HospitalInspections.org

Based on observation, document review, and interview the Governing Body failed to ensure:

A. the facility COVID-19 plan was followed and provide a safe environment for psychiatric patients.

B. physician orders were obtained when restricting patient rights in 1 (Patient #1) of 1 patient charts reviewed.

C. a suicidal patient was closely monitored behind a closed door

D. COVID-19 positive patients were closely monitored and vital signs were taken to ensure no emergency medical condition existed in 7 (Patient #1, #2, #4, #5, #6, #7, and #16) of 7 patient records reviewed

The deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Refer to A0144


E. a Registered Nurse was available 24 hours a day.

Refer to Tag A1703


F. the facility followed the Nurse Staffing Plan and evaluate staffing needs based on patient acuity-established criteria and anticipated admission, transfers, and discharges for 10 of 12 days reviewed (from 7/08/2022-7/11/2022 and 08/01/2022 -08/08/2022)

G. and have adequate and safe staffing for nursing and mental health techs so patients received full assessments, adequate time to conduct admissions and discharges, adequate time and staff to care for ill patients in isolation, monitor patients with high-risk behaviors, supervise staff, ability to take breaks, and meet the needs of all patients for 17 of 24 shifts reviewed (from 7/08/2022-7/11/2022 and 08/01/2022 -08/08/2022).

Refer to Tag A1704

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

A. follow the facility COVID-19 plan and provide a safe environment for psychiatric patients.

B. ensure physician orders were obtained when restricting patient rights in 1 (Patient #1) of 1 patient charts reviewed.

C. monitor a suicidal patient behind a closed door

D. closely monitor COVID-19 patients vital signs to ensure no emergency medical condition existed in 7 (Patient #1, #2, #4, #5, #6, #7, and #16) of 7 patient records reviewed

The deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Refer to A0144

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

A. follow the facility COVID-19 plan and provide a safe environment for psychiatric patients.

B. ensure physician orders were obtained when restricting patient rights in 1 (Patient #1) of 1 patient charts reviewed.

C. monitor a suicidal patient behind a closed door

D. closely monitor COVID-19 patients vital signs to ensure no emergency medical condition existed in 7 (Patient #1, #2, #4, #5, #6, #7, and #16) of 7 patient records reviewed

The deficient practices identified were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

Findings Include:

A.

An observation tour was conducted on 8/08/2022 after 9:00 AM with Staff #1. Outside patient room #2 was a rolling plastic cart covered with a blanket. The cart had three shelves. On the shelves were yellow isolation gowns, latex gloves, disposable stethoscope, clear face shield, N95 masks, and hand sanitizer. The yellow isolation gowns were wrapped in plastic bags and the hand sanitizer was in a Ziploc bag. This rolling cart was not constantly monitored and was easily accessible by all patients. Without the cart being secured and/or always monitored this placed all patients and staff in danger. The rolling cart could easily be lifted by any patient and used as a weapon. The plastic bags and hand sanitizer were a serious threat to all patients and staff. The plastic bags could be used for suffocation, strangulation, or ingestion. The alcohol-based hand sanitizer could be ingested by patients causing serious injury or even death due to its toxic effects when indigested.

A review of the daily census for 8/08/2022 revealed Patient #1 was assigned to Room #2. The door to room #2 was closed at the time of the tour.

Staff #9 was asked how she disposed of her Personal Protective Equipment (PPE) when she left the patient's room. Staff #9 stated, "There is a red plastic bag in a box and a regular trash bag in there, so we just take them off in the room right before we come out." Staff #9 was then asked if the plastic bags stay in the room with the patient when the door is closed. Staff #9 said, "Yes they do. Is that a problem?" Staff #9 was asked if there was dedicated vital sign machine for the COVID+ patient. Staff #9 stated, "No, not at this time there is not."

Staff #1 confirmed two plastic bags were stored in the patient room for trash and used PPE. The facility left Patient #1 at great risk. The unmonitored trash bags could be easily used for asphyxiation and possible death.

On 8/10/2022 Patient #1 was moved to the end of the patient hallway in a room near the back exit door. The rolling cart that stored PPE was outside the room covered with a blanket. This surveyor and an additional surveyor put on PPE and entered Patient #1s room for an interview. Upon entering the room, Patient #1 was observed lying in the bed and it was noted there was no television and only one book beside her bed. It was noted there was no dedicated vital sign machine or cleaning equipment near the patient's room. This surveyor pressed the call light that goes directly to the nurse's station and after 8 minutes, no nurse reported to the room. Patient #1 stated, "It takes them a really long time to come down here sometimes." Patient #1 stated it had been very difficult staying in the room with the door closed and unable to leave. Patient #1 confirmed that she has a history of depression and had been suicidal. She stated that she felt better today and denied suicidal ideations.

Upon exiting the room, the surveyors doffed (took off) the PPE with no place to dispose of the contaminated PPE. Staff #9 was asked how the PPE was to be disposed. Staff #9 stated, "We just roll it up and take it to the biohazard bin and dispose of it there." Staff #9 confirmed the staff would have to walk up the hallway past the nurses station to dispose of the PPE. This could expose patients and staff in the hallway to potential contaminated biohazard waste. Staff #9 immediately went to obtain a biohazard box with a red plastic bag and placed it outside the patient's room. The staff member then asked if she needed to stay outside the room and watch the bag. Staff #9 was unsure what precautions needed to be taken to keep patients safe from potential hazards.

Staff #3 and Staff #9 confirmed the findings.

B.

A review of Patient #1's medical record revealed she was a 63-year-old female admitted voluntarily on 7/29/2022 with a diagnosis of Bipolar Disorder, severe and Sedative/hypnotic/anxiolytic use disorder. She had a passed medical history of Hypertension (high blood pressure), Coronary Heart Disease, Type 2 Diabetes, and Hyperlipidemia (high cholesterol). She was placed on Close Observations (Q 15-minute checks) and fall precautions

A review of the Psychiatric Evaluation by Staff #19 was as follows:

" ...History of Present Illness: She presents to hospital due to profound depression, manic-like symptoms, suicidal ideation with a plan to overdose on medications ..."

A review of the multi-Disciplinary note dated 8/05/2022 at 6:13 PM revealed Patient #1 complained of body aches, sore throat, decreased appetite, and a temperature of 101.1 Fahrenheit and an order was received from Staff #18 for the patient to be tested for COVID-19. Test result on 8/05/2022 at 9:00 PM for COVID-19 was positive. No documentation was in the medical record that the Physician had been notified of the test result. No order was in the medical record for isolation or room restriction until 8/09/2022 at 10:45 AM. Patient #1 was restricted to a private room for greater than 72 hours without a physician order.

A review of the physician order was as follows:

"8/09/2022 10:45 LE. Contact isolation for COVID+ results with droplet precautions for 5 full days if fever-free for 24 hours. VORB (verbal order read back) Staff #18. Signed by Staff #3."

Staff #1 confirmed the findings.

C.

An interview was conducted with Staff #9 at 10:15 AM on 8/08/2022. Staff #9 was asked to provide her observation notes for review. Staff #9 began her shift at 7:00 AM on 8/08/2022 and no documentation was completed on the Q 15-minute observations at the time of the interview. Staff #9 stated, "I am behind because I had to take care of 2 incontinent patients." Staff #9 was asked if the patient was restricted to her room or was she allowed to go out to the day room and watch TV? Staff #9 replied, "No, she cannot come out of her room because she has COVID."

A review of the Nursing shift assessment dated 8/08/2022 by Staff #12 was completed at 7:40 AM. " ...Nursing Interventions: Close Obs q (observations every)15 minutes, Milieu Therapy, VS (vital signs), O2 sat, Monitor Intake, Toilet q2 w/awake, Rounds Q2 (every 2 hours). At risk for falls: Yes ..." The items were all checked as completed.

Patient #1 was in a closed room with no close monitoring. There were plastic bags inside the room used to dispose contaminated PPE and trash that were immediately available for self-harm. There was no monitoring completed on the morning of 8/08/2022 for over 2 hours when Patient #1 was also on fall precautions.

D.

A review of the document titled, "COVID-19 FACILITY SPECIFIC PLAN" with a last reviewed date of 1/1/2022 was as follows:

" ...3. Hospital will create a designated area for COVID positive patients at the end of the patient hall in the event hospital has a COVID positive patient. Hospital will create a visual barrier prior to entering the designated COVID area.
a. This is a floor to ceiling barrier.
b. This will be the COVID division of the unit.
c. If the census is elevated, and we are unable to use the double doors as a barrier and someone tests positive for COVID, we will move the patient(s) to the furthest room at the end of the hall, erect a barrier wall and isolate patient accordingly.
d. In the event we are unable to successfully isolate a COVID positive patient due to elevated census where a private room is not available, and have exhausted all discharge possibilities, the patient will be discharged to a higher level of care.


4. Referrals & Admissions...

5. For patients in pending COVID test patient room:
...c. If patient is noncompliant with isolation precautions pending COVID test results, staff will contact physician for further direction/orders. All less restrictive options must be tried/considered. If a patient is non- compliant with transmission-based precautions, they are a danger to other patients. As long as staff have tried/considered other options, the chart reflects that other options have been attempted/considered, then seclusion is warranted. Keep in mind that if a 1:1 is ordered and the goal is to keep the patient isolated in their room, this is seclusion. Seclusion is to be used when a patient is a danger to self or others.
d. For any patient who tests positive for COVID, they will be placed in the designated area for COVID patients...

6. ALL COVID positive patients will be isolated to the designated COVID rooms.
a. Duration of isolation will be based on current CDC guidelines with a minimum quarantine of 10 days ...


7. Hospital will create a designated area or Donning of PPE in the COVID positive area (the empty room beside designated COVID area ...

8. There will be a designated Nurse assigned only to COVID Patients in the designated area.
a. If hospital has 2 COVID patients, they will share a room (and smart TV, group therapy, rec therapy) with door kept open and nursing table/station in direct line of site in front of room.)
b. If these patients are at high risk of suicide, and additional monitoring is required, a 1:1 order can be made.


9. All meals, meds, therapies, provider visits, and assessments will occur in designated COVID rooms by staff wearing appropriate PPE.
a. Hospital will provide a PPE isolation unlocked cart to be placed in an empty patient room (called the PPE ROOM) for donning PPE with quick access to PPE supplies.
b. All positive COVID patients will have vital signs checked every 2 hours.
c. Hospital will provide a designated cleaning cart to only be used for the COVID patient area.
d. Hospital will provide a box with bag to be placed inside COVID patient room at doorway for doffing of PPE to properly dispose of PPE. Bag will be properly disposed of when near full.
e. Medical equipment used in clean/non COVID area will NOT be transported/used in designated COVID
area. i.e. med cart, Dynamap, housekeeping cart, etc.
f. Dirty linens will be bagged and stored in designated linen cart in the designated bathroom in the Supply Room (to keep dirty separated for clean supplies).

10. COVID policies will be updated with addendums to reflect more specific CDC recommendations that hospital has adopted.

11. Hospital will review current COVID Plan to ensure it meets specific layout of hospital ..."


An interview was conducted with Staff #1 and Staff #5 in the afternoon on 8/09/2022. Staff #1 and #5 were asked if there was one nurse and one MHT specifically assigned to the COVID positive patient in the hospital now. Staff #1 replied, "No. We only have the one positive patient right now." Staff #5 stated, "We cannot increase the staffing for one positive patient. We do not have the means to do that. We cannot keep up with the bonuses that the local hospitals are offering. We offer bonuses for staff to work extra shifts and Staff #1 and Staff #3 are already filling in on the unit at times." Staff #5 also stated, "Oceans Behavioral Health is opening 6 new facilities in the State of Texas."


Patient #1
Patient #1 was a 63-year-old female admitted to the facility on 7/29/2022 at 2:45PM with a diagnosis of Bipolar Disorder, Depressed Severe without psychotic features with a past medical history of Type 2 Diabetes, Hypertension, Coronary Artery Disease with a Myocardial Infarction (Heart attack), Fibromyalgia, Arthritis, Obesity, and Hyperlipidemia.

Patient #1 tested positive with COVID-19 on 8/05/2022 at 9:00 PM after complaints of shortness of breath, tiredness, headache, and fatigue.

No frequent vital sign documentation was found in the medical record. Vital Signs were taken 1 time per shift, or twice a day from 8/05/2022 to 8/09/2022.

Staff #1 and #3 confirmed this finding


Patient #2
Patient #2 was a 64-year-old male admitted to the facility on 5/23/2022 at 5:00 PM with a diagnosis of Alzheimer's with behavioral disturbance with a past medical history of Chronic Back Pain, Chronic Constipation, and History of Traumatic Brain Injury.

Patient #2 tested positive for COVID-19 on 7/07/2022 at 12:20 PM with symptoms of tiredness, lethargy, agitated, and he was found stooped over. He was transferred to the COVID Unit. The first set of vital signs after the positive test were not taken until 7:15 PM on 7/07/2022. Vital signs were documented every 4 hours beginning 7/7/2022 at 7:15 PM. A nursing shift assessment was completed at 8:15 PM by Staff #16. Staff #16 failed to document the patient's breath sounds. At 9:00 AM on 7/8/2022 the patient's vital signs, taken by Staff #10 were as follows: Blood Pressure: 80/49, Pulse: 74. Respirations: 17, Temperature: 98.4, Pulse Oximetry: 88%. No documentation was in the medical record that the nurse or the physician were notified of the abnormal findings. The low blood pressure and low pulse oximetry with a positive COVID-19 test could lead to a medical emergency. There was no repeat of the vital signs until 11:00 AM.

A review of the document titled "Observation Check Sheet" completed by the MHTs revealed there was no Q 15-minutes documented by a MHT from 7:00 PM on 7/08/2022 until 7:00 AM on 7/09/2022. No RN reviewed the document every 2 hours as required by facility policy. The document is used to monitor the patients behaviors, activity, location, intake and output, and vital signs.

Staff #18 was notified of an 80% O2 Sat and a new order for Albuterol inhalation treatments to be given as needed and an order to notify him if the O2 saturations fall below 88%. A chest x-ray was ordered by Staff #19 at 11:00 AM. Staff #18 does not see patients in the hospital, he only does telehealth visits. On 7/12/2022 Patient #2 started to run a fever of 101.2 Fahrenheit. A recheck on the vital signs 4 hours later revealed the temperature was 100.1 Fahrenheit and the O2 sat was 88%. An Albuterol Inhalation treatment was given and the O2 saturations came up to 94%. On 7/13/2022 Patient #2 was transferred to the hospital for worsening symptoms of COVID-19 and admitted to the hospital with COVID Pneumonia, Respiratory Failure, Hypoxemia with an O2 Sat of 87% (normal is 100%), and Hypokalemia with a level of 2.9 (normal level is 3.5-5.0).


Patient #4
Patient #4 was admitted to the facility on 7/06/2022 at 2:20 PM with a diagnosis of Major Depressive Disorder with psychotic features with a past medical history of Hypertension, Hyperlipidemia, Atrial Fibrillation, Gout, Coronary Artery Disease, Chronic Kidney Disease, and a history of cardiac pacemaker.

Patient #4 tested positive for COVID-19 on 7/17/2022 after complaints of cough, shortness of breath, tiredness, body aches, and headache.

Vital signs were taken 1 time per shift, or twice a day on 7/17/2022 and 7/18/2022. A review of the document titled; "Frequent Vital Signs" confirmed vital signs were taken every 4 hours from 7/14/2022 at 3:00 PM until she was transferred to the hospital on 7/22/2022 after a fall. Vital signs were taken every 4 hours from 7/19/2022 at 7:00 AM until 7/27/2022 at 11:00 AM. Patient #4 was discharged on 7/27/2022.


Patient #5
Patient #5 was an 88-year-old male admitted to the facility on 7/06/2022 at 8:21 PM with a diagnosis of Alzheimer's with Behavioral Disturbances and a past medical history of Dementia and Hypertension.

A review of the progress note dated 7/14/2022 by Staff #19 revealed Patient #5 was scheduled for discharge on 7/14/2022. Patient #5 was COVID tested as a requirement for his discharge back to the Assisted Living. The COVID-19 test was positive on 7/14/2022 at 12:15 PM. Vital signs were not taken until 3:00 PM on 7/14/2022 by Staff #10. Patient #5 discharged on 7/14/2022 at 4:30 PM. This was one set of vital signs in 4 hours and 15 minutes.


Patient #6
Patient #6 was a 79-year-old female admitted to the facility on 7/11/2022 at 6:30 PM with a diagnosis of Dementia with Behavioral Disturbances with a past medical history of Atrial Fibrillation, Insomnia, Anxiety, Iron Deficiency Anemia, Irritable Bowel Syndrome, Coronary Artery Disease, Hypertension, and Hyperlipidemia.

Patient #6 tested positive for COVID-19 on 7/14/2022 at 1:30 PM after reported symptoms of headaches, body aches, sore throat, and nasal congestion.

A review of the document titled; "Frequent Vital Signs" confirmed vital signs were taken every 4 hours from 7/14/2022 at 3:00 PM until she was transferred to the hospital on 7/22/2022 after a fall.


Patient #7
Patient #7 was a 74-year-old female admitted to the facility on 7/15/2022 at 12:52 PM with a diagnosis of Major Depressive Disorder with Psychotic Features with a past medical history of Hypertension, Hyperlipidemia, Hypothyroidism, and admitted on antibiotics for an ear infection.

Patient #7 tested positive for COVID-19 on 7/18/2022 at 5:50 PM after complaints of worsening runny nose.

A review of the document titled; "Frequent Vital Signs" confirmed vital signs were taken every 4 hours from 7/18/2022 at 7:00 PM until she was discharged from the COVID Unit on 7/23/2022 at 9:00 AM. The last frequent vital sign was taken at 7:00 AM on 7/23/2022.


Patient #16
Patient #16 was a 56-year-old female was admitted to the facility on 7/12/2022 at 5:30 PM with a diagnosis of Major Depressive Disorder with severe Psychotic features and a past medical history of Cerebral Vascular Attack, Transient Ischemic Attack, Hypertension, Migraine headache, Celiac Disease, and Gastroesophageal Reflux.

Patient #16 tested positive for COVID-19 on 7/15/2022 at 10:30 AM after complaints of sore throat, headaches, and body aches.

A review of the document titled; "Frequent Vital Signs" confirmed vital signs were taken every 4 hours from 7/15/2022 until 7/20/2022 at 3:00P. Patient #16 was discharged on 7/20/2022.


An interview was conducted on 8/08/2022 after 9:00 AM with Staff #9. Staff #9 was asked how often the vital signs were taken on a COVID positive patient. Staff #9 replied, "I think it is every 2 hours."


An interview was conducted with Staff #1 on 8/08/2022 after 11:00 AM. Staff #1 was asked how often vital signs are taken on COVID positive patients. Staff #1 stated, "The staff take vital signs on COVID patients every 2 hours and document them on the frequent vital sign sheets." Staff #1 was asked who monitors the vital sign sheets to ensure that the vital signs are within range and being completed. Staff #1 replied, "The RNs look at the vital signs sheet and they sign off on the MHT note every 2 hours."


An interview was conducted with Staff #8 and Staff #9 on 8/10/2022 after 9:00 AM. Staff #8 and Staff #9 were asked how of the COVID positive patients are monitored. Staff #8 stated, "We monitor the patients whatever monitoring level the Doctor has ordered". Staff #8 was then asked how often vital signs are taken on COVID patients. Staff #8 stated, "I think it's every two hours."

Staff #8 and Staff #9 confirmed they have not seen nor read the COVID-19 Specific Facility Plan.

Staff #1, #5, #7, and #9 confirmed the findings.

Based on document review and interview the facility failed to develop, implement, and maintain an effective and ongoing process to measure and track the performance to ensure that improvements are sustained.


Findings Include:


The facility failed to:

1. Audit and track that the Pharmacist in Charge (PIC) was involved in the Pharmacy and Therapeutics (P&T) meetings and the Quality Meetings.

2. Audit and track that the Important Message from Medicare was given to patients within 2 days of discharge.

3. Audit and track that all voluntary consents signed by patients had was understood by a competent adult that had the capacity to consent.

4. Audit and track all patient consents signed for psychotropic medications received an explanation by the nurse or physician for the name of the psychotropic medications, the beneficial effects on the patient's mental illness, or the condition expected as a result of treatment with psychotropic medications.

5. Audit and track the processes of chemical restraint care, management, and documentation.

6. Audit and track the daily surveillance rounds for infection control.


Refer to Tag A0283

Based on interview and document review the facility failed to have an ongoing program to analyze, track, and measure quality patient care.

Findings Include:

An interview was conducted with Staff #1 on 8/08/2022 after 10:00 AM. Staff #1 was asked to provide the audit tools used for the Plan of Correction with a survey exit date of 6/02/2022 and correction date of 7/29/2022. Staff #1 stated, "The Quality and Infection Control Director, (Staff #6) only work part time but we can get those things for you."


A review of the document titled, "Oceans Behavioral Hospital Longview Survey Readiness Document" was as follows:

The document contained 5 columns across the top of the page. The 5 columns were Focus Area, Elements of Performance, Status (met, partial, unmet) Reviewer, and Comments and Action Plan.

The areas to be surveyed and reviewed were documented as Nutrition Room, Storage Room, Medication Room, Exam Room, Nursing Station, Soiled Utility, Clean Utility, Corridor for clean and soiled linen, Tub Room, Seclusion Room, Pharmacy Area, Kitchen, Laundry Room, Chart Review, and Hand Hygiene.

The Chart reviews consisted of the following:

Is the admission IMM signed and present on the record, Is the IMM signed between 2 days before discharge and not later than 4 hours of discharge and present on the record, Consent to Treatment Present, Signed, witnessed, dated, and timed, Telemedicine consent present, signed, witnessed, dated, and timed, Financial responsibility consent present, signed, witnessed, dated, and timed, Release of information present, signed, witnessed, dated, and timed, Advanced Directive present, signed, witnessed, dated, and timed, and Acknowledges receipt of handbook, signature, witnessed, dated, and timed.

The document was blank.


During the exit conference Staff #1 and Staff #5 asked if the monitoring and quality information could be sent to the surveyors at a later date. The surveyors denied the request stating, "If it is not presented for review before we leave the facility the documents will not be accepted."

After multiple requests for the Quality meeting minutes, P&T Committee meeting minutes, weekly Admin Team Meetings, and Infection Control Surveillance Rounds, none were provided.

Staff 1 and #5 confirmed the findings.

Based on chart review and interview Nursing failed to:


A. assess and monitor a patient receiving medication to manage hyperkalemia. The nurse failed to monitor vital signs, monitor cardiac, pulmonary systems, and report elevated vital signs to avoid life-threatening neuromuscular and cardiac complications. Nursing failed to assess for gastric distress or side effects of the medication and document in 1 (#9) of 1 patient charts reviewed.

B. closely monitor COVID-19 patients vital signs to ensure no emergency medical condition existed in 7 (Patient #1, #2, #4, #5, #6, #7, and #16) of 7 patient records reviewed.

Refer to Tag A0395

Based on chart review and interview Nursing failed to:

A. assess and monitor a patient receiving medication to manage hyperkalemia. The nurse failed to monitor vital signs, monitor cardiac, pulmonary systems, and report elevated vital signs to avoid life-threatening neuromuscular and cardiac complications. Nursing failed to assess for gastric distress or side effects of the medication and document in 1(#9) of 1 patient charts reviewed.

B. closely monitor COVID-19 patients vital signs to ensure no emergency medical condition existed in 7 (Patient #1, #2, #4, #5, #6, #7, and #16) of 7 patient records reviewed.

A.
Review of Patient #9's chart revealed she was admitted to the facility on 7/27/22 at 18:00. She was a 75-year-old female admitted from a local acute care hospital. Patient #9 was admitted with a diagnosis of depression and suicidal ideation (SI). Review of patient #9's Psychiatric Evaluation dated 7/28/22 revealed Patient #9 had multiple medical co-morbidities. The following issues were listed, Chronic Obstructive Pulmonary Disease, Hypertension, Type 2 Diabetes, Gastroesophageal Reflux Disease, Peripheral Vascular Disease, Coronary Artery Disease, and Severe Chronic Back Pain.

Review of Patient #9's chart revealed she had blood work done on 7/28/22 and her Potassium (K+) was elevated at a 5.8(H). According to the laboratory report the range for females was listed at 3.5 to 5.3. Elevated potassium (called "hyperkalemia") is a medical problem in which you have too much potassium in your blood.

According to www.ncbi.nlm.nih.gov/pmc/articles/PMC1497179, "Geriatric patients should be considered at risk of developing hyperkalemia, especially when they are prescribed certain medications. Potassium levels should be monitored at appropriate intervals when these patients are treated with potassium-altering medications. Appropriate management of hyperkalemia in the elderly can avoid life-threatening neuromuscular and cardiac complications. If hyperkalemia comes on suddenly and you have very high levels of potassium, you may feel heart palpitations, shortness of breath, chest pain, nausea, or vomiting. Sudden or severe hyperkalemia is a life-threatening condition. It requires immediate medical care."

Review of the chart revealed Patient #9 was ordered 1 Liter of normal saline IV at 125ml/hr. and Kayexalate 15 gm po x1 now for elevated potassium on 7/28/22 at 1:35PM. The RN documented on the Medication Administration Record (MAR) that the IV and the Kayexalate were administered at 2:00PM.

Review of the Multi-Disciplinary Note dated 7/28/22 at 2:05PM stated, "22 gauge IV placed to left forearm. Pt tolerates procedure well, no evidence of infiltration or redness identified. NS running at 250 ml/hr per physician order." There was no documentation about the Kayexalate administration, the effects of the medication, cardiac monitoring, or any side effects such as gastric distress. The RN documented at 4:30PM that Patient #9 had completed her IV fluids and vital signs were taken. Blood pressure was elevated at 198/82 and pulse 64. The nurse documented that the physician was notified with no new orders. There was no further documentation or evaluation of the patient's response to the Kayexalate.

Review of the Mental Health Technician's (MHT) observation check sheet revealed Patient #9's vital signs were taken on 7/28/22 at 7:00AM. The MHT documented the blood pressure was elevated at 180/92 and her pulse was 65. There was no documentation that the RN was notified of the elevated blood pressure.

Review of the physician progress note revealed on 7/28/22 at 11:04AM that the patient's blood pressure was 133/80. The physician would not have taken the blood pressure. The physician used telemedicine (calls over on an iPad and visits with the patient by video.) The nurse does all the physical evaluation.

Review of the nurses noted revealed Patient #9 was assessed by the RN on 7/28/22 at 11:15AM (11minutes later) and vital signs were taken. The RN documented Patient #9 had an elevated blood pressure of 180/92 and an elevated pulse of 95 but there was no documentation that the physician was notified of the increased blood pressure from 11 minutes prior or if the elevated blood pressure and pulse were addressed and treated.

Review of the Nurses notes dated 7/28/22 at 10:10PM revealed the same RN assessed the patient at this time. The RN failed to document any pain assessment, cardio/pulmonary, breath sounds, neurological, musculoskeletal/safety, nutrition/fluid, elimination assessment for this patient. The form was blank in those areas.

According to www.accessdata.fda.gov/drugsatfda_docs/label/2009/011287s022lbl.pdf
"Caution is advised when KAYEXALATE is administered to patients who cannot tolerate even a small increase in sodium loads (i.e., severe congestive heart failure, severe hypertension, or marked edema). In such instances compensatory restriction of sodium intake from other sources may be indicated. In the event of clinically significant constipation, treatment with KAYEXALATE should be discontinued until normal bowel motion is resumed. Magnesium-containing laxatives or sorbitol should not be used (see PRECAUTIONS, Drug Interactions). Side effects of KAYEXALATE cardiac arrhythmia (any abnormal heart rate or rhythm), chest pain or tightness, vomiting, difficulty with breathing, severe stomach pain, seizures, numbness and tingling, bloody diarrhea, stomach or bowel problems (e.g., bleeding, colitis, constipation, perforation), history of-Avoid use in patients with these conditions. The first test that should be ordered in a patient with suspected hyperkalemia is an ECG since the most lethal complication of hyperkalemia is cardiac condition abnormalities which can lead to dysrhythmias and death. K=5.5 to 6.5 mEq/L ECG will show tall, peaked t-wave."

According to www.ncbi.nlm.nih.gov/books/NBK568741 nursing assessment and monitoring when administering Kayexalate to a patient should involve cardiac monitoring ECG closely to look for peaked T waves. "The management of hyperkalemia is multidisciplinary because of its potential to induce cardiac arrest and severe weakness. Once hyperkalemia is diagnosed, the primary condition must be treated. Patients with hyperkalemia need cardiac monitoring and nurses should be familiar with ECG features of hyperkalemia, which are often the first to appear. The pharmacist has to ensure that all nephrotoxic medications and agents that raise potassium are discontinued."

Review of Patient #9's chart revealed she was in an acute care hospital before her admission with low blood levels and required blood transfusions due to a gastric bleed. The chart revealed the patient's blood levels were normal at discharge but had not addressed her GI bleed. The patient was referred at discharge (from acute hospital) to a GI specialist. Kayexalate can cause gastric distress and diarrhea.

There was no documentation that the nurse was monitoring the patient's input or output. There was no documentation if Patient #9 had a bowel movement or if it was observed for any bleeding. Review of the physician orders revealed a verbal order was obtained by the nurse on 7/29/22 at 10:30PM for "Imodium A-D 2 mg po Q6hr PRN/Diarrhea."
The order was obtained 32 hours after the medication was administered. There was no documentation that the medication was administered or if the patient had any diarrhea or bowel movements after the administration of the Kayexalate.

Review of Patient #1's chart revealed there was no documentation of the patient's hyperkalemia or medications ordered on the treatment plan. The patient was ordered to have her Lisinopril (for hypertension) increased on 8/4/22, Oxybutynin 5 mg 2x a day for overactive bladder, and was started on a diabetic medication Metformin 500mg po daily. There was no documentation of these medications being ordered and changed on the treatment plan nor any updated actions or goals.

An interview was conducted with Staff #3 on 8/10/22 at 11:00AM. Staff #3 confirmed the findings on patient #9 and was unable to give an explanation on why the patient was not monitored properly. Staff #3 confirmed that she was not aware that the patient had been ordered the medications.

An interview with Staff #11 and #15 was conducted on 8/10/22 at 11:45AM. Staff #15 stated that she was usually the only RN on her shift, and it was very difficult to assess all the patients in a timely manner. Staff #15 stated that she could have multiple admission, discharges, sick patients and patients having behavioral issues all at one time. Staff #15 stated that it can be very time consuming, and she confirmed that she cannot get all her work done. Staff #17 was asked if she ever requested help from her superiors. Staff #17 stated if it's a weekday I can get help sometimes or if there is a bridge nurse (a nurse working half of the day shift and half of the night shift) but that was not frequent due to staffing issues. Staff #17 confirmed that when staffing had been short the facility continued to keep admitting patients. Staff #11 confirmed that the administrative team does not come to help them when they are short staffed. Staff #11 stated that administration was aware they were short staffed when they leave for the day and on weekends.


40989


B.

A review of the document titled, "COVID-19 FACILITY SPECIFIC PLAN" with a last reviewed date of 1/1/2022 was as follows:

" ...3. Hospital will create a designated area for COVID positive patients at the end of the patient hall in the event hospital has a COVID positive patient. Hospital will create a visual barrier prior to entering the designated COVID area.
a. This is a floor to ceiling barrier.
b. This will be the COVID division of the unit.
c. If the census is elevated, and we are unable to use the double doors as a barrier and someone tests positive for COVID, we will move the patient(s) to the furthest room at the end of the hall, erect a barrier wall and isolate patient accordingly.
d. In the event we are unable to successfully isolate a COVID positive patient due to elevated census where a private room is not available, and have exhausted all discharge possibilities, the patient will be discharged to a higher level of care.


4. Referrals & Admissions...

5. For patients in pending COVID test patient room:
...c. If patient is noncompliant with isolation precautions pending COVID test results, staff will contact physician for further direction/orders. All less restrictive options must be tried/considered. If a patient is non- compliant with transmission-based precautions, they are a danger to other patients. As long as staff have tried/considered other options, the chart reflects that other options have been attempted/considered, then seclusion is warranted. Keep in mind that if a 1:1 is ordered and the goal is to keep the patient isolated in their room, this is seclusion. Seclusion is to be used when a patient is a danger to self or others.
d. For any patient who tests positive for COVID, they will be placed in the designated area for COVID patients...

6. ALL COVID positive patients will be isolated to the designated COVID rooms.
a. Duration of isolation will be based on current CDC guidelines with a minimum quarantine of 10 days ...


7. Hospital will create a designated area or Donning of PPE in the COVID positive area (the empty room beside designated COVID area ...

8. There will be a designated Nurse assigned only to COVID Patients in the designated area.
a. If hospital has2 COVID patients, they will share a room (and smart TV, group therapy, rec therapy) with door kept open and nursing tale/station in direct line of site in front of room.)
b. If these patients are at high risk of suicide, and additional monitoring is required, a 1:1 order can be made.


9. All meals, meds, therapies, provider visits, and assessments will occur in designated COVID rooms by staff wearing appropriate PPE.
a. Hospital will provide a PPE isolation unlocked cart to be placed in an empty patient room (called the PPE ROOM) for donning PPE with quick access to PPE supplies.
b. All positive COVID patients will have vital signs checked every 2 hours.
c. Hospital will provide a designated cleaning cart to only be used for the COVID patient area.
d. Hospital will provide a box with bag to be placed inside COVID patient room at doorway for doffing of PPE to properly dispose of PPE. Bag will be properly disposed of when near full.
e. Medical equipment used in clean/non COVID area will NOT be transported/used in designated COVID
area. i.e. med cart, Dynamap, housekeeping cart, etc.
f. Dirty linens will be bagged and stored in designated linen cart in the designated bathroom in the Supply Room (to keep dirty separated for clean supplies).

10. COVID policies will be updated with addendums to reflect more specific CDC recommendations that hospital has adopted.

11. Hospital will review current COVID Plan to ensure it meets specific layout of hospital ..."


An interview was conducted with Staff #1 and Staff #5 in the afternoon on 8/09/2022. Staff #1 and #5 were asked if there was one nurse and one MHT specifically assigned to the COVID positive patient in the hospital now. Staff #1 replied, "No. We only have the one positive patient right now." Staff #5 stated, "We cannot increase the staffing for one positive patient. We do not have the means to do that. We cannot keep up with the bonuses that the local hospitals are offering. We offer bonuses for staff to work extra shifts and Staff #1 and Staff #3 are already filling in on the unit at times." Staff #5 also stated, "Oceans Behavioral Health is opening 6 new facilities in the State of Texas."


Patient #1
Patient #1 was a 63-year-old female admitted to the facility on 7/29/2022 at 2:45PM with a diagnosis of Bipolar Disorder, Depressed Severe without psychotic features. She had a past medical history of Type 2 Diabetes, Hypertension, Coronary Artery Disease with a Myocardial Infarction (Heart attack), Fibromyalgia, Arthritis, Obesity, and Hyperlipidemia. She tested positive with COVID-19 on 8/05/2022 at 9:00 PM after complaints of shortness of breath, tiredness, headache, and fatigue.

No frequent vital sign documentation was found in the medical record. Vital Signs were taken 1 time per shift, or twice a day from 8/05/2022 to 8/09/2022.

Staff #1 and #3 confirmed this finding


Patient #2
Patient #2 was a 64-year-old male admitted to the facility on 5/23/2022 at 5:00 PM with a diagnosis of Alzheimer's with behavioral disturbance. He had a past medical history of Chronic Back Pain, Chronic Constipation, and History of Traumatic Brain Injury. He tested positive for COVID-19 on 7/07/2022 at 12:20 PM with symptoms of tiredness, lethargy, agitated, and he was found stooped over. He was transferred to the COVID Unit. The first set of vital signs after the positive test were not taken until 7:15 PM on 7/07/2022. Vital signs were documented every 4 hours beginning 7/7/2022 at 7:15 PM. A nursing shift assessment was completed at 8:15 PM by Staff #16. Staff #16 failed to document the patient's breath sounds. At 9:00 AM on 7/8/2022 the patient's vital signs, taken by Staff #10 were as follows: Blood Pressure: 80/49, Pulse: 74. Respirations: 17, Temperature: 98.4, Pulse Oximetry: 88%. No documentation was in the medical record that the nurse or the physician were notified of the abnormal findings. The low blood pressure and low pulse oximetry with a positive COVID-19 test could lead to a medical emergency. There was no repeat of the vital signs until 11:00 AM.

A review of the document titled "Observation Check Sheet" completed by the MHTs revealed there was no Q 15-minutes documented by a MHT from 7:00 PM on 7/08/2022 until 7:00 AM on 7/09/2022. No RN reviewed the document every 2 hours as required by facility policy. The document is used to monitor the patient's behaviors, activity, location, intake and output, and vital signs.

Staff #18 was notified of an 80% O2 Sat and a new order for Albuterol inhalation treatments to be given as needed and an order to notify him if the O2 saturations fall below 88%. A chest x-ray was ordered by Staff #19 at 11:00 AM. Staff #18 does not see patients in the hospital, he only does telehealth visits. On 7/12/2022 Patient #2 started to run a fever of 101.2 Fahrenheit. A recheck on the vital signs 4 hours later revealed the temperature was 100.1 Fahrenheit and the O2 sat was 88%. An Albuterol Inhalation treatment was given and the O2 saturations came up to 94%. On 7/13/2022 Patient #2 was transferred to the hospital for worsening symptoms of COVID-19 and admitted to the hospital with COVID Pneumonia, Respiratory Failure, Hypoxemia with an O2 Sat of 87% (normal is 100%), and Hypokalemia with a level of 2.9 (normal level is 3.5-5.0).


Patient #4
Patient #4 was admitted to the facility on 7/06/2022 at 2:20 PM with a diagnosis of Major Depressive Disorder with psychotic features. She had a past medical history of Hypertension, Hyperlipidemia, Atrial Fibrillation, Gout, Coronary Artery Disease, Chronic Kidney Disease, and a history of cardiac pacemaker. She tested positive for COVID-19 on 7/17/2022 after complaints of cough, shortness of breath, tiredness, body aches, and headache.

Vital signs were taken 1 time per shift, or twice a day on 7/17/2022 and 7/18/2022. A review of the document titled; "Frequent Vital Signs" confirmed vital signs were taken every 4 hours from 7/14/2022 at 3:00 PM until she was transferred to the hospital on 7/22/2022 after a fall. Vital signs were taken every 4 hours from 7/19/2022 at 7:00 AM until 7/27/2022 at 11:00 AM. Patient #4 was discharged on 7/27/2022.


Patient #5
Patient #5 was an 88-year-old male admitted to the facility on 7/06/2022 at 8:21 PM with a diagnosis of Alzheimer's with Behavioral Disturbances. He had a past medical history of Dementia and Hypertension.

A review of the progress note dated 7/14/2022 by Staff #19 revealed Patient #5 was scheduled for discharge on 7/14/2022. Patient #5 was COVID tested as a requirement for his discharge back to the Assisted Living. The COVID-19 test was positive on 7/14/2022 at 12:15 PM. Vital signs were not taken until 3:00 PM on 7/14/2022 by Staff #10. Patient #5 discharged on 7/14/2022 at 4:30 PM. This was one set of vital signs in 4 hours and 15 minutes.


Patient #6
Patient #6 was a 79-year-old female admitted to the facility on 7/11/2022 at 6:30 PM with a diagnosis of Dementia with Behavioral Disturbances. She had a past medical history of Atrial Fibrillation, Insomnia, Anxiety, Iron Deficiency Anemia, Irritable Bowel Syndrome, Coronary Artery Disease, Hypertension, and Hyperlipidemia. She tested positive for COVID-19 on 7/14/2022 at 1:30 PM after reported symptoms of headaches, body aches, sore throat, and nasal congestion.

A review of the document titled; "Frequent Vital Signs" confirmed vital signs were taken every 4 hours from 7/14/2022 at 3:00 PM until she was transferred to the hospital on 7/22/2022 after a fall.


Patient #7
Patient #7 was a 74-year-old female admitted to the facility on 7/15/2022 at 12:52 PM with a diagnosis of Major Depressive Disorder with Psychotic Features. She had a past medical history of Hypertension, Hyperlipidemia, Hypothyroidism, and admitted on antibiotics for an ear infection. She tested positive for COVID-19 on 7/18/2022 at 5:50 PM after complaints of worsening runny nose.

A review of the document titled; "Frequent Vital Signs" confirmed vital signs were taken every 4 hours from 7/18/2022 at 7:00 PM until she was discharged from the COVID Unit on 7/23/2022 at 9:00 AM. The last frequent vital sign was taken at 7:00 AM on 7/23/2022.


Patient #16
Patient #16 was a 56-year-old female was admitted to the facility on 7/12/2022 at 5:30 PM with a diagnosis of Major Depressive Disorder with severe Psychotic features. She has a past medical history of Cerebral Vascular Attack, Transient Ischemic Attack, Hypertension, Migraine headache, Celiac Disease, and Gastroesophageal Reflux. She tested positive for COVID-19 on 7/15/2022 at 10:30 AM after complaints of sore throat, headaches, and body aches.

A review of the document titled; "Frequent Vital Signs" confirmed vital signs were taken every 4 hours from 7/15/2022 until 7/20/2022 at 3:00P. Patient #16 was discharged on 7/20/2022.

An interview was conducted on 8/08/2022 after 9:00 AM with Staff #9. Staff #9 was asked how often the vital signs were taken on a COVID positive patient. Staff #9 replied, "I think it is every 2 hours."


An interview was conducted with Staff #1 on 8/08/2022 after 11:00 AM. Staff #1 was asked how often vital signs are taken on COVID positive patients. Staff #1 stated, "The staff take vital signs on COVID patients every 2 hours and document them on the frequent vital sign sheets." Staff #1 was asked who monitors the vital sign sheets to ensure that the vital signs are within range and being completed. Staff #1 replied, "The RNs look at the vital signs sheet and they sign off on the MHT note every 2 hours."


An interview was conducted with Staff #8 and Staff #9 on 8/10/2022 after 9:00 AM. Staff #8 and Staff #9 were asked how of the COVID positive patients are monitored. Staff #8 stated, "We monitor the patients whatever monitoring level the Doctor has ordered". Staff #8 was then asked how often vital signs are taken on COVID patients. Staff #8 stated, "I think it's every two hours."

Staff #8 and Staff #9 confirmed they have not seen nor read the COVID-19 Specific Facility Plan.

Staff #1, #5, #7, and #9 confirmed the findings.

Based on observation, document review and interview the facility failed to follow the facility policy and properly secure and store a patients home medications in 1 of 1 Medication Rooms.


Findings:

During an observation tour on 8/09/2022 after 9:00 AM with Staff #1 and Staff #4 the following was observed:

A lower cabinet in the medication room was designated as Home Meds. On the cabinet door a sign was posted that read, "HOME MEDICATIONS ONLY ON TOP SHELF IN THIS CABINET". The cabinet was unlocked. On the top shelf there was multiple plastic bags with prescription bottles belonging to patients. There were two plastic bags that contained personal medication boxes belonging to Patient #18 and Patient #19. Patient #18 had a 7-day pill organizer that contained medications. Patient #19 had a 7-day pill organizer that contained medications. No prescription bottles were included in the bags. There was no documented list of the medications or a total count of the pills by the Admitting RN in either plastic bag. The medications had not been identified by a pharmacist.

Patient #18 was admitted on Wednesday, 8/03/2022 and Patient #19 was admitted on Friday, 8/05/2022.

During an interview with the Staff #21 on 8/12/2022 at 10:40 AM, Staff #21 stated he was only at the facility on Tuesdays and Saturdays. Staff #21 confirmed he was not asked to identify the medications in the medication boxes belonging to Patient #18 and Patient #19. Staff #21 could not confirm nor deny if the medications were a controlled substance.

A review of the facility policy titled, "HOME MEDICATIONS" Policy number MM-04, with a revised dated of 7/01/2022 was as follows:

" ...PURPOSE:
To establish protocol for the inpatient program regarding the regulation of medications brought into the facility from a patient's home.

POLICY:
All medications brought into the facility by persons in the inpatient program (or their family members/significant others) will be immediately surrendered to the nursing staff for the purpose of safeguarding during treatment, and communicating to admitting physician any medications patient may have been taking prior to admission.
...
PROCEDURE:
...
Admit RN:
3. Completes home medication form or the designated home medication listing in the EMR, as applicable. If home medications are controlled substances, the number of pills is counted and witnessed with along with a 2nd witnessed nurse. Both nurses document the count, date/time, and sign the form.
4. If the home medication is a controlled substance, two nurses count and document same and begin a count log. Controlled medications are stored in the locked medication cart or designated cabinet. The key to the designed (sic) cart or cabinet is stored in Automated Medication Dispensing System.
5. Non-narcotic medications are bagged in a security bag and copy of the Home Medication List form is attached to bag.
6. The home medication is then stored within a locked secure area within the medication room or behind double locks ..."

An interview was conducted with Staff #11 on 8/10/2022 after 10:00 AM. Staff #11 was asked who places the patients home medications in the cabinet. Staff #11 stated, "The admitting nurse is supposed to do that, they are all supposed to have a med list when they get placed in the cabinet and it's supposed to be locked." Staff #11 was asked if patients brought a pill box that contained medications how would the facility know if the medication was a controlled substance/narcotic. Staff #11 replied, "I guess we wouldn't know. If it's a narcotic they are supposed to be counted by two nurses but if we don't know what it is I guess we just assume it's not a narcotic."
During an interview with Staff #3 on 8/09/2022 it was confirmed that the identity of the medications was not complete. Staff #3 could not confirm nor deny if the medications in the personal medication boxes of Patient #18 and Patient #19 were a narcotic. Staff #3 also confirmed the cabinet should remained locked at all times unless it is being accessed by a staff member.

Staff #1, #3, #4, and #11 confirmed the findings.

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

1. ensure a clean and sanitary environment to prevent the transmission of infectious diseases in 4 (Patient Nutrition Room, Kitchen, Exam/Treatment Room, and Medication Room) of 9 areas observed.

2. follow the facility policy and ensure the refrigerator/freezer temperatures were monitored in 1 (Patient Medication Refrigerator) of 3 refrigerators observed to provide safe storage for patient medications.

Cross Refer to Tag A0749

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

1. ensure a clean and sanitary environment to prevent the transmission of infectious diseases in 4 (Patient Nutrition Room, Kitchen, Exam/Treatment Room, and Medication Room) of 9 areas observed.

2. follow the facility policy and ensure the refrigerator/freezer temperatures were monitored in 1 (Patient Medication Refrigerator) of 3 refrigerators observed to provide safe storage for patient medications.


Findings Include:

Observation tours were conducted 8/08/2022-8/10/2022 with Staff #1 and Staff #4.

1.

Exam/Treatment Room

On the inside of the patient specimen refrigerator, the bottom was soiled with dirt and dust.


Patient Nutrition Room

Inside the Patient Nutrition Room was a refrigerator with a sign that read, "Patient Food and Drinks Only No Staff Food". The freezer was noted to be soiled with dust and debris. Inside the refrigerator near the drawers, was a dried liquid that was red in color. The inside of the door was noted with a red colored dried liquid that had dirt and dust. At the base of the door, there was a dark red/brown color in the grooves of the door. On the countertop was a large, 5-gallon orange container with a liquid inside. The container was used to serve multiple patients. There was no identification of the liquid inside or the date it was made. In the cabinets below the orange container, chipped wood on the bottom shelf was noted exposing the porous surface. The porous surface cannot be sanitized to mitigate the spread of infectious diseases. A large square hole was noted in the back of the cabinet exposing a metal pipe hanging into the cabinet area. A can of "Hot Shot Ant, Roach, & Spider Killer" was sitting inside this cabinet. In the next lower cabinet, a punch bowl was noted on the lower shelf. Inside the punch bowl was heavy dust. Next to the punch bowl was a "fly swatter" laying on the bottom of the shelf. The cabinet was soiled with a dried liquid, dirt and dust was also noted. On top of the counter were plastic bins that held dried goods, i.e., crackers, snacks, and potato chips. The inside of the bins were soiled with food crumbs, dirt, and dust. On the floor was opened and used sugar packets.

An interview was conducted with Staff #20 on 8/10/2022 after 10:00 AM. Staff #20 was asked who was responsible for ensuring the Patient Nutrition Room is clean. Staff #20 replied, "We will clean it when we stock the room but the staff on the unit are supposed to keep it clean throughout the day."


Kitchen

The pre-wash sink was not in working order. The sink was not secure to the wall and could be moved around. The unpainted and chipped sheetrock behind the sink was exposed. At the bottom of the sink, a drainpipe was not secured to the wall, The bracket securing the pipe to the wall was hanging down with sheetrock noted on the screw. A hole in the sheetrock was noted where the bracket was once screwed to the wall. This left an opening in the sheetrock that could allow for insect infestation. Inside the sink a 5-gallon bucket being used to defrost meat was noted. Staff #1 asked Staff #20 why was the sink not working and what was wrong with it. Staff #20 replied, "The sink has not worked since we opened the kitchen. We use the sink to clean the vegetables. Right now, we are not able to do that."


Medication Room

A pill crusher on the countertop was covered with dirt and dust.

In the sink, a rust color was noted on the drain. Behind the sink was a plastic bin containing multiple patient medications. This had the potential for contaminated water to breach the medication barrier and contaminate the patient's medications. A splash guard was noted to the left of the sink.

A large medication disposal container was noted on the floor of the medication room. The container was full. The lid was open. On the outside of the container was a label that read, "Stericycle Hazardous Waste Pharmaceuticals, Keep Lid Closed". The top of the large medication disposal container was heavily soiled with dust next to the medication preparation area.

In the upper cabinets an opened 10 oz. container of Thick-It (a food and beverage thickener used for patients with swallowing difficulties) was opened and half empty. The open date on the container was 5/18/2022. Staff #4 could not confirm the beyond use date after the product was opened. No patient label was noted on the container.

An 8 oz. bottle of Skintegrity Wound Cleanser was open and half empty with an open date of 6/25/2022. A 6.3 oz. of Sterile Saline Wound wash was open and half empty with an open date of 7/4/2022. Neither item had a patient label. This placed all patients requiring wound care at great risk of an infectious disease from cross contamination between patients. Staff #4 could not confirm the beyond use date for the products.

A lower cabinet in the medication room was designated as Home Meds. On the cabinet door a sign was posted that read, "HOME MEDICATIONS ONLY ON TOP SHELF IN THIS CABINET". The cabinet was unlocked. Inside the cabinet on the top shelf was a bag that contained shoestrings and a belt with a patients first name only, a gray bag with colostomy supplies was stored with no patient name, clear plastic bags with patient prescription medication bottles, and 2 plastic bags with patient medication boxes were noted. A 1-gallon jug of distilled water with Patient #17's name was noted open and half used on the bottom shelf. There was no open date marked on the container. The bottom shelf contained nebulizers, new and unused patient plastic bags and 3 items wrapped in pink bubble wrap. One of the items was unwrapped by this surveyor and could not be identified. Staff #4 stated, "It looks like a battery of some kind."


An interview was conducted with Staff #11 on 8/10/2022 after 10:00 AM. Staff #11 was asked if the wound cleanser or the Thick-it was used for one patient or multiple patients. Staff #11 stated, "I'm not sure, but it was probably used on different patients."

The small refrigerator in the medication room was used to store patient medications. The freezer was thickened with ice and needed to be defrosted. On the top shelf of the refrigerator were 3 plastic bins storing medications. This surveyor removed one plastic bin storing Albuterol (a medication used for breathing treatments) and it was full of water. The water spilled over to the floor. The other two bins were removed, and water was pooled on the top shelf. A plastic bin containing 6 boxes of Influenza Vaccine was noted. Each box contained a 5 ml multidose vial. All 6 boxes expired June 15, 2022. In the door of the refrigerator were 13 boxes of insulin belonging to Patient #20.

An interview was conducted with Staff #21 on 8/12/2022 at 10:40 AM. Staff #21 was asked if he was aware that the refrigerator was holding water in the plastic bins. Staff #21 replied, "I had to throw out 4 boxes of insulin because the boxes got wet and could have contaminated the medications making it unsafe for the patients that required the insulin. At the time, there was no patient that required insulin, so I was able to get it replaced before it was needed. I notified Staff #1 and I was told it would be taken care of, and apparently it has not. I am only there twice a week and if I am not told by the staff that there was a problem with the refrigerator I have no way of knowing. No one from this facility has called to tell me there was a problem with the refrigerator."


Staff #1, #4, and #11 confirmed the findings.



2.

Patient Medication Refrigerator

A review of the temperature log for the patient medication refrigerator located in the Medication Room was incomplete. There was no documentation of the temperature for 1 of 31 days in July and 1 of 9 days in August 2022.

An interview was conducted with Staff #1 on 8/10/2022 after 10:00 AM. Staff #1 was asked if someone was monitoring the temperature logs. Staff #1 replied, "Those days that are missing the temperatures were probably agency nurses. Yes, the logs are being looked at."

An interview was conducted on 10/12/2022 at 10:40 AM with Staff #21. Staff #21 was asked if the temperature ranges for the medication refrigerator were within the parameters to keep the medications for patients safe. Staff #21 replied, "The corporate pharmacy gets the temperature readings. On July 21, I got an email from Staff #22 regarding the temperature being too low and was asked to look at it on my next restock. That was on a Thursday, and I restock on Tuesday and Saturdays." The email dated July 21, 2022, at 5:33 AM from Staff #22 read, "I've notified the facility in addition to them getting these notifications. The temperature is still too low in the refrigerator. Will you investigate during your restock?"

Staff #21 confirmed the Administration team was aware of the out-of-range readings and that Staff #1 reassured him that it will be corrected.


A review of the facility policy titled, "Care and Monitoring of Refrigerators and Freezers", Policy Number EOC-54 with a Revision date of 8/01/2021 was as follows:

" ...POLICY:
Medications, food and nutrition products, and laboratory specimens will be stored under proper condition of sanitation, temperature, light, moisture, ventilation, and security to maintain stability.

All refrigerator/freezer temperatures shall be maintained within acceptable standards to inhibit microbial growth and reduce the risk of infection.

TEMPERATURE:

There are two options for monitoring temperatures in refrigerators and freezers:

Option 1: The temperature for any refrigerator or freezer that contains drugs, patient food, lab specimens, or blood will be checked and recorded in degrees Fahrenheit (F) on a log.

Option 2: For refrigerators that have an internal thermometer with a temperature display:

The temperature will be displayed continuously.

Maintenance:

Refrigerators/freezers will be cleaned according to the following schedule:
Patient food, Drugs (medication), and Laboratory Specimens will be cleaned monthly and as needed ..."



Staff #1 and Staff #4 confirmed the findings.


The facility failed to correct this deficiency which was cited on the visit with an exit date of 06/02/2022 which had a plan of correction completion date of 07/29/2022.









Based on observation, document review and interview the facility failed to follow the facility policy and ensure patient home medications were secured in a locked cabinet.

Findings:
During an observation tour

A lower cabinet in the medication room was designated as Home Meds. On the cabinet door a sign was posted that read, "HOME MEDICATIONS ONLY ON TOP SHELF IN THIS CABINET". The cabinet was unlocked. Inside the cabinet on the top shelf was a bag that contained shoestrings and a belt with a patients first name only. A bag with colostomy supplies was stored with no patient name. A 1-gallon jug of distilled water with Patient #17's name was noted open and half used on the bottom shelf. There was no open date marked on the container. The bottom shelf contained nebulizers, new and unused patient plastic bags and 3 items wrapped in pink bubble wrap. One of the items was unwrapped and could not be identified. Staff #4 stated, "It looks like a battery of some kind." On the top shelf, there was home medications in a personal pill container. The medications belonged to Patient #18 and Patient #19. The containers had pills in the box. The medications had not been identified and no prescription bottles were with the home medication bins.

During an interview with the Staff #21 on 8/12/2022 at 10:40 AM, Staff #21 confirmed he was unaware the unidentified medications were there and the cabinet was unlocked.
An interview was conducted with Staff #1 on 8/10/2022 after 11:00 AM. Staff #1 was asked if Patient #20 was still an inpatient. Staff #1 stated, "No he was discharged about two months ago to a nursing home. I will see if we can get this medication over to the nursing home."

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

A. ensure a Registered Nurse was available 24 hours a day.

Refer to Tag A1703


B. follow its own Staffing Plan to evaluate staffing needs based on patient acuity-established criteria and anticipated admission, transfers, and discharges for 10 of 12 days reviewed (from 7/08/2022-7/11/2022 and 08/01/2022 -08/08/2022)

C. have adequate and safe staffing for nursing and mental health techs to ensure patients received full assessments, adequate time to conduct admissions and discharges, adequate time and staff to care for ill patients in isolation, monitor patients with high-risk behaviors, supervise staff, ability to take breaks, and meet the needs of all patients for 17 of 24 shifts reviewed (from 7/08/2022-7/11/2022 and 08/01/2022 -08/08/2022).

Refer to Tag A1704

Based on observation, interview, and record review, the facility failed to ensure a Registered Nurse (RN) was available 24 hours a day.

This deficient practice had the likelihood to cause harm to all patients on 1 of 1 unit observed. If the RN was not immediately available on the patient care unit, it increases the risk of harm to all patients and staff during a behavioral or medical emergency. For leadership nursing staff to be available from the Administration area, they would have to access two locked doors before entering the unit to be of assistance to the Licensed Vocational Nurse (LVN) and/or Unlicensed personnel.


Findings:


During an observation tour on 8/08/2022 after 10:00 AM with Staff #1, 1 RN, 1 LVN and 4 Mental Health Techs (MHT) were observed giving direct patient care for 22 patients.

A review of the staffing schedules, staffing matrix, and employee timecards for 7/08/2022-7/11/2022 and 08/01/2022 -08/08/2022 (2 shifts per day for a total of 24 shifts) with Staff #7 on 8/09/2022 at 2:15 PM revealed the following:

7/08/2022
Day Shift Patient census was 20. A review of the timecard for Staff #15 revealed she had clocked out for her scheduled 30-minute lunch break leaving Staff #11 unsupervised by an RN and responsible for 20 patients.

Night shift- Patient Census was 20. A review of the timecard for Staff #12 revealed she had clocked out for her scheduled 30-minute lunch break leaving Staff #25 unsupervised by an RN and responsible for 16 patients.

Staff #14 was listed as "Leadership RN 8 hours" on the night shift staffing sheet but the facility was unable to confirm the hours that Staff #14 was present on the unit.

On this day there were 4 COVID positive patients.

A review of the Staffing Matrix for 20 patients on the day and night shift was 1 RN, 1 LVN, and 4 MHTs.

7/09/2022

Day Shift- Patient census was 16. A review of the timecard for Staff #15 revealed she had clocked out for her scheduled 30-minute lunch break leaving Staff #11 unsupervised by an RN and responsible for 16 patients.

Night shift- Patient Census was 20. A review of the timecard for Staff #12 revealed she had clocked out for her scheduled 30-minute lunch break leaving Staff #25 unsupervised by an RN and responsible for 16 patients.

Staff #14 was listed as "Leadership RN 8 hours" on the night shift staffing sheet but the facility was unable to confirm the hours Staff #14 was present on the unit.

On this day there were 6 COVID positive patients.

A review of the Staffing Matrix for 16 patients on the day and night shift was 1 RN, 1 LVN, and 3 MHTs.


7/11/2022

Day Shift- Patient census was 16. Staff #3 was written in as Charge RN. Staff #14 was written in as "Leadership RN 8 hours". The facility was unable to confirm the time Staff #3 and Staff #14 were present on the unit.

Night shift- Patient Census was 16. A review of the timecard for Staff #16 revealed she had clocked out for her scheduled 30-minute lunch break leaving the LVN unsupervised by an RN and responsible for 16 patients.

On this day there were 6 COVID positive patients.

A review of the Staffing Matrix for 16 patients on the day and night shift was 1 RN, 1 LVN, and 3 MHTs.




8/01/2022

Day Shift- Patient census was 14. A review of the timecard for Staff #15 revealed she was clocked out for her scheduled 30-minute lunch break leaving Staff #11unsupervised by an RN and responsible for 14 patients

Night shift- Patient Census was 16. A review of the timecard for Staff #12 revealed she had clocked out for her scheduled 30-minute lunch break leaving Staff #25 unsupervised by an RN and responsible for 16 patients.

Staff #1 was written in as Leadership RN on nights. No time was documented on the staffing sheet and the facility was unable to confirm the hours Staff #1 was present on the unit.


A review of the Staffing Matrix for 14 and 16 patients on the day and night shift was 1 RN, 1 LVN, and 3 MHTs.



8/02/2022

Day Shift- Patient census was 16. A review of the timecard for Staff #17 revealed she was clocked out for her scheduled 30-minute lunch break leaving Staff #11 unsupervised by an RN and responsible for 16 patients

Night shift- Patient Census was 17. A review of the timecard for Staff #12 revealed she had clocked out for her scheduled 30-minute lunch break leaving Staff #25 unsupervised by an RN and responsible for 17 patients


A review of the Staffing Matrix for 16 and 17 patients on the day and night shift was 1 RN, 1 LVN, and 3 MHTs.

8/05/2022

Day Shift...

Night shift- Patient Census was 21. A review of the timecard for Staff #12 revealed she had clocked out for her scheduled 30-minute lunch break leaving Staff #25 unsupervised by an RN and responsible for 21 patients.

Staff #1 was written in on the 7P-7A shift staffing sheet for "Bridge RN till (sic) 8 PM". The facility was unable to confirm the hours Staff #1 was present on the unit.

A review of the Staffing Matrix for 19 patients on the day shift and 21 patients on night shift was 1 RN, 1 LVN, and 4 MHTs.


8/06/2022

Day Shift- Patient census was 21. A review of the timecard for Staff #15 revealed she had clocked out for her scheduled 30-minute lunch break leaving Staff #11 unsupervised by an RN and responsible for 21 patients.

Night shift- Patient Census was 22. A review of the timecard for Staff #12 revealed she had clocked out for her scheduled 30-minute lunch break leaving Staff #25 unsupervised by an RN and responsible for 22 patients.

Staff #7 confirmed there was no Bridge RN on this day.


A review of the Staffing Matrix for 21 patients on the day shift was 1 RN, 2 LVNs, and 4 MHTs and the staffing matrix for the night shift for 22 patients was 1 RN, 1 LVN, and 4 MHTs.


8/07/2022

Day Shift- Patient census was 22. A review of the timecard for Staff #15 revealed she was clocked out from 11:30 AM-12:00 PM for her scheduled 30-minute lunch break leaving Staff #11 unsupervised by an RN and responsible for 22 patients.

Night shift...


A review of the Staffing Matrix for 22 patients on the day shift was 1 RN, 2 LVNs, and 4 MHTs and the staffing matrix for the night shift for 22 patients was 1 RN, 1 LVN, and 4 MHTs.


8/08/2022

Day Shift- Patient census was 22. Staff #3 was written in a "Charge Nurse for the day shift but the facility was unable to provide the time Staff #3 was present on the unit.

A review of the Staffing Matrix for 22 patients on the day shift was 1 RN, 2 LVNs, and 4 MHTs.



An interview was conducted with Staff #11 and Staff #17 on 8/10/2022 after 10:00 AM. Staff #11 and #17 were asked if the Leadership Team would come and relieve the RNs for lunch. Staff #11 stated, "That's funny. They hardly ever come back here unless there is a crisis, or if we don't have an RN at all. Sometimes it is just me and the MHTs at times when the RN goes to lunch. If they have to come back here and work during the week, they are never here before shift change. We have called them on the weekends, and they don't come in then. Most of the time we cannot get them on the weekend because they are not scheduled to work on the weekends. They say they are on call but hardly ever come to help. As soon as you all left here last time, they went right back to doing the very things that were wrong." Staff #17 confirmed what Staff #11 stated.

An interview was conducted with Staff #7 on 8/08/2022 after 11:00 AM. Staff #7 was asked how the facility showed that an exempt employee was on the unit working. Staff #7 stated, "There is no way for anyone to show when they work or when they don't work. We talked about this last time you were here, and they were supposed to be documenting the times that they work on the unit, but I guess they don't. You would have to pull every chart to see if they even documented anything. Some of the nurses complain because they don't feel like they can get any relief. They say at times they never even answer the calls or go back there to help. There is nothing that I have that can prove to you that the leadership RN team was working on the unit."



A review of the Texas Board of Nursing, Practice-Licensed Vocational Nurse Scope of Practice was as follows:

The Texas Nursing Practice Act (NPA) and the Board's Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN),

" ...15.27 The Licensed Vocational Nurse Scope of Practice

The LVN scope of practice is a directed scope of practice and requires appropriate supervision of a registered nurse, advanced practice registered nurse, physician assistant, dentist, or podiatrist ..."



Staff #1, #5, #7, #11, and #17, confirmed the above findings.

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

A. follow its own Staffing Plan to evaluate staffing needs based on patient acuity-established criteria and anticipated admission, transfers, and discharges for 10 of 12 days reviewed (from 7/08/2022-7/11/2022 and 08/01/2022 -08/08/2022)

B. have adequate and safe staffing for nursing and mental health techs to ensure patients received full assessments, adequate time to conduct admissions and discharges, adequate time and staff to care for ill patients in isolation, monitor patients with high-risk behaviors, supervise staff, ability to take breaks, and meet the needs of all patients for 17 of 24 shifts reviewed (from 7/08/2022-7/11/2022 and 08/01/2022 -08/08/2022).


This deficient practice had the likelihood to cause harm to all patients on 1 of 1 unit observed. If the Registered Nurse (RN) is not immediately available on the patient care unit, it increases the risk of harm to all patients and staff during a behavioral or medical emergency. For leadership nursing staff to be available from the Administration area, they would have to access two locked doors before entering the unit to be of assistance to the Licensed Vocational Nurse (LVN) and/or Unlicensed personnel.


Findings Include:


During an observation tour on 8/08/2022 after 10:00 AM with Staff #1, 1 RN, 1 LVN and 4 Mental Health Techs (MHT) were observed giving direct patient care for 22 patients.

A review of the staffing schedules, staffing matrix, and employee timecards for 7/08/2022-7/11/2022 and 08/01/2022 -08/08/2022 (2 shifts per day for a total of 24 shifts) with Staff #7 on 8/09/2022 at 2:15 PM revealed the following:


7/08/2022

Day Shift- Patient census was 20. The Unit was short 1 MHT after 11:00 AM. A review of the timecard for Staff #15 on the day shift revealed she had clocked out for her scheduled 30-minute lunch break leaving Staff #11 unsupervised by an RN and responsible for 20 patients.

Night shift- Patient Census was 20. The Unit was short 2 MHT's. A review of the timecard for Staff #12 on the night shift revealed she had clocked out for her scheduled 30-minute lunch break leaving Staff #25 unsupervised by an RN and responsible for 16 patients.

Staff #14 was listed as "Leadership RN 8 hours" on the night shift staffing sheet but the facility was unable to confirm the hours that Staff #14 was present on the unit.

On this day there were 4 COVID positive patients.

A review of the Staffing Matrix for 20 patients on the day and night shift was 1 RN, 1 LVN, and 4 MHTs.


7/09/2022

Day Shift- Patient census was 16. The Unit was short 1 MHT. A review of the timecard for Staff #15 on the day shift revealed she had clocked out for her scheduled 30-minute lunch break leaving Staff #11 unsupervised by an RN and responsible for 16 patients.

Night shift- Patient Census was 20. A review of the timecard for Staff #12 on the night shift revealed she had clocked out for her scheduled 30-minute lunch break leaving Staff #25 unsupervised by an RN and responsible for 16 patients.

Staff #14 was listed as "Leadership RN 8 hours" on the night shift staffing sheet but the facility was unable to confirm the hours Staff #14 was present on the unit.

On this day there were 6 COVID positive patients.

A review of the Staffing Matrix for 16 patients on the day and night shift was 1 RN, 1 LVN, and 3 MHTs.


7/10/2022

Day Shift- Patient census was 16. The Unit was short 1 MHT after 1:15 PM.

Night shift- Patient Census was 16. The Unit was short 1 MHT.

On this day there was 6 COVID positive patients.

A review of the Staffing Matrix for 16 patients on the day and night shift was 1 RN, 1 LVN, and 3 MHTs.


7/11/2022

Day Shift- Patient census was 16. Staff #3 was written in as Charge RN. Staff #14 was written in as "Leadership RN 8 hours". The facility was unable to confirm the time Staff #3 and Staff #14 were present on the unit.

Night shift- Patient Census was 16. A review of the timecard for Staff #16 revealed she had clocked out for her scheduled 30-minute lunch break leaving the LVN unsupervised by an RN and responsible for 16 patients.

On this day there were 6 COVID positive patients.

A review of the Staffing Matrix for 16 patients on the day and night shift was 1 RN, 1 LVN, and 3 MHTs.


8/01/2022

Day Shift- Patient census was 14. A review of the timecard for Staff #15 on the day shift revealed she was clocked out for her scheduled 30-minute lunch break leaving Staff #11 unsupervised by an RN and responsible for 14 patients

Night shift- Patient Census was 16. A review of the timecard for Staff #12 on the night shift revealed she had clocked out for her scheduled 30-minute lunch break leaving Staff #25 unsupervised by an RN and responsible for 16 patients.

Staff #1 was written in as Leadership RN on nights. No time was documented on the staffing sheet and the facility was unable to confirm the hours Staff #1 was present on the unit.


A review of the Staffing Matrix for 14 and 16 patients on the day and night shift was 1 RN, 1 LVN, and 3 MHTs.


8/02/2022

Day Shift- Patient census was 16. A review of the timecard for Staff #17 on the day shift revealed she was clocked out for her scheduled 30-minute lunch break leaving Staff #11 unsupervised by an RN and responsible for 16 patients

Night shift- Patient Census was 17. The unit was short 1 MHT. A review of the timecard for Staff #12 revealed she had clocked out for her scheduled 30-minute lunch break leaving Staff #25 unsupervised by an RN and responsible for 17 patients


A review of the Staffing Matrix for 16 and 17 patients on the day and night shift was 1 RN, 1 LVN, and 3 MHTs.


8/05/2022

Day Shift- Patient census was 19. The unit was short 1 LVN until 12:39 PM when Staff #24 clocked in. Staff #3 was written on the staffing sheet for LVN coverage. The facility could not confirm the hours Staff #3 was present on the unit.

Night shift- Patient Census was 21. The unit was short 3 MHTs until 9:00 PM and short 2 MHTs after 9:00 PM. A review of the timecard for Staff #12 revealed she had clocked out for her scheduled 30-minute lunch break leaving Staff #25 unsupervised by an RN and responsible for 21 patients.

Staff #1 was written in on the 7P-7A shift staffing sheet for "Bridge RN till (sic) 8 PM". The facility was unable to confirm the hours Staff #1 was present on the unit.

A review of the Staffing Matrix for 19 patients on the day shift and 21 patients on night shift was 1 RN, 1 LVN, and 4 MHTs.


8/06/2022

Day Shift- Patient census was 21. The unit was short 1 LVN and short 2 MHTs after 11:00 AM. A review of the timecard for Staff #15 revealed she had clocked out for her scheduled 30-minute lunch break leaving Staff #11 unsupervised by an RN and responsible for 21 patients.

Night shift- Patient Census was 22. The unit was short 1 MHT. until 9:00 PM and short 2 MHTs after 9:00 PM. A review of the timecard for Staff #12 revealed she had clocked out for her scheduled 30-minute lunch break leaving Staff #25 unsupervised by an RN and responsible for 22 patients.

Staff #7 confirmed there was no Bridge RN on this day.


A review of the Staffing Matrix for 21 patients on the day shift was 1 RN, 2 LVNs, and 4 MHTs and the staffing matrix for the night shift for 22 patients was 1 RN, 1 LVN, and 4 MHTs.


8/07/2022

Day Shift- Patient census was 22. The unit was short 1 LVN and short 1 MHT. A review of the timecard for Staff #15 revealed she was clocked out from 11:30 AM-12:00 PM for her scheduled 30-minute lunch break leaving Staff #11 unsupervised by an RN and responsible for 22 patients.

Night shift- Patient Census was 22. The unit was short 2 MHTs.


A review of the Staffing Matrix for 22 patients on the day shift was 1 RN, 2 LVNs, and 4 MHTs and the staffing matrix for the night shift for 22 patients was 1 RN, 1 LVN, and 4 MHTs.


8/08/2022

Day Shift- Patient census was 22. The unit was short 1 LVN. Staff #3 was written in a "Charge Nurse for the day shift but the facility was unable to provide the time Staff #3 was present on the unit.

A review of the Staffing Matrix for 22 patients on the day shift was 1 RN, 2 LVNs, and 4 MHTs.


An interview was conducted with Staff #11 and Staff #17 on 8/10/2022 after 10:00 AM. Staff #11 and #17 were asked if the Leadership Team would come and relieve the RNs for lunch. Staff #11 stated, "That's funny. They hardly ever come back here unless there is a crisis, or if we don't have an RN at all. Sometimes it is just me and the MHTs at times when the RN goes to lunch. If they have to come back here and work during the week, they are never here before shift change. We have called them on the weekends, and they don't come in then. Most of the time we cannot get them on the weekend because they are not scheduled to work on the weekends. They say they are on call but hardly ever come to help. As soon as you all left here last time, they went right back to doing the very things that were wrong." Staff #17 confirmed what Staff #11 stated.

An interview was conducted with Staff #7 on 8/08/2022 after 11:00 AM. Staff #7 was asked how the facility showed that an exempt employee was on the unit working. Staff #7 stated, "There is no way for anyone to show when they work or when they don't work. We talked about this last time you were here, and they were supposed to be documenting the times that they work on the unit, but I guess they don't. You would have to pull every chart to see if they even documented anything. Some of the nurses complain because they don't feel like they can get any relief. They say at times they never even answer the calls or go back there to help. There is nothing that I have that can prove to you that the leadership team was working on the unit."



A review of the Texas Board of Nursing, Practice-Licensed Vocational Nurse Scope of Practice was as follows:

The Texas Nursing Practice Act (NPA) and the Board's Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN),

" ...15.27 The Licensed Vocational Nurse Scope of Practice

The LVN scope of practice is a directed scope of practice and requires appropriate supervision of a registered nurse, advanced practice registered nurse, physician assistant, dentist, or podiatrist ..."



A review of the policy titled, "STAFFING PLAN" Policy Number NSG-06 with a revision date of 7/01/2019 was as follows:

" ...Policy:
The Governing Body has adopted, implemented, and enforces a written Nurse Staffing policy to ensure that an adequate number and skill mix of nurses are available to meet the level of patient care needed.
...
Procedure:
*Patient census and staffing matrix are used to determine staffing needs.
*A core staffing pattern is utilized and adjusted every shift to meet facility and patient
needs.
*Patient acuity and number of admissions and discharges are factored in daily to ensure
all patient needs are met.
*A registered nurse is physically present and immediately available at all times when a
patient is present on the unit. As used in this policy, "immediately available" requires
the registered nurse to be physically present in the patient common area, nursing station
lounge area adjacent to the nursing station, or in other areas in which the overhead
paging system is audible. This policy does not require the registered nurse to be
regularly interrupted during a meal period. Instead, the registered nurse can and should
schedule a 30-minute uninterrupted meal period and request coverage form the
LPN/LVN on duty to ensure that the meal period is not interrupted.
...
*Criteria for staffing:
Minimum of one (1) RN in the facility and immediately available at all times.
Utilize LPN/LVN's whenever possible as second licensed staff under the RN
Charge ..."




Staff #1, #5, #7, #11, and #17, confirmed the above findings.