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Based on document review and interview, the facility failed to ensure a patients safety requirements were met related to a patient being physically assaulted (Tag 142), failed to ensure patients were provided care in a safe setting by identifying patients at risk of intentionally trying to harm others (Tag 144), and failed to ensure patients were free from abuse and harassment related to inadequate staffing (Tag 145).

The cumulative effects of the above prevented the facility from protecting and promoting patient rights.

Based on document review and interview, the facility failed to ensure a patient's safety and security were maintained during one (1) inpatient admission. (Patient # 1)

Findings include;

1. Review of the hospital policy titled, "Patient Rights and Responsibilities", origination date 11/05/2005, indicated the "Patient's Rights and Responsibilities" are guidelines to promote the dignity and autonomy of its patients and to contribute to the quality of patient care. I...The "right to expect reasonable personal safety and security as far as the hospital practices and environment are concerned...patients may be placed in protective privacy when considered necessary for personal safety". This policy was last reviewed 07/05/2018 with no changes made.

2. Review of the hospital patient's handbook titled, "What Every Patient Should Know-Patient Rights and Responsibilities", copyright 2016, indicated on pg 5 of 32: "As a Patient You Have the Right to"....pg 7..."Expect reasonable personal safety and security", and "be free from "all abuse".

3. Review of the closed MR for patient # 1 indicated the following:
A. The patient was a 21 y/o (year/old) admitted to room 283-2 at H # 1 (Psychiatric Hospital) on 06/21/2018 at 1:06 am, on a "72 hour emergency detention order".
B. The Comprehensive Psychiatric Evaluation/Discharge Summary completed on 06/24/2018 at approximately 12:30 pm by MS # 1 (Physician), once the patient was admitted to the unit, he/she was given "Benadryl 50 mg (milligrams) IM (intramuscular), Haldol 5 mg IM and Ativan 2 mg IM".
C. The patient's diagnoses included, but were not limited to, Axis I: Bipolar disorder, manic with psychotic symptoms, rule out schizoaffective disorder, and rule out substance induced psychosis.
D. Review of the narrative note dated 06/21/2018 at approximately 2:00 am, by NS # 1, indicated the patient "is resting in bed ( room # 283) with eyes closed' and even, unlabored respirations noted. "No s/sx" (signs/symptoms) "distress noted" at this time. "PRN" (as needed) "Haldol, Benadryl, and Ativan" were effective.
E. Review of the "Patient Monitoring Rounds" sheet from 06/21/2018 indicated at 2:00 am, 2:15 am, 2:30 am and 3:00 am the patient's "Mood" (calm), "Behavior" (eyes closed/resting) and "Location" (bed) had been documented.
G. Review of the narrative note dated 06/21/2018 at approximately 7:14 am, by NS # 1 (Registered Nurse), indicated "upon entry" to the room at approximately 3:15 am, the patient was found lying "face down on the floor" between patient one (1) and patient two's (2's) bed. Blood was "on the floor" between the two beds, on patient # 1's "pillow", and on patient # 1's "mattress". Both of the patient's "eyes were swollen", and the patient's left eye, nose and mouth were also bloody. "Strips of redness" were noted to the "patient's anterior (front) neck". The patient "was not responsive to auditory or tactile stimulus". NS # 2 called "911", security and MS # 4 (Nurse Practitioner). NS # 2 (Registered Nurse) and PS # 1 (Mental Health Technician) continued to help the patient while the second MHT grabbed the crash cart.
H. Review of the Fire Department data indicated they arrived on scene at 3:26 am, were with the patient at 3:30 am, departed the scene at 3:40 am, and arrived at H # 2 (Acute Care Hospital) at 3:44 am.
I. Review of the Discharge Summary from H # 2 dated 06/25/2018 by MS # (Physician), indicated the patient was admitted to the ICU (Intensive Care Unit) on 06/21/2018 with "unresponsiveness, respiratory failure, and seizure like activity". The patient was "intubated" and started on "propofol sedation" and was "not following commands". The patient was demonstrating significant conjunctival hemorrhage with scleral edema. Multiple tests were completed with negative findings. An EEG (electroencephalography) demonstrated signs of "possible metabolic/toxic encephalopathy". The patient was weaned off propofol, "opening" his/her "eyes upon command", and was "moving all extremities". The patient was extubated and transferred to a telemetry unit. The patient's "cognition continues to be clouded, but cognitive abilities improve on a daily basis". The patient was transferred to a medical surgical unit after telemetry monitoring had been discontinued. "With regards to further medical issues, the patient was stable and ready for discharge." The patient was "discharged home in good condition" on 06/25/2018.

4. Review of the closed MR for patient # 2 indicated the following:
A. The patient was a 22 y/o admitted to H # 1 on 05/21/2018 on a "72 hour emergency detention order" and then was extended. The patient had made several statements "about obtaining a firearm".
B. The Comprehensive Psychiatric Evaluation completed on 05/22/2018 at approximately 5:29 pm by MS # 1, indicated the patient made the statement "I'm going down, I'm taking a lot of them with me". The patient has made "several statements" about "obtaining a firearm" for protection against those he/she feels are after him/her.
C. The patient's diagnoses included, but were not limited to, Axis I: Bipolar one (1) disorder with psychotic features and Axis IV Severe social/environmental stressors and abuse history.
D. Review of the narrative note dated 06/18/2018 by NS # 3 RN at approximately 11:27 am, indicated the patient was telling staff members that if he/she gets a "new roommate" he/she will "strangle them".
E. The Psychiatric Progress Note completed on 06/19/2018 by MS # 2 (Nurse Practitioner), indicated the patient thinks he/she "has PTSD (Post Traumatic Stress Disorder) at night now". The patient indicated that he/she "is not comfortable with roommates". The patient feels "insecure lately" and does "not like it when he/she does not get to meet and know" the person "before he/she has to share a room" with them. "This is something that he/she has told me previously in sessions".
F. Review of the "Patient Monitoring Rounds" sheet from 06/21/2018, indicated at 2:15 am and 2:30 am the patient's "Mood" (calm), "Behavior" (watching tv/leisure) and "Location" (day room) had been documented. At 2:45 am the patient's "Mood" changed to "agitated", the patient's "Behavior" changed to "pacing/restless", and the patient's "Location" remained in the "day room". At 3:00 am the patient's mood and behavior remained the same but the "Location" was changed to "bed" room (# 283). At 3:15 am the patient's mood and behavior remained the same but the "Location" changed again to "day room".

5. Review of the PD # 1 (Police Department) Incident Report completed on 06/21/2018 at approximately 5:24 am by PO # 4 (Police Officer), indicated the following summary: "The following is a report of an assault on" patient # 1 "by" patient # 2 "done at" H # 1 "Adult Acute unit room # 283 on 06/21/2018 at approximately 3:10 am".

6. In interview on 08/06/2018 at approximately 2:50 pm with PO # 1 (Chief of Police), confirmed the "camera's were not working or recording". There weren't any indicators suggesting the recording devices were not recording. "We were unable to view the footage from 06/21/2018 at approximately 3:10 am, the night of the incident."

7. In interview on 08/08/2018 at approximately 11:50 am with administrative staff member A # 1 (Director Patient Care), confirmed the "facility failed to follow their policies and procedures related to patient rights" with the "patient being free" and the "right to expect personal safety and security" as far as the "hospital practices".

8. In interview on 08/08/2018 at approximately 3:00 pm with PS # 1, confirmed patient # 2 "came out of room (# 283) and wanted to work out'. The patient had been working out in his/her room (# 283) so he/she "wasn't happy" with the new admission. Patient # 2 went in the room and "I heard a thump" and the door to the patients room was "closed". When I started to enter the room, patient # 2 "met me at the doorway", I asked what the "noise" was and he/she had indicated that he/she "had stumbled". At that time patient # 1 "was in bed" and his/her "eyes were closed". When patient # 2 left the room he/she "slammed the door". The patient requested to work out in the day room and was told that it would be fine to work out in the day room. The patient then went "back in to room" and "shut the door". It seemed like the "patient was gone for about four (4) minutes" and when he/she came out of room he/she "slammed the door" then went and sat down at the table. The patient stated "I wouldn't go in there if I were you". Immediately "I went in the room # 283" and observed patient # 1 "on the floor in a puddle of blood". I immediately went to get the RN.

Based on document review and interview, the facility failed to ensure patients were provided care in a safe setting by identifying patients at risk of intentionally harming others in two (2) instance with no interventions implemented. (Patient # 2 & Patient # 4).

Findings include:

1. Review of the hospital policy titled, "Patient Rights and Responsibilities", origination date 11/05/2005, indicated the "Patient's Rights and Responsibilities" are guidelines to promote the dignity and autonomy of its patients and to contribute to the quality of patient care. I...The "right to expect reasonable personal safety and security as far as the hospital practices and environment are concerned...patients may be placed in protective privacy when considered necessary for personal safety". This policy was last reviewed 07/05/2018 with no changes made.

2. Review of the hospital patient's handbook titled, "What Every Patient Should Know-Patient Rights and Responsibilities", copyright 2016, indicated on pg 5 of 32: "As a Patient You Have the Right to"....pg 7..."Expect reasonable personal safety and security", and "be free from "all abuse".

3. Review of the closed MR for patient # 2 indicated the following:
A. The patient was a 22 y/o (year/old) admitted to H # 1 (Psychiatric Hospital) on 05/21/2018 on a "72 hour emergency detention order" and then was extended. The patient had made several statements "about obtaining a firearm".
B. The Comprehensive Psychiatric Evaluation completed on 05/22/2018 at approximately 5:29 pm by MS # 1, indicated the patient made the statement "I'm going down, I'm taking a lot of them with me". The patient has made "several statements" about "obtaining a firearm" for protection against those he/she feels are after him/her.
C. The patient's diagnoses included, but were not limited to, Axis I: Bipolar one (1) disorder with psychotic features and Axis IV Severe social/environmental stressors and abuse history.
D. Review of the narrative note dated 05/24/2018 by PS # 4 (Mental Health Technician-MHT) at approximately 12:49 am, indicated during a room check at 11:45 pm "a ripped towel made into a rope necklace that could have been used as a harmful object" was found and removed.
E. Review of the Psychiatric Progress note dated 05/25/2018 at approximately 9:43 pm by MS # 1, indicated the patient displayed no "abnormal thoughts" related to "homicidal ideation" (HI).
F. Review of the narrative note dated 05/31/2018 by SW # 1 (Social Worker) at approximately 8:51 am, indicated the patient has a history of "aggressive behaviors and psychosis".
G. Review of the narrative note dated 05/31/2018 by NS # 4 (RN) at approximately 1:00 pm, indicated the "patient was verbally aggressive in hallway", and stating "people are talking about me, I'm going to kill someone if I can't calm down".
H. Review of the narrative note dated 06/01/2018 by SW # 2 (Social Worker) at approximately 8:35 am, indicated the "patient continues to verbalize paranoid ideation about others on the unit, often threatening to harm others".
I. Review of the Psychiatric Progress note dated 06/01/2018 at approximately 8:16 pm by MS # 1, indicated the patient displayed (?) under "abnormal thoughts" related to "homicidal ideation".
J. Review of the narrative note dated 06/18/2018 by NS # 3 RN at approximately 11:27 am, indicated the patient was telling staff members that if he/she gets a "new roommate" he/she will "strangle them".
K. Review of the Psychiatric Progress note on 06/18/2018 at approximately 11:48 am by MS # 1, indicated the patient displayed no "abnormal thoughts" related to "homicidal ideation".
L. The Psychiatric Progress Note completed on 06/19/2018 by MS # 2 (Nurse Practitioner), indicated the patient thinks he/she "has PTSD (Post Traumatic Stress Disorder) at night now". The patient indicated that he/she "is not comfortable with roommates". The patient feels "insecure lately" and does "not like it when he/she does not get to meet and know" the person "before he/she has to share a room" with them. "This is something that he/she has told me previously in sessions".
M. Review of the Psychiatric Progress note on 06/20/2018 at approximately 1:06 pm by MS # 1, indicated the patient displayed no "abnormal thoughts" related to "homicidal ideation".
N. Review of the narrative note documented on 06/20/2018 at approximately 1:17 am by NS # 5 RN, indicated the patient was up at the nurses station complaining that he/she hasn't been able to sleep, reported feeling very agitated inside because he could not lock the bedroom door. Patient was insistent earlier that the room be locked because he/she "does not know this people they might try to steal shit from me".
O. Review of the Care Plan/Treatment Plan for Tuesday 08/07/2018, indicated the plan was lacking any documentation related to any HI interventions throughout the patient's admission.
P. Review of the "Patient Monitoring Rounds" sheet from 06/21/2018, indicated at 2:15 am and 2:30 am the patient's "Mood" (calm), "Behavior" (watching tv/leisure) and "Location" (day room) had been documented. At 2:45 am the patient's "Mood" changed to "agitated", the patient's "Behavior" changed to "pacing/restless", and the patient's "Location" remained in the "day room". At 3:00 am the patient's mood and behavior remained the same but the "Location" was changed to "bed". At 3:15 am the patient's mood and behavior remained the same but the "Location" changed again to "day room".
Q. Review of the narrative note documented on 06/21/2018 at approximately 3:17 am by NS # 1 RN, indicated patient stated "Yeah, I'd like to see you try to resuscitate this guy and smirked".

4. Review of the open MR for patient # 4 indicated the following:
A. The patient was a 33 y/o who was emergently admitted to H # 1 on 08/01/2018 on a voluntary basis due to "suicide and homicide ideation with plan".
B. The Comprehensive Psychiatric Evaluation completed on 08/02/2018 at approximately 7:53 pm by MS # 1 (Physician), indicated the patient "had impulses to take the shot gun" that his roommate had and "use it" against the family and himself. The patient indicated that he/she "was so frustrated" and "wanted to end everyone involved".
C. The patient's diagnoses included, but were not limited, to bipolar disorder-depressed and chronic mental illness.
D. Review of the narrative note dated 08/03/2018 by NS # 3 (Registered Nurse) at approximately 9:20 am, indicated the "patient admitted to HI (homicidal ideation) unchanged plan to hurt" his/her family.
E. Review of the Care Plan/Treatment Plan for Tuesday 08/07/2018, indicated the plan lacked any documentation for interventions and short term goals.

5. In interview on 08/07/2018 at approximately 3:05 pm with administrative staff member A # 2 (Manager Patient Care), confirmed that it was "expected of the staff to complete the treatment plan interventions" because it was an "important and necessary part of the care for patient's with HI.

6. In interview on 08/08/2018 at approximately 10:35 am with administrative staff member A # 3 (Safety & Accreditation Coordinator), confirmed that H # 1 considers the patient treatment plan the patient care plan.

7. In interview on 08/08/2018 at approximately 11:45 am with administrative staff member A # 1 (Director Patient Care), confirmed the "nurse should have some kind of action items" and the "team should had reflected the HI on the treatment plan" for patient # 2 and patient # 4.

8. In interview on 08/08/2018 at approximately 11:50 am with administrative staff member A # 1 (Director Patient Care), confirmed the "facility failed to follow their policies and procedures related to patient rights" with the "patient being free" and the "right to expect personal safety and security" as far as the "hospital practices".

Based on document review and interview, the facility failed to protect and promote a patient's rights, related to adequate staffing to ensure a patient's safety/security was maintained, and free from abuse during one (1) inpatient admission. (Patient # 1).

Findings include:

1. Review of the hospital policy titled, "Patient Rights and Responsibilities", origination date 11/05/2005, indicated the "Patient's Rights and Responsibilities" are guidelines to promote the dignity and autonomy of its patients and to contribute to the quality of patient care. I...The "right to expect reasonable personal safety and security as far as the hospital practices and environment are concerned. This policy was last reviewed 07/05/2018 with no changes made.

2. Review of the hospital patient's handbook titled, "What Every Patient Should Know-Patient Rights and Responsibilities", copyright 2016, indicated on pg 5 of 32: "As a Patient You Have the Right to"....pg 7..."Expect reasonable personal safety and security", and "be free from all abuse".

3. Review of the facility policy, "Guidelines for Reducing Associates", origination date 01/30/2009, indicated associates on "released on-call status are required to report to work when they are called". This policy was last reviewed 04/20/2018.

4. Review of the facilities staffing matrix for the "Adult Acute" unit, dated 07/28/2015, indicated the unit was required to staff two (2) RN's on days/nights for a patient census of eight (8) to fourteen (14), and three (3) registered nurses for a census of fifteen (15) to twenty (20) patients.

5. Review of the facilities staffing matrix for the "Adult Acute" unit, dated 07/28/2015, indicated the unit was required to staff two (2) MHT's on days/nights for a patient census of seven (7) to thirteen (13), and three (3) MHT's for a patient census of fourteen (14) to twenty (20) patients.

6. There was an incident that occurred on 06/21/2018 at approximately 3:10 am at H # 1 on the "Adult Acute" unit which resulted in a medical emergency for patient # 1.

7. Review of the "staffing pattern worksheet" and "daily census sheet" provided by the facility, indicated the "Adult Acute" unit was short staffed on June 20, 2018. The patient census was thirteen (13), with two (2) admissions, and only two (2) MHT's were staffed with one (1) MHT put on call at 7:00 pm.

8. In interview on 08/07/2018 at approximately 4:15 pm with administrative staff member A # 2, confirmed the "census warranted an additional MHT" on the evening/night shift on 6/20/18. The "MHT should have been called" in to work.

9. In interview on 08/08/2018 at approximately 11:50 am with administrative staff member A # 1 (Director Patient Care), confirmed the "facility failed to follow their policies and procedures related to patient rights" with the "patient being free" and the "right to expect personal safety and security" as far as the "hospital practices".

Based on document review and interview, the facility failed to follow their policy ensuring the electronic report of a safety incident, which had occurred on the unit (Adult Acute), was completed by "an individual knowledgeable about the facts" or "directly involved" in one (1) instance (# 22168), and failed to ensure staff accurately completed a safety incident report in four (4) instances (# 22083, # 22092, # 22093, & # 22096).

Findings include:

1. Review of the hospital policy titled, "Incident Reporting", origination date 03/12/2007, indicated "incident reporting will be completed by an individual knowledgeable about the facts of the incident, this is usually someone who was directly involved in the issue". The incident reports are to be completed "soon after the event". Provide the facts regarding the incident, and "make certain the following information is included on the form:....Patient (or visitor) name". The "Safety Officer", or Risk Management or their designee, carries out the "initial assessment of any reported incident" to determine if it appears to be a sentinel event. This policy was last reviewed on 10/13/2016.

2. Review of the hospital policy titled, "Patient Safety Program", origination date 03/27/2003, indicated the "authority for the Patient Safety Plan rests with the Hospital Board of Directors. The Board of Directors delegates the authority to implement and maintain the activities described herein to the President of the hospital.

3. Review of the Governing Board Bylaws of H # 2 (Acute Care Hospital), dated May 26, 2016, indicated the board of directors, responsibility was to "oversee quality of services, and patient, employee and medical providers satisfaction and community health assessments".

4. Review of the assault/abuse incident report # 22168, which occurred on 6/21/2018 at approximately 3:10 am on the Adult Acute unit, indicated the incident report was documented completed on 07/03/2018 by administrative staff member A # 2 (Manager Patient Care) who was not "directly involved" with the incident event.

5. Review of the assault/abuse incident reports for the month of June 2018 indicated the following:
A. The assault/abuse incident report # 22083 dated 06/21/2018 was missing the patient's name.
B. The assault/abuse incident report # 22092 dated 06/23/2018 was missing the patient's name.
C. The assault/abuse incident report # 22093 dated 06/23/2018 was missing the patient's name.
D. The assault/abuse incident report # 22096 dated 06/23/2018 was missing the patient's name.

6. In interview with administrative staff member A # 2 on 08/06/2018 at approximately 4:00 pm, confirmed that the incident report # 22168 should have been completed by NS # 1 (Registered Nurse-RN) or PS # 1 (Mental Health Technician-MHT). The "staff receive training during their orientation on how to accurately complete an incident report", but acknowledged the additional four (4) incident reports (# 22083, # 22092, # 22093, & # 22096) reviewed from June 2018 "were not completed accurately".

Based on document review and interview, the facility failed to follow their staffing matrix to supply the patient care unit (Adult Acute) with the number of registered nurses (RN's) and mental health technicians (MHT's) required to provide adequate patient care in eight (8) instances.

Findings include:

1. Review of the facility policy, "Guidelines for Reducing Associates", origination date 01/30/2009, indicated associates on "released on-call status are required to report to work when they are called".

2. Review of the facilities staffing matrix for the "Adult Acute" unit, dated 07/28/2015, indicated the unit was required to staff two (2) RN's on days/nights for a patient census of eight (8) to fourteen (14), and three (3) registered nurses for a census of fifteen (15) to twenty (20) patients.

3. Review of the facilities staffing matrix for the "Adult Acute" unit, dated 07/28/2015, indicated the unit was required to staff two (2) MHT's on days/nights for a patient census of seven (7) to thirteen (13), and three (3) MHT's for a patient census of fourteen (14) to twenty (20) patients.

4. Review of the "staffing pattern worksheet" and "daily census sheet" provided by the facility, indicated the "Adult Acute" unit was short staffed on the following nights:
A. The patient census was fifteen (15) on 06/03/2018-two (2) RN's were staffed and there should have been three (3) according to the staffing matrix.
B. The patient census was eighteen (18) on 06/04/2018-two (2) RN's and two (2) MHT's were staffed and there should have been three (3) of each according to the staffing matrix.
C. The patient census was fourteen (14) on 06/06/2018-two (2) MHT's were staffed and there should have been three (3) according to the staffing matrix.
D. The patient census was fifteen (15) on 06/08/2018-two (2) RN's were staffed and there should have been three (3) according to the staffing matrix.
E. The patient census was sixteen (16) on 06/09/2018-two (2) RN's were staffed and there should have been three (3) according to the staffing matrix
F. The patient census was sixteen (16) on 06/10/2018-two (2) RN's were staffed and there should have been three (3) according to the staffing matrix
G. The patient census was thirteen (13) on 06/20/2018 at the beginning of the nigh shift (7am-7pm), with two (2) admissions, and only two (2) MHT's were staffed with one (1) MHT put on call at 7:00 pm. The staffing matrix required three (3) MHT's.

5. In interview on 08/07/2018 at approximately 4:15 pm with administrative staff member A # 2 (Manager Patient Care), confirmed the "census warranted an additional MHT" that evening on 06/20/2018. The "MHT should have been called" in to work

6. In interview on 08/08/2018 at approximately 12:20 pm with administrative staff member A # 1 (Director of Patient Care), confirmed the staffing matrix for the RN's and MHT's had not been changed and the "ones reviewed were the current/correct ones". The "MHT should have been called in to work".

Based on document review, and interview the registered nurse failed to follow the policy and procedure related to accurately and thoroughly recording the safety precautions and NGASR (Nurses' Global Assessment of Suicide Risk) scores on the patient's daily monitoring rounding form for ten (10) of the thirty-two (32) days (Patient # 2), failed to complete a "Patient Monitor Rounding form" for one (1) of the thirty-two (32) days the patient was admitted to the facility (Patient # 2), and failed to ensure the attending physician and family member for a medical emergency involving a patient were notified. (Patient # 1)

Findings include:

1. Review of the hospital policy titled, "Patient Monitoring Rounds", origination date 04/07/2011, indicated patient monitoring "is an essential component in maintaining the safety and security of the patients." Patient monitoring consists of nurses and MHT (medical health technician) observations and documentation of patients' psychological and physiological well being. "All patients" will be monitored at least every (Q) fifteen (15) minutes. "The employee will mark the Safety Precautions on the rounding form" for the specific patient. The "NGASR score" per the Registered Nurse are also "recorded on the Rounding form". This policy was last revised on 02/28/2018.

2. Review of the hospital policy titled, "Precautions", origination date 04/07/2011, indicated that "Assault Precautions" are an "alert status" and are utilized for a patient who "threatens" or fears he/she "may hurt another person". The documentation procedure indicated "all areas" of the "Patient Monitoring Record must be completed accurately and thoroughly" including the name, date, and "precautions". This policy was last revised 03/23/2018.

3. Review of the hospital policy titled, "Code Blue", origination date 04/07/2011, indicated the "nurse in charge of the patient should inform the patient's family...and attending physician of the medical emergency." This policy was last revised 03/25/2016.

4. Review of patient # 2's "Patient Monitoring Rounds" from 05/21/2018 through 06/21/2018 indicated the following:
A. The patient was a 22 y/o (year/old) admitted to H # 1 (Psychiatric Hospital) on 05/21/2018. A comprehensive psychiatric evaluation completed by MS # 2 (Nurse Practitioner-NP) indicated the following diagnoses: Bipolar I disorder with psychotic features, poly-substance abuse, and social/environmental stressors.
B. The initial order written on 05/21/2018 at approximately 11:23 pm by MS # 3 (Physician), indicated to place the patient on "Assault Precautions" and to complete a NGASR Risk Assessment.
C. The "Patient Monitoring Round" forms were lacking nursing/MHT documentation for "Safety Precautions" for the following dates in May: 21, 22, & 30 2018, and on June 19, 2018.
D. The "Patient Monitoring Round" forms were lacking nursing/MHT documentation for "NGASR" scores on the following dates in May: 21, 22, 24, 28, 29, & 30 2018, and the following dates in June: 02, 13, 19, & 20 2018.
E. The MR lacked any documentation and/or form dated 05/25/2018 indicating patient # 2 was being monitored every fifteen (15) minutes.

5. Review of patient # 1's closed MR (medical record), indicated the MR lacked documentation related to notification of MS # 1 (Physician) and notification of the patient's family member which was listed on the patient's registration as contact one (1) by the registered nurse, after the medical emergency which occurred at approximately 3:10 am on 06/21/2018.

6. In interview with administrative staff member A # 2 (Manager Patient Care) on 08/08/2018 at approximately 10:20 am, confirmed that the MR lacked the documentation where any staff contacted patient # 1's family member and/or attending physician after the emergency had occurred. "The staff didn't call them".

7. In interview on 08/08/2018 at approximately 10:30 am with administrative staff member A # 2 (Manager Patient Care), confirmed that the patient fifteen (15) minute "Monitor Rounds" form should have been filled out completely and accurately. The "safety precautions" are an "essential" component.

8. In interview with administrative staff member A # 2 (Manager Patient Care) on 08/08/2018 at approximately 10:20 am, confirmed that the MR lacked the documentation where any staff contacted patient # 1's family member and/or attending physician after the emergency had occurred. "The staff didn't call them".

9. In interview on 08/08/2018 at approximately 10:45 am with administrative staff member A # 2 and administrative staff member A # 1 (Director of Patient Care), confirmed that all boxes, on the "Patient Monitoring Round" form, should have been completely/accurately filled out by the staff.

10. In interview on 08/08/2018 at approximately 10:48 am with administrative staff member A # 3 (Safety & Accreditation Coordinator), confirmed the MR was missing the completed "Q15 minute monitoring rounding form" for 05/25/2018.

Based on document review and interview, the facility failed to ensure the nursing staff followed the policy and procedure related to developing and updating the patients plan of care (treatment plan) for one (1) of three (3) patient open medical records (MR's) reviewed (Patient # 4), and one (1) of seven (7) patient closed MR's reviewed. (Patient # 2)

Findings include:

1. Review of the hospital policy titled, "Assessment and Care Planning-Admission Ongoing, and Reassessment, Nursing", origination date 07/1994, indicated the "assessment process begins upon patient's arrival on the nursing area". The registered nurse (RN) "is responsible for the overall analysis of the assessed patient information and formulation of the nursing plan of care". This policy was last revised 04/04/2018.

2. Review of the open MR for patient # 4 indicated the following:
A. The patient was a 33 y/o (year/old) who was emergently admitted to H # 1 (Psychiatric Hospital) on 08/01/2018 on a voluntary basis due to "suicide and homicide ideation with plan".
B. The Comprehensive Psychiatric Evaluation completed on 08/02/2018 at approximately 7:53 pm by MS # 1 (Physician), indicated the patient "had impulses to take the shot gun" that his roommate had and "use it" against the family and himself. The patient indicated that he/she "was so frustrated" and "wanted to end everyone involved".
C. The patient's diagnoses included, but were not limited, to bipolar disorder-depressed and chronic mental illness.
D. Review of the narrative note dated 08/03/2018 by NS # 3 (Registered Nurse) at approximately 9:20 am, indicated the "patient admitted to HI (homicidal ideation) unchanged plan to hurt" his/her family.
E. Review of the Care Plan/Treatment Plan for Tuesday 08/07/2018, indicated the plan lacked any documentation for interventions and short term goals.

3. Review of the closed MR for patient # 2 indicated the following:
A. The patient was a 22 y/o (year/old) admitted to H # 1 on 05/21/2018 on a "72 hour detention" and then was extended. The patient had made several statements "about obtaining a firearm".
B. The Comprehensive Psychiatric Evaluation completed on 05/22/2018 at approximately 5:29 pm by MS # 1, indicated the patient made the statement "I'm going down, I'm taking a lot of them with me". The patient has made "several statements" about "obtaining a firearm" for protection against those he/she feels are after him/her.
C. The patient's diagnoses included, but were not limited, to bipolar one (1) disorder with psychotic features, severe social/environmental stressors and abuse history.
D. Review of the narrative note dated 05/24/2018 by PS # 4 (Mental Health Technician-MHT) at approximately 12:49 am, indicated during a room check at 11:45 pm "a ripped towel made into a rope necklace that could have been used as a harmful object" was found and removed.
E. Review of the narrative note dated 05/31/2018 by SW # 1 (Social Worker) at approximately 8:51 am, indicated the patient has a history of "aggressive behaviors and psychosis".
F. Review of the narrative note dated 05/31/2018 by NS # 4 (Registered Nurse-RN) at approximately 1:00 pm, indicated the "patient was verbally aggressive in hallway", and stating "people are talking about me, I'm going to kill someone if I can't calm down".
G. Review of the narrative note dated 06/01/2018 by SW # 2 (Social Worker) at approximately 8:35 am, indicated the "patient continues to verbalize paranoid ideation about others on the unit, often threatening to harm others".
H. Review of the narrative note dated 06/18/2018 by NS # 3 RN at approximately 11:27 am, indicated the patient was telling staff members that if he/she gets a "new roommate" he/she will "strangle them".
I. The Psychiatric Progress Note completed on 06/19/2018 by MS # 2 (Nurse Practitioner-NP), indicated the patient thinks he/she "has PTSD" (Post Traumatic Stress Disorder) at "night now". The patient indicated that he/she was "not comfortable with roommates". The patient feels "insecure lately" and "does not like it" when he/she "does not get to meet and know the person before" he/she has to "share a room with them". "This is something" that he/she "has told me previously in sessions".
J. Review of the Care Plan/Treatment Plan for Tuesday 08/07/2018, indicated the plan lacked any documentation related to HI interventions throughout the patient's admission.

4. In interview on 08/07/2018 at approximately 1:02 pm with administrative staff member A # 2 (Manager Patient Care), confirmed that patient # 4 had an "incomplete treatment plan with no interventions or plan for HI in place" from the date of admission. At 3:05 pm A # 2, confirmed that it was "expected of the staff to complete the treatment plan interventions" because it was an "important and necessary part of the care for the patient".

5. In interview on 08/08/2018 at approximately 10:35 am with administrative staff member A # 3 (Safety & Accreditation Coordinator), confirmed that H # 1 considers the patient treatment plan the patient care plan.

6. In interview on 08/08/2018 at approximately 11:45 am with administrative staff member A # 1 (Director Patient Care), confirmed the "nurse should have some kind of action items" and the "team should had reflected the HI on the treatment plan" for patient # 4 and patient # 2.