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Based on policy and procedure review, patient medical record review, and staff interview, the facility failed to ensure that nursing staff implemented the facility policy related to the requirement for a time limited restraint order for one patient (pt. #5).

Findings:
1. Review of the policy and procedure "Restraint Or Seclusion Use - CMS Regulations", policy number II.C.16, with a last revised date of 04/2014, indicated:
a. On page 5 under "Following Guidelines for Behavioral Restraint (Violent or self-destructive behavior) are IN ADDITION to the above MEDICAL Restraints. 1. The physician's order must be time limited and cannot exceed: age 18 and over: cannot exceed 4 hrs...".

2. Review of the medical record for patient #5 indicated that telephone orders written by the RN at 1945 hours on 4/20/14 read: "Per Dr. [named] physical hold for patient safety and staff safety X 1"

3. At 3:30 PM on 6/18/14, interview with staff member P2, the director of nursing, indicated:
a. It is unclear what the nurse meant by "X 1".
b. The telephone order written by the nurse for pt. #5 does not include a time limitation as required by facility policy.

Based on policy and procedure review, employee file review, facility staffing document review, and staff interview, the facility failed to ensure the implementation related to CPR (cardiopulmonary resuscitation) certification for 1 of 4 RN (registered nurse) files reviewed (staff member N1).

Findings:
1. Review of the policy and procedure "License Registration Certification", policy number I - B.14, with a last revised date of 7/29/09, indicated:
a. On page 2 under item 3. "Employees of Hospital", it reads: "a. Licensure, Registration and/or Certification Requirements i. All employees are responsible for and must maintain current license, registration, and or certification if required for his/her specific position...".
b. On page 2 under item 3. "Employees of Hospital", it reads in "c. Tracking of Documentation": "I. Human Resource Department tracks all licenses, registration, and required certifications...". c. On page 2 under item 3. "Employees of Hospital", it reads in item d.: "Consequences of Non-Renewal...ii..Employees who are required to have CPR or ACLS (advanced cardiac life support) as defined in their applicable job description will have a 30 day grace period upon expiration of appropriate certification to complete the required courses for renewal...iii. Employees who do not renew their license, registration, and/or certification may be placed on suspension as of midnight of the expiration date...".

2. Review of employee files indicated that RN N1 had CPR certification that expired in 04/2014.

3. Review of the Daily Schedule Sheets for 6/2/14 and 6/16/14 indicated that RN N1 was still scheduled, and working, at the facility after their CPR had expired, and after the 30 day "grace" period had expired.

4. At 2:00 PM on 6/18/14, interview with staff member P6, the human resources director, indicated:
a. RN N1 had CPR that expired in April of 2014.
b. The facility policy gives a 30 day "grace" period.
c. An e-mail was sent to the previous director of nursing that alerted them to the expired CPR in April.
d. RN N1 is beyond the 30 day grace period, which ended on 5/31/14, has continued to work, and was not suspended, as per facility policy.

Based on policy and procedure review, review of the April fall log, review of the April incident report log, patient medical record review, and interview, the nursing administrator (Director of Nursing) failed to ensure the implementation of the facility policy related to the completion of incident reports for patient falls for 2 of 11 patients with falls documented in their medical records (Pts. #2 and #5).

Findings:
1. Review of the policy and procedure titled "Incident Reports", policy number III-B.11, with a last revised date of 12/2013, indicated:
a. Under "Purpose", it read: "...An Incident is defined as: any event which is not consistent with the routine operation of Doctors NeuroPsychiatric Hospital and that adversely affects or threatens to affect the well-being of the Patients, employees, medical staff, visitors, consultants, or property of, regardless of whether an actual injury is involved or not."
b. Under "Procedure", it read: "...2. An Incident Report should be completed immediately when an incident occurs by the employee who witnessed or was informed of the incident;...".

2. Review of the April 2014 "Monthly Fall Log" indicated that there was no listing for patients #2 or #5.

3. Review of the April 2014 "Doctors NeruoPsychiatric Hospital Incident Log April 2014" indicated that there was no listing, related to falls, for patients #2 or #5.

4. Review of patient medical records indicated:
a. Pt. #2 had the following documentation in the nursing notes on 4/1/14: "2130 Staff with pt, when pt slid to floor with staff...".
b. Pt. #5 had documentation in the nursing notes at 2305 hours on 4/18/14: "Bed alarm on pt. Found beside bed on [pt's] knees.". And, on 4/19/14 at 0015 hours, nursing charted: "To clarify: pt found with hands hanging onto side rails et (and) crawling out of bed with knees on floor beside bed."

5. Interview with staff member P2, the director of nursing, at 3:30 PM on 6/18/14 indicated:
a. Neither pt. #2, nor pt. #5, are listed on the fall log for April 2014, or the April 2014 incident report log (for incidents related to falls).
b. Nursing documentation for both pt. #2 and pt. #5 indicates that the patients had an event that should have triggered the initiation of an incident report for each patient, related to falls.

Based on policy and procedure review, document review, and personnel interview, nursing service failed to provide adequate numbers of licensed registered nurses and licensed practical nurses to provide nursing care to all patients as needed for 5 of 7 (5/29/14, 5/31/14, 6/1/14, and 6/2/14 both shifts) nursing staffing shifts reviewed.

Findings:

1. Policy No.: II-C.103 titled "Staffing Acuity Plan", revised/reapproved 3/14, was reviewed on 6/17/14 at approximately 1131, and indicated on pg:
A. 1, under Purpose section, "The primary purpose of this staffing plan is to support the provision of safe patient care by allocating adequate nursing staff based on patient care requirements for each shift and each unit" and under Policy section, "An acuity based staffing system is used at [this facility] to appropriately staff in compliance with federal, state, and regulatory requirements. The Director of Nursing (DON) shall ensure that a staffing plan is established, implemented, documented, and annually reviewed and revised as needed."
B. 3, point 2., "Scheduled core staffing for a predetermined average daily census shall establish a minimum number of nursing staff to ensure nursing care needs of each patient."
C. 4, point 12., "The patient's acuity level will be documented on the assignment sheet along with the nurses name assigned to the patient to include first and last names, designation and if contract labor, the name of the contracted agency."

2. Review of Nursing Staffing Pattern, Acuity, and Census for the Inpatient Unit for 5/1/14 through 6/18/14, was reviewed on 6/18/14 at approximately 1345 and facility did not meet its guidelines as follows:
A. days 5/29/14 for 17 patients staffing guideline called for 2 RNs, 1 LPN (Licensed Practical Nurse), and 3 CNAs/MHTs (Certified Nursing Assistants/Mental Health Technicians), but were lacking 1 LPN.
B. nights 5/31/14 for 18 patients staffing guideline called for 2 RNs, 1 LPN, and 2 CNAs/MHTs, but were lacking 1 RN.
C. nights 6/1/14 for 20 patients staffing guideline called for 2 RNs, 1 LPN, and 2 CNAs/MHTs, but were lacking 1 LPN.
D. nights 6/2/14 for 20 patients staffing guideline called for 2 RNs, 1 LPN, and 2 CNAs/MHTs, but were lacking 1 LPN.
E. days 6/2/14 for 20 patients staffing guideline called for 2 RNs, 1 LPN, and 3 CNAs/MHTs, but were lacking 1 LPN.
F. patient acuity level not documented on the assignment sheet along with the nurses name assigned to the patient to include first and last names, designation and if contract labor, the name of the contracted agency for: days and nights 5/20/14, 5/21/14, 5/29/14, 5/30/14; nights 5/31/14; and days and nights 6/1/14 and 6/2/14 as required by facility policy and procedure.

3. Personnel P2, Interim Chief Nursing Officer, was interviewed on 6/18/14 at approximately 0230 and confirmed staffing was inadequate for:
A. days 5/29/14 for 17 patients staffing guideline called for 2 RNs, 1 LPN (Licensed Practical Nurse), and 3 CNAs/MHTs (Certified Nursing Assistants/Mental Health Technicians), but were lacking 1 LPN. There was a patient fall on this shift.
B. nights 5/31/14 for 18 patients staffing guideline called for 2 RNs, 1 LPN, and 2 CNAs/MHTs, but were lacking 1 RN. There were 2 patient falls on this shift.
C. nights 6/1/14 for 20 patients staffing guideline called for 2 RNs, 1 LPN, and 2 CNAs/MHTs, but were lacking 1 LPN. There was a patient fall on this shift.
D. nights 6/2/14 for 20 patients staffing guideline called for 2 RNs, 1 LPN, and 2 CNAs/MHTs, but were lacking 1 LPN. There were 2 patient falls on this shift.
E. days 6/2/14 for 20 patients staffing guideline called for 2 RNs, 1 LPN, and 3 CNAs/MHTs, but were lacking 1 LPN. There were 2 patient falls on this shift.

Based on policy and procedure review, medical record review, and personnel interview, nursing staff failed to supervise and evaluate the nursing care for each patient related to lack of reconciliation of medications on discharge and lack of following physician's orders for notification for 1 of 9 (N1) closed patient medical records reviewed.

Findings:

1. Policy No.: II-C.46 titled "Medication Reconciliation (Admission and Discharge Instructions)", revised/reapproved 12/11, was reviewed on 6/18/14 at approximately 1359, indicated on pg. 3 under Discharge Reconciliation section, "At the time of discharge the MD (Medical Doctor) or RN (Registered Nurse) will review the discharge medications with the Medication Reconciliation List that was completed at the time of admission...2. Any medication that will be discontinued will be checked '(discharge) Discontinue'."

2. Review of closed patient medical records on 6/17/14 and 6/18/14 at approximately 1330 and 0917, respectively, indicated:
A. patient N1 was an 88-year-old who was admitted to the Inpatient Unit on 5/16/14 for dementia with aggression and agitation:
a. per Daily Nursing Record dated:
i. 5/21/14 at 2320 and 2345, patient seen lying face down between beds with large amount of blood under head...1" laceration on left cheekbone...Nurse placed steri-strips on laceration and covered with gauze dressing after cleaning area...Physician notified via phone, neuro checks initiated, ice to area, CT (computed tomography) scan ordered for the morning and patient to be monitored.
ii. 5/22/14 at 0120, neuro checks WNL, no complaint of pain. Dressing removed and new dressing applied. Informed nurse of bleeding who stated patient on Coumadin and will take a while to stop. Ice bag refilled and placed on area. At 0415, new dressing applied, nurse aware of bleeding. At 0650, dressing applied with small amount of blood showing through. At 0810, left cheek below eye laceration with bright red blood drainage, dressing changed, ice pack applied...CT scan pending, department called and verified with writer patient on first schedule, neuro assessment continued...no change in level of consciousness (LOC) noted.

B. per Physician's Orders dated:
a. 5/21/14 at 2335, notify NP (Nurse Practitioner) if bleeding will not stop.
b. 5/22/14 at 1210, hold Coumadin today.

C. per Patient Discharge Medications/Medication Reconciliation dated 5/22/14 at 1210, Warfarin (Coumadin) was selected to be continued.

D. per Warfarin (Coumadin) Summary Sheet, it was indicated this medication is a blood thinner and should not be used if patient has any health problems that cause bleeding.

E. per Discharge Summary dated 5/22/14,on page 2 the physical examination indicated, "does have a small superficial laceration to the left cheek which was bleeding heavily secondary to his/her anticoagulation...was transferred in stable condition with dressing intact to left face..."

3. Personnel P7, FNP (Family Nurse Practitioner), was interviewed on 6/18/14 at approximately 0935 and confirmed:
A. patient N1 had an order to hold Coumadin on 5/22/14 at 1210, but it was continued on the Patient Discharge Medications/Medication Reconciliation on discharge on 5/22/14 at 1225. Facility policy and procedure was not followed.
B. patient N1 had fallen on 5/21/14 at 2320 and sustained a laceration to left cheek which was bleeding. There was an order on 5/21/14 at 2335 to notify the NP if continued bleeding. There is no documentation this was done and nurse notes confirm bleeding and dressing changes did continue.