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Based on record review and interview, the hospital failed to meet the Condition of Participation for Governing Body. The hospital's governing body failed to effectively carry out its responsibilities for the conduct of the hospital for the hospital's compliance not only with the specific standards of the governing body CoP, but also with the following CoPs. This deficient practice is evidenced by:
1) failure of the governing body to protect and promote each patient's rights, which resulted in two Immediate Jeopardy Situations. S1ADM was notified on 08/06/2024 at 1:46 p.m. of the first Immediate Jeopardy situation resulting from failure of the hospital to prevent patient access into the kitchen where items that could be used as weapons are kept. S1ADM was notified on 08/07/2024 at 7:56 p.m. of the second Immediate Jeopardy situation resulting from the hospital failure to provide supervision as ordered by the physician. (See Findings in A0115);
2) failure of the governing body to ensure the hospital had an organized nursing service. This noncompliance resulted in a third Immediate Jeopardy situation. S1ADM was notified on 08/08/2024 at 3:35 p.m. the Immediate Jeopardy situation existed resulting from the hospital failure to ensure the registered nurses did not practice out of their scope of practice. (See findings in A0385);
3) failure of the governing body to ensure the Quality Assessment Performance Improvement (QAPI) Program specified the method and frequency of data collection for indicators. Failure of the governing body to ensure the hospital's Quality Assurance and Performance Improvement (QAPI) program identified opportunities for improvement, implemented effective action, measured success and tracked performance. Failure of the governing body to ensure the hospital tracked and analyzed all events involving abuse and neglect. Failure of the governing body to ensure the medical staff and administrative officials were responsible and accountable for implementing and maintaining an ongoing program for quality improvement and patient safety. Failure of the governing body to ensure sufficient staff was available to conduct the Quality Assurance/Performance Improvement (QAPI) functions of the hospital (See findings in A0263);
4) failure of the governing body to ensure an active hospital-wide program for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. Failure of the governing body to ensure programs that demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic resistant organisms (See findings in A0747);
5) failure of the governing body to ensure an effective Utilization Review (UR) plan that provides for review of services furnished by the institution and by members of the medical staff to patients entitled to benefits under the Medicare and Medicaid programs (See findings in A652).
6) failure of the governing body to consult directly with the member/members of the hospital's medical staff assigned the responsibility for the organization and conduct of the hospital's medical staff (See findings in A0053).

Based on record review and interview the psychiatric hospital's governing body failed to consult directly with the member/members of the hospital's medical staff assigned the responsibility for the organization and conduct of the hospital's medical staff, or his or her designee. This deficient practice is evidenced by failure to provide documented evidence of direct consultation with medical staff assigned the responsibility for the organization and conduct of the hospital's medical staff, or his or her designee.
Findings:

Review of the Medical Staff Bylaws, no documented date of last review but was presented to the surveyors as the current bylaws, revealed in part: Section 2. Committees and Subcommittees in part: A ....The function of the Medical Executive Committee shall include, but not be limited to, in part: 2) receiving and acting upon reports and recommendations from medical staff committees, subcomittees, services and assigned activity groups and reporting these activities to the Governing Board. 8) reviewing and discussing matters of hospital and medical staff policy, practice, planning as requested by ...the Governing Board.

Review of Governing Board Meeting minutes dated 01/09/2024-07/31/2024, failed to reveal documented evidence of direct consultation with medical staff assigned the responsibility for the organization and conduct of the hospital's medical staff, or his or her designee.

In an interview on 08/05/2024 at1:07 p.m., S1ADM confirmed that the Governing Board Meeting minutes dated 01/09/2024-07/31/2024 failed to reveal documented evidence of direct consultation with medical staff assigned the responsibility for the organization and conduct of the hospital's medical staff, or his or her designee.

Based on observation, record review, and interview, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. The hospital failed to protect and promote each patient's rights as evidenced by:
1) failure of the hospital to provide supervision as ordered by the physician which resulted in an Immediate Jeopardy Situation. S1ADM was notified on 08/07/2024 at 7:56 p.m. The hospital provided the following plan of removal for the Immediate Jeopardy situation 08/12/2024 at 9:55 a.m.:
A. Director of Nursing observed PM shift on 8/7/2024 via remote surveillance. As a result, the MHT from 8/3/2024, who was observed then with electronics, food, and delinquency in Q15 rounded, will be terminated immediately for neglect and false documentation during the 8/7/2024 PM shift.
B. Immediate reeducation of RNs and MHTs to include:
1. Purpose-To establish guidelines and procedures for completion of the Patient Observation Record Sheet. To ensure that the patient's safety and well-being are maintained and documented. To have a continuous record of patient behavior and location.
2. Policy 4.2.0 PATIENT OBSERVATION RECORD
a. Emphasizing 15 minute rounds for Mental Health Technicians and 2 hour rounds for Charge Nurses.
b. Precaution Level ordered for each patient:
i. Suicide Precautions
ii. Assault Precautions
iii. Elopement Precautions
iv. Fall Precautions
v. Seizuure Precautions
c. Level of Observation ordered for each patient:
i. Close Observation with Unit Restriction
ii. Close Observation without Unit Restriction
iii. Visual Contact
iv. 1:1
v. Other
3. Focus on the Mission Statement:
a. "It is the mission of Community Care Hospital to continually improve the health and well-being of our patients, and to provide caring and personal treatment to our patients and their families."
4. Education will be confirmed by the signature of the employee and placed in the personnel file. Return demonstration executed in real time and monitored by video surveillance.
C. Immediate real time video review and confirmation of PM shift rounding to include; 2 hour RN rounding and Q15 MHT rounding.
D. The Administrator, DON, or designee will view historical video from 18:30 to 06:30 in 2-hour intervals commencing at 20:00, 22:00, 00:00, 02:00, 04:00, and 06:00 while the shift is ongoing "real time." All 12 hours of video will be reviewed.
E. This video review will remain nightly until 90% compliance is demonstrated for Q15s and 100%compliance for 2-hour RN rounds.
F. After that compliance level has been maintained for 2 weeks, the video review will change to a random 3 night a week schedule.
G. When compliance levels are maintained for 1 month, weekly next day video review will commence on a random night rotation for quality and performance improvement.
H. Enforcement of progress discipline will be imposed on all staff members found to be out of compliance including termination.
I. Compliance data will be collected and included in the nursing QAPI reports.
J. Immediate termination of the Charge Nurse who displayed egregious disregard for the safety and wellbeing of the patients in his care on 08/06/2024. This Charge Nurse will also be reported to the Louisiana Board of Nursing for neglect and false documentation.
K. Current staff must complete training prior to shift with ongoing training until total staff is completed
On 08/12/2024 at 3:29 p.m., the Immediate Jeopardy Situation was lifted but there was not enough evidence to determine sustainability of compliance for the Condition of Patient Rights to be cleared therefore the deficiencies remain at Condition levels (See findings in A0144);

2) failure of the hospital to prevent patient access into the kitchen where items that could be used as weapons are kept resulted in an Immediate Jeopardy Situation. S1ADM was notified on 08/06/2024 at 1:46 p.m. The hospital provided the following plan of removal for the Immediate Jeopardy situation 08/07/2024 at 8:37 a.m.:
A. It was determined that this door is not a protected fire exit.
B. The door can be closed and locked.
C. A key lock will be placed on this door immediately on Tuesday 08/06/2024.
D. The door will be locked unless food service is underway. At that time, the door will be locked upon ingress and egress.
E. A door alarm will be installed by 08/07/2024 that will activate a tone when the door is opened.
F. A sign with the following information will be posted on both sides of the door:
1. This Door Must Remain Locked At All Times!
2. You Must Lock The Door Each Time You Pass In Or Out!
G. Staff will be educated through a communication memo in the Communication binder located on each unit (entered 08/06/2024) and face to face at the beginning of each shift until all current staff have signed off on the education.
H. Orientation to which key and confirmation of the "always locked" requirement will be included.
I. The education will also include the possible impact on patient and staff safety if the door is not locked.
J. Corrective actions to be completed 08/15/2024 including the education of current staff.
On 08/07/2024 at 9:00 a.m., the Immediate Jeopardy Situation was lifted but there was not enough evidence to determine sustainability of compliance for the Condition of Patient Rights to be cleared therefore the deficiencies remain at Condition levels(See findings in A0144);

3) failure to ensure incidents involving serious and unexplainable injuries are investigated and reported in order to determine if abuse or neglect had occurred (See findings in A0145);
4) failure to ensure restraint and seclusion was used only when less restrictive interventions had been determined to be ineffective to protect the patients from harm. (See findings in A0164);
5) failure to ensure the patients basic right to respect, dignity, and comfort while in restraints and seclusion (See findings in A0143);
6) failure to ensure patients on suicide precautions are not provided clothing containing ligature risk (See findings in A0144);
7) failure to ensure staff does not provide items considered ligature risks to patients (See findings in A0144);
8) failure to ensure the hospital's security staff were educated, trained and demonstrated knowledge on the use of nonphysical intervention skills (See findings in A0200);
9) failure to ensure security staff personnel records contained documentation demonstrating that Orientation was successfully completed and Patient Rights competencies had been successfully completed upon hire (See findings in A0208);
10) failure to ensure required numbers of staff when transporting patients in the elevator (See findings in A0144);
11) failure to ensure all exit doors were secure (See findings in A0144);
12) failure to ensure patients are escorted off unit in a manner to maintain safety (See findings in A0144);
13) failure to ensure sharps are disposed of in a manner to minimize the potential for injury (See findings in A0144);
14) failure to secure staff personal belongings (See findings in A0144);
15) failure to ensure patients did not have access to items considered ligature risk and contraband (See findings in A0144);
16) failure to ensure maintenance cart filled with tools that could be potential weapons was covered in patient care areas (See findings in A0144); and
17) failure to properly label Embrace Pro Glucose Test Strips and Embrace Pro Control Solutions upon initial opening of new containers (See findings in A0144).

Based on record review and interview, the hospital failed to ensure the patient /patient representative's right to participate in the development and implementation of his or her plan of care was met. This deficient practice was evidenced by failure to ensure the patient /patient representative was included in the development and implementation of the patient's plan of care for 6 (#6, #R1, #R3 - #R6) of 16 (#1- #7, #R1 - #R9) patient medical records reviewed for care plan development and implementation.
Findings:

Review of the hospital's policy titled, "Patient Rights", approved 06/2024, revealed in part: Procedure, in part: ...All patients have the right to ...7. The right to participate in the development and implementation of his/her plan of care. 8. Make informed decisions regarding his/her care. 9. Be informed of his/her health status, be involved in care planning and treatment, and be able to request or refuse treatment.

A medical record review on 08/12/2024 for patient participation in the development and implementation of patient's treatment plan of care revealed:

Patient #6 was admitted 08/05/2024 and the current treatment plan was dated 08/05/2024 at 9:49 a.m. The treatment plan revealed in part: "A Treatment Plan was created or reviewed today, 08/05/2024, for Patient #6." Further review failed to reveal documentation Patient #6 participated in the development in his plan of care.

Patient #R1 was admitted 08/04/2024 and the current treatment plan was dated 08/05/2024 at 9:42 a.m. The treatment plan revealed in part: "A Treatment Plan was created or reviewed today, 08/05/2024, for Patient #R1." Further review failed to reveal documentation Patient #R1 participated in the development in his plan of care.

Patient #R3 was admitted 08/06/2024 and the current treatment plan was dated 08/07/2024 at 9:24 a.m. The treatment plan revealed in part: "A Treatment Plan was created or reviewed today, 08/07/2024, for Patient #R3." Further review failed to reveal documentation Patient #R3 participated in the development in his plan of care.

Patient #R4 was admitted 07/31/2024 and the current treatment plan was dated 08/01/2024 at 9:40 a.m. The treatment plan revealed in part: "A Treatment Plan was created or reviewed today, 08/01/2024, for Patient #R4." Further review failed to reveal documentation Patient #R4 participated in the development in his plan of care.

Patient #R5 was admitted 08/03/2024 and the current treatment plan was dated 08/05/2024 at 9:35 a.m. The treatment plan revealed in part: "A Treatment Plan was created or reviewed today, 08/05/2024, for Patient #R5." Further review failed to reveal documentation Patient #R5 participated in the development in his plan of care.

Patient #R6 was admitted 07/29/2024 and the current treatment plan was dated 07/29/2024 at 9:44 a.m. The treatment plan revealed in part: "A Treatment Plan was created or reviewed today, 08/05/2024, for Patient #R6." Further review failed to reveal documentation Patient #R6 participated in the development in his plan of care.

In an interview on 08/12/2024 at 2:00 p.m. S2DON confirmed the above mentioned findings.

Based on observation and interview the hospital failed to ensure Patient #2's basic right to respect, dignity, and comfort while in restraints and seclusion.
Findings:

Review of hospital's policy titled, "Patient Rights," approved 06/2024, revealed in part: Procedure: ...4. The right to be treated with consideration, respect and recognition of their individuality, including the need for privacy in treatment.

Review of Patient #2's medical record revealed a diagnosis of Down's Syndrome.

On 08/05/2024 at 3:15 p.m., a review of video footage for the night of 08/03/2024 at 8:48 p.m. was navigated by S1ADM. Review of footage of Unit A revealed staff carrying Patient #2, naked except for a shirt bunched up around her neck and around her armpits. Patient #2 was carried by her arms and legs out of her bedroom, past Unit A's nurses station, down Unit A hallway towards Unit A seclusion room. Patient #2 remained in seclusion room on a bare mattress with no sheet and with no clothes to the bottom half of her body. At 12:16 a.m. she was provided with green, drawstring-waist scrub pants just before she left Unit A's seclusion room.

In an interview on 08/08/2024 at 12:30 p.m., S1ADM confirmed the above video findings.

In an interview on 08/08/2024 at 12:40 p.m., S2DON stated that staff should have attempted to provide Patient #2 clothing to protect her right to respect and dignity.

Based on observation, record review, and interview, the hospital failed to ensure patients receive care in a safe setting as evidenced by:
1) failure of the hospital to provide supervision as ordered by the physician of 17 (#1-#3, #5, #6, #R1, #R2, #R4-#R6, #R10-#R16) of 17 (#1-#3, #5, #6, #R1, #R2, #R4-#R6, #R10-#R16) psychiatric patients observed;
2) failure of the hospital to prevent patient access into the kitchen where items that could be used as weapons are kept;
3) failure to ensure patients on suicide precautions are not provided clothing containing ligature risk;
4) failure to ensure staff does not provide items considered ligature risks to patients;
5) failure to ensure required numbers of staff when transporting patients in the elevator;
6) failure to ensure all exit doors were secure;
7) failure to ensure patients are escorted off unit in a manner to maintain safety;
8) failure to ensure sharps are disposed of in a manner to minimize the potential for injury;
9) failure to secure staff personal belongings;
10) failure to ensure patients did not have access to items considered ligature risk and contraband;
11) failure to ensure maintenance cart filled with tools that could be potential weapons was covered in patient care areas; and
12) failure to properly label Embrace Pro Glucose Test Strips and Embrace Pro Control Solutions upon initial opening of new containers.
Findings:

1) Failure of the hospital to provide supervision as ordered by the physician to 18 (#1-#3, #5, #6, #R1-#R6, #R10-#R16) of 18 (#1-#3, #5, #6, #R1-#R6, #R10-#R16) psychiatric patients observed.

On 08/07/2024 at 2:50 p.m., a review of video footage navigated by S1ADM of Unit C on 08/03/2024 within the timeframe of 12:00 a.m. to 4:24 a.m. revealed the RN did not round every two hours. Further review revealed that the MHTs failed to round between:
12:00 a.m. to 12:30 a.m. (30 minutes)
12:30 a.m. to 2:30 a.m. (2 hours)
2:30 a.m. to 4:24 a.m. (1 hour and 54 minutes)

Continued review revealed between 2:48 a.m. until 3:08 a.m. (20 minutes) there was only 1 MHT on the Unit C.

On 08/07/2024 at 3:50 p.m. a review of video footage navigated by S1ADM of Unit A on 08/06/2024 from 9:36 p.m. to 11:00 p.m. revealed the registered nurse left the unit at 10:43 p.m. and did not return until 11:00 p.m. (17 minutes) leaving the 2 MHTs alone.

Continued review of video footage of Unit A on 08/06/2024-08/07/2024 from 10:10 p.m. to 6:34 a.m. revealed the MHTs failed to round between:
10:10 p.m. to 10:35 p.m. (25 minutes)
11:05 p.m. to 12:12 a.m. (1 hour and 7 minutes)
12:20 a.m. to 12:55 a.m. (35 minutes)
12:55 a.m. to 1:35 a.m. (40 minutes)
1:56 a.m.-3:45 a.m. (1 hour and 49 minutes)
4:23 a.m. to 5:35 a.m. (1 hour and 12 minutes)
5:35 a.m. to 6:34 a.m. (59 minutes)

Further review revealed S46RN was sitting in Unit A nursing station, in a chair, slumped with head bobbing and computer inactive at 11:26 p.m. until 2:00 a.m. (2 hours and 34 minutes).

Additional review revealed S46RN remained in chair in nurses' from 2:10 a.m. to 5:05 a.m. (2 hours and 55 minutes).

Review of observation records failed to reveal documentation that S46RN completed his every 2 hour rounding as per policy from 12:00 a.m. until 6:00 a.m. (6 hours) on 08/07/2024.

Review of patient records for Unit C revealed 1 patient (#R11) on visual contact and suicide precautions, 2 patients (#R12 and #3) on suicide and assault precautions, and 2 patients (#R2 and #R14) on suicide precautions.

Review of patient records for Unit A revealed 1 patient (#6) on suicide, withdrawal and fall precautions, 2 patients (#2 and #R5) on seizure precautions and 1 patient (#R3) on visual contact precautions.

In an interview on 08/07/2024 at 3:04 p.m., S1ADM confirmed rounding was not implemented per physician orders and hospital policy on patients #1-#3, #5, #6, #R1-#R6, #R10-#R16 by staff on the nights of 08/03/2024 and 08/06/2024-08/07/2024. S1ADM agreed this placed all 18 patients at risk for serious injury, serious harm, serious impairment or death.

2) Failure of the hospital to prevent patient access to items that could be used as weapons by leaving the door to the kitchen open during patient meal time.
Observation of area oo 08/06/2024 at 11:28 a.m. revealed 7 (#R1-#R6) patients with 2 MHTs. Further observation revealed door to ss wide open with 1 staff member (S58Kit) in the kitchen preparing meals with her back to the open entry door. Continued observation from outside of the kitchen revealed the back door to the kitchen was ajar.

In an interview on 08/06/2024 at 11:29 a.m., S58kit stated the back door is usually open in case she has deliveries or maintenance needs to enter.

In an interview on 08/06/2024 at 11:28 a.m., S59MHT stated that the kitchen has many things like knives that are safety issues in the kitchen. S59MHT also reported that patients could elope out the back door of the kitchen or someone could unknowlingly come into the hospital from the open back door of the kitchen.

3) Failure to ensure patients on suicide precautions are not provided clothing containing ligature risk.
Review of hospital's policy titled "Patient Rights" dated 06/2024 revealed in part: All patients have the right to...18. ...receive care in a safe setting.

Observations of hospital conference room on 08/05/2024 at 12:30 p.m. revealed stacks of green scrubs including pants with drawstring waistbands that extend to 4 ft 9 inches.

Observations of Unit C on 08/05/2024 at 1:41 p.m. guided by S1ADM revealed Patient #1 in green scrubs with drawstring waist.

Review of Patient #1's medical record revealed Patient #1 was admitted on 08/05/2024. Further review revealed admit orders for suicide precautions.

Observations of Unit A on 08/05/2024 at 2:08 p.m. guided by S1ADM revealed Patient #6 in green scrubs with drawstring waist.

Review of Patient #6's medical record revealed Patient #6 was admitted on 08/02/2024 at 8:00 p.m. Further review revealed admit orders for moderate suicide precautions.

In an interview on 08/05/2024 at 12:57 p.m., S1ADM stated the green scrubs were provided to patients that were admitted without a change of clothing. S1ADM confirmed the green scrubs with drawstrings that extend to 4 ft 9 inches were a ligature risk and should not be available for patient use.

In an interview on 08/05/2024 at 1:41 p.m., S1ADM stated that Patient #1 should be provided with alternative clothing immediately for her safety. S1ADM instructed an MHT to provide Patient #1 with appropriate clothing immediately.

In an interview on 08/05/2024 at 2:33 p.m., S1ADM stated that Patient #6 should be provided with alternate clothing immediately.

4) Failure to ensure staff does not provide items considered ligature risks to patients.
Observation on 08/05/2024 at 10:58 a.m. revealed room e. Continued observation revealed 7 zip ties in closet of room e. Review of census revealed Patient #6 was assigned to room e.

Review of Patient #6's medical record revealed Patient #6 was admitted on 08/02/2024 at 8:00 p.m. Further review revealed admit orders for moderate suicide precautions.

In an interview on 08/05/2024 at 10:59 a.m., Patient #6 reported staff gave him the zip ties to help keep his pants from falling off. Patient #6 did not remember when staff gave him the zip ties and he could not recall the staff member's name.

In an interview on 08/052024 at 11:02 a.m., S1ADM verified that Patient #6 should not have zip ties because zip ties were considered a ligature risk.

5) Failure to ensure required numbers of staff when transporting patients in the elevator
Review of hospital's policy titled, "Escorting Patients Off the Unit", dated 01/2024, revealed, in part: Policy Statement: Staff members assigned to escort a patient, or a group of patients shall be responsible for the safety and well-being of the individual and/or group from the time of leaving the unit until return to the unit. Purpose: To establish guidelines for the safe transport of patients off the unit. Procedure, in part: 1 ....The staff-patient ration will be no less than two staff members for every group of up to ten patients when leaving the secured nursing unit. This will apply to meal times and smoke breaks. 6. Staff members should see that the group stays together.

Review of video footage dated 08/06/2024, navigated by S1ADM on 08/08/2024 at 12:59 p.m. revealed the following:
View of area rr:
5:10 p.m. - Security guard stood in area rr with 7 patients. S39MHT and Patient #R2 not in camera view.
5:11 p.m. - S39MHT walked out of cafeteria to the elevator and with 7 patients on elevator held elevator door open.
5:12 p.m. - S39MHT held elevator open while security guard walked into cafeteria and walked out from dining room, arm-in-arm with Patient #R2 who appeared unsteady and escorted her on to elevator.
5:13 p.m.-S52MHT walked out of cafeteria with two pitchers of water and was not in the elevator with S39MHT leaving 1 MHT alone with the 8 patients
View of Unit C:
5:16 p.m. - S39MHT picked Patient #R2 from under her arms and dragged her off elevator and set her on floor outside elevator.

In an interview on 08/08/2024 at 1:05 p.m., S1ADM verified 2 MHT's should have been in the elevator with 8 patients per hospital policy.

6) Failure to ensure all exit doors were secure.
On 08/05/2024 at 11:05 a.m. toured the back stairwell from floor 2 down to first floor with S1ADM. 1st floor back stairwell opens into back hallway with an exit door to front lobby and an exit door to exterior of facility. The back exit door upon inspection was found partially ajar. The door was not secured and could be opened from the outside.

During tour on 08/05/2024 at 11:07 a.m., S1ADM confirmed the findings above.

On 08/06/2024 at 11:29 a.m., hospital video footage was reviewed for the day of the incident that occurred in room rr on 08/05/2024, navigated by S1ADM. Review of the video footage revealed the following:
08/05/2024 View of room rr:
4:09:39 p.m. - S39MHT enters into room rr and stops at door to stairwell with patients and family walking into room rr. S40MHT is behind the remaining patients and family walking into room rr.
4:09:48 p.m. - A visitor of R7 walks out the front entrance of the facility.
4:09:49 p.m. - R7 runs out front entrance.
4:09:54 p.m. - S39MHT turns and runs out door after R7.
4:10:02 p.m. - S24SEC stands up from desk, walks from desk toward front door.
4:10:07 p.m. - S24SEC at front door.
08/05/2024 View of outside front entrance:
4:09:54 p.m. - R7 viewed running out front door to the left down the street. S39MHT walks out front door.
4:11 p.m. - S39MHT returns to front door without R7 and is talking with visitor.

Review of incident report revealed on 08/05/2024 at 4:10 p.m. R7 "left AMA after visitation with family. Patient ran out of front door lobby and jumped into her girlfriends car." Type of incident: Elopement (law enforcement notified). Witnesses: S39MHT and S40MHT. Action taken: Law enforcement notified: "unavailable" Date & Time: 08/05/2024 at 4:10 p.m. S1ADM notified 4:32 p.m. S6PsyMD notified at 4:22 p.m.

During interview on 08/06/2024 at 11:35 a.m. S1ADM confirmed that security is supposed to stand at front door entrance when patients enter and exit room rr.

During interview on 08/06/2024 at 11:40 a.m. S1ADM confirmed that staff failed to secure the front door entrance when the patients and family entered room rr. S1ADM confirmed that he was notified of this incident at 5:41 p.m. on 08/05/2024.

During interview on 08/06/2024 at 3:00 p.m. S24SEC confirmed that neither S39MHT nor S40MHT informed her that they were coming out of room oo into room rr in order for S24SEC to position herself at the front entrance.

7) Failure to ensure patients are escorted off unit in a manner to maintain safety
Review of hospital's policy titled, "Escorting Patients Off the Unit", dated 01/2024, revealed, in part: Policy Statement: Staff members assigned to escort a patient, or a group of patients shall be responsible for the safety and well-being of the individual and/or group from the time of leaving the unit until return to the unit. Purpose: To establish guidelines for the safe transport of patients off the unit. Procedure, in part: 1 ....The staff-patient ration will be no less than two staff members for every group of up to ten patients when leaving the secured nursing unit. This will apply to meal times and smoke breaks. 6. Staff members should see that the group stays together.

On 08/08/2024 at 11:52 a.m., hospital video review of Unit C on 08/07/2024, navigated by S1ADM revealed the following:
08/07/2024
7:49 p.m. - S18MHT and S39MHT rounding on patients.
7:50 p.m. - S45RN rounds on unit.
7:57 p.m. - S18MHT leaves Unit C with R8 and R9 via stairwell.
8:07 p.m. - S39MHT rounds on remaining patients on the unit.
8:11 p.m. - S18MHT returns to Unit C via elevator with R8 and R9.

During an interview on 08/08/2024 at 12:12 p.m. S1ADM confirmed staff are not to take patients off the unit down a stairwell unless the elevator is out of service. S1ADM also confirmed that patients should not leave the unit to go smoke with only 1 MHT.

8) Failure to ensure sharps are disposed of in a manner to minimize the potential for injury
Review of hospital policy titled, "Sharps," last revised January 2023, revealed in part: Policy: Sharps include needles ... and "anything that might produce a puncture wound which would expose patients or employees to blood or other potentially infection material." Any used contaminated sharp is to be treated as capable of transmitted blood borne pathogens. Purpose: To establish guidelines and procedures for sharps disposal. To minimize the potential of injury by puncture producing items. C. Uncooperative Patients: 1. Self-sheathing needles shall be used whenever possible. 2. The nurse shall be accompanied by as many personnel as deemed necessary to safely administer the infection or perform phlebotomy, or any necessary venipuncture. 3. If non-self-sheathing needles are used, a small sharps container is to be brought to the room prior to the injection, and all procedures as previously stated under needles are to be implemented.

During an observation on 08/05/2024 of Unit C, Patient #2 was witnessed having seizure like activity in the main hallway at 10:44 a.m. S55RN medicated Patient #2 with an Intramuscular injection in the hallway. S55RN then walked through Unit C while holding the syringe with a used uncapped needle pointed upward, and went into room mm where he disposed of the used needle at 10:51 a.m.

During an interview on 08/05/2024 at 10:45 a.m. S1ADM confirmed that staff should not be walking around with a used uncapped needle. S1ADM also confirmed that this could be used as a weapon by a patient.

9) Failure to secure staff personal belongings
Review of hospital policy titled, "Employee Lockers," last revised January 2024, revealed in part: Policy Statement: Our facility will provide a locker to each employee for his/her personal use. Procedure: 1. Our facility provides a locker ... for safekeeping his/her personal effects.

On 08/05/2024 at 10:44 a.m., S52MHT was observed having her personal belongings (cross body purse) on her person while on the unit. While S52MHT was assisting a seizing patient during this time, S52MHT was observed removing her cross body purses and setting it on the floor behind her in the hallway. Further observation of S52MHT revealed that she put her cross body purse back on after assisting the patient, at which point she continued to wear it while in patient care areas.

During an interview on 08/05/2024 at 11:00 a.m. S1ADM confirmed that employees should not have their personal belongings with them while on the unit. S1ADM also confirmed that the strap from the cross body purse could a ligature risk.

On 08/07/2024 at 2:50 p.m., hospital video review of Unit C on 08/03/2024, navigated by S1ADM revealed S42MHT having a computer tablet on the table in front of him in the main hallway.

During an interview on 08/07/2024 at 3:15 p.m., S1ADM confirmed that employees should not have their personal belongings with them while on the unit. S1ADM also confirmed that the computer tablet could be used as a weapon.

On 08/08/2024 at 11:10 a.m., hospital video review of Unit A on 08/07/2024, navigated by S1ADM revealed S43MHT having a computer tablet on her lap while playing on her cell phone in the main hallway.

During an interview on 08/08/2024 at 11:35 a.m., S1ADM confirmed that employees should not have their personal belongings with them while on the unit. S1ADM also confirmed that the computer tablet could be used as a weapon.

On 08/08/2024 at 12:18 p.m., hospital video review of Unit A on 08/04/2024, navigated by S1ADM revealed S38MHT having a earbuds in her ear and a backpack on the floor next to her in the main hallway. Further review of the video revealed S38MHT leaving her personal belongings unattended.

During an interview on 08/08/2024 at 12:30 p.m., S1ADM confirmed that employees should not have their personal belongings with them while on the unit. S1ADM also confirmed that the backpack could contain items that may be used to harm themselves or others.

During an interview on 08/12/2024 at 1:15 p.m. S2DON confirmed that staff are not supposed to have personal belongings on the unit, stating it is a safety risk for the patients.

10) ensure patients did not have access to items considered ligature risk and contraband.
Review of hospital's policy titled, "Unit Safety Rounds Checklist," section 4.14.0 approved 06/2024, revealed in part: Policy Statement: Safety is of utmost importance. The environment of care must be safe for psychiatric patient care. At the beginning of each shift, the Registered Nurse must oversee the environmental rounds to be done by the Mental Health Technicians ...Procedure: At the beginning of each shift, Mental Health Technicians must: 1. Make environmental rounds of their unit. 2. Correct or resolve any issues immediately (ie clear hallways ...remove contraband items from patient rooms ...

A review of a facility notice placed in the locked toiletry cabinets of Units A - C revealed in part: 1. Body wash: 2 tubes (no more than 2 tubes), 2. Shampoo: 2 tubes (no more than 2 tubes), 3. Toothbrush: 1 (Instruct patient not to throw away after 1 use), 4. Toothpaste: 2 tubes (no more than 2 tubes), 5. Deodorant: 1, 6. Hairbrush or comb: 1. The above mentioned items must always be kept in the bins. None of the above items are to be kept in the patient rooms.

Observations during a tour of the hospital on 08/05/2024 from 9:30 a.m. to 11:25 a.m. revealed patient hygiene products in the possession of patient and not securely stored when not in use. The following includes the toiletry items observed and there location:
Room s: Blue toothbrush on bedside table A and comb on bedside table B;
Room q: 2 tubes of Fresh Scent Body wash 30ml container in a brown paper bag;
Room kk: One unlabeled patient toiletry bucket was on top of a locked cabinet and within patient reach. The contents included Fresh Scent Toothpaste 6 oz. tube x 2, Fresh Scent Stick Deodorant 0.5 oz. x 2, Toothbrush (blue) x 1, and Fresh Scent Body Wash 30 ml tube x 2;
Room f: Fresh Scent Toothpaste 6 oz. tube x 1, Fresh Scent Stick Deodorant 0.5 oz. x 1, Toothbrush (blue) x 1, and Fresh Scent Body Wash 30 ml tube x 1 on bedside table A; and
Room b: Toiletry bins located in the closet by Bed #A and on the bedside table of Bed #B. Both of these toiletry bin's included the same items - Fresh Scent Toothpaste 6 oz. tube x 1, Fresh Scent Stick Deodorant 0.5 oz. x 1, Toothbrush (blue) x 1, and Fresh Scent Body Wash 30 ml tube x 1.

Interview on 08/05/2024 at 9:45 a.m. S39MHT confirmed the body wash located in Room q and further confirmed patients are allowed to have toiletries as part of their allowed possessions in their rooms.

In an interview on 08/05/2024 at 10:35 a.m. Patient #5 and present in his assigned room f, confirmed the toiletry items (Fresh Scent Toothpaste 6 oz. tube x 1, Fresh Scent Stick Deodorant 0.5 oz. x 1, Toothbrush (blue) x 1, and Fresh Scent Body Wash 30 ml tube x 1) at his bedside and further confirmed the items have been at his bedside his entire admission. Patient #5 also confirmed he was never instructed his toiletries could not remain at his bedside.

In an interview on 08/05/2024 and present during the tour, S1ADM confirmed the above mentioned findings and further confirmed the toiletry items should be locked up and not in the possession of patients when not in use.

Observation on 08/05/2024 at 9:44 a.m. of room r revealed hair extensions approximately 2 feet long on floor among Patient #3's belongings.

In an interview on 08/05/2024 at 9:45 a.m., S39MHT reported Patient #3 sometimes went into room r to be alone for quiet time. S39MHT confirmed the ligature risk and stated he would put it with her other personal belongings that are in a locked storage locker.

Observation on 08/05/2024 at 11:00 a.m. of Patient #R5's room revealed 4 batteries among patient belongings in closet. Patient #R5 stated he took the batteries out of the TV remote the other day.

In an interview on 08/05/2024 at 11:02 a.m., S1ADM verified Patient #R5 was in possession of 4 batteries and stated batteries are considered contraband. S1ADM reported the batteries should have been located during environmental rounds completed by Mental Health Technicians per policy.

11) Failure to ensure maintenance cart filled with tools that could be potential weapons was covered in patient care areas
Review of hospital's policy titled, "Unit Safety Rounds Checklist," section 4.14.0 approved 06/2024, revealed in part: Policy Statement: Safety is of utmost importance. The environment of care must be safe for psychiatric patient care. At the beginning of each shift, the Registered Nurse must oversee the environmental rounds to be done by the Mental Health Technicians ...Procedure: At the beginning of each shift, Mental Health Technicians must: 2. Correct or resolve any issues immediately (ie clear hallways ...remove contraband items from ...patient care areas ... Mental Health Tech Rounding Sheet includes access to sharps ...access to suffocants ...no doors propped open ... No Doorstops or doors are not propped open ...

Observations on 08/05/2024 at 10:27 a.m. of Unit B revealed an open cart of tools propping open the door of bathroom y. Further review revealed the following items identified on the cart:
Hammer
Handheld screwdrivers
Batteries
Power pack electric drill
Tray of drill bits
Long drill bits
Silicone gun
Silicone filler

In an interview on 08/05/2024 at 10:29 a.m., S23EVS confirmed the cart was not covered in order to prevent patient access to tools that could be potential weapons.

In an interview on 08/05/2024 at 10:45 a.m., S1ADM stated S23EVS was in the vicinity of the cart but that the cart should still be covered.

12) Failure to properly label Embrace Pro Glucose Test Strips and Embrace Pro Control Solutions upon initial opening of new containers
A review of facility policy, "Glucose Test Log," Section 4.9.0, last revised 01/2024, revealed in part: Policy Statement: The hospital nursing staff performs capillary blood glucose levels for patients when ordered by a physician or nurse practitioner. Registered Nurses and Mental Health Technicians must be deemed competent to perform the procedure. Control tests confirm that the meter is functioning properly. The policy did not relate to the documentation of open and beyond use dates on the test strips or control solutions.

A review of the Glucometer Control Testing Instructions placed in each unit's binder containing their corresponding glucometer's quality control testing log revealed in part: Expiration of Glucometer Control: Glucometer controls expires 6 months after opening. Both the opening date and the expiration date (beyond use date) should be written on the control solutions. Expiration of Glucometer Test Strips expire 3 months after opening (beyond use date). Both the opening date and the expiration date (beyond use date) should be written on the strips.

Observations during a tour of the hospital on 08/05/2024 from 9:30 a.m. to 11:25 a.m. revealed Embrace Pro Glucose Test Strips vials and Embrace Pro Control Solutions vials being opened and not properly labeled with an open date and beyond use date (expiration date). This would present a risk for harm or injury to a patient related to treatment being rendered based on the results of a capillary blood glucose reading via a glucometer that has not been properly quality control tested. The undocumented vials were as follows:

Unit A: Embrace Pro Glucose Test Strip vial had an open date of 08/02/2024 marked on the vial, no beyond use date was marked on the vial. Embrace Pro Control Solution #1 vial and Embrace Pro Control Solution #2 vial had no open date or beyond use date marked on each open vial.

In an interview on 08/05/2024 at 10:40 a.m., S55RN confirmed the above mentioned findings.

Unit B: Embrace Pro Glucose Test Strip vial, Embrace Pro Control Solution #1 vial and Embrace Pro Control Solution #2 vial had no open date or beyond use date marked on each open vial.

In an interview on 08/05/2024 at 10:30 a.m., S56RN confirmed the above mentioned findings.

Unit C: Embrace Pro Glucose Test Strip vial, Embrace Pro Control Solution #1 vial and Embrace Pro Control Solution #2 vial had no open date or beyond use date marked on each open vial.

In an interview on 08/05/2024 at 09:55 a.m., S48RN confirmed the above mentioned findings.



48051





50453

Based on observation, record review and interview, the hospital failed to ensure all patients were free from all forms of abuse or neglect. This deficiency is evidenced by failure to ensure incidents involving serious and unexplainable injuries are investigated and reported in order to determine if abuse or neglect had occurred in 1 (#R2) of 3 (#R2, #R7, and #R24) incidents reviewed.
Findings:

Review of hospital's policy titled, "Abuse and/or Neglect of Patients," approved 06/2024, revealed in part: Policy: It is the policy of [the hospital] that ... patients will be given competent and timely medical care. A. definitions, in part: Neglect - a form of abuse. The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. B. Prevention of Abuse and Neglect 3. Unit acuity is assessed every shift to determine that the staff to patient ration is appropriate to meet the specific needs of the patient. C. Identification or Abuse and/or Neglect 1. Inadequate supervision of patients whose physical or mental condition may result in poor judgment, and who are therefore at risk of injury or illness without supervision. D. Reporting Abuse and/or Neglect of Patients. Staff are required to report any incident, which they believe, might constitute abuse or neglect of patients. Because safety of patients is our first concern, a reasonable suspicion about the observed behavior is sufficient to warrant reporting the situation so that any necessary corrections can be made to prevent or reduce harm to the patient.

Review of hospital's policy titled, "Patient Rights," approved 06/2024, revealed in part: [the hospital] supports and protects the basic human, civil, and constitutional rights of all patients. The principle of this policy is the patient's right to respect, dignity, and comfort. 17. The right to be free from all forms of abuse and harassment.

Review of hospital's policy titled, "Escorting Patients Off the Unit", dated 01/2024, revealed, in part: Policy Statement: Staff members assigned to escort a patient, or a group of patients shall be responsible for the safety and well-being of the individual and/or group from the time of leaving the unit until return to the unit. Purpose: To establish guidelines for the safe transport of patients off the unit. Procedure, in part: 1 ....The staff-patient ration will be no less than two staff members for every group of up to ten patients when leaving the secured nursing unit. This will apply to meal times and smoke breaks. 6. Staff members should see that the group stays together.

Review of Patient #R2's medical record revealed an admission date of 05/14/2024 at 7:40 p.m. Diagnosis: Schizoaffective disorder and GERD. Strengths include physically healthy and communicates. Patient was verbal. Patient was on low risk suicide precautions per admit orders. Review of psychiatric Evaluation dated 05/16/2024 at 10:06 a.m. revealed patient was judicially committed and transferred to facility for further stabilization.

A review of Incident Report Binder on 08/08/2024 at 11:46 a.m. revealed one incident report dated 08/02/2024 for the month of August.

In an interview on 08/08/2024 at 11:47 a.m., S54LPN reported that nurses will place incident reports in a box on her door or she will collect them from the units. She then has S2DON sign the incident report before submitting to administrator. Once administrator signs the incident report she places it in a binder with the other incident reports.

In an interview on 08/08/2024 at 11:52 a.m., S1ADM reported he did not know of any new incidents occurring since 08/05/2024.

On 08/08/2024 at 12:00 p.m. S54LPN presented an updated incident report binder. Review of the binder revealed an incident that had occurred on 08/06/2024at 5:10 p.m involving an injury sustained in the elevator. Further review revealed Patient #R2 fell in elevator. Continued review revealed one witness, S39MHT. Comments revealed right lower leg swollen. Actions taken revealed vital signs, temperature 97.2, pulse 82, respirations 17, and blood pressure 151/74. DON notified on 08/06/2024 at 5:41 p.m. Additional review of actions taken revealed an order to transfer Patient #R2 to ER for evaluation and an order for an x-ray. Continued review failed to reveal date and time physician, psychiatrist, administrator and family were notified.

Review of Patient #R2's nursing note dated 08/06/2024 at 6:21 p.m. revealed the following: 6:11 p.m. At approximately 5:10 p.m. patient standing on elevator, returning to floor from dinner, patient dropped to ground in elevator. Staff carried off elevator on to Unit C and assisted to wheel chair. Front of right lower leg swollen, S10NP and MD. X-ray ordered. Patient placed on fall precautions. Assisted to wheel chair. Instructed patient to ask for assistant getting in/out of bed to wheel chair.

Review of video footage dated 08/06/2024, navigated by S1ADM on 08/08/2024 at 12:59 p.m. revealed the following:
View of area rr:
5:10 p.m. - Security guard stood in area rr with 7 patients. S39MHT and Patient #R2 not in camera view.
5:11 p.m. - S39MHT walked out of cafeteria to the elevator and with 7 patients on elevator held elevator door open.
5:12 p.m. - S39MHT held elevator open while security guard walked into cafeteria and walked out from dining room, arm-in-arm with Patient #R2 who appeared unsteady and escorted her on to elevator.
5:13 p.m.-S52MHT walked out of cafeteria with two pitchers of water.
View of Unit C:
5:16 p.m. - S39MHT picked Patient #R2 from under her arms and dragged her off elevator and set her on floor outside elevator.
5:17 p.m. S53RN beside Patient #R2.

Review of Patient #R2's physician orders revealed the following:
08/06/2024 at 5:15 p.m. Okay to send to ER for fall. RBVO/ S36NP/S37RN.
08/06/2024 at 5:51 p.m. Cancel above order to send to ER. RBVO/ S36NP/S38RN.
08/06/2024 at 6:09 p.m. Place on Fall precautions. RBVO/S36NP/No RN signature.
08/06/2024 9:00 p.m. Send patient out ASAP to E.D. nearest. TO/S36NP/S39RN

Review of Patient #R2's medical record revealed the x-ray was read on 08/06/2024 at 9:00 p.m. Further review revealed a displaced fracture of the mid to lower shaft of the right tibia and a displaced fracture of proximal fibula.

Review of Patient #R2's ED records from Hospital B revealed Patient #R2 was triaged in the emergency department at 10:11 p.m. on 08/06/2024 (approximately 5 hours after the incident). Further review revealed the following ED diagnoses:
1. Closed displaced oblique fracture of shaft of right tibia
2. Closed fracture of proximal fibula.
3. Tibia/fibula fracture right closed
4. Closed displaced spiral fracture of shaft of right fibula with malunion.

Continued review revealed patient was placed in splint post reduction in ED. Despite reduction, patient still appeared to have displaced right tibia fracture that needed surgical intervention. Underwent an Open Reduction Internal Fixation (ORIF) of right tibia on 08/08/2024 at 12:15 p.m.

In an interview on 08/08/2024 at 1:20 p.m., S2DON stated she had started the process of investigating the incident but she did not report the incident to state.

In an interview on 08/08/2024 at 2:55 p.m. S2DON reported that she had no documentation or anything else to provide related to the investigation of the incident involving #R2's leg fracture and therefore she was unable to determine if abuse or neglect had occurred.

In an interview on 08/08/2024 at 4:41 p.m., S2DON confirmed that S53RN informed her the patient fell (in an undetermined location) and her leg gave out when on the elevator. S2DON stated she did not look at footage as of time of this interview. S2DON stated she spoke with S39MHT and S52MHT on the day of the incident. S2DON stated she did not recall the time she spoke with MHT's but remembers she spoke face-to-face with S52MHT and spoke over the phone with S39MHT. S2DON confirmed that she did not investigate the timeframe before Patient #R2 was on the elevator. S2DON stated S53RN told her Patient #R2 was her "normal self" prior to the incident. S53RN reported that both MHT's denied Patient #R2 had injuries before the incident on the elevator.

In an interview on 08/08/2024 at 4:56 p.m. S1ADM stated he was informed of the incident when the x-ray results came back and Patient #R2 was sent out. S1ADM reported that if the incident report had been brought to him he would have looked at the video, and as of this interview, he had not reviewed. S1ADM stated that when there is an incident, S54LPN will pick up the incident reports from the unit and give them to S1DON who will lead the investigation and then he will receive a copy of the incident report.

Based on observation, record review and interview, the psychiatric hospital failed to ensure restraint and seclusion was used only when less restrictive interventions had been determined to be ineffective to protect the patient from harm for 1 (#2) of 7 (#1-#6, #R1) sampled patients reviewed for restraint and seclusion.
Findings:

Review of hospital's policy titled, "Patient Rights," approved 06/2024, Section 12.1.0, revealed in part: [the hospital] supports and protects the basic human, civil, and constitutional rights of all patients. The principle of this policy is the patient's right to respect, dignity, and comfort. Purpose: To ensure the ethical treatment of persons receiving professional health care services. Without exception, all persons in this facility are entitled to receive ethical treatment. Procedure, in part: 16. The right to be free from restraints of any form that are not medically necessary or are used as a means of coercion, discipline, convenience or retaliation by staff ...

Review of hospital's policy titled, "Restraint and Seclusion R/T Patient's Rights", Section 9.13.0, Approved 01/2024 revealed in part: Policy Statement: Use of seclusion and/or restraint may be used only after all other therapeutic interventions have been found to be ineffective to protect the patient or others from harm ....

Review of hospital's policy titled, "Safe Implementation of Restraint and Seclusion", Section 12.6.0, Approved 01/2024 revealed in part: Policy Statement: Use of seclusion and/or restraint may be used only after all other therapeutic interventions have been found to be ineffective to protect the patient or others from harm ....Procedures: ...There must be evidence of documentation in patient's medical record reflecting alternatives or other less restrictive interventions attempted by clinical personnel.

On 08/05/2024 at 3:15 p.m., a review of video footage of Unit A for the night of 08/03/2024 at 8:26 p.m. was navigated by S1ADM. Review of footage with audio revealed the following:
8:12 p.m. Patient #2 in room ff where she was sitting at table with pen and paper writing.
8:23 p.m. Patient #2 left room ff and walked to her room then back out into hallway nn where she stopped to speak with S18MHT then walked back to her room.
8:26 p.m. S17RN was in nursing station where she was preparing medication cups. S17RN handed Patient #2 her medications and Patient #2 asked S17RN what medications were in the cup. S17RN told her that once she was finished passing medications she would let her know what medications she was taking.
8:28 p.m. Patient #2 became frustrated clapping her hands together, then Patient #2 walked away. S17RN was heard saying. "She likes to play games with people and I don't like to play games".
8:32 p.m. Patient #2 returned to nursing station and S17RN read her the list of medications from the computer. Patient #2 started yelling, "don't you know I have down syndrome" while cursing and walking off.
8:36 p.m. - Patient #2 standing across from nurses' station against the wall.
8:37 p.m. - S18MHT left to take the other patients down to smoke, while Patient #2 remained on unit and walked to her room out of camera view. Audio revealed sound of loud noises coming from the direction Patient #2 went, while S17RN was sitting at nurses' station. Audio revealed S17RN stating aloud "she can just let out her frustration". S17RN then stated, "OK, you're going in restraints."
8:39 p.m. - Audio revealed crying sounds from patient. S17RN remained in nurses' station.
8:39:48 p.m. - S17RN walked out of view to patient room.
8:40 p.m. - S18MHT returned to Unit A. S17RN left Patient #2's room and said, "Let's put her down".
8:41 p.m. - Audio revealed loud banging ceased and Patient #2 crying, stating she wanted to go downstairs with the group. S17RN replied "not with that behavior." Patient #2 began yelling.
8:42 p.m. - S17RN left to get restraints. Audio revealed S18MHT calmed Patient #2 down while S17RN retrieved restraints.
8:44 p.m. - S17RN walked back to patient room. Audio revealed Patient #2 yelling, "Don't you know what Down Syndrome is, you're a nurse."
8:45 p.m. - Another MHT arrived to unit.
8:47 p.m. - loud noises heard on audio coming from Patient #2's room.
8:48 p.m. - staff carried Patient #2, naked, by her arms and legs towards seclusion room c.

Review of Patient #2's medical record revealed an admission date of 07/28/2024 at 7:00 a.m. and discharged on 08/06/2024 at 7:50 a.m. Further, review revealed patient diagnoses of Down's Syndrome, Suicidal Ideation with plan to cut wrists, Major Depressive Disorder with psychosis, and pseudo seizures on Keppra.

Further review of Patient #2's medical record revealed a Restraint and Seclusion Form dated 08/03/2024 at 8:50 p.m. for Patient #2. Continued review failed to reveal less restrictive interventions had been used to protect the patient, staff members, or others from harm prior to initiating restraints and seclusion.

In an interview on 08/05/2024 at 3:58 p.m., S1ADM confirmed that video/audio footage revealed less restrictive interventions had not been used to protect the patient, and staff members, or others from harm prior to initiating restraints and seclusion.

In an interview on 08/06/2024 at 9:48 a.m., S2DON stated that de-escalation is a core standard of practice for a psychiatric registered nurse and should be implemented in order to prevent restraint and/or seclusion.

Based on record review and interview, the hospital failed to ensure the hospital's security staff were educated, trained and demonstrated knowledge on the use of nonphysical intervention skills as evidenced by 7 (S24SEC, S25SEC, S26SEC, S27SEC, S28SEC, S29SEC, S30SEC) of 7 (S24SEC, S25SEC, S26SEC, S27SEC, S28SEC, S29SEC, S30SEC) security staff personnel files reviewed.
Findings:

Review 7 (S24SEC, S25SEC, S26SEC, S27SEC, S28SEC, S29SEC, S30SEC) of 7 (S24SEC, S25SEC, S26SEC, S27SEC, S28SEC, S29SEC, S30SEC) security staff personnel files revealed no education or training for nonphysical intervention skills required for the patient population served.


In an interview on 08/08/2024 at 10:11 a.m., S22HR verified S24SEC, S25SEC, S26SEC, S27SEC, S28SEC, S29SEC, S30SEC currently have not received education, training, or demonstrated knowledge of nonphysical intervention skills.

48050

Based on record review and interviews, the hospital failed to ensure security staff personnel records contained documentation demonstrating that Orientation was successfully completed and Patient Rights competencies had been successfully completed upon hire for 7 (S24SEC, S25SEC, S26SEC, S27SEC, S28SEC, S29SEC, S30SEC) of 7 (S24SEC, S25SEC, S26SEC, S27SEC, S28SEC, S29SEC, S30SEC) security staff reviewed for Orientation with Patient Rights training.
Findings:

Review of hospital policy titled "HR Policies and Procedures, Orientation Program 8.8", revealed, in part: Policy Statement: An orientation program shall be conducted for all newly hired employees that will assess the competency of the employee as it relates to his or her job performance upon hire and at least every three years thereafter. Procedure, in part: 1. All newly hired personnel must attend an orientation program within their first five (5) days of employment. Then every three years thereafter. d. An introduction to our administrative structure, which includes, in part: (4) A review of resident rights. (5) A review of abuse reporting procedures.

Observations of Unit B on 08/05/2024 at 10:22 a.m. revealed a visitor was allowed up to unit by security guard during non-visting hours.

In an interview on 08/05/2024 at 10:23 a.m., S56RN stated visitors should not be on the unit except during visiting hours due to visitor, patient, and staff safety issues.

In an interview on 08/05/2024 at 10:24 a.m., S1ADM stated the guard made a mistake.

Review of S24SEC, S25SEC, S26SEC, S27SEC, S28SEC, S29SEC, S30SEC personnel files failed to reveal any orientation education including Patient Rights training.

In an interview on 08/08/2024 at 10:11 a.m., S22HR confirmed that S24SEC, S25SEC, S26SEC, S27SEC, S28SEC, S29SEC, S30SEC did not go through hospital employee orientation with Patient Rights training upon hire.

Based on record reviews and interview, the hospital failed to meet the requirements of the Condition of Participation for Quality Assessment and Performance Improvement (QAPI) as evidenced by failing to implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. This deficient practice is evidenced by:
1) the hospital failed to ensure the Quality Assessment Performance Improvement (QAPI) Program specified the method and frequency of data collection for indicators as evidenced by failure to have documented evidence of current data on quality indicators (see findings in A-0273);
2) the hospital's Quality Assurance and Performance Improvement (QAPI) program failed to identify opportunities for improvement, implement effective action, measure success and track performance related to not having quality improvement activities (see findings in A-0283);
3) the hospital failed to track and analyze all events involving abuse and neglect. The deficient practice is evidenced by failure to investigate several patient-to-patient, patient-to-staff, and staff-to-patient incidents. (see findings in A-0286);
4) the hospital's governing body, medical staff and administrative officials failed to be responsible and accountable for ensuring that an ongoing program for quality improvement and patient safety is implemented, and maintained as evidenced by failing to have a current written, approved and implemented Quality Assurance/Performance Improvement (QAPI) plan and program (see findings in A-0309) and
5) the governing body failed to provide adequate resources for measuring, assessing, improving, and sustaining the hospital's performance by having insufficient staff designated to conduct the Quality Assurance/Performance Improvement (QAPI) functions of the hospital. (see findings in A-0315).

Based on record review and interview, the hospital failed to ensure the Quality Assessment Performance Improvement (QAPI) Program specified the method and frequency of data collection for indicators as evidenced by failure to have documented evidence of current data on quality indicators.
Findings:

In an interview on 08/07/2024 at 3:20 p.m., S1ADM stated that he was one year behind in aggregating Quality Assurance and Performance Improvement (QAPI ) data. He has not been able to collect or update Quality Assurance and Performance Improvement (QAPI) data and minutes for the last year.

Based on record review and interview, the hospital failed to identify opportunities for improvement. This deficient practice was evidenced by failing to investigate and collect the data necessary to identify opportunities for improvement and changes that will lead to improvement.
Findings:

In an interview on 08/07/2024 at 2:35 p.m., S1ADM again verified that the hospital did not have Quality Assurance and Performance Improvement (QAPI ) data. He agreed that without the necessary data, the hospital is unable to identify opportunities for improvement and changes that will lead to improvement. S1ADM confirmed the QAPI program had no updated quality indicators and there were no corrective action plans because they have not identified problems.

Based on record review and interview, the hospital failed to ensure the hospital wide QAPI program's performance improvement program implemented preventive actions. This deficient practice is evidenced by the lack of an implemented preventive action plan following an increase in patient safety incidents and injuries.
Findings:

Review of hospital policy titled, "Risk Management," last revised January 2024, revealed in part: Policy Statement: The Risk Management Plan of the hospital is designed to ensure that the standard of care provided by the staff is maintained at an acceptable level, to reduce the risk of patient injury as a consequence of that care, and to minimize financial loss to the institution. Investigation of Occurrences: The hospital Risk Management incident reports will be used to document investigation results. The event reporting system will be used to document investigation results. Risk Management Committee: Results of the investigation shall be presented to the appropriate committee for a final standard of care determination. There shall be two committees that perform Risk Management activities: 1. Safety Risk Committee 2. Medical Executive Committee (MEC). The MEC functions as the final authority in reviewing and approving all risk management standards of care decisions involving members of the medical staff. It is compromised of the officers of the medical staff, along with the Medical Director, and representatives from administration and quality management. Findings of the committees shall be forwarded to the Safety Officer, who shall have responsibility to file quarterly reports with the Governing Board. Minimizing Occurrences: 3. Data Compilation and Analysis: Data collected by the Safety Risk Committee falls into, but is not limited to, the following categories: a. Patient related: Medication error, Patient falls with or without injury, Diagnostic procedure and treatment delay or error, Blood administration/Needle stick error, Leave against medical advice, Policy and procedure not followed, Unexpected transfer to an acute care facility, Patient injury, Patient/family complaint. b. Non-Patient related: Needle stick, equipment failure, fire, theft and loss, sharps, narcotic count incorrect, employee complaint ... Data relevant to reported variances will be compiled by the DON, Safety Officer and Quality Management staff in the form of statistical summary and will be used for identifying trends and patterns in practice and patient care. Occurrence screening data regarding medical staff functions shall be analyzed so that root cause of the occurrence can be determined and corrective measures established to minimize recurrence. Active cooperation of hospital staff, medical staff, and administration of the Hospital is essential. Medical and department quality improvement findings will be presented quarterly to the Governing Board, Administration, Medical Executive Committee, Quality Improvement Committees, and other affected hospital functions ( ... infection control, safety).

Review of hospital policy titled, "Safety Risk Committee," last revised January 2024, revealed in part: The Safety Risk Committee shall ensure that all operations of the hospital will be conducted in such a manner that is consistent with the best health and safety interests of patients, visitors and staff. Procedure: 1. In order to assure constant awareness of, and response to issues of health, safety and environment, a Safety Risk Committee shall establish, periodically review, and as necessary, modify and update applicable regulations and procedures. b. Committee Meetings: The Committee shall meet quarterly, or more often as it deems necessary for the discharge of its duties and responsibilities. Meeting dates, times and places shall be established, with reasonable notice, by the Safety Officer. 2. Committee Reports: At least quarterly, the Safety Risk Committee will report identified issues and a summary of Committee activities to the Performance Improvement Committee, the Medical Executive Committee, and the Governing Board. 3. Implementation of Committee Recommendations: The Administrator or designee will be responsible for implementation of procedures designed to attain standards adopted by the Committee. Monitoring and reporting results will be the responsibility of the Performance Improvement Committee.

Review of incident reports for July and August 2024 revealed, in part:
Incident Reporting Log for July 2024:
07/03/2024 Self Injurious Behavior
07/03/2024 Fall
07/04/2024 Elopement
07/08/0224 Injection
07/09/2024 Fall
07/17/2024 Elopement
07/18/2024 Sexual Misconduct
07/25/2024 Contraband
07/29/2024 Fall
07/30/2024 Fall
Incident Reporting Log for August 2024:
08/02/2024 Fall
08/04/2024 Elopement
08/05/2024 Elopement
08/06/2024 Fall with broken leg

In an interview on 08/07/2024 at 2:40 p.m., S1ADM stated that he had not been able to collect or update Quality Assurance and Performance Improvement (QAPI) data and minutes for the last year. S1ADM reported the hospital did not have documented actions taken to prevent incidents and patient injuries on the Performance Improvement meeting minutes because the hospital has not had QAPI meetings to discuss preventive action plans and the hospital has not investigated and collected data on the incidents discussed above.

In an interview on 08/12/2024 at 2:06 p.m., S1ADM stated the Risk Management Committee and Safety Committee should meet with the Medical Executive Committee at least quarterly, and they should meet immediately after incidences.





50453

Based on record review and interview, the hospital's Governing Body failed to ensure the QAPI program reflected the complexity of the hospital's services as evidenced by failing to include all hospital services in the QAPI program. This deficient practice was evident by failing to include the following contracted services: linen service, elevator service, fire systems, generator, fuel for generator, plumbing, pest control, electrician, biohazard waste, security, telephone service, and equipment, managed IT.
Findings:

Review of list of contracted services provided by S1ADM revealed the following services: linen service, elevator service, fire system, generator, fuel for generator, plumbing, pest control, electrician, biohazard waste, security, managed IT, telephone service, and equipment.

In an interview on 08/07/2024 at 2:30 p.m., S1ADM verified the hospital is at least one year behind on collecting any QAPI data including contracted services.

In an interview on 08/07/2024 at 2:30 p.m., S1ADM reported the hospital has no QAPI program at this time.

Based on record review and interview, the hospital's governing body, medical staff and administrative officials failed to be responsible and accountable for ensuring that an ongoing program for quality improvement and patient safety is defined, implemented, and maintained as evidenced by failing to have a current written, approved and implemented Quality Assurance/Performance Improvement (QAPI) plan and program.
Findings:

Review of hospital document provided by S1Admin, titled "Amended and Re-Statement of the By-Laws of [Hospital]", signed and dated by Governing Body's only member on 06/01/2021, revealed, in part: pages 2,4,6, and 8 are missing. Section 1 Page 9, revealed, in part: The Hospital will document appropriate remedial action to address deficiencies found to the quality assurance program. The Hospital will document the outcome of the remedial action.
Policies and Procedures, Section 1, in part: The following policies/procedures/plans must be created and approved by the Board of Managers: Quality Assurance Plan.

Review of Governing Body meeting minutes from January 2024 - July 2024 provided by S1ADM, failed to indicate an ongoing program for quality improvement and patient safety because no indicators were discussed.

Review of most recent Medical Executive Meeting minutes dated 01/15/2024, provided by S1ADM, failed to indicate an ongoing program for quality improvement and patient safety because no indicators were discussed.

Based on record review and interview, the Hospital's Governing Body failed to ensure adequate resources were allocated for measuring, assessing, improving, and sustaining the hospital's performance improvement functions as evidenced by insufficient staff designated to conduct the Quality Assessment Performance Improvement (QAPI) program functions of the hospital.
Findings:

Review of the hospital's organizational chart provided by S1ADM revealed the position for Quality Assurance and Infection Control Coordinator was filled by S57QAPIM.

Review of the Governing Body Meeting Minutes provided by S1ADM for January 2024 through July 2024, failed to reveal S57QAPIM was appointed Quality Assurance and Infection Control Coordinator

In an interview on 08/07/2024 at 2:45 p.m., S1ADM verified that S57QAPIM was the dedicated person for Quality Assurance Coordinator but had not been appointed by the Governing Body. S1ADM stated that S57QAPIM lives out of state and rarely visits the hospital, therefore is unable to complete the tasks required of the the Quality Assurance Coordinator. S1ADM also stated he has not done any QAPI data collection/analysis for this year because he has not had time to do so.

Based on record review and interview, the hospital failed to ensure the medical staff was accountable to the governing body for the quality of medical care provided to patients. This deficient practice is evidenced by:
1) failure of medical staff to participate in governing body meetings;
2) failure of medical staff to participate in Infection Control Committee;
3) failure of medical staff to participate in Utilization Review Program; and
4) failure of medical staff to participate in the Quality Performance Improvement Committee.
Findings:

Review of the hospital medical staff bylaws reveals in part: the bylaws provide the framework for self-governance in order to permit the Medical Staff to discharge its responsibilities in matters involving the quality of medical care and patient safety. E. Duties of Officers 1. Medical Director: e) interacting with the Administrator and Governing Board in all matters of mutual concern with the Medical Staff. g) Representing the views and policies of the Medical Staff to the Governing Board and to the Administrator. j) Overseeing the medical and clinical operations of the Hospital. Section 2. Committees and Subcommittees A. The Medical Executive Committee shall be composed of the Officers of the Medical Staff ... meet as often as necessary, but not less than quarterly, maintain a record of its proceedings and actions. The function of the Medical Executive Committee shall include, but not be limited to: 2) receiving and acting upon reports and recommendations ... and reporting these activities to the Governing Board; 6) overseeing the organization of quality assurance and performance review activities and mechanisms of the Medical Staff and its committees; 11) evaluating the overall medical care rendered to patients in the Hospital. B. The Infection Control Committee shall meet at least quarterly. It shall maintain a record of its proceedings and shall submit reports of its activities and recommendations to the Medical Executive Committee. C. The Performance Improvement Committee shall ... 5) reviewing findings of quality assurance, utilization review and Performance Improvement activities performed by all Medical Staff Committees and all Hospital Services; 7) ...disclose findings to the Medical Executive Committee and Governing Board.

1) Failure of medical staff to participate in governing body meetings.
Review of governing body meeting minutes dated 01/09/2024 - 07/31/2024 failed to reveal meetings with medical staff.

2) Failure of medical staff to participate in Infection Control Committee.
Review of hospital documents failed to reveal an Infection Control Program.

3) Failure of medical staff to participate in Utilization Review Program.
Review of hospital documents failed to reveal a Utilization Review Program.

4) Failure of medical staff to participate in the Quality Performance Improvement Committee.
Review of hospital documents failed to reveal a Quality Performance Improvement Program.

During an interview on 08/12/2024 at 2:06 p.m., S1ADM confirmed medical staff has not participated in meetings with the committees listed above.

Based on record review and interview, the hospital failed to ensure that the medical staff enforced their bylaws. This deficiency is evidenced by failing to carry out their responsibilities to meet quarterly as stated in their medical staff bylaws.

Review of medical staff bylaws revealed in part: Section 2. Committees and Subcommittees. A ... The Medical Executive Committee shall meet as often as necessary, but not less than quarterly, maintain a record of its proceedings and actions.

Review of the Medical Staff Meeting Minutes revealed the last Medical Executive Meeting was January 15, 2024 at 5:30 p.m.

During an interview on 08/05/2024 at 2:15 p.m. S1ADM confirmed there has not been a Medical Staff Meeting since they last met on January 15, 2024 and that he has no additional medical staff meeting minutes to provide. S1ADM also confirmed that the medical staff has not been meeting quarterly as stated in the medical staff bylaws.

Based on record review, and interview the facility failed to meet the requirements for the Condition of Participation (CoP) for Nursing Services. The deficient practice is evidenced by failure of the nursing staff to contact the licensed practitioner for patient orders at the time of admission (see Findings in A-0405).
Findings:

An Immediate Jeopardy situation was identified after consultation with State Office, on 08/08/2024 at 3:35 p.m., S1ADM was notified that the practice of allowing the nursing staff to fill out the admission and medication orders without consulting the licensed practitioner was outside of the scope of practice for a registered nurse and placed all 19 admitted patients and future admitted patients at risk for serious injury, serious harm, and serious impairment or death.

To verify the nursing practice of filling out admission and medication orders without consulting the licensed practitioner was not an isolated event as suggested by S1ADM, S31RN was interviewed on 08/08/2024 at 3:51 p.m. S31RN verified the admitting nurse chose which as needed medications each patient would be prescribed and fill out the admission orders without consulting the admitting licensed practitioner.

On 08/12/2024 plan of correction was presented to State Office. The plan included encouraging the use of electronic or faxed orders by the licensed practitioners and discouraging the routine use of verbal admission orders. Nursing staff was immediately re-education on the verbal order policy and the medication administration policy. A final plan to ensure adherence would be developed by 08/14/2024. The Immediate Jeopardy was removed on 08/12/2024 at 3:29 p.m., but there was not enough evidence to determine sustainability of compliance for the Condition of Nursing Services to be cleared. Noncompliance remains at the Condition Level.

Based on interview and record review, the hospital failed to ensure there was a plan for administrative authority for nursing services to ensure the nursing services was under the direction of one RN employed by the hospital in the absence of the DON. This deficient practice is evidenced by failing to have coverage for nursing services provided in the absence of the DON.
Findings:

Review of Governing Body minutes dated 01/09/2024-07/31/2024 failed to reveal an appointed administrative authority for nursing services to ensure the nursing services was under the direction of one RN employed by the hospital in the absence of the DON.

Review of Governing Body minutes dated 01/09/2024-07/31/2024 revealed on 06/03/2024, S2DON appointed Director of Nursing subject to satisfactory background check.

Further review failed to review S2DON was appointed DON following receipt of background check as stated in minutes dated 06/03/2024.

In an interview on 08/05/24 at 9:16 a.m., S1ADM indicated S2DON was not always available during the day because she has been working the night shifts due to short staffing. S1ADM reported that the hospital did not have an assistant director of nursing with administrative authority in the absence of S2DON.

In an interview on 08/07/24 at 9:43 a.m., S1ADM indicated the hospital usually uses a nurse supervisor, S32RN, that was once the interim DON to act in the absence of S2DON. S1ADM confirmed that no RN employed at the hospital had been designated as the registered nurse in charge of nursing services at times when S2DON was unavailable and/or on leave from the hospital.

In an interview on 08/12/2024 at 9:15 a.m. S2DON reported she did not know that the hospital was under a 2nd IJ since 08/07/2024 because she was not in the hospital when the IJ was called. Therefore she did not educate staff as per the hospital removal plan for the IJ. S2DON stated that she has hired an ADON to act as DON in her absence and is waiting on the results of her background check.

Previously cited 06/12/2024.

Based on observations, record review and interview the hospital failed to ensure adequate numbers of licensed registered nurses and nurse support staff were available to provide nursing care to all patients as evidenced by failure to ensure a registered nurse was physically present on each unit of the hospital at all times.
Findings:

Review of hospital policy titled "Staffing Plans and Delivery of Care", dated 01/2021, revealed in part: Census: 1-12 patients requires: 1 Registered Nurse and 2 Mental Health Technicians.

On 08/07/2024 at 5:15 p.m., hospital video review of Unit A on 08/06/2024, navigated by S1ADM, revealed S46RN left the unit at 10:43 p.m., was gone for 17 minutes and returned at 11:00 p.m. leaving S49MHT and S50MHT alone with 7 (#5, #6, R1, R3, R4, R5, and R6) patients.

During an interview on 08/07/2024 at 5:45 p.m. Greg confirmed that the S46RN should not have left the unit without an RN present.

On 08/08/2024 at 11:10 a.m., hospital video review of Unit A on 08/07/2024, navigated by S1ADM, revealed S47RN left the unit at 10:41 p.m., was gone for 11 minutes and returned at 10:52 p.m. and then left a second time at 10:55 p.m., was gone for 11 minutes and returned at 11:06 p.m. This left S16MHT and S43MHT alone with 5 (#5, R1, R3, R4, and R5) patients.

During an interview on 08/08/2024 at 11:32 a.m. S1ADM confirmed S47RN should not have left the unit without another RN present.

Based on observations, record review and interview, the hospital failed to have a registered nurse supervise and evaluate the nursing care for each patient. This deficient practice was evidenced by an assessment and documentation related to Patient #R1's transfer to and return from Hospital #B's emergency department not being performed.

A review of facility policy, "Medical Emergency Transfer to Another Facility," Section 5.3.0, approved: 06/2024, revealed in part: Policy Statement: Patients requiring emergency medical care beyond the facility's scope of service and capacity are transferred via ambulance to a designated emergency department. Purpose: to establish guidelines and procedure for medical emergency transfer to another facility. To provide the receiving facility with complete appropriate information to resume care of a transferred patient. Procedure: After the emergency procedures have been initiated and the physician has given transfer orders, the Registered Nurse must: 3. Complete the Emergency Transfer Sheet.

On 08/08/2024 at 12:18 p.m., the video footage was reviewed with S1ADM for an incident that occurred on 08/04/2024. Review of video footage for Unit A seclusion room revealed the following:
12:10 a.m. - Patient #R1 arrived to Unit A.
12:19 a.m. - Patient #R1 to seclusion room with door remaining unlocked. Patient #R1 had not been searched since arriving to Unit A.
1:08 a.m. - S17RN and S18MHT with patient. S17RN on phone in room.
1:13 a.m. - S17RN and S18MHT standing near door, across the room from Patient #R1. Patient #R1 walks swiftly into the wall in front of him and hits his forehead on the wall. The patient then falls backward on to the floor while clutching his head in his hands. S17RN in room at time of incident.
1:15 a.m. - S18MHT walks Patient #R1 to bed. S17RN still on cell phone in doorway. S17RN had not assessed the patient.

During an interview on 08/08/2024 at 1:00 p.m., S1ADM confirmed that Patient #R1 should have been searched immediately upon arrival to unit. S1ADM also confirmed that S17RN failed to perform an assessment upon arrival and following incident.

A review of Patient #R1's medical record revealed the patient involved in an incident on 08/04/2024 requiring him to be transferred to Hospital #B. A review of nursing notes did not reveal documentation of the time of the patient's departure or return to the facility, documentation of an Emergency Transfer Sheet, or the documentation of a nurse assessment being performed upon the patient's return to the facility.

In an interview on 08/12/2024 at 3:00 p.m. S1ADM and S2DON confirmed the above mentioned information.


50453

50453

Based on observation and interview, the hospital failed to ensure that the director of nursing service provided adequate supervision and evaluation of all nursing personnel who provide services in the hospital. This deficiency is evidenced by:
1) failure to ensure staff have been properly educated and deemed competent on performing an EKG; and
2) failure to ensure staff have been properly educated and deemed competent on the appropriate monitoring of a patient placed in restraints.
Findings:

1) Failure to ensure staff have been properly educated and deemed competent on performing an EKG.
Review of hospital policy titled, "Electrocardiogram Machine (EKG Machine)," last revised January 2024, revealed in part: Policy Statement ... Registered Nurses, Licensed Practical Nurses, and Mental Health Technicians can operate the EKG machine when they have been observed, evaluated, and deemed competent with documentation. Purpose: To provide guidelines and procedures for use of the EKG machine. To interpret the electrical activity of the heart for Physicians and nurse Practitioners to diagnosis and treat. Procedure: 3. Turn power on. 4. Input patient's Name, Age, and Date of Birth. To input patient's information, push the keys.

During an interview on 08/08/2024 at 1:52 p.m. S2DON confirmed all nurses are able to read an EKG or send it to the doctor to read it. S2DON stated all have been oriented, trained, and deemed competent to perform an EKG. Per S2DON, staff needs an order to perform an EKG. S2DON additionally stated that staff read what the print out of the EKG says the rhythm is at the top. S2DON confirmed the hospital does not have a company or physician that reads the EKG for them. Per S2DON, the RN working decides if the EKG is questionable or not.

During an interview on 08/08/2024 at 1:57 p.m. S1ADM stated that all staff are not trained to do EKG's. S1ADM stated EKG's are ordered and read by S51MD.

During an interview on 08/08/2024 at 2:00 p.m. S19RN stated she has not been trained to perform an EKG.

During an interview on 08/08/2024 at 2:02 p.m. S44MHT, S52MHT, and S37MHT confirmed they have not received training to perform EKG's.

During an interview on 08/08/2024 at 2:06 p.m. S32RN confirmed that she has not received formal training on how to perform an EKG. S32RN stated she received an informal training and that she is not competent to perform an EKG on her own. S32RN confirmed that she also does not feel comfortable interpreting an EKG.

During an interview on 08/08/2024 at 2:10 p.m. S31RN confirmed that she has been employed for 1 year and has not received education on how to perform an EKG. S31RN also confirmed EKG education was not included in her orientation.

During an interview on 08/08/2024 at 2:12 p.m. S53MHT confirmed she has not received training to perform an EKG.

2) Failure to ensure staff have been properly educated and deemed competent on the appropriate monitoring of a patient placed in restraints

A review of facility policy, "Safe Implementation of Restraint and Seclusion," Section 9.13.0, approved: 01/2024, revealed in part: Purpose: To establish guidelines for the same (safe) implementation of restraint and seclusion ... To abide by state and federal guidelines for the use of restraint and seclusion. Procedures: RN and trained staff personnel must engage in the monitoring of patients in restraints to recognize changes to indicate the restraint or seclusion in no longer necessary. Restraint/Seclusion use is permitted by trained staff only ... frequencies of monitoring and assessment; assessment content (e.g., vital signs, circulation, hydration needs, elimination needs, level of distress and agitation, mental status, cognitive functioning, skin integrity, etc.); providing for nutritional needs, range of motion exercises and elimination needs; and mental status and neurological evaluation, that the use of restraint or seclusion is discontinued at the earliest possible time. Hospital policies are expected to guide staff in determining appropriate intervals for assessment and monitoring based on the individual needs of the patient, the patient's condition and the type of restraint or seclusion used ... The patient placed in seclusion or restraints must be personally always observed by staff and documentation of the patient's progress must occur every 15 minutes. Documentation of patient progress must include the status of the patient's needs, such as bathing, meals, hydration, use of toilet, and behavior. Exercise of limbs and circulation checks must all be included when limb restraints are in use. All these measures ensure that the patient is not suffering undue physical discomfort, harm or paint. The patient must be given the opportunity for motion and exercise not less than 10 minutes every two hours. Documentation: Documents needed to complete restraint and seclusion procedures include Restraint and Seclusion Preprinted Orders, Restraint and Seclusion Debriefing Form, Restraint and Seclusion Flow Sheet, Restraint and Seclusion Log and the Incident Report Form. In addition to documenting patient status and staff interventions every 15 minutes on the designated seclusion and/or restraint flow sheet, the Registered Nurse must document every hour in the patient's nursing daily progress note. The nursing care plan should be updated within 24 hours of the initiation of the restraint/seclusion.

A medical record review of Patient #2 revealed the patient being placed in 4 point restraints on 08/03/2024 from 8:50 p.m. to 10:45 p.m. There was continued documentation by the MHT on the routine Patient Observation Log every 15 minutes. However, during this timeframe, there was no document of assessments being performed regarding vital signs, circulation, hydration needs, elimination needs, mental status, cognitive functioning and/or skin integrity. There was no documentation of a debriefing being performed after the patient was released. There was no documentation every hour in the patient's nursing daily progress notes. A review of facility incident reports revealed no documentation related to an incident report being completed on 08/03/2024 for this patient being placed in restraints.

In an interview on 08/12/2024 at 3:00 p.m. S2DON confirmed the above mentioned findings.

Based on record review, and interview the facility failed to ensure all medications and biologics were administered according to the orders of a licensed practitioner. The deficient practice is evidenced by:
1) failure of the nursing staff to contact the licensed practitioner for orders for prescribed medications at the time of admission;
2) failure to ensure medication errors related to the timing of medication administration were tracked and analyzed to determine their causes;
3) failure of the nursing staff to document the administration of an as needed medications;
4) failure of nursing staff to document the effectiveness of an as needed medication being administered;
5) failure of nursing staff to document the indication for an as needed medication to be administered; and
6) failure of the nursing staff to document the location (site) of an injectable medication.
Findings:

1) Failure of the nursing staff to contact the licensed practitioner for orders for prescribed medications at the time of admission.
Review of the policy, "Medication Administration," approved January 2024, revealed in part,
"Policy Statement-Only those medications ordered by physicians shall be given . . . . "

Review of the Medical Staff Bylaws, which had no documented date of last review but was presented to the surveyors as the current bylaws, revealed in part:

Admissions:
(a) No patient shall be admitted to the Hospital until after a provisional diagnosis has been stated and been approved by the Medical Director or his designee. All patients will be under the care of a physician while in the hospital. . . .

(d) No inpatient or outpatient may be assigned to the service of any other practitioner without that practitioner's specific authorization. . . .

General Unit:
(a) The admitting physician may consult the referring physician for medical management, as necessary.
(b) The Medical Director or his designee must approve all admissions. . . .

(d) Admitting orders shall be dated, timed and signed by the admitting or attending practitioner and shall include at least the following:
a. Order for admission;
b. Level of activity/ restriction;
c. Vital Sign frequency;
d. Medications;
e. Diagnostic testing;
f. Diet;
g. Consultations; and
h. Provisional Diagnosis

(e) Verbal orders, if used, must be used infrequently. This means that the use of verbal orders must not be a common practice. Verbal orders pose an increased risk of miscommunication that could contribute to a medication or other error, resulting in a patient adverse event. Verbal orders should be used only to meet the care needs of the patient when it is impossible or impractical for the ordering practitioner to write the order or enter it into an electronic prescribing system without delaying treatment. Verbal orders are not to be used for the convenience of the ordering practitioner.
(f) Verbal orders are to be signed within 48 hours of the given order.
Initial admitting orders may be verbal orders, phone orders, and standing orders.

Initial review of medical records during the survey revealed admission orders were a printed set of orders to be initiated as verbal orders and many were not signed by the licensed practitioner within 48 hours as required. The frequency of the unsigned verbal admission orders was concerning and the need for further review of the admission process was acknowledged.

In interview on 08/08/2024 between 1:49 p.m. - 1:53 p.m., S32RN explained the admission process for Patient R8, who she was admitting. S32RN explained that she had already completed the admission and medication orders and faxed them to the pharmacy, but had not completed her admission assessment because the patient was sleeping when brought to the floor. S32RN explained that when new patients were admitted, she used the records sent from the referral source to find the current medications and then listed the on the "Home Medication History & Reconciliation" form and then faxed it to the pharmacy to be filled by the pharmacy. At the bottom of the form "Telephone Order/ VORB per Dr. ___ Date___ Time___" was printed at the bottom. The form was filled out with the name of the practitioner, 08/08/2024 and timed 1:30 p.m. S32RN explained that she checked hold on the Risperdal 2 milligrams by mouth twice a day because it was documented in the medical record that the patient had received Zyprexia 10 milligrams while in the emergency department and she felt it was not safe to give the morning dose of Risperdal. S32RN also pointed out the order for Norvasc 5 milligrams by mouth each day which she also held because his blood pressure was fine.

Review of the "Physician Admit Orders," revealed the following as needed medication orders were checked:

Ativan 2 milligrams by mouth or intramuscular every 6 hours as needed for agitation;
Benadryl 50 milligrams by mouth or intramuscular every 6 hours as needed for agitation;
Haldol 5 milligrams by mouth or intramuscular every 6 hours as needed for agitation;
Tylenol 650 milligrams by mouth every 6 hours as needed for temperature greater than 100 F;
Ibuprofen 400 milligrams by mouth every 6 hours as needed for pain;
Milk of Magnesia 30 cubic centimeters by mouth each day as needed for constipation; and
Mylanta 30 cubic centimeters by mouth every 6 hours as needed for indigestion.

S32RN was asked if she contacted the licensed practitioner for orders when each patient was admitted and she said that it was not necessary because the practitioner knew he was on call for the day and would evaluate all the patients admitted to him later when he came to the facility.

The above findings were recognized as an Immediate Jeopardy situation. After communication with State Office, on 08/08/2024 at 3:35 p.m., S1ADM was notified that the practice of allowing the nursing staff to fill out the admission and medication orders without consulting the licensed practitioner was outside of the scope of practice for a registered nurse and placed all 19 admitted patients and future admitted patients at risk for serious injury, serious harm, and serious impairment or death.

To verify the nursing practice of filling out admission and medication orders without consulting the licensed practitioner was not an isolated event as suggested by S1ADM, S31RN was interviewed on 08/08/2024 at 3:51 p.m. S31RN verified the admitting nurse chose which as needed medications each patient would be prescribed and fill out the admission orders without consulting the admitting licensed practitioner.

On 08/12/2024 plan of correction was presented to State Office. The plan included encouraging the use of electronic or faxed orders by the licensed practitioners and discouraging the routine use of verbal admission orders. Nursing staff was immediately re-education on the verbal order policy and the medication administration policy. A final plan to ensure adherence would be developed by 08/14/2024. The Immediate Jeopardy was removed on 08/12/2024 at 3:29 p.m., but there was not enough evidence to determine sustainability of compliance for the Condition of Nursing Services to be cleared. Noncompliance remains at the Condition Level.

2) Failure to ensure medication errors related to the timing of medication administration were tracked and analyzed to determine their causes.
A review of hospital's policy, titled "Medication Variance Reporting," Section 7.8.0, Approved 01/2024, revealed in part: All medication variances are to be reported on Medication Variance Report forms ...Purpose: To establish guidelines for reporting a medication error. To track and tend medication variances to reduce the rate of occurrence. Procedure: 3. Complete Medication Variance Report form. 4. Turn Medication Variance Report form to Director of Nursing. a. DON will monitor compliance in the documentation of medication variance through 10% concurrent review. B. DON will investigate each Medication Variance Report; provide documentation and results to administrator within 24 hours of occurrence for appraisal ...

Review of hospital documents provided failed to reveal Medication Variance Reports used to track and analyze medication errors related to the timing of medication administration.

In an interview on 08/08/2024 at 2:10 p.m, S2DON stated she did not know the hospital had medication variance reports. S2DON confirmed she did not keep a Medication Variance Report log. S2DON reported that she realizes that the information related to medication errors should be tracked and analyzed but she has only recently started in the DON position and has not yet addressed the medication variance reports.

3) Failure of the nursing staff to document the administration of an as needed medications

A review of hospital policy, "Medication Administration," Section 7.3.0, Approved: 01/2024, revealed in part: Policy Statement: ... All medication shall be documented on the patient's Medication Administration Record (MAR) immediately after administration ... Purpose: To provide clinical direction for Registered Nurses (RN) and Licensed Practical Nurses (LPN) on medication administration procedures to administer medications and treatments as ordered by the physician. To ensure the safe preparation and administration of medications including dose, frequency, route, exact strength, and instructions for use and medication administration procedures as ordered by the physician ... Procedure: Medication Administration: ... Chart medications on MAR. Effects of as needed medications and the site of injection must be recorded in the progress notes as well ... Medication Administration Documentation: The RN or LPN: Documents administration of medication by recording the time of administration in the corresponding column of the proper drug column. If the medication is administered by injection, records the site of administration in the integrated progress notes. Initials the appropriate "box/slot" with corresponding medication, date and time, indicating that the medication has actually been given ... Documents the administration of as needed medication in the same manner as routine medications ... Charts all medications (scheduled, as needed and STAT) in appropriate box/slot indicating time on the patient's MAR immediately after administered ...

A medical record review of Patient #2 revealed a nursing note from 08/02/2024 at 3:25 a.m., entered by S17RN, "Patient with noted seizure activity lasting for approximately 10 minutes. Vitals assessed. S60NP notified. Ativan 2 mg IM left gluteal administered. There was no documentation related to the administration of this medicine on the MAR. A nursing note from 08/05/2024 at 11:49 a.m. and entered by S55RN revealed, "S60NP present for seizure like activity. Order for Ativan 2 mg IM x 1." There was no documentation as to the administration of this medication in the nursing notes or the Medication Administration Record. Of note, this was the time frame the surveyors were present on this unit and did witness the patient with seizure like activity and also witnessed this nurse administer an injection to this patient. A nursing note from 08/05/2024 at 5:40 p.m. and entered by S55RN revealed in part, "1700: ... Patient had some seizure like activity in chair in hallway. MHT and RN maintained safety and supported head. VSS. S60NP with patient and ordered for one time IM Ativan dose. Patient is not postictal." There was no documentation as to the administration of this medication in the nursing notes or the Medication Administration Record.

In an interview on 08/08/2024 at 3:30 p.m. S1ADM confirmed the above mentioned findings.

4) Failure of nursing staff to document the effectiveness of an as needed medication being administered
A review of hospital policy, "Medication Administration," Section 7.3.0, Approved: 01/2024, revealed in part: Policy Statement: ... All medication shall be documented on the patient's Medication Administration Record (MAR) immediately after administration ... Purpose: To provide clinical direction for Registered Nurses (RN) and Licensed Practical Nurses (LPN) on medication administration procedures to administer medications and treatments as ordered by the physician. To ensure the safe preparation and administration of medications including dose, frequency, route, exact strength, and instructions for use and medication administration procedures as ordered by the physician ... Procedure: Medication Administration: ... Chart medications on MAR. Effects of as needed medications and the site of injection must be recorded in the progress notes as well ...

A medical record review of Patient #2 revealed a nursing note from 08/02/2024 at 3:25 a.m., entered by S17RN, "Patient with noted seizure activity lasting for approximately 10 minutes. Vitals assessed. S60NP notified. Ativan 2 mg IM left gluteal administered. There was no nursing documentation related to the follow up of the patient's response to the effectiveness of this as needed medication administration. A nursing note from 08/05/2024 at 11:49 a.m. and entered by S55RN revealed, "S60NP present for seizure like activity. Order for Ativan 2 mg IM x 1." There was no documentation as to the administration of this medication in the nursing notes or the Medication Administration Record. Of note, this was the time frame the surveyors were present on this unit and did witness the patient with seizure like activity and also witnessed this nurse administer an injection to this patient. There was no nursing documentation related to the follow up of the patient's response to the effectiveness of this as needed medication administration. A nursing note from 08/05/2024 at 5:40 p.m. and entered by S55RN revealed in part, "1700: ... Patient had some seizure like activity in chair in hallway. MHT and RN maintained safety and supported head. VSS. S60NP with patient and ordered for one time IM Ativan dose. Patient is not postictal." There was no documentation as to the administration of this medication in the nursing notes or the Medication Administration Record. Further, there was no nursing documentation related to the follow up of the patient's response to the effectiveness of this as needed medication administration.

In an interview on 08/08/2024 at 3:30 p.m. S1ADM confirmed the above mentioned findings.


5) Failure of nursing staff to document the indication for an as needed medication to be administered
A review of hospital policy, "Medication Administration," Section 7.3.0, Approved: 01/2024, revealed in part: Policy Statement: ... All medication shall be documented on the patient's Medication Administration Record (MAR) immediately after administration ... Purpose: To provide clinical direction for Registered Nurses (RN) and Licensed Practical Nurses (LPN) on medication administration procedures to administer medications and treatments as ordered by the physician. To ensure the safe preparation and administration of medications including dose, frequency, route, exact strength, and instructions for use and medication administration procedures as ordered by the physician ... Procedure: Medication Administration: ... Chart medications on MAR. Effects of as needed medications and the site of injection must be recorded in the progress notes as well ... Medication Administration Documentation: The RN or LPN: Documents administration of medication by recording the time of administration in the corresponding column of the proper drug column. If the medication is administered by injection, records the site of administration in the integrated progress notes. Initials the appropriate "box/slot" with corresponding medication, date and time, indicating that the medication has actually been given ... Documents the administration of as needed medication in the same manner as routine medications ... Charts all medications (scheduled, as needed and STAT) in appropriate box/slot indicating time on the patient's MAR immediately after administered ...


A Review of the Medication Administration Record revealed an as needed Ativan 2 mg IM injection being administered on 08/03/2024 at 9:15 p.m. by S17RN. There was no associated nursing note as to the reason for the administration of this as needed medication.

In an interview on 08/08/2024 at 3:30 p.m. S1ADM confirmed the above mentioned findings.

6) Failure of the nursing staff to document the location (site) of an injectable medication
A review of hospital policy, "Medication Administration," Section 7.3.0, Approved: 01/2024, revealed in part: Policy Statement: ... All medication shall be documented on the patient's Medication Administration Record (MAR) immediately after administration ... Purpose: To provide clinical direction for Registered Nurses (RN) and Licensed Practical Nurses (LPN) on medication administration procedures to administer medications and treatments as ordered by the physician. To ensure the safe preparation and administration of medications including dose, frequency, route, exact strength, and instructions for use and medication administration procedures as ordered by the physician ... Procedure: Medication Administration: ... Chart medications on MAR. Effects of as needed medications and the site of injection must be recorded in the progress notes as well ... Medication Administration Documentation: The RN or LPN: Documents administration of medication by recording the time of administration in the corresponding column of the proper drug column. If the medication is administered by injection, records the site of administration in the integrated progress notes ...

A Review of the Medication Administration Record revealed an as needed Ativan 2 mg IM injection being administered on 08/03/2024 at 9:15 p.m. by S17RN. This documentation failed to reveal the location the injection was administered.

In an interview on 08/08/2024 at 3:30 p.m. S1ADM confirmed the above mentioned findings.


47397




48051

Based on record review and interview, the hospital failed to have medical record services that are appropriate to the scope and complexity of the services performed and the hospital failed to employ adequate personnel to ensure prompt completion, filing, and retrieval of records. This deficient practice was evidence by the medical records department not being under the supervision of a qualified medical records practitioner.
Findings:

A review of S5MR personnel record revealed a signed job description on 06/27/2024 for the job title of Medical Records Technician. A review of her education background revealed a transcript for the completion of a Master of Public Health. The reviewed information does not indicate the qualifications for the position of Medical Records Practitioner. Further, the signed job description does not relate to the position of Medical Records Practitioner.

In an interview on 08/06/2024 at 2:55 p.m. S1ADM confirmed S5MR does not have the qualifications for the position of Medical Records Practitioner.

Based on observation and interview, the hospital failed to maintain a system of record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This deficient practice was evidenced by the storage of medical records without protection from potential destruction by fire, water or other damage.
Findings:

A review of facility policy, "The Medical Record," Section 3.1.0, last approved: 01/2024, revealed in part: Section: Responsibility for the Medical Record: It is the responsibility of the facility to provide a record for each patient and safeguard the record and its content against loss, damage, tampering and unauthorized use. Item B. CEO/Administrator: ... administrator is responsible for providing adequate direction, space, equipment, and personnel to perform these tasks effectively. Item E. Medical Staff: ... Licensure, certification and accreditation agencies all have standards requiring that the medical staff rules and regulations address certain issues regarding the medical record ... including provisions for the keeping of accurate and complete clinical records.

A review of facility policy, "Retention and Destruction," Section 3.7.0, last approved 01/2024, revealed in part: Policy Statement: The Health Information Management Department will strive to ensure that medical records and other information medium will be maintained in secure and restricted areas ... Procedures: II. Destruction: Item 3. Destruction Due to Unplanned Disaster: In anticipation of unplanned disasters, the hospital will make every attempt to safeguard health information records, documents and other storage medium in structurally sage, fire-resistant, and water resistant storage environments. Also, general safeguarding will ensure that combustible and/or hazardous chemicals and materials are maintained in a supervised environment with minimal risk for damage to hospital property. At all times, the hospital will strive to meet building and fire codes and OSHA guidelines. Item 4-a. Flooding/Water Damage: Medical records will be maintained in permanent storage filing cabinets and/or drawer units that are raised from the floor to prevent flooding and/or water damage.

A review of facility policy, "Storage and Retrieval," Section 3.8.0, last approved 01/2024, revealed in part: Policy Statement: A comprehensive, centralized system for storage and retrieval of medical records, from creation through destruction shall be established and maintained in the HIM Department. Procedure: I. Storage: A-3. Safeguard records and documents from tampering, loss and advertent destruction. III. Storage Space Specifications: A. Storage Space Specifications: Storage space shall be selected and maintained to protect records from unauthorized access, loss and destruction. Storage space shall be selected to meet the following specifications: adequate lighting, controlled environment (60º - 80º F, 50% humidity), freedom from dust, protection against fire, including the sprinkler system, and freedom from hazards, such as flooding or damage from broken water pipes.

Observations during a tour on 08/06/2024 from 9:30 a.m. to 11:45 a.m. of the facility's IOP clinic location revealed 12 bankers storage boxes of medical records from 2019 to 2023 in Room #vv, 37 patient medical records laying on top of a cabinet in Room #vv and 12 bankers storage boxes of medical records from 2014 to 2018 in Room #ww being stored in a manner that lacked protection from potential destruction by fire, water or other damage.

In an interview on 08/06/2024 and present during the tour, S33DSS confirmed the above mentioned findings.

Based on observation and interview, the hospital failed to remove outdated or otherwise unusable drugs and biologicals available for patient use. This deficient practice was evidenced by expired Influenza Virus Vaccine being available for patient use.
Findings:

Observations during a tour on 08/06/2024 from 9:30 a.m. to 11:45 a.m. of the facility's IOP clinic location revealed an open, 5ml vial of Influenza Virus Vaccine, 2016 - 2017 Formula, expired 04/2017.

In an interview on 08/06/2024 and present during the tour, S33DSS confirmed the above mentioned findings.

Based on record review and interview, the hospital failed to meet the Conditions of Participation (CoP) of Utilization Review. This deficient practice was evidenced by the hospital failing to have an effective utilization review (UR) plan that provides for review of services furnished by the institution and by members of the medical staff to patients entitled to benefits under the Medicare and Medicaid programs. This deficient practice was evidenced by the hospital failing to provide a utilization review (UR) plan that provides for the review of the medical necessity of admissions, duration of stays and professional services rendered to patients furnished by the institution and by members of the medical staff to patients entitled to benefits under the Medicare and Medicaid programs. (See Findings A-0653).

Based on record review and interview, the hospital failed to provide a utilization review (UR) plan that provides for the review of the medical necessity of admissions, duration of stays and professional services rendered to patients furnished by the institution and by members of the medical staff to patients entitled to benefits under the Medicare and Medicaid programs. This deficient practice was evidenced by the facility failing to have a UR Plan that included the establishment of a UR committee to carry out the review of the medical necessity of admissions, duration of stays and professional services rendered to patients.
Findings:

Review of the facility's policy and procedure manual did not reveal a policy related to a UR Plan/Policy. Review of the facility's Governing Body Meeting Minutes dated 01/09/2024-07/31/2024 and Medical Executive Meeting Minutes dated 01/15/2024 failed to reveal documentation related to an approval of a UR plan/Policy, appointment of providers to a UR committee, or any review of Medicare and Medicaid patients related to the medical necessity of admissions, duration of stays and professional services rendered in the facility. This deficient practice had the potential to affect any current patient or future patient receiving care at the hospital.

In an interview on 08/06/2024 at 2:03 p.m., S13SW confirmed the hospital did not have Utilization Review Committee.

In an interview on 08/07/2024 at 11:15 a.m. S1ADM confirmed the hospital did not have Utilization Review Plan or Utilization Review Committee.

48051

Based on observation and interview, the hospital failed to maintain the condition of the physical plant and hospital environment in such a manner to assure the safety and well-being of patients.
This deficient practice is evidenced by:
1) Failure to maintain the security of Unit A - C nursing stations because of inoperable door latches;
2) Failure to properly secure bedside nightstands;
3) Failure to maintain the ceiling tiles of the IOP;
4) Failure to maintain the ceiling light fixtures of the IOP; and
5) Failure to maintain the physical plant in good repair.

Findings:

1) Failure to maintain the security of Unit A - C nursing stations because of inoperable door latches
Observations during a tour of the hospital on 08/05/2024 from 9:30 a.m. to 11:25 a.m. revealed Unit A - C nursing station's entry doors were not secure upon closure. It was noted all 3 unit's nursing station doors had an inoperable door latch. This would allow any patient on the unit the opportunity to access the nurse's station which could place the patient or staff at risk for harm or injury.

In an interview during the tour on 08/05/2024, S1ADM confirmed the above mentioned findings.

2) Failure to properly secure bedside nightstands
Observations during a tour of the hospital on 08/05/2024 from 9:30 a.m. to 11:25 a.m. revealed the following bedside nightstand to be insecurely or loosely attached to the adjacent wall:
Room u-Bedside table b
Room s-Bedside table b
Room l-Bedside table a
Room k-Bedside table a and b
Room f-Bedside table a and b

In an interview during the tour on 08/05/2024, S1ADM confirmed the above mentioned findings.

3) Failure to maintain the ceiling tiles of the IOP
Observations during a tour on 08/06/2024 from 9:30 a.m. to 11:45 a.m. of the facility's IOP clinic location revealed missing ceiling tiles in the following rooms:
Room yy-2 tiles
Room aaa-1 ceiling tile
Room bbb-1 ceiling tile

In an interview on 08/06/2024 and present during the tour, S33DSS confirmed the above mentioned findings.

4) Failure to maintain the ceiling light fixtures of the IOP
Observations during a tour on 08/06/2024 from 9:30 a.m. to 11:45 a.m. of the facility's IOP clinic location revealed all of the clinic's 2 ft x 4 ft fluorescent light fixture coverings were not securely attached to the light fixture and were secondarily supported by a strip placed on the exterior side of the covering and across the center. These light coverings appeared to be yellowed with cracked edges.

In an interview on 08/06/2024 and present during the tour, S33DSS confirmed the above mentioned findings.

5) Failure to maintain the physical plant in good repair.
Observations during a tour of the hospital on 08/05/2024 from 9:30 a.m. to 11:25 a.m. revealed the following:
A. Bathrooms v, x, and z failed to reveal a soap dispenser attached to wall.
B. Bathroom w failed to reveal a functioning sink.
C. Main hallway on Unit A near room g near elevator revealed a loose handrail that was not secured to the wall.
D. Main hallway on Unit B near room n near elevator revealed a loose handrail that was not secured to the wall. Further observation revealed holes in the wall where the rail is only partially attached.
E. Missing floor baseboard molding: Room u next to toilet, Room x next to toilet, and Room c next to door frame.
F. Room q revealed a hole to the left side bottom of the door frame.
G. Room x revealed a hole in the wall behind the toilet.
H. Outside of Room w revealed a sagging/stained tile.
I. Hallway pp with mildew noted to ceiling tiles.
J. Sink in room g bathroom with non-functioning water faucet.

In an interview during the tour on 08/05/2024, S1ADM confirmed the above mentioned findings.

In an interview on 08/12/2024 at 11:25 a.m., S33DSS confirmed the loose handrails on Units A and B.




50453

Based on observations and interviews the hospital failed to ensure facilities, supplies, and equipment were maintained to ensure an acceptable level of safety and quality. This deficient practice is evidenced by:
1) failure to ensure Vac-Assist Suction Units and Oxygen Concentrators were maintained to ensure an acceptable level of safety and quality;
2) Failure to ensure expired supplies were not available for patient use;
Findings:

1) Failure to ensure Vac-Assist Suction Units and Oxygen Concentrators were maintained to ensure an acceptable level of safety and quality.
Observations during a tour on 08/12/2024 at 10:40 a.m., Unit A, Unit B, and Unit C revealed the following findings:
Brand C Vac-Assist Suction Unit:
Unit A: ID# SU11I01036, Biomedical Inspection due date: 10/12/2021
Unit B: ID# SU11I01649, Biomedical Inspection due date: 10/12/2021
Unit C: ID# SU11I01251, Biomedical Inspection due date: 10/12/2021
Brand C Oxygen Concentrator:
Unit A: ID#: N0510-22822, Biomedical Inspection due date: 10/25/2019
Unit B: ID#: 0712-11761, Biomedical Inspection due date: 10/15/2021
Unit C: ID#: 9R-021000, Biomedical Inspection due date: 10/12/2021

During an interview on 08/12/2024 at 10:50 a.m. during the tour of the Unit B, S19RN confirmed that the biomedical inspection dates are past due.

During an interview on 08/12/2024 at 10:55 a.m. during the tour of the Unit C, S48RN confirmed that the biomedical inspection dates are past due.

During an interview on 08/12/2024 at 11:05 a.m. during the tour of the Unit A, S33DSS confirmed that the biomedical inspection dates are past due.

During an interview on 08/12/2024 at 2:00 p.m. S1ADM confirmed that the biomedical inspections did not occur when due and he was immediately calling out biomedical technician to conduct an inspection of the equipment.

2) Failure to ensure expired supplies were not available for patient use

Observations during a tour of the hospital on 08/05/2024 from 9:30 a.m. to 11:25 a.m. revealed BD Vacutainers (purple top) x 6 tubes, expired on 06/30/2022 in the medication room of Unit C.

In an interview on 08/05/2024 at 09:55 a.m., S48RN confirmed the above mentioned findings.

Observations during a tour on 08/06/2024 from 9:30 a.m. to 11:45 a.m. of the facility's offsite Intensive Outpatient Program (IOP) clinic location revealed the following expired supplies:
Vacuette Safety Blood Collection Set and Luer Adapter, 21 gauge needle with expiration on 11/30/2021 - Quantity 41;
Vacuette Safety Blood Collection Set and Luer Adapter, 23 gauge needle with expiration on 11/28/2021 - Quantity 22 and expiration on 04/06/2023 - Quantity 23;
Terumo Sun Guard 3 Safety Hypodermic Needle (20 gauge, 2 inch needle) with expiration 04/30/2021 - Quantity 2, expiration 10/31/2021- Quantity 1, and expiration 02/23/2022 - Quantity 1;
Terumo Sun Guard 3 Safety Hypodermic Needle (21 gauge, 2 inch needle) with expiration 07/31/2024 - Quantity 1;
Terumo Sun Guard 3 Safety Hypodermic Needle (22 gauge, 1½ inch needle) with expiration 07/31/2024 - Quantity 2;
SMP Safety Needle 22 gauge, 1½ inch needle with expirations: 08/04/2018 - Quantity 1, 11/09/2018 - Quantity 1, 11/17/2018 - Quantity 1, 09/06/2019 - Quantity 1, 02/12/2020 - Quantity 1, 10/05/2020 - Quantity 1, 11/06/2020 - Quantity 1, 11/26/2021 - Quantity 1, 04/11/2022 - Quantity 1, and 01/26/2024 - Quantity 1;
SMP Safety Needle 23 gauge, 1 inch needle with expirations: 09/30/2018 - Quantity 1, 10/08/2018 - Quantity 1, 01/28/2019 - Quantity 4, 03/21/2019 - Quantity 2, 05/09/2019 - Quantity 2, 06/12/2019 - Quantity 2, 06/13/2019 - Quantity 1, 06/26/2019 - Quantity 1, 07/18/2019 - Quantity 2, 08/24/2019 - Quantity 3, 02/13/2020 - Quantity 1, 02/23/2020 - Quantity 1, 03/14/2020 - Quantity 1, 05/20/2021 - Quantity 1, 12/19/2021 - Quantity 1, 03/11/2022 - Quantity 2, 06/27/2022 - Quantity 1, and 01/26/2024 - Quantity 1;
Chloraprep Single Swab Stick with expiration 02/2020.
Sure Comfort Insulin Syringes (1 ml syringe with 29 gauge ½ inch needle) with expiration 05/31/2022 - Quantity 60;
BD Vacutainer Eclipse Blood Collection Needle with expiration 01/31/2023 - Quantity 48;
Microtainer Blood Tubes (1 ml purple top) with the expirations: 10/31/2018 - Quantity 12, 12/31/2018 - Quantity 7, 05/31/2019 - Quantity 7;
BD Vacutainer Collection Tube (purple top) with expiration 07/31/2023 - Quantity 6;
BD Vacutainer Collection Tube with Sodium Fluoride/Potassium Oxalate additive with expiration of 12/31/2019 - Quantity 1;
BD Vacutainer Serum Tube with expiration 01/31/2019 - Quantity 60;
BD Vacutainer SST Tube with expirations: 04/30/2018 - Quantity 50, 01/31/2019 - Quantity 56;
BD Vacutainer C&S Transfer Straw Kit C&S Preservative Plus Urine Tube (4 ml) with expiration 05/2019 - Quantity 18; and
Kendal Monojet Safety Syringe (1 ml) with expiration 07/2016 - Quantity 4.

In an interview on 08/06/2024 and present during the tour, S33DSS and S4LPN confirmed the above mentioned findings


48051




50453

Based on observation and interview, the hospital failed to provide proper ventilation and lighting in all area of the facility. This deficient practice is evidenced by inoperable light fixtures in the facility's IOP location.
Findings:

Observations during a tour on 08/06/2024 from 9:30 a.m. to 11:45 a.m. of the facility's IOP clinic location revealed non-functioning ceiling lighting in the following rooms:
Room uu: 2 of 5 light fixtures;
Room vv: 2 of 5 light fixtures;
Room ww: 1 of 1 light fixtures;
Room yy: 2 of 4 light fixtures;
Room xx: 2 of 3 light fixtures;
Room zz 1 of 3 light fixtures; and
Room aaa: 2 of 4 light fixtures.

In an interview on 08/06/2024 and present during the tour, S33DSS confirmed the above mentioned findings.

Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Infection Control by failure to have active hospital-wide programs for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship. This was evidenced by failure of the hospital to maintain an infection prevention and control program which included surveillance, prevention, and control of HAIs, and maintainance of a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities (See findings in A749 and A0750).

Based on observation and interview, the hospital infection prevention and control program failed to employ methods for preventing and controlling the transmission of infections within the hospital. This deficient practice was evidenced by:
1) failure to sanitize a mattress between patient use;
2) failure to properly sanitize equipment after patient use; and
3) failure to store clean items separate from dirty items.
Findings:

1) Failure to sanitize a mattress between patient use.
Review of hospital policy titled, "Equipment Cleaning," last revised: January 2023, revealed in part: Policy Statement: The following procedures define and establish standards for assuring that non-critical (defined by the Centers for Disease Control (CDC) as items that come into contact with skin but not mucous membranes), shared patient care equipment is clean before use and that all used or contaminated equipment is appropriately cleaned before reuse. B. Non-critical items, as defined by the CDC, come in contact with intact skin but not mucous membranes. Soiled environmental surfaces can be a source of contamination to hands or other objects that may have contact with the patient. Patient Care Equipment managed by patient care units or services must be wiped with a hospital-approved detergent/disinfectant daily and when visibly soiled. These items include but are not limited to: Commode, Wheelchair, Electronic Thermometers, Pulse Oximeters, Blood Pressure Devices.

Review of hospital policy titled, "Infection Control Committee Structure," last revised January 2023, revealed in part: 5. Procedures for infection prevention, surveillance, and control in relation to the inanimate hospital environment; including practices in disinfection, housekeeping, laundry ... and waste management.

On 08/08/2024 at 12:18 p.m., hospital video review of Unit A on 08/04/2024, navigated by S1ADM revealed the following:
08/04/2024:
12:10 a.m. - R1 arrives to Unit A.
12:15 a.m. - S17RN and S38MHT walk to Room c. Patient #2 is viewed laying on a uncovered bare mattress and has no clothing on below her waist.
12:16 a.m. - Patient #2 is given green scrub pants by S38MHT.
12:17 a.m. - S38MHT escorts Patient #2 out of Room c.
12:19 a.m. - R1 is brought to Room c by S17RN and S18MHT.

R1 lays on the mattress in Room c without a sheet or cover on the mattress. The mattress was not cleaned between Patient #2 and R1 being placed in Room c.

During an interview on 08/08/2024 at 12:30 p.m. S1ADM confirmed that the mattress and Room c were not cleaned between patient use. S1ADM also confirmed that Patient #2 was laying on the mattress without clothing covering the bottom half of her body and that R1 laid on this same mattress.

During an interview on 08/12/2024 at 3:19 p.m. S2DON confirmed that when Patient #2 was taken out of Room c, the mattress should have been cleaned prior to placing R1 in the room.

2) Failure to properly sanitize equipment after patient use
Observations during a tour of the hospital on 08/05/2024 from 9:30 a.m. to 11:25 a.m. revealed patient infrared thermometer on Unit C being held together by loosely wrapped tape that had become sticky. The stickiness prevented the proper sanitary cleaning of the thermometer after patient use.

In an interview on 08/05/2024 at 09:55 a.m., S48RN confirmed the presence of the tape on the surfaces of the thermometer.

3) Failure to store clean items separate from dirty items
Observations during a tour of the hospital on 08/05/2024 from 9:30 a.m. to 11:25 a.m. revealed a brown paper bag stored in the soiled utility closet of Unit C. The bag had the writing on it "donated clothing." The bag did appear to have items within it.

In an interview during the tour on 08/05/2024, S1ADM confirmed the brown bag was being stored in the soiled utility, was not sure if the clothing in the bag was clean or dirty and should not be stored in the soiled utility.



50453

Based on observation, record review and interview, the hospital failed to maintain an infection prevention and control program which includes surveillance, prevention, and control of HAIs, and maintains a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities. This deficient practice was evidenced by failure of the Infection Control Officer to gather and/or provide data and present it to the Infection Control Committee as per policy.
Findings:

Review of hospital policy titled, "Infection Control Plan," last revised January 2023, revealed in part: Infection Control Function: The principal functions of the Infection Control Officer include the following: 1. To obtain and manage critical data and information, including surveillance of infections 2. To develop and recommend policies and procedures 3. To intervene directly to prevent infections 4. To educate and train ... The infection Control Officer is responsible for carrying out all aspects of the infection control program. Environmental Considerations: b. Evaluate compliance with standards set by the infection control committee. Epidemiology: b. Investigation: Maintain adequate records ... Compile and analyze surveillance data and present deviations from baseline data to the IC Committee and to other appropriate committees, departments or services.

Review of hospital policy titled, "Infection Control Committee Structure," last revised January 2023, revealed in part: Policy Statement: The Committee will meet at least four (4) times a year. The Committee will ... make complete and accurate minutes of all meetings. In the absence of a physician, the Committee can make no policies or clinical decisions. C. The Infection Control Committee will be responsible for the initiation and supervision of an active, hospital-wide infection control program which will include: 5. Procedures for infection prevention, surveillance, and control in relation to the inanimate hospital environment; including practices in disinfection, housekeeping, laundry, engineering and maintenance, food sanitation, and waste management. These procedures will be reviewed and evaluated annually and revised as necessary.

Review of hospital policy titled, "Duties of Infection Control Officer," last revised January 2023, revealed in part: A. Duties: The Infection Control Officer works under the direction of the Infection Control Committee. 5. The Infection Control Officer prepares monthly infection surveillance reports for the Infection Control Committee. 10. The Infection Control Officer collaborates with the PI Committee to study problems and possible solutions.

Review of hospital policy titled, "Surveillance Program," last revised January 2023, revealed in part: Policy Statement: it is the policy of the hospital to have an Infection Control Surveillance Program in place. Procedure: A. Infection Control Nurse will gather data on all possible infections occurring in the hospital. From this data, he/she will prepare a surveillance report monthly. This report is presented quarterly at the Infection Control Committee Meeting.

Review of hospital policy titled, "Surveillance Reports," last revised January 2023, revealed in part: Policy Statement: Surveillance reports will be regularly prepared. Procedure: A. The Infection Control Officer shall regularly prepare a report for the Infection Control Committee that reflects the types and numbers of infections present in the hospital. C. The statistical report shall be made available to the Infection Control Committee, Hospital Administrator, CEO, and the Nursing Leadership.

Review of hospital policy titled, "Control of Head or Body Lice Infestation," last revised January 2023, revealed in part: Purpose: To establish lice infestation control measures. Procedure: B. An effective way to accomplish this is to have daily head checks with all patients and document findings in a special log designed for this purpose. C. This log is to be maintained by MHTs under the supervision of the Charge Nurse. Copies with log should be turned into the Infection Control Department Weekly.

Review of hospital documents failed to reveal an active Infection Control Program.

Data being collected for analysis for Infection Control was requested numerous times during the survey and the facility failed to gather or provide the requested information.

During an interview on 08/07/2024 at 2:27 p.m. S1ADM confirmed that the Infection Control Committee has not had any meetings per policy. S1ADM stated he does not have any meeting minutes to provide. S1ADM also confirmed that staff are not maintaining a daily head check log to turn into Infection Control as per lice policy.

Based on record review and interview, the psychiatric hospital failed to ensure social service records included interviews with patients, family members and others, assessment of home plans, family attitudes, and community resource contacts as well as a social history and early discharge planning. This deficiency is evidenced by failure of social services to complete the psychosocial assessment as ordered by the provider for 1 (#5) of 7 (#1-#6) patient records reviewed.
Findings:

Review of hospital's policy titled, "Documentation Completion Time Frames", Section 3.9.0 approved 01/2024, revealed in part: Procedure: Psychosocial assessments. Completion time 72 hours after admission.

On 08/06/2024 at 8:45 a.m. a review of Patient #5's medical record revealed admission on 07/31/2024 at 9:55 a.m. with admitting diagnosis of psychosis and major depressive disorder. Further review failed to reveal a completed psychosocial evaluation.

A review of Patient #5's admit orders revealed consult for social services for psychosocial assessment ...

In interview on 08/08/2024 at 3:30 p.m., S33DSS verified the psychosocial assessment was not in Patient #5's medical record per provider orders. S33DSS stated the psychosocial assessment included but was not limited to interviews with patients, family members and others, assessment of home plans, family attitudes, and community resource contacts as well as a social history and early discharge planning. S33DSS confirmed the psychosocial assessment should be completed within 72 hours of admission per hospital policy.

Based on record review and interview, the hospital failed to demonstrate that the director of nursing monitored and evaluated the nursing care furnished thereby ensuring accordance with safe, acceptable standards of nursing practice. This deficient practice was evidenced by:
1) failure to ensure the registered nurse documented rounds per patient policy for (15) of (20) patients reviewed;
2) failure to ensure the mental health technician noted precaution levels per hospital policy for (13) of (20) patients reviewed;
3) failure to ensure the registered nurse completed assignment sheets per hospital policy;
Findings:

1) Failure to ensure the registered nurses documented rounds per patient policy for (15) of (20) patients reviewed.
Review of hospital policy titled, "Patient Observation Record," Section 4.2.0, approved 06/2024, revealed in part: Patients must be observed at least every 15 minutes. The observation with documented location and behavior must be documented, verified by the observer's initials, at least every 15 minutes. Purpose: To ensure that the patient's safety and well-being are maintained and documented. To have a continuous record of patient behavior and location. Procedure: The RN is responsible for MHT assignments (Patient Observation Record) 1. A review of this record is performed every 2 hours. 2. A rounding of all patients is to be performed every 2 hours and documented on the Patient Observation Record ...

Patient #1
Review of Patient #1's observation records revealed the following:
08/05/2024-observation sheet failed to reveal RN rounding from 9:45 a.m.-12:00 p.m.

Patient #2
Review of Patient #2's observation records revealed the following:
08/06/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-8:00 a.m.

Patient #3
Review of Patient #3's observation records revealed the following:
08/03/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-6:00 a.m.
08/04/2024-observation sheet failed to reveal RN rounding from 8:00 p.m.-11:45 p.m.

Patient #4
Review of Patient #4's observation records revealed the following:
07/25/2024-observation sheet failed to reveal RN rounding from 2:00 a.m.-6:00 a.m.
07/26/2024-observation sheet failed to reveal RN rounding from 1:45 a.m.-6:00 a.m.
07/27/2024-observation sheet failed to reveal RN rounding from 5:45 a.m.-8:00 a.m.
08/05/2024-observation sheet failed to reveal RN rounding from 5:45 a.m.-8:00 a.m.

Patient #5
Review of Patient #5's observation records revealed the following:
08/04/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-8:00 a.m. or MHT observations from 5:45 a.m.-7:00 a.m.
08/05/2024-observation sheet failed to reveal RN rounding from 11:45 a.m.-8:00 a.m.
08/06/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-8:00 a.m.

Patient #6
Review of Patient #6's observation records revealed the following:
08/03/2024-observation sheet failed to reveal RN rounding from 05:45 a.m.-8:00 a.m.
08/06/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-8:00 a.m.

Patient #R1
Review of Patient #R1's observation records revealed the following:
08/06/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-8:00 a.m.

Patient #R2
Review of Patient #R2's observation records revealed the following:
06/26/2024-observation sheet failed to reveal RN rounding from 8:00 p.m.-11:45 p.m.
06/27/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-6:00 a.m. and 8:00 p.m.-11:45 p.m.
06/28/2024-observation sheet failed to reveal RN rounding from 8:00 p.m.-11:45 p.m.
06/29/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-8:00 a.m.
07/01/2024-observation sheet failed to reveal RN rounding from 8:00 p.m.-11:45 p.m.
07/02/2024-observation sheet failed to reveal RN rounding from 8:00 p.m.-11:45 p.m.
07/03/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-8:00 a.m.
07/05/2024-observation sheet failed to reveal RN rounding from 8:00 a.m.-2:00 p.m.
07/11/2024-observation sheet failed to reveal RN rounding from 8:00 a.m.-6:00 p.m.
07/17/2024-observation sheet failed to reveal RN rounding from 8:00 p.m.-11:45 p.m.
07/19/2024-observation sheet failed to reveal RN rounding or MHT observations from 12:00 a.m.-7:00 a.m.
07/20/2024-observation sheet failed to reveal RN rounding from 8:00 p.m.-11:45 p.m.
07/21/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-8:00 a.m. and 6:00 p.m.-11:45 p.m.
07/29/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-6:00 a.m. and 8:00 p.m.-11:45 p.m.
07/31/2024-observation sheet failed to reveal RN rounding from 8:00 a.m.11:45 p.m.
08/01/2024-observation sheet failed to reveal RN rounding from 5:45 a.m.-8:00 a.m. and 8:00 p.m.-11:45 p.m.
08/02/2024-observation sheet failed to reveal RN rounding from 8:00 p.m.-11:45 p.m.
08/03/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-6:00 a.m.
08/04/2024-observation sheet failed to reveal RN rounding from 8:00 p.m.-11:45 p.m.

Patient #R3
Review of Patient #R3's observation records revealed the following:
08/06/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-8:00 a.m.

Patient #R4
Review of Patient #R4's observation records revealed the following:
08/05/2024-observation sheet failed to reveal RN rounding from 5:45 a.m.-8:00 a.m.
08/06/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-8:00 a.m.

Patient #R5
Review of Patient #R5's observation records revealed the following:
08/05/2024-observation sheet failed to reveal RN rounding from 5:45 a.m.-10:00 a.m.
08/06/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-8:00 a.m.

Patient #R6
Review of Patient #R6's observation records revealed the following:
08/05/2024-observation sheet failed to reveal RN rounding from 5:45 a.m.-10:00 a.m.
08/06/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-8:00 a.m.

Patient #R10
Review of Patient #R10's observation records revealed the following:
08/03/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-6:00 a.m.

Patient #R15
Review of Patient #R15's observation records revealed the following:
08/03/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-6:00 a.m.

Patient #R23
Review of Patient #R23's observation records revealed the following:
08/03/2024-observation sheet failed to reveal RN rounding from 12:00 a.m.-6:00 a.m.

In an interview on 08/08/2024 at 2:10 p.m., S2DON verified the above findings.

2) Failure to ensure mental health technicians noted precaution levels per hospital policy for (13) of (20) patients reviewed.
Review of hospital policy titled, "Patient Observation Record," Section 4.2.0, approved 06/2024, revealed in part: The MHT is to note the Precaution Level ordered for each patient...

Patient #1
Review of Patient #1's admit orders dated 08/05/2024 revealed an order for Suicide Preecautions. Continued review of Patient #1's physician orders dated 08/05/2024-08/07/2024 failed to reveal an order to discontinue suicide precautions.

Review of Patient #1's observation record dated 08/06/2024 failed to reveal "Precaution Level-Suicide" noted.

Patient #2
Review of Patient #2's admit orders dated 07/28/2024 revealed an order for Fall and Seizure Precautions.

Patient #2's observation records failed to reveal "Precaution Level-Seizures and Fall" noted on the following dates: 07/31/2024-08/03/2024, and 08/06/2024.

Patient #3
Review of Patient #3's admit orders dated 08/01/2024 revealed an order for Suicide and Assault Precautions.

Patient #3's observation records failed to reveal "Precaution Level-Suicide and Assault" noted on the following dates: 08/01/2024-08/05/2024.

Patient #4
Review of Patient #4's admit orders dated 07/24/2024 revealed an order for Suicide Precautions.

Patient #4's observation records failed to reveal "Precaution Level-Suicide" noted on the following dates: 07/28/2024-08/02/2024 and 08/05/2024.

Patient #6
Review of Patient #6's admit orders dated 08/02/2024 revealed an order for "Suicide and Fall Precautions".

Patient #6's observation records failed to reveal "Precaution Level-Suicide and Fall" noted on the following dates: 08/03/2024, 08/04/2024, and 08/06/2024.

Patient #R2
Review of Patient #R2's admit orders dated 05/14/2024 revealed an order for suicide precautions. Continued review of Patient #R2's physician orders dated 05/15/2024-08/06/2024 failed to reveal an order to discontinue suicide precautions. Additional review revealed Patient #R2 was discharged to Hospital B with leg fracture on 08/06/2024.

Review of Patient #R2's observation records failed to reveal Precaution Level-Suicide noted on the following dates:
06/26/2024-06/29/2024, 07/01/2024-07/03/2024, 07/05/2024, 07/11/2024, 07/12/2024, 07/17/2024, 07/19/2024-07/21/2024, 07/29/2024, 07/31/2024, and 08/01/2024-08/06/2024.

Patient #R5
Review of Patient #R5's admit orders dated 08/03/2024 revealed an order for Seizure Precautions.

Review of Patient #R5's observation records failed to reveal "Precaution Level-Seizure" noted on the following dates:
08/05/2024.

Patient #R6
Review of Patient #R6's admit orders dated 07/29/2024 revealed an order for Suicide Precautions.

Review of Patient #R6's observation records failed to reveal "Precaution Level-Suicide" noted on the following dates:
08/05/2024 and 08/06/2024

Patient #R8
Review of Patient #R8's admit orders dated 07/27/2024 revealed an order for Suicide and Assault Precautions.

Review of Patient #R8's observation records failed to reveal "Precaution Level-Suicide and Assault" noted on the following dates:
08/03/2024-08/05/2024.

Patient #R11
Review of Patient #R11's admit orders dated 07/24/2024 revealed an order for Suicide Precautions.

Review of Patient #R11's observation records failed to reveal "Precaution Level-Suicide and Assault" noted on the following dates:
08/03/2024-08/05/2024.

Patient #R14
Review of Patient #R14's admit orders dated 07/30/2024 revealed an order for Suicide Precautions.

Review of Patient #R14's observation records failed to reveal "Precaution Level-Suicide" noted on the following dates:
08/03/2024-08/05/2024.

Patient #R18
Review of Daily Nursing Assignment Sheet dated 07/28/2024 revealed Patient #R18 was on Suicide Precautions.

Review of Patient #R18's observation record dated 08/05/2024 failed to reveal "Precaution Level-Suicide" noted.

Patient #R21
Review of Daily Nursing Assignment Sheet dated 08/02/2024 revealed Patient #R21 was on Homicide Precautions.

Review of Patient #R21's observation record dated 08/05/2024 failed to reveal "Precaution Level-Assault" noted.

In an interview on 08/08/2024 at 2:10 p.m. S2DON verified the above findings. S2DON stated that sometimes suicide assessment may indicate the patient no longer at risk but the nurse should always notify the physician and obtain an order to discontinue suicide precautions. S2DON stated she was not sure if the hospital had a policy regarding the process of discontinuing physician ordered precautions.

Previously cited on 07/24/2024

3) Failure of the Dirctor of Nursing to ensure the registered nurse completed assignment sheets per hospital policy.
Review of hospital policy titled "Staffing Plans and Delivery of Care", dated 01/2021, revealed in part: Policy: The Director of Nursing shall outline a staffing plan that shall be used to determine the personnel recommended for each shift as outlined in the units core coverage and as necessary to provide the scope of services ...Census: 1-12 patients requires: 1 Registered Nurse and 2 Mental Health Technicians.

Review of Daily Nursing Assignment Sheet for Unit B dated 07/24/2024, day shift, revealed a census of 12. Continued review failed to reveal each patient was assigned a Mental Health Technician.

Review of Daily Nursing Assignment Sheet for Unit B dated 07/25/2024, day shift, revealed a census of 11. Continued review failed to reveal each patient was assigned a Mental Health Technician.

Review of Daily Nursing Assignment Sheet for Unit B dated 07/26/2024, day shift, revealed a census of 11. Continued review failed to reveal each patient was assigned a Mental Health Technician.

Review of Daily Nursing Assignment Sheet for Unit C dated 08/01/2024, day shift, revealed a census of 11. Continued review failed to reveal each patient was assigned a Mental Health Technician.

Review of Daily Nursing Assignment Sheet for Unit C dated 08/01/2024, night shift, failed to reveal a census. Continued review failed to reveal the names of the patients assigned to the Mental Health Technicians.

Review of Daily Shift Assignments for Unit C dated 08/05/2024, day shift, failed to reveal a census. Continued review failed to reveal the names of the patients assigned to the Mental Health Technicians.

In an interview on 08/08/2024 at 2:15 p.m. S2DON reported she had created new assignment sheets but the nurses are still using the old sheets and are not completing the assignment sheet as they should.

In an interview on 08/08/2024 at 3:15 p.m., S1ADM confirmed that the assignments were not properly completed.

Based on record review and interview, the psychiatric hospital failed to provide adequate numbers of nursing staff to provide the nursing care necessary under each patient's active treatment plan. This deficiency is evidenced by failure of the psychiatric hospital to have adequate staffing of mental health technicians (MHT) per the psychiatric hospital's staffing matrix for 11 of 18 staffing assignments reviewed.

Review of hospital's policy titled "Staffing Plans and Delivery of Care", Section 1.8.0 approved 01/2024 revealed in part: Policy: The director of nursing shall outline a staffing plan that shall be used to determine the personnel recommended for each shift ...Purpose: to define guidelines for the utilization of RNs and MHTs in providing delivery of patient care. Procedure, in part: Core coverage: The minimum staffing needed for each unit (RN, MHT) is set forth by the nurse-patient ratio guidelines (See table) ... Table: Census 1-12=RN-1 and MHT-2.

Review of hospital policy titled "Shift Assignments", last reviewed 01/2022, revealed, in part: Purpose: To ensure a safe, therapeutic milieu and delivery of quality patient care by designating specific duties to appropriate staff members... Procedure, in part: 1. Charge Nurse: The charge nurse will determine the nursing care assignments for that shift based on patient acuity and capabilities of available staff.

On 08/05/2024 at 9:24 a.m., a request was made in writing to S1ADM for the nursing assignment sheets for each unit for June and July 2024. On 08/06/2024 at 10:48 a.m. surveyor was provided with Daily Nursing Assignment Sheets for the timeframe 07/24/2024-08/05/2024, which did not include all Units. S2DON reported she was looking for the rest and would provide them when found.

A review of the Daily Nursing Assignment Sheets provided for Unit A revealed the following:
08/01/2024-day shift-Census 7 (no precautions noted on assignment sheet). Staff: 1 RN (Name not on current employee contact list) and 1 MHT (S62MHT).
08/02/2024-day shift-Census 7 (including Patient #2 with seizure and fall precautions noted on assignment sheet). Staff: 1 RN (S17RN) and 1 MHT (S40MHT).
08/02/2024-night shift-Census 7 (including Patient #2 with seizure and fall precautions noted on assignment sheet). Staff: 1 RN (S48RN) and 1 MHT (S63MHT).

A review of the Daily Nursing Assignment Sheets provided for Unit B revealed the following:
07/22/2024-night shift-Census 10 (including Patient #R17 with seizure and fall precautions noted on assignment sheet). Staff: 1 RN (S64RN) and 1 MHT (S65MHT). Noted by S64RN on assignment sheet "S65MHT only tech for shift.
07/25/2024-night shift-Census 11 (no precautions noted on assignment sheet). Staff: 1 RN (Name not on current employee contact list) and 1 MHT (S53MHT).
07/27/2024-day shift-Census 7 (including Patients #R8, #R18 and #R19 with suicide precautions noted on assignment sheet). Staff: 1 RN (S66RN-Name not on current employee contact list) and 1 MHT (S39MHT).
07/28/2024-day shift-Census 7 (including Patients #R8, #R18 and #R19 with suicide precautions noted on assignment sheet). Staff: The document failed to reveal the staff RN and MHTs caring for patients on this shift.
07/29/2024-day shift-Census 8 (including Patient #R20 with suicide precautions noted on assignment sheet). Staff: 1 RN (S48RN) and 1 MHT (S39MHT).
07/30/2024-day shift-Census 8 (no precautions noted on assignment sheet). Staff: 1 RN (S32RN) and 1 MHT (S52MHT).
07/31/2024-night shift-Census 6 (no precautions noted on assignment sheet). Staff: 1 RN (S46RN) and 1 MHT (S67MHT).
08/01/2024-night shift-Census 8 (including Patients #R21 and #R22 with homicide precautions and Patient #R20 with suicide precautions noted on assignment sheet). Staff: 1 RN (S48RN) and 1 MHT (S52MHT).

In an interview on 08/08/2024 at 11:15 a.m., S2DON confirmed the above findings and agreed the staffing was not adequate per the hospital staffing matrix.

In an interview on 08/08/2024 at 3:15 p.m., S1ADM verified staffing was short with only 1 MHT. S1ADM confirmed the hospital policy requires 2 MHTs at all times.