HospitalInspections.org

Based on observations and interviews, the hospital failed to ensure that patients hospitalized on the acute care psychiatric unit received care in a safe and therapeutic setting by:

1. Failing to ensure that rolls of toilet paper were available and appropriately stored in the patient bathrooms in order to prevent contamination of patients who use the toilet paper as evidenced by the rolls of toilet paper being on the bathroom floor. Findings:
Observations were made on the North Wing (10 bed adolescent psychiatric unit) in the presence of the Director of Quality on 1/11/10 between 11:00 a.m. and 11:45 a.m. These observations revealed the following:
? Patient Room #148- Toilet paper roll dispenser was not functional and the only roll of toilet paper in this bathroom was a full roll of toilet paper that was noted to be placed on the floor.
Observations were made on the West Wing (24 bed adult psychiatric unit) in the presence of the Director of Quality on 1/11/10 between 11:45 a.m. and 12:10 p.m. These observations revealed the following:
? Patient Room #234- Toilet paper roll dispenser was not functional and the only roll of toilet paper in this bathroom was a partial roll of toilet paper that was noted to be placed on the floor.
Observations were made on the East Wing (22 bed adult psychiatric unit) on 1/11/10 between 2:15 p.m. and 2:30 p.m. These observations revealed the following:
? Patient Room #254- Toilet paper roll dispenser was not functional and the only rolls of toilet paper in this bathroom were two (2) rolls of toilet paper that were noted to be placed on the floor.
? Patient Room #262- Toilet paper roll dispenser was not functional and a partial roll of toilet paper was noted to be placed on the floor.
The Director of Quality confirmed the above findings at the time of the observations.

2. Failing to ensure that patients did not have access to shower cords and/or restraint straps. Findings:
Observations were made on the East Wing (22 bed adult psychiatric unit) on 1/11/10 between 2:15 p.m. and 2:30 p.m. These observations revealed the following:
? Seclusion Room- Noted to be unlocked and unsecured with a 4 foot shower cord hanging in the bathroom and 4 restraint straps each measuring approximately 3 foot in length on the floor next to the bed in the seclusion restraint room. This finding was confirmed by S5 (LPN) who was present during this observation. S5 reported that the seclusion room should have been locked.

3. Failing to ensure that the windows were maintained in a manner to ensure the safety of patients. Findings:
Observations were made on the West Wing (24 bed adult psychiatric unit) in the presence of the Director of Quality on 1/11/10 between 11:45 a.m. and 12:10 p.m. These observations revealed the following:
? Patient Room #218- Window frame loose with metal stripping noted to be unsecured with jagged and sharp metal edges.
? Patient Room #222- Window frame loose with metal stripping noted to be unsecured with jagged and sharp metal edges.
Observations were made on the East Wing (22 bed adult psychiatric unit) on 1/11/10 between 2:15 p.m. and 2:30 p.m. These observations revealed the following:
? Patient Room #252- Window frame loose with metal stripping noted to be unsecured with jagged and sharp metal edges.
The Director of Quality confirmed the above findings at the time of the observations.

4. Failing to ensure that the environment of care was free of graffiti including phone numbers, inappropriate phrases and curse words. Findings:
Observations were made on the North Wing (10 bed adolescent psychiatric unit) in the presence of the Director of Quality on 1/11/10 between 11:00 a.m. and 11:45 a.m. These observations revealed the following:
? Patient Room #142- Graffiti including phrases like "Don't take the medicine" and "Run before they catch you" were written with a pen and/or marker on the standing closet in this room.
? Patient Room #144- Graffiti including multiple phone numbers were written with a pen and/or marker on the standing closet in this room.
? Patient Room #146- Graffiti including multiple curse words and multiple phone numbers were written with a pen and/or marker on the standing closet in this room.
? Patient Room #151- Graffiti including multiple curse words were written with a pen and/or marker on the standing closet in this room.
Observations were made on the West Wing (24 bed adult psychiatric unit) in the presence of the Director of Quality on 1/11/10 between 11:45 a.m. and 12:10 p.m. These observations revealed the following:
? Phone Room- Greater than 50 phone numbers, curse words and inappropriate phrases were written on the wall with a pen and/or marker in this room. The phone numbers were assessable to patients hospitalized on this psychiatric unit.
The Director of Quality confirmed the above findings at the time of the observations.

Based on observations, record review and interview, the hospital failed to set priorities for its Quality Assurance Performance Improvement program that focused on high risk, high volume, or problem prone areas that affect patient safety and quality of care. This was evidenced by 1) the failure to identify and incorporate into the QAPI program information relating to the hospital's failure to ensure adequate supervision and evaluation of patient care by failing to ensure that at least one (1) Registered Nurse was physically present and immediately available to provide care to psychiatric patients hospitalized on the locked acute care psychiatric unit and 2) the failure to ensure that the facilities were maintained in a manner to ensure the safety and well being of patients hospitalized on an acute care locked psychiatric unit. Findings:

1. Failing to identify and incorporate into the QAPI program information relating to the hospital's failure to ensure adequate supervision and evaluation of patient care by failing to ensure that at least one (1) Registered Nurse was physically present and immediately available to provide care to psychiatric patients hospitalized on the locked acute care psychiatric unit.

Interviews with S11 (RN) on 01/12/10 at 11:00 a.m., S4 (RN) on 01/12/10 at 12:35 p.m. and S3 (RN) on 01/12/10 at 2:00 p.m. revealed that the psychiatric units are being left unattended by a registered nurse due to the registered nurse assigned to the unit being pulled off the unit to attend treatment team meetings in locations off the unit.

The Director of Quality was interviewed on 1/13/10 at 1:00 p.m. When asked if quality indicators had been identified and incorporated into the hospital QAPI program relating to the practice of pulling the registered nurse off of the acute care locked psychiatric unit for treatment team meetings without providing RN coverage, the Director of Quality reported that the QAPI program failed to identify this as a problem and failed to incorporate quality indicators relating to this practice.


2. Failing to ensure that the facilities were maintained in a manner to ensure the safety and well being of patients hospitalized on an acute care locked psychiatric unit.

Observations of the patient rooms and patient care unit in the presence of the Director of Quality on 1/11/10 between 11:00 a.m. and 2:30 p.m. revealed the following:

? Patient Room #142- Graffiti including phrases like "Don't take the medicine" and "Run before they catch you" were written with a pen and/or marker on the standing closet in this room.
? Patient Room #144- Graffiti including multiple phone numbers were written with a pen and/or marker on the standing closet in this room.
? Patient Room #146- Graffiti including multiple curse words and multiple phone numbers were written with a pen and/or marker on the standing closet in this room.
? Patient Room #148- Toilet paper roll dispenser was not functional and a full roll of toilet paper was noted to be placed on the floor.
? Patient Room #151- Graffiti including multiple curse words were written with a pen and/or marker on the standing closet in this room. In addition, a hole measuring 5 inch in diameter was noted on the wall near the head of the bed.
? Patient Room #218- Window frame loose with metal stripping noted to be unsecured with jagged and sharp metal edges.
? Patient Room #220- Toilet loose and not securely fastened to the floor in bathroom.
? Patient Room #222- Window frame loose with metal stripping noted to be unsecured with jagged and sharp metal edges.
? Patient Room #224- Hole in door measuring approximately 3 inches in diameter.
? Patient Room #226- Sheetrock noted to be separating and peeling from wall secondary to moisture in bathroom.
? Patient Room #228- 5 inch crack noted in panel door
? Patient Room #232- Broken/cracked sections of ceramic measuring approximately 1 square foot were noted near bathtub faucet. The 1 square foot section was covered with strips of duct tape. Water damage noted on sheetrock in the bathroom.
? Patient Room #234- Toilet paper roll dispenser was not functional and a partial roll of toilet paper was noted to be placed on the floor.
? Patient Room #236- Hole in door measuring approximately 2 inches in diameter.
? Patient Room #238- Dresser drawer broken.
? Patient Room #240- Covering to light switch was broken.
? Phone Room- Greater than 50 phone numbers, curse words and inappropriate phrases were written on the wall with a pen and/or marker in this room. The phone numbers were assessable to patients hospitalized on this psychiatric unit.
? Seclusion Room- Noted to be unlocked and unsecured with a 4 foot shower cord hanging in the bathroom and 4 restraint straps each measuring approximately 3 foot in length on the floor next to the bed in the seclusion restraint room. This finding was confirmed by S5 (LPN) who was present during this observation. S5 reported that the seclusion room should have been locked.
? Patient Room #252- Window frame loose with metal stripping noted to be unsecured with jagged and sharp metal edges.
? Patient Room #254- Missing section of formica on the countertop in this room. In addition, the toilet paper roll dispenser was not functional and two (2) rolls of toilet paper were noted to be placed on the floor. One of the rolls that was on the floor appeared to be the roll being used by patients in this room.
? Patient Room #256- Hole in door measuring approximately 2 inches in diameter.
? Patient Room #258- Hole in bathroom door measuring approximately 2 inches in diameter.
? Patient Room #260- Hole in door measuring approximately 2 inches in diameter. In addition, water damage was noted to the sheetrock in this room as a layer of sheetrock was peeling from the wall.
? Patient Room #262- Toilet paper roll dispenser was not functional and a partial roll of toilet paper was noted to be placed on the floor.

The Director of Quality was interviewed on 1/13/10 at 1:00 p.m. When asked if quality indicators had been identified and incorporated into the hospital QAPI program relating to the failure to ensure a safe and therapeutic environment on the acute care locked psychiatric units, the Director of Quality reported that the QAPI program failed to identify this as a problem and failed to incorporate quality indicators relating to the environment of care.

Based on review of medical records, review of policies/procedures, review of nurse staffing reports, observations and interviews with staff, an Immediate Jeopardy Situation was identified on 1/12/10 at 3:00 p.m. relative to the responsibilities of Nursing Services. The Immediate Jeopardy Situation was relating to the hospital's failing to ensure that at least one (1) Registered Nurse was physically present and immediately available to provide care to psychiatric patients hospitalized on the locked acute care psychiatric unit. This was evidenced by the hospital's practice of allowing the Registered Nurse to leave the locked acute care psychiatric unit to hold treatment team meetings at locations off the unit resulting in no (0) Registered Nurse being physically present and immediately available to patients hospitalized on the acute care psychiatric unit.

The hospital's Chief Executive Officer (S2) was notified of the Immediate Jeopardy Situation on 1/12/10 at 3:00 p.m. S2 verbalized understanding and indicated that the hospital's leadership team would immediately formulate and implement a corrective action plan to ensure that a Registered Nurse was physically present and immediately available to provide care to patients hospitalized on the locked acute care psychiatric unit. S2 presented a corrective action plan on 1/12/10 at 4:00 p.m. The corrective action plan included documentation indicating that "As of today all treatment teams will be held on the units. In addition, the assigned RN will not leave their assigned unit unattended without ensuring adequate RN coverage". The corrective action plan indicated that training would be provided to all Medical and RN staff with regard to this requirement. The objective is documented to "Ensure RN coverage for each unit 24/7" and the timeline is effective "Immediately".

The Immediate Jeopardy Situation was lifted on 1/12/10 at 4:02 p.m., which was prior to the completion of this survey, and compliance with the Condition of Participation for Nursing Services was achieved before the conclusion of the survey.

Based on review of Acadia Vermillion Hospital (AVH) Staffing Sheets, Time Detail cards, policies and interviews the hospital failed failed to ensure an RN was physically present and immediately available and on duty at all times on the East, West and North distinct locked psychiatric units. Findings:
1. S11, RN was interviewed on 01/12/10 at 11:00 a.m. S11 indicated she has been the West Unit Nurse Manager for 1 1/2 years. S11 further indicated that she attends treatment team meetings off the acute care locked psychiatric unit on Mondays, Tuesdays, Thursdays and Fridays. S11 reported that the patients on the acute care locked psychiatric unit are left with no Registered Nurse present on these days from 30 minutes to 1 hour.

S12, MHT was interviewed on 01/12/10 at 1:15 p.m. S12 indicated that the Registered Nurse leaves for Treatment Team Planning in the a.m. on Mondays, Tuesdays, Thursdays and Fridays and usually there is only an LPN and a MHT left on the acute care locked psychiatric unit. S12 reported that she had been in a situation where she was the only MHT on the unit with an LPN who was administering medications. S12 reported that she has had to leave the acute care locked psychiatric unit to discharge a patient so the LPN was on the acute care locked psychiatric unit alone while a PRN RN was off the unit for a break.

S4, RN Nurse Manager of the East Unit was interviewed on 01/12/10 at 12:35 p.m. S4 indicated her date of employment was 01/2009. S4 indicated that she attends treatment team meeting off the unit and the unit is without an RN present during this time. S4 reported that no other RN relieves her so she can attend the treatment team meeting. Further S4 indicated the East Unit is an adult speciality unit which services the chronically mental ill psychiatric patient and the severe detox patient and often there are not enough staff to ensue a safe environment. Further she indicated there shoual be an acuity grid for the unit but there was no acuity grid in place to determine staffing ratio.

S3, RN Nurse Manager of the Adolescent North Unit was interviewed on 01/12/10 at 2:00 p.m. S3 indicated that he attends Treatment Team Meetings on Monday and Thursdays off the unit and the adolescent patients are on the unit with the MHT with no Registered Nurse present.

The CEO, the Director of Nursing and the Assistant Director of Nursing were interviewed on 01/12/10 at 2:45 p.m. When asked if they had knowledge of the Registered Nurse leaving the locked acute care psychiatric unit to attend treatment team meetings being held off of the unit resulting in there being no registered nurse on the acute care locked psychiatric unit, the responses were as follows:
The Assistant Director of Nursing reported that she was aware of this current practice and stated that she had informed the CEO in mid to late November of 2009. The Assistant Director of Nursing confirmed that the acute care locked psychiatric units are being left without an RN present during treatment team meetings.
The CEO confirmed that she had been made aware of this practice in mid to late November of 2009 but stated that it was her understanding that this practice (RN leaving the unit) had stopped at that time.
The Director of Nursing reported that she had no knowledge of this practice (RN leaving the unit) occurring and indicated that the Assistant Director of Nursing handles staffing issues.


2. Review of the AVH Staffing sheets revealed, 12/30/09 7a- 3p West Census 13; East Census 6; North Census 2 Total day census 21: Further review revealed S11, RN was assigned to the East and West separate distinct locked units and S10, LPN was assigned to the West Unit. Documentation also revealed one MHT staffed the West Unit and two Mental Health Technicians (MHT) staffed the East Unit and 1 of those was 1:1 with a patient. Review of the AVH Staffing sheets revealed, 12/31/09 7a- 3p West Census 17; East Census (3 Adolescents); North Census (blank) Total day census 20: Further review revealed S11, RN was assigned to the East Unit and S18 RN was assigned to the West Unit. Review of the printed "Time Detail" cards dated 12/30/09 and 12/31/09 confirmed the unit staffing.
S6, RN Assistant Director of Nurses (ADON), was interviewed face to face on 01/12/10 at 3:30pm. S7 reviewed the Staffing Sheet and the printed "Time Detail" card and confirmed there was only one RN staffed for the East and West units on 12/30/09 for the 7a to 3pm shift.
S11, RN West Wing Charge Nurse was interviewed face to face on 01/12/10 at 11am. She indicated her time of employment was 2 ? years. S10 confirmed she was the only RN available and on duty for the separate distinct locked East and West units 12/30/09. Further the LPN was assigned to administer medications. S10 indicated she was told to sit in the West Unit med room which had another door which also opened to the East Unit. Further she indicated she just couldn't sit in the medication room and observe both the East and West Units as she had to leave the med room and go to the West Unit and East Unit nurse's station to access the patient' s records and attend team meeting. Further the total census combined was 19 patients and the acuity was high with psychotic patients. Further the East and West Unit patients were combined on the West Wing Unit at 11am; the Adolescent Unit was closed at 3:30pm and one Adolescent patient was transferred to the East Unit at this time. Further S10 verified she had been assigned on 12/31/09 to the East Unit with the 3 Adolescents and to administer medications to the West Unit patients with a total of 17 patients. S10 indicated she was told to remain in the West Unit Medication room to administer medications to the West unit patients even though she was assigned to the Adolescents on the East Unit.
S17, MHT was interviewed face to face on 01/13/10 at 1:45pm. S17 indicated she was the MHT on the West Unit on 12/30/09. Further S11 RN was the only RN assigned to both the East and West Units. Further she indicated there was a patient on the East Unit that required 1:1 observation and a MHT was assigned to the patient and there was another MHT also on the East Unit. Further S11 had spent most of the day on the East Unit and the LPN was on the West Unit without an RN present on the unit at all times.
S5, LPN was interviewed face to face on 01/12/10 at 10:40am. S5 indicated she was the Medication Nurse for the East Unit. Further she had reported to work on 12/31/09 at 7am but was told to go home, because of the census after the combining the East and West Unit patients, and the transfer of the adolescents to the East Unit. S5 indicated there was no RN on the East Unit with the Adolescents and S11, RN was in the West Unit medication room pouring medications and administering medications to both units. Further the only staff on the East Unit with the adolescents was the MHT.
S12, MHT was interviewed face to face on 01/12/10 at 1:15pm. S12 indicated she had been employed 1 1/2 years and had worked the 7a to 3p shift on 12/31/09 on the East Unit with the 3 adolescents. She indicted the RN was stationed in the West Unit Medication room and administering meds to the East and West units. Further there was an RN assigned to the West Unit and an RN never came to the East Unit.
S3, RN Nurse Manager of the Adolescent Unit was interviewed face to face on 01/11/10 at 10:50am. S3 indicated the Adolescents were moved to the East Unit on 12/30/09. Further an RN was assigned to the East Unit but was assigned to also administer medications to both the East and West distinct locked units. Further he indicated he did not feel comfortable being in charge of the adolescents on the East Unit and passing medications to patients on the West Unit so he requested the days off.
Review of the AVH Staffing sheets revealed, 12/30/09 3p-11p West Census 17; East Census 1; North Census Closed Total eve census 18: Further review revealed S18, RN was assigned to the West Unit and S8, RN was assigned to the East Unit. One MHT was assigned to the West Unit and one MHT to the East Unit. There was a floating MHT between the East and West Units. Review of the AVH Staffing sheets revealed, 12/31/09 3p-11p West Census 19; East Census 3; (Adolescents) North Census (blank) Total eve census 22. Further review revealed S18, RN was assigned to the West Unit and S8, Sheila Phillips, RN was assigned to the East Unit. Two MHTs was assigned to the West Unit and one MHT to the East Unit. Review of the printed "Time Detail" cards dated 12/30/09 and 12/31/09 confirmed the unit staffing.
S8, RN was interviewed face to face on 01/11/10 at 3:45pm. S8 verified she had worked 12/30/09 and 12/31/09 3p-11p when the East and West Units were combined and the adolescents patients were on the East unit. S8 indicated even though she was assigned to the East Unit she was the medication nurse for both the East and West unit patients.
S13, RN was interviewed face to face on 01/12/10 at 2:50pm. S13 indicated his date of hire was 12/02/09 and he had staffed the West Unit on 12/30/09 and 12/31/09 on the 3p to 11pm shift. Further the East and West adult patients had been combined on the West Unit and the Adolescents were on the East Unit. Further he indicated S8, RN who was assigned to the East Unit also administered medications to the 19 patients on the West Unit.
Review of the AVH Staffing sheets revealed, 12/30/09 11p-7a West Census 17; East Census 3; (Adolescents) North Census closed, Total Night census 20. Further review revealed S14, RN was assigned to the East/West Units and S15, RN was assigned to the East/West Units. One MHT was assigned to the West Unit and one MHT to the East Unit. There was a floating MHT between the East and West Units. Review of the AVH Staffing sheets revealed, 12/31/09 11p-7a West Census 18; East Census 4; North Census (blank) Total night census 22. Further review revealed S14, RN was assigned to the West Unit and S15, RN was assigned to the East Unit. Two MHTs were assigned to the West Unit and one MHT to the East Unit. . Review of the printed "Time Detail" cards dated 12/30/09 and 12/31/09 confirmed the unit staffing.
S14, RN was interviewed face to face on 01/13/10 at 8:20am. She indicated she worked the East Unit from 11p to 7a Monday through Friday. S14 further indicated her DOE was 04/2009 and she had worked as a Psychiatric Nurse for 40 years. Further she was assigned to staff both the East and West Units on 12/30/09 and 12/31/09. S14 indicated S15, RN was assigned to administer medications. S14 indicated she was told to use the West Unit nurse's station and S15 RN was to remain in the West Unit medication room and administer medications to the East and West Unit patients. Further there had been an LPN in the past to administer medications but the LPN had been removed from the unit since the hiring of the new DON.
S15, RN was interviewed face to face on 01/13/10 at 9am. S15 confirmed S14's statement and indicated she remained in the West Unit mediation unit and gave all the medications for both units on 12/30/09 and 12/31/09.
Review of the hospital Staffing Sheet grid presented by S6, ADON revealed staffing was determined using the grid. Further review revealed the staffing grid was designed for a two unit hospital. Review of the grid revealed in part if a total hospital census was 18 to 31 patients only 2 RN's were required to staff the hospital. However AVH is a three distinct unit hospital so 3 RNs would always be required to staff each distinct unit.
S6, ADON was interviewed face to face on 01/12/10 at 3:30pm. S6 indicated her DOE was 11/2009. Further she indicated she determines staffing and uses the staffing grid to determine daily staffing. Further she was told to follow the grid but had a problem with the grid because it was a grid for a two unit hospital. Further she indicated she had brought this to the attention of S2, CEO but was told to continue to use the grid as a tool.
S2, CEO was interviewed face to face on 01/11/10. She verified the staffing grid was for a two unit hospital but was implemented as a tool to determine staffing ratio for AVH.
S11, was interviewed face to face on 01/12/10 at 11am. S11 indicated she has been the West Unit Nurse Manager for 1 1/2 years. S11 further indicated she attends treatment team meetings off the unit on Mondays, Tuesdays, Thursdays and Fridays. Further patients on the unit are left unattended with no RN on these days from 30 minutes to 1 hour. Further she indicated this practice had been going on for 2 ? years. Further she indicated the staffing ratio had changed since the hiring of new administration. S11 indicated the West Unit use to be staffed with 1 RN, 1 LPN, 2 MHTs the unit census was greater than 15 patients. Further she indicated now the units are staffed according to the total hospital census with the Adolescent Unit combined in the census and that unit is always staffed with 1 RN and 1 tech for the 10 bed unit. Further she indicated now with a census of 19 she now has 1 RN, 1 LPN and 1 MHT. Further since this was implemented she felt the unit was unsafe especially with visiting hours on Tuesdays and Thursdays and AA meetings on Thursdays with a census greater than 15 patients.
S12, MHT was interviewed face to face on 01/12/10 at 1:15pm. S12 indicated the RN leaves the unit for Treatment Team Planning in the am of Mondays, Tuesdays, Thursdays and Fridays and usually there is only an LPN and a MHT on the unit. Further she had been in a situation where she was the only MHT on the unit with an LPN who was administering medications. Further S12 had to leave the unit to discharge a patient so the LPN was on the unit alone while a PRN RN was off the unit for a break.
S4, RN Nurse Manager of the East Unit was interviewed face to face on 01/12/10 at 12:35pm. S4 indicated her DOE was 01/2009. S4 further indicated she attends treatment team meeting off the unit and the unit is without an RN present during this time. Further no other RN relieves her so she can attend the meeting.
S3, RN Nurse Manager of the Adolescent North Unit was interviewed face to face on 01/12/10 at 2pm. S3 indicated he attends Treatment Team Meetings on Monday and Thursdays off the unit and the adolescent patients are on the unit with the MHT with no RN present.
S2, CEO and S7, DON were interviewed face to face on 01/12/10 at 2:45pm. They indicated they were not aware of the RN going to treatment team meetings off the units and the units were left unattended without an RN present.
A tour was done on the East and West Units on 01/11/10 at 4pm. Observation revealed two distinct locked units. The West Wing Medication room was also assessable to the East Unit by a locked door and the upper half of the door could be opened to observe both units. The Medication room for the East Unit was observed situated towards the middle of the unit.
Review of the Acadia Vermillion Hospital (AVH) Written Plan for Professional Services and Staff Composition revealed in part,
VI. General Descriptions of Services: The Acadia Vermillion Hospital continuum offers comprehensive treatment to persons experiencing acute crisis and psychiatric dependency illness who have found themselves in emotional and behavioral dysfunction. * Two adult units exist with specific tracks operate to meet the specific needs of our patients: programming and milieu management change and evolve to meet the unique needs within our community:
1. Adult High Functioning Services a) Psychiatric Track b) Chemical Dependency/Addictive Disorder Track c) Dual Diagnosis Track c) Geriatric Track
2. Adult Specialty Services a) Chronically Mental ill psychiatric patient b) Severe detox patient
3. One adolescent unit exists to serve children ages 12-17
VII. Organizational Structure of the Continuum Units: B Multidisciplinary Treatment Team Members: Nursing Staff: The nursing staff consists of registered nurses, licensed practical nurses, and mental health technicians. It is the responsibility of the primary nurse assigned to maintain familiarity with the patient's ongoing status and to formulate nursing goals objectives and interventions on the multidisciplinary treatment plan for the patient. The inpatient units are staffed with Registered Nurses on a 24-hour per day basis, seven days a week and supplemented with daily staffing per shift of LPNs and Mental Health Technicians sufficient to provide and address the clinical acuity status of patients on each unit.
IX. Program Descriptions: The hospital is comprised of 3 units. Each unit specializes in the needs of a specific patient population.
The East Unit specializes in providing services to lower functioning patients who require a higher intensity of nursing interventions to meet their unique needs. Adults who require more behavioral observation, lack significant cognitive capability, or require assistance with activities of daily living are more appropriate for the unit.
The West Unit specializes in providing services to higher functioning patients with greater ability to understand and benefit from insight or oriented therapy, individual therapy and whose familial situation is generally intact.
The North Unit exists to serve adolescents ages 12-17 years. AVH's focus is on treatable psychiatric disorders that can be stabilized in a length of stay less than two weeks.
Review of the AVH policy entitled "Staffing Matrix" presented as their current policy revealed in part, "PURPOSE: To provide guidelines to ensure safe and adequate staffing for the inpatient units. POLICY: It is the policy of Acadia Vermillion Hospital to provide adequate and safe staffing levels. At no time will patient safety be compromised to meet budget constraints. The hospital is staffed by a matrix based on census. When special needs and high acuity is noted, more staff will be assigned."
Review of the AVH policy entitled Staffing Plan presented as their current policy revealed in part, "PROCEDURE: INPATIENT 1. Director of Nursing considers the following factors in determining needs:
? Patient census and core staffing hours are used to determine staffing needs:
? Patient acuity, unit special needs, number of admission and discharges are factored in on a daily basis to ensure all patient needs are met.
? The unit will be staffed with an adequate number of RNs, LPN, and MHTs to maintain a therapeutic milieu and a safe environment.
? Criteria for staffing: Minimum of (1) one RN on each unit at all times.
? Utilize LPN's whenever possible as second licensed staff on each unit under the RN Charge.
Review of the AVH policy entitled "Precaution Levels" presented as their current policy revealed in part, * 1:1 Observation is defined as keeping the patients under direct supervision within arm's reach at all times. This includes the use of the bathroom and bathing."

Based on observations and interviews, the registered nurse failed to ensure the effective supervision and evaluation of care for psychiatric patients hospitalized on the acute care locked psychiatric unit by 1) failing to ensure that psychiatric patients were assessed by nursing services relative to receiving care in a safe and therapeutic setting as evidenced by patients having access to shower cords and/or restraint straps; and 2) failing to ensure that the windows were maintained in a manner to ensure the safety of patients. Findings:

1. Failing to ensure that patients did not have access to shower cords and/or restraint straps. Findings:
Observations were made on the East Wing (22 bed adult psychiatric unit) on 1/11/10 between 2:15 p.m. and 2:30 p.m. These observations revealed the following:
? Seclusion Room- Noted to be unlocked and unsecured with a 4 foot shower cord hanging in the bathroom and 4 restraint straps each measuring approximately 3 foot in length on the floor next to the bed in the seclusion restraint room. This finding was confirmed by S5 (LPN) who was present during this observation. S5 reported that the seclusion room should have been locked.

2. Failing to ensure that the windows were maintained in a manner to ensure the safety of patients. Findings:
Observations were made on the West Wing (24 bed adult psychiatric unit) in the presence of the Director of Quality on 1/11/10 between 11:45 a.m. and 12:10 p.m. These observations revealed the following:
? Patient Room #218- Window frame loose with metal stripping noted to be unsecured with jagged and sharp metal edges.
? Patient Room #222- Window frame loose with metal stripping noted to be unsecured with jagged and sharp metal edges.
Observations were made on the East Wing (22 bed adult psychiatric unit) on 1/11/10 between 2:15 p.m. and 2:30 p.m. These observations revealed the following:
? Patient Room #252- Window frame loose with metal stripping noted to be unsecured with jagged and sharp metal edges.
The Director of Quality confirmed the above findings at the time of the observations.

Based on record review and interview, the registered nurse failed to ensure that all medications were administered in accordance with the orders of the licensed practitioner for 2 of 12 sampled patients (Patient #1 & Patient #2). Findings:

The hospital's policy/procedure titled "Medication Administration" was reviewed. The policy/procedure documents in part "before administering a medication, the licensed independent practitioner or qualified individual administering the medication does the following: Verifies that the medication selected for administration is the correct one based on the medication order, prescriber instructions, preprinted MAR and product label".

The medical record of Patient #1 was reviewed. This review revealed that the patient was admitted to the hospital on 12/20/09. Review of the psychiatric evaluation revealed that the patient's Axis I diagnosis was Bipolar Affective Disorder, mixed with psychotic features. Review of the medical record revealed orders dated 12/21/09 at 4:40 p.m. to " ^ Abilify (antipsychotic medication) 20mg po TID, AM, 1PM, HS". Review of the medication administration record revealed that the patient did not receive the HS dose of Abilify as ordered on 12/23/09, 12/24/09, 12/25/09, 12/26/09, 12/27/09 & 12/28/09. Documentation on the medication administration record revealed that 10mg of Abilify was administered to the patient at HS on 12/23/09, 12/24/09, 12/25/09, 12/26/09, 12/27/09 & 12/28/09. There was no documentation to indicate that the patient received the 20mg of Abilify as ordered at HS on 12/23/09, 12/24/09, 12/25/09, 12/26/09, 12/27/09 & 12/28/09. Documentation revealed that Patient #1 exhibited disruptive and aggressive behavior and was given the following prn medications:
? 12/27/09- Abilify 10mg ODT at 9:00 a.m., 2:15 p.m., 10:00 p.m. (prn dose increased psychosis)
? 12/28/09- Abilify 10mg ODT at 12:30 a.m. (prn dose increased psychosis)
? 12/28/09- Abilify 10mg ODT at 9:15 a.m. and 1:05 p.m. (prn dose increased psychosis)
? 12/28/09- Abilify 9.75mg administered IM at (time not legible)
? 12/28/09- PRN dose of Thorazine 200mg administered IM at 8:00 p.m. and 8:15 p.m.
? 12/28/09- PRN dose of Ativan 4mg administered IM at 8:30 p.m.
? 12/29/09- Abilify 10mg ODT at 5:20 p.m. (prn dose increased agitation)

This review revealed that medication errors occurred at HS on 12/23/09, 12/24/09, 12/25/09, 12/26/09, 12/27/09 & 12/28/09 in that 10mg of Abilify was administered when the order was for the Abilify to be increased to 20mg. In an interview with the Director of Quality (S1) on 1/13/10 at 1:55 p.m., S1 confirmed that the Abilify was not administered to Patient #1 as ordered on 12/23/09, 12/24/09, 12/25/09, 12/26/09, 12/27/09 & 12/28/09.

Further review of Patient #1's medical record revealed that the patient was placed in 4 point restraints on 12/28/09 at 9:26 p.m. and remained in 4 point restraints until 12:07 a.m. on 12/29/09 (2 hours 31 minutes) for safety secondary to aggressive & threatening behavior. Review of the physician progress notes revealed documentation by the psychiatrist (S16) dated 12/28/09 indicating " The pt has been increasingly intrusive and assaulted another (very volatile) patient. He has been enraging other patients ... walked up to a card game and grabbed cards, placing him in danger of being assaulted and he assaulted another patient. He was placed in seclusion for his safety and given Abilify .. to help reestablish control". Further review of the physician progress notes revealed documentation by the psychiatric nurse practitioner dated 12/29/09 indicating "Patient placed on 1:1 by me & also given 0 roommate orders. Continues to be very impulsive and intrusive however easier to redirect with 1:1 staff member" and "discovered by nursing that only partial doses of two of his night medications have been given last two nights. May explain exacerbation partly".

Patient #1's attending psychiatrist (S16) was interviewed on 1/13/10 at 11:05 a.m. S16 reviewed the medical record of Patient #1 and reported that he could not recall if he had been notified of the medication errors that occurred while providing care to Patient #1. S16 confirmed that the hospitals failure to ensure that the Abilify was administered to Patient #1 as ordered on 12/21/09 at 4:40 p.m. could have possibly contributed to Patient #1's exacerbation as documented by the psychiatric nurse practitioner. When asked if he (S16) thought staffing played a role in the failure to increase the Abilify as ordered, S16 reported that he was not sure if staffing played a role in these medication errors but did report that he would like to see more nursing staff on the units.

The medical record of Patient #2 was reviewed. This review revealed that the patient was admitted to the hospital on 12/28/09. Review of the medical record revealed that the patient's Axis I diagnosis included Major Depression. Review of the record revealed orders dated 12/28/09 for 300mg of Trileptal to be given by mouth every 8 hours. Review of the medication administration record revealed that the a.m. dose of Trileptal scheduled for 7:00 a.m. was not administered as ordered on 12/29/09. In an interview with the Director of Quality (S1) on 1/13/10 at 1:55 p.m., S1 confirmed that there was no documentation to indicate that the scheduled a.m. dose of Trileptal was administered to Patient #2 as ordered on 12/29/09.

Based on observations and interviews, the hospital failed to ensure that the facilities were maintained in a manner to ensure an acceptable level of safety and quality. Findings:

Observations were made on the North Wing (10 bed adolescent psychiatric unit) in the presence of the Director of Quality on 1/11/10 between 11:00 a.m. and 11:45 a.m. These observations revealed the following:

? Patient Room #142- Graffiti including phrases like "Don't take the medicine" and "Run before they catch you" were written with a pen and/or marker on the standing closet in this room.
? Patient Room #144- Graffiti including multiple phone numbers were written with a pen and/or marker on the standing closet in this room.
? Patient Room #146- Graffiti including multiple curse words and multiple phone numbers were written with a pen and/or marker on the standing closet in this room.
? Patient Room #148- Toilet paper roll dispenser was not functional and a full roll of toilet paper was noted to be placed on the floor.
? Patient Room #151- Graffiti including multiple curse words were written with a pen and/or marker on the standing closet in this room. In addition, a hole measuring 5 inch in diameter was noted on the wall near the head of the bed.

The Director of Quality confirmed the above findings at the time of the observations.

Observations were made on the West Wing (24 bed adult psychiatric unit) in the presence of the Director of Quality on 1/11/10 between 11:45 a.m. and 12:10 p.m. These observations revealed the following:

? Patient Room #218- Window frame loose with metal stripping noted to be unsecured with jagged and sharp metal edges.
? Patient Room #220- Toilet loose and not securely fastened to the floor in bathroom.
? Patient Room #222- Window frame loose with metal stripping noted to be unsecured with jagged and sharp metal edges.
? Patient Room #224- Hole in door measuring approximately 3 inches in diameter.
? Patient Room #226- Sheetrock noted to be separating and peeling from wall secondary to moisture in bathroom.
? Patient Room #228- 5 inch crack noted in panel door
? Patient Room #232- Broken/cracked sections of ceramic measuring approximately 1 square foot were noted near bathtub faucet. The 1 square foot section was covered with strips of duct tape. Water damage noted on sheetrock in the bathroom.
? Patient Room #234- Toilet paper roll dispenser was not functional and a partial roll of toilet paper was noted to be placed on the floor.
? Patient Room #236- Hole in door measuring approximately 2 inches in diameter.
? Patient Room #238- Dresser drawer broken.
? Patient Room #240- Covering to light switch was broken.
? Phone Room- Greater than 50 phone numbers, curse words and inappropriate phrases were written on the wall with a pen and/or marker in this room. The phone numbers were assessable to patients hospitalized on this psychiatric unit.

The Director of Quality confirmed the above findings at the time of the observations.

Observations were made on the East Wing (22 bed adult psychiatric unit) on 1/11/10 between 2:15 p.m. and 2:30 p.m. These observations revealed the following:

? Seclusion Room- Noted to be unlocked and unsecured with a 4 foot shower cord hanging in the bathroom and 4 restraint straps each measuring approximately 3 foot in length on the floor next to the bed in the seclusion restraint room. This finding was confirmed by S5 (LPN) who was present during this observation. S5 reported that the seclusion room should have been locked.
? Patient Room #252- Window frame loose with metal stripping noted to be unsecured with jagged and sharp metal edges.
? Patient Room #254- Missing section of formica on the countertop in this room. In addition, the toilet paper roll dispenser was not functional and two (2) rolls of toilet paper were noted to be placed on the floor. One of the rolls that was on the floor appeared to be the roll being used by patients in this room.
? Patient Room #256- Hole in door measuring approximately 2 inches in diameter.
? Patient Room #258- Hole in bathroom door measuring approximately 2 inches in diameter.
? Patient Room #260- Hole in door measuring approximately 2 inches in diameter. In addition, water damage was noted to the sheetrock in this room as a layer of sheetrock was peeling from the wall.
? Patient Room #262- Toilet paper roll dispenser was not functional and a partial roll of toilet paper was noted to be placed on the floor.

The Director of Quality confirmed the above findings at the time of the observations.