HospitalInspections.org

Based on Medical Record (MR) documentation, video recordings review, facility policy and procedure, Incident and Grievance Log, Daily Census Reports, Staffing Sheets, and interviews with staff, it was determined the facility failed to ensure:

1. Patients were free from abuse.
2. Patients were in a safe environment.
3. Patients were monitored by staff per policy.
4. The psychiatric units were staffed per policy.
5. Every 15 minute patient observations were completed by the staff and documented per policy.

Refer to tags: A 0144, A 0145

Based on review of medical records, facility policy and procedure, Risk Occurrence/Incident Reports and Grievance Log, video recordings, and interviews with staff, it was determined the hospital failed to ensure:

1. The patients were in a safe environment.

2. Patients were monitored by staff per policy.

3. Incidents and grievances were reported and investigated.

3. Every 15 minute patient observations were completed by the staff and documented per policy.

This deficient practice affected five of ten medical records reviewed including Patient Identifier (PI) # 3, PI # 8, PI # 7, PI # 9, PI # 10, and had the potential to affect all patients admitted to the psychiatric units.

Findings include:

Facility Policy: Incident Reports
Policy Number: Not Listed
Revised: 4/2023

Policy: In order to provide a safe environment for patients, employees, ... actual or potential incidents and events that could endanger the health and safety of individuals within the facility, shall be routinely monitored and investigated through to resolution.

Procedure:

A. Methods to identify situations or conditions that may cause injury, or negative outcome shall include:

1. Reporting of unexpected patient outcomes.
2. Unusual and unexpected events.

B. Reporting events and incidents shall:

1. Be investigated.
2. Have action taken as appropriate.
3. Have follow-up taken to resolution...

Facility Policy: Patient Complaint and Grievance Process
Policy Number: Not Listed
Reviewed: 4/10/23

...Procedure

...All verbal or written complaints regarding abuse, neglect, patient harm ...are to be considered a grievance that requires immediate redress. The Chief Executive Officer and/or Chief Nursing Officer will interview the patient and/or patient's representative for additional information as needed. The Chief Executive Officer and/or the Chief Nursing Officer will also query other members of the healthcare team that have been involved in the care of the patient...

All grievances receive immediate priority and must be investigated with efforts made toward resolution within 24 hours...

Facility Policy: Close Observation of Patients in Inpatient Psychiatric Services
Policy Number: C.2
Reviewed: 6/9/23

Policy: All patients admitted to Inpatient Psychiatric Services will be monitored under close observation unless the physician orders an enhanced observation frequency.

Procedure:

Close Observation:

A. Close Observation requires that the patient's assigned Mental Health Technician monitor the patient by direct visual contact every fifteen minutes, which will be documented on that patient's Observation Log by the Mental Health Technician.

B. Close observation requires that the patient's assigned Nurse monitor the patient by direct visual contact every hour, which will be documented on that patient's Hourly Rounding Log by the Nurse...

Facility Policy: One to One Observation & One to One Observation Within Arm's Reach.
Policy Number: O.1
Reviewed: 6/9/23

Policy purpose: One-to-One supervision is close observation of patients who have been identified as an imminent danger to themselves or others...

Procedure for One-to-One Observation:

One-to-One supervision requires that a patient is under constant observation by a staff member...The patient is accompanied by the staff member at all times, including bathing, showering, shaving, and toileting.

Procedure for One-to-One within Arm's Reach:

Patients...must never be more than an arm's length away from the observing staff member. The patient is accompanied by the staff member at all times, including bathing, showering, shaving, and toileting.

Documentation: Observation of the patient will be documented on the Observation Log.

Facility Policy: Developmentally Disabled Crisis Inpatients Supervision.
Policy Number: DD.1
Reviewed: 4/12/23

Policy Purpose: Provide guidelines for supervision of Developmentally Disabled patients admitted during Crisis.

Guidelines: All patients admitted to Developmentally Disabled Crisis Services will begin with One to One Observation also called 1:1 Line of Sight or LOS...

1. PI # 3 was admitted to the Gateway Adult Developmental Disabilities Unit on 1/21/24 with a primary diagnosis of Autism and was discharged to a group home on 2/14/24.

Review of the Patient Progress Notes (PPN) dated 2/10/24 at 12:20 PM revealed the nurse documented "Patient was coming down hall with staff to dining room, (he/she) got aggressive with staff and was trying to bite them. (He/She) lost (his/her) balance and fell on wall, head hit light plate cover, (he/she) sustained a 3 cm (centimeter) laceration to (area) above left eye..."

Review of the Risk Occurrence/Incident Reports and Grievance Log from November 2023 through February 2024 revealed no documentation of a report of a fall of PI # 3 on 2/10/24.

A review of the video recordings dated 2/10/24 was conducted on 2/14/24 at 4:15 PM with Employee Identifier (EI) # 3, Facilities Manager, EI # 18, Registered Nurse (RN), House Supervisor, and EI # 2, Chief Nursing Officer.

At 11:09 AM a patient identified by staff present as PI # 3 was seen on the Gateway short hallway at the entrance to the Developmental Disabilities unit. EI # 6, Mental Health Technician (MHT) approached PI # 3 from the rear to turn him/her around.

At 11:09.41 AM, EI # 6 was seen walking down the hallway with PI # 3. EI # 6 reached over to PI # 3's arm. PI # 3 pulled away from EI # 6 and backed up approximately five feet.

At 11:09.58 AM, EI # 6 stepped toward PI # 3, grabbed him/her by the arm and chest and slammed him/her against the wall, close to the light switch. EI # 6 then threw PI # 3 face down onto the floor, landing on top of him/her.

At 11:10.06 AM, EI # 6 rolled PI # 3 over onto his/her back and pressed his/her hand onto PI # 3's throat. Another employee, identified as EI # 8, MHT, was seen walking toward EI # 6 and PI # 3.

At 11:10.21 AM, EI # 6 pulled PI # 3 up by his/her arms and escorted PI # 3 down the hallway. PI # 3's gait appeared unsteady and blood was seen on the left forehead and left cheek.

In an interview conducted on 2/15/24 at 9:45 AM, EI # 18, stated EI # 6 told him/her on 2/10/24 that PI # 3 had tried to bite him/her and PI # 3 fell against the wall. EI # 18 further stated he/she had asked EI # 16, RN, to do an incident report and he/she reported to his/her supervisor, EI # 2.

In an interview conducted on 2/15/24 at 10:15 AM, EI # 16 stated the incident was reported to him/her by EI # 6, but he/she forgot to complete an incident report and did not review the video of the incident. EI # 16 further stated he/she talked with EI # 18, about the incident on 2/10/24.

In an interview conducted on 2/16/24 at 8:45 AM, EI # 6 stated PI # 3 had bitten him/her a week earlier and on 2/10/24, PI # 3 got aggressive and charged at him/her and he/she had to take PI # 3 down to de-escalate PI # 3. EI # 6 further stated he/she did not complete an incident report stating EI # 16, was supposed to complete the report.

In an interview conducted on 2/16/24 at 10:55 AM, EI # 8 stated he/she was in the day room when he/she heard a commotion and walked into the hallway. EI # 8 stated PI # 3 had hit his/her head on the wall. EI # 8 stated he/she reported the incident to EI # 16 but he/she did not complete an incident report.

In an interview conducted on 2/16/24 at 9:45 AM, EI # 1, Chief Executive Officer, confirmed an incident report was not completed and the incident had not been investigated.

2. PI # 8 was admitted to the Golden Years Geriatric Psychiatric unit on 1/19/24 with a primary diagnosis of Bipolar Disorder Manic/Delusional and discharged on 2/12/24.

Review of the PPN dated 1/28/24 at 12:08 PM revealed the nurse documented PI # 8 was aggressive with other patients and staff and scratched a MHT in the face.

Review of the PPN dated 2/7/24 at 9:42 AM revealed the nurse documented PI # 8 hit another patient on the bottom inappropriately and hit a MHT in the chin with his/her fist.

Review of the PPN dated 2/8/24 at 7:30 AM revealed the nurse documented PI # 8 was throwing items at other patients in the day room and being inappropriate.

Review of the PPN dated 2/9/24 at 9:45 AM revealed the nurse documented PI # 8 was verbally and physically aggressive with staff and other patients.

Further review of the PPN dated 2/9/24 revealed at 10:06 AM the nurse documented PI # 8 struck another patient in the arm and stomach twice.

Review of the Risk Occurrence/Incident Reports and Grievance Log from November 2023 through February 13, 2024 revealed no documentation the incidents on 1/28/24, 2/7/24, 2/8/24, or the two incidents on 2/9/24 were reported and investigated.

In an interview conducted on 2/16/24 at 11:18 AM, EI # 1 confirmed there were no incident reports completed for the above incidents and no investigations were completed. EI # 1 was asked what was done to ensure the safety of other patients, EI # 1 responded, "(PI # 8) should have been removed from the unit."

3. PI # 7 was admitted to the Gateway unit on 1/31/24 with a primary diagnosis of Schizoaffective Disorder, Bipolar Type and was discharged on 2/13/24 at 4:20 PM.

Review of the Observation Log dated 2/13/24 revealed the staff documented every 15 minute observation checks from 4:30 PM through 11:45 PM. PI # 7 was not in the hospital during those times.

In an interview conducted on 2/16/24 at 11:03 AM, EI # 1 confirmed the patient had been discharged and the Observation Log was not accurate.

4. PI # 9 was admitted to the facility on 11/20/23 with a diagnosis of Psychosis and discharged on 11/27/23.

Review of the physician orders dated 11/20/23 included One-to-One (line of sight) observation, suicide/homicide precautions.

Review of the Patient Progress Notes dated 11/20/23 revealed, "Ambulatory with a steady gait and Fall Risk Assessment Score: Low."

Review of the Observation Log dated 11/26/23 at 9:00 PM to 11/27/23 at 5:45 AM revealed every 15 minute checks completed by EI # 17 MHT, and documentation revealed the following: patient in bedroom, appears asleep, room door open, bathroom door open.

Review of the Patient Rounding Flowsheet - Psych completed by the RN dated 11/26/23 at 9:00 PM to 11/27/23 at 5:05 AM revealed PI # 9 was in his/her bedroom, lying quietly.

Review of the Facility Investigation of Report of Fall for PI # 9 dated 11/27/23 revealed documentation by EI # 17 that he/she heard a loud boom about 3:45 AM and he/she got up and walked into PI # 9's room and asked what caused the loud noise. PI # 9 stated it was the bathroom door. EI # 17 documented he/she then sat back down and got back up around 5:00 AM and started to get everyone up on the long and short halls. When EI # 17 made his/her way back to PI # 9's room (at 5:15 AM per video), he/she saw blood on the floor.

Further review of the Facility Investigation revealed EI # 20, CRNP (Certified Registered Nurse Practitioner) received a report from another patient that staff was rough with PI # 9 and staff threw him/her up against the wall on his/her arm in the dayroom.

Review of the PPN dated 11/27/23 at 8:10 AM by EI # 22, LPN revealed, "...I informed the patient that if anyone hurt him he could tell me. PT (patient) stated the big man on night shift picked him up and pushed him against the wall..."

Review of the Risk Occurrence/Incident Report dated 11/27/23 at 8:20 AM revealed PI # 9 was unable to move his/her right arm and it was swollen. When he/she was asked what happened, he/she did not respond.

Further review of the Observation Logs revealed no other staff was assigned to ensure the safety of PI # 9 when EI # 17 left his/her chair around 5:00 AM to get everyone up.

An interview conducted on 2/16/24 at 11:40 AM with EI # 2 confirmed no one was within line of sight of PI # 9 when EI # 17 left his/her chair around 5:00 AM on 11/27/23 and the every 15 minute checks completed by EI # 17 were not accurate.

Review of the video dated 11/26/23 to 11/27/23 of the DD hallway outside PI # 9's door was conducted with EI # 19, Registered Nurse, House Supervisor and revealed the following:

On 11/26/23 at 10:05 PM until 11/27/23 at 4:13 AM, EI # 17, identified by staff present, is observed sitting in a chair in the hallway outside the DD (Developmental Disability) double doors leading to PI # 9's room. EI # 17 has his/her feet propped up in another chair and is slumped back in a supine position (lying horizontally with the face and torso facing up). EI # 17 is not within line of sight of PI # 9 and one of the double doors to the hallway is left open.

EI # 19 confirmed at the time of the video review, that PI # 9 was not within line of sight of EI # 17 and there was no other staff positioned within line of sight of PI # 9. EI # 17 further confirmed that no safety checks were completed by staff from 11/26/23 at 10:05 PM until 11/27/23 at 5:15 AM and one of the double doors to the hallway was left open and should have remained closed.

Further review of the video revealed the following:

On 11/27/23 at 5:15 AM, EI # 17 entered PI # 9's room and exited at 5:16 AM which was one minute later.

On 11/27/23 at 5:18 AM a nurse, identified by staff present, and EI # 17 entered PI # 9's room and exited along with PI # 9, identified by staff present, at 5:22 AM which was 3 minutes later.

Review of the physician orders dated 11/27/23 revealed orders to consult the MD (Doctor of Medicine) in the ER (Emergency Room) to evaluate the patient's right arm and facial trauma, XR (X-ray) Humerus RT (Right), XR RT Elbow, CT (Computed Tomography) Head w/o (without contrast), CT facial bones w/o.

Review of the ER Consult Note dated 11/27/23 and signed by EI # 21, MD at 7:27 AM revealed, "The patient fell and lacerated the underside of (his/her) chin. There is a 1.5 cm laceration of the underside of chin..."

Review of the ER Consult Note dated 11/27/23 and signed by EI # 21 at 2:24 PM revealed, "Earlier today, I saw this patient in the emergency room for a laceration of (his/her) chin after a fall. The chin was steri-stripped to satisfaction. (He/she) was returned to the psychiatric ward where they noticed (his/her) right arm was swollen and the patient did begin to complain of pain...We x-rayed the right upper arm and found (him/her) to have a distal humerus fracture which was just above the epicondyles and was comminuted (broken into more than two pieces) and requires surgery..."

Review of the Discharge Summary dated 11/27/23 revealed, "patient had incident while in psychiatric unit. Patient no longer communicating, details are limited. It was reported that patient had a fall, patient was taken to ER where (he/she) received sutures to (his/her) chin and found to have a fractured distal humerus. Patient sent to (another hospital) for higher level of care and surgery to arm. At time of discharge, patient is quiet, poor eye contact, reports pain."

An interview conducted on 2/16/24 at 11:40 AM with EI # 2 confirmed, the facility investigation of the occurrence did not include ensuring staff had oversight of PI # 9 to ensure the patient's safety and the video of the hallway outside the double doors leading to PI # 9's room was not reviewed as part of the investigation. EI # 2 also confirmed that after the investigation was completed, no actions have been taken to ensure the safety of all patients.

5. PI # 10 was admitted to the facility on 12/10/23 with a diagnosis of Mental Illness and discharged on 2/5/24.

Review of the Physician Orders dated 12/10/23 revealed orders for every 15 minute observation and Suicide/Homicide Precautions.

Review of the Skin Condition Record completed by the nurse dated 1/4/24 (no time documented) revealed, "red color mark to right side of nose."

Review of the Observation Log dated 1/4/24 from 12:00 AM until 11:45 PM revealed every 15 minute checks were completed with activities including one to one observation. There was no documentation of an injury.

Review of the Observation Log dated 1/5/24 from 12:00 AM until 11:30 PM revealed every 15 minute checks were completed. One to one observation was documented until 7:30 PM. There was no documentation of one to one observation from 7:30 PM through 11:30 PM and there was no documentation of an injury.

Further review of the medical record revealed no physician order to discontinue one to one observation.

Review of the Patient Rounding Flowsheets - Psych completed by the nurse dated 1/4/24 and 1/5/24 revealed hourly documentation but no documentation of an injury or trauma.

Review of the Pressure Ulcer/Wound Location documentation dated 1/5/24 at 10:05 AM revealed an abrasion noted to the right side of patient's nose.

Further review of the medical record revealed no documentation of how the redness occurred.

Review of the Physician Orders dated 1/5/24 at 10:27 AM revealed CT of Head w/o and CT of Facial Bones w/o. Reason for test: trauma.

Review of the Risk Occurrence/Incident Reports and Grievance Log dated 11/29/23 to 2/2/24 revealed no documentation an occurrence report was completed for PI # 10. There was no documentation the injury documented on 1/5/24 to PI # 10 was investigated.

An interview was conducted on 2/16/24 at 11:40 AM with EI # 2 who confirmed there was no physician order to discontinue one to one observation and suicide/homicide precautions including one to one, line of sight observation. EI # 2 further confirmed there was no documentation of how the injury occurred, no occurrence report completed and no investigation of the trauma received by PI # 10.

6. A tour of the Gateway unit was conducted on 2/13/23 at 5:00 AM with EI # 10, RN. There were 25 current patients on the unit with two RNs, one LPN (Licensed Practical Nurse), and two MHTs. Three of the patients were on line-of-site One-to-One observation.

Review of the eight Patient Rounding Flowsheets dated 2/13/24 at 5:15 AM completed by EI # 23, LPN, revealed documentation on each of the eight patients every hour through 5:15 AM. Review of the Observation Log of a patient on One-to-One observation on a separate locked hall revealed EI # 23 documented every 15 minute checks through 5:15 AM. There were no other staff initials on the observation log to indicate the One-to-One observation was being completed while EI # 23 was away from the hall.

Review of the Observation Logs dated 2/13/24 at 5:15 AM and completed by EI # 12, MHT, revealed every 15 minute checks had been completed and initialed through 7:15 AM on 12 patients, which was two hours in advance.

Review of the Observation Logs dated 2/13/24 at 5:15 AM and completed by EI # 13, MHT, revealed EI # 13 documented every 15 minute checks on six patients through 7:15 AM, which was two hours in advance.

Review of the Observation Log of a One-to-One observation patient on a separate locked hall revealed EI # 13 documented every 15 minutes through 7:15 AM, which was two hours in advance. There were no other staff initials on the observation logs to indicate the One-to-One observations were being completed while EI # 13 was away from the hall.

Review of the Rounding Sheets dated 2/13/24 at 5:15 AM and completed by EI # 11, RN, revealed EI # 11 documented every one hour checks on seven patients. Review of the Observation Log revealed EI # 11 also documented every 15 minutes on a One-to-One observation patient on a separate locked hall through 7:15 AM, which was two hours in advance. There were no other staff initials on the logs to indicate the observations were being completed by another staff member while EI # 11 was away from the hall.

In an interview conducted during the tour of the unit on 2/13/24 at 6:18 AM, EI # 10 confirmed the Observation Logs and Rounding Sheets had not been completed accurately. EI # 10 further stated unit was short staffed on MHTs and the unit would normally have four MHTs on the shift.

In an interview conducted on 2/16/24 at 11:03 AM, EI # 1 confirmed the Observation Logs and Rounding Sheets were not accurate and pre documenting observations prior to the actual observation, was not per facility policy.



42144

Based on Medical Record (MR) documentation, video recordings review, facility policy and procedure, Incident and Grievance Log, Daily Census Reports, Staffing Sheets, and interviews with staff, it was determined the facility failed to ensure the patients were free from abuse by staff.

This deficient practice affect one of ten MR reviewed including Patient Identifier (PI) # 3, and had the potential to affect all patients admitted to this facility.

Findings include:

Facility Policy: Abuse and Neglect of Patients
Policy Number: A.1
Reviewed: 2/12/23

Policy: This policy establishes standards for addressing findings of client abuse, neglect, mistreatment...report all suspected incidents of abuse and neglect as soon as possible...

Standards: It is the responsibility of all Bullock County Hospital employees to treat all clients with dignity and respect, .... and to provide all clients with protection from abuse,...

Facility Policy: Patient Rights: Inpatient Psychiatric Services
Policy Number: P.5
Reviewed: 4/12/23

Policy: Inpatient Psychiatric Services will follow the established Patient Rights Policy implemented and followed by the hospital with the addition of psychiatric specific rights required by the State of Alabama...

Facility Policy: Incident Reports
Policy Number: None Listed
Revised: 4/2023

Policy: In order to provide a safe environment for patients, employees, ... actual or potential incidents and events that could endanger the health and safety of individuals within the facility, shall be routinely monitored and investigated through to resolution.

Procedure:

A. Methods to identify situations or conditions that may cause injury, or negative outcome shall include:

1. Reporting of unexpected patient outcomes.
2. Unusual and unexpected events.

B. Reporting events and incidents shall:

1. Be investigated.
2. Have action taken as appropriate.
3. Have follow-up taken to resolution...

Facility Policy: Patient Complaint and Grievance Process
Policy Number: Not Listed
Reviewed: 4/10/23

...Procedure

...All verbal or written complaints regarding abuse, neglect, patient harm ...are to be considered a grievance that requires immediate redress. The Chief Executive Officer and/or Chief Nursing Officer will interview the patient and/or patient's representative for additional information as needed. The Chief Executive Officer and/or the Chief Nursing Officer will also query other members of the healthcare team that have been involved in the care of the patient...

All grievances receive immediate priority and must be investigated with efforts made toward resolution within 24 hours...

1. PI # 3 was admitted to the Gateway Adult Developmental Disabilities Unit on 1/21/24 with a primary diagnosis of Autism and was discharged to a group home on 2/14/24.

Review of the Patient Progress Notes (PPN) dated 2/10/24 at 12:20 PM the nurse documented "Patient was coming down hall with staff to dining room, (he/she) got aggressive with staff and was trying to bite them. (He/She) lost (his/her) balance and fell on wall, head hit light plate cover, (he/she) sustained a 3 cm (centimeter) laceration to (area) above left eye..."

Review of the Risk Occurrence/Incident Reports and Grievance Log from November 2023 through February 2024 revealed no documentation of a report of a fall of PI # 3 on 2/10/24.

A review of the video recordings from 2/10/24 was conducted on 2/14/24 at 4:15 PM with Employee Identifier (EI) # 3, Facilities Manager, EI # 18, Registered Nurse (RN), and EI # 2, Chief Nursing Officer.

At 11:09 AM a patient identified by staff as PI # 3 was seen on the Gateway short hallway at the entrance to the Developmental Disabilities unit. EI # 6, Mental Health Technician (MHT) approached PI # 3 from the rear to turn him/her around.

At 11:09.41 AM, EI # 6 walked down the hallway with PI # 3. EI # 6 reached over to PI # 3's arm. PI # 3 pulled away from EI # 6 and backed up approximately five feet.

At 11:09.58 AM, EI # 6 stepped toward PI # 3, grabbed him by the arm and chest and slammed him against the wall, close to the light switch. EI # 6 then threw PI # 3 face down onto the floor, landing on top of him/her.

At 11:10.06 AM, EI # 6 rolled PI # 3 over onto his/her back and pressed his/her hand onto PI # 3's throat. Another employee, identified as EI # 8, MHT, walked toward EI # 6 and PI # 3.

At 11:10.21 AM, EI # 6 pulled PI # 3 up by his/her arms and escorted PI # 3 down the hallway. PI # 3's gait appeared unsteady and blood was seen on the left forehead and left cheek.

Review of the Emergency Department Consult Note dated 2/10/24 revealed the physician documented PI # 3 had a two centimeter laceration to the left eyebrow without active bleeding. A staple was placed and covered with a dressing. There was no documentation x-rays were performed.

In an interview conducted on 2/15/24 at 9:45 AM, EI # 18, RN, House Supervisor, stated EI # 6 told him/her on 2/10/24 that PI # 3 had tried to bite him/her and PI # 3 fell against the wall. EI # 18 further stated he/she had asked EI # 16, RN, to do an incident report and he/she reported to his/her supervisor, EI # 2.

In an interview conducted on 2/15/24 at 10:15 AM, EI # 16 stated the incident was reported to him/her by EI # 6, but he/she forgot to complete an incident report and did not review the video of the incident. EI # 16 further stated he/she talked with EI # 18, about the incident on 2/10/24.

In an interview conducted on 2/16/24 at 8:45 AM, EI # 6 stated PI # 3 had bitten him/her a week earlier and on 2/10/24, PI # 3 got aggressive and charged at him/her and he/she had to take him/her down to de-escalate PI # 3. EI # 6 further stated he/she did not complete an incident report stating EI # 16, RN, was supposed to complete the report.

In an interview conducted on 2/16/24 at 10:55 AM, EI # 8 stated he/she was in the day room when he/she heard a commotion and walked into the hallway. He/She stated PI # 3 had hit his/her head on the wall. EI # 8 stated he/she reported the incident to EI # 16 but he/she did not complete an incident report.

In an interview conducted on 2/16/24 at 9:45 AM, EI # 1, Chief Executive Officer confirmed an incident report was not completed and the incident had not been investigated.

Based on review of Census Reports and Staffing Sheets dated 1/1/24 through 2/13/24, the BCH (Bullock County Hospital) Psych (Psychiatric) Unit Staffing Grid policy, and interviews with staff, it was determined the facility failed to ensure the psychiatric units were staffed per policy.

This had the potential to affect all patients admitted to the facility.

Findings include:

Facility Policy: Staffing
Policy Number S.7
Reviewed: 4/12/23

Policy: The purpose of the staffing pattern is to maximize staff based upon patient requirements and priorities for care that are matched with knowledge and skills of the nursing staff.

Procedure: Bullock County Hospital (BCH) will ensure that there are sufficient numbers, types and qualifications of supervisory and staff nursing personnel to respond to the appropriate nursing needs and care of the patient population...

BCH Psych Unit Staffing Grid...

( 7 AM - 7 PM shift

...Census 1 to 4...2 total (staff)
...Census 5 to 6...3 total (staff)
...Census 7 to 8...4 total (staff)
...Census 9 to 13...5 total (staff)
...Census 14 to 16...6 total (staff)
...Census 17 to 20...7 total (staff)
...Census 21 to 24...8 total (staff)...

7 PM - 7 AM shift

...Census 1 to 4...2 total (staff)
...Census 5 to 8...3 total (staff)
...Census 9 to 12...4 total (staff)
...Census 13 ...5 total (staff)
...Census 14 to16...6 total (staff)
...Census 17 to 20...7 total (staff)
...Census 21 to 24...9 total (staff)...

1. On 1/10/24, the Gateway unit had 21 patients and was staffed with three Registered Nurses (RNs), one Licensed Practical Nurse (LPN), and three Mental Health Technicians (MHTs) on the night shift, which was one less than the Staffing Grid.

2. On 1/12/24, the Golden Years unit had five patients and was staffed with one RN and one MHT on the night shift, which was one less than the Staffing Grid.

3. On 1/13/24, the Golden Years unit had five patients and was staffed with one RN, one LPN, and two MHTs on the day shift, which was one less than the Staffing Grid.

4. On 1/14/24, the Golden Years unit had five patients and was staffed with one RN and one MHT on the night shift, which was one less than the Staffing Grid.

5. On 1/15/24, the Gateway unit had 22 patients and was staffed with two RNs, one LPN, and four MHTs on the day shift, which was one less than the Staffing Grid. The night shift was staffed with three RNs, one LPN, and three MHTs, which was one less than the Staffing Grid.

6. On 1/16/24, The Gateway unit had 22 patients and was staffed with two RNs, one LPN, and four MHTs on the day shift, which was one less than the Staffing Grid. The night shift was staffed with three RNs and three MHTs, which was two less than the Staffing Grid. The Golden Years unit had eight patients and was staffed with two RNs and one MHT on the day shift, which was one less that the Staffing Grid. The night shift was staffed with two RNs and one MHT, which was one less than the Staffing Grid.

7. On 1/18/24, the Golden Years unit had nine patients and was staffed with one RN, one LPN, and two MHTs on the day shift, which was one less than the Staffing Grid. The night shift was staffed with one RN and one MHT, which was two less than the Staffing Grid.

8. On 1/20/24, The Golden Years unit had nine patients and was staffed with two RNs and two MHTs on the day shift, which was one less than the Staffing Grid.

9. On 1/21/24, the Gateway unit had 22 patients and was staffed with three RNs, one LPN, and three MHTs on the night shift, which was one less than the Staffing Grid. The Golden Years unit had nine patients and was staffed with two RNs and two MHTs on the day shift, which was one less than the Staffing Grid.

10. On 1/22/24, the Gateway unit had 21 patients and was staffed with one RN, two LPNs, and four MHTs on the night shift, which was one less than the Staffing Grid.

11. On 1/31/24, the Gateway unit had 23 patients and was staffed with one RN, two LPNs, and four MHTs on the night shift, which was one less than the Staffing Grid.

12. On 2/1/24, the Gateway unit had 22 patients and was staffed with two RNs, two LPNs, and three MHTs on the night shift, which was one less than the Staffing Grid.

13. On 2/2/24, the Golden Years unit had nine patients and was staffed with one RN and one MHT on the day shift, which was three less than the Staffing Grid.

14. On 2/4/24, the Gateway unit had 24 patients and was staffed with three RNs and three MHTs on the night shift, which was two less than the Staffing Grid. The Golden Years unit had nine patients and was staffed with one RN and two MHTs on the day shift, which was two less than the Staffing Grid.

15. On 2/5/24, the Gateway unit had 23 patients and was staffed with one RN, two LPNs, and four MHTs on the night shift, which was one less than the Staffing Grid.

16. On 2/6/24, the Gateway unit had 24 patients and was staffed with one RN, two LPNs, and four MHTs on the night shift, which was one less than the Staffing Grid. The Golden Years unit had nine patients and was staffed with one RN, one LPN, and one MHT on the day shift, which was one less than the Staffing Grid.

17. On 2/7/24, the Gateway unit had 25 patients and was staffed with two RNs, one LPN, and four MHTs on the day shift, which was one less than the Staffing Grid. The night shift was staffed with three RNs and three MHTs, which was two less than the Staffing Grid. The Golden Years unit had 10 patients and was staffed with two RNs and one MHT on the day shift, which was two less than the Staffing Grid. The night shift was staffed with two RNs and two MHTs, which was one less than the Staffing Grid.

18. On 2/8/24, the Gateway unit had 23 patients and was staffed with three RNs and three MHTs on the night shift, which was two less than the Staffing Grid. The Golden Years unit had 10 patients and was staffed with two RNs and two MHTs on the day shift, which was one less than the Staffing Grid.

19. On 2/9/24, the Gateway unit had 25 patients and was staffed with three RNs and four MHTs on the night shift, which was one less than the Staffing Grid. The Golden Years unit had 10 patients and was staffed with one RN, one LPN, and two MHTs on the day shift, which was one less than the Staffing Grid. The night shift was staffed with one RN, one LPN, and two MHTs, which was one less than the Staffing Grid.

20. On 2/10/24, the Gateway unit had 25 patients and was staffed with one RN, one LPN, and four MHTs on the night shift, which was two less than the Staffing Grid. The Golden Years unit had 10 patients and was staffed with one RN and two MHTs on the night shift, which was two less than the Staffing Grid.

21. On 2/11/24, the Gateway unit had 25 patients and was staffed with three LPNs and four MHTs on the night shift, which was one less than the Staffing Grid. The Golden Years unit had 10 patients and was staffed with one RN, one LPN, and two MHTs on the night shift, which was one less than the Staffing Grid.

22. On 2/12/24, the Gateway unit had 25 patients and was staffed with two RNs, one LPN, and four MHTs on the day shift, which was one less than the Staffing Grid. The night shift was staffed with two RNs, one LPN, and three MHTs, which was two less than the Staffing Grid. The Golden Years unit had 10 patients and was staffed with two RNs and one MHT on the day shift, which was two less than the Staffing Grid.

23. On 2/13/24, the Gateway unit had 23 patients and was staffed with two RNs, one LPN and four MHTs on the day shift, which was one less than the Staffing Grid. The night shift was staffed with three RNs and three MHTs, which was two less than the Staffing Grid. The Golden Years unit had 10 patients and was staffed with two RNs and one MHT on the day shift, which was two less than the Staffing Grid. The night shift was staffed with two RNs and two MHTs, which was one less than the Staffing Grid.

In an interview conducted on 2/13/24 at 6:35 AM, EI # 11, RN, stated the unit was short staffed every night and the MHTs were assigned patients on the Gateway hall and patients on one to one observations behind double doors who they could not see.

In an interview conducted on 2/16/24 at 9:45 AM, EI # 1, Chief Executive Officer, stated the Staffing Grid was used as a guide only, the units were staffed by patient acuity and needs of the patients.

Based on medical record (MR) review and interviews with staff, it was determined the facility failed to ensure physician orders were followed for obtaining fingerstick blood sugars and administering sliding scale insulin.

This affected one of ten MRs reviewed including Patient Identifier (PI) # 1 and had the potential to affect all patients admitted to this hospital.

Findings include:

1. PI # 1 was admitted on 2/6/24 with diagnoses including Schizo Affective Disorder, Suicide Ideations, Hypertension, and Diabetes.

Review of the Physician's Orders dated 2/7/24 revealed orders for Regular Insulin Subcutaneous by sliding scale at 6:00 AM and 9:00 PM.

Review of the Medication Record from 2/6/24 to 2/12/24 revealed the nurse documented on 2/11/24 at 9:21 PM and 2/12/24 at 6:42 AM the insulin was omitted due to being out of testing strips.

Review of the Patient Progress Notes (PPN) dated 2/11/24 revealed the nurse documented the FSBS (finger stick blood sugar) was not obtained due to no blood sugar strips in the building. There was no documentation the physician was notified and no documentation the blood sugar was obtained by other means and no documentation the insulin was given.

In an interview conducted on 2/16/24 at 10:50 AM, Employee Identifier (EI) # 1, Chief Executive Officer, confirmed the blood sugars were not obtained, the insulin was not given, and the physician was not notified.