HospitalInspections.org

Based on record review and interview the facility staff failed to provide a safe environment when clothing and linens were not removed from patient room per physician order for 1 of 20 patients (Patient #11), who were screened for suicide risk, in a total sample of 20.

Findings include:

Review of policy #04-284-1220 titled "Suicide--Risk Assessment, Prevention and Precautions" effective 12/07/2020 revealed "Procedure: Risk Assessment: A. To ensure safety, patients at admission will enter each level of care with a Safety Standard Order set. This standard will remain in place until the Suicide Risk Assessment (SRA) can be completed. E. Once nursing or social services has completed the SRA the provider will complete a consolidation of the information in the medical record and provide any necessary orders associated with level of risk of patient. F. The treatment plan will be updated accordingly. Safety precautions: Once a risk level has been formulated, using all available data, appropriate interventions will be assigned that differentiate between levels of suicide risk."

Review of nursing suicide risk assessment completed on 5/9/2021 at 8:35 PM revealed, "Part One: Ideation, Plan and Intent. 1) Wish to be dead: Past month, yes. 2) Current sucidial thoughts: Past month, yes. 3) Suicidal thoughts with method: Past month, yes. CSSRS (Columbia Suicide Severity Risk Score) OD (overdose) at home, cuting....Final consideration and risk determination: Rational for final risk determination: 16 year old [gender] admitted straight from [name] hospital after taking hand sanitizer a 'a lot of alcohol' on 5/4/21. Patient is admitted for SI (suicidal ideation) with no specific plan but with 'intent to carry through with anything that comes to mind because I want to kill myself, I want to die so bad maybe my family will be happier without me when I die.' Patient has been to [name] many times before. Patient reports 2 past SAs (suicide attempts)....SRA high MD [name] notified and agreed, orders entered. CSSRS Final Risk Determination: High"

Review the Psychiatric Evaluation completed on 5/10/2021 at 12:30 PM revealed, "Patient #11 is a 16 year old [race] [gender] who presents voluntarily for his/her 10th psychiatric inpatient admission as recommended from Children's Hospital of Wisconsin after an intentional overdose on alcohol-containing substances ....Suicide Risk Assessment: Consolidated Suicide Risk Level: High. Pt's risk for suicide and self-harm continues to be higher than the general population due to pt's struggles with depression, anxiety, family conflict, and substance abuse. Pt has long term risk factors including perceived interpersonal rejection, recent losses, decreased self-esteem, ....The impact of development and the risk of acting impulsively will need to be monitored ongoing as they add to the risk for this patient. Plan: 1. Admit to Child/Adolescent Inpatient Unit on a voluntary status ....5. Family: Family session be scheduled to be held within the next 48 hours to discuss treatment options and obtain additional formation (sic) (information) regarding patient's history. Estimated length of stay: Eight days to ten days. Risk of self-harm: High. Diagnoses: 1. Severe, recurrent major depression with psychotic features. 2. GAD (generalized anxiety disorder) 3. Suicide attempt by alcohol poisoning."

Review of Patient #11 physician orders on 5/24/2021 at 11:48 AM revealed "Constant order, safety (clothing and linen restriction) through discharge."

Review of Advance Practice Nurse Prescriber (ANAP) progress note on 6/2/2021 at 1:53 PM revealed "S/he did have access to his/her clothing and which I do have an order in place that s/he is not to have clothing or linen and I asked staff to remove that as well."

During an interview on 6/29/2021 at 2:00 PM with Executive Director of Nursing (DON) C stated "We prefer that patients wear their clothing but if they have a clothing restriction order we provide sweats with no drawstrings or they can wear street clothes without any strings."

Based record review and interview the facility failed to ensure a Registered Nurse (RN) supervised and evaluated the nursing care of all patients assigned to a Licensed Practical Nurse (LPN) and to complete nursing assessments in a timely manner as per physician orders in 10 of 10 records reviewed (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) with a LPN assigned patient care, in a total sample of 10 records reviewed.

Findings include:

Staff failed to ensure a RN supervised and evaluated the nursing care of all patients assigned to a LPN . See tag A-0395.

Staff failed to ensure nursing assessments are completed timely in 10 of 10 records reviewed. See tag A-0395.

The cumulative effect of these systemic problems resulted in the inability of the facility to ensure all nursing services that were provided by an LPN were supervised by an RN.

Based record review and interview the facility failed to ensure a Registered Nurse (RN) supervises and evaluates the nursing care of all patients assigned to a Licensed Practical Nurse (LPN) and that nursing assessments are completed timely as per physician orders in 10 of 10 records reviewed (Patient #1, 2, 3, 4, 5, 6, 7, 8, 9, 10) with a LPN assigned patient care, in a total sample of 10 records reviewed.

Findings Include:

Review of policy and procedure titled, "Clinical Documentation" effective date 1/1/19, revealed the following:
1. Each patient's assessment includes consideration of the physical, psychological, social, environmental, self-care deficits including functional status, education needs, suicide/safety risks, family involvement, drug and alcohol use, nutritional status, and discharge planning factors.
2. The RN will also assess allergies, current physical and mental status, risk factors and a review of systems. The RN will note those problems which are not current, active, or require attention at this time on the Problem list.
3. All late entries must be labeled as such. The actual time of the entry into the electronic health record cannot be adjusted at any time.
4. Inpatient: A patient care note will be completed by the RN once per shift indicating a summary of the patient's physical and emotional status. The RN will review the treatment plan once per shift and document any changes or completed interventions.

Review of the LPN "Job Description" last revised on 04/22/2017 revealed that the LPN will "Observe, document and monitor each patient's psychiatric and physical changes and responses to treatment under the direction of the registered nurse." Per LPN Job Description the LPN will also, "Provide care in complex situations under the standards of the State that they provide care in; under the general supervision of the RN, physician, or other State approved medical profession." Per LPN Job Description, the LPN duties includes but are not limited to, "Participate in the patient nursing assessment process."

Review of the Registered Nurse "Job description" last revised on 11/25/14 revealed that the RN will "Supervise and delegate task to LPN/psychiatric technician..."

Review of the policy and procedure titled, "Substance Withdrawal Assessment" last reviewed on 06/01/2020 revealed, "To provide the (facility) nursing staff with a standard basis in utilization of the withdrawal assessment tools. For alcohol or benzodiazepine detox, nursing will utilize the Clinical Institute Withdrawal Assessment for Alcohol (CIWA). For opioid detox, nursing will utilize the Clinical Opiate Withdrawal Scale (COWS). The Substance Withdrawal Assessment policy revealed, "The CIWA and COWS assessment tools will be initiated per physician's order, or by a RN, based on clinical necessity." "Implement assessment and document, per tool instructions, the withdrawal findings from the CIWA for alcohol...and/or COWS for opioid withdrawal into the EHR." The policy stated that patients are to be instructed as to the purpose of the assessment and informed of treatment interventions as indicated by the assessment tool.

Review of the CIWA Job Aide for "Documenting a CIWA" revealed an alcohol withdrawal assessment of the following categories: tremors, anxiety, agitation, sweats, orientation and clouding of sensorium (intellectual and cognitive function), tactile (sense of touch) disturbances, auditory (hearing) disturbances, visual disturbances, and headache. Further review of the CIWA Job Aide revealed, "Cerner will automatically add the score for you, but you must then choose what level of withdrawal the patient/resident is in. You can then medicate or perform other patient specific interventions based on the score."

Review of the COWS Job Aide for "Documenting a COWS Assessment" revealed an opiate withdrawal assessment for the following categories: restlessness, pupil size, bone or joint aches, runny nose or tearing, GI (gastrointestinal) upset, tremor, yawning, anxiety/irritability, and gooseflesh skin. The COWS Job Aide revealed, "Cerner automatically adds the score for you. You should medicate and provide patient specific interventions based on this score."

Review of Patient (Pt) #1's medical record revealed Pt #1 was admitted on 06/15/21 with the diagnosis of Alcohol Use Disorder Severe. Pt #1 had a physician order on 06/15/21 for CIWA's every 2 hours. Review of Pt #1's CIWA assessments revealed 7 CIWA's were completed by the LPN on 06/16/21 at 1:15 am and 4:29 am, and 06/17/21 at 12:13 am, 6:00 am, 4:00 pm, 6:00 pm, and 8:00 pm. There was no documented evidence identified of a RN supervising and evaluating Pt #1's CIWA assessments performed by the LPN.

Review of Pt #1's CIWA assessments dated 6/16/21 to 6/20/21 revealed on 06/17/21 the CIWA's due at 4:00 pm, 6:00 pm, and 8:00 pm were signed off as "Completed" at 10:53 pm. There was no documented evidence of nursing staff performing Pt #1's CIWA every 2 hours as per physician order.

Review of Pt #1's "Patient Care Note" dated 06/17/21 at 10:47 pm completed by LPN J revealed LPN J documented the "Mental Status Assessment", "Brief Physical Assessment", "Communicable Disease Form--Daily Screener", "Anchors of Care", and an "Inpatient Note Addendum". There was no evidence identified that a RN completed a patient care note once per shift indicating a summary of the patient's physical and emotional status and reviewed the treatment plan once per shift as per the "Clinical Documentation" policy.

Review of Pt #2's medical record revealed Pt #2 was admitted on 06/17/21 with the diagnosis of Opioid Intoxication. Pt #2 had a physician order on 06/17/21 for COWS every 4 hours. Review of Pt #2's COWS assessments dated 06/17/21 revealed 2 COWS were completed by the LPN. No documented evidence was identified of an RN supervising and evaluating Pt #2's COWS assessments performed by the LPN.

Review of Pt #2's COWS assessments revealed the following: on 06/17/21 the COWS assessments due at 4:00 pm and 8:00 pm were signed off as "Completed" at 11:01 pm; on 06/18/21, the COWS assessments due at 4:00 pm and 8:00 pm were signed off as "Completed" at 10:55 pm. There was no documented evidence identified of nursing staff performing Pt #2's COWS assessment every 4 hours as per physician order.

Review of Pt #2's "Patient Care Note" dated 06/17/21 at 10:56 pm completed by LPN J revealed LPN J documented the "Mental Status Assessment", "Brief Physical Assessment", "Communicable Disease Form--Daily Screener", "Anchors of Care", and an "Inpatient Note Addendum". Review of Pt #2's "Patient Care Note" dated 06/17/21 at 5:14 am completed by LPN L, revealed L documented an "Inpatient Patient Care Note--NOC (nights)", including but not limited to, "Sleeping Assessment", "Symptoms of Sleep Apnea", " BH (behavioral health) Safety Concerns", "Medication Given for Sleep", "Pain Present", and "Has the Patient's Condition Changed". There was no evidence identified that a RN completed a patient care note once per shift indicating a summary of the patient's physical and emotional status and reviewed the treatment plan once per shift as per the "Clinical Documentation" policy.

Review of Pt #3's medical record revealed Pt #3 was admitted on 06/09/21 with the diagnosis of Opiate Dependency. Pt #3 had a physician order on 06/09/21 for a COWS assessment every 4 hours. Per medical record review, the LPN completed 2 COWS assessments on 06/12/21. There was no documented evidence identified of an RN supervising and evaluating Pt #3's COWS assessments performed by the LPN.

Review of Pt #3's of the COWS assessments completed on 06/10/21 revealed the following: COWS assessment due at 4:00 pm was not documented as "Completed" until 6:17 pm; COWS assessment due at 8:00 pm was not documented as "Completed" until 10:43 pm. There was no documented evidence identified of nursing staff performing Pt #3's COWS assessments every 4 hours as per physician order.

Review of Pt #3's "Patient Care Note" dated 06/12/21 at 5:35 am and 06/14/21 at 5:31 am completed by LPN L, revealed L documented an "Inpatient Patient Care Note--NOC (nights)", including but not limited to, "Sleeping Assessment", "Symptoms of Sleep Apnea", " BH (behavioral health) Safety Concerns", "Medication Given for Sleep", "Pain Present", and "Has the Patient's Condition Changed". There was no evidence identified that an RN completed a patient care note once per shift indicating a summary of the patient's physical and emotional status and reviewed the treatment plan once per shift as per the "Clinical Documentation" policy.

Review of Pt #4's medical record revealed Pt #4 was admitted on 06/16/21 with the diagnosis of Bipolar Disorder. Review of Pt #4's "Patient Care Note" dated 06/17/21 at 10:20 pm completed by LPN J revealed LPN J documented the "Mental Status Assessment", "Brief Physical Assessment", "Communicable Disease Form--Daily Screener", "Anchors of Care", and an "Inpatient Note Addendum". There was no evidence identified that an RN completed a patient care note once per shift indicating a summary of the patient's physical and emotional status and reviewed the treatment plan once per shift as per the "Clinical Documentation" policy.

Review of Pt #5's medical record revealed Pt #5 was admitted on 06/10/21 with the diagnosis of Schizophrenia. Review of Pt #5's "Patient Care Note" dated 06/11/21 at 10:14 pm and 06/17/21 at 10:24 pm completed by LPN J, revealed LPN J documented the "Mental Status Assessment", "Brief Physical Assessment", "Communicable Disease Form--Daily Screener", "Anchors of Care", and an "Inpatient Note Addendum". Review of Pt #5's "Patient Care Note" dated 06/12/21 at 5:41 am completed by LPN L, revealed L documented an "Inpatient Patient Care Note--NOC (nights)", including but not limited to, "Sleeping Assessment", "Symptoms of Sleep Apnea", " BH (behavioral health) Safety Concerns", "Medication Given for Sleep", "Pain Present", and "Has the Patient's Condition Changed". There was no evidence identified that an RN completed a patient care note once per shift indicating a summary of the patient's physical and emotional status and reviewed the treatment plan once per shift as per the "Clinical Documentation" policy.

Review of Pt #6's medical record revealed Pt #6 was admitted on 06/15/21 with the diagnosis of Major Depressive Disorder. Review of Pt #6's "Patient Care Note" dated 06/17/21 at 10:29 pm and 06/20/21 at 11:09 pm completed by LPN J, revealed LPN J documented the "Mental Status Assessment", "Brief Physical Assessment", "Communicable Disease Form--Daily Screener", "Anchors of Care", and an "Inpatient Note Addendum". There was no documented evidence identified of an RN supervising and evaluating Pt #6's nursing care provided by LPN J.

Review of Pt #7's medical record revealed Pt #7 was admitted on 06/14/21 with a diagnosis of Bipolar Disorder. Review of Pt #7's "Patient Care Note" dated 06/17/21 at 10:33 pm completed by LPN J, revealed LPN J documented the "Mental Status Assessment", "Brief Physical Assessment", "Communicable Disease Form--Daily Screener", "Anchors of Care", and an "Inpatient Note Addendum". Review of Pt #7's "Patient Care Note" dated 06/17/21 at 4:54 am completed by LPN L, revealed L documented an "Inpatient Patient Care Note--NOC (nights)", including but not limited to, "Sleeping Assessment", "Symptoms of Sleep Apnea", " BH (behavioral health) Safety Concerns", "Medication Given for Sleep", "Pain Present", and "Has the Patient's Condition Changed". There was no evidence identified that an RN completed a patient care note once per shift indicating a summary of the patient's physical and emotional status and reviewed the treatment plan once per shift as per the "Clinical Documentation" policy.

Review of Pt #8's medical record revealed Pt #8 was admitted on 06/16/21 with a diagnosis of Schizoaffective Disorder. Review of Pt #8's "Patient Care Note" dated 06/17/21 at 10:53 pm completed by LPN J, revealed LPN J documented the "Mental Status Assessment", "Brief Physical Assessment", "Communicable Disease Form--Daily Screener", "Anchors of Care", and an "Inpatient Note Addendum". Review of Pt #8's "Patient Care Note" dated 06/17/21 at 5:12 am completed by LPN L, revealed L documented an "Inpatient Patient Care Note--NOC (nights)", including but not limited to, "Sleeping Assessment", "Symptoms of Sleep Apnea", " BH (behavioral health) Safety Concerns", "Medication Given for Sleep", "Pain Present", and "Has the Patient's Condition Changed". There was no evidence identified that an RN completed a patient care note once per shift indicating a summary of the patient's physical and emotional status and reviewed the treatment plan once per shift as per the "Clinical Documentation" policy.

Review of Pt #9's medical record revealed Pt #9 was admitted on 06/08/21 with a diagnosis of Alcohol Use Disorder. Pt #9 had a physician order on 06/08/21 for CIWA's every 2 hours. Review of Pt #9's CIWA assessments revealed 4 CIWA's completed by the LPN. There was no documented evidence identified of an RN supervising and evaluating the CIWA assessments performed by the LPN.

Review of Pt #9's CIWA assessments revealed on 06/08/21 the CIWA's due at 4:00 pm, 6:00 pm, and 8:00 pm were signed off as "Completed" at 11:01 pm. There was no documented evidence of nursing staff performing Pt #9's CIWA every 2 hours as per physician order.

Review of Pt #9's "Patient Care Note" dated 06/11/21 at 10:25 pm completed by LPN J revealed LPN J documented the "Mental Status Assessment", "Brief Physical Assessment", "Communicable Disease Form--Daily Screener", "Anchors of Care", and an "Inpatient Note Addendum". Review of Pt #9's "Patient Care Note" dated 06/12/21 at 6:01 am completed by LPN L, revealed L documented an "Inpatient Patient Care Note--NOC (nights)", including but not limited to, "Sleeping Assessment", "Symptoms of Sleep Apnea", " BH (behavioral health) Safety Concerns", "Medication Given for Sleep", "Pain Present", and "Has the Patient's Condition Changed". There was no evidence identified that an RN completed a patient care note once per shift indicating a summary of the patient's physical and emotional status and reviewed the treatment plan once per shift as per the "Clinical Documentation" policy.

Review of Pt #10's medical record revealed Pt #10 was admitted on 06/12/21 with diagnosis of Alcohol Use Disorder. Pt #10 had a physician order on 06/12/21 for CIWA's every 2 hours. Review of Pt #10's CIWA assessments on 06/13/21 and 06/16/21 revealed 4 CIWA's completed by the LPN. There was no documented evidence identified of an RN supervising and evaluating Pt #10's CIWA assessments performed by the LPN.

Review of Pt #10's "Patient Care Note" dated 06/13/21 at 5:54 am, 06/14/21 at 6:04 am, and 06/17/21 at 5:04 am completed by LPN L, revealed L documented an "Inpatient Patient Care Note--NOC (nights)", including but not limited to, "Sleeping Assessment", "Symptoms of Sleep Apnea", " BH (behavioral health) Safety Concerns", "Medication Given for Sleep", "Pain Present", and "Has the Patient's Condition Changed". There was no evidence identified that an RN completed a patient care note once per shift indicating a summary of the patient's physical and emotional status and reviewed the treatment plan once per shift as per the "Clinical Documentation" policy.

Per interview with Compliance Lead A during medical record review on 06/21/21 from 1:00 pm to 3:00 pm and and 06/22/21 from 11:00 am to 4:00 pm, Compliance Lead A stated that he/she was unable to find documented evidence of an RN completeting a patient care note once per shift and reviewing the treatment plan once per shift as per policy when Pt #1, 2, 3, 4, 5, 6, 7, 8, 9, 10 were assigned to LPN J and LPN L.

Per interview with LPN L on 06/22/21 at 9:10 am, LPN L stated, L does not know if RN's are evaluating the care of the patients L is assigned. L Stated, "It doesn't happen that someone goes behind me and checks everything I've done." Per interview with L, when asked how the RN supervises and evaluates the care he/she provides to the patients, L stated that he does not know.

Per interview with LPN J on 06/21/21 at 3:30 pm, J stated that RN's do not sign off as having reviewed LPN J's Patient Care Notes, CIWA, or COWS documentation.

Per interview with Director of Nursing (DON) D on 06/21/21 beginning at 2:55 pm, DON D stated that for a while RN's were cosigning LPN notes, "maybe sometimes they are and sometimes they aren't", D stated that there was no standard process in place. Per D there is no policy and procedure guiding RN supervision of LPN's.

Based on interview, record review, and observations the facility failed to follow a hospital-wide infection prevention program that followed Centers for Disease Control (CDC) infection control guidelines to prevent the spread of COVID-19. Staff failed to post signs/visual alerts in strategic places in 1 of 1 public elevators, 1 of 1 patient/visitor waiting areas (Front entrance) 1 of 1 cafeteria observed, 1 of 1 staff break room observed, 1 of 1 Gym observed, and 4 of 4 patient units observed (3 adult, 1 child/adolescent); failed to ensure all patients wear appropriate source control (mask) while in the facility in 4 of 8 patients observed. This has the potential to affect all patients, staff and visitors in the facility.

Findings Include:

Review of the CDC guidelines "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic" last updated on 03-10-21 revealed the following recommendations:

1. Establish a process to ensure everyone (patients, healthcare personnel, and visitors) entering the facility is assessed for symptoms of COVID-19, or exposure to others with suspected or confirmed SARS-CoV-2 infection and that they are practicing source control (facemask).
2. Post visual alerts at the entrance and in strategic places (waiting areas, elevators, and cafeterias) to provide instructions about wearing a well-fitting form of source control and how and when to perform hand hygiene.
3. Patients and visitors should wear their own well-fitting form of source control upon arrival to and throughout their stay in the facility.
4. Educate patients, visitors, and HCP (Healthcare Professional) about the importance of performing hand hygiene, including immediately before and after any contact with their cloth mask, facemask, or respirator.
5. Healthcare delivery requires close physical contact between patients and HCP. However, when possible, physical distancing (maintaining at least 6 feet between people) is an important strategy to prevent SARS-CoV-2 transmission.

Review of the facility's "Covid-19 Action & Response Plan" dated "Fall 2020" revealed the following:
1. Furniture removed from common areas to encourage physical distancing. Where unable to remove furniture, common areas are taped off to avoid personal use, and the use of blue tape indicates spots to sit/stand while maintaining social distancing of at least 6 feet. To reduce congregation, spaces were marked/identified with blue tape or social distancing stickers.
2. To help prevent spread of the virus, all patients and employees are expected to wear a surgical mask at all times.

During a tour of the facility on 06/21/21 between 10:30 am and 12:00 pm with Manager E and Manager F, the following was observed: front entrance waiting area, public elevator, cafeteria, main employee break room, 3 inpatient adult units, 1 child/adolescent unit, and gym. Per observation, these areas did not contain visual alerts/signage including but not limited to; physical distancing (6 feet), hand hygiene, and/or wearing appropriate form of source control (mask). Manager E and F stated at the time of the observations, that signs should be posted in all common areas and hallways of units; signs should address physical distancing, hand hygiene, and mask requirements.

Per interview with Manager F on 06/21/21 at 11:00 am, Manager F stated that it is "Routine to check on signs but sometimes we miss it."

During a tour of the facility on 06/21/21 between 10:30 am and 12:00 pm, observed group therapy in session through a closed door on the Adolescent Unit. Per observation, 1 patient was not wearing a mask and 3 patients had their mask below their nose.

Manager E and Manager F confirmed this observation on interview during tour and stated that all patients should be wearing a mask when in group therapy sessions.

Per interview with Infection Prevention K on on 06/22/21 at 8:30 am, K stated the facility follows CDC Guidelines for COVID-19 plan. Infection Prevention K stated there should be signs for physical distancing, hand hygiene, and mask requirements posted at entrances, common areas, hallways, doors, and elevators. Infection Prevention K stated the facility is no longer removing and/or taping chairs but signs should be posted related to physical distancing.

Based on record review and interview the facility failed to ensure all staff have Infection Control training related to COVID-19 in 1 of 5 personnel files reviewed (Registered Nurse N).

Findings Include:

Review of the facility's "Covid-19 Action & Response Plan" dated "Fall 2020" revealed that the facility has developed and implemented training for staff on Isolation precautions, Personal Protective Equipment (PPE) and, Standard precautions. The training was provided in the electronic Learning Management System titled, "Isolation, Precautions, PPE, and COVID-19."

Review of Personnel files for Registered Nurse (RN) N on 06/22/21 at 11:00 am revealed, N did not have evidence of completing the "Isolation, Precautions, PPE, and COVID-19" training.

Per interview with Director O during personnel file review, O confirmed she/he was unable to find evidence of RN N completing the above mentioned training. Per O this training was assigned to all staff in April 2020 and should have been completed with in 30 days.