HospitalInspections.org

Based on review of hospital policies/procedures, medical records and interview, it was determined that the hospital failed to require documentation of informed consent for Electroconvulsive Therapy (ECT) and transport for 2 of 2 inpatients undergoing ECT at an outside medical facility (Pts # 14 and 21).

Findings include:

Review of hospital policy/procedure titled Electroconvulsive Therapy revealed: "...The procedure will occur at a designated Medical facility not within the (name of hospital) facility...Prerequisites to electroconvulsive treatment will include:...Documentation of informed consent...Written Informed Consent will be signed by the patient or Title 36 Guardian and witnessed...Registered Nurse...Checks patient's clinical record to ensure the following are available:...Signed Electroconvulsive Therapy Consent for current ECT series...."

Review of hospital policy/procedure titled Transport, Patient-Non emergent Medical revealed: "...Non-emergent medical transport occurs when a patient is transported to another healthcare institution for outpatient medical services with the intent of returning the patient to the hospital...The practitioner or designee is responsible for obtaining informed consent from the patient or legal representative. Informed consent includes risks and benefits of transport based on the patient's medical condition and the mode of transport. This information must be documented in the patient's medical record...Documentation in the patient's medical record includes:...Consent for transport by the patient or patient's representative or why consent could not be obtained...."

Review of Pt #14's medical record revealed that she underwent ECT at an outside medical center on 2/6/13.

Pt #14's medical record did not contain documentation of her informed consent for transport or ECT.

Review of Pt #21's medical record revealed that she underwent ECT at an outside medical center on 2/6/13.

Pt #21's medical record did not contain documentation of her informed consent for transport or ECT.

Employee # 29 confirmed on 2/7/13, that on 2/6/13, a Behavioral Health Technician (BHT) transported both Pts #14 and 21 via hospital van to (name of medical center) for ECT.

RN # 42 confirmed during interview conducted on 2/8/13, that the medical records of Pts # 14 and 21 did not contain the required consents.

Based on review of hospital policy/procedure, medical records and interview, it was determined that the hospital failed to ensure that 2 of 5 patients in seclusion and/or restraints were monitored as required (Pts #9 and 16).

Findings include:

Review of the hospital policy/procedure titled Restraint revealed: "...The patient shall be monitored and reassessed through continuous in-person observation...Restraint episodes will be documented on the following forms:...Restraint/Seclusion Flow Sheet...."

Review of the hospital policy/procedure titled Seclusion revealed: "...The patient shall be monitored and reassessed through continuous in-person observation. Continuous means ongoing without interruption...Seclusion episodes will be documented on the following forms:...Restraint/Seclusion Flow Sheet...."

Review of Pt # 9's medical record revealed nursing documentation on 1/27/13 at 1815: "Patient escorted to seclusion room and given injection. Patient remaining in seclusion room with door closed and staff observing patient...." Review of the Restraint/Seclusion Flowsheet revealed a section titled Patient Monitoring "Document MINIMUM q (every) 15 minutes." An RN recorded entries at the following times: 1810, 1815, 1820, 1900, 1945, and 1950. At 1945, the RN documented: "...Released from seclusion to room...."

Review of Pt # 16's medical record revealed nursing documentation on 1/27/13 at 1830: "Patient escorted to seclusion room and given injection. Patient remained in seclusion room with door closed and staff observing patient...." An RN recorded entries on the Restraint/Seclusion Flowsheet at the following times: 1810, 1815, 1820, 1900, 1945 and 1950. At 1945, the RN documented: "...Released from seclusion...."

The hospital's Interim Risk Manager confirmed, during interview conducted on 2/7/13, that the patients' medical records did not contain documentation of staff monitoring every fifteen minutes as required.

Based on review of Medical Staff Bylaws, hospital policies and procedures, medical records and interviews, it was determined that the hospital failed to require physician's orders for 2 of 2 inpatients transported for Electroconvulsive Therapy at an outside medical facility (Pts # 14 and 21).

Findings include:

Review of the hospital's Medical Staff Bylaws revealed: "...The responsibilities of the Medical Staff are:...to monitor, enforce, review...these bylaws and rules and Regulations and Facility policies...."

Review of hospital policy/procedure titled Electroconvulsive Therapy revealed: "...If there are no members of the medical staff who are credentialed to do electroconvulsive therapy a referral will be made to a local provider for the service...Electroconvulsive treatments will be administered only upon written order by the patient's attending physician. The procedure will occur at a designated Medical facility not within the (name of facility)...Prerequisites to electroconvulsive treatment will include:...Written order for ECT treatment...Clinical Records for patients receiving outpatient ECT will include:...the physician's order for ECT...The patient will be transported to (name of Medical Center) outpatient surgery by (name of facility) staff and will be returned to unit by this staff upon release from outpatient surgery center...."

Review of hospital policy/procedure titled Transport, Patient-Non Emergent Medical revealed: "...When it becomes necessary to transport a patient to another facility for medical services not provided by the hospital, the transport should be conducted in a way that protects the health and safety of the patient...Non-emergent medical transport occurs when a patient is transported to another healthcare institution for outpatient medical services with the intent of returning the patient to the hospital...Transport of a patient is initiated by practitioner order. The order includes rationale for transport (...ECT...), destination, and mode of transport...."

Review of Pt # 14's medical record revealed:

On 2/6/12 (sic) at 0945, a physician wrote a progress note: "...Pt to start ECT #1 this AM...."
On 2/6/13 at 1030, an RN documented: "...Off unit to ECT...."
On 2/6/13 at 1345, an RN documented: "...Returned to unit from ECT...."
Documentation of an "Electroconvulsive Therapy Post-Procedure Note," dated 02/06/2013.

Pt #14's medical record did not contain a physician's order for ECT or a physician's order for transport.

Review of Pt # 21's medical record revealed:

On 2/6/13 at 0645, a physician wrote a progress note: "...Pt to start ECT this AM...."
On 2/6/13 at 0645, a physician wrote an order: "NPO (nothing by mouth) midnight 2/5 for ECT #1 2/6 AM...."
On 2/6/13 at 1000, an RN documented: "...Compliant (with) NPO for ECT...Observe/assess (after) Returns from ECT appt...."
On 2/6/13 at 1510, an RN documented: "...Returned from ECT (with staff...."
Electroconvulsive Therapy Discharge Instructions from (name of medical center).

Pt #21's medical record did not contain a physician's order for ECT or a physician's order for transport.

RN # 28 confirmed, during interview conducted on 2/7/13, that neither Pt #14's nor Pt #21's medical records contained the required physician orders.

MD #2 confirmed during interview conducted on 2/7/13, that neither Pt #14's nor Pt # 21's medical records contained the required physician orders.

Based on record review, policy and procedure review, direct observation, and interview, it was determined that the hospital failed to provide an organized nursing service with an adequate number of registered nurses and competent nursing staff to assess and meet patients' care needs as evidenced by the:

(A0386) failure of the DON responsible for the operation of the service to require policies and procedures to delineate how soon after admission the nursing Suicide Risk Assessment (SRA) would be conducted, when a child under the age of six (6), admitted to the hospital for increasing suicidal ideation and threatening to kill himself, was not administered a Suicide Risk Assessment (SRA) by a registered nurse until thirty-eight hours subsequent to admission (Patient #1);

(A0395) failure to require that a Registered Nurse (RN) supervise and evaluate the nursing care provided for 2 of 2 suicidal patients (Pts #2 and 3); notify the physician or implement precautions for Patient #2 who had an increase in suicidal ideation with a plan to overdose or cut herself; assess/reassess 3 of 3 child/adolescent patients (Pt #'s 1, 2 and 3); measure and record Intake and Output as required for 1 of 1 adult patient (Patient # 20); measure and record patient vital signs as ordered for 2 of 2 patients (Pts # 17 and 25) and administer medication as ordered for 1 of 2 patients (Pt # 25); assess patient withdrawal symptoms and administer medications as ordered for 2 of 2 patients admitted with Alcohol Dependence (Pts # 11 and 24); record the daily weight of 1 of 1 patient who was court ordered for treatment and in danger of death from starvation (Pt # 15); and document nursing assessments prior to transport and upon return for 2 of 2 patients transported to an outside medical center for electroconvulsive therapy;

(A0397) failure to require that an RN assign the nursing care of each patient in accordance with the patient's needs and competence of nursing staff; and

(A0405) failure to require that medication for 1 of 1 patients' be administered according to physician's orders.

The cumulative effect of these systemic problems resulted in the Hospital's failure to provide an adequate, organized nursing service and ensure the provision of quality healthcare in a safe environment.

Based on record review, policy and procedure review, and interview, it was determined that the Director of Nursing (DON) failed to be responsible for the operation of the service, when there were no policies and procedures in place to delineate the timeframe in which a Suicide Risk Assessment (SRA) was to be conducted as evidenced by a child, on the child/adolescent unit, under the age of six (6), admitted to the hospital for increasing suicidal ideation and threatening to kill himself, was not administered a Suicidal Risk Assessment (SRA) by a registered nurse until thirty-eight hours subsequent to admission (Patient #1).

Findings include:

The policy and procedure titled "Suicide Risk Assessment" revealed: "Sonora is to identify patient's (sic) at risk for suicide. Suicide risk assessment is completed for all patients and includes specific factors and features that may increase or decrease risk for suicide. The patient's immediate safety needs are addressed...Identification of patients at risk for suicide is an important first step in protecting and planning the care of these at risk individuals...2. The Admitting Nurse will complete the initial suicide risk assessment as part of the nursing assessment...."

The policy and procedure titled "Assessment of Inpatients" revealed: Procedure: 1. The following assessments will be conducted by designated staff and within required timeframes. See Exhibit A. Exhibit A revealed that the "Nursing Assessment" "Time Frame Requirements" was required to be completed within 8 hours of admission.

Patient #1, a child under the age of six (6), was admitted to the Hospital on 02-04-13 at 1:30 A.M. The "Psychiatric Evaluation" revealed: "The patient is actually a (age and gender documented), who lives in foster care, who was transferred here from the hospital, up in (name of city), for increasing suicidal ideation and threatening to kill himself with a knife... The "Chief Complaint/Reason for Admission" was: "Suicidal ideation with a plan to stab himself...The patient's foster mother reports that over the past month he has been increasingly aggressive. Most recently he has increasing ongoing temper tantrums since being placed at the foster home. He does not want to follow and will become explosive, hitting himself on things, including banging his head violently, screaming, yelling, and having severe tantrums. He has needed to be physically restrained. He also attempted to run away...The patient's foster mother reports that he wanted to hurt himself, that he got a knife and was trying to cut himself with a knife, and continues to think about that...the foster mother reports that he also attacked their 11-month-old...."

The "History and Physical Examination" "Impression" revealed: "1. History of post-traumatic stress disorder. 2. Depression with suicidal ideation."

The "Suicide Risk Assessment" (SRA) that at the time of admission to the pediatric unit revealed an SRA form dated and timed 02-04-13 at 2:00 A.M. contained a blank form with a cursive annotation: "Unable to assess pt (patient) scared, not able to interact verbally on admit."

RN #22 acknowledged, during interview conducted on 02-05-13 at 4:50 P.M., that she had conducted the Suicide Risk Assessment at 3:30 P.M. on 02-05-13. She then timed and dated the interview as follows: "2/5/13 @ 1530 (3:30 P.M.)."

The Suicide Risk Assessment was not conducted by the RN in charge of supervising and evaluating the care of Patient #1 until thirty-eight (38) hours subsequent to admission to the Hospital. RN #22, the RN supervising and evaluating the care of Patient #1 on 02-05-13, failed to evaluate the need to conduct the child's suicide risk in a timely manner, even though the admission nursing assessment revealed that at admission he was verbalizing suicidal ideation and the "Potential for self harm" was checked as "yes."

The CEO stated, during interview conducted on 02-08-13 at 4:30 P.M., that the referenced policy at the beginning of this Tag applied to the Assessment & Referral Admissions Nurse, and did not apply to staff nurses admitting patients on the child/adolescent unit. The CEO stated that if the patient was admitted after hours, as was Patient #1, the referenced policy did not apply to the nurses conducting the initial SRA on the Unit. The CEO acknowledged there was no Governing Board approved policy indicating who was responsible to ensure an SRA was conducted on child/adolescent patients in a timely manner.

Based on record review, job description review, policy and procedure review, direct observation, and interview, it was determined that a Registered Nurse (RN) failed to supervise and evaluate the nursing care for each patient as evidenced by the:

1. failure to provide continuous observation and supervision of an adolescent female admitted with increased suicidal ideation and an adolescent female admitted subsequent to an acute care hospital admission for a suicide attempt (Pts #2 and 3);

2. failure to notify the physician or implement precautions for an adolescent female admitted for increase in suicidal ideation with a plan to overdose or cut herself who had a change in condition whereby she endorsed homicidal ideation on two successive shifts (Pt #2);

3. failure to complete nursing assessments, reassessments and suicide risk assessments which address specific needs of child/adolescent patients for 3 of 3 patients (Pts #1, 2 and 3);

4. failure to measure and record Intake and Output and document antibiotic as ordered for 1 of 1 adult patient who had a diagnosis of a Urinary Tract Infection (Patient # 20);

5. failure to measure and record patient vital signs as ordered for 2 of 2 patients (Pts # 17 and 25) and administer medication as ordered for 1 of 2 patients admitted with Opiate Dependence (Pt # 25);

6. failure to assess patient withdrawal symptoms as required and administer correct dose of medications as ordered for 2 of 2 patients admitted with Alcohol Dependence (pts # 11 and 24);

7. failure to measure and record the daily weight of 1 of 1 patient who was court ordered for treatment and in danger of death from starvation (Pt # 15); and

8. failure to complete and document nursing assessments prior to transport and upon return for 2 of 2 patients transported to an outside medical center for electroconvulsive therapy (Pt #'s 14 and 21).

Findings include:

1. The Sonora Behavioral Health Hospital policy titled "Levels of Observation" revealed: "...8.2 Line of Sight Observation (LOS) Guidelines for implementation of this level of precaution include, but are not limited to, the following:...8.2.2. The patient should be within visual range of the assigned staff at all times."

The Sonora Behavioral Health Hospital job description for a Registered Nurse revealed: "...Position Summary:

Conducts patient assessments and provides nursing interventions to patients as assigned.

Maintains a safe and efficient working and treatment environment per facility policies and procedures.

Communicates effectively with the treatment team to ensure safe, quality care is provided to all patients.

Provides supervision to Licensed Practical Nurses and Behavioral Health Technicians...."

"...ESSENTIAL JOB FUNCTIONS

Complete admission nursing assessment as assigned.

Complete nursing reassessments as assigned, and any time a change in status is observed or reported by team members...

Assess patients for risk of danger to self or others at time of assessment and ongoing through treatment. Document assessments and communicate concerns to the treatment team members through verbal and written methods...."

- Patient #2

Patient #2 was admitted to the Hospital on 01-31-13, after being hospitalized at Sonora Behavioral Health Hospital previously from 01-09-13 through 01-17-13. The "Psychiatric Evaluation" revealed in the "Mental Status Examination" that the patient had suicidal ideation with "a plan to cut on herself." The "Mental Status Examination" also revealed that Insight and Judgment were both: "Poor. She is pretty impulsive and struggles."

The "Psychiatric Evaluation," "Diagnostic Impression" revealed: "Basically this is actually a (age and gender documented) who comes in with increase in suicidal ideation in the context of increase isolation, increase in depression, who feels that she is caught in a male body and wants to be female to male. Struggling with increased anxiety, panic attacks, and adjusting to (city in which she currently lives)...."

The Child Psychiatrist in charge of the care of Patient #2 wrote an order on 02-06-13, at 10:00 A.M.: "Continue L.O.S" (Line-of-Sight).

Direct surveyor observation, conducted on 02-06-13 at 11:50 A.M., revealed Patient #2 in a television room independent of the main milieu, with no staff observing the patient in Line-of-Sight as ordered by the child's psychiatrist. The Director of Nursing (DON) was accompanying the surveyor when the observation was made.

At the time of the direct observation, RN #22, the RN responsible for the unit at the time, was observed in the nursing station, working with her back to the milieu. Behavioral Health Technician (BHT) #33 was observed walking about the milieu in a position where she was unable to keep the patient in LOS.

- Patient #3

Patient #3, an adolescent, was admitted to the Hospital on 01-30-13, from an acute care hospital, where she had been treated for an intentional drug overdose.

The "Psychiatric Evaluation" revealed in "Identifying Information": "The patient is actually a (age and ethnicity documented) female who was transferred here from (acute care hospital) after being medically cleared status post a serious overdose, in which she was found unresponsive by father and transferred to (acute care hospital)...."

The "History of Present Illness" revealed: "...She reports that she stashed away some pills of amitriptyline before and she also took some Tylenol. She said that she took two handfuls of this bottle after she got in a fight with (family member). The patient reports that she was thinking about dying when she did take the pills and she did not call for help. She just lay down and then the (family member) found her unresponsive because her girlfriend texted (family member)...She was discharged from here less than two weeks ago on the 17th...."

The "Diagnostic Impression" revealed: "A (adolescent) who comes with a complicated history with increase in depression, vegetative symptoms, and also who now has been struggling status post a serious overdose in the context of conflicts with her (family member)."

The "Mental Status Examination" revealed that the patient had poor insight and was very impulsive.

The "History and Physical Examination" revealed in the "History of Present Illness": "She says that she had an argument with her (family member) and made an impulsive decision to overdose on some pills that she had...."

On 02-06-13 at 10:30 A.M., the child psychiatrist in charge of the patient's care wrote an order: "Continue on line of sight while awake."

Patient #3 was also ordered to be on LOS at the time that direct surveyor observation revealed both patients not to be on Line-of-Sight observation on 02-06-13.

The DON acknowledged, during interview conducted on 02-06-13 at 12:00 noon, that the patients #2 and 3 were not in the Line-of-Sight of staff members assigned to the patients as ordered.

2.

- Patient #2

Refer to #1 this Tag for Patient #2's psychiatric history.

On 01-31-13, the "Nursing Reassessment" for Patient #2, in the field designated for "Suicide/Homicide Risk Assessment," had a mark in the box titled "Suicidal." On 02-01-13 at 3:40 P.M., and at 11:30 P.M., respectively, there was a mark in the box titled "Suicidal."

On 02-02-13 at 5:00 P.M., and 9:50 P.M., respectively, the field designated for "Suicide/Homicide Risk Assessment," revealed that "Homicidal" was marked during both times. There was no documentation in the record that the RNs supervising and evaluating patient's care, respectively, notified the physician of the change in condition, or implement precautions.

The DON acknowledged, during interview conducted on 02-06-13, that when homicidal ideation was identified on 02-02-13 at 5:00 P.M. and 9:50 P.M., respectively, on the nursing reassessment, that the RNs should have taken appropriate follow-up action.

Employee #10 stated, during interview conducted on 02-06-13 at 11:35 A.M., that when homicidal ideation was identified, the physician should have been notified.

3. Record review for child/adolescent Patients #1, 2 and 3 revealed that the same nursing assessment forms were being used for the child/adolescent population as the adult population.

The "Sonora Behavioral Health Hospital Integrated Assessment-Nursing Assessment" for child/adolescent patients revealed that it was the same form used for the adult population. The "Fall Risk Potential" was assigned for three age groups as follows: <70 years of age, 70-79 years of age, or > 80 years of age. The "Nursing Assessment" revealed: "Pain in the Elderly or in Patients with Cognitive or Language Impairments." The "Nursing Assessment Nutrition Screen" included questions such as: "Does patient have UNPLANNED weight loss greater than 10 pounds in past month or under ideal body weight. Home/Nursing Home use of enteral or parenteral nutrition." The Nutrition assessment form depicted an adult Body Mass Index (BMI) chart. The "Functional Screen" asked the following: "...9. Is there a diagnosis of CVA (Cerebral Vascular Accident), TIA (Transient Ischemic Attack), MS (Multiple Sclerosis), COPD (Chronic Obstructive Pulmonary Disease), Parkinson's (Parkinson's Disease)...12. Wears dentures?" The "Medical History Review" included in the field labeled "REPRODUCTIVE": "Prostate problems, Abnormal PAP (Papanicolaou) test, Abnormal Mammogram, and Impotence." The "Review of Systems" form depicted a human body that appeared to be that of an adult human.

The "Nursing Flow Sheet" "Progress Notes" was the same form as used for adult patients. The "Multidisciplinary Treatment Plan" was the same form as used for adults.

The "Suicide Risk Assessment" form used for child/adolescent patients was the same form used for adults at the Hospital. The form included seventeen (17) elements: Ideations, Plan, Means, Lethality, Intent, Patient History, Family History, Substance Abuse Use, Acute Life Stressors, Depression/Agitation, Hopelessness, Psychotic Processes, Medical Factors, Behavioral Cues, Coping Skills, Support System, and Other Factors.

The youngest child on the child/adolescent unit at the time of the survey, was a child under the age of six (6), whose medical record reflected that the adult form had been used for his nursing assessments.

There was no documented evidence that RNs supervising and evaluating the nursing care of child/adolescent psychiatric patients considered the use of adult forms for children, or that they considered the lack of documentation available to assess developmental milestones. There was no documented evidence the RNs questioned why the assessments did not include issues such as childhood diseases, growth and development milestones for children and adolescents, etc.

Medical Staff #4, a child psychiatrist, acknowledged, during interview conducted on 02-06-13 at 10:45 A.M., that the Suicide Risk Assessment (SRA) tool used on the child/adolescent unit should be specific to the patient population served on the unit.

4. Patient #20:

Review of policy/procedure titled Hydration Management/ I & O revealed: "...any time an order for...I and O an Intake and Output record must be completed and documented...The shift RN is responsible for ensuring the totals are correct, documented in the chart and any irregular findings communicated to the practitioner...."

Review of policy/ procedure titled Medication Administration revealed: " ...Pharmaceutical products and services are administered when ordered by practitioners...Each dose of medication is recorded on the Patient's Medication Administration Record (MAR) by the person who administers the drug, stating the time and dose given...If a medication is refused, the medication nurse circles his/her initials and indicates that the medication was refused. The nurse will notify the practitioner of the refusal and document the refusal in the daily progress note...."

Review of Registered Nurse's job description revealed: "...Review practitioner orders...Documentation for medical records and reports is timely...and in required format...Document as required...."

Review of Patient #20 medical record revealed the patient was admitted to the Hospital on 01-30-13, with diagnosis of major depressive disorder, a history of mild mental retardation, Asperger's and Autism. Patient had a diagnosis of Urinary Tract Infection.

Review of Patient # 20's medical record revealed a Physician order dated 1/31/13 at 14:26: "...I's, O's (Intake and Output)...."

Review of Patient # 20's medical record revealed no documentation of Intake for the dates of 2/2/13, and 2/3/13. There was no documentation of Output for 1/31/13 through 2/4/13. There was no order to discontinue the Intake or Output.

The Nurse Executive and RN # 4 confirmed in interviews conducted on 2/5/13 at 1630, that the medical record for Patient #20 did not contain documentation of recorded intake or output for the dates of 1/31/13 through 2/4/13. The employees also confirmed there was no order to discontinue the intake and output for Patient # 20.

Review of Patient # 20's Medical record revealed a Physician order dated 2/1/13 at 0800: "...Start Bactrim DS 1 PO BID X 7 days, Please call if resistant...."

Review of Patient # 20's Medication Administration Record for dates of 02/01/13 through 2/04/13 revealed: "Bactrim DS 1 tab PO BID X 7 days, please call if resistant...." There was no documentation of this medication being given as per facility's policy and procedure for the date and time of 2/02/13 at 2100.

The medical record revealed no documentation that that the patient refused, or that the physician was notified as per the orders.

The Nurse Executive confirmed on 2/6/13 the review of the Pyxis history that the Bactrim for patient #20 was removed at 1538 on 2/2/13 and the dose was not due until 2100.

The Nurse Executive and RN # 4 confirmed in interviews conducted on 2/5/13 at 1630 that the medical record for Patient #20 did not contain documentation of the medication being given or the physician being notified as per orders of the medication being refused for the date of 2/2/13 at 2100.

5. Review of the hospital form titled Admission Orders-Opiate Detox/CINA (Clinical Institute Narcotic Assessment) Protocol revealed that it contained the following orders: "...PROTOCOL:...Patient may be awakened at nurse's discretion...cloNIDine 0.1 mg PO (by mouth) every 2 hours PRN (per nursing judgment) opiate withdrawal evidenced by any positive CINA items 2, 3, 4, 5, 7, and 10. If CINA score is >10 complete vital signs every 2 hours prn for withdrawal symptoms. If CINA score is (equal to or less than) 10 complete vital signs every 4 hours prn for withdrawal symptoms...."

Review of Pt # 17's medical record revealed that it contained the form titled Admission Orders-Opiate Detox/CINA Protocol.

An RN signed the form on 1/28/12 at 1827, to indicate a physician's telephone order.

On 1/30/13 at 0600, an RN recorded the patient's CINA score as 14 and administered 0.1 mg Clonidine at 0550. An RN recorded vital signs at 0800. An RN did not record the patient's CINA score at 0800. At 1000, an RN recorded vital signs and a CINA score of 18. An RN did not record vital signs or a CINA score at 1200. The medical record contained documentation that the patient was asleep at 1200 and 1400. An RN recorded vital signs and a CINA score of 0 at 1400. An RN recorded vital signs at 1600. An RN did not record a CINA score at 1800. An RN recorded vital signs and a CINA score of 13 at 1900. An RN did not record vital signs or CINA score at 2100. An RN documented that the patient was asleep at 2300. On 1/31/13 at 1800, an RN recorded vital signs and a CINA score of 11. At 2000, an RN recorded vital signs but did not record a CINA score until 0230.

Review of Pt # 25's medical record revealed that it contained the form titled Admission Orders-Opiate Detox/CINA Protocol. An RN signed the form on 2/5/13 at 1245, to indicate a physician's telephone order.

On 2/5/13 at 1320, an RN recorded the patient's vital signs and a CINA score of 30. An RN did not record the patient's vital signs or CINA score at 1520. An RN recorded vital signs at 1600 and a CINA score of 25 at 1630. An RN did not record vital signs or a CINA score at 1830. At 2110, an RN recorded vital signs and a CINA score of 25. An RN did not record vital signs or a CINA score at 2310. The medical record contained documentation that the patient was asleep from 2145 through 0345 and from 0415 through 0545. At 0315 an RN recorded vital signs and a CINA score of 21. The patient scored positive on items 2, 3, 4, 5 and 10. An RN did not document administration of Clonidine. An RN recorded vital signs at 0515 but did not record a CINA score until 0915. The score at that time was 20.

The Director of Nursing confirmed, during interview conducted on 2/8/13, that the nurses did not follow/implement the protocol as required.

6. Review of the hospital form titled Admission Orders-Alcohol Detox/CIWA (Clinical Institute Withdrawal Assessment) Protocol revealed that it contained the following orders:

"...Protocol:...patient may be awakened at nurse's discretion...Medications:...Lorazepam (Ativan) Protocol...CIWA Above 19...Lorazepam 2 mg orally PRN...Vital Signs Every 1 hour...CIWA Due Every 1 hour...CIWA 15-19...Lorazepam 1.5 mg orally PRN...Vital Signs...Every 2 hours...CIWA Due Every 2 hours...CIWA 10-14...Lorazepam 1 mg orally PRN...Vital Signs Every 3 hours...CIWA Due Every 3 hours...CIWA 0-9...0.5 mg orally PRN...Vital Signs Every 4 hours...CIWA Due Every 4 hours...."

Review of Pt # 24's medical record revealed that it contained the form titled Admission Orders-Alcohol Detox/CIWA Protocol. An RN signed the form on 2/4/13 at 1750, to indicate a physician's telephone order.

On 2/4/13 at 2210, an RN recorded the patient's vital signs and CIWA score of 20. An RN did not record a CIWA score at 2310 as required. The medical record contained documentation that the patient was asleep at 2330. An RN documented administration of 1 mg Lorazepam at 2215. The required dose for a score of 20 was 2 mg. The medical record contained documentation that the patient was asleep from 2330 through 0415. At 0435 on 2/5/13, an RN recorded the patient's vital signs and CIWA score of 11. The RN recorded the patient's vital signs and CIWA score of 18 at 0820. The RN did not record vital signs or a CIWA score at 0735 as required. The RN did not record the patient's vital signs and CIWA score at 1020 as required. At 1215, the RN recorded vital signs and the patient's CIWA score of 14. At 1425, an RN administered 2 mg Ativan intramuscularly as ordered by physician. An RN recorded patient vital signs and a CIWA score of 16 but did not record the time. The same vital signs were recorded on the graphic sheet at 1600.

The Director of Nursing confirmed, during interview conducted on 2/8/13, that the nurses did not follow/implement the protocol as required.

Review of Pt # 11's medical record revealed that it contained the form titled Admission Orders-Alcohol Detox/CIWA Protocol. An RN signed the form on 2/3/13 at 1345, to indicate a physician's telephone order.

On 2/3/13, an RN administered 2 mg PO of Ativan to Pt # 11 at 1420 and 1720. On 2/3/13, an RN charted two entries of vital signs and CIWA scores, but did not record the time. The CIWA scores were 19 and the RN wrote below the vital signs "...2 mg Ativan given...." The correct dose of Ativan for a CIWA score of 19 is 1.5 mg. At 2000, an RN recorded vital signs and a CIWA score of 19. The RN administered 2 mg Ativan. An RN did not record vital signs or a CIWA score at 2200 as required. An RN documented that the patient was resting with eyes closed at 2400. On 2/4/13 at 0320, an RN recorded vital signs and a CIWA score of 19 and administered 2 mg of Ativan. The required dose was 1.5 mg. On 2/5/13, an RN recorded CIWA scores at 0800, 1300 and 1515. The scores were all recorded as 19. The RN administered 2 mg Ativan at 0800, 1300 and 1500. The required dose was 1.5 mg.

RN # 4 confirmed during interview conducted on 2/5/13, that the RN's did not administer the medication as required by protocol.

7. Review of Pt # 15's medical record revealed that she was admitted on 1/21/13 via petition for court ordered evaluation.

On 1/22/13, a physician documented in the Psychiatric Evaluation Title 36: "...She is extremely malnourished and delusional with intent to continue to starve herself...initial weight being 90 pounds...extremely underweight given that she is 5 feet 8 inches tall...She feels God has called her to fast...."

On 1/23/13, the physician ordered: "...Daily Blind Weights in gown (at) varying times...."

On 1/27/13, the physician ordered: "Continue (with) daily wts (weights)...."

Pt #15's medical record did not contain documentation of her weight on 1/26/13, 1/28/13, 2/3/13, 2/4/13 and 2/5/13.

The Dietician confirmed during interview conducted on 2/6/13, that Pt # 18 was not on a calorie count and that nursing staff were recording the food that she was eating but did not measure and record the patient's weight as ordered.

8. Review of hospital policy/procedure titled Electroconvulsive Therapy revealed: "...The procedure will occur at a designated Medical facility not within the (name of hospital) facility...The patient will be transported to (name of medical center) outpatient surgery by (name of hospital) staff and will be returned to unit by this staff upon release from outpatient surgery center...."

Review of hospital policy/procedure titled Transport, Patient-Non Emergent Medical revealed: "...Non-emergent medical transport occurs when a patient is transported to another healthcare institution for outpatient medical services with the intent of returning the patient to the hospital...The registered nurse or practitioner will assess the patient immediately prior to transport and upon return to the hospital. Patients requiring transport will be transported by the appropriate transportation method...The order includes rationale for transport (i.e....ECT...)...Documentation in the patient's medical record includes: Assessment by registered nurse or medical staff practitioner prior to patient transporting and upon return...The date and the time of the transport to the receiving health care institution...The date and the time of the patient's return to the sending hospital...the mode of transportation...."

Review of Pt # 14's medical record revealed:

On 2/6/13 at 1030, an RN documented: "...Off unit to ECT...." The medical record contained patient vital signs recorded at 0452. The RN completed a nursing reassessment form at 1000, but vital signs were not recorded. On 2/6/13 at 1345, an RN documented: "...Returned to unit from ECT, ambulatory, in room in bed resting comfortable, disoriented, no distress." The RN did not document a reassessment or vital signs at the time of the patient's return from ECT.

Review of Pt # 21's medical record revealed:

A physician's progress note completed on 2/6/13 at 0645. On 2/6/13 at 1000, an RN completed a nursing reassessment. Vital signs were recorded at 0449. The medical record did not contain documentation of the time that the patient was transported for ECT. The Discharge Instructions completed by personnel at the outside medical facility were signed by that facility's staff at 1330. On 2/6/13 at 1510, an RN documented: "Returned from ECT (with) staff 'tired' Remains in w/c (wheelchair) in good spirits able to tolerate crackers (with) some ginger...." The patient's vital signs were recorded at 1600. A nursing reassessment was completed on 2/7/13 at 0303.

RN # 42 confirmed, on 2/8/13, that the medical records of Pt #'s 14 and 21 did not contain the required documentation.

Based on record review, personnel file and job description review interviews and review of hospital documents, it was determined that the Hospital failed to require that a registered nurse assign the nursing care of each patient to other nursing personnel according to the patient's needs and competence of the available nursing staff as evidenced by the:

1. failure of a Registered Nurse (RN) and a Behavioral Health Technician (BHT) caring for pediatric patients to have demonstrated pediatric competencies;

2. failure of an RN to assign the care of patients on the Acute Adult Unit based on patient care needs; and

3. failure of nursing to determine the number of LPN's and BHT's required for each unit based on patient care needs.

Findings include:

1. Refer to Tag 395 regarding Patient #'s 1, 2 and 3, who were assigned on the Catalina (Pediatric) Unit to the care of RN #22.

Review was conducted of the personnel file of RN #22. The review revealed no documented pediatric competencies for the care of the pediatric patient, including medical and/or psychiatric conditions.

Review was conducted of the personnel file of BHT #33. The review revealed no documented pediatric competencies for the care of the pediatric patient, including medical and/or psychiatric conditions.

The Director of Nursing (DON) acknowledged, during interview conducted on 02-06-13, that there were no pediatric competencies assessed for RN #22 or BHT #33.

2. Review of the patient assignment sheet for the Acute Adult Unit on 2/5/13, revealed that patients were listed on the assignment sheet in consecutive order by room number under the Charge Nurse's name and the second RN's name. RN # 4 confirmed that s/he assigned patients based on the side of the hall where the patient was located. S/he also stated that the second RN worked from 0700 to 1530 and would "hand off" his patients to the oncoming nurse.

The Charge Nurse also confirmed that s/he made patient assignments for the BHT's based on the side of the hall where the patients were located.

During interview conducted on 2/6/13, RN # 28 stated that assessment of individual patient acuity/care needs is not used to determine the need for additional staff. The RN's assessment of the milieu is used to determine additional staff.

3. Review of the hospital policy/procedure titled Nursing Staff Allocation revealed: "...The mechanism for determination of staffing and assignment of nursing staff among departments includes consideration of the following: Requirements and qualifications for employment as a nursing staff member...The mechanism used for determining the deployment of nursing staff members among departments is as follows:...Staffing mix-Consideration is given in the staffing plan to the utilization of registered nurses, licensed practical nurses, and unlicensed assistive personnel according to identified requirements for nursing care and the scope of practice...Patient care responsibilities are assigned to nursing staff based on four general considerations including: the patient acuity, environment in which nursing care is provided, staff competency, and supervision required by and available to each nursing staff member assigned responsibility...."

Review of the hospital policy/procedure titled Acuity System revealed that it did not contain the maximum number of patients assigned to an RN, LPN, or BHT. It also did not contain how an RN is to use individual patient acuity to determine the number of LPN's or BHT's required.

Review of the assignment sheet for the Adolescent Unit revealed that one RN was responsible for all 19 adolescent patients. An LPN was assigned to assist the RN and BHT's were assigned to tasks and to patients listed on the assignment sheet in order of room number.

During interview, RN # 35 stated that s/he works the day shift on the Adolescent Unit. S/he completes an acuity assessment of each patient by 1300 to assist in staffing the next shift. The acuity assessment from the night shift is not available to RN # 35 in order to use for assignments of patients to BHT's or to determine whether one RN is sufficient for the day shift.

The DON confirmed during interview conducted on 2/8/13, that the patient acuity system is utilized to staff the units based on individual patient care needs, milieu acuity and staff competence and experience. She confirmed that it does not include guidelines for determining the number of LPN's or BHT's based on individual patient care needs and does not include the maximum number of patients that an RN can safely care for.

Based on document review, policy and procedure review, and interview, it was determined that the Hospital failed to require that notes written by Behavioral Health Technicians (BHTs) describing the patient's progress and behaviors throughout the shift were not directly integrated into the patient's medical record.

Findings include:

The Sonora Behavioral Health Hospital policy and procedure titled "Medical Record Content" revealed: "POLICY: The medical record must contain sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers. The medical record must be complete for the purposes of facilitation of patient care, to serve as a financial and legal record...PROCEDURE: 4. the record and findings of the patient's assessment...13. multidisciplinary progress notes that contain pertinent observations and information...."

Reviews were conducted of medical records on the child/adolescent unit on 02-06-13. During the course of record reviews, the surveyor was made aware that BHT objective observations and narrative documentation did not become part of the permanent medical record.

A document used to document objective and narrative comments by BHTs contained documented BHT observations and notes regarding patients. The name-redacted copy provided to the surveyor revealed that for each of two (2) shifts daily the BHT noted the following behaviors: Danger to Self, Danger to Others, Isolating, Focus Level, Hallucinations, Attended Groups, Oriented x 3 (oriented to person, place, and time), Delusions, Complaints, Boundary Issues, participation, Current level (level of independence).

On 02-05-13, day shift the "Supporting Comments" revealed: "Pt (patient) up and visible all shift Pt states she felt a little anxious (sic) not as depressed today."

On 02-05-13, night shift the "Supporting Comments" revealed: "Pt attended group, upset that she just met her therapist. Buying into (another patient's) acting out, needed staff intervention."

Staff #22 acknowledged, during interview conducted on 02-06-13, that the BHT's objective observations and narrative notes are supposed to be imparted to the RN. The BHT's observations are not recorded as documented by the BHT in the patient's hospital record.