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Based on record review and interview the hospital failed to ensure patients received care in a safe setting by staffing a unit with a census of 26 patients with 2 Psych Aides and no other staff (Registered Nurse, Licensed Practical Nurse, Security, or other Psych Aides) during the change of shift (start of the 6:00 p.m. - 6:00 a.m. shift) for 1 of 22 days reviewed (1/12/2011). Findings:

Review of a hospital "Client Incident, Injury and Data Reporting Form" dated 1/12/2011 revealed in part, "pt. (patient/ #2) stated she (#2) was in the shower room when pt. (#1) came in and bumped her (#2) and then started attacking her (#2) for no reason. (W)when staff entered the bathroom both pts (#1 and #2) were physically fighting and had to be separated using verbal redirection." This form was signed by Psych Aide S6.

Review of Patient #1's Progress Notes dated 1/12/2011 at 1805 (6:05 p.m./ start of the 6:00 p.m. - 6:00 a.m. shift) revealed in part, "pt (patient/#1) came to nurse's station, stating that pt (#2) kept bothering her (#1) in the shower. Staff instructed pt (#1) to have a seat in the dayroom until pt. (#2) was finished but she (#1) went to the shower anyway. Pt. (#1) came out and told staff that pt (#2) bump her (#1), pt. (#1) was told to wait, that staff was coming to see what the problem was between (as written), before staff could get to the shower room pt. (#1) was physically fighting with pt (#2). . . the nurse was notified." This documentation was signed by Psych Aide S6.

Review of Patient #2's Progress Notes dated 1/12/2011 at 1805 (6:05 p.m.) revealed in part, "Pt (Patient #2) stated she (#2) was in the shower room when pt (#1) came in and bumped her (#2) and then started attacking her (#2) for no reason. (W)when staff entered the bathroom both pts (#1 and #2) were physically fighting and had to be separated. . . the nurse was notified." This documentation was signed by Psych Aide S6.

Review of staffing for the female unit of the hospital (Evangeline 4) on the date of 1/12/2011 revealed the census was 26 with no patients on special precautions. Further review revealed 1 Registered Nurse and 3 Psych Aides were scheduled for the unit for day and night shift (12 hour shifts).

During a telephone interview on 2/21/2011 at 10:05 a.m., Psych Aide S4 indicated she (S4) had been scheduled to work on 1/12/2011 from 6:00 p.m. until 6:00 a.m. S4 indicated that a truck had overturned on the highway and she (S4) had not been able to get to work at the scheduled time. S4 indicated that by the time she (S4) arrived; on 1/12/2011, the altercation between Patient #1 and Patient #2 had already occurred.

During a telephone interview on 2/21/2011 at 11:00 a.m., Psych Aide S6 indicated she (S6)had been one of the two Psych Aides staffing the unit (Evangeline 4) where Patient #1 and Patient #2 were involved in an altercation at 1805 (6:05 p.m.) on 1/12/2011. Psych Aide S6 indicated that the unit (Evangeline 4) had been short staffed, at the time, due to the Registered Nurse and Psych Aide Supervisor being off the unit for report (Hand off communication). S6 indicated she (S6) and one other Nurse Aide (S8) were the only staff on the unit. S6 indicated that the normal procedure during "shower time" was for one Psych Aide to directly monitor the shower room and the other two Psych aides were to monitor the patients that remained on the unit. S6 indicated that she (S6) stood near the shower on the date of 1/12/2011 at 6:00 p.m. and attempted to observe shower room activity and also observe patients on the unit, since there had only been 2 Psych Aides on the unit at the time. S6 indicated she (S2) had been aware of conflict between Patient #1 and #2 regarding the use of the shower. S6 indicated Patient #1 had been instructed to stay out of the shower until Patient #2 had finished; however, Patient #1 had managed to get into the shower room after being instructed to wait. S6 indicated she had not seen Patient #1's entrance into the shower room although she(S6) had attempted to monitor shower room activity. S6 indicated when she (S6) became aware that a fight had started between Patient #1 and #2 in the shower room, she (S6) had called out for help. S6 indicated the two patients (#1 and #2) had stopped fighting when she (S6) had verbally redirected them. S6 indicated there had been no need for physical intervention.

Unsuccessful attempts were made to reach Psych Aide S8 for an interview on 2/21/2011 at 11:45 a.m., 11:50 a.m., 1:10 p.m., and 1:15 p.m.

During a telephone interview on 2/21/2011 at 11:35 a.m., Registered Nurse S7 indicated he (S7) had been the House Supervisor and the Registered Nurse covering Evangeline 4 on the 6:00 p.m. - 6:00 a.m. shift for the date of 1/12/2011. S7 indicated the practice at the hospital had been for all Registered Nurses; to include oncoming and offgoing, to meet in the Conference Room located in the center of the Building (Evangeline) for Report (Hand off communication) and counting of narcotics at the change of shift. S7 confirmed that all Patient Care Units (Evangeline 1, 2, 3, and 4) were left without RN coverage during "Report" which averaged anywhere from 15 to 30 minutes. S7 indicated that Narcotic Count would also been performed during this time frame. S7 indicated 2 Psych Aides to provide care for 26 patients would not be adequate coverage.

During a face to face interview on 2/22/2011 at 9:55 a.m., Director of Nursing S2 indicated all Nursing Staff had been educated regarding the need to have at least one Registered Nurse on every clinical care unit during Code Blue calls (confirmed with record review) . S2 indicated he had not been aware that Registered Nurses had left the clinical units without Registered Nurse coverage during Hand Off Communication at the change of shift. S2 further indicated that he would think Registered Nurses would know if they could not leave clinical units unattended by a Registered Nurse during a Code Blue that it would not be acceptable to leave the unit without RN coverage during change of shift.

Review of the hospital policy titled, "Staffing Variances" presented by the hospital as their current policy revealed in part, "The nurse assesses the cumulative needs for patient care and determines the staffing needs based on professional judgment, experience, and an acquired sense of the relative care needs of patients. This is accomplished without forms or tools, using a combination of professional judgment and knowledge of current care models and staffing practices. Psychiatric mental health head nurses supervises and direct patient care and therefore, possess a critical front-line perspective of nursing practice problems, i.e. patient care, staffing, and organizational management concerns. Professional care is directed toward healing the patient, preparing the patient for return to normalcy, or managing the patient's personal challenges or family issues. . ."

Review of the hospital policy titled, "Hand Off, effective March 15, 2006" presented by the hospital as their current policy revealed in part, "Hand off communications shall take place whenever there is a change in the patient's/client's/resident's caregivers. caregivers shall include all clinical staff and physicians. . . "





25452

Based on record review and interview the hospital failed to ensure there was adequate numbers of nursing personnel to meet the needs of the patients by:
1) failing to ensure adequate numbers of nursing personnel were provided during the change of shift for 1 of 4 units (Evangeline 4) on 1 of 22 days reviewed (1/12/2011) by having no Registered Nurse on the unit and having 2 Psych Aides (S6 and S8) provide care for 26 patients during the change of shift. Two patients (#1, #2) became involved in an altercation during the change of shift on 1/12/2011.
2) failing to ensure adequate numbers of Psych Aides were provided as per the hospital's staffing grid for 1 of 22 days reviewed (10/09/2010). Findings:

1)
Review of a hospital "Client Incident, Injury and Data Reporting Form" dated 1/12/2011 revealed in part, "pt. (patient/ #2) stated she (#2) was in the shower room when pt. (#1) came in and bumped her (#2) and then started attacking her (#2) for no reason. (W)when staff entered the bathroom both pts (#1 and #2) were physically fighting and had to be separated using verbal redirection." This form was signed by Psych Aide S6.

Review of Patient #1's Progress Notes dated 1/12/2011 at 1805 (6:05 p.m./ start of the 6:00 p.m. - 6:00 a.m. shift) revealed in part, "pt (patient/#1) came to nurse's station, stating that pt (#2) kept bothering her (#1) in the shower. Staff instructed pt (#1) to have a seat in the dayroom until pt. (#2) was finished but she (#1) went to the shower anyway. Pt. (#1) came out and told staff that pt (#2) bump her (#1), pt. (#1) was told to wait, that staff was coming to see what the problem was between (as written), before staff could get to the shower room pt. (#1) was physically fighting with pt (#2). . . the nurse was notified." This documentation was signed by Psych Aide S6.

Review of Patient #2's Progress Notes dated 1/12/2011 at 1805 (6:05 p.m.) revealed in part, "Pt (Patient #2) stated she (#2) was in the shower room when pt (#1) came in and bumped her (#2) and then started attacking her (#2) for no reason. (W)when staff entered the bathroom both pts (#1 and #2) were physically fighting and had to be separated. . . the nurse was notified." This documentation was signed by Psych Aide S6.

Review of staffing for the female unit of the hospital (Evangeline 4) on the date of 1/12/2011 revealed the census was 26 with no patients on special precautions. Further review revealed 1 Registered Nurse and 3 Psych Aides were scheduled for the unit for day and night shift (12 hour shifts).

During a telephone interview on 2/21/2011 at 10:05 a.m., Psych Aide S4 indicated she (S4) had been scheduled to work on 1/12/2011 from 6:00 p.m. until 6:00 a.m. S4 indicated that a truck had overturned on the highway and she (S4) had not been able to get to work at the scheduled time. S4 indicated that by the time she (S4) arrived; on 1/12/2011, the altercation between Patient #1 and Patient #2 had already occurred.

During a telephone interview on 2/21/2011 at 11:00 a.m., Psych Aide S6 indicated she (S6)had been one of the two Psych Aides staffing the unit (Evangeline 4) where Patient #1 and Patient #2 were involved in an altercation at 1805 (6:05 p.m.) on 1/12/2011. Psych Aide S6 indicated that the unit (Evangeline 4) had been short staffed, at the time, due to the Registered Nurse and Psych Aide Supervisor being off the unit for report (Hand off communication). S6 indicated she (S6) and one other Nurse Aide (S8) were the only staff on the unit. S6 indicated that the normal procedure during "shower time" was for one Psych Aide to directly monitor the shower room and the other two Psych aides were to monitor the patients that remained on the unit. S6 indicated that she (S6) stood near the shower on the date of 1/12/2011 at 6:00 p.m. and attempted to observe shower room activity and also observe patients on the unit, since there had only been 2 Psych Aides on the unit at the time. S6 indicated she (S2) had been aware of conflict between Patient #1 and #2 regarding the use of the shower. S6 indicated Patient #1 had been instructed to stay out of the shower until Patient #2 had finished; however, Patient #1 had managed to get into the shower room after being instructed to wait. S6 indicated she had not seen Patient #1's entrance into the shower room although she(S6) had attempted to monitor shower room activity. S6 indicated when she (S6) became aware that a fight had started between Patient #1 and #2 in the shower room, she (S6) had called out for help. S6 indicated the two patients (#1 and #2) had stopped fighting when she (S6) had verbally redirected them. S6 indicated there had been no need for physical intervention.

Unsuccessful attempts were made to reach Psych Aide S8 for an interview on 2/21/2011 at 11:45 a.m., 11:50 a.m., 1:10 p.m., and 1:15 p.m.

During a telephone interview on 2/21/2011 at 11:35 a.m., Registered Nurse S7 indicated he (S7) had been the House Supervisor and the Registered Nurse covering Evangeline 4 on the 6:00 p.m. - 6:00 a.m. shift for the date of 1/12/2011. S7 indicated the practice at the hospital had been for all Registered Nurses; to include oncoming and offgoing, to meet in the Conference Room located in the center of the Building (Evangeline) for Report (Hand off communication) and counting of narcotics at the change of shift. S7 confirmed that all Patient Care Units (Evangeline 1, 2, 3, and 4) were left without RN coverage during "Report" which averaged anywhere from 15 to 30 minutes. S7 indicated that Narcotic Count would also been performed during this time frame. S7 indicated 2 Psych Aides to provide care for 26 patients would not be adequate coverage.

During a face to face interview on 2/22/2011 at 9:55 a.m., Director of Nursing S2 indicated all Nursing Staff had been educated regarding the need to have at least one Registered Nurse on every clinical care unit during Code Blue calls (confirmed with record review) . S2 indicated he had not been aware that Registered Nurses had left the clinical units without Registered Nurse coverage during Hand Off Communication at the change of shift. S2 further indicated that he would think Registered Nurses would know if they could not leave clinical units unattended by a Registered Nurse during a Code Blue that it would not be acceptable to leave the unit without RN coverage during change of shift.

Review of the hospital policy titled, "Staffing Variances" presented by the hospital as their current policy revealed in part, "The nurse assesses the cumulative needs for patient care and determines the staffing needs based on professional judgment, experience, and an acquired sense of the relative care needs of patients. This is accomplished without forms or tools, using a combination of professional judgment and knowledge of current care models and staffing practices. Psychiatric mental health head nurses supervises and direct patient care and therefore, possess a critical front-line perspective of nursing practice problems, i.e. patient care, staffing, and organizational management concerns. Professional care is directed toward healing the patient, preparing the patient for return to normalcy, or managing the patient's personal challenges or family issues. . ."

Review of the hospital policy titled, "Hand Off, effective March 15, 2006" presented by the hospital as their current policy revealed in part, "Hand off communications shall take place whenever there is a change in the patient's/client's/resident's caregivers. caregivers shall include all clinical staff and physicians. . . "

2)
Review of Staffing for the date of 10/09/2010 revealed the 6:00 p.m. to 6:00 a.m. shift on Evangeline 4 to be staffed with one Registered Nurse and two Psych Aides. Further review revealed the census for Evangeline 4 on the date of 10/09/2011 was 25.

Review of the hospital's "Nursing Staff Variance Sheet" presented by the hospital as current revealed in part, Evangeline 4's required staffing for Day Shift (6:00 a.m. - 6:00 p.m.) was 1 Registered Nurse and 3 Psych Aides. Further review revealed the required staffing for Night Shift (6:00 p.m. - 6:00 a.m.) was 1 Registered Nurse and 3 Psych Aides.

During a face to face interview on 2/21/2011 at 9:55 a.m., Director of Nursing S2 indicated there had been a call in on the date of 10/09/2010 which had left Evangeline 4 understaffed. S2 further indicated there had been no staff that could have been pulled from other units at the time. S2 indicated one Psych Aide would have had to observe 12 patients and the other 13 patients. S2 confirmed the staffing of Evangeline 4 on the night shift of 10/09/2010 had been understaffed and it would be difficult for 1 Psych Aide to properly monitor 12 to 13 patients assigned to her care.





26458

Based on observation and interview the hospital failed to ensure the construction of the building was maintained at an acceptable level of quality by having an irregular shaped hole in the ceiling; measuring 4 feet by 3 feet, in the hallway leading from Cedarview to the hospital's Cafeteria for 1 of 2 Buildings reviewed (Cedarview). Findings:

Observations on 2/18/2011 at 11:20 a.m., revealed an irregular shaped hole in the ceiling; measuring 4 feet by 3 feet, located in the hallway leading from Cedarview to the hospital's Cafeteria. This finding was confirmed by Director of Nursing S2 at the time of the observation.

During a face to face interview on 2/21/2011 at 11:55 a.m., Acting Assistant Administrator S1 indicated the hospital had a proposal/plan to have the ceiling repaired in the Cedarview Building by the year 2013; although it would most likely be completed before that time. S1 indicated all patients housed in the building were currently being moved to another building and patients were being routed through a different entrance to enter the cafeteria; however, the hospital planned to re-house patients in the Cedarview Building after downsizing of the hospital was complete (date undetermined).





26458