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Based on observations, record reviews, and interviews, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights as evidenced by failure to ensure the patient's physical environment was free of safety risks and didn't afford opportunities for self-injury or harm to self and others as observed on 06/25/19 from 8:55 a.m. to 10:40 a.m. and on 06/26/19 from 9:10 a.m. to 9:35 a.m. (see findings in tag A0144).

Based on observations, record reviews, and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by:
1) Failing to ensure the patient's physical environment was free of safety risks and didn't afford opportunities for self-injury or harm to self and others and
2) Failing to ensure shift change environmental safety rounds were conducted by the MHTs each shift in accordance with hospital protocol on the night shift of 06/24/19 and the day shift on 06/25/19 on Hall B and the night shift of 06/23/19, the day shift of 06/24/19, the night shift of 06/24/19, and the day shift of 06/25/19 on Hall A.
Findings:

1) Failing to ensure the patient's physical environment was free of safety risks and didn't afford opportunities for self-injury or harm to self and others:
Observation on 06/25/19 at 8:55 a.m. with S1ADM present revealed Hall A had 30 beds (17 rooms) and Hall B had 34 beds (19 rooms). Further observation revealed the patient rooms on Hall B had showers, sinks, and toilets, and the rooms on Hall A had a sink and toilet. Further observation revealed the toilets in all patient rooms, the Shower Rooms on each hall, and the Restraint/Seclusion Room on each hall had an approximate 6 inch space between the wall and the base of the toilet that presented a potential ligature point. Each patient room on both halls except Room "e" had a "school type" bell securely attached to the night stand that was a potential ligature point (unable to move the bell when pulled against by the surveyor). The call bells in Rooms "c", "d", "f", and "i" had been taken apart, with the silver dome covering having been removed, leaving the approximately 3 inch sharp metal part inside the bell exposed that provided a further ligature point and a safety risk. There was an AAA battery inside the exposed bell in Room "f." Continuous observation revealed the Restraint/Seclusion Room entrance door on Hall B was open, and each of the 2 seclusion room doors were open as well as the bathroom door.
Continuous observation revealed multiple patient hygiene items, such as liquid soap, toothpaste, alcohol-free mouthwash, toothbrushes, combs, and brushes, in Rooms "a", "b", "c", "d", "e", "g", and "h." Patients in Rooms "r", "s", "a", "b", "c", "d", "e", "f", "g", "h", "t", and "j" were on SP (17 of 24 patients on Hall B were on SP). Continuous observation revealed 3 plastic medicine cups containing steroid cream (as told by Patient R1) were at the bedside in Room "i." A plastic medicine cup containing antibiotic cream (told by Patient R2 it was for his eye) was at the bedside in Room "j." These observations were confirmed by s1ADM at the time of the observations.

Observation on Hall A on 06/25/9 at 10:10 a.m. with s1ADM present revealed there were multiple patient hygiene items, such as liquid soap, toothpaste, alcohol-free mouthwash, toothbrushes, combs, and brushes, in Rooms "k", "l", "m", "n", and in the Shower Room. Continuous observation in the Shower Room revealed a plastic surround was placed around the toilet flush handle on the wall behind the toilet (cited on a previous complaint survey) that had an opening at the bottom of the surround that provided enough space for the flush device to remain a potential ligature point. The toilet in the Shower Room had 2 long screws extending out that was a potential ligature point and safety issue. The floor board in the corner behind the toilet in the Shower Room was extending from the wall about 2 inches that left an opening and a potential site to hide contraband. Continuous observation revealed the Restraint/Seclusion Room entrance door was open with the doors to each of 2 seclusion rooms open. The bed in one seclusion room had metal handles to which restraints could be attached that could be used as a ligature point, and the bed in the other seclusion room had 6 openings in the wood frame that were ligature points. These observations were confirmed at the time of the observation by S1ADM.

Observation on Hall B with S1ADM present on 06/26/19 at 9:10 a.m. revealed the following:
Room "h" - the door was locked from the outside and required a key to be opened by S1ADM (the patient could open the door from within); Patient R3, who was on SP, was in the room unsupervised;
Room "g" - the door was locked with Patient R4, who was on SP, in the room unsupervised.
The patients were listed as being on SP/HP precautions on the patient roster presented as the current roster by S1ADM.

Observation on Hall B on 06/26/19 at 9:25 a.m. revealed Room "f" was locked with Patient R5, who was on SP, and patient R6, who was on SP and HP, in the room unsupervised.

Observation on Hall A on 06/26/19 at 9:25 a.m. revealed the door to Room "k" was closed with Patient R7, who was on SP, in the room unsupervised. Continuous observation revealed the door to Room "o" was closed with Patient R8, who was on SP, in the room unsupervised. Further observation revealed the doors to Rooms "p" and "q" were open with no patients in the room (doors were to remain closed/locked if patients were not in the room).
The patients were listed as being on SP/HP precautions on the patient roster presented as the current roster by S1ADM.

Review of the "Suicide precautions Physician Orders", presented by S11RN, revealed interventions included the patient room door was to remain open, the patient was to be placed in a room closest to the nursing station with the door open, and the patient was to have bathroom accompaniment.

Review of the policy titled "Precautions", presented as a current policy by S1ADM, revealed it was the policy of the hospital to identify those patients who require special precautions and determine adequate actions to alleviate the threat posed by the particular precaution through additional observation, staff communication, room changes, or other process variations. Suicide precautions were to be used for a patient with suicidal thoughts, ideas, or a plan. Suicide prevention interventions listed included the patient's room door must remain open when the patient is in the room and bathroom accompaniment.

Review of the policy titled "Contraband", presented as a current policy by S1ADM, revealed it was the policy of the hospital that staff ensure the strict control of contraband and unauthorized use of permitted items in order to provide a secure and safe environment for patients, staff, and visitors. Included in the list of contraband items that may be permitted under supervision of staff or as part of a therapeutic activity were any medication and batteries.

Review of the "Patient Handbook", presented as the current patient handbook by S3QAC, revealed items needed for daily grooming may be checked out at designated times, and staff will see that all items checked out were returned to Storage.

In an interview on 06/25/19 at 8:55 a.m., S1ADM indicated patients were allowed in their rooms with the doors closed if they weren't on SP and were allowed unsupervised bathroom privileges unless they were on 1:1 level of observation. He further indicated patients were allowed to use the Restraint/Seclusion Room bathroom rather than going into their individual room to use the bathroom, so the Restraint/Seclusion Room door remained unlocked or open.

In an interview on 06/26/19 at 9:15 a.m., S11RN indicated they "like" to have patients on SP in the dayroom, but with only 1 dayroom and patients with anxiety issues, patients prefer to be in their room. She indicated if patients on SP were in their room, they have to have the door open. If the patient isn't in the room, the door has to remain shut. If the patient has to go to the bathroom, the MHT can open the door, but if they want to stay in their room, they have to ask the nurse if it's alright to do so. She indicated they have a bathroom in the restraint/seclusion room, so patients were encouraged to use it rather than go to their room. She indicated patients on SP can go to the bathroom unsupervised if they were not on one-to-one level of observation. When the surveyor told S11RN that the SP precaution policy stated patients have to be escorted to the bathroom, she indicated most patients want the door closed, so staff have to constantly check. After S11RN printed the SP list, she indicated the MHT waits in the hall at the patient's entrance door.

In an interview on 06/26/19 at 9:35 a.m., S12MHT indicated the patient's room door "is supposed to be unlocked if the patient is not in the room." He referred to the form for SP that showed the patient door is to be open. He indicated he had been hired about 2 weeks ago.

In an interview on 06/25/19 at 9:40 a.m., S3QAC indicated patients weren't supposed to have personal hygiene items in their rooms.
In an interview on 06/26/19 at 1:57 p.m., S2DON indicated patient hygiene products were not supposed to be in the room after 2:00 p.m. bath time. She further indicated they pass them out in the morning also. She confirmed the observation findings noted above were truly ligature points. She indicated the seclusion room doors should not have been opened, but the entrance door remains unlocked, so patients can use the bathroom. She indicated the patient room doors should remain open if the patient is on SP, and the nurse is supposed to be checked with if a patient wants to go to their room.

2) Failing to ensure shift change environmental safety rounds were conducted by the MHTs each shift in accordance with hospital protocol:
Review of the "Mandatory Shift Change Environmental Safety Rounds Checklist", present as the current checklist by S1ADM, revealed environmental safety rounds were to completed each shift by the assigned MHTs. Any "NO" answer should be reported to the nursing staff for immediate action. Further review revealed 1 MHT from the oncoming shift will round with 1 MHT from the outgoing shift. Further review revealed the "0700 shift" (7:00 a.m.) or "1900 shift" (7:00 p.m.) was to be circled, and the oncoming MHT and the outgoing MHT had a place to sign the checklist.

Review of the "Mandatory Shift Change Environmental Safety Rounds Checklist" for Hall A dated 06/23/19 for the day shift, presented by S1ADM, revealed no documented evidence the outgoing MHT had signed the checklist. Further review revealed no documented evidence a checklist had been completed for the night shift of 06/23/19, the day and night shift for 06/24/19, and the day shift of 06/25/19 when a request was made to review the checklists on 06/25/19 at 10:35 a.m.

Review of the patient assignment sheet for Hall A revealed "shift rounds" was assigned to a MHT on the night shift of 06/23/19 and the night shift of 06/24/19. There was no documented evidence "shift rounds" was documented on the assignment sheet for the day shift of 06/24/19 and 06/25/19.

Review of the "Mandatory Shift Change Environmental Safety Rounds Checklist" for Hall B revealed no documented evidence a checklist had been completed for the night shift of 06/24/19 and the day shift of 06/25/19 (when the surveyor asked to review them on 06/25/19 at 10:45 a.m.).

Review of the patient assignment sheet for Hall B revealed "shift rounds" were assigned to a MHT on the night shift on 06/24/19. There was no documented evidence the "shift rounds" had been assigned for the day shift of 06/25/19.

In an interview on 06/25/19 at 9:35 a.m. with S5MHT and S6MHT present, S6MHT indicated the MHT from the night shift was supposed to round with the oncoming day MHT, and the shift rounds sheet was usually given to whomever was assigned to do the shift rounds. He further indicated there were only 2 MHTs last night (06/24/19), so it probably wasn't done. He indicated it usually is done at the beginning and end of each shift. He indicated since the night shift didn't do one, the night MHT didn't hand off a round sheet this a.m. to the day MHT. S6MHT confirmed a shift round was not done this a.m.by MHTs on Hall B.

In an interview on 06/25/19 at 10:40 a.m., S7MHT indicated the day shift on Hall A did a safety round on 06/23/19, but the night shift didn't sign it. He further indicated the night shift last night (06/24/19) didn't assign anyone to do it for the day shift of 06/25/19. S7MHT confirmed there was no "shift rounds" documented for review for the night shift of 06/23/19, the day and night shift for 06/24/19, and the day shift of 06/25/19.

Based on record reviews and interviews, the hospital failed to ensure the RN supervised and evaluated the nursing care of each patient as evidenced by failure to have documented evidence of a thorough RN assessment of a patient's change in condition, injury, or report of an alleged incident by a patient for 3 (#1, #2, #4) of 5 patient records reviewed for RN assessment from a sample of 5 patients.
Findings:

Review of the policy titled "Acute Changes in Patient Conditions", presented as a current policy by S3QAC, revealed in the event of a medical acute change in patient condition, staff should perform a general assessment and obtain vital signs. Further review revealed medical changes in patient condition may include but were not limited to falling and bleeding.

Patient #1
Review of a self-report made to LDH-HSS by the hospital of an allegation of physical abuse on 05/07/19 revealed Patient #1 alleged that S16MHT hit her in the face early in the morning when she was receiving an injection.

Review of Patient #1's medical record revealed S18RN documented "no swelling noted" on 05/07/19 at 8:12 a.m. There was no documented evidence of a full assessment including vital signs and neurovascular assessment.

In an interview on 06/26/19 at 10:00 a.m., S18RN indicated patient #1 was one of the patients assigned to her on 05/07/19 and confirmed the patient's son reported an allegation of abuse by S16MHT. She indicated she assessed Patient #1's face, and she didn't see any swelling or bruising on her face. She indicated "that's all I documented" (referring to "no swelling"), but the other nurse and I saw no bruising or swelling. She indicated she would look for bruising, redness, abrasions, and tenderness. When asked if she should have assessed neurovascular status, she indicated "yes, that goes along with swelling, bruising, and such. She indicated she didn't do or document that, because she didn't see any swelling or bruising. She confirmed she should have documented a full assessment including neurovascular status.

Patient #2
Review of the self-report submitted by the hospital to LDH-HSS, presented for review by S1ADM, revealed Patient #2 alleged on 05/19/19 at 7:30 a.m. a male patient went into her room and sexually assaulted her during shower time. Further review of the report revealed S19RN assessed the patient on 05/21/19 at 5:10 p.m. when the incident was reported.

Review of Patient #2's medical record revealed no documented evidence of an assessment by a RN after the hospital was notified of an allegation of sexual assault.

In an interview on 06/26/19 at 2:15 p.m., S2DON indicated S19RN will be coming at 3:00 p.m. to be interviewed. S19RN did not appear for an interview as of the time of exit on 06/26/19 at 4:30 p.m.

Patient #4
Review of the self-report to LDH-HSS presented by S1ADM regarding Patient #4 revealed S3QAC became aware of the incident by receiving a notification from the accrediting organization's extranet site on 06/11/19 of the allegation which stated that during visitation, staff were witnessed physically abusing a patient and kicking her while she was on the ground on 05/26/19 at 4:08 p.m..

Review of Patient #4's Multidisciplinary note by S10RN on 05/26/19 at 5:00 p.m. revealed Patient #4 was unable to be verbally redirected during visiting hours. She was arguing with S13MHT by the nurse's station when she said that S13MHT pushed her down. Further review revealed documentation of no lacerations, bruises, scratches, or bumps were noted on any part of her body, and her scalp was free of bruises, lacerations, and scratches or bumps. Her pulse and respirations were within normal limits. There was no documented evidence of a neurovascular check, VS, or an assessment of injury to other parts of her body.

In an interview on 06/25/19 at 3:45 p.m., S10RN indicated she was working as charge nurse on the day of the incident with Patient #4 on 05/26/19. She indicated she saw her "start to go down" while she (S10RN) was in the nursing station. She indicated she did an assessment, but doesn't remember if she documented the assessment in the patient's record.

In an interview on 06/26/19 at 1:57 p.m., S2DON indicated she would have assessed and documented vital signs, including blood pressure, pulse, and respirations.

Based on record review and interview, the RN failed to ensure the nursing care of each patient was assigned to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the available nursing care staff as evidenced by failure to have documented evidence of the a competency evaluation in performing the required duties of a MHT for 1 (S14MHT) of 4 (S13MHT, S14MHT, S15MHT, S16MHT) MHT personnel files reviewed for competency evaluations.
Findings:

Review of S14MHT's personnel file revealed he was hired as a MHT on 03/06/19. Further review revealed there was no documented evidence of a 90 day evaluation performed that would have included an evaluation of S14MHT's competence in performing specific MHT duties, such as monitoring patients as ordered by the physician and performing contraband searches and safety rounds.

In an interview on 06/26/19 at 4:20 p.m., S1ADM confirmed S14MHT's personnel file had no evidence that a competency evaluation in performing the MHT duties had been conducted by a RN.