HospitalInspections.org

Based on interview and policy review there was a failure of the excluded PPS (Prospective Payment Systems) psychiatric unit to show evidence that utilization review was being done for the types of care being offered in the unit. Findings include:

Per document review there was no evidence that the unit was performing any utilization review of the types of care provided and/or had a specific policy related to this.

Per interview with the Unit Director on 12/3/12 at 12:21 PM, S/He stated that S/He had been monitoring measures that CMS (Centers for Medicare and Medicaid) had expected the facility to review; however, S/He did not have any documentation and/or policies related to quality and/or utilization review for the unit.

Based on interview and policy review there was a failure of the excluded PPS psychiatric unit to ensure 3 of 7 (Staff #1, #4 and #7) professional and technical staff were qualified. Findings include:

Per review of several documents provided by the Unit Director on 12/6/21, there was no evidence that Staff #1, #4, and
#7 had BLS/CPR (Basic Life Support/Cardiopulmonary Resuscitation) certification and/or that they had completed other necessary training's used in helping to evaluate, assess, and treat the patient population that was served.

Per interview with the Unit Director on 12/6/21 at 11:22 AM, S/He stated that the expectation was that staff were BLS/CPR certified prior to being hired and that S/He was currently working to ensure all staff were trained on unit specific policies and procedures.

Based on interview and record review the Community Access Hospital (CAH) failed to deliver health care services according to their policies for patient rights & responsibilities and code of conduct for 1 applicable patient (Patient #1); and prevention of patient abuse and neglect through screening for 5 of 7 staff members (Staff #1, 2, 4, 6, 7). Findings include:

1.) Per review of nursing admission note from 11/18/21, Patient #1 arrived at the facility via ambulance from an area Emergency Department. Prior to this admission, the patient was at a treatment facility which caused him/her "a great deal of stress and suicidal ideation". During a physical assessment, it was noted that S/He had a "small pick mark" on his/her left hand. S/He was well known to the staff and stated S/He was "feeling safe" and "denies urge to SH (self-harm)". Per review of a nursing note from 11/19/21 at 8:39 PM, "Pt appears anxious ...pt states feeling anxious and tired". S/He "reports being woken up several times and feels screaming triggered PTSD (post-traumatic stress disorder) d/t peer on unit". S/He "states urge to s/h early in day after poor sleep and anxiety ...denies S/I (suicidal ideation), H/I (homicidal ideation) and safety concerns". Per review of a provider's history and physical note from 11/19/21, Patient #1 had a history of depression, anxiety, post-traumatic stress, and alcohol abuse. S/He had previously been admitted to the facility on 10/12/21. Upon evaluation, the patient "continues to report decreased ability to sleep, feelings of hopelessness, worthlessness, increasing depressive thoughts and increased thoughts of self-harm without a plan". "Plan for a short hospital stay. The patient became very comfortable here during prolonged admission last time".

Per a nursing note from 11/20/21 at 5:25 AM, "Slept all night ...6.5 hours for this shift". At 7:30 AM, "attempted blood draw ...in both arms, unsuccessfully". At 10:49 AM, the patient reported "'Having a hard day' .... experiencing 'lots of triggers' ...Affect flat ...Denies any urges to SH ...Contracts verbally for safety". At 2:29 PM, "Pt tearful when sharing that one of the staff 'triggered her' ...the staff had "wanted" him/her to "rap to a song" S/He "found inappropriate ...and made comments about" his/her appearance". The patient was "shaking and crying when sharing" his/her experience". The patient "notes" that S/He "does not feel safe" when the staff member is working. Per a provider's note from 11/20/21, the patient "had difficulty engaging with treatment team ...was violently shaking this am". S/He would not disclose what had happened; however, later stated that a staff member was making "inappropriate sexual jokes and being flirtatious". S/He "attempted to scratch herself on the arm but states that" S/He "is not suicidal". Per a nursing note from 11/21/21 at 5:38 AM, the patient had "Mid cycle awakening ...Appears to have slept 5.5 hours this shift". At 9:33 AM, the patient had "no feeling of SH but 'scared ...do not want retaliation'". At 10:18 PM, "Pt appeared tired and irritable ...had a phone call" from a family member. "Pt went to" his/her "room and napped for a few hours. Denies SI". On 11/22/21 at 10:21 AM, "Affect sad, sits with hands clenched ...Pt prefers to stay" at the facility. "Pt reports feeling safe ... as there are staff" S/He "knows will keep" him/her "safe". On 11/24/21. "Pt appeared depressed and tearful ...Pt concerned about possibly staying at a motel as a short stay until more stable housing ...is not ready ... and 'do not want to be kicked out'".

Per interview on 12/3/21 at 10:44 with Patient #1, S/He stated that "most staff" were "supportive"; S/He had an issue with a night shift nurse who was making "inappropriate comments". S/He stated that the staff member had attempted to draw blood and "stood over" him/her and S/He felt "very vulnerable". The staff member further commented "how beautiful" S/he "was and that" S/He "deserved to have" his/her "feet rubbed ...and any man" ... "was lucky to have" him/her. The staff member also made "inappropriate jokes". S/He stated that the Nurse Practitioner did question him/her about whether S/He felt safe in the facility. S/He stated that S/He did not want to leave the facility; however, S/He didn't "feel safe at night ...really not the way" S/He "used to", and that S/He "did not have any further contact" with Staff #4. S/He also stated that S/He "felt like, since the incident they are pushing" him/her "out the door".

Per interview on 12/6/21 at 10:36 AM with Staff Nurse #4, S/He stated that the unit expectation for drawing blood was that it would be done early in the morning, before morning report. On 11/20/21, S/He went to draw Patient #1's blood, it was unsuccessful, and S/He asked the other nurse on duty to try, and S/He also was unsuccessful. Staff Nurse #4 stated that S/He had asked Patient #1 if S/He had a "dad joke for the day". S/He stated that Patient #1 "told an inappropriate joke". And then S/He "told two inappropriate jokes". S/He stated S/He didn't "know if" S/He "said anything about how the patient looked". S/He further stated that S/He "did say two dirty jokes and don't know why ...not proud of this ...don't have any reason why". S/He further stated that S/He remembered signing the facility's code of conduct and that the code meant to "dress neatly, be professional, take care of patients".

Per review of the policy "Patient Rights & Responsibilities"-approved 4/16/2021, it states, "While You are a Patient in This Hospital, You Have the Right to: Respect for your personal privacy, dignity and comfort. Receive care in a safe setting".

Per review of the policy "Code of Conduct"-approved 1/21/2020 it states, "to provide quality care to our patients. As part of this, we strive to ensure an ethical and compassionate approach to healthcare delivery and management. We must demonstrate consistently that we act with absolute integrity in the way we do our work and they way we live our lives ...Patients are treated in a manner that preserves their dignity, autonomy, self-esteem, civil rights, and involvement in their own care ...colleagues will receive training about patient rights in order to clearly understand their role in supporting them". The facility "requires all colleagues to sign an acknowledgement confirming they have received the Code and understand it represents mandatory policies of" the facility. "New colleagues will be required to sign this acknowledgement as a condition of employment".



2.) Per review of personnel files for Staff Members #1, 2, 4, 6, 7 there was no evidence that the state child and adult abuse checks were done.

Per interview on 12/6/21 at 12:20 PM with the Human Resources Manager, S/He stated that the facility policy was to perform background checks upon hire and that those checks included state child and adult abuse.

Per interview on 12/6/21 at 2:09 PM with the Director of Quality/Risk and the Chief Nursing Officer they confirmed that state child and adult abuse checks were not done and/or that there was no record of them being done for the above staff members.

Per review of the policy "Prevention of Abuse and Neglect of Patients by Staff" -approved 10/14/2020 it states, "Each patient has the right to be free from abuse, corporal punishment, and involuntary seclusion. Patients must not be subjected to abuse by anyone, including but not limited to, facility staff, other patients, consultants of volunteers, staff of other agencies serving the patient, family members or legal guardians, friends, or other individuals ...Procedure A. Screening of Employees- All individuals who have applied for employment at" the facility "will be screened for a history of abuse, neglect, mistreating of patient's as defined above ...The Human Resources Department, upon any substantiated abuse complaint will report the individual to the state officials, including the state survey and certification agencies, in accordance with state law within 48 hours of occurrence".

Based on interview and record review, the CAH failed to ensure that nursing staff were adequately trained, competent, and their clinical activities were evaluated for 5 of 5 staff reviewed. Findings include:

Per review Staff #1's personnel file there was no evidence of certification for BLS/CPR, that S/He had received training regarding blood draws, training specific to the patient needs of the PPS psychiatric unit, and no consistent evidence of "ongoing" training for abuse/neglect.

Per review of Staff #2's personnel file his/her BLS/CPR certification expiration expired on 3/19/21; and there was no consistent evidence of "ongoing" training for abuse/neglect and no evidence of consistent competency and/or performance evaluations.

Per review of Staff #4's personnel file there was no evidence of certification for BLS/CPR, that S/He had received training regarding blood draws, and/or training specific to the patient needs of the PPS psychiatric unit, and no consistent evidence of "ongoing" training for abuse/neglect.

Per review of Staff #3 & #5's personnel files there was no evidence of "ongoing" training for abuse/neglect and no evidence of consistent competency and/or performance evaluations.

Per interview on 12/3/21 at approximately 5:00 PM with the Director of Quality/Risk, S/He stated that the facility's education and human resources systems were not in line with each other and that there were some "gaps" in the processes.

Per interview on 12/6/21 at 11:22 AM with the Unit Director, S/He stated that BLS/CPR was to be completed upon hire and they were currently working on ensuring staff were trained with the skills needed for the psychiatric unit. S/He confirmed that the current "system was disjointed".

During an interview on 12/6/21 at 2:09 PM with the Chief Nursing Officer, S/He stated that the facility did not have a definition for "ongoing" as it read in the facility's abuse/neglect policy therefore, S/He was not able to verify how often this training was taking place for staff.

Per review Per review of the policy "Prevention of Abuse and Neglect of Patients by Staff" -approved 10/14/2020 it states, "B. Training of Employees-In order to prevent the abuse or neglect of patients and to ensure a safe environment, all staff at" the facility, "in any capacity, will receive training through orientation, and ongoing sessions, on issues related to abuse prevention practices. The content should include: 1. What constitutes abuse, neglect, and misappropriation of patient property. 2. How staff can recognize signs of burnout, frustration, and stress that may lead to abuse, and resources that are available for help. 3. How staff should report their knowledge, related to allegations of abuse, without fear of reprisal. 4. Appropriate interventions to deal with aggressive and/or catastrophic reactions of patients. 5. How staff will report abuse and to whom. Records of orientation, and ongoing training programs, will be kept by the Professional Development Department in the employee's file."