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Based upon observation, interviews and record reviews, the facility failed to ensure that Registered Nurses are available on the Behavioral Health Unit to provide care to all patients which include: i). Fifteen minutes round are performed, per policy and that vital signs are documented per Physician Order, in 2 (Patients #1 and 2) of 14 sampled patients. ii) Nursing Assessments are documented each shift, per policy, in 7 Patients # 3, 4, 5, 6, 7, 8 and 9) of 14 sampled patients. iii) And the immediate availability of a registered nurse for bedside care of the 23 patients on 07/28/2014.



The findings include:

i). Review of SP #1 closed medical record revealed that the patient was admitted to the facility on 06/22/14 and with complaints of suicidal attempt associated with alcohol use. Sampled patient #1 was transported from the Emergency Department (ED) to Behavioral Health Unit (BHU) on 06/22/14 at 4:35 pm. Review of Admission Orders on 06/22/14 at 4:45pm showed orders for vital signs every 8 hours. Review of the vital sign records did not show that the patient ' s vital signs were taken every 8 hours as ordered by the physician. There were no documented vital signs for the patient after 4:45pm on 06/22/14.

Review of SP#2 closed medical record revealed that on 06/20/14, the patient visited the ED for bizarre behavior. Physician orders on 06/21/14 at 3:05 am showed an order for vital signs every shift. Review of vital signs assessments showed that the patient ' s vital signs were taken daily, and not every 8 hours as ordered. The patient's vital signs were only assessed on 06/21/14 at 2:30am, and at 5:30am. On 06/22/14 the vital signs were only taken at 7:30am. On 06/23/14 the vital signs were taken at 8:01am and on 06/24/14 at 6am.

In an interview with the Unit Leader of Behavioral Health Unit (BHU) on 07/29/14 at 11:20am, the Registered Nurse states, the vital signs are done daily, most likely at 6am. If the doctor orders vital signs, we follow the order.



ii.) Review of SP#3 open medical record reveal that on 07/24/14, the patient visited the ED with complaints of depression. The ED Physician History and Physical reported on 07/24/14 that the patient is tearful in ED and admits to suicidal ideation. Review of the BHU Nursing Reassessments showed that of the two shifts on 07/26/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/27/14 at 12:59am, and of the two shifts on 07/27/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/27/14 at 11:32pm.

Review of SP#4 open medical record showed that the patient was admitted to Behavioral Health Unit on 07/19/14 for schizoaffective disorder. Review of the patient ' s plan of care showed that the patient is a potential for self- injury and that the RN will continually assess the patient ' s self- harm urges, impulses and feelings. Review of the BHU Nursing Reassessments showed that of the two shifts on 07/26/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/27/14 at 12:31am, and of the two shifts on 07/27/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/27/14 at 10:57pm.

Review of SP#5 open medical record showed that the patient was arrived at the facility ED on 07/23/14 at 7:35pm with complaints of suicidal ideation and chest pain. Review of the patient ' s medical record showed that the patient was transferred from the medical floor to BHU on 07/25/14 at 7:19pm. Review of Nursing Reassessments showed that of the two shifts on 07/26/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/28/14 at 1:11am.

Review of SP#6 open medical record showed that the patient was admitted to the facility on 07/24/14 for major depressive disorder. Review of the ED Physician History and Physical dated 07/20/14, showed that the patient visited the ED for complaints of depression with an onset of 1 (one) month ago. Review of the Nursing Reassessments showed that of the two shifts on 07/27/14 (7am to 7pm and 7pm to 7am), only one Nursing Reassessment was documented on 07/27/14 at 11:15pm.

Review of SP#7 open medical record showed that the patient was admitted to the facility on 07/25/14 for major depressive disorder. Review of the patient ' s Baker Act Order on 07/24/14 also showed that the patient was depressed, delusional and had self- inflicted wounds to arms. Review of Nursing Reassessment showed that of the two shifts on 07/26/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/27/14 at 12:46am, and of the two shifts on 07/27/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/27/14 at 10:59pm.


Review of SP#8 open medical record showed that the patient was admitted to the facility on 07/21/14 for major depressive disorder with psychotic features. Review of ED Physician History and Physical on 07/20/14 shows that the patient visited the ED on 07/20/14 for complaints of suicidal ideation and depression. Review of Nursing Reassessment showed that of the two shifts on 07/27/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/27/14 at 11:24pm. Review of the SP#8 Plan of Care shows that the patient is a potential for self- injury and that the RN will continually assess the patient ' s self- harm urges, impulses and feelings.


Review of SP#9 open medical record show that the patient was admitted to the facility on 07/25/14 for major depressive disorder with psychotic features. According to the ED Physician History and Physical, the patient has history of seizures. Review of Nursing Reassessment showed that of the two shifts on 07/27/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/28/14 at 12:01am.


In an interview with the Charge Nurse on 07/28/14 at 2:25pm, the nurse stated that on each shift, the RN does an assessment. There are three shifts.

In an interview with the Interim Program Director of HCA on 07/29/14 at 10:20 am, he stated that the standard is every shift for assessments. There are three shifts during the week and two shifts on weekends.

In an interview with the Unit Leader of BHU on 07/29/14 at 11:20 am, the nurse stated, that assessments are done every shift. Mondays thru Fridays, there are three shifts: 7am to 3pm, 3pm to 11pm and 11pm to 7am. On Saturdays and Sundays, there are two shifts: 7am to 7am and 7pm to 7am. The Unit Leader of BHU also stated that the patient's nurse documents assessments/reassessments, but if the nurse is busy the Unit Leader take over and make sure the assessments are documented.


Review of the facility ' s policy titled, " Safety Rounds/ Patient Care Rounds, " revised on 02/13, stated that on admission, when patient ' s enter the unit (Behavioral Health Unit), the Admitting Nurse will ask the Mental Health Technician to initiate a safety round shift for the patient; where the special precautions are recorded. Mental Health Technicians or Registered Nurse assigned to conduct safety rounds at Patient ' s Admission and they are conducted every 15 minutes, thereafter. When conducting safety rounds the staff members will enter patient ' s rooms to confirm patient ' s location and safety. If the door is closed staff will knock at the door and announce his/her presence in the room by saying " staff " and inform the patient that staff will enter the room.

The facility ' s Behavioral Health Policy : Admission Procedure Guidelines( effective date: 06/20/2013) note that on every shift BH R.N. (Behavioral Health Registered Nurse) will reassess the patient and will reassess more frequently as warranted by the patient's condition.




iii). Observation was made on the Behavioral Health Unit (BHU) on 07/28/14 at 10:55am, in the presence of the Director of Risk Management and the Charge Nurse of BHU. Review of the staffing assignment for 07/28/14 showed that there were two Registered Nurses (RN) and 23 patients. One RN was assigned patients who were in rooms 3101A to 3109B, and one RN was assigned patients who were in rooms 3110A to 3115B.

At 11:56 am on 07/28/14, the Charge Nurse of BHU stated that there were now two RNs on the unit [the RN who had stayed till 11am, left]. The Charge Nurse stated that there were 23 patients at this time. The Charge Nurse stated that she had call staff to come in to help but no one came. "We have this situation for a long time, " the Charge Nurse stated, we've been short staff for a long time. The Charge Nurse also stated," according to the Supervisor, interviewing is in process for hiring staff, we need staff. "


In an interview with RN#A on 07/18/14 at 11:43am, she stated, " sometimes staffing is low, sometimes there are 2 RNs and 1 tech (technician). We cover each other. It can be difficult when you have to give breakfast, lunch, snack and dinner. If one tech is a sitter, there is only one other tech on the unit. Sometimes, we call the supervisor. Sometimes, staffing is a problem. "

In an interview with the Interim Program Director of HCA (Hospital Corporation of America) on 07/29/14 at 10:20am (on the BHU), he stated, " It is a challenge with staffing. We terminated three staff from one shift, and one staff from another. Sometimes, we had to stop from admitting patients. At times, patients are held in the ED (Emergency Department) until patients on the units are discharged to avoid giving the RNs too much. Our staffing is based on one RN with 6 to 7 patients. "

Based upon interview and record review, the facility failed to ensure that the nursing staff develops, and keeps current, a nursing care plan that include: i.) the patient ' s vital signs for 2 Sampled patients (SP) # 1 and #2) of 14 sampled patients; ii.) And reassessments are completed in 7 out of 14 sampled patients (SP)# 3 thru #9.

The findings include:

i.) Review of SP #1 closed medical record revealed that the patient was admitted to the facility on 06/22/14 and with complaints of suicidal attempt associated with alcohol use. Sampled patient #1 was transported from the Emergency Department (ED) to Behavioral Health Unit (BHU) on 06/22/14 at 4:35 pm. Review of Admission Orders on 06/22/14 at 4:45pm showed orders for vital signs every 8 hours. Review of the vital sign records did not show that the patient ' s vital signs were taken every 8 hours as ordered by the physician. There were no documented vital signs for the patient after 4:45pm on 06/22/14.

Review of SP#2 closed medical record revealed that on 06/20/14, the patient visited the ED for bizarre behavior. Physician orders on 06/21/14 at 3:05 am showed an order for vital signs every shift. Review of vital signs assessments showed that the patient ' s vital signs were taken daily, and not every 8 hours as ordered. The patient's vital signs were only assessed on 06/21/14 at 2:30am, and at 5:30am. On 06/22/14 the vital signs were only taken at 7:30am. On 06/23/14 the vital signs were taken at 8:01am and on 06/24/14 at 6am.

In an interview with the Unit Leader of Behavioral Health Unit (BHU) on 07/29/14 at 11:20am, the Registered Nurse states, the vital signs are done daily, most likely at 6am. If the doctor orders vital signs, we follow the order.



ii.) Review of SP#3 open medical record revealed that on 07/24/14, the patient visited the ED with complaints of depression. The ED Physician History and Physical reported on 07/24/14 that the patient is tearful in ED and admits to suicidal ideation. Review of the BHU Nursing Reassessments showed that of the two shifts on 07/26/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/27/14 at 12:59am, and of the two shifts on 07/27/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/27/14 at 11:32pm.

Review of SP#4 open medical record showed that the patient was admitted to Behavioral Health Unit on 07/19/14 for schizoaffective disorder. Review of the patient ' s plan of care showed that the patient is a potential for self- injury and that the RN will continually assess the patient ' s self- harm urges, impulses and feelings. Review of the BHU Nursing Reassessments showed that of the two shifts on 07/26/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/27/14 at 12:31am, and of the two shifts on 07/27/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/27/14 at 10:57pm.

Review of SP#5 open medical record showed that the patient was arrived at the facility ED on 07/23/14 at 7:35pm with complaints of suicidal ideation and chest pain. Review of the patient ' s medical record showed that the patient was transferred from the medical floor to BHU on 07/25/14 at 7:19pm. Review of Nursing Reassessments showed that of the two shifts on 07/26/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/28/14 at 1:11am.

Review of SP#6 open medical record showed that the patient was admitted to the facility on 07/24/14 for major depressive disorder. Review of the ED Physician History and Physical dated 07/20/14, showed that the patient visited the ED for complaints of depression onset 1 (one) month ago. Review of the Nursing Reassessments showed that of the two shifts on 07/27/14 (7am to 7pm and 7pm to 7am), only one Nursing Reassessment was documented on 07/27/14 at 11:15pm.

Review of SP#7 open medical record showed that the patient was admitted to the facility on 07/25/14 for major depressive disorder. Review of the patient ' s Baker Act Order on 07/24/14 also showed that the patient was depressed, delusional and had self- inflicted wounds to arms. Review of Nursing Reassessment showed that of the two shifts on 07/26/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/27/14 at 12:46am, and of the two shifts on 07/27/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/27/14 at 10:59pm.


Review of SP#8 open medical record showed that the patient was admitted to the facility on 07/21/14 for major depressive disorder with psychotic features. Review of ED Physician History and Physical on 07/20/14 shows that the patient visited the ED on 07/20/14 for complaints of suicidal ideation and depression. Review of Nursing Reassessment showed that of the two shifts on 07/27/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/27/14 at 11:24pm. Review of the SP#8 Plan of Care shows that the patient is a potential for self- injury and that the RN will continually assess the patient ' s self- harm urges, impulses and feelings.


Review of SP#9 open medical record show that the patient was admitted to the facility on 07/25/14 for major depressive disorder with psychotic features. According to the ED Physician History and Physical, the patient has history of seizures. Review of Nursing Reassessment showed that of the two shifts on 07/27/14 (7am to 7pm and 7pm to 7am) only one Nursing Reassessment was documented on 07/28/14 at 12:01am.


The facility ' s Behavioral Health Policy : Admission Procerdure Guidelines( effective date: 06/20/2013) note that on every shift BH R.N. (Behavioral Health Registered Nurse) will reassess the patient and will reassess more frequently as warranted by the patient's condition.

In an interview with the Charge Nurse on 07/28/14 at 2:25pm, the nurse stated that on each shift, the RN does an assessment. There are three shifts.

In an interview with the Interim Program Director of HCA on 07/29/14 at 10:20 am, he stated that the standard is every shift for assessments. There are three shifts during the week and two shifts on weekends.

In an interview with the Unit Leader of BHU on 07/29/14 at 11:20 am, the nurse stated, that assessments are done every shift. Mondays thru Fridays, there are three shifts: 7am to 3pm, 3pm to 11pm and 11pm to 7am. On Saturdays and Sundays, there are two shifts: 7am to 7am and 7pm to 7am. The Unit Leader of BHU also stated that the patient's nurse documents assessments/reassessments, but if the nurse is busy the Unit Leader take over and make sure the assessments are documented.