HospitalInspections.org

Based on document review, observation and interview, the facility failed to provide care in a safe setting in 4 (patients #1, 6, 11 and 13) of 23 inpatients on 8/8/2018.

Findings include:

1. Facility Policy CC.13, titled Suicide Precautions, last reviewed 8/2017, indicated: Suicide precautions will be ordered by the physician for potentially self destructive patients to establish specific guidelines for staff observation of these patients. All patients placed on suicide precautions will be assigned an acuity level based on the severity of the suicidal thoughts; the levels are:
A. Every 15 minutes observation
B. Line of sight (LOS) observation
C. 1:1 observation at all times (most restrictive and involves continuous monitoring).

2. Facility Policy CC.46, titled Assaultive/Combative Patients-Management of, last revised 8/2017, indicated: The purpose of this policy is to provide a safe environment for patients and staff.
A. Policy: In the event the patient escalates and becomes assaultive/combative, all safety measures shall be provided to the patient, other patients and staff, with the least restrictive interventions based on the level of acuity and the patient needs.
B. Procedure: The established leader will direct the intervention team as to the type of intervention to be utilized per organization's policy and procedure for treatment interventions.

3. Facility lacks policy on Sexually Acting Out (SAO). Staff have no guidelines for care, in the event a patient exhibits SAO behaviors on the unit.

4. Facility 'Patient Acuity Scoring Tool' (not a policy), (no date), indicated: The acuity level is based on a patient scoring 3 or more indicators in an identified acuity.
A. Mild Acuity: verbal aggression or threats, but no physical aggression. Low fall risk with a moderately steady gait, rarely acts out during care, and does not cause injury or harm to others.
B. Moderate Acuity: threatening behaviors, high fall risk, elopement risk, moderate suicide risk, requires assistance to walk, needs assistance with feeding and Activities of Daily Living (ADL), non ambulatory for 12 hours or more, patient is LOS.
C. Severe Acuity: Physically aggressive, elopement risk, high fall risk, incontinent, complete feed, total ADL care, non ambulatory, high suicide risk, patient is 1:1 or LOS.

5. Review of Inpatient Admission orders for patient #1, written 7/27/2018, indicated patient to be on high fall precautions and sexually acting out (SAO) precautions. Unable to determine what interventions were to be implemented based on order.

6. Review of Inpatient Admission orders for patient #6, written 7/24/2018, indicated patient to be on high fall precautions and aggression precautions (no level indicated). Unable to determine what interventions were to be implemented based on order.

7. Review of Inpatient Admission orders for patient #11, on 8/7/2018, indicated patient was placed on 1:1 for aggression precautions.

8. Review of Inpatient Admission orders for patient #13, on 8/01/2018, indicated patient was placed on 1:1 for suicide precautions.

9. Observation:
A. On 8/8/2018, between 0830 to 0900 hours and 1200 to 1207 hours, accompanied by staff member #4, Corporate Office Manager, the mental health unit was toured. A list of who was on 1:1 precautions was requested. Was told patients #1, 6, 11 and 13 were on 1:1 precautions. The census was 23 patients (full).
(1.) Patient #1, SAO precautions, was still in room, alone, without 1:1 attendant.
(2.) Patient #6, aggression precautions, was in a chair, in milieu, without 1:1 attendant.
(3.) Patient #11, aggression precautions, was observed in milieu without 1:1 attendant, between 1200 through 1207 hours. Staff members were observed to be delivering meal trays to patients in the area.
(4.) Patient #13, suicide precautions, was alone in patient room, with no staff present.

10. Interviews:
A. Staff member #6, staff RN, also indicated in interview on 8/8/2018 hours at 0900 hours, that patients on 1:1 precautions should have a staff member with them at all times.

Based on document review, the facility failed to provide adequate nursing staff to provide patient safety on night of 8/1/18 through day of 8/2/18.

Findings include:
1. Facility Policy titled Patient Acuity and Staffing, NU 96, issued 7/2018, indicated: The minimum staffing levels may be adjusted up or down based on workload assessment. Staffing policies lack numerical guidelines regarding how many staff should be present for safe patient care.

2. On 7/31/2018, date of patient #1 allegation of Sexually Acting Out (SAO), 8/01-02/2018, on nights 5 staff members were present: 3 Certified Nursing Assistants (CNA) and 2 Registered Nurses (RN), (6 staff had been scheduled); and 8 staff members were present on days on 8/02/2018 (9 were scheduled). At least 6 of 23 patients were identified to be on some type of precautions, #1; SAO and assault (1:1), #3; assault (1:1), #4; aggression, #5; aggression, #6 aggression, and #13; suicide (1:1). In addition all 23 patients were on fall precautions. At least 3 staff would be needed to care for the 3 patients on 1:1 precautions, leaving only 2 other staff on nights and 3 other staff on days to do all other nursing care for the census of 23 patients.

Based on document and interview, 2 (#N4 and N13) of 15 nurses on staffing schedule, lacked nursing personnel files which would provide information regarding the licensing of staff.

Findings include:

1. Per MR review, Nursing staff members #N4 and #N13, RNs, had provided patient care to patient #1.

2. Review of staff personnel files (from names obtained from staffing sheets), indicated nurses #N4 and #N13 lacked personnel files, or documentation of any type, regarding licensing or other information.

3. In interview on 8/9/2018 at 1455 hours, staff #8, Human Resources Director, indicated that the nursing staff without personnel files must be agency and the facility had no file on them.

Based on document review, nursing care lacked adequate supervision and evaluation, as evidenced by lack of staffing requirements for precautions, for 6 (patients #1, 3, 4, 5, 6 and 13) of 23 MRs reviewed; and lack of accurate documentation for 1 (patient #3) of 23 MRs reviewed.

Findings included:

1. On 8/01-2/2018, at least 6 of 23 patients were identified to be on some type of precautions, #1; Sexually Acting Out (SAO), #3; assault, #4; aggression, #5; aggression, #6 aggression, and #13; suicide, in addition to all patients being on fall precautions. Documentation lacked consistency regarding what precautions and levels (low, medium and high), patients were on.

2. Daily nursing documentation for entire patient stay up to the date of survey, from 7/27/2018 through 8/6/2018, for patient #1 , indicated: 8/6/2018, no precautions noted at 2100 hours and SAO, aggression and fall precautions noted at 1100 hours; on 8/5/2018 at 2300 hours, precautions noted were SAO and fall; on 8/4/2018 at 0600 and 1900 hours SAO and fall precautions noted; on 8/3/2018 at 1500 hours, SAO and fall precautions noted; on 8/02/2018 at 1500 hours, SAO and fall precautions noted; on 8/1/2018 at 1500 hours, SAO and fall precautions noted; on 7/31/2018 at 2300 hours, SAO and aggression and fall precautions noted; on 7/30/2018 at 0350 and 2130 hours, SAO, aggression and fall precautions noted; on 7/29/2018 at 0700 hours, SAO precautions noted and at 1730 hours, fall precautions noted.

3. Review of Nursing Daily Assessment Notes for patient #3 dated 7/18/2018 at 0300 hours, written by staff #21, RN, indicated patient had bruising/scabs, but lacked documentation as to where on body. Patient #3's MR lacked Nursing Daily Assessments notes on 7/21/2018 and 7/23/2018.

Based on document review and interview, 2 (nursing staff #N4 and N13) of 15 nurses on staffing schedule, lacked nursing personnel files which would provide information regarding the specialized qualifications of staff.

Findings included:

1. Review of Policy Patient Acuity and Staffing Guide, NU 96, issued 7/2018 indicated personnel assigned to patient care shall have completed competency documents.

2. Format of Employee Files indicated that they should contain New Hire checklist, professional license online check, reporting of patient safety, Cardio-Pulmonary Resuscitation (CPR), and orientation checklist.

3. Per MR review, Nursing staff members #N4 and #N13, RNs, had provided patient care to patient #1.

4. Review of staff personnel files (from names obtained from staffing sheets), indicated nurses #N4 and #N13 lacked personnel files, or documentation of any type, regarding what should be contained in facility personnel files or their qualifications.

5. In interview on 8/9/2018 at 1455 hours, staff #8, Human Resources Director, indicated that the nursing staff without personnel files must be agency and the facility had no file on them.