HospitalInspections.org

Based on review of clinical records, hospital documents, and staff interviews, for two of two clinical records reviewed of patients who were accepted in transfer from other hospitals, it was determined the hospital accepted the transfers of the patients without an accepting provider and without available inpatient beds at the time the patients were accepted. The patients had been assessed by Emergency Department (ED) physicians and evaluated by Behavioral Health professionals at the referring hospitals who determined the patients required inpatient psychiatric services. The patients were evaluated by a behavioral health staff member after their arrival to St. Luke's and then admitted by a provider to their observation/stabilization unit which is a lower level of care. (Patients #19 and #35)

Findings include:

The hospital's 2021 Plan for the Provision of Patient Care included: "The Observation Services for Children & Adolescents (OSCA) Program - serves children ages 5 through 17 years of age. The program provides observation services for eligible children. OSCA provides a safe and therapeutic environment to assess mental health status with plan to de-escalate the crisis or develop a plan to do so within 23.59 hours. Complimented by Inpatient, the patient may transition from crisis to home or another level of care here or in the community...The OSCA Program also functions as a safe haven for...youth who may be victim of domestic minor sex trafficking...."

The Governing Board meeting minutes dated 03/03/21 included: "Working on a plan to route patients through OSCA (Observation Services for Children & Adolescents) before going inpatient...Need to get our program running well before we face any competition." Documentation in the Governing Board meeting Minutes dated 05/05/2021 included: "...The whole reason for OSCA is to relieve the emergency room from holding behavioral patients."

The Medical Executive Committee General Session meeting minutes dated 05/25/2021 included: "...complaints received the last week of April. Concerns with OSCA bringing in patients and putting on lower level of care...Will need to change status before 23.5 (sic) hours. Will need to provide services while on Obs unit...."

Patient #19:

Patient #19 was transferred from an acute care hospital in the community to St. Luke's Behavioral Health Center on 08/21/2021 for inpatient admission.. Documentation in the acute care hospital's Emergency Department (ED) record revealed the adolescent presented there after an intentional overdose. A psychosocial assessment was performed at that hospital and it was determined the patient required "inpatient psychiatric treatment for safety and stabilization." The documentation also included: "...spoke with (staff name) at St. Luke's...(staff name) confirmed available beds and will call nursing for report...." The time of the patient's arrival to St. Luke's Behavioral Health Center was on or around 3:49 p.m. A Mental Health Evaluation was performed at 5:05 p.m.. The name of the staff who completed the evaluation was not on the evaluation, however, the electronic medical record showed the author to be a "Mental Health Provider." The reason for the evaluation was documented on the form as "OSCA eval." The evaluation identified the patient's presentation and history as documented in the psychosocial evaluation at the acute care hospital. The Mental Health Provider's documentation included: "patient denied current suicidal ideations. However patient has history of suicide attempts...Suicide Risk Level High...Intervention...Patient will be receive (sic) an evaluation while on the children and adolescent unit...Treatment Plan...Patient will receive an evaluation while on the children and adolescent unit." The evaluation was reviewed with the on-call provider who provided orders to admit the patient to the OSCA unit. The patient was taken to the OSCA Unit at 8:53 p.m. A Psychiatry Consultation was performed by a Nurse Practitioner (NP) on 08/22/2021 at 11 a.m. on the OSCA Unit. The NP's Assessment and Plan was " Admit to a level 1 inpatient psychiatric facility for further assessment and evaluation, medication stabilization, and appropriate referrals upon discharge. The patient remained on the OSCA unit until 08/23/2021 at 1:29 p.m., a period of over forty hours. The patient was then placed in an "overcapacity bed/room" which is a portable bed placed in a group therapy room. The room serves as a group room during the day and then the patient's room to sleep in a night. The patient remained in the "overcapacity room" until a licensed bed became available on 08/24/2021 at 8:30 p.m., a period of over 24 hours.

A review of the census, staffing sheets, and Supervisor Reports for 08/21/2021 revealed there were no inpatient beds available on the Child and Adolescent Units in which to admit Patient #19. There was also documentation in the census, staffing sheets and Supervisor Reports that staffing was inadequate on the CAS unit on 08/23/2021 and 08/24/2021.

Patient #35:

Patient #35, an adolescent) was transferred from an acute care hospital on 08/29/2021 for inpatient admission to St. Luke's Behavioral Health Center. Documentation in the ED record from the transferring hospital included: "...Will set up direct admission to St. Luke's. Holding here for flight risk...received call from (name) that pt has a bed at St. Luke's Bhx hospital (sic)...." The patient arrived at St. Luke's at 2:43 p.m. A Mental Health Evaluation was performed by a Mental Health Counselor which was staffed with the on-call NP who ordered the patient to be admitted to the OSCA Unit. The patient was transferred to the OSCA Unit at 5:20 p.m. A Psychiatry Consultation was performed at 8 a.m. on 08/30/2021, and the NP wrote admission orders for inpatient treatment. The patient remained in the OSCA Unit until 08/31/2021 at 9:52 p.m. when she was transferred to an over-capacity bed on the CAS Unit.

A review of census, staffing sheets, and Supervisor Reports for 08/29/2021 revealed there were no child/adolescent inpatient beds available in which to admit Patient #35.

There was no documentation in Patient #19 or Patient #35's clinical records that the requests from the sending hospitals were reviewed with a St. Luke's provider prior to acceptance to the hospital and no documentation that the referring hospitals were notified by St. Luke's that they did not have any available inpatient beds and that the patients would be evaluated and admitted to a lower level of care and held there until a bed became available.

Observations of the OSCA Unit on different times during the survey revealed an open room containing reclining chairs OSCA patients were admitted to and where they received meals and slept. On one day of observations, the patient ages ranged between six years and 17 years. Some patients were OSCA patients and some were inpatients waiting for an inpatient bed to become available.

The Clinical Manager of the Intake and Assessment Department reported during a tour of the unit on 08/23/2021 that all calls and written requests from other hospitals to transfer a patient to St. Luke's Behavioral Health Center comes through the Intake and Assessment Department. The Clinical Manager stated the requests for transfers in are reviewed by a Registered Nurse who make the decision on whether or not to accept a patient. The Clinical Manager stated the requests for transfer are not reviewed with a provider prior to accepting the transfer unless there is a concern and they don't always have an accepting provider. After the patient arrives, an evaluation is performed and then the provider is consulted.

Staff #54 was asked during an interview on 08/25/2021 if requests from other hospitals to transfer a patient to St. Luke's was reviewed with a physician who accepted the patient prior to transfer, and the staff responded, "No."

In summary, the hospital accepted the transfers of the patients without an accepting provider and without available inpatient beds at the time the patients were accepted. The patients had been assessed by Emergency Department (ED) physicians and evaluated by Behavioral Health professionals at the referring hospitals who determined the patients required inpatient psychiatric services. The patients were evaluated by a behavioral health staff member after their arrival to St. Luke's and then admitted by a provider to their observation/stabilization unit which is a lower level of care. Patient #35 remained in the OSCA unit for over 48 hours and was placed in an "overcapacity bed" (group room on the unit) for over 24 hours before being placed in a licensed inpatient bed. Patient #19 remained in the OSCA unit for over 40 hours and then placed in an "overcapacity bed" where she remained for over 24 hours before being placed in a licensed bed.

Based on review of hospital policy/procedure, Nursing's July 2021, and August 2021, work schedule and hospital documents, it was determined that the hospital failed to ensure that each unit was staffed with the number of personnel and the types of required personnel to provide nursing care to all patients as needed. This deficient practice poses a risk to the health and safety of patients and staff, when the hospital does not have the number of personnel that are required to meet the needs of the patients.

Findings include:

The hospital policy titled "Inpatient Staffing/Acuity Plan and Patient Acuity Tool Guidelines" requires that " ...Each unit will have sufficient staff to maintain a safe and therapeutic environment. The total number of staff is determined by the number and acuity of patients ...On the day and evening shifts the maximum patient to registered nurse (RN) ratio is 15:1 ...On the day and evening shift the maximum patient to Behavioral Health Technician (BHT) is 15:1 on the adult units and 10:1 for children and adolescent units ...On the 11-7 shift, the staffing matrix is followed with the maximum patient to RN ratio of 15:1 with a minimum of one (1) RN on the unit at all times ...The maximum patient to BHT ratio is 18:1 ...Acuity levels are assigned an approximate time allowance to help determine staffing needs and may be used as a guideline for making assignments ...Patient care assignments will be made taking into consideration the acuity and nursing care needs of the patients and will not be made based on geographic room locations of patients on any unit ...." The policy listed the Acuity Based Guidelines for each shift for each unit.

Review of the Staffing Schedule, Shift Assignment Sheets and House Supervisor Reports for the month of July 2021 revealed that thirty-nine (39) of sixty-two (62) shifts were short staffed at least one (1) staff member based on census and the acuity matrix. Of those 62 total shifts, there were thirty-four (34) shifts that were short staffed at least 1 staff member when the hospital was overcapacity in census one (1) to four (4) beds. Further review of the House Supervisor Report revealed on 07/06/21 day shift, the facility had 3 overcapacity beds and unit AP5 had an acuity of 78 requiring 3 RN's, however 2 core staff RN's worked with the unit utilizing 1 RN orientee as the third (3rd) core staff member. Additionally, on 07/26/21 day shift Unit AP1 had an acuity of 70 requiring 3 RN's, however 2 core RN's worked and utilized 1 RN orientee as core staff. Further review for that day revealed on Unit CAS day shift had an acuity of 54 requiring 2 RN's, however 1 RN worked with 2 RN orientees who were utilized as core staff. Further review of the House Supervisor Report revealed thirty-one (31) shifts in July where staff were floated between units to cover for shortage of staff.

Review of the Staffing Schedule, Shift Assignment Sheets and House Supervisor Reports for the month of August 2021 revealed that forty-seven (47) of sixty-two (62) shifts were short staffed at least one (1) staff member based on census and the acuity matrix. Of those 62 total shifts, there were thirty (30) shifts that were short staffed at least 1 staff member when the hospital was overcapacity in census 1 to 3 beds. Further review of the House Supervisor Report revealed thirty-two (32) shifts in August where staff were floated between units to cover for shortages of staff. Further review of the House Supervisor Report revealed on 08/26/21 day shift the hospital was overcapacity 1 bed, and Unit AP1 had an acuity of 63 requiring 3 BHT's, however there were only 2 core staff BHT's from 1500-1900 hours with the unit utilizing the 1 BHT orientee as the third (3rd) core staff BHT.

An interview was conducted on 08/23/21 with RN Employee #14 who stated shift assignments are usually done by dividing the unit in half and each nurse takes one half. "One nurse gets the top half of the unit and the other nurse gets the bottom half. Acuity isn't really considered, if it looks like the assignment is off balance we can adjust the assignments if needed."

An interview was conducted on 08/24/21 with RN Employee #26 who stated "there is no maximum patient to nurse ratio for each nurse to be assigned. There is no written guide regarding acuity and staffing that should be assigned to a unit. Total acuity is really considered when assigning staff for a unit."

An interview was conducted on 09/07/21 with Employee #3 who acknowledged the hospital did not have enough RN and BHT staff. S/he further stated there are more deficiencies in the schedule with RN's than BHT's. S/he stated the hospital staffs according to the acuity matrix. S/he continued that orientees are not to be included in the acuity ratio or staffing. S/he further stated it may be necessary to float staff from one unit to another to cover staff shortages. S/he further stated that the hospital will continue admitting patients into overcapacity despite having no beds or staff to accommodate because "that's how it has always been done."

Conclusion: The allegation on inadequate staffing was substantiated. Based on review of policies and procedures, documents, and interview, it was determined that the Administrator failed to ensure that each unit was staffed with the number of personnel and the types of required personnel to provide nursing care to all patients as needed. Deficiency was cited.

Based on review of Life Safety Code, observations on tour, and interviews, the hospital failed to ensure the proper use of extension cords, power strips, and the use of a multi plug adaptor. This defiecent practice poses a potential risk to patient health and safety due to the risk of extension cords, power strips, and multi plug adaptors overheating and causing a fire.

Findings include:

NFPA 101, Life Safety Code, 2012. Chapter 2, Section 2.1 The following documents or portions thereof are referenced within this Code as mandatory requirements and shall be considered part of the requirements of this Code. Chapter 2 "Mandatory References" NFPA 99 "Standard for Health Care Facilities," 2012 Edition. NFPA 99, Chapter 6, Section 6.3.2.2.6.2 , "All Patient Care Areas," Sections 6.3.2.2..6.2 (A) through 6.3.2.2.6.2 (E) Receptacles (2) "Minimum Number of Receptacles." "The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters."

Observations while on tour August 23-25, 2021, revealed many locations throughout the facility with improper use of extension cords and power strips and one multi plug adaptor. Extension cords used as permanent equipment, multi plug adaptors without surge protection and 10 different locations had heavy load drawing appliances (refrigerators, microwaves and large printers) plugged into power strips. Policy titled "Utilities Management Plan 2021 " revealed the Security Section described power strips as "Relocatable Power Taps" and stated "RPTs must be permanently mounted" and there were power strips laying on the floor. The policy also stated "Extension cords are not used as a substitute for fixed wiring in a building" contrary to this policy extension cords were found in four locations as permanent fixtures.

During the exit conference conducted on August 25, 2021, Employee #1, #11, and #19, confirmed the improper use of power strips, extension cords, and multi plug adaptors without surge protection.

Based on review of policies and procedures, video review, and employee interviews, it was determined the hospital failed to ensure that staff followed COVID-19 policies and procedures, including wearing face shields, goggles, or eye protection when entering a patient room as evidenced by the night shift not following appropriate personal protective equipment when providing services to patients and participating in staff activities when required by the hospital policies and procedures.This deficient practices poses a potential health and safety risk to patients and staff when policies are not followed to decrease the risk of contracting or spreading an infection.

Finding include:

Policy titled "COVID 19 Psychiatry Service Interim Guidelines" revealed: " ...Definitions ...Enhanced Droplet Precautions: the use of an isolation mask with eye protection (goggles or face shield) when caring for select patient or patient populations ...II. Care Delivery A. Enhanced Droplet precautions will be implemented for all patients regardless of Covid-19 Status. 1. All Healthcare workers will wear surgical masks and eye protection when seeing all patients regardless of COVID-19 status ...."

Document titled "2021 Infection Control Program, Goals, Objectives & Risk Assessment" revealed that the targeted area of isolation activities and respiratory hygiene action plan is to monitor the use of PPE for all precaution patients and compliance of PPE use by staff.

Video review of 09/04/2021, from 09:20 p.m. to 11:00 p.m., CAS (Child and Adolescent) Unit (280's) conducted on 09/07/2021, with Employee #29, revealed that two (2) Behavioral Health Technicians (BHTs) had their eye protection on backwards when entering patient rooms.

Video review of 09/05/2021, from 11:00 p.m. to 09/06/2021, 2:02 a.m., CAS Unit (260's) conducted on 09/08/2021, with Employee #2 revealed that three (3) BHTs on the unit were not wearing eye protection when entering a patient room, including a BHT on a one to one (1:1) patient assignment.

Employee #29 confirmed during an interview conducted on 09/07/2021, during video review, that two (2) BHT's were not wearing their eye protection appropriately.

Employee #2 confirmed during an interview conducted on 09/08/2021, during video review, that three (3) BHT's entering patient rooms, including a BHT on a one to one (1:1) assignment, were not wearing eye protection appropriately, or at all, when entering a patient room.