HospitalInspections.org

Based on record review, observation and interview it was determined that the hospital failed to protect patients' rights. This deficiency has the potential to affect all patients served by this hospital.

Findings include:

The hospital failed to ensure that patients were monitored and kept safe from contraband medications. (See Tag A-144)

The cumulative effect of these systemic patient rights problems has the potential to lead to unsafe procedures and an unsafe environment.

Based on record review, observation and interview the hospital failed to ensure the safety of patients in 5 of 5 areas (3 Adult units and 2 Child/Adolescent units), in 1 of 1 body check reviewed and in 1 of 1 security checks reviewed. This deficiency has the potential to affect all patients served by the hospital.

Findings include:

Facility policy entitled; "Patient (pt.) Belongings and Searches" dated March 2012 was reviewed on 05/12/2015 at 11:00 AM, it states under procedure; "Document all contraband found and the disposition of such."

Pt. #1 was admitted on 01/21/2015 with a diagnosis of chronic depression and anxiety per record review on 05/11/15 at 12:30 PM. Pt. #1 was found on the afternoon of 01/22/15 in bed. According to nursing notes on 01/22/15 at 2:57 PM; "pt in bed lethargic, search done of pt. room, travel jar full of yellow rock substance found in night stand in pt. room, search done of pt. clothing syringe and tourniquet found in pt. scrub pocket, pt also had bag full of multiple pills in bra. security called. pt bag full of pills contained xanax and unknown white pills."

A "Belongings Inventory" in pt. #1's medical record (MR) was found to be completed but was lacking a staff signature with date and time. The inventory documented that medications had been secured in the medication drawer but did not indicate which med's they were.

The facility policy entitled; "Patient Checks (Unit Checks) dated 03/15 was reviewed on 05/12/15 at 3:30 PM, it stated; ......"Values of Respect and Integrity require us to ensure knowledge of the location and safety of patients on a 24-hour basis."...."Associates are assigned to do patient checks" on "Adult Inpatient Every 30 minutes".

Pt. #3's MR was reviewed on 05/11/15 at 2:00 PM, nursing notes from 02/03/15 at 10:17 PM stated: "Pt. was in room rest when staff did rounds, when staff did next set of rounds, pt. was no where to be found. staff found pt. in the ceiling. he had removed tile and was crawling around trying to 'escape' 'They are trying to kill me, I need to get out of here' staff was able to convince pt to come down from the ceiling. Md notified. order obtained for 1:1 for patient safety."

According to documentation reviewed on 05/11/15 at 2:00 PM pt. #6 eloped from an adult inpatient treatment unit. The hospital performed a root cause analysis (RCA) which revealed that staff were unaware of pt. #6's absence between the hours of 12:13 PM and 3:00 PM on 03/02/2015. At the time of this discovery it was determined that pt. #6 had been taken home by a spouse. The RCA revealed that staff had not properly identified pt. #6 during security rounds mistaking another pt. for pt. #6.

During a tour of 5 pt. care units (3 Adult and 2 Child/Adolescent) on 05/11/15 at 2:30 PM with VP I the layout of the units was observed. The location of all the nursing stations did not allow for direct visualization of hallways by staff.

Based on, observation, interviews and record reviews, the nursing service failed to show nursing organization, authority and oversight for 1 of 6 off site locations (mental health unit). (See A 386 and A 144) In 1 of 1 staffing policy, acuity was not defined, and inconsistently applied when determining staffing requirements, and 22 of 22 days (12/21/14 - 1/3/15 and 03/29/15 - 04/05/15) of staffing schedules reviewed, staffing patterns were below minimum staffing levels. Five (5) of 5 staff (A, E, P K and M) admitted to knowing about, or being involved in falsifying nursing safety rounding sheets, related to being short staffed. (See A 392)
The cumulative effects of the systematic nursing issues, prevented the hospital from having an organized nursing service responsible for all nursing services, including offsite locations under their hospital's authority.

Based on observation, interview and record review, the nursing service failed to have an organized nursing staff with authority and oversight for 1 of 6 off site locations (mental health unit).
Findings include:
On 05/12/15 at 9:15 AM during an interview about Pt #6's elopement, RN (Registered Nurse) P stated P #6, was able to leave the unit because of multiple practice breakdowns. RN P state P left the unit with Pt #6 hanging out near the locked door and did not check the door to ensure it was locked after exiting. RN P stated these actions did not follow unit policies. Patients are not to hang out near the locked doors. Safety rounding did not see Pt #6 in a location prohibited to patient. Nursing staff logged #6 as safe and in the facility for about 3 hours after #6 eloped.
RN P was asked about knowledge of sexual assaults on any of the mental health units. RN P stated sexual assaults happens a lot at night. The Psychiatric Intensive Care (PIC) unit does accept known sexual offenders. RN P acknowledged nursing administration is aware the sexual assault issues, incident reports are filed.
On 05/12/15 between 9:33 AM -11:05 AM during an interview Director of Medical Services (DMS) K stated there are many areas in the facility that nursing staff cannot visualize from the nursing unit. DMS K stated the nurses "huddle" at the nursing station and do not go out on the floor.
DMS K stated "search" procedures are lax, and nursing policy is not followed.
Incident #1 provided by DMS K, nursing staff have been conducting one-person searches, the policy requires 2-person search, and at least one of the nursing staff must be of the same sex as the patient being searched. Nursing notes from 01/21/15 at 2:57 PM and documentation for Pt. #1 related to this incident supported this interview.
Incident #2 provided by DMS K, all patients admitted to the locked psychiatric unit are to remove all their clothes, for a physical assessment and search for contraband. DMS K stated that a Pt. #1 was not searched per P&P, and brought in a drug assumed to be heroin, and other pills, needles, and a tourniquet. Pt.#1 was using the drugs on the unit. 01/21/15 at 2:57 PM nursing notes and documentation for Pt. #1 related to this incident supported this interview.
Incident #3 on the child/adolescent unit a Pt. # 3 was able to remove a ceiling tile, at the end of a hallway near a window, crawled up into the ceiling, and hid without staff seeing or hearing the incident. Nursing notes dated 02/03/15 at 10:17 AM supported this interview.
Incident #4 a patient (#6) eloped from our locked unit and never came back, and staff were still marking the patient in the unit after the patient eloped. A review of the incident and hospitals investigation identified Pt. #6 eloped and on 3/2/15 between 12:13 PM and 3:00 PM staff conducting rounding incorrectly identify Pt #6, for 2 hours and 57 minutes.
DMS K confirmed the nursing staff lacks clear direction and support.
When asked about patient sexual assaults and sexual misconduct, DMS K stated "I won't lie and say it doesn't happen", but the unit set up doesn't help. There are blind spots, no cameras except by the locked exit, and with staff huddling in the nursing station, not all areas can be seen. Look at the end of B hall. You have to physically walk down there to see into the rooms and visualize the end of the hall.
On 05/12/15 at 8:35 AM a tour, with Clinical Therapy N, confirmed without staff walking down the hall of patient rooms on Unit B, staff could not visualize rooms or observe what happens at the end of the hall.
Nursing staff Q, O, P M and S were asked, "Who is the overall Director of Nursing (DON) responsible for nursing service?"
On 05/12/15 at 11:16 AM during an interview RN Q stated, we have no current manager, so I guess, VP of Operation I, or a supervisor.
On 05/12/15 at 11:17 AM, during an interview behavioral health associate (BHA) O stated, we have no manager and no director, so BHA O would refer to VP of Operation I.
On 05/12/15 at 11:17 AM, during an interview RN P stated, we have no director of nursing, I guess supervisor M or VP of Operation I.
On 05/12/15 at 11:57 AM, during an interview Supervisor M stated, nursing services has no manager or director for the service. Supervisor M stated, currently VP of Operation I is the "interim everything".
Supervisor M stated that the expectation is that when staff round, they walk through the halls.
Review of Patient Checks (Unit Checks) Policy, Effective Date: March 2012, date of last revision 3/15 related to unit elopements, does not address the steps staff should take to identify patients to ensure the correct patient is documented on during safety rounds, or the hospital expectation for how to conduct safety rounds.
On 05/12/15 at 12:27 PM, RN S stated, "I think" Chief Nursing Office T is the one at the main campus, but we have never seen T. Maybe the VP of Service (I) is functioning as the DON. RN S stated, it has been a revolving door with managers and director here (offsite mental health unit).
When RN S was asked about the patients that are known sexual offenders, RN S stated those patients would go to the PIC unit. RN S stated that nursing staff is not always provided the patient history and then known sexual offenders are placed on the open units with 30 minute checks, instead of the 1:1 or 15 minute checks.
The facility did not have a policy on unit placement for known sexual predators. On 05/12/15 at 3:30 PM, an internal binder was identified and copied, that listed Pt. #8 under the tab "seek alternative placement".
On 05/12/15 at 2:50 PM during a telephone interview with Anonymous staff E stated, E wants to feel safe, and have it safer for the patients. E stated difficult to handle adolescents are sometime sent to the adult PIC unit. E stated this is where the violent offenders and sexual predators are treated. E stated, on numerous occasions E has taken these concerns to the unit supervisor and managers, without any changes.
As a part of the complaint, a rape incident was reviewed during this survey. The history noted in 2012 Pt #8 was found Not Guilty by Reason of Insanity (NGRI) from charges of a 2nd degree sexual assault. Pt #8 was admitted on 03/09/14 to open behavior unit and placed on standard 30 minute checks, on 03/11/14 Pt. #8 sexually assaulted Pt. #4.
The facility did not have a policy on unit placement for known sexual predators. On 05/12/15 at 3:30 PM, an internal binder was identified and copied, that listed Pt. #8 under the tab "seek alternative placement". The binder was hand written and no date of entry was documented.
On 05/12/15 at 1:57 PM during a telephone interview Chief Nursing Office (CNO) T, when asked if CNO T, knew what was happening at this mental health off site location or if CNO T had been to this off site location to see what is going on? CNO stated, "no", the mental health program "service line" reports through quality council annually. CNO T stated T's responsibility along with VP Chief Operating Officer (COO) G is to provide resources, labor, performance, benchmarks and safe staffing.
CNO T stated VP of Operations (I) was the director of nursing for the mental health unit.
When asked if annual oversight of this mental health off site service was enough?, CNO T stated the Executive Team meets weekly, to look at operational issues, but does not look at all services, but some services are looked at. There are safety committees, environmental rounds and regulatory rounds.
A request was made for Executive Team meeting minutes, or any leadership meeting minutes, along with any of the safety, regulatory or environmental rounds for the past year that would identify issues unique to this off site mental health unit, be brought for review.
Concerns shared with CNO T, that nursing unit staff and supervisors at this offsite mental health location did not understand, or know the line of nursing authority, and could not identify their overall nursing director responsible for all nursing services and that there was no communication between this off site mental health unit and the main hospital campus services.
On 05/12/15 at 2:25 PM during an interview, VP of Operations I stated, the VP of Operations is responsible for the day-to-day operations of the mental health unit.
A review of two current organizational charts for nursing services were provided and reviewed with VP of Operations I. The organization chart for WF titled "CNO matrix" revised 4/17/15, shows Chief Nursing Office T as the head of nursing services.
There was no nurse authority on the CNO matrix, between CNO T and 6 off site services (Inpatient Rehab, Cancer Center, Lakeshore Manor, Mental Health Services Adult Inpatient, Mental Health Service Child/Adolescent, and WF Clinics). This was noted with a dash line between Chief Nursing Office T and 6 offsite services (Inpatient Rehab, Cancer Center, Lakeshore Manor, Mental Health Services Adult Inpatient, Mental Health Service Child/Adolescent, and WF Clinics).
A second organization chart presented by VP of Operations I and reviewed, was specific the mental health unit. The chart was titled "Mental Health Organization Chart" and not dated. VP of Operations I, stated the title "Administrative Director" on this authority flow chart, is their hospitals title for the unit specific unit RN director. The "Administrative Director" position is currently vacant. The VP of Operations stated, currently director of nursing position for the offsite mental health unit is vacant.
When asked, are you the Director of Nurses, VP or Operations I, stated, "as of today, I guess I am".
On 05/12/15 at 3:00 PM VP of Operations I provided the following documents on behalf of Chief Nursing Officer T, to show the nursing authority and oversight to this offsite mental health unit. The documents were reviewed with VP of Operations I and Director of Quality U:
"Medical Executive Committee" meeting minutes were provided and reviewed with VP of Operations I and Director of Quality U, for the following period: July 16-2014 - August 19, 2014, September 17, 2014 - October 21, 2014, January 21, 2015 - February 17, 2015. No meeting minutes were provided for Nov-Dec 2014, "Medical Executive" meeting minutes for the January - February 2015 stated, the "search policy" was discussed and sent to physicians for review and feedback.
The December 3, 2014 "Operating Council" meeting minutes were provided and reviewed with VP of Operations I and Director of Quality U, no information was identified specific to this offsite mental health unit.
The February 4, 2015 "Management Council" were provided and reviewed with VP of Operations I and Director of Quality U noted a policy update for "Utilization of a Companion Providing Direct 1:1 Observation for the Non-Suicidal Patient."
November 11, 2014 "Nursing Practice Council" meeting minutes were provided and reviewed with VP of Operations I and Director of Quality U, noting behavior health personnel attended.
A Joint Commission (TJC) tool dated 12/02/2014 based on (TJC) survey was provided, that included two areas for monitoring behavioral health; patient suicide, and patient assessments, but no data collection or monitoring provided.
Director of Quality U stated, U understood the off site locations were disconnected from the main campus hospital. Director of Quality U stated, U sees this same issue with the off site clinics billed under the hospital number.
VP of Operations I stated the flow of nursing authority and oversight to this mental health unit is confusing.

Based on interview and record review, the nursing service failed to define acuity or minimum staffing in 1 of 1 nurse staffing policy and procedure, inconsistent staffing patterns were present for 22 of 22 days reviewed (12/21/14 - 01/03/15 and 03/29/15 - 04/05/15). This deficiency has the potential to affect all patients served by the hospital.

Findings include:
On 05/12/15 at 8:25 AM, VP of Operations I in an interview and review of Policy, titled: "Staff Plan-Nursing", effective date March 2012, last revised 6/14.
I. "Child/Adolescent Inpatient/Partial and Outpatient Programs"
A. 2. " Days, PM and NOC: 1 RN & 1 Support Associate "
A. 3. "Daily staffing decisions are based upon acuity of the patients, the ratio for children and adolescent patients, the census and the admitting and discharge activities that are occurring".
II. "Adult Inpatient and Outpatient Programs"
A. 2. Day, PM, NOC: 1 RN & 1 Support Associate
A. 3. "Daily staffing decisions are based upon acuity of the patients, the census of the service, the ration of the patients in intensive treatment unit vs. the step-down unit, the census and the admitting and discharge activities that are occurring."
During the interview VP of Operations I stated, acuity was not defined in policy and the hospital had no matrix for consistent application when determining staffing patterns.
VP of Operations I acknowledged the policy for minimum staffing patterns did not address patient census.
When asked what "acuity" meant, VP of Operations I stated, "Admissions, Alcohol scales and medical concerns".
VP of Operation I said it is left up to the nursing supervisor on that shift to make acuity judgments.
On 05/12/15 between 9:33 AM and 10:30 AM, when asked what acuity meant, when determining staffing levels, Director of Medical Services (DMS) K, asked "what type of acuity medical and psychiatric?" DMS K stated, this is a behavior health unit, but we accept patients with medical conditions.
DMS K, stated there are no acuity matrix to guide supervisor for consistent application, right now the supervisors rely on the staff nurses, and staff nurse base acuity of workload, not patient specific acuity, such as, aggressive behaviors, medical needs, sexual inappropriateness or clinical withdrawals.
On 04/30/15 at 12:30 PM during a telephone interview, Anonymous A stated nursing staff and supervisors were falsifying patient safety rounding sheets, and this was an accepted practice on this unit. Anonymous A stated, A tried to address the record falsification with nursing supervisor and management without change.
On 05/12/15 at 9:15 AM RN P admitted the patient safety rounding documents were filled in by unit staff including RN P and observed firsthand unit staff or supervisors documenting work they had not completed by filling in the safety rounding sheets because of being short staffed.
RN P stated, RN Supervisor V (terminated from hospital employment) gave nursing staff directive to complete safety rounds even if nursing staff were shorthanded and could not complete the work. RN Supervisor V was terminated and could not be interviewed to support or refute the statement.
RN P stated it was going on so long, it was the expectation and unit culture, "to make it look good".
On 05/12/15 at 12:27 PM RN S admitted the patient safety rounding documents were filled in by unit staff including RN S and observed firsthand other unit staff documenting work they had not completed by filling in the safety rounding sheets because of being short staffed. RN S stated it was going on so long, it was the expectation and unit culture.
On 05/12/15 at 2:50 PM during a telephone interview Anonymous E admitted the patient safety rounding documents were filled in by unit staff including RN P and observed firsthand unit staff or supervisors documenting work they had not completed by filling in the safety rounding sheets because of being short staffed.
Anonymous E stated it was going on so long, it was the expectation and a part of the unit culture.
Anonymous E stated E was on the unit and observed firsthand Supervisor M fill in safety check sheets that were incomplete.
On 05/12/15 at 11:57 AM, RN Supervisor M stated I (M) did not fill in the safety rounds, and stated, I (M) "told them no, don't chart what you don't do." RN Supervisor acknowledged as the supervisor, M was aware of the practice.
Supervisor M stated determining a patient's acuity is up to each supervisor.
On 05/12/15 at 2:00, VP of Operations I denied knowledge of safety round records being falsified, or that it was the unit culture to falsify records.
On 05/12/15 between 3:45 PM and 4:15 PM Resource Management Assistant and Staffing Scheduler W provided and reviewed two staffing models (adults and child/adolescent) used for staffing schedulers to us. The two staffing models are not a part of the policy. Also reviewed were time off logs, and staffing logs for December 21, 2014 through January 3, 2015 and March 29 through April 5 2015 (22 days total).
On 12/21/14 on the evening shift based on the "staffing model", the evening shift (PM) was 1 staff under minimum on the adult unit and 1 staff under minimum for the second half of the PM shift on the child/adolescent unit.
On 12/22/14 on the evening shift based on the staffing model, the PM shift was 1 staff under minimum on the adult unit and 1 staff under minimum for the second half of the shift. On the child/adolescent unit, the PM shift was down ½ staff the entire shift.
On 12/23/14, the child/adolescent unit-staffing log shows two staff (1 RN and 1 LPN) on the night shift. Reviewing the time off log, on this date the RN is listed as "off". Leaving the night shift of 8 child/adolescent patients on that unit, 1 under minimum and without an RN on the unit.
On 12/24/14, the child/adolescent unit was 1 staff under minimum for the first half of the PM shift.
On 12/29/14 the adult unit was 1 staff below minimum for the first half of the PM shift.
On 03/29/15, the child/adolescent unit was 1 staff below minimum on the second half of the PM shift.
On 03/30/15, the child/adolescent unit was 1 staff below minimum on the second half of the PM shift.
On 04/03/15, the child/adolescent unit was 2 staff below minimum on the first half of the PM shift, and 1 staff below minimum on the second half of the PM shift.
For dates 12/25, 12/26, 12/27, 12/30, 12/31 2014 and 3/30, 3/31, 4/1, 4/2, 4/3, 4/4 and 4/5 2015 the census is below 22, the staffing model for the adult unit provides guidance for patient census of 22-54.
On 05/12/15 between 3:45 PM and 4:15 PM, in an interview about how to determine the staffing for levels below 22, Staffing Scheduler W stated, they would staff minimum and leave it up to the supervisor on duty, if they needed extra staff.
Staffing logs for both the adult and child/adolescent unit failed to include the census for all three shifts 1/1/2015 through 1/3/2015. No census for all three shifts between the dates of 1/1/2015 through 1/3/2015 was provided as of 4:30 PM, 5/13/15.
On 05/12/15 at 4:30 PM, in a review of staffing findings with VP of Operations I, without a clear definition of what acuity levels the mental health unit uses, and no consistent definition of patient acuity, Staffing Scheduler W used the two "staffing models" for the adult and adolescent unit, used by the staffing schedulers:
12 of the 22 days (12/25, 12/26, 12/27, 12/30, 12/31 2014 and 3/30, 3/31, 4/1, 4/2, 4/3, 4/4 and 4/5 2015) went below the staffing model census guidelines. No determination could be made if the staffing met policy, because the model did not provide guidance for the census levels below 22, and the policy does not define minimum or acuity.
Three (3) of 11 days (1/1/2015 through 1/3/2015) did not have a census available to make a determination.
The remaining 8 days (12/21, 12/22, 12/23, 12/24, 12/29/2014 and 3/29, 3/30 and 4/3/2015) had below minimum requirements 8 of 8 days with 7 of the 8 days (12/21, 12/22, 12/24, 12/29/2014 and 3/29, 3/30 and 4/3/2015) being the PM shift.