HospitalInspections.org

Based on observation, interview, and record review, the hospital failed to provide an organized governing body responsible for the conduct of the hospital that ensured enough staff to provide patient care and that the patients being admitted met the criteria for the hospital's skill set and staffing levels.

The facility also failed to ensure patients admitted via an emergency detention order had legal consents before they administered antipsychotic medications.

The facility failed to ensure that initial psychiatric evaluations were performed by a doctor.

The facility failed to ensure that restraints were ordered by a licensed doctor before being administered to the patient.

This practice had the potential to injure patients and staff.

Refer to A0263
Refer to A0338
Refer to A0618
Refer to A0747
Refer to A0799
Refer to A1680

Based on review and interview the facility failed to,

1.
provide and have signed the Important Message from Medicare not more than two calendar days before the patient's discharge in 2 of 2(patient #II, and D) discharged patient charts.

Review of patient chart #II and #D revealed the patient's received the initial IMM letters but did not receive the letters before discharge.

An interview was conducted with staff #13 and staff #33 on 5/22/23. Staff #13 and staff #33 confirmed they have never given a medicare patient an IMM letter at discharge. Both staff #13 and #33 was unaware of the process.

Refer to Tag A0117


2.
follow the policy and procedures for prompt resolutions of complaints and grievances, incomplete investigations, failure to report a patient request for a the patient advocate, failure to compile, analysis, monitor, and report the data on grievances and complaints to medical staff and governing body in 6 out of 6 (Dec. 2022-May 2023) months reviewed.

Refer to Tag A0118

3.
ensure the patient has the right to participate in the development and implementation of his or her plan of care
Refer to Tag A0130

4.

A. ensure the patients were instructed on their involuntary status, and warrants were filed in a timely manner with results available to the patient and surveyor. Failed to have written documentation that the patient was aware of their rights, court hearing dates, and awareness of the judge's decision on their legal status after the court hearings, and failed to release the patient without the proper warrants in place in 3 of 3(#F, AA, and II) charts reviewed.

B. ensure a signed Order of Protective Custody with a forced medication order granted by the county judge was on the medical record before administering psychotropic medications to patients with the inability to consent or refused medications and treatment in 1 of 1(#II) patient medical records reviewed.

C. ensure the patient had the capacity to consent to the administration of psychotropic medications, the beneficial effects on the patient's mental illness, or the condition expected as a result of treatment with psychotropic medication in 5 of 5 (#AA, BB, JJ, II, and LL) charts reviewed.

D. ensure psychoactive medications were administered to 1 of 2 patients (Patient #E) without first obtaining properly, informed consent from the patient or the patient's legally authorized representative.

The deficient practices were identified under the following Condition of Participation, CFR 482.13 Patient Rights, and were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death.
Refer to Tag A0131

5.
protect the patient's right to care in a safe setting, as 2 of 2 patients (Patients D & E) were not observed at the appropriately precaution or observation levels during their stay.
Refer to Tag A0144

6.
ensure that a patient with an eating disorder #N, was given the proper assessments, monitoring, and nursing care for diagnosis.
Refer to Tag A0145

7.
provide a process to safely use seclusion as an approved restraint within the facility, failed to provide a key or a written process on how to properly access the key for seclusion, failed to educate the staff on least restrictive methods of restraints, and failed to review the policy and procedures to remove restraint information not approved for use to direct staff in 2 of 2(unit #1 and #4) patient units.
Refer to Tag A0159

8.
A. ensure only a physician ordered a chemical/emergency behavioral medication (EBM) restraint.

B. ensure a process was in place for continuous monitoring after administering a chemical restraint/emergency behavioral medication for side effects, respiratory or cardiac distress, and assessment of medication effectiveness and safety after administration in 2 of 2(Patients #MM and #W) patient charts reviewed.

C. follow their own policy and procedures to ensure the restraint packet was filled out appropriately and completely, a face-to-face was conducted by a trained individual that was not part of the restraint process, and patient/ staff debriefing was completed and appropriate in 2 of 2 (# MM and #W) charts reviewed.

D. ensure staff was educated on the administration of the chemical/emergency behavioral medication (EBM) restraint for appropriate assessment, reassessment, and black box warnings for psychotropic medications.

E. ensure chemical restraints were added to the restraint log and were monitored through Risk and Quality in 2 of 2(#MM and #W) charts reviewed.

The deficient practices were identified under the following Condition of Participation, CFR 482.13 Patient Rights, and were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death.

Refer to Tag A0160

9.
ensure that two different RN's complete the initiation of restraint and the one hour face-to face evaluation as directed by the Texas state regulation in 1 of 1 charts (# JJ) restraint charts reviewed, and shown in their policy and procedure of Restraint/seclusion.
Refer to Tag A0180

Based on review of documents and staff interview, the facility failed to implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program as evidenced by the facility failing to:

A. have an ongoing program that showed measurable improvement in indicators which measured, analyzed, and tracked quality indicators (Cross Refer A0273)

B. ensure the QAPI program collected data and set priorities for its performance improvement activities that (i) focused on high-risk, high-volume, or problem-prone areas; (ii) considered the incidence, prevalence, and severity of problems in those areas; and (iii) affected health outcomes, patient safety, and quality care (Cross Refer A0283)

C. identify and reduce medical errors; measure, analyze, and track adverse patient events and have performance improvement activities that tracked medical errors and adverse patient events, analyzed their causes, and implemented preventive actions and mechanisms that included feedback and learning throughout the hospital (Cross Refer A0286)

D. conduct performance improvement projects (Cross Refer A297)

E. ensure the QAPI program reflected the complexity of the hospital's organization and services; involved all hospital departments and services (including those furnished under contract or arrangement); and failed to maintain and demonstrate evidence of its QAPI program for review by CMS (Cross Refer A0308)

F. ensure: (1) That an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained; (2) That the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated; and (5) That the determination of the number of distinct improvement projects is conducted annually (Cross Refer A0309)

G. ensure adequate resources were allocated for measuring, assessing, improving, and sustaining the hospital's performance and reducing risk to patients (Cross Refer A0315)

Based on review of records and interviews the facility failed to lay out rules and regulations of the medical staff to provide acceptable quality of medical care for all patients in diagnostic, medical, and pyschiatric services. Refer to A0347

The facility failed to have a nursing service the allowed for a Registered Nurse to be available and to be able to supervise all patient care. This had the potential for injury to patients and staff. The failure of Nursing Services to be in compliance prevented the patients from recieving all care, treatments, and safety measures.


The deficient practices were identified under the following Condition of Participation, CFR 482.23 Nursing Services, and were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death.

Refer to A0395
Refer to A0396

Based on observation, record review and confirmed in interview, the facility failed to ensure adequate direction and staffing of dietary services and to ensure the dietary staff followed acceptable standards of dietary practice regarding food handling and sanitation as evidenced by:

Facility failed to employ a qualified Food and Dietetic Services Director to ensure dietary staff were following acceptable standards of dietary practice regarding food handling and sanitation. Refer to A0620

Facility failed to employ a dietician to supervise the nutritional aspects of patient care. Refer to A0621

Facility failed to ensure all dietary staff were competent in their duties. Refer to A0622

Facility failed to ensure two of ten patients received the correct therapeutic diet as ordered by the provider. Refer to A0629

Facility failed to ensure all patient diets were ordered by the physician or provider for three of ten patients reviewed. Refer to A0630

Based on observations, review of documents, and staff interview, the facility failed to have an active hospital-wide program for the surveillance, prevention, and control of HAIs and other infectious diseases, and for the optimization of antibiotic use through stewardship, as evidenced by:

A. failing to ensure the individual, who was qualified through education, training, experience, or certification in infection prevention and control, was appointed by the governing body as the infection control professional responsible for the infection prevention and control program and that the appointment was based on the recommendations of medical staff leadership and nursing leadership (Cross Refer A0748).

B. failing to ensure the hospital infection prevention and control program, as documented in its policies and procedures, employed methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings (Cross Refer A0749).

C. failing to ensure the hospital infection prevention and control program included surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities (Cross Refer A0750).

D. failing to ensure that a hospital-wide antibiotic stewardship program: demonstrated coordination among all components of the hospital responsible for antibiotic use and resistance, including, but not limited to, the infection prevention and control program, the QAPI program, the medical staff, nursing services, and pharmacy services (Cross Refer A0761).

E. failing to ensure the infection control professional was responsible for competency-based training and education of hospital personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the hospital, on the practical applications of infection prevention and control guidelines, policies, and procedures (Cross Refer A0775).

These findings had the likelihood to cause harm by increasing the risk of infection to all patients and staff at the facility.

Based on a review of documentation and interview, the facility failed have an effective discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care as evidence by:
1. The facility failed to assess its discharge planning process on a regular basis. The assessment must include ongoing, periodic review of a representative sample of discharge plans, including those patients who were admitted within 30 days of a previous admission, to ensure that the plans are responsive to the patient post-discharge needs. Please refer to A0803.
2. The facility failed to ensure that discharge planning evaluation included establishing an appropriate discharge plan, with the results of the evaluation discussed with the patient (or the patient's representative). Please refer to A0808.
3. The facility failed to ensure the transfer of all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient's follow-up or ancillary care. Please refer to A0813.

In interview on 05/25/23, the facility Chief Executive Officer and the Midwestern Regional Chief Executive Officer both verified the facility does not currently have a Discharge Planning Policy in place to guide staff through the discharge process at the facility.

Based on observation, document review, and interview the facility failed to;

1.
ensure a Registered Nurse (RN) was available 24 hours a day on 8 of 8 days reviewed on 3 (Unit 100 Medically Compromised/Geriatric Patients, Unit 300 General Adult Patients, and Unit 400 Acute Adult Patients) of 3 patient care units.

Refer to Tag A1703


2.
A. ensure Nursing Services was adequately staffed to provide safe care on 3 (Unit 100 Medically Compromised/Geriatric patients, Unit 300-General Adults, and Unit 400 Acute Adults) of 3 units. Nursing and/or BHAs (Behavioral Health Aides) staffing was short for 23 of 23 shifts reviewed.

B. follow their own Nurse Staffing and Patient Acuity Plan.

Refer to Tag A1704

3.
provide an effective therapeutic activities program.


The deficient practices were identified under the following Conditions of Participation and were determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death. Refer to tags A1703 and A1704

Based on review and interview the facility failed to provide and have signed the Important Message from Medicare not more than two calendar days before the patient's discharge in 2 of 2(patient #II, and D) discharged patient charts.

Review of patient chart #II and #D revealed the patient's received the initial IMM letters but did not receive the letters before discharge.

An interview was conducted with staff #13 and staff #33 on 5/22/23. Staff #13 and staff #33 confirmed they have never given a medicare patient an IMM letter at discharge. Both staff #13 and #33 was unaware of the process.

Based on review and interview the facility failed to follow the policy and procedures for prompt resolutions of complaints and grievances, incomplete investigations, failure to report a patient request for a the patient advocate, failure to compile, analysis, monitor, and report the data on grievances and complaints to medical staff and governing body in 6 out of 6 (Dec. 2022-May 2023) months reviewed.

A review of the facility grievance log revealed there were three grievances for December 2022.

Patient #CC had a complaint dated 12/15/22 on "unfair tx- and racism" staff #1 (Patient Advocate) documented that the complaint was resolved on 12/20/22, 5 days later. Staff #1 did not change the complaint over into a grievance. There was no documentation of the allegations or if the patient was interviewed concerning his complaint. The patient was not sent any follow-up letter.

A review of the policy and procedure Patient Grievance Procedure- policy ID 13517667 stated, " A patient grievance is a written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present and or CEO) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with the CMS Hospital Conditions of Participation (CoP) or Joint Commission.

Staff present includes any hospital staff present at the time of the complaint or who can quickly be at the patient's location (i.e., nursing, administration, nursing supervisors, and patient advocates) to resolve the patient's complaint.

A written complaint is always considered a grievance, whether from an inpatient, released/discharged patient, or his/ her representative regarding the patient care provided, abuse or neglect, or the hospital's policies and procedures."

A review of patient #DD's entry stated the complaint was filed on 12/9/23 and resolved on 12/9/23. A review of the Staff #1's note stated, " 1577- pt requested to speak with a patient advocate. Pt reports feeling unsafe d/t peer on unit. Pt was educated on voluntary legal status and discharge process. Pt was given support and encouragement. Nurse advised to provide AMA letter and notify MD info passed onto treatment team. 1805- Pt wife (ROI in chart) in lobby requesting to speak with patient advocate. Wife voiced frustration with admission process and other complaints. Wife was educated on pt signing AMA letter and legal process. Wife also given info on hospital policies for visitation. Wife gave collateral info on pt- states that he took approx.. (illegible) Remeron while she walking dog (sic). Info passed along to treatment team. "

The advocate did not provide any detailed information about the patient's complaints, if he was in danger or being threatened by another patient, if the patient received a 4-hour discharge notice, and what the outcome was. There was no evidence the complaint was resolved.

Patient #EE also complained on 12/9/22 that he felt unsafe on the unit. The patient asked to speak to the advocate. The note written by Staff #1 on 12/9/22 stated, " ...Pt expressed multiple complaints, mainly feels he's not getting proper tx and feels unsafe on unit. Pt. requesting to discharge ...pt was allowed to vent frustrations, given encouragement, and support. Pt was educated on discharge process ..." There was no found documentation on patient EE's "multiple complaints". There was no information if the patient's accusations about feeling unsafe on the unit were verified or what was done to ensure the patient's safety. There no was documentation if the patient was discharged or what the outcome was.

A review of the complaint log for March revealed patient #FF complained of lost dentures on 3/1/23. The log stated it was listed as a "complaint." The log stated under "status" that the complaint was substantiated. There was no grievance letter sent to the patient. The date resolved was 3/24/23 by staff #1. There was no documentation found or provided on whether the dentures were found, if the patient was provided new dentures, nor any other documented outcomes.

A review of the April grievance log revealed patient #GG's made a complaint of stolen property on 4/14/23. The complaint was turned over as a grievance and was not documented on the log as resolved until 4/25/23, 11 days later. There was no grievance letter sent to the patient. A note was attached dated 4/27/23. The note stated, "Re: Reimbursement for ____ (patient #GG)
When ____ (patient #GG) discharged on April 14, 2023 it was discovered that he was missing $1019.00 in cash. An investigation was done by ____( staff #2), CEO. Staff were interviewed and camera playback was reviewed. It was discovered that the cash was in a sealed security bag and was placed in the patient's belongings in the storage room instead of being placed in the valuables safe. A staff member was observed on camera on April 8, 2023 taking the security bag from the patient's belongings in the storage room. The staff member placed the security bag in his pocket then went to the bathroom. The staff member has been terminated."

There was no information documented if the patient received a letter concerning the incident, or if the money was paid back to the patient, there was no receipt attached, and there was no information if charges were placed upon the terminated employee.

A review of patient #F's chart revealed she was admitted on 5/10/23. A review of the log revealed patient #F had made a complaint concerning her legal status. A note was found from staff #1 that was dated 5/18/23 at 1430. The note stated, " Pt requested to speak to patient advocate. Pt has complaints about legal status, "I'm not f-ing paranoid" Attempted to educate pt. on legal stays but pt is screaming and cursing. Attempted to educate pt. on use of court-appointed attorney but is difficult to redirect."

A review of patient #F's written complaint revealed there were many topics that were not addressed. Patient #F stated it took 4 days to get psych and pain medications prescribed, no clean linens or towels were available, threats by staff, no way to shower, no therapy, and patient complained of falls. There was no evidence that patient #F's complaints were addressed or resolved. There was no documentation of a grievance. Staff #1 had documented on the log as unsubstantiated.

5/15/23 at 1600- Staff #37 documented, " pt keeps asking to talk to pt advocate or DON all day with no legitimate complaint." There was no documentation that Staff #37 ever notified the patient advocate on behalf of the patient.

A review of patient #F's chart revealed a note on 5/16/23 from the patient advocate at 10:15 AM. Staff #1 documented the patient was "paranoid with rambling speech. Focused on discharge with poor insight." The advocate explained her involuntary status and gave her the number to her court-appointed attorney at 1630. There was no documentation of what the patient's complaints were concerning the legal status and if the patient was able to contact her attorney. The complaint /grievance was not documented on the log.

An interview was conducted with staff #1 on 5/25 at 9:48 AM. Staff #1 was asked if she knew when a complaint would turn into a grievance. Staff #1 stated, "It becomes a grievance when it's written or if it concerns monetary value." Staff #1 confirmed she was not aware of the policy and procedure definition of a complaint vs grievance. Staff #1 stated that she had not been vigilant in keeping up with the grievances due to all the changes and responsibilities she had been given. During the review time frame staff #1 had been the interim Director of Nurses, Patient Advocate, Quality Director, Patient Safety Officer, Infection Control Nurse, and Staff Nurse when needed. Staff #1 stated that she had not been able to aggregate data for Quality concerning complaints and grievances and had no additional information to provide us.

Based on review of documentation and interviews, the facility failed to ensure the patient has the right to participate in the development and implementation of his or her plan of care.

Findings included:

Facility policy "Patient Treatment Plan" (PolicyStat ID 12386362) stated in part,
"POLICY:

Each patient shall have a written, comprehensive, individualized treatment plan that is based on assessment of his/ her medical, clinical and nursing needs. Individualized treatment planning shall be based on patient need.

A. Patients have the right to ongoing participation in their treatment plan ...

K. Treatment plans will be provided to the patient or the guardian ...

PROCEDURE:

Preliminary Treatment Plan:

Upon admission, the nurse shall initiate the Interdisciplinary Treatment Plan for the patient's identified nursing care needs as part of the admission assessment. This plan will be based on the patient assessment and an evaluation of the patient's presenting problems, physical health, emotional status and behavior and provider input. An initial discharge plan will be completed along with the admission assessment.

Once the treatment plan has been developed, a staff person shall review the treatment plan with the patient. This participation shall be noted by the staff's signature on the treatment plan."

Facility policy, "Plan of Care-Protocol for the Use of the Interdisciplinary Format" (PolicyStat ID 12197123) stated in part,
"Phase II: Formulating the Interdisciplinary Treatment Plan (Initial Session)
Prior to the initial Interdisciplinary Treatment Plan session for the patient, the social worker will incorporate the information gathered from the history and physical, psychiatric evaluation, social service meetings, nursing, and therapy services assessments into the initial Interdisciplinary Treatment Plan. This integration will reflect all assessed strengths and limitations.
The Interdisciplinary Treatment Team will meet on a weekly basis to ensure the preparation, review, and update of each patient's individualized problem, goals, and approaches through an interdisciplinary approach. The Interdisciplinary Treatment Team meetings will be attended by at least the Psychiatrist or designee, Director of Nursing or designee, Social Worker, Psychology, Therapy Services, Medical Provider (or designee), Utilization Review, Dietary, and Pharmacy.
Family, caretakers, guardians and/or significant members of the patient's support system may be included by patient permission. When this occurs, the Social Worker will contact the significant person to arrange for their inclusion. The individual's Interdisciplinary Treatment plan will be adjusted as necessary to accommodate family input and wishes ...

Each team member will provide their signature to signify their agreement with the plan ...

Phase Ill: Ongoing Treatment Review (Subsequent Sessions) ...
The Interdisciplinary treatment team will sign the patient's updated Interdisciplinary Treatment Plan."


Review of treatment planning documentation for 7 Patients revealed that only Nurse Practitioners and Social Workers were typically present for and actively participating in Treatment Plan Meetings at the facility. Also that patient's and family members did not consistently have opportunities to participate in treatment planning:

Regarding Patient #F:
* On the initial Interdisciplinary Treatment Plan dated 05/11/23 the boxes to indication the patient or the patient representative participated in planning were not checked.
* The Weekly Interdisciplinary Treatment Plans dated 05/12/23 and 05/19/23 under "DISCHARGE PLAN/NEEDS" indicated "Communication will be completed weekly with:" the "Family/Guardian/POA:" Only representatives from Clinical Services and Psychiatry signed this form to indicate participation. Only one social worker note indicated discussing the care plan with Patient #F. There was no documentation that the patient and/or family members participated in the development and implementation of their plan of care.

Regarding Patient #G:
* The Weekly Interdisciplinary Treatment Plan dated 05/16/23, only representatives from Clinical Services and Psychiatry signed this form to indicate participation. There was no documentation that the patient participated in the development and implementation of their plan of care at this meeting.

Regarding Patient #H:
* The Weekly Interdisciplinary Treatment Plan dated 05/15/23, only representatives from Clinical Services and Psychiatry signed this form to indicate participation. There was no documentation that the patient's family members participated in the development and implementation of their plan of care, despite indicating weekly communication.

Regarding Patient #K
* On the initial Interdisciplinary Treatment Plan dated 05/15/23 the boxes to indication the patient or the patient representative participated in planning were not checked.
* The Weekly Interdisciplinary Treatment Plan dated 05/15/23, only representatives from Clinical Services and Psychiatry signed this form to indicate participation. There was no documentation that the patient or the patient's family members participated in the development and implementation of their plan of care.

Regarding Patient #L:
* On the initial Interdisciplinary Treatment Plan dated 05/17/23 the boxes to indication the patient or the patient representative participated in planning were not checked.
* The Weekly Interdisciplinary Treatment Plans dated 05/17/23 under "DISCHARGE PLAN/NEEDS" indicated "Communication will be completed weekly with:" the "Family/Guardian/POA:" Only representatives from Clinical Services and Psychiatry signed this form to indicate participation. There was no documentation that the patient and/or family members participated in the development and implementation of their plan of care.

Regarding Patient #M
The Weekly Interdisciplinary Treatment Plans dated 05/12/23 under "DISCHARGE PLAN/NEEDS" indicated "Communication will be completed weekly with:" the "Family/Guardian/POA:" Only representatives from Clinical Services and Psychiatry signed this form to indicate participation. Two social worker notes on 05/12/23 and 05/17/23 indicated discussing the care plan with Patient #M and a family member. There was no documentation that the patient and/or family members participated in the development and implementation of their plan of care.

Regarding Patient #Q:
* On the initial Interdisciplinary Treatment Plan dated 05/15/23 indicated involvement of Patient #Q. The boxes to indication patient representative participated in planning was not checked.
* The Weekly Interdisciplinary Treatment Plan dated 05/15/23 under "DISCHARGE PLAN/NEEDS" indicated "Communication will be completed weekly with:" the "Family/Guardian/POA: mother [name]" and "Community Mental Health: [name]". Only representatives from Clinical Services and Psychiatry signed this form to indicate participation. There was no documentation that the patient's family members participated in the development and implementation of their plan of care, despite indicating weekly communication.

In an interview with staff member #3, the Director of Nursing (DON), on 05/23/23 at 11:00 AM, they were asked when treatment team meetings occurred? Staff member #3 replied, "I don't know. Afternoons, maybe Wednesdays?" On 05/23/23 at 11:05 AM, a staff nurse, staff member #13, was asked if they ever participated in treatment planning. Staff member #3 replied, "No. We start the initial treatment plan only."

In interview on 05/23/23 at 11:30 AM, staff member #11, a social worker was asked when treatment team meetings occurred. Staff member # 11 replied, "Monday, Wednesday, and Friday a 1100, based on nurse practitioner availability." Staff member #11 was asked if any other staff members attend treatment team planning? Staff member #11 replied, "It's just us, the nurse practitioner and me." Staff member #11 was asked if patients or family members participate in treatment team. Staff member #11 replied, "The patient isn't there. Since I've been here the patient is never there. With the previous psych team the entire medical team, including UR (utilization review) was present at treatment planning." Regarding treatment planning staff member #11 stated, "There is no standardized or systemic way to do it. I usually go over it with them on the phone, we talk about goals, discharge, and continuum of aftercare."

In an interview with staff member #13, Director of Clinical Services, on 05/25/23 at 9:30 AM, they verified that typically treatment plan meetings only have the nurse practitioner and social worker present. Staff member #15 added, "It's not that patient and family aren't invited, it's that processes here have changed, before the physician and family and nursing would have been involved."

Based on the above findings the facility failed to provide opportunities for patient and their family or LAR to exercise their right to participate in the development and implementation of his or her plan of care.

Based on record review and interview the facility failed to;

A. ensure psychoactive medications were administered to 1 of 2 patients (Patient E) without first obtaining properly, informed consent from the patient or the patient's legally authorized representative.

B. ensure the patients were instructed on their involuntary status, and warrants were filed in a timely manner with results available to the patient and surveyor. Failed to have written documentation that the patient was aware of their rights, court hearing dates, and awareness of the judge's decision on their legal status after the court hearings, and failed to release the patient without the proper warrants in place in 3 of 3(#F, AA, and II) charts reviewed.

C. ensure a signed Order of Protective Custody with a forced medication order granted by the county judge was on the medical record before administering psychotropic medications to patients with the inability to consent or refused medications and treatment in 1 of 1(#II) patient medical records reviewed.

D. ensure the patient had the capacity to consent to the administration of psychotropic medications, the beneficial effects on the patient's mental illness, or the condition expected as a result of treatment with psychotropic medication in 5 of 5 (#AA, BB, JJ, II, and LL) charts reviewed.

The deficient practices were identified under the following Condition of Participation, CFR 482.13 Patient Rights, and were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death.

Findings were:

A.
Patient E was admitted on 2-28-23 and discharged on 3-8-23. He was prescribed and administered the following psychoactive medications during his stay:
* Haldol - 1 dose
* Risperdone - 10 doses
* Vistaril/Atarax - 11 doses
* Buspar - 11 doses
* Depakote - 14 doses
* Lexapro - 7 doses

The clinical record contained no documentation that the facility had obtained informed consent from the patient for any of the above-listed medications.

Facility policy 10041880 titled "Informed Consent Process" states, in part:
"Policy:
All patient medical records shall contain evidence of informed consent for medical care and psychiatric treatment specified by state or federal laws/regulations. This is to include consents for psychotropic medications.
The Hospital's informed consent process assures patients or their legal representatives are given the information and disclosures needed to make an informed decision about whether to consent to medical care and psychiatric treatment, and psychotropic medications.
(a) Informed medication consent must be obtained for each individual medication, not by medication class.
(b) Informed consent for the administration of each psychoactive medication will be evidenced by a completed copy of NPH's Informed Consent for the Use of Psychotropic Medications.

The above was confirmed in an interview with staff #1 during the complaint investigation.

B.
Patient #F requested to talk to the surveyor on 5/22/23 in the afternoon. Patient #F stated that she had been in the facility for a couple of weeks, and no one will explain to her why she cannot leave. Patient #F stated that she volunteered to come in for depression. Patient #F stated, "I am bipolar, and I have been medicated for a long time. I know I was having issues and suffering from depression, but I wanted to get help. I have not seen a psychiatrist since I have been here, and I have asked to speak to the patient advocate several times. She had spoken to me a couple of times but will not listen to me and she cannot tell me why I am being held here." Patient #F stated that they told her that she had a warrant against her. Patient #F stated that the advocate told her she had an attorney and gave her the number. Patient #F stated that she had attempted to call the attorney numerous times but received no callback. Patient #F stated that she had not been before a judge or given any information concerning her detainment.

A review of patient #F's chart revealed she was admitted on 5/10/23. A review of the log revealed patient #F had made a complaint concerning her legal status. A note was found from staff #1 that was dated 5/18/23 at 1430. The note stated, " Pt requested to speak to patient advocate. Pt has complaints about legal status, "I'm not f-ing paranoid" Attempted to educate pt. on legal stays but pt is screaming and cursing. Attempted to educate pt. on use of court-appointed attorney but is difficult to redirect."

A review of patient #F's written complaint revealed there were many topics that were not addressed. Patient #F stated it took 4 days to get psych and pain medications prescribed, no clean linens or towels were available, threats by staff, no way to shower, no therapy, and the patient complained of falls. There was no evidence that patient #F's complaints were addressed or resolved. There was no documentation of a grievance. Staff #1 had documented on the log as unsubstantiated.

5/15/23 at 1600- Staff #37 documented, " pt keeps asking to talk to pt advocate or DON all day with no legitimate complaint." There was no documentation that Staff #37 ever notified the patient advocate on behalf of the patient.
A review of patient #F's chart revealed a note on 5/16/23 from the patient advocate at 10:15 AM. Staff #1 documented the patient was "paranoid with rambling speech. Focused on discharge with poor insight." The advocate explained her involuntary status and gave her the number to her court-appointed attorney at 1630. There was no documentation of what the patient's complaints were concerning the legal status and if the patient was able to contact her attorney. The complaint /grievance was not documented on the log.

A review of patient #F's chart revealed the physician admission order dated 5/10/23 at 1730 stated the patient was admitted voluntarily. A review of the physician orders dated 5/11/23 at 1635 revealed staff #47 Nurse Practitioner (NP) wrote an order to start the court commitment process.

A review of the psychiatric evaluation revealed the NP performed the evaluation however the physician documented he also saw the patient on 5/11/23 at 8:30 AM but there was no other documentation that the psychiatrist saw the patient again. In the body of the evaluation, patient #F asked when she was going to see the physician. A review of patient #F's chart revealed the patient was seen every day from 5/12/23 -5/22/23(excluding 5/19/23) only by the nurse practitioner for her psychiatric care.

A review of patient #F's chart revealed a request to the court for an Order of Protective Custody (OPC) on 5/11/23. Staff #14 Court Liaison made an application on behalf of the hospital to court-commit patient #F on 5/12/23.

An OPC is an order issued by a Texas county judge that allows the psychiatric facility to hold the patient and provide treatment. The judge has determined that the proposed patient presents a substantial risk of serious harm may be demonstrated by the proposed patient's behavior or by evidence that the proposed patient cannot remain at liberty.

An order of protective custody and notice of hearing form was in the chart. A hearing was set for 5/15/23 at 12:00 PM for the probable cause hearing. The hearing for the application for OPC was set for 5/22/23 at 9:00 AM. There was no found evidence that the hearing was performed and what the results of the hearing were. There was no documentation that the patient had an opportunity to speak at her court appointment hearing, that she was informed of the dates and times of her hearings, and was aware of the final judgment. There was no evidence the patient was being held lawfully.

A review of patient # AA's chart revealed she was admitted to the facility on 5/11/23 as a voluntary patient. A review of the chart signed by the justice on 5/12/23 revealed she had an order of protective custody and notice of hearing. There was no physician order to change the patient status to involuntary. The date for the probable cause hearing was set for 5/15/23 and the hearing for the application for OPC was on 5/19/23. There was no found evidence that the hearing was performed and what the results of the hearing were. There was no documentation that the patient had an opportunity to speak at her court appointment hearing, that she was informed of the dates and times of her hearings and was aware of the final judgment. There was no evidence the patient was being held lawfully.

C.
A review of patient #II's chart revealed he was admitted as a voluntary patient by nurse practitioner staff #27 on 5/12/23. There was no psychiatric evaluation or any psychiatric notes on the patient's chart. A review of the nurse's notes dated 5/12/23 (no time) stated, " pt a/o only to self. Pt is with a history of autism and appears to be non-verbal. Pt was seen in his room and appeared to be masturbating. Pt was humming in his room and throughout the day as well as other noises but no words unable to assess with for SI/HI/AVH or pain due to patient's limitations ..."
A review of patient #II's chart revealed he was allowed to sign in as a voluntary patient even though the patient did not have the capacity to consent. The patient's signature was just circles and a line. A motion for an OPC was started in Henderson County and an order to transport the patient to the facility was signed by the judge. There were no further court orders found that were filed on the patient's behalf for Harris County for court commitment.

Review of patient #II's chart revealed he was administered psychotropic medication without the capacity to consent and did not have an OPC with forced medication order.

Review of the Consent for Admission and Treatment stated, "POLICY:
Patients can be admitted to the facility on a voluntary or involuntary basis. Only the patient is able to sign him/herself in for voluntary treatment. If a patient is a danger to self, danger to others, and/ or gravely disabled and refuses to sign in voluntarily; a physician will assess the patient to determine if an Emergency Detention Order (EDO) should be initiated."

A review of patient #II's medication administration record (MAR) revealed patient II was administered Invega (psychotropic) from 5/16/22 through 5/22/23 and Risperdal (psychotropic) from 5/12/23 through 5/14/23.

An interview was conducted with staff #14 court liaison on 5/23/23. Staff # 14 stated that she does not assist the patients with speaking with their attorneys or court appearances. Staff #14 stated," I don't know who helps out the patients, I'm not the advocate." Staff #14 stated that she looks in well sky(computer program) for new admissions and sees if they need to have the paperwork completed for the courts. Staff #14 stated, " I just fill out the paperwork and take it to the courts." Staff #14 was unable to give the surveyor a court decision or time frame on how long the patients are committed through the court system. Staff #14 stated that she just gets emails through a court link when the court hearings are and "we do the process through tele court."

Staff #14 was unable to give the surveyor any final court hearings on patients #F and #AA. Staff #14 confirmed patient #II was voluntary and did not have an OPC in place for Harris County.


D.
Record review of the facility's policy titled, "Informed Consent," dated 07/21, showed the following:

"Written authorization for medical care and psychiatric treatment including changes in medication therapy or addition of new medication both psychotropic and non-psychotropic shall be on the patient's medical record prior to initiation of care, treatment, or services."

"Written authorization will not be obtained when a patient admission is court ordered under emergency detainment terms."

"Texas Administrative Code 414.405; notes the consent by mentally incompetent patients. This section applies to a patient who is deemed incompetent shall provide consent for treatment through the informed consent of the following:"

"The patient's legal guardian or other court appointed representative."

Patient #BB

Review of patient #BB medical record (Emergency Apprehension and Detention Warrant [EDO]) showed the patient #BB was admitted via an EDO from Harris County on 05/13/23 at 15:37.

Review of Patient #BB medical record (Order of protective custody) from Harris County Texas was approved on 5/15/23 at 1:25 PM.

Review of Patient #BB medical record showed an authorization for medical care and psychiatric treatment was signed by the patient on 5/13/23 at 17:00. The patient was deemed incompetent to by the EDO.

Review of Patient #BB medical record (Medication Administration Record) for 5/14/23 showed Prozac 30mg was given at 0900. An informed consent for the use of psychotropic medication dated 05/17/23 showed patient #BB signature, indicating that the patient who was deemed incompetent on an EDO had signed the informed consent.

Review of Patient #BB medical record showed no clearance from a doctor that the patient was now competent to sign consents.

Review of Patient #BB medical record showed that a court order to give Psychotropic Medication was not requested for by the facility at the time of admission nor before the administration of the medication by the nurse.

Review of Patient #BB medical record showed that Psychotropic medication was administered without consent.

Patient AA

Review of patient #AA medical record (Emergency Apprehension and Detention Warrant [EDO]) showed the patient #AA was admitted via an EDO from another hospital on 5/11/23. An Order for Protective Custody was requested by MBHCL and granted on 5/15/23.

Review of Patient #AA medical record showed a Certificate of Medical Examination completed on 05/11/23 by MD from another hospital, Harris Health Lyndon B. Johnson Hospital. The medical exam indicated the patient needed to be hospitalized and was not able to make this decision. "Likely to cause harm to self and likely to cause harm to others".

Review of Patient #AA medical record (Order of protective custody) from Harris County Texas was approved on 5/15/23 at 11:25 PM.

Review of Patient #AA medical record showed an authorization for medical care and psychiatric treatment was signed by the patient on 05/11/23.

Review of Patient #AA medical record (Medication Administration Record) showed that Patient received psychotropic medications (Depakote and Seroquel) without a consent 33 times from 05/11/23 to 05/22/23.

PATIENT #JJ

Review of patient #JJ medical record (Emergency Apprehension and Detention Warrant [EDO]) showed the patient #JJ was admitted via an EDO from another hospital on 5/12/23. An Order for Protective Custody and transfer to MBHCL no further documentation was provided it is unknown if it was approved.

Review of Patient #JJ medical record showed a Certificate of Medical Examination completed on 05/14/23 by MD from HCA . The medical exam indicated the patient needed to be hospitalized and was not able to make this decision. "Likely to cause harm to self and likely to cause harm to others".

Review of Patient #JJ medical record (Order of protective custody) from Montgomery County Texas was approved on 5/15/23 at 11:25 PM.

Review of Patient #JJ medical record showed the patient had no consents for any Psychotropic medication to be given by the court.

Review of Patient #JJ medical record (Medication Administration Record) showed that Patient received psychotropic medications (Depakote, Haldol, Ativan, and Trazadone) without a consent 63 times from 05/15/23 to 05/23/23.

Patient #LL

Review of patient #LL medical record (Emergency Apprehension and Detention Warrant [EDO]) showed the patient #LL was admitted via an EDO from Harris County on 05/12/23 at 15:30.

Review of Patient #LL medical record (Medication Administration Record) From 05/12/23 to 05/22/23 showed the patient received psychotropic medication(Depakote and Zyprexa) without a legal consent 25 times.

Review of Patient #LL medical record an informed consent for the use of psychotropic medication dated 05/12/23 showed patient #LL signature, indicating that the patient who was deemed incompetent on an EDO had signed the consent.

Based on a review of clinical records and facility documentation, the facility failed to protect the patient's right to care in a safe setting, as 2 of 2 patients (Patients D & E) were not observed at the appropriately precaution or observation levels during their stay.

Findings were:

Patient D was admitted to the facility on 11-23-22 at approximately 9:30 pm. The patient was admitted on q 5 minute checks as well as elopement, assault and fall precautions.

A review of observation/precaution sheets completed during the patient's stay revealed the following:
* 11-23-22 - q 5 minute observation level as well as elopement, assault and fall precautions not noted
* 11-24-22 - elopement, assault and fall precautions not noted
* 11-25-22 - q 15 minute observation level is noted, although patient was on q 5 minute observation level
* 11-26-22 - elopement precaution not noted
* 11-27-22 - elopement precaution not noted
* 11-28-22 - fall precaution not noted
* 11-29-22 - sheet completed correctly
* 11-30-22 - fall precaution not noted
* 12-1-22 - elopement precaution not noted
* 12-2-22 - elopement precaution not noted

Patient E was admitted to MBH on 2-28-23 at 10:45 am. The patient was admitted to the adult unit and placed on q 15 minute checks as well as precautions for suicide and elopement.

A review of observation/precaution sheets completed during the patient's stay revealed the following:
* 2-28-23 - sheet contained no indication of observation level or precaution levels
* 3-1-23 - sheet incorrectly stated that the patient was on a q 5 minute monitoring level and did not indicate his precaution levels
* 3-2-23 - no observation sheet found in clinical record for this date
* 3-3-23 - time blanks were labeled "LOA" from 12:00 pm until 4:35 pm and no observations were made at all from 4:40 pm through 6:55 am on 3-4-23.
* 3-4-23 - time blanks were labeled "LOA" from 7:00 am through 10:45 am, when documentation of q 15 minute checks resumed (although nursing notes state that the patient returned to the facility at 9:45 am, an hour prior to the resumption of his q 15 checks)
* 3-5-23 - sheet was properly completed
* 3-6-23 - sheet was properly completed
* 3-7-23 - sheet contained no documentation of the suicide precaution
* 3-8-23 - no observation sheet found in clinical record for this date, although the patient did not discharge from the facility until 2:14 pm

Facility policy 12385972 titled "Patient Observation" states, in part:
"POLICY:
On admission, patients shall be assigned an observation level. An order indicating the observation level shall be based on an assessment of the patient's emotional, physical, cognitive, and behavioral status as determined by the nursing personnel assessing the patient for admission with specific consideration as to the risk posed to themselves or others. Patients will continue to be assessed and monitored during their treatment to ensure observation levels are appropriate.
PROCEDURE:
1. On admission, the patients will be assessed for the level of observation. The provider will order the one of three observation levels. All patients will be admitted to the patient care unit with a minimum of "every 15 minutes" (Q 15) observation level.
2. Observation levels can be increased or decreased by a provider's order.

A. Provider Orders: Providers will order specific precautions for any patient(s) who requires a level of monitoring other than routine, including but not limited to:
1. Assault
2. Aspiration
3. Elopement
4. Fall
5. Self-Harm
6. Seizure
7. Sexually acting out
8. Suicide

B. Observation Levels: A frequency or intensity of observation assigned to a patient during which a health care professional, or their designee, will observe a patient. The approved observation levels assigned are:
1. Q 15 Minute Observation
a. All patients on this level are on every 15 minute observation, at a minimum.
b. This is the minimum acceptable level for all patients; for patients at a lower risk
c. The location of the patient should be known to staff at all times but they are not necessarily within sight.
2. Q 5 Minute Observation
a. All patients on this level are on every 5 minute observation, at a minimum.
b. This is an increased level of observation for patients that are determined to be higher risk and require more frequent monitoring.
c. The location of the patient should be known to staff at all times but they are not necessarily within sight.
3. 1:1 Observation
a. The patient is to be under constant visual observation by an assigned staff member, regardless of other unit activities.
b. Staff member must remain in close proximity to the patient, to include patient bathing and toileting activities. Under these conditions, the patient's safety and protection outweighs his/her right to privacy. For bathing and toileting activities, staff of the same sex may be utilized if available.
c. Staff will continuously monitor the patient's behavior and immediately report any changes in conditions of circumstances to the nurse.
d. Q 5 minute documentation is to be completed when patients are on 1:1 observation.
e. Staff is not to engage in personal activities such as reading, eating, phone use, or similar activity that could distract or otherwise interfere with the continuous observation of the patient.
3. All patients on a 1:1 should be re-evaluated each shift. A provider order to continue or discontinue 1:1 observation is to be documented daily.
4. 1:1 is to be discontinued at the earliest possible time.
5. Documentation:
A. Documentation of all observations will be completed in the patient's record at least once per 15 minute increment.
B. Staff will complete the patient observation record using a coding system described on the Patient Observation Rounds form."

The above was confirmed in an interview with staff #1 during the complaint investigation.

Based on Observation, record review and interview the facility failed to ensure that a patient with an eating disorder #N, was given the proper assessments, monitoring, and nursing care for diagnosis.

Observation: This surveyor (37492) observed Patient #N on unit 300 in the milieu area. Patient was emaciated and frail in appearance, with dry skin and hair. She was wearing several layers of clothing.

Review of Patient #N medical record nursing admission assessment dated 05/12/23 at 00:15 showed the Patient #N was admitted with a weight of 66.4 pounds at 4 feet 9 inches her Body Mass Index (BMI) was at 14.4 indicating she was underweight. The question for eating disorder was left blank. The question for Malnutrition was answered, yes, by the RN (signature was illegible).

Record of Patient #N medical record (History and Physical Exam), dated 05/12/23, by Staff Doctor #47. The review of symptoms for Nausea/vomiting was left blank, but the history of present illness indicates the patient denies nausea and vomiting. The patient's weight and appearance were not addressed.

Review of Patient #N medical record showed an Internal Medicine Progress Note written by Staff FNP #48, dated 05/16/23, written under the title, "Assessment/Plan" Patient has an eating disorder and throws up food.

Review of Patient #N medical record showed an admitting Psychiatric Evaluation, dated 05/12/23, written by Staff Nurse Practitioner #47, under the Admitting Diagnosis lists Body Dysmorphic disorder (F45.22).

Review of Patient #N medical record showed a doctor's order, dated 05/12/23 at 16:00, written by Staff Nurse Practitioner #47, monitor during meals, daily weights, calorie count, and monitor patient in bathroom after meals.

Review of Patient #N medical record showed a doctor's order, dated 05/16/23 at 15:00, written by Staff Nurse Practitioner #47, the order calls for 1:1 monitoring for one hour post meals and a nutritional consult.

Review of Patient #N medical record (Nutritional Consult), dated 05/18/23, written by Staff Dietician #24, listed under other problems the Dietician wrote Nausea and Vomiting and Eating Disorder.

Review of Patient #N medical record (Nutritional Consult), dated 05/18/23, written by Staff Dietician #24, altered labs related to intake and medical condition as evidenced by patient presenting with diagnosis of Irritable Bowel Disease (IBS) and symptoms of bulimia. Nutritional Diagnosis: inadequate fluid intake, underweight. Nutritional interventions: Monitor weight, signs and symptoms of dehydration, and nutritional intake.

Review of Patient #N medical record (Nursing Notes) from 05/12/23 till 05/20/23 showed the no documentation of monitoring the patient after meals, calorie counts, daily weight are not listed in the chart.

Interview with Staff RN #36 on 05/22/23 at 14:30 showed the following:
There is no place to write a patient's intake of food "I guess we can put in the nursing notes".
We do not do one to one monitoring for food intake.
We do not weight the patient at the same time every day. It depends on how many staff are on.
When asked about caloric intake documentation no response was given.

Interview with staff CEO #2 on 05/22/23 about Patient #N and the fact that no documentation was found on the patient's chart to indicate monitoring was done. The CEO stated, "You can't prove we didn't do it."

Interview with the Staff Medical Director #04 on 05/23/23 showed that the facility doesn't treat eating disorders and the patient was admitted with depression. There are no facilities in the Houston area that do.

Based on review and interview the facility failed to provide a process to safely use seclusion as an approved restraint within the facility, failed to provide a key or a written process on how to properly access the key for seclusion, failed to educate the staff on least restrictive methods of restraints, and failed to review the policy and procedures to remove restraint information not approved for use to direct staff in 2 of 2(unit #1 and #4) patient units.

On 5/22/23 an observation was made in unit 4 (acute adult unit) of patient #MM. Patient #MM had been placed on a 1:1 observation due to her behavioral outbursts and self-inflicting harm. Patient #MM had an open wound on her forehead. Staff #19 stated patient #MM had injured herself the night before by banging her head on the wall.

An interview was conducted with Staff #13 on 5/22/23 at 11:00 AM. Staff #13 was asked about restraints and what would be appropriate for Patient #MM when she was having behavioral outbursts or inflicting self-harm. Staff #13 stated that she would try to de-escalate the patient by talking to her or trying to meet her needs. Staff #13 stated that if she was unable to de-escalate the patient, she would call the nurse practitioner or physician for a chemical restraint/emergency behavioral medication (EBM). Staff #13 was asked what other types of restraints the facility use and staff #13 stated, "We just usually give them a shot." Staff #13 confirmed the facility did not use or have any mechanical restraints. Staff #13 stated that staff uses physical holds on the patients if needed and they do have a seclusion room, but they never use it. Staff #13 stated, "We don't have a key to the seclusion room." Staff #13 stated that she was not aware of why they did not have a key for the seclusion room but if they needed to use the room, she would have to call a house supervisor. Staff #13 was asked what restraint would be least restrictive a hold, seclusion, or an intramuscularly injection (IM) chemical restraint/EBM? Staff #13 stated, "A shot." It was confirmed by staff #1 on 5/22/23 that there were no house supervisors available for an interview. Both house supervisors were out due to vacation and illness.

Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior.
Staff #13 confirmed that she was not aware that there was no antidote for psychotropic medications that are administered IM for behavioral emergencies. Staff #13 was not aware of the black box warnings for Haldol or Geodon.

A review of the policy and procedure "Restraints and/or Seclusion use" stated,
"Restraint - any method (physical or chemical) of restricting a patient's freedom of movement, physical activity, or normal access to his or her body that is not a customary part of a medical diagnostic or treatment procedure to which the patient or his/her representative has consented; is not indicated to treat the patient's condition or symptoms and/or cannot be easily removed by the patient in the same manner that it was applied.
.
Emergency Medication - a medication, when used, to manage the patient's behavior or restrict and is NOT a standard treatment or dosage for the patient's condition. Emergency Medications cannot be ordered as a PRN or as needed medication. (Medications which are part of the patient's regular medical regimen, even if PRN, are not considered emergency medications, even if their purpose is to control ongoing behavior).

Seclusion - the confinement of a person alone in a room or an area where the person is physically prevented from leaving.

DISCONTINUATION OF RESTRAINT/
SECLUSION:
Restraints/seclusion must be discontinued as soon as safely possible, regardless of the length of time identified in the order.

A nurse may discontinue the restraint/seclusion as soon as the unsafe situation ends, or a less restrictive measure can be used. The criteria for early release of restraint/seclusion is documented on the physician order such as the patient is no longer a danger to self or others and the staff /patient is able to construct a safety plan."

Physical holds, seclusion, and mechanical restraints can be released immediately ending the restraint process. However, a psychotropic medication such as Geodon, Haldol, or Zyprexa, given as a chemical restraint or EBM has no antidote. The patient must metabolize the medications or in case of overdose may require hospitalization and respiratory ventilation support.

An interview was conducted with Staff #16 on 5/23/23. Staff #16 stated that the unit did not have a key to the seclusion room for months and she had not used it due to no key. Staff #16 confirmed the DON placed the key there the day before. Staff #16 got the key and off the ring in the nurse's station and showed it to the surveyors. Staff #16 confirmed the facility does not use mechanical restraints. Staff #16 stated, "We can hold them and give them a shot. I guess now since we have a key we can use the seclusion room." Staff #16 confirmed that she was not aware that psychotropic medications given for behavioral emergencies IM or IV did not have an antidote. Staff #16 was not aware of the black box warnings for Haldol or Geodon.

A review of the policy and procedure "Restraints and/or Seclusion use" revealed the policy does not list approved restraints. The policy had multiple areas of direction for the staff for mechanical restraints. The policy stated,

"INITIATION OF RESTRAINT & SECLUSION
Any staff member trained in CPI techniques may initiate a CPI hold in an emergency. A mechanical restraint may only be initiated by a trained Nurse, Physician, or LP ...Patients will have range of motion movement to any restrained extremity at least every 2 hours. Each restrained extremity will be released for range of motion for at least 2 minutes each 2 hours. As appropriate to the situations, only one extremity need be released at a time ...

REMOVAL OF RESTRAINTS: Restraint removal may take place when: Two staff members must be present to remove restraints, Patient must have exhibited criteria for release, Patient is sleeping while in restraints, Patient is exhibiting physiological symptoms that indicate restraints may be harmful, Patient is exhibiting psychological trauma that indicates restraints may be harmful."

An interview was conducted with Staff #3 on 5/23/23. Staff #3 stated that he had not been at the facility long and was still learning. Staff #3 stated that the staff should attempt to de-escalate the patients to avoid behavioral restraint. Staff #3 stated that he believed a chemical restraint/ EBM would be the least restrictive restraint and then seclusion if needed. Staff #3 was not aware of the policy and procedure for seclusion and restraints and spoke about the use of mechanical restraints. Staff #3 stated he was not aware that the nurses did not have a key to the seclusion rooms and had not been using them due to having no key or control of the room. Staff #3 was unable to tell me the process for placing a patient in seclusion.

Based on record review and interview the facility failed to,
A. ensure only a physician ordered a chemical/emergency behavioral medication (EBM) restraint.

B. ensure a process was in place for continuous monitoring after administering a chemical restraint/emergency behavioral medication for side effects, respiratory or cardiac distress, and assessment of medication effectiveness and safety after administration in 2 of 2(Patients #MM and #W) patient charts reviewed.

C. follow their own policy and procedures to ensure the restraint packet was filled out appropriately and completely, a face-to-face was conducted by a trained individual that was not part of the restraint process, and patient/ staff debriefing was completed and appropriate in 2 of 2(# MM and #W) charts reviewed.

D. ensure staff was educated on the administration of the chemical/EBM restraint for appropriate assessment, reassessment, and black box warnings for psychotropic medications.

E. ensure chemical restraints were added to the restraint log and were monitored through Risk and Quality in 2 of 2(#MM and #W) charts reviewed.

The deficient practices were identified under the following Condition of Participation, CFR 482.13 Patient Rights, and were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death.

Findings:
Patient #MM

A review of patient #MM's file revealed she was admitted to the facility on 5/17/23 at 04:00 AM.
A review of the admission order dated 5/17/23 revealed the patient was admitted by staff #27 (nurse practitioner NP) and given a legal status of voluntary. The reason for admission was blank. There was no diagnosis for the admission, The initial treatment plan problems section was left blank, and the nurse signed the order on 5/17/23 at 5:30 AM. The nurse practitioner signed and dated the order on 5/17/23 but failed to document the time the order was signed. The patient was placed on seizure precautions. The physician failed to write an admission order.

According to Texas Administrative Code TITLE 26, PART 1, CHAPTER 568, SUBCHAPTER B, RULE §568.22 STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS, ADMISSION, Voluntary Admission
(h) Admission examination.
(1) The admission examination referenced in subsection (d)(2)(A) of this section shall be conducted by a physician in accordance with Texas Health and Safety Code Chapter 572 and include a physical and psychiatric examination conducted in the physical presence of the patient or by using audiovisual telecommunications.
(2) The physical examination may consist of an assessment for medical stability.
(3) The physician may not delegate conducting the admission examination to a non-physician.
(i) Documentation of admission order. In accordance with Texas Health and Safety Code §572.0025(f) (l), the order described in subsection (f)(2)(B) of this section shall:
(1) be issued in writing and signed by the issuing physician; or
(2) be issued orally or electronically if, within 24 hours after its issuance, the hospital has a written order signed by the issuing physician."

A review of the nurse notes dated 5/17/23 at 4:10 AM stated, "Pt arrived via EMS from___ (hospital) for pseudo seizures. Pt A, O x3. Pt denies SI/HI/AVH at this time. Consents signed. Pt checked for contraband. Pt. walked with nurse to unit 100 RM 107 B. 5:00 AM Pt shaking on floor. Does not respond to verbal stimuli. V/S 97.9, B/P 162/94, P 89, RR 16 O2 sat 97.6. 5:10 AM. Pt sitting up and talking to nurse. Pt escorted to rm 107. 5:30 AM Pt sitting on floor beating head against the wall, blood on wall, pt c/o feeling dizzy. Pt refuses blood draw and refuses to set (sic) in bed. Call placed to Dr. ____ waiting call back. 5:45 AM no call back from MD will send out to ____ (ER) for eval of head. 5:55 AM Report called to ___ (ER) 6:00 AM calling (illegible) ambulance for transport, spoke with ___, ETA 30-40 min."

A review of patient #MM's chart revealed there was no information on what time she left the facility and if she was escorted by the staff.

A review of the nurse's note dated 5/17/23 at 12:30 PM revealed patient #MM returned to the facility. The nurse documented, "Pt returned via EMS and was having pseudo seizures, so they took her back to the ER and ER said they can't do anything for pseudo seizures and told EMS to take her back to us. She immediately started head banging and having pseudo seizures upon return here. ____ (staff #27) NP wrote order to transfer to 400 as soon as bed available." There was no further documentation on what the staff did to protect the patient from injury, if there were de-escalation attempts, or if the patient was placed on a 1:1. There was no documentation found that the physician was aware of patient #MM's ER visit, return from the ER, or that the patient continued to self-harm.
A review of the physician notes revealed staff #27 NP documented on 5/18/23 at 5:51 AM Patient presented on unit 400 for assessment. She was transferred to a more acute unit due to her impulsive, aggressive and self-harming behavior. Per staff reports, the patient started banging her head on the wall causing a hematoma and abrasion to her forehead. When staff intervened she became verbally and physically aggressive. Started to attempt to strike and spit at staff. She had to be restrained for safety and emergency medication was administered (Zyprexa 10mg IM, Ativan 1 mg IM, Benadryl 50mg IM). The patient verbally requested discharge. A 4-hour letter was completed and administration, supervising psychiatrist and Court liaison was notified. Due to her continued self-harming behaviors and aggression. Her request for release was denied and the commitment process was started. After administration the patient was evaluated by Internal Medicine. It was decided that she be sent out to the ER for a CT scan. Neuro Check was performed by provider. Later she decided to engage in assessment. Reports that she started engaging in self-harming behaviors because she wanted to leave. I am just tired of being here. "She later apologized for verbal aggression. Reports no side effects to medication. Reports that she continues to have mood instability. Irritability, racing thoughts. Command auditory hallucinations to harm herself and SI.".

No further documentation was found that a physician or an NP saw the patient after 5/18/23. There was no documentation found in the chart that a psychiatrist had evaluated the patient from 5/17/23 to 5/24/23.

5/18/23

A review of patient #MM's nurse notes dated 5/18/23 at 9:30 AM stated, "pt A,O x3 able to verbalize needs (4 illegible words) Administered emergency meds per provider orders due to combative and impulsive aggressive behavior. Continue to monitor during the (illegible.) There was no documentation on the medication administration record that the medication was administered or by whom. There was no order written for emergency medications until 5/18/23 at 11:00 AM. There was no further assessment or reassessment found in the nursing notes until 22:35 (10:35 PM), 11.5 hours later.

A review of patient #MM's physician orders dated 5/18/23 at 6:47 AM revealed staff #27 wrote an order to change the level of observation to every 5 minutes. "place on self-harm precautions."
10:57 AM "send to ER CT of Head"
11:02 AM "Start commitment process." No further orders were noted for patient #MM on 5/18/23.
A review of the patient observation round sheet revealed patient #MM was on q 15-minute observations until 11:50 AM. Pt #MM was not placed on q 5-minute observation for 6 hours after the order was written. There was no found documentation that justified the delay in care and safety.

A review of patient #MM's chart revealed a restraint packet dated 5/18/2023 at 11:00 AM. Review of the order written by Staff #36, RN read, "Zyprexa 10 mg, Lorazepam 1 mg IM and Benadryl 50mg IM... for "aggression, combative with nursing staff." The orders stated verbal de-escalation as an alternative to restraint/ seclusion attempted and indication for the order was "hematoma forehead bang head on the wall ...combative with staff." There was no documentation from the RN that this was a verbal order. Staff #27 NP signed the order on 5/18/23 at 11:00 AM for a chemical/EBM restraint.

A review of patient #MM's restraint packet dated 5/18/23 at 11:00 AM revealed the same nurse, staff #36 RN initiated the restraint and documented the face-to-face. The nurse documented on the face-to-face form that the intervention (medication administration) was initiated on 5/18/23 at 11:00 AM and the initial face-to-face was initiated at 11:00 AM. Staff #36 RN was completing both tasks. Staff #36 documented the patient's response to the intervention was "patient sleeping." Staff #36 documented that patient #MM had denied pain, had no aggression, was cooperative and thought process was clear, speech wnl, and alert to person, place, and situation, even though patient #MM was just given a chemical/EBM restraint for aggressive and combative behavior.

A review of the second page of the face-to-face form dated 5/18/23 at 12:00 PM revealed staff #36 documented the patient's vital signs. Staff #36 also documented, "Pt lying in bed resting in supine position. No distress noted. No behaviors noted at this time. Pt calm. Respirations even and unlabored. Open area to the forehead area, pt apologized to nursing staffing (sic). Continue to monitor during shift." A review of the patient observation round sheet revealed patient #MM was not in her room at 12:00 PM but was in the dining room alert and cooperative. The mental health technician documented that patient #MM was in the dining room from 11:30 AM - 12:20 PM.

A review of the staff debriefing sheet dated 5/18/23 at 12:30 PM revealed there was no staff listed that was involved in the debriefing.

A review of patient #MM's treatment plan revealed there was no documentation of the chemical restraint/ EBM administration that was administered on 5/18/23.

5/19/23

A review of the nurses' notes dated 5/19/23 revealed patient #MM was banging her head on the wall. The nurse documented patient #MM was able to be redirected. On 5/19/23 at 10:00 AM the nurse documented the patient fell in the shower and was still on a 1:1 observation level. 2:00 PM- patient was spitting on the staff. 2:40 PM staff #27 NP was called and an order for po Zydis was ordered but patient refused. A review of the MAR revealed the nurse signed out on the po Zydis as given to the patient.

A review of patient #MM's chart revealed a medication order was written on 5/19/23 at 1550 (3:50 PM) by staff #27 NP to administer Ativan 1 mg IM x 1 dose "now agitation" and Benadryl 50mg IM x 1 dose "now agitation."
There was no nursing documentation found on patient # MM's chart from 2:40 PM until 9:00 PM. There was no documentation found of the patient's behavior, what attempts were made to de-escalate the patient, or what other options were used before the administration of a chemical/EBM restraint. A review of the MAR revealed the medication was given at 4:04 PM. There was no assessment or reassessment of the patient after the medication administration.

Upon reviewing patient #MM's chart, it was discovered that the restraint packet was incomplete. The packet only contained a 1-hour face-to-face form and a blank debriefing sheet for the patient. The face-to-face session took place on 5/19/23 at 4:50 PM, where the nurse indicated that the intervention was for "emergency medications." The patient's response to the intervention was noted as "patient sleeping." Additionally, the nurse documented that the patient refused vital signs, denied pain, and was cooperative with a normal mood and orientation to person, place, time, and situation. There was no documentation of any vital signs, how the patient reacted to the medication, if any side effects were noted, or the effectiveness of the medication. The patient had been sent to the emergency room two days in a row for head injuries. There was no mention of neuro checks or neurological assessments after the administration of psychotropic medications and sedatives.

A review of the patient observation rounds revealed the patient was on a 1:1 observation level. The mental health technician's documentation was to be done every 5 minutes. The technician documentation should show the patient's location and behaviors. A review of the 5/19/23 observation round sheets revealed there was no documentation on patient #MM from 7:00 AM until 1:05 PM and from 8:05 PM until 10:25 PM. There was no documentation of why the mental health technician failed to document the patients' observations or if there was a 1:1 assigned as ordered.
A review of the treatment plan revealed there was no mention of the chemical restraint/EBM administered on 5/19/23.

5/21/23

A review of patient #MM's nurse notes revealed on 5/21/23 at 10:45 AM the RN documented, "Pt continues on 1:1 at bedside. Pt started spitting on staff and hit staff. Pt kept swinging at staff being physical and verbally aggressive. NP ____ (staff #47) on unit. New order for Benadryl 50 IM and Ativan 1 mg IM. Nurse administered shot to each deltoid. Pt took shot with no resistance. Pt tolerated well. Pt. med complaint with po meds as well. VSS (vital signs stable)." The nurse stated that the patient was medication complaint however, there was no documentation that the patient was offered any po meds at the time of her behavioral emergency. There was no documentation of any de-escalation techniques used or any other options before the administration of a chemical restraint/ EBM.

A review of patient #MM's chart revealed there was an incomplete restraint packet. A face-to-face was documented for 5/21/23 at 12:00 PM. The patient was given "emergency medication." The patient had improved behavior and vital signs were taken. On the bottom of the face-to-face form was a line for the name of the physician that was notified of the findings of the face-to-face. The form stated, "Physician notification of evaluation (if evaluated by RN/NP/PA). The nurse documented that NP staff #47 was notified and not the physician.

Patient #W

A review of patient #W's chart revealed he was admitted to the facility on 5/15/23. A review of patient #W's psychiatric evaluation revealed it was performed by Staff #27 NP on 5/18/23 at 5:51 AM. Staff #27 had also documented that she was on another unit assessing patient #MM on 5/18/23 at 5:51 AM.

A review of patient #W's psychiatric evaluation stated, "Patient is a 78-year-old, who was admitted from Spindletop Center Service. However, due to the patient's diminished cognitive function collateral information was obtain from the patient's wife and daughter. According to patient's wife the patient was diagnosed with dementia two and a half years ago, and his behavior has started to get progressively worst(sic) every day. She reports that the patient has been verbally and physically abusive towards her ..."

A review of patient #W's nurse notes dated 5/21/23 at 4:16 PM revealed the patient was being verbally aggressive towards staff and patients. A review of the chart revealed a restraint packet dated 5/21/23 at 5:00 PM. The verbal order stated to give the patient Benadryl 25 mg IM x 1 now and Haldol 2.5mg IM x 1 now. Staff #47 NP gave the order for restraint.

A review of the face-to-face revealed the nurse initiated it on 5/21/23 at 6:30 PM. Vital signs were taken, and the nurse documented the patient had improved. The nurse failed to report the face-to-face to the physician but reported the findings to the nurse practitioner.

There was no further documented time of assessment or reassessment until 5/22/23 at 5:20 AM.
According to the Texas Administrative Code TITLE 25 HEALTH SERVICES PART 1, CHAPTER 415, SUBCHAPTER F, RULE §415.260 Initiation of Restraint or Seclusion in a Behavioral Emergency stated, "(b) Physician's order. Only a physician member of the facility's medical staff may order restraint or seclusion. (2) If restraint or seclusion was ordered by telephone, the ordering physician shall personally sign and date the telephone order, including the time of the order, within 48 hours of the time the order was originally issued."

An interview was conducted with Staff #13 on 5/22/23 at 11:00 AM. Staff #13 was asked about restraints and what would be appropriate for Patient #MM when she was having behavioral outbursts or inflicting self-harm. Staff #13 stated that she would try to de-escalate the patient by talking to her or trying to meet her needs. Staff #13 stated that if she was unable to de-escalate the patient, she would call the nurse practitioner or physician for a chemical restraint/emergency behavioral medication (EBM). Staff #13 was asked what other types of restraints the facility used and staff #13 stated, "We just usually give them a shot." Staff #13 confirmed the facility did not use or have any mechanical restraints. Staff #13 stated that staff uses physical holds on the patients if needed and they do have a seclusion room, but they never use it. Staff #13 stated, "We don't have a key to the seclusion room." Staff #13 stated that she was not aware of why they did not have a key for the seclusion room but if they needed to use the room, she would have to call a house supervisor. Staff #13 was asked what restraint would be least restrictive, a hold, seclusion, or an intermuscular injection (IM) chemical restraint/EBM? Staff #13 stated, "A shot." It was confirmed by staff #1 on 5/22/23 that there were no house supervisors available for an interview. Both house supervisors were out due to vacation and illness.

Staff #13 confirmed that she was not aware there was no antidote for psychotropic medications that are administered IM for behavioral emergencies. Staff #13 was not aware of the black box warnings for Zyprexa, Haldol or Geodon. Staff #13 was asked how the patient was supposed to be reassessed, how frequently, and for how long after the patient received a chemical restraint/EBM. Staff #13 stated, "I try to keep an eye on them but confirmed she was unaware.

According to the FDA.gov Black Box Warning
Zyprexa is not approved for older adults with dementia-related psychosis as the drug can increase the risk of death in this population by 60% to 70%. The FDA placed a black box warning on all antipsychotics (atypical and typical) due to this increased mortality risk.

Black Box warnings for psychotropic medications revealed causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies suggest that similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug, as opposed to some characteristic(s) of the patients, is not clear.

An interview was conducted with Staff #16 on 5/23/23. Staff #16 stated that the unit did not have a key to the seclusion room for months and she had not used it due to no key. Staff #16 confirmed the DON placed the key there the day before. Staff #16 got the key off the ring in the nurse's station and showed it to the surveyors. Staff #16 confirmed the facility does not use mechanical restraints. Staff #16 stated, "We can hold them and give them a shot. I guess now since we have a key, we can use the seclusion room." Staff #16 confirmed that she was not aware that psychotropic medications given for behavioral emergencies IM or IV did not have an antidote. Staff #16 was not aware of the black box warnings for Zyprexa, Haldol, or Geodon. Staff #16 was asked how the patient was supposed to be reassessed, how frequently, and for how long after the patient received a chemical restraint/EBM. Staff #16 stated, "We do a face-to-face within 1 hour and that's when we get the vital signs." Staff #16 stated she was not sure what the time frames were.

An interview was conducted with Staff #3 on 5/23/23. Staff #3 stated that he had not been at the facility long and was still learning. Staff #3 stated that the staff should attempt to de-escalate the patients to avoid behavioral restraint. Staff #3 stated that he believed a chemical restraint/ EBM would be the least restrictive restraint and then seclusion if needed. Staff #3 was not aware of the policy and procedure for seclusion and restraints. Staff #3 stated he was not aware that the nurses did not have a key to the seclusion rooms and had not been using them due to having no key or control of the room. Staff #3 was unable to tell me the process for placing a patient in seclusion. Staff #3 was asked about the process for evaluating a patient after the administration of a chemical restraint/EBM. Staff # 3 stated they should be checking on them frequently and doing a 1-hour face to face to check vital signs. Staff #3 confirmed he was unaware of how frequently and for how long the nurse should assess the patient after the administration of an IM chemical restraint/EBM.

A review of the policy and procedure Restraint and/or Seclusion Use revealed there was no process for how the nurse was to monitor the patient after a chemical/EBM restraint. The policy stated, "EVALUATION DURING RESTRAINT/SECLUSION:
Patients in simultaneous restraint and seclusion will be directly observed by one-to-one staff observation
A nurse shall observe and assess patients in restraint or seclusion approximately every 60 minutes including respiratory and circulatory status, skin integrity, and vital signs.In some circumstances, approaching the patient may be dangerous and may increase patient agitation. Visual checks may be performed if the patient is too agitated to approach. but at a minimum, the patient must be assessed for safety and signs of injury, as well as readiness for discontinuation of restraint or seclusion.

The patient's response to the intervention or interventions used shall be documented every fifteen (15) minutes throughout the duration of the restraint or seclusion. The fifteen (15) minute monitoring must include the monitoring of the patient's physical and psychological condition including, but not limited to:
Respiratory and circulatory status;
Skin integrity;
Vital signs:" The policy stated the patient shall be observed every 15 minutes throughout the duration of the restraint or seclusion. There was no documented information on how the nurse was to determine the ending of a chemical/ EBM restraint.

An interview was conducted with Staff #1 on 5/24/23 at 10:21 AM. Staff #1 stated that she did have a restraint log, but it was not complete. Staff #1 stated that the administration including the physician had discussed changing the restraint packets and putting in "every 15-minute' observation for the patients after a chemical/EBM restraint but that had not been completed or changed at this time. Staff #1 confirmed the staff was still using the same restraint packets. Staff #1 stated the face-to-face training was done upon hire in the orientation process but staff #1 was unable to provide the surveyor with specific face-to-face training. Staff #1 supplied the surveyor with clinical orientation training on seclusion and restraint and stated that this was what was used for the face-to-face training. One slide was in the training stating the regulation of face-to-face. There was no specific training information found. Staff #1 confirmed that she did not have any QAPI she could provide at this time for restraints and no data to report.

Based on record review and interview the facility failed to ensure that two different RN's complete the initiation of restraint and the one hour face-to face evaluation as directed by the Texas state regulation in 1 of 1 charts (# JJ) restraint charts reviewed, and shown in their policy and procedure of Restraint/seclusion.

415.260[c][1] Face-to-face evaluation. A physician, physician assistant as provided in paragraph (3) of this subsection, or a registered nurse who is trained and has demonstrated competence in assessing medical and psychiatric stability, other than the registered nurse who initiated the use of restraint or seclusion, shall conduct a face-to-face evaluation of the individual within one hour following the initiation of restraint or seclusion to personally verify the need for restraint or seclusion.

1. Review of the facility's current policy titled, Restraint and or Seclusion, Policy ID #10854266, last revised 12/2021, Approved 12/2021, revealed the following information: It failed to contain the additional provision that the state requires for 2 different RN's to complete the initial then the face to face.

Review of Patient #JJ medical record (Restraint, Seclusion, and Emergency Medication), dated 05/16/23 at 17:00, showed that RN (illegible signature [no signature key provided]) completed the initial face to face evaluation was completed at 17:00. The one hour face to face evaluation was completed by the same RN with an illegible signature at time of 18:00.

Based on review of documents and staff interview, the facility failed to ensure the QAPI program included all required elements:

(a) Program scope.
(1) The program must include, but not be limited to, an ongoing program that showed measurable improvement in indicators for which there is evidence that it will improve health outcomes and identify and reduce medical errors.
(2) The hospital must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital service and operations.

(b) Program data.
(1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions.
(2) The hospital must use the data collected to-
(i) Monitor the effectiveness and safety of services and quality of care; and
(ii) Identify opportunities for improvement and changes that will lead to improvement.

(3) The frequency and detail of data collection must be specified by the hospital's governing body.

Findings were:

On the afternoon of 5/23/23, in an interview with Staff #1, Director of Quality and Infection Control, she reported she had been in her position since October of 2022 and had no prior QAPI experience. Monthly, from October through December 2022, she had been submitting quality data to corporate to include items such as antibiotic stewardship, behavioral/recreational therapy, hospital-acquired conditions, and infection control. She reported quality data had not been collected since December, except for seclusion and restraint information. When asked what happened when data was previously collected, she reported, "We would send it to corporate;" there was no analyzing, tracking, or trending of quality indicators. The data was not used to monitor the effectiveness and safety of services and quality of care. When asked if there were any performance improvement plans in place, she reported they were monitoring restraint and seclusions only.

Review of the job description for Staff #1, Director of Quality and Infection Control, stated in part, "Position Summary: The Clinical Quality and Infection Control Specialist supports the implementation and monitoring of the quality assurance measurements and audits, and assists in improving patient safety processes throughout the hospital through coordinating and engaging in activities to proactively promote implementation of evidence based best practices and resolve deficiencies.
...Job Functions
o Implements and monitors quality and infection control goals and objectives to measure the organization's processes and outcomes while administering programs that focus on improved outcomes of patient care or patient safety.
o Interacts with physicians, nurses, department managers, supervisors, and any/all other staff members to provide resource information, and identify new opportunities to improve service and reduce costs.
...o Prepares reports, presentations and statistical data that go to the Quality Assurance and Performance Improvement Committee Meetings, Infection Control Committee Meetings, facility's administration and other committees as needed. Analyzes data to identify trends and resource utilization for use in optimizing compliance.
o Assists with the annual assessment of the quality and infection control programs from the prior year activities.
o Investigates incidents within the facility and coordinates with the Corporate Compliance to complete the root cause analysis and develop action plans to prevent incidents in the future.
o Establish a structure to ensure that patient care activities are addressed in a coordinated manner involving quality improvement and infection control functions."

Review of the facility-provided document titled "Quality Assurance & Performance Improvement Workplan (QAPI) 2022" stated in part, "1. Purpose and Intent
Medical Behavioral Hospital of Clear Lake (MVHCL) is committed to excellent patient care and continuous quality improvement ... The QAPI allows for a systematic, coordinated and continuous approach to process design, performance measure, analysis and improvement, focusing upon the aspects and dimensions that address these values. The overarching goal of the program is continual improvement in patient care and safety practices. The QAPI Workplan is a working document for the monitoring, implementation, and documentation of efforts to improve in the quality of care delivered to patients.
...5.NPH Quality Review Committee
The NPH Quality Review Committee (NPH QRC) is responsibility [sic] for reviewing the quality assurance and performance improvement activities of each hospital's Quality Council prior to reporting to MEC and GB. The NPH QRC is responsible for the following:
o Reviews and evaluates the results of quality assurance & performance improvement activities ...

6. Medical Behavioral Hospital of Clear Lake (MBHCL) Quality Council
The MBHCL Quality Council (QC) is hospital-based and is responsible for reporting and reviewing their quality metrics.
...Data will be collected monthly for all quality indicators and will be submitted to the MBHCL Quality Council. A report, which will provide summary data about the indicators, will be prepared for the Medical Executive Committee and Governing Board."

Based on review of documents and staff interview, the facility failed to ensure the QAPI:
(ii) Program data collected, identified opportunities for improvement and changes that will lead to improvement.

(1) Program Activities set priorities for its performance improvement activities that-
(i) Focused on high-risk, high-volume, or problem-prone areas;
(ii) Considered the incidence, prevalence, and severity of problems in those areas; and
(iii) Affected health outcomes, patient safety, and quality of care.

(3) took actions aimed at performance improvement.

Findings were:

On the afternoon of 5/23/23, in an interview with Staff #1, Director of Quality and Infection Control, she reported the only quality data collected or tracked was restraint and seclusion information. She stated data collection was "not being done." She collected the data for about a month when she first stared, but stated, "We have no data since then."
The facility had not been collecting data to identify opportunities for improvement and changes. The quality program had not been using data to set priorities for its performance improvement activities that: focused on high-risk, high-volume, or problem-prone areas; that considered the incidence, prevalence, and severity of problems in those areas; and affected health outcomes, patient safety, and quality of care. The facility did not take any actions aimed at performance improvement.

Review of the facility-provided document titled "Quality Assurance & Performance Improvement Workplan (QAPI) 2022" stated in part,
"3. Continuous Quality Improvement Activities
o MBHCL has adopted the following continuous quality improvement activities:
o Collecting and analyzing data to measure against the goals, or prioritized areas of improvement that have been identified;
o Identifying opportunities for improvement and deciding which activities to pursue;
o Identifying relevant committees internal or external to ensure appropriate exchange of information with the Quality Council (QC);
o Obtaining input from providers, staff, and leadership in identifying barriers to quality care and administrative services;
o Designing and implementing interventions for improving performance..."

Based on review of documents and staff interview, the facility failed to identify and reduce medical errors; measure, analyze, and track adverse patient events and have performance improvement activities that tracked medical errors and adverse patient events, analyzed their causes, and implemented preventive actions and mechanisms that included feedback and learning throughout the hospital.

Findings were:

Review of the facility-provided document titled "Quality Assurance & Performance Improvement Workplan (QAPI) 2022" stated in part, "7. Subcommittees
Other committees shall be established and/or incorporated over the course of the year per the 2023 Workplan. The general roles of and responsibilities of these Council and Committees are as follows:
o EOC/Patient Safety Committee (PSC) -The Patient Safety Committee is responsible for oversight of best practices, including; National Patient Safety Goals, hospital culture and patient and employee satisfaction. The PSC meets quarterly at minimum and makes recommendations on areas that may need to be addressed with a performance improvement project.
...o Employee Engagement Committee (EEC) (Implementation Phase) -The Employee Engagement Committee meets quarterly, at minimum, to identify opportunities to increase staff morale and job satisfaction, increase retention of staff and to improve open communication with staff on areas for improvement. The EEC makes recommendations on areas that may need to be addressed.
o Orientation & Education Committee (OEC) (Implementation Phase) -The Orientation & Education Committee meets quarterly, at minimum, to review and update the orientation program and to identify areas that need additional education and/or training. Changes to the program are reviewed and recommendations may be made for additional monitoring for impact of training."

On the afternoon of 5/24/23, in an interview with Staff #1, Director of Quality and Infection Control, she stated, "No, we don't have a safety officer right now, it was Plant Ops (the person previously in that position)," the facility currently did not have a Plant Ops (Operations) Director or a Safety Officer appointed. She reported there was no quality data that was monitored, tracked, trended, or analyzed except restraint and seclusion. When asked about the quality subcommittees: PSC, EEC, and OEC referenced in the QAPI plan, she stated, "I don't know those."

Based on review of documents and staff interview, the facility failed to ensure the hospital conducted performance improvement projects.

Findings were:

On the afternoon of 5/23/23, in an interview with Staff #1, Director of Quality and Infection Control, she reported there were no performance improvement projects and quality was monitoring only restraints and seclusions. There was no documentation of quality improvement projects as none were being implemented.

Review of the facility-provided document titled "Quality Assurance & Performance Improvement Workplan (QAPI) 2022" stated in part,

"11. Performance Improvement Processes and Methodology
The Quality Improvement Plan is a framework for Medical Behavioral Hospital of Clear Lake's ongoing and systematic measurement, assessment and performance improvement activities. The components of this plan include:
A structured process quality and improvement method such as but not limited to Dashboards and/or graphs.

...2023 Quality Assurance & Performance Improvement Workplan
This is a living document and may be changed as needed.
During 2023, NPH as an organization, is committed to four organizational performance improvement initiatives:
1. Develop more robust quality program
2. Improve clinical outcomes
3. Enhance data-driven decision-making
4. Staff education and engagement
2023 measurable objectives are incremental and based on Quality Council and NPH's Executive Leadership's judgment of what is manageable and possible to achieve in one year based on current resources. Each year NPH will review the previous year's findings and adjust its measurable objectives accordingly. NPH's longer-term goal is to improve performance expectations every year to improve the quality of care, safe work environment and increase employee satisfaction.

Initiative 1: Develop More Robust Quality Program
1. Lay out of NPH quality program.
2. Develop the NPH 2023 Quality Assurance & Performance Improvement Workplan
3. Review and update quality metrics for departments.
4. Build culture of patient safety and clinical excellence through partnership with Patient Safety and creation of various committees.
5. Develop benchmarks at the end of the 2023 year for 2024.

Initiative 2: Improve Clinical Outcomes
1. Provide ongoing training about measuring outcomes to hospital administration and department heads.
2. Require all departments to have at least one outcome measure that they monitor regularly.
3. Produce quality performance dashboards surrounding priority clinical initiatives so that hospitals can make data-driven decisions that lead to better clinical outcomes. Initiatives to be rotated as needed.
4. Choose two evidence-based practices that improve clinical outcomes and develop staff trainings on these methods.

...2023 Pl Priorities identified by Leaders
Department : Pl Project
Infection Control, Quality Performance, Nursing : Influenza vaccine for patients, HBIPS
Pharmacy, Nursing : Overrides
Contracted Services, Nursing : LabCorp Quality Reporting & Specimen Acceptability
Additional performance improvement projects may be identified and conducted throughout the course of the 2023 year."

Based on review of documents and staff interview, the facility failed to ensure the QAPI program reflected the complexity of the hospital's organization and services; involved all hospital departments and services (including those furnished under contract or arrangement); and failed to maintain and demonstrate evidence of its QAPI program for review by CMS.

Findings were:

On the afternoon of 5/23/23, in an interview with Staff #1, Director of Quality and Infection Control, she reported the only data collection or performance improvement project for quality for 2023 was regarding restraints and seclusions. There was no other data, there was no monitoring, analyzing, tracking, or trending. There was no documentation, as there had been no data collection or quality meetings for 2023. The facility QAPI program did not involve all hospital departments and services including: nursing, dietary, pharmacy, laboratory, physical environment, housekeeping, infection control and antibiotic stewardship, discharge planning, therapy services, patient safety, etc.

Review of the facility-provided document titled "Quality Assurance & Performance Improvement Workplan (QAPI) 2022" stated in part, "4. Governing Board & Medical Staff
The Governing Board is ultimately responsible for the quality of patient care provided. The Governing Board requires the medical staff, to implement and report on the quality assessment and performance improvement activities and the mechanisms for process design and performance measurement, analysis and improvement; to monitor, assess and evaluate the quality of patient care, to identify and reduce the risk of sentinel events; to resolve
problems and to identify opportunities to improve patient care and services. This process addresses those departments/disciplines that have direct or indirect effect on patient care, including management and administrative functions.
The medical staff provides effective mechanisms to monitor, assess and improve the quality and appropriateness of patient care and the clinical performance and competency of all individuals with delineated clinical privileges. Performance improvement opportunities are addressed, with improvement strategies and actions implemented, to assure improved performance is achieved and sustained.
The Medical Executive Committee delegates the oversight responsibility for performance activity monitoring, assessment and improvement of patient care services provided throughout the facility to the Quality Council, and to the facility Administrator/ Quality Official and/or his or her designee."

Based on review of documents and staff interview, the hospital's governing body, medical staff, and administrative officials failed to ensure the following:
(1) That an ongoing program for quality improvement and patient safety, including the reduction of medical errors, is defined, implemented, and maintained.
(2) That the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated.
(5) That the determination of the number of distinct improvement projects is conducted annually.

Findings were:

On the afternoon of 5/23/23, in an interview with Staff #1, Director of Quality and Infection Control, she reported the only data collection or performance improvement project for quality for 2023 was regarding restraints and seclusions. There was no other data, there was no monitoring, analyzing, tracking, or trending. There had been no data collection or quality meetings for 2023.

Review of the facility-provided document titled "Quality Assurance & Performance Improvement Workplan (QAPI) 2022" stated in part, "8. Medical Behavioral Hospital of Clear Lake
...Management/ Staff Responsibility
Every department within Medical Behavioral Hospital of Clear Lake's responsible for implementing quality and any needed performance improvement activities. Each department manager is responsible for monitoring the performance of their department. Managers and department staff identify quality indicators, collect and analyze data, develop and implement changes to improve service delivery. Ongoing monitoring assures that improvement is made and sustained. The ultimate goal is to improve the quality and safety of care that is routinely provided to the patients of Medical Behavioral Hospital of Clear Lake.
...12. Communication
Medical Behavioral Hospital of Clear Lake's Chief Executive Officer, along with select Corporate staff members, provides oversight of performance improvement activities. The Data tracking, trending and aggregates from a variety of sources will be used to prepare reports for NPH Quality Council, Medical Executive Committee and Governing Board. Communication on organizational and departmental performance is ongoing.
13. Education
"Everyone in the organization is responsible for quality and safety. Therefore, education all employees at all levels of the organization is critical to the success of QPI. Because the most common cause of failure in any QPI effort is uninvolved or indifferent top and middle management, it is essential that all leaders be educated from the start. Training should begin at the top and cascade down through the organization." (White, 2012, p. 79). Education is provided to Hospital Administration and department leaders regarding Quality and impact of Quality to patient care and the overall organization.

Based on review of documents and staff interview, the facility failed to ensure adequate resources were allocated for measuring, assessing, improving, and sustaining the hospital's performance and reducing risk to patients.

Findings were:

On the afternoon of 5/23/23, in an interview, Staff #1, Director of Quality and Infection Control, reported she had been in her position since October of 2022 and had no prior QAPI experience. Monthly, from October through December 2022, she had been submitting quality data to corporate, but there was no analyzing, tracking, or trending of quality indicators. When asked if she had been trained in quality, she reported she had one phone call regarding quality and has been looking to implement the quality program but has not had time.

Review of the job description for Staff #1, Director of Quality and Infection Control, stated in part, "Position Summary: The Clinical Quality and Infection Control Specialist supports the implementation and monitoring of the quality assurance measurements and audits, and assists in improving patient safety processes throughout the hospital through coordinating and engaging in activities to proactively promote implementation of evidence based best practices and resolve deficiencies.
...Specialized Knowledge and Skill Requirements
Professional knowledge of clinical practice, leadership, performance improvement and research statistics in order to conduct surveillance and prepare related reports at a level normally acquired through the completion of a Bachelor's degree from an approved School of Nursing.
Job Functions
o Implements and monitors quality and infection control goals and objectives to measure the organization's processes and outcomes while administering programs that focus on improved outcomes of patient care or patient safety.
o Interacts with physicians, nurses, department managers, supervisors, and any/all other staff members to provide resource information, and identify new opportunities to improve service and reduce costs.
o Generates effectual quality and infection control related policies and procedures for the department and hospital that ensures compliance with JC, OSHA, CDC, CMS and other county, state, and federal regulatory agencies.
o Prepares reports, presentations and statistical data that go to the Quality Assurance and Performance Improvement Committee Meetings, Infection Control Committee Meetings, facility's administration and other committees as needed. Analyzes data to identify trends and resource utilization for use in optimizing compliance.
o Assists with the annual assessment of the quality and infection control programs from the prior year activities.
o Investigates incidents within the facility and coordinates with the Corporate Compliance to complete the root cause analysis and develop action plans to prevent incidents in the future.
o Establish a structure to ensure that patient care activities are addressed in a coordinated manner involving quality improvement and infection control functions.
...Participates in root-cause analysis, sentinel events, adverse events and identifies trends as directed by Compliance or Operations. Recommends ways to redesign systems for improvements if needed."

Review of the facility-provided document titled "Quality Assurance & Performance Improvement Workplan (QAPI) 2022" stated in part, "6. Medical Behavioral Hospital of Clear Lake (MBHCL) Quality Council
The MBHCL Quality Council (QC) is hospital-based and is responsible for reporting and reviewing their quality metrics. The MBHCL QC meets quarterly at minimum to review data and performance improvement activities. Meetings may occur more often as needed. The MBHCL QC is responsible for identifying metrics not meeting the 90% benchmark for possible implementation of a performance improvement project (PIP), based on cause of the decline in the performance of the metric. Departments report progress on PIPs each meeting.
Data will be collected monthly for all quality indicators and will be submitted to the MBHCL Quality Council. A report, which will provide summary data about the indicators, will be prepared for the Medical Executive Committee and Governing Board.
...12. Communication
Medical Behavioral Hospital of Clear Lake's Chief Executive Officer, along with select Corporate staff members, provides oversight of performance improvement activities. The Data tracking, trending and aggregates from a variety of sources will be used to prepare reports for NPH Quality Council, Medical Executive Committee and Governing Board. Communication on organizational and departmental performance is ongoing.
13. Education
'Everyone in the organization is responsible for quality and safety. Therefore, education all employees at all levels of the organization is critical to the success of QPI. Because the most common cause of failure in any QPI effort is uninvolved or indifferent top and middle management, it is essential that all leaders be educated from the start. Training should begin at the top and cascade down through the organization.' (White, 2012, p. 79). Education is provided to Hospital Administration and department leaders regarding Quality and impact of Quality to patient care and the overall organization. "

Based on review of the facility's Medical Staff Bylaws, record review, and confirmed in interview the facility failed to ensure that the medical staff were organized and accountable for the medical care provided to the patients.

Findings included:

Review of the facility's Medical Staff Bylaws under function, it states in part "the committee shall be responsible for governance of the Medical Staff, shall serve as a liaison mechanism between the Medical Staff, Hospital administration and the Board and shall be empowered to act for the Medical Staff in intervals between Medical Staff meetings, within the scope of its responsibilities as defined below. When approval of procedural details related to credentialing, corrective action, or selection and duties of leadership are delegated to the MEC, it shall represent to the Board the organized Medical Staff's view on issues of patient safety and quality of care. The authority of the MEC is outlined in this Section and additional functions may be delegated or removed through amendment of this Section. The functions and responsibilities of the MEC shall include at least the following:
(a) Receiving and acting upon committee reports
(f) Assuring regular reporting of QAPI and other staff issues to the Board as well as communicating findings, conclusions, recommendations and actions to improve performance to the Board and appropriate Medical Staff members
(g) Assuring an annual evaluation of the effectiveness of the Hospital's QAPI program is conducted
(h) Developing and monitoring compliance with the Bylaws, Rules & Regulations, policies and other Hospital standards...
MEETINGS
The MEC shall meet as needed, but at least quarterly and maintain a permanent record of its proceedings and actions...
STANDING ORGANIZATIONAL COMMITTEES AND FUNCTIONS
GENERAL PROVISIONS AND FUNCTIONS
(a) The primary function of each organizational committee is to implement specific review, measurement and evaluation activities that contribute to the preservation and improvement of the quality and efficiency of patient care provided in each of the Hospitals.
(b) The Medical Executive Committee may appoint special or ad hoc committees to perform functions that are not within the stated functions of one (1) of these committees.
(c) Each committee shall keep a permanent record of its proceedings and actions. All committee actions shall be reported to the MEC.
(d) All information pertaining to activities performed by Medical Staff committees shall be privileged and confidential to the full extent provided by law.
(e) The CEO or their designee shall serve as an ex-officio member, without vote, of each organizational Standing and special Medical Staff committees.
COMMITTEE POLICIES
All organizational Standing Committees shall have written policies which govern the activity of their committee. These policies shall be approved by the Governing Board.
MEDICAL STAFF COMMITTEES
9.3(a) COMMITTEE CATEGORIES
There shall be Medical Staff Committees of: Quality, Pharmacy and Therapeutic, Infection Control and Utilization Review. The Medical Director or Director of Medical Services shall duly appoint or facilitate elections of Medical Staff to organizational committees.
9.3(b) QUALITY COMMITTEE
The Medical Staff Quality Committee will pursue Hospital quality initiatives and select cases for presentation at Medical Staff meetings that will contribute to the continuing education of every
Practitioner. Such review shall include a consideration of all deaths, selected patients with infections, serious life-threatening complications,significant errors in diagnosis and treatment, proper utilization of facilities and services, and other significant patient care matters. The quality committee will meet at least quarterly.
The Ouality Committee shall be responsible for assuring that all medical records meet the standards of patient care, usefulness and historical validity. The Medical Staff representatives shall be specifically responsible for assuring that the medical records reflect realistic documentation of medical events. The committee shall ensure that monthly review of currently maintained records is conducted to assure that they properly describe the condition and progress of the patient, the therapyprovided and results thereof, the identification of responsibility for all actions taken and that the records are sufficiently complete so as to meet the criteria of medical comprehension of the case in the event of transfer of physician responsibility for patient care.
They shall also ensure that a reviewof records of discharged patients is conducted to determine the promptness, pertinence, adequacy and completeness thereof.
9.3(c) PHARMACY AND THERAPEUTICS COMMITTEE
(a) The Pharmacy and Therapeutics committee shall be responsible for the development and review of all drug utilization policies and practices within the Hospital organization.
Pharmacists shall report to the Pharmacy and Therapeutics committee. The committee shall assist in the formulation of broad professional policies regarding the evaluation, appraisal, selection, procurement, storage, distribution, use, safety procedures, and all other matters relating to medication use in the Hospital organization. It shall also perform the following specific functions:
Serve as an advisory group to the Medical Staff and the pharmacist in matters pertaining to the choice of available drugs
Make recommendations concerning drugs to be stocked on the nursing units and by other services
Develop and review periodically a formulary or drug list for use in the Hospital
Evaluate clinical data concerning new drugs or preparations requested for use in the Hospital
(b) The Pharmacy and Therapeutics Committee shall be responsible for the development and oversight of proper and appropriate utilization of drugs used for Hospital patients. The following specific functions will be monitored:
Therapeutic, empiric and prophylactic use of drugs to assess effectiveness, patient safety and appropriate choice
Drug adverse reactions, whether due to the drug itself or interaction with other drug regimens to decrease health risk
Drug therapies in association with the Hospital's pharmacy provider, administration, and nursing service
Drug utilization considered in the Medical Staff reappointment processes
Medication errors delegated to pharmacy services
(c) Pharmacy and Therapeutics Committee shall be composed of at least 2 members of the Medical Staff who shall be encouraged to attend all meetings. At least one member of the Medical Staff must be present for any action to be taken. More formal attendance requirements will be instituted if necessary.
9.3(d) INFECTION CONTROL COMMITTEE
(a) The Infection Control Committee shall be responsible to monitor inadvertent Hospital infection potentials, review summary reports and infection analysis, review and analyze actual infections, promote a preventative and corrective action program designed to minimize infection hazards, and the supervision of infection control practices in the following situations:
sterilization procedures isolation procedures prevention of cross-infection testing of personnel for carrier/contagious status disposal of infectious material outbreak investigation other situations as may be requested by the Governing Body
(b) The Infection Control Committee will review summary reports of all mortalities in the hospital. The mortality review shall determine whether all cases had appropriate evaluation and care.
(c) Joint advisor function will be served through Medical Staff representation on the board by the Medical Director or Director of Medical Services.
(d) All other required functions are served directly through or with reporting relationships with the Quality Committee. The Quality Committee reports to the Medical Executive Committee, who then reports to the Board.
9.3(e) UTILIZATION REVIEW COMMITTEE
(a) Utilization Review Committee is composed of one member of the Medical Staff appointed by the Medical Director or Director of Medical Services who must not have any ownership interest in the Hospital or other actual or potential conflicts of interest which may interfere with their disinterested performance of this responsibility. Members will also not review cases in which they were professionally involved in the patient care. The other members of the committee are appointed by the Board based on their knowledge and responsibilities within the organization, which enables them to assist this committee.
(b) The committee is responsible for review of:
The medical necessity of admissions
The appropriateness of the setting
The medical necessity of extended staff
The medical necessity of professional care including drugs and biologicals
(c) The utilization review function will not be limited to government payer sources.
(d) The medical records administration shall be a resource to the committee. Confidentiality of review will be maintained and utilization review activities are categorized as peer review.
(e) The Utilization Review Plan will be utilized in accomplishing reviews for:
Preadmission certification
Admission and continued stay
it. Potential patterns of ineffective resource utilization-by exception, exceeding LOS standard
Denials-retrospective by exception- physician disagrees
Professional services furnished thru QAPI evolution of concerns vi. Length of stay-by exception (f) Practitioners responsible for cases where the admission or continued stay is deemed by the review not to be necessary are notified by the committee for a presentation of their views to the chair. If issue is not resolved, the Medical Director or Director of Medical Services and/or administration may become involved to attempt to achieve resolutions. If committee denial of medical necessity is not reversed, written notification is given no later than two days after the determination to the hospital, patient and the practitioners) responsible for the patient's care.
The Utilization Review Committee must make a periodic review of each current inpatient admission receiving hospital services during a continuous period of extended duration.
(g) The committee will also be responsible for review of professional services as this affects utilization review and will perform this function in collaboration with the quality representative who will be an ad-hoc member of the committee. Professional services are an integral part of quality and information sharing facilitates the function of quality and utilization review.
MEETINGS
The Medical Staff Committees shall meet as needed, but at least quarterly and maintain a permanent record of its proceedings and actions."

Review of the Medical Staff Meeting minutes from 2022 and 2023 revealed no documentation of the above committee meetings (Quality, Pharmacy and Therapeutic, Infection Control and Utilization Review) to include the functions and responsiblities outlined in the Medical Staff Bylaws. Furthermore, no policies of each committee were availalble for review.

An interview with the the Director of Quality (Staff #1) on 05/23/2023 at 0240 PM in the conference room confirmed that there are no separate committee meetings. Only the directors of Nursing, Quality and CEO, COO each gathered data to present in the medical staff meeting quarterly but it does not include all the functions above. She also acknowledged that pharmacy does not participate in any meetings.

I. Based on observation, interview, and record review, the facility failed to ensure a Registered Nurse (RN) was available 24 hours a day on 8 of 8 days reviewed on 3 (Unit 100 Medically Compromised/Geriatric Patients, Unit 300 General Adult Patients, and Unit 400 Acute Adult Patients) of 3 patient care units.

This deficient practice had the likelihood to cause harm to all patients. If the RN was not immediately available on the patient care units, it increased the risk of harm to all patients and staff during a behavioral or medical emergency. For leadership nursing staff to be available from the Administration area, they would have to access locked doors before entering the unit to be of assistance to the Licensed Vocational Nurse (LVN) and/or Unlicensed personnel.

The deficient practices were identified under the following Condition of Participation, CFR 482.23 Nursing Services, and were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death.

Findings:

During a tour of Unit 100 on 5/22/2023 at 10:25 AM, 1 RN, 1 LVN, and 4 Behavioral Health Aides (BHA's) were observed giving direct patient care for 22 patients.

An interview was conducted with Staff #16 (RN) on 5/22/2023 at 10:30 AM. Staff #16 was asked who made the staffing assignments for each unit. Staff #16 replied, "The RN's make the assignments for the day and put them on the assignment sheet and post it on the unit."

A review of the document titled, "Staff Assignment Sheet" for 5/22/2023 for 7 am-7 pm revealed Staff #16 was scheduled for lunch at 10:30 AM. At 10:40 AM Staff #16 was observed leaving the unit for lunch leaving the LVN (licensed vocational nurse) unsupervised by an RN and responsible for 22 patients.

An interview was conducted with Staff #17 (LVN) on 5/22/2023 at 10:45 AM. Staff #17 was asked if another RN was available for assistance if needed. Staff #17 stated, "I guess I could call someone if I needed help or one of the BHAs could go and get help." Staff #17 confirmed that the RN and LVN relieve each other for lunch daily. Staff #17 stated, "We do not have enough staff to come and relieve us for lunch so, if we want to take a lunch then we have to let each other go."

A review of the staffing schedules, staffing matrix, and staff assignment sheets dated 5/16/2023 through 5/22/2023 was conducted with Staff #3 (Director of Nursing, DON) on 5/23/2023 and revealed the following:


5/16/2023
Unit 100
Day shift patient census was 20. A review of the staff assignment sheet revealed Staff #36 (RN) took a scheduled 30-minute lunch break at 3:00 PM leaving Staff #17 (LVN) unsupervised by an RN and responsible for 20 patients.

Unit 300
Day shift patient census was 11. A review of the staff assignment sheet revealed Staff #37 (RN) was the only nurse scheduled. Staff #3 (DON) confirmed Staff #37 was deducted a 30-minute lunch break. Staff #3 confirmed there was no relief nurse documented and he was unable to confirm or deny if a RN relieved Staff #37 for lunch.

Night shift patient census was 11. A review of the staff assignment sheet revealed Staff #38 (RN) was the only nurse scheduled. Staff #3 (DON) confirmed Staff #38 was deducted a 30-minute lunch break. Staff #3 confirmed there was no relief nurse documented and he was unable to confirm if an RN relieved Staff #38 for lunch.


Unit 400
Day shift patient census was 18. A review of the staff assignment sheet revealed Staff #40 (RN) took a scheduled 30-minute lunch break at 2:00 PM leaving Staff #39 (LVN) unsupervised by an RN and responsible for 18 patients.

5/17/2023
Unit 100
Night shift patient census was 22. A review of Staff #34's (RN) timesheet revealed she took a scheduled 30-minute lunch break leaving Staff #41 (LVN) unsupervised by an RN and responsible for 22 patients.

Unit 300
Night shift patient census was 12. A review of the staff assignment sheet revealed Staff #42 (RN) was the only nurse scheduled. Staff #3 (DON) confirmed Staff #42 was deducted a 30-minute lunch break. Staff #3 confirmed there was no relief nurse documented and he was unable to confirm if an RN relieved Staff #42 for lunch.


5/18/2023
Unit 100
Day shift patient census was 22. A review of the staff assignment sheet revealed Staff #16 (RN) took a scheduled 30-minute lunch break at 10:30 AM leaving Staff #17 (LVN) unsupervised by an RN and responsible for 22 patients.

Unit 300
Day shift patient census was 12. A review of the staff assignment sheet revealed Staff #33 (RN) was the only RN scheduled. Staff # 3 (DON) confirmed Staff #33 took a scheduled 30-minute lunch break at 2:00 PM. Staff #3 confirmed he was unable to confirm if an RN relieved Staff #37 for lunch.

Night shift patient census was 12. A review of the staff assignment sheet revealed Staff #42 (RN) was the only nurse scheduled. Staff #3 confirmed Staff #42 was deducted a 30-minute lunch break. Staff #3 confirmed there was no relief nurse documented and he was unable to confirm if an RN relieved Staff #42 for lunch.

Unit 400
Day shift patient census was 18. A review of the staff assignment sheet revealed Staff #36 (RN) took a scheduled 30-minute lunch break at 3:00 PM leaving Staff #35 (LVN) unsupervised by an RN and responsible for 18 patients.

Night shift patient census was 18. A review of the staff assignment sheet revealed Staff #42 (RN) was the only RN scheduled. Staff # 3 confirmed Staff #42 took a scheduled 30-minute lunch break but was unable to confirm if an RN relieved Staff #42 for lunch.

5/19/2023
Unit 300
Day shift patient census was 11. A review of the staff assignment sheet revealed Staff #3 (DON) was assigned to the unit from 11:00 AM-7:00 PM. Staff #3 took a scheduled 30-minute lunch break at 3:30 PM. Staff #3 confirmed there was no documentation that an RN relieved him for lunch. Staff #3 stated, "I would not have left the unit unsupervised by a nurse, but I do that I would never leave the unit without a nurse, but I cannot confirm that I was relieved by another RN for a lunch break. I may have eaten my lunch on the unit that day."

Night shift patient census was 11. A review of the staff assignment sheet revealed Staff #38 (RN) was the only nurse scheduled. Staff #3 confirmed Staff #38 was deducted a 30-minute lunch break but was unable to confirm if an RN relieved Staff #38 for lunch.

Unit 400
Day shift patient census was 21. A review of the staff assignment sheet revealed Staff #37 (RN) took a scheduled 30-minute lunch break at 2:00 PM leaving Staff #39 (LVN) unsupervised by an RN and responsible for 21 patients.


5/20/2023
Unit 100
Day shift patient census was 23. A review of the staff assignment sheet revealed Staff #36 (RN) took a scheduled 30-minute lunch break at 3:00 PM. Staff #3 (DON) confirmed Staff #36 was deducted a 30-minute lunch break but was unable to confirm if an RN relieved Staff #36 for lunch.


Unit 300
Day shift patient census was 12. A review of the staff assignment sheet revealed Staff #33 (RN) took a scheduled 30-minute lunch break at 2:30 PM. Staff #3 (DON) confirmed Staff #33 was deducted a 30-minute lunch break but was unable to confirm if an RN relieved Staff #33 for lunch.

Night shift patient census was 12. A review of the staff assignment sheet revealed Staff #3 (DON) took a scheduled 30-minute lunch break at 2:30 AM. Staff #3 confirmed there was no documentation that an RN relieved him for lunch. Staff #3 stated, "I would not have left the unit unsupervised by a nurse, but I know I was either relieved by an RN or I ate my lunch on the unit."

Unit 400
Day shift patient census was 22. A review of the staff assignment sheet revealed Staff #37 (RN) took a scheduled 30-minute lunch break at 3:00 PM leaving Staff #39 (LVN) unsupervised by an RN and responsible for 22 patients.


5/21/2023
Unit 100
Day shift patient census was 24. A review of the staff assignment sheet revealed Staff #20 (RN) took a scheduled 30-minute lunch break at 10:00 AM leaving Staff #17 (LVN) unsupervised by an RN and responsible for 24 patients.

Unit 300
Day shift patient census was 12. A review of the staff assignment sheet revealed Staff #33 (RN) was the only nurse scheduled. Staff #3 (DON) confirmed Staff #33 was deducted a 30-minute lunch break but was unable to confirm if an RN relieved Staff #33 for lunch.

Night shift patient census was 12. A review of the staff assignment sheet revealed Staff #19 (RN) was the only nurse scheduled. Staff #19 documented a 30-minute lunch break at 12:30 AM. Staff #3 (DON) confirmed Staff #19 was deducted a 30-minute lunch break but was unable to confirm if an RN relieved Staff #19 for lunch.

Unit 400
Day Shift patient census was 22. A review of the staff assignment sheet revealed Staff #37 (RN) took a scheduled 30-minute lunch break at 4:00 PM leaving Staff #39 (LVN) unsupervised by an RN and responsible for 24 patients.


5/22/2023-No PM shift was provided for review
Unit 100
Day shift patient census was 22. During observation on the unit, Staff #16 (RN) left the unit for lunch at 10:40 AM leaving Staff #17 (LVN) unsupervised by an RN and responsible for 20 patients.

Unit 300
Day shift census was 12. A review of the daily assignment sheet revealed Staff #33 (RN) was the only nurse on the unit and had a scheduled lunch break at 3:00 PM. A review of Staff #33's timecard revealed she was deducted for a 30-minute lunch break. Staff #3 (DON) confirmed there was no documentation of who relieved the nurse for lunch. There was no documentation provided to the surveyor to ensure that Unit 300 was supervised by a RN during Staff #33's scheduled 30 minute lunch break.

Unit 400
Day shift patient census was 19. A review of the daily assignment sheet revealed Staff #34 (RN) was scheduled until 11:00 AM. Staff #3 (DON) confirmed there was no other nursing personnel written on the daily assignment sheet. A review of the document titled, "Computerized schedule management" provided by Staff #3 revealed Staff #13 (RN) was scheduled to work on the unit from 10:30 AM to 7:30 PM and Staff #35 (LVN) was scheduled to work from 10:30 AM-7:30 PM. A review of the timecard for Staff #13 (RN) revealed she was deducted a 30-minute lunch break leaving Staff #35 (LVN) unsupervised and responsible for 19 patients.


5/23/2023
Unit 100
Day shift patient census was 22. During an observation of Unit 100 on 5/23/2023 at 11:20 AM Staff #16 (RN) was off the unit for a 30-minute scheduled lunch break. At 11:35 AM Staff #36 (RN) escorted this surveyor off the locked unit to the hospital entrance. This left no licensed nurse on the unit to assess a patient if there was a medical or behavioral emergency.

Night shift patient census was 22. A review of Staff #34's (RN) timesheet revealed she took a scheduled 30-minute lunch break leaving Staff #41 (LVN) unsupervised by an RN and responsible for 22 patients.

An interview was conducted with Staff #3 (DON) on 5/25/2023 after 11:00 AM. Staff #3 was asked how he determined the scheduling needs for each unit. Staff #3 replied, "I use a computerized scheduling program. I can put the employee name, time, and the unit they are scheduled to work on into the program. It is made out in advance and is subject to change because people call in sick, or they are on vacation, or need to leave early and so on. I can go back in and enter the changes so that it reflects who actually worked on that day. The handwritten daily assignment sheet is completed by the charge nurse on each unit. It shows the staff names, assignments, lunch break times, and patients that are on increased observations. That daily assignment sheet is made out by the charge nurse on each unit."

Staff #3 was asked if the LVN's were supervised by a RN at all times. Staff #3 replied, "There is a RN scheduled with the LVN. There is never a LVN scheduled on the unit alone. I understand they must be supervised by a RN. We are hiring more RNs and have some in orientation right now, but they are not ready to be on the units. Most of our shifts are staffed with a LVN and a RN. Somedays we have House Supervisors (Nursing Supervisors) that can go and relieve nurses for lunch or assist with other duties as needed."

Staff #3 confirmed the staffing matrix he was currently using was as follows:

"1-7 patients for the day and night was 1 RN and 1 BHA's
8-12 patients for the day and night was 1 RN and 2 BHA's
13-18 patients for the day and night shift was 1 RN, 1 LVN or additional RN, and 2 BHA's
19-24 patients for the day and night shift was 1 RN, 1 LVN or additional RN, and 3 BHA's."

Staff #3 confirmed there was no documentation of who or if anyone relieved the RN for a scheduled 30-minute lunch break. Staff #3 also confirmed that the LVN was giving direct patient care and supervising unlicensed personnel without the supervision of a RN while the RN was on a scheduled 30-minute lunch break.

An interview was conducted with Staff #43 (Payroll) on 5/24/2023 at 4:30 PM. Staff #43 was asked if employees had to clock in and out for their lunch breaks. Staff #43 replied, "They are supposed to clock out if they leave the premises. Otherwise, a 30-minute lunch break is deducted daily." She was then asked how the employees notify the payroll department if they were unable to take a 30-minute lunch. She replied, "There is a variance form that the employee fills out and turns it in so they can get paid for their lunch. I have not had any variance forms for the month of May. That tells me that everyone has been taking their lunch breaks."

A review of the Texas Board of Nursing, Practice-Licensed Vocational Nurse Scope of Practice was as follows:

The Texas Nursing Practice Act (NPA) and the Board's Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN),

" ...15.27 The Licensed Vocational Nurse Scope of Practice
The LVN scope of practice is a directed scope of practice and requires appropriate supervision of a registered nurse, advanced practice registered nurse, physician assistant, dentist, or podiatrist ..."

Staff #3 confirmed there was no written documentation on the staffing assignment sheets dated 5/16/2023 through 5/24/2023 on 3 (Unit 100, Unit 300, and Unit 400) of 3 patient care units when the RN was on a scheduled 30-minute lunch break to ensure that an RN was immediately available to assist the LVN or unlicensed personnel during a medical or behavioral emergency.

II. Based on observation, document review and interview the facility failed to:

A. ensure Nursing Services was adequately staffed to provide safe care on 3 (Unit 100 Medically Compromised/Geriatric patients, Unit 300-General Adults, and Unit 400 Acute Adults) of 3 units. Nursing and/or BHAs (Behavioral Health Aides) staffing was short for 23 of 23 shifts reviewed.

B. follow their own policy for nurse staffing and patient acuity.


Findings


A review of the staffing matrix and daily staff assignment sheets dated 5/17/2023 through 5/20/2023 for Units 100, 300, and 400 was conducted with Staff #3 on 5/23/2023 and revealed the following:

Review of the document titled, "Nurse Staffing and Patient Acuity Plan", Policy Stat ID 10995137 with a last revised date of 2/2022 was as follows:
"POLICY:
Staffing for patient care is based on acuity and level of care needed for the medical/psychiatric patient.
The acuity tool is meant to provide an assessment tool based on patient medical conditions, behaviors and needs of the medical/psychiatric patient. This will be used for making patient assignments.
To provide a framework for nursing staff to evaluate the nurse-to-patient ratio and nursing level of care needed.
To provide adequate nursing coverage and ensure/maximize a safe therapeutic environment.
To prevent/minimize the use of physical holds.
GENERAL INFORMATION:
Staffing Plan:
The staffing and acuity plan are the hospital's method for establishing nursing personnel requirements needed to meet the patient needs/acuity. The plan is evaluated annually by clinical and senior leadership. Appropriate staffing requirements are based on a review of the current patient population, individual safety needs, historical and projected data, department specific quality indicators, and therapeutic goals. Each unit has a pre-determined core staffing patient to staff ratio used as a guideline.
Core Staffing Matrix per unit
Inpatient Programs for Days (7am-7pm) - Includes weekends and holidays
1-12 Patients-1 Registered Nurse, 1 Aide/Tech
13-24 Patients-1 Registered Nurse plus 1 other Nurse, 2 Aides/Techs
If only one unit is open in the facility 1-24 Patients- 1 Registered Nurse plus 1 other Nurse, 2 Aides/Techs
Inpatient Program for Nights (7pm-7am) - Includes weekends and holidays

1-12 Patients-1 Registered Nurse, 1 Aide/Tech
13-24 Patients-1 Registered Nurse plus 1 other Nurse, 2 Aides/Techs
If only one unit is open in the facility 1-24 Patients- 1 Registered Nurse plus 1 other Nurse, 2 Aides/Techs.

Daily Staffing:
The hospital utilizes twelve (12) hour shifts to provide continuous twenty-four (24) hour coverage. The Registered Nurse on the patient unit completes the acuity classification for the patient prior to the final determination of the next shift. It is the responsibility of the Registered Nurse on the nursing unit to make the nurse staff/patient shift assignments.

Procedure:
Each shift at the hospital, the acuity worksheet is completed by the Director of Nursing and/or
Registered Nurse assigned to the patient to ensure recognition of any change in a patient's condition requiring additional intervention(s) by nursing staff. The Registered Nurse and aide/tech allocations are reviewed and revised, as appropriate, based on the acuity contributory factors listed on the tool. The patients will be scored individually on the acuity worksheet and given a score.

Acuity Assignment:
1. The hospital acuity tool will be completed on each twelve (12) hour shift approximately three
hours prior to the end of the shift. The registered nurse will assign a number to the categories for each patient using the information gained during the shift, the report sheet and patient
assessment data.
2.The Registered Nurses will complete the Acuity Tool and assign staff (nurse, aide/tech) to the patients based on the needs/acuity. For example: if there are two (2) nurses for 16 patients on day shift, and two (2) of the patients are considered a level 4 acuity, those two patients will be split between the nurses. The level three (3) acuity patients will then be split between the staff, then the level two (2) patients will be divided among the staff, and lastly the level one (1)
patients will be divided among the staff.

3.A staff member will be assigned exclusively to an individual if the patient requires continuous 1 :1 monitoring. Another aide/tech or nurse depending on the total census and patient acuity will be assigned to make rounds, supervision, and safety checks for other patients. Staffing decisions are a collaborative effort between the Director of Nursing and Registered Nurse. When additional resources are warranted, unit assignments can be changed, staff requesting additional hours can be contacted or PRN Staff can be added.

4.A Registered Nurse is available 24 hours a day to evaluate the need for making staffing
changes. If there are changes in patient status, admissions or discharge, staffing changes will be made accordingly. The Director of Nursing and/or an Administrator On-Call is available for support, validation, and/or assistance with problem resolution.

5.At all times nursing administration has ultimate responsibility for providing adequate staff
coverage to provide a safe therapeutic environment. The physical environment, other crises, staff makeup, staff experience, staff qualifications, patient diagnoses, patient co-occurring
conditions, patients ages, and patient developmental functioning may have an effect on the acuity of the unit and therefore on staffing levels.

Staffing Variances:

1.Completed Acuity Sheets are maintained in a binder at the Nurses Station for review and
retention. When the Acuity binder is purged the acuity, sheets are to be stored on site in the Director of Nursing's Office and/or designated area.

2.Variations from staffing plans are documented with explanation by the Director of Nursing or Designee."

Staff #2 confirmed the policy did not give clear direction on when to increase the staffing to ensure safe care. It was also confirmed the policy did not give direction on how to address the acuity of each patient or when to increase or decrease the acuity levels.


Staff #3 was asked to explain the staffing plan for Unit 100, and Unit 400. Staff #3 replied, "We are staffing the units according to patient acuity. I always try and staff above our staffing grid but its not always possible. I use a computerized program to prepare the schedule in advance. The Charge Nurse makes the daily assignments at the beginning of each shift and puts them on the Staffing Assignment Sheet posted on each unit.
Sometimes what I have in the computer is not who actually works because there may be call-ins, vacations, emergency leave and so on, so it is subject to change." Staff #3 stated, "We are staffing to the patient acuity levels and the staffing matrix is the same for all units." Staff #3 could not provide any documentation on how to determine a patients acuity. There was no plan on when to increase staffing to ensure safe care was provided to all patients. He was unable to


Staff #3 confirmed the staffing matrix currently being used was as follows:

"1-7 patients for the day and night shift was 1 RN (Registered Nurse) and 1 BHA's (Behavioral Health Aid),
8-12 patients for the day and night shift was 1 RN and 2 BHA's
13-18 patients for the day and night shift was 1 RN, 1 LVN (Licensed Vocational Nurse) or additional RN, and 2 BHA's
19-24 patients for the day and night shift was 1 RN, 1 LVN or additional RN, and 3 BHA's.

Considerations: Acuity of Unit, Heavy Admits/Discharges Day, # (number) 1:1, Q5."


During an interview with Staff #3 on 5/23/2023 after 10:00 AM Staff #3 stated he was unsure if the Governing Body had approved the staffing matrix. Staff #3 was asked if the staffing matrix was an attachment to a policy. Staff #3 replied he had been using the matrix since he started. He stated he had only been there about 6 weeks. Staff #3 said, "I was told before I took this job what kind of shape the hospital was in. I was aware of all the problems before I accepted the position. They were open about everything. This was the staffing matrix that I was given when I started, and I have been using it ever since." Staff #3 was asked if there was a Nurse Staffing Committee that held routine meetings to help determine the staffing needs and evaluate the staffing plan that was being used. Staff #3 confirmed there was not a committee.



5/17/2023
Unit 100
Census-22 patients

A review of the day shift Staff Assignment Sheet revealed 3 RNs and 4 BHAs were scheduled. Two RNs split one shift with one scheduled from 7am-11am and the other 11am-7pm. There was 1 patient on a 1:1 observation and 2 patients on Q (every) 5-minute observations for safety. Both RNs took a scheduled 30-minute lunch break leaving 1nurse responsible for 22 patients. The unit was short 1 nurse during this time. The minimum staffing grid was met for the BHAs. There was no documentation of the patients acuity on this unit before the staffing assignments were made.

A review of the night shift Staff Assignment Sheet revealed 1 RN, 1 LVN and 4 BHAs were scheduled. Both nurses took a scheduled 30-minute lunch break leaving 1 nurse responsible for 22 patients. The unit was short 1 nurse during this time. 1 BHA was scheduled to leave at 11:00 PM. There were 2 patients on a 1:1 for safety, one patient on a 1:1 while awake and 3 patients on Q 5-minute observations. There was no BHA scheduled to monitor the 19 patients that were not on a 1:1. After 11:00 PM the unit was short 2 BHAs.

An interview was conducted with Staff #3 on 5/23/2023 after 10:00 AM. Staff #3 was asked what happens if the patient on the 1:1 while awake stayed awake all night. Staff #3 confirmed the staff would have to try and call the doctor and see if they could get any of the 1:1 observation patients changed to a lower level of monitoring.

Staff #3 confirmed after 11:00 PM the 3 BHAs on the schedule were assigned to the 3, 1:1 observation patients. Staff #3 was asked who was responsible for monitoring the 19 patients that were not on a 1:1 after 11:00 PM. Staff #3 stated, "I see what you are saying." Staff #3 gave no other options to ensure appropriate and safe staffing.


5/17/2023
Unit 300
Census-12 patients

Review of the day shift Staff Assignment Sheet revealed 1 RN and 2 BHAs were scheduled. The BHAs took a scheduled 30-minute lunch break leaving 1 BHA responsible for 12 patients. 3 of the 12 patients were on increased Q5 minute observations for safety.

Review of the night shift Staff Assignment Sheet revealed 1 RN and 2 BHAs were scheduled. A review of Staff #42s timecard revealed the RN took a scheduled 30-minute lunch break. There was no documentation the Staff #42 was relieved by another nurse for her lunch. Staff #3 could not confirm nor deny if the RN left the unit leaving the patients and staff unsupervised by a RN. 2 BHAs took a scheduled 30-minute lunch break leaving 1 BHA responsible for 12 patients. 5 of 12 patients were on an increased Q 5-minute observations for safety. Staff #3 did not take into consideration the acuity of the patients for staffing needs.


5/17/2023
Unit 400
Census-20 patients

A review of the day shift Staff Assignment Sheet revealed 1 RN, 1 LVN, and 4 BHAs were scheduled. There was 1 patient on a 1:1 observation for safety. The LVN took a scheduled 30-minute lunch break leaving the RN responsible for 20 patients. The unit was short 1 nurse during this time. Unit 400 was a high acuity unit requiring acute care.

A review of the night shift Staff Assignment Sheet revealed 2 RNs and 3 BHAs were scheduled. 3 patients were on Q 5-minute observations for safety. The RNs took a scheduled 30-minute lunch break leaving 1 nurse responsible for 20 patients. The unit was short 1 nurse during this time.

5/18/2023
Unit 100
Census-22 patients

Review of the day shift Staff Assignment Sheet revealed 1 RN, 1 LVN, and 4 BHAs were scheduled. Two patients were on a 1:1 observation and 3 patients were on Q 5-minute observation for safety. The RN took a scheduled 30-minute lunch break leaving the LVN responsible for 22 patients. The unit was short 1 nurse during this time. 2 BHAs were assigned to the two patients on a 1:1 observation. 2 BHAs were assigned to the remaining 20 patients. During the BHAs scheduled 30-minute lunch breaks the unit was short 1 BHA.

Review of the night shift Staff Assignment Sheet revealed 1 RN, 1 LVN and 4 BHA were scheduled. 2 patients were on a 1:1 observation and 2 patients were on Q 5-minute observations for safety. The nurses took a scheduled 30-minute lunch break leaving the unit short 1 nurse to care for 22 patients during this time. 2 BHAs were assigned to the two 1:1 patients leaving 2 BHAs to monitor 20 patients. During the BHAs scheduled 30-minute lunch break the unit was short 1 BHA.


5/18/2023
Unit 300
Census-12 patients

A review of the day shift Staff Assignment Sheet revealed 1 RN and 2 BHAs were scheduled. There were 5 patients on increased Q 5-minute observation checks for safety. The RN took a scheduled 30-minute lunch break. Staff #3 could not confirm nor deny if the RN left the unit unsupervised without a nurse. Staff #3 confirmed there was no documented RN relief on the assignment sheet. The BHAs took a scheduled 30-minute lunch break leaving 1 BHA responsible for 12 patients. 5 of the 12 patients were on an increased Q 5-minute observation for safety.
A review of the night shift Staff Assignment Sheet revealed 1 RN and 2 BHAs were scheduled. There were 6 patients on Q 5-minute observation for safety. A review of Staff #42s timecard revealed the RN took a scheduled 30-minute lunch break. Staff #3 could not confirm nor deny if the RN left the unit. Staff #3 confirmed there was no documented RN relief on the assignment sheet. Both BHAs took a scheduled 30-minute lunch break leaving 1 BHA responsible for 12 patients. 6 of the 12 patients were on Q 5-minute observations for safety.


5/18/2023
Unit 400
Census-18 patients

A review of the day shift Staff Assignment Sheet revealed 1 RN, 1 LVN, and 4 BHAs were scheduled. There were 3 patients Q 5-minute observations for safety. The nurses took a scheduled 30-minute lunch break leaving 1 nurse responsible for 18 patients. The unit was short 1 nurse during this time.


A review of the night shift Staff Assignment Sheet revealed 1 RN and 3 BHAs were scheduled. One patient was on a 1:1 and 2 patients were on Q 5-minute observations for safety. This left 1 nurse responsible for 18 patients. The unit was short 1 nurse. A review of Staff #42's timecard revealed she was deducted 30 minutes for a scheduled lunch break. Staff #3 could not confirm nor deny if the RN left the unit. Staff #3 also confirmed there was no documented RN relief on the assignment sheet. 1 BHA was assigned to the 1:1 observation patient leaving 2 BHAs responsible for 17. All 3 BHAs had scheduled 30-minute lunch breaks with no documented relief. The unit was short 1 BHA during this time.



5/19/2023
Unit 100
Census-23 patients

There was no day shift assignment sheet provided for review.

A review of the night shift Staff Assignment Sheet revealed 2 RNs and 3 BHAs were scheduled. There were 4 patients on Q 5-minute observations for safety. Both RNs took a scheduled 30-minute lunch break leaving one nurse responsible for 23 patients. 1 BHA was scheduled to leave at 3:00 AM. This left 2 BHAs responsible for 23 patients with 4 patients on Q 5-minute observations for safety.


5/19/2023
Unit 300
Census-11 patients

A review of the day shift Staff Assignment Sheet revealed 1 RN and 2 BHAs were scheduled. There were 5 patients on Q 5-minute observations for safety. The RN took a scheduled 30-minute lunch break at 3:30 PM. Staff #3 confirmed there was no documentation that an RN relieved him for lunch. Staff #3 stated, "I would not have left the unit unsupervised by a nurse. I may have eaten lunch on the unit that day." Both BHAs took a scheduled 30-minute lunch break leaving 1 BHA responsible for 11 patients and 5 of the 11 patients were on Q 5 minute observations for safety.

A review of the night shift Staff Assignment Sheet revealed 1 RN and 2 BHAs were scheduled. There were 4 patients on Q 5-minute observations for safety. The RN documented a scheduled lunch break at 12:00 AM. Staff #3 could not confirm nor deny if the RN left the unit unsupervised by a RN. Staff #3 confirmed there was no documented RN relief on the assignment sheet. Both BHAs took a scheduled 30-minute lunch break leaving 1 BHA responsible for 11 patients and 4 of the 11 patients were on Q 5-minute observations for safety.

5/19/2023
Unit 400
Census-21 patients

A review of the day shift Staff Assignment Sheet revealed 1 RN, 1 LVN, and 3 BHAs were scheduled. 1 BHA was scheduled to leave at 11:00 AM. There was 1 patient on a 1:1 and 1 patient on Q 5-minute observations for safety. Both nurses took a scheduled 30-minute lunch break leaving 1 nurse responsible for 21 patients. Two BHAs took a scheduled 30 minute lunch break leaving 1 BHA to monitor a 1:1 patient and 20 other patients during the lunch period. The unit was short 1 nurse during this time. The staffing matrix requires 2 BHAs for 20 patients.


A review of the night shift Staff Assignment Sheet revealed 2 RNs and 3 BHAs were scheduled. There was 1 patient on a 1:1 observation level for safety. Both nurses took a scheduled 30-minute lunch break leaving 1 nurse responsible for 21 patients. The unit was short 1 nurse during this time. One BHA was assigned to the 1:1 observation patient leaving 2 BHAs responsible for 20 patients. The BHAs took a scheduled 30-minute lunch break leaving the unit 1 BHA short during this time.


5/20/2023
Unit 100
Census-23 patients

A review of the day shift Staff Assignment Sheet revealed 1 RN and 4 BHAs were scheduled. There were 4 patients on Q 5-minute observations for safety. The RN took a scheduled 30-minute lunch break at 3:00 PM. There was no documented lunch relief for the RN on the assignment sheet. The unit was short 1 nurse.

Based on review of facility policy, record review, and confirmed in interview, the facility failed to ensure that a nursing care plan was up to date and addressed all the patient's needs in 5 of 5 patients.

The deficient practices were identified under the following Condition of Participation, CFR 482.23 Nursing Services, and were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death.

Findings include:

Review of Facility policy titled, "Patient Treatment Plan" (PolicyStat ID 12386362), dated showed the following:

"Each patient shall have a written, comprehensive, individualized treatment plan that is based on assessment of his/ her medical, clinical and nursing needs. Individualized treatment planning shall be based on patient need."

"A. Patients have the right to ongoing participation in their treatment plan ..."
"K. Treatment plans will be provided to the patient or the guardian ..."

Preliminary Treatment Plan:
"Upon admission, the nurse shall initiate the Interdisciplinary Treatment Plan for the patient's identified nursing care needs as part of the admission assessment. This plan will be based on the patient assessment and an evaluation of the patient's presenting problems, physical health, emotional status and behavior and provider input. An initial discharge plan will be completed along with the admission assessment."

"Once the treatment plan has been developed, a staff person shall review the treatment plan with the patient. This participation shall be noted by the staff's signature on the treatment plan."

Review of the facility policy, "Plan of Care-Protocol for the Use of the Interdisciplinary Format" (PolicyStat ID 12197123, dated 2021) showed the following:

"Phase II: Formulating the Interdisciplinary Treatment Plan (Initial Session)
Prior to the initial Interdisciplinary Treatment Plan session for the patient, the social worker will incorporate the information gathered from the history and physical, psychiatric evaluation, social service meetings, nursing, and therapy services assessments into the initial Interdisciplinary Treatment Plan. This integration will reflect all assessed strengths and limitations."

"Each team member will provide their signature to signify their agreement with the plan ..."
"Phase Ill: Ongoing Treatment Review (Subsequent Sessions) ..."
"The Interdisciplinary treatment team will sign the patient's updated Interdisciplinary Treatment Plan."

Patient #LL
Review of Patient #LL medical record (History and Physical), dated 05/13/23, completed by Staff NP #48 cosigned by Staff Doctor #28, showed that the patient had cellulitis of right leg and was receiving antibiotics and dressing changes.
Review of Patient #LL medical record (History and Physical), dated 05/13/23, completed by Staff NP #48 cosigned by Staff Doctor #28 showed that the patient had a traumatic brain injury with diminished mental capacity.

Review of Patient #LL medical record (Interdisciplinary Treatment Plan), dated 05/12/23, written by RN #00 (illegible signature), showed that the patients treatment plan, failed to address skin integrity, dressing changes, active infection and decreased cognitive function.

Patient #N
Review of Patient #N medical record nursing admission assessment, dated 05/12/23 at 00:15, showed the Patient #N was admitted with a weight of 66.4 pounds at 4 feet 9 inches her Body Mass Index (BMI) was at 14.4 indicating she was underweight. The question for eating disorder was left blank. The question for Malnutrition was answered, yes, by the Staff RN (signature illegible).

Review of Patient #N medical record showed an Internal Medicine Progress Note written by Staff FNP #48, dated 05/16/23, written under the title, "Assessment/Plan" Patient has an eating disorder and throws up food.

Review of Patient #N medical record showed an admitting Psychiatric Evaluation, dated 05/12/23, written by Staff Nurse Practitioner #47, under the Admitting Diagnosis lists Body Dysmorphic disorder (F45.22).

Review of Patient #N medical record showed a doctor's order, dated 05/12/23 at 16:00, written by Staff Nurse Practitioner #47, monitor during meals, daily weights, calorie count, and monitor patient in bathroom after meals.

Review of Patient #N medical record showed a doctor's order, dated 05/16/23 at 15:00, written by Staff Nurse Practitioner #47, the order calls for 1:1 monitoring for one hour post meals and a nutritional consult.

Review of Patient #N medical record (Nutritional Consult), dated 05/18/23, written by Staff Dietician #24, listed under other problems the Dietician wrote Nausea and Vomiting and Eating Disorder.

Review of Patient #N medical record (Nutritional Consult), dated 05/18/23, written by Staff Dietician #24, altered labs related to intake and medical condition as evidenced by patient presenting with diagnosis of Irritable Bowel Disease (IBS) and symptoms of bulimia. Nutritional Diagnosis: inadequate fluid intake, underweight. Nutritional interventions: Monitor weight, signs and symptoms of dehydration, and nutritional intake.

Review of Patient #N medical record (Interdisciplinary Treatment Plan), dated 05/12/23, written by RN (illegible signature showed that the patients treatment plan, failed to address nutrition and dehydration. The (IDT) was not updated through 05/23/23.

Interview with Staff RN #36 on 05/22/23 at 14:30 showed the following:
There is no place to write a patient's intake of food "I guess we can put in the nursing notes"
We do not do one to one monitoring for food intake.
We do not weight the patient at the same time every day. It depends on how many staff are on.
When asked about caloric intake documentation no response was given.

Interview with staff CEO #2 on 05/22/23 about Patient #N and the fact that no documentation was found on the patient's chart to indicate monitoring was done. The CEO stated, "You can't prove we didn't do it."

Patient #BB
Review of Patient #BB medical record (Nursing Notes) showed that the patient had a right hip open reduction and internal fixation (ORIF) on 05/02/23 at another Hospital with staples still in place. The following order on 05/13/23 at 17:40, (day of Admission), wound care written by Staff Doctor #45 was ordered. No further information on the order was given (type of dressing, Cleaning, Times per day). No contact was documented to Staff Doctor #45 for clarification of that order.

Review of Patient #BB medical record (Interdisciplinary Treatment Plan), dated
05/11/23 at 2330,showed that the patient's wound care, range of motion, and fall risk were not addressed with the patient's treatment plan. The (IDT) was not updated through 05/23/23.

Patient #AA
Review of Patient #AA medical record (Psychiatric Evaluation), dated 05/12/23 at 11:26, written by Staff Nurse Practitioner #27, showed that the patient has an intellectual impairment and morbidly obese.

Review of Patient #AA medical record (Interdisciplinary Treatment Plan), dated 05/11/23 at 23:30, written by Staff RN #49 showed that the patients treatment plan, failed to address nutrition and intellectual impairment. The (IDT) was not updated through 05/23/23.

Patient #JJ
Review of Patient #JJ medical record (History and Physical), dated 05/16/23, completed by Staff NP #48 cosigned by Staff Doctor #28, showed the patient had a history of seizures and needed seizure precautions.

Review of Patient #JJ medical record (Interdisciplinary Treatment Plan), dated 05/15/23, written by Staff RN #37 showed that the patient's treatment plan, failed to address seizure precautions. The (IDT) was not updated through 05/23/23.

Interview with the Staff Director of Nursing (DON) #03, on 05/23/23 at 11:00 AM, they were asked when treatment team meetings occurred?
Staff member #3 replied, "I don't know. Afternoons, Wednesdays?"

On 05/23/23 at 11:05 AM, a Staff RN #13, was asked if they ever participated in treatment planning. Staff DON #3 replied, "No, we start the initial treatment plan only."

Based on observation, record review and confirmed in interview, the facility failed to have a full-time qualified Food and Dietetic Services Director to ensure dietary staff were following acceptable standards of dietary practice regarding food handling and sanitation.

Findings included:

An interview with Staff #6 (housekeeping/dietary services manager) on 05/24/2023 at 1050 am in the kitchen, she stated that there has not been a Food Service Director since December 2022. She stated that she reported to the Chief Executive Officer (Staff #2). Her job description signed on 12/26/2022 confirmed that she reported to the CEO and supervises the housekeeping and dietary staff. Review of her qualifications included a certificate of completion of the Food Manager's Certification Training Program. Her experience did not include any prior work in dietary services.

Review of the job description for housekeeping/dietary services manager included the following job functions:
"Establishes policies and procedures to ensure all foods prepared according to established recipes.
Prepares and assures staff supervised prepares all food indicated on menus provided for patient and employ food services.
Creates menus along with standardized recipes for all dietary departments.
Perform sanitation inspections throughout scheduled shift and as provided in the sanitation checklist.
Ascertains that temperature sheets and cleaning schedules are dated and signed in a timely manner."
Surveyor requested to review the policies and procedures for dietary on 05/22/2023, 05/23/2023, and again on 05/24/2023. No policies were available for review by the end of the survey on 05/25/2023.
Surveyor observations on 05/22/2023 at 1140 am revealed Staff #8 who was preparing the lunch meal for all opened units (unit 100, 300, 400) for a census of 58 patients. He prepared the beef brisket, potatoes, and brussel sprouts onto Styrofoam containers stacked on the prep table. No holding temperature nor serving temperature were taken of any food. In an interview with Staff #8 on 05/22/2023 at 1145 am in the kitchen, he stated that he usually uses a digital thermometer but was unable to find it that day. No logs of the cook temperature, holding temperature, or serving temperature were available for review. Surveyor observations also revealed Staff #8 made provisions for special requests: he substituted hamburgers for patient #V and provided double portions for Patient #N and Patient #U. He stated that he's never consulted with the dietician for any substitutions.
Review of the dietary orders for Patient #V, #N, and #U revealed no orders for the above changes by the provider nor the dietician.
Staff #8 proceeded to stack the filled Styrofoam containers onto an opened rolling rack, divided by each unit. They were delivered by Staff #7 to the units at 1200 noon where she unloaded each set of containers for each unit. No temperature checks nor verification of the meals were documented prior to serving to patients.
Review of the facility-based policy titled "MBHCL Infection Prevention Plan" with a last revised date of 01/2022, stated in part, "Meals are prepared by staff, and transported to the inpatient areas on enclosed carts, with the appropriate food temperature checks prior to service."
An interview with Staff#6 on 05/23/2023 at 110 pm in the kitchen, she stated that they had discontinued using the meal delivery carts at the start of Covid and do not use them. She stated that there are no plans to go back to trays. They will continue to serve using the Styrofoam containers.
Review of the menus and special diet menus revealed the provision for regular diets as well as no added salt; controlled carbohydrate; finger foods; gluten free; vegetarian and texture modification (mechanical soft and puree) and consistency-liquids (thin liquids, honey think, nectar think). The facility had just implemented a new menu on 05/07/2023 with 4 different weekly rotations of the same menu. In an interview with Staff #6 on 05/23/2023 at 1130 am in her office, she stated that she does not handle the menu and/or planning. Staff #8 (chef) does the ordering weekly per the menu provided.

An observation tour of the dietary department was conducted on 05/22/2023 at 10:00 am with the Staff #6, the Housekeeping and Dietary Services manager. There were two dietary staff (Staff#8, chef; and Staff #7, kitchen aide) working in dietary on this date.

The following observations were made during the tour in the following areas:

Dry food storage
-visible dirt on doors, floors, and walls
-half-filled clear plastic container of "long grain rice, prepared 02/04/2023, use by 04/04/2023"
-one full plastic container of rice, unlabeled, undated
-opened bag of cereal closed with a plastic tie, unlabeled, undated
-

Freezer #1
-Unknown food, unmarked, unlabeled. An interview with Staff #6 on 05/22/2023 at 1015 am she stated that she thinks it's "fish or maybe chicken."
-Shipping boxes used for food storage, undated, unlabeled
external shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of a corrugated material, serve as generators of and reservoirs for dust

Kitchen general idea
-Clean items stored and stacked wet, which can create conditions for growth of bacteria and fungi
-Rusted knives with visible dirt ready for use, visible dirt on sink and Refrigerator #2
-Sink under knives, Refrigerator #2, build-up on floors, walls, and equipment
-Visible dirt in sink under knives
-Visible build-up of dirt on prep table
-Unlabeled, undated, unknown stored substances under prep table. In an interview on 5/22/23 at 1021 am with Staff #6, Dietary Services Manager, she reported she did not know what was in the containers and stated, "Maybe flour?" In an interview with Staff #7 on 5/22/23 at 10:21 am, she reported she did not know what was in the containers and did not know how long they had been there.
-visible dirt and grease on table holding containers for patient meals; unknown and unlabeled container of cleaner
-visible dirt and grease on second shelf of table holding containers for patient meals
-prep area, visible dirt on boards and tables, unlabeled opened oil
-Visible dirt build-up on outside and inside of ovens. An interview with Staff #6 on 05/22/2023 at 1025, she reported all ovens were cleaned this weekend.
-stored clean pots on protective barrier with visible dirt, visible dirt on storage cart and floor
-three heavy duty containers with plastic scoops stored under prep table, unlabeled, undated
-visible stain on cutting boards and rust and dust on the holder
-grease and stains on the cooktop

Refrigerator #1
-half full closed plastic container of "veggie soup, prepared on 05/14/2023, and use by 05/19/2023"
-unlabeled, undated red substance in closed container

Freezer #2, Freezer #3
-shipping boxes used as food storage, unlabeled and undated food items
-visible dirt and grease on handles and along outside

Dishwashing area
-Visible dirt build-up on sink by dishwasher
-visible build-up of dirt and grease on and around dishwasher area including faucet spray
-Visible dirt build-up on dishwasher
-Clean items stacked wet which creates good conditions for growth of bacteria and fungi
During the initial tour of the kitchen on 05/22/2023 at 1000 am, staff # 6 (housekeeping and dietary services manager) stated all meals were served on the Styrofoam disposable products. The pots, pans, and cooking tools were washed in the Ecolab dishwashing machine and/or 3-compartment sink for manual ware washing.

When prompted to perform the sanitation checks for both the Ecolab ES-2000 dishwashing machine and/or the 3-sink compartment sink for manual ware washing, staff #6 was unable to perform either checks.
Staff #6 stated that they do not use the strips found by the dishwashing machine (Hydrion Peracetic Acid Test Strips or the hydrion QT-40) as they had switched companies. Staff #8, the cook, confirmed that they did not use those strips anymore and had none they currently used.

Neither Staff #6 nor Staff #8 were aware if the Ecolab ES-2000 dishmachine was a high temp or a low temp sanitizer dishmachine.

Furthermore, no checks could be done on the 3-sink compartment for manual ware dishwashing since the facility ran out of sanitizer. Only the dishwashing machine was available for use on 05/22/2023.

Review of the Ecolab ES-2000 information label on the dishmachine indicated the minimum wash and rinse temperature of 120F and 50PPM for chlorine.

No logs were maintained to ensure the dishmachine had the minimum temperature or the correct sanitation levels. No logs of the sanitation checks for the manual ware dishwashing were available for review.

In an interview with Staff#6 on 05/22/2023 at 1040 am, she stated that the kitchen is cleaned daily but they do not document it. She also confirmed that no quality assurance was maintained to ensure the dietary services were following the facility protocol for food handling and sanitation.

Based on personnel and facility record reviews and confirmed in interview, the facility failed to employ a dietician to supervise the nutritional aspects of patient care.

Findings included:

Review of the Consulting Services Agreement signed by the CEO (Staff #2) and the dietician consulting group on 04/2023 delineated the following services:
"Assists with menu development, menu changes, menu review and approval as requested by community.
Provide consultation with the food service manager regarding food and supply purchasing, food preparation and service, food storage, equipment selection and utilization, kitchen layout and design, vendor selection, cost control, budget process and record keeping.
Observe meal preparation and service and recommend changes as needed.
Perform a kitchen inspection and recommend changes as needed.
Develop and present training for COMMUNITY'S staff and document all training.
Assist in developing managerial and supervisory skills of COMMUNITY'S Dining Manager through on the job training, correspondence or online coursework and preceptorship of the Certified Dietary Manager course.
Assist in the development of appropriate Dining Department policies and procedures.
Provide consultation to residents/patients and or families related to diets or nutrition care.
Provide recommendations necessary to comply with Federal, State, or County regulations.
RDN will exit with community leadership and will submit an electronic report to the Executive Director/Administrator and other designated community staff following each visit, which shall include findings and recommendations, progress on prior recommendations and evaluation of goals."

Review of the menus available revealed four rotating weekly menus. An interview with Staff #6 on 05/24/2023 at 1310 hours, she stated that the chef (Staff #8) places the food orders weekly and that she is not responsible for the menu. She stated that she has not met with the dietician, nor does she consult with them regarding the facility dietary needs. No logs were documented as to when the dietician came for consultations nor was Staff #6 aware if the dietician had ever performed a kitchen inspection or any training per the consulting agreement.

An interview with the CEO (Staff #2) on 05/24/2023 at 1600 hours in the conference room confirmed that the facility does not maintain logs following each visit.

Based on review of facility records, observation throughout kitchen, and confirmed in interview, the facility failed to ensure two of two dietary staff (Staff#7 and #8) maintained a sanitary environment for patient food preparation and storage in accordance with assigned duties and facility policies.

Findings included:

Review of the job description for Cook/Kitchen Aid included the following job functions:

"Maintains a clean working area during food production.
Holds and stores perishable food items in compliance with applicable standards of the Indiana State Board of Health (ISBH).
Perform sanitation inspections throughout scheduled shift and as provided in the sanitation checklist.
Shares responsibility for maintaining a clean and safe environment.
Ascertains that temperature sheets and cleaning schedules are dated and signed in a timely manner as required during their working time.
Cleans and sanitizes dishwashing area."

An observation tour of the dietary department was conducted on 05/22/2023 at 10:00 am with the Staff #6, the Housekeeping and Dietary Services manager. There were two dietary staff (Staff#8, cook; and Staff #7, kitchen aide) working in dietary on this date.
The following observations of unsanitary conditions were made during the tour in the following areas:

Kitchen general idea
-Clean items stored and stacked wet, which can create conditions for growth of bacteria and fungi
-Rusted knives with visible dirt ready for use, visible dirt on sink and Refrigerator #2
-Sink under knives, Refrigerator #2, build-up on floors, walls, and equipment
-Visible dirt in sink under knives
-Visible build-up of dirt on prep table
-Unlabeled, undated, unknown stored substances under prep table. In an interview on 5/22/23 at 1021 am with Staff #6, Dietary Services Manager, she reported she did not know what was in the containers and stated, "Maybe flour?" In an interview with Staff #7 on 5/22/23 at 10:21 am, she reported she did not know what was in the containers and did not know how long they had been there.
-visible dirt and grease on table holding containers for patient meals; unknown and unlabeled container of cleaner
-visible dirt and grease on second shelf of table holding containers for patient meals
-prep area, visible dirt on boards and tables, unlabeled opened oil
-Visible dirt build-up on outside and inside of ovens. An interview with Staff #6 on 05/22/2023 at 1025, she reported all ovens were cleaned this weekend.
-stored clean pots on protective barrier with visible dirt, visible dirt on storage cart and floor
-three heavy duty containers with plastic scoops stored under prep table, unlabeled, undated
-visible stain on cutting boards and rust and dust on the holder
-grease and stains on the cooktop

Dishwashing area
-Visible dirt build-up on sink by dishwasher
-visible build-up of dirt and grease on and around dishwasher area including faucet spray
-Visible dirt build-up on dishwasher
-Clean items stacked wet which creates good conditions for growth of bacteria and fungi

During the initial tour of the kitchen on 05/22/2023 at 1030 am, staff # 6 (housekeeping and dietary services manager) stated all meals were served on the Styrofoam disposable products. The pots, pans, and cooking tools were washed in the Ecolab dishwashing machine and/or 3-compartment sink for manual ware washing.

When prompted to perform the sanitation checks for both the Ecolab ES-2000 dishwashing machine and/or the 3-compartment sink for manual ware washing, staff #6 was unable to perform either checks.
Staff #6 stated that they do not use the strips found by the dishwashing machine (Hydrion Peracetic Acid Test Strips or the Hydrion QT-40) as they had switched companies. Staff #8, the cook, confirmed that they did not use those strips anymore and had none they currently used.
Neither Staff #6 nor Staff #8 were aware if the Ecolab ES-2000 dishmachine was a high temp or a low temp sanitizer dishmachine. Furthermore, no checks could be done on the 3-sink compartment for manual ware dishwashing since the facility ran out of sanitizer. Only the dishwashing machine was available for use on 05/22/2023.

Review of the Ecolab ES-2000 information label on the dishmachine indicated the minimum wash and rinse temperature of 120F and 50PPM for chlorine.

No logs were maintained to ensure the dishmachine had the minimum temperature or the correct sanitation levels.

No logs of the sanitation checks for the manual ware dishwashing were available for review.
On 05/23/2023, the facility received the sanitizer solution for the 3-compartment sink for manual ware washing. Staff #8 was able to perform the sanitizer check for the 3-compartment sink. Surveyor observations on 05/23/2023 at 1123 am revealed a dirty cook pan in the middle sink (rinse sink) and a half submerged pan rack on the sanitization sink. When asked about the dirty cook pan, Staff #6 stated that Staff#7 will scrub the pan in the middle sink before washing it. No process was in place to prevent cross traffice between the dirty side and clean side.
Staff #6 attempted to perform the sanitizer check on the Ecolab ES-2000 dishmachine but stated that she needed to call service since the sanitizer checks were not working as it should. On 05/24/2023 at 1010 am, Staff #6 was able to perform the check after service was called.

Moreover, no logs of the cook temperature, holding temperature, or serving temperature were available for review when preparing food on 05/22/2023. In an interview with Staff #8, the cook, he stated that he typically uses a digital thermometer but was unable to find it that day. The following day on 05/23/2023, Staff #8 started recording the temperature on a blank sheet of paper. He stated that he found his digital thermometer. In an interview with Staff #8 at 1115 am in the kitchen, he stated cooked food should be "above 140 F for hot food and below 45 F for cold food."

Temperature documented included the following temperatures:

Breakfast
Oatmeal: cook at 200; holding 156; serving 155; delivery 140
Eggs: cook198; holding 182; serving 170; delivery 145
Cream Cheese: cook 38; holding 39; serving 40; delivery 40
Bagels cook 155; holding 150; serving 145; delivery 140
Lunch
Ham: cook 200
Zucchini: cook 195
Sweet potatoes: cook 200
Tenders [chicken]: cook 205
Burger: cook 170
Pizza: cook 165

Review of Staff #7 performance evaluation from 02/2022 revealed staff #7 comments that included "I would like if the staff could welcome new team members more with welcome hands instead they [are] disrespectful [they] don't want to show others the way around the kitchen or show us how to do the job how it['s] suppose[d] to be done."

In an interview with Staff#6 on 05/22/2023 at 1040 am, she stated that the kitchen is cleaned daily but they do not document it. She also confirmed that no quality assurance was maintained to ensure the dietary services were following the facility protocol for food handling and sanitation.

Based on review of patient orders and dietary worksheets and confirmed in interview, the facility failed to ensure two (Patient #X and Patient #N) of three patients received the therapeutic diets ordered.

Findings included:

Patient #X
Review of the Patient #X dietary orders revealed a regular diet with a texture modification of pureed that was ordered on 05/10/2023.

Review of the census worksheet from 05/22/2023 and 05/23/2023 that Staff #8 used to prepare meals revealed Patient #X received double portions of the regular diet. No modification of the texture was provided to the patient until surveyor asked for the confirmation of the orders on 05/24/2023. Staff #8 then added the patient onto his worksheet on 05/24/2023 for the lunch service to reflect the correct order. He stated he was unaware he had a texture modification and could not remember if he ever had pureed for his meals.

In an interview with the nurse on unit 400 Staff #13 on 05/24/2023 at 1000 am, she stated that Patient #X was ordered a pureed diet from where he was transferred from. The orders were just carried over. She was unaware that he was not receiving the pureed diet. An interview with the BHA teck (Staff #32) 05/24/2023 at 1010 am confirmed that Patient N had been eating a regular diet.

Patient #N
Review of the dietary orders for Patient # N revealed an RD (Registered Dietician) consult for regular diet with Ensure supplements three times a day after lunch, dinner, and at bedtime on 05/18/2023.

Review of Patient #N chart from 05/18/2023 to 05/23/2023 revealed no documentation to ensure the supplement orders above were provided to the patient.

Based on review of the facility policy, patient orders and dietary worksheets and confirmed in interview, the facility failed to ensure three of ten patients reviewed received the correct diet as ordered by the provider or dietician.

Findings included:

Review of the facility policy Food Services and Nutritional Balance (last revised 01/2020) stated

"To ensure that patients receive their diets as ordered by the physician and safety during meal times. To provide guidelines for nursing staff regarding supervision and monitoring of patients at meal times.
Special diets and altered diets are accommodated.
Patient preferences are to be communicated to the dietitian.
Accommodate a patient's special diet and altered diet unless contraindicated
Notify physician of any problems with diet type or intake
Weights will be obtained weekly or otherwise ordered, should patient refuse, that will be documented."

Review of the census worksheet from 05/22/2023 and 05/23/2023 that Staff #8 used to prepare meals revealed Patient #X received double portions of the regular diet.

Review of the dietary order for Patient #U and Patient #Y revealed regular diets were ordered at admission. Review of the census worksheet from 05/22/2023 and 05/23/2023 that Staff #8 used to prepare meals revealed Patient #U and Patient #Y received double portions of the regular diet.

No orders for the double portion for the above patients (Patient #X, Patient #U, Patient #Y) were available for review.

Based on review of documents and staff interview, the facility failed to ensure the individual (or individuals), who was qualified through education, training, experience, or certification in infection prevention and control, was appointed by the governing body as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment was based on the recommendations of medical staff leadership and nursing leadership.

Findings were:

Review of the personnel file for Staff #1, Director of Quality and Infection Control revealed no requirements of infection control training, experience, or certification in infection prevention and control.

In an interview on the afternoon of 5/23/23, Staff #1, Director of Quality and Infection Control reported she had no training, experience, or certification in infection control. When asked if she had any additional infection control training on top of general staff, she reported when she started in October of 2022, she had one phone-based training with a centralized corporate person. She stated, "Since I've been hired, everything was centralized in corporate and now it's centralized here. We're working on getting it centralized here."

Staff #1's job description stated in part, " ...Specialized Knowledge and Skill Requirements
Excellent verbal communication skills necessary in order present quality and infection control reports, provide staff education and to instruct and comfort patients and their families. Maintain effective contacts with a variety of Hospital Personnel. Professional knowledge of clinical practice, leadership, performance improvement and research statistics in order to conduct surveillance and prepare related reports at a level normally acquired through the completion of a Bachelor's degree from an approved School of Nursing."

Based on review of documents and staff interview, the facility failed to ensure the hospital infection prevention and control program, as documented in its policies and procedures, employed methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings.

Findings were:

The facility was asked for infection prevention and control policies and procedures several times throughout the survey starting with the entrance conference on the morning of 5/22/23. The only policies provided were the "Infection Control and Prevention Annual Plan and Risk Assessment-Evaluation" dated 01/2023 and "MBHCL Infection Prevention Plan" with a last revised date of 01/2022.

During a tour of the facility on the morning of 5/22/23 with Staff #6, Housekeeping/Dietary Services Manager, she stated the facility recently ended their contract with Ecolab and had a new contract for different cleaning supplies. When asked if staff had received training on the new cleaning equipment and chemicals, she reported they had.

On the afternoon of 5/22/23, in an interview, Staff #22 and 23, BHA staff, were asked what they used to clean. Staff #22 and 23 reported they used "whatever was around" and provided an unlabeled bottle. When asked what was in the bottle, Staff #22 and 23 were unaware, but stated they used it to clean the machines, tables, and chairs on the unit. When asked what the "wet" time was, Staff #22 and 23 were unaware.

On the morning of 5/23/23, during an interview, Staff #25, BHA, reported they used the "Purple Tops" to clean laundry machines, tables, and chairs. When asked what the "wet" time was, Staff #25 was unsure and stated, "It stays wet for a while."
Review of the Micro-kill one germicidal alcohol wipes stated in part, "1- minute wet time."

On the afternoon of 5/23/23, during an interview, Staff #9, housekeeping, reported they had not been trained on the new cleaning chemicals.

In an interview on the afternoon of 5/23/23, Staff #1, Director of Quality and Infection Control reported she had collected Infection Control data for quality purposes when she first started, but no infection control information had been gathered in 2023. When asked if any infection control meetings had been implemented, she reported they had not, but they should be done quarterly. When asked about the new cleaning chemicals, Staff #1 reported there was no training completed regarding the new cleaning chemicals. Staff #1 reported there were no policies related to the new cleaning chemicals.

There was no data collection or surveillance that was done to control and prevent infections. These findings had the likelihood to cause harm by increasing the risk of infection to all patients and staff at the facility.

Review of the facility-based "Infection Control and Prevention Annual Plan and Risk Assessment-Evaluation" dated 01/2023 stated in part, "SCOPE OF SERVICE
Infection Prevention Control Program (IPCP) is hospital wide quality improvement activity, involving all departments and services. The Infection Control Committee determines the specific focus of surveillance, education, and consultation efforts on an ongoing basis, dependent on hospital epidemiology, community disease surveillance and real or perceived local or world threats.
AUTHORITY AND RESPONSIBILITIES
The Infection Prevention Nurse responsibilities are:
1. To act as a point of contact (POC) for the patient care unit for IC issues.
2. To monitor IC related work practices to include but not limited to hand hygiene and isolation precautions within their patient care work environment.
3. To report questions/concerns to hospital ICC.
4. To attend regularly scheduled ICC meetings.
CORE GOALS:
1. Minimize unprotected exposure to pathogens throughout the hospital. Limiting transmission of infections by monitoring, documenting isolation practices.
2. Reduce risk of transmission of infections associated with the use of medical equipment, devices and supplies specifically CAUTI, CLABSI.
3. Facility-wide hand hygiene (NPSG) program to improve compliance following World Health Organization guidelines.
4. Compliance with monitoring and documenting surveillance data ..."

Based on review of documents and staff interview, failed to ensure the hospital infection prevention and control program included surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities.

Findings were:

During a tour of the facility on the afternoon of 5/22/23 with Staff #6, Housekeeping/Dietary Services Manager, the following infection control issues were observed:
Unit 300 laundry room:
-Tipped and open container of detergent sitting on the ground.
-Daily Clothes Washer and Dryer Cleaning and Disinfecting Log that was not completed

Unit 300 Nutrition Room:
-Ice machine with visible build-up, indicating inappropriate cleaning
-Dirt build-up on floor and in corners

Unit 400 laundry room:
-12 patient dirty clothes bags sitting on the ground
-Sink with visible dirt and rust, indicating it was not effectively cleaned
-Several items stored underneath the sink. Items should not be stored under sinks due to the risk of water contamination and potential bacterial growth.
-Possibly used gloves and paper towels sitting in a cabinet ready for use
-Open container of detergent with no lid, sitting on the ground

Patient Belonging's Room Unit 300 & 400:
-Belongings throughout room with items on the floor and unorganized
-Dirt and trash noted throughout

Unit 100 Laundry room:
-Dirt and trash noted throughout
-Socks, lint, and trash behind machines
-Items stored on the floor
-Used shoes and plunger sitting on floor next bucket of unsealed detergent
-Daily Clothes Washer and Dryer Cleaning and Disinfecting Log that was not completed except for on 5/22/23

Unit 100 Nutrition Room:
-2 pitchers for patient use with visible build-up noted, indicating inappropriate cleaning
-Ice machine with visible build-up, indicating inappropriate cleaning
-Dirt build-up on floor and in corners

Unit 100 Patient Belonging's Room:
-Belongings throughout room with items on floor and unorganized
-Dirt and trash noted throughout

Exam Room:
-Two full sharps containers - one secured to the wall, one sitting on the counter
-Visible dirt noted on floors

Housekeeping closet:
-items stored on the ground including used plunger, mop, corrugated box with several items unsure if clean or dirty; Cardboard boxes harbor parasites, insects, and microorganisms.
-visible dirt noted throughout, including stopper sink

Seclusion rooms:
-visible dirt on ground and walls
-trash on ground

On the afternoon of 5/22/23, in an interview, Staff #22 and 23, BHA staff, were asked what they used to clean the washing machines. Staff #22 and 23 reported they used "whatever was around" and provided an unlabeled bottle. When asked what was in the bottle, Staff #22 and 23 were unaware, but stated they used it to clean the machines, tables, and chairs on the unit. When asked what the "wet" time was, Staff #22 and 23 were unaware.

On the morning of 5/23/23, during an interview, Staff #25, BHA, reported they used the "Purple Tops" to clean laundry machines, tables, and chairs. When asked what the "wet" time was, Staff #25 was unsure and stated, "It stays wet for a while."
Review of the Micro-kill one germicidal alcohol wipes stated in part, "1- minute wet time."

Review of the posted laundry instructions stated in part, "Even though you constantly remove cleaned clothes from your washer and dryer, both of these appliances have to be periodically cleaned as well...
Method 1
Clean Your Washer
1 Clean the top of the lid and underneath the lid of the washer with a damp sponge.
2. Pull out the lint trap (if your machine has one) and rinse it under running water.
3. Clean out the soap, bleach and fabric softener dispensers...
4. Get rid of mold and mildew odors...
5. Run a cycle of hot water and 1 gallon of white vinegar if you have hard water once a month or every 10 loads...

Before/After Every Load
1. Clean out dryer lint filter to maximize efficiency.
2. Dry the washer's door and gaskets after using..."

In an interview on the afternoon of 5/23/23, Staff #1, Director of Quality and Infection Control, she reported she does environmental rounds once a week, but has not completed rounds this week due to the survey. When discussing the documented infection control rounds, Staff #1 stated, "I don't have the seclusion room on there, I do make sure the doors are locked." When asked if she went into all areas of the hospital, including the kitchen, she reported she did not but, "I probably should." When asked how and how often the washing machines and dryers should be cleaned, Staff #1 was unsure.

Based on review of documents and staff interview, the facility failed to ensure the infection control professional was responsible for competency-based training and education of hospital personnel and staff, including medical staff, and, as applicable, personnel providing contracted services in the hospital, on the practical applications of infection prevention and control guidelines, policies, and procedures.

Findings were:

In an interview on the afternoon of 5/23/23, Staff #1, Director of Quality and Infection Control reported she had not conducted any competency-based infection control training or education with hospital personnel and staff. When asked about the new cleaning chemicals, Staff #1 reported there was no training completed regarding the new cleaning chemicals. Staff #1 reported there were no policies related to the new cleaning chemicals.

Review of personnel records for a variety of personnel (nursing, housekeeping, dietary, and medical staff; Staff #3, Staff #6-13, Staff #22-23, Staff #26-29) revealed no competency-based training or education.

Based on a review of documentation and interviews, the facility failed to assess its discharge planning process on a regular basis. The assessment must include ongoing, periodic review of a representative sample of discharge plans, including those patients who were admitted within 30 days of a previous admission, to ensure that the plans are responsive to the patient post-discharge needs.

Findings included:

In an interview on 05/25.23, staff member #15, Director of Clinical Social Services, was asked if the facility had a formal process to assess the discharge process. Staff member #15 verified there was "no formal process" to accomplish an assessment of the discharge process. Staff member #15 was asked if the facility reviews patients that are re-admitted within 30 days. Staff member #15 replied, "I might look and see the previous time they were here if I remember the patient from before. It's a work in process".
Based on the above findings the facility does not currently have a process to assess its discharge planning on a regular basis.

Based on a review of documentation and interviews, the facility failed to ensure that discharge planning evaluation included establishing an appropriate discharge plan, with the results of the evaluation discussed with the patient (or the patient's representative).

Findings included:

Facility policy "Social Services" (PolicyStat ID 12197125) stated in part,
"Social work contact with the patient, family and significant others occurs during, or as soon as possible, after patient admission ...
Treatment and discharge planning activities, liaison/follow-up efforts are based upon the goals, including discharge goals, and staff responsibilities specified in the plan of care...

Social work functions may include the following functions: ...

Continuity of care is an important social work principle and may be demonstrated through case management and a major role in discharge planning. Activities, in conjunction with the patient's wishes, may include contact with patient's family, identifying and assisting in referral of the patient to community-based agency(ies) at the time of discharge. Finally, post-discharge follow-up may be done to assure that linkage of the patient with community resources has occurred to reduce re-hospitalization.

Social service staff responsibilities must include, but are not limited to:

Participating in discharge planning."

Review of the Treatment Team and Discharge Documentation for 10 patients, revealed 7 out of 10 records did not reflect involvement of patient family members/representatives in discharge planning:
* Patient #F on the Interdisciplinary Treatment Planning Discharge Form, dated 05/21/23, indicated that "Communication will be completed weekly with each of the following selected as appropriate" and had a check mark beside "Family/Guardian/POA:".
* Patient #H on the Interdisciplinary Treatment Planning Discharge Form, dated 05/17/23 indicated that "Communication will be completed weekly with each of the following selected as appropriate" and had a check mark beside "Family/Guardian/POA:" with "mother" written in.
* Patient #K on the Interdisciplinary Treatment Planning Discharge Form, dated 05/15/23 indicated that "Communication will be completed weekly with each of the following selected as appropriate" and had a check mark beside "Family/Guardian/POA:".
* Patient #L on the Interdisciplinary Treatment Planning Discharge Form, dated 05/17/23 indicated that "Communication will be completed weekly with each of the following selected as appropriate" and had a check mark beside "Family/Guardian/POA:" with "pt and mother" written in.
* Patient #M on the Interdisciplinary Treatment Planning Discharge Form, dated 05/12/23 indicated that "Communication will be completed weekly with each of the following selected as appropriate" and had a check mark beside "Family/Guardian/POA:".
* Patient #Q on the Interdisciplinary Treatment Planning Discharge Form, dated 05/21/23, indicated that "Communication will be completed weekly with each of the following selected as appropriate" and had a check mark beside "Family/Guardian/POA:".
* Patient #U on the Interdisciplinary Treatment Planning Discharge Form, dated 05/01/23, indicated that "Communication will be completed weekly with each of the following selected as appropriate" and had a check mark beside "Family/Guardian/POA: [name]".


The 7 Patients above all had documented desire to involve family members/representative in their treatment planning/discharge planning. The medical records for the 7 patients listed above did not reflect weekly communication to the patient's family/representatives regarding the discharge plans for the above patients. Per facility policies, social services are to involve patients and patient representatives in their discharge planning. By failing to involve the patients' representatives in the planning process, there is no evidence that evaluation of the discharge plan was discussed with the patient or their representatives.

Based on a review of documentation and interviews, the facility failed to ensure the transfer of all necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient's follow-up or ancillary care.

Findings included:

Facility policy "Social Services" (PolicyStat ID 12197125) stated in part,

"Social work functions may include the following functions: ...

Continuity of care is an important social work principle and may be demonstrated through case management and a major role in discharge planning. Activities, in conjunction with the patient's wishes, may include contact with patient's family, identifying and assisting in referral of the patient to community-based agency(ies) at the time of discharge. Finally, post-discharge follow-up may be done to assure that linkage of the patient with community resources has occurred to reduce re-hospitalization."

Review of medical record for 4 discharged patients revealed the following:
* For Patient #R the "INTERDISCIPLINARY DISCHARGE PLAN/ORDER" dated 03/20/23 included a follow up appointment with a psychiatrist, however the portion of the form indicating "This interdisciplinary plan/order was [box] faxed or [box] emailed to the above provider" did not have check marks present to indicate that pertinent information was transmitted for the patient's follow up care to their after-care provider.
* For Patient #S the "INTERDISCIPLINARY DISCHARGE PLAN/ORDER" dated 03/24/23 included a follow up appointment with a psychiatrist, however the portion of the form indicating "This interdisciplinary plan/order was [box] faxed or [box] emailed to the above provider" did not have check marks present to indicate that pertinent information was transmitted for the patient's follow up care to their after-care provider.
* For Patient #T the "INTERDISCIPLINARY DISCHARGE PLAN/ORDER" dated 03/20/23 included a follow up appointment with a psychiatrist, however the portion of the form indicating "This interdisciplinary plan/order was [box] faxed or [box] emailed to the above provider" did not have check marks present to indicate that pertinent information was transmitted for the patient's follow up care to their after-care provider.
* For Patient #U the "INTERDISCIPLINARY DISCHARGE PLAN/ORDER" dated 05/15/23 included a follow up appointment with a psychiatrist, however the portion of the form indicating "This interdisciplinary plan/order was [box] faxed or [box] emailed to the above provider" did not have check marks present to indicate that pertinent information was transmitted for the patient's follow up care to their after-care provider.

Based on the above findings, the facility failed to ensure the transmission necessary medical information pertaining to the patient's current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and other outpatient service providers and practitioners responsible for the patient's follow-up or ancillary care.

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

A. ensure Nursing Services was adequately staffed to provide safe care on 3 (Unit 100 Medically Compromised/Geriatric patients, Unit 300-General Adults, and Unit 400 Acute Adults) of 3 units. Nursing and/or BHAs (Behavioral Health Aides) staffing was short for 23 of 23 shifts reviewed.

B. follow their own policy for nurse staffing and patient acuity.

The deficient practices were identified under the following Condition of Participation, CFR 482.62 Special Staff Requirements and were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death.


Findings


A review of the staffing matrix and daily staff assignment sheets dated 5/17/2023 through 5/20/2023 for Units 100, 300, and 400 was conducted with Staff #3 on 5/23/2023 and revealed the following:

Review of the document titled, "Nurse Staffing and Patient Acuity Plan", Policy Stat ID 10995137 with a last revised date of 2/2022 was as follows:
"POLICY:
Staffing for patient care is based on acuity and level of care needed for the medical/psychiatric patient.
The acuity tool is meant to provide an assessment tool based on patient medical conditions, behaviors and needs of the medical/psychiatric patient. This will be used for making patient assignments.
To provide a framework for nursing staff to evaluate the nurse-to-patient ratio and nursing level of care needed.
To provide adequate nursing coverage and ensure/maximize a safe therapeutic environment.
To prevent/minimize the use of physical holds.
GENERAL INFORMATION:
Staffing Plan:
The staffing and acuity plan are the hospital's method for establishing nursing personnel requirements needed to meet the patient needs/acuity. The plan is evaluated annually by clinical and senior leadership. Appropriate staffing requirements are based on a review of the current patient population, individual safety needs, historical and projected data, department specific quality indicators, and therapeutic goals. Each unit has a pre-determined core staffing patient to staff ratio used as a guideline.
Core Staffing Matrix per unit
Inpatient Programs for Days (7am-7pm) - Includes weekends and holidays
1-12 Patients-1 Registered Nurse, 1 Aide/Tech
13-24 Patients-1 Registered Nurse plus 1 other Nurse, 2 Aides/Techs
If only one unit is open in the facility 1-24 Patients- 1 Registered Nurse plus 1 other Nurse, 2 Aides/Techs
Inpatient Program for Nights (7pm-7am) - Includes weekends and holidays

1-12 Patients-1 Registered Nurse, 1 Aide/Tech
13-24 Patients-1 Registered Nurse plus 1 other Nurse, 2 Aides/Techs
If only one unit is open in the facility 1-24 Patients- 1 Registered Nurse plus 1 other Nurse, 2 Aides/Techs.

Daily Staffing:
The hospital utilizes twelve (12) hour shifts to provide continuous twenty-four (24) hour coverage. The Registered Nurse on the patient unit completes the acuity classification for the patient prior to the final determination of the next shift. It is the responsibility of the Registered Nurse on the nursing unit to make the nurse staff/patient shift assignments.

Procedure:
Each shift at the hospital, the acuity worksheet is completed by the Director of Nursing and/or
Registered Nurse assigned to the patient to ensure recognition of any change in a patient's condition requiring additional intervention(s) by nursing staff. The Registered Nurse and aide/tech allocations are reviewed and revised, as appropriate, based on the acuity contributory factors listed on the tool. The patients will be scored individually on the acuity worksheet and given a score.

Acuity Assignment:
1. The hospital acuity tool will be completed on each twelve (12) hour shift approximately three
hours prior to the end of the shift. The registered nurse will assign a number to the categories for each patient using the information gained during the shift, the report sheet and patient
assessment data.
2.The Registered Nurses will complete the Acuity Tool and assign staff (nurse, aide/tech) to the patients based on the needs/acuity. For example: if there are two (2) nurses for 16 patients on day shift, and two (2) of the patients are considered a level 4 acuity, those two patients will be split between the nurses. The level three (3) acuity patients will then be split between the staff, then the level two (2) patients will be divided among the staff, and lastly the level one (1)
patients will be divided among the staff.

3.A staff member will be assigned exclusively to an individual if the patient requires continuous 1 :1 monitoring. Another aide/tech or nurse depending on the total census and patient acuity will be assigned to make rounds, supervision, and safety checks for other patients. Staffing decisions are a collaborative effort between the Director of Nursing and Registered Nurse. When additional resources are warranted, unit assignments can be changed, staff requesting additional hours can be contacted or PRN Staff can be added.

4.A Registered Nurse is available 24 hours a day to evaluate the need for making staffing
changes. If there are changes in patient status, admissions or discharge, staffing changes will be made accordingly. The Director of Nursing and/or an Administrator On-Call is available for support, validation, and/or assistance with problem resolution.

5.At all times nursing administration has ultimate responsibility for providing adequate staff
coverage to provide a safe therapeutic environment. The physical environment, other crises, staff makeup, staff experience, staff qualifications, patient diagnoses, patient co-occurring
conditions, patients ages, and patient developmental functioning may have an effect on the acuity of the unit and therefore on staffing levels.

Staffing Variances:

1.Completed Acuity Sheets are maintained in a binder at the Nurses Station for review and
retention. When the Acuity binder is purged the acuity, sheets are to be stored on site in the Director of Nursing's Office and/or designated area.

2.Variations from staffing plans are documented with explanation by the Director of Nursing or Designee."

Staff #2 confirmed the policy did not give clear direction on when to increase the staffing to ensure safe care. It was also confirmed the policy did not give direction on how to address the acuity of each patient or when to increase or decrease the acuity levels.


Staff #3 was asked to explain the staffing plan for Unit 100, and Unit 400. Staff #3 replied, "We are staffing the units according to patient acuity. I always try and staff above our staffing grid but its not always possible. I use a computerized program to prepare the schedule in advance. The Charge Nurse makes the daily assignments at the beginning of each shift and puts them on the Staffing Assignment Sheet posted on each unit.
Sometimes what I have in the computer is not who actually works because there may be call-ins, vacations, emergency leave and so on, so it is subject to change." Staff #3 stated, "We are staffing to the patient acuity levels and the staffing matrix is the same for all units." Staff #3 could not provide any documentation on how to determine a patients acuity. There was no plan on when to increase staffing to ensure safe care was provided to all patients. He was unable to


Staff #3 confirmed the staffing matrix currently being used was as follows:

"1-7 patients for the day and night shift was 1 RN (Registered Nurse) and 1 BHA's (Behavioral Health Aid),
8-12 patients for the day and night shift was 1 RN and 2 BHA's
13-18 patients for the day and night shift was 1 RN, 1 LVN (Licensed Vocational Nurse) or additional RN, and 2 BHA's
19-24 patients for the day and night shift was 1 RN, 1 LVN or additional RN, and 3 BHA's.

Considerations: Acuity of Unit, Heavy Admits/Discharges Day, # (number) 1:1, Q5."


During an interview with Staff #3 on 5/23/2023 after 10:00 AM Staff #3 stated he was unsure if the Governing Body had approved the staffing matrix. Staff #3 was asked if the staffing matrix was an attachment to a policy. Staff #3 replied he had been using the matrix since he started. He stated he had only been there about 6 weeks. Staff #3 said, "I was told before I took this job what kind of shape the hospital was in. I was aware of all the problems before I accepted the position. They were open about everything. This was the staffing matrix that I was given when I started, and I have been using it ever since." Staff #3 was asked if there was a Nurse Staffing Committee that held routine meetings to help determine the staffing needs and evaluate the staffing plan that was being used. Staff #3 confirmed there was not a committee.



5/17/2023
Unit 100
Census-22 patients

A review of the day shift Staff Assignment Sheet revealed 3 RNs and 4 BHAs were scheduled. Two RNs split one shift with one scheduled from 7am-11am and the other 11am-7pm. There was 1 patient on a 1:1 observation and 2 patients on Q (every) 5-minute observations for safety. Both RNs took a scheduled 30-minute lunch break leaving 1nurse responsible for 22 patients. The unit was short 1 nurse during this time. The minimum staffing grid was met for the BHAs. There was no documentation of the patients acuity on this unit before the staffing assignments were made.

A review of the night shift Staff Assignment Sheet revealed 1 RN, 1 LVN and 4 BHAs were scheduled. Both nurses took a scheduled 30-minute lunch break leaving 1 nurse responsible for 22 patients. The unit was short 1 nurse during this time. 1 BHA was scheduled to leave at 11:00 PM. There were 2 patients on a 1:1 for safety, one patient on a 1:1 while awake and 3 patients on Q 5-minute observations. There was no BHA scheduled to monitor the 19 patients that were not on a 1:1. After 11:00 PM the unit was short 2 BHAs.

An interview was conducted with Staff #3 on 5/23/2023 after 10:00 AM. Staff #3 was asked what happens if the patient on the 1:1 while awake stayed awake all night. Staff #3 confirmed the staff would have to try and call the doctor and see if they could get any of the 1:1 observation patients changed to a lower level of monitoring.

Staff #3 confirmed after 11:00 PM the 3 BHAs on the schedule were assigned to the 3, 1:1 observation patients. Staff #3 was asked who was responsible for monitoring the 19 patients that were not on a 1:1 after 11:00 PM. Staff #3 stated, "I see what you are saying." Staff #3 gave no other options to ensure appropriate and safe staffing.


5/17/2023
Unit 300
Census-12 patients

Review of the day shift Staff Assignment Sheet revealed 1 RN and 2 BHAs were scheduled. The BHAs took a scheduled 30-minute lunch break leaving 1 BHA responsible for 12 patients. 3 of the 12 patients were on increased Q5 minute observations for safety.

Review of the night shift Staff Assignment Sheet revealed 1 RN and 2 BHAs were scheduled. A review of Staff #42s timecard revealed the RN took a scheduled 30-minute lunch break. There was no documentation the Staff #42 was relieved by another nurse for her lunch. Staff #3 could not confirm nor deny if the RN left the unit leaving the patients and staff unsupervised by a RN. 2 BHAs took a scheduled 30-minute lunch break leaving 1 BHA responsible for 12 patients. 5 of 12 patients were on an increased Q 5-minute observations for safety. Staff #3 did not take into consideration the acuity of the patients for staffing needs.


5/17/2023
Unit 400
Census-20 patients

A review of the day shift Staff Assignment Sheet revealed 1 RN, 1 LVN, and 4 BHAs were scheduled. There was 1 patient on a 1:1 observation for safety. The LVN took a scheduled 30-minute lunch break leaving the RN responsible for 20 patients. The unit was short 1 nurse during this time. Unit 400 was a high acuity unit requiring acute care.

A review of the night shift Staff Assignment Sheet revealed 2 RNs and 3 BHAs were scheduled. 3 patients were on Q 5-minute observations for safety. The RNs took a scheduled 30-minute lunch break leaving 1 nurse responsible for 20 patients. The unit was short 1 nurse during this time.

5/18/2023
Unit 100
Census-22 patients

Review of the day shift Staff Assignment Sheet revealed 1 RN, 1 LVN, and 4 BHAs were scheduled. Two patients were on a 1:1 observation and 3 patients were on Q 5-minute observation for safety. The RN took a scheduled 30-minute lunch break leaving the LVN responsible for 22 patients. The unit was short 1 nurse during this time. 2 BHAs were assigned to the two patients on a 1:1 observation. 2 BHAs were assigned to the remaining 20 patients. During the BHAs scheduled 30-minute lunch breaks the unit was short 1 BHA.

Review of the night shift Staff Assignment Sheet revealed 1 RN, 1 LVN and 4 BHA were scheduled. 2 patients were on a 1:1 observation and 2 patients were on Q 5-minute observations for safety. The nurses took a scheduled 30-minute lunch break leaving the unit short 1 nurse to care for 22 patients during this time. 2 BHAs were assigned to the two 1:1 patients leaving 2 BHAs to monitor 20 patients. During the BHAs scheduled 30-minute lunch break the unit was short 1 BHA.


5/18/2023
Unit 300
Census-12 patients

A review of the day shift Staff Assignment Sheet revealed 1 RN and 2 BHAs were scheduled. There were 5 patients on increased Q 5-minute observation checks for safety. The RN took a scheduled 30-minute lunch break. Staff #3 could not confirm nor deny if the RN left the unit unsupervised without a nurse. Staff #3 confirmed there was no documented RN relief on the assignment sheet. The BHAs took a scheduled 30-minute lunch break leaving 1 BHA responsible for 12 patients. 5 of the 12 patients were on an increased Q 5-minute observation for safety.
A review of the night shift Staff Assignment Sheet revealed 1 RN and 2 BHAs were scheduled. There were 6 patients on Q 5-minute observation for safety. A review of Staff #42s timecard revealed the RN took a scheduled 30-minute lunch break. Staff #3 could not confirm nor deny if the RN left the unit. Staff #3 confirmed there was no documented RN relief on the assignment sheet. Both BHAs took a scheduled 30-minute lunch break leaving 1 BHA responsible for 12 patients. 6 of the 12 patients were on Q 5-minute observations for safety.


5/18/2023
Unit 400
Census-18 patients

A review of the day shift Staff Assignment Sheet revealed 1 RN, 1 LVN, and 4 BHAs were scheduled. There were 3 patients Q 5-minute observations for safety. The nurses took a scheduled 30-minute lunch break leaving 1 nurse responsible for 18 patients. The unit was short 1 nurse during this time.


A review of the night shift Staff Assignment Sheet revealed 1 RN and 3 BHAs were scheduled. One patient was on a 1:1 and 2 patients were on Q 5-minute observations for safety. This left 1 nurse responsible for 18 patients. The unit was short 1 nurse. A review of Staff #42's timecard revealed she was deducted 30 minutes for a scheduled lunch break. Staff #3 could not confirm nor deny if the RN left the unit. Staff #3 also confirmed there was no documented RN relief on the assignment sheet. 1 BHA was assigned to the 1:1 observation patient leaving 2 BHAs responsible for 17. All 3 BHAs had scheduled 30-minute lunch breaks with no documented relief. The unit was short 1 BHA during this time.



5/19/2023
Unit 100
Census-23 patients

There was no day shift assignment sheet provided for review.

A review of the night shift Staff Assignment Sheet revealed 2 RNs and 3 BHAs were scheduled. There were 4 patients on Q 5-minute observations for safety. Both RNs took a scheduled 30-minute lunch break leaving one nurse responsible for 23 patients. 1 BHA was scheduled to leave at 3:00 AM. This left 2 BHAs responsible for 23 patients with 4 patients on Q 5-minute observations for safety.


5/19/2023
Unit 300
Census-11 patients

A review of the day shift Staff Assignment Sheet revealed 1 RN and 2 BHAs were scheduled. There were 5 patients on Q 5-minute observations for safety. The RN took a scheduled 30-minute lunch break at 3:30 PM. Staff #3 confirmed there was no documentation that an RN relieved him for lunch. Staff #3 stated, "I would not have left the unit unsupervised by a nurse. I may have eaten lunch on the unit that day." Both BHAs took a scheduled 30-minute lunch break leaving 1 BHA responsible for 11 patients and 5 of the 11 patients were on Q 5 minute observations for safety.

A review of the night shift Staff Assignment Sheet revealed 1 RN and 2 BHAs were scheduled. There were 4 patients on Q 5-minute observations for safety. The RN documented a scheduled lunch break at 12:00 AM. Staff #3 could not confirm nor deny if the RN left the unit unsupervised by a RN. Staff #3 confirmed there was no documented RN relief on the assignment sheet. Both BHAs took a scheduled 30-minute lunch break leaving 1 BHA responsible for 11 patients and 4 of the 11 patients were on Q 5-minute observations for safety.

5/19/2023
Unit 400
Census-21 patients

A review of the day shift Staff Assignment Sheet revealed 1 RN, 1 LVN, and 3 BHAs were scheduled. 1 BHA was scheduled to leave at 11:00 AM. There was 1 patient on a 1:1 and 1 patient on Q 5-minute observations for safety. Both nurses took a scheduled 30-minute lunch break leaving 1 nurse responsible for 21 patients. Two BHAs took a scheduled 30 minute lunch break leaving 1 BHA to monitor a 1:1 patient and 20 other patients during the lunch period. The unit was short 1 nurse during this time. The staffing matrix requires 2 BHAs for 20 patients.


A review of the night shift Staff Assignment Sheet revealed 2 RNs and 3 BHAs were scheduled. There was 1 patient on a 1:1 observation level for safety. Both nurses took a scheduled 30-minute lunch break leaving 1 nurse responsible for 21 patients. The unit was short 1 nurse during this time. One BHA was assigned to the 1:1 observation patient leaving 2 BHAs responsible for 20 patients. The BHAs took a scheduled 30-minute lunch break leaving the unit 1 BHA short during this time.


5/20/2023
Unit 100
Census-23 patients

A review of the day shift Staff Assignment Sheet revealed 1 RN and 4 BHAs were scheduled. There were 4 patients on Q 5-minute observations for safety. The RN took a scheduled 30-minute lunch break at 3:00 PM. There was no documented lunch relief for the RN on the assignment sheet. The unit was short 1 nurse for the day shift. Staff #3 was asked who relieved the RN for lunch. Staff #3 confirmed there was no lunch relief documented on the assignment sheet. Staff #3 could not confirm nor deny if the RN left the unit unsupervised by a RN. The BHAs were staffed according to the staffing matrix for the day shift.


A review of the night shift Staff Assignment Sheet revealed 2 RNs and 3 BHAs were scheduled. There were 4 patients on Q 5-minute observations for safety. Both RNs took a scheduled 30-minute lunch break leaving the unit short 1 nurse to care for 23 patients during this time. The BHAs were staffed according to the staffing matrix for the day shift.


5/20/2023
Unit 300
Census-12 patients

A review of the day shift Staff Assignment Sheet revealed 1 RN and 2 BHAs were scheduled. There were 4 patients on Q 5-minute observations for safety. The RN took a scheduled 30-minute lunch break at 2:30 PM. Staff #3 could not confirm nor deny if the RN left the unit unsupervised without a nurse. Staff #3 confirmed there was no documented RN relief on the assignment sheet. The BHAs were staffed according to the staffing matrix for the day shift.

A review of the night shift Staff Assignment Sheet revealed 1 RN and 2 BHAs were scheduled. There was 1 patient on Q 5-minute observation checks for safety. Staff #3 took a scheduled lunch break at 2:30 (AM or PM not documented) with no documented lunch relief. Staff #3 confirmed there was no documented RN relief on the assignment sheet. The BHAs were staffed according to the staffing matrix for the day shift.


5/20/2023
Unit 400
Census-22 patients

A review of the day shift Staff Assignment Sheet revealed 1 RN, 1 LVN, and 3 BHAs were scheduled. There was 1 patient on a 1:1 observation. Both nurses took a scheduled 30-minute lunch break leaving 1 nurse responsible for 22 patients. The unit was short 1 nurse during this time. One BHA was assigned to the 1:1 observation patient leaving the other two BHA responsible for 21 patients. All 3 BHAs took a scheduled 30-minute lunch break. During the scheduled 30-minute lunch breaks by the BHAs, the unit was short 1 BHAs because 1 BHA was still assigned to the 1:1 patient and the other BHA was assigned to the other 21 patients. Staff #3 confirmed the staffing matrix requires 3 BHAs for 21 patients.


A review of the night shift Staff Assignment Sheet revealed 2 RNs and 4 BHAs were scheduled. There was 1 patient on a 1:1 observation level for safety. Both nurses took a scheduled 30-minute lunch break leaving 1 nurse responsible for 22 patients. The unit was short 1 nurse during this time. The BHAs were staffed according to the staffing matrix.



An interview was conducted with Staff #16 and Staff #17 on 5/22/2023 after 10:00 AM. Staff #16 was asked if she was relieved by another RN when she went to lunch. Staff #16 replied, "Are you kidding me? No, I am not. We just have to let each other go. The BHAs work their lunches out between them." Staff #16 was asked if she felt the nurse staffing and the BHA assignments were adequate and safe for the patients and the staff. Staff #16 stated, "Well, no, it is not safe. I have come to work and realized there was only one nurse that worked the entire night shift by herself on more than one occasion. We are given 2 nurses per shift and its usually 1 LVN and 1 RN. The RN is always the charge nurse and responsible for the assignments. I do the best I can with what they give me for the day. It's really too much on any RN. We are responsible for all the admissions, discharges, transfers, the 12-hour shift assessments, we have to be the unit secretary too because they took away the unit clerks. We are assigned to all the medical and behavioral codes on the unit. We have to process all the orders from the physicians and Nurse Practitioners. It takes me all day to just get the assessments completed. I like to have a conversation with my patients to see where they are mentally. This unit is supposed to be Geriatrics and medically compromised patients but they have patients from all ages on this unit because they didn't have a bed on the other unit and they wanted the admits so, they put them on this unit. So now the age ranges from 26 years old to 83 years old. We have 2 patients that have seizures and one that is blind. So, it is a lot of work for the nurses. Staff #17 stated, "We do not have people come back here to relieve us for lunch. The LVN is usually the medication nurse, but the RN has had to pass medications too. Basically that's all we are allowed to do anymore."

An interview was conducted with Staff #36 on 5/24/2023 after 9:00 AM. Staff #36 was asked if the patient acuity levels were documented so that the staff could be increased if needed. Staff #36 stated, "They used to use a tool to determine the patients acuity but they haven't used that in a long time. We do not give the DON (Director of Nurses) anything regarding patient acuity. He makes the staffing decisions not us. We do need more help back here." Staff #36 was asked if she knew how to determine a patients acuity. Staff #36 confirmed she did not know how to determine that.

During an interview with Staff #2 on 5/23/2023 after 1:00 PM it was confirmed the nursing staff did not utilize a patient acuity tool to help determine safe nurse staffing. Staff #2 was asked about the tool referenced by the staff. Staff #2 stated, "We do not use that. There is no one here now that was here when that was used." Staff #2 was asked how the nurses determined the patient's acuity. Staff #2 did not answer the question.

An interview was conducted with Staff #1 on 5/23/2023 after 1:00 PM. Staff #1 was asked who relieved the staff on the units for their scheduled 30-minute lunch breaks. Staff #1 replied, "Somedays there are House Supervisors that do that." Staff #1 was asked how the staff would show they relieved someone for lunch. Staff #1 confirmed there was no documentation showing where a nurse relieved another nurse for a lunch break.

An interview was conducted with Staff #43 on 5/24/2023 at 4:30 PM. Staff #43 was asked if employees had to clock in and out for their lunch breaks. Staff #43 replied, "They are supposed to clock out if they leave the premises. Otherwise, a 30-minute lunch break is deducted daily." She was then asked how the employees notify the payroll department if they were unable to take a 30-minute lunch. She replied, "There is a variance form that the employee fills out and turns it in so they can get paid for their lunch. I have not had any variance forms for the month of May. That tells me that everyone has been taking their lunch breaks."

Staff #13, #16, and #36 confirmed there was no lunch relief for the nurses and the nurses working the units relieved each other.
Findings:

An observation of unit 4 was made on 5/22/23 at 9:50 AM. The observation revealed that Staff #19 (RN) was the only nurse working on the unit. The patient census revealed there was 22 patients on the unit. Staff #19 stated that she had worked the shift prior and had been there all night. Staff #19 pulled all the patient's drugs and placed them in paper cups to distribute to the patients. There were 17 cups of medications lined out on the nurse's desk waiting to be distributed but there was no identification on the medications on which patient's it belonged to. Staff #19 stated she had marked the bottom of the cups but review of two medication cups revealed there was no patient identification. Staff #19 stated that she had been told that the facility had hired some nurses, but they had been working short-handed. Staff #19 stated that she just does the best that she can and depends on the technicians to help her.

An interview was conducted with Staff #3 on 5/22/23 at 10:00 AM. Staff #3 was asked about the nurse shortage in unit #4 and what was being done to assist the nurse that had worked the shift prior and was working alone as the nurse. Staff #3 stated that he was aware she was working by herself, and he was "going" to see if he could assist her. Staff #3 was asked why he had not checked on her needs before now and he stated he just had not got over to that unit, but he would try to find some help. Staff #3 confirmed that he was aware of the shortage since 7:00 AM on 5/22/23.

Based on a review of documentation and interviews, the facility failed to ensure that a hospital-wide antibiotic stewardship program: demonstrated coordination among all components of the hospital responsible for antibiotic use and resistance, including, but not limited to, the infection prevention and control program, the QAPI program, the medical staff, nursing services, and pharmacy services.

Findings included:

Facility based policy, "Antibiotic Stewardship Program" (PolicyStat ID 12079601) stated in part,
"Policy:
Demonstrate hospital-wide coordination of antimicrobial use and factors that lead to antimicrobial resistance, in the departments including, but not limited to, Infection Prevention, Quality, Medical Staff, Nursing, and Pharmacy. The Antimicrobial Stewardship Program is a hospital-wide program, supported by hospital leadership as an organizational priority...

e. Tracking: Monitoring the ASP outcomes
i. Appropriateness in the areas listed above shall be tracked and trended on an ongoing basis.
ii. The following items shall be assessed for each ordered antimicrobial:
1. Appropriate dosage
2. Appropriate duration
3. Appropriate selection based on indication and microbiology data
4. Potential for IV to PO conversion
5. Renal Adjustments in accordance with policy II-F.32
6. Any noted adverse effects due to an antimicrobial

f . Reporting, Regularly reporting information on the ASP to licensed practitioners, nursing, and relevant staff
i. ASP Data shall be reported monthly to the Quality Committee and quarterly to the Pharmacy and Therapeutics Committee. Information from the Pharmacy and Therapeutics Committee is then reported to Quarterly Quality meetings.
ii. ASP reporting data shall be included in the quarterly Pharmacy and Therapeutic meeting packets, to become a part of the hospital's permanent records.
iii. The following elements shall be reported:
1. Appropriate Dosage
2. Appropriate Duration
3. Appropriate selection based on indication and microbiology data
4. Reported Adverse Events from antimicrobials
5. Days of Therapy per Patient Days
iv. Elements with a success rate of <90% shall be addressed with an action plan, with the exception of DOT per PD."

Review of the facility Pharmacy & Therapeutics Committee Minutes revealed the last discussion of the Antibiotic Stewardship Program was 07/12/22.

In an interview on 05/24/23, staff member #1, Director of Infection Control verified that the facility was not currently tracking/trending antibiotic stewardship or meeting to report the findings per policy.

In an interview on 05/25/23 with staff member #31, facility pharmacist, stated they had not performed any antibiotic stewardship tracking. Staff member #31 stated they thought that antibiotic stewardship was tracked "at a corporate level".

The Pharmacist provided the surveyor with a binder of forms entitled, "48-72 Hour Antibiotic Time-Out Review" for the Antibiotic Stewardship Program revealed these forms were completed from 02/22/22 to 12/30/22. However all these forms are incomplete with no "Reason Antibiotic Prescribed", "Antibiotic Appropriateness, "Red Flags (select all that apply)", and/or "Actions to Take (select all that apply)" documented.

Based on the above findings, the facility does not have a coordinated or an effective antibiotic stewardship program in place involving the infection prevention and control program, the QAPI program, the medical staff, nursing services, and pharmacy services.

Based on review of the Texas Administrative Code, patient record review and interview, the facility failed to ensure that a Physician performed the initial and re-evaluation of the Psychiatric exam for 5 of 5 patients reviewed.

Findings included:

Review of the Texas Administrative Code RULE §568.62 Medical Services, it states:

" Psychiatric evaluation. A physician shall conduct an initial psychiatric evaluation of a patient. The results of the initial evaluation shall include:
(1) a description of the patient's medical history;
(2) a determination of the patient's mental status;
(3) a description of the onset of the patient's mental illness, any substance-related or addictive disorder, and the circumstances leading to admission;
(4) an estimation of the patient's intellectual functioning, memory functioning, and orientation;
(5) a description of the patient's strengths and limitations; and
(6) the diagnoses of the patient's mental illness and, if applicable, any substance-related and addictive disorders.
(g) Re-evaluation. A physician shall re-evaluate a patient:
(1) once a day for five of the first seven days after the initial psychiatric evaluation described in subsection (f) of this section is conducted and once a week thereafter; and
(2) as clinically indicated."

Review of in patient charts revealed the following five patients had the initial evaluation performed by a nonphysician. The first five daily re-evaluation of the first seven days after the initial psychiatric evaluation was also performed by a nonphysician for five of five patients reviewed (Patient #AA, #N, #LL, #BB, #JJ).

Patient #AA
Review of patient #AA medical record showed patient #AA was admitted via an Emergency Detention Order (EDO) on 05/11/23. A Psychiatric Evaluation was completed by a Staff NP #27 and cosigned by Staff Doctor #44 on 05/12/23. The NP performed the re-evaluation daily after admission for five of the first seven days.

Patient #N
Review of patient #N medical record showed patient #N was admitted as a voluntary patient on 05/12/23. A Psychiatric Evaluation was completed by a Staff NP #27 and cosigned by Staff Doctor #44 on 05/12/23. The NP performed the re-evaluation daily after admission for five of the first seven days.

Patient #LL
Review of patient #LL medical record showed patient #LL was admitted via an EDO from Harris County on 05/12/23 at 15:30. A Psychiatric Evaluation was completed by a Staff NP #27 on 05/14/23 at 10:50 and cosigned by Staff Doctor #44 on 05/12/23.
The NP performed the re-evaluation daily after admission for five of the first seven days.

Patient #BB
Review of patient #BB medical record showed patient #BB was admitted via an EDO from Harris County on 05/15/23 at 15:37. A Psychiatric Evaluation was completed by a NP Staff #27 and cosigned by Staff Doctor #44 on 05/15/23. The NP performed the re-evaluation daily after admission for five of the first seven days.

Patient #JJ
Review of patient #JJ medical record showed patient #JJ was admitted via an EDO from Montgomery County on 05/15/23 at 15:30. A Psychiatric Evaluation was completed by a NP Staff #47 and cosigned by Staff Doctor #28 on 05/15/23. The NP performed the re-evaluation daily after admission for five of the first seven days.

An interview with the Director of Psychiatry (Staff #4) on 05/23/2023 at 1:51 PM in the conference room confirmed the above findings. He was unaware of the Texas state code requirements.

Based on observation, interview, and record review, the facility failed to ensure a Registered Nurse (RN) was available 24 hours a day on 8 of 8 days reviewed on 3 (Unit 100 Medically Compromised/Geriatric Patients, Unit 300 General Adult Patients, and Unit 400 Acute Adult Patients) of 3 patient care units.


This deficient practice had the likelihood to cause harm to all patients. If the RN was not immediately available on the patient care units, it increased the risk of harm to all patients and staff during a behavioral or medical emergency. For leadership nursing staff to be available from the Administration area, they would have to access locked doors before entering the unit to be of assistance to the Licensed Vocational Nurse (LVN) and/or Unlicensed personnel.

The deficient practices were identified under the following Condition of Participation, CFR 482.62 Special Staff Requirements and were determined to pose an Immediate Jeopardy (IJ) to patient health and safety and placed all patients in the facility at risk for the likelihood of harm, serious injury, and possible death.


Findings:


During a tour of Unit 100 on 5/22/2023 at 10:25 AM, 1 RN, 1 LVN, and 4 Behavioral Health Aides (BHA's) were observed giving direct patient care for 22 patients.

An interview was conducted with Staff #16 (RN) on 5/22/2023 at 10:30 AM. Staff #16 was asked who made the staffing assignments for each unit. Staff #16 replied, "The RN's make the assignments for the day and put them on the assignment sheet and post it on the unit."

A review of the document titled, "Staff Assignment Sheet" for 5/22/2023 for 7 am-7 pm revealed Staff #16 was scheduled for lunch at 10:30 AM. At 10:40 AM Staff #16 was observed leaving the unit for lunch leaving the LVN (licensed vocational nurse) unsupervised by an RN and responsible for 22 patients.

An interview was conducted with Staff #17 (LVN) on 5/22/2023 at 10:45 AM. Staff #17 was asked if another RN was available for assistance if needed. Staff #17 stated, "I guess I could call someone if I needed help or one of the BHAs could go and get help." Staff #17 confirmed that the RN and LVN relieve each other for lunch daily. Staff #17 stated, "We do not have enough staff to come and relieve us for lunch so, if we want to take a lunch then we have to let each other go."

A review of the staffing schedules, staffing matrix, and staff assignment sheets dated 5/16/2023 through 5/22/2023 was conducted with Staff #3 (Director of Nursing, DON) on 5/23/2023 and revealed the following:


5/16/2023
Unit 100
Day shift patient census was 20. A review of the staff assignment sheet revealed Staff #36 (RN) took a scheduled 30-minute lunch break at 3:00 PM leaving Staff #17 (LVN) unsupervised by an RN and responsible for 20 patients.

Unit 300
Day shift patient census was 11. A review of the staff assignment sheet revealed Staff #37 (RN) was the only nurse scheduled. Staff #3 (DON) confirmed Staff #37 was deducted a 30-minute lunch break. Staff #3 confirmed there was no relief nurse documented and he was unable to confirm or deny if a RN relieved Staff #37 for lunch.

Night shift patient census was 11. A review of the staff assignment sheet revealed Staff #38 (RN) was the only nurse scheduled. Staff #3 (DON) confirmed Staff #38 was deducted a 30-minute lunch break. Staff #3 confirmed there was no relief nurse documented and he was unable to confirm if an RN relieved Staff #38 for lunch.


Unit 400
Day shift patient census was 18. A review of the staff assignment sheet revealed Staff #40 (RN) took a scheduled 30-minute lunch break at 2:00 PM leaving Staff #39 (LVN) unsupervised by an RN and responsible for 18 patients.

5/17/2023
Unit 100
Night shift patient census was 22. A review of Staff #34's (RN) timesheet revealed she took a scheduled 30-minute lunch break leaving Staff #41 (LVN) unsupervised by an RN and responsible for 22 patients.

Unit 300
Night shift patient census was 12. A review of the staff assignment sheet revealed Staff #42 (RN) was the only nurse scheduled. Staff #3 (DON) confirmed Staff #42 was deducted a 30-minute lunch break. Staff #3 confirmed there was no relief nurse documented and he was unable to confirm if an RN relieved Staff #42 for lunch.


5/18/2023
Unit 100
Day shift patient census was 22. A review of the staff assignment sheet revealed Staff #16 (RN) took a scheduled 30-minute lunch break at 10:30 AM leaving Staff #17 (LVN) unsupervised by an RN and responsible for 22 patients.

Unit 300
Day shift patient census was 12. A review of the staff assignment sheet revealed Staff #33 (RN) was the only RN scheduled. Staff # 3 (DON) confirmed Staff #33 took a scheduled 30-minute lunch break at 2:00 PM. Staff #3 confirmed he was unable to confirm if an RN relieved Staff #37 for lunch.

Night shift patient census was 12. A review of the staff assignment sheet revealed Staff #42 (RN) was the only nurse scheduled. Staff #3 confirmed Staff #42 was deducted a 30-minute lunch break. Staff #3 confirmed there was no relief nurse documented and he was unable to confirm if an RN relieved Staff #42 for lunch.

Unit 400
Day shift patient census was 18. A review of the staff assignment sheet revealed Staff #36 (RN) took a scheduled 30-minute lunch break at 3:00 PM leaving Staff #35 (LVN) unsupervised by an RN and responsible for 18 patients.

Night shift patient census was 18. A review of the staff assignment sheet revealed Staff #42 (RN) was the only RN scheduled. Staff # 3 confirmed Staff #42 took a scheduled 30-minute lunch break but was unable to confirm if an RN relieved Staff #42 for lunch.

5/19/2023
Unit 300
Day shift patient census was 11. A review of the staff assignment sheet revealed Staff #3 (DON) was assigned to the unit from 11:00 AM-7:00 PM. Staff #3 took a scheduled 30-minute lunch break at 3:30 PM. Staff #3 confirmed there was no documentation that an RN relieved him for lunch. Staff #3 stated, "I would not have left the unit unsupervised by a nurse, but I do that I would never leave the unit without a nurse, but I cannot confirm that I was relieved by another RN for a lunch break. I may have eaten my lunch on the unit that day."

Night shift patient census was 11. A review of the staff assignment sheet revealed Staff #38 (RN) was the only nurse scheduled. Staff #3 confirmed Staff #38 was deducted a 30-minute lunch break but was unable to confirm if an RN relieved Staff #38 for lunch.

Unit 400
Day shift patient census was 21. A review of the staff assignment sheet revealed Staff #37 (RN) took a scheduled 30-minute lunch break at 2:00 PM leaving Staff #39 (LVN) unsupervised by an RN and responsible for 21 patients.


5/20/2023
Unit 100
Day shift patient census was 23. A review of the staff assignment sheet revealed Staff #36 (RN) took a scheduled 30-minute lunch break at 3:00 PM. Staff #3 (DON) confirmed Staff #36 was deducted a 30-minute lunch break but was unable to confirm if an RN relieved Staff #36 for lunch.


Unit 300
Day shift patient census was 12. A review of the staff assignment sheet revealed Staff #33 (RN) took a scheduled 30-minute lunch break at 2:30 PM. Staff #3 (DON) confirmed Staff #33 was deducted a 30-minute lunch break but was unable to confirm if an RN relieved Staff #33 for lunch.


Night shift patient census was 12. A review of the staff assignment sheet revealed Staff #3 (DON) took a scheduled 30-minute lunch break at 2:30 AM. Staff #3 confirmed there was no documentation that an RN relieved him for lunch. Staff #3 stated, "I would not have left the unit unsupervised by a nurse, but I know I was either relieved by an RN or I ate my lunch on the unit."

Unit 400
Day shift patient census was 22. A review of the staff assignment sheet revealed Staff #37 (RN) took a scheduled 30-minute lunch break at 3:00 PM leaving Staff #39 (LVN) unsupervised by an RN and responsible for 22 patients.


5/21/2023
Unit 100
Day shift patient census was 24. A review of the staff assignment sheet revealed Staff #20 (RN) took a scheduled 30-minute lunch break at 10:00 AM leaving Staff #17 (LVN) unsupervised by an RN and responsible for 24 patients.

Unit 300
Day shift patient census was 12. A review of the staff assignment sheet revealed Staff #33 (RN) was the only nurse scheduled. Staff #3 (DON) confirmed Staff #33 was deducted a 30-minute lunch break but was unable to confirm if an RN relieved Staff #33 for lunch.

Night shift patient census was 12. A review of the staff assignment sheet revealed Staff #19 (RN) was the only nurse scheduled. Staff #19 documented a 30-minute lunch break at 12:30 AM. Staff #3 (DON) confirmed Staff #19 was deducted a 30-minute lunch break but was unable to confirm if an RN relieved Staff #19 for lunch.

Unit 400
Day Shift patient census was 22. A review of the staff assignment sheet revealed Staff #37 (RN) took a scheduled 30-minute lunch break at 4:00 PM leaving Staff #39 (LVN) unsupervised by an RN and responsible for 24 patients.


5/22/2023-No PM shift was provided for review
Unit 100
Day shift patient census was 22. During observation on the unit, Staff #16 (RN) left the unit for lunch at 10:40 AM leaving Staff #17 (LVN) unsupervised by an RN and responsible for 20 patients.

Unit 300
Day shift census was 12. A review of the daily assignment sheet revealed Staff #33 (RN) was the only nurse on the unit and had a scheduled lunch break at 3:00 PM. A review of Staff #33's timecard revealed she was deducted for a 30-minute lunch break. Staff #3 (DON) confirmed there was no documentation of who relieved the nurse for lunch. There was no documentation provided to the surveyor to ensure that Unit 300 was supervised by a RN during Staff #33's scheduled 30 minute lunch break.

Unit 400
Day shift patient census was 19. A review of the daily assignment sheet revealed Staff #34 (RN) was scheduled until 11:00 AM. Staff #3 (DON) confirmed there was no other nursing personnel written on the daily assignment sheet. A review of the document titled, "Computerized schedule management" provided by Staff #3 revealed Staff #13 (RN) was scheduled to work on the unit from 10:30 AM to 7:30 PM and Staff #35 (LVN) was scheduled to work from 10:30 AM-7:30 PM. A review of the timecard for Staff #13 (RN) revealed she was deducted a 30-minute lunch break leaving Staff #35 (LVN) unsupervised and responsible for 19 patients.


5/23/2023
Unit 100
Day shift patient census was 22. During an observation of Unit 100 on 5/23/2023 at 11:20 AM Staff #16 (RN) was off the unit for a 30-minute scheduled lunch break. At 11:35 AM Staff #36 (RN) escorted this surveyor off the locked unit to the hospital entrance. This left no licensed nurse on the unit to assess a patient if there was a medical or behavioral emergency.

Night shift patient census was 22. A review of Staff #34's (RN) timesheet revealed she took a scheduled 30-minute lunch break leaving Staff #41 (LVN) unsupervised by an RN and responsible for 22 patients.

An interview was conducted with Staff #3 (DON) on 5/25/2023 after 11:00 AM. Staff #3 was asked how he determined the scheduling needs for each unit. Staff #3 replied, "I use a computerized scheduling program. I can put the employee name, time, and the unit they are scheduled to work on into the program. It is made out in advance and is subject to change because people call in sick, or they are on vacation, or need to leave early and so on. I can go back in and enter the changes so that it reflects who actually worked on that day. The handwritten daily assignment sheet is completed by the charge nurse on each unit. It shows the staff names, assignments, lunch break times, and patients that are on increased observations. That daily assignment sheet is made out by the charge nurse on each unit."

Staff #3 was asked if the LVN's were supervised by a RN at all times. Staff #3 replied, "There is a RN scheduled with the LVN. There is never a LVN scheduled on the unit alone. I understand they must be supervised by a RN. We are hiring more RNs and have some in orientation right now, but they are not ready to be on the units. Most of our shifts are staffed with a LVN and a RN. Somedays we have House Supervisors (Nursing Supervisors) that can go and relieve nurses for lunch or assist with other duties as needed."

Staff #3 confirmed the staffing matrix he was currently using was as follows:

"1-7 patients for the day and night was 1 RN and 1 BHA's
8-12 patients for the day and night was 1 RN and 2 BHA's
13-18 patients for the day and night shift was 1 RN, 1 LVN or additional RN, and 2 BHA's
19-24 patients for the day and night shift was 1 RN, 1 LVN or additional RN, and 3 BHA's."

Staff #3 confirmed there was no documentation of who or if anyone relieved the RN for a scheduled 30-minute lunch break. Staff #3 also confirmed that the LVN was giving direct patient care and supervising unlicensed personnel without the supervision of a RN while the RN was on a scheduled 30-minute lunch break.

An interview was conducted with Staff #43 (Payroll) on 5/24/2023 at 4:30 PM. Staff #43 was asked if employees had to clock in and out for their lunch breaks. Staff #43 replied, "They are supposed to clock out if they leave the premises. Otherwise, a 30-minute lunch break is deducted daily." She was then asked how the employees notify the payroll department if they were unable to take a 30-minute lunch. She replied, "There is a variance form that the employee fills out and turns it in so they can get paid for their lunch. I have not had any variance forms for the month of May. That tells me that everyone has been taking their lunch breaks."

A review of the Texas Board of Nursing, Practice-Licensed Vocational Nurse Scope of Practice was as follows:

The Texas Nursing Practice Act (NPA) and the Board's Rules and Regulations define the legal scope of practice for licensed vocational nurses (LVN),

" ...15.27 The Licensed Vocational Nurse Scope of Practice
The LVN scope of practice is a directed scope of practice and requires appropriate supervision of a registered nurse, advanced practice registered nurse, physician assistant, dentist, or podiatrist ..."

Staff #3 confirmed there was no written documentation on the staffing assignment sheets dated 5/16/2023 through 5/24/2023 on 3 (Unit 100, Unit 300, and Unit 400) of 3 patient care units when the RN was on a scheduled 30-minute lunch break to ensure that an RN was immediately available to assist the LVN or unlicensed personnel during a medical or behavioral emergency.

Based on a review of documentation, interviews, and observations, the facility failed to provide an effective therapeutic activities program.

Findings included:

Facility based policy "Therapy Services - Scope of Service" (PolicyStat ID 12197180) stated in part, "

"B. Objectives ...

3. To meet the rehabilitation, education, and training needs of the patients and their caregivers.
4. To provide individualized education and treatment procedures according to the specific needs, age, and impairment of each patient with the optimal frequency as determined by the Physical Therapist, Occupational Therapist, Behavior Analyst, and Speech-Language Pathologist.
5. To provide physical therapy, occupational therapy, behavior therapy and speech-language therapy care in an adequate and appropriate environment to maximize patient interest and participation in his/her own recovery, and to promote a good learning atmosphere for their caregivers.
6. To obtain good outcomes by utilizing the latest and the best techniques, research, and technology in the treatment of the patients ...

G. Availability of Necessary Staff ...
3. The hours of operation have been determined for each site to meet the individual needs and fulfill patient care criteria. Inpatient Rehabilitation Services are provided five (7) days per week."

The facility-based Programming Schedule (posted on all the units) for the whole facility indicated that therapeutic activities were provided at the facility, seven days a week, Monday-Sunday. The following activities were listed: Exercise Group 10:00 AM-10:45 AM, Community Group 11"15 AM-11:45 AM, Recovery Skills/Coping Skill (alternating days) 1:30 PM-2:15 PM, Social Skills Group 2:20 PM-3:15 PM, Goal Visualization 3:45 PM-5:00 PM (Monday-Saturday), on Sundays, Movie Time replaces Social Skills and Goal Visualization from 2:30 PM-5:00 PM.

Review of documentation of therapies provided at the facility for 8 Patients revealed the following:

Patient #F (admitted 05/10/23) had therapeutic groups documented on the following dates:
05/11/23: 1430 Group, 1600 Exercise, and 1630 Personal Strengths.
05/12/23: 1330 Cornhole (Leisure)
05/15/23: 1100 Pet Therapy and 1630 CBT group
05/16/23: 1100 Exercise and 1430 Scattergories
05/17/23: 1100 Dart Board, 1330 Leisure-choice, and 1630 Boundaries group
05/18/23: 1100 Social Support group and 1630 Positive relationship goals.
05/19/23: 1100 Cornhole
05/20/23: 1110 CBT group
05/22/23: 1000 Coping Skills

Patient G (admitted 05/16/23) had therapeutic groups documented on the following dates:
05/17/23: 1000 Dart Board, 1400 Group session, 1430 Leisure group
05/18/23: 1000 Social Support group
05/19/23: 1000 Cornhole
05/20/23: 1100 CBT Group
05/22/23: 1000 Coping Skills, 1100 Stress Management Group

Patient #H (admitted 05/12/23) had therapeutic groups documented on the following dates:
05/16/23: 1000 Exercise/Meditation, 1330 Scattergories
05/17/23: 1000 Dart Board, 1430 Leisure Choice
05/18/23: 1000 Support Arts
05/19/23: 1100 Cornhole
05/22/23: 1000 Coping Skills

Patient #I (admitted 05/17/23) had therapeutic groups documented on the following dates:
05/17/23: 1000 Dart Board, 1400- 50 Ways to Take a Break
05/18/23: 1000 Social Support
05/19/23: Cornhole
05/20/23: CBT Group
05/22/23: Coping Skills

Patient #K (admitted 05/14/23) had therapeutic groups documented on the following dates:
05/15/23: 1100 Pet Therapy, 1630 CBT
05/16/23: 1100 Exercise/Meditation, 1430 Scattergories, 1630 Personal Goals Group
05/17/23: 1100 Dart Board, 1630 Boundaries Group
05/18/23: 1630 Positive Relationship Goals
05/20/23: 1000 CBT Group

Patient #L (admitted 05/16/23) had therapeutic groups documented on the following dates:
05/17/23: 1100 Dart Board, 1330 Leisure Choice
05/18/23: 1330 Pictionary
05/19/23: 1000 Cornhole
05/22/23: 1330 Teamwork Group


Patient #M (admitted 05/11/23) had therapeutic groups documented on the following dates:
05/11/23: 1430 Crafts
05/12/23: 1330 Cornhole
05/13/23: 1000 Anger Iceberg
05/15/23: 1100 Pet Therapy
05/16/23: 1000 Exercise/Meditation, 1430 Scattergories
05/17/23: 1100 Dart Board, 1330 Pictionary, 1630 Boundaries Group
05/18/23: 1630 Positive Relationship Goals
05/19/23: 1000: Cornhole


Patient #Q (admitted 05/12/23) had therapeutic groups documented on the following dates:
05/13/23: 1000 Anger Iceberg
05/15/23: 1200 Pet Therapy
05/16/23: 1000 Exercise/Meditation, 1330 Scattergories
05/17/23: 1000 Dartboard, 1400- 50 Ways to Take a Break
05/18/23: 1000 Social Support Group
05/19/23: 1000 Cornhole
05/20/23: 1000 CBT Group
05/22/23: 1000 Coping Skills

On 05/22/23 on Unit 300 the therapist working on that date stated that typically they can only run one group per day due to inadequate staffing. The same staff member indicated they were having to cover multiple units that date and only able to provide one group session per unit on that date (05/22/23).

On 05/22/23 Patient #N stated she was told "This is stabilization unit. They don't do individualized therapy here." Two other patients verified that no individualized therapy is provided at the facility.

In an interview on 05/25/23 at 9:30 AM, staff member #15, the Director of Social Services stated that currently the facility is only providing therapeutic services/programming "Monday through Saturday" Staff member #15 stated that weekend therapy was not offered consistently, due to staffing issues. "We are trying to get back to seven days a week but we are down several staff .... For about a month or so I know we've only been able to offer groups 5 days a week." Staff member #15 was asked why only one to two therapy/group session per day were documented on the sample of 8 patients above? Staff member #15 stated they had at least one social services staff member that would report they were running groups, "but I don't know if they just aren't documented the groups, or if they are not running them."

Staff member #15 was asked if individualized therapy is offered at the facility. Staff member #15 replied, "We try to meet with patients at least once a week to go over their treatment and discharge planning."

Based on the above findings, the facility failed to provide therapy and rehabilitative services seven days a week per facility Programming Schedule and facility policy. The facility also failed to provide individualized therapy to patients.