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Based on interview and record review, the hospital failed to ensure the MCW reassessed at a minimum of once a week as per the hospital's P&P for one of 25 sampled patients (Patient 4). This failure created the potential for the delay in the discharge process and placement for the patient.

Findings:

Review of the hospital's P&P titled Clinical Social Work Assessment, Reassessment dated 1/17/21, showed in the inpatient unit, reassessment of inpatients should be documented at a minimum of once a week until the patient is discharged.

On 5/23/23 at 1140 hours, an interview and concurrent review of Patient 4's medical record was conducted with the 2E Nurse Manager.

Patient 4's medical record showed Patient 4 was admitted to the hospital on 5/26/22.

Review of the Discharge Planning-Text dated 5/9/23 at 1346 hours, showed the Admission Coordinator of Facility 1 contacted the hospital's MCW. Patient 4 was accepted by Facility 1; however, Facility 1 had no beds available. Patient 4 would be the first on their waitlist and the hospital would expect to have a bed available for the patient sometime next week. The MCW would continue to follow up. However, as of review date of 5/23/23, there was documented evidence the MCW had followed up with Facility 1 to check on the bed availability.

On 5/23/23 at 1242 hours, an interview and concurrent review of Patient 4's medical record was conducted with the MCW. The MCW was asked about the discharge planning for Patient 4 and how often the MCW followed up with Facility 1 to check on Facility 1's available bed for their patients. The MCW stated once a week. The MCW was asked about the placement of Patient 4 referring to the note the MCW wrote on 5/9/23. The MCW stated the MCW was not able to follow up because the MCW was off the previous week, and in case he was off longer, other staff should review his cases.

Based on observation, interview, and record review, the hospital failed to ensure the P&P was developed specifically for the use of bed side rails. This failure created an increased risk of using the bed side rails inappropriately for the patients.

Findings:

On 5/24/23 at 1420 hours, a tour at the 2E unit was conducted with Clinical Nursing Director 1, the 2E Nurse Manager and Assistant Hospital Administrator 1. During an observation of Rooms A, B, C, and D, Patients 8, 9, 10, and 11 were observed to have all four bed side rails up.

Review of medical records for Patients 8, 9, 10, and 11 did not show documented evidence the physician had ordered for the use of four bed side rails to be up for Patients 8, 9, 10, and 11.

When asked about the P&P for the use of the bed side rails, Clinical Nursing Director 1 stated Clinical Nursing Director 1 developed the P&P on the restraint use including the bed side rails.

On 5/25/23 at 1530 hours, an interview and concurrent record review was conducted with Assistant Nursing Director 1. Assistant Nursing Director 1 was asked to show the P&P for the use of bed side rails. Assistant Nursing Director verified there was no written policy specifically for the use of bed side rails.

Based on interview and record review, the hospital failed to ensure one RN (RN 1) had the competency for the Restraints or Seclusion to be completed every two years as per the hospital's P&P. This failure created an increased risk of using the restraints inappropriately for the patients.

Findings:

Review of the hospital's P&P titled Restraints/Seclusion dated 11/21/22, showed the purpose of the policy is to guide the appropriate use of restraints and seclusion when deemed necessary to manage patient behavior and to preserve the dignity, safety, and rights of each individual while in restraints. The staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for patient in a restraints or seclusion before performing any actions and as part of the orientation, and every two years thereafter.

On 5/30/23 at 1430 hours, an interview and concurrent record review was conducted with the HR Manager. The HR Manager was asked to show documented evidence of the restraint retraining or competency for RN 1. The HR Manager showed RN 1's most recent competency for restraints or seclusion was in 2019. The HR Manager confirmed the findings.

Based on observation, interview, and record review, the hospital's governing body failed to ensure an ongoing QAPI program to improve patient safety and patient care as evidenced by:

1. Failure to ensure the hospital's P&P related to environmental assessment for ligature risk included the frequency for conducting the Patient Safety and Ligature Risk Assessment on the Behavioral Health/Medical Surgical Unit.

2. Failure to ensure the Code Gold Mock Drills were conducted on a scheduled basis.

3. Failed to ensure the P&P was developed to address the recreational activity for the patients with legal hold who were admitted to the medical floor.

These failures created the risk of perfomrance issues not addressed by performance improvement activity.

Findings:

1. Review of the hospital's P&P titled Suicide Risk Screening, Assessment, and Prevention Plan dated 11/2/22, showed in part:

* The Suicide Risk Assessment Plan is intended to protect patients at risk for suicide in designated and non-designated areas of the hospital. The plan incorporates the following components of care: maintaining a safe patient care environment.

* Environment Assessment for Ligature Risk: Hospitals are expected to demonstrate how they identify patients at risk and steps to minimize those risks. For LPS designated areas of our hospital (name of hospital's psychiatric unit), the hospital will assess all units through the...Mental Health Environment of Care Checklist monthly. For all non-designated areas with a higher-than-normal volume of behavioral patient's (Medical Behavioral Unit, ED...), Patient Safety and Ligature Risk Checklist will be used to risk assess and implement mitigating actions to prevent patient suicides; and the risk assessment audit will be done on an ongoing basis.

On 5/30/23 at 1512 hours, an interview and concurrent review of the P&P Suicide Risk Screening, Assessment, and Prevention Plan and the hospital's document was conducted with Clinical Nursing Director 1. Clinical Nursing Director 1 stated the "Ligature" Risk Assessment was conducted on an ongoing basis as shown in the hospital's P&P. When asked, Clinical Nursing Director 1 was not able to identify the frequency for conducting the risk assessment. Clinical Nursing Director 1 stated the last "Ligature" Risk Assessment was conducted on 2/16/22.

2. Review of the hospital's P&P titled Behavior Response Team dated 8/16/21, showed in part:

* Purpose: To describe the roles and responsibilities of the Behavior Response Team (BRT) in managing severely aggressive or self-destructive patient who places self or others in imminent danger.

* The BRT is utilized to provide control of the situation and de-escalation through the use of less restrictive alternatives, in collaboration efforts among all team members.

* Code Gold Activation: Call extension 111...Request to activate Code Gold...The operator will do an overhead page and activate the BRT group pager...The operator shall call the requesting ward to verify the BRT's response.

* Training: Prior to participating in Code Gold, BRT members shall receive training and demonstrate competency in Nonviolent Crisis Intervention, Nonviolent Crisis Intervention Refresher annually, Restraint Application, Restraint and/or Seclusion Policy/Protocol, Care of Patients in Restraints and/or Seclusion, and Restraint Documentation.

* Mock Code Gold drills are conducted on a scheduled basis to evaluate competency and effectiveness of BRT members.

On 5/24/23 at 1315 hours, an interview and concurrent review of the hospital's Class Rosters titled 2E BRT Drill dated 10/13/22 at 0500 and 0900 hours was conducted with the Senior Instructor.

When asked about the schedule of BRT (Code Gold) Mock Code drills to evaluate competency and effectiveness of BRT members, the Senior Instructor stated there was no set schedule for the drills. The drills were "fit/work them in couple times a year."


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3. On 5/23/23 at 1430 hours, a tour of the 2E unit was conducted with the Clinical Nursing Director 1, the 2E Nurse Manager, and Assistant Hospital Administrator 1. During the tour, three individuals were observed in the activity room. The 2E Nurse Manager was asked who the individuals in the activity room were. The 2E Nurse Manager stated the RT was with the two patients.

On 5/23/23 at 1440 hours, an interview was conducted with the RT. The RT was asked about the therapy that the RT provided to the patients. The RT stated the behavioral patients were entitled to activities. There were two RTs assigned to 2E and each RT had their assigned patients. The activities and recreation included to educate the patients with anger management, stress management, leisure skills management, teamwork, how to work with other patients on group sessions; and provide relaxation and exercise. The patients could go to open air patio for fresh air with the nurse and the RT could do activities with the patients. The RT was asked if the recreational therapy provided was a part of the patient's treatment plan. The RT stated the recreational therapy was voluntary for whoever wanted to join the sessions and was not needed a physician's order. The RT stated the RT wrote notes after each therapy that was provided to his patients. The RT was asked if he provided activities and recreational therapy to patients with Hold orders that were admitted to the medical floors. The RT stated no. The RT was asked the reason he provided the recreational activity to the patients in the 2E unit and if there was the hospital's P&P to address the recreational activity. The RT stated it was in the Patient Rights handbook for the patients to receive activity and recreation.

On 5/23/23 at 1500 hours, an interview was conducted with Clinical Nursing Director 1 and the 2E Nurse Manager. Clinical Nursing Director 1 was asked about the recreational therapy in the 2E unit. The Clinical Nursing Director 1 stated the recreational therapy was diversional activities provided to the patients in the 2E unit only. Clinical Nursing Director 1 was asked for the posting of patient rights for the mental health patients or patients with behaviors. Clinical Nursing Director 1 showed the posting on the wall of the Patient Rights for Mental Health Patients and a copy of the handbook and stated the handbook was provided to all patients who were on "Hold" in the 2E unit and in other floor. When asked for the hospital's P&P for the activity and recreational activity, Clinical Nursing Director 1 could not show the hospital's P&P.

Based on interview and record review, the hospital failed to ensure the hospital's P&Ps were implemented as evidenced by:

1. The nursing staff did not utilize the PCC Request Form and did not place a PCC order in the EHR as per the hospital's P&P.

2. The use of the green scrub top, gown, or jacket for patients who would be at risk for elopement was not implemented as per the hospital's P&P.

These failures created the increased risk of poor health outcomes to the patients receiving services in the hospitals.

Findings:

1. Review of the hospital's P&P titled Patient Care Companion (PCC) dated 3/2021 showed in part:

* Policy: The need for a PCC is assessed every shift by a RN.

* Procedure: the primary RN will follow PCC Request Process (Addendum B) and complete the PCC Request Form (Addendum C). If the patient meetings PCC criteria, the RN will place a PCC order in the electronic health record (EHR). Once the order is placed, the RN will receive a task list reminder every shift to review the continued need for a PCC.

* Attachment C or "Care Companion Request Form": the section of "Date/Time Reviewed" was (blank)

On 5/31/23 at 1055 hours, an interview and concurrent review of the hospital's PCC P&P was conducted with ANO 1 and RN 2. ANO 1 stated the nursing staff did not utilize the PCC Request Form (Addendum C) as shown in the hospital's P&P and Addendum C which was an outdated form. RN 2 stated the nursing staff did not place a PCC order in the EHR as shown in the hospital's P&P.

2. Review of the hospital's P&P titled Elopement Policy dated 3/15/23, showed in part:

* Policy: Any patient on an involuntary psychiatric hold, not in a locked unit, will have elopement precautions implemented. The nurse initiates actions defined in this policy depending on the level of risk identified.

* Definitions: An elopement is defined as any patient who is on a voluntary psychiatric hold and who departs the healthcare facility.

* Procedure: Upon placement of an involuntary psychiatric hold outside of a fully locked psychiatric unit, the RN will initiate the following general elopement precautions:

- Place the patient in a green scrub top, gown, or jacket.

- Place a wristband on the patient with a green clip attached to signify elopement risk.

On 5/25/23 at 1605 hours, an interview was conducted with the 2E Nurse Manager. When asked about the use of the green scrub top, gown, or jacket for patients who would be at risk for elopement, the 2E Nurse Manager stated the hospital had not implemented the use of the green attire to easily identify the patients at risk for elopement.

On 5/25/23 at 1615 hours the findings were shared with the Assistant Nursing Director 1.