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Based on review of policies and procedures, hospital documents and staff interviews, it was determined the hospital failed to ensure the hospital was staffed with the required number of staff to provide nursing care as needed for one shift as evidenced by one (1) Registered Nurse (RN) assigned to the entire census of 20 patients for a twelve (12) hour night shift with no other staff working. This deficient practice poses a risk to the health and safety of patients and staff, when the hospital does not have the number of personnel that are required to meet the needs of the patients.

Findings include:

Policy titled "Nursing Acuity Plan" revealed: " ...Purpose: The hospital is dedicated to the provision of quality nursing care and maintenance of a safe environment for patients ...General Information: Staffing Plan: ...Core Staffing Matrix per unit: ...Inpatient Programs for Nights (7pm-7am)-Includes weekends and holidays: 1-9 Patients: 1 Nurse and 1 Aide/Tech; 10-20 Patients: 2 Nurses and 2 Aides/Techs; 21-24 Patients: 3 Nurses and 3 Aides/Techs ...Daily Staffing: The hospital utilizes twelve (12) hour shifts to provide continuous twenty-four (24) hour coverage. The Registered Nurse on the patient unit completes the acuity classification for the patient prior to the final determination of the next shift. It is the responsibility of the Registered Nurse on the nursing unit to make the nurse staff/patient shift assignments ...Acuity Assignment: ...4. A Registered Nurse is available 24 hours a day to evaluate the need for making staffing changes ...5. At all times nursing administration has ultimate responsibility for providing adequate staff coverage to provide a safe therapeutic environment ...."

Policy titled "Organizational Performance Improvement" revealed: " ...Mission: We provide unparalleled service excellence to our patients ...."

Policy titled "Patient Rights and Responsibilities" revealed: " ...Procedure:..You have the right to: ...16. Receive meaningful access to high quality health care ...18. Receive care in a safe setting ...."

Hospital document titled " NeuroPsychiatric Hospitals Patient Acuity Tool" revealed: " ...Low Acuity Patient (1): Minimal monitoring needed; No history , thoughts or plans of self-injury; Not currently hallucinating or having unpredictable behaviors; Independent with ADLs; No or low risk for falls; No medical equipment used. Moderate Acuity Patient (2): Patient has a history of suicidal ideation, self- injury, or homicidal ideation; Patient has hallucinations or delusions but is easily redirected; Sliding scale insulin; Oxygen/CPAP at night; Self-catherization & I&O's; Occasional Incontinence. Complex Acuity Patient (3) Patient at high risk to become aggressive or self-injurious; Patient is actively Psychotic or impulsive; Requires partial assistance with toileting, showering, transfers, feeding& ambulating; Foley catheter with I&Os; Continuous O2. High Acuity Patient (4): 1:1 monitoring; Patient has current intent for suicide, self-harm, or harm to others; Delusions, hallucinations or sexual inappropriateness that is putting others at risk for harm; Requires full assistance with toileting, showering, transfers, and feedings; Frequent incontinence; Has fallen during the past 24 hours; Uncontrolled DM requiring close monitoring; Cardiac symptoms requiring EKG and potential send out ...."

Hospital document titled "Schedule" dated 10/31/2021 revealed the following staff scheduled to work the night shift 6:00 pm to 6:30 am: One (1) Registered Nurse (RN). Further review of the schedule revealed no other nursing staff or Aides/Techs were scheduled for that shift.

Hospital document titled "Night Shift Assignment Sheets" dated 10/31/2021 revealed One (1) RN was assigned the entire unit of 19 patients, with an admission during the shift to increase the census to 20 patients. Further review of the assignment sheet revealed "No Techs tonight" written in the Tech assignment section of the form. Further review revealed in the section "sick calls" one (1) RN had called in sick for the shift.

Hospital document titled "Daily Staffing Report" dated 10/31/2021 revealed one (1) RN was assigned to work the night shift for 10/31/2021.

Employee # 3 (Director of Nursing/DON) confirmed during the one-on-one interview conducted on 12/28/2021 that there was only one (1) RN working the night shift on 10/31/2021 with no additional staff members scheduled for that shift. Employee #3 acknowledged that having only one (1) nurse with no additional staff for entire shift was unacceptable. Employee #3 stated the expectation is that there are two (2) nurses on every shift, regardless of the census, and a minimum of two (2) aides/techs on every shift.

Based on review of policies and procedures, documents, medical records, and interview, the department determined the hospital failed to ensure that provider telephone orders were authenticated within 48 hours of the order being placed. This deficient practice poses a potential risk to the health and safety of patients due to an increased risk of medical errors that may lead to an adverse patient event.

Findings include:

Policy titled "Verbal-Written Orders-General Practices" revealed: " ...3. Verbal/Telephone Orders ...c. Telephone orders shall be used only when necessary to provide patient care when the Provider is not readily available on-site ...k. The prescribing practitioner must sign the written record of the verbal/telephone order in accordance with the Rules and Regulations of the Medical Staff ...."

Document titled "Rules and Regulations of the Medical Staff" revealed: " ...f. ORDERS All orders must be appropriately authenticated by the responsible provider. Authentication of all diagnostic and therapeutic orders, including telephone orders...shall be obtained ...The practitioner who gives the telephone order, or another provider from the same group is required to sign, date and time the order promptly. Telephone orders must be authenticated within 48 hours with the signature dated and timed ...."

Medical Records reviewed for eight (8) patients (Patient #3, Patient #4, Patient #5, Patient #11, Patient #13, Patient #14, Patient #15, and Patient #16) revealed that ten (10) telephone orders had not been authenticated by a provider, with the oldest order not being signed was dictated on 11/23/2021, 21:05.

Employee #1 confirmed during an interviewed conducted on 12/29/2021, that s/he has reviewed all of the facilities contracts. Employee #1 acknowledged that the Psychiatry group has not been acknowledging their telephone orders and that s/he has contacted the provider regarding this issue.

Based on the review of hospital documents and in a one-on-one interview, the Department determined that the hospital failed to ensure group therapy was provided to patients per their treatment plan. The deficient practice of not providing group therapy to patients per their treatment plan poses the potential risk of delayed and prolonged treatment of patients in the facility including extended hospital stays and ineffective treatments.

Findings include:

Hospital document titled "November Group Calendar" revealed five (5) groups scheduled for Mondays in November.

Sign in sheets for all groups on 11/29/2021 were requested. Two (2) documents titled "Social Work Daily Groups and Individual Sessions" were received dated 11/29.

Medical record for Patient #8 dated 11/17/2021, revealed that an Interdisciplinary Treatment Plan included goals to attend group therapy as part of her/his treatment goal and patient interventions while in the facility.

Employee #11 confirmed in a one-on-one interview that the only group therapy provided to the patients was on 11/29/2021.