HospitalInspections.org

Based on a review of documentation, the hospital failed to provide an effective governing body that was legally responsible for the conduct of the hospital.

Findings were:

During a review of the personnel record for staff #1, it was revealed that, although the staff member ' s employment with BCA Permian Basin began 7-9-12, no employee paperwork, including infection control training, was completed until 9-13-12.

In an interview with staff #19, she stated that she had a concern related to infection control. She stated that, on the evening of 9-9-12, she had observed staff #1 unclog a toilet on unit 1 and, still wearing the same white overcoat, serve dinner to the patients in the cafeteria.

Per page #16 in the new employee packet furnished to the survey team by staff #4, " All newly hired employees must complete the designated new employee orientation within the first 30 days of their employment. "

During a review of the 10 clinical records that contained treatment plans, none of the 10 plans were individualized to the specific patient.

Facility policy titled " Treatment Planning " states, in part, " An individualized interdisciplinary Treatment Plan will be developed for each patient admitted to the Hospital. "

In an interview with staff #19 on 9-12-12, she stated that, because she and the adolescent RN are not allowed to leave their respective units and are the only RNs in the building on the weekends, they are not allowed to have their meal breaks.

Facility policy titled " Hours of Work " states, in part, " In the event a 12-hour shift is worked, the employee should be allowed two meal or rest breaks of at least one-half hour each. "

In an interview on 9-13-12 with staff #2, she stated that she had been instructed by the corporate office (in an e-mail) to staff the units at a ratio of 1 staff member for every 6 patients when making the staffing schedule but that her final approval and instructions for staffing come from the facility administrative staff and the facility controller. She stated that nurses and direct-care staff were counted as staff members for the 1:6 ratio and that the Director of Nursing looks over the schedule when she has completed it.

During a tour of the adult/geriatric unit on 9-11-12 at approximately 3:00 pm, it was noted by the surveyor that the total census was 26 patients. A review of the census revealed that, as of 3:45 pm, two patients had been discharged and two more admitted, keeping the census constant at 26 patients. One of the 26 patients was being observed on a 1:1 for hyponatremia and excessive voluntary water consumption.

A review of the staffing for the unit revealed that the staff assignment consisted of one registered nurse, one licensed vocational nurse and two mental health associates.

An e-mail from the facility controller to staff #2 sent 8-24-12 contains the following statement, " On the units we need to maintain the 1:6 staffing ratio. "

Per a facility document titled " BCA Permian Basin ...2012 Operating Budget " , the minimum staffing for the adult unit with 25 to 28 patients on the day shift is as follows:
? 4.2 Registered Nurses (from 7a to 7p)
? 4.2 Mental Health Associates (from 7a to 7p)
? 1.4 Licensed Vocational Nurses (from 7a to 3p)
? 2.8 Mental Health Associates (from 7a to 3p)

The above was confirmed in an interview with the facility Vice-President of Regulatory Compliance, the CEO, the Director of Nursing and the Clinical Director on the afternoon of 9-14-12 in the facility conference room.

Based on observation, the hospital did not maintain a completed medical record for every individual evaluated or treated in the hospital.

Findings were:

During a review of 19 clinical records, 5 of the 19 (patients #2, #4, #5, #6, #12) records contained a history and physical not performed within 24 hours of admission.

During a review of 19 clinical records, 16 of the 19 (patients #1, #4 - #18) records contained no discharge summary.

During a review of 19 clinical records, 9 of the 19 (patients #6, #7, #10 - #12, #15 - #18) records contained no treatment plan.

During a review of the 10 clinical records that contained treatment plans, none of the 10 plans were individualized to the specific patient.

During a review of 19 clinical records, 2 of the 19 (patients #6, #12) contained no psychiatric evaluation.

During a review of 19 clinical records, 1 of the 19 (patient #15) contained a psychiatric evaluation not performed within 60 hours of admission.

During a review of 1 clinical record pulled randomly from the facility restraint & seclusion log (patient #3), 1 of 1 patient did not receive a face-to-face evaluation within 1 hour of the initiation of the restraint and/or seclusion.

The above was confirmed in an interview with the facility Vice-President of Regulatory Compliance, the CEO, the Director of Nursing and the Clinical Director on the afternoon of 9-14-12 in the facility conference room.

Based on interviews, a review of facility documentation and a personnel file, the facility failed to maintain a sanitary environment to avoid sources and transmission of infections and communicable diseases. There was no documentation of an active program for the prevention, control, and investigation of infections and communicable diseases.

Findings were:

In an interview with staff #19, she stated that, on the evening of 9-9-12, she observed staff #1 unclog a toilet on unit 1 and, still wearing the same white overcoat, serve dinner to the patients in the cafeteria.

During a review of the personnel record for staff #1, it was revealed that, although the staff member ' s employment with BCA Permian Basin began 7-9-12, no employee paperwork, including infection control training, was completed until 9-13-12.

During a review of infection control data for 2012, there was no documentation for the months of January, February, May, June, July and August that infection rates were reviewed and/or monitored.

The above was confirmed in an interview with the facility Vice-President of Regulatory Compliance, the CEO, the Director of Nursing and the Clinical Director on the afternoon of 9-14-12 in the facility conference room.

Based on a review of clinical records and staffing, the hospital failed to meet all special provisions applying to psychiatric hospitals

Findings were:

Cross-reference:
B0103
B0136

The above was confirmed in an interview with the facility Vice-President of Regulatory Compliance, the CEO, the Director of Nursing and the Clinical Director on the afternoon of 9-14-12 in the facility conference room.

Based on a review of 19 clinical records, the records failed to permit determination of the degree and intensity of the treatment provided to individuals who were furnished services in the institution.

Findings were:

Cross-reference:
B0111
B0118
B0133

The above was confirmed in an interview with the facility Vice-President of Regulatory Compliance, the CEO, the Director of Nursing and the Clinical Director on the afternoon of 9-14-12 in the facility conference room.

Based on a review of clinical records, not all patients received a psychiatric evaluation that was completed within 60 hours of admission.

Findings were:

During a review of 19 clinical records, 2 of the 19 (patients #6, #12) contained no psychiatric evaluation.

During a review of 19 clinical records, 1of the 19 (patient #15) contained a psychiatric evaluation not performed within 60 hours of admission.

The above was confirmed in an interview with the facility Vice-President of Regulatory Compliance, the CEO, the Director of Nursing and the Clinical Director on the afternoon of 9-14-12 in the facility conference room.

Based on a review of clinical records, each patient did not have an individual, comprehensive treatment plan.

Findings were:

During a review of 19 clinical records, 9 of the 19 (patients #6, #7, #10 - #12, #15 - #18) records contained no treatment plan.

During a review of the 10 clinical records that contained treatment plans, none of the 10 plans were individualized to the specific patient.

The above was confirmed in an interview with the facility Vice-President of Regulatory Compliance, the CEO, the Director of Nursing and the Clinical Director on the afternoon of 9-14-12 in the facility conference room.

Based on a review of clinical records, each discharged patient did not have a discharge summary that included a recapitulation of the patient's hospitalization.

Findings were:

During a review of 19 clinical records, 16 of the 19 (patients #1, #4 - #18) records contained no discharge summary.

The above was confirmed in an interview with the facility Vice-President of Regulatory Compliance, the CEO, the Director of Nursing and the Clinical Director on the afternoon of 9-14-12 in the facility conference room.

Based on a review of facility documentation, interviews with staff and a tour of the facility, the hospital did not provide adequate numbers of qualified professional and supportive staff to
evaluate patients, formulate written, individualized comprehensive treatment plans, provide active treatment measures and engage in discharge planning.

Findings were:

Cross reference:
B0150

The above was confirmed in an interview with the facility Vice-President of Regulatory Compliance, the CEO, the Director of Nursing and the Clinical Director on the afternoon of 9-14-12 in the facility conference room.

Based on a review of facility documentation, interviews with staff and a tour of the facility, the hospital did not provide adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary under each patient's active treatment program.

Findings were:

In an interview with staff #14 on 9-11-12, he stated that the units were not being staffed adequately, risking the safety of the patients and staff. He stated that the nurse:patient ratio was " terrible " . He also stated that there were numerous times when his 1:1 orders were not followed and that often, when he would write a 1:1 order for a patient, he was encouraged by administrative personnel to discontinue the order.

In an interview with staff #18 on 9-12-12, she was asked to explain the adult/geriatric staffing observed on the day shift of 9-11-12. Her attention was called by the surveyor to facility document titled " BCA Permian Basin, 2012 Operating Budget " , which appeared to represent a staffing matrix for the adult unit. Per the document, the minimum staffing for the adult unit with 25 to 28 patients on the day shift is as follows:
? 4.2 Registered Nurses (from 7a to 7p)
? 4.2 Mental Health Associates (from 7a to 7p)
? 1.4 Licensed Vocational Nurses (from 7a to 3p)
? 2.8 Mental Health Associates (from 7a to 3p)

When asked if she could explain how the presence of only three staff (one MHA, one RN, one LVN) would be appropriate if the facility was following a 1:6 staffing ratio, she was unable to do so.

In an interview with staff #19 on 9-12-12, she stated that the units were not staffed safely, especially not on the weekends. She stated that, on the weekends, she and the adolescent unit registered nurse (RN) are the only registered nurses in the building and that there is often not a registered nurse on call, either. When asked to name any RN-specific (not able to be performed by the licensed vocational nurse) nursing duties on the unit, she stated that the RN is responsible for all tube-feedings (liquid nutrition provided through a tube into some part of the digestive tract, the patient is usually not allowed to ingest anything by mouth), all nebulizer treatments and all finger stick blood glucose checks (accuchecks). She stated that tube feedings have to be performed in the patient ' s room (due to privacy issues) and that doing so takes her away from the desk for a period of time, as the feedings enter through the body through gravity only.

When asked to provide feedback regarding the RN ' s role in an emergency, the surveyor presented staff #19 with the scenario of a medically-injured man arriving at the locked front doors of the facility at approximately 1:00 pm on a Saturday. The staff member was asked what she thought she would do in such a situation and she replied that she would call 911 (emergency medical services). When asked if a woman in active labor were to present, instead, in the same manner at approximately the same time of day, the staff member stated that she would definitely leave her unit and go to the front and stabilize the patient and call 911. When asked how she responds to a Dr. Armstrong (all available help needed on unit) on the weekend with minimal staffing, she stated that she and the licensed vocational nurse remain on the unit and she will send any MHAs (mental health associates) she has.

An e-mail from the facility controller to staff #2 sent 8-24-12 contains the following statement, " On the units we need to maintain the 1:6 staffing ratio. "

Per a facility document titled " BCA Permian Basin ...2012 Operating Budget " , the minimum staffing for the adult unit with 25 to 28 patients on the day shift is as follows:
? 4.2 Registered Nurses (from 7a to 7p)
? 4.2 Mental Health Associates (from 7a to 7p)
? 1.4 Licensed Vocational Nurses (from 7a to 3p)
? 2.8 Mental Health Associates (from 7a to 3p)

During a tour of the adult/geriatric unit on 9-11-12 at approximately 3:00 pm, it was noted by the surveyor that the total census was 26 patients. A review of the census revealed that, as of 3:45 pm, two patients had been discharged and two more admitted, keeping the census constant at 26 patients. One of the 26 patients was being observed on a 1:1 for hyponatremia and excessive voluntary water consumption.

A review of the staffing for the unit revealed that the staff assignment consisted of one registered nurse, one licensed vocational nurse and two mental health associates

The above was confirmed in an interview with the facility Vice-President of Regulatory Compliance, the CEO, the Director of Nursing and the Clinical Director on the afternoon of 9-14-12 in the facility conference room.