HospitalInspections.org

Based on review of hospital documents, policies/ procedures, medical records, observation, and interview, it was determined the hospital failed to protect and promote each patient's rights as evidenced by:

(A144) failing to provide care to patients in a safe setting;

(A168) failing to use restraint or seclusion in accordance with the order of a physician or other licensed independent practitioner (LIP);

(A175) failing to monitor the patient who is restrained or secluded at an interval determined by hospital policy; and

(A178) failing to assure that a patient is seen face-to-face within 1 hour after the initiation of a seclusion or restraint used for the management of violent or self-destructive behavior.

The cumulative effect of these systemic problems resulted in the hospital's failure to protect and promote each patient's rights.

Based on review of hospital documents, policies and procedures, observation, interview, and review of nationally accepted standards, it was determined that the hospital failed to provide a safe setting for patient care as evidenced by:

1. failure to provide procedural guidelines and equipment necessary to meet patient care needs during respiratory distress and failure to provide equipment listed on the Code Bag Inventory for use in other patient emergencies; and

2. failure to limit patient access to hazardous items.

Findings include:

1. Review of facility document titled "...Inpatient Program Description..." revealed: "...Detoxification:The hospital provides short-term medical detoxification services for Alcohol, Benzodiazepines and Opiates. Services are available 24 hours a day, seven days a week...The patient will be monitored and evaluated during the detoxification process by medical and nursing staff...Alcohol detoxification...Treatment will be offered for withdrawal symptoms such as tremor, diaphoresis, tachycardia, nausea, vomiting...Benzodiazepine detoxification...withdrawal symptoms as described above for Alcohol...."

Review of the DSM-IV-TR, Alcohol Withdrawal 291.81 revealed: "...the withdrawal syndrome includes...nausea or vomiting; and rarely, grand mal seizures...Sedative, Hypnotic, or Anxiolytic Withdrawal 292.0...This withdrawal syndrome is characterized by...nausea sometimes accompanied by vomiting...A grand mal seizure may occur in perhaps as many as 20%-30% of individuals undergoing untreated withdrawal from these substances...."

Review of the hospital policy/procedure titled Code Blue revealed: "...If a patient appears to be in cardiac or respiratory distress or evidences some other type of emergent physical ailment, a 'Code blue' will be initiated and all available clinical staff will respond...."

The policy/procedure does not contain procedural guidelines regarding responding to a patient in respiratory distress. It does contain a statement: "...Staff should initiate First Aid, as appropriate, or begin basic life support using CPR guidelines & responding staff members will bring a 'Code Bag' to the scene...." It does not contain procedural guidelines regarding initiating CPR, applying oxygen, utilizing an oropharyngeal airway or suctioning a patient via the oral cavity to prevent aspiration of oral secretions or vomitus.

Review of the contents of the "Code Bag" available to staff for Unit 100 and Unit 300 revealed that it contained an oxygen tank and two ambu bags. Neither ambu bag had a mask attached or immediately accessible for use with the ambu bag. The list titled Code Bag Inventory included "EMP pocket mask with O2 inlet." The Code Bag did not contain this mask. One Ambu bag had no tubing to connect to the oxygen tank. The Code Bag contained no oropharyngeal airways or a suction machine.

In addition, the Accucheck test strips in the bag expired 12/31/09. The bag contained no gloves (as listed on the inventory).

The Director of Nursing confirmed, on 8/11/10, that the Code Bag did not contain the tubing (to connect the Ambu bag to the oxygen tank), the masks (including the EMP pocket mask with O2 inlet) and the gloves. She also confirmed that the Code Bag is not stocked with oropharyngeal airways and that the medical staff determined that no suction machine would be available. She confirmed that the small blue bulb syringe in the Code Bag, packaged with "Ear Syringe" on the wrapper, is to be used for suctioning patients.

She also confirmed that the Accucheck test strips were expired .

Review of the 6/24/09 Utilization Management Committee Minutes revealed: "...(_____) expressed concern regarding the suction machine availability during a code blue...(CEO) reported that there is one in the hospital, but we are to just take the Emergency Bags to codes...The committee recommended that (Medical Director) request bulb syringe in case the patient aspirates...."

Review of product information for a "Bulb Syringe Aspirator 3 Ounce" revealed: "...is an efficient way to clear nasal passages in infants and newborns...."

Review of the Medical Executive Committee meeting Minutes of 6/26/09 revealed: "...(Medical Director) asked the physicians if they felt that we need a suction machine or if the syringe bulbs were appropriate...(Internist)...here...we are not performing aggressive CPR...The committee further recommended approval of the syringe bulbs at this time but for (Director of Nursing) to continue researching what other facilities are using...."

Review of the facility document titled "...Inpatient Program Description..." revealed: "...Population Served...Adults...Adolescents, age 13-17...A 12.6 year old child may be considered for admission...."
Infants are not admitted to the facility.

The Director of Nursing confirmed, on 8/11/10, that the medical staff had determined that a suction machine would not be available for use at the facility, and that the blue bulb syringe in the Code Bag is to be used in its place.

2. Review of the facility document titled "...Inpatient Program Description..." revealed: "...is a Level I Psychiatric Acute Hospital...Criteria for Admission & Re-admission...patients must meet the diagnostic criteria of the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revised) and one or more utilization criteria for hospitalization as follows: Behavior which is life threatening, destructive or disabling to self or others...Actively or potentially suicidal, assaultive or homicidal threats, plans or attempts in the past 24 hours...Acute mania...Behaviors which require continuous observation, rapid tranquilization, seclusion and/or restraint...."

On 8/5/10, during tour of Units 200, 300, and 500, the fire extinguishers were observed to be easily accessible by patients from the hallway which leads to and from all of the patient rooms. The compartment doors were easily opened. The extinguisher tanks easily lifted and removed from the compartment providing potential harm to self or others.

The American Institute of Architects' 2006 Guidelines for Design and Construction of Health Care Facilities, pp. 60 & 61 revealed: "...3.8 Psychiatric Nursing Unit...A3.8.1.4 A safe environment is critical...Patients of inpatient psychiatric treatment facilities are considered at high risk for suicide; the environment should avoid physical hazards while maintaining a therapeutic environment...Staff awareness of their environment, latent risks of that environment, and the behavior risks and needs of the patient served in the environment are absolute necessities...."

On 8/5/10, the Director Risk Management/Quality confirmed that the fire extinguishers were easily accessible.

Based on review of hospital policy and procedure, medical records and interview, it was determined the hospital failed to assure that the use of seclusion and/or restraint was in accordance with the order of a licensed independent practitioner for 1 of 1 patients that required one or more renewal orders for seclusion/restraint (patient #23).

Findings include:

Review of hospital policy/procedure titled Seclusion and Restraint required: "...S/R may never be used on an as needed...basis, but is given as one time order, per crisis situation, from a provider...."

Patient #23, an adolescent, was admitted on 04/09/10 with diagnoses of Post Traumatic Stress Disorder, Severe and Chronic; Major Depressive Disorder, Severe and Recurrent; and Pseudoseizures. The patient's medical record contains documentation that the patient was in seclusion on 4/10/10 from 1940 until 2300.

The medical record contains a form titled Seclusion/Restraint Physician Order. The form contains pre-printed statements in specific categories, including: "...Type of emergency Safety Response...Seclusion/Restraint ordered due to...Duration...Criteria for Release...Medication Intervention...." The professional recording the orders, marks the boxes next to selected words/statements.

On 4/10/10, at 1940, an RN used the form to document a telephone order from a Nurse Practitioner for Seclusion and Restraint of patient #23. The RN completed the form, indicating the reason for the seclusion/restraint, the duration of the order, the criteria for release, and medications ordered. The form also contains writing in a space at the side of the pre-printed selections: "...in @ 1940...out @ 2000...in @ 2015...out @ 2100...in at 2130...out at 2300. This notation is not signed. The medical record contains no specific order for either restraint or seclusion at 2015 or 2130.

An RN completed the form titled MD/CNP/QMP Face to Face Assessment. The RN documented Time Intervention Initiated as 1940 and Time of Post Intervention Assessment as 2300. The RN wrote: "...Pt was in and out of Seclusion/Time Out Room several times during this time frame. The RN signed the form (in the space for the QMP signature) at 2040. Below the QMP signature is an unsigned statement: "...Renewal Seclusion order from (a Nurse Practitioner) 2140...." The medical record contains no specific order signed by an RN as a telephone order or signed by a LIP or authenticated by a LIP.

The form titled Care and Observation Codes contains documentation of "Checks Made on Patient" every 15 minutes. It contains no documentation that the patient was out of seclusion between 1940 until 2300.

The Director of Nursing confirmed, on 8/11/10, that the RN failed to correctly obtain and document the renewal orders for restraint/seclusion.

Based on review of policy and procedure, medical records and interview, it was determined the hospital failed to assure that the condition of the patient in restraint and/or seclusion was monitored at the interval determined by hospital policy for 4 of 4 patients who were in seclusion/restraint longer than 1 hour (patients #23, 24, 25, & 26).

Findings include:

Review of hospital policy/procedure titled Seclusion and Restraint required: "...The Charge Nurse or designated Registered Nurse will assess the patient every hour for appropriateness of behavior, adequate circulation, condition of skin, and need to relieve pressure on coccyx, buttock, or heels and document findings...."

Patient #23, an adolescent, was admitted on 04/09/10 with diagnoses of Post Traumatic Stress Disorder, Severe and Chronic; Major Depressive Disorder, Severe and Recurrent; and Pseudoseizures. The patient's medical record contains documentation that the patient was in seclusion on 4/10/10 from 1940 until 2300. The medical record contains no documentation that an RN assessed the patient every hour per hospital policy.

Patient #24, an adolescent, was admitted on 04/25/10 with a diagnosis of Bipolar Disorder, Mixed, with Psychotic Features and Attention Deficit Hyperactivity Disorder. The patient's medical record contains documentation that the patient was in seclusion and/or restraint on 5/1/10 from 1415 to 1645 . The medical record contains no documentation that an RN assessed the patient every hour per hospital policy.

Patient #25, an adolescent, was admitted on 06/23/10 with a diagnosis of Mixed Bipolar Disorder and Attention Deficit Hyperactivity Disorder. The patient's medical record contains documentation that the patient was in seclusion and/or restraints on 6/8/10 from 1230 until 1345. The medical record contains no documentation that an RN assessed the patient every hour per hospital policy.

Patient #26, an adolescent, was admitted on 07/07/10 with a diagnosis of Bipolar Disorder, Mixed, with Psychosis. The patient's medical record contains documentation that the patient was in seclusion on 07/17/10 from 1400 until 1530. The medical record contains no documentation that an RN assessed the patient every hour per hospital policy.

The Director of Nursing confirmed, on 8/11/10, that the RN failed to document an assessment every hour.

Based on review of hospital policy and procedure, medical records and interview, it was determined the hospital failed to assure that a patient was seen face-to-face within 1 hour after the initiation of a seclusion or restraint used for the management of violent or self-destructive behavior for 2 of 8 seclusion/restraint events (patients #23 & 25).

Findings include:

Review of the hospital policy/procedure titled Seclusion and Restraint required: "...The patient must have a face-to-face assessment by a provider or qualified medical professional within one hour of the initiation of S/R (Seclusion/Restraint) even if the patient has been released...."

Patient #23 was in seclusion on 4/10/10 from 1940 until 2300. The record contains documentation that the QMP completed the face-to-face assessment at 2300.

Patient #25 was in seclusion and/or restraints on 6/8/10 from 1230 until 1345. The record contains documentation that the QMP completed the face-to-face assessment at 1345.

The Director of Nursing confirmed, on 8/11/10, that the face-to-face assessment was not completed within one hour of the initiation of the seclusion/restraint.

Based on review of hospital documents and interviews, it was determined the hospital failed to provide an organized nursing service 24-hours per day with an adequate number of registered nurses and competent nursing staff to assess patients' care needs and deliver, assign and supervise the care required by each patient as evidenced by:

(A392) failing to have adequate numbers of licensed registered nurses;

(A395) failing to assure that a registered nurse supervise and evaluate the nursing care for each patient;

(A397) failing to assure that a registered nurse assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available;

(A398) failing to assure that non-employee licensed nurses and non-employee nursing personnel adhere to the policies and procedures of the hospital and are adequately supervised; and

(A404) failing to assure that nursing staff administer medications according to physicians' orders.

The cumulative effect of these systemic problems resulted in the hospital's failure to provide an adequate, organized nursing service.

Based on review of hospital documents, and interview, it was determined that the hospital failed to have adequate numbers of licensed registered nurses to provide nursing care to all patients as needed as evidenced by:

1. failing to schedule and assign a registered nurse to each unit per hospital policy; and

2. failing to assure that an RN is responsible to assess each patient at least once in an 8 hr period; and complete the acuity classification for each patient; utilizing the LPN in an assistive role in reassessment of patients per hospital policy.

Findings include:

1. Review of hospital document titled "...Inpatient Program Description..." revealed: "...each unit is staffed with a minimum of one Registered Nurse and one Behavioral Health Technician at all times...Client to Staff Ratios...All units having one or more patients will have a minimum of one RN and one Behavioral Health Technician (B.H.T.) at all times...."

Review of hospital document titled "...Nursing Acuity & Staffing Plan...." revealed a sheet titled Staffing Matrix which contained three sections, indicating the minimum staffing for "Psych," "Adolescent," and "Detox" units. Each section includes columns for the number of RN's, LPN's and BHT's needed depending on the patient census. The document indicates that a minimum of 1 RN is required per unit even with a patient census of 1.

Review of the staffing schedule for Tuesday, August 10, 2010, revealed that one LPN was scheduled to work on the 7a-3:30p shift on Unit 400. No RN was scheduled for Unit 400.

Review of the Unit 400 Assignment Sheet for 8/10/10, 7a-3:30p shift revealed the name of LPN #15, indicating that LPN #15 made the assignments for Unit 400. "LPN" was not written after his/her name. LPN # 15's name was recorded above the names of all 6 patients next to "RN" which was crossed out and "LPN" was written over the "RN." The assignment sheet contained a space for Staff Nurses. LPN #15's name was written in this space. RN #17's name was also written in this space with "RN Charge" after his/her name. This RN was listed as a staff nurse on Unit 600 with 9 patients assigned. Another RN was assigned to the other 9 patients on Unit 600. LPN #15 confirmed that h/she was assigned to all of the patients on Unit 400.

LPN #16 confirmed, on 8/10/10, that s/he was assigned to all of the patients on Unit 400 on 8/9/10 on the 3-11:30p shift.

Review of the staffing schedule for July 31, 2010 revealed that on the 11p-7:30a shift, LPN #1, a registry LPN, was scheduled to work on Unit 100. LPN #13, another registry LPN, was scheduled to work on Unit 300. One RN was scheduled to work on both Unit 300 and Unit 100. Review of the Assignment Sheet for Unit 100 revealed that LPN #1 was assigned to 10 patients on Unit 100 and the RN was assigned to 6 patients on Unit 100. LPN #13 was assigned to 8 patients on Unit 300 and a BHT was assigned to the other 8 patients on Unit 300. The RN was not assigned to patients on Unit 300. The assignment sheet for Unit 100 indicates that the LPN was responsible for the assignment sheet.

The assignment sheets described above includes a total of 32 patients on Units 100 and 300 with one RN scheduled for both units, but assigned to 6 individual patients on Unit 100.

Review of the staffing schedule for Saturday, July 31, 2010 revealed that on the 3-11 shift, on Unit 600, two LPN's were scheduled. No RN was scheduled for Unit 600 on the 3-11 shift.

Review of the Assignment Sheet for 7/31/10, 3-11:30 shift, Unit 600, revealed the names of two LPN's written on the line designated "Staff Nurses." The assignment sheet contains no RN name.

The Director of Nursing confirmed, on 8/11/10, that an RN was not scheduled or assigned to work on each unit.

2. Review of hospital document titled "...Nursing Acuity & Staffing Plan..." revealed: "...The Registered Nurse is responsible to assess each patient at the time of admission and at least once in an eight hour period to determine the individual's patient care needs...The Nurse assesses and monitors the conditions of the patient, delegates care through assignment...The Registered Nurse assignment includes patients requiring nursing assessment, evaluation, and interventions based on the complexity of patient care activities...Responsibilities of Licensed Practical Nurses...provide patient care under the supervision & direction of the Registered Nurse...under the supervision of the Registered Nurse will assist with the reassessment of the health status of individuals...the primary responsibility of the Licensed Practical Nurse is to provide medication services & procedures within their scope of practice...The Registered Nurse responsible for the care of the patient completes the acuity classification for each patient prior to final determination of staffing for the next shift...."

LPN #16 confirmed, on 8/10/10, that s/he completes the entire nursing reassessments for her patients, including: Mental Status, Medical Assessment, Nursing Acuity and Suicide Assessment. The RN reviews the Nursing Reassessment and co-signs the form utilized to record the reassessment. Rarely, the RN may change the acuity level for the patient if the patient's condition has changed and/or the patient has required 1:1 supervision during the shift. However, this is rare because the LPN ordinarily would have adjusted the acuity level of the patient. S/he explained that the RN utilizes the acuity levels recorded by the LPN to determine staffing. LPN #16 gives change of shift report to the oncoming shift.

Review of the LPN job descriptions provided by the hospital revealed: "...General Purpose of Job: To deliver quality direct patient care under appropriate clinical supervision...." The job description does not contain a statement that the LPN works under the supervision of the RN. The job description contains a statement: "...Completes nursing assessments under supervision of RN...."

The LPN job description is also utilized by the facility to document his/her 90 day evaluation and annual evaluation. A section of the LPN job description titled Meets Expectations included: "...Assessments are conducted upon admission or within eight hours of admission...assessments contain the following data: review of relevant major body systems and appropriate physiological parameters...current medication status...initial discharge plan...environmental factors that may have a bearing on treatment plan and discharge plan...Review of...an emotional/behavioral evaluation is conducted on each patient within eight hours of admission and includes the following data: definition and history of presenting problem...suicide attempts and risk...social/family assessment...Evidence of ongoing reassessment is consistently reflected in patients' treatment plan and progress notes; weekly staffings document these reassessments...In cases of patient transfers, an assessment reflects the following: risk status...Room assignments are appropriate to patients' needs, age, gender, level of functioning and condition; unit placement recommendation reflects patients' ability to interact within the therapeutic community. A section titled Exceeds Expectations included: "...Effectively assesses unusual, complex or otherwise difficult cases...proactively identifies potential problems and educates other unit staff so that improved patient care may be realized...Provides training to other employees on processing Needs Assessment calls...Demonstrates advanced or sophisticated level of skill in identifying optimal use of resources, internal or external, in patient's best interest...."

The RN job description is also utilized by the facility to document his/her 90 day evaluation and annual evaluation. The same portion of the RN job description (compared to the LPN job description) titled Meets Expectations revealed that it included the same factors as the LPN job description. The section of the RN job description titled Exceeds Expectations included the same factors as listed in the LPN job description.

The Director of Nursing confirmed, on 8/11/10, that the LPN job description does not indicate that the LPN is working under the supervision of the RN. She also confirmed that numerous aspects of the RN and LPN job descriptions are identical and that the LPN job description is difficult to differentiate from the RN job description.

Based on review of hospital documents medical records and interview, it was determined that the hospital failed to assure that a registered nurse supervise and evaluate the nursing care for each patient as evidenced by:

1. failing to assure that a registered nurse is responsible to assess each patient at least once in an eight hour period to determine the individual patient's care needs and assess and monitor the conditions of the patient per hospital policy for 5 of 6 patient (Pts # 12, 13, 14, 16, & 17); and

2. failing to supervise and evaluate the nursing care for each patient.

Findings include:

Review of hospital document titled "...Nursing Acuity & Staffing Plan..." revealed: "...The Registered Nurse is responsible to assess each patient at the time of admission and at least once in an eight hour period to determine the individual's patient care needs...The Nurse assesses and monitors the conditions of the patient, delegates care through assignment...Responsibilities of Licensed Practical Nurses...provide patient care under the supervision & direction of the Registered Nurse...."

1. Patient #12. The patient was admitted on 8/8/10. A physician documented: "...migraine, low back pain, GERD (Gastroesophageal reflux disease), H/O (History of) necrotizing fasciitis, UTI (Urinary Tract Infection)...." The medical record contained Treatment Plan-Problem Sheets for "...Necrotic fasciitis--L (Left) arm pain..." and "...UTI...."

On 8/9/10, at 1840, a nurse documented on the Nursing Reassessment form in the Medical Assessment section: "...Review of Systems...No Issue...GI (Gastrointestinal)...GU (genitourinary)...Musculoskeletal...."

The nursing reassessment contained no documentation that an RN completed an assessment related to the patient's medical conditions.

Patient #13. The patient was admitted on 8/8/10. The medical record contained information gathered at the time of admission: the patient had lost forty pounds in thirty days; s/he had Multiple Sclerosis, Hypertension and Gastroenteritis. The medical record also contained a Treatment Plan-Problem Sheet for "...Hypertension..." recorded on 8/8/10.

On 8/9/10, at 1500, a physician wrote an order for "...Baclofen 10mg po (by mouth) q6 (every 6 hours) prn (as needed) (spasm)...."

On 8/8/10, at 2215, an LPN signed the Nursing Reassessment form. At 2300, an RN signed the form.

A nurse documented in the Medical Assessment section: "...Review of Systems...No Issue... Neuro...GI...Cardiovascular...Musculoskeletal...Endocrine...Other...." The Medical Assessment section "...Review of Systems..." on the Nursing Reassessment form completed by an RN on 8/9/10, evening shift also indicated "No Issue" for the same systems. The nursing reassessment contained no documentation that an RN completed an assessment related to the patient's medical conditions.

Patient #14. The patient was admitted on 8/6/10. The medical record contained documentation that the patient was "...S/P (Status Post) Post partum X 1 wk."

On 8/8/10 at 1445, an RN documented in the Medical Assessment section of the Nursing Reassessment form: "...Review of Systems...Other...Pt Pregnant...." The medical record contained no laboratory results or any information to indicate that the patient was pregnant at the time of admission.

Patient #16, was admitted on 06/11/10 at 0221, and transferred/admitted to an acute care hospital on 06/12/10 at 0530. The physician documented: "...ETOH (alcohol) Dependence...Discharge Diagnosis:...reactive airway disease...Hepatitis C...chronic obstructive pulmonary disease...hypertension...Cirrhosis of the liver...." The patient wrote on admission, that s/he was experiencing "detoxic (sic)...stomach pain...asthma...hands shaking...."

The physician's orders included: "...Albuterol inhaler 2 puffs QID (4 times daily) PRN SOB (shortness of breath)...Advair 50/100 1 puff BID (twice daily)...Alb (albuterol) SVN (small volume nebulizer) Q 6...."

The Medical Assessment section of the Nursing Reassessment form "Review of Symptoms" record revealed the patient's "GI (gastrointestinal)...Cardiovascular...Respiratory...Endocrine..." systems, were "no issue." There was no documentation to conclude that the nurse assessed the patient's medical condition. In addition, nursing administered Advair, and Albuterol (per inhaler and SVN), according to the medication administration record, however, there was no documentation to verify that the nurse assessed the patient's respiratory status.

Patient #17, was admitted on 05/04/10 at 1253, and discharged on 05/06/10 at 0035. The physician documented: "...Problem List:...hypertension, hepatitis C (chronic), peripheral neuropathy, gastroesophageal reflux disease...."

The Medical Assessment section of the Nursing Reassessment form "Review of Symptoms" record revealed the patient's "Cardiovascular...Gastrointestinal...Endocrine...Neuro..." systems, were "no issue." There was no documentation to conclude that the nurse assessed the medical condition of the patient.

2. Review of the facility staffing schedule for July 31, 2010 revealed that on the 11p-7:30a shift, LPN #1, a registry LPN, was scheduled to work on Unit 100. LPN #13, a registry LPN was scheduled to work on Unit 300. One RN was scheduled to work on both Unit 300 and Unit 100. Review of the Assignment Sheet for Unit 100 revealed that LPN #1 was assigned to 10 patients on Unit 100 and the RN was assigned to 6 patients on Unit 100. LPN #13 was assigned to 8 patients on Unit 300 and a BHT was assigned to the other 8 patients on Unit 300. The RN was not assigned to any of the patients on Unit 300. The assignment sheet for Unit 100 indicates that the LPN was responsible for the assignment sheet.

Review of the staffing schedule for Saturday, July 31, 2010 revealed that on the 3-11 shift, on Unit 600, two LPN's were scheduled. No RN was scheduled for Unit 600 on the 3-11 shift.

Review of the Assignment Sheet for 7/31/10, 3-11:30 shift, Unit 600, revealed the names of two LPN's written on the line designated "Staff Nurses." The assignment sheet contains no RN name.

The Director of Nursing confirmed, on 8/11/10, that the assignment sheets contained no documentation to indicate that the care provided by the LPN's was supervised by a registered nurse.

Based on review of hospital documents and interview, it was determined that the hospital failed to require that a registered nurse assign the nursing care of each patient to nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available.

Findings include:

Review of the staffing schedule for Tuesday, August 10, 2010, revealed that one LPN was scheduled to work on the 7-3 shift on Unit 400. No RN was scheduled for Unit 400.

Review of the Unit 400 Assignment Sheet for 8/10/10, 7a-3:30p shift revealed the name of LPN #15, indicating that s/he made the assignments for Unit 400. LPN # 15's name is recorded above the names of all 6 patients next to "RN" which is crossed out and "LPN" is written over the "RN." In addition, the list of duties on the assignment sheet indicated that LPN # 15 was responsible for the assignment sheet.

LPN #15 confirmed, on 8/10/10, that s/he was responsible for all of the patients on Unit 400.

Review of the facility staffing schedule for July 31, 2010 revealed that on the 11p-7:30a shift, LPN #1, a registry LPN, was scheduled to work on Unit 100. LPN #13, another registry LPN, was scheduled to work on Unit 300. One RN was scheduled to work on both Unit 300 and Unit 100. Review of the Assignment Sheet for Unit 100 revealed that LPN #1 was assigned to 10 patients on Unit 100 and the RN was assigned to 6 patients on Unit 100. LPN #13 was assigned to 8 patients on Unit 300 and a BHT was assigned to the other 8 patients on Unit 300. The RN was not assigned to any of the patients on Unit 300. The assignment sheet for Unit 100 indicated that the LPN was responsible for the assignment sheet.

Review of the staffing schedule for Saturday, July 31, 2010 revealed that on the 3-11:30p shift, on Unit 600, two LPN's were scheduled. No RN was scheduled for Unit 600 on the 3-11 shift.

Review of the Assignment Sheet for 7/31/10, 3-11:30 shift, Unit 600, revealed the names of two LPN's written on the line designated "Staff Nurses." The assignment sheet contained no RN name. The space designated "Assigned By" was blank, however the list of duties on the assignment sheet indicated LPN's were responsible for the assignment sheet.

The Director of Nursing confirmed, on 8/11/10, that the assignment sheets contained no documentation that an RN assigned the nursing care of each patient.

Review of documents provided by the hospital revealed that LPN #1 is a registry LPN. One document, titled "...Staffing Licensed Practical/Vocational Nurse Adult Skills and Checklist..." contained lists regarding the LPN's competence/experience. One list contained several psychiatric diagnoses and conditions including: Psychosis, Schizophrenia, Manic Behavior, Anorexia/Bulimia, Bipolar Disorder, Assaultive Behavior. The number one was recorded next to these conditions. "...1=Knowledge, little or no experience, require additional training or supervision...."

The same document contained a section titled Age Specific Competency: "Adult 18-65...Geriatric >65 only."

The orientation packet included with the documents contained a statement: "...List training or inservices you have for working with mentally ill: CPI (Crisis Prevention Institute), Alzheimers/Dementia...."

Review of the facility staffing schedule for July 31, 2010 revealed that LPN #1 was scheduled to work on Unit 100 on the 11p-7:30a shift. An RN was scheduled to work on both Unit 300 and Unit 100. Review of the Assignment Sheet for Unit 100 for 7/31/10, 11p-7:30a shift revealed that LPN #1 was assigned to 10 patients and that LPN #1 was responsible for the assignment sheet.

During tour on 8/5/10, the Director Risk Management/Quality confirmed that Unit 100 is the Intensive Psychiatric Unit.

Review of the facility staffing schedule for July 26, 2010 revealed that LPN #1 was scheduled to work on both Unit 200 (an adolescent unit) and Unit 500 (an adolescent unit which may be converted to an adult unit depending on need).

The Director of Nursing confirmed, on 8/11/10, that the facility had no documentation of LPN #1's competence related to the general patient population in the hospital. She also confirmed that the assignment sheet for 7/31/10, 11p-7:30a contained no documentation to indicate that LPN #1 was being supervised by the RN.

Review of the facility staffing schedule for July 31, 2010, 3-11:30p shift, revealed that Behavioral Health Technician (BHT) #10 was scheduled to work, floating between Units 400 and 600. Review of documents provided by the hospital revealed that BHT #10's orientation packet/check list contained no documentation of orientation to the facility.

Review of the facility staffing schedule for July 31, 2010, 3-11:30p shift, revealed that BHT #12 was scheduled to work on Unit 100. BHT #12 was also scheduled to work on Unit 600, on July 26, 2010, 11p-7:30a, providing 1:1 supervision of an adult patient. Review of documents provided by the hospital revealed that BHT #12's orientation packet/checklist contained no documentation of orientation to the facility.

Review of the facility staffing schedule for July 31, 2010 revealed that BHT # 11 was scheduled to work on Unit 200 on the 3-11 shift, providing 1:1 supervision of an adolescent patient. BHT #11 was also scheduled to work on Unit 600, on July 26, 2010, 3-11:30p, providing 1:1 supervision of an adult patient. Documents provided by the hospital contain no documentation of BHT #11's orientation to the facility or prior experience.

Review of the facility staffing schedule for July 31, 2010 revealed that RN #14 was scheduled to work on Unit 500 on the 3-11:30p shift. Documents provided by the hospital contain no orientation packet/checklist for RN #14.

The Director of Nursing confirmed, on 8/11/10, that the files contained no documentation of orientation for personnel #'s 10, 11, 12, & 14 and that these personnel are working as registry staff in the facility.

On August 10, 2010, RN #17 described the process s/he used in making assignments for the shift. S/he assigned the patients in the odd numbered rooms to her/himself and assigned the patients in the even numbered rooms to the other RN. S/he assigned the LPN to the other unit to all of the patients. RN #17 confirmed that s/he does not use the acuity classification of patients to make assignments.

On August 10, 2020, RN #9 described the process s/he routinely uses in making assignments for the shift. S/he assigns the patients to the nurse who originally admitted them. If several of those patients seem to be so acute that they may require seclusion or restraint during the shift s/he attempts to distribute them more evenly, unless the nurse who admitted them has the best rapport with the patient. S/he assigns the BHT's to each nurse's patients and to specific tasks. S/he confirmed that s/he does not use the acuity classification of patients to make assignments.

RN #9 also demonstrated how s/he completes computations, using the acuity level of the patients for staffing the unit. The assigned nurse reports the patient acuity levels for the shift. RN #9 does not have a list of the patients with their individual acuity levels. S/he takes the total number of patients with each acuity level, multiplies that number by a pre-determined number, totals all of the answers and then divides by 8. The final number is the total staff required to staff the unit. This number does not reflect the number of RN's, LPN's or BHT's required. RN #9 did not know how the multipliers were determined or how the skill mix was determined. S/he listed on the sheet the numbers of RN's, LPN's and BHT's scheduled for the shift and confirmed that frequently the total number of staff scheduled on the unit is not equal to the number required.

The hospital failed to assure that an RN makes patient assignments and that those assignments are made in accordance with the patient's care needs/acuity classification and the qualifications and competence of the nursing staff.

Based on review of facility documents and interview, it was determined that the hospital failed to provide non-employee licensed nurses and other non-employee nursing personnel, who are working in the hospital, with orientation to the policies and procedures of the hospital for 3 of 3 Behavioral Health Technicians (BHT's) and 1 of 3 licensed nurses.

Findings include:

Review of facility document titled "...Nursing Acuity & Staffing Plan..." revealed: "...Responsibilities of Behavioral Health Technicians...responsibility is to provide direct patient care and observation...Responsibility of Registered Nurses...are involved in various aspects of a patient's care directly or indirectly as it relates to their scope of practice...The Nurse assesses and monitors the conditions of the patient, delegates care through assignment, monitors the workload of staff...The registered Nurse assignment includes patients requiring nursing assessment, evaluation and interventions based on the complexity of patient care activities...."

Review of the unit staffing schedule for July 31, 2010 revealed that personnel #10 was scheduled to work as a BHT, floating between Units 400 and 600 on the 3-11 shift. Review of documents provided by the hospital revealed that personnel #10 is a registry BHT. His/her orientation packet/check list contained no documentation of orientation to the facility's policies and procedures, no signature and no date.

Review of the unit staffing schedule for July 31, 2010 revealed that personnel #12 was scheduled to work as a BHT on Unit 100 on the 3-11 shift. Personnel #12 was also scheduled to work as a BHT on Unit 600, on July 26, 2010, providing 1:1 supervision of an adult patient. Review of documents provided by the hospital revealed that personnel #12 is a registry BHT. His/her orientation packet/checklist contained no documentation of orientation to the facility's policies and procedures.

Review of the unit staffing schedule for July 31, 2010 revealed that personnel # 11 was scheduled to work as a BHT on Unit 200 on the 3-11 shift, providing 1:1 supervision of an adolescent patient. Personnel #11 was also scheduled to work as a BHT on Unit 600, on July 26,2010, providing 1:1 supervision of an adult patient. Review of documents provided by the hospital revealed that personnel #11 is a registry BHT. His/her orientation packet/checklist contained no documentation of orientation to the facility's policies and procedures.

Review of the unit staffing schedule for July 31, 2010 revealed that personnel #14 was scheduled to work as an RN on Unit 500 on the 3-11 shift. Review of documents provided by the hospital revealed that personnel #14 is a registry RN. His/her file contained no orientation packet/checklist.

On 8/11/10, during interview, the Director of Nursing confirmed that these personnel are employed by registries and have been scheduled to work in the hospital. She also confirmed the absence of documentation of orientation of these registry personnel to the facility's policies and procedures.

Based on review of hospital policies/procedures, medical records, and staff interviews, it was determined that the nursing staff failed to administer medications according to physicians' orders, for 2 of 3 patients (Pts #16 & #18).

Findings include:

The hospital policy titled Medication Ordering, Dispensing and Administration (last revised 01/09) requires: "...If the nurse finds any discrepancies...the nurse will contact the physician for confirmation and clarification...All drugs administered shall be verified with the physician's orders...."

Patient #16. The physician's Inpatient Admit Orders"...Alcohol Withdrawal Protocol" (06/11/09 at 0415), revealed: "...If CIWA (Clinical Institute Withdrawal Assessment) score 8-11 give...Ativan 2 mg P.O. (orally) now and repeat assessment every 2 hours...If CIWA score greater than 11 give...Ativan 2 mg P.O. now and repeat assessment every hour...."

Nursing administered Ativan 2 mg, according to the medication administration record, as follows:

06/11/10 (1000): CIWA 5
06/11/10 (2100): CIWA 7
06/11/10 (0500): CIWA 9
06/11/10 (1700): CIWA 8

The Director of Nursing (DON) stated during an interview and record review conducted on 08/11/10, that the patient was "detox-ed appropriately and according to protocol." However, the order did not state to administer Ativan if the CIWA was less than 8, nor to repeat the Ativan on successive assessments.

The nursing staff did not clarify and/or follow the physician's orders.

Patient #18. The physician ordered on 06/17/10 at 1505: "...Glucophage 500 mg 2 tabs P.O. BID (twice daily)...SS = BS - 200 (divided by) 10 = reg I (sliding scale = blood sugar minus 200 divided by 10 = regular insulin)...."

Nursing documented the following, according to the patient's Diabetic Medication Administration Record:

06/25/10 (1700): BS 83. No insulin. Glucophage held.
06/25/10 (2100): BS 354. No insulin. Nurse noted, "...given metformin (Glucophage) that was held at 1700...."
06/25/10 (2200): BS 374. Calculated # of insulin units required was 17.4. Nurse administered 10 units, and noted,"...given 10 units per NSG (nursing) judgement...."
06/25/10 (2230): BS 284. No insulin.
06/25/10 (2325): BS 225. No insulin.

There was no physician order to hold the Glucophage on 06/25/10 at 2100, to administer 10 units of insulin instead of 17 units on 06/25/10 at 2200, to hold insulin on 06/25/10 at 2230, or hold insulin on 06/25/10 at 2325.

The nursing staff did not follow the physicians' orders.

Based on review of hospital policies/procedures, medical records, and staff interviews, it was determined that the pharmacist failed to require that the pre-printed Medication Administration Record accurately reflected the pre-printed physicians' orders for 2 of 2 patients (Pt # 3 & #16).

Findings include:

The hospital policy titled Medication Ordering, Dispensing and Administration #61 (last revised 01/09) requires: "...The pharmacy will verify each physician's order for...Completeness, Appropriateness, Drug Interactions, Food-Drug interactions, Allergies, Polypharmacy...."

Patient #3. The physician's Inpatient Admit Orders "...Alcohol Withdrawal Protocol" (08/07/10 at 1010), revealed: "...If Valium CIWA (Clinical Institute Withdrawal Assessment) score 5-7 give...Valium 5 mg P.O. (orally) now, reassess within 1 hour. If CIWA score 8-11 give...Valium 10 mg P.O. now, reassess CIWA score within 1 hour. If CIWA score greater than 11 give...Valium 2 mg P.O. now, reassess every hour...."

The pre-printed PRN Medication Administration Record revealed:

"...CIWA (5-7) Assess Every 4 hrs Valium 5 mg P.O. or -
CIWA (8-11) Assess Every 2 hrs Valium 10 mg P.O. or -
CIWA greater than 11 Assess Every hour Valium 20 mg P.O....."

The pre-printed physicians' orders did not correlate with the pre-printed medication administration record that the nursing staff used for documenting Valium administration.

Patient #16. The physician's Inpatient Admit Orders"...Alcohol Withdrawal Protocol" (06/11/09 at 0415), revealed: "...If CIWA score 8-11 give (lorazepam) Ativan 2 mg P.O. now and repeat assessment every 2 hours...If CIWA score greater than 11 give...Ativan 2 mg P.O. now and repeat assessment every hour...."

The pre-printed PRN Medication Administration Record revealed:

"...CIWA (5-7) Assess Every 4 hrs Ativan 1 mg P.O. or -
CIWA (5-7) Assess Every 4 hrs Ativan 2 mg P.O. or -
CIWA (8-11) Assess Every 2 hrs Ativan 2 mg P.O. or -
CIWA greater than 11 Assess Every hour Ativan 2 mg P.O....."

Nursing administered Ativan 2 mg, according to the medication administration record, as follows:

06/11/10 (0500): CIWA 9
06/11/10 (1000): CIWA 5
06/11/10 (1700): CIWA 7
06/11/10 (2100): CIWA 7

The Director of Nursing (DON) stated during an interview and record review conducted on 08/11/10, that the patient was "detox-ed appropriately and according to protocol". However, the order did not state to administer Ativan if the CIWA was less than 8, nor to repeat the Ativan on successive assessments.

The Pharmacist reviewed the medical record and confirmed that the pre-printed physicians' orders did not correlate with the pre-printed medication administration record, during an interview conducted on 08/11/10 at 1315.

Based on observation and interview, it was determined that the hospital failed to maintain the facility at an acceptable level of cleanliness to ensure patient safety.

Findings include:

The inpatient units contain seclusion rooms equipped with restraint beds to meet the needs of patients who become an eminent danger to themselves or othes. Bathrooms are available to meet the needs of patients who require seclusion and/or restraint.

One seclusion room is located between Units 200 and 500. Two seclusion rooms are located between Units 100 and 300 and Units 400 and 600. A bathroom is located adjacent to the seclusion rooms on each unit. The bathrooms and seclusion rooms open out into an enclosed space behind the nurses' station/medication room. During tour on 8/5/10, the seclusion room between Units 200 and 500 was observed to have loose debris on the floor and accumulated dirt along the baseboard and around the bottom of the restraint bed. The bathroom between Units 200 and 500 was observed to have a strong, foul smelling odor and used wash cloths or towels were tucked between the faucet and wall at the sink. The toilet was stained at the water line. The seclusion rooms between Units 100 and 300 were also observed to have loose debris on the floors and accumulated dirt along the baseboards and around the bottom of the restraint beds. The bathroom between Units 100 and 300 was observed to have a strong, foul smelling odor; loose debris was observed on the floor; the water line in the toilet was very low and the water was discolored and contained toilet paper.

The Director Risk Management/Quality confirmed, during tour, that the seclusion rooms and bathrooms did not meet an acceptable level of cleanliness.

On 8/6/10, the Infection Control Nurse, confirmed, during a follow-up inspection, that the accumulated
dirt along the baseboard presented an infection control hazard and that environmental rounds had not been conducted during July.