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Based on record review and staff interview, the hospital failed to ensure nursing service had adequate numbers of nurse and psych counselors (PC) on the 11:00 p.m. to 7:00 a.m. shift according to the revised staffing ratio of 1:9 staff to patient on 6 of 18 11 p.m. to 7 a.m. shifts reviewed for 3 units. Findings:

Review of the hospital's corrective action plan from the 08/20/14 survey revealed the nursing staffing grid was revised to assign a 1:6 staff to patient ration on the day and evening shifts and a 1:9 staff to patient ration on the night shift (11:00 p.m. to 7:00 p.m.).

Review of the revised Staffing Grid revealed the Child & Adolescent Unit, Trauma Unit, Dual Diagnosis Unit, and the Adult Unit would only have 2 staff on the 11:00 p.m. to 7:00 a.m. shift for a patient census from 2 to 24 patients. The grid revealed an additional staff member was not added until the patient census reached 25 patients, resulting in a staff to patient ratio greater than 1:9 when the patient census was 19 up to and including 24.

Review of the Nursing Assignment Sheets from 10/10/14 to 10/15/14 for the Adult Unit, and the Dual Diagnosis Unit revealed the following on the 11:00 p.m. to 7:00 a.m. shift:
Dual Diagnosis Unit:
10/10/14 - census of 21 with 1RN and 1 PC (Ratio 1:10, 1:11)
10/11/14 - census of 21 with 1RN and 1 PC (Ratio 1:10, 1:11)
10/13/14 - census of 24 with 1RN and 1 PC (Ratio 1:12)
10/14/14 - census of 20 with 1RN and 1 PC (Ratio 1:10)

Adult Unit:
10/12/14 - census of 19 with 1 RN and 1 PC (Ratio 1:9, 1:10)
10/14/14 - census of 19 with 1 RN and 1 PC (Ratio 1:9, 1:10)

In an interview on 10/15/14 at 2:15 p.m., S2DON (Director of Nursing) stated the Staffing Grid was the "Bare minimum." S2DON verified they do not increase the 11:00 p.m. to 7:00 a.m. staff until the census reaches 25 patients. She verified this was not a 1:9 staff to patient ratio. S2DON stated there was no policy to explain the Staffing Grid and they had only revised the Staffing Grid. S2DON stated she thought the Staffing Grid reflected a 1:9 ratio and again verified there are only 2 staff on the 11:00 p.m. to 7:00 a.m. shift until the census reaches 25 for the Adult Unit, Trauma Unit, Dual Diagnosis Unit, and the Child/Adolescent Unit. After reviewing the above Nursing Assignment Sheets, S2DON confirmed the above shifts did not have a 1:9 staff to patient ratio.





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Based on interview and record review, the hospital failed to ensure drugs and biologicals were controlled and distributed by acceptable standards of practice as evidenced by the pharmacist failing to review all first dose medications for appropriateness, duplication, interactions, allergies, sensitivities or other contraindications before the dose was dispensed and administered to patients.

Findings:

Review of the hospital's policy titled, "Access to Medication When the Pharmacy is Closed", policy number 5.09, provided by S1ADM (Administrator) revealed in part the following: ....Medications are only obtained prior to a pharmacist's review, when the clinical condition of the patient warrants immediate administration of that medication....When the pharmacy is closed, medication orders are reviewed by a health care professional determined to be qualified by the hospital....A pharmacist is readily available, either on-call or at another location, to provide medication information or provide medications that are not accessible to non-pharmacy staff. A pharmacist conducts a retrospective review of all medication orders as soon as a pharmacist is available or the pharmacy opens....

In an interview on 10/15/14 at 11:10 a.m., S3Director of Risk Management/PI (Performance Improvement) stated the hospital contracted the pharmacy services and stated the Pharmacy was open from 6:30 a.m./7:00 a.m. to 3:00 p.m. S3Director of Risk Management/PI stated after hours the hospital uses a "Night Locker" of medications and the "PINC" (Pharmacy Intervention Nursing Compliance) system to check for contraindications of the medication when a new medication is ordered after the pharmacy is closed. S3Director of Risk Management/PI explained the "PINC" system was a computer software system developed by the consulting pharmacy. She explained the nurse enters the patient's name into the system and the system pulls up the patient's medication profile. She stated the nurse then enters the new medication and the "PINC" system alerts if there are any contraindications. S3Director of Risk Management/PI stated if the "PINC" system identified any contraindications, the nurse was to contact the patient's physician. S3Director of Risk Management/PI stated the Pharmacist does not review the patient's medications until the next day when the pharmacy is open. S1ADM (Administrator) who was also present for the interview stated the staff does not start all medications at night, and stated they only give the patients what they need at night and what the physician orders.

In an interview on 10/16/14 at 10:05 a.m., S4RPH stated he was the Director of Pharmacy. S4RPH verified the hospital used the "PINC" system to review new medications ordered after the pharmacy closed at 3:00 p.m. S4RPH stated he reviews new medication orders when he comes in the following day at 6:00 a.m. S4RPH stated, "It's the first thing we do." S4RPH verified this review was after the patient had received the first dose of the new medication. S4RPH further stated he was on-call 24 hours a day and was called 3 times last night. S4RPH stated he did not have a way to review patient medications at home and stated the staff would have to verbally report the patient's medications. S4RPH stated one of the calls he received last night was a nurse who was not sure about contraindications. S4RPH stated he did not do a review of the patient's medications and he instructed the nurse to contact the physician. A log of the medication usage from the "Night Locker" was requested for review.

Review of the Pharmacy Night Cabinet Log from 10/01/14 to 10/15/14 revealed 25 routinely ordered new medications were removed from the "Night Locker." for 23 different patients.

Review of the medical record for Patient #4 revealed the patient was admitted to the hospital on 10/13/14 at 10:57 a.m. with a diagnosis of PTSD (Post Traumatic Stress Disorder). Review of the physician's orders dated/timed 10/13/14 at 9:10 p.m. revealed a verbal order as follows: Unit Restriction. Haldol 5 mg. Benadryl 25 mg. by mouth every 6 hours as needed for agitation. Haldol 5 mg./Benadryl 25 mg. Intramuscular injection (IM) every 6 hours as needed for psychotic agitation. If psychotic agitation continues after Haldol 5mg./Benadryl 25 mg. injection is given, add Ativan 2 mg. IM every 6 hours as needed for psychotic agitation. Review of the MAR (Medication Administration Record) dated 10/13/14 revealed the patient received the oral dose of Haldol/Benadryl at 9:10 p.m. and the IM dose of Haldol/Benadryl at 9:20 p.m. There was no documented evidence that the medications were removed from the "Night Locker" (not on Pharmacy Night Cabinet Log) and there was no evidence the pharmacist reviewed the medication orders prior to the first dose.

In an interview on 10/16/14 at 2:20 p.m., S3Director of Risk Management/PI provided the following information on the "PINC" system for review: "Using the "PINC" program to review medication orders during times when the pharmacy is closed. Your facility has provided you with a new tool to help with the review and documentation process of medications that are being removed from the pharmacy night cabinet during times when the pharmacy is closed. This software program allows approved personnel access to review the patient pharmacy profile and "post" newly prescribed medications against existing profiled medications to determine whether there are drug/drug, food/drug, or patient allergy. If a problem is found the operator will be prompted on screen that the software system found a problem and will automatically print out a drug/drug, food/drug, or allergy monograph....Nursing Administration will determine which individuals will have access to the "PINC" program...." S3Director of Risk Management/PI stated the program required 2 nurses to access and stated one of the nurses was the Supervisor.

Based on record review and staff interview, the hospital failed to ensure the comprehensive treatment plan was updated with the use of seclusion for 1 of 1 (#1) sampled patients reviewed for restraint/seclusion out of a total sample of 4 (#1-#4). Findings:

Review of the hospital policy titled, "Restraint and Seclusion Function: Care of Patient" revised date of 09/14, revealed in part the following:....15.0 Treatment Plan Review/Revision: when the patient has presented behavior that is dangerous to themselves or others so that restraint/seclusion were indicated, a review and modification of the treatment plan is indicated. based upon the consultation with the attending physician or LIP (Licensed Independent Practitioner), information gathered from the debriefing with the patient, and the 1-hour fae-to-face assessment, the RN shall review and update the treatment plan within 8 hours. The entire treatment team will review the plan at the next scheduled review. The updated treatment plan shall reflect:
15.1 The identification of an assessed problem associated with the use of restraint/seclusion.
15.2 Goals related to prevention of the further use of restraint/seclusion.
15.3 Interventions which define alternative approaches to address the identified problem. Responsibility for each intervention is assigned.
15.4 Review of the plan with the patient.....
Treatment plan review/revision following the episode of restrain/seclusion. The treatment plan revision will include interventions to prevent future use.

Patient #1
Review of the medical record for Patient #1 revealed the patient was a 10 year old female admitted to the hospital on 10/11/14 under a PEC (Physician's Emergency Certificate) for homicidal ideations, dangerous to others, and unable to seek voluntary admission.

Review of the patient's record revealed on 10/11/14 at 9:05 p.m., Patient #1 was placed in locked seclusion for 30 minutes after banging on the wall, throwing a table, chairs and cups of water at staff.

Review of the Master Treatment Plan revealed on 10/11/14 the problem, "Danger to Others" was added to the treatment plan. Review of the pre-printed problem sheet titled, "Danger to Others" revealed short-term goals of, "Patient will not assault peers or staff while hospitalized", and "Patient will not verbally lash out/threaten others for 3 days."
The pre-printed interventions selected to meet the stated goals were as follows:
RN to assess patient's behavior.
Licensed nurse to administer medication as ordered: (No specific medication documented)
Staff will not room patient with another patient who is vulnerable.
Staff to keep distance when interacting with patient.
Staff will assist patient to identify alternative coping skills.
Utilize chosen de-escalation techniques when redirection necessary.
There was no documented evidence specific individualized interventions to prevent further use of seclusion. There was no mention of the use of seclusion in the treatment plan. There was no documented evidence of specific alternative coping skills or the chosen de-escalation techniques.

Further review of the patient's medical record revealed Patient #1 was again placed in seclusion on 10/12/14 at 1:30 p.m. for 8 minutes after throwing chairs, ripped papers out of charts, throwing items at staff, and attempted to turn over the television. Review of the Master Treatment Plan revealed no documented evidence of a revision after the second episode of the use of seclusion.

In an interview on 10/16/14 at 11:40 a.m., S2DON (Director of Nursing) reviewed the Master Treatment Plan for Patient #1 and verified the only revision to the treatment plan after the seclusion was the "Danger to Others" pre-printed form. S2DON verified there was no revision after the second use of seclusion. S2DON verified the use of seclusion was not documented in the treatments plan.



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