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Based on review of observations, review of facility policies and procedures, review of facility documents, review of medical records (MR), and interviews with staff it was determined the Governing Body failed to ensure the facility meet standards for licensing established by the agency of the State or locality responsible for licensing hospitals, (A022), failed to ensure compliance with the Condition -Patient Rights (A-0115), failed to ensure the patient had the right to receive care in a safe setting (A-0144), failed to enure medication was not used to manage a patient's behavior (A-0160), failed to ensure the least restrictive interventions were utilized (A-0164), failed to ensure physician orders for restraints were obtained per facility policy (A-0168), failed to ensure physician orders for restraints were not written as a standing order or PRN order (A-0169), failed to ensure a face to face interview was performed within an hour of restraint application (A-0178), failed to ensure compliance with Condition - Nursing Services (A-0385), failed to ensure a registered nurse was available on each unit (A-0392), failed to ensure a registered nurse completed and reviewed patient care assignments (A-0397), failed to ensure current and accurate records were kept for the receipt of scheduled drugs (A-0494), failed to ensure expired medications were not available for use (A-0505), failed to ensure there was a full-time Dietetic Director (A-0620), failed to ensure compliance with Condition - Utilization Review (A-0652), failed to ensure the composition of Utilization Review Committee (A-0654), failed to ensure compliance with the Condition - Physical Environment (0700), failed to ensure proper routine storage and disposal of trash (A-0713), failed to ensure its facilities and equipment were maintained (A-0724), failed to ensure the designated infection control officer developed polices to control infections (A-0748), failed to ensure compliance with Condition - Discharge Planning (A-0799), failed to ensure compliance with the Condition - Organ, Tissue and Eye Procurement (A-0884), failed to ensure there were written policies for organ procurement (A-0885), failed to incorporate an agreement with an OPO (A-0886), failed to incorporate an agreement with one tissue bank and one eye bank (A-0887), failed to designate an individual to initiate the request to the family (A-0889), failed to ensure staff education for organ procurement (A-0891).

Findings include:

Review on June 22, 2017, of facility document "By-Laws of KidsPeace Children's Hospital, Inc." effective February 1, 2002, revealed "Article I Purpose Section. The purpose of the Corporation is to provide high quality care, education, treatment and prevention services for children, youth and their families ... Section 3. Chief Executive Officer ... shoal ... have the general powers and duties of supervision and management usually vested in the office of the Chief Executive Officer of a corporation and shall plan and direct the affairs of the corporation in accordance with policy set by the Board of Directors The Chief Executive Officer shall have authority over all other officers and employees of the corporation and shall be directly responsible to the Board for the management affairs."

Cross Reference:

482.11(b) - Standard -Licensure of Hospital
482.13 Condition of Participation: Patient's Rights
482.13(c)(2) Standard- Patient Right Care in a safe setting.
482.13(e)(1)(i)(b) Standard - Patient Rights Restraint or Seclusion
482.13 (e)(2) Standard -Restraint or Seclusion
482.13(e)(5) Standard-Restraint or seclusion
482.13(e)(6) Standard - Restraint or seclusion
482.13(e)(12) Standard - Restraint or seclusion
482.23 Condition Nursing Services
482.23(b) Standard- Staffing and Delivery of Care
482.23(b)(5) Standard- Patient Care Assignments
482.25(a)(3) Standard - Pharmacy Drug Records
482.25(b)(3) Standard- Unsable Drugs Not Used
482.28(a)(1)- Standard- Director of Dietary Services
482.30 Condition -Utilization Review
482.30(b)- Standard - Utilization Review Committee
482.41 Condition- Physical Environment
482.41(b)(6)- Standard - Disposal of trash
482.41(c)(2) - Standard - Facilities, supplies and equipment maintenance
482.42(a) Standard: Infection Control Officer
482.43- Condition - Discharge Planning
482.45 Condition- Organ, Tissue and Eye Procurement
482.45(a) Standard- Written policies and procedures
482.45(a)(1)- Standard - OPO Agreement
482.45(a)(2)- Standard- Tissue and Eye Bank Agreements
482.45(a)(3)- Standard- Designated requestor
482.45(a)(5)- Standard -Staff Education

Based on review of facility policies and procedures, review of medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure compliance with the Condition of Participation for Patient Rights.

Cross Reference:

482.12 - Condition - Governing Body
482.13(c)(2) Standard- Patient Right Care in a safe setting.
482.13(e)(1)(i)(b) Standard - Patient Rights Restraint or Seclusion
482.13 (e)(2) Standard -Restraint or Seclusion
482.13(e)(5) Standard-Restraint or seclusion
482.13(e)(6) Standard - Restraint or seclusion
482.13(e)(12) Standard - Restraint or seclusion

Based on review of facility documents and interview with staff (EMP) it was determined the facility failed ensure a Registered Nurse was on duty and immediately available for every shift, everyday (A-0392) and failed to ensure a Registered Nurse completed patient care assignments (A-0397).

Cross Reference:
482.12 - Condition: Governing Body
482.23 (b)Staff and delivery of care
482.23 (b)(5) Patient care assignments

Based on review of facility documents and interview with staff (EMP) it was determined the facility failed to ensure two or more physicians or other qualified practitioners were members of the Utilization Review (UR) committee and failed to ensure physician members were not professionally involved in the care of patients reviewed at the meeting.(A-0654)

cross reference:
482.12 Condition - Governing Body
482.30(b) Utilization Review Committee

Based on review of facility documents, review of facility policy and procedures, observation of patient care units and interview with staff (EMP), it was determined the facility failed to ensure a safe physical environment was provided to all patients in eight of eight patient care modules (nursing units) observed.

Findings include:

Review on June 20, 2017, of "Board of Directors Meeting Minutes" dated April 5, 2017, revealed " ... Faucets will be replaced with anti-ligature facets so capital funds dedicated to other physical plant upgrades will be reallocated to that project."

Review on June 19, 2017, of facility document "KidsPeace Hospital Anti-Ligature Assessment," undated, revealed, " ... The physical plant areas that were assessed include: 1. patient bathroom sinks, 2. patient bathroom faucets 3. patient room doors 4. patient room closet doors 5. patient room sprinklers 6. patient room beds 7. patient room shower handles 8. patient room shower heads 9. patient room toilets ... 2. Patient room faucets are currently being replaced with anti-ligature type fixtures. Several have been installed recently, and the rest (approx 80) will be installed before the end of 2017. 3. The bathroom doors do not have standard hinges and are okay. Several rooms have private "suites" within the room, and these doors should have anti-ligature hinges. (piano hinge). The exterior door to the room would need to be open in order to loop something over the hinge, and the door closer is also on the outside of the door. 4. Closet doors are square. There is the possibility of looping something over. These will need to be evaluated for a different type door (arched doors or a standard door w/ anti-ligature hardware) 5. current sprinkler will be replaced with institute type heads. This will be budgeted for in 2018. 6. Current beds are set up for mechanical restraint systems, which have slots/holes along each side of the bed. These slots will be covered over with wood or composite wood material. 7. Although the shower handles are antiligature, some shower handles have been identified that are protruding out further from the wall. These will either need to be reset, or replaced. 8 All shower heads are anti-ligature 9. Toilets were not identified as being a risk."

Observation on June 19, 2017, Northeast module - census 13, North Central module and South Central module - closed due to census/staffing, at the time of observation tour, Central Lower Unit- census 13, North Lower Level- census 9, North West unit/module- 13, South East Module- 11 census, South West Module -census 14 between 11:00 AM and 3:00 PM of eight patient care modules revealed the following:

The entrance/exit door to the Northeast module unit had loopable door hinges at the top right side of the door and a vertical metal locking strip that was bent and loopable. All patient care units: there were regular and Phillips screws throughout the unit in door jams, door mounts, windows, Air Conditioning grills and signage. Patient wooden beds had six loopable holes on each side of each bed. Patient bedroom doors when opened had loopable door closures at the top and loopable three pins on the inside of the door accessible to patient when door was closed. Bathrooms had toilet paper dispensers with sharp edges, loopable vanity faucets, loopable shower faucets, bathroom soap dishes had sharp cracked edges. Bathroom doors at top were loopable when open. Toilet plumbing extending from wall to toilet fixture was loopable with greater than seven inches from floor. Group/activity areas had tables used by patients that had stools connected to underneath of the table by a metal tubing creating a ligature point. There were unit hallway doors that had loopable door knobs. Nurse station door handles had knobs that were on the hallway side and accessible to patients. These knobs presented a loopable possibility. Staff bathroom doors had handles had knobs that were on the hallway side and accessible to patients. The Washer and Dryer rooms had had knobs that were on the hallway side and accessible to patients. These knobs presented a loopable possibility. These knobs presented a loopable possibility. Electrical closet doors had knobs that were on the hallway side and accessible to patients. These knobs presented a loopable possibility. Alcove doors had knobs that were on the hallway side and accessible to patients. These knobs presented a loopable possibility. Clean linen rooms had knobs that were on the hallway side and accessible to patients. These knobs presented a loopable possibility.

Electrical outlets were uncovered. There were sitting benches near the entrance of the modules that had slots in between the wood that presented a loopable possibility. The Heating, Ventilation, and Air Conditioning vents in patient rooms had slots in them that were not covered and accessible to patients. These Heating, Ventilation, and Air Conditioning vents in patient rooms presented a loopable possibility. In the "Great Rooms" there were handles on the kitchenette passthrough doors that were accessible to patients. These handles presented a loopable possibility.

Most of the rooms on the eight patient care modules, excluding patient room numbers, had no signage to identify what type of room was behind the door. These included the washer and dryer rooms, electrical closets, Clean linen rooms, staff toilet rooms, and staff storage rooms.

The evacuation route sign near on the Northeast module, located by the exit doors to the outside, was not an accurate presentation of how to exit the building in an emergency.

Laundry rooms had black marks on floor, washing and dryer units had black marks on the outside of the units; laundry was observed placed directly on the floor during tour. Patient bathroom shower stalls had gray, blacks stains on shower floor, grout was stained with gray, bathroom sinks were not cleaned and had toothpaste buildup. Kitchen on units had sticky floors, sticky counters and cabinets, refrigerators had food debris stuck on refrigerator shelving, and the outside of unit had black marks. The kitchenettes on the six open patient care modules and two closed patient care units had sticky floors, cabinets, and countertops. There was dirt and debris on the floors and on top of the refrigerators.

Interviews during the observations tours with EMP1, EMP2, EMP4, EMP11 on June 19, 2017, between 11:00 AM and 3:00 PM confirmed the observations on the patient care modules.

Interview with EMP3 on June 19, 2017, at 2:45 PM confirmed the "KidsPeace Hospital Anti-Ligature Assessment," was completed "on Friday" (June 16, 2017). EMP3 further confirmed that the cleaning of kitchenettes on the patient care modules was to be done by environmental services employees, mental health techs, and dietary employees.

Immediate Jeopardy was called on June 19, 2017, at 2:45 PM for an unsafe physical environment for psychiatric patients in all eight patient care modules (nursing units). At the time, six modules were open and had patients. Two modules were closed and had no patients.


Cross Reference:
482.12 - Condition -Governing Body
482.13 - Condition -Patient Rights
482.41(b)(6)-Disposal of Trash
482.41(c)(2)-Facilities, Supplies, Equipment Maintenance

Based on review of facility documents and interview with staff (EMP) it was determined the facility failed to ensure a discharge planning process was developed and specified in writing

Findings include:

Review on June 21, 2017, of facility policy "Discharge Summary, last reviewed February 28, 1997," revealed no provision regarding the discharge planning process, no provision for staff member responsibilities for discharge plan evaluation, the discharge plan implementation or the ongoing reassessment of the patient for discharge.

Interview on June 21, 2017, at 1:40 PM with EMP11 confirmed the discharge policy does not include the above findings.

Cross Reference:
482.12 - Condition- Governing Body

Based on review of facility policies and procedures, and interview with staff (EMP), it was determined the facility failed to ensure compliance with the Condition of Participation for Organ, Tissue and Eye Procurement.

Cross Reference:
482.12 Condition - Governing Body
482.45(a)-Written Policies and Procedures
482.45(a)(1)-OPO Agreement
482.45(a)(2)-Tissue and Eye Bank Agreements
482.45(a)(3)-Designated Requestor
482.45(a)(5)-Staff Education

Based on record review and interview it was determined that the facility failed to ensure:

1. Psychosocial Assessments for eight (8) of eight (8) active sample patients (A1, A2, B1, C1, D10, E8, E10 and F5) contained a description of the anticipated role of the social service staff in discharge planning. (B108 for details.)

2. Psychiatric Evaluations for three (3) of eight (8) active sample patients (A1, A2 and B1) included an assessment of patient assets in descriptive not interpretive fashion . (Refer to B117 for details)

3. Treatment Plans for eight (8) of eight (8) patients included:

a. Treatment goals stated in behavioral measurable terms (B121 for details)

b. Treatment interventions that were patient specific and/or were more than discipline generic tasks. (Refer toB122 for details)

c. The responsible treatment team member identified who would be held accountable to ensure that interventions were carried out. (Refer to B123 for details)

These failures result in Treatment Plans that are uninformative with an absence of specific plans to direct staff in the implementation, evaluation and revision of care based on individual patient findings, and hold no specific staff member responsible for monitoring and evaluating the effectiveness of selected modalities.

Based on record review and interview, the facility failed to ensure the presence of a registered nurse on each ward on all three shifts (days, evenings and nights) for all six (6) patient units. This staffing pattern results in a lack of professional on-going assessment of patients and direction and supervision of non-professional nursing personnel in the provision of nursing care. (Refer to B149)

Based on review of facility documents, it was determined the facility failed to ensure the current "Provisional" Certificate of Compliance issued from the Pennsylvania Department of Human Services was on display.

Findings include:

Review on June 19, 2017, of facility's current Certificate of Compliance issued by The Department of Human Services revealed , "Pennsylvania Dept of Human Services Certificate of Compliance in effect from March 1, 2017, until September 1, 2017." Further review of the Certificate revealed "PROVISIONAL" was displayed across the certificate in bold letters.

Observation on June 22, 2017, at 10:10 AM of the facility's Certificate of Compliance on display in the hospital main entrance waiting room revealed it was dated effective July 26, 2016, until July 26, 2017, and did not contain "PROVISIONAL" across the certificate in bold letters.

Interview with EMP1 on June 22, 2017, at 10:10 AM confirmed the facility had a Provisional License from the Department of Human Services and the "Provisional" license was not on display.

___________

Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to conform to all applicable State laws.

Act 13 of 2002, Medical Care Availability and Reduction of Error (MCARE) Act 40 PS. §1303.310 Patient safety committee. (a) Composition.-- (1) A hospital's patient safety committee shall be composed of the medical facility's patient safety officer and at least three health care workers of the medical facility and two residents of the community served by the medical facility who are not agents, employees, or contractors of the medical facility.

KidsPeace Orchard Hills Campus was not in compliance as evidenced by:

Based on review of facility documents and interview with staff (EMP), it was determined that KidsPeace Orchard Hills Campus failed to ensure that one of the two community members of the Patient Safety Committee were not contractors of the facility.

Findings include:

Review on June 20, 2017, at 12:00 PM of facility policy "Hospital Safety Plan," effective June 11, 2004 revealed " ... B. Patient Safety Committee 2. g. At least two residents of the community will be appointed to the committee to provide feedback regarding the mission and direction of patient safety initiatives and shall not be agents, employees, or contractors of the hospital."

Review of Patient Safety Meeting Minutes dated December 2016 through May 2017 revealed a community member was a contractor of the facility

Interview with EMP1 on June 20, 2017, at 12:15 PM confirmed one of two community members of the Patient Safety Committee was a contractor of the facility.
_____________

Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to conform to all applicable State laws.

Act 13 of 2002, Medical Care Availability and Reduction of Error (MCARE) Act 40 PS. §1303.308 Reporting and notification ... (b) Duty to notify patient - A medical facility through an appropriate designee shall provide written notification to a patient affected by a serious event or, with consent of the patient, to an available family member or designee within seven days of the occurrence or discovery of a serious event ... If an adult member of the immediate family cannot be identified or located, notification shall be given to the closest adult family member. For unemancipated patients who are under 18 years of age, the parent or guardian shall be notified in accordance with this subsection."

KidsPeace Orchard Hills Campus was not in compliance as evidenced by:

Based on review of facility documents, review of medical records and interview with staff, it was determined the facility failed to ensure the written notification of a serious event with relevant details was sent to the available family member or designee within seven (7) calendar days.

Findings include:

Review on June 20, 2017, at 12:00 PM of facility policy "Hospital Safety Plan," effective June 11, 2004 revealed, " .... D. Family Notification of Serious Medical Event ... 2. The Hospital Safety Officer or designee will ensure that a written notification of the serious event with relevant details is completed and sent to the available family member or designee within seven (7) calendar days."

Review on June 20, 2017, of MR8, MR9, MR10, MR11, MR12, MR13, MR15 revealed a serious event was reported while the patient was admitted to the facility.

Request was made to EMP1 on June 19, 2017, at 2:00 PM for written serious event notification letters sent to the available family member or designee within seven days for MR8, MR9, MR10, MR11, MR12, MR13, MR15. None was provided.

Interview with with EMP1 on June 20, 2017, at 12:00 PM confirmed there was no documentation of written notification of serious event being sent to available family members or designees within seven days of the event.

____________

Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to conform to all applicable State laws.

KidsPeace Orchard Hill Campus was not in compliance with the following State law:

"Act 52 of 2007, Medical Care Availability and Reduction of Error (MCARE) Act Chapter 4. Health Care-Associated Infections 40 P.S.§ 1303.403. Infection control plan (a) Development and Compliance. - Within 120 days of the effective date of this section, a health care facility and an ambulatory surgical facility shall develop and implement an internal infection control plan that shall be established for the purpose of improving the health and safety of patients and health care workers and shall include: (1) A multidisciplinary committee ..."

This is not met as evidenced by:

Based on review of facility documents and interview with staff (EMP), it was determined the facility did not have a laboratory representative, pharmacy representative or community member appointed to the infection control committee and the committee minutes were not specific to the hospital.

Findings include:

Review on June 21, 2017, of facility documents "Infection Control Committee" meeting minutes dated January 1-, 2017, April 11, 2017, May 9, 2017, revealed no documented evidence that Laboratory representative, Pharmacy representative or community member was appointed to the committee. further review of the meeting minutes revealed the committee was integrated with other corporate programs not under the hospital license.

Interview on June 23, 2017, at 9:15 AM with EMP5 confirmed the Infection Control Committee did not have an assigned Laboratory representative, Pharmacy representative or community member appoint to the committee. Further interview with EMP5 confirmed the committee met at the same time with other corporate programs not under the hospital license.


Cross Reference:
482.12 Governing Body

Based on review of facility document, observation and patient care modules and interviews with staff (EMP), it was determine the facility failed to ensure a safe environment for psychiatric patients on eight (8) of eight (8) patient care modules (units).

Findings include:

Review on June 20, 2017, of "Board of Directors Meeting Minutes" dated April 5, 2017, revealed " ... Faucets will be replaced with anti-ligature facets so capital funds dedicated to other physical plant upgrades will be reallocated to that project."

Review on June 19, 2017, of facility document "KidsPeace Hospital Anti-Ligature Assessment," undated, revealed, " ... The physical plant areas that were assessed include: 1. patient bathroom sinks, 2. patient bathroom faucets 3. patient room doors 4. patient room closet doors 5. patient room sprinklers 6. patient room beds 7. patient room shower handles 8. patient room shower heads 9. patient room toilets ... 2. Patient room faucets are currently being replaced with anti-ligature type fixtures. Several have been installed recently, and the rest (approx 80) will be installed before the end of 2017. 3. The bathroom doors do not have standard hinges and are okay. Several rooms have private "suites" within the room, and these doors should have anti-ligature hinges. (piano hinge). The exterior door to the room would need to be open in order to loop something over the hinge, and the door closer is also on the outside of the door. 4. Closet doors are square. There is the possibility of looping something over. These will need to be evaluated for a different type door (arched doors or a standard door w/ anti-ligature hardware) 5. current sprinkler will be replaced with institute type heads. This will be budgeted for in 2018. 6. Current beds are set up for mechanical restraint systems, which have slots/holes along each side of the bed. These slots will be covered over with wood or composite wood material. 7. Although the shower handles are antiligature, some shower handles have been identified that are protruding out further from the wall. These will either need to be reset, or replaced. 8 All shower heads are anti-ligature 9. Toilets were not identified as being a risk.

Observation on June 19, 2017, Northeast module - census 13, North Central module and South Central module - closed due to census/staffing, at the time of observation tour, Central Lower Unit- census 13, North Lower Level- census 9, North West unit/module- 13, South East Module- 11 census, South West Module -census 14 between 11:00 AM and 3:00 PM of eight patient care modules revealed the following:

The entrance/exit door to the Northeast module unit had loopable door hinges at the top right side of the door and a vertical metal locking strip that was bent and loopable. All patient care units: there were regular and Phillips screws throughout the unit in door jams, door mounts, windows, A/C grills and signage. Patient wooden beds had six loopable holes on each side of each bed. Patient bedroom doors when opened had loopable door closures at the top and loopable three pins on the inside of the door accessible to patient when door was closed. Bathrooms had toilet paper dispensers with sharp edges, loopable vanity faucets, loopable shower faucets, bathroom soap dishes had sharp cracked edges. Bathroom doors at top were loopable when open. Toilet plumbing extending from wall to toilet fixture was loopable with greater than seven inches from floor. Group/activity areas had tables used by patients that had stools connected to underneath of the table by a metal tubing creating a ligature point. There were unit hallway doors that had loopable door knobs. Nurse station door handles had knobs that were on the hallway side and accessible to patients. These knobs presented a loopable possibility. Staff bathroom doors had handles had knobs that were on the hallway side and accessible to patients. The Washer and Dryer rooms had had knobs that were on the hallway side and accessible to patients. These knobs presented a loopable possibility. Electrical closet doors had knobs that were on the hallway side and accessible to patients. These knobs presented a loopable possibility. Alcove doors had knobs that were on the hallway side and accessible to patients. These knobs presented a loopable possibility. Clean linen rooms had knobs that were on the hallway side and accessible to patients. These knobs presented a loopable possibility.

Electrical outlets were uncovered. There were sitting benches near the entrance of the modules that had slots in between the wood that presented a loopable possibility. The Heating, Ventilation, and Air Conditioning vents in patient rooms had slots in them that were not covered and accessible to patients. These Heating, Ventilation, and Air Conditioning vents in patient rooms presented a loopable possibility. In the "Great Rooms" there were handles on the kitchenette pass through doors that were accessible to patients. These handles presented a loopable possibility.

Interviews during the observations tours with EMP1, EMP2, EMP4, EMP11 on June 19, 2017, between 11:00 AM and 3:00 PM confirmed the observations on the patient care modules.

Interview with EMP3 on June 19, 2017, at 2:45 PM confirmed the "KidsPeace Hospital Anti-Ligature Assessment," was completed "on Friday" (June 16, 2017).


482.12 - Condition - Governing Body
482.13 - Condition - Patient Rights
482.13(e)(1)(i)(b) Standard - Patient Rights Restraint or Seclusion
482.13 (e)(2) Standard -Restraint or Seclusion
482.13(e)(5) Standard-Restraint or seclusion
482.13(e)(6) Standard - Restraint or seclusion
482.13(e)(12) Standard - Restraint or seclusion

Based on review of policies/procedures, medical records (MR) and an interview with EMP it was determined the facility failed to follow established policies for the use of physical, mechanical for two (2) of two (2) medical records reviewed (MR1, and MR15) and failed to have an established policy for the use of chemical restraint for two (2) of (2) medical records reviewed (MR1 and MR15).

Findings include:

Review of policy: CH.4207, "Restraint Use in KidsPeace", origination date: October 5, 2009...last review date: March 17, 2017. Section I. Policy statement, " It is the policy of KidsPeace to provide its staff members with a clearly defined system of initiating, ordering, discontinuing, debriefing, documenting physical restraint procedures and making necessary notifications"., section IV. General; philosophy; "KidsPeace maintains a treatment environment that ensures the safety and well-being of our clients... Restraint may only be imposed to ensure the immediate physical safety of the client, a staff member, or others and is to be discontinued at the earliest possible time. KidsPeace Children's Hospital establishes and adheres to the following statements:
1. Hospital leadership is responsible for creating a culture that supports a client's right to be free from restraint.
13. Physical restraint must be utilized in a manner that is designed to protect the client's safety, dignity, and emotional well being".

Review of policy: CH.4208, "Mechanical Restraints", origination date March 4, 1997... effective date/last revision: October 28, 2015. Section I. Policy Statement, "A mechanical restraint is recognized as the most restrictive procedure permitted at KidsPeace Hospital to establish client safety"..., IV. General... 1. Indicated by a failure to establish safety with less restrictive physical an non-physical crisis intervention procedures...., 3. Initiated by a physician order for no more than 30 minutes unless in an emergency situation where a nurse may initiate and later obtain the order as soon as possible from the physician".

A request to review a policy on chemical restraint revealed that the hospital did not have a documented policy on the use of chemical restraint.

Review of MR1 on 06/19/2017 at 1:00PM revealed a PRN progress note documenting, "Client was extremely anxious and began yelling for the "voices to stop" and then began shoving staff. Client placed in SCM but went supine and hold released as per protocol. Client offered a prn which she initially declined but then agreed to take. PRN administered PO at 15:25. PRN effective".
Review of MR1, "medication administration record" revealed the client had been given: Ativan 2mg PO for anxiety, Haldol 5mg PO for anxiety, and Benadryl 50mg PO with no specific reason documented as to why it was administered. No documentation was noted that any other interventions following the physical restraint had been attempted to de-escalate the clients behavior nor was any documentation noted that the "as needed" (PRN) medications ordered were listed on the client's treatment plan. No documented evidence was noted supporting that the medication administered was part of the client's regular medication regimen.

Review of MR15 on 06/19/2017 at 1:30 PM revealed: Restraint Progress note, "Date/Time of Incident: 05/28/2017 18:54, Client went to walk out of the great room,...Client ran out of the room and ran into the back of the boy's hallway and started banging on the doors that connect the south west module with the south central module...Client ran into his room at this time and climbed up on his counter and began kicking his window...This writer, staff 1 and staff 2 attempted to calm Client down more but at this time Client attempted to hit this writer with a closed right fist,... this writer initiated a single standing upper torso and immediately transitioned into a single seated upper torso SCM procedure...At this time, this writer attempted to offer Client to count or deep breather in order to calm down but Client was still unable to contract for safety... At 1906 Client was transitioned into the mechanical restraint papoose board... Client continued to struggle and was fully secured in the papoose board at 1910... Due to continuous struggle and attempts to get out of the mechanical restraint, Client was given PRN via IM. At 1945 Client was able to remain calm and meet safety expectations therefore was released from the mechanical restraint". Review of "Physician's Orders" revealed, "Place client in physical hold and Mechanical (1910-1945) restraint for the protection of self and others. Give client Haldol 5mg IM with Benadryl 50 mg x1 dose. (1910). 5/28/17".
No reason given for the order to administer medication while the client was in mechanical restraint provided by the ordering physician. No documented evidence of an additional order written for the additional six (6) minutes client remained in mechanical restraint following first thirty (30). Total time in mechanical restraint 1910-1945 = 36 minutes.

An interview with the EMP1 on 06/19/2017 at 2:30PM confirmed the policies to be current and the above findings.



Cross Reference:
482.12 - Condition - Governing Body
482.13 - Condition - Patient Rights
482.13(c)(2) Standard- Patient Right Care in a safe setting.
482.13 (e)(2) Standard -Restraint or Seclusion
482.13(e)(5) Standard-Restraint or seclusion
482.13(e)(6) Standard - Restraint or seclusion
482.13(e)(12) Standard - Restraint or seclusion

Based on review of facility policy and procedures, review of medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure policy and procedures for mechanical restraints included types of mechanical restraints used, the least restrictive mechanical restraint used or the option for two point mechanical restraints for three of three medical records reviewed for mechanical restraints (MR8, MR17, MR19).

Findings include:

Review on June 21, 2017, of facility policy and procedure "Mechanical Restraints," effective October 28, 2015, revealed " ... A mechanical restraint is recognized as the most restrictive procedure permitted at KidsPeace Hospital to establish client safety." Further review of the policy revealed no documented evidence it contained the types of mechanical restraint used (papoose, four point restraint) or provided the option for two point restraints.

Review on June 22, 2017, of MR8 revealed the patient was placed in papoose mechanical restraint on May 16, 2017.

Review on June 22, 2017, of MR17 revealed the patient was placed in papoose restraint on June 17, 2017.

Review on June 22, 2017, of MR19 revealed the patient was placed in papoose mechanical restraint on February 5, 2017.

Interview with EMP3 on June 22, 2017, at 9:30 AM confirmed the facility policy for Mechanical Restraints did not contain what type of mechanical restraints were utilized by the facility. Further interview with EMP3 confirmed the facility does not utilize two point restraints.

Interview with EMP1 on June 21, 2017, at 3:00 PM confirmed when a patient is placed in mechanical restraints, the electronic physican restraint order does not specify the type of mechanical restraints ordered, and a verbal order is obtained by staff or the physician writes an order for the mechanical restraint.

Further interview with EMP1 on June 21, 2017, at 3:15 PM confirmed when a patient is placed in mechanical restraints, the physician can order a papoose mechanical restraint and four point restraints.


Cross Reference:
482.12 - Condition - Governing Body
482.13 - Condition - Patient Rights
482.13(c)(2) Standard- Patient Right Care in a safe setting.
482.13(e)(1)(i)(b) Standard - Patient Rights Restraint or Seclusion
482.13(e)(5) Standard-Restraint or seclusion
482.13(e)(6) Standard - Restraint or seclusion
482.13(e)(12) Standard - Restraint or seclusion

Based on review of facility policies and procedures, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to follow their policy and procedure on obtaining restraint orders for three occurrences in two of two medical records reviewed for restraint orders (MR29, MR30).

Findings include:

Review on June 22, 2017, of facility policy "Restraint Use in KidsPeace Children's Hospital" effective March 17, 2017, revealed " ... V. Policy ... B. Ordering a physical 1. All restraints require an order from a physician. a) In some situations, the need for intervention may occur so quickly that an order cannot be obtained prior to the application of restraint. In these emergency application situations, the order must be obtained by a registered or licensed practical nurse either during the emergency application of the restraint or immediately after the restraint has been applied."

Review of MR29 on June 22, 2017, revealed the patient was placed in physical restraints on May 8, 2017, at 17:50. Review of the physician order for physical restraint for MR29 was documented on May 8, 2017, at 19:10. Further review of MR29 revealed the patient was placed in physical restraints on May 18, 2017, at 18:04. Review of the physician order for physical restraints on May 18, 2017, was documented as 19:04.

Review of MR30 on June 22, 2017, revealed the patient was placed in physical restraints on June 12, 2017, at 17:36. Review of the physician order for the physical restraint for MR30 revealed it was obtained at 19:18.

Interview with EMP1 on June 22, 2017, at 12:40 PM confirmed the above times the physician order was obtained for the occurrences application of physical restraints for MR29 and MR30.

Cross Reference:
482.12 - Condition - Governing Body
482.13 - Condition - Patient Rights
482.13(c)(2) Standard- Patient Right Care in a safe setting.
482.13(e)(1)(i)(b) Standard - Patient Rights Restraint or Seclusion
482.13 (e)(2) Standard -Restraint or Seclusion
482.13(e)(6) Standard - Restraint or seclusion
482.13(e)(12) Standard - Restraint or seclusion

Based on review of facility policies and procedures, review of medical records (MR), and interview with staff (EMP), it was determined the facility failed to ensure restraint orders were never written as a standing ordered or on as needed basis (PRN) for one of three medical records reviewed for PRN restraint orders (MR17).

Findings include:

Review of facility policy and procedure "Restraint Use in KidsPeace Children's Hospital," effective date March 17, 2017, revealed "V. ... D. Contents of Orders 1. Orders for the use of physical restraint maybe not written as a standing order or on an as needed basis (PRN)."

Review of facility policy and procedures "Mechanical Restraints," effective date October 28, 2015, revealed it did not contain documented evidence that a mechanical restraint would never be written as a standing order or on an as needed basis (PRN).

Review on June 21, 2017, of MR17 revealed a physician ordered dated June 17, 2017, "May papoose client for up to 30 minutes." Continued review of physician orders for MR17 dated June 16, 2017, revealed, " ... Age appropriate restraint, no upper torso no four point ... ".

Interview on June 21, 2017, at 3:30 PM confirmed the restraint orders for MR17 were documented as "May papoose client for up to 30 minute" and "... Age appropriate restraint, no upper torso no four point ... ".

Cross Reference:
482.12 - Condition - Governing Body
482.13 - Condition - Patient Rights
482.13(c)(2) Standard- Patient Right Care in a safe setting.
482.13(e)(1)(i)(b) Standard - Patient Rights Restraint or Seclusion
482.13 (e)(2) Standard -Restraint or Seclusion
482.13(e)(5) Standard-Restraint or seclusion
482.13(e)(12) Standard - Restraint or seclusion

Based on review of facility policies and procedures, review of medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure the patient was seen face to face within one hour after the initiation of the restraint intervention for three of three medical records reviewed for face to face intervention (MR8, MR19, MR29).

Findings include:

Review of facility policy and procedures "Restraint Use in KidsPeace Children's Hospital," effective march 17, 2017, revealed " ... V. Policy ... I. 1. for all physical restraints: within 1 hour of the initiation of the physical restraint, a medial licensed profession must conduct a face to face assessment of the physical and psychological well being of the client ... ".

Review of facility policy and procedures "Mechanical Restraints," effective October 28, 2015, revealed it did not contain documented evidence that a face to face was required within one hour of the initiation of the restraint intervention.

Review on June 21, 2017, of MR19 revealed the patient was placed in restraints on February 5, 2017, at 14:02. Review of the date/time of assessment of face to face intervention for MR19 was 15:55.

Review on June 22, 2017 of MR8 revealed the patient was placed in physical restraints on June 5, 2017, at 9:55 AM. Review of the time of assessment of the face to face intervention for MR8 was 11:00 AM.

Review on June 22, 2017, of MR29 revealed the patient was placed in physical restraints on May 8, 2017, at 17:50. Review of the time of the assessment of the face to face intervention for MR29 was documented as 19:00.

Interview with EMP1 on June 21, 2017, at 3:45 PM confirmed the face to face intervention for MR19 was not completed within an hour of the initiation of the restraint for MR19.

Interview with EMP16 on June 22, 2017, confirmed the face to face intervention for MR8 was not completed within an hour of the initiation of the restraint.

Interview with EMP1 on June 22, 2017, at 11:30 AM confirmed the face to face intervention for MR29 was not completed within an hour of the initiation of the restraint.



Cross Reference:
482.12 - Condition - Governing Body
482.13 - Condition - Patient Rights
482.13(c)(2) Standard- Patient Right Care in a safe setting.
482.13(e)(1)(i)(b) Standard - Patient Rights Restraint or Seclusion
482.13 (e)(2) Standard -Restraint or Seclusion
482.13(e)(5) Standard-Restraint or seclusion
482.13(e)(6) Standard-Restraint or seclusion

Based on review of facility documents and interview with staff (EMP) it was determined the facility failed ensure a Registered Nurse was on duty and immediately available for 7 of 8 patient module staffing schedules reviewed. South Central (SC), South West (SW), Lower Level central (LLC), North East (NE), North West (NW), Lower Level North (LLN), and South East (SE).

Findings include:

Review on June 19, 2017, of facility document "KidsPeace Core Staffing Projections" revised 9/30/2015 revealed the Registered Nurse staffing requirements for each patient module, on each each shift, everyday of the week and holidays was one RN.

Review on June 19, 2017, of facility document "Direct Nursing Staffing Form" no review date, revealed "Please list all direct care nursing staff actually on duty for the dates shown. Include supervisors only if they provide direct patient care."

Review on June 19, 2017, of the staffing schedule for module SC for the following dates 6/9/2017, 6/10/2017, 6/11/2017, 6/16/2017 (unit closed), 6/17/2017 (unit closed), 6/18/2017 (unit closed), and 6/19/2017 (unit closed), revealed a RN was not on duty and immediately available for 2 of 6 shifts when the unit was opened.

Review on June 19, 2017, of the staffing schedule for module SW for the following dates 6/9/2017, 6/10/2017, 6/11/2017, 6/16/2017, 6/17/2017, 6/18/2017, and 6/19/2017, revealed a RN was not on duty and immediately available for 5 of 14 shifts.

Review on June 19, 2017, of the staffing schedule for module LLC for the following dates 6/9/2017, 6/10/2017, 6/11/2017, 6/16/2017, 6/17/2017, 6/18/2017, and 6/19/2017, revealed a RN was not on duty and immediately available for 10 of 14 shifts.

Review on June 19, 2017, of the staffing schedule for module NE for the following dates 6/9/2017, 6/10/2017, 6/11/2017, 6/16/2017, 6/17/2017, 6/18/2017, and 6/19/2017, revealed a RN was not on duty and immediately available for 7 of 14 shifts.

Review on June 19, 2017, of the staffing schedule for module NW for the following dates 6/9/2017, 6/10/2017, 6/11/2017, 6/16/2017, 6/17/2017, 6/18/2017, and 6/19/2017, revealed a RN was not on duty and immediately available for 5 of 14 shifts.

Review on June 19, 2017, of the staffing schedule for module LLN for the following dates 6/9/2017, 6/10/2017, 6/11/2017, 6/16/2017, 6/17/2017, 6/18/2017, and 6/19/2017, revealed a RN was not on duty and immediately available for 6 of 14 shifts.

Review on June 19, 2017, of the staffing schedule for module SE for the following dates 6/9/2017, 6/10/2017, 6/11/2017, 6/16/2017, 6/17/2017, 6/18/2017, and 6/19/2017, revealed a RN was not on duty and immediately available for 2 of 14 shifts.

Interview June 19, 2017, at 1:10 PM with EMP6 confirmed he was an LPN and was functioning as the charge nurse on module SW.

Interview on June 19, 2017 at 1:25 PM with EMP7 confirmed they are an RN Manager and "covers" two or more units when there are insufficient RN's to staff every unit, on every shift, everyday. Further interview confirmed LPN's (Licensed Practical Nurses) function as charge nurses on the units when RN coverage is not available.

Interview on June 20, 2017, 12:05 PM with EMP1 confirmed RN's are scheduled to cover 2 or more patient modules with RN's covering 2 or more units to perform patient assessments and respond to emergencies.

Cross Reference:
482.12 - Condition: Governing Body
482.23 -Condition: Nursing Services
482.23 (b)(5) Patient care assignments

Based on review of facility documents and interview with staff (EMP) it was determined the facility failed to ensure a Registered Nurse (RN) assigned the care of each patient and failed to ensure an RN reviewed and signed patient care assignments when completed by non-licensed staff (MHT) for 4 of 4 patient care assignments reviewed. (NE, NW, SW and LLN)

Findings include:

On June 20, 2017, a request was made to EMP1 for a policy and procedure regarding the protocol for completing patient care assignments. None provided.

1. Review on June 20, 2017, of "North East (NE) 1st Shift Assignment Sheet" dated June 19, 2017, revealed a Mental Health Technician (MHT) assigned the care of each patient for the first shift on the NE module. Further review revealed no documented evidence the patient care assignment sheet was reviewed and signed by a RN.

Interview on June 20, 2017, at 1:25 PM with EMP15 confirmed a MHT assigned the care of patients on the NE module. Further interview confirmed there was no documented evidence the patient care assignment sheet was reviewed or signed by an RN.

2. Review on June 20, 2017, of "North West (NW) 1st Shift Assignment Sheet" dated June 19, 2017, revealed a MHT assigned the care of each patient on the NW module for the first shift. Further review revealed no documented evidence the assignment sheet was reviewed and signed by an RN.

Interview on June 20, 2017, at 1:25 PM with EMP6 confirmed a MHT assigned the care of patients on the NW module. Further interview confirmed there was no documented evidence the assignment sheet was reviewd or signed by an RN.

3. Review on June 20, 2017, of "Lower Level North (LLN) 1st Shift Assignment Sheet" dated June 19, 2017, revealed a MHT assigned the care of each patient for the first shift LLN module. Further review revealed no documented evidence the assignment sheet was reviewed and signed by a RN.

Interview on June 20, 2017, at 2:00 PM with EMP6 confirmed an MHT assigned the care of each patient on the LLN module for the first shift. Further interview confirmed there was no documented evidence the patient care assignment sheet was reviewed or signed by an RN.

4. Review on June 20, 2017, of "South West (SW) 1st Shift Assignment Sheet" dated June 19, 2017, revealed a MHT assigned the care of each patient on the SW module for the first shift. Further review revealed no documented evidence the assignment sheet was reviewed and signed by a RN.

Interview on June 20, 2017, at 4:00 PM with EMP1 confirmed the MHT was non-licensed staff and were responsible for assigning the care of each patient on the NE, NW, SW and LLN modules. Further interview confirmed there was no documented evidence the assignment sheets were reviewed and signed by the RN.

Cross Reference:
482.12 - Condition: Governing Body
482.23 -Condition: Nursing Services
482.23 (b)Staff and delivery of care

Based on observation and interview with staff (EMP), it was determined that facility failed to ensure current and accurate records were maintained for the receipt and distribution of all scheduled drugs.

Findings include:

Observation of the facility on June 19, and 21, 2017, revealed there was an automated medication dispensing unit located in an unmarked, locked room near the North East patient care module.

On June 21, 2017, surveyor requested EMP1 for policies and procedures and documented evidence of records of receipt for scheduled drugs at the time of pharmacy delivery for two automated medication dispensing units. None were provided.

Interview with EMP1 on June 23, 2017, at 10:00 AM confirmed there were no policies and procedures for the automated medication dispensing unit and there was no documented evidence of records for receipt of scheduled drugs at the time of pharmacy delivery.


Cross Reference:
482.12- Condition - Governing Body
482.25(b)(3) - Standard - Unusable Drugs Not Used

Based on review of facility policy and procedures, observation and interview with staff (EMP), it was determined the facility failed to ensure expired medication were not available for patient use.

Findings include:

Review on June 19, 2017, at 5:30 PM of facility policy " Storage and Preparation of Medications," effective September 16, 2014, revealed " ... V. Policy A. KidsPeace Children's Hospital ... 12. Expired medications are to be returned to the pharmacy provider on a monthly basis ... ".

Observation on June 19, 2017, at 12:30 PM of the Southside Hallway Supply Room that contained an emergency code cart revealed it contained Epi Pen Jr. 2 Pak with expiration date of January 2017 and Epinephrine injection autoinjector with expiration of May 2017.

Interview with EMP1 on June 19, 2017, at 12:30 PM confirmed the Epi Pen Jr. 2 Pak and Epinephrine injection autoinjector medications were expired.


Cross Reference:
482.12- Condition - Governing Body
482.25(a)(3) -Standard - Pharmacy Drug Records

Based on review of facility documents and interviews with staff (EMP), it was determined the Food and Dietetic Services Director was not a full-time employee devoted exclusively to the hospital.

Findings include:

Review on June 20, 2017, of the Food and Dietetic Services Director's Job Description, no date, revealed the "Location:" section was blank. Further review of this document revealed "Job Duties/Essential Functions ... Achieve compliance with federal, state, and local agencies to include the National School Lunch program [this is not part of the hospital]."

Interview with EMP14 on June 20, 2017, at 1:47 PM, confirmed EMP14 oversees four additional KidsPeace programs that are not part of the hospital. These included the Residential treatment facility, two outpatient programs, and the school program. EMP14 confirmed she is not exclusively devoted to the management of the hospital's dietary department in a full-time capacity.

___________________________________________________________________________

Based on review of facility documents, observation and interview with staff (EMP), it was determined the Food and Dietetic Services Director failed to ensure dietary services were provided in safe and sanitary environment for 4 of 4 kitchenettes located on patient modules.

Findings include:

Review on June 20, 2017, of facility policy "Food Service Safety" last reviewed August 4, 2004, revealed "IV. General-Food service handlers; any staff, volunteer, parent, guardian, or client involved in the preparation, handling and storage of food or food items at KidsPeace Programs ..."

Review on June 20, 2017, of facility policy "Food Storage" reviewed October 28, 2013, revealed "II. Purpose- to establish necessary guidelines for the proper storage of food ... III. Scope- KidsPeace Corporation ... V. Policy, A. Proper Food Storage, 1. All food that is being stored shall be protected against any contamination including dust, vermin, flies, rodents and overhead leaks."

1. Observation on June 19, 2017, at 10:50 AM of the North East module's kitchenette refrigerator/freezer revealed one box of precooked sausages that was opened and dated, one plastic container labeled "Meat Entrees" dated 4/18, one plastic container labeled "Vegetarian" dated 4/18.

Interview on June 19, 2017, with EMP1 confirmed they did not know if the dates on the container were considered the "used-by" date or the date the food was delivered to the unit.

2. Observation on June 19, 2017, at 11:15 AM of the Lower Level Central module's kitchenette revealed an open cardboard box containing the following foods that were opened and not dated: one bag of pretzels, one box of rice cereal, one bag of gluten-free pretzels, one box of gluten-free pastries and one box of snack crackers. Further observation of the kitchenette cabinets revealed six boxes of cereal that were opened and not dated.

Interview on June 19, 2017, at 11:25 AM with EMP2 confirmed the packages of food in the cardboard box and cabinets were opened and not dated.

3. Observation on June 19, 2017, at 11:33 AM, of the Northwest module's kitchenette revealed seven boxes of cereal and two containers of cereal which were opened but not dated. Further observation revealed there was significant dirt and debris build up inside of the freezer. The floors, cabinets, and countertops were sticky to touch.

Interview on June 19, 2017, at 11:35 AM with EMP 11 confirmed there were seven boxes of cereal and two containers of cereal which were opened but not dated in Northwest module's kitchenette. EMP 11 also confirmed the floors, cabinets, and countertops were sticky to touch.

4. Observation on June 19, 2017, at 2:03 PM, of the Lower Level North module's kitchenette revealed there was food in open containers in the freezer that was opened and not dated. Further review of the kitchenette revealed the refrigerator's freezer had a dirty yellowish like substance and a separate red like substance in it. The shelving in the refrigerator had numerous brown like stains in it.

Interview on June 19, 2017, at 2:05 PM, with EMP11 confirmed there was food in open containers in the freezer that was opened and not dated in Lower Level North module's kitchenette. EMP11 further confirmed the refrigerator's freezer had a dirty yellowish like substance and a separate red like substance in it and that the shelving in the refrigerator had numerous brown like stains in it.

Cross Reference:
482.12 - Condition -Governing Body

Based on review of facility documents and interview with staff (EMP), it was determined the facility failed to ensure two or more physicians or other qualified practitioners were members of the Utilization Review (UR) committee and failed to ensure physician members were not professionally involved in the care of patients reviewed at the meeting.

Findings include:

Review of facility policy "Concurrent Utilization Review Plan," revised 5/20/2016, revealed "... C. Committee Composition and Organization- The UR Committee, is established to perform the required functions for the National Hospital, will consist of the following individuals: Manager of Utilization Management, Chairperson (EMP13); Executive Director, Hospital; Director of Nursing, Hospital (EMP1); Director of Social Services, Hospital (EMP11); Child Psychiatrist, Hospital (OTH3); Family Practice Physician, Hospital; Medical Records Representative (EMP12); Appeals Coordinator ..."

1. Review of facility document "UR Committee Meeting, January 10, 2017, at 1:00 PM" revealed the following members were present at the meeting: "UR Supervisor, Physician Assistant, Psychiatrist, Administrative Assistant, Director of Hospital, Administrative Assistant."

2. Review of facility document "UR Committee Meeting, February 14, 2017, at 1:00 PM" revealed the following members were present at the meeting: "UR Supervisor, Physician Assistant, Psychiatrist, Administrative Assistant."

3. Review of facility document "UR Committee Meeting, March 21, 2017, at 1:00 PM" revealed the following members were present at the meeting: "UR Supervisor (EMP13), Physician Assistant (OTH6), Psychiatrist (OTH3), Administrator Assistant, Director of Admissions."

4. Review of facility document "UR Committee Meeting, April 11, 2017, at 1:00 PM" revealed the following members were present at the meeting: "UR Supervisor, Physician Assistant, Psychiatrist, Director of Operations."

5. Review of facility document "UR Committee Meeting, May 9, 2017, at 1:00 PM" revealed the following members were present at the meeting: "UR Supervisor, Physician Assistant, Psychiatrist, Director of Hospital, Director of Social Services."

Interview on June 22, 2017, at 10:15 AM with EMP13 confirmed the required committee members were not present at the UR Committee meetings from January 2017 thru May 2017 and confirmed 2 physicians were not present at the meetings.

6. Review on June 22, 2017, of facility document "UR Committee Meeting Minutes," dated January 10, 2017, revealed MR23 was reviewed at the meeting. Further review revealed OTH3 attended the meeting and was professionally involved with MR23's care.

7. Review on June 22, 2017, of facility document "UR Committee Meeting Minutes," dated February 14, 2017, revealed MR23 was reviewed at the meeting. Further review revealed OTH3 attended the meeting and was professionally involved with MR23's care.

8. Review on June 22, 2017, of facility document "UR Committee Meeting Minutes," dated March 21, 2017, revealed MR23 was reviewed at the meeting. Further review revealed OTH3 attended the meeting and was professionally involved with MR23's care.

9. Review on June 22, 2017, of facility document "UR Committee Meeting Minutes," dated April 11, 2017, revealed MR23 was reviewed at the meeting. Further review revealed OTH3 attended the meeting and was professionally involved with MR23's care

10. Review on June 22, 2017, of facility document "UR Committee Meeting Minutes," dated May 9, 2017, revealed the following medical records (MR) were reviewed: MR23, MR24, MR25 and MR30. Further review revealed OTH3 attended the meeting and was professionally involved with the patients care.

Interview on June 22, 2017, at 10:20 AM confirmed OTH3 was a member of the UR Committee and attended the meetings monthly. Further interview confirmed OTH3 was professionally involved in the care of the patients in MR23, MR24, MR25 and MR30.

Cross Reference:
482.12 Condition - Governing Body
482.30 Condition - Utilization Review

Based on review of facility documents, and interviews with staff (EMP), it was determined the facility failed to have a policy and procedure for the storage and disposal of trash.

Findings include:

Review on June 21, 2017, of facility policies and procedures revealed there was no policy for the storage and disposal of trash.

Interview on June 21, 2017, at 2:27 PM, confirmed there was no policy and procedure for the storage and disposal of trash.


Cross Reference:
482.12 - Condition -Governing Body
482.41(c)(2)-Facilities, Supplies, Equipment Maintenance

Based on observations, review of facility policies and procedures, and interviews with staff (EMP), it was determined the facility failed to maintain its facilities and maintain its equipment in eight out of eight patient care modules observed.

Findings include:

1) Review on June 23, 2017, of facility document, dated June 21, 2017, 2:26 PM, revealed " ... Subject: Hospital PM [Preventative Maintenance] Numbers Year to Date for Hospital and all its assets; PM's Created=502 PM's Completed 323 PM Backlog = 178 ..."

Interview with EMP1 on June 21, 2017, at 4:09 PM, confirmed the above findings in the facility document was for hospital assets and equipment.

2) A request was made to EMP1 and EMP2 on June 19, 2017, for 6-12 months worth of "Environment of Care" tours. EMP2 provided the surveyors with one month for January 2017. No other "Environment of Care" tour documents were provided.

3) A request was made on June 22, 2017, to EMP2, for the hospital's cleaning policies and procedures. Interview with EMP2 on June 22, 2017, at 12:05 confirmed the hospital did not have written cleaning policies and procedures.

4) Review on June 20, 2017, of facility documents, revealed ten out of ten Air Handler units had "required completion Dates" of January 31, 2016. Further review revealed the "date completed" for these Air Handlers was May 11, 2016. This was greater than three months past the required completion dates.

A request was made on June 20, 2017, to EMP1 for the facility's policy and procedure for the hospital's preventative maintenance program.

Interview with EMP1 on June 21, 2017, at 4:09 PM, confirmed the facility did not have a policy and procedure for the hospital's preventative maintenance program. EMP1 provided the survey a policy and confirmed that the policy was created on June 21, 2017.

5) Observation on June 19, 2017, of the patient care modules between 11 AM and 3 PM revealed the following:

The kitchenettes on the six open patient care modules had sticky floors, cabinets, and countertops. There was dirt and debris on the floors and on top of the refrigerators.

Interview with EMP3 on June 19, 2017, at 2:45 PM confirmed the cleaning of kitchenettes on the patient care modules was to be done by environmental services employees, mental health techs, and dietary employees.

Bathroom shower floors had black, moldy like substances on them. The carpets on the units were stained and sticky. There were areas with rips and tears in the carpets.

Laundry rooms on the patient care modules had black marks amd debris on the floor, the washer/dryer units had black marks on the outside, laundry was placed on the floors.

A request was made to EMP1, on June 19, 2017, for documentation that the carpets were steamcleaned and for a schedule of when such cleaning takes place on a routine schedule. None was provided.

Interview with EMP11, on June 19, 2017, between 11 AM and 3 PM, confirmed the above findings.


Cross Reference:
482.12 - Condition -Governing Body
482.41(c)(2)-Facilities, Supplies, Equipment Maintenance

Based on review of facility document, review of personnel file (PF) and interview with staff (EMP), it was determined the facility failed to ensure that the designated infection control officer had ongoing education or specialized training in infection control other than what was required by facility staff.

Findings include:

Review on June 21, 2017, of facility document "Job Description Infection Control Committee Chair," revealed, "Qualifications ... training and experience in Infection Control preferred ... "

Review on June 20, 2017, of PF4 revealed no documentation of ongoing control training or specialized training other than what was required by facility staff.

Interview with EMP5 on June 21, 2017, at 9:30 AM confirmed they were the designated infection control officer. Further interview with EMP5 confirmed they did not have ongoing education or specialized training in infection control other than what was required by facility staff.

_____________

Based on review of facility policy and procedures and interview with staff (EMP), it was determined the facility failed to ensure there were approved policies and procedures relevant to construction, renovation, maintenance demolition, and repair, including the requirement for an infection control risk assessment (ICRA) to define the scope of the project and need for barrier measure before a project gets underways.

Findings include:

On June 21, 2017, surveyor requested a facility Infection Control policy and procedure for infection control risk assessment (ICRA). None was provided.

Review on June 21, 2017 of facility Infection Control Policies and Procedures were no documented evidence of approved policies relevant to construction, renovation, maintenance demolition, and repair, including the requirement for an infection control risk assessment (ICRA) to define the scope of the project and need for barrier measure before a project gets underways.

Interview with EMP5 on June 21, 2017, at 9:30 AM the facility did not have approved policies relevant to construction, renovation, maintenance demolition, and repair, including the requirement for an infection control risk assessment (ICRA) to define the scope of the project and need for barrier measure before a project gets underways.


Cross Reference:
482.12 - Condition- Governing Body

Based on review of facility policies and procedures, and interviews with staff (EMP), it was determined the facility failed to have written policies and procedures to address its organ procurement responsibilities.

Findings include:

A request was made to EMP2 on June 20, 2017, for the facility's written policies and procedures that addressed the facility's organ procurement responsibilities. None was provided.

Interview with EMP2 on June 20, 2017, at 3:40 PM, confirmed the facility did not have written policies and procedures that addressed the facility's organ procurement responsibilities.

Cross Reference:
482.12 Condition - Governing Body
482.45 Condition - Organ, Tissue, Eye Procurement
482.45(a)(1)-OPO Agreement
482.45(a)(2)-Tissue and Eye Bank Agreements
482.45(a)(3)-Designated Requestor
482.45(a)(5)-Staff Education

Based on review of facility documents, and interviews with staff (EMP), it was determined the facility failed to have a written agreement with an Organ Procurement Organization.

Findings include:

Review on June 20, 2017, of facility documents revealed no written agreement with an Organ Procurement Organization.

A request was made to EMP2 on June 20, 2017, for the facility's written agreement with an Organ Procurement Organization. None was provided.

Interview with EMP2 on June 20, 2017, at 3:45 PM, confirmed the facility did not have a written agreement with an Organ Procurement Organization.


Cross Reference:
482.12 Condition - Governing Body
482.45 Condition - Organ, Tissue, Eye Procurement
482.45(a)-Written Policies and Procedures
482.45(a)(2)-Tissue and Eye Bank Agreements
482.45(a)(3)-Designated Requestor
482.45(a)(5)-Staff Education

Based on review of facility documents, and interviews with staff (EMP), it was determined the facility failed to have an agreement with at least one tissue bank and one eye bank.

Findings include:

Review on June 20, 2017, of facility documents revealed no written agreement with at least one tissue bank and one eye bank.

A request was made to EMP2 on June 20, 2017, for the facility's written agreement with at least one tissue bank and one eye bank. None was provided.

Interview with EMP2 on June 20, 2017, at 3:50 PM, confirmed the facility did not have a written agreement with at least one tissue bank and one eye bank.


Cross Reference:
482.12 Condition - Governing Body
482.45 Condition - Organ, Tissue, Eye Procurement
482.45(a)-Written Policies and Procedures
482.45(a)(1)-OPO Agreement
482.45(a)(3)-Designated Requestor
482.45(a)(5)-Staff Education

Based on review of facility policies and procedures, and interviews with staff (EMP), it was determined the facility failed to designate an individual to initiate the request to the family for organ procurement.

Findings include:

A request was made to EMP2 on June 20, 2017, for the facility's written policies and procedures that addressed the facility's organ procurement responsibilities including designating an individual to speak to families of deceased patients. None was provided.

Interview with EMP2 on June 20, 2017, at 3:40 PM, confirmed the facility did not have written policies and procedures that addressed the facility's organ procurement responsibilities including designating an individual to speak to families of deceased patients.

Cross Reference:
482.12 Condition - Governing Body
482.45 Condition - Organ, Tissue, Eye Procurement
482.45(a)-Written Policies and Procedures
482.45(a)(1)-OPO Agreement
482.45(a)(2)-Tissue and Eye Bank Agreements
482.45(a)(5)-Staff Education

Based on review of facility policies and procedures, and interviews with staff (EMP), it was determined the facility failed to have written policies and procedures to address its organ procurement responsibilities including staff education.

Findings include:

A request was made to EMP2 on June 20, 2017, for the facility's written policies and procedures that addressed the facility's organ procurement responsibilities including staff education. None was provided.

Interview with EMP2 on June 20, 2017, at 3:40 PM, confirmed the facility did not have written policies and procedures that addressed the facility's organ procurement responsibilities including staff education.

Cross Reference:
482.12 Condition - Governing Body
482.45 Condition - Organ, Tissue, Eye Procurement
482.45(a)-Written Policies and Procedures
482.45(a)(1)-OPO Agreement
482.45(a)(2)-Tissue and Eye Bank Agreements
482.45(a)(3)-Designated Requestor

Based on record review and staff interview it was determined that for eight (8) of eight (8) Psychosocial Assessments (Patients A1, A2, B1, C1, D10, E8, E10 and F5) there was a failure to include the anticipated role of the social service staff toward discharge planning. This failure results in other members of the multidisciplinary team not knowing what efforts are being considered in the discharge planning.

Findings include:

A. Medical Record Review:

1. Patient A1: The Psychosocial Assessment, dated 6/15/17, had no description of the anticipated role for social service staff.

2. Patient A2: The Psychosocial Assessment, dated 6/14/17, had no description of the anticipated role of the social service staff.

3. Patient B1: The Psychosocial Assessment, dated 6/15/17, had no description of the anticipated role of the social service staff.

4. Patient C1: The Psychosocial Assessment, dated 5/10/17, had no description of the anticipated role of the social service staff.

5. Patient D10: The Psychosocial Assessment, dated 3/27/17, had no description of the role of the social service staff.

6. Patient E8: The Psychosocial Assessment, dated 6/7/17, had no description of the role of the social service staff.

7. Patient E10: The Psychosocial Assessment, dated 6/12/17, had no description of the role of the social service staff.

8. Patient F5: The Psychosocial Assessment, dated 4/11/17, had no description of the role of the social service staff.

B. Staff Interview:

On 6/20/2017 at 9:45a.m., the facility's Director of Clinical Services and the Director of Hospital Services, both Social Workers, were interviewed by the surveyors. They were shown three (3) of the Psychosocial Assessments referenced in Section A above. After examining them, both agreed that the anticipated role for social service staff toward discharge planning was not described.

Based on medical record review and interview it was determined that for three (3) of eight (8) patients (Patients A1, A2 and B1) their Psychiatric Evaluations failed to describe patient assets in descriptive, not interpretive fashion. This failure results in no information such as hobbies, interests, achievements, etc. that might be used in therapeutic endeavors.

Findings include:

A Record Review:

1. Patient A1: The Psychiatric Evaluation, dated 6/15/17, had no description of patient assets.

2. Patient A2: The Psychiatric Evaluation, dated 6/15/17, stated as the sole patient asset "Patient is a good swimmer." It should be noted the facility has no swimming pool for the acutely ill patients.

3. Patient B1: The Psychiatric Assessment, dated 6/16/17, stated "[S/he] doesn't have neurovegetative symptoms of depression and has good intellectual functioning."

B. Interview:

On 6/21/17 at 10:00a.m., the facility's clinical director was interviewed, including a focus on the findings described in Section A above. The clinical director agreed that the assessments did not include patient specific assets that might be utilized in therapeutic endeavors.

Based on record review and interview it was determined that for eight (8) of eight (8) patients (Patients A1, A2, B1, C1, D10, E8, E10 and F5) the Master Treatment Plans failed to include:

I. goals that were stated in a behaviorally measurable terms. (Refer to B121 for details)

11. Treatment interventions that were more than generic discipline functions and were individualized in order to be patient specific in intent. (Refer to B122 for details)

III. Responsible staff to monitor the effectiveness of chosen modalities identified by name and discipline. (Refer to B 123 for details)

These failures result in treatment plans that are uninformative, lack patient specific treatment interventions and delineate which member of the multidisciplinary treatment team is to be held accountable.

Based on medical record review and staff interview it was determined that the multidisciplinary treatment plans for eight (8) of eight (8) patients (Patients A1, A2, B1, C1, D10, E8, E10 and F5) were not written in observable, measurable patient behaviors. This failure results in an inability to determine if the chosen treatment modalities are successful or if they need to be revised.

Findings include:

A. Record Review:

1. Patient A1: The Master Treatment Plan, dated 6/17/17, stated as goals "[name of patient] will show increasing ability to control impulses to harm [him/herself]. Client will verbally contract for safety." Also "[name of patient] will report a decrease in suicidal impulses or ideation and return to previous level of daily functioning. Client will utilize a safety plan to use when not feeling safe."

2. Patient A2: The Master Treatment Plan, dated 6/14/17, stated as goals "[name of patient] will show increasing ability to control impulses to harm [him/herself] and others. [Name of patient] will no longer present as a danger to self or others." Also, "[name of patient] will show evidence of elevated mood and ability to function safely in daily activities. [Name of patient] will show a decrease in depressive symptoms."

3. Patient B1: The Master Treatment Plan, dated 6/16/17, stated as goals "[name of patient] will show increasing ability to control impulses to harm self or others. [name of patient] will learn and utilize coping skills that help [him/her] avoid hurting [him/herself] and others." Also, "[name of patient] will report a reduction in suicidal impulses or ideation and return to highest previous level of daily functioning. Client will explore triggers for suicidal ideation and positive coping skills [s/he] can utilize to express [his/her] emotions safely."

4. Patient C1: The Master Treatment Plan, dated 6/13/17, stated as goals "[name of patient] will show increasing ability to control impulses to harm [him/herself] and others. Client will demonstrate an ability to manage [his/her] moods and behaviors through positive coping strategies."

5. Patient D10: The Master Treatment Plan, dated 6/8/17, stated as goals "[name of patient] will show increasing ability to control impulses to harm [him/herself] and others. Client will exemplify their ability to utilize anger management and coping skills to control [his/her] urges to harm [him/herself] and others."

6. Patient E8: The Master Treatment Plan, dated 6/8/17, stated as goals "[name of patient] will show increasing ability to control impulses to harm [him/herself] and others. Name of patient] will learn and utilize coping skills as to not harm [him/herself]." Also, "[name of patient] will demonstrate an increased ability to manage [his/her] impulses. [Name of patient] will identify safe ways to communicate [his/her] feelings."

7. Patient E10: The Master Treatment Plan, dated 6/9/17, stated as goals "[name of patient] will show increasing ability to control impulses to harm [him/herself] and others. [name of patient] will learn and utilize coping skills in order to help [him/her] avoid harming [him/herself] and others."

8. Patient F5: The Master Treatment Plan, dated 6/10/17, stated as goals "[name of patient] will show increasing ability to control impulses to harm [him/herself] and others. Client will learn and utilize coping skills as to not harm [him/herself]."

B Interview:

An interview was conducted on 6/20/17 at 10:00a.m. with the facility's Director of Clinical Services and the Director of Social Work who had been identified by administration as responsible for the formulation and appropriateness of Master Treatment Plans utilized on the 6 "modules" of acute care services. Both were shown examples cited in Section A above. Both agreed that, as stated, the goals were not expressed in a measurable fashion.

Based on record review and interview it was determined that eight (8) of eight (8) patients (Patients A1, A2, B1, C1, D10, E8, E10 and F5) had Master Treatment Plans that failed to include the patient specific treatment modalities that would be utilized .Rather a listing of generic discipline functions were stated. In addition, there were no interventions stated in B1's MTP for the psychiatrist or the collaborative nurse practioner. This failure results in a simple naming of modalities and/or approaches that also lacked a focus of the treatment and a description of individualized patient specific approaches.

Findings include:

A. Record Review:

1. Patient A1: The Master Treatment Plan, dated 6/16/17, stated for the Problem "Danger to Self" "Nursing staff will make the hospital a safe place where feelings can be shared." "Staff will .provide daily individual and group sessions that will coach [name of patient] in building skills to safely manage and express [him/herself]." "Staff will set firm and consistent limits to give [name of patient] choices and self-control."

2. Patient A2: The Master Treatment Plan, dated 6/14/17, stated for the Problem "Danger to Self and Others" "Staff will set firm and consistent limits to give [name of patient] choices and encourage self-control." "Rec. Therapist to provide on-going assessment and involve [name of patient] in an activity modality providing expressive outlet for self-harming thoughts and emotions." (The facility has not had a Rec. Therapist per facility Vice-Pres. for several years.) "Staff will provide daily individual and group sessions that will coach [name of patient] in building skills to manage and express [him/herself]."

3. Patient B1: The Master Treatment Plan, dated 6/16/17, stated for the Problem "Danger to Self and Others" "Nursing staff will make the hospital a safe place where feelings can be shared." "Nursing staff will ensure [name of patient's] safety and monitor daily by following special precautions or protocols as ordered." There were no interventions stated by the psychiatrist or collaborative nurse practioner.

4. Patient C1: The Master Treatment Plan, dated 6/13/17, stated for the Problem "Danger to Self or Others" "[name od doctor]o assess pervasiveness of [name of patient's] presenting symptoms and determine through interview whether a situational or long standing issue, while exploring relevant family history" For the Problem "Impulse Control Problems" "Nursing staff will help [name of patient] in group(s) and individual session(s) to make and share a list of ideas [s/he] can use to control [his/her] impulses."

5. Patient D10: The Master Treatment Plan, dated 6/8/17, stated for the Problem "Danger to Self and Others" ""Nursing staff will make the hospital a safe place where feelings can be shared." "Staff will set firm and consistent limits to give [name of patient] choices and encourage self control."

6. Patient E8: The Master Treatment Plan, dated 6/8/17, stated for the Problem "Danger to Self and Others" "[name of doctor] will order medications as needed and monitor the effects daily." "Nursing staff will make the hospital a safe place where feelings can be shared." For the Problem "Anger Management" the intervention was "Nursing will help [name of patient] in daily group(s) and individual session(s) to make a list of ideas [s/he] can use to help manage [his/her] anger."

7. Patient E10: The Master Treatment Plan, dated 6/9/2017 stated for the Problem "Danger to Self and Others" "[name of doctor] will order medications as needed and monitor the effects daily." "Nursing staff will make the hospital a safe place where feelings can be shared."

8. Patient F5: The Master Treatment Plan dated 6/10/17, stated for the Problem "Danger to Self and Others" "[name of doctor] will order medications as needed and monitor the effects daily." "Nursing will make the hospital a safe place where feelings can be shared."

B. Interview:

On 6/20/17 at 10:00 a.m. the Director of Hospital Services, who is the supervisor of the facility's Director of Social Work and the Social Work Director, were interviewed. They were selected as having been identified as responsible for Treatment Plan quality throughout the 6 "modules" on the acute care component of the facility. They were shown several of the examples described in Section A above. They both agreed that the interventions were generic discipline functions, that several different patients had the same interventions listed, and that not all disciplines had interventions.

Based on record review and interview it was determined that for eight (8) of eight (8) patients (Patients A1, A2, B1, C1, D10, E8, E10 and F5) the Master Treatment Plans failed to identify the responsible staff member for the various treatment modalities chosen. This failure to identify a responsible staff member results in no one being held accountable for monitoring the effectiveness of the modalities selected.

Findings include:

A.Record Review:

All eight (8) active sample patients had "staff" or "nursing staff" as providing various interventions: (dates of Master Treatment Plans in parentheses) Patient A1 (6/16/2017),Patient A2 (6/14/2017), Patient B1(6/17/2017),Patient C1 (6/13/2017), Patient D10(6/8/2017), Patient E8(6/8/2017), Patient E10 (6/9/2017) and Patient F5( 6/10/2017)

B. Interview:

On 6/20/17 at 10:00a.m., the Director of Hospital Operations and the Director of Social Work were interviewed. A partial focus of the interview was the absence of an identification of a responsible nursing staff member by name and credential when the Master Treatment Plan stated various modalities for that discipline. They agreed that the findings were valid.

Based on medical record review and staff interview it was determined that the clinical director failed to ensure that:

1) For three (3) of eight (8) patients (Patients A1, A2 and B1) Psychiatric Evaluations contained a description of patient assets in descriptive, not interpretive fashion. This failure results in no information about patient interests, accomplishments, goals, hobbies, etc. that might be used as a basis for therapeutic endeavors such as the selection of treatment modalities. For details, see B117

2) For eight (8) of eight (8) active sample patients (A1, A2, B1, C1, D10, E8, E10 and F5), Master Treatment Plans were written that contained:

a. Goals written in measurable behaviorable terms. See B121 for details

b. Interventions that were not generic discipline functions. See B122 for details

c. Responsible staff by name and discipline to hold accountable for monitoring the appropriateness and effectiveness of chosen modalities. See B123 for details

These failures result in Master Treatment Plans that are uninformative, not patient specific and lack the identification of which member of the multidisciplinary treatment team is to be held accountable.

Based on record review and interview, it was determined that the Director of Nursing failed to ensure that:

A. Nursing interventions were individualized to meet the specific needs of eight (8) of eight (8) active sample patients (A1, A2, B1, C1, D11, E8, E10, and F5).

Findings include:

Record Review

1. Patient A1: The Master Treatment Plan, dated 6/16/17, stated for the Problem "Danger to Self" "Nursing staff will make the hospital a safe place where feelings can be shared." "Staff will provide daily individual and group sessions that will coach [name of patient] in building skills to safely manage and express [him/herself]." "Staff (includes nursing staff) will set firm and consistent limits to give [name of patient] choices and self-control."

2. Patient A2: The Master Treatment Plan, dated 6/14/17, stated for the Problem "Danger to Self and Others" "Staff will set firm and consistent limits to give [name of patient] choices and encourage self-control." "Staff will provide daily individual and group sessions that will coach [name of patient] in building skills to manage and express [him/herself]."

3. Patient B1: The Master Treatment Plan, dated 6/16/17, stated for the Problem "Danger to Self and Others" "Nursing staff will make the hospital a safe place where feelings can be shared." "Nursing staff will ensure [name of patient's] safety and monitor daily by following special precautions or protocols as ordered."

4. Patient C1: The Master Treatment Plan, dated 6/13/17, stated for the Problem "Impulse Control Problems" "Nursing staff will help [name of patient] in group(s) and individual session(s) to make and share a list of ideas [s/he] can use to control [his/her] impulses."

5. Patient D10: The Master Treatment Plan, dated 6/8/17, stated for the Problem "Danger to Self and Others" ""Nursing staff will make the hospital a safe place where feelings can be shared." "Staff will set firm and consistent limits to give [name of patient] choices and encourage self-control."

6. Patient E8: The Master Treatment Plan, dated 6/8/17, stated for the Problem "Danger to Self and Others" "Nursing staff will make the hospital a safe place where feelings can be shared." For the Problem "Anger Management" the intervention was "Nursing will help [name of patient] in daily group(s) and individual session(s) to make a list of ideas [s/he] can use to help manage [his/her] anger."

7. Patient E10: The Master Treatment Plan, dated 6/9/2017 stated for the Problem "Danger to Self and Others" "Nursing staff will make the hospital a safe place where feelings can be shared."

8. Patient F5: The Master Treatment Plan dated 6/10/17, stated for the Problem "Danger to Self and Others" "Nursing will make the hospital a safe place where feelings can be shared."

B. The full name and discipline of the nursing staff responsible for carrying out nursing interventions was present on Master Treatment Plans. (Refer to B123)

C. The facility provided adequate numbers of registered nurses (RNs) on all tours of duty to provide direct patient care and to supervise non-professional nursing personnel. The Director of Nursing had "zero" RNs out of a total 84 shifts for six units (staffing analysis of 14 shifts over seven days for all 6 for twenty 12 hour shifts units, totaling 84 shifts). This results in a lack of professional nurses to provide on-going patient assessments, direction and supervision of non-professional nursing personnel. (Refer to B149)

D. There was supervision and monitoring of patient care through appropriate nursing staff assignments at all times for all 6 inpatient units. This lack of adequate professional nursing staff creates a potential for inadequate physical and mental care for these patients. (Refer to B150.)

Based on record review and interview, the facility failed to provide adequate numbers of registered nurses (RNs) on all tours of duty to provide direct patient care and to supervise non-professional nursing personnel. The Director of Nursing had "zero" RNs for twenty 12 hour shifts out of a total 84 shifts for six units (staffing analysis of 14 shifts over seven days times 6 units totals 84 shifts.) This results in a lack of professional nurses to provide on-going patient assessments, direction and supervision of non-professional nursing personnel.

Findings include:

A. Record Review

(Note: the licensed nursing personnel work 12 hour shifts)
Seven days of nurse staffing data for the period of 6/9/17 - 6/11/17 and 6/16/17 - 6/19/17 were provided by the Director of Nursing. An analysis of the data revealed the following:

1. There was one 7:00 p.m. to 7:00 a.m. shift (6/18/17) with zero RN coverage on North East Unit and 0.5 RN (1 nurse covering two units - South East and LLC [Lower Level Central] located in the basement of the building). One LPN was in-charge on 6/18/17 from 7:00 p.m to 7:00 a.m. on the North East unit.

2. There were zero RNs covering 7:00 a.m. to 7:00 p.m. shifts on North West Unit on 6/16/17, 6/17/17, 6/18/17 and 6/19/17. A LPN was in charge of these shifts.

3. There was zero RN coverage 7:00 a.m. to 7:00 p.m. shift on LLN [Lower Level North] Unit 4 7:00 a.m. to 7:00 p.m. shifts on 6/9/17, 6/10/17, 6/11/17 and 6/17/17 and 0.5 RN (one nurse covering 2 units) 6/10/17 (North West and LLN).

4. There was 1 RN covering two units (Lower Level North and South East) on 7:00 p.m. to 7:00 a.m. shift on 6/10/17 and 6/18/17.

5. South Center Unit -For period of 6/9/17 to 6/11/17, there were zero RNs on the 7:00 a.m. to 7:00 p.m. shifts. There was 0.5 RN (one nurse covering two units - South Central and Southwest) from 7 p.m. to 7 a.m. on 6/10/17.

6. There were three 7:00 a.m. to 7:00 p.m. shifts on Southwest Unit on 6/17/17, 6/18/17 and 6/19/17 with zero RNs. An LPN was in charge these days. There was 0.5 RN on Southwest Unit (one nurse covering South Central and Southwest units on 6/10/17.)

7. There were five 7:00 a.m. to 7:00 p.m. shifts on LLC [Lower Level Central] on 6/9/17, 6/10/17, 6/11/17, and 6/18/17 and 6/19/17, that had zero RN staff. There were two 7p.m. to 7a.m. shifts that had zero RNs on (6/16/17 and 6/17/17). Two 7:00 p.m. to 7:00 a.m. shifts had 0.5 RNs (one nurse covering two units) on 6/10/17 and 6/18/17).

B. Interview

1. On 6/19/17 at 12:00 noon with LPN #1, she stated that she was the charge nurse on Northwest Unit.

2. In an interview on 6/20/17 at 2:30 p.m., the finding of LPNs on many units in the charge nurse capacity was discussed with the Nursing Director. She acknowledged that this situation existed, but stated they were working on hiring more professional nurses (RNs) to eliminate the problem.

Based on record review and interview, the facility failed to ensure the supervision and monitoring of patient care through appropriate nursing staff assignments at all times for all six (6) inpatient units. This lack of adequate professional nursing staff creates a potential for inadequate physical and mental care for these patients.

Findings include:

A. Record Review

An analysis of 7 days of nurse staffing data provided by the Director of Nursing for the period of 6/9/17 - 6/11/17 and 6/16/17 - 6/19/19 revealed the following:

1. Northeast Unit had two 7:00 p.m. to 7:00 a.m. shifts (6/10/17 and 6/18/17) where on 6/10/17 one RN covered two patient units (Northeast and Northwest) and one LPN covered Northeast from 7:00 p.m. to 7:00 a.m. and Northwest from 7:00 p.m. to 10:00 p.m. The nursing needs assessment sheet for Northwest, dated 6/19/17, had one patient with diabetic checks, one patient with potential assaultive behavior, one patient with actively assaultive behavior within last 48 hours, one intermediate risk suicidal (high potential for self-injury( requires close observation), 4 patients admitted within the last 48 hours, one constantly demanding staff time (eg. request, interruptions), one 1:1 (one to one supervision), one under constant line of sight, 10 patients with every 15 - 30 minute supervision checks and 12 patients who attend activities off ward without accompaniment.

2. Northwest Unit had one RN covering three 7:00 a.m. to 7:00 p.m. shifts (6/9/17, 6/10/17, and 6/11/17). The nursing needs assessment form, completed 6/19/17, had one patient with diabetic checks, one potentially assaultive ( has occasionally demonstrated during hospitalization), one actively assaultive (has evidenced physically/ verbally within 48 hours), one immediate risk suicidal (high potential for self-injury (requires close observation), 4 patients admitted within last 48 hours, one patient who was on special monitoring due to eating disorders, one patient on 1:1 supervision, one patient under constant line of sight supervision, 10 patients requiring every 10 - 15 minute supervision, and 12 patients who attend off ward activities with staff.

3. Lower Level North (LLN) Unit had 1 RN covering 6/10/17 from 7:00 a.m. to 3:00 p.m.; one RN covering 7:00 a.m. to 7:00 p.m. on 6/10/17 and 6/12/17, and one RN covering 11:00 a.m. to 7:00 p.m. on 6/16/17, one LPN covered as charge nurse on 6/9/17, 6/10/17, and 6/11/17 from 7:00 a.m. to 7:00 p.m. and on 6/16/17 from 7:00 a.m. to 7:00 p.m. One RN covered two units (LLN and Southeast) from 7:00 p.m. to 7:00 a.m. on 6/10/17 and 6/18/17.

The nursing needs assessment forms, completed 6/19/17, had one patient potentially assaultive (has occasionally demonstrated during hospitalization), one actively assaultive (has evidenced physically, verbally within last 48 hours), one low risk suicidal (requires some protection against impulses), one intermediate risk suicidal (high potential for self-injury - requires close observation), one patient placed in seclusion and/or restraints (leather, wrist to waist, fully body, etc. within last 48 hours), one constantly demanding staff time (e.g. requests, interruptions), 2 who are on special monitoring due to eating disorders, one on 1:1 supervision, 2 under constant line of sight supervision, 6 on every 15 - 30 minute supervision checks and 9 attending activities off ward with staff.

4. Southeast Unit had one RN covering 7:00 a.m. to 7:00 p.m. on 6/9/17 - 6/11/17 and 6/17/17 - 6/19/17, one RN covering 7:00 p.m. to 7:00 a.m. on 6/9/17, 6/11/17, 6/16/17, 6/17/17 and 6/19/17. 1 RN covered two units (LLN and Southeast) on 6/10/17 and 6/18/17 from 7:00 p.m. to 7:00 a.m. The nursing needs assessment sheet from Southeast, dated 6/19/17 had 4 patients requiring partial assistance from staff, 2 patients who were potentially assaultive (has occasionally demonstrated during hospitalization), 3 patients who were actively assaultive (has evidenced physically/verbally within last 48 hours), one patient admitted within the last 48 hours, one patient who constantly demanded staff time (e.g. request, interruptions), 11 patients on every 3 - 4 hours supervision checks, and 11 patients who attend activities off ward with staff.

5. Southwest Unit had one RN 3 (State level for pay purposes) 7:00 a.m. to 7:00 p.m. shifts on 6/9/17, 6/10/17, 6/11/17 and 6/16/17 and a LPN in charge on 3 shifts on 6/17/17, 6/18/17 and 6/19/17. There was one RN covering 2 units (0.5 RN) on 6/10/17 and 6/18/17 (Southwest and Lower Level Central). The needs assessment sheet, dated 6/19/17, for Southwest had 2 patients who were potentially assaultive (has occasionally demonstrated during hospitalization), 2 patients actively assaultive (has evidenced physically/verbally within last 48 hours), 1 patient on low risk suicidal (has occasionally demonstrated during hospitalization), 2 patients who were actively assaultive (has evidenced physically/verbally within last 48 hours), one patient on low risk suicidal (requires some protection against impulses), one acute risk suicidal (in immediate danger of suicide), 2 patients were admitted within the last 48 hours, one patient on full precautions, one patient who was on special monitoring due to eating disorder, one patient on 1:1 supervision, one patient under constant line of sight supervision, 13 patients on every 15 - 30 minutes supervision checks, and 15 patients who attend activities off ward with staff.

6. Lower Level Central Unit had 1 RN on 7:00 a.m. to 7:00 p.m. shift on 6/16/17 and 1 LPN in charge on 7:00 a.m. to 7:00 p.m. shift on 6/9/17 - 6/11/17 and on 6/17/17 and 6/19/17. There was 1 RN on 7:00 p.m. to 7:00 a.m. shift six of seven shifts on dates of 6/9/17, 6/11/17, and 6/16/17). 1 RN covered 2 units (0.5 RN) on 6/10/17 7:00 p.m. to 7:00 a.m. and on 6/18/17 for same shift. The two units were Southwest and South Central on 6/10/17; the two units were Lower Level Central and Southeast on 6/18/17. The nursing needs assessment form The Lower Level Central assessment form, dated 6/19/17, had 2 patients who were potentially assaultive (has occasionally demonstrated during hospitalization), 2 actively assaultive (has evidenced physically/verbally within last 48 hours), one patient low risk suicidal (requires some protection against impulses), one patient on acute risk - suicidal (in immediate danger of suicide), 2 patients were admitted within the last 48 hours, one patient was receiving ECT [Electric Convulsive therapy], one patient who was on special monitoring due to eating disorder, one patient on 1:1 supervision, one patient under constant line of sight supervision, 13 patients on every 15 - 30 minute supervision checks, and 15 patients attending activities off ward with staff.


B. Interview

In an interview on 6/20/17 at 2:35 p.m., the lack of sufficient coverage by professional nurses (RNs) on the inpatient units at all times was discussed with the Nursing Director. She did not dispute the findings.

Based on medical record review and staff interview it was determined that the Director of Social Work failed to ensure that for eight (8) of eight (8) patients (Patients A1, A2, B1,C1, D10, E8, E10 and F5) their Psychosocial Assessments contained a description of the anticipated role of the social service staff in discharge planning. This failure results in no information being available to the other members of the multidisciplinary treatment team about possible discharge efforts.

The findings include----

A. Record Review:

1. Patient A1: The Psychosocial Assessment, dated 6/15/17, had no description of the anticipated role for social service staff.

2. Patient A2: The Psychosocial Assessment, dated 6/14/17, had no description of the anticipated role of the social service staff.

3. Patient B1: The Psychosocial Assessment, dated 6/15/17, had no description of the anticipated role of the social service staff.

4. Patient C1: The Psychosocial Assessment, dated 5/10/17 had no description of the anticipated role of the social service staff.

5. Patient D10: The Psychosocial Assessment, dated 3/27/17, had no description of the role of the social service staff.

6. Patient E8: The Psychosocial Assessment, dated 6/7/17, had no description of the role of the social service staff.

7. Patient E10: The Psychosocial Assessment, dated 6/12/17, had no description of the role of the social service staff.

8. Patient F5: The Psychosocial Assessment, dated 4/11/17, had no description of the role of the social service staff.

B. Interview:

On 6/20/2017 at 9:45 am the facility's Director of Clinical Services and the Director of Hospital Services, both Social Workers, were interviewed by the surveyors. They were shown 3 of the Psychosocial Assessments referenced in Section A above. After examining them, both agreed that the anticipated role for social service staff toward discharge planning was not described.

Based on interview, it was determined that the facility failed to provide rehabilitation services and therapeutic activities for eight (8) of eight (8) active sample patients (A1, A2, B1, C1, D11, E8, E10, and F5). This failure to provide appropriate activity services results in lack of active treatment based on the identified needs of these patients.

Findings include:

During the initial meeting with executive staff on 6/19/17 around 8:40 a.m., when asked about identifying the names of an occupational or recreational staff person to interview at the facility, the Vice President of the company stated they had not had any of these (OT or RT person) in several years.

Based on record review and interview, the facility failed to plan and implement structured programming of therapeutic/leisure activities for eight (8) of eight (8) active sample patients (A1, A2, B1, C1, D11, E8, E10, and F5). The failure results in inconsistent availability and provision of individualized therapeutic activities services based on patient needs.

Findings include:

A. Record Review

A review of each unit's program schedule showed activities during the week and on weekends. The surveyor was told by the Assistant Director of Nursing that all patients were expected to attend the groups held on their unit. When shown the activity schedule for the Northwest unit, the Assistant Nursing Director was asked what disciplines provided the group. She stated that he nursing staff (RNs and MHTs) run all of the groups except the "Process Group," held by the social work staff.

B. Interviews

1. In an interview on 6/16/17 at 11:07 a.m., MHT1 was asked how s/he determines what topics to discuss in each group s/he holds. MHT1 stated, "I look through printed information and get ideas from television and morning team reports to decide what might work for the patients present on the unit." When asked what s/he documents in each patient's record, MHT1 stated, "I put the topic of the group and whether the patient participated or not."

2. In an interview on 6/16/17 at 11:40 a.m., active sample patient B1 was asked how s/he liked the groups being provided to him/her. S/he stated, "I don't like them. I'm bored."

3. In an interview on 6/16/17 around 1:00 p.m. with active sample patient A2, s/he was asked if the staff kept them busy on the unit. S/he stated, "Yes. We go to the gym one time during the week and 2 times on the weekend. They keep us busy on the weekend watching movies and playing cards."

4. In an interview on 6/16/17 at 11:07 a.m., MHT1 stated that the mental health technicians run the majority of the activity groups on each patient unit, and do not do an assessment of each patient's individual needs.

5. In an interview on 6/17/17 at 10:50 a.m. with RN1, the lack of activity assessments of patient's needs by nursing and MHTs doing groups was discussed. S/he did not dispute the findings.

Based on interview and record review, the facility failed to provide adequate numbers of qualified therapeutic staff to offer services to meet the needs of eight (8) of eight (8) active sample patients (A1, A2, B1, C1, D11, E8, E10, and F5). This failure results in fragmented treatment for the patients and hinders patient's progress toward treatment goals.

Findings include:

A. Interviews

1) During the initial meeting with executive staff on 6/19/17 around 8:40 a.m., when asked about identifying the names of an occupational or recreational staff person to interview at the facility, the Vice President of the company stated they had not had any of these (OT or RT person) in several years.

2) When shown the activity schedule for the Northwest unit, the Assistant Nursing Director was asked what disciplines provided the groups. She stated that the nursing staff (RNs and MHTs) run all of the groups except the "Process Group," which is led by a Social Worker.

3) In an interview on 6/16/17 at 11:07 a.m., MHT1 stated that the mental health technicians run the majority of the activity groups on each patient unit.

B. Record Review

A review of the Master Treatment Plans of the eight (8) active sample patients showed that no specific groups from each unit's schedule were put in the Master Treatment Plans.