HospitalInspections.org

Based on a review of facility documentation and staff interviews, the governing body of the facility failed to:

A. Ensure quality care was provided by its medical staff for each patient undergoing restraint and/or seclusion as 1 of 2 patients undergoing such an episode (Patient #9) was restrained and secluded in a manner inconsistent with current standards of psychiatric and medical practice (Cross refer to A0049)

B. The facility continued out of compliance with Conditions of Participation for Patient Rights and Nursing Services (from survey of date 2/20/18).


The cumulative effect of these systemic deficient practices and ongoing non-compliance with Conditions of Participation resulted in continued non-compliance with the Condition of Participation for Governing Body.

Based on a review of facility documentation and staff interviews, the governing body of the facility failed to ensure quality care was provided by its medical staff for each patient undergoing restraint and/or seclusion, as 1 of 2 patients undergoing such an episode (Patient #9) was restrained and secluded in a manner inconsistent with current standards of psychiatric and medical practice.

Findings were:

Facility policy #1000.44 entitled "Physical Restraint," last revised 2/18, included the following:
"PROCEDURE: ...
2. Staff should employ a physical restraint / escort only when less restrictive interventions (i.e., de-escalation techniques, decreasing environmental stimulus, re-direction, time-out, medications as per physician's order) have proven ineffective in preventing:
2.1 Imminent probably death or substantial bodily harm to the patient due to an active suicidal act or serious self-harm behavior.
2.2 Imminent physical harm to others because of acts the patient commits.
2.3 Active destruction of property which may cause serious harm to self and others.
2.4 An active attempt to elope from the cottage/unit ...

3.4 Each initial written order will be time limited and not to exceed 15 minutes.
3.5 Physical restraints/escort should be used for the shortest period of time necessary and should be terminated as soon as the patient demonstrates the release behaviors specified by the physician's order ...
4. No physical restraint / escort shall be used:
4.1 As means of discipline, retaliation, punishment, or coercion.
4.2 For the purpose of convenience of staff members or other individuals.
4.3 As a substitute for effective treatment or rehabilitation ..."

Facility policy #1000.45 entitled "Seclusions," last revised 2/18, included the following:
"POLICY: Seclusion is an emergency behavioral intervention of last resort in which preventive, de-escalate, or verbal techniques have been considered and determined to be ineffective and it is immediately necessary to seclude the patient in order to prevent harm to self and others.
Definition: The involuntary confinement of a patient away from other patients for any period of time in a hazard-free room or other area in which direct observation can be maintained and from which egress is prevented ...
3.4 No seclusion shall be used as means of discipline, retaliation, punishment or coercion ...
3.4 [sic] Each initial order will be time limited and not to exceed: ...Two (2) hours for ages 9-17 (facility's bold) ...
3.5 The seclusion should be used for the shortest period of time necessary and should be terminated as soon as the patient demonstrates the release behaviors specified by the physician ...
4.2 The physician's order for seclusion must:
4.2.1 Specify the date, time of day, and maximum length of time the seclusion may be used.
4.2.2 Describe the specific behaviors which constituted the emergency which resulted in the seclusion.
4.2.3 Describe the specific release behaviors that the patient must demonstrate before the seclusion will be discontinued ..."

Patient #9 was a 14-year-old female patient admitted to Cedar Crest Hospital on 3/12/18 with principal diagnosis of Bipolar Disorder. Included in the long list of secondary diagnoses was Intentional Self-Harm by Unspecified Sharp Ob (presume Object). Several lacerations of different areas of the body were listed as well. A Psychiatric Evaluation on 3/13/18 at 1:50 p.m. included the following:
" ...Admits to being sad & mad yesterday and tried to hang self & cut leg multiple times with a "spring from a pen." Denies much bleeding, noting it has stopped. Tried hanging self with sheet ...Multiple suic att (suicide attempts) since age 11. Last one before this was [illegible word], wrist age 13 ..."

Patient #9 was discharged on 3/20/18 at approximately 2:00 p.m. A Physician's Order for emergency medication on 3/20/18 at 9:25 a.m. read as follows:
"Thorazine 50 mg IM x 1 dose now
Benadryl 50 mg x 1 dose
Ativan 2 mg IM x 1
Restrain due to self-harm, Assault to staff."

The order included no reference to patient seclusion. There were no alternate interventions documented prior to this episode of patient restraint/seclusion. No release behaviors were specified.

MHA notes on 3/20/18 documented her continued one-to-one observation level every hour on a "blue note":
9:00 a.m. -
"Pt is doing crossword puzzles in quiet room.
Pt was aggressive. Jumped over nurses station. Fought a [sic] RN.
Pt ran to the nurse's station and threw milk on Dr.
Pt was restraint [sic].
Dr. ordered doors in quiet room to be locked."
10:00 a.m. - "Pt appears to be sleep."
11:00 a.m. - "Pt appears to be sleep."
12:00 p.m. - "Pt is up. Pt is eating lunch in quiet room."
1:00 p.m. - "Pt is patiently waiting to be discharge."
2:00 p.m. - "Pt discharged."

Patient #9 was discharged from Cedar Crest that afternoon, after receiving emergency psychotropic medication and having been restrained and secluded for "self-harm." No additional restraint/seclusion documentation for this episode could be found in the patient record, and the facility was unable to supply additional documentation.

A Physician's Discharge Note on that date at 1:35 p.m. read as follows:
"Pt is very manipulative, attention seeking, not participating in any groups, [illegible word] hitting staff and destroying property, needs to be discharged ..."

The above findings were confirmed in an exit interview with the facility CEO and other administrative staff on the afternoon of 3/28/18 in the facility conference room. No additional information was provided to this surveyor at that time.

Based on observation, staff interview and record review, the facility demonstrated ongoing non-compliance with the Condition of Participation for Patient Rights as evidenced by failing to ensure each patient received:

A. Protection from harm through adequate staffing which allowed for observation levels to be implemented as ordered for 3 of 5 patients (Patients #6-7 and #9) whose observation levels were reviewed (Cross refer to A0144)

B. Appropriate assessment of patients' physical/medical status for 5 of 5 patients with medical issues (Patients #1-5) (Cross refer to A0144)

C. The right to be free from restraint or seclusion unless it was to ensure the immediate physical safety of the patient, a staff member or others, for 1 of 2 patients reviewed undergoing restraint/seclusion (Patient #9). The facility also failed to discontinue the restraint at the earliest possible time for the same patient (Cross refer to A0154)

D. The right to restraint or seclusion being used only when less restrictive interventions had been determined and documented to be ineffective to protect the patient or staff from harm for 1 of 2 patients reviewed undergoing restraint/seclusion (Patient #9) (Cross refer to A0164)

E. The right that an order for restraint or seclusion used for the management of violent or self-destructive behavior was renewed according to specified regulatory time limits for 1 of 2 patients reviewed who underwent restraint/seclusion (Patient #9) (Cross refer to A0171)

F. The right that each patient record receive a 1-hour face-to-face medical and behavioral evaluation for 1 of 2 patients reviewed undergoing restraint/seclusion (Patient #9) (Cross refer to A0184)


The cumulative effect of these systemic deficient practices resulted in ongoing non-compliance with the Condition of Participation for Patient Rights.

Based on a review of facility documentation and staff interviews, the facility failed to ensure each patient received care in a setting that provided:
A. protection from harm through adequate staffing allowing for observation levels to be implemented as ordered for 3 of 5 patients (Patients #6-7 and #9) whose observation levels were reviewed; and
B. appropriate assessment of patients' physical/medical status for 5 of 5 patients with medical issues (Patients #1-5).

Findings were:

A review of the facility's Patient Rights document included the following:
" ...Personal Safety
To expect reasonable safety in so far as the hospital practices and environment are concerned, including the right to be free from all forms of abuse or harassment ..."

A. Facility policy #1000.17 entitled "Observation / Precaution Levels," last revised 1/17, included the following:
"POLICY: To ensure the safety of each patient, various levels of observation or monitoring will be utilized based on assessed individual patient acuity ...
Patients admitted or later placed on a higher observation level, i.e. Q.15 minute checks, Line-of-Sight (LOS) or 1:1 will be re-assessed by the physician / NP on a daily basis for appropriateness of observation level, and a Doctor's order to either continue or decrease in observation level will be entered in the patient's medical record ...
1:1
One (1) unit staff will provide constant visual observation and remain within arms-length of the patient (facility's underline). This continuous direct visual observation will continue even when patients shower, change clothes or use the bathroom ...
Staff will monitor patients on 1:1 observation on the unit, unless the physician gives an order, the patient may not leave the unit ..."

Patient #6 was a 15-year-old male admitted to Cedar Crest Hospital on 3/12/18 for Major Depressive Disorder, and secondary diagnosis "Personal history of physical and sexual abuse ..." A physician order written on 3/13/18, no time, read as follows:
"SAOP (Sexual Acting Out Precautions) protocol
Blocked room please
"Checking precautions"

The rationale included with the order stated, "Sexually assaultive." The SAOP precaution level was first noted on the patient Precaution/Observation Checklist on 3/17/18 - 4 days after the precautions were ordered. A review of Unit 4 room assignments revealed Patient #6 was in 405A on 3/17/18. A 16-year-old male patient was noted to be in 405B on 3/17/18. The record of Patient #6 included no order to unblock his room.

Patient #7 was a 13-year-old male patient admitted on 1/10/18 with principal diagnosis of Bipolar Disorder and secondary diagnosis of Autistic Disorder. The patient was on a one-to-one observation level from 1/12/18 through 2/14/18 according to nursing documentation. Physician orders to continue this level of observation were noted only on the following dates: 1/12/18, 1/15/18, 1/17/18, 1/20/18, 1/21/18, 1/22/18, 1/25/18, 1/26/18, 1/31/18, 2/6/18, 2/7/18, 2/8/18, 2/9/18, and 2/14/18. The patient was discharged on 2/15/18.

In an interview with the Interim Chief Nursing Officer, on the morning of 3/28/18 in the facility conference room, she stated, "We document observation of a one-to-one patient every hour on a blue note. They should document each hour ...One-to-ones stay on the unit ..."

On the morning of 2/13/18, observation notes for the one-to-one observation of Patient #7 were made at the following times: 7:45 a.m., 9:45 a.m., 11:15 a.m., 12:15 p.m., 3:39 p.m., 6:09 p.m., and 7:00 p.m. From 7:00 p.m., notes were made each hour. The facility could provide no additional documentation that this patient had been monitored at a one-to-one observation level.

MHA notes on 2/13/18 read as follows:
12:15 p.m.: "Pt went to gym [with] peers."
3:39 p.m.: "While in the gym a peer hit pt in the back of the head for allegedly hitting/kicking peer ..." Facility policy required one-to-one patient monitoring to occur only on the unit.

Patient #9 was a 14-year-old female patient admitted to Cedar Crest Hospital on 3/12/18 with principal diagnosis of Bipolar Disorder. Included in the long list of secondary diagnoses was Intentional Self-Harm by Unspecified Sharp Ob (presume Object). Several lacerations of different areas of the body were listed as well. A Psychiatric Evaluation on 3/13/18 at 1:50 p.m. included the following:
" ...Admits to being sad & mad yesterday and tried to hang self & cut leg multiple times with a "spring from a pen." Denies much bleeding, noting it has stopped. Tried hanging self with sheet ...Multiple suic att (suicide attempts) since age 11. Last one before this was [illegible word], wrist age 13 ..."

A Physician's Order on 3/13/18 at 1:58 p.m. initiated a one-to-one observation level "due to safety."
A Physician's Order on 3/14/18 at 3:00 p.m. read as follows: "Continue 1:1."
"Blue note" required hourly observation notes for this patient's one-to-one observation level included the following:
3/14/18 - 3:00 p.m. to 11:00 p.m. - "Pt @ NS (nurses station) upon arrival. Pt defiant and resistant to room restriction. Pt had a roll of tape on her person when I arrived. Pt, female group with male staff had to be out of site [sic] on 2 occasions. RN was aware of situation. Pt also was with another staff temporarily when Pt was out of site and closed in another female pt room without permission. Pt was allowed OS (outside) time until pt started to write profanity on the walls with chalk & crayon. Pt was taken inside and pt refused to rm (room) on her own. Pt [illegible word] in several items of contraband on her own, but became very upset and defiant when RN asked rm to be searched. No additional items found. [Illegible word] turned in a broken compact with glass inside, a set of shoe strings, and a rusty nail. Pt settled down and did room searches. When pt was compliant and requested, pt sat outside ..."

A review of the staffing on Unit 4 on 3/14/18, 3:00 p.m. to 11:00 p.m., included one (RN) and two (2) MHAs (mental health assistants). One of these MHAs was supposed to be assigned solely to the one-to-one observation of Patient #9. Thus, the remainder of the patients were to be monitored by one RN and one MHA. The patient census was not clear for that date as there were a number of discharges and admissions, but it appeared to be between 30 to 40 patients. The facility Nurse Staffing Grid for Unit 4 on this shift with 30-35 and/or 36-40 patients required one (1) RN, one (1) LVN, and 4 MHAs. MHAs assigned to one-to-one observation of patients are not counted in the staff numbers, according to facility policy.


B. Facility policy #1000.3 entitled "Vital Signs / Weights / Pain Level," last revised 7/15, included the following:
"2. Acute Care Unit
2.1 Routine Vital Signs are taken on every patient at the time of admission, then on a daily basis.
2.2 Additionally, vital signs are taken in compliance with specific MD orders, Detox protocols or as indicated by the RN due to patient complaints of physical symptoms which might indicate the need for Vital Signs checks ..."

Facility policy #1000.107 entitled "Glucometer Glucose Testing," last reviewed 3/18, included the following:
"B. Blood Glucose Testing ...
5. Document the results on the MAR (medication administration record) and notify the physician of any significant high or low readings ..."

A review of the medical record of Patient #1 revealed he was a 35-year-old patient admitted to Cedar Crest Hospital on 2/7/18. Physician's Preadmission Examination Orders and Preliminary Plan of Care on 2/7/18 at 5:23 p.m. included the following:
"Vital Signs: Q4 hours x 24 hours then Qshift if stable
Notify MD if Systolic BP > 190 or < 90, HR > 100 or < 60, T > 100.3 ...
Initiate CIWA (Clinical Institute Withdrawal Assessment Alcohol Scale) scale assessments upon admission to unit and record score on flow sheet ..."

A review of the patient's Vital Signs Record included only the following entries:
2/8/18 at 2:28 p.m.: BP 134/69, P 130, T 97.6, RR 18
2/9/18 at 6:00 a.m.: BP 127/81, P 87, T 98.0, RR 16

Additional vital signs entries on a Clinical Institute Withdrawal Assessment for alcohol revealed the following:
2/8/18 at 10:00 a.m.: Pt refused
2/8/18 at 6:00 p.m: Pt sleeping
2/8/18 at 6:05 p.m.: Pt refused

2/9/18 at 10:00 a.m.: Pt sleeping
2/9/18 at 2:00 p.m: BP 130/72, Resp 18, Pulse 110, Temp 97.8
2/9/18 at 6:00 p.m.: BP 134/78, Resp 18, Pulse 92, Temp 97.9

No additional vital signs were found in the patient record. There was no documented evidence in the patient record that the physician had been notified of pulse/heart rate elevated above 100 on 2/8/18 or 2/9/18. Patient #1 was discharged on 2/11/18.

A review of the medical record of Patient #2 revealed Physician's Preadmission Examination Orders and Preliminary Plan of Care on 2/6/18 at 8:00 a.m. as follows:
"Admit Recommendation: Admit to inpatient, inclusive of groups and programming ...
Vital Signs: Routine
Notify MD if Systolic BP > 190 or < 90, HR > 100 or < 60, T > 100.3 ..."

Review of a Vital Signs Record for Patient #2 included only the following vital sign entries (all entries within normal parameters):
--2/5/18 at 4:40 p.m.
--2/9/18 at 6:00 a.m.
--2/14/18 at 6:00 a.m.
--2/15/18 at 6:00 a.m.
--2/18/18 at 6:00 a.m.
--2/19/18 at 6:00 a.m.
--2/20/18 at 6:00 a.m.

Patient #3 had vital sign monitoring ordered on 3/1/18 at 9:00 a.m. to be "Routine ...Notify MD if Systolic > 190 or < 90, HR > 100 or < 60, T > 100.3 ..." The patient was admitted on 2/28/18. The only vital signs noted in the patient record as follows:
2/28/18 - no times - two sets of vital signs were noted
3/8/18 - no time - BP 106/66, P 109, no temperature noted, Respiratory Rate 15.
3/9/18 - no time - BP 117/44, P 105, no temperature noted, RR 17
3/10/18 - no time - vital signs within normal ranges
3/23/18 - no time - BP 109/80, P 103, T 97.2, RR 17
3/24/18 - no time - BP 87/51, P 93, no temperature noted, RR 16
3/26/18 - no time - BP 87/46, P 98, no temperature noted, RR 17

The patient record included no documentation of a physician having been notified of the patient's elevated heart rate/pulse on 3/8/18, 3/9/18, or 3/23/18, or of her low blood pressure on 3/24/18 and 3/26/18. Vital sign readings were missing for numerous dates.

Patient #4 was admitted on 2/1/18 with diagnoses of Bipolar Disorder and Post-Traumatic Stress Disorder. Lithium 150 mg p.o. BID and 300 mg p.o. BID was first administered to the patient on 2/13/18. A physician order on 2/13/18 ordered a lithium level be drawn "in 3 days." There was no lithium level result to be found in the patient record.

A Nursing Progress Note on 2/4/18, no time, read as follows:
" ...McLanes ER
CT of head & neck - negative
Given Tordol [sic] & Tylenol. Given Rx."
A Nursing Daily Shift Note on 2/4/18 at 8:00 p.m., read as follows:
"Sent to ER."

The record included no other documentation related to Patient #4's having been sent to a hospital ER. The facility could provide no additional documentation regarding the ER visit of this patient.

Patient #5 was admitted on 3/9/18. Physician's MOT Orders and Preliminary Plan of Care on 3/9/18 at 8:15 p.m. included the following:
"Active Medical Diagnosis or Issues: Chronic Hep-C, Chronic pain syndrome, Diabetes E11.9, HTN/high BP ..." The orders included a DM (Diabetes Mellitus) Control Protocol which included: "Fingerstick blood glucose: QID AC and at bedtime ..." along with sliding scale insulin amounts and the note: "Anything < 70 mg/dl or > 300 mg/dl - NOTIFY MD on CALL ..."
The patient was ordered to be on Zyprexa, an anti-psychotic medication, while at the facility. A long-known side effect of Zyprexa is elevated blood sugar levels.

Accucheck results of this patient's blood sugar levels were noted as follows:
o 3/10/18 at 8:00 p.m. - 419
o 3/11/18 at 6:30 a.m. - 315
o 3/11/18 at 8:00 p.m. - 400
o 3/12/18 at 6:30 a.m. - 350
o 3/12/18 at 11:30 a.m. - 435
o 3/12/18 at 5:30 p.m. - 456
o 3/12/18 at 8:00 p.m. - 335
o 3/13/18 at 6:30 a.m. - 398
o 3/13/18 at 11:30 a.m. - 379
o 3/13/18 at 5:30 p.m. - 534
o 3/13/18 at 8:00 p.m. - 505
o 3/14/18 at 6:30 a.m. - 335
o 3/14/18 at 5:30 p.m. - 450
o 3/14/18 at 8:00 p.m. - 516
o 3/15/18 at 6:30 a.m. - 571
o 3/15/18 at 11:30 a.m. - "Hi - called MD"
o 3/15/18 at 5:30 p.m. - "@ ER"
o 3/15/18 at 8:00 p.m. - 339
o 3/16/18 at 8:00 p.m. - 360

Only the level on 3/15/18 included the note of "called MD" as documentation of having notified a physician. Patient #5 was sent to an ER twice during her stay at Cedar Crest. The first time was on her date of admission on 3/9/18. The second time was on 3/15/18.

Two unsigned physician orders in the patient record included:
3/9/18 at 9:48 p.m. - "BS = 518, 10 units insulin given per SS (sliding scale). [Name], PA (physician assistant) notified. Will recheck in one hour and notify him of results."
3/9/18 at 10:35 p.m. - "BS > 600 x 2 checks. Send pt to ER due to hyperglycemia."

The patient was again sent to an acute care hospital ER on 3/15/18 for hyperglycemia. A physician's order on that date at 2:30 p.m. read as follows: "Send patient to Scott and White ER for hyperglycemia ..."

All the above findings were confirmed in an interview with the facility CEO and other administrative staff on the afternoon of 3/28/18 in the facility conference room.

Based on a review of facility documentation and staff interviews, the facility failed to ensure that each patient had the right to be free from restraint or seclusion unless it was to ensure the immediate physical safety of the patient, a staff member, or others, for 1 of 2 patients (Patient #9) reviewed undergoing restraint/seclusion. The facility also failed to discontinue the restraint at the earliest possible time for the same patient.

Findings were:

Facility policy #1000.44 entitled "Physical Restraint," last revised 2/18, included the following:
"PROCEDURE: ...
2. Staff should employ a physical restraint / escort only when less restrictive interventions (i.e., de-escalation techniques, decreasing environmental stimulus, re-direction, time-out, medications as per physician's order) have proven ineffective in preventing:
2.1 Imminent probably death or substantial bodily harm to the patient due to an active suicidal act or serious self-harm behavior.
2.2 Imminent physical harm to others because of acts the patient commits.
2.3 Active destruction of property which may cause serious harm to self and others.
2.4 An active attempt to elope from the cottage/unit ...

3.4 Each initial written order will be time limited and not to exceed 15 minutes.
3.5 Physical restraints/escort should be used for the shortest period of time necessary and should be terminated as soon as the patient demonstrates the release behaviors specified by the physician's order ...
4. No physical restraint / escort shall be used:
4.1 As means of discipline, retaliation, punishment, or coercion.
4.2 For the purpose of convenience of staff members or other individuals.
4.3 As a substitute for effective treatment or rehabilitation ..."

Facility policy #1000.45 entitled "Seclusions," last revised 2/18, included the following:
"POLICY: Seclusion is an emergency behavioral intervention of last resort in which preventive, de-escalate, or verbal techniques have been considered and determined to be ineffective and it is immediately necessary to seclude the patient in order to prevent harm to self and others.
Definition: The involuntary confinement of a patient away from other patients for any period of time in a hazard-free room or other area in which direct observation can be maintained and from which egress is prevented ...
3.4 No seclusion shall be used as means of discipline, retaliation, punishment or coercion ...
3.4 [sic] Each initial order will be time limited and not to exceed: ...Two (2) hours for ages 9-17 (facility's bold) ...
3.5 The seclusion should be used for the shortest period of time necessary and should be terminated as soon as the patient demonstrates the release behaviors specified by the physician ...
4.2 The physician's order for seclusion must:
4.2.1 Specify the date, time of day, and maximum length of time the seclusion may be used.
4.2.2 Describe the specific behaviors which constituted the emergency which resulted in the seclusion.
4.2.3 Describe the specific release behaviors that the patient must demonstrate before the seclusion will be discontinued ..."

Patient #9 was a 14-year-old female patient admitted to Cedar Crest Hospital on 3/12/18 with principal diagnosis of Bipolar Disorder. Included in the long list of secondary diagnoses was Intentional Self-Harm by Unspecified Sharp Ob (presume Object). Several lacerations of different areas of the body were listed as well. A Psychiatric Evaluation on 3/13/18 at 1:50 p.m. included the following:
" ...Admits to being sad & mad yesterday and tried to hang self & cut leg multiple times with a "spring from a pen." Denies much bleeding, noting it has stopped. Tried hanging self with sheet ...Multiple suic att (suicide attempts) since age 11. Last one before this was [illegible word], wrist age 13 ..."

Patient #9 was discharged on 3/20/18 at approximately 2:00 p.m. A Physician's Order for emergency medication on 3/20/18 at 9:25 a.m. read as follows:
"Thorazine 50 mg IM x 1 dose now
Benadryl 50 mg x 1 dose
Ativan 2 mg IM x 1
Restrain due to self-harm, Assault to staff."

The order included no reference to patient seclusion. There were no alternate interventions documented prior to this episode of patient restraint/seclusion. No release behaviors were specified.

MHA notes on 3/20/18 documented her continued one-to-one observation level every hour on a "blue note":
9:00 a.m. -
"Pt is doing crossword puzzles in quiet room.
Pt was aggressive. Jumped over nurses station. Fought a [sic] RN.
Pt ran to the nurse's station and threw milk on Dr.
Pt was restraint [sic].
Dr. ordered doors in quiet room to be locked."
10:00 a.m. - "Pt appears to be sleep."
11:00 a.m. - "Pt appears to be sleep."
12:00 p.m. - "Pt is up. Pt is eating lunch in quiet room."
1:00 p.m. - "Pt is patiently waiting to be discharge."
2:00 p.m. - "Pt discharged."

Patient #9 was discharged from Cedar Crest that afternoon, after receiving emergency psychotropic medication and having been restrained and secluded for self-harm. No additional restraint/seclusion documentation for this episode could be found in the patient record, and the facility was unable to supply additional documentation.

A Physician's Discharge Note on that date at 1:35 p.m. read as follows:
"Pt is very manipulative, attention seeking, not participating in any groups, [illegible word] hitting staff and destroying property, needs to be discharged ..."

The above findings were confirmed in an exit interview with the facility CEO and other administrative staff on the afternoon of 3/28/18 in the facility conference room. No additional information was provided by the facility at that time.

Based on a review of facility documentation and staff interviews, the facility failed to ensure that each patient had the right to restraint or seclusion being used only when less restrictive interventions had been determined and documented to be ineffective to protect the patient or staff from harm for 1 of 2 patients reviewed undergoing restraint/seclusion (Patient #9).

Findings were:

Facility policy #1000.44 entitled "Physical Restraint," last revised 2/18, included the following:
"PROCEDURE: ...
1. Staff should attempt alternative interventions prior to any decision to utilize a physical restraint or physical escort.
2. Staff should employ a physical restraint / escort only when less restrictive interventions (i.e., de-escalation techniques, decreasing environmental stimulus, re-direction, time-out, medications as per physician's order) have proven ineffective in preventing:
2.1 Imminent probably death or substantial bodily harm to the patient due to an active suicidal act or serious self-harm behavior.
2.2 Imminent physical harm to others because of acts the patient commits.
2.3 Active destruction of property which may cause serious harm to self and others.
2.4 An active attempt to elope from the cottage/unit ..."

Facility policy #1000.45 entitled "Seclusions," last revised 2/18, included the following:
"POLICY: Seclusion is an emergency behavioral intervention of last resort in which preventive, de-escalate, or verbal techniques have been considered and determined to be ineffective and it is immediately necessary to seclude the patient in order to prevent harm to self and others.
Definition: The involuntary confinement of a patient away from other patients for any period of time in a hazard-free room or other area in which direct observation can be maintained and from which egress is prevented ..."

Patient #9 was a 14-year-old female patient admitted to Cedar Crest Hospital on 3/12/18 with principal diagnosis of Bipolar Disorder.

The patient was discharged on 3/20/18 at approximately 2:00 p.m. A Physician's Order for emergency medication on 3/20/18 at 9:25 a.m. read as follows:
"Thorazine 50 mg IM x 1 dose now
Benadryl 50 mg x 1 dose
Ativan 2 mg IM x 1
Restrain due to self-harm, Assault to staff."

The order included no reference to patient seclusion. There were no alternate interventions documented prior to this episode of patient restraint/seclusion. No release behaviors were specified.

The patient was discharged from Cedar Crest that afternoon, after receiving emergency psychotropic medication and having been restrained and secluded for self-harm.

The above findings were confirmed in an exit interview with the facility CEO and other administrative staff on the afternoon of 3/28/18 in the facility conference room.

Based on a review of facility documentation and staff interview, the facility failed to ensure each order for restraint or seclusion used for the management of violent or self-destructive behavior was renewed according to specified regulatory time limits for 1 of 2 patients reviewed who underwent restraint/seclusion (Patient #9).

Findings were:

Facility policy #1000.45 entitled "Seclusions," last revised 2/18, included the following:
"POLICY: Seclusion is an emergency behavioral intervention of last resort in which preventive, de-escalate, or verbal techniques have been considered and determined to be ineffective and it is immediately necessary to seclude the patient in order to prevent harm to self and others.
Definition: The involuntary confinement of a patient away from other patients for any period of time in a hazard-free room or other area in which direct observation can be maintained and from which egress is prevented ...
3.4 No seclusion shall be used as means of discipline, retaliation, punishment or coercion ...
3.4 [sic] Each initial order will be time limited and not to exceed: ...Two (2) hours for ages 9-17 (facility's bold) ..."

Patient #9 was a 14-year-old female patient admitted to Cedar Crest Hospital on 3/12/18 with principal diagnosis of Bipolar Disorder. A Physician's Order on 3/13/18 at 1:58 p.m. initiated a one-to-one observation level "due to safety."

She was discharged on 3/20/18 at approximately 2:00 p.m. A Physician's Order for emergency medication on 3/20/18 at 9:25 a.m. read as follows:
"Thorazine 50 mg IM x 1 dose now
Benadryl 50 mg x 1 dose
Ativan 2 mg IM x 1
Restrain due to self-harm, Assault to staff."

MHA notes on 3/20/18 documented her continued one-to-one observation level every hour on a "blue note":
9:00 a.m. -
"Pt is doing crossword puzzles in quiet room.
Pt was aggressive. Jumped over nurses station. Fought a [sic] RN.
Pt ran to the nurse's station and threw milk on Dr.
Pt was restraint [sic].
Dr. ordered doors in quiet room to be locked."
10:00 a.m. - "Pt appears to be sleep."
11:00 a.m. - "Pt appears to be sleep."
12:00 p.m. - "Pt is up. Pt is eating lunch in quiet room."
1:00 p.m. - "Pt is patiently waiting to be discharge."
2:00 p.m. - "Pt discharged."

The patient was discharged from Cedar Crest that afternoon, after receiving emergency psychotropic medication and having been restrained and secluded for self-harm. No additional restraint/seclusion documentation for this episode could be found in the patient record, and the facility was unable to supply additional documentation.

The above findings were confirmed in an exit interview with the facility CEO and other administrative staff.

Based on a review of facility documentation and staff interviews, the facility failed to ensure that each patient record included documentation of a 1-hour face-to-face medical and behavioral evaluation for 1 of 2 patients reviewed undergoing restraint/seclusion (Patient #9).

Findings were:

Facility policy #1000.45 entitled "Seclusions," last revised 2/18, included the following:
"POLICY: Seclusion is an emergency behavioral intervention of last resort in which preventive, de-escalate, or verbal techniques have been considered and determined to be ineffective and it is immediately necessary to seclude the patient in order to prevent harm to self and others.
Definition: The involuntary confinement of a patient away from other patients for any period of time in a hazard-free room or other area in which direct observation can be maintained and from which egress is prevented ...

4.5 The physician or clinically competent nurse must conduct a face-to-face evaluation within 1 hour following the initiation of the seclusion (facility's bold) with subsequent documentation in the patient's medical record ..."

Patient #9 was a 14-year-old female patient admitted to Cedar Crest Hospital on 3/12/18 with principal diagnosis of Bipolar Disorder.

The patient was discharged on 3/20/18 at approximately 2:00 p.m. A Physician's Order for emergency medication on 3/20/18 at 9:25 a.m. read as follows:
"Thorazine 50 mg IM x 1 dose now
Benadryl 50 mg x 1 dose
Ativan 2 mg IM x 1
Restrain due to self-harm, Assault to staff."

The order included no reference to patient seclusion. There were no alternate interventions documented prior to this episode of patient restraint/seclusion. No release behaviors were specified.

MHA notes on 3/20/18 documented her continued one-to-one observation level every hour on a "blue note":
9:00 a.m. -
"Pt is doing crossword puzzles in quiet room.
Pt was aggressive. Jumped over nurses station. Fought a RN.
Pt ran to the nurse's station and threw milk on Dr.
Pt was restraint [sic].
Dr. ordered doors in quiet room to be locked."
10:00 a.m. - "Pt appears to be sleep."
11:00 a.m. - "Pt appears to be sleep."
12:00 p.m. - "Pt is up. Pt is eating lunch in quiet room."
1:00 p.m. - "Pt is patiently waiting to be discharge."
2:00 p.m. - "Pt discharged."

The patient was discharged from Cedar Crest that afternoon, after receiving emergency psychotropic medication and having been restrained and secluded for self-harm. No additional restraint/seclusion documentation for this episode could be found in the patient record, and the facility was unable to supply additional documentation. There was no documentation of a face-to-face evaluation of the patient one hour following the initiation of the seclusion.

A Physician's Discharge Note on that date at 1:35 p.m. read as follows:
"Pt is very manipulative, attention seeking, not participating in any groups, [illegible word] hitting staff and destroying property, needs to be discharged ..."

The above findings were confirmed in an exit interview with the facility CEO and other administrative staff on the afternoon of 3/28/18. No additional documentation of a face-to-face evaluation was provided.

Based on observation, staff interview and record review, the facility demonstrated ongoing non-compliance with the Condition of Participation for Nursing Services as evidenced by failing to ensure each patient received nursing care in a setting that provided:

A. Adequate staffing allowing for observation levels to be implemented as ordered for 3 of 5 patients (Patients #6-7 and #9) whose observation levels were reviewed (Cross refer to A0395)

B. Appropriate nursing assessment and supervision of patients' physical/medical status for 5 of 5 patients with medical issues (Patients #1-5) (Cross refer to A0395)

C. An adequate number of registered nurses, licensed vocational nurses and mental health assistants/technicians required to provide nursing care necessary to ensure general patient and staff safety. This placed all patients and staff at risk for harm due to lack of supervision of patient medical issues, the inability of staff to monitor the suicidal and self-harming behavior of patients, the inability to protect other patients and staff from aggressive/assaultive patients and the inability to provide treatment as ordered (Cross refer to B0150)


The cumulative effect of these systemic deficient practices resulted in ongoing non-compliance with the Condition of Participation for Nursing Services.

Based on a review of facility documentation and staff interviews, the facility failed to ensure each patient received nursing care in a setting that provided:

A. Adequate staffing allowing for observation levels to be implemented as ordered for 3 of 5 patients (Patients #6-7 and #9) whose observation levels were reviewed; and

B. Appropriate nursing assessment and supervision of patients' physical/medical status for 5 of 5 patients with medical issues (Patients #1-5).

Findings were:

A. Facility policy #1000.17 entitled "Observation / Precaution Levels," last revised 1/17, included the following:
"POLICY: To ensure the safety of each patient, various levels of observation or monitoring will be utilized based on assessed individual patient acuity ...
Patients admitted or later placed on a higher observation level, i.e. Q.15 minute checks, Line-of-Sight (LOS) or 1:1 will be re-assessed by the physician / NP on a daily basis for appropriateness of observation level, and a Doctor's order to either continue or decrease in observation level will be entered in the patient's medical record ...
1:1
One (1) unit staff will provide constant visual observation and remain within arms-length of the patient (facility's underline). This continuous direct visual observation will continue even when patients shower, change clothes or use the bathroom ...
Staff will monitor patients on 1:1 observation on the unit, unless the physician gives an order, the patient may not leave the unit ..."

Patient #6 was a 15-year-old male admitted to Cedar Crest Hospital on 3/12/18 for Major Depressive Disorder, and secondary diagnosis "Personal history of physical and sexual abuse ..." A physician order written on 3/13/18, no time, read as follows:
"SAOP (Sexual Acting Out Precautions) protocol
Blocked room please
"Checking precautions"

The rationale included with the order stated, "Sexually assaultive." The SAOP precaution level was first noted on the patient Precaution/Observation Checklist on 3/17/18 - 4 days after the precautions were ordered. A review of Unit 4 room assignments revealed Patient #6 was in 405A on 3/17/18. A 16-year-old male patient was noted to be in 405B on 3/17/18. The record of Patient #6 included no order to unblock his room.

Patient #7 was a 13-year-old male patient admitted on 1/10/18 with principal diagnosis of Bipolar Disorder and secondary diagnosis of Autistic Disorder. The patient was on a one-to-one observation level from 1/12/18 through 2/14/18 according to nursing documentation. Physician orders to continue this level of observation were noted only on the following dates: 1/12/18, 1/15/18, 1/17/18, 1/20/18, 1/21/18, 1/22/18, 1/25/18, 1/26/18, 1/31/18, 2/6/18, 2/7/18, 2/8/18, 2/9/18, and 2/14/18. The patient was discharged on 2/15/18.

In an interview the facility Interim Chief Nursing Officer, on the morning of 3/28/18 in the facility conference room, she stated, "We document observation of a one-to-one patient every hour on a blue note. They should document each hour ...One-to-ones stay on the unit ..."

On the morning of 2/13/18, observation notes for the one-to-one observation of Patient #7 were made at the following times: 7:45 a.m., 9:45 a.m., 11:15 a.m., 12:15 p.m., 3:39 p.m., 6:09 p.m., and 7:00 p.m. From 7:00 p.m., notes were made each hour. The facility could provide no additional documentation that this patient had been monitored at a one-to-one observation level.

MHA notes on 2/13/18 read as follows:
12:15 p.m.: "Pt went to gym [with] peers."
3:39 p.m.: "While in the gym a peer hit pt in the back of the head for allegedly hitting/kicking peer ..." Facility policy required one-to-one patient monitoring to occur only on the unit.

Patient #9 was a 14-year-old female patient admitted to Cedar Crest Hospital on 3/12/18 with principal diagnosis of Bipolar Disorder. Included in the long list of secondary diagnoses was Intentional Self-Harm by Unspecified Sharp Ob (presume Object). Several lacerations of different areas of the body were listed as well. A Psychiatric Evaluation on 3/13/18 at 1:50 p.m. included the following:
" ...Admits to being sad & mad yesterday and tried to hang self & cut leg multiple times with a "spring from a pen." Denies much bleeding, noting it has stopped. Tried hanging self with sheet ...Multiple suic att (suicide attempts) since age 11. Last one before this was [illegible word], wrist age 13 ..."

A Physician's Order on 3/13/18 at 1:58 p.m. initiated a one-to-one observation level "due to safety."
A Physician's Order on 3/14/18 at 3:00 p.m. read as follows: "Continue 1:1."
"Blue note" required hourly observation notes for this patient's one-to-one observation level included the following:
3/14/18 - 3:00 p.m. to 11:00 p.m. - "Pt @ NS (nurses station) upon arrival. Pt defiant and resistant to room restriction. Pt had a roll of tape on her person when I arrived. Pt, female group with male staff had to be out of site [sic] on 2 occasions. RN was aware of situation. Pt also was with another staff temporarily when Pt was out of site and closed in another female pt room without permission. Pt was allowed OS (outside) time until pt started to write profanity on the walls with chalk & crayon. Pt was taken inside and pt refused to rm (room) on her own. Pt [illegible word] in several items of contraband on her own, but became very upset and defiant when RN asked rm to be searched. No additional items found. [Illegible word] turned in a broken compact with glass inside, a set of shoe strings, and a rusty nail. Pt settled down and did room searches. When pt was compliant and requested, pt sat outside ..."

A review of the staffing on Unit 4 on 3/14/18, 3:00 p.m. to 11:00 p.m., included one (RN) and two (2) MHAs (mental health assistants). One of these MHAs was supposed to be assigned solely to the one-to-one observation of Patient #9. Thus, the remainder of the patients were to be monitored by one RN and one MHA. The patient census was not clear for that date as there were a number of discharges and admissions, but it appeared to be between 30 to 40 patients. The facility Nurse Staffing Grid for Unit 4 on this shift with 30-35 and/or 36-40 patients required one (1) RN, one (1) LVN, and 4 MHAs. MHAs assigned to one-to-one observation of patients are not counted in the staff numbers, according to facility policy.

B. Facility policy #1000.3 entitled "Vital Signs / Weights / Pain Level," last revised 7/15, included the following:
"2. Acute Care Unit
2.1 Routine Vital Signs are taken on every patient at the time of admission, then on a daily basis.
2.2 Additionally, vital signs are taken in compliance with specific MD orders, Detox protocols or as indicated by the RN due to patient complaints of physical symptoms which might indicate the need for Vital Signs checks ..."

Facility policy #1000.107 entitled "Glucometer Glucose Testing," last reviewed 3/18, included the following:
"B. Blood Glucose Testing ...
5. Document the results on the MAR (medication administration record) and notify the physician of any significant high or low readings ..."

A review of the medical record of Patient #1 revealed he was a 35-year-old patient admitted to Cedar Crest Hospital on 2/7/18. Physician's Preadmission Examination Orders and Preliminary Plan of Care on 2/7/18 at 5:23 p.m. included the following:
"Vital Signs: Q4 hours x 24 hours then Qshift if stable
Notify MD if Systolic BP > 190 or < 90, HR > 100 or < 60, T > 100.3 ...
Initiate CIWA (Clinical Institute Withdrawal Assessment Alcohol Scale) scale assessments upon admission to unit and record score on flow sheet ..."

A review of the patient's Vital Signs Record included only the following entries:
2/8/18 at 2:28 p.m.: BP 134/69, P 130, T 97.6, RR 18
2/9/18 at 6:00 a.m.: BP 127/81, P 87, T 98.0, RR 16

Additional vital signs entries on a Clinical Institute Withdrawal Assessment for alcohol revealed the following:
2/8/18 at 10:00 a.m.: Pt refused
2/8/18 at 6:00 p.m: Pt sleeping
2/8/18 at 6:05 p.m.: Pt refused

2/9/18 at 10:00 a.m.: Pt sleeping
2/9/18 at 2:00 p.m: BP 130/72, Resp 18, Pulse 110, Temp 97.8
2/9/18 at 6:00 p.m.: BP 134/78, Resp 18, Pulse 92, Temp 97.9

No additional vital signs were found in the patient record. There was no documented evidence in the patient record that the physician had been notified of pulse/heart rate elevated above 100 on 2/8/18 or 2/9/18. Patient #1 was discharged on 2/11/18.

A review of the medical record of Patient #2 revealed Physician's Preadmission Examination Orders and Preliminary Plan of Care on 2/6/18 at 8:00 a.m. as follows:
"Admit Recommendation: Admit to inpatient, inclusive of groups and programming ...
Vital Signs: Routine
Notify MD if Systolic BP > 190 or < 90, HR > 100 or < 60, T > 100.3 ..."

Review of a Vital Signs Record for Patient #2 included only the following vital sign entries (all entries within normal parameters):
--2/5/18 at 4:40 p.m.
--2/9/18 at 6:00 a.m.
--2/14/18 at 6:00 a.m.
--2/15/18 at 6:00 a.m.
--2/18/18 at 6:00 a.m.
--2/19/18 at 6:00 a.m.
--2/20/18 at 6:00 a.m.

Patient #3 had vital sign monitoring ordered on 3/1/18 at 9:00 a.m. to be "Routine ...Notify MD if Systolic > 190 or < 90, HR > 100 or < 60, T > 100.3 ..." The patient was admitted on 2/28/18. The only vital signs noted in the patient record as follows:
2/28/18 - no times - two sets of vital signs were noted
3/8/18 - no time - BP 106/66, P 109, no temperature noted, Respiratory Rate 15.
3/9/18 - no time - BP 117/44, P 105, no temperature noted, RR 17
3/10/18 - no time - vital signs within normal ranges
3/23/18 - no time - BP 109/80, P 103, T 97.2, RR 17
3/24/18 - no time - BP 87/51, P 93, no temperature noted, RR 16
3/26/18 - no time - BP 87/46, P 98, no temperature noted, RR 17

The patient record included no documentation of a physician having been notified of the patient's elevated heart rate/pulse on 3/8/18, 3/9/18, or 3/23/18, or of her low blood pressure on 3/24/18 and 3/26/18. Vital sign readings were missing for numerous dates.

Patient #4 was admitted on 2/1/18 with diagnoses of Bipolar Disorder and Post-Traumatic Stress Disorder. Lithium 150 mg p.o. BID and 300 mg p.o. BID was first administered to the patient on 2/13/18. A physician order on 2/13/18 ordered a lithium level be drawn "in 3 days." There was no lithium level result to be found in the patient record.

A Nursing Progress Note on 2/4/18, no time, read as follows:
" ...McLanes ER
CT of head & neck - negative
Given Tordol [sic] & Tylenol. Given Rx."
A Nursing Daily Shift Note on 2/4/18 at 8:00 p.m., read as follows:
"Sent to ER."

The record included no other documentation related to Patient #4's having been sent to a hospital ER. The facility could provide no additional documentation regarding the ER visit of this patient.

Patient #5 was admitted on 3/9/18. Physician's MOT Orders and Preliminary Plan of Care on 3/9/18 at 8:15 p.m. included the following:
"Active Medical Diagnosis or Issues: Chronic Hep-C, Chronic pain syndrome, Diabetes E11.9, HTN/high BP ..." The orders included a DM (Diabetes Mellitus) Control Protocol which included: "Fingerstick blood glucose: QID AC and at bedtime ..." along with sliding scale insulin amounts and the note: "Anything < 70 mg/dl or > 300 mg/dl - NOTIFY MD on CALL ..."
The patient was ordered to be on Zyprexa, an anti-psychotic medication, while at the facility. A long-known side effect of Zyprexa is elevated blood sugar levels.

Accucheck results of this patient's blood sugar levels were noted as follows:
o 3/10/18 at 8:00 p.m. - 419
o 3/11/18 at 6:30 a.m. - 315
o 3/11/18 at 8:00 p.m. - 400
o 3/12/18 at 6:30 a.m. - 350
o 3/12/18 at 11:30 a.m. - 435
o 3/12/18 at 5:30 p.m. - 456
o 3/12/18 at 8:00 p.m. - 335
o 3/13/18 at 6:30 a.m. - 398
o 3/13/18 at 11:30 a.m. - 379
o 3/13/18 at 5:30 p.m. - 534
o 3/13/18 at 8:00 p.m. - 505
o 3/14/18 at 6:30 a.m. - 335
o 3/14/18 at 5:30 p.m. - 450
o 3/14/18 at 8:00 p.m. - 516
o 3/15/18 at 6:30 a.m. - 571
o 3/15/18 at 11:30 a.m. - "Hi - called MD"
o 3/15/18 at 5:30 p.m. - "@ ER"
o 3/15/18 at 8:00 p.m. - 339
o 3/16/18 at 8:00 p.m. - 360

Only the level on 3/15/18 included the note of "called MD" as documentation of having notified a physician. Patient #5 was sent to an ER twice during her stay at Cedar Crest. The first time was on her date of admission on 3/9/18. The second time was on 3/15/18.

Two unsigned physician orders in the patient record included:
3/9/18 at 9:48 p.m. - "BS = 518, 10 units insulin given per SS (sliding scale). [Name], PA (physician assistant) notified. Will recheck in one hour and notify him of results."
3/9/18 at 10:35 p.m. - "BS > 600 x 2 checks. Send pt to ER due to hyperglycemia."

The patient was again sent to an acute care hospital ER on 3/15/18 for hyperglycemia. A physician's order on that date at 2:30 p.m. read as follows: "Send patient to Scott and White ER for hyperglycemia ..."

All the above findings were confirmed in an interview with the facility CEO and other administrative staff on the afternoon of 3/28/18 in the facility conference room.

Based on observation, staff interviews and document review, the hospital failed to ensure an adequate number of registered nurses, licensed vocational nurses and mental health assistants/technicians required to ensure general patient and staff safety. This placed all patients and staff at risk for harm due to lack of supervision of patient medical issues, the inability of staff to monitor the suicidal and self-harming behavior of patients, the inability to protect other patients and staff from aggressive/assaultive patients and the inability to provide treatment as ordered.

Findings were:

The following interviews were conducted with RNs, LVNs and MHAs (Mental Health Associates) of Cedar Crest Hospital. The age range of these individuals was approximately 20-65. The interviews reference Unit 3 -- adult acute patients, and Unit 4 -- children and adolescent patients. Unit 3 has 14 rooms with 28 total beds. Unit 4 has 20 patient rooms with double occupancy, and thus can house 40 patients.

In an interview with Staff #6 on 3/27/18 in the facility conference room, she stated, "We have bad issues with staffing on the unit. The acuity is high on that unit. We're staffed with two MHAs and then there's an RN and an LVN. And that often doesn't even happen...It can be chaotic with the high acuity. There are many times when I've been there by myself with 18 or 19 people. We don't have enough people to do one-to-ones even. We've had one person in the hallway sometimes monitoring two one-to-ones. That's not supposed to happen. And on the weekends, it's bad a lot of the times. That's when things seem to happen more ...It's all female staff on the unit - and really at the hospital. We don't have many, if any, male staff to help us out. I've had some people leave the agency and I'm left with whoever they can find to fill in ...I do the best I can to keep patients safe ...There's been no improvement at all in the staffing levels over the last few months ...The patients are watching us to see who's where and what coverage we have. We all need to have a certain amount of staff - for everyone's sake. This isn't just on my unit. It's primarily on both Units 3 & 4. They get a lot of call outs on weekends." She clarified that "call outs" were employees calling in to take off.

In an interview with Staff #7 on 3/27/18 in the facility conference room, she stated, "I believe we should be staffing according to acuity...There have been times working on [the unit] when the acuity being so high with such aggressive patients - males and females - and it's been just me. The RNs and the MHA - we're all females. We'll call a Dr. Armstrong code. That's when we notify the entire hospital on our paging system that we have a situation and we need help. I'll look up after calling the code, and there will be all females coming. We're just doing the best that we can so that we don't get hurt. So there have been some scary times when it's just been us three females ...Units 3 and 4 - they're bad. We have to know our therapeutic communication and use it constantly ...Our last few cpi trainings [de-escalation skills training] - we're just reading from the book. That was pretty different from any training I've had. They stress no hands-on. We need to know those skills for everyone's safety ..."

In an interview with Staff #4 on 3/27/18 in the facility conference room, she stated, "We still have issues with staffing. The CEO isn't very concerned about that. The unit is very violent and there are a lot of aggressive patients. The acuity level can be through the roof. I've called and said we need a male over here. It's just all females. Usually it's the RN, LVN and a mental health assistant..."

In an interview with Staff #8 on 3/27/18, Staff #8 stated, "There's never enough staff. I think nurses taking q 15 minute checks isn't really part of their job description ...There [can be] 24 patients for two MHAs ...There's no time to take care of everyone - do groups. There are no MHA groups happening now ...There are times when there's just one MHA ... [I remember one time] there were 27 female adolescents. I had 25 patients, and then there were two one-to-ones that each had an MHA with them. There was a riot. The police showed up. Someone went to the ER ...It's hard to have staff feel safe and patient often express to me that they don't feel safe ..."

In an interview with Staff #9 on 3/27/18 in the facility conference room, Staff #9 stated, "Staffing is a huge issue here. When we're not in the ratio, there's a risk of increased harm. There's less patient care. The program pretty much stops. The MHA groups are non-existent. I've left therapists or group facilitators with 5-18 patients by themselves sometimes ...When the techs are stressed out, that gets passed on to the patients. A lot of the incidents happen on the weekends - especially on unit 4 [child & adolescent unit]. There have been riots recently ...Even though people are supposed to be getting told in training what it's like here, I don't think they understand until they get out there. Mentorship on the unit just isn't happening. I mean there's no orientation. They're thrown in. Mentoring is getting shorter and shorter. You'd be lucky to get a few days. You can see the terror on some of the new people's faces. [One day there were] 10 adolescent girls that didn't have any supervision all day..."

In an interview with Staff #10 and Staff #11 on 3/27/18 in the facility conference room, Staff #10 stated, "We're always short-staffed...We'll [have] a one-to-one and [CEO will] put other patients with us. By law, I think that's not supposed to happen ...I've been on the unit by myself with 15 female patients. We're never on ratio - we never are. [CEO] tells us he'll be getting us help at the beginning of a shift and then we never get anyone. Nurses are by themselves ..."

Staff #11 stated, "It's common on [the unit] for us to have 36 or 37 patients ...We're on our own. [CEO] will come in and actually send people home when we need them ...He'll [unblock] beds that [physicians have] ordered blocked ...The patients know when we're understaffed too ...[Date given] There weren't even enough beds...[We had] only [one] RN with 2 MHAs and an LVN...The RN's doing all the admissions and discharges. [CEO] didn't stop one admission. [We had an MHA who] they continued to let her work while she was under investigation by the hospital ...Now she's gone but that means we're even more short-staffed."

In an interview with Staff #3 on 3/27/18 in the facility conference room, she stated, "...It's units 3 and 4. They're the ones...The ratio there [should be] 1:5 [one staff to 5 patients]. The RNs are counted into that. Unit 4 especially is a very busy unit with many admissions and discharges. Usually there's one RN and one LVN...There are many issues with the techs too. They're expecting them to do a job that is almost impossible. When we do phone calls, a lot of times we're looking up numbers - especially for the children - but for the adults too. The room where the patients are is left behind - the activity room. The phone is in a different area. So, one tech is with phone calls. That leaves another tech for the remainder of the patients. In the evenings, there are phone calls. There's visitation. That's when things get stirred up. MHAs get pulled off the unit for visitation. Unit 4 is especially bad, but unit 3 can be bad too. But on unit 4, [staff are] calling parents or guardians for med consents, and so on. The line-of-sight patients aren't able to be staffed any differently than the q 15 minute patients. Unit 4 has a maximum of 40 patients. Unit 3 is 26 or 27...On units 3 and 4, admissions has accepted a patient and because they've over-accepted the patients we have beds for, or we didn't have a discharge they thought was going to happen, we'll be over our max. We've had patients spend the night in the quiet room ..."

In an interview with the Interim Chief Nursing Officer on the morning of 3/27/18 in the facility conference room, she stated, "I don't really know when our staffing grid was devised or according to what ...Our next nurse staffing committee will be on Thursday, and we have good people for it now. The grid we have doesn't take acuity into account ..."

In an interview with Staff #12 on 3/27/18 in the facility conference room, she stated, "We're very understaffed. It's a constant problem. We don't have staffing for one-to-ones. Some just aren't happening as they should. We had a one-to-one who tried to hang themselves. The person who was supposed to be watching her also had 15 other girls. That was about two weeks ago...[CEO] tries to take patients off of one-to-ones all the time because he doesn't want them staffed ...They'll admit patients to the unit even if rooms are blocked and we don't have a room ...The unit just isn't staffed ...Sometimes a tech will be with the latency group. That's way at the end of the hallway. The latency patients are the younger kids. So we had one tech for the big boys, one for latency, and zero techs for the girls. I was fairly certain this wasn't legal ..."

In an interview with Staff #13 on 3/27/18 in the facility conference room, she stated, "We've got so much tension on the units because there aren't enough staff ... One weekend on unit 4...the adolescent girls had no one watching them. It was chaos...There were two techs on the unit that has areas separated by a large physical distance. Down where the latency patients are is way down one hallway. No one had radios to communicate, so there was no way for them to even know what was going on..."

During a tour of the Children & Adolescent Unit - Unit 4, on the afternoon of 3/28/18 with the Interim CNO, she stated, "Adolescent girls will make phone calls at the new nurses' station - across from the latency activity room. That's where the little kids make phone calls as well. The big boys make their calls in the big boys' activity room that's way at the other end of the hall. So if there are two techs each helping patients make phone calls, there's an LVN passing meds and an RN busy with admissions and discharges - and that's at full staff, there's a big, big distance between where staff can be. And if something happened at one end [it could be bad]...Where visitation occurs is usually in the cafeteria. That's in a completely separate building. So one staff person is drawn from the unit when that happens." The tour continued to the cafeteria which was in a completely separate building at some distance from the unit and which was not within eyesight of the unit.

In an interview with the Plant Ops Director on the afternoon of 3/28/18 in the facility conference room, he provided a map of the Children & Adolescents Unit - Unit 4. Distances between various points on the unit were marked in feet. From the boys' activity room where boys make phone calls, to the latency area across from the new nurses' station where the adolescent girls and young children make phone calls was 202 feet. From the new nurses' station to the old nurses' station, where the RN and LVN would most likely be, was 124 feet.

In a subsequent interview with the facility Interim CNO and CEO on the morning of 3/28/18 in the facility conference room, the CEO discussed the current and proposed facility staffing grids ...When asked about input received from the nurse staffing committee regarding the old and new staffing grids, he said that the former chief nursing officer had left a few months ago, and stated, "I have no access to minutes of the nurse staffing committee from the time she was here. We were having the meetings. I just can't get to the minutes to show you we were having the meetings. So we've been talking to corporate support and they've recommended some changes. We'll see if the nurses like it..." It was mentioned that this surveyor had reviewed the facility's governing board meeting minutes, and that the last mention of any kind of nurse staffing committee in those minutes had been in 2015. When asked which nursing indicators had been used to assess the adequacy of the current staffing levels, he stated, "I can't tell you because I don't have those minutes ...The reason we've had problems with not having enough staff is because people haven't been held accountable for calling in. So now we're holding people accountable, and that will all change. We've had people abusing the system ..."

In discussing the difference between the current staffing grid and the proposed staffing grid he recently devised, he stated, "The new staffing grid is very clear cut. In the old staffing grid, we had what the staffing should be for a range of a number of patients. For example, in the old grid, for 15-20 patients on Unit 4 on the day shift, we should have 1 RN, 1 LVN and 2 MHAs. The new grid is much more clear. It has a certain number of staff required for one specific number of patients. For example, if we have 15 patients on that unit during the day, then we should have 1 RN, 1 LVN and 2 BHTs (behavioral health technicians, same as mental health assistants)." When asked if they had 17 patients on the day shift on the unit, he said, "Then we'd need 1 RN, 1 LVN and 2 BHTs." When it was pointed out that the numbers seemed the same, he said, "But it's spelled out and very specific." When asked how acuity was taken into account in the grid, he stated, "It's not. That's when we'd have to step outside the grid." He added, "This new grid will go into effect ...I believe that's on May 5th."

As an additional example of staffing levels, a review of staffing variance sheets for Unit 3, the adult acute unit, included the following dates and numbers:

Sunday, 3/11/18 - patient census 24 adult psychiatric patients with two patients on 1:1 precautions and one patient on LOS (line of sight). Actual staff present was:
Day Shift: 1 RN, no LVN signed in, 1 MHT (MHA) from 6:45 a.m. to 3:15 p.m.
An additional MHT worked from 1:00 p.m. to 7:00 p.m.
No additional staff was listed for the two 1:1 patients.
Night Shift: 1 RN, 1 LVN, 2 MHTs. No additional staff was listed for the two 1:1 patients.
One patient was discharged at 7:15 a.m. This was one of the patients that was on 1:1
observation status.
A review of the Nurse Staffing Grid for a census of 21-25 patients on Unit 3 revealed required staffing to be:
Day Shift: 1 RN, 1 LVN, 3 MHAs
Night Shift: 1 RN 1 LVN, 3 MHAs

Facility policy #1000.17 entitled "Observation / Precaution Levels," last revised 1/17, included the following:
"POLICY: To ensure the safety of each patient, various levels of observation or monitoring will be utilized based on assessed individual patient acuity ...
Patients admitted or later placed on a higher observation level, i.e. Q.15 minute checks, Line-of-Sight (LOS) or 1:1 will be re-assessed by the physician / NP on a daily basis for appropriateness of observation level, and a Doctor's order to either continue or decrease in observation level will be entered in the patient's medical record ...
1:1
One (1) unit staff will provide constant visual observation and remain within arms-length of the patient (facility's underline). This continuous direct visual observation will continue even when patients shower, change clothes or use the bathroom ...
Staff will monitor patients on 1:1 observation on the unit, unless the physician gives an order, the patient may not leave the unit ..."

Patient #6 was a 15-year-old male admitted to Cedar Crest Hospital on 3/12/18 for Major Depressive Disorder, and secondary diagnosis "Personal history of physical and sexual abuse ..." A physician order written on 3/13/18, no time, read as follows:
"SAOP (Sexual Acting Out Precautions) protocol
Blocked room please
"Checking precautions"

The rationale included with the order stated, "Sexually assaultive." The SAOP precaution level was first noted on the patient Precaution/Observation Checklist on 3/17/18 - 4 days after the precautions were ordered. A review of Unit 4 room assignments revealed Patient #6 was in 405A on 3/17/18. A 16-year-old male patient was noted to be in 405B on 3/17/18. The record of Patient #6 included no order to unblock his room.

Patient #7 was a 13-year-old male patient admitted on 1/10/18 with principal diagnosis of Bipolar Disorder and secondary diagnosis of Autistic Disorder. The patient was on a one-to-one observation level from 1/12/18 through 2/14/18 according to nursing documentation. Physician orders to continue this level of observation were noted only on the following dates: 1/12/18, 1/15/18, 1/17/18, 1/20/18, 1/21/18, 1/22/18, 1/25/18, 1/26/18, 1/31/18, 2/6/18, 2/7/18, 2/8/18, 2/9/18, and 2/14/18. The patient was discharged on 2/15/18.

In an interview with Interim Chief Nursing Officer, on the morning of 3/28/18 in the facility conference room, she stated, "We document observation of a one-to-one patient every hour on a blue note. They should document each hour ...One-to-ones stay on the unit ..."

On the morning of 2/13/18, observation notes for the one-to-one observation of Patient #7 were made at the following times: 7:45 a.m., 9:45 a.m., 11:15 a.m., 12:15 p.m., 3:39 p.m., 6:09 p.m., and 7:00 p.m. From 7:00 p.m., notes were made each hour. The facility could provide no additional documentation that this patient had been monitored at a one-to-one observation level.

MHA notes on 2/13/18 read as follows:
12:15 p.m.: "Pt went to gym [with] peers."
3:39 p.m.: "While in the gym a peer hit pt in the back of the head for allegedly hitting/kicking peer ..." Facility policy required one-to-one patient monitoring to occur only on the unit.

Patient #9 was a 14-year-old female patient admitted to Cedar Crest Hospital on 3/12/18 with principal diagnosis of Bipolar Disorder. Included in the long list of secondary diagnoses was Intentional Self-Harm by Unspecified Sharp Ob (presume Object). Several lacerations of different areas of the body were listed as well. A Psychiatric Evaluation on 3/13/18 at 1:50 p.m. included the following:
" ...Admits to being sad & mad yesterday and tried to hang self & cut leg multiple times with a "spring from a pen." Denies much bleeding, noting it has stopped. Tried hanging self with sheet ...Multiple suic att (suicide attempts) since age 11. Last one before this was [illegible word], wrist age 13 ..."

A Physician's Order on 3/13/18 at 1:58 p.m. initiated a one-to-one observation level "due to safety."
A Physician's Order on 3/14/18 at 3:00 p.m. read as follows: "Continue 1:1."
"Blue note" required hourly observation notes for this patient's one-to-one observation level included the following:
3/14/18 - 3:00 p.m. to 11:00 p.m. - "Pt @ NS (nurses station) upon arrival. Pt defiant and resistant to room restriction. Pt had a roll of tape on her person when I arrived. Pt, female group with male staff had to be out of site [sic] on 2 occasions. RN was aware of situation. Pt also was with another staff temporarily when Pt was out of site and closed in another female pt room without permission. Pt was allowed OS (outside) time until pt started to write profanity on the walls with chalk & crayon. Pt was taken inside and pt refused to rm (room) on her own. Pt [illegible word] in several items of contraband on her own, but became very upset and defiant when RN asked rm to be searched. No additional items found. [Illegible word] turned in a broken compact with glass inside, a set of shoe strings, and a rusty nail. Pt settled down and did room searches. When pt was compliant and requested, pt sat outside ..."

A review of the staffing on Unit 4 on 3/14/18, 3:00 p.m. to 11:00 p.m., included one (RN) and two (2) MHAs (mental health assistants). One of these MHAs was supposed to be assigned solely to the one-to-one observation of Patient #9. Thus, the remainder of the patients were to be monitored by one RN and one MHA. The patient census was not clear for that date as there were a number of discharges and admissions, but it appeared to be between 30 to 40 patients. The facility Nurse Staffing Grid for Unit 4 on this shift with 30-35 and/or 36-40 patients required one (1) RN, one (1) LVN, and 4 MHAs. MHAs assigned to one-to-one observation of patients are not counted in the staff numbers, according to facility policy.

Facility policy #1000.3 entitled "Vital Signs / Weights / Pain Level," last revised 7/15, included the following:
"2. Acute Care Unit
2.1 Routine Vital Signs are taken on every patient at the time of admission, then on a daily basis.
2.2 Additionally, vital signs are taken in compliance with specific MD orders, Detox protocols or as indicated by the RN due to patient complaints of physical symptoms which might indicate the need for Vital Signs checks ..."

Facility policy #1000.107 entitled "Glucometer Glucose Testing," last reviewed 3/18, included the following:
"B. Blood Glucose Testing ...
5. Document the results on the MAR (medication administration record) and notify the physician of any significant high or low readings ..."

A review of the medical record of Patient #1 revealed he was a 35-year-old patient admitted to Cedar Crest Hospital on 2/7/18. Physician's Preadmission Examination Orders and Preliminary Plan of Care on 2/7/18 at 5:23 p.m. included the following:
"Vital Signs: Q4 hours x 24 hours then Qshift if stable
Notify MD if Systolic BP > 190 or < 90, HR > 100 or < 60, T > 100.3 ...
Initiate CIWA (Clinical Institute Withdrawal Assessment Alcohol Scale) scale assessments upon admission to unit and record score on flow sheet ..."

A review of the patient's Vital Signs Record included only the following entries:
2/8/18 at 2:28 p.m.: BP 134/69, P 130, T 97.6, RR 18
2/9/18 at 6:00 a.m.: BP 127/81, P 87, T 98.0, RR 16

Additional vital signs entries on a Clinical Institute Withdrawal Assessment for alcohol revealed the following:
2/8/18 at 10:00 a.m.: Pt refused
2/8/18 at 6:00 p.m: Pt sleeping
2/8/18 at 6:05 p.m.: Pt refused

2/9/18 at 10:00 a.m.: Pt sleeping
2/9/18 at 2:00 p.m: BP 130/72, Resp 18, Pulse 110, Temp 97.8
2/9/18 at 6:00 p.m.: BP 134/78, Resp 18, Pulse 92, Temp 97.9

No additional vital signs were found in the patient record. There was no documented evidence in the patient record that the physician had been notified of pulse/heart rate elevated above 100 on 2/8/18 or 2/9/18. Patient #1 was discharged on 2/11/18.

A review of the medical record of Patient #2 revealed Physician's Preadmission Examination Orders and Preliminary Plan of Care on 2/6/18 at 8:00 a.m. as follows:
"Admit Recommendation: Admit to inpatient, inclusive of groups and programming ...
Vital Signs: Routine
Notify MD if Systolic BP > 190 or < 90, HR > 100 or < 60, T > 100.3 ..."

Review of a Vital Signs Record for Patient #2 included only the following vital sign entries (all entries within normal parameters):
--2/5/18 at 4:40 p.m.
--2/9/18 at 6:00 a.m.
--2/14/18 at 6:00 a.m.
--2/15/18 at 6:00 a.m.
--2/18/18 at 6:00 a.m.
--2/19/18 at 6:00 a.m.
--2/20/18 at 6:00 a.m.

Patient #3 had vital sign monitoring ordered on 3/1/18 at 9:00 a.m. to be "Routine ...Notify MD if Systolic > 190 or < 90, HR > 100 or < 60, T > 100.3 ..." The patient was admitted on 2/28/18. The only vital signs noted in the patient record as follows:
2/28/18 - no times - two sets of vital signs were noted
3/8/18 - no time - BP 106/66, P 109, no temperature noted, Respiratory Rate 15.
3/9/18 - no time - BP 117/44, P 105, no temperature noted, RR 17
3/10/18 - no time - vital signs within normal ranges
3/23/18 - no time - BP 109/80, P 103, T 97.2, RR 17
3/24/18 - no time - BP 87/51, P 93, no temperature noted, RR 16
3/26/18 - no time - BP 87/46, P 98, no temperature noted, RR 17

The patient record included no documentation of a physician having been notified of the patient's elevated heart rate/pulse on 3/8/18, 3/9/18, or 3/23/18, or of her low blood pressure on 3/24/18 and 3/26/18. Vital sign readings were missing for numerous dates.

Patient #4 was admitted on 2/1/18 with diagnoses of Bipolar Disorder and Post-Traumatic Stress Disorder. Lithium 150 mg p.o. BID and 300 mg p.o. BID was first administered to the patient on 2/13/18. A physician order on 2/13/18 ordered a lithium level be drawn "in 3 days." There was no lithium level result to be found in the patient record.

A Nursing Progress Note on 2/4/18, no time, read as follows:
" ...McLanes ER
CT of head & neck - negative
Given Tordol [sic] & Tylenol. Given Rx."
A Nursing Daily Shift Note on 2/4/18 at 8:00 p.m., read as follows:
"Sent to ER."

The record included no other documentation related to Patient #4's having been sent to a hospital ER. The facility could provide no additional documentation regarding the ER visit of this patient.

Patient #5 was admitted on 3/9/18. Physician's MOT Orders and Preliminary Plan of Care on 3/9/18 at 8:15 p.m. included the following:
"Active Medical Diagnosis or Issues: Chronic Hep-C, Chronic pain syndrome, Diabetes E11.9, HTN/high BP ..." The orders included a DM (Diabetes Mellitus) Control Protocol which included: "Fingerstick blood glucose: QID AC and at bedtime ..." along with sliding scale insulin amounts and the note: "Anything < 70 mg/dl or > 300 mg/dl - NOTIFY MD on CALL ..."
The patient was ordered to be on Zyprexa, an anti-psychotic medication, while at the facility. A long-known side effect of Zyprexa is elevated blood sugar levels.

Accucheck results of this patient's blood sugar levels were noted as follows:
o 3/10/18 at 8:00 p.m. - 419
o 3/11/18 at 6:30 a.m. - 315
o 3/11/18 at 8:00 p.m. - 400
o 3/12/18 at 6:30 a.m. - 350
o 3/12/18 at 11:30 a.m. - 435
o 3/12/18 at 5:30 p.m. - 456
o 3/12/18 at 8:00 p.m. - 335
o 3/13/18 at 6:30 a.m. - 398
o 3/13/18 at 11:30 a.m. - 379
o 3/13/18 at 5:30 p.m. - 534
o 3/13/18 at 8:00 p.m. - 505
o 3/14/18 at 6:30 a.m. - 335
o 3/14/18 at 5:30 p.m. - 450
o 3/14/18 at 8:00 p.m. - 516
o 3/15/18 at 6:30 a.m. - 571
o 3/15/18 at 11:30 a.m. - "Hi - called MD"
o 3/15/18 at 5:30 p.m. - "@ ER"
o 3/15/18 at 8:00 p.m. - 339
o 3/16/18 at 8:00 p.m. - 360

Only the level on 3/15/18 included the note of "called MD" as documentation of having notified a physician. Patient #5 was sent to an ER twice during her stay at Cedar Crest. The first time was on her date of admission on 3/9/18. The second time was on 3/15/18.

Two unsigned physician orders in the patient record included:
3/9/18 at 9:48 p.m. - "BS = 518, 10 units insulin given per SS (sliding scale). [Name], PA (physician assistant) notified. Will recheck in one hour and notify him of results."
3/9/18 at 10:35 p.m. - "BS > 600 x 2 checks. Send pt to ER due to hyperglycemia."

The patient was again sent to an acute care hospital ER on 3/15/18 for hyperglycemia. A physician's order on that date at 2:30 p.m. read as follows: "Send patient to Scott and White ER for hyperglycemia ..."

The above findings were confirmed in interviews with the Interim Chief Nursing Officer and the CEO throughout the survey. A final interview with the CEO and other administrative staff on the afternoon of 3/28/17 reiterated the above findings. No additional information was provided at that time by the facility.