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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13 PATIENT RIGHTS, was out of compliance.

A-0144 The patient has the right to receive care in a safe setting. Based on observations, interviews and document review, the facility failed to ensure a safe patient care environment. Specifically, the facility failed to ensure adolescent and adult populations were not commingled in ways that compromised patient safety. The failure was identified in four of 10 records reviewed for adolescent patients (Patient #7, #10, #21, #22). Additionally, the facility failed to ensure items which posed a safety risk to patients or others were not accessible in the inpatient psychiatric units. The failure was identified in three of seven records reviewed for patients who demonstrated self-harm behaviors during their hospitalization (Patient #2, #6 and #24).

A-0168 The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. Based on document review and interviews, the facility failed to ensure a physician order for new and renewed patient seclusion was obtained. Document review showed 3 of 3 secluded patients lacked new orders when continued seclusion occurred to specify excessive seclusion time limits and the behavior-based criteria required to end seclusion (Patient #3, #10 and #12). (Cross-reference A-0283 and A-0396)

Based on observations, interviews and document review, the facility failed to ensure a safe patient care environment. Specifically, the facility failed to ensure adolescent and adult populations were not commingled in ways that compromised patient safety. The failure was identified in four of 10 records reviewed for adolescent patients (Patient #7, #10, #21, #22). Additionally, the facility failed to ensure items which posed a safety risk to patients or others were not accessible in the inpatient psychiatric units. The failure was identified in three of seven records reviewed for patients who demonstrated self-harm behaviors during their hospitalization (Patient #2, #6 and #24).

Findings include:

Facility policies:

The Plan for Provision of Care read, the adult psychiatric program is designed for the treatment of adult patients, ages 18 and over, with primary psychiatric diagnoses. The youth and adolescent treatment programs are designed for the treatment of adolescents, ages 12 through 18. Group therapy is utilized to help alleviate interpersonal and social dysfunction, to develop communication and relationship skills, to develop identity with allegiance to a group of peers and testing within age-appropriate limits.

Adolescent and adult group therapy programs are separately listed and described in the policy.

The Nursing Rounds policy read, observations and communication with staff and patients are to occur to evaluate the status of all patients, determine the overall status of the unit and identify administrative needs through nursing rounds.

The Nursing General Safety policy read, client rooms should be clean and tidy at all times, remove items from the floor which may cause tripping and be knowledgeable of contraband and assure compliance.

The Levels of Observation policy read, utilize the least restrictive measure in order to provide a safe therapeutic environment. Fifteen-minute observations are the minimum level of observation for all patients. Staff will observe and document on the patient observation form at intervals no longer than 15 minutes. Assigned staff will make direct visual contact with patients and confirm they are in no danger or distress. Line of sight (LOS) requires the patient to be in sight of a staff member at all times and 15-minute checks are documented. One to one observation (1:1) is where a staff member is assigned to a patient to care for them in constant attendance and remain at arm's length at all times.

The Room Occupancy Child and Adolescent policy read, the facility promotes the concept of safe, appropriate, age-specific living space for each resident served. Child and adolescent patients are assigned according to age-specific groups. In the event the patient has been identified as not being appropriate for the child and adolescent unit, they will be clinically assessed to be transferred or admitted to an adult unit with guardian consent. If the child or adolescent patient is transferred or admitted to an adult unit with guardian consent, a line of sight or 1:1 observation level is instituted.

References:

According to a facility document provided by the Director of Quality, Compliance and Risk on 6/23/21, the facility's six units were designated by age, diagnosis and population. The units were designated as follows: Unit 200 detoxification and dual diagnoses, Unit 300 low acuity older adults, Unit 400 high acuity adults, Unit 500 high to medium acuity adults, Unit 600 child/adolescent, and Unit 700 child/adolescent.

According to the facility Contraband and Patient Safety document, a list of contraband items included pencils, combs, anything with strings, anything sharp or which could be made sharp, as well as other items.

1. The facility failed to ensure adolescent and adult patients were not commingled in a way which compromised patient safety.

A. Patient #22

a. Observations revealed Patient #22 was an adolescent placed on an adult unit.

i. On 6/22/21 at 9:14 a.m., Patient #22 was observed in the unit 500 dayroom with six adult patients. According to facility documents, the unit 500 was a unit designated for treatment of high to medium acuity adult patients.

b. Patient #22's medical record was reviewed which revealed an adolescent with a history of abuse by adult males was placed on an adult unit.

i. According to the psychiatric evaluation completed by Provider #22 on 6/5/21, Patient #22 was a 14 year-old who was admitted to the facility on 6/4/21 due to suicidal and homicidal ideations. Patient #22 had a history of sexual abuse and had diagnoses of depression, anxiety and post-traumatic stress disorder. Provider #22 documented the placement of Patient #22 was age appropriate.

On 6/6/21, the psychiatric progress note entered by Provider #22 documented Patient #22 was admitted to unit 600, which according to facility documents was unit designated for treatment of child and adolescent patients, for the acute adolescent mental health program.

ii. On 6/15/21 at 3:54 p.m., a registered nurse documented Patient #22 was placed in a primary restraint technique (PRT) at 2:11 p.m. after the patient charged at a peer in the courtyard. The nurse documented the provider was notified and an order to transfer Patient #22 to unit 500, a unit designated for adult patients, was received. At 3:00 p.m. on the same day Provider #22 placed the transfer order and an order for line of sight (LOS) monitoring while out of room.

On 6/16/21 at 9:11 a.m., the psychiatric progress note entered by Provider #22 documented Patient #22 was on unit 500.

iii. Patient #22 remained on unit 500 until she was discharged on 6/22/21. Only one of twelve Mental Health Technician (MHT) shift notes entered during the time Patient #22 was on the adult unit 500 documented LOS was required while Patient #22 was out of her room.

iv. The patient observation sheets for Patient #22 from 6/15/21 at 3:00 p.m. through 6/22/21 at 9:15 a.m., which was the time the patient was on the adult unit 500, were reviewed. According to the observation sheets completed by the MHTs, 18 observations were late as indicated by more than 15 minutes between observations by staff. Of the 18 observations which were late, four of the observations were completed at greater than 20 minute intervals. This was in contrast to facility policy, which read fifteen-minute observations were the minimum level of observation for all patients and staff were to observe and document on the patient observation form at intervals no longer than 15 minutes. The policy specified 15 minute checks were to be completed for patients who required LOS.

v. Review of the medical record revealed there was no documentation of discussion with Patient #22's guardian to consent for the adolescent patient to move to an adult unit. This was in conflict with the Room Occupancy Child and Adolescent policy which required guardian consent to move an adolescent to an adult unit.

c. Patient #22 interview revealed she did not feel safe on the adult unit.

i. On 6/22/21 at 9:31 a.m., Patient #22 was interviewed in the adult unit 500 hallway. Patient #22 stated she was 14 years old and was transferred to the adult unit one week ago. Patient #22 stated she had a history of sexual abuse by her step-father. She stated she did not feel safe with adult males on the unit due to the history of abuse. Patient #22 stated she did not sleep well on the adult unit and feared an old, adult male would enter her room and touch her. Patient #22 stated she was supposed to be on LOS monitoring while out of her room but it did not occur at all times. Patient #22 stated adult patients had entered her room. Patient #22 stated she was treated like an adult and attended programming sessions with the adults on the unit.

d. Leadership interviews revealed the facility did not follow the expected process prior to moving Patient #22 to an adult unit.

i. On 6/22/21 at 10:33 a.m., an interview was conducted with Provider #22. Provider #22 stated movement of adolescent patients to the adult units was rare and it was a last resort after other interventions failed. He stated the if an adolescent was moved to an adult unit he ordered line of sight or 1:1 observation to ensure the patient's safety. Provider #22 stated if the adolescent patient improved while on the adult unit, an attempt was always made to return the patient to the adolescent unit. He stated Patient #22 was not considered for transfer back to the adolescent unit as it never came up.

Provider #22 stated adolescents received less therapeutic benefit from treatment on an adult unit. He stated Patient #22 was threatening and did not participate in groups and she was moved from the adolescent unit to the adult unit to benefit the other kids.

ii. On 6/22/21 at 1:39 p.m., an interview was conducted with Corporate Quality and Compliance (CQC) #25. CQC #25 stated she was not aware an additional adolescent was currently on an adult unit until during the interview. CQC #25 stated other interventions could have been tried first with Patient #22 prior to the decision to move the patient to an adult unit. She stated after discussing with staff and VP #23, they decided the facility would no longer have adults and adolescents on the same unit.

iii. On 6/22/21 at 9:16 a.m., an interview was conducted with Chief Nursing Officer (CNO) #13. CNO #13 stated moving an adolescent patient to an adult unit was the last resort after all other interventions were tried. She stated the decision to move a patient was discussed as part of the treatment team, but the provider was the one who ultimately made the determination. CNO #13 stated nurses on the unit were ultimately responsible for the safety of adolescent patients on adult units.

e. Staff interviews revealed staff was concerned regarding the safety of adolescents on adult units.

i. On 6/22/21 at 9:20 a.m., MHT #10 was interviewed. MHT #10 stated Patient #22 was transferred from the adolescent unit 600 to the adult unit 500 one week ago. MHT #10 stated Patient #22 was to be on LOS while out of her room but this was not done at all times as ordered due to staffing. MHT #10 stated Patient #22 was getting too close to Patient #23, an adult patient, and was ordered to remain more than ten feet away from Patient #23.

MHT #10 stated the nursing observations for each patient were required at least every 15 minutes. MHT#10 stated if the 15 minute observations were late or delayed the patient's safety was at risk as the patient might self-harm, attempt suicide or die.

ii. On 6/22/21 at 11:04 a.m., an interview was conducted with Case Manager (CM) #21. CM #21 stated unit 500 was an adult unit. She stated recently more children were admitted to the unit and commingling of adults and adolescents was common. CM #21 stated she was concerned Patient #22 who had a history of sexual abuse by adult males was admitted to a unit with adult males. She stated it was possible for an adult on the unit to have a history of sexual assault on children without the facility knowing and she stated she was concerned for the adolescent's safety.

iii. On 6/22/21 at 10:41 a.m., an interview was conducted with Registered Nurse (RN) #5. RN #5 stated if an adolescent patient was admitted to an adult unit and LOS observations were not done according to policy, the adolescent was at risk of a physical or sexual assault by an adult.

d. Observation, medical record review and interview revealed staff did not adhere to facility policies to ensure Patient #22's safety as an adolescent patient on an adult unit. The medical record did not have evidence Patient #22 was considered for the return to an adolescent unit and there was no documentation of other interventions attempted prior to Patient #22's transfer to the adult unit. Additionally, review of the medical record revealed multiple observations for safety were performed at greater than 15 minute intervals while Patient #22 was on the adult unit, which conflicted with the Levels of Observation policy in which staff were to conduct and document observations on each patient at intervals no longer than 15 minutes. Finally, staff interviews revealed placement of Patient #22 on an adult unit and lapses in staff safety monitoring created potential safety risks to the patient.

B. Patient #21

a. Observations revealed Patient #21 was an adolescent placed on an adult unit.

i. On 6/22/21 at 10:52 a.m., Patient #21 was observed on unit 400, which according to facility documents was designated for treatment of high acuity adult patients, in group therapy in the dayroom with other adult patients.

b. Document review revealed Patient #21 had received treatment on two units designated for adult patients.

i. Review of the current facility census for 6/22/21 revealed Patient #21 was 17 years old and was on the adult unit 400.

ii. Review of the adult unit 500 census sheet for 6/20/21 and 6/21/21 revealed Patient #21 was on the adult unit 500 on these dates. According to the census sheets Patient #21 was admitted to the facility on 6/11/21 with suicidal and homicidal ideations, post-traumatic stress disorder and autism.

c. Interviews revealed Patient #21 was an adolescent transferred to an adult unit after an altercation with staff on the adolescent unit.

i. On 6/22/21 at 10:52 a.m., an interview was conducted with Certified Nursing Assistant (CNA) #26 in the hallway of the adult unit 400. CNA #26 stated Patient #21 was 17 years old and was currently in group therapy. CNA #26 stated Patient #21 was transferred from another adult unit, unit 500, on 6/21/21 due to staff using a PRT on the patient.

ii. On 6/22/21 at 3:29 p.m., an interview was conducted with Director of Quality, Compliance and Risk (Director) #15. Director #15 confirmed Patient #21 was 17 years old and was moved from the adolescent unit to the adult unit 500 after an altercation with staff on 6/17/21. Director #15 was unable to provide details regarding the altercation and PRT.

This was in contrast with the Room Occupancy Child and Adolescent policy in which the adolescent was to be clinically assessed for transfer to an adult unit if identified as not being appropriate for the adolescent unit.

C. Patient #7

a. Patient #7's medical record revealed Patient #7 was an adolescent placed on an adult unit.

i. According to the psychiatric evaluation by Provider #22 on 5/31/21, Patient #7 was a 17 year-old male admitted on 5/31/21 due to suicidal ideations. Patient #7 had a history of trauma but Provider #22 documented the patient did not want to elaborate. Patient #7 also had a history of depression and post-traumatic stress disorder. Provider #22 certified Patient #7 required hospitalization and his placement was age appropriate.

ii. Psychiatric progress notes entered by Provider #22 from 6/1/21 through 6/4/21 documented Patient #7 was on the 700 unit, which was a unit designated for adolescent patients. On 6/4/21 at 10:25 a.m., Provider #22 ordered the transfer of Patient #7 to unit 300, which according to facility documents was a unit designated for low acuity older adults, due to sexual inappropriateness. According to Provider #22's daily progress notes, Patient #7 remained on the adult unit 300 until he discharged on 6/8/21.

iii. On 6/4/21 at 5:00 p.m., Licensed Social Worker (SW) #28 documented a one-on-one session with Patient #7. SW #28 documented Patient #7 had a sexual encounter with a patient on the previous unit and was subsequently moved to the adult unit 300.

iv. The patient observation sheets for Patient #7 were reviewed from 6/4/21 through 6/8/21, which were the dates Patient #7 was on the adult unit 300. On 6/4/21 at 2:33 p.m., line of sight level of observation was added to the log. According to the observation sheets completed by the MHTs, 24 observations were late as indicated by more than 15 minutes between observations by staff. Of the 24 observations which were late, four of the observations were completed at greater than 20 minute intervals. This was in conflict with facility policy, which read observations were to be conducted at intervals no longer than 15 minutes.

v. The medical record did not include documentation of consideration by the treatment team to transfer Patient #7 back to an adolescent unit.

D. Patient #10

a. Patient #10's medical record revealed Patient #10 was an adolescent patient placed on an adult unit.

i. According to the psychiatric evaluation completed by Provider #22 on 1/15/21, Patient #10 was a 14 year-old female admitted on 1/14/21 due to suicidal ideations. Patient #10 also had a history of depression, disruptive mood dysregulation disorder and oppositional defiant disorder. Provider #22 certified Patient #10 required hospitalization and her placement was age appropriate. Patient #10 discharged from the facility on 1/30/21.

ii. Psychiatric progress notes were reviewed. Psychiatric providers documented Patient #10 was on a dedicated adolescent unit 600 from 1/14/21 until 1/22/21. On 1/17/21 at 12:34 p.m., Provider #27 documented Patient #10 reported a history of sexual abuse and was uncomfortable around males.

iii. From 1/18/21 through 1/22/21 nursing staff documented Patient #10 exhibited aggressive and assaultive behaviors, some which required PRT and seclusion. On 1/22/21 at 5:50 p.m., Provider #22 entered an order to transfer Patient #10 to adult unit 500. On 1/22/21 at 6:18 p.m., an RN documented Patient #10 assaulted a staff member. The RN documented Patient #10's father was contacted and consented to move the patient to another unit which may have had fewer triggers. On 1/23/21 at 10:16 a.m., Provider #22 ordered line of sight observation while out of room.

iv. The patient observation sheets for Patient #10 from 1/22/21 through 1/30/21, which were the dates Patient #10 was on the adult unit 500, were reviewed. On 1/22/21 at 6:51 p.m., an alert for age less than 21 years of age was added to the log. According to the observation sheets completed by the MHTs, 15 observations were late as indicated by more than 15 minutes between observations by staff.

v. Review of the medical record did not reveal documentation of consideration by the treatment team to transfer Patient #10 back to an adolescent unit. Additionally, the medical record lacked evidence of Patient #10's father was informed unit 500 was an adult unit and Patient #10 was with adult males.

E. According to a the Over Under document provided by Director of Assessment and Referral (Director) #14 on 6/22/21, the number of adolescents placed on adult units since 3/1/21 was 18. The adolescents ranged in ages from 14 to 17 years old and were placed on dedicated adult units 400 and 500.

F. An adult patient was on an adolescent unit.

a. Interviews revealed in addition to placement of adolescent patients on adult units, the facility had initiated a practice of placing adult patients on adolescent units.

i. On 6/17/21 at 11:05 a.m., an interview was conducted with Director #14. Director #14 stated the assessment team assigned patients to a unit based on patients' age and clinical presentation. Director #14 stated the unit descriptions changed based on community needs. She stated the assessment team updated and monitored the bed board, which was a list of each unit and the patients assigned to each unit. Director #14 stated unit 700 was for patients aged 14 to 19 years of age due increased adult referrals received by the facility. She stated permission from parents of the adolescents was obtained when a 19 year-old was assigned to the unit. This was in contrast to facility policy, which specified the youth and adolescent treatment programs were designed for the treatment of adolescents ages 12 through 18.

ii. On 6/17/21 at 7:53 a.m., an interview was conducted with Assessment and Referral Coordinator (AR) #16. AR #16 stated her job duties included assessment and assignment of patients to units if they qualified for inpatient psychiatric care. She stated due to increased adult admissions the age for the adolescent unit was increased to 19 years old.

iii. On 6/22/21 at 1:39 p.m., an interview was conducted with VP #23. VP #23 stated he was unaware the facility placed 19 year old patients on the adolescent unit. He stated the placement of 19 year-old adults with adolescents was intended only in the case of lower cognitive functioning adults. VP #23 stated leadership discussed the practice of adults and adolescents placed on units together and they decided to discontinue the practice immediately.

b. Document review revealed adult patients had been admitted to a designated adolescent unit.

i. Review of census sheets for 6/17/21 revealed a 19 year-old female was admitted on 6/16/21 to adolescent unit 700.

ii. On 6/17/21, Director #14 provided the bed board documents for review. Review of the documents with Director #14 revealed the description for unit 700 read it was designated for patients ages 15-19.

iii. According to a the Over Under document provided by Director #14 on 6/22/21, one adult older than 18 years of age was placed on adolescent units since 3/1/21. The 19 year-old was admitted from 6/4/21 to 6/14/21 and was placed on the dedicated adolescent unit 700.

G. Facility leadership was unable to provide national guidance to support the safety of adolescent patients when commingled with adult patients for inpatient psychiatric treatment.

2. The facility failed to ensure items which posed a safety risk to patients or others were not accessible in the inpatient psychiatric units.

A. Observations revealed items in multiple patient rooms which posed a potential safety risk to patients and others.

a. On 6/14/21 at 3:36 p.m., observations were conducted on unit 700. Two surgical masks with elastic ear loops were observed in room 705, three masks in room 707 and one mask in room 709. The masks were not being worn by patients and patients were not monitored in the rooms.

b. On 6/14/21 at 4:00 p.m., observations were conducted on unit 600. One pencil was observed in room 608 and an ice pack in room 604. Masks were also observed in rooms 603, 605 and 606.

c. On 6/22/21 at 5:30 p.m., observations were conducted on unit 700. Two pencils, a comb, a mask and five elastic ear loop strings from masks were observed in room 705, which was Patient #24's room.

B. Medical records revealed patients were able to use masks and other items observed in patient rooms to self-harm.

a. Patient #2 was admitted on 4/4/21 with a diagnosis of depression, anxiety, oppositional defiant disorder and unspecified trauma. He had a history of self-harm with suicide attempts of overdose and hanging.

i. On 4/5/21 around bedtime, RN #36 documented Patient #2 endorsed suicidal ideation (SI) and self-harming thoughts and reported to staff he removed the wire from his face mask that he brought in from home and scratched his face with the wire. Patient #2 turned in the wire to staff and contracted for safety with RN #36 and unit MHT. He stated his anxiety and depression were triggered and the decision to self-harm was made due to being a patient in the facility and he kept doing the same behaviors and thinking the same thoughts. Patient #2 was continued on safety checks every 15 minutes.

ii. On 4/6/21 around 9:30 p.m., Patient #2 was found in his shower self-harming with the elastic from a facility provided mask. Patient #2 was crying and had visible marks on his neck. The provider ordered Patient #2 to be on line of sight (LOS) while awake for three days.

iii. On 4/9/21 during evening shift Patient #2 was noticed in the bathroom by MHT #8. MHT #8 documented she was the only staff member on the unit, so she went to check on all the other patients on the unit first. When she returned to Patient #2's room he had self-harmed by scratching his forearm and cheek with a staple. Patient #2 was noted to have scratches and blood. MHT #8 documented Patient #2 was provided a suicide blanket and stripped all items which could be used for self-harm from his room.

Licensed Practical Nurse (LPN) #7 documented Patient #2 remained on LOS while awake, even though staff had failed to do so at the time Patient #2 was able to self-harm in his room.

iv. On 4/11/21 around 9:45 p.m., Patient #2 went to bed at lights out and then self-harmed with the face masks provided by the facility. Even though Patient #2 was on LOS while awake, he was able to wrap the elastic from the mask around his neck. This was self-reported by the patient, not identified by staff. The nurse documented Patient #2 was provided a safety blanket and remained on LOS while awake.

v. Even though Patient #2 has three incidents of self-harming around bedtime, the facility did not maintain LOS while the patient was awake and did not implement a higher level of observation or other interventions to prevent self-harm prior to occurring.

b. Patient #6 was admitted on 6/7/21 with a diagnosis of suicidal ideations, bipolar disorder and paranoid schizophrenia. He had a history of self-harm with multiple suicide attempts by overdose.

i. On 6/9/21 at 6:09 p.m., RN #34 documented Patient #6 wrapped a sweater around his neck using the arms and tightening it. An alert for staff to respond immediately was called. After the sweater was removed by staff, Patient #6 attempted to wrap a blanket around his neck. RN #34 notified Provider #37 and she documented in her note an order for LOS while awake and suicide vest were obtained.

Review of orders revealed an order from Provider #37 for LOS while awake for 14 days was given on 6/9/21 at 6:33 p.m. However, the suicide vest order was not entered on 6/9/21.

ii. On 6/10/21 at around 6:40 p.m. while in his room, Patient #6 tied a scrub top around his neck. Patient #6 became increasingly agitated and the staff was unable to remove the scrub top from around his neck. After Patient #6 refused oral medication, RN #35 documented in a nurse note she obtained an order from Provider #38 for medication administration by injection, 1:1 observation and suicide vest (safety smock due to suicide attempts). RN #35 noted the patient had three suicide attempts in two days.

iii. On 6/11/21 at 7:54 a.m., Provider #37 documented Patient #6 was transferred to another unit the day prior due to self-harming behaviors in which Patient #6 tied a sheet or sweater around his neck. Patient was on 1:1 but the provider planned to change to LOS observation. Provider #37 did not document the rationale to decrease Patient #6's level of observation from 1:1 to every 15 minute checks despite the patient's suicide attempt the previous evening.

Review of orders revealed an order for observations every 15 minutes was entered by Provider #38 on 6/11/21 at 11:05 a.m. Patient #6 did not have LOS observation ordered on 6/11/21 and there was no documentation by Provider #38 for rationale to decrease Patient #6's level of observation despite his recent suicide attempt.

iv. On 6/11/21 at 4:18 p.m., Patient #6 was in his bedroom and staff called an alert for additional staff to respond after he was found with a pillowcase wrapped around his neck. Patient #6 was upset because a psychiatrist had not seen him. Staff reminded him he had been seen. Patient #6 refused to remove the pillowcase until 4:20 p.m. when the staff was able to remove it without difficulty. RN #5 notified the provider and no orders were received.

v. On 6/12/21 at 1:46 p.m., Provider #38 entered an order to discontinue the suicide vest.

vi. On 6/13/21 at approximately 10:15 a.m., Patient #6 told RN #5 another patient had his sweatshirt. Patient #6 walked away from the nurse and into his bedroom. MHT staff asked the patient to keep his door open and keep LOS at that time. Shortly afterwards, Patient #6 was found in his bedroom with a scrub top wrapped around his neck. He was alert and talked to staff about how he was upset another patient had his sweatshirt. Patient #6 refused to remove the scrub top from around his neck but staff was able to remove it. He then grabbed a towel and wrapped it around his neck. RN #5 notified the provider but no new orders were obtained.

vii. Patient #6's medical record revealed after three documented suicide attempts, Provider #37 documented a plan to change 1:1 observation to LOS on 6/11/21. However, the order for LOS was not entered and instead an order was placed for routine 15 minute observations, which was the minimum required level of observation for all patients. Patient #6 had three subsequent suicide attempts after the 1:1 order was discontinued while he was on routine 15 minute observation checks. Two of the suicide attempts were after the safety smock was discontinued. The facility did not maintain a level of observation and safety interventions to ensure Patient #6 did not access and use items for self-harm.

c. Patient #24 was admitted on 5/4/21 with a diagnosis of depression, anxiety and post-traumatic stress disorder. She had a history of self-harm with multiple suicide attempts of overdose and cutting.

i. On 6/1/21 at approximately 2:15 p.m., Patient #24 removed the metal nose piece from her mask and scratched her left forearm. Patient #24 told RN #36 she felt anxious. According to documentation by RN #36, Patient #24 had received the mask from the facility upon admission.

ii. According to the medical record Patient #24 was admitted for suicidal ideations and evidence of self-harming behavior. However, observations of Patient #24's room on 6/22/21 revealed she had items which could have been used to self-harm, including two pencils, a comb and a mask with elastic ear loops.

C. Interviews revealed staff did not ensure patients were monitored to prevent access to items which could be used for self-harm.

a. On 6/17/21 at 1:23 p.m., an interview was conducted with MHT #8. MHT #8 stated LOS observation was ordered to ensure patient safety and keep eyes on a patient, such as patients with self-harm behaviors or suicidal gestures or attempts. MHT #8 stated if the order was for LOS while awake, staff was to maintain sight of the patient at all times while awake. She stated if the patient was sleeping and woke up staff was to resume LOS according to the order.

MHT #8 stated if staff felt the reason for the LOS order was not serious, staff did not always maintain LOS according to provider orders. This was in contrast to facility policy which read LOS required the patient to be in sight of a staff member at all times.

MHT #8 stated she performed the 15 minute observation checks on 4/9/21 after Patient #2 went to bed. She noted Patient #2 was in the bathroom and he sounded strange. MHT #8 asked Patient #2 if he was self-harming and he told her no. MHT #8 stated she was the only one on the unit and had to complete the other 15 minute safety checks so she completed those first and then returned to check on Patient #2. MHT #8 stated she found Patient #2 in the bathroom with scratches on his cheek and forearm. He told MHT #8 he used a staple from a pamphlet given to him.

b. On 6/17/21 at 9:50 a.m., an interview was conducted with RN #2. RN #2 stated contraband was any object which a patient used for self-harm or to cause harm to others. Examples given were shoelaces, earrings, tongue rings, drugs, guns, sharp objects or illegal items. RN #2 stated if a patient exhibited self-harming behavior with an object which was not normally considered contraband, such as a mask, the patient should not have access to the object. She stated if a patient exhibited self-harming behaviors with a sheet or bedding, staff was to remove the objects from the patient's room as well as items from the patient's roommate and notify the provider.

RN #2 reviewed the medical record of Patient #2. RN #2 stated Patient #2 was able to self-harm while the patient was on LOS while awake because the observation conducted was not adequate. RN #2 stated Patient #2 was unsafe and should have been LOS at all times or 1:1 observation at all times.

c. On 6/17/21 at 5:34 a.m., an interview was conducted with MHT #9. MHT #9 stated the role of the MHTs was to perform the safety checks every 15 minutes which included monitoring patients for self-harm activities and assessing rooms for objects which may be used for self-harm. MHT #9 stated patients were given masks to wear with the metal removed. He stated if the mask was taken apart the staff was to dispose of the masks. He stated some patients removed the elastic loops from the masks and use them as hair ties and shoelaces which was not allowed.

d. While on tour on 6/22/21 at 5:30 p.m., an interview was conducted with MHT #11 in Patient #24's room. MHT #11 stated staff wa

Based on document review and interviews, the facility failed to ensure a physician order for new and renewed patient seclusion was obtained. Document review showed 3 of 3 secluded patients lacked new orders when continued seclusion occurred to specify excessive seclusion time limits and the behavior-based criteria required to end seclusion (Patient #3, #10 and #12). (Cross-reference A-0283 and A-0396)

Findings include:

Facility policy:

The Seclusion Restraint Physical Hold Policy defined seclusion as confinement of the patient in a room or area involuntarily. The confinement of the patient to a room or area through the use of staff intervention or by means of a locked door to prevent the patient from leaving, constitutes seclusion.

Use of seclusion will be permitted for the management of violent or self-destructive behavior to secure the immediate physical safety of the patient, staff and others. Seclusion orders must specify the date and time the order was placed and the behavior-based criteria required for the seclusion to end. Orders for seclusion must be time-limited, not exceed four hours and seclusion orders were not to be written as standing orders or "as needed" (PRN) orders. To continue seclusion beyond the time limit indicated in the order, a renewal order must be written by the psychiatrist/physician. Additionally, once seclusion ended a new seclusion order would be required to reinitiate placement of the patient in seclusion. Seclusion must end when the safety of the patient, staff and others has been ensured, regardless if the seclusion order has not expired.

1. The facility failed to ensure new orders for continued seclusion were written to specify time-limited durations and the behavior-based criteria required for seclusion to end.

a. According to facility policies, new orders for seclusion were required for patients to remain in seclusion. Seclusion orders were to be time-limited and not exceed a duration of four hours. Additionally, seclusion orders were to indicate the behavior-specific criteria required to end seclusion.

b. A review of the seclusion log and patient records from 1/14/21 to 5/31/21 revealed a lack of seclusion orders for each four hour episode the patient was secluded. Furthermore, time-limited durations were not specified or were in excess of four hours. Examples included:

i. Review of Patient #11's seclusion orders and documentation read, Patient #11 was placed in seclusion on 5/8/21 at 5:25 p.m. Patient #11 remained secluded until 5/11/21 at 2:44 p.m. (a total of two days and 21 hours).

Further review revealed the seclusion orders for Patient #11 were written on 5/8/21 at 5:19 p.m., 5:41 p.m., 6:23 p.m., and at 7:33 p.m. Each seclusion order specified the time limit duration was one hour, for a total of four continuous hours in seclusion. All four seclusion orders lacked the specific behavior-based criteria needed for seclusion to end.

At 7:40 p.m. on 5/8/21, a new seclusion order was written. The order specified the patient was to remain secluded for 14 hours (until 5/9/21 at 9:40 a.m. in the morning). A new order for seclusion was not written until 5/9/21 at 3:00 p.m., approximately five hours and 20 minutes after the previous seclusion order expired. The seclusion order written on 5/9/21 at 3:00 p.m. specified the duration of time the patient was to remain secluded was 24 hours. On 5/10/21 at 3:00 p.m. a new seclusion order was written which specified the patient was to remain secluded for 24 hours.

According to the policy, seclusion orders were not to exceed four hours and were required to state the behavior-based criteria for release from seclusion. Furthermore, according to facility policy four additional seclusion orders should have been written for the patient to remain secluded on 5/8/21, a total of five additional seclusion orders should have been written for the patient to remain secluded on 5/9/21 and a total of five additional seclusion orders should have been written for the patient to remain secluded on 5/10/21. All the seclusion orders written lacked the specified behavior-based criteria needed for seclusion to end.

ii. On 5/12/21 at 12:25 p.m. Patient #11 was placed back in seclusion and remained secluded until 5/13/21 at 9:54 a.m. (a total of 21 hours and 30 minutes). Record review revealed on 5/12/21 at 12:20 p.m. a seclusion order was written and the order specified the patient was to remain secluded for four hours. At 4:22 p.m. on 5/12/21 a new order for continued seclusion was written and specified the patient was to remain secluded until 5/13/21 at 10:00 a.m. (a total of 17.5 hours). Additionally, the seclusion orders written on 5/12/21 at 12:20 p.m. and 4:42 p.m. lacked the behavior-based criteria the patient needed to meet in order for seclusion to end.

According to facility policy, four additional seclusion orders should have been written for the patient to remain secluded from 5/12/21 at 12:25 p.m. until he was released on 5/13/21 at 9:54 a.m. Additionally, seclusion orders were not to exceed four hours and were required to indicate behavior-based criteria for the patient to be released from seclusion.

iii. Review of Patient #3's seclusion orders and documentation read, Patient #3 was placed in seclusion on 3/2/21 at 7:18 p.m. and remained in seclusion until 9:08 p.m. (approximately two hours). The seclusion order was written at 7:04 p.m. and did not specify the time-limited duration for seclusion. In addition, the seclusion order did not state the behavior-based criteria for the patient to be released from seclusion

According to facility policy, seclusion orders must specify a time limit for seclusion and indicate the behavior-based criteria for the patient to be released from seclusion.

iv. Review of Patient #10's seclusion orders and documentation read, Patient #10 was placed in seclusion on 1/20/21 at 11:10 a.m. and remained in seclusion until 12:12 p.m. (approximately one hour). The seclusion order was written at 11:07 a.m. and did not specify the time limit the patient was to be secluded and lacked the specified behavior based criteria for the patient to be released from seclusion. According to the policy, seclusion orders must specify a time limit for seclusion and indicate the behavior-based criteria for the patient to be released from seclusion.

c. Interviews with staff revealed written orders for seclusion were required for patients placed in seclusion and for the patient who required continued secluded. According to staff interviews, the behavior-based criteria required for removal from seclusion was indicated in a behavioral note instead of the seclusion order.

i. On 6/16/21 an interview with RN #1 was conducted. RN #1 stated documentation for the use of seclusion was always performed. RN #1 stated the patients were informed of the behavior-based criteria to be released from seclusion. RN #1 stated the behavior-based criteria the patient needed to display was documented in a behavioral note within the medical record.

This was in contrast to facility policy which stated the seclusion order was required to specify the duration of time the patient could be secluded.

ii. On 6/23/21 at 11:31 a.m., an an interview with Provider #22 was conducted. Provider #22 stated the provider placed the order for seclusion..seclusion. Provider #22 stated the provider determined the time-limit duration and specified the duration in the seclusion order. Provider #22 stated seclusion orders stated the date and time the order was placed and the time limit the patient may be secluded for. Provider #22 stated an order for seclusion was seclusion orders were required when the patient was initially placed in seclusion, and new orders were required to be when the seclusion order needed to be renewed.

Provider #22 stated the registered nurse informed the patient verbally of the behavior-based criteria for release from seclusion. Provider #22 stated the registered nurse was to release the patient from seclusion when appropriate.

Information provided from the interviews was in contrast with facility policy. According to facility policy, seclusion orders must be written with the time-limit the patient could be secluded ed and not exceed a duration of four hours. Additionally, and seclusion orders must indicate the behavior-specific criteria required to release the patient from seclusion.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §416.43 QUALITY ASSESSMENT & PERFORMANCE IMPROVEMENT, was out of compliance.

A-0286 (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital's governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ...(3) That clear expectations for safety are established. Based on interviews, document review and record review, the facility failed to ensure adverse patient safety events were reported, investigated and analyzed in order to identify contributing factors and implement preventive actions in 9 of 9 medical records (Patient #1, #2, #6, #7, #10, #12, #16, #17 and #18). (Cross-reference A0144, A0168, A0395, A0396)

Based on interviews, document review and record review, the facility failed to ensure adverse patient safety events were reported, investigated and analyzed in order to identify contributing factors and implement preventive actions in 9 of 9 medical records (Patient #1, #2, #6, #7, #10, #12, #16, #17 and #18). (Cross-reference A0144, A0168, A0395, A0396)

Findings include:

Facility plan:

The Quality and Performance Improvement Plan for 2021 read, the plan shall be the program used to monitor and improve patient safety processes, structures and outcomes. This program shall provide consistent, systematic evaluation of patient services, performance processes and performance improvement within all departments.

The Quality and Performance Improvement Plan defines performance improvement as systematic detection and analysis of problems related to performance processes, the development and design of process interventions, implementation of process interventions, evaluation of intervention results and sustained process improvement.

Quality and performance improvement model program goals and objectives: To support, maintain and enhance patient care, safety and quality by: Systematic objective monitoring, evaluation and improvement of systems and processes in order to provide appropriate, safe, effective, continuous and compassionate patient care. Identification, assessment and feedback of actual or potential patient safety events and risks related to clinical services provided and the delivery of safe patient care. Implementation of integrated patient safety systems by means of interdisciplinary performance improvement teams. Evaluation and documentation of appropriate corrective actions implemented to alleviate and resolve identified patient safety problems or concerns and their effectiveness. Aggregation of data/information collected from the integration and implementation of new or redesigned processes. Development and utilization of an performance improvement (PI) indicator database for identifying and evaluating undesirable or adverse patient care events.

The PI system identified areas of improvement related to patient care and clinical services provided. PI activities will be monitored by the Quality and Performance Improvement Council. The Quality and Performance Improvement Council is composed of the following staff: The Chief Executive Officer (CEO), the Medical Director, the Chief Nursing Officer (CNO), the Director of Clinical Services, the Director of Quality, Compliance and Risk, Hospital managers and department/services staff representatives. Additionally, the Director of Quality, Compliance and Risk shall be Chair of the committee. As committee chair, the Director of Quality, Compliance and Risk will facilitate coordination of all quality and PI activities. Hospital-wide PI activities, pertinent patient care issues, PI process findings and significant adverse patient safety events will be relayed by the Director of Quality, Compliance and Risk to the Governing Board, Medical Executive Committee and the medical staff.

The Quality and Performance Improvement Plan defined the following as types of patient safety events: adverse event, an incident which resulted in harm or injury to a patient. Sentinel event, an adverse event which resulted in death, permanent harm, or severe temporary harm to a patient. A near miss, a variation in process which did not result in harm, but recurrence of the variation poses potential for a serious adverse outcome.

The Director of Quality, Compliance and Risk shares joint responsibility for the operation of the risk management program and the hospital wide patient safety program with the medical staff. Hospital department directors and managers will review reported incidents related to patient safety events and perform or assign investigation of the event. Identification of adverse patient safety events will be relayed to the Director of Quality, Compliance and Risk for further investigation, assessment and implementation of corrective action.

The List of Performance Indicators 2021 were derived from findings generated from the Quality and Performance Improvement Plan process and evaluation. Identified PI indicators are to be monitored and tracked. The following PI indicators have been identified as high risks for negative patient health outcomes: Nursing Services: Treatment plan containing all pertinent medical comorbidities. Risk Assessment/Risk Management: Adverse patient events reviewed through RCA process.

Facility policies:

The Completion of Incident Reports policy read, the incident reports should be thoroughly completed. Incident reports must be completed on the shift the staff member worked and prior to the end of their shift. The incident report should include only facts related to the incident. Facts are defined as observations of what occurred and should not be based on speculation or hearsay. The names of witnesses to the incident should be included in the incident report. The staff member must sign, title, date, and time the incident report when completed.

The PI Mandatory Reviews policy read, Risk Management and Safety will perform patient well-being monitors to evaluate staff response to situations/incidents where potential for harm occurred. Patient safety/patient well-being improvement opportunities identified by Risk Management and Safety will be communicated to the PI Committee.

The Risk Management/Incident Reporting policy defined an patient safety event as an injury or potential injury to a patient, staff member or visitor caused by an unexpected or unusual event. Examples of patient safety events consist of: Acts of violence, threats of violence, inappropriate sexual behavior, contraband, potential for harm to occur and any unusual situation. Employees who witness or were made aware of an incident must complete an IR at the time the employee is made aware of the incident.

1. The facility failed to investigate and analyze adverse events and implement preventive action involving patient restraint and seclusion, contraband, self-harm, potential injury, violence, sexual allegations, suicide attempts and attempted patient elopements. (Cross-reference A0144, A0168, A0392, A0395, A0396)

a. According to the Quality and Performance Improvement Plan, patient safety events were defined as patient safety events resulting in potential harm or injury to an individual or patient.

b. According to the Risk Management/Incident Reporting policy, patient safety events were injury or potential injury to a patient, staff member or visitor caused by an unexpected or unusual event. Examples included: Acts of violence, threats of violence, inappropriate sexual behavior, contraband, potential for harm to occur and any unusual situation. Employees who witness or were made aware of a patient safety event must complete an IR.

c. Facility patient safety events were reviewed in conjunction with patient medical records. Multiple patient safety events as defined by facility policy were identified in patient medical records, however the events were not reported by staff according to facility policy and the Quality and Performance Improvement Plan.. Examples of patient safety events not reported by staff included:

i. Review of Patient #10's medical record revealed on 1/17/21 the patient was agitated and depressed and refused to engage in therapy. Nursing documentation indicated the Patient #10 self-harmed and nursing staff were made aware of the event.

On 1/18/21, Patient #10 displayed self-harming and aggressive behavior. Nursing documentation in the medical record read Patient #10 engaged in two separate self-harm events where she repeatedly punched the wall and bed in her room. The behavior continued until Patient #10 physically caused her knuckles to bleed. A third event occurred on the same day when Patient #10 proceeded to barricade herself in her room and inflicted additional injury upon herself.

On 1/19/21, Patient #10 became verbally aggressive with staff and participated in self-harming behaviors. According to the medical record, Patient #10 aggressively punched the wall and mattress in her room and aggressively scratched herself. Additionally, Patient #10 expressed fear of harm from staff. Communication related to fear of staff was relayed to the unit nurse.

There was no evidence staff reported the patient safety events which involved Patient #10, which included events of self-harm, aggressive behavior and fear of staff. Because staff did not report the events according to facility policy, the patient safety events were not tracked and trended and additional investigation of the events did not occur.

ii. According to Patient #16's medical record, Patient #16 presented as a walk-in patient for detox services on 3/27/21. The patient collapsed while sitting and became unresponsive. An internal emergency code was initiated and 911 was called for immediate emergency medical assistance. The patient was transferred to another facility. Members of the staff responded to the internal emergency code to assist and stabilize the patient until emergency medical assistance arrived. The patient safety event which involved Patient #16's emergent transfer was not reported, and the event was not tracked or trended nor did additional investigation occur.

iii. Patient #2's medical record revealed on 4/5/21 the patient engaged in self-harming activity. Patient #2 removed the wire from his disposable mask and repeatedly scratched his face with the wire.

On 4/9/21 Patient #2 again engaged in self-harming activities. Patient #2 cut his left arm and right cheek with a staple he removed from a pamphlet. The unit nurse addressed the self-harm event with the patient and cleaned and dressed the wounds.

On 4/10/21, Patient #2 became physically aggressive with another patient. Patient #2 threatened to physically strike the other patient. Patient #2 physically struck the patient he threatened in the face. Patient #2 reviewed the event with the unit nurse immediately after it occurred.

Staff did not report the patient safety events which involved Patient #2 self-harming or assaulting another patient. The events were not tracked or trended and additional investigation of the patient safety events did not occur.

iv. Patient #1's medical record was reviewed. According to the medical record on 4/13/21 Patient #1 eloped from the cafeteria and physically attacked staff members. The patient was physically restrained until he was able to de-escalate. Nursing staff were present when the patient attempted to elope and when the patient became physically aggressive. Staff did not report the patient safety event and the event was therefore not tracked or trended nor did additional investigation occur.

v. Review of Patient #12's medical record revealed on 4/23/21, Patient #12 presented as a walk-in patient for detox services. While sleeping in the lobby an attempt was made to rouse the patient and the patient was unresponsive. An internal emergency code was initiated and 911 was called for immediate emergency medical assistance. The patient was transported to another facility. Members of the staff responded to the internal emergency code to assist and stabilize the patient until emergency medical assistance arrived. The event in which Patient #12 required emergent transfer was not reported. The event was not tracked or trended and additional investigation of the patient safety event did not occur.

vi. According to Patient #6's medical record on 6/7/21 Patient #6 eloped from the unit. Nursing staff were present when the patient elopement occurred.

On 6/9/21, Patient #6 attempted to elope from the unit twice. Following the second elopement attempt the patient became physically agitated and punched the access door to the unit. Nursing staff were present when the patient attempted to elope both times and when the patient became physically aggressive.

On 6/10/21, Patient #6 eloped from the cafeteria. A code green, the internal alert code for a patient elopement, was initiated. The patient was located and escorted back to the unit. Nursing staff were present when the patient attempted to elope. Once back on the unit the patient proceeded to his room where he engaged in a suicide attempt. The patient tied a scrub top around his neck, staff were able to remove the garment, and no injuries were noted for the patient.

On 6/11/21, Patient #6 engaged in another suicide attempt while in his room. The patient was found in his room with a pillowcase tied around his neck. A code purple, the internal alert code for a suicide attempt, was initiated. Nursing staff removed the pillow case from the patient's neck.

On 6/13/21, Patient #6 engaged in back to back suicide attempts in his room. The patient initially wrapped a scrub top around his neck and refused to remove the scrub top. Staff advised the patient the scrub top would be removed at which time the patient grabbed a nearby towel and wrapped it around his neck. Nursing staff removed the towel was removed from the patient's neck.

Staff did not report the patient safety events involving Patient #6, which included elopements and elopement attempts, physical aggression and suicide attempts. The patient safety events involving Patient #6 were therefore not tracked or trended and additional investigation of the events did not occur.

d. Leadership interviews revealed a lack of facility oversight and analysis of patient safety events and failure to implement necessary interventions to prevent reoccurrence.

i. On 6/24/21 at 9:15 a.m., Director of Quality, Compliance and Risk (Director) #15 was interviewed. Director #15 stated she was responsible for the quality program, compliance adherence and risk management. Director #15 stated she monitored and evaluated risk utilizing the Quality and Performance Improvement Plan and the Performance Indicators list. Director #15 stated her responsibilities included investigation, evaluation and tracking of adverse patient events.

Director #15 stated staff reported a patient safety event when situations occurred outside the facility's normal scope of activity. Director #15 stated the reports provided detailed information about what occurred and which staff were present. Director #15 stated reports were completed for the following situations: falls, seizures, contraband, attempted elopements/elopements, inappropriate behaviors by staff or patients, sexual allegations/familiarity, medical emergencies, self-harm, suicide attempts, seclusion and restraint initiation/use and displays of violent or aggressive behaviors. Director #15 stated staff were to complete and turn in reports of patient safety events prior to the end of their shift.

Director #15 stated all reported events were entered into a log and tracked on the quality control dashboard. Director #15 stated she updated the log and the quality control dashboard when staff reported patient safety events. Director #15 stated both the log and the quality dashboard tracker identified areas of increased reporting trends and patterns. Additionally, she stated reports of patient safety events were investigated based on the severity of the event and when increased trends were identified.

Director #15 stated patient safety events which required further investigation were considered adverse events. Director #15 stated a mini root cause analysis (mini RCA) was conducted to investigate adverse events. Director #15 stated if staff did not report patient safety events the events could not be tracked or trended. Subsequently, she acknowledged when staff did not complete reporting patient safety events an investigation of the event would not occur.

Director # 15 acknowledged a patient safety event report was not completed for Patient #12, #16 and #18. Furthermore, she confirmed the adverse events involving Patient #16 and #18 could have been avoided had a report been completed and investigated for Patient #12. Director #15 stated because staff did not report patient safety events it resulted in potential harm to patients.

ii. On 6/22/21 at 4:37 p.m., Chief Nursing Officer (CNO) #13 was interviewed. CNO #13 stated she was a member of the Quality and Performance Improvement Council. CNO #13 stated she participated in reviewing the high-risk indicators described in the Nursing Services PI Indicator List.

CNO #13 stated staff received training regarding how to report patient safety events upon hire and annually. CNO #13 stated she facilitated the annual training which reviewed the process for reporting patient safety events. CNO #13 stated during weekly huddles, which were the weekly debriefing meetings performed with the nursing staff, she reviewed how to complete the form to report a patient safety event forms and the various types of patient safety events staff were required to report. CNO #13 stated IR forms should be completed for the following types of patient safety events: falls, medication errors, inappropriate behaviors towards staff, peers and patients, injury or harm to patients or staff, occurrences of self-harm, suicide attempts, suicidal gestures and attempted elopements. She further stated the report form provided a comprehensive list of reportable patient safety events.

CNO #13 reviewed Patient #6's medical record. CNO #13 stated patient safety event reports were missing for Patient #6. CNO #13 stated staff should have reported multiple events documented in Patient #6's record, including events which involved suicide attempts and elopement attempts. CNO #13 stated when staff did not report a patient safety event a review of the event could not occur. Subsequently, she acknowledged there was increased risk for harm and poor patient outcomes occurred when patient safety events were not reported. CNO #13 she was aware of deficient documentation related to patient safety event reports.

iii. On 6/16/21 at 4:21 p.m., Registered Nurse (RN) #1 was interviewed. RN #1 stated patient safety event reports were needed anytime a patient safety event occurred. RN #1 staff reported the following patient safety events: patient placement in seclusion, use of restraints, patient attempted elopements, contraband use, discovery of sexual interactions between patients, anytime a patient displayed inappropriate or aggressive behavior, and any time there was doubt or concern about an event. RN #1 stated completion of IRs indicated a patient safety event occurred. RN #1 stated staff were required to report patient safety events immediately after an event occurred and were to complete the report before the end of shift.

RN #1 stated reports of patient safety events were provided to the CNO after staff completed them. RN #1 stated patient safety event reporting allowed staff to improve, provide better care and keep patients safe. RN #1 stated the risk for increased harm to the patient occurred when staff did not report patient safety events.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §416.46 NURSING SERVICE, was out of compliance.

A-0392 The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. Based on observations, interviews and document review, the facility failed to properly staff separate units and the desk at the main entrance. Specifically, the facility failed to ensure it staffed each functional area/inpatient unit with a registered nurse (RN) per shift, as well as failed to have supervisory staff available to ensure the immediate availability of a RN for patient care. Further, the facility failed to ensure it staffed the reception area to ensure patients had immediate access to an assessment to determine the level of care they required. These failures were identified in two of six inpatient nursing units and one of one reception area.

A-0395 A registered nurse must supervise and evaluate the nursing care for each patient. Based on observation, interviews and document review, the facility failed to ensure a registered nurse (RN) supervised and evaluated the nursing care for all patients who arrived at the facility seeking detox (to rid the body of alcohol or chemicals) treatment. (Cross Reference A-0286, A-0392)

A-3096 The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs. The nursing care plan may be part of an interdisciplinary care plan. Based on interviews, document review and record review, the facility failed to ensure a registered nurse developed, reviewed and revised patient care plans to maintain patient safety in 10 of 10 medical records (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10). (Cross-reference, A-0168)

Based on observations, interviews and document review, the facility failed to properly staff separate units and the desk at the main entrance. Specifically, the facility failed to ensure it staffed each functional area/inpatient unit with a registered nurse (RN) per shift, as well as failed to have supervisory staff available to ensure the immediate availability of a RN for patient care. Further, the facility failed to ensure it staffed the reception area to ensure patients had immediate access to an assessment to determine the level of care they required. These failures were identified in two of six inpatient nursing units and one of one reception area.

Findings include:

Facility policies:

The Plan for Provision of Care dated 2/09 read, inpatient care is provided on a 24-hour basis, seven days a week. Referrals are accepted from the community, the patient or the patient's significant other. Qualified mental health professionals perform intake screening and evaluations and make a recommendation for the appropriate level of treatment according to the admission criteria and practitioner recommendation. Nursing care is defined and delivered in accordance with the laws of the state of Colorado, the mission of the facility and the philosophy and standards of the department of nursing. Nursing care services are organized under the direction of the Director of Nursing as identified in the hospital plan for nursing care. The primary goal of nursing service is to provide planned, comprehensive, therapeutic, safe and consistent nursing care 24 hours a day, seven days a week. Assignments for nursing care are made according to programmatic and patient acuity needs as defined in the hospital plan for nursing care.

The Hospital Plan for Provision of Nursing Care dated 2/09 read, staffing will be sufficient at all times to ensure a registered nurse (RN) defines, directs, supervises, evaluates, prescribes, delegates and coordinates the nursing care of each patient. All patient assignments given to non-registered nurse care givers will be co-assigned to an RN. Each functional area is staffed by at least one RN per shift. Each nursing unit will have a basic staffing pattern which gives consideration to the unique needs of the patients' service. One RN is scheduled per shift, per unit, dependent on the census and acuity needs. RNs will be available to participate in the delivery and supervision of nursing care on a continuous and ongoing basis.

The Staffing Plan for Provision of Care dated 2/09 read, a plan provides an overview of each unit which includes staffing plans based on acuity data and core staffing data. A qualified nurse is on duty at all times. There shall be a sufficient number of qualified and competent RNs on the unit to provide patients with nursing services which require the judgment and specialized skills of the competent RN. Nursing staffing shall also be sufficient to promptly recognize untoward change in a patient's condition and to intervene appropriately utilizing nursing, medical or hospital staff. In striving to assure optimal, achievable, quality nursing care and a safe patient environment, nursing staffing and patient assignment shall be based upon identified minimum staffing requirements by unit and actual patient needs as assessed through use of the acuity tool. Based on census and patient acuity, the needs of each unit are evaluated on a shift or partial shift basis by the charge nurse or house supervisor daily, who makes patient assignments each shift and adjusts the assignments based on changes in daily acuity.

The Types of Admissions policy dated 2/09 read, admissions occur during regular business hours, evenings, weekends and holidays. Admissions may be scheduled, unscheduled (emergency) or as a result of a walk-in. All persons seeking care will perceive an appropriate screening and assessment to determine the level of care they require. A bona fide emergency exists when there is imminent and grave danger to self and others. A crisis exists when the patient and/or his family is in sufficient turmoil to warrant timely intervention. Timely intervention may result in either a scheduled or an emergency admission. The admissions assessor will obtain necessary information regarding the patient and notify the appropriate hospital personnel as well as arrange an immediate emergency admission review and admission if appropriate.

1. The facility failed to staff nursing units to ensure a RN was immediately available to direct and supervise the care of each patient. This conflicted with the facility's Hospital Plan for Provision of Nursing Care and Staffing Plan for Provision of Care.

a. Observations and document review revealed the facility failed to ensure a registered nurse (RN) was immediately available for each inpatient unit.

i. On 6/17/21 at 5:11 a.m., a nurse was not present on unit 600 or 700. During the tour, RN #31 stated RN #39 was the only nurse scheduled for units 600 and 700. RN #39 returned to the shared nurses' station for units 600 and 700 three minutes later and stated she was on her break away from the units. RN #39 confirmed she was the only nurse assigned to units 600 and 700.

ii. Review of the Core Staffing Matrix, provided by the Chief Nursing Officer (CNO) #13 on 6/17/21, revealed each of the facility's six inpatient units was to have at least one RN assigned each shift. Units 600 and 700 were listed as separate units.

b. Documents provided by the facility and staff interviews revealed units 600 and 700 were distinct with different age populations, schedules and location in the facility. Documents further revealed units 600 and 700 were not staffed with a dedicated RN for 37 shifts over 45 days reviewed.

i. Review of the Bed Board, provided by the Director of Assessment and Referral (AR) #14 on 6/17/21, revealed each unit was listed separately with a description of the unit and the list of current patients. Unit 600 patients were seven to 14 years of age and unit 700 patients were 15 to 19 years of age.

ii. On 6/17/21 at 9:50 a.m., an interview was conducted with RN #2. RN #2 stated units 600 and 700 were different units. She stated the age ranges on the two units were different and the patients did not have access to the other unit. RN #2 stated unit 600 was for younger adolescents aged seven to 14 year of age and unit 700 was for ages 14 to 18 years.

iii. Review of the daily unit schedules for units 600 and 700 revealed the units had separate schedules. The patients ate meals at different times and therapy groups were scheduled at different times.

iv. Review of the floor plan received by the facility on 6/20/21 revealed units 600 and 700 were separate units and patients only had access to the unit in which they were assigned.

v. On 6/21/21, CNO #13 provided a list of dates from 5/1/21 through 6/14/21 when one RN was assigned to two units (units 600 and 700). Review of the document revealed there were 13 shifts when one RN was assigned to both units from 1:30 a.m. until 6:00 a.m. and an additional 24 shifts when one RN was assigned to both units from 3:30 a.m. until 6:00 a.m. Together, there were a total of 37 shifts over 45 days when one RN was assigned to the two separate units. (See above; the list did not include the observation on 6/17/21.)

vi. Review of the medical record for Patient #2 who resided on the 600 unit revealed Mental Health Technician (MHT) #8 documented during her shift on 4/9/21 she was the only staff present on the unit when she was performing 15 minute wellness observations. No RN was identified in the documentation. MHT #8 wrote Patient #2 was in the bathroom and sounded strange but due to being the only staff member on the unit, MHT #8 completed the remaining 15 minute observations before checking on Patient #2. MHT #8 found Patient #2 had self-harmed by scratching his cheek and forearm with a staple.

c. Interviews confirmed the facility failed to properly staff each unit in order to have a RN immediately available to direct and supervise the care of each patient, as well as failed to have supervisory staff available to ensure the immediate availability of a RN for patient care.

i. On 6/17/21 during the tour at 5:11 a.m., RN #31 was interviewed. RN #31 stated units 600 and 700 were sharing a RN due to the facility not having enough staff. She said there was no house supervisor on duty either, as the supervisor had left at 3:00 a.m., handing house supervisor phone to another staff member. RN #31 stated a lot of staff had recently quit. She stated the DON had tried to hire people, but they only lasted a month or so. She stated the facility did not use agency or travel staff to fill the staffing gaps.

ii. On 6/17/21 during the tour at 5:11 a.m., RN #39 was away from both the 600 and 700 units (see observation above). RN #39 stated she was taking a break at 5:11 a.m. and once she learned of surveyors' arrival, she returned to the unit. RN #39 stated when she was on break, there was no nurse covering either the 600 or the 700 unit. She stated if there was a house supervisor, she would tell them she was going on break; however, she confirmed there was no house supervisor this shift. RN #39 stated she was the RN assigned to both the 600 and the 700 units since the other RN had left at 1:00 a.m.

iii. House Supervisor (Supervisor) #12 was interviewed when she arrived at work on 6/17/21 at 6:05 a.m. Supervisor #12 stated even though they shared a nurses' station, unit 600 and 700 were separate units. However, she stated both units could share a RN depending on staffing and the number of patients. She stated unit 600 had 11 patients and unit 700 had nine patients currently. She stated often there would be no house supervisor when the night shift left between 1:00 a.m. and 3:00 a.m. until she arrived to work between 5:30 a.m. and 6:00 a.m.

iv. On 6/17/21 at 8:43 a.m., an interview was conducted with CNO #13. CNO #13 stated units 600 and 700 had separate halls, were separate units, but shared a nurses' station. She stated the facility could assign one nurse to cover units 600 and 700 together due to the shared nurses' station. CNO #13 stated the regulatory reference to have supervisory staff immediately available meant a nurse was on the unit.

CNO #13 stated she was responsible for staffing and assignments of nurses to units throughout the facility. She stated each unit had a nurse assigned for the safety of patients and staff. CNO #13 repeated, however, that during night shift, units 600 and 700 shared a nurse after a float nurse left at 1:00 a.m. or 3:00 a.m. until the next shift started at 7:00 a.m. CNO #13 further stated units 400 and 500 also shared one nurse after float staff and mid-shift nurses went home.

The facility's Core Staffing Matrix provided by CNO #13 (see above) was reviewed with her. The minimum number of nurses assigned to each unit was one. Units 600 and 700 were listed separately, and read each required a minimum staffing of one nurse per unit. CNO #13 stated she was aware of the staffing matrix and the purpose of the matrix was for budgeting.

v. On 6/17/21 at 1:22 p.m., an interview was conducted with MHT #8. MHT #8 stated one nurse was assigned to cover units 600 and 700 on night shift due to staffing shortages. MHT #8 stated patient and staff safety was at risk when only one nurse was assigned to cover both units. MHT #8 stated when the nurse went on break, no nurse was available for two units. MHT #8 stated approximately one month ago, an incident occurred which was a violent and dangerous situation. MHT #8 stated the facility did not have adequate staff to respond and only had four or five staff members in addition to one admissions staff to respond. MHT #8 stated patients and staff were safer when a nurse was assigned to each unit.

2. The facility failed to properly staff the reception area to ensure patients had immediate access to an assessment to determine the level of care they required, contrary to the facility's Types of Admissions policy.

a. Observation on 6/17/21 at 5:00 a.m., the facility's main entrance doors were locked and no staff were present at the reception desk. The main entrance was where patients arrived for walk-in services and assessments. When the buzzer was repeatedly pressed, no staff responded. Approximately ten minutes later, a housekeeping staff member who was reporting for work opened the main door.

i. On 6/17/21 during the tour at 5:11 a.m., RN #31 was interviewed. She stated the receptionist quit a week ago, so there was no one scheduled to let patients in the building, other than the house supervisor.

ii. On 6/21/21 at 1:00 p.m., an interview was conducted with AR #18. AR #18 stated her job duties included assessment of patients and determination of which level of care was appropriate. If the patient required admission to an inpatient unit, AR #18 used the bed board guide to determine the appropriate unit. She stated units 600 and 700 were separate units and age determined which unit the adolescent was placed.

iii. On 6/17/21 at 11:05 a.m., an interview was conducted with AR #14. AR #14 stated the facility was open 24 hours a day for psychiatric emergencies. AR #14 stated she was responsible for staffing the reception desk at the main entrance. She stated the night of 6/16/21, the facility did not have a receptionist scheduled at the main entrance desk due to a recent resignation of staff. AR #14 stated the admissions staff was responsible to cover the reception desk when there was not dedicated staff assigned to cover the desk. She stated the admissions staff was not able to perform some of their duties at the desk, such as phone calls and authorizations. During these tasks, the admissions staff worked from the back office and not at the reception desk which left the desk at the main entrance unstaffed.

iv. On 6/17/21 at 7:53 a.m., an interview was conducted with AR #16. AR #16 stated the reception desk at the main entrance, where patients presented for care as a walk-in patient, was not staffed the night of 6/16/21. AR #16 stated the admissions and referrals staff had to cover the reception desk when staff was not scheduled to work the desk. She stated patients risked a delay in care if admissions and referrals staff was working in the back office and did not respond to the buzzer at the main entrance.

Interviews revealed staffing of the inpatient units and reception desk was in contrast with facility policies which stated each unit was required to have a dedicated RN for immediate availability and care for patients.

Based on observation, interviews and document review, the facility failed to ensure a registered nurse (RN) supervised and evaluated the nursing care for all patients who arrived at the facility seeking detox (to rid the body of alcohol or chemicals) treatment. (Cross Reference A-0286, A-0392)

Findings include:

Facility policies:

The Nursing Care and Physical Health Emergencies policy read, the facility offers reasonable care in determining whether an emergency exists, renders lifesaving first aid, and makes appropriate referrals to the nearest facilities capable of providing needed services. Patients, staff, or visitors who are involved in an accident or incident and sustain injuries requiring treatment or evaluation beyond the capabilities of this facility will be transferred to an Emergency Room the hospital has agreements with. These actions are coordinated by the Charge RN or Designee. Notify Attending Physician or Medical Director of all injuries. Notify House Supervisor, DON, and AOC of all injuries. Staff will stay with the affected individual during a Medical Emergency, monitoring appropriate vital signs and the individual's conditions. This person is responsible for ensuring all appropriate documentation is completed. The staff administers necessary first aid and medical intervention, within the scope of their training, to stabilize the patient until transfer to an emergency room is completed. Assess the individual's condition.

The Admission Process policy read, the point of entry or initiation of the admission process begins in Assessment and Referral (AR). AR will gather all clinical and medical information to determine whether the patient meets admission criteria. AR will review the potential admission with the psychiatrist on-call regarding all patients accepted for inpatient admission. Once accepted for admission, AR will notify the unit charge nurse. AR will perform initial assessments in their offices.

The Emergency Walk In Services policy read, the client will be interviewed within a timely manner of presentation. Mental Health Clinicians include but are not limited to Social Worker, Professional Counseling, and Marriage & Family Therapist. If the client presents with an emergent medical condition, assessed by the Physician (if available in house) and/or a Registered Nurse, to require immediate care, steps to stabilize patient will be initiated, and appropriate medical transfer, with the patient's (or a legally responsible person acting in his/her behalf) informed consent, will be arranged to provide the optimal level of care required. Documentation will designate reason for medical transfer, name of receiving facility, mode of transportation, name and title of staff receiving report, name and title of staff giving report, and date and time of contact. Copies of medical records and any pertinent information relevant to the emergent condition will be sent to receiving facility with the patient at the time of transfer.

References:

The Medstaff Bylaws read, Qualified Medical Person or Personnel (QMP) - in addition to a physician, qualified medical persons may perform a medical screening examination. Individuals in the following professional categories who have demonstrated current competence in the performance of medical screening examination, and who are functioning within the scope of his or her license and policies of the hospital, have been approved by the board as qualified medical personnel: Registered Nurse, Social Worker, Licensed Professional Counselor, or Psychologist.

1. The facility failed to ensure a clinical RN evaluated, supervised and monitored detox patients.

A. Document review revealed a lack of timely nursing assessment and supervision.

a. Patient #15

i. According to the transfer log, Patient #15 presented for an assessment on 3/10/21 and told the receptionist he overdosed on medication. Patient #15 started seizing and foaming at the mouth in the assessment room. He was transferred to an acute care hospital for medical clearance.

ii. Review of the facility's review revealed Patient #15 checked in with the receptionist at 11:10 a.m. and was taken to the assessment room at 11:25 a.m., which was 15 minutes after he reported he overdosed. A code white (medical alert) was called at 11:40 a.m., 30 minutes after the patient reported he overdosed, when the patient started to medically decompensate. The RN called 911 and went to the patient's car to identify what pills he took. The provider directed the code.

iii. Review of the medical record revealed no evidence an RN assessed Patient #15 for a medical emergency on arrival once he declared he overdosed. There was no evidence in the medical record the patient was evaluated, supervised or stabilized by an RN on 3/10/21. The first nursing note or assessment was dated for 3/15/21 when Patient #15 returned from the acute care hospital.

iv. On 3/16/21 the provider documented in the History and Physical (H&P) Patient #15 took 59 tablets of Trileptal (an anticonvulsant medication) on 3/10/21 as a suicide attempt. According to the H&P he was immediately taken to the assessment room where he became lethargic, stated he didn't feel well, his throat was closing off, became disoriented, had slurred speech and became unresponsive and fell over to his right side while seated in his chair. A code white was called and answered by nursing and medical staff.

v. The medical record included a discharge summary from the acute care hospital where Patient #15 was transferred on 3/10/21. Review of the discharge summary revealed when he arrived from the facility, he was no longer protecting his airway and was emergently intubated (insertion of a tube into the airway to assist with breathing and oxygenation).

vi. The facility's review and transfer log were the only evidence the patient received care while in the lobby during the code white on 3/10/21. The provider documented a note once the patient returned to the facility on 3/15/21, five days after the code white event in the lobby. There was no evidence an RN evaluated the patient once he declared he overdosed to determine if the patient needed to be sent out to an acute care facility for medical clearance.

b. Patient #16

i. According to the transfer log, Patient #16 presented for a detox assessment on 3/26/21. He collapsed out of the chair and was nonresponsive. A code white was called and Patient #18 was transferred to the hospital via 911.

ii. Review of the medical record revealed no evidence an RN assessed Patient #16 for a medical emergency when he arrived at the facility. There was no evidence in the medical record the patient was evaluated, supervised or stabilized by an RN on 3/26/21. The first nursing note or assessment was dated for 3/27/21 when Patient #16 returned from the acute care hospital.

iii. Patient #16's medical record included a discharge summary from the acute care hospital where the patient was transferred on 3/26/21. Review of the discharge summary revealed he was sent to the hospital from the facility on 3/26/21 with an ethanol level of 455 mg/dl. The comment attached to the result read, results greater than or equal to 80 mg/dl was considered under the influence.

c. Patient #18

i. According to the transfer log, Patient #18 presented for a detox assessment on 5/27/21. He had taken an unknown amount of an unknown combination of substances. Patient #18 was sent to an acute care hospital for medical clearance.

ii. The patient safety event was reviewed. Patient #18 arrived at the lobby seeking assistance for detox on 5/27/21 at 5:21 p.m. He had taken an unknown amount of Pyrazolam or Xanax (both benzodiazepines which were tranquilizers). Patient #18 was not taken to the assessment room until 5/28/21 at 1:26 a.m., almost eight hours after he arrived at the facility. He vomited on himself and became difficult to arouse. At 2:00 a.m., the provider was notified and transport service was called to transfer Patient #18 to an acute care hospital.

iii. The facility's review for this event was reviewed.

Receptionist #32 documented Patient #18 arrived at the facility on 5/26/21 at 5:41 p.m.(different time than the patient safety event) and was alert but confused, so she called the assessment and referral (AR) staff to evaluate him. The AR staff did a breathalyzer test on the patient, which was negative.

Receptionist #29 documented he arrived for work on 5/26/21 at 6:30 p.m., and Patient #18 was waiting in the lobby for an assessment. At 10:00 p.m., Receptionist #29 noticed Patient #18 was sleeping heavily, so he went to assess his breathing. At 12:00 a.m., Receptionist #29 was told by AR staff Patient #18 would not be assessed for another hour, so he called an RN to assess Patient #18. Receptionist #29 documented RN #31 woke Patient #18 and spoke with him, and the patient seemed tired but coherent. Patient #18 was taken to AR "a little while later", according to the review.

AR staff (AR) #30 documented in the facility review, Receptionist #29 had been monitoring Patient #18's respirations while he was sleeping in the lobby. AR #30 documented RN #31 told the AR staff she assessed Patient #18 because Receptionist #29 asked her to. RN #31 told AR #30 the patient had vomited on himself, but was "ok" to be seen by the AR staff.

AR staff (AR) #16 documented in the facility review, RN #31 had told her Patient #18 was unresponsive, purple and vomited on himself, but he was coherent enough to be seen by the AR staff.

According to the facility's review of the event Patient #18 waited in the lobby for approximately eight hours before admission staff assessed him. It was unclear in the facility's review exactly when the RN evaluated the patient to see if he needed to be sent to an acute care facility for medical clearance. Even though there were different accounts of the RN's assessment, the facility did not get a statement from the RN for their review.

Action items were created from the facilities review. However, there were no action items related to the nursing assessment timeframe required for a detox patient seeking treatment, the nursing supervision of an altered detox patinet or the nursing re-assessment of a detox patient who remained in the lobby. There were no action items related to the RN #31 who had reported discrepancies in her assessment of the patient, or additional training identified for nursing staff. Additionally, it was not identified if the receptionist and the AR staff acted out of scope of their training.

iv. An email was sent from the Chief Operating Officer (CEO) #24 to other leadership on 5/27/21 at 4:38 p.m., which outlined the following actions to be effective immediately: reception would place detox patients in the right hand area of the lobby so they were visible to the receptionists; reception would notify AR staff when a detox patient arrived to the facility so nursing staff would assess the patient as soon as possible to determine if the patient needed medical clearance; and the house supervisor would periodically check in with the receptionist to determine if there were any medical concerns on patients in the lobby awaiting assessment.

The new process did not specify the timeframe in which the RN should assess a patient or what was an acceptable lobby wait time. There was no direction for the RN to reassess detox patients who had an extended lobby wait time. Additionally, there was no medical person assigned to monitor the status of lobby patients.

d. The Detox Wait Times log from 5/1/21 to 6/24/21 was reviewed. The log revealed frequent extended lobby wait times. Examples: There were 14 detox patients with lobby wait times of two hours, nine detox patients with lobby wait times of three hours, two detox patients with lobby wait times of four hours and four detox patients with lobby wait times of approximately five hours or greater. Additionally, there were 20 patients whose wait times were not tracked on the log, therefore it was unknown their lobby wait times. According to the Emergency Walk In policy, the patient would be assessed in a timely manner and if the client presented with an emergency medical condition, immediate steps to stabilize the patient would be initiated by the provider or RN.

B. Interviews with staff revealed patients were monitored in the lobby by a nonmedical receptionist until seen by the nonmedical admissions staff.

a. On 6/17/21 at 8:43 a.m., Chief Nursing Officer (CNO) #13 was interviewed. She stated her role was to ensure a safe environment for patients and staff. She stated the facility was open 24 hours a day, seven days a week and treated mental health and detox patients. CNO #13 stated the facility had seen an increase in chemical dependency patients since the beginning of the year. CNO #13 stated even though her role was to ensure the safety of patients, she was not in charge of the process to admit patients and was unable to speak of the process, including if nursing evaluated patients or the timeline for assessment. CNO #13 stated the Director of Assessment and Referral (AR) #14 oversaw the admission processes. CNO #13 stated AR #13 was not a nurse.

b. On 6/17/21 at 11:05 a.m., an interview with the Director of Assessment and Referral (Director) #14 was conducted. Director #14 stated her degree was in psychology and she did not have a medical degree. Director #14 stated the facility offered mental health services 24 hours a day, seven days a week. She stated the admissions staff all had master's level degrees in counseling, social work or psychology. Director #14 stated the admissions staff were trained on how to assess patients and determine which level of care was the most appropriate.

Director #14 stated when there was no one staffed to be the receptionist, the AR staff performed the reception job as well as admissions of patients into the facility. She stated when patients walked in, they received paperwork to fill out and then admissions were called to notify them the patient needed to be seen. Once the patient filled out the paperwork, the AR staff determined the patient's acuity and prioritized patients to be seen and evaluated. While the patient filled out the paperwork the receptionists, who were not medically trained and were only required to have their high school diploma, monitored the patients in the lobby and give AR staff updates as needed.

Director #14 stated ideally a walk-in patient would be seen within 15 to 30 minutes of the patient's arrival. However, review of the facility's Detox Wait Times log revealed patients routinely waited over two hours to be seen. There were also extended wait time of over five hours to be seen.

Director #14 stated the facility had just started discussing wait times for patients and the admission process as of 6/14/21 at a 2:45 p.m. meeting. She stated she did not track and trend outcomes, nor did she watch video to ensure processes were being followed.

Director #14 stated the AR staff were the staff in the facility who determined if a patient was having a mental health emergency, therefore they performed the admission assessments. According to the Bylaws, the AR staff were listed as Qualified Medical Providers (QMP)s to perform admission assessments for all patients even though they were not medical. She stated the risk to patients if a delay occurred in assessment would be a negative impact to their mental health. She stated delays in assessment could cause patients to not reach out for help again or they could die but stated hopefully that wouldn't happen.

c. On 6/17/21 at 7:53 a.m., an interview with assessment and referral coordinator (AR) #16 was conducted. She stated she had a psychology degree, which was not a medical degree, and her primary role was to assess patients when they arrived at the facility to determine what program they qualified for, such as inpatient care. AR #16 stated patients were prioritized according to how the patients arrived: patients who arrived by ambulance were seen first, then patients with appointments were seen, then walk-in patients were seen.

AR #16 stated she was the only assessor present on the night Patient #18 presented to the facility. AR #16 stated Patient #18 was waiting in the lobby when she arrived to work and he had to wait for a couple hours to be seen. She stated Patient #18 had to be intubated in the parking lot. She stated she had to run his insurance before she assessed him because he was a detox patient and she knew he would be admitted.

d. On 6/21/21 at 1:00 p.m., an interview with assessment and referral coordinator (AR) #18 was conducted. AR #18 stated she had a degree in clinical psychology and her role included assessing patients to determine which level of care was appropriate.

AR #18 stated a patient's insurance was determined prior to assessing the patient to determine their benefits and what they qualified for. She stated the AR staff (who were not medical) performed the medical screening exam. AR #18 stated she was not a medical professional, but she would ask a patient what chemical they used, how often, their withdrawal history and if they had withdrawal symptoms. She stated she could identify if the patient was having withdrawal symptoms if she saw the patient sweating or if they stated they were nauseous. AR #18 stated once she performed her assessment, she would call the provider with her findings to see if the provider wanted to admit the patient to the facility as an inpatient or to send the patient to an acute care facility for medical clearance.

She stated it was a new process for nurses to go to the waiting room to evaluate if the patient was stable to wait for the admission assessment. She stated this was new since Patient #18 waited so long in the lobby to be seen. She stated according to the new process the RN would determine when the patient would be seen by the AR staff.

C. On 6/23/21 at 2:04 p.m., a mock exercise was observed for the arrival and assessment of a patient who requested assistance for detox. At 2:07 p.m., the house supervisor was notified a patient was in the lobby seeking detox treatment. At 2:15 p.m., House Supervisor (Supervisor) #12 arrived in the front lobby to assess the mock detox patient. Supervisor #12 took vital signs and asked questions. Supervisor #12 stated she deemed the mock patient high risk due to their risk of having a seizure and would call the AR staff and have them perform a mental health assessment on the patient sooner because this patient would take priority. She stated she was unaware of what a QMP stood for or if she was designated a QMP in the facility.

Supervisor #12 stated she would then leave the area and go back to her regular duties. Even though she deemed the mock patient high risk, she would not stay with the patient until assessed by AR or reassess the patient at a later time. Supervisor #12 stated the AR staff would call the provider and relay her findings after they assessed the patient. She stated if AR staff were not able to assess the patient right away, she would call the provider.

a. The Director of Assessment and Referral (Director)#14 was present during the mock patient admission and assessment. Director #14 stated the RN would assess a detox patient to determine if the patient was medically cleared, then the RN would leave the patient with the admission staff in the lobby. Director #14 stated the lobby staff and admissions staff were not medical. Director #14 stated the RN did not speak with the provider to discuss their assessment prior to leaving the patient with admissions staff.

b. According to the Emergency Walk In policy, a Qualified Medical Professional was supposed to do the medical screening exam (MSE); if an RN or provider determined there was an emergent medical condition (EMC) they were to initiate steps to stabilize the patient. According to the Bylaws, the positions of physicians, RN, Social Worker, Licensed Professional Counselor, or Psychologist who had demonstrated competence in the performance of medical screening examination, and who were functioning within the scope of his or her license and policies of the hospital, had been approved by the board as qualified medical personnel. However, the process at the facility was for the nonmedical AR staff to assess patients and determine if they had an EMC. Even though the facility had seen an increase in detox patients walking in to the facility to seek treatment, the facility had not changed the process to require an RN or a physician to see each detox patient to determine if they had an EMC. Instead the facility continued the process of nonmedical AR staff to conduct a medical assessment for patients who were seeking to be seen for detox instead of a mental health emergency.

Based on interviews, document review and record review, the facility failed to ensure a registered nurse developed, reviewed and revised patient care plans to maintain patient safety in 10 of 10 medical records (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10). (Cross-reference, A0168)

Findings include:

Facility policies:

The Nursing Assessment policy read, following the completion of the initial patient assessment, the nurse will be responsible for the development of an individualized patient treatment plan to include identification of patient specific behaviors and nursing treatment interventions. The nurse will perform assessments and reassessments of the patient's needs and update the patient's individualized treatment plan continually during the inpatient stay.

The Hospital Plan for Provision of Nursing Care outlined nursing responsibilities, nursing scope of practices and standards of practice which included the following: The nurse shall contribute to patient treatment plans through the implementation of nursing interventions and patient specific goals. Implementation of nurse driven actions should strive to promote, maintain and/or restore the patient's physical and mental well-being to prevent adverse patient events, illness and improve patient rehabilitation.

Resources:

The Registered Nurse (RN) job description read, the registered nurse will provide direct patient care in conjunction with the following responsibilities: Oversight and supervision of nursing services provided for the care and treatment of the patient. Development, implementation and evaluation of patient care plans. The assessment and reassessment of the patient, communication of patient concerns and changes in condition and of the patient to the interdisciplinary team.

The Licensed Practical Nurse (LPN) job description read, under general supervision the LPN will provide nursing care. Nursing services provided will assume responsibility for communication of critical concerns and routine patient updates to support continuity of care for patients in collaboration with members of the multidisciplinary team.

1. The facility failed to ensure nursing care plans were updated, reflected changes in the patient's condition and defined nursing concerns related to adverse patient safety events, health outcomes and treatment progression.

a. According to facility policies and resources, the registered nurse was responsible to develop, implement and evaluate patient care plans and individualized treatment plans. Specifically, nursing documentation, updates and revisions to the patient care plan and individualized treatment plan were to include adverse patient safety events, health outcomes and treatment progression.

b. A review of patient medical records for patients hospitalized from 1/14/21 to 6/24/21 revealed the patient records lacked nursing care plan updates. Examples included:

i. Record review for Patient #10 revealed the patient had a diagnosis of severe recurrent major depressive disorder with psychotic symptoms and disruptive mood dysregulation disorder (a condition in which adolescents experience and display extreme irritability, anger, and frequent and intense temper outbursts) when she was admitted on 1/14/21.

On 1/15/21 a treatment plan was established for the patient. Further review revealed Patient 10's medical record lacked nursing documentation and revisions to the patient care plan and individualized treatment plan related to adverse patient safety events, health outcomes and treatment progression.

ii. Record review for Patient #2 revealed the patient had a diagnosis of depression and suicidal ideation when he was admitted on 4/4/21.

On 4/5/21 a treatment plan was established for the patient. Further record review revealed Patient #2's medical record lacked nursing documentation and revisions to the patient care plan and individualized treatment plan related to adverse patient safety events, health outcomes and treatment progression.

iii. Record review for Patient #1 revealed the patient had a diagnosis of disruptive mood dysregulation disorder attention deficit hyperactivity disorder (ADHD), suicidal ideation and homicidal ideation when he was admitted on 4/8/21.

On 4/9/21 a treatment plan was established for the patient. Further review revealed Patient 1's medical record lacked nursing documentation and revisions to the patient care plan and individualized treatment plan related to adverse patient safety events, health outcomes and treatment progression.

iv. Record review for Patient #6 revealed the patient had a diagnosis of attempted suicide, bipolar disorder (a mental health disorder which causes extreme and drastic mood swings) and paranoid schizophrenia (a mental health disorder which affects a person's ability to think and respond) when he was admitted on 6/7/21.

On 6/8/21 a treatment plan was established for the patient. Further review revealed Patient #6's medical record lacked nursing documentation and revisions to the patient care plan and individualized treatment plan related to adverse patient safety events, health outcomes and treatment progression.

v. Seven other medical records (Patient #3, #4, #5, #7, #8 and #9) were reviewed. All seven medical records lacked evidence of nursing documentation and revisions to the patient care plan and individualized treatment plans related to adverse patient safety events, health outcomes and treatment progression.

c. Interviews with staff revealed patient treatment plans should be updated and reviewed daily by the nurse.

i. On 6/16/21 at 4:21 p.m., Registered Nurse (RN) #1 was interviewed. RN #1 stated patient treatment plans were updated daily. RN #1 stated changes to treatment plans were to be documented when a change in patient status occurred.

ii. On 6/17/21 at 9:51 a.m., RN #2 was interviewed. RN #2 stated treatment plans were to be updated by the registered nurse. RN #2 stated the treatment plans were updated as part of the nursing care delivery section of the treatment plan. RN #2 stated treatment plans allowed the staff and the patient to monitor treatment progress. Registered Nurse #2 stated prevention of adverse patient events and illness helped to improve patient care.

RN #2 reviewed the medical record for Patient #2. RN #2 stated she was unable to find treatment plan updates in the medical record.