HospitalInspections.org

Based on observations, records review and interviews, the hospital failed to meet the requirements for the Condition of Participation of Patient Rights as evidenced by:


Failing to ensure that patients received care in a safe setting for 2 of 5 (#2, #3) patients reviewed as evidenced by:


1) Failure to ensure the safety of patients during transportation by hospital staff for 1 of 5 (#3) sampled patients reviewed for transportation on the DNP unit (Developmental Neuropsychiatric Program).


The hospital failed to address in policy and procedure the staff to patient ratio during transport, the staff/patient seating arrangements during transport, and staff directives for handling patient behavior incidents that occur during transport of patients. The hospital failed to ensure staff were trained and had demonstrated competency in the transportation of patients prior to making transportation assignments.


See findings in tag A0144; and


2) Failure to ensure patients with a history of suicidal ideations were in an environment free of potentially harmful objects, such as shoestrings, that could have been used for strangulation for 1 of 5 (#2) sampled patient records reviewed on the DNP unit.


The hospital did not have policies and procedures that addressed the use of shoestrings, cords, or belts as potentially harmful objects.


See findings in tag A0144.

Based on observations, record reviews, and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by:


1) failing to ensure the safety of patients during transportation by hospital staff for 1 of 5 (#3) sampled patients reviewed for transportation on the DNP unit (Developmental Neuropsychiatric Program).


The hospital failed to address in policy and procedure the staff to patient ratio during transport, the staff/patient seating arrangements during transport, and staff directives for handling patient behavior incidents that occur during transport of patients.


The hospital failed to ensure staff were trained and had demonstrated competency in the transportation of patients prior to making transportation assignments.


2) failing to ensure patients with a history of suicidal ideations were in an environment free of potentially harmful objects, such as shoestrings, that could have been used for strangulation for 1 of 5 (#2) sampled patient records reviewed on the DNP unit. The hospital did not have policies and procedures that addressed the use of shoestrings, cords, or belts as potentially harmful objects.

Findings:

1) Failing to ensure the safety of patients during transportation by hospital staff:
Review of the clinical record for Patient #3 revealed the patient was a 13 year old male admitted to the hospital's DNP Unit on 06/19/12 with diagnoses of Oppositional Defiant Disorder (ODD), Attention Deficit Hyperactivity Disorder (ADHD), Rule Out Bipolar Disorder, Rule Out Conduct Disorder, and Mild Mental Retardation. The patient's medical problems included Diabetes Mellitus and Obesity.


Review of the Physician's Certificate for a Minor dated/timed 06/19/12 at 10:00 a.m. revealed the patient was "very aggressive-lashes out at people", and immediate psychiatric treatment in a facility was determined based on mental illness, requires care and treatment in an institution, and can benefit from inpatient treatment. The Physician's Certificate was signed by S6 Psychiatrist.


Review of Patient #3's "Treatment Plan Integrated Summary" signed by Psychiatrist S6 on 06/22/12, 07/25/12, 08/22/12, 09/19/12, 10/17/12, and 11/14/12 (2 days before the pass on 11/16/12) revealed that Patient #3 was a moderate suicide risk and a high violence risk.


Review of the Treatment Plan Integrated Summary dated 09/19/12 revealed the patient had his first weekend pass with his mother from 09/14/12 to 09/17/12 and did fairly well. Review of the Treatment Plan Integrated Summary dated 10/17/12 revealed the patient had his second weekend pass from 10/12/12 to 10/15/12 and 7 major behaviors were reported by the patient's aunt and mother. The behaviors reported were: not following directives, leaving the house without permission, and destroying head phones. Review of the Treatment Plan Integrated Summary dated 11/14/12 revealed the patient would go on his third pass from 11/16/12 to 11/26/12 (10 days).


Review of the Suicide/Violence/Elopement Risk Assessment forms revealed the risk assessment had been documented on 06/16/12 (Admit), 08/01/12 (day pass on 8/5), 10/12/12 (week end pass), and 11/15/12 (10 day pass).


Review of the Suicide/Violence/Elopement Risk Assessment dated 11/15/12 and signed by S6 Psychiatrist, revealed the following: Suicide Risk: Low, Violence Risk: Low, has shown continued improvement. Elopement Risk: Low, Elopement Precautions: Yes/No were both unchecked. There was no documentation of a risk assessment prior to the first week end pass on 09/14/12 to 09/17/12.


Review of the Daily Trip List dated 11/16/12 revealed Patient #2, Patient #3, Patient #5 and Patient R1 were transported in the same van for the purpose of home passes. The Daily Trip List revealed the patient/staff ratio was 4/1 and the driver was S3 Mobile Equipment Operator.

Review of the progress notes dated/time 11/16/12 at 12:41 p.m. and documented by S17 BSS (Behavior Shaping Specialist) revealed during the transport for the home passes of Patient #2, Patient #3, Patient #5 and Patient R1, S3 Mobile Equipment Operator observed an altercation between Patient #3 and Patient #2. The entry revealed Patient #3 continued to mumble when redirected and S3 had to inform him that she would turn around and return him to the hospital before he became compliant with directives. The record revealed both patients received a PA1 (Physical assault 1- type of consequence for behavior) for the altercation.


In a face-to-face interview on 12/05/12 at 8:05 a.m., S3 Mobile Equipment Operator verified she was the van driver on 11/16/12 when Patient #3 was transported to the drop off location for his home pass. S3 stated she took Patient #3 and 3 other patients in the van on 11/16/12 to drop them off for their pass. S3 stated a little boy from W ward (R1) was seated on the back row (third row of seating) between Patient #3 and Patient #2. S3 stated Patient #5 was seated behind the passenger seat and a BSS (couldn't remember which BSS it was) was seated behind the driver. S3 further stated Patient #3 and Patient #2 were fighting over the little boy in the middle. S3 stated the BSS tried to talk to them, but when S3 told them she would turn the van around and take them back, they responded and were quiet. S3 stated there was 1 BSS on this trip, but she did not know her name.


In a face-to-face interview on 12/10/12 at 3:15 p.m. S17 BSS verified she was assigned to go on the van trip with Patients #2, #3, and #5 on 11/16/12. S17 stated there was a child from the W ward (R1) also on the van, and he was seated on the back seat between Patient #2 and Patient #3. S17 stated Patient #5 was seated behind the passenger seat and another staff member was seated behind the driver, but she did not know her name. S17 stated she sat in the front passenger seat. S17 stated S3 decided who sat where in the van. S17 stated the patients always sit in the back. S17 stated staff always sit by the doors behind the driver or the front passenger seat. When asked if the child-locks were in place on the sliding doors, she stated, "I don't know about that, the driver handles the child locks." S17 also stated the driver has to let them out, because the doors were locked. When asked if she had any training on transporting patients in the van, she stated no. S17 stated when she was employed, her supervisor told her clients never sit by the door. S17 verified Patient #3 and Patient #2 had an altercation during the trip on 11/16/12.


Further review of the progress notes for 11/20/12 revealed that S18 Psychologist documented Patient #3 was doing well on pass. S6 Psychiatrist documented on 11/21/12 that the patient was doing well while at home. The progress notes revealed on 11/26/12 that Patient #3 was not at the designated pick up location when the hospital's van arrived for pick up. Another pick up by the hospital's van was rescheduled for 11/27/12 from the patient's home.


Further review of the progress notes revealed the following:


11/27/12 at 0930 - BSS S4 left to accompany driver S3 to pick client up from his mother's house in City B (town over 1 hour's drive from the hospital), signed by S12 RN, Charge Nurse.


11/27/12 at 1200 - TC (Telephone call) from S3 driver, who reports that client became aggressive, jumped out of the van, and that she has called 911 to assist with the situation, signed by S12 RN (registered nurse), Charge Nurse.


11/27/12 at 1208 - TC form S3 driver who reports that client ran back and forth across the interstate and has been struck by a vehicle and that EMT (Emergency Medical Technician) is now putting client on a stretcher to be taken to (Hospital A) ER (Emergency Room). Above reported to S16 RN Manager (acting RN Manager), S2 Administrator/CEO (Chief Operating Officer) and S20 Program Director...Staff from hospital S3 and S4 are accompanying client to the ER, signed by S12RN, Charge Nurse.


11/27/12 at 1700 - The client was picked up from his home in City B. He stated that he had a good pass. The client's grandmother stated that their pass went well. Before we left his house the driver and I reassured that the child-lock on the back seat doors were secure and locked. The client was talkative and seemed happy. The driver and I were both engaged in conversation with him for most of the ride. When we got closer to Exit A the client began to cry and say, 'I want to go home'. I tried to counsel him and calm him down. The driver also attempted to calm him down. The client unfastened his seat belt and was asked several times to buckle his seat belt back. The client began to get up and struggle with me to get to the front seat. He overpowered me and jumped into the front seat. During this time the driver realized what he was trying to do and pulled over to the side of the interstate onto the shoulder. As soon as the van stopped the client unlocked the front door and jumped out and took off running. I chased the client down and was able to talk him back to the van. As we were back at the van he was refusing to get all the way in the van. The driver had called 911 when he ran out of the van. As he was sitting in the van he heard some ambulance sirens and jumped out of the van again. He picked up a piece of sharp plastic off the ground and stabbed me in the leg. It was not enough to break my skin but I felt it was a warning and the look in his eyes were furious. So he took off running again and we decided it would be best to stop chasing him in case he would run into the oncoming traffic. He ran about a half mile away from the van. Then decided to run across the five lanes of interstate traffic. When he got to the other side of the interstate he decided to quickly run back across the five lanes. When he got to the third lane all of the traffic cars were slamming on their brakes. A tow truck struck him and he flew to the shoulder of the road. There were EMT services directly behind the accident and immediately pulled over to help him, signed by S4 BSS.


Review of a typed statement signed by S3 Mobile Equipment Operator and dated 11/28/12 revealed the van arrived at Patient #3's home at 11:15 a.m. The statement revealed when the van was near Airport A the patient began to cry and stated he wanted to go back home. The patient then unfastened his seatbelt and was asked repeatedly to fasten his seatbelt. S3 documented the patient kept repeating he wanted to go home and as she was nearing Exit A, the patient pushed S4 BSS and attempted to get into the front seat. S3 documented she began to slow down and pull to the side of the interstate. The statement then revealed: "As I got to the shoulder, the client made it to the front passenger seat and was attempting to unlock the door, but I was holding down the lock button. He managed to get the door unlocked and he exited the vehicle. S4 BSS then climbed into the front seat and exited the vehicle behind him. He began running down the side of the road alongside the interstate and S4 BSS ran behind him. I got on the phone and called 911 and then I call the hospital.... Patient #3 managed to run about a half of a mile or more before S4 BSS caught up to him and grabbed him, encircling her arms around his waist. It appeared to me, through the rearview mirror, that she was counseling him. She was able to talk him into coming back to the van. Upon arriving back at the van, S4BSS opened the sliding door on the passenger side and he stated to me (S3) 'I don't want anyone to ride in the back with me'. I didn't respond to him, I just made eye contact with S4 BSS. He then became agitated again and stabbed S4 BSS in the leg with a plastic object that he picked up from the side of the road (it did not break the skin), and he took off walking down the side of the interstate. S4 BSS made another attempt to go after him and I stated to her, 'Do not chase him. He could run out into traffic in front of a car', hoping that the police would be coming right away. He walked about a half of a mile or more down Highway A away from the van, towards City A and that's when I saw him walking across Highway A...."


A hand written statement dated 11/29/12, signed by S3 Mobile Equipment Operator, attached to the typed statement revealed S3 was in the driver's seat, S4 BSS was in the passenger seat behind the driver, and Patient #3 was in the other passenger seat on the side of S4 BSS and they were in Van A.


In a face-to-face interview on 12/05/12 at 7:35 a.m., S3 Mobile Equipment Operator confirmed that she was the van driver on 11/27/12 when Patient #3 was picked up from his home pass. She indicated that Patient #3 had a frown on his face when he was picked up from home. She further indicated that Patient #3, BSS S4, and herself (S3) talked about all of them having seen the same movie when she (S3) heard Patient #3 begin to cry. S3 indicated that when they were near Airport A BSS S4 attempted to get Patient #3 to talk about what he was feeling, but he just removed his seat belt and began hollering "I want to go home". She further indicated that he continued hollering and refusing to re-buckle his seat belt. S3 indicated that when she neared Exit A, Patient #3 was attempting to get into the front seat while BSS S4 was trying to pull him back his seat. She further indicated that she was not at a complete stop when Patient #3 was out the front passenger door. When asked about Patient #3 remaining unbuckled from his seat belt from Airport A to Exit A (third exit after the airport), S3 indicated that there was no way to pull to the side of the highway due to construction. When asked if there was restraints kept in the van, S3 indicated that Patient #3 could have been physically restrained if they had additional staff on the trip. She further indicated that they had brought restraints in the past when they had an aggressive client on board, but with a child on a home pass, they don't bring restraints. S3 indicated that Patient # 3 never got back into the van and kept saying that he didn't want anyone to sit in the back with him. S3 indicated that BSS S4 had opened the side sliding door of the van when she returned with Patient #3 when he heard a siren on the opposite side of the highway, and he started walking down Highway A again. S3 indicated that called 911 and notified the hospital charge at the time of the incident and again after the accident.


S3 indicated that she was not required to have CPSI (crisis prevention and supportive intervention) training. She further indicated that she had not been made aware of any changes to the procedure for transporting patients since the accident occurred. Regarding the trip on 11/16/12 when she was the driver who took 4 patients, including Patient #3, on pass for home visits, S3 indicated that Patient #5 was seated in the bucket seat behind the passenger seat, and Patient #2, Patient #4, and Patient R1 were seated in the back passenger seat (third row of the van) with Patient R2 seated in the middle. She further indicated that there was a BSS in attendance, but she couldn't remember her name. S3 indicated that there was a "hitting match" between Patient #2 and Patient #3. She further indicated that after the BSS told the patients something about their behavior with no results, she (S3) spoke to them, and they were quiet for the rest of the trip.


In a telephone interview on 12/05/12 at 9:45 a.m., S4 BSS confirmed she was the BSS assigned to pick up Patient #3 from his pass on 11/27/12. S4 confirmed the events in her documentation in the progress notes. S4 also stated she did not know where on Highway A they were when the patient's behavior started. S4 stated she had asked the patient several times to buckle his seatbelt, and she had tried to calm him down. S4 stated it was a "pushing match" between her and Patient #3 to try and get him to sit down in his seat. S4 stated Patient #3 got past her and dove into the front passenger seat. S4 stated the driver began pulling over to the side of the highway and just as she stopped the patient got the door open. S4 stated she went thru the middle to the front seat to get out and chased the patient down and was able to talk him back to the van. S4 stated that upon returning the patient sat in the bucket seat but refused to put one foot in the van, so she could not close the van door. S4 stated the patient heard sirens, looked at her, and jumped out of the van. S4 confirmed she did not chase after the patient this time and was hoping the police would arrive and help with the situation. S4 stated patients cannot sit behind the driver.


S4 stated no one had instructed her that she had to sit behind the driver and stated, "I feel better there." S4 confirmed she had received CPSI (Crisis Prevention Supportive Intervention) training after employed at the hospital. S4 also stated she was in training for a month, but the training did not include transportation of clients. S4 stated she had not received any training on transporting patients, nor had she received any direction or guidance on how to handle behavior incidents during transport.


S4 confirmed she was hired in September 2012 and the trip on 11/27/12 was her first home pass pick up. S4 stated she had gone on transports to local doctor appointments, but 11/27/12 was the longest trip she had been on. S4 stated she was assigned to class room monitoring on 11/27/12 and was pulled to go on the transport. S4 stated she spoke to a supervisor (unable to recall her name) and was told to go, "it was very fast." When asked if there was anything that could have prevented this incident, S4 stated they should have sent someone more experienced or a male. S4 stated the patient had been away from the program so long he was used to being home and did not want to return. S4 stated she was not aware of any changes in the transportation process since this incident.


In a face-to-face interview on 12/05/12 at 8:10am, Program Director of DNP S20 (psychologist) indicated that the decision of whether a patient could go on pass was based on safety. She further indicated that this was Patient #3's third pass. When asked who decides the number of people needed to escort a patient, S20 indicated that the nurse made that decision. When asked if an altercation occurred during the trip home between patients (like that of 11/16/12), would that have resulted in the pass being denied and the patient brought back to the hospital, S20 indicated that "it was a little altercation and the patients responded to redirection quickly." When asked if she thought anything could have been done to prevent the accident, S20 indicated there was discussion about inserting a cage device to separate the back seats from the driver, but in her opinion, if that was necessary, the patient would not be ready to go on home. She further indicated that the other option could be that 2 staff members would accompany patients on pass, but then again she thought if this was needed, the patient was not ready to go on pass. She further indicated that 2 staff members could be assigned for medical appointments or court attendance if the physician deemed it necessary.


In a face-to-face interview on 12/05/12 at 8:50am, Psychiatrist S6 indicated that he did a risk assessment prior to Patient #3 going on pass on 11/16/12. He further indicated that "to be honest, it's more that we make sure we do some kind of assessment prior to the pass"...He further indicated that he generally reviews how the patient has been and whether there has been any behavioral changes, whether the child has a history of wanting to hurt someone, whether there's an elopement issue, or suicide threats.


S6 indicated that Patient #3 had a history of running away in the past, but he had 2 successful passes prior to the one on 11/16/12. He further indicated that if anything, he would have been concerned about Patient #3 punching someone. When shown the Treatment Plan Integrated Summary that he (S6) had signed on 06/22/12, 07/25/12, 08/22/12, 09/19/12, 10/17/12, and 11/14/12 and assessed Patient #3's suicide risk as moderate and his violence risk as high, while his Suicide Risk Assessment completed on 11/15/12 for the pass on 11/16/12 revealed Patient #3's suicide risk was low, his violence risk was low, and there was no elopement risk, Psychiatrist S6 indicated that the Treatment Plan Integrated Summary must have an automatic check mark in the computer system that he didn't catch when he signed it.


When S6 was asked how Patient #3's assessment of violence could go from high to low risk within one day, S6 indicated that it was worth sending him on a pass to home with his family where he wanted to be. He further indicated that he would consider him a low risk while with family but still violent at the hospital. S6 indicated that he sat with Administrator S2 to evaluate the accident, spoke with Driver S3, and reviewed the hospital protocols. He further indicated that the only thing they came up with that might help would be to put a barrier between the front and back seats, but it would then look like a jail rather than a hospital. S6 indicated that S3 indicated that she would have liked someone in the front seat, but he thought that the protocol that a staff member had to be in the back seat. He further indicated that if a patient were seated behind the driver, the patient could choke the staff or interfere with the driver. S6 indicated that he thought Patient #3's "modus operandi was if I try something outrageous, they'll bring me home".


In a face-to-face interview on 12/05/12 at 9:10am, Psychologist S18 indicated that she was Patient #3's primary psychologist. She further indicated that she spoke with his mother on Tuesday, and she said the pass was going well, as Patient #3 was able to visit with his aunt and uncle and would be returning home that night. S18 indicated that when the pick-up did not occur on 11/26/12 as scheduled, it was decided by herself and Psychiatrist S6 to have him return on 11/27/12 rather than wait for the family to bring him on the weekend. She further indicated that they (S18 and S6) were concerned about Patient # having enough medication for that extended period and it would be too long to have him from the hospital program.


On 12/10/12 at 8:45 a.m. an observation was made of Van A with S7 Mobile Equipment Operator. S7 stated Van A was assigned to S3 Mobile Equipment Operator and was the van used when Patient #3 was picked up from a home pass on 11/27/12. Observation of the van revealed individual seats for the driver and front passenger. Individual (bucket) seats were also noted behind the driver and the front passenger (2nd row). The third or back seat was observed to be a bench seat with 3 seatbelts. Sliding doors were observed on both sides of the vehicle adjacent to the second row seating. Child-locks were observed to be present on both sliding doors and were noted to be engaged in the locked position. Both sliding doors were observed to be unable to be opened from the inside when the vehicle was in park, drive, or when the vehicle was turned off. The front passenger door was observed to have a button and a switch above the door handle to lock and unlock the door. Observation of the vehicle in park and drive positions revealed the door could be unlocked manually in both positions, and the front doors automatically unlocked when the vehicle was placed in the park position. Further observation revealed the front passenger door could be opened even if the lock was held down by the driver. There was no barrier noted between the passenger area and the driver or the front passenger seat. S7 stated clients are not to sit on the 2 bucket (individual) seats behind the driver. S7 stated the staff are to sit on the second row behind the front passenger seat and the clients are supposed to sit on the back (3rd) seat. S7 stated never should staff sit in the front seat, but stated she has seen it happen. S7 stated they don't usually engage the child lock on the right behind the front passenger side.


S7 stated she transported a client on 12/07/12 and she had to pull over because she saw the client in her rear view mirror walking to the front of the van. S7 stated the client was redirectable after she threatened to call the police. S7 stated the drivers have asked what they should do when a client removed their seatbelt, but they were never given a direct answer. S7 stated she was familiar with the hospital's policies regarding transportation of clients and stated the policy did not include where clients were to sit, the number of staff that should accompany clients, or any directives on dealing with client behavior during transport. S7 stated all drivers have at some time been CPSI trained, but they are not required to be current in CPSI training. S7 stated the Nursing or the unit determined which staff accompanied patients on transport.


In a face-to-face interview on 12/10/12 at 9:50 a.m. Administrator S2 indicated the only action taken since the incident with Patient #3 was a memo to the Medical Staff from the Medical Director to ensure all trips were necessary, to ensure the Medical Staff was extra vigilant to make sure they were comfortable with all client trips, and to review any concerns with patients on trips. S2 confirmed there are no policies or procedures addressing the seating of clients during transport and stated there was an unwritten protocol followed by the drivers. S2 stated the drivers do not like clients to sit behind them. S2 stated the driver and the clinical staff determine where the patient sits. S2 indicated the only training for transporting clients would be in the CPSI training. S2 stated the driver would be responsible for driving and was not required to have CPSI training. S2 indicated verbal re-direction should be used if a client removed his/her seat belt and if safe the driver should pull over. S2 stated the staff should call 911 for any situation beyond their control, particularly a safety issue they cannot handle.


In a face-to-face interview on 12/10/12 at 10:12 a.m., S8 RN Instructor verified she was a CPSI instructor. S8 verified the van drivers do not receive CPSI training. S8 stated client transportation was not addressed in CPSI training, but stated it was taught in the "Basics" course the PA (Psychiatric Aide) and the BSS are taught when hired.


In a face-to-face interview on 12/10/12 at 11:00 a.m., S10 PA/BSS Instructor verified she taught the "Basics" course to PA and BSS staff. S10 stated the "Basics" was a 9 day course taught to all newly hired PA and BSS staff. S10 stated Day 5 of the "Basics" course covered elopement and restraint/seclusion. S10 stated she did not cover in the "Basics" class on what to do when clients act out while transporting. S10 indicated she was a Master Mentor Instructor for CPSI and stated she was a PA (Psychiatric Aide) prior to becoming an instructor.


In a face-to-face interview on 12/10/12 at 11:50am, RN Manager S16 indicated that she was covering for Nurse Manager of DNP S5 on 11/27/12. She further indicated that she was formerly working on the adult male unit prior to downsizing and closure of the unit. S16 indicated that Mobile Equipment Operator S3 called her to say that S3 was ready for the trip to pick up Patient #3 from home. She further indicated that she called the DNP Unit and spoke with BSS Supervisor S21 and asked whose turn it was to take a trip. She further indicated that she was told by S21 that it was BSS S4's turn, and she asked S21 to tell S4 to come to the front of the hospital to meet the driver. S16 indicated that BSS S4 passed by S16's office and asked where she was to meet the driver. She further indicated that BSS S4 never expressed discomfort with the assignment, and S16 never heard that S4 expressed discomfort to any other staff. S16 indicated that the process of escorting patients was covered in the basic PA orientation. She further indicated that when the BSS went to the unit after orientation, the BSS Supervisor paired them with another BSS for the first time for a trip. A request was made during this interview of the passes made by BSS S4 with evidence of the BSS who accompanied her. This information was not provided by the time the survey ended.


In a face-to-face interview on 12/10/12 at 12:10pm, BSS Supervisor S21 indicated that she received the phone call from RN Manager S16 requesting a driver to pick up Patient #3 from a home pass on 11/27/12. She further indicated that she went to the U side of the DNP Unit where BSS S4 was working. S21 indicated that she asked BSS Supervisor S14 who she wanted to send on the trip. She further indicated that she didn't remember if BSS S4 was on the DNP unit, in the hall, or in the classroom. She further indicated that BSS Supervisor S14 decided to send BSS S4 on the trip.


When S21 was asked who determines if a BSS was competent to be the BSS during transporting patients off grounds, S21 indicated that it was her understanding that once a BSS went through the education on the unit, he/she was competent to go on a trip. She further indicated that she couldn't make a decision of competence.


S21 indicated that escorting a patient on a trip was the most comfortable task for a new employee, because they "just ride and pick up". She indicated that if a staff member was not comfortable with escorting a patient, she would expect the staff member to say so. She further indicated that she didn't know if any discomfort had been voiced by BSS S4. S21 indicated that according to her knowledge, a BSS was not paired up to go on trips. When asked about the evaluation of competency of BSS staff, S21 indicated that there's usually a paper to check off for escorting done by the BSS Supervisor. She further indicated that the BSS Supervisor would be the one to determine competency of BSS/PA staff (even though she indicated earlier in the interview that she couldn't make a decision of competence for escorting).


In a face-to-face interview on 12/10/12 at 1:15pm, Nurse Manager of DNP S5 indicated that she had recently transferred to her present position when the adult unit had closed. She further indicated that on the adult unit if a staff member had never been on a transport before, they would send other staff with the BSS. She further indicated that "D-Observation" on the competency checklist may not mean that she observed the skill/task. S5 stated she coordinated with the BSS Supervisor. After reviewing the competency checklist for S4 BSS, S5 stated she may have observed S4 taking a client to a medical clinic appointment. S5 stated she did not know what kind of trips S4 had been on. S5 indicated that BSS S4 had been on transports before 11/27/12, and the BSS Supervisor followed the list of which BSS was next to go on a transport. She further indicated that the patient was never to be allowed to sit behind the driver and next to the door. When asked if the hospital had any documentation of transports made by BSS S4 and whether S4 had gone alone or was accompanied by other staff, S5 indicated that she would check and let the surveyor know. No additional documentation or an answer to the question was supplied by S5 by the end of the survey.


In a telephone interview on 12/10/12 at 1:45pm, RN S12 indicated that she was the charge nurse on the DNP Unit on 11/27/12. She further indicated that when the driver called to ask who was going with her to pick up Patient #3, S12 told the driver that she would have to call RN Manager S15.


S12 indicated that she was new to the DNP Unit and was assigned from Adult Services when the adult unit was closed. She further indicated that at the time of the call she was in the midst of giving medications. S12 indicated that had she not been busy, she would have looked at the trip cards to see which BSS was next in line to go on a transport, but she didn't know if trips cards were used on DNP or if the unit staff goes by memory.


Regarding assignment of staff, RN S12 indicated that on the adult unit it was determined by the PA Supervisor and on DNP it would be the BSS Supervisor unless an unusual circumstance existed with the patient. S12 indicated that she did not have specific training or orientation for DNP, but when she was hired she was required to go to all the wards during orientation. She further indicated that most of the policies and procedures were the same for the adult unit and DNP. When asked if being a psychiatric nurse qualified her to care for adult, child, and adolescent patients, S12 indicated "not necessarily". She further indicated

Based on records review and interviews, the hospital failed to set priorities for its performance improvement activities that focused on high-risk, high-volume, or problem-prone areas on the DNP (Developmental Psychiatric Program) Unit. The hospital did not include the transport of patients to off-ground appointments and home passes as a high-volume, high-risk, and problem-prone activity and did not identify opportunities for improvement that included ensuring that the policy and procedure for transporting patients included the staff to patient ratio during transport, the staff/patient seating arrangements during transport, and staff directives for handling patient behavior incidents that occur during transport of patients.


Findings:


Review of Patient #3's medical record revealed that during the transport from his home pass back to the hospital on 11/27/12, Patient #3 eloped from the van, crossed the highway, and was hit by oncoming vehicle traffic and subsequently died.


Review of the "Department PI (performance improvement) Monitoring Plan for FY (fiscal year) 11-12", submitted by Director of Nursing (DON) S1 on 12/10/12 at 4:45pm, revealed no documented evidence that the transport of patients to off-ground appointments and home passes had been included as an indicator that was tracked to identify opportunities for improvements of a high-volume, high-risk, problem-prone task encountered on the DNP Unit.


In a face-to-face interview on 12/10/12 at 3:05pm, DON S1 indicated that the hospital-wide QAPI (quality assessment and performance improvement) plan included indicators for medication errors, restraint/seclusion, treatment plans, and occurrences. She further indicated that the Nursing PI hospital-wide included quality indicators for pain management, infection control, hand hygiene, utilization of 2 patient identifiers for medication administration, restraint/seclusion documentation, and human resources including hiring, competency, staff ratios, staff assignments, and mandatory education. S1 indicated that they did not have transportation of patients to off-ground appointments and home passes as an indicator for tracking and identifying opportunities for improvement. She further indicated that transporting patients would be considered high-risk, high-volume, and problem-prone, since there were large volumes of transports done. S1 indicated that she had looked at the volume of trips related to staffing needs, but she had not compiled any data or done anything with the information that she reviewed.


Review of the "Performance Improvement Plan 2011-2012" submitted by DON S1 on 12/10/12 at 4:45pm revealed that data collected on key aspects of care related to the organization and client care functions included high risk, high volume, and problem prone processes. Further review revealed that the list of processes included management of high risk processes such as medication management, restraint/seclusion, behavior management, and resuscitation/Code Blue.

Based on observations, records review and interviews, the hospital failed to meet the requirements for the Condition of Participation for Special Staff Requirements for Psychiatric Hospitals as evidenced by:


1) Failing to ensure that there was a Registered Nurse (RN) on duty 24 hours each day on the DNP Unit (Developmental Neuropsychiatric Program) for 14 days of staffing reviewed from 11/18/12 through 12/01/12.


See findings in tag B0149.


2) Failing to ensure qualified, professional staff were employed on the Developmental Neuropsychiatric Program (DNP) Unit for adolescents as evidenced by:


a) failing to ensure the Registered Nurses (RN) had the orientation/training and verified competencies to care for the DNP adolescent patients for 3 of 3 RN staff of the DNP unit reviewed out of a total of 5 personnel records reviewed (S5, S12, S16), and


b) failing to ensure all nursing staff completed annual CPSI (Crisis Prevention and Supportive Intervention) annual training as required by hospital policy for 1 of 4 personnel records reviewed for staff required to have CPSI training from a total of 5 personnel records (S5).


See findings in tag B0137.

Based on record reviews and interviews, the hospital failed to ensure qualified, professional staff were employed on the Developmental Neuropsychiatric Program (DNP) Unit for adolescents as evidenced by:


1) failing to ensure the Registered Nurses (RN) had the orientation/training and verified competencies to care for the DNP adolescent patients for 3 of 3 RN staff of the DNP unit reviewed out of a total of 5 personnel records reviewed (S5, S12, S16) and


2) failing to ensure all nursing staff completed annual CPSI (Crisis Prevention and Supportive Intervention) annual training as required by hospital policy for 1 of 4 personnel records reviewed for staff required to have CPSI training from a total of 5 personnel records (S5).


Findings:


1) Failing to ensure the RNs had the orientation/training and verified competencies to care for the DNP adolescent patients:


On 12/03/12 at 10:35 a.m., S5RN introduced herself to the survey team as the Nurse Manager for the DNP Unit.


On 12/10/12 at 1:25 p.m., in a face-to-face interview, S5RN Nurse Manager for the DNP unit was asked how staff was assigned to accompany patients on off ground transports. S5RN indicated the procedure on the Adult Unit was they would ask if the PA (Psychiatric Aide) had been on a trip before and if they had not, they would send 2 PAs. S5 indicated she was not sure how the assignment was made on the DNP unit.


Review of the personnel record for S5RN revealed a date of hire of 12/11/06. Review of the Position Description and attached Organizational Chart dated 02/24/12 revealed S5RN was RN Supervisor of the Adult Male Unit. There was no documented evidence of any orientation to the DNP adolescent unit. There was no documented evidence when S5RN was transferred to the DNP unit.


In a face-to-face interview on 12/10/12 at 3:50 p.m., S13 Human Resources verified S5RN was the Supervisor on the Adult Intermediate Unit. S13 stated on 10/15/12 S5RN was transferred to the DNP unit as Nurse Manager when the Adult Intermediate Unit closed due to budget cuts. After review of the personnel record, S13 stated the transfer to DNP happened quickly and there was no documentation of any orientation to the DNP unit for S5RN.



On 12/03/12 at 10:35 a.m., S12RN introduced herself to the survey team as the RN Charge Nurse for the DNP adolescent unit.


Review of the personnel record for S12RN revealed a date of hire of 04/25/11. Review of the Position Description and attached Organizational Chart dated 03/19/12 revealed S5RN was a Registered Nurse 3 on the Adult Male Unit. Review of the Age Related Competency Evaluation dated 05/12/11 revealed the competency evaluation was only for the adult age group. The Adolescent and Child competencies were not assessed. There was no documented evidence of any orientation to the DNP adolescent unit. There was no documented evidence when S12RN was transferred to the DNP unit.


In a telephone interview on 12/10/12 at 1:45pm, RN S12 indicated that she was the charge nurse on the DNP Unit on 11/27/12. S12 indicated that she did not have specific training or orientation for DNP, but when she was hired she was required to go to all the wards during orientation. She further indicated that most of the policies and procedures were the same for the adult unit and DNP. When asked if being a psychiatric nurse qualified her to care for adult, child, and adolescent patients, S12 indicated "not necessarily". She further indicated that anyone should be able to work anywhere, but she thought that she "could have used a little more orientation, but with people flying out of there, you do what you need to do".


In a face-to-face interview on 12/10/12 at 3:50 p.m., S13 Human Resources verified S12RN was the Supervisor on the Adult Intermediate Unit. S13 stated on 11/05/12 S12RN was transferred to the DNP unit as an RN Charge Nurse when the Adult Intermediate Unit closed due to budget cuts. After review of the personnel record, S13 verified there was no documented evidence of any orientation to the DNP unit for S12RN, and her competency evaluation only included the adult age group.



In a face-to-face interview on 12/10/12 at 2:55 p.m., S16RN stated she was the RN Manager over the Adult Intermediate Male Unit until that unit closed. S12 stated she was moved to a float position for the House Managers on 10/30/12. S16RN confirmed she had filled in as the DNP Nurse Manager the week of 11/26/12 and was the Nurse Manger on duty on 11/27/12 when Patient #3 eloped from the hospital van during transport. S16 stated she had not received any orientation to the DNP unit but had worked at the hospital for 15 years. S16 stated she was told she was responsible for payroll and scheduling, but, "didn't have to worry about the program."


Review of the personnel record for S16RN revealed a date of hire of 06/22/98. There was no documented evidence of any orientation or competency evaluation for the DNP unit.


Review of the Competency Plan approved 05/03/10, and provided as current by S13 Human Resources revealed in part the following:


Purpose: To establish standards for assessing the competency of individuals employed by, or providing services to, Southeast Louisiana Hospital....


B. The hospital provides an adequate number of staff members whose qualifications are consistent with job responsibilities...


The Developmental Neuropsychiatry Program (DNP) serves adolescents with a psychiatric diagnosis and a co-occurring developmental or learning disability. This is a highly structured program utilizing complex behavior management plans to modify behavior. Therefore, there is a higher ratio of psychologist to client while the social worker to client ratio is reduced as the average length of stay ranges between 12 and 18 months. The nursing services ratio is similar to that of an acute unit due to high levels of acuity among this population...


C. An orientation process provides initial job training and information and assesses the staff's ability to fulfill specified responsibilities...Department Orientation - completed within two weeks of employment. It provides specific orientation to the assigned unit and departmental policies and procedures, to include a discussion of the position requirements, expectations, and management of information, infection control, and Performance Improvement/Quality Management. Mandatory Training - Nurse Orientation, Clinical Orientation...


D. The hospital leadership ensures that competence of all staff members is assessed, maintained, demonstrated, and improved continually...


3. Requirements...


A. Age-related competency - All clinical staff, including program managers, must demonstrate knowledge and skills necessary to perform duties for the client population assigned...


C. Clinical Orientation Checklist - This is an orientation checklist to be completed within the first 30 days of hire, promotion, or reassignment to another clinical program or department.


Review of the hospital policy titled, Orientation Checklist, Policy #HR-1301, revised 04/23/09, and provided as current policy by S13 Human Resources, revealed in part the following:


It is the policy of Southeast Louisiana Hospital that a ....Clinical Orientation Checklist be completed for all new or reassigned clinical employees. Clinical Orientation Checklist: 2. The form is to be completed within two weeks after the employee has attended the Clinical Orientation Class or two weeks after being reassigned.


2) Failing to ensure all nursing staff completed annual CPSI annual training as required by hospital policy:



On 12/03/12 at 10:35 a.m., S5RN introduced herself to the survey team as the Nurse Manager for the DNP Unit.


Review of the personnel record for S5RN revealed a date of hire of 12/11/06. Review of the Staff Education and Training form dated 12/10/12 for S5RN revealed the most recent CPSI training was done was 10/24/11.


In a face-to-face interview on 12/10/12 at 3:50 p.m., S13 Human Resources verified S5RN had not taken CPSI training since 10/24/11. S22 verified S5RN was the Nurse Manager for the DNP unit. S13 stated CPSI training was required annually and should have been done in the employee's birth month. S13 stated S5RN should have taken the CPSI training in August 2012 and confirmed the training was over 3 months past due.


Review of the hospital policy titled, Education Courses, Policy # PF-0300, revised 06/20/12, and provided as current by S13 Human Resources, revealed in part the following:


4. Crisis Prevention and Supportive Intervention - A sixteen (16) hour course mandatory for all Direct Care clinical and security staff. Courses content includes therapeutic communication, de-escalation skills, restraint and seclusion, object recovery, and lateral violence. Skills competency is required of all staff. Post testing is required.


5. A CPSI Refresher Course is required yearly for all Direct Care clinical staff and security. Clinical staff are required to view the CPSI Power Point presentation.

Based on observations, records review and interviews, the hospital failed to ensure that there was a Registered Nurse (RN) on duty 24 hours each day on the DNP Unit (Developmental Neuropsychiatric Program) for 14 days of staffing reviewed from 11/18/12 through 12/01/12.


Findings:


Observation of the U Ward of the DNP Unit on 12/03/12 at 10:35 am with Nurse Manager of DNP S5 present revealed that Unit U had 2 nursing units with a nursing station and patient rooms in each unit. Further observation revealed that the 2 units were separated by 3 locked doors, the middle door leading into the medication room with a locked door that opened to each nursing station. Further observation revealed a locked door to each side of the medication room door that opened into each unit.


Review of the staffing pattern documented and submitted by Director of Nursing (DON) S1 for 11/18/12 through 12/01/12 revealed less than 1 RN was on the U Ward of the DNP Unit on the evening shift of 11/20/12 and 11/24/12, on the day shifts of 11/22/12, 11/23/12, and 11/24/12, and on the night shift of 11/24/12.


In a face-to-face interview on 12/10/12 at 3:05pm, Director of Nursing (DON) S1 indicated that staffing on the U Ward of DNP was 1:3 (one staff for 3 patients) on days and 1:4 on nights. She further indicated that she was familiar with the state licensing regulations, but she did not view the separation of the 2 sides of the unit as each having a nursing station.


S1 confirmed that she did not staff a RN to be assigned to each nursing station on the U Ward or the V Ward that was structured the same as the U Ward and a part of the DNP Unit. The V Ward was located across the hall from the U Ward but was not observed during the survey.


She also confirmed that she did not have 1 RN on 4 of the 7 days of the week of 11/18/12. S1 indicated that she had 1 RN who covered both Units U and V because of the proximity of the 2 units (across the hall from each other separated by locked doors). She further indicated that the reason for sharing the RNs was due to lay offs, closing of the adult unit, staff resignations, and the inability to obtain flex pool or agency coverage. S1 indicated that although the staffing ratio for the unit was met, there was no RN directly supervising the unit, and she was not aware of the occurrence.


Review of the hospital policy titled "Nursing Staffing Plan", policy number NS.1005, revised 09/12, and submitted as the current policy by DON S1 on 12/10/12 at 3:10pm revealed the following:


1. Staffing ratios are established to determine the required number of staff for each shift on each unit based on the population served (age, gender mix, diagnoses), level of care (acute, intermediate, long term), and the geographic's of the unit (distance between units, location of the nurse's station, and visibility of the patient care areas). The staffing ratio included RN, LPN (licensed practical nurse), and PA (psychiatric aide)/BSS (behavior shaping specialist) positions.


2. Basic coverage included RN, LPN, PA-BSS. The RN counted as a staff nurse on the unit or 0.5 per unit as a supervisor; only as a last resort would the charge nurse be included in the ration when required to give medications on the day shift.


3. A RN must be assigned supervision of each unit; assignment of a 0.5 RN on the U and V Wards (weekends, holidays, nights) required DON/ADON (assistant director of nursing) approval.


4. Acuity factors that required adjusted staffing included off ground trips, precautions (suicide precautions, elopement precautions, visual contact, and 1:1), and a medically ill client with hospital admission requiring supervision and returning from the hospital admission or treatment.


Review of the hospital policy titled "Staff Assignments", policy number NS 1065, revised 05/12, and submitted as the current policy by DON S1 on 12/10/12 at 3:10pm revealed the following:


1. The RN assumed hospital and legal responsibility for the delegation of duties and the supervision of the delivery of nursing care while on duty.


2. The RN was responsible for the appropriateness, completeness, and accuracy of the assignment sheet.


3. The PA/BSS Supervisor initiated the assignment sheet, however, the RN Charge Nurse must review the assignments for completeness and appropriateness and sign as approving the delegation of the functions as noted.