HospitalInspections.org

Based on staff interviews, review of video monitoring (3 North), review of medical records and review of policies it was determined the Director of Nursing failed to ensure nursing personnel followed hospital policies on Staffing/Supervision on nine (9) of nine (9) units: 1 East, 2 East, 2 West, 2 North, 3 East, 3 West, 3 North, 4 West, and 5 West in the facility. This has the potential for all patients to have the ability to cause self harm or harm to others.

Findings include:

1. A tour of Three (3) North Adolescent Unit was conducted on 8/8/16 at 1:36 p.m. During the tour the Program Director for the facility was providing information related to an incident which allegedly occurred on the evening of 6/24/16. She stated "There was no other nurse on the unit when the nurse took her break".

2. Review of video monitoring (3 North) on 8/8/16 at 3:40 p.m. with the Chief Nursing Officer (CNO) for the evening of 6/24/16 revealed at 19:37 Registered Nurse (RN) #1 left the unit for break with no other nurse present on the unit. Mental Health Technician (MHT) #1 was sitting at the nurse's station desk on the telephone at 19:37. Patient #1 appeared in the hallway at 19:37. At 19:38 patient #1 was standing by the post at the nurse's station. At 19:39 patient #1 moves to the other side of the hallway. At 19:39:02 patient #2 appears in the alcove shaking his head. At 19:40 patient #1 joins patient #2 in the alcove. At 19:42:09 patient #2 exits the alcove and enters his room. At 19:42:31 patient #2 re-enters the alcove. At 19:42:43 patient #2 exits the alcove and enters his room. At 19:42:54 patient #1 exits the alcove and straightens her clothes. At 19:44 patient #1 is back at the nurse's station.

3. Review of facility policy titled "Weekday, Weekend and Holiday Safety: Staffing/Supervision", with a last revision date of 11/15, states in part "The Nursing Supervisor and/or additional supervisory staff conduct frequent rounds of all units and perform the following tasks: ensure adequate supervision and staffing; providing breaks and fill-in as needed".

4. Review of the Daily Staffing Report for 6/24/16 revealed:

Day Shift: one (1) RN 1 East; one (1) RN and one (1) Licensed Practical Nurse (LPN) 2 East; one (1) RN 2 North; zero (0) RN and one (1) LPN 2 West; one (1) RN 3 East; one (1) RN 3 North; zero (0) RN and two (2) LPNs 3 West; one (1) RN and one (1) LPN 4 West; one (1) RN 5 West; two (2) intake RNs and two (2) supervisor/float RNs.

Evening Shift: one (1) RN 1 East; three (3) RNs 2 East; two (2) RNs 2 North; one (1) RN 2 West; one (1) RN 3 East; one (1) RN 3 North; one (1) RN and one (1) LPN 3 West; two (2) RNs and one (1) LPN 4 West; zero (0) RN and one (1) LPN 5 West; three (3) intake RNs and one (1) supervisor/float RN.

Midnight Shift: one (1) RN 1 East; one (1) RN and one (1) LPN 2 East; zero (0) RN 2 North; one (1) RN 2 West; one (1) RN 3 East; zero (0) RN and one (1) LPN 3 North; one (1) RN 3 West, one (1) RN and one (1) LPN 4 West; zero (0) RN 5 West; one (1) intake RN and one (1) supervisor/float RN.

5. On 8/10/16 at 11:00 a.m. the Program Director confirmed the Daily Staffing Report for 6/24/16 was correct. She reported the intake nurses also float to other units if there are no patients to process.

6. A telephone interview was conducted on 8/10/16 at 11:57 a.m. with MHT #1 regarding an incident which allegedly occurred on 3 North on the evening of 6/24/16. He stated: "This is not my normal unit to work on; I was pulled there due to that unit being short staffed". He stated: "I am not familiar with the procedures on that unit and I was the only person working the floor at that time". He further stated: "We do not do hall checks on my unit".

7. On 8/10/16 at 12:16 p.m. the Chief Executive Officer (CEO) clarified the statement "We do not do hall checks on my unit" made by MHT #1. He reported safety checks are done on every unit. On the unit MHT #1 normally works on the MHTs do not physically have to be in the hallways.

8. An interview was conducted on 8/8/16 at 1:40 p.m. with the Program Director when questioned regarding the incident which allegedly occurred on the evening of 6/24/16 she confirmed there was no other nurse present on the unit while the nurse was on break. She reported the Recreation Technician (RT) left the facility at approximately 7:37 the evening of 6/24/16. She reported there were two (2) house supervisors in the facility on 6/24/16 for the shift and the MHTs are based on census. She stated "We call the other units and let them know the nurse is going on break and let the house supervisor know". She also stated: "I did not know a nurse had to be on the unit when the nurse took her break".

9. On 8/9/16 at 8:20 a.m. the CNO concurred the other unit nurses and house supervisors do not normally cover the units when the nurse goes on break.