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Based on observation, interview, and document review, the Director of Nursing failed to ensure that a Registered Nurse (RN) was present at all times and on all shifts on the acute patient care unit (Nicolet Psychiatric Center). The RNs left the unit to attend treatment team meetings, medical codes and were called to assist with patient care issues in the adjacent 15-bed non-certified residential unit (Bay Haven) and the 63-bed nursing home (Bay Shore Village). This staffing results in the certified patient care unit potentially being without an RN to assess and monitor patient care, provide immediate response to crisis interventions and supervise and direct/guide para-professionals (LPN[Licensed Practical Nurse]s and Mental Health Technicians) in their performance of patient care duties. This failure affects the quality of patient care, increases the timeliness for crisis resolution, and is a safety risk for the patients and staff.

A. Observations and Interviews:

1. During observations on the Nicolet Psychiatric Center unit on 8/30/17 at 10:35 a.m., the surveyor was not able to find an RN on the unit. When MHT2 was asked where the RN (s) was, she responded, "They are in treatment team meetings." When asked where the meetings were being held, she reported that the treatment teams meet in offices outside of the patient unit. MHT2 walked with the surveyor to the hallway where these team meeting offices were located. These offices were located beyond two (2) locked doors from the unit. Even though the RNs could return to the unit without unlocking doors, these offices were two (2) hallways away and through three (3) doors (including the office door). When MHT2 was asked what she would do if a patient emergency occurs, she reported that one of the technicians would have to go around to the office and get the RN or call one of them on the phone. During this time the technician(s) remaining on the unit would respond to the patient incident and call a behavior code. If there were only two (2) technicians on the unit at that time, there would be only one (1) technician to immediately respond to any patient emergency as one technician would need to go for the RN or make the phone calls.

2. During an interview on 8/30/17 at 10:50 a.m., MHT 3 reported that at one time she had been on the unit when both RNs were off the unit at the same time. One RN was in an office on the hallway adjacent to the unit through 2 doors (one of these locked) and the second RN on duty had been called to the adjacent unit (non-certified residential Bay Haven Unit) to help a technician with a patient issue. MHT 3 said that if there had been a patient incident, she would have had to go off the unit to get one of the RNs or call them by phone to have them return to the acute care unit.

3. During an interview on 8/30/17 at 11:20 a.m., RN 1 verified that there is no RN on the Nicolet Psychiatric certified unit during team meetings (held several times weekly) as the two treatment team meetings are held simultaneously -1 RN in each team meeting. She stated that it would be difficult if there were a patient "situation" while both RNs were off the unit. RN 1 verified that an RN on the Nicolet Psychiatric Center unit might have to go to "help out" on the adjacent non-certified patient care unit. She added that an RN does not arrive on the non-certified unit until 9:00 a.m. and the technician on that unit may call for assistance if s/he has "an issue with medications" before that time. RN 1 reported that at least one RN should be on the Nicolet Psychiatric Center unit at all times. When asked if she were aware of this expectation because of written policy or verbal direction, she responded that she was not sure that she had seen this information in writing, nor had been told this requirement. RN 1 said that she would feel that she "should go help a patient if there were an incident in a non-certified unit (even if she were the only RN on duty in the acute unit)."

4. During an interview on 8/30/17 at 2:20 p.m., the DON stated that she realized this morning that the team meetings held simultaneously off the patient unit have become a problem. She reported that at least one RN should be on the acute certified unit at all times. She stated that if there is only one RN on the unit that RN is not supposed to go to a medical code off the unit, nor leave the unit to go help with a patient issue in another unit. When asked if these expectations for coverage were stated in policy, she replied, "I'll look, but not as far as I'm aware." As of 9/1/17, no policy was available.

5. During an interview on 8/30/17 at 3:00 p.m., the scheduling specialist clarified that if an emergency code were called in the non-certified parts of the facility (Bay Haven, residential or Bay Shore Village, nursing home), the RN from the certified area would go to help if there was no RN in the non-certified area.

6. During an interview on 8/31/17 at 11:00 a.m., the Charge Nurse (from the certified part) stated that she spent approximately 2 hours of each12 hour shift in the residential section and 2-4 hours in the nursing home section. The charge nurse works 9:00 a.m.-9:00 p.m. 5 days/weekly. She said that her hours would vary but that she always spent time in the two non-certified areas during her shifts. Charge nurse verified that she or one of the Nicolet RNs carried the "charge phone" for the three (3) inpatient units at all times.

7. During an interview on 8/31/17 at 11:30 a.m., the Director of Nursing clarified that she would "expect the Registered Nurse on the certified psychiatric unit to respond to medical codes in the non-certified areas when there was no RN there."

B. Review of staffing documents

1. A review of the nursing staffing for the 15-bed non-certified residential area of the facility (Bay Haven) revealed that there was no full-time RN scheduled for the shifts August 24-30 2017. The Charge Nurse from the Nicolet Psychiatric Center (certified part) provided RN coverage for this unit on these shifts of duty. When the RN from the Nicolet Psychiatric Unit was helping in the non-certified unit, the certified unit was short 1 RN.

2. A review of the nursing staffing for the 63-bed non-certified nursing home area of the facility (Bay Shore Village) revealed that there was no RN scheduled for the nights of 8/26/17 and 8/27/17. On these nights, the RN from the certified part (Nicolet Psychiatric Center) would have to respond to any emergencies (as the Director of Nursing noted above).

C. Policy Review

Policy ID 3800110 dated 8/2017, "Code E.R., Medical Emergencies," stated "The Nicolet Psychiatric Center code ER Cart and supplies will be brought to codes in all others area to include Nicolet Psychiatric Center, Bay Have CBRF, Administrative Area, Outpatient Community Treatment Program, Lab, Dietary, Facilities and Parking Lots" and "Staff on break will return to their units immediately to cover while licensed staff respond to the Code ER."

This policy did not specify what staff would take the cart and supplies from Nicolet Psychiatric Center to other areas of the facility, nor did it identify which licensed staff was to respond to the "Code ER" emergencies.