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Based on observation, interview and record review, the hospital failed to meet the requirements of the Condition of Participation of Patient Rights. This was evidenced by:
1) failure to inform patients or patients' representative of patients' rights in advance in a language or manner non-English speaking Patient #3 could understand (See findings under Tag A0117);
2) failure to ensure non-English speaking Patient #3 had a translator to assist with the development and implementation of the patient's plan of care (See findings under Tag A0130);
3) failure to use an interpreter/translator to assist non-English speaking patient #3 in understanding and agreeing with multiple consents found in the In-Patient Admission Packet (See findings under Tag A0131);
4) failure to ensure the hospital was free of ligature risks (See findings under Tag A0144);
5) failure to have mechanisms/methods in place that ensure non-English speaking patients have the use of an interpreter/translator to assist with the communication of needs (See findings under Tag A0145).

Based on record review and interview the psychiatric hospital failed to inform the patients or patients' representative of the patients' rights in advance as evidenced by failure to explain in a language or manner Patient #3 could understand.
Findings:

Review of hospital policy titled "Patient Rights", dated 09/01/2023, revealed, in part: Purpose, in part: To ensure that all patients are aware of their rights while being treated at this facility ....Policy:, in part: Every patient shall receive a written copy of their rights and responsibilities as a patient as part of the Patient handbook and shall sign an acknowledgement that they are aware of their rights.

Review of hospital policy titled "Communication with Persons of Limited English Proficiency", dated 02/01/2021, revealed, in part: Purpose: The purpose of this policy is to ensure proper services to anyone who is Limited English Proficient (LEP). All patients have a right to communications in a language and format understandable to the individual for all services provided. Policy, in part: It is the policy of the facility to provide communication aids at no cost to individuals who are LEP, including current and prospective patients, and family. Patients will be provided with alternative communication methods, which allow them to participate more fully in their care. Procedure, in part: 2. The facility will provide oral and written translation services, free of charge to any patient in need of such services. This may be accomplished by utilizing the facility's contracted language interpretation services.

Review of hospital document titled "Job Description, Director of Nursing", dated 11/01/2023, revealed, in part: Position Summary, in part: ...demonstrates...cultural sensitivity. Essential Functions, in part: 8. ensures staff compliance with patient care, documentation, hospital/unit policies and procedures, protocols, and guidelines...

Review of hospital document titled "Job Description, Assistant Director of Nursing", dated 11/01/2023, revealed, in part: Essential Functions, in part: 36. Upholds and enforces the policies and procedures, governing patient rights, confidentiality and safety.

Review of Patient #3's medical record revealed patient #3 was admitted on 12/22/2023 with a diagnosis of Dementia, Psychosis, and behavior disturbances, Traumatic Brain Injury with cerebral hemorrhage, Alcohol abuse, and Depression with suicidal ideations.

Further review revealed a document titled hospital "Multidisciplinary Progress Note", dated 12/22/2023 at 7:15 a.m. Continued review revealed Patient #3 was non-English speaking.

Review of Patient #3's Inpatient Admission Packet dated 12/28/2023 (6 days after admission) failed to reveal evidence the hospital used an interpreter/translator to assist with Patient #3's understanding and agreement with the acknowledgment of his rights as a patient, privacy rights, safe keeping of his personal property, and end of life decisions.

In an interview on 01/10/2023 at 4:35 p.m., S3DON confirmed the Inpatient Admission Packet was dated 12/28/2023, 6 days after admission and further verified that there was no evidence the hospital used an interpreter/translator to aid in Patient #3's understanding of his rights as a patient, including but not limited to, privacy rights, safe keeping of his personal property, and end of life decisions.

Based on record review and interview, the psychiatric hospital failed to ensure the patient /patient representative's right to participate in the development and implementation of his or her plan of care was met. This deficient practice was evidenced by failure to ensure Spanish speaking Patient #3 had a translator to assist with the development and implementation of the patient's plan of care
Findings:

Review of hospital policy titled "Patient Rights", dated 09/01/2023, revealed, in part: Policy:, in part: Treatment, in part: you have the right to be involved in making decisions regarding the nature of care, treatment, and services that you will receive and to make decisions about your care. If you are unable to make decisions about the care, treatment, and services, the rights of involvement of family/surrogate decisions maker instead on the patient's behalf will be respected in accordance law and regulations.

Review of Patient #3's Interdisciplinary Treatment Plan Master Sheet, dated 12/22/2023, revealed "Language Preference"-Hispanic. Further review revealed the patient was unable to participate in the development of this treatment plan because patient was non-English speaking, unable to process what was being educated on and asked.

Continued review failed to reveal evidence the hospital used an interpreter/translator to assist Patient #3 with his right to participate in the development of his treatment plan.

Review of Patient #4's Interdisciplinary Treatment Plan 01/10/2024 failed to reveal Problem, Outcomes/Goals and interventions for "Communication Barriers". Further review failed to reveal evidence the hospital used an interpreter/translator to assist Patient #3 with understanding treatment goals, agreeing with the individual treatment plan and participating in his plan of care.

In an interview on 01/10/2024 at 4:01 p.m., S3DON confirmed their was no documented evidence of the use of an interpreter/translator to assist Patient #3 with his right to participate in the development of his treatment plan, to understand treatment goals and to agree with the individual treatment plan as developed.

Based on record review and interview, the hospital failed to ensure patients/representatives had the right to make informed decisions regarding care. This is evidenced by failing to use an interpreter/translator to assist non-English speaking patient (#3) in understanding and agreeing with multiple consents found in the Inpatient Admission Packet.
Findings:

Review of non-English speaking Patient #3's medical record revealed an admission date of 12/22/2023. Continued review revealed an In-Patient Admission Packet dated 12/28/2023 (6 days after admission).

Further review failed to reveal evidence that the hospital used an interpreter/translator to assist Patient #3 in understanding and agreeing with the following consents and forms found within the Inpatient Admission Packet:
a) Consent for Treatment;
b) Consent for Transportation;
c) Consent to Photograph;
d) Consent for Emergency Treatment and Transfer;
e) PCP acknowledgment;
f) Certification that Patient #3 read fully and completely understood, and agreed with the above provisions;
g) acknowledgement of receipt of Patient Handbook.
h) Consent & Authorization for Alcohol and Substance Use;
i) Health Insurance Portability and Accountability Act acknowledgement;
j) Consent for Involvement in Treatment;
k) Advanced Directives.

In an interview on 01/10/2023 at 4:22 p.m., S3DON confirmed that there was no documented evidence the hospital used an interpreter/translator to assist non-English speaking Patient #3 in understanding and agreeing with the consents and forms found in the Inpatient Admission Packet.

Based on observation and interviews, the hospital failed to ensure patients received care in a safe setting as evidenced by failure to ensure the hospital was free of ligature risks.
Findings:

Review of hospital policy titled "Environmental Services Guidelines", dated 05/01/2023, revealed, in part: Procedure: 9. Plastic bags are never allowable in patient care areas.

An observation on 01/10/2024 at 8:55 a.m. of patient area A revealed a blue plastic trash liner in trashcan.

In an interview on 01/10/2024 at 8:55 a.m., S1HIM confirmed the blue plastic trash liner in the trashcan of patient area A.

In an interview on 01/10/2024 at 9:21 a.m., S3DON verified that there should be no plastic liners in any trashcans in any patient areas.

An observation on 01/10/2024 at 8:58 a.m. of room g revealed bathroom with non-ligature resistant paper towel dispenser attached to wall creating a ligature risk.

An observation on 01/10/2024 at 9:01 a.m. of rooms e and f revealed shared bathroom with non-ligature resistant paper towel dispenser attached to wall creating a ligature risk.

An observation on 01/10/2024 at 9:03 a.m. of rooms c and d revealed shared bathroom with non-ligature resistant paper towel dispenser attached to wall creating a ligature risk.

An observation on 01/10/2024 at 9:04 a.m. of rooms h and i revealed shared bathroom with non-ligature resistant paper towel dispenser attached to wall creating ligature risk.

An observation on 01/10/2024 at 9:13 a.m. of rooms a and b revealed shared bathroom. Further observation revealed commode booster seat made with pvc-like piping, damaged safety box around pipes under sink falling out of the wall with two loose screws hanging from holes and non-ligature resistant paper towel dispenser attached to wall, all creating ligature risks.

An observation on 01/10/2024 at 10:55 a.m. of room j revealed a non-ligature resistant air-conditioning grille located in the ceiling, easily reached by standing on the bed; a non-ligature resistant paper towel dispenser in room j's bathroom.

In an interview on 01/10/2024 at 10:55 a.m., S18DQ confirmed ligature risks located in room j and room j's bathroom.

In an interview on 01/10/2024 at 9:33 a.m., S3DON confirmed ligature risks located in shared bathroom of rooms a and b; c and d; e and f; and h and i.

In an interview on 01/10/2024 at 10:30 a.m., S4RN reported 7 of 15 patients on the census were on suicide precautions.

In an interview on 01/10/2024 at 11:26 a.m., S5PM confirmed paper towel dispensers were installed using four B brand anchors each with weight limit of 75-100 lbs. S5PM stated paper towel dispensers were ligature risks.

An observation on 01/10/2024 at 12:29 p.m. revealed S3ADON and S18DQ demonstrating the paper towel dispensers were ligature risks.

Based on observation, record review and interview, the hospital failed to provide an environment free from all forms of neglect. This is evidenced by failing to have mechanisms/methods in place that ensure non-English speaking patients have the use of an interpreter/translator to assist with their communication of needs.
Findings:

Review of hospital policy titled "Communication with Persons of Limited English Proficiency", dated 02/01/2021, revealed, in part: Purpose: The purpose of this policy is to ensure proper services to anyone who is Limited English Proficient (LEP). All patients have a right to communications in a language and format understandable to the individual for all services provided. Policy, in part: It is the policy of the facility to provide communication aids at no cost to individuals who are LEP, including current and prospective patients, and family. Patients will be provided with alternative communication methods, which allow them to participate more fully in their care. Procedure, in part: 2. The facility will provide oral and written translation services, free of charge to any patient in need of such services. This may be accomplished by utilizing the facility's contracted language interpretation services.

Observation on 01/10/2024 at 9:00 a.m. revealed Patient #3 attempted to leave the dining room and walk down the hallway. He attempted to communicate his needs in Spanish to S16MHT but was unable to communicate his needs to S16MHT in English. Continued observation failed to reveal S16MHT was proficient in Spanish. Further observation failed to reveal S16MHT used a translator.

In an interview on 01/10/2024 at 9:01 a.m., S16MHT stated that she could use a translator on her phone to communicate with Patient #3 but she believed he understood what she communicated to him in English. S16MHT believed he wanted to go to his room and lay down; therefore, she did not need to use a translator.

In an interview on 01/10/2024 at 9:02 a.m. S2ADON stated they attempt to use phone translators to communicate to non-English speaking patients and she was not sure why S16MHT was not using one since she was not speaking Spanish.

Based on observation, record review and interview, the nursing services department of the hospital failed to provide adequate numbers of support personnel to provide nursing care to all patients as needed. This deficient practice was identified for 11 (11/11/23PM, 11/17/2023PM, 11/18/2023PM, 11/19/23PM, 11/23/23PM, 11/24/23PM, 11/25/23PM, 11/26/23PM, 11/27/23PM, 11/29/23PM and 01/10/2024AM) of the 31 shifts (11/11/23AM and PM, 11/16/23AM and PM, 11/17/2023AM and PM, 11/18/2023AM and PM, 11/19/23AM and PM, 11/20/23AM and PM, 11/21/23AM and PM, 11/22/23AM and PM, 11/23/23AM and PM, 11/24/23AM and PM, 11/25/23AM and PM, 11/26/23AM and PM, 11/27/23AM and PM, 11/28/23AM and PM, and 11/29/23AM and PM and 01/10/2024AM) reviewed and had the potential to affect any of the 16 inpatients receiving care and services during the time of the survey.
Findings:

Review of hospital document titled "Job Description, Director of Nursing", dated 11/01/2023, revealed, in part: Essential Functions, in part: 2. Supervises nursing personnel including: Determining workload and delegating assignments ...8. ...Ensures appropriate nursing staff for each unit to meet patient needs.

Review of hospital document titled "Job Description, Assistant Director of Nursing", dated 11/01/2023, revealed, in part: Position Summary, in part: ...Communicates, coordinates and facilitates adequate staffing of all nursing units under the supervision of the Director of nursing. Essential Functions, in part: 3. Supervises subordinate personnel including: determining workload and delegating assignments ...24. Ensures appropriate nursing staff for each unit to meet patient needs.

Review of hospital policy titled "Staffing Plan", dated 09/01/2022, revealed, in part: Procedure, in part: Patient census and staffing matrix are used to determine staffing needs.

Review of hospital document titled "Governing Board 2022 4th Quarter and Annual for 2023 Meeting Minutes", dated February 15, 2023, revealed, in part: Current Hospital Staffing, in part: Geri Unit 1:6 ratio Mental Health Technician (MHT).

Review of sixteen daily nursing staffing sheets for day and night shifts revealed on the following shifts, nursing services failed to meet the ratio of 1 MHT to 6 patients:

11/11/2023 on the PM shift with a census of 10 patients, the required ratio of 1 MHT to 6 patients called for 2 MHTs; review of the daily staffing sheet revealed 1 MHT making the hospital deficient by 1 MHT on that shift; and,

In an interview on 01/10/2024 at 1:30 p.m., S18DQ verified the deficient staffing.

11/17/2023 on the PM shift with a census of 14 patients, the required ratio of 1 MHT to 6 patients called for 3 MHTs; review of the daily staffing sheet revealed 2 MHTs making the hospital deficient by 1 MHT on that shift; and,

In an interview on 01/10/2024 at 1:32 p.m., S18DQ verified the deficient staffing.

11/18/2023 on the PM shift with a census of 15 patients, the required ratio of 1 MHT to 6 patients called for 3 MHTs; review of the daily staffing sheet revealed 2 MHTs making the hospital deficient by 1 MHT on that shift; and,

In an interview on 01/10/2024 at 1:35 p.m., S18DQ verified the deficient staffing.

11/19/2023 on the PM shift with a census of 16 patients, the required ratio of 1 MHT to 6 patients called for 3 MHTs; review of the daily staffing sheet revealed 2 MHTs making the hospital deficient by 1 MHT on that shift; and,

In an interview on 01/11/2024 at 12:15 p.m., S3DON verified the deficient staffing.

11/23/2023 on the PM shift with a census of 17 patients, the required ratio of 1 MHT to 6 patients called for 3 MHTs; review of the daily staffing sheet revealed 2 MHTs making the hospital deficient by 1 MHT on that shift; and,

In an interview on 01/10/2024 at 1:37 p.m., S18DQ verified the deficient staffing.

11/24/2023 on the PM shift with a census of 15 patients, the required ratio of 1 MHT to 6 patients called for 3 MHTs; review of the daily staffing sheet revealed 2 MHTs making the hospital deficient by 1 MHT on that shift; and,

In an interview on 01/11/2024 at 10:29 a.m., S18DQ verified the deficient staffing.

11/25/2023 on the PM shift with a census of 16 patients, the required ratio of 1 MHT to 6 patients called for 3 MHTs; review of the daily staffing sheet revealed 2 MHTs making the hospital deficient by 1 MHT on that shift; and,

In an interview on 01/11/2024 at 10:30 a.m., S18DQ verified the deficient staffing.

11/26/2023 on the PM shift with a census of 16 patients, the required ratio of 1 MHT to 6 patients called for 3 MHTs; review of the daily staffing sheet revealed 2 MHTs making the hospital deficient by 1 MHT on that shift; and,

In an interview on 01/11/2024 at 10:32 a.m., S18DQ verified the deficient staffing.

11/27/2023 on the PM shift with a census of 14 patients, the required ratio of 1 MHT to 6 patients called for 3 MHTs; review of the daily staffing sheet revealed 2 MHTs making the hospital deficient by 1 MHT on that shift; and,

In an interview on 01/11/2024 at 10:34 a.m., S18DQ verified the deficient staffing.

11/29/2023 on the PM shift with a census of 14 patients, the required ratio of 1 MHT to 6 patients called for 3 MHTs; review of the daily staffing sheet revealed 2 MHTs making the hospital deficient by 1 MHT on that shift; and,

In an interview on 01/11/2024 at 12:15 a.m., S13DON verified the deficient staffing.

01/10/2024 at 8:45 a.m. observation of the hospital unit revealed the following staff: S16MHT, S17MHT and S4RN.

Review of census for 01/10/2024 revealed 15 patients, 7 patients on suicide precautions, 1 on 1:1 observation and 1 on Line of Sight Observation. The required ratio of 1 MHT to 6 patients called for 3 MHTs.

01/10/2024 at 8:59 a.m. observation of room h revealed Patient R1 lying in bed with no sheets and no pillow. Patient R1s medical record revealed he was admitted on 01/03/2024 with diagnosis of Dementia with behavioral disturbance and psychosis with MDD and anxiety. Placed on high fall risk with Q 15 minute observation.

In an interview on 01/10/2024 at 9:04 a.m., S2ADON confirmed that the patient had made his way to his room, was sleeping without sheets, on bare mattress with no pillow and stated he should have sheets and a pillow.

In an interview on 01/10/2024 at 9:28 a.m., R4RN reported she had one patient who was 1:1 and one patient who was "Line of Site", only 2 MHTs and one patient acting out which made it difficult to keep track of Patient R1 who was on high fall risk precautions.

In an interview on 1/10/2024 at 1:30 p.m. S18DQ confirmed staffing was short on the days indicated on staffing sheets above.

Based on record review and interview the hospital failed to ensure the Registered Nurse evaluated the care of each patient upon admission in accordance with accepted standards of nursing practice and hospital policy. This deficiency is evidenced by failure to use an interpreter/translator to complete the Nursing Admit Assessment, which also included the Columbia Suicide Severity Rating Scale, for non-English speaking Patient #3.
Findings:

Review of hospital policy titled "Communication with Persons of Limited English Proficiency", dated 02/01/2021, revealed, in part: Purpose: The purpose of this policy is to ensure proper services to anyone who is Limited English Proficient (LEP). All patients have a right to communications in a language and format understandable to the individual for all services provided. Policy, in part: Patients will be provided with alternative communication methods, which allow them to participate more fully in their care. Procedure, in part: 2. The facility will provide oral and written translation services, free of charge to any patient in need of such services. This may be accomplished by utilizing the facility's contracted language interpretation services.

Review of hospital policy titled "Suicide/Homicide Risk Assessment" revealed, in part: Purpose: The purpose of this policy is to ensure an effective method for suicide/homicide screening, assessment, monitoring, and treatment of patients at risk for suicide/homicide. Procedure: Inpatient, in part: 2. The Registered Nurse will complete the Suicide ...risk Assessment as a part of the Admit Nursing Assessment. Suicide ...risk level will be determined, and appropriate precautions are implemented and incorporated into the treatment plan if applicable.

Review of hospital document titled "Job Description, Director of Nursing", dated 11/01/2023, revealed, in part: Essential Functions, in part: 8. Ensures staff complaince with patient care, documentation, hospitalunit policies and procedures, protocols, and guidelines.

Review of hospital document titled "Job Description, Assistant Director of Nursing", dated 11/01/2023, revealed, in part: Essential Functions, in part: 36. Upholds and enforces the policies and procedures, governing patient rights, confidentiality and safety.

Review of Patient #3's Admit Nursing Assessment dated 12/22/2023 revealed patient was non-English speaking.

Continued review failed to reveal documented evidence the nurse used an interpreter/translator to assist with the process of the Admit Assessment, which also included the Columbia Suicide Severity Rating Scale.

In an interview on 01/10/2024 at 4:01 p.m., S3DON verified the Admit Nursing Assessment dated 12/22/2023, revealed patient was non-English speaking. S3DON confirmed the Admit Assessment failed to reveal documented evidence the nurse used an interpreter/translator to assist with the process of the Admit Assessment, which also included the Columbia Suicide Severity Rating Scale.

Based on record review and interview the hospital failed to ensure all nursing staff followed the policies and procedures of the hospital. This deficiency is evidenced by failure of the hospital to complete performance evaluations on 1 (S7ARN) of 1 (S7ARN) Agency Registered Nurse personnel files reviewed for performance evaluations.
Findings:

Review of hospital policy titled "Nursing Staff Orientation", dated 12/01/2021, revealed, in part: Policy: New nursing personnel will receive orientation to their position and to (hospital) policies and procedures. The orientation program shall include a review of the policy/procedures, job descriptions, competency evaluation, on-the-job orientation and performance expectations. Procedure, in part: 5. Evidence of all components of the nursing employee orientation and competency assessment are maintained in the employee's human resource file.

Review of hospital document titled "Job Description, Director of Nursing", dated 11/01/2023, revealed, in part: Essential Functions, in part: 2. Supervises nursing personnel including: ...evaluating performance. Conducts and reviews evaluations on individual staff ....3. Accountable for nursing performance improvement ...9. Directs appropriate training activities for all permanent and temporary nursing employees ...

A review of S7ARN's personnel file revealed year of hire 2015. Further review revealed S7ARN was an agency acquired Registered Nurse. Continued review of S7ARN's personnel file failed to reveal documented evidence of a completed performance evaluation since hire.

In an interview on 01/11/2024 at 12:45 p.m. S17HR confirmed there was no evidence of a completed performance evaluation for S7ARN. S17HR stated she was not aware that agency staff were expected to undergo performance evaluations.

Based on observations and interviews, the hospital failed to ensure the condition of the physical plant and overall hospital environment was maintained in a manner that provided an acceptable level of safety and well-being for patients, staff, and visitors. This deficient practice was evidenced by failure to maintain the physical plant in good repair and failure to maintain a safe patient care environment.
Findings:

Review of hospital policy titled "Environmental Services Guidelines", dated 05/01/2023, revealed, in part: Policy: Facility shall provide the necessary services required to maintain a clean, sanitary, and safe environment in accordance with industry best practices. Procedure, in part: Patient rooms-Daily. 3. Cleaning in patient rooms is always conducted with a top-to-bottom cleaning method. Bathrooms and Showers-Daily, in part: 1. Bathrooms are to be cleaned a minimum of one time per day by environmental services staff.

Review of hospital document titled "Job Description, Housekeeping", revealed, in part: Position Summary, in part: ...Aspects of services include, but are not limited to , cleaning occupied and discharged patient rooms ...Essential functions, in part: 2. Cleans and disinfects patients' rooms and baths daily. 3. Performs terminal cleaning after transfer or discharges 100% of the time. 4. Cleans, empties, dusts, and sanitizes ...restrooms ...9. Reports broken, defective patient care/room equipment ...

Observations on 01/10/2024 beginning at 8:45 a.m. with S1HIM, 9:04 a.m. S2ADON joined, 9:27 a.m., S3DON joined and 9:31 a.m. S18DQ joined. Observed the following:

8:57 a.m.: Rooms e and f revealed a shared bathroom with crackled, flaking and peeling paint created exposed areas of drywall above the commode.

9:04 a.m.: Room i revealed crackled, flaking, and peeling paint with cracked plaster and a hole in the wall above air conditioning unit. Bathroom shared with rooms h and i revealed crackled, flaking, and peeling paint created exposed areas of drywall above the commode.

9:13 a.m.: Rooms a and b revealed a shared bathroom with toilet paper shoved into crevices along rail next to commode. Brown substance smeared on commode. Crackled, flaking, and peeling paint created exposed areas of drywall above the commode and the sink. Room a revealed ceiling with large water stain with crackled, flaking and peeling paint over patient bed.

9:15 a.m.: Room b revealed bare mattress and no sheets, bedside table with exposed particleboard and peeling paint. Exposed metal with sharp edges and loose metal parts attached to bedside table.

9:20 a.m.: Rooms c and d revealed shared bathroom with room c's bathroom door hanging off velcro hinges; crumpled tissue on the floor by commode; loose faucet coming out of the sink; brown substance smeared above sink; peeling paint next to commode. Room c with baseboard flap coming off wall next to air conditioning unit.

9:22 a.m.: Room k revealed crackled, flaking and peeling paint on wall and windowsill with peeling paint above air conditioning unit.

10:55 a.m.: Room j revealed the patient side of the door had peeling paint with exposed wood and white cloudy dried substance dripping from window; bed with dirt and dirty cotton balls under mattress; bathroom trashcan containing toilet paper with brown substance; crackled, flaking, and peeling paint above commode with safety box covering pipes pulling away from the wall.

In an interview on 01/10/2024 at 10:56 a.m., S3DON and S18DQ confirmed the above observations failed to reveal a clean, safe and sanitary environment.