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Based on observation and interviews, the hospital failed to ensure patients requiring acute inpatient psychiatric care, who have been admitted for being a danger to self and others, received care in a safe setting. This deficient practice was evidenced by failure to ensure the physical environment was maintained in a manner to assure an acceptable level of safety for patients by having screws that were not tamper resistant and having the door to the room labeled oxygen propped open with an oxygen storage rack. The room contained oxygen tanks, wheel chairs, other supplies and equipment as well as a window.

Findings:

An observation of the A- Hall Unit revealed non- tamper resistant screws in the followng locations:
- The resident phone area on the phone line box;
- Both doorways to the group room frame;
- Group room dry erase board and sockets;
- Fenced area exit door fame and push handle;
- Fire exit door frame and push handle.

In an interview on 08/03/2021 at 9:50 a.m. S1Adm verified the above findings.

At 9:55 a.m. a tour of the B- Hall revealed non-tamper resistant screws in the following locations:
- On the B-Hall entry door frames and doors;
- Various door frames and door handle face plates;
- Various electrical face plates and blank face plates.

In an interview on 08/03/2021 at 10:00 a.m. S1Adm verified the non-tamper resistant screws on B- Hall.


On 08/03/2021 at 10:05 a.m. an observation revealed the door to the Oxygen room was propped open with an oxygen tank in a metal cage holder. The room contained oxygen tank, wheelchairs, supplies, equipment and an exterior window, which could have been broken for elopement or used as a weapon.

In an interview on 08/03/2021 at 10:05 a.m. in an interview S1Adm verified the door should not have been propped open and was a safety risk for patients and staff. He also stated the door is to remain locked and secured at all times.

Based on observation, record reviews and interviews, the hospital failed to ensure there was an adequate number of MHTs to provide nursing care to all patients as needed as evidenced by failure to have an adequate ratio of MHTs to patients 05/09/2021 on the A and B - Hall Units and on 08/03/2021 A- Hall Unit.

Findings:

A review of the Nursing Grid Utilization by Census 2019 revealed the following:
A- Hall Day Shift 17- 27 patients = 3 MHTs
A- Hall Night Shift 17- 27 patients = 3 MHTs
B- Hall Night Shift 17- 34 patients = 3 MHTs

A review of the A- Hall Census for 05/09/2021 revealed 23 patients and a review of the staffing sheet and time card for 05/09/ 2021 revealed 2 MHTs were scheduled and worked 7:00 a.m. - 7 p.m. and 7:00 p.m. - 7:00 a.m.

A review of the B- Hall Census for 05/09/2021 revealed a census of 29 patients and a review of the staffing sheet and time card for 05/09/2021 revealed only 2 MHTs were scheduled and worked 7:00 p.m. - 7:00 a.m.

In an interview on 08/04/2021 at 3:00 p.m. S1Adm reviewed the employees time cards for 05/09/2021, the patient census and staff scheduled and verified the above information. He verified the A- Hall and B- Hall units were under staffed as noted above.

An observation on 08/03/2021 during a tour of the facility with S1Adm revealed the A-Hall unit contained 30 beds with current census of 20 residents and 2 MHTs working.

A review of the staff assignments revealed 4 MHTs on the assignment sheet; however, only 2 MHTs, S6Staff and S16Staff were working on the A Hall with 20 residents.

In an interview on 08/03/2021 at 9:25 a.m. S6Staff stated he was trying to catch up with his Q15 minute observation check list since they were short staffed. He stated it was only he and S16Staff with 20 residents.

An observation on 08/03/2021 at 9:30 a.m. revealed S9Staff was now on A- Hall Unit and received several patient observation sheets from S6Staff and S16Staff.

In an interview on 08/03/2021 at 9:30 a.m. S9Staff stated he did not have any patient assignment since arriving at 7:00 a.m. He verified only 2 MHTs had been working with 20 patients since 7:00 a.m. and he was aware several staff had called out before the shift started.

In an interview on 08/03/2021 at 9:50 a.m. S1Adm verified the inadequate staffing.

In an interview on 08/03/2021 at 12:20 p.m. S9Staff verified the A- Hall unit was not adequately staffed 08/03/2021 between 7:00 a.m. and 9:30 p.m. He further stated the MHT staffing for A- Hall is as follows:
1 MHT- up to 8 residents
2- up to 16 residents
3- 17-27 residents
4- 28- 30 residents

Based on record review and interviews, the registered nurse responsible for supervision and evaluation of the nursing care failed to ensure that care was provided in accordance with hospital policy relative to patient observation documentation. This deficient practice was evidenced by MHTs failing to document q 15 minute observations real time for 38 (R1-R38) of 43 (1-5, R1-R38) oatient Observation Checklist reviewed for completeness.

Findings:


A review of the hospital policy titled Patient Observation last reviewed 05/11/2021 revealed in part:

Definitions:
1. Standard observation:
Visual contact is made between staff member and patient at least every 15 minutes. This observation must be documented in real time per every visual contact performed.

Procedure:
1. All patients admitted to the hospital are automatically on standard observation (q 15 minute checks), unless deemed necessary for a higher level of precaution by the admitting physician or charge nurse.


On 08/03/2021 at 9:30 a.m. a review of the following Observational Checklist revealed no q 15-minute observation documentation real time for the following times:
Patients R2- R6 no documentation 8:30 a.m. through 9:30 a.m.
Patient R7 no documentation 7:00 a.m. through 9:30 a.m.
Patents R8 and R9 no documentation for 7:15 am and 7:45 a.m. through 9:30 a.m.

In an interview on 08/03/2021 at 9:30 a.m. S9Staff verified the Observation Checklist were not documented real time and many times were blank as noted above. S9Staff also verified the documentation is to be done real time as per policy.

In an interview on 08/03/2021 at 9:35 a.m. S6Staff verified the Observation Checklist were missing real time documentation, resulting in many blank times.

On 08/03/2021 at 10:00 a.m. a review of the Observational Checklist for Patients R1, R10 - R38 revealed no q 15-minute observation documentation real time from 7:00 a.m. through 10:00 a.m.

In an interview on 08/03/2021 at 10:05 a.m. S7Staff stated they usually have 4-5 MHT per shift. She also verified all q 15-minute Observation Checklist were blank.

In an interview on 08/03/2021 at 10:10 a.m. S5Staff verified the Observation Checklist were blank since 7:00 a.m. and they should be completed up to the current time and should be completed real time.

Based on record review and interview the facility failed to ensure medical records were completed per hospital policy. This failure is evidenced by 4 of 4 (#1, #2, #3, and #5) closed patient records reviewed with no discharge summary.
Findings:

Review of hospital policy IM-005, "Documentation," revealed in part, "a physician's discharge summary is required by the 30th day and included: reason for hospitalization; significant findings; the patient clinical course; condition and prognosis at the time of discharge; discharge diagnosis; physical and psychiatric needs to include medications, diet, exercise; after care plans; communication with those providing continuing care."

Review of the medical records revealed all of the closed charts reviewed (#1, #2, #3, and #5) were closed for greater than 30 days and did not have a discharge summary.

In interview on 08/04/2021 at 10:16 a.m., S11Staff verified the charts were missing the formal discharge summary and all records had been closed for greater than thirty days.