PRINTED: 8/6/2018

FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
OMB NO. 0938-0391
(X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
IDENTIFICATION NUMBER: A. BUILDING ____________________ COMPLETED

290005 B. WING _______________________ 06/14/2018

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

NORTH VISTA HOSPITAL 1409 E LAKE MEAD BLVD, NORTH LAS VEGAS, NEVADA ,89030

(X4) SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX REGULATORY TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG OR LSC IDENTIFYING INFORMATION) DEFICIENCY)

0000 Initial Comments - 0000

Inspector Comments: This Statement of

Deficiencies was generated as a result of a
complaint investigation conducted at your
facility on June 13, 2018 and June 14, 2018
, in accordance with the Nevada
Administrative Code (NAC), Chapter 449,
Requirements for Hospitals. The census at
the time of the survey was 101. The sample
size was two. There were two complaints
investigated. Complaint #NV00053185 was
substantiated. The allegation the facility
was not reporting abuse was substantiated.
(See Tag S 0320). The following allegations
could not be substantiated: Allegation #1 an
employee attacked patients for being
verbally aggressive and choked, kicked,
punched, slammed and used profanity
against them. Allegation #2 an employee
did not use techniques approved by the
facility to control aggressive patients.
Allegation #3 staff and supervisors closed
door to patients room trapping the patient
with an abusive employee. Allegation #4
patients limbs were broken as a result of a
restraint that an employee had done on the
patient. Allegation #5 an employee had a
patient in a choke hold until the patient
passed out and heart stopped beating.
Allegation #6 documentation was being
done fraudulently and did not report
incidents as they happened. Allegation #7 a
patient was assaulted by three employees
and the facility did not take action for two
weeks after the incident occurred.
Allegation #8 the facility threw patients out
of the facility who were still experiencing a
psychotic break. Allegation #9 the facility
had released patients that were not in their
right mind to be discharged and still needed
medical attention at a facility. Allegation #10
the facility discharged patients with no
clothes, no shoes and nowhere to go, just a
bus pass or cab voucher. Allegation #11
patients' belongings were missing or stolen
by employees and patients were told they
didn't come in with those things and their
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER Name: CHASE BENNION Title: Manager of Performance Improvement Date: 07/11/2018
REPRESENTATIVE'S SIGNATURE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date
of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these
documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PR7I11 Facility ID: Page 1 of 7
 PRINTED: 8/6/2018
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES OMB NO. 0938-0391
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING ____________________ COMPLETED

290005 B. WING _______________________ 06/14/2018

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

NORTH VISTA HOSPITAL 1409 E LAKE MEAD BLVD, NORTH LAS VEGAS, NEVADA ,89030

(X4) SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX REGULATORY TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG OR LSC IDENTIFYING INFORMATION) DEFICIENCY)

belongings were thrown away. Allegation

#12 a Physician did drugs in the hospital
elevator. Allegation #13 a Physician was
reported for sexual harassment against
workers. Allegation #14 a Physician brought
strippers and street women into the facility
and told staff to say they were his students
if asked. During the complaint investigation
another regulatory deficiency was identified
related to the lack of assessment of injuries
of unknown origin (See Tag S 0310). The
investigation into the allegations included:
Observations were conducted in the Mental
Health Hospitalization Tower 3 (T3) and
Geri -psych Unit. Interviews were conducted
with the Chief Executive Officer, the
Manager of Improvement and Quality
Assurance, the Director of Case
Management, the Facility Clinical Educator,
a Psychiatrist, three Registered Nurses and
two Behavioral Health Technicians. Two
clinical records were reviewed. Review of
the facility policies titled Restraints: Violent
Behaviors or Seclusion, Restraints: Non
Violent Behaviors, Security of Patient
Belongings and Valuables, Abuse, Neglect,
Exploitation, Standards of Conduct, Patient
Rights and Responsibilities and General
Procedures for Discharge and Transfer.
Review of personnel records, including
training and qualifications. Complaint
#NV0053352 with the allegation the facility
was not clean could not be substantiated.
The investigation into the allegation include:
Observations were conducted in two
patients' rooms, the Mental Health
Hospitalization Tower 3 (T3) and Geri-
Psych Unit and hallways. Interviews were
conducted with the Chief Executive Officer,
three Registered Nurses and two
Behavioral Health Technicians. The findings
and conclusions of any investigation by the
Division of Public and Behavioral Health
shall not be construed as prohibiting any
criminal or civil investigations, actions or
other claims for relief that may be available
to any party under applicable federal, state,
or local laws. The following deficiencies
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PR7I11 Facility ID: Page 2 of 7
 PRINTED: 8/6/2018
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES OMB NO. 0938-0391
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING ____________________ COMPLETED

290005 B. WING _______________________ 06/14/2018

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

NORTH VISTA HOSPITAL 1409 E LAKE MEAD BLVD, NORTH LAS VEGAS, NEVADA ,89030

(X4) SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX REGULATORY TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG OR LSC IDENTIFYING INFORMATION) DEFICIENCY)

were identified:
0310 NAC 449.3624 - Assessment of Patient - 1. 0310 Upon discovery of patient injuries of 07/11/201
SS= D To provide a patient with the appropriate unknown origin, assessments will be 8
care at the time that the care is needed, the conducted in a timely manner consistent
needs of the patient must be assessed with hospital policy and state regulations.
continually by qualified hospital personnel Staff will be educated on identification and
throughout the patient's contact with the assessment of patients presenting with
hospital. The assessment must be injuries. Random audits will be conducted
comprehensive and accurate as related to on assessments of patients to ensure timely
the condition of the patient. and appropriate assessments are occurring.
Audits will begin on July 16th and results
Inspector Comments: Based on interviews, will be reported out to the Quality
record reviews and document review, the Committee. The Director of Behavioral
facility failed to ensure injuries of unknown Health is responsible for this corrective
origin were assessed in a timely manner for action plan. The Risk Manager will review
one patient (Patient #1). Findings include: all events to ensure compliance with
Patient #1 Patient #1 was admitted on hospital policy and regulatory agencies.
03/01/18, with diagnoses including bipolar
disorder, psychosis, and hypertension.
History and Physical dated 03/01/18 at 5:30
PM, revealed a physician performed a
physical examination which included the
patient's eyes. The eye examination did not
document abnormal findings. Nursing
progress note dated 3/5/18 at 9:00 AM,
documented Patient #1 was noted with
redness on both eyes and discoloration on
both periorbital areas. According to the
nursing note, the patient verbalized her
father hit her, but the patient had not had
visitors since admission. The nursing note
indicated two physicians, the Charge Nurse
and the Unit Manager were notified. On
6/14/18 at 10:10 AM, the Chief Executive
Officer (CEO) explained the management
team knew about Patient #1's bruises on
03/05/18 in the morning and an
investigation was initiated it was not
determined if the injuries were self-inflicted
or caused by an altercation with a staff
member or other patient. The patient was
interviewed and accused two staff members
for the inflicted injuries. As part of the
investigation, the videos from the
surveillance cameras located in the
psychiatric unit were reviewed and did not
show incidents that could be related to the
injuries. The videos revealed some staff
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PR7I11 Facility ID: Page 3 of 7
 PRINTED: 8/6/2018
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES OMB NO. 0938-0391
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING ____________________ COMPLETED

290005 B. WING _______________________ 06/14/2018

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

NORTH VISTA HOSPITAL 1409 E LAKE MEAD BLVD, NORTH LAS VEGAS, NEVADA ,89030

(X4) SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX REGULATORY TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG OR LSC IDENTIFYING INFORMATION) DEFICIENCY)

members were not monitoring the patients

every 15 minutes and as a consequence,
they were terminated. The CEO indicated a
video recorded on 03/04/18 around 7:30
AM, exhibited the patient showing the
bruises to a Registered Nurse (RN) but the
patient was ignored. The CEO verbalized
the RN was interviewed and denied having
seen the injuries. The CEO said the bruises
could be seen in the video. The CEO stated
due to the lack of documentation in the
medical record and the lack of cooperation
with the investigation, the origin of the
injuries and the abuse allegations could not
be determined. The CEO confirmed some
staff members were terminated and the
case reported to law enforcement. Nursing
progress notes dated 03/04/18 at 7:11 AM
and 9:34 AM, did not document Patient #1
had redness on the eyes or bruises in the
periorbital areas. A nursing progress note
dated 03/04/18 at 1:41 PM, documented the
patient was noted with delusional grandeur
and verbally aggressive with staff. The note
indicated visual monitoring was done and
would continue to monitor for changes. The
nursing progress note did not document the
patient had eye redness or discoloration in
the periorbital areas. Another nursing
progress note that was written 29 minutes
later, on 03/04/18 at 2:10 PM, documented
the patient had redness on the right eye.
The note indicated the patient changed the
topic when asked what happened and a
physician was made aware. Psychiatrist
progress note dated 03/04/18 at 9:51 AM,
revealed a psychiatric evaluation was
performed. The note indicated the patient
was irritable and hostile with the
examination, uncooperative with the care
provided and with brief eye contact. The
psychiatric evaluation did not document the
patient had eye redness or discoloration in
the periorbital areas. On 06/14/18 at 12:14
PM, the attending Psychiatrist explained he
attempted to perform a psychiatric
evaluation, but the patient was hostile,
aggressive and agitated with his presence
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PR7I11 Facility ID: Page 4 of 7
 PRINTED: 8/6/2018
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES OMB NO. 0938-0391
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING ____________________ COMPLETED

290005 B. WING _______________________ 06/14/2018

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

NORTH VISTA HOSPITAL 1409 E LAKE MEAD BLVD, NORTH LAS VEGAS, NEVADA ,89030

(X4) SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX REGULATORY TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG OR LSC IDENTIFYING INFORMATION) DEFICIENCY)

and refused the assessment. The

Psychiatrist verbalized the eye redness or
discoloration in the periorbital areas were
not identified since direct contact with the
patient did not occur due to the aggressive
behaviors. The Psychiatrist indicated the
patient had a history of delusions, paranoid
ideation, auditory hallucinations and self-
inflicted injuries. The medical record lacked
documented evidence a physical
assessment was performed on 03/04/18
due to the injuries suffered by Patient #1.
There was no evidence the injuries were
reported to a supervisor to initiate an
investigation. The facility policy titled Abuse,
Neglect, Exploitation last revision date April
2015, documented treatment and actions to
be taken for potential abuse victims
included to provide examination and
treatment to the patient and document all
examinations, findings and statements
made by the patient in the medical record.
Severity: 2 Scope: 1 Complaint
#NV00053185
0320 NAC 449.3628 - Protection of Patient - 1. A 0320 Upon discovery of suspected abuse, North 07/11/201
SS= D governing body shall develop and carry out Vista Hospital will report within 24 hours as 8
policies and procedures that prevent and per hospital policy and state regulations.
prohibit: (a) Verbal, sexual, physical and Staff will continue to be educated on
mental abuse of patients documentation and reporting of suspected
abuse. Spot audits will be conducted
Inspector Comments: Based on record beginning July 16th to ensure compliance
review, interviews and document review, with documentation and reporting are
the facility failed to ensure injuries of occurring per hospital policy and state
unknown origin were reported in a timely regulations. Audit results will be reported to
manner for one patient (Patient #1). Quality Committee to ensure compliance.
Findings include: The facility policy titled The Risk Manager will be responsible for
Abuse, Neglect, Exploitation last revision this corrective action plan and will review all
date April 2015, documented staff who events to ensure compliance with hospital
found signs of abuse were legally required policy and regulatory agencies. Mandatory
to report the incident. Patient #1 Patient #1 education has been assigned and will be
was admitted on 03/01/18, with diagnoses completed by staff by September 15th.
including bipolar disorder, psychosis and
hypertension. Nursing progress note dated
3/5/18 at 9:00 AM, documented Patient #1
was noted with redness on both eyes and
discoloration on both periorbital areas.
According to the nursing note, the patient
verbalized her father hit her, but the patient
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PR7I11 Facility ID: Page 5 of 7
 PRINTED: 8/6/2018
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES OMB NO. 0938-0391
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING ____________________ COMPLETED

290005 B. WING _______________________ 06/14/2018

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

NORTH VISTA HOSPITAL 1409 E LAKE MEAD BLVD, NORTH LAS VEGAS, NEVADA ,89030

(X4) SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX REGULATORY TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG OR LSC IDENTIFYING INFORMATION) DEFICIENCY)

had not had visitors since admission. On

6/14/18 at 10:10 AM, the Chief Executive
Officer (CEO) explained the management
team knew about Patient #1's bruises on
03/05/18 in the morning and an
investigation was initiated. It was not
determined if the injuries were self-inflicted
or caused by an altercation with a staff
member or another patient. The patient was
interviewed and accused two staff members
for the inflicted injuries. The CEO reported
the videos from the surveillance cameras
located in the psychiatric unit were reviewed
and did not show incidents that could be
related to the injuries. The videos revealed
some staff members were not monitoring
the patients every 15 minutes and as a
consequence, they were terminated. The
CEO indicated a video recorded on
03/04/18 around 7:30 AM, exhibited the
patient showing the bruises to a Registered
Nurse (RN) but the patient was ignored.
The CEO verbalized the RN was
interviewed and denied having seen the
injuries. The CEO said the bruises could be
seen in the video. The CEO stated due to
the lack of documentation in the medical
record and the lack of cooperation with the
investigation from some staff members, the
origin of the injuries and the abuse
allegations could not be determined. The
CEO confirmed some staff members were
terminated and the case reported to law
enforcement on 03/09/18. The CEO
acknowledged the incident was not reported
in a timely manner to law enforcement
authorities. Nursing progress notes dated
03/04/18 at 7:11 AM and 9:34 AM, did not
document Patient #1 had redness on the
eyes or bruises in the periorbital areas. A
nursing progress note dated 03/04/18 at
1:41 PM, documented the patient was noted
with delusional grandeur and verbally
aggressive with staff. The note indicated
visual monitoring was done and would
continue to monitor for changes. The
nursing note did not document the patient
had eye redness or discoloration in the
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PR7I11 Facility ID: Page 6 of 7
 PRINTED: 8/6/2018
FORM APPROVED
DEPARTMENT OF HEALTH AND HUMAN SERVICES OMB NO. 0938-0391
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING ____________________ COMPLETED

290005 B. WING _______________________ 06/14/2018

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

NORTH VISTA HOSPITAL 1409 E LAKE MEAD BLVD, NORTH LAS VEGAS, NEVADA ,89030

(X4) SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

ID (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX REGULATORY TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
TAG OR LSC IDENTIFYING INFORMATION) DEFICIENCY)

periorbital areas. Another nursing note that

was written 29 minutes later, on 03/04/18 at
2:10 PM, documented the patient had
redness on the right eye. The note indicated
the patient changed the topic when asked
what happened and a physician was made
aware. A Psychiatrist progress note dated
03/04/18 at 9:51 AM, revealed a psychiatric
evaluation was performed. The note
indicated the patient was irritable and
hostile with the examination, uncooperative
with the care provided and with brief eye
contact. The psychiatric evaluation did not
document nurses reported the patient
injuries. On 06/13/18 at 1:40 PM, the
Entrance Manager of the Behavioral Health
Services verbalized the staff received abuse
and neglect training upon hire and annually.
The Entrance Manager confirmed the
management team did not receive the
report of the injuries until a Unit Manager
noted the bruises and redness on 03/05/18
in the morning. On 06/14/18 at 12:14 PM,
the attending Psychiatrist verbalized he was
made aware about the injuries on 03/05/16.
The Psychiatrist verbalized he did not
receive any report on 03/04/18. The medical
record lacked documented evidence the
injuries were reported to a supervisor on
03/04/18, to initiate an investigation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PR7I11 Facility ID: Page 7 of 7