HospitalInspections.org

Based on contract review, document review, and interview, the Governing Body failed to ensure patients were provided safe care by trained and competent staff for 2 of 2 (Agency staff #1 and #2) agency staff reviewed.

The findings included:

1. Review of a Client Service Agreement (contract) between the staffing agency and hospital, revealed the client (Corporation owning hospital) acknowledged the providers (Behaviorial Health Associates (BHA), Certified Nuring Assistant (CNA), Licensed Practical Nurse (LPN), and Registered Nurse (RN) were independent contractors operating as self-employed individuals who used staffing agencies' platforms and services to offer and provide halthcare services to clients/patients. The hospital maintained no employee or training records on the agency staff. The hospital did not conduct background checks or checks of the Abuse Registry on agency staff. Agency staff were not required to complete an orientation that included training and competencies required of this hospital's staff prior to assigment to work on a unit. Agency staff were not required to complete the mandatory training in Cardiopulmonary Resuscitation (CPR), Abuse, Seclusion & Restraint, Handle-with-Care/de-escalation techniques prior to beginning work on the units at the hospital.

Review of agency staff training records and competencies revealed there was no documentation of mandatory training records and competencies for Agency staff #1 and Agency staff #2.

In an interview on 02/23/2024 at 9:10 AM, the Human Resources Director stated there was no formal process for monitoring agency staff for mandatory training and competencies required prior to beginning direct patient care.

Refer to A-084

Based on contract review, document review and interview, the Governing Body failed to ensure staff under contract were trained and competent to provide care in a safe and effective manner for 2 of 2 (Agency staff #1 and #2) agency staff reviewed.

The findings included:

1. Review of a Client Service Agreement (contract) between the staffing agency and hospital, with an effective date of 02/17/2023, revealed the client Corporation owning the hospital acknowledged the providers (Behavioral Health Associates (BHA), Certified Nursing Assistant (CNA), Licensed Practical Nurse (LPN), and Registered Nurse (RN)) were independent contractors operating as self-employed individuals who used the staffing Agency platforms and services to offer and provide healthcare services to clients/patients. The hospital maintained no employee or training records on the agency staff. The hospital did not conduct background checks or checks of the Abuse Registry on agency staff. The hospital staff reported that the staffing agency had a portal where the agency staff training could be viewed. The hospital did not verify information viewed in that portal. Agency staff were not required to complete an orientation that included training and competencies required of this hospital's staff prior to assignment to work on a unit. Agency staff were not required to complete the mandatory training in Cardiopulmonary Resuscitation (CPR), Abuse, Seclusion & Restraint, Handle-with-Care/de-escalation techniques prior to beginning work on the units at the hospital. Agency staff were not allowed to provide any hands-on-care and could not assist with combative or aggressive patients, holding patients for as needed (PRN) injections ordered for agitated/combative patients, restraints, or seclusion of patients. Agency staff were included in the unit staff/patient ratios (even though the agency staff could not provide hands-on-care or assistance with combative/aggressive patients).

2. Review of agency staff training and competency records for Agency staff #1 revealed no documentation of mandatory training records and competencies.

3. Review of agency staff training and competency records for Agency staff #2 revealed no documentation of mandatory training records and competencies.

In an interview on 02/21/2024 at 9:00 AM, the Administrator stated agency staff did not provide hands-on care if the patient required physical restraint. The Administrator stated the agency staff should not touch the patient at all if it was related to Handle-with-Care/de-escalation and agency staff cannot provide physical assistance in dealing with combative/aggressive patients. The Administrator stated agency staff cannot hold patients for as needed (PRN) medications. The Administrator stated she was not sure if the hospital had a written policy regarding this and stated the hospital had verbally communicated with the Agency regarding this rule. When questioned whether the hospital rule was documented anywhere, the Administrator replied that it was a "yes/no" answer. She stated, "In the beginning, we did have them sign off that they received it (the rule that agency staff did not provide hands-on care for patients), but some have been done just verbally by nursing leadership."

In an interview on 02/23/2024 at 9:10 AM, the Human Resources Director stated there was no formal process for monitoring agency staff for mandatory training and competencies required prior to beginning direct patient care.

Based on policy review, document review, and interview, the facility failed to ensure patients' rights to be free from verbal and physical abuse by staff were protected as evidence by review of the hospital incidents for 5 of 13 (Incident #1, #2, #3, #4, #5) reviewed abuse incidents related to staff.

The findings included:

1. Review of the facility's "Workplace Violence Policy, #HR [Human Resource] - 620" policy revealed, "... [named Corporation] had a Zero Tolerance approach to workplace violence and was committed to providing an environment free from all forms of violence for its employees, patients, families, and vendors..."

Review of the facility's "Patient Abuse and Neglect, #HR-001" policy revealed, ".....Patients have the right to be free from mental, physical, sexual and verbal abuse, neglect, and exploitation. [Named Hospital] shall protect patients from real or perceived abuse, neglect or exploitation from anyone, including staff members, students, volunteers, other patients, visitors or family members... Mental/Psychological Abuse... Acts that inflict emotional harm, invoke fear and/or humiliate, intimidate, degrade, demean or otherwise negatively impact the mental health..."

Review of the facility's "Patient Rights and Responsibilities" policy revealed, "... Patients have the following rights... Patients have the right to be treated with consideration, respect, and full recognition of their dignity and individuality... Patients have the right to be protected by the licensee from neglect; from physical, verbal, and emotional abuse... "

2. Review of the Grievance/Complaint Log data from 9/1/2023 to 2/21/2024 revealed 5 complaints of patient abuse by staff that were substantiated by the hospital upon completion of their investigation.

Review of Incident #1 revealed on 10/27/23 on the East Unit, Patient #1 reported verbal and physical abuse by Behavioral Health Associates (BHA) #1. BHA #1 was terminated upon the completion of the facility's investigation.

Review of Incident #2 revealed on 10/31/23 on the East Unit, Medical Doctor (MD) #1 reported witnessing BHA #2 yelling and cursing at Patient #2. BHA #2 was placed on administrative leave during the facility's investigation and required to complete zero tolerance training.

Review of Incident #3 revealed on 11/24/23 on the North Unit, several staff members (unnamed) reported witnessing Registered Nurse (RN) #1 cursing at Patient #3. RN #1 received a "final warning" disciplinary action and was to complete zero tolerance training and customer service training.

Review of Incident #4 revealed on 1/21/24 on the East Unit, Activity Therapy Manager #1 reported BHA #3 was overheard calling patients "ugly", telling patients she wasn't there to do what the patient says, and telling a patient to "jump". BHA #3 received a "final warning" as a disciplinary notice.

Review of Incident #5 revealed on 2/12/24 on the North Unit, Patient #4 reported BHA #4 exchanged words with him and became verbally aggressive after being told she didn't know how to do her job. BHA #4 was terminated upon completion of the facility's investigation.

3. In an interview on 02/21/2024 at 11:00 AM, the Interim Risk Manager stated she reviewed the Incident Logs, did a risk analysis, and made sure the witness statement was completed. She dealt only with the patient aspect of the incident. She would only do a root cause analysis if a patient was attacked by staff. She had to do a root cause analysis if violent, aggressive patients either engaged in self-harm or physical confrontations with staff or other patients. She hadn't yet encountered anything that had repeatedly occurred.

In an interview on 02/21/2024 at 12:00 PM, the Quality Director (QD) stated she reviewed the Grievance/Complaint logs in the Quality Council monthly meetings and verified she hasn't done anything with the Incident Log. The QD stated the Risk Director was responsible for handling all incident reports and some risk reports.

In an interview on 02/21/2024 at 1:00 PM, the Patient Advocate stated he worked with the Interim Risk Management, talked with her every morning, and addressed patient complaints with her via Flash Notes (online marketplace to buy and sell course specific notes, flashcards, and other items) and TEAMS (video conferencing service) meetings. The Patient Advocate stated he had no interaction with the Compliance Manager.

Refer to A145.

Based on policy review, document review, and interview, the facility failed to ensure patients' rights to be free from verbal and physical abuse by staff were protected as evidence by review of 5 of 13 (Incident #1, #2, #3, #4, #5) reviewed abuse incidents related to staff.

The findings included:

1. Review of the hospital's policy "Workplace Violence Policy, #HR [Human Resource] - 620" with an effective date of 12/09/2007 and revised 09/01/2015 revealed, "... [named Corporation] had a Zero Tolerance approach to workplace violence and was committed to providing an environment free from all forms of violence for its employees, patients, families, and vendors. Workplace violence included but was not limited to harassment, intimidation, threats (verbal, written, or physical) or acts of physical assault and other disruptive behavior..."

Review of hospital's policy "Patient Abuse and Neglect, #HR-001" dated 12/20/2021 revealed, ".....Patients have the right to be free from mental, physical, sexual and verbal abuse, neglect, and exploitation. [Named Hospital] shall protect patients from real or perceived abuse, neglect or exploitation from anyone, including staff members, students, volunteers, other patients, visitors or family members... Mental/Psychological Abuse... Acts that inflict emotional harm, invoke fear and/or humiliate, intimidate, degrade, demean or otherwise negatively impact the mental health... Examples include derogatory, threatening, belittling, humiliating, or profane or obscene language toward a patient, physical intimidation... Verbal Abuse... The use of offensive and/or intimidating language that can provoke or upset an individual... Examples include cursing /verbally threatening a patient, cursing/verbally threatening in front of a patient even if not directed toward the patient, verbally criticizing a patient and family..."

Review of the hospital's policy "Patient Rights and Responsibilities" dated 12/2021 and reviewed 3/2023 revealed, "... Patients have the following rights... Patients have the right to be treated with consideration, respect, and full recognition of their dignity and individuality... Patients have the right to be protected by the licensee from neglect; from physical, verbal, and emotional abuse... "

2. Review of the Grievance/Complaint Log data from 9/1/2023 to 2/21/2024 revealed 5 complaints of abuse by staff that were substantiated by the hospital upon completion of their investigation.

Review of Incident #1 revealed on 10/27/23 on the East Unit, Random Patient #1 reported verbal and physical abuse by Behavioral Health Associates (BHA) #2. Random Patient #1 reported BHA #2 flipped him out of a chair, pushed him in the back, and called him "sissy" and "faggot". East Unit had a census of 26 patients and was staffed by 2 nurses, 3 BHAs and 1 supervisor at the time of the reported abuse. BHA #2 was terminated upon the completion of the facility's investigation.

Review of Incident #2 revealed on 10/31/23 on the East Unit, MD #1 reported witnessing BHA #3 yelling and cursing at Random Patient #2. East Unit had a census of 26 patients and was staffed by 2 nurses and 4 BHAs at the time of the reported abuse. BHA #3 was placed on administrative leave during the facility's investigation and required to complete zero tolerance training. BHA #3's zero tolerance training was not completed until 12/1/23, after he returned to work on 11/9/23.

Review of Incident #3 revealed on 11/24/23 on the North Unit, several staff members (unnamed) reported witnessing RN #10 cursing at Random Patient #3. RN #1 told Random Patient #3 "Fuck you". North Unit had a census of 17 patients and was staffed by 2 nurses and 2 BHAs at the time of the reported abuse. RN #1 received a "final warning" disciplinary action and was to complete zero tolerance training and customer service training. Review of RN #1's training revealed Zero Tolerance training was not completed until 1/12/24. There was no documentation of customer service training.

Review of Incident #4 revealed on 1/21/24 on the East Unit, Activity Therapy Manager #1 reported BHA #4 was overheard calling patients "ugly", telling patients she wasn't there to do what the patient says, and telling a patient to "jump". East Unit had a census of 27 patients and was staffed by 2 nurses and 3 BHAs at the time of the reported abuse. BHA #4 received a "final warning" as a disciplinary notice.

Review of Incident #5 revealed on 2/12/24 on the North Unit, Random Patient #4 reported BHA #5 exchanged words with him and became verbally aggressive after being told she didn't know how to do her job. North Unit had a census of 19 patients and was staffed by 3 nurses and 2 BHAs at the time of the reported abuse. BHA #5 was terminated upon completion of the facility's investigation.

3. In an interview on 02/21/2024 at 11:00 AM, the Interim Risk Manager (RM) stated her role was to identify facility risks, including environmental risks. The Interim RM stated she collected, reviewed, and entered incident reports into the system. The Interim RM stated she did morning rounds on each unit, pulled out the incident report, looked at the report while on the unit, and mentioned concerns to the nurse and other staff while on the unit. The Interim RM stated she completed investigations of incident reports and discussed findings in the daily Leadership Meeting and identified any risks and immediately acted to mitigate those risks. The Interim RM stated she had never heard of a Quality Assurance and Performance Improvement (QAPI) Team or QAPI Report. The Interim RM stated she would only do a root cause analysis if a patient was attacked by staff and would do a root cause analysis if violent, aggressive patients either engaged in self-harm or physical confrontations with staff or other patients. The Interim RM stated she hadn't yet encountered anything that had repeatedly occurred.

In an interview on 02/21/2024 at 12:00 PM, the Quality Director (QD) stated she reviewed the Grievance/Complaint logs in the Quality Council monthly meetings but did not do anything with the Incident Log. The QD stated the Risk Director was responsible for handling all incident reports and some risk reports.

In an interview on 02/21/2024 at 1:00 PM, the Patient Advocate stated he worked with Risk Management, talked with her every morning, and addressed patient complaints with her via Flash Notes (online marketplace to buy and sell course specific notes, flashcards, and other items) and TEAMS (video conferencing service) meetings. The Patient Advocate stated he had no interaction with the Compliance Manager.

Based on policy review, document review, medical record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program fully analyzed adverse events (incidents) and implemented measures to prevent future occurrences for 2 of 3 (Patients #2 and #4) sampled patients reviewed with adverse events, and failed to track, analyze and implement preventative measures for all other adverse events as part of the facility wide QAPI program.

The findings included:

1. Review of the facility's "PROCESS IMPROVEMENT PROGRAM" policy revealed, "...The Process Improvement Program is designed to provide a coordinated, objective, and systematic approach to facility-wide quality assurance activities...Objectives are...To foster a safe and just culture so that errors are managed appropriately through supportive systems, education on at-risk behaviors, and correction as needed...Review incident report data...to determine the presence or absence of patterns and/or trends or opportunities for improvement in patient care outcomes, as well as the appropriateness of corrective action..."

Review of the facility's "Risk Management Incident Investigation Policy" revealed, "...It is the policy of [named hospital] to utilize investigation as a preventative tool to strive to avoid incidents from reoccurring and to improve quality of care..."

2. Medical record review for Patient #2 revealed an admission date of 10/6/2023 with admitting diagnosis of Schizoaffective Disorder, Depressive type.

Review of the facility's Incident Report beginning 9/1/2023 through 2/21/2024 revealed on 10/7/2023 Patient #2 with an incident description of "Restraint". The incident "Summary" revealed Patient #2 became upset after her initial assessment. Patient #2 became "irate" (great anger) and stated would self-harm. A physician ordered chemical and physical restraint to calm Patient #2. There was no documentation the facility implemented specific measures to help prevent future incidents involving Patient #2.

3. Medical record review for Patient #4 revealed an admission date of 2/7/2024 with admitting diagnosis of Major Depressive Disorder, recurrent, severe with psychosis.

Review of the facility's Incident Report beginning 9/1/2023 through 2/21/2024 revealed on 2/11/2024 Patient #4 had 2 incidents of restraints, and 1 incident of seclusion. On 2/12/2024 Patient #4 had 2 incidents of restraints, and 1 incident of seclusion. There was no documentation the facility implemented specific measures to help prevent future incidents involving Patient #3.

4. Review of Performance Improvement meeting minutes beginning September 2023 through February 2024 revealed the following:

-November 3, 2023 meeting; review of September 2023 data revealed, " ...We had a total of 71 incidents in September ...Action To Be Taken ..." There was no documentation the facility tracked, analyzed and implemented specific measures to address incidents for September 2023.

-December 1, 2023 meeting; review of October 2023 data revealed, " ...QAPI ...We had 74 incidents in October ...Action To Be Taken ...Continue to look at data for the quarter and make PI [Performance Improvement] teams for 2024..." There was no documentation the facility tracked, analyzed and implemented specific measures to adequately address incidents for October 2023.

-December 22, 2023 meeting; review of November 2023 data revealed, " ...QAPI ... We had 66 incidents in November ...Action To Be Taken ...Make sure we are properly documenting with Suicide gestures. Will educate nursing staff ..." There was no documentation the facility tracked, analyzed and implemented specific measures to adequately address incidents for November 2023.

-February 9, 2024 meeting; review of December 2023 data revealed, " ...QAPI ...We had 112 incidents in December ...Risk is having safety Huddles daily. Significant increase in December. Numbers are higher because more are being reported even when they are being handled ...Action To Be Taken ...Several patients were responsible for multiple incidents and more high acuity patients made for higher numbers ..." There was no documentation the facility tracked, analyzed and implemented specific measures to adequately address the significant increase in incidents for December 2023.

-March 1, 2024 meeting; review of January 2024 data revealed no documentation of incident data for January 2024.

-March 22, 2024 meeting; review of February 2024 data revealed no documentation of incident data for February 2024.

In an electronic mail (email) communication with the Administrator on 02/28/2024 at 4:00 PM, the Administrator addressed the increased December incidents stating, "... No root cause analysis was done. Incidents were discussed in Quality and flash meetings and recommendations made to ensure safety..."

Refer to A 0286.

Based on policy review, document review, medical record review and interview, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program fully analyzed adverse events (incidents) and implemented measures to prevent future occurrences for 2 of 3 (Patients #2 and #4) sampled patients reviewed with adverse events, and failed to track, analyze and implement preventative measures for all other adverse events as part of the facility wide QAPI program.

The findings included:

1. Review of the facility's "PROCESS IMPROVEMENT PROGRAM" policy (revised 1/2024) revealed, "...The Process Improvement Program is designed to provide a coordinated, objective, and systematic approach to facility-wide quality assurance activities...Objectives are...To foster a safe and just culture so that errors are managed appropriately through supportive systems, education on at-risk behaviors, and correction as needed....Facility-wide quality assessment and robust process improvement activities include...medication use, safety, risk management...The authority and responsibility of the Performance Improvement Director includes...Review incident report data, patient surveys, employee surveys such as Culture of Safety survey, and patient complaints to determine the presence or absence of patterns and/or trends or opportunities for improvement in patient care outcomes, as well as the appropriateness of corrective action..."

Review of the facility's "Risk Management Incident Investigation Policy" (reviewed 3/2023) revealed, "...It is the policy of [named hospital] to utilize investigation as a preventative tool to strive to avoid incidents from reoccurring and to improve quality of care. Additionally, investigations help to cultivate an educational mindset of safety amongst all levels of employees at the facility..."

2. Medical record review for Patient #2 revealed an admission date of 10/6/2023 with admitting diagnosis of Schizoaffective Disorder, Depressive type. Patient #2 was an involuntary admission who was hearing voices, paranoid, agitated, confused, and considered a danger to self and others. Patient #2 was housed on the East Unit.

Review of the facility's Incident Report beginning 9/1/2023 through 2/21/2024 revealed on 10/7/2023 Patient #2 with an incident description of "Restraint". The incident "Summary" revealed Patient #2 became upset after her initial assessment. Patient #2 became "irate" (great anger) and stated would self-harm. A physician ordered chemical and physical restraint and documented they were required to calm Patient #2.

There was no documentation the facility implemented specific measures to help prevent future incidents involving Patient #2.

3. Medical record review for Patient #4 revealed an admission date of 2/7/2024 with admitting diagnosis of Major Depressive Disorder, recurrent, severe with psychosis. Patient #4 had a suicidal plan to cut her throat with a knife, was psychotic, and hearing command voices. Patient #4 was housed initially on the North Unit.

Review of the facility's Incident Report beginning 9/1/2023 through 2/21/2024 revealed on 2/11/2024 Patient #4 had 2 incidents of restraints, and 1 incident of seclusion. On 2/12/2024 Patient #4 had 2 incidents of restraints, and 1 incident of seclusion. Patient #4 had reportedly punched windows, walls, made verbal and physical threats toward staff, climbed over a nursing station, and verbalized wanting to self-harm.

There was no documentation the facility implemented specific measures to help prevent future incidents involving Patient #3.

4. Review of the facility's Incident Report documentation beginning 9/1/2023 through 2/21/2024 revealed the following:

September 2023 Incidents included: "Restraints (included holds and seclusion)- 6, Patient to Patient altercations- 14, Patient to Staff altercations- 3, Falls (observed and unobserved)- 2, Misconduct (included boundary violations and sexual misconduct)- 5, Physician orders not carried out- 1, Property Damage- 1, Contraband- 2, Medication variances- 2".

October 2023 Incidents included: "Restraints- 13, Patient to Patient altercations- 12, Patient to Staff altercations- 1, Falls- 7, Misconduct- 4, Property Damage- 3, Contraband- 6, Medication variances- 2, Self-inflicted injuries- 5, Staff to Patient alleged abuse (verbal/physical)- 3".

November 2023 Incidents included: "Restraints-5, Patient to Patient altercations- 9, Patient to Staff altercations- 3, Falls- 4, Misconduct- 9, Property Damage- 3, Contraband- 3, Medication variances- 2, Self-inflicted injuries- 1, Staff to Patient alleged abuse- 2, Suicidal gesture- 3".

December 2023 Incidents included: "Restraints- 20, Patient to Patient altercations- 28, Patient to Staff altercations- 2, Falls- 10, Misconduct- 6, Property Damage- 9, Contraband- 4, Medication variances- 1, Self-inflicted injuries- 2, Suicidal gestures- 2, attempted elopement- 2".

January 2024 Incidents included: "Restraints- 9, Patient to Patient altercations- 17, Patient to Staff altercations- 6, Falls- 7, Misconduct- 1, Property Damage- 2, Contraband- 2, Self-inflicted injuries- 5, Physician orders not carried out- 1, Patient wandering- 1, Staff to Patient alleged abuse- 2".

February 2024 Incidents included: "Restraints- 19, Patient to Patient altercations- 16, Patient to Staff altercations- 2, Falls- 1, Misconduct- 4, Property Damage- 1, Contraband- 2, Medication variance- 3, Suicidal gestures- 3, Staff to Patient alleged abuse- 1".

Review of Performance Improvement meeting minutes beginning September 2023 through February 2024 revealed the following:

November 3, 2023 meeting; "review of September 2023 data" revealed, "...QAPI ...Risk Management Scorecard/Incidents- We had a total of 71 incidents in September ...Action To Be Taken ..." There was no documentation the facility tracked, analyzed and implemented specific measures to address incidents for September 2023.

December 1, 2023 meeting; "review of October 2023 data" revealed, " ...QAPI ...Risk Management Scorecard/Incidents- We had 74 incidents in October ...Action To Be Taken ...Continue to look at data for the quarter and make PI [Performance Improvement] teams for 2024. CEO [Chief Executive Officer] talk with Risk to update training in orientation to review zero tolerance/abuse ..." There was no documentation the facility tracked, analyzed and implemented specific measures to adequately address incidents for October 2023.

December 22, 2023 meeting; "review of November 2023 data" revealed, " ...QAPI ... Risk Management Scorecard/Incidents- We had 66 incidents in November ...Sexual intercourse Pt/Pt [patient to patient] increased from 0 to 3 and Suicide gestures went from 0 to 3 ...Action To Be Taken ...Make sure we are properly documenting with Suicide gestures. Will educate nursing staff ..." There was no documentation the facility tracked, analyzed and implemented specific measures to adequately address incidents for November 2023.

February 9, 2024 meeting; "review of December 2023 data" revealed, " ...QAPI ...Risk Management Scorecard/Incidents- We had 112 incidents in December ...Risk is having safety Huddles daily. Significant increase in December. Numbers are higher because more are being reported even when they are being handled ...Action To Be Taken ...Several patients were responsible for multiple incidents and more high acuity patients made for higher numbers ..."
There was no documentation the facility tracked, analyzed and implemented specific measures to adequately address the significant increase in incidents for December 2023.

March 1, 2024 meeting; "review of January 2024 data" revealed no documentation of incident data for January 2024.

March 22, 2024 meeting; "review of February 2024 data" revealed no documentation of incident data for February 2024.

In an electronic mail (email) communication with the Administrator on 02/28/2024 at 4:00 PM, the Administrator addressed the increased December incidents stating, "... No root cause analysis was done. Incidents were discussed in Quality and flash meetings and recommendations made to ensure safety...moving patients to different units...Plan addressed...added to 2024 PI [Performance Improvement] Plan under Risk/Workplace Violence Committee..."

Based on policy review, document review, medical record review observation and interview, the hospital failed to ensure the Director of Nursing (DON) operated an organized nursing service for 4 of 4 (East, North, South, West) units reviewed, failed to ensure nursing services provided adequate oversight and supervision for safe care for 2 of 4 (Patients #2 and #4) sampled patients, failed to follow the staff patient ratio goal for 20 of 20 (10/6/2023 - 10/19/2023 and 2/7/2024 - 2/12/2024) days reviewed and failed to ensure medications were administered per physician order for 7 of 7 (Patients #5, 6, 7, 8, 9,10 and 11) patients reviewed for medication variances.

The findings included:

1. Review of the job description for "Chief Nursing Officer [CNO; also called Director of Nursing (DON)]" revealed, "... Purpose Statement: Direct, plan, coordinate, monitor and supervise the effective use of the operations of nuring..."

Request to review organizational chart for Nursing Services revealed the facility was unable to provide documentation of an organizational chart for Nursing Services.

In an interview on 02/04/2024 at 11:55 AM, the Administrator verified there was no organizational chart for Nursing Services.

Refer to A-0386

2. Review of the facility's "PATIENT RIGHTS AND RESPONSIBILITIES" policy revealed, " ...Patients have the right to be protected by the licensee from neglect; from physical, verbal, and emotional abuse ..."

Review of the facility's "ASSIGNMENT OF NURSING STAFF" policy revealed, " ...It is the policy of this facility to maintain a staffing level, which supports safe and effective care for each clinical program..."

3. Medical record review for Patient #2 revealed an admission date of 10/6/2023 with diagnoses that included Schizoaffective Disorder, Depressive type.

On 10/07/2023, Patient #2 became upset over involuntary status, threatening to kill self, refused as needed (PRN) medication, and attempted to barricade self in day room. Patient #2 required physical restraint by staff for administration of a PRN medication.

On 10/10/2023, Patient #2 became upset again after meeting with the patient advocate. Patient #2 began beating on the nurse's station window and medication room window, yelling, screaming, and threatening to slap a staff member. Patient #2 required chemical and physical restraint, with seclusion ultimately ordered.

Nursing oversight failed to prevent Patient #2 from endangering himself through behaviors, and failed to prevent staff and other patients from physical harm by Patient #2.

Review of the daily staffing and census beginning 10/6/2023 through 10/19/2023 for the East Unit (where Patient #2 was housed) revealed the facility failed to meet their staff ratio goal of 1 staff to 5 patients on each day reviewed.

4. Medical record review for Patient #4 revealed an admission date of 2/7/2024 with diagnoses that included Schizoaffective disorder, Depressive type.

Patient #4 was involved in incidents including restraint (physical and chemical), seclusion and attacks on staff beginning 2/8 -2/12/2024. Patient #4's incidents on 2/12/2024 resulted in a fractured arm.

Nursing oversight failed to ensure Patient #4 was free from injury, including a fractured arm, after repeated, ongoing behaviors while admitted to the facility.

Review of the daily staffing and census beginning 2/7/2024 through 2/12/2024 on the East Unit revealed the facility failed to meet the staff ratio goal of 1 staff to 5 patients on each day reviewed.

5. Observations on the North Unit on 02/21/2024 at 9:20 AM, revealed there were twenty (20) patients on the unit. Two (2) Behavioral Health Associates (BHAs) were present. Nineteen (19) patients required monitoring every fifteen (15) minutes. One (1) patient required monitoring every five (5) minutes. The ratio of Behavioral Health Associates (BHA) to patients was 2:20.

Observations on the South Unit on 02/21/2024 at 9:30 AM, revealed seventeen (17) patients were on the unit, one (1) BHA, two (2) Registered Nurses (RN), and one (1) Licensed Practical Nurse (LPN).

6. In an interview on 02/21/2024 at 9:50 AM, the Chief Financial Officer (CFO) reported the staffing ratio goal for direct care staff to patients is one (1) staff to five (5) patients.

In an interview on 02/21/2024 at 10:05 AM, RN #2 stated there was sometimes only one behavior health assistant on the unit.

In an interview on 02/21/2024 at 10:15 AM, RN #1 stated there was not sufficient staff on the units, and the units were short of staff every day. RN #1 stated the lack of sufficient staffing made it more dangerous for patients and staff.

Refer to A-0392.

7. Review of the facility's "MEDICATION ADMINISTRATION AND DOCUMENTATION" policy revealed, "...All ordered medications administered to patients will be documented on the Medication Administration Record...Check patient's Medication Administration Record (MAR) to ensure that the order is accurate..."

Review of the facility's Incident Report log beginning 9/1/2023 through 2/21/2024 revealed 7 patient related medication variances.

Medical record review for Patient #5 revealed a Zyprexa dose on 9/29/2023 was given in the evening at approximately 9:00 PM, instead of 9:00 AM as ordered.

Medical record review and Incident Report log review for Patient #6 revealed on 9/30/2023
Tramadol (opioid analgesic) 50 milligram (mg) was given instead of ordered Trazadone.

Medical record review and Incident Report log review for Patient #7 revealed the patient did not recieve ordered Celexa that had been brought from home due to the medication could not be located.

Medical record review for Patient #8 revealed Trazodone 50 mg was administered at 1:45 PM instead of at bedtime as ordered.

Medical record review and Incident Report log for Patient #9 revealed Patient #9 identified herself as another patient to a nurse administering medications. Patient #9 received a dose of Trazadone 50 mg that was not prescribed to her.

Medical record review for Patient #10 revealed the patient received an ordered dose of Vistaril
3 hours and 40 minutes after it was instructed to be given "now".

Medical record review and Incident Report log review for Patient #11 revealed the patient received the wrong dose of Haldol on 2/4/2024.

Refer to A-0405.

Based on job description review, document review and interview, the facility failed to ensure the Director of Nursing (DON) was responsible for and operated an organized Nursing Service for 4 of 4 units (North, South, East, and West) reviewed.

The findings included:

1. Review of the job description for "Chief Nursing Officer [CNO; also called Director of Nursing (DON)]" dated 01/01/2020 revealed, "... Purpose Statement: Direct, plan, coordinate, monitor and supervise the effective use of the operations of nursing... and the delivery of behavioral health/nursing services... Manage the daily operations of nursing services... Evaluate service needs and staffing requirements to ensure needs of patients are met..."

2. Request to review organizational chart for Nursing Services revealed the facility was unable to provide documentation of an organizational chart for Nursing Services.

3. In an interview on 02/04/2024 at 11:55 AM, the Administrator verified there was no organizational chart for Nursing Services.

In an interview on 02/21/2024 at 12:20 PM, the Chief Nursing Officer (CNO) stated she began her position at the hospital on January 12, 2024. The CNO stated the Unit assignments for Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Behavioral Health Associates (BHAs) were completed by the Staff Coordinator and that the Staff Coordinator, Assistant Director of Nursing (ADON), and CNO reviewed the unit staffing assignments every morning. The CNO stated the person who completed the changes in staffing assignment depended on the time of day. The CNO stated she did not feel that the current staff/patient ratio was safe for patients and staff and verified she was unaware of what the staff ratio parameters should be. The CNO stated she had heard it was one (1) staff to five (5) patients. The CNO stated that the Chief Executive Officer and Chief Financial Officer configured the census needs. The CNO stated the appropriate number of staff to assign to a unit was determined by the staff/patient ratio and patient needs to staff and that the hospital "is not sticking to either one." The CNO stated she was told by the previous CNO that the parameters for staff to patient ratio was 1:5 and that ratio also included the nurses. The CNO stated she was involved in the Governing Body Meetings and had been to one (1) Quality Meeting.

Based on policy reivew, document review, medical record review, observation and interview, the facility failed to ensure Nursing Services provided adequate oversight and supervision of nursing staff to ensure patients were provided care in a safe setting for 2 of 4 (Patients #2, #4) sampled patients and failed to follow their staff to patient ratio goal of one (1) staff for every five (5) patients for 20 of 20 (10/6/2023 - 10/19/2023 and 2/7/2024 - 2/12/2024) days reviewed.

The findings included:

1. Review of the facility's "PATIENT RIGHTS AND RESPONSIBILITIES" policy (reviewed 3/2023) revealed, " ...Patients have the right to be protected by the licensee from neglect; from physical, verbal, and emotional abuse ..."

Review of the facility's "ASSIGNMENT OF NURSING STAFF" policy (reviewed 4/18/23) revealed, " ...It is the policy of this facility to maintain a staffing level, which supports safe and effective care for each clinical program ...1. Nursing Services use a 24-hour staffing pattern. a. Nurse is assigned to each shift. b. Nurse provides supervision on the shifts ...d. Staffing increases with acuity and changes in census, assessed by the Nurse and/or Supervisor and communicated to Nursing Administration ..."

2. Review of the facility's "Chief Nursing Officer[CNO]" job description revealed, " ...Direct, plan, coordinate, monitor and supervise the effective and efficient use of the operations of nursing, other departments and the delivery of behavioral health/nursing services with a positive, empathetic, and professional attitude toward customers. Recognize that patient safety is a top priority ...Evaluate service needs and staffing requirements to ensure needs of patients are met ...

Review of the facility's "RN [Registered Nurse]" job description revealed, " ...Responsible for providing professional nursing care to patients with a positive, empathetic, and professional attitude to foster a supportive and therapeutic environment. Recognize that patient safety is a top priority ..."

Review of the facility's "BEHAVIORAL HEALTH ASSOCIATE " job description revealed, " ...Responsible for providing personal care services to patients at the facility under the direction of clinical or nursing leadership ...Assist in providing a safe, secure and comfortable environment for patients, significant others and staff ..."

3. Medical record review for Patient #2 revealed an admission date of 10/6/2023 with diagnoses that included Schizoaffective Disorder, Depressive type. Patient #2 was an emergency involuntary admission who was hearing voices, paranoid, very agitated, confused and a danger to self and others. Patient #2 was housed on the East Unit. (Patient #2 was discharged from the facility on 10/19/2023).

On 10/07/2023, Patient #2 became upset over involuntary status, threatening to kill self, refused as needed (PRN) medication, and attempted to barricade self in day room. Patient #2 required physical restraint by staff for administration of a PRN medication.

On 10/10/2023, Patient #2 became upset again after meeting with the patient advocate. Patient #2 began beating on the nurse's station window and medication room window, yelling, screaming, and threatening to slap a staff member. Patient #2 required chemical and physical restraint, with seclusion ultimately ordered.

Review of a 10/15/2023 Psychiatry Progress Note documented, " ...easily influenced and provoked. Reported as assaulting another patient on yesterday ...Behaviors remain unpredictable ..."

There was no documentation of nursing oversight or a nursing plan to prevent Patient #2 from endangering himself through behaviors, and no documentation of nursing oversight and a plan to prevent staff and other patients from physical harm by Patient #2.

Review of the daily staffing and census beginning 10/6/2023 through 10/19/2023 for the East Unit revealed the following:

10/6/2023- Day shift 2 nurses, 3 BHAs.
Evening shift 2 nurses, 1 BHA.
Night shift 2 nurses, 2 BHA's for census of 21. Evening shift and Night shift did not meet the staff ratio goal of 1 staff to 5 patients.

10/7/2023- Day shift 2 nurses, 2 BHAs.
Evening shift 2 nurses, 1 BHA.
Night shift 2 nurses, 2 BHAs for census of 23. Day, Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients.

10/8/2023- Day shift 1 nurse, 2 BHAs.
Evening shift 2 nurses, 1.5 BHAs.
Night shift 2 nurses, 2 BHAs for census of 24. Day, Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients.

10/9/2023- Day shift 2 nurses, 2 BHAs.
Evening shift 2 nurses, 2 BHAs.
Night shift 2 nurses, 2 BHAs for census of 27. Day, Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients.

10/10/2023- Day shift 2 nurses, 4 BHAs.
Evening shift 2 nurses, 3.5 BHAs.
Night shift 2 nurses, 2 BHAs for census of 27. Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients.

10/11/2023- Day shift 2 nurses, 3 BHAs.
Evening shift 2 nurses, 2 BHAs.
Night shift 2 nurses, 2 BHAs for census of 25. Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients.

10/12/2023- Day shift 2 nurses, 2 BHAs.
Evening shift 2 nurses, 2 BHAs.
Night shift 2 nurses, 2 BHAs for census of 26. Day, Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients.

10/13/2023- Day shift 2 nurses, 2 BHAs.
Evening shift 2 nurses, 3 BHAs.
Night shift 1 nurse, 3 BHAs for census of 26. Day, Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients.

10/14/2023- Day shift 2 nurses, 3 BHAs.
Evening shift 2 nurses, 1.5 BHAs.
Night shift 2 nurses, 2 BHAs for census of 27. Day, Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients.

10/15/2023- Day shift 2 nurses, 3 BHAs.
Evening shift 2 nurses, 2 BHAs.
Night shift 2 nurses, 2 BHAs for census of 25.
Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients.

10/16/2023- Day shift 2 nurses, 2 BHAs.
Evening shift 2 nurses, 2 BHAs.
Night shift 2 nurses, 3 BHAs for census of 27. Day, Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients.

10/17/2023- Day shift 2 nurses, 2 BHAs.
Evening shift 2 nurses, 3 BHAs.
Night shift 2 nurses, 4 BHAs for census of 24. Day shift did not meet the staff ratio goal of 1 staff to 5 patients.

10/18/2023- Day shift 2 nurses, 3 BHAs.
Evening shift 2 nurses, 3 BHAs.
Night shift 2 nurses, 4 BHAs for census of 27. Day and Evening shifts did not meet the staff ratio goal of 1 staff to 5 patients.

10/19/2023- Day shift 2 nurses, 2 BHAs.
Evening shift 2 nurses, 3 BHAs.
Night shift 2 nurses, 3 BHAs for census of 27. Day, Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients.

The facility failed to meet the staffing ratio goal of 1 staff member to every 5 patients on the East unit from 10/6/2023 through 10/19/2023, the entirety of Patient #2's admission at the facility.

4. Medical record review for Patient #4 revealed an admission date of 2/7/2024 with diagnoses that included Schizoaffective disorder, Depressive type. Patient #4 admitted to the facility with a suicidal plan to cut her throat with a knife, was psychotic, and was hearing voices. Patient #4 had a history of mental illness and previous suicide attempts.

On 2/8/2024, Patient #4 required Ativan (anti-anxiety medication), Benadryl (antihistamine), and Haldol (antipsychotic medication used for mental disorders) intramuscularly (IM) for agitation, and psychosis (a mental disorder characterized by a disconnection from reality).

On 2/9/2024, Patient #4 required Vistaril (antihistamine) for anxiety, Risperdal (antipsychotic medication used for mental disorder) for psychosis, Celexa (antidepressant) for depression, and Trazadone (antidepressant and sedative) for sleep. Patient #4 complained of right wrist pain on 02/09/2024. An x-ray was taken of the right wrist with results documented as normal.

On 2/10/2024, Patient #4 was placed on elopement precautions and unit restrictions.

On 2/11/2024, a 1:40 PM nursing note revealed Patient #4 was assaulting and combative toward staff, was climbing on the nursing station and refusing to come down. Attempts to deescalate the patient were unsuccessful. Patient #4 required restraints and ultimately seclusion, where she was hitting and banging her arm on the wall of the seclusion room. Upon completion of seclusion, Patient #4 was calm and cooperative.

On 2/12/2024, a 6:45 PM progress note documented, " ...EMS [Emergency Medical Services] states patient [Patient #4] husband called the police to the facility & [and] Stated his wife's arm was broken. Spoke with East charge nurse and she stated [Patient #4] had an xray of her right hand; and xray to hand was normal. EMS was Informed that [Patient #4] was admitted under involuntary status and [named doctor] Gave a phone order to do not transport. During this time it is believed that Husband was going to attempt to pick [Patient #4] up from front lobby or hospital ...7:10 PM [Patient #4] returns to unit, but is angry ...patient yelling and cursing; Repeatedly punching nursing station window, med [medication] window, and wall. Pt. [Patient #4] successful punched out one of nursing station windows. [Patient #4] threatening to jump in med [medication] room or nursing station station and grabbed gloves from nursing Station. [Patient #4] had to be removed from unit due to self harming behaviors and Verbal and physical attack to staff. During transport to hallway to seclusion Room [Patient #4] was kicking and scratching staff. Once placed in seclusion, [Patient #4] complained of right arm pain again ...NP [nurse practitioner] to order Stat xray ...9:47 PM Xray technician arrived to unit; informed staff that a break in ulnar [arm] is observed ...12:15 AM Ambulance on unit to transport [Pateint #4] to hospital ..."

Nursing oversight failed to ensure Patient #4 was free from injury, including a fractured arm, after repeated, ongoing behaviors while admitted to the facility.

Review of the daily staffing and census beginning 2/7/2024 through 2/12/2024 on the East Unit revealed the following:

2/7/2024-
Day shift 1 nurse, 4 BHAs.
Evening shift 2 nurses, 3 BHAs.
Night shift 2 nurses, 2 BHAs for census of 26. Day, Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients.

2/8/2024- Day shift 2 nurses, 3 BHAs.
Evening shift 2 nurses, 2 BHAs.
Night shift 2 nurses, 2 BHAs for census of 25. Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients.

2/9/2024- Day shift 2 nurses, 3 BHAs.
2 nurses, 2 BHAs, and 1 Certified Nursing Assistant (CNA) for ½ shift, then Night shift 2 nurses, 2 BHAs for census of 21. Night shift did not meet the staff ratio goal of 1 staff to 5 patients.

2/10/2024- Day shift 2 nurses, 3 BHAs.
Evening shift 2 nurses, 1.5 BHAs.
Night shift 2 nurses, 1 BHA for census of 22. Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients.

2/11/2024- Day shift 1.5 nurses, 2 BHAs.
Evening shift 1 nurse, 2 BHAs.
Night shift 2 nurses, 1 BHA for census of 28. Day, Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients.

2/12/2024- Day shift 2 nurses, 2 BHAs.
Evening shift 2 nurses, 2.5 BHAs.
Night shift 2 nurses, 2 BHAs for census of 27. Day, Evening and Night shifts did not meet the staff ratio goal of 1 staff to 5 patients.

The facility failed to meet the staffing ratio goal of 1 staff member to every 5 patients on the East unit from 2/7/2024 through 2/12/2024 during Patient #4's admission to the facility.

5. Observations on the North Unit on 02/21/2024 at 9:20 AM, revealed the unit was housed with patients who were high acuity (patients who required closer monitoring and interventions such as patients diagnosed with major psychoses). There were twenty (20) patients on the unit. Two (2) Behavioral Health Associates (BHAs) were present. Nineteen (19) patients required monitoring every fifteen (15) minutes. One (1) patient required monitoring every five (5) minutes. Patients were observed to be wandering all over the unit. Some patients were in the day room, some patients were in the hallway, and some patients were in group recreation. The ratio of Behavioral Health Associates (BHA) to patients was 2:20. Two nurses were charting in the nurses' station.

Observations on the South Unit on 02/21/2024 at 9:30 AM, revealed the unit housed patients with a lower acuity (Patients who required less monitoring and interventions). There were seventeen (17) patients were on the unit, one (1) BHA, two (2) Registered Nurses (RN), and one (1) Licensed Practical Nurse (LPN).

6. In an interview on 02/21/2024 at 9:50 AM, the Chief Financial Officer (CFO) reported the staffing ratio goal for direct care staff to patients is one (1) staff to five (5) patients. The staff included in that ratio included the unit registered nurses and licensed practical nurses.

In an interview on 02/21/2024 at 10:05 AM, Registered Nurse (RN) #2 stated she worked as needed, primarily on the North unit. RN #2 stated the North unit had 20 beds, and the average census was sixteen (16) to twenty (20) patients. RN #2 stated it was rare that the census was fifteen (15) patients or less, and the staff mix for the North unit was usually two (2) licensed staff and two (2) or more BHAs. RN #2 stated there was sometimes only one behavior health assistant on the unit.

In an interview on 02/21/2024 at 10:15 AM, RN #1 confirmed she was assigned to the North unit (high acuity patients) with a census of twenty (20) patients on the unit and a staff assignment of two (2) BHA and two (2) nurses. RN #1 stated one (1) patient was on observations every five (5) minutes, and the remaining nineteen (19) patients required observation every fifteen (15) minutes. RN #1 stated the BHAs and nurses did all the patient observations, and the patient who required observation every five (5) minutes required documentation /progress notes every two (2) hours. RN #1 stated a behavior health assistant typically attended patient group therapies. RN #1 stated that if a patient became violent or physically aggressive, staff called a code. RN #1 stated agency staff could not assist with restraining a patient or with any other activity that required hands-on-care. RN #1 confirmed she was injured by a patient while on-duty at the hospital. RN #1stated there was not sufficient staff on the units, and the units were short of staff every day. RN #1 stated the lack of sufficient staffing made it more dangerous for patients and staff. RN #1 confirmed on the day she was attacked, there were two (2) BHAs assigned to the unit and probably eighteen (18) patients on the unit. RN #1 stated it was not unusual to have only one BHA assigned to a unit.

In an interview on 02/21/2024 at 10:20 AM, RN #3 stated she primarily worked on the East unit (a high acuity unit). RN #3 stated the census for the East unit was usually at its maximum of twenty-eight (28) patients, and the hospital normally staffed two (2) licensed staff and two (2) BHAs. RN #3 stated there were times when only one (1) BHA was assigned to the unit, and this happened more frequently than it should. RN #3 stated the hospital has utilized [named Agency] BHAs, but agency staff were not allowed to touch the patients. RN #3 stated her main concern was when the hospital didn't have enough BHAs assigned to the unit, the registered nurses or licensed practical nurses had to work as BHAs. RN #3 stated this caused the licensed staff's work to get behind.

In an interview on 02/21/2024 at 10:30 AM, RN #4 stated she primarily worked the East unit. That unit was usually staffed with one (1) registered nurse, one (1) licensed practical nurse, and two (2) BHA. RN #4 stated the staff assigned to the unit included [named Agency] BHAs who could not assist with restraining patients. RN #4 stated staff often complained about not having enough BHAs.

In an interview on 02/21/2024 at 10:35 AM, BHA #1 stated she was assigned all seventeen (17) patients on the unit, but she had been assigned as many as twenty (20) patients at one time. BHA #1 stated if something was going on, or there was a one to one (1:1) patient assignment, the nurses watched the other patients. BHA #1 stated the hospital needed more staff because the staff assigned to the units could not watch the patients adequately. BHA #1 stated she felt the unit was not staffed sufficiently which put both patients and staff in danger. BHA #1 stated she was aware that one (1) of the agency staff was injured by a patient, and a therapist was injured by a patient a couple of days later and sent to the hospital via ambulance due to the injury.

In an interview on 02/21/2024 at 10:35 AM, RN #5 reported he primarily worked on the South unit which can have twenty (20) patients. RN #5 stated the patients on the South unit were usually there for self-harm or detoxification. RN #5 stated he primarily worked as the Charge Nurse or medication nurse for the unit. RN #5 stated unit staffing usually consisted of two (2) RNs or one (1) RN and one (1) LPN with one (1) or two (2) BHAs. RN #5 stated the hospital used agency staff to supplement staffing on the unit.

In an interview on 02/21/2024 at 10:43 AM, RN #6 stated she currently worked on the West unit which held a maximum of twelve (12) patients. RN #6 stated the patients on the West unit were elderly, usually sixty (60) to eighty (80) years-old, and were diagnosed with depression or suicidal ideations. RN #6 stated the present daily census was ten (10) patients, and there was one (1) RN staffed for the West unit. RN #6 stated depending on acuity, number of fall risks, and incontinent patients, they could have one (1) certified nursing assistant (CNA) and one (1) behavior health assistant. RN #6 stated the hospital would staff with one (1) licensed nurse and one (1) certified nursing assistant or one (1) behavior health assistant if the acuity of the patients was lower. RN #6 stated she wished that the nurse/patient ratio was better. RN #6 stated she believed there was a problem with the safety of the patients and staff. RN #6 stated when there were fights between the patients, the behavior health assistants were not able to handle those incidents, and the BHAs were scared to respond to the fights. RN #6 stated the nurse workload could be overwhelming due to the lack of staffing.

In an interview on 02/21/2024 at 11:00 AM, the Interim Risk Manager stated the parameters for unit staffing included three (3) or four (4) staff for every fifteen (15) patients.

In an interview on 02/21/2024 at 12:20 PM, the Chief Nursing Officer (CNO) stated unit staffing assignments were completed by the Staffing Coordinator. The Staffing Coordinator, Assistant Director of Nursing, and Chief Nursing Officer reviewed the unit staffing assignments every morning. The CNO stated changes in staffing depended on the time of day, and the Unit Nurse Manager contacted the Staffing Director to get staff called in if necessary, The CNO stated the staff to patient ratio goal was 1:5 which included the registered nurses and licensed practical nurses. The CNO stated the Chief Executive Officer and Chief Financial Officer configured the census needs range based on staff to patient ratio and patient needs, but the hospital "is not sticking to either one." The CNO confirmed it was her responsibility to provide oversight of nursing scheduling to make sure the needs of the patients were met.

In an interview on 2/21/2024 at 2:05 PM, the Human Resources (HR) Director stated she had seen an increase in injuries to staff related to patient aggressive/violent episodes, and she had received an increasing number of employee concerns/complaints regarding insufficient unit staff. The HR Director stated the hospital's goal for staffing was to have a 1:5 staff to patient ratio, depending on patient acuity. The HR Director stated the hospital used unit nurses to figure the staff to patient ratio, but the unit nurses alternated their nursing duties with patient assignment duties. The HR Director stated that neither nurses nor behavior health assistants were assigned to specific patients, and the only patient directly assigned to a specific behavior health assistant or nurse was one who required one to one monitoring. The HR Director stated patients who required monitoring every five (5) minutes were grouped with the other patients in determining the number of direct care staff to assign to the unit. The HR Director stated staff had expressed concerns to her regarding staff safety as well as their increased work caseload.

In an interview on 02/21/2024 at 2:05 PM, the Director of Clinical Services stated a therapist was injured several weeks ago while conducting a Process Group. The Director of Clinical Services stated the group had started when another patient came to the group with a cup with feces in it. The patient hit the therapist and threw the feces on her. The Director of Clinical Services stated the therapist was transported to the hospital by an ambulance, but she did not recall what the therapist's injuries were. The Director of Clinical Services stated the therapist had not returned to work since the incident. The Director of Clinical Services stated there have been multiple situations where staff had been injured while dealing with patients over the past six months. The Director of Clinical Services confirmed the hospital had room for improvement related to staffing.

In an interview on 02/21/2024 at 3:45 PM, the Scheduler for nursing services stated her duty was to make staff assignments. When questioned as to whether [named hospital] had parameters related to staff/patient ratios, the Scheduler stated, "Not really." She stated that if there was a one to one (1:1) patient observation on the unit, extra staff was called in for that unit. The Scheduler stated that if necessary, she personally worked on the units to fill in for staff needs. She stated that she was "going to work as a tech [technician] tonight due to a staff call-in."

In an interview on 02/23/2024 at 9:10 AM, the Administrator stated the unit registered nurse might be responsible for nursing care for two units at the same time, and both units were locked and divided by a hallway.

In an interview on 02/23/2024 at 9:50 AM on the South unit, RN #8 reported the patient census was eighteen (18) and in addition to herself, there was one (1) behavioral health assistant on the unit.

In an interview on 02/23/2024 at 9:52 AM, RN #6 stated she was the only licensed staff on the West unit. There was one (1) certified nursing assistant or behavior health assistant for eleven (11) patients.

Based on medical record review, observations and interviews, the hospital failed to ensure a Registered Nurse (RN) provided supervision and oversight to ensure the patients' needs were met and prevent accidents and incidents.

The findings included:

1. Review of medical record for Patient #2 revealed an admission date of 10/06/2023. Patient #2 was an emergency involuntary admission who was hearing voices, paranoid, very agitated, confused and a danger to self and others. Patient #2 required physical and chemical restraints on 10/06/2023 and was ordered to receive Benadry (antihistamine), Haldol (medication given to agitated patients, reduce hallucinations and delirium), Ativan (sedative; used to treat seizure disorders or anxiety) administered intramuscularly (IM).

On 10/07/2023, Patient #2 was upset over involuntary status, threatening to kill self, refused PRN medication, attempted to barricade self in day room. Required physical restraint by staff for administration of as needed (PRN) medication.

On 10/10/2023, Patient #2 was beating on the nurses station window and medication room window, yelling, screaming, threatening. Patient #2 assaulted a staff member. The patient required chemical and physical restraint. Patient #2 received a one (1) x (time) order for Geodon (antipsychotic used to treat mental health conditions) 20 milligrams (mg) IM every (q) 12 hours PRN agitation. Seclusion ordered. Had to be carried to the seclusion room. On 10/14/2023 and 10/15/2023, Patient #2 assaulted other patients on the unit.

2. Review of medical record for Patient #4 revealed an admission date of 02/07/2024 with a suicidal plan to cut her throat with a knife, was psychotic, and was hearing command voices. Patient #3 had a history of mental illness and previous suicide attempts. Patient #3 had poor judgement, poor insight, agitation, irritability, depressed mood, and hallucinations. The patient suffered a self-injury (broken hand) while hospitalized at this hospital.

On 02/08/2024, the patient required Ativan (anti-anxiety medication), Benadryl (antihistamine), and Haldol (antipsychotic medication used for mental disorders) intramuscularly (IM) for agitation, Extrapyramidal side effects (EPS; drug-induced movement disorder) prevention, and psychosis (a mental disorder characterized by a disconnection from reality).

On 02/09/2024, the patient required Vistaril (antihistamine) for anxiety, Risperdal (antipsychotic medication used for mental disorder) for psychosis, Celexa (antidepressant) for depression, and Trazadone (antidepressant and sedative) for sleep. Patient #3 complained of right wrist pain on 02/09/2024. An x-ray was taken of the right wrist with results documented as normal.

On 02/10/2024, the patient was placed on elopement precautions and unit restrictions.

On 02/11/2024, the patient required Geodon (antipsychotic used to treat schizophrenia and bipolar disorder) intramuscular (IM) and was placed in restraints until calm.

On 02/12/2024, the patient climbed the nurses station, punched the glass and door, and was very threatening and disruptive on the unit. Risperdal (antipsychotic used to treat schizophrenia and bipolar disorder) and Celexa were increased on 02/12/2024 and she required as needed (PRN) Thorazine (antipsychotic used to treat mental illness and behavioral disoders).

While in the control room, Patient #4 was observed hitting the walls and to be verbally threatening others. Patient #4's right arm was noted to be swollen "from previous self-injury", and her right hand was also noted to be swollen "from previous self-injury." Order were received for transfer to an acute care hospital for evaluation. Emergency Medical Services (EMS) and Police arrived at facility at 7:45 PM on 02/12/2024. Patient #3's husband called police, stating his wife's arm was broken. EMS was informed the Patient's previous x-ray was normal, patient was involuntary status, and Medical Doctor (MD) gave phone order "Do Not Transport." Patient #4 refused to return to the unit until escorted by staff. Patient #4 returned to unit angry, yelling, cursing, repeatedly punching nurses station window, medication room window, wall. Patient #4 punched out one of nurses station windows. Patient #4 threatened to jump in the nurses station or medication room and grabbed gloves from nurses station. Patient #4 had to be removed from unit due to self-harming behaviors and verbal/physical attack on staff. During transport to seclusion room, Patient #4 was kicking and scratching herself. Once in seclusion room, Patient #4 complained of pain again in the right arm. The Nurse called the Nurse Practitioner for stat x-ray. Patient #4 continued to yell at staff and punch the walls. An X-ray was performed and Patient #4 was diagnosed with a broken arm. A verbal order was received from the Physician to transport Patient #4 to an acute care hospital. The ambulance arrived on the unit at 12:15 AM to transport Patient #4 to an acute care hospital. Patient #3 returned to hospital at 3:05 AM with a soft plaster cast on the right arm.

2. Observations on the North Unit on 02/21/2024 at 9:20 AM, revealed the unit was housed with patients who were high acuity (patients who required closer monitoring and interventions such as patients diagnosed with major psychoses). There were twenty (20) patients on the unit. Two (2) Behavioral Health Associates (BHAs) were present. Nineteen (19) patients required monitoring every fifteen (15) minutes. One (1) patient required monitoring every five (5) minutes. Patients were observed to be wandering all over the unit. Some patients were in the day room, some patients were in the hallway, and some patients were in group recreation. The ratio of Behavioral Health Associates (BHA) to patients was 2:20. Two nurses were charting in the nurses' station.

3. Observations on the South Unit on 02/21/2024 at 9:30 AM, revealed the unit housed patients with a lower acuity (Patients who required less monitoring and interventions). There were seventeen (17) patients were on the unit, one (1) BHA, two (2) Registered Nurses (RN), and one (1) Licensed Practical Nurse (LPN).

In an interview on 02/21/2024 at 9:50 AM, the Chief Financial Officer (CFO) reported the staffing ratio goal for direct care staff to patients is one (1) staff to five (5) patients. The staff included in that ratio included the unit registered nurses and licensed practical nurses.

In an interview on 02/21/2024 at 10:05 AM, RN #2 stated she worked as needed, primarily on the North unit. RN #2 stated the North unit had 20 beds, and the average census was sixteen (16) to twenty (20) patients. RN #2 stated it was rare that the census was fifteen (15) patients or less, and the staff mix for the North unit was usually two (2) licensed staff and two (2) or more BHAs. RN #2 stated there was sometimes only one behavior health assistant on the unit. RN #2 stated she was unaware of who were contract employees, but she knew that contract employees were not allowed to touch the patients.

In an interview on 02/21/2024 at 10:15 AM, RN #1 confirmed she was assigned to the North unit (high acuity patients) with a census of twenty (20) patients on the unit and a staff assignment of two (2) BHA and two (2) nurses. RN #1 stated one (1) patient was on observations every five (5) minutes, and the remaining nineteen (19) patients required observation every fifteen (15) minutes. RN #1 stated the BHAs and nurses did all the patient observations, and the patient who required observation every five (5) minutes required documentation /progress notes every two (2) hours. RN #1 stated a behavior health assistant typically attended patient group therapies. RN #1 stated that if a patient became violent or physically aggressive, staff called a code. RN #1 confirmed she had worked with behavior health assistants and nurses from [named Agency]. RN #1 stated agency staff could not perform "hands-on-care," but they were counted as part of the staff/patient ratio. RN #1 stated agency staff could not assist with restraining a patient or with any other activity that required hands-on-care. RN #1 confirmed she was injured by a patient while on-duty at [named hospital]. RN #1 stated a patient was sitting on the floor as RN #1 exited the nurses' station, and the patient bit her on the thigh. RN #1 stated there was not sufficient staff on the units, and the units were short of staff every day. RN #1 stated the lack of sufficient staffing made it more dangerous for patients and staff. RN #1 confirmed on the day she was attacked, there were two (2) BHAs assigned to the unit and probably eighteen (18) patients on the unit. RN #1 stated that one of the BHAs was reassigned to another unit which left only one behavior health assistant on the unit. RN #1 stated it was not unusual to have only one BHA assigned to a unit.

In an interview on 02/21/2024 at 10:20 AM, RN #3 stated she primarily worked on the East unit (a high acuity unit). RN #3 stated the census for the East unit was usually at its maximum of twenty-eight (28) patients, and the hospital normally staffed two (2) licensed staff and two (2) BHAs. RN #3 stated there were times when only one (1) BHA was assigned to the unit, and this happened more frequently than it should. RN #3 stated the hospital has utilized [named Agency] BHAs, but agency staff were not allowed to touch the patients. RN #3 stated her main concern that was when the hospital didn not have enough BHAs assigned to the unit, the registered nurses or licensed practical nurses thad to work as BHAs. RN #3 stated this caused the licensed staff's work to get behind.

In an interview on 02/21/2024 at 10:30 AM, RN #4 stated she primarily worked the East unit. That unit was usually staffed with one (1) registered nurse, one (1) licensed practical nurse, and two (2) BHA. RN #4 stated the staff assigned to the unit included [named Agency] BHAs who could not assist with restraining patients. RN #4 stated staff often complained about not having enough BHAs.

In an interview on 02/21/2024 at 10:35 AM, BHA #1 stated she was assigned all seventeen (17) patients on the unit, but she had been assigned as many as twenty (20) patients at one time. BHA #1 stated if something was going on, or there was a one to one (1:1) patient assignment, the nurses watched the other patients. BHA #1 stated the hospital needed more staff because the staff assigned to the units could not watch the patients adequately. BHA #1 stated she felt the unit was not staffed sufficiently which put both patients and staff in danger. BHA #1 stated she was aware that one (1) of the agency staff was injured by a patient, and a therapist was injured by a patient a couple of days later and sent to the hospital via ambulance due to the injury.

In an interview on 02/21/2024 at 10:35 AM, RN #5 reported he primarily worked on the South unit.which can have twenty (20) patients. RN #5 stated the patients on the South unit were usually there for self-harm or detoxification. RN #5 stated he primarily worked as the Charge Nurse or medication nurse for the unit. RN #5 stated unit staffing usually consisted of two (2) RNs or one (1) RN and one (1) LPN with one (1) or two (2) BHAs. RN #5 stated the hospital used agency staff to supplement staffing on the unit.

In an interview on 02/21/2024 at 10:43 AM, RN #6 stated she currently worked on the West unit which held a maximum of twelve (12) patients. RN #6 stated the patients on the West unit were elderly, usually sixty (60) to eighty (80) years-old, and were diagnosed with depression or suicidal ideations. RN #6 stated the present daily census was ten (10) patients, and there was one (1) RN staffed for the West unit. RN #6 stated depending on acuity, number of fall risks, and incontinent patients, they could have one (1) certified nursing assistant (CNA) and one (1) behavior health assistant. RN #6 stated the hospital would staff with one (1) licensed nurse and one (1) certified nursing assistant or one (1) behavior health assistant if the acuity of the patients was lower. RN #6 stated she wished that the nurse/patient ratio was better. RN #6 stated she believed there was a problem with the safety of the patients and staff, and she felt that the facility should have security on the units. RN #6 stated when there were fights between the patients, the behavior health asistants were not able to handle those incidents, and the BHAs were scared to respond to the fights. RN #6 stated the hospital got panic buttons last week after a therapist was attacked by a patient, but the hospital was still working to "get the bugs out" of the staff using the panic buttons. RN #6 stated the nurse workload could be overwhelming due to the lack of staffing.

In an interview on 02/21/2024 at 11:00 AM, the Interim Risk Manager stated the parameters for unit staffing included three (3) or four (4) staff for every fifteen (15) patients.

In an interview on 02/21/2024 at 12:20 PM, the Chief Nursing Officer (CNO) stated unit staffing assignments were completed by the Staffing Coordinator. The Staffing Coordinator, Assistant Director of Nursing, and Chief Nursing Officer reviewed the unit staffing assignments every morning. The CNO stated changes in staffing depended on the time of day, and the Unit Nurse Manager contacted the Staffing Director to get staff called in if necessary, The CNO stated the staff to patient ratio goal was 1:5 which included the registered nurses and licensed practical nurses. The CNO confirmed a patient kicked a behavioral health assistant several weeks ago, and she investigated the incident. The CNO stated she did not know how many patients the behavioral health assistant was assigned at the time of the incident, but it was typical to have only one (1) behavioral health assistant assigned to each unit on the second shift. The CNO stated agency staff were required to participate in the facility mandatory training, but agency staff did not participate in the physical restraining of the patients. The CNO stated if a patient needed to be restrained, staff would call a code to handle violent/aggressive situations on the unit. The CNO stated agency staff would be utilized to keep their eyes on the other patients. When asked if agency staff received training for de-escalation, seclusion, and restraints, the CNO stated, "I am pretty sure they [agency staff] have been trained in Handle-with-Care/de-escalation and Seclusion/Restraints." The CNO stated the Chief Executive Officer and Chief Financial Officer configured the census needs range based on staff to patient ratio and patient needs, but the hospital "is not sticking to either one." The CNO confirmed it was her responsibility to provide oversight of nursing scheduling to make sure the needs of the patients were met. The CNO stated it was the responsibility of the House Supervisor to ensure that new hires were properly trained before they were allowed to provide care to patients. The CNO stated De-escalation Training and Restraint/Seclusion Training was not currently mandatory for agency staff prior to unit assignment.

In an interview on 2/21/2024 at 2:05 PM, the Human Resources (HR) Director stated there was no formal process for monitoring agency staff for psychiatric work experience, or training that was mandatory for [named hospital] staff prior to beginning direct patient care. The staff educator provided agency staff with orientation as a direct care provider, including Handle-with-Care/de-escalation training. The HR Director stated if agency staff had not completed Hands-on-Care/de-escalation training, they could not provide hands-on care for patients. When questioned as to who handled monitoring of agency staff to ensure they did not provide hands on care, the HR Director stated, "The charge nurse monitored agency staff to ensure they didn't provide hands-on care to patients unless they had completed the Handle-with-Care training." The HR Director stated she had seen an increase in injuries to staff related to patient aggressive/violent episodes, and she had received an increasing number of employee concerns/complaints regarding insufficient unit staff. The HR Director stated the hospital's goal for staffing was to have a 1:5 staff to patient ratio, depending on patient acuity. The HR Director stated the hospital used unit nurses to figure the staff to patient ratio, but the unit nurses alternated their nursing duties with patient assignment duties. The HR Director stated that neither nurses nor behavior health assistants were assigned to specific patients, and the only patient directly assigned to a specific behavior health assistant or nurse was one who required one to one monitoring. The HR Director stated patients who required monitoring every five (5) minutes were grouped with the other patients in determining the number of direct care staff to assign to the unit. The HR Director stated staff had expressed concerns to her regarding staff safety as well as their increased work caseload.

In an interview on 02/21/2024 at 2:05 PM, the Director of Clinical Services stated a therapist was injured several weeks ago while conducting a Process Group. The Director of Clinical Services stated the group had started when another patient came to the group with a cup with feces in it. The patient hit the therapist and threw the feces on her. The Director of Clinical Services stated the therapist was transported to the hospital by an ambulance, but she did not recall what the therapist's injuries were. The Director of Clinical Services stated the therapist had not returned to work since the incident. The Director of Clinical Services stated there have been multiple situations where staff had been injured while dealing with patients over the past six months. The Director of Clinical Services confirmed the hospital had room for improvement related to staffing.

In an interview on 02/21/2024 at 2:20 PM, the Nurse Educator stated nursing leadership handled the orientation for agency staff. The Nurse Educator stated she maintained copies of staff training records but did not maintain training records for agency staff. The Nurse Educator stated she and Human Resources had dual responsibilities to ensure that direct care staff had mandatory/required competencies prior to being assigned to work on a unit. The Nurse Educator stated nursing leadership and Human Resources had dual responsibilities to ensure that agency staff had the required competencies prior to unit assignment.

In an interview on 02/21/2024 at 3:45 PM, the Scheduler for nursing services stated her duty was to to make staff assignments. When questioned as to whether [named hospital] had parameters related to staff/patient ratios, the Scheduler stated, "Not really."

In an interview on 02/23/2024 at 9:10 AM, the Administrator stated that agency staff did not provide hands-on-care or physical restraints and did not touch the patient at all if it was related to Handle-with-Care/de-escalation situations. The Administrator stated agency staff could not provide physical assistance in dealing with combative/aggressive patients or physically hold patients for injections. The Administrator stated that was a hospital rule and not the staffing agency's rule, but the hospital communicated this rule with the agency. The Administrator stated agency staff were not required to have seclusion and restraint, Handle-with-Care, or de-escalation training prior to assigment to a unit. The Administrator stated the unit registered nurse might be responsible for nursing care for two units at the same time, and both units were locked and divided by a hallway.

In an interview on 02/23/2024 at 9:50 AM on the South unit, RN #8 reported the patient census was eighteen (18) and in addition to herself, there was one (1) behavioral health assistant on the unit.

In an interview on 02/23/2024 at 9:52 AM, RN #6 stated she was the only licensed staff on the West unit. There was one (1) certified nursing assistant or behavior health assistant for eleven (11) patients.

Based on policy review, document review, medical record review and interview, the facility failed to ensure medications were administered per physician order for 7 of 7 (Patients #5, 6, 7, 8, 9,10 and 11) patients reviewed with medication variances.

The findings included:

1. Review of the facility's "MEDICATION ADMINISTRATION AND DOCUMENTATION" policy (reviewed 3/2023) revealed, "...All ordered medications administered to patients will be documented on the Medication Administration Record...Check patient's Medication Administration Record (MAR) to ensure that the order is accurate...1. Verify patient 2. Verify medication 3. Verify dosage 4. Verify route 5. Verify frequency 6. Verify stop date 7. Note any cautionary statements..."

2. Review of the facility's Incident Report log beginning 9/1/2023 through 2/21/2024 revealed the following:

September 2023- 2 patient related Medication Variances.
October 2023- 1 patient related Medication Variances.
November 2023- 1 patient related Medication Variances.
December 2023- 1 patient related Medication Variances.
January 2024- 0 patient related Medication Variances.
February 2024- 2 patient related Medication Variances.

3. Medical record review for Patient #5 revealed an admission date of 9/20/2023 with diagnoses that included Major Depressive Disorder.

Review of the September 2023 MAR revealed Zyprexa (used to treat certain mental/mood disorders) 7.5 milligrams (mg) daily (9:00 AM). The Zyprexa dose on 9/29/2023 was given in the evening, approximately 9:00 PM, instead of 9:00 AM as ordered.

4. Medical record review for Patient #6 revealed an admission date of 9/19/2023 with diagnoses that included Bipolar disorder with psychosis.

Review of 9/30/2023 physician orders revealed Trazadone (antidepressant) 50 mg by mouth every bedtime as needed.

Review of the September 2023 Medication Administration Record (MAR) revealed Trazadone 50 mg documented as given on 9/30/2023 at 8:00 PM.

Review of the facility's Incident Report log revealed Tramadol (opioid analgesic) 50 mg was given instead of the ordered Trazadone on 9/30/2023 at 8:00 PM.

5. Medical record review for Patient #7 revealed an admission date of 10/4/2023 with diagnoses that included Schizoaffective Disorder, Bipolar type.

Review of 10/10/2023 physician orders revealed "Start Celexa [used to treat Depression] 5mg p.o. [by mouth] daily"

Review of October 2023 MAR revealed Celexa 5 mg was signed out as given on 10/11/2023 through 10/13/2023.

Review of the facility's Incident Report log for Patient #7 revealed, "Patient had an order to receive Celexa 5mg PO [by mouth] and did not receive it. Patient brought this medication from home and it has not been administered due to the medication being unable to be located in the med [medication] room, although nursing staff signed off on the MAR that they gave this medication to the patient"

6. Medical record review for Patient #8 revealed an admission date of 11/2/2023 with diagnoses that included Schizoaffective Disorder, Bipolar type.

Review of 11/2/2023 Medication Reconciliation orders revealed Trazodone 50 mg PO every (Q) bedtime (HS) as needed (prn).

Review of Patient #8's November MAR revealed on 11/8/2023 Trazodone 50 mg was administered at 1:45 PM. Not at bedtime as ordered.

7. Medical record review for Patient #9 revealed an admission date of 12/25/2023 with diagnoses that included Schizoaffective disorder, Bipolar type.

Review of the facility's Incident Report log documentation revealed while housed on the East Unit on 12/26/2023, Patient #9 identified herself as another patient to the nurse administering medications. Patient #9 received a dose of Trazadone 50 mg that was not prescribed to her.

8. Medical record review for Patient #10 revealed an admission date of 1/27/2024 with diagnoses that included Schizophrenia.

Review of 2/1/2024 medication orders written at 10:50 AM revealed "Vistaril [used to treat anxiety and tension] 50 mg PO every 6 hours prn; 1st dose now".

Review of Patient #10's February 2024 MAR revealed on 2/1/2024 Vistaril 50 mg was documented as given at 2:30 PM, 3 hours and 40 minutes after the order was written to be given "now".

9. Medical record review for Patient #11 revealed an admission date of 1/9/2024 with diagnoses that included Major Depressive disorder with psychosis.

Review of 2/3/2024 physician orders revealed Haldol (antipsychotic) 15 mg (1/2 tab [tablet]) by mouth twice daily.

Review of February 2024 MAR revealed Haldol 15 mg (1/2 tab) twice daily was documented as given on 2/4/2024 at 9:00 AM and 9:00 PM.

Review of the facility's Incident Report log revealed a whole tablet (15 mg) was given on 2/4/2024 at the 9:00 PM dose instead of the ½ tablet as ordered.

In an electronic correspondance (email) on 4/10/2024, the Risk Manager verified the medication variances for Residents #5, 6, 7, 8, 9,10 and 11.

Based on policy reivew, document review, observation and interview, the hospital failed to maintain sufficient staff to ensure safe and adequate care for for 2 of 4 (Patient #2 and #4) sampled patients reviewed.

The findings included:

1. Review of the facility's "ASSIGNMENT OF NURSING STAFF" policy (reviewed 4/18/23) revealed, " ...It is the policy of this facility to maintain a staffing level, which supports safe and effective care for each clinical program ...1. Nursing Services use a 24-hour staffing pattern. a. Nurse is assigned to each shift. b. Nurse provides supervision on the shifts ...d. Staffing increases with acuity and changes in census, assessed by the Nurse and/or Supervisor and communicated to Nursing Administration ..."

2. Review of the facility's "RN [Registered Nurse]" job description revealed, " ...Responsible for providing professional nursing care to patients with a positive, empathetic, and professional attitude to foster a supportive and therapeutic environment. Recognize that patient safety is a top priority ..."

Review of the facility's "BEHAVIORAL HEALTH ASSOCIATE 1" job description revealed, " ...Responsible for providing personal care services to patients at the facility under the direction of clinical or nursing leadership ...Assist in providing a safe, secure and comfortable environment for patients, significant others and staff ..."

3. Medical record review for Patient #2 revealed an admission date of 10/6/2023 with diagnoses that included Schizoaffective Disorder, Depressive type. Patient #2 was an emergency involuntary admission who was hearing voices, paranoid, very agitated, confused and a danger to self and others. Patient #2 was housed on the East Unit. (Patient #2 was discharged from the facility on 10/19/2023).

On 10/07/2023, Patient #2 became upset over involuntary status, threatening to kill self, refused as needed (PRN) medication, and attempted to barricade self in day room. Patient #2 required physical restraint by staff for administration of a PRN medication.

On 10/10/2023, Patient #2 became upset again after meeting with the patient advocate. Patient #2 began beating on the nurse's station window and medication room window, yelling, screaming, and threatening to slap a staff member. Patient #2 required chemical and physical restraint, with seclusion ultimately ordered. Review of a 10/15/2023 Psychiatry Progress Note documented, " ...easily influenced and provoked. Reported as assaulting another patient on yesterday ...Behaviors remain unpredictable ..."

Nursing oversight failed to prevent Patient #2 from endangering himself through behaviors, and failed to prevent staff and other patients from physical harm by Patient #2.

Review of the facility's daily census and staffing documentation revealed the facility failed to meet the staffing ratio goal of 1 staff member to every 5 patients on the East unit from 10/6/2023 through 10/19/2023, the entirety of Patient #2's admission at the facility.

4. Medical record review for Patient #4 revealed an admission date of 2/7/2024 with diagnoses that included Schizoaffective disorder, Depressive type. Patient #4 admitted to the facility with a suicidal plan to cut her throat with a knife, was psychotic, and was hearing voices. Patient #4 had a history of mental illness and previous suicide attempts.

On 2/8/2024, Patient #4 required Ativan (anti-anxiety medication), Benadryl (antihistamine), and Haldol (antipsychotic medication used for mental disorders) intramuscularly (IM) for agitation, and psychosis (a mental disorder characterized by a disconnection from reality).

On 2/9/2024, Patient #4 required Vistaril (antihistamine) for anxiety, Risperdal (antipsychotic medication used for mental disorder) for psychosis, Celexa (antidepressant) for depression, and Trazadone (antidepressant and sedative) for sleep. Patient #4 complained of right wrist pain on 02/09/2024. An x-ray was taken of the right wrist with results documented as normal.

On 2/10/2024, Patient #4 was placed on elopement precautions and unit restrictions.

On 2/11/2024, a 1:40 PM nursing note revealed Patient #4 was assaulting and combative toward staff, was climbing on the nursing station and refusing to come down. Attempts to deescalate the patient were unsuccessful. Patient #4 required restraints and ultimately seclusion, where she was hitting and banging her arm on the wall of the seclusion room. Upon completion of seclusion, Patient #4 was calm and cooperative.

On 2/12/2024, a 6:45 PM progress note documented, " ...EMS [Emergency Medical Services] states patient husband called the police to the facility & [and] Stated his wife arm was broken. Spoke with East charge nurse and she stated Patient had an xray of her right hand; and xray to hand was normal. EMS was Informed that patient was admitted under involuntary status and [named doctor] Gave a phone order to do not transport. During this time it is believed that Husband was going to attempt to pick patient up from front lobby or hospital ...7:10 PM Patient returns to unit, but is angry ...patient yelling and cursing; Repeatedly punching nursing station window, med [medication] window, and wall. Pt. [Patient #4] successful punched out one of nursing station windows. Patient threatening To jump in med room or nursing station station and grabbed gloves from nursing Station. Patient had to be removed from unit due to self harming behaviors and Verbal and physical attack to staff. During transport to hallway to seclusion Room patient was kicking and scratching staff. Once placed in seclusion, Patient complained of right arm pain again ...NP [nurse practitioner] to order Stat xray ...9:47 PM Xray technician arrived to unit; informed staff that a break in ulnar is observed ...12:15 AM Ambulance on unit to transport patient to hospital ..."

Nursing oversight failed to ensure Patient #4 was free from injury, including a fractured arm, after repeated, ongoing behaviors while admitted to the facility.

Review of the facility's daily census and staffing documentation revealed the facility failed to meet the staffing ratio goal of 1 staff member to every 5 patients on the East unit from 2/7/2024 through 2/12/2024 during Patient #4's admission to the facility.


5. Observations on the North Unit on 02/21/2024 at 9:20 AM, revealed the unit was housed with patients who were high acuity (patients who required closer monitoring and interventions such as patients diagnosed with major psychoses). There were twenty (20) patients on the unit. Two (2) Behavioral Health Associates (BHAs) were present. Nineteen (19) patients required monitoring every fifteen (15) minutes. One (1) patient required monitoring every five (5) minutes. Patients were observed to be wandering all over the unit. Some patients were in the day room, some patients were in the hallway, and some patients were in group recreation. The ratio of Behavioral Health Associates (BHA) to patients was 2:20. Two nurses were charting in the nurses' station.

Observations on the South Unit on 02/21/2024 at 9:30 AM, revealed the unit housed patients with a lower acuity (Patients who required less monitoring and interventions). There were seventeen (17) patients were on the unit, one (1) BHA, two (2) Registered Nurses (RN), and one (1) Licensed Practical Nurse (LPN).

6. In an interview on 02/21/2024 at 9:50 AM, the Chief Financial Officer (CFO) reported the staffing ratio goal for direct care staff to patients is one (1) staff to five (5) patients. The staff included in that ratio included the unit registered nurses and licensed practical nurses.

In an interview on 02/21/2024 at 10:05 AM, RN #2 stated there was sometimes only one behavior health assistant on the unit.

In an interview on 02/21/2024 at 10:15 AM, RN #1 stated there was not sufficient staff on the units, and the units were short of staff every day. RN #1 stated the lack of sufficient staffing made it more dangerous for patients and staff.

In an interview on 02/21/2024 at 10:20 AM, RN #3 stated she primarily worked on the East unit (a high acuity unit).RN #3 stated the census for the East unit was usually at its maximum of twenty-eight (28) patients, and the hospital normally staffed two (2) licensed staff and two (2) BHAs. RN #3 stated there were times when only one (1) BHA was assigned to the unit, and this happened more frequently than it should.

In an interview on 02/21/2024 at 10:30 AM, RN #4 stated she primarily worked the East unit. That unit was usually staffed with one (1) registered nurse, one (1) licensed practical nurse, and two (2) BHA. RN #4 stated the staff assigned to the unit included [named Agency] BHAs who could not assist with restraining patients. RN #4 stated staff often complained about not having enough BHAs.

In an interview on 02/21/2024 at 10:35 AM, BHA #1 stated she was assigned all seventeen (17) patients on the unit, but she had been assigned as many as twenty (20) patients at one time. BHA #1 stated if something was going on, or there was a one to one (1:1) patient assignment, the nurses watched the other patients. BHA #1 stated the hospital needed more staff because the staff assigned to the units could not watch the patients adequately. BHA #1 stated she felt the unit was not staffed sufficiently which put both patients and staff in danger.

In an interview on 02/21/2024 at 10:43 AM, RN #6 stated she currently worked on the West Unit. RN #6 stated she wished that the nurse/patient ratio was better. RN #6 stated she believed there was a problem with the safety of the patients and staff. RN #6 stated when there were fights between the patients, the behavior health assistants were not able to handle those incidents, and the BHAs were scared to respond to the fights. RN #6 stated the nurse workload could be overwhelming due to the lack of staffing.

In an interview on 02/21/2024 at 11:00 AM, the Interim Risk Manager stated the parameters for unit staffing included three (3) or four (4) staff for every fifteen (15) patients.

In an interview on 02/21/2024 at 12:20 PM, the Chief Nursing Officer (CNO) stated unit staffing assignments were completed by the Staffing Coordinator. The Staffing Coordinator, Assistant Director of Nursing, and Chief Nursing Officer reviewed the unit staffing assignments every morning. The CNO stated changes in staffing depended on the time of day, and the Unit Nurse Manager contacted the Staffing Director to get staff called in if necessary, The CNO stated the staff to patient ratio goal was 1:5 which included the registered nurses and licensed practical nurses. The CNO stated the Chief Executive Officer and Chief Financial Officer configured the census needs range based on staff to patient ratio and patient needs, but the hospital "is not sticking to either one." The CNO confirmed it was her responsibility to provide oversight of nursing scheduling to make sure the needs of the patients were met.

In an interview on 2/21/2024 at 2:05 PM, the Human Resources (HR) Director stated she had seen an increase in injuries to staff related to patient aggressive/violent episodes, and she had received an increasing number of employee concerns/complaints regarding insufficient unit staff. The HR Director stated the hospital's goal for staffing was to have a 1:5 staff to patient ratio, depending on patient acuity. The HR Director stated the hospital used unit nurses to figure the staff to patient ratio, but the unit nurses alternated their nursing duties with patient assignment duties. The HR Director stated staff had expressed concerns to her regarding staff safety as well as their increased work caseload.

In an interview on 02/21/2024 at 3:45 PM, the Scheduler for nursing services stated her duty was to make staff assignments. When questioned as to whether [named hospital] had parameters related to staff/patient ratios, the Scheduler stated, "Not really." She stated that if there was a one to one (1:1) patient observation on the unit, extra staff was called in for that unit. The Scheduler stated that if necessary, she personally worked on the units to fill in for staff needs. She stated that she was "going to work as a tech [technician] tonight due to a staff call-in."

In an interview on 02/23/2024 at 9:10 AM, the Administrator stated the unit registered nurse might be responsible for nursing care for two units at the same time, and both units were locked and divided by a hallway.

Refer to A-0392.