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Based on document review and interview, the facility failed to follow their staffing policy and/or grid for 14 of 21 days reviewed on the youth unit.

Findings include:

1. Facility policy titled, Staffing and Scheduling, PolicyStat ID 15820124, last revised 05/2024, indicated under PROCEDURE: 1. Planning. a. A plan for meeting staffing needs are developed by the CNO, based on the following: i. patient needs/acuity/census. b. Staffing guidelines are developed by nursing leadership with input from executive leadership. Guidelines serve as a reference point for planning. Staffing is adjusted each shift or more frequently based upon patient acuity, activity level, employee qualifications and census changes. 5. Staffing. A. Staffing numbers and mix for each unit will be reviewed daily and adjusted each shift according to the staffing grid. g. Additional staff coverage is considered when there is a patient on a 1:1 status or is in seclusion/restraint.

2. Facility staffing grid indicated the youth unit should be staffed with 1 nurse from the hours of 7:00 am - 7:30 pm/7:00 pm-7:30 am with a patient census of 1-15, 2 nurses from 7:00 am-7:30 pm/7:00 pm - 7:30 am with a patient census of 16-26. 1 MHT (Mental Health Tech) from 7:00 am-3:30 pm/3:00 pm -11:30 pm/11:00 pm- 7:30 am with a patient census of 1-8. 2 MHTs from 7:00 am-3:30 pm/3:00 pm -11:30 pm/11:00 pm- 7:30 am with a patient census of 9-16. 3 MHTs from 7:00 am-3:30 pm/3:00 pm -11:30 pm with a patient census of 17-26. 2 MHTs 11:00 pm- 7:30 am with a patient census of 17-26. Additional MHT(s) would be needed depending on the number of 1:1 observation patient assignments.

3. Staffing pattern worksheet for H1 was reviewed for dates 9/15/24-10/10/24 indicated the youth unit was not adequately staffed per facility staffing policy and/or grid r/t acuity and census. Dates, number of clinical staff member(s) lacked and patient census are indicated as follows:
a. 9/15/24 short 1 MHT (Mental Health Tech) from 7:00 pm - 11:00 pm with a patient census (PC) of 18. 4 MHTs were needed but only 3 MHTs were present. PC included a 1:1 observation.
b. 9/16/24 short .5 of an RN (Registered Nurse) from 11:00 pm - 3:00 am with a PC of 17. 2 RNs were needed but only 1.5 RNs were present. PC included a 1:1 observation.
c. 9/17/24 short 1 RN from 7:00 pm - 7:00 am with a PC of 17-18. 2 RNs were needed but only 1 RN was present. PC included a 1:1 observation.
d. 9/18/24 short 1 RN from 7:00 am - 7:00 pm and 7:00 pm-7:00 am with a PC of 18-19. 2 RNs were needed but only 1 RN was present. PC included a 1:1 observation.
e. 9/21/24 short 1 RN from 7:00 am - 7:00 pm and short 1 MHT from 7:00 pm-7:00 am with a PC of 19-20. 2 RNs were needed but only 1 RN was present. PC included a 1:1 observation.
f. 9/22/24 short 1 MHT (Mental Health Tech) from 7:00 pm - 3:00 pm, 3:00 pm -11:00 pm, and short 2 MHTs from 11:00 pm - 3:00 am with a PC of 20. 4 MHTs were needed but only 3 were present between 7:00 pm - 3:00 pm, 3:00 pm -11:00 pm. 4 MHTs were needed between 11:00 pm - 3:00 am. PC included a 1:1 observation.
g. 9/23/24 short 1 MHT from 7:00 am - 11:00 am, 7:00 pm -11:00 pm, and 11:00 pm - 3:00 am with a PC of 20. 4 MHTs were needed but only 3 were present. PC included a 1:1 observation.
h. 9/24/24 short 1 RN and 1 MHT from 7:00 am - 11:00 am with a PC of 20. 2 RNs were needed but only 1 RN was present. 4 MHTs were needed but only 3 were present. PC included a 1:1 observation.
g. 9/26/24 short .75 of an RN 7:00 am - 11:00 am, .75 of an RN from 3:00 pm-7:00 pm, 1 RN from 7:00 pm-7:00 am with a PC of 18-20. 2 RNs were needed but only 1 RN was present.
h. 9/27/24 short 1 RN 7:00 am - 7:00 pm and 7:00 pm- 7:00 am with a PC of 18-29. 2 RNs were needed but only 1 RN was present.
i. 9/28/24 short 1 RN 7:00 am - 7:00 pm and .5 of an MHT from 11:00 am-3:00 pm with a PC of 19. 2 RNs were needed but only 1 RN was present. 3 MHTs were needed but only 2.5 were present.
j. 9/29/24 short 1 RN 7:00 am - 7:00 pm and 7:00 pm- 7:00 am with a PC of 19. 2 RNs were needed but only 1 RN was present.
k. 9/30/24 short 1 RN 7:00 am - 3:00 pm with a PC of 19. 2 RNs were needed but only 1 RN was present.
l. 10/5/24 short 1 RN 7:00 pm - 7:00 am, short 2 MHTs from 7:00 pm-11:00 pm with a PC of 17. 2 RNs were needed but only 1 RN was present and 4 MHTs were needed but only 3 were present. PC included a 1:1 observation.

4. In telephone interview on 10/16/24 at approximately 3:45 pm with A7 (Chief Executive Officer) confirmed the youth unit of H1 did not have, but should have had, adequate staffing based on the facility matrix and grid (lacking either RN's and/or MHT's) on variable shift blocks for dates 9/15/24, 9/16/24, 9/17/24, 9/18/24, 9/21/24, 9/22/24, 9/23/24, 9/24/24, 9/26/24, 9/27/24, 9/28/24, 9/29/24, 9/30/24, and 10/5/24.

Based on document review and interview, nursing staff failed to complete emergency transfer notes for 1 of 10 medical records (MR) reviewed. (P10)

Findings include:

1. The facility policy titled, Interfacility Patient Transfer, PolicyStat ID 15820403 last approved 05/2024, indicated under PROCEDURE: 2. If an emergency situation exists, the nursing staff calls 911. The RN completes the Emergency Transfer Note prior to the transfer.

2. MR review for P10 indicated emergency transport documentation for 9/25/24 d/t (due/to) seizure activity, 9/27/24 d/t seizure activity and 9/28/24 d/t seizure activity had no been completed by nursing staff per policy. On 9/25/24 the documentation lacked a psychiatric diagnosis, notification of family for the need of transport including the name and time of notification, name of facility contacted ,time contacted, name of contacted facility employee and title, time emergency services was called and arrival time, and RN (Registered Nurse) Signature along with date and time. On 9/27/24 the documentation lacked psychiatric diagnosis, name of ambulance service with time called and time arrived, and RN (Registered Nurse) Signature along with date and time. MR lacked an Emergency Transport Note for 9/28/24.

3. In the interview on 10/10/24 at approximately 4:35 pm with A1 (Director of Risk Management) confirmed emergency transfer note documentation was not completed by facility nursing staff members for P10 on 9/25/24, 9/27/24, and 9/28/24 and should have been.