HospitalInspections.org

Based on interview and record review, the facility's governing body (GB, defined as the entity legally responsible for the conduct of the hospital, including the provision of safe and effective care and the development of policies and procedures) failed to ensure the following:

1. Policies and procedures with clear guidelines ensuring safety and proper monitoring of patients with specific legal and mental health needs during transportation for external appointments outside the psychiatric care facility (a healthcare institution specializing in diagnosing, treating, and managing mental health conditions, offering services ranging from crisis stabilization to long-term care in a structured and therapeutic environment) were established and implemented to mitigate any potential risks to the patients, transport personnel, or the public.

This deficient practice resulted in Patient 1's elopement (when individuals leave an area they are expected to stay within, for their safety) during transportation to court on 7/24/2024. Additionally, this deficient practice had the potential to result in significant harm, including risks such as injury, or harm to themselves or others, for all facility psychiatric (patients with mental, emotional, and behavioral disorders) patients requiring transportation and monitoring during transportation.

2. A defined and documented policy-making process and mechanism for the development, approval, revision, and review of policies was developed in accordance with federal and local regulatory requirements.

This deficient practice had the potential to negatively impact patient outcomes by leading to outdated or lacking policies that could compromise patient safety, reduce the effectiveness of care, and increase the risk of harm due to the lack of alignment with current regulatory standards and best practices.

3. Provide oversight on Nursing Services department to ensure there was adequate staffing based on census (number of census) and patient acuity, and ensure staff consistently performed and documented patient acuity assessments (defined as evaluations of the severity of a patient's condition and care needs to determine the appropriate level of nursing care required), as required by the facility's policy and regulatory standards to determine appropriate staffing levels and align staff assignments with patient care needs.

This deficient practice had the potential to result in patients' needs not to be met, compromising patients' safety and the delivery of quality patient care due to a lack of oversight in implementing and monitoring policies to ensure appropriate staffing levels and assignments were based on patient care needs.


Findings:

1. During an interview on 12/3/2024 at 2:19 p.m. with the facility's Director of Quality Management (DQM) and the Chief Nursing Officer (CNO), regarding Patient 1, who, on 7/24/2024, eloped (leaving a designated area without authorization or supervision, posing a safety risk) from the court, the DQM stated the following: On 7/24/2024, at around 8:45 a.m. at Superior Court in [name of City], Patient 1 eloped from the conservatorship court (a legal proceeding where decisions regarding the care and management of an individual deemed unable to care for themselves are made) where Patient 1 was ordered to appear for a conservatorship hearing (the hearing determines whether the individual requires a permanent conservatorship based on their mental health condition and inability to care for themselves).

During the same interview on 12/3/2024 at 2:19 p.m., the CNO stated the following: The conservatorship court hearing was held in person to allow the judge to determine whether the patient (Patient 1) required permanent conservatorship. Prior to the hearing, the facility had called ahead to notify the court of the patient's (Patient 1) intention to escape. The patient (Patient 1) was on a temporary conservatorship (T-Con) and under a hold (an involuntary detention of a person at a mental health facility, where they are temporarily held against their will to receive a psychiatric evaluation and treatment because they are considered a danger to themselves or others due to a mental health crisis) while awaiting placement (defined as the process of securing a suitable long-term care facility, such as facilities to provide necessary mental health treatment and support). Additionally, the patient (Patient 1) fell under the [Name of] program, which includes individuals referred by the Department of Mental Health (DMH, a government agency responsible for overseeing and providing mental health services, programs, and support to individuals with mental health conditions) after completing their jail sentences.

During an interview on 12/3/2024 at 2:27 p.m. with the Director of Quality Management (DQM), DQM explained that the [Name of] program works in collaboration with the Department of Mental Health (DMH) to provide long-term therapeutic support for patients. The program's goal was to transition these patients to an Institution for Mental Diseases (IMD) for continued care. Patients in the [Name of] program, many of whom have spent months in detention centers, were required to attend court hearings for conservatorship decisions. The judge preferred to see the patient in person to assess their condition, and the patient has the right to challenge the court's decision. In some cases, the judge may decide not to grant conservatorship.

During an interview on 12/3/2024 at 2:31 p.m. with the Director of Clinical Services (DCS), DCS stated the following: The [Name] program, initiated by the Department of Mental Health (DMH) in Los Angeles County, was designed to address the needs of mentally ill individuals, often homeless, who had been incarcerated for minor offenses (defined as non-violent infractions or misdemeanors such as loitering, petty theft, or public disturbances). The program aimed to prevent these individuals from being housed in jails within the area. Many of these patients had been noncompliant with medications and lacked access to necessary resources. Instead of discharging them back to the streets, the court places these individuals on temporary conservatorship (T-con) to ensure oversight and care. The [Name] program was funded by DMH, and the facility collaborates with the department to secure long-term placements for these patients. However, the waitlist for an Institution for Mental Diseases (IMD) placement was currently about one year, presenting a significant challenge in transitioning patients to appropriate care settings.

During the same interview on 12/3/2024 at 2:31 p.m., the DCS further stated that upon admission to the facility, patients received care, including appropriate medications, which often resulted in significant improvement in their condition. All patients under the [Name] program were required to be transported to conservatorship court hearings, where judges issued specific orders for their appearances.

During a record review of Patient 1's medical record (MR) titled, "Initial Psychiatric Evaluation," dated 7/12/2024, the MR indicated that Patient 1 was admitted to the facility on 7/12/2024 on a 5150 hold (a 72-hour involuntary psychiatric hold authorized for individuals who, due to a mental health disorder, pose a danger to themselves, others, or are gravely disabled) for being gravely disabled (GD, defined as the inability to provide for basic personal needs, such as food, clothing, or shelter, due to a mental health condition). The MR also indicated that Patient 1 had been noncompliant with medication treatment in the past, acknowledging that they [Patient 1] only took medications when incarcerated or hospitalized because it was mandated. The MR stated that during an interview on 7/12/2024, Patient 1 showed episodes of angry outbursts, was verbally abusive, and threatening.

During further record review of Patient 1's MR titled, "Initial Psychiatric Evaluation," dated 7/12/2024, the MR indicated that Patient 1 had a past medical history (PMH, the patient's prior documented health conditions, including physical and mental health issues) of episodes of aggressive behavior, prior psychiatric hospitalizations, an extensive legal history (refers to a pattern or record of multiple encounters with the legal system, which may include arrests, charges, convictions, or incarcerations over an extended period), and polysubstance use (the use of multiple substances, often simultaneously or in a pattern, including legal or illicit drugs), specifically alcohol and methamphetamine (a powerful and highly addictive stimulant that affects the central nervous system).

During a review of Patient 1's medical record (MR) titled, "The Application for Lanterman-Petris-Short (LPS) Conservatorship (gives legal authority to one adult (called a conservator) to make certain decisions for a seriously mentally ill person (called a conservatee) who is unable to take care of him/ herself)" [for Patient 1], dated 6/26/2024, the MR indicated that temporary conservatorship (T-con, temporary legal authority granted to a conservator to oversee and make decisions for a person deemed gravely disabled due to a mental disorder) for Patient 1 had been granted. The MR further indicated that Patient 1 had to be detained, evaluated, and treated for the mental disorder responsible for the condition of grave disability. Additionally, the MR inidcated that the facility had been informed of the temporary conservatorship prior to Patient 1's admission (7/12/2024) and that a court date was pending and scheduled for 7/22/2024.

During a review of Patient 1's medical record (MR) titled, "Notice of Certification for Intensive Treatment Pursuant to Section 5250," dated 7/14/2024, the MR indicated that Patient 1's hold was extended for an additional 14 days. Section 5250 refers to the California Welfare and Institutions Code, which allows for the extension of an initial 72-hour involuntary psychiatric hold (under Section 5150) by up to 14 days for individuals requiring continued intensive treatment due to a mental health condition that poses a danger to themselves or others or results in grave disability.

During an interview on 12/3/2024 at 2:39 p.m. with the Chief Nursing Officer (CNO), the CNO stated that on 7/24/2024, the day of Patient 1's transportation to court, two staff members, the driver and the program coordinator, accompanied Patient 1. The staff brought breakfast, lunch, and snacks for the patient (Patient 1), anticipating that it would be a long day. The CNO further said that as they (the driver, the program coordinator/specialist, and Patient 1) entered the court building and passed through the metal detector, Patient 1 suddenly ran off. The staff, adhering to policy, did not physically intervene, as restraining (something that limits freedom of movement or action) or tackling individuals off-campus is prohibited. Following the incident, the staff promptly notified the facility's supervisor and the judge. The CNO said, "We notified everyone."

During an interview on 12/3/2024 at 2:46 p.m. with the Director of Clinical Services (DCS), DCS stated that staff were not permitted to physically intervene when a patient was outside the facility. The DCS explained, "Once the patient is out the door, we do not stop the patient; we call the police." The DCS further said that staff may only use restraints (methods used to limit a person's movement or access to their body) if the patient was presenting an imminent danger to themselves or others while inside the facility. The DCS then said, "We would not compromise the safety of staff once the patient is outside the facility and is eloping. We are a psychiatric facility, not a jail. The DMH (Department of Mental Health) or the public guardian (an appointed legal representative responsible for managing the personal and financial affairs of individuals unable to do so themselves) would not question us about why the patient eloped."

During an interview on 12/3/2024 at 2:53 p.m. with the Director of Quality Management (DQM), the DQM stated that the Quality Improvement team conducted a review of the process following the incident involving Patient 1's elopement on 7/24/2024. As part of the review, the team evaluated the relevant policies and implemented changes to address identified gaps. The DQM stated, "We made it very clear with the transportation," referencing the updates made to the policy titled "Supervision of Patients/Patient Rounds," which was revised in August 2024 following the July [2024] adverse event. The updated policy included the following changes:

a. A minimum of two staff members must accompany any patient for outside appointments.
b. The Chief Nursing Officer (CNO) will assess and determine if additional staff are required for specific situations.
c. Staff members with a good rapport with the patient may be assigned to accompany the patient to ensure better communication and cooperation.

The DQM further said that, in certain cases, three staff members may be assigned for patient transportation based on the patient's risk level and specific needs. The DQM said that the incident was formally reported to the governing body in August 2024 as part of the facility's commitment to process improvement and patient safety.

During an interview on 12/3/2024 at 3:12 p.m. with the Director of Clinical Services (DCS) regarding Patient 1's high risk for elopement during transportation to court, the DCS stated the following: Prior to Patient 1's transport to court on 7/24/2024, the facility consulted with the public guardian, who shared the same concern about the possibility of the patient running away. This concern was also communicated to the judge. However, the judge maintained the requirement to see the patient in person.

During the same interview on 12/3/2024 at 3:12 p.m., the DCS further said the following: WebX (a virtual conferencing platform used for remote meetings and hearings) was utilized during the pandemic (a widespread outbreak of an infectious disease, specifically referring to COVID-19, which necessitated remote interactions to limit physical contact and ensure safety) for court proceedings. Despite this precedent (an established practice or example set in the past), the court now mandates that patients appear in person for hearings.

During an interview on 12/3/2024 at 3:12 p.m. with the Chief Nursing Officer (CNO) regarding the [Name] program agreement, the CNO stated, "We made a contract with the Department of Mental Health (DMH), but did we know what we were really getting into? No. It's a brand-new entity. Then we found out we need to escort the patients to court."

During an interview on 12/3/2024 at 3:17 p.m. with the Director of Quality Management (DQM) regarding the facility's process for transporting patients on involuntary hold to appointments or court hearings prior to the incident of Patient 1's elopement on 7/24/2024, the DQM stated, "There was a transportation process before, but it was not as robust, so we created a new process (after the incident with Patient 1 but was not in place when the facility initially entered into a contract with the program)."

During an interview on 12/3/2024 at 3:24 p.m. with the Chief Nursing Officer (CNO), the CNO explained that the agreement negotiations for the [Name] program took considerable time due to multiple concerns, stating, "We didn't know how staff would react to having these patients from the jail." The CNO further stated that the previous Chief Executive Officer, who was initially the head of the [Name] program, is no longer with the facility. The CEO had been responsible for overseeing the contractual agreement terms and conditions and presenting them to the governing body (GB).

During an interview on 12/3/2024 at 3:34 p.m. with the Director of Quality Management (DQM), the DQM stated the following: A Root Cause Analysis (RCA, a structured method used to identify the underlying causes of an issue or adverse event and develop strategies to prevent recurrence) was not conducted. However, the case [Patient 1's elopement on 7/24/2024] was thoroughly reviewed and discussed among the relevant teams. The DQM further stated that there was no adequate policy in place prior to the incident to provide clear guidelines and procedures for the safe and secure transport of patients. Immediate action was taken to establish and implement clear standards of practice to address the gaps identified during the review process (following the incident with Patient 1 and not prior to the incident).

During an interview on 12/4/2024 at 2:14 p.m. with the Program Specialist (PS 1), whose responsibilities included, but were not limited to, transporting patients to court, PS 1 stated the following: "It is my responsibility to ensure that patients get to court safely. Before the transport, I called the court multiple times to inform them of Patient 1's high elopement risk and history of assault (involves the threat or attempt to physically harm someone). Typically, this is not my responsibility, but I was told the patient still needed to appear in court in front of the judge." The PSI also stated the following: "On 7/24/2024, I, along with the driver, took the patient (Patient 1) to court. When we arrived at the courthouse, we began walking the patient (Patient 1) inside. As I placed my belongings in the basket at the metal detector, the patient (Patient 1) walked through the metal detector, turned to the right, and fled out of the building."

During the same interview on 12/4/2024 at 2:14 p.m., the PS 1 further said, "As I watched the patient (Patient 1) run past the door, I picked up my belongings and followed her (Patient 1) to the parking garage. However, I did not physically pursue her because our policy prioritizes safety and states that we do not physically pursue patients. Ensuring both my safety and the patient's safety is paramount. I went up to the court and informed the judge and the public defender (a court-appointed attorney responsible for providing legal representation to individuals who cannot afford to hire private counsel, ensuring their legal rights are upheld), but they said there was nothing we could do."

During an interview on 12/6/2024 at 4:08 p.m. with the Chief Executive Officer (CEO, the highest-ranking executive responsible for the overall management and operations of the facility), the CEO stated the following regarding the facility's governing body (GB) responsibilities:

"The GB reviews all Performance Improvement (PI) metrics. We monitor a range of factors, including safety issues within the hospital, staff turnover, and staff-related controls. We also track all patient-related metrics, focusing on the vast majority of patient care indicators. Additionally, we monitor performance with physicians, allied health professionals, and financial measures. The governing body develops action plans and executes them to address deficiencies, environmental care issues, and monitoring resolutions for any identified problems."

During the same interview on 12/6/2024 at 4:29 p.m. with the Chief Nursing Officer (CNO) and the Chief Executive Officer (CEO), the CEO provided the following information regarding the process for reviewing and approving contracts of this nature, specifically the [Name] program contracted with the Department of Mental Health (DMH): "It is reviewed internally first and then sent to legal. It goes through our corporate office, and legal is our first line. Legal approves it, sends it back for revisions, and then it is sent back to us for finalization." The CEO also stated that they (CEO) have held the position of CEO for about two months now and will now serve as the new contract manager for this agreement. The facility is currently in the process of updating the contact person for the DMH.

In the same interview, on 12/6/2024 at 4:29 p.m., the CNO stated the following regarding how the governing body (GB) assessed the facility's capacity and capability, including the transportation of patients to external appointments, before entering into the contract with the Department of Mental Health (DMH): "The previous CEO (referred to as CEO 2) was a major spearhead for this contract, serving as the primary contact person (contract manager) for the agreement and initiating this contract." The CNO also said that the [Name] patients are not different from any other patients in the facility. The CNO said: "We started receiving patients in July 2024," the CNO stated. "It was the same population that we already had. We do not take predators, and we don't take pregnant patients. We go through the same screening process as we do for any other patients in the facility."

During the same interview on 12/6/2024 at 4:29 p.m., the Chief Nursing Officer (CNO) stated the following regarding how the facility ensured that patients on involuntary holds were transported safely and securely to off-site appointments, court hearings, or other required commitments: "I don't know. We don't know because we were not here," the CNO said, also referring to the Chief Executive Officer (CEO) and the Director of Quality Management (DQM).

During further interview on 12/6/2024 at 4:34 p.m. with the Chief Nursing Officer (CNO), the CNO provided the following information regarding the lack of a formal, written policy for transporting patients on involuntary holds (defined as patients detained under legal authority due to mental health or safety concerns, requiring secure and monitored care) to external appointments such as dental visits or court hearings: "There was no specific transportation policy, or at least not one addressing these situations prior and at the time when the contract was created with the Department of Mental Health (DMH). We have a transportation policy now. Key components include: two staff members accompanying a patient, and if more than one patient is going to court, I send more than one staff member. They have to go in the morning, and oftentimes, they will be there all day. We send them with two meals."

During further interview on 12/6/2024 at 4:54 p.m. with the Chief Executive Officer (CEO), the Chief Nursing Officer (CNO), and the Director of Quality Management (DQM), regarding the revised policy addressing the facility's safety transportation measures and guidelines, the following information was provided when asked if factors such as patient acuity (defined as the severity of a patient's condition or the intensity of care required), potential elopement risk, need for restraints, or security presence were considered in the new transportation policy:

The CNO stated that staff responsible for transporting patients were not nurses and, therefore, cannot administer medications such as insulin for diabetic patients. In the event of a medical emergency, staff were instructed to call 911 immediately. The CNO further said that staff who accompany patients do not document events during transport, do not record patients' behaviors, and were not permitted to restrain patients. Additionally, the CNO said that there wass no policy in place that dictates the staff-to-patient ratio during off-site transportation.

The CEO and the DQM stated that, in creating and refining the transport policy, the facility relied solely on existing internal policies and analyses. The facility did not consult external entities, such as legal counsel or Department of Mental Health (DMH) representatives, to assess its legal and regulatory obligations for off-site care of patients on holds.

During an interview on 12/6/2024 at 4:57 p.m. with the Director of Quality Management (DQM), the DQM stated that the facility measures the effectiveness of the new transportation policy by monitoring incidents of patient elopement during off-site transport. The DQM said that there has been one additional elopement of a patient during transport to court since the initial incident involving Patient 1 [7/24/2024]. The DQM further stated that, at this time, no ongoing improvements or revisions to the current transportation policy have been considered. However, the facility might now evaluate potential changes after identifying certain gaps in the policy.

During a review of the facility's contract for Acute Psychiatric Inpatient Services (APIS, defined as intensive, short-term psychiatric care provided to individuals experiencing severe mental health crises, requiring immediate stabilization in a hospital setting), last amended on 10/11/2023, the contract indicated the following:

-The contractor (the facility) shall admit and provide Acute Psychiatric Inpatient Services to all clients referred by the [County] Department of Mental Health.

-Scope of APIS Services (Section 2.0): APIS consists of 24/7 intensive services designed to provide psychiatric treatment with the specific intent to address symptoms that pose a danger to self, others, or result in the inability to provide for basic needs such as food, clothing, and shelter due to mental disability, as determined by qualified mental health professional staff of the facility.

-The contractor (the facility) assumes total liability and responsibility for the provision of all acute psychiatric services rendered to clients.

-Service Requirements (Section 2.1): APIS includes 24 hours a day, seven days a week, 365 days a year (24/7/365) mental health admission, evaluation, referral, and evidence-based psychiatric treatment services. Services encompass all necessary mental health treatment and care required for the entire period the individual is under the facility's care in accordance with the Lanterman-Petris-Short (LPS) Act (Welfare and Institutions Code, or WIC, Section 5000 et seq.), which establishes the legal framework for involuntary mental health treatment, including criteria for 72-hour holds, conservatorships, and rights of individuals under psychiatric care.

-Transportation Responsibility (Section 2.4.4): The contractor (the facility) is responsible for transporting inpatient conserved individuals to and from conservatorship hearings.

-Quality and Compliance (Section 4.0): The contractor (the facility) must comply with and cooperate with all applicable provisions of the following:

-Welfare and Institutions Code (WIC): A set of California statutes governing mental health care, conservatorships, and social services for individuals unable to care for themselves due to mental illness or developmental disabilities.
-California Code of Regulations (CCR): The official compilation of regulations adopted by California state agencies, including standards related to mental health care facilities and practices.
-Code of Federal Regulations (CFR): Federal regulations governing healthcare facilities, patient rights, and Medicaid/Medicare compliance.
-Policies and procedures from the Department of Health Care Services (DHCS) and the [County] Department of Mental Health (DMH) related to Quality Improvement and Quality Assurance, ensuring the facility maintains a complete and integrated quality management system.

During a review of the facility's bylaws of the Board of the Governing Body (defined as the entity legally responsible for the operation and oversight of the hospital, including ensuring compliance with all applicable laws, regulations, and standards), Article V, Duties and Responsibilities, it was indicated that the principal duties and responsibilities of the Board included the following:

1. Advise on policies and procedures related to hospital operation and management to ensure compliance with all applicable laws, regulations, and accreditation standards.
2. Advise the Chief Executive Officer (CEO) regarding matters pertaining to hospital operation.
10. Advise on reasonable steps needed to ensure that the hospital conforms to all applicable federal, state, and local laws and regulations.

During a review of the facility's policy and procedure (P&P) titled, "Appropriate Use of Involuntary Commitment," last revised 5/2022, the P&P indicated that involuntary commitment is a legal intervention by which persons designated by the State of California may order a person with symptoms of a serious mental disorder, and meeting other specified criteria, to be confined in a psychiatric hospital for a period of time as defined by the State. The facility recognizes and follows the laws of the State related to involuntary commitment.

2. During a record review of Patient 1's medical record (MR) titled, "Initial Psychiatric (a medical specialty focusing on mental, emotional, and behavioral disorders) Evaluation," dated 7/12/2024, the MR indicated that Patient 1 was admitted to the facility on 7/12/2024 on a 5150 hold (a 72-hour involuntary psychiatric hold authorized for individuals who, due to a mental health disorder, pose a danger to themselves, others, or are gravely disabled) for being gravely disabled (GD, defined as the inability to provide for basic personal needs, such as food, clothing, or shelter, due to a mental health condition). The MR also indicated that Patient 1 had a past medical history (PMH, the patient's prior documented health conditions, including physical and mental health issues) of episodes of aggressive behavior, prior psychiatric hospitalizations, an extensive legal history (refers to a pattern or record of multiple encounters with the legal system, which may include arrests, charges, convictions, or incarcerations over an extended period), and polysubstance use (the use of multiple substances, often simultaneously or in a pattern, including legal or illicit drugs), specifically alcohol and methamphetamine (a powerful and highly addictive stimulant that affects the central nervous system [made up of the brain and the spinal cord]).

During a review of Patient 1's medical record (MR) titled, "The Application for Lanterman-Petris-Short (LPS) Conservatorship (gives legal authority to one adult (called a conservator) to make certain decisions for a seriously mentally ill person [called a conservatee] who is unable to take care of him/ herself)" [for Patient 1], dated 6/26/2024, the MR indicated that temporary conservatorship (T-con: temporary legal authority granted to a conservator to oversee and make decisions for a person deemed gravely disabled due to a mental disorder) for Patient 1 had been granted. The MR further indicated that Patient 1 had to be detained, evaluated, and treated for the mental disorder responsible for the condition of grave disability. Additionally, the MR indicated that the facility had been informed of the temporary conservatorship prior to Patient 1's admission (7/12/2024) and that a court date was pending and scheduled for 7/22/2024.

During an interview on 12/3/2024 at 2:39 p.m. with the Chief Nursing Officer (CNO), the CNO stated that on 7/24/2024, the day of Patient 1's transportation to court, two staff members, the driver and the program coordinator, accompanied Patient 1. The staff brought breakfast, lunch, and snacks for the patient (Patient 1), anticipating that it would be a long day. The CNO further said that as they (the driver, the program coordinator/specialist, and Patient 1) entered the court building and passed through the metal detector, Patient 1 suddenly ran off.

During an interview on 12/3/2024 at 2:53 p.m. with the Director of Quality Management (DQM), the DQM (a governing body member) stated that the Quality Improvement team conducted a review of the process following the incident involving Patient 1's elopement on 7/24/2024. As part of the review, the team evaluated the relevant policies and implemented changes to address identified gaps. The DQM further stated that the review highlighted the need for clearer protocols regarding elopement (when individuals leave an area they are expected to stay within, for their safety) risk assessments, patient supervision, and documentation, and that these updates were shared with staff to ensure compliance and prevent similar incidents in the future. stated, "We made it very clear with the transportation," referencing the updates made to the policy titled "Supervision of Patients/Patient Rounds," which was revised in August 2024 following the July [2024] adverse event. The DQM further stated that there was no adequate policy in place prior to the incident to provide clear guidelines and procedures for the safe and secure transport of patients on involuntary hold. Immediate action was taken to establish and implement clear standards of practice to address the gaps identified during the review process.

During an interview on 12/6/2024 a

Based on interview and record review, the facility failed to ensure that one of 30 sampled patients (Patient 30) or Patient 30's legal representative (Patient 30) had a documentation acknowledging information provided regarding her (Patient 30) rights (Example: the right to respectful care, the right to refuse treatment, etc. Patient Rights ensure a safe and equitable treatment during the patient's stay in the hospital.) as a patient, in accordance with the facility's policy and procedure regarding "Notification of Rights and Denial of Rights."

This deficient practice had the potential for Patient 30 to be unable to make informed decision (a choice made after thoroughly considering all relevant information and potential outcomes) about her (Patient 30) own healthcare, potentially leading to unwanted treatments, and missed opportunities for alternative options.

Findings:

During a review of Patient 30's "Initial Psychiatric (focused on mental, emotional, and behavioral disorders) Evaluation (psych eval, a complete patient assessment including a review of the patient's medical history, mental status, and current symptoms)," the psych eval indicated Patient 30 was admitted to the facility on 11/13/2024 to be evaluated for change in mood, aggression toward facility staff, and self-harm behavior. The psych eval also indicated Patient 30 had a history of polysubstance abuse (use of several drugs, illegal or prescription, at once) including the use of alcohol, methamphetamine (a powerful and highly addictive stimulant that affects the central nervous system [includes the brain and the spinal cord]), and marijuana. This report indicated Patient 30 had a history of psychiatric (branch of medicine that deals with mental, emotional, or behavioral disorders) hospitalizations and medication noncompliance (term used in regard to a patient who does not take prescribed medication or a course of treatment).

During an interview on 12/6/2024 at 1:00 p.m. with the Risk Management and Performance Improvement Coordinator (CRMPI), in the conference room, CRMPI acknowledged Patient 30 had not signed and acknowledged her (Patient 30) understanding of her rights. CRMPI subsequently stated documents indicating patient understanding of patient rights should have been signed by Patient 30 at the time of admission and that Patient 30 should have access to the process for filing a complaint.

During a review of the document titled, "Patient Rights," dated 11/13/2024, this form indicated patients that were admitted to the facility were entitled to the following not all inclusive rights: to use the patient's own personal belongings; to have access to a private storage for patient belongings; to see visitors each day; to have access to a telephone to receive and send confidential calls; to have access to letter writing materials; to refuse shock treatment (a medical procedure where a brief electrical current is passed through the brain to induce a small seizure [episode of abnormal electrical activity in the brain that can cause changes in movement, behavior, feeling, and awareness], primarily used to treat severe depression [a mental health condition that involves a prolonged low mood or loss of interest in activities that hasn't responded to other treatments]); to refuse psychotherapy (a type of treatment that involves talking with a licensed mental health professional to help identify and change troubling thoughts, emotions, and behaviors) as defined in the Welfare and Institutions Code (a collection of state statutes that establish public social services and programs to promote the public welfare); to have access to a process for filing confidential complaints. The final statement in this document indicated the patient (Patient 30) attested to understanding these rights and had received the Patient's Rights Handbook. However, there was no signature indicating Patient 30's understanding of patients' rights.

During a review of the form titled, "[Name of facility] - Patient Acknowledgements," dated 11/13/2024, this document indicated Patient 30 had been advised of the following: Patient guidelines; Patient visitation after being discharged; Patient understanding of rules against inappropriate sexual behavior; Fall (an unintentional event that results in the person coming to rest on the ground or another lower level) prevention information; Patient and family education regarding use of patient seclusion (the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving) and restraint (something that limits freedom of movement or action). This document was not acknowledged by Patient 30's signature at the bottom of the form.

During a review of the facility's policy and procedure titled, "Notification of Rights and Denial of Rights" (Policy RI-13, updated 8/2019), this document indicated the intent was to notify each patient of his/her rights in understandable language as well as any denial of rights with good cause. This policy indicated the procedure for notifying patients of their rights: Upon admission each patient will be notified of his/her rights in understandable written form and given a copy of the Patient's Rights Handbook; A copy of the notification of rights will be placed in the patient's chart; If the patient refuses to sign the notification, this fact will be written on this form by the admitting nurse; The patient will be oriented to the poster containing the list of patient rights and the complaint procedure that is posted on the unit.

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

1. Ensure the safety of one of 30 sampled patients (Patient 1) when Patient 1, who was admitted on a legal hold (an involuntary psychiatric hold due to being gravely disabled [GB, unable to provide for basic personal needs due to a mental health disorder]) and had a documented history of eloping (when individuals leave an area they are expected to stay within, for their safety) and aggressive behavior, was transported to an off-site location.

This deficient practice resulted in Patient 1's elopement from the court, potentially compromising the patient's safety, disrupting the legal process, and posing a safety risk to the patient (Patient 1) and others.

2. Ensure that one of one sampled medication room (a secure area designated for the storage and preparation of medications) remained locked and the medication cart (a mobile unit used for storing and organizing medications for patient administration) inside the medication room remained locked when not in use, in accordance with the facility's policy regarding medication areas.

This deficient practice had the potential for medications to be stolen or tampered with, leading to potential overdoses or medication errors thus compromising patient safety.

Findings:

1. During a record review of Patient 1's medical record (MR) titled, "Initial Psychiatric (mental, emotional, or behavioral conditions) Evaluation," dated 7/12/2024, the MR indicated that Patient 1 was admitted to the facility on 7/12/2024 on a 5150 hold (a 72-hour involuntary psychiatric hold authorized for individuals who, due to a mental health disorder, pose a danger to themselves, others, or are gravely disabled). The hold was initiated for being gravely disabled (GD), defined as the inability to provide for basic personal needs, such as food, clothing, or shelter, due to a mental health condition. The MR also indicated that Patient 1 had a history of noncompliance with medication treatment, acknowledging that they [Patient 1] only took medications when incarcerated (confined in a jail or prison) or hospitalized, as it was mandated. Additionally, the MR indicated that during an interview on 7/12/2024, Patient 1 exhibited episodes of angry outbursts, was verbally abusive, and made threatening remarks.

During further record review of Patient 1's MR titled, "Initial Psychiatric Evaluation," dated 7/12/2024, the MR indicated that Patient 1 had a past medical history (PMH, the patient's prior documented health conditions, including physical and mental health issues) of episodes of aggressive behavior, prior psychiatric hospitalizations, an extensive legal history (refers to a pattern or record of multiple encounters with the legal system, which may include arrests, charges, convictions, or incarcerations over an extended period), and polysubstance use (the use of multiple substances, often simultaneously or in a pattern, including legal or illicit drugs), specifically alcohol and methamphetamine (a powerful and highly addictive stimulant that affects the central nervous system [includes the brain and the spinal cord]).

During a review of Patient 1's medical record (MR) titled, "The Application for Lanterman-Petris-Short (LPS) Conservatorship (gives legal authority to one adult (called a conservator) to make certain decisions for a seriously mentally ill person [called a conservatee] who is unable to take care of him/ herself)" [for Patient 1], dated 6/26/2024, the MR indicated that temporary conservatorship (T-con: temporary legal authority granted to a conservator to oversee and make decisions for a person deemed gravely disabled due to a mental disorder) for Patient 1 had been granted. The MR further indicated that Patient 1 had to be detained, evaluated, and treated for the mental disorder responsible for the condition of grave disability. Additionally, the MR stated that the facility had been informed of the temporary conservatorship prior to Patient 1's admission (7/12/2024) and that a court date was pending and scheduled for 7/22/2024.

During a review of Patient 1's medical record (MR) titled, "Notice of Certification for Intensive Treatment Pursuant to Section 5250," dated 7/14/2024, the MR indicated that Patient 1's hold was extended for an additional 14 days. Section 5250 refers to the California Welfare and Institutions Code, which allows for an extension of an initial 72-hour involuntary hold (Section 5150) by up to 14 days for individuals requiring intensive treatment due to a mental health condition that makes them a danger to themselves or others or gravely disabled.

During an interview on 12/3/2024 at 2:19 p.m. with the facility's Director of Quality Management (DQM) and Chief Nursing Officer (CNO), regarding Patient 1, who, on 7/24/2024, eloped (leaving a designated area without authorization or supervision, posing a safety risk) from the court, where Patient 1 was ordered to appear for a conservatorship hearing (the hearing determines whether the individual requires a permanent conservatorship based on their mental health condition and inability to care for themselves), the CNO stated that prior to the hearing, the facility had called ahead to notify the court of the patient's (Patient 1) intention to escape. The patient (Patient 1) was on a temporary conservatorship (T-Con) and under a hold while awaiting placement (the process of securing a suitable long-term care facility to provide necessary mental health treatment and support) to ensure Patient 1 continues to receive mental health services.

During an interview on 12/3/2024 at 3:24 p.m. with the Chief Nursing Officer (CNO), the CNO stated the following regarding the facility's assessment procedures for assessing patients for elopement risk: the assessment involves identifying behaviors, history, and statements that indicate a patient may attempt to leave a supervised setting without authorization. The CNO said that nursing patient care for all patients falls under the CNO's responsibility and said that the responsibility for identifying patients at high risk for elopement lies with the facility's manager, in whom the CNO has trust.

During a review of Patient 1's prior-to-admission medical record (MR), dated 6/13/2024, the MR indicated that Patient 1 had a history of, but not limited to:
- Battery: Intentional and unlawful use of force or violence against another person.
- Assault and Battery: A combination of an intentional threat or attempt to cause harm (assault) and the actual infliction of physical harm (battery).
- Battery on Person: Specific physical contact or violence against an individual.
- Willful Cruelty to Child/Child Endangerment: Intentionally inflicting harm, placing a child in danger, or failing to act to protect a child from harm.
The MR also indicated that Patient 1 had a history of aggression in the community, refusal to take prescribed medications to manage their (Patient 1) mental health condition and was identified as a very high risk for elopement due to a prior history of ODR -AWOL (Outpatient Diversionary Rehabilitation Absence Without Leave: leaving a facility or treatment program without authorization).

During a concurrent interview and record review on 12/4/2024 at 10:57 a.m. with the house supervisor (HS 1), Patient 1's medical record (MR) titled, "Nursing Admission Assessment," dated 7/12/2024, was reviewed. The MR indicated that Patient 1's elopement risk assessment was documented as "none." HS 1 stated that nurses only document what the patient reports during the assessment and do not include other information unless clearly disclosed by the patient. HS 1 added that the nurse can initiate a separate treatment plan and document in the progress notes if a patient is identified as having a risk based on the history. The HS 1 then reviewed Patient 1's treatment plan (a documented plan outlining the care, interventions, and strategies to address a patient's specific health issues or risks), dated 7/12/2024 through 7/24/2024 and said that a "Risk for Elopement" treatment plan was not initiated during Patient 1's stay in the facility.

During an interview on 12/4/2024 at 2:14 p.m. with the Program Specialist (PS 1), whose responsibilities include, but are not limited to, transporting patients to court, PS 1 stated the following: "It is my responsibility to ensure that patients get to court safely. Before the transport, I called the court multiple times to inform them of Patient 1's high elopement risk and history of assault. Typically, this is not my responsibility, but I was told the patient still needed to appear in court in front of the judge." The PSI also stated the following: "On 7/24/2024, I, along with the driver, took the patient (Patient 1) to court. When we arrived at the courthouse, we began walking the patient (Patient 1) inside. As I placed my belongings in the basket at the metal detector, the patient (Patient 1) walked through the metal detector, turned to the right, and fled out of the building."

During the same interview on 12/4/2024 at 2:14 p.m., the Program Specialist (PS 1) stated, "I have been working here for over seven years. We do take patients to off-site appointments aside from court hearings, and this was the first time I have experienced an issue with patient transport and elopement. There was a chance this patient (Patient 1) might elope." PS 1 further said that there was no required documentation during transport, such as a rounds sheet (a tool used to track patient whereabouts and activities during specific intervals) or observations of patient behavior. PS 1 said, "I typically do not update patients' charts. I was only required to document a progress note regarding the incident [Patient 1's elopement incident on 7/24/2024] in Patient 1's record."

During an interview on 12/6/2024 at 3:30 p.m. with the Director of Quality Management (DQM), the DQM stated that they (DQM) began working at the facility in April 2024. The DQM further stated that, following Patient 1's elopement on 7/24/2024, an internal investigation and incident review were conducted. This review identified that the facility lacked an existing policy and procedure for transporting patients on a hold to off-site locations, such as court hearings.

During an interview on 12/6/2024 at 5:07 p.m. with the Chief Nursing Officer (CNO), the CNO stated that there was no patient safety risk assessment or documentation completed prior to transporting patients to external appointments. The CNO also confirmed that patient behavior during transportation is neither documented nor tracked.

During an interview on 12/6/2024 at 5:23 p.m. with the Chief Nursing Officer (CNO), the CNO said the following: The process for how nursing staff initially identifies and assesses patients for elopement risk includes assessing patients upon admission by asking direct questions and gathering collateral information (information obtained from external sources such as family, caregivers, or other professionals to supplement the patient's self-reported data). The elopement risk assessment is conducted only during the admission process, and re-assessments are expected to be performed during every shift once the patient is identified as being at risk for elopement. Nurses are then required to initiate an elopement risk treatment plan. The corresponding intervention would be documented in the patient's observation record, including 15-minute safety checks (regular checks performed every 15 minutes to monitor and ensure the safety and well-being of patients) and any required elopement risk precautions.

During the same interview on 12/6/2024 at 5:23 p.m. with the Chief Nursing Officer (CNO), the CNO stated that the facility's daily shift assessment forms do not include a built-in elopement risk assessment tool for nurses to document elopement risk. Instead, nurses are expected to re-assess elopement risk every shift and document their findings in the progress notes. The CNO further stated, "I just have to trust the staff. When the behavior is seen or observed, it should be documented in the progress note." The CNO added that it is the responsibility of house supervisors and charge nurses to oversee the accuracy and completeness of required patient assessments to ensure that the assessments are conducted properly.

During a review of the facility's policy and procedure (P&P) titled, "Patient Precautions," last revised 2/2022, the P&P indicated that "It is the facility's policy to identify and assess risk factors of all patients in order to provide care in a safe and therapeutic environment. All patients are assessed for risks for ...assault, ...and elopement upon admission. All patients are also re-assessed for the same risk factors on a daily basis throughout their hospitalization to determine if there are any changes in their level of risk. II. Upon admission, patient information may be gathered from the patient, other hospitals, physicians, and documented in the nursing admission assessment form. The appropriate corresponding precautions are implemented. A physician or a charge nurse can initiate any precautions. A physician may order elopement precautions in the event of the following patient risk factors: a. History of elopement from a previous hospitalization or another facility ...The elopement risk will be included in the treatment planning process."

During a review of the facility's policy and procedure (P&P) titled, "Supervision of Patient/Patient Rounds," last revised on 7/2023, the P&P indicated that "10. When a patient leaves the hospital grounds (e.g., scheduled outings, dental appointments), a copy of the Rounds sheet must be completed by the staff member accompanying the patient, if applicable. The copy will be filed in the patient's chart with the original upon the patient's return."

During a review of the facility's policy and procedure (P&P) titled, "Elopement of a Patient," last reviewed 3/2022, the P&P indicated that all patients will be assessed upon admission for AWOL (Absent Without Leave, when a patient leaves a designated area without authorization or supervision) elopement potential. AWOL protocol will include early identification, observation, intervention, response, and a notification plan. Guidelines for staff: Patients are not to be physically contained unless they meet the criteria for an involuntary hold or are presenting dangerous behaviors while eloping, and sufficient staff are available to restrain the patient safely.

During a review of the facility's policy and procedure (P&P) titled, "Scope of Assessment," last reviewed 3/2022, the P&P indicated that an interdisciplinary assessment process, involving the patient and family, includes data collected from pre-admission up to 72 hours after admission. Data sources shall include patient self-reported information, family, transfer documents, previous admission documents, observation, and current documentation information. Care decisions shall be made based on an analysis of the assessment information.

During a review of the facility's policy and procedure (P&P) titled, "Appropriate Use of Involuntary Commitment," last revised 5/2022, the P&P indicated that involuntary commitment is a legal intervention by which persons designated by the State of California may order a person with symptoms of a serious mental disorder, and meeting other specified criteria, to be confined in a psychiatric hospital for a period of time as defined by the State. The facility recognizes and follows the laws of the State related to involuntary commitment.

2. During a concurrent interview and observation on 12/3/2024 at 11:37 a.m. in the Youth Services Unit (a specialized area providing psychiatric care for adolescent patients), inside the nurses' station (a restricted area accessible to licensed nursing staff and other clinical team members), with Charge Nurse 1 (CN 1), the medication room (a secure area designated for the storage of medications, including controlled substances, patient-specific medications, and sharps [e.g., syringes, needles] required for medical procedures) door was observed to be unlocked and slightly open. Inside the medication room, the medication cart (a mobile unit used for storing and organizing medications for patient administration) was observed parked by the wall and was also unlocked. CN 1 stated that the door to the medication room should be locked, and when the door is locked, the medication cart can remain unlocked.

During an interview on 12/5/2024 at 12:23 p.m. with Nurse Educator 1 (NE 1), NE 1 stated the following: The medication cart in the medication room must be locked when not in use, and the medication room should always be locked for safety. No one who is unauthorized to be in the medication room should enter. The medication room is only accessible to licensed staff.

During a review of the facility's policy and procedure (P&P) titled, "Medication Area Inspection," dated 3/2010, the P&P indicated that nursing unit medication dispensing areas (e.g., medication rooms, medication carts, medication refrigerators) must comply with all State and Federal laws and local standards of practice, for the betterment of patient care. The P&P also indicated that the medication cart must be locked when not in use.

Based on observation, interview, and record review, the facility failed to ensure the Condition of Participation (CoP) for Nursing Services was met as evidenced by:

1. The facility failed to provide adequate staffing based on census (number of patients in the unit) and ensure nursing staff consistently performed and documented patient acuity report (defined as evaluations of the severity of a patient's condition and care needs to determine the appropriate level of nursing care required), in accordance with the facility's policy and procedure regarding acuity system to determine appropriate nursing staffing levels and align staff assignments with patient care needs on four of four sampled behavioral health units (BHU [inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders] 1, 2, 3 and 5).

This deficient practice had the potential to result in the inability to meet patients' needs in a timely manner, thus compromising patients' safety and the delivery of quality patient care. (Refer to A-0392)

2. The facility failed to ensure for two of 30 sampled patients (Patients 16 and 18), a proper screening and assessment of risk of self-harm or suicide (death caused by injuring oneself with the intent to die), were completed and appropriate steps to protect the patient were implemented, in accordance with the facility's policy and procedure regarding "Assessment for Suicide risk Potential."

This deficient practice had the potential result in patient harm and or death when patients are not properly screened to determine risks for suicide. (Refer to A-0395)

3. The facility failed to ensure the nursing staff performed accurate patient assessment to assess and evaluate a patient's care needs for one of 30 sampled patients (Patient 9), in accordance with the facility's policy and procedure regarding nutritional screening (a process used to quickly identify individuals who might be at risk of malnutrition [a condition that occurs when the body doesn't have the right amount of nutrients to function properly] by asking a series of brief questions about their dietary habits, weight changes, and medical history), when nursing staff failed to identify Patient 9's nutritional risk and need for dietician (a healthcare professional who is specifically trained in nutrition and food science) evaluation.

This deficient practice had the potential for Patient 9 not to receive the appropriate therapeutic diet (a meal plan that limits certain foods or nutrients to treat a medical condition) due to lack of dietician evaluation. This deficient practice also had the potential to result in complications such as weight loss, delayed recovery, etc. (Refer to A-0395)

4. The facility failed to ensure one of 30 sampled patients (Patient 18) had a care plan for hyperglycemia (high blood sugar) and dysphagia (difficulty swallowing), initiated upon admission, in accordance with the facility's policy and procedure regarding patient centered care planning (a detailed document that outlines a patient's specific healthcare needs, goals, and the interventions required to achieve those goals). Patient 18 was identified with hyperglycemia, was on insulin (medication use to treat high blood sugar levels) and had dysphagia on admission.

This deficient practice had the potential to result in Patient 18's needs and risks not identified and may cause a delay in the delivery of necessary treatment to address hyperglycemia which might result in complications such as coma (a state of prolonged unconsciousness where a person is unresponsive to their surroundings and cannot be awakened), and/or death. This deficient practice may also result in complications such as aspiration (the accidental inhalation of foreign material, such as food, liquid, or vomit, into the lungs), weight loss, malnutrition (a condition that occurs when the body doesn't have the right amount of nutrients to function properly), etc. when Patient 18's dysphagia problem is not properly addressed. (Refer to A-0396)

5. The facility failed to ensure one of 30 sampled patients (Patient 23) had a comprehensive care plan initiated upon admission including a care plan with interventions to prevent falls (an unintentional event that results in the person coming to rest on the ground or another lower level), in accordance with the facility's policy and procedure regarding patient centered care planning and fall risk assessment and prevention. Patient 23 fell and hit her head on the floor, ten days after admission.

This deficient practice resulted in Patient 23's needs and risks not identified and may cause a delay in the implementation of preventive measures such as fall precautions to prevent complications from a fall such as concussion (a mild traumatic brain injury [TBI] that occurs when the brain bounces or twists inside the skull due to a blow, bump, or jolt to the head), fracture (break in the bone), etc. (Refer to A-0396)

6. The facility failed to ensure the nursing staff performed medication reconciliation (a process that ensures patients have the correct list of medications they are taking at home, and that any discrepancies are identified and addressed) and communicate with the physician regarding the medication list, in accordance with the facility's policy and procedure regarding medication reconciliation for five of 30 sampled patients (Patient 8, 17, 18, 19, and 22), when home medications were not evaluated by physician during their hospitalization at the facility.

This deficient practice had the potential to compromise patient's medical condition such as worsening infection, worsened mental or behavioral issues, etc. as their (Patient 8, 17, 18, 19, and 22) routine home medications were not reviewed and resumed by the hospital staff. (Refer to A-0398)

7. The facility failed to complete and document a skin assessment for one of 30 sampled patients (Patient 2), in accordance with the facility's policy on skin checks.

This deficient practice had the potential to result in delayed identification and treatment of skin conditions for Patient 2 including lack of monitoring and follow-up, thus placing Patient 2 at higher risk for skin breakdown (damage to the skin and underlying tissue, usually caused by prolonged pressure on a specific area). (Refer to A-0398)

8. The facility failed to ensure that a medication brought in from home for one of 30 sampled patients (Patient 2) was documented in the Home Medication List section of Patient 2's chart.

This deficient practice had the potential for a patient's medication, brought in from home, to be unverified by pharmacy and may not be administered to a patient in a timely manner following a physician's order. (Refer to A-0398)

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality healthcare in a safe environment and potentially placing patients at risk of not receiving necessary care and treatments.

Based on interview and record review, the facility failed to provide adequate staffing based on census (number of patients in the unit) and ensure nursing staff consistently performed and documented patient acuity report (defined as evaluations of the severity of a patient's condition and care needs to determine the appropriate level of nursing care required), in accordance with the facility's policy and procedure regarding acuity system to determine appropriate nursing staffing levels and align staff assignments with patient care needs on four of four sampled behavioral health units (BHU [inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders] 1, 2, 3 and 5).

This deficient practice had the potential to result in the inability to meet patients' needs in a timely manner, thus compromising patients' safety and the delivery of quality patient care.

Findings:

During a review of Patient 10's "Initial Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health])," dated 11/27/2024, the psych eval indicated, Patient 10 was admitted to the facility on a 5585-hold (allows a minor to be involuntarily detained for up to 72 hours in a psychiatric hospital [a specialized medical facility that focuses on treating individuals with severe mental disorders] for a mental health crisis) with diagnosis of disruptive mood dysregulation disorder (a mental health condition that causes children and adolescents to experience severe irritability and frequent temper outburst) for evaluation of her (Patient 10) mood state and self-harm behavior claiming, "I am going to take a bunch of gummy melatonin (medication that helps someone to fall asleep)."

During an interview on 12/3/2024 at 11:38 a.m. with Patient 10 at Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) 5, Patient 10 stated the following: she (Patient 10) was at the facility for about one week. There were a lot of fights going on with other patients and it happened in front of her (Patient 10). She (Patient 10) would just stay away and remained quiet. Patient 10 stated, "It took some time for staff to come and intervene."

During a concurrent interview and record review on 12/3/2024 at 11:51 a.m. with Charge Nurse (CN) 1 at BHU 5, BHU 5 Patient Care Assignment (nursing assignment indicating who are the staff assigned to the patients and their tasks) 7 a.m. to 3:30 p.m. morning shift, dated 12/3/2024, was reviewed. The Patient Care Assignment indicated BHU 5 had census of 22 patients and was staffed four licensed nursing staff (CN 1, Registered Nurse [RN] 2, RN 3 and Licensed Vocational Nurse [LVN] 2) and one Mental Health Technician (MHT, psychiatric assistant provides direct patient care support with mental health issue under charge nurse direction) 3. CN 1 stated he (CN 1) had patients currently and RN 3 just came in at 11 a.m. They had to utilize LVN 2 to help with 15-minute rounding (rounding done every 15 minutes in behavioral health unit to ensure patient safety) because there was only one (1) MHT (MHT 3) on the floor.

During an interview on 12/4/2024 at 11:59 a.m. with Charge Nurse (CN) 2 at Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) 2, CN 2 stated it was the charge nurse's responsibility to make the assignment for the unit and complete the acuity (a medical term that refers to the severity of a patient's condition and how urgent their care needs are, the higher the acuity the more care is needed) sheet. CN 2 stated acuity reflected how heavy the patient load was. CN 2 stated she (CN 2) did not do the acuity today because she (CN 2) was behind with her (CN2) work. CN2 stated she (CN 2) split the assignment among her (CN 2) and two other licensed nursing staff based on the number of patients in the unit (BHU 2).

During an interview on 12/4/2024 at 12:40 p.m. with Charge Nurse (CN) 3 at Behavioral Health Unit (BHU) 3, CN 3 stated patient acuity should be done to make sure there was enough staffing. CN 3 stated she (CN 3) did not do the patient acuity today because she (CN 3) was busy.

During an interview on 12/5/2024 at 2:42 p.m. with Nurse Manager (NM) 2 of BHU 2 and BHU 3, NM 2 stated the following: the facility was currently in the process of changing the acuity tool. Acuity was not being done currently. Acuity would tell how acute the patients were, and it played a role in making nursing assignment. It would be inappropriate to assign all high acuity patients to one nurse because it would not be manageable. The nursing staff would not be able to provide quality care to patients when he or she had all heavy (high acuity) patients.

During an interview on 12/5/2024 at 2:53 p.m. with Nurse Manager (NM) 1 of BHU 5, NM 1 stated the following: patient acuity was done to let the facility how much staff was needed to provide adequate staff to provide quality care to patients and maintain safety. Acuity should be done by the day shift charge nurse every day. However, the facility changed the acuity tool in August 2024 per corporate directive, but it was still in the process of implementation. Patient acuity had not been done since August 2024 (five months).

During a review of Patient 13's "Initial Psychiatric Evaluation (psych eval)," dated 12/2/2024, the psych eval indicated, Patient 13 was admitted to the facility on an involuntary hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) due to danger to self by attempting carbon monoxide (colorless, odorless and tasteless gas that can be harmful to humans and deadly if inhaled in large amounts) poisoning in the car with diagnosis of major depression.

During an interview on 12/6/2024 at 9:55 a.m. with Patient 13 in Behavioral Health Unit (BHU) 1, Patient 13 stated she (Patient 13) saw patients fighting in BHU 1 and staff would try to intervene.

During a concurrent interview and record review on 12/6/2024 at 10 a.m. with the Nurse Manager (NM) 3 of BHU 1, BHU 1's unit staffing assignment dated 12/6/2024 was reviewed. The staffing assignment did not indicate any patient acuity. NM 3 stated patient acuity was not done in BHU 1.

During an interview on 12/6/2024 at 10:20 a.m. with Mental Health Technician (MHT) 2 at BHU 1, MHT 2 stated the following: MHT would be assigned as one to one observation on patient when needed. MHTs were responsible to perform rounding every fifteen (15) minutes on all patients in the unit to check on patients' location and behavior. MHT would help to intervene when patients got into fights by talking to and separating patients. MHT would also take patients out to patio for activity and provide patients items such as snacks, juice and shampoo upon request. There should be three (3) MHTs on the floor in BHU 1 but a lot of time there was not enough staff. It was hard to attend to patient's need in a timely manner because he (MHT 2) needed to perform rounding every 15 minutes for all patients.

During a concurrent record review on 12/6/2024 at 11:01 a.m. with the Nurse Manager (NM) 3 at BHU 1, BHU 1's unit staffing assignment from 12/1/2024 to 12/6/2024, was reviewed. The staffing assignment indicated the following:

-On 12/1/2024, 7 a.m. to 3:30 p.m. day shift with census of 44, BHU 1 was staffed with three (3) licensed nursing staff (three RNs) and three (3) MHTs. One patient (Patient 15) requiring one on one observation.

-On 12/1/2024, 3:30 p.m. to 11 p.m. evening shift with census of 44, BHU 1 was staffed with four (4) licensed nursing staff and three (3) MHT. One patient (Patient 15) requiring one on one observation.

-On 12/2/2024, 11 p.m. to 7 a.m. night shift with census of 42, BHU 1 was staffed with three (3) licensed nursing staff and three (3) MHT. One patient (Patient 15) requiring one on one observation.

During the same interview on 12/6/2024 at 11:01 a.m. with the Nurse Manager (NM 3), NM 3 stated the following: there were not enough MHTs scheduled on the floor on 12/1/2024 day shift, 12/1/2024 evening shift and 12/2/2024 night shift. There are only 2 MHTs on the floor rounding because one of them was assigned to do one on one observation for Patient 15. MHTs are needed to perform rounding every 15 minutes on patients to maintain safety for patients. MHTs also needed to assist with patient's needs such as getting water and respond to any emergency in the unit.

During a review of Patient 15's "Initial Psychiatric Evaluation (psych eval)," dated 11/26/2024, the psych eval indicated Patient 15 was admitted to the facility on a 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) due to danger to self by walking in front of on-coming traffic and hitting his (Patient 15) head and with diagnosis of bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration).

During a review of Patient 15's physician order dated 12/1/2024, the physician order indicated, "one on one observation (a type of care where a patient is constantly monitored by a staff member) for head banging/self-injurious behavior."

During an interview on 12/6/2024 at 11:49 a.m. with the Chief Executive Officer (CEO), CEO stated patient acuity should be incorporated when it came to staffing because of the level of safety needs for patients, varies from one to another. CEO stated there should be additional MHTs on the floor when there was any patient needing one on one observation. CEO stated it was nursing administration responsibility to provide oversight on staffing.

During an interview on 12/6/2024 at 5:10 p.m. with the Chief Nursing Officer (CNO), CNO stated the following: she (CNO) was responsible to oversee staffing. Appropriate staffing was important to provide care for patients. The facility did not have a grid for staffing but the facility staff one licensed nurse and one MHT for every ten (10) patients. When the census was at forty (40), there should be four (4) MHTs especially for day shift and evening shift because there are more activities going on. Additional MHT should be provided when there's patients requiring one on one observation. When the unit acuity was high, it would require more nursing attention and more staff. The goal was to spread out high acuity patients in order to balance staff workload. It would also benefit the floor and patient safety. CNO stated, "we do not have a tool to evaluate patients' acuity currently."

During a review of the facility's policy and procedure (P&P) titled, "Appropriate Staffing Levels," dated 9/2023, the P&P indicated, "It is the policy of [the facility] to utilize a defined procedure to determine staffing requirements based on patient needs ... In order to maintain quality nursing care, staffing will be planned according to the assessment of patient's needs by the Registered Nurse Charge Nurse and in consultation with, as needed, the Chief Nursing Office and/or the House Supervisor ... The Criteria for assignment of nursing personnel is based on acuity (A patient classification system) that is approved by the Medical Executive Committee and the Board of Trustees of the hospital ... Multiple factors influence the functioning of a patient care unit and the CNO and/or designee(s) are responsible to modify staffing as needs arise on a day-by-day and shift-by-shift basis to provide safety. Factors which affect the need to alter staffing levels up or down include but are not limited to: a. Overall acuity on unit based on formal scoring ... patients place on one on one monitoring ... high risk conditions such as aggressive and/or violent patient towards self and other."

During a review of the facility's policy and procedure (P&P) titled, "Acuity System/Report," dated 3/2022, the P&P indicated, "To ensure that an acuity system is used that addresses patient care needs and satisfies these needs by providing the required nursing hours according to skill mix ... the department of nursing at [the facility] utilizes the patient acuity report to determine individual patient acuity and staffing requirements for each patient care unit ... acuity cane change from day to change and that staffing must fluctuate to assure quality care of each patient ... the charge nurse Registered Nurse (RN) completes the Acuity Report every day at 10:30 a.m. and submit the report to the Chief Nursing Officer (CNO) or Nursing Supervisor ... Biological needs, psychological needs and social needs are rated utilizing the Acuity Rating Criteria Grid. Each patient is rated a score of 1 for low, 2 for moderate and 3 for high acuity."

During a review of the facility's policy and procedure (P&P) titled, "Minimum/ Core Nursing Staffing Plan Per Unit," dated 5/2024, the P&P indicated, "It is the policy of [the facility] to ensure that the appropriate numbers and qualifications of nursing staff are available at all times for the care of patients. The Chief Nursing Officer (CNO) is responsible for the development and ongoing review of staffing requirements based on numbers of patients, population served, acuity."

During a review of the facility's policy and procedure (P&P) titled, "Hospital Plan for Nursing Services," dated 3/2022, the P&P indicated, "The nursing staff at [the facility] provides quality psychiatric nursing services to all patients on a 24-hours, 7 days a week basis, in a continuous, consistent, safe and caring manner ... Assignment of nursing staff ... Each unit shall have a designated number of Licensed Psychiatric Technicians, Licensed Vocational Nurses, and/or Psychiatric Assistants working under the charge nurse based on unit census, patient acuity, and other patient care need requirement ... the Governing Board is kept informed of nursing activities via the Chief Nursing Officer (CNO), who attends Governing Board meetings quarterly."

Based on interview and record review the facility failed to:

1. Ensure for two of 30 sampled patients (Patients 16 and 18), a proper screening and assessment of risk of self-harm or suicide (death caused by injuring oneself with the intent to die) were completed and appropriate steps to protect the patient were implemented, in accordance with the facility's policy and procedure regarding "Assessment for Suicide risk Potential."

This deficient practice had the potential result in patient harm and or death when patients are not properly screened to determine risks for suicide.

2. Ensure the nursing staff performed accurate patient assessment to assess and evaluate a patient's care needs for one of 30 sampled patients (Patient 9), in accordance with the facility's policy and procedure regarding nutritional screening (a process used to quickly identify individuals who might be at risk of malnutrition [a condition that occurs when the body doesn't have the right amount of nutrients to function properly] by asking a series of brief questions about their dietary habits, weight changes, and medical history), when nursing staff failed to identify Patient 9's nutritional risk and need for dietician (a healthcare professional who is specifically trained in nutrition and food science) evaluation.

This deficient practice had the potential for Patient 9 not to receive the appropriate therapeutic diet (a meal plan that limits certain foods or nutrients to treat a medical condition) due to lack of dietician evaluation. This deficient practice also had the potential to result in complications such as weight loss, delayed recovery, etc.

Findings:

1.a. During a concurrent interview and record review on 12/4/2024 at 11:56 a.m. with the House Supervisor (HS), Patient 16's medical record titled, "Nursing Admission Assessment," dated 11/2/2024, was reviewed. Patient 16's medical record indicated that Patient 16 was admitted to the hospital on 11/2/2024 at 8:00 p.m. and was being admitted for high-risk behavior, passive suicide ideation (a type of suicidal thought that involves thinking about death or suicide without a specific plan to act on those thoughts) attempted on 10/19/2024. Patient 16 told her friend she (Patient 16) wanted to harm herself.
The Medical record also indicated that a suicide screen was completed with the use of a Columbia-Suicide Severity Rating Scale ([C-SSRS], a tool that supports suicide risk screening through a series of simple, plain-language questions that nurses ask. The answers help nurses identify whether a patient is at risk for suicide, determine the severity and immediacy of that risk, and gauge the level of support that the patient needs) where admitting nurse identified Patient 16 to be at low risk for suicide.

During the same interview on 12/4/2024 at 11:56 a.m., HS stated that the assessment was not completed correctly, the admitting nurse identified patient (Patient 16) to be "Low Risk" but did not consider the collateral information available to her (nurse) where records indicated of a suicide attempt by patient (Patient 16) on 10/19/2024. HS stated that the Nurse should have elevated risk to "Moderate" or "High" and completed those set of question for that level of risk in the CSSRS tool. This could have explored and accurately assessed patient 16's 10/19/2024 incident of suicide attempt. HS further said it was important for nurses to complete the CSSRS tool and take into consideration other collateral information as this helps identify a patient's level of risk accurately, and that proper interventions would be implemented based on the level of risk identified.

During a review of the facility's policy and procedure (P&P) titled, "Assessment for Suicide risk Potential," with last revised date of 4/2022, the P&P indicated the following:

Suicide Screening:
1.Intake/Admitting Staff will screen all patients with an evidence-based tool presenting for a face -to- face admission to identify specific patient characteristics that may indicate an increased risk of suicide.
2.Nursing Staff will screen all patients with an evidence -based tool who are admitted to the hospital to identify specific patient characteristics that may indicate an increased risk of suicide.
3. As indicated by the screening tool, the identified intervention will be enacted.

Assessment of Risk:
1.Patients who are admitted into the hospital will be screened with an evidenced based tool. Based on the screening, the RN will determine risk level and document the individualized actions to take and contact the physician for appropriate orders, including the level of observation and precaution orders. If the patient scores high on the screening tool they will be assessed further regarding intensity of ideation and suicidal behavior.
An RN may initiate suicide precautions or an increased level of observation while awaiting a formal order from the physician. An RN may not discontinue precautions or reduce the level of observation. Nursing may request a change in Observation Level when they assess patient acuity, but a physician's order is required for any change in Level of Observation.

2.The Psychiatrist will assess suicide risk of each patient during the initial psychiatric evaluation.

3.All assessments shall be considered by the treatment team and incorporated into the patient's individualized treatment plan.



1.b. During a concurrent interview and record review on 12/5/2024 at 12:00 p.m. with Nurse Manager 3 (NM 3), Patient 18's medical record titled, "Nursing Admission Assessment," dated 10/20/2204, was reviewed. Patient 18's medical record indicated that patient (Patient 18) was admitted to the hospital on 10/20/2024 at 9:15 p.m. The medical record also indicated that a suicide screen (a procedure in which a standardized instrument or protocol is used to identify individuals who may be at risk for suicide) was completed with the use of a Columbia-Suicide Severity Rating Scale ([C-SSRS], a tool that supports suicide risk screening through a series of simple, plain-language questions that nurses ask. The answers help nurses identify whether a patient is at risk for suicide (death caused by injuring oneself with the intent to die), determine the severity and immediacy of that risk, and gauge the level of support that the patient needs) where a nurse identified Patient 18 to be at low risk for suicide.

During the same interview on 12/5/2024 at 12:00 p.m. with Nurse Manager 3 (NM 3), NM 3 stated that the assessment was not completed correctly, the admitting nurse identified patient to be "Low Risk" but did not complete the second part of the CSSRS tool where the risk may be elevated to "Moderate" or "High," depending on how patient answers those set of question on the CSSRS tool. NM 3 said the nurse failed to ask those questions and complete that part of the CSSRS tool. Nurse should have completed the CSSRS tool correctly and ask the questions that would have potentially identified patient (Patient 18) to be at moderate or high risk of suicide. NM 3 further stated it was important for nurses to complete the CSSRS tool correctly as this helps identify a patient's level of risk accurately, and that proper intervention would be implemented.

During a review of the facility's policy and procedure (P&P) titled, "Assessment for Suicide risk Potential," with last revised date of 4/2022, the P&P indicated the following:

Suicide Screening:
1.Intake/Admitting Staff will screen all patients with an evidence-based tool presenting for a face -to- face admission to identify specific patient characteristics that may indicate an increased risk of suicide.
2.Nursing Staff will screen all patients with an evidence -based tool who are admitted to the hospital to identify specific patient characteristics that may indicate an increased risk of suicide.
3. As indicated by the screening tool, the identified intervention will be enacted.

Assessment of Risk:
1.Patients who are admitted into the hospital will be screened with an evidenced based tool. Based on the screening, the RN will determine risk level and document the individualized actions to take and contact the physician for appropriate orders, including the level of observation and precaution orders. If the patient scores high on the screening tool they will be assessed further regarding intensity of ideation and suicidal behavior.
An RN may initiate suicide precautions or an increased level of observation while awaiting a formal order from the physician. An RN may not discontinue precautions or reduce the level of observation. Nursing may request a change in Observation Level when they assess patient acuity, but a physician's order is required for any change in Level of Observation.

2.The Psychiatrist will assess suicide risk of each patient during the initial psychiatric evaluation.

3.All assessments shall be considered by the treatment team and incorporated into the patient's individualized treatment plan.


2. During a review of Patient 9's "Initial Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health])," dated 9/12/2024, the psych eval indicated Patient 9 was admitted to the facility on a 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) due to danger to self with plan to ingest helium (exposure to high level of helium [a gas that is lighter than air] can cause dizziness, headache, loss of consciousness and death). The psych eval also indicated Patient 9's admitting diagnoses included but not limited to major depression disorder (MDD - a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), generalized anxiety disorder (a mental health condition that causes people to experience excessive, uncontrollable worry about everyday activities), and diabetes (a chronic disease when the body cannot regulate blood sugar resulting blood sugar too high).

During an interview on 12/5/2024 at 10:18 a.m. with the Registered Dietician (RD, a healthcare professional who is specifically trained in nutrition and food science) 1, RD 1 stated the following: she (RD 1) would perform nutrition consultation based on nursing referral and per patient's request. During nutrition consultation, she (RD 1) would obtain patient's medical history and spoke with patient to determine which type of diet would be best for the patient. It would be better for diabetic patients to be on consistent carbohydrate (CCHO, a dietary approach that involves eating the same amount of carbohydrates each day to help manage blood sugar levels) diet for better control in blood sugar.

During an interview on 12/5/2024 at 10:27 a.m. with RD 1, RD 1 stated there was no dietician referral and consult notes done on Patient 9.

During a concurrent interview and record review on 12/5/2024 at 4 p.m. with the Nurse Manager (NM) 2, Patient 9's "Nursing Admission Assessment," dated 9/12/2024, was reviewed. The nursing admission assessment indicated Patient 9's height of five (5) feet (ft, a unit of measure), weight of 200 pounds (lb, a unit of measure) and body mass index (BMI, a calculation that estimates body fat based on a person's weight and height) of 39. The nursing admission assessment also indicated "no issues identified" was checked off under nutritional screen. The nutritional screen indicated a list of problems including but not limited to "BMI greater than 36" or "BMI less than 19."

During the same interview on 12/5/2024 at 4 p.m. with the Nurse Manager 2 (NM 2), NM 2 stated the following: the admitting nurse did not complete Patient 9's nutritional screen (a quick process used to identify individuals who may be at risk of malnutrition by evaluating certain factors like weight loss, dietary intake, and medical history) correctly. Patient 9's BMI was 39 which would fit the problem listed in nutritional screen of "BMI greater than 36." If a patient reported or nurse observed any of the problems listed in nutritional screen, the nurse should refer the patient for dietician consult. Patient 9 was diabetic, it was important to have a dietician to see her (Patient 9) for blood sugar control and to recommend appropriate diet. Patient 9 could be at risk for elevated blood sugar when diet was not being managed.

During an interview on 12/6/2024 at 10:41 a.m. with physician (MD 4), MD 4 stated a diabetic patient should be on therapeutic diet with CCHO diet to control blood sugar. MD 4 stated it was important to control blood sugar level for diabetic patients during the hospital stay because symptoms of hypoglycemia (when blood sugar level was too low) and hyperglycemia (when blood sugar level was too high) might falsely present as mental illness symptoms or be mistaken as psychiatric condition.

During a review of Patient 9's physician order, dated 9/12/2024, the physician order indicated Patient 9 was placed on regular diet.

During a review of the facility's policy and procedure (P&P) titled, "Nutritional Screening/Assessment Request," dated 3/2022, the P&P indicated, "Nutritional screening will be completed on all patients admitted to [the facility]. Nutritional assessment will be requested by nursing for all patients identified as having nutritional risk ... Nursing staff will complete the 'Nutrition Screening' portion of nursing assessment for each patient, including all of the following: a. actual height and weight of the patient, b. under 'Nutritional Screening,' check boxes which apply to the patient, c. if any boxes are checked 'yes' a nutritional assessment is required ... If a nutritional assessment is required, nursing is to leave a voicemail for the dietician ... the Registered Dietician will complete a 'nutritional assessment record' within 72 hours of assessment notification ... an assessment and plan will be formulated ... dietary staff will be notified of any diet changes."

During a review of the facility's policy and procedure (P&P) titled, "Nutritional Charting/Care Planning," dated 3/2022, the P&P indicated, "Nursing will complete the nutrition screening portion of the nursing assessment and notify the dietician with request of nutritional assessment ... the dietician will complete the 'nutritional assessment record' by gathering additional subjective and objective information to formulate a nutritional assessment and plan ... Plan includes any recommendations for diet changes, supplement orders or diet education."

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

1. Ensure one of 30 sampled patients (Patient 18) had a care plan for hyperglycemia (high blood sugar) and dysphagia (difficulty swallowing), initiated upon admission, in accordance with the facility's policy and procedure regarding patient centered care planning (a detailed document that outlines a patient's specific healthcare needs, goals, and the interventions required to achieve those goals). Patient 18 was identified with hyperglycemia, was on insulin (medication use to treat high blood sugar levels) and had dysphagia on admission.

This deficient practice had the potential to result in Patient 18's needs and risks not identified and may cause a delay in the delivery of necessary treatment to address hyperglycemia which might result in complications such as coma (a state of prolonged unconsciousness where a person is unresponsive to their surroundings and cannot be awakened), and/or death. This deficient practice may also result in complications such as aspiration (the accidental inhalation of foreign material, such as food, liquid, or vomit, into the lungs), weight loss, malnutrition (a condition that occurs when the body doesn't have the right amount of nutrients to function properly), etc. when Patient 18's dysphagia problem is not properly addressed.

2. Ensure one of 30 sampled patients (Patient 23) had a comprehensive care plan initiated upon admission including a care plan with interventions to prevent falls (an unintentional event that results in the person coming to rest on the ground or another lower level), in accordance with the facility's policy and procedure regarding patient centered care planning and fall risk assessment and prevention. Patient 23 fell and hit her head on the floor, ten days after admission.

This deficient practice resulted in Patient 23's needs and risks not identified and may cause a delay in the implementation of preventive measures such as fall precautions to prevent complications from a fall such as concussion (a mild traumatic brain injury [TBI] that occurs when the brain bounces or twists inside the skull due to a blow, bump, or jolt to the head), fracture (break in the bone), etc.

Findings:

1. During a review of Patient 18's "History and Physical (H&P, a formal and complete assessment of the patient and the problem)," dated 10/21/2024, the H&P indicated that patient (Patient 18) had dysphagia (difficulty swallowing) and hyperglycemia (high blood sugar).

During a concurrent interview and record review on 12/5/2024 at 12:27 p.m. with the Nurse Manager (NM) 3, Patient 18's medical record titled, "Initial and Master Treatment Plan (is the first comprehensive document outlining a patient's mental health diagnosis, treatment goals, specific interventions, and monitoring strategies, created after an initial psychiatric evaluation, serving as a roadmap for the patient's ongoing therapy and care)," was reviewed. The medical record indicated that Hyperglycemia and dysphagia were not included in the treatment plan.

During the same interview on 12/5/2024 at 12:27 p.m. with the Nurse Manager (NM) 3, NM 3 stated that the admitting nurse failed to identify and include hyperglycemia and dysphagia on the master treatment plan. NM 3 added that it was important to include hyperglycemia and dysphagia in the treatment plan problem list because the care team need to determine the progress and measure the effectiveness of interventions with each identified medical problem. NM 3 said the patient (Patient 18) was on insulin (medication to used to treat high blood sugar levels) and was on a mechanical soft diet (a dietary plan where food is modified to be soft and easy to chew and swallow, allowing patient with difficulty chewing or swallowing due to conditions swallowing disorders [dysphagia] to eat safely).

During a review of the facility's policy and procedure (P&P) titled, "Interdisciplinary Patient Centered Care Planning," with effective date of 1/2023, the P&P indicated the following:

Developing the Treatment Plan
1. The Nurse completing the Nursing Assessment or designee shall develop the Initial Treatment Plan within eight (8) hours of admission. The nurse will utilize the problems and specific behavioral manifestations identified in the initial assessment and nursing assessment to develop clinically appropriate and individualized goals and interventions which will be included in the Initial Treatment Plan.

A. Any medical problems or diagnoses that are not receiving treatment will be listed on the Treatment Plan cover sheet/problem list as deferred with justification provided. If the medical problem requires active treatment, it will either be included in the plan as a "Chronic/Stable" medical problem if only routine care is provided or on a separate problem sheet if more than routine care is indicated.

B. At the time of the development of the Interdisciplinary Master Treatment Plan (MTP), the Initial Treatment Plan will be considered resolved, with psychiatric problems either moved to the MTP or fully resolved and medical problems moved to the MTP.

2. During an observation on 12/5/2024 at 11:45 a.m., the room that Patient 23 had stayed on 7/18/2024 was located approximately 30 feet from the nursing station. This was the closest patient room to the nursing station.

During a record review of the "Initial and Master Treatment Plan," this form indicated one of the problems assessed for care planning was fall (an unintentional event that results in the person coming to rest on the ground or another lower level) risk. The short-term goal for prevention of fall in this plan included Patient 23 not falling for 7 consecutive days and Patient 23 will be able to describe 2 fall prevention techniques. The goals did not include specific nursing activities to prevent Patient 23 from falling.

During a record review of a "Progress Note," dated 7/18/2024 at 2:30 p.m., the progress note indicated Patient 23 was walking in the hallway when she (Patient 23) suddenly lost her balance and fell to the floor and hit her (Patient 23) head. The attending doctor was notified and 911 was called at 1:50 p.m., vitals (vital signs, includes heart rate, blood pressure, respiratory rate) were taken and Patient 23 was transferred out by 911 team at 2:10 p.m.

During an interview on 12/5/2024 at 11:40 a.m. with Nurse Manager (NM) 2, NM 2 stated the falls care plan for Patient 23 was incomplete. The specific activities to prevent falling should be in the 'Treatment Team Interventions' (Modality/Activity) part of the 'Multidisciplinary Treatment Plan - Potential for Falls.' Concurrently, after reviewing Patient 23's medical record, NM 2 stated there was no documentation of Patient 23 being instructed on fall precautions.

During a review of Patient 23's "Edmonson Psychiatric Fall Risk Assessment (a specific assessment designed to evaluate the risk of falls in inpatient psychiatric [focused on mental, emotional, and behavioral disorders] patients, taking into account unique factors like medication changes, sleep disturbances, mental status, and nutritional issues that can contribute to falls in this population)," this document indicated the risk factors included in a fall prevention plan. Some of the risk for patient fall included the following: Intermittent (irregular intervals) confusion; Psychotropic medications (drugs affecting emotions and behavior and used to treat mental illness, depression (a serious mental health condition characterized by persistent feelings of sadness, loss of interest in activities, and a significant impact on daily functioning, often accompanied by changes in sleep, appetite, energy levels, and concentration), and anxiety [a feeling of fear and uneasiness]); Psychiatric diagnosis; Ability of patient to ambulate. This tool displayed Patient 30's fall risk score was 93 and that any score greater than 90 indicated a fall risk. Finally, this assessment verified Patient 23 needed to be placed on fall precautions.

During a review of the facility's Policy and Procedure (P&P) titled, "Fall Risk Assessment and Prevention" (Policy PC-8, effective 10/97), the P&P indicated its purpose was to: Identify patients at risk for falls; Implement a fall prevention plan for those patients at risk of falls; Manage patients who fall; Educate patients and families on measures to prevent falls and promote safety. This policy specified that after a patient is assessed for risk of falls, the following fall risk precautions should be implemented (not all inclusive): Develop and implement an individualized treatment plan with interventions specific to the patient's needs; Consider placing the patient in a room close to the nursing station; Provide easy access to wheelchair or other assistive devices; Give patient 'Fall Risk' yellow wristband to wear; Encourage patient to wear non slip footwear; Document education provided to the patient and family about fall prevention measures.

During a review of the facility's policy and procedure (P&P) titled, "Interdisciplinary Patient Centered Care Planning," with effective date of 1/2023, the P&P indicated the following:

Developing the Treatment Plan
1. The Nurse completing the Nursing Assessment or designee shall develop the Initial Treatment Plan within eight (8) hours of admission. The nurse will utilize the problems and specific behavioral manifestations identified in the initial assessment and nursing assessment to develop clinically appropriate and individualized goals and interventions which will be included in the Initial Treatment Plan.

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

1. Ensure the nursing staff performed medication reconciliation (a process that ensures patients have the correct list of medications they are taking at home, and that any discrepancies are identified and addressed) and communicate with the physician regarding the medication list, in accordance with the facility's policy and procedure regarding medication reconciliation for five of 30 sampled patients (Patient 8, 17, 18, 19, and 22), when home medications were not evaluated by physician during their hospitalization at the facility.

This deficient practice had the potential to compromise patient's medical condition such as worsening infection, worsened mental or behavioral issues, etc. as their (Patient 8, 17, 18, 19, and 22) routine home medications were not reviewed and resumed by the hospital staff.

2. Complete and document a skin assessment for one of 30 sampled patients (Patient 2), in accordance with the facility's policy on skin checks.

This deficient practice had the potential to result in delayed identification and treatment of skin conditions for Patient 2 including lack of monitoring and follow-up, thus placing Patient 2 at higher risk for skin breakdown (damage to the skin and underlying tissue, usually caused by prolonged pressure on a specific area).

3. Ensure that a medication brought in from home for one of 30 sampled patients (Patient 2) was documented in the Home Medication List section of Patient 2's chart.

This deficient practice had the potential for a patient's medication, brought in from home, to be unverified by pharmacy and may not be administered to a patient in a timely manner following a physician's order.

Findings:

1.a. During a review of Patient 8's "Initial Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health])," dated, 6/21/2024, the psych eval indicated, Patient 8 was admitted to the facility on a 5150-hold (a 72-hour involuntary psychiatric hold authorized for individuals who, due to a mental health disorder, pose a danger to themselves, others, or are gravely disabled) because he was found naked covered in feces and was unable to provide a self-care plan with diagnosis of schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions).

During an interview on 12/6/2024 at 12:17 p.m. with the Registered Nurse (RN) Nursing Educator (NE 1), NE 1 stated the process of home medication reconciliation (a process that ensures patients have the correct list of medications they are taking at home, and that any discrepancies are identified and addressed) was to obtain a list of patient's home medications which could be auto populated by the facility's electronic health record system or recorded by the Registered Nurse (RN). The admitting RN was responsible to confirm the home medications with the patient to see which medications he or she was still taking or no longer taking. Then the RN should communicate with the physician to go over each home medication for continuation or discontinuation.

During a concurrent interview and record review on 12/6/2024 at 12:20 p.m. with the Registered Nurse (RN) Nursing Educator (NE 1), Patient 8's "Admission Home Medication Orders (home med recon, list of patient's home medications), undated, was reviewed. The home med recon indicated five medications on the list: aripiprazole (medication to treat mental condition) 662 milligram (mg, a unit of measure) per 2.4 milliliters (ml, a unit of measure) injection (medication delivered directly into a muscle), clotrimazole (skin cream to treat skin fungal [characterized by rash and itchiness] or yeast infection [with symptoms like itching, redness, and a white discharge depending on the affected area of the body]) one (1) percent (%, a unit of measure) cream, hydrocortisone (medication to treat a variety of skin conditions such as insect bites and dermatitis [a general term for a group of skin conditions that cause inflammation and irritation]) 1% cream, polymyxin B and trimethoprim (eye drop to treat bacterial infection of the eyes) eye drops 1000 units 1mg/ml, and triamcinolone (skin cream to treat various skin condition such as itchiness, redness, and dryness) 0.1% cream. NE 1 stated based on review, Patient 8's admission home medication reciliation was not done as there was no confirmation that it was reviewed by nursing and physician. NE 1 stated Patient 8 did not receive any of his (Patient 8's) home medications during his (Patient 8) hospitalization.

During an interview on 12/6/2024 at 5:06 p.m. with the Chief Nursing Officer (CNO), CNO stated she (CNO) expected nursing staff to document what patients were on as home medications and to get an order from the physician to continue or discontinue the home medications within 24 hours upon admission. CNO stated the home medication reconciliation process was important because "We do not want the patient to miss doses of their usual medications. CNO also stated it was important for patients to continue their home medications to manage their current medical illness for stability.

During a review of the facility's policy and procedure (P&P) titled, "Medication Reconciliation Record," dated 6/2019, the P&P indicated, "To accurately reconcile medications across the continuum of care. To provide a process for obtaining and documenting a complete list of the patient's current medications upon the patient's entry to the hospital with the involvement of the patient. This includes a comparison of the medications the organization provides to those on the list ... the admitting nurse will document ... patient's current medications with dose, route, frequency and date/time of last dose and compliance."

1.b. During a concurrent interview and record review on 12/4/2024 at 3:37 p.m. with the House Supervisor (HS) Patient 17's medical record titled, "Admission Home Medication Orders," was reviewed. Patient 17's medical record indicated (1) unreconciled admission medication of azithromycin (an antibiotic medicine used to treat infections). HS stated that the admitting nurse failed to complete and confirm the home medication list for Patient 17. HS said it was the admitting nurse's responsibility to document and confirm patient's current home medications with its dose, route, and frequency. Physician will then review the list and decide on which home medication patient will continue taking while patient was admitted in the facility.

During an interview on 12/6/2024 at 12:17 p.m. with the Registered Nurse (RN) Nursing Educator (NE 1), NE 1 stated the process of home medication reconciliation (a process that ensures patients have the correct list of medications they are taking at home, and that any discrepancies are identified and addressed) was to obtain list of patient's home medications which could be auto populated by the facility's electronic health record system or recorded by the Registered Nurse (RN). The admitting RN was responsible to confirm the home medications with the patient to see which medications he or she was still taking or no longer taking. Then the RN should communicate with the physician to go over each home medication for continuation or discontinuation.

During an interview on 12/6/2024 at 5:06 p.m. with the Chief Nursing Officer (CNO), CNO stated she (CNO) expected nursing staff to document what patients were on as home medications and to get an order from the physician to continue or discontinue the home medications within 24 hours upon admission. CNO stated the home medication reconciliation process was important because "We do not want the patient to miss doses of their usual medications. CNO also stated it was important for patients to continue their home medications to manage their current medical illness for stability.

During a review of the facility's policy and procedure (P&P) titled, "Medication Reconciliation Record," with effective date of 6/2019, the P&P indicated the following:

-The Admitting Nurse will document patient's admitting weight, height, allergies, patient's current medications with dose, route, frequency and date/ time of last dose and compliance.
-The Attending Physician or Discharging Nurse will list new medications, discontinued medications, compliance, and returned patient-owned medications which is given to the patient and/or family/guardian.
-Patient receives a copy of the completed form; original form goes to the patient chart.

1.c. During a concurrent interview and record review on 12/5/2024 at 12:19 p.m. with the Nurse Manager (NM) 3, Patient 18's medical record titled, "Admission Home Medication Orders," was reviewed. Patient 18's medical record indicated no record found pertaining to a list of home medication orders for Patient 18. NM 3 stated that the admitting nurse failed to confirm the home medication list for Patient 18.

The system indicated "no records found" because it auto generates patient medication from other facilities. It was still the admitting nurse's responsibility to confirm that the list was accurate. Confirming it in the system would indicate that the nurse reviewed the list, showing up in the system, with the patient, and that the medication list was accurate.

During an interview on 12/6/2024 at 12:17 p.m. with the Registered Nurse (RN) Nursing Educator (NE 1), NE 1 stated the process of home medication reconciliation (a process that ensures patients have the correct list of medications they are taking at home, and that any discrepancies are identified and addressed) was to obtain list of patient's home medications which could be auto populated by the facility's electronic health record system or recorded by the Registered Nurse (RN). The admitting RN was responsible to confirm the home medications with the patient to see which medications he or she was still taking or no longer taking. Then the RN should communicate with the physician to go over each home medication for continuation or discontinuation.

During an interview on 12/6/2024 at 5:06 p.m. with the Chief Nursing Officer (CNO), CNO stated she (CNO) expected nursing staff to document what patients were on as home medications and to get an order from the physician to continue or discontinue the home medications within 24 hours upon admission. CNO stated the home medication reconciliation process was important because "We do not want the patient to miss doses of their usual medications. CNO also stated it was important for patients to continue their home medications to manage their current medical illness for stability.

During a review of the facility's policy and procedure (P&P) titled, "Medication Reconciliation Record," with effective date of 6/2019, the P&P indicated the following:

-The Admitting Nurse will document patient's admitting weight, height, allergies, patient's current medications with dose, route, frequency and date/ time of last dose and compliance.
-The Attending Physician or Discharging Nurse will list new medications, discontinued medications, compliance, and returned patient-owned medications which is given to the patient and/or family/guardian.
-Patient receives a copy of the completed form; original form goes to the patient chart.

1.d. During a concurrent interview and record review on 12/5/2024 at 3:30 p.m. with Nurse manager (NM) 3, Patient 19's medical record titled, "Admission Home Medication Orders," was reviewed. Patient 19's medical record indicated one (1) unreconciled admission medication of Ozempic (a weekly injection medication that helps lower blood sugar). NM 3 stated that the admitting nurse failed to complete and confirm the home medication list for Patient 19. NM 3 said it was the admitting nurse's responsibility to document and confirm a patient's current home medications with its dose, route, and frequency. Physician will then review the list and decide on which home medication patient will continue taking while patient was admitted in the facility.

During an interview on 12/6/2024 at 12:17 p.m. with the Registered Nurse (RN) Nursing Educator (NE 1), NE 1 stated the process of home medication reconciliation (a process that ensures patients have the correct list of medications they are taking at home, and that any discrepancies are identified and addressed) was to obtain list of patient's home medications which could be auto populated by the facility's electronic health record system or recorded by the Registered Nurse (RN). The admitting RN was responsible to confirm the home medications with the patient to see which medications he or she was still taking or no longer taking. Then the RN should communicate with the physician to go over each home medication for continuation or discontinuation.

During an interview on 12/6/2024 at 5:06 p.m. with the Chief Nursing Officer (CNO), CNO stated she (CNO) expected nursing staff to document what patients were on as home medications and to get an order from the physician to continue or discontinue the home medications within 24 hours upon admission. CNO stated the home medication reconciliation process was important because "We do not want the patient to miss doses of their usual medications. CNO also stated it was important for patients to continue their home medications to manage their current medical illness for stability.

During a review of the facility's policy and procedure (P&P) titled, "Medication Reconciliation Record," with effective date of 6/2019, the P&P indicated the following:

-The Admitting Nurse will document patient's admitting weight, height, allergies, patient's current medications with dose, route, frequency and date/ time of last dose and compliance.
-The Attending Physician or Discharging Nurse will list new medications, discontinued medications, compliance, and returned patient-owned medications which is given to the patient and/or family/guardian.
-Patient receives a copy of the completed form; original form goes to the patient chart

1.e. During a concurrent interview and record review on 12/5/2024 at 3:30 p.m. with Nurse Manager (NM) 3, Patient 22's medical record titled, "Admission Home Medication Orders," was reviewed. Patient 22's medical record indicated five (5) unreconciled admission medications as follows:

-Lamotrigine (a medication that treats epilepsy (a chronic brain disorder characterized by recurrent seizure [abnormal electrical activity in the brain that can cause a range of symptoms] and bipolar disorder [a mental illness that causes extreme shifts in mood, energy, activity, and concentration])

-Acetaminophen (a medication used to treat many conditions such as headache, muscle aches, arthritis [a group of conditions that cause inflammation of the joints], backache, toothaches, colds and fevers)

-Azithromycin (an antibiotic medicine used to treat infections)

-Ibuprofen (a medication that can reduce a fever and also treats mild to moderate pain, inflammation and arthritis)

-Penicillin (an antibiotic used to treat bacterial infections).

During the same interview on 12/5/2024 at 3:30 p.m., NM 3 stated that the admitting nurse failed to complete and confirm the home medication list for Patient 22. NM 3 said it was the admitting nurse's responsibility to document and confirm a patient's current home medications with its dose, route, and frequency. Physician will then review the list and decide on which home medication the patient will continue taking while patient was admitted in the facility.

During an interview on 12/6/2024 at 12:17 p.m. with the Registered Nurse (RN) Nursing Educator (NE 1), NE 1 stated the process of home medication reconciliation (a process that ensures patients have the correct list of medications they are taking at home, and that any discrepancies are identified and addressed) was to obtain list of patient's home medications which could be auto populated by the facility's electronic health record system or recorded by the Registered Nurse (RN). The admitting RN was responsible to confirm the home medications with the patient to see which medications he or she was still taking or no longer taking. Then the RN should communicate with the physician to go over each home medication for continuation or discontinuation.

During an interview on 12/6/2024 at 5:06 p.m. with the Chief Nursing Officer (CNO), CNO stated she (CNO) expected nursing staff to document what patients were on as home medications and to get an order from the physician to continue or discontinue the home medications within 24 hours upon admission. CNO stated the home medication reconciliation process was important because "We do not want the patient to miss doses of their usual medications. CNO also stated it was important for patients to continue their home medications to manage their current medical illness for stability.

During a review of the facility's policy and procedure (P&P) titled, "Medication Reconciliation Record," with effective date of 6/2019, the P&P indicated the following:

-The Admitting Nurse will document patient's admitting weight, height, allergies, patient's current medications with dose, route, frequency and date/ time of last dose and compliance.
-The Attending Physician or Discharging Nurse will list new medications, discontinued medications, compliance, and returned patient-owned medications which is given to the patient and/or family/guardian.
-Patient receives a copy of the completed form; original form goes to the patient chart.

2. During a review of Patient 2's "Initial Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health])," dated 9/20/2024, the psych eval indicated that Patient 2 was admitted on 9/20/2024 for a chief complaint of feeling suicidal (experiencing thoughts or ideations of self-harm or ending one's life).
The psych eval also indicated that Patient 2 had a past medical history of depression (a mental health condition characterized by persistent sadness, loss of interest, and emotional distress that interferes with daily functioning) and anxiety (a mental health condition marked by excessive worry, fear, or nervousness that can be persistent and difficult to control).

During a concurrent interview and record review on 12/5/2024 at 12:30 p.m. with Nurse Educator 1 (NE 1), Patient 2's medical chart titled, "Progress Record," included a photograph depicting multiple scratches/cuts on Patient 1's bilateral (both sides of the body) forearms, labeled with Patient 1's name, and attached to a progress note. NE 1 stated that a date written next to the photograph indicated 9/20/2024 at 12:45 a.m., on arrival; however, no signature or printed nurse's name was recorded. NE 1 also stated that the facility's policy does not require nurses to obtain photographs of patients' skin wounds. NS 1 then said that the staff likely took the photograph upon admission.

During a concurrent interview and record review on 12/5/2024 at 12:38 p.m. with Nurse Educator 1 (NE 1), NE 1 reviewed Patient 2's History and Physical (H&P, a document summarizing the patient's medical history and findings from a physical examination), dated 9/20/2024, and stated that the H&P did not include any documented skin issues in Patient 2's physical assessment.

During a review of Patient 2's medical record (MR) titled, "Nursing Admission Assessment," dated 9/20/2024 at 12:05 a.m., the MR indicated that Patient 2 had a left elbow scar, left shin scar, and left ankle scar. The MR also indicated that two staff members signed the completed skin assessment for Patient 1 on 9/20/2024.

During an interview on 12/5/2024 at 12:41 p.m. with Nurse Educator 1 (NE 1), NE 1 reviewed Patient 1's "Nursing Admission Assessment," dated 9/20/2024, and stated that areas identified on Patient 2's skin assessment record were scars, not cuts or scratches. This information was verified by two staff members who signed the assessment form. However, NE 1 was unable to identify the staff members because they did not write their full names as required on the assessment form and only provided signatures.

During further review of Patient 1's medical record (MR) titled, "Nursing Admission Assessment-Narrative Summary," dated 9/20/2024, the MR indicated that Patient 2 reported cutting themself (Patient 2) with scissors. The MR also did not include a printed nurse's name under the section designated for "Printed Name and Title," only a handwritten signature was present.

During a concurrent interview and record review on 12/5/2024 at 12:42 p.m. with Nurse Educator 1 (NE 1), Patient 2's medical record (MR) titled, "Daily Nursing Shift Assessments," dated 9/20/2024 at 6:45 a.m. and 11:00 p.m., was reviewed. The MR indicated that Patient 2 had no marked skin issues, such as scratches or scars, and the assessments were marked as within normal limits (WNL). NE 1 stated that if nurses had identified skin issues, such as cuts or scratches, they should have documented the findings in the daily shift assessments but did not.

During a review of the facility's policy and procedure (P&P) titled, "Nursing Assessment and Reassessment," last reviewed 3/2022, the P&P indicated that the Nursing Admission Assessment must be completed within 8 hours of admission by a registered nurse (RN). The Body/Skin Check must be completed by two staff members, with at least one being a licensed staff member, such as an RN or licensed vocational nurse (LVN).

3. During a review of Patient 2's "Initial Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician who specializes in mental health])," dated 9/20/2024, the psych eval indicated that Patient 2 was admitted on 9/20/2024 for a chief complaint of feeling suicidal (experiencing thoughts or ideations of self-harm or ending one's life). The psych eval also indicated that Patient 2 had a past medical history of depression (a mental health condition characterized by persistent sadness, loss of interest, and emotional distress that interferes with daily functioning) and anxiety (a mental health condition marked by excessive worry, fear, or nervousness that can be persistent and difficult to control).

During a review of Patient 2's medical record (MR) titled, "Home Medication List," dated 9/20/2024, the medical record indicated that the Home Medication List section of the MR contained no documentation of the medications Patient 2 had brought to the hospital upon admission.

During a concurrent interview and record review on 12/5/2024 at 12:23 p.m. with Nurse Educator 1 (NE 1), Patient 1's "Medication Administration Record (MAR)," dated 9/20/2024 through 9/24/2024, was reviewed. NE 1 stated that the MAR contained documentation of the administration of 25 milligrams (mg) of Pristiq (a prescription antidepressant used to treat major depressive disorder) as brought from home. NE 1 further explained that medications brought from home should be documented in the Home Medication List section of the patient's chart. The medication is then sent to the pharmacy, where it is verified, a scanning label is created, and the medication is dispensed if a physician's order for administration is present. NE 1 also said that the facility does not have a specific policy regarding the process of patient's own home medications being sent to pharmacy for verification, creating a scanning label, and administering the medication to the patient once ordered by the physician.

During further review of Patient 2's medical record (MR) titled, "Belongings List," dated 9/24/2024, the MR indicated that a bottle of Pristiq medication was returned to Patient 2 on 9/24/2024 upon discharge.

During a review of the facility's policy and procedure (P&P) titled, "Patient's Own Medications," last reviewed 1/2013, the P&P indicated that all medications brought to the hospital from home by a patient should be given to the person accompanying them at the time of admission. If this is not possible, the medication must be placed in the Patient's Valuables Envelope. The name, strength, and quantity of the medication must be recorded in the Record of Patient's Own Medications section of the patient's belongings. The envelope is then sealed and stored in a locked box in the nursing unit's medication room. Before the patient is discharged, the medication is retrieved by nursing staff and returned to the patient.

Based on observation, interview and record review, the facility failed to ensure there was mechanism to ensure kitchen staff are competent in their duties for two of two sampled dietary staff (Dietary Aide [DA] 1 and Certified Dietary Manager [CDM]) when:

1. DA 1 failed to follow menu instruction to provide fourteen French fries on patients' lunch tray
2. CDM failed to identify the correct serving size of a gray handle scoop in the kitchen

This deficient practice had the potential to result in serving patients with incorrect food serving and portion in meals and not meeting patients' nutritional needs due to overeating or undereating.

Findings:

1. During a concurrent observation and interview on 12/4/2024 at 11:38 a.m. with the Dietary Aide (DA 1) at the facility's kitchen, the Dietary Adie (DA) 1 was at the tray line using tongs to grip French fries two times into a food tray. There was no menu visible at the tray line. DA 1 stated she (DA 1) was busy preparing forty (40) lunch trays for patients and did not count how many French fries for each lunch tray. DA 1 stated, "I just estimated."

During a concurrent interview and record review on 12/4/2024 at 11:40 a.m. with the Dietary Manager (CDM), the dietary master menu (a comprehensive list of meals, carefully planned by a registered dietitian, that outlines a variety of food options designed to meet specific nutritional needs, often catering to different dietary restrictions or medical conditions, and serves as a foundational guide for meal planning in a healthcare setting or institution), dated 10/2024, was reviewed. The Dietary Master Menu Cycle 1 Regular/NAS (No Added Salt, dietary approach that involves avoiding adding salt while cooking or preparing food) indicated, today's menu to serve eight (8) ounces (oz, a unit of measure) milk, three (3) oz beef, hamburger with one (1) bun, one (1) slice cheese, one (1) slice each lettuce and tomato, fourteen (14) French fries, half cup coleslaw, one (1) chocolate chip cookie.
CDM stated each patient's tray should have fourteen (14) French fries per master menu and staff should follow the menu when preparing food. CDM also stated the master menu should be at the tray line for the staff to see when preparing food to make sure they prepare the exact portion as stated on the master menu.

During an interview on 12/5/2024 at 10:31 a.m. with the Registered Dietician (RD 1), RD 1 stated dietary staff must follow the master menu when preparing food for patients because everything was calculated on the master menu to provide the exact calories and protein in order to meet patient nutritional needs. RD 1 stated there would be risk for patients overeating or undereating when food was not prepared per master menu.

During an interview on 12/6/2024 at 2:24 p.m. with the Director of Human Resources (HRD), HRD stated it was important to have unit specific competency (directly impacts patient safety by ensuring healthcare professionals possess the necessary knowledge, skills, and abilities to deliver high-quality care) done on staff to make sure he/she was qualified and competent to do the job.

During an interview on 12/6/2024 at 4:04 p.m. with CDM, CDM stated there was no unit specific competency done for dietary staff, CDM stated staff performance was monitored through qualification, experience and supervision.

During a review of the facility's policy and procedure (P&P) titled, "Master Menu," dated 3/2022, the P&P indicated, "The patient master menu ... is planned to provide adequate nutrition in accordance with approved [facility's] diet manual."

During a review of the facility's policy and procedure (P&P) titled, "Tray Identification," dated 3/2022, the P&P indicated, "during tray-line dietary workers use menu as guide in serving each patient."

2. During a concurrent interview and record review on 12/4/2024 at 11:40 a.m. with the Dietary Manager (CDM), the dietary master menu dated 10/2024, was reviewed. The Dietary Master Menu Cycle 1 Regular/NAS indicated, today's menu to serve eight (8) ounces (oz, a unit of measure) milk, three (3) oz beef, hamburger with one (1) bun, one (1) slice cheese, one (1) slice each lettuce and tomato, fourteen (14) French fries, half cup coleslaw, one (1) chocolate chip cookie.

CDM stated each patient's tray should have fourteen (14) French fries per master menu and staff should follow the menu when preparing food. CDM also stated the master menu should be at the tray line for the staff to see when preparing food to make sure they prepare the exact portion as stated on the master menu.

During a concurrent observation and interview on 12/4/2024 at 11:45 a.m. with the Dietary Manager (CDM) at the facility's kitchen, a dietary aide (DA 1) was using a gray color handle scoop to scoop coleslaw. CDM stated DA 1 was using a number twelve (12) scoop which did not provide half cup serving size.

During an interview on 12/4/2024 at 11:46 a.m. with DA 1, DA 1 stated different color handle scoops provided different serving size. DA 1 stated she (DA 1) believed the gray handle scoop was the number eight (8) scoop but there was number or serving size indicated on the gray handle scoop. DA 1 also stated there was no scoop guide in the kitchen for staff to reference different scoops and their serving sizes.

During an interview on 12/4/2024 at 2:05 p.m. with the CDM, CDM stated the following: she (CDM) looked up the information from the internet and noted she (CDM) provided the wrong information. DA 1 actually used number eight (8) scoop which would provide half cup serving. CDM stated there should be a guide in the kitchen for staff to reference the scoops and serving sizes.

During a concurrent interview and record review on 12/6/2024 at 2:24 p.m. with the Director of Human Resources (HRD), CDM's personnel file was reviewed. CDM's personnel file indicated there was no competency completed in relation to food handling or kitchen related tasks. HRD stated it was important to have unit specific competency done on staff to make sure he/she was qualified and competent to do the job.

During an interview on 12/6/2024 at 3:36 p.m. with the Director of Plant Operation (DPO), DPO stated he (DPO) oversee dietary department. DPO stated all dietary staff including the CDM should be familiar with the sizes of the scoops to make sure portion of food was properly maintained to provide adequate nutrition.

During a review of the CDM's job description titled, "Dietary Manager," dated 8/22/2024, the job description indicated "specialized skills and knowledge ... 5. Industrial equipment and utensils, and skill in utilizing such... essential job duties/responsibilities ... provide in-service education and orientation to the food service staff, and when appropriate, to other facility staff."

During a review of the facility's policy and procedures (P&P) titled, "Hiring Procedure," dated 4/2020, the P&P indicated, "The Human Resources Department is responsible for an individual orientation of new employees for the processing of all employment forms. The Manager is responsible for any necessary job training and competencies."

Based on interview and record review, the facility failed to ensure its staff provided accurate nutritional screening (a process used to quickly identify individuals who might be at risk of malnutrition [a condition that occurs when the body doesn't have the right amount of nutrients to function properly] by asking a series of brief questions about their dietary habits, weight changes, and medical history) for one of 30 sampled patients (Patient 9), in accordance with the facility's policy and procedure regarding nutritional screening and assessment, when nursing staff failed to identify Patient 9's nutritional risk and need for nutritional assessment by a registered dietician (RD, a healthcare professional who is specifically trained in nutrition and food science). Hence, Patient 9 did not receive the proper menu as a diabetic (high blood sugar level) patient.

This deficient practice had the potential for Patient 9 not to receive the appropriate therapeutic diet (a meal plan that limits certain foods or nutrients to treat a medical condition) due to lack of dietician evaluation. This deficient practice also had the potential to result in complications such as delayed recovery, increased blood sugar level, etc.


Findings:

During a review of Patient 9's "Initial Psychiatric Evaluation (psych eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health])," dated 9/12/2024, Patient 9 was admitted to the facility on a 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) due to danger to self with plan to ingest helium (exposure to high level of helium [a gas that is lighter than air] can cause dizziness, headache, loss of consciousness and death).

The psych eval indicated Patient 9's admitting diagnoses including but not limited to major depression disorder (MDD - a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), generalized anxiety order (a mental health condition that causes people to experience excessive, uncontrollable worry about everyday activities), and diabetes (a chronic disease when the body cannot regulate blood sugar resulting blood sugar too high).

During an interview on 12/5/2024 at 10:18 a.m. with the Registered Dietician (RD) 1, RD 1 stated the following: she (RD 1) would perform nutrition consultation based on nursing referral and per patient's request. During nutrition consultation, she (RD 1) would obtain patient's medical history and spoke with patient to determine which type of diet would be best for the patient. It would be better for diabetic patients to be on consistent carbohydrate (CCHO, a dietary approach that involves eating the same amount of carbohydrates each day to help manage blood sugar levels) diet for better control in blood sugar.

During an interview on 12/5/2024 at 10:27 a.m. with RD 1, RD 1 stated there was no dietician referral and consult notes done on Patient 9.

During a concurrent interview and record review on 12/5/2024 at 4 p.m. with the Nurse Manager (NM) 2, Patient 9's "Nursing Admission Assessment," dated 9/12/2024, was reviewed. The nursing admission assessment indicated Patient 9's height of five (5) feet (ft, a unit of measure), weight of 200 pounds (lb, a unit of measure) and body mass index (BMI, a calculation that estimates body fat based on a person's weight and height) of 39. The nursing admission assessment also indicated "no issues identified" was checked off under nutritional screen. The nutritional screen indicated a list of problems including but not limited to "BMI greater than 36" or "BMI less than 19."

NM 2 stated the following: the admitting nurse did not complete Patient 9's nutritional screen correctly. Patient 9's BMI was 39 which would fit the problem listed in nutritional screen of "BMI greater than 36." If a patient reported or nurse observed any of the problems listed in nutritional screen, the nurse should refer the patient for dietician consult. Patient 9 was diabetic, it was important to have a dietician to see her (Patient 9) for blood sugar control and to recommend appropriate diet. Patient 9 could be at risk for elevated blood sugar when diet was not being managed.

During an interview on 12/6/2024 at 10:41 a.m. with physician (MD 4), MD 4 stated diabetic patient should be on therapeutic diet with CCHO diet to control blood sugar. MD 4 stated it was important to control blood sugar level for diabetic patients during the hospital stay because symptoms of hypoglycemia (when blood sugar level was too low) and hyperglycemia (when blood sugar level was too high) might falsely present mental illness symptoms or be mistaken as psychiatric condition.

During a review of Patient 9's physician order, dated 9/12/2024, the physician order indicated Patient 9 was placed on regular diet.

During a review of the facility's policy and procedure (P&P) titled, "Nutritional Screening/Assessment Request," dated 3/2022, the P&P indicated, "Nutritional screening will be completed on all patients admitted to [the facility]. Nutritional assessment will be requested by nursing for all patients identified as having nutritional risk ... Nursing staff will complete the 'Nutrition Screening' portion of nursing assessment for each patient, including all of the following: a. actual height and weight of the patient, b. under 'Nutritional Screening,' check boxes which apply to the patient, c. if any boxes are checked 'yes' a nutritional assessment is required ... If a nutritional assessment is required, nursing is to leave a voicemail for the dietician ... the Registered Dietician will complete a 'nutritional assessment record' within 72 hours of assessment notification ... an assessment and plan will be formulated ... dietary staff will be notified of any diet changes."

During a review of the facility's policy and procedure (P&P) titled, "Nutritional Charting/Care Planning," dated 3/2022, the P&P indicated, "Nursing will complete the nutrition screening portion of the nursing assessment and notify the dietician with request of nutritional assessment ... the dietician will complete the 'nutritional assessment record' by gathering additional subjective and objective information to formulate a nutritional assessment and plan ... Plan includes any recommendations for diet changes, supplement orders or diet education."

Based on interview and record review, the facility failed to provide adequate mental health workers based on census (number of patients in the unit) and ensure nursing staff consistently performed and documented patient acuity report (defined as evaluations of the severity of a patient's condition and care needs to determine the appropriate level of nursing care required), in accordance with the facility's policy and procedure regarding acuity system to determine the appropriate staffing levels and align staff assignments with patient care needs for four of four sampled behavioral health units (BHU [inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders] 1, 2, 3 and 5).

This deficient practice had the potential to result in the inability to meet patients' needs in a timely manner, thus compromising patients' safety and the delivery of quality patient care.

Findings:

During a review of Patient 10's "Initial Psychiatric Evaluation (Psych Eval, a formal and complete assessment of the patient and the problem done by Psychiatrist [physician specializes in mental health])," dated 11/27/2024, the psych eval indicated, Patient 10 was admitted to the facility on a 5585-hold (allows a minor to be involuntarily detained for up to 72 hours in a psychiatric hospital [a specialized medical facility that focuses on treating individuals with severe mental disorders] for a mental health crisis) with diagnosis of disruptive mood dysregulation disorder (a mental health condition that causes children and adolescents to experience severe irritability and frequent temper outburst) for evaluation of her (Patient 10) mood state and self-harm behavior claiming, "I am going to take a bunch of gummy melatonin (medication helps someone to fall asleep)."

During an interview on 12/3/2024 at 11:38 a.m. with Patient 10 at Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) 5, Patient 10 stated the following: she (Patient 10) was at the facility for about one week. There were a lot of fights going on with other patients and it happened in front of her (Patient 10). She (Patient 10) would just stay away and remain quiet. Patient 10 stated, "It took some time for staff to come and intervene."

During a concurrent interview and record review on 12/3/2024 at 11:51 a.m. with Charge Nurse (CN) 1 at BHU 5, BHU 5 Patient Care Assignment (nursing assignment indicating who are the staff assigned to the patients and their tasks) 7 a.m. to 3:30 p.m. morning shift, dated 12/3/2024, was reviewed. The Patient Care Assignment indicated BHU 5 had census of 22 patients and was staffed four licensed nursing staff (CN 1, Registered Nurse [RN] 2, RN 3 and Licensed Vocational Nurse [LVN] 2) and one Mental Health Technician (MHT, psychiatric assistant provides direct patient care support with mental health issue under charge nurse direction) 3. CN 1 stated he (CN 1) had patients currently and RN 3 just came in at 11 a.m. They had to utilize LVN 2 to help with 15-minute rounding (rounding done every 15 minutes in behavioral health unit to ensure patient safety) because there was only one (1) MHT (MHT 3) on the floor.

During an interview on 12/4/2024 at 11:59 a.m. with Charge Nurse (CN) 2 at Behavioral Health Unit (BHU, inpatient unit that provide treatment and therapy for people who have mental, emotional and behavioral disorders) 2, CN 2 stated it was the charge nurse's responsibility to make the assignment for the unit and complete the acuity (a medical term that refers to the severity of a patient's condition and how urgent their care needs are, the higher the acuity the more care is needed) sheet. CN 2 stated acuity reflected how heavy the patient load was. CN 2 stated she (CN 2) did not do the acuity today because she (CN 2) was behind with her (CN2) work. CN2 stated she (CN 2) split the assignment among her (CN 2) and two other licensed nursing staff based on the number of patients in the unit (BHU 2).

During an interview on 12/4/2024 at 12:40 p.m. with Charge Nurse (CN) 3 at Behavioral Health Unit (BHU) 3, CN 3 stated patient acuity should be done to make sure there was enough staffing. CN 3 stated she did not do the patient acuity today because she (CN 3) was busy.

During an interview on 12/5/2024 at 2:42 p.m. with Nurse Manager (NM) 2 of BHU 2 and BHU 3, NM 2 stated the following: the facility was currently in the process of changing the acuity tool. Acuity was not being done currently. Acuity would tell how acute the patients were, and it played a role in making nursing assignment. It would be inappropriate to assign all high acuity patients to one nurse because it would not be manageable. The nursing staff would not be able to provide quality care to patients when he or she had all heavy (high acuity) patients.

During an interview on 12/5/2024 at 2:53 p.m. with Nurse Manager (NM) 1 of BHU 5, NM 1 stated the following: patient acuity was done to let the facility how much staff was needed to provide adequate staff to provide quality care to patients and maintain safety. Acuity should be done by the day shift charge nurse every day. However, the facility changed the acuity tool in August 2024 per corporate directive, but it was still in the process of implementation. Patient acuity had not been done since August 2024 (five months).

During a review of Patient 13's "Initial Psychiatric Evaluation (psych eval)," dated 12/2/2024, the psych eval indicated, Patient 13 was admitted to the facility on an involuntary hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) due to danger to self by attempting carbon monoxide (colorless, odorless and tasteless gas that can be harmful to humans and deadly if inhaled in large amounts) poisoning in the car and with diagnosis of major depression (a serious mood disorder that can affect how you feel, think, and behave).

During an interview on 12/6/2024 at 9:55 a.m. with Patient 13 in Behavioral Health Unit (BHU) 1, Patient 13 stated she (Patient 13) saw patients fighting in BHU 1 and staff would try to intervene.
During a concurrent interview and record review on 12/6/2024 at 10 a.m. with the Nurse Manager (NM) 3 of BHU 1, BHU 1's unit staffing assignment dated 12/6/2024, was reviewed. The staffing assignment did not indicate any patient acuity. NM 3 stated patient acuity was not done in BHU 1.

During an interview on 12/6/2024 at 10:20 a.m. with Mental Health Technician (MHT) 2 at BHU 1, MHT 2 stated the following: MHT would be assigned as one to one observation on patient when needed. MHTs were responsible to perform rounding every fifteen (15) minutes on all patients in the unit to check on patients' location and behavior. MHT would help to intervene when patients got into fights by talking to and separating patients. MHT would also take patients out to patio for activity and provide patients items such as snacks, juice and shampoo upon request. There should be three (3) MHTs on the floor in BHU 1 but a lot of time there was not enough staff. It was hard to attend to patient's need in a timely manner because he (MHT 2) needed to perform rounding every 15 minutes for all patients.

During a concurrent record review on 12/6/2024 at 11:01 a.m. with the Nurse Manager (NM) 3 at BHU 1, BHU 1's unit staffing assignment from 12/1/2024 to 12/6/2024 was reviewed. The staffing assignment indicated the following:

-On 12/1/2024, 7 a.m. to 3:30 p.m. day shift with census of 44, BHU 1 was staffed with three (3) licensed nursing staff (three RNs) and three (3) MHTs. One patient (Patient 15) requiring one on one observation.

-On 12/1/2024, 3:30 p.m. to 11 p.m. evening shift with census of 44, BHU 1 was staffed with four (4) licensed nursing staff and three (3) MHT. One patient (Patient 15) requiring one on one observation.

-On 12/2/2024, 11 p.m. to 7 a.m. night shift with census of 42, BHU 1 was staffed with three (3) licensed nursing staff and three (3) MHT. One patient (Patient 15) requiring one on one observation.

NM 3 stated the following: there were not enough MHTs scheduled on the floor on 12/1/2024 day shift, 12/1/2024 evening shift and 12/2/2024 night shift. There are only 2 MHTs on the floor rounding because one of them was assigned to do one on one observation for Patient 15. MHTs are needed to perform rounding every 15 minutes on patients to maintain safety for patients. MHTs also needed to assist with patient's needs such as getting water and respond to any emergency in the unit.

During a review of Patient 15's "Initial Psychiatric Evaluation (psych eval)," dated 11/26/2024, Patient 15 was admitted to the facility on a 5150-hold (allows an adult experiencing a mental health crisis to be involuntary detained for a 72-hour psychiatric [a branch of medicine focused on the diagnosis, treatment, and prevention of mental, emotion, and behavioral disorders] evaluation and treatment) due to danger to self by walking in front of on-coming traffic and hitting his (Patient 15) head and with diagnosis of bipolar disorder (a mental illness that causes unusual shifts in mood, energy, and concentration).

During a review of Patient 15's physician order dated 12/1/2024, the physician order indicated, "one on one observation for head banging/self-injurious behavior."

During an interview on 12/6/2024 at 11:49 a.m. with the Chief Executive Officer (CEO), CEO stated patient acuity should be incorporated when it came to staffing because of the level of safety needs for patients varies from one to another. CEO stated there should be additional MHTs on the floor when there was any patient needing one on one observation. CEO stated it was nursing administration's responsibility to provide oversight on staffing.

During an interview on 12/6/2024 at 5:10 p.m. with the Chief Nursing Officer (CNO), CNO stated the following: she (CNO) was responsible to oversee staffing. Appropriate staffing was important to provide care for patients. The facility did not have a grid for staffing, but the facility staffed one licensed nurse and one MHT for every ten (10) patients. When the census was at forty (40), there should be four (4) MHTs especially for day shift and evening shift because there are more activities going on. Additional MHT should be provided when there's a patient requiring one on one observation. When the unit acuity was high, it would require more nursing attention and more staff. The goal was to spread out high acuity patients in order to balance staff workload. It would also benefit the floor and patient safety. CNO stated, "we do not have a tool to evaluate patients' acuity currently."

During a review of the facility's policy and procedure (P&P) titled, "Appropriate Staffing Levels," dated 9/2023, the P&P indicated, "It is the policy of [the facility] to utilize a defined procedure to determine staffing requirements based on patient needs ... In order to maintain quality nursing care, staffing will be planned according to the assessment of patient's needs by the Registered Nurse Charge Nurse and in consultation with, as needed, the Chief Nursing Office and/or the House Supervisor ... The Criteria for assignment of nursing personnel is based on acuity (A patient classification system) that is approved by the Medical Executive Committee and the Board of Trustees of the hospital ... Multiple factors influence the functioning of a patient care unit and the CNO and/or designee(s) are responsible to modify staffing as needs arise on a day-by-day and shift-by-shift basis to provide safety. Factors which affect the need to alter staffing levels up or down include but are not limited to: a. Overall acuity on unit based on formal scoring ... patients place on one on one monitoring ... high risk conditions such as aggressive and/or violent patient towards self and other."

During a review of the facility's policy and procedure (P&P) titled, "Acuity System/Report," dated 3/2022, the P&P indicated, "To ensure that an acuity system is used that addresses patient care needs and satisfies these needs by providing the required nursing hours according to skill mix ... the department of nursing at [the facility] utilizes the patient acuity report to determine individual patient acuity and staffing requirements for each patient care unit ... acuity cane change from day to change and that staffing must fluctuate to assure quality care of each patient ... the charge nurse Registered Nurse (RN) completes the Acuity Report everyday at 10:30 a.m. and submit the report to the Chief Nursing Officer (CNO) or Nursing Supervisor ... Biological needs, psychological needs and social needs are rated utilizing the Acuity Rating Criteria Grid. Each patient is rated a score of 1 for low, 2 for moderate and 3 for high acuity."

During a review of the facility's policy and procedure (P&P) titled, "Minimum/Core Nursing Staffing Plan Per Unit," dated 5/2024, the P&P indicated, "It is the policy of [the facility] to ensure that the appropriate numbers and qualifications of nursing staff are available at all times for the care of patients. The Chief Nursing Officer (CNO) is responsible for the development and ongoing review of staffing requirements based on numbers of patients, population served, acuity."

During a review of the facility's policy and procedure (P&P) titled, "Hospital Plan for Nursing Services," dated 3/2022, the P&P indicated, "The nursing staff at [the facility] provides quality psychiatric nursing services to all patients on a 24-hours, 7 days a week basis, in a continuous, consistent, safe and caring manner ... Assignment of nursing staff ... Each unit shall have a designated number of Licensed Psychiatric Technicians, Licensed Vocational Nurses, and/or Psychiatric Assistants working under the charge nurse based on unit census, patient acuity, and other patient care need requirement ... the Governing Board is kept informed of nursing activities via the Chief Nursing Officer (CNO), who attends Governing Board meetings quarterly."