HospitalInspections.org

Based on a review of documentation and an interview with staff, the facility failed to protect and promote each patients right to care in a safe setting, as evidenced by:

* 4 of 16 clinical records contained admission assessments performed by a licensed vocational nurse or not performed at all.

* 15 of 21 clinical records contained 12-hour reassessments performed by licensed vocational nurses (not registered nurses).

* The facility failed to make sure a registered nurse was on duty on each unit where patients were present.

As comprehensive assessments were performed by licensed vocational nurse (although those assessments fall outside the scope of practice of a licensed vocational nurse), the above listed patients were placed at an increased risk of harm.

Based on a review of documentation and an interview with staff, the facility failed to ensure that patients receive care in a safe setting, as the facility failed to perform admission assessments, reassessments in accordance to the hospital's policy and failed to ensure that a registered nurse is present on each unit.


Findings were:

Based on a review of documentation and an interview with staff, the facility failed to ensure that all patients received an initial, comprehensive nursing assessment within 8 hours of their admission.


The clinical records for 16 current patients were reviewed (current patients #1 through #16). Of the 16 records reviewed, 4 of 16 patients did not receive an initial, comprehensive nursing assessment by a registered nurse within 8 hours of their admission. Failure to perform the assessments (or the assessments being performed by a licensed vocational nurse) poses the likelihood of not identifying the medico-nursing needs of the patients and in turn, increasing the likelihood of not meeting those needs.


* Patient #6 - record contained no admission assessment

* Patient #13 - the admission assessment was performed by staff #24 (a licensed vocational nurse) and cosigned by a registered nurse

* Patient #14 - the admission assessment was performed by staff #24 (a licensed vocational nurse) and cosigned by a registered nurse

*Patient #15 - the admission assessment was performed by staff #24 (a licensed vocational nurse)

All signatures were confirmed in an interview with staff #3.



Facility policy 900.02 titled "Documentation Overview" states, in part:

"4.0 Procedure
A. The medical record includes at least the following:

2. Assessment Data

5. Nursing Assessment - The patient must be assessed by an RN within 8 hours of admission."


According to Texas Board of Nursing online reference site https://www.bon.texas.gov/pdfs/practice_dept_pdfs/position_statements_pdfs/positionstatements2014.pdf,
" ...The LVN performs focused assessments and contributes to care planning, interventions, and evaluations. The RN is responsible for the overall coordination of care and performs comprehensive assessments, initiates the nursing care plan, implements and evaluates care of the client or patient."


According to the Texas Board of Nursing online reference site https://www.bon.texas.gov/faq_nursing_practice.asp#t25,
"The question of an RN co-signing after an LVN most often arises in situations when an attempt is made to expand the LVN's scope of practice by holding the RN responsible for expanded tasks performed by the LVN. The RN co-signing for something that is beyond the LVN's scope of practice does not legitimize the LVN's actions. A nurse never functions "under the license" of another nurse. For example, if a patient requires a comprehensive assessment performed by an RN, the assignment (or a portion thereof) may not be given to an LVN. If such an assignment is given to an LVN, he/she is responsible for notifying the nurse who made the assignment that it is beyond his/her scope of practice to perform the assigned task [Board Rule 217.11(1)(S) & (T)]. Each nurse has a duty to maintain client safety [Board Rule217.11(1)(B)] that includes communication with appropriate personnel [Board Rule217.11(1)(P)]. Position Statement 15.14, Duty of a Nurse in Any Setting, further explains a nurse's duty to a client."


25 TAC 411.473(f) states: "(f) Reassessment. An RN shall reassess a patient, based on the patient's needs, but at least every 12 hours after the initial comprehensive nursing assessment, required by subsection (e) of this section, is conducted."


Clinical records for 21 patients were reviewed (5 former patients, 16 current patients). Findings were as follows:


* Former patient #1 received 15 (out of 18 performed) 12-hour assessments performed by a licensed vocational nurse.

* Former patient #2 received 6 12-hour assessments performed by a licensed vocational nurse.

* Former patient #3 received 15 12-hour assessments performed by a licensed vocational nurse.

* Former patient #4 received 5 12-hour assessments performed by a licensed vocational nurse.

* Former patient #5 received 13 12-hour assessments performed by a licensed vocational nurse.

Of the 16 current clinical records reviewed, patients #1 - #5 and #15 had been reassessed only by registered nurses.

* Current patient #6 received 7 12-hour assessments performed by a licensed vocational nurse.

* Current patient #7 received 7 12-hour assessments performed by a licensed vocational nurse.

* Current patient #8 received 4 12-hour assessments performed by a licensed vocational nurse.

* Current patient #9 received 6 12-hour assessments performed by a licensed vocational nurse.

* Current patient #10 received 3 12-hour assessments performed by a licensed vocational nurse.

* Current patient #11 received 5 12-hour assessments performed by a licensed vocational nurse.

* Current patient #12 received 3 12-hour assessments performed by a licensed vocational nurse.

* Current patient #13 received 14 12-hour assessments performed by a licensed vocational nurse.

* Current patient #14 received 1 12-hour assessment performed by a licensed vocational nurse.

* Current patient #16 received 2 12-hour assessments performed by a licensed vocational nurse.

A comprehensive assessment is outside the scope of practice for a licensed vocational nurse. This practice increases the potential for harm to the patients.


Facility policy 200.03 titled "Nursing Documentation Standards" states, in part:

"III Procedure:
...
3. The Nursing Admission Assessment will be completed leaving no blank spaces (mark N/A in those areas which are blank).
...
d. Each patient reassessed by the nurse every 12 hours. The reassessments are completed on the Nursing Shift Assessment."


According to Texas Board of Nursing online reference site https://www.bon.texas.gov/pdfs/practice_dept_pdfs/position_statements_pdfs/positionstatements2014.pdf,
" ...The LVN performs focused assessments and contributes to care planning, interventions, and evaluations. The RN is responsible for the overall coordination of care and performs comprehensive assessments, initiates the nursing care plan, implements and evaluates care of the client or patient."


25 TAC 411.473(g)(1)(B) states: "(g) Staffing plan. (1) The DPN shall develop and implement a written staffing plan that: (B) provides for at least one RN to be physically present and on-duty at all times on each unit when a patient is present on the unit."


Based on a review of documentation and an interview with staff, the Director of Psychiatric Nursing failed to provide for at least one RN to be physically present and on-duty at all times on each unit when a patient is present on the unit. This practice places all patients at risk for inadequate assessments and delayed treatment.


Findings were:

Staffing/census sheets for both day and night shifts were reviewed for the time period of 9-1-18 through 9-13-18, for a total of 26 shifts. Of the 26 shifts, 22 of the 26 shifts did not provide for at least one RN [registered nurse] to be physically present and on-duty at all times on each unit. Patients were present on each unit. The results were as follows:

* 9-1-18 day shift - No RN present on 1 of the 5 units

* 9-1-18 night shift - No RN present on 2 of the 5 units (leaving only a LVN [licensed vocational nurse] on 1 of 2 units after 10 pm)

* 9-2-18 day shift - No RN present on 1 of the 5 units

* 9-3-18 day shift - No RN present on 1 of the 5 units

* 9-3-18 night shift - No RN present on 2 of the 5 units (leaving only a LVN on 1 of those 2 units after 11 pm)

* 9-4-18 day shift - No RN present on 1 of the 5 units

* 9-4-18 night shift - No RN present on 2 of the 5 units (leaving only a LVN on 1 of those 2 units after 11 pm)

* 9-5-18 day shift - No RN present on 1 of the 5 units

* 9-5-18 night shift - No RN present on 2 of the 5 units

* 9-6-18 day shift - No RN present on 1 of the 5 units

* 9-6-18 night shift - No RN present on 2 of the 5 units

* 9-7-18 night shift - No RN present on 1 of the 5 units

* 9-8-18 night shift - No RN present on 3 of the 5 units

* 9-9-18 night shift - No RN present on 2 of the 5 units (leaving only a LVN on 1 of those 2 units after 11 pm)

* 9-10-18 day shift - No RN present on 1 of the 5 units

* 9-10-18 night shift - No RN present on 2 of the 5 units

* 9-11-18 day shift - No RN present on 1 of the 5 units

* 9-11-18 night shift - No RN present on 4 of the 5 units

* 9-12-18 day shift - No RN present on 1 of the 5 units

* 9-12-18 night shift - No RN present on 3 of the 5 units

* 9-13-18 day shift - No RN present on 1 of the 5 units

* 9-13-18 night shift - No RN present on 1 of the 5 units


Patients were present on all 5 units during the period the staffing sheets were reviewed.


The above was confirmed in an interview with the Chief Nursing Officer and Chief Operating Officer (both of Dallas Behavioral Health, an associated facility) on the afternoon of 9-17-18.

Based on a review of documentation and an interview with staff, the facility failed to ensure that a qualified staff served as the Director of Psychiatric Nursing.


Findings were:


A review of the personnel file for staff #3 (DPN) revealed that staff #3 had received an Associate Degree in Nursing in December 2014.


Facility job description for "Director of Nursing" listed the following minimum education requirement:

"BSN required: MSN [Master's of Science in Nursing], Advanced Practice preferred"


In an interview with staff #3 on 9-14-18, stated that [staff #3] had an Associate's Degree in Nursing and was planning on attending a Bachelor's Degree program in the future. The personnel file for staff #3 contained a "Job Description Acknowledgement" (signed by staff #3 on 8-20-18) that stated that staff #3 acknowledged receipt of the Chief Nursing Officer job description and that [staff #3] was responsible for reviewing and understanding its content.


The above was confirmed in an interview with the Chief Nursing Officer and Chief Operating Officer (both of Dallas Behavioral Health, an associated facility) on the afternoon of 9-17-18.

Based on a review of documentation and an interview with staff, the Director of Psychiatric Nursing failed to ensure that a registered nurse supervise and evaluated the nursing care for each patient.


Findings were:


Staffing/census sheets for both day and night shifts were reviewed for the time period of 9-1-18 through 9-13-18, for a total of 26 shifts. Of the 26 shifts, 22 of the 26 shifts did not provide for at least one RN [registered nurse] to be physically present and on-duty at all times on each unit. Patients were present on each unit. The results were as follows:

* 9-1-18 day shift - No RN present on 1 of the 5 units

* 9-1-18 night shift - No RN present on 2 of the 5 units (leaving only a LVN [licensed vocational nurse] on 1 of 2 units after 10 pm)

* 9-2-18 day shift - No RN present on 1 of the 5 units

* 9-3-18 day shift - No RN present on 1 of the 5 units

* 9-3-18 night shift - No RN present on 2 of the 5 units (leaving only a LVN on 1 of those 2 units after 11 pm)

* 9-4-18 day shift - No RN present on 1 of the 5 units

* 9-4-18 night shift - No RN present on 2 of the 5 units (leaving only a LVN on 1 of those 2 units after 11 pm)

* 9-5-18 day shift - No RN present on 1 of the 5 units

* 9-5-18 night shift - No RN present on 2 of the 5 units

* 9-6-18 day shift - No RN present on 1 of the 5 units

* 9-6-18 night shift - No RN present on 2 of the 5 units

* 9-7-18 night shift - No RN present on 1 of the 5 units

* 9-8-18 night shift - No RN present on 3 of the 5 units

* 9-9-18 night shift - No RN present on 2 of the 5 units (leaving only a LVN on 1 of those 2 units after 11 pm)

* 9-10-18 day shift - No RN present on 1 of the 5 units

* 9-10-18 night shift - No RN present on 2 of the 5 units

* 9-11-18 day shift - No RN present on 1 of the 5 units

* 9-11-18 night shift - No RN present on 4 of the 5 units

* 9-12-18 day shift - No RN present on 1 of the 5 units

* 9-12-18 night shift - No RN present on 3 of the 5 units

* 9-13-18 day shift - No RN present on 1 of the 5 units

* 9-13-18 night shift - No RN present on 1 of the 5 units


Patients were present on all 5 units during the period the staffing sheets were reviewed. On units staffed only with a LVN, the LVN performed all nursing care, including shift assessments.


Facility policy 200.03 titled "Nursing Documentation Standards" states, in part:

"III Procedure:
...
3. The Nursing Admission Assessment will be completed leaving no blank spaces (mark N/A in those areas which are blank).
...
d. Each patient reassessed by the nurse every 12 hours. The reassessments are completed on the Nursing Shift Assessment."


According to Texas Board of Nursing online reference site https://www.bon.texas.gov/pdfs/practice_dept_pdfs/position_statements_pdfs/positionstatements2014.pdf,
" ...The LVN performs focused assessments and contributes to care planning, interventions, and evaluations. The RN is responsible for the overall coordination of care and performs comprehensive assessments, initiates the nursing care plan, implements and evaluates care of the client or patient."

The above was confirmed in an interview with the Chief Nursing Officer and Chief Operating Officer (both of Dallas Behavioral Health, an associated facility) on the afternoon of 9-17-18.