HospitalInspections.org

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Based on document review and interview, the hospital failed to develop and implement a process to ensure staff had appropriate credentials and licensure for the individual's scope of practice.

Failure to ensure that staff obtained appropriate credentials and licensure for their scope of practice risks patient's safety.

Reference: WAC 246-841-400 - Standards of practice and competencies for nursing assistants.

WAC 246-810- 015 - Agency Affiliated Counselor: Scope of practice and credentialing requirements.

Findings included:

1. Document review of the hospital's job description titled, "Mental Health Technician," showed that the job position was structured under the Nursing Department. The Mental Health Technician (MHT) works under the direction of the Registered Nurse (RN). Required qualifications for the MHT included Certified Nursing Assistant or Nursing Assistant Registered and Agency Affiliated Counselor registration. Major job responsibilities included taking and recording vital signs properly. Observing and documenting changes in the patient's appearance, behavior or ability to work toward treatment plan goals. The MHT communicates changes in the patient's condition to the RN.

2. On 08/21/19 at 10:00 AM, Investigators #3 and #5 reviewed the employee personnel and training files for nine nursing staff including two MHTs. The review showed:

a. Investigator #3 found no evidence that the Washington State Department of Health had issued a Certified Nursing Assistant license or Nursing Assistant Registration to Staff #301. The training file showed that Staff #301 had an original hire date of 03/21/19 for a patient care sitter position. No job description could be located in the file. The training file showed Staff #301 had completed skill competencies for Vital Signs measurement, Urine Drug Screen testing, Urine HcG (pregnancy testing), Rapid Strep test, Glucose Monitoring, and Breathalyzer (Alcohol) test on 03/28/19. Investigator #3 found no evidence in the personnel file that Staff #301 had a valid and current Affiliated Agency Counselor registration. An application for Affiliated Agency Counselor registration was in the personnel file dated 07/11/19.

b. At the time of review, Investigator #3 interviewed the Director of Human Resources (Staff #302) about Staff #301's personnel training file. Staff #302 stated that Staff #301 transitioned to a MHT position on 06/13/19. Staff #302 did not know if Staff #301 had a current Affiliate Agency Counselor registration and would need to get back to the investigator with this information.

c. Investigator #5 found no evidence the hospital ensured that Staff #507 had a valid and current Affiliate Agency Counselor registration.

Investigator #5 found a copy of an application for an Affiliate Agency Counselor registration which showed that Staff #507 began performing MHT duties on 04/15/19, and that the hospital completed the employment verification form on 05/03/19.

d. At the time of the review, Staff #302 stated that she did not know if Staff #507 had a current Affiliate Agency Counselor registration and she would need to get back to the investigator with this information.

3. On 08/21/19 at 8:13 AM, Investigator #3 and #5 interviewed the interim Chief Nursing Officer (CNO) (Staff #303) about nursing services. Staff #303 stated there are no current patient sitters in the organization. The two individuals who were previously patient sitters had transitioned into other positions within the hospital. One individual had transitioned into an administrative clerk position and the other individual into a MHT role. The CNO stated that MHTs are not required to be a Certified Nursing Assistant or Nursing Assistant Registered only that they have an Affiliated Agency Counselor registration and Basic Life Support certification. She stated that MHTs do not perform any point of care testing like glucose monitoring. When asked how Nursing Services track their staff licensure status, Staff #303 stated that Human Resources sends out a list to the directors for tracking.

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Based on interview, document review, and review of hospital policies and procedures, the hospital failed to ensure that Program Therapists were designated as qualified personnel for discharge planning responsibilities for 4 of 4 personnel files reviewed.

Failure to designate which personnel are qualified to perform discharge planning risks patients receiving inadequate or unsafe discharge plans.

Findings included:

1. Document review of the hospital policy and procedure titled, "Discharge," no policy number, effective 05/17, showed that discharge planning begins the day of admission and continues through outpatient treatment. The therapist and client /guardian will develop a specific discharge plan upon developing the initial treatment plan. The client's family are involved in the discharge planning process with consent from the client. The completed discharge plan is signed by the therapist and client/guardian.

Document review of the hospital policy and procedure titled, "Discharge Planning," no policy number, effective 05/17 showed that the discharge plan should prepare the patient and family for the transition to the next level of care. The discharge plan should include timely and direct communication with and transfer of information to other programs, agencies, or individuals that will be providing continuing care.

Document review of the job description titled, "Program Therapist," last revised 04/18 did not include discharge planning responsibilities or competencies listed under performance standards for the social services practices and competencies section.

2. On 09/05/19 at 8:45 AM, Investigator #3 interviewed the Director of Clinical Services (Staff #301) about the discharge planning process. Approximately one year ago (prior to the arrival of Staff #301 in her current position), the hospital stopped using discharge planners. Those duties were reassigned to the program therapy staff. She stated Program Therapists are primarily responsible for development and implementation of the discharge plan.

3. On 09/06/19 at 3:25 PM, Investigator #3 had a follow-up interview with Staff #301. Investigator #3 asked Staff #301 to review the Program Therapist's current job description and show where the discharge planning responsibilities were located. She confirmed that there was no specific mention of discharge planning responsibilities in the current job description.

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ITEM #1 - Post-discharge living arrangements
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Based on record review, interview, and review of hospital policies and procedures, the hospital staff failed to verify or reassess post-discharge living arrangements to ensure that patients have access to a safe and appropriate living environment for 1 out of 4 patients reviewed (Patient #301).

Failure to reassess the patient's discharge plan when the patient's social support services may not be verified risks discharging the patient to an inadequate living environment.

Findings included:

1. Document review of the hospital policy and procedure titled, "Discharge Planning," no policy number, effective 05/17, showed that the discharge plan prepares the patient and family for the transition to the next level of care. The plan will identify the responsibility for ensuring that the prescribed follow-up is accomplished.

2. On 09/05/19 at 3:15 PM, Investigator #3 reviewed the discharged medical record of Patient #301, who was involuntary admitted on 08/14/19 for treatment for psychosis. The record reviewed showed:

-An intake assessment completed on 08/14/19 showed the patient was living in an adult family home (AFH) and eloped with a missing person's report filed. Patient was found loitering at a grocery store and was unable to say where he had been or why he left the AFH. The patient was transported to an emergency room for evaluation.

- A psychiatric evaluation completed on 08/15/19 showed the patient was experiencing auditory and visual hallucinations and did not feel safe in the community. The patient reported that he is currently homeless and does not know where he was going to live.

- The medical admission history and physical completed on 08/15/19 showed the patient's medical problems included spina bifida, shunt placement and insertions, and a recent hospitalization for osteomyelitis of the coccyx requiring six weeks of antibiotic treatment.

-The psychosocial assessment completed on 08/16/19 showed under the section titled "Assessment of Treatment and Aftercare Needs" that the patient does not want to go back to the AFH and cannot live with family. Patient #301 stated, "They need to help me with housing" (referring to non-profit organization Compass Health).

- A program therapist treatment team meeting note dated 08/27/19 at 10:00 AM showed the discharge plan was to discharge the patient to a shelter. The patient was adamant about not wanting to go an AFH. The Program Therapist (Staff #302) wrote, "Psychiatrist informed Program Therapist and the rest of treatment team that patient informed him that patient wants to dc [discharge] to a motel." The Program Therapist asked how was the patient going to pay for the lodging. Staff #301 wrote that the Psychiatrist stated, "He said his mother is going to pay for it all." The therapist documented her concerns that she was never able to connect with the patient's mother on the phone in all the time the patient had been at the hospital. Staff #301 wrote that Psychiatrist stated to "let's let him go". There was no further input from the treatment team at that time.

-The discharge and transition plan dated 08/27/19 at 4:15 PM showed that Patient #301 was provided transportation by Hopelink to a Travel Lodge Motel in Everett. The plan also included an appointment for a walk-in evaluation for medication management and therapy.

3. On 09/06/19 at 12:45 PM, Investigator #3 interviewed Patient #301's attending staff Psychiatrist (Staff #303) about the discharge plan for Patient #301. Staff #303 stated he felt it was a safe discharge in terms of his behavioral health. He stated that he is always cautious with discharge and will not discharge someone if he thinks it might not be safe. The Psychiatrist stated that he wanted the patient to go back to a group home setting but the patient was insistent on going to a motel. The investigator asked Staff #303 if he had discuss directly with the mother the discharge plan of Patient #301 going to the motel. He stated he had not but the treatment team had told him the patient was ok to go to the hotel.

4. On 09/06/19 at 1:20 PM, Investigator #3 interviewed a Registered Nurse (Staff #304) who participated in the treatment team meeting about the discharge plan for Patient #301. Staff #304 stated that the Patient #301 spoke several times daily to his mother throughout the stay and felt the patient was ready for discharge however, she had never spoke directly with the mother about the discharge plan.

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ITEM #2 - Suicide risk assessment

Based on interview, record review, and review of policies and procedures, the hospital staff failed to reassess a patient's suicide risk prior to discharge for 1 of 11 patient records reviewed (Patient #1102).

Failure to reassess a patient's suicide risk prior to discharge places patients at risk of discharge while suicidal and may result in patient self-harm or death.

Findings included:

1. Record review of Patient #1102's medical records for admission on 08/17/19 and subsequent readmission on 08/23/19 showed:

a. The patient was initially admitted on 08/17/19 for treatment of depression, anxiety, and suicidal ideation.

b. According to the admission intake assessment, the patient was assessed to be a moderate suicide risk.

c. The patient was placed on suicide precautions upon admission and removed from suicide precautions the next day.

d. On 08/22/19 at 1:46 PM, the patient was evaluated by a provider (Staff #1105) via telepsych. The provider's note stated that the patient had improved mood, and was less depressed, less withdrawn and less anxious. The provider stated that the patient had suicidal ideation the day before but denied it on the day of discharge.

d. The patient was discharged on 08/22/19 at 3:00 PM. The form titled, "Columbia-Suicide Severity Rating Scale, Psychiatric Inpatient Setting - Discharge Screener," used by the hospital to assess suicide risk prior to discharge was not found in the medical record.

e. On 08/22/19 at 9:55 PM, the patient was admitted to a hospital emergency department for high risk of suicide.

f. On 08/23/19, the patient was readmitted to the same psychiatric hospital for treatment of depression, anxiety, and suicidal ideation.

2. On 09/06/19 at 3:25 PM, Investigator #11 interviewed the Director of Clinical Services (Staff #1102) about the suicide risk assessment performed by staff prior to patient discharge. Staff #1102 stated that the suicide risk assessment must be completed by the Psychiatrist, a Registered Nurse or a Program Therapist prior to discharge.

3. On 09/06/19 at 4:05 PM, Investigator #11 interviewed a Registered Nurse (RN)(Staff #1106) about the use of the form titled, "Columbia-Suicide Severity Rating Scale, Psychiatric Inpatient Setting - Discharge Screener," used to screen for suicide risk prior to discharge. Staff #1106 stated that the RN or the Program Therapist would always complete this form prior to discharge. Staff #1106 stated that they never review the psychiatrist's notes for their assessment of suicide risk in lieu of completing the suicide discharge screener form. The suicide risk assessment is completed just prior to discharge since the patients risk of suicide could change following the psychiatrists assessment.

4. Record review of the hospital's policy and procedure titled, "Precaution: Suicide," no policy number, revised 03/18, showed that patients will be assessed for suicide risk at least upon admission and at discharge. The policy and procedure did not indicate what type of suicide risk assessment should be completed prior to discharge nor who was responsible for completing the assessment or when the discharge assessment should be completed.

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