HospitalInspections.org

Based on policy review, medical record review, job description review, videotape surveillence footage review, Behavioral Health census review, observations, facility environment team assessment review and staff and physician interviews, the hospital's Governing Body failed to provide oversight and have systems in place to ensure a safe setting for the protection of psychiatric patients, staff and visitors and an organized nursing service to ensure the safety of patients.

The findings include:

1. The Behavioral Medicine Unit (BMU) nursing staff failed to ensure safe patient care in the BMU.

~cross refer to 482.13 Patient Rights' Condition: Tag A 0115.

2. The hospital failed to have an organized nursing service providing oversight of day-to-day operations to ensure registered nursing staff assessed, supervised and monitored patients in the behavioral medicine unit to ensure a safe environment.

~cross refer to 482.23 Nursing Services Condition: Tag A 0385.

3. The hospital failed to implement and maintain an effective quality assessment and performance improvement program to ensure the safety of patients.

~cross refer to 482.21 Quality Assessment Performance Improvement, Condition: Tag A 0263.

4. The hospital failed to develop and maintain the conditions on the Behavioral Medicine Unit (BMU) in such a manner that the safety and well-being of patients, staff and visitors are assured.

~cross refer to 482.41 Physical Environment, Condition: Tag A 0700 .

Based on policy and procedure review, job description review, videotape surveillance footage review, closed medical record review, Behavioral Health census review, observations and staff and physician interviews, the Behavioral Medicine Unit (BMU) nursing staff failed to ensure safe patient care in the BMU.

The findings include:

1. The Behavioral Medicine Unit (BMU) nursing staff failed to ensure safe patient care and failed to report an alleged assault in the BMU.

~cross refer to 482.13(c)(2) Patient Rights' Standard: Tag A0144.

Based on policy and procedure review, job description review, videotape surveillance footage review closed medical record review, Behavioral Health census review, observations and staff and physician interviews, the Behavioral Medicine Unit (BMU) nursing staff failed to ensure a safe setting for patient care and failing to report an alleged assault in the BMU for 1 of 1 alleged sexual assault patient reviewed (#1).

The findings include:

Review of the hospital's policy, "Precautions", revised 12/2011, revealed, "...Policy: It shall be the policy of the Behavioral Medicine Service to provide a safe environment by initiating a special precautionary category according to the needs of the patient. Procedure: ...Close Precautions: Close precautions are the minimum level of precautions used in Behavioral Medicine. They provide an appropriate level of safety for the non-suicidal patient...For non-suicidal patients only. All patients are observed every 15 minutes and observation is documented on ARMC FORM 5092A. Patient may not keep sharp items...in their rooms or on their person. ...".

Review of hospital policy, "Sexual Intercourse Among Patients", revised 07/2011, revealed, "Purpose: To define the procedure that must be instituted in the event that sexual intercourse occurs between hospital patients. Policy: It is the policy of (Hospital Name) to ...respond promptly in assessing/treating patients who have had sexual intercourse while hospitalized. Procedure: The physicians of all patients involved are to be notified. ...Documentation of the incident and staff response must be included in each patients clinical record. ...The following are to be notified of the incident: Program Manager, Unit Nurse Coordinator, Nursing Supervisor. ... " .

Review of the hospital's job description for a registered nurse, dated 12/2007, revealed," I. Job Summary: Assesses, plans, implements, documents, organizes, prioritizes, delegates, supervises and coordinates the care of... patients as prescribed within the parameters of the NC Nurse Practice Act and hospital complex. ...Standards of Performance: ...7. Delivers patient care within an environment conducive to Patient Safety... " .

During tour of the Behavioral Medicine Unit (BMU) on 2/23/2012 at 1130 four patients were observed in the Day Room #1. Observation revealed no staff monitoring the 3 male patients and 1 female patient in Day Room #1. The patients were observed for over 5 minutes without monitoring of the staff. Interview during the tour with the Behavioral Medicine Director revealed the patients are allowed in the day room without supervision because the patients are checked every 15 minutes.

During tour of the Behavioral Medicine Unit (BMU) on 2/24/2012 starting at 1030 a patient was observed in a patient bedroom L24 sitting on the end of the bed with a sharpened pencil. The patient was observed staring at the floor and holding the pencil greater than 10 minutes. No staff were observed monitoring the patient. The patient was observed taking the pencil's sharpened end and "picking" around his fingernails. Observation revealed a female patient with an assigned CNA for 1:1 observation (within arms length). The CNA was observed standing in the hall beside the patient. Observation revealed a male patient walking in the direction of the CNA and patient. The CNA stepped aside allowing the male patient between her and the female. Observation revealed the staff member was not within arms length of the patient.

Closed medical record review of Patient #1 revealed a 27 year-old female involuntarily
committed to the hospital's behavioral medicine unit (BMU) 02/11/2012 for self-injurious behavior and bipolar disorder. Record review revealed Patient #1's guardian as ARC (Association of Retarded Citizens). Record review revealed documentation dated 02/16/2012 at 1800 that Patient #1 was in Dayroom #1; 1815 in Dayroom #2; 1830 in her room; 1845 in her room and 1900 in Dayroom #1. Further record review revealed nursing documentation by RN (Registered Nurse) #1 dated 02/17/2012 at 2037, "Patient heard to say she was raped during the night by a male patient. Message told to (CNA - certified nursing assistant) and another nurse about the incident and was afraid to tell anyone. ...(Name of nursing supervisor) notified about patient's accusations. (Physician #1) notified. Dr in to follow-up on the accusations...". Further record review revealed Patient #1 was taken to the hospital's ED (emergency department) for a sexual assault exam at 2310. Review of the NC Sexual Assault Data Form revealed, " ...Pt reports she was pushed to the floor in her bathroom while she was naked and forced to have sex while being verbally threatened. Pt and suspect were both in-patients on the Beh (Behavioral) Med (Medicine) Unit... " . Further record review revealed the completion of the Evidence Checklist and Disposition of Evidence to the local law enforcement agency. Further record review revealed Patient #1 was transferred back to the Behavioral Medicine Unit and assigned a 1:1 sitter. Record review revealed Patient #1 was discharged to a group home 02/21/2012.

Review of Patient #1's "Observation Documentation" form, dated 02/16/2012, revealed:
? 1815 - Patient #1 in Dayroom #1.
? 1830 - Patient #1 in her room.
? 1845 - Patient #1 in her room.
? 1900 - Patient #1 in Dayroom #1.

Review of hospital videotape surveillence footage from the camera in the hallway located outside Patient #1's room (Room 4) revealed the following:
? 1820 - Patient #1 leaves room, goes out of camera sight, returns with towels.
? 1828 - Patient #1 out of room.
? 1833 - Patient #1 back into room.
? 1837 - Patient #2 into Patient #1's room, walks in and out.
? 1838 - Patient #2 into Patient #1's room.
? 1845 - Patient #2 out of Patient #1's room (7 minutes later).

Closed medical record review of Patient #2 revealed a 28 year old male presenting to the emergency department at 0041 on 2/13/2012 via Emergency Medical Services. Record review revealed the chief complaint was Delirium Tremors (DTs), actively hallucinating and alcohol withdrawal. Record review revealed the patient was involuntarily committed (IVC) for "mentally ill and dangerous to self and others or mentally ill and in need of treatment in order to prevent further disability or deterioration that would predictably result in dangerousness". Record review revealed the patient was admitted to the medical unit on 2/13/2012 at 1105. Record review revealed on 2/16/2012 physician documentation "patient threatened to leave hospital. The patient's RN was informed of the patient's threat of leaving the hospital. The sitter was told to be at the patient's bedside at all times. Patient's case discussed with Physician #3 (patient's attending psychiatrist) who said she would re-evaluate the patient and possibly arrange transfer to behavior medicine. Patient is being transferred...". Record review revealed the patient arrived on the behavioral medicine unit (BMU) on 2/16/2012 at 1044. Review of Physician #3's Behavioral Medicine Unit's admission history and physical revealed "It was reported that at times he was confused, agitated, threatening. He had a sitter all along. He was transferred to BMU after he threatened to leave against medical advice while delirious and unable to make sound decisions... He is wearing two hospital gowns while walking about the unit. He has no change of clothes". Review of the record revealed documentation dated 2/16/2012 at 1000 "NECESSITY FOR INVOLUNTARY COMMITMENT". Review of the IVC documentation completed by the physician revealed "(Name of Patient #2) is an alcoholic. He was admitted for alcohol detox. He is delirious. He wants to leave. He has no capacity to resolve medical decisions". Record review revealed observation status ordered was "Behavioral Medicine Unit Close Observation". Record review revealed the patient was discharged on 2/17/2012 at 1539.

Review of Patient #2's "Observation Documentation" form, dated 02/16/2012, revealed:
? 1815 - Patient #2 in Dayroom #2
? 1830 - Patient #2 in hall (no designation of which hall).
? 1845 - Patient #2 in his room.
? 1900 - Patient #2 in Hall on telephone.

Review of Patient #2's "Observation Documentation" form, dated 02/17/2012, revealed:
? 1515 - Patient #2 in Hall.
? 1530 - no documentation of the patient's location and initialed by staff observing.
? 1545 - no documentation of the patient's location and initialed by staff observing.
? 1600 - no documentation of the patient's location and initialed by staff observing.

Interview on 2/24/2012 at 0905 with physician #3 (patient #2's attending psychiatrist) revealed the medical physician called her on Thursday (2/16/2012) informing her patient #2 was "trying to leave, he was confused, demanding and threatening and had 7 doses of Ativan". The interview revealed she talked to the patient with the patient's sitter present while on the medical unit. The interview revealed she evaluated the patient while he was on the medical unit. The interview revealed when she talked with him prior to the transfer to BMU he was not confused. The interview revealed she wanted to observe him without Ativan being given and to evaluate him for his delirium. The interview revealed the BMU was a locked unit and it would be keep him from leaving. The interview revealed she initiated a second IVC paperwork to assist keeping him at the hospital because she did not know the patient was on IVC when admitted from the ED. The interview revealed she learned from ED staff that he was hallucinating in the ED looking for a cat under the bed. The interview revealed she received a call on Friday (2/17/2012) from Physician #1 informing her patient #2 had raped patient #1. The interview revealed there are "possible changes that need to be made. Hard to make changes from the inside".

Review of the hospital's Behavioral Medicine Unit's census for 02/16/2012 revealed 22 patients.

Review of the Behavioral Medicine Unit's nursing assignment sheet dated 02/16/2012 revealed Patient #1 was assigned to RN #3 beginning at 1700 and RN #1 beginning at 1900. Review of the assignment sheet revealed no documentation of CNA assignments.

Interview on 02/23/2012 at 1600 with CNA (Certified Nursing Assistant) #1 revealed the CNA was working 02/16/2012 beginning at 1500. Interview revealed, "when I came in, I started doing 15 minute checks. I did not get report on the status of the patients, I just started doing checks". Interview further revealed, "when I have 25 patients, it takes me more than 15 minutes to do the checks. It probably takes 30 minutes. When I came in that day, I had 25 patients to do 15 minute checks on". Interview further revealed, "the nurse doesn't review the 15 minute check sheets". Interview revealed, "I went by her (Patient #1's) room at 1830, she was in her room. I didn't hear water running. At 1845, she was still in her room and I did' t hear water running". Interview further revealed, "it is an unrealistic expectation to think I can do 15 minute checks on that many patients. Since the incident, we now have 2 CNAs doing the 15 minute checks. I think that started Tuesday" (5 days after the incident).

RN #3 was not available for interview.

Interview on 02/23/2012 with US (Unit Secretary) #1 revealed the US was working the desk 02/16/2012 from 0800 until 2000. Interview revealed, "I am not peeled to the camera monitors. The cameras are not utilized for patient safety monitoring". Interview further revealed the Behavioral Health Unit currently staffs a Unit Secretary on Thursdays and Sundays from 0800 until 2000.

Interview with RN #4 on 02/22/2012 at 1525 revealed the RN is a staff nurse on the Behavioral Medicine Unit. Interview revealed the patients are divided into 3 teams when fully staffed, with one RN assigned to each team of 8 or 9 patients. Interview further revealed the CNAs are not assigned to a team and are not assigned to a particular patient. Interview revealed, "our census has been high and our acuity has been higher recently". Interview further revealed, "no nurse is assigned charge. Nurses are not supervising the 15 minute safety checks". Interview further revealed, "since the incident last week, we are making sure the CNAs are roaming. When we have only 2 CNAs, it's difficult to make a safe environment".

Interview on 02/24/2012 with RN#2 revealed, "I was not assigned to (Patient #1) on February 17th. I got involved with her about 3:00 (pm) because she was smoking in her room. We were short a nurse and she refused to take her meds from the other nurse. I tried to get the matches from her and she wouldn't give them up. She got them from (Patient #2). He was still on the unit, waiting to be discharged and somebody must have given him his cigarettes and matches back". Interview further revealed, "sometime between 4:30 and 5:00 (p.m.), she told me she needed a morning after pill. She told me the patient that had just left forced himself on her in the shower the night before". Interview further revealed, "I became distracted. I didn't follow-up with her at that time. I didn't report it to (RN #1) when she came on". Interview further revealed, "I didn't complete an occurrence report, call the unit coordinator or the doctor". Interview revealed, "it was about an hour and a half or so before she told someone else". Interview confirmed RN #2 failed to follow hospital policy for reporting an alleged rape.

Interview on 02/23/2012 at 1400 with MD #1 revealed the physician was the attending physician for Patient #1. Interview revealed Patient #1 was scheduled for discharge on 02/17/2012. Interview revealed, "when I came in Friday morning, (Patient #1) was distraught and anxious. She was not the (Patient's name) I saw on Thursday. I cancelled her discharge to look at her meds. She was out of character from Thursday". Interview further revealed, "I got a call Friday night about the rape and immediately came in to see her and talk with her. I went with her to the ED for the SANE (sexual assault nurse exam). On Saturday and Sunday, she was having flashbacks. I ordered a 1:1 sitter with her to make her feel safer". Interview further revealed, "she felt safe here until Thursday night".

Interview on 02/24/2012 at 1205 with MD #2, the behavioral medicine unit's medical director, revealed, "Our structure is not optimal for safety. Supervision is difficult".

Interview with the charge nurse after the observation revealed the patients are allowed in their rooms with sharpened pencils and no monitoring by the staff. The interview revealed patients need pencils to complete their daily menu choices and to write in a journal. The interview revealed the staff should always remain within arms length when on 1:1 observation. The interview revealed the CNA should not have allowed another patient to get between the staff member and the assigned patient.

Based on hospital policy review and staff interview, the hospital failed to implement and maintain an effective quality assessment and performance improvement program to ensure the safety of patients.

The findings include:

1. The hospital's Behavioral Medicine Program failed to monitor patient safety on the behavioral medicine unit.

~cross refer to 482. 21(c)(1) QAPI Standard: Tag A0285

2. The hospital staff failed to complete an occurrence report of alleged sexual assault involving a patient on the Behavioral Medicine Unit.

~cross refer to 482.21(c)(2) QAPI Standard: Tag A0286

Based on hospital policy review and staff interview, the hospital's Behavioral Medicine Program failed to monitor patient safety on the behavioral medicine unit.

The findings include:

Review of hospital policy, "Performance Improvement - Behavioral Medicine Program", reviewed 08/2011, revealed, "Purpose: To provide a mechanism for monitoring the performance and appropriateness of patient care services; and for resolving identified problems. Policy: It is the policy of the (Hospital Name), Behavioral Medicine Service to participate in the (Name of Hospital) hospital-wide Performance (PI) program and develops projects specific to Behavioral Medicine Services...".

Interview on 02/23/2012 at 1525 with a Behavioral Medicine Unit staff nurse revealed registered nurses are not monitoring the 15 minute patient safety checks completed by the certified nursing assistants.

Interview on 02/24/2012 at 0930 with RN # 2 revealed he found Patient #1 with cigarettes and matches on 02/17/2012 after the patient was found smoking in her room. Interview revealed, "contraband is common on the unit. We don't fill out an occurrence report if we find contraband".

Interview on 02/24/2012 at 1330 with Administrative staff for the Behavioral Medicine Unit revealed the PI (performance improvement) indicators currently being monitored for the Behavioral Medicine Unit are restraint/seclusion time and suicide assessment. Interview revealed the unit has had zero restraint/seclusion since July 2011. Interview further revealed no monitoring of safety checks or contraband on the unit.

Based on hospital policy review and staff interview, the hospital staff failed to complete an occurrence report of an alleged sexual assault involving a patient on the Behavioral Medicine Unit.

The findings include:

Review of the hospital's policy, "Confidential Occurrence Reports", revised 06/2008, revealed, "POLICY: It shall be the policy of (Name of Hospital) to document immediately: pertinent unanticipated circumstances occurring in the course of medical care. ...PROCEDURE: ...II. The employee(s) detecting or having knowledge of the occurrence are responsible for submitting the report. ...IV. Submitted Confidential Occurrence reports are to be viewed by the working copy of the Department Manager or designee immediately. V. The Risk Management Department reviews the Occurrence Report and assigns to the appropriate designee follow up on the medical status of the patient involved, as indicated. NOTE: An occurrence involving significant patient injury or complaint should be reported to the Risk Management Department immediately, in addition to completion of the Confidential Occurrence Report.
...".

Interview on 02/24/2012 at 0815 with RN (Registered Nurse) #1 revealed the nurse was staffing the Behavioral Medicine Unit on 02/17/2012 overheard a CNA (Certified Nursing Assistant) talking about a patient getting raped on 02/16/2012. Interview revealed the nurse failed to complete an occurrence report. Interview confirmed the hospital policy for documenting an occurrence report was not followed.

Interview on 02/24/2012 at 1100 with Administrative Staff confirmed no documentation of an occurrence report being completed for the reported rape of a patient on the Behavioral Medicine Unit on 02/16/2012.

Based on hospital policy review, job description review, medical record and videotape surveillence footage review, Behavioral Health census review, staff and physician interview, observation during tour and patient assignment sheets the hospital failed to have an organized nursing service providing oversight of day-to-day operations to ensure registered nursing staff assessed, supervised and monitored patients in the behavioral medicine unit to ensure a safe environment.

The findings include:

1. The hospital's nursing staff failed to supervise and evaluate the nursing care of patients on the behavioral medicine unit for 2 of 2 closed psychiatric patients reviewed (Patients #1 and #2) and failed to report an alleged sexual assault of a patient (Patient #1).

~cross refer to 482.23(b)(3) Nursing Services Standard: Tag A0395

2. The hospital's behavioral medicine unit's nursing staff failed to ensure staff assignments were made to assure the safe delivery of care for behavioral health patients.

~cross refer to 482.23(b)(5) Nursing Services Standard: Tag A0397

Based on hospital policy review, job description review, medical record and videotape surveillence footage review, Behavioral Health census review, staff and physician interview and observation during tour, the hospital's nursing staff failed to supervise and evaluate the nursing care of patients on the behavioral medicine unit for 2 of 2 closed psychiatric patients reviewed (Patients #1 and #2) and failed to report an alleged sexual assault of a patient (Patient #1).

The findings include:

Review of the hospital's policy, "Precautions", revised 12/2011, revealed, "...Policy: It shall be the policy of the Behavioral Medicine Service to provide a safe environment by initiating a special precautionary category according to the needs of the patient. Procedure: ...Close Precautions: Close precautions are the minimum level of precautions used in Behavioral Medicine. They provide an appropriate level of safety for the non-suicidal patient...For non-suicidal patients only. All patients are observed every 15 minutes and observation is documented on ARMC FORM 5092A. Patient may not keep sharp items...in their rooms or on their person. ...".

Review of hospital policy, "Sexual Intercourse Among Patients", revised 07/2011, revealed, "Purpose: To define the procedure that must be instituted in the event that sexual intercourse occurs between hospital patients. Policy: It is the policy of (Hospital Name) to ...respond promptly in assessing/treating patients who have had sexual intercourse while hospitalized. Procedure: The physicians of all patients involved are to be notified. ...Documentation of the incident and staff response must be included in each patients clinical record. ...The following are to be notified of the incident: Program Manager, Unit Nurse Coordinator, Nursing Supervisor. ... " .

Review of the hospital's job description for a registered nurse, dated 12/2007, revealed," I. Job Summary: Assesses, plans, implements, documents, organizes, prioritizes, delegates, supervises and coordinates the care of... patients as prescribed within the parameters of the NC Nurse Practice Act and hospital complex. ...Standards of Performance: ...7. Delivers patient care within an environment conducive to Patient Safety... " .

Closed medical record review of Patient #1 revealed a 27 year-old female involuntarily
committed to the hospital's behavioral medicine unit (BMU) 02/11/2012 for self-injurious behavior and bipolar disorder. Record review revealed Patient #1's guardian as ARC (Association of Retarded Citizens). Record review revealed documentation dated 02/16/2012 at 1800 that Patient #1 was in Dayroom #1; 1815 in Dayroom #2; 1830 in her room; 1845 in her room and 1900 in Dayroom #1. Further record review revealed nursing documentation by RN (Registered Nurse) #1 dated 02/17/2012 at 2037, "Patient heard to say she was raped during the night by a male patient. Message told to (CNA - certified nursing assistant) and another nurse about the incident and was afraid to tell anyone. ...(Name of nursing supervisor) notified about patient's accusations. (Physician #1) notified. Dr in to follow-up on the accusations...". Further record review revealed Patient #1 was taken to the hospital's ED (emergency department) for a sexual assault exam at 2310. Review of the NC Sexual Assault Data Form revealed, " ...Pt reports she was pushed to the floor in her bathroom while she was naked and forced to have sex while being verbally threatened. Pt and suspect were both in-patients on the Beh (Behavioral) Med (Medicine) Unit... " . Further record review revealed the completion of the Evidence Checklist and Disposition of Evidence to the local law enforcement agency. Further record review revealed Patient #1 was transferred back to the Behavioral Medicine Unit and assigned a 1:1 sitter. Record review revealed Patient #1 was discharged to a group home 02/21/2012.

Review of Patient #1's "Observation Documentation" form, dated 02/16/2012, revealed:
? 1815 - Patient #1 in Dayroom #1.
? 1830 - Patient #1 in her room.
? 1845 - Patient #1 in her room.
? 1900 - Patient #1 in Dayroom #1.

Review of hospital videotape surveillence footage from the camera in the hallway located outside Patient #1's room (Room 4) revealed the following:
? 1820 - Patient #1 leaves room, goes out of camera sight, returns with towels.
? 1828 - Patient #1 out of room.
? 1833 - Patient #1 back into room.
? 1837 - Patient #2 into Patient #1's room, walks in and out.
? 1838 - Patient #2 into Patient #1's room.
? 1845 - Patient #2 out of Patient #1's room (7 minutes later).

Closed medical record review of Patient #2 revealed a 28 year old male presenting to the emergency department at 0041 on 2/13/2012 via Emergency Medical Services. Record review revealed the chief complaint was Delirium Tremors (DTs), actively hallucinating and alcohol withdrawal. Record review revealed the patient was involuntarily committed (IVC) for "mentally ill and dangerous to self and others or mentally ill and in need of treatment in order to prevent further disability or deterioration that would predictably result in dangerousness". Record review revealed the patient was admitted to the medical unit on 2/13/2012 at 1105. Record review revealed on 2/16/2012 physician documentation "patient threatened to leave hospital. The patient's RN was informed of the patient's threat of leaving the hospital. The sitter was told to be at the patient's bedside at all times. Patient's case discussed with Physician #3 (patient's attending psychiatrist) who said she would re-evaluate the patient and possibly arrange transfer to behavior medicine. Patient is being transferred...". Record review revealed the patient arrived on the behavioral medicine unit (BMU) on 2/16/2012 at 1044. Review of Physician #3's Behavioral Medicine Unit's admission history and physical revealed "It was reported that at times he was confused, agitated, threatening. He had a sitter all along. He was transferred to BMU after he threatened to leave against medical advice while delirious and unable to make sound decisions... He is wearing two hospital gowns while walking about the unit. He has no change of clothes". Review of the record revealed documentation dated 2/16/2012 at 1000 "NECESSITY FOR INVOLUNTARY COMMITMENT". Review of the IVC documentation completed by the physician revealed "(Name of Patient #2) is an alcoholic. He was admitted for alcohol detox. He is delirious. He wants to leave. He has no capacity to resolve medical decisions". Record review revealed observation status ordered was "Behavioral Medicine Unit Close Observation". Record review revealed the patient was discharged on 2/17/2012 at 1539.

Review of Patient #2's "Observation Documentation" form, dated 02/16/2012, revealed:
? 1815 - Patient #2 in Dayroom #2
? 1830 - Patient #2 in hall (no designation of which hall).
? 1845 - Patient #2 in his room.
? 1900 - Patient #2 in Hall on telephone.

Review of Patient #2's "Observation Documentation" form, dated 02/17/2012, revealed:
? 1515 - Patient #2 in Hall.
? 1530 - no documentation of the patient's location and initialed by staff observing.
? 1545 - no documentation of the patient's location and initialed by staff observing.
? 1600 - no documentation of the patient's location and initialed by staff observing.

Interview on 2/24/2012 at 0905 with physician #3 (patient #2's attending psychiatrist) revealed the medical physician called her on Thursday (2/16/2012) informing her patient #2 was "trying to leave, he was confused, demanding and threatening and had 7 doses of Ativan". The interview revealed she talked to the patient with the patient's sitter present while on the medical unit. The interview revealed she evaluated the patient while he was on the medical unit. The interview revealed when she talked with him prior to the transfer to BMU he was not confused. The interview revealed she wanted to observe him without Ativan being given and to evaluate him for his delirium. The interview revealed the BMU was a locked unit and it would be keep him from leaving. The interview revealed she initiated a second IVC paperwork to assist keeping him at the hospital because she did not know the patient was on IVC when admitted from the ED. The interview revealed she learned from ED staff that he was hallucinating in the ED looking for a cat under the bed. The interview revealed she received a call on Friday (2/17/2012) from Physician #1 informing her patient #2 had raped patient #1. The interview revealed there are "possible changes that need to be made. Hard to make changes from the inside".

Review of the hospital's Behavioral Medicine Unit's census for 02/16/2012 revealed 22 patients.

Review of the Behavioral Medicine Unit's nursing assignment sheet dated 02/16/2012 revealed Patient #1 was assigned to RN #3 beginning at 1700 and RN #1 beginning at 1900. Review of the assignment sheet revealed no documentation of CNA assignments.

Interview on 02/23/2012 at 1600 with CNA (Certified Nursing Assistant) #1 revealed the CNA was working 02/16/2012 beginning at 1500. Interview revealed, "when I came in, I started doing 15 minute checks. I did not get report on the status of the patients, I just started doing checks". Interview further revealed, "when I have 25 patients, it takes me more than 15 minutes to do the checks. It probably takes 30 minutes. When I came in that day, I had 25 patients to do 15 minute checks on". Interview further revealed, "the nurse doesn't review the 15 minute check sheets". Interview revealed, "I went by her (Patient #1's) room at 1830, she was in her room. I didn't hear water running. At 1845, she was still in her room and I did' t hear water running". Interview further revealed, "it is an unrealistic expectation to think I can do 15 minute checks on that many patients. Since the incident, we now have 2 CNAs doing the 15 minute checks. I think that started Tuesday" (5 days after the incident).

RN #3 was not available for interview.

Interview on 02/23/2012 with US (Unit Secretary) #1 revealed the US was working the desk 02/16/2012 from 0800 until 2000. Interview revealed, "I am not peeled to the camera monitors. The cameras are not utilized for patient safety monitoring". Interview further revealed the Behavioral Health Unit currently staffs a Unit Secretary on Thursdays and Sundays from 0800 until 2000.

Interview with RN #4 on 02/22/2012 at 1525 revealed the RN is a staff nurse on the Behavioral Medicine Unit. Interview revealed the patients are divided into 3 teams when fully staffed, with one RN assigned to each team of 8 or 9 patients. Interview further revealed the CNAs are not assigned to a team and are not assigned to a particular patient. Interview revealed, "our census has been high and our acuity has been higher recently". Interview further revealed, "no nurse is assigned charge. Nurses are not supervising the 15 minute safety checks". Interview further revealed, "since the incident last week, we are making sure the CNAs are roaming. When we have only 2 CNAs, it's difficult to make a safe environment".

Interview on 02/24/2012 with RN#2 revealed, "I was not assigned to (Patient #1) on February 17th. I got involved with her about 3:00 (pm) because she was smoking in her room. We were short a nurse and she refused to take her meds from the other nurse. I tried to get the matches from her and she wouldn't give them up. She got them from (Patient #2). He was still on the unit, waiting to be discharged and somebody must have given him his cigarettes and matches back". Interview further revealed, "sometime between 4:30 and 5:00 (p.m.), she told me she needed a morning after pill. She told me the patient that had just left forced himself on her in the shower the night before". Interview further revealed, "I became distracted. I didn't follow-up with her at that time. I didn't report it to (RN #1) when she came on". Interview further revealed, "I didn't complete an occurrence report, call the unit coordinator or the doctor". Interview revealed, "it was about an hour and a half or so before she told someone else". Interview confirmed RN #2 failed to follow hospital policy for reporting an alleged rape.

Interview on 02/23/2012 at 1400 with MD #1 revealed the physician was the attending physician for Patient #1. Interview revealed Patient #1 was scheduled for discharge on 02/17/2012. Interview revealed, "when I came in Friday morning, (Patient #1) was distraught and anxious. She was not the (Patient's name) I saw on Thursday. I cancelled her discharge to look at her meds. She was out of character from Thursday". Interview further revealed, "I got a call Friday night about the rape and immediately came in to see her and talk with her. I went with her to the ED for the SANE (sexual assault nurse exam). On Saturday and Sunday, she was having flashbacks. I ordered a 1:1 sitter with her to make her feel safer". Interview further revealed, "she felt safe here until Thursday night".

Interview on 02/24/2012 at 1205 with MD #2, the behavioral medicine unit's medical director, revealed, "Our structure is not optimal for safety. Supervision is difficult".

During tour of the Behavioral Medicine Unit (BMU) on 2/23/2012 at 1130 four patients were observed in the Day Room #1. Observation revealed no staff monitoring the 3 male patients and 1 female patient in Day Room #1. The patients were observed for over 5 minutes without monitoring of the staff. Interview during the tour with the Behavioral Medicine Director revealed the patients are allowed in the day room without supervision because the patients are checked every 15 minutes.

During tour of the Behavioral Medicine Unit (BMU) on 2/24/2012 starting at 1030 a patient was observed in a patient bedroom L24 sitting on the end of the bed with a sharpened pencil. The patient was observed staring at the floor and holding the pencil greater than 10 minutes. No staff were observed monitoring the patient. The patient was observed taking the pencil's sharpened end and "picking" around his fingernails. Observation revealed a female patient with an assigned CNA for 1:1 observation (within arms length). The CNA was observed standing in the hall beside the patient. Observation revealed a male patient walking in the direction of the CNA and patient. The CNA stepped aside allowing the male patient between her and the female. Observation revealed the staff member was not within arms length of the patient.

Interview with the charge nurse after the observation revealed the patients are allowed in their rooms with sharpened pencils and no monitoring by the staff. The interview revealed patients need pencils to complete their daily menu choices and to write in a journal. The interview revealed the staff should always remain within arms length when on 1:1 observation. The interview revealed the CNA should not have allowed another patient to get between the staff member and the assigned patient.

Based on review of hospital policy, patient assignment sheets and staff interview, the hospital's behavioral medicine unit's nursing staff failed to ensure staff assignments were made to assure the safe delivery of care for behavioral health patients.

The findings include:

Review of the hospital's policy, "Assignment of Care", revised 07/2011, revealed, "Purpose: To provide guidelines for assignment of care in Behavior Medicine Services. Policy: It is the policy of (Name of Hospital) Behavioral Medicine to assign patients to appropriate treatment team members to meet patient care needs. Procedure: Nursing: Assignment of patient care: Goal: Patient assignments are made using the concept of therapeutic milieu, patient acuity, level of staff competence and number of staff available. ... Purpose: To provide the highest quality of patient care. To facilitate the effective use of competent personnel. ... Patient Care Assignments: Patient care assignments are based upon these elements. Elements: The complexity of each patient's condition. The dynamics of the patient's status, including the frequency with which the need for specific nursing care activities changes. The complexity of the assessment required by the patient...The degree of supervision required by each nursing staff member...The safety needs of patients, staff and visitors. ...".

Review of the behavioral medicine unit's staffing assignments dated 02/16/2012 revealed a census of 22 patients with 3 registered nurses assigned to the patients beginning at 1500. Review of the staffing sheet revealed no names of CNAs assigned to patients. Review of the assignments revealed RN #3 was assigned to Patient #1 from 1700 until 1900 and RN #1 was assigned to Patient #1 from 1900 until 0700 on 02/17/2011.

Interview on 02/24/2012 at 0815 with RN #1 revealed the nurse staffed the behavioral medicine unit beginning 1900 on 02/16/2012. Interview revealed the behavioral medicine unit's nurse staffing assignment is based on 3 teams, with one RN per team of patients. Interview revealed the nursing assistants are not assigned a team of patients and are not assigned to a nurse. Interview revealed the nursing assistants are assigned a task, with one CNA doing the 15 minute safety checks and the other taking vital signs and assisting with meals. Interview revealed the patient teams are based on security code numbers given to patients on admission. Interview revealed the patient teams are not based on acuity or location on the unit. Interview revealed the patient teams are based solely on the code numbers given to patients on admission. Interview revealed, "the Assignment of Care policy does not pertain to behavioral health".

Interview on 02/23/2012 at 1525 with RN #4 revealed no nurse is assigned to be the charge nurse on the behavioral medicine unit. Interview further revealed the CNAs are not assigned to a nurse for supervision. Interview revealed, "all nurses supervise the CNAs".

Interview on 02/24/2012 at 0930 with RN #2 revealed the CNAs are not assigned to a nurse. Interview revealed, "nobody is supervising the CNAs. It would be better if they were assigned to a nurse then you would have accountability".

Based on hospital Behavioral Medicine Unit Environment Assessment Team review, staff interviews, observations during tours, the hospital staff failed to develop and maintain the conditions on the Behavioral Medicine Unit (BMU) in such a manner that the safety and well-being of patients, staff and visitors are assured.

The findings include:

1. The hospital failed to develop and maintain conditions on the Behavioral Medicine Unit (BMU) in such a manner that the safety and well-being of patients, staff and visitors are assured.

~Cross-refer to 482.41(a) Physical Environment Standard Tag A 0701.

Based on Behavioral Medicine Unit Environment Assessment Team review, observations and staff interviews the hospital failed to develop and maintain conditions on the Behavioral Medicine Unit (BMU) in such a manner that the safety and well-being of patients are assured.

The findings include:

Review of the "Suicide Prevention in the Behavioral Built Environment Assessment Team progress report dated 2/18/2010 revealed on page 7 the team identified "lightweight dining room furnishings" that could be "thrown to harm others or to break items (TV, window)". Further review revealed the tables are to be replaced with "tables bolted to floor and heavier chairs to meet standard of care". Review of the assessment revealed a picture of the lightweight chair.

Observation during tour of the BMU on 2/24/2012 at 1030 revealed in the Community room, a lightweight table with a metal center pedestal and 4 metal feet at the base of the pedestal. Also in the community room a computer on wheels was observed with 3 to 4 feet of cording attached to the wall electrical socket. Observation of day room #2 revealed two lightweight chairs with metal arms and legs and another table the exact type as noted in the community room. Outside of the day room #2 a lightweight chair was used to prop open a door leading to the outside court yard. Interview during tour with the charge nurse and risk management administrative staff revealed the chairs and tables should not be on the unit. The interview revealed the doors should not be propped open at any time.

Observation during tour of the BMU on 2/23/2012 at 1130 revealed all patients have access to all patient bedrooms on the unit and all hall ways that do not have patient bedrooms. Observation revealed patients having access to three day rooms and one community room. Observation revealed the layout of the BMU is the nursing station at the center with patient bedroom halls extending outward from the central nursing station (like spokes on a wheel). Observation revealed halls containing rooms that were not patient bedrooms also extending from the central nursing station. Observation revealed the nursing station had windows to visualize areas around the station and the hallways. Observation revealed the three day rooms and the community room could not be visualized from the station. The nursing station contained monitors with camera views from throughout the unit. Observation revealed staff were not monitoring the camera routinely.

Interview with the BMU director during the tour revealed patient bedrooms are open at all times. The interview revealed dayroom #2 and #3 are locked at night and the "big" dayroom #1 stays open at all times for the patients. The interview revealed during visiting hours each day the visitors enter the unit from the "sally port". The interview revealed the visitors and patients have access to all rooms. The interview revealed visitors are allowed on the patient hallways and in the patient rooms. The interview revealed the patients are allowed to shut their bedroom doors. The interview revealed the patients are monitored by the staff performing the 15 minute checks.

Interview with RN #4 on 2/23/2012 at 1330 revealed Day Room #2 has an area located on the left side when entering the room that can not be visualized by the camera. The interview revealed you have to go to this area to see it.

Interview with RN #1 on 2/24/2012 at 0820 revealed the third shift staff decided to lock the large day room (Day Room #1) during the third shift. The interview revealed patients were staying in the room and not going to bed. The interview revealed the RN was unaware if administrative staff were aware of this decision.

Interview with RN #2 revealed they were a staff nurse on the BMU. Interview on 2/24/2012 at 0935 revealed on Friday 2/17/2012 Patient #1 was noted to be smoking in her room. The interview revealed staff saw smoke coming out of her room. The interview revealed the patient did have matches and refused to give them to the staff initially. The interview revealed contraband does get on the unit. The interview revealed the staff do not write reports notifying administration when contraband is found. The interview revealed RN #2 did not complete a report (variance) for the occurrence of smoke on the BMU.

NC00078830