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Based on record reviews and interviews, the hospital failed to ensure that each patient had the right to privacy, dignity, and comfort as evidenced by requiring patients with physician orders for strict visual contact (patient to be seen by a staff member at all times 24 hours a day) to sleep on a sofa in the dayroom or a mattress on the floor of the dayroom in order to be observed during sleep hours by a staff member for 2 of 2 current patients with physician orders for strict visual contact (#5, #6) on the adult psych unit.

Findings:

Review of the hospital policy titled "Observation Statuses", reviewed and revised July 2014 and presented as the current observation policy by S3Director of Risk Management, revealed that strict visual contact means that the patient is to be seen by a staff member at all times 24 hours a day which always included times the patient attends to personal hygiene as well as when he/she is sleeping. Further review revealed that the patient is to remain in an unobstructed view within 15 feet of the staff member and must be directly, physically accessible to staff.

Patient #5
Review of Patient #5's medical record revealed she was a 20 year old female admitted to the adult psych unit on 08/18/14 at 6:50 p.m. with diagnoses of Bipolar Disorder and Post Traumatic Stress Disorder (PTSD). Review of her "Physician's Admission Orders And Diagnostic Work" received by telephone order by S23RN (registered nurse) revealed Patient #5 was ordered to be on strict visual contact (SVC).

Patient #6
Review of Patient #6's medical record revealed she was a 49 year old female admitted to the adult psych unit on 08/18/14 at 8:30 p.m. with diagnoses of Bipolar Disorder and Homicidal Ideations. Review of her "Physician's Admission Orders And Diagnostic Work" received by telephone order by S23RN revealed Patient #6 was ordered to be on SVC.

In an interview on 08/19/14 at 11:20 a.m., Patient #5 indicated that she had to sleep on the floor on a mattress in the dayroom (multi-purpose area), because "I had to be watched." She further indicated that she had been a patient at River Oaks previously and knew that she would have to sleep in the dayroom, so she could be watched by staff.

In an interview on 08/19/14 at 11:35 a.m., Patient #6 indicated that she slept on the sofa in the dayroom the previous night. She further indicated that she was offered to sleep on her mattress on the floor in the dayroom, but she didn't want to sleep on the floor. Patient #6 indicated that it bothered her that she couldn't sleep in her bed in her room.

In a telephone interview on 08/20/14 at 9:20 a.m., S14RN indicated both Patient #5 and Patient #6 were admitted to the adult psych unit on the evening shift of 08/18/14. She further indicated that both Patient #5 and Patient #6 had physician orders to be on SVC. She further indicated Patient #6 slept on the sofa in Dayroom C of the unit where she (S14RN) could observe her, and Patient #5 slept on a mattress on the floor in Dayroom A where S17PC (psych counselor) could observe her. S14RN indicated staff present during this night shift was herself and S17PC with 24 patients, 2 of whom were ordered to be on SVC. When asked why patients were not allowed to sleep in their rooms, S14RN indicated this was done because the staff had to see the patients.

Based on observations, record review, and interviews, the hospital failed to ensure that patients received care in a safe setting as evidenced by:

1) Having plastic forks, multiple plastic bags containing napkins, plates, and cups, and a microwave in the kitchen area on the Trauma Unit that was accessible to patients at intervals during the day without staff supervision that could be used to harm oneself or others;

2) Having long electrical cords and computer cords in equipment in the computer room on the Trauma Unit;

3) Having a large number of plastic bags containing Styrofoam cups and plastic bowls in an unlocked cabinet in the kitchen area on the Adult Psych Unit that was accessible to patients at intervals during the day without staff supervision that could be used to harm oneself or others;

4) Having patient room door hinges throughout the hospital separated widely enough to facilitate a potential ligature risk.

Findings:

1) Having plastic forks, multiple plastic bags containing napkins, plates, and cups, and a microwave in the kitchen area on the Trauma Unit that was accessible to patients at intervals during the day without staff supervision that could be used to harm oneself or others:
Observation of the kitchen area on the Trauma Unit on 08/18/14 at 1:40 p.m. revealed a cabinet drawer with multiple plastic-wrapped plastic forks with sharp edges. Further observation revealed a cabinet under the counter contained a large opened box of plastic-wrapped plastic forks with sharp edges (box originally contained a count of 1000). Further observation revealed another cabinet contained large plastic bags containing napkins, Styrofoam cups, and plates. There was a microwave on the counter top.

In an interview at the time of the observation on 08/18/14 at 1:40 p.m., S9Nurse Manager for the Trauma Unit indicated that patients were allowed to access the kitchen unattended at 6 different times between 7:45 a.m. and 8:20 p.m. each day. She confirmed that plastic bags could be used as a means of suffocation, the microwave could become a safety hazard if food was heated to extreme temperatures, and the sharp edges of the forks could present a means of injury for patients.

2) Having long electrical cords and computer cords in equipment in the computer room on the Trauma Unit:

Observation in the computer room on the Trauma Unit on 08/18/14 at 2:00 p.m. revealed an electrical cord strip attached to the wall outlet with long electrical cords and computer cords attached that could present a ligature risk.

In an interview during the observation on 08/18/14 at 2:00 p.m., S9Nurse Manager of the Trauma Unit indicated that patients were allowed in the computer room with the door open, but staff were not always present in the room or able to see patients when they were in the computer room. She confirmed that long cords were ligature risks.

3) Having a large number of plastic bags containing Styrofoam cups and plastic bowls in an unlocked cabinet in the kitchen area on the Adult Psych Unit that was accessible to patients at intervals during the day without staff supervision that could be used to harm oneself or others:

Observation of the kitchen area on the Adult Psych Unit on 08/18/14 at 2:15 p.m. revealed cabinets under the counter had multiple large plastic bags containing Styrofoam cups and plastic bowls. This observation was confirmed by S3Director of Risk Management. She confirmed that patients were allowed to access the kitchen unattended at several times of the day.

4) Having patient room door hinges throughout the hospital separated widely enough to facilitate a potential ligature risk:

Observation of the patient room doors on the Adult Psych Unit on 08/18/14 at 2:30 p.m. revealed the door hinges were separated widely enough to present a potential ligature risk.

In an interview on 08/18/14 at 2:30 p.m., S4Director of Plant Operations indicated that all patients' entrance doors to their rooms throughout the hospital contained this same type of hinge. In the same interview S7Interim Nurse Manager for the Adult Psych Unit confirmed that patients were allowed to be in their rooms with the door closed.

Based on record review and interview, the hospital failed to ensure that the hospital's policy was implemented for the use of physical restraint (physical hold) for 1 of 1 patient whose record was reviewed for use of restraints (#3) from a total of 6 patients.

The hospital failed to ensure the physician's verbal order received by S9Nurse Manager of the Trauma Unit was dated and timed and the order authenticated by the physician within 24 hours as required by hospital policy.

Findings:

Review of the hospital policy titled "Restraint And Seclusion", reviewed June 2014 and presented as the hospital's current restraint policy by S3Director of Risk Management, revealed that two kinds of restraint processes are classified as a physical restraint, mechanical restraints and physical/therapeutic hold. Further review revealed that telephone orders for restraint may be received and recorded by the RN (registered nurse), and the physician shall authenticate the telephone order within 24 hours.

Review of Patient #3's medical record revealed she was a 29 year old female admitted to the Trauma Unit on 05/01/14 at 11:30 a.m. with diagnoses of Asperger's, Seizure Disorder, and Reports Trauma. She was discharged on 05/06/14. Review of her "Restraint/Seclusion Order/Record" documented by S9Nurse Manager of the Trauma Unit on 05/01/14 at 1:20 p.m. revealed that Patient #3 was placed in a physical hold at 1:20 p.m. due to her hitting the door, pushing staff, attempting to bite staff, screaming, and pulling off her bandages. S9Nurse Manager of the Trauma Unit documented that an order was received from S25Physician with no documented evidence of the date or time the order was received. Further review revealed no documented evidence that the verbal order had been authenticated by S25Physician as of the record review on 08/18/14, 110 days since the physical hold took place.

In an interview on 08/19/14 at 12:45 p.m., S9Nurse Manager of the Trauma Unit indicated that S25Physician was on the unit at the time that Patient #3 became aggressive. She reviewed Patient #3's medical record and confirmed that she didn't document the date or time that she received the verbal order from S25Physician and that S25Physician had not authenticated the verbal order.

Based on record review and interview, the hospital failed to ensure that the patient's attending physician was consulted after a physical hold restraint had been verbally ordered by another physician for 1 of 1 patient whose record was reviewed for use of restraints (#3) from a total of 6 patients.

Findings:

Review of the hospital policy titled "Restraint And Seclusion", reviewed June 2014 and presented as the hospital's current restraint policy by S3Director of Risk Management, revealed that two kinds of restraint processes are classified as a physical restraint, mechanical restraints and physical/therapeutic hold.

Further review revealed that telephone orders for restraint may be received and recorded by the RN (registered nurse), and the physician shall authenticate the telephone order within 24 hours.

Further review revealed that if the attending physician did not order the restraint, he/she must be consulted as soon as possible, in most cases within 4 hours, but no longer than 12 hours after initiation of the restraint.

Review revealed that if the one-hour evaluation after initiation of the restraint is performed by the RN, he/she must consult with the attending physician responsible for the patient's care as soon as possible (within 30 minutes) after the evaluation.

Review of Patient #3's medical record revealed she was a 29 year old female admitted to the Trauma Unit on 05/01/14 at 11:30 a.m. with diagnoses of Asperger's, Seizure Disorder, and Reports Trauma. Her attending physician was S10Psychiatrist. She was discharged on 05/06/14. Review of her "Restraint/Seclusion Order/Record" documented by S9Nurse Manager of the Trauma Unit on 05/01/14 at 1:20 p.m. revealed that Patient #3 was placed in a physical hold at 1:20 p.m. due to her hitting the door, pushing staff, attempting to bite staff, screaming, and pulling off her bandages. S9Nurse Manager of the Trauma Unit documented that an order was received from S25Physician with no documented evidence of the date or time the order was received. Further review revealed that S9Nurse Manager of the Trauma Unit conducted the one-hour evaluation of Patient #3 after initiation of the physical hold. Review of the entire restraint record revealed no documented evidence that S10Psychiatrist, Patient #3's attending physician, was notified of the physical hold.

In an interview on 08/19/14 at 12:45 p.m., S9Nurse Manager of the Trauma Unit indicated that S25Physician was on the unit at the time that Patient #3 became aggressive. She reviewed Patient #3's medical record and confirmed that she didn't document the date or time that she received the verbal order from S25Physician. She offered no explanation for not notifying S10Psychiatrist of Patient #3 being placed in a physical hold as required by hospital policy.

Based on record reviews and interviews, the hospital failed to ensure that a patient placed in physical hold/restraint was seen face-to-face within one hour after initiation of the intervention by a physician or licensed independent practitioner or a registered nurse (RN) or physician assistant who has been trained for 1 of 1 patient whose record was reviewed for use of restraints (#3) from a total of 6 patients. Patient #3 was evaluated by S9Nurse Manager of the Trauma Unit after having been placed in a physical hold on 05/01/14, and there was no documented evidence that S9Nurse Manager of the Trauma Unit had received special training and demonstrated competency in performing the one hour face-to-face evaluation.

Findings:

Review of the hospital policy titled "Restraint And Seclusion", reviewed June 2014 and presented as the hospital's current restraint policy by S3Director of Risk Management, revealed that nurses who are authorized to conduct the one hour face-to-face evaluation after initiation of physical restraint/physical hold will receive additional training and demonstrate competency to conduct both a physical and behavioral assessment of the patient. All records documenting completion of training and competency demonstration will be maintained in staff personnel files.

Review of Patient #3's medical record revealed she was a 29 year old female admitted to the Trauma Unit on 05/01/14 at 11:30 a.m. with diagnoses of Asperger's, Seizure Disorder, and Reports Trauma. She was discharged on 05/06/14. Review of her "Restraint/Seclusion Order/Record" documented by S9Nurse Manager of the Trauma Unit on 05/01/14 at 1:20 p.m. revealed that Patient #3 was placed in a physical hold at 1:20 p.m. due to her hitting the door, pushing staff, attempting to bite staff, screaming, and pulling off her bandages.

Review of the personnel file of S9Nurse Manager of the Trauma Unit revealed no documented evidence of training and demonstrated competency in the performance of the one hour face-to-face evaluation after initiation of physical restraint/physical hold.

In an interview on 08/19/14 at 12:45 p.m., S9Nurse Manager of the Trauma Unit confirmed that she was the RN who performed the one hour face-to-face evaluation of Patient #3 after she had been placed in a physical hold on 05/01/14.

In an interview on 08/20/14 at 2:05 p.m., S3Director of Risk Manager indicated that the one hour face-to-face evaluations were conducted by nurse managers or nurse supervisors. She confirmed that S9Nurse Manager of the Trauma Unit had not received the training or demonstrated competency to perform the evaluation. She further confirmed that S9Nurse Manager of the Trauma Unit was the RN who performed the one hour face-to-face evaluation of Patient #3 after she was placed in a physical hold on 05/01/14.

Based on record reviews and interview, the hospital failed to ensure that staff was trained and able to demonstrate competency in the application of restraints or physical holds for 1 (S9) of 6 RNs (registered nurses) (S7, S9, S14, S15, S16, S23) whose personnel files were reviewed for competency in application of restraints and physical holds. S9Nurse Manager of the Trauma Unit was the RN responsible for Patient #3 when a physical hold was performed on 05/01/14 at 1:20 p.m.

Findings:

Review of the hospital policy titled "Organizational Plan For Competency And Staff Development", revised January 2014 and presented as a current policy by S3Director of Risk Management, revealed that the competency assessment/development process shall be ongoing, and each clinical staff member must participate in competency enhancement programs. Further review revealed that initial and annual mandatory training in seclusion and restraint and Handle With Care was required.

Review of the hospital policy titled "Restraint And Seclusion", reviewed June 2014 and presented as the hospital's current restraint policy by S3Director of Risk Management, revealed that direct care staff are required to attend aggression management training and show evidence of competency related to participating in a code situation, application of restraints, or the monitoring, assessment, and care of a patient in restraints or seclusion. All records documenting completion of training and competency demonstration will be maintained in staff personnel files.

Review of Patient #3's medical record revealed she was a 29 year old female admitted to the Trauma Unit on 05/01/14 at 11:30 a.m. with diagnoses of Asperger's, Seizure Disorder, and Reports Trauma. She was discharged on 05/06/14. Review of her "Restraint/Seclusion Order/Record" documented by S9Nurse Manager of the Trauma Unit on 05/01/14 at 1:20 p.m. revealed that Patient #3 was placed in a physical hold at 1:20 p.m. due to her hitting the door, pushing staff, attempting to bite staff, screaming, and pulling off her bandages.

Review of the personnel file of S9Nurse Manager of the Trauma Unit revealed no documented evidence of demonstrated competency in the application of restraints or physical holds.

In an interview on 08/20/14 at 2:05 p.m., S3Director of Risk Manager indicated that S9Nurse Manager of the Trauma Unit had transferred to the position of Nurse Manager of the Trauma Unit in December 2013 and did not have Handle With Care training yet. She further indicated that Handle With Care training is presented by S18Patient Advocate, and it's in this course where staff are evaluated for competency in the application of restraints and performing physical holds. S3Director of Risk Manager indicated that S9Nurse Manager of the Trauma Unit had been the Utilization Review Nurse which did not require Handle With Care training. She could not explain why S9Nurse Manager of the Trauma Unit had not attended Handle With Care training when she returned to direct care as required by hospital policy.

Based on record reviews and interviews, the hospital failed to meet the requirement of the Condition of Participation of Nursing services as evidenced by:

Failing to ensure the nursing service had adequate numbers of nurses and psych counselors (PC) to provide nursing care as ordered by the MD to meet the needs of the patients and according to the hospital's staffing grid. The hospital did not meet the staff requirements according to its staffing grid for a total of 61 shifts from 12/08/13 through 08/18/14 on the Trauma, Dual Diagnosis, and Adult Psych Units. The staffing on the Adult Psych Unit resulted in 2 patients (#5, #6) with physician orders for strict visual contact (SVC) ( patient to be within a staff member's sight at all times) not being observed by psych counselors (PC) as ordered by the physician and according to hospital policy and requiring the 2 patients to sleep on a mattress on the floor and a sofa in the dayroom to be able to be observed by the 2 staff members (1 RN and 1 PC) who were assigned the care of 24 patients, 2 of whom were on SVC, on 08/18/14 from 11:00 p.m. through 7:00 a.m. on 08/19/14 (see findings in tag A0392).

Based on record reviews and interviews, the hospital failed to ensure the nursing service had adequate numbers of nurses and psych counselors (PC) to provide nursing care as ordered by the MD to meet the needs of the patients and according to the hospital's staffing grid.

The hospital did not meet the staff requirements according to its staffing grid for a total of 61 shifts from 12/08/13 through 08/18/14 on the Trauma, Dual Diagnosis, and Adult Psych Units. The staffing on the Adult Psych Unit resulted in 2 current inpatients (#5, #6) with physician orders for strict visual contact (SVC) ( patient to be within a staff member's sight at all times) not being observed by psych counselors (PC) as ordered by the physician and according to hospital policy therefore; requiring the 2 patients of whom were on SVC to sleep on a mattress on the floor and a sofa in the dayroom to be able to be observed by the 2 staff members (1 RN and 1 PC) who were assigned the care of 24 patients, on 08/18/14 from 11:00 p.m. through 7:00 a.m. on 08/19/14.

Findings:

Review of the hospital policy titled "Staffing Standards", reviewed September 2009 and presented as a current policy by S3Director of Risk Management, revealed that River Oak Hospital's policy is to provide adequate nursing staff to meet the defined needs of patients. An adequate supply of nurses and support personnel are available on a continuing basis.

Further review revealed that the patient requirements for nursing care had the potential for changing from shift to shift, and schedules were to be adjusted on each shift. Nurse Managers were to stay up-to-date on the unit needs and adjust staffing with the nursing staffing coordinator. The admission department could also alert the unit to the admission of a more acute patient requiring closer observation.

Review of the hospital policy titled "Acuity Level Staffing Levels", last reviewed July 2011, currently under review, and presented as a current policy by S3Director of Risk Management, revealed that staffing is adjusted based on acuity, patient census, and staff skill mix. At the start of each shift, the off-going supervisor reports to the on-coming supervisor any patient and staffing issues. The on-coming supervisor checks each unit to discuss the acuity level of patients and the nursing care needs expected for that shift.

Further review revealed that it's the responsibility of the RN (registered nurse) of the unit to notify the Nursing Supervisor of any change in acuity. It's the responsibility of the Supervisor to continually assess staffing throughout the shift and plan for the on-coming shift. In circumstances of higher acuity, staff absences, or admissions, the Supervisor may redistribute staff, call in PRN (as needed) employees, or utilize himself or herself as direct patient caregivers. the Charge Nurse on each shift is to communicate changes in acuity to the Nursing Supervisor, especially related to staffing needs.

Review of the hospital policy titled "Observation Statuses", reviewed and revised July 2014 and presented as the current observation policy by S3Director of Risk Management, revealed that strict visual contact means that the patient is to be seen by a staff member at all times 24 hours a day which always included times the patient attends to personal hygiene as well as when he/she is sleeping. Further review revealed that the patient is to remain in an unobstructed view within 15 feet of the staff member and must be directly, physically accessible to staff.

Review of the hospital's staffing grid revealed the following guidelines for staffing based on census for the Trauma, Dual Diagnosis, and Adult Psych Units:

Census 17 to 19 patients on weekdays: 32 FTEs (full time equivalents) on the day shift - 1 Nurse Manager, 1 RN, and 2 PCs; 32 FTEs on the evening shift - 2 RNs and 2 PCs; 16 FTEs on the night shift - 1 RN and 1 PC;

Census 17 to 19 patients on the weekend: 32 FTEs on the day and evening shifts - 2 RNs and 2 PCs; 16 FTEs on the night shift - 1 RN and 1 PC;

Census 20 to 23 patients on weekdays: 40 FTEs on the day shift - 1 Nurse Manager, 1 RN, and 3 PCs; 40 FTEs on the evening shift - 2 RNs and 3 PCs; 24 FTEs on the night shift -1 RN and 2 PCs;

Census 20 to 23 patients on the weekend: 40 FTEs on the day and evening shifts - 2 RNs and 3 PCs; 24 FTEs on the night shift - 1 RN and 2 PCs;

Census 24 to 26 patients on weekdays: 40 FTEs on the day shift - 1 Nurse Manager, 1 RN, and 3 PCs; 50 FTEs on the evening shift - 2 RNs and 4 PCs (grid shows total evening shift FTEs as 40 hours rather than 50 hours); 24 FTEs on the night shift - 1 RN and 2 PCs;

Census 24 to 26 patients on the weekend: 40 FTEs on the day shift - 2 RNs and 3 PCs; 50 FTEs on the evening shift (2 RNs and 4 PCs) (staffing grid shows total evening shift FTEs as 40 hours rather than 50 hours); 24 FTEs on the night shift - 1 RN and 2 PCs.

Review of the "Nurse Staffing Form" completed by S11Staffing Coordinator for the Trauma Unit and the Adult Psych Unit for 08/05/14 through 08/18/14 and 04/27/14 through 05/10/14 and for the Dual Diagnosis Unit for 08/05/14 through 08/18/14 and 12/08/13 through 12/21/13 revealed staffing did not meet the hospital's guidelines as follows:

Trauma Unit - 10 shifts out of 84 shifts: day shift of 08/15/14; evening shift on 08/06/14, 05/03/14, 04/28/14; night shift on 08/18/14, 08/15/14, 08/14/14, 08/13/14, 08/12/14, 08/06/14;

Dual Diagnosis Unit - 29 shifts out of 84 shifts: day shift of 08/17/14, 08/15/14; evening shift on 08/17/14, 08/15/14, 12/21/13, 12/15/13; night shift on 08/17/14, 08/15/14, 08/14/14, 08/13/14, 08/12/14, 08/11/14, 08/10/14, 08/09/14, 08/08/14, 08/07/14, 12/21/13, 12/20/13, 12/19/13, 12/18/13, 12/17/13, 12/16/13, 12/15/13, 12/14/13, 12/13/13, 12/12/13, 12/11/13, 12/09/13, 12/08/13;

Adult Psych Unit - 22 shifts out of 84 shifts: day shift on 05/03/14, 04/28/14, 04/27/14; evening shift on 08/18/14, 08/15/14, 08/12/14, 08/11/14, 05/07/14, 05/06/14, 05/05/14, 05/02/14, 04/28/14; night shift on 08/18/14, 08/17/14, 08/15/14, 08/11/14, 08/10/14, 08/09/14, 05/06/14, 05/05/14, 04/28/14, 04/27/14.

Patient #5
Review of Patient #5's medical record revealed she was a 20 year old female admitted to the adult psych unit on 08/18/14 at 6:50 p.m. with diagnoses of Bipolar Disorder and Post Traumatic Stress Disorder (PTSD). Review of her "Physician's Admission Orders And Diagnostic Work" received by telephone order by S23RN (registered nurse) revealed Patient #5 was ordered to be on strict visual contact (SVC).

In an interview on 08/19/14 at 11:20 a.m., Patient #5 indicated that she had to sleep on the floor on a mattress in the dayroom (multi-purpose area), because "I had to be watched." She further indicated that she had been a patient at River Oaks previously and knew that she would have to sleep in the dayroom, so she could be watched by staff. Patient #5 indicated that she was able to go to the bathroom alone yesterday (08/18/14) when she arrived on the unit and also fell asleep in her bedroom without staff present to observe her.

Patient #6
Review of Patient #6's medical record revealed she was a 49 year old female admitted to the adult psych unit on 08/18/14 at 8:30 p.m. with diagnoses of Bipolar Disorder and Homicidal Ideations. Review of her "Physician's Admission Orders And Diagnostic Work" received by telephone order by S23RN revealed Patient #6 was ordered to be on SVC.

Review of Patient #6's nursing assessment revealed that her initial admit assessment was completed by S14RN on 08/18/14 (should be 08/19/14) at 12:00 a.m.

In an interview on 08/19/14 at 11:35 a.m., Patient #6 indicated that she was admitted on the evening of 08/18/14 and slept on a sofa in the day room last night. She further indicated that she was told she could sleep on the mattress on the floor of the day room, but she didn't want to sleep on the floor. She further indicated that it bothered her that she could not sleep in her own bed in her room.

In an interview on 08/19/14 at 3:15 p.m., S11Staffing Coordinator indicated she schedules staffing for all nursing units of the hospital. She further indicated that she does it based on the hospital's nursing grid.

She confirmed that the schedule for the night shift (11:00 p.m. on 08/18/14 to 7:00 a.m. on 08/19/14) on 08/18/14 for the Adult Psych Unit had 1 RN and 1 PC scheduled to work.

She further indicated that all the units that night had 1 RN and 1 PC scheduled and working. She further indicated that the staffing grid called for 3 staff, 1 RN and 2 PCs on the night shift for a census of 20 to 24 patients, but she has staffed with 1 RN and 1 PC. When asked if having 2 patients on SVC observation would require additional staff, she answered, "SVC patients should indicate increased acuity and would increase staffing."

S11Staffing Coordinator indicated that she was not notified of patients on SVC before she left for the day at 3:30 p.m. or 4:00 p.m., and she didn't know if the evening supervisor was notified of the need for additional staff.

In an interview on 08/19/14 at 3:25 p.m., S12Evening Supervisor indicated she works the 3:00 p.m to 11:00 p.m. shift. She indicated that she was not informed that the 2 new patients admitted to the Adult Psych Unit were ordered to be on SVC.

She further indicated that the nurse was to inform the patient that SVC meant the patient had to be seen by staff at all times and was supposed to ask the patient if he/she was comfortable sleeping outside their room where they can be seen by staff.

She further indicated that the staff would bring a mattress by the nursing station in the day room in order to have the patient observed by the staff. When asked why the patient can't sleep in his/her own room, S12Evening Supervisor answered, "staff is not able to see the patient at all times with only 2 staff."

When asked if patients have to sleep on a mattress or sofa in the day room because there isn't enough staff, she answered, "I suppose you can say that... if I was told 2 patients were on SVC, I might have tried to get another staff, because to have 2 (patients on SVC), that's pretty serious."

In a telephone interview on 08/20/14 at 9:20 a.m., S14RN indicated both Patient #5 and Patient #6 were admitted to the adult psych unit on the evening shift of 08/18/14. She further indicated that Patient #6's nursing admission assessment had not been done when she came on duty at 11:00 p.m., and she did the nursing assessment for Patient #6.

S14RN indicated that Patient #6 was upset, because she had been on the unit since 8:30 p.m., and no one had done her assessment yet. She further indicated that Patient #6 made statements to the staff that she "will kill herself at River Oaks Hospital."

S14RN indicated that she placed Patient #6 on SVC after that statement was made. She further indicated that Patient #6 had homicidal ideations when she arrived at the hospital, but she wasn't on SVC when she (S14RN) came on duty.

S14RN indicated that she called Patient #6's physician to report the statement made to the staff, and he ordered SVC observation. S14RN indicated Patient #6 slept on the sofa in Dayroom C of the unit where she (S14RN) could observe her, and Patient #5 slept on a mattress on the floor in Dayroom A where S17PC (psych counselor) could observe her.

S14RN indicated that S17PC made the every 15 minute rounds on the other 22 patients on the unit. She further indicated that while S17PC was making the rounds on the other 22 patients, she (S14RN) could not see Patient #5. She further indicated that when S17PC made rounds on Unit C and patient rooms in the alcoves of Unit A and B, he could not see Patient #5. When asked if S17PC had Patient #5 in his sight at all times, she answered, "No, we can't do that; it would be impossible... there's only 2 of us and with 2 SVCs (patients on SVC), we can't see both at all times."

S14RN confirmed that Patient #5 was not observed by a staff member at all times from 11:00 p.m. on 08/18/14 through 7:00 a.m. on 08/19/14. When asked if having patients sleep on a mattress or sofa in the dayroom to be observed when on SVC and not allowed to sleep in their bed in their room is due to staffing, she answered, "Yes."

S14RN indicated that she has asked many times over the years for additional staff, but she didn't ask this night, because "I knew what the policy was... told that no matter what the situation, we would not be given more staff on the night shift." When asked who told her this about the policy, she answered, "it was passed down to me from Administration."

In a telephone interview on 08/20/14 at 2:55 p.m., S23RN indicated that she did not admit Patient #6 and would not have placed on her SVC unless a staff member told her (S23RN) that Patient #6 was ordered to be on SVC. She further indicated that she may have received Patient #6 as a patient for the unit, but she didn't admit her and didn't look at the physician's orders.

In an interview on 08/20/14 at 10:20 a.m., when asked how staffing is affected when there are more than 24 patients on the Dual Diagnosis Unit, since the staffing grid reflects up to a census of 24 patients, S11Staffing Coordinator answered, "the grid continues the same as for 24 patients."

In an interview on 08/20/14 at 11:00 a.m., S11Staffing Coordinator if any changes to staffing are needed after 3:00 p.m., the evening supervisor will handle the staffing needs. She further indicated that she was aware that the staffing for the Trauma, Dual Diagnosis, and Adult Psych Units did not meet the staffing grid based on patient census for the 2 week period from 08/05/14 through 08/18/14. She further indicated that she has been told by S1Administrator to staff 1 RN and 1 PC on the night shift on all the units regardless of census.

In an interview on 08/20/14 at 11:10 a.m., S2Director of Nursing (DON) indicated that she had been the DON at River Oaks Hospital for the past 2 years. She further indicated that the hospital was "staffed like that before I was here."

When asked if, as DON, she had brought to the attention of S1Administrator that the staffing was not being done according to the staffing grid based on patient census, she answered, she answered "It's my understanding that the grid is a guideline... I have addressed that staffing wasn't adequate." She indicated that although the staffing numbers were not changed according to the grid, she was able to get approval to hire a full-time admission person on the night shift to free the nursing supervisor.

S2DON indicated that the person hired had recently quit, and they were trying to replace the position. S2DON indicated that patients sleeping on mattresses in the dayroom when on SVC has always been done since she's been DON, and it has never been addressed. She further indicated that she had no documented evidence of any reports made by her to S1Administrator related to staffing issues.

In an interview on 08/20/14 at 11:20 a.m., S1Administrator indicated that the hospital has staffing guidelines that they try to meet, and when additional staff are available, they "plug them in" where needed. She further indicated that she thinks sometimes physicians order patients to be on SVC when it isn't needed. She indicated that she "thought minimum staffing was 2 staff per census... we don't always get there, that's our goal."

S1Administrator indicated the supervisor and the DON look at admissions and determine if the hospital has the capability to provide the care needed. She further indicated they go on rounds during the day. S1Administrator indicated "there's no piece of paper (to determine acuity) based on what the coordinator or DON feel... don't have an acuity sheet like we had 20 years ago." She could provide no data used to assess patient or unit acuity to determine when additional staff would be required.

Based on record reviews and interviews, the hospital failed to ensure the registered nurse (RN) supervised and evaluated the nursing care of each patient as evidenced by failure of the RN to ensure that patients were observed by psych counselors (PC) as ordered by the physician and according to hospital policy for 2 (#5, #6) of 4 (#1, #4, #5, #6) current inpatients reviewed from a total sample of 6 patients.

Findings:

Review of the hospital policy titled "Observation Statuses", reviewed and revised July 2014 and presented as the current observation policy by S3Director of Risk Management, revealed that strict visual contact means that the patient is to be seen by a staff member at all times 24 hours a day which always included times the patient attends to personal hygiene as well as when he/she is sleeping. Further review revealed that the patient is to remain in an unobstructed view within 15 feet of the staff member and must be directly, physically accessible to staff.

Patient #5
Review of Patient #5's medical record revealed she was a 20 year old female admitted to the adult psych unit on 08/18/14 at 6:50 p.m. with diagnoses of Bipolar Disorder and Post Traumatic Stress Disorder (PTSD). Review of her "Physician's Admission Orders And Diagnostic Work" received by telephone order by S23RN (registered nurse) revealed Patient #5 was ordered to be on strict visual contact (SVC).

Review of Patient #5's "Progress Notes" revealed an entry documented by S23RN on 08/18/14 at 10:00 p.m. that included "Suicidal thoughts & (and) Depression. Can't commit to safety. Placed on SVC for safety/observation."

In an interview on 08/19/14 at 11:20 a.m., Patient #5 indicated that she had to sleep on the floor on a mattress in the dayroom (multi-purpose area), because "I had to be watched." She further indicated that she had been a patient at River Oaks previously and knew that she would have to sleep in the dayroom, so she could be watched by staff.

Patient #5 indicated that she was able to go to the bathroom alone yesterday (08/18/14) when she arrived on the unit and also fell asleep in her bedroom without staff present to observe her. During the interview Patient #5 accompanied the surveyor to her bedroom to demonstrate that S8PC stood outside the open door of the bedroom while she (Patient #5) used the bathroom with the bathroom door slightly ajar. It was noted that a view inside the bathroom was not possible when one stood in the open doorway of the patient room.

In an interview on 08/19/14 at 11:30 a.m., S8PC accompanied the surveyor to Patient #5's bedroom to demonstrate where she stood when Patient #5 used the bathroom. S8PC indicated that she stood in the open doorway of the room while Patient #5 used the bathroom with the bathroom door slightly ajar.

S8PC confirmed that she could not visibly see Patient #5 while she (Patient #5) was in the bathroom. She indicated that the hospital policy for SVC stated that the staff member had to be able to see the patient at all times. She confirmed that she did not follow Patient #5's physician orders or hospital policy when could not visibly see Patient #5 when she was in the bathroom.

Patient #6
Review of Patient #6's medical record revealed she was a 49 year old female admitted to the adult psych unit on 08/18/14 at 8:30 p.m. with diagnoses of Bipolar Disorder and Homicidal Ideations. Review of her "Physician's Admission Orders And Diagnostic Work" received by telephone order by S23RN revealed Patient #6 was ordered to be on SVC.

Review of Patient #6's "Progress Notes" revealed an entry documented by S14RN that included "49 yo (year old) WF (white female) ... alert, oriented x 4 (times 4) pt (patient) angry, agitated, went to her doctor for regular visit stated she would come back with a gun. Pt made statement on unit that she would kill herself while she was here. Placed on SVC status for protection of pt."

Review of Patient #6's nursing assessment revealed that her initial admit assessment was completed by S14RN on 08/18/14 (should be 08/19/14) at 12:00 a.m.

In an interview on 08/19/14 at 11:35 a.m., Patient #6 indicated that she was admitted on the evening of 08/18/14 and slept on a sofa in the day room last night. She further indicated that she was told she could sleep on the mattress on the floor of the day room, but she didn't want to sleep on the floor.

In a telephone interview on 08/20/14 at 9:20 a.m., S14RN indicated both Patient #5 and Patient #6 were admitted to the adult psych unit on the evening shift of 08/18/14.

She further indicated that Patient #6's nursing admission assessment had not been done when she came on duty at 11:00 p.m., and she did the nursing assessment for Patient #6.

S14RN indicated that Patient #6 was upset, because she had been on the unit since 8:30 p.m., and no one had done her assessment yet. She further indicated that Patient #6 made statements to the staff that she "will kill herself at River Oaks Hospital."

S14RN indicated that she placed Patient #6 on SVC after that statement was made. She further indicated that Patient #6 had homicidal ideations when she arrived at the hospital, but she wasn't on SVC when she (S14RN) came on duty.

S14RN indicated that she called Patient #6's physician to report the statement made to the staff, and he ordered SVC observation. S14RN indicated Patient #6 slept on the sofa in Dayroom C of the unit where she (S14RN) could observe her, and Patient #5 slept on a mattress on the floor in Dayroom A where S17PC (psych counselor) could observe her.

S14RN indicated that S17PC made the every 15 minute rounds on the other 22 patients on the unit. She further indicated that while S17PC was making the rounds on the other 22 patients, she (S14RN) could not see Patient #5.

She further indicated that when S17PC made rounds on Unit C and patient rooms in the alcoves of Unit A and B, he could not see Patient #5. When asked if S17PC had Patient #5 in his sight at all times, she answered, "No, we can't do that; it would be impossible... there's only 2 of us and with 2 SVCs (patients on SVC), we can't see both at all times."

S14RN confirmed that Patient #5 was not observed by a staff member at all times from 11:00 p.m. on 08/18/14 through 7:00 a.m. on 08/19/14.

In a telephone interview on 08/20/14 at 2:55 p.m., S23RN indicated that she did not admit Patient #6 and would not have placed on her SVC unless a staff member told her (S23RN) that Patient #6 was ordered to be on SVC. She further indicated that she may have received Patient #6 as a patient for the unit, but she didn't admit her and didn't look at the physician's orders.

In an interview on 08/20/14 at 9:55 a.m., S11Staffing Coordinator indicated S17PC was on vacation out of town and was not available to be interviewed.

Based on record review and interview, the hospital failed to ensure the nursing staff developed and kept current a nursing care plan for identified nursing care needs for each patient as evidenced by failure to develop a care plan for interventions to be used to avoid the need for physical hold during acts of aggression and to address history of bulimia, elopement, seizure disorder, symptoms of Asperger's, and left forearm wound for 1 (#3) of 6 (#1 - #6) patient records reviewed for development and implementation of a nursing care plan.

Findings:

Review of the hospital policy titled "Admission Of Patients - Nursing Assessment", reviewed and revised June 2014 and presented as a current policy by S3Director of Risk Management, revealed that the initial treatment plan is completed within 24 hours of admission and based on the nursing assessments, the Admission's assessment, observation of the patient's behavior, and expressed needs/goals.

Review of the hospital policy titled "Treatment Plan: Initial, Master And Update", reviewed and revised July 2014 and presented as a current policy by S3Director of Risk Management, revealed that the Master Treatment Plan (MTP) is formulated with input from all members of the treatment team including the patient.

Further review revealed that the MTP will be updated and revised according to ongoing reassessment of the patient's clinical needs. The MTP must be completed within 72 hours of admission. Problems which emerge during the patient's hospitalization will be added and dated by the discipline who will address that problem with the patient. Specific goals and measurable objectives or outcomes, interventions planned, recommendations, frequency of treatment procedures and the person responsible are to be documented by the discipline responsible.

Review of Patient #3's medical record revealed she was a 29 year old female admitted to the Trauma Unit on 05/01/14 at 11:30 a.m. with diagnoses of Asperger's, Seizure Disorder, and Reports Trauma. She was discharged on 05/06/14. Review of her "Restraint/Seclusion Order/Record" documented by S9Nurse Manager of the Trauma Unit on 05/01/14 at 1:20 p.m. revealed that Patient #3 was placed in a physical hold at 1:20 p.m. due to her hitting the door, pushing staff, attempting to bite staff, screaming, and pulling off her bandages. Patient #3 was then transferred to the Adult Psych Unit.

Review of Patient #3's medical record revealed she was placed on elopement precautions, had physician orders for treatment of a burn wound to the left forearm, had a history of bulimia and reported her last purging to be a few months prior to hospitalization, and reported having a seizure the week prior to admission to River Oaks Hospital.

Review of Patient #3's "Initial Treatment Plan" documented by S9Nurse Manager for the Trauma Unit on 05/01/14 (no documented evidence of the time the plan was initiated) revealed the sections for educational needs and factors that may influence the patient's ability and readiness to learn were left blank. No identified problems were documented. Goals developed were that the patient will remain safe at the hospital and she will increase positive coping skills. There was no documented evidence that the goals were written as observable, measurable patient behaviors in order to determine when the goals were met.

Review of Patient #3's "Master Treatment Plan" initiated by S13LPC (licensed professional counselor) on 05/04/14 at 12:15 p.m. revealed Patient #3's diagnoses were Asperger's, Seizure Disorder, and report of Trauma. Her problem list included "PTSD" (Post Traumatic Stress Disorder). There was no documented evidence in Patient #3's medical record that she was diagnosed with PTSD by S10Psychiatrist. The treatment plan for "Past Trauma Issues - Generic" included the long term goal that Patient #3 "will learn skills to cope with past trauma issues and be able to manage symptoms in an outpatient setting. There was no documented evidence that the goal was written as observable, measurable patient behaviors in order to determine when the goal would be met.

Review of Patient #3's "Master Treatment Plan" revealed no documented evidence that her treatment plan was developed to include her identified problems of aggression, bulimia, elopement, seizure disorder, Asperger's, and left forearm burn wound with interventions to be used to address these diagnoses and problems.

In an interview on 08/19/14 at 10:40 a.m., S7Interim Nurse Manager for the Adult Psych Unit indicated that developing a treatment plan for PTSD for Patient #3 "looks like a mistake." She confirmed that there was no evidence in Patient #3's medical record that she had been diagnosed by S10Psychiatrist with PTSD. She confirmed that Patient #3's treatment plan did not address the use of restraint, wound care, seizure disorder, Asperger's, and elopement, and it should have. S7Interim Nurse Manager for the Adult Psych Unit indicated that she has done self-study on care plans since taking the role of manager, because the former nurse manager was the only staff who did patients' treatment plans. She further indicated that the staff on her unit need more education on care plans.

In an interview on 08/19/14 at 12:45 p.m., S9Nurse Manager of the Trauma Unit confirmed that she initiated Patient #3's nursing care plan, and it was incomplete. She confirmed that the plan should have addressed restraints, seizures, elopement, and wound care.

In a telephone interview on 08/19/14 at 1:40 p.m., S10Psychiatrist indicated that he did not diagnose Patient #3 as having PTSD, because he didn't have the time to work with her to make the determination that she had PTSD. He further indicated that because someone has trauma doesn't mean that they have PTSD.

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

1) The registered nurse (RN) assigned the nursing care of each patient to nursing personnel who had been trained and demonstrated competency in aggression management as evidenced by having no documented evidence of training and competency for 1 (S9) of 6 RNs' (S7, S9, S14, S15, S16, S23) and 1 (S17) of 2 (S8, S17) psych counselors' (PC) personnel files reviewed for competency in aggression management and

2) RNs had demonstrated competencies in providing care to psychiatric patients on the Adult Psych Unit as evidenced by having competencies determined by completion of tests with no demonstration of nursing skills for 1 (S7) of 6 RNs' (S7, S9, S14, S15, S16, S23) personnel files reviewed for competency in providing psychiatric patient care.

Findings:

1) The registered nurse (RN) assigned the nursing care of each patient to nursing personnel who had been trained and demonstrated competency in aggression management:
Review of the hospital policy titled "Organizational Plan For Competency And Staff Development", revised January 2014 and presented as a current policy by S3Director of Risk Management, revealed that the competency assessment/development process shall be ongoing, and each clinical staff member must participate in competency enhancement programs. Further review revealed that initial and annual mandatory training in Handle With Care was required.

Review of the hospital policy titled "Restraint And Seclusion", reviewed June 2014 and presented as the hospital's current restraint policy by S3Director of Risk Management, revealed that direct care staff are required to attend aggression management training and show evidence of competency related to participating in a code situation, application of restraints, or the monitoring, assessment, and care of a patient in restraints or seclusion. All records documenting completion of training and competency demonstration will be maintained in staff personnel files.

Review of the personnel files of S9Nurse Manager of the Trauma Unit and S17PC revealed no documented evidence of current training and competency in aggression management.

In an interview on 08/20/14 at 2:05 p.m., S3Director of Risk Manager indicated that S9Nurse Manager of the Trauma Unit had transferred to the position of Nurse Manager of the Trauma Unit in December 2013 and did not have Handle With Care training yet. She further indicated that Handle With Care training is presented by S18Patient Advocate, and it's in this course that staff are evaluated for competency in the application of restraints, performing physical holds, and aggression management. S3Director of Risk Manager indicated that S9Nurse Manager of the Trauma Unit had been the Utilization Review Nurse which did not require Handle With Care training. She could not explain why S9Nurse Manager of the Trauma Unit had not attended Handle With Care training when she returned to direct care in December 2013 as required by hospital policy.

In an interview on 08/20/14 at 2:12 p.m., S18Patient Advocate indicated that S17PC's Handle With Care Training had expired on 03/06/14, and he had not attended a course to renew it as required by hospital policy.

2) RNs had demonstrated competencies in providing care to psychiatric patients on the Adult Psych Unit:

Review of the hospital policy titled "Organizational Plan For Competency And Staff Development", revised January 2014 and presented as a current policy by S3Director of Risk Management, revealed that orientation and competency assessment/development shall involve a combination of instruction/documentation by the preceptor, verbal understanding validation by the learner, and demonstration of necessary skills/interventions by the learner.

Review of the personnel file of S7Interim Nurse Manager of the Adult Psych Unit revealed she was hired on 03/11/14 and was licensed as an RN on 01/27/14. Further review revealed that all competencies were evaluated by completion of tests. There was no documented evidence of the observed demonstration of skills and interventions required for providing care to adult psychiatric patients to determine if S7Interim Nurse Manager of the Adult Psych Unit was competent to perform such duties.

In an interview on 08/20/14 at 2:05 p.m., S3Director of Risk Management and Staff Development confirmed that she had no documented evidence of observed evaluations of S7Interim Nurse Manager of the Adult Psych Unit performing psychiatric skills and interventions as required by hospital policy.

Based on observation, interviews, and record reviews, the hospital:

1) failed to ensure that the hospital's policy for medication administration was followed by nursing staff for patient medication management. This failed practice was evidenced by the wrong medication being administered to 1 of 1 patient (#2) out of 3 (#1, #2, #4) sampled patient's medical records reviewed for medication management, and

2) failed to ensure that medication variances were analyzed and integrated into the hospital's work processes in order to meet the needs of the patients and promote patient safety. This failed practice was evidenced by no documented evidence that the hospital was tracking, trending and analyzing medication variances to determine their root causes and no documented evidence that the hospital was integrating medication variances into the hospital work processes.

Findings:

1) failing to ensure that the hospital's policy for medication administration was followed by nursing staff for patient medication management

A review of the hospital policy titled, "Medication and Pharmacy Function: Medication Management", as provided by administration as the most current, revealed in part: The nurse must identify each patient before giving medications using double identifiers to assure patient safety. The nurse will review the patient's MAR verifying the name of the medication, the dosage, the frequency and the route of administration before administering medication to each patient. The nurse will assure that the patient has taken the medication. The nurse will chart the medication administered on the patient's MAR.

An observation on 8/18/14 at 3:00 p.m. of the Medication Room revealed posted signage indicating the 5 (five) rights of patient medication administration (right patient, right medicine, right dose, right route, right time).

Patient #2, a 37 year old male, was admitted to the hospital on 12/09/13 for Drug Rehabilitation and Detoxification with a diagnosis of Opioid Drug Dependence. Patient #2's physician orders included in part: Suboxone 8mg (milligrams) (sublingual) three times a day, Prozac 20 mg daily, Multivitamin daily, Thiamine 100mg daily and Omeprazole 20mg twice a day. S15RN nurse's notes on 12/14/13 revealed the patient began exhibiting rapid "detox withdrawal symptoms" after being administered his 9:00 a.m. medicines. S15RN nurse's notes further revealed that the patient's physician, S22Physician, was notified, and "detox withdrawal symptom protocols" were initiated to help relieve Patient #2's "detox withdrawal symptoms".

A review of the "Healthcare Peer Review Report" (Occurrence Report) for Patient #2 on 12/14/13 revealed in part: Patient #2 was administered the wrong medication (Naltrexone) on 12/14/13 at 9:00 a.m. by S15RN that resulted in rapid "detox withdrawal symptoms" being inadvertently initiated in the patient. The report further revealed the patient's physician (S22Physician) was notified, and the physician ordered "detox withdrawal symptom protocols" to be initiated to help relieve Patient #2's "detox withdrawal symptoms" and she (S22Physician) indicated that Patient #2 most probably received Naltrexone.

In an interview on 08/19/14 at 1:30 p.m. with S15RN, she indicated that she was the Medicine Nurse on the morning of 12/14/13 and administered all the medicines to the patients on the unit to include the morning medicines to Patient #2. S15RN was asked about the "wrong medication" Occurrence Report involving Patient #2 on 12/14/13. S15RN indicated that the morning of 12/14/13 was family day, and it was a very busy day. S15RN indicated that she most probably gave Patient #2 another patient's Naltrexone tablet (which could cause a more rapid detox withdrawal for patients who are on Suboxone). S15RN indicated that when Patient #2 began to suddenly exhibit detox withdrawal symptoms, she notified the patient's physician, S22Physician, who indicated that the patient most probably received Naltrexone.

In an interview on 08/20/14 at 1:30 p.m. with S3Dir. (Director) of RiskMgt (Management)/P.I. (Performance Improvement), she was asked about the "wrong medication" Occurrence Report involving Patient #2 on 12/14/13. S3Dir.of RiskMgt/P.I. indicated that a "Healthcare Peer Review Report" (Occurrence Report) for Patient #2 was completed because the nurse involved did not follow hospital policy on Medication Administration.

2) failing to ensure that medication variances were analyzed and integrated into the hospital's work processes in order to meet the needs of the patients and promote patient safety.

A review of the hospital policy titled, " Medication Variances Documentation and Evaluation Function: Medication Management ", provided by administration as the most current, revealed in part: The purpose of evaluating and documenting medication variances was to help evaluate the types of frequencies of the variances to aid in establishing trends in order to provide a method of medication administration review for nursing personnel. The policy further revealed that all medication variances would be documented and a "Healthcare Peer Review Report" (Occurrence Report) would be completed and forwarded to Risk Management to be reviewed and thoroughly investigated for appropriate action and follow-up.

In an interview on 8/19/14 at 10:30 a.m. with S3Dir.of RiskMgt/P.I., she indicated that she was the Risk Manager for the hospital and all "Healthcare Peer Review Report" (Occurrence Report) for medication variances for nursing were forwarded to her for review.

S3Dir.of RiskMgt/P.I. indicated that the number of the hospital's medication variances were reported to the Corporate office each month and a monthly report (PsychSafe Dashboard) was generated that identified several Patient Safety Work Product benchmarks and Medication Variance percentages was one of them.

S3Dir.of RiskMgt/P.I. indicated that the hospital's Medication Variance percentages were usually below the Corporate national benchmark average of 2.48%. A review of the Corporate report (PsychSafe Dashboard) from December 2013 to July 2014 was reviewed with S3Dir.of RiskMgt/P.I.

The Corporate report (PsychSafe Dashboard) revealed that the national Corporate benchmark percentage average for Medication Variances was established at 2.48%. The report further revealed that the hospital's Medication Variance percentage rate for December 2013 was 3.01% and the Medication Variance percentage rate for March 2014 was 2.86%.

S3Dir.of RiskMgt/P.I. was asked for the hospital's Medication Variances reports for those 2 months and/or the tracking and trending analysis that identified possible root causes for the hospital being over the Corporate national percentage average for those 2 months.

S3Dir.of RiskMgt/P.I. indicated that she used to track and trend medication variances, but she was not tracking and trending medication variances at the present time. S3Dir.of RiskMgt/P.I. further indicated that she was not, at present, evaluating the types of frequencies of the variances or identifying trends to provide a method of medication administration review for the nursing personnel. S3Dir.of RiskMgt/P.I. was unable to provide any hospital specific Medication Variance information that was being analyzed and integrated into the hospital's work processes and/or Performance Improvement committee.

In an interview on 8/20/14 at 10:20 a.m. with S1Administrator, she indicated that the hospital's Risk Management Department was under her direction. S1Administrator was made aware of the interview with S3Dir.of RiskMgt/P.I. S1Administrator indicated that S3Dir.of RiskMgt/P.I. should have been tracking and analyzing all medication variances in order to identify trends and initiate corrective interventions. S1Administrator further indicated that she was not aware that medication variances were not being integrated into the hospital's work processes and/or Performance Improvement committee.

Based on interviews and record reviews, the hospital failed to ensure that the Pharmacist was responsible for supervising and coordinating all the activities of the hospital-wide pharmacy services. This failed practice was evidenced by the Director of Pharmacy failing to establish a process for medication administration review for evaluating and monitoring medication variances.

Findings:

A review of the hospital policy titled, "Medication and Pharmacy Function: Medication Management", as provided by administration as the most current, revealed in part: The hospital had its own Pharmacy and a pharmacist was provided on a contractual basis to supervise and coordinate the activities of the Pharmacy Department.

In an interview on 08/19/14 at 10:45 a.m. with S21RPh (Registered Pharmacist), he indicated that he was the hospital's Director of Pharmacy. S21RPh further indicated that he was responsible for the activities of the hospital's Pharmacy Department. S21RPh was asked for the documentation of the Pharmacy Department's medication variance reports. S21RPh indicated that he only monitored the pharmacist's variances in dispensing the medications as ordered. S21RPh indicated that the nursing department may be monitoring the nursing medication variances, but he was not sure. S21RPh was unable to provide any documentation on medication variances that evaluated and monitored the medication variances for the hospital as part of the hospital's medication administration review.

In an interview on 08/20/14 at 10:20 a.m. with S1Administrator, she indicated that the hospital had its own pharmacy and that a pharmacist was provided on a contractual basis. S1Administrator further indicated that the contract pharmacist, S21RPh, was the Director of the Pharmacy Department and was responsible for all the activities of the Pharmacy Department to include: developing, supervising and coordinating the hospital's Pharmacy Department services. S1Administrator was made aware of the interview with S21RPh. S1Administrator indicated that the contract pharmacist, S21RPh, as the Director of the Pharmacy Department, was responsible for all the activities of the Pharmacy Department and indicated that she was not aware that S21RPh did not have a process in place for medication administration review in order to evaluate and monitor all medication variances.

Based on record reviews and interviews, the hospital failed to meet all special provisions applying to psychiatric hospitals as evidenced by:

1) Failing to meet the requirements for the Condition of Participation for the Special Staffing Requirements For Psychiatric Hospitals (see findings in tag B0136).

Based on record reviews and interviews, the hospital failed to meet the requirements of the Condition of Participation for:

1) Nursing Services as evidenced by failing to ensure the nursing service had adequate numbers of nurses and psych counselors (PC) to provide nursing care to all patients to meet the needs of the patients and according to the hospital staffing grid.

The hospital did not meet the staff requirements according to its staffing grid for a total of 61 shifts from 12/08/13 through 08/18/14 on the Trauma, Dual Diagnosis, and Adult Psych Units.

The staffing on the Adult Psych Unit resulted in 2 patients (#5, #6) with physician orders for strict visual contact (SVC) ( patient to be within a staff member's sight at all times) not being observed by psych counselors (PC) as ordered by the physician and according to hospital policy and requiring the 2 patients to sleep on a mattress on the floor and a sofa in the dayroom to be able to be observed by the 2 staff members (1 RN and 1 PC) who were assigned the care of 24 patients, 2 of whom were on SVC, on 08/18/14 from 11:00 p.m. through 7:00 a.m. on 08/19/14 (see findings in tag A0392).

Based on record review and interview, the hospital failed to ensure each patient had an individualized comprehensive treatment plan as evidenced by failure to develop a treatment plan for interventions to be used to avoid the need for physical hold during acts of aggression and to address a history of bulimia, elopement, seizure disorder, symptoms of Asperger's, and left forearm wound for 1 (#3) of 6 (#1 - #6) patient records reviewed for development and implementation of an individualized comprehensive treatment plan.

Findings:

Review of the hospital policy titled "Admission Of Patients - Nursing Assessment", reviewed and revised June 2014 and presented as a current policy by S3Director of Risk Management, revealed that the initial treatment plan is completed within 24 hours of admission and based on the nursing assessments, the Admission's assessment, observation of the patient's behavior, and expressed needs/goals.

Review of the hospital policy titled "Treatment Plan: Initial, Master And Update", reviewed and revised July 2014 and presented as a current policy by S3Director Of Risk Management, revealed that the Master Treatment Plan (MTP) is formulated with input from all members of the treatment team including the patient.

Further review revealed that the MTP will be updated and revised according to ongoing reassessment of the patient's clinical needs. The MTP must be completed within 72 hours of admission. Problems which emerge during the patient's hospitalization will be added and dated by the discipline who will address that problem with the patient. Specific goals and measurable objectives or outcomes, interventions planned, recommendations, frequency of treatment procedures and the person responsible are to be documented by the discipline responsible.

Review of Patient #3's medical record revealed she was a 29 year old female admitted to the Trauma Unit on 05/01/14 at 11:30 a.m. with diagnoses of Asperger's, Seizure Disorder, and Reports Trauma. She was discharged on 05/06/14.

Review of her "Restraint/Seclusion Order/Record" documented by S9Nurse Manager of the Trauma Unit on 05/01/14 at 1:20 p.m. revealed that Patient #3 was placed in a physical hold at 1:20 p.m. due to her hitting the door, pushing staff, attempting to bite staff, screaming, and pulling off her bandages. Patient #3 was then transferred to the Adult Psych Unit.

Review of Patient #3's medical record revealed she was placed on elopement precautions, had physician orders for treatment of a burn wound to the left forearm, had a history of bulimia and reported her last purging to be a few months prior to hospitalization, and reported having a seizure the week prior to admission to River Oaks Hospital.

Review of Patient #3's "Initial Treatment Plan" documented by S9Nurse Manager for the Trauma Unit on 05/01/14 (no documented evidence of the time the plan was initiated) revealed the sections for educational needs and factors that may influence the patient's ability and readiness to learn were left blank. No identified problems were documented.

Review of Patient #3's "Master Treatment Plan" initiated by S13LPC (licensed professional counselor) on 05/04/14 at 12:15 p.m. revealed Patient #3's diagnoses were Asperger's, Seizure Disorder, and report of Trauma. Her problem list included "PTSD" (Post Traumatic Stress Disorder). There was no documented evidence in Patient #3's medical record that she was diagnosed with PTSD by S10Psychiatrist.

Review of Patient #3's "Master Treatment Plan" revealed no documented evidence that her treatment plan was developed to include her identified problems of aggression, bulimia, elopement, seizure disorder, Asperger's, and left forearm burn wound with interventions to be used to address these diagnoses and problems.

In an interview on 08/19/14 at 10:40 a.m., S7Interim Nurse Manager for the Adult Psych Unit indicated that developing a treatment plan for PTSD for Patient #3 "looks like a mistake." She confirmed that there was no evidence in Patient #3's medical record that she had been diagnosed by S10Psychiatrist with PTSD. She confirmed that Patient #3's treatment plan did not address the use of restraint, wound care, seizure disorder, Asperger's, and elopement, and it should have. S7Interim Nurse Manager for the Adult Psych Unit indicated that she has done self-study on care plans since taking the role of manager, because the former nurse manager was the only staff who did patients' treatment plans. She further indicated that the staff on her unit need more education on care plans.

In an interview on 08/19/14 at 12:45 p.m., S9Nurse Manager of the Trauma Unit confirmed that she initiated Patient #3's nursing care plan, and it was incomplete. She confirmed that the plan should have addressed restraints, seizures, elopement, and wound care.

In a telephone interview on 08/19/14 at 1:40 p.m., S10Psychiatrist indicated that he did not diagnose Patient #3 as having PTSD, because he didn't have the time to work with her to make the determination that she had PTSD. He further indicated that because someone has trauma doesn't mean that they have PTSD.

Based on record review and interview, the hospital failed to ensure that each patient's individualized comprehensive treatment included short-term and long range goals that were written in a way that allowed changes in the patient's behavior to be measured as evidenced by not having long range goals written in observable, measurable patient behaviors for for 1 (#3) of 6 (#1 - #6) patient records reviewed for short-term and long range goals of the individualized comprehensive treatment plan.

Findings:

Review of the hospital policy titled "Admission Of Patients - Nursing Assessment", reviewed and revised June 2014 and presented as a current policy by S3Director of Risk Management, revealed that the initial treatment plan is completed within 24 hours of admission and based on the nursing assessments, the Admission's assessment, observation of the patient's behavior, and expressed needs/goals.

Review of the hospital policy titled "Treatment Plan: Initial, Master And Update", reviewed and revised July 2014 and presented as a current policy by S3Director Of Risk Management, revealed that the Master Treatment Plan (MTP) is formulated with input from all members of the treatment team including the patient. Further review revealed that the MTP will be updated and revised according to ongoing reassessment of the patient's clinical needs. The MTP must be completed within 72 hours of admission. Problems which emerge during the patient's hospitalization will be added and dated by the discipline who will address that problem with the patient. Specific goals and measurable objectives or outcomes, interventions planned, recommendations, frequency of treatment procedures and the person responsible are to be documented by the discipline responsible.

Review of Patient #3's "Initial Treatment Plan" documented by S9Nurse Manager for the Trauma Unit on 05/01/14 (no documented evidence of the time the plan was initiated) revealed the sections for educational needs and factors that may influence the patient's ability and readiness to learn were left blank. No identified problems were documented. Goals developed were that the patient will remain safe at the hospital and she will increase positive coping skills. There was no documented evidence that the goals were written as observable, measurable patient behaviors in order to determine when the goals were met.

Review of Patient #3's "Master Treatment Plan" initiated by S13LPC (licensed professional counselor) on 05/04/14 at 12:15 p.m. revealed Patient #3's diagnoses were Asperger's, Seizure Disorder, and report of Trauma. Her problem list included "PTSD" (Post Traumatic Stress Disorder). There was no documented evidence in Patient #3's medical record that she was diagnosed with PTSD by S10Psychiatrist. The treatment plan for "Past Trauma Issues - Generic" included the long term goal that Patient #3 "will learn skills to cope with past trauma issues and be able to manage symptoms in an outpatient setting. There was no documented evidence that the goal was written as observable, measurable patient behaviors in order to determine when the goal would be met.

Review of Patient #3's "Master Treatment Plan" revealed no documented evidence that her treatment plan was developed to include her identified problems of aggression, bulimia, elopement, seizure disorder, Asperger's, and left forearm burn wound with interventions to be used to address these diagnoses and problems with observable, measurable short-term and long range goals.

In an interview on 08/19/14 at 10:40 a.m., S7Interim Nurse Manager for the Adult Psych Unit indicated that developing a treatment plan for PTSD for Patient #3 "looks like a mistake." She confirmed that there was no evidence in Patient #3's medical record that she had been diagnosed by S10Psychiatrist with PTSD. She confirmed that Patient #3's treatment plan did not address the use of restraint, wound care, seizure disorder, Asperger's, and elopement with related interventions and goals, and it should have. S7Interim Nurse Manager for the Adult Psych Unit indicated that she has done self-study on care plans since taking the role of manager, because the former nurse manager was the only staff who did patients' treatment plans. She further indicated that the staff on her unit need more education on care plans.

In an interview on 08/19/14 at 12:45 p.m., S9Nurse Manager of the Trauma Unit confirmed that she initiated Patient #3's treatment plan, and it was incomplete. She confirmed that the plan should have addressed interventions and goals related to restraints, seizures, elopement, and wound care.

In a telephone interview on 08/19/14 at 1:40 p.m., S10Psychiatrist indicated that he did not diagnose Patient #3 as having PTSD, because he didn't have the time to work with her to make the determination that she had PTSD. He further indicated that because someone has trauma doesn't mean that they have PTSD.

Based on record reviews and interviews, the hospital failed to meet the requirements for the Condition of Participation of Special Staff Requirements for Psych Hospitals as evidenced by:

1) Failing to provide an adequate number of nurses and mental health workers to provide the nursing care necessary under each patient's active treatment program as evidenced by:

a) The staffing of 1 RN (registered nurse) and 1 PC (psych counselor) on the Adult Psych Unit on the night shift of 08/18/14 (11:00 p.m. to 7:00 a.m.) with 24 patients, 2 (#5, #6) of whom were physician-ordered to be on strict visual contact (SVC) (patient to be within a staff member's sight at all times), resulted in Patient #5 and Patient #6 not being observed at all times by psych counselors (PC) as ordered by the physician and according to hospital policy. Patient #5 was required to sleep on a mattress in the dayroom and Patient #6 was required to sleep on the sofa in the dayroom in order for the 2 staff members to attempt to keep the patients within their sight and

b) The hospital did not provide an adequate number of nurses and mental health workers to meet the needs of the patients and according to its staffing grid for a total of 61 shifts from 12/08/13 through 08/18/14 on the Trauma, Dual Diagnosis, and Adult Psych Units. (see findings in tag B0150).

Based on record reviews and interviews, the hospital failed to provide an adequate number of nurses and mental health workers to provide the nursing care necessary under each patient's active treatment program as evidenced by:

1) The staffing of 1 RN (registered nurse) and 1 PC (psych counselor) on the Adult Psych Unit on the night shift of 08/18/14 (11:00 p.m. to 7:00 a.m.) with 24 patients, 2 (#5, #6) of whom were physician-ordered to be on strict visual contact (SVC) (patient to be within a staff member's sight at all times), resulted in Patient #5 and Patient #6 not being observed at all times by psych counselors (PC) as ordered by the physician and according to hospital policy. Patient #5 was required to sleep on a mattress in the dayroom and Patient #6 was required to sleep on the sofa in the dayroom in order for the 2 staff members to attempt to keep the patients within their sight.

2) The hospital did not provide an adequate number of nurses and mental health workers to meet the needs of the patients and according to its staffing grid for a total of 61 shifts from 12/08/13 through 08/18/14 on the Trauma, Dual Diagnosis, and Adult Psych Units.

Findings:

Review of the hospital policy titled "Staffing Standards", reviewed September 2009 and presented as a current policy by S3Director of Risk Management, revealed that River Oak Hospital's policy is to provide adequate nursing staff to meet the defined needs of patients. An adequate supply of nurses and support personnel are available on a continuing basis. Further review revealed that the patient requirements for nursing care had the potential for changing from shift to shift, and schedules were to be adjusted on each shift. Nurse Managers were to stay up-to-date on the unit needs and adjust staffing with the nursing staffing coordinator. The admission department could also alert the unit to the admission of a more acute patient requiring closer observation.

Review of the hospital policy titled "Acuity Level Staffing Levels", last reviewed July 2011, currently under review, and presented as a current policy by S3Director of Risk Management, revealed that staffing is adjusted based on acuity, patient census, and staff skill mix. At the start of each shift, the off-going supervisor reports to the on-coming supervisor any patient and staffing issues. The on-coming supervisor checks each unit to discuss the acuity level of patients and the nursing care needs expected for that shift. Further review revealed that it's the responsibility of the RN (registered nurse) of the unit to notify the Nursing Supervisor of any change in acuity. It's the responsibility of the Supervisor to continually assess staffing throughout the shift and plan for the on-coming shift. In circumstances of higher acuity, staff absences, or admissions, the Supervisor may redistribute staff, call in PRN (as needed) employees, or utilize himself or herself as direct patient caregivers. the Charge Nurse on each shift is to communicate changes in acuity to the Nursing Supervisor, especially related to staffing needs.

Review of the hospital policy titled "Observation Statuses", reviewed and revised July 2014 and presented as the current observation policy by S3Director of Risk Management, revealed that strict visual contact means that the patient is to be seen by a staff member at all times 24 hours a day which always included times the patient attends to personal hygiene as well as when he/she is sleeping. Further review revealed that the patient is to remain in an unobstructed view within 15 feet of the staff member and must be directly, physically accessible to staff.

1) The staffing of 1 RN and 1 PC on the Adult Psych Unit on the night shift of 08/18/14 with 24 patients, 2 of whom were physician-ordered to be on SVC, resulted in Patient #5 and Patient #6 not being observed at all times by PCs as ordered by the physician and according to hospital policy:

Patient #5
Review of Patient #5's medical record revealed she was a 20 year old female admitted to the adult psych unit on 08/18/14 at 6:50 p.m. with diagnoses of Bipolar Disorder and Post Traumatic Stress Disorder (PTSD). Review of her "Physician's Admission Orders And Diagnostic Work" received by telephone order by S23RN (registered nurse) revealed Patient #5 was ordered to be on strict visual contact (SVC).

In an interview on 08/19/14 at 11:20 a.m., Patient #5 indicated that she had to sleep on the floor on a mattress in the dayroom (multi-purpose area), because "I had to be watched." She further indicated that she had been a patient at River Oaks previously and knew that she would have to sleep in the dayroom, so she could be watched by staff. Patient #5 indicated that she was able to go to the bathroom alone yesterday (08/18/14) when she arrived on the unit and also fell asleep in her bedroom without staff present to observe her.

Patient #6
Review of Patient #6's medical record revealed she was a 49 year old female admitted to the adult psych unit on 08/18/14 at 8:30 p.m. with diagnoses of Bipolar Disorder and Homicidal Ideations. Review of her "Physician's Admission Orders And Diagnostic Work" received by telephone order by S23RN revealed Patient #6 was ordered to be on SVC.

Review of Patient #6's nursing assessment revealed that her initial admit assessment was completed by S14RN on 08/18/14 (should be 08/19/14) at 12:00 a.m.

In an interview on 08/19/14 at 11:35 a.m., Patient #6 indicated that she was admitted on the evening of 08/18/14 and slept on a sofa in the day room last night. She further indicated that she was told she could sleep on the mattress on the floor of the day room, but she didn't want to sleep on the floor. She further indicated that it bothered her that she could not sleep in her own bed in her room.

In an interview on 08/19/14 at 3:25 p.m., S12Evening Supervisor indicated she works the 3:00 p.m to 11:00 p.m. shift. She indicated that she was not informed that the 2 new patients admitted to the Adult Psych Unit were ordered to be on SVC. She further indicated that the nurse was to inform the patient that SVC meant the patient had to be seen by staff at all times and was supposed to ask the patient if he/she was comfortable sleeping outside their room where they can be seen by staff. She further indicated that the staff would bring a mattress by the nursing station in the day room in order to have the patient observed by the staff.

When asked why the patient can't sleep in his/her own room, S12Evening Supervisor answered, " staff is not able to see the patient at all times with only 2 staff." When asked if patients have to sleep on a mattress or sofa in the day room because there isn't enough staff, she answered, "I suppose you can say that... if I was told 2 patients were on SVC, I might have tried to get another staff, because to have 2 (patients on SVC), that's pretty serious."

In a telephone interview on 08/20/14 at 9:20 a.m., S14RN indicated both Patient #5 and Patient #6 were admitted to the adult psych unit on the evening shift of 08/18/14. She further indicated that Patient #6's nursing admission assessment had not been done when she came on duty at 11:00 p.m., and she did the nursing assessment for Patient #6.

S14RN indicated that Patient #6 was upset, because she had been on the unit since 8:30 p.m., and no one had done her assessment yet. She further indicated that Patient #6 made statements to the staff that she "will kill herself at River Oaks Hospital."

S14RN indicated that she placed Patient #6 on SVC after that statement was made. She further indicated that Patient #6 had homicidal ideations when she arrived at the hospital, but she wasn't on SVC when she (S14RN) came on duty.

S14RN indicated that she called Patient #6's physician to report the statement made to the staff, and he ordered SVC observation. S14RN indicated Patient #6 slept on the sofa in Dayroom C of the unit where she (S14RN) could observe her, and Patient #5 slept on a mattress on the floor in Dayroom A where S17PC (psych counselor) could observe her. S14RN indicated that S17PC made the every 15 minute rounds on the other 22 patients on the unit.

She further indicated that while S17PC was making the rounds on the other 22 patients, she (S14RN) could not see Patient #5. She further indicated that when S17PC made rounds on Unit C and patient rooms in the alcoves of Unit A and B, he could not see Patient #5. When asked if S17PC had Patient #5 in his sight at all times, she answered, "No, we can't do that; it would be impossible... there's only 2 of us and with 2 SVCs (patients on SVC), we can't see both at all times."

S14RN confirmed that Patient #5 was not observed by a staff member at all times from 11:00 p.m. on 08/18/14 through 7:00 a.m. on 08/19/14. When asked if having patients sleep on a mattress or sofa in the dayroom to be observed when on SVC and not allowed to sleep in their bed in their room is due to staffing, she answered, "Yes."

S14RN indicated that she has asked many times over the years for additional staff, but she didn't ask this night, because "I knew what the policy was... told that no matter what the situation, we would not be given more staff on the night shift." When asked who told her this about the policy, she answered, "it was passed down to me from Administration."

In a telephone interview on 08/20/14 at 2:55 p.m., S23RN indicated that she did not admit Patient #6 and would not have placed on her SVC unless a staff member told her (S23RN) that Patient #6 was ordered to be on SVC. She further indicated that she may have received Patient #6 as a patient for the unit, but she didn't admit her and didn't look at the physician's orders.

2) The hospital did not meet the staff requirements according to its staffing grid for a total of 61 shifts from 12/08/13 through 08/18/14 on the Trauma, Dual Diagnosis, and Adult Psych Units:

Review of the hospital's staffing grid revealed the following guidelines for staffing based on census for the Trauma, Dual Diagnosis, and Adult Psych Units:

Census 17 to 19 patients on weekdays: 32 FTEs (full time equivalents) on the day shift - 1 Nurse Manager, 1 RN, and 2 PCs; 32 FTEs on the evening shift - 2 RNs and 2 PCs; 16 FTEs on the night shift - 1 RN and 1 PC;

Census 17 to 19 patients on the weekend: 32 FTEs on the day and evening shifts - 2 RNs and 2 PCs; 16 FTEs on the night shift - 1 RN and 1 PC;

Census 20 to 23 patients on weekdays: 40 FTEs on the day shift - 1 Nurse Manager, 1 RN, and 3 PCs; 40 FTEs on the evening shift - 2 RNs and 3 PCs; 24 FTEs on the night shift -1 RN and 2 PCs;

Census 20 to 23 patients on the weekend: 40 FTEs on the day and evening shifts - 2 RNs and 3 PCs; 24 FTEs on the night shift - 1 RN and 2 PCs;

Census 24 to 26 patients on weekdays: 40 FTEs on the day shift - 1 Nurse Manager, 1 RN, and 3 PCs; 50 FTEs on the evening shift - 2 RNs and 4 PCs (grid shows total evening shift FTEs as 40 hours rather than 50 hours); 24 FTEs on the night shift - 1 RN and 2 PCs;

Census 24 to 26 patients on the weekend: 40 FTEs on the day shift - 2 RNs and 3 PCs; 50 FTEs on the evening shift (2 RNs and 4 PCs) (staffing grid shows total evening shift FTEs as 40 hours rather than 50 hours); 24 FTEs on the night shift - 1 RN and 2 PCs.

Review of the "Nurse Staffing Form" completed by S11Staffing Coordinator for the Trauma Unit and the Adult Psych Unit for 08/05/14 through 08/18/14 and 04/27/14 through 05/10/14 and for the Dual Diagnosis Unit for 08/05/14 through 08/18/14 and 12/08/13 through 12/21/13 revealed staffing did not meet the hospital's guidelines as follows:

Trauma Unit - 10 shifts out of 84 shifts: day shift of 08/15/14; evening shift on 08/06/14, 05/03/14, 04/28/14; night shift on 08/18/14, 08/15/14, 08/14/14, 08/13/14, 08/12/14, 08/06/14;

Dual Diagnosis Unit - 29 shifts out of 84 shifts: day shift of 08/17/14, 08/15/14; evening shift on 08/17/14, 08/15/14, 12/21/13, 12/15/13; night shift on 08/17/14, 08/15/14, 08/14/14, 08/13/14, 08/12/14, 08/11/14, 08/10/14, 08/09/14, 08/08/14, 08/07/14, 12/21/13, 12/20/13, 12/19/13, 12/18/13, 12/17/13, 12/16/13, 12/15/13, 12/14/13, 12/13/13, 12/12/13, 12/11/13, 12/09/13, 12/08/13;

Adult Psych Unit - 22 shifts out of 84 shifts: day shift on 05/03/14, 04/28/14, 04/27/14; evening shift on 08/18/14, 08/15/14, 08/12/14, 08/11/14, 05/07/14, 05/06/14, 05/05/14, 05/02/14, 04/28/14; night shift on 08/18/14, 08/17/14, 08/15/14, 08/11/14, 08/10/14, 08/09/14, 05/06/14, 05/05/14, 04/28/14, 04/27/14.

In an interview on 08/19/14 at 3:15 p.m., S11Staffing Coordinator indicated she schedules staffing for all nursing units of the hospital. She further indicated that she does it based on the hospital's nursing grid.

She confirmed that the schedule for the night shift (11:00 p.m. on 08/18/14 to 7:00 a.m. on 08/19/14) on 08/18/14 for the Adult Psych Unit had 1 RN and 1 PC scheduled to work.

She further indicated that all the units that night had 1 RN and 1 PC scheduled and working. She further indicated that the staffing grid called for 3 staff, 1 RN and 2 PCs on the night shift for a census of 20 to 24 patients, but she has staffed with 1 RN and 1 PC.

When asked if having 2 patients on SVC observation would require additional staff, she answered, "SVC patients should indicate increased acuity and would increase staffing." S11Staffing Coordinator indicated that she was not notified of patients on SVC before she left for the day at 3:30 p.m. or 4:00 p.m., and she didn't know if the evening supervisor was notified of the need for additional staff.

In an interview on 08/20/14 at 10:20 a.m., when asked how staffing is affected when there are more than 24 patients on the Dual Diagnosis Unit, since the staffing grid reflects up to a census of 24 patients, S11Staffing Coordinator answered, "the grid continues the same as for 24 patients."

In an interview on 08/20/14 at 11:00 a.m., S11Staffing Coordinator indicated if any changes to staffing are needed after 3:00 p.m., the evening supervisor will handle the staffing needs. She further indicated that she was aware that the staffing for the Trauma, Dual Diagnosis, and Adult Psych Units did not meet the staffing grid based on patient census for the 2 week period from 08/05/14 through 08/18/14. She further indicated that she has been told by S1Administrator to staff 1 RN and 1 PC on the night shift on all the units regardless of census.

In an interview on 08/20/14 at 11:10 a.m., S2Director of Nursing (DON) indicated that she had been the DON at River Oaks Hospital for the past 2 years. She further indicated that the hospital was "staffed like that before I was here."

When asked if, as DON, she had brought to the attention of S1Administrator that the staffing was not being done according to the staffing grid based on patient census, she answered, "It's my understanding that the grid is a guideline... I have addressed that staffing wasn't adequate." She indicated that although the staffing numbers were not changed according to the grid, she was able to get approval to hire a full-time admission person on the night shift to free the nursing supervisor.

S2DON indicated that the person hired had recently quit, and they were trying to replace the position. S2DON indicated that patients sleeping on mattresses in the dayroom when on SVC has always been done since she's been DON, and it has never been addressed. She further indicated that she had no documented evidence of any reports made by her to S1Administrator related to staffing issues.

In an interview on 08/20/14 at 11:20 a.m., S1Administrator indicated that the hospital has staffing guidelines that they try to meet, and when additional staff are available, they "plug them in" where needed.

She further indicated that she thinks sometimes physicians order patients to be on SVC when it isn't needed. She indicated that she "thought minimum staffing was 2 staff per census... we don't always get there, that's our goal."

S1Administrator indicated the supervisor and the DON look at admissions and determine if the hospital has the capability to provide the care needed. She further indicated they go on rounds during the day.

S1Administrator indicated "there's no piece of paper (to determine acuity) based on what the coordinator or DON feel... don't have an acuity sheet like we had 20 years ago." She could provide no data used to assess patient or unit acuity to determine when additional staff would be required.