HospitalInspections.org

Based on review of job description, facility policy review, interviews, and review of licensed personnel time punches, the Governing Body failed to ensure Nursing Services was directed by a Chief Nursing Officer, failed to ensure the facility was staffed with licensed personnel and a Registered Nurse 24 hours per day, and failed to provide a Social Worker and Recreational Therapist for patients admitted to the facility.

The findings include:

Review of facility job description, policy review, review of licensed personnel time punches, and interviews revealed the facilty failed to have nursing services lead by a Chief Nursing Officer for 53 days (4/16/2022-6/7/2022) and failed to ensure the facility was staffed with licensed personnel and a Registered Nurse for 1 hour and 15 minutes on 5/17/2022 affecting 5 patients, and failed to provide a Social Worker since 12/8/2021 and a Recreational Therapist since 3/25/2022.

Refer to A-1700, A-1703, A-1704, A-1715, and A-1725.

Based on review of job description, facility policy review, review of facility scope of service, interviews, and review of licensed personnel time punches, the facility failed to provide adequate number of qualified staff to ensure Nursing Services was directed by a Chief Nursing Officer, failed to ensure the facility was staffed with licensed personnel and a Registered Nurse 24 hours per day, and failed to provide a Social Worker and Recreational Therapist for patients admitted to the facility.

The findings include:

Review of facility job description, policy review, review of licensed personnel time punches, and interviews, revealed the facilty failed to have nursing services lead by a Chief Nursing Officer for 53 days (4/16/2022-6/7/2022) and failed to ensure the facility was staffed with licensed personnel and a Registered Nurse for 1 hour and 15 minutes on 5/17/2022 affecting 5 patients, and failed to provide a Social Worker since 12/8/2021 and a Recreational Therapist since 3/25/2022.

Refer to A-1700, A-1703, A-1704, A-1715, and A-1725.

Based on review of the Chief Nursing Officer's job description and interview the facility failed to ensure Nursing Services was directed by a Chief Nursing Officer for 53 days (4/16/2022-6/7/2022; there were no admissions to the facility after 6/7/2022).

The findings include:

Review of the Chief Nursing Officer (CNO) job description, last revised 1/19/2021 showed "...The Chief Nursing Officer (CNO) is responsible and accountable for organizing and directing all aspects of nursing services. Work collaboratively with the hospital Administrator in supporting patient care and healthcare delivery. The CNO provides leadership and management in the areas of patient care, safety, and patient satisfaction. Provides and ensures patient advocacy, quality improvement, leadership, and professional development for nursing staff..."

During an interview on 8/16/2022 at 10:50 AM, in the conference room, the Human Resources (HR) Director stated the CNO's last day of employment was 4/15/2022 and confirmed the facility had not hired another CNO.

During a telephone interview on 8/18/2022 at 3:35 PM, the Chief Executive Officer confirmed the facility had not hired another CNO.

Based on review of facility policy, medical record review, employee time punches, and interviews the facility failed to ensure licensed staff (RN or Licensed Practical Nurse) was on duty for 1 shift out of 46 shifts for 1 hour 15 minutes on 5/17/2022 affecting five (5) of 10 sampled patients (Patient #2, #3, #4, #5, and #6) and failed to ensure a Registed Nurse (RN) was available to supervise patient care for 10 days of 23 days reviewed.

The findings include:

Review of the facility's policy "Clinical Staffing" dated 8/4/2020 showed "Nursing...A registered nurse qualified by education and experience in the care of the mentally ill provides leadership to the nursing staff on the unit...A minimum of two nursing staff are assigned and are present on the inpatient unit at all times. These two nursing staff should be licensed nurses, of which one is always a registered nurse...When a deviation from this staffing pattern occurs, the second nursing staff may be a qualified mental health technician or nurse's aide..."

Medical record review showed Patient #2 was admitted to the facility from 4/6/2022-5/18/2022 with diagnoses including Dementia, Agitation, Aggression, Major Depressive Disorder and Anxiety. There was no documentation to indicate Patient #2 had behaviors of agitation or aggression on 5/17/2022.

Medical record review showed Patient #3 was admitted to the facility from 4/19/2022-5/20/2022 with diagnoses including Dementia with Behavioral Disturbance, Agitation and Aggression. There was no documentation to indicate Patient #3 had behaviors of agitation or aggression on 5/17/2022.

Medical record review showed Patient #4 was admitted to the facility from 4/29/2022-5/18/2022 with diagnoses including Dementia with Behavioral Disturbance, Agitation, and Aggression. There was no documentation to indicate Patient #4 had behaviors of agitation or aggression on 5/17/2022.

Medical record review showed Patient #5 was admitted to the facility from 5/26/2022-6/7/2022 with diagnoses including Dementia with Behavioral Disturbance, Agitation, and Aggression. There was no documentation to indicate Patient #5 had behaviors of agitation or aggression on 5/17/2022.

Medical record review showed Patient #6 was admitted to the facility from 5/4/2022-5/24/2022 with diagnoses including Dementia with Behavioral Disturbances, Agitation, and Aggression. There was no documentation to indicate Patient #6 had behaviors of agitation or aggression on 5/17/2022.

Review of employee time punches showed there were 2 Certified Nurse Assistants (CNAs) and no licensed staff (Registered Nurse or Licensed Practical Nurse) on duty between 5:45 PM-7:00 PM (1 hour 15 minutes) on 5/17/2022.

Review of the facility census (number of patients) showed there were 5 patients in the facility on 5/17/2022.

Review of employee time punches for 5/16/2022-6/8/2022 showed the following shifts had Licensed Practical Nurses, but did not have a Registered Nurse on duty:
5/17/2022 - 9:15 AM-7:00 PM
5/18/2022 - 7:00 AM-7:00 PM
5/19/2022 - 7:00 AM-7:00 PM
5/20/2022 - 3:00 PM-7:00 PM
5/21/2022 - 4:00 PM-6:45 PM
5/26/2022 - 7:00 AM-11:00 AM
5/29/2022 - 3:00 PM-7:00 PM
6/3/2022 - 5:30 PM-7:00 PM
6/4/2022 - 11:00 AM-7:00 PM
6/5/2022 - 7:00 AM-7:00 PM
6/6/2022 - 7:30 AM- 9:00 AM and 5:00 PM-6:00 PM
6/7/2022 - 7:30-9:00 AM

During an interview on 8/16/2022 at 12:00 PM, in the conference room the Nursing Home Administrator (assisted with investigation) confirmed the Psychiatric Nurse Practitioner of the behavioral health facility notified her there was "...no nurse in the building [behavioral health facility]..." on the evening of 5/17/2022. The Nursing Home Administrator stated the Certified Nurse Assistants (CNA's) were told the Licensed Practical Nurse (LPN) stationed on the other side of the door (the nursing home and behavioral health facility were separated by locked double doors) would assist them in the event of an emergency.

During an interview on 8/17/2022 at 1:20 PM, in the conference room, the Nursing Home Administrator verified the behavioral health facility's census (number of patients) was 5 on 5/17/2022.

During an interview on 8/17/2022 at 1:35 PM, in the conference room, LPN #1 stated she agreed to work at the facility from 9:00 AM-5:00 PM on 5/17/2022. LPN #1 stated she notified the Nursing Home Administrator there was not a RN or LPN in the facility to relieve her on 5/17/2022. LPN #1 confirmed there were only 2 CNA's on duty at the facility when she left on 5/17/2022.

During a telephone interview on 8/17/2022 at 2:20 PM, LPN #2 stated she was told she needed to stand on the nursing home side of the locked double doors separating the behavioral health facility and the nursing home. LPN #2 stated the CNAs would open the doors if they needed assistance with the patients.

During a telephone interview on 8/17/2022 at 2:30 PM, the Behavioral Health Nurse Manager stated the Nursing Home Administrator informed her there was no licensed staff, only 2 CNA's, in the behavioral health facility the evening of 5/17/2022. The Behavioral Health Nurse Manager confirmed there were only 2 CNA's in the facility when she arrived for her shift at 7:00 PM on 5/17/2022.

During a telephone interview on 8/18/2022 at 1:20 PM, the Nursing Home Administrator confirmed the behavioral health facility had not provided 24 hour RN coverage as outlined in the facility policy "Clinical Staffing".

During a telephone interview on 8/18/2022 at 2:00 PM, CNA #1 confirmed there were only 2 CNAs, no licensed staff, in the behavioral health facility when she arrived for one 7:00 PM shift (she could not recall the date).

During a telephone interview on 8/18/2022 at 3:35 PM, the Chief Executive Officer (CEO) stated "...staffing was a mess..." due to COVID. He stated the LPN had made it known she would have to leave at 5:00 PM. The CEO stated the Nursing Home Administrator contacted him around 5:30 PM on 5/17/2022 and notified him the LPN (#1) had left and there were no RN's or LPN's in the facility.

During a telephone interview on 8/19/2022 at 3:50 PM, the Psychiatric Nurse Practitioner stated she had called the facility on the evening of 5/17/2022 and was told there were no RN's or LPN's present in the facility.

Based on review of facility policy, medical record review, employee time punches, and interview the facility failed to ensure licensed staff (Registered Nurse or Licensed Practical Nurse) was on duty for 1 shift (1 hour 15 minutes on 5/17/2022) of 46 shifts reviewed affecting 5 patients (#2, #3, #4, #5, and #6) of 10 patients reviewed.

The findings include:

Review of the facility's policy "Clinical Staffing" dated 8/4/2020 showed "Nursing...A registered nurse qualified by education and experience in the care of the mentally ill provides leadership to the nursing staff on the unit...A minimum of two nursing staff are assigned and are present on the inpatient unit at all times. These two nursing staff should be licensed nurses, of which one is always a registered nurse...When a deviation from this staffing pattern occurs, the second nursing staff may be a qualified mental health technician or nurse's aide..."

Medical record review showed Patient #2 was admitted to the facility from 4/6/2022-5/18/2022 with diagnoses including Dementia, Agitation, Aggression, Major Depressive Disorder and Anxiety. There was no documentation to indicate Patient #2 had behaviors of agitation or aggression on 5/17/2022.

Medical record review showed Patient #3 was admitted to the facility from 4/19/2022-5/20/2022 with diagnoses including Dementia with Behavioral Disturbance, Agitation and Aggression. There was no documentation to indicate Patient #3 had behaviors of agitation or aggression on 5/17/2022.

Medical record review showed Patient #4 was admitted to the facility from 4/29/2022-5/18/2022 with diagnoses including Dementia with Behavioral Disturbance, Agitation, and Aggression. There was no documentation to indicate Patient #4 had behaviors of agitation or aggression on 5/17/2022.

Medical record review showed Patient #5 was admitted to the facility from 5/26/2022-6/7/2022 with diagnoses including Dementia with Behavioral Disturbance, Agitation, and Aggression. There was no documentation to indicate Patient #5 had behaviors of agitation or aggression on 5/17/2022.

Medical record review showed Patient #6 was admitted to the facility from 5/4/2022-5/24/2022 with diagnoses including Dementia with Behavioral Disturbances, Agitation, and Aggression. There was no documentation to indicate Patient #6 had behaviors of agitation or aggression on 5/17/2022.

Review of employee time punches showed there were 2 Certified Nurse Assistants and no licensed staff (Registered Nurse or Licensed Practical Nurse) on duty between 5:45 PM-7:00 PM (1 hour 15 minutes) on 5/17/2022.

Review of the facility census (number of patients) showed there were 5 patients in the facility on 5/17/2022.

During an interview on 8/16/2022 at 12:00 PM, in the conference room the Nursing Home Administrator (assisted with investigation) confirmed the Psychiatric Nurse Practitioner of the behavioral health facility notified her there was "...no nurse in the building [behavioral health facility]..." on the evening of 5/17/2022. The Nursing Home Administrator stated the Certified Nurse Assistants (CNA's) were told the Licensed Practical Nurse (LPN) stationed on the other side of the door (the nursing home and behavioral health facility were separated by locked double doors) would assist them in the event of an emergency.

During an interview on 8/17/2022 at 1:20 PM, in the conference room, the Nursing Home Administrator verified the behavioral health facility's census (number of patients) was 5 on 5/17/2022 and confirmed there were no licensed staff in the behavioral health facility from 5:45 PM-7:00 PM on 5/17/2022.

During an interview on 8/17/2022 at 1:35 PM, in the conference room, LPN #1 stated she agreed to work at the facility from 9:00 AM-5:00 PM on 5/17/2022. LPN #1 stated she notified the Nursing Home Administrator there was not a RN or LPN in the facility to relieve her on 5/17/2022. LPN #1 confirmed there were only 2 CNA's on duty at the facility when she left on 5/17/2022.

During a telephone interview on 8/17/2022 at 2:30 PM, the Behavioral Health Nurse Manager stated the Nursing Home Administrator informed her there were no licensed staff, only 2 CNA's, in the behavioral health facility the evening of 5/17/2022. The Behavioral Health Nurse Manager confirmed there were only 2 CNA's in the facility when she arrived for her shift at 7:00 PM on 5/17/2022.

During a telephone interview on 8/18/2022 at 2:00 PM, CNA #1 confirmed there were only 2 CNA's, no licensed staff, in the behavioral health facility when she arrived for one 7:00 PM shift (she could not recall the date).

During a telephone interview on 8/18/2022 at 3:35 PM, the Chief Executive Officer (CEO) stated "...staffing was a mess..." due to COVID. He stated the LPN had made it known she would have to leave at 5:00 PM. The CEO stated the Nursing Home Administrator contacted him around 5:30 PM on 5/17/2022 and notified him the LPN (#1) had left and there were no RN's or LPN's in the facility.

During a telephone interview on 8/19/2022 at 3:50 PM, the Psychiatric Nurse Practitioner stated she had called the facility on the evening of 5/17/2022 and was told there were no RN's or LPN's present in the facility.

Based on review of facility policy, medical record review, and interview the facility failed to ensure social services was provided for 8 patients (#1, #2, #3, #4, #5, #6, #7, and #10) of 10 patients reviewed.

The findings include:

Review of the facility's policy "Program Elements" dated 8/14/2018 showed "...Group Therapy Sessions...Are conducted daily by a master's prepared/or qualified staff..."

Review of the facility's policy "Philosophy Of Treatment/Scope of Service" revised 7/15/2020 showed "...This Program provides 24-hours a day intensive interdisciplinary treatment through a patient centered, trauma sensitive recovery model of care for patient 55 years or older with acute psychiatric disorders, and cognitive impairment while addressing and treating co morbid medical conditions..."

Review of the facility's policy "Clinical Staffing" dated 8/4/2020 showed "...Social Services...A master's prepared social worker monitors and evaluates the quality and appropriateness of social services provided...A minimum of one qualified social worker by experience and education provides services for up to 10 patients..."

Medical record review showed Patient #1 was admitted to the facility from 5/25/2022-6/3/2022 with diagnoses including Major Depressive Disorder, Recurrent Severe without Psychotic Features, Suicidal Ideations, and Dementia. There was no documentation to show Patient #1 was evaluated by social services or that social services was provided for the patient.

Medical record review showed Patient #2 was admitted to the facility from 4/6/2022-5/18/2022 with diagnoses including Dementia, Agitation, Aggression, Major Depressive Disorder and Anxiety. There was no documentation to show Patient #2 was evaluated by social services or that social services was provided for the patient.

Medical record review showed Patient #3 was admitted to the facility from 4/19/2022-5/20/2022 with diagnoses including Dementia with Behavioral Disturbance, Agitation and Aggression. There was no documentation to show Patient #3 was evaluated by social services or that social services was provided for the patient.

Medical record review showed Patient #4 was admitted to the facility from 4/29/2022-5/18/2022 with diagnoses including Dementia with Behavioral Disturbance, Agitation, and Aggression. There was no documentation to show Patient #4 was evaluated by social services or that social services was provided for the patient.

Medical record review showed Patient #5 was admitted to the facility from 5/26/2022-6/7/2022 with diagnoses including Dementia with Behavioral Disturbance, Agitation, and Aggression. There was no documentation to show Patient #5 was evaluated by social services or that social services was provided for the patient.

Medical record review showed Patient #6 was admitted to the facility from 5/4/2022-5/24/2022 with diagnoses including Dementia with Behavioral Disturbances, Agitation, and Aggression. There was no documentation to show Patient #6 was evaluated by social services or that social services was provided for the patient.

Medical record review showed Patient #7 was admitted to the facility from 4/28/2022-5/17/2022 with diagnoses including Dementia with Behavioral Disturbance, Agitation, and Aggression. There was no documentation to show Patient #7 was evaluated by social services or that social services was provided for the patient.

Medical record review showed Patient #10 was admitted to the facility from 1/10/2022-5/5/2022 with diagnoses including Anxiety, Dementia, Hypertension, and Gastroesophageal Reflux Disease. There was no documentation to show Patient #10 was evaluated by social services or that social services was provided for the patient.

During an interview on 8/16/2022 at 2:00 PM, in the conference room, the Human Resources (HR) Director stated the Social Worker's last day of employment was 12/18/2021 and confirmed the facility had not had a social worker since that time.

During a telephone interview on 8/18/2022 at 12:47 PM, the previous Chief Nursing Officer stated the facility did not have anyone to sit down and have 1:1 therapy sessions with the patients after the Social Worker walked out.

During a telephone interview on 8/18/2022 at 3:35 PM, the Chief Executive Officer (CEO) stated the Social Worker "...walked out..." with no notice at the end of 12/2021 and confirmed the facility had not had a Social Worker since that time.

Based on review of facility policy, medical record review, and interview the facility failed to ensure consistent availability and provision of therapeutic activities for 6 patients (#1, #2, #3, #4, #6, and #7) of 10 patients reviewed.

The findings include:

Review of the facility's policy "Program Elements" dated 8/14/2018 showed "...Occupational/Recreation/Activity Groups...Conducted daily or as prescribed by state regulation..."

Review of the facility's policy "Philosophy Of Treatment/Scope of Service" revised 7/15/2020 showed "...This Program provides 24-hours a day intensive interdisciplinary treatment through a patient centered, trauma sensitive recovery model of care for patient 55 years or older with acute psychiatric disorders, and cognitive impairment while addressing and treating co morbid medical conditions..."

Review of the facility's policy "Clinical Staffing" dated 8/4/2020 showed "...The therapeutic activity program is provided by qualified therapists, support personnel, and consultants..."

Medical record review showed Patient #1 was admitted to the facility from 5/25/2022-6/3/2022 with diagnoses including Major Depressive Disorder, recurrent severe without Psychotic Features, Suicidal Ideations, and Dementia. There was no documentation to indicate Patient #1 received recreational activities/therapy on 5/27/2022 and 5/28/2022 (2 of 8 days).

Medical record review showed Patient #2 was admitted to the facility from 4/6/2022-5/18/2022 with diagnoses including Dementia, Agitation, Aggression, Major Depressive Disorder and Anxiety. There was no documentation to indicate Patient #2 received recreational activities/therapy on 5/12/2022, 5/13/2022, 5/14/2022, 5/15/2022, or 5/16/2022 (5 of 22 days).

Medical record review showed Patient #3 was admitted to the facility from 4/19/2022-5/20/2022 with diagnoses including Dementia with Behavioral Disturbance, Agitation and Aggression. There was no documentation to indicate Patient #3 received recreational activities/therapy on 5/11/2022, 5/12/2022, 5/13/2022, 5/14/2022, 5/15/2022, and 5/16/2022 (6 of 31 days).

Medical record review showed Patient #4 was admitted to the facility from 4/29/2022-5/18/2022 with diagnoses including Dementia with Behavioral Disturbance, Agitation, and Aggression. There was no documentation to indicate Patient #4 received recreational activities/therapy on 5/11/2022, 5/12/2022, 5/13/2022, 5/14/2022, 5/15/2022, and 5/16/2022 (6 of 19 days).

Medical record review showed Patient #6 was admitted to the facility from 5/4/2022-5/24/2022 with diagnoses including Dementia with Behavioral Disturbances, Agitation, and Aggression. There was no documentation to indicate Patient #6 received recreational activities/therapy on 5/10/2022, 5/11/2022, 5/12/2022, 5/13/2022, 5/14/2022, 5/15/2022, 5/16/2022, 5/20/2022, 5/21/2022, 5/22/2022, 5/23/2022, and 5/24/2022 (12 of 20 days).

Medical record review showed Patient #7 was admitted to the facility from 4/28/2022-5/17/2022 with diagnoses including Dementia with Behavioral Disturbance, Agitation, and Aggression. There was no documentation to indicate Patient #7 received recreational activities/therapy on 5/12/2022, 5/13/2022, 5/14/2022, 5/15/2022, and 5/16/2022 (5 of 19 days).

During an interview on 8/16/2022 at 2:00 PM, in the conference room, the Human Resources (HR) Director stated the Recreational Therapist last day of employment was 3/25/2022 and confirmed the facility had not had a Recreational Therapist since that time.

During an interview on 8/17/2022 at 4:00 PM, in the conference room, the Executive Director confirmed the facility had not provided daily recreational activities/therapy for Patients #3 and #4.

During an interview on 8/17/2022 at 5:00 PM, the Nursing Home Administrator (assisted with investigation) confirmed the facility had not provided daily recreational activities/therapy for Patients #1, #2, #6, and #7.