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Based on observation, record review, and interview the facility failed to meet the requirements for the Condition of Participation (CoP) for Patients' Rights. This deficient practice is evidenced by:
1) failure to provide appropriate staffing to ensure care in a safe setting(see findings under Tag A0144);
2) failure to ensure patients admitted into hospital did not have potentially harmful contraband in their possession(see findings under Tag A0144);
3) failure to ensure nursing staff recognized ligature risks in a patient with suicidal ideations (see findings under Tag A0144);
4) failure to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients with safety risks (see findings under Tag A0144);
5) failure to provide medical attention in a timely manner(see findings under Tag A0145) and
6) failure to monitor and thereby prevent Patient #2, who was on "assault" and "sexual acting out" precautions, from attacking Patient #1 which likely led to Patient #1's fractured shoulder (see findings under Tag A0145).

Based on record review and interview, the hospital failed to ensure every patient, or his/her designated representative, shall whenever possible, make informed decisions regarding his or her care. This deficiency is evidenced by failure to have Patient #1 or her representative sign a written consent form prior to transfer to another facility.
Findings:

Review of Hosptial policy titled, "EMTALA", dated 09/2017, revealed, in part: Policy, in part: It is the policy of this Hospital to assess, stabilize and transfer persons who present with an emergency medical condition relative to their presenting clinical condition. Purpose: To provide guidelines which meet the requirements and associated responsibilities for the treatment and transfer of individuals ....Forms, in part: Consent for Transfer. Procedure, in part: 1. any person who presents to the Hospital will be evaluated to determine whether the person has an emergency medical condition. If so, the patient must be stabilized, and/or appropriately transferred. 2. Emergency Medical Condition, in part: The following criteria shall be used to determine whether such an emergency exists: a. ...an acute medical condition that without immediate medical attention, could reasonably be expected to result in serious jeopardy of the health of an individual ...or serous impairment or dysfunction of any bodily organ or part. 12. Notice to Patient. a. The individual or the individual's representative if any is present, must be notified of the transfer and of the reasons for such transfer. The individual's acknowledgment of such notification should be reflected in an appropriate "Request/Consent for Transfer" form.

Review of Patient #1's Medical record revealed an admit date of 01/26/2024. Further review revealed an incident report dated 01/30/2024 detailing an incident that occurred on 01/30/2024 at 11:15 a.m. At approximately 11:15 a.m. on 01/30/2024, a sudden outburst was heard from hallway, upon further observation patient was seen on floor being repeatedly hit by a peer who was on top of her yelling and cursing. Altercation was broken up by the maintenance staff. The patient complained of hitting her right shoulder on the floor when she was attacked. Redness and limited range of motion was noted to the site. Medical provider ordered a mobile xray of the right shoulder at 11:30 a.m.

Review of Patient #1's mobile xray findings signed by radiologist at 01/30/2024 at 5:04 p.m. and received by hospital at 6:05 p.m., revealed suspected nondisplaced fracture of greater tuberosity.

Review of January 2024's Hospital Transfer list revealed Patient #1 was transferred to an Emergency Department on 01/30/2024 at 7:15 p.m.

Review of Patient #1's Medical Record revealed an Authorization to Disclose Healthcare Information dated 01/27/2024. Continued review revealed signed permission to disclose treatment information to a specific individual with the contact's phone number documented.

Review of Patient #1's Medical Record failed to reveal evidence of a signed consent for transfer. Continued review failed to reveal Patient #1's contact was notified of the transfer and of the reasons for such transfer.

In an interview on 02/20/2024 at 1:25 p.m., S4RM confirmed Patient #1's medical record failed to reveal a signed consent for transfer. S4RM verified Patient #1's medical record failed to reveal her contact was notified of the transfer and of the reasons for such transfer.

Based on observation, record review and interview, the hospital failed to ensure care in a safe setting. This deficient practice was evidenced by:
1) failure to provide appropriate staffing to ensure care in a safe setting;
2) failure to ensure patients admitted into hospital did not have potentially harmful contraband in their possession;
3) failure to ensure nursing staff recognized ligature risks in a patient with suicidal ideations;
4) failure to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients with safety risks;
5) failure to ensure that ordered levels of observations were implemented per Hospital policy for 5 (#R1-#R5) of 5 (#R1-#R5) patients reviewed for observation levels.
Findings:

1) Failure to provide appropriate staffing to ensure care in a safe setting.
Review of hospital policy titled "Assignment of Nursing Staff", dated 02/2023, revealed, in part: Policy, in part: To assure quality nursing care and a safe patient environment ...

Review of Hospital incident reports dated 01/28/2024-02/19/2024 revealed 12 falls unobserved by staff and 10 incidents regarding patient-to-patient attacks.

Review of Hospital Grievance Communication Form completed by Patient R8 on 11/27/2023 revealed the following: Patient R8 was located on Unit D and admitted for less than 48 hours and had seen 3 fights all with males. Patient R8 reported that there were only female workers on the unit and the place was not safe for the female workers or female patients. Patient R8 wrote that she would be looking for someone on a higher level to address this issue. Patient R8 planned to follow up on this matter. Patient R8 reported she would like to be transferred to a different hospital or home because the place was not safe. Patient R8 would be reaching out to the news outlets about this situation because it was a major issue.

Review of Hospital response to Patient R8's complaint revealed, in part: ....We were unable to substantiate this allegation. When compared to other psychiatric hospitals in this region, this hospital has low incidents.

Review of incident reports revealed two incidents involving patient attack and patient injury that occurred on 11/27/2024 on Unit D.

In an interview on 02/20/2024 at 10:50 a.m., S4RM confirmed the incidents and stated that she recognizes there is an increased trend of unobserved falls and patient-to-patient attacks.

In an interview on 02/20/2024 at 10:53 a.m. S4RM stated that she and S1CNO asked for increased staffing in December of 2023 due to increasing trends related to patient safety and staffing. S4RM and S1CNO reported they have created action plans to measure staffing ratio versus acuity levels with plans to present results to upper management.

2) Failure to ensure patients admitted into hospital did not have potentially harmful contraband in their possession.
Review of Hospital Incident Report Form dated 12/12/2024 revealed 5 sewing needles (labeled as Contraband/Weapons) were found in Patient R9's room.

Review of grievance/complaint/Self-Report log failed to reveal documentation that an investigation as to how/why Patient R9 was admitted into the hospital with 5 sewing needles that could potentially be used as weapons.

In an interview on 02/20/2024 at 11:00 a.m., S4RM stated she did not know how Patient R9 was able to bring in the 5 sewing needles since the intake department has metal detector wands. S4RM verified the self-report log failed to reveal a self-report for this incident.

3) Failure to ensure nursing staff recognized ligature risks in a patient with suicidal ideations.
Review of Hospital Policy titled, "Precautions, Suicide" revealed, in part: Policy ...The psychiatric practitioner shall order observation and precautions consistent with the assessed level of risk. Procedure, in part: 3 ...Suicide precautions may also trigger a combination of the following actions, in part: Increased observation level based on risk ...Limit linens and belongings.

Observations of Unit B on 02/19/2024 at 10:40 a.m. guided by S1CNO revealed Patient #R4 in Room a on telephone with a towel wrapped around her head. Further Observation revealed S1CNO realized Patient #R4 had a towel wrapped around her head and explained to S8BHA that Patient #R4 should not have a towel wrapped around her head because she was a suicide risk on Suicide Precautions.

In an interview on 02/19/2024 at 10:41 a.m., S8BHA reported Patient #R4 had taken a shower about 45 minutes prior and must have wrapped the towel around her head after her shower before going into Room a to use the telephone. S8BHA stated the patient was on Q 15 minute observations. S1CNO reviewed Patient #R4's observation sheet and pointed out to S8BHA that Patient #R4 was actually on Q 5 minute observations. S1CNO and S8BHA went into Room a and retrieved the towel wrapped around Patient #R4's head.

In an interview on 02/19/2024 at 1:20 p.m., S8BHA reported she did not realize Patient #R4 having a towel wrapped around her head was a ligature risk. S8BHA was not sure how long Patient #R4 had the towel in Room a. S1CNO reported that the hospital collects the towels after showering so that they cannot be used as ligature risk. S1CNO stated that S8BHA probably missed collecting the towel wrapped around R4's head. S1CNO confirmed the linens should be limited in a patient on Suicide Precautions and observation level of Q 5 minutes.

4) Failure to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for psychiatric patients with safety risks.
Observation of Unit C on 02/19/2024 at 10:50 a.m. guided by S1CNO, revealed an exit to area E used for patient outdoor recreation. Upon exit, observation of outside patient area revealed a plastic bag among other trash lying on sidewalk that led to area E.

In an interview on 02/19/2024 at 10:55 a.m., S1CNO confirmed the plastic bag was an asphyxiation risk and should not be lying on sidewalk with other trash in patient recreation area.

5) Failure to ensure that ordered levels of observations were implemented per Hospital policy for 5 (#R1-#R5) of 5 (#R1-#R5) Patients reviewed for observation levels.
Review of Hospital policy titled, "Patient Rights", dated 06/2023, revealed, in part: Procedure, in part: 1. The following rights shall be afforded to all patients and are not subject to modification, in part: g. Patients have the right to be protected by the Hospital from neglect; from physical, verbal and emotional abuse ...

Review of Hospital policy titled, "Observations, Patient", revealed in part: Policy, in part: In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the nurse. Documentation of Observations: Staff documents all levels of observation in the medical record. Each entry is to include the following ...Level of observation, Precautions, Location, Behavior, and Activity. Documentation of the observation is to be completed once the patient has been observed. It is not permissible to complete in advance and/or to back fill time frames that were not completed in a timely manner. Q 5 minute rounds, in part: All patients are monitored at minimum once in every 5-minute block of time ...During rounds staff are to, in part: Make direct visual contact; look for signs of danger or distress.

Review of Patient #R1's Observation Sheet dated 02/19/2024 on 02/19/2024 at 10:20 a.m. revealed observation level Q 5 minutes and Suicide Precautions. Further review failed to reveal documentation that the patient was observed from 10:05-10:20 a.m.

Review of Patient #R2's Observation Sheet dated 02/19/2024 on 02/19/2024 at 10:20 a.m. revealed observation levels Q 5 minutes and Suicide, Seizure and Fall Precautions. Further review failed to reveal documentation that the patient was observed from 10:10-10:20 a.m.

Review of Patient #R3's Observation Sheet dated 02/19/2024 on 02/19/2024 at 10:20 a.m. revealed observation levels Q 5 minutes and Suicide Precautions. Further review failed to reveal documentation that the patient was observed from 10:10-10:20 a.m.

In an interview on 02/19/2024 at 10:25 a.m., S1CNO verified that Observation Sheet for Patient #R1, #R2, #R3 and #R5 failed to reveal documentation these patients were observed per policy.

Review of Patient # R4's Observation Sheet 02/19/2024 on 02/19/2024 at 1:20 p.m. revealed R4 was on Q 5 minute observations and Suicide and Fall precautions. Continued review failed to reveal documentation R4 was observed from 12:55 p.m. through 1:20 p.m.

In an interview on 02/19/2024 at 1:20 p.m., S1CNO verified that Observation Sheet for Patient #R4 failed to reveal documentation that Patient #R4 was observed from 12:55 p.m. through 1:20 p.m.

Review of Patient #R5's Medical Record revealed an admit date of 02/19/2024 at 9:00 a.m.

Review of Patient #R5's Observation Sheet on 02/19/2024 at 10:18 a.m. revealed patient was on Q 5 minute observations and Suicide, Seizure and Fall Precautions. Further review failed to reveal documentation that Patient #R5 was observed from 9:30 a.m.-10:20 a.m.

In an interview on 02/19/2024 at 10:20 a.m., S17BHA reported that there were issues going on with other patients that distracted her from documenting observations on Patient #R5.

In an interview on 02/19/2024 at 12:10 p.m., S4RM confirmed the observation sheets failed to reveal documentation that the patients was observed per policy. S4RM reported that the number of patients for 1 BHA to observe has been an issue for the units in the past.

Based on record review and interview, the facility failed to ensure each patient was free from abuse, neglect and harassment. The deficient practice is evidenced by:
1) failure to provide medical attention in a timely manner;
2) failure to monitor Patients #1 and #2 per policy, potentially causing Patient #1 to obtain a fractured shoulder;
3) failure to investigate fully, reports of Abuse or Neglect;
4) failure to notify Patient #1's designated contact of Patient #1's abuse.
Findings:

1) Failure to provide medical attention in a timely manner.
Review of Hospital policy titled, "Patient Rights", dated 06/2023, revealed, in part: Procedure, in part: 1. The following rights shall be afforded to all patients and are not subject to modification, in part: g. Patients have the right to be protected by the Hospital from neglect; from physical, verbal and emotional abuse ...

Review of Patient #1's Medical record revealed an admit date of 01/26/2024. Further review revealed an incident report dated 01/30/2024 detailing an incident that occurred on 01/30/2024. At approximately 11:15 a.m. a sudden outburst was heard from hallway, upon further observation, Patient #1 was seen on floor being repeatedly hit by Patient #2 who was on top of her yelling and cursing. Altercation was broken up by the maintenance staff. Patient #1 complained of hitting her right shoulder on the floor when she was attacked. Redness was noted to the site with limited range of motion also noted. Medical provider ordered a mobile xray of the right shoulder at 11:30 a.m.

Review of nursing note dated 01/30/2024 revealed the mobile xray was ordered at 12:40 p.m.

Review of nursing note dated 01/30/2024 at approximately 4:00 p.m., revealed Patient #1 was screaming that she was in severe pain.

Review of observation sheet for 01/30/2024 revealed Patient #1 was crying at 6:30 p.m.

Review of Patient #1's mobile xray revealed findings of a suspected nondisplaced fracture of greater tuberosity were signed by radiologist on 01/30/2024 at 5:04 p.m. The results were received by hospital at 6:05 p.m., almost 7 hours after the injury occurred.

Review of nurses note revealed orders to transfer to Emergency Department were dated 01/30/2024 at 6:38 p.m.

Review of January 2024's Hospital Transfer list revealed Patient #1 was finally transferred to an Emergency Department on 01/30/2024 at 7:15 p.m., 8 hours following the injury.

In an interview on 02/20/2024 at 1:15 p.m., S4RM verified that it took approximately 8 hours after Patient #1's injury to be transferred to Emergency Room. S4RM was not able to determine why there was a delay in treatment.

2) Failure to monitor Patients #1 and #2 per policy, potentially causing Patient #1 to obtain a fractured shoulder.
Review of Hospital policy titled, "Precautions, Assault", revealed, in part: Policy ...implement appropriate treatment at the onset of increased patient agitation. Procedure, in part: Upon admission, all patients will be evaluated for level of assaultive crisis ...During hospitalization, all patients will be assessed and observed for ...behaviors which may increase the potential for assaultive behavior ...Any changes in behavior or events which may impact on a patient's Potential for assaultive behavior are to be reported to the Charge Nurse.

Review of Hospital policy titled, "Observations, Patient", revealed in part: Policy, in part: In order to maintain patient safety, the hospital staff makes and documents routine safety rounds on the patients in accordance with the level of observation ordered by the practitioner and or initiated by the nurse. Documentation of Observations: Staff documents all levels of observation in the medical record. Each entry is to include the following ...Level of observation, Precautions, Location, Behavior, and Activity. Documentation of the observation is to be completed once the patient has been observed. It is not permissible to complete in advance and/or to back fill time frames that were not completed in a timely manner. Q 5 minute rounds, in part: All patients are monitored at minimum once in every 5-minute block of time ...During rounds staff are to, in part: Make direct visual contact; look for signs of danger or distress.

Review of Hospital Job Description titled, "Behavioral Health Associate I", dated 01/01/2020, revealed, in part: Essential Functions, in part: Responsible for conducting safety checks and ensuring that supervision is conducted at 15 minute intervals, as noted in special precautions, or in accordance with individualized supervision guidelines as needed. Document timely, accurate and appropriate clinical information in patient's medical record.

Review of Hospital self-report #69871 dated 01/31/2024 revealed the incident involving the attack by Patient #2 on Patient #1 occurred at 11:15 a.m. in the hallway.

Review of Patient #1's observation report, mistakenly dated 01/29/2024, confirmed by S4RM to have the incorrect date. S4RM verified the correct date for the observation report reviewed was 01/30/2024. Continued review revealed Patient #1 was on Q 15 minute observations and suicide precautions. Additional review revealed documentation that Patient #1 was located in her room, calm and sitting/lying from 10:45 a.m. until 12:00 p.m.

In an interview on 02/20/2024 at 1:22 p.m., S4RM verified that the documentation on Patient #1's observation sheet was incorrect.

Review of Patient #2's observation report dated 01/30/2024 revealed Q 5 minute observations. Further review revealed Patient #2 was on Elopement, Suicide, Assault and Sexual Acting Out precautions. Continued review revealed documentation that Patient #2 was located in the activity room, calm and watching television from 11:10 a.m. until 12:10 p.m.

In an interview on 02/20/2024 at 1:22 p.m., S4RM verified that the documentation on Patient #2's observation sheet was incorrect.

In an interview on 02/20/2024 at 1:25 p.m., S4RM stated Patient #2 had walked out of the treatment team room around 11:15 a.m., angry and aggressive because she was on elopement precautions and could not go into the dining area. When she came out of the treatment team room angry, she went down hallway and jumped on Patient #1. It was the maintenance man who separated the patients. S4RM confirmed the acuity level to staff ratio was inefficient and may have contributed to this incident especially because staff were not near the treatment room.

3) Failure to investigate fully, reports of Abuse or Neglect.
Review of Hospital policy titled, "Abuse and Neglect", revealed, in part: Procedure, in part: 8. Investigation, in part: a. Reports of Abuse or Neglect, which occur while the patient is hospitalized, will be thoroughly investigated by the Risk Manager or other staff as assigned by the Chief Executive Officer.

Review of self-report #69871 dated 01/31/2023, provided by the facility to the Louisiana Department of Health, failed to reveal a final report indicating the incident was fully investigated.

In an interview on 02/20/2024 at 1:20 p.m., S4RM verified that she had not completed the investigation of the Abuse/Neglect incident occurring on 01/30/2024 involving the abuse of Patient #1 by Patient #2.

4) Failure to notify Patient #1's designated contact of Patient #1's abuse.
Review of Hospital policy titled, "Abuse and Neglect", revealed, in part: Procedure, in part: 3. Patient-to-Patient Abuse, in part: c. The registered nurse will notify the designated family contact and/or legal representative of the patient who was abused.

Review of Patient #1's Medical Record revealed an Authorization to Disclose Healthcare Information dated 01/27/2024. Continued review revealed signed permission to disclose treatment information to a specific individual with the contact's phone number documented.

Review of Patient #1's Medical Record failed to reveal evidence that Patient #1's contact was notified she was the victim of Patient-to-Patient Abuse.

In an interview on 02/20/2024 at 2:05 p.m., S4RM verified Patient #1's Medical Record failed to reveal evidence that Patient #1's contact was notified she was the victim of Patient-to-Patient Abuse.

Based on record review and interview, the hospital failed to ensure the use of restraint was in accordance with safe and appropriate restraint and seclusion techniques as per hospital policies and procedures for 1 (#2) of 1 (#2) patient records reviewed for use of restraints.
Findings:

Review of Hospital policy titled, "Seclusion, Restraint, and Therapeutic Time Out" dated 10/2023, revealed, in part: IV. Procedure, in part: 10. The registered nurse will complete required documentation of seclusion and restraint episodes in [Hospital] Seclusion and Restraint Packet. 13. A practitioner or trained registered nurse shall conduct an in-person evaluation of the patient within one hour of initiation of seclusion and/or restraint to assess physical and psychological status. The in-person evaluation includes the patient's immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the intervention. The evaluation must be completed even if the seclusion and/or restraint has been discontinued prior to the in person evaluation. Documentation of the one-hour face-to-face assessment occurs in [Hospital] Seclusion and Restraint Packet. 18. The patient is debriefed by a staff person to determine the sequence of events or circumstances that precipitated the need for seclusion and/or restraint. Debriefing occurs in order to develop a plan that actively involves the patient to prevent future episodes from occurring. 19. The legal representative or an immediate family member as requested by the patient shall be promptly notified of the seclusion and /or restraint.

A review of Patient #2's Medical Record revealed and admit date of 01/25/2024. Further review revealed on 01/30/2024 at approximately 11:15 a.m. Patient #2 was restrained by staff in a physical hold after attacking Patient #1. Continued review revealed 20 mg of Zyprexa administered intramuscularly as a onetime dose following the incident. Additional review failed to reveal the required Seclusion and Restraint Packet that would have included documentation of the following: 1) An in-person evaluation of the patient within one hour of initiation of seclusion and/or restraint to assess physical and psychological status, the patient's immediate situation, reaction to the intervention, medical and behavioral condition, and the need to continue or terminate the intervention. 2) Documentation of the one-hour face-to-face assessment. 3) Patient debriefing by a staff person to determine the sequence of events or circumstances that precipitated the need for seclusion and/or restraint.

In an interview on 02/20/2024 at 1:47 p.m., S4RM verified that Patient #2 was restrained during the attack on Patient #1. S4RM confirmed that Patient #2 received a onetime dose 20 mg of Zyprexa intramuscularly after the incident. S4RM further verified that Patient #2's medical record did not contain a restraint packet and stated that policy required documentation per the restraint packet.

Based on record review, observation, and interview, the hospital failed to meet the requirements of the Condition of Participation for Nursing Services as evidenced by:
1) Failure of nursing services to meet the staffing ratios required to provide a safe environment for patients (See findings under Tag A0392), and
2) Failure of nursing services to ensure a Registered Nurse completed all patient care assignments at the beginning of each shift (See findings under Tag A0397).

Based on observation, record review and interview, the nursing services department of the hospital failed to provide adequate numbers of support personnel to provide nursing care to all patients as needed. This deficient practice was identified for 16 of 33 daily nurse staffing sheets reviewed and had the potential to affect any of the 71 inpatients receiving care and services during the time of the survey.
Findings:

Review of hospital document titled "Job Description, Director-Nursing Acute", dated 01/01/2020, revealed, in part: Purpose Statement, in part: ...Recognize that patient safety is a top priority. Essential Functions, in part: Anticipates and effectively manage changes in census and acuity and allocates nursing resources based on measurement of patient acuity/care needed. Evaluate service needs and staffing requirements to ensure needs of patients are met.

Review of Hospital Document titled "[Behavioral Health Associate] BHA Task Responsibility List" revealed, in part:
- Q15 and Q 5 minutes checks (know where your patients are and what they are doing at all times)
- Vital signs-to be done at shift start and at the discretion of the nursing staff
- Provider Rounds-ensure patients see the providers timely when requested
- Meal times and escort-ensure the nursing staff know who did not eat, or who is refusing to eat/drink
- Admissions-ensure that all patients that are received on the unit from intake have a contraband search once on the unit. Ensure belongings brought are appropriately accounted for and documentd.
- Declutter and organize the unit for the oncoming shift.
- Patient phone-time duty-Patients are to be observed while on the phone.
- Once per shift, use the linen 'cans on wheels' to collect used linen from your patient's rooms and hallways, then transpose the linen collected to blue plastic bags once off the unit and place in the proper linen receptacle.
- Laundry-When doing patient laundry duty be sure all laundry, on all of your assigned patients, are collected cleaned, folded, and put away. Be sure clothes are given to the correct patient.
- Ensure the laundry room is tidy.
- Biohazard room is neat and organized (no dirty bags on floor).
- Ensure all logs (refrigerator logs) are checked and signed every day
- ADL's (Be sure that the patients are dressed appropriately, are well groomed, their beds made, and their allowed belongings are stored neatly In their assigned spaces. Rounds should be completed at least twice a shift
- ADL baskets are stocked and all personal items are labeled.
- Showers (offer a shower to the patients each day, and ensure that the nursing staff know th last time a patient showered).
- Safety and Environmental checks on your assigned patients (check rooms, storage area and bathroom) for contraband at least 1 time every shift. Ensure doors are locked per the schedule.

Review of hospital "Nursing Staffing Grid" approved by Medical Executive Committee revealed, in part: Procedure, in part:
AM Shift
Census: 01-13 1RN 1BHA
Census: 14-16 1RN 1Nurse 1BHA
Census: 17-18 1RN 1Nurse 2BHA
Census: 19-26 1RN 1Nurse 2 BHA
PM Shift
Census: 01-13 1RN 1BHA
Census: 14-16 1RN 1Nurse 1BHA
Census: 17-18 1RN 1Nurse 1BHA
Census: 19-26 1RN 1Nurse 2 BHA

Review of 33 daily nursing staffing sheets for day and night shifts revealed on the following 16 shifts, nursing services failed to meet the staffing ratios required to provide a safe environment for patients:
Review of Unit Assignments dated 01/26/24 AM shift for Unit A revealed a census of 18. Further review revealed 1 patient on 1:1 observation and 8 patients on Q 5 observations. Review of assigned staff revealed 1 RN and 1 Nurse. Based on the Nursing Staffing Grid, staff assignments should include 2 BHAs.
In an interview on 02/20/2024 at 2:21 p.m., S4RM verified deficient staffing.

Review of Unit Assignments dated 01/26/24 AM shift for Unit B revealed a census of 14. Further review revealed 1 patient on 1:1 observation and 7 patients on Q 5 observations. Further review of assigned staff revealed 1 RN, 1 BHA on 1:1 and 1 BHA assigned to the remaining patients. Based on the Nursing Staffing Grid, staff assignments should include another nurse.

In an interview on 02/20/2024 at 2:23 p.m., S4RM verified deficient staffing.

Review of Unit Assignments dated 01/26/24 PM shift for Unit B revealed a census of 14. Further review revealed 3 patients on 1:1 observation and 6 patients on Q 5 observations. Further review of assigned staff revealed 1 RN, 1 BHA assigned to each 1:1 and 1 BHA assigned to the remaining patients. Based on the Nursing Staffing Grid, staff should include another nurse.

In an interview on 02/20/2024 at 2:26 p.m., S4RM verified deficient staffing.

Review of Unit Assignments dated 02/01/24 AM shift for Unit A revealed a census of 18. Further review revealed 1 patient on 1:1 observation and 4 patients on Q 5 observations. Review of assigned staff revealed 1 RN, 1 LPN, 1 BHA assigned to 1:1 and 1 BHA assigned to the remaining patients. Based on the Nursing Staffing Grid, staff should include another BHA.

In an interview on 02/20/2024 at 2:28 p.m., S4RM verified deficient staffing.

Review of Unit Assignments dated 02/03/24 AM shift for Unit D revealed a census of 17. Further review revealed 2 patients on 1:1 observation. Review of assigned staff revealed 1 RN, 1 LPN, 1 BHA assigned to 1:1 and 1 BHA assigned to the remaining patients. Based on the Nursing Staffing Grid, staff should include another BHA.

In an interview on 02/20/2024 at 2:33 p.m., S4RM verified deficient staffing.

Review of Unit Assignments dated 02/04/24 PM shift for Unit B revealed a census of 14. Further review revealed 1 patient on 1:1 observation and 8 patients on Q 5 observations. Review of assigned staff revealed 1 RN, 1 BHA assigned to 1:1 and 1 BHA assigned to the remaining patients. Based on the Nursing Staffing Grid, staff should include another nurse.

In an interview on 02/20/2024 at 2:35 p.m., S4RM verified deficient staffing.

Review of Unit Assignments dated 02/05/24 AM shift for Unit B revealed a census of 14. Further review revealed 1 patient on 1:1 observation and 8 patients on Q 5 observations. Review of assigned staff revealed 1 RN, 1 BHA assigned to 1:1 and 1 BHA assigned to the remaining patients. Based on the Nursing Staffing Grid, staff should include another nurse.

In an interview on 02/20/2024 at 2:38 p.m., S4RM verified deficient staffing.

Review of Unit Assignments dated 02/12/24 undocumented shift for Unit D revealed a census of 22. Review revealed 2 patients on 1:1 observation and 10 patients on Q 5 observations. Review of assigned staff revealed 1 RN, 2 BHAs assigned 1 to each 1:1 and 2 BHAs assigned to the remaining patients. Based on the Nursing Staffing Grid, staff should include another nurse.

In an interview on 02/20/2024 at 2:41 p.m., S4RM verified deficient staffing.

Review of Unit Assignments dated 02/13/24 undocumented shift for Unit D revealed a census of 21. Review revealed 2 patients on 1:1 observation and 7 patients on Q 5 observations. Review of assigned staff revealed 1 RN, 2 BHAs assigned 1 to each 1:1 and 1 BHA assigned to the remaining patients. Based on the Nursing Staffing Grid, staff should include another BHA.

In an interview on 02/20/2024 at 2:42 p.m., S4RM verified deficient staffing.

Review of Unit Assignments dated 02/13/24 AM shift for Unit A revealed a census of 18. Review of assigned staff revealed 1 RN, 1 LPN and 1 BHA assigned to patients. Based on the Nursing Staffing Grid, staff should include another BHA.

In an interview on 02/20/2024 at 2:44 p.m., S4RM verified deficient staffing.

Review of Unit Assignments dated 02/13/24 PM shift for Unit A revealed a census of 18. Review of assigned staff revealed 1 RN and 2 BHAs assigned to patients. Based on the Nursing Staffing Grid, staff should include another nurse.

In an interview on 02/20/2024 at 2:47 p.m., S4RM verified deficient staffing.

Review of Unit Assignments dated 02/14/24 AM shift for Unit A revealed a census of 18. Review of assigned staff revealed 1 RN, 1 LPN and 1 BHA assigned to patients. Based on the Nursing Staffing Grid, staff should include another BHA.

In an interview on 02/20/2024 at 2:48 p.m., S4RM verified deficient staffing.

Review of Unit Assignments dated 02/16/24 PM shift for Unit A revealed a census of 16. Review of assigned staff revealed 1 RN and 2 BHAs assigned to patients. Based on the Nursing Staffing Grid, staff should include another nurse.

In an interview on 02/20/2024 at 2:49 p.m., S4RM verified deficient staffing.

Review of Unit Assignments dated 02/17/24 AM shift for Unit A revealed a census of 17. Review of assigned staff revealed 1 RN, 1 LPN and 1 BHA assigned to patients. Based on the Nursing Staffing Grid, staff should include another BHA.

In an interview on 02/20/2024 at 2:52 p.m., S4RM verified deficient staffing.

Review of Unit Assignments dated 02/17/24 PM shift for Unit A revealed a census of 16 with 5 patients on Q 5 observations. Review of assigned staff revealed 1 RN, and 2 BHAs assigned to patients. Based on the Nursing Staffing Grid, staff should include another nurse.

In an interview on 02/20/2024 at 2:51 p.m., S4RM verified deficient staffing.

Review of Unit Assignments dated 02/19/24 AM shift for Unit B revealed a census of 12 with 5 patients on Q 5 observations. Review of assigned staff revealed 1 RN, and 1 BHA assigned to patients.

Observation on 02/19/2024 at 1:18 p.m. of Unit B revealed 1 nurse (S18RN) on the unit. S18RN was observed in medication room pulling medications and administering medications through the medication window. Continued observation failed to reveal nursing staff on the unit while S18RN was in the medication room.

In an interview on 02/19/2024 at 1:30 p.m., S18RN reported S8BHA left the unit around noon. S18RN stated it was difficult to observe the patients on suicide precautions with Q 5 observation levels while distributing and administering medications on her own.

In an interview on 02/19/2024 at 1:20 p.m., S1CNO confirmed that between 11:50 a.m. and 1:20 p.m., staffing was deficient.

Based on observation, record review and interview the hospital failed to ensure a registered nurse assigned the nursing care of each patient to other nursing personnel in accordance with Hospital policy and the patient's needs. This deficiency is evidenced by failing to ensure a Registered Nurse completed all patient care assignments at the beginning of each shift.
Findings:

Review of hospital policy titled "Assignment of Nursing Staff", dated 02/2023, revealed, in part: Policy, in part: To assure quality nursing care and a safe patient environment ...Procedure, in part: Staffing assignments reflective of this policy will be completed at the beginning of each shift by the Charge Nurse. Staffing assignments will be documented on the Staffing Assignment Sheet. The name and title of the staff member to be assigned will be entered in the space provided. The names of the patients assigned to the staff member will be entered in the space provided. Non-direct care assignments are to be included on the assignment sheet. It is the responsibility of each staff member to review his/her assignment when it is completed. The Assignment Sheet will be available to staff throughout the shift. The Staffing Assignment Sheets will be reviewed and maintained by the Chief Nursing Officer, or designee.

Review of Unit Assignment Sheet dated 01/27/2024 for AM shift of Unit A failed to reveal the names and titles of the staff members to be assigned were entered in the space provided. Continued review failed to reveal the observation levels of each patient. Further review failed to reveal the names of non-direct care assignments were included on the assignment sheet.

In an interview on 02/20/2024 at 2:27 p.m., S4RM verified the Unit Assignment Sheet dated 01/27/2024 for AM shift of Unit A was not completed per policy.

Review of Unit Assignment Sheet dated 02/05/2024 for AM shift of Unit A failed to reveal the names and titles of the staff members to be assigned were entered in the space provided. Further review failed to reveal the names of non-direct care assignments were included on the assignment sheet.

In an interview on 02/20/2024 at 2:36 p.m., S4RM verified the Unit Assignment Sheet dated 02/05/2024 for AM shift of Unit A was not completed per policy.

Review of Unit Assignment Sheet dated 02/08/2024 for PM shift of undocumented unit, failed to reveal the names and titles of the staff members to be assigned were entered in the space provided. Further review failed to reveal the names of non-direct care assignments were included on the assignment sheet.

In an interview on 02/20/2024 at 2:39 p.m., S4RM verified the Unit Assignment Sheet dated 02/08/2024 for PM shift of undocumented unit was not completed per policy.

Review of Unit Assignment Sheet dated 02/11/2024 for undocumented shift of undocumented unit, failed to reveal the names and titles of the staff members to be assigned were entered in the space provided. Continued review failed to reveal the names and precautions/observation levels of patients assigned to staff members were entered in the space provided. Further review failed to reveal the names of non-direct care assignments were included on the assignment sheet.

In an interview on 02/20/2024 at 2:40 p.m., S4RM verified the Unit Assignment Sheet dated 02/11/2024 for undocumented shift of undocumented unit was not completed per policy.

Review of Unit Assignment Sheet dated 02/12/2024 for undocumented shift of undocumented unit, failed to reveal the names and titles of the staff members to be assigned were entered in the space provided. Continued review failed to reveal the names and precautions/observation levels of patients assigned to staff members were entered in the space provided. Further review failed to reveal the names of non-direct care assignments were included on the assignment sheet.

In an interview on 02/20/2024 at 2:42 p.m., S4RM verified the Unit Assignment Sheet dated 02/12/2024 for undocumented shift of undocumented unit was not completed per policy.

Review of Unit Assignment Sheet dated 02/12/2024 for undocumented shift of Unit B, failed to reveal the names and titles of the staff members to be assigned were entered in the space provided. Continued review failed to reveal the names and precautions/observation levels of patients assigned to staff members were entered in the space provided. Further review failed to reveal the names of non-direct care assignments were included on the assignment sheet.

In an interview on 02/20/2024 at 2:42 p.m., S4RM verified the Unit Assignment Sheet dated 02/12/2024 for undocumented shift of Unit B was not completed per policy.

Review of Unit Assignment Sheet dated 02/15/2024 for undocumented shift of undocumented unit, failed to reveal the names and titles of the staff members to be assigned were entered in the space provided. Continued review revealed documentation the nurse in orientation completed Unit Assignment Sheet. Further review failed to reveal the names of non-direct care assignments were included on the assignment sheet.

In an interview on 02/20/2024 at 2:48 p.m., S4RM verified the Unit Assignment Sheet dated 02/15/2024 for undocumented shift of undocumented unit was not completed per policy.

Review of Unit Assignment Sheet dated 02/16/2024 for undocumented shift of undocumented unit, failed to reveal the names and precautions/observation levels of patients assigned to staff members were entered in the space provided. Further review failed to reveal the names of non-direct care assignments were included on the assignment sheet.

In an interview on 02/20/2024 at 2:49 p.m., S4RM verified the Unit Assignment Sheet dated 02/16/2024 for undocumented shift of undocumented unit was not completed per policy.

Review of Unit Assignment Sheet dated 02/17/2024 for undocumented shift of undocumented unit, failed to reveal the names and precautions/observation levels of patients assigned to staff members were entered in the space provided. Further review failed to reveal the names of non-direct care assignments were included on the assignment sheet.

In an interview on 02/20/2024 at 2:51 p.m., S4RM verified the Unit Assignment Sheet dated 02/17/2024 for undocumented shift of undocumented unit was not completed per policy.

Review of Unit Assignment Sheet on 02/19/2024 at 10:07 a.m. for Unit A revealed the assignment sheet was completely blank.

In an interview on 02/19/2024 at 10:07 a.m., S1CNO verified the Unit Assignment Sheet on 02/19/2024 for Unit A was not completed per policy.

In an interview on 02/19/2024 at 10:08 a.m., S22RN reported she did not have time to fill out the assignment sheet.

Review of Unit Assignment Sheet on 02/19/2024 at 10:50 a.m. for Unit C failed to reveal the names and precautions/observation levels of patients assigned to staff members were entered in the space provided. Further review failed to reveal the names of non-direct care assignments were included on the assignment sheet.

In an interview on 02/19/2024 at 10:50 a.m., S1CNO verified the Unit Assignment Sheet on 02/19/2024 for Unit C was not completed per policy.

Review of Unit Assignment Sheet on 02/19/2024 at 11:12 a.m. for Unit D revealed the assignment sheet was completely blank.

In an interview on 02/19/2024 at 11:12 a.m., S21RN reported that she did not have time to complete the assignment sheet.

In an interview on 02/19/2024 at 11:12 a.m., S1CNO verified the Unit Assignment Sheet on 02/19/2024 for Unit D was not completed per policy.