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Based on review of hospital policies/procedures, documents, and staff interviews, it was determined that the nurse executive failed to ensure that each unit was staffed with the number of personnel and the types of personnel required to meet the needs of the patients as evidenced by scheduling personnel to rotate between/among units on the same shift leaving staffing resources limited on the unit when the staff member leaves one unit to go to another.

This deficient practice poses a risk to the health and safety of patients, when staffing based on patient acuity is not utilized to ensure the proper types and numbers of nursing staff needed on a unit.

Findings include:

The document titled "Valley Hospital Nurse Staffing Plan" requires that " ...a daily per shift assignment will be made for each nurse on the unit clearly defining how many patients on the assignment with room numbers and acuity levels ...assignments will be done for each member of the team to include LPNs and BHTs ...."

During an interview conducted on 10/01/20, Employee #2 revealed that the patient acuity system is on an Excel spreadsheet that is not currently accessible. The hospital was at capacity (122) when the system went down. Employee #2 stated that they have basing staffing on the patient acuities calculated on 09/26/20, because the facility does not have a down time policy or procedure for calculating patient acuities.

Review of the Shift Assignment Sheets for each unit between 09/27/20-10/05/20 revealed that of the nine (9) shifts that had patient assignments indicated with patient names, five (5) of the shifts had RNs who were assigned greater than nine (9) patients. The other 63 shifts did not have patient assignments indicated with patient names. The Shift Assignment Sheets only indicated whether the nurse had the "even" or the "odd" side of the hall. Additionally, the census and patient acuity are not documented on the Shift Assignment Sheets. There is a place to document patient names and which special safety precautions the patient is on. However, this area was frequently left blank.

During an interview conducted on 10/05/20, Employee #2 revealed that they are not currently staffing to the acuities calculated on 09/26/20. Employee #2 explained that because the census has gone down, they have reduced staff per the "ratio", which is nine (9) patients to one (1) nurse.

During an interview conducted on 10/05/20, Employee #12 confirmed that staff had been "estimating" patient acuity based on what it was prior to the computer outage. Additionally, " ...the Care Center admits people whether we have staff or not. There is not good communication ...."

Review of the Shift Assignment Sheets for each unit between 09/27/20-10/05/20 revealed that on 2N, 2S, and 1S there was at least one staff member per unit that was assigned to float between more than one unit. On some Shift Assignment Sheets it is documented that staff are "floating" between two units. On others, the staff is just written into a slot on both units. The staff that float do not do so in blocks of time, rather for rounds it can switch hour to hour. For the time a BHT is not assigned to do patient safety rounds, there is no indicated where the staff are assigned.

During an interview conducted on 10/05/20, Employee #13 revealed that on the paper assignment sheet there is no place to document patient acuity. Additionally, " ...no matter what the acuities state we get the same amount of nurses ...and night shift seem to suffer more than day shift ...night shift house supervisors fill in on the floor, but have to still be house supervisor too ...we are ridiculously short on BHTs ...."

During an interview conducted on 10/05/20, Employee #2 revealed that the facility has "plenty of staff." The facility utilizes "Shift Town" to bid on their schedules. When there are open shifts, the staffing coordinator sends out a text blast requesting help. They are currently offering bonuses to RNs, LPNs, and BHTs. If no one offers to come in, which "rarely happens", then administration comes in.

During interviews conducted on 10/05/20 and 10/06/20, staff made the following statements regarding their experiences with staffing and acuities. Several nurses expressed that there always seems to be "holes" in the schedule and staff frequently calls off of work. Several nurses expressed that they were frequently asked to stay late to pass medications on night shift, or to pick up an additional shift, causing fatigue among nurses and techs. Many nurses felt the acuity system needed to be reviewed, as it does not seem to accurately represent the numbers of staff needed.

Based on review of hospital policies/procedures and staff interviews, it was determined that the Administrator failed to require that medications were administered to patients in compliance with a physician's order. This deficient practice poses a risk to the health and safety of patients, when medications are administered without a written physician's order to reference and confirm the validity of the order.

Findings include:

The policy titled "Medication Administration Record (MAR)" states that " ...The MAR is a legal record of all drugs administered to the patient ...." Additionally, " ...In the event that the computer is down, the offsite storage of the e-pharmacy will be downloaded and paper MARs will be used ...."

During an interview conducted on 10/01/20, Employee #23 revealed that the MARS are backed up to a computer that is offsite and is linked to UHS. The downtime plan included only if something happened at the hospital, not system wide.

During an interview conducted on 10/5/20, Employee #2 stated that when this happened s/he looked to see if the backed up MARs were available and they were not. We asked the nurses to go to the patient's medication drawers and write the meds down that were there and get the lists to the doctors for new orders but that didn ' t happen. The doctor saw their patients on 09/27/20. On 10/01/20, the doctors did come in and see their patients later that day. Some of them rewrote orders, but it was never a rewrite of the entire MAR. The nurses were supposed to get the meds out of the drawers and get the orders from the doctors. There was no check or balance during the next four days. Employee #2 conceded that the nurses did give the meds without orders.

During an interview conducted on 10/05/20, Medical Staff #3 stated that the physicians did not know what was happening with the computer system until 09/27/20. Medical Staff #3 stated that s/he reviewed the medications for the new patients but did not go over the medications with the patients that had been in the hospital prior to the system going down because " ...I saw them every day and knew what they were taking ...."

During an interview conducted on 10/05/20, Medical Staff #1 stated that " ...this is a really serious situation and we should have dealt with this immediately; but now I understand how serious this is and we are trying to fix it the best we can ...."  
The policy titled "General Medication Dispensing" states that " ...Nurses shall compare drugs supplied with the Medication Administration Record (MAR) or prescriber's order and report irregularities to the pharmacy ...."

During interviews conducted on 10/05/20 and 10/06/20, staff made the following statements regarding their experiences with administering medication since 09/27/20.

Employee #13- " ...I was concerned about medication safety for the patients and me. If there was no order I would call the doctor. Some of the meds that were in the patient ' s box were sometimes things that were discontinued and yet their box still contained the old stuff. The nurses were told to use their nursing judgment regarding passing meds on 09/27/20 ...."
Employee #14- " ...I was not instructed on much. I was given report and told 'this is how we are going to do it.' Then I just followed what was in our MAR. I was just trusting who wrote the MAR. I can ' t answer how the MAR came to be ...."

Employee #16 - " ...I remembered my patients ...but we had to start calling doctors and getting orders for meds. I called the doctors and discussed individual meds ...We tried to grab the doctors immediately and get their orders ...."

Employee #17- " ...when I came in there was no computer access and the night shift said there was no MARS available ...The pharmacy came in said we would have to hand write the MARS. We stopped what we were doing and called the DON. The DON wanted me to call the doctors but they couldn ' t remember all the patient's meds so we went off the medication charts ...it was chaotic that morning because you are so used to running off the MAR ...."

Employee #28-" ...Night shift said the computers went down around two. They started some paper MARs from the meds in the patient's drawers. We were later able to obtain orders from the doctors ...there was no process and we got multiple answers ...." Employee #28 stated that Employee #4 said that if you aren't comfortable, then don't pass the meds and Employee #37 said not to worry about passing meds because it wouldn't be held against you. 

During an interview conducted on 10/05/20, Employee #1 stated that no patients were injured, but that they could have been.

Based on review of hospital policies/procedures, medical records, and staff interviews, it was determined that the administrator failed to ensure the availability of patient medical records to nursing staff. This deficient practice poses a risk to the health and safety of patients, when nursing staff do not have access to physician orders entered into the electronic MAR when administering medications.

Findings include:

The policy titled "Patient Profiles" requires that " ...The pharmacy shall maintain a patient profile (drug therapy profile) for each patient. Patient profiles shall include: name and location of the patient, sex and age (or birth date) of the patient, weight of the patient (if needed for dosage calculations), pertinent problems or diagnosis(es), comorbidities, and concurrently occurring conditions, drug allergies or sensitivities (or NKA), other information relating to the patient's drug regimen, current drug therapy including: prescription and nonprescription drugs, date ordered/reordered and stop date, drug name, strength, and dose form, ancillary labels/information ...and Patient profiles (or the information in patient profiles) shall be available for review by all appropriate health care professionals and staff responsible for the patient's care via e-Pharmacy ...."

Review of medical records revealed that all patients admitted before 09/27/20 had incomplete physician orders, and which did not did not correlate with the MARs the nurses were utilizing to administer medications patients.

Employee #2 confirmed during an interview conducted on 10/02/20, that the MARs for patients admitted before 09/27/20 had incomplete physician orders.

Based on review of hospital policies/procedures, documents, and staff interviews, it was determined that the Administrator failed to ensure that all medical records contained informed consent for psychotropic medications before medications were administered. This deficient practice poses a risk to the health and safety of patients, when all of the side effects and risks of a medication are not understood by a patient before taking a particular medication.

Findings include:

The policy titled "Informed Consent for Medication Administration" requires that " ...Informed Consent for the administration of psychoactive medication shall be required for all patients, voluntary or involuntary. Such consent must be written and made a part of the medical record ...."

During interviews conducted on 10/05/20 and 10/06/20, all nursing staff interviewed confirmed that in order to verify if informed consent has been obtained, they must refer to a document in the paper medical record.

During an interview conducted on 10/05/20, Employee #2 revealed that neither the electronic MAR, nor the paper MAR, include documentation of whether or not informed consent has been obtained.

During an interview conducted on 10/06/20 Employee #23 revealed that they were looking at a "consent needed" button in the EMAR. It is currently pending while DocuSign capability is integrated into the EMAR.

The policy titled "Informed Consent for Medication Administration" requires that " ...Before administering psychoactive medication that the patient has not previously been taking to any patient the treating physician shall explain to the patient and/or the patient's legally authorized representative, the following in simple, non-technical language: ...a description of the proposed course of treatment with the medication ...the side effects of medication ...alternatives to the proposed treatment with medication ...a review of Patient's Rights under the Consent to Treatment with Psychoactive Medications Rule ...."

Medical record review on the 1 South unit revealed that 10 of 18 patients (#s 3,4 10-15, 23, & 24) did not have a signed "Informed Consent for Psychotropics" form in their medical record.

Medical record review on 2 North Freedom Care unit revealed that 10 of 17 patients (#s 25,31,34,38,39,41-44, & 62 ) had a signed "Informed Consent for Psychotropics" form in their medical record. However, the signatures were obtained anywhere from three to seven days after the medication had been administered.
The "Valley Hospital Medical Staff Rules and Regulations" require that " ...Physicians shall discuss fully with patients and appropriate relatives the indications and side effects of prescribed medications with documentation as established by the Facility and accepted medical practice ...."
During an interview conducted on 10/05/20, Employee #2 revealed that physicians get the consent from the patients when they admit them and they get the "Informed Consent for Psychotropics" form signed right away. 
During an interview conducted on 10/05/20, Medical Staff #1 explained that because patients often come in in a "hard detox", they are not able to sign the "Informed Consent for Psychotropics" form. It is expected that the signatures are obtained as soon as possible.

During interviews conducted on 10/05/20 and 10/06/20, nursing staff revealed that the doctor usually explains the medications to the patients but "sometimes we get to do that honor" and "we help a fair amount of the time with the consents."

Based on review of the facility's Emergency Management Plan, policy and procedure review, document review and staff interviews, it was determined, the facility failed to review and update the Plan at least every two years. Failure to review and update the Plan poses a potential risk to the patients of being properly cared for during an emergency.

Findings include:

Review of the "Valley Hospital Emergency Operations Plan" revealed "...January, 2018...." as the date of the Plan.

Review of document titled "Governing Board Minutes, 02/26/2020" revealed "...Emergency Plan...." was on the agenda.

Employee #4 confirmed during an interview on 10/06/20 that the Governing Board Minutes of 02/26/2020 should have listed the Emergency Plan as pending. It was not prepared for review and it was not in the packet given to the Governing Board. It was further confirmed that the Emergency Plan has not been reviewed since January, 2018.

Based on review of the facility's Emergency Plan, policy and procedure review, document review and staff interviews, it was determined, the facility failed to review and update policies and procedures based on the emergency plan at least every two years to address a system of medical documentation that preserves patient information and secures and maintains availability of records. Failure to review and update policies and procedures relating to preserving patient information and maintaining availability of records poses a risk to the patients of being properly medicated and treated during an emergency.

Findings include:

Policy titled "Disaster Recovery" revealed "...The Director of Pharmacy (DOP) shall ensure compliance with the facility's Disaster Plan...All e-pharmacy information is backed up daily to a server that is offsite...In the event the hospital server goes offline, the back-up data from the outside server will be used and MARs will be converted to paper...."

A policy regarding the availability of UHS flash drives to back up the facility's computers was requested, however it was not provided.

Document titled "Valley Hospital Medical Staff Rules and Regulations" revealed "...5.4.1 All orders for medication and/or treatment for patients admitted to the Facility shall be in writing. Orders must be written clearly and legibly and must be complete, including the date, time and justification for the order...."

Observation made of the Emergency Operations manual identified that 20 out of 20 policies were dated 03/2016 or earlier. No policies were found that had been reviewed within the last four years.

Provider #1 confirmed during an interview on 10/05/20 that almost all of the orders are entered electronically, not written.

Employee #4 confirmed in an interview on 10/06/20 that the policies and procedures have not been reviewed within the last four years.

Employee #5 confirmed during an interview on 10/06/20 that the facility's computers are not backed up.

Employees #2 and #4 confirmed during interviews on 10/05/20 that Corporate does not allow the facility to back up the computers to an off-site location and that the facility is not allowed to back up on a flash drive.

Employee #1 confirmed during an interview on 10/07/20 that the facility is allowed to use a flash drive to back up the computers but it must be a UHS flash drive.

Employee #29 confirmed during an interview on 10/05/20 that on arrival to work on 09/27/20 they were given report by the night staff that the computer system had gone down during the early morning hours. It was very chaotic, there were no medication administration records (MARs) for the patients. They were creating lists from memory and the patients' medication bags in the medication room. There were no orders visible to be reviewed so doctors had to be called.