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Based on record review and interview, the hospital failed to ensure the patient /patient representative's right to participate in the development and implementation of his or her plan of care was met. This deficient practice was evidenced by failure to ensure the patient /patient representative was included in the development and implementation of the patient's plan of care for 2 (#2, #4) of 4 (#1- #4) patient medical records reviewed for care plan development and implementation.
Findings:

Review of the hospital's policy titled, "Interdisciplinary Patient-Centered Care Planning", Revised: 04/2024, revealed in part: Policy: It is the policy of the hospital to provide therapeutic services based upon a patient-centered, individualized treatment plan. The treatment team, led by the attending psychiatrist, works with the patient and family/representative to collaboratively identify the patient's assessed needs to be addressed during treatment and develop appropriate goals and interventions. Procedure: Developing the Treatment Plan: 5.The patient/family and/or representative is to sign the treatment plan to indicate their agreement with and participation in development of the plan. If the patient refuses to sign or is unwilling to sign, that will be documented.

A medical record review for patient participation in the development and implementation of patient's treatment plan of care revealed:

Patient #2 was admitted 06/27/2024 and the Interdisciplinary Master Treatment Plan was dated 06/30/2024. The last page of the treatment plan revealed in part, an area to indicate patient participation (with the options to be selected by checking a box next to the following: Contributed to goals/plan, Aware of plan, Unable to participate due to clinical reasons, Refused to participate, Refused to sign, and/or Unable to Sign), an area to document the patient's stated goal and an area for the patient's signature and date acknowledging the following statement, "This treatment plan has been presented and reviewed with me in language that I understand. I had the opportunity to ask questions." There was no documentation to patient participation, patient's stated goal, or the signature of the patient to indicate the involvement with the treatment plan.

Patient #4 was admitted 07/11/2024 and the Interdisciplinary Master Treatment Plan was dated 07/14/2024. The last page of the treatment plan revealed in part, an area to indicate patient participation (with the options to be selected by checking a box next to the following: Contributed to goals/plan, Aware of plan, Unable to participate due to clinical reasons, Refused to participate, Refused to sign, and/or Unable to Sign), an area to document the patient's stated goal and an area for the patient's signature and date acknowledging the following statement, "This treatment plan has been presented and reviewed with me in language that I understand. I had the opportunity to ask questions." There was no documentation to patient participation, patient's stated goal, or the signature of the patient to indicate the involvement with the treatment plan.

In an interview on 08/20/2024 at 3:45 p.m. S9RMPI confirmed the above mentioned findings.

Based on observation and interview, the hospital failed to provide care in a safe setting. This deficient practice was evidenced by toiletry items remaining in the presence of patients when not in use.
Findings:

A review of facility policy, "Admission to Discharge: Personal Belongings, Valuables, Safety/Skin, & Contraband Searches" last revised: 03/2024, revealed in part: Policy: 7.0 Certain items that are considered unsafe for patients to have will be classified as contraband ...all patients and family member will be advised at the time of admissions of the facility's policy on contraband. Procedure: Categories of controlled items: Contraband: ... prohibited or unauthorized items. Any item that poses a safety risk may be considered contraband or if an item poses a safety risk or interferes with the rights of others. Monitored: Items may be used by patients under the direct supervision of staff members. Items are monitored by staff and kept in a safe place on the unit when not in use. Excessive amount of any monitored item will not be permitted. Restricted: Item that may be checked out by patients for short periods of time. Restricted items will be kept in a safe place on the unit not accessible to patients when not in use. Excessive amounts of any restricted item will not be permitted. Section Contraband/Permissible Items: 1. Personal hygiene items will be provided by the hospital including: Hygiene items and buckets will be provided to patients during hygiene times, 1.1 Shampoo, 1.2 Conditioner, 1.3 Body Wash, 1.4 Deodorant, 1.5 Toothbrush.

Observations during a tour of the facility on 08/19/2024 from 10:15 a.m. to 12:15 p.m. revealed toiletry items in Patient #R1's restroom and Room "a" restroom. Toiletry items available included:
Patient #R1 restroom: 2 tan toothbrushes, 2 tubes of Freshmint Toothpaste, 4 McKesson Shampoo/Body Wash - 8 ounce bottles; and
Room "a": 1 McKesson Shampoo/Body Wash - 8 ounce bottle and 1 black hair brush.
These items would be considered contraband and pose a safety risk when not in use.

In an interview on 08/19/2024 at 10:35 a.m. Patient #R1 confirmed his current room assignment and restroom. He further confirmed the toiletry items in his restroom were not his possessions and he had returned his toiletry items after use.

In an interview on 08/19/2024 and present during the tour, S10CNO and S11DirPO confirmed the above mentioned findings.

Based on record review and interview, the hospital failed to ensure the hospital's direct care staff were educated, trained and demonstrated knowledge on the use of nonphysical intervention skills as evidenced by 1 (#S6MHT) of 2 (S6MHT, and S7MHT) direct care staff sampled for nonphysical intervention skills training failing to have documented evidence of nonviolent behavior training.
Findings:

Review of hospital's policy titled "Staff Competency and Training", approved 04/2024, revealed in part: Orientation...Clinical/Nursing Staff will receive additional training, apprpopriate to their positions, in at least the following areas: Management of aggresive behaviors. Annual Retraining:...Management of aggresive behaviors.

Review of daily staffing report for 08/11/2024, 08/14/2024, 08/15/2024, 08/19/2024, and 08/20/2024 revealed S6MHT was staffed as an mental health techinician for Unit A. Further review revealed on 08/16/2024 and 08/18/2024, S6MHT was staffed as an mental health techinician on Unit B. Continued review revealed on 08/10/2024, S6MHT was staffed as an mental health techinician on Unit C.

Review of S6MHT's personnel record revealed a date of hire of 8/07/2024. Further review failed to reveal evidence S6MHT was educated and trained and that she demonstrated knowledge on the use of nonphysical intervention skills.

In an interview on 08/21/2024 at 1:26 p.m., S1EDU verified there was no documented evidence of S6MHT's education, training and demonstratration of the knowledge on the use of nonphysical intervention skills.

In an interview on 08/21/2024 at 2:15 p.m., S9RMPI verified S6MHT is currently on the schedule.

48051

Based on record review and interview, the hospital failed to have a registered nurse (RN) supervise and evaluate the nursing care for each patient. This deficient practice is evidenced by 1 (#2 and #R2) of 5 (#1-#4, and #R2) patient medical records reviewed lacking an initial nursing admission assessment.
Findings:

A review of facility policy, "Assess and Reassess FUNCTION: Nursing: Provision of Care" last revised 12/2023, revealed in part: POLICY: All patients admitted to the hospital will have a Nursing Assessment completed on admission within 8 hours. PROCEDURE: Nursing assessment will be completed within 8 hours of their admission. If the patient refuses the assessment or is unable to participate in the assessment process, the RN/LPN will document this in the daily nursing progress note and/or on the assessment. Continued attempts to complete the assessment will be documented on the form at minimum of every day.

A review of Patient #2's medical records revealed an admission on 06/27/2024 at 12:40 p.m. A nursing note on the Nursing Admission Assessment from 06/27/2024 at 3:25 p.m. revealed in part, "Pt AAO x 2, drowsy, sedated and confused. Pt unable to answer questions, unable to assess the patient." The Nursing Admission Assessment had an area on the bottom of page #1 that revealed, "If unable to complete full Assessment, document ongoing efforts to complete: RN must complete all objective aspects of assessment, including narrative of patient presentation/behaviors/condition." This area included Attempt #1, Attempt #2 and Attempt #3 for the nurse to document the date, time, and reason for being unable to complete an assessment. This area had no documentation in the blanks. A review of all nursing notes during the course of the patient's admission did not reveal any documentation related to an attempt to perform an initial nursing admission assessment.

A review of Patient #R2 medical records revealed an admission on 06/15/2024 at 4:45 a.m. Continued review revealed #R2's 10 page Nursing Admission Assessent with the following information indicated on the form:
Page 1:
Gender: female
Method of Arrival: Wheelchair
Source of information: Patient
Preferred language: English
Primary thnicity: non-hispanic or Lation
Height: 4'11" and weight: 120 lbs.
Skin assessment: "T" located on shoulders, legs, and back.
Pages 2-10: blank.

In an interview on 08/20/2024 at 2:35 p.m., S9RMPI confirmed the above mentioned findings.