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Based on record review, complaint investigation, and interview the facility failed to ensure the patient participated in the development and implementation of his/her treatment plan for 1 of 8 patients in the survey sample (Patient #5).

The findings included:

Review of Patient #5's medical record (paper and electronic) revealed the patient was admitted on January 18, 2013 and discharged on February 4, 2013; a seventeen (17)-day hospital stay. Review of Patient #5's medical record and EMR (electronic medical record) did not reveal the interdisciplinary treatment team had met with the patient to include the patient in the development of his/her treatment plan. Patient #5's medical record and EMR did not provide evidence of patient involvement in weekly or every 5-7 day updates to his/her treatment plan. Patient #5's medical record and EMR did not document the patient's refusal or inability to participate in the development and implementation of his/her treatment plan.

Review of the facility's policy "Interdisciplinary Treatment Planning Inpatient/Residential" read, "The clinical staff of [The name of the facility] conducts regular interdisciplinary treatment team sessions that integrate the information from various assessments as well as identify and assign priorities to ensure that they are appropriate to the treatment needs. The treatment team consist of the patient/resident, physician, nurse, social worker, case manager, ... activity therapist ... Plans are problem focused and developed in collaboration with the patient/resident and the family/significant other (with written consent). The treatment plan is reviewed and updated every 5-7 days then weekly thereafter on inpatient ..."

An interview was conducted on June 11, 2013 at 1:03 p.m., with Staff #16. Staff #16 reported treatment team sessions were held on every patient every seven (7) days. The surveyor requested copies of Patient #5's treatment team session or any updates to Patient #5's treatment plan.

During the interview conducted with Staff #16 on June 12, 2013 at 8:37 a.m., Staff #16 reported the case manager would provide Patient #5's treatment plans to the surveyor.

An interview was conducted on June 12, 2013 at 10:28 a.m., with Staff #7. Staff #7 stated, "I reviewed [name of Patient #5]'s record we didn't conduct any treatment team sessions." Staff #7 reported during Patient #5's 17-day stay no treatment sessions were conducted per the facility's policy of "every 5-7 days." Staff #7 stated, "Sometimes we get busy, they were not done." Staff #7 stated, "We were performing morning Huddle meetings, but the Docs complained it was taking up too much time. So we have stopped doing the Huddles recently." Staff #7 reported the patients were not included in the morning Huddles, which were discussions related to patient activities and behaviors within the milieu.

Based on document review and interviews the facility failed to maintain a complete and accurate medical record for 5 of 10 patients' (Patient #1, 4, 5, 6, and 7) medical records reviewed.

The findings include:
Patient #1's medical record was reviewed on 6/11/13. Patient #1 was admitted to the facility on 6/4/13 and placed on close observation.
Staff Member #16 stated, "The Medical Screening Information Nursing Assessment Part I is to be completed by the Registered Nurse (RN) on the unit the patient is admitted to." The sections of the Medical Screening Information Nursing Assessment Part I that pertain to falls, injuries, pain, functioning, medical illness, special needs, physical screening, current medications and infectious diseases were all blank. There is no RN signature on the form.
The physician signed the medication reconciliation clinical Summary Report dated 6/4/13 as 7/10/13, which date has not occurred.
The Observation Flow Sheet for June 4, 5, 6, 7, 8 and 9, 2013 documented the following.
6/4/13 from 2340 to 6/5/13 0650 (7 hours and 10 minutes) the same staff initials appear on the Q 10 (every 10) minute checks with no breaks. On 6/5/13 from 0740 to 1430 (7 hours)the same staff initials appear on the Q 10 (every 10) minute checks with no breaks. On 6/6/13 from 2340 to 6/7/13 0650 (7 hours and 10 minutes) the same staff initials appear on the Q 10 (every 10) minute checks with no breaks. On 6/7/13 from 2340 to 6/8/13 0650 (7 hours and 10 minutes) the same staff initials appear on the Q 10 (every 10) minute checks with no breaks.

Patient #7's medical record was reviewed on 6/12/13. Patient #7 was admitted on 6/9/13 at 12:03 P.M. via a TDO (Temporary Detention Order) and placed on close observation, suicidal precautions, danger to others and elopement precautions. The Observation Flow Sheet for June 9, 10, 11 and 12, 2013 were reviewed as a part of the medical record review. On June 9, 2013 from 1540 to 2330 the same staff initials appear on the Q 10 (every 10) minute checks with no breaks. Also on 6/9/13 from 1630 to 1650 it appears the location of the patient has been altered with no initials and date of the alteration. The word Patio appears to have been written over something else. Staff Member #16 reviewed the medical record and stated, "It appears to have been altered."

Also while making observation on ITP (Intensive Treatment Program) on 6/11/13 the Observation Flow Sheets for five random patients on precautions were reviewed. The staff member initialing the observations left the unit at 12 noon and did not return until after 1230. The same staff member initialed observations of the 5 patients on 1210, 1220 and 1230. All 5 patients were on suicide, homicide and elopement precautions as indicated on the Observation Flow Sheets.

The policy Correcting or Amending Medical Records by Nursing and Clinical Staff with a review date of 06/2013 was provided by Staff Member #4. The policy indicates under the section titled Errors in the Paper Record section a: Draw a single, thin line through each line of the inaccurate material, making certain it is still legible. b: Indicate "error", along with the current date and your initials.

Based on observations and interviews the facility staff failed to ensure there was a mechanism in place for patients to call for help in the restroom of the Assessment/Admissions Department and failed to ensure every door in the facility had a unique identifying number in the event of an emergency.

The findings include:

On 6/10/13 at approximately 10:40 A.M. a tour of the facility was started with Staff Member #16. The Assessment/Admissions Department was toured and the single restroom in the area did not have a mechanism in place for a potential patient or visitor to call for help (emergency call bell) should there be some type of medical emergency. Staff Member #19 stated, "There has never been a call bell in the restroom."

During the initial tour of the facility on 6/10/13 no means of identifying each room was available except patient rooms that were numbered. In the event of an emergency there was no way to specifically identify the other rooms on the patient care areas.

Based on observations, interviews and document review the facility staff failed to ensure the hospital was maintained in a sanitary manner and that chairs used by patients who could become incontinent could be cleaned.

The findings include:

On 6/10/13 during the initial tour of the facility with Staff Member #16 the following items/conditions were noted:
ITP (Intensive Treatment Program):
Intake Room described by Staff Member #16 as, "The room is used when a TDO (Temporary Detention Order) brought in by the police." Had 1 cloth chair that could not be disinfected if it became soiled was bolted to the floor. Staff Member #16 stated, "It (the chair) probably should have been removed."
Large Community Room 10 of 12 chairs had tears and one chair had splintered wood on the frame.
Random patient rooms were observed to have dirty floors with dirt built up in the corners and along the baseboards.
Room: 306 Part of the privacy panel for the bathroom door was torn away
Room: 300 and 301 had a cracked door to the room with jagged edge by the doorknob
Small Community Room #1: 5 out of 12 chairs had tears
Small Community Room #2: 2 of 5 chairs had tears
Court Room: 3 of 10 chairs had tears
Room: 311 an empty room described as cleaned and ready for the next patient had dirty tissue(s) under the bed
Linen Cart in hallway: Cover over linen was torn in several places
Room 208: Clean linen room: Had linen stored on an uncovered cart with a dirty air vent blowing air directly on the linen, furniture stored in the room, clothes in a bag stored next to the linen cart
Consult Room (next to Room 208): Dirt or sand on the floor, dirty cloth on the floor
Consult Room #2: Dirty floor
Room labeled as Group Room was the restraint and seclusion area for adults. The room had a foyer and 4 seclusion/restraint room, 2 bathrooms (one at each end of the foyer area): No soap or hand antiseptic at either sink, Seclusion room #1 had torn cracked baseboard, Seclusion room #2 had a hole in the wall and cracked floor tile, Seclusion room #3 had a mattress with red splatters on it that looked like blood. Staff Member #16 stated, "I agree with you on that." In the foyer area was a blue mattress that was torn and cracked. Seclusion room #4 had baseboard coming off the wall. Bathroom #2 had a rusted jagged door frame that was approximately 2 inches tall from the floor. The seclusion room floor had stains, dirt built up in the corners, the mattresses did not appear as if they had been cleaned for sometime. One mattress stuck to the floor.

Adult Psychiatric Services (APSY):
Vital signs room: The room was used by staff to take a patient(s) vital signs. Had a cloth chair that could not be disinfected if it became soiled. There were 2 blood pressure machines with multiple blood pressure cuffs stored in each one. There was nothing in the room to clean the blood pressure cuffs between patient use. There was a linen cart in the room with the cover folded back exposing the linen. The cover was pulled down by Staff Member #16 and the cover was torn. The air vent over the linen was dirty.
The medication room: At approximately 12 noon during the initial tour with Staff Member #16 the glucometer was observed sitting in the recharge holder. It was removed and had dried blood on the back of the glucometer. Staff Member #24 was asked how many patients blood sugars had been obtained and was the glucometer cleaned between each patient. Staff Member #24 stated, "Three patients had their blood sugars checked and no I did not clean the glucometer between them." There was no product available in the medication room for cleaning a glucometer.
Main hallway of Adult Psychiatric Services: Cloth chair that could not be cleaned/disinfected if it became soiled was observed sitting in the hallway.
Large Community Room: 6 of 19 chairs had tears and 1 chair had a soiled band-aide lying on it.
Doctors Consult Room: 2 of 2 chairs where cloth with stains and what appeared to be animal hair on the chairs that could not be disinfected if it became soiled.
Laundry Room used by patients: air vent over the washer and dryer had copious amount of lint in the vent.
Room 245: Rusted bathroom door frame.

Child and Adolescent Services:
Hallway: 3 cloth chairs that could not be disinfected if it became soiled.
Large Community Room: 2 of 19 chairs were cloth that could not be disinfected if it became soiled. Four of the 6 loveseats had tears.
Meeting room: 6 of the chairs were cloth that could not be disinfected if it became soiled.
Patient refrigerator: Bread, peanut butter and jelly in plastic bag with no name or date as to when placed in the refrigerator.
Treatment team room: 8 of 8 chair were cloth that could not be disinfected if it became soiled.
Room 169 (Patient room): Broken baseboard.
Medication room: Both a high and low control for checking the glucometer were in the high box neither were labeled as to when they were opened and accessed. 2 of 2 bottles of test strips for the glucometer were opened and accessed with no date as to when they were opened and accessed. Staff Member #16 stated, "They (the control bottles) are good for 90 days after they are opened."
Seclusion area for Child and Adolescent area: The foyer area contained one sink and bathroom. The sink area had no paper towel dispenser. An area by the sink had no baseboard. The light in seclusion room #2 did not work. The floors in all 4 rooms were soiled. The mattress in room #2 was torn and had used wrist restraint covers on it that were soiled. Staff Member #16 stated, "That doesn't make sense they (wrist restraint covers) are disposable." Seclusion room #1 had a dirty floor.

On 6/10/13 at approximately 2 P.M. the kitchen used to prepare and serve food to the patients was toured with Staff Member #16:
Ice machine had no air gap and the drains from the ice machine had a black residue in the drains. One drain was submerged approximately 10 inches in water in the sewage drain with with visible trash floating in the water. Staff Member #23 stated, "Yes, I know we need an air gap."
The dry storage area had 3 items that had been opened and accessed and not dated as to when they were opened and accessed (macaroni noodles, long grain rice and chicken flavored gravey mix). The long grain rice was not rewrapped once opened.
The reach in refrigerator had a bag of shredded cheddar cheese that had been opened and accessed, not resealed and not dated as to when opened and accessed. Staff Member #23 stated, "They (other staff members) know they need to date and reseal items once they are opened."
The drying rack for clean pans had a dirty employee jacket hanging on one side and a dirty plastic apron hanging on the other side of the rack. Approximately 7-10 of 27 pans were stored upside down wet.
The ice/water dispenser in the serving line was not working. Staff Member #23 stated, "It has not worked for sometime but cost to much to remove and to get it fixed."
Walk-in refrigerator: 14 of 14 skim milk cartons expired on 6/9/13.
Walk-in freezer: had one of 2 lights out. Staff Member #23 stated, "It goes out all the time from the door being slammed." There was trash on the floor of the freezer and large areas of ice on the floor and the left wall. Staff Member #23 stated, "We will get some one to check out the ice and the floor is (name of an employee) job and he is on vacation right now." The walk-in freezer is out side of the building. To get to the freezer Staff Member #23 propped the door from the dry storage area open with a bread rack. Staff Member #23 stated, "We can unlock the door but then we have to remember to relock it when we come back in. It is easier to prop the door open."

The weight room was also inspected on 6/10/13 at approximately 3:00 P.M. and was found to have an ab roller with a torn and duct taped back support and a torn speed bag making them difficult to clean after use by patients.

The examination room on Adult Psychiatric Services was inspected on 6/11/13 at approximately 1:49 P.M. with Staff Member #16 and found to have a torn exam table cover with paper over it that appeared to have been used. The paper roll was on top of the table where it could come in contact with patients. A bottle of what was labeled "Virex" was found in the exam table drawer with used dirty washcloths. Also in the exam room was approximately 30 of 30 blue top vaccutainers that were expired in March 2013.

An interview was conducted with Staff Member #2 regarding the facility's infection control program. Staff Member #2 stated, "We follow the guidelines of CDC for our infection prevention program. We have a patient safety huddle meeting daily where we can discuss imminent infection control problems. Then we perform a weekly surveillance and have quarterly meetings. We are focusing on hand hygiene right now with trying to educate the staff including the physicians." Staff Member #2 provided a copy of the surveillance documentation. A form titled Environment of Care for the months of May and April 2013 were provided.

The Environment of Care documentation for April 2013 indicated there were no problems except with the lights in lobby and near gym, ceiling tile in lobby bathroom missing, a desk and a vacuum cleaner were in the hallway in the outpatient area and the out patient parking lot had holes that needed repaired. The Environment of Care documentation for May 2013 indicated the following: problems with air vents in patient rooms (coming out of the ceiling, rusting, dirty in consult room on APSY ), exposed sprinkler head, cracked plastic at bottom of bathroom privacy doors, tiles coming up from floor, baseboard molding coming off in seclusion room on ITP, mattresses torn, doors not labeled.

Staff Member #4 provided a copy of the facility policy titled Management of Clean and Soiled Linen with a last reviewed date of 07/2012. The policy states the environmental staff stocks shelves with clean linen in the Clean Linen Room...assures that linen carts are kept covered at all times.
Also Staff Member #4 provided a copy of the facility policy titled Blood Glucose Management which had DRAFT printed across each page. The policy stated on page 10 Section C. Cleaning the Glucometer
1. The meter should never be immersed in any cleaning agent. Always apply the cleaning agent to a soft cloth to wipe the meter surface. Once complete, immediately dry thoroughly. When cleaning the meter, please follow the guidelines listed below:
a. Dilute bleach. A 10% solution of household bleach (Sodium Hypochlorite) may be used or 70% Isopropyl (rubbing) Alcohol may be used. Commercial surface decontamination preparations that are approved for used by the facility can be used.

Based on record review and interviews the nursing director failed to direct, monitor and evaluate the nursing care furnished to the facility's patients as evidence by:

1. Nursing staff documented a patient had been assessed, was safe and sleeping however the patient had eloped and had not been present on the unit for approximately 12 hours for 1 of 1 eloped patient included in the sample (Patient #4).

2. Nursing staff failed to ensure physician prescribed precautions for 2 of 2 newly admitted patients (Patients #4 and Patient #7) were followed to maintain patient safety

The findings included:

1. Review of Patient #4's medical record and EMR (Electronic medical record) revealed the patient was admitted to the facility on June 9, 2013 under temporary detainment order. Patient #4's physician prescribed the following precautions elopement risk, danger to others related to homicidal ideation, suicidal, and close observation, which included checking the patient every ten (10) minutes. Review of the EMR progress notes revealed Patient #4 eloped from the facility at approximately 4:45 p.m. on June 9, 2013.

Review of the EMR progress notes revealed as documented on:

June 9, 2013 at 7:03 a.m. - The patient arrived on the unit at 5:10 a.m., accompanied by the police. The nursing note documented Patient #4's precautions as ordered by the physician. Nursing documented Patient #4 "REFUSED TO COOPERATE WITH NURSING ASSESSMENT..."

June 9, 2013 at 12:18 p.m., the physician documented "Mental Status Exam: The patient was seen [his/her] room laying in [his/her] bed. [He/she] kept [his/her] eyes closed for most of the interview. [He/she] had some speech latency. [His/her] speech was soft in volume. [He/she] was not cooperative with the interview ... [He/she] has homicidal ideations towards "a lot of people" but did not specify any names ... Thought process was slow but goal-directed. Insight and judgment is poor."

Patient #4's EMR and medical record did not contain documentation by licensed nursing staff on June 9, 2013 related to notification and details of the patient's elopement.

Review of Patient #4's EMR progress notes documented on June 10, 2013 revealed:

At 00:05 a.m.- "Patient reported to have left the building during the evening shift ..." The progress note indicated the medical director was notified of the patient's status at midnight and that the patient would remain on the census for 24 hours "following the time [he/she] escaped."

At 4:49 a.m. Staff # 15 documented the following, "Pt (patient) monitored q10 (every 10) minutes on close observation, danger to others, elopement and suicidal precautions for safety and well-being. Pt remained in bed resting with eyes closed. Pt did not attempt to harm self or others. Pt did not attempt to elope. Pt will remain on precautions and will be monitored for health and safety."

At 8:48 a.m., the EMR documentation revealed Patient #4 was discharged from the facility related to his/her elopement on June 9, 2013.

Review of the facility's policy related to documentation "Nursing Documentation" read, "Nursing documentation in the medical record is accurate, timely, reflects treatment provided, and is consistent with medical record documentation policies ... Procedure: 1. Nursing staff documents in the Medical Record every shift ... 2. An additional entry is made in the record whenever any unusual event or incident occurs. This note includes a description of the event, the patient's/resident's response, and the staff's intervention ..."

An interview was conducted on June 11, 2013 at 3:25 p.m., with Staff #16. Staff #16 reported reading Patient #4's documentation in his/her EMR. Staff #16 reported Staff #15's documentation is inaccurate the patient was not on the unit.

The administrative staff was informed of the findings at approximately 5:35 p.m., on June 11, 2013.

An interview was not conducted with Staff #15 during the survey prior to exit. Staff #15 did not respond to telephone voice mails requesting an interview.

2. Documentation related to close observation and elopement risk:

Review of Patient #4's medical record and EMR (Electronic medical record) revealed the patient was admitted to the facility on June 9, 2013 at approximately 5:10 a.m. Patient #4's medical record contained an "Observation Flow Sheet" for "Close Observations" which did not reflect the physician's orders for danger to others, elopement risk, homicidal and suicidal risk. Nursing staff failed to incorporate the physician ordered precautions to maintain the patient's safety and safety of others. Patient #4 eloped from the facility, while outside the building but on an enclosed patio.

Review of Patient #7's medical record and EMR revealed the patient was admitted to the facility at approximately 12:00 p.m. on June 9, 2013. Patient #7's medical record revealed the patient was admitted under a temporary detention order after running into moving traffic and hitting moving cars. Patient #7's medical record documented the physician had ordered precautions related to the patient's elopement risk, homicidal and suicidal risk, being a danger to others and close observation. Patient #7's observation form revealed on June 9, 2013 at 4:40 p.m. facility staff documented the patient was allowed to have outside privileges.

An interview was conducted on June 12, 2013 at 8:24 a.m., with Staff #9. Staff #9 reported nursing staff performed a briefing at the start and end of each shift. Staff #9 reported the patients' precautions were documented on their "close observation" forms. Staff #9 reported either the nurse or coordinator completed the observation forms. Staff #9 reported due to the patient's liability, the patient's mood, thought processes, or behavior could change quickly. Staff #9 stated, "Whether a patient is on precautions or not, I only let those go out that I feel comfortable with going out." Staff #9 reported if a new admission was on elopement precautions, danger to others, suicide precautions and close observation, "I would not feel comfortable taking them outside."

An interview was conducted on June 12, 2013 at 9:05 a.m., with Staff #16. Staff #16 reviewed Patient #4's medical record. Staff #16 stated, "This was a high risk patient. My expectation is [he/she] should have been identified as not being able to go outside. [He/she] should have been assessed by the nurse and a discussion should have occurred with the psych tech." Staff #16 reported although the evening charge nurse documented Patient #4 had denied the desire to elope, the physician's note that morning documented Patient #4 had homicidal ideations. Staff #16 reported the staff " should have read " Patient #4's medical record and recognized he/she was high risk.

An interview was conducted on June 12, 2013 at 9:40 a.m., with Staff #6. Staff #6 reported patients that were under a temporary detention order, elopement precautions and close observation needed to be assessed on the unit for "at least 24 to 48 hours prior to being granted outside privileges. Staff #6 stated, "The primary focus should be their behavior on the unit before being allowed outside."

An interview was conducted on June 12, 2013 at 10:01 a.m., with Staff #12. Staff #12 reported the facility allows patients on temporary detention orders, elopement, homicidal, and suicidal risks to attend groups and have outside privileges with close observations and "if sufficient staff" are available. Staff #12 reported the nursing staff were to assess the patient's ability to have outside privileges in relationship to the physician ordered precautions.

An interview conducted on June 12, 2013 at 2:29 p.m. with Staff #14. Staff #14 reported that six patients were on the patio at the time Patient #4 climbed up on one of the patio tables and jumped to the fence. Staff #14 reported Patient #4 did not respond to "redirection given three times but continued to scale the fence." Staff #14 stated, "If I had known [he/she] had been on elopement precautions, I would never have allowed [him/her] outside."

The nursing director failed to ensure nursing staff caring for patients implemented physician ordered monitoring for patients' safety and the well-being of others as evident by the failure to document physician ordered precautions on the observations form. The nursing director failed to direct nursing staff to ensure policies and procedures were followed for documentation. Patient #4's EMR did not contain details related to the patient's elopement on June 9, 2013 as to notification or details related to Patient #4's elopement. The nursing director failed to ensure nursing staff's documentation reflected the current patient situation, related to Staff #15's documentation that Patient #4 had been assessed and was on the unit when the patient had eloped approximately 12 hours prior to the progress note. The nursing director failed to ensure nursing staff evaluated the assessments by the physician, and other staff prior to allowing Patient #4 to be on an enclosed outside patio with a ratio of one staff to six patients.