HospitalInspections.org

Based on review of policies and procedures, facility documents, medical records, observation, and interview, it was determined that the hospital failed to ensure the safety of patients and minimize the risk for adverse events, which has the potential risk for patient harm if safety issues and adverse events are not addressed.

Findings include:

The Condition level deficiency is the result of the standard deficiency found under the Condition of Participation for Patient Rights for the following tag:

(A0144) The hospital failed to ensure (2) of (2) patients were monitored in a safe environment which resulted in one patient's suicide attempt and adverse outcome.

The cumulative effect of these systemic failures resulted in the hospital's inability to protect and promote the patient rights and safety.

Based on review of policy and procedure, facility documents, medical records, video surveillance footage, and interview, it was determined that the facility failed to ensure:

1. staff monitored a suicidal patient (Patient #1) every 5 minutes as ordered which resulted in the patient's suicide attempt.

2. staff monitored a new admission in the intake area as ordered every 5 minutes as ordered.

Failure to require staff to conduct observational monitoring of vulnerable patients poses a potential risk of increased morbidity and mortality in the patient population at the facility.

Findings include:

1. and 2. The facility policy titled "Patient Acuity" requires: "...Staffing for patient care is based on matrix and additional staff above matrix is based on acuity for the inpatient psychiatric hospital...To provide for adequate coverage and ensure/maximize a safe therapeutic environment...Level of observation will be utilized to determine BHS staff above matrix. An additional BHS or RN will be staffed for each unity that have more than 5 Q5 observation patients...
STAFFING MATRIX...
Day Shift...
1-5 Patients...1 RN...1:12 BHT to Patient Ratio...
6-12 Patients...1 RN...1:12 BHT to Patient Ratio...
13-20 Patients...1.5 RN...1:12 BHT to Patient Ratio...."

The facility policy titled "Levels of Patient Observation" requires: "...Every 5 Minute Observations...Staff assigned to 5 Minute Observations must hand-off responsibility for maintaining observation of the assigned patient(s) for any break. Staff will observe patient and document on the Patient Observation Record every 5 minutes. Assigned staff will make direct visual contact with patients and confirm they are in no danger or distress. Staff will be vigilant for potential risk factors identified for specific patients (levels of precautions). Sleeping patient will be observed at close enough proximity to confirm they are in no physical distress. Staff will observe the patient at a minimum arm's length distance to ensure the ability to clearly see the patient ' s identity and rise and fall of chest to verify respirations, and make sure patient has moved positions. Staff should use a flashlight to ensure adequate illumination...."

The policy titled "Suicide Prevention Program" requires: "...Staff are to identify patients at risk for suicide, assess patients for risk, notify relevant treatment team members and treat/prescribe appropriate levels of observation, precautions and interventions...Environmental Risk Reduction...Environmental Risks are identified and monitored via the following: ...Contraband Searches on Admission and Throughout Stay...Locking doors during program hours...Excess Linens and Clothing monitoring...Ensuring Staff are competent and trained/have access to policies related to Suicide Prevention, care planning and discharge care planning...Competencies for various job duties (SRA's, assessments, Q's) are completed for all staff...All policies available on Public Drive...PC 002/CTS 002-Assessments...PC 003/CTS 003-Levels of Observation...PC 010/CTS 010-Levels of Precaution...PC 203/CTS 203-Suicide Prevention Program...PC132/CTS 132-Multidisciplinary Treatment Plan...PC 165/CTS 165-Discharge Care Planning...."
The policy titled "Level of Precautions" requires: "...Other precautions for a patient with potential for suicide attempt may include: Vigilant monitoring by staff for the following behaviors: ...Isolative behaviors...Vigilant monitoring of environment for: ...All linens and shower curtains are accounted for...Communication...Communicate clearly with the patient asking questions about ideations, plans, and/or feelings...Communicate clearly with all staff members about patient behavior, statements, and mood/affect observed...Hand off communication to all staff covering break/meal times and to oncoming staff at shift changes...."

1. Patient #1

Patient #1's Psychosocial Assessment dated 05/26/2022 revealed: "...transferred via ambo (Sic). Px presents SI with attempt to hang self with shoe strings...Px has hx of Si with 4 attempts in 5 years by hanging and overdose on meth...Px reports 4 mental health hospitalizations for SI...."

Patient #1's suicide risk assessment dated 05/26/2022 at 1837 revealed: "...High Suicide Risk...Suicidal ideation with intent or intent with plan in past month...Px presented and reported having feelings of increasing hopelessness about things in the past and recent relapse. Px has current SI with attempt by hanging self with shoe strings. Px has hx of SI with attempt by OD on meth and hanging self. Px was referred by [Flagstaff} and transferred via ambo...."

Patient #1's High Risk Notification Form dated 05/26/2022 at 2217 revealed: "...Suicidal Ideation with plan...Plan to tie string around his neck...."

Patient #1's Nursing Reassessment dated 05/27/2022 at 2106 revealed a late entry by the registered nurse: "...pt slept most of day. at around 1300 long piece of narrow cloth found at foot of pt's bed. pt moved to day room. sheets removed from bed. blankets left for cover....pt remains on Q5 min observation for SI...."

Patient #1's Progress note dated 05/27/2022 at 2115 revealed: "...at approx 1825 this nurse was called to room 515 by tech (name of Employee #22). Pt was found slumped in corner of room by door. Pt assessed and ligature removed from pt neck. LLigature (Sic) was loose with 2 finger width between neck and ligature. pt was unresponsive and had no pulse or respirations. Called for help, 911 called and code blue called. CPR began immediatley (Sic) by this nurse. code team arrived with code cart. AED applied. continued CPR until Paramedics arrived. pt was stabilized and transported to hospital for further care. pt remained unconscious...."

The incident report dated 05/27/2022 revealed that a "code" had been called at room #515 for a suicide attempt by Patient #1 at 1830. CPR was initiated and local fire/EMS arrived at 1838 to take over care of the patient. Patient #1 was transferred to the local ED.

The incident investigation report dated 05/27/2022 revealed that Patient #1 was admitted to the facility on 05/26/2022 for suicidal ideation and a plan to hang himself. The day shift RN found a ligature on Patient #1's bed on 05/27/2022 at 1300. The patient was moved to the day room and the provider ordered continued q5 minute observations. The patient reported being tired and wanted to sleep and was assigned to room #515. At approximately 1730 on 05/27/2022, the BHT escorted the patients not restricted to the unit down to the dining room for dinner . Patient #1 was restricted to the unit and remained in his room. The BHT and other patients returned to the unit at 1804. The BHT attempted to enter Patient #1's room at 1828 but encountered resistance. The patient was found in the corner between the door and wall unresponsive without a pulse or respirations.

Patient #1's ancillary orders dated 05/262022 at 2200 revealed a physician's order to limit linens. The order was stopped on 05/27/2022 at 1203. A new order to limit linens was given by the provider on 05/27/2022 at 1400.

Employee #1 and 8 confirmed on 06/7/2022 and 06/08/2022 that Patient #1 had used ripped binding from bed linens to tie a ligature around his neck and a knot on the other end of the fabric to slip over the bedroom door before closing it to create a tie-off point.

The root cause analysis and corrective action initiated on 06/01/2022 revealed that it was identified staff did not conduct q5 minute safety checks for Patient #1 per policy, that registry staff did not have appropriate training, that assigned staff were pulled off the unit to work in other areas creating a staffing deficit, that nurses were tasked with additional duties pulling them from direct care of the patient, and that there was not appropriate hand off of the patients restricted to the unit before staff left the unit.

The house supervisor report dated 05/27/2022 DAY revealed that Sage unit had one assigned RN (Employee #20) who was a registry nurse and one assigned BHS (Employee #22) who was also registry. An additional RN (Employee #21) was assigned to float between Agave and Sage units. A third nurse (Employee #31) was assigned BHS duties for Agave and Sage units.

Employee #21 confirmed on 06/08/2022 that Employee #31 was pulled off his assignment on Agave and Sage units at some point during the day but did not know the exact time. Employee #21 confirmed that Employee #31 was not on the unit at the time of the incident involving Patient #1. Additionally, Employee #21 confirmed that she and Employee #20 were each assigned new patient admits at the same time and not out on the unit with patients. Employee #21 stated that Employee #22 left the unit with patients who were allowed off for dinner and did not report off or let the nurses know that Patient #1 remained on the unit unobserved. Employee #21 stated that the BHS called a "code green" at approximately 1830 to room #515 to which she responded. Employee #21 stated that a code green is used to designate a psychiatric emergency; however, when she responded to Patient #1's room she determined that it was actually a code blue, that the patient had a ligature tied around his neck and had no pulse or respirations. Employee #21 confirmed that observations for Patient #1 has not been completed from 1635 until the patient was found at 1830.

Patient #1's "Patient Observations - 5 minutes" rounding sheet dated 05/27/2022 revealed that the last 5-minute observations were completed at 1635.

Review of video footage revealed that observations were not conducted despite being documented as such on the form from 1520 through 1550, and from 1625 until 1828 on 05/27/2022.

Patient #1's "Patient Observations - 5 minutes" rounding forms revealed that staff were documenting every 5-minute observations in two separate areas of the hospital simultaneously. Staff documented every 5 minutes from 2140 through 2230 that the patient was present in the intake area in the lobby, and was calm, and sitting/lying down. Staff also documented that the patient was on the Agave unit from 2140 through 2230 in the hallway, calm, sitting/lying down.

Employee #1 confirmed on 06/08/2022 that staff in the intake area charted observations every 5 minutes for almost an hour for Patient #1 who was no longer in the intake area.

Employee #12 confirmed on 06/07/2022 that staff did not monitor Patient #1 every five minutes as ordered by the physician prior to Patient #1 hanging himself.

Documentation of orientation and training for registry staff (Employees #16, 18, 19, 20, 22, 23, 24, 25 and 26) were requested but not provided.

Employee #10 confirmed on 06/07/2022 that the facility did not have any documentation for orientation and training or verification of skills and knowledge or training on facility policies for registry staff.

Registry staff (Employees #15, 16, and 18) confirmed that they were not provided orientation and training prior to providing services at the facility before the incident on 05/27/2022.

Employee #13 confirmed on 06/08/2022 that registry staff called a code green for a psychiatric emergency for Patient #1 before realizing that it was a code blue situation for Patient #1 hanging himself.

Employees #1 and 8 confirmed on 06/08/2022 that staff should have recognized that Patient #1's bedroom door was closed as this is not allowed during the day and programming.

Patient #1's history and physical form [Chandler Regional Medical Center] dated 05/27/2022 revealed: "...Per EMS, they were called to the patient's behavioral health facility, where he was last seen normal at 1730 before being found by staff at 1830 with a torn sheet wrapped around his neck and the other end stuffed into a door jam...."

Patient #1's discharge summary from [Chandler Regional Medical Center] dated 05/27/2022 revealed that patient #1 presented as a "...red trauma after a suicide attempt via hanging on 27May...CT showed diffuse anoxic injury...Neurology was consulted and discussed with the family that this was a non-survivable injury...the patient's family opted for donation after cardiac death...On 31May, the patient was extubated. He did not expire within the allotted 90 minutes per donor network/transplant surgery...He was transferred back to the ICU on comfort measures. On 1Jun he was discharged to hospice...."

Employees #1, 5, and 8 confirmed on 06/09/2022 and 06/10/2022 that Patient #1 was not monitored as ordered and per facility policy every 5 minutes leading up to the patient's suicide attempt, that registry staff on the unit had not been trained on the facility's policies for suicide prevention prior to providing care, and that the wrong code was called when Patient #1 was found pulseless and not breathing on 05/27/2022.

2. Patient #13

Video footage of the intake area was reviewed from 05/26/2022. Patient #13 was present in the intake area at 1846 using his personal cell phone. Employee #29 was seen bringing in a mattress into assessment room #3. Patient #13 followed the employee into the assessment room and was seen plugging in his cell phone charger into the wall, then connecting his cell phone to it and leaning the mattress up against the wall and cell phone and charger. Patient #13 used a waste basket to wedge between the door and door frame to keep it propped open. The patient is seen several times entering and exiting the assessment room over several hours. Staff were seen bringing in linens into the room and the patient making a bed on the floor before going to sleep for the night at 1923. No staff were observed conducting 5-minute observations while the patient was in the assessment room or while sleeping that night until 0243 on 05/27/2022 when he was taken to another unit to be admitted.

Employee #7 confirmed on 06/09/2022 that all patients admitted and in the intake are all on every 5-minute observation. Employee #7 stated that staff did not monitor Patient #13 every 5 minutes while sleeping in the assessment room on 05/26/2022. Additionally, that Patient #13 should not have had a cell phone and charger after admission and while not supervised or monitored.

Based on review of policies and procedures, documents, medical records, and interview, it was determined the facility failed to ensure that the hospital followed their policies and procedures related to incidents, incident reporting and investigation. This deficient practice poses a potential risk to the health and safety of patients when potential system or individual performance problems may not be addressed.

Findings include:

Policy titled " Abuse and Neglect " revealed: " ...Patient to Patient Abuse: The registered nurse may place the patient committing the offense on Q 5 minute observations or 1:1 observation and notify the attending/covering physician ...The registered nurse will complete a nursing assessment of the patient who was abused to evaluate the patients physical and mental condition ...The registered nurse will notify the designated family contact and/or legal representative of the patient who was abused .... "

Policy titled " Incident Reporting " revealed: " ...Any facility staff member who witnesses, discovers, or has direct knowledge of an incident must complete an Incident Report before the end of the shift/work day ...If the incident involves a patient, staff must chart relevant information in the patient ' s medical record...DEFINITIONS OF AN INCIDENT...Boundary Violation/Sexual Allegation...Boundary...Patient/Patient - Any allegation of action, behavior, or relationship between Pt/Pt that could interfere with a safe, therapeutic enviroment and care at the facility...Body Exposure/Misconduct: Patient/Patient - Any allegation of deliberate action where a patient's genitals were exposed to, or touched by another patient...The Shift Supervisor of Facility Designated Individual will conduct a preliminary incident review. Risk Manager will further investigate if deemed necessary and/or will document the investigation under Level "I" and "II". .... "

Policy titled " Levels of Patient Observation " revealed: " ...Every 15 Minute Observation: Minimum level of observation for all patients ...Staff swill observe patient and document on the Patient Observation Record every 15 minutes ...Assigned staff will make direct visual contact with patients and confirm they are in no danger or distress ...Each patient ' s location and behavior at time of check will be entered on the Patient Observation Record, using the list of abbreviations found on the Patient Observation record itself ...The House Supervisor will be immediately notified of any patient who cannot be located at the time of check .... "

Hospital document titled " Patient Rights " revealed: " ...A patient is not subjected to sexual assault .... "

Patients #6 and 12

Patient #6's Psychiatry Progress note dated 03/02/2022 revealed: " Just seeing Patient #12 pisses me off. This male peer is no longer Patient #6 roommate. She says peer tells "girls to suck his dick at night or to give him a hand job." She says she gave this peer oral sex twice the first two (2) nights at Oasis and then refused most recently. She says peer "forced" her head down. When asked why she didn't tell techs, she says, "I did tell them and they moved him out of my room."

Patient #6's Case Management note dated 03/02/2022 revealed: " ...SW talked to Patient's mom regarding the incident that was reported with the Provider this morning...Patient mom stated she did not want to press charges of parents would be notified or involved...SW will provide further updates as an IR was completed ...."

Patient #6's Case Management note dated 03/02/2022 revealed: " ...SW updated mom, per Assistant Director of Nursing patient will be transferring to the Mesquite unit due to the incident with a peer on Cholla reported on 03/02/2022 ...."

Patient #6's Case Management note dated 03/04/2022 revealed: " ...Patient will be transferred to a different unit as it is related to the incident disclosed on 03/02/2022 regarding a peer and inappropriate boundary violations ...."

Patient #12

Patient #12's Case management note dated 03/02/2021 revealed: " ...CFT was conducted and information was provided regarding incident of inappropriate sexual behavior ...."

Patient #12's Psychiatry Note date 03/02/2021 revealed: " ...When asked if he was involved with sexually inappropriate behaviors with a TG peer he vehemently denies this. 'She was trying to make out with me and I said no, and I told staff and that's why my room changed'."

A request for an incident report related to the alleged incident was requested. The facility was unable to provide an incident report.

Employee #1 confirmed during an interview conducted on 06/09/2022 that there was no incident report filed on the alleged incident between Patient #6 and Patient #12. Employee #1 confirmed an incident report should have been completed and an investigation should have been conducted.

Employee #1 confirmed Patient #6 did inform staff of the alleged incident but staff did not follow policies and procedures and follow through with required actions.

Patients #5 and 9

Hospital document titled "Incident Report" revealed: "...10/12/2021 incident time 1145 approximate, Patient #5 was found in room 512 bathroom by a Behavioral Health Tech (BHT), after Patient #5 left the room the BHT found Patient #9 hiding in the shower of the bathroom fully clothed...While attempting to clean room 511 housekeeping states Patient #9 was holding door shut and would not allow housekeeper into room. Housekeeper states s/he saw Patient #5 pulling down her shirt...Both patients deny any physical contact while in the rooms...Interventions: Unit change...Nursing assessment: patient denies current/recent pain, no physical evidence of discomfort noted...Physician notified at 1200 on 10/12/2021 and ordered patients separated and Q 5 observations.... "

Patient #5 was under Q 5-minute observation from admission on 10/11/2021 until 1245 10/12/2021.

A review of the Q 5 observations for 10/12/2021 revealed Patient #5 was in the bathroom at 1150 and 1155.

The Observation form revealed the Q 5 observations ended at 1245 and the patient was on Q 15-minute observation.

Patient #5's chart revealed the patient was transferred to the Agave unit on 10/12/2021 at 1200.

Patient #5's nurse note dated 10/12/2021 at 1205 revealed: " ...patient found in bathroom with a male peer. Patient moved to Agave unit to prevent further boundary issues ...."

Patient #5's Psychiatry Progress note dated 10/13/2021 revealed: " ...patient is impulsive and high risk, yesterday she went inside a much older male adult patient ' s room. The room's door was closed and the janitor alerted hospital staff. It is not clear what happened while the patient and the male patient were behind closed doors ...."

A Psychiatry Progress noted dated 10/16/2021 revealed: " ...Patient open to talk about incident from Tuesday this week...She then went on to say that on Tuesday this week, she had sexual intercourse with a male patient (Patient #9). She states that during the sexual intercourse she was in pain and asked Patient #9 to stop but he continued. She states that she is fearful that she is pregnant after the sexual intercourse...The patient states she wants to speak to the police and press rape charges against Patient #9 ...."

A Case Management note dated 10/15/2021 revealed: " ...patient informed SW of an incident that occurred on the unit with her and another patient ...."

A Medical Provider Consultation note dated 10/19/2021 revealed: " ...I was raped before I was admitted, want to be tested for AIDS, pregnancy ...."

A review of Patient #5 laboratory results revealed: " ...Sexually Transmitted Disease Profile testing was performed on 10/19/2021 and 10/26/2021 with negative results. An HIV test was performed on 10/20/2021 with a negative test result. A urine pregnancy test was performed on 10/12/2021 with a negative result ...."

Patient #9's Case Management note dated 10/12/2021 revealed: " ...CM was informed by Behavioral Health Technician that patient had been discovered in an unauthorized location on the unit with a younger female patient, and appeared to have been engaging in physical relations. As a result, patient and the female patient were designated to separate units. During treatment team, provider indicated that patient would be discharged administratively ...."

Employee #1 confirmed during an interview conducted on 06/09/2022 that there were two (2) incidents on the same day involving both patients. Employee #1 stated both patients were found in room 512 by a BHT and then later in room 511 by a housekeeper. Employee #1 stated both patients denied any physical contact or sexual activity. Employee #1 stated review of video footage revealed both patients walking in the hallway together and each entering the rooms and shortly after staff finding the patients in the rooms. Employee #1 stated the patients were separated and Patient #5 was transferred to a different unit. Employee #1 stated Patient #5 changed the circumstances of the incident throughout her entire hospital stay. Employee #1 confirmed that there was no investigation conducted as required by facility policy.

Patient #4

A Case Mangement Note dated 12/23/2021 at 1258 revealed: "...SW (Employee #30)....monitored a face to face call for (Patient #4) and his parents along with his sister. Dcs was present with the patients and the sister...."

A Case Mangement Note dated 12/23/2021 at 1608 revealed: "...Pt disclosed during the meeting with his parents that he was touched inappropriately by another Pt. When SW (Employee #30) asked (Patient #4) who the other Pt was (Patient #4) could not identify them, except that the Pt was no longer on the unit. (Patient #4) reported to SW that when he told staff about the inappropriately (Sic) that he was moved...."

A request for an incident report related to the alleged incident was requested. The facility was unable to provide an incident report.

Employee #2 confirmed on 06/10/2022 that the medical record did not contain any further information about the alleged abuse or staff response and interventions.

Based on review of policy and procedure, facility documents, medical records, observation, and interview, it was determined that the facility failed to:

(A0392) ensure there were an adequate number of staff to provide patient services which has the potential risk of inadequate monitoring of patients and lack of patient care.

(A0397) ensure the acuity plan was comprehensively implemented which poses a risk of having inadequate staffing to meet the acuity needs of patients.

(A0398) ensure that (9) of (9) contracted registry staff had appropriate orientation and training prior to providing patient care services which poses a potential risk that they may not be qualified to provide safe patient care.

The cumulative effect of these systematic deficient practices resulted in the facility's failure to meet the requirement for Condition of Participation for Nursing Services, which poses a potential risk to the health and safety of patients by not ensuring there are sufficient number of qualified personnel to meet the needs of the patients and ensuring a safe environment for patients.

Based on review of policy and procedure, facility documents, and interview, it was determined that the facility failed to ensure there were an adequate number of staff to provide patient services which has the potential risk of inadequate monitoring of patients and lack of patient care.

Findings include:

The facility policy titled "Patient Acuity" requires: "...Staffing for patient care is based on matrix and additional staff above matrix is based on acuity for the inpatient psychiatric hospital...To provide for adequate coverage and ensure/maximize a safe therapeutic environment...Level of observation will be utilized to determine BHS staff above matrix. An additional BHS or RN will be staffed for each unity that have more than 5 Q5 observation patients...
STAFFING MATRIX...
Day Shift...
1-5 Patients...1 RN...1:12 BHT to Patient Ratio...
6-12 Patients...1 RN...1:12 BHT to Patient Ratio...
13-20 Patients...1.5 RN...1:12 BHT to Patient Ratio...."

The House Supervisor report dated 03/24/2022 Day shift revealed insufficient staffing on Ocotillo unit for BHS. There were two BHS for 16 total patients with 7 Q5 observation patients. A required additional BHS was not assigned to the unit.

The House Supervisor report dated 03/26/2022 Day shift revealed insufficient staffing on Agave unit for BHS with one BHS for 16 patients. A required additional BHS was not assigned to the unit.

The House Supervisor report dated 03/27/2022 Day shift revealed insufficient staffing on Agave unit for BHS with one BHS for 16 patients; insufficient staffing on Ocotillo unit for BHS with one BHS for 20 patients; and insufficient staffing for BHS with one BHS for 15 patients. Required additional BHS staff were not assigned to the units.

The House Supervisor report dated 05/27/2022 Day shift revealed insufficient staffing on Sage and Agave units for BHS staff. Sage unit had one BHS with 18 patients and Agave unit had one BHS with 15 patients with a third BHS assigned to float between the units.

Employee #21 confirmed on 06/08/2022 that the float staff was pulled off the Sage and Agave units to another area in the hospital leaving the units short staffed.

The House Supervisor report dated 06/07/2022 day shift revealed insufficient BHS staffing on Sage, Agave, Ocotillo, and Cholla units. Sage unit had 19 patients with 6 Q5 observations and 1 - 1:1 observation patient. A required additional BHS was not assigned to the unit. Agave unit had 15 patients with 9 Q5 observations and 1 - 1:1 observation patient. A required additional BHS was not assigned to the unit. Ocotillo unit had 18 patients with 6 Q5 observation patients. A required additional BHS was not assigned to the unit. Cholla unit had 16 patients with 7 Q5 observation and 1 - 1:1 observation patient. A required additional BHS was not assigned to the unit.

Employees #1 and 8 confirmed on 06/09/20222 that the facility did not have sufficient staffing on the above listed days and units as required by facility policy. Additionally, that the facility has had experienced difficulty in maintaining appropriate staffing levels since the COVID pandemic.

Based on review of policy and procedure, facility documents, and interview, it was determined that the facility failed to ensure the acuity plan was comprehensively implemented which poses a risk of having inadequate staffing to meet the acuity needs of patients.

Findings include:

The policy titled "Patient Acuity" requires: "...The purpose of this policy is to define the established acuity/staffing plan to meet patient care needs at Oasis Behavioral Health Hospital...Staffing for patient care is based on matrix and additional staff above matrix is based on acuity...The staff nurse will complete the acuity assessment tool for each their (sic) assigned patients every shift. This assessment is based on information communicated during the shift. Acuity Tool calculates protocols, suicide ideation, homicidal ideation, aggressions, unpredictable behavior, precautions, and utilization of nursing care. The acuity tool is for determination of RN staffing only. Maximum acuity scores for a RN is 20 points...Level of observation will be utilized to determined BHS staff above matrix. An additional BHS or RN will be staffed for each unity that have more than 5 Q5 observation patients...STAFFING MATRIX...
Day Shift...
1-5 Patients...1 RN...1:12 BHT to Patient Ratio...
6-12 Patients...1 RN...1:12 BHT to Patient Ratio...
13-20 Patients...1.5 RN...1:12 BHT to Patient Ratio...
Night Shift...
1-5 Patients...1 RN...1:16 BHT to Patient Ration...
6-16 Patients...1 RN...1:16 BHT to Patient Ratio...
17-20 Patients...1.5 RN...1:16 BHT to Patient Ratio...."

The policy included a scoring tool for calculating patient acuity for nursing. The tool included criteria for scoring SI/HI; unpredictable behaviors of catatonia, disorganization, altered mental state, hallucinations, delusions; precautions for AWOL, 1:1, elopement; utilization for frequently symptomatic, PRN usage, non compliance, and oppositional behavior.

Nursing assignment sheets were reviewed from March 2022 through June 2022 and revealed that nursing staff assigned patients a score based on scoring criteria for acuity; however, the scores were not utilized in adjusting staff based on the calculation of these scores to determine acuity.

Employee #8 confirmed on 06/08/2022 that the staffing is set based on the staffing matrix and that the only factor utilized currently for determining an increase in staff is for BHS based on the number of Q5 observation patients. The patient acuity policy does not incorporate or delineate how and when additional nursing staff would be added to staffing based on the scores derived for RN staffing.

Based on personnel records request and interview, it was determined the facility failed to ensure that (9) of (9) contracted registry staff had appropriate orientation and training prior to providing patient care services which poses a potential risk that they may not be qualified to provide safe patient care.

Findings include:

Documentation of orientation and training for registry staff (Employees #16, 18, 19, 20, 22, 23, 24, 25 and 26) were requested but not provided.

Employee #10 confirmed on 06/07/2022 that the facility did not have any documentation for orientation and training or verification of skills and knowledge or training on facility policies for registry staff.

Registry staff (Employees #15, 16, and 18) confirmed that they were not provided orientation and training prior to providing services at the facility.