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Based on record review and interview, the facility failed to provide social work assessments that included specific social work recommendations that described anticipated social work roles in treatment and/or discharge planning for 6 of 8 active sample patients (A11, A28, B4, C2, C19 and D7). This failure results in a lack of information to the treatment team for the development of goals and interventions.
Findings include:

A. Record Review

1. Patient A11: A Social History and Assessment dated 12/17/10 noted the following under the section titled "Interventions and Discharge Recommendations:" "Once the client has met maximum hospital benefits as deemed by client will be detoxed. The client's mood will be more stable with no thoughts of self harm. The client will be able to return to community living. The client stated that she has a home to return to with her brother; however, she does not feel comfortable living with her brother at this time. The client has looked into different treatment facilities. The client has also been seen by the CMHC in Norman and they have identified some services to her. Upon discharge the client will be referred to the CMHC in Norman in order to get medication follow-up and therapy. The client will also be referred to Narcotics Anonymous meetings." There was no discussion about what services the social workers would provide for the patient during the hospitalization within the body of the assessment.

2. Patient A28: A Social History and Assessment dated 11/16/10 noted the following under the section titled "Interventions and Discharge Recommendations:" "I recommend that when [A28] is discharged that attempts be made to reunite him with his family in Texas, and then a referral will be made to the appropriate CMHC for outpatient services." There was no discussion about what services the social workers would provide for the patient during the hospitalization within the body of the assessment.

3. Patient B4: A Social History and Assessment dated 02/19/10 noted the following under the section titled "Interventions and Discharge Recommendations:" "Patient will continue to receive his pharmacological management. He receives individual counseling with a therapist at least one time per week. He also participates in therapeutic groups and classes when his behavior permits. Once patient is stable in his behaviors and has had a significant period of time of engaging in adaptive type behaviors and not engaging in inappropriate self mutilating, sexual inappropriate, or assaultive behaviors we will explore discharge placement likely to a residential care type facility." There was no discussion about what services the social workers would provide for the patient during the hospitalization within the body of the assessment.

4. Patient C2: A Social History and Assessment dated 11/08/10 noted the following under the section titled "Interventions and Discharge Recommendations:" "[C2] will continue to be treated for Chronic Schizophrenia and stabilized on medications. He will continue to reside at Griffin Memorial Hospital until he is willing or able to assist the social worker in exploring other options for discharge. Preference would be for him to sign consent forms for discharge processing to be started. He refuses to do that at this time. Will continue to work on that as [C2] does need to be discharged from the hospital." There was no discussion about what services the social workers would provide for the patient during the hospitalization within the body of the assessment.

5. Patient C19: In a Social History and Assessment dated 12/29/10 noted the following under the section titled "Interventions and Discharge Recommendations:" "When [C19] is discharge, I recommend he return to live with his family in Norman. A referral will be made to Central Oklahoma Mental Health Center for outpatient services." There was no discussion about what services the social workers would provide for the patient during the hospitalization within the body of the assessment.

6. Patient D7: In a Social History and Assessment dated 03/11/10 noted the following under the section titled "Interventions and Discharge Recommendations:" "I recommend that when [D7] is discharged that he return to his home in Norman where he lives by himself and that he be followed up by Cleveland County PACT for outpatient services." There was no discussion about what services the social workers would provide for the patient during the hospitalization within the body of the assessment.

B. Interview

In an interview on 01/13/11 at 9:30a.m., the information noted above was shown to the Director of Program Services and the Lead Social Worker, and it was discussed at length. The Director of Program Services agreed with the findings and stated "Our people really should be putting into the assessments what they're doing for our patients."

Based on record review and staff interview, the facility failed to provide a psychiatric evaluation that contained a sufficiently complete record of mental status for 8 of 8 active sample patients (A11, A28, B4, B25, C2, C19, D7 and D14). Mental status examination findings were not descriptive and did not contain any supportive information related to the assessment of insight and judgment. This deficiency makes it impossible to track changes in the mental health status in response to treatment.

Findings include:

A. Record Review

1. Patient A11: In a Psychiatric Evaluation dated 12/13/10, under the section entitled "Mental Status Exam," there was no notation regarding insight or judgment.

2. Patient A28: In a Psychiatric Evaluation dated 11/13/10, under the section entitled "Mental Status Exam," there was no notation regarding insight or judgment.

3. Patient B4: In a Psychiatric Evaluation dated 02/25/10 noted the following under the section entitled "Mental Status Exam": "Insight and judgment is good."

4. Patient B25: In a Psychiatric Evaluation dated 11/30/10 noted the following under the section entitled "Mental Status Exam": "Judgment and insight were poor."

5. Patient C2: In a Psychiatric Evaluation dated 09/22/10 noted the following under the section entitled "Mental Status Exam": "He has no insight. Judgment is poor."

6. Patient C19: In a Psychiatric Evaluation dated 12/28/10 noted the following under the section entitled "Mental Status Exam": "Judgment and Insight: I was unable to obtain from this patient. He had poor insight."

7. Patient D7: In a Psychiatric Evaluation dated 12/28/10 noted the following under the section entitled "Mental Status Exam": "He does not have any insight into the degree of his problem. Judgment is impaired."

8. Patient D14: In a Psychiatric Evaluation dated 12/16/10 noted the following under the section entitled "Mental Status Exam": "She has no insight into her illness and judgment remained impaired."

B. Interview

In an interview on 01/12/10 at 1:15p.m., the Clinical Director agreed with the findings and stated "The information on mental status exam is not descriptive enough."

Based on record review and interview, the facility failed to provide a psychiatric evaluation for 1 of 8 active sample patients (A28) that described the precipitating factors for the patient's admission, signs and symptoms of the present illness, or any treatment received prior to admission. This failure compromises the development of a database which can be used to generate a comprehensive treatment plan for the patient.

Findings include:

A. Record Review

1. Patient A28: A Psychiatric Evaluation dated 11/13/10 noted the following under the section for "History of Present Illness:" "I am unable to obtain much information from the patient because the patient is very agitated, disorganized and has disruptive behavior. He is pacing around in the admission area and refusing to talk to a woman. He keeps saying that he needs to get rid of all women, but boys are OK." The rest of the Psychiatric Evaluation failed to identify any precipitating factors for admission, other signs or symptoms, or information about previous treatment. There also was no mention that further information would be gathered at a later time or that collateral sources were contacted or obtained.

B. Interview

In an interview on 01/12/11 at 1:15p.m. with the Clinical Director, the information described above was shown to him. The Clinical Director agreed with the findings and stated "This information isn't adequate."

Based upon record review and interview, it was determined that for 7 of 8 active sample patient's psychiatric evaluations (A11, A28, B4, C2, C19, D7 and D14), the hospital failed to assure the reporting of memory functioning and/or intellectual functioning in measurable, behavioral terms which clearly reflected the patient's ability to function in those areas. This compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured.

Findings include:

A. Record Review

1. Patient A11: In a Psychiatric Evaluation dated 12/13/10, memory and intellectual functioning were noted under the section titled "Mental Status Exam" as "Immediate and remote memory is good as she can spell HOUSE forward and backward. Cognition is average."

2. Patient A28: In a Psychiatric Evaluation dated 11/13/10, memory function was noted under the section titled "Mental Status Exam" as "Memory cannot be assessed because he refuses to answer questions." There was no description of an estimation of intellectual function in the evaluation. There also was no evidence within the patient's written or electronic record that a follow-up examination was performed to complete the evaluation.

3. Patient B4: In a Psychiatric Evaluation dated 02/25/10, memory and intellectual functioning were noted under the section titled "Mental Status Exam" as "His memory for immediate, recent and remote events is good." There was no estimation of intellectual functioning noted within the evaluation.

4. Patient C2: In a Psychiatric Evaluation dated 09/22/10, memory and intellectual functioning were noted under the section titled "Mental Status Exam" as "His memory for immediate, recent and remote events is poor." There was no estimation of intellectual functioning noted within the evaluation.

5. Patient C19: In a Psychiatric Evaluation dated 12/28/10, memory and intellectual functioning were noted under the section titled "Mental Status Exam" as "Memory, fund of knowledge: I was unable to obtain from this patient." There was no evidence within the patient's written or electronic record that reexamination was performed at a later date.

6. Patient D7: In a Psychiatric Evaluation dated 12/28/10, memory and intellectual functioning were noted under the section titled "Mental Status Exam" as "Memory is intact in some areas, but poor in others." There was no estimation of intellectual functioning within the evaluation.

7. Patient D14: In a Psychiatric Evaluation dated 12/16/10, memory and intellectual functioning were noted under the section titled "Mental Status Exam" as "She some memory issues. Long term memory is fair." There was no estimation of intellectual functioning within the evaluation.

B. Policy Review

Facility Medical Staff Bylaws (page 51) notes the following under the section titled "Responsibilities: Section 2.10.2.5.1": ..."A psychiatric evaluation includes: 'methods used to determine memory functioning' are documented."

C. Interview

In an interview on 01/12/11 at 1:15p.m. with the Clinical Director, the examples of memory and intellectual functioning noted above were shown and discussed. The Clinical Director stated "These aren't detailed or specific; I agreed they are not adequate."

Based on record review, policy review and interview, the facility failed to provide psychiatric evaluations that included an assessment of patient assets in descriptive fashion for 8 of 8 active sample patients (A11, A28, B4, B25, C2, C19, D7 and D14). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in therapy.
Findings include:

A. Record Review

1. Patient A11: A Psychiatric Evaluation dated 12/13/10 noted under the section "Assets and Liabilities:" "Assets: This is a young and ambulatory female."

2. Patient A28: A Psychiatric Evaluation dated 11/13/10 noted under the section "Assets and Liabilities:" "Assets: The patient is a young male. Appears healthy."

3. Patient B4: A Psychiatric Evaluation dated 02/25/10 noted under the section "Assets and Liabilities:" "Assets: Ambulatory. Diabetes Mellitus is under control. He is pleasant and cooperative. He can verbalize his needs."

4. Patient B25: A Psychiatric Evaluation dated 11/30/10 noted under the section "Assets and Liabilities:" "This is a young, ambulatory female who has no significant physical illness. She is uncooperative. She is unemployed. She has no good social support."

5. Patient C2: A Psychiatric Evaluation dated 09/22/10 noted under the section "Assets and Liabilities:" "He is physically healthy. He can verbalize his needs."

6. Patient C19: A Psychiatric Evaluation dated 12/28/10 noted under the section "Assets and Liabilities:" "This is a young ambulatory male who has a history of ADD. He is cooperative, but cannot sit still. He looks like he has good family support."

7. Patient D7: A Psychiatric Evaluation dated 12/28/10 noted under the section "Assets and Liabilities:" "The patient is ambulatory and has no physical handicap. Receiving Social Security Income."

8. Patient D14: A Psychiatric Evaluation dated 12/16/10 noted under the section "Assets and Liabilities:" "The patient is pleasant the majority of the time. She is compliant with medications while she is here. She can verbalize her needs."

B. Policy Review

Facility Medical Staff Bylaws noted the following statement within the "Responsibilities" section on page 51 (Section 2.10.2.6): "A psychiatric evaluation includes: a descriptive inventory of the patient's assets."

C. Interview

In an interview on 01/12/10 at 1:15p.m., the Clinical Director was shown the information above. The Clinical Director stated "These are not assets we can use in treatment."

I. Based on record review, policy review and interview, the facility failed to ensure that physicians dictated, transcribed and filed patient discharge summaries within 30 days of discharge as required by hospital bylaws in 5 of 5 discharge records reviewed (DS1, DS2, DS3, DS4 and DS5). Four of the 5 discharge records reviewed (DS2, DS3, DS4 and DS5) were dictated by the physician after the 14 day deadline set by the facility's medical staff bylaws. Failure to communicate information about the patient's final diagnosis, current medications, course of treatment, summary of relevant labs and testing, anticipated problems and discharge plan with outpatient providers in a timely manner can result in inadequate follow-up for the patient.

II. Based on record review and interview, the facility failed to provide a discharge summaries for 2 of 5 discharged patients whose records were reviewed (DS3 and DS4), that summarized all the treatment received in the hospital and the patients' response to treatment other than medication. This failure compromises the effective transfer of the patient's care to the next care provider by not providing information that identifies either effective or ineffective treatment strategies for the individual patient.

Findings include:

I. Timeliness of Discharge Summaries

A. Policy Review

1. Facility Medical Staff Bylaws dated 04/16/07 notes on page 50 under the section titled "Responsibilities" (Section 2.8.2): "If the record remains incomplete after 30 days after discharge, it will be considered delinquent."

2. Facility Medical Staff Bylaws dated 04/16/07 notes on pages 49-50 under the section titled "Responsibilities" (Section 2.8): "All medical records should be complete at the time of discharge from the hospital including progress notes and final diagnosis. The discharge summary shall be dictated within 14 days." (Typed as written including bolding)

3. Griffin Memorial Hospital Policy Number PC-15-30 Subject: Discharge, dated 08/09/10 notes under the section titled "Procedure": "A summary of the individual's course of hospitalization shall be dictated within fifteen (15) days following discharge."

B. Record Review

1. Patient DS1, discharged from the facility on 11/30/10, had a Discharge Summary signed and dated 01/11/11. (42 days after discharge)

2. Patient DS2, discharged from the facility on 11/18/10, had a Discharge Summary dictated 12/05/10 (17 days after discharge) and signed and dated 12/30/10. (42 days after discharge)

3. Patient DS3, discharged from the facility on 11/24/10, had a Discharge Summary dictated 12/10/10 (16 days after discharge) and signed and dated 01/11/11. (48 days after discharge)

4. Patient DS4, discharged from the facility on 11/15/10, had a Discharge Summary dictated 12/10/10 (25 days after discharge) and signed and dated 01/07/11. (57 days after discharge)

5. Patient DS5, discharged from the facility on 11/04/10, had a Discharge Summary that was dictated on 12/20/10 (46 days after discharge) and had not been signed and dated as of the date of the survey 01/12/10. (69 days after discharge)

C. Interview

In an interview on 01/12/10 at 1:15p.m., the Clinical Director agreed with the findings above and stated "We've had trouble with transcription and getting doctors to sign records on time."

II. Insufficient summarization of hospital care

A. Record Review

1. Patient DS3: A Discharge Summary dated 01/11/11 noted under the section for "Course and Progress:" "The patient was admitted to 53-300. He was started on Zyprexa 10 milligrams po qHS; Haldol 5 milligrams and Ativan 2 milligrams po prn, it was given to him one time on 09/26/10. He was also given on 09/27/10 a one-time dose of Haldol and Ativan. Then he was started on Depakote 500 milligrams two po at night. [Blank] 20 milligrams at bedtime on 09/28/10. Discontinued Zyprexa on 10/17/10 and Risperdal was given 2 milligrams po bid on 10/17/10. The Depakote was decreased to 500 milligrams po qHS as the levels came up high at 122. He was also started on Haldol Deconoate 100 milligrams IM every four weeks. Cogentin 1 milligram po bid prn for EPS. He was fit to be discharged to home on 11/24/10."

2. Patient DS4: A Discharge Summary dated 01/07/11 noted under the section for "Course and Progress:" "The patient was admitted to 53-400. He was started on Zyprexa 10 milligrams po daily which was to po qHS. Depakote 250 milligrams po tid. The patient showed some aggression during his initial days of admission and he was placed on a Hold, not to exceed 10 minutes. Patient's Zyprexa was increased to 20 milligrams later on. Depakote ER was started with 1000 milligrams po qHS and Depakote 250 milligrams tid was discontinued. The patient responded well to these medications and his mood and psychosis stabilized. He started sleeping well at night and gained insight into his situation. As patient was stable enough and was able to take care of his personal needs, he was deemed stable for outpatient treatment. Patient agreed with this and he was willing to follow-up as an outpatient."

B. Interview

In an interview on 01/12/10 at 1:15p.m., after being shown the two discharge summaries noted above, the Clinical Director acknowledged that the discharge summaries only referred to medication management and did not include any information about the patients' response to the entire course of hospitalization.

Based on interview and record review, the facility failed to ensure that there was a continuing education program for nursing personnel, especially in the areas of psychiatric nursing and prevention and management of violent behavior. The clinical nurse educator position was cut, and no continuing education was being provided to nursing staff. There was a high number of "call ins" [staff who call saying they cannot report to work] which resulted in a high number of overtime hours for nursing staff (883 overtime hours for nursing staff during a 2 week period in December 2010). The acuity of the patient population was high with multiple nursing needs. There also were 260 incidents of assaultive behavior reported during November and December, 2010, and the first week of January 2011. The absence of a continuing program of psychiatric nursing education, especially in the prevention and management of violent behavior, results in missed opportunities to develop staff competence in therapeutic interaction with patients, ensure safety, and increase job satisfaction among staff, potentially reducing the need for excess overtime hours. (Refer to B148 and B150)

Based on record review, policy review and interview, the Clinical Director failed to:

I. Ensure that physicians provided a psychiatric evaluation that contained a sufficiently complete record of mental status for 8 of 8 active sample patients (A11, A28, B4, B25, C2, C19, D7 and D14). The mental status examination findings were not descriptive and did not contain any supportive information related to the assessment of insight and judgment. This deficiency makes it impossible to track changes in a patient's mental status in response to treatment. (Refer to B113)

II. Ensure that physicians provided a psychiatric evaluation for 1 of 8 active sample patients (A28) that described the precipitating factors for the patient's admission, signs and symptoms of the present illness, or any treatment received prior to admission. This failure compromises the development of a database which can be used to generate a comprehensive treatment plan for the patient. (Refer to B114)

III. Ensure that physicians provided a psychiatric evaluation that adequately described memory functioning and/or intellectual functioning in measurable, behavioral terms which clearly reflected the patient's ability to function in those areas for 7 of 8 active sample patients (A11, A28, B4, C2, C19, D7 and D14). This deficiency compromises the database from which diagnoses are determined and from which changes in response to treatment interventions may be measured. (Refer to B116)

IV. Ensure that physicians provided a psychiatric evaluation that included an assessment of patient assets in descriptive fashion for 8 of 8 active sample patients (A11, A28, B4, B25, C2, C19, D7 and D14). The failure to identify patient assets impairs the treatment team's ability to choose treatment modalities that utilize the patient's attributes in therapy. (Refer to B117)

V. Ensure that discharge summaries were dictated, transcribed and filed within 30 days of discharge per hospital bylaws for 5 of 5 discharge records reviewed (DS1, DS2, DS3, DS4 and DS5). Four of the 5 discharge records reviewed (DS2, DS3, DS4 and DS5) were dictated by the physician after the 14 day deadline set by the facility's medical staff bylaws. Failure to communicate information about a patient's final diagnosis, current medications, course of treatment, summary of relevant labs and testing, anticipated problems and discharge plan with outpatient providers in a timely manner can result in inadequate follow-up care for the patient (Refer to B133-I)

VI. Ensure that physicians provided a discharge summary that summarized all the treatment received in the hospital and the patients' response to treatment other than medication for 2 of 5 discharged patients whose records were reviewed (DS3 and DS4). This failure compromises the effective transfer of the patient's care to the next care provider by not providing information that identifies either effective or ineffective treatment strategies for the individual patient. (Refer to B133-II)
VI1. Additionally, based on policy review, record review and interview, the Clinical Director failed to ensure that annual psychiatric evaluations and history and physical examinations were updated in a timely manner for 2 of 3 active sample patients who needed annual updates (B4 and C2). This deficiency can lead to failure to address the current treatment needs of patients.

Findings include:

A. Policy Review

Griffin Memorial Hospital Policy Number PC 2-20, Subject: Assessments, Review date: 03/10/09 notes the following: "[Formal Discipline] Assessments shall be reviewed and revised annually for patients with a length of stay greater than 365 days."

B. Record Review

1. Patient B4, admitted 02/23/09, had an Admission History and Physical dated 02/23/09. There was no evidence in the patient's written or electronic record that an updated history and physical had been completed as of the date of the survey (01/12/11). This patient had an active medical problem list that included insulin dependent diabetes and a difficult-to-control seizure disorder.

2. Patient C2, admitted 09/05/2000, had an Annual Psychiatric Assessment completed on 09/22/10 (17 days late according to Policy PC 2-20 noted above).

C. Interview

In an interview on 01/12/11 at 1:15p.m., the Clinical Director agreed with the findings noted above and stated "[Patient B4] really should have had an update given his medical problems."

Based on interview and record review, the Director of Nursing failed to ensure that there was a continuing education program for nursing personnel, especially in the areas of psychiatric nursing and prevention and management of violent behavior. The acuity of the patient population was high with multiple nursing needs, and there were numerous incidents of assaultive behavior by patients. For November and December 2010 and the first week of January 2011, 260 incidents of assaultive behavior were reported. There also was excessive use of overtime hours for nursing staff. During a 2 week period in December 2010, there were 883 hours of nursing staff overtime reported, which would equal 74 12-hour shifts during that period with a staff member who was not originally scheduled to be there. There were 3 PCAs on Extended Leave/OJI [on the job injury] status. The absence of a continuing program of psychiatric nursing education, especially in the prevention and management of violent behavior, results in missed opportunities to develop staff competence in therapeutic interaction with patients, ensure safety, and increase job satisfaction among staff, potentially reducing the need for excess overtime hours.

Findings include:

A. Staff Interviews

1. In an interview on 01/11/2011 at 1:50PM, RN 1, the charge nurse on ward 53-400, stated that she was very busy and was working "volunteered overtime." RN 1 reported that there were 24 patients on the ward; with one discharge and 3 new admissions. She said that all patients were monitored by Q15 minute checks [the time and place of the observation as well as the patient's behavior] which required "the time of one or more staff." RN 1 stated that the LPN was in the medication room helping patients with their medications although she was also assigned to be "monitoring the hall." She also said that the one male PCA was on call for any problems with a patient on another ward, "leaving me with 3 female staff and I feel that with our patients, we need a male PCA available."

2. In an interview on 01/11/2011 at 4:15PM, RN 2 stated that she is now working overtime to relieve RN 1, who was on overtime. RN 2 stated that one problem with staffing is that "with 12 hour shifts, it is hard to get someone to come in for an extra shift."

3. In an interview on 1/12/2011 at 9:20AM, RN 3, the nurse manager on ward 52-400, stated that there are problems with 'call ins' and "the night shift has to call security if there is a problem with an acting out patient."

4. The Director of Nursing was interviewed on 01/12/2011 at 11:05AM. In answer to a question about a shortage of nursing staff reported by staff members, he stated "That's not true." The DON stated "The problem is getting people to come to work...'call ins' [staff who call stating they cannot come in to work] are significant." When asked about education for nursing staff, he stated "That's where we have a problem...there is no nursing educator now...the state cut that position." He stated that there "is no schedule of nursing education...the nursing coordinators are responsible [for nursing education]."

5. In an interview on 01/12/2011 at 1:00PM, the Clinical Director stated that there was no ongoing education program for nursing staff, and that a new program for preventing and managing aggressive behavior "has not yet involved the nursing staff."

B. Record Review

1. The acuity of current active patients was reported on the Nursing Needs Assessment form supplied by the surveyor. The census on the first day of the survey was 105; all patients were monitored by Q15 minute checks [the time and place of the observation as well as the patient's behavior recorded]. On the first day of the survey the Nursing Needs Assessment forms included:

a. Ward 52-400, with geriatric and other adult psychiatric patients: census was 24, with 6 patients requiring total assistance in 3 or more self help skills and the rest of the patients requiring partial assistance, 6 dressing changes, 4 patients potentially assaultive, and 2 actively assaultive.

b. Ward 53-200, with adult psychiatric patients: census was 29, with 20 patients needing partial assistance with self care, 8 diabetic checks, 4 seizure precautions, 29 needing escort to meals, 1 on detoxification protocol, 3 patients who take medications reluctantly and 3 who have forced/non-voluntary or parenteral [injected] medications, 29 patients who constantly demand staff time, and 3 on 1:1 [1 staff to 1 patient] supervision.

c. Ward 53-300, with all adult psychiatric patients: census was 30, with 20 requiring partial assistance with self care, 12 diabetic checks, 4 seizure precautions, 3 potentially assaultive, 3 actively assaultive, 3 with hallucinations or delusions, 2 admitted within the last 48 hours, 1 with an off grounds appointment with nursing staff accompaniment, and 30 who constantly demand staff time.

d. Ward 53-400, with adult psychiatric patients: census was 26, with 20 patients requiring partial assistance from staff with self care, 3 potentially assaultive, 3 actively assaultive, 3 having hallucinations/delusions, 4 admitted within the past 48 hours, and 2 on assault precautions.

2. A document entitled "Overtime Query" was provided at the request of the surveyor and dated 01/12/2011. This was not a nursing document, but was obtained from the financial department. For the 2 weeks from December 1-14, 2010, 883 hours of overtime were recorded for nursing staff.

3. A list of incident reports was provided to the surveyors on request. From 11/01/2010 through 01/09/2011, there were 260 incidents of patient assaultive behavior reported. One suicide attempt by hanging was reported. The "Reviewer's Comments" after the suicide attempt incident stated "Client states he was upset with staff after receiving an IM [intramuscular medication injection] secondary to assaultiveness and wanted to get staff attention - client told RN."

4. In a staffing pattern document provided by the Director of Nursing, one section was titled "EXTENDED LEAVE/OJI [on the job injury] STAFF." There were 3 PCAs listed as on leave because of on the job injury -- 2 from Building 52 and 1 from Building 53.

Based on interview and record review, the facility failed to ensure that nursing had sufficient regular staffing on units maintain a safe and therapeutic environment. Staff reported that there was a shortage of RNs (registered nurses) and PCAs (patient care assistants) on the units, because of 'call ins' [staff who call stating they cannot report to work] which resulted in staff overtime, staff being called to other units, or lack of sufficient staff on that shift. During a 2 week period in December, 2010, there were 883 hours of nursing staff overtime reported, which would equal 74 12-hour shifts during that period with a staff member who was not originally scheduled to be there. There were 3 PCAs on Extended Leave/OJI [on the job injury] status. There also were numerous incidents of assaultive behavior by patients. For November and December 2010 and the first week of January 2011, 260 incidents of assaultive behavior were reported. Failure to ensure regular nursing staffing potentially results in lack of continuity of care as well as concerns about patient and staff safety.

Findings include:

A. Staff Interviews

1. In an interview on 01/11/2011 at 1:50PM, RN 1, the charge nurse on ward 53-400, stated that she was very busy and short of staff. She stated she was working "volunteered overtime," and that there were also "1 LPN and 4 PCAs (patient care assistants) on duty for this ward; 5 PCAs were assigned, but one is escorting a patient to a local hospital for an appointment." RN 1 also reported that there were 24 patients on the ward, with one discharge and 3 new admissions. She said that all patients were monitored by Q15 minute checks [the time and place of the observation as well as the patient's behavior] which required "the time of one or more staff." She also said that the LPN was in the medication room helping patients with their medications although she {the LPN] was also assigned to be "monitoring the hall." RN 1 stated that the one male PCA was on call for any problems with a patient on another ward, "leaving me with 3 female staff and I feel that with our patients, we need a male PCA available." She added "We are really down on staffing now; the state doesn't pay well; there are injuries; people leave...Last weekend, there were not enough staff to take patients to the dining room, so they called the kitchen staff who made sack lunches for the patients."

2. In an interview on 01/11/2011 at 4:15PM, RN 2 stated that she is now working overtime to relieve RN 1, who was also on overtime. RN 2 stated that one problem with staffing is that "with 12 hour shifts, it is hard to get someone to come in for an extra shift."

3. In an interview on 01/12/2011 at 9:20AM, Physician 1 stated "We are always short of nurses-they are always welcome to come in with us [to a treatment team meeting with the attending psychiatrist and social worker] but are usually too busy."

4. In an interview on 1/12/2011 at 9:25 AM, RN 3, the Nurse Manager on ward 52-400, stated that there are problems with 'call ins' and "the night shift has to call security if there is a problem with an acting out patient."

B. Record Review

1. The acuity of current active patients was reported on the Nursing Needs Assessment form supplied by the surveyor. The census on the first day of the survey was 105; all patients were monitored by Q 15 minute checks [the time and place of the observation as well as the patient's behavior recorded]. On the first day of the survey, the Nursing Needs Assessment forms included:

a. Ward 52-400, with geriatric and other adult psychiatric patients: census was 24, with 6 patients requiring total assistance in 3 or more self help skills and the rest of the patients requiring partial assistance, 6 dressing changes, 4 patients potentially assaultive, and 2 actively assaultive.

b. Ward 53-200, with adult psychiatric patients: census was 29, with 20 patients needing partial assistance with self care, 8 diabetic checks, 4 seizure precautions, 29 needing escort to meals, 1 on detoxification protocol, 3 patients who take medications reluctantly and 3 who have forced/non-voluntary or parenteral [injected] medications, 29 patients who constantly demand staff time, and 3 on 1:1 [1 staff to 1 patient] supervision.

c. Ward 53-300, with all adult psychiatric patients: census was 30, with 20 requiring partial assistance with self care, 12 diabetic checks, 4 seizure precautions, 3 potentially assaultive, 3 actively assaultive, 3 with hallucinations or delusions, 2 admitted within the last 48 hours, 1 with an off grounds appointment with nursing staff accompaniment, and 30 who constantly demand staff time.

d. Ward 53-400, with adult psychiatric patients: census was 26, with 20 patients requiring partial assistance from staff with self care, 3 potentially assaultive, 3 actively assaultive, 3 having hallucinations/delusions, 4 admitted within the past 48 hours, and 2 on assault precautions.

2. A document entitled "Overtime Query" was provided at the request of the surveyor and dated 01/12/2011. This was not a nursing document, but was obtained from the financial department. For the 2 weeks from December 1-14, 2010, 883 hours of overtime were recorded for nursing staff.

3. A list of incident reports was provided to the surveyors on request; the list included the following:

a. From 11/01/2010 through 01/09/2011, there were 260 incidents of patient assaultive behavior reported.

b. For the 2 weeks from December 1-14, 2010, there were 54 reported incidents of assaultive behavior by patients. Of these incidents, 21 were patient to patient assaults; 26 were patient to staff assaults, and 7 were patient destruction of property. There were 6 injuries reported. Patient injuries included: 1) a "small red swollen area left hand", 2) a "bruise, swelling-neck" and 3) "hair pulled out". The injuries to staff were: 1) "rule out fracture", 2) "struck in head, kicked & hit in side" and 3) "laceration."

c. One suicide attempt by hanging was reported. The "Reviewer's Comments" after the attempted suicide incident stated "Client states he was upset with staff after receiving an IM [intramuscular medication injection] secondary to assaultiveness and wanted to get staff attention - client told RN."

4. In a staffing pattern document provided by the Director of Nursing, one section was titled "EXTENDED LEAVE/OJI [on the job injury] STAFF." There were 3 PCAs listed as on leave because of on the job injury -- 2 from Building 52 and 1 from Building 53.

Based on record review and interview, The Director of Patient Services (who is responsible for overall supervision of social services) failed to ensure the adequate completion of Psychosocial Assessments for 6 of 8 active sample patients (A11, A28, B4, C2, C19 and D7). Specifically, the social services staff did not identify discipline specific interventions for these patients. Failure to document social work interventions can result in patients not receiving these services, potentially prolonging their hospitalization.

Findings include:

A. Record Review

1. Patient A11: A Social History and Assessment dated 12/17/10 noted the following under the section titled "Interventions and Discharge Recommendations": "Once the client has met maximum hospital benefits as deemed by client will be detoxed. [sic] The client's mood will be more stable with no thoughts of self harm. The client will be able to return to community living. The client stated that she has a home to return to with her brother; however, she does not feel comfortable living with her brother at this time. The client has looked into different treatment facilities. The client has also been seen by the CMHC in Norman and they have identified some services to her. Upon discharge the client will be referred to the CMHC in Norman in order to get medication follow-up and therapy. The client will also be referred to Narcotics Anonymous meetings." The history and assessment included no discussion about what services the social workers would provide for the patient during the hospitalization.

2. Patient A28: A Social History and Assessment dated 11/16/10 noted the following under the section titled "Interventions and Discharge Recommendations": "I recommend that when [A28] is discharged that attempts be made to reunite him with his family in Texas, and then a referral will be made to the appropriate CMHC for outpatient services." The Assessment included no discussion about what services the social workers would provide for the patient during the hospitalization.

3. Patient B4: A Social History and Assessment dated 02/19/10 noted the following under the section titled "Interventions and Discharge Recommendations": "Patient will continue to receive his pharmacological management. He receives individual counseling with a therapist at least one time per week. He also participates in therapeutic groups and classes when his behavior permits. Once patient is stable in his behaviors and has had a significant period of time of engaging in adaptive type behaviors and not engaging in inappropriate self mutilating, sexual inappropriate, or assaultive behaviors we will explore discharge placement likely to a residential care type facility." The history and assessment included no discussion about what services the social workers would provide for the patient during the hospitalization.

4. Patient C2: A Social History and Assessment dated 11/08/10 noted the following under the section titled "Interventions and Discharge Recommendations": "[C2] will continue to be treated for Chronic Schizophrenia and stabilized on medications. He will continue to reside at Griffin Memorial Hospital until he is willing or able to assist the social worker in exploring other options for discharge. Preference would be for him to sign consent forms for discharge processing to be started. He refuses to do that at this time. Will continue to work on that as [C2] does need to be discharged from the hospital." The history and assessment included no discussion about what services the social workers would provide for the patient during the hospitalization.

5. Patient C19: In a Social History and Assessment dated 12/29/10 noted the following under the section titled "Interventions and Discharge Recommendations": "When [C19] is discharge, I recommend he return to live with his family in Norman. A referral will be made to Central Oklahoma Mental Health Center for outpatient services." The history and assessment included no discussion about what services the social workers would provide for the patient during the hospitalization.

6. Patient D7: In a Social History and Assessment dated 03/11/10 noted the following under the section titled "Interventions and Discharge Recommendations": "I recommend that when [D7] is discharged that he return to his home in Norman where he lives by himself and that he be followed up by Cleveland County PACT for outpatient services." The history and assessment included no discussion about what services the social workers would provide for the patient during the hospitalization.

B. Interview

In an interview on 1/13/11 at 9:30a.m. with the Director of Patient Services and the Lead Social Worker, the psychosocial assessments for Patients A11, A28, B4, C2, C19 and D7 were discussed at length. Both professionals stated that they did not supervise or monitor the social service staff with regard to including specific social service interventions within the Psychosocial Evaluations. The Director of Patient Services also stated that she did not directly supervise the Baccalaureate level Social Workers for competency in regard to the quality of Psychosocial Evaluations.