HospitalInspections.org

Based on interview, observation, record and video review the hospital failed to ensure patients' rights were protected and promoted according to the Condition of Participation: CFR 482.13 Patient's Rights. Findings:

The hospital failed to Ensure:

1 patient was protected from all forms of abuse or harassment by an employee.
Reference at A tag 145

Implemented physical restraints were identified and documented in accordance with facility policies.
Reference at A tag 159

Implemented seclusion was identified and documented in accordance with facility policies for 1 patient.
Reference A tag 162

The treatment plan was reviewed and updated based on timeframes specified by hospital policy and a treatment plan and/or plan of care reflected the current assessment and evaluation of patient cognitive and medical needs.
Reference A tag 166

Staff used facility approved physical restraint techniques for 1 patient.
Reference A tag 167

The facility was out of compliance with the Condition during the investigation. These failed practices placed patients at risk for not having their rights protected, denied them the ability to receive care in a safe environment, and protect them from abuse and/or harassment.

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Based on record review, interview, and video review the facility failed to protect 1 patient (#3) out of 10 sampled patients, from physical abuse by an employee. Specifically, the employee pulled the patient's hair when performing a brief manual hold (BMR - physical hold that restricts patient movement). The facility did not ensure the patient was protected from further harm, as the event was not reported or identified by the facility until 3 weeks after the incident. This failed practice placed the patient at risk for further abuse. Findings:

Record review on 8/26/19 revealed Patient #3 was admitted to the facility with diagnoses that included schizophrenia (fixed delusions and/or hallucinations), fetal alcohol syndrome, and history of traumatic brain injury. The Patient had a history of physical and sexual trauma in his/her past.

During an interview on 8/26/19 at 3:30 pm, when asked about Patient #3's care and restraint events, Psychiatric Nursing Assistant (PNA) #3, stated the Patient had a history of abuse and trauma.

Review of the facility's notes revealed Patient #3 had 6 BMR holds from 5:23 pm until 10:25 pm on 7/28/19.

Review of the "Brief Manual Restraint Event", dated 7/29/19 at 7:40 pm, revealed "Reason for the Brief Manual Restraint
Danger to Others
Clinical rational for Brief Manual Restraint/ denial of rights
[Patient] lunges at staff and tried to choke staff and also tried to bite [him/her] while in BMR.

Less restrictive interventions attempted before Brief Manual Restraint:
verbal intervention
Redirection
Voluntary Time Out
PRN [as needed] Medications"

Review of an earlier BMR note, dated 7/29/19 at 5:23 pm, revealed Patient #3 " ...turned and ran after peer, grabbing his hair and holding on. [Patient #3] placed in BMR while [he/she] was talked into releasing peers hair ...."

Observation on 9/3/19 at 1:11 pm of the camera footage dated 7/29/19 at 7:41 pm revealed PNA #4 and PNA #5 were escorting Patient #3 to the Oak Room (area used for seclusion, mechanical restraints and voluntary time-outs). As the staff and patient were entering the Oak Room Sally Port (area that connected the unit corridor to the Oak Room), PNA #4's hand was grasping the Patient's hair. Specifically, PNA #4 was grabbing the Patient's hair with a complete closed fist as he/she and PNA #5 were escorting the Patient to the Oak Room. Additional review of the footage revealed PNA #5 was looking directly at PNA #4's hand that was grasping the Patient's hair.

During an interview on 9/3/19 at 1:11 pm, the Director of Nursing stated this was not an approved restraint technique authorized by the facility. In addition, the Director of Nursing acknowledged PNA #5's field of vision was directed at PNA #4's hand that was grasping the Patient's hair.

Review of the facility provided incident review form, dated 8/22/19, revealed "[PNA #4], who was choked[,] grasps [Patient #3's] hair during 1st escort to Oak room ...Same PNA should have disengaged when [Patient #3's] came out of voluntary timeout and was argumentative and focused on PNA."

During an interview, on 9/3/19 at 3:22 pm, when asked about the review of the incident that occurred on 7/29/19 at 7:40 pm with Patient #3, Registered Nurse (RN) #2 stated the Quality Director, had asked for him/her to review that case to see if the facility practice of restraints and/or seclusion could be improved upon.

Review of the facility's policy "Abuse and Neglect Prevention Policy," effective date 3/14/19, revealed "DEFINITIONS ...Physical Abuse: Physical abuse is any physical act or threat of a physical act ...such as ...hair-pulling." Further review of the policy revealed any staff who were alleged to have abused or neglected a patient would have been immediately removed from patient care duties.

Review of the facility's policy "PNA Responsibilities," effective date 8/24/16, revealed "GENERAL EXPECTATIONS ...Report any inappropriate staff behavior to the Charge Nurse ...Any behavior that puts patients in jeopardy or behavior that could be [dangerous] should be reported immediately ..." Further review of the policy revealed "Treat patients with dignity and respect at all times ..."

Review of the facility's policy "Standards of Conduct," dated 6/20/18, revealed "All [API - Alaska Psychiatric Institute] Employees are prohibited from ...Physical misconduct, abusive, or lewd behaviors, including but not limited to: ...Patient abuse, neglect or serious misconduct as defined by LD-020-13-Conduct Involving Patients ...Failure to report abuse or neglect of any patient ..."

Review of the facility's policy "Conduct Involving Patients," dated 3/14/19, revealed " ...Prevention of abuse, neglect and serious misconduct are of paramount importance ...abuse, neglect, and other serious misconduct by API employees ...toward patients must be immediately reported and investigated."

Further review of the policy revealed "Abuse, Neglect, and Other Serious Unacceptable Behavior ..." included " ...Using more force than is reasonable ...The improper or illegal restraint or seclusion of patient ..."


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Based on observation, record review and interview the facility failed to ensure implemented physical restraints were identified and documented in accordance with facility policies for 1 patient (#5) out of 10 sampled patients. This failed practice created a non-therapeutic environment and increased potential for adverse psychological outcomes and injury. Findings:

Observation of the camera footage review on 9/3/19 at 1:11 pm revealed the following related to an event that occurred on 8/23/19 from 3:48 pm to 3:54 pm:

- 3:48 pm - PNA (Psychiatric Nurse Assistant) #1 transported Patient #5 into the Oak Room via ambulation and a simultaneous brief manual hold (BMR - physical restraint) from the corridor. Once in the Oak Room, PNA #1 released Patient #5 and stated "..have a seat." Next, Patient #5 attempted to walk out of the Oak Room (area used for mechanical restraints, seclusions and voluntary times outs) and PNA #1, while standing in the doorway, repeatedly stated "Have a seat." Patient #5 attempted to swing at PNA #1's waist area. PNA #1 then held Patient #5's right arm and used his/her other hand to guide the patient back to the restraint bed located in the middle of the Oak Room.

- 3:49 pm - Patient #5 stood from the bed and attempted to walk to the door. PNA #1 proceeded to meet the patient at the doorway of the Oak Room. PNA #1 instructed Patient #5 was to sit down in the Oak Room while he/she cleaned up the area outside of the Oak Room. PNA #1 then placed both hands near Patient #5's lower torso and the Patient began to swing at the PNA. The Patient was then escorted back to the bed area of the Oak Room and informed to sit down.

- 3:50 pm - Patient #5 attempted to exit the Oak Room. PNA #1 stood in front of the Patient asking him/her to stop hitting. The Patient proceeded to continue to hit the PNA. Next, PNA #2 wrapped both arms around the Patient from behind and then escorted Patient #5 back into the Oak Room. PNA #1 asked PNA #2 if Patient #5's actions were enough to "close the door." The Patient was seated on the bed. Both PNAs left the room and eventually left the area out of sight of Patient #5.

- 3:54 pm - Patient #5 stood up and walked out of the Oak Room without staff intervention.

Record review of Patient #5 medical record on 9/3/19 reveled one BMR event was documented for 8/23/19 between 3:48 pm and 3:49 pm for hitting staff at the nurses' station. Further review revealed no additional documentation of additional BMRs that were conducted in the Oak Room between 3:48 pm and 3:50 pm.

During an interview on 9/3/19 at 1:47 pm, the Director of Nursing stated the episode had three separate BMR events while reviewing the video footage of the 8/23/19 event with the Surveyor.

During an interview on 9/3/19 at 2:08 pm MANDT (a form of intervention when behaviors poses a threat and verbal de-escalation techniques) Instructor #1 stated a BMR event starts at the initiation of the physical restraint and ends when the physical restraint is released. The MANDT Instructor stated that each event would need to be documented as individual events in the patients' medical record.

Review of the facility's policy "Seclusion and Restraint," dated 1/15/19, revealed "RESTRAINT Any manual method ...that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely." Further review revealed " ...The [Registered Nurse] will assess the patient and document ...a description of the patient behaviors, physical, and mental status ...behaviors which required the need for seclusion or restraint ..."

Review of the facility's policy "Documentation Standards," dated 5/9/13, revealed "The health record reflects patient care and is used ...to reflect and document the quality of care rendered [to] the patient ...Documentation of the following must be reflected in the applicable [Electronic Medical Record - EMR] template by responsible staff ...use of emergency seclusion/restraint ..."

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Based on record review, observation and interview the facility failed to ensure an implemented seclusion was identified and documented in accordance with facility policies for 1 patient (#5) out of 10 sampled patients. This failed practice created a non-therapeutic environment and increased potential for adverse psychological outcomes and injury. Findings:

Observation of the camera footage review on 9/3/19 at 1:11 pm revealed the following related to an event that occurred on 8/23/19 from 3:48 pm to 3:54 pm:

- 3:48 pm - PNA (Psychiatric Nurse Assistant) #1 transported Patient #5 into the Oak Room via ambulation and a simultaneous brief manual hold (BMR - physical restraint) from the corridor. Once in the Oak Room, PNA #1 released Patient #5 and stated "..have a seat." Next, Patient #5 attempted to walk out of the Oak Room (area used for mechanical restraints, seclusions and voluntary times outs) and PNA #1, while standing in the doorway, repeatedly stated "Have a seat." Patient #5 attempted to swing at PNA #1's waist area. PNA #1 then held Patient #5's right arm and used his/her other hand to guide the patient back to the restraint bed located in the middle of the Oak Room.

- 3:49 pm - Patient #5 stood from the bed and attempted to walk to the door. PNA #1 proceeded to meet the patient at the doorway of the Oak Room. PNA #1 instructed Patient #5 was to sit down in the Oak Room while he/she cleaned up the area outside of the Oak Room. PNA #1 then placed both hands near Patient #5's lower torso and the Patient began to swing at the PNA. The Patient was then escorted back to the bed area of the Oak Room and informed to sit down.

- 3:50 pm - Patient #5 attempted to exit the Oak Room. PNA #1 stood in front of the Patient asking him/her to stop hitting. The Patient proceeded to continue to hit the PNA. Next, PNA #2 wrapped both arms around the Patient from behind and then escorted Patient #5 back into the Oak Room. PNA #1 asked PNA #2 if Patient #5's actions were enough to "close the door." The Patient was seated on the bed. Both PNAs left the room and eventually left the area out of sight of Patient #5.

- 3:54 pm - Patient #5 stood up and walked out of the Oak Room without staff intervention.

Record review of Patient #5 medical record on 9/3/19 reveled one BMR event was documented for 8/23/19 between 3:48 pm and 4:00 pm. Further review revealed documentation of a "Voluntary Timeout Note," dated 8/23/19 from 3:49 pm to 3:54 pm. In addition, the medical record did not contain any documentation of seclusion on 8/23/19 from 3:48 pm through 4:00 pm.

Review of the facility's policy "Seclusion and Restraint," dated 1/15/19, revealed "Seclusion ...area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior ...The decision to use a restraint or seclusion is not driven by diagnosis but by a comprehensive individual assessment." Further review revealed " ...DOCUMENTING SECLUSION ...The [Registered Nurse] will assess the patient and document ...a description of the patient behaviors, physical, and mental status ...behaviors which required the need for seclusion or restraint ..."

Review of the facility's policy "Voluntary Timeout," dated 6/4/18, revealed a timeout is defined as "A voluntary procedure used to help a patient regain emotional control that involves a staff caregiver suggesting to a patient ...the use of a quite area ...Timeout is an intervention in which the patient consents to being alone in a designated area for an agreed upon timeframe from which the patient is not physically prevented from leaving ...and from which the patient is not prevented from leaving nor given the impression that they are not allowed to leave."

Further review of the "Voluntary Timeout" policy revealed "If a patient attempts to leave the Oak Room ...and their path is block in any way, (e.g. touching the patient in any way, posturing ...) the event becomes a seclusion."

During an interview on 9/3/19 at 2:08 pm MANDT (a form of intervention when behaviors poses a threat and verbal de-escalation techniques) Instructor #1 stated when staff did not allow a patient to exit the Oak Room during a voluntary time out results in a seclusion. When asked if a staff stood between the exit and the corridor and informed the patient to remain seated in the Oak Room could result in a seclusion, the MANDT Instructor stated yes, if the patient was prevented from exiting the Oak Room and required to stay seated per staff instruction.

Review of the facility's policy "Documentation Standards," dated 5/9/13, revealed "The health record reflects patient care and is used ...to reflect and document the quality of care rendered [to] the patient ...Documentation of the following must be reflected in the applicable [Electronic Medical Record - EMR] template by responsible staff ...use of emergency seclusion/restraint ..."

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Based on record review, observation and interview the facility failed to ensure: 1) the treatment plan was reviewed and updated based on timeframes specified by hospital policy and 2) a treatment plan and/or plan of care reflected the current assessment and evaluation of patient cognitive and medical needs. These failed practices placed 1 patient (#5) out of 10 patients reviewed at risk for receiving less that optimal and therapeutic care and services. Findings:

1) Treatment Plan/Plan of Care Reviews:

Record review of Patient #5's "Treatment Plan Review," dated 7/15/19, revealed the Patient was involved in eight BMR (brief manual hold - type of physical restraint) from 7/8/19 to 7/14/19.

Record review of Patient #5's "Treatment Plan Review," dated 8/12/19, revealed the area under "Restraint and Seclusion Review" was blank and did not indicated any seclusions or restraints since the last review date of 7/15/19. Additional review revealed "Risk for Violence-Others Directed," as several instances of aggressive behavior and responds better with visual representations or gestures to come with staff rather than verbal prompt. Further review revealed an identified issue of "Brief Manual Restraint Closed as of 7/18/19."

Review of the facility provided document "[Alaska Psychiatric Institute] MANUAL HOLD, RESTRAINT AND SECLUSION EVENTS," event dates from 7/14/19 to 8/18/19, revealed the Patient had seven BMR episodes.

Observation on 9/3/19 at 1:11 pm, of the camera footage of a restraint/seclusion event on 8/23/19 from 3:48 pm to 3:54 pm, revealed Patient #5 was placed in three BMRs. Further observation revealed the Patient was placed in the Oak Room without release criteria or indication of his/her freedom to leave, as well as, prevented from leaving by staff. This resulted in an undocumented and unidentified seclusion.

Record review of Patient #5 medical record on 9/3/19 reveled one BMR event was documented for 8/23/19 between 3:48 pm and 4:00 pm. Further review revealed documentation of a "Voluntary Timeout Note," dated 8/23/19 from 3:49 pm to 3:54 pm. In addition, the medical record did not contain any documentation of additional BMRs and a seclusion on 8/23/19 from 3:48 pm through 4:00 pm.

During an interview on 9/3/19 at 1:47 pm the Director of Nursing identified three separate BMR events while reviewing the video footage of the 8/23/19 event with the Surveyor. The Director of Nursing further stated due to the cognitive status of Patient #5, he/she would not be able to understand release criteria or expectations of a voluntary time out.

Record review on 9/3/19 of Patient #5's Master Treatment Plan [MTP] with an identified issue of "Risk for violence: Other Directed," last updated 8/11/19, revealed the Patient has a diagnosis of Dementia with aggressive behaviors toward others. Further review revealed staff were to offer the Patient the opportunity to sit in a chair located in the hallway when agitated. In addition, the treatment plan did not reflect BMRs or Seclusions that occurred between 7/15/19 and 8/23/19.

Review of the facility's policy "Treatment Planning," dated 8/30/19, revealed "Problems may be identified by any discipline beginning at the time of admission and continuing throughout hospitalization. The MTP Problem List includes each identified active and deferred problem ...When a patient requires seclusion or restraint, the MTP will be updated ...The problem will remain open for the duration of the patient's admission and will be closed upon discharge."

Further review of the policy "Treatment Planning" revealed "The MTP is reviewed using the MTP Review Form, and each objective is measured for progress toward goals at the following times: ...When the patient requires seclusion or restraint."


2a) Treatment Plan/Plan of Care Reflect Patients Current Medical Needs:

Record review of a "[LIP -Licensed Individual Practitioner] Physiatrist Progress Note," dated 8/22/19, revealed diagnosis that included dementia with behavior disturbances; violent behaviors; paranoid schizophrenia; neurocognitive disorder. Further review revealed the Patient was not oriented to time, place or situation; impaired short term memory; and inadequate attention span/concentration. Review of the progress note revealed a section titled "Changes since last encounter ..." which revealed the facility had received an involuntary medication petition which included the use of divalproex sprinkles (a medication typically used to treat various types of seizures, migraines and bipolar disorder). The medication petition also grated "mandatory/involuntary phlebotomy [act of drawing blood] for metabolic functioning and valproic acid levels [blood test to determine levels of divalproex/valproic acid in the blood]."

During an interview on 8/30/19 at 10:50 am LIP #1 stated that the Patient needed to be prescribed divalproex sprinkles, which required important and medically necessary blood test. LIP #1 further stated the Patient's liver function and medication levels in the blood needed to be tested to ensure the body could handle the medication and maintain therapeutic levels in the blood. In addition, the LIP stated that Patient #5 was cognitively impaired and would not allow staff to draw blood so the facility obtained a court order to physically restraint the patient each time a blood test needed to be conducted. The LIP stated he/she started the medication on 8/22/19 and the Patient had to be restrained to obtain blood samples.

2b) Treatment Plan/Plan of Care Reflect Patients Current Cognitive Needs:

Observation on 9/3/19 at 1:11 pm of the camera footage of an event on 8/23/19 from 3:48 pm to 3:54 pm revealed Patient #5 was placed in Oak Room without release criteria or indication of his/her freedom to leave, as well as, prevented from leaving by staff indicating the Patient had to sit in the Oak Room and intervened when Patient walked out of the Oak Room.

Record review of Patient #5 medical record on 9/3/19 reveled documentation of a "Voluntary Timeout Note," dated 8/23/19 from 3:49 pm to 3:54 pm. In addition, the medical record did not contain any documentation of a seclusion event on 8/23/19 from 3:48 pm through 4:00 pm.

Review of the facility's policy "Voluntary Timeout," dated 6/4/18, revealed a timeout is defined as "A voluntary procedure used to help a patient regain emotional control that involves a staff caregiver suggesting to a patient ...the use of a quite area ...Timeout is an intervention in which the patient consents to being alone in a designated area for an agreed upon timeframe from which the patient is not physically prevented from leaving ...and from which the patient is not prevented from leaving nor given the impression that they are not allowed to leave."

Further review of the "Voluntary Timeout" policy revealed "If a patient attempts to leave the Oak Room ...and their path is block in any way, (e.g. touching the patient in any way, posturing ...) the event becomes a seclusion."

During an interview on 9/3/19 at 1:47 pm, the Director of Nursing stated due to the cognitive status of Patient #5, he/she would not be able to understand release criteria or expectations of a voluntary time out. The DON further stated that a review of the Patient's behavior plan would need to have been conducted to identify any interventions that were to be used during a voluntary time out.

Review of Patient #5's "Individualized Behavioral Plan," updated 6/12/19, revealed the plan was focused around providing care during episode of incontinence and self-care. Further review revealed no individualized interventions pertaining to restraint, seclusion or voluntary time out expectations as it related to the Patient's impaired cognitive function.

Record review of Resident #5's most recent "Treatment Plan Review," dated 8/12/19, revealed no individualized interventions pertaining to restraint, seclusion or voluntary time out expectations as it related to the Patient's impaired cognitive function.

Review of the facility's policy "Treatment Planning," dated 8/30/19, revealed "TREATMENT PLAN REVIEWS ...The MTP is reviewed using the MTP Review Form, and each objective is measured for progress toward goals at the following times ... When there is a significant change in the patient's condition or diagnosis ...When a patient requires seclusion or restraint."

Record review on 9/3/19 of Patient #5's Master Treatment Plan, last updated 8/11/19, revealed no individualized interventions pertaining to restraint, seclusion or voluntary time out expectations as it related to the Patient's impaired cognitive function.

Review of the facility's policy "Treatment Planning," dated 8/30/19, revealed "[API Alaska Pyschiatric Institute] will develop and keep current a Master Treatment Plan (MTP) for each patient, based on multi-disciplinary assessments..."

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Based on observation, interview and record review the facility failed to ensure staff used facility approved physical restraint techniques for 1 (#3) out 10 patients reviewed. This failed practice resulted in the patient receiving less than optimal therapeutic care and services, as well as, increased the risk of injury. In addition, this failed practice resulted in the patient enduring abusive behaviors imposed by an employee. Findings:

Observation on 9/3/19 at 1:11 pm of the camera footage dated 7/29/19 at 7:41 pm revealed PNA #4 and PNA #5 were escorting Patient #3 to the Oak Room (area used for seclusion, mechanical restraints and voluntary time-outs). As the staff and patient were entering the Oak Room Sally Port (area that connected the unit corridor to the Oak Room), PNA #4's hand was grasping the Patient's hair. Specifically, PNA #4 was grabbing the Patient's hair with a complete closed fist as he/she and PNA #5 were escorting the Patient to the Oak Room. Additional review of the footage revealed PNA #5 was looking directly at PNA #4's hand that was grasping the Patient's hair.

During an interview on 9/3/19 at 1:11 pm, the Director of Nursing stated this was not an approved restraint technique authorized by the facility. In addition, the Director of Nursing acknowledged PNA #5's field of vision was directed at PNA #4's hand that was grasping the Patient's hair.

Review of the facility's employee training records revealed PNA #4 and PNA #5 had received restraint training prior to the event.

Review of the facility's policy "Standards of Conduct," dated 6/20/18, revealed "All [API - Alaska Psychiatric Institute] Employees are prohibited from ...Physical misconduct, abusive, or lewd behaviors, including but not limited to: ...Patient abuse, neglect or serious misconduct as defined by LD-020-13-Conduct Involving Patients ...Failure to report abuse or neglect of any patient ..."

Review of the facility's policy "Conduct Involving Patients," dated 3/14/19, revealed " ...Prevention of abuse, neglect and serious misconduct are of paramount importance ...abuse, neglect, and other serious misconduct by API employees ...toward patients must be immediately reported and investigated."

Further review of the policy revealed "Abuse, Neglect, and Other Serious Unacceptable Behavior ...Using more force than is reasonable ...The improper or illegal restraint or seclusion of patient ..."

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Based on interview and observation the facility failed to ensure nursing care was assigned to competent nursing personnel. Specifically, the facility failed to ensure nursing staff assigned to oversee patient care of 2 of 3 units were provided with shift-specific orientation. This failed practiced placed 36 out of 43 patients at risk for receiving less than optimal care. Findings:

During an interview on 8/27/19 at 7:05 pm, Registered Nurse (RN) #4 stated he/she had not had any type of formal orientation on night shift nursing duties. The RN further stated that RNs get three weeks of classroom orientation and three orientation days on the floor during the day shift. RN #4 further stated that he/she had been switched to night shift recently. In addition, the RN stated he/she did not feel comfortable working any part of the night shift without any training or orientation specific to night shift nursing duties. RN #4 stated further concern as he/she was scheduled to work several night shifts in the next week without any orientation or preceptor.

During an observation on 8/27/19 at 7:43 pm RN #4 received an admission and stated he/she was unsure how to call the provider for admission orders. The RN stated feeling overwhelmed as medication pass needed to be completed at the same time as an admission. The RN contacted the Nursing Supervisor (NS) #1 for assistance. The Supervisor directed the RN to complete medication pass. No additional support or direction from the Supervisor was observed at that time.

During the same observation, RN #4 made several errors in asking for orders and documenting the provider's request. These errors were corrected by RN #5 during the telephone call with the provider.

During an interview on 8/27/19 at 8:12 pm RN #5, who was the day nurse, stated he/she did not feel comfortable leaving RN #4 as he/she could see how overwhelmed RN #4 was with the new admission process and medication pass. RN #5 further stated he/she decided to stay and help since the supervisor didn't send RN #5 any support. When asked what the expectation was when nursing staff got overwhelmed or needed help with unfamiliar process, RN #4 stated the house supervisor should have come to assist or provided support to RN #4. RN #5 further stated he/she was not scheduled to stay and assist RN #4 on a predetermined basis.

During an interview on 8/27/19 at 8:15 pm, RN #5 stated he/she had never called for admission orders for a new patient and was unsure how that process was conducted.

During an interview on 8/27/19 at 8:30 pm the NS #1 stated that RN #4 was a new nurse to the facility and new to night shift. NS #1 further stated that RN #4 had never been alone on nights before. When asked about the simultaneous event of receiving an admission and medication pass, NS #1 stated RN #4 was overwhelmed and required additional assistance and education.

During an interview on 8/27/19 at 8:35 pm RN #3 stated that recently day shift nurses had been informed they were to work night shift for the next two weeks. When asked what orientation he/she had on nights, RN #3 stated he/she received three weeks of classroom orientation and three orientation days on the nursing unit during day shift. The RN further stated that 8/27/19 was his/her first shift on nights and did not receive any formal training on night shift duties prior to working that night shift. RN #3 further stated that he/she was scheduled to work additional night shifts during that week. When asked about staffing and safety, the RN stated that an additional nurse would have been helpful while he/she learned the responsibilities of a night shift nurse.

During an interview on 8/30/19 at 3:46 pm Trainer #1 stated new nursing employees should have received three weeks classroom orientation and three orientation days on the shift in which they were assigned. Trainer #1 further stated if a change in shift occurred, the nursing employee should have received orientation on the new shift duties and responsibilities. In addition, Trainer #1 stated that while on orientation the nursing employee should not have been counted as a primary nurse and should have an experienced nurse assigned to that shift and unit. When asked if a unit required two nurses, based on facility determined ratios, and there was a nurse in orientation how should staffing have been set up, Trainer #1 stated two established and experienced nurses should have been assigned and the nurse being oriented would have been a third nurse.

Record review of the facility's form "[Registered Nurse] CLINICAL SKILLS CHECKLIST," revision date 7/11/16, revealed 9 areas of skills specific to night shift nurses.

Review of the facility's policy "Nursing Responsibilities," dated 4/6/15, revealed "Employees are responsible for knowing and following Hospital Policy & Procedures (P&Ps) and Nursing Department Procedures (NPDs)." Additional review of the same policy, updated 8/30/19 revealed the same expectation for nursing responsibilities.

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