HospitalInspections.org

Based on staff interviews, review of facility policy, and review of the staff schedule, it was determined that the facility failed to ensure that there are an adequate number of qualified professional and supportive staff to provide active treatment measures for all patients.

Findings include:

1. The facility failed to ensure that there is a Director of Social Services for the Behavioral Health Unit. (Refer to Tag 1715)

2. The facility failed to provide a therapeutic program that is appropriate to the needs and interest of patients that is directed toward restoring and maintaining optimal levels of physical and psychosocial functioning. (Refer to Tag 1725)

3. The facility failed to ensure that there are an adequate number of therapists and support personnel available to provide comprehensive therapeutic activities with each patient's active treatment program. (Refer to Tag 1726)

Based on staff interviews and review of facility documents, it was determined that the facility failed to ensure that there is a Director of Social Services for the Behavioral Health Unit (BHU) who oversees the quality and appropriateness of the social services provided by the facility.

Findings include:

On 12/12/23 at 10:10 AM, Staff 2 (S2), Chief Nursing Officer, stated that S32, the Patient Care Director, was a Registered Nurse (RN) with a Master of Science in Nursing (MSN) and who was also the current Nursing Director on the BHU. S2 confirmed that there was no one assigned as the "Director of Social Work" for the BHU. S2 further stated, "the Patient Care Director (Nurse Manager) supervises the Social Workers on the BHU."

Upon interview on 12/12/23 at 10:43 AM, S32 stated, "I oversee the nursing staff, Social Workers, Behavioral Health Technician, Patient Care Providers, and Activities Therapists. There is no 'Director of Social Work' for the BHU." S32 confirmed there has not been a Director of Social Services for the unit since he/she was hired as the Patient Care Director "a few years ago." S32 confirmed that he/she administratively supervises the social workers on the BHU but is not professionally qualified to clinically supervise social workers.

On 12/12/23 at 10:45 AM, S34, Social Worker, stated that he/she is the "only social worker on this unit." S34 explained his/her job responsibilities include treatment planning, discharge planning, family meetings, and immediate social needs of the patients. When asked to identify his/her supervisor, S34 stated, "S32 is my supervisor. There is no 'Director of Social Work' for this unit."

Review of the staff list for the BHU 5B Inpatient Unit, confirmed that there was no 'Director of Social Work' identified on the list.

On 12/12/23 at 2:45 PM, upon interview, S2 confirmed that the facility does not have a Director of Social Work for the Behavioral Health 5B Inpatient Unit.

Based on observation of the daily patient schedule posted in the Adult Behavioral Health Unit (BHU), staff interviews, and review of facility policy, it was determined that the facility failed to provide a therapeutic program that is appropriate to the needs and interest of patients that is directed toward restoring and maintaining optimal levels of physical and psychosocial functioning.

Findings include:

On 12/12/23 at 10:40 AM, a tour of the BHU was conducted in the presence of Staff (S2), the Chief Nursing Officer and S41, the Clinical Nurse Quality Department.

Upon arrival to the unit at 10:43 AM, the Weekly Patient Schedule titled, "Weekly Planner: DECEMBER" was observed to be posted on a bulletin board across from the nursing station.

The patient schedule for Tuesday was observed to be as follows: " ...9:30-Coping Sk.(Coping Skills group); 10am-Community; ...1:30-Art Therapy Boards." The bottom of the schedule stated, "(Staff #39 [S39], Licensed Social Worker): Tuesday & Thursday-Group Therapy 5pm" and "RN Group: Medication Group, Coping skills Grp (Group), Wrap up Grp (Group.)"

Upon interview at 11:15 AM, S36, Registered Nurse (RN), confirmed that the patient schedule that is posted on the bulletin board was the current schedule that the staff and patients follow. S36 stated, "I ran group today at 10:00 AM, but only two patients attended. I write group notes for each of the patients, whether they attend group or not. If they didn't attend group, I document the reason that they did not attend it."

Upon interview at 2:15 PM, S32, RN/Patient Care Director, stated that their full-time Recreational Therapist (S33) has been on bereavement leave since 12/4/23 and they have no other full-time Recreational Therapist. S32 stated further that they have a part-time Recreational Therapist that works every other weekend and a Social Worker (S39) that works part time and runs groups on Tuesday and Thursday evenings. S33 continued that nursing staff will run group when the Recreational Therapist is off and that the Behavioral Health Technician (BHT) will run group at times.

On 12/12/23 at 2:30 PM, S32 confirmed that when the full-time Recreational Therapist left for bereavement leave on 12/04/23, the unit has not provided groups to the patients as scheduled. S32 stated that the facility is actively hiring another recreational therapist but they're hard to find and that the patients watch a lot of movies.

A review of the facility policy titled, "Program Elements" (Effective 09/08/23, Reviewed December 2023), stated, " ...Daily therapeutic programming includes the following at a minimum: ... B.) The therapeutic program schedule reflects a minimum of 30 hours of scheduled therapeutic activities for the week. It reflects a minimum of 3 hours daily of active, group-oriented therapeutic activities on Saturday, Sunday, and holidays (excluding visitation.) ... G.) The program schedule is prominently displayed, ... checked for accuracy daily and reflects changing groups, lectures, times, based on patient needs."

Based on staff interviews and review of facilty documents, it was determined that the facility failed to ensure that there are an adequate number of therapists and support personnel available to provide comprehensive therapeutic activities with each active treatment program.

Findings include:

Review of the Adult Behavioral Health Unit staff list and staff schedule (12/03/23-12/30/23) was completed on 12/12/23 at 1:30 PM, and revealed the following:

- Patient Care Director- Staff (S)32, RN
- Full-time Recreational Therapist-S33 (currently on bereavement leave)
- Part-time Recreational Therapist-S49, (works every other weekend)
- Full-time Social Worker-S34
- Part-time Social worker-S39 (works Tuesday and Thursday evenings)
- One BHT (Behavioral Health Technician)-S38
- Eight PCPs (Patient Care Providers)
- 14 Registered Nurses (RNs.)

Review of the staff schedule (12/3/23 through 12/30/23) revealed that there was no Recreational Therapist scheduled for a total of 13 days in the month of December, on the following dates: 12/06/23, 12/08/23, 12/11/23, 12/13/23, 12/15/23, 12/16/23, 12/17/23, 12/18/23, 12/20/23, 12/21/23, 12/25/23, 12/29/23, and 12/30/23.

On 12/12/23 at 2:30 PM, S32 confirmed that when the full-time Recreational Therapist left for bereavement leave on 12/04/23, the unit has not provided therapeutic activities to the patients as scheduled because of lack of staff. S32 stated, "I'm actively trying to hire another activity therapist but they're hard to find. The patients watch a lot of movies."