Research Psychiatric Center

Based on observation, interview and record review the facility failed to:

-Ensure contracted Anesthesia (a drug which results in loss of bodily sensation with or without loss of consciousness) staff developed and maintained specific ECT (psychiatric treatment in which seizures are electrically induced in anesthetized patients (patient has the loss of bodily sensation with or without loss of consciousness) for treatment of severe depression) policies and procedures directing safe anesthesia be provided to ECT patients;

-Ensure two out of two current inpatients (#11 and #27) and 10 out of 10 outpatients (#14, #15, #16, #17, #18, #19, #20, #22, #23 and #24) had obtained informed consents that were properly documented prior to ECT.

-Ensure two out of two current inpatients (#11 and #27) and 10 out of 10 outpatients (#14, #15, #16, #17, #18, #19, #20, #22, #23 and #24) received a post-anesthesia assessment prior to discharge from the ECT department.

-Develop and consistently follow a time out procedure (a safety check conducted and documented just prior to any procedure where anesthesia was used) for two current inpatients (#11 and #27) and four outpatients (#17, #23, #20 and #14) before providing ECT treatments for six time out procedures observed.

The facility routinely provided ECT treatments for 16 to 17 patients three times a week. These failures had the potential to affect all inpatients and outpatients who received ECT. The facility census was 71.

Findings included:

1. Review of the American Society of Anesthesiologist (ASA) Statement on Documentation of Anesthesia Care last amended 10/22/08 showed the following direction:

-The anesthesia department's policies and procedures should be compiled in a single set of rules and regulations or in a procedure and policy manual.

-Such policies and procedures should be consistent with the medical staff bylaws, the facility's operating room policies and local law.

-The policies and procedures should be based on the ASA Manual for Anesthesia Department Organization and Management and other ASA guidelines.

2. During an interview on 02/13/13 at 9:00 AM, Staff OO, Anesthesiologist, stated that anesthesia staff did not have separate policies and procedures and he thought the policies for anesthesia had been included in the ECT nursing policy.

3. During an interview on 02/13/13 at 9:40 AM, Staff CC, Anesthesiologist, stated that anesthesia staff would refer to the policies and procedures from another facility.

4. During an interview on 02/13/13 at 2:30 PM, Staff C, ECT Staff Registered Nurse (RN) stated that the ECT department had anesthesia policies and procedures and she could refer to them if she had a question related to anesthesia. Staff C stated that if she did have a question about policies or procedures for the ECT department, she would refer to Staff G, RN, ECT Supervisor, and not the policy and procedure manual.

5. During an interview on 02/13/13 at 3:00 PM, Staff E, ECT Staff RN, stated that a lot of the department's policies and procedures were on-line. Staff E stated that she would refer to Staff G if she had any questions about a policy or procedure for the ECT department instead of going on-line. Staff E stated that the ECT department did have policies and procedures related to anesthesia services.

6. During an interview on 02/13/13 at 3:30 PM, Staff F, ECT Staff RN, stated that the ECT department's policies and procedures were on-line. Staff F stated that she would refer to Staff G if he was available if she had a question before she would look up a policy or procedure. Staff F stated that she trusted her team before she would look up a specific policy or procedure.

7. During an interview on 02/13/13 at 3:50 PM, Staff G, RN, ECT Supervisor, stated that all the anesthesia policies and procedures were included in the ECT nursing policy and procedure. Staff G stated that staff would ask him questions they had related to the department's policies and procedures if he was available. Staff G stated that the ECT department did not have separate anesthesia policies and procedures. Staff G stated that the ECT department did not have anesthesia policies and procedures on-line and did not have a manual available to staff.

8. Record review of the facility policy title, Informed Consent #603.112.85 last revised 02/13 showed the following direction:

-Informed consent shall be obtained for surgical procedures and ECT.

-Any other procedures where consent is required by law.

-Informed consent that is required for any procedure or treatment must additionally indicate evidence that the physician has signed the consent before the procedure or treatment can proceed.

-Such signature delineates that the physician has provided the patient with information specific to a discussion about the patient's proposed care, treatment, and services, and reasonable alternatives, and the risks, benefits, and side effects of the proposed care, treatment or services.

-For any ECT procedure or other procedure/treatment where such signature of the physician is required, assessment for the signature will occur prior to the start of the procedure/treatment and the procedure/treatment halted or postponed until such signature is obtained.

9. During an interview on 02/12/13 at 11:30 AM, Staff L, Psychiatrist, stated that approximately two years ago a patient had to be brought out from anesthesia before they received ECT because the consent form had not been done before the start of the procedure.

10. During an interview on 02/13/13 at 9:00 AM, Staff OO, Anesthesiologist, stated that patients were informed of the risks and benefits of anesthesia but did not sign an informed consent.

11. During an interview on 02/13/13 at 9:40 AM, Staff CC, Anesthesiologist (past Chairman of the Department of Anesthesia) stated that Anesthesia Services did not have a policy for informed consent or a policy that directed staff to obtain a separate consent for ECT. Staff CC stated that he was not aware of the anesthesia consent form used by nursing staff.

12. During an interview on 02/13/13 at 2:24 PM, Staff C, ECT Staff RN stated that ECT nursing staff reviewed with the patients the risks and benefits of anesthesia not the anesthesiologist. Staff C stated that she did not know if there was an informed consent policy for the ECT department or not.

13. During an interview on 02/13/13 at 3:02 PM, Staff E, ECT Staff RN, stated that Anesthesiologist did not review risks and benefits with each patient prior to ECT and that nursing staff signed the consent forms and not the anesthesiologist.

14. Record review of inpatients #11 and #27 and outpatients #14, #15, #16, #17, #18, #19, #20, #22, #23 and #24 Consent for Anesthesia Services form showed for both inpatients and outpatients the patient and nurse signed the forms. The forms did not have the signatures of the anesthesiologist.

15. Review of the ASA Statement on Documentation of Anesthesia Care, last amended on 10/22/08 showed the following direction:

-Documentation was a factor in the provision of quality care and was the responsibility of an anesthesiologist.

-While anesthesia care was a continuum, it was usually viewed as consisting of pre-anesthesia (before), intra-operative/procedural anesthesia, and post-anesthesia (after) components.

-Anesthesia care should be documented to reflect these components and to facilitate review.

16. During an interview on 02/12/13 at 10:46 AM, Staff J, Psychiatrist, stated that patients would need an anesthesia assessment/evaluation prior to ECT.

17. During an interview on 02/12/13 at 11:30 AM, Staff L, Psychiatrist, stated that on average he had one to five patients that received ECT each week and that anesthesia staff performed pre and post anesthesia assessments.

18. During an interview on 02/13/13 at 3:00 PM, Staff E stated that anesthesiologist do not reassess the patients post-anesthesia status before they are discharged from the ECT department. Staff E stated that the anesthesiologist only see a patient if there is a problem.

19. During an interview on 02/13/13 at 3:30 PM, Staff F stated that anesthesia did not assess or see patients before they were discharged from the ECT department. Staff F stated that she had never seen anesthesiologist on the patient units.

20. During an interview on 02/13/13 at 3:50 PM, Staff G, RN, ECT Supervisor, stated that the ECT nursing policy and procedure did not include direction for the anesthesiologist to perform a pre or post anesthesia evaluation. Staff G stated that anesthesia performed a pre assessment when patients arrived to the ECT department.

21. During an interview on 02/14/13 at 9:16 AM, Staff CC, Anesthesiologist, stated that he would begin doing a face to face (post-anesthesia assessment) for both inpatients and outpatients on 02/15/13.

22. Review of the Association of Operating Room Nurses (AORN) Perioperative Standards and Recommended Practices 2012 edition, Position Statement, Preventing Wrong-Patient, Wrong-Site, Wrong Procedure Events, gives direction for multidisciplinary teams that include Perioperative RNs, surgeons, anesthesia care providers, risk managers, and other health care professionals who should collaboratively develop procedures and protocols to prevent wrong-patient, wrong-site, and wrong-procedure events.

23. Record review of the facility's policy titled ECT Pre-Verification and Time Out Procedure #603.311.09 last revision dated 08/12 showed the following direction:

-A time-out will occur immediately before starting the procedure.

-Time-out must involve the entire ECT team, at least, but not limited to, psychiatrist, treating RN, and anesthesia personnel.

-Use active communication.

-Initiation of the time-out will be the responsibility of the treating nurse and be conducted in a fail-safe mode, that is, the procedure is not started until any questions or concerns are resolved.

-Include the following elements in the documentation: correct patient identity, agreement on the procedure to be performed.

-If there is a discrepancy in agreement between the team members, an immediate STOP will occur. Any discrepancy must be reconciled before ECT treatment can proceed.

24. During an interview on 02/13/13 at 3:00 PM, Staff E, RN, stated that the following elements were included in the time-out:

-Name of the patient.

-Consent signed by the anesthesiologist.

-Spinal x-ray on the chart.

-Required laboratory test on the chart.

25. During an interview on 02/13/13 at 3:50 PM, Staff G stated that time-out is performed with each patient before ECT. Staff G stated that his time-out is a modified standard surgical time-out. Staff G stated that time-out is used for patient safety to ensure the correct patient and procedure before treatment is administered. Staff G stated that a time-out should be documented in patients' medical records. Staff G stated that the following elements were done in time-out before ECT:

-Check NPO status of the patient.

-Identify the patient.

-Check that consent had been obtained from the patient.

-Check to ensure required laboratory tests were on the chart.

26. Observation in the ECT area showed on 02/11/13 at 1:05 PM, ECT staff failed to perform a time-out prior to the ECT procedure of Patient #17 and on 02/13/13 at 7:20 AM ECT staff failed to perform a time-out prior to the ECT procedure of Patient #22.

27. Observation on 02/13/13 at 8:00 AM of Patient #23 showed Staff G asked Staff QQ, Psychiatrist, if the consent was signed. No time-out was performed prior to the ECT procedure.

28. Observation on 02/13/13 at 8:25 AM of Patient #20 showed Staff G announced time-out and stated the patient's name and that the patient was NPO (had taken nothing by mouth) prior to the ECT procedure.

29. Observation on 02/13/13 at 9:14 AM of Patient #14 showed Staff G announced the patient's name and Staff OO, Anesthesiologist, responded, okay. Staff G stated time-out and stated that the patient was NPO and asked Staff J, Psychiatrist, if the consent was signed prior to ECT procedure.

30. Observation on 02/13/13 at 12:35 PM of Patient #27 showed Staff G verified the patient's name and date of birth with patient. Staff G did not perform a time-out prior to the ECT procedure.

31. Observation on 02/13/13 at 1:06 PM of Patient #11 showed Staff G stated time-out and verified with Patient #11 her name and NPO status. Staff G did not perform time-out prior to ECT procedure.

Violation Name: PRE-ANESTHESIA EVALUATION(A-1003)

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Based on observation, interview, record review, review of the American Society of Anesthesiologist (ASA) Standards for Anesthesia Care and review of the facility quality assessment/performance improvement data, the facility failed to ensure a pre-anesthesia evaluation was documented by an anesthesiologist for each ECT (electroconvulsive therapy, a psychiatric treatment in which seizures are electrically induced in anesthetized patients for therapeutic effect) patient. The facility's quality assessment/performance improvement (QA/PI) data repeatedly identified non-compliance with the requirement over an extended period of time and the facility failed to address the deficient practice with any corrective actions.

The facility census was 71. The facility routinely provided ECT treatment for 16 to 17 patients three times a week.

Findings included:

1. Review of the ASA Statement on Documentation of Anesthesia Care, last amended on 10/22/08 showed the following direction:

-Documentation was a factor in the provision of quality care and was the responsibility of an anesthesiologist.

-While anesthesia care was a continuum, it was usually viewed as consisting of pre-anesthesia (before), intra-operative/procedural (during) anesthesia and post-anesthesia (after) components.

-Anesthesia care should be documented in the patient's medical record to reflect each component.

2. Review of the facility's Medical Staff By-Laws, Section E, paragraph 17, showed direction for the Pre-anesthesia assessment to be completed prior to each ECT treatment and directed that the ECT anesthesia preoperative evaluation should be completed and signed by the anesthesiologist.

3. Record review of the contract between the facility and the Anesthesia Associates of Kansas City (AAKC), Exhibit A Additional terms and Conditions, paragraph 2A, dated 07/01/00 showed direction for all patients requiring anesthesia services will receive a pre-anesthesia assessment by an anesthesiologist. The contract further directed that the assessment should be documented in the progress notes of the patient's medical record.

4. During an interview on 02/13/13 at 3:50 PM Staff G, ECT Unit Supervisor stated that the anesthesia policy and procedures were included in the facility nursing ECT policy and procedure. Staff G stated that the ECT Unit did not have a policy directing the anesthesiologists to perform pre-treatment and post-treatment evaluation of the patients. Staff G, stated that the department staff looked for completeness of the medical record and completeness of the anesthesia record for a quality improvement (QI) study.

5. During an interview on 02/12/13 at 10:10 AM, Staff K, Psychiatrist, stated that he expected the anesthesiologist to do the following for a patient prior to ECT treatment:

-Review the medical record of each patient.

-Review each patients' medications.

-Perform a pre-admission evaluation prior to each ECT treatment for each patient.

-Document and complete an assessment form before the ECT treatment for each patient.

-Staff K also stated that the ECT Peer Review Committee monitored the quality of anesthesia services on a quarterly basis and there had been problems identified concerning the completion of the pre-anesthesia assessment form.

6. Review of Department Specific Performance Improvement Plan, 2012, for the ECT Unit, Indicator #2 showed the standard was one hundred percent of the pre-anesthesia assessments will be completed to demonstrate compliance with the requirement.

7. Review of the ECT Peer Review Committee's meeting minutes showed the committee was aware of the lower than expected anesthesia documentation studies:

-During the first quarter of 2012, only 92% or 467 of 509 medical records reviewed showed compliance with the requirement;

-During the second quarter of 2012, (dated 07/10/12) only 93% or 366 of 393 medical records reviewed showed compliance with the requirement;

-The committee planned to merely continue to monitor and report findings to the performance improvement (PI) committee meeting. The Committee also planned to report the findings to the ECT Peer Review Committee during the next quarter. The committee planned to develop a corrective action plan to present to Medical Executive Committee that would address the necessary actions to meet the standards. A follow-up evaluation was planned for December, 2012;

-During the third quarter of 2012, (dated 12/04/12) only 93% or 337 of 363 medical records reviewed showed compliance with the requirement;

-The committee again planned to merely continue to monitor and report findings to the PI Committee. The committee also planned to report the findings of deficient performance to the ECT Peer Review Committee next quarter. The committee again planned to develop a corrective action plan to present to the Medical Executive Committee that would address necessary actions to meet the standards that anesthesia staff had failed to meet for the last nine months. A follow up evaluation was now planned for February, 2013.

Violation Name: POST-ANESTHESIA EVALUATION(A-1005)

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Based on observation, interview, record review and review of the American Society of Anesthesiologist (ASA) Standards for Anesthesia Care, the facility failed to develop and maintain a policy that directed a post-anesthesia evaluation was documented for each ECT (electroconvulsive therapy, a psychiatric treatment in which seizures are electrically induced in anesthetized patients for therapeutic effect) patient.

The facility census was 71. The facility routinely provided ECT treatment for 16 to 17 patients three times a week.

Findings included:

1. Review of the American Society of Anesthesiologist (ASA) Statement on Documentation of Anesthesia Care, last amended on 10/22/08 showed a facility should develop and maintain policies and procedures directing the following:

-Documentation was a factor in the provision of quality care and was the responsibility of an anesthesiologist.

-While anesthesia care was a continuum, it was usually viewed as consisting of pre-anesthesia (before), intra-operative/procedural (during) anesthesia and post-anesthesia (after) components.

-Anesthesia care should be documented in the patient's medical record to reflect the components.

2. During an interview on 02/13/13 at 9:40 AM, Staff CC, Anesthesiologist (past Chairman of the Department of Anesthesia), stated that any anesthesia policies for the ECT unit would be included in the facility ECT policy. Staff CC stated that Anesthesia staff would refer to the policies and procedures from another sister facility.

3. During an interview on 02/13/13 at 3:50 PM, Staff G, RN, ECT Unit Supervisor, stated that policies and procedures relating to anesthesia were included in the ECT policy and procedure. Staff G stated that the ECT policy and procedure did not include a requirement for the anesthesiologist to document a pre-anesthesia assessment or a post-anesthesia assessment. Staff G stated that the ECT department did not have separate anesthesia policies and procedures.

4. During an interview on 02/13/13 at 3:00 PM, Staff E, RN stated that anesthesiologists did not re-assess the patient before they were discharged from the department. Staff E stated that the anesthesiologist would only see a patient if there were any problems.

5. During an interview on 02/13/13 at 3:30 PM, Staff F, RN stated that anesthesia did not see any of the out patients before they were discharged .

Violation Name: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE(A-0724)

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Violation Name: INFECTION CONTROL PROGRAM(A-0749)

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Based on observation interview and record review the facility failed to ensure Food and Nutrition (F&N) staff used appropriate food handling techniques to prevent cross contamination through:

-Failure to perform appropriate hand hygiene before applying clean and after removing soiled disposable gloves;

-Failure to ensure the Director of Dietary used effective hand hygiene after licking his finger tips to turn pages in manuals, policy books and other department documents and before touching equipment and surfaces in the food production and service areas;

-Failure to use effective hair restraints and effective beard restraints; and

-Failure to ensure patient meals were served at appropriate temperatures to protect against bacterial growth that may cause food borne illness.

The facility census was 66.

Findings included:

1. During an interview on 12/10/12 at 1:45 PM Staff B, Director of Food and Nutrition (F&N) stated the facility infection control practitioner did not approve or have any input on the department's food sanitation policies and procedures.

2. Review of the U. S. Department of Health and Human Services (USDHHS), Public Health Service (PHS), Food and Drug Administration (FDA), 2005 Food Code showed the following direction:

-In Chapter 2-301.14 When to wash. Food employees shall clean their hands.

-In Chapter 2-301.14 (A) After touching bare human body parts (such as mouth, lips, tongue) other than clean hands and clean, exposed portions of arms.

-In Chapter 2-301.14 (H) Before donning gloves for working with food.

-In Chapter 2-301.14 (I) After engaging in other activities that contaminate the hands.

-In Chapter 3 304.15 Gloves, Use Limitation (A) Gloves shall be used for only one task such as ready to eat foods or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.

3. Review of the facility's policy titled Hand washing (HACCP, Hazard Analysis Critical Control Point, a preventative approach to food safety through identification of possible food safety hazards and methods to control those to eliminate or reduce the risk of food borne illness) dated March, 2006 showed the following direction:

-All employees associated with the handling of food shall wash hands.

-Hands shall be washed at the following times: before putting on gloves; after any other activity that may contaminate the hands.

-Procedures included: All food handlers should use sinks designated for hand washing

Review of the facility's policy titled Personal Hygiene, effective March, 2010 showed the following direction:

-Purpose: To prevent the spread of food borne illness.

-Hand washing: Employees must wash hands before beginning/returning to work or when necessary.

-Hand washing: Wash hands frequently.

-To prevent cross contamination and the transmission of disease-carrying organisms, plastic gloves will be worn.

-Disposable gloves must be changed with each activity or whenever gloves become torn or contaminated.

-Other guidelines to further prevent the spread of illness: Hands also must be washed after scratching heads, touching hair, sneezing, blowing nose and other acts of personal nature.

4. Observations on 12/10/12 from 1:45 PM through 2:46 PM showed Staff B, Director, licked his fingers while turning multiple pages in the department policy manual, department training records, facility menus, nutrient analysis of the menus and quality assessment/performance improvements documents and failed to perform hand hygiene to remove saliva from his hands before touching multiple surfaces in the dry food storeroom, in the walk-in refrigerator, before touching a bulk sugar bin, door handles and multiple other surfaces in the kitchen.

5. Observation on 12/11/12 at 10:48 AM in the patient meal tray assembly area showed Staff Z, Diet Aide reapplied her hair restraint, failed to perform hand hygiene, applied gloves then, returned to patient meal tray assembly.

During an interview on 12/11/12 at 10:49 AM Staff Z stated she had not performed hand hygiene after touching her hair and applying gloves.

6. Observation on 12/11/12 at 11:05 AM on the Intensive Treatment Unit (ITU) dining area showed Staff Z applied gloves without performing hand hygiene.

During an interview on 12/11/12 at 11:05 AM Staff Z stated she knew she should perform hand hygiene however there was no sink in the ITU dining area so, she could not perform hand hygiene.

7. Observation on 12/11/12 at 11:05 AM in the ITU showed Staff B rubbed his hand across his mouth then without performing hand hygiene handled patient meal trays.

8. Record review of the USDHHS, PHS, FDA, 2005 Food Code showed the following direction in Chapter 2-402 Food handlers should wear effective hair restraints including beard restraints to keep hair from exposed foods, clean equipment and utensils.

9. Review of the facility's policy titled Personal Hygiene, effective March, 2010 showed the following direction:

-Policy: Associates will practice good personal hygiene habits at all times while on duty.

-Purpose: To prevent the spread of food borne illness.

-Guidelines: Dress Code: Associates wear approved hair restraints, including beard guards.

10. Observation on 12/11/12 at 10:48 AM in the patient meal tray assembly area showed Staff Z, Diet Aide, placed portioned foods on each patient meal tray and failed to cover two to three inches of hair on each side of her head with an effective hair restraint.

11. During an interview on 12/11/12 at 10:48 AM Staff D, Lead Dietitian stated Staff Z failed to wear an effective hair restraint.

12. Observation on 12/11/12 at 10:55 AM showed Staff AA, Diet Aide in the cold food area (where other staff portioned uncovered cream pies) without a beard cover over facial hair.

During an interview on 12/11/12 at 10:55 AM Staff AA stated he had never been told by F&N supervisory staff to wear a beard cover over facial hair.

13. Observation on 12/11/12 at 10:58 AM showed Staff BB, Diet Aide carried a stack of cleaned trays from the dish washing room to the cafeteria area and failed to wear a beard cover over facial hair

During an interview on 12/11/12 at 10:58 AM Staff BB stated no one in the F&N department had told him to wear a beard cover over facial hair.

14. Review of the USDHHS, PHS, FDA, 2005 Food Code showed the following direction in Chapter 3-501 Foods should be maintained at a temperature less than 41 degrees Fahrenheit or above 135 degrees Fahrenheit to decrease growth of bacteria that could cause food borne illness.

15. Review of an undated form titled Food and Nutrition Services Test Tray Evaluation, provided during the survey by Staff C, Dietitian showed the following permissible temperature ranges for foods served on a test tray:

-Hot entrees should be served at greater than 140 degrees Fahrenheit.

-Vegetable should be served at greater than 140 degrees Fahrenheit.

-Dessert should be served at lesser than 40 degrees Fahrenheit.

16. Observation on 12/11/12 at 11:17 AM showed staff served a test meal tray with foods at the following temperatures:

-Roast pork at 114 degrees Fahrenheit.

-Spinach at 118 degrees Fahrenheit.

-Canned pineapple at 51.1 degrees Fahrenheit.

17. During an interview on 12/11/12 at 11:17 AM the Staff C, Dietitian stated the following:

-The roast pork and the spinach should be served at 135 degrees Fahrenheit and it was not.

-The canned pineapple should be served at or below 40 degrees Fahrenheit and it was not.

-The roast pork and the spinach need to be warmer.

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and record review the facility failed to:

-Complete accurate and comprehensive admission contraband assessments for eight patients (#16, #17, #19, #1, #21, #4, #5, and #22) of twelve patients on the adolescent unit and for one patient (#6) of fifteen patients on the Intensive Treatment Unit (ITU-utilized to treat the more acutely ill, behavior problem patients).

-Take action to prevent Patient #4 from acquiring a lighter, a pack of cigarettes, and an unknown pill;

-Complete accurate and comprehensive interventions according to the mandatory education process initiated on 10/10/12 for control of contraband;

-Identify old and potential newly-acquired contraband, and add those items to inventory lists for three of 38 patients reviewed (Patients #13, #51, and #52).

-Assess and document size, description, and take photos of a reddened skin issue on one of one patient identified with skin issues (Patient #13); and

-Assess and document goals and interventions to prevent skin irritation related to poor hygiene of one patient identified with skin issues (Patient

#13).

These failures had the potential to affect all patients, and could potentially lead to harm of the patients admitted to the facility. The facility census was 66.

Findings included:

1. Record review of the facility policy titled, Control of Contraband, revised 11/12, showed the following direction:

- [The facility] will make all reasonable efforts to provide a safe environment for patients and staff of the center by establishing and maintaining a consistent process for identifying, securing and preventing potentially dangerous or harmful contraband items from reaching the inpatient units;

- To accomplish control of contraband and to assure a safe, therapeutic environment, certain items will not be allowed into any patient areas under any circumstances;

- Restricted items include, but are not limited to; electronics, chemicals, corded items, glass, fire hazards/weapons, and personal items;

- Restricted personal items included razors & sharp metal objects, mirrors, items with cords, prescription & over the counter medications, shaving lotion, and nail polish remover, to name a few;

- Patients who present for a medical screening exam (pre-admission assessment) will be asked to place their personal items into a locked container, to remain in their presence until their disposition to the next level of treatment. Patients refusing to cooperate with the search will remain with staff until an inspection takes place. Security may be called to assist for patients resistant to the search;

- A second check for contraband items will take place during the nursing assessment on the inpatient unit;

- To prevent inadvertent entry of contraband items that cannot be detected through electronic wands, patients with an acute history of suicidal ideation, gesture or attempt shall, upon admission to their nursing unit, be required to put on a patient gown, (while maintaining privacy with a screen) and have all clothing searched before allowing the patient to wear these items within the unit environment.

2. Record review of the facility mandatory education titled, Control of Contraband with an effective date of 10/10/12 showed the following requirements for direct care staff:

- Upon admission to the unit, patient belongings will be placed in a secure place until they can be searched. All clothing items will be checked for strings and cords and removed before returning to patient;

- The patient will be placed in a paper gown without underwear until he/she can be searched. Privacy will be maintained but safety is the first priority;

- As soon as possible after admission, patient belongings will be searched and documented on a medical record form (Belongings List and Contraband Assessment);

3. Record review of the contraband assessment portion of the Belongings List and Contraband Assessment form included the following:

- Wanded for metal;

- Checked for contraband;

- Placed in gown;

- Photo and description of injury.

Record review on 12/11/12 of the admission Belongings List and Contraband Assessment forms showed staff failed to complete the contraband assessment portion for eight patients (#1, #21, #16, #17, #19, #4, #5, and #22) out of twelve patients reviewed on the adolescent unit.

4. Record review of the last documented suicide risk scores dated 12/11/12 for the eight patients on the adolescent unit without the contraband assessment showed Patient #1 with a score of 6 (high risk), Patient #21 with a score of 4 (moderate risk), Patients #16, #17, and #19 with a score of 2 (low risk), Patients #4 and #5 with a score of 1 (low risk), and Patient #2 with a score of zero (low risk).

5. Review of medical record for Patient #4 on 12/10/12 showed:

- Patient admitted on [DATE] after she told her aunt she wanted to die;

- Patient had a history of cutting and had fresh scratches on her left arm;

- Progress documentation dated 12/03/12 noted the patient with a pack of cigarettes and lighter on the day shift and the patient's aunt found a pill in her pocket..

6. During an interview on 12/11/12 at approximately 1:00 PM, Staff R, Registered Nurse (RN), stated that contraband checks are completed upon admission, environmental rounds are completed twice per day, staff on evenings conducts contraband searches after visitation, she did not know how cigarettes and lighter got in, and she did not know that a pill was found on patient.

7. During an interview on 12/11/12 at approximately 11:00 AM, Staff W, Mental Health Technician (MHT), stated that she was aware Patient #4 was found with a lighter and cigarettes and still does not know how it happened. She further stated that she, as an experienced MHT, conducts training for new staff including procedures for contraband checks, belongings inventory, and documentation requirements.

8. During an interview on 12/11/12 at approximately 2:20 PM, Patient #22 (Adolescent Unit), stated that a contraband check was not conducted upon his admission on 12/08/12 and he did not change into a gown or pajamas.

9. During an interview on 12/12/12 at 9:35 AM, Staff Q, Adolescent Unit Director, stated that:

- Belongings are secured and checked upon admission for contraband;

- Patients receive a contraband search in examination room;

- Patients at low to high risk of suicide are searched in a paper gown with underwear removed;

- By report, two MHT staff conducted Patient #4's admission contraband assessment and that she did not remove her underwear during the search;

- He did not understand how cigarettes and a lighter were not found during search; and

- He was unable to submit evidence of an admission contraband search from the patient's medical record.

10. During an interview on 12/12/12 at approximately 2:00 PM, Staff F (RN) and Charge Nurse on the Adolescent Unit, stated that:

- During a contraband assessment, the patient is required to change into paper scrubs after removing clothes and underwear;

- The requirement was included in mandatory training on Control of Contraband; and

- She does not understand why some staff do not want to have underwear removed when a patient stands behind a screen to change for privacy.

11. During an interview on 12/11/12 at approximately 1:30 PM, Staff R, RN stated that if contraband is found, the nurse is to contact the physician, determine the level of monitoring, search room clothes, document on an incident report and notify the Director.

The findings noted above show that policies, procedures and interventions do not provide patients on the adolescent unit with consistent and effective supervision and contraband searches,thereby placing them at potential risk of acquiring harmful objects (contraband).

12. Review of the Adult and Intensive Treatment Units' suicidal risk assessment documentation dated 12/10/12, showed sixteen of thirty-eight patients with a suicidal risk score of 3-6, or a moderate-high risk for suicidal tendencies.

13. Review of Patient #6's History and Physical (H&P) dated 12/07/12, showed the patient was admitted to the ITU on that date with a diagnosis of schizoaffective disorder, bipolar type (a condition whereby the patient hears voices, and has manic [high-energy] days and depressed days).

Review of the patient's suicidal risk score dated 12/10/12, showed the patient was rated as being a moderate risk for suicide with a score of 3.

Review of the patient's Physician's orders dated 12/07/10, showed the patient was to be monitored by staff every 15-minutes.

14. Observation and concurrent interview on 12/10/12 at 1:50 PM showed Patient #6 had a purple/plumb colored top lying on her bed with four fabric ties sewn to the side seam at the waistband. Each tie was approximately 12-15-inches long (probably used to tie a bow at the waist). These long ties could have been removed from the top and utilized as a hanging/looping hazard. Staff Y, Quality RN, stated that the patient should not have this top with ties. Staff Y stated that the top should have been removed by staff either in the inspection process during admission and/or upon discovery during environmental rounds completed each shift.

Even though this top was found in the patient's room, review of the patient's List of Personal Possessions, undated, showed no such top in her possession and review of the Environmental Rounds documentation dated 12/10/12, not timed, showed no such top with ties.

15. During an interview on 12/11/12 at 3:06 PM, Staff SS, MHT, stated that he admitted Patient #6 and never saw a top with long ties on it. Staff SS stated that if the top was brought in by family after the admission process, it should have been inventoried by staff and removed from the patient because it was considered contraband, or a hazard to this patient and all others at risk.

Staff failed to search the patient and/or room in a thorough manner in order to protect all patients from potential harm related to contraband.

16. Review of Patient #51's H&P dated 12/04/12, showed the patient was admitted on [DATE] with a diagnosis of suicidal ideations and attempt by hanging.

Review of the patient's suicidal risk score dated 12/10/12, showed the patient was a low risk (0-2) with a score of 1. Her roommate had a score of 2.

Review of the Adult Environmental Rounds documentation for the date of 12/11/12 showed the patient had contraband in her room (Mentholatum ointment, a topical pain relieving rub). This ointment could be inappropriately consumed or applied.

17. Review of Patient #52's H & P dated 12/05/12, showed the patient was admitted on [DATE] with a diagnosis of bipolar disorder.

Review of the Adult Environmental Rounds documentation for the date of 12/11/12 showed the patient had a wire-bound notebook and a dress with strings. The wire from the notebook could be used by the patient to injury herself. The strings could be utilized for a potential looping hazard.

18. Review of Patient #53's H&P dated 12/06/12, showed the patient was admitted on [DATE] with a diagnosis of suicidal ideations and a history of suicide attempt by overdose.

Review of the Adult Environmental rounds documentation dated 12/11/12 showed the patient had a glass bottle in her room. This bottle could potentially be used as a cutting weapon.

19. Review of Patient #13's H & P dated 12/01/12, showed the patient was admitted on [DATE] with a diagnosis of schizoaffective disorder.

Review of the Adult Environmental Rounds documentation for the date of 12/11/12 showed the patient had shoes with strings. These strings could be utilized for a potential looping hazard.

20. Record review of the Control of Contraband mandatory education, dated effective 10/10/12 showed the following requirements:

-Staff will complete an admission checklist (form required to be completed on every patient as an audit/review tool and is not part of the medical record) and turn into the team RN.

-The admission checklist includes: a) belongings removed upon admission to unit, b) patient placed in paper gown and searched, c) clothing searched for contraband and strings/cords removed before returning to patient, d) patient belongings searched and logged on valuables checklist, e) valuables and medications locked in appropriate safes, f) requirement to complete on every patient admitted , g) Signature authentication by Mental Health Technician (MHT) conducting the search, and h) signature authentication by the team RN.

-The team RN will review to make sure the checklist is complete and turn into the Director. The Director or designee will randomly check staff for completeness of contraband checks weekly and will document on the audit form.

21. Following request on 12/12/12 for audit information on control of contraband, Staff F (Adolescent unit RN), Staff Q (Adolescent unit Director) and Staff A (Chief Nursing Officer) did not submit any completed audit forms for review. Therefore, the facility failed to show completed admission checklists on every patient.

22. Review of a facility policy titled, Skin Assessment for Bruising, Pressure Ulcers and other Skin Markings, revised 06/12, showed the following:

-The Registered Nurse (RN) completed the Plan for Nursing Care, including;

-Specific nursing interventions for psychological, psychosocial, and environmental factors;

-The Plan is specific, individualized and goal oriented.

-The Plan will be based on the patients' strengths, liabilities, and patient care needs;

-Team members will develop quantifiable short-term and long-term goals for which specific interventions are developed;

-The Plan will be evaluated and revised every 48-hours;

-Skin assessment will be completed via the Braden (a tool used to assess risk for skin breakdown) on admission and daily thereafter if the Braden score is less than or equal to 16;

-Photos are taken bi-weekly of identified sites;

-The physician is notified of a change in skin condition, and the abnormal skin area is documented with general skin appearance (color, warmth, integrity) and identifying characteristics (bruises, skin tears, stitches, etc.);

-Wounds should be measured in centimeters (cm) with a detailed description in the daily nursing assessment.

23. Review of Patient #13's Psychiatric Report dated 12/01/12, showed the patient was admitted on [DATE] with a diagnosis of schizoaffective disorder. The patient also had a history of obstructive sleep apnea, was morbidly obese (486 pounds) with poor hygiene and had a bad odor.

Review of Patient #13's Braden scale score on admission showed a score of 14, or at risk. A Braden scale is used to predict the risk of skin breakdown.

Review of the patient's medical record showed no description, size or photos of the patient's redness/yeast areas.

Review of a physician's note dated 12/09/12, showed the patient had redness to areas on backs of arms, axilla (underarms), buttocks and inner thighs. The patient had limited mobility and had to be encouraged to be more mobile to prevent breakdown and also had to be encouraged to perform hygiene.

Review of nurses' and social workers' notes showed the following:

-On 12/01/12 the patient's grooming was poor;

-On 12/03/12 the patient had poor hygiene and had skin breakdown between abdominal folds where skin touches, smells horrible, appearance disheveled with strong body odor;

-On 12/04/12 the patient had a history of not bathing and was reported to authorities for self-neglect;

-On 12/06/12 the patient's activities of daily living were poor.

Review of a Consult Note dated 12/02/12, showed the patient had moist skin with redness and a yeasty odor under the skin folds of the abdomen, near the groin.

Review of physician's orders dated 12/09/12, the physician ordered Desitin (zinc oxide) ointment to be applied to the reddened area, twice daily until healed.

24. During an interview on 12/11/12 at 1:00 PM, Staff D, Registered Dietitian, stated that Patient #13 had mobility and hygiene issues which lead to the skin breakdown.

25. Observation and concurrent interview on 12/11/12 at 9:08 AM, showed Patient #13 walking down the hallway emitting a very discernible body odor. Staff TT, RN, confirmed the patient typically had an odor, had just finished a shower, and generally resisted showering/hygiene. The patient had a large area of redness under the large folds of her abdomen, measuring approximately 15-inches across by six-inches wide.

26. During an interview on 12/11/12 at 1:52 PM, Staff Y, Quality RN, stated that she did not believe staff were required to document size/description, and take photos of a redness/yeast area (as stated in policy), just staged pressure sores.

27. During an interview on 12/12/12 at 9:14 AM, Staff A, Chief Nursing Officer, stated that there was no facility policy addressing a redness/yeast area. Staff A stated it was a nursing judgment if a skin issue worsened, with report to the physician, oncoming nurse, and documentation reflecting the change. However, Staff A could not specifically relate how the nurses would track condition from one shift to the next without the description, size, etc. documented in the record. Staff A stated that depression typically lead to poor hygiene, and poor hygiene could lead to skin issues. If hygiene improved, the skin condition would also improve. Staff A stated that quality monitoring of skin assessment/documentation was not typically an issue on the Adult/ITU, just the senior unit.

28. During an interview on 12/12/12 at 1:47 PM, Patient #13 stated that the redness/yeast area would come and go, and itched.

29. Review of facility quality monitoring documentation, for the third quarter of 2012, showed no performance indicator for skin assessment and documentation on the Adult/ITU.

Violation Name: NURSING CARE PLAN(A-0396)

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review the facility failed to develop/maintain a comprehensive, individualized care plan, with a problem, goal and specific interventions for two of eight care plans reviewed (Patients #4 and #13). This failure could potentially lead to improper identification and provision of care needs. The facility census was 66.

Findings included:

1. Review of facility policies titled, Treatment Plan, revised 08/12; and Multidisciplinary Treatment Plan, revised 11/12 showed the following:

-The Registered Nurse (RN) completed the Plan for Nursing Care, including;

-Specific nursing interventions for psychological, psychosocial, and environmental factors,

-The Plan is specific, individualized and goal oriented;

-The Plan will be based on the patients' strengths, liabilities, patient care needs;

-Team members will develop quantifiable short-term and long-term goals for which specific interventions are developed;

-The Plan will be evaluated and revised every 48-hours.

2. Review of Patient #13's Psychiatric Report dated 12/01/12, showed the patient was admitted on [DATE] with a diagnosis of schizoaffective disorder. The patient also had a history of obstructive sleep apnea, was morbidly obese (486 pounds) with poor hygiene and had a bad body odor.

Review of a physician's note dated 12/09/12, showed the patient had to be encouraged to perform hygiene.

Review of nurses' and social workers' notes showed the following:

-On 12/01/12 the patient had sleep apnea and grooming was poor;

-On 12/03/12 the patient had poor hygiene, smelled horrible, appearance was disheveled with strong body odor;

-On 12/04/12 the patient had a history of not bathing and was reported to authorities for self-neglect;

-On 12/06/12 the patient's activities of daily living were poor.

Review of a physician Consult Note dated 12/02/12, showed the patient utilized a CPAP (continuous positive airway pressure used to assist in breathing) machine in her home related to the sleep apnea.

Review of physician's orders dated 12/06/12 showed the patient required oxygen at two liters per nasal cannula (tubing) at bedtime and during naps.

3. Observation and concurrent interview on 12/11/12 at 9:08 AM, showed Patient #13 walking down the hallway emitting a very discernible body odor. Staff TT, RN, confirmed the patient typically had an odor, and generally resisted showering/hygiene.

4. During an interview on 12/11/12 at 11:03 AM, Staff X, RN, stated that Patient #13 had Chronic Obstructive Pulmonary Disease related to her weight which compromised her breathing.

5. During an interview on 12/12/12 at 9:14 AM, Staff A, Chief Nursing Officer, stated that depression typically leads to poor hygiene. Staff A stated that she did not feel like oxygen use and poor hygiene was something that needed to be added to the treatment plan for this patient because they were not new problems.

6. During an interview on 12/12/12 at 1:47 PM, Patient #13 stated that she gets short-of-breath with exertion and required oxygen at night and during naps. Patient #13 stated that the oxygen helped a lot.

7. Review of the patient's Treatment Plan dated 12/01/12 showed staff failed to address the patient's lack of hygiene, history of and current odors. There was only one intervention, Assist with performance of basic living. A problem of altered skin integrity (the patient had developed a yeasty rash under her abdominal folds as a result of poor hygiene) showed an intervention to keep the patient clean and dry. Staff also failed to address the patient's need for oxygen at bedtime and during naps in the treatment plan.

8. Review of Patient #4's medical record on 12/12/12 showed:

- Patient admitted on [DATE] at 9:19 PM after she told her aunt she wanted to die; had a history of cutting and had fresh scratches on her left arm; and reported that her mother died of a heart attack three months ago;

- Progress documentation dated 12/03/12 noted the patient had a pack of cigarettes and lighter (contraband) on the day shift, the patient's aunt found a pill in the patient's pocket; and the patient displayed secretive behaviors;

- A Physician's order dated 12/04/12 at 9:45 PM for close observation (patient to remain within eyesight of staff);

- A Physician's order dated 12/07/12 at 7:10 PM for unit restriction (patient to remain on unit) and 1:1 supervision (one staff is assigned to supervise one patient at all times);

- The Physician re-ordered 1:1 supervision and unit restriction on 12/08/12 at 11:00 AM, until the patient was discharged .

9. Review of Patient #4's treatment care plan dated 12/02/12 showed:

-No comprehensive treatment/care plan to address 1:1 supervision, unit restriction, and/or contraband interventions.

10. During an interview on 12/12/12 at approximately 9:00 AM, Staff Q (Adolescent Unit Director) stated that Patient #4 had been on 1:1 and close observation; however, these interventions were not included in treatment plans.

Violation Name: INFECTION CONTROL PROFESSIONAL(A-0748)

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Based on interview and record review the facility failed to follow their infection control policy regarding Tuberculosis (TB-a contagious respiratory disease) testing for two of seventeen employees reviewed. This has the potential to affect all employees and patients if an outbreak would occur. The facility census was 66.

Findings included:

1. Review of a facility policy titled, New Employee and Annual TB Screening and Testing, revised 06/12, showed the following:

-Baseline TB screening will be performed on all new hires, using the two-step method;

-Then, all employees will need to complete an annual TB health assessment form;

-If an employee has been exposed to TB a screening will be completed with a follow-up screen in three months.

Review of a facility policy titled, Infection Control Guidelines for the Nursing Department, revised 06/12, showed the following:

-Nursing personnel will review at least annually and comply with the standards set forth for the TB control plan;

-There will be monitoring tools to evaluate whether personnel are complying with stated infection control policies.

3. Review of the Tuberculosis Infection Surveillance Plan, dated October 2011, showed that to reduce the risk for transmitting TB, employees shall be screened and protected from health hazards associated with TB.

4. During an interview on 12/12/12, Staff G, Infection Control Registered Nurse, confirmed the above process and policies.

5. Review of employee records on 12/12/12, showed Staff B, Director of Dietary, had no documentation of TB screening, or the annual risk health assessment since 07/04. Staff MM, Physical Therapy, had no documentation of TB screening, or the annual risk health assessment since hire on 07/12/10.

6. During an interview on 12/12/12 at 2:55 PM, Staff NN, Director of Human Relations (HR), confirmed the failure to have TB screening evidence in the above personnel files.

7. During an interview on 12/12/12 at 3:06 PM, Staff A, Chief Nursing Officer, confirmed there was no additional evidence of TB screening for the above two employees. Staff A stated that HR utilizes an employee roster to track annual TB screenings, and was not sure how these two got missed.

Violation Name: PATIENT RIGHTS: GRIEVANCES(A-0118)

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Based on observation, interview, and record review, the facility failed to provide the Department of Health and Senior Services telephone number for filing a complaint to 11 patients (#4, #5, #9, #10, #12, #13, #14, #22, #33, #48, and #49) of 12 patients reviewed and failed to include the telephone number on two posted patient rights signs. These failures had the potential to affect all patients admitted to the facility. The facility census was 66.

Findings included:

1. Review of the facility policy, Patients' Rights and Responsibilities Policy last revised 09/2012 (September 2012) showed these directives for facility staff: Prior to the provision of services, all patients will be provided with a written statement of the facility's Patient Rights. This information will be reviewed verbally and a signed copy of the patient rights shall evidence acknowledgement of the receipt of this document. The list of rights included the right to file a complaint with the State Department of Health (sic) regarding a concern about patient abuse, neglect, misappropriation of patient property in the facility, or other unresolved complaint.

2. Review of the Patients' Rights form in a patient admission packet showed no contact telephone number for filing a complaint with the Department of Health and Senior Services.

3. Review of the signed Patients' Rights forms in the medical records of Patients #4, #5, #9, #10, #12, #13, #14, #48, and #49 showed no contact telephone number to file a complaint with the Department of Health and Senior Services.

4. During an interview on 12/12/12 at 1:40 PM, Patient #13 stated that she was not aware of whom to contact if she needed to file a complaint/grievance. Patient #13 had no name of an entity to report to, or telephone number.

5. During an interview on 12/12/12 at 2:25 PM, Patient #22 stated that no rights, complaint process, or Department of Health and Senior Services phone number was reviewed or given to him upon admission.

6. During an interview on 12/12/12 at 2:30 PM, Patient #33 stated that no rights, complaint process, or Department of Health and Senior Services phone number was reviewed or given to him upon admission.

7. During an interview on 12/12/12 at 1:35 PM, Patient #49 stated that she was not aware of whom to contact if she needed to file a complaint/grievance. Patient #49 had no name of an entity to report to, or telephone number.

8. Observation on 12/10/12 at 1:45 PM showed no contact telephone number for filing a complaint with the Department of Health and Senior Services on the Patients' Rights posted on the wall of Hallway B in the Senior Adult Unit.

9. Observation on 12/11/12 at approximately 10:30 AM showed no contact telephone number or information for filing a complaint with the Department of Health and Senior Services on a wall posting behind the Adolescent Unit nursing station.

Violation Name: UTILIZATION REVIEW COMMITTEE(A-0654)

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Violation Name: CHIEF EXECUTIVE OFFICER(A-0057)

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Based on observation, interview and record review the facility's Chief Executive Officer (CEO) failed to manage the operation of the facility to ensure that:

-All patients received a telephone number and name of an entity they could file a complaint and/or grievance with;

-All intended staff received the required education on contraband identification and seizure since the survey of 10/04/12, during which problems with contraband (items patients were not supposed to have because of their potential harmful properties) were found. The facility census was 66.

Findings included:

1. Review of the facility policy, Patients' Rights and Responsibilities Policy last revised 09/2012 showed that prior to the provision of services, all patients will be provided with a written statement of the facility's Patient Rights. This information will be reviewed verbally and a signed copy of the patient rights shall evidence acknowledgement of the receipt of this document. The list of rights included the right to file a complaint with the State Department of Health (sic) regarding a concern about patient abuse, neglect, misappropriation of patient property in the facility, or other unresolved complaint.

2. Review of the patient rights form in a patient admission packet showed no contact telephone number for filing a complaint with the Department of Health and Senior Services (DHSS).

3. Review of the signed patient rights forms in the medical records of Patients #4, #5, #9, #10, #12, #13, #14, #48, and #49 showed no contact telephone number to file a complaint with the DHSS.

4. During an interview on 12/12/12 at 1:35 PM, Patient #49 stated that she was not aware of whom to contact if she needed to file a complaint/grievance. Patient #49 had no name of an entity to report to, or telephone number.

5. During an interview on 12/12/12 at 1:40 PM, Patient #13 stated that she was not aware of who to contact if she needed to file a complaint/grievance. Patient #13 had no name of an entity to report to, or telephone number.

6. Record review of the facility policy titled, Control of Contraband, revised 11/12, showed the facility will make all reasonable efforts to provide a safe environment for patients and staff of the center by establishing and maintaining a consistent process for identifying, securing and preventing potentially dangerous or harmful contraband items from reaching the inpatient units;

7. During an interview on 12/11/12 at approximately 2:20 PM, Patient #22 (Adolescent Unit), stated that a contraband check was not conducted upon his admission on 12/08/12.

8. Record review of the Belongings List and Contraband Assessment forms showed eight (Patients #1, #21, #16, #17, #19, #4, #5, and #22) of twelve patients without the admission contraband assessment portion of the forms completed on the adolescent unit.

9. During an interview on 12/12/12 at 9:14 AM, the CNO stated that the education of staff related to contraband had not been completed as of this date, but would be with the annual skills fair/competencies during the week of 12/17/12.

10. Review of education documentation dated 12/12/12, revealed that 14% of staff intended to receive the contraband re-inservicing information had not yet received it.

11. During an interview on 12/12/12 at 3:34 PM, the CEO stated that he had relied upon the CNO to ensure issues since the prior survey were indeed corrected. The CEO stated that he was completely unaware that the education piece had not been met. The CEO stated that he would have thought it would have been required of all staff prior to return to work status, rather than wait until the week of 12/17/12.

Violation Name: NURSING SERVICES(A-0385)

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Violation Name: STAFFING AND DELIVERY OF CARE(A-0392)

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review the facility failed to:

- Follow their staffing plan and have an adequate number of nursing staff to ensure patient safety rounds (visual inspection to the location and safety of each patient) were completed every 15 minutes for eight (#24, #25, #26, #27, #29, #30, #31, and #32) of 11 patients on 10/02/12; and for seven (#24, #26, #45, #27, #29, #31, and #32) of ten patients on 10/03/12 in the ITU (Intensive Treatment Unit) wing of the Adult Unit.

-Provide constant oversight for nine ( #12, #16, #49, #52, #53, #54, #55, #56 and #57) of nine patients on the Senior Unit while the patients were eating in a central dining room located off of the Senior Unit.

These failures had the potential to affect all patients residing on two of three units (Senior and Adult/Intensive Treatment Unit) of this psychiatric in-patient hospital. The facility census was 76.

Findings included:

1. Review of a facility policy titled, Staffing Plan, revised 07/12, showed the following:

-There shall be a sufficient number of professional nurses on duty at all times to meet the needs of the patients;

-Staff in orientation were not counted as actual staff within the guidelines;

-The unit specific staffing plans shall indicate the actual staffing and patient census for each shift;

-Additional staff is added when in the judgment of the Nursing Manager that additional staff is required;

-Staffing less than the plan dictates is discussed with the Chief Nursing Officer (CNO);

-Staffing, both in numbers and competency, will be sufficient at all times to ensure that assessment/reassessment and interventions address patient care needs on admission, during their stay, reassessment as patient condition changes, upon transfer, and discharge; And, patient safety requirements are met.

2. Observation on 10/01/12 showed three psychiatric treatment areas:

-An Adolescent Unit;

-A Senior Unit for older adults; and

-An Adult/Intensive Treatment Unit (ITU-utilized to treat the acutely ill psychiatric patient), which is a combined unit with a total bed capacity of 56; 36 beds on the Adult side and 20 beds on the ITU side. A doorway divides the two units. Each side of the combined unit has a nurses station.

3. Review of the 2012 facility staffing guidelines for the combined Adult/Intensive Treatment Unit required the following:

-For a census of 27-33 on day and evening shifts= 3 Registered Nurses (RNs) and 3 Mental Health Technicians (MHTs), and on night shift= 2 RNs and 2 MHTs;

-For a census of 34-40 on day and evening shifts= 4 RNs, and 4 MHTs, and on night shift= 2 RNs and 2 MHTs;

-For a census of 41-44 on day and evening shifts= 4 RNs and 4 MHTs, and on night shift= 3 RNs and 2 MHTs;

-For a census of 45-51 on day and evening shifts= 5 RNs and 4 MHTs, and on night shift= 3 RNs and 3 MHTs;

-For a census of 52-56 on day and evening shifts= 6 RNs and 4 MHTs, and on night shift= 4 RNs and 4 MHTs.

4. Review of the facility's staffing for the week of 09/23/12 through 09/29/12 showed for the ITU wing:

-On 9/23 one MHT short on the evening shift and night shift;

-On 9/24 one RN short on evening shift, and one RN and one MHT short on night shift;

-On 9/25 one MHT short on night shift;

-On 9/28 one MHT short on day shift, and one RN short for one-half of the evening shift;

-On 9/29 one MHT short for one-half of the evening shift and one MHT short on the night shift.

5. During an interview on 10/02/12 at 9:35 AM, Staff I, RN, Adult ITU Supervisor, stated that the facility had been having trouble with staffing on the weekends. Staff I stated that managers were supposed to come in and cover any shortages.

The review of the staffing for the combined Adult/Intensive Treatment Unit for the week of 09/23/12 through 09/29/12 showed nine shifts were understaffed according to the 2012 staffing guidelines.

6. During an interview on 10/02/12 at 4:20 PM, Staff A, the Chief Nursing Officer (CNO), stated that it was a challenge to constantly bring in good people (hiring of staff) that are kind and patient. Staff A stated that she expected the managers to fill in if short a staff person. Staff A confirmed the lack of staff listed on the reviewed staffing schedules. Staff A stated that when she reviewed the staffing schedules she confirmed additional management staff had failed to cover staffing shortages.

7. Review of facility data regarding nursing vacancies showed the facility RN vacancy had increased from 1.4% in October 2011 to 18.2% in June 2012.

8. During an interview on 10/01/12 at 3:37 PM, Staff F, RN, stated that:

-The current combined census on the Adult/ITU unit was 43.

-There were currently four RNs and three MHTs (this indicated one MHT short based on the facility provided staffing guideline);

-Suicide risk was assessed daily for those patients considered low (score of 0-2) to medium risk (score of 3-5) and twice daily for those considered high risk (score of 6-9);

-All patients were on 15-minute monitoring via an Observation Flowsheet unless they were on a physician-ordered close observation (one staff member for one patient with the patient in line of sight at all times) or one-on-one status (one staff member per one patient with the patient being within an arms length of a staff member.)

9. Review of staffing documentation, census and patient rounding for the combined Adult/ITU unit for 10/01/12 showed the following:

-Staff documented the census as 43 on a dry erase board in the staff work room;

-The nursing staff schedule, dated 10/01/12, showed only three RNs and three MHTs on duty ( indicating one RN and one MHT short based on the facility provided staffing guidelines);

-The patient's individual rounding sheets showed a pre-printed 15-minute interval whereby staff documented they observed the patient, showing where and what the patient was doing;

-The patient census, dated 10/01/12, which included the suicide risk score of each, showed 19 of the 43 patients on the combined Adult/ITU were a medium risk for suicide. One patient was considered a high risk for suicide (Patient #1).

10. Review of facility wide event logs, from 01/01/12 -10/01/12, showed four elopements (two in 02/12, one in 04/12, and one in 06/12) and six suicide attempts.

11. During an interview on 10/04/12 at 10:13 AM, Staff GG, MHT, stated that staffing in general was not good, but especially on the weekends. Staff GG stated that the RNs don't do MHT work when counted as such. Staff GG stated that he did not feel patients were safe with the current staffing patterns, and this had been the situation for about eight to nine months.

12. Record review of the facility policy, Observation of the Patient Through 1:1, Close Observation and 15-Minute Checks, showed the following requirements:

-On admission, all inpatients will be placed on a minimum of 15-minute checks for safety;

-In order to reduce their predictability, 15-minute checks are to be done in a random order within each 15-minute period of time so that the patient cannot anticipate when the staff member will next return;

-The staff member will observe the patient within every 15-minute increment of time, and document their location and activity on the Observation Flow sheet throughout their hospitalization ; and

-The Charge Nurse will be notified in the event of interruptions so that 15-minute checks can be reassigned and continued.

13. Record review of the facility's Nursing Staff Schedule for the ITU wing dated 10/02/12 showed a census of 11 with one RN and two MHTs scheduled for patient care on the day shift (7:00 AM to 3:30 PM.)

14. However observation on 10/02/12 from 2:00 PM to 3:00 PM, showed one RN (Staff U) and only one MHT (Staff T) present in the ITU. The ITU unit was short one MHT.

Staff F, RN Supervisor confirmed through payroll records that Staff GG, MHT, left at 1:57 PM, which left one RN and one MHT for patient care on the ITU.

15. Record review on 10/02/12 at 2:30 PM, of ITU's Observation Flowsheets (15 minute patient safety rounds form) dated 10/02/12, showed no 15 minute rounding documentation for patient safety from 2:15 PM through 2:30 PM (15 minutes) for eight (Patients #24, #25, #26, #27, #29, #30, #31, and #32) of eleven patients. The ITU suicide risk score report for 10/02/12 showed three of 11 patients on the unit were at medium to high risk for suicide.

16. During an interview on 10/02/12 at 3:00 PM, Staff U, (the RN on duty in ITU) stated that between 2:15 PM and 2:30 PM:

-One RN (Staff U) and one MHT (Staff T) provided care for patients in ITU;

-Staff T, MHT (Mental Health Technician) prepared three patients for discharge which caused the omission of patient safety rounds.

-Staff T, provided off unit escort for one patient who was discharged ;

-She (Staff U) prepared patients for discharge and that caused her inability to provide back up to complete the patient safety rounds;

-She (Staff U) denied requesting assistance to complete patient care; and

-She (Staff U) assessed she had sufficient staff in ITU.

The two staff on duty between 2:00 PM and 3:00 PM for patient care in ITU were unable to document evidence of patient safety rounds on Observation Flowsheets for eight patients as required by facility policy. The number of staff assigned to provide care and lack of documented patient rounds placed eight of 11 patients in ITU at potential risk of harm.

17. Record review of the facility's Nurse Staff Schedule for ITU dated 10/03/12 showed patient care assignments of one RN and one MHT for the day shift with a census of ten.

18. Record review on 10/03/12 at 1:45 PM, of ITU's Observation Flowsheets dated 10/03/12, showed no 15 minute rounding documentation for patient safety from 1:30 PM to 1:45 PM (15 minutes) for six (Patients #24, #45, #27, #29, #31, and #32) patients on ITU and no documentation from 1:15 PM to 1:45 PM (30 minutes) for one (Patient #26) out of 10 patients. In addition, there were no Observation Flowsheets for two patients (Patient #7 and #46). The unit's suicide score report for 10/03/12 showed seven of ten patients at medium to high risk for suicide.

19. During an interview on 10/03/12 at 2:00 PM, Staff F, RN Supervisor, stated that Staff X, MHT, was responsible for conducting two patient safety rounds between 1:15-1:45 PM, and that he (Staff X) did not complete the safety rounds as expected.

The staff assigned patient care were unable to document evidence of patient safety rounds from 1:30 PM to 1:45 PM for six patients, and from 1:15 PM to 1:45 PM for one patient. This failure to conduct patient safety rounds placed nine of 10 patients in ITU at potential risk of harm.

20. Record review of the facility's policy, Cafeteria, Use Of, updated 08/12, showed staff members will supervise behavior of patients in the cafeteria. Appropriate behavior is required to ensure patient safety and to re-emphasize acceptable behavior in society.

Record review of the facility's policy, Safety, Nursing Responsibilities, updated 06/12 showed the following:

- Utilize appropriate patient precautions;

- Follow procedures for patient who may be on any specific precautions related to assaultive, elopement and suicide;

- Perform duties according to procedures;

- Monitor patients on an ongoing basis in accordance with appropriate level of observation (15-minute checks, close observation, one to one) at all patient locations during all patient activities;

- Escort patients to and from all activities;

- Follow procedures for monitoring patients for safety;

- Hand-off any patients being observed to other staff when taking meal breaks or other situations that require you to leave the area.

21. Record review of the facility's 2012 Staffing Guidelines for the Senior Unit showed, for a census of 19, the day shift staffing requirements were one Nurse Manager, one Team Charge Nurse, two RNs, three MHTs, and 0.5 Unit Coordinator (UC.)

22. During an interview on 10/04/12 at 8:45 AM Staff JJ, RN, Nurse Manager for the unit, stated that the Senior Unit census for the day was 19 patients. Staff JJ stated that the staffing for the unit included three RNs (one RN was the Team Charge Nurse), two MHTs and one Nurse Manager. Staff JJ stated the unit did not have a unit coordinator for the day.

According to the staffing guidelines, for a census of 19, the unit was short staffed one MHT and 0.5 UC.

23. Observation on 10/04/12 at 12:10 PM, showed Staff EE MHT escorted nine patients( #12, #16, #49, #52, #53, #54, #55, #56 and #57) from the Senior Unit to the central cafeteria/dining room. The central cafeteria was not a lock area. At one point, Staff EE got up from her chair, exited the cafeteria leaving the patients unattended and left the clip board with patient's rounding sheets on a table. Staff EE did not ask anyone to monitor the patients or hand off the clip board before she exited the cafeteria. No other staff was available in the cafeteria to monitor the patients. Staff EE left the patients in the cafeteria unattended for approximately five to eight minutes. During Staff EE's absence one patient left the area to get a drink and when Staff EE returned to the cafeteria she did not notice the patient had left the table. When all patients finished eating, Staff EE lined up the patients to exit the cafeteria. Staff EE allowed eight patients to exit the cafeteria and return to the Senior Unit without supervision and oversight. After the eight patients left the cafeteria, Staff EE stayed behind in the cafeteria with a patient in a wheelchair for approximately 10 minutes before she returned to the Senior Unit.

24. Record review of Patient #12's Nursing assessment dated [DATE] showed he was on assault precautions.

25. Record review of Patient #16's Nursing assessment dated [DATE] showed he was on elopement and wandering precautions.

26. Record review of Patient #49's Nursing assessment dated [DATE] showed she was on self harm potential alert.

27. Record review of Patient #52's Nursing assessment dated [DATE] showed potential for self harm and wandering and suicide precautions.

28. Record review of Patient #53's Nursing assessment dated [DATE] showed the patient was assaultive to others and was on assault precautions.

29. Record review of Patient #54's Nursing assessment dated [DATE] showed she was on fall and seizure precautions.

30. Record review of Patient #55's Psychiatric Evaluation dated 09/29/12 showed she was extremely agitated and had been residing at a local nursing home and was aggressive with others. She was not on any type of precautions.

31. Record review of Patient #56's Nursing assessment dated [DATE] showed she was on wandering precautions.

32. Record review of Patient #57's Psychiatric Evaluation dated 09/29/12 showed she recently eloped from a nursing home, went into a street and tried to get hit by a car recently. Record review of the patient's Nursing assessment dated [DATE] showed she was on elopement and fall precautions.

The facility failed to monitor the Senior Unit patients at all times while in the dining room. The facility allowed patients at risk for elopement, wandering, self harm, suicide, falls and assaultive behavior to wander the halls when the patients were allowed to leave the cafeteria without staff oversight/escort. This gave the patients ample time to wander, get lost or attempt elopement.

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review the facility failed to:

- Complete accurate, comprehensive assessments and re-assessments with individualized interventions put into place to prevent patient elopements (a patient who is aware he is not permitted to leave, but does so with intent) for two patients (#42 and #33) on the adult unit;

- Complete accurate, comprehensive assessments and re-assessments with individualized interventions put into place to prevent suicide attempts for two patients (#41 and #43) on the adult unit and two patients

(#39 and #35) on the adolescent unit; and

-Provide line-of-sight observation for one discharged patient (#40,) while awake, as ordered on the Senior Adult Unit.

A total of two patients were reviewed for elopement and five patients reviewed for suicide attempt. The facility census was 76.

Findings included:

1. Review of a facility policy titled, Elopement Precautions, revised 06/12, showed the following:

-Every psychiatric patient is to be considered a potential elopement risk;

-The unit charge nurse will observe the patient and notify the physician with an assessment of the patient's behavior;

-The unit charge nurse can initiate elopement precautions for the protection and safety of the patient without a physician's order;

-Patients with an elopement risk shall not be permitted outside in the patio areas until authorized by the physician.

2. During an interview on 10/04/12 at 9:17 AM, Staff C, Quality RN, stated that the facility did not have an official/documented assessment that identified elopement risk. Staff C stated that the staff based the elopement risk on observations and ongoing assessments of the patient.

3. Observation on 10/01/12 at 3:37 PM, showed:

-An Adult/Intensive Treatment Unit (ITU-utilized to treat the acutely ill psychiatric patient), which is a combined unit with a total bed capacity of 56; 36 beds on the Adult side and 20 beds on the ITU side. A doorway divided the two units. Each side of the combined unit had a nurses station.

-There was a locked doorway leading outside to a fenced-in area, approximately 20 feet by 20 feet, utilized for the smoking patients. (Any outdoor smoking area created an area and opportunity for elopement if patients are not carefully observed by staff.)

4. Review of a facility policy titled, Smoking, revised 07/12, showed patients were allowed to smoke at designated times and in designated places (the patio outside the adult/ITU), if there were no elopement precautions in place.

5. Review of Patient #33's history and physical dated 02/14/12, showed the patient was admitted on [DATE] with a recent past history of suicide attempt by hanging. He was admitted from a local jail on an involuntary basis.

The medical record did not document that Patient #33 was an elopement risk. Staff failed to assess that the patient was an elopement risk based on his involuntary admission and possible return to the jail.

6. Record review of Patient #33's Nurses' Notes dated 02/15/12, at 7:50 PM, showed the patient had a flat affect and depressed mood. (These could be considered flight/elopement risk factors) The patient reported he had just gotten some bad news. The patient rated his mood an 8 on a scale of 1-10 with 10 being the worst mood. The patient rated his anxiety as a 5-6 on the same type scale. (These could be considered elopement risk factors) The patient was on standard 15-minute checks.

7. Record review of an Event Report dated 02/16/12 at 12:30 AM, showed the Patient #33 Went over the fence during smoke break on 02/15/12 at 9:00 PM (last smoke break scheduled from 9:00 PM to 9:20 PM each day) ....and isn't back yet. The report showed staff discovered the patient was missing three and 1/2 hours after the smoke break. Staff found the patient

had stuffed blankets under the bedspread [in his room] to make it look as if he was in bed.

8. Record review of the Observation Flowsheets dated 02/15/12 from 9:00 PM through 12:30 AM on 02/16/12 showed staff documented Patient #33 was on the patio smoking from 9:00 PM through 9:15 PM. Then, staff documented the patient was in the dayroom, or in bed, from 9:30 PM to 12:30 AM. (The patient eloped from the facility between 9:00 PM and 9:15 PM).

9. Record review of Sentinel Event (a risk or an event that may cause an unexpected or unanticipated outcome, death or serious injury) minutes dated 03/01/12, showed the patient had been distraught at 9:00 PM [on 02/15/12] after he was informed he would return to jail after discharge from the hospital [a strong elopement indicator or assessment piece]. Staff EE, Mental Health Technician (MHT) took the patient out to the patio for a smoke break. Staff EE was asthmatic and stayed inside the door of the patio. Just shortly after 9:00 PM, a peer (another patient) witnessed Patient #33 elope over the patio area fence. From 9:30 PM through 11:15 PM Staff FF, MHT, documented that the patient was in the dayroom. And, from 11:30 PM through 12:30 AM on 02/16/12, the patient was in bed. The resolution to this event directed staff to accompany patients outside at all times, and place themselves between the patients and the fence to deter elopements over the fence.

10. During an interview on 10/03/12 at 3:05 PM, Staff EE, MHT, stated that she did not know Patient #33 had eloped until the morning after the incident. Staff EE stated that she did not count patients as they went out onto the smoking patio or when they came back in, to verify all were accounted for. Staff EE stated that she did not go outside with the patients during the scheduled smoke break. Staff EE stated that she was the only MHT on duty that evening monitoring patients on smoke break.

11. During an interview on 10/03/12 at 3:20 PM, Staff FF, MHT stated that Patient #33 eloped during a smoke break on 02/15/12. Staff FF stated that he was really busy and he admitted documenting the patient was actually in the facility. Staff FF was unaware of the patient's elopement until the day after the elopement. Staff FF stated that additional staff would help at times.

12. During an interview on 10/03/12 at 10:05 AM, Staff W, Psychiatrist, stated that the patient (#33) was bipolar and became distraught when he found out he was going back to jail after discharge. Staff W stated that the patient was clever and created the appearance of sleeping in bed to allude the staff.

13. Observation on 10/03/12 at 10:38 AM showed the patio area consisted of an area about 20-feet by 20-feet with a concrete patio surrounded by a 10-foot wooden fence. While standing inside the facility at the patio doorway, two corners of the outside area could not be visualized (creating a place for patients to hide).

Patient #33 never returned to the hospital.

The facility failed to reassess involuntary Patient #33 for potential elopement risk after being informed the patient would be returning to jail after his discharge.

14. Review of Nurse Practitioner notes dated 06/21/12 for Patient #42, showed the patient was admitted on [DATE] with a diagnosis of schizophrenia (characterized by paranoia and by seeing/hearing things).

15. Review of Nurses' Notes dated 06/22/12, at 4:10 AM, showed Patient #42 was pacing the floor (could be an elopement risk factor).

16. Review of the initial Social Work assessment dated [DATE], showed Patient #42 had been depressed and increasingly agitated. The patient's goals were to go home as soon as possible (could be an elopement risk factor).

17. Review of Nurses' Notes dated 06/22/12, at 9:42 PM, showed Patient

#42 felt she was ready for discharge.

18. Review of physician's orders dated 06/23/12, at 2:00 PM, showed Patient #42 was transferred to the adult side of the unit (utilized for less intensive, more stable patients) with anticipated discharge in two days.

19. Review of Nurses' Notes dated 06/23/12, at 7:08 PM, showed Patient #42 was anxious and told the staff several times, It would only take one hit and I could knock her out (referring to peer). The patient was loud and provoking and threatening towards her peers.

20. Review of Nurses' Notes dated 06/23/12, at 10:19 PM, showed Patient #42 was missing when the 9:00 PM patient 15-minute rounds were conducted.

21. Record review of an Event report dated 06/23/12, showed that other patients saw Patient #42 elope through the unit exit door into the main hospital hallway. The report showed a nurse was distracted when her key got stuck in the unit's door lock with the door in the open position and the patient walked out the open door. The patient then walked out the front door of the facility when an ambulance was bringing another patient through the door.

The nurse failed to observe and stop an unescorted patient from leaving a locked unit, who then left the building. The facility also failed to reassess Patient #42 after she exhibited anxious behavior and the desire to be discharged .

22. Review of Nurses' Notes dated 06/24/12, at 7:46 AM, showed Patient

#42 returned to her family home. The patient never returned to the hospital.

23. During a telephone interview on 10/04/12 at 1:40 PM, Staff DD, Medical Director, stated that if the nursing assessment shows a patient is an elopement risk, the patient should be confined to the ITU unit. Staff DD stated that patients typically don't speak of elopement so prediction of elopement is difficult and elopement precautions were usually not in place. Staff DD stated staff did not inform him of the elopement regarding Patient #42.

24. During observation on 10/01/12 at 3:37 PM showed on the Adult/ITU unit, each patient room had regular round doorknobs, and three regular hinges. These were a potential looping/hanging hazard.

-The sink in each patient room had regular paddle-type or round faucet handles. Suicidal patients could potentially use the faucet handles as looping hazard, increasing the potential for hanging.

-Two patient-use telephones located in the hallway had cords approximately 18-30 inches long, which could create looping/hanging hazards.

Twenty-three of the 43 patients on the combined unit were on suicide precautions. Patients were allowed access to items which were looping/hanging hazards.

25. Review of a facility policy titled, Suicide Risk Monitoring Tool For patients at Risk For Suicide/Self-Harm, dated 09/11, showed the following:

-It shall be the policy to create an environment of care that will foster the accurate identification and successful management of patients who are at an increased risk for suicide or self destructive behaviors.

-The suicide Risk Monitoring Tool will be the standard tool used by licensed registered nurses and clinical social workers on the inpatient units to evaluate all patients deemed to be at risk for self-harm.

-Although the patient will be rated with a numerical rating, direct observation of the patient and the lethality of method/plan can increase the level of observation and care required for the patient. The numerical rating is not intended to replace the assessment and judgment of the skilled clinician. The registered nurse/licensed clinical social worker shall have the authority to move the patient to a higher level of risk assessment until evaluated by the physician and a determination is made.

-The minimum frequency for completing the suicide assessment tool will be every 24 hours (on patients assessed as a low risk).

-Patients who exhibit a sudden or significant change in mental status, including level of depression, agitation, or level of anxiety will have a reassessment accomplished to determine the need for continued, increased or decreased observation.

-Reassessments shall be documented in the medical record.

-An initial suicide risk assessment will be performed on each patient when they present to the ComPAS Department (area where screening for admission takes place) using the Intake Psychiatric Assessment form and the suicide risk Monitoring Tool. The Suicide Risk Monitoring Tool is a stand-alone form developed to assist in determining the possible suicide risk a patient may present.

For individuals determined to be at a low risk (score 0-2):

a. Place on 15 minute checks.

b. Contraband search of valuables and other belongings will be performed at a minimum of once on the day shift and once on the evening shift and the night shift as indicated by patient admission to the hospital or at staff's discretion. The contraband search will be accomplished in accordance with each individual unit's contraband list.

c. Completion of the suicide risk assessment tool once every 24 hours.

d. Documentation per shift in the progress notes related to the status of the patient.

For individuals determined to be at a medium risk (score 3-5):

a. Place on 15 minute checks or close observation depending on the degree of lethality involved with the patient and as specified by the physician's order

For individuals determined to be at a higher risk (score 6-9):

a. Place on 15 minute checks, close observation, or 1:1 status depending on the degree of lethality involved with the patient and as specified by the physician's order.

c. Reassessment with the suicide Risk Monitoring Tool every shift during hospitalization .

d. Documentation per shift in the progress notes related to the status of the patient.

26. Record review of Patient #43's Psychosocial assessment dated [DATE], showed the patient was admitted [DATE] because, I want to kill myself, and for electroconvulsive therapy (ECT-a treatment for depression consisting of delivery of a short electric current to the brain). The patient had a history of seven to eight recent suicide attempts (mostly by hanging). This was the fifth psychiatric hospitalization in six months. The patient stated she would attempt suicide during this hospitalization by using a sheet over a doorknob and hanging herself. The patient also stated that she knew she had 15-minutes between patient checks to accomplish this hanging [a strong advance message to staff to monitor for suicide attempt]. The anticipated treatment for this patient included family contact, coordination of care, discharge planning and referral to community resources.

27. Review of the admission physician orders, dated 01/30/12, at 4:15 PM, showed staff were to monitor Patient #43 using standard 15-minute patient checks.

28. Review of a Nurses' Note dated 01/30/12, at 9:21 PM, showed Patient #43 thought of suicide.

Review of a Nurses' Note dated 01/31/12, at 6:18 AM showed Patient #43 remained on standard 15-minute patient checks.

29. Review of a Social Worker assessment dated [DATE], at 5:18 PM, showed Patient #43 had attempted to hang herself at 11:00 AM earlier that day (less than 24-hours after admission).

30. Review of a facility internal investigation of the suicide attempt, dated 01/31/12, showed the following:

-Staff GG made normal 15-minute rounds and found Patient #43 on the floor with one sleeve of a sweater around her neck and the other sleeve wrapped around a door knob;

-The patient told Staff GG that she had been telling people (staff) for days that she was suicidal and no one listened;

-The patient placed on one-on-one status and transferred to the ITU, after the patient attempted suicide.

31. Review of a physician's order dated 01/31/12, at 2:00 PM, showed after the hanging attempt, the physician transferred Patient #43 to the ITU side of the unit and placed the patient on one-to-one observation status (staff to be within an arms length of the patient at all times).

32. During an interview on 10/04/12 at 10:13 AM, Staff GG, MHT, stated that Patient #43 had been very attention seeking that day, wanting the MHT to remain with her all day. Staff GG stated that she found the patient later that day on the floor of her room with one end of a sweater wrapped around her neck and the other end wrapped around the room doorknob.

Facility staff failed to review and/or consider Patient #43's history and current assessment, failed to reassess the patient and place the patient on an appropriate monitoring status based on the risk factors presented.

33. Review of facility policies titled, Contraband, use of the Metal Detector Wand for Search, and Control of Contraband, revised 06/12 showed the following:

-This is to ensure patients do not retain items that can be used to harm the patient or others;

-Admissions staff to ask patients to remove items from their pockets;

-Coins, nail clippers, nail files, pocket knives, and other sharp objects, hairpins, earrings, and studs are considered contraband;

-Items restricted to [from] patient areas include medications, any string, drawstring, shoestring or any corded item;

-Staff to make environmental rounds twice daily to observe for contraband.

-Upon admission, staff will issue to the patient and family a list of the items not allowed in the patient areas. Patients will be instructed to send restricted items home with family, placed in their vehicle or have hospital personnel lock the items in their closet or safe until the patients discharge. Patients refusing to cooperate with the search will remain with staff until an inspection for contraband takes place.

-A second check for contraband items will take place during the nursing assessment on the inpatient unit.

-Family and visitors shall comply with contraband policies, and appraising staff of items brought in.

-Staff will make environmental rounds twice a day to observe for contraband.

34. Review of Patient #41's psychiatric report, dated 11/26/11, showed the patient was admitted on [DATE] with a diagnosis of bipolar mood disorder and severe depression with suicidal thoughts. The patient's judgment and insight was fair. The patient had a history of suicide attempts.

35. Review of the triage assessment, dated 11/25/11, showed Patient #41 felt she needed to die and had been noncompliant with medications. The patient had taken six milligrams (mg) of Xanax (an anti-anxiety medication, the typical maximum daily dose is four mg) at home and drank two glasses of wine. The patient fell asleep and when she woke she attempted to cut herself with scissors.

36. Review of the initial psychiatric evaluation, dated 11/25/11, showed Patient #41 was severely depressed, was an imminent risk to harm self or others, and could not be treated in a less restrictive environment. The patient was on a 15-minute patient observation status.

37. Review of a physician's progress note, dated 11/27/11, showed Patient #41 was feeling hopeless, and anxious.

38. Review of Nurses' Note dated 11/28/11, at 10:14 PM, showed Patient

#41 had earlier in the shift approached a nurse and said she was having a panic attack and the nurse did not help her. The patient couldn't sleep because of anxiety and she stated she didn't feel safe in her room.

39. Review of the patient's Observation Flowsheet (documentation of 15-minute patient rounds) dated 11/29/11, showed Patient #41 was on standard monitoring (patient rounds every 15-minutes).

40. Review of Nurses' Note dated 11/29/11, at 2:24 PM, showed Patient

#41 admitted she had eight Xanax pills hidden in a small pocket of her running pants (note did not say where/how the patient got the pills.)

41. Review of a Risk Management Report dated 11/29/11, at 2:51 PM, showed Patient #41 had barricaded the door to her room and was found standing on a chair in the shower. The patient had a length of ribbon around her neck and was attempting to hang herself on 11/29/11 at 12:15 PM.

42. Review of the Patient #41's Observation Flowsheet dated 11/29/11, after the attempt of suicide, showed the patient was placed on one-to-one observation.

43. Review of physician's orders dated 11/29/11, at 12:25 PM, showed Patient #41 was transferred to ITU, and placed on close observation (patient to be within the line of sight of staff), after an attempt of suicide.

44. Review of a physician's progress note dated 11/30/11, showed Patient #41 had been stashing pills in her bed.

Facility staff failed to review and/or consider the patient's history and reassess the patient based on statements made by the patient. Staff failed to place the patient on an appropriate monitoring status based on the risk factors presented. The staff also failed to conduct thorough environmental rounds and/or observation of patient medication consumption.

45. Review of Patient #39's medical record showed:

- The patient was admitted on [DATE] due to drug overdose.

- The was allowed to use the gym bathroom unattended, while staff observed other patients shooting baskets.

- Patient found lying on the gym bathroom floor with a shoe string (considered contraband) around her neck on 12/26/11 at 3:15 PM.

- Patient was pulling the shoe string tightly around her neck.

- Patient placed on routine 15-minute checks.

46. Record review of the facility investigation showed Patient #39 obtained the shoestring from the roommates slippers.

The facility staff failed to remove contraband from the roommate's slippers.

47. Record review showed only one contraband check for Patient #39 at admission on 12/20/11. The record failed to contain documentation of environmental rounds twice a day (per facility policy) to observe for contraband.

48. Review of Patient #35's medical record showed:

- Patient admitted on [DATE] with suicidal thoughts and a history of cutting self.

- Patient suicide risk score was 6 (high risk score) on admission.

- Patient stated that she had anxiety and felt like killing herself.

- Patient was placed on routine 15-minute checks.

- Patient found in her room with two strings (considered contraband) tied together and wrapped around her neck in attempted self harm/suicidal gesture at 9:57 PM on 09/03/12.

- Record review showed contraband check on admission.

- Review of facility investigation showed the patient had hidden strings in her underwear.

The facility failed to adequately check Patient #35 for contraband on admission.

49. During an interview on 10/04/12 at 2:30 PM, Staff D, RN, unit director stated maybe the facility should initially place a patient in a gown for contraband checks.

50. Record review of discharged Patient #40's medical chart showed the patient was admitted to the facility on [DATE] with complaints of mood disorder and suicide attempt.

51. Record review of Patient #40's Psychiatric Evaluation dated 01/21/12 showed he was transferred from a local hospital after he stabbed himself multiple times in the chest. The patient was adamant that he was not going to kill himself in the hospital, but said he was willing to talk to staff about it.

52. Record review of the patient's Suicide Risk Monitoring Tool Intake assessment dated [DATE] showed staff assessed Patient #40 at high risk for suicide.

53. Record review of the Contraband Checklist dated 01/20/12 showed Patient #40 arrived in gowns.

54. Record review of Patient #40's Physician Orders showed the following:

-On 01/20/12 at 7:50 PM the physician ordered the patient placed on one-to-one status.

-On 01/21/12 at 11:09 AM the physician wrote an order to have the patient in line of sight of staff while awake, can d/c (discontinue) one-to-one.

-On 01/28/12 at 5:12 AM the physician ordered to place the patient on one-to-one.

-On 01/28/12 at 10:45 AM the physician ordered to continue one-to-one sitter.

55. Record review of the patient's Behavioral Health Progress Notes showed staff documented the following:

- On 01/26/12 Patient #40 said, What's the point of being alive? Patient had ruminative (repetitively focusing on the symptoms of distress, and on its possible causes and consequences) thoughts, depressed, hopeless and poor energy. Positive suicide ideation with thoughts of wishing he was dead. Insight and judgment poor. Depression-severe.

- On 01/28/12 at 10:18 AM severe depression, hopeless and helpless. Positive suicide ideation. Patient was found last evening with strings of gown tied around his neck. He verbalizes a little regret for this now, but still suicide risk. Suicide attempt last night-remains high risk.

56. Record review of the facility's investigation showed the following:

-On 01/27/12 Patient #40 appeared disheveled and mood was described as depressed with flat affect, but still positive. Staff noticed a change in his behavior, he was jovial and joking. He had asked for a chair and puzzles and staff answered his request.

-On 01/28/12 at 5:30 AM the MHT made a random check on the patient and found him sitting in a chair with two gowns wrapped around his neck. When the patient saw staff he pulled the gowns tighter. The patient later stated to the MHT he heard her coming down the hall and thought he had enough time to attempt suicide, but the MHT changed her routine and interrupted his suicide attempt. The patient was placed on one-to-one status.

57. Record review of Patient #40's Observation Flowsheet dated 01/28/12 from 4:30 AM to 5:30 AM showed staff documented the patient was awake in bed.

On 01/20/12 at 11:09 AM the physician wrote an order for Patient #40 to be in line of sight of staff while awake. Staff did not document line of sight for the patient from 4:30 AM to 5:30 AM when he was awake in bed.

58. Record review of Patient #40's medical chart showed no documentation of the patient's nursing suicide assessment tool for the following dates: 01/26/12, 01/27/12, 01/28/12 or 01/29/12.

59. During an interview on 10/04/12 at 1:25 PM, Staff C, Quality and Performance Improvement, RN, stated she could not find the nursing suicide assessment tool for Patient #40 for 01/26/12, 01/27/12, 01/28/12 or 01/29/12.

Violation Name: PATIENT RIGHTS: RESTRAINT OR SECLUSION(A-0178)

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Based on record review and interview the facility failed to ensure a face to face assessment following behavioral restraint episodes was completed by staff trained in evaluating the patient's immediate situation, the patient's reaction to the restraint, the patient's medical and behavioral condition and the need to continue or terminate the restraint in three (Staff A, Staff U and Staff V) of five staff training records reviewed who completed face to face assessments of patients in restraint/seclusion. The facility census was 91.

Findings included:

1. Review of the facility's policy titled, Seclusion and Restraint dated 04/11 showed the attending psychiatrist or delegate of another psychiatrist, nurse practitioner, medical physician, or specifically designated and trained registered nurse (RN), must see and assess the patient within one hour of issuing a seclusion and restraint order.

2. Record review of discharged Patient #22's restraint documentation showed the physician ordered five point leather restraints, a physical escort and physical holding for medication on 07/28/11 at 10:44 AM. Review of the face to face evaluation dated 07/28/11 at 12:00 PM showed Staff A, RN and Director of the Senior Adult unit completed the face to face evaluation.

Review of the personnel record for Staff A showed no training documented for assessing a patient following a restraint/seclusion episode.

During an interview on 10/20/11 at 10:20 AM, Staff A, Director of the Senior Adult unit, stated, I didn't have training on doing a face to face evaluation. Staff A acknowledged he/she had completed a face to face evaluation following a restraint episode for Patient #22. Staff A stated that he/she had completed a face to face evaluation on a second patient sometime in the past year, but could not recall the name of the patient.

3. Record review of discharged Patient #24's restraint documentation showed the physician ordered five point leather restraints, a physical escort and physical holding on 08/03/11 at 4:18 PM. Review of the face to face evaluation dated 08/03/11 at 4:30 PM showed Staff U, Family Nurse Practitioner completed the face to face evaluation.

Review of the credentialing file for Staff U showed Staff U is a family practice nurse practitioner. No specific training was documented for assessing a patient following a restraint/seclusion episode.

During an interview on 10/20/11 at 11:10 AM, Staff S, Chief Nursing Officer, stated that Staff U is a family nurse practitioner and is not a psychiatric nurse practitioner. Staff S stated that the facility has no record Staff U had specific training to complete the face to face evaluation on patients following a restraint/seclusion episode.

4. Review of discharged Patient #26's physician's orders showed seclusion orders dated 09/06/11, 09/08/11, 09/12/11 and again on 09/13/11.

Record review of Patient #26's Seclusion/Restraint Justification Record forms showed on 09/06/11, 09/08/11, 09/12/11 and 09/13/11 the patient was released from seclusion and a face to face assessment was completed by Staff V, Supervisory RN.

During an interview on 10/20/11 at 11:25 AM Staff T, Human Resources Generalist stated Staff V had not been trained on how to perform a face to face assessment of a patient in seclusion or restraint.

DISCLAIMER: The CMS violation information provided by HCA Vs. America on https://hcavsamerica.org/ is for general informational purposes only. The data and findings displayed on this page(s) originated from the Centers for Medicare and Medicaid Services (CMS) and can be found at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/Hospitals HCA Vs. America makes no representation or warranty of any kind, express or implied, regarding the accuracy, validly, availability of any information on this website and is simply reporting information that is publicly available by CMS.

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Research Psychiatric Center

16 CMS Violations since 2011-10-20

Immediate Jeopardy Violations

Violation Name: ANESTHESIA SERVICES(A-1000)

Non Immediate Jeopardy Violations

Violation Name: DELIVERY OF ANESTHESIA SERVICES(A-1002)

Violation Name: PRE-ANESTHESIA EVALUATION(A-1003)

Violation Name: POST-ANESTHESIA EVALUATION(A-1005)

Violation Name: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE(A-0724)

Violation Name: INFECTION CONTROL PROGRAM(A-0749)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: NURSING CARE PLAN(A-0396)

Violation Name: INFECTION CONTROL PROFESSIONAL(A-0748)

Violation Name: PATIENT RIGHTS: GRIEVANCES(A-0118)

Violation Name: UTILIZATION REVIEW COMMITTEE(A-0654)

Violation Name: CHIEF EXECUTIVE OFFICER(A-0057)

Violation Name: NURSING SERVICES(A-0385)

Violation Name: STAFFING AND DELIVERY OF CARE(A-0392)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: PATIENT RIGHTS: RESTRAINT OR SECLUSION(A-0178)

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Research Psychiatric Center

16 CMS Violations since 2011-10-20

Non Immediate Jeopardy Violations

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395) toolTips('.tooltip_post_id_custom_ef194e7ee8a5a440e753c26fc2938b42','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>A registered nurse must supervise and evaluate the nursing care for each patient\.');

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395) toolTips('.tooltip_post_id_custom_863de7ef4efe29b630359dedff245464','\<p\>\<span style\=\'color\:white;padding\:1px;font\-weight\:bold;min\-width\:500px\'\>A registered nurse must supervise and evaluate the nursing care for each patient\.');

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)

Violation Name: RN SUPERVISION OF NURSING CARE(A-0395)