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Based on document review and interview it was determined that for 2 of 6 patient units (Intensive Treatment Unit and 2 West) toured, the Hospital failed to ensure complete room checks were performed each shift to maintain care in a safe setting. This potentially affected the average daily census of 12 patients on Intensive Treatment Unit (ITU) and 15 patients on Pediatrics (2 West).

Findings include:

1. The Hospital's policy titled, "Hospital Staff Responsibility for Patient, Visitor, and Employee Safety (revised 5/2019)" was reviewed on 12/1/2020 and required, "10. Complete room checks on each shift to identify any items in need of repair or that may present a danger to the patient or staff."

2. During a tour of the Intensive Treatment Unit, on 12/1/2020 between 9:45 AM - 10:30 AM, the Clinical and Safety Walking Rounds logs for October and November 2020, were reviewed. The logs lacked documentation of the room checks for safety on the following shifts/dates:

- 7:00AM - 3:00PM shift on: 10/9/2020, 10/15/2020, 11/15/2020, 11/20/2020, 11/22/2020 and 11/29/2020.
- 3:00 PM - 11:00 PM shift on: 10/7/2020, 10/8/2020, 11/19/2020, 11/24/2020 and 11/26/2020.
- 7:00 AM - 3:00 PM and 3:00 PM - 11:00 PM shifts on: 10/12/2020, 10/17/2020, 11/14/2020 and 11/23/2020.

3. During a tour of the 2 West Unit, on 12/1/2020 between 10:35 AM and 11:15 AM, the Clinical and Safety Walking Rounds logs for October and November 2020, were reviewed. The logs lacked documentation of the room checks for safety on the following shifts/dates:

- 7:00 AM - 3:00 PM shift on: 10/3/2020, 10/4/2020, 10/9/2020, 10/14/2020, 10/17/2020, 10/18/2020 and 11/6/2020.
- 3:00 PM - 11:00 PM shift on: 10/6/2020, 10/10/2020 and 10/20/2020.
- 11:00 PM - 7:00 AM shift on 10/5/2020.

4. During an interview on 12/1/2020 at approximately 11:00 AM, the Assistant Director of Nursing Child/Adolescent (E#5) stated that the walking rounds should be completed every shift and documented on the log.

Based on document review and interview, it was determined that for 1 of 10 (Pt #3) clinical records reviewed for initial nursing treatment plans, the Hospital failed to ensure an initial nursing treatment plan was completed with goals and outcomes prior to Pt #3 signing the treatment plan.

Findings include:

1. On 12/1/2020, the Hospital's policy titled, "Master Plan for Care, Treatment and Service" (approved 10/2020) was reviewed and indicated, "...Admitting RN initiates the Initial Nursing Treatment Plan on admission within 24 hours of admission - documents primary psychiatric problem, and medical problems if relevant, identifies interventions that will be utilized...goals and outcomes for each identified problem and the target date for completion..."

2. On 12/1/2020, Pt #3's clinical record was reviewed and indicated the following:

-Pt #3 was admitted to the Hospital on 11/29/2020 with the diagnosis of paranoid schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly).

-Pt #3's initial nursing treatment plan, dated 11/29/2020, was blank (without any problems, goals or outcomes) and was signed by Pt #3 and a Registered Nurse (E #4) on 11/29/2020.

3. On 12/1/2020 at 10:20 AM, an interview was conducted with the Director of Nursing (E #2). E #2 stated that the initial nursing treatment plan should have been completed within 8 hours of admission and then signed. E #2 stated that the blank initial nursing treatment plan should not have been signed by the nurse and Pt #3.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Full Survey Due to a Complaint conducted on December 1, 2020, the facility failed to provide and maintain a safe environment for patients and staff.

This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of the Full Survey Due to a Complaint conducted on December 1, 2020, the facility does not comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with K-Tags.

Based on document review and interview, it was determined that for 1 of 10 (Pt #20) clinical records reviewed for psychiatric evaluations, the Hospital failed to ensure that the psychiatric evaluation was completed within 60 hours of admission, as required.

Findings include:

1. On 12/1/2020, the Hospital's policy titled, "Psychiatric Evaluation" (approved 10/2020) was reviewed and indicated, "Attending Psychiatrist - writes or dictates the psychiatric assessment within 24 hours of admission, which may serve as the Psychiatrist's admission note, and will include identifying data, chief complaint, mental status, history of present illness, past psychiatric history, medical history, family psychiatric history and personal/social/developmental history..."

2. On 12/1/2020, Pt #20's clinical record was reviewed and indicated the following:

-Pt #20 was admitted to the Hospital on 11/26/2020 with the diagnosis of schizophrenia (psychiatric disorder characterized by episodes of not functioning in reality).

-Pt #20's psychiatric evaluation & treatment plan, dated 11/26/2020, noted, "Pt #20 unable to be assessed because Pt #20 was in the shower..." Pt #20's psychiatric evaluation & treatment plan, dated 11/26/2020, lacked documentation of Pt #20's chief complaint, mental status examination and general intellectual functioning. Pt #20's clinical record lacked documentation of a complete psychiatric evaluation within 60 hours of admission, as the psychiatric evaluation was still not complete as of 12/01/2020.

3. On 12/3/2020 at 9:20 AM, an interview was conducted with Pt #20's Psychiatrist (MD #1). MD #1 stated that psychiatric evaluations should be completed within 24 hours of admission. MD #1 stated that MD #1 attempted to meet with Pt #20, but Pt. #20 was in the shower. MD #1 stated that MD #1 obtained information regarding Pt #20 from Pt #20's chart review and by speaking to Pt. #20's therapist.