentation)." Further review revealed no documented evidence of Patient #F5's response to the administration of Benadryl at 6:15 p.m. Review of Patient #F5's entire medical record revealed no documented nursing progress notes for Patient #F5 from 9/19/2011 at 0845 (8:45 a.m.) until the next entry at 2000 (8:00 p.m.). Review of Patient #5's entire medical record revealed no documented assessment of Patient #F5's EPS symptoms, vital signs, or monitoring of the patient during the recovery period post injection of Cogentin/Benadryl. Review of Patient #F5's Graphic Flow Sheet revealed Patient #F5's vital signs at 5:29 a.m. on 9/19/2011 to be blood pressure 89/51, pulse 72, and respiratory rate of 18. The next documented vital signs were recorded at 0600 (6:00 a.m.) on 9/20/2011. Review of "Nurse Rounds" area located on the Nursing Assessment AM shift form revealed the pre-printed times of 0800 (8:00 a.m.), 1000 (10:00 a.m.), 1200 (12:00 p.m.), 1400 (2:00 p.m.), 1600 (4:00 p.m.), and 1800 (6:00 p.m.) with preprinted documentation stating "code behavior" . Review of Patient #F5's Nursing Assessment AM shift form for the 7 a.m. - 7 p.m. shift on 9/19/2011 revealed no entries in the blanks next to the times of 0800 (8:00 a.m.), 1000 (10:00 a.m.), 1200 (12:00 p.m.), 1400 (2:00 p.m.), 1600 (4:00 p.m.), and 1800 (6:00 p.m.).
During a face to face interview on 9/21/2011 at 1715 (5:15 p.m.), Director of Nursing FS2 indicated he (FS2) had been the nurse providing care to Patient #F5 on 9/19/2011 when the patient presented to the Nursing Station complaining of inability to open his mouth. FS2 further indicated Patient #F5 had positive symptoms of Cog wheeling at the time. FS2 indicated Patient #F5's physician had been contacted and an order for medication had been received. FS2 confirmed that the medical record for Patient #F5 revealed a one hour delay from the receipt of the verbal order for stat Cogentin until the administration of Cogentin. FS2 indicated he (FS2) had no explanation for the delay in documented time of administration of Cogentin because he (FS2) thought he (FS2) had administered it soon after receiving the physician's order. FS2 confirmed that no vital signs had been taken at any time during Patient #F5's experience of side effects and recovery from side effects post Cogentin/Benadryl administration for EPS. Further FS2 confirmed there was no documented evidence of an assessment of Patient #F5 at the time of onset of symptoms of EPS side effects or during the recovery phase post injection for treatment of EPS side effects (Cogentin/Benadryl). FS2 indicated a patient experiencing EPS side effects of dystonia could have breathing difficulty and should be monitored closely. FS2 indicated he (FS2) had been the nurse in Charge that day and had failed to show adequate monitoring of Patient #F5 during his presentation of EPS side effects and during the recovery period after treatment of the side effects. FS2 indicated he (FS2) remembered Patient #F5 presenting at the nursing station after having already received Cogentin IM with his tongue protruding. FS2 indicated Benadryl was then given as per order of the patient's physician.
During a face to face interview on 9/21/2011 at 1715 (5:15 p.m.), Clinical Coordinator SF3 indicated the hospital had no policy or education material on EPS/Dystonia. SF3 indicated nursing staff did have Internet access available to them. SF3 further indicated there was no hospital policy indicating the time frame for stat medication.
During a telephone interview on 9/23/11 at 1415 (2:15 p.m.), Medical Director Psychiatrist FS17 indicated he would expect any patient with a Dystonic Reaction/EPS to be monitored closely for possible Respiratory Distress. FS17 further indicated that any medication ordered "STAT" by the physician should be given within 15 minutes.
Patient #FR2: The medical record of Patient #FR2 was reviewed. Patient #FR2 was admitted to the hospital on 9/23/2011 with diagnoses that included Bipolar Disorder. Review of Patient #FR2's " Nursing Assessment A.M. Shift/Nursing Note" revealed in part, "9/26/2011, 1250 (12:50 p.m.), pt (patient) came to the nurses stating that his face is locked up. (Physician Assistant FS18) informed, Ativan 2 mg (milligrams) IM now dose for Extrapyramidal effect (EPS) ordered." and "1300 (1:00 p.m.), Ativan 2 mg (milligrams) IM given per (LPN FS19) Pt saying (Paranoid) "someone poison my food" 1:1 visual maintained. Will continue to monitor" and "1345 (1:45 p.m./45 minutes after Ativan administered) noted sleeping." Review of Patient #FR2's Graphic Flow sheet revealed vital signs at 6:00 a.m. on 9/26/2011 to be blood pressure 80/47, pulse 87, respirations 20. Further review revealed the next recorded vital signs as 9/26/2011 at 1800 (6:00 p.m.) as blood pressure (none recorded), pulse 75, respirations 18. Review of Patient #FR2's entire medical record revealed no documented evidence of vital signs between 6:00 a.m. and 6:00 p.m. on 9/26/2011. Review of Patient #FR2's vital signs on 9/25/2011 (day before) revealed 6:00 a.m. blood pressure of 136/89 and 6:00 p.m. blood pressure of 120/87. Review of Patient #FR2's entire medical record revealed no documented evidence of a nursing assessment describing Patient #FR2's EPS/Side Effects/Respiratory status at the time the patient presented with symptoms of EPS and during the recovery period post administration of medication. Review of Patient #FR2's Medication Administration Record revealed no documented evidence of an evaluation of the Patient's response to Ativan administered at 1300 (1:00 p.m.) on 2/26/2011.
The hospital's video surveillance was reviewed with Director of Nursing FS2 on 9/28/2011. The date of the surveillance recording reviewed was 9/26/2011 from 1255 (12:55 p.m.) through 1400 (2:00 p.m.). Review revealed Patient #FR2 appeared at the nursing station window on 9/26/2011 at 12:52:24 p.m. Further review revealed Registered Nurse SF21 and Licensed Practical Nurse FS19 entering Patient #FR2's room on 9/26/2011 at 12:55:08 and exiting at 12:57:47. Review revealed Patient #FR2 walking in and out of his room and from one end of the hall to the other at repeated intervals. A Mental Health Technician was viewed in attendance of the patient (#FR2) but remained at a distance when following Patient #FR2 up and down the hall. Further the Mental Health Tech was noted to be seated in a chair outside Patient #FR2's room at 13:14:25 with his back to the patient's door (no visibility of patient while patient was in his room). Further review of video surveillance revealed no contact/interaction between any Registered Nurse or Licensed Practical Nurse and Patient #FR2 from 12:57:47 until Registered Nurse SF21 stood at Patient #FR2's doorway, without entering the Patient's room at 14:00:00 (2:00 p.m.).
During a face to face interview on 9/28/2011 at 9:25 a.m., Patient #FR2 indicated he (#FR2) had a reaction to medication (9/26/2011). #FR2 indicated his (#FR2) face locked up, his (#FR2) jaw and neck tightened, and he (#FR2) could barely breathe. #FR2 indicated he (#FR2) had been administered medication by a nurse and it took from 20-30 minutes for him (#FR2) to respond and get better.
During a face to face interview on 9/28/2011 at 9:30 a.m., Registered Nurse FS21 indicated she (FS21) had been assigned to patient #FR2 on 9/26/2011 when the patient had symptoms of EPS. FS21 indicated she (FS21) had called the Patient's (#FR2) physician and handed the phone to LPN (Licensed Practical Nurse) FS19 to take a verbal order for medication after Patient #FR2 complained of his face being locked up. FS21 indicated she (FS21) had monitored Patient #FR2 every 15 minutes after the patient's reported EPS (video surveillance showed no RN/LPN monitoring of Patient #FR2 from 12:57 p.m. until 2:00 p.m./confirmed by Director of Nursing FS2). FS21 indicated she (FS21) had monitored Patient #FR2's vital signs after the patient's complaint of EPS. FS21 was not able to produce any evidence of monitoring Patient #FR2's vital signs. FS21 then stated she (FS21) had thought that LPN FS19 had taken vital signs because she (FS21) thought any one that administered medications for EPS would take vital signs first. FS21 confirmed that she (FS21) was the nurse assigned to the care of Patient #FR2 on 9/26/2011. Registered Nurse FS21 was interviewed again on 9/28/2011 at 11:40 a.m. and 1320 (1:20 p.m.). FS21 indicated EPS would be considered an emergency situation and the patient should have a nursing assessment, vital signs, notification of the patient's physician, and close monitoring for problems with breathing/respirations. FS21 further indicated that she (FS21) had checked on Patient #FR2 by asking the Mental Health Technician (non-licensed professional); that was monitoring the patient (#FR2) for behavior problems, how Patient #FR2 was doing and the Mental Health Tech told her (FS21) that Patient #FR2 was sleeping. FS21 further indicated it was her (#FS21) practice to sit in group every morning and listen to how patients checked in regarding their sleep pattern for the previous night and any complaints expressed. FS21 indicated that she (#FS21) would do an assessment in the hall way of any patient that expressed a problem during group check in, otherwise she would complete the Nursing Assessment based on sighting the patient in group and hearing their report regarding sleep/problems.
During a telephone interview on 9/28/2011 at 9:50 a.m., Licensed Practical Nurse FS19 indicated she (FS19) had administered medication to Patient #FR2 on 9/26/2011 for EPS. FS19 indicated she (FS19) did not take vital signs on Patient #FR2 in response to EPS experienced on 9/26/2011. FS19 indicated she (FS19) had checked on Patient #FR2 approximately 30 minutes after administering Ativan for EPS and found the patient (#FR2) to be lying in his bed asleep (Video Surveillance revealed no contact between any RN or LPN and Patient #FR2 from 12:57:47 until 14:00:00.)
During a face to face interview on 9/28/2011 at 1325 (1:25 p.m.), Registered Nurse FS22 indicated she (FS22) had been a nurse for 18 years and had worked off and on in psychiatric facilities. FS22 further indicated she (FS22) had been in orientation with a mentor at St. James Behavioral hospital for 3 days. FS22 indicated she (FS22) had been assigned to two different nurses during this orientation phase. FS22 indicated one of the nurses had performed no hands on assessment of her assigned patients. FS22 indicated that the nurse had simply located the patients by visualizing them. FS22 indicated the other nurse that she (FS22) had worked with in orientation had used a stethoscope and performed a full body assessment before group, in the hallway. Registered Nurse FS22 further indicated any patient with a Dystonic Reaction/EPS should be observed very closely because the patient could stop breathing.
4) failing to observe a patient on suicidal precautions while taking a shower per hospital policy resulting in a suicidal patient being left alone in a shower room with metal removable shower rods:
Patient #F4
Review of Patient #F4's medical record revealed he was admitted on 09/15/11 with a diagnosis of schizophrenia. Further review revealed he was PEC'd on 09/15/11 at 1455 (2:55pm) secondary to being suicidal, dangerous to self, gravely disabled, and unable to seek voluntary admission. Patient #F4 was CEC'd (coroner's emergency certificate) on 09/16/11 at 3:05pm secondary to being suicidal, dangerous to self, gravely disabled, and unable to seek voluntary admission. Review of Patient #F4's "Physician Admit Orders & (and) Problem List" and "Physicians Orders" revealed suicide precautions were ordered on 09/15/11 at 1920 (7:20pm) with no documented evidence of the level of observation to be maintained for Patient #F4. Further review of the "Physicians Orders" revealed an order on 09/17/11 at 1430 (2:30pm) to change Patient #F4 from close observation to routine observation. Review of the entire medical record revealed no documented evidence of a physician's order to discontinue suicide precautions for Patient #F4.

Review of the hospital's video surveillance of the hallways containing the male shower room revealed the following: 09/21/11 at 2005 (8:05pm) MHT (Mental Health Tech) opening the locked shower door and an unidentified patient entering the shower room. MHT left the shower room with patient unattended. 2012 (8:12pm) MHT went in and came right out of the male shower room. 2017 (8:17pm) MHT stuck his head in the male shower room. 2018 (8:18pm) MHT went in and out of shower room. 2019 (8:19pm) MHT went in and out of shower room. 2020 (8:20pm) Patient came out of shower. 2023 (8:23pm) Patient went back into shower room. MHT sitting on chair outside of male shower room. 2032 (8:25pm) Patient out of the male shower room. No patients in the male shower room at this time.
09/21/11 at 2049 (8:49pm) Patient #F4 went into unlocked and unattended male shower room. 2050 (8:50pm) MHT stuck head in shower room. 2051 (8:51pm) MHT opened the door to the male shower room, left a small crack in the door and put a chair close to the door. 2054 (8:54pm) MHT left the chair and walked out of sight. 2100 (9:00pm) MHT back to chair. 2104 (9:04pm) MHT left male shower room unattended. 2105 (9:05pm) MHT back to chair outside male shower room. 2106 (9:06pm) MHT left male shower room unattended. 2109 (9:09pm) MHT back and looked into the male shower room. 2110 (9:10pm) Patient comes out of bathroom. MHT removes chair from bathroom door, door closed and locked.

5) failing to perform an accurate suicide assessment
Patient #F8:
The medical record for Patient #F8 was reviewed. Patient #F8 was admitted to the hospital on 9/20/2011 with diagnoses that included Depression and Suicidal Attempt with overdose.
Review of Patient #F8's Initial Admission Nursing Summary dated 9/20 (2011) at 5:30 (a.m./p.m. not specified) completed by Director of Nursing FS2, revealed in part, "Fa (father) suicide, Mo (mother) to NH (nursing home). . . Historically husband told her (#F8) he (husband) was leaving her (F8)."
Review of Patient #F8's Suicide Risk Assessment dated 9/20 (2011) at 5:30 (a.m./p.m. not specified) completed by Director of Nursing FS2, revealed in part, "Have any family members or loved ones committed suicide? (Marked No) Has the patient experienced a recent significant loss, such as a spouse, child, job, etc? (Marked No)."

During a face to face interview on 9/23/2011 at 12:40 p.m., Director of Nursing FS2 indicated he had been the nurse that had performed the initial RN assessment for Patient #F8 to include the Suicide Risk Assessment. FS2 further confirmed the Suicide Risk Assessment had not been accurate. FS2 indicted the section stating "Have any family members or loved ones committed suicide?" should have been marked as "Yes" because the patient's father had killed himself and the section titled, "Has the patient experienced a recent significant loss, such as a spouse, child, job, etc?" should have been marked "Yes" because the patient had her (#F8) mother placed in a Nursing Home and her (#F8) husband had threatened to leave her (#F8).

6) Failing to supervise and ensure assess the clinical status of patients on suicide precautions every 8 hours according to hospital policy and/or assess patients at least every 2 hours who had orders for every 15 minutes observation:
Patient #F1
Review of the medical record for Patient #F1 revealed a 20 year old male admitted on 08/16/11 per PEC (Physician ' s Emergency Certificate) for suicidal ideation and paranoia.

Review of the Nursing Assessment AM Shift for Patient #F1 revealed no documented evidence the RN (Registered Nurse) made rounds on 09/17/11 at 1600 (4:00pm) and 1800 (6:00pm) and 09/19/19 at 1600 (4:00pm). Review of the Nursing Assessment for PM Shift #F1 revealed no documented evidence RN rounds at 2200 (10:00pm), 09/18/11 at 2400 (12:00pm), 0200 (2:00am), 0400 (4:00am) and 0600 (6:00am). Further review of the Nursing Assessment revealed no documented evidence the nurse made written entries into the narrative notes describing the behavior of the suicidal patient.

Patient #F2
Review of Patient #F2's medical record revealed she was admitted on 09/20/11 with a diagnosis of Major Depressive Disorder. Further review revealed Patient #F2's medical problems included Hypertension, Hyperlipidemia, Mitral Valve Prolapse, Anemia, and Osteoarthritis. Further review revealed she was PEC'd (physician's emergency certificate) on 09/20/11 secondary to being gravely disabled and unable to seek voluntary admission. Review of Patient #F2's "Physician Orders" revealed a telephone order received on 09/21/11 at 0100 (1:00am) by RN (registered nurse) FS14 from Medical Director FS17 for suicide precautions. Further review revealed no documented evidence of an order for the level of observation for Patient #F2.

Review of Patient #F2's "Nursing Assessment AM Shift" (covers time period of 7:00am to 7:00pm) for 09/21/11 revealed she was assessed by the RN at 8:30am and 12:00pm. Review of the "Nursing Assessment PM Shift" (covers time period of 7:00pm to 7:00am) for 09/21/11 revealed no documented evidence that the RN performed routine observation checks on Patient #F2 every 2 hours as required by hospital policy for a patient on 15 minutes observation. Further review revealed no documented evidence the RN documented the clinical status of Patient #F2 every 8 hours on 09/21/11 as required by hospital policy for a patient on suicide precautions. Review revealed documentation of nursing assessments on 09/21/11 at 12:00pm and 2200 (10:00pm), an interval of 10 hours rather than 8 hours as required by hospital policy. Further review revealed no documented evidence of a nursing assessment of the clinical status of Patient #F2 at 6:00am on 09/22/11.

Patient #F3
Review of Patient #F3's medical record revealed the patient was admitted to the hospital on 9/19/2011 with diagnoses that included Major Depressive Disorder. Further review of Patient #F3's entire medical record revealed no documented evidence of nursing rounds on 9/20/2011 from 2420 (12:20 a.m.) until 0700 (7:00 a.m.).
Patient #F4
Review of Patient #F4's medical record revealed he was admitted on 09/15/11 with a diagnosis of schizophrenia. Further review revealed he was PEC'd on 09/15/11 at 1455 (2:55pm) secondary to being suicidal, dangerous to self, gravely disabled, and unable to seek voluntary admission. Patient #F4 was CEC'd (coroner's emergency certificate) on 09/16/11 at 3:05pm secondary to being suicidal, dangerous to self, gravely disabled, and unable to seek voluntary admission. Review of Patient #F4's "Physician Admit Orders & (and) Problem List" and "Physicians Orders " revealed suicide precautions were ordered on 09/15/11 at 1920 (7:20pm) with no documented evidence of the level of observation to be maintained for Patient #F4. Review of Patient #F4's "Physicians Orders" revealed an order on 09/17/11 at 1430 (2:30pm) to transfer Patient #F4 from close observation to routine observation.

Review of Patient #F4's "Nursing Assessment AM Shift" and "Nursing Assessment PM Shift" revealed no documented evidence that the RN performed routine observation checks on Patient #F4 every 2 hours as required by hospital policy for a patient on 15 minutes observation and routine observation on 09/17/11, 09/18/11, and 09/19/11. Further review revealed no documented evidence the RN documented the clinical status of Patient #F4 every 8 hours on 09/17/11, 09/18/11, 09/19/11, and 09/21/11 as required by hospital policy for a patient on suicide precautions.

Patient #F5
Review of Patient #F3's medical record revealed the patient was admitted to the hospital on 9/19/2011 with diagnoses that included Major Depressive Disorder. Further review of Patient #F3's entire medical record revealed no documented evidence of nursing rounds on 9/20/2011 from 2420 (12:20 a.m.) until 0700 (7:00 a.m.). Is this #5 or #3 - info is same as #3 above
Patient #F6 Review of Patient #F6's medical record revealed the patient was admitted to the hospital on 9/15/2011 with diagnoses that included Major Depressive Disorder. Further review of Patient #F6's entire medical record revealed no documented evidence of nursing rounds on 9/17/2011 from 2000 (8:00 p.m.) until 0600 (6:00 a.m.), no documented evidence of nursing rounds on 9/18/2011 from 1000 until 1600 (4:00 p.m.), and 9/20/2011 from 2200 (10:00 p.m.) until 0700 (7:00 a.m.).
Patient #F9
Review of Patient #F9's medical record revealed he was admitted on 09/17/11 with a diagnosis of Depression with suicide ideations. Review of the "Order For Protective Custody" dated 09/17/11 at 10:25am revealed, in part, "...This morning Patient #F9 involved in argument with wife called 911 and hung up. Patient #F9 then took his shotgun out into the back yard. Sheriffs Deputy came to investigate the 911 call and found Patient #F9 very agitated and told deputy there was no gun outside. The Deputy detained Patient #F9 when he found the shotgun ...". Further review of Patient #F9's medical record revealed he was PEC'd on 09/17/11 at 12:21pm secondary to being suicidal, dangerous to self, and unwilling and unable to seek voluntary admission. Further review revealed he was CEC'd on 09/18/11 at 12:10pm secondary to being dangerous to self and unwilling to seek voluntary admission. Review of Patient #F9's "Physician Admit Orders & Problem List" dated 09/17/11 at 3:30pm revealed an order for suicide precautions with close observation every 15 minutes.

Review of Patient #F9's "Nursing Assessment AM Shift" and "Nursing Assessment PM Shift" revealed no documented evidence that the RN performed

Based on record review and interviews, the hospital failed to ensure the nursing staff developed and kept current an individualized nursing care plan for each patient as evidenced by failure to have the patient's medical problems included in the care plan (#F9) and failure to update the patient's care with changes in the patient's condition (#F4, #F5, #F6, #FR2) for 4 of 11 sampled patients and 1 of 2 random patients. Findings:

Patient #F9
Review of Patient #F9's medical record revealed he was admitted on 09/17/11 with a diagnosis of Depression with suicide ideations. Review of the "Physician Admit Orders & (and) Problem List " dated 09/17/11 at 3:30pm revealed an order for non-insulin dependent diabetes mellitus accuchecks twice a day.
Review of Patient #F9's "Multidisciplinary Integrated Treatment Plan - Master" initiated on 09/17/11 revealed the identified patient problems were depressed mood with suicidal ideations and high risk for falls. Further review revealed no documented evidence Patient #F9's diabetes and subsequent accuchecks had been incorporated into his treatment plan.

Patient #F4
Review of Patient #F4's medical record revealed he was admitted on 09/15/11 with a diagnosis of schizophrenia.
Review of Patient #F4's "Initial Psychiatric Evaluation" performed on 09/16/11 revealed admission/provisional diagnoses were chronic paranoid schizophrenia, acute exacerbation, hypertension; diabetes mellitus, moderate medication noncompliance, and polysubstance abuse.
Review of Physician FS37's "Progress Note" dated 09/18/11 revealed a possibility of a chalazion to the left upper eyelid, for which FS37 would prescribe TobraDex Ophthalmic solution and Claritin. Further review revealed Physician FS37's "Progress Note" of 09/19/11 included an assessment of GERD (gastroesophageal reflux disease) for which he would prescribe Nexium.
Review of Patient #F4's "Multidisciplinary Integrated Treatment Plan - Master" initiated on 09/15/11, with no documented evidence of the signature of the nurse who initiated the plan, revealed the problems identified were hallucinations, medication non-compliance, diabetes, psychosis with suicidal ideations, and altered thoughts. Further review revealed no documented evidence Patient #F4's hypertension was included in the treatment plan, and the plan was not updated to include the possible chalazion to the left upper eyelid identified on 09/18/11 and the GERD identified on 09/19/11.

Review of Patient #F5 ' s medical record revealed the patient was admitted to the hospital on 9/19/2011 with diagnoses that included Bipolar Disorder. Further review revealed Nursing Notes dated 9/24/2011 at 1245 (12:45 p.m.) indicating, " On smoke break, patient was caught kissing another patient (male) on the cheek which was recipicated (reciprocated) . . . "

Review of Patient #F5 ' s Multidisciplinary Integrated Treatment Plan revealed no documented evidence of updating Patient #F5 ' s treatment plan to include inappropriate sexual behavior and interventions to ensure the behavior did not re-occur.

Review of Patient #FR2 ' s medical record revealed the patient (#FR2) was admitted to the hospital on 9/23/2011 with diagnoses that included Bipolar Disorder, Mood Disturbance, and Paranoia. Further review revealed Nursing Notes dated 9/24/2011 at 1245 (12:45 p.m.) indicating, " Pt (patient) was kissing fondling another pt. Pt instructed that he could not kiss and touch on other patients, pt replied screaming yeah I ' m going to jail and yeah dope me up. Pt educated that he was not going to jail but that type of behavior will not be tolerated. . . " Review of Patient #FR2 ' s physician orders dated 9/24/2011 at 1305 (1:05 p.m.) revealed an order for 1:1 obs (observation) visual. " Review of Psychiatric Attending Progress notes for Patient #FR2 revealed in part, " 9/24/2011 (no documented time) Manic, Labile. Court female pt (pt) inapprop (inappropriate) / female pt is also allowing it. . . 1:1 obs (one to one observation). 9/26/2011 1015 (10:15 a.m.), fixated on female peer. On 1:1 for safety. . . "

Review of Patient #FR2 ' s Multidisciplinary Integrated Treatment Plan revealed no documented evidence of updating Patient #FR2 ' s treatment plan to include inappropriate sexual behavior and interventions to ensure the behavior did not re-occur.

Observations on 9/26/2011 at 11:37 a.m. revealed Patient #FR2 and Patient #F5 lined up in hallway, side by side.

Observations on 9/26/2011 at 11:49 a.m. revealed Patient #FR2 and Patient #F5 to be seated in chairs next to one another in the Social Work Group.

During a face to face interview on 9/26/2011 at 1510 (3:10 p.m.), Director of Nursing FS2 indicated the treatment plans for Patients #FR2 and #F5 should have been updated with interventions for all staff to follow regarding sexually inappropriateness between the two patients. FS2 indicated Patients #FR2 and #F5 should have been kept a safe distance from one another. FS2 indicated Patient #FR2 and #F5 should not have been allowed to line up next to one another or sit side by side.

Review of Patient #F6 ' s medical record revealed the patient was admitted to the hospital on 9/15/2011 with diagnoses that included Major Depressive Disorder. Further review revealed Nursing Notes dated 9/20 (2011) (no documented time) indicating, " Pt (patient) with 1:1 present overheard stating she will kill her mo (mother) after she gets out. "

Review of Patient #F6 ' s Multidisciplinary Integrated Treatment Plan revealed no documented evidence of identifying homicidal ideation as a problem and no documented interventions to indicate how the staff would address Patient #F6 ' s threat to kill her mother when she got out of the hospital.

This finding was confirmed by Director of Nursing FS2 on 9/23/2011 at 12:40 p.m. in a face to face interview. FS2 indicated he should have performed an assessment of Patient #F6 ' s homicidal ideation at the time a Mental Health Tech reported the threat to him and should have updated the patient ' s Treatment Plan to include Homicidal Ideation.

In a face-to-face interview on 09/26/11 at 3:00pm, Clinical Coordinator FS3 indicated that chart audits had identified that the treatment plans were not being updated or individualized. FS3 further indicated she thought the underlying cause was lack of education. FS3 was not able to provide any education provided to correct the identified lack of knowledge of the nurses regarding the development of and updating of the treatment plans.

Review of the hospital policy titled "Nursing Documentation Guidelines"; policy number 2.14 originated 03/10 and submitted by Clinical Coordinator FS3 as their current policy for nursing documentation, revealed, in part, "...A Registered Nurse shall be responsible for completing the initial patient assessment. The RN must identify problems, measurable and objective goals and interventions for the patient. A nursing plan of care is to be established. An interdisciplinary plan of care is done weekly and nursing is to contribute to development and revision... "

Review of the hospital policy titled, "Treatment Plans, #1.37" presented by the hospital as current revealed in part, "Each patient will have an individualized treatment plan that is based upon assessments of the patient's clinical needs and is reviewed regularly and revised if needed during the course of treatment. It shall be written in a language that is understandable to all staff. . . Include interventions which are services, activities, and programs addressing the patient's problems. . . Include any test results, medical conditions, medical treatment, rehabilitative service, diet limitations, significant lab findings and medications."




25059







25065

Based on record review and interview the hospital failed to develop and implement a system to ensure all employees were assessed for competency before being assigned to patient care as evidenced by: 1) failing to ensure all presently employed staff had been assessed yearly for competency; 2) failing to ensure all agency personnel were oriented and assessed as competent before being assigned to patient care for 7 of 7 agency personnel assigned to patient care at the hospital (RN FS28, RN FS29, RN FS30, RN FS31, MHT FS32, MHT FS33, MHT FS34); 3) failing to ensure all newly hired employees had completed an orientation process and were assessed for competency resulting in nursing staff with no previous psychiatric experience being assigned patient care before completion of an orientation process for 6 of 6 new employee files reviewed and 1 of 1 new employee interviewed regarding competency and experience (FS5, FS10, FS13, FS15, FS16, FS21, FS25); and 4) failing to ensure 2 of 2 MHTs reviewed for competency had prior psychiatric experience and were assessed for competency prior to being assigned to patient care (FS11, FS12). Findings:

1) Failing to ensure all presently employed staff had been assessed yearly for competency:
Review of the Competency Assessment forms used by the hospital to assess staff competency revealed ... "Instructions: ... Each employee will annually complete the self-assessment prior to yearly education, and goals will be developed based on your educational needs. Completion of 100% of the clinical skills for the Annual Validation is required annually".

In a face to face interview on 09/21/11 at 12:15pm, FS4 Representative with contracted Company "a" for Human Resource services revealed the role of Company "a" was to set up a system to organize the hospital's Human Resource (HR) department. Further FS4 indicated at the present time her company is interviewing for a HR employee for the hospital. FS4 indicated her role was to assist in reviewing the personnel files, identifying the missing information, and setting up a tickler file for the hospital, so the person assigned can start communicating to the managers who needs what, i.e. (for example) annual competency, TB (tuberculosis), CPR, etc.. Further FS4 indicated it was not the responsibility of Company "a" to perform any of the education or performance reviews.

In a face to face interview on 09/22/11 at 1:35pm Clinical Coordinator FS3 indicated there were so many issues from the last survey that we addressed the most serious, and we are starting to "chip away" at the others. Further FS3 indicated the hospital had been without a Human Resource person, and the Nursing Department has had to take on that responsibility as well.

2) Failing to ensure all agency personnel were oriented and assessed as competent before being assigned to patient care:
Personnel files could not be submitted by the hospital for RN FS28, RN FS29, RN FS30, RN FS31, MHT FS32, MHT FS33 and MHT FS34 staff from Agency "a".

In a face to face interview on 09/22/11 at 1:35pm Clinical Coordinator FS3 indicated the hospital did not require personnel files for agency personnel. Further FS3 indicated the hospital relied on the agency to provide qualified and competent personnel to the hospital for patient care, which included licensure if appropriate and required training such as CPR (cardiopulmonary resuscitation), ACLS (advanced cardiac life support), and CPI (crisis prevention intervention). FS3 indicated the agency personnel were provided with an abbreviated orientation before being assigned to patient care; however it did not include competency assessment. FS3 could produce no documented evidence the orientations had been performed.

3) Failing to ensure all newly hired employees had completed an orientation process and were assessed for competency:
Review of the Competency Assessment forms used by the hospital to assess staff revealed the employee was expected to complete a self assessment according to the job duties listed in each appropriate job description. Further the employees were to answer and evaluate as follows: Have you ever performed the skill? (Yes/No); Do you feel competent? (Yes/No); Action Plan (1) If you can do the skill independently, (2) if you need to practice the skill and then perform it under supervision, and (3) if you need to learn the skill, practice it, and perform it under supervision; and Discussed/Class with date and initials of the preceptor.

RN FS5
Review of RN FS5's personnel file revealed she was hired on 09/06/11. Review of her application revealed she had no former full-time employment in an inpatient psychiatric facility. Further review revealed FS5 had worked as an agency RN in medical/surgical, telemetry, pediatric, nursery, emergency, long term care, psychiatric, orthopedic, oncology, intensive care, and dialysis units.
Review of RN FS5's "Seclusion & (and) Restraints Competency Check-Sheet" signed by RN SF5 on 09/12/11 and by DON (director of nursing) FS2 on 09/13/11 revealed the column titled "needs improvement" had been marked for "verbalizes specific guidelines/protocol for initiation of seclusion & restraints", "demonstrates use of verbal intervention", and "demonstrates appropriate physical containment skill". Further review revealed no documented evidence that additional training had been provided to RN FS5 on these topics and a repeat competency assessment performed.
Review of RN FS5's "Nurses Competency Checklist" revealed the column titled "evaluation summary: Initials verify that the above named demonstrated the process, performed the skill competently" was dated 09/13/11 and initialed by RN FS14 for all listed items to be assessed. Further review of RN FS5's self-assessment revealed she rated the following items a "2", which meant she needed to practice the skill and then perform it under supervision: death procedures; post mortem care; organ donation policy/procedure; LOPA (Louisiana Organ Procurement Agency); Dr. (doctor) Strong Code (pt. (patient) out of control); applying restraints/removing restraints; seclusion-restraint policy & procedure; prevention and management of aggressive behavior; documentation guidelines for aims, folstein, and 72 hour notice, discharge/transfer, documentation, and patient satisfaction survey; care of the suicidal/homicidal patient; special precautions; therapeutic milieu; legal status related to formal voluntary admission, physician emergency certificate, coroner's emergency certificate, and order of protective custody; and interdisciplinary treatment plans. Further review revealed no documented evidence RN FS5 had practiced the skills and been assessed as competent to perform them.

In a face-to-face interview on 09/22/11 at 1:20pm, Clinical Coordinator FS3 indicated RN FS5 had not had training in crisis prevention intervention, and the next scheduled training was to be conducted in 11/11.

In a face-to-face interview on 09/23/11 at 9:15am, RN FS14 indicated she had worked at the hospital since 03/09/11 as a prn (as needed) nurse and was made a full-time employee in 07/11. FS14 further indicated her orientation consisted of working one day shift and one night shift with another RN for 12 hours each. FS14 confirmed she performed the competency assessment for RN FS5. FS14 indicated she performed her competency assessment of RN FS5 by working two shifts with her. FS14 indicated RN FS5 completed a self-assessment of her skills. FS14 further indicated "a lot of stuff won't happen" during the shift, so she had to rely on what FS5 had documented on her self-assessment. FS14 further indicated she had checked FS5 as being competent with wound care, but she (FS14) based that assessment on FS5's statement of experience on her (FS5) self-assessment. FS14 indicated she did document her assessment of RN FS5's competency with restraint application and community group meeting, when she (FS14) did not observe these skills.

LPN (licensed practical nurse) FS10
In a telephone interview on 09/23/11 at 10:45am, LPN FS10 indicated she received her LPN license in June 2011. She further indicated she began to work at St. James Behavioral Hospital in a PRN position in June 2011 after receiving her nursing license. FS10 indicated she was oriented to her job by following another LPN for 2 day shifts and 1 night shift. FS10 confirmed she had no formal training provided by the hospital and did not have training on crisis prevention intervention.

LPN FS13
Review of LPN FS13's personnel file revealed she was hired 09/01/11. Further review revealed no documented evidence of orientation to her job duties, assessment of competency, and training for and demonstration of restraint application and monitoring.

MHT SF15
Review of the application for employment for MHT (Mental Health Technician) SF15 dated 09/06/11 revealed previous work experience as a cashier and dance instructor. Further review revealed no documented evidence of work experience and/or training as a mental health technician working with psychiatric patients. Review of the personnel file revealed no documented evidence FS15 had attended the CPI course or that she had completed orientation and had been assessed as competent to begin accepting assignments for patient care.

In a face to face interview on 09/22/11 at 1:30pm FS3 Clinical Coordinator verified there was no documented evidence of a completed orientation in the personnel file of FS15. Further FS3 indicated the responsibility of returning the completed Competency Checklist was that of the employee, and if it is not in the personnel file, the employee probably still had it.

MHT SF16
Review of the application for employment for MHT SF16 (no date documented) revealed she graduated from a medical assistant program in 2005 which included 240 hours of externship in a medical facility. Further review of the application revealed SF16's work experience was in retail, secretarial, and the food industry.
Review of the Mental Health Tech Competency Checklist dated 09/15/11 for SF16 revealed the document to be a self-assessment of the employee's skills. Further review revealed SF16 documented that she did not feel competent and needed to learn the skill, practice it and perform it under supervision for the following: orientation of a patient to the hospital; keeping the nurses' station orderly and cleaned; equipment use and care of IVAC thermometer, portable vital signs monitor, Hoyer lift, geri chair; medical emergencies related to the location of the medical equipment, role in Code Blue, Dr. Strong Code (Patient out of control), seclusion and restraint policy and procedure; role in QI (Quality Improvement); keeping hallways clear; body assessment policy; proper mechanic for lifting and moving patients; handwashing procedures; isolation procedures; red-bagging procedures (hazardous waste); cleaning body fluid spills; communicating I&O (Intake and Output) to nurse; obtaining stool and 24-hour urine specimens; providing comfort measures; assist or feed patient as needed; perineal care, applying peri-pad; catheter care; positioning and turning; admission/discharge/transfer of patient; post mortem care; communication at shift change; bed monitor alarms; ensure safe bed position; adjusting bed controls; transporting by wheelchair or stretcher; assisting patient in moving/sitting/ambulating if needed; obtaining supplies; doing laundry; patient pm care; give and remove bedpan/urinals; assist patient to/from bathroom; restraints; seclusion; psychiatric disorders; care of a dependent patient; care of a suicidal patient; care of a hallucinating patient; limit setting; therapeutic millieu; legal status; therapeutic communication; interdisciplinary treatment plan; and age specific competency. SF16 indicated she needed practice and performance under supervision of the following: performance of height, weight, vital signs (blood pressure, pulse, respirations, temperature); telephone use; greeting visitors/patients; taking messages; keeping patients' rooms clean and free of clutter; universal precautions; and labeling specimens. Further review of the competency form dated 09/15/11 revealed all needed skills and tasks were learned, practiced and performed under supervision on 09/19/11 and SF16 was assessed as competent by SF27 MHT.

RN FS21
Review of the personnel file for RN FS21 revealed she (FS21) performed a self assessment of her skills on 09/02/11 and was signed by RN FS6 Charge Nurse on 09/02/11. Further review of the Nurses' Competency Checklist used by the hospital to assess competency revealed no documented evidence a staff member of the hospital had observed RN FS21 for competency.

MHT FS25
Review of the personnel file for MHT FS25 revealed no documented evidence he (FS25) had completed an orientation program as per hospital policy or had been assessed as competent.

4) Failing to ensure 2 of 2 MHTs reviewed for competency had prior psychiatric experience and were assessed for competency prior to being assigned to patient care:
MHT FS11
Review of MHT FS11's personnel file revealed he was hired on 05/13/11. Review of his application revealed the only documented experience in a health care setting was as a driver of clients to a wellness center.
Review of MHT FS11's "Seclusion & Restraints Competency Check-Sheet" signed by MHT FS11 and DON FS2 on 08/11/11 revealed the column titled "needs improvement" was checked for the following skills: verbalizes understanding of seclusion &/or restraint policy; verbalizes specific guidelines/protocol for initiation of seclusion & restraints; continually checks patient circulation and respirations during and after applying restraints; and verbalizes what measures should be initiated if any distress observed. Further review revealed no documented evidence MHT FS11 was re-educated and assessed as competent for the skills needing improvement.
Review of MHT FS11's "Observation Test" for the observation written exam revealed FS11 scored a 75% (per cent), while hospital policy required an 85% pass rate. Further review revealed no documented evidence MHT FS11 had been re-educated on the observation policy and the test repeated with a pass score of at least 85%.
Review of MHT FS11's entire personnel file revealed no documented evidence that a "Mental Health Tech Competency Checklist" had been completed.

MHT FS12
Review of MHT FS12's personnel file revealed her last employment in health care was in 2003 as a certified nursing assistant in a nursing home. Further review revealed no documented evidence of experience in a psychiatric setting.
Review of MHT FS12's "Mental Health Tech Competency Checklist" revealed FS12 completed a self-assessment and documented that she felt competent to perform all skills. Further review revealed FS12 had never applied or removed restraints, but she documented that she felt competent to perform these skills. Further review revealed no documented evidence that MHT FS12 had been assessed for competency for any of the listed skills. Further review revealed the front page of the checklist was signed by Clinical Coordinator FS3 on 08/11/11 as the evaluator.

Review of the hospital policy titled "Observation Precautions", policy number 8.21a revised 08/11/11 and submitted by Administrator FS1 as the current policy for observation precautions, revealed, in part, "...e. Training: 1. All current employees shall be oriented to the policies that define the responsibilities of patient observation. 2. Within 30 days of employment and when possible, prior to coming in contact with patients, new employees shall receive instructions on these policies and procedures. 3. Documentation shall include the Observation Written Exam with a pass rate of 85%...".

Review of the policy titled "Selection and Hiring of Personnel" no date of approval, review of revision, submitted as the one currently in use revealed..... "Hiring: 11. All new employees (to include both clinical and non-clinical employees) must participate in an orientation program, which will include a general orientation component, as well as a clinical component specifically geared to the job description and role of the applicant within the hospital structure".

Review of Policy 9.8 titled "Competency Assessment", no date of approval, review of revision, submitted as the one currently in use revealed..... "Orientation and Introductory Period: 2. All personnel will be assessed by their designated preceptor while performing required skills for their individual job description in accordance with the appropriate Skills and Inventory and Orientation Checklist. Upon successful completion of the requirements of these documents, the employee's orientation and introductory period shall be deemed complete".



25059




25065




26351

Based on record review and interview the hospital failed to ensure medications were administered as per physicians orders for 2 of 11 sampled patients and failed to ensure medications were administered as per hospital policy for 1 of 1 medication administration announced on the loud speaker as beginning at 10:10 a.m. for 9:00 a.m. scheduled medications (9/22/2011). Findings:

Review of patient #F3's medical record revealed the patient was admitted to the hospital on 9/19/2011 with diagnoses that included Major Depressive Disorder. Further review revealed an order for Risperdal 0.5 milligrams tab one by mouth two times per day dated 9/20/2011 at 1600 (4:00 p.m.). Review of Patient #F3's Medication Administration Record revealed no documented evidence that Patient #F3 was administered Risperdal on 9/20/2011 at 2100 (9:00 p.m.) as ordered.

During a face to face interview on 9/21/2011 at 1615 (4:15 p.m.), Registered Nurse SF6 confirmed the absence of any documented evidence that Patient #F3 received Risperdal 0.5 milligrams at 9:00 p.m. on 9/20/2011 as ordered by the patient's physician.

Review of Patient #F8's medical record revealed the patient was admitted to the hospital on 9/20/2011 with diagnoses that included Major Depressive Disorder. Review of Patient #F8's physician's orders dated 9/20/2011 at 5:35 (a.m./p.m. not specified) revealed an order to Continue Premarin 0.3 milligrams every day. Further review revealed a physician's order for Patient #F8 dated 9/20 (2011) at 6p (6:00 p.m.) for Remeron 15 milligrams by mouth every hour sleep. Review of Patient #F8's Medication Administration Record (MAR) revealed a page dated 9/20/2011 with a notation next to the 9:00 a.m. scheduled dose of Premarin as "not available". Further review revealed documentation indicating Remeron was administered to the patient on 9/20/2011 at 21 (9:00 p.m.). Review of Patient #F8's entire medical record revealed no documented MAR for the date of 9/21/2011.

During a face to face interview on 9/22/2011 at 9:55 a.m., Licensed Practical Nurse FS7 confirmed the absence of any MAR for Patient #F8 on the date of 9/21/2011. FS7 indicated that it appeared to her as if the MAR for 9/20/2011 had been used for both days: 9/20/2011 and 9/21/2011. FS7 indicated the first MAR was often used for 2 days while awaiting a typed MAR from the pharmacy. FS7 indicated Patient #F8 had been admitted on 9/20/2011 at 5:30 p.m. therefore she would assume the notation of "Not available" for Premarin was meant for 9/21/2011. FS7 further indicated she was not sure if Remeron had been given on 9/20/2011 or 9/21/2011.

During a face to face interview on 9/22/2011 at 10:00 a.m., the above findings were reviewed with Clinical Coordinator FS3. FS3 indicated the documentation was confusing.

Review of the hospital policy titled, "Medication Administration, #12.14" presented by the hospital as current revealed in part, "Observe the five rights in giving medications: The right patient, the right medicine, the right time, the right dose, and the right method of administration. . . "

Review of the hospital policy titled, "Administration of medications using the MAR system

Observation on 09/22/11 at 10:10am (1 hour and 10 minutes past the scheduled 9:00 a.m. medication administration time) revealed an announcement was made over the hospital speaker system for patients to "line up for med pass".

Observation on 09/22/11/at 10:30am (1 hour and 30 minutes past the scheduled 9:00 a.m. medication administration time) revealed an announcement was made over the hospital speaker system by DON (director of nursing) FS2 of "if anyone has not received meds (medications), line up at the nursing station".

Review of 23 patients ' Medication Administration Records for the date of 9/22/2011 with medications due at 9:00 a.m. (copied and presented to surveyors on 9/22/2011 at 1630/4:30 p.m.) revealed 4 of the 19 patients to have a line drawn through the 9:00 a.m. scheduled time with initials next to the time. Further review revealed 19 of the Medication Administration Records to have no documentation at the 9:00 scheduled dosages to indicate not given (circle around medication) or given (line through medication with initials) or the correct time of administration (7 ? hours after the scheduled administration time of 9:00 a.m.).

Review of the hospital policy titled, " Administration of Medications Using the MAR (Medication Administration Record) System, #12.2 " presented by the hospital as current policy revealed in part, " Charting is done immediately after medication is given by initialing the appropriate square of the MAR. "

Review of the hospital policy titled, " Standard Hours for Routine Medication, #12.23 " presented by the hospital as current policy revealed in part, " Medications may be given within 60 minutes before or after the hour ordered. "







25059




25065

Based on observation, record review, and interview the hospital failed to ensure all entries in the medical record were accurate as evidenced by two Mental Health Techs (MHT) assigned the observation of two suicidal patients every fifteen minutes documenting the patients had been observed in the medical record after both patients (#F1 and #F2) were observed being left unmonitored in their rooms for 46 minutes and 60 minutes respectively. Findings:

Patient #F1
Review of the medical record for Patient #F1 revealed a 20 year old male admitted to the hospital on 08/16/11 per a PEC (Physician's Emergency Certificate) with the diagnosis of SI (Suicidal Ideation) and polysubstance abuse. Review of the Physician's Admit Orders dated 08/16/11 revealed Patient #F1 was ordered to be placed on suicide precautions (monitoring every 15 minutes).

Observations on 09/21/11 at 11:01am through 11:47am in the hallway outside of Patient #F1's room revealed he (#F1) remained in his room during this time with the door closed until 11:20am, when the housekeeper entered and exited the room and left the door with a small crack in it. Further observation revealed no staff member came to his room during the time period of 11:01am through 11:47am.

Review of the "Patient 15"(minute) &/or 30" Observation For AM Shift" dated 09/21/11 for Patient #F1 revealed the following: 11:00am 10/20/21/12 (Monitoring/Awake/Cooperative/ in Group; 11:15am 10/20/21 (Monitoring/Awake/Cooperative); 11:30am (Monitoring/Awake/Cooperative); 11:45am (Monitoring/Awake/Cooperative).

Mental Health Technician SF12 declined to return phone calls by the hospital per the Clinical Coordinator SF3 for an interview. Review of the "Employee Reprimand/Disciplinary Report" for MHT SF12 dated 09/27/11 revealed SF12 was suspended for two days without pay for not performing rounds on a patient and falsifying the observations in the medical record.

Review of Policy 10.5 titled "Entries into the Clinical Record" last revised 03/11 and submitted as the one currently in use revealed ...."Policy: 1. Documentation in the clinical record is detailed and accurate and reflects the care of services provided".

Patient #F2
Review of Patient #F2's medical record revealed she was admitted on 09/20/11 with a diagnosis of Major Depressive Disorder. Further review revealed Patient #F2's medical problems included Hypertension, Hyperlipidemia, Mitral Valve Prolapse, Anemia, and Osteoarthritis. Further review revealed she was PEC'd (physician's emergency certificate) on 09/20/11 secondary to being gravely disabled and unable to seek voluntary admission. Review of Patient #F2's "Physician Orders" revealed a telephone order received on 09/21/11 at 0100 (1:00am) by RN (registered nurse) FS14 from Medical Director FS17 for suicide precautions. Further review revealed no documented evidence of an order for the level of observation for Patient #F2.

Observation on 09/21/11 at 10:47am revealed Patient #F2 was lying in her bed near the window in room "a" with the door to the room with an opening that allowed one to view the patient lying in the bed near the window. Further observation revealed no staff member was present in the room or in the hall outside room "a".

Observation on 09/21/11 at 10:58am (with continuous observation since 10:47am) revealed a surveyor and Administrator FS1 entered room "a" to inspect the windows and closed the door upon exiting the room.

Continuous observation on 09/21/11 from 10:47am through 11:47am revealed Patient #F2 never left her room (room "a"), and no nurse or MHT (mental health tech) entered room "a" to observe Patient #F2 every 15 minutes as required for suicide precautions per hospital policy.
Review of Patient #F2's "Patient 15" (minutes) & (and)/or 30" Observation Form AM Shift" for 09/21/11 revealed no documented evidence of the type of observation ordered. Further review revealed MHT SF11 documented from 10:45am through 12:45pm that Patient #F2's staff intervention was monitoring, and her behaviors were asleep with respirations visible while in her room.

In a telephone interview on 09/23/11 at 9:53am, MHT FS11 confirmed that he was the MHT assigned to observe Patient #F2 on 09/21/11. FS11 indicated Patient #F2 was lying in her bed most of that morning. He further indicated Patient #F2 did not attend group on the morning of 09/21/11, because she was in her room sleeping. FS11 indicated if a patient he was assigned to observe was in his/her room, he (FS11) would go to the room to observe the patient. When MHT FS11 was told that the continuous observation by the surveyor on 09/21/11 from 10:47am through 11:47am revealed no observation that he had checked on Patient #F2 while she was in her room, FS11 indicated he could not remember if he was maybe assisting the physician during that time. FS11 confirmed he did not transfer the observation of Patient #F2 to another MHT at any time. He could offer no explanation for not making observations every 15 minutes but documenting that he did observe Patient #F2 to be asleep in her room.

In a face-to-face interview on 09/23/11 at 11:05am, DON (director of nursing) FS2 and Clinical Coordinator FS3 could offer no explanation when told that continuous observations for one hour revealed no evidence that MHT FS11 made every 15 minutes observations but documented that they were done for Patient #F2.




20638




26351

Based on record review and interview the hospital failed to develop a system for ensuring all employees were screened for TB annually as evidenced by having an inaccurate TB Tracking List which included employees no longer employed at the hospital and no documented evidence of current TB skin testing for of 126 employees. Findings:

Review of the Employee List submitted by the hospital as the tool used to track the date of the employee's current TB skin test and the results. Further review revealed the document had last been updated September 2011.

In a face to face interview on 09/21/11 at 12:15pm FS4 indicated Company "a" was responsible for compiling the information submitted by the hospital. Further FS indicated she was in the process of setting up a "tickler" type system for the person whom the hospital hires for their Human Resource position to alert him/her on a monthly basis those employees in need of TB screening.

In a face to face interview on 09/26/11 at 2:00pm RN FS2 DON (Director of Nursing) indicated the employee list for TB is inaccurate and contains the names of employees that have not worked in the hospial for a long time. FS2 could not explain why accurate information was not provided to the consulting Human Resource company responsible for developing hospital data.











26458

Based on record review and interview, the hospital failed to meet the Condition of Participation of Special Provisions Applying to Psychiatric Hospitals by failing to be in compliance with the hospital Conditions of Participation specified in ?482.1 through ?482.23 and ?482.25 through ?482.57 by failing to meet the CoP of Nursing Services at ?482.23 (See findings at A0385, A0395, A0396, A0397 and A0404).






26458

Based on record review and interview, the Psychiatric hospital failed to meet the Conditions of Participation specified in ?482.1 through ?482.23 and ?482.25 through ?482.57 by failing to be in compliance with the Hospital's Condition of Participation requirements for Nursing Services at ?482.23 (See findings at A0385, A0395, A0396, A0397 and A0404).







26458

B0122
Based on record review and interview the hospital failed to: 1) ensure discharge criteria and long term goals were developed based on the diagnosis and attainable goals for 1 of 11 sampled patients (#F1) and 2) failed to implement the treatment plan by admitting a suicidal patient on a Friday and discharging him on the Monday without any documented evidence of daily therapy group with the social worker or attendance at group therapy for coping skills, medication education, and communication skills for 1 of 11 sampled patients (#F7). Findings:

1) ensure discharge criteria and long term goals were developed based on the diagnosis and attainable goals
Review of the medical record for Patient #F1 revealed a 20 year old male admitted on 08/16/11 per PEC (Physician ' s Emergency Certificate) for suicidal ideation and paranoia.
Review of the Initial Psychiatric Evaluation for Patient #F1 dated 08/17/11 revealed he had a history of depression and was receiving psychiatric treatment with his last appointment being two weeks ago. #F1 ' s social history revealed a 9th grade education, a girlfriend currently on drugs, and the patient himself a chronic marijuana user with use of mescaline two weeks ago. Further review of the Psychiatric Evaluation revealed #F1 reported he had sexually abused his younger brother, two female cousins, and a neighbor when he was " 4-5 " years of age and considered himself " sexually addicted " .

Review of the Multidisciplinary Integrated Treatment Plan dated 08/16/11 for Patient #F1 revealed the discharge criteria and long term goals were to " eliminate acute, reactive, psychotic symptoms and return to normal functioning in effect, thinking and relating " . Further review revealed the patient (#F1) was still hospitalized as of 09/28/11 with no change in the goals, discharge criteria or intervention.

In a face to face interview on 09/28/11 at 2:00pm RN FS3 Clinical Coordinator indicated the Social Worker was the person responsible for developing and documenting the goals and discharge criteria on the Multidisciplinary Treatment Plan. Further FS3 indicated she had identified problems with the discharge criteria and goal setting with the Social Worker, FS3, concerning the use of the word normal instead of specific descriptions.

2) failed to implement the treatment plan by admitting a suicidal patient
Review of the medical record for Patient #F7 revealed 32 year old male admitted to the hospital on 09/19/11 under an Order for Protective Custody (OPC) because due to anxiety, manic depression and threatening to kill his father-in-law and himself. Further review of the OPC revealed #F7 had texted a suicide note which indicated he was also going to burn his father-in-law ' s house down. #F7 was PEC (Physician ' s Emergency Certificate) on 09/19/11 for suicidal thoughts. Further review revealed #F7 was PEC ' d on 09/19/11 and CEC ' d (Coroner ' s Emergency Certificate) on 09/20/11 for suicidal thoughts and increased depression.

Review of the Initial Psychiatric Evaluation dated 09/20/11 revealed #F7 treatment and plan of care was involvement in all therapies here all aimed at stabilizing and improving his mood, decreasing his anxiety, improving his insight, coping skills, and knowledge deficits regarding his medications and mental illness. He will be free of suicidal ideations for at least 72 hours prior to discharge. Estimated Length of Stay: 7-10 days.

Review of the Multidisciplinary Integrated Treatment Plan dated 09/19/11 for Patient #F7 revealed the following problems, responsible discipline, interventions, expected date to achieve goal and date actually achieved: Depression with Suicidal Ideation: (RN) Patient will identify strategies for coping when feeling suicidal, goal date 09/26/11 with interventions of administer and monitor meds (medication), staff encourage mediation compliance and re-direct as needed, no documented date goal achieved; (Social Worker) Patient will verbalize and exhibit decrease depression and anxiety symptoms, presenting with brighter affect, hope and positive statements about the future, verbalize no suicidal or homicidal ideations, date to achieve 09/26/11, Patient will attend therapy group with social worker daily (coping skills, triggers, communications, etc) and 1:1 therapy provided as needed, achieved on 09/22/11 (the date of discharge); and (Activity Therapist) Promote positive thoughts and behaviors through therapeutic groups daily, goal date 09/26/11, Therapeutic groups of leisure/social skills, task skills, coping skills, and expression, no documented date achieved.

Review of Patient #F7 ' s medical record revealed o documented evidence the patient had attended any group therapy. Further review revealed MD FS17 performed the psychiatric assessment on 09/20/11 and then saw the patient again on 09/22/11 at which time he (FS17) determined #F7 ready for discharge.





20638




26351

Based on record review and interview the Hospital failed to meet the Condition of Participation of Special Staff Requirements for Psychiatric Hospital's as evidenced by:

1) failing to ensure all presently employed staff had been assessed yearly for competency (See findings at A0397);

2) failing to ensure all agency personnel were oriented and assessed as competent before being assigned to patient care for 7 of 7 agency personnel assigned to patient care at the hospital (RN FS28, RN FS29, RN FS30, RN FS31, MHT FS32, MHT FS33, MHT FS34) (See findings at A0397);

3) failing to ensure all newly hired employees had completed an orientation process and were assessed for competency resulting in nursing staff with no previous psychiatric experience being assigned patient care before completion of an orientation process for 6 of 6 new employee files reviewed and 1 of 1 new employee interviewed regarding competency and experience (FS5, FS10, FS13, FS15, FS16, FS21, FS25) (See findings at A0397); and

4) failing to ensure 2 of 2 MHTs reviewed for competency had prior psychiatric experience and were assessed for competency prior to being assigned to patient care (FS11, FS12) (See findings at A0397).




26458

Based on record review and interview the hospital failed to develop and implement a system to ensure all employees were assessed for competency before being assigned to patient care as evidenced by: 1) failing to ensure all presently employed staff had been assessed yearly for competency; 2) failing to ensure all agency personnel were oriented and assessed as competent before being assigned to patient care for 7 of 7 agency personnel assigned to patient care at the hospital (RN FS28, RN FS29, RN FS30, RN FS31, MHT FS32, MHT FS33, MHT FS34); 3) failing to ensure all newly hired employees had completed an orientation process and were assessed for competency resulting in nursing staff with no previous psychiatric experience being assigned patient care before completion of an orientation process for 6 of 6 new employee files reviewed and 1 of 1 new employee interviewed regarding competency and experience (FS5, FS10, FS13, FS15, FS16, FS21, FS25); and 4) failing to ensure 2 of 2 MHTs reviewed for competency had prior psychiatric experience and were assessed for competency prior to being assigned to patient care (FS11, FS12). Findings:

1) Failing to ensure all presently employed staff had been assessed yearly for competency:
Review of the Competency Assessment forms used by the hospital to assess staff competency revealed ... "Instructions: ... Each employee will annually complete the self-assessment prior to yearly education, and goals will be developed based on your educational needs. Completion of 100% of the clinical skills for the Annual Validation is required annually".

In a face to face interview on 09/21/11 at 12:15pm, FS4 Representative with contracted Company "a" for Human Resource services revealed the role of Company "a" was to set up a system to organize the hospital's Human Resource (HR) department. Further FS4 indicated at the present time her company is interviewing for a HR employee for the hospital. FS4 indicated her role was to assist in reviewing the personnel files, identifying the missing information, and setting up a tickler file for the hospital, so the person assigned can start communicating to the managers who needs what, i.e. (for example) annual competency, TB (tuberculosis), CPR, etc.. Further FS4 indicated it was not the responsibility of Company "a" to perform any of the education or performance reviews.

In a face to face interview on 09/22/11 at 1:35pm Clinical Coordinator FS3 indicated there were so many issues from the last survey that we addressed the most serious, and we are starting to "chip away" at the others. Further FS3 indicated the hospital had been without a Human Resource person, and the Nursing Department has had to take on that responsibility as well.

2) Failing to ensure all agency personnel were oriented and assessed as competent before being assigned to patient care:
Personnel files could not be submitted by the hospital for RN FS28, RN FS29, RN FS30, RN FS31, MHT FS32, MHT FS33 and MHT FS34 staff from Agency "a".

In a face to face interview on 09/22/11 at 1:35pm Clinical Coordinator FS3 indicated the hospital did not require personnel files for agency personnel. Further FS3 indicated the hospital relied on the agency to provide qualified and competent personnel to the hospital for patient care, which included licensure if appropriate and required training such as CPR (cardiopulmonary resuscitation), ACLS (advanced cardiac life support), and CPI (crisis prevention intervention). FS3 indicated the agency personnel were provided with an abbreviated orientation before being assigned to patient care; however it did not include competency assessment. FS3 could produce no documented evidence the orientations had been performed.

3) Failing to ensure all newly hired employees had completed an orientation process and were assessed for competency:
Review of the Competency Assessment forms used by the hospital to assess staff revealed the employee was expected to complete a self assessment according to the job duties listed in each appropriate job description. Further the employees were to answer and evaluate as follows: Have you ever performed the skill? (Yes/No); Do you feel competent? (Yes/No); Action Plan (1) If you can do the skill independently, (2) if you need to practice the skill and then perform it under supervision, and (3) if you need to learn the skill, practice it, and perform it under supervision; and Discussed/Class with date and initials of the preceptor.

RN FS5
Review of RN FS5's personnel file revealed she was hired on 09/06/11. Review of her application revealed she had no former full-time employment in an inpatient psychiatric facility. Further review revealed FS5 had worked as an agency RN in medical/surgical, telemetry, pediatric, nursery, emergency, long term care, psychiatric, orthopedic, oncology, intensive care, and dialysis units.
Review of RN FS5's "Seclusion & (and) Restraints Competency Check-Sheet" signed by RN SF5 on 09/12/11 and by DON (director of nursing) FS2 on 09/13/11 revealed the column titled "needs improvement" had been marked for "verbalizes specific guidelines/protocol for initiation of seclusion & restraints", "demonstrates use of verbal intervention", and "demonstrates appropriate physical containment skill". Further review revealed no documented evidence that additional training had been provided to RN FS5 on these topics and a repeat competency assessment performed.
Review of RN FS5's "Nurses Competency Checklist" revealed the column titled "evaluation summary: Initials verify that the above named demonstrated the process, performed the skill competently" was dated 09/13/11 and initialed by RN FS14 for all listed items to be assessed. Further review of RN FS5's self-assessment revealed she rated the following items a "2", which meant she needed to practice the skill and then perform it under supervision: death procedures; post mortem care; organ donation policy/procedure; LOPA (Louisiana Organ Procurement Agency); Dr. (doctor) Strong Code (pt. (patient) out of control); applying restraints/removing restraints; seclusion-restraint policy & procedure; prevention and management of aggressive behavior; documentation guidelines for aims, folstein, and 72 hour notice, discharge/transfer, documentation, and patient satisfaction survey; care of the suicidal/homicidal patient; special precautions; therapeutic milieu; legal status related to formal voluntary admission, physician emergency certificate, coroner's emergency certificate, and order of protective custody; and interdisciplinary treatment plans. Further review revealed no documented evidence RN FS5 had practiced the skills and been assessed as competent to perform them.

In a face-to-face interview on 09/22/11 at 1:20pm, Clinical Coordinator FS3 indicated RN FS5 had not had training in crisis prevention intervention, and the next scheduled training was to be conducted in 11/11.

In a face-to-face interview on 09/23/11 at 9:15am, RN FS14 indicated she had worked at the hospital since 03/09/11 as a prn (as needed) nurse and was made a full-time employee in 07/11. FS14 further indicated her orientation consisted of working one day shift and one night shift with another RN for 12 hours each. FS14 confirmed she performed the competency assessment for RN FS5. FS14 indicated she performed her competency assessment of RN FS5 by working two shifts with her. FS14 indicated RN FS5 completed a self-assessment of her skills. FS14 further indicated "a lot of stuff won't happen" during the shift, so she had to rely on what FS5 had documented on her self-assessment. FS14 further indicated she had checked FS5 as being competent with wound care, but she (FS14) based that assessment on FS5's statement of experience on her (FS5) self-assessment. FS14 indicated she did document her assessment of RN FS5's competency with restraint application and community group meeting, when she (FS14) did not observe these skills.

LPN (licensed practical nurse) FS10
In a telephone interview on 09/23/11 at 10:45am, LPN FS10 indicated she received her LPN license in June 2011. She further indicated she began to work at St. James Behavioral Hospital in a PRN position in June 2011 after receiving her nursing license. FS10 indicated she was oriented to her job by following another LPN for 2 day shifts and 1 night shift. FS10 confirmed she had no formal training provided by the hospital and did not have training on crisis prevention intervention.

LPN FS13
Review of LPN FS13's personnel file revealed she was hired 09/01/11. Further review revealed no documented evidence of orientation to her job duties, assessment of competency, and training for and demonstration of restraint application and monitoring.

MHT SF15
Review of the application for employment for MHT (Mental Health Technician) SF15 dated 09/06/11 revealed previous work experience as a cashier and dance instructor. Further review revealed no documented evidence of work experience and/or training as a mental health technician working with psychiatric patients. Review of the personnel file revealed no documented evidence FS15 had attended the CPI course or that she had completed orientation and had been assessed as competent to begin accepting assignments for patient care.

In a face to face interview on 09/22/11 at 1:30pm FS3 Clinical Coordinator verified there was no documented evidence of a completed orientation in the personnel file of FS15. Further FS3 indicated the responsibility of returning the completed Competency Checklist was that of the employee, and if it is not in the personnel file, the employee probably still had it.

MHT SF16
Review of the application for employment for MHT SF16 (no date documented) revealed she graduated from a medical assistant program in 2005 which included 240 hours of externship in a medical facility. Further review of the application revealed SF16's work experience was in retail, secretarial, and the food industry.
Review of the Mental Health Tech Competency Checklist dated 09/15/11 for SF16 revealed the document to be a self-assessment of the employee's skills. Further review revealed SF16 documented that she did not feel competent and needed to learn the skill, practice it and perform it under supervision for the following: orientation of a patient to the hospital; keeping the nurses' station orderly and cleaned; equipment use and care of IVAC thermometer, portable vital signs monitor, Hoyer lift, geri chair; medical emergencies related to the location of the medical equipment, role in Code Blue, Dr. Strong Code (Patient out of control), seclusion and restraint policy and procedure; role in QI (Quality Improvement); keeping hallways clear; body assessment policy; proper mechanic for lifting and moving patients; handwashing procedures; isolation procedures; red-bagging procedures (hazardous waste); cleaning body fluid spills; communicating I&O (Intake and Output) to nurse; obtaining stool and 24-hour urine specimens; providing comfort measures; assist or feed patient as needed; perineal care, applying peri-pad; catheter care; positioning and turning; admission/discharge/transfer of patient; post mortem care; communication at shift change; bed monitor alarms; ensure safe bed position; adjusting bed controls; transporting by wheelchair or stretcher; assisting patient in moving/sitting/ambulating if needed; obtaining supplies; doing laundry; patient pm care; give and remove bedpan/urinals; assist patient to/from bathroom; restraints; seclusion; psychiatric disorders; care of a dependent patient; care of a suicidal patient; care of a hallucinating patient; limit setting; therapeutic millieu; legal status; therapeutic communication; interdisciplinary treatment plan; and age specific competency. SF16 indicated she needed practice and performance under supervision of the following: performance of height, weight, vital signs (blood pressure, pulse, respirations, temperature); telephone use; greeting visitors/patients; taking messages; keeping patients' rooms clean and free of clutter; universal precautions; and labeling specimens. Further review of the competency form dated 09/15/11 revealed all needed skills and tasks were learned, practiced and performed under supervision on 09/19/11 and SF16 was assessed as competent by SF27 MHT.

RN FS21
Review of the personnel file for RN FS21 revealed she (FS21) performed a self assessment of her skills on 09/02/11 and was signed by RN FS6 Charge Nurse on 09/02/11. Further review of the Nurses' Competency Checklist used by the hospital to assess competency revealed no documented evidence a staff member of the hospital had observed RN FS21 for competency.

MHT FS25
Review of the personnel file for MHT FS25 revealed no documented evidence he (FS25) had completed an orientation program as per hospital policy or had been assessed as competent.

4) Failing to ensure 2 of 2 MHTs reviewed for competency had prior psychiatric experience and were assessed for competency prior to being assigned to patient care:
MHT FS11
Review of MHT FS11's personnel file revealed he was hired on 05/13/11. Review of his application revealed the only documented experience in a health care setting was as a driver of clients to a wellness center.
Review of MHT FS11's "Seclusion & Restraints Competency Check-Sheet" signed by MHT FS11 and DON FS2 on 08/11/11 revealed the column titled "needs improvement" was checked for the following skills: verbalizes understanding of seclusion &/or restraint policy; verbalizes specific guidelines/protocol for initiation of seclusion & restraints; continually checks patient circulation and respirations during and after applying restraints; and verbalizes what measures should be initiated if any distress observed. Further review revealed no documented evidence MHT FS11 was re-educated and assessed as competent for the skills needing improvement.
Review of MHT FS11's "Observation Test" for the observation written exam revealed FS11 scored a 75% (per cent), while hospital policy required an 85% pass rate. Further review revealed no documented evidence MHT FS11 had been re-educated on the observation policy and the test repeated with a pass score of at least 85%.
Review of MHT FS11's entire personnel file revealed no documented evidence that a "Mental Health Tech Competency Checklist" had been completed.

MHT FS12
Review of MHT FS12's personnel file revealed her last employment in health care was in 2003 as a certified nursing assistant in a nursing home. Further review revealed no documented evidence of experience in a psychiatric setting.
Review of MHT FS12's "Mental Health Tech Competency Checklist" revealed FS12 completed a self-assessment and documented that she felt competent to perform all skills. Further review revealed FS12 had never applied or removed restraints, but she documented that she felt competent to perform these skills. Further review revealed no documented evidence that MHT FS12 had been assessed for competency for any of the listed skills. Further review revealed the front page of the checklist was signed by Clinical Coordinator FS3 on 08/11/11 as the evaluator.

Review of the hospital policy titled "Observation Precautions", policy number 8.21a revised 08/11/11 and submitted by Administrator FS1 as the current policy for observation precautions, revealed, in part, "...e. Training: 1. All current employees shall be oriented to the policies that define the responsibilities of patient observation. 2. Within 30 days of employment and when possible, prior to coming in contact with patients, new employees shall receive instructions on these policies and procedures. 3. Documentation shall include the Observation Written Exam with a pass rate of 85%...".

Review of the policy titled "Selection and Hiring of Personnel" no date of approval, review of revision, submitted as the one currently in use revealed..... "Hiring: 11. All new employees (to include both clinical and non-clinical employees) must participate in an orientation program, which will include a general orientation component, as well as a clinical component specifically geared to the job description and role of the applicant within the hospital structure".

Review of Policy 9.8 titled "Competency Assessment", no date of approval, review of revision, submitted as the one currently in use revealed..... "Orientation and Introductory Period: 2. All personnel will be assessed by their designated preceptor while performing required skills for their individual job description in accordance with the appropriate Skills and Inventory and Orientation Checklist. Upon successful completion of the requirements of these documents, the employee's orientation and introductory period shall be deemed complete".




26458