HospitalInspections.org

Based on observation, interview and record review, the facility failed to ensure a safe environment for 5 of 5 patients on Suicide Precautions (Patient #'s 11, 19, 20, 21, and #22) as shown by inconsistent staff knowledge regarding use of patient beds and inconsistent staff knowledge of facility policy for patients on Suicide Precautions and using facility's suicide risk assessment tool. In addition, the facility failed to ensure rights to patient safety as shown by 2 out of 19 patients (Patient #'s 23 and #24) not wearing armbands showing patient's name identification present on their arms.

Findings included:

Record review of facility policy titled "Suicide Precautions" , policy ID:10044964, last approved 1/21 stated in part on page 3 of 4, regarding Staff Training and Education, that upon hire, staff will be trained for Suicide Screening, Suicide Assessment, Monitoring , Safety and Environmental Rounds. In addition, page 2 of 4 stated under "5. Nursing staff: ...communicates the precaution and level of monitoring to unit staff ..." to communicate the level of monitoring.

Record review of facility policy titled Assessment for Risk and Harm, ID:8818387, last revised 1/20, stated staff will conduct ongoing safety checks such as ligature risks and other available means of self harm.

Observation on 6/29/21 at 9:00 am of facility showed there were two units in use; Unit 100 (all adult males, current census of 20) and Unit 200 (all adult females, current census 17).

There were specialized mechanical electrical hospital beds in each room. These beds were made to be able to move in several different positions for special patient-needs and comfort. They were called "Spirit Behavioral Health Beds" made by the company Stryker. There were a total of 24 beds on Unit 100 and 21 beds on Unit 200. Each bed had buttons to press to move and manipulate them, located on the patient's siderails and also located at the foot of the bed. These beds allowed for the patient's siderails buttons to be locked by using the buttons at the foot of the bed made for the caregiver. However, it was possible for a patient to press and manipulate the lockout buttons at the foot of the bed; there were pictures of a 'lock' on the buttons.

Review of the bed manufacturer's descriptions of bed features showed that any of the bed's functions could be locked to restrict patient use, which most staff were aware of. However, manufacturer description also stated that behavioral beds were equipped with an additional security code lock-out. There were no staff that were interviewed who were familiar with additional security code lock-out.

Record review of the facility's Patient Safety and Ligature Risk Assessment, last revised 12/1/20 identified the Stryker Bed as a possible patient safety issue. It also stated the Stryker beds were ligature resistant. The "Clinical Mitigation Plan" to ensure patient safety was "All patients upon entrance assessed for suicidal behavior. Q15 completed, level of observation is noted and staff execute". There were no specific safety issues regarding protection of the patient from harming self with the bed.

In an interview on 6/30/21 at 9:40 am, while in an empty patient room in front of bed, CNA-Staff#E stated that the bed can be locked from patient use by pressing buttons at the foot of the bed and stated if a patient was very confused, they probably could not figure out how to unlock the bed.

In an interview on 6/30/21 at 10:05 am, while in an empty patient room in front of bed, DPO-Staff #Q stated he was not very familiar with the bed functions and was not present during the Safety Risk Assessment. He referred to the beds as "CHG rated for mental health facilities". Staff #Q also stated he was the person who did weekly Environment of Care rounds. He stated there was a way for the caregiver to lock the bed but was unsure how exactly to use these features. He also added that the bed motor could pose a safety risk for a patient who wanted to harm themselves.

In an interview on 6/30/21 at 10:50 am with COO-Staff#P, she stated if a patient was a high risk for suicide, then there would be a 1:1 (a staff member assigned to be with the patient at all times), or, a "box bed" would be used (Note: there were no box beds on either open units. There were 2 more units not in use-300 and 400, which contained plain box beds but they were all bolted to the floor and could not be moved). Staff#P than stated that for patients on suicide precautions, the Stryker beds can be unplugged and the cords could be secured under the bed in a type of box (Note: no other staff interviewed were aware of this feature).

In an interview on 6/30/21 at 11:05 am with UC-Staff #M, she stated that if a patient was on Suicide Precautions (acuity level not mentioned), they would have a 1:1 sitter.

In an interview on 6/30/21 at 11:35 with RN-Staff #N, she stated that for suicidal patients (acuity level not mentioned) they would be put on 1:1. No other interventions, such as securing bed, were mentioned.

Record review and interview showed there were currently 5 patients on Suicide Precautions but none were on 1:1 close observations. No other interventions such as securing bed were mentioned.

In an interview on 6/30/21 at 11:50 am with RN-Staff #O, she stated that if a patient was on Suicide Precautions (acuity level not mentioned) they would be rounded on every 15 minutes (Q15 min close observation rounds). No other interventions such as securing bed were mentioned.

In an interview on 7/1/21 at 12:00 pm with RN-Staff #L, she stated if a patient was high-risk for suicide, as per initial Suicide Risk Assessment, nursing would notify provider and do "closer observations". When questioned if anything was done with the beds, she said nothing is done, but nurses did have the capability to lock them.

Record review of C-SSRS Columbia Suicide Risk assessment, which the facility uses to assess risk for suicide, one of the interventions for high suicide risk was to offer a suicide blanket. All three nurses, CNA, and Unit Clerk were unfamiliar with what this blanket was.

Record review of the 5 current patients who were on Suicide Precautions showed the following:
-Patient #20 was currently on Suicide Precautions, Room 205 A. There was
nothing different about her care addressing this compared to other patients not
on precautions.
-Patient #11 was currently on Suicide Precautions, Room 201 A. There was
nothing different about her care addressing this compared to other patient not
on precautions.
-Patient #19 was currently on Suicide Precautions, Room 203-B. There was
nothing different about her care addressing this compared to other patients not
on precautions.
- Patient #21 was currently on Suicide Precautions, Room 103-A. His Columbia
Risk Assessment tool was incorrectly completed with "N/A" as answers to
questions. It failed to indicate the patient's risk level (high, medium, or low) as
this portion was not filled-out. The Risk tool stated "NA No suicide thoughts or
behavior".
-Patient #22 was currently on Suicide Precautions, Room 112-B. His Risk
Assessment Tool was not completed at all.

Policy ID# 8818525 last revised 1/20 titled "Patient Identification for Clinical Care and Treatment" stated, in part, " ...Patient wristband: A tamperproof, non-transferable identification band shall be prepared and affixed to the patient ...". The band will include the patient's name and hospital ID number, date of birth, age, sex and doctor.

Also, policy stated that each healthcare provider performing assessments on patient shall include a check of the patient's identification band.

Observation on 6/29/21 at 9:30 am of Patient #25 showed he was not wearing an identification armband. When questioned, the patient could not clearly state his name. Staff #E, who was in the room, stated the patient should have been wearing an armband.

Observation on 6/29/21 at 9:40 am of Patient #24 showed he was not wearing an armband. When questioned, the patient could not state his name clearly. Staff #E, who was present in the room, stated the patient should have wearing an armband.






37322

Based on observation on 6/29/2021 at 9:00 a.m. revealed four (3) out of fifteen (15) patients on the female unit, that did not have an arm band, one (1) patient had on an arm band that was not legible.

Findings Included:
Patient (ID#7) 84-year-old female, admitted on 06/24/2021 with a diagnosis of major neurocognitive disorder and unspecific dementia, and when questioned she could not tell me her name.

Patient (ID# 10) a 60-year-old female, admitted on 06/16/2021 with a diagnosis of schizophrenia, with a history of physical aggression, impulsive, hallucinations, and delusions.

Patient (ID#9) a 44-year-old female, admitted 06/16/2021 with a diagnosis with catatonia, schizophrenia, diabetes and hypertension, and when questioned she could not tell me her name.

Patient (ID#28) a 77-year-old female, admitted on /11/2021, spoke Spanish only and when questioned she smiled and did not answer.

Patient (D# 8) a 63-year-old female, had an arm band that was not legible, admitted on 05/26/2021, spoke Spanish only and when questioned did not answer.


Based on record review and interview the facility was currently treating two (2) current patients out nine (9) patients without signed consents.

Findings Included:

Record review on 06/30/2021 at 0930 of patient, (ID#7), who was admitted on 06/24/2021, revealed no consents were signed for admission, medications, notice of physician on-site availability, patient visitation rights, release of patient access code, census acknowledgment, and telehealth services.

Record review on 06/30/2021 at 0940 of patient, (ID#9), who was admitted on 06/16/2021, revealed no consents were signed for admission, medications, notice of physician on-site availability, patient visitation rights, release of patient access code, census acknowledgment, and telehealth services.

Record review of the facility policy "Admission of Patients" last reviewed 01/2020, stated:
Patients or their designees (POA/Guardian) must sign a voluntary consent and authorization for treatment during the admission process.

Interview on 06/30/2021 at 0945 with staff nurse, (ID#O), who stated "I have no idea why it's not signed; it's supposed to be signed.

Based on record review and interview, the hospital failed to ensure restraint/seclusion interventions were initatied and evaluated by a registered nurse and that post-restraint evaluation was completed by a registered nurse other than the one who initiated the intervention for 1 patient (ID 30 ) whose seclusion intervention were initiated and evaluated by the same Licensed Vocational Nurse (LVN).


Findings included:

Review of facility policy titled Restraint or Seclusion Use, dated 1/2020 showed the following information:

Initiation of Restraint & Seclusion

-Any staff member trained in CPI techniques may initiate a CPI hold in an emergency.
-A mechanical restraint may only be initiated by a trained nurse, physician or licensed practitioner.

One-hour Face-to-face assessment:

-A licensed practitioner or registered nurse with a working knowledge of the restraint/seclusion policy and trained to do so will provide a face to face assessment in person within one hour of the use of restraint/seclusion using the restraint seclusion packet.

Ongoing Assessment, Monitoring and Evaluation During Restraint/Seclusion:
-Per Indiana Administrative Code440 IAC 1.5-3-13 The consumers response ...


Review of Medical record for patient (ID 30), Restraint and Seclusion Flow Sheet dated 5/15/21 at 1236 PM LVN (ID U) initiated the behavioral interventions including seclusion. Area titled "Licensed Practitioner (MD, NP, PA or trained RN) notified of need for 1-hour face-to-face evaluation" was left blank. Area titled "Responded completed 1-hour face-to-face evaluation and documentation" was left blank. LVN (ID U) completed the portion titled "1 Hour Face to Face & Hourly RN Assessment Notes": (Document when restrains and/or seclusion is initiated and every 1 hour thereafter) this portion of the document read as follows: A licensed practitioner (MD, PA, NP) or specially trained RN with a working knowledge of the restraint/seclusion policy, will provide a face to face assessment in person within one hour of the use of restraint/ seclusion/CPI hold. Documentation must include:
-the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition and documentation RE. Continued need or discontinuation of the restraints and/or seclusion/ CPI hold as measured by criteria for discontinuation. Also completed by LVN (ID U) was the Nursing Hourly Narrative for the first hour, second hour, third hour and the Restraint/Seclusion Patient Debriefing.

Interview with Staff B, chief nursing officer on 7/1/21 at 2:30 PM, he stated that a Registered Nurse (RN) must initiate the restraint/seclusion, he also stated that a different RN must complete the hourly face-to-face evaluation.

Based on interview and record review, the facility failed to document, investigate, and implement preventative measures for four (4) different occurrences per facility policy. [Citing Patient ID# 16 ]

Patient ID # 16 was involved in four (4) different episodes of physical assault/ aggression that involved facility staff and/or another patient.

Findings included:

TX00385157; TX00383755; TX00385099

Record review of facility policy titled "Incident Reports," dated 1/2020, showed:

"...An incident is defined as: any event which is not consistent with the routine operation of the hospital and that adversely affects or threatens to affect the well-being of the patients, employees...regardless of whether an injury is involved or not...Any hospital staff member who witnesses, discovers, or had direct involvement and /or knowledge of an event must complete an incident report...

TIME FRAME for completion of an incident report:...hospital staff must complete an incident report as soon as possible...preferably before staff leaves at end of shift.. but no later than 24 hours.. "

Record review of facility policy titled " Patient Safety Plan," dated 1/2021, showed: "...Risk Manager responsibilities include:...investigate reported incidents...assure timely interventions when risk events occur..."

Record review on 6/302021 of Patient ID # 16's medical record showed he was a 77 year old male admitted to the facility on 5/20/2021 for behavioral disturbances, agitation, aggression. Patient ID # 16 has Alzheimer's dementia disease and had been residing in an Alzheimer's care center.

Review of the nursing progress notes for Patient 16 showed the following documentation :

5/24 /2021 (1740) - attempts to hit staff;

5/24/2021 ( 2140)-attempting to come out of room naked--hits staff in abdomen during transport back to room;

5/25/2021 (710)-kicks staff and very aggressive when staff assists with activities of daily living (ADLs) ;

5/28/2021 (1800)- physically assaulted a medication aide (MA) and bit her;

5/29/2021 (0830)-patient became angry and slapped staff and kicked a patient sitting in a wheelchair --verbally & physically aggressive.

Review of the psychiatric (psych) provider / nurse practitioner (NP) notes showed:

Psych progress note, dated 5/25/21: "pt abruptly struck staff hard in stomach during shower. Patient becoming aggressive during cleaning and ADL care, punched a caregiver at left side of face and kicked caregiver # 2, and bit the medication tech's fingers and inner arm."

Record review of facility "Incident Report Log" for May & June 2021 failed to show any documented Incidents and investigations that involved Patient # 16.

During an interview on 7/01/2021 at 2:45 p.m. with the Staff ID # A, Chief Executive Officer (CEO), he acknowledged that episodes of physical assault and aggression were considered Incidents. They should be documented and investigated.

Separate telephone interviews were conducted on 7/05/2021 with Staff A, CEO and Staff B, CNO.

-Staff A, CEO: stated he had been in his current position for a little over 2 weeks at time of this interview. He was not in facility at the time of incidents and had no knowledge or information regarding Patient ID # 16.

-Staff B, CNO: stated he began his position on 5/17/2021. He did not have additional information to provide related to Patient ID # 16 .

There was no facility documentation to show: actual assessments of patient and staff involved for injuries; or actions taken by facility to mitigate risks.


37322

Based on record review and interview the facility did not initiate a incident/variance report on patient, (ID#13) who fell at the facility per their facility policy.

Findings Included:

Record review of the facilities incident/variance log from April 2021 to current did not have patient (ID#13) listed.

Record review of the daily nursing documentation record dated 4/23/2021 at 3:40 p.m. by staff nurse RN (ID#T) who documented "patient was in the wheelchair in the milieu area and slide down in chair on purpose and went to her knees". The patients (ID#13) granddaughter was called at 6:00 p.m. the same evening.

Record review of the grievance investigation, dated 05/07/2021 at 9:15 a.m., revealed the granddaughter of patient (ID#13), had filed a grievance. According to the documentation patient (ID#13) slipped out of the wheelchair and was notified. The granddaughter alleges patient (ID#13) was reported to have had another fall two (2) weeks later. The granddaughter reported her grandmother, patient (ID#13) was having surgery for a fractured hip, and the surgeon stated it must have occurred within the last 24-48 hours.

Interview on 7/01/2021 at 2:45 p.m. with the CEO, ID#A, who stated "I am ultimately responsible for ensuring these incidents reports are done, but nursing will do them."

Record review of the facility policy "Incident Reports" last reviewed 01/2020, stated:
A. An Incident Report should be complete in the RLDaltix system by the end of the shift in which the incident occurred but no later than twenty-four (24) hours from the time the event occurred.

Based on record review and interview, the facility failed to have patient's initial nursing assessment completed by a Registered Nurse (RN) as required (ID 30, 23)

Findings include:

Review of facility policy titled Assessment/Reassessment, dated 1/2020 showed the following information:
POLICY:

1. All patients admitted to this facility will be evaluated by Intake prior to admission to assure that the candidate meets appropriate utilization review and admission criteria.

2. Nursing staff completes the nursing admission database upon admission...

3. Upon Admission each patient's physical, psychological and social status are assessed by nursing.

Medical record for patient (ID 30) showed initial nursing assessment to be completed by Licensed Vocational Nurse (ID U) on 5/17/21. Portions of the initial nursing assessment left blank included page 8-10 of 14 titled Safe-T Protocol with C-SSRS (Columbia Risk and Protective Factors)- Recent and the Morse Fall Scale.

Medical record review for patient (ID 23) showed his initial nursing assessment to have blank pages including: page 3 documentation of physical pain, page 4-7 which included review of health systems, Health safety concerns, restraint risks, compliance and education and health care education provided. Also left blank were pages 8-14 which included the Safe-T Protocol with C-SSRS (Columbia Risk and Protective Factors)- Recent, Abnormal involuntary movement scale, the Morse Fall Scale, Braden pressure ulcer risk assessment, skin assessment, Nurse Signature, time and date.

Interview with Chief Nursing Officer (ID B) on 7/1/21 at 2 PM, he stated initial nursing assessments had to be completed by RNs (Registered Nurse), not Licensed Vocational Nurses (LVN). He acknowledged that portions of the nursing assessments were not completed as required.

Based on observation, interview, and record review, the facility was not maintained to ensure the the safety and well-being of the patients.

Two(2) of eleven (11) patient rooms observed on the 100 hallway had large holes in the wall (rooms 104 and 112). Room 112 was occupied by a patient on suicide precautions.

Findings included:

Review of facility policy titled "Precautions,"dated 1/2020, showed :

PURPOSE : to ensure a safe environment for patients and to establish specific guidelines for staff observation and the prevention of injury to these patients...
-Suicide (precautions):...conduct safety checks to identify objects that pose a risk for self-harm and remove them from the immediate vicinity.."

Observation on 6/29/2021, between 9:40 and 10:30 AM, during the initial tour of the 100 hallway showed the following:

-Room 112 : a large hole (approximately 8 to 10 inches in diameter) in the sheetrock wall. The edges were frayed and torn. This material could easily be broken off and ingested. Patient # 22 was currently admitted to this room.

Record review on 6/29/2021 of Patient ID # 22's "Patient Safety Observation Rounds" form showed he was currently on suicide precautions. This was confirmed by review of physician order.

-Room 104: a large hole (approximately 8 to 10 inches in diameter) in the sheetrock wall near the entrance doorway on the lower portion of the wall.

On 06/29/2021 , these findings were acknowledged by the Chief Nursing Officer (CNO) who said the holes in the walls were on the list to be repaired.

Based on record review and interview, the facility failed to have physicians complete psychiatric evaluations as required for patients (IDs 16, 7, 23, 18, 29).

Findings include:

Review of facility policy titled: Psychiatric Evaluation, dated 1/2020 showed the following: Each patient receives a psychiatric evaluation that must: Be completed by the psychiatrist or nurse practitioner. If completed by a nurse practitioner (NP), the psychiatrist will review and sign, date and time within 60 hours of the patient's admission.

Review of medical records for patient's (ID 16, 23, 18,and 29) showed that the psychiatric evaluations were completed by an Advanced Practice Nurse and co signed by the psychiatrist at a later time.

Review of medical record for patient (ID 7) on 6/30/21 showed admission date of 6/24/21,psychiatric evaluation completed by nurse practitioner (ID G) on 6/25/21. No physician signature was documented on the patient's psychiatric evaluation.

During an interview on 6/29/2021 at 12:00 PM with Staff G, she said she was one of the psychiatric (psych) NPs. She stated that the psych NPs perform all the patients' Psychiatric Evaluations. The MD psychiatrist co-signed the evaluations.

Based on record review and interview, the facility failed to complete interdisciplinary treatment plans on three patients ID 30, 31,and 32.

Findings include:

Faciity policy titled: Patient Treatment Plan, dated 1/2020 showed the following information:
Policy:
Each patient shall have a written comprehensive individualized treatment plan that is based on assessment of his/her medical clinical and nursing needs. Individualized treatment planning shall be based on patient need.
A. Patients have the right to ongoing participation in their treatment plan.

B. Patients have the right to a reasonable explanation of their treatment plan.

C. The treatment plan reflects a multidisciplinary comprehensive holistic culturally sensitive approach to evaluating and treating each patient.

D. Overall development implementation and supervision of the treatment plan is the responsibility of the patient's providers. Responsibility for ensuring that the treatment plan is accurate up-to-date and reviewed regularly is the responsibility of the interdisciplinary care team.

E. The treatment plan is individualized to the needs of the patient.

F. The treatment plan describes the least restrictive conditions and interventions necessary to meet the individual patient's needs.

G. The treatment plan attempts to clarify the patient's responsibilities.

H. The treatment plan includes:

1. A description of the patient strengths.
2. Description of the patient psychiatric disabilities and disorder.
3. A description of the patients physical and medical disabilities and disorder.
4. A description of the patients problem behaviors associated with their psychiatric or physical disabilities.
5. A precise description of the patient's diagnosis.
6. Long range goals that are
a. Individualized to the patient's needs
b. Appropriate for the identified problems
c. Described as specific behavior all outcomes for the patient (observable and measurable)
d. Dated (expected date of achievement)
7. Short term goals that are:
a. Individualized to the patient's needs
b. Appropriate for the identified problems
c. Described as specific behavior all outcomes for the patient (observable and measurable)
d. Dated (expected date of achievement)

8. Treatment modalities/interventions for each goal that are:
a. Individualized to the patient's needs
b. Focused on the identified problems
c. A realistic and appropriate means for achieving the identified goals
d. Stated a specific interventions rather than general services.

9. A list of the individuals responsible for the interventions including the individuals discipline/profession.


Review of medical record for patient (ID 30) showed interdisciplinary tratment plan dated 5/19/21 with substantiated diagnosis AXIS I and AXIS III left blank.

Review of medical record for patient (ID 31) showed interdisciplinary tratment plan dated not dated with substantiated diagnosis AXIS I and AXIS III left blank, Learning needs left blank, patient input into treatment plan left blank, pateint strenghts, potential limitations, anticipated discharge needs/ plans, patient signature left blank

Review of medical record for patient (ID 32) showed interdisciplinary tratment plan dated not dated with substantiated diagnosis AXIS I and AXIS III left blank, Learning needs left blank, patient input into treatment plan left blank, pateint strenghts, potential limitations, anticipated discharge needs/ plans, patient and nurse signature left blank.

Interview with Chief nursing officer (ID B) on July 1, 2021 at 2:00 PM aknowledged that the treatment plans were not complete.

Based on interview and record review, the facility failed to establish realistic interventions to reach treatment plan goals per policy, based upon the patient's condition on admission. (Citing Patient ID # 16)

Findings included:

Record review of facility policy titled "Patient Treatment Plan," dated 01/2020, showed "The Treatment Plan includes:

-Treatment interventions for each goal that are "a realistic and appropriate approach for achieving the identified goals..."

Record review of Patient ID 16's admission 'Psychiatric Evaluation', dated 5/21/2021, showed:

-patient not complying with questions; patient does not respond to most of questions
-oriented to his name; disoriented to time, place, and situation
-patient not communicating clearly
-patient has thought-blocking, not able to communicate. Unable to answer questions
-per documentation, has lost his speech, unable to communicate
-patient has history of Alzheimer's dementia
-chronic mental health, advanced stage Alzheimer's affecting patient's speech
Diagnostic impressions: neurocognitive disorder; psychosis

Record review of Patient ID # 16's 'Interdisciplinary Treatment Plan' dated 5/20/2021, showed:

"Strengths: quick learner"

Problem: Impulsive / Out of Control :

GOAL: Decreased Impulsive / Out of Control Behaviors:

Interventions included:

1:1 education and interventions on ways to manage impulsive behavior.
1:1 education at least 3 times a week to help patient improve social skills.

GOAL: takes medication as prescribed:
Interventions included:

-Medication Education: Group 3 times a week
-1:1 education about prescribed medications and importance of medication compliance.

GOAL: Desire for No Self-Harm:

Interventions included:

1:1 education on recognizing and identifying at least 3 triggers for self-harm and help patient name reasons to avoid self-harm.

GOAL : Uses Healthier Coping Skills:

Interventions included:

1:1 education 3 times a week to assist patient to identify new ways to cope, including ("list"-- left blank)

1:1 education at least 3 times a week to help patient recognize triggers and stressors leading to impulsive behavior. Have patient verbally list these stressors.

On 06/30-2021 at 1:15 PM , these findings were shared with Staff B, Chief Nursing Officer (CNO). The CNO acknowledged that treatment plan interventions must be appropriate to the patient's condition.

Based on observation, interview, and record review, the facility failed to ensure adequate and safe staffing per facility policy and staffing grid on the "male patient unit/ 100 Hallway" on 6/29/2021.

Observation on 6/29/21 showed the 100 hallway was inadequately staffed per the staffing grid:

-Nineteen (19) patients went without the required 'every 15 minute' safety monitoring for 2 and 1/2 hours;

-Two (2) of the 19 patients were currently on suicide precautions ( Patient IDs # 21; # 22).

Findings included :

Record review of a facility policy titled "Nursing Staffing Policy," dated 1/2020 showed:

-"A minimum staffing level system is used at the hospital to appropriately staff in compliance with federal, state, and regulatory requirements...;

-The Director of Nursing (DON) is accountable to ensure a sufficient number of qualified staff are in duty at all times to provide patients with quality care...;

-All patient care areas are staffed based upon special needs identified by staff and/or the DON..."

Record review on 07/01/2021 of the current Staffing Grid provided by Staff B, CNO showed required staffing for 19 patients for the 100 hallway:

Day shift: 19-24 patients: 3 RNs and 3 aides; [Actual staffing was : 1.5 RNs and 1 aide at time of observation on 6/29/21]

Observation on 6/29/2021 at 9:30 AM on the male unit: 100 Hallway, showed one (1) Registered Nurse (RN), Staff D, preparing medications inside the nursing station. Certified Nurse Aide (CNA) ID # E entered the male patient unit at the same time as the surveyors and said "I was called to work this unit because someone called in sick--this is not my usual unit."

Record review of the current patient census was 19 patients. At 9: 30 AM, eleven (11) patients were observed sitting in the common area. At this time, the location of the remaining 8 patients was unknown.

During an interview on 6/29/2021 at 9:40 AM with Staff E, CNA, she was asked if any of the patients were on suicide precautions? Staff E said she would have to check the "observation rounding sheets" to see what precautions each patient was on.

Record review on 6/29/2021 at 9:40 AM of the "Patient Safety Observation Rounds" forms for all 19 current patients showed there had been no documentation of the required "every 15 minute" safety rounds for this current shift. Eleven (11) observation entries were missing ( 7:00 AM through 9:40 AM) for all 19 patients.

During an interview on 6/29/2021 at 9:45 AM with Staff D, RN, she stated this was her second week at the facility . Staff D said there were a total of 3 RNs: one for each unit ( male & female) and 1 RN shared between the male & female units. She said usually there were 2 CNAs on each unit. At the present time on the unit, there was one RN ( herself) and 1 CNA ID # E, and a unit secretary.

During an interview in 7/01/2021 at 12:15 PM with Staff B, Chief Nursing Officer (CNO), he stated he had not put together a Nursing Staffing Committee or held a meeting. He said the facility was actively hiring nurses ; hiring and maintaining adequate staffing was a priority.


37322

Based on observation and interview the facility failure to ensure adequate numbers of nursing personnel to provide nursing care to all patients.


Findings Included:

Record review on 07/01/2021 of the current Staffing Grid provided by Staff B, CNO showed required staffing for 14 patients for the 200 hallway:

Day shift: 9-18 patients: 2 RNs and 2 aides

[Actual staffing was : 1 RN and 1.5 aide at time of observation on 7/01/2021 for 14 patients]

Observation on 06/29/2021 at 9:00 a.m., revealed two (2) registered nurses and one (1) certified nursing assistant available for fifteen (15) female patients. Registered nurse (RN), (ID#L) was working both the male and female sides of the unit.

RN (ID#L) had ten patients, six (6) on the female side of the facility and four (4) on the male side of the building. The units were separated by two locked doors and the patients were not visible until the nurse enters each unit.

Interview on 06/29/2021 at 9:30 a.m. with RN (ID#L) stated "I am floating to both sides; we usually have ten (10) patients a piece."

Interview on 06/29/2021 at 10:00 a.m. with RN (ID#R) who stated, "I have had to take eight (8) patients its hard and stressful and we don't have enough staff. They are hiring more people now".

Observation on 07/01/2021 at 11:10 a.m., of current staffing validated there were fourteen (14) female patients were on the unit with current staffin of one (1) RN and one (1) certified nursing assistance to provide care.

There was a certified nursing assistance floating to both the men and female units to assist.

Interview 07/01/2021 at 11:15 with the CNO (ID#B) who stated he miscounted the available staff.

Based on observation, record review and interview, the facility failed to conduct therapeutic activities on 2 of 2 patient units ( unit 200 female unit and unit 100 male unit).

Findings Include:

Review of facility policy titled Therapy Services dated 1/2020, showed the following information:
PURPOSE: To advocate, promote, facilitate and utilized leisure, recreation and Wellness opportunities for persons with physical, emotional, mental and social challenges has a way of enriching their health and well-being.

POLICY: Patients admitted to the hospital will receive therapy on a daily basis. Patients will not be a threat to other patients' well-being during participation in therapy. Group therapy will be offered to each patient by the therapy services team. On-to-one therapy will be offered to those patients that are not physically or emotionally able to tolerate group therapy.

EQUIPMENT: Under the supervision of therapy services staff, various supplies are available for the use of therapy period such supplies include, but are not limited to:
-arts and crafts supplies
-athletic equipment
-board games
-books
-tablet or iPad
-cooking utensils
-gardening equipment
-grooming supplies
-holiday and special events supplies and decorations
-magazines
-musical instruments
-video movies/DVD's

PROCEDURE: Therapy services staff will be notified of new patients admitted to the hospital by the intake department. And assessment will be completed by therapy services staff member within 72 hours of the admission date. Treatment goals will be established in collaboration with the multidisciplinary treatment team at the 72-hour initial plan of care session.

Therapy group activities will include but are not limited to:
-cognitive stimulation
-animal assisted therapy
-arts and crafts
-current events
-exercise program
-sensory stimulation
-life skills
-relaxation techniques
-music therapy
-self-awareness
-social skills
-coping skills
Therapy services will attend weekly interdisciplinary treatment meetings and give feedback to the team has two progress on goals and response to therapy process.

On 6/29/21 at 9:00 a.m. patients were observed pacing the floor and sitting in the day room without staffs' presence.

Review of the facility's unit activities calendar provided by facility's staff and posted on the unit revealed documentation which indicated that patients were scheduled to have goal setting at this time. Daily Schedule was printed as follows:
0600-0700 Rise and Shine
0700-0800 Breakfast
0800-0830 ADLS
0845-0930 Exercise
1000-1030 Goal Setting
1030-1100 Snack
1100-1145 Coping Skills
1200-1300 Lunch
1300-1345 Recovery Skills
1400-1445 Social Skills
1445-1515 Snack
1515-1555 Discharge Planning
1600-1700 Milieu Choice/ games
1700-1800 Dinner
1800-1900 Relaxation
1930-2000 Snack
2100-2200 ADLs

Interview with Certified Nursing Assistant (CNA) (ID V) on 6/29/21 at 9:10 AM revealed she said she was the only tech assigned to the unit. She went on to say that there is no programming or therapy for the patients. There is a schedule posted, but none of it is happening. Some nurses will sometimes come on the unit and interact with patients, but they are mainly at the nurse's station. She also said that she tries to sit and talk with the patients and sometimes color, but it is hard when she is the only one on the unit.

Interview on 6/29/21 at 10:30 AM with the Social Worker (ID W) She said there were not any therapy services currently being provided for patients. The schedule was posted yesterday but they have not started yet. New Certified Therapeutic Recreation Specialists (CTRS) will be putting new groups together starting Monday. She went on to say that she just found out that she and the other social worker just found out last week that they were supposed to be having goal setting and discharge planning groups daily.


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100 Hallway: male patient unit :

Observation on the 100 hallway 6/29/2021 at 9:45 AM showed eleven (11) male patients sitting in the common area. Most were just sitting in chairs staring ; some had their heads on the tables. There was no television;no activities of any kind noted ; no staff in attendance.

During an interview at the time of observation with Staff E, CNA , she was asked about what the patients did all day? She said that sometimes she turned off the TV and had the patients color. Staff E went on to say she had worked at the facility since it opened. There used to be activities several months ago but there had not been any in a long time.

Staff E, CNA, pointed to a colored activity schedule posted inside the nurse's station. She said it was posted yesterday and the facility was hiring additional staff.