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Based on interviews and record reviews, the hospital failed to ensure patients received care in a safe setting as evidenced by failure to provide adequate staffing levels to ensure appropriate observation and monitoring for 2 (Pt. #4 and Pt. #5) of 2 (Pt. #4 and Pt. #5) patients on a 1:1 observation status.
Findings:

Review of the policy and procedure titled, "Levels of Observation" effective 09/01/2011 and last revised on 09/25/2020 revealed, in part, the hospital recognizes that many risks may be decreased by providing an appropriate level of observation to meet the patient's individual needs. 1:1 observation is maintained when a patient is considered at high risk and requires observation by a staff member dedicated only to that patient. The staff member assigned to 1:1 cannot be assigned any other patients or tasks during that period. Close proximity is to be maintained in that the staff member must never be separated from the assigned patient by a barrier such as a closed door or window. An order may specify the proximity to be maintained (i.e. arm's length) but must then specify any exceptions to the proximity (e.g. unless using the bathroom or in bed).

Review of the policy and procedure titled, "Nursing Service" effective 09/01/2011 and last revised on 03/21/2018 revealed, in part, the hospital maintains an organized nursing service supervised by a qualified registered nurse. Inpatient units provide 24 hour nursing services. All nursing staff members (including both licensed and unlicensed) are supervised by a qualified registered nurse. Inpatient units are assigned at least one registered nurse to each unit, 24 hours a day, 7 days a week to supervise and/or furnish care and to be readily available to the patient as needed. Numbers and types of nursing staff provided will be based on the needs of the patients, the qualifications and training of the nursing staff members, and the acuity of the department or unit (which may be affected by factors involving the physical plant or the therapeutic milieu). Inpatient Units: Although a minimum core staffing matrix is provided, the number and types of nursing staff members assigned to an inpatient unit will be acuity-based as determined by collaboration between the Charge Nurse (an RN) and nursing leadership on duty and/or on call. Further review revealed with a census of 22 - 28 patients, the number of staff should be 7.

Review of the daily staffing schedule dated 12/19/2022 for the day shift, 7:00AM - 7:00PM, revealed, in part, an inpatient census of 24 and 1 inpatient admit pending. Census documentation revealed 3 of the 24 patients on a 1:1 observation status. Further review revealed, there were a total of 9 staff members. Based on review of the staffing matrix, the hospital failed to staff the unit properly with 7 staff members for a census of 22-28 patients plus an additional 3 staff members for those patients on 1:1 observation status.

Review of an incident report dated 12/19/2022 revealed, in part, Patient #5 who was on a 1:1 observation status entered Patient #4's room who was also on a 1:1 observation status.

In interview on 02/01/2023 at 10:45 a.m. S7MHT indicated while walking down the hall she observed Patient #5 entering Patient #4's room. S7MHT indicated she intervened and caught the door before it closed and removed
Patient #5 from Patient #4's room. S7MHT further indicated she observed no staff members providing 1:1 observations for Patient #4 or Patient #5.

In interview on 02/01/2023 at 11:30 a.m. S1RN reviewed the "Nursing Service" policy and procedure along with the approved staffing matrix and verified on the day shift of 12/19/2022, the unit was not staffed according to the policy and procedure.

In interview on 02/01/2023 at 11:32 a.m. S3RN reviewed the "Nursing Service" policy and procedure along with the approved staffing matrix and verified on the day shift of 12/19/2022, the unit was not staffed according to the policy and procedure.

In interview on 02/01/2023 at 11:59 a.m. S2Adm reviewed the "Nursing Service" policy and procedure along with the approved staffing matrix and verified on the day shift of 12/19/2022, the unit was not staffed according to the approved staffing grid.

Based on interviews and record review, the hospital failed to ensure a registered nurse assigned the nursing care of each patient to other nursing personnel in accordance with the patient's needs for 2 (Pt. #4 and Pt. #5) of 2 (Pt. #4 and Pt. #5) sampled patients reviewed.
Findings:

Review of the policy and procedure titled, "Levels of Observation" effective 09/01/2011 and last revised on 09/25/2020 revealed, in part, the hospital recognizes that many risks may be decreased by providing an appropriate level of observation to meet the patient's individual needs. 1:1 observation is maintained when a patient is considered at high risk and requires observation by a staff member dedicated only to that patient. The staff member assigned to 1:1 cannot be assigned any other patients or tasks during that period. Close proximity is to be maintained in that the staff member must never be separated from the assigned patient by a barrier such as a closed door or window. An order may specify the proximity to be maintained (i.e. arm's length) but must then specify any exceptions to the proximity (e.g. unless using the bathroom or in bed).

Review of the policy and procedure titled, "Nursing Service" effective 09/01/2011 and last revised on 03/21/2018 revealed, in part, the hospital maintains an organized nursing service supervised by a qualified registered nurse. Inpatient units provide 24 hour nursing services. All nursing staff members (including both licensed and unlicensed) are supervised by a qualified registered nurse. Inpatient units are assigned at least one registered nurse to each unit, 24 hours a day, 7 days a week to supervise and/or furnish care and to be readily available to the patient as needed. Numbers and types of nursing staff provided will be based on the needs of the patients, the qualifications and training of the nursing staff members, and the acuity of the department or unit (which may be affected by factors involving the physical plant or the therapeutic milieu). Inpatient Units: Although a minimum core staffing matrix is provided, the number and types of nursing staff members assigned to an inpatient unit will be acuity-based as determined by collaboration between the Charge Nurse (an RN) and nursing leadership on duty and/or on call. Inpatient Units: The RN develops a written assignment at the start of each shift. The assignment may be updated throughout the shift, as needed. The RN assigns patient care to nursing staff members based on: The individualized needs of the patient. Care provided by any nursing staff member that is not a registered nurse shall be supervised by a registered nurse. Nursing Services may be furnished by RNs, LPNs, and MHTs, and student nurses (per contractual agreement).

Review of the Registered Nurse job descriptions revealed, in part, assures that the nursing care provided remains compatible and reflects the ANA standards of psychiatric-mental health service provision. During assigned shift, is responsible for supervising LPNs, CNAs, and/or MHTs

Review of the Mental Health Tech job description revealed, in part, assists in provision of maintaining a safe and therapeutic milieu by monitoring and complying with program rules and hospital policies; Observes patients in accordance with prescriber orders and hospital policy; documents and reporting findings to supervisor immediately if behavior and/or activity is significant. Conducts and documents safety rounds per policy.

Review of the daily staffing schedule for the day shift, 7:00 a.m. - 7:00 p.m. and dated 12/19/2022 revealed, in part, 3 patients were on 1:1 levels of observation with S4MHT, S9MHT and S10MHT assigned to their care. Further review of the daily staffing schedule revealed S4MHT, S9MHT and S10MHT were assigned other tasks on the unit including observation rounds of all inpatients for 2 hour increments, trash/environment rounds, coolers clean and hydration.

In interview on 2/1/23 at 10:05 a.m., S4MHT indicated on the day shift of 12/19/2022 he was assigned to Patient #5 as a 1:1 staff member. S4MHT further indicated he was assigned to "tablet time" and other tasks on the unit for that shift.

In interview on 02/01/2023, S6RN indicated she was charge nurse on 12/19/2022. S6RN indicated staff members assigned to patients on 1:1 status also perform other duties such as observation rounds or "tablet time" on other patients and other unit tasks. S6RN indicated it has she has been employed at the hospital for 3 months and the assignments have always included all MHTs assigned to 1:1 observation also doing other tasks on the unit.

In interview on 02/01/2023 at 10:45 a.m., S7MHT indicated those staff members assigned to perform 1:1 observation on patients perform observation rounds on all patients on the unit after switching assignments with other staff members. S7MHT indicated those staff members assigned to 1:1 observations are assigned to other tasks on the unit.

In interview on 02/01/2023 at 11:30 a.m., S1RN indicated those staff performing 1:1 observations were counted as part of the total staff number in the grid. S1RN further indicated the MHTs assigned to 1:1 observations "switch out" with other staff members to perform observation rounds on all of the patients and perform other tasks on the unit. After reviewing the policy and procedure titled, "Nursing Service", S1RN verified the unit was short 1 staff member.

In interview on 02/01/2023 at 11:59 a.m., S2Adm indicated staff assigned 1:1 observation should have no other assigned responsibilities on the unit. After reviewing the 12/19/2022 daily staffing sheet, S2Adm verified staff assigned to 1:1 were performing other tasks which was not the hospital's policy.