Name    Stacey Werth Sweeney
E-mail    stacey.werthsweeney@nebraska.gov
Facility Name    Lincoln Regional Center
Facility CEO    Bill Gibson
Facility Address    PO Box 94949, Folsom and W. Prospector Place, Lincoln, NE 68509-4949
Facility Description (Brief)    Licensed for 250 beds inpatient mental health facility.  We are state owned and operated and are part of the NE Department of Health and Human Services.  We are the Behavioral Health Division.  In addition to the hospital beds for adults, we have a 16 bed Community Based Residential for adolescent male sex offenders, and an 8 bed Treatment Group home for adolscent male sex offenders.  We also have a 40 bed male and 5 bed female Sex Offender Residential/Transitional program.

# Beds - Adult    295
# Beds - Child & Adol    24
# Beds - Sub Abuse    0
# Beds - Forensic    included in our adult bed count
# Beds - MR/DD    0
# Beds - TotaL    319 (not all in use)
# Beds - CMS Distinct Part    90 inpt certified and the adolescent units

Survey Type    Unannounced
Surveying Agency    JCAHO
Survey Dates (inclusive)    1/14/08-1/18/08
Survey Days (e.g., Mon - Weds)    Monday-Friday
Number of Surveyors    3
Priority Focus Areas    Hospital and Behavioral Health residential areas
Last Survey Ending Date    1/18/08

Profile - Surveyor #1 (Name/Disc/Tm Role/Traits/Quirks)    Teresa L. Stewart

• Ms. Stewart joined the survey process mid way and stated that she was there to review the performance of Macklin.  She seemed rather abrasive at first but was very direct and firm in her responses.  It seemed that the entire survey process was going okay with Macklin and Troester and then when she arrived, it went completely awry.  She thought that we had not completed a sentinel event, assumed the Psychiatrist that we had that ultimately died from assault he endured in our FMHS unit, was a patient.  When that was finally clarified that we were not in the wrong then they pulled apart the root cause we did after that event and cited us with Immediate Threat stating that Dr. Macklin felt threatened when he was on this same unit that our Psychiatrist was assaulted.  In the root cause we did after the Psychiatrist was fatally injured, we identified several steps that we would do to improve safety one being the installation of camera equipment, another to move the water fountain, etc...  They felt strongly that we needed to have guards, move our medication room, and to identify a way to handle our emergency alarm system.  When she returned for the follow up, she seemed very helpful and although very direct in the way she communicated, she seemed genuinely pleased with the follow up measures we did to correct the immediate threat.
  

Profile - Surveyor #2 (Name/Disc/Tm Role/Traits/Quirks)    Dwayne L. Smith*
Profile - Surveyor #3 (Name/Disc/Tm Role/Traits/Quirks)    Martin R. Macklin, MD, PHD

• He seemed more concerned about the history and physicals and emergency management information than he did with anything else.  He only reviewed one treatment plan and didn't seem real concerned with a tracer taking him through the medical record.  We did not learn from him that he was nervous or scared of our FMHS unit until after Ms. Stewart was here and announced the immediate threat.  In fact, the morning review with Macklin and Troester was very positive and then 4 hours later they put us on notice that we were placed in Immediate Threat.  When this was brought up to the survey team, they didn't answer why they were not upfront with us.  It was very unusual and seemed suspect.
  

Profile - Surveyor #4 (Name/Disc/Tm Role/Traits/Quirks)    Dyana L. Troester, MA, MSN

• Ms. Troester was very helpful, spent the majority of her time on our behavioral health units.  Spent a great deal of her time with the Treatment Teams, reviewing cases, the actual record etc...  She seemed very interested in the actual course of treatment and what the team process was, how they involved the patients and their families.
  

*More info/feedback is needed on these surveyors. To add your input, click here.  Thank you.

  
# of Non-Compliant Standards    7

APR/NPSG Cites (Tag#/EP#/Brief Descrip/Surveyor)   
NPSG Requirement 2C, EP# 2. The organization defines the acceptable length of time between the ordering of critical tests and reporting the critical tests and critical results and values.
o    The hospital has not defined the acceptable length of time between ordering of critical tests and reporting of the results.
NPSG Requirement 2C, EP# 3. The organization defines the acceptable length of time between the availability of critical tests and critical results and values and receipt by the responsible licensed caregiver.
o    The organization has not defined the acceptable length of time between the availability of critical results and receipt by the responsible licensed caregiver.

NPSG Requirement 2C, EP# 4. The organization collects data on the timeliness of reporting critical tests and critical results and values.
o    No data is being collected relative to critical test results.
NPSG Requirement 2C, EP# 5. The organization assesses the data and determines whether there is a need for improvement.
o    There was no data available for review


RI/PC/MM/IC Cites (Stnd#/EP#/Brief Descrip/Surveyor)   
RI.2.130, EP# 4. The organization provides for the safety and security of patients and their property. 
o    Safety and security, as defined by the organization, for (several) patients, has not been provided in this inpatient unit which contains patients with unpredictable aggressive behaviors.

PC.2.130, EP #EP 1. Each patient is assessed per organization policy.
o    A nutritional screen was not done for 2 diabetic patients.
o    A nutritional screen was not done for a patient with a major motor seizure disorder and a history of head injury.
o    A patient with a history of head trauma and a major motor seizure disorder did not have a functional assessment.
o    2 patients did not have a functional screen/assessment.

PC.2.130, EP #EP 2. Each patient's initial assessment is conducted within the time frame specified by the needs of the patient, organization policy, and law and regulation
o    A history and physical exam which was done on a patient admitted on 1/10/2008 was not on the medical record on 1/14/2008. The examination was dictated on 1/11/2008. It was found and placed on the medical record prior to the conclusion of thee tracer activity.
o    A patient admitted on 1/10/2008 had refused to have a history and physical examination completed. There was no indication on the chart that the examining physician had recorded her observations of the patient's physical condition without the benefit of as completed examination at the time of the refusal of a complete examination. The patient permitted the examination on 1/14/2008; however there was no indication that the patient had refused to be examined on the days between 1/10/2008 and 1/14/2008.
o    A patient admitted on 10/8/2004 had his physical exam dictated on 10/12/2004.

MM.2.20, EP#2. Medications are stored under conditions suitable for product stability.
o    In the medication refrigerator that there were three opened insulin multi-dose vials that had not been dated when opened. A staff nurse stated that the hospital rule was that the multi-dose vial would expire 28 days after being opened.

PI/LD/HR/IM Cites (Stnd#/EP#/Brief Descrip/Surveyor)   
HR.1.25, EP#1. Disaster responsibilities are assigned only when the following two conditions are present: the emergency management plan has been activated, and the organization is unable to meet immediate patient needs.
o    The hospital does not have a policy or procedures for assigning disaster responsibilities to volunteer practitioners

LD.3.80, EP#4. The leaders provide for adequate equipment and other resources. 
o    The facility has a PFI item which is currently 19 months past it's "projected completion date". This item has an estimated cost of $1000, yet funding has not been provided to enable this deficiency to be corrected.
o    Leadership has not provided adequate equipment and personnel resources to provide for a safe environment on the inpatient forensic unit for staff and patients. Adequate resources as defined by the risk assessment conducted by the organization included items such as additional monitoring capabilities, emergency notification devices, and qualified rapid response staff in addition to the assigned unit staff.

LD.3.90, EP#2. Policies and procedures are consistently implemented. 
o    Policy indicates each discipline update current assessment data upon transfer of patients to the residential unit; however, an assessment addendum was not completed by the Psychiatrist, as required by policy.
o    The History and Physical reassessment upon transfer of a patient to residential was not contained in the Assessment Addendum, as stated in the organization policy. The physician had reassessed the patient per policy, however did not document according to policy.

LD.1.20, EP# 6. Governance provides for coordination and integration among the organization's leaders to establish policy, maintain quality care and patient safety, and provide for necessary resources. 
o    The Governing Body has not provided the resources needed to enhance the safety of patients and staff at the hospital. The hospital has identified the need for additional security staff and surveillance equipment. The governing body has not provided the additional funding and/or resources to the hospital leadership to satisfy these needs.

IM.6.50, EP#3. When required by law or regulation, verbal or telephone orders are authenticated within the specified time frame.
o    A verbal order written on 1/10/2008 was not signed on1/14/2008. The hospital medical staff rules and regulations in section F, 8,c states that "All verbal/telephone orders for medications shall be authenticated in the medical record within 48 hours." Section d states that "All high risk verbal/telephone orders shall be authenticated within 24 hours." The order in question was to initiate SA status. Since there is no medical staff rule as to when this telephone order must be signed, it is assumed that either the 24 hour or the 48 hour rule would obtain. After four days the order was not authenticated.
o    A verbal order taken on 7/3/2007 was authenticated on 8/27/2007
o    A verbal order taken on 8/31/2007 was authenticated on 9/3/2007. For the same patient an order taken on 1/1/2008 was authenticated on 1/8/2008


MS/NR Cites (Stnd#/EP#/Brief Descrip/Surveyor)   
MS.4.10, EP#5. The organization verifies that the practitioner requesting approval is the same practitioner identified in the credentialing documents…
o    During the review of the credentials file of a practitioner (ZS) newly credentialed in 2008, it was found that there was no documentation of the viewing of a photo ID.

MS.4.10, EP#6. The credentialing process requires that the organization verifies in writing and from the primary source whenever feasible, or from a credentials verification organization (CVO)…
o    Two practitioners (GW, SR) had their license expire on 10/1/2007; however their current licensure status was not determined until 10/17/2007 to verify that their licenses had been renewed.
o    One practitioners (CS) had their license expire on 3/1/2007; however their current licensure status was not determined until 6/14/2007 to verify that their license had been renewed.

EC Cites (Stnd#/EP#/Brief Descrip/Surveyor)   
EC.2.10, Ep# 4. The organization uses the risks identified to select and implement procedures and controls to achieve the lowest potential for adverse impact on security.
o    As a result of an assault on a physician in July 2007 a security risk assessment was completed. This assessment identified a number of procedures that would enhance security of staff and patients. These included additional monitoring cameras which have not been put into place; additional security staff in he building which have not been put into place; communication devices which have not been put into place.

EC.7.40, EP#5. The organization tests each emergency generator at least once every 36 months for a minimum of four continuous hours….
o    Four hour operational tests of the facilities emergency generators had not been ran as of the date of the survey. 

EC.5.20, EP#2. A current, organization wide electronic Statement of Conditions™ compliance document (eSOC™)* has been prepared.
o    The facility has a single open PFI calling for the repair of fireproofing on structural steel in building 10. The projected completion date for this project is shown as 6/30/06 and the estimated cost for this repair is $1000.  As of the date of the survey, this PFI had not been completed due to a lack of funding.

IF an emergency management tracer was conducted using a mass casualty simulation, please indicate which scenario was used.   

**Surveyor Compliments (Policies, Procedures, etc noted by which surveyor)

Preliminary Survey Result    JC: Preliminary Denial of Accreditation
Will you send us a copy of your survey report?    Yes
Will you send us a copy of your ESC?    Yes

**Misc Comments, Suggestions, Etc: Our facility was placed in an Immediate Threat situation and we were required to do a "sentinel event".  However, it was interesting that the JC did not want us and directed us to not complete the sentinel event via the extranet, but instead had us send it via fax and email.  We were taken out of the immediate threat in February and reinstated to full accreditation.

***Note: Some of the original wording of surveyor findings and text of standards above has been combined or condensed for the sake of brevity.
 

Stacey Werth Sweeney