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Based on review and interview nursing failed to follow its own policy and procedures to update the treatment plan after the application of a physical hold or administration of a chemical restraint. The treatment plan failed to reveal the restraint, assessments, treatment, interventions, or goals in 3(Patient #10, 19 and 20) of 3 patient charts reviewed.

Patient #20
Review of patient #20's chart revealed a physician order in the seclusion and restraint package. The order was dated 5/17/21 at 1400 (2:00PM). The order was for a manual hold of the patient due to "Violent self-destructive behavior to self" but there was no description of those behaviors on the order set.

Review of the Manual hold assessment by RN dated 5/17/21 stated the hold was initiated at 1350 (1:50PM).
The nurse documented the hold was due to "Violent self-destructive behavior to self" but there was no description of those behaviors.

Under Medication Administered During Restrictive Intervention the nurse documented, "Zyprexa 5 mg IM was administered at 1400 (2:00PM)", due to "aggression." There was no documentation of what staff members were involved during the restraint process and what staff member was holding the patient.

Review of POLICY AND PROCEDURE: 1000.37 Restraints and Seclusion stated, "Page 9, d. If physical restraint is indicated, 2 staff must participate in the physical hold application. If the physical restraint/hold is on a small statured patient, one staff may implement the hold (e.g. Modified PRT for very small children) while a second staff serves as a witness to monitor patient and staff safety for the duration of the hold."

Review of the restraint and seclusion monitoring sheet dated 5/17/21 revealed the observation started at 1350 (1:50PM) Patient #20 was "agitated, crying, and harm to self/others." Under nutrition and hydration section the nurse documented "other" with no explanation. In comments the nurse documented, "pt. became agitated in day room. Manual hold for 20 minutes. The nurse documented at 1400 (2:00PM) that patient #20 was still "agitated, crying, and harm to self/others." In comments the nurse documented, "Zyprexa 5 mg IM given to rt deltoid." The nurse documented at 1410 (2:10PM) that patient #20 was "oriented, cooperative and could perform self-care. Pt became calm and manual hold discontinued." Review of the chart revealed there was no further documented nursing observation of any vital signs, effectiveness of medication after hold release, behaviors, or general nursing care until 5/18/21 at 1:24AM; 11.5 hours later.

Review of POLICY AND PROCEDURE: 1000.37 Restraints and Seclusion stated, "Page 17, 9. Following the use of a restraint or seclusion a staff shall continue monitoring the patient for a minimum of thirty (30) minutes or as clinically indicated."

Review of patient #20's chart and restraint and seclusion packet dated 5/17/21 revealed there was no debriefing of patient or staff. The form for patient debriefing was marked through and stated, "n/a". There was no staff signatures date or time.

Review of POLICY AND PROCEDURE: 1000.37 Restraints and Seclusion stated, "Page 17, 1. 1. The use of restraint techniques or seclusion shall be discussed with all staff involved in the emergency safety intervention and the patient participates in a face-to-face discussion. This shall occur within the shift when the restraint or seclusion occurred but if the patient is unwilling, the facility has up to 24 hours to complete the debriefing.
2. This discussion may also include other staff and the patient's parent(s)/legal guardian(s) when it is deemed appropriate. The discussion must be in a language which is understood by all parties. The discussion will include:
a. An opportunity for both the patient and staff to discuss the circumstances resulting in the use of the restraint or seclusion
b. Strategies to be used by the staff, the patient, or others which could prevent the future use of a restraint or seclusion.
c. Evaluate if the patient's physical well-being, psychological comfort and right to privacy were addressed.
d. The de-briefing form will be placed in patient's chart
e. Provide counseling to the patient for any trauma which may have resulted from the incident.
f. All staff involved will meet in a post-intervention conference (debriefing) to discuss the event and offer feedback to one another before the end of shift concerning events which took place and possible alternate methods which could be used to change behaviors. The administrative staff are included in the staff debriefing process.
g. Patients Treatment Plan will be updated after each restraint or seclusion event."

Review of the Treatment Plan revealed there was no updated nursing documentation concerning Patient #20's behavioral emergency, manual hold or administration of a chemical restraint on 5/17/21.

Patient #10

Review of the Nursing Progress note dated 5/15/21 at 9:01AM stated, "_____ (patient #10) was in her room. She came outside stating she needed to go to the hospital, stating very loud that she was bleeding to death. She had her right leg uncovered, with the bottom of her pants on the right leg pulled up, showing her right lower leg. She tried to be redirected by tech and quickly got agitated, soon after getting out of control, started yelling louder, screaming, started running through the hall, and getting more agitated, not following any redirection attempts, started trying to grab tech in a very agitated state, proceeding to restrain her. ____(Nurse Practitioner) NP was called by _____RN and notified and orders obtained for lorazepam 2mg IM, haldol 10mg IM and benadryl 50mg IM all administered to right deltoid in 2 different syringes, benadryl in one syringe, lorazepam and haldol on the other syringe. Patient was very agitated, yelling very loud, thrashing, having to be restrained for 25 minutes until she calmed down. She stayed in hall unrestrained with other techs until she completely settled and went by herself back to her room."

Review of patient #10's chart revealed a physician order in the seclusion and restraint package. The order was dated 5/15/21 at 8:41AM. The order was for a manual hold from 8:41AM until 9:04AM. The order was for "violent self- destructive behavior towards others" but there was no description on the order of those behaviors.

Review of the "Manual Hold Assessment by the RN" in the restraint package revealed on 5/15/21 that the hold was "Unsuccessful. Did not deescalate." The only interventions documented on the form for alternative interventions performed was verbal De-escalation. The nurse documented that Patient #10 was administered Haldol 10mg IM, Benadryl 50mg IM and Lorazepam 2 mg IM at 8:47AM. There was no medication order in the packet for a chemical restraint. A physician order was found on the medication orders for the chemical restraint as a now order at 8:41AM only one minute into the physical hold. There was no documentation noted in the chart that the nursing staff used any other less restrictive restraint. The staff failed to use the seclusion rooms before administering chemical restraints.

Review of the face to face dated 5/15/21 at 9:38AM stated the patient behaviors that justified the actions were "attempted to grab tech while in a very agitated state. Yelling and screaming, very agitated for 25 minutes." On the chemical restraint portion of the form, the nurse performing the face to face failed to document the Benadryl and stated the patient refused vital signs. The nurse documented that respiratory status was within normal limits but there were no respirations documented. Respirations can be observed and counted without touching the patient. The nurse documented the circulatory status was within normal limits but there were unchecked boxes on pulses present and no vital signs obtained. The nurse documented on the monitoring sheet at 8:38AM and again at 9:04AM. There was no documentation that Patient #10 was observed every 15 minutes for at least 30 minutes per policy.

Review of the Debriefing form revealed there was no information on what staff member was holding the patient. The nurse documented that Patient #10 was given Seroquel (Antipsychotic) by mouth 100mg. There was no documentation on any of the nursing assessments (in the restraint package) that Patient #10 was offered any medications prior to the hold or chemical restraint. Review of the Medication Administration Record (MAR) revealed Patient #10 was given Seroquel 100mg by mouth at 8:18AM. The nurse documented the response to the medication as "tolerated." The response to the medication was documented on 5/16/21 at 9:44AM, over 24 hours later.

Review of the Nursing Progress note dated 5/15/21 at 9:29AM stated, At approximately 0841 pt was in restraint due to physical aggression and verbal aggression towards self and staff. _____NP was made aware, ordered Ativan, Haldol, and Benadryl IM Stat. Medications were administered to _____ (Patient #10) right arm. Tolerated well. This nurse witnessed restraint. Pt was shouting stating staff was sex traffickers trying to abduct her, stated she had STD's and wanted to infect staff, and also attempted to hit and bite staff. PT is now calm and cooperative sitting in dayroom having breakfast Fluids were encouraged."

There was no further documentation on the effectiveness of the medications. There was no further documentation of patient observation by the nurse until 5/15/21 at 1646 (4:16PM). There were no vital signs documented on the patient. The only documentation that vital signs were attempted was on 5/16/21 at 7:37AM and the patient refused.
Review of every 15-minute check sheet reveled at 8:45AM the MHT had marked over a previous documented behavior code and location code of "awake and alert -courtyard" to "psychotic and hall." The MHT documented at 9:00AM that Patient #10 was calm and in her room.

Review of the Treatment Plan revealed there was no updated nursing documentation concerning Patient #10's behavioral emergency, manual hold or administration of a chemical restraint on 5/15/21.


Patient #19

Review of patient #19's nursing progress notes dated 5/9/2021 5:50AM stated, "5/9/2021 05:50 Pt displayed increased agitation. pt yelling, using threating vulgar language and attempting to charge staff. Informed provider on call, order received for Benadryl 50mg IM, Ativan 2mg IM and Haldol 10mg IM. Informed pt of plan of care, pt accepted and received IM to left and right deltoid at 0550. pt tolerated procedure well. AOC made aware.

Review of patient #19's chart revealed there was a restraint and seclusion physician order in a packet dated 5/9/21 at 5:50AM. The order revealed the reason for emergency medication "pt. yelling, threatening staff, disrupting the milieu, pt. charging staff, pt.___ (illegible) property." The patient was ordered, "Haldol 10mg IM at 5:50AM, Ativan 2 mg IM at 5:50AM, and Benadryl 50mg IM at 5:50AM."

The face to face was written as performed on 5/9/21 at 6:30AM but there was no signature of who completed the face to face. No debriefing was included in the packet for patient or staff. There were no documented vital signs, effectiveness of medications, other than the face to face assessment completed at 6:30AM there was no further nursing assessment documented until 5/9/21 at 11:26AM.

Review of patient #19's nursing progress notes dated 5/9/2021 1346 (1:46PM) stated, Patient being aggressive and threatening staff and peers. Patient slamming and hitting door. Attempted to redirect patient but was unsuccessful. Received an order for thorazine 50 IM and benadryl 25 mg IM from Rosemary. Patient was injected at 1310. 1320 Patient is asleep and show no signs of distress. Respirations are even and unlabored.

Review of patient #19's chart revealed there was a restraint and seclusion packet. The physician order dated 5/9/21 at 1310 (1:10PM) stated, "Thorazine 50mg IM at 1310 (1:10PM) and Benadryl 25mg IM at 1310 (1:10PM)." The reason for the medication was checked as "Violent self-destructive behavior towards others. There was no description of that behavior. The chemical restraint was a verbal order given by a nurse practitioner. The physician order form was incomplete, and the following questions were left blank:
"Physician /provider ordering communicated with attending physician yes or no, attending physician/provider concurred with intervention? Complications with restrictive intervention yes or no." There was no documented evidence that the physician was notified in a timely manner.

The face to face was performed on 5/9/21 at 1400(2:00PM). The nurse stated the patient was being aggressive and threatening towards staff and peers. Patient asleep. The nurse stated patient "refused" vital signs but documented pt "asleep." No vital signs were obtained. The nurse documented that the patient denied pain or discomfort but was documented as asleep. The nurse documented the circulatory status was in normal limits but did not check pulses or vital signs. There was no debriefing with staff or patient.

Review of the Treatment Plan revealed there was no updated nursing documentation concerning Patient #19's behavioral emergency or administration of a chemical restraint on 5/09/21 at 5/9/21 at 6:30AM and again on 1310 (1:10PM).

Based on review and interview the facility failed to follow its own policy and procedures for the application of a physical hold or administration of a chemical restraint, that appropriate assessments were performed and the patients were monitored for at least 30 minutes, physician orders and the restraint packets were completed in 3 of 3( Patient #20,10, and 19) charts reviewed.

Patient #20
Review of patient #20's chart revealed a physician order in the seclusion and restraint package. The order was dated 5/17/21 at 1400 (2:00PM). The order was for a manual hold of the patient due to "Violent self-destructive behavior to self" but there was no description of those behaviors on the order set.

Review of the Manual hold assessment by RN dated 5/17/21 stated the hold was initiated at 1350 (1:50PM). The nurse documented the hold was due to "Violent self-destructive behavior to self" but there was no description of those behaviors. There was no documentation of what staff members were involved during the restraint process and what staff member was holding the patient.

Under Medication Administered During Restrictive Intervention the nurse documented, "Zyprexa 5 mg IM was administered at 1400 (2:00PM)", due to "aggression."

Review of POLICY AND PROCEDURE: 1000.37 Restraints and Seclusion stated, "Page 9, d. If physical restraint is indicated, 2 staff must participate in the physical hold application. If the physical restraint/hold is on a small statured patient, one staff may implement the hold (e.g. Modified PRT for very small children) while a second staff serves as a witness to monitor patient and staff safety for the duration of the hold."

Review of the restraint and seclusion monitoring sheet dated 5/17/21 revealed the observation started at 1350 (1:50PM) Patient #20 was "agitated, crying, and harm to self/others." Under nutrition and hydration section the nurse documented "other" with no explanation. In comments the nurse documented, "pt. became agitated in day room. Manual hold for 20 minutes. The nurse documented at 1400 (2:00PM) that patient #20 was still "agitated, crying, and harm to self/others." In comments the nurse documented, "Zyprexa 5 mg IM given to rt deltoid." The nurse documented at 1410 (2:10PM) that patient #20 was "oriented, cooperative and could perform self-care. Pt became calm and manual hold discontinued." Review of the chart revealed there was no further documented nursing observation of any vital signs, effectiveness of medication after hold release, behaviors, or general nursing care until 5/18/21 at 1:24AM; 11.5 hours later.

Review of POLICY AND PROCEDURE: 1000.37 Restraints and Seclusion stated, "Page 17, 9. Following the use of a restraint or seclusion a staff shall continue monitoring the patient for a minimum of thirty (30) minutes or as clinically indicated."

Review of patient #20's chart and restraint and seclusion packet dated 5/17/21 revealed there was no debriefing of patient or staff. The form for patient debriefing was marked through and stated, "n/a". There was no staff signatures date or time.

Review of POLICY AND PROCEDURE: 1000.37 Restraints and Seclusion stated, "Page 17, 1. 1. The use of restraint techniques or seclusion shall be discussed with all staff involved in the emergency safety intervention and the patient participates in a face-to-face discussion. This shall occur within the shift when the restraint or seclusion occurred but if the patient is unwilling, the facility has up to 24 hours to complete the debriefing.

2. This discussion may also include other staff and the patient's parent(s)/legal guardian(s) when it is deemed appropriate. The discussion must be in a language which is understood by all parties. The discussion will include:
a. An opportunity for both the patient and staff to discuss the circumstances resulting in the use of the restraint or seclusion
b. Strategies to be used by the staff, the patient, or others which could prevent the future use of a restraint or seclusion.
c. Evaluate if the patient's physical well-being, psychological comfort and right to privacy were addressed.
d. The de-briefing form will be placed in patient's chart
e. Provide counseling to the patient for any trauma which may have resulted from the incident.
f. All staff involved will meet in a post-intervention conference (debriefing) to discuss the event and offer feedback to one another before the end of shift concerning events which took place and possible alternate methods which could be used to change behaviors. The administrative staff are included in the staff debriefing process.
g. Patients Treatment Plan will be updated after each restraint or seclusion event."

Review of the Treatment Plan revealed there was no updated nursing documentation concerning Patient #20's behavioral emergency, manual hold or administration of a chemical restraint on 5/17/20.

An interview was conducted with Staff #4 and #2 on the morning of 5/26/21. Staff #4 stated part of the corrective action from the previous citation was to monitor the restraint packages and charts. The monitoring would ensure the restraints were properly documented and performed. Staff #4 provided a restraint log and stated that the indicators that are being monitored were on the log and was being looked at by the quality department and nursing administration. Staff #2 stated that he had not been reviewing the restraint packets. Staff #2 stated that he had just been placed in the role of Director of Nursing a week ago.

Review of the restraint log and monitoring tool provided by Quality revealed Patient #20 was listed as having a manual hold and chemical restraint on 5/17/21. The monitoring tool stated patient #20 discussed feelings, problem solving was attempted with the patient, and patient #20 was on a 1:1 with staff. There was no physician order found or documentation that Patient #20 was on a 1:1. There was no debriefing in the restraint packet or any nursing notes after the restraint or medication administration concerning the patients restraint or medical condition until the morning of 5/18/21.

Patient #10

Review of the Nursing Progress note dated 5/15/21 at 9:01AM stated, "_____ (patient #10) was in her room. She came outside stating she needed to go to the hospital, stating very loud that she was bleeding to death. She had her right leg uncovered, with the bottom of her pants on the right leg pulled up, showing her right lower leg. She tried to be redirected by tech and quickly got agitated, soon after getting out of control, started yelling louder, screaming, started running through the hall, and getting more agitated, not following any redirection attempts, started trying to grab tech in a very agitated state, proceeding to restrain her. ____(Nurse Practitioner) NP was called by _____RN and notified and orders obtained for lorazepam 2mg IM, haldol 10mg IM and benadryl 50mg IM all administered to right deltoid in 2 different syringes, benadryl in one syringe, lorazepam and haldol on the other syringe. Patient was very agitated, yelling very loud, thrashing, having to be restrained for 25 minutes until she calmed down. She stayed in hall unrestrained with other techs until she completely settled and went by herself back to her room."

Review of patient #10's chart revealed a physician order in the seclusion and restraint package. The order was dated 5/15/21 at 8:41AM. The order was for a manual hold from 8:41AM until 9:04AM. The order was for "violent self- destructive behavior towards others" but there was no description on the order of those behaviors.

Review of the "Manual Hold Assessment by the RN" in the restraint package revealed on 5/15/21 that the hold was "Unsuccessful. Did not deescalate." The only interventions documented on the form for alternative interventions performed was verbal De-escalation. The nurse documented that Patient #10 was administered Haldol 10mg IM, Benadryl 50mg IM and Lorazepam 2 mg IM at 8:47AM. There was no medication order in the packet for a chemical restraint. A physician order was found on the medication orders for the chemical restraint as a now order at 8:41AM only one minute into the physical hold. There was no documentation noted in the chart that the nursing staff used any other less restrictive restraint. The staff failed to use the seclusion rooms before administering chemical restraints.

Review of the face to face dated 5/15/21 at 9:38AM stated the patient behaviors that justified the actions were "attempted to grab tech while in a very agitated state. Yelling and screaming, very agitated for 25 minutes." On the chemical restraint portion of the form, the nurse performing the face to face failed to document the Benadryl and stated the patient refused vital signs. The nurse documented that respiratory status was within normal limits but there were no respirations documented. Respirations can be observed and counted without touching the patient. The nurse documented the circulatory status was within normal limits but there were unchecked boxes on pulses present and no vital signs obtained. The nurse documented on the monitoring sheet at 8:38AM and again at 9:04AM. There was no documentation that Patient #10 was observed every 15 minutes for at least 30 minutes per policy.

Review of the debriefing form revealed there was no information on what staff member was holding the patient. The nurse documented that Patient #10 was given Seroquel (Antipsychotic) by mouth 100mg. There was no documentation on any of the nursing assessments (in the restraint package) that Patient #10 was offered any medications prior to the hold or chemical restraint. Review of the Medication Administration Record (MAR) revealed Patient #10 was given Seroquel 100mg by mouth at 8:18AM. The nurse documented the response to the medication as "tolerated." The response to the medication was documented on 5/16/21 at 9:44AM, over 24 hours later.

Review of the Nursing Progress note dated 5/15/21 at 9:29AM stated, At approximately 0841 pt was in restraint due to physical aggression and verbal aggression towards self and staff. _____NP was made aware, ordered Ativan, Haldol, and Benadryl IM Stat. Medications were administered to _____ (Patient #10) right arm. Tolerated well. This nurse witnessed restraint. Pt was shouting stating staff was sex traffickers trying to abduct her, stated she had STD's and wanted to infect staff, and also attempted to hit and bite staff. PT is now calm and cooperative sitting in dayroom having breakfast Fluids were encouraged."

There was no further documentation on the effectiveness of the medications. There was no further documentation of patient observation by the nurse until 5/15/21 at 1646 (4:16PM). There were no vital signs documented on the patient. The only documentation that vital signs were attempted was on 5/16/21 at 7:37AM and the patient refused.
Review of every 15-minute check sheet reveled at 8:45AM the MHT had marked over a previous documented behavior code and location code of "awake and alert -courtyard" to "psychotic and hall." The MHT documented at 9:00AM that Patient #10 was calm and in her room.

Patient #19

Review of patient #19's nursing progress notes dated 5/9/2021 5:50AM stated, "5/9/2021 05:50 Pt displayed increased agitation. pt yelling, using threating vulgar language and attempting to charge staff. Informed provider on call, order received for Benadryl 50mg IM, Ativan 2mg IM and Haldol 10mg IM. Informed pt of plan of care, pt accepted and received IM to left and right deltoid at 0550. pt tolerated procedure well. AOC made aware.
Review of patient #19's chart revealed there was a restraint and seclusion physician order in a packet dated 5/9/21 at 5:50AM. The order revealed the reason for emergency medication "pt. yelling, threatening staff, disrupting the milieu, pt. charging staff, pt.___ (illegible) property." The patient was ordered, "Haldol 10mg IM at 5:50AM, Ativan 2 mg IM at 5:50AM, and Benadryl 50mg IM at 5:50AM."

The face to face was written as performed on 5/9/21 at 6:30AM but there was no signature of who completed the face to face. No debriefing was included in the packet for patient or staff. There were no documented vital signs, effectiveness of medications, other than the face to face assessment completed at 6:30AM there was no further nursing assessment documented until 5/9/21 at 11:26AM.

Review of patient #19's nursing progress notes dated 5/9/2021 1346 (1:46PM) stated, Patient being aggressive and threatening staff and peers. Patient slamming and hitting door. Attempted to redirect patient but was unsuccessful. Received an order for thorazine 50 IM and benadryl 25 mg IM from Rosemary. Patient was injected at 1310. 1320 Patient is asleep and show no signs of distress. Respirations are even and unlabored.

Review of patient #19's chart revealed there was a restraint and seclusion packet. The physician order dated 5/9/21 at 1310 (1:10PM) stated, "Thorazine 50mg IM at 1310 (1:10PM) and Benadryl 25mg IM at 1310 (1:10PM)." The reason for the medication was checked as "Violent self-destructive behavior towards others. There was no description of that behavior. The chemical restraint was a verbal order given by a nurse practitioner. The physician order form was incomplete, and the following questions were left blank:
"Physician /provider ordering communicated with attending physician yes or no, attending physician/provider concurred with intervention? Complications with restrictive intervention yes or no." There was no documented evidence that the physician was notified in a timely manner.

The face to face was performed on 5/9/21 at 1400(2:00PM). The nurse stated the patient was being aggressive and threatening towards staff and peers. Patient asleep. The nurse stated patient "refused" vital signs but documented pt "asleep." No vital signs were obtained. The nurse documented that the patient denied pain or discomfort but was documented as asleep. The nurse documented the circulatory status was in normal limits but did not check pulses or vital signs. There was no debriefing with staff or patient.

Based on review and interview the facility failed to ensure training was developed and competencies performed for the One Hour Face to Face evaluation in 4 out 4 (#6,7,13, and 14) Registered Nurse (RN) employee files.

An interview was conducted on 5/26/21 in the afternoon with Staff #1, #2, #7 #13 and #14. Staff #7, #13 and #14 stated they had both done face to face evaluations on patients after the administration of restraints.

Staff #13 confirmed that the training she received concerning face to face was verbal from a previous Director of Nurses. Staff #13 was told to just fill out the form in the restraint packet and to make sure it was done within 1 hour of the restraint. Review of Staff #13 employee file revealed a Competency Requirements sheet dated 8/2/12. The competency to perform the face to face was checked off as completed.

Staff #14 reported that they were told to just fill out the face to face form but was not given any instructions on specific items to focus on or a clear understanding of "why" the form is done. Review of his employee file revealed there were no competencies checked off for one-hour face to face examination.

Staff #1 and #2 confirmed they were unable to provide any training and was not aware of any training set up specifically for one-hour face to face evaluation.

Review of the employee HR files for Staff #6,7,13,and 14 revealed there was no face to face training in the files that addressed competency in how to conduct a physical and behavioral assessment of the patient, the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion.

Review of the policy and procedure "seclusion and restraints, revealed,
"Staff Training
1.All staff participating in the provision of the care and treatment for persons with mental illnesses shall receive annual training or annual certification of competency.
2.All staff with direct patient contact who administer restraint/seclusion techniques shall receive the training during orientation and annual training on lower level behavioral interventions such as Crisis Prevention Intervention (CPI).
3.All staff placing patients in restraints will be trained in the use of these restraint techniques monitoring procedures and data collection during orientation and annual skill review.
4.All staff placing patients in restraints or seclusion shall be proficient in the use of first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic recertification.
5.All staff with direct patient contact shall be trained and certified in the use of these procedures during orientation, annual skill reviews, and ongoing in-service education. Education will be documented on in-service records and in staff personnel files. Staff who have not yet been trained and deemed competent to perform the techniques shall not be allowed to participate in the restraint or seclusion procedures.
6. RNs must complete all requirements of the training as outlined above. In addition, the RN providing 1-hour face-to-face evaluations will be trained to evaluate the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition, and the need to continue or terminate the seclusion or restraint. This training will be provided during orientation and annually thereafter."

Based on review of records, observations, and interviews, the facility failed to ensure a means of determining if staffing of the nursing services was adequate/safe for the care of patients on 4 of 4 hospital units (Unit 300, Unit 400, Unit 500 and Unit 600). As a result, the facility was not able to demonstrate that adverse patient events were not a result of unsafe staffing levels. Additionally, current provisions for staffing did not allow for a Registered Nurse (RN) to be physically present on each Unit to ensure immediate availability of the RN for patient care needs on that Unit.

Findings included:

On the morning of 5-24-21, during the entrance conference, Staff #1 explained that the facility had 4 separate units opened at that time. Unit 300 was for adults who were "less acute". Unit 400 was for adults who were acute and required closer care. Unit 500 was an adolescent girls' unit. Unit 600 was an adolescent boys' unit.

After the entrance conference was completed, a tour of the facility was made. Unit 300 and Unit 400 were located on one wing of the hospital. The units were observed to be two separate, locked units. Each unit had 2 locked doors, one that opened to a lobby area and one that opened to the nursing station. The two locked units shared a nursing station and medication room. Unit 300 had 20 patients and two nurses with 7 discharges to process. Unit 400 (patients who are acutely ill and require closer care) had 14 patients and 1 nurse and 3 discharges to process. When patients were not attending scheduled programming such as outdoor time, meals, therapy, etc., they remained on the unit. Each unit was observed to have their own dayroom where patients assigned to the unit could sit, visit, and watch television if they wanted.

A tour of Unit 500 and 600 was made. The units were observed to have the same physical arrangement with the shared nursing station and medication room, and separate dayrooms on the units. Unit 500 had 14 female adolescent patients. Unit 600 had 6 male adolescent patients. There was only 1 Registered Nurse (RN) assigned to each unit. Staff #6 was interviewed during the tour. Staff #6 explained that when there are only 2 nurses assigned for the day, they help each other out. Staff #6 stated that the RN assigned to Unit 600 only had 6 patients so that RN was also assigned to 4 patients on Unit 500. That way, each RN had 10 patients. Staff #6 was asked who was responsible for the patients when Unit 600's RN was on Unit 500 taking care of patients. Staff #6 stated that the patients had Mental Health Technicians (MHTs) with them, observing them all the time.
By accepting patient assignments on Unit 500 and Unit 600, the RN assigned to Unit 600 would not be able to be physically present on Unit 600 for immediate patient care needs if attending to patients on Unit 500. Unit 500 and Unit 600 were observed to be two separate, locked units with a shared nursing station. The patients on Unit 600 would then be left under the care of unlicensed personnel (MHTs). Review of the Nurse Staffing sheets for 5/25/2021 showed that only 1 MHT was present on the Unit 600 that day. This created a situation where the Unit 600 MHT could have been required to leave the locked unit and patients to locate the Unit 600 RN who had left to go to Unit 500 (a separate locked unit) to care for assigned patients on Unit 500.

On 5-24-2021 during the entrance conference, nurse staffing sheets and the nurse staffing plan were requested. Upon review of the documents provided on the morning of 5-25-2021, nurse staffing sheets were found to be incomplete with much information missing. Review of the nurse staffing plan did not contain a minimum staffing grid or matrix to show what had been determined to be the minimum safe staffing and/or when the nursing staff was to be increased.

On 2-25-2021, an interview was conducted with the Director of Nursing (DON). The DON explained that he had just accepted the position the previous week. When asked about his experience as a Director of Nursing, the DON stated that he had not been a Director of Nursing prior to this position.

The DON was asked if there were other staffing sheets and if there was a staffing grid or matrix. The DON said there weren't any other staffing sheets and that the hospital did not have a grid or matrix. When I asked how he based safe staffing needs, he stated that all staffing was based on acuity. The DON was asked if he could provide an acuity scale that would let staff know when the nursing staff needed to be increased. The DON stated the facility did not have any scale or guideline for the staff. The DON explained that it is all based on patient behavior and level of observation. He stated the facility tried to keep staffing to 1 Mental Health Technician (MHT) per 6 patients and 1 RN per 10 patients. When asked if there was a policy or staffing plan that stated this, he said that there was not one. When asked how he could determine that staffing was adequate, he again stated that it was all based on patient acuity.

When asked if the hospital had House Supervisors (RNs who could float to all units and provide breaks, coordinate care outside of the routine care such as patient transfers, responding to problems such as codes, assisting when units have special needs such as multiple admissions and discharges at the same time, etc.). The DON stated that they had house supervisors up until this year. When the house supervisors left, they just did not fill those positions again. The DON confirmed that on night shift, the nursing staff on the unit did not have nursing supervisory personnel at the facility to respond to special needs. The DON was asked if he knew how the Nurse Staffing Plan provided had been evaluated, reviewed, and approved. The DON explained that since he had only started the previous week, he did not.

Review of Palms Behavioral Health policy, SUBJECT: Staffing Plan for Provision of Care, POLICY AND PROCEDURE: 1300.10, EFFECTIVE DATE: 10/01/2016, REVIEWED/REVISED: 4/14/2020 was as follows:

"INTRODUCTION
Palms Behavioral Health needs to consider unique regulatory and professional requirements in the design of a staffing plan. This document serves to describe the Plan for the Provision of Patient Care for Palms Behavioral Health.

GOAL OF NURSING CARE ASSIGNMENT
Nursing care assignments, regardless of the reporting relationship of the staff providing such care, shall be commensurate with the qualifications and competency of the individual and shall be designed to meet the identified nursing care needs of patients. A registered nurse shall assess nursing care needs.

DEFINITION OF NURSING PRACTICE
...
PURPOSE
1 ...
2 ...
3. The Director of Nursing is responsible and accountable to ensure consistent standards are utilized. This plan provides the overview of each unit, which includes staffing plans based on acuity data and core staffing data. Criteria have been established for each unit to determine when staffing levels are to be adjusted. Staff adjustments are always based on acuity of patients and specialization of the unit. A qualified nurse is on duty at all times. If supplemental nursing staff from outside agencies are to be utilized ...
4 ...
5 ...
6. The Director of Nursing is responsible for and accountable to ensure consistent standards are used to monitor and evaluate quality of care.
7 ...
8 ...
LOCATION OF NURSING CARE DELIVERY
Based upon the definition of nursing practice at Palms Behavioral Health, psychiatric nursing services are delivered to patients in the following areas:
1. Adolescent Unit
2. Adult Unit
3. Geriatric Unit
ASSIGNMENT OF STAFF TO PROVIDE NURSING SERVICES
1. Individual patient care assignment is based upon:
a. The complexity of the patient's condition and requirements for nursing care
b. The dynamics of the patient's status, including frequency with which the need for nursing care activities changes.
c. The complexity of the assessment required by the patient including the knowledge and skills required of a nursing staff member in order to effectively complete the required assessment.
d. The type of technology employed in providing nursing care, with consideration given to the knowledge and skills required to effectively use the technology.
e. The degree of supervision required by each nursing staff member based upon his/her previously assessed level of competency and current competence in relation to the nursing care of the patient.
f. The availability of supervision appropriate to the assessed and current competency of the nursing staff member(s) being assigned responsibility for providing nursing care to the patient(s).
g. Relevant infection control and safety issues.
GENERAL STAFFING GUIDELINES/ASSUMPTIONS UNDER WHICH THE PLAN FOR NURSING STAFF IS BASED
1. There shall be sufficient number of qualified and competent registered nurses on the unit to provide patients with nursing services which require the judgement and specialized skills of the competent registered nurse. Nurse staffing shall also be sufficient to promptly recognize untoward changes in a patient's condition and to intervene appropriately utilizing nursing, medical and hospital staff. In striving to assure optimal, achievable, quality nursing care and a safe patient environment, nursing staffing and patient assignment shall be based upon identified minimum staffing requirements by unit (as delineated within subsequent pages within this document), actual patient needs (as assessed through use of the acuity tool) and the following:
a ...
b ...
c ...
d ...
e. The Nursing Department shall define, implement and maintain a system for determining patient requirements for nursing care on the basis of demonstrated patient needs, appropriate nursing intervention and priority for care. This acuity staffing system shall be based upon objective assessment tools which qualify the number of nursing staffing members needed to fulfill patient needs on each unit.
f ...
g. Managers and staff members use the findings from performance improvement activities and feedback from clients to assist in the evaluation of patient care provided. Findings shall be used to compare actual client outcomes with defined standards of care and practice. If staffing is adequate, both in terms of the number and qualifications of staff, correlation between actual health outcomes and standards should be positive.
PROCEDURE
1. Master staffing plans for the unit are on file in the Charge Nurse Binder in the Nurse's station. The unit has a master/core staffing plan which identifies staff which will be assigned when any patients are present.
2. Staffing is based upon patient census and acuity.
3. Staff includes a mixture of RNs, LPNs, CNAs, Psychiatric Technicians and Mental Health Workers, and may include a Unit Clerk. [Staffing Model for 2 will not have LPNs or CNAs if that matters]
4. Staffing schedules for the nursing department (RNs, LPNs, MHTs and CNAs) are planned by the Director of Nursing ...
5 ...
6. Variances between projected needs and actual staffing are described, acknowledged and justified according to census and acuity.
7 ...
8 ...
ANNUAL EVALUATION OF THE HOSPITAL PLAN FOR THE PROVISION OF NURSING CARE
1. Palms Behavioral Hospital's plan for the provision of nursing care is evaluated on an annual basis as a preliminary activity to the budget process. The Director of Nursing and Director of Clinical Services conduct this evaluation. This evaluation will consider at least the following three factors:
a. The patient requirements for patient on which the plan for nursing staff was based,
b. Patient care programs or patient populations which were added or eliminated or are planned which have resulted or may result in changes in case mix, and
c. Information available regarding the effectiveness of Palms Behavioral Health Hospital's plan for provision of care and our ability to meet the needs of the patients and staff."

The DON stated that "there's no set ratio" of staff to patients, it's all based on acuity. Per the policy above, "This acuity staffing system shall be based upon objective assessment tools which qualify the number of nursing staffing members needed to fulfill patient needs on each unit." However, there was no objective written guideline for what factored into acuity level.
The policy above stated, "Criteria have been established for each unit to determine when staffing levels are to be adjusted." The Director of Nursing and nursing staff were unaware of and unable to find established criteria for each unit.

The policy above repeatedly indicated that staffing was determined by a minimum, core staffing level and an objective acuity tool. Neither was found in the policy. In interview, the Director of Nursing denied that either one existed. On the afternoon of 5-26-2021, Unit 300 and Unit 400 nursing station was observed. Staff #10 was asked if there was a Charge Nurse Binder for staffing. Staff #10 removed and binder marked Staffing from the counter. When asked if there was grid/matrix that showed the minimum staffing required, Staff #10 opened the binder and looked at the documents inside. Staff #10 was unable to find any such document. Staff #10 denied ever having seen a document that showed the minimum staffing required. When the survey examined the binder, the surveyor was unable to find a grid/matrix of minimum staffing for the unit or an acuity tool to be used in determining if staffing needed to be increased.

The policy above required an annual evaluation. However, the heading at the top of the policy showed that the last evaluation was completed 4/14/2020 and had not been updated for 2021. The policy contained information that was inaccurate for the hospital. The policy referenced a Geriatric Unit that had been closed down. Under "PROCEDURES", the policy referenced LPNs (licensed practical nurses) instead of LVNs (licensed vocational nurses) along with what appeared to be draft revision notes, "[Staffing Model for 2 will not have LPNs or CNAs if that matters]".

Review of the staffing sheets showed that 1 staffing sheet was used to record staffing for all 4 units. The form contained the following elements to be filled in:

Shift Lead (MHT that floats between units as needed)
Date: AM/PM
Census @ Shift Start
End of Shift Census
Pending Admits
D/C's (discharges)
1:1's (1 staff member assigned to observe 1 patient)
LOS (line of sights)
Total Techs

The form contained a section for each specific unit that contained the following:

(specific unit- 300, 400, etc.)= ______ (this blank line contained the unit census)
MHT's 1. 2. 3. 4.
RN Assigned to Unit
Lunch Times: 1. 2. 3. 4. (used to indicate when each of the MHTs was to go to lunch)

Transports Scheduled:
Patient
Time Out
Location
Tech Assigned
Time In


Cancellations:
PTO:
Tech assigned to Laundry/Hotbox:
Call In's

Code Response Team

Review of the Staffing Sheets showed that adequate staffing could not be determined due to lack of information on the staffing sheets and not having defined minimum, core staffing level and an objective acuity tool. The staffing sheets did not indicate patient assignments. For instance, review of staffing sheets for 4/24/2021 AM shift showed that Unit 300 had 9 patients and Unit 400 had 11 patients. The staffing sheet showed that Unit 300 had 4 MHTs. One MHT was assigned to a 1:1 and one MHT was shadowing the MHTs. The staffing sheet did not contain patient assignments, so it could not be determined if one MHT had been assigned the remaining 10 patients while the other MHT trained the MHT that was shadowing or if the MHT's had split the patient assignments.

No nurses were listed on the staffing sheet for any of the units. Unit 500 had 10 patients and Unit 600 had 3 patients. Because staff assignments were not listed, it could not be determined if the RN assigned to Unit 600 had accepted patient assignments on Unit 500 as had been the case during unit observations on 5/24/2021. Review of the restraint log showed that a patient on Unit 600 had to be restrained on this shift. Lack of information on the staffing sheet such as the number of RNs assigned to the unit, the acuity level of patients on the unit, and staff assignments for the unit prevent the determination of staffing as being a potential factor in this incident.

Review of staffing sheets for 4-26-2021 AM shift, Unit 300 had 16 patients and one MHT assigned. Unit 400 had 12 patients and one MHT assigned. No nurses were listed on the staffing sheet so it could not be determined who was actually working that day without pulling payroll records. Review of the Incident Log showed that an incident on Unit 400 occurred on 4-26-2020 that was classified as a Patient Care/Treatment incident that required a patient transfer. Lack of information on the staffing sheet such as the number of RNs assigned to the unit, the acuity level of patients on the unit, and staff assignments for the unit prevent the determination of staffing as being a potential factor in this incident. While timecards would show who was clocked into the facility, they would not show who was assigned to the unit, the patient assignment distribution, or the acuity of patients assigned to the RN or MHT.

Review of nurse staffing sheets from 4-24-2021 through 5-24-2021 (31 day/62 shifts) showed that 41 out 62 shifts were missing names of RNs assigned to the units.

Per the Nurse Staffing Plan, "Managers and staff members use the findings from performance improvement activities and feedback from clients to assist in the evaluation of patient care provided. Findings shall be used to compare actual client outcomes with defined standards of care and practice. If staffing is adequate, both in terms of the number and qualifications of staff, correlation between actual health outcomes and standards should be positive." If a negative correlation between actual health outcomes and standards was found, staffing could not be analyzed due to lack of sufficient accurate staffing information required, such as staff present on the unit, patients assignments that were made to individual staff members, or acuity level of the patients that were assigned.

Based on review and interview the facility failed to follow its own policy and procedures to complete medical records in a timely manner in 3(#2,4, and 5) of 3 charts reviewed.

Review of Patient #2's medical chart revealed she was admitted on 2/13/21. Review of the physician orders revealed there was 18 out of 28 orders not signed by the physician as of 5/26/21.

Review of Patient #5's medical chart revealed he was admitted on 1/27/21. Review of the physician orders revealed there was 25 out of 35 orders not signed by the physician as of 5/26/21.

Review of Patient #4's medical chart revealed he was admitted on 10/18/20. Review of the physician orders revealed there was 24 out of 66 orders not signed by the physician as of 5/26/21.

Review of the policy and procedure 1400.34 Incomplete Record Notification and Suspensions reviewed/revised 1/23/19 stated, "POLICY:
The patient's medical record will be considered complete when the
required contents are assembled and authenticated, including the
recording of final diagnosis, dictation of discharge summary and the
insertion of any reports, but not longer than 30 days from discharge. If a
record is not completed by the physician within 30 days of discharge, it will
result in the suspension of the physician's admitting or consulting
privileges until the records are completed.
PURPOSE:
To ensure the completeness of medical record information.
PROCEDURE:
Health Information Management Personnel:
A. A deficiency list is generated weekly for physicians and staff.
B. Medical records that are not completed by the physician 30 days
following discharge will result in automatic suspension of the
physician's admitting or consulting privileges.
C. Physicians must complete chart with discharge summary within 15
days of discharge. If not, these records are considered delinquent.
D. The Health Information Management Department will prepare a
delinquent record list weekly.
E. Deficiency lists and/or reminder letters will be sent weekly to
physicians with incomplete charts, encouraging them to complete
these charts before they become delinquent.
F. Physicians with delinquent charts are given 7 additional days to
complete these records. If the records are not complete after the 7
days, a letter will be sent by certified mail to the doctor notifying
him/her that their admitting privileges will be suspended unless the
records are completed before 30 days post-discharge.
G. The suspension list is distributed by the Health Information
Management Department to Administration, Admitting, Medical
Staff Office, and Nursing Service.
H. Upon completion of the delinquent medical records, the physician's
admitting privileges will be reinstated.
I. Health Information Management is responsible for notifying
Administration, Admitting, the Medical Staff Office and Nursing
Service as soon as the physician on the suspension list has
completed his/her records."

An interview was conducted with Staff #20 and Staff #1 on 5/26/21 at 11:10AM. Staff #20 confirmed that there were incomplete charts that are awaiting physician signatures for over 30 days. Staff #20 stated that in the past they had sent out letters to the providers letting them know about delinquent charts. They would even call the managers of the physician office and get them involved to get the charts current. Staff #20 stated the previous administration would not allow her to send any of the letters or put the physicians on suspension for delinquent charts. Staff #20 did have a system in place but was not allowed to utilize it. Staff #1 stated that a Medical Executive Meeting (MEC) was being held on 5/28/21 and the medical staff would be notified of the delinquencies and the policy would be enforced.

Based on review of records and interview, the facility failed to ensure that a physician evaluated the patient and completed the initial psychiatric evaluation for 1 patient (Patient #19) out of 3 patients' Initial Psychiatric Evaluations completed. The Initial Psychiatric Evaluation had been completed by the Nurse Practitioner and countersigned by the physician. The Medical Staff Rules and Regulations restricted the regulatory 60 hour time frame to complete an Initial Psychiatric Evaluation to 24 hours. This restricted time frame contributed to an incomplete Psychiatric Evaluation with missing information.

Findings included:

A review of Patient #19's record showed that the patient had been admitted on 5/8/2021. The Initial Psychiatric Evaluation was completed on 5/9/2021 at 14:56 (2:56 PM). It was completed by an Advanced Practice Registered Nurse (APRN) as evidenced by the report being "Signed by" the APRN on 5/9/2021 at 14:56 (2:56 PM). Physician Staff #17 electronically counter-signed the report at the same time, 5/9/2021 at 14:56 (2:56 PM).

The Initial Psychiatric evaluation must be done within 60 hours of admission per regulatory requirements [CFR 482.61(b)(1)], providing the physician with the time necessary to assess and evaluate the patient and collect the required information for the completion of a psychiatric evaluations. However, the Medical Staff Rules and Regulations restricted that time to 24 hours.

Review of Palms Behavioral Health Medical Staff Rules and Regulations 2021 showed that:
"Medical Record Requirements
The organized medical staff monitors the quality of medical histories and physical examinations through the FPPE (focused professional practice evaluation) and OPPE (ongoing professional practice evaluation) process.
4. Each patient, on admission, is to have a psychiatric evaluation including mental status evaluation and a complete medical history and physical examination accomplished. Both documents must be completed within twenty-four (24) hours of the patient's admission.
...
5. The psychiatric evaluation will include, at a minimum, the following elements and other information deemed to be relevant by the examining provider:
-Reason for admission
-Chief complaint in patient's own words
-Precipitating stress
-History of Present Illness
-Past Psychiatric History
-Medical history which encompasses medical and surgical components
-Allergies
-Social History
-Mental Status including thought, mood, and behavior, memory, insight (including method of determining) judgement (including method of determining), intellectual functioning, developmental disability (including basis for estimation of intellectual functioning, basis for estimation of memory function, and basis for determining memory).
-Assets or strengths
-Plan of Care"

Review of the Initial Psychiatric Evaluation completed by the APRN and countersigned by Physician Staff #17 documented that the History and Physical (H&P) Examination of the patient by a medical physician (required to be completed within 24 hours of admission) was "Not available at this time". Other information not on the evaluation included:

"Patient reason for admission in patient's own words Pt didn't respond"

"Current living arrangements pt didn't respond"

"Emotional support from whom & how Unknown"

"Describe relationships that could affect patient treatment Unknown"

"Positive Physical Findings See H&P"

"Previous Medication Trials Unknown"

"Appearance / Behavior Asleep, didn't respond"

"Thought Form UTA (unable to assess)"

"Thought Content UTA and Received emergency medication for aggressive behavior"

"Support Systems Unknown"

"Fund of knowledge UTA"

"Abstract thinking UTA"

"Memory UTA"

"Memory - 5 min. UTA"

"Calculation 100-35=___X2=___ UTA"

"Serial 7's UTA"

"Describe how judgment is assessed (i.e., Find a letter by mailbox) UTA"

"Reaction to Hospitalization Asleep, pt didn't respond"

The Initial Plan of Care documented on the Initial Psychiatric Evaluation was as follows:
"Admit to Inpatient Hospital for concerns of danger to self or others. Pt assessed via HIPAA-adherent telepsych service platform. Pt was observed sleeping and unable to respond to assessment questions. Pt has been aggressive, disrupting milieu, yelling, agitated, not redirecting. Pt has received emergency medication x2 see MAR (medication administration record). CK level ordered."

The report reflected that the patient had been unable to participate in an assessment due to being medicated with emergency behavioral medications that resulted in him sleeping and being unable to respond. Despite the patient's inability to participate in the evaluation, the evaluation was not deferred until the patient could be appropriately assesses for all required elements of an Initial Psychiatric Evaluation.

Because the Initial Psychiatric Evaluation was completed by an APRN and not a physician, Patient #19's Initial Psychiatric Evaluation was the APRN's assessment and evaluation of the patient to which the physician agreed with (indicated by electronic signature) based on the APRN's reported findings and not the physician's direct observation and evaluation/assessment of the patient. Many of the findings were incomplete because Patient #19 had been medicated, was sleeping, and unable to participate in the Initial Psychiatric Evaluation. Due to the restricted 24-hour timeframe, the evaluation was not deferred and completed when the physcian could evaluate the patient, the patient could participate in the evaluation, and necessary information such as the History and Physical was available for the physician to consider in the physician's total assessment and appraisal of the patient's illness.

Interview was conducted with Staff #1. Staff #1 confirmed that the facility was not aware that the Initial Psychiatric Evaluation was a physician's assessment to which an APRN could assist in gathering information such as the Mental Status Examination. This would be shown as a separate assessment by the APRN which would be countersigned by the physician and incorporated into the physician's Initial Psychiatric Evaluation, completed and signed by the physician after the physician evaluated the patient.

Based on review of records and interview, the facility failed to ensure that a process was implemented and enforced, that required a Licensed Master Social Work (LMSW) to review and document the review of the initial psychosocial evaluation for quality and appropriateness when completed by anyone other than an LMSW for 6 patient psychosocials (Patient #14, #15, #16, #18, #19, and #20).

Findings included:

Review of patient #14's chart showed that the patient was admitted on 5-22-2021. The initial psychosocial evaluation was completed on 5-23-2021 by a Licensed Professional Counselor - Associate (LPC-A). The evaluation did not contain the signature of a LMSW who reviewed the assessment.

Review of patient #15's chart showed that the patient was admitted on 5-20-2021. The initial psychosocial evaluation was completed on 5-21-2021 by an LPC-A/Licensed Chemical Dependency Counselor (LCDC). The evaluation did not contain the signature of a LMSW who reviewed the assessment.


Review of patient #16's chart showed that the patient was admitted on 5-22-2021. The initial psychosocial evaluation was completed on 5-23-2021 by an LPC-A. The evaluation did not contain the signature of a LMSW who reviewed the assessment.

Review of patient #18's chart showed that the patient was admitted on 5-5-2021. The initial psychosocial evaluation was completed on 5-6-2021 by an LPC-A. The evaluation did not contain the signature of a LMSW who reviewed the assessment.

Review of patient #19's chart showed that the patient was admitted on 5-8-2021. The initial psychosocial evaluation was completed on 5-9-2021 by an LPC-A. The evaluation did not contain the signature of a LMSW who reviewed the assessment.

Review of patient #20's chart showed that the patient was admitted on 5-12-2021. The initial psychosocial evaluation was completed on 5-13-2021 by an LPC-A. The evaluation did not contain the signature of a LMSW who reviewed the assessment.

An interview was conducted on 5-26-2021 with Staff #11 and Staff #12, both LPC-As. When asked if there was a process for the LMSW to review the initial psychosocials after completion and sign off on them, both stated there was not. Staff #11 stated that there had been a process at one time, but then they were told an LMSW didn't have to review them.

An interview was conducted with Staff #15, the Interim Director of Social Work, on the morning of 5-27-2021. Staff #15 confirmed that she had accepted the position as Interim Director of Social Work the week prior and was an LMSW. When asked about reviewing the psychosocial and documenting the review, Staff #15 stated that she had not been previously aware of the requirement until 5-26-2021 but was putting a process in place.