HospitalInspections.org

Based on record review and interview, the hospital failed to:

a. ensure that contracted services were evaluated for safety and effectiveness. (see Tag A-0084)

b. maintain separation between the acute facility and PRTF ( Psychiatric Residential Treatment Facilities) for all operational and matters pertaining to the Conditions of Participation regulations for Acute Psychiatric Hospitals ( see findings below).

This failed practice had the potential to provide services that are incongruent with CMS Condition of Participation regulations for Acute Psychiatric Hospitals.

Findings:

a. Contracted services (see Tag A-0084)

b. Under its CMS provider number, the hospital provided acute adult and adolescent psychiatric inpatient services. Also, on the campus was a residential treatment facility (PRTF), which operated under the same Governing Body as the Psychiatric Hospital.

A 2017 CMS communication stated PRTFs are never a hospital or a part of a hospital. Some are owned by hospital entities, but they are never a part of the hospital. A hospital entity may own a separately certified PRTF. A co-located PRTF must be a separate distinct entity. A PRTF co-located with a hospital, or psychiatric hospital must never behave as a unit of the hospital.

A review of operational and quality documents showed combined information for both acute inpatient and residential services and were not kept separated.

Board of Directors meeting minutes for 03/31/17 consisted of discussions that included residential and acute activities, including combined quality evaluations of waiting times, restraint events, and revenue/expenditure information.

Board of Directors meeting minutes for 01/25/17 consisted of discussions that combined restraint-seclusion statistics for the acute units and PTRF.

The hospital policy titled, "Care and treatment Nursing Staffing, Flexible Use of Nursing 08/11" included staffing matrices and rules for acute and residential units combined.

A hospital policy titled "Seclusion/Restraint Adult Acute" showed RN responsibilities included the completion of a face to face assessment within 1 hour of the initiation of restraint/seclusion. Staff I stated Registered Nurses (RN) could not perform a face to face on their assigned unit; however, this practice was not documented in the seclusion/ restraint policy.

On 05/23/17 at 9:00 am, Surveyor observed Staff I, the only RN working on the Adult Unit, being called away to conduct a face to face assessment at the residential unit at a different building on the hospital campus. The surveyor observed no RN on the unit for at least 25 minutes. The unit had 14 patients with various psychiatric and medical issues including alcohol "detox", diabetes, hallucinations, and violent outbursts.

The hospital quality report titled, "Incident Report- All Types dated from 03/14/17 to 04/29/17" listed incidents in chronological order. The location of the incidents (acute unit or PRTF) were not listed on the document.

On 05/23/17 at 11:30 am Staff A stated the document contained incidents from the acute and PRTF units combined.

The hospital document titled, "Performance Improvement 4th quarter 2016" showed combined acute and PRTF data for restraints/seclusion events and other ongoing monitors, such as: waiting times, falls, suicide attempts, self-harm incidents, staff injuries, medication occurrence report, and grievances in the acute and residential units.

The hospital quality report titled, "Suicide Attempts & Self Harm January to March 2016 & 2017" contained combined incidents from both the acute units and PRTF.

The hospital quality report titled, "Medication Errors 2016" documented the medication errors for the acute units and PRTF individually and recorded a combined total.

Based on record review, interview, and observation, the hospital failed to:

a. ensure a registered nurse was supervising patient care at all times. (see tag A-0392)

b. ensure nursing service was included in the Quality Assurance Performance Improvement (QAPI) program, and quality initiatives included evaluating the adequacy of staffing of the licensed nurses and their competency to meet needs of patients (see below findings, Tag A-0392, and see Tag A-0395).

These failed practices had the potential to negatively affected the care and safety of the acute inpatients on the adult and adolescent units.