HospitalInspections.org

Based on review of facility documents and staff interviews (EMP), it was determined that the facility failed to follow the established time frames for review of grievances and the provision of a response per facility policy for nine of nine grievances reviewed.

Findings include:

Review of Warren State Hospital's (WSH), "Patient/Family Handbook", ... . page 21 INDIVIDUAL COMPLAINT POLICY , revealed " An individual has the right to file a complaint while at WSH. Step 1 - Complaints may be made either "Informally" through the Treatment Team or the Client Rights Representative; or "Formally" by completing a complaint form ... . Step 2 - The Treatment Team will discuss the complaint and inform the individual of its decision within two (2) working days. Step 3 - If the individual is not satisfied, the complaint then goes to the Client's Right Representative, who will review the matter and inform the individual within ten (10) working days. Step 4 - If ... still not satisfied ... appeal ... WSH Human Rights Committee ... will review at next scheduled committee meeting and inform ... within ten (10) working days. Step 5 - If ... still not satisfied ... appeal ... Warren State Hospital CEO who will review the matter and inform ... within ten (10) working days."

Review of Warren State Hospital Policy No. 3014 - "Client Rights, Grievance and Appeal Policy/Procedure. ... . B. The protection and advocacy of all rights are implemented through the Human Rights and Advocacy Committee and through the Client Rights Representative. Procedures have been established .. to resolve grievances, both formally and informally ... . C. The Human Rights and Advocacy Committee, along with Client Rights Representative, will promote human rights education through a variety of means ... concerning patient rights, grievance and appeal procedures. ... GRIEVANCE PROCEDURES: ... B. 5. Resolution and documentation of the complaint as well as informing the complainant of the proposed resolution must be done within two (2) working days of receipt of the complaint unless extension of time is negotiated with the complainant for reasonable purposes (e.g.: at the next Treatment Team Meeting). C. Formal Complaint Procedures. ... . Step 2: Treatment Team will discuss ... within two (2) working days after receipt of the complaint by the team director, unless extension of time is negotiated with the complainant. ... . b. team must inform in writing ... decision within two working days of the meeting. ..."

Review of Policy Number: 811 "Patient Abuse Policies and Procedures - ... . IV. Patient Abuse Investigation Process A. Overview 1. Upon receipt of a complaint of suspected abuse, ... . a. Immediately begin the investigation. ... . 2. A preliminary investigation should be completed ASAP but within 3 calendar days of initiation of the investigation. ... . 3. Full scale patient abuse investigations should be completed within 7 calendar days with written report to follow ... ."

1. On May 4, 2015, from approximately 10:45 AM - 11:00 AM, the complaint/ grievance procedure log was reviewed and nine complaints/grievances were randomly selected for review. The nine selected files were reviewed on May 4, 2015, from 12:30 PM to 3:45 PM. Nine of the nine files selected for review were not investigated and resolved according to the facility's timeline policy. There was no documentation in the complainants' files or medical records (MR3, MR21 and MR22) that the complainant had agreed to extend the investigation timeline per facility policy. Further review of the nine selected files revealed that none of the selected complaints/grievances had received written notification of their decisions within the 30 days as established by the facility's policy. Four of the nine did not receive any written notification following the completion of the complaint investigation. Of the five letters reviewed, the dates ranged from anywhere from six (6) to nine (9) months after the investigation completion dates.

2. An interview on May 5, 2015, at 10:55 AM with EMP4 revealed that the facility follows the DPW 5100 regulation timeline for Grievances and Appeals. The surveyor reviewed the informal process which states written notification within two (2) working days. EMP4, stated, "Yes that is correct." The surveyor then reviewed the Formal policy which states, "Team discusses within two (2) working days and then within two days of the meeting informs the individual in writing of its decision." When asked if surveyor should see written notification within 48 hours regardless of whether the complaint/grievance was considered informal or formal, EMP4, nodded and said "Yes, I will need to redo the policy because we do resolution outcome letters within 48 hours."

3. An interview with EMP4 on May 6, 2015, at 1:50 PM verified the complaints were not in compliance with the investigation timeframe requirements per the facility's policies. EMP4 stated, "I cannot explain the content or timeframe for the letters. You will need to discuss them with EMP1."

4. An interview conducted with EMP1 on May 6, 2015, at 3:30 PM confirmed only five of the nine complaints/grievances reviewed received a letter. EMP1 also verified all nine should have received written notification within 30 days of the completion of the investigation per facility policy. EMP1 explained the process of notifying Labor Relations, Union representative and presenting all the information gathered in the investigation to the various committees, etc. and noted all those steps slows down the process. EMP1 noted that the process makes it very difficult to complete the alleged abuse investigations within 7 days as required per facility policy and to provide the follow up written notification of the outcome of the complaint/grievance within the 30 day timeframe per the facility policy. EMP1 agreed there was no documentation in the file or medical record to indicate that the patient had been consulted to request an extension to complete the investigations outside the facility policies timelines.

Based on review of facility documents and staff interviews (EMP), it was determined that the facility failed to provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion per facility policy requirement for nine of nine complaint/grievances reviewed.

Findings include:

Review of Warren State Hospital's (WSH), "Patient/Family Handbook", ... . INDIVIDUAL COMPLAINT POLICY, Warren State Hospital Policy No. 3014 - "Client Rights, Grievance and Appeal Policy/Procedure and Review of Policy Number: 811 "Patient Abuse Policies and Procedures on May 4, 2015 from approximately 12:30 PM to 2:00 PM and May 5, 2015 from approximately 10:00 AM to 11:00 AM , revealed no reference to the provision of a written notice of a decision regarding the complaint, requirement for the name of the hospital contact person, steps taken to investigate on behalf of the patient, results of the process, nor the date of completion .

1. Review of nine random grievances on May 4, 2015, from 12:30 PM to 3:45 PM revealed nine of nine were not investigated and resolved according to facility policy. There was no documentation in the individuals' files or medical records (MR3, MR21 and MR22) that the complainant had agreed to extend the investigation per facility policy. Further review of the nine files revealed none of the nine complainants received written notification of their decisions as set forth in the facility's policy. Four of the nine did not receive any written notification following the completion of the complaint investigation. The five written outcome notification letters that were sent to the individuals did not include any information related to the resolution of the complaint (i.e. substantiated or unsubstantiated), nor did they contain any information about the steps that had been taken to investigate and resolve the complaint on behalf of the complainant. The letters did not contain the name of the facility contact person; just the instruction to call to schedule an appointment if they wished to know the details of the complaint investigations.

2. During an interview on May 5, 2015, at 10:55 AM with EMP4, the informal process which states written notification will be sent to the individual within two (2) working days was reviewed. EMP4, stated, "Yes that is correct. " When asked if written notification outcome letters were available for all complaints/grievances, regardless of whether the complaint/grievance was considered informal or formal, EMP4, nodded and said "Yes, I will need to redo the policy because we do outcome resolution letters within 48 hours of receiving all complaints/grievances. ..."

3. An interview with EMP4 on May 6, 2015, at 1:50 PM verified the complaint/grievances letters were not completed per the facility policy.

4. An interview conducted with EMP1 on May 6, 2015, at 3:30 PM confirmed only five of the nine complaint/grievances reviewed received written notification letters. EMP1 also verified all nine should have received written notification of the Team's decisions that should have contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion per facility policy.

Based on review of facility documents and medical records (MR), and staff interviews (EMP), it was determined that the facility failed to ensure that all medical record entries were complete, dated, timed and authenticated for seven of 22 medical records (MR1, MR3, MR4, MR13, MR14, MR19 and MR20).

Findings include:

Review of the Warren State Hospital procedure manual NO. 1859, revised March 2015 revealed, "SUBJECT: DOCUMENTATION GUIDELINES ... PURPOSE: To establish uniform documentation and authentication standards for a complete and accurate health record. ... PROCEDURE: ... 3. Every entry must be fully dated and timed using military or 24 hour time (Ex: 2/1/11 14:30) The time and date of each entry must be accurately documented. timing and dating entries is necessary for patient safety and quality of care. ... 5. All entries in the medical record must be complete. ... 8. Each entry must be legibly signed by the individual making the entry. The signature must include the first name, complete surname and identifying professional initials or title. ... 13. Initials are not considered to be a signature. ... 16. When pre-printed forms are being used, the entry must be signed/initialed, dated, timed and authenticated by the author."

Review of the Warren State Hospital Procedure Manual No. 1865 "Progress Note Documentation" revealed, "3. All entries must be fully dated (month, day, year), must be timed using military time ... at the time of entry and authenticated by the person responsible for providing or evaluating the service provided ... 5. All entries in the medical record must be complete ... 8. Each entry must be legibly signed by the individual making the entry. The signature must include the first name, complete surname and identifying professional initials or title ... 12. The signature should follow the completion of the entry. 13. Initials are not considered to be a signature ..."

Review of Medical/Surgical Patient Transfer Agreement between Warren State Hospital and [Acute Care Hospital] signed by Warren State Hospital on February 12, 2015, and by [Acute Care Hospital] signed on February 20, 2015, revealed, "To ensure continuity of care, [Acute Care Hospital] and WSH mutually agree: ... to promptly provide each other with the medical information required for the necessary care and treatment required by the patient's condition; to provide each other with any information or documentation required for continuing accreditation, certification as a Medicare/Medicaid provider, or any licensure requirements; ... upon request, to provide each other with copies of the patient's medical record maintained by either [Acute Care Hospital] and/or WSH in order to facilitate continuity of care and to assess the quality of the transfer process and care rendered; ... In furtherance of this agreement, WSH agrees to provide [Acute Care Hospital] with: a copy of the patient's medical advance directive, if completed; a completed WSH-[Acute Care Hospital] transfer form that contains relevant medical information necessary for continuity of care. The form will contain information such as reason for referral/transfer, summary of medical examination findings at WSH, any relevant available laboratory findings, current mental/psychiatric status and treatment, current medications and dosages, significant findings of physical examinations and history; and any known allergies or sensitivities of the patients; ..."

Review of Procedure No. 1827 "Medically Ill/Unstable/Injured Patient and Transfer to Acute Care Facility" revised June 20, 2014, revealed, "f. Continuity of care will be ensured and records will be processed and sent to the receiving facility per Warren State Hospital Policies #1874-Consultations of Warren State Hospital Patient's with other Health Care Providers and Facilities and #1800 Outpatient Services. g. Hospital employee must accompany the patient to the general hospital..."

Review of Warren State Hospital Procedure Manual No. 1800 "Outpatient Services" revised April 2015 revealed, "Responsibility: It is the responsibility of Nursing Services to initiate a Consultation/Interagency Transfer form (No. MH-13) and to present the form to the service provider at the time the service is rendered. Procedure: 1. The Chief of Medicine (or designee) or other physicians will notify Nursing Services of the need for doctor or hospital out-patient services as written on the Doctor's order sheet. 2. Nursing services will: A. Initiate Form MH-13 (which has four copies) Consultation/Interagency Transfer Form, and enter the patient information, vital signs, complete Nursing assessment section, including to list the line with allergies in red pen ... C. Forward form to ordering Medical physician. The attending Physician will fill any additional information for the consultation and check mark information in the "send" box what information needs to be sent with the patient (i.e., psych evaluation, H&P, x-ray, medication list, etc.). Refer to Policy 1874 to ensure appropriate records are sent tot he consultant. D. Send the MH-13 form to the Medical Department Secretary for processing... E. Receive MH-13 form back to unit and then place it in appointment envelope in ward office with accompanied information until appointment date. F. On the actual day of the consult, send a copy of the allergy cardstock form which list all allergies as well as ensure allergies are written in the line of the interagency, plus send a med list also generated on the day of the consult... Also, on date of service, tear off the fourth yellow copy of the MH-13 form prior to the service to show all appropriate information was completed prior to the services being rendered. The yellow copy of the form will be placed in he consult section of the chart until the original is returned. G. After the patient receives the service, the nursing escort staff is to complete the bottom left hand section of the form, including both signature and printed name... I. File the original first copy (white) on the patient's chart in the consult section. The second copy (pink) goes to the WSH Accounting Office. The third copy (goldenrod) will remain with the provider at the time service is rendered. And the yellow copy previously filed in the consult section prior to the service may now be discarded once the original is returned..."

Review of Warren State Hospital Procedure Manual No. 1874 "Consultation of Warren State Hospital Patient's with Other Health Care Providers and Facilities; Emergency and Non-Emergency Release of Information" revised May 2013 revealed, "The staff of Warren State Hospital will send appropriate information to the receiving facility or consultant, providing care for Warren State Hospital patients in both emergency and non-emergency situations... Procedure: A. Emergency Consultations to outside facilities (i.e. Emergency Room) 1. In emergency situations, all necessary medical records maybe sent/faxed via Nursing without authorization for disclosure including: Most recent H&P, Psychiatric Evaluation, Medication List, Allergy List, Copy of MH-13 1000 3-08 Consultation/Interagency Form (original to be sent with patient) Medical Advance Directive, Code Status, Immunization/PPD Form, WSH-508 (both sides) and Database I... B. Non-Emergent Consultations 1. A referral for consultation must be ordered by a physician ... 2. The RN takes the order off the DOS. 3. The RN will initiate the consult tracking form WSH-564 in the medical record for all consults... 4. The RN determines if the consult can be completed in-house ... 6. For Outside Consultations ... The RN will initiate the following: a. Interagency/Consultation Transfer Form MH-13 ... and process per policy/procedure 1800..."

1. Review of MR1 revealed an order dated April 3, 2015, for monitoring of Intake and Output each shift . Review of the Intake and Output form for April 2015 revealed no documentation for 133 of 138 possible entries. On May 5, 2015, at 11:30 AM, EMP6 confirmed the missing I & O documentation for MR1.

Additional review of MR1 revealed six orders related to changes to the consistency of the patient's diet between March 25, 2015, and April 21, 2015. Review of MR1 revealed no documentation of the food consistency received by the patient for the corresponding orders. On May 5, 2015, at 11:41, EMP6 confirmed the missing dietary documentation stating, "It (food being received by the patient) would be on the card. It is what is current. It won't be on the record. ... It is a pencil document. It changes."

2. Review of MR3 revealed entries on one or more of the following forms and/or documents incomplete for one or more of the following: the date, time and authentication of the person making the entry; Consultation Tracking Sheet, Modified DISCUS, Tuberculin Skin Test, Immunization Record, Immunization Screen, Clinical Record, Vital Signs record and Patient Pain Assessment. On May 7, 2015, EMP14 reviewed and confirmed the aforementioned incomplete documentation on MR3.

3. Review of MR4 revealed Consultation/Interagency Transfer forms on October 30, 2013, October 31, 2013, February 26, 2014, May 28, 2014, August 29, 2014, September 4, 2014, September 16, 2014, September 24, 2014, October 16, 2014, October 23, 2014, November 20, 2014, November 26, 2014, December 9, 2014, December 19, 2014, February 23, 2014 (should be 2015), April 12, 2015, April 30, 2015, and an illegible yellow copy of an unknown date. Further review of the forms revealed inconsistent information accompanied the patient and the forms were not always complete or legible. The same form was used for emergency transfers and routine appointments as well as transfers for testing.

A. The Consultation/Interagency Transfer form did not include documentation of vital signs on October 30, 2013 for eye exam, February 26, 2014 for an orthopedic appointment, August 29, 2014 for a Barium Swallow, September 16, 2014 for an orthopedic appointment, September 24, 2014 for a dexascan (bone density test), October 16, 2014 for orthopedic appointment, October 23, 2014 for a mammogram, November 20, 2014 for a barium swallow, November 26, 2014 for an orthopedic appointment, December 9, 2014 for (pre-surgical evaluation for?) a colonoscopy, December 19, 2014 for a colonoscopy, and ? February 23, 2015 for an orthopedic appointment.

B. The Consultation/Interagency Transfer form did not include documentation of a nursing assessment on December 19, 2014 for a colonoscopy.

C. The Consultation/Interagency Transfer form contained insufficient and/or conflicting information regarding the ambulatory status of the patient. On October 30, 2013 the form was marked "ambulates unaided," on October 31, 2013 it was marked "ambulates with walker," on February 26, 2014 it was marked ambulates with assistance [without specifying what type of assistance], "on May 28, 2014 it was marked, "ambulates unaided," on October 16, 2014, it was marked "ambulates with assistance," on November 20, 2014 it was marked "ambulates unaided,"and on an unknown date the form initiated on April 12, 2015 was marked "ambulates with assistance." The other transfer forms noted the patient ambulated without assistance with a walker or ambulated with a walker.

D. The Consultation/Interagency Transfer form did not contain dates and times the form was initiated on August 29, 2014 (no date), October 16, 2014 (no time), October 23, 2014 (no time), November 20, 2014 (no time), November 26, 2014 (no time), December 9, 2014 (no time), December 19, 2014 (no date or time), and February 23, 2015 (no time).
E. The consultation/ Interagency Transfer form did not contain the dates of service on ? April 12, 2015, and on an unknown date.

F. The Consultation/Interagency Transfer form was the last page of a 4 page carbon form that was almost entirely unreadable.

Interview on May 5, 2015, at approximately 8:45 AM with EMP16 revealed, "There is a list of things that are sent with a patient when they are transferred during time time Medical Records is open (5 days/week, 8:00 AM-4:00 PM). Medical records will make the copies." When asked who copied the records outside of regular Medical Record hours, EMP16 replied, "Nursing." When asked what forms were copied when nursing had to send medical records with the patient, EMP16 replied, "I don't know. I know what Medical Records does."

Interview on May 5, 2015, at approximately 12:00 PM with EMP2, confirmed the above missing information from the medical record.

October 30, 2013-vision & cataract check [no vital signs], [no medical records sent]. A nursing assessment was documented. Current med list and allergy list was not marked. Ambulates unaided.

October 31, 2013-fell hitting the back of her head, transported by ALS, pertinent vital signs, copies of H&P, Psych eval, current med list, allergy list, noted full code, nursing assessment ambulates with walker.

Feb 26, 2014 f/u ortho-current med list and allergy list marked, nursing assessment marked, date appointment made was November 26, 2014 [no time]. Nurse escorting the patient signed [Service was received on (Date) was blank] No vital signs listed.
February 26, 2014 9:00 AM-bilateral steroid inj [injection] of knees. H&P, Current med list, allergy list, and any prior knee x-rays. Ambulates with assistance. Nursing assessment performed. Pertinent vital signs.
May 28, 2014 -Ortho. No records marked as going with the patient, Vital signs marked, nursing assessment, ambulates unaided.
August 29, 2014-Barium swallow. Nursing assessment done. No vital signs documented No medical records documented as sent with patient Date that the service was initiated was blank time 10:45.
September 4, 2014-orthopedic f/u. Current med list and allergy list sent.
September 16, 2014-orthopedic follow up. No vital signs documented, nursing assessment completed. Current med list and allergy list sent.
September 24, 2014-Dexascan. No vital signs, current med list and allergy list sent, nursing assessment documented.
October 16, 2014-Ortho followup. Time the form was initiated was blank No vital signs, current med list and allergy list sent. Nursing assessment completed. Ambulates with assistance.
October 23, 2014- Annual mammogram. No time the form was initiated, no vital signs, current med list and allergy list sent with the patient. Ambulates with assistive device. Sent with patient
November 20, 2014-Barium swallow, hx esophageal stricture. No time the form was initiated. No vital signs, no records sent with patient. Nursing assessment-Ambulates unaided.
November 26, 2014-Ortho f/u. No time the form was initiated. No vital signs, sent current med list and allergy list. Ambulates with assistance Assistive device sent with the patient.
Review of a list of items that medical records sent with a patient when a patient was transferred to the ER included, Data Base 1 & 11, advance directive, immunization, allergy list, list of medications, psychiatric evaluation, medical evaluation, pertinent labs, OPS/interagency, and x-rays.
4. Review of MR13 on May 6, 2015, at 9:00 AM, revealed a "Vital Signs Record," which included entries dated from February 8, 2014, through July 5, 2014, that did not include a time or signature of the person who documented the entries. On May 5, 2015, at 11:30 AM, EMP5 confirmed the missing documentation for all vital sign forms.

5. Review of MR14 on May 6, 2015, at 2:00 PM, revealed a "Vital Signs Record," which included entries dated from July 12, 2014, through May 2, 2015, that did not include a time or signature of the person who documented the entries. On May 5, 2015, at 11:30 AM, EMP5 confirmed the missing documentation for all vital sign forms.

Additional review of MR14 revealed two entries on a "Tuberculin Skin Test (TST) form for February 16, 2014, and February 8, 2015, which did not include the time that the test was administered or the time that the result was read. Review of MR14 also revealed an order dated January 21, 2015, which indicated, "2000 cal [calorie] ... Limit fluids 1500ml/day. There was no documentation of the meal or fluid consumption for MR14. Continued review of MR14 revealed a page of the Medication Administration Record dated May 2015 that contained no signatures of the nurses that administered the medication.

During an interview on May 6, 2015, at approximately 10:00 AM, EMP5 indicated, "The nurses sign only one time on the MAR each month, there is a Master Sheet with all of the nurses names...they only have to sign one sheet of the MAR each month ..."

During an interview on May 6, 2015, at approximately 10:00 AM EMP25 confirmed that only recorded by nursing if the patient is on a specific calorie count ordered for three days or for a specific time period.

During an interview on May 7, 2015, at approximately 10:00 AM EMP1 confirmed that meal consumption is not recorded for every patient for each meal.

6. Review of MR19 on May 6, 2015, at 1:30 PM, revealed a "Vital Signs Record," which included entries dated from March 22, 2014, through May 2, 2015, that did not include a time or signature of the person who documented the entries. On May 6, 2015, at 1:50 PM, EMP4, confirmed the missing documentation for all vital sign forms.

Continued review of MR19 revealed three of ten pages of the Medication Administration Record (MAR) dated from February, 2015 through May 2015 that contained no signatures of the nurses that administered the medications. The other seven pages contained the initials and signatures of the nurses.

During an interview on May 6, 2015, at approximately 10:00 AM, EMP5 indicated, "The nurses sign only one time on the MAR each month, there is a Master Sheet with all of the nurses names ... they only have to sign one sheet of the MAR each month ..."

7. Review of MR20 on May 6, 2015, at 12:30 PM, revealed a "Vital Signs Record," which included entries dated from May 31, 2014, through May 2, 2015, that did not include a time or signature of the person who documented the entries. On May 6, 2015, at 1:55 PM, EMP4, confirmed the missing documentation for all vital sign forms.

Continued review of MR20 revealed three pages of the Medication Administration Record (MAR) dated March, 2015, that contained no signatures of the nurses that administered the medications.

During an interview on May 6, 2015, at approximately 10:00 AM, EMP5 indicated, "The nurses sign only one time on the MAR each month, there is a Master Sheet with all of the nurses names ... they only have to sign one sheet of the MAR each month ..."

Review of facility documents and medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure that medical records were complete within 30 days from the date of discharge.

Findings include:

Review of Warren State Hospital Procedure Manual No. 1885 "Filing an Incomplete Record" revised September 2014, revealed, "A medical record is completed within 30 days from the date the patient is discharged, expired or treatment is terminated. Procedure: 1. Medical Records Department will notify facility staff, as appropriate of the need to sign, date/time the record. 2. If the entries cannot be completed, The Medical Records Director will establish the extent to which the medical record is incomplete..."

1. Review on May 6, 2015, of a list requested for delinquent medical records provided by the facility revealed thirty-six names of patients with the medical record numbers, admission date, discharge date, and "Status." Seventeen of the thirty-six medical record status' were marked, "Not audited for deficiencies." Five of the thirty-six medical records were noted to have "uncorrectable deficiencies." Discharge dates of the delinquent records ranged from August 5, 2014-March 20, 2015.

2. Review on May 5 and 6, 2015, of MR16 and MR17 revealed a progress note flagged for a physician's signature on each of the medical records above that were not on the delinquent medical records list provided by the facility.

3. Interview on May 5, 2015, at 8:40 AM with EMP16 revealed, "We didn't have a Medical Records Director for a while... At this hospital they don't suspend physicians [for incomplete medical records]... Most of the issues are nursing. Sometimes nursing has had a problem completing the medical records because they can't access the records. Medical Records is open 8:00 AM to 4:00 PM Monday through Friday..."

Based on review of facility policy, observation and staff interviews (EMP), it was determined the facility failed to conduct crash cart checks as outlined in facility policy for four of eight carts observed.

Findings include:

Review of facility policy "Crash Cart" revised December 17, 2013, revealed, "PLAN...E. Each shift will do a daily inventory of the unit Crash Cart and initial the Crash Cart Check List. IB-E will be responsible for the inventory of the SCU dining room cart and the clinic cart. The CDR Crash Cart will be checked by assigned Evening shift licensed staff. The Recovery Center Crash Cart will be checked by assigned Night Shift licensed staff."

1. On May 5, 2015, at approximately 9:00 AM observation of the crash cart in the Israel Building (IB) treatment room revealed no documentation of crash cart checks for two of 13 shifts for May 2015 (May 1, 2015, 7-3 and May 2, 2015, 11-7).

On May 5, 2015, at 9:05 AM when asked if the treatment room crash cart should have been checked every shift, EMP6 stated, "It should have been."

2. On May 6, 2015, at approximately 9:25 AM observation of the Israel Building (IB) SCU (Special Care Unit) dining room crash cart revealed the current inventory sheet was signed March 4, 2015, 7-3 shift and April 8, 2015, 7-3 shift.

At the time of the observation, EMP6 indicated that monitoring of this crash cart was done by EMP21.

3. On May 6, 2015, at approximately 9:35 AM observation of the Israel Building clinic crash cart revealed the current inventory sheet was signed May 1, 2015, 7-3 shift and May 6, 2015, 7-3 shift.

At the time of the observation, EMP21 revealed, "I only do it on Wednesdays when I'm over here in the clinic." EMP21 also stated they did not believe he/she was responsible for monitoring of the crash cart in the SCU. "I believe it is nursing unit staff responsibility."

4. On May 6, 2015, at 9:40 AM an observation of the 3IF Unit revealed five of seventeen crash cart checks were not completed for May 2015.

Interview at that time with EMP18 confirmed the crash cart was to be checked every shift and confirmed the missing information on the crash cart check list.

Based on interview, record review and policy, the facility failed to provide social work assessments that include a summative formulation of findings for eight (8) of eight (8) patients in the sample, (Patients A7, B5, B9, C4, D1, E16, G8 and G25). Recommendations for interventions described the generic role of the social worker instead of patient specific interventions for six (6) of eight (8) patients in the sample (Patients B5, B9, C4, D1, E16 and G8). This resulted in the absence of coordinated social services care for eight (8) of eight (8) patients in the sample, (Patients A7, B5, B9, C4, D1, E16, G8 and G25).

Findings are:

A. Record review

1. Summative Formulation. Record review of Social and Rehabilitative Services Unified Assessment for A7, B5, B9, C4, D1, E16, G8 and G25 found no summative formulation of findings by a social worker.

2. Generic Interventions

a. The interventions for patient B5 reads "social worker will provide case work services for B5 including finding suitable housing and financial assistance in managing tasks that include social worker keeping family informed of his progress and after care discharge planning needs and assist BSU with arranging after care services and other plans upon discharge."

b. The interventions for patient B9 reads "social service will act as communication liaison between the client's treatment team, next of kin and the county BSU and encourage client to follow his treatment plan. The social worker will offer professional support in dealing with financial matters, insurances and benefits. Social worker will coordinate all aspects of discharge planning once client deemed discharge ready."

c. The interventions for patient C4 read "social worker will work with client and family and Mercer county BSU to address C4's social casework needs. Social worker will also work to obtain some of C4's medical records."

d. The interventions for patient D1 reads "Social worker will assist the client in securing basic identification, including birth certificate, photo ID, and social security card. Social worker will notify the Clearfield Co. BSU and D1's mother of her treatment progress and discharge planning issues. Social worker will assist D1 in applying for SSDI benefits in the community."

e. The interventions for patient E16 reads "Social worker will act as a communication liaison between E16's treatment team, NOK and county BSU. Social worker will encourage E16 to follow his treatment plan and offer professional supports in dealing with financial matters, insurances and benefits. Social worker is attempting to coordinate all aspects of E16's discharge plans.

f. The interventions for patient G8 reads "social worker will continue to provide all needed case work services. There will be at least bi-weekly patient contacts to assess patient's progress and needs as tolerated by the patient. Necessary contacts will be made with both Mercer county BSU liaison and G8's family members".

B. Interview

1. During interview with the Director of Social Work on 11/10/15 at 1:00 p.m., she confirmed there was no summative formulation for A7, D1, G8, and G25. She said "the format for the social work evaluations were standard and did not include a summative formulation".

2. During interview with Director of Social work on 11/10/15 at 1:00 p.m., she confirmed that the interventions for patients D1 and G8 were discipline specific and not individualized for each patient.

3. On 11/10/15 At 3:00 p.m., the Director of Quality Improvement said that the "Social and Rehabilitative Services Unified Assessment is a standard form that is completed by social services and it does not incorporate a formulation and that a formulation is not completed by the discipline of social work".

C. Policy

Medical records completion schedule procedure manual No. 1856 from April 2015 states the "Unified admission assessment is to be completed by SRS (social services) disciplines before the ITP is completed".

Based on observation, interview and document review, the Director of Nursing failed to staff adequate numbers of total nursing personnel, including Registered Nurses on all three tours of duty (day, evening and night) for six (6) of seven (7) Units (2NM, 2SW, 3IF, 3IM, 3NM and 3SW). This staffing pattern hindered on-going monitoring and supervision of patients and oversight of Licensed Practical Nurses (LPNs) and Health Care Technicians (HCTs) functions due to the lack of sufficient numbers of staff and the frequent absence of the RN from the wards resulting in a potential safety risk for patients and staff. (Refer to B150)

Based on observation, interview and document review, the Director of Nursing failed to staff adequate numbers of total nursing personnel, including Registered Nurses on all three (3) tours of duty (day, evening and night) for six (6) of seven (7) Units (2NM, 2SW, 3IF, 3IM, 3NM and 3SW). This staffing pattern hindered on-going monitoring and supervision of patients and oversight of Licensed Practical Nurses (LPNs) and Health Care Technicians (HCTs) functions due to the lack of sufficient numbers of staff and the frequent absence of the RN from the wards resulting in a potential safety risk for patients and staff. (Refer to B150)

Based on observation, interview and document review, the Director of Nursing failed to staff adequate numbers of total nursing personnel, including Registered Nurses on all three tours of duty (day, evening and night) for six (6) of seven (7) Units (2NM, 2SW, 3IF, 3IM, 3NM and 3SW). This staffing pattern hindered on-going monitoring and supervision of patients and oversight of Licensed Practical Nurses (LPNs) and Health Care Technicians (HCTs) functions due to the lack of sufficient numbers of staff and the frequent absence of the RN from the wards resulting in a potential safety risk for patients and staff.

Findings are:

A. Overview Information:

1. Six (6) of seven (7) patient care Units (2NM, 2SW, 3IF, 3IM, 3NM and 3SW) provided RN coverage for the adjacent patient Unit for meals, patient emergency codes, treatment team meetings, etc. This pattern occurred on all three shifts seven days of the week. This resulted in an RN not immediately present on each ward and the risk for a patient event on each of these wards was always a potential occurrence. There was no formal system to ensure that each RN was relieved when off the ward to ensure professional supervision for each patient unit.

2. On all six (6) of the above listed patient units on all tours of duty an insufficient number of total nursing personnel (RNs, LPNs and/or HCTs) were assigned. When nursing personnel were required to leave the ward for meals, breaks, patient escorts, etc., a sufficient number of nursing personnel were not present on each unit to provide on-going monitoring and supervision.

3. All six (6) of the above listed patient units were wards with long halls, some requiring as many as 3-4 nursing personnel to provide basic monitoring and supervision of patients while they were in their assigned rooms to ensure safety and privacy.

4. Patients from Unit 3NM go to Unit 3IM and patients from 3SW go to Unit 3IF for medications. The open door between the units and movement of patients in other patient units for medication administration results in an added safety risk for patients.

B. Overview Interview:

1. During interview on 11/10/15 at 10:00 a.m. with RNs W10 and W11, the following information was reported:

a. RN W10 reported that there is always three (3) staff, including 1 RN, assigned to Unit 2SW; one of these staff members is a "floater." Sometimes the assigned "floater" is reassigned to another ward due to a patient incident. RNW10 reported that often there are only two (2) nursing personnel members working on 2SW.

b. It is required that all nursing personnel on each Unit receive one 30 minute meal break on the day, evening and night tours of duty. Two additional 15 minute breaks are given to each nursing staff member when possible.

c. The RN on most shifts spend much of their assigned shifts in the nursing station or medication rooms (completing assigned tasks).

d. RN W10 reported that even though Units 2NM and 2SM are considered "open" units, 3-4 patient incidents occur on these units each year. These 2 Units are only open about 2 hours/day. RN W10 added that some of these patients presented behavioral problems.

e. RN W11 reported that one of the biggest staffing issues is staffing required for patients who are on 1:4 privileges. This privilege requires one (1) staff member for each group of four (4) patients who go off the unit. Another issue is covering for staff meal break and escorting patients to go to appointments, etc. RN W11 stated, "We do the best with what we have, I know the potential (risk) that we open ourselves to."

f. During interview on 11/10/15 at 3:30 p.m., the DON stated, "It is difficult to hire because of the union".

C. Specific Unit Findings:

1. UNIT 2NM:

a. Unit 2NM is a 36 bed male discharge preparation unit. This unit has two (2) long hall ways and two short hallways; all patient rooms are single. A minimum of two (2) nursing personnel are required to view all doors when the patients are in their assigned rooms. This does not allow for hourly monitoring of the patients when in their rooms since the staff member is not able to leave the view point between two (2) hallways. This staffing does not allow for staff members who are monitoring the patients to leave the ward for meal breaks, codes, etc.

b. Review of Patient Nursing Needs Assessments completed by an RN for the patients on the first day of the survey (11/9/15) revealed that Unit 2NM had a census of 31-5 patients required diabetic checks; four (4) received range of motion exercises; seven (7) were provided skin care; 29 patients had to be escorted off ward for meals; eight (8) patients were demanding of staff time; one (1) patient was on line-of-sight supervision and one (1) patient was on every 15 minute monitoring checks.

c. Review of reported patient incidents from Unit 2NM from 8/1/15 to 11/9/15 provided by the Director of Quality Improvement revealed that for this time period there were two (2) patient to patient assaults; and four (4) patient falls; two (2) patient aggressive events; one (1) event of patient presenting sexual behaviors and one (1) patient elopement.

d. According to the Director of Nursing RN coverage (RNs off the unit for meals, patient codes, etc.) for Unit 2NM is shared with Unit 2SW.

e. Review of Staffing Schedules provided by the Director of Nursing for seven (7) days, including the first day of the survey (11/9/15), revealed the following staffing deficiencies on Unit 2NM based on the information documented in the above sections a through d.

1). On the day shift on 11/3/15, 11/5/15 and 11/9/15 there was only one (1) RN assigned to the unit without scheduled relief when the RN was off the unit.


2). On the evening shifts from 11/3/15 through 11/8/15 there was only one (1) RN assigned to the unit without scheduled relief when the RN was off the unit.

3). On the night shifts from 11/5/15 through 11/9/15 there was only one (1) RN assigned to the unit without scheduled relief when the RN was off the unit.

On the night shifts from 11/3/15 through 11/5/15 and from 11/7/15 through 11/9/15 there were only three (3) nursing personnel, including the RN, assigned to Unit 2NM.

f. Observation and Interviews for 2NM

1). During rounds on Unit 2NM on 11/9/15 at 12:20 p.m., RN W5 reported that staffing for this shift, in addition to her, was one (1) LPN and two (2) HCTs. She stated that one of the HCTs was on a 1:1 patient assignment. The census of this unit was 31.

2). During rounds on Unit 2NW on 11/10/15 at 12:05 p.m., HCTW8 reported that the RN was off the unit on lunch break. When asked, who was covering for the RN, she stated, "The LPN covers for her. At that time RN W5 entered the nursing station as she was still on the unit." When asked who she tells when she leaves the unit, she responded, "We just share that with each other. We all know where each other are." When RNW5 was asked who staff were to call when needed when she was off the unit, she responded, "They should call upstairs to 3IM." HCTW9 spoke up stating, "I probably would call upstairs or someone close." At this time the DON verified that the RN from this unit would share RN coverage with Unit 2NM. RNW5 reported that she did not tell the RN on 2NM that she was going off the unit.

3). During rounds on Unit 3IM on 11/9/15 at 10:55 a.m., there was one (1) RN, one (1) LPN and two (2) HCTs assigned to the unit with a census of 16 patients. One HCT was providing 1:1 for one of the patients. At this time RN W2 was providing 1:1 for a patient who had just been placed on 1:1 for safety until an additional nursing staff member could be sent to the ward for this new assignment. One assigned HCT was off the Unit for meal break and one (1) HCT had taken a patient off the hospital grounds.

At this time, RN W2 reported that when the RN assigned to Unit 3IM goes off the ward for lunch breaks, etc. the RN assigned to Unit 3NM covers the ward. When asked what this coverage means, RN W2 stated, "If any problems arise, the nurse on the other Unit is called." RN W2 reported that Unit 3IM serves as coverage back-up for Unit 2NW.


2. UNIT 2SW:

a. Unit 2SW is a 25 bed female discharge preparation unit. This unit has two (2) long hall ways and two short hallways one (1) with a blind area at the end of the hall due to a door; all patient rooms are single. A minimum of three (3) nursing personnel are required to view all doors when the patients are in their assigned rooms. This does not allow for hourly monitoring of the patients when in their rooms since the staff member is not able to leave the view point between two (2) hallways. This staffing also does not allow for staff members who are monitoring the patients to leave the ward for meal breaks, codes, etc.

b. Review of Patient Nursing Needs Assessments completed by an RN for the patients on the first day of the survey (11/9/15) revealed that Unit 2SW had a census of 19-1 patient to seizure precautions; three (3) patients were potentially assaultive; two (2) patients were at low risk for suicide; 10 patients had off-ground appointments; one (1) patient was on elopement precautions and one (1) patient was on fall precautions.

c. Review of reported patient incidents from Unit 2SW from 8/1/15 to 11/9/15 provided by the Director of Quality Improvement revealed that for this time period there were 3 patient aggressive events; 1 patient transferred due to a medical event; 7 patient falls (5 with injury); 2 patient elopements and 1 elopement attempt.

d. According to the Director of Nursing RN coverage (RNs off the unit for meals, patient codes, etc.) for Unit 2SW is shared with Unit 2NM.

e. Review of Staffing Schedules provided by the Director of Nursing for 7 days, including the first day of the survey (11/9/15), revealed the following staffing deficiencies on Unit 2SW based on the information documented in the above sections a through d.

1). On the day shift on 11/3/15, 11/4/15 and 11/6/15 there was only one (1) RN assigned to the unit without scheduled relief when the RN was off the unit.


2). On the evening shifts from 11/3/15 through 11/9/15 there was only one (1) RN assigned to the unit without scheduled relief when the RN was off the unit.

On the evening shifts on 11/3/15, 11/4/15, 11/7/15 and 11/8/15 there were only three (3) nursing personnel, including the RN, assigned to Unit 2SW.


3). On the night shifts from 11/5/15 through 11/9/15 there was only one (1) RN assigned to the unit without scheduled relief when the RN was off the unit.

On the night shifts from 11/4/15 through 11/7/15 there were only three (3) nursing personnel, including the RN, assigned to Unit 2SW.

f. Observation and Interview for 2SW

1). During rounds of Unit 2SW on 11/9/15 at 12:05 p.m., LPN Y1 was on the ward in the nursing station. At this time there were 21 patients on the Unit. During interview, LPN Y1 reported that one (1) RN was on lunch break and the other RN working on Unit 2SW had gone to a medical code on Unit 3SW located on the above floor. An RN would need to be called from the adjoining unit (2SM) if a patient event was to occur. At this time there was one (1) LPN and one (1) aide remaining on the Unit 2SW with the patients with immediate RN supervision and direction.

2). At 12:00 p.m. on 11/10/15, there was no staff in the hallway of 2SW and one (4) patients were in the hall. Upon approach to nurse's station HCTY1 came out to perform hourly rounds. LPNY1 said that "RNY2 was on break and no RN was able to cover ward 2SW, that the nursing supervisor who's office was on the unit had been off for 2 days".


3. UNIT 3IM:

a. Unit 3IM is a 19 bed admission unit for males with high acuity. This unit has 1 long hall way and two short hallways (1 with a blind area at the end of the hall due to a door); all patient rooms are single. A minimum of two (2) nursing personnel are required to view all doors when the patients are in their assigned rooms. This does not allow for hourly monitoring of all patients when in their rooms. This staffing also does not allow for staff members who are monitoring the patients to leave the ward for meal breaks, codes, etc.

b. Review of Patient Nursing Needs Assessments completed by an RN for the patients on the first day of the survey (11/9/15) revealed that Unit 3IM had a census of 18. Two (2) patients required dressing changes; Three (3) patients required diabetic checks; one (1) patient required catheter care; 12 patients required escort to meals; 15 patients were potentially assaultive; three (3) patients were actively assaultive; 16 patients were a low risk for suicide; two (2) patients were an intermediate risk for suicide; eight (8) patients had active hallucinations/delusions; one (1) patient had off-ground appointment; one (1) patient was on elopement precautions; three (3) patients were on fall precautions; 10 patients were demanding of staff time; two (2) patients required monitoring due to eating disorders and five (5) patients required constant line-of sight supervision.

c. Review of reported patient incidents from Unit 3IM from 8/1/15 to 11/9/15 provided by the Director of Quality Improvement revealed that for this time period there were 17 patient aggressive events; 14 patient to patient assaults; five (5) patient assaults on staff; four (4) patient elopements; six (6) patient transfers due to medical events; 14 patients found with contraband; 11 patient falls three (3) with injury; one (1) self-injurious event and events of patient presenting sexual behaviors.

d. According to the Director of Nursing RN coverage (RNs off the unit for meals, patient codes, etc.) for Unit 3IM is shared with Unit 3NM.

e. Review of Staffing Schedules provided by the Director of Nursing for 7 days, including the first day of the survey (11/9/15), revealed the following staffing deficiencies on Unit 3IM based on the information documented in the above sections a through d.

1). On the day shift from 11/3/15 through 11/9/15 there was only one (1) RN assigned to the unit without scheduled relief when the RN was off the unit.


2). On the evening shifts from 11/4/15 through 11/6/15 and on 11/9/15 there was only one (1) RN assigned to the unit without scheduled relief when the RN was off the unit.

3). On the night shifts from 11/5/15 through 11/9/15 there was only one (1) RN assigned to the unit without scheduled relief when the RN was off the unit.

On the night shifts from 11/3/15 through 11/6/15 there were only three (3) nursing personnel, including the RN, assigned to Unit 3IM. This does not allow scheduled relief when staff are off the units for meals, etc.

f. Observation and Interviews for 3IM

1). During rounds on Unit 3IM on 11/9/15 at 10:55 a.m., there was one (1) RN, one (1) LPN and 2 HCTs assigned to the unit with a census of 16 patients. One (1) HCT was providing 1:1 for one of the patients. At this time RN W2 was providing 1:1 for a patient who had just been placed on 1:1 for safety until an additional nursing staff member could be sent to the ward for this new assignment. One (1) assigned HCT was off the Unit for meal break and 1 HCT had taken a patient off the hospital grounds.

At this time, RN W2 reported that when the RN assigned to Unit 3IM goes off the ward for lunch breaks, etc. the RN assigned to Unit 3NM covers the ward. When asked what this coverage means, RN W2 stated, "If any problems arise, the nurse on the other Unit is called." RN W2 reported that Unit 3IM serves as coverage back-up for Unit 2NW.

4. UNIT 3NM:

a. Unit 3NM is a 25 bed admission unit for males. This unit has 1 long hall way and one short hallway; all patient rooms are single. A minimum of two (2) nursing personnel are required to view all doors when the patients are in their assigned rooms. This does not allow for hourly monitoring of all patients when in their rooms. This staffing also does not allow for staff members who are monitoring the patients to leave the ward for meal breaks, codes, etc.

b. Review of Patient Nursing Needs Assessments completed by an RN for the patients on the first day of the survey (11/9/15) revealed that Unit 3NM had a census of 25- 2 patients required diabetic checks; one (1) patient required range of motion exercises; four (4) patients required skin care; eight (8) patients required escort to meals; two (2) patients were potentially assaultive; one (1) patient was an intermediate risk for suicide; one (1) had active hallucinations/delusions; one (1) patient had off-ground appointment; two (2) patients were on elopement precautions; one (1) patient required constant line-of-sight supervision and one (1) patient was on Electric Convulsive Therapy.

c. Review of reported patient incidents from Unit 3NM from 8/1/15 to 11/9/15 provided by the Director of Quality Improvement revealed that for this time period there was one patient who had an adverse drug reaction; three (3) patient aggressive events; seven (7) patient to patient assaults; one (1) patient assault on staff; 12 patient falls (4 with injury) and 1 patient seizure.

d. According to the Director of Nursing RN coverage (RNs off the unit for meals, patient codes, etc.) for Unit 3NM is shared with Unit 3IM.

e. Review of Staffing Schedules provided by the Director of Nursing for 7 days, including the first day of the survey (11/9/15), revealed the following staffing deficiencies on Unit 3NM based on the information documented in the above sections a through d.

1).On the day shift on 11/3/15 and from 11/5/15 through 11/9/15 there was only one (1) RN assigned to the unit without scheduled relief when the RN was off the unit.

2).On the evening shifts from 11/4/15 through 11/8/15 there was only one (1) RN assigned to the unit without scheduled relief when the RN was off the unit.

3). On the night shifts from 11/4/15 through 11/7/15 and on 11/9/15 there was only one (1) RN assigned to the unit without scheduled relief when the RN was off the unit.

f. Observation and Interview for 3NM

1). During rounds on Unit 3IM on 11/9/15 at 10:55 a.m., there was 1 RN, 1 LPN and 2 HCTs assigned to the unit with a census of 16 patients. One HCT was providing 1:1 for one of the patients. At this time RN W2 was providing 1:1 for a patient who had just been placed on 1:1 for safety until an additional nursing staff member could be sent to the ward for this new assignment. One assigned HCT was off the Unit for meal break and 1 HCT had taken a patient off the hospital grounds.

At this time, RN W2 reported that when the RN assigned to Unit 3IM goes off the ward for lunch breaks, etc. the RN assigned to Unit 3NM covers the ward. When asked what this coverage means, RN W2 stated, "If any problems arise, the nurse on the other Unit is called." RN W2 reported that Unit 3IM serves as coverage back-up for Unit 2NW.

2). During treatment team on 11/9/15 the RN responsible for the care of the patients on 3NM remained in the conference room of unit 3IM from 8:30 a.m. through 11:00 a.m.

3). At 9:52 a.m. on 11/10/15, RNY3 from 3NM said she "worked night shift and often took a break on the unit because there is only one RN on duty, but other RNs leave campus when they take a break and go to Walmart (which is off campus across the street) for their break." Night shift on 3NM is staffed with one (1) RN at night. She extended her shift through the 7:00 a.m. - 3:30 p.m. shift to help cover an RN shortage on 11/10/15.


5. UNIT 3IF:

a. Unit 3IF is an 11 bed admission unit with borderline focus for females. This unit has one (1) hallway; all patient rooms are single.

b. Review of Patient Nursing Needs Assessments completed by an RN for the patients on the first day of the survey (11/9/15) revealed that Unit 3IF had a census of 8- 1 patient required diabetic checks; 1 patient required dressing changes; 6 patients required escort to meals; 2 patients were potentially assaultive; 3 patients had a low risk for suicide; 5 patients had an intermediate risk for suicide; 5 patients were demanding of staff time; 1 patient required special monitoring due to an eating disorder and 1 patient was on Electric Convulsive Therapy.

c. Review of reported patient incidents from Unit 3IF from 8/1/15 to 11/9/15 provided by the Director of Quality Improvement revealed that for this time period there was one patient who had an accident with injury; 1 patient had an adverse drug reaction; 1 patient aggressive event; 2 patient to patient assaults; 2 patients transferred due to medical event; 6 patient falls (3 with injury) and 50 incidents of self-injury.

d. According to the Director of Nursing RN coverage (RNs off the unit for meals, patient codes, etc.) for Unit 3IF is shared with Unit 3SW.

e. Review of Staffing Schedules provided by the Director of Nursing for 7 days, including the first day of the survey (11/9/15), revealed the following staffing deficiencies on Unit 3IF based on the information documented in the above sections a through d.

1). On the day shift from 11/3/15 through 11/8/15 there was only 1 RN assigned to the unit without scheduled relief when the RN was off the unit.

2). On the evening shifts from 11/5/15 through 11/9/15 there was only 1 RN assigned to the unit without scheduled relief when the RN was off the unit.

3). On the night shifts from 11/3/15 through 11/7/15 and on 11/9/15 there was only 1 RN assigned to the unit without scheduled relief when the RN was off the unit.

f. Observation and Interview for 3IF

1). At 12:15 p.m. on 11/10/15, there were 7 patients in the hallway of 3SW. At this time Patient C1 was arguing with C11, screaming in the hall. There was no staff in the hallway at this time. RNW3 came out of the closed nurse's station as did HCTY2; second HCTY3 was off of the unit at this time getting lunch trays for 3SW and 3IF. Prior to HCTY3 returning, HCTY2 took 6 patients off of the unit to lunch leaving RNW3 alone on the unit with 8 visible patients including C1 who was still upset and argumentative. No one from 3IF came to assist during this time. At 12:20 on 11/10/15 the RN on duty on 3IF said she "heard the noise through the door but was with her own group of patients at the time".

6. UNIT 3SW:

a. Unit 3SW is a 19 bed admission unit for females. This unit has 1 long hall way and one short hallway; all patient rooms are single. A minimum of 2 nursing personnel are required to view all doors when the patients are in their assigned rooms. This does not allow for hourly monitoring of all patients when in their rooms. This staffing also does not allow for staff members who are monitoring the patients to leave the ward for meal breaks, codes, etc.

b. Review of Patient Nursing Needs Assessments completed by an RN for the patients on the first day of the survey (11/9/15) revealed that Unit 3SW had a census of 15- 3 patients required diabetic checks; 1 patient required dressing changes; 1 patient required decubitus care; 5 patients required escort to meals; 7 patients were potentially assaultive; 4 patients had a low risk for suicide; 5 patients presented delusions/hallucinations; 1 patient had an off-grounds appointment with escort; 4 patients were on assault precautions; 2 patients were on elopement precautions; 1 patient was on falls precautions; 1 patient received Electric Convulsive Therapy; 2 patients were demanding of staff time and 3 patients required special monitoring due to eating disorders.

c. Review of reported patient incidents from Unit 3IF from 8/1/15 to 11/9/15 provided by the Director of Quality Improvement revealed that for this time period there was one patient who had an accident with injury; 1 patient had an adverse drug reaction; 19 aggressive events by patients; 23 patient to patient assaults; 11 patient to staff assaults; 1 patient elopement and 3 elopement attempts; 1 patient contraband possession incident; 5 patient falls (1 with injury) and 18 incidents of self-injury.

d. According to the Director of Nursing RN coverage (RNs off the unit for meals, patient codes, etc.) for Unit 3SW is shared with Unit 3IF.

e. Review of Staffing Schedules provided by the Director of Nursing for 7 days, including the first day of the survey (11/9/15), revealed the following staffing deficiencies on Unit 3SW based on the information documented in the above sections a through d.

1).On the day shift on 11/3/15 and 11/5/15 through 11/8/15 there was only 1 RN assigned to the unit without scheduled relief when the RN was off the unit.

2).On the evening shifts on 11/3/15 and from 11/6/15 through 11/9/15 there was only 1 RN assigned to the unit without scheduled relief when the RN was off the unit.

3). On the night shifts from through 11/4/15 and through 11/9/15 there was only 1 RN assigned to the unit without scheduled relief when the RN was off the unit.

f. Observation and Interview for 3SW

1). During interview on Unit 3SW on 11/9/15 at 12:00 p.m., RN W3 reported that the RNs on Unit 3SW and Unit 3IF provide RN coverage for the adjoining unit when one of the RNs is off his/her assigned unit (e.g. meal break). RN W3 stated that the RN could be off the assigned Unit for as long as 30 minutes if a patient assessment and interventions are required

2). At 12:01 p.m. on 11/9/15, patient F6 fell in the hallway of 3SW and was seizing, an emergency was called and RN's responded from a variety of units including RNY1 from Unit 2SW involved, She said "an LPN and HCT remained on unit 2SW" while she was on unit 3SW for the 20 minutes until 911 removed the patient. At 12:08 p.m., the Director of Quality Improvement identified "4 RN's at the emergency and said they responded from other units".

3). At 12:15 p.m. on 11/10/15, there were seve (7) patients in the hallway of 3SW. At this time Patient C1 was arguing with C11, screaming in the hall. There was no staff in the hallway at this time. RNW3 came out of the closed nurse's station as did HCTY2; second HCTY3 was off of the unit at this time getting lunch trays for 3SW and 3IF. Prior to HCTY3 returning, HCTY2 took six (6) patients off of the unit to lunch leaving RNW3 alone on the unit with eight (8) visible patients including C1 who was still upset and argumentative.