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Based on interview and record review, the hospital failed to identify after a root cause analysis of an adverse event a staffing shortage that impacted safety and quality of care of the patients. This deficient practice was evidenced by the hospital having 4 MHTs on Unit "A" instead of 5 MHTs as the hospital staffing matrix indicated. During this time period two patients were discovered to have had sex in the seclusion room's bathroom.

Findings:
Review of the hospital policy titled, Staffing Plan, revealed in part, the unit will be staffed with an adequate number of RNs, LPNs, and MHTs to maintain a therapeutic milieu and a safe environment.

Review of a self-report to LDH revealed on 03/01/2022 at 7:50 p.m. it was discovered that Patient #1 and Patient #2 had admitted to having sex in the seclusion room's bathroom.

Review of the census for 03/01/2022 at 7:50 p.m. Unit "A" had a census of 19 patients, with 15 patients on Level II observation level (being observed every 5 minutes).

Review of the staffing matrix for Unit "A" indicated at 7:00 p.m. with 19 patients the base amount of staff needed was 2 RNs, 3 MHTs.

An interview was conducted with S6DON at 3/23/2022 at 10:30 a.m. S6DON reported for every 6 patients on every 5 minutes observation level (level II), the hospital adds an additional MHT to the staffing matrix. S6DON reported since Unit "A" had 15 patients on Level II observation level, the unit should be staff with 2 additional MHTs, which would make the appropriate staffing for the unit 2 RNs and 5 MHTs. With review of the schedule for 03/01/2022 the 7 p.m. evening shift, she confirmed there were 2 RNs and 4 MHTs on the shift and the unit was short one MHT.

An interview was conducted with S2RM on 03/23/2022 at 8:30 a.m. S2RM stated with conducting the root cause analysis of the incident between Patient #1 and Patient #2, she did not identify Unit "A" was short one MHT during the time the incident occurred.

Based on record review and interview, the hospital failed to have an adequate number of MHTs to provide care and supervision of the patients. This deficient practice is evidenced by the hospital being short staffed, according to the hospital's staff matrix, by 1 MHT for 3 shifts (03/01/22; 7 p.m. shift, 03/19/2022; 7 p.m. shift, and 3/20/2022; 7 p.m. shift) reviewed from March 1, 2022 to March 23, 2022.
Findings:


Review of the hospital policy titled, Staffing Plan, revealed in part, the unit will be staffed with an adequate number of RNs, LPNs, and MHTs to maintain a therapeutic milieu and a safe environment.

March 1, 2022; 7 p.m. shift
Review of the census for 03/01/2022 at 7:50 p.m. Unit "A" had a census of 19 patients, with 15 patients on Level II observation level (being observed every 5 minutes).

Review of the staffing matrix for Unit "A" indicated at 7:00 p.m. with 19 patients the base amount of staff needed was 2 RNs, 3 MHTs.

An interview was conducted with S6DON at 3/23/2022 at 10:30. S6DON reported for every 6 patients on every 5 minutes observation level, the hospital adds one additional MHT to the staffing matrix. S6DON reported since the Unit "A" had 15 patients on Level II observation level, Unit "A" should be staff with 2 additional MHTs which would make the appropriate staffing for the unit 2 RNs and 5 MHTs. With review of the schedule for 03/01/2022 the 7 p.m. (evening shift) on 03/01/2022, she confirmed there were 2 RNs and 4 MHTs on the shift and the unit was short one MHT.

March 19, 2022; 7 p.m. shift
Review of the staffing schedule for March 19, 2022 at 7 p.m. revealed the census on Unit "A" was 19 patients, with 7 patient on every 5 minute observation (Level II) and one patient on level III observation level (constant observation, 1:1). With further review of the schedule revealed 2 nurses and 2 MHTs were on the schedule.

Review of the staffing matrix for Unit "A" indicated at 7:00 p.m. with 19 patients the base amount of staff needed was 2 RNs, 3 MHTs." Further review of the census indicated that one additional MHT should have been added for the 7 patients on 5 minute observation.

An interview was conducted with S6DON on 03/23/2022 at 12:00 p.m. S6DON reported she had multiple staff call-ins for this shift and she confirmed Unit "A" was short 1 MHT on the 7 p.m. shift (evening shift).

March 20, 2022; 7 p.m. shift
Review of the staffing schedule for March 20, 2023 at 7 p.m. revealed the census on Unit "A "was 20 patients with 7 patients on every 5 minute observation (Level II) and one patient on Level III (constant observation; 1:1). With further review of the schedule revealed 2 nurses and 3 MHT were on the schedule.

Review of the staffing matrix for Unit "A" indicated at 7:00 p.m. with 20 patients the base amount of staff needed was 2 RNs, 3 MHTs." Further review of the census indicated that 1 additional MHT should have been added for the 7 patients on 5 minute observation.

An interview was conducted with S6DON on 03/23/2022 at 12:00 p.m. S6DON reported she had multiple staff call-ins for this shift and she confirmed Unit "A" was short 1 MHT on the 7 p.m. shift (evening shift) .

Based on record review and interview the provider failed to ensure drugs and biologicals were administered in accordance with with accepted standards of practice and according to hospital policy. This deficiency is evidenced by failure of the nursing staff to document refusal of medication according to hospital policy in 1 (#4) of 5 (#1, #2, #3, #4, and #5) records reviewed.
Findings:

Review of the hospital policy, "Medication Administration: Oral, Liquid, and Injectable," revised 2/2021, revealed in part, " 9. If the patient refuses the medication after multiple attempts:
a. The provider will be notified for additional orders.
b. The nurse will document in the progress notes that the patient refused medications and reasons.
c. The nurse will circle their initials on the Medication Administration record to designate that the medications were not given."

Review of the Medical Record of Patient #4 revealed admission on 02/20/2022 with a diagnosis of depressive disorder, recurrent, Post traumatic Distress Disorder and Type 1 diabetes mellitus.

Review of the orders revealed on 02/11/2022 at 7:41 a.m. orders placed for accucheck before eating and at bedtime and 2:00 a.m. each day. The patient was to receive insulin, regular, 100 U/ml as directed according to a sliding scale based on accucheck readings as follows:
61- 150 mg/dl No coverage
151-200 mg/dl 1 unit regular insulin SQ
201 -250 mg/dl 2 units regular insulin SQ
251 -300 mg/dl 3 units regular insulin SQ
301 -350 mg/dl 4 units regular insulin SQ
351 -400 mg/dl 5 units regular insulin SQ
401+ mg/dl 6 units regular insulin SQ and notify provider

Further review of the orders revealed nursing staff was to notify the internal medicine provider if the blood glucose was greater than 300 mg/dl. and if under 75 mg/ dl to treat per protocol.

Review of the medication administration record revealed on 02/15/2022 at 6:00 a.m. the accucheck was 260 mg/dl and the patient refused the insulin with a note, "said will after breakfast."

Review of the nurse notes for 2/15/2022 there is no documentation that the insulin was given at a later time and there is no indication the provider was notified of the refusal.

Review of the medication administration record revealed on 02/23/2022 at 12:00 p.m. the accucheck was 270 mg/dl and the patient refused insulin at that time and at 8:00 p.m. the accucheck was 333 mg/dl and the patient only allowed 3 units of insulin to be given.

Review of the nurse notes for 02/23/2022 revealed no documented reason for refusal of the 12:00 p.m. dose and no documentation the provider was notified of the patient's refusal. There was also no documentation the provider was notified the 8:00 p.m. dose was not administered as ordered and no documentation that the provider was notified the accucheck was above 300 mg/dl.

In interview on 03/23/2022 at 12:08 p.m. S6DON verified the above errors of documentation related to medication refusal.