HospitalInspections.org

Based on record reviews and interviews, the hospital failed to ensure each patient who filed a grievance was provided written notice of the hospital's decision regarding the resolution of the grievance for 2 of 2 grievances reviewed (R1, R2). Findings:

Patient R1
Review of the hospital form titled "Concern Form: Confidential", completed on 09/27/12 at 0900 (9:00am) by PI/Risk Mgr. S16 (Performance Improvement/Risk Manager), revealed that Patient R1 "states I've not been treated well since I've been here, I've gotten unnecessary shots. I'm stressed & (and) may be homeless when I leave I will need help getting to Florida". Review of the section titled "Investigation/Review/Analysis" revealed the entry "9-27-12 0920 (9:20am) Spoke (with) pt. (patient) See attached documentation". Review of the attached documentation revealed no documented evidence of any investigation conducted. Review of the section titled "Resolution" revealed "pt. thanked me for coming to speak (with) him. Pt. stated (name of patient's attorney) was scheduled to meet (with) him today". Further review revealed no documented evidence that any reference was made to Patient R1's complaints of not being treated well, getting unnecessary shots, and his need for help to get to Florida upon discharge.

In a face-to-face interview on 10/17/12 at 9:30am, PI/Risk Mgr. S16 indicated that she spoke with Patient R1's nurse and reviewed his MARs (medication administration record), but she did not document the interview or the chart review findings. She further indicated that she had not handled the complaint as a grievance and did not send a written notice of her findings to Patient R1.

Patient R2
Review of the "Concern Form: Confidential" completed on 09/05/12 at 11:45am by PI/Risk Mgr. S16 revealed Patient R2 stated that "Licensed Practical Nurse R12 gave me Respiridol I threw it in the garbage, after time was offered the med (medication) again & told if I didn't take it I would get an injection. Staff assisted held me down while injection was given. 9-5-12 1030 (10:30am) attempted to use the phone to call the Advocacy & was told I couldn't. Told phone time was over. was very upset about not leaving yesterday". Review of the "Investigation/Review/Analysis" revealed S16 documented on 09/05/12 at 1430 (2:30pm) that she "spoke (with) pt. pt agreed to take his medications & cooperate as a pt to work towards his goal of being DC'd (discharged) ASAP (as soon as possible). pt. was appreciative of having someone to listen to him & talk (with) him". Review of the "Resolution" revealed S16 documented "pt. was happy & voiced relief in me going to talk to him".

In a face-to-face interview on 10/17/12 at 9:30am, PI/Risk Mgr. S16 indicated that she checked Patient R2's MARs, and the medication was administered as ordered. She further indicated that she remembered that a Code White (a call for extra help due to a patient's behaviors) was called for Patient R2, and the documentation for that would be in his patient medical record in the nurse's notes. S16 confirmed that she did not interview any staff related to this complaint to determine if Patient R2 was actually held down for the injection to be administered. She further indicated that she was not aware that holding a patient down to force medication was considered a physical restraint and required a physician's order. S16 confirmed that the hospital's grievance policy was not clearly written, since one paragraph revealed no further action was necessary, and the next paragraph revealed that a written letter was to be sent.

When Patient R2's medical record was requested, a medical record for another time interval was presented.

In a face-to-face interview on 10/17/12 at 9:20am, Director of Medical Records S22 indicated that there was no medical record for Patient R2 for the time interval that included 09/05/12.

Review of Patient R3's medical record, presented by Director of Medical Records S22, revealed Patient R3 was admitted on 08/27/12. Review of his nurse's note for 09/04/12 revealed an entry at 1300 (1:00pm) by LPN (licensed practical nurse) S12 of "Risperdal 1 mg (milligram) po (by mouth) BID (twice a day) ordered. Attempted x 2 (times 2) to give pt. first dose. Pt refused loud, Intrusive, Threw pill in garbage. Unable to redirect. Pt inappropriate... Unable to redirect pt. Haldol 5 mg, Ativan 2 mg, & Benadryl 50 mg IM (intramuscular) given. Pt tolerated well..."

In a face-to-face interview on 10/17/12 at 2:08pm, PI/Risk Mgr. S16 indicated that Patient R3 identified himself to her by the name of Patient R2. She further indicated that she didn't realize the different name when she reviewed Patient R3's medical record. S16 indicated that she identified Patient R3 by looking at his name band and thought that it read Patient R2's name, but she can't be 100% (per cent) certain. She further indicated that she was 100% certain that she spoke with Patient R3 when she received the complaint. S16 could offer no further explanation for the complaint being documented for Patient R2, when it was really presented by Patient R3.

In a face-to-face interview on 10/17/12 at 4:30pm, Corporate Compliance Officer S7, after reviewing the hospital's grievance policy, indicated that the policy was not clear.

Review of the hospital policy titled "Patient Complaints and Grievances", policy number NU.205, revised 10/09/12, and presented by Acting Administrator S6 as the current grievance policy, revealed, in part, "...F. The Director of Nursing is the designated individual responsible for the facilitation and implementation of the system for an orderly management of patient/family grievances... E. The Charge Nurse is responsible for notifying the Director of Nursing who will make personal contact with the patient with the patient making the request within two working days of receipt of the grievance. 1. Jointly, the patient and the Care Connection Representative will discuss the patient's verbal or written request in order to clarify the patient's concerns and formulate a statement of grievance. 2. Should the Care Connection Representative and the patient come to a resolution of the problem expressed, no further action will be necessary. 3. A written response will be provided to the patient within three working days of the initial meeting of the Care Connection Representative and the patient. ... E. If the problem or concern is not resolved at this stage, the Care Connection Representative is responsible for facilitating the Grievance Process..."

Based on record reviews and interviews, the hospital failed to ensure that each patient received care in a safe setting. The hospital failed to protect vulnerable psychiatric patients from Patient #2 who exhibited agitation, aggression towards staff and peers, anxiety, and combativeness that resulted in Patient #2 hitting another patient on 09/20/12 and 09/21/12.

Findings:

Review of Patient #2's medical record revealed that she was a 20 year old female who was admitted on 09/12/12 with a diagnosis of Psychosis. Further review revealed that she was discharged on 09/24/12.

Review of Patient #2's medical record revealed the following documented occurrences of agitation, aggression towards staff and peers, anxiety, and combativeness:


09/14/12 at 11:30am - threatening staff and stating "I'm going to punch you"; noted "swinging fists through the air"; threatening to punch walls and windows; threatening aloud that "I'm going to kill myself" with plan to "go the cafeteria get a fork, knife, or something else & (and) cut myself & bleed to death"; attempting to break window and punch walls; threatening to hurt herself and others;
09/15/12 at 7:40am - increased agitation, crying, being disruptive;
09/16/12 at 11:10am - loud verbal outbursts, increased agitation;
09/16/12 at 4:10pm - upset and escalating after being told she was not being discharged; ran out of visitation with family cursing loudly and becoming aggressive with staff;
09/17/12 at 3:25pm - very agitated, hitting staff, yelling and screaming, cursing;
09/18/12 at 3:30pm - yelling and punching staff;
09/19/12 at 8:30am - combative, punching staff and attempting to punch peers;
09/20/12 at 9:35am - increased agitation, crying, yelling loudly; verbally aggressive with staff;
09/20/12 at 2:40pm - increased agitation; hitting Patient #4; having verbal outbursts and swinging at staff;
09/20/12 at 3:30pm - continues to remain agitated, still crying and swinging at staff;
09/21/12 at 11:05am - increased agitation, yelling, swinging at staff; laid on floor and stomped feet;
09/21/12 at 2:00pm - no documented evidence in nurse's notes that Patient #2 hit Patient #5 as noted by the "Alleged Incident / Accident Report" dated 09/21/12 at 1400 (2:00pm);
09/22/12 at 4:00pm - parents visited with patient punching and hitting mother and pushed father;
09/23/12 at 2:30pm - increased agitation, hitting staff, cursing, and very combative; laying on floor and crying.

Review of the hospital's "Alleged Incident / Accident Report" dated 09/20/12 at 1400 (2:00pm) and signed by RN (registered nurse) S9 revealed that Patient #2 "became agitated (increasingly) and hit peer #816 (Patient #4) on left arm, client was escorted to room (with) staff x 2 (times 2). MD (physician) made aware - 1:1 (one-to-one) started. PRN (as needed) admin (administered) per MD order. (Nurse Practitioner S21 on call for Psychiatrist S8)".

Review of the hospital's "Alleged Incident / Accident Report" dated 09/21/12 at 1400 (2:00pm) and signed by RN S9 revealed that Patient #2 "was maintained 1:1 Level 3 status (with) MHT (mental health tech) S14. Client became (increased) agitated when MD told her that she was not going to be seen on demand and client would have to wait her turn to be seen. Client was walking (with) MHT to left at arms' length and while patient was passing row of clients sitting in milieu, she struck peer #808 (Patient #5) with left hand (open hand) & struck peer in face near (R) (right) eye. ... Client was promptly escorted to room & remained in room (with) 1:1 staff. Client rec'd (received) PRN..."


Review of Patient #2's admit orders revealed her ordered level of observation was Level 1 (location of patient is known at all times; patient is observed with visual checks every 15 minutes documented on the observation sheet). Further review revealed Psychiatrist S8 ordered Patient #2 to be on 1:1 observation (Level 3 which means a staff member is assigned to care for the patient and is in constant attendance within arm's length at all times; documentation includes every 15 minutes checks) on 09/14/12 with no documented evidence of the time the order was written (order was noted by Licensed Practical Nurse S11 on 09/14/12 at 1245pm). Psychiatrist S8 changed Patient #2's level of observation to Level 2 (patient must be in visual line of sight during the day and night and observation documented every 15 minutes on the flow sheet) on 09/15/12 at 9:40am. Nurse Practitioner S21 ordered Patient #2 to be maintained on 1:1 observation (Level 3) on 09/20/12 at 1400 (2:00pm). Further review revealed Patient #2 remained on 1:1 observation until her discharge on 09/24/12.


Review of Patient #2's "Interdisciplinary Treatment Plan" initiated on 09/12/12 revealed problem #3 was "Risk For Other/Self Directed Violence" as evidenced by self-inflicted cuts to the left forearm, hitting a window at home, and physically punches (no documented evidence of who or what was punched). Further review revealed the short term objectives were that Patient #2 would make no attempt to harm herself or others and would respond to staff direction and efforts to decrease agitation with a target date for both of 09/22/12.

Review of the interventions revealed that the physician would monitor medication and physiological aspects of disruption/agitation and provide for interventions to address it, and nursing would assure a safe and therapeutic environment by providing precautions if needed as well as supportive measures every shift. Further review revealed no documented evidence that the treatment plan was reviewed weekly as required by hospital policy and revised each time that Patient #2's level of observation changed, and there was no documented evidence that the interventions were revised when Patient #2's behaviors revealed that she was not meeting the short term objectives. Further review revealed the short term objectives were noted to be completed on 09/24/12 when she was discharged (Patient #2 had behaviors that warranted PRN medication on 09/23/12).

Review of Patient #2's "Interdisciplinary Treatment Plan" initiated on 09/12/12 revealed problem #6 was "Poor Impulse Control" as evidenced by punching people, windows, and self-inflicted cuts to the forearm. Further review revealed the short term objectives were that Patient #2 would identify feelings, events, or situations that trigger disruptive behaviors, would no longer exhibit physical aggression or acting out behaviors for 2 consecutive days, and would develop specific coping strategies to resist impulsive urges. Further review revealed no documented evidence that the treatment plan was reviewed weekly as required by hospital policy and revised each time that Patient #2's level of observation changed, and there was no documented evidence that the interventions were revised when Patient #2's behaviors revealed that she was not meeting the short term objectives. Further review revealed the short term objectives were noted to be completed on 09/24/12 when she was discharged (Patient #2 had behaviors that warranted PRN medication on 09/23/12).

In a face-to-face interview on 10/16/12 at 1:35pm, Psychiatrist S8 indicated that she treated Patient #2 during her inpatient stay at the hospital. She further indicated that she developed a behavioral plan for her patients. When asked about Patient #2's treatment plan not being revised when her behaviors of agitation, aggression, and combativeness continued while she was on 1:1, S8 indicated that Patient #2 had only one further instance of hitting a peer after she had hit one peer and placed on 1:1 observation. She further asked what more could she have done.

Review of the hospital policy titled "Patient and Family Rights", policy number NU.207, reviewed 05/09/10, and presented by Acting Administrator S6 as the current policy, revealed, in part, "...6. To receive care in a safe setting and be free from all forms of abuse or harassment..."

Review of the hospital policy titled "Levels of Observation - Therapeutic Safety Measures", policy number NU.432, revised 05/01/12, and presented by Acting Administrator S6 as the current policy for observation levels, revealed, in part, "...1. Level 1 a. Location of patient is known at all times. b. The patient is observed with visual checks every 15 minutes documented on observation sheet. 2. Level 2 a. The patient must be in visual line of sight during the day and night. b. Patient must be documented on every 15 minutes on flow sheet... f. All patients admitted to the inpatient acute units are on Level 2 unless nursing or physician, assess need for lower/higher level. 3. Level 3 a. One-to-one nursing care is where a staff member is assigned to a patient to care for them in constant attendance at all times. Patient must be arm's length of staff at all times. Documentation includes 15 minute checks. b. Patients on 1:1 status must have a physician's order..."

Review of the hospital policy titled "Inter-Disciplinary Treatment Planning-Overview", policy number NU.706, revised 06/29/10, and presented by Acting Administrator S6 as the current policy, revealed, in part, "...Each client admitted to the psychiatric unit shall have an individualized treatment plan which is based on interdisciplinary clinical assessments. ... The Master Problem List is initiated by the admitting nurse upon admission. ... Throughout the client's stay, problems are entered on the Master Problem List. ... Problem Sheet ... 3. The problem should then be described how it has affected the individual... 5. Short-term objectives ... must be specific, measurable, and represent a client's steps toward reaching the long-term goal. A target date should be indicted (indicated) as well as a date objectives are met or revised. 6. Interventions are completed by each discipline and should include the specific plan of intervention as well as frequency. ... By day seven of the client's admission, the initial and preliminary treatment plans have been initiated, reviewed and refined based on completion of all assessments, consults and implementation of interventions with indication of client's response to same. ... Weekly reviews are done ... will provide valuable information about client progress, need for continued treatment, revision of interventions as well as discharge planning. Weekly review is indicated by placing the date of treatment team staffing in the box marked Week 1, Week 2 ... Any revisions, additions or resolutions are indicated in the appropriate space under objectives or interventions..."

Based on record reviews, policy and procedures, and interviews, the hospital failed to meet the requirements for the Condition of Participation for Nursing Services as evidenced by:

1) Failing to ensure that the registered nurse (RN) supervised and evaluated the nursing care of each patient.

a) The RN failed to assess a change in the patient's condition prior to PRN (as needed) medication being administered for behaviors exhibited such as agitation, anxiety, combativeness, and aggression towards staff and peers for 2 of 2 patients requiring PRN medications from a total sample of 6 patients (#2, #6).
b) The RN on Unit C failed to obtain admit orders from the admitting psychiatrist as evidenced by Psychiatrist S8 relying on standing orders for admission.
c) The RN failed to assess a patient's bowel status on a patient who did not have a bowel movement for 7 days for 1 of 6 sampled patients (#2).
d) The RN failed to assess a patient for injury after the patient was hit by another patient for 2 of 2 patients' records reviewed who had been hit by another patient from a total sample of 6 patients (#4, #5).
e) The RN failed to evaluate the documentation of patient observations by the MHT (mental health tech) to ensure that the ordered level of observation was maintained for 2 of 2 patients' records reviewed that had changes in the level of observation from a total of 6 sampled patients (#2, #6) (see findings in tag A0395);

2) Failing to meet the hospital's staffing grid for the number of MHTs (mental health tech) assigned on 09/15/12, 09/16/12, 09/17/12, 09/18/12, 09/23/12/ 09/25/12, 10/09/12, 10/10/12, 10/11/12, 10/12/12, 10/13/12, and 10/14/12 and did not increase staffing when patients were ordered to have 1:1 observation. (see findings at tag A0392);

3) Failing to ensure a registered nurse (RN) was on duty on Unit C from 11:00pm on 09/21/12 to 7:00am on 09/22/12 (see findings at tag A0393);

4) Failing to ensure that the RN assigned the nursing care of each patient to nursing personnel who had been assessed for competency and met the qualifications of their job description for 1 of 4 RNs' personnel files reviewed from a total of 21 RNs (S9), 3 of 3 LPNs' (licensed practical nurse) personnel files reviewed from a total of 20 LPNs (S11, S12, S20), and 2 of 3 MHTs' (mental health tech) personnel files reviewed from a total of 57 MHTs (S14, S15) (see findings in tag A0397).

Based on record reviews and interviews, the hospital failed to meet the hospital's staffing grid for the number of MHTs (mental health tech) assigned on 09/15/12, 09/16/12, 09/17/12, 09/18/12, 09/23/12/ 09/25/12, 10/09/12, 10/10/12, 10/11/12, 10/12/12, 10/13/12, and 10/14/12 and did not increase staffing when patients were ordered to have 1:1 observation.


Findings:


Review of the "Staffing Grid" presented by Acting Administrator S6 for 7:00am to 7:00pm and the 7:00pm to 7:00am shifts revealed there would be 3 MHTs on each shift when the census was 16-20 patients.


Review of the staffing pattern presented by Interim Director of Nursing (DON) S3 for 09/12/12 through 09/24/12 and 10/08/12 through 10/14/12 revealed the following MHT to patient ratio:
09/15/12 - 16 patients with 2 patients 1:1; 3 MHTs assigned on both shifts;
09/16/12 - 17 patients with 1 patient 1:1; 3 MHTs assigned each shift;
09/17/12 - 17 patients with 1 patient 1:1; 3 MHTs assigned each shift;
09/18/12 - 17 patients with 1 patient 1:1; 3 MHTs assigned each shift;
09/23/12 - 18 patients with 2 patients 1:1; 3 MHTs assigned each shift;
09/25/12 - 19 patients with 1 patient 1:1; 3 MHTs assigned each shift;
10/09/12 - 16 patients with 1 patient 1:1; 3 MHTs assigned on the day shift, and 2 MHTs assigned to the evening and night shifts;
10/10/12 - 16 patients with 2 MHTs assigned to each shift;
10/11/12 - 17 patients with 2 MHTs assigned on the day and evening shift and 1 MHT assigned on the night shift;
10/12/12 - 17 patients - 2 MHTs assigned to each shift;
10/13/12 - 17 patients with 2 MHTs assigned to the night shift;
10/14/12 - 17 patients with 1 patient 1:1; 3 MHTs assigned to each shift.


In a face-to-face interview on 10/16/12 at 3:30pm, MHT S10 indicated that sometimes there were 2 MHTs scheduled with 3 patients on Level 2 observation (patient must be in visual line of sight during the day and night). He further indicated that it's difficult to monitor 2 patients who are Level 2 observation and to be able to see both patients at all times. S10 indicated that he would go back and forth to check where the patients were, but there were times that he didn't actually see one of the patients at all times.


In a face-to-face interview on 10/17/12 at 2:15pm, Interim DON S3 indicated that the staffing grid for 16 to 20 patients on each shift had "3(PRN)" listed as the staffing requirements. She further indicated that this meant there should be at least 2 MHTs, and one additional MHT could be added. When asked why the grid had 3 and not 2, S3 could offer no explanation. S3 indicated that the number of MHTs on the staffing grid did not take into account patients who were on 1:1, so that meant that the number of MHTs required were in addition to the number required for 1:1 observations. S3 confirmed that the staffing of MHTs was not according to the staffing grid, and the staffing grid was not clear in determining whether 2 or 3 MHTs were required for 16 to 20 patients.

Based on record reviews and interview, the hospital failed to ensure a registered nurse (RN) was on duty on Unit C from 11:00pm on 09/21/12 to 7:00am on 09/22/12.


Findings:


Review of the nurse staffing patterns presented by Interim Director of Nursing (DON) S3 revealed no documented evidence That Unit C had a RN on duty from 11:00pm on 09/21/12 to 7:00am on 09/22/12.


In a face-to-face interview on 10/15/12 at 2:23pm, Interim DON S3 indicated the RN scheduled to work the night of 09/21/12 did not show up and did not call. She further indicated that they were not able to find a replacement. S3 confirmed that Unit C did not have a RN on the unit at all times from 11:00pm on 09/21/12 to 7:00am on 09/22/12.

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Based on record reviews and interviews, the hospital failed to ensure that the registered nurse (RN) supervised and evaluated the nursing care of each patient.

1) The RN failed to assess a change in the patient's condition prior to PRN (as needed) medication being administered for behaviors exhibited such as agitation, anxiety, combativeness, and aggression towards staff and peers for 2 of 2 patients requiring PRN medications from a total sample of 6 patients (#2, #6).

2) The RN on Unit C failed to obtain admit orders from the admitting psychiatrist as evidenced by Psychiatrist S8 relying on standing orders for admission.

3) The RN failed to assess a patient's bowel status on a patient who did not have a bowel movement for 7 days for 1 of 6 sampled patients (#2).

4) The RN failed to assess a patient for injury after the patient was hit by another patient for 2 of 2 patients' records reviewed who had been hit by another patient from a total sample of 6 patients (#4, #5).

5) The RN failed to evaluate the documentation of patient observations by the MHT (mental health tech) to ensure that the ordered level of observation was maintained for 2 of 2 patients' records reviewed that had changes in the level of observation from a total of 6 sampled patients (#2, #6).

6) The RN failed to assess patients' vital signs as ordered by the physician 5 of 6 sampled patients (#1, #2, #3, #5, #6).

Findings:

1) The RN failed to assess a change in the patient's condition prior to PRN medication being administered for behaviors exhibited such as agitation, anxiety, combativeness, and aggression towards staff and peers:

Patient #2

Review of Patient #2's medical record revealed that she was a 20 year old female who was admitted on 09/12/12 with a diagnosis of Psychosis. Review of Patient #2's "Physician Orders - Routine" revealed an order written by Psychiatrist S8 on 09/14/12 (no time the order was written) for Haldol 5 mg (milligram), Ativan 2 mg, and Benadryl 50 mg by mouth, if necessary IM (intramuscular), every 6 hours PRN (as needed) for agitation. Further review revealed a telephone order given by Nurse Practitioner S21 on 09/20/12 at 1400 (2:00pm) to give Benadryl 50 mg IM, Ativan 2 mg IM, and Haldol 5 mg IM now.

Review of Patient #2's nurses' notes and MARs (medication administration record) revealed she received an injection of Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg IM due to increased agitation, aggression, and/or disruptive behavior on 09/15/12 at 7:40am, 09/18/12 at 3:30pm, 09/20/12 at 9:35am, 09/20/12 at 2:40pm, 09/21/12 at 11:05am, 09/23/12 at 2:30pm, and 09/24/12 at 2:30pm (documented on MAR but record revealed Patient #2 was discharged this day at 1:45pm). Further review revealed she received Haldol 5 mg, Ativan 2 mg, and Benadryl 50 mg by mouth on 09/16/12 at 11:10am, 09/16/12 at 4:10pm.

Review of the entire medical record revealed no documented evidence that Patient #2's behavior was assessed by the RN prior to the LPN (licensed practical nurse) administering the PRN medication. Patient discharged on 09/24/12.

Patient #6

Review of the medical record for Patient #6 revealed that the patient was admitted on 09/30/12 at 0410 (4:10 am) with a primary diagnosis of Paranoid Schizophrenia chronic. The patient was discharged on 10/15/12.
Review of an Interdisciplinary progress note completed by S11, LPN and dated 09/30/12 at 1050 (10:50 am) revealed "Pt becoming [increasingly] agitated/psychotic [and]threatening, cursing staff, states " xxx you! They work me to death every time I'm here! Redirection attempted [with no] success. Ativan 2 mg IM, Haldol 5 mg IM, Benadryl 50mg IM given. Charge Nurse [S9] RN aware. Will continue to monitor". Further review of the progress note dated 09/30/12 at 1130 (11:30 a.m.) revealed further documentation by S11, LPN of "No further agitation/psychosis noted [at] this time. Pt resting quietly in room. No acute distress noted". There was no documented evidence that an RN completed an assessment of Patient #6's behavior prior to the patient receiving medication due to a change in the patient's behavior.
In a face-to-face interview on 10/16/12 at 11:15am, Interim Director of Nursing (DON) S3 indicated that the RN should be assessing a patient's change in condition and exhibited behaviors prior to PRN injections being administered, and the assessment should be documented by the RN in the nurses' notes.

In a face-to-face interview on 10/16/12 at 2:00pm, RN S9 confirmed that she did not document an assessment of Patient #2's behaviors that warranted PRN medication on 09/15/12, 09/16/12, and 09/20/12.

In a face-to-face interview on 10/16/12 at 3:40pm, Corporate Compliance Officer S7 indicated that RN S13 was not available to be interviewed, since she was out of the country.

In a face-to-face interview on 10/16/12 at 3:45pm, LPN (licensed practical nurse) S11 indicated that she worked as the LPN on Unit C on 09/14/12 with RN S13 and on 09/15/12, 09/16/12, 09/20/12, and 09/21/12 with RN S9. After reviewing Patient #2's medical record, S11 confirmed that there was no documented evidence of a RN's assessment of Patient's change in behaviors prior to her administering PRN medication. S11 indicated that she always cleared the need for PRN medication with the RN, and she just assumed that the RN documented an assessment.

In a face-to-face interview on 10/17/12 at 8:45am, LPN S12 indicated that she worked as the LPN on Unit C on 09/18/12 with RN S13. After reviewing Patient #2's medical record, S12 indicated that there was no documented evidence that Patient #2 was assessed by RN S13 prior to her (S12) administering the PRN medication for a change in her behavior.

In a face-to-face interview on 10/17/12 at 1:40pm, LPN S20 indicated that she worked as the LPN on Unit C on 09/19/12 with RN S13. After reviewing Patient #2's medical record, S20 indicated there was no documented evidence of a RN assessment on 09/22/12 prior to her administering PRN medication for a change in behavior.

Review of the hospital policy titled "Nursing Assessment", policy number NU.306, revised 05/13/09, and presented by Acting Administrator S6 as the current nursing assessment policy, revealed, in part, "...the R.N. will: ... 3. Reassess needs when patient's condition warrants in order to update the Treatment Plan".

Review of the Louisiana State Board of Nursing's "Administrative Rules Defining RN Practice LAC46:XLVII" revealed, in part, "3703. Definition of Terms Applying to Nursing Practice ... Delegating Nursing Interventions - ... The registered nurse retains the accountability for the total nursing care of the individual. ... The registered nurse shall assess the patient care situation which encompasses the stability of the clinical environment and the clinical acuity of the patient, including the overall complexity of the patient's health care problems. The assessment shall be utilized to assist in determining which tasks may be delegated and the amount of supervision which will be required. a. Any situation where tasks are delegated should meet the following criteria: i. the person has been adequately trained for the task; ii. the person has demonstrated that the task has been learned; iii. the person can perform the task safely in the given nursing situation; iv. the patient's status is safe for the person to carry out the task; v. appropriate supervision is available during the task implementation; vi. the task is in an established policy of the nursing practice setting and the policy is written, recorded and available to all. b. The registered nurse may delegate to licensed practical nurses the major part of the nursing care needed by individuals in stable nursing situations, i.e. (that is), when the following three conditions prevail at the same time in a given situation: i. nursing care ordered and directed by R.N./M.D. (medical doctor) requires abilities based on a relatively fixed and limited body of scientific fact and can be performed by following a defined nursing procedure with minimal alteration, and responses of the individual to the nursing care are predictable; and ii. change in the patient's clinical conditions is predictable; and iii. medical and nursing orders are not subject to continuous change or complex modification..."

2) The RN on Unit C failed to obtain admit orders from the admitting psychiatrist as evidenced by Psychiatrist S8 relying on standing orders for admission:

Review of the "Admit Orders & (and) Preliminary TX (treatment) Plan" revealed a pre-printed form that included the following:
Patient allergies, height, and weight;
Legal status;
Admitting Diagnosis;
Immediate Goals;
"***If Labs That Are Needed Were Completed In ER (emergency room) With Documentation/Values No Need To Repeat";
List of diagnostic tests with a column for yes or no to be checked;
List of Consultations/Assessments with a column for yes or no with the yes column pre-checked;
Observation level with a choice of Level 1, Level 2, or Level 3;
Special Precautions with a block to check for fall precaution, withdrawals vital signs, and seizure precautions;
Blank labeled Other;
PRN medications with a column for yes or no for Tylenol, Mylanta, Motrin, and Milk of Magnesia;
Blank labeled Other PRN;
Blank labeled "Verbal/Telephone Order Read Back By Nurse Signature: Date: Time:"
Blank labeled "Noted By Nurse Signature: Date: Time:"

Review of Patient #1's admit orders revealed no documented evidence whether the orders were obtained verbally or by telephone by RN S23 from Psychiatrist S8 on 10/12/12 at 1930 (7:30pm).

Review of Patient #2's admit orders revealed no documented evidence whether the orders were obtained verbally or by telephone by RN S23 from Psychiatrist S8 on 09/12/12 at 2315 (11:15pm).

Review of Patient #5's admit orders revealed no documented evidence whether the orders were obtained verbally or by telephone by RN S13 from Psychiatrist S8 on 09/18/12 at 1420 (2:20pm).

In a face-to-face interview on 10/16/12 at 1:35pm, Psychiatrist S8 indicated that she was the psychiatrist who treated patients on Unit C. She further indicated that she used standing orders for admission, and the nurses knew that they could start a patient's home medications except narcotics and Benzodiazepines, for which they would have to call her for orders. S8 indicated that the nurses don't call her for admit orders, and they use the standing orders. She further indicated that the nurse in charge determined the observation level for the patient at the time of admit. S8 indicated that she was not aware that the RNs were documenting that the order was given verbally or by telephone when they were actually not calling her for orders.


In a face-to-face interview on 10/16/12 at 2:00pm, RN S9 indicated that when she admitted a patient to Unit C she would ask the patient for a list of the home medications and compare it to the list that was sent with the patient from the ED (emergency department). She further indicated that Psychiatrist S8 had the nurses use the admit orders as a standing order. S9 indicated that she looked at the intake packet, and if the patient had labs at the ED, she would not order the labs. S9 indicated that each patient was admitted as a Level 1 observation, and if she assessed a need for a greater observation level, she would use her nursing judgment and increase the level of observation. When asked, S9 confirmed that she would not call Psychiatrist S8 to increase the level of observation. S9 indicated that she documented the order as a verbal/telephone order when she actually did not call or speak to the physician to obtain the order. She further indicated that the only time she would call the physician would be if she had a question about medications or behaviors.


RNs S13 and S23 were not available to be interviewed during the survey.


Review of the hospital policy titled "Admission Procedure - On Unit", policy number NU.304, revised 04/25/10, and presented by Acting Administrator S6 as the current policy, revealed, in part, "... Admit orders should be obtained from attending physician prior to arrival on the unit..."


Review of the hospital's policy titled "Levels of Observation - Therapeutic Safety Measures", policy number NU.432, revised 05/01/12, and presented by Acting Administrator S6 as the current policy, revealed, in part, "...All patients admitted to the inpatient acute units are on Level 2 unless nursing or physician, assess need for lower/higher level..."


3) The RN failed to assess a patient's bowel status on a patient who did not have a bowel movement for 7 days which resulted in a patient not having a bowel movement for 7 days without intervention by the nursing staff:


Review of Patient #2's medical record revealed that she was a 20 year old female who was admitted on 09/12/12 with a diagnosis of Psychosis. Further review revealed that she was discharged on 09/24/12.


Review of Patient #2's admission orders received 09/12/12 at 2315 (11:15pm) revealed an order for Milk of Magnesia 30 cc (cubic centimeters) by mouth every 6 hours as needed for constipation, and if no relief, give Dulcolax 5 mg, 2 tablets, by mouth now and every 12 hours as needed. Further review revealed no documented evidence of the time interval to wait between the administration of Milk of Magnesia and the Dulcolax tablets. Further review revealed an order for Mylanta 30 cc by mouth every 4 hours as needed for gastric distress.


Review of Patient #2's "Vital Signs Log" revealed a column labeled BM (bowel movement) PRN. Further review revealed Patient #2 had a bowel movement on 09/11/12, 09/14/12, and 09/22/12 (8 days since the previous bowel movement).


Review of Patient #2's nurses' notes revealed she complained of her stomach hurting during the admit nursing assessment with no intervention by the RN. Further review revealed Patient #2 complained of her stomach hurting on 09/13/12 for which she was administered Mylanta. Further review revealed Patient #2 requested Prilosec for a stomach ache on 09/14/12 at 8:00pm, was told there was no physician order for Prilosec, and Maalox was administered. Review of the nurses' notes for 09/15/12 revealed Motrin was administered at 8:00am for complaints of "cramping" , and at 10:30am Patient #2's briefs were changed secondary to having an incontinent stool. Review of the entire medical record revealed no documented evidence of an assessment by a RN of Patient #2's bowel status, her complaints of her stomach hurting and having "cramping", and the absence of a bowel movement for 7 days.


In a face-to-face interview on 10/16/12 at 1:35pm, Psychiatrist S8 indicated that she would expect to be notified if a patient did not have a bowel movement for 3 to 4 days. She further indicated that she was not notified that Patient #2 had not had a bowel movement for 8 days (actually 7 days since Patient #2 had an incontinent stool on 09/15/12).


In a face-to-face interview on 10/16/12 at 2:00pm, RN S9 indicated that she didn't recall if she assessed Patient #2's elimination status by reviewing the documentation from the MHT. She further indicated that she was not aware when she was charge nurse on 09/20/12 that Patient #2 had not had a bowel movement since 09/14/12 (6 days).


Review of the hospital policy titled "Nursing Assessment", policy number NU.306, revised 05/13/09, and presented by Acting Administrator S6 as the current nursing assessment policy, revealed, in part, "...the R.N. will: ... 3. Reassess needs when patient's condition warrants in order to update the Treatment Plan".


Review of the Louisiana State Board of Nursing's Practice Act revealed, in part, "...Chapter 39. Legal Standards of Nursing Practice ?3901. Legal Standards A. The Louisiana State Board of Nursing recognizes that assessment, planning, intervention, evaluation, teaching, and supervision are the major responsibilities of the registered nurse in the practice of nursing..."


4) The RN failed to assess a patient for injury after the patient was hit by another patient:

Patient #4

Review of an "Alleged Incident / Accident Report" completed by RN S9 on 09/21/12 at 1400 (2:00pm) revealed Patient #4 (documented as peer #816 on the report) was struck by Patient #2 on the left arm. Review of Patient #4's medical record revealed no documented evidence that Patient #4 was assessed by a RN after she was struck.

In a face-to-face interview on 10/17/12 at 12:15pm, RN S18 indicated, after reviewing the medical record of Patient #4, that Patient #2 was on Unit C, and she (S18) worked on Unit A. She further indicated that she did not recall that Patient #4 was hit by another patient that day.

In a face-to-face interview on 10/17/12 at 12:30pm, LPN S19 indicated that she was responsible for Patient #4's observations on 09/21/12, and she did not recall her being hit by another patient.

Review of the discharge log for October 2012 for Unit C revealed no documented evidence that Patient #4 was on Unit C.

The hospital could not confirm by the end of the survey who "peer #816" was and did not present a medical record with a documented RN assessment after the patient was struck by Patient #2.


Patient #5

Review of an "Alleged Incident / Accident Report" completed by RN S9 on 09/21/12 at 1400 (2:00pm) revealed Patient #5 was struck in the face near her left eye by Patient #2. Further review revealed the incident report was completed for Patient #2, and there was no documented evidence of a completed incident report for Patient #5.

Review of Patient #5's medical record revealed no documented evidence that she was hit by Patient #2 and no documented evidence of a RN assessment for injury to the face and left eye.

In a face-to-face interview on 10/16/12 at 11:15am, Interim DON S3 indicated that when a patient was hit by another patient, there should be documentation of the occurrence in the chart of the patient who was hit. She further indicated that there should be an assessment for injury, but the assessment doesn't have to be performed by the RN. When asked if she was aware of the Louisiana State Board of Registered Nurse's Practice Act related to assessments, S3 indicated that the RN had to assess a patient every 24 hours. When informed that a RN had to assess a patient with a change in condition, S3 indicated the nurses have their license under which they practice. S3 confirmed that a patient being hit by another patient would be considered a change in condition.

In a face-to-face interview on 10/16/12 at 2:00pm, RN S9 confirmed that she did not document in Patient #5's medical record that she was hit by Patient #2 on 09/21/12. She further indicated that she did not perform a physical assessment of Patient #5 to determine if she had been injured. S9 indicated that she looked at Patient #5 and saw that she had no apparent injury.

Review of the hospital policy titled "Nursing Assessment", policy number NU.306, revised 05/13/09, and presented by Acting Administrator S6 as the current nursing assessment policy, revealed, in part, "...the R.N. will: ... 3. Reassess needs when patient's condition warrants in order to update the Treatment Plan".


5) The RN failed to evaluate the documentation of patient observations by the MHT to ensure that the ordered level of observation was maintained:


Patient #2

Review of Patient #2's medical record revealed that she was a 20 year old female who was admitted on 09/12/12 with a diagnosis of Psychosis. Further review revealed that she was discharged on 09/24/12.

Review of Patient #2's physician orders revealed she was placed on Level 1 observation at the time of admit. Further review revealed an order written by Psychiatrist S8 on 09/14/12, with no documented evidence of the time the order was written, to place Patient #2 on 1:1 observation for unpredictable behavior (nurse's note for 09/14/12 revealed S8 arrived at 12:00pm). Further review revealed a telephone order was received to change Patient #2's level of observation to level 2 on 09/15/12 at 9:40am. Further review revealed a telephone order was received to change Patient #2's level of observation to Level 3 (1:1) on 09/20/12 at 2:00pm.

Review of Patient #2's "Observation Log", which is documented by the staff member who conducted the observations, for 09/14/12 revealed her level of observation for the entire time from 12:00am to 11:45pm on 09/14/12 was Level 1. There was no documented evidence that Patient #2's level of observation was changed to Level 3 (1:1) on 09/14/12 at 12:00pm. Review of the "Observation Log" dated 09/15/12 revealed the observation level was "2 / 1:1". There was no documented evidence to determine when Patient #2 was on Level 2 observation and when she became a 1:1 observation (ordered 1:1 until 9:40am when she became a Level 2 observation). Review of Patient #2's "Observation Log" for 09/20/12 revealed her observation was "2 (with a line slashed through the number) 3". There was no documented evidence when she was on Level 2 and when she became 1:1 (ordered 1:1 at 2:00pm).


Patient #6

Review of Observation Logs for Patient #6 revealed an Observation Log dated 10/08/12 that reflected the precaution level ordered was "1/3". There was no documented evidence on the observation log to reflect when the patient's observation level was a "1" and when the patient's observation level was a "3".

In a face-to-face interview on 10/16/12 at 10:20am, Acting Administrator S6 indicated that her review of the chart revealed that the change to 1:1 observation on 09/14/12 at 12:00pm was not put on Patient #2's "Observation Log", so she was not assigned a MHT to observe her 1:1 from 2:15am to 9:40am.

In a face-to-face interview on 10/16/12 at 3:30pm, MHT S10 indicated that if a patient's level of observation changed during the shift, the nurse would let him know. He further indicated that they cross out the level and put the new level in the blank for "precaution ordered". He further indicated that the actual time that the observation level changed was not documented on the log.

In a face-to-face interview on 10/17/12 at 10:25am, MHT S14 indicated that she was never given instruction by a hospital staff member on how to document the change in a patient's level of observation on the observation log.

In a face-to-face interview on 10/17/12 at 2:15pm, Interim DON S3 indicated, after reviewing the medical records, that there was no way to determine the level of observation of the patient when the level was slashed through and a new number was written.

Review of the hospital's policy titled "Levels of Observation - Therapeutic Safety Measures", policy number NU.432, revised 05/01/12, and presented by Acting Administrator S6 as the current policy, revealed, in part, "...The RN is to assure that the observation sheets reflect each Level status with 15-minute checks. Documentation in the progress note should include Level of observation and reason..."


6) The RN failed to assess patients' vital signs as ordered by the physician:


Patient #1

Review of Patient #1's medical record revealed that she was a 24 year old female admitted on 10/12/12 at 7:30pm with a diagnosis of Major Depressive Disorder with Suicidal Ideations.

Review of Patient #1's physician admit orders revealed an order to take her vital signs every 8 hours for 72 hours then daily.

Review of Patient #1's "Vital Signs Log" revealed no documented evidence that Patient #1's vital signs were assessed on 10/13/12 at 3:30am and 11:30am, on 10/14/12 at 3:30am and 11:30am, and on 10/15/12 at 3:30am as ordered by the physician.

In a face-to-face interview on 10/15/12 at 12:10pm, RN S4 confirmed that Patient #1's vital signs were not assessed every 8 hours as ordered by the physician.
Patient #2

Review of Patient #2's medical record revealed that she was a 20 year old female who was admitted on 09/12/12 with a diagnosis of Psychosis. Further review revealed that she was discharged on 09/24/12.

Review of Patient #2's physician admit orders revealed an order to take her vital signs every 8 hours for 72 hours then daily.

Review of Patient #2's "Vital Signs Log" revealed no documented evidence that Patient #2's vital signs were assessed on 09/13/12 at 6:00am, 2:00pm, and 10:00pm, on 09/14/12 at 6:00am, 2:00pm, and 10:00pm, and 09/15/12 at 6:00am, 2:00pm, and 10:00pm as ordered by the physician.


Patient #3

Review of the medical record for Patient #3 revealed that the patient was admitted to the hospital on 10/10/12 with an admitting diagnosis of Psychosis.
Review of the Admit orders dated 10/10/12 at 2020 (8:20 pm) revealed an order for vital signs [every] 8 hours times 72 hours then daily. Review of the Vital Signs log revealed no documented evidence that the vital signs were assessed every 8 hours as ordered by the physician.
Patient #5


Review of Patient #5's medical record revealed that she was a 42 year old female admitted on 09/18/12 with diagnoses of Psychosis and Substance Abuse. Review of her admit orders revealed an order to assess vital signs every 8 hours for 72 hours then daily. Review of her "Vital Signs Log" revealed no documented evidence that her vital signs were assessed every 8 hours as ordered by the physician.

Patient #6

Review of the Admit Orders for Patient #6 revealed an order for vital signs every 8 hours times 72 hours then daily. Review of the Vital Signs log revealed no documented evidence that the vital signs were assessed every 8 hours as ordered by the physician.
In a face-to-face interview on 10/16/12 at 11:15am, Interim DON S3 indicated that she was not aware that the patients' vital signs were not being assessed every 8 hours. She confirmed that although the vital signs policy revealed that the vital signs should be taken three times a day, the nursing staff was to follow the orders of the physician and take them every 8 hours.
Review of the hospital's policy related to Vital Signs revealed, in part, "...It shall be the policy of this hospital that vital signs be taken "t.i.d." for the first three days of hospitalization and daily thereafter. A physician's order will always take precedence over the routine schedule for taking vital signs..."

Based on record reviews and interviews, the hospital failed to ensure:

1) the nursing staff developed a nursing care plan that included the patient's medical problems for 1 of 6 sampled patients (#2) and
2) the nursing staff implemented the physician's orders for labs for 3 of 6 sampled patients (#1, #2, #5).

Findings:


1) Nursing care plan that included the patient's medical problems:

Review of Patient #2's medical record revealed that she was a 20 year old female who was admitted on 09/12/12 with a diagnosis of Psychosis. Further review revealed that she was discharged on 09/24/12.

Review of Patient #2's admission orders received 09/12/12 at 2315 (11:15pm) revealed an order for Milk of Magnesia 30 cc (cubic centimeters) by mouth every 6 hours as needed for constipation, and if no relief, give Dulcolax 5 mg, 2 tablets, by mouth now and every 12 hours as needed. Further review revealed no documented evidence of the time interval to wait between the administration of Milk of Magnesia and the Dulcolax tablets. Further review revealed an order for Mylanta 30 cc by mouth every 4 hours as needed for gastric distress. Further review revealed a telephone order was received on 09/13/12 at 8:25am for Zofran 4 mg by mouth every 6 hours as needed for nausea or vomiting.

Review of Patient #2's "Vital Signs Log" revealed a column labeled BM (bowel movement) PRN. Patient #2 had a bowel movement on 09/11/12, 09/14/12, and 09/22/12 (8 days since the previous bowel movement).

Review of Patient #2's nurses' notes revealed she complained of her stomach hurting during the admit nursing assessment with no intervention by the RN. Patient #2 complained of her stomach hurting on 09/13/12 for which she was administered Mylanta. Patient #2 requested Prilosec for a stomach ache on 09/14/12 at 8:00pm, was told there was no physician order for Prilosec, and Maalox was administered. Review of the nurses' notes for 09/15/12 revealed Motrin was administered at 8:00am for complaints of "cramping" , and at 10:30am Patient #2's briefs were changed secondary to having an incontinent stool. Further review revealed that Patient #2 received Zofran by mouth on 09/13/12 at 8:30am, 09/14/12 at 6:35pm, 09/16/12 at 11:20am, 09/20/12 at 6:25pm, and 09/23/12 at 10:00am for complaints of nausea or vomiting.

Review of Patient #2's "Interdisciplinary Treatment Plan" revealed no documented evidence that her medical problems of nausea, vomiting, and stomach pain were incorporated into her treatment plan.

In a face-to-face interview on 10/16/12 at 11:15am, Interim Director of Nursing (DON) S3 indicated that patients' medical problems should be included in their treatment plan.

Review of the packet presented by Acting Administrator S6 when asked for the policy on the nursing care plan revealed a blank "Interdisciplinary Treatment Plan" was presented that included the list of problems to be identified that included "constipation; perceived/risk". There was no documented evidence of the procedure for completing the treatment plan that addressed including the patient's medical problems.


2) Physician's orders for labs:


Patient #1
Review of Patient #1's medical record revealed that she was a 24 year old female admitted on 10/12/12 at 7:30pm with a diagnosis of Major Depressive Disorder with Suicidal Ideations. Review of the admit orders dated 10/12/12 at 2315 (11:15pm) revealed an order to obtain a serum pregnancy test, RPR (rapid plasma reagin), T4 (thyroid) and TSH (thyroid stimulating hormone), and a TB (tuberculosis) test.

Review of Patient #1's medical record revealed her TB test was administered on 10/14/12 (2 days after it was ordered), and her lab test were drawn on 10/14/12 (2 days after they were ordered).

In a face-to-face interview on 10/15/12 at 12:10pm, RN (registered nurse) S4 confirmed that there was a delay in administering the TB test and drawing the lab specimen, that both should have been done on 10/13/12. She further indicated that if there was a delay in the TB test and lab draws, the nurse should have documented the reason in the nurse's notes. After reviewing the medical record, S4 indicated there was no documented evidence for the reason in the delay.


Patient #2
Review of Patient #2's medical record revealed that she was a 20 year old female who was admitted on 09/12/12 with a diagnosis of Psychosis. Further review revealed that she was discharged on 09/24/12. Review of the admit orders dated 09/12/12 at 2315 (11:15pm) revealed an order for a TB test and to draw a serum pregnancy test, RPR, and T4. and TSH.

Review of Patient #2's medical record revealed no documented evidence of the results of the serum pregnancy test, RPR, T4, and TSH and whether the labs were drawn.

In a face-to-face interview on 10/16/12 at 2:50pm, Interim DON S3 presented a copy of the lab results that were faxed to the hospital on 10/16/12. She could offer no explanation for the lab results not being on the chart.


Patient #5
Review of Patient #5's medical record revealed that she was a 42 year old female admitted on 09/18/12 with diagnoses of Psychosis and Substance Abuse. Review of the admit orders dated 09/18/12 at 1420 (2:20pm) revealed an order for a serum pregnancy test, RPR, and a TB test.

Review of Patient #5's medical record revealed no documented evidence of the lab results and whether or not the labs were drawn.

In a face-to-face interview on 10/16/12 at 11:15am, Interim DON S3 indicated that labs were drawn at the hospital and transported to the acute care hospital lab for testing. She further indicated that the acute care hospital would fax the results within 24 hours, and the night nurse would check for lab results and follow-up with the acute care hospital if the lab results had not been received. She confirmed that there evidently was a problem with the process, since the patients lab results were not on 2 of the 6 sampled patients' charts reviewed.

In a face-to-face interview on 10/17/12 at 4:10pm, Interim DON S3 indicated that the lab did not have results for Patient #5.

Based on record reviews and interviews, the hospital failed to ensure that the RN (registered nurse) assigned the nursing care of each patient to nursing personnel who had been assessed for competency and met the qualifications of their job description for 1 of 4 RNs' personnel files reviewed from a total of 21 RNs (S9), 3 of 3 LPNs' (licensed practical nurse) personnel files reviewed from a total of 20 LPNs (S11, S12, S20), and 2 of 3 MHTs' (mental health tech) personnel files reviewed from a total of 57 MHTs (S14, S15).

Findings:

RN S9
Review of RN S9's personnel file revealed she was hired on 02/05/10. Further review revealed no documented evidence that S9 was assessed for competency prior to performing care for psychiatric patients.


LPN S11
Review of LPN S11's personnel file revealed that she was hired on 02/13/12. The LPN job description required 1 year of nursing experience and 1 year of psychiatric experience. Review of S11's application revealed that she was employed as a CNA (certified nursing assistant) prior to being hired as a LPN. Further review revealed no documented evidence of orientation to the LPN job duties and an assessment of competency prior to S11 being assigned patient care.

In a face-to-face interview on 10/16/12 at 3:45pm, LPN S11 indicated that she graduated from LPN school in December 2011, and this was her first employment as a LPN. She confirmed that she did not have 1 year of nursing or psychiatric experience prior to being hired.


LPN S12
Review of LPN S12's personnel file revealed that she was hired on 10/06/11. The LPN job description required current competency in CPI (crisis prevention intervention). Review of S12's personnel file revealed that her CPI certification had expired on 01/31/12.


LPN S20
Review of LPN S20's personnel file revealed that she was hired on 05/02/12. Further review revealed no documented evidence of orientation to the LPN job duties and an assessment of competency prior to S20 being assigned patient care.


MHT S14
Review of MHT S14's personnel file revealed that she was hired on 03/22/12. Further review revealed no documented evidence of an assessment of competency prior to S14 being assigned patient care.


MHT S15
Review of MHT S15's personnel file revealed that she was hired on 06/27/12. Further review revealed no documented evidence of an assessment of competency prior to S15 being assigned to patient care. Further review revealed S15 signed that she had been trained on proper hand washing, proper contraband search, and the proper procedure for reporting a patient complaint or grievance, and there was no documented evidence that the respective instructor had signed and dated that he/she had performed the instruction and confirmed S15's competency.

In a face-to-face interview on 10/17/12 at 2:15pm, Interim Director of Nursing (DON) S3 indicated that competency assessment was done annually and was not done at the time of hire or prior to assigning the staff member to patient care. When re-asked if she meant that the staff were assessed for competency annually and not at the time of orientation and prior to assigning the staff member to patient care, S3 again indicated that competency assessment was done annually. S3 indicated that the employee signed that they were comfortable with and understood the skill, and the person who signed off was saying that they've explained the procedure, and the employee was capable of doing it. S3 confirmed that LPN S11 did not meet the job description qualifications to have been hired and that LPN S12's CPI certification had expired.