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Based on record review and interviews, the facility failed to provide social work assessments for 8 of 8 active sample patients (A1, A2, B1, B2, C1, C2, E1, E2). This made it impossible to assess whether or not social workers assessed patient needs to determine anticipated social work roles in treatment and/or discharge planning. In addition, failure to have Psychosocial Assessments available to the treatment team results in the treatment teams working without the necessary psychosocial information to adequately treat their patients.

Findings include:

A. Record Review

The inpatient medical records of the eight active sample patients were reviewed (A1, A2, B1, B2, C1, C2, E1, and E2).
Patient A1 was admitted 3/25/11.
Patient A2 was admitted 3/20/11.
Patient B1 was admitted 3/24/11.
Patient B2 was admitted 3/22/11.
Patient C1 was admitted 3/24/11.
Patient C2 was admitted 3/18/11.
Patient E1 was admitted 3/18/11.
Patient E2 was admitted 3/15/11.
None of these medical records contained a Psychosocial Assessment at the time of the survey, 3/28/11.

B. Interviews

1. In an interview on 3/28/11 at 4:20pm with the Director of Social Work, the records of the eight active sample patients were reviewed. The Director was asked why none of the records contained a Psychosocial Assessment. The Director explained that although the assessments had been dictated, Psychosocial Assessments had low priority for transcribing and may run two months behind. The Director was asked whether this meant that the eight sample patients would be treated and discharged before their Psychosocial Assessments were typed and made available to the treatment team. The Director replied that that was the case.

2. In an interview on 3/28/11 at 5:00pm, the Hospital Chief Executive Officer (CEO) was informed that none of the eight active sample patients had a Psychosocial Assessment completed within the patient's record, and that the Director of Social Work reported that they were running two months behind, the CEO stated, "That's not acceptable."

3. In an interview on 3/29/11 at 9:00am with the Director of Heath Information Services, the Director stated that due to staff shortages the transcription of Psychosocial Assessments and Discharge Summaries was currently running two months late. The Director acknowledged that this left treatment teams working without a Psychosocial Assessment for their patients.

4. In an interview on 3/29/11 at 10:45am, MD1 stated that it was routine for the treatment teams to work without having the Psychosocial Assessments of their patients available.

5. In an interview on 3/29/11 at 11:00am, SW1 stated that social workers work without their Psychosocial Assessments in treating patients. SW1 stated they work from memory and informal notes.

Based on record review and interviews, the hospital failed to complete Discharge Summaries for 5 of 5 discharge records reviewed (D1, D2, D3, D4, D5). Failure to complete Discharge Summaries impedes the flow of information that subsequent providers of treatment require for continuing care.

Findings include:

A. Record review

5 discharge patient records were reviewed on 3/28/11:

1. D1 - discharge date, 3/11/11
2. D2 - discharge date, 3/11/11
3. D3 - discharge date, 3/11/11
4. D4 - discharge date, 3/11/11
5. D5 - discharge date, 3/11/11

None of these five records contained the required Discharge Summary.

Hospital policy PC-15-30 "Subject: Discharge" under the Section titled "Procedure" stated: "A summary of the individuals course of hospitalization shall be dictated within fifteen days following discharge."
All five discharge summaries were 2 days overdue in the sampled records at the time of the review.

B. Interviews

1. In an interview on 3/28/11 at 1:20pm, the Medical Director explained that the hospital's dictations were running significantly behind. The Medical Director acknowledged that none of the 5 sample discharge patients had discharge summaries completed and in the records within 15 days of discharge as hospital policy requires.

2. In an interview on 3/28/11 at 1:30pm, the records of the five sample discharge patients (D1, D2, D3, D4, D5) were reviewed with the Director of Quality Assurance. The Director acknowledged that none of the records contained the Discharge Summaries that hospital policy required.

3. In an interview on 3/29/11 at 9:00am, the Director of Heath Information Services stated that due to staff shortages the transcription of Psychosocial Assessments and Discharge Summaries were currently running two months late.

Based on interview and record review, the facility failed to ensure that there was an adequate 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 had not been reinstated. The hospital provided training statistics on 3/28/11 that showed that very little training had been provided to the nursing staff since the previous survey in January 2011. There continued to be 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. (between 312.5 and 836.75 overtime hours for nursing staff during the first three weeks of March 2011). The acuity of the patient population remained high, with multiple nursing needs. There also were 126 incidents of assaultive behavior reported between January 8 and March 26, 2011. In addition, staff not usually used as Patient Care Attendants were being used to cover unit staffing shortages, who may be unknown to the pts, each other, or other clinical staff.

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 interviews, the Medical Director failed to ensure that:

I. Social Service staff provided Psychosocial Assessments for 8 of 8 active sample patients (A1, A2, B1, B2, C1, C2, E1, E2). Failure to have Psychosocial Assessments available to the treatment team results in the treatment team working without the necessary psychosocial information to adequately address the needs for all 8 of 8 active sample patients. (Refer to B108)

II, Physicians provided Discharge Summaries for 5 of 5 discharge patient records reviewed (D1, D2, D3, D4, D5). Failure to complete Discharge Summaries impedes the flow of information that subsequent providers of treatment require for continuing care. (Refer to B133)

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 remained high with multiple nursing needs The hospital reported in a document titled "Assault Episodes" that beginning 1/8/11, there were a total of 126 incidents of assaultive behavior incidents between 1/8/11 and 3/26/11. There also was excessive use of overtime hours for nursing staff. The hospital reported a peak use of overtime of 836 hours in a one-week period ending 3/5/11. 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. Record Review

The hospital was asked to provide training records that would demonstrate that the hospital was now providing training to nursing personnel in clinical areas, particularly related to de-escalation of patients for the prevention of violence. The Assistant Director of Nursing and the Data Specialist presented data on 3/28/11, which the Assistant Director stated, "looks pretty bad." The data presented was for the Nursing Department and titled "Griffin Memorial Hospital: Percent Complete by Departments." The document showed as of 3/28/11, only 48% of nursing staff had been trained in Creating a Positive Environment (CAPE) Physical. Only 50 % of nursing staff had been trained in CAPE Verbal. Only 20 % of nursing staff had been trained in Alternatives to Seclusion and Restraint. Only 6% had been trained in Nursing Medication Management. Only 8 % had been trained in Nursing Medication Administration. Only 5% had been trained in Nursing Restraint Application: Psychiatric Emergencies. Only 27% had been trained in Seclusion and Restraint: Policy/Procedures.

In addition, the hospital reported using clerical staff, recreational therapists and housekeepers in the role of Patient Care Attendants (PCAs), resulting in PCA staff who may be unknown to the pts, each other, or other clinical staff.

B. Interviews:

1. In an interview on 3/28/11 at 2:00pm with the Assistant Director of Nursing, who was covering for the absent Director of Nursing, the Assistant Director of Nursing acknowledged that the hospital had not met its training goals for the Nursing Department.

2. In an interview on 3/28/11 at 1:30pm, the Quality Assurance Director acknowledged that the training statistics "do not look good."

3. In an interview on 3/28/11 at 5:00pm, the CEO acknowledged that the hospital had not met the training goals.

Based on record review and interviews, the hospital failed to ensure that the nursing department had sufficient regular staffing on the units to maintain a safe and therapeutic environment. There were a large number of "call-ins" [staff who call saying they cannot report to work], which required the continued use of high numbers of overtime hours. Nurses on the units reported RN shortages and high overtime use. When asked to provide the current overtime data at the time of the 3/28/11 survey, the hospital reported using up to 836.75 hours of overtime per week (that amount was during a one-week peak period ending 3/5/11). The hospital also reported using clerical staff, recreational therapists and housekeepers in the role of Patient Care Attendants (PCAs), as well as using Patient Care Attendants from a neighboring children's facility, who were not familiar with the patient population.


Findings include:

A. Record review:

1. Assault incidents and overtime use

a. The acuity of the patient population remains high. The hospital reported in a document titled "Assault Episodes" that there had been 126 incidents of assaultive behavior reported between 1/8/11 and 3/26/11.
b. For the first three weeks of March, 2011, the hospital reported the following Nursing Department overtime use:
For the week ending 3/5/11, 836.75 hours of overtime
For the week ending 3/12/11, 312.5 hours of overtime
For the week ending 3/19/11, 400.5 hours of overtime

2. Training Statistics

The hospital was asked to provide training records from 1/8/11 to 3/28/11. The Assistant Director of Nursing and the Data Specialist presented data on 3/28/11, which the Assistant Director stated, "looks pretty bad." The data presented was for the Nursing Department and titled "Griffin Memorial Hospital: Percent Complete by Departments." The document showed as of 3/28/11, only 48% of nursing staff had been trained in Creating a Positive Environment (CAPE) Physical. Only 50 % of nursing staff had been trained in CAPE Verbal. Only 20 % of nursing staff had been trained in Alternatives to Seclusion and Restraint. Only 6% had been trained in Nursing Medication Management. Only 8 % had been trained in Nursing Medication Administration. Only 5% had been trained in Nursing Restraint Application: Psychiatric Emergencies. Only 27% had been trained in Seclusion and Restraint: Policy/Procedures II.

3. Direct Nursing Staffing

The Assistant Director of Nursing and unit RNs reported that each inpatient unit was to be staffed at 2RNs, 1LPN and 4 PCAs. However, Nursing Staffing Forms completed by the hospital showed a staffing pattern of 1 RN and 3 PCAs per unit, representing a shortage of both disciplines, on the following occasions:
Unit 52-4 on the 11-7 shift on 3/21/11
Unit 53-4 on the 3-11 shift on 3/20/11
Unit 53-4 on the 11-7 shift on 3/22/11
Unit 53-3 on the 11-7 shift on 2/15/11
Unit 53-3 on the 11-7 shift on 2/16/11
Unit 53-4 on the 11-7 shift on 2/14/11
Unit 53-4 on the 11-7 shift on 2/18/11

The staffing pattern supplied by the hospital for unit 53-3 for 2/16/11 on the 11-7 shift showed 1 Nurse, 0 LPNs and 2 MHTs

B. Interviews:

1. In an interview on 3/28/11 at 11:25am with the hospital Chief Executive Officer (CEO), the CEO stated that call-ins and overtime remained high. The CEO acknowledged that staff shortages also made it hard for the hospital to achieve its training goals.

2. In an interview on 3/28/11 at 1:30pm with the Director of Quality Assurance, the Director presented the overtime figures cited above for the Nursing Department. The Director acknowledged that shortages and high overtime use made it difficult to train staff.

3. In an interview on 3/28/11 at 2:00pm, the Assistant Director of Nursing stated that call-ins and overtime use continued to be high, frequently causing staff shortages.

4. In an interview on 3/29/11 at 10:10am with RN1 on B52-400, RN1 stated the unit should be staffed by 2 RNs, 1LPN and 4 PCAs, with the number of PCAs increasing according to acuity. RN1 stated it was not uncommon to be short an RN or LPN.

5. In an interview on 3/29/11 at 10:20am with RN2 on B53-200, RN2 stated the unit should have 2 RNs, but frequently only had one due to call-ins and staff shortages.

6. In an interview on 3/29/11 at 10:30am with RN3 on B3-400, RN3 stated the unit should be staffed with 2RNs, but the unit was frequently short of staff, as it was at the time of the interview.

7. In an interview on 3/29/11 at 10:40am with RN4 on B53-300, RN4 stated the unit should have 2RNs, but it was not uncommon to be short staffed due to call-ins.

Based on record review and interviews, the Director of Social Work failed to ensure that social service staff provided Psychosocial Assessments for 8 of 8 active sample patients (A1, A2, B1, B2, C1, C2, E1, E2). Failure to have Psychosocial Assessments available to the treatment team results in the treatment team working without the necessary psychosocial information to adequately address the needs for all eight active sample patients. Failure to provide assessments also precludes the supervisory Social Work staff from having access to the information that social work staff use in assessing patient needs, thereby precluding adequate supervision of the clinical staff providing direct patient care,

Findings include:

A. Record Review

The records of eight active sample patients were reviewed (A1, A2, B1, B2, C1, C2, E1, E2). None of these medical records contained a Psychosocial Assessment. (Refer to B108)

B. Interviews

1. In an interview on 3/28/11 at 4:20pm with the Director of Social Work, the records of the eight active sample patients were reviewed. The Director was asked why none of the records contained a Psychosocial Assessment. The Director explained that although the assessments had been dictated, Psychosocial Assessments had low priority for transcribing and may run two months behind. The Director was asked whether this meant that the eight active sample patients would be treated and discharged before their Psychosocial Assessments were typed and made available to the treatment team. The Director replied that that was the case.
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The Director was asked for the time frame for completion of Psychosocial Assessments. The Director replied that they should be dictated within 4 days of admission, unless the patient was discharged before the 4 day mark, in which case no Psychosocial Assessment would be completed. The Director was asked to provide the policy or procedure that stated patients admitted for fewer than 4 days would not receive a Psychosocial Assessment. The Director was unable to locate such a directive or policy in writing, but explained that it was a "tradition" that she inherited when she came to the hospital eight years ago as Social Work Director.

In an interview on 3/29/11 at 11:00am, the Director provided data that there had been 346 hospital admissions between 1/12/11 and 3/28/11. Of those 346 admissions, 58 admissions stayed fewer than four days and did not receive a Psychosocial Assessment. This constituted 16.76% of these admissions, according to the hospital's data.

The Director was asked how Masters level social workers or the Director could provide supervision to Bachelors level social workers for active sample patients, if no Psychosocial Assessments were available to be reviewed. The Director acknowledged that this would not be possible.

2. In an interview on 3/28/11 at 5:00pm with the Hospital Chief Executive Officer (CEO), the CEO was informed that none of the eight active sample patients had a Psychosocial Assessment completed on the record, the CEO stated, "That's not acceptable."

3. In an interview on 3/29/11 at 9:00am with the Director of Heath Information Services, The Director acknowledged that this failure leaves treatment teams working without a Psychosocial Assessment for their patients.

4. In an interview on 3/29/11 at 10:45am with the attending psychiatrist MD1 on unit B53-300, MD1 stated that it is routine for the treatment teams to work without having the Psychosocial Assessments of their patients available.

5. In an interview on 3/29/11 at 11:00am with social worker SW1 on unit B53-300, SW1 stated that social workers work without their Psychosocial Assessments in treating patients. SW1 stated they work from memory and informal notes.