HospitalInspections.org

Based on document review and interview, the hospital failed to ensure that patient's rights to receive care in a safe setting were in accordance with policies and procedures (P&P) for 2 of 10 patients (P1 and P2) consistent with their developmental needs.

Findings include:

1. Review of hospital P&Ps indicated the following:
A. Child & Adolescent Rights, Revised 12/17, indicated the following: Personal Safety: The child...has the right to have mother, father or guardian expect reasonable safety insofar as the hospital practices and environment are concerned as manifested by the following rights: 1. To a safe, secure and therapeutic environment. 3. To have reasonable safety through the understanding of the staff that safety measures will be consistent with his/her developmental needs.
B. Observation Level, Last Revision June 2016, indicated the following: Purpose: To provide a system of maintaining patient safety consistent with the patient's clinical status and to direct staff with regard to their responsibility and accountability for specific patients. Level III (Highest Risk, 1:1). 1. Visual observation will be continuously one-to-one (direct line of sight, within arm's reach at all times, including while in the bathroom and throughout the night) and documented on the patient's observation checklist. Procedure: 4. A Close Observation Form must be completed for all patients during their hospitalization. 5. The MHT/LPN (mental health technician/licensed practical nurse) assigned to the unit completes the close observation form on a 15 minutes basis, indicating behavior/activity and location via visualization. 7. The MHT's assigned to the patient will be documented on the Patient Assignment Sheet...and are to be rotated out every 2 hours...

2. Review of medical records (MR) indicated 2 of 10 patients with non-verbal developmental needs were ordered close observation safety measures. The MRs indicated the following:
A. Patient P1 was admitted 11/20/17 and discharged 11/30/17. The MR indicated the patient was nonverbal. On 11/20/17 the patient was placed on 1:1 AAT (at all times) care/observation. On 11/24/17 the physician ordered 2:1 AAT while awake and 1:1 AAT while asleep. The MR indicated the patient remained at that status throughout admission. The Q15 (every 15 minutes) Close Observation forms lacked documentation of every 15 minute observations as follows: On 11/24/17 between 14:30 hours and 15:00 hours no observations were recorded. On 11/27/17 between 15:15 hours and 17:30 hours and between 21:45 hours and 23:00 hours no observations were recorded. On 11/29/17 between 06:45 hours and 07:30 hours and between 17:45 hours and 18:45 hours no observations were recorded. The Close Observation Forms also lacked documentation of 2:1 observations.
B. Patient P2 was admitted 12/13/17 and discharged 12/18/17. The MR indicated the patient was nonverbal. On 12/13/17 at 09:03 PM, physician orders indicated the patient was to be 1:1 AAT, frequency: continuously. The Q15 Close Observation forms lacked documentation of every 15 minute observations as follows: On 12/16/17 from 22:45 hours until 12/17/17 15:30 hours.

3. Review of facility Child Unit staffing sheets lacked documentation of 1:1 and/or 2:1 nursing staff assignments during the above patient's stays as follows:
Staffing assignments 11/23/17 through 11/30/17
11/23/17 - Day lacked documentation of 1:1 assignment. Evening lacked documentation of 1:1 assignment. Night lacked documentation of 1:1 assignment.
11/24/17 - Day lacked documentation of 1:1 or 2:1 assignments. Evening lacked documentation of 1:1 or 2:1 assignments. Night lacked documentation of 1:1 or 2:1 assignments.
11/25/17 - Day lacked documentation of 1:1 or 2:1 assignments. Night lacked documentation of 1:1 or 2:1 assignments.
11/26/17 - Night lacked documentation of 1:1 or 2:1 assignments.
11/27/17 - Evening lacked documentation of 1:1 or 2:1 assignments. Night lacked documentation of 1:1 or 2:1 assignments.
11/28/17 - Night lacked documentation of 1:1 or 2:1 assignments.
11/29/17 - Day lacked documentation 1/2 assignments for 2:1 observation. Night lacked documentation of 1:1 or 2:1 assignments.
11/30/17 - Night lacked documentation of 1:1 or 2:1 assignments.
Staffing assignments 12/13/17 through 12/18/17
12/13/17 - Lacked documentation of 1/1 RN and lacked documentation of a 1:1 assignment.
12/14/17 - Night lacked documentation of a 1:1 assignment.
12/15/17 - Evening lacked documentation of a 1:1 assignment.
12/16/17 - Day lacked documentation of a 1:1 assignment due to one name in the 1:1 assignment was marked off and indicated "move" and another name in the 1:1 assignment area was marked off and indicated "C/O". Night lacked documentation of 1:1 assignment.
12/17/17 - Day lacked documentation of 1:1 assignment. Night lacked documentation of a 1:1 assignment.
12/18/17 - Night lacked documentation of a 1:1 assignment. *Note: Only 1 MHT was on the schedule for the unit on this date for night shift.

4. On 2/26/18 between approximately 10:40am and 12:30pm, during MR review, A2 indicated the following: A2 indicated nonverbal patients are considered to need extra assistance and must be provided 1:1 or greater care. On 2/26/18 at approximately 5:45pm, A2 verified MRs lacked documentation of Q15 documentation and inability to determine who was assigned 1:1 and/or 2:1 with patients. A2 verified lack of documentation of census and 1:1 and/or 2:1 assignments on staffing sheets.

Based on document review and interview, the hospital failed to ensure written evidence of adequate numbers of nursing staff and other personnel were schedule in correlation to the number and acuity of patients for 14 of 14 dates reviewed (11/23/17, 11/24/17,11/25/17, 11/26/17, 11/27/17, 11/28/17, 11/29/17, 11/30/17, 12/13/17, 12/14/17, 12/15/17, 12/16/17, 12/17/17 and 12/18/17) of 1 unit (Child).

Findings include:

1. Review of hospital P&Ps indicated the following:
A. Observation Level, Last Revision June 2016, indicated the following: Purpose: To provide a system of maintaining patient safety consistent with the patient's clinical status and to direct staff with regard to their responsibility and accountability for specific patients. Level III (Highest Risk, 1:1). 1. Visual observation will be continuously one-to-one (direct line of sight, within arm's reach at all times, including while in the bathroom and throughout the night) and documented on the patient's observation checklist. Procedure: 4. A Close Observation Form must be completed for all patients during their hospitalization. 7. The MHT's assigned to the patient will be documented on the Patient Assignment Sheet.
B. Review of the staffing grid for the Child Unit indicated the following to be staffed in accordance with census as follows: RN (registered nurse), LPN (licensed practical nurse), MHT (mental health technician). Areas with an x were blank on the staffing grid.

Day Shift - Census/Staff - RN, LPN, MHT: Census (C) 7/RN 1, LPN 0, MHT 2. C 8/RN 1, LPN 0, MHT 2. C 9/RN 1, LPN 0, MHT 3. C 10/RN 1, LPN 0.5, MHT 3. C 11/RN 1, LPN 0.5, MHT 3. C 12/RN 1, LPN 0.5, MHT 3. C 13/RN 1, LPN 0.5, MHT 4. C 14/RN 1, LPN 0.5, MHT 4. C 15/RN 1, LPN 0.5, MHT 4.

Evening Shift - Census /Staff - RN, LPN, MHT: C 7/RN 1, LPN 0, MHT 2. C 8/RN 1, LPN 0, MHT 2. C 9/RN 1, LPN 0, MHT 3. C 10/RN 1, LPN 0.5, MHT 3. C 11/RN 1, LPN 0.5, MHT 3. C 12/RN 1, LPN 0.5, MHT 3. C 13/RN 1, LPN 0.5, MHT 4. C 14/RN 1, LPN 0.5, MHT 4. C 15/RN 1, LPN 0.5, MHT 4.

Night Shift - Census/Staff - RN, LPN, MHT: C 7/RN 1, LPN x (means blank on staffing grid), MHT 1. C 8/RN 1, LPN x, MHT 1. C 9/RN 1, LPN x, MHT 1. C 10/RN 1, LPN x, MHT 2. C 11/RN 1, LPN x, MHT 2. C 12/RN 1, LPN x, MHT 2. C 13/RN 1, LPN x, MHT 2. C 14/RN 1, LPN x, MHT 2. C 15/RN 1, LPN x, MHT 2.

2. Review of facility Child Unit staffing sheets indicated the following dates/shifts did not meet facility staffing requirements in accordance with staffing grid and/or hospital policies in the following manner for shifts indicated: (Note, days reviewed were days during which MR documentation indicated the children's unit had a patient with 1:1 or 2:1 care needs).

A. Staffing assignments 11/23/17 through 11/30/17 lacked the following on dates/shifts indicated:
11/23/17 - Day - census of 8 + 1 and a 1:1 observation. Lacked documentation of who was assigned as 1:1. Documentation further indicated that a person/MHT was assigned as 1:1, but was marked off and indicated as "move". Evening lacked documentation of census or of 1:1 assignment. Night - census 9 with a 1:1. Lacked documentation of an RN (registered nurse) 0/1, indicated only 2/3 MHTs and lacked documentation of 1:1 assignment.
11/24/17 - Day - census 9 and a 1:1 observation lacked documentation of 1:1 or 2:1 assignments. Documentation indicated 1 MHT was assigned, but was marked off with "CI" written in. Evening - census was not documented, a 1:1 was indicated. Lacked documentation of 1:1 or 2:1 assignments. Unable to determine staffing needs were met. Night - census 9 with a 2:1. Lacked documentation of a nurse, 0/1 RN and lacked 1:1 or 2:1 assignments.
11/25/17 - Day - census 9 + 1 and a 1:1 observation. Lacked documentation of 1:1 or 2:1 assignments. Night - census 10 with a 2:1. Lacked documentation of an RN, 0/1, and lacked documentation of 1:1 or 2:1 assignments.
11/26/17 - Day - census 9, lacked documentation of 1:1 or 2:1 and unable to determine correct number of MHTs due to mark offs with "C/I" indicated and 3 MHT names in 1:1 assignment section. Evening - census 9 and a 2:1. Lacked documentation of 3 MHTs (2/3 scheduled) with 2 additional indicated as 1:1, 1 other MHT was marked off and noted as "moved". Night - census 11 and a 2:1. Lacked documentation of an RN, 0/1 and lacked documentation of 1:1 or 2:1 assignments.
11/27/17 - Day - census 11 and a 2:1. Lacked documentation of 0.5/0.5 LPN (licensed practical nurse). Evening - census 11 and a 2:1. Lacked documentation of of 0.5/0.5 LPN and lacked documentation of 1:1 or 2:1 assignments. Night - census 13 lacked documentation of a 1:1 or 2:1, lacked documentation of an RN, 0/1 and lacked documentation of 1:1 or 2:1 assignments.
11/28/17 - Evening - census 13 with a 2:1 observation. Lacked documentation of 0.5/0.5 LPN, lacked documentation of 1/4 MHTs due to 1/4 marked through and 2 others assigned 1:1/2:1. Night - lacked documentation of census, lacked documentation of 2:1, lacked documentation of a nurse (RN or LPN), 0/1 and 0.5/0.5, and lacked documentation of 1:1 or 2:1 assignments.
11/29/17 - Day - census 13 with a 2:1. Lacked documentation of 0.5/0.5 LPN and lacked documentation 1/2 assignments for 2:1 observation. Evening - census 14 with a 2:1. Lacked documentation of 0.5/0.5 LPN. Night - lacked documentation of census, lacked documentation of 1:1 or 2:1, lacked documentation of an RN, 0/1 and lacked documentation of 1:1 or 2:1 assignments.
11/30/17 - Day - census 15 with a 2:1 observation. Lacked documentation of 0.5/0.5 LPN. Night - census 11 with a "1:1" indicated. Lacked documentation of 1/1 RN and lacked documentation of 1:1 or 2:1 assignments.

B. Staffing assignments 12/13/17 through 12/18/17 lacked the following on dates/shifts indicated:
12/13/17 - Day - census 14 without a 1:1 observation noted. Lacked documentation of 0.5/0.5 LPN, lacked documentation of 1/4 MHTs (3/4 on schedule) with 1 additional listed with a 1:1 assignment. Evening - census 14 and 1:1. Lacked documentation of a nurse (RN or LPN) - 1/1 RN and 0.5/0.5 LPN. Night - census 12 and a 1:1. Lacked documentation of 1/1 RN and lacked documentation of a 1:1 assignment.
12/14/17 - Day - census 12 and a 1:1. Lacked documentation of 0.5/0.5 LPN. Night - census 8 and a 1:1. Lacked documentation of 1/1 RN and lacked documentation of a 1:1 assignment.
12/15/17 - Day - census 10 and a 1:1. Lacked documentation of 0.5/0.5 LPN. Evening - census 9 and a 1:1. Lacked documentation of a 1:1 assignment. Night - census 8 and a 1:1. Lacked documentation of 1/1 RN.
12/16/17 - Day - census 9 and a 1:1. Lacked documentation of a 1:1 assignment due to one name in the 1:1 assignment was marked off and indicated "move" and another name in the 1:1 assignment area was marked off and indicated "C/O". Night - lacked documentation of census, lacked documentation of 1:1(s), lacked documentation of a nurse (RN or LPN) and lacked documentation of 1:1 assignments.
12/17/17 - Day - lacked documentation of census, indicated a 1:1. Unable to determine staffing needs. Night - lacked documentation of census or 1:1 observation needs. The shift documentation lacked documentation of an RN and lacked documentation of a 1:1 assignment.
12/18/17 - Evening - census 10 and a 1:1. Lacked documentation of 0.5/0.5 LPN. Night - census 7, lacked indication of 1:1 observation needs. Lacked documentation of 1/1 RN and lacked documentation of a 1:1 assignment. *Note: Only 1 MHT was on the schedule for the unit on this date for night shift.

3. On 2/26/18 at approximately 5:45pm, A2, CNO (chief nursing officer), verified lack of documentation of census and 1:1 and/or 2:1 assignments on staffing sheets.

Based on document review and interview nursing staff failed to supervise and evaluate care for 9 of 10 (P1, P2, P3, P4, P5, P6, P8, P9 and P10) patients to assure care was provided in accordance with hospital policies and procedures.

Findings include:

1. Review of hospital policies and procedures (P&P) indicated the following:
A. Observation Level, Last Revision: June 2016. Purpose: To provide a system of maintaining patient safety consistent with the patient's clinical status and to direct staff with regard to their responsibility and accountability for specific patients. Level III (Highest Risk, 1:1). 1. Visual observation will be continuously one-to-one (direct line of sight, within arm's reach at all times, including while in the bathroom and throughout the night) and documented on the patient's observation checklist. Procedure: 4. A Close Observation Form must be completed for all patients during their hospitalization. 5. The MHT/LPN (mental health technician/licensed practical nurse) assigned to the unit completes the close observation form on a 15 minutes basis, indicating behavior/activity and location via visualization. 7. The MHT's assigned to the patient will be documented on the Patient Assignment Sheet...and are to be rotated out every 2 hours...
B. Clinical Assessments, Last Revision July 2017. Within 24 hours after admission to the unit, the admitting nurse, RN or LPN, (registered nurse or licensed practical nurse)...will complete a nursing assessment...
C. Skin Assessment, Last Revision: December 2017. Policy: Each patient will receive a skin assessment within 24 hours of the time of admission, every 7 days thereafter during hospitalization, and within 24 hours prior to discharge. Procedure: 3. The assessment shall be completed by a Registered Nurse (RN) or an LPN (licensed practical nurse) under the supervision of an RN. 7. Any change in skin condition from the previous skin assessment requires the completion of an incident report and notification to the CNO (chief nursing officer).
D. Personal Hygiene, Last Revision: July 2015. Daily shower or sponge bath to be provided with staff supervision and/or assistance. Clothing: Laundry facilities are available for patient use with staff supervision and assistance. Documentation: Each shift must indicate with a check those items completed on the Activities of Daily Living (ADL) Record.
E. Handling and Storage of Healthcare Textiles, Effective Date: December 19, 2016. Patient Laundry: Patient laundry will be placed into a mesh bag for washing...Laundry will be washed and dryed (sic) in the mesh bag. When laundry is complete, they will return the clothing to the patient's room...

2. Review of medical records (MR) indicated the following:
A. Review of the MR for P1 indicated the patient was admitted 11/20/17 and discharged 11/30/17. The patient was indicated to have been nonverbal and was initially ordered 1:1 AAT (at all times) care on 11/20/17. On 11/24/17, 2:1 AAT care while awake with 1:1 while asleep was ordered. Close Observation forms lacked documentation of Q15 minute checks during admission as follows: 11/24/17 between 14:30 hours and 15:00 hours; 11/27/17 between 15:15 hours and 17:30 hours and between 21:45 hours and 22:45 hours; on 11/29/17 between 06:45 hours and 07:30 hours and between 17:45 hours and 18:45 hours. The MR indicated the patient required assistance with bathing, toileting and laundry. Daily Hygiene/bathing, recorded on the ADL (Activities of Daily Living) Record lacked documentation of daily baths as follows: On 11/23/17 and 11/26/17. The Close Observation Record lacked documentation of observation of the patient showering/bathing on the following dates: 11/20/17, 11/22/17, 11/26/17 and 11/30/17. The MR lacked documentation of patient clothing having been laundered.
B. Review of the MR for patient P2 indicated the patient was admitted 12/13/17 and discharged 12/18/17. The patient was indicated to have been nonverbal and was ordered 1:1 AAT, frequency: Continuously, on 12/13/17 at 09:03 PM. The Q15 Close Observation forms lacked documentation of Q15 minute checks during admission dates as follows: On 12/16/17 from 22:45 hours until 12/17/17 15:30 hours. The MR indicated the patient required assistance with bathing, toileting, grooming, dressing and laundry. The Close Observation Record lacked documentation of observation of the patient showering/bathing on the following dates: 12/14/17, 12/16/17, 12/17/17 and 12/1/8/17. The MR lacked documentation of patient clothing having been laundered.
C. Review of the MR for patient P3 indicated the patient was admitted 11/24/17 and discharged 12/1/17. Daily Hygiene/bathing, recorded on the ADL Record lacked documentation of a daily bath on 11/26/17. The MR lacked documentation of patient clothing having been laundered.
D. Review of the MR for patient P4 indicated the patient was admitted 1/25/18 and discharged 2/1/18. Daily Hygiene/bathing, recorded on the ADL Record lacked documentation of a daily bath on 1/27/18. The MR lacked documentation of patient clothing having been laundered.
E. Review of the MR for patient P5 indicated the patient was admitted 1/18/18 and discharged 1/24/18. Daily Hygiene/bathing, recorded on the ADL Record lacked documentation of daily baths as follows: On 1/20/18 and 1/21/18. The MR lacked documentation of patient clothing having been laundered.
F. Review of the MR for patient P6 indicated the patient was admitted 11/26/17 and discharged 11/30/17. Daily Hygiene/bathing, recorded on the ADL Record lacked documentation of daily baths as follows: On 11/27/17 and 11/29/17. The MR lacked documentation of patient clothing having been laundered.
G. Review of the MR for patient P8 indicated the patient was admitted 12/11/17 and discharged 12/14/17. Daily Hygiene/bathing, recorded on the ADL Record lacked documentation of a daily bath on 12/13/17. The MR lacked documentation of patient clothing having been laundered.
H. Review of the MR for patient P9 indicated the patient was admitted 12/10/17 and discharged 12/14/17. Daily Hygiene/bathing, recorded on the ADL Record lacked documentation of a daily bath on 12/13/17. The MR lacked documentation of patient clothing having been laundered.
I. Review of the MR for patient P10 indicated the patient was admitted 1/13/18 and discharged 1/19/18. The initial Nursing Assessment/Skin Assessment indicated the following was present upon admission: 2 scratches left inner elbow, 1 scab and 1 red spot right inner elbow, 1 scratch right top of foot, 1 scab front left leg. The MR lacked documentation of skin assessment at discharge. Daily Hygiene/bathing, recorded on the ADL Record lacked documentation of a daily bath on 1/13/18 and on 1/14/18. The MR lacked documentation of patient clothing having been laundered.

3. On 2/26/18 between approximately 10:45a and 12:15pm, A2, CNO (chief nursing officer), indicated that prior to January 2018 the facility had no specific skin assessment policy, but that skin would have/should have been addressed upon admission in the clinical assessment. At approximately 5:45pm, A2, verified MRs lacked documentation of patient clothing having been laundered. A2 also verified lack of bathing documentation on ADL Forms.