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1351 ONTARIO RD

GREEN BAY, WI 54311

PATIENT SAFETY

Tag No.: A0286

Based on interview, record review, and observations the facility failed to ensure adverse events are analyzed for root cause including staffing shortages and that preventative actions are implemented and monitored for effectiveness per policy in 2 of 4 Patient (Pt) Adverse Events/Incident Reports reviewed involving (Pts 1, 2, 3, and 11) in a total sample of 4 incident reports reviewed.

Findings include:

Review of policy and procedure titled, "Risk Management Plan" last reviewed 11/20219 revealed the following:
-Appropriate action will be implemented to eliminate or reduce risks identified as actual or potential. Such actions may include, but are not limited to, the following:
a. Staff development programs (professional, clinical, support, and administrative personnel).
b. Implementation of new or revised policy and procedure statements.
c. Staffing/personnel alterations.
d. Equipment of facility changes.
e. Teaching and guidance.
-Periodic monitoring and evaluation of the results of corrective action will be conducted as determined by the Medical Staff and Quality Committees to assure actual or potential risks have been elimated or satisfactorily reduced and impact on patient care is evident.
-Documentation must report all actions taken as a result of assessment to correct the identified problem to an acceptable level with demonstrated acceptable resolution.
-Follow up activities to demonstrate sustained resolution of the problem are documented.

Review of policy and procedure titled, "Environmental Unit Rounds" last reviewed 04/14/2021 revealed, "If the patient is not in his/her room, ensure that the door is secured.

Incident #1:

Review of Incident Report "Case Notes" for Pt #3 dated 08/17/2021 at 11:17 am, revealed that an investigation was conducted by Quality Director A via "camera review and interviewed parties involved". Per Case Notes details, "Pt (#3) reported that he/she snuck into a past patient's room (Pt #11), Pt (#3) reported he/she hid in the patient's (Pt #11) bathroom then (Pt #11) went into his/her room, Pt (#3) then reported that he/she performed a sexual act on (Pt #11)." Per Director of Quality Case Notes based on reviewing the surveillance video, "The incident appeared to have been strategically planned... (Pt #3) was interviewed on 8/9, (Pt #3) was asked to explain what occurred on 8/7 afternoon...(Pt #3) confirmed that (he/she) entered (Pt #11's) room while no one was looking and waited for him/her inside (Pt #11's) room...(Pt #3) was asked if (she/he) gave (Pt #11) permission? The (Pt #3) responded 'yes I wanted it, I was in jail for 3 months and I needed this". Per Case Notes, "...(Pt #11) was interviewed on 08/12/2021 while he/she was in the outpatient program, (Pt #11) also confirmed the incident and assured the staff that they both consented and it was planned."

On 09/10/2021 at 11:35 am observed surveillance video dated 08/07/2021 from 1:30 pm to 2:30 pm, leading up to the incident between Pt #3 and Pt #11. At approximately 1:31 pm Pt #3 left his/her room with door open, at 1:46 pm Pt #3 came back to his/her room briefly as door continued to stay open and then exited the room again. At 2:01 pm the Mental Health Technician (MHT) completed a 15 minute check but did not continue down to the end of the hallway where Pt #3 and Pt #11's rooms were located to ensure all patient room doors were secured if patients were not in their rooms. This is inconsistent with facility policy stating if a patient is not in his/her room staff must ensure the room door is secured. At 2:17 pm Pt #3 came back to his/her room, and then at 2:22 pm proceeded to walk across the hall into Pt #11's room and waited for Pt #11 to enter. At 2:20 pm Pt #3's roommate entered their room and then at 2:22 pm the MHT checked Pt #3's room for the roommate; Pt #3's roommate exited the room with the MHT and the MHT did not close and secure Pt #3's room door despite no patients being in the room. At 2:22 pm, Pt #11 entered his/her room where Pt #3 was in the bathroom waiting for Pt #11. At 2:25 pm the Registered Nurse (RN) entered Pt #11's room looking for him/her then exited Pt #11's room and waited for Pt #11 to finish up in the bathroom. Pt #11 then exited his/her room wiping hands with a paper towel and proceeded to talk to the RN (the RN did not secure Pt #11's room). Pt #11 blocked the RN's view of Pt #11's door, and at 2:26 pm Pt #3 was able to exit Pt #11's room and enter Pt #3's room without being seen by the RN.

Per interview with Quality Director A on 09/10/2021 at 12:50 pm, during the investigation into this incident between Pt #3 and Pt #11, Quality Director A determined there was an issue with "Door Management" and that the MHT and RN should have ensured the doors were closed and locked when no patients were in the rooms. Per interview, Director A stated that an action plan to address the issue surrounding "Door Management" has not yet been developed and implemented. Director A stated that the investigation showed no issues with 15 minute checks and the monitoring of patients during the time of the incident, but Director A did confirm the risk of this happening could have been mitigated if the doors were closed and secured as per policy. Per Director A hallways should be monitored by a RN or MHT at all times and if this is not possible the MHT or RN should radio for assistance to ensure hallways are always continuously monitored by staff.

Incident #2:

Per review of the Incident Report for Pt #1 and Pt #2 dated 06/20/2021, "As seen on camera review after an anonymous note was passed to the units MHTs, (Pt #1) is seen entering a male peers room on 06/19/2021 on PM shift and staying in the for 30 seconds. (Pt #1) is again seen entering the same male peers room on 06/20/2021 on AM shift and staying in room for approximately 2 minutes."

Per review of the "Event Description" in the Investigation Report for Pt #1 and Pt #2, on Saturday 06/19/2021 between 7:43:47 pm to 7:44:22 pm, "...MHT left the unit to get clothes from the laundry room...MHT was positioned between the hall and the dayroom, so she is able to visualize both areas. One of the patients in the dayroom started digging through the trash. While (MHT) is talking to the patient in the dayroom (Pt #1) runs down the hall and goes into (Pt #2's) room. (Pt #1) was in there approximately 30 seconds and immediately exited (Pt #2's) room."

Per review of the "Event Description" of the Investigation Report for Pt #1 and Pt #2, on Sunday 06/20/2021 at 12:36:18 pm to 12:38:48 pm, "...MHT is standing near the nurses' station but in the dayroom where he would not be able to fully visualize the hall. it isn't clear where the second MHT is at this time. While (MHT) is talking to one of the patients, (Pt #1) ran into (Pt #2's) room. She was in his room approximately 2 1/2 minutes before exiting the room. During this time (Pt #2) look out of (his/her) room a few times to see who is in the hall."

Per interview with Quality Director A on 09/09/2021 at 12:30 pm the Incident between Pt #1 and Pt #2 was investigated and based on review of the surveillance video Director A determined that there was an issue with staff being in view of the hallways at all times and staff location. Per Director A, in response to this incident a few of the staff members were disciplined and written up due to not properly supervising the hallways. In addition, nursing staff and MHT staff were reeducated on milieu (hallway, day room, group room) supervision to include proper positioning of staff to maintain visualization of day room, hallway, and/or group room when more than 1 patient is present in that area; All nursing and MHT staff should reach out to nursing supervisor via walkie talkie if assistance is needed with supervision of the milieu; nursing supervisor to allocate additional staff assistance to area if needed. Per interview with Quality Director A, A stated surveillance video audits should be done weekly to monitor the effectiveness of the action plan, however staff are behind in audits due to staffing issues.

Per review on 09/10/2021 of the "Patient Observation Round-Camera Audit", video audits were conducted daily 07/04/2021 through 07/10/2021; on 09/8/2021 for date of 08/01/2021; on 09/09/2021 for dates of 08/2/2021 and 08/03/2021. No additional video audits were conducted for July 2021, August 2021, and September 2021 as of date of review, to ensure ongoing monitoring and sustainability of the action plan.

Review of the "Patient Observation Round-Camera Audit" revealed the following categories:
-"Patient level (being monitored) Level of Observation"; "Time: (documentation of four 15 minute intervals)"; "Clip Board/Tablet with staff rounding"; "Documentation Times Accurate"; "Policy followed Per Level of Observation." Per review of the "Patient Observation Round -Camera Audit" it does not include a category to observe that staff are continuously in view of hallways and monitoring day rooms and group rooms if patients are present as per action plan.

Per interview with RN C on 09/09/2021 at 11:10 am, RN C stated due to staffing shortages the Milieu is not always in view of staff. Per RN C the MHT does 15 minute checks and is responsible for vital signs and occasionally runs groups. C stated the RN can not always cover for the MHT due to rounding with the physician, administering medications, and completing assessments on patients. RN C stated patients have gone into other patient's rooms due to not having "enough eyes in the hallways."

Per interview with RN D on 09/09/2021 at 11:10 am, RN D stated MHT assigned to hallways also complete 15 minute checks and are often distracted by the needs of the patients, so there are times when the hallway is not in view of staff at all times. Per interview with RN D, D stated that there are times when RN D has had to cover the MHT's lunch and due to staffing shortages RN D has been tasked with performing MHT duties and RN duties, so it is sometimes very difficult to visualize the hallways at all times.

Per interview with Director of Nursing (DON) E on 09/09/2021 at 2:40 pm, the hallways should be "visualized by staff at all times." Per E the RN does occasionally cover for MHT during lunch breaks and can use a "COW(computer on wheels)" to wheel computers into the hallway and position self to watch the hallway while working on documentation (This practice is inconsistent with staff being able to continuously view hallway at all times). Per interview with DON E, E stated that RNs and MHTs are suppose to radio the Nursing Supervisor and/or DON E for help if milieu staff are unable to visualize the hallways due to obtaining supplies or other issues that may arise. However, when DON E was asked how shifts and lunches are being covered due to staffing shortages, E responded the Nursing Supervisors and DON E have had to cover patient assignments and help to cover lunches for RNs.

Per review of the action plan in response to the incident between Pt #1 and Pt #2, the action plan did not address how staffing shortages will be managed to ensure patients are kept safe and hallways are visualized by staff at all times. Staffing shortages were not identified as a potential problem related to hallways not being monitored appropriately; per interviews with RN C and RN D, staffing shortages was the main barrier to ensuring hallways were being visualized at all times and that patients are kept safe from other patients accessing their rooms.

RN SUPERVISION OF NURSING CARE

Tag No.: A0395

Based on record review and interview the facility failed to ensure Registered Nurses (RN) complete a progress note and perform nursing reassessments every shift on all patients as per policy in 4 of 10 patient (Pt) records (Pt #3, 5, 6, 7) in a total sample of 10 medical records reviewed, failed to ensure RNs administered medications on time as per policy in 4 of 10 Patient records (Pt #4, 6, 7, 9) in a total sample of 10 medical records reviewed, and failed to ensure medications were administered per physician orders in 3 of 10 records reviewed (Pt #6, 7, 9) in a total sample of 10 medical records reviewed.

Findings include:

Nursing Assessments & Progress Notes:

Review of policy and procedure titled, "Assessment & Reassessment of the Patient" last reviewed 12/2019 revealed the following:
1. Each patient is reassessed daily, every shift and as the patient's condition/needs warrant by a RN.
2. Reassessment is done to determine the patient's response to treatment.

Review of policy and procedure titled, "Clinical Services Documentation in Patient Record" last reviewed 12/2019 revealed the following:
1. The Registered Nurse will document in the Medical Record every shift and, more often as indicated by a change in the patient's condition.
2. The Clinical Staff write routine or daily entries addressing problems identified on the treatment plan, the staff intervention prescribed by the treatment plan, and the patient response to the intervention.

Review of Pt #3's medical record revealed Pt #3 was admitted to the facility on 08/5/2021 and discharged on 08/18/21 with a diagnosis of Suicidal Ideation. Per review of Pt #3's progress notes there was no evidence of a "Nursing Progress Note" completed by the day shift (6:00 am to 6:00 pm) nurse on 08/7/2021, 08/08/2021, 08/16/2021, and 08/17/2021, to determine the patient's response to treatment as per policy.

Review of Pt #5's medical record revealed Pt #5 was admitted to the facility on 07/15/2021 and discharged 07/29/2021 with a diagnosis of Bipolar Disorder. Per review of Pt #5's progress notes there was no evidence of a "Nursing Progress Note" and a "Nursing Physical Assessment" completed by the day shift nurse on 07/22/2021, to determine the patient's response to treatment as per policy.

Review of Pt #6's medical record revealed Pt #6 was admitted to the facility on 07/23/2021 and discharged on 07/30/2021 with a diagnosis of Bipolar Disorder. Per review of Pt #6's progress notes there was no evidence of a "Nursing Progress Note" completed by the day shift nurse on 07/24/2021 and 07/28/2021 and no evidence of a "Nursing Physical Assessment" completed by the day shift nurse on 07/24/2021, to determine the patient's response to treatment as per policy.

Review of Pt #7's medical record revealed Pt #7 was admitted to the facility on 08/11/2021 and discharged on 08/18/2021 with the diagnosis of Alcohol Dependency and Major Depressive Disorder. Per review of Pt #7's progress notes there was no evidence of a "Nursing Progress Note" completed by the day shift nurse on 08/13/2021 and 08/17/2021, to determine the patient's response to treatment as per policy.

Per interview with Nurse Educator B on 09/10/2021 at 2:00 pm, nursing staff should be completing a nursing physical assessment and nursing progress note on every shift.

Medication Administration:

Review of policy and procedure titled, "Medication Administration" last reviewed 11/2019 revealed that the nurse will administer medications within the following time frames: "Routine" (scheduled)--1 hour before or after the indicated time; "Now"--15 minutes before or after the indicated order time. Per policy, "When a patient in not able to receive a medication at the scheduled time (as defined by a window of 1 hour before to 1 hour after), the nurse will: indicate in eMar medication was not given...write a brief explanation."

Per review of Pt #4's Medication Administration Record (MAR), Pt #4 was scheduled to receive Lexapro (treats depression & generalized anxiety) at 8:00 am; the RN did not administer this medication until 9:17 am (1 hours and 17 minutes later). There was no documented evidence of why this medication was not administered with in the time parameters as per the Medication Administration policy.

Per review of Pt #6's MAR, Pt #6 was not administered the following medications within the time parameters as per the Medication Administration policy:
-Metoprolol for hypertension two times daily at 8:00 am and 8:00 pm; on 7/24/2021 the 2nd dose was given at 9:08 pm (1 hour and 8 minutes later); on 07/25/2021 the 2nd dose was given at 9:09 pm (1 hour and 9 minutes later); on 07/26/2021 the 2nd dose was given at 9:09 pm (1 hour and 9 minutes later).

-Metformin for diabetes 2 times daily at 8:00 am and 8:00 pm; on 07/24/2021 and 07/26/2021 the 2nd dose was given at 9:08 am (1 hour and 8 minutes later); on 07/25/2021 the 2nd dose was given at 9:09 am (1 hour and 9 minutes later).

-Gabapentin 3 times daily for pain at 8:00 am, 2:00 pm, and 8:00 pm; on 07/24/2021 and 07/26/2021 the 3rd dose was given at 9:07 pm (1 hour and 7 minutes later); on 07/25/2021 the 3rd dose was given at 9:09 pm (1 hour and 9 minutes later).

-Buspar 2 time daily for anxiety at 8:00 am and 8:00 pm; on 07/24/2021 the 2nd dose was given at 9:06 pm (1 hour and 6 minutes later); on 07/25/2021 the 2nd dose was given at 9:10 pm (1 hour and 10 minutes later); on 07/26/2021 the 2nd dose was given at 9:08 pm (1 hour and 8 minutes later).

Per review of Pt #6's MAR there was no documented evidence of the following medications being "Administered" or "Not Administered" to Pt #6 as ordered and documenting an explanation if not administered as per the Medication Administration policy (These medications were never documented as being discontinued):
-Buspar increased to 3 times daily scheduled to start on 07/28/2021 at 2:00 pm.

-Seroquel (antipsychotic) at bedtime scheduled to start on 07/29/2021 at 8:00 pm.

-Minipress (blood pressure) at bedtime scheduled to start on 07/29/2021 at 8:00 pm.

-Trazodone (sleep) at bed time scheduled to start on 07/29/2021 at 8:00 pm.

Per review of Pt #7's MAR, Pt #7 was ordered to received the following medications "Now" (Per policy "NOW" orders should be administered within 15 minutes before or after the ordered time):
-Effexor XR for depression was ordered "NOW" on 08/13/2021 at 4:52 pm and was medication was documented as given at 6:27 pm (1 hour and 35 minutes later).

-Electrolyte replacement with Pedialyte for "Ativan detox" was ordered "NOW" on 08/11/2021 at 8:04 pm and was not documented as given at 9:37 pm (1 hour and 33 minutes later).

Per review of Pt #7's MAR there was no documented evidence of the following medications being "Administered" or "Not Administered" to Pt #7 as ordered and documenting an explanation if not administered as per the Medication Administration policy (These medications were never documented as being discontinued):
-Trazodone at bedtime scheduled to start on 08/14/2021 at 8:00 pm.

-Revia for alcohol dependence scheduled to start on 08/16/2021 at 8:00 am.

-Vibramycin for acne scheduled to start on 08/17/2021 at 8:00 pm.

Per review of Pt #9's MAR there was no documented evidence of the following medications being "Administered" or "Not Administered" to Pt #9 as ordered and documenting an explanation if not administered as per the Medication Administration policy (These medications were never documented as being discontinued):
-Vitamin D scheduled to start on 08/17/2021 at 8:00 am.

-Prozac for major depressive disorder scheduled to start on 08/17/2021 at 8:00 am and stopped on 08/18/2021 at 2:46 pm.

-Prozac dose increased and scheduled to start on 08/19/2021 at 8:00 am.

Per interview with Nurse Educator B on 09/10/2021 at 2:00 pm, nursing staff should be administering medications no more than one hour before or one hour after scheduled medication time as per policy.