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Based on observation, record review and interview, the hospital failed to ensure each patient's basic right to respect, dignity, and comfort. This deficient practice is evidenced by failure to complete incontinence and soiling assessment per policy on 1 (#1) of 1 patients sampled for incontinence checks.
Findings:

Review of hospital policy number: NSG-42 titled Activities of Daily Living (ADL) revealed, in part: Policy, in part: Depending upon the functioning abilities of each patient, the nursing staff will supervise, assist, teach, and/or provide activities of daily living, including personal hygiene. Procedure: 1. The Registered Nurse (RN) is responsible for assessing the patient's level of performing activities of daily living (ADLs). This includes: showering/bathing, changes underwear and outer garments, and bowel and bladder habits. 2. Nursing Staff will assist patient who are unable to perform their activities of daily living independently or perform activities of daily living for those patients who need assistance. 3. Nursing personnel will clean and/or bathe incontinent patients (or assists with these activities) immediately upon voiding or soiling with due regard for patient's privacy and maintain patient's dignity. 4. Nursing personnel will assess all incontinent frequently for soiling.

A review of the hospital policy titled "Level of Observation" revealed, in part:
Purpose: To provide staff with a framework for monitoring patients to ensure safety. Procedure, in part: 3. Staff members utilize the close observation checklist form to document the ongoing observation and location of the patient. The Registered Nurse (RN) will conduct routine rounds to visually observe each patient for safety at least once every 2 hours (unless more often is warranted) and will validate rounds by initialing in the appropriate section(s) of the form.
Every 15-minute Observation, in part: RN makes observations at least every 2 hours during the shift and initials the RN observations on the close observations sheet. The staff will visually observe the patient every 15 minutes to monitor their location and activity, with an emphasis on any noticeable behaviors of escalation, aggression, and unsafe activities. Physically walks to find each patient on q 15 minute observations. Documents patient's location and reports identified risk to RN when indicated. Documents the location on the close observation form and documents the activity when indicated, e.g., water offered, etc. Initials the form every 15 minutes.

Review of Patient #2's observation sheets dated 07/30/2023 revealed the following documentation per S15MHT:
7:00 a.m. incontinence check q 2 in the day room sitting.
9:00 a.m. incontinence check q 2 in the day room sleeping (eyes closed).
7:00 p.m. incontinence check q 2 in the day room sitting.
9:00 p.m. incontinence check q 2 in the day room taking medications.
11:00 p.m. incontinence check q 2 in the day room sleeping (eyes closed).
1:00 a.m. incontinence check q 2 in the day room sleeping (eyes closed).
3:00 a.m. incontinence check q 2 in the day room sleeping (eyes closed).
5:00 a.m. incontinence check q 2 in the day room sleeping (eyes closed).
6:15 a.m. Incontinent/Check Q 2hrs. Bathroom.

Review of video footage dated 07/30/2023 failed to reveal nursing personnel assessing for incontenicnce and soiling every 2 hours as per policy.
9:00 a.m. Nursing Staff failed to physically walk over to patient to verify incontinence or soiling as documented on observation sheet.
3:00 p.m. Nursing Staff failed to physically walk over to patient to verify incontinence or soiling as documented on observation sheet.
5:00 p.m. Nursing Staff failed to physically walk over to patient to verify incontinence or soiling as documented on observation sheet.
7:00 p.m. Nursing Staff failed to physically walk over to patient to verify incontinence soiling as documented on observation sheet.

In an interview on 07/31/2023 at 11:00 a.m., S1DON confirmed video footage failed to reveal nursing staff physically walking over to patient to verify incontinence and soiling every 2 hours as documented on observation sheet by S15MHT as per policy.

Based on record reviews and interview, the registered nurse failed to supervise and evaluate the nursing care of each patient. This deficient practice is evidenced by:
1) failure of nursing staff to perform Oxygen Therapy assessments on 1 (#2) of 1 patients sampled for Oxygen Therapy.
2) failure of nursing staff to obtain an order for Oxygen Therapy on 1 (#2) of 1 patients sampled for Oxygen Therapy.
3) failure to perform nursing shift assessments in 2 (#3 and #4) of 5 (#1-#5) patient sampled.
4) failure to assess a colostomy in 1 (#5) of 1 patients sampled with colostomy.
Findings:

Review of hospital policy number: NSG-02, titled "Nursing Documentation" revealed, in part: Procedure, in part: Admission. In part: The nurse records a notation of the admission information in the medical record which can include the following information, in part: Patient's physical/emotion status (include skin assessment) any other significant information obtained or observed. 1. All notes must be related to the patient's problems on the treatment plan.
Daily: The Registered Nurse (RN) documents or reviews the LPN/LVN documentation on the Nursing Shift Assessment a minimum of once per shift. 4. Documents pertinent and factual information including assessment.

1) Failure of nursing staff to perform Oxygen Therapy assessments on 1 (#2) of 1 patients sampled for Oxygen Therapy.
Review of Patient #2's medical record revealed patient was admitted on 07/26/2023 with diagnoses of COPD including right lower lobe pneumonia .

Review of Patient #2's History & Physical Examination dated 07/27/2023 revealed, in part: Assessment: 5. COPD-monitor oxygen saturations on 2 liters nasal cannula.

Review of Patient #2's Nursing Admit Assessment dated 07/26/2023 22:45 p.m. failed to reveal assessment or documentation that the nurse was monitoring or administering oxygen therapy.

Review of Paitent #2's Plan of Care dated 07/27/2023 revealed, in part: Interventions: 8. Administer O2 via nasal cannula.

Review of Patient #2's Nurse Shift Assessment dated 07/30/2023 at 12:01 p.m. failed to reveal assessment or documentation that the nurse was monitoring or administering oxygen therapy.

Review of Patient #2's Nursing note failed to reveal assessment or documentation that the nurse was monitoring or administering oxygen therapy.

Review of Patient #2's provider note dated 07/31/2023 at 8:00 a.m. #2's revealed Patient's oxygen saturation was 82% on 3 liters just prior to transfer to emergency department via ambulance.

In an interview on 07/31/2023 at 2:05 p.m., S1DON confirmed there was no evidence of an assessment or documentation that the nurse was monitoring or administering oxygen therapy in Patient #2's medical record.

2) Failure of nursing staff to obtain an order for Oxygen Therapy on 1 (#2) of 1 patients sampled for Oxygen Therapy.
Review of Patient #2's medical record revealed Orders for Patient #2 dated 07/26/2023. Continued review of Patient #2's Orders failed to reveal an order for monitoring oxygen therapy and saturations or settings for oxygen therapy.

In an interview on 07/31/2023 at 4:08 p.m., S1DON confirmed there were no orders for monitoring oxygen therapy and saturations or settings for oxygen therapy in Patient #2's medical record. S1DON stated that the registered nurses caring for Patient #2 should have obtained the order from the medical physician/nurse practitioner.

3) Failure to perform a Nursing Shift Assessment in 2 (#3 and #4) of 5 (#1-#5) patients sampled.
Patient #3
Review of Patient #3's medical record failed to reveal Nursing Shift assessments for the day shift and the night shift 07/28/2023 and on the night shift for 07/29/2023 and 07/31/2023.

In an interview on 08/02/2023 at 1:30 p.m., S12QA confirmed Patient #3's medical record failed to reveal evidence of Nursing Shift assessments for the day shift and the night shift 07/28/2023 and on the night shift for 07/29/2023 and 07/31/2023.

Patient #4
Review of Patient #4's medical record failed to reveal Nursing Shift Assessments for the day shift of 06/26/2023, 06/27/2023, and 06/28/2023.

In an interview on 08/02/2023 at 2:14 p.m., S12QA confirmed Patient #4's medical record failed to reveal evidence of Nursing Shift Assessments for the day shift of 06/26/2023, 06/27/2023, and 06/28/2023.

4) Failure to assess a colostomy in 1 (#5) of 1 patients sampled with colostomy.
Review of Patient #5's History & physical Examination completed on 07/29/2023 revealed patient with a history of dementia, aggression, and transferred from nursing home under non-contested admission for evaluation and psychiatric care. Patient was confused with poor insight in to his admission and a poor historian. Diagnosis of dementia and major depressive disorder, malnutrition, GERD, AFIB, BPH, OA.
Further review revealed Patient #5's abdominal assessment completed by physician revealed: Colostomy.
Patient #5's Skin assessment completed by physician revealed: Colostomy.

Review of Patient #5's Nursing Initial Assessments and Nursing Shift Assessments failed to reveal colostomy assessments on the following dates: 07/28/2023, 07/29/2023, 07/30/2023 and 07/31/2023.

In an interview on 07/31/2023 at 3:07 p.m., S1DON confirmed there was no evidence of colostomy assessments completed on Patient #5 on 07/28/2023, 07/29/2023, 07/30/2023 and 07/31/2023.

Based on record review the hospital failed to ensure that the medical record for each patient contained accurate patient identification information. This deficient practice is evidenced by the facility failing to provide the correct date of birth and name on 1 (#2) of 1 patients sampled for accurate medical records.
Findings:

Review of hospital policy number: NSG-02 titled "Documentation" revealed, in part:
Purpose: To provide concise and comprehensive information as part of a legal document. Documentation Guidelines: 4. All forms must have labels with two patient identifiers displayed or documented on them.

Review of Patient #2's medical record revealed a Coroner's Emergency Certificate dated 07/29/2023 at 1:23 a.m.. Further review revealed Patient #2's date of birth documented as: 09/08/1948. Continued review revealed Patient #2's name.

Review of Patient #2's medical record revealed an Observation Check sheet dated 07/29/2023 and 07/30/2023. Further review revealed Patient #2's date of birth documented as: 09/12/1948.

Review of Patient #2's medical record revealed a Pre-Admission Patient Screening dated 07/11/2023 revealed a date of birth documented as: 09/12/1948. Further review revealed a different name listed on the pre-admission screening.

Review of Patient #2's medical record revealed a Nursing Initial Assessment dated 07/11/2023. Further review revealed a different name and a date of birth documented as: 09/12/1948. Further review revealed a different name listed on the Nursing Initial Assessment.

In an interview on 07/31/2023 at 3:35 p.m., S1DON confirmed that the two different names and two different dates of birth were inaccurate. S1DON stated that there was confusion regarding the correct name and date of birth and she thought the confusion had been addressed.

Based on record review and interview, the hospital failed to ensure the appropriate arrangements for post-hospital care were made before discharge. This deficient practice is evidenced by failing to ensure the appropriate level of psychosocial/physical care, treatment and services for post-treatment placement in 1 (#1) of 5 (#1-#5) patients sampled.
Findings:

Review of hospital policy number: PC-18 titled "Discharge Planning: Transition Record" revealed, in part: Purpose: To establish guidelines for assisting patients to the appropriate level of psychosocial/physical care, treatment and services for post-treatment placement, follow-up and/or transfer. Procedure, in part: 3, in part: Discharge planning should encompass the following areas: Review of the precipitating events and stressors which led to current treatment and what resources the patient will need to deal with these events/stressors post-discharge. Review of any daily living changes (need for nursing home, group home, home health, etc.) patient may need to decrease relapse potential. Review of community resources needs of patient post-discharge and availability of same (i.e., vocational rehabilitation, private therapist, educations, etc.). Family's needs post discharge. Patient/family's continued education needs. Orders for continuing care to meet physical and psychosocial needs for discharge or transfer. 4, in part: Social Services/Case Management personnel shall: Participate/facilitate discharge planning and develops mechanisms for exchanging information with service providers outside the facility. Contact the post discharge referral source to ascertain the suitability of placement, schedule any appointments, and to facilitate coordination of transfer. Establishes communication with referral sources as needed to promote optimal transition of care, treatment, and services. When feasible, prior to discharge or transfer to a loser level of care, conducts a discharge conference with patient (and family/significant others, as appropriate) tp: Finalize living arrangements and post-treatment care plans to meet ongoing needs for care and services. Review patient progress in treatment. Discuss patient and family's expectations of patient's behavior and participation in recommended therapies post-discharge. 5, in part: The nurse shall: Upon discharge provide the patient recommendations for anticipated continuing care, treatment, and services and discharge medication interventions.

Review of hospital policy number : PC-01 titled "Admission and continued Stay Criteria" revealed, in part: Policy, in part: Throughout the course of the patient's care the hospital ensures that continued stay for any given level of care is determined by whether the patient still exhibits clinical criteria as outlined for that level of service provision. Procedure, in part: 2. The Medical Director or the Administrator reserves the right to refuse admission or to recommend to the attending physician that a patient be referred to another facility because the patient's needs cannot be met at this level or because treatment cannot be adequately provided within the scope of any program offered. 3, in part: The facility ensures that the patient meets admission and continued stay criteria. Level of Care Determination: Symptoms and behaviors indicative of the need for services, in part: Inpatient Hospital, in part: Must meet all criteria with a (*) by it plus at least one criterion under intensity of service/severity of illness, in part: Gravely Disabled*, in part: *Requires a multi-modal, comprehensive, coordinated, intensive, individualized active treatment program to include 24 hour a day medical supervision/coordination because of mental/emotional decompensation. *Failure of outpatient treatment or patient requires 24-hour professional observation. *Has hospital specific manageable medical conditions. Intensity of Services/Severity of Illness Criteria, in part: Acute disorder/bizarre behaviors or psychomotor agitation/retardation that interferes with ADLs so that patient cannot function at a less intensive level of care currently evidence by the following: Severe depression, Hallucinations, Delusions, Mania, Other. Cognitive impairment, i.e., disorientation or memory loss, due to acute mental disorder that endangers the welfare of self or others. A dementing disorder needing evaluation treatment of a psychiatric co-morbidity: Aggressive, Psychosis, Severe depression. Mental disorder causing inability to maintain adequate nutrition or self-care and family/community support cannot provide reliable essential care. Mental disorder causing major disability in ADLs, social, interpersonal, occupational and /or educational functioning that is leading to a dangerous or life threatening situation.

Review of Patient #1's medical record revealed Patient #1 was discharged from rehab facility 'a' on 01/18/203 to hospital 'd'. Further review revealed Patient #1 was admitted on 01/18/2023 with diagnosis of Dementia and Werncke encephalopathy. Primary reason for Admission was aggressive behavior.

Review of Patient #1's medical record revealed a S16RN's nursing progress note dated 01/21/2023 at 2:46 a.m. The progress note stated that the patient was observed getting naked and having bowel movement on the floor of another patient's room. Patient was placed in Geri-chair due to severe confusion and high safety risk. Patient isolative and withdrawn to self. Patient is responding to internal stimuli as evidenced by patient talking to someone who is not there and grabbing at air as if patient is trying to grab someone. Redirection and reality orientation provided. Patient disheveled and malodorous. Patient with a concrete thought process. Patient with a dysphoric mood and a flat affect. Patient attempting to climb out of chair multiple times. Patient with an unsteady gait. Patient requires assistance with ADL's.

Review of Patient #1's medical record revealed S17LPC's progress note dated 01/21/2023 at 9:30 a.m. The progress note stated that the therapist spoke with patient significant other and notified the patient will discharge home today. Facility 'a' will not accept the patient back. Significant other stated she will come pick up the patient around 3 pm. Therapist went over transition record over the phone-will send a referral to facility 'b' on Monday.

Review of Patient #1's medical record revealed S19MD's Discharge Summary dated 01/21/2023 at 12:02 p.m. The Discharge Summary stated the patient was unable to provide a logical chief complaint. A clear demented process, he was grossly confused, he was anomic and could not even name an ink pen or wristwatch. Rambled in practically incomprehensible fashion. He was in a geri-chair and ambulating around the unit urinating in corners. Seemed disorganized disheveled and rather emaciated. Reason for admission: Major Depressive Disorder, Major Neurocognitive Disorder due to ETOH abuse severe with behavioral disturbances. Treatment and interventions included: aftercare management. S19MD documented the following Criteria Achieved:
Absence of suicidal ideations and homicidal ideations.
Improved Coping Skills.
Decreased Anxiety.
Absence of Aggressive Behavior.
Improved ADL.
Improved Social Functioning.
Effective Management of Mental Illness.
Improved Thought Process.
Absence of Hallucinations, Delusions.
Relapse Prevention Plan in Place.
Motivation of Outpatient Counseling.
Improved Mood and Affect.

A further review of discharge summary failed to reveal documentation regarding Patient #1 getting naked and having bowel movement on the floor of another patient's room. That Patient #1 was placed in Geri-chair due to severe confusion and high safety risk. That Patient #1 was isolative and withdrawn to self. That Patient #1 was responding to internal stimuli as evidenced by patient talking to someone who was not there and grabbing at air as if patient was trying to grab someone. That Patient #1 needed Redirection and reality orientation. That Patient #1 had an unsteady gait and required assistance with ADL's.

Review of Patient #1's medical record revealed S18LPC's progress note dated 01/21/2023 at 2:07 p.m. The progress note stated that S18LPC spoke with patient's wife for approximately 30 minutes. Discussed the criteria for Acute Psych and explained that Patient #1 was no longer displaying psychiatric symptoms and that is the reason for discharge. Explained that they would look into a home health referral.

In an interview on 08/02/2023 at 4:00 p.m., Complainant reported Patient #1 was on vent with Wernicke-Korsakoff Syndrome. He seemed to be doing better once he was extubated. Feeding and dressing himself. When he went to hospital named in complaint, he came back completely different. He was disoriented, in diapers, bruising on forehead, arms, knee. He was emancipated. Unable to get information. Doctor said he needed to be discharged. Did not make sense. They called her on the weekend, a Saturday when it was pouring down rain. She has vision loss due to stroke and cannot drive and was told she had to pick up patient. Psychiatrist said he wanted patient discharge immediately. When she stated she could not pick him up, she was told she could be charged with senior abuse. Said "Just never mind I will just have him transported". She did not understand why he had to be transported so quickly. Told if she didn't think she could handle him than bring him to ER. She brought him to ER immediately after he arrived and it took two weeks before he could be placed.

In an interview on 07/31/2023 at 10:38 a.m., S1DON reviewed and confirmed that on 01/21/2023 at 2:42 a.m. Patient #2's nurse documentation stating that Patient #2 was getting naked and having bowel movement on the floor of another patient's room. That Patient #2 was placed in Geri-chair due to severe confusion and high safety risk. That Patient #2 was isolative and withdrawn to self. That Patient #2 was responding to internal stimuli as evidenced by patient talking to someone who was not there and grabbing at air as if patient was trying to grab someone. That Patient #2 was disheveled and malodorous. That Patient #2 had a concrete thought process. That Patient #2 was with a dysphoric mood and a flat affect. That Patient #2 had an unsteady gait and required assistance with ADL's.

S1DON further confirmed that 11 hours 35 minuts later S18LPC documented on the progress note dated 01/21/2023 at 2:07 p.m. that Patient #2 no longer met the criteria for Acute Psych and explained that Patient #1 was no longer displaying psychiatric symptoms and that was the reason he was being discharged.

S1DON reviewed and verified after S16RN documented Patient #1's above behaviors on 01/21/2023 at 2:46 a.m. 9 hours and 10 minutes later Patient #1's physician, S19MD documented in the Discharge Summary dated 01/21/2023 at 12:02 p.m. that Patient #1 Achieved the following:
Absence of suicidal ideations and homicidal ideations.
Improved Coping Skills.
Decreased Anxiety.
Absence of Aggressive Behavior.
Improved ADL.
Improved Social Functioning.
Effective Management of Mental Illness.
Improved Thought Process.
Absence of Hallucinations, Delusions.
Relapse Prevention Plan in Place.
Motivation of Outpatient Counseling.
Improved Mood and Affect.

S1DON confirmed the discharge summary failed to reveal documentation regarding Patient #1 getting naked and having bowel movement on the floor of another patient's room. That Patient #1 was placed in Geri-chair due to severe confusion and high safety risk. That Patient #1 was isolative and withdrawn to self. That Patient #1 was responding to internal stimuli as evidenced by patient talking to someone who was not there and grabbing at air as if patient was trying to grab someone. That Patient #1 needed Redirection and reality orientation. That Patient #1 had an unsteady gait and required assistance with ADL's.

Based on record review and interview, the hospital failed to ensure the written treatment plan included adequate documentation to justify the diagnosis and the treatment and rehabilitation activities carried out. This deficient practice is based on the failure of the content of the progress and treatment notes to indicate what the hospital staff are doing to carry out the treatment plan and the patient's response to the interventions in 1 (#2) of 5 (#1-#5) patients sampled.
Findings:

A review of Patient #2's plan of care dated 07/27/2023 revealed Problem #4, Alteration in Health Maintenance related to Medical Treatment, Comfort Alteration, Potential for infection, Respiratory difficulties, Blood Sugar, Deviations Cardiac Output, Knowledge deficit of disease as evidence by History of hypertension, History of diabetes, Fluid retention, complaints of pain, History of Asthma, variations in vital signs, decreased respiratory pattern, decreased cardiac output, history of UTI.
Continued review revealed Interventions #8: Administer O2 via NC.

A review of Patient #2's orders dated 07/26/2023 failed to reveal an order for oxygen therapy and failed to reveal settings for oxygen therapy.

A review of Patient #2's Nursing shift assessment 7A-7P, dated 7/30/2023 failed to reveal documentation in the progress and treatment notes that indicated what the hospital staff was doing to carry out the treatment plan and the patient's response to the interventions.

In an interview on 07/31/2023 at 10:55 a.m., S1DON confirmed there were no orders for oxygen therapy for Patinet #2 and further stated the nursing shift assessment 7A-7P, dated 7/30/2023 failed to reveal documentation in the progress and treatment notes that indicated what the hospital staff was doing to carry out the treatment plan and the patient's response to the interventions pertaining to oxygen therapy via nasal cannula.

Based on interview and record review, the hospital failed to ensure that active treatment measures were furnished in accordance with accepted standards of professional practice providing the patient assistance with resolving or ameliorating the problems or circumstances that led to the hospitalization for 3 (#3-#5) of 5 (#1-#5) patients sampled for active treatment.
Findings:

Review of hospital policy number: CS-05 titled "Group Therapy" revealed, in part: Procedure: 1. The patient will attend all groups as assigned on program schedule. Should a patient not attend a scheduled group session, the therapist will follow-up with the patient to determine the cause of the absence, provide alternative intervention, and document appropriately in the medical record.

Patient #3
Review of the medical record for Patient #3 revealed an admit date of 07/27/2023 at 4:15 p.m. via a non-contested admission from assisted living signed by her husband. Diagnosis: Dementia with behavioral disturbances with depressive component.

Review of Group Therapy Note dated 07/28/2023 for 9:30 a.m. revealed, in part: a checkmark next to the statement: Patient Did not Attend group, Alternative Offered (describe in comments). Review of the comments section revealed a blank line. Further review revealed the Group Therapy Note signed by S20CSW on 07/31/2023 at 11:36 a.m.

Review of Group Therapy Note dated 07/29/2023 for 9:30 a.m. revealed, in part: a checkmark next to the statement: Patient Did not Attend group, Alternative Offered (describe in comments). Review of the comments section revealed patient declined offer to attend group therapy session. When Counselor checked in on patient after session, patient was incoherent and drifting in and out of sleep.

Review of Group Therapy Note dated 08/01/2023 for 1:15 p.m. revealed, in part: a checkmark next to the statement: Patient Did not Attend group, Alternative Offered (describe in comments). Review of the comments section revealed Therapist attempted to meet with patient for check in; she appeared sleeping.

In an interview on 08/02/2023 at 3:00 p.m., S12QA confirmed that no alternative was offered on 07/28/2023 as per policy. S12QA stated that the therapist attempted to provide an alternative intervention on 07/29/2023 and 08/01/2023.

Patient #4
Review of the medical record for Patient #4 revealed an admit date of 06/24/2023 via Physicians Emergency Commitment from assisted living after being found wandering in the woods. Diagnosis: Dementia with behavioral disturbances.

Review of Group Therapy Note dated 06/25/2023 for 9:00 a.m. revealed, in part: a checkmark next to the statement: Patient Did not Attend group, Alternative Offered (describe in comments). Review of the comments section revealed Attempted to engage.

Review of Group Therapy Note dated 06/26/2023 for 9:45 a.m. revealed, in part: a checkmark next to the statement: Patient Did not Attend group, Alternative Offered (describe in comments). Review of the comments section revealed Attempted to engage.

Review of Group Therapy Note dated 06/27/2023 for 9:30 a.m. revealed, in part: No checkmark next to the statement: Patient Did not Attend group, Alternative Offered (describe in comments). Review of the comments section revealed a blank line.

Review of Group Therapy Note dated 06/28/2023 for 8:45 a.m. revealed, in part: a checkmark next to the statement: Patient Did not Attend group, Alternative Offered (describe in comments). Review of the comments section revealed Attempted to engage.

Review of Group Therapy Note dated 06/29/2023 for 8:30 a.m. revealed, in part: No checkmark next to the statement: Patient Did not Attend group, Alternative Offered (describe in comments). Review of the comments section revealed a blank line.

In an interview on 08/02/2023 at 2:25 p.m., S12QA confirmed that no alternative was offered on 06/27/2023 and 06/29/2023 as per policy. S12QA stated that the therapist attempted to provide an alternative intervention on 06/25/2023, 06/26/2023, and 06/28/2023.

Patient #5
Review of the medical record for Patient #5 revealed an admit date of 07/28/2023 via a non-contested admission. Diagnosis: Dementia with behavioral disturbances .

Review of Group Therapy Note dated 07/29/2023 for 9:30 a.m. revealed, in part: A checkmark next to the statement: Patient Did not Attend group, Alternative Offered (describe in comments). Review of the comments section Patient did not attend Group Therapy Session due to being asleep.

Review of Group Therapy Note dated 07/30/2023 for 9:00 a.m. revealed, in part: A checkmark next to the statement: Patient Did not Attend group, Alternative Offered (describe in comments). Review of the comments section Patient did not attend Group Therapy Session due to being asleep.

In an interview on 07/31/2023 at 2:11 p.m., S11CD confirmed there was no alternative intervention provided as per policy on the dates 07/29/2023 and 07/30/2023.

Based on record review and interview the psychiatric hospital failed to provide adequate numbers of nursing staff to provide the nursing care necessary under each patient's active treatment plan. This deficiency is evidenced by failure of the facility to have adequate staffing of mental health technicians (MHT) per the facility staffing matrix for 1 (08/02/2023) of 2 (07/31/2023 and 08/02/2023) staffing assignments reviewed.
Findings:

Based on record review and interview, the registered nurse failed to ensure the assigned nursing care of each patient to other nursing personnel was appropriate for the patient's needs. This deficiency is evidenced by failing to ensure the proper number of Mental Health Technicians were available to provide nursing care for each patient in accordance with the individual needs of each patient.

Review of hospital policy titled "Plan for The Provision of Nursing" revealed, in part: 1. Qualifications/Skill Level of Nursing Staff, in part: Mental health Technicians (MHT). Mental Health technicians (MHTs) are internally trained paraprofessional members of the nursing staff. Under the supervision of the RN, they provide ongoing patient guidance, support, supervision and assistance in activities of daily living. The Mental health Technicians assist in the care and observation of patients. 2. Staffing Levels/Mix, in part: Determination of appropriate staffing levels and daily allocation of staff are based on the average daily census (ADC) and patient population needs. The staffing matrix will serve as a guide for unit-based staffing. The matrix will be a guideline to determine the number of and type of staff to provide care for patient specific needs. Nursing staff mix consists of Registered Nurses, Licensed Practical/vocational Nurses and Mental Health Technicians. If disparities due to increased demand for staff cannot be satisfactorily addressed within the available staff, additional staff is accessed from the PRN pool; If that resource is exhausted then the facility attempts contracted agency staffing.

A review of facility document "Staffing Grid" revealed the following:
Census: 28-MHT: 5

A review of facility document "7P-7A Assignment Sheet" dated 08/02/2023 revealed a census of 28. Further review of Assignment Sheet revealed 5 MHTs assigned. One of the 5 MHTs assigned was MHT15.

Observation of unit on 08/02/2023 at 8:10 a.m. failed to reveal MHT15 was present.

In an interview on 08/02/2023 at 8:11 a.m., S1DON confirmed MHT15 was not on the unit or in the building. S1DON further stated the MHTs usually arrive between 6:00 a.m. and 6:30 a.m. in order to begin their 7:00 a.m. shift.