HospitalInspections.org

Based on record review and interview, the Hospital failed to meet the Condition of Participation for Patient Rights by:


1. Failure to ensure that all patients are provided care in a safe setting as evidenced by the Registered Nurse failing to make staff assignments in accordance with the acuity level of the patient and supervise the non-licensed personnel to ensure that the ordered observation levels are consistently maintained for all patients at all times. This staffing failure resulted in Patient #4 being left unsupervised for 1 hour and 40 minutes which resulted in the hanging death of Patient #4 on 10/08/10. (see findings at A0145)
2. a) Failure of the hospital to ensure that a policy/procedure was in place relating to the process to follow when employees are named or involved in situations of alleged and/or actual abuse/neglect. The failure to develop and implement policies in this area resulted in the hospital's inability to provide documented evidence of action taken by Administration that included at a minimum additional training to a mental health technician (S27) who was found to have failed to supervise 3 adolescent male patients (ordered to be on a continuous visual observation level) in May of 2010. This same mental health technician reported that he falsified the documentation in the medical record of Patient #4 indicating that he had conducted every 15 minute visual observations on the patient just prior to her (Patient #4) being found hanging from a bathroom door in her room on 10/08/10 when in fact he (S27) did not perform the every 15 minute visual observations. b) Failure of the hospital to ensure that S26 MHT, who was observed by a LPN pinching Patient #1 on the right shoulder muscle on 4/10/10 bringing him to the ground, had no documented evidence of disciplinary action. (see findings at A0145)

Based on record review and interview, the hospital failed to ensure adolescent psychiatric patients received care in a safe setting as evidenced by: 1.Failure of the hospital to ensure adequate staff are on duty to meet the care needs of every patient as evidenced by a male MHT being responsible for orders relating to every 15 minute visual observations on an adolescent female patient, who was in her room where a male MHT is not allowed. 2. Failure of the hospital to ensure that a policy/procedure was in place relating to the process to follow when employees are named or involved in situations of alleged and/or actual abuse/neglect. and 3. Failure of the hospital to ensure a RN was assigned, and immediately available, to each patient care unit at all times. Findings:
1. Failure of the hospital to ensure adequate staff are on duty to meet the care needs of every patient as evidenced by a male MHT being responsible for orders relating to every 15 minute visual observations on an adolescent female patient, who was in her room where a male MHT is not allowed. The every 15 minute visual observations were not conducted as ordered by the physician which resulted in the patient (Patient #4) not being checked by the MHT for approximately 1 hour and 40 minutes during which time the patient (Patient #4) hanged herself. Findings:
Patient #4: Review of the medical record revealed that Patient #4 was admitted to Crossroads Regional Hospital (CRH) on 09/24/10 at 3:45 p.m. Review of the admission orders revealed S30MD was the attending physician and gave a provisional admitting diagnosis of depression. Further review of the admission orders revealed S30 MD ordered for Patient #4 to be assigned a "Status B" (Constant Visual Observation, Unit Restriction) observation level. Review of the Psychiatric Evaluation dated 09/25/10 revealed that Patient #4 had poor insight, poor judgement, and poor impulse control. Further review of the Psychiatric Evaluation revealed that Patient #4's Axis I "Provisional Diagnosis" was "Mood Disorder NOS (not otherwise specified)", "Impulse Control Disorder NOS", "Conduct Disorder Adolescent Onset" and "History of Polysubstance Abuse (in forced remission)". The justification for inpatient hospitalization included "Potential danger to self as evidenced by her self-injurious behavior". Review of the record revealed orders dated 10/01/10 at 9:45 a.m. to place Patient #4 on a Status C observation level which is visual observation of the patient at least every 15 minutes.

Review of the Multi-Disciplinary Progress Note for 10/08/10 at 11:00 p.m. revealed documentation by S44RN that read: "Patient noted approximately 1710 (5:10 p.m.) in bed area tied with sheet to bathroom door non-responsive, write(r) unable to remove sheet that was taut under patient's chin and under flat door handle. Other staff immediately summoned to help get patient down, 911 called, staff down hall immediately in room CPR (cardiopulmonary resuscitation) started til [sic] help arrived. Dr. (S30MD) contact approximately 1710 (5:10 p.m.) arrived 1725 (5:25 p.m.). Ambulance arrived. (S1CEO) and (S2DON) arrived later. Police (APD) (Alexandria Police Department) on unit later. Writer unable to reach OCS. OCS contacted later per (S1CEO) and arrived on unit later and notified. Patient taken out per stretcher per ambulance workers. CPR in progress. Patient still unresponsive on departure".

Review of a handwritten Physician Progress Notes with a date/time of 10/08/10 at 5:40 p.m. read: "Addendum. Called by RN earlier this afternoon with report that pt was found hanging from a door in her room. I returned to the hospital and found staff doing CPR on patient. Pt was observed with no pulse and no spontaneous breathing. Staff had already called 911 and the ambulance arrived within a minute of my being there. Paramedics continue to do CPR until pt was taken to the local hospital for continued resuscitation".

Review of a handwritten Physician Progress Notes with a date/time of 10/08/10 at 7:40 p.m. read: "Spoke by phone with Dr. (name) at (hospital "b") E.R. (emergency room) who told me that pt expired. Will ask hospital to notify OCS and family".

Review of the Tech Notes/Observation Sheet for 10/08/10 revealed that S27 (Mental Health Technician) documented the q 15 minute checks from 3:15 p.m. to 4:45 p.m. on Patient #4. The documentation read as follows: 3:15 p.m. - PD (group/Continuous Visual); 3:30 p.m. - HD (Room Awake/Continuous Visual); 3:45 p.m. - H (Room Awake); 4:00 p.m. - H (Room Awake); 4:15 p.m. - H (Room Awake); 4:30 p.m. - H (Room Awake); 4:45 p.m. - H (Room Awake). The 4:45 p.m. entry was the last entry on the Tech Notes/Observation Sheet relating to the 15 minute observations of Patient #4.

The registered nurse (S44) who worked as the Female Adolescent Unit Charge Nurse on the evening shift (3:00 p.m. to 11:00 p.m.) on 10/08/10 was interviewed on 10/11/10 at 5:30 p.m. S44 stated she came on duty on 10/08/10 at 3:00 p.m. S44 stated that she went to take patient report and that S24LPN, S29MHT and S27MHT were not in report. S44 stated that group was in session when she finished report at about 3:15 p.m. S44 stated that she was unsure if Patient #4 was in group. S44 stated that she went outside after report as all the patients were either in the dayroom or outside as were all 4 of the MHT's on duty. S44 stated she did not ensure that all patients had an MHT assigned to them and that she did not make patient care assignments on 10/08/10. S44 stated she was not aware of Patient #4's whereabouts from 3:00 p.m. until 5:10 p.m. on 10/08/10. S44 stated that she took Patient #5 to the restroom across the hall from Patient #4's room at approximately 5:05 p.m. on 10/08/10. S44 stated that upon leaving the room with Patient #5 she could see the legs of Patient #4 "hanging". S44 stated that she noticed a sheet "tight" around the neck of Patient #4 and that she (Patient #4) was "unresponsive". S44 indicated that she then went to the nurse's station calling out for someone to, "Call 911". S44 indicated that she opened the window to the Adult unit and told the RN (S4RN) to, "Call 911, I got a patient and I think she is dead". S44 stated that the shift was short staffed in MHT's. In a follow up interview on 10/13/10 at 11:15 a.m., S44 confirmed that she was the unit charge nurse and only registered nurse assigned to the adolescent girls unit on the evening shift on 10/08/10. S44 confirmed that she did not make the MHT assignments on the adolescent girls unit on the evening shift on 10/08/10. S44 reported that she did not check the assignment sheet to ensure all patients had an MHT assigned to them.

The MHT (S27) who documented on the Tech Note/Observation Sheet that he conducted the every 15 minute observations on Patient #4 from 3:15 p.m. to 4:45 p.m. on 10/08/10 was interviewed on 10/11/10 at 2:40 p.m. S27 reported that he arrived on the adolescent girls unit at approximately 2:30 p.m. on 10/08/10. S27 reviewed the assignment sheet for the 10/08/10 evening shift (3:00 a.m. through 11:00 p.m.) and indicated that three patients including Patient #4 had no MHT assigned to them based on the assignment sheet for this shift. S27 reported that he had the Tech Note/Observation Sheet for these three patients including Patient #4. S27 stated that S23MHT "handed him" the "Tech Sheets" and he did not refuse them. S27 indicated that male MHT's are not supposed to take "Tech Sheets" on adolescent girl patients because male MHT's are not allowed down the halls of the adolescent girls unit to check on the female patients. S27 indicated that he took a group of girls to the outside area of the unit at approximately 3:30 p.m. - 3:45 p.m. and did not re-enter the inside of the unit until approximately 5:00 p.m. S27 stated that Patient #4 did not attend the group session that begins at 3:00 p.m. and ends at 3:30 p.m. S27 reviewed the documentation on the Tech Notes/Observation Sheet for Patient #4. S27 confirmed that he documented that Patient #4 was in group at 3:15 p.m. under constant visual observation, was in Room Awake under constant visual observation at 3:30 p.m., and was in Room Awake at 3:45 p.m., 4:00 p.m., 4:15 p.m., 4:30 p.m., and 4:45 p.m. S27 indicated that he did not see Patient #4 from the time he went to the outside area of the unit at approximately 3:30 p.m. - 3:45 p.m. thru the time she (Patient #4) was found hanging in her room at approximately 5:10 p.m. on 10/08/10. S27 indicated that the documentation he entered on the Tech Note/Observation Sheet (from 3:30 p.m. thru 4:45 p.m.) on 10/08/10 indicating that he performed the q 15 minute visual observations on Patient #4 was false as he did not perform the q 15 minute visual observations on Patient #4 for this period of time. S27 indicated that he did not ask any of the female staff members to go and perform the q 15 minute checks on Patient #4 and was not sure if the q 15 minute visual observations were actually performed on Patient #4 for this period of time on 10/08/10. On 10/11/08 at 6:05 p.m., S27 (MHT) was re-interviewed after APD1 was informed of the reported false documentation by S27. In this interview S27 stated that he was aware that Patient #4 was in her room as early as 3:30 p.m. to 3:45 p.m. when he went outside with other patients on the unit. S27 further stated that he did not ask anyone to go check on Patient #4 for him, as he had the Tech/Observation sheet, and that he did not go down the hall to check on Patient #4 at anytime during his shift prior to the patient being found hanging in her room. S27 stated it is "common practice" for documentation to be falsified.

The Director of Nursing (DON) was interviewed on 10/13/10 at 11:12 a.m. The DON reported that the registered nurse was responsible for patient assignments to the MHT's. The DON reviewed the assignment sheet for the evening shift on the female adolescent unit and reported that the assignment sheet was not complete in that 3 patients (including Patient #4) were not assigned to a MHT. The DON reported that S27 is a male MHT and indicated that a male MHT should not have had Tech/Observation sheets on a female adolescent patient. The DON explained that unless in an emergency situation, male MHT's are not allowed to go down the hall on a female adolescent unit to check on, or to perform 15 minute observations, on female adolescent patients. The DON was unable to provide documentation to indicate that the registered nurse had assigned patient care duties to the mental health technicians based on the registered nurses assessment of the patients needs.

The hospital approved policy/procedure titled "Assessment/Treatment of Patients" was reviewed. The policy/procedure documents "It is the policy of Crossroads Regional Hospital that each patient will be monitored throughout his or her hospitalization according to an assigned observation status. The patient's status is assigned at the time of admission, re-evaluated and changed as clinically indicated. Observation of the patient by clinical staff members will be accomplished to maintain patient/employee safety in the least restrictive manner". The policy/procedure indicates that there are three status levels, Status A which is a strict One to One observation within arms reach length of the patient at all times, Status B which is constant visual observation maintaining line of sight on the patient at all times, and Status C which is visualizing the patient at least every 15 minutes.

2. a) Failure of the hospital to ensure that a policy/procedure was in place relating to the process to follow when employees are named or involved in situations of alleged and/or actual abuse/neglect. The failure to develop and implement policies in this area resulted in the hospital's inability to provide documented evidence of action taken by Administration that included at a minimum additional training to a mental health technician (S27) who was found to have failed to supervise 3 adolescent male patients (ordered to be on a continuous visual observation level) in May of 2010. This same mental health technician reported that he falsified the documentation in the medical record of Patient #4 indicating that he had conducted every 15 minute visual observations on the patient just prior to her (Patient #4) being found hanging from a bathroom door in her room on 10/08/10 when in fact he (S27) did not perform the every 15 minute visual observations. b) Failure of the hospital to ensure that S26 MHT, who was observed by a LPN pinching Patient #1 on the right shoulder muscle on 4/10/2010 bringing him to the ground, had no documented evidence of disciplinary action. Findings:

Findings documented above revealed that employee S27 (Mental Health Technician) reported that he did not perform every 15 minute observations as ordered on a patient (Patient #4) on the evening shift on 10/08/10 just prior to her being found hanging from a bathroom door in her room when documentation in the medical record indicated that he (S27) had performed these every 15 minute observations on this patient (Patient #4).
The personnel record of S27 (Mental Health Technician) was reviewed. This review revealed that S27 was previously named in an allegation of patient abuse/neglect relating to an incident on 5/24/10 involving three adolescent male patients (Patient #R11, Patient #R12, & Patient #R13). The allegations resulted in an investigation being conducted by the hospital's risk management department and the Office of Community Services. Review of the report from the Office of Community Services revealed findings of "Failure to Supervise" the three patients that S27 was assigned to supervised. The findings revealed that the three adolescent male patients were ordered to be on a continuous visual observation level at all times. The findings revealed that S27 left the acute care psychiatric unit that the three adolescent male patients were on to get linen from another acute care psychiatric unit without first arranging for another staff member to assume his (S27) assigned duties of performing the continuous visual observations on these three patients. This resulted in the three adolescent male patients who were ordered to be on a continuous visual observational level being unsupervised for a period of time at which the three patients reported that they engaged in sexual activities with each other during the time that S27 left them unsupervised. Review of the report from the hospital's internal investigation confirmed that S27 failed to supervise the three adolescent patients. Documentation in the personnel record of S27 revealed a document titled "Human Resources Department Employee Unit Restriction" that indicated that S27 was temporarily restricted from the boys unit. Documentation revealed that the staff member (S27) was restricted from the unit on 5/25/10 and remained on unit restriction "Until investigation concluded. To end at time of discharge of pts. 19507, 19515 & 19459". Documentation on this form revealed instructions indicating "This section is to be used when the restriction, if temporary, is lifted". Review of this section revealed a signature line for the Employee, the Director of Nursing, and the HR representative. This section was incomplete as there were no signatures from the employee, the Director of Nursing, or the HR representative to indicate that the unit restriction was lifted. Review of the personnel record of S27 revealed no documentation to indicate that the hospital took any disciplinary action in regards to S27's failure to supervise the three male adolescent patients other than a temporary unit restriction or to indicate that any additional education was provided to S27 relating to his failure to supervise the three adolescent male patients.
The Director of Human Resources was interviewed on 10/14/10 at 2:20 p.m. The Director of Nursing confirmed that the findings of the two investigations revealed that S27 failed to supervise the three male adolescent patients who were assigned to him on 5/24/10. The Director of Human Resources confirmed that there was no documentation to indicate that the hospital took any disciplinary action in regards to S27's failure to supervise the three male adolescent patients other than a temporary unit restriction. The Director of Human Resources also confirmed that there was no documentation to indicate that any additional education was provided to S27 relating to his failure to supervise the three adolescent male patients. When asked for all hospital policies/procedures relating to abuse/neglect, the Director of Human Resources presented a nine (9) page policy/procedure titled "Identifying and Reporting Patient Abuse and Neglect" and reported that this was the hospital's only policy/procedure relating to abuse/neglect. Review of this policy/procedure revealed documentation indicating "At no time will physical, psychological, sexual, or any other type of abuse by any employee toward a patient be tolerated and will result in termination of employment". There was no additional documentation to indicate the steps the hospital will take in regards to the employment status of staff members once an allegation of abuse/neglect has been made such as will the staff member be limited from the performance of any patient care duties pending an internal investigation or will disciplinary action occur if the employee is found to be neglectful in any of their assigned patient care duties. The Director of Human Resources confirmed that the hospital's only policy/procedure relating to abuse/neglect did not address these issues. When asked if there was a policy/procedure in place relating to the process to follow with employees named in situations involving alleged and/or actual abuse/neglect, the Director of Human Resources reported that she was not aware of any policies/procedures relating to the process to follow with employees named in situations involving alleged and/or actual abuse/neglect. The Director of Human Resources reported that the hospital should have a policy/procedure relating to this but does not. When asked how the hospital handles staff members named in situations involving alleged and/or actual abuse, the Director of Human Resources reported that decisions relating to the employment status of staff members named in situations involving alleged and/or actual abuse are made by the Chief Executive Officer. The Director of Human Resources confirmed that S27 was the same Mental Health Technician who reported that he falsified the documentation in the medical record of Patient #4 indicating that he had conducted q 15 minute visual observations on the patient just prior to her (Patient #4) being found hanging from a bathroom door in her room when in fact he (S27) did not perform the q 15 minute observations.
The Chief Executive Officer (CEO) was interviewed on 10/14/10 at 2:30 p.m. The CEO confirmed that there is no policy/procedure in place relating to the process to follow with employees named in situations involving alleged and/or actual abuse/neglect. When asked how the hospital handles staff members named in situations involving alleged and/or actual abuse, the CEO reported that she looks at each staff member on a case by case basis and then makes a determination of what to do with the staff member. The CEO confirmed that S27 was the same Mental Health Technician who reported that he falsified the documentation in the medical record of Patient #4 indicating that he had conducted the 15 minute visual observations on the patient just prior to her (Patient #4) being found hanging from a bathroom door in her room when in fact he (S27) did not perform the every 15 minute observations.
The Director of Nursing was interviewed on 10/15/10 at 9:30 a.m. The Director of Nursing reported that she had no documentation to indicate that the hospital took any disciplinary action in regards to S27's failure to supervise the three male adolescent patients other than a temporary unit restriction. The Director of Nursing also confirmed that there was no documentation to indicate that any additional education was provided to S27 relating to his failure to supervise the three adolescent male patients.
The Risk Manager was interviewed on 10/15/10 at 10:00 a.m. The Risk Manager reported that she conducted an internal investigation on the allegations of abuse/neglect relating to the incident on 5/24/10 involving S27 and the three adolescent male patients. The Risk Manager stated that she notified the Health Standards Section of the Department of Health & Hospitals of the allegation abuse/neglect and of the findings of the investigation and the actions taken by the hospital as a result of the findings that involved S27. The Risk Manager confirmed that the findings of the investigation revealed that S27 failed to supervise the three male adolescent patients who were assigned to him on 5/24/10. The Risk Manager stated that she felt the adolescent male patients engaged in some form of sexual activities (but not intercourse) during this period of time they were unsupervised by S27. The Risk Manager confirmed that there was no documentation to indicate that the hospital took any disciplinary action in regards to S27's failure to supervise the three male adolescent patients other than a temporary unit restriction. The Risk Manager also confirmed that there was no documentation to indicate that any additional education was provided to S27 relating to his failure to supervise the three adolescent male patients. When asked if there was a policy/procedure in place relating to the process to follow with employees named in situations involving alleged and/or actual abuse/neglect, the Risk Manager reported that she was not aware of any policies/procedures relating to the process to follow with employees named in situations involving alleged and/or actual abuse/neglect. The Risk Manager confirmed that S27 was the same Mental Health Technician who reported that he falsified the documentation in the medical record of Patient #4 indicating that he had conducted the 15 minute visual observations on the patient just prior to her (Patient #4) being found hanging from a bathroom door in her room when in fact he (S27) did not perform the the 15 minute observations.
b)Patient #1: Review of the medical record for Patient #1 revealed he was admitted to the hospital on 4/8/10 with diagnosis of intermittent explosive disorder, and oppositional defiant disorder. Further review of the nurses notes revealed an entry dated 4/10/10 at 11:00 p.m. indicating that the patient was heard yelling, "He broke my arm". The patient was observed lying on the floor of the seclusion room and refused to get up and return to his room. The documentation revealed the patient was propping himself up on the "affected arm, still yelling, and demanding to speak to his mother". The MD/NP was informed of the incident and an order was given for an X-Ray of the left shoulder. Further review of the documentation revealed that the patient returned to his room without further complaint of pain to the affected arm. Patient #1 was examined by S45 MD on 4/11/10 at 8:10 a.m. The documentation by S45 MD revealed that Patient #1 complained of pain with range of motion. There was no noted redness or edema. When the patient was asked to remove his shirt for an assessment he did and had no problem with range of motion. After the patient put his shirt back on he complained of pain with the slightest palpitations and had facial grimacing with limited range of motion. He had equal bilateral strength. The impression noted by S45 MD on the consultation form was a possible strain. He recommended ice, Motrin, X-Ray and no physical activity for three days. Review of radiology report on 4/11/10 at 11:10 a.m. revealed the impression to be a normal exam of the shoulder.
Review of the statement written by S46 MHT on 4/14/10 related to the incident on 4/10/10 revealed he and S48 MHT were walking down the hall when they noticed Patient #1 in his room kicking the walls, bumping his head, and jumping across the beds. S46 MHT indicated S48 MHT placed the patient in a basket hold to redirect him then released Patient #1 two minutes later from the hold. The patient claimed at that time his arm was broken.
Review of the statement written by S40 LPN on 4/14/10 related to the incident on 4/10/10 revealed she heard a young boy screening, "He broke my arm." S40 documented that she saw S46 MHT pinching Patient #1 on the right shoulder muscle bringing him to the ground. S40 documented she reported this incident to the oncoming RN and went to check on the patient and helped calm him down.
Review of the conclusion of the incident investigation by S43 Risk Management revealed there was a possibility that S46 MHT held the patient's shoulder inappropriately. The documentation revealed S48 MHT by his own admission placed his hands on the patient by grabbing the patient's arm to make him stand still, putting the patient's face to the wall and held him there forcefully, restraining the patient face down on a bed and laying his weight on the patient.
An interview was conducted with S43 Risk Management on 10/14/10 at 2:00 p.m. S43 indicated that S48 MHT was given a verbal suspension following the incident on 4/10/10 pending results of the hospital investigation. S43 further indicated S48 remained on suspension after the incident and did not return to work following the incident on 4/10/10. S43 added S48 MHT was terminated from the hospital on 5/21/10.
An interview was held with S47 RN Director of Compliance on 10/14/10 at 2:30 p.m. S47 indicated S46 MHT was still employed at the hospital at this time. S47 added that following the incident on 4/10/10, S46 MHT received no additional training on abuse or restraints nor was there any documentation that the employee had been counseled. S47 indicated S46 MHT had received training in Supportive Therapeutic Encounters for Positive Success (STEPS) on 4/9/09. S47 added that S46 should have received counseling after the incident on 4/10/10 and that he should have attended another STEPS program but added, "That did not happen".
An interview was held with S2 DON on 10/14/10 at 2:20 p.m. S2 indicated the hospital had no documentation of counseling of S46 MHT and S48 MHT after the incident of alleged abuse on 4/10/10.

3. Failure of the hospital to ensure a RN was assigned, and immediately available, to each patient care unit at all times by not having a RN on the adolescent girls unit on 10/08/10 from 12:53 p.m. until 2:35 p.m. due to the RN leaving the acute care psychiatric unit due to illness without a replacement registered nurse. This affected all 19 patients on the adolescent girls unit on 10/08/10. Findings:
In an interview on 10/13/10 at 9:15 a.m., S14 (LPN) stated that she was the LPN assigned to the adolescent girls unit on 10/08/10 for the 7:00 a.m. to 3:00 p.m. shift. S14 further stated that the RN on the unit "left at lunch because she was not feeling well". S14 indicated that no RN was assigned to the adolescent girls unit from approximately 1:00 p.m. till approximately 3:00 p.m. on 10/08/10.

Review of the Electronic Time Record for 10/08/10 revealed the RN (S41RN) who was assigned to the adolescent girls unit on 10/08/10 for the 7:00 a.m. to 3:00 p.m. shift clocked out at 12:53 p.m. This left 19 adolescent girls on the unit without an RN from 12:53 p.m. until 3:00 p.m.

In an interview on 10/13/10 at 2:00 p.m., the Chief Executive Officer and the Director of Nursing confirmed that there was no registered nurse on the female adolescent unit on 10/08/10 from 12:53 p.m. thru 2:35 p.m. as the day shift registered nurse (S41) left at 12:53 p.m. and the oncoming registered nurse clocked in at 2:35 p.m.

The hospital approved policy/procedure titled "Nursing Staffing & Patient Classification Acuity System" was reviewed. The "Policy" is documented as "It is the policy of Crossroads Regional Hospital (CRH) to ensure that patients receive quality nursing care, through the specialized skills of RNs, LPNs and Mental Health Technicians to provide a safe therapeutic environment. CRH utilizes a standard format for measuring individual patient acuity levels". The "Purpose" of the policy/procedure is documented as "CRH provides a measurement of the psychological, psychosocial, and physical needs of each patient to promote consistency and continuity in the delivery of patient care by staff on all shifts". The "Procedure" documents that a RN is assigned to each unit, each shift, and will supervise and evaluate the nursing care each patient receives.

26458


Based on record review and interview, the Hospital failed to meet the Condition of Participation for Nursing Services as evidenced by:

An Immediate Jeopardy situation was identified on 10/13/10 at 2:18 p.m. and the Chief Executive Officer and the Director of Nursing were notified of the Immediate Jeopardy situation at that time (10/13/10 at 2:18 p.m.).

The Immediate Jeopardy situation was a result of:

The hospital failed to meet the nursing care needs of the patients by: 1) failing to staff the acute care psychiatric unit in accordance with the hospital approved policy/procedure titled "Nursing Staffing & Patient Classification Acuity System" resulting in the hospital's inability to ensure the safety and supervision of patients hospitalized on the acute care psychiatric unit. The hospital failed to ensure that the nursing unit was staffed with the number of nursing personnel as indicated in their policy/procedure on multiple days including 10/08/10. This was evidenced by nursing services inability to ensure the safe supervision and delivery of care to adolescent psychiatric patients hospitalized on the acute care psychiatric unit as evidenced by the hanging death of Patient #4 on 10/08/10; 2) failing to ensure that nursing assignments were in accordance with the patient's needs as evidenced by the registered nurse allowing the mental health technician to make patient care assignments. This resulted in a male mental health technician being responsible for 15 minute visual observations on a female patient (Patient #4) who was found hanging from the bathroom door in an area of the adolescent girls unit that the male mental health technician was not allowed to go into.

The Immediate Jeopardy was lifted on 10/15/10 at 2:40 p.m. after the hospital submitted an acceptable Plan of Removal which included:

- The revision of the policy/procedure titled "Nursing Staffing and Patient Classification Acuity System" to reflect that the Charge RN on each shift will assess each patient's needs before making assignments to other nursing staff.

- The revision of the "Patient Classification/Observation Status Assignment Form" to reflect that the Charge RN will complete the Patient Classification Observation Status Assignment Form and determine the staff requirements for the oncoming shift based on 1:6 staff to patient ratio. This 1:6 staff to patient ratio does not include the registered nurse or the licensed practical nurse. Efforts to meet staffing requirements will include increasing the PRN pool of nursing personnel, administrative authorization of overtime, and utilization of agency personnel when necessary.

- The hospital's refusal to accept and admit new patients when staffing levels are not met.

- The provision of training/education to all clinical staff regarding the revised policies/procedures.

- The implementation of quality assurance indicators to evaluate both compliance with and the effectiveness of the revised policies/procedures.

The Hospital is out of compliance with the Condition of Participation for Nursing Services as evidenced by:

1. Failure of the Registered Nurse to supervise and evaluate the care provided to a patient (Patient #4) by failing to ensure that orders relating to every 15 minute visual observation levels were conducted as ordered by the physician which resulted in the patient (Patient #4) not being checked by the MHT for approximately 1 hour and 40 minutes during which time the patient (Patient #4) hanged herself. (Cross reference to findings cited at A0392 & A0397)
2. Failure of the hospital to ensure a RN was assigned, and immediately available, to each patient care unit at all times by not having a RN on the adolescent girls unit on 10/08/10 from 12:53 p.m. until 2:35 p.m. due to the RN leaving the acute care psychiatric unit due to illness without a replacement registered nurse. This affected all 19 patients on the adolescent girls unit on 10/08/10. (Cross reference to findings cited at A0392 & A0397)
3. Failure to assign a Registered Nurse on Unit B on on 10/15/10 at 10:42 a.m. while the RN assigned to the unit left the unit for 50 minutes to attend a meeting. The unit had a census of 18 adolescent patients left under the supervision of only non-licensed MHT's. (Cross reference to findings at A0392)

Based on record review, interview and observations, the hospital failed to meet the nursing care needs of the patients by 1) failure to staff the acute care psychiatric unit in accordance with the hospital approved policy/procedure titled "Nursing Staffing & Patient Classification Acuity System" resulting in the hospital's inability to ensure the safety and supervision of patients hospitalized on the acute care psychiatric unit. The hospital failed to ensure that the nursing unit was staffed with the number of nursing personnel as indicated in their policy/procedure on multiple days including 10/08/10. This was evidenced by nursing services inability to ensure the safe supervision and delivery of care to adolescent psychiatric patients hospitalized on the acute care psychiatric unit as evidenced by the hanging death of Patient #4 on 10/08/10; 2) failure of the hospital to ensure a RN was assigned to each unit of the hospital at all times by not having a RN on Unit A on 10/08/10 from 12:53 p.m. until 2:35 p.m. due to the RN leaving the hospital for illness without a replacement RN on the unit. This affected all 19 of the patients on Unit A on 10/08/10 between the hours of 12:53 p.m. until 2:35 p.m.; and 3) failure to assign a Registered Nurse to Unit B on 10/15/10 at 10:42 a.m. while the Registered Nurse assigned to the unit left the unit for 50 minutes to attend a meeting in another part of the hospital. The unit had a census of 18 adolescent patients who were left under the supervision of only non-licensed MHT's. Findings:

1. Failure to staff the acute care psychiatric unit in accordance with the hospital approved policy/procedure titled "Nursing Staffing & Patient Classification Acuity System" resulting in the hospital's inability to ensure the safety and supervision of patients hospitalized on the acute care psychiatric unit. The hospital failed to ensure that the nursing unit was staffed with the number of nursing personnel as indicated in their policy/procedure on multiple days including 10/08/10. This was evidenced by nursing services inability to ensure the safe supervision and delivery of care to adolescent psychiatric patients hospitalized on the acute care psychiatric unit as evidenced by the hanging death of Patient #4 on 10/08/10.

Patient #4: Review of the medical record revealed that Patient #4 was admitted to Crossroads Regional Hospital (CRH) on 09/24/10 at 3:45 p.m. Review of the admission orders revealed S30MD was the attending physician and gave a provisional admitting diagnosis of depression. Further review of the admission orders revealed S30 MD ordered for Patient #4 to be assigned a "Status B" (Constant Visual Observation, Unit Restriction) observation level. Review of the Psychiatric Evaluation dated 09/25/10 revealed that Patient #4 had poor insight, poor judgement, and poor impulse control. Further review of the Psychiatric Evaluation revealed that Patient #4's Axis I "Provisional Diagnosis" was "Mood Disorder NOS (not otherwise specified)", "Impulse Control Disorder NOS", "Conduct Disorder Adolescent Onset" and "History of Polysubstance Abuse (in forced remission)". The justification for inpatient hospitalization included "Potential danger to self as evidenced by her self-injurious behavior". Review of the record revealed orders dated 10/01/10 at 9:45 a.m. to place Patient #4 on a Status C observation level which is visual observation of the patient at least every 15 minutes.

Review of the Multi-Disciplinary Progress Note for 10/08/10 at 11:00 p.m. revealed documentation by S44RN that read: "Patient noted approximately 1710 (5:10 p.m.) in bed area tied with sheet to bathroom door non-responsive, write(r) unable to remove sheet that was taut under patient's chin and under flat door handle. Other staff immediately summoned to help get patient down, 911 called, staff down hall immediately in room CPR (cardiopulmonary resuscitation) started til [sic] help arrived. Dr. (S30MD) contact approximately 1710 (5:10 p.m.) arrived 1725 (5:25 p.m.). Ambulance arrived. (S1CEO) and (S2DON) arrived later. Police (APD) (Alexandria Police Department) on unit later. Writer unable to reach OCS. OCS contacted later per (S1CEO) and arrived on unit later and notified. Patient taken out per stretcher per ambulance workers. CPR in progress. Patient still unresponsive on departure".

Review of a handwritten Physician Progress Notes with a date/time of 10/08/10 at 5:40 p.m. read: "Addendum. Called by RN earlier this afternoon with report that pt was found hanging from a door in her room. I returned to the hospital and found staff doing CPR on patient. Pt was observed with no pulse and no spontaneous breathing. Staff had already called 911 and the ambulance arrived within a minute of my being there. Paramedics continue to do CPR until pt was taken to the local hospital for continued resuscitation.

Review of a handwritten Physician Progress Notes with a date/time of 10/08/10 at 7:40 p.m. read: "Spoke by phone with Dr. (name) at (hospital "b") E.R. (emergency room) who told me that pt expired. Will ask hospital to notify OCS and family".

Review of the Tech Notes/Observation Sheet for 10/08/10 revealed that S27 (Mental Health Technician) documented the q 15 minute checks from 3:15 p.m. to 4:45 p.m. on Patient #4. The documentation read as follows: 3:15 p.m. - PD (group/Continuous Visual); 3:30 p.m. - HD (Room Awake/Continuous Visual); 3:45 p.m. - H (Room Awake); 4:00 p.m. - H (Room Awake); 4:15 p.m. - H (Room Awake); 4:30 p.m. - H (Room Awake); 4:45 p.m. - H (Room Awake). The 4:45 p.m. entry was the last entry on the Tech Notes/Observation Sheet relating to the 15 minute observations of Patient #4.

The registered nurse (S44) who worked as the Female Adolescent Unit Charge Nurse on the evening shift (3:00 p.m. - 11:00 p.m.) on 10/08/10 was interviewed on 10/11/10 at 5:30 p.m. S44 stated she came on duty on 10/08/10 at 3:00 p.m. S44 stated that she went to take patient report and that S24LPN, S29MHT and S27MHT were not in report. S44 stated that group was in session when she finished report at about 3:15 p.m. S44 stated that she was unsure if Patient #4 was in group. S44 stated that she went outside after report as all the patients were either in the dayroom or outside as were all 4 of the MHT's on duty. S44 stated she did not ensure that all patients had an MHT assigned to them and that she did not make patient care assignments on 10/08/10. S44 stated she was not aware of Patient #4's whereabouts from 3:00 p.m. until 5:10 p.m. on 10/08/10. S44 stated that she took Patient #5 to the restroom across the hall from Patient #4's room at approximately 5:05 p.m. on 10/08/10. S44 stated that upon leaving the room with Patient #5 she could see the legs of Patient #4 "hanging". S44 stated that she noticed a sheet "tight" around the neck of Patient #4 and that she (Patient #4) was "unresponsive". S44 indicated that she then went to the nurse's station calling out for someone to "call 911". S44 indicated that she opened the window to the Adult unit and told the RN (S4RN) to "call 911, I got a patient and I think she is dead". S44 stated that the shift was short staffed in MHT's. In a follow up interview on 10/13/10 at 11:15 a.m., S44 confirmed that she was the unit charge nurse and only registered nurse assigned to the adolescent girls unit on the evening shift on 10/08/10. S44 confirmed that she did not make the MHT assignments on the adolescent girls unit on the evening shift on 10/08/10. S44 reported that she did not check the assignment sheet to ensure all patients had an MHT assigned to them.

The MHT (S27) who documented on the Tech Note/Observation Sheet that he conducted the q 15 minute observations on Patient #4 from 3:15 p.m. to 4:45 p.m. on 10/08/10 was interviewed on 10/11/10 at 2:40 p.m. S27 reported that he arrived on the adolescent girls unit at approximately 2:30 p.m. on 10/08/10. S27 reviewed the assignment sheet for the 10/08/10 evening shift (3:00 a.m. thru 11:00 p.m.) and indicated that three patients including Patient #4 had no MHT assigned to them based on the assignment sheet for this shift. S27 reported that he had the Tech Note/Observation Sheet for these three patients including Patient #4. S27 stated that S23MHT "handed him" the "Tech Sheets" and he did not refuse them. S27 indicated that male MHT's are not supposed to take "Tech Sheets" on adolescent girl patients because male MHT's are not allowed down the halls of the adolescent girls unit to check on the female patients. S27 indicated that he took a group of girls to the outside area of the unit at approximately 3:30 p.m. - 3:45 p.m. and did not re-enter the inside of the unit until approximately 5:00 p.m. S27 stated that Patient #4 did not attend the group session that begins at 3:00 p.m. and ends at 3:30 p.m. S27 reviewed the documentation on the Tech Notes/Observation Sheet for Patient #4. S27 confirmed that he documented that Patient #4 was in group at 3:15 p.m. under constant visual observation, was in Room Awake under constant visual observation at 3:30 p.m., and was in Room Awake at 3:45 p.m., 4:00 p.m., 4:15 p.m., 4:30 p.m., and 4:45 p.m. S27 indicated that he did not see Patient #4 from the time he went to the outside area of the unit at approximately 3:30 p.m. - 3:45 p.m. thru the time she (Patient #4) was found hanging in her room at approximately 5:10 p.m. on 10/08/10. S27 indicated that the documentation he entered on the Tech Note/Observation Sheet (from 3:30 p.m. thru 4:45 p.m.) on 10/08/10 indicating that he performed the q 15 minute visual observations on Patient #4 was false as he did not perform the q 15 minute visual observations on Patient #4 for this period of time. S27 indicated that he did not ask any of the female staff members to go and perform the q 15 minute checks on Patient #4 and was not sure if the q 15 minute visual observations were actually performed on Patient #4 for this period of time on 10/08/10.

The Director of Nursing (DON) was interviewed on 10/13/10 at 11:12 a.m. The DON reported that the registered nurse was responsible for patient care assignments to the MHT's (Mental Health Technicians) on the unit. The DON reviewed the assignment sheet for the evening shift on the female adolescent unit and reported that the assignment sheet was not complete in that 3 patients (including Patient #4) were not assigned to a MHT. The DON reported that S27 is a male MHT and indicated that a male MHT should not have had Tech/Observation sheets on a female adolescent patient. The DON explained that unless in an emergency situation, male MHT's are not allowed to go down the hall on a female adolescent unit to check on, or to perform 15 minute observations, on female adolescent patients. The DON was unable to provide documentation to indicate that the registered nurse had assigned patient care duties to the mental health technicians based on the registered nurses assessment of the patients needs.

The hospital approved policy/procedure titled "Assessment/Treatment of Patients" was reviewed. The policy/procedure documents "It is the policy of Crossroads Regional Hospital that each patient will be monitored throughout his or her hospitalization according to an assigned observation status. The patient's status is assigned at the time of admission, re-evaluated and changed as clinically indicated. Observation of the patient by clinical staff members will be accomplished to maintain patient/employee safety in the least restrictive manner." The policy/procedure indicates that there are three status levels, Status A which is a strict One to One observation within arms reach length of the patient at all times, Status B which is constant visual observation maintaining line of sight on the patient at all times, and Status C which is visualizing the patient at least every 15 minutes.
The Chief Executive Officer (CEO) and Director of Nursing (DON) were interviewed on 10/12/10 at 10:30 a.m. When asked how nursing staffing levels and needs are determined on the acute care psychiatric units in the hospital, the CEO indicated that staffing levels and staffing needs are based on the number and acuity level of patients who are on the unit. The DON confirmed that staffing levels and staffing needs are based on the number of patients on the unit and the acuity level of the patients who are on the unit. When asked for the policy/procedure relating to staffing the acute care psychiatric units, the CEO presented the hospital approved policy/procedure titled "Nursing Staffing & Patient Classification Acuity System" (most recent revision date of this policy/procedure was 7/16/10).
The hospital approved policy/procedure titled "Nursing Staffing & Patient Classification Acuity System" was reviewed. The "Policy" is documented as "It is the policy of Crossroads Regional Hospital (CRH) to ensure that patients receive quality nursing care, through the specialized skills of RNs, LPNs and Mental Health Technicians to provide a safe therapeutic environment. CRH utilizes a standard format for measuring individual patient acuity levels". The "Purpose" of the policy/procedure is documented as "CRH provides a measurement of the psychological, psychosocial, and physical needs of each patient to promote consistency and continuity in the delivery of patient care by staff on all shifts". The "Procedure" documents that a RN is assigned to each unit, each shift, and will supervise and evaluate the nursing care each patient receives. The "Procedure" further documents that the RN in charge will evaluate each patient utilizing the 3 established patient classification levels (Level 1 or Status A, Level 2 or Status B, & Level 3 or Status C). The "Procedure" documents "After completion and review of acuity sheets by the charge RN, plans for staffing are based on the required nursing hours. Accuracy of acuity data is reviewed daily by the DON, Staffing Coordinator, or other designee". Review of page 3 of the policy/procedure revealed a worksheet that is used to determine staffing needs based on the patients observation status. The worksheet is titled "Patient Classification Rating/Observation Status Assignment Form". This worksheet is to be completed by the unit charge nurse and identifies the acuity level of the patients on the unit by factoring in the number of patients on the unit who are assigned to be on an Observation Status A, the number of patients on the unit who are assigned to be on an Observation Status B, and the number of patients on the unit who are assigned to be on an Observation Status C. Interview with the DON on 10/12/10 at 11:50 a.m. revealed that this worksheet is used by her (DON) and/or the Staffing Coordinator to determine the number of nursing personnel needed to staff each unit on each shift.
The "Patient Classification Rating/Observation Status Assignment Form" worksheets (10/01/10 thru 10/09/10 with focus on the female adolescent unit) were reviewed on 10/12/10 at 3:00 p.m. in the presence of the DON. This review revealed inconsistencies with the completion of these worksheets by the unit charge nurses. Several of the worksheets were noted to be incomplete in that the section relating to the observation level of the patients was not filled in resulting in the inability to determine the number of patients assigned to be on an observation status A (one to one), observation status B (constant visual observation), and observation status C (visual observations at least every 15 minutes). The worksheets from the female adolescent unit were incomplete on the day shift (7:00 a.m. thru 3:00 p.m.) on 10/01/10, 10/05/10, 10/06/10, and the evening shift (3:00 p.m. thru 11:00 p.m.) on 10/05/10. The DON confirmed that there are inconsistencies with the completion of these worksheets. The DON reported that these worksheets should have been completely filled out by the unit charge nurses so that they could be used to determine the staffing needs of the unit. When asked if there was another method to determine the acuity level of patients on the female adolescent unit, the DON reported that information relating to the acuity level of the unit could be found on the daily staffing sheets.

The nursing services daily staffing sheets (10/01/10 thru 10/09/10 with focus on the female adolescent unit) were reviewed on 10/13/10 at 8:30 a.m. in the presence of the DON. The daily staffing sheets included information such as the unit census, the observation status of the patients on the unit, and the staff who worked on the unit. This review revealed inconsistencies with the completion of the daily staffing sheets as information relating to the observation status of the patients on the unit was not consistently included on the staffing sheets. The observation status of the patients on the female adolescent unit was not documented on the staffing sheets for the day shift (7:00 a.m. thru 3:00 p.m.) on 10/02/10 and 10/03/10; the evening shift (3:00 p.m. thru 11:00 p.m.) on 10/02/10, 10/03/10, 10/04/10, 10/05/10, 10/07/10 and 10/08/10; and the night shift (11:00 p.m. thru 7:00 a.m.) on 10/01/10, 10/02/10, 10/03/10, 10/04/10, 10/05/10, 10/07/10 and 10/09/10. The DON confirmed that information relating to the observation status of patients on the unit was not consistently included on the staffing sheets and indicated that this information should be included on the staffing sheet.
On 10/13/10 between 12:30 p.m. and 2:00 p.m., the "Patient Classification Rating/Observation Status Assignment Form" worksheets, the nursing services daily staffing sheets, employee time sheets and the hospital approved policy/procedure titled "Nursing Staffing & Patient Classification Acuity System" were reviewed in the presence of the DON. The purpose of this review was to obtain information relating to the census and observation status of the patients on the female adolescent unit (10/01/10 thru 10/09/10) in order to determine the number of staff needed to provide care in a safe setting to the patients hospitalized on this acute care psychiatric unit. After factoring in the number and observation status of the patients on the female adolescent unit, it was determined that the female adolescent unit was not staffed in accordance with the hospital's policy/procedure. The female adolescent unit was found to be understaffed by at least one (1) nursing services staff member on all shifts on 10/01/10, 10/02/10, 10/03/10, 10/04/10, 10/07/10 and 10/08/10. In addition, it was determined that there was no registered nurse on the female adolescent unit for approximately 1.5 hours on the day shift on 10/08/10. The registered nurse (S41) assigned to the female adolescent unit on the day shift (7:00 a.m. thru 3:00 p.m.) clocked out at 12:53 p.m. on 10/08/10 and the oncoming registered nurse (S44) clocked in at 2:35 p.m. on 10/08/10 resulting in no registered nurse being immediately available for the 19 female adolescent patients on this locked acute care psychiatric unit for over 1.5 hours (12:53 p.m. thru 2:35 p.m.). The DON confirmed that the unit was understaffed by at least one (1) nursing services staff member on 10/01/10, 10/02/10, 10/03/10, 10/04/10, 10/07/10 and 10/08/10. The DON reported that the shortage was due to the high acuity level of the patients on the female adolescent unit as the majority of patients were on a status B observation level which is constant visual observation. The DON confirmed that there was no registered nurse assigned to the female adolescent unit on 10/08/10 from 12:53 p.m. thru 2:35 p.m. as the day shift registered nurse (S41) left early.
The CEO was interviewed on 10/13/10 at 2:00 p.m. The CEO reviewed the "Patient Classification Rating/Observation Status Assignment Form" worksheets, the nursing services daily staffing sheets, employee time sheets and the hospital approved policy/procedure titled "Nursing Staffing & Patient Classification Acuity System" and confirmed that the female adolescent unit was understaffed by at least 1 nursing services staff member on all shifts on 10/01/10, 10/02/10, 10/03/10, 10/04/10, 10/07/10 and 10/08/10.

2. Failure of the hospital to ensure a RN was assigned to each unit of the hospital at all times by not having a RN on Unit A on 10/08/10 from 12:53 p.m. until 2:35 p.m. due to the RN leaving the hospital for illness without a replacement RN on the unit. This affected all 19 of the patients on Unit A on 10/08/10 between the hours of 12:53 p.m. until 2:35 p.m.

In an interview on 10/13/10 at 9:15 a.m. with S14LPN she stated she was the LPN assigned to Unit A on 10/08/10 for the 7:00 a.m. to 3:00 p.m. shift. S14 further stated that the RN on the unit "left at lunch because she was not feeling well." She further stated that no RN was assigned to Unit A from 1:00 p.m. to 3:00 p.m. on 10/08/10.

By review of the Electronic Time Records it was determined that there was no registered nurse on Unit A for approximately 1.5 hours on the day shift on 10/08/10. The registered nurse (S41) assigned to Unit A for the day shift (7:00 a.m. to 3:00 p.m.) clocked out at 12:53 p.m. on 10/08/10 and the oncoming registered nurse (S44) clocked in at 2:35 p.m. on 10/08/10. This resulted in no registered nurse being immediately available for the patients on Unit A which is a locked acute care psychiatric unit for over 1.5 hours (12:53 p.m. through 2:35 p.m.).
The DON confirmed that there was no registered nurse assigned to Unit A on 10/08/10 from 12:53 p.m. through 2:35 p.m. as the day shift registered nurse (S41) left early.

3. Failure to assign a Registered Nurse to Unit B on 10/15/10 at 10:42 a.m. while the Registered Nurse assigned to the unit left the unit for 50 minutes to attend a meeting in another part of the hospital. The unit had a census of 18 adolescent patients who were left under the supervision of only non-licensed MHT's.
An observation was made on Unit B on 10/15/10 at 10:42 a.m. that revealed neither a Registered Nurse (RN) nor a Licensed Practical Nurse (LPN) was on the unit at this time.
An interview was held with S34 Lead Mental Health Technician on 10/15/10 at 10:42 a.m. S34 indicated the RN and LPN assigned to Unit B had been off of the unit since 10:00 a.m. to attend an in-service meeting. S34 reported there were currently 18 patients on Unit B, ranging in ages from 7 to 17 years of age. S34 added that all of the patient's were listed as a Status B which required the 18 patients to be within eyesight at all times.
An additional observation and an interview was held with S17RN and S24LPN on 10/15/10 at 10:50 a.m. on Unit B in the presence of S1CEO. S17 and S24 indicated they had just returned to Unit B after attending a mandatory in-service meeting. S17 and S24 indicated they left the unit at 10:00 a.m. to attend the meeting. S17 and S24 further indicated they were aware there were no nurses on the unit when they left their assigned patients on Unit B in the care of Mental Health Technicians at 10:00 a.m.
Review of the staff development sign in sheet for the meeting held on 10/15/10 at 10:00 a.m. revealed S17RN and S24LPN had signed in and were in attendance at this meeting. The agenda for this meeting included patient acuity classification system, staffing plan, patient observation status categories, unit staff break log, assignment sheets, personal phone calls, Monday through Friday Clerk and duties, assigning staff to respond to codes, and dress codes.
An interview was held with S1CEO 10/15/10 at 11:15 a.m. S1 confirmed that Unit B had been left without a Registered Nurse from 10:00 a.m. to 10:50 a.m. S1 further indicated she got S17RN and S24LPN out of the in-service meeting to return to their assigned patients on Unit B. S1 indicated she was not aware there was no RN on Unit B during the 10:00 a.m. mandatory in-service meeting. S1 added both nurses used no critical thinking skills when leaving the unit unattended by a nurse.






25452

Based on record review and interview, the hospital failed to meet the nursing care needs of the patients by failing to ensure that nursing assignments were in accordance with the patient's needs as evidenced by the registered nurse allowing the mental health technician to make patient care assignments. This resulted in a male mental health technician being responsible for 15 minute visual observations on a female adolescent patient (Patient #4) who was found hanging from the bathroom door in an area of the adolescent girls unit that the male mental health technician was not allowed to go into. Findings:

Patient #4: Review of the medical record revealed that Patient #4 was admitted to Crossroads Regional Hospital (CRH) on 09/24/10 at 3:45 p.m. Review of the admission orders revealed S30MD was the attending physician and gave a provisional admitting diagnosis of depression. Further review of the admission orders revealed S30 MD ordered for Patient #4 to be assigned a "Status B" (Constant Visual Observation, Unit Restriction) observation level. Review of the Psychiatric Evaluation dated 09/25/10 revealed that Patient #4 had poor insight, poor judgement, and poor impulse control. Further review of the Psychiatric Evaluation revealed that Patient #4's Axis I "Provisional Diagnosis" was "Mood Disorder NOS (not otherwise specified)", "Impulse Control Disorder NOS", "Conduct Disorder Adolescent Onset" and "History of Polysubstance Abuse (in forced remission)". The justification for inpatient hospitalization included "Potential danger to self as evidenced by her self-injurious behavior". Review of the record revealed orders dated 10/01/10 at 9:45 a.m. to place Patient #4 on a Status C observation level which is visual observation of the patient at least every 15 minutes.

Review of the Multi-Disciplinary Progress Note for 10/08/10 at 11:00 p.m. revealed documentation by S44RN that read: "Patient noted approximately 1710 (5:10 p.m.) in bed area tied with sheet to bathroom door non-responsive, write(r) unable to remove sheet that was taut under patient's chin and under flat door handle. Other staff immediately summoned to help get patient down, 911 called, staff down hall immediately in room CPR (cardiopulmonary resuscitation) started til [sic] help arrived. Dr. (S30MD) contact approximately 1710 (5:10 p.m.) arrived 1725 (5:25 p.m.). Ambulance arrived. (S1CEO) and (S2DON) arrived later. Police (APD) (Alexandria Police Department) on unit later. Writer unable to reach OCS. OCS contacted later per (S1CEO) and arrived on unit later and notified. Patient taken out per stretcher per ambulance workers. CPR in progress. Patient still unresponsive on departure".

Review of a handwritten Physician Progress Notes with a date/time of 10/08/10 at 5:40 p.m. read: "Addendum. Called by RN earlier this afternoon with report that pt was found hanging from a door in her room. I returned to the hospital and found staff doing CPR on patient. Pt was observed with no pulse and no spontaneous breathing. Staff had already called 911 and the ambulance arrived within a minute of my being there. Paramedics continue to do CPR until pt was taken to the local hospital for continued resuscitation."

Review of a handwritten Physician Progress Notes with a date/time of 10/08/10 at 7:40 p.m. read: "Spoke by phone with Dr. (name) at (hospital "b") E.R. (emergency room) who told me that pt expired. Will ask hospital to notify OCS and family".

Review of the Tech Notes/Observation Sheet for 10/08/10 revealed that S27 (Mental Health Technician) documented the q 15 minute checks from 3:15 p.m. to 4:45 p.m. on Patient #4. The documentation read as follows: 3:15 p.m. - PD (group/Continuous Visual); 3:30 p.m. - HD (Room Awake/Continuous Visual); 3:45 p.m. - H (Room Awake); 4:00 p.m. - H (Room Awake); 4:15 p.m. - H (Room Awake); 4:30 p.m. - H (Room Awake); 4:45 p.m. - H (Room Awake). The 4:45 p.m. entry was the last entry on the Tech Notes/Observation Sheet relating to the 15 minute observations of Patient #4.

The registered nurse (S44) who worked as the Female Adolescent Unit Charge Nurse on the evening shift (3:00 p.m. - 11:00 p.m.) on 10/08/10 was interviewed on 10/11/10 at 5:30 p.m. S44 stated she came on duty on 10/08/10 at 3:00 p.m. S44 stated that she went to take patient report and that S24LPN, S29MHT and S27MHT were not in report. S44 stated that group was in session when she finished report at about 3:15 p.m. S44 stated that she was unsure if Patient #4 was in group. S44 stated that she went outside after report as all the patients were either in the dayroom or outside as were all 4 of the MHT's on duty. S44 stated she did not ensure that all patients had an MHT assigned to them and that she did not make patient care assignments on 10/08/10. S44 stated she was not aware of Patient #4's whereabouts from 3:00 p.m. until 5:10 p.m. on 10/08/10. S44 stated that she took Patient #5 to the restroom across the hall from Patient #4's room at approximately 5:05 p.m. on 10/08/10. S44 stated that upon leaving the room with Patient #5 she could see the legs of Patient #4 "hanging". S44 stated that she noticed a sheet "tight" around the neck of Patient #4 and that she (Patient #4) was "unresponsive". S44 indicated that she then went to the nurse's station calling out for someone to "call 911". S44 indicated that she opened the window to the Adult unit and told the RN (S4RN) to "call 911, I got a patient and I think she is dead". S44 stated that the shift was short staffed in MHT's. In a follow up interview on 10/13/10 at 11:15 a.m., S44 confirmed that she was the unit charge nurse and only registered nurse assigned to the adolescent girls unit on the evening shift on 10/08/10. S44 confirmed that she did not make the MHT assignments on the adolescent girls unit on the evening shift on 10/08/10. S44 reported that she did not check the assignment sheet to ensure all patients had an MHT assigned to them.

The MHT (S27) who documented on the Tech Note/Observation Sheet that he conducted the q 15 minute observations on Patient #4 from 3:15 p.m. to 4:45 p.m. on 10/08/10 was interviewed on 10/11/10 at 2:40 p.m. S27 reported that he arrived on the adolescent girls unit at approximately 2:30 p.m. on 10/08/10. S27 reviewed the assignment sheet for the 10/08/10 evening shift (3:00 a.m. thru 11:00 p.m.) and indicated that three patients including Patient #4 had no MHT assigned to them based on the assignment sheet for this shift. S27 reported that he had the Tech Note/Observation Sheet for these three patients including Patient #4. S27 stated that S23MHT "handed him" the "Tech Sheets" and he did not refuse them. S27 indicated that male MHT's are not supposed to take "Tech Sheets" on adolescent girl patients because male MHT's are not allowed down the halls of the adolescent girls unit to check on the female patients. S27 indicated that he took a group of girls to the outside area of the unit at approximately 3:30 p.m. - 3:45 p.m. and did not re-enter the inside of the unit until approximately 5:00 p.m. S27 stated that Patient #4 did not attend the group session that begins at 3:00 p.m. and ends at 3:30 p.m. S27 reviewed the documentation on the Tech Notes/Observation Sheet for Patient #4. S27 confirmed that he documented that Patient #4 was in group at 3:15 p.m. under constant visual observation, was in Room Awake under constant visual observation at 3:30 p.m., and was in Room Awake at 3:45 p.m., 4:00 p.m., 4:15 p.m., 4:30 p.m., and 4:45 p.m. S27 indicated that he did not see Patient #4 from the time he went to the outside area of the unit at approximately 3:30 p.m. - 3:45 p.m. thru the time she (Patient #4) was found hanging in her room at approximately 5:10 p.m. on 10/08/10. S27 indicated that the documentation he entered on the Tech Note/Observation Sheet (from 3:30 p.m. thru 4:45 p.m.) on 10/08/10 indicating that he performed the q 15 minute visual observations on Patient #4 was false as he did not perform the q 15 minute visual observations on Patient #4 for this period of time. S27 indicated that he did not ask any of the female staff members to go and perform the q 15 minute checks on Patient #4 and was not sure if the q 15 minute visual observations were actually performed on Patient #4 for this period of time on 10/08/10.

The hospital approved policy/procedure titled "Nursing Staffing & Patient Classification Acuity System" was reviewed. The "Policy" is documented as "It is the policy of Crossroads Regional Hospital (CRH) to ensure that patients receive quality nursing care, through the specialized skills of RNs, LPNs and Mental Health Technicians to provide a safe therapeutic environment. CRH utilizes a standard format for measuring individual patient acuity levels". The "Purpose" of the policy/procedure is documented as "CRH provides a measurement of the psychological, psychosocial, and physical needs of each patient to promote consistency and continuity in the delivery of patient care by staff on all shifts". The "Procedure" documents that the RN on each shift will assess each patient's needs before making assignments to other nursing staff.. The "Procedure" further documents "The patient care assignments are assigned in accordance to the acuity of the patient and the qualifications of each staff member" and "The RN will ensure prompt recognition of any change in a patient's condition and facilitate appropriate intervention by the nursing staff".
The hospital approved policy/procedure titled "Assessment/Treatment of Patients" was reviewed. The policy/procedure documents "It is the policy of Crossroads Regional Hospital that each patient will be monitored throughout his or her hospitalization according to an assigned observation status. The patient's status is assigned at the time of admission, re-evaluated and changed as clinically indicated. Observation of the patient by clinical staff members will be accomplished to maintain patient/employee safety in the least restrictive manner". The policy/procedure indicates that there are three status levels, Status A which is a strict One to One observation within arms reach length of the patient at all times, Status B which is constant visual observation maintaining line of sight on the patient at all times, and Status C which is visualizing the patient at least every 15 minutes.

The Director of Nursing (DON) was interviewed on 10/13/10 at 11:12 a.m. The DON reported that the registered nurse was responsible for patient care assignments to the MHT's (Mental Health Technicians) on the unit. The DON reviewed the assignment sheet for the evening shift on the female adolescent unit and reported that the assignment sheet was not complete in that 3 patients (including Patient #4) were not assigned to a MHT. The DON reported that S27 is a male MHT and indicated that a male MHT should not have had Tech/Observation sheets on a female adolescent patient. The DON explained that unless in an emergency situation, male MHT's are not allowed to go down the hall on a female adolescent unit to check on, or to perform 15 minute observations, on female adolescent patients. The DON was unable to provide documentation to indicate that the registered nurse had assigned patient care duties to the mental health technicians based on the registered nurses assessment of the patients needs on the 10/08/10 evening shift on the girls adolescent unit.

Based on observation, record review, and interview, the hospital failed to meet the Condition of Participation of Special Provisions Applying to Psychiatric Hospitals by:

1) failing to be in compliance with the hospital Conditions of Participation specified in ?482.1 through ?482.23 by failing to meet the CoP of Patient Rights at ?482.13 and the CoP of Nursing Services at ?482.23. (cross reference findings at A0115 and A0385)

2) failing to meet the Condition of Participation for Psychiatric Hospital's Special Staffing requirements specified in ?482.62. ( cross reference findings at B136)

Based on observation, record review, and interview, the Psychiatric hospital failed to meet the Conditions of Participation specified in ?482.1 through ?482.23 by failing to be in compliance with the Hospital's Condition of Participation requirements for Patient Rights at ?482.13 and Nursing Services at ?482.23.

Based on record review, interview and observations, the hospital failed to meet the Condition of Participation for Psychiatric Hospital's Special Staffing requirements specified in ?482.62. (cross reference B136)

Based on observation, interview and record review, the hospital failed to meet the Condition of Participation of Special Staff Requirements for Psychiatric Hospitals by:

1) failing to staff the acute care psychiatric unit in accordance with the hospital approved policy/procedure titled "Nursing Staffing & Patient Classification Acuity System" resulting in the hospital's inability to ensure the safety and supervision of the adolescent patients hospitalized on the acute care psychiatric unit. The hospital failed to ensure that the nursing unit was staffed with the number of nursing personnel required for the number of patients as indicated in their policy/procedure for multiple days including 10/08/10. This staffing failure resulted in Patient #4 being left unsupervised for a period of time which resulted in the hanging death of Patient #4 on 10/08/10. (see findings at B150)

An Immediate Jeopardy situation was identified on 10/13/10 at 2:18 p.m. and the Chief Executive Officer and the Director of Nursing were notified of the Immediate Jeopardy situation at that time (10/13/10 at 2:18 p.m.).

The Immediate Jeopardy situation was a result of:

The hospital failed to meet the nursing care needs of the patients by: 1) failing to staff the acute care adolescent psychiatric unit in accordance with the hospital approved policy/procedure titled "Nursing Staffing & Patient Classification Acuity System" resulting in the hospital's inability to ensure the safety and supervision of adolescent patients hospitalized on the acute care psychiatric unit. The hospital failed to ensure that the nursing unit was staffed with the number of nursing personnel as indicated in their policy/procedure on multiple days including 10/08/10. This was evidenced by nursing services inability to ensure the safe supervision and delivery of care to adolescent psychiatric patients hospitalized on the acute care psychiatric unit as evidenced by the hanging death of Patient #4 on 10/08/10; 2) failing to ensure that nursing assignments were in accordance with the patient's needs as evidenced by the registered nurse allowing the mental health technician to make patient care assignments. This resulted in a male mental health technician being responsible for 15 minute visual observations on a female patient (Patient #4) who was found hanging from the bathroom door in an area of the adolescent girls unit that the male mental health technician was not allowed to go into.

The Immediate Jeopardy was lifted on 10/15/10 at 2:40 p.m. after the hospital submitted an acceptable Plan of Removal which included:

- The revision of the policy/procedure titled "Nursing Staffing and Patient Classification Acuity System" to reflect that the Charge RN on each shift will assess each patient's needs before making assignments to other nursing staff.

- The revision of the "Patient Classification/Observation Status Assignment Form" to reflect that the Charge RN will complete the Patient Classification Observation Status Assignment Form and determine the staff requirements for the oncoming shift based on 1:6 staff to patient ratio. This 1:6 staff to patient ratio does not include the registered nurse or the licensed practical nurse. Efforts to meet staffing requirements will include increasing the PRN pool of nursing personnel, administrative authorization of overtime, and utilization of agency personnel when necessary.

- The hospital's refusal to accept and admit new patients when staffing levels are not met.

- The provision of training/education to all clinical staff regarding the revised policies/procedures.

- The implementation of quality assurance indicators to evaluate both compliance with and the effectiveness of the revised policies/procedures.


2) failed to meet the nursing care needs of the patients by failing to ensure that nursing assignments were in accordance with the patient's needs. This was evidenced by the registered nurse allowing the mental health technician to make patient care assignments. This resulted in a male mental health technician being responsible for 15 minute visual observations on a female patient (Patient #4) who was found hanging from the bathroom door in an area of the adolescent girls unit that the male mental health technician was not allowed to go into. (see findings at B146)

3) failing to ensure a RN was assigned to each unit of the hospital at all times by not having a RN on Unit A on 10/08/10 from 12:53 p.m. until 2:35 p.m. due to the RN leaving the hospital for illness without a replacement RN on the unit. Unit A had a census of 19 patients on 10/08/10. (see findings at B149)
4) failure to assign a Registered Nurse on Unit B on on 10/15/10 at 10:42 a.m. while the RN assigned to the unit left the unit for 50 minutes to attend a meeting. The unit had a census of 18 adolescent patients left under the supervision of only non-licensed MHT's. (see findings at B149)
5) failing to ensure the RN supervised the care of each patient as evidenced by MHT's not having documented evidence of performing the every 15 minute observations of the patients. (see findings at B149)

Based on record review and interview, the hospital failed to meet the nursing care needs of the patients by failing to ensure that nursing assignments were in accordance with the patient's needs. This was evidenced by the registered nurse allowing the mental health technician to make patient care assignments. This resulted in a male mental health technician being responsible for 15 minute visual observations on a female patient (Patient #4) who was found hanging from the bathroom door in an area of the adolescent girls unit that the male mental health technician was not allowed to go into. Findings:

1. Patient #4: Review of the medical record revealed that Patient #4 was admitted to Crossroads Regional Hospital (CRH) on 09/24/10 at 3:45 p.m. Review of the admission orders revealed S30MD was the attending physician and gave a provisional admitting diagnosis of depression. Further review of the admission orders revealed S30 MD ordered for Patient #4 to be assigned a "Status B" (Constant Visual Observation, Unit Restriction) observation level. Review of the Psychiatric Evaluation dated 09/25/10 revealed that Patient #4 had poor insight, poor judgement, and poor impulse control. Further review of the Psychiatric Evaluation revealed that Patient #4's Axis I "Provisional Diagnosis" was "Mood Disorder NOS (not otherwise specified)", "Impulse Control Disorder NOS", "Conduct Disorder Adolescent Onset" and "History of Polysubstance Abuse (in forced remission)". The justification for inpatient hospitalization included "Potential danger to self as evidenced by her self-injurious behavior". Review of the record revealed orders dated 10/01/10 at 9:45 a.m. to place Patient #4 on a Status C observation level which is visual observation of the patient at least every 15 minutes.

Review of the Multi-Disciplinary Progress Note for 10/08/10 at 11:00 p.m. revealed documentation by S44RN that read: "Patient noted approximately 1710 (5:10 p.m.) in bed area tied with sheet to bathroom door non-responsive, write(r) unable to remove sheet that was taut under patient's chin and under flat door handle. Other staff immediately summoned to help get patient down, 911 called, staff down hall immediately in room CPR (cardiopulmonary resuscitation) started til [sic] help arrived. Dr. (S30MD) contact approximately 1710 (5:10 p.m.) arrived 1725 (5:25 p.m.). Ambulance arrived. (S1CEO) and (S2DON) arrived later. Police (APD) (Alexandria Police Department) on unit later. Writer unable to reach OCS. OCS contacted later per (S1CEO) and arrived on unit later and notified. Patient taken out per stretcher per ambulance workers. CPR in progress. Patient still unresponsive on departure".

Review of a handwritten Physician Progress Notes with a date/time of 10/08/10 at 5:40 p.m. read: "Addendum. Called by RN earlier this afternoon with report that pt was found hanging from a door in her room. I returned to the hospital and found staff doing CPR on patient. Pt was observed with no pulse and no spontaneous breathing. Staff had already called 911 and the ambulance arrived within a minute of my being there. Paramedics continue to do CPR until pt was taken to the local hospital for continued resuscitation."

Review of a handwritten Physician Progress Notes with a date/time of 10/08/10 at 7:40 p.m. read: "Spoke by phone with Dr. (name) at (hospital "b") E.R. (emergency room) who told me that pt expired. Will ask hospital to notify OCS and family".

Review of the Tech Notes/Observation Sheet for 10/08/10 revealed that S27 (Mental Health Technician) documented the q 15 minute checks from 3:15 p.m. to 4:45 p.m. on Patient #4. The documentation read as follows: 3:15 p.m. - PD (group/Continuous Visual); 3:30 p.m. - HD (Room Awake/Continuous Visual); 3:45 p.m. - H (Room Awake); 4:00 p.m. - H (Room Awake); 4:15 p.m. - H (Room Awake); 4:30 p.m. - H (Room Awake); 4:45 p.m. - H (Room Awake). The 4:45 p.m. entry was the last entry on the Tech Notes/Observation Sheet relating to the 15 minute observations of Patient #4.

The registered nurse (S44) who worked as the Female Adolescent Unit Charge Nurse on the evening shift (3:00 p.m. - 11:00 p.m.) on 10/08/10 was interviewed on 10/11/10 at 5:30 p.m. S44 stated she came on duty on 10/08/10 at 3:00 p.m. S44 stated that she went to take patient report and that S24LPN, S29MHT and S27MHT were not in report. S44 stated that group was in session when she finished report at about 3:15 p.m. S44 stated that she was unsure if Patient #4 was in group. S44 stated that she went outside after report as all the patients were either in the dayroom or outside as were all 4 of the MHT's on duty. S44 stated she did not ensure that all patients had an MHT assigned to them and that she did not make patient care assignments on 10/08/10. S44 stated she was not aware of Patient #4's whereabouts from 3:00 p.m. until 5:10 p.m. on 10/08/10. S44 stated that she took Patient #5 to the restroom across the hall from Patient #4's room at approximately 5:05 p.m. on 10/08/10. S44 stated that upon leaving the room with Patient #5 she could see the legs of Patient #4 "hanging". S44 stated that she noticed a sheet "tight" around the neck of Patient #4 and that she (Patient #4) was "unresponsive". S44 indicated that she then went to the nurse's station calling out for someone to "call 911". S44 indicated that she opened the window to the Adult unit and told the RN (S4RN) to "call 911, I got a patient and I think she is dead". S44 stated that the shift was short staffed in MHT's. In a follow up interview on 10/13/10 at 11:15 a.m., S44 confirmed that she was the unit charge nurse and only registered nurse assigned to the adolescent girls unit on the evening shift on 10/08/10. S44 confirmed that she did not make the MHT assignments on the adolescent girls unit on the evening shift on 10/08/10. S44 reported that she did not check the assignment sheet to ensure all patients had an MHT assigned to them.

The MHT (S27) who documented on the Tech Note/Observation Sheet that he conducted the q 15 minute observations on Patient #4 from 3:15 p.m. to 4:45 p.m. on 10/08/10 was interviewed on 10/11/10 at 2:40 p.m. S27 reported that he arrived on the adolescent girls unit at approximately 2:30 p.m. on 10/08/10. S27 reviewed the assignment sheet for the 10/08/10 evening shift (3:00 a.m. thru 11:00 p.m.) and indicated that three patients including Patient #4 had no MHT assigned to them based on the assignment sheet for this shift. S27 reported that he had the Tech Note/Observation Sheet for these three patients including Patient #4. S27 stated that S23MHT "handed him" the "Tech Sheets" and he did not refuse them. S27 indicated that male MHT's are not supposed to take "Tech Sheets" on adolescent girl patients because male MHT's are not allowed down the halls of the adolescent girls unit to check on the female patients. S27 indicated that he took a group of girls to the outside area of the unit at approximately 3:30 p.m. - 3:45 p.m. and did not re-enter the inside of the unit until approximately 5:00 p.m. S27 stated that Patient #4 did not attend the group session that begins at 3:00 p.m. and ends at 3:30 p.m. S27 reviewed the documentation on the Tech Notes/Observation Sheet for Patient #4. S27 confirmed that he documented that Patient #4 was in group at 3:15 p.m. under constant visual observation, was in Room Awake under constant visual observation at 3:30 p.m., and was in Room Awake at 3:45 p.m., 4:00 p.m., 4:15 p.m., 4:30 p.m., and 4:45 p.m. S27 indicated that he did not see Patient #4 from the time he went to the outside area of the unit at approximately 3:30 p.m. - 3:45 p.m. thru the time she (Patient #4) was found hanging in her room at approximately 5:10 p.m. on 10/08/10. S27 indicated that the documentation he entered on the Tech Note/Observation Sheet (from 3:30 p.m. thru 4:45 p.m.) on 10/08/10 indicating that he performed the q 15 minute visual observations on Patient #4 was false as he did not perform the q 15 minute visual observations on Patient #4 for this period of time. S27 indicated that he did not ask any of the female staff members to go and perform the q 15 minute checks on Patient #4 and was not sure if the q 15 minute visual observations were actually performed on Patient #4 for this period of time on 10/08/10.

The hospital approved policy/procedure titled "Nursing Staffing & Patient Classification Acuity System" was reviewed. The "Policy" is documented as "It is the policy of Crossroads Regional Hospital (CRH) to ensure that patients receive quality nursing care, through the specialized skills of RNs, LPNs and Mental Health Technicians to provide a safe therapeutic environment. CRH utilizes a standard format for measuring individual patient acuity levels". The "Purpose" of the policy/procedure is documented as "CRH provides a measurement of the psychological, psychosocial, and physical needs of each patient to promote consistency and continuity in the delivery of patient care by staff on all shifts". The "Procedure" documents that the RN on each shift will assess each patient's needs before making assignments to other nursing staff.. The "Procedure" further documents "The patient care assignments are assigned in accordance to the acuity of the patient and the qualifications of each staff member" and "The RN will ensure prompt recognition of any change in a patient's condition and facilitate appropriate intervention by the nursing staff".
The hospital approved policy/procedure titled "Assessment/Treatment of Patients" was reviewed. The policy/procedure documents "It is the policy of Crossroads Regional Hospital that each patient will be monitored throughout his or her hospitalization according to an assigned observation status. The patient's status is assigned at the time of admission, re-evaluated and changed as clinically indicated. Observation of the patient by clinical staff members will be accomplished to maintain patient/employee safety in the least restrictive manner". The policy/procedure indicates that there are three status levels, Status A which is a strict One to One observation within arms reach length of the patient at all times, Status B which is constant visual observation maintaining line of sight on the patient at all times, and Status C which is visualizing the patient at least every 15 minutes.

The Director of Nursing (DON) was interviewed on 10/13/10 at 11:12 a.m. The DON reported that the registered nurse was responsible for patient care assignments to the MHT's (Mental Health Technicians) on the unit. The DON reviewed the assignment sheet for the evening shift on the female adolescent unit and reported that the assignment sheet was not complete in that 3 patients (including Patient #4) were not assigned to a MHT. The DON reported that S27 is a male MHT and indicated that a male MHT should not have had Tech/Observation sheets on a female adolescent patient. The DON explained that unless in an emergency situation, male MHT's are not allowed to go down the hall on a female adolescent unit to check on, or to perform 15 minute observations, on female adolescent patients. The DON was unable to provide documentation to indicate that the registered nurse had assigned patient care duties to the mental health technicians based on the registered nurses assessment of the patients needs on the 10/08/10 evening shift on the girls adolescent unit.

Based on observation, interview and record reviews, the hospital failed to ensure a Registered Nurse (RN) was available to supervise the care of patients and staff on all of the psychiatric units of the hospital. This was evidenced by 1) failure of the hospital to have the availability of a RN should a patient experience a medical or psychiatric emergency which required the services of a RN. This was evident when a RN on Unit A left the hospital ill on 10/08/10 between the hours of 12:53 p.m. until 2:35 p.m. without a replacement RN assigned to the unit. The unit had 19 adolescent patients on Unit A on 10/08/10 between the hours of 12:53 p.m. until 2:35 p.m.; 2) failure to assign a Registered Nurse on Unit B on 10/15/10 at 10:42 a.m. while the RN assigned to the unit left the unit for 50 minutes to attend a meeting. The unit had a census of 18 adolescent patients left under the supervision of only non-licensed MHT's; 3) failure of the hospital to ensure the RN supervised the care of each patient and the MHT's as evidenced by MHT's not having documented evidence of performing the every 15 minute observations of the patients. Findings:

1. Failure of the hospital to have the availability of a RN should a patient experience a medical or psychiatric emergency which required the services of a RN. This was evident when a RN on Unit A left the hospital ill on 10/08/10 between the hours of 12:53 p.m. until 2:35 p.m. without a replacement RN assigned to the unit. The unit had 19 adolescent patients on Unit A on 10/08/10 between the hours of 12:53 p.m. until 2:35 p.m.

In an interview on 10/13/10 at 9:15 a.m. with S14LPN, she stated she was the LPN assigned to Unit A, which is a locked adolescent unit, on 10/08/10 for the 7:00 a.m. to 3:00 p.m. shift. She further stated that the RN on the unit "left at lunch because she was not feeling well." She further stated that no RN was assigned to Unit A from 1:00 p.m. to 3:00 p.m. on 10/08/10. (the actual times from the Electronic Time Records were 12:53 p.m. to 2:35 p.m. when the evening shift RN came in) The unit had a census of 19 adolescent patients on 10/08/10.

By review of the Electronic Time Records it was determined that there was no registered nurse on Unit A for approximately 1.5 hours on the day shift on 10/08/10. The registered nurse (S41) assigned to Unit A for the day shift (7:00 a.m. to 3:00 p.m.) clocked out at 12:53 p.m. on 10/08/10 and the oncoming registered nurse (S44) clocked in at 2:35 p.m. on 10/08/10. This resulted in no registered nurse being immediately available for the patients on Unit A which is a locked acute care psychiatric unit for over 1.5 hours (12:53 p.m. through 2:35 p.m.).
The DON confirmed that there was no registered nurse assigned to Unit A on 10/08/10 from 12:53 p.m. through 2:35 p.m. as the day shift registered nurse (S41) left early.

2. Failure to assign a Registered Nurse on Unit B on 10/15/10 at 10:42 a.m. while the RN assigned to the unit left the unit for 50 minutes to attend a meeting. The unit had a census of 18 adolescent patients left under the supervision of only non-licensed MHT's.
An observation was made on Unit B on 10/15/10 at 10:42 a.m. that revealed neither a Registered Nurse (RN) nor a Licensed Practical Nurse (LPN) was present on the unit at this time.
An interview was held with S34 Lead Mental Health Technician on 10/15/10 at 10:42 a.m. S34 indicated the RN and LPN assigned to Unit B had been off of the unit since 10:00 a.m. to attend an in-service meeting. S34 reported there were currently 18 patients on Unit B ranging in ages from 7 to 17 years of age. S34 added that all of the patient's were listed as a Status B which required the 18 patients to be within eyesight of a staff member at all times.
An additional observation and an interview was held with S17RN and S24LPN on 10/15/10 at 10:50 a.m. on Unit B in the presence of S1CEO. S17 and S24 indicated they had just returned to Unit B after attending a mandatory in-service meeting. S17 and S24 indicated they left the unit at 10:00 a.m. to attend the meeting in another area of the hospital. S17 and S24 further indicated they were aware there were no nurses on the unit when they left their assigned patients on Unit B in the care of Mental Health Technicians at 10:00 a.m. until their return to Unit B at 10:50 a.m.
Review of the staff development sign in sheet for the meeting held on 10/15/10 at 10:00 a.m. revealed S17RN and S24LPN had both signed in and were in attendance at this meeting. The agenda for this meeting included patient acuity classification system, staffing plan, patient observation status categories, unit staff break log, assignment sheets, personal phone calls, Monday through Friday Clerk and duties, assigning staff to respond to codes, and dress codes.
An interview was held with S1CEO 10/15/10 at 11:15 a.m. S1 confirmed that Unit B had been left without a RN for 50 minutes, from 10:00 a.m. to 10:50 a.m. S1 further indicated she got S17RN and S24LPN out of the in-service meeting to return to their assigned patients on Unit B. S1 indicated she was not aware there was no RN on Unit B during the 10:00 a.m. mandatory in-service meeting. S1 added both nurses used no critical thinking skills when leaving their assigned unit unattended by a nurse.

3. Failure of the hospital to ensure the RN supervised the care of each patient and the MHT's as evidenced by MHT's not having documented evidence of performing the every 15 minute observations of the patients as ordered.
Review of the Tech/Observation sheets for 10/11/10 at 11:35 a.m. for 10 patients assigned to S20MHT (R1, R2, R3, R4, R5, R6) and S21MHT (R7, R8, R9, R10) revealed the documentation for all 10 patients assigned to the 2 MHT's had no documented evidence of the every 15 minute observation for 11:15 a.m. and 11:30 a.m. being performed per the physician order.
In an interview with S17RN at the time of the finding she confirmed that all 10 Tech/Observation sheets had no documented evidence of the every 15 minute observation for 11:15 a.m. and 11:30 a.m. She further confirmed that all 10 patients were status B patients which is constant visual observation maintaining line of sight on the patient at all times.
Review of a Tech/Observation sheet at 1:25 p.m. of a patient assigned to S21MHT on 10/10/10 at 1:30 p.m. revealed one of his patients (R7) had no documented evidence of the every 15 minute observation for 12:30 p.m., 12:45 p.m., 1:00 p.m., and 1:15 p.m. being performed.
In an interview with S1CEO at the time of the finding she confirmed there was no documented evidence of the every 15 minute observation for 12:30 p.m., 12:45 p.m., 1:00 p.m., and 1:15 p.m. being performed.
Review of a Tech/Observation sheet at 1:25 p.m. of a patient assigned to S21MHT on 10/10/10 at 1:30 p.m. revealed one of his patients (R3) had no documented evidence of the every 15 minute observation for 1:00 p.m. and 1:15 p.m. being performed.
In an interview with S1CEO at the time of the finding she confirmed there was no documented evidence of the every 15 minute observation for 1:00 p.m. and 1:15 p.m. being performed.
The hospital approved policy/procedure titled "Assessment/Treatment of Patients" was reviewed. The policy/procedure documents "It is the policy of Crossroads Regional Hospital that each patient will be monitored throughout his or her hospitalization according to an assigned observation status. The patient's status is assigned at the time of admission, re-evaluated and changed as clinically indicated. Observation of the patient by clinical staff members will be accomplished to maintain patient/employee safety in the least restrictive manner". The policy/procedure indicates that there are three status levels, Status A which is a strict One to One observation within arms reach length of the patient at all times, Status B which is constant visual observation maintaining line of sight on the patient at all times, and Status C which is visualizing the patient at least every 15 minutes.

Based on record review, interview and observations, the hospital failed to meet the nursing care needs of the patients by 1) failure to staff the acute care psychiatric unit in accordance with the hospital approved policy/procedure titled "Nursing Staffing & Patient Classification Acuity System" resulting in the hospital's inability to ensure the safety and supervision of patients hospitalized on the acute care psychiatric unit. The hospital failed to ensure that the nursing unit was staffed with the number of nursing personnel as indicated in their policy/procedure on multiple days including 10/08/10. This was evidenced by nursing services inability to ensure the safe supervision and delivery of care to adolescent psychiatric patients hospitalized on the acute care psychiatric unit as evidenced by the hanging death of Patient #4 on 10/08/10; 2) failure of the hospital to ensure a RN was assigned to each unit of the hospital at all times by not having a RN on Unit A on 10/08/10 from 12:53 p.m. until 2:35 p.m. due to the RN leaving the hospital for illness without a replacement RN on the unit. This affected all 19 of the patients on Unit A on 10/08/10; 3) failure to assign a Registered Nurse on Unit B on on 10/15/10 at 10:42 a.m. while the RN assigned to the unit left the unit for 50 minutes to attend a meeting in another part of the hospital. The unit had a census of 18 adolescent patients left under the supervision of only non-licensed MHT's. Findings:

1. Failure to staff the acute care psychiatric unit in accordance with the hospital approved policy/procedure titled "Nursing Staffing & Patient Classification Acuity System" resulting in the hospital's inability to ensure the safety and supervision of patients hospitalized on the acute care psychiatric unit. The hospital failed to ensure that the nursing unit was staffed with the number of nursing personnel as indicated in their policy/procedure on multiple days including 10/08/10. This was evidenced by nursing services inability to ensure the safe supervision and delivery of care to adolescent psychiatric patients hospitalized on the acute care psychiatric unit as evidenced by the hanging death of Patient #4 on 10/08/10.

Patient #4: Review of the medical record revealed that Patient #4 was admitted to Crossroads Regional Hospital (CRH) on 09/24/10 at 3:45 p.m. Review of the admission orders revealed S30MD was the attending physician and gave a provisional admitting diagnosis of depression. Further review of the admission orders revealed S30 MD ordered for Patient #4 to be assigned a "Status B" (Constant Visual Observation, Unit Restriction) observation level. Review of the Psychiatric Evaluation dated 09/25/10 revealed that Patient #4 had poor insight, poor judgement, and poor impulse control. Further review of the Psychiatric Evaluation revealed that Patient #4's Axis I "Provisional Diagnosis" was "Mood Disorder NOS (not otherwise specified)", "Impulse Control Disorder NOS", "Conduct Disorder Adolescent Onset" and "History of Polysubstance Abuse (in forced remission)". The justification for inpatient hospitalization included "Potential danger to self as evidenced by her self-injurious behavior". Review of the record revealed orders dated 10/01/10 at 9:45 a.m. to place Patient #4 on a Status C observation level which is visual observation of the patient at least every 15 minutes.

Review of the Multi-Disciplinary Progress Note for 10/08/10 at 11:00 p.m. revealed documentation by S44RN that read: "Patient noted approximately 1710 (5:10 p.m.) in bed area tied with sheet to bathroom door non-responsive, write(r) unable to remove sheet that was taut under patient's chin and under flat door handle. Other staff immediately summoned to help get patient down, 911 called, staff down hall immediately in room CPR (cardiopulmonary resuscitation) started til [sic] help arrived. Dr. (S30MD) contact approximately 1710 (5:10 p.m.) arrived 1725 (5:25 p.m.). Ambulance arrived. (S1CEO) and (S2DON) arrived later. Police (APD) (Alexandria Police Department) on unit later. Writer unable to reach OCS. OCS contacted later per (S1CEO) and arrived on unit later and notified. Patient taken out per stretcher per ambulance workers. CPR in progress. Patient still unresponsive on departure".

Review of a handwritten Physician Progress Notes with a date/time of 10/08/10 at 5:40 p.m. read: "Addendum. Called by RN earlier this afternoon with report that pt was found hanging from a door in her room. I returned to the hospital and found staff doing CPR on patient. Pt was observed with no pulse and no spontaneous breathing. Staff had already called 911 and the ambulance arrived within a minute of my being there. Paramedics continue to do CPR until pt was taken to the local hospital for continued resuscitation.

Review of a handwritten Physician Progress Notes with a date/time of 10/08/10 at 7:40 p.m. read: "Spoke by phone with Dr. (name) at (hospital "b") E.R. (emergency room) who told me that pt expired. Will ask hospital to notify OCS and family".

Review of the Tech Notes/Observation Sheet for 10/08/10 revealed that S27 (Mental Health Technician) documented the q 15 minute checks from 3:15 p.m. to 4:45 p.m. on Patient #4. The documentation read as follows: 3:15 p.m. - PD (group/Continuous Visual); 3:30 p.m. - HD (Room Awake/Continuous Visual); 3:45 p.m. - H (Room Awake); 4:00 p.m. - H (Room Awake); 4:15 p.m. - H (Room Awake); 4:30 p.m. - H (Room Awake); 4:45 p.m. - H (Room Awake). The 4:45 p.m. entry was the last entry on the Tech Notes/Observation Sheet relating to the 15 minute observations of Patient #4.

The registered nurse (S44) who worked as the Female Adolescent Unit Charge Nurse on the evening shift (3:00 p.m. - 11:00 p.m.) on 10/08/10 was interviewed on 10/11/10 at 5:30 p.m. S44 stated she came on duty on 10/08/10 at 3:00 p.m. S44 stated that she went to take patient report and that S24LPN, S29MHT and S27MHT were not in report. S44 stated that group was in session when she finished report at about 3:15 p.m. S44 stated that she was unsure if Patient #4 was in group. S44 stated that she went outside after report as all the patients were either in the dayroom or outside as were all 4 of the MHT's on duty. S44 stated she did not ensure that all patients had an MHT assigned to them and that she did not make patient care assignments on 10/08/10. S44 stated she was not aware of Patient #4's whereabouts from 3:00 p.m. until 5:10 p.m. on 10/08/10. S44 stated that she took Patient #5 to the restroom across the hall from Patient #4's room at approximately 5:05 p.m. on 10/08/10. S44 stated that upon leaving the room with Patient #5 she could see the legs of Patient #4 "hanging". S44 stated that she noticed a sheet "tight" around the neck of Patient #4 and that she (Patient #4) was "unresponsive". S44 indicated that she then went to the nurse's station calling out for someone to "call 911". S44 indicated that she opened the window to the Adult unit and told the RN (S4RN) to "call 911, I got a patient and I think she is dead". S44 stated that the shift was short staffed in MHT's. In a follow up interview on 10/13/10 at 11:15 a.m., S44 confirmed that she was the unit charge nurse and only registered nurse assigned to the adolescent girls unit on the evening shift on 10/08/10. S44 confirmed that she did not make the MHT assignments on the adolescent girls unit on the evening shift on 10/08/10. S44 reported that she did not check the assignment sheet to ensure all patients had an MHT assigned to them.

The MHT (S27) who documented on the Tech Note/Observation Sheet that he conducted the q 15 minute observations on Patient #4 from 3:15 p.m. to 4:45 p.m. on 10/08/10 was interviewed on 10/11/10 at 2:40 p.m. S27 reported that he arrived on the adolescent girls unit at approximately 2:30 p.m. on 10/08/10. S27 reviewed the assignment sheet for the 10/08/10 evening shift (3:00 a.m. thru 11:00 p.m.) and indicated that three patients including Patient #4 had no MHT assigned to them based on the assignment sheet for this shift. S27 reported that he had the Tech Note/Observation Sheet for these three patients including Patient #4. S27 stated that S23MHT "handed him" the "Tech Sheets" and he did not refuse them. S27 indicated that male MHT's are not supposed to take "Tech Sheets" on adolescent girl patients because male MHT's are not allowed down the halls of the adolescent girls unit to check on the female patients. S27 indicated that he took a group of girls to the outside area of the unit at approximately 3:30 p.m. - 3:45 p.m. and did not re-enter the inside of the unit until approximately 5:00 p.m. S27 stated that Patient #4 did not attend the group session that begins at 3:00 p.m. and ends at 3:30 p.m. S27 reviewed the documentation on the Tech Notes/Observation Sheet for Patient #4. S27 confirmed that he documented that Patient #4 was in group at 3:15 p.m. under constant visual observation, was in Room Awake under constant visual observation at 3:30 p.m., and was in Room Awake at 3:45 p.m., 4:00 p.m., 4:15 p.m., 4:30 p.m., and 4:45 p.m. S27 indicated that he did not see Patient #4 from the time he went to the outside area of the unit at approximately 3:30 p.m. - 3:45 p.m. thru the time she (Patient #4) was found hanging in her room at approximately 5:10 p.m. on 10/08/10. S27 indicated that the documentation he entered on the Tech Note/Observation Sheet (from 3:30 p.m. thru 4:45 p.m.) on 10/08/10 indicating that he performed the q 15 minute visual observations on Patient #4 was false as he did not perform the q 15 minute visual observations on Patient #4 for this period of time. S27 indicated that he did not ask any of the female staff members to go and perform the q 15 minute checks on Patient #4 and was not sure if the q 15 minute visual observations were actually performed on Patient #4 for this period of time on 10/08/10.

The Director of Nursing (DON) was interviewed on 10/13/10 at 11:12 a.m. The DON reported that the registered nurse was responsible for patient care assignments to the MHT's (Mental Health Technicians) on the unit. The DON reviewed the assignment sheet for the evening shift on the female adolescent unit and reported that the assignment sheet was not complete in that 3 patients (including Patient #4) were not assigned to a MHT. The DON reported that S27 is a male MHT and indicated that a male MHT should not have had Tech/Observation sheets on a female adolescent patient. The DON explained that unless in an emergency situation, male MHT's are not allowed to go down the hall on a female adolescent unit to check on, or to perform 15 minute observations, on female adolescent patients. The DON was unable to provide documentation to indicate that the registered nurse had assigned patient care duties to the mental health technicians based on the registered nurses assessment of the patients needs.

The hospital approved policy/procedure titled "Assessment/Treatment of Patients" was reviewed. The policy/procedure documents "It is the policy of Crossroads Regional Hospital that each patient will be monitored throughout his or her hospitalization according to an assigned observation status. The patient's status is assigned at the time of admission, re-evaluated and changed as clinically indicated. Observation of the patient by clinical staff members will be accomplished to maintain patient/employee safety in the least restrictive manner." The policy/procedure indicates that there are three status levels, Status A which is a strict One to One observation within arms reach length of the patient at all times, Status B which is constant visual observation maintaining line of sight on the patient at all times, and Status C which is visualizing the patient at least every 15 minutes.
The Chief Executive Officer (CEO) and Director of Nursing (DON) were interviewed on 10/12/10 at 10:30 a.m. When asked how nursing staffing levels and needs are determined on the acute care psychiatric units in the hospital, the CEO indicated that staffing levels and staffing needs are based on the number and acuity level of patients who are on the unit. The DON confirmed that staffing levels and staffing needs are based on the number of patients on the unit and the acuity level of the patients who are on the unit. When asked for the policy/procedure relating to staffing the acute care psychiatric units, the CEO presented the hospital approved policy/procedure titled "Nursing Staffing & Patient Classification Acuity System" (most recent revision date of this policy/procedure was 7/16/10).
The hospital approved policy/procedure titled "Nursing Staffing & Patient Classification Acuity System" was reviewed. The "Policy" is documented as "It is the policy of Crossroads Regional Hospital (CRH) to ensure that patients receive quality nursing care, through the specialized skills of RNs, LPNs and Mental Health Technicians to provide a safe therapeutic environment. CRH utilizes a standard format for measuring individual patient acuity levels". The "Purpose" of the policy/procedure is documented as "CRH provides a measurement of the psychological, psychosocial, and physical needs of each patient to promote consistency and continuity in the delivery of patient care by staff on all shifts". The "Procedure" documents that a RN is assigned to each unit, each shift, and will supervise and evaluate the nursing care each patient receives. The "Procedure" further documents that the RN in charge will evaluate each patient utilizing the 3 established patient classification levels (Level 1 or Status A, Level 2 or Status B, & Level 3 or Status C). The "Procedure" documents "After completion and review of acuity sheets by the charge RN, plans for staffing are based on the required nursing hours. Accuracy of acuity data is reviewed daily by the DON, Staffing Coordinator, or other designee". Review of page 3 of the policy/procedure revealed a worksheet that is used to determine staffing needs based on the patients observation status. The worksheet is titled "Patient Classification Rating/Observation Status Assignment Form". This worksheet is to be completed by the unit charge nurse and identifies the acuity level of the patients on the unit by factoring in the number of patients on the unit who are assigned to be on an Observation Status A, the number of patients on the unit who are assigned to be on an Observation Status B, and the number of patients on the unit who are assigned to be on an Observation Status C. Interview with the DON on 10/12/10 at 11:50 a.m. revealed that this worksheet is used by her (DON) and/or the Staffing Coordinator to determine the number of nursing personnel needed to staff each unit on each shift.
The "Patient Classification Rating/Observation Status Assignment Form" worksheets (10/01/10 thru 10/09/10 with focus on the female adolescent unit) were reviewed on 10/12/10 at 3:00 p.m. in the presence of the DON. This review revealed inconsistencies with the completion of these worksheets by the unit charge nurses. Several of the worksheets were noted to be incomplete in that the section relating to the observation level of the patients was not filled in resulting in the inability to determine the number of patients assigned to be on an observation status A (one to one), observation status B (constant visual observation), and observation status C (visual observations at least every 15 minutes). The worksheets from the female adolescent unit were incomplete on the day shift (7:00 a.m. thru 3:00 p.m.) on 10/01/10, 10/05/10, 10/06/10, and the evening shift (3:00 p.m. thru 11:00 p.m.) on 10/05/10. The DON confirmed that there are inconsistencies with the completion of these worksheets. The DON reported that these worksheets should have been completely filled out by the unit charge nurses so that they could be used to determine the staffing needs of the unit. When asked if there was another method to determine the acuity level of patients on the female adolescent unit, the DON reported that information relating to the acuity level of the unit could be found on the daily staffing sheets.

The nursing services daily staffing sheets (10/01/10 thru 10/09/10 with focus on the female adolescent unit) were reviewed on 10/13/10 at 8:30 a.m. in the presence of the DON. The daily staffing sheets included information such as the unit census, the observation status of the patients on the unit, and the staff who worked on the unit. This review revealed inconsistencies with the completion of the daily staffing sheets as information relating to the observation status of the patients on the unit was not consistently included on the staffing sheets. The observation status of the patients on the female adolescent unit was not documented on the staffing sheets for the day shift (7:00 a.m. thru 3:00 p.m.) on 10/02/10 and 10/03/10; the evening shift (3:00 p.m. thru 11:00 p.m.) on 10/02/10, 10/03/10, 10/04/10, 10/05/10, 10/07/10 and 10/08/10; and the night shift (11:00 p.m. thru 7:00 a.m.) on 10/01/10, 10/02/10, 10/03/10, 10/04/10, 10/05/10, 10/07/10 and 10/09/10. The DON confirmed that information relating to the observation status of patients on the unit was not consistently included on the staffing sheets and indicated that this information should be included on the staffing sheet.
On 10/13/10 between 12:30 p.m. and 2:00 p.m., the "Patient Classification Rating/Observation Status Assignment Form" worksheets, the nursing services daily staffing sheets, employee time sheets and the hospital approved policy/procedure titled "Nursing Staffing & Patient Classification Acuity System" were reviewed in the presence of the DON. The purpose of this review was to obtain information relating to the census and observation status of the patients on the female adolescent unit (10/01/10 thru 10/09/10) in order to determine the number of staff needed to provide care in a safe setting to the patients hospitalized on this acute care psychiatric unit. After factoring in the number and observation status of the patients on the female adolescent unit, it was determined that the female adolescent unit was not staffed in accordance with the hospital's policy/procedure. The female adolescent unit was found to be understaffed by at least one (1) nursing services staff member on all shifts on 10/01/10, 10/02/10, 10/03/10, 10/04/10, 10/07/10 and 10/08/10. In addition, it was determined that there was no registered nurse on the female adolescent unit for approximately 1.5 hours on the day shift on 10/08/10. The registered nurse (S41) assigned to the female adolescent unit on the day shift (7:00 a.m. thru 3:00 p.m.) clocked out at 12:53 p.m. on 10/08/10 and the oncoming registered nurse (S44) clocked in at 2:35 p.m. on 10/08/10 resulting in no registered nurse being immediately available for the 19 female adolescent patients on this locked acute care psychiatric unit for over 1.5 hours (12:53 p.m. thru 2:35 p.m.). The DON confirmed that the unit was understaffed by at least one (1) nursing services staff member on 10/01/10, 10/02/10, 10/03/10, 10/04/10, 10/07/10 and 10/08/10. The DON reported that the shortage was due to the high acuity level of the patients on the female adolescent unit as the majority of patients were on a status B observation level which is constant visual observation. The DON confirmed that there was no registered nurse assigned to the female adolescent unit on 10/08/10 from 12:53 p.m. thru 2:35 p.m. as the day shift registered nurse (S41) left early.
The CEO was interviewed on 10/13/10 at 2:00 p.m. The CEO reviewed the "Patient Classification Rating/Observation Status Assignment Form" worksheets, the nursing services daily staffing sheets, employee time sheets and the hospital approved policy/procedure titled "Nursing Staffing & Patient Classification Acuity System" and confirmed that the female adolescent unit was understaffed by at least 1 nursing services staff member on all shifts on 10/01/10, 10/02/10, 10/03/10, 10/04/10, 10/07/10 and 10/08/10.
2. Failure of the hospital to ensure a RN was assigned to each unit of the hospital at all times by not having a RN on Unit A on 10/08/10 from 12:53 p.m. until 2:35 p.m. due to the RN leaving the hospital for illness without a replacement RN on the unit. This affected all 19 of the patients on Unit A on 10/08/10.

In an interview on 10/13/10 at 9:15 a.m. with S14LPN she stated she was the LPN assigned to Unit A on 10/08/10 for the 7:00 a.m. to 3:00 p.m. shift. She further stated that the RN on the unit "left at lunch because she was not feeling well." She further stated that no RN was assigned to Unit A from 1:00 p.m. to 3:00 p.m. on 10/08/10.

By review of the Electronic Time Records it was determined that there was no registered nurse on Unit A for approximately 1.5 hours on the day shift on 10/08/10. The registered nurse (S41) assigned to Unit A for the day shift (7:00 a.m. to 3:00 p.m.) clocked out at 12:53 p.m. on 10/08/10 and the oncoming registered nurse (S44) clocked in at 2:35 p.m. on 10/08/10. This resulted in no registered nurse being immediately available for the patients on Unit A which is a locked acute care psychiatric unit for over 1.5 hours (12:53 p.m. through 2:35 p.m.).
The DON confirmed that there was no registered nurse assigned to Unit A on 10/08/10 from 12:53 p.m. through 2:35 p.m. as the day shift registered nurse (S41) left early.

3. Failure to assign a Registered Nurse on Unit B on on 10/15/10 at 10:42 a.m. while the RN assigned to the unit left the unit for 50 minutes to attend a meeting in another part of the hospital. The unit had a census of 18 adolescent patients left under the supervision of only non-licensed MHT's.
An observation was made on Unit B on 10/15/10 at 10:42 a.m. that revealed neither a Registered Nurse (RN) nor a Licensed Practical Nurse (LPN) was on the unit at this time.
An interview was held with S34 Lead Mental Health Technician on 10/15/10 at 10:42 a.m. S34 indicated the RN and LPN assigned to Unit B had been off of the unit since 10:00 a.m. to attend an in-service meeting. S34 reported there were currently 18 patients on Unit B, ranging in ages from 7 to 17 years of age. S34 added that all of the patient's were listed as a Status B which required the 18 patients to be within eyesight of the five Mental Health Technicians at all times.
An additional observation and an interview was held with S17RN and S24LPN on 10/15/10 at 10:50 a.m. on Unit B in the presence of S1CEO. S17 and S24 indicated they had just returned to Unit B after attending a mandatory in-service meeting. S17 and S24 indicated they left the unit at 10:00 a.m. to attend the meeting. S17 and S24 further indicated they were aware there were no nurses on the unit when they left their assigned patients on Unit B in the care of Mental Health Technicians at 10:00 a.m.
Review of the staff development sign in sheet for the meeting held on 10/15/10 at 10:00 a.m. revealed S17RN and S24LPN had signed in and were in attendance at this meeting. The agenda for this meeting included patient acuity classification system, staffing plan, patient observation status categories, unit staff break log, assignment sheets, personal phone calls, Monday through Friday Clerk and duties, assigning staff to respond to codes, and dress codes.
An interview was held with S1CEO 10/15/10 at 11:15 a.m. S1 confirmed that Unit B had been left without a Registered Nurse from 10:00 a.m. to 10:50 a.m. S1 further indicated she got S17RN and S24LPN out of the in-service meeting to return to their assigned patients on Unit B. S1 indicated she was not aware there was no RN on Unit B during the 10:00 a.m. mandatory in-service meeting. S1 added both nurses used no critical thinking skills when leaving the unit unattended by a nurse.