HospitalInspections.org

Based on review of facility documents and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to ensure that a registered nurse assign the nursing care of each patient to other nursing personnel in accordance with the patient's individual needs and the specialized qualifications of staff available for 16 of 72 behavioral health shifts.
Findings include:
1. The facility, upon request, failed to provide a policy requiring a registered nurse assign the nursing care of each patient to other nursing personnel in accordance with the patient's individual needs and the specialized qualifications of staff available.
2. Review of the facility job description, "Registered Nurse," no date, revealed, "Duties And Responsibilities: 1. Provide patient care and medication administration utilizing nursing principles while attending to the responsibilities and needs of assigned patients."
3. Review of the facility job description, "Licensed Practical Nurse," no date, revealed, "Duties And Responsibilities: 1. Provide patient care and medication administration utilizing nursing principles while attending to the responsibilities and needs of assigned patients."
4. Review of the facility job description, "Behavioral Health Technician," no date, revealed, "Duties And Responsibilities: 1. Participates as a member of a multidisciplinary team attending to the responsibilities and needs of assigned patients."
5. Review of nursing assignment sheets for the Geriatric Behavioral Health Unit from March 29, 2011, to May 3, 2011, revealed seven of 24 shifts to contain no staff assignments for the care of patients on the unit.
6. Review of nursing assignment sheets for the Adolescent Behavioral Health Unit from March 29, 2011, to May 3, 2011, revealed six of 24 shifts to contain no staff assignments for the care of patients on the unit.
On May 4, 2011, at 1:15 PM EMP7 confirmed the shifts on the Geriatric and Adolescent Behavioral Health Units with no staff assignments for the care of patients on the units. EMP7 further stated, "The assignments should have been filled in."
7. Review of nursing assignment sheets for the Adult Behavioral Health Unit from March 29, 2011, to May 3, 2011, revealed three of 24 shifts that did not contain staff assignments for the care of patients on the unit.
On May 4, 2011, at approximately 1:30 PM EMP6 confirmed that the Patient Assignment sheets did not contain staff assignments for the care of patients on the unit for the night shift of April 2, April 3, and May 2, 2011.

Based on review of facility documentation and medical records (MR), and staff interview (EMP), it was determined that the facility failed to enforce its policy that a post-anesthesia evaluation be completed and documented by an individual qualified to administer anesthesia no later than 24 hours after surgery or a procedure requiring anesthesia services for two of two medical records (MR13 and MR14).
Findings include:
Review of the Millcreek Community Hospital, "Postanesthesia Rounds," effective date July 1, 2010, revealed, "Policy: Postanesthesia rounds requires that the rounds shall be made by the anesthesiologist within a reasonable length of time but no greater than 24 hours. ... Procedure: ... C. The postanesthesia section of the anesthesia record should be completed including date and time. If there are no postanesthetic complications, this should be noted on the form and the form signed by the anesthesiologist or designated RN/CRNA."
1. Review of MR13 revealed six procedures requiring anesthesia services. Further review of MR13 revealed no documentation of post-anesthesia evaluations, completed within 24 hours after the procedures.
2. Review of MR14 revealed five procedures requiring anesthesia services. Further review of MR14 revealed no documentation of post-anesthesia evaluations, completed within 24 hours after the procedures.
On May 5, 2011, at approximately 2:30 PM, EMP1 confirmed the lack of documentation of post-anesthesia visits for MR13 and MR14.