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Based upon observation and interview the facility failed to provide and maintain adequate physical facilities for the safety and needs of the patients and was found not in compliance with the requirements for participation in Medicare and/or Medicaid at 42 CFR Subpart 482.41(b), Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19 Existing Health Care. Findings include

See the individually and below cited K-tags dated January 9, 2019.
K-0223
K-0321
K-0353
K-0355
K-0372
K-0712

Based on observation, interview, and document review, the facility failed to maintain a clean and sanitary environment resulting in the potential for transmission of infectious agents to all 256 patients in the facility. Findings include:

See Specific Tags:

A-0749 Failure to clean and sanitize 4 of 4 kitchenettes and 8 of 8 medication rooms; failure to change personal protective equipment during medication administration for 16 of 34 patients; failure to maintain a cleanable surface for 2 of 4 mattresses inspected; failure to clean 1 of 4 seclusion room floors; failure to keep food out of a clean work space

Based on observation, interview, and document review, the facility failed to maintain a clean and sanitary environment in 1) 4 of 4 kitchenettes and 8 of 8 medication rooms reviewed, 2) failed to change personal protective equipment during medication administration for 16 (#37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52) of 34 patients on the unit, 3) failed to have a cleanable surface for 2 of 4 mattresses inspected, 4) failed to clean 1 of 4 seclusion room floors viewed, and 5) failed to keep food out of a clean work area resulting in the potential for transmission of infectious agents to all 256 patients in the facility. Findings include:

1) During the initial tour of the facility on 1/7/2019 at 1033, the kitchenette between units S1 and S2 was entered. Upon opening the freezer, the three racks present were found to be rusty with speckled white color food stains on the floor of the freezer and on the inside of the door. The refrigerator door was opened and white color food stains and fluid drips that had dried were found to be present on all 3 interior walls and the interior door. Additionally, there were crumbs and a dark, sticky, dried area of fluid on the floor of the refrigerator. Two serving carts were found next to the refrigerator/freezer unit. Both carts had crumbs and other small paper debris as well as dried brown liquid spills present.

Further observations revealed cabinets on either side of the door leading into the dining area. 3 of the 8 lower cabinets and 5 of 16 drawer faces were found to have a dried, whitish-opaque substance streaking down the front of them. The corner of the cabinet door under the sink was found to be missing part of the laminate, exposing the wood underlayment. There was also damage present to the drawer front labeled "Food Cups" which exposed the wood underlayment of the drawer. 5 cupboard doors and 5 drawers were found to have stickers present that were curling at the edges with discoloration on the exposed adhesive portion of the sticker. Caulk between the counter and backsplash behind the sink was found to be cracked and black in color. 8 of 8 upper cabinets had debris, dried brown colored fluid stains, and sticky residue present. 3 of 8 of the upper cabinets also had varying amounts of unpackaged coffee grounds present that was littered over the bottom shelf of the cabinet. The interior of 10 of 16 drawers were found to have dust in the corners, dried dark brown liquid stains, and various small bits of debris present. 2 of 2 microwaves had dried food splatter present on all three walls, the ceiling and floor, as well as the door. These findings were all confirmed with Staff G at the time of discovery.

Staff G, who served as a tour guide, was queried on 1/7/2019 at 1045 as to who was responsible to clean the kitchenette to which he replied, "My guess is housekeeping or nursing. I don't know for a fact." He was then queried as to if food were prepared on site to which he replied, "No. It is brought in by (another nearby psychiatric facility.)"

On 1/7/2019 at 1355, the kitchenette between S3 and S4 was entered and found to have 3 of 3 racks/shelves which were rusted, dried/frozen food crumbs and fluid present on the floor of the freezer, as well as a thick, white-colored fluid streak running down the left interior wall. Dried food debris and streaks of dried fluid were found to be on the 3 side walls, interior door, and the floor of the refrigerator. Additionally, there were 3 buns and 1 sandwich individually wrapped in waxed paper present that were not labeled with date or name, and 4 2-liter bottles of soda which were opened and undated.

Dietician Staff X was queried on 1/7/2019 at 1400 as to if staff were expected to date food items in the refrigerator to which she stated, "Yes."

Further review of the S3/S4 kitchenette revealed 2 of 2 microwaves with dried food splatter present on the 3 interior walls, ceiling, floor and door. There were dried opaque streaks running down the front of the lower sink cabinet. 8 of 8 upper cabinets to have dust, food debris, and dried brown colored fluid stains present; 4 of 8 upper cabinets also had unpackaged coffee grounds in various amounts littering the lower shelf of the cabinet. 4 of 16 drawers had dust/dirt debris in the interior front corners. A large laminate strip was found to be missing from the front face of the countertop exposing the wood underlayment. Tape residue and residual was found to be present on 6 of 16 drawers. These findings were all confirmed by Staff D, X, and Y at the time of discovery.

The kitchenette between E1 and E2 was entered on 1/7/2019 at 1417 and was found to have frozen/dried food debris and fluid on the floor of the freezer. The refrigerator was found to have 4 opened 2-liters of pop present which were undated. Additionally, there were 12 small cartons of apple juice present that had no expiration date present. The serving cart next to the refrigerator/freezer unit was found to have small bits of food debris present on the second and third shelves. 6 of 8 upper cupboards had sticky shelves and various small bits of food debris present. 1 of 16 drawer fronts was missing. Inside the drawer with the missing front was sawdust mixed with other small bits of food and paper debris. The wood underlayment of the drawer was exposed where the drawer front was missing. A piece of laminate was missing from the corner of the countertop exposing the wood underlayment. There was a large amount of tape residual and residue present on the front of the ice machine. 2 of 2 microwaves had dried food debris present on the 3 interior walls and ceiling. 3 of 8 lower cabinets had small bits of food debris, dust, and dried brown fluid stains present. These findings were all confirmed by Staff D, X, and Y at the time of discovery.

On 1/7/2019 at 1425, Staff D stated that work orders had been made for some of the identified deficiencies. A request was made for the work order for review.

The kitchenette between E3 and E4 was entered on 1/7/2019 at 1434 and was found to have dried/frozen food particles and dried opaque fluid streaks present on the interior walls and floor of both the freezer and refrigerator. A piece of laminate was missing from the corner of the countertop exposing the wood underlayment of the cabinet. 2 of 8 upper cupboards contained a small amount of unpackaged coffee grounds and other small bits of food and paper debris present on the shelf. The shelf also contained an area of sticky brown fluid which had dried. 9 of 16 drawers had dried brown stains present on the outside of them while 6 of 16 drawers had dried brown fluid stains on the inside of them along with small bits of food and paper debris. Additionally, 2 of 2 microwaves were found to have dried food debris on the interior ceiling of the units. These findings were confirmed by Staff D at the time of discovery.

Staff D was queried on 1/7/2019 at 1444 as to who was responsible to clean the kitchenettes to which she replied, "The nursing supervisor on the unit is responsible for cleaning the kitchenettes."

Facility policy titled "Kitchen and Food Handling" last revised 7/2018 states, "Unit Supervisor will inspect the kitchen including the appliances, sinks, counter-tops, tables and waste containers for cleanliness at shift change and after serving food."

On 1/9/2019 at 1150, Director of the Physical Plant Staff R brought the maintenance log book and a "Service Request" for review. Staff R stated, "I've looked all the way back to the beginning of October and this is all I can find. If you'd like, I can continue to look." The log identified on 10/10/2018 that the "Front drawer face" from the E1/E2 kitchenette needed repair. The "Service Request" form #6320.R, also dated 10/10/2018, stated, "Brought drawer face back to shop-Cut support to fit and re-installed drawer front." The "Service Request" form showed a completed date of 10/15/2018.


2) While touring the S1 unit on 1/7/2019 at 1127, the medication room was entered and found to have sticker residual and adhesive residue present on the upper cupboard and a piece of laminate missing from the countertop. Upon looking in the freezer, dried fluid stains were present. These findings were confirmed by Staff G at the time of discovery.

Nurse Staff W was queried on 1/7/2019 at 1127 as to who was responsible to clean the medication room to which she stated, "I'm not sure. There is no scheduled cleaning time that I'm aware of."

While touring the S2 unit on 1/8/2019 at 0848, the medication room was entered and Nurse Staff AA was observed wearing a pair of gloves while passing oral medication to Patient #37. Upon completion, Staff AA accessed the computer and cupboard before opening a drawer on the medication cart and obtaining medication for Patient #38. Upon completion of giving Patient #38 his medications, Staff AA accessed the computer, rubbed both of her lower legs, put her hands in her pockets, and accessed the medication cart for the next patient's medication. All of these actions were completed without changing her gloves or performing hand hygiene. Continued observation revealed that Staff AA completed a medication pass for Patient #39, 40, 41, 42, 43, 44 45, 46, 47, 48, 49, 50, 51, and 52 without changing her gloves or performing hand hygiene between each one. After Patient #52 was given his medication, Staff AA shut the door to the medication room, cleaned off the counter, and stated that she would now begin to prepare for the next medication pass which would happen around lunch-time. She then removed her gloves and used hand sanitizer.

Staff AA was informed of the above observation and queried on 1/8/2019 at 0920 as to if she should change her gloves and perform hand hygiene between each patient to which she replied, "I guess you're right. I didn't change them in between...I didn't even realize I did that."

Further observations in the medication room revealed a 4-pack of Jell-O present in the refrigerator that had expired 1/12/2018 as well as a 6-pack of applesauce that had expired on 9/22/2018. Additionally, paper towels were stored on the counter next to the sink within the splash zone, dingy white tape was found to be present on the holder for the scanning tool and had a dark brown colored stain present, the computer mouse had multiple strips of clear adhesive tape present which were not completely affixed and had adhesive exposed, and a large strip of laminate was missing from the front of the countertop. These findings were all confirmed by Staff G at the time of discovery.

Director of Nursing Staff D was queried on 1/8/2019 at 1300 as to her expectations for changing gloves and hand hygiene during medication administration to which she replied, "It would be just like any other hospital. You should change gloves and sanitize or wash your hands between each patient."

Facility policy titled "Medication Administration" last revised 1/2019 states, "Wash hands immediately before preparing medications and after each direct patient contact...The medication nurse has the responsibility to maintain the medication room. The nurse must empty their own trash and restock necessary items..."


3) During the facility tour on 1/7/2019 at 1101, patient-ready room #S1-122 was entered and found to have a streak of dried opaque fluid running down the interior side of the glass viewing area on the door. The bare mattress was observed to be on the bed leaning against the wall. The bottom of the mattress had a myriad of small cracks which exposed the fabric mesh underneath covering most of the bottom of the mattress. The top side of the mattress was also inspected and found to have several small cracks which exposed the fabric mesh underneath as well. These findings were confirmed by Staff G at the time of observation.

Seclusion room #112 was entered on 1/7/2019 at 1112 and found to have a mattress on the floor leaning against the wall. Upon inspection, cracks were present exposing the mesh underlayment and small holes were also present.


4) During the facility tour on 1/7/2019 at 1112, seclusion room #112 was entered and the floor was found to have multiple large swirls and streaks of a brownish-yellow dried fluid substance present. These findings were confirmed by Staff G at the time of observation.

Staff G was queried on 1/7/2019 at 1113 as to what was on the floor to which he stated, "I know what it looks like, but I don't know for sure what it is."

On 1/8/2019 at 1600, a policy regarding cleaning of the environment and equipment, as it was not found within the infection control policy, was requested of Staff B; however, Staff B reported back on 1/9/2019 at 0855 that no policy could be found.





02967

1) On January 7, 2019 at 1130 during the tour of the facility it was noted that the reach-in refrigerators and freezers in all four kitchenettes lacked inside thermometers. The outside temperature gauges were off calibrations showing a range of 44 to 46 degrees Farenheit (F) temperature for both the refrigerators and freezers. Per Michigan food code the temperature for cold food is to be 41 degrees F or below.

On January 7, 2019 at 1330 during the tour of the facility it was noted that stacks of clean paper towel and cups stored on the sink counter at the splash zone (within two-three feet from the sink) in all eight medication rooms, serving patient care units.

On January 7, 2019 at 1330 during the tour of the facility it was noted that numerous supplies, including juice containers, brown paper bags, bedpans, cleaning supplies, and space fans were noted to be stored on top of medication refrigerators in all eight medication rooms, serving the patient care units.

5) On January 8, 2019 at 1030 during the tour of the facility it was noted that the Pharmacy work place contained numerous food items, and an employee food refrigerator.

The above findings were confirmed at the time of observation with staff "R'" and "S".

Based on document review, record review, observations and interviews, the facility failed to:

I. Ensure that active treatment measures, such as group and/or individual treatment, were provided for two (2) patients (B2 and B3), added to the sample in order to evaluate active treatment. Specifically, Patients B2 and B3 were unable or unwilling to attend their scheduled treatment groups and failed to have alternative treatments listed on their Master Treatment Plans (MTPs). Failure to provide active treatment results in the affected patient being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement. (Refer to B125-I).

II. Provide therapeutic and leisure groups to address the needs of patients who were not assigned groups in the Treatment Mall or who were on unit restriction and could not go to the Treatment Mall. In addition, there were limited leisure and therapeutic activities provided in the evenings and on week-ends. Failure to provide scheduled treatment activities that address individual patient needs prevents the patient from learning new ways of coping and can delay the recovery process. (Refer to B125-II)

Based on record review and interview, the facility failed to provide Master Treatment Plans (MTPs) that identified individualized patient-related, long-term and short-term goals in observable, measurable behavioral terms. This has the potential to result in a document that fails to identify expected treatment outcomes in a manner that can be understood by treatment staff and patients in eight (8) of eight (8) records reviewed. (A1, A2, A3, A4, A5, A6, A7 and A8).

Findings Include:

A. Medical Record Review

1. Patient A1's MTP dated 1/15/18, listed for the Problem "Psychotic Disorder with Delusions," the following non-measurable Short Term Goals (STGs) with a Target Date of 06/10/19:
- "[Patient A1]'s history of hallucinations and disorganized thinking will diminish to the extent that [s/he] is able to engage in a focused conversation with peers or staff for 15 minutes per shift."
- "[Patient A1] will acknowledge once per week that [s/he] has a mental illness."

2. Patient A2's MTP dated 11/20/18, listed for the Problem "Psychosis," the following non-measurable Long Term Goal (LTG) with a Target Date of 11/20/19:
- "[Patient A2] will increase reality testing as psychotic processing decreases. [S/he] will decrease [his/her] symptoms to the point where discharge is possible. [S/he] will increase [his/her] understanding of [his/her] mental illness and compliance with necessary medication."

3. Patient A3's MTP dated 12/20/18, listed for the Problem "Psychosis," the following non-measurable STG:
- "[Patient A3] will verbalize the connection between the crime and [his/her] mental illness and discuss this with clinician. [Patient A3] will identify symptoms of the illness during individual therapy."

4. Patient A4's MTP Scheduled Review dated 1/17 /19, listed for the Problem "Psychosis," the following non-measurable LTG with a Target Date of 1/17/20:
- "[Patient A4] will increase [his/her] understanding of [his/her] mental illness and compliance with necessary medication."

5. Patient A5's MTP dated 1/17/19, listed for the Problem "Psychosis," the following non-measurable STG:
- "[Patient A5]'s thought disorder will improve to the extent that [s/he] is able to participate in individual therapy for 30 minutes 2 times per week."

6. Patient A6's MTP dated 1/8/19, listed for the Problem "Psychosis," the following non-measurable LTG: (There was no STG listed for this problem.)
- "[Patient A6] will increase reality testing as psychotic processing decreases."

7. Patient A7's MTP dated 11/19/18, listed for the Problem "Psychosis," the following non-measurable STG:
- "[Patient A7] will increase [his/her] understanding of [his/her] mental illness and compliance with necessary medications."

8. Patient A8's MTP dated 2/4/19, listed for the Problem "Psychotic Disorder," the following non-measurable STG:
- "[Patient A8] will identify coping skills."

B. Interviews:

1. During an interview on 2/12/19 at 12:30 p.m., the Director of Nursing (DON) and the Director of Quality Improvement voiced an understanding that the specific goals were non-measurable.

2. During an interview on 2/13/19 at 9:45 a.m., the Director of Social Services confirmed that there was not a hospital policy to define requirements for documenting observable, measurable behavioral STGs on the hospital's Master Treatment Plans.

3. During an interview on 2/13/19 at 10:45 a.m., the findings regarding short-term and long-term goals were discussed with the Acting Clinical Director who did not disagree with the findings.

Based on record review and interview, the hospital failed to develop treatment interventions based on the individual needs of the patients for eight (8) of eight (8) patients (A1, A2, A3, A4, A5, A6, A7 and A8). Treatment interventions listed only routine discipline functions rather than individualized treatment options. This practice has the potential to lead to failure of individualized treatment interventions and to result in staff being unable to provide direction, consistent approaches, and focused treatment for patients' identified problems.

Findings Include:

A. Medical Record Review

1. Patient A1's Master Treatment Plan (MTP) dated 1/15/18, listed the Short-Term Goal (STG), "[Patient A1]'s history of hallucinations and disorganized thinking will diminish to the extent that [s/he] is able to engage in a focused conversation with peers or staff for 15 minutes per shift." The only RN intervention listed on the MTP for this goal was, "Unit RN: See Nursing Care Plan."

2. Patient A2's MTP dated 11/20/18, listed the Long-Term Goal (LTG), "[Patient A2] will increase reality testing as psychotic processing decreases. [S/he] will decrease [his/her] symptoms to the point where discharge is possible. [S/he] will increase [his/her] understanding of [his/her] mental illness and compliance with necessary medication." The generic RN Intervention listed for this goal was, "Unit RN will administer medication and explain side effects to [Patient A2] as needed."

The Forensic Security Aide's (FSA's) generic, routine intervention was, "Unit FSA will offer [patient] the use of the quiet room and/or the resource cart when [he/she] is observed to become agitated or anxious."

3. Patient A3's MTP dated 12/20/18, listed the STG "[Patient A3] will verbalize the connection between the crime and [his/her] mental illness and discuss this with clinician. [Patient A3] will identify symptoms of the illness during individual therapy." The generic nursing intervention listed for this goal was, "RN will administer medication as ordered and explain side effects to [Patient A3] as needed."

4. Patient A4's MTP Scheduled Review dated 1/17 /19, listed the LTG, "[Patient A4] will increase [his/her] understanding of [his/her] mental illness and compliance with necessary medication." The generic nursing intervention for this goal was "Unit RN will offer [Patient A4] a PRN [as needed medication] when [s/he] is observed to become agitated."

The FSA generic intervention for this goal was, "Unit FSA will offer [Patient A4] the use of the quiet room and or the resource cart as needed when [s/he] is observed to be becoming agitated."

5. Patient A5's MTP dated 1/17/19, listed the STG, "[Patient A5]'s thought disorder will improve to the extent that [s/he] is able to participate in individual therapy for 30 minutes 2 times per week." The routine, generic nursing interventions for this STG was, "Unit RN will offer [Patient A5] a PRN when [s/he] is observed to become agitated. RN will administer medication as ordered and explain side effects to [Patient A5] ...."

6. Patient A6's MTP dated 1/8/19, listed the LTG, "[Patient A6] will increase reality testing as psychotic processing decreases." The routine, generic nursing interventions listed for this STG was, "RN will offer support and praise for positive, focused interactions. Unit RN will offer [Patient A6] a PRN when [he/she] is observed to become agitated."

7. Patient A7's MTP dated 11/19/18, listed the STG, "[Patient A7] will increase [his/her] understanding of [his/her] mental illness and compliance with necessary medications." The routine generic Psychiatrist intervention listed was, "Psychiatrist will prescribe and monitor medications to help control psychotic processing." The only nursing intervention listed for this Problem was "See Nursing Care Plan."

8. Patient A8's MTP dated 2/4/19, listed the STG, "[Patient A8] will identify coping skills." The generic routine Psychiatrist intervention listed was "Psychiatrist will prescribe and monitor medications to help control psychotic processing." The only RN intervention listed for this problem was "See Nursing Care Plan."

B. Interviews:

1. During an interview on 2/12/19 at 12:30 p.m., the Director of Nursing (DON) acknowledged that the nursing interventions were generic, would be done for all patients, and were not individualized.

2. During an interview on 2/13/19 at 9:45 a.m., the Director of Social Services confirmed that there was not a policy to define requirements for documenting individualized patient interventions on the hospital's Master Treatment Plans.

3. During an interview on 2/13/19 at 10:45 a.m., the findings regarding the interventions on the MTP were discussed with the Acting Clinical Director who did not disagree with the findings.

Based on document review, observations and interviews, the facility failed to:

I. Ensure that active treatment measures, such as group and/or individual treatment, were provided for two (2) patients (B2 and B3), that were added to the sample in order to evaluate active treatment. Specifically, patients B2 and B3 were unable or unwilling to attend their scheduled treatment groups and failed to have alternative treatments listed on their Master Treatment Plans (MTPs). Failure to provide active treatment results in the affected patient being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement.

II. Provide therapeutic and leisure groups to address the needs of patients who were not assigned groups in the Treatment Mall or were on unit restriction and could not go to the Treatment Mall. In addition, there were limited leisure and therapeutic activities provided in the evenings and on week-ends. Failure to provide scheduled treatment activities that address individual patient needs prevents the patient from learning new ways of coping and can delay the recovery process.

Findings Include:

I. Failure to Provide Active Treatment

A. Specific Patient Findings

1. Patient B2 was admitted on 12/21/1990. The Annual Psychiatric Evaluation, dated 1/15/18, stated that the patient was admitted after being found NGRI (Not Guilty by Reason of Insanity) for a murder committed while the patient was in a psychotic state. His/her current condition was described as continuing to have hallucinations along with grandiose and paranoid delusions.

The MTP Scheduled Review, dated 12/6/18, stated under "Summary of Progress Toward Treatment" that Patient B2, " ...continues to present with active psychotic symptoms, including auditory hallucinations evidenced by responding to internal stimuli and delusional ideations ...[s/he] mostly follows unit rules and will mainly keep to [her/himself] on the unit. [S/he] enjoys to [sic] clean tables, but no longer goes to groups." The MTP included the following interventions:

- "Psychologist will encourage [Patient] to attend once a week for 50 minutes in Legal Matters group to increase [his/her] understanding of the role of mental illness in the NGRI offense," and "Rehabilitation Service staff will provide a minimum of two (2) on unit weekly therapeutic groups one (1) hour each (i.e. Personal Interest, Wellness)."

The MTP also listed the Short-Term Goal (STG), "[Patient] will attend a minimum of two (2) Rehab Services groups for 50 minutes each per week. [S/he] will engage in reality based conversation two (2) times per group and focus on task/group focus for 40 minutes per group."

Review of the weekly personal schedule for Patient B2 showed that s/he was scheduled for seven (7) groups per week and two (2) Individual PSR sessions (Psychosocial Rehab sessions). The schedule showed "Unassigned" after 11:10 a.m. on Monday-Thursday and "Unit Special Event" from 1:00 p.m.-3:00 p.m. on Friday. Review of the Posted Program List revealed that there were no scheduled unit groups from 1:00 p.m.-3:00 p.m. on Friday.

During observation on Unit South 4 on 2/11/19 from 1:00 p.m-2:30 p.m., Patient B2 was observed in the dining room, wiping down tables and washing the countertops with soap and water. During observation on Unit South 4 on 2/12/19 from 1:45 p.m.-2:15 p.m., Patient B2 was observed sitting in the dayroom watching television.

During interview on 2/11/19 at 1:00 p.m., FSA1 and FSA3 stated that Patient B2 never went to groups even though s/he had groups listed on his/her weekly personal schedule. FSA1 further stated that Patient B2 was too psychotic to go to groups. During this same time, when asked if Patient B2 received money for cleaning the tables, FSA4 responded that s/he did not get paid but got a cup of coffee when finished. FSA4 added that the patient did not always clean the tables and if s/he didn't, one of the FSAs would clean. Patient B2's MTP did mention cleaning tables but did not identify that task as an intervention to a specific problem and goal.

Although the surveyor attempted to interview Patient B2, the patient refused.

2. Patient B3 was admitted on 11/16/15. The Annual Psychiatric Evaluation dated 11/29/18 stated that the patient was found Incompetent to Stand Trial (IST) on a Felonious Assault Charge due to " ...overt psychosis and inability to rationally communicate."

The MTP Update, dated 11/30/19, described Patient B3 as, "[Patient B3] continues to be disorganized in [his/her] thoughts and has paranoid and delusional beliefs. Often observed talking and laughing to self." The MTP included the following interventions:
- "The Psychologist will offer to meet with [Patient B3] once a week for 50 minutes in a supportive psychotherapeutic group, Positive Psychology, to facilitate the experience of positive emotions, the development of personal strengths and the improvement of one's sense of self-efficacy," and "The Rehabilitation Therapist will include [Patient B3] in weekly 50 minute groups, both on and off unit."
- The MTP also listed a short-term goal that stated, "[Patient B3] will participate in at least one (1) Rehabilitation Services Group per week and focus on task for at least 30 minutes with no redirecting from therapist." The only acknowledgment that Patient B3 was not attending groups was under the "Summary of Progress Toward Treatment" section of the MTP which stated, "Lack of Participation-Patient has been offered special meal incentive if [s/he] attends two (2) PSR (Psychosocial Rehab) groups per week."

Review of the weekly personal schedule for Patient B3 showed that s/he was scheduled for nine (9) groups per week on the unit. The schedule showed "Unassigned" after 11:05 a.m. on Monday-Friday. The facility could not produce any documentation that Patient B3 attended any of his/her assigned groups.

During observations on Unit South 4 on 2/11/19 from 1:00 p.m.-2:30 p.m., Patient B3 was observed standing at the end of the hallway looking out the window. S/he paced the halls and then sat for a while in the dayroom before pacing again. During observations on Unit South 4 on 2/12/19 from 1:45 p.m.-2:15 p.m., Patient B3 was observed sitting in a chair in the dayroom. There was a Leisure Skills group being offered to anyone wanting to participate on the unit.

During an interview on 2/11/19 at 1:00 p.m., FSA1 and FSA3 stated that Patient B3 never goes to group and had not for a long time. Both acknowledged that s/he did have a schedule with assigned groups on it.

During an interview on 2/11/19 at 2:00 p.m. with Patient B3, when asked about going to groups, Patient B3 stated, "I don't go to groups. I have a Ph.D. so why should I go. I am the [mother/father] of all the children in the world."

II. Failure to Provide Therapeutic and Leisure Groups:

A. Observations:

1. During observation on Unit South 4 on 2/11/19 at 1:15 p.m., the census was reported to be 30 patients. Sixteen of the patients were at the Treatment Mall and the remaining 14 were on the unit. There were no therapeutic or leisure groups being offered on the unit. Patients were sleeping at tables and in chairs in the dayroom, watching television or walking the hallway. During observation on Unit South 4 at 2:15 p.m., 19 patients were on the unit (11 were at the Treatment Mall). There were no therapeutic or leisure groups being offered on the unit and patients were sleeping at tables and in chairs in the dayroom, watching television or walking the hallway.

2. During observation on Unit East 1 on 2/11/19 at 1:35 p.m., QA, RN1 and the surveyor confirmed that there were 13 of 29 patients on the unit not engaged in any therapeutic activities. Patients were sitting idly in the dayroom or walking around the unit.

3. During observation on Unit South 1 on 2/11/19 at 2:30 p.m., the census was reported to be 32 patients. Seven (7)patients were at the Treatment Mall and the remaining 25 were on the unit. There were no unit scheduled groups on the Posted Program List for Unit South 1 and patients were sitting in the dayroom, sleeping in chairs, walking around or watching television.

4. During observation on Unit South 2 on 2/12/19 at 1:20 p.m., the census was 32 patients. Five (5) patients were at the Treatment Mall and the remaining 27 were on the unit. Six (6) patients were sleeping in chairs and the others were watching television or walking around the unit. There were no therapeutic activities being offered on the unit.

5. During observation on Unit South 1 on 2/12/19 at 1:37 p.m., the census was reported to be 33 patients. Ten patients were in a unit Arts and Crafts group, four patients were at the Treatment Mall and the remaining 19 patients were on the unit sleeping in chairs, watching television or walking around the unit.

6. During observation on Unit South 4 on 2/12/19 at 1:43 p.m., the census was reported to be 30 patients. Five (5)patients were in a unit Leisure group, six patients were at the Treatment Mall and the remaining 19 patients were on the unit sleeping in chairs, watching television or walking around the unit.

7. During observation on Unit East 2 on 2/12/19 at 1:45 p.m., the QA, RN1 and the surveyor observed five (5) patients in the library area either asleep or lying in the chairs and not using the library. Staff informed the surveyor that the patients were in the library because their group had been cancelled.

8. During observation on Unit South 4 on 2/12/19 at 2:00 p.m., the census was reported to be 30 patients. Seven (7) patients were at the Treatment Mall and the remaining 23 patients were on the unit. There were no therapeutic or leisure activities scheduled on the Posted Program List and no activity was occurring. The patients were either watching television, sleeping in the chairs or walking around the unit.

B. Interviews:

1. During an interview on 2/11/19 at 1:00 p.m., FSA3 who was asked what the patients did if they were not in group, replied that they were free to watch television, play cards or go to the library on the unit.

2. During an interview on 2/11/19 at 1:30 p.m., Patient A1 stated that there were groups in the Treatment Mall that s/he had asked to attend but s/he had to wait until there was room for her/him. One of the groups was the Saturday morning Coffee Club that s/he had been waiting for weeks to get into. When asked about week-end groups, Patient A1 stated that week-ends were "our days" to do what we want. When asked if there were activities on the unit on week-ends, s/he stated that it depended on who was working.

3. During an interview on 2/11/19 at 3:00 p.m., Patient A2, when asked about week-end activities responded that s/he got up, ate breakfast, went back to bed, ate lunch and described his/her week-end activity as, "basically just eat and sleep."

4. During an interview on 11/12/19 at 11:25 a.m., the Director of Psychology, the Director of Social Services, Rehab Manager 1, Rehab Manager 2, and the Acting Clinical Director noted that groups on the unit occurred between 9:00 a.m. and 11:00 a.m. Additional treatment activities occurred in the Treatment Mall in the afternoon between 1:00 p.m. and 3:00 p.m. For those patients who were Unit Restricted and unable to attend off unit activities, there were no afternoon activities and the patients' schedules noted "Unassigned." These Directors also confirmed that there were only minimal leisure and therapeutic activities scheduled for evenings and week-ends. It was also shared that none of the Social Workers, Psychologists or Rehab Therapists work in the evenings or on week-ends.

5. During an interview on 11/12/19 at 11:50 a.m., the surveyor shared Patient A3's weekly individual schedule with the Acting Clinical Director. The schedule showed that Patient A3 was working on the Janitorial Crew from 9:10 a.m.-11:05a.m. and 1:00 p.m.-3:00 p.m. on Mondays, and from 9:10 a.m.- 10:00 a.m. on Tuesdays. The other groups scheduled for the week included Volleyball, Fitness (2 groups), Soccer, Walking, Education (school) , Pathways to Recovery, Social Skills and NGRI (Not Guilty by Reason of Insanity) groups. The Acting Director remarked "So, [s/he] is only scheduled for three therapeutic groups a week."

6. During an interview on 2/12/19 at 12:55 p.m., Patient A7 stated that the "Unassigned" sections on his/her personal schedule were times when s/he could "lay [her/his] head down, watch TV, walk around the unit, use the computer ..." S/he further indicated that the unassigned time meant that s/he could determine how to spend the time. S/he stated that week-ends were free time spent relaxing, laying down on the sofa, etc. S/he stated that "staff don't do groups." Patient A7 had her/his weekly schedule and confirmed that except for three hours during the afternoon when s/he had Yoga, Fitness, and Arts and Leisure, s/he had all unassigned time for the remainder of the week.

7. During an interview on 2/12/19 at 1:05 p.m., Patient A8 indicated that unassigned time on the schedule was essentially free time. Upon review of Patient A8's individualized schedule, which was in her/his possession, s/he confirmed that the "Unassigned Time" on the schedule on Monday through Friday after 11:05 a.m., until evening, was free/leisure/relax time except for "Drawing and Painting" on Tuesday and Wednesday from 2:00 p.m. until 3:00 p.m. S/he further confirmed that week-end time was essentially free time as well.

8. During an interview on 2/12/19 at 2:00 p.m., FSA7 stated that patients who did not go off the unit could engage in various self-selected activities including games, television, etc. Upon questioning if there were regularly scheduled groups/activities for patients who could not leave the unit, she stated, "We just wing it."

Based on document review, record review, observations, video review and interviews, the facility failed to:

I. Ensure that the Acting Clinical Director monitored active treatment and took needed corrective action. Specifically, the Acting Clinical Director failed to:

A. Ensure the provision of Treatment Plans that identified individualized, patient-related long- and short-term goals in observable, measurable behavioral terms. This has the potential to result in a document that fails to identify expected treatment outcomes in a manner that can be understood by treatment staff and patients in eight (8) of eight (8) records reviewed. (A1, A2, A3, A4, A5, A6, A7, and A8) (Refer to B144).

B. Ensure the development of treatment interventions based on the individual needs of the patient for eight (8) of eight (8) patients in the sample (A1, A2, A3, A4, A5, A6, A7 and A8). Treatment interventions listed only routine discipline functions rather than individualized treatment options. This practice has the potential to lead to failure of individualized treatment interventions and has the potential to result in staff being unable to provide direction, consistent approaches, and focused treatment for patients' identified problems. (Refer to B144).

C. Ensure that active treatment measures, such as group and/or individual treatment, were provided for two (2) patients (B2 and B3) that were added to the sample in order to evaluate active treatment. Specifically, Patients B2 and B3 were unable or unwilling to attend their scheduled treatment groups and failed to have alternative treatments listed on their Master Treatment Plans (MTPs). Failure to provide active treatment results in the affected patient being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement. (Refer to B144).

D. Ensure the provision of therapeutic and leisure groups to address the needs of patients who were not assigned groups in the Treatment Mall or were on unit restriction and could not go to the Treatment Mall. In addition, there were limited leisure and therapeutic activities provided in the evenings and on week-ends. Failure to provide scheduled treatment activities that address individual patient needs prevents the patient from learning new ways of coping and can delay the recovery process. (Refer to B144).

II. Ensure that the Director of Nursing monitored nursing input into the Treatment Plan and deployed staff in such a manner that patients and staff were in a safe environment and RNs were readily available to assess patients and supervise the patient care given by FSAs. Specifically, the Director of Nursing failed to:

A. Ensure the development of nursing interventions based on the individual needs of the patient for eight (8) of eight (8) patients in the sample (A1, A2, A3, A4, A5, A6, A7 and A8). Nursing interventions listed only routine discipline functions rather than individualized treatment options or simply referred to another document that was not a part of the MTP (Nursing Care Plan). This practice does not allow the nursing staff and other disciplines to know what the nursing staff should be addressing in the way of individual interventions and has the potential to result in nursing staff being unable to provide direction, consistent approaches, and focused treatment for patients' identified problems. (Refer to B148).

B. Deploy adequate numbers of Forensic Security Aides (FSAs) to ensure safety of staff and patients. Specifically, Forensic Security Supervisor 1 (FSS1) was working as a FSA on the night of 1/23/19 and was assigned to work alone in an upstairs sleeping area with 21 male patients on Unit East 2. While monitoring the patient sleeping area, FSS1 was attacked by Patient B1. Another patient, B4, pulled Patient B1 off FSS1 before staff could respond from the first floor. Failure to provide adequate numbers of FSAs to ensure the safety of staff and patients can lead to negative outcomes and preventable injuries. (Refer to B150-I)

C. Deploy adequate numbers of Registered Nurses (RNs) to provide for the assessment of patients and supervision of the FSAs providing care to patients. On the "midnight" shift the usual staffing on all units was one (1) to one-and-a-half (1.5) RNs. All units were designed so that 10 patients slept on the first floor and twenty (plus) patients slept on the second floor. The stairwell on the first floor was open (no door) and the door to the second floor was open when patients were on the second floor. A FSA was assigned to monitor the second floor cameras from the nurses' station on the first floor. The practice was for the RN to be stationed on the first floor and to round on the second floor three (3) times a night. Failure to deploy RNs in numbers that are readily available to assess patients and supervise the care being given by FSAs, can lead to escalating patient behavior, staff and patient safety issues and failure to meet individual patient care needs. (Refer to B150-II).

Based on medical record review, observation, and interview, the Acting Clinical Director failed to ensure:

1. The provision of Treatment Plans that identified individualized patient-related long- and short-term goals in observable, measurable behavioral terms. This has the potential to result in a document that fails to identify expected treatment outcomes in a manner that can be understood by treatment staff and patients in eight (8) of eight (8) records reviewed. (A1, A2, A3, A4, A5, A6, A7, and A8). (Refer to B121).

2. The development of treatment interventions based on the individual needs of the patient for eight (8) of eight (8) patients in the sample (A1, A2, A3, A4, A5, A6, A7 and A8). Treatment interventions listed only routine discipline functions rather than individualized treatment options. This practice has the potential to lead to failure of individualized treatment interventions and has the potential to result in staff being unable to provide direction, consistent approaches, and focused treatment for patients' identified problems. (Refer to B122).

3. Active treatment measures, such as group and/or individual treatment, were provided for two (2) patients (B2 and B3) that were added to the sample in order to evaluate active treatment. Specifically, Patients B2 and B3 were unable or unwilling to attend their scheduled treatment groups and failed to have alternative treatments listed on their Master Treatment Plans (MTPs). Failure to provide active treatment results in the affected patient being hospitalized without all interventions for recovery being delivered in a timely fashion, potentially delaying their improvement. (Refer to B125-I).

4. The provision of therapeutic and leisure groups to address the needs of patients who were not assigned groups in the Treatment Mall or were on unit restriction and could not go to the Treatment Mall. In addition, there were limited leisure and therapeutic activities provided in the evenings and on week-ends. Failure to provide scheduled treatment activities that address individual patient needs prevents the patient from learning new ways of coping and can delay the recovery process. (Refer to B125-II).

Interview:

During an interview on 2/13/19 at 10:45 a.m., the findings regarding short and long-term goals, treatment interventions, and active treatment were discussed with the Acting Clinical Director who did not disagree with the findings.

Based on record review and interview, the Director of Nursing failed to:

1. Ensure the development of nursing interventions based on the individual needs of the patient for eight (8) of eight (8) patients (A1, A2, A3, A4, A5, A6, A7 and A8). Nursing interventions listed only routine discipline functions rather than individualized treatment options or simply referred to another document that was not a part of the MTP (Nursing Care Plan). This practice does not allow the nursing staff and other disciplines to know what the nursing staff should be addressing in the way of individual interventions and has the potential to result in nursing staff being unable to provide direction, consistent approaches, and focused treatment for patients' identified problems.

Findings Include:

1. Patient A1's Master Treatment Plan (MTP) dated 1/15/18, listed the Short-Term Goal (STG), " [Patient A1]'s history of hallucinations and disorganized thinking will diminish to the extent that [s/he] is able to engage in a focused conversation with peers or staff for 15 minutes per shift." The only RN intervention listed on the MTP for this goal was, "Unit RN: See Nursing Care Plan."

2. Patient A2's MTP dated 11/20/18, listed the Long-Term Goal (LTG), "[Patient A2] will increase reality testing as psychotic processing decreases. [S/he] will decrease [her/his] symptoms to the point where discharge is possible. [S/he] will increase [her/his] understanding of [her/his] mental illness and compliance with necessary medication."

The generic RN Intervention listed for this goal was, "Unit RN will administer medication and explain side effects to [Patient A2] as needed."

The Forensic Security Aide's (FSA's) generic, routine intervention was, "Unit FSA will offer [Patient A2] the use of the quiet room and/or the resource cart when [he/she] is observed to become agitated or anxious."

3. Patient A3's MTP dated 12/20/18 listed the STG, "[Patient A3] will verbalize the connection between the crime and [his/her] mental illness and discuss this with clinician. [Patient A3] will identify symptoms of the illness during individual therapy." The generic nursing intervention listed for this goal was, "RN will administer medication as ordered and explain side effects to [Patient A3] as needed."

4. Patient A4's MTP Scheduled Review dated 1/17 /19, listed the LTG, "[Patient A4] will increase [his/her] understanding of [his/her] mental illness and compliance with necessary medication."

The generic nursing intervention for this goal was "Unit RN will offer [Patient A4] a PRN [as needed medication] when [s/he] is observed to become agitated."

The FSA generic intervention for this goal was, "Unit FSA will offer [Patient A4] the use of the quiet room and or the resource cart as needed when [s/he] is observed to be becoming agitated."

5. Patient A5's MTP dated 1/17/19, listed the STG, "[Patient A5]'s thought disorder will improve to the extent that [s/he] is able to participate in individual therapy for 30 minutes two (2) times per week."

The routine, generic nursing interventions for this STG was, "Unit RN will offer [Patient A5] a PRN when [s/he] is observed to become agitated. RN will administer medication as ordered and explain side effects to [Patient A5] ...."

6. Patient A6's MTP dated 1/8/19, listed the LTG, "[Patient A6] will increase reality testing as psychotic processing decreases."

The routine, generic nursing interventions listed for this STG was, "RN will offer support and praise for positive, focused interactions. Unit RN will offer [Patient A6] a PRN when [he/she] is observed to become agitated."

7. Patient A7's MTP dated 11/19/18 listed the STG, "[Patient A7] will increase [his/her] understanding of [his/her] mental illness and compliance with necessary medications."

The only nursing intervention listed for this Problem was "See Nursing Care Plan."

8. Patient A8's MTP dated 2/4/19 listed the STG, "[Patient A8] will identify coping skills."

The only RN intervention listed for this problem was "See Nursing Care Plan."

Interview:

During an interview on 2/12/19 at 12:30 p.m., the Director of Nursing (DON) acknowledged that the nursing interventions were generic, would be done for all patients, and were not individualized.

I. Deploy adequate numbers of Forensic Security Aides (FSAs) to ensure safety of staff and patients. Specifically, Forensic Security Supervisor 1 (FSS1) was working as a FSA on the night of 1/23/19 and was assigned to work alone in an upstairs sleeping area with 21 male patients on Unit East 2. While monitoring the patient sleeping area, FSS1 was attacked by Patient B1. Another patient, B4, pulled Patient B1 off FSS1 before staff could respond from the first floor. Failure to provide adequate numbers of FSAs to ensure the safety of staff and patients can lead to negative outcomes and preventable injuries. (Refer to B150-I).

II. Deploy adequate numbers of Registered Nurses (RNs) to provide for the assessment of patients and supervision of the FSAs providing care to patients. On the "midnight" shift the usual staffing on all units is one (1) to one-and-a-half (1.5) RNs. All units are designed so that 10 patients sleep on the first floor and twenty (plus) patients sleep on the second floor. The stairwell on the first floor is open (no door) and the door to the second floor is open when patients are on the second floor. A FSA is assigned to monitor the second floor cameras from the nurses' station on the first floor. The practice is for the RN to be stationed on the first floor and to round on the second floor three (3) times a night. Failure to deploy RNs in numbers that are readily available to assess patients, de-escalate behavior when needed, mentor and supervise the care being given by FSAs, can lead to escalating patient behavior, staff and patient safety issues and failure to meet individual patient care needs. (Refer to B150-II).

Based on document review and interviews, the facility failed to:

I. Deploy adequate numbers of Forensic Security Aides (FSAs) to ensure safety of staff and patients. Specifically, Forensic Security Supervisor 1 (FSS1) was working as a FSA on the night of 1/23/19 and was assigned to work alone in an upstairs sleeping area with 21 male patients on Unit East 2. While monitoring the patient sleeping area, FSS1 was attacked by Patient B1. Another patient, B4, pulled Patient B1 off FSS1 before staff could respond from the first floor. Failure to provide adequate numbers of FSAs to ensure the safety of staff and patients can lead to negative outcomes and preventable injuries.

II. Deploy adequate numbers of Registered Nurses (RNs) to provide for the assessment of patients and supervision of the FSAs providing care to patients. On the "midnight" shift the usual staffing on all units is one (1) to one-and-a-half (1.5) RNs. All units are designed so that 10 patients sleep on the first floor and twenty (plus) patients sleep on the second floor. The stairwell on the first floor is open (no door) and the door to the second floor is open when patients are on the second floor. A FSA is assigned to monitor the second floor cameras from the nurses' station on the first floor. The practice is for the RN to be stationed on the first floor and to round on the second floor three (3) times a night. Failure to deploy RNs in numbers that are readily available to assess patients, de-escalate behaviors when needed, mentor and supervise the care being given by FSAs, can lead to escalating patient behavior, staff and patient safety issues and failure to meet individual patient care needs.

Findings Include:

I. FSA Deployment

A. Document Review

1. The Incident Report (3649) IR-190123-0339-E2-PSA, dated 1/23/19, revealed that a FFS1 was working that night in the role of a FSA and monitoring patients who were sleeping on the second floor of Unit East 2. The report stated that Patient B1 was taken downstairs at 3:10 a.m. by the FSA who was being relieved by FSS1. The patient was delusional and upset about a peer touching him inappropriately. Patient B1 saw the RN downstairs and was encouraged to go back to bed. The RN then rounded on the second floor and talked with FSS1 regarding Patient B1. Patient B1 later came out of his room, approached FSS1 and hit FSS1 in the face several times with his fists. Another patient, B4, grabbed Patient B1 and pulled him off FSS1. This was witnessed on a downstairs monitor that was being watched by a FSA who activated the duress call at 3:40 a.m.

2. Review of the report presented by the Director of Safety and Security on 2/13/19 at 10:15 a.m., revealed FSS1's statements that Patient B4 placed Patient B1 " ...in a headlock and I went to the stairs and yelled to the staff downstairs that I needed assistance upstairs." During interview with the Director of Safety and Security at this same time, the Director referred to Patient B4 as the "Patient that saved [FFS1]."

3. Review of the video of the incident at 10:30 a.m. on 2/13/19 revealed that FSS1 was seated in a chair at the end of the hall closest to the stairwell. Patient B1 approached FSS1 and was yelling. The patient then began to hit FSS1 in the face and head with his fists. Another patient, B4, pulled Patient B1 away from FSS1 who ran to the stairwell, out of camera view. FSS1 could be heard yelling for help. Patient B1 could be seen walking back down the hall. FSAs from downstairs were seen on the camera within a minute of the call for help, with the RN arriving after the FSAs had intervened. It was observed in the video, and verified by the Director of Safety and Security, that FSS1 was not wearing the Personal Protective Device (PPD) which is expected when working on the second floor.

4. Review of the Direct Nursing Staffing Forms for 2/3/19-2/9/19 revealed that the mid-night shift had four (4) FSAs assigned to five (5) of the eight (8) units. The other three (3) had six to eight (6-8) assigned due to patients on special precautions/observations. FSAs are supervised by FSSs who report ultimately to the DON. The staffing forms for the same period as above showed that on the midnight shift all the FSSs covered two units each, making their presence on any one of the units unpredictable.

B. Interviews:

1. During an interview on 2/11/19 at 1:00 p.m., FSA3 stated that all the units had beds upstairs and downstairs and that the upstairs was locked down at 6:45 a.m. and reopened from 3:30 p.m. to 4:30 p.m. (during shift change). The upstairs was relocked at 4:30 p.m. and not opened again until bed time.

2. During an interview on 2/11/19 at 1:15 p.m., FSA4 stated that only one FSA was assigned to monitor the patients upstairs on the midnight shift. Another FSA was assigned to watch the monitor which visualized the second floor. FSA4 further stated that the FSAs rotated every hour and wore a PPD for any emergency that would require assistance.

3. During an interview on 2/12/19 at 12:30 p.m., with the Director of Nursing, QA RN1 and the Director of Quality Improvement, it was stated that usually only one FSA worked upstairs on the midnight shift and it was acknowledged that it was probably not optimal staffing, although they had not had any negative outcomes since they provided monitored surveillance and PPDs. The DON stated that not all units had only one FSA upstairs but it was up to the unit. She was unable to identify which units staffed greater than one FSA and how often that occurred. The Director of Quality Improvement brought the surveyor an Incident Report on 2/12/19 at 3:30 p.m. that was dated 1/23/19, and stated that although she had been briefed on the incident, she was not aware that it had happened on the midnight shift on the second floor of Unit East 2.

4. During an interview on 2/13/19 at 9:45 a.m., the Director of Quality Improvement reported that according to the Patient Safety Check Log for 1/23/19 midnights, there were 21 patients on the second floor of Unit 2 East.

5. During an interview on 2/13/19 at 10:40 p.m., the Director of Nursing stated that FFS1 was medically evaluated outside the hospital and had abrasions after being hit in the left eye and right temple, but returned to work the next day.

II. RN Deployment

A. Document Review

Review of the Direct Nursing Staffing Forms from 2/3/19 to 2/9/19 revealed that the 56 midnight shifts across the eight (8) units were staffed as follows:
-1 RN-16 shifts (29%)
-1.25 RNs-14 shifts (25% one RN plus another RN covering four units)
-1.5 RNs-23 shifts (41% one RN plus another RN covering two units)
-2.0 RNs-3 shifts (5%)

B. Interviews

1. During an interview on 2/12/19 at 12:30 p.m., the DON and QA RN1 both acknowledged that the majority of the patients were on the second floor during the midnight shift and that the RN was usually on the first floor, except when rounding three times a night.

2. During an interview on 2/13/19 at 10:15 a.m., the DON stated that the RN covering Unit East 2 on 1/23/19 and met downstairs with Patient B1on the night of the incident, was a Float Nurse who did not know the patients on Unit East 2. When asked about the supervision of the FSAs on the unit, the DON stated that the FSSs were responsible for assigning the FSA to specific tasks but the RN had to approve the schedule and was responsible for the FSAs when they were caring for the patients.