River Park Hospital

Deficiency cited, recertification survey : E 001 Establishment of the Emergency Program (EP)

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to have an Emergency Preparedness Plan (EPP) which was specific to the PRTF. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency.

Deficiency cited, recertification survey : E 004 Develop EP Plan, Review and Update Annually

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and maintain an Emergency Preparedness Plan (EPP) which was specific to the PRTF. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility EPP revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 006 Plan Based on All Hazards Risk Assessment

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and maintain an Emergency Preparedness Plan (EPP) that was based on and included a facility- based and community-based risk assessment utilizing an all-hazards approach specific to the PRTF. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility EPP revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 007 EP Program Patient Population

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and maintain an Emergency Preparedness Plan (EPP) that addressed the patient/client population including persons at risk, the type of services the PRTF has the ability to provide in an emergency and continuity of operations including delegations of authority and succession plans. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility EPP revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 009 Local, State, Tribal Collaboration Process

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and maintain an Emergency Preparedness Plan (EPP) that included a process for cooperation and collaboration with local, State and Federal emergency preparedness officials' efforts to maintain an integrated response during a disaster or emergency situation. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility EPP revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 013 Development of EP Policies and Procedures

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and implement emergency preparedness policies and procedures for the PRTF. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 015 Subsistence Needs for Staff and Patients

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and implement emergency preparedness policies and procedures for the PRTF based on the emergency plan, the risk assessment and the communication plan. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 018 Procedures for Tracking of Staff and Patients

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and implement emergency preparedness policies and procedures for the tracking of patients and staff specific to the PRTF. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 020 Policies for Evac. and Primary/Alt. Comm.

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and implement emergency preparedness policies and procedures for the safe evacuation from the PRTF including care and treatment needs of residents, staff responsibilities, transportation, identification of evacuation locations and primary and alternate means of communication. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 022 Policies/Procedures for Sheltering in Place

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and implement emergency preparedness policies and procedures for a means to shelter in place for residents, staff and volunteers who remain in the PRTF. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 023 Policies/Procedures for Medical Documentation

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and implement emergency preparedness policies and procedures for a system of medical documentation which preserves patient information, protects confidentiality and secures and maintains availability of records for the PRTF. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 024 Policies/Procedures-Volunteers and Staffing

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and implement emergency preparedness policies and procedures for the use of volunteers in an emergency for the PRTF. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 025 Arrangement with Other Facilities

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and implement emergency preparedness policies and procedures based on the emergency plan, risk assessment and communication plan. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 026 Roles Under a Waiver Declared by Secretary

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and implement emergency preparedness policies and procedures for the role of the PRTF under a waiver declared by the Secretary in the provision of care and treatment at an alternate care site identified by emergency officials. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 029 Development of Communication Plan

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws for the PRTF. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 030 Names and Contact Information

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and maintain an emergency preparedness communication plan for the PRTF that contains names and contact information for staff, entities providing services under arrangement, resident physicians, other facilities and volunteers. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 031 Emergency Officials Contact Information

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and maintain an emergency preparedness communication plan for the PRTF that contains names and contact information for Federal, State, tribal, regional and local emergency preparedness staff and other sources of assistance. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 032 Primary/Alternate Means for Communication

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and maintain an emergency preparedness communication plan for the PRTF that included a primary and alternate means for communicating with PRTF staff, Federal, State tribal, regional and local management agencies. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 033 Methods for Sharing Information

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and maintain an emergency preparedness communication plan for the PRTF that included a method for sharing information and medical documentation for residents under the PRTF's care as needed with other health care providers to maintain the continuity of care. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 034 Information on Occupancy/Needs

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and maintain an emergency preparedness communication plan for the PRTF that included a means for providing information about the PRTF's occupancy, needs and its ability to provide assistance to the authority having jurisdiction, the Incident Command Center or designee. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 036 EP Training and Testing

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and maintain an emergency preparedness training and testing program for the PRTF that is based on the emergency plan, risk assessment and communication plan. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 037 EP Training Program

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and maintain an emergency preparedness training program for the PRTF that provided initial training in emergency preparedness policies and procedures to all new and existing staff provide emergency preparedness training every two (2) years, demonstrate staff knowledge and maintain documentation of the training. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 039 EP Testing Requirements

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to develop and maintain an emergency preparedness testing program for the PRTF that conducted testing exercises twice a year. This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility emergency preparedness plan (EPP) revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : E 042 Integrated EP Program

Based on document review and interview it was revealed the Roundtable Psychiatric Residential Treatment Facility (PRTF) failed to meet all requirements to unify and integrate with the hospital healthcare system Emergency Preparedness Plan (EPP). This failure has the potential to affect all residents residing in the PRTF in the event of an emergency. Findings include: 1. A document review of the facility EPP revealed the plan was entitled 'River Park Hospital Emergency Operations Plan' and was for the entire hospital with no specific entries for the Roundtable PRTF. 2. An interview was conducted with the Director of Plant Operations on 7/14/19 at approximately 1:10 p.m. He concurred there was not a separate EPP for the Roundtable PRTF.

Deficiency cited, recertification survey : N 126 483.356 (a)(1) PROTECTION OF RESIDENTS

Based on record review and staff interview it was determined the facility failed to ensure each resident had the right to be free from restraints of any form. This deficient practice was identified in two (2) of ten (10) medical records reviewed (patients #1 and 3). This failure has the potential to adversely affect all patients. Findings include: 1. A review of the medical record for patient #1 revealed a chemical restraint was administered intramuscularly at 5:53 p.m. on 6/5/18. The crisis intervention one (1) hour face-to-face evaluation revealed patient #1 was documented as calmly standing in the quiet room at 6/5/18 at 5:53 p.m. 2. A review of the medical record for patient #3 revealed a chemical restraint was given by mouth at 10:11 a.m. on 4/11/18. The nurse crisis intervention note revealed patient #3 was cooperative, alert and oriented times four (4) at 10:11 a.m. on 4/11/18. 3. An interview was conducted with the Nurse Manager of 2 West on 6/6/18 at 3:00 p.m. She concurred there was no documentation to justify the chemical restraints administered.

Deficiency cited, recertification survey : N 147 483.358(g)(2) ORDERS FOR USE OF RESTRAINT OR SECLUSION

Based on record review and staff interview it was determined the facility failed to ensure the date and time of all restraint or seclusion orders matched the date and time of the restraint or seclusion intervention. This deficient practice was identified in six (6) of ten (10) medical records reviewed (patients #1, 3, 4, 6, 7 and 8). This failure has the potential to adversely affect all patients. Findings include: 1. A review of the medical record for patient #1 revealed an order for Olanzapine (Zyprexa), intramuscular (IM) 10 milligrams (mg); Start time: 6/5/18 at 6:05 p.m. Stop time: 6/5/18 at 6:06 p.m. The crisis intervention flow sheet revealed the chemical restraint was initiated at 5:53 p.m. and discontinued (d/c) at 5:53 p.m. A review of the crisis intervention one (1) hour face-to-face evaluation revealed Zyprexa 10 mg was given at 5:53 p.m. 2. A review of the medical record for patient #3 revealed an order for Zyprexa, oral 5 mg; Start time: 4/11/18 at 10:42 a.m. Stop time: 4/11/18 at 10:42 a.m., and an order for seclusion, Start time: 4/13/18 at 1:00 p.m. Stop time: 4/11/18 at 10:11 a.m. A review of the crisis intervention one (1) hour face-to-face evaluation revealed Zyprexa 5 mg was given orally at 10:11 a.m. on 4/11/18. A review of the nurse crisis intervention note revealed patient #3 was placed in seclusion at 9:58 a.m. on 4/11/18 and released at 10:11 a.m. on 4/11/18. 3. A review of the medical record for patient #4 revealed an order for seclusion up to ...

Deficiency cited, recertification survey : N 040 483.364(b)(2) Monitoring Of Resident In And After Seclusion

Based on observation and staff interview it was determined the psychiatric residential treatment facility failed to ensure the seclusion room was kept free of potentially hazardous conditions. The unit failed to maintain the Plexiglas window cover in the seclusion in a secure and safe fashion. This failed practice places all residents who use the seclusion room at risk for injury. Findings include: 1. At approximately 1410 on 8/5/13 an observation of the seclusion room on the 2 W unit was conducted with the Program Director. Six (6) screws were noted to be missing from the bottom half of the Plexiglas window cover in the seclusion room. Two (2) screws were noted to be protruding from the right side of the Plexiglas window cover, one of which was easily removed by the surveyor. The Plexiglas cover was noted to be covered with multiple scratches and etching from a sharp object. The Plexiglas cover was noted to be loose around the window and the window seal was noted to be covered with a heavy layer of dust. The Program Director was present for this observation and agreed with this finding.

Deficiency cited, initial certification survey : N 048 483.370 Post Intervention Debriefings

Based on review of medical records and interview with staff the hospital failed to ensure the post intervention debriefings held with patients involved all staff who were involved in the intervention for two (2) of two (2) applicable records reviewed (Patients #1 and #2). This has the potential to affect the quality of care provided to all patients who receive restraints. Findings include: Review of the medical record for patient #1 revealed the patient received a therapeutic hold on 9/8/06 lasting approximately three (3) minutes. An entry by the Nursing Supervisor on 9/8/06 at 15:41 noted that three (3) staff participated in the therapeutic hold. The "Lifespace Interview" was documented at 17:43 by a fourth member of the staff who did not appear to be present during the therapeutic hold. The entry indicated the post intervention debriefing was held alone with the patient and the writer of the entry. The Program Director was interviewed in the morning on 4/11/07 and she stated the "Lifespace Interview" is the debriefing and that it does usually occur between the patient and one (1) staff member. She also stated that the "Patient Care Notes" entry about the intervention failed to correctly identify the fourth staff person as being present during the intervention. Review of the medical record for patient #2 revealed the patient received a therapeutic hold on 1/24/07 lasting approximately ten (10) minutes. An entry by one (1) of the participating Mental Health Technicians on ...

Deficiency cited, initial certification survey : N 075 483.376(f) Education and Training

Based on review of documents and interview with staff the hospital failed to ensure the required training and competencies relative to the use of restraints was held on a semi-annual basis. This has the potential to affect the quality of care and safety of all patients who receive restraints. Findings include: Review of the staff education and competencies of all staff who work on the unit revealed that all staff has received training and an evaluation of their competencies on an annual basis. The Director of Nursing stated during interview in the morning of 4/11/07 that the staff who were employed more than one (1) year received only one (1) scheduled training and competency evaluation for the year 2006.