HospitalInspections.org

Based on review of facility policies and documents, review of medical records, and interviews with staff, it was determined that the facility failed to maintain an organized nursing service as evidenced by: failure to ensure adequate numbers of nursing staff (A392); failure to have a Registered Nures assess a patient entering the detoxification program (A398).

Cross Reference:
482.23(b) Staffing and Delivery of Care
482.23(b)(6) Supervision of Contract Staff

Based on hospital document review, policy review, and staff interview it was determined that the Hospital failed to ensure adequate numbers of nursing staff for 8 (Unit A, B, C, D East, D West, E, G and T) of 8 patient care units, including not staffing appropriately for one-to-one observations and not ensuring a Registered Nurse (RN) is present and available on each unit. Findings include:

Review of facility policy "Nursing Accountability," effective August 1993, revised June 2023, revealed, "...Staff are assigned to units and patients by Registered Nurses based on assessment both of specific patient needs and staff competency...Inpatient nursing staff consists of Registered Nurses, Licensed Practical Nurses, and Behavioral Health Associates..."



Surveyors reviewed hospital staffing records for the following dates:

4/12-4/15/2024
4/20-4/21/2024
4/26-4/28/2024
5/4-5/5/2024
5/10-5/12/2024
5/18-5/19/2024
5/24-5/26/2024
6/1-6/2/2024
6/6-6/7/2024


Review of facility policy "Staffing Plan for Nursing Services," effective January 26, 2001, revised August 30, 2022, revealed, "...Core coverage includes ensuring there is 1 RN [registered nurse] on each unit at all times and that there is at minimum 2 staff on each unit at all times...The goal of staffing each nursing unit is to ensure patient safety in healthcare delivery..."

The following units had no RN assigned for the following dates:

Sunday 5/12/2024 3 PM to 7 PM: Unit A had a census of 22 patients. Staff assigned were one LPN (Licensed Practical Nurse) and 3 BHAs (Behavioral Health Associates).

Friday 5/24/2024 7 PM to 11 PM: Unit G had a census of 20 patients. Staff assigned were one LPN and 3 BHAs.

Sunday 6/2/2024 11 PM to 7 AM: Two Units (Unit A and Unit C) had no RN assigned. Unit A had a census of 19 patients, with 1 LPN and 1 BHA assigned. Unit C had a census of 14 patients, with 2 BHAs assigned.

Saturday, 6/8/2024 11 PM to 7 AM: Unit E had a census of 17 patients with one LPN assigned. Additionally, per hospital policy, a minimum of two staff members should be present at all times.


Review of facility policy "Routine Observation of Inpatients," effective June 2002, revised September 2020, revealed, "In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered...1:1 is the highest level of observation and is reserved for patients who are so unpredictable that without a dedicated staff member there is a risk of patient harming self or others...Staff who are assigned to monitor the patient on 1:1 observation will have no other assignments..."

The following Units did not have enough staff assigned to provide 1:1 observation as ordered for patients:

Sunday, 5/19/2024 7 AM to 3 PM: Unit B had a census of 9 patients with two ordered for 1:1 observation. Only one RN and one BHA were assigned to this Unit.
Sunday, 5/19/2024 3 PM to 7 PM: Unit B's census increased to 11 patients with two ordered for 1:1 observation. Assigned staff included one RN, one nurse, and one BHA.

Friday, 5/24/2024 7 AM to 3 PM: Unit B had a census of 12 patients with two ordered for 1:1 observation. Staff included two RNs and one BHA.

Saturday, 5/25/2024, Unit C was understaffed from 7 AM to 11 PM. From 7 AM to 3 PM, the census was 16 with 3 patients ordered 1:1 observation while awake. However, there were only two staff members present - one RN and one BHA. From 3 PM to 7 PM, the census remained 16 with 3 1:1 orders. However, there were only 3 staff members assigned - one RN, one nurse, and one BHA. From 7 PM to 11 PM, the census remained 16 with the 3 patients onrdered 1:1 observation while awake. However, only three staff members were assigned to this Unit, leaving coverage short until those 1:1 patients were asleep. The staff included one RN, one nurse, and one BHA.

Sunday, 5/26/2024, 7 AM to 3 PM: Unit C remained with 16 patients and two with 1:1 observation orders. However staff assigned were one RN, one nurse, and one BHA.



Interview conducted with EMP12 on 6/14/2024 from 10AM to 12:15PM. EMP12 stated, "Staffing ratios are 1:5 overall for 7A-3P and 3P-11P shifts and 1:10 overall for 11P-7A." Surveyors confirmed with EMP12 that the staffing ratios do not reflect patients on 1:1 observation, as those staff are not permitted to have any other assignments per facility policy.

The following Units did not meet the minimum staffing ratios by shift:

Saturday 4/13/2024 7 AM to 3 PM: Unit A; 19 patients. Staff: 1 RN, 2 BHA's. Short 1 staff member.

Sunday 4/14/2024 7 AM to 3 PM: Unit D West; 20 patients. Staff: 1 RN, 2 BHA's. Short 1 staff member.

Sunday 4/21/2024 7 AM to 3 PM: Unit A; 23 patients. Staff: 1 RN, 1 Nurse, 2 BHA's. Short 1 staff member.
Sunday 4/21/2024 3 PM to 7 PM: Unit A; 23 patients. Staff: 1 RN, 1 Nurse, 2 BHA's. Short 1 staff member.

Saturday 4/27/2024 3 PM to 7 PM: Unit D East; 19 patients. Staff: 1 RN, 1 Nurse, 1 BHA. Short 1 staff member.

Saturday 5/11/2024 3PM to 7PM: Unit B; 9 patients with 3 1:1's while awake. Staff: 1 RN and 3 BHA's. Short 1 staff member.
Saturday 5/11/2024 7PM to 11PM: Unit B; 9 patients with 3 1:1's while awake. Staff: 1 RN, 3 BHA's. Short 1 staff member.

Sunday 5/12/2024 7AM to 3PM: Unit A; 22 patients. Staff: 1 RN, 1 Nurse, 1 BHA. Short 2 staff members.
Sunday 5/12/2024 7AM to 3PM: Unit D East; 17 patients. Staff: 1 RN, 1 BHA. Short 2 staff members.
Sunday 5/12/2024 7AM to 3PM: Unit D West; 20 patients. Staff: 1 RN, 2 BHA's. Short 1 staff member.
Sunday 5/12/2024 7AM to 3PM: Unit E; 16 patients. Staff: 1 RN, 1 Nurse, 1 BHA. Short 1 staff member.
Sunday 5/12/2024 7AM to 3PM: Unit G; 20 patients. Staff: 1 RN, 1 Nurse, 1 BHA. Short 1 staff member.
Sunday 5/12/2024 7AM to 3PM: Unit T; 14 patients with 1 1:1 while awake. Staff: 1 RN, 2 BHA's. Short 1 staff member.
Sunday 5/12/2024 3PM to 7PM: Unit A; 22 patients. Staff: 1 LPN, 3 BHA's. Short 1 RN.
Sunday 5/12/2024 3PM to 7PM: Unit D West; 20 patients. Staff: 1 RN, 2 BHA's. Short 1 staff member.
Sunday 5/12/2024 3PM to 7PM: Unit T; 14 patients with 1 1:1 while awake. Staff: 1 RN, 2 BHA ' s. Short 1 staff member.
Sunday 5/12/2024 7PM to 11PM: Unit A; 22 patients. Staff: 1 RN, 1 Nurse, 2 BHA's. Short 1 staff member.
Sunday 5/12/2024 11PM to 7AM: Unit D East; 17 patients. Staff: 1 BHA. Short 1 RN.

Saturday 5/18/2024 3PM to 7PM: Unit A; 21 patients. Staff: 1 RN, 1 Nurse, 2 BHA's. Short 1 staff member.
Saturday 5/18/2024 3pm to 7PM: Unit B; 9 patients with 2 1:1's while awake. Staff: 1 RN, 2 BHA's. Short 1 staff member.
Saturday 5/18/2024 7PM to 11PM: Unit A; 23 patients. Staff: 1 RN, 2 BHA's. Short 2 staff members.
Saturday 5/18/2024 7PM to 11PM: Unit G; 16 patients. Staff: 1 RN, 1 Nurse, 1 BHA. Short 1 staff member.

Sunday 5/19/2024 7AM to 3PM: Unit A; 23 patients. Staff: 1 RN, 1 Nurse, 2 BHA's. Short 1 staff member.
Sunday 5/19/2024 7AM to 3PM: Unit B; 9 patients with 2 1:1's while awake. Staff: 1 RN and 1 BHA. Short 2 staff members.
Sunday 5/19/2024 3PM to 7PM: Unit A; 23 patients. Staff: 1 RN, 1 Nurse and 2 BHA's. Short 1 staff member.
Sunday 5/19/2024 3PM to 7PM: Unit B; 11 patients with 2 1:1 ' s while awake. Staff: 1 RN, 1 Nurse and 1 BHA. Short 1 staff member.
Sunday 5/19/2024 3PM to 7PM: Unit T; 17 patients with 1 1:1 while awake. Staff: 1 RN and 2 BHA's. Short 2 staff members.
Sunday 5/19/2024 7PM to 11PM: Unit T; 17 patients. Staff: 1 RN and 2 BHA's. Short 1 staff member.

Friday 5/24/2024 7AM to 3PM: Unit G; 20 patients. Staff: 1 RN, 1 Nurse and 1 BHA. Short 1 staff member.
Friday 5/24/2024 7AM to 3PM: Unit B; 12 patients with 1 1:1 and 1 1:1 while awake. Staff: 2 RN's and 1 BHA. Short 1 staff member.
Friday 5/24/2024 3PM to 7PM: Unit A; 22 patients. Staff: 1 RN, 1 Nurse and 2 BHA's. Short 1 staff member.
Friday 5/24/2024 3PM to 7PM: Unit C; 14 patients with 1 1:1 and 1 1:1 while awake. Staff: 2 RN's and 2 BHA's. Short 1 staff member.
Friday 5/24/2024 7PM to 11PM: Unit A; 22 patients. Staff: 1 RN, 1 Nurse and 2 BHA's. Short 1 staff member.
Friday 5/24/2024 7PM to 11PM: Unit C; 14 patients with 2 1:1's. Staff: 1 RN and 3 BHA's. Short 1 staff member.

Saturday 5/25/2024 7AM to 3PM: Unit C; 16 patients with 3 1:1's. Staff: 1 RN and 1 BHA. Short 4 staff members.
Saturday 5/25/2024 3PM to 7PM: Unit C; 16 patients with 3 1:1's while awake. Staff: 1 RN, 1 Nurse and 1 BHA. Short 3 staff members.
Saturday 5/25/2024 7PM to 11PM: Unit C; 16 patients with 3 1:1's while awake. Staff: 1 RN, 1 Nurse and 1 BHA. Short 3 staff members.

Sunday 5/26/2024 7AM to 3 PM: Unit C; 16 patients with 2 1:1's while awake. Staff: 1 RN, 1 Nurse and 1 BHA. Short 2 staff members.
Sunday 5/26/2024 3PM to 7PM: Unit C; 16 patients. Staff: 1 RN and 2 BHA's. Short 1 staff member.
Sunday 5/26/2024 7PM to 11PM: Unit C; 16 patients. Staff: 1 RN and 2 BHA's. Short 1 staff member.

Saturday 6/1/2024 7PM to 11PM: Unit D West; 16 patients. Staff: 1 RN, 1 Nurse and 1 BHA. Short 1 staff member.

Sunday 6/2/2024 7PM to 11PM: Unit D East; 18 patients. Staff: 1 RN, 1 Nurse and 1 BHA. Short 1 staff member.
Sunday 6/2/2024 7PM to 11PM: Unit D West; 16 patients. Staff: 1 RN and 2 BHA's. Short 1 staff member.
Sunday 6/2/2024 11PM to 7AM: Unit C; 14 patients. Staff: 2 BHA's. Short 1 RN.

Friday 6/7/2024 3PM to 7PM: Unit A; 23 patients. Staff: 1 RN and 2 BHA's. Short 2 staff members.
Friday 6/7/2024 3PM to 7PM: Unit D East; 16 patients. Staff: 1 RN and 2 BHA's. Short 1 staff member.
Friday 6/7/2024 7PM to 11PM: Unit A; 23 patients. Staff: 1 RN, 1 Nurse and 2 BHA's. Short 1 staff member.

Saturday 6/8/2024 3PM to 7PM: Unit A; 23 patients. Staff: 1 RN, 1 Nurse and 2 BHA's. Short 1 staff member.
Saturday 6/8/2024 7PM to 11PM: Unit A; 23 patients. Staff: 1 RN, 1 Nurse and 2 BHA's. Short 1 staff member.
Saturday 6/8/2024 11PM to 7AM: Unit E; 17 patients. Staff: 1 LPN. Short 1 RN.

Sunday 6/9/2024 7AM to 3PM: Unit A; 23 patients. Staff: 1 RN, 1 Nurse and 1 BHA. Short 2 staff members.
Sunday 6/9/2024 3PM to 7PM: Unit A; 23 patients. Staff: 1 RN, 1 Nurse and 2 BHA's. Short 1 staff member.
Sunday 6/9/2024 3PM to 7PM: Unit D West; 17 patients. Staff: 1 RN and 2 BHA's. Short 1 staff member.
Sunday 6/9/2024 7PM to 11PM: Unit A; 23 patients. Staff: 1 RN, 1 Nurse and 2 BHA's. Short 1 staff member.

Monday 6/10/2024 7AM to 3PM: Unit A; 23 patients. Staff: 1 RN, 1 Nurse and 2 BHA's. Short 1 staff member.

These findings were confirmed with EMP12 on 6/14/2024 from 10AM-12:15PM.

Based on policy review, document review, medical record (MR) review, employee record review and staff interview, it was determined that for 1 out of 12 patients (Patient #3) in the patient sample, the Hospital failed to adhere to the policies and procedures of the hospital. Findings include:

Review of facility policy "Detoxification," effective April 1999, revised December 2016, revealed, "...Patients who are experiencing significant medical withdrawal from addictive substances are admitted to an inpatient program and managed safely...All patients receive a level of care assessment in admissions that includes an assessment of...Substance use history...Presence/history of psychiatric disorder/current risks to self and others...History of drug and alcohol/mental health treatment...Intensity of recent use and other risk factors for acute withdrawal reaction...This assessment is conducted by a Registered Nurse..."


A review of MR3's "Face Sheet" revealed "... Admitting Diagnosis...Opioid Abuse with Withdrawal..."

A review of MR3's "Meadowwood Behavioral Health Intake", from 4/20/24 at 5:20 PM, revealed the following information completed by EMP25, Admissions Specilaist: "...presented...for detox from opiates...Pt [patient] using 5-6 ...bags Fentanyl X [times] 2 years snorting last use 4-19-24. Pt using crack cocaine...Pt denies SI [suicidal ideation], HI [homicidal ideation] and psychotic symptoms with history of suicide attempt via OD [overdose] pills 5 years ago...Pt not feeling well due to symptoms...Past Diagnosis: Bipolar disorder, Opiate use disorder...List of Current Medications...No meds...Level of Care Recommendations...Physician Contacted: [EMP33-Physician]...Contact Date: 4/20/24...Contact Time: 6:00PM...Diagnosis per Physician: Opiate use disorder..."

Per resume provided by EMP7 on 6/14/2024, EMP25, Admissions Specialist, is not an RN. EMP25 was not qualified to complete the level of care assessment per the facility's "Detoxification" policy.

This finding was confirmed with EMP2 on 6/14/2024 at 12:42PM.

Based on observation, staff interview, review of medical records (MR), and policy review, it was determined that for 5 of 5 medical records (MR4, MR5, MR6, MR7, and MR8) sampled, the Hospital failed to ensure the "Interdisciplinary Treatment Plan" was developed collaboratively by the treatment team and the patient, as evidenced by a signature of acknowledgement. Findings include:


Review of facility policy "Treatment Planning," effective May 1996, revised June 2023, revealed, " It is the policy of MeadowWood Behavioral Health System to develop a Multidisciplinary treatment plan for each patient admitted to an inpatient program...will be individualized and identify the specific needs and goals of the patient and the specific interventions to be conducted by staff to promote ongoing recovery...The purpose of the Multidisciplinary treatment plan is to guide the staff treating the patient...Each clinical discipline has specific intervention(s) that they will utilize...Treatment Plan Review...The multidisciplinary treatment reviews the treatment plan with the patient...The multidisciplinary treatment team members and the patient sign the treatment plan..."


1. Medical record review revealed no evidence of physician/provider signature on the "Interdisciplinary Treatment Plan Update" from 6/14/24 for 4 of 5 (MR4, MR5, MR7 and MR8) records sampled.


2. Medical record review revealed no evidence that the Interdisciplinary Treatment Plan reflected the involvement of the patient for 2 of the 5 (MR6 and MR7) medical records sampled, as evidenced by patient signature.

Review of MR6's "Interdisciplinary Treatment Plan Master Sheets" dated 6/4/2024, stated, "...Patient/Legal Representative Involvement: This Treatment Plan has been presented to/reviewed with the patient...The Patient/legal rep have been given the opportunity to ask questions and make suggestions. (By signing this, patient/legal rep agrees that he/she has actively participated in treatment planning and agrees to the plan.) ...Patient Signature: Blank [no signature noted] ..."

Review of MR6's "Interdisciplinary Treatment Plan Update", dated 6/14/24, stated, "...Treatment Team/Conference Date: 6/14/24...Patient/Family/ Legal Representative Involvement: Changes in the Treatment Plan have been reviewed with the patient and/or family/legal representative. The patient has been given an opportunity to ask questions and provide feedback on the revisions to the Interdisciplinary Treatment Plan...Patient Signature: Blank [no signature noted] ..."

Review of MR7's "Interdisciplinary Treatment Plan Update", dated 5/6/24, stated, "...Treatment Team/Conference Date: May 6, 2024....Patient/ Family/ Legal Representative Involvement: Changes in the Treatment Plan have been reviewed with the patient and/or family/legal representative. The patient has been given an opportunity to ask questions and provide feedback on the revisions to the Interdisciplinary Treatment Plan...Patient Signature: Blank [no signature noted] ..."


3. There was no evidence that the interdisciplinary treatment plan reflected the involvement of nursing for 2 of the 5 (MR6 and MR7) patients sampled.

Review of MR6 revealed:

"Interdisciplinary Treatment Plan Master Sheets", dated 6/4/24, stated, "...Date of Admission: 6/4/24...Staff Signatures of those involved in the Treatment Plan and Physician Approval of the Treatment Plan...Nursing: Blank [no signature noted] ..."
"Interdisciplinary Treatment Plan Update", dated 6/14/24, stated, "...Treatment Team/Conference Date: 6/14/24...Nurse Signature/Credentials....Blank [no signature noted] ..."

Review of MR7 revealed:

"Interdisciplinary Treatment Plan Update", dated 5/10/24, stated "...Treatment Team/Conference Date: May 10, 2024... Nurse Signature/Credentials....Blank [no signature noted] ..."
"Interdisciplinary Treatment Plan Update", dated 5/20/24, stated "...Treatment Team/Conference Date: May 20, 2024... Nurse Signature/Credentials....Blank [no signature noted] ..."
"Interdisciplinary Treatment Plan Update", dated 6/7/24, stated "...Treatment Team/Conference Date: June 7, 2024... Nurse Signature/Credentials....Blank [no signature noted] ..."