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Based on document review, observation, and interview, it was determined the hospital failed to ensure patients treated in the Emergency Departments Crisis Stabilization Unit (CSU/locked behavioral health unit) were provided care in a safe setting and that Hospital policy was followed. This has the potential to affect all patients treated at the CSU with an average monthly census of 222.

Findings include:

1. The policy titled "Patient Supervision" (revised 04/23/21) was reviewed on 5/23/23 and noted "Crisis Stabilization Unit (CSU) policy... II... D. An RN must be present on the unit when patients are there ..."

2. Staff schedule dated 4/19/23, was reviewed on 5/23/23 and noted a 4 hour shift (7:00 AM - 11: 00AM) was not staffed with a RN.

3. During an interview with E#3 (Licensed Social Worker) on 5/23/23. E#3 stated only E#3 and E#4 (Peer Recovery Specialist/Unit Secretary) were taking care of patients on 4/19/23, day of complaint. There had been times when patients required medicine and asked the ED staff for assistance and was refused assistance and/or the medications were given late.

4. During an interview on 5/23/23, E#4 stated they were told by E#2 (Director of Crisis Services) that E#4 would be in charge of the unit and an ED technician would come over to the CSU to round on patients every hour and if a medication needs to be given the ED charge nurse would give it. E#4 stated "I am scared. This is not safe."

5. On 5/24/23 a tour of the ED and CSU was conducted with E#1 (Emergency Department Director), E#2 and E#5 (Director of Robert Young Services). During the tour E#1 stated the ED is sometimes short of staff for RN's and fills in with Agency Staff or leaders will pick up extra hours. E#5 stated "The ED nurses don't cover for the CSU staff. The 2 North (Behavioral Psychiatric Unit) staff is to cover for CSU." During the tour E#2 stated CSU patient's medical screening exam is conducted by the ED providers. CSU's staff usually consists of 2 RN's on 11:00 AM to 11:00 PM and 1 RN all the other times, 1 clinician, 1 peer recovery specialist and 1 security guard. E#2 was unable to provide documentation that 2 North was to cover and/or assist the CSU. E#2 verbally agreed the CSU didn't have a nurse on staff for 4/19/23 shift when patients were being treated.

Based on observation, document review and interview, it was determined the hospital failed to provide emergency care under one clinical supervisor in accordance with acceptable standards of practice. This has the potential to affect all patients who receive care in the Emergency Department.

Findings include:


1. The hospital failed to ensure emergency services were clearly organized, with direct delineation of responsibilities for the clinical nursing management of the ED patients in the Emergency Department's Crisis Intervention Unit in a manner to provide safe patient care. Please see A-1101

2. The hospital failed to ensure the ED's nursing staff was available to adequately meet the patient's needs. Please see A-1112

Based on observation, document review and interview, it was determined the hospital failed to ensure emergency services were clearly organized by one clinical supervisor, for the ED patients placed in the CSU for continued nursing assessment and treatment during the clinical evaluation time to determine admission or discharge, in a manner to provide safe patient care. This has the potential to affect all patients who receive treatment by the Emergency Department.

Findings include:

1. The organizational charts of H#1 and F#2 were reviewed on 5/23/23. The organizational chart of H#1 noted the Hospital's Director of the Emergency Department as E#1. The organizational chart of F#2 noted the Facilities Director of Crisis Services (E#2).

2. The policy titled "(F#2) Crisis Intervention Services" (reviewed by hospital 3/14/22) was reviewed on 5/23/23. The policy noted "C. CSU 1. Crisis Clinicians provide crisis evaluation and stabilization 24/7, 365 days per year. 2. The crisis team evaluate patients face to face in the (H#1) ED, CSU... 3. CSU a. A Medical Screening Exam (MSE) in conducted by the emergency provider and when the patient is medically cleared, an order is placed for a crisis evaluation... c. Disposition is determined in consultation with the on-call Psychiatrist and/or the Emergency Department Provider (EDP) 1. Tele-psychiatry discharge requires consultation and recommendation from the ED Physician 2. Discharges without a Psychiatrist consultation require recommendation from the ED Physician."

2. During a tour of the Emergency Department on 5/23/23 at approximately 1:00 PM, 22 monitored rooms, 8 rapid assessment rooms, 1 trauma room and 6 crisis stabilization rooms located between ED room #9 and ED room #10 through a set of locked double doors.

3. During an interview on 5/26/23 at approximately 9:30 AM, E#1 and E#6 (Risk Manager) stated the CSU patients were considered and billed as ED patients. The Behavioral Health nurses were paid for out of the ED budget but were technically F#2's employees and report to the Director of F#2 (E#2). E#1 stated "I don't have any control over their (CSU's) staffing. I don't know if someone calls in or not. They (CSU staff) report to E#2." E#1 reviewed CSU's staff schedules, CSU Time Log and Pt #3, Pt #4, Pt #5, and Pt #6's records and verbally agreed the CSU unit lacked a staffed nurse on 4/19/23 from 7 am through 11 am.

4. During the tour an interview on 5/23/23, E#2 stated the 2 North Behavioral Health Unit (H#1) nurses would cover shifts in the CSU if needed. E#2 was unable to provide documentation of the process of coverage nor show documentation if the coverage had occurred.

5. The CSU staffing schedules dated 4/9/23 through 4/22/23, 5/7/23 through 5/20/23 and 5/21/23 through 6/3/23 and the correlating CSU Time Log (log of patients who enter the CSU, location, times, and clinician assigned) were reviewed on 5/23/23. The schedule noted 7 open nursing shifts between 4/9/23 and 5/22/23; 2 shifts (4/9/23 and 5/21/23) had no patients in the unit; 4 shifts (4/9/23, 4/21/23, 5/20/23, 5/22/23) noted Behavioral Health Nurses were assigned and in the CSU; 1 shift (4/19/23) noted 2 patients (Pt #3, Pt #6) were in the CSU without a Behavioral Health Nurse.

Based on document review and interview, it was determined for 2 of 2 (Pt #3, Pt #6) patients records reviewed who received care on 4/19/23 between 7:00 AM and 11:00 AM, the hospital failed to have Nurse staffing guidelines for the managment of the ED's patients in the CSU unit as demonstrated by nursing staff was not available to adequately meet the patients needs. This has the potential to affect all patients who receive treatment by the Emergency Department.

Findings include:

1. On 5/24/23 a tour of the ED and CSU was conducted with E#1 (Emergency Department Director), E#2 and E#5 (Director of Robert Young Services). During the tour E#1 stated the ED is sometimes short of staff for RN's and fills in with Agency Staff or leaders will pick up extra hours. E#5 stated "The ED nurses don't cover for the CSU staff. The 2 North (Behavioral Psychiatric Unit) staff is to cover for CSU." During the tour E#2 stated CSU patient's medical screening exam is conducted by the ED providers. CSU's staff usually consists of 2 RN's on 11:00 AM to 11:00 PM and 1 RN all the other times, 1 clinician, 1 peer recovery specialist and 1 security guard. E#2 was unable to provide documentation that 2 North was to cover and/or assist the CSU. E#2 verbally agreed the CSU didn't have a nurse on staff for 4/19/23 shift when patients were being treated.

2. The policy titled "Patient Supervision" (reviewed by hospital 4/23/21) was reviewed on 5/26/23. The policy noted "Crisis Stabilization Unit (CSU) Policy... ll. Close Supervision (CS)... D. An RN must be present on the unit when patients are there."

3. The policy titled "Medication Administration" (reviewed by hospital 4/21/23) was reviewed on 5/23/23. The policy noted "D. Medication must be administered within the time period of 60 minutes before or after the specified administration time."

4. The CSU staffing schedules dated 4/9/23 through 4/22/23, 5/7/23 through 5/20/23 and 5/21/23 through 6/3/23 were reviewed on 5/23/23. The schedule dated 4/19/23 lacked documentation a nurse was scheduled between 7:00 AM and 11:00 AM.

5. Pt #3 was admitted to the emergency departments CSU unit on 4/18/23 at 6:13 PM through 4/20/23 at 9:46 PM for Suicidal Ideation. The record lacked nursing documentation on 4/19/23 between 7:00 AM and 11:00 AM. An ED Physician's order for Keppra (seizure medication) twice daily was ordered on 4/18/23 through 4/20/23. The record noted Keppra was administered on 4/19/23 at 11:00 AM by the Behavioral Health Nurse whose shift was scheduled to start at 11:00 AM.

6. Pt #6 was admitted to the emergency departments CSU unit on 4/19/23 at 12:29 AM through 4/20/23 at 8:28 AM for Suicidal Ideation. The record lacked nursing documentation on 4/19/23 between 7:00 AM and 11:00 AM. A urinalysis with reflex microscopic testing and a urine pregnancy test were ordered to be conducted "STAT" on 4/19/23 at 5:04 AM. The record noted the urinalysis specimen collection time was 9:20 AM, greater than 4 hours later.

7. During an interview on 5/23/23 at approximately 2:50 PM, E#4 (Peer Recovery Specialist) stated "If a patient is on the unit (CSU), there has to be a nurse back there. I don't know if it's in writing but that's always been the way it has been portrayed. We have our own nurses now... On 4/19/23 I got a call from the Director (E#2) who told me that myself and the counselor were going to staff the unit that day... We called the ED and ask for a nurse to come over and give (Pt #3) meds and also there was a urine that needed collected but a nurse has to sign off on the order before collection."

8. During an interview on 5/24/23 at approximately 11:30 AM, E#7 (Clinical Informatics Specialist) entered a Keppra order into the electronic health record to demonstrate the times at which a twice daily medication is assigned to be given. The order demonstrated 9:00 AM and and 11:00 PM.

9. During an interview on 5/26/23 at approximately 9:30 AM, E#1 reviewed the CSU staffing schedule and Pt #3 and Pt #6's records and verbally agreed the CSU lacked a staffed nurse on 4/19/23 from 7:00 AM through 11:00 AM.