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Based on interview and record review, the facility failed to ensure the informed consents for the use of psychotropic medications were obtained prior to administration. This failure had the potential to limit the patients or their responsible parties to exercise their right to refuse or participate in their plan of care.

Findings:

Review of Patient 1's Medication Administration Record dated 11/17/17 to 11/19/17, indicated the patient received Risperdal and Zyprexa (psychotropic medications). There were no informed consents for the use of these psychotropic medications.

During an interview on 1/4/18 at 2:50 p.m., the director of nursing (DON) reviewed the clinical record and stated there were no informed consents for the use of psychotropic medications and nurses should verify it prior to administration of medications.

Review of the facility's 10/2016 policy "Informed Consent for Psychotropic Medication" indicated after the physician has discussed the recommended medication(s) with the patient and the patient has indicated a reasonable understanding of the content of the informed consent and has agreed to the administration of the recommended medication, the patient and physician will sign and date the form. No medication(s) will be administered in the absence of asigned consent form.

Based on interview and record review, the hospital failed to comply with the Condition for Coverage for Nursing Services as evidenced by:

1. Failure to conduct necessary training and evaluation (refer to A0386)
2. Failure to provide adequate numbers of licensed nurses (refer to A0392)

The cumulative effects of these systemic problems resulted in the facility's inability to ensure the provision of quality and safe health care environment for the patients.

Based on interview and record review, the facility failed to conduct necessary training and evaluation. These failures had the potential to impact the patients' care and safety.

Findings:

1. Review of new hired Mental Health Technicians (MHTs)'s employee files indicated four (4) of four (4) MHTs (MHTs A, B, C, and D) did not have 90 days evaluations.

During an interview with the director of human resources (DHR) on 1/4/18 at 1:50 p.m., she reviewed the employee files and confirmed there was no 90 days evaluations for MHTs A, B, C, and D.

During an interview with the director of nursing (DON) on 1/4/18 at 2:50 p.m., she stated the new hired nursing staff were evaluated 90 days after hired and then annually. She stated she should oversee the evaluation of nursing staff.

2. During an interview with DON on 1/4/18 at 2:50 p.m., she stated she had not conducted Code Blue drills and the first drill was performed in October, 2017 when a sentinel event occurred in the hospital.

Review of the facility's 3/29/16 policy "CODE BLUE" indicated the DON will conduct Code Blue drills each shift, minimum quarterly.

There were no documentation the quarterly drill for Code Blue were conducted.

3. Review of MHT E's employee file on 1/3/18, indicated his CPI (Crisis Prevention Institute) training certificate was expired on 12/20/17.

Review of registered nurse F (RN F)'s employee file on 1/3/18, indicated her CPI (Crisis Prevention Institute) training certificate was expired on 12/20/17.

During an interview on 1/3/18 at 1:45 p.m., the DON verified CPI training certificates for MHT E and RN F were expired.

Review of the facility's job prescription "DIRECTOR OF NURSING" indicated the DON hire, orient, train, supervise, and evaluate employees.

Based on interview and record review, the facility failed to follow the nurse-patient ratios. This failure potentially impacts patient's care and safety.

Findings:

During an interview on 1/3/18 at 10 a.m., the director of nursing (DON) stated the licensed nurse-to-patient ratio is 1:6.

Review of the hospital's staffing assignment and the census from 11/1/17 to 12/31/17, indicated the licensed nurse-to-patient ratio did not meet 1:6.

The night shift assignment and the census, dated 11/5/17, were reviewed. In Unit A, the census was 22, two registered nurses (RNs) worked, and the nurse-to-patient ratio was 1:11. In Unit B, the census was 16, one RN worked, and the ratio was 1:16. In Units C and D, the census was 37, three RNs worked, and the ratio was 1:12.3.

The night shift assignment and the census, dated 11/12/17, were reviewed. In Unit A, the census was 20, one RN worked, and the ratio was 1:20. In Unit B, the census was 16, two RNs worked, and the ratio was 1:8. In Unit C, the census was 22, one licensed vocational nurse (LVN) worked, and the ratio was 1:22. In Unit D, the census was 16, one RN worked, and the ratio was 1:16.

During an interview with RN G on 1/3/18 at 9:01 p.m., she stated she called 911 for Resident 1 and another nurse initiated the Code Blue for Patient 1. She also confirmed she had 35 patients for the night shift and two mental health techs (MHT) on 11/19/17, night shift. She stated it has always been that way--one RN and two MHTs.

Review of Patient 1's Code Blue (a hospital code used to indicate a patient requiring immediate resuscitation) Record dated 11/20/17, indicated at 4:25 a.m. Code Blue was activated in Unit C for the patient.

Review of night shift assignment and the census, dated 11/19/17, indicated the census in Unit C was 35, One RN worked in Unit C and another RN worked in both Units C and D. The ratio was 1:17.5
The night shift assignment and the census, dated 11/26/17, were reviewed. In Unit A, the census was 23, on RN worked, the ratio was 1:23. In Unit B, the census was 14, one RN worked, the ratio was 1:14. In Unit C, the census was 21, one RN worked, the ratio was 1:21. In Unit D, the census was 17, two RNs worked and one RN left at 3 a.m. The ratio after 3 a.m. was 1:17.

During an interview on 1/4/18 at 1:40 p.m., the DON stated for the licensed nurse-to-patient ratio, the ratio 1:6 was the ideal ratio and the usual ratio was 1:8 or 1:9. She stated she was aware of the short staff and the management was also fully aware regarding the short staff issue.

The hospital did not have a policy regarding the licensed nurse-to-patient ratio.