HospitalInspections.org

Based on observation, record review, and interview the hospital failed to meet the Conditions of Participation (CoP) of Patient Rights as evidenced by the hospital failing to perform every 15 minute observation checks on 10 (#3, #5 - #8, #11 - #15) of 12 (#3 - #14, #16) patients with physician orders for Routine Levels of Observation on the night shift of 03/18/2024. (See findings under Tag A0144).

An Immediate Jeopardy (IJ) situation was identified on 03/19/2024 at 12:20 p.m. and reported to S1ADM, S2CNO, S3DQ, S6LS, S11CMO, S12VPO, S13CNOC, S14CC and S15CCEOC. The Immediate Jeopardy situation was a result of the hospital failing to complete 15 minute observation checks as ordered by the physician

On 03/20/2024 at 10:28 a.m. S2CNO presented the plan for lifting the immediacy of the IJ situation via email to state office. The plan included the following:
1. On 3/18/2024, S4DBHC implemented a change in procedure whereby the nurse was to complete a patient check every 2 hours. A revision to the 15 Minute Check Patient Observation Record form was made and staff were educated on the need to perform Q15-minute observations on all patients as ordered. Completed 03/18/2024;
2. S4DBHC met with staff to review Policy PC-1013: Levels of Patient Observation and Policy PC-1014: Patient Observation Record (15 Minute Check Sheet). Completed 03/19/2024;
3. Night shift staff were interviewed and counseled regarding their failure to ensure that the Insights BHU patients received care in a safe setting. An Employee Conference Report was completed for each employee, indicating corrective action taken as a Final Written Warning. Completed 03/19/2024;
4. Administrative staff to perform random, in-person spot checks of the patient observation process to ensure that appropriate and accurate patient monitoring is occurring per policy. Initiated on 03/19/2024 for 48 hours;
5. Following the random, in-person spot checks that occurred on 3/19/24 and 3/20/24, it was found that an employee had inconsistencies in their Q15 minute documentation despite education given to the employee on 3/19/24. S9CMA will be terminated. To be completed on 03/20/2024;
6. A new Performance Improvement (PI) monitor will be implemented immediately whereby licensed nursing staff will randomly audit Patient Observation Records in real time, at least 3 times per shift. Licensed nurse is expected to address any deficiencies on the spot and report the findings on the Q15 Audit Log, which is to be submitted to the Nurse Manager nightly. The Nurse Manager is expected to address any fallouts with staff upon notification. Compliance with levels of observation will be monitored via PI monitor and results shall be reported to the PI Committee on a monthly basis. Initiated on 03/20/2024;
7. All staff will attend a retraining prior to their next shift. Ongoing; and
8. Administrative staff reviewed security video footage of Q-15 monitoring last night. Completed on 03/20/2024.

All documentation presented in the email was reviewed by state office and surveyor.

On 03/20/2024 at 1:38 p.m. the Immediate Jeopardy was removed.

Based on observation, record review and interview, the hospital failed to provide care in a safe setting. This deficient practice is evidenced by:
1) Failing to perform every 15 minute observation checks on 10 (#3, #5 - #8, #11 - #15) of 12 (#3 - #14, #16) patients with physician orders for Routine Levels of Observation on the night shift of 03/18/2024;
2) Failing to perform every 15 minute observation checks 5 (#10, #11, #12, #14, #16) of 13 (#3 - #14, #16) patients with physician orders for Routine Levels of Observation on the day shift of 03/18/2024;
3) Observation of toilet seats and metal toilet paper dispensers in 15 (#a - #o) of 15 (#a - #o) patient rooms creating ligature points;
4) Observation of electric hospital beds with rails in 7 (#a - #d, #k - #n) of 15 (#a - #o) patient rooms with ligature points on each bed.
Findings:

A review of facility policy, "Subject: Levels of Patient Observation," with an effective date of 1995 and last reviewed: 05/2023 revealed in part, Policy: All patients are monitored as to their location and activity at regular intervals. The degree of this monitoring is dependent upon the individual patient's assessed psychiatric condition. Procedure: The charge nurse is responsible, in conjunction with the staff providing direct patient care, to assess the level of observation to each patient. Item A: Routine Levels of Observation includes: 1) all patients are monitored a minimum of once every 15 minutes, 3) staff assigned to the charting on patients will include documentation in the Nursing Progress Notes as to the location and frequency of checks.

A review of the New and Floating Nurse Orientation checklist revealed in part, Item Charting: nurses chart once per shift, unless something unexpected happens, then the event or behavior is to be documented as well. Nurses round on patients at least every two hours, but this rounding can be captured once in the B-I-R-P notes.

A review of the Mental Health Tech Orientation Process checklist revealed in part, Task: Patient Safety, a check off for each of the following: Fall Prevention/Fall Huddles and Monitoring (1:1, q15, never leaving pts alone). It also included Task: Associate Engagement and Responsibilities which revealed in part, a check off for Walking Rounds. This orientation check list did not reveal any items regarding the check off of charting observation checks.

1) Failing to perform every 15 minute observation checks on 10 (#3, #5 - #8, #11 - #15) of 12 (#3 - #14, #16) patients with physician orders for Routine Levels of Observation on the night shift of 03/18/2024
An observation on 03/19/2024 at 10:00 a.m. with S6LS presenting video recorded on the Insights Behavioral Unit from 03/18/2024 at 10:00 p.m. to 03/19/2024 at 5:20 a.m. revealed the following:
The review consisted of 3 different cameras capturing all the hallways and patient rooms. The camera capture of the day room is very limited to an edge of the room by Camera SC401-404.
Camera SC405-409 view covers the hallway by rooms #e - #i. Video observed from 03/18/2024 at 11:30 p.m. to 03/19/2024 at 5:00 a.m. revealed an MHT walking across the hallway at 11:57 p.m. and 2:14 a.m. with no indication of a patient observation taking place. The MHT opens the door of room #e and #h at 2:38 a.m.
Camera SC401-404 view covers the hallway by rooms #a - #d. Video observed from 03/18/2024 at 10:01 p.m. to 03/19/2024 5:06 a.m. revealed patient movement at 10:01 p.m., day room movement at 10:36 p.m. and nurse movement on the hall at 5:06 a.m.
Camera SC410-415 view covers the hallway by rooms #j - #o. Video observed from 03/18/2024 at 10:33 p.m. to 03/19/2024 at 5:19 a.m. revealed an MHT in room #j at 10:33 p.m., patient in the hallway at 4:22 a.m., an MHT in hallway at 5:06 a.m. - opens a patient door, and a nurse enters room #j at 5:19 a.m.
The video revealed a 5 hour time span (11:00 p.m. to 4:00 a.m.) of limited to no activity on the hall ways of the unit.
A review of the Patient Observation Records revealed all 12 patients on the Insights Unit during the night shift of 03/18/2024 had documentation of observation checks being performed from 11:00 p.m. to 4:00 a.m.

In an interview on 03/19/2024 at 10:45 a.m. S6LS confirmed the above mentioned findings on video.

In an interview on 03/19/2024 at 11:00 a.m. S3DQ and S4DBHC confirmed the above mentioned findings.

In an interview on 03/19/2024 at 5:00 p.m. S10MHT confirmed she worked on the night shift of 03/18/2024. She further confirmed patient observations were not performed every 15 minutes as documented and she did not want to leave Patients #9 and #10 unattended in the day room because they were active and restless.

In an interview on 03/19/2024 at 5:10 p.m. S8LPN confirmed she worked on the night shift of 03/18/2024. She confirmed she documented the completion of observation checks being performed, but did not complete them.

In an interview on 03/19/2024 at 5:25 p.m. S9MHT confirmed she worked on the night shift of 03/18/2024. She confirmed the patient observations were not performed every 15 minutes because she did not want to leave Patients #9 and #10 unattended in the day room and she does not want to disturb the patients while sleeping. S9MHT was asked about her routine for observing patients, she replied, "If you wake the patients up, they will not go back to sleep and they up roaming the halls. I try not to disturb them, if you open the door, they wake up." S9MHT was asked how often she observed the patients, she replied, "If you understaffed, how ya gonna check them all. Are you saying we need to check them every 2 hours."

In an interview on 03/20/2024 at 8:25 a.m. S7RN confirmed she worked the night shift on 03/18/2024. She further confirmed patient observations were not performed by her and when she signed her name on the Patient Observation Record, she was thinking it was to ensure the MHTs were completing their rounds. She was unaware it was for the nurse to observe the patient at that time.

2) Failing to perform every 15 minute observation checks 5 (#10, #11, #12, #14, #16) of 13 (#3 - #14, #16) patients with physician orders for Routine Levels of Observation on the day shift of 03/18/2024

During a tour of the BHU on 03/18/2024 at 3:20 p.m. a review of Patient Observation Records revealed 5 (#10, #11, #12, #14, #16) of 13 (#3 - #14, #16) patient Observation Records for the current day being incomplete. The records revealed the following:
Patient #10 was on every 15 minute checks with the last observation at 11:30 a.m.(3 hours, 50 minutes late);
Patient #11 was on every 15 minute checks with the last observation at 11:45 a.m. (3 hours, 35 minutes late);
Patient #12 was on every 15 minute checks with the last observation at 11:15 a.m. (4 hours, 5 minutes late);
Patient #14 was on every 15 minute checks with the last observation at 11:30 a.m. (3 hours, 50 minutes late); and
Patient #15 was on every 15 minute checks with the last observation at 1:15 p.m. (2 hours, 5 minutes late).

In an interview on 03/18/2024 at 3:25 p.m. S3DQ and S4DBHC confirmed the above mentioned findings.

3) Observation of movable toilet seats and metal toilet paper dispensers in 15 (#a - #o) of 15 (#a - #o) patient rooms creating ligature points

A facility tour of the BHU from 2:40 to 3:40 p.m. revealed 15 (#a - #o) of 15 (#a - #o) patient rooms with toilet seats and metal toilet paper dispensers that would be consider ligature risks.

In an interview on 03/18/2024 at 2:54 p.m. S2CNO, S3DQ, and S4DBHC confirmed the above mentioned findings.

4) Observation of electric hospital beds with rails in 7 (#a - #d, #k - #n) of 15 (#a - #o) patient rooms with ligature points on each bed

A facility tour of the BHU from 2:40 to 3:40 p.m. revealed 7 (#a - #d, #k - #n) of 15 (#a - #o) patient rooms with electric hospital beds with side rails and the underside framing of the bed exposed. All of these locations of the bed would be considered ligature points and exposes the patient a potential to electric shock if they were to attempt to plug the bed in to the wall socket.

In an interview on 03/18/2024 at 3:00 p.m. S2CNO, S3DQ, and S4DBHC confirmed the above mentioned findings.

Based on observation, record review, and interview the hospital failed to meet the Conditions of Participation (CoP) of Nursing Services. The deficient practice is evidenced by:

1). Failing to provide adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed (see finding in A0392);

2) Falsifing documentation of observation checks being performed by the MHT and RN on 10 (#3, #5 - #8, #11 - #15) of 12 (#3 - #14, #16) patients with physician orders for Routine Levels of Observation over a 5 hour time span (See findings in A0395);

3) No documentation of observation checks being performed by the MHT and RN on 5 (#10, #11, #12, #14, #16) of 13 (#3 - #14, #16) patients with physician orders for Routine Levels of Observation over a 5 hour time span.
(See findings in A0395);

4) the hospital failing to ensure the nursing care plan for each patient was kept current and reflected the patient's goals and the nursing care to be provided to meet the patient's needs (See findings in A0396); and

5) failing to provide adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer (See findings in A0398).

Based on record review and interview, the hospital failed to provide adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed.
Findings:

A review of the BHU staffing matrix revealed the number of staff to patient ratio with a census of 12 - 13 patients. Day Shift: RN-1, LPN-1, MHT-3. Evening Shift: RN-1, LPN-1, MHT-3.

A review of the staffing for 03/18/2024 and 03/19/2024 evening (night) shifts revealed a census of 12 patients each night. The staffing for each of those night shifts were RN-1, LPN-1, MHT-2.

In an interview on 03/20/2024 at 10:30 a.m. S3DQ and S4DBHC confirmed the above mentioned findings.

In an interview on 03/20/2024 at 8:20 a.m. S7RN confirmed the census and staff present on the night shifts she worked of 03/18/2024 and 03/19/2024.

Based on observation, record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care for each patient. This deficient practice is evidenced by:
1) Falsified documentation of observation checks being performed by the MHT and RN on 10 (#3, #5 - #8, #11 - #15) of 12 (#3 - #14, #16) patients with physician orders for Routine Levels of Observation over a 5 hour time span; and
2) No documentation of observation checks being performed by the MHT and RN on 5 (#10, #11, #12, #14, #16) of 13 (#3 - #14, #16) patients with physician orders for Routine Levels of Observation over a 5 hour time span.
Findings:

A review of facility policy, "Subject: Levels of Patient Observation," with an effective date of 1995 and last reviewed: 05/2023 revealed in part, Policy: All patients are monitored as to their location and activity at regular intervals. The degree of this monitoring is dependent upon the individual patient's assessed psychiatric condition. Procedure: The charge nurse is responsible, in conjunction with the staff providing direct patient care, to assess the level of observation to each patient. Item A: Routine Levels of Observation includes: 1) all patients are monitored a minimum of once every 15 minutes, 3) staff assigned to the charting on patients will include documentation in the Nursing Progress Notes as to the location and frequency of checks.

A review of the New and Floating Nurse Orientation checklist revealed in part, Item Charting: nurses chart once per shift, unless something unexpected happens, then the event or behavior is to be documented as well. Nurses round on patients at least every two hours, but this rounding can be captured once in the B-I-R-P notes.

A review of the Mental Health Tech Orientation Process checklist revealed in part, Task: Patient Safety, a check off for each of the following: Fall Prevention/Fall Huddles and Monitoring (1:1, q15, never leaving pts alone). It also included Task: Associate Engagement and Responsibilities which revealed in part, a check off for Walking Rounds. This orientation check list did not reveal any items regarding the check off of charting observation checks.

1) Falsified documentation of observation checks being performed by the MHT and RN on 10 (#3, #5 - #8, #11 - #15) of 12 (#3 - #14, #16) patients with physician orders for Routine Levels of Observation over a 5 hour time span

An observation on 03/19/2024 at 10:00 a.m. with S6LS presenting video recorded on the Insights Behavioral Unit from 03/18/2024 at 10:00 p.m. to 03/19/2024 at 5:20 a.m. revealed the following:
The review consisted of 3 different cameras capturing all the hallways and patient rooms. The camera capture of the day room is very limited to an edge of the room by Camera SC401-404.
Camera SC405-409 view covers the hallway by rooms #e - #i. Video observed from 03/18/2024 at 11:30 p.m. to 03/19/2024 at 5:00 a.m. revealed an MHT walking across the hallway at 11:57 p.m. and 2:14 a.m. with no indication of a patient observation taking place. The MHT opens the door of room #e and #h at 2:38 a.m.
Camera SC401-404 view covers the hallway by rooms #a - #d. Video observed from 03/18/2024 at 10:01 p.m. to 03/19/2024 5:06 a.m. revealed patient movement at 10:01 p.m., day room movement at 10:36 p.m. and nurse movement on the hall at 5:06 a.m.
Camera SC410-415 view covers the hallway by rooms #j - #o. Video observed from 03/18/2024 at 10:33 p.m. to 03/19/2024 at 5:19 a.m. revealed an MHT in room #j at 10:33 p.m., patient in the hallway at 4:22 a.m., an MHT in hallway at 5:06 a.m. - opens a patient door, and a nurse enters room #j at 5:19 a.m.
The video revealed a 5 hour time span (11:00 p.m. to 4:00 a.m.) of limited to no activity on the hall ways of the unit.

A review of the Patient Observation Records revealed all 12 patients on the Insights Unit during the night shift of 03/18/2024 had documentation of observation checks being performed from 11:00 p.m. to 4:00 a.m.

In an interview on 03/19/2024 at 10:45 a.m. S6LS confirmed the above mentioned findings on video.

In an interview on 03/19/2024 at 11:00 a.m. S3DQ and S4DBHC confirmed the above mentioned findings.

In an interview on 03/19/2024 at 5:00 p.m. S10MHT confirmed she worked on the night shift of 03/18/2024. She further confirmed patient observations were not performed every 15 minutes as documented.

In an interview on 03/19/2024 at 5:10 p.m. S8LPN confirmed she worked on the night shift of 03/18/2024. She confirmed she documented the completion of observation checks being performed, but did not complete them.

In an interview on 03/19/2024 at 5:25 p.m. S9MHT confirmed she worked on the night shift of 03/18/2024. She confirmed the patient observations were not performed every 15 minutes as documented.

In an interview on 03/20/2024 at 8:25 a.m. S7RN confirmed she worked the night shift on 03/18/2024. She further confirmed patient observations were not performed by her and when she signed her name on the Patient Observation Record, she was thinking it was to ensure the MHTs were completing their rounds. She was unaware it was for the nurse to observe the patient at that time.

2) No documentation of observation checks being performed by the MHT and RN on 5 (#10, #11, #12, #14, #16) of 13 (#3 - #14, #16) patients with physician orders for Routine Levels of Observation over a 5 hour time span.
During a tour of the Insights Behavioral Unit on 03/18/2024 at 3:20 p.m. a review of Patient Observation Records revealed 5 (#10, #11, #12, #14, #16) of 13 (#3 - #14, #16) patient Observation Records for the current day being incomplete. The records revealed the following:
Patient #10 was on every 15 minute checks with the last observation at 11:30 a.m.(3 hours, 50 minutes late);
Patient #11 was on every 15 minute checks with the last observation at 11:45 a.m. (3 hours, 35 minutes late);
Patient #12 was on every 15 minute checks with the last observation at 11:15 a.m. (4 hours, 5 minutes late);
Patient #14 was on every 15 minute checks with the last observation at 11:30 a.m. (3 hours, 50 minutes late); and
Patient #15 was on every 15 minute checks with the last observation at 1:15 p.m. (2 hours, 5 minutes late).

In an interview on 03/18/2024 at 3:25 p.m. S3DQ and S4DBHC confirmed the above mentioned findings.

Based on record review and interview, the hospital failed to ensure the nursing care plan for each patient was kept current and reflected the patient's goals and the nursing care to be provided to meet the patient's needs. This deficient practice was evidenced by 1 (#1) of 3 (#1-#3) patient medical records reviewed not having an updated care plan to reflect a fall with a noted head injury and neurological assessment completion.
Findings:

A review of facility policy, "Fall Policy/Risk Assessment," with an origination of 12/2015 and last revised 11/2023, revealed in part a fall being a sudden, unintentional descent to the floor with or without injury to the patient and may be witnessed or un-witnessed. A physiological fall is caused by a sudden physiological event, side effects of known drugs, or can be attributed to some aspect of the patient's physical condition. The policy indicates all patients will be assessed for risk of falling upon admission, with reassessments routinely performed to determine ongoing need for fall prevention precautions. Any patient determined to be at risk for a fall will be placed on fall prevention precautions. Procedure: A. Assessments, Item 1. Inpatients, including Behavioral Health Unit will be assessed for level of fall risk: a. on admissions and every shift thereafter, b. Upon transfer from one inpatient unit to another within the facility. Psychiatric departments will use the Edmonson Psychiatric Fall Risk Assessment tool. Head Injuries: 1. All patients who have an un-witnessed fall or a witnessed fall where they hit their head will be monitored in accordance with current standards of nursing practice. 2. When a patient sustains (or suspected to have sustained) a head injury, he or she will be assessed by a licensed nurse according to the following schedule as a minimum: every 30 minutes for 1 hour, every hour for 3 hours, and then every 4 hours for the next 24 hours. 3. The assessment(s) will include vital signs, level of consciousness, pupil reaction, hand grasps, motor functions and other observations.

A review of Patient #1 medical record revealed the patient sustaining a fall on 01/12/2024 at approximately 6:35 a.m. Nursing notes revealed in part, nurse doing walking rounds heard a "thud." Nurse opened the door and found the patient on the floor, positioned on his knees and elbows facing down and the patient reported he had hit his head. The note indicated there was a reddened area the size of a half dollar on the top of the patient's forehead.

Patient #1's fall risk increased from 85 on 12/29/2023 (day of admission) to 95 on 1/12/2024 per the Edmonson Psychiatric Fall Risk assessment. The Edmonson Psychiatric Fall Risk indicates a fall risk when a score is greater than or equal to 90.

There was no documentation indicating a change to the care plan or the initiation of and ongoing neurologic assessments of Patient #1, related to the fall and the resulting head injury.

In an interview on 03/20/2024 at 10:30 a.m. S3DQ confirmed the above mentioned findings.

Based on record review and interview, the hospital failed to ensure all licensed nurses who provide services in the hospital adhere to the policies and procedures of the hospital. The director of nursing service failed to provide adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer.
Findings:

A personnel record review of S8LPN revealed a Licensed Practical Nurse-New Hire Competency Skills Assessment from Company C, with an effective date of 06/02/2023 and submitted by S4DBHC. The Competency Skill Assessment was incomplete and was not signed by the employee. S8LPN was part of the night shift staff on 03/18/2024.

In an interview on 03/20/2024 at 11:30 a.m. S16HRC confirmed the above mentioned findings

In a telephone interview on 03/20/2024 at 8:20 a.m. S7RN confirmed she was a recent hire working her 5th shift. She further confirmed she was oriented to Company C's policies and procedures and but was not oriented to the hospitals policies and procedures. She further indicated she did not feel like she had received adequate orientation and training from the hospital or Company C. S7RN was part of the night shift staff on 03/18/2024.

In an interview on 03/20/2024 at 10:30 a.m. S3DQ and S4DBHC confirmed the above mentioned findings.

Based on record review and interview, the hospital failed to promptly authenticate verbal orders by the order practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations. This deficient practice is evidence by verbal orders not being authenticated within the timeframe stipulated by the medical staff by laws.
Findings:

A review of the hospital's Policy and Procedure Manual for the Medical Staff revealed policy 1.10 Verbal Orders: Verbal orders shall be signed, dated and timed within ten (10) days following the date an order is given.

A medical record review of Patient #2 and Patient #3 on 03/20/2024 revealed the following:
Patient #2 was admitted on 01/23/2024 with verbal admission orders being initiated at 4:00 p.m. The practitioner authenticated the orders by electronic signature on 02/12/2024 at 1:36 p.m. This was 20 days after the verbal order.
Patient #3 was admitted on 03/09/2024 with verbal admission orders being initiated at 2:15 a.m. The practitioner had not authenticated the orders as of the review of this medical record.

In an interview on 03/20/2024 at 10:00 a.m. S3DQ confirmed the above mentioned findings.

Based on observations and interviews, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being of patients are assured. This deficient practice was evidenced by failing to maintain the physical plant in good repair.
Findings:

Observations during a tour of the BHU on 03/18/2024 from 2:40 p.m. till 3:40 p.m. with S2CNO, S3DQ and S4DBHC present, revealed the following:
a) Peeling paint and exposed dry wall on the wall under the television in Room #p; and
b) Exposed wood on the hallway side of Room #l's entry door.
Both of these areas lacked a cleanable surface.

In an interview on 03/18/2024 during the tour, S3DQ and S4DBHC confirmed the above mentioned findings.

Based on observation, policy review, and interview, the facility failed to ensure supplies and equipment were maintained to ensure an acceptable level of safety and/or quality. This deficient practice is evidenced by:
1) Failing to ensure expired supplies were not available for patient use; and
2) Failing to ensure crash cart checks were performed daily.
Findings:

1) Failing to ensure expired supplies were not available for patient use.

A review of the New and Floating Nurse Orientation checklist revealed in part, Topic: Last Sunday of each month, check unit and crash cart for expired items and discard them.

A review of the Mental Health Tech Orientation Process checklist revealed in part, Task: Unit Cleanliness: Removing expired items off of unit.

Observations during a tour of the BHU on 03/18/2024 from 2:40 p.m. till 3:40 p.m. with S2CNO, S3DQ and S4DBHC present, revealed eSwab Collection and Preservation sets (consisting of 1 swab with a collection tube), quantity 8, with an expiration of 12/31/2023 and being available for patient use.

In an interview on 03/18/2024 during the tour, S3DQ and S4DBHC confirmed the above mentioned findings.

2) Failing to ensure crash cart checks were performed daily.

A policy regarding daily crash cart checks was not presented when requested.

Observations during a tour of the BHU on 03/18/2024 from 2:40 p.m. till 3:40 p.m. with S2CNO, S3DQ and S4DBHC present, revealed crash cart check lists not being performed on 02/03/2024, 02/05/2024, 02/06/2024, 02/15 - 18/2024, 02/21 - 23/2024, 03/07/2024, 03/12/2024, and 03/17/2024.

In an interview on 03/18/2024 during the tour, S3DQ and S4DBHC confirmed the above mentioned findings.

Based on record review and interview, the hospital failed to ensure a complete neurological examination was recorded at the time of the admission physical examination for 1 (#1) of 3 (#1-3) patient records reviewed for a completed neurological examination at the time of the admission physical examination.
Findings:

A review of facility policy, "Medical Record Completion Policy," with no effective date, reveled in part, Section 1.3 History and Physical, Item E. Senior Care Unit: Upon admission to the Senior Care Unit, a complete neurological examination must be recorded at the time of the admission physical examination. Section 1.5 Psychiatric Evaluation: Must be completed for patients admitted to the Senior Care unit within 60 hours of admit.

Review of Patient #1's medical record revealed a history and physical dated 12/30/2023 at 1:04 p.m. Further review of the history and physical revealed an incomplete neurological assessment with no documentation of a cranial nerve exam.

In an interview on 03/19/2024 at 4:30 p.m. S3DQ confirmed the above mentioned findings.

Based on record review and interview, the hospital failed to ensure there were adequate numbers of registered nurses, licensed practical nurses and mental health workers with the necessary training to provide the nursing care under each patient's active treatment program. This deficient practice is evidence by 3 (#S8LPN, #S9MHT, #S17MHT) of 10 (S2CNO, S5IP, S4DBHC, S7RN, S8LPN, S9MHT, S10MHT, S17MHT, S18MHT, S19LPN) personnel files reviewed for psychiatric care education, training and experience.
Findings:

A review of personnel files revealed the current documentation of a Competency Skills Assessments on the following personnel:

S8LPN had a date of hire as 06/01/2023. The Licensed Practical Nurse - New Hire Competency Skills Assessment revealed an effective date of 06/02/2023, was initiated on 06/26/2023 at 10:19 a.m. and submitted by S4DBHC. The assessment includes: "Competency Statement: Demonstrates knowledge and skills necessary to provide safe, ethical care of the patient/client appropriate to their role." The specific competencies being evaluated on this assessment did not have a manager scoring of the clinical performance on each item. Further, the employee had not signed the last page with the following statement, "Approval Instructions, Employee: by signing below I have satisfactorily performed all criteria of the Registered Nurse personnel competency." Of note this competency was titled/indicated for a LPN. Also this staff member worked on the night shift of 03/18/2024.

S9MHT had a date of hire as 06/01/2023. The Mental Health Technician - New Hire Competency Skills Assessment revealed an effective date of 06/01/2023, was initiated on 06/23/2023 at 1:47 p.m. and submitted by S4DBHC. The assessment includes: "Competency Statement: Demonstrates knowledge and skills necessary to provide safe, ethical care of the patient/client appropriate to their role." All the competencies on the assessment had the scoring of a 1 (which indicated proficiency) except the competency, Suicide Precautions - there was no indication of proficiency. Further, the employee had not signed the last page with the following statement, "Approval Instructions, Employee: by signing below I have satisfactorily performed all criteria of the Mental Health Technician personnel competency." Of note this staff member worked the night shift of 03/18/2024.

S17MHT had a date of hire as 06/01/2023. There was no documentation in the personnel file of a Mental Health Technician - New Hire Competency Skills Assessment being initiated or a skills assessment checklist on file. Of note this employee worked the day shift of 03/18/2024 and was observing the patients that had missed observation checks when the surveyor reviewed current Patient Observation Records when touring the BHU.

In an interview on 03/20/2024 at 11:30 a.m. S16HRC confirmed the above mentioned findings and further indicated the New Hire Competency Skills Assessment should be completed within 30 days of first day of orientation.

In an interview on 03/20/2024 at 12:30 p.m. S4DBHC confirmed the above mentioned findings.