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Based upon observations, reviews of records, staffing matrix/schedules, and staff interviews, the hospital failed to ensure adequate staff were present to provide monitoring of all patients to ensure physician ordered Observation Level II (staff must be within 20 feet of patient at all times), was implemented for 14 of 18 patients (#s 1, 3, 4, 6-8, 10-12, 14-18) on 03/06/14, and 5 of 17 patients (#s 3, 7, 12, 16, 19) on 03/07/14. Findings:

Observations made, 03/06/14 at 12:45pm, revealed according to the census board at the nurses station there were 18 patients (18 bed psychiatric hospital). Review of the daily census sheet revealed 14 out of 18, were identified as Observation Level II (staff must be within 20 feet of patient at all times). There were 2 staff members (Mental Health Technicians S6, S7), present in the dayroom with the patients. There was also a Registered Nurse (RN), a Licensed Practical Nurse (LPN) and an LPN orientee on duty.

Review of a Nursing Staffing schedule, dated 03/06/14, revealed the staffing was 1 RN, 1 LPN and 2 MHTs for a census of 18. The hospital failed to ensure additional numbers of nursing staff were present to monitor the safety of all patients (whose acuities were increased based on their observation level) as there were 14 patients on Level II (observation required staff member within 20 feet of the patient at all times).

Observations conducted, 03/07/14 at 11:00am, revealed the daily census was 17 (according to the census board at the nurses station), and there were 4 staff members present (1 RN, 1 LPN, 2 MHTs) and one LPN orientee. The nurses were observed in the nurses station, and 1 MHT was observed in the dayroom with the patients. According to the daily census sheet, 5 of the 17 patients (#s 3, 7, 12, 16, 19) were ordered to be on Observation Level II (this required the staff member to be within 20 feet of the patient at all times).

Interview, 03/07/14 at 11:00am, with S8 MHT revealed, S6 MHT had to accompany a patient to another facility, and the hospital's driver was filling in for S6 MHT.

Continued observations, 03/07/14 at 11:00am, and review of the daily census sheet revealed Patient #3, Patient #16 and Patient #19 had physician orders to be on Observation Level II (staff within 20 feet of patient at all times). There was 1 MHT (S8) observed in the dayroom with 15 of the patients present, including Patients #1, #3, #13, #16 and #19. S8 MHT was asked to assist Patient #1 make a telephone call. When S8 MHT entered the telephone room with Patient #1, this left other patients unattended, including Patient #s 3, 16, and 19. Although the hospital's driver was filling in for S6 MHT, the driver was not observed in the dayroom with the other patients while S8 MHT was assisting Patient #1 with the telephone.

The scheduled numbers of staff met the staffing matrix requirement based on the census on 03/06/14 and 03/07/14; however, the staffing matrix failed to take into consideration the increased acuities of the patients. The hospital failed to ensure additional staff were available to provide Observation Level II monitoring as ordered by the physician to keep all patients safe.

Based upon observations, review of nurse staffing schedules, the hospital's staffing matrix, medical records, and interviews, the hospital failed to ensure there were enough staff members present to provide patients with nursing care/monitoring based on their various acuities, as evidenced by:

1) Failure to adequately staff on 03/06/14 to ensure 14 of 18 patients were provided monitoring in accordance with the physician orders (#1, 3, 4, 6-8, 10-12, 14-18);

2) Failure to adequately staff on 03/07/14 to ensure 5 of 17 patients were provided monitoring in accordance with the physician orders (#3, 7, 12, 16, 19).

Findings:

1) Observations, on 03/06/14 at 12:45 p.m, revealed according to the daily census form, there were 18 patients on the unit. Of these 18 patients, 14 were ordered Observation Level II; this level required staff to be within 20 feet of the patient at all times. At the time of the observations, staff present on the unit were 2 Mental Health Technicians (MHT), one Licensed Practical Nurse (LPN), who was in and out of the medication room with an LPN orientee, and one Registered Nurse who was sitting at the nursing station.

Observations, 03/06/14 at 1:20pm, revealed other than the Counselor conducting therapy, there were no other direct staff in the group therapy room. Interview, 03/06/14 at 1:40 pm, with S5 RN confirmed this observation.

Review of the staffing matrix requirements revealed for 18 patients there were to be 4 staff members (1 RN, 1 LPN, 2 MHTs), present on the unit. The hospital failed to provide additional staff to provide care/monitoring for 14 of 18 patients who had higher acuities as they were on observation level II (required staff to be within 20 feet of patient at all times).

Interview, 03/06/14 at 1:30pm, with S2 Director of Nursing revealed when asked if 2 MHTs could adequately monitor 14 patients (who were on Observation Level II) if 2 of the patients required the use of the bathroom at the same time; S2 Director of Nursing replied, "I can see where that could be a problem". S2 Director of Nursing agreed in order to ensure the safety/monitoring of all patients (18 total) there needed to be additional staff present.

2) Observations, 03/07/14 at 10:50am, revealed there were 17 patients on the unit. Observations conducted, 03/07/14 at 10:50am through 11:45am (of the patients in the dayroom), revealed one MHT monitoring all 17 patients. Interview, 03/07/14 at 11:00am, with S8 MHT revealed, S6 MHT had to accompany a patient to another facility, and the hospital's driver was filling in for S6 MHT.

According to the daily census form, there were 17 patients; of these 17 patients, 5 were ordered observation level II.

According to the staffing matrix for 17 patients, there were to be 4 staff members (1 RN, 1 LPN, 2 MHTs). The staffing matrix failed to take into consideration the higher acuity of 5 patients (#s 3, 7, 12, 16, 19) who required monitoring based on the physician ordered observation level II--staff within 20 feet of patient at all times. Interview, 03/07/14 at 11:00am, with S8 MHT confirmed he could not monitor (maintain 20 feet within patients at all times) for all 5 patients who were ordered observation level II.

Interview, 03/07/14 at 1:15pm, with S2 Director of Nursing revealed when asked if there had been adequate nursing staff present to provide on-going nursing re-assessments and monitoring, he replied the staffing was based on the staffing matrix and agreed there should have been additional staff available on 03/06/14 and 03/07/14 because of the increased acuity levels (14 of 18 patients on 03/06/14; and 5 of 17 patients on 03/07/14).

Review of the hospital's staffing matrix failed to account for increased acuity in patients, i.e. 1:1 observations, Level II--within 20 feet); although the Director of Nursing based nursing staff on the staffing matrix, he failed to ensure patient acuity was also included in the determination of additional staff.

Interview, 03/07/14 at 1:15pm, with S2 Director of Nursing (DON) revealed when asked about the hospital's policy for staffing based on increased acuities; S2 DON replied the staffing for increased acuity levels "was in his head" and there was not a documented policy.

Interviews, 03/07/14 at 1:35pm, with S1 CEO (Chief Operating Officer) and S2 DON confirmed there should be additional staff members present when patient acuity levels were increased as observed on 03/06/14 (14 of 18 patients on observation level II) and 03/07/14 (5 of 17 patients on observation level II--staff member within 20 feet of patient at all times).

Based on reviews of medical records (18 of 18), policy/procedures and interviews, the hospital failed to ensure medical records contained all information necessary to monitor the patient's condition as evidenced by failure of the nursing staff and psychiatrist to document in the patient's medical records the reason/cause of changing and/or continuing the patients' observation status for: 1) 14 of 18 patients (#s 1, 3, 4, 6-8, 10-12, 14-18) on 03/06/14; and 2) 5 of 17 patients (#s 3, 7, 12, 16, 19) on 03/07/14. Findings:

1) Review of 14 of 18 medical records (#1, 3, 4, 6-8, 10-12, 14-18) revealed the nursing notes, dated 03/06/14, failed to contain documentation relative to the patients' behaviors that warranted continuing observation level II (required staff to be within 20 feet at all times). Review of physician/psychiatrist progress notes, dated 03/06/14, revealed there failed to be documentation that supported continuing the patients' current levels of observation--level II.

2) Review of 5 of 17 medical records (#s 3, 7, 12, 16, 19) revealed the nursing notes and physician notes, dated 03/07/14, failed to have documented evidence of assessments of the patients' behaviors that warranted continuing their present levels of observation (level II).

Review of a hospital policy titled, "PATIENT OBSERVATION LEVELS", Reference #2015, revealed: "It is the policy...monitoring is instituted to prevent patients from harming themselves or others...PROCEDURE 1. In order to provide protection to patients, three levels of staff monitoring are provided A. Level I: constant monitoring within arms-length distance B. Level II: constant monitoring within 20 feet distance C. Level III: monitoring on a routine basis every 15 minutes 2. Special Precautions will be initiated...will continue until orders are received from the attending physician to discontinue. A. An RN will assign a Special Precaution Level based on assessments, observation and history...B...All changes must be documented to include the level of monitoring and the reasons for the monitoring level...C...The order will document the reason for the increased level of monitoring...G. The patient's behavior is documented on the Nurses Flow Sheet."

Review of hospital policy titled, "ROUNDS FOR PATIENT OBSERVATION", Reference #1029.05, revealed: "POLICY: An accurate record of the whereabouts of all patients on the Behavioral Health Unit will be maintained during each shift. PROCEDURE: ...Every patient must be seen by a staff member at least every 15 minutes during the day...unless more frequently by MD order and checked off on the Close Observation Form as present...DOCUMENTATION: Document frequency of checks in Nurse's note (i.e., rounds check every 15 minutes)..."

Interview, 03/07/14 at 1:30pm, with S9 Registered Nurse (RN) revealed when questioned how and who determined the patients' observation levels, she responded that each morning the day shift (7a-3p) RN telephoned S11 Psychiatrist and discussed each patient with her (S11 Psychiatrist), and the patients' observation status was either decreased, increased or remained the same based upon their discussion. S9 RN confirmed there failed to be documentation of these discussions in the patients' medical records. S9 RN agreed the documentation in the patients' medical record failed to contain documentation for the reason of the ordered observation levels.