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Based on observation and interview, the hospital failed to ensure patients requiring acute inpatient psychiatric care received care in a safe setting. This deficient practice was evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety by having an unlocked supply room accessible to patients.
Findings:

Observation on 04/09/2024 at 9:19 a.m. revealed patients ambulating in the hallway where the supply room located. Observation revealed the door to the supply room not locked and staff not present in the room. Further observation of supplies in the room revealed, in part, germicidal disposable wipes, wound cleansers, needles, oxygen tubing, and syringes along with other various patient care supplies.

In an interview on 04/09/2024 at 9:22 a.m., S2DON confirmed the supply room should be locked at all times when staff not present to ensure patient safety.

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by failing to ensure capillary blood glucose levels were obtained for 1 (#3) of 3 sampled patients with a diagnosis of diabetes mellitus.
Findings:

Review of the hospital Glucometer Method for Obtaining CBGs policy, revised date: 07/01/2022 revealed, in part:
Purpose: To establish procedural guidelines for obtaining capillary blood glucose levels (CBG's) for the purpose of diagnosis and treatment.
Policy: CBG's will be performed with physician orders by licensed nursing staff and mental health tech (MHTs) who are deemed competent to perform the procedure.

Review of Patient #3's medical record revealed an admit date of 04/02/2024.

Review of Patient #3's History & Physical Examination dated 04/03/2024 revealed, in part:
Past Medical History: Diabetes.
Assessment & Plan. 6. Diabetes Mellitus: Cardiac/ADA diet. Januvia 50 mg (used to treat type 2 diabetes) every day. Insulin Sliding Scale with coverage per protocol.

Review of Patient #3's medical record revealed no physician orders or plan for obtaining CBGs. Further review revealed Patient #3 had CBGs obtained twice on 04/03/2024. There were no other CBGs documented.

In an interview on 04/08/2024 at 3:03 p.m., S2DON confirmed Patient #3 did not have physician orders or plan for obtaining CBGs. S2DON confirmed a RN should have contacted the physician to clarify the plan for diabetes treatment and obtain orders for CBGs.

In an interview on 04/09/2024 at 8:57 a.m., S2DON confirmed Patient #3's physician was contacted regarding the plan for diabetes treatment. S2DON confirmed Patient #3's physician ordered CBGs before meals and bedtime starting 04/09/2024.

Based on record review and interview, the hospital failed to ensure the nursing staff developed an individualized nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs. This deficient practice was evidenced by the failure to develop a care plan to address diabetes mellitus for 1 (#3) of 3 sampled patients with a diagnosis of diabetes mellitus.
Findings:

Review of Patient #3's medical record revealed an admit date of 04/02/2024.

Review of Patient #3's History & Physical Examination dated 04/03/2024 revealed, in part:
Past Medical History: Diabetes.
Assessment & Plan. 6. Diabetes Mellitus: Cardiac/ADA diet. Januvia 50 mg (used to treat type 2 diabetes) every day. Insulin Sliding Scale with coverage per protocol.

Review of Patient #3's medical record revealed no documented evidence a nursing care plan had been developed to include diabetes mellitus or treatment interventions.

In an interview on 04/09/2024 at 9:58 a.m., S2DON confirmed Patient #3 did not have nursing care plan developed for diabetes mellitus.