HospitalInspections.org

Based on review of clinical records, review of facility documents, and staff interview, the facility failed to protect and promote each patient's rights when:

A. Four patients (patients #1, 2, 3, and 4) on suicide precautions eloped from the facility. The four elopements reviewed occurred between 6/24/21 (patient #2) with the most recent on 8/11/21 (patient #4).

B. Three patients (#12, 13, and 14) who presented voluntarily with suicidal thoughts waited for several hours in the Behavioral Health Access area for a medical screening exam with no treatment or management of symptoms, were able to discharge AMA.

C. Review of Access Area Incident Reports for 6/20/21 through 7/6/21 (a two week period) revealed 8 of 15 incidents involved physical aggression and/or staff required security presence. The Access Area had no staffing grid or staffing sheets; therefore, it was difficult to determine who was working or if the Access Area was staffed appropriately, placing patients at risk of adverse events.

Refer A0144

Based on review of clinical records, review of facility documents, and staff interview, the facility failed to ensure each patient had the right to receive care in a safe setting when:

A. Four patients (#1, 2, 3, and 4) on suicide precautions eloped from the facility.

B. Three patients (#12, 13, and 14) who presented voluntarily with suicidal thoughts waited for several hours in the Behavioral Health Access area for a medical screening exam with no treatment or management of symptoms, were able to discharge AMA.

C. Review of Access Area Incident Reports for 6/20/21 through 7/6/21 (a two week period) revealed 8 of 15 incidents involved physical aggression and/or staff required security presence; with no staffing grid and no staffing sheets for the Access Area, it was difficult to determine who was working during certain shifts and if the Access Area was staffed appropriately.

Findings were:

A. Review of the clinical record for patient #1 revealed, they arrived at the ED on 7/5/21 at 6:28 am on an EDO for overdose and attempted suicide. The EDO dated 7/5/21 at 5:59 am stated in part,

"2. I have reason to believe and do believe that the above-named person evidences a substantial risk of serious harm to himself/herself or others based upon the following: Statements made of self harm, subject stated he had a plan and had already attempted suicide an hour ago by OD [overdose].

3. I have reason to believe and do believe that the above risk of harm is imminent unless the above-named person is immediately restrained.

4. My beliefs are based upon the following recent behavior, overt acts, attempts, statements, or threats observed by me or reliably reported to me: Subject stated he wanted to kill himself, subject stated to me he took 18 of his prescription clonidine, Subject also made statements he would jump in front of traffic." This was signed by the Peace Officer.


Patient #1's Suicide Risk Assessment dated 7/5/21 at 6:31 am indicated their C-SSRS Risk Level was High Risk. The Suicide High Risk Interventions stated in part, "Notify Provider of patient risk level for Psych consult, Initiated Observation. Placed on Suicide Precautions, Placed on Elopement Precautions, personal belongings removed, Consider limiting or restricting visitors ..."


Patient #1's clinical record contained the following progress notes:

-ED Physician note dated 7/5/21 at 9:19 am stated in part, "Patient evaluated for overdose attempt on clonidine. Work-up here largely unremarkable vital signs were appropriate. Monitored for total of 6 hours post ingestion. Closely monitored here in the emerge [sic] department. Is informed by nursing staff that he eloped from the emergency department. Police were called. They reviewed to find the patient and he was medically cleared for Pavilion access."

-Nursing note dated 7/5/21 at 9:22 am stated in part, "Was notified by [another staff member] at triage that my patient in room 17 had just fled out the front doors of the emergency room. Security and APD was notified. Direction of travel was east. Charge nurse notified."

-Sitter [staff #9] note dated 7/5/21 at 9:27 am stated in part, "Gave Pt the phone. Pt was unable to get ahold of person they were trying to call after several attempts. Pt gave phone back to me @ 0859. I went to put the phone back where it belongs. Pt then ran out of room @ 0900 into the lobby, out the door, and to the south. I went after Pt, informed triage to call security and Pt was to [sic] far away to catch. Security looked around the premises for Pt. Pt was unable to be located."

APD located patient #1 walking the streets and brought him to the behavioral health department, where he was admitted and discharged on 7/8/21.

Review of the clinical record for patient #1 revealed there was no sitter documentation, which was confirmed in an interview with staff #1, the Director of Quality, on the morning of 8/12/21. Staff #1 stated, "We thought we saw the sitter observation sheet, but it was this;" staff #1 provided the observation sheet from the time the patient arrived at the Behavioral Health department.


In an interview with staff #9 on 8/11/21 at 5:02 pm, when asked about the night patient #1 eloped, they stated, "They told me to sit with him. He was pretty calm. He got a little agitated and said he wanted to make a phone call because he didn't get to tell anyone he was here. He made his phone call. When he was done, I went around the corner to give the phone back. By the time I turned around, he was in the lobby. I called security and APD because he was on papers and told security which direction he went." Staff #9 showed surveyors which room patient #1 was in, where the nurse was sitting, and stated, "I handed [the nurse] the phone, and when I turned around, [patient #1] was at the door." When asked if anything was done in response to this, staff #9 stated, "[ED Manager] reeducated me and told me to ensure I keep Line of Sight."


Review of the medical record for patient #2 revealed, patient #2 presented to the ED on 6/24/21 at 6:37 am for intentional ingestion - overdose.

Patient #2's suicide risk assessment on 6/24/21 at 6:47 am and on 6/24/21 at 7:24 am indicated C-SSRS Suicide Risk Level was High Risk. The Suicide High Risk Interventions stated in part, "Notify Provider of patient risk level for Psych consult, Initiated Observation. Placed on Suicide Precautions, Placed on Elopement Precautions, personal belongings removed, Consider limiting or restricting visitors ..."

Patient #2's medical record contained the following progress notes:

-ED Physician note dated 6/24/21 at 9:12 am stated in part, "Observed to peak onset time. No decompensation. Got charcoal. Vitals improved ... will medically clear for Pavilion."

-Nursing note dated 6/24/21 at 10:04 am stated in part, "pt eloped from unit. pt [sic] removed [their] own iv before elopement. APD dispatch notified of elopement. Physician and charge nurse notified of elopement."

Patient #2 was not found and was not admitted to the behavioral health department as recommended by the ED physician.

Review of the clinical record for patient #2 revealed there was no sitter order or documentation.


Review of the clinical record for patient #3 revealed, they presented to the Behavioral Health Access area involuntarily on 8/6/21 at 11:00 pm by APD after the patient made suicidal statements and threats. The intake assessment note dated 8/6/21 at 11:53 pm stated in part, "Pt presents hx of recent inpatient treatment admission wit [sic] d/c date on 08/05 with similar situations and symptoms. Pt presents hx of MDD dx an [sic] use of alcohol. Unknown if pt followed up with d/c plan. Per APD report pt made statements to the police officer which included 'kill me please' and responded 'yes' when asked if he was feeling SI. No other details of SI plan or self-harm were noted. During assessment pt presented uncooperative, agitated, angry and explosive while screaming, yelling, and attempting to elope from ACCESS lobby area ... Current symptoms include depression, high anxiety, explosive behavior, anger, agitation, irrational thinking and behavior with reported SI and recent d/c from SI with plan. The case was staffed with [psychiatrist] who advised admission to inpatient treatment at NWTHS PAV for pt safety and stabilization ..."

Behavioral Health intake assessment dated 8/6/21 at 11:53 pm indicated patient #3's C-SSRS suicide risk level was high. On 8/7/21 at 12:04 am, the intake assessment was reviewed with the psychiatrist who's recommended disposition was "Patient meets inpatient criteria."

Patient #3's medical record contained the following progress notes:

-Case Management (CM) note dated 8/7/21 12:29 am that stated in part, "Pt was transferred to ED for med clearane [sic] to sec [security] room, scorted [sic] by NWTHS SEC [facility security]. Pt Invountary [sic].

-CM note dated 8/7/21 at 12:45 am stated in part, "Pt was brought to ER for medical clearance once a bed became available. Pt was escorted by security. Security called Access at 12:45 am to say that the pt had eloped. APD dispatch was notified."

-CM note dated 8/7/21 at 1:42 am stated in part, "Attempted to get pt med clear through telehealth, unable to do so as pt continued agitated [sic], telehealth doc ... unable to continue waiting due to other pt in their lobby."

-CM note dated 8/7/21 at 1:45 am that stated in part, "APD in ACCESS revising involuntary paperwork of pt. APD has report and they are looking for pt to bring back if found."

-Nursing note dated 8/7/21 at 2:33 am that stated in part, "PT WAS BROUGHT TO SEC FROM PAVILLION BY NWTHS SEC. PER SEC HE PUT PT IN SECURITY HOLDING TO LOOK FOR THIS CN TO LET ME KNOW PT WAS IN ROOM. IN THAT TIME PT LEFT SECURITY HOLDING. UNKNOWN PT WHERE ABOUTS. ACCESS NOTIFIED, SECURITY ALSO NOTIFIED APD AND ACCESS CONTACTED APD [sic]."

Although patient #3 was a high risk for suicide and tried to elope from the behavioral health area, the patient was able to leave the ED as patient #3 was not being monitored appropriately. Patient #3 was not found and was not admitted to the behavioral health department as recommended by the psychiatrist.


Review of the clinical record for patient #4 revealed, they presented to the Behavioral Health Access Area voluntarily on 8/10/21 with a provisional diagnosis of MDD. Intake assessment dated 8/10/21 at 2:38 pm stated in part, " ...presents voluntary to ACCESS requesting a mental health evaluation after feeling increase though [sic] of SI with plan to shoot self ... When asked if he had done anything to harm himself, he appeared delayed of speech and nodded 'no'. Pt reported detail SI plan stating 'I will drive outside of the city limits, text 911 and shoot myself from mouth pointing to the brain'. Pt admitted to his wish to die [sic]. Current symptoms include depression, high anxiety, muted, lack of sleep and lack of appetite and increase in SI with plan and wish to die ... Pt appears to be in need of intervention and would benefit from medication management, MH treatment and safe environment. The case is staffed with [psychiatrist] who advised admission to inpatient treatment for safety, treatment and stabilization ..."

Patient #4's suicide assessment dated 8/10/21 at 2:22 pm and on 8/10/21 at 4:59 pm indicated their C-SSRS suicide risk level was high.

Patient #4's medical record contained the following progress notes:

Nursing note dated 8/11/21 at 5:40 am stated in part,

"3:28 pm - Pt. sent to ED for medical clearance.

10:45 pm - called ED to inquire if pt. was coming back to Pavilion, per [staff] pt. was discharged back to Pavilion at 6:13 per notes. Reported to her pt. did not return to the Pavilion.

10:50 pm - Called Security to ask if they escorted pt, they reported when they got to the ED for transport pt. had left.

10:57 pm - Attempted to reach pt. by phone on number he provided at admission. No answer

11:04 pm - APD called for welfare check, dispatcher reports an officer is being sent to check on pt.

11:42 pm - Officer called and reported he spoke to pt. who was at home watching TV, he denied being suicidal and stated he left the ED because he didn't want to be admitted, he only went because his therapist wanted him to."

Although patient #4 was a high risk for suicide and tried to elope from the behavioral health area, the patient was able to leave the ED as patient #4 was not being monitored appropriately.


Although patients #1, 2, 3, and 4 were assessed as a high suicide risk, they were not being monitored appropriately and were able to elope from the facility.


Facility Policy titled "PC 068 - Identification and Management of Patients At Risk for Suicide (UHS)" stated in part,

"II. Purpose: The purpose of this policy is to outline the requirements for ensuring the safety of patients in the Emergency Department and inpatient or observation level patients with actual or potential thoughts of self-harm or suicide. The hospital is committed to ensuring the rights of all patients to receive care in a safe setting by identifying patients at risk for suicide or intentional harm to self, identifying environmental safety risks for such patients, and providing educations and training for staff.

...IV. Policy

...B. Suicide Precautions and Observation Levels

1. upon admission, all patients are screened using the Columbia-Suicide Severity Rating Scale (C-SSRS) Assessment by the admitting nurse.

...3. Patient assessed to be at a high risk level will have the following initiated in both the Emergency Department ...:

*Sitter

*Completion of the Suicide Precautions Environmental Checklist (attachment A)

*Sitters must remain in the patient's room with an unobstructed view of the patient. Sitter will document no less frequently than ever 15 minutes using the close observation form. Attachment B

...Patient's initial and subsequent risk levels will be assessed and documented at a minimum of every 12 hours.

...C. Civil Involuntary Commitment (Emergency Detention)

...4. Initiation, Changes and Discontinuation of Suicide Precautions

a. Initiation of Suicide Precautions:

i. When indicated by the patient's suicide screening and risk assessment ... appropriate suicide precautions should be initiated immediately, including but not limited to an appropriate level of patient observation.

ii. The care team should also consider if additional precautions are appropriate, such as Elopement Precautions ..."


B. Review of the clinical record for patient #12 revealed, they presented to the ACCESS behavioral health area on 7/29/21 at 4:08 p.m. A form entitled, "Welcome to the NWTH Pavilion," included the question "What is the reason for your visit?" Patient #12 answered, "Suicidal thoughts, cutting myself ..." Patient #12 was observed in the Access area from 4:25 p.m. to 10:00 p.m.

A note on 7/29/21 at 10:17 p.m. by a MPA stated in part, "BH Evaluator Impression: Pt presented to Access at the behest of the Sheriff of Wheeler Co. Pt was being interviewed by the Sheriff for something, 'Confidential that I can't talk about.' and she became angry. Pt said, sometimes when she is angry, she gets suicidal. Gma [believe meaning grandmother] said something about having been at the Bridge earlier today, so it is possible the Pt was being questioned about sexual assault ... Pt denied feeling suicidal during the psych interview. She admitted to feeling that way earlier today, but not now.

Pt staffed with [psychiatrist], who said to admit the Pt. The Pt's grandma got tired of waiting, due to the ER's not being able to do a MSE, so the Pt left with grandma, AMA."

An addition MPA note on 7/29/21 also at 10:17 p.m. included the following:

" ...The Pt and grandmother had to wait a long time, as the ER's were back up and could not get to the Pt's MSE. This writer asked if they wanted to go to the NWTHS ER [freestanding ER], but they declined and they decided to go home, as it is a long drive. Grandmother signed the Pt out AMA, signing the Refusal form and the Referral form ..."


Patient #12 had presented as suicidal and had to wait approximately 6 hours before deciding to say she was no longer suicidal so she could leave. She was not stabilized.


Review of the clinical record for patient #13 revealed they presented to NWTHS Behavioral Health on 8/7/21 at 1:26 a.m. She answered the question "What is the reason for your visit" on the "Welcome to NWTH Pavilion" form as follows: "Someone stole my fathead. I think people can hear my thoughts. I want to kill myself and I think thats wat [sic] they want me to do."

Despite the 1:26 a.m. listing for presentation at the facility, she was observed on 8/7/21 beginning at 12:00 midnight. She had observation entries until 8:00 a.m. The sheet indicated she was discharged at that time.

A note by a LMSW on 8/7/21 at 2:49 a.m. stated in part, "presents voluntary to ACCESS with transportation by APD. Per APD pt called asking for help to come to the pavilion for assessment as she was going 'crazy' and felt she wanted to die. Pt present hx of MH with dx of schizophrenia. At the time of assessment, pt presents with SI complaints with no specific plan ... Pt appeared to have a hard time concentrating and participating in assessment while actively hallucinating with auditory stimulant. Pt appeared to respond and engaged while focusing on mumbling, and responding to herself ... Pt appeared preoccupied asking to be 'voluntary' while stating 'which means I can leave without an address right?' and continuously repeated herself ... Current symptoms include auditory hallucinations, paranoia, persecutory thoughts, and SI. Pt appears to be in need of intervention and would benefit from medication management, MH treatment and a safe environment. The case was staffed with [psychiatrist] who advised admission to inpatient treatment at NWTHS PAV for pt safety and stabilization ..."

A LMSW note on 8/7/21 at 2:58 a.m. stated in part, " ...contacted requesting bed for pt for MSE. Pt actively hallucinating, unable to med clear through telehealth. RN at 1622 [facility resource to call for MSE in ED], no bed available at this moment, will call when bed available."

A "High Risk Notification Alert" on 8/7/21 at 3:22 a.m. indicated patient #13 had high risk factors for suicide/self harm and for "hallucinations aud[ible]."

A behavioral therapist note on 8/7/21 at 7:45 a.m. read as follows (in entirety):

"pt requested to leave AMA stating 'i've [sic] been waiting for hours i [sic] want to leave". pt denied current s/i. staffed with [psychiatrist] who determine pt can leave. pt sign AMA form."

Patient #13 signed the AMA/Refusal of Transport or Treatment form on 8/7/21, time unknown. Of note, patient #13 was unable to sign consents, for example a consent for photography, videotape, audiotape upon presentation at the behavioral health. Noted on the consent was the following: "Pt ref (refused) to sign, hallucinating."

Patient #13 had presented as suicidal and actively hallucinating and had to wait almost 8 hours before deciding to say she wished to leave. She was not stabilized.


Review of the clinical record for patient #14 revealed, she was seen at the facility in their outpatient program. CM note dated 7/23/21 at 4:30 pm stated in part, "[Patient #14] was discharged to inpatient services ... For safety, [patient #14] was escorted to NWTHS - BH intake department for further assessment ..."

Patient #14's BH intake assessment dated 7/23/21 at 4:40 pm stated in part, "Pt stated current SI with no plan or intent ... Staffed with [psychiatrist] who recommends inpatient services as pt meets criteria for inpatient. Provisional Dx: Major Depressive Disorder ...

BH Clinical Reviewed with Physician Dt/Tm [date/time]: 7/23/21 3:19 pm

BH Physician's Recommended Disposition: Patient meets inpatient criteria"


Therapy evaluation note [by staff #16] dated 7/23/21 at 3:09 pm stated in part, "[Patient #14] met with the therapist after an individual session, she was not oriented to time or date and stated she could not remember coming to out-patient services yesterday ... [Patient #14] stated she is having thoughts about suicide but mostly she feels 'exhausted' she reported she has not felt rested in a long time and 'cannot think straight.' ...She stated she feels like nothing helps and is worried about going inpatient but she knows she is not feeling right and that her thinking is jumbled ... [Patient # 14] was assessed in Access and admitted to inpatient treatment ..."

"Acceptance of Referral" form was signed by the patient on 7/23/21 at 3:50 pm. There was no other AMA forms in patient #14's clinical record.

BH therapist note on 7/23/21 at 4:51 pm that was "performed on 7/23/21 at 3:39 pm" stated in part, "Pt presented VOL but left AMA. [Psychiatrist] released at 1:39 pm ..."

CM note dated 7/27/21 at 7:54 am stated in part, "[Patient #14] did not admit to NWTHS - BH inpatient. [Patient #14] returned to the outpatient program for group therapy 7/26/21."


In an interview with staff #16 on the morning of 8/11/21, when asked about the situation with patient #14, staff #16 stated, "She was with us and she had made some statements that we wanted to refer her to inpatient, so we walked her upstairs to get assessed by Access." When asked why staff #16's note indicated patient #14 was admitted to inpatient treatment. Staff #16 stated, "I was under the impression because I spoke with the nurse practitioner." Staff #16 went on to say, "I brought her to access and stayed with her until she got Assessed. I probably wrote this note because I was under that impression and the nurse practitioner was as well [that patient #14 was going inpatient status]."

On 7/23/21, the date patient #14 presented for inpatient treatment, there was no completed suicide risk assessment despite her vocalizations of SI. There was no documentation or clear picture of what happened with patient #14. Although all documentation revealed patient #14 met inpatient criteria and the psychiatrist recommended inpatient admission on 7/23/21 at 3:19 pm, a note timed 4:51 pm stated patient #14 left AMA per psychiatrist at 1:39 pm.

There was no evidence discussion, including risks of leaving and benefits of staying, occurred between the physician and patient #14. There was no signed AMA form prior to the departure of patient #14. There was no documentation of the circumstances of patient #14's AMA in the nurse's notes."

In an interview on the morning of 8/11/21, Staff #3 verified the above and stated, "We should have gone back in and put another note."


Facility Policy titled "BH RR 001 - Patient Rights and Responsibilities" stated in part, "List of Rights: 1. Without limitation patient shall be entitled to:

a. Considerate, respectful, humane care and treatment

c. Be treated with human dignity and in an environment that contributes to a positive self-image

d. Medical care and treatment in accordance with the highest standards accepted in medical practice to the extent that the facilities, equipment and personnel are available

e. Care in a safe and sanitary setting

h. Receive prompt evaluation and care, treatment, habilitation or rehabilitation about which he/she is informed insofar he/she is capable of understanding ..."


Facility Policy titled "RRI 016 - Against Medical Advice (AMA) Discharges" stated in part, "Policy: A patient may wish to leave the hospital contrary to his/her attending physician's opinion that continued stay is medically indicated. Generally, except by court order, the hospital may not detain the patient against his or her will, unless the patient has been determined by a physician to be incompetent to make health care decisions.

However, since the hospital is charged with the responsibility of patient welfare, some AMA discharges or refusals to accept treatment will indicate a need for staff to seek additional direction with regard to patient care and hospital liability.

Procedure:

*If a patient insists on leaving the hospital against his physician's advice, the physician will be notified of the patient's intention as soon as possible after the request has been made. Discussion, including risks of leaving and benefits of staying, should occur between the physician and patient/legal representative. The physician should ensure that the patient/legal representative adequately understands the potential consequences of leaving AMA, and this discussion should be documented in the medical record.

*The physician will determine if there is cause to believe the patient might meet the criteria for court-mental health services or emergency detention. If not, the physician will write the order for an AMA discharge.

*The patient or responsible party will be encouraged to sign an AMA form (attachment 1) prior to the departure of the patient. If the patient refuses to sign an AMA form, documentation of the circumstances must be in the nurse's notes, and noted on the AMA form."


C. Review of Incident Reports for 6/20/21 through 7/6/21 (a two week period) revealed 8 of 15 incidents in the Access area were related to physical aggression or staff requested security presence; one of which involved two patients fighting.

In an interview with staff #5, Nurse Manager of Access, on 8/10/21 at 9:47 am, when asked how many people the Access area was staffed with, staff #5 stated, "At least 2 members. It's usually 4-6 in the morning. We can staff down if we need to. During the day, usually 3-5 people are here. There's always at least one assessor on. In the afternoons, we have 2 call specs [Call Specialists, unlicensed staff with responsibilities of answering phones and doing observation round of the patients in the Access area] assigned - one rounding and one doing valuables." When asked about training for call specs, staff #5 stated, "They have 4 weeks of training. It's a hard position. Most have bachelor's degrees. They have to work different shifts with different counselors. And they have to work all shifts. We want to give them more exposure to all kinds of situations."

When asked if staff get help in Access, staff #5 stated, "Say someone is rounding. I know that person's rounding so I watch out for them. We know how to be a partner with our coworker. We'll watch them. If something happens, we immediately call someone through the overhead, and then we call security. The house supervisor is here 24 hours a day too."


In an interview on 8/10/21 with staff #10, who works in the Access Area, on 8/10/21, when asked if they felt it was a lot to manage call spec duties in the Access area, staff #10 stated, "Sometimes, it is a lot."


In an interview on 8/10/21 with staff #8, who works in the Access Area, surveyors mentioned it seemed call specs had many duties -- watching cameras, answering the phone and doing observation rounds. Staff #8 stated, "It is a lot to do, yes." When asked if the amount of work ever endangered staff or patients, staff #10 stated, "I think there are practices that could be looked at to be improved." When asked if they had any concerns about the Access area, staff #8 stated, "It's a very difficult place to be in. It's basically just a lobby. We can't medicate patients there if they need it, and things like that."


Review of the staffing grids and assignment sheets of the Behavioral Health Department revealed no staffing grid or guidelines for the Access area. When asked for the last 6 months of nurse staffing sheets, the Access area was not provided. Several times throughout the survey, the facility was asked for Access area staffing. In an interview on the afternoon of 8/10/21 with staff #5, Nurse Manager of Access, they presented typed sheets with staff working. Staff #5 stated, "I went through the time sheets to see who was working."


In an interview on the morning of 8/12/21 with staff #1, the Quality Director, staff #1 provided 4 weeks of typed schedules to reveal who was working the Access area and stated, "Here are the schedules, we went through the timesheets ... We recognize there's a problem."


Facility policy titled "BH 040 - Appropriate Staffing Levels" stated in part, "Scope: All operating inpatient facilities that are Behavioral Health Division subsidiaries ...

Policy: It is the policy of Northwest Texas Healthcare System Behavioral Health Services to ensure that the appropriate numbers and qualifications of nursing staff are available at all times for the care of patients. The Chief Nursing Officer (CNO) is responsible for the development and ongoing review of staffing requirements based on numbers of patients, population served, acuity and measurements of patient outcomes that include patient falls, restraint/seclusion, medication errors, infection rates, patient complaints and grievances, as well as other types of incident occurrences ..."

8 of 15 incidents reviewed involved physical aggression and/or staff required security presence; with no staffing grid and no staffing sheets for the Access Area, it was difficult to determine who was working during certain shifts and if the Access Area was staffed appropriately.