HospitalInspections.org

Based on review and interview the facility failed to

1.
have policies and procedures that clearly applied to the hospital in 2 of 2 (Seclusion and Restraint, Suspected Child, Adult, Disabled Person or Elderly Abuse/Neglect/Exploitation) policies reviewed.

A review of the policy and procedures revealed that the policies were corporate policies and had multiple states within the policies. There was no clear understanding that the following policies had been adopted and vetted through the Governing Body for the individual facility.

A review of the policy and procedure Seclusion and Restraint, Applicability Springstone Corporate last revised 1-2024. The policy gives direction for two different states North Carolina, and Texas.

A review of policy and procedure Suspected Child, Adult, Disabled Person or Elderly Abuse/Neglect/Exploitation, applicability Springstone Corporate, last revised 9/2023 revealed the policy was for Washington State, North Carolina, Arizona, and Texas.

A review of the Governing Board Minute Meetings dated 2/22/2024 revealed the annual review and approval of policy and procedures.

An interview was conducted with staff #2 on 3/4/24. Staff #2 stated that she was not aware of the multiple states in the policy and procedures. Staff #2 stated she did not have an available list of the policies and procedures that were approved during the annual review.

2.
A. ensure chemical restraints that were given or may be administered IM or IV for behavioral emergencies were identified and monitored as a chemical restraint.
B. ensure the policy and procedures addressed and gave clear instructions for the assessment and reassessment of a patient after the administration of a chemical restraint.
C. ensure staff was educated on the administration of chemical restraints and safe monitoring after administration.
D. ensure Chemical restraints were added to the restraint log monitored through Risk and Quality in 2 of 2 (#20 and #4) charts reviewed.


Refer to Tag A0160

3.
ensure a physical assessment was completed on 2 of 2 (Patient #13 and #24) patients reviewed.

Refer to Tag A0395


4.
a. ensure safe staffing levels by providing an adequate number of Registered Nurses (RN) and Patient Care Assistants (PCA) to meet the needs of the patients safely on 4 (Meadows, Cedars, Willows, and Sunrise) of 4 patient care units.

b. have an approved staffing matrix/grid for 4 (Meadows, Cedars, Willows, and Sunrise) of 4 patient care units.

c. have an approved process to determine patient acuity levels to assist the staffing coordinator/house supervisor on when to increase or decrease staff to ensure patient and staff safety on 4 (Meadows, Cedars, Willows, and Sunrise) of 4 patient care units.

d. ensure all staff had adequate coverage during scheduled meal and break times on 4 of 4 (Meadows, Cedars, Willows, and Sunrise) patient care units.

e. ensure adequate staffing was provided to ensure patient rights were not violated in 1 of 1 (Patient #14) patient's medical records reviewed on 1 of 1 (Willows Unit) Patient care units.

f. follow its own Staffing Plan to evaluate staffing needs based on patient acuity-established criteria and anticipated admission, transfers, and discharges in 4 (Meadows, Cedars, Willows, and Sunrise) of 4 patient care units.

The deficient practices were identified under the following Condition of Participation, CFR 482.62: Special Staff Requirements, were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death.


Refer to Tag A1704

Based on document review and interview the Governing Body failed to ensure the medical staff had written policies and procedures for the care of all individuals treated in the Emergency Treatment Room.


Findings:


After multiple requests for the Emergency Treatment Room Policy, one was not provided. A review of the hospital's policies revealed that there was no policy or procedure for the care of an individual treated in the Emergency Treatment Room.

An interview was conducted with Staff #7 on 3/4/2024 after 1 PM. RN Staff #7 confirmed the facility did not have any policies or procedures for the Emergency Treatment room.

Based on review and interview the facility failed to:

A. ensure chemical restraints that were given or may be administered IM or IV for behavioral emergencies were identified and monitored as a chemical restraint.

B. ensure the policy and procedures addressed and gave clear instructions for the assessment and reassessment of a patient after the administration of a chemical restraint.

C. ensure staff was educated on the administration of chemical restraints and safe monitoring after administration.

D. ensure Chemical restraints were added to the restraint log monitored through Risk and Quality in 2 of 2 (#20 and #4) charts reviewed.

E. ensure an order was received from a physician during a behavioral emergency before placing a patient in seclusion in 1 (Patient #4) of 1 medical record reviewed.

Refer to Tag A0160

Based on review and interview the facility failed to:
A. ensure chemical restraints that were given or may be administered IM or IV for behavioral emergencies were identified and monitored as a chemical restraint.

B. ensure the policy and procedures addressed and gave clear instructions for the assessment and reassessment of a patient after the administration of a chemical restraint.

C. ensure staff was educated on the administration of chemical restraints and safe monitoring after administration.

D. ensure Chemical restraints were added to the restraint log monitored through Risk and Quality in 2 of 2 (#20 and #4) charts reviewed.


A review of patient # 20's chart revealed he was a 17-year-old black male admitted for major depression with psychotic symptoms. He was admitted voluntarily on 2/25/24. Patient #20 was placed on precautions for Aggression and moderate suicide. Patient #20's level of observation was every 15 minutes.

A review of patient #20's chart revealed he had a physician order for a 1:1 observation level for "psychotic, wandering, and trying to elope." The order was written on 2/27/24 at 12:45 PM.

A review of patient #20's chart revealed there was a restraint packet in the patient's chart. The packet was incomplete as follows.

Page #1 out of 7 revealed it was an initiation of a restraint order. Staff # 10 RN documented on 2/28/24 at 18:25 (6:25 pm) "Pt ran for door when staff was exiting pt was physically restrained and escorted back to unit and punching staff." Staff #10 RN documented that the physical hold started at 1805 (6:05 pm) and ended at 1805 (6:05 pm). Staff # 10 RN charted that a verbal physician order was received for the hold on 2/28/24 at 18:25 (6:25 pm). The bottom of the page required a name, date, and time the RN supervisor was notified and the attending physician. This information was blank. The physician did not sign the intervention restraint hold order until the next day on 12/29/24 at 12:10 pm.

Page #2 out of 7 revealed Staff # 10 RN failed to chart who the face-to-face evaluator was or if the evaluation was completed within the hour. Staff # 10 RN charted that patient #20's father was notified at 18:10 (6:10 pm). The only documented alternative intervention attempted before the restraint was documented as a "1:1 verbal interaction." The signature for the treatment plan update was left blank.

Page #3 out of 7 revealed it was for a face-to-face evaluation and it was completely blank. The page asked for the date and time of completion, what the patient's response was to the intervention, an assessment of the immediate condition (including vital signs), a review of health systems, and a mental status/behavioral assessment.

Page #4 out of 7 was completely blank. The page required medical history physical and psychological, behavioral criteria for discontinuation of restraint, and a summary of communication including the patient's physician.

Page #5 out of 7 was completed by another nurse on a different shift. The RN signed the patient debriefing on 2/29/24 at 8:20 am, 14 hours after the initiation of a physical hold restraint. There was no documentation on why the debriefing was delayed by 14 hours.

Page #6 out of 7 was completely blank. The page was for a staff debriefing. There was no documentation on what staff were involved during the restraint process.

Page #7 out of 7 was for monitoring activities. The RN filled out the form at 1805 for monitoring the patient during the hold but did not sign the form until 19??. The time on the form was illegible. The RN had written a different time over the original time.

A review of the physician orders dated 2/28/24 at 18:25 (6:25 pm) revealed an order for Haldol 5 mg IM, Benadryl 50mg IM, and Ativan 1 mg IM once for aggression. A review of the Medication Administration Record (MAR) dated 2/28/24 revealed the medication was administered at 18:25 (6:25 pm). The order was not written as a verbal order. The physician did not sign the order until 2/29/24 at 14:47 (2:47 pm).

The medication was administered to patient #20 at the same time as the documented hold. The medication was not added to the restraint packet. A separate 2-page form was found on the chart that stated, "Emergency Medications-One Hour Face to Face Evaluation." The form stated the intervention was on 2/28/24 at 1830 and the face-to-face was done at 1930. The nurse documented, "pt took emergency medication without restraint. Haldol 5/Ativan 1/ Benadryl 50 IM." A review of page 2 revealed that the nurse performing the face-to-face should have written a clinical summary of the intervention. There was no documentation that the nurse performing the face-to-face documented any patient evaluation factors that may have contributed to the violent or self-destructive behavior, and whether the intervention was appropriate to address the violent or self-destructive behavior.

A review of the policy and procedure for Restraints and Seclusions stated, "Emergency Medications (Texas Facilities Only)
A drug or medication that has been ordered to be given "now" because it is immediately necessary to address the signs and symptoms of a patient's mental illness and to prevent:
A. Imminent probable death or substantial bodily harm to the patient because the patient:
1. is threatening or attempting to commit suicide or serious bodily harm; or
2. is behaving in a manner that indicates that the patient is unable to satisfy the patient's need for nourishment, essential medical care, or self-protection; or
8. Imminent physical harm to others because of threats, attempts, or other acts the patient makes or commits ...
A review of the complete policy revealed that the policy fails to recognize emergency behavioral medication administration (EBM) as a restraint. There was no information in the policy on how to assess a patient after they have received an EBM.

An interview was conducted with staff #10 RN was conducted on 3/4/24 at 3:30 pm. Staff #10 stated that he did not know of any restraint logs and that when he must give medications IM for behavioral emergencies, they are not considered restraints if the patient is willing to take them on their own. Staff #10 stated that they do not have any mechanical restraints they just hold the patient, place them in seclusion, and administer medications per physician orders. Staff #10 was asked when an EBM is administered for a behavioral emergency what was the order or protocol for assessing the patient? How soon do you go back to check the patient after the administration, how often do you assess the patient, and for how long? Staff #10 stated there was no protocol other than the face-to-face within 1 hour. Staff #10 confirmed it could be 1 hour before anyone assessed a patient after an EBM administration.
Psychotropic medications such as Geodon, Haldol, and Zyprexa can cause over-sedation. These drugs have no known antidote. According to https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8037562/#:~:text=Chemical%20restraint%20use%20can%20lead,12%2C13%2C14%5D. "Chemical restraint use can lead to decrease in functional and cognitive performance, falls and fractures, excess sedation, and respiratory depression [12,13,14]. Prescribing of antipsychotics has been linked to an increased risk of stroke and mortality [15,16]."

A review of patient #20's chart revealed there was a second restraint package in his chart for Seclusion and Restraint. The package revealed he was in a physical hold from 18:15 (6:15 pm) to 18:15 (6:15 pm) on 2/28/24. The nurse had documented on the first page "pt repeatedly kicking door to courtyard. Pt physically restrained to prevent self harm". There was no documentation that the staff used seclusion as an option before administering a chemical restraint/ EBM. Pages 3,4 and 6 of the restraint package were left blank.

A review of the nurse's notes dated 2/28/24 revealed the nurses did not perform any physical assessments on the patient for 24 hours. The notes stated the patient refused assessments at 8:24 am. There was no other attempt to assess the patient. A review of the nurse's note for 2/29/24 revealed there was no assessment performed on the patient for over 24 hours and no further attempts were documented. Patient #20 was discharged per parents request on 2/29/24.

An interview was conducted with staff # 3 and staff # 2 on 3/5/24 in the afternoon. Staff #3 confirmed that the restraint log did not include chemical restraints /EBM. Staff #2 stated that she was not aware that the chemical restraints/EBM were to be monitored on the restraint log. Staff #2 was unable to describe to the surveyor the process for chart audits for restraints. Staff #2 stated that the nurses are supposed to check them and make sure they are complete. Staff #2 was unable to bring any monitoring tools used for restraints. Staff #2 confirmed there were no protocols that she was aware of to monitor the patients after the administration of an EBM.


40989

Patient #4

A review of patient #4's medical record revealed the following:

Patient #4 was a 17-year-old male admitted to the hospital on 4/14/2023 with a diagnosis of bipolar disorder most recently depression, anxiety disorder, and Auditory Processing Disorder (a condition that makes it hard to understand speech). He was placed in the Sunrise Unit on moderate suicide precautions (SP) and Q (every) 15-minute observations.

A review of patient #4's chart revealed a document titled, "Restraint and Seclusion Initiation of Intervention/Order." Physician #24 gave a telephone order to RN Staff #27 on 4/20/2021 for a physical restraint and emergency medication.

Rationale for intervention: Danger to self and others.

Type of intervention utilized: Physical Restraint and Emergency Medication ordered by Physician #24 ...
Medications: 50 mg (milligrams) of Thorazine (an antipsychotic medication) intramuscular (IM) for aggression.
Registered Nurse (RN) Staff #28 documented the initiation of the physical restraint started at 5:47 PM and ended at 5:50 PM ..."

A review of the medication administration record (MAR) revealed RN Staff #27 administered Thorazine 50 mg IM on 4/20/2021 at 5:51 PM.

A review of the progress note dated 4/20/2021 at 5:51 PM by RN Staff #27 was as follows: " ...This RN came onto the unit to hear patient yelling **** you to a Patient Care Assistant (PCA) and a nurse on the unit. Patient was escorted off the unit. This nurse followed RN and patient to seclusion. Doctor was present and ordered emergency medication. This RN got emergency medication and gave to patient. RN then went back to unit to make sure all other patients were ok ..."

A review of the document titled; "Seclusion& Restraint Monitoring Activities" was documented by RN Staff #27. RN Staff #27 documented that Patient #4 was in a physical hold on the unit beginning at 5:35 PM, transported to the seclusion room at 5:50 PM, and remained in a physical hold in the seclusion room until 6:05 PM. Patient #4 was released from the restraint/seclusion at 6:15 PM.

RN Staff #27 and RN Staff #28 were former employees and were unable to interview for clarification.

A review of the Close Observation Sheet dated 4/20/2021 revealed Patient #4 was on a Q-15-minute observation. The Patient Care Assistant (PCA) documented the Q-15-minute observation checks as follows:
" ... 5:30 PM Patient #4 was in the Day Room not complying and being disrespectful; 5:45 PM Patient #4 was in the Seclusion Room agitated and tearful; 6:00 PM Patient #4 was in the Seclusion Room agitated and tearful and at 6:15 PM Patient #4 was in his bedroom calm ..."

There was no physician order for the Seclusion (involuntary confinement in a room where a patient is physically prevented from leaving or gives the perception that threatens the patient with physical intervention if they attempt to leave the room).

Staff #3 confirmed there was no order for patient #4 to be placed in seclusion.

Vital signs were documented by RN Staff #27 from 5:35 PM to 6:15 PM. The vital sign documentation read, "Unable to perform due to safety risk" from 5:35 PM to 6:10 PM. Respiration count was documented as "fast" from 5:35 PM to 6:00 PM and "regular" from 6:05 PM to 6:15 PM. There was no respiration count documented by RN Staff #27 for the entirety of the restraint/seclusion.

The surveyor was unable to determine who monitored Patient #4 during seclusion and after the administration of the emergency behavioral medication because the documentation by RN Staff #27 contradicted the progress note dated 4/20/2021 at 5:51 PM. RN Staff #27 documented on 4/20/2021 that she arrived on the unit at 5:51 PM, transported the patient to seclusion, administered the emergency medications, and returned to the unit. Also, RN Staff #27 documented she monitored the patient in seclusion from 5:35 PM until 6:15 PM.

A review of the hospital policy titled, "Restraint and Seclusion" Policy Stat ID 15084525, with an origination date of 1/2012 and a revised date of 1/2024 was as follows:

" ...Purpose
To provide guidelines for the use of seclusion and/or restraints at the Hospital and Clinics ...
Definitions ...
Seclusion
Any involuntary confinement of a patient alone in a room or area where he/she is physically prevented from leaving. This includes situations where a staff physically prevents the patient from leaving or gives the perception that threatens the patient with physical intervention if he/she attempts to leave the room ...
Procedure
Who Does What ...
Practitioners/Providers/Physicians
A. Provides verbal and written order (sic) for the employment of seclusion/restraint. The order is documented on the Seclusion/Restraint.
1. Order/Progress Note form and includes:
a. Reason/purpose for seclusion and restraint intervention.
b. Type of restriction.
c. Be time limited, not to exceed: 4 hours for adults 18 and older.
d. Criteria for release/termination seclusion/restraint.
e. Medications ordered, if applicable ...

Physician/Qualified Trained RN
Conducts an in-person, face-to-face assessment of patient in seclusion/restrain within one (1) hour of initiation and documents findings on the One Hour Face-to-Face Evaluation. The face-to-face evaluation is performed even in those situations where the person is released early (prior to one hour) ...

Monitoring Activities ...
Safety Committee
Analyzes and aggregates seclusion/restraint data and reports to the Quality Committee. The data includes, but not limited to: Shift, the length of each episode, the date and time each episode was initiated, the day of the week each episode was initiated, the type of restrictive intervention used, whether injuries were sustained by the patient or staff, age of the patient, and gender of the patient ...

The Performance Improvement process and treatment plan includes information from the patient and staff debriefings in order to reduce the use of seclusion and restraints.

Procedures for Emergency Medications (Texas Only)
Following the administration of the Emergency Medications, the RN must complete a 1-hour face to face evaluation of the patient to continue the surveillance of the immediate situation, evaluation of the patient's reactions to the Emergency Medication, assessment of the medical and behavioral condition of the patient, and determining the need for additional interventions ..."

During an interview on 3/05/2024 with Staff #3, it was confirmed that the DON was responsible for monitoring the chemical restraints and she had not received any data to date.

Based on observation, document review, and interview, Nursing failed to ensure a physical assessment was completed on 2 of 2 (Patient #13 and #24) patients reviewed.

Refer to Tag A0395

Based on observation, document review, and interview, Nursing failed to ensure a physical assessment was completed on 2 of 2 (Patient #13 and #24) patients reviewed.

Findings:
An observation was conducted on the Cedars Unit on 3/05/2024 after 9:00 AM. This surveyor observed RN Staff #4 passing medications and completing an assessment through a small window in the medication room. The medication room has a small window with an opening at the bottom so the nurse can pass medications through and talk with the patient. The 12-hour shift assessment was completed by asking the patient questions and documenting the patient's answers on the hospital's assessment sheet titled, "7:00 AM-7:00 PM Nursing Assessment".

A review of the document titled, "7:00 AM-7:00 PM Nursing Assessment" revealed it was a 2-page document. On page 2 of the document, it required a physical assessment for Pain, interventions attempted for pain, Respiratory, GI (Gastrointestinal), and COVID-19 Screen.
On the Respiratory assessment, there are boxes to check for: "Normal, Wheezing, Congested, Sore throat, Labored, Cough, Short of breath, and If on O2(oxygen), list liter and O2 sat".
On the GI assessment, there are boxes to check for: "Normal, Constipation, Diarrhea, and Nausea".

RN Staff #4 was observed asking 2 of 2 (Patients #13 and #24) patients if they were experiencing any symptoms related to the Respiratory and GI systems. RN Staff #4 never used a stethoscope (a medical device to listen to sounds generated internally by the heart, lungs, and intestinal tract) to listen to Patient #13 and #24's lungs or intestinal tract.
RN Staff #4 failed to take vital signs (blood pressure, heart rate, respiratory rate, and oxygen level) during her assessment. There were no vital signs documented on the 7:00 AM to 7:00 PM assessment. RN Staff #4 confirmed the vital signs were taken by the Patient Care Assistant (PCA) and posted at the nurse's station. RN Staff #4 did not take the vital sign document into the medication room while she completed her physical assessment to ensure that the patient's vital signs were within normal range before giving any medications to 2 of 2 (Patients #13 and #24) patients observed.

A physical assessment is described as an inspection, palpation (feeling with the fingers or hands), percussion (tapping body parts with fingers, hands, or a small instrument), and auscultation (listening to sounds from the heart, lungs, or other organs typically with a stethoscope).

An interview was conducted on 3/5/2024 after 11:00 AM with RN Staff #4. RN Staff #4 was asked if the nursing staff always completed the 12-hour assessments through the medication window. RN Staff #4 stated "Yes". RN Staff #4 was asked if they ever touched the patient during the 12-hour assessments or listened to the patient's lungs or bowel sounds. RN Staff #4 stated, "Only if the patient complains of any symptoms". RN Staff #4 was asked how they assess patients with known medical conditions. RN Staff #4 stated, "If the patient is complaining of any symptoms, they would do more to assess the patient".

RN Staff #4 again confirmed all shift assessments were completed during the administration of medications. This surveyor was unable to determine how and when a shift assessment was completed if the patient refused to take medications and refused to come to the medication window.

A review of the facility policy titled, "Shift Nursing Assessment/Reassessment", PolicyStatID 14314198 with a last revised date of 5/2018 and an expiration date of 9/2024 was as follows:
" ...Purpose
To provide a concise record of physical and psychological interventions and assessments.
Policy
The Shift Nursing Assessment will be completed on all patients for each shift of the day.
Procedure ...
B. The RN will complete the required assessment each shift ....".

The policy failed to have clear guidance on what was required by the RN during the "required assessment".

RN Staff #4 confirmed the nursing assessments were completed through the medication window and there was not a physical assessment completed on patients unless the patient had a complaint or previous medical history.

Based on observation, document review, and interview the hospital failed to:

a. ensure safe staffing levels by providing an adequate number of Registered Nurses (RN) and Patient Care Assistants (PCA) to meet the needs of the patients safely on 4 (Meadows, Cedars, Willows, and Sunrise) of 4 patient care units.

b. have an approved staffing matrix/grid for 4 (Meadows, Cedars, Willows, and Sunrise) of 4 patient care units.

c. have an approved process to determine patient acuity levels to assist the staffing coordinator/house supervisor on when to increase or decrease staff to ensure patient and staff safety on 4 (Meadows, Cedars, Willows, and Sunrise) of 4 patient care units.

d. ensure all staff had adequate coverage during scheduled meal and break times on 4 of 4 (Meadows, Cedars, Willows, and Sunrise) patient care units.

e. ensure adequate staffing was provided to ensure patient rights were not violated in 1 of 1 (Patient #14) patient's medical records reviewed on 1 of 1 (Willows Unit) Patient care units.

f. follow its own Staffing Plan to evaluate staffing needs based on patient acuity-established criteria and anticipated admission, transfers, and discharges in 4 (Meadows, Cedars, Willows, and Sunrise) of 4 patient care units.

The deficient practices were identified under the following Condition of Participation, CFR 482.62: Special Staff Requirements, were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death.


Refer to Tag A1704

Based on observation, document review, and interview the hospital failed to:

a. ensure safe staffing levels by providing an adequate number of Registered Nurses (RN) and Patient Care Assistants (PCA) to meet the needs of the patients safely on 4 of 4 (Meadows, Cedars, Willows, and Sunrise) patient care units.

b. have an approved staffing matrix/grid for 4 of 4 (Meadows, Cedars, Willows, and Sunrise) patient care units.

c. have an approved process to determine patient acuity levels to assist the staffing coordinator/house supervisor on when to increase or decrease staff to ensure patient and staff safety on 4 of 4 (Meadows, Cedars, Willows, and Sunrise) patient care units.

d. ensure all staff had adequate coverage during scheduled meal and break times on 4 of 4 (Meadows, Cedars, Willows, and Sunrise) patient care units.

e. ensure adequate staffing was provided to ensure patient rights were not violated in 1 of 1 (Patient #14) patient's medical records reviewed on 1 of 1 (Willows Unit) Patient care units.

f. follow its own Staffing Plan to evaluate staffing needs based on patient acuity-established criteria and anticipated admission, transfers, and discharges in 4 of 4 (Meadows, Cedars, Willows, and Sunrise) patient care units.

The deficient practices were identified under the following Condition of Participation, CFR 482.62: Special Staff Requirements, were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death.

Findings:

An observation tour was conducted on 3/04/2024 at 9:10 AM with Staff #1. Staff #1 confirmed the current patient census was 64. The hospital was divided into 4 units. The Willows Unit was an adolescent female unit with 12 patient beds. The current patient census was 7. The Cedars Unit was an adult unit with 12 patient beds. The current patient census was 11. The Willows Unit and the Cedars Unit shared a medication room. The Meadows unit was an adult unit with 24 patient beds. The current patient census was 23. The Sunrise Unit was an adolescent unit with 24 patient beds. The current patient census was 23.

An interview was conducted with RN Staff #1 and RN Staff #2 on 3/05/2024 at 10:30 AM. RN Staff #2 was asked how she determined the staffing needs for each unit. She replied, "I look at the patient census and decide how many staff are needed for each unit." RN Staff #2 was asked if the units were staffed based on patient acuity. The question went unanswered by Staff #1 and RN Staff #2. Staff #1 was asked to provide the patient acuity tool that was used to determine the number of staff needed for each unit to ensure quality care for patients and patient and staff safety.
After multiple requests for an acuity tool, one was not presented for review. During an interview on 3/05/2024 after 9:00 AM, Staff #1 confirmed the facility did not have an acuity tool to assist in determining the nurse staffing needs to ensure patients were cared for appropriately and safely on 4 (Willows, Meadows, Cedars, and Sunrise) of 4 patient care units.

RN Staff #2 was asked to provide a staffing matrix/grid to align with the facility policy titled, "Plan for the Provision of Nursing Care in Psychiatric Specialty Areas". RN Staff #2 provided a grid and stated, "This is what I have been using since the second week of January." RN Staff #2 was asked if the staffing matrix/grid had been approved by the Governing Body. She confirmed the staffing matrix/grid had not been approved by the Medical Staff, Governing Body, or the Nursing Staffing Committee.

Further review of the document provided by RN Staff #2 revealed the staffing matrix/grid belonged to another hospital and had not been approved by the hospital's Governing Body.

A review of the current unapproved staffing matrix/grid being used by RN Staff #2 to staff 4 of 4 (Meadows, Cedars, Willows, and Sunrise) patient care units was divided into two shifts, 7:00 AM-7:00 PM and 7:00 PM-7:00 AM. On 3/05/2024, RN Staff #2 confirmed that the matrix/grid being used required only 1 RN and two PCAs for 12 patients and did not take into consideration the patient's age or acuity of the patients.

An interview was conducted with Staff #20 on 3/05/2024 at 11:30 AM. Staff #20 was asked how the nurse staffing was scheduled. She stated, "Well, I let them know who is available and put them on the schedule. I usually get this done a couple of weeks in advance. Then the house supervisors decide what unit they will work on. If they don't need all the staff scheduled due to discharges or if they need more staff, then the house supervisors or the Director of Nurses (DON) are responsible for that. I will assist in scheduling PRN (as needed) employees if needed."

This surveyor was informed of three separate incidents that occurred in the Willows Unit.

1. Patient #14 was forced to sleep on the floor of the dayroom for 4 nights because she was on a line-of-sight observation with only 1 PCA scheduled. The leadership failed to increase the nurse staffing from 3/01/2024 to 3/04/2024 to safely monitor patients as ordered by the physician and not restrict Patient #14's patient rights.

2. Physician #24 was attacked by a patient in the unlocked nurse's station when the RN left her alone on the unit with a patient on 2/03/2024.

3. Patient #16 restrained the RN on the unit to allow two patients to have a physical altercation on 2/03/2024.


Further review was as follows:

1.
A review of Patient #14's medical record revealed she was a 14-year-old female admitted on 2/26/2024 with a diagnosis of Disruptive mood dysregulation disorder and Major depressive disorder with psychotic features. She was experiencing visual hallucinations. She was placed on a line of sight (LOS) observation, sexually acting out (SAO) precautions (perpetrator), suicide precautions (SP), and required to be placed in a blocked room (could not have a roommate) for her safety and the safety of other patients.
A Review of the Close Observation documents dated 3/1/2024-3/04/2024 revealed Patient #14 was sleeping on the dayroom floor for 4 (3/1/2024-3/04/2024) of 4 nights reviewed.

An interview was conducted with PCA Staff #15 on 3/04/2024 at 3:00 PM. PCA Staff #15 was asked why Patient #14 slept on the floor in the day room. PCA Staff #15 stated, "Her mattress was brought to the dayroom, and she was sleeping on the floor so that we could monitor her. She was on a line-of-sight observation and there was not enough staff to monitor her while she was in her room. She's been doing that since Friday".
RN Staff #14 confirmed Patient #14 had slept in the dayroom because there was not enough staff to monitor her at the level of observation ordered by the physician.

An interview was conducted with Patient #14 on 3/04/2024 after 12:00 PM. Patient #14 was asked if she was sleeping in her room during the night. She stated, "No, I have to sleep out here so they can watch me".

A review of the Night shift (7:00 PM to 7:00 AM) staffing schedules and assignment sheets dated 3/1/2024 through 3/04/2023 for the Willows unit was as follows:

" ...3/01/2024-Patient Census was 9. 1 RN and 1 PCA were scheduled. Patient #14 was on a LOS observation and the remaining 8 patients were on Q (every) 15-minute observations. There were 8 patients on moderate suicide precautions (SP), 1 patient on low SP, 5 patients on sexually acting out (SAO) precautions (1 perpetrator and 2 victims), 2 patients on elopement precautions (EP), 3 patients on aggression precautions, 1 patient on fall precautions, and 1 patient on seizure precautions.

3/02/2024- Patient Census was 8. 1 RN and 1 PCA were scheduled. Patient #14 was on a LOS observation and the remaining 7 patients' observation levels were not documented. There were 8 patients on moderate SP, 4 patients on SAO precautions (1 perpetrator and 1 victim), 1 patient on EP, 2 patients on aggression precautions, 1 patient on fall precautions, and 1 patient on seizure precautions.

3/03/2024- Patient Census was 7. 1 RN and 1 PCA were scheduled. Patient #14 was on a LOS observation and the remaining 6 patients' observation levels were not documented. There were 4 patients on moderate SP, 3 patients on low SP, 3 patients on SAO precautions (1 perpetrator), and 4 patients on aggression precautions.

3/04/2024- Patient Census was 7. 1 RN and 1 PCA were scheduled. Patient #14 was on a LOS observation and the remaining 6 patients' observation levels were not documented. There were 2 patients on moderate SP, 5 patients on low SP, 3 patients on SAO precautions (1 perpetrator), and 4 patients on aggression precautions ..."

During an interview with Physician #17 on 3/05/2024 at 10:45 AM it was confirmed that Patient #14 was sleeping in the day room on a mattress because there was not enough staff to monitor her on a line of sight if she slept in her room. Physician #17 stated, "The patient had to remain on LOS observations for her safety and the safety of the other patients".

The nurse staffing for 3/1/2024 through 3/4/2024 on the Willows Unit was inadequate and violated Patient #14's rights by forcing her to sleep in a day room on a mattress because the facility failed to increase the staffing to allow her to have a private place to sleep and continue to be monitored at a safe level as ordered by Physician #17.

2.
A review of the incident report dated 2/03/2024 revealed Patient #19 was left alone on the Willows Unit while Physician #24 was working in the nurse's station. Patient #19 walked into an unlocked nurse's station and attacked Physician #24. Patient #19 placed her hands around Physician #24's neck and began to strangle her.


A review of the progress note dated 2/03/2024 at 11:49 AM by RN Staff #24 was as follows:
" ...Pt met with psychiatrist and was placed on LOS due to reporting HI (Homicidal ideation) thoughts of hurting people and unable to plan for safety at this time. Physician #24 gave verbal orders for new medications to be given. Pt. stayed back from lunch while peers went to the cafeteria. Pt sitting in dayroom, appears anxious. Pt declined to utilize any coping skills/activities offered by this RN such as drawing, coloring, journaling. Pt declined to eat when lunch tray was brought to unit. Physician #24 was sitting in nurses station working. This RN briefly stepped into med room to ask Cedars RN to verify orders, while in the med room, heard Physician #24 calling for help. Found Pt behind nurses station with arms around Physician #24's neck attempting to choke/strangle her. At 11:46 hands on patient to make her release Physician #24, restrained by this RN and code 100 called. Pt struggling against restraint hold, additional staff came to unit and assisted with restraint and transfer to seclusion room ...11:54 AM Zyprexa (antipsychotic medication) IM (intramuscular) given for agitation ...At 12:15 PM pt sitting quietly, able to walk back to unit. Pt placed on 1:1 for safety ..."

A review of the Staff assignment sheet dated 2/03/2024 for the 7:00 AM-7:00 PM shift revealed the patient census was 12. Two patients were on a LOS observation. There were no precautions documented on the staffing assignment sheet for 12 of 12 patients. There were no observation levels documented on the staffing assignment sheet for 10 of 12 patients on the unit.
There was no documented increase in the nurse staffing on the Willows Unit after Patient #19 was increased to a 1:1 observation. This left 1 PCA to monitor 12 patients. One patient was on a LOS observation and one patient was on a 1:1 observation.

There was no documentation that patients were monitored per physician orders for safety. This placed all patients and staff at risk of serious harm.

An interview was conducted with RN Staff #21 on 3/05/2024 after 10:00 AM. RN Staff #21 was asked if the Willows Unit increased its staffing after Patient #19 was placed on a 1:1 after attacking Physician #24. RN Staff #21 stated, "I'm sure someone went over to the unit. A PCA was probably pulled from another unit to go over and help. They did have someone assigned to the patient on the night shift but I can't tell about the day shift because there is nothing written on the assignment sheet. We can ask for all the help we need but never get it. The staffing is horrible here and it is very unsafe. The RNs and the PCAs do the best they can but it is just not safe.".

3.
A review of the incident report dated 2/06/2024 revealed Patient #16 placed RN Staff #22 in a restraint to allow two patients to have a physical altercation on the Willows Unit. A review of the medical record for Patient #16 revealed the patient was on moderate suicide precautions, aggression precautions, sexually acting out precautions, fall precautions, and seizure precautions. She was also experiencing auditory hallucinations.

A review of the progress note dated 2/06/2024 at 2100 (9:00 PM) documented by RN Staff #22 was as follows;
" ...A patient was attempting to attack another patient on the Willows Unit at approximately 1820 (6:20 PM). This RN was standing between the two patients in an attempt to stop the attack when Patient #16 put this nurse into a restraint by placing the front of her body directly against the back of this RN's body and tightly wrapping her arms around this RNs body to significantly limit this RNs movement. It is noted that Patient #14 is double the weight of this RN. It is further noted that restraint of this RN resulted in another patient being attacked ..."


A review of the Staffing assignment sheets dated 2/06/2024 for 7:00 AM-7:00 PM and 7:00 PM-7:00 AM revealed the following:
" ...7:00 AM-7:00 PM. The patient census was 10. 1 RN and 2 PCAs were scheduled. At the beginning of the shift, there was 1 patient on a 1:1 observation and 2 patients on LOS observation, 6 patients were on aggression precautions, 10 patients were on Suicide Precautions, 4 patients on SAO precautions, 1 patient on seizure precautions, and 2 patients on fall precautions.

7:00 PM-7:00 AM The patient census was 10. 1 RN and 1 PCA were scheduled. There were 2 patients on a LOS observation that were assigned to 2 different rooms, 5 patients were on aggression precautions, 10 patients were on SP, 3 patients were on SAO precautions, 1 patient was on seizure precautions, and 2 patients were on fall precautions ..."

One PCA would not be able to monitor two patients on a LOS that were assigned to different rooms. The RN would not be able to monitor a patient on LOS while working as the only RN on the unit and completing other assigned duties such as medication passes, physician orders, and shift assessments.


A review of the progress note dated 2/06/2024 at 8:55 PM by RN Staff #23 was as follows:
" ...While doing rounds PCA noted patient on the floor on the right side of her bed with a pair of underwear around her neck attempting to strangle herself ..."
Patient #14 was on LOS observations and was able to attempt self-strangulation in her room because there was not enough staff to ensure her safety. There were two patients on a LOS and only one PCA available. The RN documented that while the PCA was doing rounds the patient was noted on the floor on the right side of her bed with a pair of underwear around her neck attempting to strangle herself.

RN Staff #21 confirmed Patient #16 should have always been in a staff member's LOS as ordered by the physician and she was not. The inadequate staffing and monitoring by the hospital allowed Patient #16 to be alone in her room and attempt self-strangulation.


Confidential interviews were conducted on 3/04/2024 and 3/05/2024 between 9:00 AM and 5:00 PM. Staff members were asked if the nurse staffing levels were safe. Multiple staff members (RN #4, #10, #14, #18, #21, #22, PCA Staff #11, #12, #15, and #19,) confirmed the nurse staffing levels were inadequate and difficult to work in. The staff stated they did not feel safe and could not provide the quality of care that patients deserved.

RN Staff #4, #10, #14, #18, #21, #22, PCA Staff #11, #12, #15, and #19 were asked if they were relieved by another staff member for their scheduled lunch breaks. RN Staff #4, #14, #18, and PCA Staff #15 confirmed if they were working on a 12-bed unit they just ate at the desk or in the med room. The RNs and PCAs stated they used to have a float RN and a float PCA but that was taken away from them recently. RN Staff #4, #14, #18, and PCA Staff #15 confirmed if there were two nurses on the unit, they were expected to relieve each other for lunch and that left only 1 RN responsible for up to 24 patients. RN Staff #4, #10, #14, #18, #21, #22, PCA Staff #11, #12, #15, and #19 were asked if the hospital automatically deducted daily lunch breaks. Staff stated that at the end of the day when they clocked out, the time clock would ask if they had taken a lunch break and you had to answer yes or no. RN Staff #4, #10, #14, #18, #21, #22, PCA Staff #11, #12, #15, and #19 staff said it's best that you say you did, or you have to fill out a missed lunch sheet and get "ridiculed" for it. RN Staff #4, #21, #22, PCA Staff #15, and #19 confirmed they could fill out a missed lunch form but they get asked why they didn't take a lunch and if we tell them there was no one to relieve us, the Director of Nurses (DON) tells us we are stealing from the company and just being lazy. The RN staff was asked if the house supervisor could relieve them for lunch. RN Staff#18 stated, "Sometimes she would but she was also doing all the treatment team meetings, and if someone called in or didn't show up, she would have to work on the floor".

RN Staff #4, #14, #21 and PCA Staff #15, and #19 confirmed that if they informed the Chief Executive Officer (CEO) or DON that there was not enough staff to relieve staff for scheduled lunch breaks, the CEO just said that the hospital had a nursing budget and they had to stay within that budget. That's all we hear is budget, budget, budget regardless of what is needed on the patient units.

RN Staff #4, #14, #21, PCA Staff #15, and #19 informed this surveyor they had to leave the unit for a restroom break because there was no staff restroom on any patient care unit in the hospital. RN Staff #4 stated, "We just called one of the nurses on another unit and let them know we are going to the restroom". RN Staff #4 confirmed that on the units with 12 patients that would leave only one PCA to monitor all 12 patients.

RN Staff #4, #14, and #18 were asked what duties the RN was required to do on a scheduled shift. The nursing staff confirmed they were responsible for all medication passes, discharges, admissions, shift assessments, taking physician orders, assisting the physician when needed during patient visits on the unit, and playing the role of the unit secretary because there was not one assigned to each unit.


A review of the facility policy titled, "Plan for the Provision of Nursing Care in Psychiatric Specialty Areas", PolicyStat ID 13812300, revised 6/2023 was as follows:

" ...Policy:
The Hospital will provide outstanding psychiatric nursing care in response to individual needs of patients who have a mental disorder and/or substance use disorder as outlined in the most current DSM. In support of this mission, the nursing department is dedicated to providing quality person-centered care to all patients. Licensed nurses at the Hospital function as interdependent members of the multidisciplinary treatment team ...

Staffing Plan Guidelines:
A. There shall be a sufficient number of qualified and competent Registered Nurses and PCAs on each unit to provide patients with nursing services that require the judgment and specialized skills of the competent nursing staff. Nursing staffing shall also be sufficient to promptly recognize untoward changes in a patient's condition and to intervene appropriately utilizing nursing, medical, or Hospital staff. In striving to ensure optimal, achievable, quality nursing care and a safe patient environment, nursing staffing and patient assignment shall be based upon identified minimum staffing requirements by the unit and the following:

* 1. A Registered Nurse plans, delegates, supervises, and evaluates the nursing care of each patient on a 24-hour basis. Licensed nurses may provide nursing care within the scope of the State Nurse Practice Act. This may include gathering data, such as vital signs, giving medications, and/or evaluating treatment effects.

* 2. A Registered Nurse makes a patient assessment before delegating appropriate aspects of nursing care to other competent members of the healthcare team and includes considerations that minimize the risk of the transfer of infections and accidental contamination; the patient care assignment is commensurate with the qualifications and competence of each nursing staff member, the identified needs of the patient, and the prescribed medical plan.

* 3. A PCA can assist the RN with delegated tasks such as obtaining vital signs, assisting with personal care and hygiene of the patient, assisting with meals, providing patient supervision and monitoring the patient on their individual prescribed level of observation, can conduct educational groups, provide supervision of visitation, ln some cases when competent may assist in obtaining phlebotomy and lab specimens, assist with checking in patient belongings, and ensuring the unit is safe and free from contraband. (This list may not be all inclusive).

* 4. Responsibility for nursing care related duties is retained by the Hospital Nursing Department when nursing students or nursing personnel from outside agencies are providing patient care within a patient care unit.

* 5. Adequate staffing for nursing personnel to participate in educational programs, performance improvement activities, and other activities that foster professionalism and innovation in nursing is provided...

B. The Nursing Department shall define, implement, and maintain a system for determining patient requirements for nursing care on the basis of demonstrated patient needs, appropriate nursing intervention, and priority for care. This acuity staffing system shall be based upon objective assessment tools that qualify the number of nursing staffing members needed to fulfill patient needs on each unit. The Assessment Coordinator utilizes input from the Chief Executive Officer, the unit charge nurses, or designee prior to admission placement decisions so that patient care needs can be coordinated with available resources.

C. Individualized, goal-directed nursing care is provided to all patients through use of the nursing process.

D. The Nursing Department uses findings from performance improvement activities and feedback from clients to assist in the evaluation of patient care provided. Findings shall be used to compare actual client outcomes with defined standards of care and practice. If staffing is adequate, both in terms of the number and qualifications of staff, correlation between actual health outcomes and standards should be positive.

Procedure:
A. Master staffing plans for the units are on file in the facility. The unit has a master/core staffing grid that identifies the size of the unit, skills mix utilized on the unit, and minimum number of staff that will be assigned when any patients are present. Plans include permanently assigned staff and per diem employees.

B. Staffing is based upon patient census, acuity, and relevant treatment needs.

C. Staffing includes a mixture of RNs, LPNs and PCAs

D. Staffing schedules are planned by the Nurse Manager or their designee for a two week period that coincides with each pay period.

E. Based on census and patient acuity, the needs of each unit are evaluated collaboratively on a shift or partial shift basis between the House Supervisor RN, the nurse manager, and DON to provide optimal patient care that is fiscally sound. Staffing adjustments, which may include additional staff, cancellation of staff, or reassignment of staff, are made by the House Supervisor, Nurse Manager or his/her designee. Schedules are updated as necessary. 12-hour staffing schedules are posted on each unit. Patients will be divided into units based on specific treatment needs in order to deliver the most appropriate care. Master copies of all schedules, daily staffing sheets and acuity reports are kept digitally for a period of three (3) years.

F. Variance between projected needs and actual staffing are described, acknowledged, and justified according to census and acuity.

G. It is necessary, at times, to reassign nursing personnel, on a daily or temporary basis, in order to meet patient care needs. NO NURSING STAFF WILL BE ASSIGNED SPECIFIC TASKS FOR WHICH HE/SHE HAS NOT DEMONSTRATED COMPETENCY.

H. All staff are to contact the Scheduler or House Supervisor during the day or the charge nurse/house supervisor after hours when unable to work an assigned shift. All calls are to be made (3) hours prior to start of the shift. In the event that a patient care unit has few or no patients assigned to that unit, nursing staff may be canceled or reassigned. When staff cancellation is necessary, the nursing staff is notified (2) hours before the beginning of the shift for which they were scheduled to work ....

Sample Unit Staffing Description:
Skills Mix: Registered Nurses, Licensed Practical Nurses and Patient Care Associates provide nursing care.
Core Staffing: Staff is adjusted according to patient census, safety concerns, and acuity levels. Staffing grids will be adjusted based on specific state regulatory requirements ..."



A review of the staffing assignment sheets was conducted with RN Staff #2, Staff #20, and RN Staff #21 on 3/04/2024 and 3/05/2024 for 4 (Willows, Meadows, Cedars, and Sunrise) of 4 patient care units.

This surveyor was unable to determine if 4 (Willows, Meadows, Cedars, and Sunrise) of 4 patient care units were staffed adequately and safely because the facility failed to have an approved staffing matrix/grid or an acuity tool to assist in determining the minimum number of staff required to safely provide the care ordered by the physicians.

The nurse staffing assignment sheets did not consistently address patient room assignments, patient acuity, such as special monitoring, special visitations, observation levels, or the additional staff needed for hall monitoring on the adolescent unit. The potential for additional staffing shortages existed when these situations were factored in but could not be determined based on the information provided on the nurse staffing sheets.

An interview was conducted with RN Staff #2 on 3/05/2024 at 9:20 AM. RN Staff #2 was asked if she felt like the nurse staffing was adequate and safe for the patients and staff. RN Staff #2 replied, "If you are only here for complaints why are you looking at staffing". Again, RN Staff # 2 was asked if the nurse staffing was adequate and safe for the patients and the staff. RN Staff #2 did not answer the question and exited the room.

On 3/05/2024 after 2:00 PM, CEO Staff #1 and DON, RN Staff #2 confirmed the facility did not use Licensed Vocational Nurses (LVN). Also, the CEO confirmed the facility did not have an approved staffing matrix/grid or acuity tool to assist in determining the minimum numbers of RNs and PCAs to ensure that all patients received quality care and all staff and patients were safe on 4 (Meadows, Cedars, Willows, and Sunrise) of 4 patient care units.