HospitalInspections.org

Based on review of hospital policies and procedures, documents, medical records, and interviews, it was determined that the Governing Body failed to be legally accountable for the conduct of hospital operations as evidenced by:
A049 failure to ensure that the organization of the medical staff was under the leadership of a Medical Staff Director. This failure posed the potential health and safety risk to the patient of poor quality medical care; and
A057 failure to ensure that the Chief Executive Officer (CEO) was responsible for hospital operations. This failure posed a health and safety risks to patients, including patient death; and
A083 failure to ensure that contracted services be evaluated annually. This failure posed a risk to patient health and safety.
The cumulative effect of these systemic deficiencies resulted in the hospital's failure to meet the requirements of the Condition of Participation for Governing Body.

Based on review of hospital policies and procedures, documents, medical records, and interviews, it was determined that the Governing Body failed to ensure that the organization of the medical staff was under the leadership of a Medical Staff Director. This failure posed the potential health and safety risk of poor quality medical care.
Findings include:
Review of the Governing Board Bylaws Article 2 General Provisions revealed: "...The Governing Body is ultimately accountable for the safety and quality of care treatment, and services provided by the Facility. The primary function of the Governing Board is to assure that the Facility and its Medical Staff provide quality medical care that meet the needs of the community...."
Review of the Medical Staff Committee Minutes dated 08/05/15, revealed that Physician #3 would continue to cover as Medical Director until Physician #31 was transitioned and ready to assume Medical Director duties for the hospital. Physician #31 began his duties on 09/09/15. Review of Governing Body Meeting Minutes dated 01/06/16 revealed Physician #31 resigned unexpectedly on 10/02/15.
Physician's #'s 1, 2, 4, and 25 confirmed, during confidential interviews conducted on 01/26/16 and 01/27/16, respectively, that the hospital does not have a Medical Director. The physicians confirmed during the same interviews that if they had a concern or a need for guidance and leadership from a Medical Director, they would ask a colleague or the nurse practitioner.
The Director of Quality Management confirmed, during a confidential interview conducted on 01/26/16, that the hospital does not have, and has not had a Medical Director or interim Director since Physician #31 resigned in October, 2015.
The CEO confirmed, during a confidential interview conducted on 01/26/16, that the facility does not have, and has not had, a Medical Director or interim Director since Physician #31 resigned in October, 2015.

Based on review of policies and procedures, document review, medical record review, and interview, it was determined that the governing body failed to ensure that the Chief Executive Officer (CEO) was responsible for hospital operations. This failure posed a health and safety risk to patients, including a patient death.

Findings include:

1. The CEO failed to ensure that patients received care in a safe setting.

(Cross reference Tag A 0144 # 1):

An RN was responsible for the 5 minute observations of Patient #1 which were not done prior to the suicide.

(Cross reference Tag A 0144 # 2):

A tour was conducted of the acute patient unit on 01/20/16, at 9:55 A.M.
Direct observation revealed that both the bedroom and bathroom doors of the room assigned to the index case (Patient # 1) had three non-contiguous, heavy metal hinges. The hospital had remodeled the doors of one patient room on the acute unit and replaced the hinges with "piano hinges." However, the other door hinges on the unit were not replaced, causing a safety hazard, since these door hinges provide a surface for the placement of a ligature to be used for patient self-harm.

2. The CEO failed to provide oversight to medical staff and nursing personnel to ensure that orders for restraint/seclusion met hospital requirements; staff monitored patients in restraint/seclusion in accordance with hospital requirements; medical staff obtained the required training related to restraint/seclusion; and that staff evaluated the medical condition of patients who underwent restraint/seclusion, as required.

(Cross reference tag A0169):

The telephone order of MD # 28, recorded by an RN, on Pt # 3's medical record at 2125, on 12/31/15, was a PRN order for restraints and not permitted.

(Cross reference Tag A0171):

The orders for restraint and/or seclusion contained in the medical records of Pt #s 15, 16, 17 and 20, were not in compliance with hospital requirements.

(Cross reference Tag A0175):

Nursing staff did not document the required monitoring of Pt # 17 for 1 hour and 15 minutes while s/he was in Seclusion.

(Cross reference Tag A0176):

The hospital was unable to provide documentation of training related to restraint and/or seclusion or working knowledge of the hospital's policies/procedures related to restraint and/or seclusion for MD # s 1, 2, 3, 4, 25 and/or PMHNP # 6.

(Cross reference Tag A0179):

The medical records of Pt #s 15, 16, 17 and 20, did not contain evaluations of those Pts' medical conditions after staff initiated restraint and/or seclusion, as required.

3. The CEO failed to provide oversight for the operation of Nursing Services, when nursing leadership failed to require timely documentation of patient assessment and a Code Blue for Pt # 1, who expired after hanging; when nursing leadership failed to implement a staffing plan that determines the type and numbers of nursing personnel necessary to provide nursing care for all areas of the hospital; when nursing leadership failed to ensure supervisory and staff personnel to ensure the immediate availability of an RN for bedside care of all patients; when nursing failed to supervise and evaluate the nursing care of patients; when nursing failed to assign nursing care of each patient in accordance with the patient's care needs and staff qualifications and competence; and when nursing leadership failed to provide for the orientation, supervision and evaluation of contracted agency RNs.

(Cross reference Tag A0386 # 1):

There was no supporting evidence that the Director of Nursing (DON) assumed responsibility for the operation of Nursing Services, when the DON failed to require timely documentation of a patient assessment and Code Blue involving death.

(Cross reference Tag A086 # 2):

The Acuity Tools are not completed by the Shift Supervisors, as required, and the acuity plan does not determine the type of staff required to provide care to the patients.

The Staffing Matrix does not represent a minimum number of staff required by patient census, but is only suggested staffing. The minimum number of RNs required for each unit was 1 RN. The patient capacity for the (child and adolescent) Tortolita Unit is 22; Rincon Unit is 24; Santa Rita Unit is 14 and Catalina (acute adult) Unit is 12.

The hospital was unable to provide documented evidence of the establishment and implementation of a staffing plan that determines the type and numbers of nursing personnel necessary to provide nursing care for all areas of the hospital.

(Cross reference Tag A0392):

The permanent Shift Supervisors have resigned their positions and it has been necessary to utilize staff RNs to serve in that function. Frequently, those RNs are responsible for the direct care of all of the patients on a unit.

(Cross reference Tag A0395 # 1):

No RN was covering the patients on the Catalina Unit, when Pt # 1 committed suicide by hanging.

(Cross reference Tag A0395 #2):

Staff did not record the required observations of Pt #s 22, 23, 24, 26, 27 and 28, on 1/14/16.

Cross reference Tag A0395 # 3):

RN # 33 discontinued Pt # 10's Q 5 minute direct observations, and placed her on Q 15 minute routine observations without a physician's order. The reduction of the level of observations requires a physician's order. Staff discovered Pt # 10, attempting to secure a sheet to hang herself.

(Cross reference Tag A0395 # 4):

Blood pressures were not measured/recorded as required by practitioner order, and the Clonidine had not been administered by RNs as required by practitioner order for Pt # 14's elevated blood pressure.

(Cross reference Tag A0395 # 5):

RN #s 35, 36, 37, 38 and 17 charted administration of Valium for anxiety when the Valium was ordered for alcohol withdrawal.

The hospital was unable to provide documentation that the RN's were competent to provide for the care of patients withdrawing from alcohol.

(Cross reference Tag A0395 #6):

Staff did not record the required observations of Pt # 3.

(Cross reference Tag A0395 # 7):

An RN did not complete the required assessment of Pt # 3 or documentation of his/her discharge, on the day that s/he was discharged.

(Cross reference Tag A0397):

A BHT assigned to provide supervision and observation of patients on the Catalina Unit on the shift when Pt # 1 committed suicide, had no documented competence to care for psychiatric patients and his/her only documented prior employment experience was as a "driver."

The facility was unable to provide documentation of patient assignments based on individual patient care needs and staff specialized qualifications/competence. BHTs are assigned to tasks; RNs are assigned to all of the patients on a unit or assigned by patient room number. LPNs are assigned by patient room number and tasks.

(Cross reference Tag A0398):

RN #s 30, 33, 17 and 11 did not have verified, documented competence to provide care to the patients for whom each RN was providing care, nor could the hospital provide documentation that RN #s 30, 33, 17 and 11 had been oriented to the hospital or its pertinent policies/procedures. He was unable to provide documentation of hospital supervision and evaluation of the above listed contracted agency RNs.

The CEO, appointed by the Governing Body, failed to ensure that the hospital protected the health and safety of the patients.

Based on review of facility 's documentation and staff interviews, it was determined the governing body failed to ensure that the contracted services were evaluated annually for the departments of pharmacy, lab and radiology. This failure of the hospital to address the annual evaluations of the contracted services has a potential risk of deteriorating quality of care and standards provided by the contracted services.

Findings include:

The surveyor was presented with the contract book containing all the different contracted services such as pharmacy, laboratory, radiology, and nurses registry for the facility.

The annual evaluations for pharmacy, laboratory, and radiology were requested and not provided to the surveyor.

The Director of Quality and Risk Management confirmed in a confidential interview conducted on January 28, 2016, the facility did not have documentation of the evaluations for Pharmacy, Laboratory and Radiology contracted services.

Based on review of hospital policies/procedures, medical records and interviews, it was determined that the hospital failed to protect and promote each patient's rights as evidenced by:

(A144) failure to ensure that patients received care in a safe setting, posing a risk to the health and safety of patients;

(A169) failure to ensure that orders for the use of restraint or seclusion never be written as a standing order or on an as needed basis (PRN), posing a potential risk of unnecessary restraint and patient harm;

(A171) failure to ensure that each order for restraint or seclusion, used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of a patient or others, be time limited and indicate the reason for restraint/seclusion, posing a risk of unlimited and unnecessary restraint/seclusion;

(A175) failure to ensure that trained staff monitor the condition of a patient placed in seclusion for the management of behavior which was dangerous to self and/or others, as required by hospital/policy/procedure, posing a risk to patient safety;

(A176) failure to specify the training requirements of practitioners and/or document that practitioners, authorized to order restraint or seclusion have a working knowledge of hospital policy regarding the use of restraint or seclusion, posing a risk to patient safety; and

(A179) failure to ensure evaluation of a patient's medical condition, at the time of the face-to-face evaluation by a practitioner or trained RN, within one hour of the initiation of restraint or seclusion for the management of violent or self-destructive behavior, posing a risk of an unidentified development of
or change in medical condition.

The cumulative effect of these systemic problems resulted in the hospital's failure to meet the requirements of the Condition of Participation for Patient Rights.

Based on review of medical records, policy and procedure, job description, direct observation, and interview, it was determined that the hospital failed to ensure that patients received care in a safe setting as evidenced by:

1. failure to ensure that the environment, and elements of the environment, provided a safe setting for 1 of 1 patients who committed suicide on the unit with an element (sheet) in the environment (Patient #1); and

2. failure to ensure that non-contiguous door hinges were removed from the acute unit (Acute Unit Patients), when piano-hinge type hinges were installed on one remodeled patient room on the unit; which poses a high potential safety risk if the non-contiguous door hinges can be used as ligature points.

Findings include:

1. Patient #1 was admitted to the hospital's acute unit on a Title 36 Petition, with an admitting diagnosis of "Psychotic D/O" (Psychotic Disorder). The petition paperwork for Patient #1 on 01/11/2016, 01/12/2016, and 01/13/2016 from a crisis response center, revealed that the patient was determined to be a Danger-to-Self (DTS) and Danger-to-Others (DTO).

Cross Reference Tag 0395 for additional information regarding the care of Patient #1, and the patient's suicide on the nursing unit.

The Director of Nursing job description revealed: "The Director of Nursing Services is responsible for: providing leadership and oversight to nursing and mental health technician staff...demonstrates exemplary understanding of requirements related to...and patient rights...."

The Registered Nurse job description revealed: "...Maintains a safe and efficient working and treatment environment...."

The "Plan for the Provision of Care" policy revealed: "...Registered Nurse ...8. Maintenance of safe and effective nursing practice in the provision of patient care directly or indirectly...."

At 4:10 A.M. on the day of admission, the "Sonora Behavioral Health Observation Rounds" record for Patient #1 revealed that the patient's observation level changed from every 15 minute checks to every 5 minute checks. The "Reason for Q (Every) 5 minute observation was: (zero with diagonal slash indicating 'no'" SRA (Suicide Risk Assessment)/pt (patient) drowsy."

Patient #1's medical record revealed that every 5 minute observations were conducted from 4:10 A.M. until 7:00 A.M., when the day shift (7:00 A.M.-3:00 P.M.) RN assumed responsibility for the care of the patient. The observation form was completed with every 5 minute observations on the day shift until 8:35 A.M.

The day shift observation record revealed that the patient was in her room from 7:05 A.M. until 7:50 A.M., at which time the record revealed that the patient was in the unit "Dayroom."

The observation form revealed blank entry fields for 8:35 A.M., 8:40 A.M., 8:45 A.M., and 8:50 A.M.

The Observation Rounds form for Patient #1 revealed that Staff #10, an RN, documented at 8:55 A.M. that the patient was in the "bathroom" and that "CPR" (Cardiopulmonary Resuscitation) was being performed at 8:55 A.M., and 9:00 A.M., respectively.

The Emergency Medical System (EMS) documentation for Patient #1 revealed: "...Found Pt (patient) unconscious and unresponsive lying supine on the floor of (hospital) with bystander CPR ongoing. Pt was found to be pulseless at carotid (artery) and apneic (no respirations)...(EMS Unit) arrived on scene and established an IO (intraosseous)" (insertion of a line for administration of fluids and medications) in Pt's right tibia...."

EMS personnel intubated the patient, administered epinephrine 1:10,000 six (6) times with one dose of sodium bicarbonate. The EMS record revealed: "...Staff O/S (on site) stated Pt was last seen 20-30 minutes PTA (Prior to Arrival)."

Patient #1 was transferred to an acute care hospital at 9:29 A.M. on the day of admission, and arrived at the acute care hospital at 9:32 A.M., where she expired.

Staff #34 stated, during interview conducted on 01/20/16 at 5:20 P.M., that Staff #29, an RN, was responsible for the 5 minute observations of Patient #1 which were not done prior to the suicide.

Staff #16 acknowledged, during interview conducted on 01/26/16 at 10:00 A.M., that Staff #29, an RN had left the unit to get coffee at the time Patient #1 hanged herself on the unit.

2. The Sonora Behavioral Health Hospital policy titled: "Providing a Safe Environment" revealed: "It is the policy of (hospital) to develop and implement plans, programs and processes which will promote a safe and functional environment...PROCEDURE: The organization designs, constructs, and maintains features of the environment to promote patient safety by providing diagnosis, treatment and care for the appropriate needs of the patients...1. Interior spaces shall meet the needs of the patient population and are safe and suitable to the care, treatment and services provided...."

A tour was conducted of the acute patient unit on 01/20/16, at 9:55 A.M.
Direct observation revealed that both the bedroom and bathroom doors of the room assigned to the index case (Patient # 1) had three non-contiguous, heavy metal hinges.

All of the patient rooms on the acute unit had similar hinges, with the exception of one room. The room with different hinges had continuous hinges from top to bottom, sometimes referred to as "piano hinges," which are generally used to prevent a patient from using a standard non-contiguous hinge as a ligature point.

Patient #1 draped a bed sheet over a bathroom door and hung themself by shutting the door.

The Regional Director of Clinical Services accompanied surveyor on tour of the Acute Unit where the suicide of Patient #1 was actuated. The room with the "piano hinge" doors had been remodeled several years prior to the current survey, at which time the "piano hinges" were added to the remodeled room.

The Regional Director of Clinical Services, during interview conducted on 01-20-16 at 9:55 A.M., when asked why, if the need for "piano hinges" were deemed appropriate to keep patients safe when the one room on the acute unit was remodeled, that judgment would not extrapolate that all patient rooms needed "piano hinges"? The Director did not provide an answer.

Based on review of hospital policy/procedure, Rules and Regulations of the Medical Staff, medical record and interview, it was determined that the hospital failed to ensure that orders for restraint never be written on an as needed basis for 1 of 1 minor patient (Pt # 3), which poses a potential risk of unnecessary restraint and patient harm.

Findings include:

Review of hospital policy/procedure titled Restraint revealed: "...Orders for restraint shall never be written as a standing order or on an as needed basis (PRN)...."

Review of Rules and Regulations of the Medical Staff revealed: "...The use of Restraints or Seclusion shall not be based on standing orders or on as needed ("PRN")...."

Review of Pt # 3's medical record revealed:

On 12/31/15, at 2125, an RN recorded a verbal order from MD # 28: "...1:1 for safety...May use restraints if needed...."

On 1/1/16, at 1050, an RN recorded a telephone order from MD # 29: "D/C (Discontinue order for restraints if needed...."

The order to utilize restraints if needed was an active order for 13+ hours.

The Director of Quality confirmed during interview conducted on 1/26/16, that the order was a PRN order and not permitted.

Based on review of hospital policies/procedures, Rules and Regulations of the Medical Staff, medical records and interview, it was determined that the hospital failed to ensure that each order for restraint or seclusion, used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of a patient or others, be time limited and indicate the reason for restraint/seclusion, as required by policy/procedure, for 4 of 4 patients (Pts #15, 16, 17 and 20), posing a high potential risk of unnecessary and unlimited restraint and/or seclusion.

Findings include:

Review of the Medical Staff Bylaws revealed: "...General Responsibilities of Staff Membership...In addition to the other obligations described in these bylaws, each applicant by applying for or being granted any category of membership or Clinical Privileges, obligates himself to:...abide by the Medical Staff Bylaws, Rules and Regulations and by all other standards, policies, procedures, and rules of the facility and the Board as they may exist now or in the future...."

Review of the Rules and Regulations of the Medical Staff revealed: "...Orders-A Practitioner must order the Restraints or Seclusion, the use of which is limited to Emergency Situations...Orders for Management of Violent or Self-Destructive Behavior are limited to the duration of the Emergency Situation and must not exceed the following time limits: Three (3) hours for adult patients...Two (2) hours for children and adolescents ages 9-17...."

Review of hospital policy/procedure titled Restraint revealed: "...Physical restraint includes manual measures approved by CPI (Crisis Prevention Institute) to limit or restrict body movement. Orders for use of physical restraint shall not exceed 30 minutes...Mechanical Restraint:...Orders for use of mechanical restraint shall not exceed the following time limits: 3 hours for adults 18 years of age or older; 2 hours for children and adolescents 9 to 17 years of age...The order shall indicate the reason and maximum duration of restraint...."

Review of hospital policy/procedure titled Seclusion revealed: "...Orders for use of seclusion shall not exceed the following time limits: 3 hours for adults 18 years of age or older; 2 hours for children and adolescents...The order shall indicate the reason and maximum duration of seclusion...."

Review of Pt # 15's medical record revealed:

Pt # 15 is older than 18 years of age. On 1/18/16, at 2315 an RN documented: "...came charged @ staff, banging on the exit door, banging on walls and screaming, Redirection unsuccessful...."

On 1/19/16, at 0000, an RN documented: "...IM's drawn up, pt refused them...charging @ staff slapping BHT, pt was then placed on bed by a gentle hold of X3 BHT while this nurse administered the IM injections...."

Pt # 15's medical record did not contain documentation of a practitioner's order for the physical hold at 0000. A pre-printed sticker, used for documentation of the order for Physical Hold, contained blank lines in the spaces provided to record the name of the ordering practitioner, the name of the nurse receiving the order and the date and time received.

On 1/19/16, at 0048 an RN documented: "...Hold and release to give IMs...."
An RN recorded MD # 2's verbal order for a Physical Hold and Mechanical Restraint on 1/19/16, at 0050. The order did not contain indication of the reason for the restraint.

Review of Pt # 16's medical record revealed:

Pt # 16 was an adolescent on 11/9/15.

On 11/9/15 at 1830, an RN recorded a telephone order from PMHNP (Psychiatric Mental Health Nurse Practitioner) # 6: "Physical Hold for out of control behavior...."

On 11/9/15 at 1845, an RN recorded a telephone order from PMHNP # 6: "Seclusion after IM medications until pt becomes calm...."

On 11/9/15, at 1830, an RN documented an unsigned note: "...Pt began punching the window in his room and walls...Pt was placed in a physical hold and walked to the quiet room. Pt continued to punch, spit and threaten staff. IM medications were given per doctors order...remained at risk for self & staff injury and remained in seclusion until he was able to remain calm...."

Neither of the above orders were time limited, as required by hospital policies/procedures and Medical Staff Rules and Regulations. The order for seclusion did not indicate the reason for seclusion.

The RN documentation did not contain the length of time that the patient remained in seclusion.
The Restraint/Seclusion Flowsheet contained documentation that Pt # 16 was in seclusion from 1835 until 2000. Staff did not document monitoring of the patient between 1845 and 2000.

Review of Pt # 17's medical record revealed:

Pt # 17 is older than 18 years of age.

Pt # 17's medical record contained documentation that he "punched" an LPN on "the left cheek" after the LPN had administered a "TB test after consent." When Pt # 17 prepared to deliver another "punch," staff lowered him to the floor and subsequently moved him to the seclusion room. The LPN administered medication to the patient and staff placed the patient in mechanical restraints.

On 1/6/16, at 0830, an RN recorded a telephone order from PMHNP # 6: "...4 point restraint in the seclusion room...."

The above order was not time limited and did not include the reason for restraint, as required.

The Restraint/Seclusion Flowsheet contained documentation that staff applied mechanical restraints at 0835. Pt # 17 remained in mechanical restraints until 0915.

Review of Pt # 20's medical record revealed:

Pt # 20 was an adolescent on 11/9/15.

On 11/9/15, at 1655, an RN documented an unsigned note: "...pt got upset and began pushing on his 1:1 staff. Pt was walked to the quiet room and continued to escalate and push on 1:1 staff. Pt was offered quiet time to calm down and was placed in seclusion per doctors (sic) order for 5 minutes...."

On 11/9/15, at 1700, RN # 30 recorded a telephone order from PMHNP # 6: "Place pt in seclusion for out of control behavior...."

The above order was not time limited, as required.

The DON confirmed, during interview conducted on 1/28/16, that the above orders were not in compliance with hospital requirements.

Based on review of hospital policy/procedure and medical record, it was determined that the hospital failed to ensure that trained staff monitor the condition of 1 of 2 minor patients who was placed in seclusion for the management of behavior which was dangerous to self and/or others, as required by hospital policy/procedure (Pt # 17), which posed a high potential risk to patient safety.

Findings include:

Review of hospital policy titled Seclusion revealed: "...The patient shall be monitored and reassessed through continuous in-person observation and documented, at a minimum, every 15 minutes. Continuous means ongoing without interruption. Monitoring to include the following: Signs of physical distress...Observed patient behavior...offering fluids at minimum every 15 minutes...Vital signs-frequency will depend on patient condition and determined by RN assessment...Offering opportunity for elimination at minimum every 2 hours...Evaluation of readiness for release from seclusion...Any other interventions...."

Review of pt # 17's medical record revealed:

The Restraint/Seclusion Flowsheet contained documentation that Pt # 17 was in Seclusion from 1835 until 2000. Documentation of patient monitoring was recorded at 1845 and 2000.

Nursing staff did not document the required monitoring of Pt # 17 for 1 hour and 15 minutes while he was in Seclusion.

Based on review of hospital policies/procedures, Medical Staff Bylaws, Rules and Regulations of the Medical Staff, Credential Files, medical records and interview, it was determined that the hospital failed to specify the training requirements of practitioners and/or document that practitioners, authorized to order restraint or seclusion, have a working knowledge of hospital policy regarding the use of restraint or seclusion for 6 of 10 active members of the medical staff with psychiatry privileges (MD # s 1, 2, 3, 4, 25 and PMHNP # 6), which posed a high potential risk to patient safety.

Findings include:

Review of hospital policy/procedure titled Restraints revealed: "...Restraint may only be ordered by a practitioner (Physician or Nurse Practitioner)...."

The Restraint policy/procedure did not contain the training requirements, related to the restraint of patients, for practitioners authorized to order restraints.

Review of hospital policy/procedure titled Seclusion revealed: "...Seclusion may only be ordered by a practitioner (Physician or Nurse practitioner)...."

The Seclusion policy/procedure did not contain the training requirements, related to the seclusion of patients, for practitioners authorized to order seclusion.

Review of the Medical Staff Bylaws and Rules and Regulations of the Medical Staff revealed that neither document contained the training requirements, related to restraint or seclusion of patients, for practitioners authorized to order restraints and/or seclusion.

Review of the credential files of MD # s 1, 2, 3, 4, 25 and PMHNP # 6 revealed that they did not contain documentation of training, related to restraint and/or seclusion. The credential files did not contain documentation that the practitioners had working knowledge of the hospital policies/procedures related to restraint and/or seclusion. Each of the above practitioners did have documented psychiatry privileges.

The hospital was unable to provide evidence that MD # s 1, 2, 3, 4, 25 and/or PMHNP # 6 had a working knowledge of hospital policies/procedures regarding the use of restraint or seclusion.

Cross reference Tag 0171 for telephone orders/verbal orders for restraint and/or seclusion from MD # 2 for Pt # 15 and from PMHNP # 6, for Pt # s 16, 17 and 20, that did not meet hospital requirements.

The Director of Quality confirmed, during an interview conducted on 1/27/16, that the hospital was unable to provide documentation of training related to restraint and/or seclusion or working knowledge of the hospital's policies/procedures related to restraint and/or seclusion for MD # s 1, 2, 3, 4, 25 and/or PMHNP # 6.

Based on review of hospital policy/procedure, medical records and interview, it was determined that the hospital failed to require an evaluation of a patient's medical condition, at the time of the face-to-face evaluation by a practitioner or trained RN, within one hour of the initiation of restraint or seclusion for the management of violent or self-destructive behavior, for 4 of 4 patients (Pts # 15, 16, 17 and 20), which posed a high potential risk of an unidentified development of, or change in medical condition.

Findings include:

Review of hospital policy titled Restraint revealed: "...A restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. This policy applies to physical restraint and mechanical restraint...A practitioner or trained registered nurse shall conduct an in-person evaluation of the patient within one hour of initiation of restraint to assess physical and psychological status. The in-person evaluation includes the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the intervention...."

Review of hospital policy titled Seclusion revealed: "...Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving...A practitioner or trained registered nurse shall conduct an in-person evaluation of the patient within one hour of initiation of seclusion to assess physical and psychological status. The in-person evaluation includes the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the intervention.

Review of Pt # 15's medical record revealed:

Nursing placed Pt # 15 in a physical hold for administration of IM medication from 0000 to 0001, on 1/19/16. An RN documented evaluation of the patient's medical condition at 0045: "pt is squirming around. pt was a 1 minute physical hold X 3 staff while IM's administered."

Nursing placed Pt # 15 in a second physical hold for administration of additional IM medication from 0047 to 0048, on 1/19/16. An RN documented evaluation of the patient's medical condition at 0150: "Pt was squirming. less than one minute hold and release."

Review of Pt # 16's medical record revealed:

On 11/9/15, at 1830, an RN documented an unsigned note: "...Pt was placed in a physical hold and walked to the quiet room...Pt continued to punch, spit and threaten staff. IM medications were given per doctor's order...remained in seclusion until he was able to remain calm...."

An RN wrote "N/A" (Not Applicable) in the space provided for "Patient's present medical condition" on the form titled ONE HOUR IN-PERSON EVALUATION BY PRACTITIONER/qualified RN). The space indicated for the time of completion of the evaluation was blank.

Review of Pt # 17's medical record revealed:

Nursing documented an unsigned note: "...patient backed up as staff approached. patient jurked (sic) head back hit the side wall. LPN and staff got a grip on patient then on to the floor...patient was moved to seclusion room...patient remained in restraints with staff...watching until patient calmed down...."

Unsigned documentation of evaluation of Pt # 17's medical condition included: "1 inch lacerations on back of head pressure was on for 10 minuts (sic) to 20 minuts (sic) then bleeding stopped patient was assessed. No other S/Sx (Signs/Symptoms) of severe head injury."

No other evaluation of the patient's medical/physical status was recorded. The space for signature of Practitioner or trained RN was blank. The space for date was blank. The space to record the time when the evaluation was completed was blank.

Review of Pt # 20's medical record revealed:

Nursing documented an unsigned note: "...was placed in seclusion per doctors (sic) order for 5 minutes...."

Pt # 20's medical record contained the form titled ONE HOUR IN-PERSON EVALUATION BY PRACTITIONER/(qualified) RN. The space designated for documentation of the patient's medical condition was blank. "N/A" was written in the space designated for the time that the one-hour assessment was completed.

The DON confirmed, during interview conducted on 1/28/16, that the above medical records did not contain evaluations of the medical conditions of the patients, as required.

Based on review of hospital policies/procedures, the hospital's Quality Program, hospital documents and interviews, it was determined that the hospital failed to implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program, involving all hospital departments and services, with indicators related to improved health outcomes and prevention and reduction of medical errors, as evidenced by:

(A286) failure to provide documentation of implementation of preventive actions and interventions that include feedback and learning opportunities throughout the hospital; failure to provide documentation of patient safety training to nursing personnel; and failure to analyze, track and trend medication errors, posing a high potential risk to patient safety;

(A308) failed to ensure the quality program reflected the annual evaluation of the contracted services for the departments of pharmacy, lab and radiology. This failure of the hospital to address the annual evaluations of the contracted services has a high potential risk of deteriorating quality of care to patients if deficiencies in services provided by the contracted services are not identified and addressed; and

(A309) failure of the governing body to ensure the medical staff were responsible and accountable for the quality assessment and performance improvement efforts for improved quality of care and patient safety as demonstrated by the absence of a current medical director or interim medical director. The absence of the medical director poses a high potential risk that the medical staff's quality of care provided to the patients will not be monitored.

The cumulative effect of these systemic problems resulted in the hospital's failure to develop, implement and maintain an effective, quality assessment and performance improvement program.

Based on review of hospital policies and procedures, facility's Quality Program, facility's documentation and staff interviews, it was determined the hospital failed to:

1. Provide documentation that the hospital identified and evaluated all areas of the hospital that utilized similar processes with the potential for a similar risk for one of one case reviewed related to patient # 3 ' s suicide attempt on December 31, 2015. The failure of the hospital to address the close call beyond the unit where the incident occurred, has a high risk for the facility not recognizing facility-wide issues related to adverse events throughout the facility as evidenced by one completed suicide (Pt # 1) and 2 attempts/near misses (Pt #s 10 and 18 ) in the facility on different units during the month of January 2016; and

2. Provide documentation of patient safety training for the nursing staff and behavioral health technicians. This failure of the hospital to address the documentation of staff safety training has a high potential risk for staff not being aware of clear expectations for providing patient safety in the facility.

3. Analyze, track, and trend medication errors in 9 of 9 errors/omissions, occurring in December, 2015. The potential risk is that patients who did not receive the drugs ordered for them and drugs given to the wrong patient could cause serious adverse outcomes.

Findings include:

1. Review of the facility documentation revealed that the facility identified training needs for the staff on the adolescent unit, regarding communication between the registered nurses and the behavioral health technicians about patient changes and observation levels. This feedback and training need was not expanded to the other areas of the facility for suicide prevention.

The Director of Quality and Risk confirmed in an interview conducted on January 28, 2016, the facility completed the investigation of the event on the adolescent unit on January 6, 2016. The Director of Quality and Risk also confirmed the facility was unable to provide the documentation that the hospital identified and evaluated all areas of the hospital utilizing similar processes with the potential for risk for suicide attempts at the time of the investigation completed on January 6, 2016.

2. The Facility Scope of Quality and Performance Improvement Activities 2015 revealed: " ...the staff competence with job requirements /skills is assessed upon hire and on a regular basis to demonstrate consistency over time...."

Staff # 20, 21, 22,23, 24, and 25 confirmed in individual confidential interviews conducted on January 27, 2016, that they did not receive safety training. They also confirmed that the training for the Behavioral Health Technicians (BHT) was not adequate for new BHT's.

The Director of Nursing and the Director of Human Resources confirmed in individual confidential interviews conducted on January 26, 2016, that there was no documentation available for surveyor review of staff safety training.

3. Surveyor reviewed 9 medication errors dated from 12/01/15 through 12/14/15. The errors involved the following: 1) Propanolol (Beta Blocker used in hypertension) given to the wrong patient, and not discovered on the 24 hour chart check; 2) Xanax that was discontinued, but still administered; 3) Zyprexa (anti-psychotic) administered to the wrong patient; 4) Missed doses of Seroquel (anti-psychotic), due to pharmacy error; 5) Stat (immediately) intramuscular dose of Geodon, Ativan, and Benadryl (anti-psychotic, anti-anxiety, and sedative, respectively) which was not documented; 6) Twelve (12) doses of missed Metformin; 7) Extra dose of Seroquel pulled from automated medication dispensing machine; and 9) An "unknown" amount of insulin administered to a patient.

The internal hospital document which revealed the errors, did not contain the names of the staff involved in the errors, in order to track and trend by staff member. The field for what action was taken as a result of the error/omission was blank.

The Pharmacy Director, a contractor, stated, during interview conducted on 01/27/16, that she sees the occurrence reports that she generates, but does not have access to review all medication occurrence reports. The Director stated that she has been told, indirectly, that she does not need to see the medication error reports. The Pharmacy Director stated that if she is not aware of a medication error, such as a medication being administered to the wrong patient, she is unable to make a recommendation regarding drug interactions, etc.

Review of internal documents revealed that the Risk Management Director signed and dated the reports, but left the field depicting action taken blank.

The Director of Risk Management acknowledged, during interview conducted on 01/28/16 at 2:20 P.M., that the December medication errors had not been tracked, trended, or analyzed.

Based on review of facility's documentation and staff interviews, it was determined the governing body failed to ensure the quality program reflected the annual evaluation of the contracted services for the departments of pharmacy, lab and radiology. This failure of the hospital to address the annual evaluations of the contracted services has a high potential risk of deteriorating quality of care to patients if deficiencies in services provided by the contracted services are not identified and addressed.

Findings include:

The surveyor was presented with the contract book containing all the facility's contracted services such as pharmacy, laboratory, radiology, and nurses registry.

The annual evaluation documentation was requested for Pharmacy, Laboratory and Radiology. The facility was unable to provide these annual evaluations.

The Director of Quality and Risk Management confirmed, in a confidential interview conducted on January 28, 2016, the facility did not have documentation of the evaluations for Pharmacy, Laboratory and Radiology contracted services.

Based on review of facility 's documentation and staff interviews, it was determined the governing body failed to ensure the medical staff were responsible and accountable for the quality assessment and performance improvement efforts for improved quality of care and patient safety as demonstrated by the absence of a current medical director or interim medical director. The absence of the medical director poses a high potential risk that the medical staff's quality of care provided to the patients will not be monitored.

Findings include:

Review of the Rules and Regulations of the Medical Staff require: "...The Governing Board...holds the Medical Director and the Medical Staff accountable for the quality of practice with in the hospital...."
During the survey, the surveyors requested that the hospital provide the job description for the Medical Director. The hospital provided a job description for job title Chief of Medical Services. Review of the Position Summary for the Chief of Medical Services revealed the following:
"...Maintains overall responsibility for all clinical programs; ensures clinical functions are integrated within all levels of care; coordinating patient care activities and concerns across programs; establishes physician roster for 24/7 coverage of all clinical services; provides administrative supervision of Physicians, Allied Staff and Pharmacist-In-Charge...."

The job description also includes the Leadership Function as follows: "...Acts as a resource to patients, employees and medical staff for resolution; serves as liaison, conducts meetings at least monthly for coordination and communication of physician services; attends and actively participates in assigned committees including Board of Trustees, Administrative Team and Quality Management...."

Review of the facility's administration emergency management call list revealed that there was no medical director listed.

Review of the quality minutes for 2015, revealed that there was no medical director after October 2015.

The Director of Quality and Risk Management confirmed in a confidential interview conducted on January 26, 2016 that there is no current medical director or interim medical director. She also confirmed that there has not been a medical director or interim medical director since October 2015.

The CEO confirmed in a confidential interview conducted on January 27, 2016 that there is no medical director or interim medical director at the time of the survey. She also confirmed that there has not been a medical director or interim medical director since October 2015. She also stated that a medical director has been selected, but will not start until April 2016.

Based on review of Rules and Regulations of the Medical Staff, Medical Staff Bylaws, hospital documents, medical records and interviews, it was determined the hospital failed to comply with the provisions for the Governing Body requiring accountability for the quality of medical care provided to patients as demonstrated by the failure to ensure that the Governing Body appoint a Chief Medical Officer. This failure poses the high potential risk to the patient's health and safety if patients receive physician services that are inappropriate, inconsistent and/or of poor quality.

The Governing Body failed to assume responsibility for all hospital operations as determined by non-compliance with the following regulation:

(A0347) The medical staff failed to organize and show accountability to the governing body for the quality of standards of medical practice provided to the patients as evidenced by failure to unite under the guidance of a single leader (Medical Director) to be responsible for the organization and conduct of the medical staff; failure to perform monthly samplings of medical records for peer review; failure to participate as a resource leader for patients, employees and medical staff for issues relating to patient care; and failure to provide a chairman for the medical executive committee.

The cumulative effect of these systemic deficient practices resulted in the hospital's failure to meet the requirements for the Condition of Participation for the Medical Staff.

Based on review of the Rules and Regulations of the Medical Staff, hospital documents and staff and physician interviews, it was determined that the medical staff failed to be organized and accountable to the governing body for the quality of medical care provided to the patients, as evidenced by:
1. failure to unite under the guidance of a single leader (Medical Director) to be responsible for the organization and conduct of the medical staff;

2. failure to perform monthly samplings of medical records for peer review;

3.failure to participate as a resource leader for patients, employees and medical staff for issues relating to patient care; and

4. failure to provide a chairman for the medical executive committee.

These failures have the potential of risk to the patient's health and safety by receiving physician services that are inappropriate, inconsistent and/or of poor quality.

Findings include:

1. Review of the Rules and Regulations of the Medical Staff require: "...The Governing Board...holds the Medical Director and the Medical Staff accountable for the quality of practice with in the hospital...."

Review of the Medical Staff Committee Minutes dated 08/05/15 revealed Physician #3 would continue to cover as Medical Director until Physician #31 was transitioned and ready to assume Medical Director duties for the hospital. Physician #31 began his duties on 09/09/2015.

Review of Governing Body Meeting Minutes, dated 01/06/16, revealed Physician #31 resigned unexpectedly on 10/02/2015.

The Director of Quality Management confirmed during a confidential interview conducted on 01/26/16 that the facility does not have and has not had a Medical Director or Interim Medical Director since Physician #31 resigned in October, 2015.

The CEO confirmed during a confidential interview conducted on 01/26/16 that the facility does not have and has not had a Medical Director or Interim Medical Director since Physician #31 resigned in October, 2015.

2. Rules and Regulations of the Medical Staff effective date February 2015 revealed: " ...A monthly sampling of medical records for each practitioner shall be reviewed by the Medical Staff or by such committee or function of the Medical staff as is designated for such peer review purposes in the Medical Staff Bylaws. The MEC will identify cases for review which are deemed to be high-risk or problem prone .... "

The surveyors requested medical record peer review evaluations during the last six (6) months (July through December) for physicians. The facility returned the following: five (5) different physicians were evaluated. Out of the 5 physicians only two (2) are current staff members. Three (3) of the physicians were evaluated by another physician and two (2) physicians were evaluated by a nurse practitioner. A total of thirteen (13) medical record peer review samples were taken from the months January, May, June, July and August 2015. All evaluations were scored satisfactory. All evaluations were signed and dated 10/26/15.

The Quality Director confirmed, during a telephone interview at 0930 hours, on 2/2/16, that the peer reviews sent were the only ones conducted; and no reviews were completed in November or December.

The Facility failed to follow the Peer Review process required by the Medical Staff Rules and Regulations.

3.During the survey, the surveyors requested that the hospital provide the job description for the Medical Director. The hospital provided a job description for job title "Chief of Medical Services". Review of the Position Summary for the Chief of Medical Services revealed the following:
"Maintains overall responsibility for all clinical programs; ensures clinical functions are integrated within all levels of care; coordinating patient care activities and concerns across programs; establishes physician roster for 24/7 coverage of all clinical services; provides administrative supervision of Physicians, Allied Staff and Pharmacist-In-Charge."

The job description also included the Leadership Function as follows: "...acts as a resource to patients, employees and medical staff for resolution: "serves as liaison, conducts meetings at least monthly for coordination and communication of physician services; attends and actively participates in assigned committees including Board of Trustees, Administrative Team and Quality Management...."

Review of Pt # 3's medical record revealed:

Pt # 3, a minor, was admitted on 1/24/15, by PMHNP # 6. Four psychiatrists saw the patient and wrote orders on his medical record, including medication changes, during his hospitalization. On 1/6/16, an RN recorded a verbal order of PMHNP # 6: "...Transfer care to (MD # 2) per CEO...."

MD # 2 confirmed, during interview conducted on 1/27/16, that the CEO had requested that he assume the care of Pt # 3, due to a conflict between physicians. MD # 2 confirmed that a Medical Director would ordinarily intervene in issues concerning the medical staff.

Physician's #'s 1, 2, 4, and 25 confirmed during confidential interviews conducted on 01/26/16 and 01/27/16, that the hospital does not have a Medical Director. The physician's confirmed during the same interviews that if they have a concern or a need for guidance and leadership from a medical director; they will ask a colleague or the nurse practitioner.

4. Review of the Medical Staff Bylaws required: ...MEDICAL EXECUTIVE COMMITTEE...MEC shall be fully licensed Practitioner Members of the Active Staff. The Medical Director shall be a member and chairman of the MEC.

Physician's #'s 2 and 25 confirmed, during confidential interviews conducted on 01/26/16 and 01/27/16, that the CEO conducts the MEC meetings because there is no Medical Director.

Based on review of Medical Staff Bylaws, Rules and Regulations, medical record and interview, it was determined that the hospital failed to enforce the bylaws when MD # 4 failed to record a progress note correlating with his orders for 1 of 1 patient who was discharged home while requiring 1:1 observation in the hospital after a suicidal gesture (Pt # 39).

Findings include:

Review of the hospital Medical Staff Bylaws revealed:

"...The responsibilities of the Medical Staff are...to monitor, enforce, review, and, if necessary or desirable, recommend amendments to these Bylaws and Rules and Regulations and Facility policies...."

Review of the Rules and Regulations of the Medical Staff revealed: "...Pertinent progress notes related to diagnosis and to treatment plan goals and objectives, sufficient to permit continuity of care, shall be recorded on the date of each visit. Each of the patient's clinical problems should be clearly identified in the progress note and correlated with specific orders, as well as results of tests and treatments...Practitioners shall be responsible for the documentation of:...Discharge Plan...."

Review of Pt #18's medical record revealed:

Pt # 18's attending psychiatrist, MD # 4, documented in a Psychiatric Daily Note on 1/27/16, at 1600: "...No neurocognitive deficits...Advised rtn (return) home with assistance. pt agreed to temporary guardianship with son & wife...."

On 1/27/16, at 1848, an RN documented: "...Pt has been seclusive to self and remaining in his room. At 1758 while rounding, author observed pt entering restroom. author noted a blanket hung over the door. RN entered bathroom and found patient standing and adjusting blanket to form a loop...obtained an order for 1:1 while awake. Q 5 minute checks while asleep. Order obtained to remove all linen from room...."

On 1/28/16, at 0845, an RN documented a verbal order from MD # 19: "...Continue 1:1 observation...."

On 1/28/16, at 1200, MD # 4 recorded an order: "...Discharge today...."

On 1/28/16, at 1500, an RN documented: "...Patient is to be discharged today...Still on 1:1 for unsteady gait and SI (Suicidal Ideation) gesture...Pt discharge order was cancelled by (MD # 4)...."

On 1/28/16, at 1855, an RN documented a verbal order from MD # 4: "...Cancel Discharge...."

On 1/28/16, at 1952, an RN documented a verbal order from MD # 4: "...D/C (Discharge) tonight...."

On 1/28/16, at 2020, an RN documented: "...Denies SI...Provided discharge instructions...follow-up appts...."

Review of the Observation Rounds sheet, dated 1/28/16, revealed that Pt # 18 was supervised/observed on a 1:1 basis, with documentation through 2000.

Pt # 18's medical record did not contain a progress note, written by a physician, after the patient had been found on 1/27/16, with a blanket over the door, adjusting the blanket to form a loop and requiring 1:1 supervision. Physician orders were recorded for 1:1 supervision on 1/28/16 at 0845. Physician orders were recorded for Discharge on 1/28/16 at 1200, then cancelled and then reinstated with no accompanying progress notes for any of the orders written on 1/28/16.

RN # 39 confirmed, during interview conducted on 1/28/16, that Pt # 18's medical record did not contain documentation by a physician of rationale for the patient's discharge home from the hospital when he continued to require 1:1 supervision.

Based on review of hospital policies/procedures, hospital documents, job descriptions, personnel files, medical records and interviews, it was determined that the hospital failed to provide an organized nursing service 24-hours per day with an adequate number of registered nurses and competent nursing staff to assess patients' care needs and deliver, assign and supervise the care required by each patient as evidenced by:

(A386) failure to ensure that a Registered Nurse was responsible for the operation of the service, posing a risk to patient health and safety;

(A392) failure to have sufficient supervisory staff to ensure the immediate availability of an RN to meet the needs of all patients, posing a risk to patient safety;

(A395) failure to ensure that a Registered Nurse supervise and evaluate the nursing care of patients, posing a risk to the health and safety of patients, up to, and including, death;

(A397) failure to ensure that a Registered Nurse assign the nursing care of each patient in accordance with the individual patients' needs and the specialized qualifications and competence of the nursing staff, posing a risk to patient safety; and

(A398) failure to ensure that contracted agency RNs have verified competence, documented orientation to the hospital and to pertinent policies/procedures and documented supervision and evaluation, posing a risk to patient health and safety.

The cumulative effect of these systemic problems resulted in the hospital's failure to provide an adequate, organized nursing service.

Based on review of medical records, policies and procedures, job descriptions, hospital documents, and interviews, it was determined that the hospital failed to ensure that a registered nurse was responsible for the operation of the service as evidenced by:

1. failure of nursing leadership to require timely documentation of patient assessment for a Code Blue for 1 of 1 patients in whom death by hanging occurred (Patient #1). The potential risk is that if nursing leadership has no documented facts related to patient assessment and a Code Blue, that other patients will be at risk to suffer a negative outcome under similar circumstances.

2. failure of nursing leadership to ensure that emergency bag contents were intact and complete for seven (7) days following a Code Blue in which a patient subsequently expired. The potential risk is that emergency equipment needed to appropriately resuscitate a patient may not be in the emergency kit as planned, which could pose a risk to health and safety.

3. failure of nursing leadership to implement a staffing plan that determines the type and numbers of nursing personnel necessary to provide nursing care for all areas of the hospital, posing a risk that the psychiatric and medical needs of the patients who require hospitalization will go unmet.

Findings include:

1. Cross reference Tag 0395 related to nursing background information on Patient #1.

The Code Blue policy revealed: "POLICY: The Code Blue is the mechanism to provide rapid emergency assistance to the person in cardiopulmonary crisis...PROCEDURE: ...2. Other staff members are instructed to:...d. Document on the Code Blue sheet.

A blank Code Blue form was provided by staff which revealed multiple fields for recording the nursing care of the patient during a code. Among the required fields were: Description of Event, Responder's names, Time CPR began, did patient regain pulse, consciousness, or resume breathing, Vital Signs (every 5 minutes), Comments, meds given, Condition of patient upon departure, and the Recorder's signature.

There was no Code Blue Record form completed for Patient #1 on the date of the occurrence, or provided during the course of the survey process.

The last documented nursing assessment of Patient #1 prior to the code arrest was by the night nurse at 4:30 A.M. There was no documented nursing assessment of Patient #1 by RN #29, the day shift nurse (7:00 A.M.-3:00 P.M.).

A "Late Entry" was completed by Staff #10 on 01-20-16 at 1:00 P.M., six (6) days subsequent to the Code Blue and Patient #1's death. The late entry revealed: "I responded to a code blue...where pt was found lying supine on the bathroom floor. (RN #29) and I confirmed pt (patient) was pulseless and apnec (sic)...Followed AED (Automated External Defibrillator) instructions until EMS arrived. EMS personnel took over...."

The Director of Nursing, stated during interview conducted on 01-20-16, that he had been involved in the interview process with staff subsequent to Patient #1's code, but was not part of the staff debriefing, or the Root Cause Analysis (RCA). The Director stated that at some point in time, that he, the Chief Executive Officer (CEO), and the Director of Risk Management reviewed part of the medical record.

There was no supporting evidence that the Director of Nursing (DON) assumed responsibility for the operation of Nursing Services, when the DON failed to require timely documentation of a patient assessment and Code Blue involving death.

2. The Director of Nursing job description revealed: "The Director of Nursing Services is responsible for: providing leadership and oversight to nursing and mental health technician staff, ensuring accountability for the quality of services they provide...."

Surveyor review was conducted on 01-21-2016, of the "Emergency Bag/AED (Automated External Defibrillator)/Suction Log" for the (Unit) dated Jan,2016.

The lock used to secure the contents of the emergency bag was documented on 01/01/16 through 01/15/16, as number "5164410." In a column on the form to the right of the "Bag Number" was a column titled "Unopened"? (An inquiry into if the kit was unopened).

In the column titled "Unopened" either a "Y" (yes) or "yes" was documented on 01/01/16 through 01/14/16, the day of the Code Blue. On 01/14/16 through 01/21/16, three different RNs wrote "opened," but failed to obtain a new lock to lock the bag. Despite the bag being documented as being "opened," the RNs continued documenting that lock #516440 was on the bag.

The log also had a column titled "AED Battery ok?" On 01/15/16, 01/16/16 and 01/17/16, "Yes" was written in the column. On 01/18/16, "No" (illegible word) was documented. On 01/19/16, "Y (yes) but needs pads (defibrillator pads to be attached to the patient) was written. On 01/20/16, "N" (not working) was documented.

On 01/21/16, when the log was reviewed by surveyor, it was determined that the AED was "not working," and there were no defibrillator pads. Surveyor questioned the DON as to how many AEDs were in the building, to which he replied that there was one. The RN on Unit #1 stated that the AED was on Unit #2. The DON was unable to locate the AED on Unit #2 in the usual place it was stored. When it was not found there, the DON looked in the maintenance office, and the "equipment room on Unit #2.

Staff #44 stated, during interview conducted on 01/21/16 at 10:20 A.M., that she believed the AED was in the Consultation Room on Unit #3.

The DON acknowledged, during interview conducted on 01/21/16 at 10:05 A.M., that he did not know where the AED was located. Subsequent to that interview, the surveyor and Director found the AED in the office of the scheduler, setting on a table to be repaired. A note was lying in view that documented: "Pads needed." Staff #32 stated that he was working on getting the new defibrillator pads, but was having trouble locating new pads.

On 01/21/16 at 4:40 P.M., the Director of Nursing acknowledged that the documentation regarding the Bag (Lock) Number and "Opened" were counterintuitive, as there cannot be a lock on a bag that is open.

Tour was conducted of the hospital's Provider-based outpatient treatment Center on 01-27-16. Observation during tour revealed that there was no record when the facility's AED was last checked. The Emergency Bag had no lock on it. Staff #40 stated that there was no record of when the AED was last checked for functionality.

3. Review of hospital policy/procedure titled Acuity System revealed: "...appropriate staffing for acuity has three components to be measured: patient individual acuity, milieu acuity, and skill mix acuity. The RN staff will proactively assess the acuity of each patient using the definitions below and listed on the back of the acuity tool as a guide. The Charge RN in collaboration with the RN Supervisor will measure the Milieu and Skill Mix acuity respectively. These assessments will assist in identifying the appropriate number and skill mix of assigned staff...Purpose: To provide a process for nursing department staff to assist in evaluating the optimal nurse to patient ratio and level of care to ensure safe, quality patient care...The acuity tool will assist in determining the staff scheduled for the next shift...completed within 2.5 hours prior to the end of the shift so appropriate staffing needs for the next shift can be addressed by the RN Supervisor or the designee...Completed acuity reports are routed to the RN Supervisor and the DON daily for review and monitoring...While staffing patterns are in place for each department, they are designed with average acuity levels and typical patient types in mind. As such, they provide a guideline from which staffing decisions can be made on a day-to-day, shift-to-shift basis...Variances for staffing patterns...are expected, given the nature of fluctuation in patient needs...Supplemental or PRN staff are utilized to provide adjustments to Master staffing plans...Staffing grids are managed by DON or designee...If staffing variances cannot be met with the use of supplemental staffing, the Administrator On Call is notified, and a decision is made regarding the need to close beds and/or direct patients, as appropriate...."

Review of hospital document titled Staffing Matrix for Nursing revealed: "...1. Identify the current unit census...2. Subtract any 1:1s for total number of patients...3. Locate final number of pts on the grid to determine the MINIMUM # of staff needed...4. Add additional staff per acuity score...5. Add additional staff for each 1:1 on the unit...5. (sic) Staff mix below is recommended based on census. Minimum 1 RN per unit each shift unless more per acuity. No minimum # BHT...6. LPN can be added in place of a BHT on Santa Rita...."

Review of the staffing for the Catalina Unit on the day shift on 1/13/16, with 11 patients, revealed that RN # 29 was the unit Charge Nurse, was assigned to orient a second RN and was also functioning as the Shift Supervisor. RN # 29 signed the Acuity Tool as the reviewing Supervisor but did not complete the Milieu Acuity or the Skill Mix Acuity. The evening and night shift acuity ratings for the Catalina Unit on 1/13/16, were not reviewed by a Supervisor and the Milieu Acuity and Skill Mix Acuity ratings were not completed by a Shift Supervisor.

The Staffing Matrix for Nursing for Tortolita Night Shift on 1/13/16, with 19 patients, required 3 staff; 1 RN and 2 BHTs. The unit was staffed with 1 RN and 1 BHT. The RN documented on the assignment sheet: "Wasn't able to chart on all pts-only 1 BHT & 2 admissions."

Review of the Night Shift Staffing for 1/13/16, for all units, revealed that only 1 RN was assigned to each unit. RN # 42, who was assigned to provide care for all 8 patients on the Santa Rita Unit, was also assigned to function as the Shift Supervisor.

The spaces for the Shift Supervisor to document review of the acuity ratings for all units on the night shift of 1/13/16 were blank. The Milieu Acuity and Skill Mix Acuity, to be determined by the Supervisor, was blank for all units on the night shift of 1/13/16.

Review of the staffing for the Catalina Unit on the day shift on 1/14/16, with 10 patients, revealed that RN # 29 was the unit Charge Nurse, was assigned to orient a second RN and was also functioning as the Shift Supervisor.

Pt # 1 was a patient on the Catalina Unit on the day shift on 1/14/16, when she completed suicide by hanging.

Review of the staffing for the Santa Rita Unit, on the day shift on 1/14/16, revealed that RN # 33 was assigned to provide care for all 8 patients. RN # 11 was assigned to provide care for all 8 patients during the evening shift. RN # 42 was assigned to provide care for all 8 patients on the Santa Rita Unit during the night shift and function as the Shift Supervisor. RNs # 11 and 33 did not have documented competency to provide care to the hospital patients. The Santa Rita Unit had 2 patients withdrawing from alcohol and the hospital was unable to provide documentation that RNs # 33, 11 or 42 were competent in assessing patients for alcohol withdrawal.

The spaces for the Shift Supervisor to document review of the acuity ratings for the Santa Rita unit on the day shift and on the night shift of 1/14/16, were blank. The Milieu Acuity and Skill Mix Acuity, to be determined by the Supervisor, were blank for the Santa Rita Unit on the day shift and night shift of 1/14/16.

Review of the staffing for the Rincon Unit, on the evening shift on 1/1/16, with 23 patients, required 5 staff: 2 RNs and 3 BHTs. The unit was staffed with one RN, one LPN and 3 BHTs. The 19 patients on the Rincon Unit on 1/1/16 day shift had a total acuity rating of 25. The 23 patients present on Rincon during the evening shift had a total acuity rating of 29 and the 23 patients on the night shift had a total acuity rating of 23. The Milieu Acuity and Skill Mix Acuity, to be determined by the Supervisor, were blank for the Rincon Unit on all three shifts, on 1/1/16. The spaces for Supervisor review of the Acuity Tool on the day shift and evening shift were blank.

Review of the staffing Matrix for the Catalina (Acute) Unit day shift on 1/6/16, with 10 patients, required 3 staff: 1 RN and 2 BHTs. RN # 29, assigned to provide care for all 10 patients on Catalina was also assigned to function as the Shift Supervisor. RN # 29 signed the Acuity Tool as the reviewing Supervisor, but did not complete the Milieu Acuity and/or Skill Mix Acuity ratings.

The Staffing Matrix for Nursing for (child and adolescent) Tortolita Unit, Day Shift on 1/26/16, with 20 patients, required 5 staff; 2 RNs and 3 BHTs. The unit was staffed with one RN and one LPN and 3 BHTs. One BHT had been "pulled" from the Unit to escort an adult patient from Rincon Unit to Court. The Tortolita Unit was staffed with 2 BHTs for over 1.5 hours. The Staffing Matrix does not include LPNs.

RN # 24 confirmed, during interview conducted on 1/26/16, that the LPN is assigned to the unit according to his/her work schedule, not specific patient needs. The RN was responsible for assessment of all 19 patients.

Staff # 32 confirmed, during interview conducted on 1/27/16, that an LPN is assigned to a unit for patient care if an RN is not available; not based on the care needs of the patients.

RN # 24 stated that one BHT had been "pulled" from the Tortolita unit, on 1/26/16, to assist on another unit. This BHT was not replaced for over 1.5 hours.

Staff # 32 confirmed, during interview conducted on 1/27/16, that one BHT had been "pulled" from the child and adolescent unit to accompany an adult patient to court during the time that the adolescents were in their rooms, completing their daily personal hygiene. It had been determined that the staff required for the Tortolita Unit could be reduced by one BHT while the patients were in their rooms. Staff # 32 confirmed that the patients' need for supervision and care had not changed just because they were in their rooms. RN # 24, the Charge Nurse on Tortolita, on 1/26/16, confirmed that the BHT reduction on Tortolita was not based on reduction in patient care needs. In fact, the loss of the BHT had affected implementation of the structured program on the unit.

The Acuity Tool, completed by the RN on the Tortolita Night Shift on 1/25/16, contained documentation of an Acuity Total of 23. The spaces for review, by the RN Supervisor, for the Acuity Tools completed on Day Shift and Evening Shift for the Tortolita Unit were blank. The Milieu Acuity and Skill Mix Acuity, to be determined by the Supervisor, were blank for day shift and evening shift on 1/26/16.

Staff #32 confirmed, during interview conducted on 1/28/16, that the Acuity Tools are not completed by the Shift Supervisors as required and that the acuity plan does not determine the type of staff required to provide care to the patients.

On 1/28/16, the CEO stated that the Staffing Matrix does not represent a minimum number of staff required by patient census, but is only suggested staffing. She stated that the minimum number of RNs required for each unit was 1 RN. The patient capacity for the (child and adolescent) Tortolita Unit is 22; Rincon Unit is 24; Santa Rita Unit is 14 and Catalina (acute adult) Unit is 12.

The hospital was unable to provide documented evidence of the establishment and implementation of a staffing plan that determines the type and numbers of nursing personnel necessary to provide nursing care for all areas of the hospital.

Based on review of job description, hospital documents and interviews, it was determined that the hospital did not have sufficient supervisory staff to ensure the immediate availability of an RN to meet the needs of all patients, posing a risk to patient safety.

Findings include;

Review of Job Description titled RN Shift Supervisor revealed: "...Leads and oversees the facility's provision of care during assigned shift. Accountable for the appropriateness and quality of services delivered to patients during the assigned shift...Provides direct patient care under the Registered Nurse job description when necessary and/or assigned...Maintain and adjust appropriate staffing patterns using patient acuity and unit variables including transfers and admissions. Maintain accurate records of call-offs and changes in staffing...Assure acuity sheets, environmental rounds and night chart audits are completed accurately and timely by each unit. Assist teams with the development of plans for intervention when acuity is high...Coordinate response to incidents including codes and seclusion and restraint incidents, per facility protocols...."

The hospital utilizes nursing staff for 3 shifts: Day, Evening and Night Shift. RN's are assigned to function as Shift Supervisor for all three shifts, unless the DON assumes responsibility for the function of Shift Supervisor.

Review of the Daily Staffing Report sheets from 1/1/15 through 1/25/16 revealed:
RN Shift Supervisors were scheduled for 75 shifts. For 33 of those shifts the RN Shift Supervisor was also assigned as an RN to a nursing unit, with direct patient care responsibilities. For 23 of the 75 shifts, the RN assigned to function as the Shift Supervisor was also assigned as the only RN on a nursing unit; directly responsible for all of the patients on that unit. No relief RN was assigned to replace this unit RN if s/he was required to leave the unit to fulfill Supervisory responsibilities.

RN #s 24 and 35 confirmed, during interviews conducted on 1/25/16 and 1/26/16 that when an RN is required to leave the unit, there is no relief RN coverage available.

The DON confirmed, during interview conducted on 1/27/16, that the permanent Shift Supervisors have resigned their positions and it has been necessary to utilize staff RNs to serve in that function. Frequently, those RNs are responsible for the direct care of all of the patients on a unit.

Cross reference Tag 386 for information regarding the responsibility of the Shift Supervisor to review the staffing and acuity ratings for each nursing unit and the lack of documentation of this review.

Based on review of medical records, the Director of Nursing job description, the Registered Nurse (RN) job description, policy and procedure review, and interview, it was determined that a Registered Nurse (RN) failed to supervise and evaluate the nursing care of patients, posing a risk to the health and safety of patients, up to, and including, death, as evidenced by:

1. failure to ensure that the patient's care was appropriately supervised, when 1 of 1 patients with a Psychotic Disorder committed suicide by hanging, while under the supervision of an RN (Patient #1);

2. failure to ensure that 6 of 8 patients, located on the "Acute" adult unit, on the day of Pt # 1's suicide, were directly observed at the required time intervals for their safety;

3. failure to ensure the required direct observation of 1 of 1 patient who was found with a "slip knot noose on the bathroom door" preparing for a suicide attempt (Pt # 10);

4. failure to ensure measurement of blood pressure and administration of medication for elevated blood pressure, as required by practitioner orders, for 1 of 1 patient with an admitting diagnosis of Alcohol Dependence (Pt # 14);

5. failure to assess and document signs of withdrawal and clarify a physician's medication order, prior to administration of medication for withdrawal, for one of one patient admitted for Alcohol Dependence (Pt # 13);

6. failure to ensure the direct observation of a minor patient who required direct observation every 5 minutes due to verbalized thoughts of self harm (Pt # 3);

7. failure to complete and document an RN assessment and discharge note for 1 of 1 minor patient who had prepared to commit suicide during his hospital stay and had required direct observation every 5 minutes up until 5 hours prior to discharge (Pt # 3).

Findings include:

The Director of Nursing job description revealed: "The Director of Nursing Services is responsible for: Providing leadership and oversight to nursing and mental health technician staff, ensuring accountability for the quality of services they provide...Assumes responsibility for the safety of patients...."

The RN job description revealed: "...Position Summary: Conducts patient assessments and provides nursing interventions to patients as assigned. Maintains a safe and efficient working and treatment environment per facility policies and procedures...assess patients for risk of danger to self or others at time of assessment and ongoing through treatment...Oversee all aspects of patient care..."

"The (Hospital) Competency Baseline for a Registered Nurse revealed: "Accurately and consistently assess patients for risk of self-harm...."

1. During the three (3) days prior to Patient #1's hospitalization at (hospital), three crisis response centers' outpatient social workers, respectively, documented that Patient #1 was "DTS" (Danger to Self).

The A&R (Intake) assessment, completed at 11:35 P.M. on 01-13-16, and completed by Staff #18 revealed that the patient believed that the lights in her home were taking pictures of her and that others could access these pictures. The assessment revealed that the patient endorsed a medical history that included Fibromyaligia, and chronic back, knee, and joint pain. In the field titled "Psychosis" there was a check in the field titled "Recent worsening," and a check in the fields titled "Delusions" and "Paranoia." In the field titled "Acute Psychiatric Inpatient" was a sub-section titled "Dangerousness." The pre-populated text revealed: "Severely impaired judgment/uncontrolled risk taking/uncontrolled destructive behavior resulting in life-threatening victimization, self-harm...." There was a check in the associated box titled "Psychotic."

Patient #1 was admitted to the hospital's acute unit on a Title 36 Petition, with an admitting diagnosis of "Psychotic D/O" (Psychotic Disorder). The petition paperwork for Patient #1 on 01/11/16, 01/12/16, and 01/13/16 from a crisis response center, revealed that the patient was determined to be a Danger-to-Self (DTS) and Danger-to-Others (DTO).

Admission orders were received at 11:17 P.M. on 01-13-16, and Staff #17, a traveler RN, initiated the "Integrated Assessment-Nursing Assessment" at 1:10 A.M. on 01-14-16. The admission orders for Patient #1 revealed that every 15 minute (routine) observations were ordered at 11:17 P.M.

The admission nursing assessment revealed that the patient had chronic pain for at least fifteen (15) years, and that her pain was "9" (on a scale of 0-10, with 10 being high). The "Effect of Pain" included poor sleep, poor physical activity, crying, and poor concentration. The average number of hours slept was "3 hours." There was no documentation that the RN administered the patient's Oxycodone IR (extended release) 30 milligrams (mg) as ordered, for back pain, when the patient reported a pain level of "9."

A scoring system on the "Integrated Assessment-Nursing Assessment" in which Tremors, Rigidity, Blink Rate, and 10 other observations were listed, also included Postural Reflexes, Observed Restlessness, and Subjective Restlessness. The scoring was determined by "Present" or "Absent." The number of symptoms present for Patient #1 was documented as "3." Below the score on the form was pre-populated: "If 2 or more symptoms are present, notify the attending physician. The fields for "Dr.____notified on Date:___ Time:___ were blank. There was no documentation by Staff #17, an RN, that the physician had been notified as required.

Staff #17 documented that at 1:15 A.M. on 01-14-16, the patient had a blood pressure of 93/63, a pulse of 81, respirations of 17, and a temperature of 97 degrees (Fahrenheit).

Staff #17 documented at 4:00 A.M. on 01-14-16, that the patient had a blood pressure of 93/63, a pulse of 81, respirations of 17, and a temperature of 97 degrees (Fahrenheit).

Staff #34 acknowledged, during interview conducted on 01-20-16, that it would be very unusual for vitals signs of the patient to be identical at 1:15 A.M., and again at 4:00 A.M.

The "Progress Notes," authored by Staff #17 at 4:30 A.M. on 01-14-16, revealed that Patient #1 had family issues and police had been involved prior to her admission. Documentation revealed that the patient tested positive for "Met (sic) (methamphetamine) and "Heroine" (sic) (heroin). Documentation also revealed that the patient had chronic illness and a recent surgery on her back. There were no further Progress Notes written for Patient #1.

The "Patient Profile," completed by Staff #17, revealed that the patient had concerns regarding the custody of a minor child. The "Supporting Comments," documented by Staff #12 at 5:00 A.M. revealed: "(write-over)...very anxious initially. Calmed down during nursing assessment."

At 4:10 A.M. the "Sonora Behavioral Health Observation Rounds" record for Patient #1 revealed that the patient's observation level changed from every 15 minute checks to every 5 minute checks. The "Reason for Q (Every) 5 minute observation was: (zero with diagonal slash indicating "no'" SRA (Suicide Risk Assessment)/pt (patient) drowsy."

Patient #1's medical record revealed that every 5 minute observations were conducted from 4:10 A.M. until 7:00 A.M. when the day shift, and Staff #29, an RN, assumed responsibility for the patient.

The day shift (7:00 A.M.-3:00 P.M.) observation record revealed that the patient was in her room from 7:05 A.M. until 7:50 A.M., at which time the record revealed that the patient was in the unit "Dayroom."

The observation form revealed blank entry fields for 8:35 A.M., 8:40 A.M., 8:45 A.M., and 8:50 A.M., respectively, on 01-14-16. There was no documented observation of Patient #1 during that 20 minute period.

The Observation Rounds form for Patient #1 revealed that Staff #10, an RN, documented at 8:55 A.M. that the patient was in the "bathroom" and that "CPR (Cardiopulmonary Resuscitation) was being performed at 8:55 A.M., and 9:00 A.M, respectively. No Code Blue form was completed for Patient #1; there was no nursing or other documentation, completed on the date of the code, of what occurred during the Code Blue .

The Emergency Medical System (EMS) documentation for Patient #1 revealed: "...Found Pt unconscious and unresponsive lying supine on the floor of (hospital) with bystander CPR ongoing. pt was found to be pulseless at carotid (artery) and apneic (no respirations)...(EMS Unit) arrived on scene and established an IO (intraosseous) (insertion of a line for administration of fluids and medications) in Pt's right tibia.

EMS personnel intubated the patient and administered epinephrine 1:10,000 six (6) times with one dose of sodium bicarbonate. The EMS record revealed: "...Staff O/S (on site) stated Pt was last seen 20-30 minutes PTA (Prior to Arrival).

Patient #1 was transferred to an acute care hospital at 9:29 A.M. on the same day as her date of admission to Sonora Behavioral Health Hospital. S/he arrived at the acute care hospital at 9:32 A.M.

The medical record from the acute care receiving hospital revealed that Patient #1 arrived in cardiac arrest on 01-14-16 at 9:42 A.M. The record revealed: "The patient presents via EMS for cardiac arrest secondary to a hanging attempt. The patient is currently at (psychiatric hospital from which she was transferred), she was last seen approximately 30 minutes prior to finding her hanging. Patient was found after what was described as suicide attempt and hanging...The "Physical Examination" revealed that the patient was unresponsive and the pupils were "dilated and nonreactive." The "Medical Decision Making Rationale" revealed: "...After multiple rounds of epinephrine and bicarbonate (sodium bicarbonate) Patient did have a return to PEA (pulseless electrical activity)...At this time code arrest was called (no further medical care was provided)...." Patient #1 expired at the acute care hospital.

Staff #16 confirmed, during interview conducted on 01-20-16 at 1:00 P.M., that the bed sheets used on the units would not break away if weight was applied. Staff #16 stated that Behavioral Health Technician (BHT) #12 found the patient hanging on the inside of the bathroom door, with a bed sheet used as a ligature around her neck. Staff #16 stated that the patient looped a sheet over the bathroom door, closed the door, and was able to hang herself.

Staff #32 stated, during interview conducted on 01-20-16 at 10:00 A.M., that he arrived on the unit to provide 1:1 care to another patient, and he heard Staff #12 shout his name. Staff #32 responded and removed the sheet used as a ligature from the patient's neck. Staff #32 stated that when he found the patient, her color was reddish or light blue on her face and hands, and that her hands were "a little cold." Staff #32 stated that the RN responsible for the patient on day shift, and an RN from the admissions department, arrived and initiated CPR.

Staff #34 stated, during interview conducted on 01-20-16 at 5:20 P.M., that Staff #29, an RN, was responsible for the 5 minute observations of Patient #1, which were not done in the period immediately prior to the suicide.

Review of the staffing sheet for 01-14-16, for the unit on which Patient #1 was hospitalized, revealed that Staff #29 was the only RN on the unit with 10 patients; the unit was considered to be the "acute" unit by hospital staff.

A written statement, containing a signature reportedly belonging to Staff #29, the RN responsible for the observation and care of Patient #1, revealed: "...I don't know how the hand off of rounds took place at breakfast. Again, I was involved in setting up + passing meds. Meds were completed at about 8:55 (A.M.). At that time, or shortly after - I told staff I was getting coffee +went (to) cafeteria-on the way back-maybe 3-4 minutes I heard the Code Blue."

Staff #16 acknowledged, during interview conducted on 01-26-16 at 10:00 A.M., that RN #29 went to the cafeteria to get coffee, and that no RN was covering the patients on the unit while the RN was gone.

2. Review of hospital policy/procedure titled Levels of Observation revealed: "...All patients will be closely observed in compliance with physician orders and prescribed protocols...The physician will order one of three levels of observation at time of admission and may change the level of observation if the patient's condition warrants a change: Routine observation (every [Q] 15 minute checks)...Every (Q) 5 minute checks...One-to-one (1:1)...Routine (Q 15 minute) Observations...This is the minimum level of observation for all patients...Assigned staff are to make direct visual contact with patients, at minimum every 15 minutes, and confirm they are in no danger or distress...The charge nurse will sign off on each Patient observation form each shift to verify that the routine (Q 15 minute) observations were conducted correctly and consistently...Q 5 Minute Observations...Staff will observe patient and document on the Patient Observation form every 5 minutes...Assigned staff are to make direct visual contact at each 5 minute observation with patients and confirm they are in no danger or distress...The charge nurse will sign off on each Patient Observation form each shift to verify that the...(Q 5 minute) observations were conducted correctly and consistently...."

Review of Job Description for Job Title Behavioral Health Technician (BHT) revealed: "...Position Summary...Under the supervision of the Registered Nurse, provides direct patient care to patients as assigned...Maintains a safe and efficient working and treatment environment per facility policies and procedures...."

Review of hospital document titled Plan for the Provision of Care revealed: "...The Behavioral Health Technician assists the nurse in the treatment and care of patients. He/she performs and documents ongoing patient observations throughout his/her assigned shift...under the direction of a licensed nurse...Perform and document patient observation rounds...."

Review of Pt # 22's medical record revealed that he required direct observation every 5 minutes by staff for his safety. His medical record did not contain documentation that he was directly observed every 5 minutes from 0100 until 0705 and from 0835 until 0900, on 1/14/16.

Review of Pt # 23's medical record revealed that she required direct observation by staff every 15 minutes for her safety. On 1/14/16, staff did not record observation of Pt # 22 from 0830 until 0900.

Review of Pt # 24's medical record revealed that he required direct observation by staff every 15 minutes for his safety. On 1/14/16, staff did not record observation of Pt # 24 from 0830 until 0900.

Review of Pt # 26's medical record revealed that he required direct observation by staff every 15 minutes for his safety. On 1/14/16, staff did not record observation of Pt # 26 from 0845 until 0900.

Review of Pt # 27's medical record revealed that he required direct observation by staff every 15 minutes for his safety. On 1/14/16, staff did not record observation of Pt # 27 from 0830 until 0900.

Review of Pt # 28's medical record revealed that she required direct observation by staff every 15 minutes for her safety. On 1/14/16, staff did not record observation of Pt # 28 from 0845 until 0900.

The Director of Quality confirmed, during interview conducted on 1/22/16, that staff did not record the required observations of the patients listed above.

3. Review of hospital policy/procedure titled Levels of Observation revealed: "...All patients will be closely observed in compliance with physician orders and prescribed protocols...The RN may not decrease the level of observation...A decrease in the level of observation or change in precaution level requires a physician order...."

Review of Pt # 10's medical record revealed:

Pt # 10 reported, on 1/20/16 at 2235, that she had thought of "many ways" to end her life.

On 1/20/16, at 2330, an RN recorded a telephone order from MD # 2: "...Q5 (minute checks) due to pt unable to contract for safety...."

On 1/21/16, at 0830, an RN documented that Pt # 3 had formulated a plan to "hang self (with) telephone cord."

On 1/21/16, at 1430, MD # 4 documented: "...hallucinations...extreme depression...."

On 1/22/16, at 1645, MD # 4 documented: "...Pt continues to have suicide thoughts & plans, every 30 minutes. 'Maybe I could commit between the 5 minute checks'...."

On 1/23/16, at 1000, an RN documented that Pt # 10 stated she would "hang self with sheets."

On 1/24/16, at 2150, an RN documented: "...Pt was taken off Q5 (minute checks) after SRA (Suicide Risk Assessment) result of 28. She requested her linen back and appears not be (sic) a threat to herself. Staff will continue to monitor patient for self harm...."

Pt # 10's medical record did not contain a physician's order to discontinue the Q 5 minute checks as required.

On 1/25/16, at 1200, an RN documented: "...Pt. argumentative throughout morning, refused am meds and breakfast, unable to redirect, BHTs concerned about pt. banging head on walls so have been doing q 5 min checks on pt. for safety though reported pt. off q 5 checks. At appros. (sic) 1115 BHT found pt. in room with sheet tyed (sic) in a slip knot noose on bathroom door, pt. told BHT per BHT report that she was trying to time with q 15 min checks. Spoke to provider, received order for 1:1...."

The DON confirmed, during interview conducted on 1/27/16, that RN # 33 discontinued Pt # 10's Q 5 minute direct observations, and placed her on Q 15 minute routine observations without a physician's order. The DON confirmed that reduction of the level of observations requires a physician's order.

The DON confirmed, during interview conducted on 1/28/16, that RN # 33 is a contracted agency RN. Review of RN # 33's personnel file revealed that it contained self-assessment of experience and competence. The DON confirmed during the same interview that the hospital was unable to provide verification of RN # 33's competence to provide care to acute psychiatric patients and did not have documentation of RN # 33's orientation to the hospital's policies/procedures.

4. Review of hospital policy/procedure titled Medication Administration revealed: "...Medications are administered to patients in a safe, effective manner in accordance with the practitioner orders and prescribed nursing principles and procedures...."

Review of Pt #14's medical record revealed:

On 1/20/16, at 0800 an RN recorded Admission Orders: "...Admitting Diagnosis Alcohol Dep (Dependence)...Vital Signs...Upon admission and Q4 hrs (every 4 hours) ATC (Around The Clock)...Clonidine 0.1mg po (by mouth) PRN BP >130/90 (as needed for blood pressure greater than 130/90)...."

Review of the form titled Graphics Record revealed a column with the heading: "RN Signature noting out of range VS (Vital Signs)." The form contained instructions: "If any VS out of range, RN must sign confirming review of VS...Normal VS Ranges...18+ yrs...Systolic BP 90-140...Dyastolic (sic) BP...60-90...."

BHT staff recorded Pt # 14's blood pressure measurements and RNs recorded administration of Clonidine as follows:

1/20/16

0731: 146/95
1330: 158/109 received Clonidine 0.1mg
1800: 132/86
2100: 154/103; at 2216, received Clonidine 0.1mg
No measurement of Blood Pressure for 11+ hours

1/21/16

0847: 174/108; (received routine Lisinopril at 0900)
No measurement of Blood Pressure for 8+ hours
1700: 155/100; at 1830, received Clonidine 0.1 mg
2100: 142/92; at 2130, received Clonidine 0.1mg

1/22/16

0102: 172/99; at 0200, received Clonidine 0.1 mg
0530: 136/90
0930: 160/95 (received routine Lisinopril at 0900)
1330: 130/85
No measurement of Blood Pressure for 8 hours
2130: 177/93 (missed required Clonidine)

1/23/16

0200: 158/96; at 0230, received 0.1mg Clonidine
0600: 144/92; at 0630, received 0.1mg Clonidine
0850: 148/86 (received routine Lisinopril at 0900)
1300: 161/109 (missed required Clonidine)
1700: 143/89
2100: 159/92 (missed required Clonidine)
No measurement of Blood Pressure for 12 hours

1/24/16

0115: 171/97; received 0.1mg Clonidine
0900: No blood pressure recorded (received routine Lisinopril at 0900)
No measurement of Blood Pressure for 24 hours

1/25/16

0100: 160/90; at 0240, received 0.1mg Clonidine
0616: 136/92 (missed required Clonidine)
0900: 148/94 (received routine Lisinopril at 0900)
1300: 161/104 (missed required Clonidine)

The spaces for RN signatures for out-of-range blood pressures were blank for 5 recorded out-of-range blood pressures.

RN # 35 confirmed, during interview conducted on 1/25/16, that blood pressures had not been measured/recorded as required by practitioner order, and the Clonidine had not been administered by RN's as required by practitioner order for Pt # 14's elevated blood pressure.

5. Review of hospital policy/procedure titled Medication Administration revealed: "...Any PRN or as needed medication must include an indication for use. PRN effectiveness must be documented on the MAR (Medication Administration Record) and in the daily progress notes...Orders are to be dated and timed, legible and clarified. If the nurse has any questions regarding the orders, it is the nurse's responsibility to clarify and verify the order prior to transcribing on to the MAR...Any questionable orders must be clarified prior to the administration of the medication...."

Review of Pt # 13's medical record revealed:

Pt # 13 was admitted on 1/21/16 at 1730 with an admitting diagnosis of Alcohol Dependence.

MD # 1 wrote an order on 1/22/16 at 2200: "...Valium 5 mg po Q 4 (hr) prn w/drawl (withdrawal)...."

RN # 35 confirmed, during interview conducted on 1/25/16, that the order did not include the withdrawal symptoms for which the Valium was to be given. S/he confirmed that the hospital did not have a reference protocol for the RNs to use for assessment of symptoms of alcohol withdrawal and/or to assess intensity of withdrawal of symptoms to determine the need for PRN medication for withdrawal. S/he confirmed that the order for Valium for withdrawal required clarification and that no clarification had been obtained/provided.

On 1/23/16, at 1000, RN # 36 documented administration of Valium 5mg po to Pt # 13, for "anxiety" with a response of (decreased) anxiety at 1200. RN # 36 did not document assessment of the patient for signs of alcohol withdrawal.

On 1/23/16, at 1530, RN # 37 documented administration of Valium 5mg po to Pt # 13, for "anxiety" with a response of (decreased) anxiety at 1540. RN # 36 did not document assessment of the patient for signs of alcohol withdrawal.

On 1/24/16, at 0210, RN # 17 documented administration of Valium 5mg po to Pt # 13, for "Anxiety", with an "Effective" response at 0150. RN # 17 recorded a progress note on 1/24/16, at 0425:"...Patient had X1 wake-up and requested for Valium, his PRN medication for pain. It was effective as patient slept after 30 minutes." RN # 17 did not document assessment of the patient for signs of alcohol withdrawal.

On 1/24/16, at 0930, RN # 35 documented administration of Valium 5mg po to Pt # 13, for "Anxiety" rating of "7/10" with a response of "2/10" at 1100. RN # 35 did not document assessment of the patient for signs of alcohol withdrawal.

On 1/24/16, at 1500, RN # 35 documented administration of Valium 5mg po to Pt # 13, for "Anxiety" rating of "7/10" with a response of "2/10" at 1530. RN # 35 did not document assessment of the patient for signs of alcohol withdrawal.

On 1/24/16, at 2130, RN # 38 documented administration of Valium 5mg po to Pt # 13, for "anxiety" rating of "3/10". RN # 38 did not document assessment of the patient for signs of alcohol withdrawal.

On 1/25/16, RN # 35 documented administration of Valium 5 mg po to Pt # 13, for "anxiety" rating of "7/10" with a response of "3/10" at 1100. RN # 35 did not document assessment of the patient for signs of alcohol withdrawal.

RN # 35 confirmed, during interview conducted on 1/25/16, that Pt # 13's medical record did not contain an order for Valium for anxiety. She confirmed that the order for Valium for withdrawal required clarification and that an RN had not clarified the order. She confirmed that all of the RNs listed above had charted administration of the Valium for anxiety and that alcohol withdrawal includes numerous other symptoms.

The DON confirmed, during interview conducted on 1/27/16, that the hospital was unable to provide documentation that RN #s 35, 36, 37, 38 or 17 were competent to provide for the care of patients withdrawing from alcohol.

6. Cross reference # 2 above for information regarding hospital policy titled Level of Observations.

Review of Pt # 3's medical record revealed:

RN # 36 documented on 12/28/15, at 1100: "...Patient was pacing around the community table in the day room...He stated he was anxious and he had thoughts of hurting himself...Patient was put on q 5 minute checks for
safety...."

MD # 1 recorded an order on 12/28/15, at 1035: "Q 5 minute checks for safety...."

Review of the Observation Rounds documentation for 12/28/15, revealed that no observations were documented on 12/28/15 from 1110 until 1215.

The DON confirmed, during interview conducted on 1/27/16, that staff did not record the required observations of Pt # 3.

7. Review of hospital job description Job Title Registered Nurse revealed: "...Conducts patient assessments and provides nursing interventions to patients as assigned...Complete nursing reassessments as assigned, and any time a change in status is observed or reported by team members...Oversee all aspects of patient care and complete assignments as assigned by the Charge Nurse...Ensure patients are discharged with all personal medication, belongings, prescriptions, discharge and referral information...Document as required including assessments, nursing notes...discharge planning...."

Review of hospital policy/procedure titled Discharge Process revealed:
"...Written aftercare plan with medical appointments, discharge medication and instructions or other special instructions including diet or activity restrictions are completed by the nurse...The nurse is to document the time of discharge...."

Review of hospital policy/procedure titled Re-assessment of Patient needs revealed: "...The Registered Nurse will complete a full re-assessment of the patient every 24-hours and document this in the daily notes...will address issues of pain management, symptoms changes and reductions, response to medications, changes in behavior demonstrated on the unit, and any physical changers...An extension to the nursing assessment form is included for all patients under 18 years of age....'

Review of Pt # 3's medical record revealed:

Pt # 3 was a minor patient who was discovered, on the night of 12/31/15, with a "...sheet around his neck with the other end stuck in the bathroom door...." He was placed on 1:1 supervision/observation from that time until 1/11/16, at 1505, when he was placed on direct observations every 5 minutes. MD # 2 discontinued the 5 minute observations on 1/12/16, at 1145 and wrote an order for discharge on 1/12/16, at 1300. Staff documented direct observation of Pt # 3 every 15 minutes, from 1145 until 1715, on 11/12/16.

Pt # 3's medical record did not contain documentation of an RN assessment or any RN progress note on 11/12/16.

Review of the Tortolita nursing assignment sheets 1/12/16, for day shift and evening shift revealed that individual patients are not assigned to the RNs or the BHTs. It was not possible to determine which staff was accountable to assess Pt # 3 or document his discharge.

Pt # 3, a minor who had required observation/supervision every 5 minutes until 1/12/16, at 1145, and was observed every 15 minutes thereafter, until 1715, left the hospital on 1/12/16, with no recorded nursing assessment, nursing discharge note, or documentation that an adult accompanied him at the time of discharge.

The DON confirmed, during interview conducted on 1/27/16 that an RN did not complete the required assessment and documentation.

Surveyor: Corrado, Vicki
Based on review of hospital policy/procedure, hospital documents and interviews, it was determined that the assignment of nursing care for each patient was not made in accordance with the individual patients' needs and the specialized qualifications and competence of the nursing staff as evidenced by:

1. failure to assign a Behavioral Health Technician (BHT) with competencies to care for acute psychiatric patients, to a patient who committed suicide on the unit, after being assigned to a BHT with no documented BHT competencies (Patient #1); and

2. failure to assure that shift assignments were made in accordance with the needs of the patients and the qualifications and competence of staff, posing a risk that the psychiatric and medical needs of patients may not be addressed.

Findings include:

Review of hospital policy/procedure titled Nursing Staff Allocation revealed: "...Assignment of Nursing Personnel...Responsibilities-It is the responsibility of the Director of Nursing Services or Nursing Supervisor (where appropriate) to make the nurse/patient shift assignments. These staff members posses (sic) the clinical and leadership knowledge and expertise to competently make assignments as evidenced in the following manner...Consideration is given to the complexity of nursing care required by the patient(s) for whom the staff member is being evaluated or assigned to provide care...Each of these staff members has documented competency in the same patient care activities that the staff are being asked to do (via performance appraisals and department specific skill check lists). This includes clinical knowledge, skills, and technology ordinarily employed in the care of patients in the department where assignments are being made...Considerations-Patient care responsibilities are assigned to nursing staff based on four general considerations including: the patient acuity, environment in which nursing care is provided, staff competency, and supervision required by and available to each nursing staff member assigned responsibility...Ensuring that staff only care for patients they are competent to care for...."

1. Cross reference Tag 0395 for background information regarding the suicide of Patient #1.

The Behavioral Health Technician (BHT) job description revealed, in the section titled "POSITION SUMMARY: "Under the supervision of the Registered Nurse, provides direct patient care to patients Maintains a safe and efficient working and treatment environment per facility policies and procedures Communicates effectively with the treatment team to ensure safety, quality care is provided to all patients...." The "Qualifications" revealed: "High School Diploma or equivalent...."

Review was conducted of the personnel file for Staff #12, the BHT assigned to conduct Observation Rounds sheets on patients on the acute unit on 01-14-16 from the start of the 7:00 A.M.-3:00 P.M. shift, which included every (Q) 5 minute checks on Patient #1.

The "Employment Application" for Staff #12 revealed that he was initially hired as a "Driver" at the hospital, with his previous employment experience documented as being a "Driver." There was no documentation that Staff #12 had worked as a BHT prior to working at the hospital, and there were no documented competencies as a BHT for Staff #12. No performance evaluation had been conducted for Staff #12 since his hire as a BHT on 05-08-15.

Staff #15 acknowledged, during interview conducted on 01-26-16 at 1:30 P.M., that Staff #12, the BHT assigned to Patient #1 prior to her suicide attempt, was not qualified to be a BHT.

2. Review of the Shift Assignment Sheet for Day Shift on the (acute adult) Catalina Unit on 1/14/16, revealed that the names of the RN and 2 BHTs were written in the spaces for staff names. No charting assignments, patient care assignments, patient rounds or observation assignments were recorded. Vital Signs were assigned to a BHT and the Codes Blue, Grey and Red were assigned.

The one RN responsible for 10 patients on the Catalina Unit was also assigned to the Shift Supervisor function.

Pt # 1 succeeded in committing suicide during the day shift on the Catalina Unit on 1/14/16.

Review of the Shift Assignment Sheet for Night Shift on the Catalina Unit on 1/13/16, revealed that it did not contain any patient names, initials or first names. RN # 17, the Charge Nurse, was responsible for all 11 patients on the unit. His "Charting Assignments" included: "RN Progress Note to be completed for any significant occurrence and for each patient awake more than 1 hour during the night shift." Two BHTs were working on the unit. One BHT was assigned to: "Unit/Pt Rounds" and the other BHT was assigned to "1:1 Observations" for a specific patient who required 1:1 supervision/observation. Neither this patient's name/nor room number was written on the assignment sheet.

Review of RN # 17's personnel file revealed that he was a contracted agency travel RN. His personnel file contained self-assessment information regarding experience and competence. It did not contain documentation of verified competence by the hospital, or orientation to the facility, or orientation to pertinent patient care policies.

The DON confirmed, during interview conducted on 1/27/16, that the Charge Nurse did not have verified, documented competence to provide care to the patients on the Catalina Unit, nor could the hospital provide documentation that he had been oriented to the hospital or its pertinent policies/procedures. The Daily Staffing Report for 1/13/16 did not contain documentation that the DON had approved RN # 17's assignment to Catalina.

Review of the Shift Assignment Sheet for the Night Shift on the child and adolescent Tortolita Unit on 1/14/16, revealed that it did not contain any patient names, initials or first names. RN # 17, the Charge Nurse, was responsible for all 16 patients on the unit. His "Charting Assignments" included: "RN Progress Note to be completed for any significant occurrence and for each patient awake more than 1 hour during the night shift." Two BHTs were working on the unit. One BHT was assigned to:"Unit/Pt Rounds" from 2330 until 0330. The Unit/Pt Rounds from 0330 until 0730 were not assigned. The names of both BHTs were recorded for "Additional Unit Assignments" and "Off Unit Assignments."

Review of the Shift Assignment Sheet for Day Shift on the child and adolescent Tortolita Unit, on 1/25/16, revealed that it did not contain any patient names, initials or first names. The two RN's responsible for patient care were assigned by room number, with the Charge Nurse assigned to: "Rounds, 1st Admit, DC's (Discharges), Chart Rm 400A-405B and Orders." The second RN was assigned to: "Meds, Orders and Chart Rm 406A-410B." The Behavioral Health Technicians (BHTs) were assigned to record notes on the "Kardex" for "boys" or "girls". Other assignments included "Activity per schedule" and "Unit/Pt Rounds". BHTs were not assigned to supervise or provide care to individual patients. RNs were not assigned to provide care to individual patients. 21 patients' initials were recorded on the document titled Acuity Tool. The Charge RN recorded the patients' acuity levels, however, RN # 24 confirmed, during interview conducted on 1/25/16, that patient assignments were made by room number, not specific patient care needs.

Review of the Shift Assignment Sheet for Day Shift on the adult psychiatric Rincon Unit, on 1/25/16, revealed that it did not contain any patient names, initials or first names. The two RN's responsible for patient care were assigned by room number with the Charge Nurse assigned to: "Rounds, orders, notes and meds". The second RN was assigned to: "Meds, orders and Assessment notes." The three BHTs were assigned to tasks, such as 15 minute observations of patients, discharges, meals, vital signs, assistance with patient Activities of Daily Living, inventorying patient belongings for discharges and "Activity per schedule". No nursing staff was assigned to the care of a patient based on individual patient needs.

RN # 23 confirmed, during interview conducted on 1/25/16, that the RN assignments, for the patients located on Rincon, were made by dividing the unit room numbers in half. BHT assignments were made to complete tasks necessary to assist all of the patients. 19 patient's initials were recorded on the document titled Acuity Tool. The Charge RN recorded the patients' acuity levels, however, RN # 23 confirmed, during interview conducted on 1/25/16, that patient assignments were made by room number for the RNs and by tasks for the BHTs.

Review of the Shift Assignment Sheet for Day Shift on the Catalina Unit, on 1/25/16, revealed that it did not contain any patient names, initials or first names. RN # 30, the Charge Nurse, was responsible for all 12 patients on the unit. Her "Charting Assignments" included: "admits, discharges, med admin and charting." Two BHTs were working on the unit and were each assigned to: "Unit rounds, activities and (charting on the) Kardex." They were also assigned to "Activities per schedule" for specific intervals of time.

The Catalina Unit is identified as the unit where the most acute adult patients are located. Review of RN # 30's personnel file revealed that she was a contracted agency RN. Her personnel file contained self-assessment information regarding experience and competence. It did not contain documentation of verified competence by the hospital, or orientation to the facility, or orientation to pertinent patient care policies. RN # 30 confirmed, during interview conducted on 1/25/16, that she had not received orientation to the hospital Patient Acuity System, yet she completed the patient acuity assessments for the shift. RN # 30 also confirmed, during interview conducted on 1/25/16, that the BHTs are assigned to patient care by splitting the duties on the unit, not by individual patients' needs or specific competence of the staff.

The Director of Nursing (DON) confirmed, during interview conducted on 1/27/16, that RN # 30 was assigned to provide care to the patients on Catalina, on 1/25/16, and did not have verified, documented competence to provide psychiatric nursing care to the Catalina patients, nor did she have documented orientation to the hospital or to the policies/procedures of the hospital.

Staff # 32 stated, during interview conducted on 1/27/16, that the Director of Nursing (DON) approves the Daily Staffing Reports on the preceding day. The Daily Staffing Report for 1/25/16 included RN # 30's name as the only RN assigned to Catalina on 1/25/16. The Staffing Report did not contain documentation that the DON had approved RN # 30's assignment to Catalina.

Review of the Shift Assignment Sheet for the Evening Shift on the Catalina Unit, on 1/25/16, revealed that it did not contain any patient names, initials or first names. RN # 33, the Charge Nurse was responsible for all 12 patients on the unit. His "Charting Assignments" included: "Charts & Meds". Three BHTs were working on the unit and were each assigned to "Checks & Unit Activities."

Review of RN # 33's personnel file revealed that he was a contracted agency RN. His personnel file contained self-assessment information regarding experience and competence. It did not contain documentation of verified competence by the hospital, or orientation to the facility, or orientation to pertinent patient care policies.

The DON confirmed, during interview conducted on 1/27/16, that RN # 33 did not have verified, documented competence to provide care to the patients located on the Catalina Unit, nor could the hospital provide documentation that he had been oriented to the hospital or its pertinent policies/procedures. The Daily Staffing Report for 1/25/16 did not contain documentation that the DON had approved RN # 33's assignment to Catalina.

Review of the Shift Assignment Sheet for Day Shift on the Tortolita Unit, on 1/26/16, revealed that it did not contain any patient names, initials or first names. An RN and LPN were listed on the assignment sheet in the spaces where the 2 RNs had been listed for 1/25/16. The Charge Nurse was assigned to: "Rounds, Chart 400A, orders, DC's and Admits." The LPN was assigned to: "Meds, chart, orders and DC's." Three BHTs names were listed with no charting or patient assignments. Their names were written under "Additional Unit Assignments" and "Off Unit Assignments."

RN # 24 confirmed, during interview conducted on 1/26/16, that the LPN is assigned to the unit according to his/her work schedule, not specific patient needs or competence of the LPN. The RN and LPN divide the patients by room number, but the RN is responsible for assessment of all 19 patients, when the RN works with an LPN.

Staff # 32 confirmed, during interview conducted on 1/27/16, that an LPN is assigned to a unit for patient care if an RN is not available; not based on the care needs of the patients or the qualifications of the nurse.

RN # 24 stated that one BHT had been "pulled" from the Tortolita unit, on 1/26/16, to assist on another unit. This BHT was not replaced for over 1.5 hours.

Staff # 32 confirmed, during interview conducted on 1/27/16, that one BHT had been "pulled" from the child and adolescent unit to accompany an adult patient to court during the time that the adolescents were in their rooms, completing their daily personal hygiene. It had been determined that the staff required for the Tortolita Unit could be reduced by one BHT while the patients were in their rooms. Staff # 32 confirmed that the patients' need for supervision and care had not changed just because they were in their rooms. RN # 24, the Charge Nurse on Tortolita, on 1/26/16, confirmed that the BHT reduction on Tortolita was not based on reduction in patient care needs. In fact, the loss of the BHT had affected implementation of the structured program on the unit.

Review of assignment sheets and personnel files described above, revealed that assignment of patient care was not based on individual patient care needs or competence/specialized qualifications of the nursing personnel. The process of assignments was confirmed as described above and the lack of verified competence and orientation of RN's assigned to the units was confirmed during interview conducted with the DON on 1/27/16.

The facility was unable to provide documentation of patient assignments based on individual patient care needs and staff specialized qualifications/competence. BHTs are assigned to tasks; RNs are assigned to all of the patients on a unit or assigned by patient room number. LPNs are assigned by patient room number and tasks.

Based on review of hospital policy/procedure, hospital documents, personnel files and interviews, it was determined that the Director of Nursing Service failed to verify competence, document orientation and document the supervision and evaluation of contracted agency RNs who provide care to patients, for 4 of 4 contracted agency RNs (RNs # 30, 33, 17 and 11), posing high potential risk to patient health and safety if RNs are not competent to provide psychiatric nursing care.

Findings include:

Review of hospital policy titled Use of Agency revealed: "...Use of Agency will occur if employees of SBH (Sonora Behavioral Health) are not available and will follow specified guidelines. Purpose: To provide consistency and quality of care for the patients of SBH...Agency staff shall be oriented to the Procedures and Policies of SBH, including confidentiality procedures and HIPAA, LOS (Line of Sight)/1:1 observation protocol, unit specific protocol, emergency/safety procedures and therapeutic interventions. Agency staff will sign their orientation packet and Sonora Behavioral Health will maintain record of that here...A DON or designee will personally review each individual's file prior to activating them for employment...."

Review of the Shift Assignment Sheet for Day Shift on the Catalina Unit, on 1/25/16, revealed that RN # 30 was the Charge Nurse; responsible for all 12 patients on the unit.

On 1/28/16, the DON confirmed that RN # 30 started working at the hospital as a contracted agency RN on 8/22/15.

On 1/28/16, the DON confirmed that RN # 33 started working at the hospital as a contracted agency RN on 9/15/15.

Cross Reference Tag # 395, # 7 for information regarding RN # 33's decrease of Pt # 10's 5 minute direct observations to 15 minute routine observations, on 1/24/16, at 2150, without the required physician's order. Pt # 10 was found with a sheet tied in a slip knot noose on the bathroom door, on 1/25/15, at 1200. Pt # 10 reported that she was trying to "time" the suicide attempt around the 15 minute observations.

On 1/28/16, the DON confirmed that RN # 17 started working at the hospital as a contracted agency travel RN on 12/7/15.

Cross Reference Tag # 395, # 1 for information regarding RN # 17, who had provided care to Pt # 1, and documented identical vital signs at 0115 and 0400 on 1/24/16. RN # 17 was the Charge Nurse on the Tortolita (child and adolescent) Unit on 1/14/16. He was responsible for all 16 patients on the Unit.

RN # 11 provided the nursing care for Pt # 3, on 12/31/15. On that date, at 2349, RN # 11 documented that Pt # 3 was "...observed to have a sheet around his neck with the other end stuck in the bathroom door...."

Review of the personnel files of RN's # 30, 33, 17 and 11 revealed that they were all contracted agency RNs with self-assessment information regarding experience and competence. They did not contain documentation of verified competence by the hospital, or orientation to the facility, or orientation to pertinent patient care policies. The hospital did not have evidence of supervision and evaluation of the above listed contracted agency RNs.

The DON confirmed, during interview conducted on 1/27/16, that RN #s 30, 33, 17 and 11 did not have verified, documented competence to provide care to the patients for whom each RN was providing care, nor could the hospital provide documentation that RN #s 30, 33, 17 and 11 had been oriented to the hospital or its pertinent policies/procedures. He was unable to provide documentation of hospital supervision and evaluation of the above listed contracted agency RNs.

Based on review of job description, Medical Staff Rules and Regulations, hospital policies/procedures, medical records and staff interviews, it was determined that the hospital failed to ensure the maintainence of each individual patient's medical record as evidenced by:

( A0438) failure to ensure that medical records were accurately written and promptly completed.

The cumulative effect of this systemic problem resulted in the hospital's failure failure to meet the requirements for the Condition of Participation for Medical Record Services.

Based on review of RN job description, Medical Staff Rules and Regulations, hospital policies and procedures, clinical records, and staff interviews, it was determined the hospital failed to ensure that medical records were accurately written and promptly completed as evidenced by:

1. failure to ensure that nursing documentation related to a Code Blue on a patient who committed suicide (Patient #1) was completed accurately and timely, to provide information to Emergency Medical Systems (EMS) and the receiving acute care hospital. The potential risk is that without written documentation of what occurred during the code, both EMS personnel and the medical team at the acute care hospital to which the patient was transferred would have inadequate medical information to make informed decisions for the patient's care.

2. failure to ensure that the discharge summaries entered into patients' legal record were completed promptly for three of three patients (Patient #s 4, 5, and 6). This is a potential health risk for the patient that information needed by all care givers is not readily available if needed.

Findings include:

1. Cross reference Tag 0395 relative to background information regarding the Code Blue performed on Patient #1.

The (Hospital) Registered Nurse job description revealed: "...DOCUMENTATION: Documentation for medical records and reports is timely, legible, thorough, and in required format. Document as required including assessments, nursing notes...."

Staff # 29 assumed care of Patient #1 at 7:00 A.M. on 01/14/16. There was no documentation of a nursing assessment of the patient by Staff #29 prior to Staff #10 documenting that the patient was in the bathroom, and that (Cardiopulmonary Resuscitation) CPR was being performed.

The Observation Rounds form for Patient #1 revealed that Staff #10, an RN, documented at 8:55 A.M. that the patient was in the "bathroom" and that "CPR was being performed at 8:55 A.M., and 9:00 A.M., respectively. No Code Blue form was completed for Patient #1; there was no nursing or other record of what occurred during the Code Blue completed on the date of the code.

The Code Blue policy revealed: "POLICY: The Code Blue is the mechanism to provide rapid emergency assistance to the person in cardiopulmonary crisis...PROCEDURE: ...2. Other staff members are instructed to:...d. Document on the Code Blue sheet.

There was no Code Blue Record completed for Patient #1 on 01/14/16, the date of the suicide, or subsequent to the occurrence. The form had multiple fields for recording the nursing care of the patient during a code. Among the required fields were: Description of Event, Responder's names, Time CPR began, did patient regain pulse, consciousness, or resume breathing, Vital Signs (every 5 minutes), Comments, meds given, Condition of patient upon departure, and the Recorder's signature.

A "Late Entry" was completed by Staff #10 on 01-20-16 at 1:00 P.M., six (6) days subsequent to the Code Blue and Patient #1's death. The late entry revealed: "I responded to a code blue...where pt was found lying supine on the bathroom floor... (RN #29) and I confirmed patient was pulseless and apnec (sic)...Followed AED (Automated External Defibrillator) instructions until EMS arrived. EMS personnel took over...."

Subsequent to the time of Patient #1's Code Arrest on 01/14/16, until 01/20/16, there was no RN documentation of patient #1's nursing care.

2. Review of the facility's Rules and Regulations of the Medical Staff reveal: "...The complete History and Physical examination in all cases will be completed and recorded in the chart within 24 hours after admission...The Psychiatric Evaluation and Mental Status Examination shall, in all cases, be completed and dictated by the Practitioner within twenty-four (24) hours after admission of the patient...The record of each discharged patient must have a discharge summary, signed by the Attending Practitioner... Completion of Medical Records- All discharge summaries and other medical record documentation shall be completed within thirty (30) days following the patient's discharge...Incomplete records exceeding thirty (30) days following discharge will be considered delinquent...."

Review of the facility's policies and procedures titled " Unit Records System Maintenance" dated 12/01/2011 revealed: "...Each hospital patient shall have an individual confidential unit record...Unit record system assures accurate, timely and detailed information of all services provided...."

Review of Patient # 4 medical record revealed Patient # 4 was admitted on 08/12/15 with a chief complaint of hearing voices. Patient # 4 was discharged from the facility on 08/19/15. Patient #4's medical record did not contain a discharge summary as of January 26, 2016.

Staff # 13 confirmed in confidential interviews conducted on January 26, 2016 that Patient # 4's medical record did not contain a discharge summary.

Review of Patient # 5's medical record revealed Patient # 5 was admitted on 8/21/15 with chief complaint of auditory hallucinations. Patient # 5 was discharged on 08/25/15. Patient # 5's medical record revealed the discharge summary was not signed until 10/20/15.

Staff # 13 confirmed in confidential interviews conducted on January 26, 2016 that Patient # 5's medical record discharge summary was not signed within the required thirty (30) days.

Review of Patient # 6's medical record revealed Patient # 6 was admitted on 05/18/15 with chief complaint of suicide attempt by overdose. Patient
# 6 was discharged on 05/26/15. Patient # 6's medical record revealed the discharge summary was not signed as of January 26, 2016.

Staff # 13 confirmed in confidential interviews conducted on January 26, 2016 that Patient # 6's medical record discharge summary was not signed as of January 26, 2016. Staff # 13 confirmed that this is not within the required thirty (30) days.