HospitalInspections.org

Based on record review and interview, the Governing Body failed to ensure:

I. 28 patient bedrooms were free of ligature risks and clothing drawers that could be used to cause injury others, and
a lunch room that was secure and minimized the risk of a patient leaving without authorization (AWOL) which resulted in a failure to provide a safe environment. ( Refer to Tag A-0144)

II. policies were approved and appropriate for the specific services and functions provided by the hospital. (Refer to finding below).

III. the Quality Improvement Program developed and implemented measurable quality indicators that were tracked, data was monitored, analyzed, and used to improve process effectiveness, safety, and quality patient outcomes for the "critical incidents" from 01/18 to 04/18, and implemented distinct annual projects. (Refer to Tags A-0273, A-0283, A-0286, A- 0297, and A-0309)

IV. a policy was implemented that required formal consultations to be conducted with the Governing Body (or their designee) and the director of the Medical Staff (or staff responsible for the organization and conduct of the medical staff) on topics including, but not limited to: scope and complexity of hospital services, patient population serviced, identified issues with patient safety, and input of the Medical Staff at minimum biannually, and conduct consultative sessions per policy. (Refer to Tag A-0053)

V. appoint a qualified Infection Control Preventionist, who provided oversight for an effective Infection Control Program which included surveillance, report findings and quality improvement initiatives in accordance to acceptable standards of practice to improve health outcomes in the areas such as safe laundry processes. (See Tag: A-0748 and A-0749).

VI. Based on record review and interview, the Governing Body failed to ensure policies and procedures contained key components of RN coverage for addressing individuals' emergency care needs. (Refer to Tag A-0093)

These failed practices:
I. These failed practices had the likelihood for injury to staff and 16 patients on the acute unit on 07/17/18, who included two patients (Patient# 1 and 10) with aggressive behavior disorders (Patient #1 had punched multiple holes in the walls and hit another patient) and three patients (Patient # 4, 8, and 9 ) with a history of suicide, two AWOL patients on unit from 06/29/18 to 07/17/18. ( Refer to Tag A-0144)

II. had the likelihood for the staff not to implement the standards of practice expectations of the Governing Body for the services the hospital provided. (Refer to finding below).

III. resulted in the following events from 01/18 to 04/18: nine staff injuries, 13 patient injuries, five patient to staff injuries, 18 falls, 26 behavioral assaults, 11 therapeutic holds (no separate stats for chemical restraints), 10 seclusions, four medical emergencies, four elopements, and nine medication errors. and had the likelihood of continuing at these rates without the implementation of quality improvement measures.and the increase in events of therapeutic holds, chemical restraints, and seclusion from 27 in 2017 to 39 events from 01/18 to 06-18. (Refer to Tags A-0273, A-0283, A-0286, A- 0297, and A-0309).

IV. resulted in the lack of action plans being developed regarding the scope and complexity of hospital services, patient populations serviced, the identification patient safety and quality issues, and had the potential for other issues that required Medical Staff input to go unrecognized, unpursued, and result in missed quality opportunities to improve patient outcomes. (Refer to Tag A-0053).

V. had the likelihood for the Infection Control Program to lack effectiveness in areas, such as: development, surveillance, investigation of issues, implementation of preventative and control measures for the approximately 16 patients who receive care daily. (See Tag: A-0748 and A-0749).

VI. This failed practice had the likelihood that nursing assigments would be made without considerations for ensuring a qualified RN was available for individuals' emergency care needs 24/7 in a hospital without a dedicated emergency room. (Refer to Tag A-0093)

Findings:

Governing Body- Organizational Structure

A review of the "Bylaws of the Medical Staff (11/15)":
* defined the Governing Body as the Commissioner of the Department of Mental Health and Substance Abuse Services (ODMHSAS) for the State of Oklahoma.
* showed the medical staff was subject to the authority of the Director [physician responsible for supervision of psychiatric entities and supervision clinical staff who provide patient care services], and ultimate authority of the Commissioner of ODMHSAS.

A review of the document titled, "Organizational Chart 05/25/18" showed the Director of Medical Staff, Performance Improvement-Risk, Inpatient Service reported to Staff A, the Executive Director, who reported to Staff V, Deputy Commissioner of ODMHSAS.

From ODMHSAS website:
The ODMHSAS central administrative office in Oklahoma City provided administrative, coordinating, and planning functions for the statewide system. The Commissioner, Chief Operating Officer, and Deputy Commissioner oversaw operations specific to the Department's program areas, facilities operation and specialized support services. Staff V was identified as Deputy Commissioner, Treatment and Recovery Services, ODMHSAS.

II. Policies
A review of the document titled,"Acute Care Unit- Policy and Procedure Manual (Jan 2018)" showed Nortwest Center for Behavioral Health (NCBH) Inpatient Director had reviewed the policy and procedure manual and approved its content. The document was signed by Staff A, Executive Director and Staff C, the Acute care Unit Director. The document showed no evidence the Staff V, Deputy Comissioner of (ODMHSAS) had approved the policy and procedure manual.

On 07/24/18 at 1:31 pm, Staff G stated quality staff and the "Governing Body" reviewed policies and procedures. Staff G stated they referred policy matters to the Executive Committee as the Governing Body.

Based on record review and interview, the Governing Body failed to ensure:

I. a policy was implemented that required formal consultations to be conducted with the Governing Body (or their designee) and the director of the Medical Staff (or staff responsibile for the organization and conduct of the medical staff) on topics including, but not limited to: scope and complexity of hospital services, patient population serviced, identified issues with patient safety and quality that required participation and input of the Medical Staff at minimum biannually.

II. consultative sessions were conducted between the Governing Body (or their designee) and the director of Medical Staff as per policy.

These failed practices resulted in the lack of action plans being developed regarding the scope and complexity of hospital services, patient populations serviced, the identification patient safety and quality issues, and had the likelihood for other issues that required Medical Staff input to go unrecognized, unpursued, and result in missed quality opportunities to improve patient outcomes.

Findings:
I. Policy

On 07/16/18 at 2:00pm, the surveyors requested a policy that designated the requirements of formal consultations between the Governing Body and the director of Medical Staff, the topics to include, but not limited to: scope and complexity of hospital services, patient population serviced, and identified issues with patient safety and quality of care that required participation and input of the Medical Staff, and none was provided.

A review of the " Medical Staff By-laws (dated 11/15)" failed to address the duties and responsibilities of the Director of the Clinical Services, including conducting formal consultative sessions with the Governing Body at minimum biannually.

On 07/24/18 at 1:31 pm, Staff G stated the hospital had no policy that designated the requirements for formal consultative sessions between the Governing Body and the Director of the Clinical Services.

II. Consultative Sessions

A review of a document titled, "Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) and Medical Staff Meeting Minutes 01/18-05/18" showed no evidence of formal consultative sessions between the Board and Director of the Clinical Services regarding scope and complexity of hospital services, patient population serviced, and identified issues with patient safety and quality of care that required participation and input of the Medical Staff.

On 07/24/18 at 1:36 pm, Staff A, (CEO) stated no formal consultative sessions occurred between the Staff V, Governing Body and Staff M, Director of the Clinical Services.

Based on record review and interview, the Governing Body failed to ensure policies and procedures contained key components for RN coverage for addressing individuals' emergency care needs.

This failed practice had the likelihood that nursing assigments would be made without considerations for ensuring a qualified RN was available for individuals' emergency care needs 24/7 in a hospital without a dedicated emergency room.

Findings:

A review of policy titled, "Emergency Services (10/17)" failed to document a qualified RN would be available 24/7 to meet needs of individuals' presenting with emergency care needs.

On 07/16/18 at 1:38 pm, Staff A stated the hospital did not have a dedicated emergency room. Staff A stated RN was available 24/7, but would leave the in-patient unit to attend to a presenting individual with emergency care needs.

Based on record review, interview, and observation, the hospital failed to provide a safe physical environment which was free of ligature risks and items that could be used to injure others, and minimized the risk of a patient leaving without authorization (AWOL) as evidenced by:
I. 28 patient bedrooms contained 10 clothing drawers that posed ligature risks, and rooms 113,116, 119, and 122 had thermostats boxes on the wall that also posed such risk.

II. 28 patient bedrooms contained 10 clothing drawers that could be removed and thrown to inflict injury.

III. unsecured cafeteria door posed a risk for patients to be able to leave without proper authority.

These failed practices had the likelihood for injury to staff and 16 patients on the acute unit on 07/17/18, who included two patients (Patient# 1 and 10) with aggressive behavior disorders (Patient #1 had punched multiple holes in the walls and hit another patient, which resulted in his diagnosis and treatment for a fractured hand), and three patients (Patient # 4, 8, and 9 ) with a history of suicide, two AWOL patients on unit from 06/29/18 to 07/17/18.

Findings:

I & II Ligature & Throwning Objects Risks

A. Bedroom Drawers
On 07/19/18 at 9:30 am, surveyors observed wooden built-in clothing bureaus, consisting of 10 sliding, removable drawers in each of the 28 patient bedrooms.

On 07/24/18 at 12:44 pm, Staff A (CEO), stated in the past, leadership had discussed removing the clothing drawers in the patient bedrooms.

On 07/17/18 @ 10:56 am, Staff H stated he/she hadn't thought the drawers were a risk, but in the past, a male removed the drawers by tearing them off the track.

B. Thermostats Boxes

On 07/24/18 at 12:42 pm, Staff G stated leadership had discussed the removal of the thermostats in patient rooms.

On 07/19/18 at 9:13 am, surveyors observed a bathrobe hanging from the wall thermostat (like a clothing rack) in room 116, and observed other similar thermostat in bedrooms 113, 119, and 122.

III. AWOL Risk

A review of the documents titled, "Critical Incident Reports" from 01/18 to 04/18 showed four elopements.

On 07/16/18 at 12:30 pm, surveyors observed the door between the patient cafeteria and the administrative conference room was not capable of locking.

On 07/16/18 at 12:30 pm, Staff A stated he/she did not realize the door did not lock.

Based on record review and interview, the Governing Body failed to ensure the Quality Improvement Program:

I. developed and implemented measurable quality indicators, and data was tracked, analyzed for events, such as "critical incidents" from 01/18 to 04-18 and used to monitor effectiveness and safety. (Refer to Tag A-0273)

II. used data to monitor and improve process effectiveness, safety ,and quality patient outcomes for high volume, high risk, and problem prone issues through tracking and analysis for issues such as "critical incidents" from 01/18 to 04-18. (Refer to Tag A-0283)

III. defined program scope, activities, and executive responsibilites and expectations for safety to improve issues such as "critical incidents" from 01/18 to 04-18 involving aggressive /violent behavior, staffing issues, and elopement. (Refer to Tag A-0286)

IV. developed and implemented annual improvement projects, which reflected the scope and complexity of services provided. (Refer to Tag A- 0297)

V. designated executive responsibilities to include, but not limited to the implementation of distinct annual projects which improved patient safety, reduced medical errors, and adverse outcomes through measuring, analyze causes and implementing preventative actions and communicating lessons learned for "critical incidents" from 01/18 to 04-18 and evaluating the increase in events of therapeutic holds, chemical restraints, and seclusion from 27 in 2017 to 39 events from 01/18 to 06-18. (Refer to Tag A-0309)

These failed practices resulted in the following events from 01/18 to 04/18: nine staff injuries, 13 patient injury, five patient to staff injuries, 18 falls, 26 behavioral assaults, 11 therapeutic holds (no separate stats for chemical restraints), 10 seclusions, four medical emergencies, four elopements, and nine medication errors, and had the likelihood of these events' rates to re-occur or increase due to the lack of implementation of quality improvement measures.

Based on record review and interview, the Governing Body failed to ensure the Quality Improvement Program developed and implemented measurable quality indicators, and data was tracked, analyzed for events, such as "critical incidents" from 01/18 to 04-18 and used to monitor effectiveness and safety.

These failed practices resulted in the following critical incident events reported from 01/18 to 04/18: nine staff injuries, 13 patient injury, five patient to staff injuries, 18 falls, 26 behavioral assaults, 11 therapeutic holds (no separate stats for chemical restraints), 10 seclusions, four medical emergencies, four elopements, and nine medication errors, and had the likelihood of these events' rates to re-occur or increase due to the lack of implementation of quality improvement measures.

Findings:
I. Quality Indicators
A review of policy titled, "Critical Incident Reporting (date 03/10)" defined critical incidents as "sentinel event, adverse drug event, self-destructive behavior, death and injuries due to consumer, staff, and visitor, medication errors, consumer patient leaving without authorization (AWOL), consumer neglect or abuse, fire, unauthorized disclosure of information, damage to or theft of property, consumer sexual activity, and events of potential litigation.

A review of document titled, "Critical Incident Review Committee" showed the committee consisted of eight leaders from multiple facilities owned by the company including the acute care unit (being surveyed) and three other facilities including a drug and alcohol treatment unit, outpatient services, and a Transitional Residential Unit (TRU). The minutes from 10/17, 11/17, 02/21/17, and 05/16/18 showed the types and number of events that occurred, but failed to show evidence the events were evaluated, data trended, benchmarks defined, and improvement initiatives were developed. The minutes reflected combined data from the acute facility, and the TRU (not being surveyed). Restraints (chemical and physical holds) or seclusions were not a part of the Critical Incident Reporting.

II. Data Tracked

A review of the document titled, "NW Center for Behavior Health (NCBH) - Patient related Critical Incidents Reports and Staff Injuries (2017 and 01/18 through 06/18) " showed data for the following incidents: Patient Injury, Suicide Attempt, AWOL, Patient to Staff Injury, Medical Problem, Death post-discharge, Staff Injury, Medication Error, AWOL attempt, Sport Injury, Patient Falls, Death. Adverse Medication Reaction, Patient to Patient Injury, and Medical Emergencies. The report blended data rates, and it was documented in the note section: "This includes all reporting facilities of NCBH.

On 07/19/18 at 9:38 am, Staff G stated the Critical Incident Report contained data from both the acute unit (hospital being surveyed) and Transition Residential Unit (TRU).

III. Data Analyzed

A review of the document titled, "NCBH Performance Improvement Monitoring and Selection Criteria" showed communication of results of data collection, evaluation/conclusions, actions taken, and follow up, as appropriate, would be provided to the Performance Improvement Board, Executive Mangement Team, Program Directors and Supervisors, Department of Mental Health and Substance Abuse Services (ODMHSAS).

A review of the critical incident events reported from 01/18 to 04/18 showed peaks in events in the following months with no evidence that analysis was performed to address the increase in events and there was no evidence improvement action plans were developed. The peaks were as follows: nine falls in 01/18, seven behavioral assaults in 02/18, nine in 03/18, and six seclusions in 03/18.

A review of the "Executive Management Team Minutes" showed the team consisted of Executive Director and 10 leaders from multiple facilities owned by the company including acute care unit [being surveyed] and other facilities. The minutes from 01/11/18 through 06/21/18 documented regular reporting of the census for the acute care unit, but failed to discuss critical incidents data, and showed no evidence of data analysis.
The patient care topics of discussion were as follows:
01/11/18: Few ideas for addressing issues on unit with staff, such as cell phones, dress code, and work appropriate behavior
03/01/18: Patient accepted from [another facility] with health condition and [Staff O] instructed the procedure to follow.
03/08/18: "Shorthanded" due to resignations
04/12/18: Had five admission "back to back". Trying to get coverage.
05/19/18: RN's better at calling- in, but issues to Staff A.
05/31/18: Wanted better training for Physical Therapeutic Options for large, strong patients.

IV. Medication Errors
A review of a document titled, "Medication Error Analysis-Performance Improvement Outcomes" from 01/18 to 04/18 showed the occurence of eight medication errors from 05/18 to 06/18 four errors occurred (Total 12 errors); yet, the breakdown of errors on the same document showed two were omissions and seven were authorization issues. No evidence was provided to show the data was analyzed and an action plan was developed to improve the error rate.

A review of the document titled, "Critical Incident Review Committee 05/16/18" showed medication errors were "up" inspite of corrective actions taken to provide education. The document showed the Director of Nursing continued to provide medication administration education specific to the incident.

A review of nine incident reports regarding medication errors from 03/13/18 to 06/29/18 classified nine errors as follows:
*One- Unauthorization drug- wrong dose- incorrect administration
* One- Unauthorized drug- extra dose
* Two- Unauthorized drug- unordered medication
* One- Unauthorized drug- wrong time
* One- Omission
* Two- Omission-Documentation - transciption
* One- Documentation- transcription
Nine of nine incident reports were completed by a Licensed Professional Counelor (LPC) or Licensed Clinical Social Worker (LCSW), the descriptions of the events were often difficult to understand and insufficient to evaluate the circumstances and response to the event. The incident report failed to include nursing or pharmacy's investigation, analysis, and evaluation.

A review of policy titled, "Medication Error Procedure (01/18)" documented all medication errors would be submitted to the Nursing Coordinator after being addressed in morning report. The policy showed the report would be forwarding to the Pharmacy and Risk Manager. The policy failed to include nursing or pharmacy's investigation, analysis, and evaluation.

A review of the Nursing Staff Meeting Minutes from 06/19/18 showed Staff C, LPC instructed / reviewed the procedure for medication administration. The minutes documented nurses discussed some of the challenges that increased the risk of medication errors, "particularly interruptions". The minutes documented Staff C would remind the Direct Care Staff (mental health technicians) that there were to be "no interruptions when the Med Room door [was] shut". There was no evidence of investigation and analysis as to the type and significance of interruptions. There was no evidence nursing and pharmacy leadership participated in discussions on medication administration or addressed the challenges discussed by the nursing staff.

Based on record review and interview, the Governing Body failed to ensure the Quality Improvement Program used data to monitor and improve program effectiveness, patient safety and quality outcomes for high volume, high risk, and problem prone issues through tracking and analysis for events, such as "critical incidents" from 01/18 to 04-18, involving aggressive/violent behavior, staffing issues, and elopement.

These failed practices resulted in the following critical incident events reported 01/18 to 04/18: nine staff injuries, 13 patient injury, five patient to staff injuries, 18 falls, 26 behavioral assaults, 11 therapeutic holds (no separate stats for chemical restraints), 10 seclusions, four medical emergencies, four elopements, and nine medication errors, and had the likelihood of these events' rates to re-occur or increase due to the lack of implementation of quality improvement measures.

Findings:

Analysis & Reporting Process
A review of the document titled, "NW Center for Behavior Health (NCBH)- Patient related Critical Incidents Reports and Staff Injuries" from 2017 and 01/18 through 06/18 showed data for the following incidents: Patient Injury, Suicide Attempt, patient leaving without authorization (AWOL), AWOL attempt, Patient to Staff Injury, Staff Injury, Medical Problem, Death post-discharge,Medication Error, Sport Injury, Patient Falls, Death, Adverse Medication Reaction, Patient to Patient Injury, and Medical Emergencies. The report documented the data included all reporting facilities of NCBH (not just the acute facility being surveyed).

A review of the minutes for "01/17/18 ODMHSAS Performance Improvement Committee" showed the "Critical Incident Report" was reviewed and determined the number of incidents had been below the national average for critical incidents, and the committee discussed wanting to reach out to the facilities to get a better understanding of what happened.

On 07/24/18 at 1:09 pm, Staff A stated he/she would periodically receive a request for incident details from Staff W, Administration Program Coordinator, for specific critical incidents. Staff A provided responses to Staff W on 11/17-01/18, 02/18, 04/18, and 05/18. No evidence was provided to show Staff V, the Deputy Commissioner/ Governing Body participated in the quality review process.

A review of Staff' A's responses to the request for incident details from 11/17 to 01/18, 02/18, 04/18, and 05/18 involved 13 restraints, and 16 seclusions. Because the incidents reviewed had occurred at multiple NCBH sites and the locations were not consistently identified, it was difficult to discern which events occurred at the acute facility. Some of the restraint/seclusion events involved in Staff W's inquiry were also associated with aggressive /assault behavior; such as, patients punching holes in the unit walls, "tearing" up the unit, patient physical attacking another patient and punching their face, patient hitting and slapping another patient, and patient aggressively touching another patient, and the patient assaulting staff with a pencil.

Staff A's responses to the Administrative Program Director failed to show evidence of the development of improvement action plans, such as processes and policies evaluations, and videos reviewed critiquing de-escalation and restraint techniques by qualified personnel to objectively validate proper technique. The responses showed inconsistent documentation that debriefings were conducted or the association (if any) with events and staffing levels, and areas of improvement were not documented. Staff A's responses consistently showed the amount of time the patients were in holds and seclusion and that patients were stabilized and discharged.

On 07/24/18 at 2:05 pm, Staff C stated after an incident happen he/she got an email, reviewed the content of the email, asked questions, may or may not watch the video, and stated he/she never documented if the video was reviewed. Staff C stated he/ she did not review the medical record or talk to staff everytime, and that his/her response was based on the event.

On 07/24/18 at 1:31 pm, Staff G stated he/she provided oversight for incident reporting, but only reviewed the report to verify it for completion and not content. Staff G stated incident reports may be reviewed by Staff A, C, or O. Staff A stated the hospital needed to develop an incident review checklist so that review would be more consistent and thorough.

Based on record review and interview, the Governing Body failed to ensure the Quality Improvement Program defined program scope, activities, and executive responsibilities to improve patient safety issues as identified in "critical incidents" from 01/18 to 04-18, such as aggressive/violent behavior, staffing issues, and elopement.

These failed practices resulted in the following critical incident events reported 01/18 to 04/18: nine staff injuries, 13 patient injury, five patient to staff injuries, 18 falls, 26 behavioral assaults, 11 therapeutic holds (no separate stats for chemical restraints), 10 seclusions, four medical emergencies, four elopements, and nine medication errors, and had the likelihood of these events' rates to re-occur or increase due to the lack of implementation of quality improvement measures.

Findings:

Analysis & Reporting Process

A review of the document titled, "NW Center for Behavior Health (NCBH)- Patient related Critical Incidents Reports and Staff Injuries" from 2017 and 01/18 through 06/18 showed data for the following incidents: Patient Injury, Suicide Attempt, patient leaving without authorization (AWOL), AWOL attempt, Patient to Staff Injury, Staff Injury, Medical Problem, Death post-discharge, Medication Error, Sport Injury, Patient Falls, Death, Adverse Medication Reaction, Patient to Patient Injury, and Medical Emergencies. The report documented the data included all reporting facilities of NCBH (not just the acute facility being surveyed).

A review of the minutes for "01/17/18 Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS) Performance Improvement Committee" showed the "Critical Incident Report" was reviewed and determined the number of incidents had been below the national average for critical incidents, but the committee discussed wanting to reach out to the facilities to get a better understanding of what happened.

On 07/24/18 at 1:09 pm, Staff A stated he/she would periodically receive a request for incident details from Staff W, Administration Program Coordinator, from for specific critical incidents. Staff A provided responses to Staff W on 11/17-01/18, 02/18, 04/18, and 05/18. No evidence was provided to show Staff V, the Deputy Commissioner/ Governing Body participated in the quality process.

A review of Staff's A responses to the request for incident details from 11/17-01/18, 02/18, 04/18, and 05/18 showed 13 restraints, and 16 seclusions. Because the incidents reviewed occurred at multiple NCBH sites and the locations were not identified, it was difficult to discern which events occurred at the acute facility. Some of the restraint/seclusion events involved in Staff W inquiry were also associated with aggressive /assault behavior; such as, patients punching holes in the unit walls, "tearing" up the unit, patient physical attacking another patient and punching their face, patient hitting and slapping another patient, and patient aggressively touching another patient, and the patient assaulting staff with a pencil.

Staff A's responses to the Administrative Program Director failed to show evidence of the development of improvement action plans, such as processes and policies evaluations, and videos reviewed critiquing de-escalation and restraint techniques by qualified personnel to objectively validate proper technique. The responses showed inconsistent documentation that debriefings were conducted or the association (if any) with events and staffing levels, and areas of improvement were not documented. Staff A's responses consistently showed the amount of time the patients were in holds and seclusion and that patients were stabilized and discharged.

On 07/24/18 at 2:05 pm, Staff C stated after an incident happen he/she got an email, reviewed the content of the email, asked questions, may or may not watch the video, and stated he/she never documented if the video was reviewed. Staff C stated he/ she did not review the medical record or talk to staff everytime, and that his/her response was based on the event.

On 07/24/18 at 1:31 pm, Staff G stated he/she provided oversight for incident reporting, but only reviewed the report to verify it for completion and not content. Staff G stated incident reports may be reviewed by Staff A, C, or O. Staff A stated the hospital needed to develop an incident review checklist so that review would be more consistent and thorough.

I. Safety

A review of the critical incident events reported from 01/18 to 04/18 showed peaks in events in the following months with no evidence that analysis was performed or improvement action plans were developed to address the peaks in events. The peaks were as follows: nine falls in 01/18, seven behavioral assaults in 02/18 and nine in 03/18, and six seclusions in 03/18.

A review of the document titled, " Goals and Objectives 2018" included, but were not limited to the following goals:
"Ensure clients are afforded care in an environment free from safety and security risks". The method for reaching the goal was to provide a nonabusive environment, provide safety committee staff training, make preventative rounds and monitor. The time frame listed was from 07/01/17 to 06/30/18. The outcome documented the goals were not met, and the safety committee would continue to monitor. Patient injuries were up 50%.

A review of the "ACU/TRU Nurses and Direct Care (MHT) Meeting Minutes" from 01/18 to 06/18 showed the following discussion topics regarding safety:
* Staff C said "do not tell clients they are being discharged until orders received". RN in charge and "should control staff".
*A nurse wanted to know how to break up a fight between clients, and Staff C demonstrated.
* Staff A discussed importance of conducting 15 minute rounds, and said some staff were not doing rounds properly. Staff A instructed the nurses to be responsible for monitoring 15 minute rounds. Staff A said the round deficiencies were due to laziness, and lack of teamwork. Staff A instructed the RN to spend time in Aide station and not to stay in RN Office.
*(01/23/18) the minutes discussed importance of conducting 15 minutes rounds. The minutes documented that some staff members were not doing rounds properly. Staff C stated he/she randomly reviewed videos and infractions would be conducted. Staff C cautioned against becoming complacent and reminded staff that clients were admitted because they were a danger to themselves or others.
* Staff C stated for staff not to tell patients of discharge until order was written, because "it caused problems."

No evidence was provided that the issues identified in the meeting were followed by a quality action plan to solve them.

On 07/19/18 at 9:34 am, during a tour of the acute unit, the surveyor observed multiple holes in the walls of the unit. Staff C said Patient #1 had punched the holes in the walls.

A review of the medical record for Patient #1 showed on 07/17/18, the client got in an altercation with another peer, went to room punching walls, and "went after peer" and "ended up at ER with fractured wrist". The record showed on 07/17/18 at 4:26 pm, Patient #1 was placed on "Assault Precautions". On 07/23/18 at 3:00 pm, Staff H said there was no type of "assault precaution" other than every 15 minute observations.

A review of the video for 07/17/18 at approximately 4:26 pm showed Patient #1 and Patient #10 pacing back and forth in dayroom and bedroom hallway talking and yelling. Staff was seen trying to walk in a fashion to create a barrier between the two patients. At one point Patient #10 sat in a chair in the day room, and Patient #1 ran across the room, leaped and grabbed Patient # 10. Patient #1 began hitting patient #10 until staff pulling the two patients apart.

II. Staffing Issues

A review of the document titled, "Goals and Objectives 2018" included, but were not limited to the following goals:"
"Improve staff work attendance rates and decrease unscheduled call-ins to increase productivity and quality of services provided." The method for reaching the goal was to continue to review procedures, emphasize attendance, and commend staff on improvements. The time frame listed was from 07/01/17 to 06/30/18. The outcome documented the goals were met, and documented staff call-ins had decreased by 26%.

A review of the document titled, "June 2018 ACU/TRU Schedule" showed the following with no relief RN assigned:

06/02/18 (Sat), 06/03/18, 06/06/18 (Sat) 06/09/18 (Sat), 06/16/18, 06/17/18 (Sat) 06/23/18, 06/24/18 (Sat) 06/30/18
7am-3pm shift: 9 of 30 shifts with only one RN on duty
3 pm -11pm shift: 30 of 30 shifts with only one RN on duty
11pm-7am shift: 30 of 30 shifts with only one RN on duty
Five of nine shifts, which had only one RN on duty, with no RN relief occurred on a Saturday.

A review of the document titled, "July 2018 ACU/TRU Schedule" showed the following with no relief RN assigned:

07/01/18 (Sun), 07/04/18 (Sat) 07/07/18, 07/08/18, 07/13/18 (Sat), 07/14/18, 07/15/18, 07/16/18, 07/17/18 (Sun), 07/22/18, 07/28118 (Sun) 07/29/18
7am-3pm shift: 12 of 30 shifts with only one RN on duty for shift
3 pm -11pm shift: 30 of 30 shifts with only one RN on duty for shift
11pm-7am shift: 30 of 30 shifts with only one RN on duty for shift
Five of 12 shifts, which had only one RN on duty, with no RN relief occurred on weekends.

On 07/17/18 at 11:42 am, Staff J stated the RN must leave the unit to perform admission nursing assessment, which would leave the unit short staffed especially if the LPN was at another building on campus (TRU).

A review of the "Executive Management Team Minutes" showed the team consisted of Executive Director and 10 members from the Company's Leadership from acute care unit [being surveyed] other facilities. The minutes from 01/11/18 through 06/21/18 documented regular reporting of the census for the acute care unit, but failed to discuss critical incidents data, showed no evidence of data analysis.
The patient care topics of discussion were as follows:
01/11/18: Few ideas for addressing issues on unit with staff; cell phones, dress code, and work appropriate behavior
03/08/18: "Shorthanded" due to resignations
04/12/18: Had five admission "back to back". Trying to get coverage.
05/19/18: RN's better at calling in issues to Staff A.
05/31/18: Wanted better training for Physical Therapeutic Options for large, strong patients.

A review of the "ACU/TRU Nurses and Direct Care (MHT) Meeting Minutes" from 01/18 to 06/18 showed the following discussion topics.
*Emergency Training"-Staff C reminded the nurses that the RN on duty was responsible for both units [acute and TRU]".
* Staff C reported there had been recent concerns with staff leaving unit during shift and going to cars. Staff C said nurses needed to monitor staff closely.
*Cell phone use was banned. Staff A said cell phones were still being used, and stated if a RN allowed aide to leave unit, the RN must make sure duties were reassigned. Staff A said two incidents in which staff left unit to make a call prior to an incident. "If client appeared to be escalating, not leave unit short staffed." "If the RN is off-unit doing an admission and a client's behavior escalated, an aide should relieve the RN so [he/she] can handle the crisis on the unit." Staff A said an aide could sit with a new admission, but RNs were needed to handle behavioral situations on unit.
*Minutes documented some leave requests had to be declined due to short staff .

On 07/17/18 at 10:56 am, Staff H stated the unit was short staffed (due to RN quitting and another was on maternity leave). Staff H said the unit was short staffed especially on the weekends and when staff had to leave the unit for admissions or leave to administer medication in another building on campus. Staff H stated patients from jail could be difficult and the unit needed bigger, stronger male staff hired.

On 07/17/18 at 11:31 am, Staff I stated when the unit was short staffed, staff would be asked to work extra. Staff I stated the unit needed big and strong staff hired. Staff I said weekend staffing was "concerning", and he/she had been hit before by a patient.

On 07/17/18 at 11:50 am, Staff K stated the unit needed bigger and stronger male staff, and working weekends were hard due to short staffing.

III. Elopement

A review of the document titled, " Goals and Objectives 2018" included, but were not limited to the following goals:
'Minimize and reduce elopements, client/staff injuries, seclusion and retraint episodes." The method for reaching the goal was to continue Therapeutic Options [A therapeutic method of manaing patient aggression and violence]. The time frame listed was from 07/01/17 to 06/30/18. The outcome documented the goals were partially met with elopements occurring at two (an rate unchanged).

On 07/16/18 at 12:30 pm, surveyors observed the door between the patient cafeteria and the administrative conference room was not capable of locking.

On 07/16/18 at 12:30 pm, Staff A stated he/she did not realize the door did not lock.

Based on record review and interview, the Governing Body failed to ensure the Quality Improvement Program developed and implemented annual improvement projects, which reflected the scope and complexity of services provided.

These failed practices resulted in the following critical incident events reported 01/18 to 04/18: nine staff injuries, 13 patient injury, five patient to staff injuries, 18 falls, 26 behavioral assaults, 11 therapeutic holds (no separate stats for chemical restraints), 10 seclusions, four medical emergencies, four elopements, and nine medication errors, and had the likelihood of these events' rates to re-occur or increase due to the lack of implementation of quality improvement measures.

Findings:

A review of policy titled, "Performance Improvement Plan 01/25/18" failed to address the performance of annual quality improvement projects.

A review of document titled, "ODMHSAS Performance Improvement Committee" minutes from 01/17/18, 03/14/18, 05/16/18, showed no evidence of Performance Improvement Projects for 2018 performed for the hospital being surveyed.

On 07/19/18 at 10:26 am, in response to the request to provided evidence of Performance Improvement Projects for 2018, Staff G stated the hospital had not developed Performance Improvement Projects for 2018.

On 07/16/2018 12:52 pm, Staff A stated Performance Improvement (PI) and Utilitization Management did a special project every year. Staff A stated the directors made up the (PI) board, and they met every month. Staff A stated the Board would ask about PI projects periodically. Staff A stated the hospital sends restraints and critical incidents to the Oklahoma Department of Mental Health Substance Abuse and Services (ODMHSAS), and that information should be reflected in their minutes.

Based on record review and interview, the Governing Body failed to ensure the Quality Improvement Program
designated executive responsibilities to include, but not limited to the implementation of distinct annual projects which improved patient safety, reduced medical errors, and adverse outcomes through measuring, analyze causes and implementing preventative actions and communicating lessons learned for "critical incidents" from 01/18 to 04-18 and evaluating the increase in events of therapeutic holds, chemical restraints, and seclusion from 27 in 2017 to 39 events from 01/18 to 06-18.

These failed practices resulted in the following critical incident events reported 01/18 to 04/18: nine staff injuries, 13 patient injury, five patient to staff injuries, 18 falls, 26 behavioral assaults, 11 therapeutic holds (no separate stats for chemical restraints), 10 seclusions, four medical emergencies, four elopements, and nine medication errors, and had the likelihood of these events' rates to re-occur or increase due to the lack of implementation of quality improvement measures.

Findings:

I. Governing Board / Executive Committee

A review of document titled, "Oklahoma Department Mental Health Substance Abuse Services (ODMHSAS) Performance Improvement Committee" minutes from 01/17/18, 03/14/18, and 05/16/18 discussed critical incidents at a statewide level and national rates. The meetings did not show evidence that specific quality improvement information for the hospital being surveyed was discussed.

A review of the minutes for "01/17/18 ODMHSAS Performance Improvement Committee" showed the "Critical Incident Report" was reviewed and determined the number of incidents had been below the national average for critical incidents, but the committee discussed wanting to reach out to the facilities to get a better understanding of what happened.

On 07/17/18 at 8:19 am, Staff A stated contracts, physician/ provider credentialing, critical incidents, medical errors, and elopement get reported to ODMHSAS.

On 07/16/18 at 2:46 pm, Staff A provided surveyors the documents titled, "Executive Management Team Minutes" and stated "here are the Governing Body Minutes".

On 07/19/18 at 9:52 am, Staff G stated the Executive Committee was equal to Governing Body, but said the hospital was accountable to the Board of Health. Staff G stated the Executive Committee Minutes could seem confusing with data from multiple facilities.

On 07/24/18 at 1:09 pm, Staff A stated he/she would periodically receive a request for incident details from Staff W, Administration Program Coordinator, for specific critical incidents. Staff A provided responses to Staff W on 11/17-01/18, 02/18, 04/18, and 05/18. No evidence was provided to show Staff V, the Deputy Commissioner/ Governing Body participated in the quality process.

A review of Staff's A responses to the request for incident details from 11/17-01/18, 02/18, 04/18, and 05/18 showed 13 restraints, and 16 seclusions. Because the incidents reviewed occurred at multiple NCBH sites and the locations were not identified, it was difficult to discern which events occurred at the acute facility. Some of the restraint/seclusion events involved in the Staff W inquiry were also associated with aggressive /assault behavior; such as, patients punching holes in the unit walls, "tearing" up the unit, patient physical attacking another patient and punching their face, patient hitting and slapping another patient, and patient aggressively touching another patient, and the patient assaulting staff with a pencil. No evidence was provided that Staff W requested details for the 12 medication errors that occurred from 01/18 to 06/18.

Staff A's responses to the Administrative Program Director failed to show evidence of the development of improvement action plans, such as processes and policies evaluations, and videos reviewed critiquing de-escalation and restraint techniques by qualified personnel to objectively validate proper technique. The responses showed inconsistent documentation that debriefings were conducted or the association (if any) with events and staffing levels, and areas of improvement were not documented. Staff A's responses consistently showed the amount of time the patients were in holds and seclusion and that patients were stabilized and discharged..

II. Performance Improvement (PI)
A review of policy titled, "Performance Improvement Plan 01/25/18" documented each reporting area was responsible to use Plan (the change) -Do (the plan) -Study (the results) -Act (on the new knowledge) (PDSA) method of PI; however, further explanation of the method only discussed monitoring and reporting. The policy failed to address the performance of annual quality improvement projects.

A review of the document titled, "NW Center for Behavior Health (NCBH)- Patient related Critical Incidents Reports and Staff Injuries" from 2017 and 01/18 through 06/18 showed data for the following incidents: Patient Injury, Suicide Attempt, patient leaving without authorization (AWOL), AWOL attempt, Patient to Staff Injury, Staff Injury, Medical Problem, Death post-discharge, Medication Error, Sport Injury, Patient Falls, Death, Adverse Medication Reaction, Patient to Patient Injury, and Medical Emergencies. The report documented the data included all reporting facilities of NCBH (not just the acute facility being surveyed).

On 07/17/18 at 8:09 am, Staff A stated ODMHSAS Board of Commissioner met monthly. Staff A stated restraint/seclusion data, credential matters, critical issue get reported to PI monthly and QAPI project established.

A review of a document titled, "Medication Error Analysis-Performance Improvement Outcomes" from 01/18 to 04/18 showed the occurence of eight medication errors and from 05/18 to 06/18 four errors occurred (Total 12 errors). The breakdown of errors on the same doocument showed two were omissions and seven were authorization issues. No evidence was provided to show the data was analyzed and an action plan was developed to improve the error rate.

A review of the "Pharmacy and Therapeutic (P &T) Committee Meeting Minutes" for 11/17, 01/18, 03/18, and 05/18 showed no discussions regarding medication errors.

On 06/25/18 at 8:03 am, Staff Q, Pharmacist, stated incident reports involving medication were reviewed by nursing and sent to the pharmacist, and the information was included on the Pharmacy and Therapeutics (P & T) Report. Staff Q stated he/she was surprised that he/she was not involved in reviewing the medication associated incidents, and felt pharmacy should be involved.

Based on document review, interview, and observation, the hospital failed to provide adequate Registered Nurse (RN) staff on the day, evening, and night shifts to meet the needs of the patients on the Acute Care Unit (ACU) especially for the aggressive / violent patient, and to provide supervision for non-professional nursing personnel under the their direction.

This failed practice had the likelihood for the care needs of an average of 16 patients on the acute unit to go unmet due to lack of RN supervision in active treatment, nursing activities, and the supervision of non-professional nursing personnel.

Findings:

I. Staffing Patterns and Issues

A review of the document titled, " Goals and Objectives 2018" included, but was not limited to the following goals:"
"Improve staff work attendance rates and decrease unscheduled call-ins to increase productivity and quality of services provided." The method for reaching the goal was to continue to review procedures, emphasize attendance, and commend staff on improvements. The time frame listed was from 07/01/17 to 06/30/18. The outcome documented the goals were met, and documented staff call-ins had decreased by 26%.

A review of the document titled, "June 2018 ACU/TRU Schedule" showed the following RN staffing deficiencies with no relief RN assigned:

06/02/18 (Sat), 06/03/18, 06/06/18 (Sat) 06/09/18 (Sat), 06/16/18, 06/17/18 (Sat) 06/23/18, 06/24/18 (Sat) 06/30/18
7am-3pm shift: 9 of 30 shifts with only one RN on duty
3 pm -11pm shift: 30 of 30 shifts with only one RN on duty
11pm-7am shift: 30 of 30 shifts with only one RN on duty
Five of nine shifts, which had only one RN on duty, with no RN relief occurred on a Saturday.

A review of the document titled, "July 2018 ACU/TRU Schedule" showed the following with no relief RN assigned:

07/01/18 (Sun), 07/04/18 (Sat) 07/07/18, 07/08/18, 07/13/18 (Sat), 07/14/18, 07/15/18, 07/16/18, 07/17/18 (Sun), 07/22/18, 07/28118 (Sun) 07/29/18
7am-3pm shift: 12 of 30 shifts with only one RN on duty for shift
3 pm -11pm shift: 30 of 30 shifts with only one RN on duty for shift
11pm-7am shift: 30 of 30 shifts with only one RN on duty for shift
Five of 12 shifts, which had only one RN on duty, with no RN relief occurred on weekends.

On 07/17/18 at 11:42 am, Staff J stated the RN must leave the unit to perform admission nursing assessment, which would leave the unit short staffed especially if the LPN was at another building on campus (TRU).

A review of the "Executive Management Team Minutes" showed the team consisted of Executive Director and 10 members from the Company's Leadership from acute care unit [being surveyed] other facilities. The minutes from 01/11/18 through 06/21/18 documented regular reporting of the census for the acute care unit, but failed to discuss critical incidents data, showed no evidence of data analysis.
The patient care topics of discussion were as follows:
01/11/18: Few ideas for addressing issues on unit with staff such as cell phones, dress code, and work appropriate behavior
03/08/18: "Shorthanded" due to resignations
04/12/18: Had five admission "back to back". Trying to get coverage.
05/19/18: RN's better at calling in issues to Staff A.
05/31/18: Wanted better training for Physical Therapeutic Options for large, strong patients.

A review of the "ACU/TRU Nurses and Direct Care (MHT) Meeting Minutes" from 01/18 to 06/18 showed the following discussion topics.
*Emergency Training- --"Staff C reminded the nurses that the RN on duty was responsible for both units [acute and TRU]".
* Staff C reported there had been recent concerns with staff leaving unit during shift and going to cars. Staff C said nurses needed to monitor staff closely.
*Cell phone use was banned. Staff A said cell phones were still being used, and stated if a RN allowed aide to leave unit, the RN must make sure duties were reassigned. Staff A said two incidents in which staff left unit to make a call prior to an incident. "If client appeared to be escalating, not leave unit short staffed." "If the RN was off-unit doing an admission and a client's behavior escalated, an aide should relieve the RN so [he/she] can handle the crisis on the unit." Staff A said an aide could sit with a new admission, but RNs were needed to handle behavioral situations on unit.
*Minutes documented some leave requests had to be declined due to short staff .

On 07/17/18 at 10:56 am, Staff H stated the unit was short staffed (due to RN quitting and another was on maternity leave). Staff H said the unit was short staffed especially on the weekends and when staff had to leave the unit for admissions or leave to administer medication in another building on campus. Staff H stated patients from jail could be difficult and the unit needed bigger, stronger male staff hired.

On 07/17/18 at 11:31 am, Staff I stated when the unit was short staffed, staff would be asked to work extra. Staff I stated the unit needed big and strong staff hired. Staff I said weekend staffing was "concerning", and he/she had been hit before by a patient.

On 07/17/18 at 11:50 am, Staff K stated the unit needed bigger and stronger male staff, and working weekends were hard due to short staffing. Staff K stated RN left unit to perform admissions assessments, and if the patient was a male, the MHT would also leave and be gone from the unit for at least 20 minutes. Staff K stated the unit needed bigger and stronger male staff, and working weekends were hard due to short staffing.

On 07/14/18 10:08 am, Staff H stated because of a RN call-in, the acute unit had one RN working on day shift for 23 patients. Staff H stated the RN must leave the unit for a 10:30 am Group Meeting and for bathroom and lunch breaks.

On 07/16/2018 12:52 PM, Staff C stated there was one RN on duty during a shift, that RN would fulfill the in-patient charge nurse role during that time, and there was no house supervisor.

II. Aggressive / Violent Patients

A review of the medical record for Patient #1 showed on 07/17/18, the client got in an altercation with another peer, went to room punching walls, and "when after peer" and "ended up at ER with fractured wrist". The record showed on 07/17/18 at 4:26 pm, Patient #1 was put on "Assault Precautions". On 07/23/18 at 3:00 pm, Staff H said there was no type of "assault precaution" other than every 15 minute observations.

A review of the video for 07/17/18 at approximately 4:26 pm showed Patient #1 and Patient #10 pacing back and forth in dayroom and bedroom hallway talking and yelling. Staff was seen trying to walk in a fashion to create a barrier between the two patients. At one point Patient #10 sat in a chair in the day room, and Patient #1 ran across the room, leaped and grabbed Patient # 10. Patient #1 began hitting patient #10 until staff pulling the two patients apart. (Patient #1 was subsequently diagnosed and treated for a fractured hand).

On 07/19/18 at 9:34 am, during a tour of the acute unit, the surveyor observed multiple holes in the walls of the unit. Staff C said that Patient #1 had punched the holes in the walls.

On 07/17/18 at 11:50 am, Staff K stated the unit needed bigger and stronger male staff, and working weekends were hard.

On 07/17/18 at 10:56 am, Staff H stated patients from jail could be difficult and needed bigger, stronger male staff hired.

On 07/17/18 at 11:31 am, Staff I stated the unit needed big and strong staff hired, and and he/she had been hit before.

Based on record review, interview, and observations, the hospital failed to ensure the Registered Nurse (RN) :

I. performed a comprehensive admitting physical nursing assessment for six (Patients # 13,14,16,17, and 18) of six patients admitted to the acute care unit from 04/05/18 to 07/12/18.

II. physician / provider were notified for changes in patient conditions in a timely manner for three (Patient #1, 14 and 18) of six patients, and four (Patient #1, 14, 16 and 18) of six patients were assessed and monitored after an event, such as an injury, fall, lab changes, or bleeding from 04/18 to to 07/18.

III. was aware the location and condition of the patients under their supervision in one (Patient # 14) of two patients as evidenced by video review.

These failed practices had the likelihood to affect patient's safety due to lack of assessments, monitoring, timely recognition of deterioration, and physician notification of condition changes.

Findings:

I. Admission Physical Assessments
A review of policy titled, "Nursing Assessment (02/18)" documented within 24 hours of admission, a RN must perform a comprehensive assessment including, but not limited to: a physical assessment- cardiovascular, respiratory, urinary system, and digestive system. The assessment policy failed to provide guidance regarding the components to be assessed in each system. A neurology assessment was not included on the assessment form.

A review of the document titled, "Oklahoma Board of Nursing- Patient Assessment Guidelines (11/16)" showed the comprehensive nursing assessment is conducted by a Registered Nurse and is an extensive data collection (initial and ongoing) for individuals, and the data collection addresses anticipated and emergent changes in the client's health status, recognizes alterations from the client's previous condition, synthesizes the biological aspects of the client's condition, evaluates the impact of nursing care.

A review of the medical record showed the following physical assessment:
Patient #1:
History of major depressive disorder with psychosis, anxiety, Diabetes II, hepatitis C, IV drug abuse
Admitted on 07/12/18: Cardiovascular: "sharp pain in chest intermittently", Respiratory "no complaints", Urinary; "flow decreased- frequent UA [urination]", Digestive: "denies"

Patient #13:
History of borderline personality disorder, hypertension, diabetes II, drug and alcohol abuse, hyperlipidema
Admit 04/05/18: Cardiovascular: "HTN" (hypertension) BP 112/68 P 89, Respiratory "unlabored"- Urinary; "unknown", Digestive: 'unknown"

Patient #14:
History of endometriosis, fibromyalgia, chronic pain (aches all over)
Admitted 07/09/18 Cardiovascular, Respiratory, Urinary system, and Digestive system were all documented as "denies abnormalities".

Patient #16:
History of schizophrenia, Charles Bonnet Syndrome [a type of psychophysical visual disturbance and the experience of complex visual hallucinations in a person with partial or severe blindness], left eye blindness
Admitted 05/17/18: Cardiovascular, Respiratory, Urinary system, and Digestive system were all documented as "denies abnormalities". No visual assessment was performed.

Patient # 17
History of schizoaffective disorder, psychosis, hypertension, gastric esophageal reflux, cataracts, and intellectual disability secondary to hypoxia in infancy
Admitted: 06/28/18: Cardiovascular "heart murmur- RR" [regular, rate, and rhythm], Respiratory "denies", Urinary system "sometimes", and Digestive system "constipation and diarrhea".

Patient # 18
History of Major depression with sever psychotic feature, cardiovascular accident, rotator cuff tear, colostomy, restless leg syndrome, foot drop, coronary artery disease, obstructive sleep apnea, chronic neck and back pain
Admitted: 05/01/18: Cardiovascular "no problems now", Respiratory "none" , Urinary system "none", and Digestive system "none". The patient had a history of a sigmoid colectomy with colostomy secondary to colovaginal fistula which was not addressed in the digestive or skin assessment.

07/14/18 10:08 am Staff H stated the hospital did not provide instructions regarding physical examinations at hire, and nurses do not do a neurological assessment on patients at admission.

II. Timely Physician Notification, and Assessment/Monitoring for Change of Condition
A review of policy titled, "Nursing Assessment (02/18)" documented patients needed and progress were continually reassess with nursing care plan changes occurring as their needs changed, and such observations and changes would be documented in the medical record.

On 07/14/18 10:08 am, Staff H stated the hospital had no policy for changes in patient's condtion, to include, but not limited to physician notification.

On 07/24/2018 12:39 pm, Staff A stated the hospital had no requirements for nursing assessments after initial assessment.

A review of the medical records showed a lack of nursing assessments/monitoring and delays in physician notification of changes in patient conditions, as follows:
Patient #1
A. Injury and Pain
On 07/15/18 at 4:30 pm, Paitent #1 became angry with a peer, and started going down men's hall punching the wall resulting in five holes in wall. Patient #1 went into his bedroom and punched two holes in the wall and began pulling out the sheetrock. The nuring note documented the doctor came to check Patient #1 arm for injury and pain medication was ordered. The record showed no assessment of the patients hand or arm.

On 07/16/18 at 2:50 am, Patient # 1 was given Norco for complaint of pain the right wrist. No assessment of wrist and no description of the pain quality or severity.

On 07/16/18 at 6:30 am, Patient # 1 was given Motrin for complaint of pain the right wrist. No assessment of wrist and no description of the pain quality or severity.

On 07/16/18 at 3:30 pm and 5:25 pm, Patient # 1 was given Motrin for complaint of pain the right wrist. No assessment of wrist and no description of the pain quality or severity.

On 07/17/18 at 2:30 am, Patient #1 was given Motrin for complaint of pain the right wrist. No assessment of wrist and no description of the pain quality or severity.

On 07/17/18 at 3:55 pm, Patient #1 began hitting walls and "attacked" another patient. The nursing note showed Patient #1 "had a swollen hand", and was examined by the provider, but provided no assessment of the hand or evaluation of pain. Subsequently, the patient was sent to another facility for evaluation of the hand, and returned at 8:15 pm with the diagnosis of fractured hand which was splint casted. There was no evidence the physician was notified of Patient #1's return and diagnosis and no orders were provided regarding the treatment for the hand.

From 07/17/18 at 6:15 pm until discharge 07/19/18, Patient #1 received pain medication multiple times for complaint of pain the right wrist. No assessment of wrist and no description of the pain quality or severity.

On 07/19/18 at 8:18 am, surveyors observed Patient #1 approached the drug room door, told Staff I the splint cast was hot and said the physician said he could remove the splint. Staff I assisted the patient in removing the splint and performed no assessment of the hand. There was no order for splint removal.

On 07/25/18 at 7:37 am, Staff M stated the physician should have been notified of the patient's return and new orders should have been written for care of the hand. Staff M stated the splint should not have been removed.

On 07/24/18 at 2:05 pm, Staff C stated Patient #1 should have been assessed after returned from the emergency department with a splint, and said Staff I did not follow the correct hospital process.

B. Diabetes
(A review of policy titled, "The Diabetes Patient (08/17)" failed to define finger stick blood sugar result parameters for notifiying physicians. ).

On 07/13/18 and 07/14/18 both at 7:00 am, Patient #1's finger stick blood sugar results were 101 mg/dl, and on 07/15/18 at 7:00 am was 265 mg/dl (normal approximately 99). The record failed to show evidence the physician was notified of the increase in blood sugar.

On 07/24/18 9:18 am, Staff D stated the hospital had no protocols regarding notification parameters for finger stick blood sugars. Staff D said if a patient's blood sugars was over 200, "we try to take action", but he/she had not provided education for the nurses to call if the BS was over 200.

On 07/24/2018 9:18 am, Staff H stated that something, somewhere told nurses to notify the physician if a patient's blood sugar was above 300.

On 07/25/18 at 7:37 am, Staff M stated nurses should notify the doctor if finger stick blood sugars were less than 100 or greater than 400.

Patient # 14
A. Pain
On 07/09/18 at 7:25 pm, admitting orders included: Actaminophen 325 mg 1-2 tabs PO (by mouth) every 4 hours PRN, or Motrin 400 mg PO every 4 hours PRN pain...

On 07/14/18 at 12:35 pm, Patient #14 complained of a headache and received Motrin and at 2:40 pm, complained of headache and received Tylenol. (patient got one hour post administration assessment and patient had no pain.) No pain scale was used to describe severity, and there was no documentation regarding the location and quality of the pain.

On 07/15/18 at Patient #14 complained of a headache at 7:30 am, 2:24 pm, 7:35 pm and received Motrin, complained of headache at 10:07 am and received Tylenol (patient got one hour post administration assessment and patient had no pain.) No pain scale was used to describe severity, and there was no documentation regarding the location and quality of the pain.

On 07/17/18, Patient #14 complained of a headache at 6:30 am, and received Motrin, and at 11:00 am complained of body ache and recived Tylenol. No pain scale was used to describe severity, and there was no documentation regarding the location and quality of the pain.

A review of an incident from 07/17/18 at 3:45 pm by Staff D, a provider, showed Patient #14 was found unresponsive in day room on floor, and complained of a throbbing headache and wrote an order the patient may have Tylenol or Motrin as ordered. The medical record failed to show evidence the provider was notified of the patient's increased need for medication for headaches.

B. Neurochecks
On 07/17/18 at 4:45 pm, Staff D ordered neurochecks every 15 mins x4 every 30 min x2 hourly x4 the every shift.

A review of Patient #14's "Nurses- Neurological Flow Sheet" showed neurocheck were completed on 07/17/18 at 8:00 pm, 07/18/ 18 at 7:00 am and 10:00 am, and provided no evidence the patient was monitored in accordance to the provider's neurochecks order.

On 07/24/2018 9:18 am, Staff D, provider, stated when on duty, he/she would verify neurochecks were being done as ordered.

Patient # 16
A. Post Fall
On 05/23/18 at 4:50 pm, Patient #16 fell and hit head on the floor and at 5:00 pm fell hitting the wall. The record documented Patient #16 had a non raised red area 2 cm x 2 cm, but failed to address the location of the injury, and did not not perform neuro check, or pain assessment. There was no subsequent evaluation of the reddened area.

On 07/24/2018 2:05 pm, Staff C stated Patient #16 was actively hallucinating, very mobile, and bumping things. Staff C stated part of the time appeared to be ducking things he saw and threatened by and that is how the fall occurred. Staff C said he/she reviewed the video of the fall, and it did not seem to a medical issue it was a psychosis issue.

Patient #18
A. Bleeding
On 04/30/18 Patient #18 was admitted, and had a history of a sigmoid colectomy with colostomy secondary to colovaginal fistula.

On 05/01/18 at 12:15 am, Staff X, patient care assistant (PCA) documented the patient assisted to the bathroom, and noticed a "fair" amount of brown substances and "trace" amount of bright red blood on her pad and underwear, which appeared to be coming from her rectum. Staff X documented he/she notified the RN. At 7:00 am, Staff X documented seeing brown substance and blood from rectum. There was no evidence a RN assessed the patient and notified the physician. The next physican record entry regarding bleeding and coordinating a tranfer was 05/01/18 at 11:00 am.

On 05/01/18 at 10:30 am, Staff Z, RN, documented a "Group Note" showing the patient did not attend the session, but, performed no assessment of the patient, whose bleeding was a change of condition. On 05/01/18 5:08 pm, Patient #18 was transferred to a higher level of care by ambulance.

On 07/25/18 at 7:37 am, Staff M stated nursing staff should have notified the provider at night, because patient was not medically stable and he/she was always available if needed.

B. Pain
On 04/30/18 at 3:50 am, Patient #18 complained of "nerve pain", and received pain medication. (Patient got one hour post administration assessment and patient had no pain.) No pain scale was used to describe severity, and there was no documentation regarding the location and quality of the pain.

On 04/30/18 at 3:43 pm, Staff J, patient care assistant, documented the patient was laid down after lunch because he/she was in pain and could not sit for long periods of time.

On 04/30/18 at 8:00 pm, Patient #18 complained of muscle pain and stiffness and received pain medication. (Patient got one hour post administration assessment and patient had no pain.) No pain scale was used to describe severity, and there was no documentation regarding the location and quality of the pain.

On 05/01/18 at 10:00 am, Patient #18 complained of "pain", and received pain medication. (Patient got one hour post administration assessment and patient had pain "less less severe".) No pain scale was used to describe severity, and there was no documentation regarding the location and quality of the pain.

III. Patient Supervision
A review of policy titled, "Fifteen Minute Unit Rounds/Special Precaution Rounds (09/17)" documented patients while at the acute care unit, would be observed closely and all activities, on and off the units, staff will be supervised in order to ensure interactions are therapeutic and and strictured.

A review of the incident report for 07/17/18 at 3:45 pm for Patient # 14 showed code blue staff arrived to find patient on floor, and found the patient's eye lids rapidly side to side. The report documented within a few moments, Patient # 14 was able to get to the couch with minimal assistance, was awake and cohorent, and the patient reported having episode of passing out since teen and was unsure of the etiology. The report did not indentify the staff's lack of assessment of the environment momentarily as they walked past the patient on the floor and headed to an outside door.

On 07/25/17 at 1:10 pm, surveyors observed the video for the incident of Patient #14 on 07/17/18 at 3:45 pm. The video showed Patient #14 sitting on the couch in the day room, and fell forward onto the floor. Another patient yelled "[Patient #14's name} down". Two staff members, who were standing at the nearby nursing station, were observed heading towards a door to the outside within feet of Patient #14 (lying on the floor) Another staff at the side station said "she is right there!", and pointed to where Patient #14 was lying.

On 07/25/17 at 1:10 pm, Staff C stated the staff thought Patient # 14 was outside. Staff C stated he/she had not reviewed the video prior to 07/25/18.

On 07/19/18 at 9:52 am, Staff G stated the hospital had no policy regarding when video should be reviewed.



















































+

Based on record review, interview, and observation, the hospital failed to administer medication in accordance with acceptable standard of practice.

This failed practices resulted in nine medication errors as evidenced by Critical Incident Report events from 01/18 to 04/18, and the likelihood to increase the risk of medication errors for the approximately 16 patients per day in the acute care unit.

Findings:

A review of a document titled, "Medication Error Analysis-Performance Improvement Outcomes" from 01/18 to 04/18 showed the occurence of eight medication errors and from 05/18 to 06/18 four errors occurred (Total 12 errors); yet, the breakdown of errors on the same document showed two were omissions and seven were authorization issues. No evidence was provided to show the data was analyzed and an action plan was developed to improve the error rate.

A review of policy titled, "Medication Administration (05/17)" instructed staff to immediately note the time and initial medications that had been administered in Mediation Administration Record (MAR). The policy showed if a patient refused medication, the refusal should be documented in the patient's medical record in the progress note. The policy showed if drugs were omitted or refused, the time should be circled and a 'R" written wihin the circle to indicate refusal.

On 07/19/18 at 8:18 am, surveyors observed a medication pass on the acute unit. Staff I was assigned as medication nurse. Surveyors observed Staff I preparing medications for 14 patients. Staff I was seen removing medication from stock bottles, placed removed pill(s) in a paper medicine cup, then would sign out medication on the medication administration record (MAR) before administration of medication.

On 07/19/18 at 9:00 am, Patient #4 unsuccessfully attempted to swallow a large size pill of fish oil. Staff I had initialed the MAR, which indicated the medication had been administered.

On 07/25/2018 10:08 am, Staff H reviewed the progress note for Patient #4 and stated the progress note contained no documented of Patient #4's ability to swallow pill. Upon review of the MAR, in the presence of the surveyor, Staff H, and Staff I, Staff I changed the initial to an"0" and stated he/she will write "0" or "R" if a patient refused medication.

Based on record review and interview, the hospital to ensure expired medications were unavailable for use in an emergency kit in the in-patient drug room.

This failed practice increased the risk that patients, requiring emergency medication(s), would be administered out-of date medication.

Findings:
On 07/24/18 at 12:13 pm, surveyors observed in the in-patient medication room, a small bag, which Staff I identified as an emergency bag. The bag contained two geodon (a medication used for the treatment of schizophrenia and manic symptoms of bipolar disorder) expired (06/18). Staff I stated it was the pharmacist's responsibility to monitor and replace expired medications in the bag.

On 06/25/18 at 8:03 am, Staff Q stated he/she did not know the emergency kit existed, or it was his/her responsibility to monitor the kit for expired medication.

Based on record review and interview, the Governing Body failed to ensure:

I. a safe physical environment was provided that was free of ligature risks and items that could be used to injury others, and minimized the risk of a patient leaving without authorization (AWOL) as evidenced by:
A. 28 patient bedrooms contained 10 clothing drawers that posed ligature risks, and patient rooms 113,116, 119, and 122 had thermostats boxes on the wall that also posed such risk.

B. 28 patient bedrooms contained 10 clothing drawers that could be removed and thrown to inflict injury.

C. unlocked cafeteria door posed a risk for patients to be able to leave without proper authority.

These failed practices had the likelihood for injury to staff and 16 patients on the acute unit on 07/17/18, who included two patients (Patient# 1 and 10) with aggressive behavior disorders (Patient #1 had punched multiple holes in the walls and hit another patient, which resulted in his diagnosis and treatment for a fractured hand), and three patients (Patient # 4, 8, and 9 ) with a history of suicide, two AWOL patients on unit from 06/29/18 to 07/17/18.
( Refer to Tag A-0144)

Based on record review and interview, the hospital failed to appoint an Infection Control Preventionist (ICP) that was qualified to develop and implement the hospital infection control program.

This failed practice had the likelihood of increased risk that the Infection Control Program would be inadequately developed and implemented due to the ICP's lack of infection control training such as in surveillance, prevention, and control.

Findings:

A review of policy titled, "Infection Control 01/28/18" documented the Executive Director should appoint an Infection Control Nurse who would develop and implement a formal, systematic infection control program.

A review of policy titled, "Job Descriptions: Members of the [IC] Committee 02/01/18" showed ICP must maintain continued education and inservice training related to surveillance, prevention, and control.

A review of document titled, "Infection Control Meeting Minutes 04/26/18" showed Staff D was appointed as Infection Control Preventionist in the absence of Staff O, who was on maternity leave.

A review of the personnel file for Staff D showed no training specific to fulfill the role of ICP, and contained no infection control training.

A review of the personnel file for Staff O showed only hand hygiene training from Association for Profession in Infection Control and Epidemiology (APIC).

On 07/24/18 at 10:00 am, Staff D stated as interim ICP, he/she was instructed to perform hand hygiene surveillance and to monitor antibiotcs use.

Based on record review and interview, the hospital failed to ensure the Infection Control Program included safe laundry practices.

This failed practice had the likelihood to contribute to the transmission of infections for average of 16 patients on the acute unit whose diagnoses included self harming behavior and hepatitis C.

Findings:

A review of the policy titled, "Laundry Operation and Responsibilities (06/17)" documented all water temperature checks in the washroom would be included in general maintenance checks and water temperature should not exceed 120 degrees.

A review of the CDC document titled, "Guidelines for Environmental Infection Control in Health-care Facilities (2003)" showed laundry in a health-care facility may include bed sheets and blanket, towel, and personal clothing. The guidelines documented the current control measures should be used to minimize the contribution of contaminated laundry to the incidence of health-care associated infections. The guidelines defined required water temperature parameters such 160 degrees for 25 minutes without the addition of chorine bleach or 135-145 degrees if designated amount of bleach was added to render textiles hygienically clean.

On 07/18/18 at 1:19 pm, Staff G states the hospital used Odoban (an odor eliminator and disinfectant) to wash patients' personal clothing.

A review of the instruction for use for "Odosban" failed to address laundry water temperature.

On 07/17/18 at 11:42 am, Staff J stated her assignments included laundering of patients' personal clothing.

On 07/17/18 @ 10:56 am, Staff H stated staff wash patient personal clothing and there was no monitoring of temperature of the water, and stated as part of patients' therapy, the patients assisted in folding general laundry ie towel and linens.

A review of the medical record for Patient #9 showed in a progress note on 02/03/18 the patient was folding laundry as therapy, which would not be conducive to adhering to laundry quality control and infection control prevention.

07/25/2018 11:12 am, Staff H stated when hospital laundered items, such as pillow cases and sheet, patients' help fold them as an activity in the evening.

Based on record review and interview, the hospital failed to ensure an organ, tissue, and eye procurement policy addressed the facility's responsibilities to include, but not limited to timely notification within one hour of the patient's death, definition of imminent death per CMS requirements, and having an organ procurement aggreement.

These failed practices had the likelihood for procurement opportunities to be missed due to the lack of knowledge of hospital responsibilities and timeframes for any patients who expired.

Findings:

A review of policy titled, "Organ / Tissue / Eye Donation - Lifeshare 01/25/18" failed to address the facility's responsibilities to include, but not limited to timely notification within one hour of the patient's death, definition of imminent death per CMS requirements, and having an organ procurement aggreement.

On 07/27/18 on 1:40 pm, Staff A reviewed the "Organ / Tissue / Eye Donation - Lifeshare 01/25/18" policy and said the policy lacked certain requirement components.

Based on record review and interview, the hospital failed to ensure an organ, tissue, and eye procurement agreement that was in place with an Organ Procurement Organization containing CMS required elements which included, but was not limited to 'timely notification" requirement of within one hour of the patient's death.

These failed practices had the likelihood for procurement opportunities to be missed due to the lack of knowledge of hospital responsibilities and timeframes.

Findings:

A review of document titled, "Agreement Between Lifeshare Transplant Donor Services of Oklahoma Inc. and Northwest Center for Behavioral Health 04/24/14" failed to address the facility's responsibilities to include, but not limited to timely notification within one hour of the patient's death and the definition of imminent death per CMS requirements.

On 07/27/18 on 1:40 pm, Staff A reviewed the "Agreement Between Lifeshare Transplant Donor Services of Oklahoma Inc. and Northwest Center for Behavioral Health 04/24/14" agreement and said the agreement lacked certain requirement components.

Based on record review and interview, the facility failed to ensure that the Medical History and Physical Examinations for four of (4) of eight (8) active sample patients (A3, A4, A5, and A7) included a neurological examination of cranial nerves II through XII was documented. This failure to record detailed neurological findings could result in the overlooking of treatable neurological conditions and inability to document changes from baseline status during the patients' hospitalization. This failure makes it impossible to ascertain progression/worsening of patient's condition on subsequent re-examination.

Findings include:

A. Record Review

1. Patient A3 had a physical examination completed 7/8/18. The neurological examination (which was part of the physical examination) stated, "Cranial nerves II to XII, grossly normal."

2. Patient A4 had a physical examination completed 7/8/18. The neurological examination (which was part of the physical examination) "Cranial nerves II to XII, grossly normal."

3. Patient A5 had a physical examination completed 7/8/18. The neurological examination (which was part of the physical examination) stated, "Cranial nerves III, IV, V, VI, VII, IX, X, XI and XII. Spaces on the form for documenting the result of the assessment of each nerve was left blank.

4. Patient A7 had a physical examination completed 7/10/18. The neurological examination (which was part of the physical examination) stated, "Cranial nerves II to XII, intact."

B. Interviews

1. In an interview with the Medical Director using (teleconferencing) on 7/18/18 at 8:55 a.m., the neurological examinations were discussed. The Medical Director agreed with the findings and stated, "that is not acceptable, we have discussed this in the past, I will send an e-mail to the doctors and I will talk with them again."

2. In an interview with Advanced Practice Registered Nurse (APRN) 2 on 7/18/18 at 10.00 a.m., the History and Physical documents were reviewed. The APRN agreed with the findings and stated, "We are working on fixing the issue."

3. In an interview with APRN 1 on 7/18/18 at 10.09 a.m., the History and Physical documents were reviewed. The APRN concurred with the findings.

Based on record review and interview the facility failed to:


I. Develop Master Treatment Plans (MTPs) Called (Treatment Plan by this facility) that identified individualized long-term goals (called goals) and short-term goals (called objectives by this facility) that were stated in observable, measurable, and behavioral terms for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Goals contained similar or identical wording for some patients regardless of the manifested symptoms or problem identified. This deficient practice hinders the treatment team's ability to measure behavioral changes in the patients as a result of treatment and may contribute to the team failure to modify the treatment plans in response to patients need. (Refer to B121).

II. Develop Master Treatment Plans (MTP's) that evidenced individualized treatment interventions with the specific focus based on individual needs and abilities of eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Interventions were stated in generic monitoring or discipline functions terms. Frequently, interventions did not identify what method (individual or group sessions) would be implemented in delivering treatment to the patients. These failures may potentially result in inconsistent or ineffective treatment that could prolong recovery. (Refer to B122).

Based on record review and interview, the facility failed to develop individualized Master Treatment Plans (MTPs) that identified short-term goals called "Objectives" stated in observable, measurable patient behaviors to be achieved for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). In addition, some of the objectives were stated as staff expectations for the patient's participation in treatment; others were incorrectly stated as staff interventions. Due to the lack of individualized symptoms, specific descriptors, and observable behaviors on the MTPs, it would be difficult to assess the effectiveness of treatment and to implement possible changes. These failures can hamper how clinical staff evaluate each patient progress or lack of, based on information provided and may contribute to the failure of the team to modify treatment plans in response to patient needs, as well as staff being unable to provide consistent and focused active treatment.

Findings include:

A. Policy/Document Review:

The facility's policy titled "Treatment Plans" "PROCEDURE: ACU CLINICAL HIM. 002. [sic]. Subject: Treatment Plans Reviewed: March 2018," stipulated under "I. SHORT TERM (STG) [sic]," "Must be stated in measurable terms."

B. Record Review:

The MTPs for the following active sample patients were reviewed (dates of plans in parenthesis): A1 (7/13/18), A2 (7/11/18), A3 (7/16/18), A4 (7/9/18), A5 (7/16/18), A6 (7/11/18), A7 (7/11/18) and A8 (7/16/18). This review revealed that the MTPs included but not limited to the following goals/objectives that were not stated in observable, measurable behaviors to be achieved with an alternative or replacement behavior that would demonstrate the patient's increased level of functioning. In addition, several patients had the identical goals/objectives despite different presenting psychiatric symptoms.

1. Patient A1- Psychiatric Evaluation, dated 6/28/18, noted the following clinical information: Diagnosis- Substance induced psychotic disorder. " ...Patient "With hx [history] of chronic alcohol/methamphetamine use presented to Hillcrest reporting depression and SI (suicide ideation) and plan to shoot [him/herself] with a gun ..."

Problem/Need: "I have a bad temper and I want medication to control it."

a. Goal was stated as: "To get medicine so I won't lose my temper."

(1). Objective- Physician: "Physician will meet with patient 1-2 times weekly to benefit from education and psychiatric medication management. [sic]" This objective/goal statement does not meet the standard for a patient goal/objective. This objective/goal was not stated in observable, measurable, and was not written in patient behaviors to be achieved.

(2). Objective- Registered Nurse: "Client will identify 3 ways to manage problems created by voices and temper outburst [sic]. [He/she] will practice independent living skills daily. Client will select or choose attend 60 minutes RN [Registered Nurse] classes at least [sic]." These objective /goal statements were written as staff expectations/compliance in treatment rather than behavioral outcomes. The objective statements did not reflect what resource information would be shared for the patient to figure out and identify "ways" to manage problems. The statements were not written in observable, measurable patient behaviors to be achieved.

b. Goal: "Practice participating in social activities and wellness groups in order to improve reality orientation and anger[sic]."

Objective- Recreational Therapist (RT): "Maintain a regular sleeping schedule to allow your [sic] body the rest and structure it needs. Eat 3 meals to replace depleted nutrients caused." This goal did not address what specific "social activities" the patient would be involved in, "in order to improve reality orientation and anger."

2. Patient A2 - Psychiatric Evaluation, dated 7/8//18, noted the following clinical information: Diagnosis- Unspecified psychosis, rule out medication induced; major depressive disorder. " ...Patient stated, "I was playing with a ghost hunting application(game), and it (application) mentioned my aunt and uncle's kids. Their grandma died and it mentioned [his/her] name...."

Problem/Need: "Medication adjustments."

a. Goal: "To get medications adjusted and to be medication compliant."

Objective- Physician: "Physician will meet with patient 1-2 times weekly to benefit from education and psychiatric medication management. [sic]" This objective/goal was not stated in observable, measurable patient behaviors to be achieved.

Problem/Need: "Having audio visual hallucinations [sic]"

b. Goal: "To get back on track."

Objective- Registered Nurse: "Client will identify 3 ways to manage problems created by voices and practice independent living skills daily. Client will select or choose attend 60 minutes RN classes at least [sic]." These objective/goal statements were written as staff expectations/compliance in treatment rather than behavior outcomes. The goals/objectives were not written in measurable, observable patient behaviors to be achieved.

Problem/Need: "Paranoia, auditory/visual hallucinations, depression, possible unresolved trauma."

c. Goal: "To lessen [his/her] depression and psychosis and will have begun working through unresolved trauma."

Objective- Recreational Therapist (RT): " Consume 3 balanced meals every day to become more aware of nutritional status. Maintain a sleeping pattern that is routine, structured and restful." This objective/goal did not address this patient's identified problems and was a staff expectation/compliance in the treatment of the patient.

3. Patient A3- Psychiatric Evaluation, dated 7/8//18, noted the following clinical information: " ... Diagnosis- Alcohol induced mood disorder. "Patient contacted a suicide hotline stating [he/she] wanted to kill [himself/herself] ... would kill [him/herself] by the end of the night ... has a hx [history] of attempted suicide in the past by overdosing and cutting wrists ..."

Problem/Need: "Client with depression and wanting to talk with staff."

a. Goal: "Client will have decreased depression by end of [his/her] treatment."

(1). Objective- Physician: "Will meet with client 1-2 times weekly to benefit from education and psychiatric medication management [sic]." This objective/goal was a routine physician function statement.

(2). Objective- Registered Nurse: "Identify and discuss ways to manage illness and practice independent learning skills 3 times weekly." This objective/goal was written as a staff expectation.

(3). Objective- Recreational Therapist (RT): "Practice a routine sleeping schedule to allow your body the rest and structure it requires [sic]. Eat 3 meals daily to provide adequate nutrition for your day to day needs [sic]." These objectives/goals were written as staff expectations and did not address the patient's identified problems.

4. Patient A4 - Psychiatric Evaluation, dated 7/8//18, noted the following clinical information: Diagnosis- Substance induced psychotic disorder. " ... with hx (history) of chronic alcohol/methamphetamine use presented to reporting depression and SI [suicide ideation] and plan to shoot [him/herself] with a gun. Reports seeing things and felt [he/she] need [sic] to go to the hospital ..."

Problem/Need: "Client with history having increased in depression over the past year with [his/her] 2nd marriage."

a. Goal: "Client will be less depressed at time of discharge."

(1). Objective- Physician: "Will meet with client 1-2 times weekly to benefit from education and psychiatric medication management [sic]." This objective/goal was a routine discipline function statement.

(2). Objective- Registered Nurse: "Client will identify 3 ways to manage depression. Client will identify 2 positive coping skills when having suicidal ideations and Client will practice independent living skills daily. Client will select or choose to attend 60 minutes RN classes at least three times weekly." These objective/goal statements were written as staff expectations/compliance in treatment rather than patient behavioral outcomes. The goals/objectives were not written in measurable, observable behaviors to be achieved.

(3). Objective- Recreational Therapist (RT): " Consume 3 balance meals every day to become more aware of nutritional status. Maintain a sleeping pattern that is routine, structured and restful. Participate in recreational activities to determine new and creative ways to enjoy life. These objective/goal statements were routine discipline functions, and the latter part of the goal/objective statement was a staff expectation/compliance in treatment.

5. Patient A5 - Psychiatric Evaluation, dated 7/2//18, noted the following clinical information: Diagnosis- bipolar 1 MRE [most recent episode] manic severe with psychosis, anxiety NOS, cannabis abuse, methamphetamine abuse. The patient stated, "I came out here with my boyfriend to go on a family trip with his kids. I stop taking my medication about 2 months ago.' [He/she] currently delusional and concerned that [he/she] killed [his/her] [boy/girlfriend] and family."

Problem/Need: "I quit taking my meds and I am feeling really bad."

a. Goal: "Get my meds restarted and start feeling better."

(1). Objective - Physician: "Will meet with client 1-2 times weekly to benefit from education and psychiatric medication management [sic]." This objective/goal was a routine discipline function.

(2). Objective- Registered Nurse: "Identify and discuss ways to manage illness and practice independent learning skills 3 times weekly." This objective/goal was the staff expectation for what the patient would be doing and was not written in observable, measurable patient behaviors to be achieved.

(3). Objective- Recreational Therapist (RT): "Practice a routine sleeping schedule to allow your body the rest and structure it requires [sic]. Eat 3 meals daily to provide adequate nutrition for your day to day needs [sic]." These objectives did not address the patient's identified problems and were not written in measurable terms.

6. Patient A6 - Psychiatric Evaluation dated, 7/5//18, noted the following clinical information: " ... Diagnosis- Benzodiazepine/Alcohol/Meth use, unspecified mood disorder, anxiety and insomnia ... The patient stated, 'I don't want to live anymore, my life is a mess, I don't know why I do the things I do.' Licensed professional reports patient is angry and tore everything in her/his girl/boyfriend house including ripping the ceiling fans out."

Problem/Need: "Tired of everything, broke everything, broke all [his/her] personal stuff. Stepmom doesn't treat Dad very well, he has cancer."

a. Goal: "I want to not be like this, I'm normally bubbly and happy."

Objective - Physician: "Will meet with client 1-2 times weekly to benefit from education and psychiatric medication management [sic]." This objective/goal statement was a routine generic discipline function, not a patient outcome statement.

Problem/Need: "Suicidal ideations with plan, anger, aggression, depression, anxiety, substance abuse, unresolved trauma."

Objective - Psychotherapy: "To be suicidal thought free, 50% decrease in depression and anxiety, work through anger issue and get to the root, will have made a decision on substance abuse treatment, will have begun working through unresolved trauma." These were staff expectations and were neither observable or measurable.

7. Patient A7 - Psychiatric Evaluation, dated 7/9//18, noted the following clinical information: " ... Diagnosis- MDD recurrent severe with psychotic features, anxiety NOS, amphetamine abuse moderate severity ... The patient stated, "things have just been getting worse and I have been cutting more so I thought it was time to get help ..."

Problem/Need: "I have been in a dark place for a while and I have been having suicidal thoughts and cutting myself."

a. Goal: "I need to get back on meds [medications] and get stable again. Stabilize client on medications."

(1). Objective - Physician: "Will meet with client 1-2 times weekly to benefit from education and psychiatric medication management [sic]." This objective/goal statement did not meet the standard for a patient-orientated goal, it was a physician's task and was neither observable or measurable.

(2). Objective- Recreational Therapist (RT): "Participate in recreational activities 5 x weekly to improve social skills and enjoyment level, as cooperation allows. Practice a routine sleeping schedules to allow your body the rest and structure it requires. Eat 3 meals daily to provide adequate nutrition for your day to day needs. Walk/Exercise for 15 minutes' periods to slowly raise physical activity to more adequate level." These objective/goals were staff expectations instead of patient's orientated goals, and they were neither observable or measurable.

(3). Objective - Psychotherapy: "Client will attend at least 2 hours of group therapy to address and increase daily functioning concerning presenting issues." This was a staff expectation and not a patient-oriented goal, and it was neither observable or measurable.

(4). Objective - Social work; "Client will gain insight into community resources that can help client manage [his /her] depression and SI [Suicide Ideations). Client will be linked with outpatient and other community services to help client remain stable in [his/her] community." These were staff expectation statements and were not observable or measurable.

8. Patient A8 - Psychiatric Evaluation, dated 6/25//18, noted the following clinical information: " ... Diagnosis- Unspecified psychosis; Intellectual disability, mild underweight, Lice infestation ... Per LMHP report, the patient's clothing was visibly soiled, [he/she] had an odor and [he/she] has been scratching [him/herself] so much that there are sores on [his/her] scalp. [Family member] reported patient has not bathed in at least 6 months to a year, and has not changed [his/her] clothing since then. Patient took [his/herself] to the Sheriff's office last week and asked an officer to lock him/her up. [He/she] had been darting in front of traffic on Oklahoma avenue putting self and others in danger ..."

Problem/Need: "[Family member] is lying and saying that I need medicine and shots that I don't need."

a. Goal: "Nothing" 'Stabilize client on medications."

(1). Objective - Physician: "Will meet with client 1-2 times weekly to benefit from education and psychiatric medication management [sic]." This objective/goal statement was generic routine discipline function, not a patient outcome statement, and was neither observable or measurable.

(2). Objective- RN: "Identify and discuss ways to manage illness and practice independent learning skills 3 times weekly. Client will select or choose to attend 60 minutes RN classes at least three times weekly." These objectives were staff expectation instead of patient-oriented objectives/goals and were not measurable.

(3). Objective- Recreational Therapist (RT): " Consume 3 balanced meals daily to replace depleted nutrients. Maintained a balanced sleeping pattern to aid in giving the body the rest it needs. Socialize with peers daily to determine new and creative ways to spend free time. Walk/Exercise 5x weekly to increase energy level, heart rate and overall wellness, as cooperation allows." This objective/goal did not address the patient's identified problems and was a staff expectation/compliance in treatment statement.

(4). Objective - Psychotherapy: "Client will attend at least 2 hours weekly of group therapy to address issues of self care and develop better functioning by at least 50." This was a staff expectation and not a patient-oriented goal, and it was neither observable or measurable.

C. Interviews:

1. In an interview on 7/17/18 at 2:00 p.m. with the Director of Inpatient Services and the P.M. Shift Nurse Coordinator, the MTP for Patients A1, A3, A4, and A5 were reviewed. They both agreed that the goals were not observable, measurable, individualized, and not written in patient behaviors to be achieved. They also admitted that several objectives were the identical statement for patients with different presenting symptoms. The Director of Inpatient Services noted that they would have to make changes to the computer programming.

2. In an interview on 7/17/18 at 4.00 p.m. with the Medical Director via telecommunication, goals and objective statements on the MTPs were discussed. The Director concurred with the findings and stated, "We will improve on them, I will meet and work with (Director of Inpatient services)."

3. In an interview on 7/18/18 at 9:00 a.m., RN I concurred that the goal statements were not written in observable, measurable, behaviors to be achieved and that the goals/objectives were not individualized.

Based on record review and interview, the facility failed to ensure that the Master Treatment Plans (MTPs) of eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8) include interventions that were individualized based on patient needs. Instead, the interventions were listed as generic monitoring and discipline assessing functions. Some interventions failed to state the frequency of contact, the specific focus of treatment for interventions, and whether interventions would be delivered in groups or individual sessions. In addition, the interventions had similar wording regardless of the patients need. These deficiencies result in treatment plans that do not reveal a comprehensive, integrated and individualized approach to interdisciplinary treatment for patients. These failures may result in inconsistent or ineffective treatment and delay in the recovery process of the patients.

Findings include:

A. Record review

1. Sample patient A1, the MTP dated 7/13/18, had the following generic interventions for the identified problem "I have a bad temper and I want medication to control it."

a. Physician: "Physician will meet with the client 1-2 times weekly to benefit from education and psychiatric medication management." This intervention was not individualized.

b. Psychotherapy: "Clinician will provide individual therapy at least 30 minutes weekly." The intervention had no focus of treatment and was not individualized.

c. Recreational Therapy: "Wellness Resource Skills Development." This intervention did not state the method of delivery (Individual or group), a focus of treatment, a frequency of contact, and was not individualized.

2. Sample patient A2, the MTP dated 7/11/18, had the following generic interventions for the identified problem "Paranoia, auditory/visual hallucinations, depression, possible unresolved trauma."

a. Recreational Therapy: "Wellness Resource Skills Development." This intervention did not state the method of delivery (Individual or group), a focus of treatment, a frequency of contact and was not individualized.

For the problem "Medication adjustments."

a. Physician: "Physician will meet with the client 1-2 times weekly to benefit from education and psychiatric medication management." This intervention was not individualized.

For the problem "Having audio visual hallucinations."

a. RN (Registered Nurse): "RN will offer group and individual education 1 hour least twice daily. Make frequent contact to develop trust and encourage reality based interaction. RN will monitor vital signs per physician orders." This intervention not individualized and contained some routine job duties of the registered nurse.

3. Sample patient A3, the MTP dated 7/16/18, had the following generic interventions for the identified problem "Client with depression and wanting to talk with staff."

a. Physician: "Physician will meet with the client 1-2 times weekly to benefit from education and psychiatric medication management." This intervention was not individualized.

b. Psychotherapy: "Client will attend at least 2 group therapy sessions each week for educational purpose, learn to recognize symptoms of illness or disease and learn better coping skill." The intervention was not individualized, and specific groups were not listed.

c. Recreational Therapy: "Wellness Resource Skills Development." This intervention did not state the method of delivery (Individual or group), a focus of treatment, a frequency of contact and was not individualized.

4. Sample patient A4, the MTP dated 79/18, had the following generic interventions for the identified problem "Client with history having increase in depression over the past year with [his/her] 2nd marriage."

a. Physician: "Physician will meet with the client 1-2 times weekly to benefit from education and psychiatric medication management." This intervention was not individualized.

b. Recreational Therapy: "Wellness Resource Skills Development." This intervention did not state the method of delivery (Individual or group), a focus of treatment, a frequency of contact and was not individualized.

c. RN (Registered Nurse): "RN will monitor vital signs per physician orders." This was a routine job duty of the registered nurse

5. Sample patient A5, the MTP dated 7/16/18, had the following generic interventions for the identified problem "I quit taking my meds and I am feeling really bad."

a. Physician: "Physician will meet with the client 1-2 times weekly to benefit from education and psychiatric medication management." This intervention was not individualized.

b. Psychotherapy: "Client will attend at least 2 group therapy sessions each week for educational purposes, learn to recognize symptoms of illness or disease and learn better coping skill." The intervention was not individualized.

c. Recreational Therapy: "Wellness Resource Skills Development." This intervention did not state the method of delivery (Individual or group), a focus of treatment, a frequency of contact and was not individualized.

6. Sample patient A6, the MTP dated 7/11/18, had the following generic interventions for the identified problem "Tired of everything, broke everything, broke all [his/her] personal stuff. Stepmom doesn't treat Dad very well, he has cancer."

a. Physician: "Physician will meet with the client 1-2 times weekly to benefit from education and psychiatric medication management." This intervention was not individualized.

b. Psychotherapy: "Client will attend at least 2 group therapy sessions each week for educational purposes, learn to recognize symptoms of illness or disease and learn better coping skill." The intervention was not individualized.

For the problem, "Suicidal ideations with plan, anger, aggression, depression, anxiety, substance abuse, unresolved trauma."

a. Psychotherapy: "Client will attend at least 2 group therapy sessions each week for educational purposes, learn to recognize symptoms of illness or disease and learn better coping skill." The intervention was not individualized

b. Recreational Therapy: "Wellness Resource Skills Development." This intervention did not state the method of delivery (Individual or group), a focus of treatment, a frequency of contact and was not individualized.

7. Sample patient A7, the MTP dated 7/11/18, had the following generic interventions for the identified problem "I have been in a dark place for a while and I have been having suicidal thoughts and cutting myself."

a. Physician: "Physician will meet with the client 1-2 times weekly to benefit from education and psychiatric medication management." This intervention was not individualized.

b. Recreational Therapy: "Wellness Resource Skills Development." This intervention did not state the method of delivery (Individual or group), a focus of treatment, a frequency of contact and was not individualized.

8. Sample patient A8, the MTP dated 7/16/18, had the following generic interventions for the identified problem "Julie is lying and saying that I need medicine and shots that I don't need."

a. Physician: "Physician will meet with the client 1-2 times weekly to benefit from education and psychiatric medication management." This intervention was not individualized.

b. Psychotherapy: "Clinician will provide individual therapy at least 30 minutes weekly." The intervention was not individualized.

c. Recreational Therapy: "Wellness Resource Skills Development." This intervention did not state the method of delivery (Individual or group), a focus of treatment, a frequency of contact, and was not individualized.

B. Interviews

1. In an interview on 7/17/18 at 1:30 p.m. with the Recreational Activity Director, the generic interventions on the MTP's were discussed. She agreed with the findings that the interventions were not individualized to meet each patient's need. She stated, "I can make it better, it does not tell you anything."

2. In an interview on 7/17/18 at 2:00 p.m. with the Director of Inpatient Services and the Acting Director of Nursing, the generic interventions on the MTPs were discussed. They both agreed with the findings that interventions were not individualized and were similarly worded for the 8 sample patients.

3. In an interview on 7/17/18 at 4:00 p.m. with the Medical Director via teleconferencing, the generic interventions on the MTP's were discussed. The Director concurred with the findings and stated, "We will improve on them, I will meet and work with (Director of In-patient services)."

4. In an interview on 7/18/18 at 9:00 a.m., RN I concurred that the intervention statements were not individualized and stated that they needed to be changed.

Based on record review and interview, it was determined that the Medical Director failed to adequately monitor the care provided to the patients at the facility. Specifically, the Medical Director failed to:

I. Ensure Medical History and Physical Examination for five (4) of (8) active sample patients (A3, A4, A5, and A7) included a complete neurological screening of cranial nerves II through XII was documented. This failure to record detailed neurological findings makes it difficult to ascertain progression/worsening of patient's condition on subsequent re-examination. (Refer to B109).

II. Develop Master Treatment Plans (MTPs) Called (Treatment Plan by this facility) that identified individualized Long term goals (called goal) and short-term goals (called objectives by this facility) that were stated in observable, measurable behavioral terms for eight (8) of eight (8) sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Goals contained similar or identical wording for some patients regardless of manifested symptoms or problem identified. This deficient practice hinders the treatment team's ability to measure behavioral changes in the patients as a result of treatment and may contribute to the team failure to modify the treatment plans in response to patients need. (Refer to B121).

III. Develop Master Treatment Plans (MTP's) that evidenced individualized physician treatment interventions with the specific focus of treatment based on individual needs and abilities of eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Interventions were stated in generic monitoring or discipline functions terms. Frequently, physician interventions did not identify what method (individual or group sessions) would be implemented in delivering treatment to the patients. These failures may potentially result in inconsistent or ineffective treatment that could prolong recovery. (Refer to B122).

B. Interviews

1. In an interview on 7/17/18 at 4:00 p.m. with the Medical Director via teleconferencing, the goals, objectives, and interventions on the MTPs for the active sample patients were discussed. The medical director concurred with the findings and stated she would meet and work with the Director of In-patient service for improvement.

2. In an interview on 7/18/18 at 8:55 a.m. with the Medical Director, via teleconferencing, the neurological screening in the medical history and physicals assessments for sample patients (A3, A4, A5, and A7) were reviewed. She agreed with the findings and stated, "that is not acceptable, we have discussed this in the past, I will send an e-mail to the doctors, and I will talk with them again."

Based on observation, record review and interview, it was determined that the Director of Nursing failed to monitor and take corrective action as needed to ensure that:

I. The identified goals/objectives in the Master Treatment Plans for eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8) were observable, measurable and address the individual patient presenting problems and needs (Refer to B121).

II. The Master Treatment Plans (MTP's) evidenced individualized nursing interventions with the specific focus based on individual needs and abilities of eight (8) of eight (8) active sample patients (A1, A2, A3, A4, A5, A6, A7, and A8). Interventions were stated in generic monitoring or discipline functions terms. Frequently, nursing interventions did not identify what method (individual or group sessions) would be implemented in delivering treatment to the patients. These failures may potentially result in inconsistent or ineffective treatment that could prolong recovery. (Refer to B122).

III. Adequate numbers of Registered Nurses (RNs) on the day shifts, evening, and night shift) were available. This potentially results in limited time for the RN to provide and supervise active treatment, nursing activities and limited opportunity to provide direction and supervision of non-professional nursing personnel in the provision of nursing care. (Refer to B149)

Based on document review, observation, and interview, the facility failed to provide adequate registered nursing staff on the day, evening and night shift to meet the needs of the patients on the Acute Care Unit (ACU). The registered nurse was required to leave the unit to attend Morning Meetings, Treatment Team meetings, and had to complete new admission assessments in the administrative building. In addition, the RN had to leave the unit for all breaks. During these absences, there was no RN relief assigned. This pattern of staffing creates a potential safety risk for the patients and the staff on the unit.

Findings include:

A. Document Review

1. Review of the "Direct Nursing Staffing Form" for 7/10/18 7/16/18 and 7/4/18 reflected one registered nurse was assigned to the ACU unit on all three shifts (day, afternoon and night shift); with no RN identified to provide relief coverage. The RN staffing schedule was as follows:

Census: 17. Date - 7/10/18 1 RN on the day shift. 1 RN on the afternoon shift. 1 RN on the night shift.
Census: 17. Date - 7/11/18 1 RN on the day shift. 1 RN on the afternoon shift. 1 RN on the night shift.
Census: 16. Date - 7/12/18 1 RN on the day shift. 1 RN on the afternoon shift. 1 RN on the night shift.
Census: 15. Date - 7/13/18 1 RN on the day shift. 1 RN on the afternoon shift. 1 RN on the night shift.
Census: 17. Date - 7/14/18 1 RN on the day shift. 1 RN on the afternoon shift. 1 RN on the night shift.
Census: 18. Date - 7/15/18 1 RN on the day shift. 1 RN on the afternoon shift. 1 RN on the night shift.
Census: 18. Date - 7/16/18 1 RN on the day shift. 1 RN on the afternoon shift. 1 RN on the night shift.
Census: 16. Date - 7/04/18 1 RN on the day shift. 1 RN on the afternoon shift. 1 RN on the night shift.

2. The census on the first day of the survey (7/16/18) was 18; with five (5) patients identified as potentially assaultive; three (3) additional patients were identified who had occasionally demonstrated aggressive behavior during their hospitalization, and another additional 2 patients were identified as actively assaultive. These patients had demonstrated physical/verbal aggression within the prior 48 hours.

3. A review of the "Nursing Needs Assessment Form" revealed that the average weekly admissions on ACU were as follows - day shift: three (3); afternoon shift: four (4); and night shift: four (4). These data showed that the average number of times the one assigned RN would be off the unit and not available for patient care and staff supervision . There were no supervisors available for coverage.

B. Observation

During an observation on the first day of the survey (7/16/18) at 1:15 p.m., there was no RN staff on the unit to cover the day shift. The "July 2018 ACU/TRU Schedule" reflected "0" RN. The "Northwest Center for Behavioral Health - Daily Work Schedule." did not include a signature of an RN scheduled to work that day. The Director of Nursing (DON) during the survey was on medical leave and the one RN on the unit was acting as interim DON.

C. Interviews

1. During an interview on 7/18/12 at 9:00 a.m., RN 1 acknowledged that there were insufficient registered nurses to manage and supervise the nursing care and active treatment measures.

2. During a discussion on 7/16/18 at 1:15 p.m., with the Director of Inpatient Services, when asked about the RN's coverage of the unit, the Director stated, "It has been difficult to hire RN."