Unity Psychiatric Care-Memphis

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 27201 Based on document review, the facility failed to conduct and document all required disaster drills to test the emergency plan. The deficient practice affected 1 of 2 smoke compartments, staff, and the census was 15. The findings include: Document review of the facility’s EP plan, on 12/03/24, at 11:00 AM, revealed the facility had not conducted one (1) of two (2) full-scale drills or exercises involving local, state, or federal officials that tested elements of the facility’s EP Plan. This finding was verified and was acknowledged by the administrator during the exit conference on 12/03/2024.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 33763 Based on policy review, medical record review, observation, and interview, the hospital failed to ensure Nursing Services developed and updated an individualized plan of care to address falls for 1 of 20 (Patient #2) sampled patients. The findings included: 1. Review of the hospital’s “Fall Prevention Program” policy revised 3/2024 revealed, “...Roles and Responsibilities...DON/ADON [Director of Nursing/Assistant Director of Nursing]...Completes Morse Fall Scale weekly...and as needed...Ensures treatment plan reflects individual goal and interventions...Nursing...Implements safety interventions based on fall scale score... Completes nurse event note on all fall-related occurrences and initiates interventions to avoid recurrence of event... Monitoring Plan... Implement/modify the patient’s current plan of care with interventions (s) associated with the cause of the fall...” 2. Medical record review for Patient #3 revealed an admission date of 11/5/2024 with diagnoses which included Brief Psychotic Disorder, Bipolar Disorder, Major Depressive Disorder, and Severe Anxiety Disorder. Review of a Morse Scale fall risk assessment completed on 11/6/2024 at 8:56 AM revealed Patient #2 had a history of falls, required the use of a walker, crutches, or cane for ambulation, and was at risk or falls. Review of the Treatment Plan dated 11/6/2024 revealed Patient #2 was at “Risk for injury related to fall AEB [as evidenced by] impaired cognition and weakness when ambulating” with interventions to help prevent falls which included prompting the Patient to ask for assistance with transfers, ambulation and activities of daily living tasks. Review of an Event Note dated 11/13/2024 at 11:19 PM revealed Patient #2 had an unwitnessed fall in her room at 10:40 PM. The Patient sustained a laceration to her head and was transferred to a local Emergency Room for evaluation and treatment. Review of a Nursing Progress Note dated 11/14/2024 at 12:05 AM revealed Patient #2 “...fell while using restroom. Pt [Patient]stated she was putting on a gown and her hands became tangled and pt fell. 1040 [10:40 PM on 11/13/2024] Pt fell found on floor by MHT [Mental Health Technician]...EMS [Emergency Medical Services] called...pt transported to [named local hospital]...” Review of a Nursing Progress Note dated 11/14/2024 at 6:53 AM revealed, “...Returned from [named local hospital]...awake, alert and oriented...Assessment done, large lump noted to back of head with old, dried blood in hair and surrounding area with small laceration open to air...No sutures notes...Head of bed elevated and bed in low position...Instructed to call or assistance prior to getting up...” Review of the Treatment Plan updated 11/15/2024 revealed Patient #2 was at risk for harm to others due to attempts to bite staff and refusing care, and at risk for impaired skin integrity due to poor cognition and refusing care. The treatment plan did not reflect the Patient was at risk for falls and also did not reflect the Patient’s fall on 11/13/2024. 3. Observations in the dining room on 11/18/2024 at 11:40 AM revealed Patient #2 was sitting upright in a wheelchair at the table engaged in a group actiivty. The Patient was appropriately dressed and had non-skid socks on her feet. Patient #2 had a bandage on her left forearm. Observations in the dining room on 11/18/2024 at 3:20 PM revealed Patient #2 was sitting upright in a wheelchair. The Patient’s hair had been groomed and her clothes were changed. The Patient continued to have a dressing in place on her left foerarm. Observations of wound care in Patient #2’s room on 11/18/2024 beginning at 3:35 PM, revealed Patient #2’s forearm dressing was removed by Licensed Practical Nurse (LPN) #1 revealing a skin tear. When asked what happened to to cause the skin tear, Patient #2 stated she fell in her room, hit her head and hurt her arm and was sent to the hospital. Patient #2 continued and stated she fell frequently. 4. During an interview on 11/19/2024 at 2:25 PM, the Director of Risk Management (DRM) stated the expectations after a fall are to “look and see if the treatment plan is updated and Morse fall is updated.” The DRM continued and stated, “We expect the treatment plan to be updated, the fall risk should have carried over to the updated treatment plan.” The DRM confirmed there was no documentation a Morse Scale fall risk assessment was completed after the fall and the care plan was not updated to reflect the Patient’s fall and/or fall risks.”

“UNUSABLE DRUGS NOT USED CFR(s): 482.25(b)(3) §482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and biologicals must not be available for patient use This Standard is not met as evidenced by: 33763 Based on policy review, document review, observation, and interview, the hospital failed to ensure expired and/or unlabeled medications were not readily available for use in 1 of 1 medication storage refrigerators. The findings included: 1. Review of the hospital’s “Medication and Biological Storage, Night Emergency Box and Backup Pharmacy” policy revised 12/2023 revealed, “...Whenever a seal of a multi-dose vial is broken it shall be initialed and dated by the nurse with an open date. The nurse shall be aware of the expiration date and date of discarding per the manufacturer specifications...” 2. Review of the “Tuberculin Purified Protein Derivative (Mantoux) Tubersol” package insert revealed, “...A vial of Tubersol which has been entered and in use for 30 days should be discarded. Do not use after expiration date...” 3. Observations in the medication storage refrigerator on 11/20/2024 at 10:28 AM revealed 1 open and unlabeled multidose vial of Tubersol, 1 open multidose vial of Tubersol with an open date of 9/6/2024, and 1 open multidose vial of Tubersol with an open date of 10/9/2024. During an interview on 11/20/2024 at 10:30 AM, Licensed Practical Nurse (LPN) #1 verified the unlabeled vial of Tubersol should have had a date opened on it. The LPN also verified both open and labeled multidose vials of Tubersol were expired. The LPN stated, the box (Tubersol) says, “Discard after 30 days.” During an interview on 11/20/2024 at 10:45 AM, the Director of Risk Management stated all multidose vials of medications should be labeled with the date opened and opened Tubersol vials should be discarded after 30 days.”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 33763 Based on policy review, observation, and interview, the hospital failed to ensure measures to prevent and decrease the transmission of infection were followed by 1 of 1 (Licensed Practical Nurse (LPN) #1) nurses observed performing wound care. The findings included: 1. Review of the hospital’s “Hand Hygiene” policy revised 12/2022 revealed, “...Hand hygiene is indicted [indicated] and will be performed under the conditions listed...Before performing invasive procedures...Before and after removing personal protective equipment (PPE), including gloves...Before and after handling clean or soiled dressings...Before performing resident care procedures...” Review of the hospital’s “Wound Care Policy” revised 4/2023 revealed, “...Care for all wounds...Cleanse the wound as indicated...Standard precautions...Aseptic technique for dressing changes...” 2. Observations of patient care on 11/18/2024 beginning at 3:35 revealed LPN #1 was preparing to perform wound care on Patient #2. The LPN performed hand hygiene, donned gloves, then opened the drawers of the supply cart and gathered supplies needed for the procedure. Without removing the gloves or performing hand hygiene, the LPN entered Patient #2’s room, removed the soiled dressing from the Patient’s left forearm. The LPN cleaned the skin tear with saline soaked gauze, then discarded the soaked gauze and gloves in the garbage. LPN #1 performed hand hygiene, opened the drawers on the supply cart and obtained a foam dressing. Without performing hand hygiene after opening the drawer to the supply cart, the LPN donned gloves and placed the dressing on the Patient’s skin tear. LPN #1 failed to perform hand hygiene after touching the handles of the supply cart and before donning gloves repeatedly. 3. During an interview on 11/20/2024 at 10:50 AM, the Director of Risk Management verified LPN #1 should have removed the gloves and performed hand hygiene after opening the drawers to the supply cart.”

“Treatment Plan - Modalities CFR(s): [The written plan must include] The specific treatment modalities utilized; This Standard is not met as evidenced by: 19001 Based on policy review, medical record review, observation, and interview, the hospital failed to ensure individual therapy modalities were used as prescribed in the treatment plan for 5 of 20 (Patient #1, 3, 5, 13 and 16) sampled patients. The findings included: 1. Review of the hospital’s “Treatment Planning and Patient Care” policy revised 3/2024, revealed, “Policy: MTP’s [Master Treatment Plans] should be developed and implemented in accordance with state laws and federal regulations...The patient’s individualized treatment plan shall be formulated by the multidisciplinary professional staff following through assessments of the patient...Procedure...3. Assignment of the treatment modality, as well as frequency and duration of treatment, shall be in accordance with the terms of the MTP...4. The provider shall dictate reports that describe treatment provided. Staff members shall document daily the treatment provided...” 2. Medical record review for Patient #1 revealed a 86 year old female admitted to the hospital on 11/7/2024 with diagnoses of Brief Psychotic Disorder and Major Depressive Disorder. Review of the MTP dated 11/8/2024 revealed, “...Problem: Risk for harm to others as evidenced by attempting to run over other with walker or hitting staff...Interventions...Social Worker will engage patient in individual therapy three times a week to improve coping skills, increase reality orientation and use behavior modification strategies to help redirect behaviors...” Further review revealed no documented individual therapy notes. During an interview on 11/19/2024 at 10:36 AM, the Director of Social Services verified she had not conducted any individual therapy sessions with Patient #1. 3. Medical record review for Patient #3 revealed an 88 year old male admitted to the hospital on 11/15/2024 with diagnoses of Alzheimer’s Disease with Behavioral Disturbance. Review of the MTP dated 11/15/2024 revealed, “...Problem: Risk for harm to others as evidenced by (He is aggressive towards staff with fighting and hitting staff...)...Interventions...Social Worker will engage patient in individual therapy three times a week to improve coping skills, increase reality orientation and use behavior modification strategies to help redirect behaviors...” Further review revealed no documented individual therapy notes. Observations of group therapy in dining room on 11/18/2024 and 11/19/2024 revealed Patient #3 was in a geri-chair making unitelligible sounds and gazing around the room. The Patient was not activily engaged in the activity and appeared to be very confused. During an interview on 11/19/2024 at 10:36 AM, the Director of Social Services verified she had not conducted any individual therapy sessions with Patient #3. The Director of Social Services continued and stated, she had only conducted “group” therapy with Patient #3, “even in group, he doesn’t understand what we’re doing.” The Director stated the social workers used individual therapy for patients with suicidal and/or homicidal ideations; the other patient problems were addressed with group therapy. The Director of Social Services then verified if individual therapy was listed as an intervention on the MTP, it should be provided. 4. Medical record review for Patient #5 revealed an 83 year old male admitted to the hospital on 11/11/2024 with diagnoses of Alzheimer’s Disease and Dementia with Psychotic Disturbance. Review of the MTP dated 11/12/2024 revealed, “...Problem: Alteration in behaviors as evidenced by urinating and defecating on floor, physical and verbal aggression towards staff and other patients...Interventions...Social Worker will engage patient in individual therapy three times a week to improve coping skills, increase reality orientation and use behavior modification strategies to help redirect behaviors...” Further review revealed no documented individual therapy notes. During an interview on 11/19/2024 at 10:36 AM, the Director of Social Services verified she had not conducted any individual therapy sessions with Patient #5. 5. Medical record review for Patient #13 revealed an 88 year old male admitted to the hospital on 11/8/2024 with diagnoses of Alzheimer’s Disease and Dementia with Psychotic Disturbance. Review of the MTP dated 11/8/2024 revealed, “...Problem: At risk of harming others (He presents with trying to get out, aggressive with staff when redirected...)... Interventions... Social Worker will engage patient in individual therapy three times a week to improve coping skills, increase reality orientation and use behavior modification strategies to help redirect behaviors...” Further review revealed no documented individual therapy notes. During an interview on 11/19/2024 at 1:40 PM, the Director of Social Services verified she had not conducted any individual therapy sessions with Patient #13. 6. Medical record review for Patient #16 revealed a 94 year old female admitted to the hospital on 11/14/2024 with diagnoses of Alzeimer’s Disease with Late Onset. Review of the MTP dated 11/14/2024 revealed, “...Problem: Risk for harm to others as evidenced by (She presents with becoming agitated, combative with trying to kick and bite nurse)...Social Worker will engage patient in individual therapy three times a week to improve coping skills, increase reality orientation and use behavior modification strategies to help redirect behaviors...” Further review revealed no documented individual therapy notes. During an interview on 11/19/2024 at 10:36 AM, the Director of Social Services verified she had not conducted any individual therapy sessions with Patient #16.”