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Based on a review of facility policies, procedures, staffing assignment numbers and interview, the facility failed to provide sufficient staffing to meet minimum safe staffing levels on 11(eleven) of 11 shifts as stipulated by the facility's staffing policy.

Findings include:

Review of facility policy #1390 entitled 'Unit Staffing, Nursing Services', last revised 4/7/2016 revealed that the nursing Department will maintain staffing that supports safe, efficient individual and quality care for each individual on each unit for the hospital.

Review of the staffing assignments for a two month interval for 3 (three) of three patient care units (East, West and Central) revealed that the facility failed to provide sufficient staffing to meet minimum safe staffing levels on 11 of 23 shifts reviewed. On 11 out of 23 days, there was inadequate nurse coverage according to the facility's standards.

During an interview at 4:17 p.m. on 4/19/2016, in the Administrative conference room the Chief Nursing Officer (CNO) admitted that the coverage for some shifts lacked sufficient licensed staff.

Based on observation, interview, and record review, the facility failed to:

I. Develop treatment plans that clearly delineated physician and nursing interventions to address the specific treatment needs of eight (8) of eight (8) sample patients (C12, C22, C33, E12, E19, W4, W29 and W33). Instead, the majority of physician and nursing interventions were listed as routine, generic discipline functions that lacked focus for treatment. This resulted in treatment plans that failed to reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment. (Refer to B122)

II. Provide active psychiatric treatment for four (4) of eight (8) active sample patients (C12, C33, W4 and W29) who were unable or not motivated to attend assigned treatment groups on each individual activity schedule. The patients regularly and repeatedly did not attend groups assigned. Treatment plans for these patients failed to include alternative modalities, including one to one intervention with staff. The lack of participation in assigned treatment modalities by patients negates the clinical effectiveness of the patients' treatment goals, potentially delaying their improvement. (Refer to B125, Section I)

III. Ensure that patients in the facility received sufficient hours of therapeutic activities and sufficient number of therapeutic groups on evening hours and on weekends. On evenings and weekends, no treatment groups were offered. Failure to provide sufficient hours of active treatment prevents and jeopardizes patients from achieving their optimal level of functioning thereby potentially delaying a timely discharge. (Refer to B125, Section II)

Based on observation and record review, the facility failed to develop written treatment plans with concrete measurable long term goals in eight (8) of eight (8) active sample patients (C12, C22, C33, E12, E19, W4, W29 and W33). Instead all long term goals in the treatment plans were non-measurable. This failure makes impossible systematic assessment of patients' progress toward a degree of recovery that permits discharge.

A. Record Review

1. Patient C12:

In the Treatment Plan, dated 5/19/15, the long term goal is defined as, "to develop a recovery plan to increase stabilization in the community and decrease readmissions."

2. Patient C22:

In the Treatment Plan, dated 1/16/15, the long term goal is defined as, "to decrease aggressive incidents by 7/13/16."

3. Patient C33:

In the Treatment Plan, various long term goals are formulated at several points of treatment plan review. On 6/15/15, the long term goal is defined as, "to manage the symptoms of his mental illness [by] 6/10/2016." On 2/15/16, the long term goal is defined as, "for C33 to be able to identify the benefits of leisure activities in the community and how to advocate for himself [by] 3/10/16." Also on 2/15/16, the long term goal is defined as, "to improve the individual's ability to communicate with the team and other individuals."

4. Patient E12:

In the Treatment Plan various long term goals are formulated at several points of treatment plan review. On 10/31/13, the long term goal is defined as, "to learn coping techniques to decrease intensity of symptoms [by] 5/28/16." Also on 10/31/13, the long term goal is defined as, "to have increased positive interaction with peers and staff in social settings and actively participate in groups and activities [by] 5/28/16." On 1/29/16, the long term goal is defined as, "for E12 to develop tools to help decrease readmissions and duration of admissions, and increase stabilization in community [by] 5/28/16."

5. Patient E19:

In the Treatment Plan, revision date of 4/8/16, the long term goals are stated as "The goal is for medication stabilization by 4/25/16," and "Seek healthier alternatives to cope with situation and manage [his/her] psychiatric problems effectively."

6. Patient W4:

In the Treatment plan, dated 4/11/16, the long term goals are stated as "The goal is for [Patient] to manage the symptoms for [his/her] mental illness by 4/22/16" and "The goal is for [Patient] manage (sic) [his/her] violence towards others by 5/7/16."

7. Patient W29:

In the Treatment Plan, with revision dated 4/8/16, the long term goals are stated as "The goal is to learn that drinking alcohol can result in negative consequences" and "The goal is to learn to decrease the symptoms of [his/her] mental illness."

8. Patient W33:

In the treatment Plan, dated 4/4/16, the long term goal is stated as "The goal is to manage the symptoms of [his/her] mental illness."

B. Staff Interview:

In an interview with the Medical Director on 4/20/16 at 09:05 AM, the Medical Director concurred that the long term goals were formulated in an overly general fashion and lacked concreteness and measurability. He added that the facility is in the process of adjusting the requirements for formulating long term goals.

Based on record review and interview, the facility failed to develop treatment plans that clearly delineated physician and nursing interventions to address the specific treatment needs of eight (8) of eight (8) sample patients (C12, C22, C33, E12, E19, W4, W29 and W33). Instead, the majority of physician and nursing interventions were listed as routine, generic discipline functions that lacked focus for treatment. This resulted in treatment plans that failed to reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment.

Findings include:

A. Record Review

1. Patient C12:

In the Treatment Plan dated 5/19/15, for problem stated as "...high risk Victimization...," there were no identified nursing interventions to monitor and prevent victimization of the patient. For problems identified as "...expressing suicide intent and self-harm..." and "reported auditory hallucinations," the only nursing interventions were listed as expected role functions related to administration of medications. There were no specific nursing interventions to address nursing care in the clinical area for these stated problems.

2. Patient C22:

In the Treatment Plan dated 1/16/15, for problem, "physical aggression," there was no physician or nursing interventions to address this safety risk.

3. Patient C33:

In the Treatment Plan with revision date of 4/13/16, for problems stated as "presented disorganized, flat affect, and guarded due to [his/her] mental illness" and "important for [him/her] to learn proper social skills and how to advocate for [himself/herself] in the community," there were no physician or nursing interventions to address these problems resulting in hospitalization.

4. Patient E12:

In the Treatment Plan with revision date of 4/1/16, for problem stated as "presents with paranoid beliefs...has a history of non-adherence with medication and outpatient mental health services," the only physician intervention was listed as a generic role function: "will meet with [Patient] for 20 minutes weekly on East Unit to prescribe medication, determine medication effectiveness, monitor side effects and educate about the benefits of taking the medication as prescribed." There were no identified nursing interventions to address these psychotic symptoms in the clinical area.

5. Patient E19:

In the Treatment Plan with revision date of 4/8/16, for problem, "disorganized behavior...reacting to internal stimuli...," the only physician intervention was listed as a generic role function: "will meet with [Patient] 20 minutes weekly on the East Unit to prescribe medication, determine medication effectiveness, monitor side effects and educate about the benefits of taking the medication as prescribed." There were no identified nursing interventions to address these psychotic symptoms in the clinical area.

For the problem, "high risk for aggression due to verbal aggression in previous hospital, admission and documented in previous admission," there are no physician or nursing interventions to address this potential safety risk in the patient environment.

6. Patient W4:

In the Treatment Plan dated 4/11/16, for the problem, "demonstrates disorganized and delusional behavior due to [his/her] mental illness. [S/he] has as history of being non-compliant with [his/her] medications," the only physician intervention was listed as a generic role function: "will meet with [Patient] twice a week for 20 minutes to prescribe, assess side effects, and educate on the importance of medication adherence." There were no specific nursing interventions to direct nursing personnel in the specific monitoring of this patient and what to do if the psychotic symptoms were shown in the clinical area. The only prevention intervention for nursing was education in a group structure even though this patient was refusing to attend groups.

For the problem, "...long history of violence towards others," there was no physician or nursing interventions to address this safety risk in the clinical area.

7. Patient W29:

In the Treatment Plan with revision date of 4/8/16, for problem stated as "Mood Disorder NOS and reported depression and anxiety" and "has significant executive functioning and memory impairment," the only nursing interventions for these foci of Patient W29's reason for hospitalization were two (2) medication management classes weekly. These classes were identified for both patient problems.

8. Patient W33:

In the treatment Plan, dated 4/4/16, for problem listed as "suicidal ideations, depression and auditory hallucinations," the only physician intervention was listed as a generic role function: "will meet with the individual for 20 minutes twice a week on West Unit to prescribe medication, assess effectiveness of medications, monitor side effects, and educate about the benefits of medication adherence." There were no nursing interventions to address this safety problem in the clinical area.



B. Interview

During interview, including review of treatment plans, on 4/19/16 in the afternoon, the Director of Nursing stated, "I know it is an issue (absence of nursing interventions especially for safety issues). These plans do not capture many interventions. They are not evident in the care plans." She reported that there are nursing plans separate from the master treatment plans, but these plans only address medical issues.

Based on observation, interview, and record review, the facility failed to:

I. Provide active psychiatric treatment for four (4) of eight (8) active sample patients (C12, C33, W4 and W29) who were unable or not motivated to attend assigned treatment groups on each individual activity schedule. The patients regularly and repeatedly did not attend groups assigned. Treatment plans for these patients failed to include alternative modalities, including one to one intervention with staff. The lack of participation in assigned treatment modalities by patients negates the clinical effectiveness of the patients' treatment goals, potentially delaying their improvement.

II. Ensure that patients in the facility received sufficient hours of therapeutic activities and sufficient number of therapeutic groups on evening hours and on weekends. On evenings and weekends, no treatment groups were offered. Failure to provide sufficient hours of active treatment prevents and jeopardizes patients from achieving their optimal level of functioning thereby potentially delaying a timely discharge.

Findings include:

I. Provide active psychiatric treatment

A. Patient Findings:

1. Patient C12

a. During an observation on 4/18/16 at 2:45p.m., at the time of the scheduled activity "Avoiding Aggression" therapy group, Patient C12 was observed continuing to lie on her bed, awake, as earlier in the day, with a sitter by the door. On 4/19/16, at 09:30, the patient was in her room, door closed, asleep on observation. A sitter was sitting outside the room.

b. During an interview with RN1 on 4/18/16, she explained that C12 "has behavior problems," and that "she doesn't go to groups, except art group once in a while." She said that there was some individual therapy offered instead, but that this consisted primarily in the sitter keeping C12 company. On 4/19/16, at 09:30 AM, RN2 was asked about the treatment plans for the day as the patient was asleep in her bed at the time. RN2 explained that "she just sits in her room, but she has behavior guidelines." The sitter was pointed out as "her 1:1" and in addition, "the doctor talks to her about anger management." 2. Patient C33

2. Patient C33

a. During an observation on 4/18/16 at 2:45p.m., at the time of the scheduled activity Avoiding Aggression therapy group, Patient C33 was observed lying on his bed with no one else in the room.

b. During an interview with BHT1 at 2:50 PM on 4/18/16, as he showed the surveyor into the room of C33, BHT1 explained that as the trained interpreter leaves the facility at 2:00 PM, there is no way C33 can benefit from participation in groups and was therefore permitted to remain in his bedroom. In an interview with the medical director on 4/19/16, at 11:00 AM, he acknowledged that outside the time an interpreter is present (8:00 a.m.- 2:00 p.m.), communication is difficult although a previous interpreter "gave us some cards to use," so that participation in psychosocial therapies is impractical.

c. Review of medical records failed to show that alternative activities based on his/her needs were offered after 2:00 p.m. and on week-ends.

3. Patient W4 was admitted to the facility on 4/7/16.

a. During an observation on 4/19/16 at 11:30 a.m., Patient W4 was asleep in his/her assigned room during a unit group to which s/he was assigned (s/he was not assigned to the treatment mall). When asked why s/he was in bed at this time of day, Patient W4 replied, "I played ball and was tired." When asked why s/he was not attending the unit group, s/he replied, "I did not know one was going on. Am I supposed to be attending a group now?"

b. During meetings with Activity Therapists on 4/19/16 in a.m. and again on 4/19/16 in the p.m., AT1 reported that activity therapists meet with patients who do not attend treatment groups 3 times daily Monday through Friday. A review of Patient 4's medical record notes from 4/11/16-4/18/16 failed to show such documentation.

c. Review of Patient W4's medical record revealed a technician note documented on 4/13/16 at 2:02 p.m. stating, "Individual had a quiet day. [S/he] slept most of the day." Another technician note documented on 4/13/16 at 10:22 p.m. stated, "[Patient] rested in [his/her] room most of the shift." Another technician note documented on 4/14/16 at 1:31 p.m. stated, "...stayed in [his/her] room most of this shift."

d. Review of the Observation Flow Sheet for Patient W4 from 4/11/15-4/18/16 revealed several hours each day when Patient remained in his/her assigned room except for fresh air break, for meals and snacks and to sit in the dayroom. Examples of long periods of time when s/he was in assigned room are: On 4/11/16 from 8:30 a.m. to 12:30 p.m. and from 3:30 p.m. to 6:00 p.m. On 4/14/16 from 9:00 a.m. to 11:00 a.m. On 4/17/16 from 8:00 a.m. to 10:30 a.m. and from 2:00 p.m. to 3:00 p.m. On 4/18/16 from 8:00 a.m. to 12:00 noon; from 3:30 p.m. to 4:30 p.m. and 6:00 p.m. to 11:30 p.m. Monitoring sheets were not provided for 4/12/16, 4/13/16, 4/15/16 and 4/16/16.

These monitoring sheets revealed attendance at only one (1) group activity on 4/18/16 at 2:00 p.m.

4. Patient W29 was admitted on 5/20/14.

a. An observation on 4/18/16 at 11:30 a.m. revealed Patient W29 with a sweatshirt hoodie on, covered up and asleep in his/her assigned bedroom. "When asked why s/he did not attend the assigned treatment mall, Patient W29 replied, I have to think about my meeting (about placement) on Wednesday."

b. An observation on 4/1/16 at 11:20 a.m. revealed Patient W29 standing by the ward telephone with the phone lying off of the hook. When asked about the phone, s/he reported that s/he was waiting for social security to answer the phone.

c. Review of treatment mall attendance sheets revealed that Patient W29 failed to attend six (6) of 12 assigned days at the treatment mall between 4/4/16 and 4/19/16. These dates were 4/4/16, 4/5/16, 4/8/16, 4/11/16, 4/18/16 and 4/19/18.

d. Review of Patient W29's medical record revealed a technician note documented on 4/4/16 at 1:40 p.m. stating, "...slept most of the shift." Another technician note documented on 4/5/16 at 1:30 p.m. stated, "Individual participated in leisure activities of choice such as socializing and watching television." Another technician note documented on 4/8/16 at 1:23 p.m. stated, "Individual refused to go to treatment mall. [S/he] slept most of the shift." A technician note on 4/11/16 at 2:45 p.m. documented "...in and out of personal room interacted (sic) with peers, use (sic) the telephone."

e. Review of treatment mall "Facilitator Progress Notes" for Patient W29's documented that this patient failed to attend many of assigned groups/activities while in the mall. These notes documented that this patient failed to attend two (2) of three (3) groups on 4/6/16, three (3) of three (3) groups on 4/7/16 and one (1) of three (3) groups on 4/14/16.

II. Failure to provide sufficient individualized therapeutic modalities including evenings and weekends.

A. Document Review

A review of the "Patient Group Schedule" for each unit presented by the facility as the current programming schedules indicated no active treatment groups were provided Monday through Friday after 4:00 PM and none on Saturdays and Sundays. The only activity scheduled on the weekends was 1-2 "Relaxation Groups" for each patient unit.

B. Staff Interviews

1. During interview on 4/18/16 in the afternoon, after reviewing the weekly schedules with the surveyor, the Director of Activity Therapy stated that "there are not sufficient groups/activities offered on evenings and weekends."

2. During an interview with the Director of Social Work, on 4/19/16, at 1:30 PM, he explained that Social Workers run no therapy groups on weekends and only one per week on the units. All other social work groups occur in the Treatment Mall.

Based on observation, interview and document review, the facility failed to ensure that a registered nurse (RN) was immediately present on all locked patient care areas on three (3) of three (3) patient care units (East, West and Central) on all shifts of duty. For eight (8) of 21 shifts of duty during the week of April 12 to April 18, 2016 (first day of the survey) there was only 1 RN assigned to cover both sides (1 male wing and 1 female wing) of designated units. At times, when an RN was assigned to each of the two wings of a unit, the RN left the assigned patient wing for various purposes (team meeting, trip to nursing station on other wing, to prepare or obtain medications in the hallway between the two locked patient wings, etc.). This staffing resulted in one of the wings being without a professional nurse to assess, monitor and supervise patient care and paraprofessionals (LPNs and Mental Health Technicians) for periods of time. This staffing pattern hinders quality patient care and results in a safety risk for all patients on all three locked units. (Refer to B150)

In addition, there was failure to provide adequate clinical leadership by medical and nursing leadership to monitor and evaluate care to patients. This resulted in patients receiving inappropriate care and the lack of monitoring of inpatient care by the Medical Director as documented in B144 and lack of supervision of active nursing care delivered as documented in B148.

The Medical Director of the facility failed to monitor and evaluate the quality and appropriateness of services and treatment provided by the medical staff as evidenced by the facility's failure to provide active psychiatric treatment for three (3) of eight (8) active sample patients (C12, C33, and W29) who were unable, unwilling, or not motivated to attend assigned treatment groups on each individual activity schedule.

For details, see B121, B122, and B125

Based on interview and document review, the Nursing Director failed to:

I. Ensure nursing interventions were included in the Master Treatment Plans (MTPs) based on the individual needs of eight (8) of eight (8) active sample patients (C12, C22, C33, E12, E19, W4, W29 and W33). This failure resulted in absence of specific plans to direct nursing personnel in the implementation, evaluation and revision of care to reflect progress/lack towards recovery.

Findings include:

A. Record Review

1. Patient C12:

In the Treatment Plan dated 5/19/15, for problem stated as "...high risk Victimization...," there were no identified nursing interventions to monitor and prevent victimization of the patient. For problems identified as "...expressing suicide intent and self-harm.." and "reported auditory hallucinations, the only nursing interventions were listed as expected role functions related to administration of medications." There were no specific nursing interventions to address nursing care in the clinical area for these stated problems.

2. Patient C22:

In the Treatment Plan dated 1/16/15, for problem, "physical aggression," there was no physician or nursing interventions to address this safety risk.

3. Patient C33:

In the Treatment Plan with revision date of 4/13/16, for problems stated as "presented disorganized, flat affect, and guarded due to [his/her] mental illness" and "important for [him/her] to learn proper social skills and how to advocate for [himself/herself] in the community," there were no nursing interventions to address these problems resulting in hospitalization.

4. Patient E12:

In the Treatment Plan with revision date of 4/1/16, for problem stated as "presents with paranoid beliefs...has a history of non-adherence with medication and outpatient mental health services," there were no identified nursing interventions to address these psychotic symptoms in the clinical area.

5. Patient E19:

In the Treatment Plan with revision date of 4/8/16, for problem, "disorganized behavior...reacting to internal stimuli...," there were no identified nursing interventions to address these psychotic symptoms in the clinical area.

For the problem, "high risk for aggression due to verbal aggression in previous hospital, admission and documented in previous admission," there are no nursing interventions to address this potential safety risk in the patient environment.

6. Patient W4:

In the Treatment Plan dated 4/11/16, for the problem, "demonstrates disorganized and delusional behavior due to [his/her] mental illness. [S/he] has as history of being non-compliant with [his/her] medications," there were no specific nursing interventions to direct nursing personnel in the specific monitoring of this patient and what to do if the psychotic symptoms were shown in the clinical area. The only prevention intervention for nursing was education in a group structure even though this patient was refusing to attend groups.

For the problem, "...long history of violence towards others," there were no nursing interventions to address this safety risk in the clinical area.

7. Patient W29:

In the Treatment Plan with revision date of 4/8/16, for problem stated as "Mood Disorder NOS and reported depression and anxiety" and "has significant executive functioning and memory impairment," the only nursing interventions for these foci of Patient W29's reason for hospitalization were two (2) medication management classes weekly. These classes were identified for both patient problems.

8. Patient W33:

In the treatment Plan, dated 4/4/16, for problem listed as "suicidal ideations, depression and auditory hallucinations," there were no nursing interventions to address this safety problem in the clinical area.

B. Interview

During interview, including review of treatment plans, on 4/19/16 in the afternoon, the Director of Nursing stated, "I know it is an issue (absence of nursing interventions especially for safety issues). These plans do not capture many interventions. They are not evident in the care plans." She reported that there are nursing plans separate from the master treatment plans, but these plans only address medical issues.

II. Ensure a registered nurse (RN) was immediately present on all locked patient care areas on three (3) of three (3) patient care units (East, West and Central) on all shifts of duty. For eight (8) of 21 shifts of duty during the week of April 12 to April 18, 2016 (first day of the survey) there was only 1 RN assigned to cover both sides (1 male wing and 1 female wing) of designated units. At times, when an RN was assigned to each of the two wings of a unit, the RN left the assigned patient wing for various purposes (team meeting, trip to nursing station on other wing, to prepare or obtain medications in the hallway between the two locked patient wings, etc.). This staffing resulted in one of the wings being without a professional nurse to assess, monitor and supervise patient care and paraprofessionals (LPNs and Mental Health Technicians) for periods of time. This staffing pattern hinders quality patient care and results in a safety risk for all patients on all three locked units. (Refer to B150)

Based on observation, interview and document review, the Director of Nursing failed to ensure a registered nurse (RN) was immediately present on all locked patient care areas on three (3) of three (3) patient care units (East, West and Central) on all shifts of duty. For eight (8) of 21 shifts of duty during the week of April 12 to April 18, 2016 (first day of the survey) there was only 1 RN assigned to cover both sides (1 male wing and 1 female wing) of designated units. At times, when an RN was assigned to each of the two wings of a unit, the RN left the assigned patient wing for various purposes (team meeting, trip to nursing station on other wing, to prepare or obtain medications in the hallway between the two locked patient wings, etc.). This staffing resulted in one of the wings being without a professional nurse to assess, monitor and supervise patient care and paraprofessionals (LPNs and Mental Health Technicians) for periods of time. This staffing pattern hinders quality patient care and results in a safety risk for all patients on all three locked units.

Findings include:

A. Description of Units:

This facility serves male and female adult patients with acute psychiatric/behavioral problems, many with complicated medical issues. All three units (East, West and Central) have 2 sides (wings) that are connected by a hallway and 2 locked doors. The medication room serving both wings (male and female) is in the hallway with one locked door between it and each wing. In addition, on two of the three units there is only 1 nursing station to serve both wings. If a Registered Nurse is one side of the unit, s/he must go through 2 locked doors and down a hallway to get to the other wing. If s/he is in the medication room, s/he must go through one locked door and down a hallway to get to the either patient wing.

B. Specific Findings:

1. East Unit is a 29-bedbed acute admission unit for male and female adults.

a. Review of the Patient Nursing Needs Assessment completed by a RN on the first day of the survey (4/18/16) revealed a census of 27 patients. Their nursing needs included: one (1) patient required diabetic checks, one (1) patient required skin care, ONE (1) patient was on seizure precautions, three (3) patients were potentially assaultive, one (1) patient was actively assaultive, two (2) patients were actively experiencing hallucinations/delusions, one (1) patient had recent off grounds appointment, two (2) patients were on assault precautions, two (2) patients were on fall precautions, three (3) patients were constantly demanding staff time, two (2) were on special monitoring due to eating disorders, three patients were on 1:1 supervision and one patient was on line of sight supervision.

b. The "Direct Nursing Staffing Form" completed by the Nurse Supervisor for 7 days including the first day of the survey (4/18/16) revealed the following shifts of duty when there was only 1 RN assigned for both sides (wings) of East Unit.

--On 4/12/16 there was only 1 RN assigned on the evening shift to provide direction and supervision for both male and female wings.

--On 4/14/16 there was only 1 RN assigned on the night shift to provide direction and supervision for both male and female wings.

--On 4/17/16 there was only 1 RN assigned on the day shift to provide direction and supervision for both male and female wings.

2. West Unit is a 42-bed acute unit for male and female adults.

a. Review of the Patient Nursing Needs Assessment completed by a RN on the first day of the survey (4/18/16) revealed a census of 40 patients. Their nursing needs included: two (2) patients required diabetic checks, one (1) patient required skin care, 14 patients were potentially assaultive, two (2) patients were actively assaultive, two (2) patients were a low risk for suicide, 20 patients took medications reluctantly, four (4) patents had difficultly taking medications, one (1) patient had off grounds appointment, four (4) patients were on elopement precautions, and two (2) patients were on fall precautions.

b. The "Direct Nursing Staffing Form" completed by the Nurse Supervisor for 7 days including the first day of the survey (4/18/16) revealed the following shifts of duty when there was only 1 RN assigned for both sides (wings) of West Unit.

--On 4/13/16 there was only 1 RN assigned on the day, evening and night shifts of duty to provide direction and supervision for both male and female wings.

--On 4/18/16 there was only 1 RN assigned on the evening shift to provide direction and supervision for both male and female wings.

3. Central Unit is a 38- bed unit for male and female adults.

a. Review of the Patient Nursing Needs Assessment completed by a RN on the first day of the survey (4/18/16) reveled that there was a census of 32 Patients. Their nursing needs included: two (2) patients required diabetic checks, three (3) patients were on seizure precautions, two (2) patients required skin care, one (1) patient was potentially assaultive, three (3) patients were actively assaultive, four (4) patients were a low risk for suicide, 17 patients were experiencing hallucinations/delusions, 22 patients took medications reluctantly, 10 patents had difficultly taking medications, five (5) patients were admitted during the last 48 hours, four (4) patients were on assault precautions, one (1) patient was on elopement precautions, three (3) patients were on fall precautions, 10 patients were constantly demanding staff time, six (6) patients were on special monitoring due to eating disorders, one (1) patient was on 1:1 supervision and three (3) patients were on line of sight supervision.

b. The "Direct Nursing Staffing Form" completed by the Nurse Supervisor for 7 days including the first day of the survey (4/18/16), revealed that on 4/15/16 there was only 1 RN assigned on the night shift of duty to provide direction and supervision for both male and female wings of Central Unit.

C. Observations and Interviews

1. During observations of the male wing of West Unit on 4/18/16 at 11:10 a.m., all RNs (RN3, RN4, RN5 and RN9) assigned to both male and female wings were in the nursing station on the male side. This included the Nurse Manager and the Charge nurse for the West Unit. When asked about the RN assignments for this shift, RN4 stated that RN9 was giving medications at this time and that RN 5 was currently responsible for both wings, but was currently assigned on the male wing. When asked what staff were on the female wing at this time since all RNs were presently on the male wing, RN 4 responded, "2 mental health technicians are over there."

2. During interview on the female side of West Unit on 4/18/16 at 12:10 p.m., RN 4 reported, "We used to make sure that there was always a RN on each of the wards [wings]. Apparently it changed due to staffing." When asked how this affected patient care, RN replied, we can't get everything done. "A RN usually stays on the female side after treatment team is over." She reported that the treatment team may be held on either the male or female side.

3. During interview on the male wing of the East Unit on 4/18/16 at 1:30 p.m., RN6 reported that a total of 3 RNs are assigned to East Unit today including the nurse manager and the charge nurse. She stated that currently she was remaining on the male wing, and that the other RN was giving medications along with the LPN. She added that the RN was in the medication room (outside of locked door) when preparing medications or when s/he went to the medication room to obtain a medication dose, at other times she was on the patient unit. She reported that the nurse manager is not always available on one of the wings. When asked if there was an RN on the female side at this time, she responded, "No." She reported that the nurse on the other side could be an LPN or an RN.

4. During interview on the female wing of Central Unit on 4/19/16, RN2 reported that when there is only 1 RN assigned for both the male and female wings of the unit, the RNs stays on one wing and makes rounds at least hourly on the other patient wing. She added that the RN also goes to the other wing "as needed."

5. During interview on 4/20/16 at 9:50 a.m., RN10 reported that it was more likely that only 1 RN was assigned responsibility for both wings of a unit on weekends. She stated, "When I am the only RN on a Unit, I stay on the male wide where the nursing station is (located), the LPN stays on the female side. I make rounds on the female side every hour and as needed." I usually eat lunch on the ward [wing]. "If I have to leave the ward, I call the nurse coordinator to come." When asked what impact the presence of only 1 RN has on patient care, she responded, "It would be better, we have new admissions and patient situations that need care (sic)."

6. During interview on 4/20/16 at 10:10 a.m., RN 11 reported that when she works on the unit without another RN assigned to the unit, she "moves from male to female side. The LPN stays on the other side." She stated that "the LPN calls the RN when there are patient incidents, when patients get agitated and anything abnormal." When asked if there have been times when she has not been able to go immediately when the LPN has called for her to come to the other unit, she responded, "Yes, sometimes I have to intervene with a patient. The patient may demand, 'I want Ms [staff's name]'. I have to make sure that patient is OK before I leave. Then, of course, I have to go (to the other wing)." She reported that she usually eats a snack on the unit, rather than going off the unit. She added, "I may leave briefly to go get something or go to the bathroom." When asked where she would go, she replied, "Just outside the locked door," indicating out of the unit.