HospitalInspections.org

Based on review of facility policy and procedures, inservice records, personnel list, 12 hour incident documentation log, Interdisciplinary Team Occurrence Investigation reports, Medical Record, Quality Improvement (QI) auditing process, facility video surveillance, and interviews with staff, it was determined the Governing Body failed to ensure staff attended all required inservices, completed weekly quality audits, and provided patients a safe environment.

This deficient practice affected Patient Identifier (PI) # 1 and had the potential to affect all patients served by this facility.

Findings include:

Policy and Procedure: Seclusion and Restraint Process Violent or Self Destructive Restraint
Date Revised: 4/23/2018

Policy:

...Seclusion/ Restraint is used for emergency management intervention when a patient demonstrates a threat of harm to self or others, and when least restrictive/ non-physical interventions have proven unsuccessful. Dignity of the patient is always maintained...

Definitions:

...Restraint- any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely, that the patient cannot easily remove...

Physical Holding/ Therapeutic Holds- The use of staff's body contact with the patient in order to restrict freedom of movement or normal access to one's body. Includes physically holding the patient during forced injections.

Procedure:

Criteria for Use- Clinical justification is required from a physician and/or registered nurse. Seclusion/ Restraint is limited to emergencies which pose an imminent risk of a patient harming self/ others and nonphysical interventions were not effective. Behaviors may include but not limited to the following:

-Confusion, disorientation, or extreme restlessness to the degree that the patient is not responsible for safe decision-making and may accidentally or purposefully harm self.

-Agitation, hostility, or aggression toward others in the form of overt actions of biting, scratching, hitting, kicking, etc. (etcetera)

-Self-injurious actions.

Physician Orders- The following are necessary elements for seclusion/ restraint orders:

-Each and every seclusion/ restraint episode requires a physician's order...

- In an emergency situation, the trained registered nurse may authorize the use of seclusion/ restraint. A physician's order (written/ verbal) for seclusion restraint must be obtained immediately following, or no later than one hour following the initiation of seclusion/ restraint. The RN (Registered Nurse) consults with the physician regarding the patient's physical/ psychological condition and release criteria.

- The physician or trained RN must see and evaluate the patient face-to-face, ...within 1 hour.
- The RN must assess the patient and complete the Initial Face-to-Face for Behavioral or Seclusion Assessment by RN form within one hour of the intervention initiated...

Staff Training/ Competence-

Staff demonstrates competency via Skills Lab for the following competencies:

-Crisis Prevention
-The initiation of seclusion.
-Application of personal restraint.
-Application restraint or seclusion.
-Monitoring of patients in restraint or seclusion.
-Management of emergency medical conditions...
-Proper documentation of seclusion and restraint episodes.
-Unity Psychiatric Care maintains documentation of training of each staff member.
-Personal safety plan.
-Proper documentation of seclusion and restraint episodes...

Review of the following revealed:

1. An Occurrence Reporting In-Service was to be conducted for all clinical staff (to include Administrative Nurses, RNs [Registered Nurses], LPNs [Licensed Practical Nurses] and Social Workers) as well as Mental Health Technicians to be completed by 7/18/2019.

The surveyor requested a personnel list in effect for 7/18/19. The list of employees was compared to the list who had attended the in-services. Out of 56 employees, 32 had not attended the Occurrence Reporting In-Service.

The Administrator was to audit incident reports weekly to ensure completion within the next business day. Once audits displayed a compliance rate of 90 % or higher for a period of 30 days, the audits would be reduced to bi-monthly. The Administrator or designee would report any findings to the QA/PI (Quality Assurance/ Performance Improvement) committee and Governing Board each month to be completed by 7/18/19.

The surveyor requested the audit forms and compliance rate from Employee Identifier (EI) # 1, Administrator. EI # 1 was unable to provide the audit forms.

During an interview conducted on 8/8/19 at 4:32 PM with EI # 1, and EI # 2, Interim Director of Nursing, it was confirmed there was no documentation the Administrator audited the incident reports weekly to ensure completion.

2. A Restraint and Seclusion In-Service was to be conducted for all clinical staff
(to include Administrative Nurses, RNs, LPNs, and Social Workers) as well as Mental Health Technicians to ensure staff have a thorough understanding of Unity Psychiatric Care Restraint and Seclusion Policy to be completed by 7/18/19.

The list of employees was compared to the list who had attended the in-services. Out of 56 employees, 13 had not attended the Restraint and Seclusion Policy In-Service.

During an interview conducted on 8/8/19 at 4:32 PM with EI # 1, and EI # 2, confirmed that 13 employees had not attended the Restraint and Seclusion Policy In-Service.

3. An Interactive Restraint Training was to be conducted with all clinical staff (to include Administrative Nurses, RNs, LPNs, and Social Workers) as well as Mental Health Technicians by 7/26/19.

The list of employees was compared to the list who had attended the in-services. Out of 56 employees, 19 had not attended an Interactive Restraint Training class.

An interview conducted on 8/8/19 at 4:32 PM with EI # 1, and EI # 2, confirmed 19 employees had not attended an Interactive Restraint Training class.

4. The Interim Risk Manager was to audit the restraint log weekly to ensure that all patient holds were documented. Once audit logs displayed a compliance rate of 90 % or higher for a period of 30 days, the audits would then be conducted bi-monthly. The Administrator or designee would report any findings to the QA/PI committee and Governing Body each month beginning 7/18/19.

An interview was conducted 8/8/19 at 3:00 PM with EI # 3, RN, Interim Risk Manager. The surveyor requested the audit forms and compliance percentages. EI # 3 stated she/he was unaware of any auditing she/he was supposed to be conducting, and could not provide any audit documentation.

5. Review of PI # 1 medical record revealed the patient was admitted to the hospital on 7/18/19 with diagnoses including Dementia with Behavioral Disturbances and Familial Encephalopathy with Neuroserpine Inclusion Bodies.

Review of the 12 Hour - Incident Documentation Log revealed PI # 1 had a fall with seclusion on 7/26/19.

Review of the video surveillance for 7/26/19 with EI # 3, revealed PI # 1 fell 12 times between 9:30 PM and 10:58 PM. PI # 1 was observed running and falling in the hallways. On fall # 3, at 9:39 PM, EI # 5, LPN, and EI # 7, MHT, were observed helping the patient to his/her feet. The other 11 falls, EI # 4, RN, Charge Nurse, EI # 5, EI # 6, LPN, and EI # 7 were observed looking at the patient, but failed to assist the patient to his/her feet, nor provide safety interventions to prevent the patient from running, tripping, and falling. At 10:58 PM, PI # 1 was escorted into the seclusion room by EI # 4, EI # 5, EI # 6, and EI # 7. At 11:18 PM, PI # 1 was brought out of the seclusion room, slumped over in a wheelchair, escorted by EI # 4.

An interview was conducted on 8/8/19 at 5:00 PM with EI # 3, who verified the content of the video as stated above.

Review of the Interdisciplinary Team Occurrences Investigation report revealed EI # 4 had not followed policy for documentation of a Restraint/ Hold, Seclusion, or documented all the falls/occurrences per policy. For Systems in Place at Time of Occurrence, the report states "Yes, staff members attended a mandatory meeting on 7/25/19 or 7/26/19 in regards to restraint/ holds/ seclusion."

Review of the attendance lists revealed EI # 4, EI # 5, EI # 6, and EI # 7 had not attended the Occurrence Reporting In-Service.

Review of the attendance lists for the Restraint and Seclusion In-Service and Interactive Restraint Training revealed EI # 6 had not attended.

During an interview on 8/7/19 at 3:10 PM with EI # 11, Chief Operating Officer, it was confirmed the facility was not following the Plan of Correction, and the Governing Body was unaware.

An interview was conducted on 8/8/19 at 4:32 PM with EI # 1 and EI # 2, who confirmed the above findings.

Based on review of medical records (MR), facility Rules and Regulations of the Medical Staff, and interview, it was determined the facility failed to ensure physician orders were signed for 1 of 6 discharged records reviewed. This affected Patient Indentifer (PI) # 9 and had the potential to negatively affect all patients admitted to this facility.

Findings include:

The Rules and Regulations of the Medical Staff
Behavioral Healthcare Center at Huntsville, Inc.
Adopted by the Medical Staff and Approved by the Board
April 2, 2015

5.4 Medical Staff Orders
a. All orders for medications and/ or treatment for patients admitted to the hospital shall be in writing. Orders must be written clearly and legibly and must be complete, including the date, time and justification for the order. A verbal order shall be considered to be written if accepted by a licensed nurse and signed, dated, and timed by the Medical Staff upon next visit but no more than 30 days.

d. All orders shall be dated and timed...

1. PI # 9 was admitted to the facility on 6/17/19 with the diagnosis of Psychosis Not Otherwise Specified.

Review of the 6/17/19 physician's verbal order revealed, "CT (Computerized Tomography) of head without contrast. Diagnosis recent fall, AMS (Altered Mental Status).Telephone Order Read Back (TORB)/physician/ Licensed Practical Nurse (LPN)."

There was no documentation the physician signed the telephone verbal order for 51 days. The physician failed to follow facility Rules and Regulations of the Medical Staff.

Review of the 6/18/19 physician's order revealed, "Discontinue (D/C) 1:1 continue 15 minute checks" from Certified Registered Nurse Practitioner (CRNP) to Registered Nurse.

There was no documentation the physician signed the verbal order for 50 days and failed to follow facility Rules and Regulations of the Medical Staff.

In an interview conducted on 8/7/19 at 4:00 PM, Employee Identifier (EI) # 2 Director of Nurses, confirmed the above findings.

Based on observation, review of facility policy and procedure and interviews with staff it was determined the facility failed to implement a process for ensuring all equipment was safe for patient use and failed to maintain a log of all medical equipment available for patient use.

Findings include:

Policy: Equipment Management Program
Policy Number: None
Revised: 1-2008

Policy: BHC-H (Behavioral Healthcare - Huntsville) will provide an equipment safe environment for all patients,staff, and visitors.

Procedure: A continuing effort will be made at all organizational levels to provide an equipment safe environment....accomplished by establishing written procedures and adhering to the same in the following areas:

1. Processing and checking new equipment purchased.

2. Inspection of all medical equipment on a routine bases - some annual, some semi-annual (based on manufacturer)

5. Written records of all inspections with equipment tagged by contracted services.

All Maintenance personnel shall be properly trained in the maintenance and detection of malfunctions of all equipment...

A tour of the facility was conducted on 8/6/19 at 8:30 AM with Employee Identifier (EI) # 1, Administrator. Twenty beds had a bed alarm with a connection cord greater than 18 inches in length. The cord was wound around to make a circle and secured to the bed with a zip tie.
Each bed was electrical, with a power cord greater than 18 inches.

In the hallway outside of the Mechanical Room was a wall mounted file box labeled "Unchecked and Unclean Alarms." There were multiple bed alarms filling the file box.

An interview was conducted on 8/6/19 at 10:20 AM with EI # 18, Maintenance Director. EI # 18 was asked to describe the process for cleaning and maintaining the bed alarms. EI # 18 stated he would retrieve the alarm from the box and "check it out to see if it was working". When asked how the device was cleaned EI # 18 stated "I wipe it with an alcohol wipe". EI # 18 was asked if that was according to the manufactory recommendations and EI # 18 replied "I really don't know." When asked what happened if an alarm was not working properly and he could not fix it, EI # 18 stated "If I can't fix it I toss it." EI # 18 could not tell the surveyor how many bed and chair alarms were available in the facility. The surveyor requested the manufactory guidelines for care and use of the bed and chair alarms. None /was provided.

In the Materials Management room located across the hall, the surveyors observed:

a. multiple wheelchairs - some had stickers with patient names, some were "tagged" as clean but had visible dust, dirt and debris on them and some had pillows, clothing and other items piled on top of the equipment.

b. One (1) Invacare mechanical lift and one Journey 340 mechanical lift with no Preventative Maintenance (PM) sticker and no indication if they were clean or dirty.

c. 4 rollator walkers - all visibly dirty.

d. 2 IV (intravenous) pumps - one with PM sticker dated as inspected April 2016 and one dated June 2018

e. Garbage bags of clothing items stacked on equipment and on the floor.

The surveyor requested the facility equipment logs and maintenance records. None were provided.

An interview conducted on 8/8/19 at 10:00 with EI # 1 confirmed the above findings.

Based on review of medical records (MR), policy and procedure and interview, the facility failed to ensure therapy staff established and documented a Plan of Care that included all required elements for care. This did affect Patient Identifier (PI) # 12, 1 of 1 records reviewed with inpatient Physical Therapy services ordered. This had the potential to negatively affect all patients receiving therapy services.

Findings include:

Facility Policy: Skilled Services Provided by Rehab
Last Approved: 01/2019

Policy:
- Rehab America will ensure that specialized services such as physical therapy, speech-language and occupational therapy meet the Rehabilition and functional needs of all patients and are readily available.

- Physical Therapy Services shall be available for patients and shall be provided in agreement qualified resources...

- Occupational Therapy shall be provided by qualified contracted resources.

- Services shall be provided in accordance with accepted professional practices...

1. PI # 12 was admitted to the facility on 8/1/19 with diagnoses including Dementia with Behavioral Disturbances, Umbilical Infection, and Left Femoral Fracture s/p (status/post) Open Reduction Internal Fixation (ORIF) 7/21/19.

Review of the medical record revealed a verbal physician's order on 8/2/19 at 12:25 PM for Physical Therapy (PT) and Occupational Therapy (OT) s/p Left Hip ORIF.

Review of the MR conducted on 8/6/19 revealed no documentation a PT/ OT had evaluated PI # 12 for therapy services.

Review of the MR conducted on 8/7/19 revealed PT had completed an evaluation visit on 8/6/19 and OT still had not evaluated PI # 12. (5 days from original physician's order)

An interview on 8/7/19 at 11:00 AM with Employee Identifier (EI) # 2, Director of Nursing confirmed the therapy services were not readily available to PI # 12 as per facility policy.

Based on review of medical record (MR), The Rules and Regulations of the Medical Staff, and interview it was determined, the facility failed to ensure a complete neurological examination had been completed by the medical provider for 3 of 5 active records reviewed. This affected Patient Identifier (PI) # 12, # 2, # 5 and had the potential to negatively affect all patients admitted to this facility.

Findings include:

The Rules and Regulations of the Medical Staff
Behavioral Healthcare Center at Huntsville, Inc.
Adopted by the Medical Staff and Approved by the Board
April 2, 2015

2.8 The Psychiatric Evaluation and Mental Status examination shall in all cases by completed and dictated within 60 hours after admission...

a. The Psychiatric Evaluation should include:...

xiv. Neurological exam...

1. PI # 12 was admitted to the facility on 8/1/19 with diagnoses including Dementia with Behavioral Disturbances, Umbilical Infection, and Left Femoral Fracture s/p (status/post) Open Reduction Internal Fixation (ORIF) 7/21/19.

Review of the 8/1/19 History and Physical (H & P) by the medical physician revealed no documentation of a complete neurological (neuro) examination.

Review of the 8/2/19 medical physician progress note revealed the neuro assessment of,
"Non-focal."

Review of the 8/3/19 medical physician progress note revealed the neuro assessment of, "moves extremities well still with impaired ambulation due to recent surgery."

Review of the 8/4/19 medical physician progress note revealed the neuro assessment of,
"Non-focal."

In an interview conducted on 8/7/19 at 8:30 AM, Employee Identifier (EI) # 2, Interim Director of Nursing, confirmed the medical physician had not completed a neuro examination which could compromise accurate diagnosis, the relationship of neurological conditions to the current mental illness, and the ability to perform future comparative reexaminations to measure changes from baseline functioning.

2. PI # 2 was admitted to the facility on 8/2/19 with the diagnosis of Dementia with Behavioral Disturbances.

Review of the 8/2/19 H & P by the medical physician revealed no documentation of a neuro examination.

Review of the 8/3/19 medical progress note revealed neuro assessment as, "able to move arms and legs well, non-focal."

Review of 8/4/19 medical progress note revealed neuro assessment as, "non-focal.".

In an interview conducted on 8/7/19 at 8:30 AM, EI # 2, confirmed a complete neurological examination was not documented.

3. PI # 5 was admitted to the facility on 8/5/19 with Dementia with Behavioral Disturbances.

Review of the MR on 8/7/19 revealed there was no documentation of an H & P or a neuro examination.

In an interview conducted on 8/7/19 at 8:30 AM, EI # 2 confirmed the above findings.

Based on review of medical records (MR), facility Rules and Regulations of the Medical Staff and interview, it was determined the facility failed to ensure the psychiatrist completed an Initial Psychiatric Evaluation and Mental Status examination to determine a psychiatric diagnosis and treatment plan for 3 of 5 current records reviewed.

This affected Patient Identifier (PI) # 3, PI # 2, PI # 12, and had the potential to negatively affect all patients admitted to the facility.

Findings include:

The Rules and Regulations of the Medical Staff
Behavioral Healthcare Center at Huntsville, Inc.
Adopted by the Medical Staff and Approved by the Board
April 2, 2015

2.6 Each patient admitted to the hospital shall undergo an admitting evaluation, a mental status examination and a physical examination...

2.7 The physical examination may be performed...by a...nurse practitioner...

2.8 The Psychiatric Evaluation and Mental Status examination shall in all cases be completed and dictated within 60 hours after admission...

1. PI # 3 was admitted to facility on 8/1/19 with the referral/ admitting diagnosis of Dementia with Behavioral Disturbances, due to increased agitation, irritability, combativeness with staff, and refusal of medications.

Review of the Medical Record on 8/6/19 revealed that an Initial Psychiatric Evaluation (IPE) was signed on "7/3/19" (8/3/19 was the correct date) at 2:00 PM by Employee Identifier (EI) # 24, Nurse Practitioner (NP) and not by the Psychiatrist.

Further review of the MR revealed no documentation the attending psychiatrist had evaluated the patient to establish a psychiatric diagnosis as of 8/6/19.

An interview was conducted on 8/9/19 at 8:30 AM with Employee Indentifer (EI) # 2, Interim Director of Nursing, who confirmed the above findings.

2. PI # 2 was admitted to the facility on 8/2/19 with the referral/ admitting diagnosis of Dementia with Behavioral Disturbances.

Review of the MR on 8/6/19 revealed that an IPE was signed on 7/3/19 at 1:00 PM by EI # 24. (8/3/19 was the correct date)

Further review of the MR revealed no documentation the attending psychiatrist completed an IPE as of 8/6/19.

In an interview conducted on 8/7/19 at 10:55 AM, EI # 2, confirmed the above findings.

3. PI # 12 was admitted to the facility on 8/1/19 with the referral/admitting diagnosis of Dementia with Behavioral Disturbances.

Review of the MR on 8/6/19 revealed that an IPE was signed on 8/3/19 at 3:00 PM by EI # 24.

Further review of the MR revealed no documentation the attending psychiatrist completed an IPE as of 8/6/19.

In an interview conducted on 8/7/19 at 10:55 AM, EI # 2, confirmed the above findings.

Based on review of medical records (MR), policy and procedure and interview, it was determined the treatment team failed to:

1. Updated the treatment plan after a fall.

2. Revise the goals due to a fall.

3. Update the interventions to meet the goals in the acute care setting.

This affected 1 of 6 discharge records which included Patient Identifier (PI) # 7 and had the potential to negatively affect all patients served by this facility.

Findings include:

Administrative Policy and Procedure
Title: Treatment Plan
Revised: 3-2016

Policy: Each patient will have an individualized comprehensive treatment plan that will be based on an inventory of the patient's strengths and disabilities. The treatment team will meet no less than every 7 days to review the treatment plan.

Procedure:

1. The interdisciplinary team should consist of 2 or more of the following: MD (Medical Director), Nurse Practitioner, Activity Therapist, Social Worker, Nurse or Case Manager, and any nursing staff or mental health technicians that are available.

2. The treatment team will meet no less than every 7 days for individual patients.

3. The treatment team will review the patient's goals and progress and record their findings.

...5. The treatment plan should include:

h. Evidence of periodic review and revisions of plan.

...9. Each patient's master treatment plan is reviewed weekly by the treatment team to evaluate progress, need to continue treatment, changes in interventions ...

b. If the patient is not making progress, a revision of the problems, goals, and / or interventions will be considered.

1. PI # 7 was admitted to the facility on 6/20/19 with diagnoses including Vascular Dementia with Behavior Disturbances and Psychosis Not Elsewhere Specified.

A review of the Master Treatment Plan for PI # 7 dated 6/20/19 revealed the following:

Risk for Falls: Problem # 2
Initiated: 6/20/19
Presenting Factors: Unsteady gait, weakness, fatigue, cognitive impairment/decline
Risk Factors: Significant Degenerative Joint Disease - Lumbar Spine.

Long Term Care Goals:
...(PI # 7) will be have the following by time of discharge:
... Will have no falls resulting in injury.
Will adhere to fall safety precautions
Will maximize scope and range of activities which can be safety engaged.
Resolve feelings of fear related to falls and associated anxiety and avoidance.

Short Term Goals:
# 1 Initiated: 6/20/19 Target Date: 6/23/19 Review Dates: 6/28/19, 7/5/19, 7/12/19 and 7/19/19.

...(PI # 7) will utilize staff assistance before ambulation for 7 days due to being chairfast/Degenerative Joint Disease.

Review of the Patient Care Notes documented by the Registered Nurse (RN) on 7/4/19 at 2:30 PM revealed, "Pt (Patient) had a fall during transfer from bed to wheelchair...found patient on the floor". There was no documentation the Interdisciplinary Team updated the treatment plan, changed the goals or updated the interventions to meet the goals after a fall on PI # 7 on 7/5/19 or 7/12/19 as directed per the facility policy.

An interview was conducted on 8/8/19 at 11:50 AM with Employee Identifier # 2, Interim Director of Nursing, who verified the staff failed to update the treatment plan.

Based on observations, review of facility policy and procedure, video surveillance footage, employee envelopes, Employee List and interviews with staff it was determined the facility failed to ensure:

1. Staff was adequately and properly trained to provide care to patients in restraints or seclusion.

2. Clinical practice staff adhered to all professional codes of conduct and ethical standards by remaining alert and observant of patient activities at all times.

3. Staff provided care by observing each patient every 15 minutes and documenting that observation.

This affected Patient Identifier (PI) # 2 and had the potential to negatively affect all patients served by this facility.

Findings include:

Policy: Code of Ethics
Policy Number: None
Revised: 4/23/2018

Policy: It is the policy of Unity Psychiatric Care that all full and part time employees, contractors...are expected to perform their designated functions in a manner that reflects the highest standards of ethical behavior.

Procedure:

2. Personal/Professional Conducts

d. Staff will conduct themselves in a professional, ethical and moral manner.

5. Clinical Practice

a. Staff will adhere to all professional codes of conduct and ethical standards for his/her specified professional discipline.

7. Quality of Care

a. Unity Psychiatric Care will provide quality behavioral health care in a manner that is appropriate, determined to be necessary, efficient and effective.

1. A tour of the facility was conducted on 8/6/19 from 8:07 AM to 10:45 AM by the surveyors and Employee Identifier (EI) # 1, Administrator.

At 9:50 AM the surveyor observed 2 envelopes at the time clock with employee's name's written on the envelopes. The surveyor asked EI # 1 if he/she could open the envelopes to allow the surveyor to see what was being posted at the time clock.

A review of 1 of 2 of the above employee envelopes, including EI # 15, Mental Health Technician (MHT) revealed the following:

1. Form:
I acknowledge that I have read, understood, and received a copy of the hospital's policy on Seclusion and Restraint process.

Employee Name:
Date:

2. Restraint/Seclusion: Test

3. Restraint/Seclusion: Example (Answer Key to Test)

An interview was conducted on 8/6/19 at 9:58 AM with EI # 16, Business Office Manager and EI # 1. The surveyor asked EI # 16 how long EI # 15 had worked at the facility. EI # 16 stated, "I'm not sure, she is a prn (as needed) employee. The surveyor then asked, "Who put the envelope with EI # 15's name on it at the time clock and when? EI # 16 stated, "EI # 17, MHT/Unit Clerk put it there I think last Friday (8/2/19)". The surveyor then asked EI # 16, "When giving an employee a test, would you expect them to have a copy of the answers?" EI # 16 stated, "No".

An interview was conducted on 8/6/19 at 10:05 AM with EI # 17, who stated, "I put the test, answer key and signature form which was given to me by ... (EI # 16) for ... (EI # 15)".

The facility failed to ensure the staff was adequately and properly trained to care for patients in restraints or seclusion.

2. A tour of the facility was conducted 8/7/19 at 2:05 AM. Upon entering the facility locked door (facility leadership had provided the entry code to the surveyors) at 2:08 AM, a nurse was observed sitting at the nurses desk with eyes closed and head positioned with chin to chest. The lead surveyor took 9 steps toward the desk before the nurse, EI # 8, Registered Nurse (RN), opened his/her eyes and raised his/her head. EI # 8 identified his/herself as the Charge Nurse for the 7 PM - 7 AM shift. EI # 8 stated there were 2 RNs, 2 MHTs and 1 Licensed Practical Nurse (LPN) on duty.

The surveyor asked EI # 8, RN, and EI # 11, LPN for the location of MHT's. EI # 11 replied, "Patient (PI # 2) kept getting up and down several times making the bed alarm go off and walking around the room. I told (EI # 12, MHT) to do 1:1 observations."

The second MHT, EI # 10, was observed on 8/7/19 at 2:10 AM sitting in the patient dining room with the lights out, at a table with his/her back toward the glass windows which provided a view of the unit hallway. There were no patients in the patient dining room.

During the facility tour on 8/7/19 at 2:05 - 3:15 AM, the surveyor asked EI # 8, Charge Nurse, how long he/she had worked at the facility? EI # 8 stated "I started on June 10 th." The surveyor asked EI # 9, RN, how long he/she had worked at the facility and EI # 9 stated "I started on July 2nd." Both RNs stated they had no prior psychiatric nursing experience.

The surveyor asked EI # 8 and EI # 9 what training and orientation they received regarding the psychotropic medications the patients receive - both stated they had no training on the medications. Neither EI # 8 or EI # 9 was able to describe side effects or potential medication interactions this patient population could exhibit.

On 8/9/19 at 8:44 AM the video surveillance footage for 8/7/19 was reviewed with EI # 3, RN Risk Manager. The review revealed EI # 10 entered the dining room at 12:51 AM, exited the dining room at 1:28 and went to the staff bathroom, returned to the dining room and did not exit the dining room again until 2:13 AM, a period of 1 hour and 22 minutes. There were no patients in the patients dining room in the video surveillance footage for 8/7/19 between 12:51 AM and 2:13 AM

An interview on 8/9/19 at 9:45 AM with EI # 3 confirmed the above findings.

Based on review of the Rules and Regulations of the Medical Staff, Interim Medical Director Services Agreement, On-Call Calendar, Current Census Report and interviews it was determined the facility failed to ensure a psychiatrist was available to complete the Initial Psychiatric Evaluation, Mental Status examination, and determine a working psychiatric diagnosis to patients admitted to the facility on August 1-2, 2019.

Findings include:

The Rules and Regulations of the Medical Staff
Behavioral Healthcare Center at Huntsville, Inc.
Adopted by the Medical Staff and Approved by the Board
April 2, 2015

2.6 Each patient admitted to the hospital shall undergo an admitting evaluation, a mental status examination and a physical examination...

2.7 The physical examination may be performed...by a...nurse practitioner...

2.8 The Psychiatric Evaluation and Mental Status examination shall in all cases be completed and dictated within 60 hours after admission...

An entrance interview was conducted on 8/6/19 at 7:40 AM with Employee Identifier (EI) # 2, Interim Director of Nursing; EI # 4, Licensed Practical Nurse (LPN) Discharge Planner; and EI # 6, Registered Nurse (RN) Charge Nurse to review the purpose of the survey and provide a list of needed items. The staff identified (physician's name) as the new Medical Director (EI # 25) as of August 1, 2019 and (name) as the new Nurse Practitioner (EI # 24) as of August 1, 2019. The surveyor asked what days the MD came to see patients and the staff were unable to provide that information.

An interview with EI # 1, Administrator, on 8/6/19 at 8:30 AM revealed the facility's former Medical Director had resigned 7/31/19 and terminated the staffing contract with his/her group of physicians and nurse practitioners. EI # 1 stated the former Medical Director discharged all his/her patients during the last week of July 2019.

EI # 1 confirmed EI # 25 had not been to the facility yet but would be on-site Friday (8/9/19). EI # 1 stated the NP was seeing all the patients. The surveyor requested the MD contract, the NP Collaborative Practice Agreement and the psychiatric on-call schedule.

Review of the Current Census Report revealed two patients were admitted on August 1, 2019 and one patient was admitted on August 2. 2019.

Review of the medical records of the three patients admitted on August 1-2, 2019 revealed the psychiatrist had not performed the Initial Psychiatric Evaluation and Mental Status examination as required by the facility's Rules and Regulations of the Medical Staff.

Review of the NP collaborative practice agreement provided on 8/6/19 revealed the Medical Director signed/dated the agreement on 8/6/19. The NP had provided services at the facility on 8/3/19 and completed the Initial Psychiatric Evaluation (IPE) for 2 patients admitted on 8/1/19 and 1 patient admitted on 8/2/19.

The IPE for these 3 patients was performed by a NP who failed to have an approved Alabama Board of Nursing Collaborative Practice Agreement with the Medical Director in place at the time these services were performed.

Review of the Interim Medical Director Services Agreement dated August 1, 2019 revealed Section 1. Services to Be Provided by the Medical Director...medical direction and clinical leadership...in conformity with: (i) Hospital polices and procedures...(ii) state and federal laws and regulations...Section 2. Hours of Service: The Medical Director...shall provide at least five (5) hours per week of medical direction and services...

The facility and the Interim Medical Director failed to ensure the Alabama Board of Nursing and Board of Medical Examiners requirements for collaborative practice were followed, resulting in services provided outside the NP scope of practice.

Review of the on-call schedule for August 2019 provided by EI # 1 revealed the EI # 24, NP, listed each day and EI # 25, MD, listed as on-call August 1, 9, 13, 16, 20, 23, 27, and 30, along with the NP.

A phone interview was conducted on 8/7/19 at 9:45 AM with EI # 24. EI # 24 confirmed he/she just started with this facility and Saturday (8/3/19) was his/her first time at the facility. The NP stated he/she had completed the credentialing process and completed a packet of documents that were returned to the corporate office. When asked who the collaborating physician was he/she stated he had signed an agreement with EI # 25.

The surveyor asked EI# 24 "how often are you on call" and the response was "So far I have not been on call, Dr (name) has been taking all calls."

A phone interview was conducted with EI # 25 on 8/7/19 at 11:55 AM. EI # 25 confirmed he/she was "new with this facility" and had not been on-site until "last night" (8/6/19). When asked how often he/she would be at the facility EI # 25 stated "at least weekly on Fridays." EI # 25 was asked who was on-call for psychiatric services and he/she stated "I am on call 24/7 but they have recently got another psychiatrist."

A phone call on 8/12/19 at 12:00 PM with the Alabama Board of Nursing confirmed there was no approved collaborative practice agreement for EI # 24 and EI # 25 referenced above and there was no data in their system that an application for collaborative practice had been initiated.

Based on review of the Interim Medical Director Services Agreement and interviews it was determined the facility failed to have a qualified (Board Certified in Psychiatry and Neurology) Medical Director available for patients admitted on August 1-2, 2019.

Findings include:

An entrance interview was conducted on 8/6/19 at 7:40 AM with Employee Identifier (EI) # 2, Interim Director of Nursing; EI # 4, Licensed Practical Nurse (LPN) Discharge Planner; and EI # 6, Registered Nurse (RN) Charge Nurse. The staff identified (physician's name) as the new Medical Director (EI # 25) as of August 1, 2019 and (name) as the new Nurse Practitioner (EI # 24) as of August 1, 2019. The surveyor asked what days the Medical Director (MD) came to see patients and the staff were unable to provide that information.

An interview with EI # 1, Administrator, on 8/6/19 at 8:30 AM revealed the facility's former Medical Director had resigned 7/31/19 and terminated the staffing contract with his/her group of physicians and nurse practitioners.

EI # 1 confirmed EI # 25 had not been to the facility yet but would be on-site Friday (8/9/19). EI # 1 stated EI # 24 was seeing all the patients. The surveyor requested the MD contract and credentialing, the NP Collaborative Practice Agreement and the psychiatric on-call schedule.

Review of the Interim Medical Director Services Agreement dated August 1, 2019 revealed Section 1. Services to Be Provided by the Medical Director...medical direction and clinical leadership...in conformity with: (i) Hospital polices and procedures...(ii) state and federal laws and regulations...Section 2. Hours of Service: The Medical Director...shall provide at least five (5) hours per week of medical direction and services...

The facility failed to provide documentation the Medical Director was qualified by Board Certification in Psychiatry and Neurology when requested on 8/6/19.

The Medical Director's Board Certification was provided to the surveyor on 8/9/19.