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Based on record review and interview, the hospital failed to ensure that each patient received care in a safe setting. The hospital failed to protect vulnerable psychiatric patients from Patient #F7 who exhibited unpredictable, unexpected physical aggression toward peers for 1 (#F4) of 7 sampled patients, and 1 (#FR1) of 1 random sampled patient. This resulted in Patient #F7 hitting Patient #F4 on 12/06/12, requiring Patient #F4 to be transferred to the emergency department, and Patient #F7 hitting Patient #FR1 on 12/08/12 and on 12/09/12. Findings:

Review of the hospital policy titled, "Inter-Disciplinary Treatment Planning-Overview", policy number NU.706, revised 11/27/12, and verified as current by Administrator SF1, revealed in part, "...The treatment planning process is continuous, beginning at the time of admission and continuing through discharge. Any psychiatric and/or medical problems that occur throughout their stay must be included in the interdisciplinary treatment plan....In order to determine the effectiveness of the master treatment plan, weekly reviews are done by the interdisciplinary team. This review will provide valuable information about client progress, need for continued treatment, revision of interventions as well as discharge planning...

Review of the hospital policy titled, "Levels of Observation -Therapeutic Safety Measures", policy number NU.432, revised 11/27/12, and verified as current policy by Administrator SF1, revealed in part, "....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....The RN assures levels of observation are placed on the patient's treatment plan and report sheet and notifies the Director of Nursing for adequate staffing....


Review of the Patient #F7's medical record revealed the patient was a 26 year old male who was admitted on 12/06/12 with diagnoses of Acute Exacerbation of Chronic Schizophrenia, Paranoid type, and Cocaine and THC (Marijuana) abuse. The record revealed the patient was admitted under a PEC (Physician Emergency Certificate) dated/timed 12/05/12 at 10:45 p.m. with Bipolar Disorder, non-compliant, and threatening family. The PEC also revealed the patient was violent, and was in need of immediate psychiatric treatment in a facility because he was gravely disabled and unwilling to seek voluntary admission. Review of the CEC (Coroner's Emergency Certificate) dated/timed 12/06/12 at 7:54 p.m. revealed the patient was in need of immediate psychiatric treatment in a facility due to he was dangerous to others, was gravely disabled, and unable to seek voluntary admission.

Review of Patient #F7's medical record revealed the following occurrences of physical aggression toward peers:
12/06/12 at 7:45 a.m. - Pt. (Patient) standing at counter of nurse's station. Oriented X3 (Person, Place, Time), yet responding to internal stimuli. No eye contact. Pt. agitated, and attacked other client in milieu. Pt. punched other client in right front side of head. Further review of the record revealed the patient was placed in seclusion, increased to 1:1 observation, and given an injection of Ativan 2 mg., Haldol 5 mg., Benadryl 50 mg. The patient was transferred to another unit in the hospital at 12:15 p.m. (Patient on Level 2 observation at time of this incident - Level 2 requires patient to be in visual line of sight during the day and night and every 15 minute observation documented).

12/08/12 at (no time documented) - Amb. (Ambulating) in NAD (No acute distress), eating and sleeping well, c/o (complained of) male peer wanting to have sex with him and raising his shirt in front of him as reason for punching male peer-he sustained no injury during physical altercation. 12:30 medicated with PRN (As needed) injection of Haldol 5 mg., Ativan 2 mg., and Benadryl 50 mg. with effectiveness. Further review of the record revealed no new interventions were identified or implemented to protect other patients from Patient #F7 after this second incident of hitting another peer (Patient was on Level 3 observation at the time of this incident - Level 3 requires one to one nursing care with a staff member assigned to be in arm's length of patient at all times).

12/09/12 at (no time documented) - Attacked male peer whom he thinks wants to have sex with him-slapped male peer's head-this happened suddenly while 1:1 with patient-no provocation noted by male peer; medicated with injection of Haldol 5 mg., Ativan 2 mg., and Benadryl 50 mg. with effectiveness-on 1:1, Dr. ( Psychiatrist SF17) gave new orders. Further review of the record revealed a 15 foot restriction from other patients was ordered (Patient was Level 3 observation status when this incident occurred).

Review of the hospital's Alleged Incident/Accident Report dated 12/06/12 at 7:45 a.m., revealed, "Patient #F7 was standing next to Patient #4 and spontaneously starting punching Patient #F4 to chest, back and head. Patient was responding to internal stimuli, appeared to be acting on hallucinations." Further review of the incident/accident reports revealed Patient #F4 was transported to Hospital A for evaluation. Review of the follow up documented on the incident report revealed x-rays were negative and the final outcome was the patient was transferred to another unit. The follow up also revealed a problem was identified as staff intervention was delayed.

Review of the hospital's Alleged Incident/Accident Report dated 12/08/12 at 1:00 p.m., signed by RN SF5 revealed, "Patient #F7 stated that male peer was raising his shirt in front of him indicating that he wanted to have sex with him, states male peer threw 1st blow and he fought back punching male peer; no injury noted." Review of the follow up to the incident revealed, "Action Taken: This patient placed on 1:1. The other patient to maintain 15 feet distance. Follow up: close monitoring to maintain distance. Was there a problem identified: Yes, patient continues with auditory hallucinations. Corrective Plan: Placed on a 1:1." The follow up section was signed by the Director of Nursing, SF2. Further review of the hospital's Alleged Incident/Accident Reports revealed Patient #FR1 was hit by Patient #F7 on 12/08/12 and sustained a small superficial laceration to his left hand. The report indicated the altercation was witnessed by staff and the altercation was unprovoked by Patient #FR1.

Review of the hospital's Alleged Incident/Accident Report dated 12/09/12 at 5:00 p.m., signed by RN SF5 revealed, "Patient #F7 attacked Male peer slapping him on his forehead; accused male peer of raising his shirt to him, in a seductive manner; this behavior was not observed by staff witness; no injury noted (male peer did not provoke patient)." Review of the follow up to the incident revealed, "Action taken: Place this patient on 1:1. Distance of 15 feet to separate patient. Follow Up: Maintain close supervision. Was there a problem identified: Yes, this patient attacked other patient without provocation. Corrective Plan: Maintain on 1:1 and keep 15 feet distance." The follow up section was signed by the Director of Nursing, SF2. Further review of the hospital's Alleged Incident/Accident Reports revealed Patient #FR1 was slapped on his forehead by Patient #F7 on 12/09/12, with no injury.

Review of Patient #F7's admit orders dated/timed 12/06/12 at 4:15 a.m. revealed the ordered level of observation was Level 2 (The patient must be in visual line of sight during the day and night. Patient must be documented on every 15 minutes on flow sheet).
There was no documented evidence of any medications orders on admit.
Review of the orders revealed Psychiatrist SF18 ordered Patient #F7 on locked seclusion and, "Haldol 5 mg., Ativan 2 mg., Benadryl 50 mg. IM or PO (Injection or by mouth) every 6 hours PRN (As needed) severe agitation, one dose now" on 12/06/12 at 7:45 a.m.
At 8:00 a.m. SF18 ordered observation level change to 1:1 status (Staff member assigned to a patient in constant attendance at arm's length at all times) until further evaluation. Review of the physician orders revealed locked seclusion was discontinued at 11:00 a.m. on 12/06/12, and at 11:30 a.m., maintain level 3 (1:1) observation was ordered.
On 12/09/12 at 5:15 p.m. a verbal order was documented from Psychiatrist SF17 to, "Restrict patient to unit, patient must stay 15 feet away from other patients." Further review revealed Patient #F7 remained on 1:1 observation until his discharge on 12/14/12.

Review of Patient #F7's "Interdisciplinary Treatment Plan" initiated on 12/06/12 revealed Problem #3 was "Risk for Other/Self Directed Violence, as evidenced by: Patient altercation another patient, Related to: Ineffective coping." Further review revealed the short term objectives were that Patient #F7 would make no attempt to harm self or others and would respond to staff direction and efforts to decrease agitation with a target date of 12/16/12.

Review of the Staff interventions revealed the physician would monitor medication and physiological aspects of disruption/agitation and provide for interventions to address it, and nursing would assure safe and therapeutic environment, providing precautions if needed as well as supportive measures every shift. Further review revealed no documented evidence the treatment plan was reviewed weekly as required by hospital policy and revised to include changes in level of observation, use of seclusion, and distance restrictions from other patients. There was no documented evidence the interventions were revised when Patient #F7's behaviors revealed he was not meeting short term objectives.

In a face-to-face interview on 12/18/12 at 9:25 a.m., RN SF7 verified she was assigned to Patient #F7 on 12/06/12 for the 7:00 a.m. to 7:00 p.m. shift. RN SF7 stated she did not see the altercation between Patient #F7 and #F4 as she was coming out of shift change report when the altercations occurred on 12/06/12. After reviewing the Interdisciplinary Treatment Plan, RN SF7 verified the treatment plan was not revised with the change in observation status, use of seclusion, distance restrictions and did not include the patient's physical attacks on other patients. RN SF7 stated, "I would love to update treatment plans, but I am the eyes and ears on 20 patients all day." RN SF7 stated she had concerns with staffing and safety. RN SF7 stated on 12/06/12 there were 2 MHTs assigned to the unit for 7:00 a.m. to 7:00 p.m. and both MHTs were small ladies. RN SF7 stated Patient #F7 was at least 6 foot 4 inches tall and 200 pounds. RN SF7 stated she had to quickly move Patient #F7 to another unit and did not have time to update the treatment plan.

In a face-to-face interview on 12/18/12 at 2:45 p.m. SF5RN verified she was assigned to Patient #F7 on 12/08/12 and 12/09/12 and witnessed the altercations between Patient #F7 and Patient #FR1. RN SF5 stated both incidents were unprovoked by Patient #FR1. After reviewing the "Alleged Incident/Accident Reports" for Patient #F7, RN SF5 verified the follow up documentation was inaccurate. RN SF5 stated the 15 foot distance restriction was not implemented until after Patient #F7 hit Patient #FR1 the second time (12/09/12). RN SF5 verified Patient #F7 was already on 1:1 observation status when he hit Patient #FR1 the first time (12/08/12).
After reviewing the Interdisciplinary Treatment Plan for Patient #F7, RN SF5 verified there were no new interventions identified or implemented to protect other patients from Patient #F7 after Patient #F7 hit Patient #FR1 on 12/08/12. RN SF5 further stated that when Patient #F7 hit Patient #FR1 on 12/08/12, the patients on the unit were lined up to go to lunch and the MHT was following Patient #F7. RN SF5 stated the altercation happened fast, and was unpredictable. RN SF5 stated on 12/09/12, the patients were on the unit and it looked like Patient #F7 was going to join the group. RN SF5 stated the MHT was on the left side of Patient #F7 and other patients (including Patient #FR1) were on the right side of Patient #F7. RN SF5 indicated the altercation could possibly have been prevented if the MHT had positioned him/herself on the side between Patient #F7 and the other patients.

In a face-to-face interview on 12/18/12 at 4:20 p.m. the Director of Nursing, SF2 verified she had reviewed all 3 Alleged Incident/Accident reports of Patient #F7 hitting other patients. When asked to explain "Staff Intervention Delayed" documented on the incident report dated 12/06/12, she stated the staff reported to her that the staff had a slow response to the altercation. After reviewing the patient's record including physician's orders and treatment plan, DON SF2 verified the follow up documented on the incident report dated 12/08/12 was inaccurate since the patient was already on 1:1 observation and the 15 foot distance restriction was not ordered until 12/09/12. DON SF2 verified the treatment plan was not revised after the patient's observation level change, after the patient was placed in seclusion, and after the patient continued to be physically aggressive toward other patients.





25065

Based on observations, record reviews, and interviews, the hospital failed to ensure the number of mental health techs (MHTs) assigned to Unit C were able to observe patients according to the physician-ordered level of observation and hospital policy for 17 twelve-hour shifts on 11 of 14 days of assignment sheets reviewed from 12/02/12 through 12/15/12. The room placement of the patients on level 2 observation (for which hospital policy required constant visual observation of the patient day and night) and the total number of level 2 observation patients and level 1 observation patients (required to be checked every 15 minutes day and night) assigned to each MHT did not allow the observations to be performed according to the physician's order and the hospital's policy for patient observations. Findings:

Review of the hospital policy titled, "Levels of Observation -Therapeutic Safety Measures", policy number NU.432, revised 11/27/12, and verified as current policy by Administrator SF1, revealed in part, "....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. g. One MHT can only be assigned maximum of 4 Level 2s at any given time. h. During hours of sleep staff members will be strategically located outside patient rooms to ensure patients are monitored every five minutes. 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....The RN assures levels of observation are placed on the patient's treatment plan and report sheet and notifies the Director of Nursing for adequate staffing....

Observation of the room placement on Unit C on 12/18/12 at 11:55am with Administrator SF1 present revealed the room was an open space with patient rooms on each side with 2 beds in each room (bed nearest the door was bed "a" and the bed nearest the window was bed "b"). Further observation revealed when entering the unit, the left wall included Rooms "Fa", "Fb", "Fc", "Fd", "Fe", and "Ff", and the right wall included Rooms "Fk", "Fj , "Fi", "Fh", and "Fg". There was a seating area in the center on each end and the nursing station was located in the center of the opening. Further observation of what part of the patient's bed could be seen when standing or seated outside the door to the room revealed the following:
Rooms "Fa", "Fb", "Fc", "Fd", "Fe", "Fi", "Fj" - only the feet of the patient in bed "a" would be visible; the entire patient in bed "b" could be seen;
Rooms "Ff", "Fg", "Fh" - cannot see head of patient in either bed.
Observation revealed that when seated in the nursing station, there is no visibility into any patient room.

Review of the staffing assignment sheets presented as the staffing assignments made for Unit C from 12/02/12 through 12/15/12 by Director of Nursing (DON) SF2 revealed 17 shifts from 12/05/12 through 12/15/12 that the MHTs were assigned from 2 to 6 patients who were on Level 2 observation that required constant visual observation at all times during the day and night while also being assigned to observe 1 to 4 patients on Level 1 observation that required that the patient be observed every 15 minutes. Further observation revealed that a MHT was assigned more than 4 patients on Level 2 observation (policy allowed 1 MHT to observe 4 patients on Level 2 observation) on the following days:
12/10/12 day shift - 1 MHT with 6 patients on Level 2 and 1 MHT with 5 patients on Level 2;
12/10/12 night shift - 1 MHT with 6 patients on Level 2;
12/14/12 night shift - 1 MHT with 6 patients on Level 2;
12/15/12 day shift - 1 MHT with 5 patients on Level 2.

In a face-to-face interview on 12/18/12 at 7:50am, RN (registered nurse) SF4 indicated that she was uncomfortable with the staffing assignments and the ability to provide for patient safety on Unit C. She further indicated that she had been "pressured" to change the acuity of a patient's level of observation based on staffing needs. RN SF4 indicated that just recently DON SF2 had told her that she needed to change 2 of her patients who were on Level 2 observation to a Level 1 observation, because she (DON SF2) needed 1 of the MHTs on Unit C to accompany a patient from another unit to the hospital when she (DON SF2) couldn't get additional staff. She (RN SF4) further indicated that this left her with 1 LPN (Licensed Practical Nurse) and a female MHT with 20 patients on Unit C. RN SF4 indicated that she received the call about 6:15am (shift ended at 7:15am) and was told to immediately make the change. She further indicated that there was no patient on Unit C who met the criteria to be changed to a Level 1 observation at the time. RN SF4 indicated that she needed a physician's order to change a patient's level of observation, but she didn't have time to call the physician, so she wrote a verbal order for the change but did not call the physician. She further indicated that she relayed the information to the oncoming RN who was relieving her. RN SF4 indicated that she was told that the MHT could have 4 patients on Level 2 and could keep the patients' doors open and check on the patient every 5 minutes. She further indicated that if the MHT heard a patient go to the bathroom, the MHT would stand outside the bathroom door. RN SF4 indicated that she had never read the observation level policy for Level 2. RN SF4 indicated that sometimes the MHT who was assigned 4 patients on Level 2 would get in the nursing station to observe patients near the station, and if the patients were in the wings off the nursing station, the MHT may sit in a chair near the patients' room to have "easy access to the room". RN SF4 indicated that it was not possible to observe Room "Fe" and Room "Fj" at the same time (after reviewing the assignment of MHTs and room locations of patients).

In a face-to-face interview on 12/18/12 at 9:20am, RN SF7 indicated that she considered there were safety issues with the present staffing assignments. She further indicated that on the day shift on 12/16/12 Unit C had 20 patients. She further indicated that 1 patient was one-to-one with a MHT, and there were 12 patients on Level 2 observations and 7 patients on Level 1 observation with 2 MHTs for the 19 patients. She further indicated that with 12 patients on Level 2 observation, there was no way that 2 MHTs could have continuous visual contact for 12 patients at all times. RN SF7 indicated that Level 2 patients should be observed even when they go to the bathroom, but the MHTs do not go into the bathroom with the patients. She further indicated that the patients go to the cafeteria with the MHTs (have to go through a locked door), and the RN and LPN remained on the unit with the patients on unit restrictions. RN SF7 indicated that sometimes they were left with 3 or 4 patients who need to monitored closely for behavioral issues, and this situation "sets you up for failure". RN SF7 indicated that she had expressed her concerns on numerous occasions to DON SF2, and her response from DON SF2 was "what do you want me to do about it". RN SF7 indicated that she was injured during a patient altercation on 12/07/12. RN SF7 indicated that she had worked at the hospital for 2 ? years, and she had been relieved 3 times in that period for lunch breaks, but she was docked each day for a lunch break. RN SF7 indicated that the staffing assignment sheets were completed by the Charge Nurse, and then an administrative person may ask to have a patient assessed to change the level of observation to accommodate staffing. She further indicated that she never changed a patient's level of observation if she didn't feel it was warranted, but then she was met with discontent from administration.

In a face-to-face interview on 12/18/12 at 10:40am, RN SF8 indicated that the biggest problem for Unit C was the staffing grid.. He further indicated that having 2 MHTs for 20 patients didn't allow the patients to be observed according to the physician orders and hospital policy. He further indicated that he had been asked by DON SF2 to change a patient's level of observation to accommodate staffing.

In a telephone interview on 12/18/12 at 11:10am, MHT SF10 indicated that patients were "scattered about the unit" on the night shift. He further indicated that when he had patients on Level 2 observation, there was no sitting down, he had to go back and forth every 5 minutes. MHT SF10 indicated that the MHT was supposed to never leave the patient's door, because the patient was supposed to be seen at all times, but he can't see all Level 2 patients at the same time. He further indicated "that's impossible". MHT SF10 indicated that when a patient went to the bathroom, he didn't go in the bathroom with the patient, because sometimes he observed female and male patients at the same time. He further indicated that he didn't go in the bathroom with the male patients, because "that's an invasion of privacy". MHT SF10 indicated that if a patient was in the bathroom for a long time, he would knock on the door and ask if everything was o.k.

In a telephone interview on 12/18/12 at 11:25am, MHT SF9 indicated that patients on Level 2 observation have to be in eyesight of the MHT at all times. She further indicated that when she was assigned patients in Rooms "Fj", "Fa", and "Fb" at the same time, she sat in the milieu and could see into Rooms "Fj" and "Fb" , but she had to get up to see in Room "Fa". She confirmed that the patient in Room "Fa" was not in her vision at all times.

In a face-to-face interview on 12/18/12 at 4:15pm with Administrator SF1, DON SF2, and Vice-President of Operations SF3 present, DON SF2 indicated that she had never asked a RN to change a patient's observation level to accommodate staffing. When informed of the observation of the room placement on Unit C in relation to the staffing assignment of the MHTs' observation of patients revealing no possibility of meeting the physician's ordered observation and hospital policy, Vice-President of Operations SF3 indicated that someone should look at that. She further indicated that she relied on the nurse to make sure that it was feasible. When asked if anyone in management had looked at the actual assignments made for the observation of 20 patients by 2 MHTs, DON SF2 indicated that they want the patients in the milieu and not in their rooms during the day. When asked again if management had looked at the assignments in relation to the room locations and the use of 2 MHTs to provide the observations, Vice-President of Operations SF3 indicated that management needed to look at the number of MHTs assigned. It was confirmed that no one in management had identified that the room placement along with the number of patients on Level 2 observation did not allow for patients to be observed as ordered by the physician and by hospital policy on Unit C.

Based on interviews, the hospital failed to ensure a registered nurse (RN) was on duty on Unit C for 24 hours a day, 7 days a week. Findings:

Review of the hospital policy titled "Plan for providing Nursing Care", policy number NU.104, revised 04/26/12, and presented by Administrator SF1 on 12/18/12 at 2:15pm as the current policy, revealed that a registered nurse defined, directed, supervised, evaluated, planned, delegated, and coordinated the nursing care of each patient. Further review revealed that each functional area was to be staffed by at least one registered nurse per shift.

In a face-to-face interview on 12/18/12 at 9:20am, RN SF7 indicated that the staff bathroom for Unit C was located off the unit through a locked door. She further indicated that if the RN went off the unit to use the bathroom rather than use the patient bathroom in the anteroom of the seclusion room, no RN was present on Unit C during this time.

In a face-to-face interview on 12/18/12 at 10:40am, RN SF8 indicated the RN and MHT (mental health tech) from Unit C had to come to the front of the hospital (off the unit through 2 locked doors) when a new admit arrived. He further indicated that the purpose of this was to take the patient's vital signs, check medical problems, and perform body searches before taking the patient to the Unit. RN SF8 indicated that when this occurred, there was no RN on Unit C.

In a face-to-face interview on 12/18/12 at 4:15pm with Administrator SF1, Director of Nursing (DON) SF2, and Vice-President of Operations SF3 present, DON SF2 indicated that when she was available, she would relieve the RN on Unit C for a bathroom break. She further indicated that sometimes the social worker would relieve the RN for a break, since the LPN (licensed practical nurse) was present on the Unit. DON SF2 confirmed that the RN had to leave Unit C without a RN present on the Unit when he/she (RN) went to the front of the hospital to receive and escort a newly admitted patient to Unit C.

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 pain and muscle spasms for 2 of 2 patients requiring PRN medications from a total sample of 7 patients (#F2, #F4).

2) The RN failed to assess a patient for injury after the patient was hit by another patient for 1 of 2 patients' records reviewed who had been hit by another patient from a total sample of 7 patients and 1 random patient (#F4).

3) 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 4 of 4 patients' records reviewed for MHT documentation of patient observations from a total of 7 sampled patients (#F2, #F4, #F5, #F6).

Findings:

1) Assess a change in the patient's condition prior to PRN medication:

Review of the hospital policy titled, "Nursing Assessment", policy number NU.306, revised 11/27/12 and verified as current by the Administrator SF1, revealed in part the following: "I. Purpose: To define the process to identify patient needs and/or problems as assessed by the R.N....F. Nursing reassessment is completed in the form of a narrative in the nurse's progress note by the R.N....2. A nursing reassessment must be completed by the RN in the event of an injury or significant change in patient's condition at the time of the injury or change in condition. This reassessment could be a full reassessment of the patient or a reassessment of specific systems related to the patients injury or change in condition. 3. A nursing reassessment must be documented prior to any PRN medication or agitation. Another reassessment must be completed and documented within thirty (30) to sixty (60) minutes regarding status of the patient.

Patient #F2
Review of the Patient #F2's medical record revealed the patient was a 29 year old female who was admitted on 12/05/12 with a diagnosis of Major Depressive Disorder. The patient's medical diagnoses included Insulin Dependent Diabetes Mellitus and Diabetic Retinopathy (Blindness). Patient #F2 was a currently a patient in Room "g".

Review of the Patient #F2's physician orders dated/timed 12/05/12 at 10:58 p.m. revealed the Lortab 10/500 mg. 1 tablet by mouth every 6 hours as needed for pain, was changed to Norco 10/325 mg. 1 tablet by mouth as needed for pain.

Review of the Interdisciplinary Progress notes revealed the following:
12/06/12 at 8:50 a.m. Norco 10 given PO (by mouth) for complaint of bilateral lower extremity pain, states, "I always have leg pain." Rates 9/10 on pain scale. Charge Nurse (RN SF7) aware. Will continue to monitor. Signed by LPN SF14 (Licensed Practical Nurse).
"Agree with above assessment." Signed by RN SF7.

12/06/12 at 9:30 a.m. Patient voices no further complaint of leg pain at this time, resting quietly in room. NADN (No acute distress noted). Signed by LPN SF14.
"Agree with above assessment." Signed by RN SF7.

12/06/12 at 2:50 p.m. Norco 10 given by mouth for complaint of bilateral lower extremity pain, states "my legs have really started hurting again." Charge Nurse (RN SF7) aware. Will continue to monitor. Signed by LPN SF14.
"Agree with above assessment." Signed by RN SF7.

12/06/12 at 3:20 p.m. Patient voices no further complain of leg pain at this time, resting quietly in room. NADN. Signed by LPN SF14.
"Agree with above assessment." Signed by RN SF7.

There was no documented evidence of an assessment by the RN before the PRN medication was administered and there was no documented evidence of a re-assessment by the RN within 30 - 60 minutes according to hospital policy.

Patient #F4
Review of Patient #F4's medical record revealed that he was a 43 year old male admitted on 12/05/12 with a diagnosis of depression, and was a current patient. Review of his H&P (history and physical) documented on 12/06/12 revealed diagnoses of suicidal ideations, substance abuse, auditory hallucinations, insomnia, and hypertension.

Review of Patient #F4's physician orders revealed an order on 12/05/12 at 11:15pm for Ultram 50 mg (milligrams) by mouth three times a day. Further review revealed an order on 12/06/12 at 10:50am for Motrin 800 mg by mouth three times a day and Flexeril 10 mg by mouth at bedtime PRN (as needed) for muscle spasms. Further review revealed a physician order on 12/06/12 at 11:10am to discontinue Motrin 800 mg by mouth three times a day since Patient #F4 was taking Ultram 50 mg by mouth three times a day.

Review of Patient #F4's "Interdisciplinary Progress Note" revealed that LPN (licensed practical nurse) SF14 administered Motrin 400 mg by mouth on 12/06/12 at 6:30pm for complaints of neck and back pain. Further review revealed documentation by LPN SF14 that RN SF7 was aware with no documented evidence of what information SF7 was aware. There was no documented evidence that RN SF7 assessed Patient #F4's complaints of neck and back pain prior to Motrin being administered, and there was no documented evidence of an order for Motrin (order had been discontinued at 11:10am).

In a face-to-face interview on 12/18/12 at 9:50am, RN SF7 indicated that she was told to document that she was aware and agreed with the LPN's assessment. She further indicated that the LPNs had always done the assessment of the patient when PRN medications were administered. SF7 indicated that there was "too much gray area" when the LPN assessed the patient, and the RN documented that she/he agreed with the assessment.

Review of Patient #F4's "Interdisciplinary Progress Note" revealed that LPN SF14 administered Vistaril 50 mg by mouth for complaints of anxiety on 12/14/12 at 8:25am, and Charge RN SF15 was aware. There was no documented evidence that RN SF15 assessed Patient #F4's complaints of anxiety prior to Vistaril being administered.

In a face-to-face interview on 12/18/12 at 4:15pm, Director of Nursing (DON) SF2 indicated that the RNs had been told that they needed to assess the patient before the LPN administered a PRN medication.


2) Assess a patient for injury after the patient was hit by another patient:

Review of the hospital policy titled "Medical Emergency Procedures", policy number NU.604, revised 05/01/10, and presented as the current policy for head injury assessment by Administrator SF1 on 12/18/12 at 2:15pm, revealed that head injury was one of the listed medical emergencies for which emergency care could be provided by hospital employees. Further review revealed that the responsible staff members included the Director of Nursing, Charge Nurse, and other staff as assigned. Further review revealed the procedure for head injury included the following: take vital signs (pulse, blood pressure, respirations); use neurological flow sheets to monitor the patient's mental/neuro status; check pupillary response to light and accommodation; assess level of consciousness; assess for visible injury and take necessary action; transport to Hospital A via ambulance when appropriate; and document the event on an Occurrence Report and on the patient's chart. Review of the attached "Neuro Vital Signs" form revealed the following assessment was required at 15 minute interval for 1 hour, 30 minutes times 2, hourly times 3, and every 4 hours times 5: level of consciousness, movement, hand grasps, pupil size, pupil reaction, speech, blood pressure, temperature, pulse, respirations.

Patient #F4
Review of Patient #F4's medical record revealed that he was a 43 year old male admitted on 12/05/12 with a diagnosis of depression, and was a current patient. Review of his H&P (history and physical) documented on 12/06/12 revealed diagnoses of suicidal ideations, substance abuse, auditory hallucinations, insomnia, and hypertension.

Review of Patient #F4's medical record revealed that he sustained a punch to the right side of his forehead from Patient #F7 on 12/06/12 at 7:45am. Further review revealed that RN SF7 documented that Patient #F4 remained oriented times 3, complaining of his head hurting, vital signs remain stable with no change in neuro status noted, and ice applied to the right side of Patient #F4's head. There was no documented evidence of a "Neuro Vital Signs" form documented in the medical record as required by hospital policy that included an assessment of Patient #F4's movement, hand grasps, pupil size, pupil reaction, speech, blood pressure, temperature, pulse, and respirations every 15 minutes. Further review revealed that Patient #F4 was transported to Hospital "A" on 12/06/12 at 8:20am for evaluation of the head injury. Further review revealed that Patient #F4 returned from Hospital "A" on 12/06/12 at 10:15am. Review of RN SF7's documentation revealed the following:
12/06/12 at 10:15am - received from Hospital "A" ER (emergency room) ambulatory accompanied by MHT (mental health tech)/Driver SF16 who reported that "tests negative"; patient stated "I'm fine. They ordered me a muscle relaxant"; V/S (vital signs) stable. There was no documented evidence in the medical record of the vital sign results;
12/06/12 at 3:00pm - patient noted calm, cooperative, and interacting with peers; states "I just feel sore all over"; V/S remain stable with no change noted in patient assessment. There was no documented evidence of the vital sign results in the medical record, performance of neuro vital signs assessment every 15 minutes for 1 hour, then 30 minutes times 2, hourly times 3, and every 4 hours times 5 as required by hospital policy.

Review of Patient #F4's medical record revealed no documented evidence of a report received from Hospital "A" that included tests performed and the results. Review of Patient #F4's physician orders upon return from Hospital "A" revealed telephone orders for Flexeril 10 mg by mouth at bedtime PRN muscle spasms and Motrin 800 mg by mouth three times a day that was subsequently discontinued, since Patient #4 was already on Ultram 50 mg by mouth three times a day. There was no documented evidence of physician orders for treatment and assessment of Patient #F4 following a head injury.

In a face-to-face interview on 12/18/12 at 9:20am, RN SF7 indicated that she did not document the vital sign results upon Patient #F4's return from the emergency room and again at 3:00pm. She further indicated that she knew that a CT (computerized tomography) Scan had been performed at Hospital "A", but after reviewing the medical record, RN SF7 confirmed that there was no documented evidence that a CT Scan had been performed or the results of such a scan for Patient #F4. RN SF7 indicated that she did not receive a phone report from Hospital "A" concerning Patient #F4's treatment in the emergency room on 12/06/12, and she did not call to ask for a report. She further indicated that she reported to DON SF2 that she did not receive a report from Hospital "A". RN SF7 confirmed that she did not receive physician orders for treatment and assessment of Patient #F4 upon his return from Hospital "A".

In a face-to-face interview on 12/18/12 at 4:15pm, DON SF2 indicated that if a report was not received from the emergency department of the treatment and tests performed for Patient #F4, the charge nurse should have called Hospital "A" for a report. She further indicated that RN SF7 didn't report to her that she (SF7) had not received a report from Hospital "A".


3) Evaluate the documentation of patient observations by the MHT:

Review of the hospital policy titled, "Levels of Observation -Therapeutic Safety Measures", policy number NU.432, revised 11/27/12, and verified as current policy by Administrator SF1, revealed in part, "....G. 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 with prompt change in treatment plan when indicated.

Patient #F2
Review of the Patient #F2's medical record revealed the patient was a current patient and was a 29 year old female who was admitted on 12/05/12 with a diagnosis of Major Depressive Disorder. The patient's medical diagnoses included Insulin Dependent Diabetes Mellitus and Diabetic Retinopathy (Blindness).

Review of Patient #F2's physician admit orders dated 12/05/12 at 9:30 p.m. revealed an order for Observation Level 2 (Level 2 observation requires the patient be in visual line of sight during the day and night and observation is documented every 15 minutes). Review of the record revealed no documented evidence of any Observation Log for 12/05/12 (9:30 p.m. on 12/05/12 to 12:00 a.m. on 12/06/12) Review of Patient #F2's "Observation Log" dated 12/06/12 revealed no documented evidence that SF10 MHT had documented the observation of Patient #F2 on 12/06/12 from 12:00 a.m. to 7:00 a.m. as evidenced by the observation log being blank during these times, and there was no documented evidence the RN had reviewed MHT SF10's documentation on 12/06/12 at 2:45 a.m. and 6:45 a.m. to assure the correct level of observation was maintained. Further review of the Observation Logs for Patient #F2 revealed no documented evidence the RN had reviewed the MHT's documentation on 12/07/12, 12/10/12, 12/12/12, 12/15/12, and 12/16/12.

In a telephone interview on 12/18/12 at 11:15 a.m., MHT SF10 verified he was assigned to Patient #F2 when she was admitted to the hospital. MHT SF10 stated he made rounds every 5 minutes and every 15 minute observations should have been documented. MHT SF10 was unable to explain why the observations were not documented on 12/06/12 from 12:00 a.m. to 7:15 a.m.

In a face-to-face interview on 12/18/12 at 4:20 p.m. the Director of Nursing SF2 confirmed the MHT was required to document on the Observation Log every 15 minutes and the RN was to review the MHT documentation and sign the Observation Log.


Patient #F4
Review of Patient #F4's medical record revealed that he was a current patient and was a 43 year old male admitted on 12/05/12 with a diagnosis of depression. Review of his H&P (history and physical) documented on 12/06/12 revealed diagnoses of suicidal ideations, substance abuse, auditory hallucinations, insomnia, and hypertension.

Review of Patient #F4's physician admit orders dated 12/05/12 at 9:15pm revealed an order for Observation Level 2. Review of Patient #F4's "Observation Log" revealed no documented evidence that RN SF4 reviewed the MHT's documentation on 12/12/12 at 6:45am to assure the correct level of observation was maintained. Further review revealed no documented evidence that MHT SF9 had documented the observation of Patient #F4 on 12/14/12 from 12:00am to 6:45am as evidenced by the observation log being blank during these times, and there was no documented evidence that RN SF8 had reviewed MHT SF9's documentation on 12/14/12 at 2:45am and 6:45am to assure the correct level of observation was maintained.

In a face-to-face interview on 12/18/12 at 10:40am, RN SF8 indicated if the MHT observation log on 12/14/12 from 12:00am to 6:45am was blank, it meant that the MHT didn't complete it, and he didn't catch it. He further indicated that he relied on the MHT to bring their observation form to him to be reviewed.

In a telephone interview on 12/18/12 at 11:25am, MHT SF9 indicated that she thought another MHT was assigned Patient #F4's observation on 12/14/12. When informed that the staffing assignment sheet revealed that she was assigned Patient #F4 during that shift, SF9 indicated that she thought Patient #F4 had to be re-assigned, because she would not intentionally fail to document her observations of Patient #F4.

Patient #F5
Review of Patient #F5's medical record revealed that he was a current patient and was a 37 year old male admitted on 12/09/12 with the diagnosis of an acute exacerbation of chronic paranoid schizophrenia. Review of his physician admit orders dated 12/09/12 at 10:25pm revealed an order for Level 2 observation.

Review of Patient #F5's "Observation Log" revealed no documented evidence that RN SF4 reviewed the MHT's observations of Patient #F5 on 12/10/12 at 6:45am and on 12/12/12 at 6:45am and 10:45pm. Further review revealed no documented evidence that RN SF19 had reviewed the MHT's observations of Patient #F5 on 12/10/12 at 10:45am.

In a face-to-face interview on 12/18/12 at 7:50am, RN SF4 indicated that she relied on the MHT to hand her their observation log to review. She confirmed that she did not review and sign the observation logs as mentioned above.


Patient #F6
Review of the Patient #F6's medical record revealed the patient was a current patient and was a 37 year old male who was admitted on 12/04/12 at 6:30 a.m. with a diagnosis of Schizoaffective Disorder and attempted to jump off a bridge. Review of the physician's admit orders dated 12/04/12 and timed 8:00 a.m. revealed an order for Level 2 observation. Review of the physician's orders revealed the level of observation was decreased to Level 1 on 12/10/12.

Review of Patient #F6's Observation Log dated 12/10/12 revealed no documented evidence of any observations from 1:45 p.m. to 7:30 p.m. as evidence by the observation log being blank during these times. Further review of the log revealed no documented evidence the RN had reviewed and signed the log at 2:45 p.m. and 6:45 p.m.





17091




13225

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

1) the nursing staff developed a nursing care plan that included the patient's medical problems for 1 of 7 sampled patients (#F4);

2) the nursing staff revised the care plan with changes in the patient's condition and behaviors for 2 of 2 patients' records reviewed with changes in condition or behaviors from a total of 7 sampled patients (#F4, #F5); and

3) the nursing staff implemented the physician's orders for labs, EKGs (electrocardiograms), and TB (tuberculin) testing for 6 of 7 sampled patients (#F1, #F2, #F3, #F4, #F5, #F6).

Findings:

1) Nursing care plan included the patient's medical problems:
Patient #F4
Review of Patient #F4's medical record revealed that he was a 43 year old male admitted on 12/05/12 with a diagnosis of depression. Review of his H&P (history and physical) documented on 12/06/12 revealed diagnoses of suicidal ideations, substance abuse, auditory hallucinations, insomnia, and hypertension. Review of Patient #F4's CEC (coroner's emergency certificate) signed on 12/06/12 at 6:12pm revealed that he had a medical history of post-traumatic stress disorder, substance abuse, hypertension, and chronic low back pain.

Review of patient #F4's nurses' notes revealed that he received pain medication for complaints of back pain on 12/06/12 at 6:30pm and 9:00pm.

Review of Patient #F4's "Interdisciplinary Treatment Plan" initiated on 12/05/12 revealed no documented evidence that his medical problems of hypertension and chronic low back pain had been included in his care plan with goals and interventions identified and implemented.

In a face-to-face interview on 12/18/12 at 7:50am, RN SF4 confirmed that Patient #F4's care plan did not include his medical problems of hypertension and low back pain. She further indicated that they should have been included in his care plan, because the problems were identified by the admitting RN. SF4 indicated that she initiated his care plan, but she didn't review Patient #F4's admission assessment that was completed by another RN.

Review of the hospital policy titled, "Inter-Disciplinary Treatment Planning-Overview", policy number NU.706, revised 11/27/12, and verified as current by Administrator SF1, revealed in part, "...Each client admitted to the psychiatric unit shall have an individualized treatment plan which is based on interdisciplinary clinical assessments....The treatment planning process is continuous, beginning at the time of admission and continuing through discharge. Any psychiatric and/or medical problems that occur throughout their stay must be included in the interdisciplinary treatment plan....


2) Nursing care plan included changes in the patient's condition and behaviors:

Review of the hospital policy titled, "Inter-Disciplinary Treatment Planning-Overview", policy number NU.706, revised 11/27/12, and verified as current by Administrator SF1, revealed in part, "...Each client admitted to the psychiatric unit shall have an individualized treatment plan which is based on interdisciplinary clinical assessments....The treatment planning process is continuous, beginning at the time of admission and continuing through discharge. Any psychiatric and/or medical problems that occur throughout their stay must be included in the interdisciplinary treatment plan....It is the purpose of this policy to set up procedures that can ensure the client receives optimal care by a well functioning, integrated treatment team....In order to determine the effectiveness of the master treatment plan, weekly reviews are done by the interdisciplinary team. This review will provide valuable information about client progress, need for continued treatment, revision of interventions as well as discharge planning...

Patient #F4
Review of Patient #F4's medical record revealed that he was a current patient and was a 43 year old male admitted on 12/05/12 with a diagnosis of depression. Review of his H&P (history and physical) documented on 12/06/12 revealed diagnoses of suicidal ideations, substance abuse, auditory hallucinations, insomnia, and hypertension.

Review of Patient #F4's medical record revealed that he sustained a punch to the right side of his forehead from Patient #F7 on 12/06/12 at 7:45am. Further review revealed that he was transported to Hospital A on 12/06/12 at 8:20am for evaluation of the head injury. Further review revealed that Patient #F4 returned from Hospital A on 12/06/12 at 10:15am.

Review of Patient #F4's "Interdisciplinary Treatment Plan" initiated on 12/05/12 revealed no documented evidence that his care plan was revised after his head injury to include goals and interventions identified and implemented.

In a face-to-face interview on 12/18/12 at 9:20am, RN SF7 indicated that Patient #F4's care plan was not revised to include his head injury.


Patient #F5
Review of Patient #F5's medical record revealed that he was a current patient and was a 37 year old male admitted on 12/09/12 with the diagnosis of an acute exacerbation of chronic paranoid schizophrenia.

Review of Patient #F5's nurses' notes revealed that he had disrobed and stood naked in the milieu on 12/11/12 at 10:00am and on 12/12/12 at 11:05am.

Review of Patient #F5's "Interdisciplinary Treatment Plan" initiated on 12/09/12 revealed no documented evidence that the plan was revised on 12/11/12 or 12/12/12 to include Patient #F5's inappropriate sexual behavior to include goals and interventions identified and implemented.

In a face-to-face interview on 12/18/12 at 7:50am, RN SF4 confirmed that Patient #F5 was not care planned for inappropriate sexual behavior. She further indicated that he went about 6 days without disrobing, and yesterday (12/17/12) he disrobed 3 times.

In a face-to-face interview on 12/18/12 at 9:20am, RN SF7 indicated that Patient #F5's care plan had not been revised when he began disrobing and standing naked in the milieu on 12/11/12, 12/12/12, and 12/17/12. She further indicated that he should have had a care plan initiated for impulse control.



3) Physician's orders for labs, EKGs, and TB testing:

Review of the hospital policy titled, "Electrocardiogram (EKG)", policy number NU.312, revised 10/06/12, and verified as current by Administrator SF1, revealed in part, "....1. An EKG is obtained on all clients admitted to the psychiatric unit within 24 hours of admission by a trained staff MHT, RN, or LPN. 2. The MHT admitting and orienting the client to the unit is responsible for completing the EKG as part of the orientation/admission process. 3. If, for any reason, the staff is unable to obtain the EKG, this must be documented on the consult form, with the reason why the test could not be completed within 24 hours of admission.

Review of the hospital policy titled, "Laboratory Services", policy number NU.313, revised 10/25/12, and verified as current by Administrator SF1, revealed in part, "....Specimen pickup/delivery will occur on a daily basis Monday through Sunday...Test results will be returned within 24 hours unless otherwise specified for a specific test.


Patient #F1
A review of Patient #F1's medical record revealed Patient #F1 a current patient and was admitted to the facility on 12/10/12 at 8:15 a.m. with diagnoses to include in part: Hallucinations, Hemorrhoids, Hernia and post Head Trauma as a teenager. A review of the physician's verbal/telephone admit orders dated 12/10/12 at 2:00 p.m. revealed an order for an EKG. A further review of Patient #F1's medical record revealed the EKG was performed on 12/13/12 at 10:28 a.m., three days after the patient was admitted.

Patient #F2
Review of Patient #F2's medical record revealed the patient was a current patient and was a 29 year old female admitted on 12/05/12 with the diagnosis of Major Depressive Disorder. The patient's medical diagnosis included Insulin Dependent Diabetes Mellitus and Diabetic Retinopathy (Blindness).

Review of Patient #F2's physician orders dated 12/05/12 at 9:15 p.m. revealed an order for an EKG, a RPR (Blood test for Syphilis), Serum Pregnancy Test, and an order for a TB (Tuberculin) test.

Review of Patient #F2's medical record revealed that the RPR and Serum Pregnancy Test lab specimens were drawn on 12/07/12 (2 days after they were ordered), and a TB test was administered on 12/08/12 at 6:55 a.m. (3 days after the TB test was ordered). Further review revealed the EKG had been performed on 12/12/12 at 5:33 p.m. (7 days after the EKG was ordered).


Patient #F3
A review of Patient #F3's medical record revealed Patient #F3 was a current patient who was admitted to the facility on 12/11/12 at 7:40 a.m. with diagnoses to include in part: Major Depressive Disorder, history of Bipolar Disorder and Hypertension. A review of the physician's verbal/telephone orders dated 12/11/12 at 7:40 a.m. revealed an order for an EKG and a TB test. Patient #F3's medical record revealed the TB test was performed on 12/14/12 at 6:00 a.m., three days after the patient was admitted. A further review of Patient #F3's medical record revealed no documented EKG report.
An interview on 12/18/12 at 9:25 a.m. was conducted with SF7RN. SF7RN indicated that EKG's and TB test are performed by the staff upon admit and should be performed in a timely manner on the same day the patient was admitted.


Patient #F4
Review of Patient #F4's medical record revealed that he was a current patient and a 43 year old male admitted on 12/05/12 with a diagnosis of depression. Review of his H&P (history and physical) documented on 12/06/12 revealed diagnoses of suicidal ideations, substance abuse, auditory hallucinations, insomnia, and hypertension.

Review of Patient #F4's physician admit orders dated 12/05/12 at 9:15pm revealed an order to obtain an EKG and a TB test.

Review of the EKG log, documented on an "Interdisciplinary Progress Note" and presented by LPN (licensed practical nurse) SF6 on 12/18/12 revealed that Patient #F4's name was listed with the date of 12/05/12 with no documented evidence whether the EKG had been performed.

Further review of Patient #F4's medical record revealed the EKG was performed on 12/07/12 (2 days after it was ordered), and the TB test was administered on 12/08/12 (3 days after it was ordered). Further review revealed no documented evidence of the reason for the delay in obtaining the EKG and the delay in administering the TB test.


Patient #F5
Review of Patient #F5's medical record revealed that he was a current patient who was a 37 year old male admitted on 12/09/12 with the diagnosis of an acute exacerbation of chronic paranoid schizophrenia.

Review of Patient #F5's physician orders dated 12/09/12 at 10:25pm revealed orders for an EKG, a RPR, and a TSH (thyroid stimulating hormone). Further review revealed that a TB test was not ordered.

Review of the EKG log, documented on an "Interdisciplinary Progress Note" and presented by LPN SF6 on 12/18/12 revealed that Patient #F5's name was listed with the date of 12/10/12 with no documented evidence of whether the EKG had been performed.

Review of Patient #F5's medical record revealed that the RPR and TSH lab specimens were drawn on 12/11/12 (2 days after they were ordered), and a TB test was administered on 12/11/12 at 10:00am (no physician order for a TB test). Further review revealed no documented evidence that an EKG had been performed and read as evidenced by no EKG report in the medical record (8 days).


Patient #F6
Review of Patient #F6's medical record revealed that he was a current patient who was a 37 year old male admitted on 12/04/12 with the diagnosis of Schizoaffective Disorder with an attempt to jump off a bridge.

Review of Patient #F6's physician orders dated 12/04/12 at 8:00 a.m. revealed an order for an EKG and a RPR. Further review revealed a Depakote level was ordered to be done on 12/13/12.

Review of Patient #F6's medical record revealed that the RPR was drawn on 12/06/12, 2 days after the test was ordered. The EKG was done on 12/12/12 at 4:01 p.m., 8 days after the EKG was ordered. Further review revealed the results of the Depakote level were obtained on 12/13/12 and the results were not received by the hospital until 12/18/12 (5 days after the specimen was drawn). Review of the Depakote level results revealed the patient's level was 37.2 (Reference range of 50-100) and the physician was notified on 12/18/12 at 9:00 a.m.

In a face-to-face interview on 12/18/12 at 8:45 a.m., LPN SF6 indicated that she had audited Patient #F6's medical record on 12/16/12 and could not find the results of the Depakote level. SF6 stated she had notified the RN the results of the Depakote level were not on the record on 12/16/12.

In a face-to-face interview on 12/18/12 at 4:20 p.m., the Director of Nursing SF2 stated drug levels take 3 days to get the results. SF2 indicated the Depakote level for Patient #F6 should have been received 3 days after the test was sent to the lab.


In a face-to-face interview on 12/18/12 at 8:45 a.m., LPN SF6 indicated that the MHTs (mental health techs) usually did the patients' EKGs, and she did not know why there would be a delay in administering the TB test. LPN SF6 indicated the RN or the LPN could administer the TB test. She further indicated that the nurses sometimes administer the TB test on admit or sometimes wait until the next morning. LPN SF6 indicated the hospital had no system in place for tracking when labs were drawn and when the results were returned. She further indicated that the TB test should not have been administered to Patient #F5 without a physician's order.

In a face-to-face interview on 12/18/12 at 9:20am, RN SF7 indicated the hospital had policies for obtaining labs and EKGs, but these policies were not enforced. She further indicated that labs, EKGs, and TB testing should be done at the time of admit.

In a face-to-face interview on 12/18/12 at 4:15pm with Administrator SF1, DON SF2, and Vice-President of Operations SF3 present, DON SF2 indicated that labs should be drawn the morning after admit, and there should be no reason for the TB test not to be administered the day it was ordered. Vice-President of Operations SF3 indicated that the EKG should be done on the shift that it was ordered. Administrator SF1 indicated that the policy stated that the EKG would be done within 24 hours of the order.




17091




30172

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 oriented and assessed for competency for 2 of 4 RNs' personnel files reviewed from a total of 21 RNs employed at the hospital (RN SF4, RN SF8), 1 of 2 MHTs' (mental health tech) personnel files reviewed from a total of 53 employed MHTs (MHT SF10), and 1 of 1 contract agency MHT's personnel file reviewed from Company A (MHT SF13). Findings:

Review of the job description for the RN Charge Nurse, revised 10/01/12 and presented by Administrator SF1 as the current job description, revealed the following duties and responsibilities:
Provide nursing care of the psychiatric patient;
Participate in the unit's therapeutic program activities;
Assist in the team development of the Master Treatment Plan;
Supervise MHTs and LPNs;
Consult with the DON concerning management of the unit; Responsible for the nursing care given to patients during his/her shift;
Assist in the admission process, writes initial nursing histories, assesses patient's condition, and develops individual care plans;
Monitors patient's behavioral, psychological, and mental status and reports changes or situations requiring expertise or follow-up to the appropriate personnel.

Review of the hospital policy titled, "Clinical Staff Orientation", Policy number HR.026, revision date 11/26/12, and verified as current by Administrator SF1, revealed in part the following: "Policy: All clinical employees will participate in Clinical Orientation within the first three months of employment....B. Each employee will participate in the scheduled orientation for clinical personnel within the first five days of hire...."

Review of the hospital policy titled, "Staff Competency", Policy number HR.036, effective date and revision date (both left blank), and provided by Human Resource Director SF20 as current, revealed in part the following: "Policy: All direct care staff members will meet performance standards of their job responsibilities as defined in a position description. Purpose: To provide a method of evaluating staff's level of competency within an assigned department and job description. Procedure: 1. Hiring qualifications....2. Orientation 3. Skills Check List, department, and/or population specific.... Competency checklist are maintained in the personnel file of the employee."

Review of the hospital policy titled, "Staff Development Plan", Policy number HR.025, revision date 11/26/12, and provided as current by Human Resource Director SF20, revealed in part the following: "....C. Each employee will also receive a thorough orientation to their department within the first five days of hire which will include: 1. Reviewing the department's Policy and Procedure Manual. 2. Reviewing the department's paperwork. 3. Skills specific testing and training.



RN SF4
Review of RN SF4's personnel file revealed that she was hired on 10/23/12. Further review revealed no documented evidence of orientation to her job duties and an assessment of competency to perform the duties of a Charge Nurse on Unit C. Further review revealed her "Competency Skills Checklist" for "CPI (crisis prevention intervention), Seclusion, and Restraints" was completed by CPI Instructor SF11 (who is a MHT) on 10/23/12. There was no documented evidence that RN SF4 had been evaluated for competency by a competent RN of her duties related to restraint and seclusion, such as physician order requirements, time limits, the RN's duties for monitoring of patients in restraints or seclusion, competency to perform the face-to-face evaluation of the patient within one hour of initiation of restraints or seclusion, and the required documentation for restraint and seclusion.

In a face-to-face interview on 12/18/12 at 7:50am, RN SF4 indicated that she worked at Greenbrier Behavioral Health 6 years ago as a LPN (licensed practical nurse), and this employment was her first in a psychiatric setting as a RN. She further indicated that her orientation included working 2 nights with another RN who she later learned was also a new nurse to the hospital and 1 night with a more experienced nurse. RN SF4 indicated that she requested another day of orientation with a nurse on the unit and was granted her request. She further indicated that one of her duties as the Charge RN was do intake if needed, and she had no orientation for intake duties. RN SF4 indicated that she received corporate orientation on 11/07/12, received her employee packet to fill out after she had worked for 1 month, and had just received her employee badge 2 days ago. RN SF4 indicated that no one who oriented her completed a competency evaluation.

RN SF8
Review of RN SF8's personnel file revealed that he was hired on 10/23/12. Further review revealed his "Competency Skills Checklist Position: RN" had a column with a list of competency skills, a column with the heading of "method of evaluation" that contained dates of evaluation and a number indicating the method of evaluation, and a column with the heading of "Evaluation Score Pass Fail". Further review of the checklist revealed that the methods of evaluation were 1 = (equals) Skills, 2 = Written Test, and 3 = Oral Evaluation/Supervision. Review of RN SF8's checklist revealed the following:
20 skills were dated as evaluated by oral evaluation/supervision with a pass score on 11/30/12;
3 skills were dated as evaluated by written test with a pass score on 11/30/12 (observation levels, medication test, documentation test);
1 skill was dated as evaluated by skills with a pass score on 11/30/12 (venipuncture);
15 skills evaluated by oral evaluation/supervision with a pass score with no documented evidence of the date of the evaluation;
5 skill evaluated by skills with a pass score with no documented evidence of the date of the evaluation (completing electrocardiograms).
The checklist was signed by RN SF8 on 11/30/12 and by Director of Nursing (DON) SF2 on 12/12/12.
There was no documented evidence of a competency assessment performed for "CPI Seclusion, and Restraints", and there was no documented evidence of orientation to his duties as a Charge RN on Unit C.

In a face-to-face interview on 12/18/12 at 10:40am, RN SF8 indicated that he had been here for a month before he had hospital/corporate orientation. He further indicated that he had a brief orientation with another nurse by working 2 days on Unit B and 1 day on Unit C while he was hired to work Unit C. He further indicated that he didn't know the role or duties of the LPN and MHT on the unit. RN SF8 indicated that he had no orientation on completing treatment plans, but the ones that were used here were outdated and not used anywhere else (had previously worked at a non-profit psychiatric facility). RN SF8 indicated that he had not been evaluated for competency since he was hired.

MHT SF10
Review of MHT SF10's personnel file revealed that he was hired on 10/03/12. Further review revealed no documented evidence of orientation to his job duties or an evaluation of competency to perform the duties of a MHT on Unit C.

In a telephone interview on 12/18/12 at 11:10am, MHT SF10 indicated that he was paired with another MHT for 7 days before being scheduled alone. He further indicated that he kept a package, and the MHT would check off when he performed a task, and the nurse would sign the form (no evidence in his personnel file).

MHT SF13 with Company A
Review of MHT SF13's personnel file revealed no documented evidence that she was oriented to the hospital's policies and procedures and her duties as a MHT on Unit C. There was no documented evidence that she was paired with an experienced MHT prior to providing direct patient care. Review of MHT SF13's "Competency Skills Checklist Position: MHT" revealed all of the skills were evaluated by oral evaluation/supervision by DON SF2 on 12/04/12 (first day of work). Further review revealed MHT SF13 signed the checklist on 12/05/12. There was no documented evidence that MHT SF13 was assessed for competency by observation of the performance of the following skills: documentation of observation skills, application of restraints, monitoring a patient in seclusion and restraints, daily room checks, patient checks for contraband, performing EKGs (electrocardiograms), monitoring patient's behavior and reporting requirements, performing vital signs, obtaining patient weight, facilitating groups, admission paperwork, and her role in Code White (procedure for handling aggressive/combative behavior).

Review of the staffing assignment sheets presented by DON SF2 revealed that MHT SF13 worked from 7:00pm to 11:00pm on 12/04/12.

In a face-to-face interview on 12/18/12 at 4:15pm with Administrator SF1, DON SF2, and Vice-President of Operations SF3 present, when asked about having CPI (crisis prevention intervention) Instructor SF11 who was a MHT assess the RN for competency with restraints and seclusion, DON SF2 indicated that she did not know how CPI Instructor SF11 evaluated the RN's competency. Administrator SF1 indicated that CPI Instructor SF11 took the employee to the unit, oriented them to the seclusion room, the locks, the restraints, and the procedure for de-escalation. DON SF2 indicated that CPI Instructor SF11 instructed the RNs, but she didn't know if he evaluated their competencies. After more discussion, Administrator SF1, DON SF2, and Vice-President of Operations SF3 confirmed that a MHT could not assess a RN or LPN for competency related to all components of CPI, restraint, and seclusion. When informed that review of the personnel files revealed a lack of documented evidence of competency assessments and orientation to the job duties and unit, Vice-President of Operations SF3 indicated that she thought it had been done. She further indicated that it was her understanding that a newly hired employee was not scheduled until the skills competency had been completed. No one (Administrator SF1, DON SF2, Vice-President of Operations SF3) could offer an explanation for the lack of documented evidence of orientation and competency for the employees listed above before they performed direct patient care.