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Based on document review and interview, the facility failed to ensure family members were notified of transfers and/or receiving facility had appropriate contact information for 2 of 21 patients (patients # 6 and 8) see tag 129 and based on document review, observation and interview, the facility failed to ensure patients received care in a safe setting by failing to ensure orders for 1:1 observation were followed in 5 instances (2/16/21, 2/19/21, 3/2/21, 3/9/21 and 4/14/21) see tag 144.


The cumulative effect of this systemic problem resulted in the facility's inability to ensure that Patient Rights were promoted.

Based on document review and interview, the facility failed to ensure family members were notified of transfers and/or receiving facility had appropriate contact information for 2 of 21 patients (patients # 6 and 8)

Findings include;

1. Review of patient #6 medical record (MR) indicated the patient was admitted to the 100 unit 1/24/21 with diagnoses including, but not limited to, major neuorcognitive disorder, generalized anxiety, hematuria, COPD (Chronic Obstructive Pulmonary Disease), and osteoarthritis. The MR indicated that family member #2 was listed as the patients POA. He/she was struck by another patient in evening of 1/29/21 and sustained a nasal injury and was sent to the hospital for evaluation and treatment. The MR lacked documentation that the the POA was notified of the transfer.

2. Review of patient #8 MR indicated the patient was admitted to the 100 unit on 3/4/21 with diagnoses including, but not limited to, major depression, psychosis, COPD, Asthma, and Chronic kidney disease stage 3. The MR indicated that family member #1 was listed as the patients Power of Attorney (POA). The nurses notes dated 3/25/21 at 0600 indicated the patient had a decline in condition and was sent to the emergency department at 0800. The nurses notes indicated a message was left for family member #1 to call facility. The medical record contained 2 facesheets. One had no contact information listed and the other had family member #1's name and no phone number or means of contact for family member #1. It could not be determined that the emergency department would have the contact information for the patients family in order to notify of the patients status.

3. Facility policy with subject of Change of Condition issued on 1/2020 states on page 2: "6. The patient's family/designee will be notified as needed of the change of condition....."

4. Facility policy titled Patient Rights and Responsibilities last revised 1/2020 states on page 1: "You have the right to:.....5....have your family and/or agent, when appropriate, be informed of your care, including unanticipated outcomes...."

5. Staff member #A4 (Interim Director of Nursing) verified the medical record information for patient #6 beginning at 12:00 p.m. on 4/13/21 and verified information for patient #8 medical record beginning at 1:50 p.m. on 4/14/21.

Based on document review, observation and interview, the facility failed to ensure patients received care in a safe setting by failing to ensure orders for 1:1 observation were followed in 5 instances (2/16/21, 2/19/21, 3/2/21, 3/9/21 and 4/14/21).

Findings include;

1. Facility policy titled Patient Observation last revised 1/2020 states on page 2: "b. At least one health care provider will be present with the patient at all times, be within arm's length of the patient....."

2. Facility policy titled Patient Rights and Responsibilities revised 1/2020 states on page 3: "18. Receive care in a safe setting...."

3. Review of patient #10 MR indicated he/she was admitted on 1/30/21 with diagnoses including, but not limited to, Bipolar, Gastroesophageal reflux disease and Autism spectrum with aggressive behavior. An order was written on 2/2/21 at 1840 for 1:1 for assault precautions. The MR lacked documentation the 1:1 was in place on 2/16 day shift, 2/19/21 day and night shift, 3/2/21 day and night shift, and 3/9/21 day and night shift.

4. Review of patient #13 medical record indicated the patient was admitted 4/3/21 with psychosis and threatening behavior. He/she was on aggressive precautions. Nursing notes dated 4/13/21 (no time listed) indicated that the patient became aggressive to another patient and punched the patient in the face. An order was written at 4:40 p.m. on 4/13/21 for 1:1 for 24 hours.

5. Review of Personnel files for P10 (Nursing Assistant), and P11 (CNA) indicated he/she had training titled "PATIENT OBSERVATION COMPETENCY" on 3/12/21 and #2 of the competency document indicated the patient on 1:1 should attend scheduled programming, maintain their 1:1 if sent to a hospital, be kept within visual range of assigned team member. Personnel file for staff member #P11 indicated he/she had same training on 3/16/21. The competency training document lacked evidence that the patient was to be at arms length per facility policy.

6. During tour of unit 200 at 12:05 p.m. on 4/14/21 and accompanied by staff members #A3 (Chief Operating Officer for Midwest), A11 (Clinical Specialist) and A4 (Interim Director of Nursing) patient #13 was observed sitting in a chair in the dining room next to a table occupied by patients. There was no staff with patient #13. There were 2 caregivers in the dining room (P10 and P11). Staff member #P10 was feeding a patient across the room and staff member P11 was passing out trays to the patients seated at tables.

7. Staff member #P10 indicated in interview at approximately 12:10 p.m. on 4/14/21 that he/she has to help the other care giver with duties especially when there are a lot of showers and that they have to keep visual eyes on a patient on a 1:1.

8. Staff member #P11 indicated in interview at approximately 12:15 p.m. on 4/14/21 that you have to be at arm's length from a patient on a 1:1 and that he/she realized they were not doing that with patient #13 and were told so by nursing.

9. Staff member #A4 (Interim Director of Nursing) verified the medical record information for patient #10 beginning at 3:40 p.m. on 4/14/21.

Based on document review and interview, the Director of Nursing failed to ensure the nursing staff provided notification of change in condition to practitioner for 1 of 20 patients (patient #10).

Findings include;

1. Review of patient #10 MR indicated he/she was admitted on 1/30/21 with diagnoses including, but not limited to, Bipolar, Gastroesophageal reflux disease and Autism spectrum with aggressive behavior. Nurses notes dated 3/10/21 at 0600 indicated the CNA (Certified Nursing Assistant) reported patient was bleeding from the rectum and the licensed staff member observed large amount of blood pouring from the rectum onto the floor with copious amounts of dark red bloody clots on the floor. The patient ' s blood pressure was 84/48. The notes indicated the practitioner on call was called with no return call and the CNO (Chief Nursing Officer) observed the patient and instructed the nurse to wait for the in-house physician or NP to evaluate the patient. Review of the Medical Progress Note dated 3/10/21 lacked evidence the rectal bleeding had been reported and was evaluated.

2. Facility policy with subject of Change of Condition issued on 1/2020 states on page 1 under procedure: "2. The nurse will evaluate the patient and notify the provider via telephone (if provider is not in building) with assessments. 3..... The change of condition will continue to be monitored and documented until resolved or a clinical decision has been determined by a provider. Documentation should reflect when the change has been resolved. 4. A sample list of possible changes in condition would include but not limited to:.....d. Drop or elevation in blood pressure outside of normal parameters (systolic below 90, diastolic above 160)..."

3. Staff member #A4 (Interim Director of Nursing) verified information for patient #10 beginning at 3:40 p.m. on 4/14/21.

Based on document review, observation and interview, the facility failed to ensure adequate numbers of licensed nurses and nursing assistants were provided for 12 of 20 days (1/24/21, 1/27/21, 1/29/21, 1/30/21, 3/21/20, 3/22/21, 3/23/21, 3/24/21, 3/25/21, 3/27/21, 4/13/21, and 4/14/21).

Findings include;

1. Review of staffing matrix indicated that for a census of 13-20 patients, the 100 unit is to be staffed with 3 licensed staff and 3 unlicensed staff each shift. Review of staffing for the 100 unit for 1/24/21 through 1/30/21 and 3/21/21 through 3/27 indicated on 1/24/21, 1/27/21, 1/29/21, 1/30/21, 3/21/20, 3/22/21, 3/23/21, 3/24/21, and 3/27/21 the unit only had 2 licensed staff for both shifts (12 hour dayshift and 12 hour nightshift). Review of staffing for the 100 unit for same period of time indicated on 1/24/21, 3/22/21 and 3/27/21 the unit only had 2 unlicensed staff for dayshift and on 1/24/21, 3/24/21, and 3/25/21 the unit only had 2 unlicensed staff members for nightshift. The unit had census of > 13 patients each day. Review of staffing matrix for the 200 unit indicated that for a census of 7-12 patients, the unit is to be staffed with 2 licensed staff members and 2 unlicensed staff members. Review of staffing for 4/13/21 nightshift indicated the unit had a census of 12 patients and only had 1 licensed staff and 2 unlicensed staff and staffing for 4/14/21 indicated the unit had a census of 11 patients and only had 2 licensed and 2 unlicensed staff. Staff were not added to accommodate the 1:1 ordered on 4/13/21.

2. During tour of unit 200 at 12:05 p.m. on 4/14/21 and accompanied by staff members #A3 (Chief Operating Officer for Midwest), A11 (Clinical Specialist) and A4 (Interim Director of Nursing) patient #13 (who had a 1:1 ordered) was observed sitting in a chair in the dining room next to a table occupied by patients. There was no staff with patient #13. The unit had a census of 11 patients and was staffed with 1 licensed staff member, 1 licensed orientee and 2 techs. There were 2 caregivers in the dining room. Staff member #P10 was feeding a patient across the room and staff member P11 was passing out trays to the patients seated at tables.

3. Facility policy titled Staffing Precaution Plan last revised 1/2020 states on page 1 under policy: "A minimum staffing level system is used at the hospital to appropriately staff in compliance with federal, state and regulatory requirements."

4. Staff member #A10 (President and Chief Operating Officer) verified staffing information in interview beginning at 12:15 p.m. on 4/15/21. He/she indicated that the facility staffing is 1:6 ratio based on requirements of the Division of Mental Health.

Based on document review and interview, the facility failed to have a designated Infection Control Specialist.

Findings Include:

1. Review of A2's (Chief Executive Officer) personnel file lacked documentation of any designation of facility Infection Control Specialist or training of such.

2. Interview on 04/15/21 with A5 (Chief Operating Officer, Midwest) at 9:20 am confirmed that A2 was the facility's Infection Control Specialist.

3. Interview on 04/15/21 with A2 at 2:00 pm denied knowing that he/she had responsibility of the Infection Control Specialist at current facility.