HospitalInspections.org

Based on review of hospital Rules and Regulations of the Medical Staff, the hospital ' s Medical Staff Bylaws, and interviews, it was determined that the Governing Body failed to determine which categories of practitioners, to include non-physician providers, are eligible for appointment by the governing body.
This failure poses a high potential health and safety risk of poor quality medical care by not delineating who can be appointed to the hospital's medical staff.

Findings include:

The facility's Medical Staff Bylaws revealed: "... Medical Staff or Staff means the organizational component of all Members, including clinical psychologists, who hold an unrestricted license in this State and who are clinically privileged to provide patient care services in the Facility...Membership on the Medical Staff or the exercise of Temporary Privileges is a privilege that shall be granted to and continued with only professionally qualified and currently competent Members...The Staff shall be divided into Active, Associate, Courtesy, Consulting , Honorary, and Residents and Interns categories...."

The facility's Rules and Regulations of the Medical Staff revealed: "...Qualified Medical Personnel are those Licensed Independent Practitioner identified on Exhibit A...The Clinical Privileges available for any Practitioner who may seek to practice at Hospital, and any minimum criteria for requesting such Clinical Privileges, shall be set forth in the list for such Practitioner ' s speciality as is complied by the MEC (Medical Executive Committee) and approved by the Governing Board...."

The facility's Rules and Regulations of the Medical Staff Exhibit A revealed: "...The following Licensed Independent Practitioners are recognized as Qualified Medical Personnel...Physicians...urse practitioners...registered nurses...masters-level social workers...other equivalent masters-level clinical staff...."

Employee # 11 confirmed during a confidential interview conducted on April 8, 2016 that she is in charge of credentialing. She also confirmed that there are two Physician Assistants ( PA-C # 1 and PA-C # 2) currently seeing patients at the hospital. She was able to answer any questions concerning the Rules and Regulations of the Medical Staff and the Medical Staff Bylaws.

The Director of Quality and Risk Management confirmed during a confidential interview conducted on April 8, 2016 that the Rules and Regulations of the Medical Staff and the Medical Staff Bylaws do not specify the categories of practitioners, to include non-physician providers, that are eligible for appointment by the governing body. She also confirmed that there is no mention of Physician Assistants being able to be appointed and have privileges at the facility. She also confirmed that there are two Physician Assistants ( PA-C # 1 and PA-C # 2) currently seeing patients at the hospital.

Based on review of hospital policies/procedures, medical records and interviews, it was determined that the hospital failed to protect and promote each patient's rights as evidenced by:

(A144) failure to ensure that patients receive care in a safe setting, for 4 of 4 minor patients that eloped from the adolescent unit (Pt #s 1, 2, 3 and 4), posing a high risk to the health, safety and well being of these four patients.

(A178) failure to ensure that patients, who require restraint for the management of violent or self-destructive behavior, be seen face-to-face within 1 hour after the initiation of the intervention by a physician, other licensed independent practitioner, trained RN or Physician Assistant, posing a risk of an unidentified change in medical condition;

(179) failure to ensure evaluation of a patient's medical condition, at the time of the face-to-face evaluation conducted after restraint for the management of violent or self-destructive behavior posing a risk of an unidentified change in medical condition; and

(A185) failure to ensure that the method of physical restraint be documented when physical restraint is required for the management of violent or self-destructive behavior posing a risk to patient safety due to use of unapproved methods of physical restraint.

The cumulative effect of these systemic problems resulted in the hospital's failure to meet the requirements of the Condition of Participation for Patient Rights.

Based on direct observation of the Octillo (Adolescent) Unit and review of a video recording of the elopement of four adolescent patients on 3/15/16, and interview, it was determined that the hospital failed to ensure that patients receive care in a safe setting, for 4 of 4 minor patients that eloped from the adolescent unit (Pt #s 1, 2, 3 and 4), posing a high risk to the health, safety and well being of these four patients.

Findings include:

Direct observation of the Ocotillo Unit, conducted on 3/22/16, revealed a chair positioned in the hallway, just outside of the nurses' station. The Director of Risk Management stated, on 3/22/16, that the chair is a heavy chair and is used to allow patients to sit while staff measure vital signs and when patients use the telephone located in the hallway. When patients are not actually seated in the chair, it remains in the hallway.

The surveyors viewed a video recording on, 3/23/16 and 3/24/16, of events which occurred on the evening of 3/15/16. The video recording revealed clear images of Pt # 4 moving the chair from in front of the nurses' station midway down the hallway, and Pt # 3 moving the chair farther down the hallway and closer to the fire doors. BHT # 8 stopped and spoke with Pt # 4 as s/he sat in the chair that s/he had moved. This chair was placed across from his/her room, and was the chair that was routinely positioned close to the nurses' station. BHT # 8 made no visible attempt to return the chair to it's usual position. BHT # 8 made no visible attempt again to return the chair to its usual position after Pt # 3 moved it closer to the end of the hall. Pts # 1, 2, 3 and 4 were all at the end of the hall with the chair and were gathered at the fire doors. The nursing staff was not visible on the video but were located at the opposite end of the hall from the four patients. Pt #s 1 and # 2 swung the chair backwards and then threw it against the fire doors, breaking the doors open. Pts # 1, 2, 3 and 4 exited the building through the doors. Staff were several feet away at the opposite end of the hall at the time the patients eloped. BHT # 9 was in the day
room with other patients at the time of the incident. RN # 4 was in the medication room and RN # 5 had just returned from seeing a patient's family during visitation. BHT # 8 was at the opposite end of the hall, assisting patients.

The Director of Risk Management and the Director of Social Services confirmed, during the viewing of the video on 3/24/16, that the video was authentic and revealed how the patients were able to move the chair down the hall toward the fire doors without staff intervention. The patients then used the chair to break open the fire doors.

Based on review of hospital policy/procedure, medical records, personnel files and interview, it was determined that the hospital failed to ensure that patients, who require restraint for the management of violent or self-destructive behavior, be seen face-to-face within 1 hour after the initiation of the intervention by a physician, other licensed independent practitioner, trained RN or Physician Assistant for 5 of 5 patients (Pt #s 12, 11, 17, 13 and 31) assessed by 6 RNs and 1 LPN, posing a risk of an unidentified change in medical condition.

Findings include:

Review of hospital policy titled Seclusion and Restraint revealed: "...Seclusion and Restraint use is implemented as a last resort to ensure the safety of patients and others...S/R (Seclusion/Restraint) procedures are considered to be unusual, high-risk events that warrant timely assessment and continuous monitoring...A provider or nursing supervisor conducts a face to face assessment of the patient within one hour of initiation of seclusion/restraint. Special consideration of abuse history, physical/psychological status, and staff's sensitivity to patient's needs is noted...."

Pt # 12's medical record contained documentation that s/he was placed in physical restraint on 3/10/16, from 1945, until 1950. Review of the documentation of the one-hour face-to-face assessment revealed that it was completed by LPN # 28, at 2005.

Pt # 11's medical record contained documentation that s/he was placed in physical restraint on 3/19/16, from 0926 until 0930 and seclusion, from 0932 until 0945. Review of the documentation of the one-hour face-to-face assessment revealed that it was completed by RN # 18, at 1000.

Pt # 11's medical record contained documentation that s/he was placed in physical restraint on 3/22/16, from 0842 until 0843 and seclusion from 0843 until 0846. Review of the documentation of the one-hour face-to-face assessment revealed that it was completed by RN # 21, at 0930.

Pt # 11's medical record contained documentation that s/he was placed in physical restraint on 3/23/16, from 1931 until 1932. Review of the documentation of the one-hour face-to-face assessment revealed that it was completed by LPN # 28, at 1945.

Pt # 17's medical record contained documentation that s/he was placed in physical restraint on 4/11/16, from 1810 until 1813 and seclusion from 1813 until 1855. Review of the documentation of the one-hour face-to-face assessment revealed that it was completed by RN # 7, at 1900.

Pt # 13's medical record contained documentation that s/he was placed in physical restraint on 3/21/16 from 1030 until 1031. Review of the documentation of the one-hour face-to-face assessment revealed that it was completed by RN # 21, at 1100.

Pt # 31's medical record contained documentation that s/he was placed in physical restraint on 11/26/15, from 2042 until 2044. Review of the documentation of the one-hour face-to-face assessment revealed that it was completed by RN # 29, at 2131.

Pt # 31's medical record contained documentation that s/he was placed in physical restraint on 11/27/15, from 1100 until 1102 and seclusion from 1102 until 1107. Review of the documentation of the one-hour face-to-face assessment revealed that it was completed by RN # 26, at 1106.

Pt # 31's medical record contained documentation that s/he was placed in physical restraint on 11/29/15, from 1043 until 1053 and seclusion from 1053 until 1115. Review of the documentation of the one-hour face-to-face assessment revealed that it was completed by RN # 30, at 1115.

The Director of Quality and Risk Management confirmed, during interview conducted on 4/12/16, that LPN # 28 was not permitted to complete the one-hour face-to-face assessment for Pt #s 11 and 12, per policy.

Review of hospital Shift Assignment Sheets revealed that RN #s 18, 21, 7, 29, 26 and 30 function as Shift Supervisors or Relief Shift Supervisors.

Review of the personnel files of the above listed RNs revealed that they did not contain documentation of competence in performing the 1 hour face-to-face evaluation of apatients' medical condition. The files did contain self-attestation agreements to abide by the requirements of the face-to-face evaluation requirements, but they did not contain documentation of training to perform assessment of each patient's medical condition after a restraint.

On 4/14/16, the Director of Nursing reviewed the training content, with the surveyor, for RN Supervisors to conduct the one-hour face-to-face assessment. She confirmed that the training does not include a review of systems, a comprehensive review of the patient's condition or determination of the RN's competence in conducting either a systems review or a physical assessment. She confirmed that the training received by the RN's consists of instructions for completion of the form used for documentation. She was unable to provide documentation of competence of RN #s 18, 21, 7, 29, 26 or 30 to evaluate the medical condition of Pt #s 11, 17, 13 and 31 after a physical restraint.

Based on review of hospital policy/procedure, medical records and interviews, it was determined that the hospital failed to ensure that an evaluation of the patients' medical condition was conducted after the restraint of 5 of 5 patients for the management of violent or self-destructive behavior (Pt #s 12, 11, 17, 13 and 31), posing a risk of an unidentified change in medical condition.

Findings include:

Review of hospital policy/procedure titled Seclusion and Restraint revealed: "...Seclusion and Restraint revealed: "...A provider or nursing supervisor conducts a face to face assessment of the patient within one hour of initiation of seclusion/restraint. Special consideration of abuse history, physical/psychological status... completed to ensure that the use of S/R (Seclusion/Restraint) poses no undue risk to the patient's physical or psychological well-being...incorporates the following:...physical and psychological well-being of the patient...."

Review of hospital form titled Seclusion and Restraint On-Site Face To Face revealed a section titled Physical Well Being. This section contained a box for the evaluator to mark: "No injuries and status physical unchanged subsequent to event (WNL)" and a box to mark, indicating: "Injuries noted". Beneath the latter choice was space to document "Location", a space for "Description" and a space for "Recommendation". The section also contained: "Treatment Orders Written: Yes; No; Not applicable."
The form did not contain space to document assessment of the patient's medical condition or vital signs.

Review of Pt # 12's medical record revealed a one-hour face-to-face assessment, completed on 3/10/16, at 2005, after a physical restraint. The box indicating "No injuries" was marked with no other documentation of the patient's medical condition. Pt # 12's History and Physical Examination (H and P), completed on 2/23/16, contained documentation of a surgical scar on Pt # 12's right arm from Spindle Cell Carcinoma surgery in 2015. It also contained documentation that Pt # 12 had "cuts" on her left arm and abdomen at the time of the H and P. Pt # 12 had started to "bang her head on the door" and "kicks the glass on door multiple times" prior to the restraint. The documentation of evaluation of Pt # 12's medical condition did not include any assessment of head, neck, or extremities. Vital signs were not documented.

Review of Pt # 11's, medical record revealed one-hour face-to-face assessments conducted after physical restraints on 3/19/16, 3/22/16 and 3/23/16. Documentation included assessment and treatment of self-inflicted "stabbing" wounds of Pt # 11 on 3/19; assessment and treatment of superficial self-inflicted "scratches" on 3/22/16; and "No injuries and status physical unchanged subsequent to event (WNL)" on 3/23/16. Pt # 11's medical record contained documentation that s/he had "started to violently throw punches at staff members" prior to the restraint on 3/19/16; s/he had "began hitting walls, kicking door, breaking ice machine...hitting, kicking, spitting at staff" prior to restraint on 3/22/16; and had thrown a chair and "kicked cafe exit door" prior to restraint on 3/23/16. Pt # 11's History and Physical Examination (H and P), completed on 2/21/16, contained documentation that Pt # 11 had an upper respiratory infection. None of the one-hour face-to-face assessments included documentation of Pt # 11's medical condition, other than the specific injuries mentioned above. No vital signs were documented as part of the assessment of Pt # 11's of medical condition.

Review of Pt # 17's medical record revealed a one-hour face-to-face assessment, completed on 4/11/16, at 1900, after a physical restraint. Documentation included that Pt # 17 was "screaming and yelling and kicking all exit doors". The one-hour face-to-face assessment was documented as: "No injuries and status physical unchanged subsequent to event (WNL). The assessment did not include documentation of the evaluation of Pt # 17's medical condition. No vital signs were recorded.

Review of Pt # 13's medical record revealed a one-hour face-to-face assessment completed on 3/21/16, at 1100, after a physical restraint. Documentation included that Pt # 13 was "hitting wall, kicking." The one-hour face-to-face assessment was documented as: "No injuries and status physical unchanged subsequent to event (WNL)." The assessment did not include documentation of the evaluation of Pt # 17's medical condition. No vital signs were recorded.

Review of Pt # 31's medical record revealed one-hour face-to-face assessments completed on 11/26/15, at 2131, on 11/27/16, at 1106, and on 11/29/16, at 1043, after physical restraints and seclusion. Documentation included that Pt # 31 was "trying to hit her head on floor and trying to scratch face" prior to the restraint on 11/26/16. Pt # 31 attempted to physically "charge" another disruptive patient prior to the restraint on 11/27/16. Pt # 31 was "found in her bathroom with pants tied around her neck tight. Pants removed from pt's neck. pt began banging head extremely hard, scratching face and attempting to bite staff" prior to the restraint on 11/29/15. All of the assessments were documented as "No injuries and status physical unchanged subsequent to event (WNL)." Pt # 31 has a documented history of asthma. None of the face-to-face assessments included documentation of the evaluation of Pt # 31's medical condition including assessment of pain, head and neck or respiratory status. No vital signs were recorded. Nursing did not contact the provider regarding possible head injury.

The Director of Quality and Risk Management confirmed, during interview conducted on 4/12/16, that the documentation of the above patients' one-hour face-to-face assessments did not include documentation of the evaluation of their medical condition.

The Director of Nursing confirmed, during interview conducted on 4/14/16, that the documentation of the above patients' one-hour face-to-face assessments did not include documentation of the evaluation of their medical condition.

Based on review of hospital policy/procedure, medical records and interview, it was determined that the hospital failed to require documentation, in 5 of 5 patients' medical records, of the method of physical restraint used, when physical restraint was required for the management of violent or self-destructive behavior. (Pt #s 12, 11, 17, 13 and 31) This deficient practice poses a high risk to patient safety due to potential use of unapproved methods of physical restraint.

Findings include:

Review of hospital policy/procedure titled Seclusion and Restraint revealed: "...The RN in collaboration with unit staff evaluates the patient's behavior and implements appropriate (Crisis Prevention Institute: CPI) techniques to maintain patient and staff safety for escort to the seclusion area...If physical restraint is indicated, 2 staff must participate in the physical hold application using CPI non-violent physical Team Control Position. One additional staff member will be present and in front of the patient to provide ongoing observation of the techniques used and the well-being of the patient and staff...If physical restraint is indicated the CPI Team Control Position will be used as a brief intervention to allow for regaining control of the patient symptoms...If physical restraint is indicated and the patient's symptoms do not resolve during the brief physical restraint staff will initiate the patient to seclusion using the CPI Team Transport Position. If the patient begins to struggle during transport staff will return to the Team Control Position immediately...."

The Quality Improvement Coordinator confirmed, during interview conducted on 4/14/16, that staff are to document the specific extremities controlled by each staff and the method used to control and/or escort each patient during a physical restraint.

Pt # 12's medical record contained documentation that s/he was placed in a physical restraint on 3/10/16, from 1945, until 1950. The Seclusion and Restraint Intervention Progress Note contained documentation of the "lead nurse", and the LPN was at the "R arm" and the BHT was at the "L arm". The Seclusion & Restraint Observation & Flow Sheet contained documentation : "...1945...Self harming behavior lead to restraint...1948...Aggressive (sic) and self harming behavior warranting restraint continued...1950...Patient is released from the restraint...."

Pt # 11's medical record contained documentation that s/he was placed in a physical restraint on 3/19/16, from 0926 until 0930 and in seclusion from 0932 until 0945. The Seclusion and Restraint Intervention Progress Note contained documentation that four RNs and three BHTs (Behavioral Health Technicians) were "Participants". Documentation on the Seclusion & Restraint Observation & Flow Sheet included: "...0926...Pt scratching at arms, spitting at staff, throwing pillow & punches at staff...0927...pt calming out of restraint...0928...tying clothing around neck...0929...pt calming out of restraint...0929...pt self harming stabbing self with pen...0930...pt released from hold...0932...seclusion initiated...0936...pt remains agitated scratching at arms...0940...pt continues to be agitated...0945...pt calming out of restraint...."

Pt # 11's medical record contained documentation that s/he was placed in a physical restraint on 3/22/16, from 0842 until 0843 and in seclusion from 0843 until 0846. The Seclusion and Restraint Intervention Progress Note contained a list of three RNs, a BHT, an Intern and the Quality Improvement Coordinator as "Staff Involved in Intervention." Next to each name were the words "Restraint" or "RN/Assessment." Documentation included: "...Pt physically restrained and placed in seclusion, nurse administered Haldol...Benadryl...Ativan...per NP (Nurse Practitioner) ordered...."

Pt # 11's medical record contained documentation that s/he was placed in a physical restraint on 3/23/16, from 1931 until 1932. The Seclusion and Restraint Intervention Progress Note contained the names of one LPN, one RN, and two BHTs. In the column headed "Role" the BHTs were listed as "observer hold/CPI" and the nurses were listed as "observer". The Seclusion and Restraint Observation & Flow Sheet contained documentation: "...Staff and patients arms become intertwined and patient breaks staffs fall...patient begins to calm down and removes herself from the dining room...." The column to record the time was blank.

Pt # 17's medical record contained documentation that s/he was placed in a physical restraint on 4/11/16, from 1810 until 1813, and in seclusion from 1832 until 1855. The Seclusion and Restraint Intervention Progress Note contained the names of three RNs and two BHTs as "Staff involved in intervention." In the column headed "Role" the BHTs were listed as "Restraint", one RN was listed as "Lead" and the other two RNs were listed as giving injections and/or obtaining orders. The Seclusion and Restraint Observation & Flow Sheet contained documentation: "...pt was aggressive & restraint initiated when she ran onto Cholla through seclusion room...."

Pt # 13's medical record contained documentation that s/he was placed in a physical restraint on 3/21/16, from 1030 until 1031. The Seclusion and Restraint Intervention Progress Note contained the first names of two RNs and three BHTs. The column headed "Role" was blank. The Seclusion and Restraint Observation & Flow Sheet contained documentation: "...1030...patient placed in physical restraint...1031...IM Haldol administered...1031...restraint released...."

Pt # 31's medical record contained documentation that s/he was placed in a physical restraint on 11/26/15, from 2042 until 2044. The Seclusion and Restraint Intervention Progress Note contained the first and last name of one BHT and the first name of an RN. The column headed "Role" was blank. The Seclusion and Restraint Observation & Flow Sheet contained documentation: "...2042...(Pt # 31) was placed in seclusion room with door open...she was laid on seclusion bed...2044...was released from restraint and sat up in bed...."

Pt # 31's medical record contained documentation that s/he was placed in a physical restraint on 11/27/15, from 1100 until 1102 and seclusion from 1102 until 1107. The Seclusion and Restraint Intervention Progress Note contained the name of one RN and one BHT. The RN was listed as "nurse" in the column headed "role" and the BHT was listed as "escort to Seclusion". The Seclusion and Restraint Observation & Flow Sheet contained documentation: "...1100...Pt. attempted to attack another pt. Escorted to seclusion.

Pt # 31's medical record contained documentation that s/he was placed in a physical restraint on 11/29/15, from 1043 until 1053 and seclusion from 1053 until 1115. The Seclusion and Restraint Intervention Progress Note contained the name of one RN and three BHTs. The column headed "Role" contained documentation for two BHTs: "Physical restraint & Seclusion"; one BHT was listed as "Seclusion" and the RN was listed as "Seclusion, orders, IM meds." The Seclusion and Restraint Observation & Flow Sheet contained documentation: "...1043...Pt escorted to seclusion room Pt refused to walk...."

The medical records of the patients listed above did not contain documentation/description of the method of physical restraint intervention used to escort and or control the patients.

The Quality Improvement Coordinator confirmed, during interview conducted on 4/14/16, that staff are to document the specific extremities controlled by each staff and the method used to control and/or escort each patient during a physical restraint. This information is to be included on the Seclusion and Restraint Intervention Progress Note. She confirmed that none of the medical records listed above contained the required documentation of the description of the intervention used by staff in the physical restraints.

Based on review of hospital policies and procedures, Restraint and Seclusion Log, facility's Quality Program, and staff interviews, it was determined the hospital's quality program failed to assess and implement new interventions for restraint and seclusion face to face assessment completed by an LPN for two of two patients. (Patient # 11 and 12)

This failure poses a high potential health and safety risk of the quality of patient care in restraints not being monitored appropriately.

Findings include:

Review of the hospital policy " Seclusion and Restraint " revealed: "...A provider or nursing supervisor conducts a face to face assessment of the patient within one hour of initiation of seclusion/restraint...."

Review of the " Restraint and Seclusion Log " revealed "...Patient # 12 's chart for restraint and seclusion was reviewed on March 14, 2016 for quality data...." The log revealed that the face to face assessment was completed by an RN at 2005.

Pt # 12's medical record contained documentation that she was placed in physical restraint on 3/10/16, from 1945 until 1950. Review of the documentation of the one-hour face-to-face assessment revealed that it was completed by LPN # 28, at 2005.

The Director of Quality and Risk Management confirmed, during interview conducted on April 15, 2016, that the data collected from the chart review conducted on March 14, 2016 was incorrect and that LPN # 28 completed the face to face assessment.

Review of the Restraint and Seclusion log revealed: " ...Patient # 11 ' s chart for restraint and seclusion was reviewed on March 28, 2016...." The log revealed that the face to face assessment was completed by an LPN with no time documented.

Pt # 11's medical record contained documentation that she was placed in physical restraint on 3/23/16, from 1931 until 1932. Review of the documentation of the one-hour face-to-face assessment revealed that it was completed by LPN # 28, at 1945.

The Director of Quality and Risk Management confirmed, during interview conducted on April 15, 2016 that the restraint and seclusion log is used by the quality program to collect data to identify opportunities for improvement and changes that will lead to improvement. She also confirmed that the data collected about the face to face assessment being completed by LPN # 28 on March 28, 2016. She also confirmed that LPN # 28 was not permitted to complete the one-hour face-to-face assessment for Pt #s 11 and 12, per policy.

There was no documentation available for surveyor review at time of the survey to show that the Quality Program put new interventions in place. The quality program identified the LPN completed the face to face assessment after a restraint on March 28, 2016. The quality program did not put into place any new interventions and evaluations of these interventions to prevent the LPN from continuing to complete the face to face assessments.

The Director of Quality and Risk Management confirmed, during interview conducted on April 15, 2016 that the facility did not have documentation that the quality management department identified the LPN completing the face to face assessment after restraints as an opportunity for improvement. She also confirmed that the facility did not have any documentation of new interventions and evaluation.

Based on review of Rules and Regulations of the Medical Staff, hospital policies/procedures, medical records and interviews, it was determined that the medical staff failed to be responsible for the quality of medical care provided to 4 of 4 minor patients who eloped from the hospital's adolescent unit, (Pt #s 1, 2, 3 and 4); which poses a high risk to health, safety and life for each of these patients.

Findings include:

Review of the Rules and Regulations of the Medical Staff revealed: "...Each clinical Practitioner will adhere to all written Hospital policies, procedures, protocols, and guidelines...The Practitioner participates in effective hand-off communication, including up-to-date information regarding the patients care, treatment, condition and any recent or anticipated changes...Each of the patient's clinical problems should be clearly identified in the progress note and correlated with specific orders, as well as results of tests and treatments...."

Review of hospital policy/procedure titled Plan for the Provision of Care revealed: "...All treatment teams are responsible to the team leader, who is the attending physician.

Review of hospital policy/procedure titled Level of Precautions revealed: "...Policy: All patients admitted to Oasis Behavioral Health (OBH) will be assessed for needs of various precautions...AWOL/Elopement precautions...All patients admitted to OBHH will be assessed at admission and throughout stay for risk factors of AWOL/elopement from the facility. Level of risk is based on assessment of history, behavior and patient statements...An RN may increase to a more restrictive level of observation prior to obtaining a provider order, but a provider order should be obtained as soon as possible...Precautions for AWOL/Elopement may include:...Maintaining close proximity to the patient...Redirecting patient away from doors, exits, or fences...Confiscate shoes or coats...Meals and activities should be on the unit except by provider order...Thorough and accurate communication and documentation...."

Review of hospital policy/procedure titled Level Of Observation revealed: "...Close Observation:...Unit restriction: patient is not permitted to leave unit for off unit activities or outside patio use until cleared by provider...Staff will engage patient to remain in common unit areas and discourage extensive stay in patient room...."

Review of Pt # 1's medical record revealed:

Pt # 1 was a minor with a history of threatening harm to others, suicidal ideation, substance abuse and multiple episodes of running away from home and treatment facilities. S/he had been expelled from school.

On 3/14/16, at 1200, PA-C # 2 (Physician's Assistant-Certified) documented in a progress note, that a fellow patient reported to staff that Pt # 1 and 2 other male patients were planning to attack a staff worker and steal keys to AWOL. The progress note did not contain any change in level of observation, implementation of precautions or a plan regarding AWOL risk or risk of Danger to Others. Pt # 1 and one of the 2 other male patients, who were identified as planning to AWOL, shared a room. This room was the closest room to the fire doors.

On 3/15/16, at 1215, PA-C # 1 documented: "...'Its ridiculous that I am on close observation. Just for the record I have no intentions of escaping'...Continued inpatient care is necessary to avoid emotional and behavioral decompensation...."

Pt # 1's medical record did not contain provider orders for AWOL Precautions or Close Observation.

Review of Pt # 2's medical record revealed:

Pt # 2 was a minor who had a history of self harm, with multiple self-inflicted lacerations. S/he had been expelled from school. S/he had thoughts to harm others and a prior suicide attempt.

On 3/14/16, at 1300, PA-C # 2 documented that a fellow patient reported to staff that Pt # 2 and 2 other male patients were planning to attack a staff worker and steal keys to AWOL. The progress note did not contain any change in level of observation, implementation of precautions or a plan regarding AWOL risk or risk of Danger to Others. Pt # 2 and Pt # 1, who were identified as planning to AWOL, shared a room. This room was the closest room to the fire doors.

Pt # 2's medical record did not contain provider orders for AWOL Precautions or Close Observation.

On 3/15/16, at 0950, PA-C # 1 documented: "...Pt reports he is not planning on going AWOL and reports its (Pt # 3)'s plan...."

Review of Pt # 3's medical record revealed:

Pt # 3 was a minor who was admitted due to Suicidal Ideation with plans and intent to overdose or shoot himself/herself. A friend had committed suicide the previous week. S/he was suspended from school. S/he had thoughts of hopelessness and was increasingly socially isolated.

On 3/14/16, at 1500, PA-C # 2 documented that a fellow patient reported to staff that Pt # 3 and 2 other male patients were planning to attack a staff worker and steal keys to AWOL. The progress note did not contain any change in level of observation or implementation of precautions or a plan regarding AWOL risk or risk of Danger to Others.

On 3/15/16, at 1400, an RN recorded PA-C # 1's verbal order to place Pt # 3 on Close Observation due to AWOL Risk. Pt # 3's medical record did not contain an order for AWOL Precautions.

Review of Pt # 4's medical record revealed:

Pt # 4 was a minor who had been admitted to the hospital with a history of running away from a Group Home, threats of suicide and previous suicide attempts. S/he stated at the time of admission that s/he did not want to be in the facility.

Pt # 4's medical record contained nursing documentation, completed by RN # 6 on 3/15/16, at 1100, of AWOL risk score of "10" and "Plotting w/peers."

PA-C # 1 documented Pt # 4's Inpatient Psychiatric Evaluation on 3/15/16, at 1350. The Psychiatric Evaluation contained documentation that Pt # 4 was "...brought in by Peoria PD (Police Department). After being a run-away from Group home...."

Pt # 4's medical record did not contain provider orders for AWOL Precautions. PA-C # 1 discontinued orders for Close Observation, on 3/15/16, at 1350.

PA-C # 1 stated in an interview conducted on 3/23/16 that PA-C # 2 informed him/her on 3/14/16 that 4 adolescents had been overheard planning to AWOL. RN # 7 had informed PA-C # 1, on 3/15/16, of the 4 adolescents' plan to AWOL. PA-C # 1 stated that since staff were already aware of the AWOL risk, PA-C # 1 did not need to write an order. RN # 7 had informed PA-C # 1 that all of the 4 adolescents were on Close Observation "per nursing judgment." PA-C # 1 stated that Pt # 1 may have been the leader of the plan and was known to be untruthful.

PA-C # 2 confirmed, during interview conducted on 3/24/16 that an RN gave him/her the information regarding the patients' plan to AWOL at the end of the day, on 3/14/16, after PA-C # 2 had finished seeing patients. S/he stated that it didn't seem like an acute risk. The RN didn't request an order. S/he stated that there is no difference between AWOL Precautions and what the staff do routinely. Staff always monitor the patients.

Nursing communicated to PA-C # 1 and # 2 of the plans of the 4 adolescents to elope. Neither PA-C # 1 nor PA-C # 2 wrote orders for AWOL precautions to be implemented for the 4 patients. Only Pt # 3 had orders for Close Observation which is not specific to AWOL risk.

Two of the four patients used a chair to break open the fire doors and all four patients eloped from the facility, on 3/15/16, at 1950.

Additional failures include:

(A339) failure of the Governing Body to determine which categories of non-physician providers are eligible for appointment by the governing body, posing a high potential risk to health and safety of patients by not delineating who can be appointed to the hospital's medical staff;

(A347) failure of the Governing Body to ensure that the medical staff executive committee was made up of a majority of physicians, posing a high potential risk to health and safety of patients of poor quality medical care; and

(A353) failure to enforce the Rules and Regulations of the Medical Staff, requiring authentication of verbal orders, posing a risk of incorrect implementation of orders and risk to health and safety of patients.

The cumulative effect of these systemic problems resulted in the hospital's failure to meet the requirements of the Condition of Participation for Medical Staff.

Based on review of hospital Rules and Regulations of the Medical Staff, the hospital 's Medical Staff Bylaws, and interviews, it was determined that the Governing Body failed to determine which categories of practitioners, to include non-physician providers, are eligible for appointment by the governing body.

This failure poses a high potential health and safety risk of poor quality medical care by not delineating who can be appointed to the hospital's medical staff.

Findings include:

Review of the Medical Staff Bylaws reveal: "... Medical Staff or Staff means the organizational component of all Members, including clinical psychologists, who hold an unrestricted license in this State and who are clinically privileged to provide patient care services in the Facility...Membership on the Medical Staff or the exercise of Temporary Privileges is a privilege that shall be granted to and continued with only professionally qualified and currently competent Members...The Staff shall be divided into Active, Associate, Courtesy, Consulting , Honorary, and Residents and Interns categories...."

Review of the Rules and Regulations of the Medical Staff reveal: "...Qualified Medical Personnel are those Licensed Independent Practitioner identified on Exhibit A...The Clinical Privileges available for any Practitioner who may seek to practice at Hospital, and any minimum criteria for requesting such Clinical Privileges, shall be set forth in the list for such Practitioner 's speciality as is complied by the MEC (Medical Executive Committee) and approved by the Governing Board...."

Review of the Rules and Regulations of the Medical Staff Exhibit A reveal: "...The following Licensed Independent Practitioners are recognized as Qualified Medical Personnel ...Physicians...nurse practitioners...registered nurses...masters-level social workers...other equivalent masters-level clinical staff...."

Employee # 11 confirmed during a confidential interview conducted on April 8, 2016 that she is in charge of credentialing. She also confirmed that there are two Physician Assistants ( PA-C # 1 and PA-C # 2) currently seeing patients at the hospital. She was able to answer any questions concerning the Rules and Regulations of the Medical Staff and the Medical Staff Bylaws.

The Director of Quality and Risk Management confirmed during a confidential interview conducted on April 8, 2016 that the Rules and Regulations of the Medical Staff and the Medical Staff Bylaws do not specify the categories of practitioners, to include non-physician providers, that are eligible for appointment by the governing body. She also confirmed that there is no mention of Physician Assistants being able to be appointed and have privileges at the facility. She also confirmed that there are two Physician Assistants ( PA-C # 1 and PA-C # 2) currently seeing patients at the hospital.

Based on review of the hospital's Medical Staff Bylaws, Medical Executive committee meeting minutes, and interviews, it was determined that the Governing Body failed to ensure that the medical staff executive committee was made up with a majority of physicians as evidenced by the medical executive committee not having a majority of physicians on the committee.

This failure poses a high potential health and safety risk of poor quality medical care by not being accountable for the quality of the medical care provided to the patients.

Findings include:

Review of the Medical Staff Bylaws reveal: "...Medical Staff Member or Member means a physician or other individual eligible to apply for Medical Staff membership who has applied for and obtained current membership with the Medical Staff...Medical Executive Committee...Composition...MEC (Medical Executive Committee) shall consist of Members, a majority of whom shall be fully licensed physician Members of the Active Staff...The remaining Members of the Committee shall be...the President of the Staff...the Vice President of the Staff (if any)...the Secretary-Treasurer of the Staff...and up to three (3) Members of the Active Staff who are elected by the Staff to serve the MEC for one (1) year...."

Review of the Medical Executive meeting minutes dated February 26, 2015 revealed that there was only one physician (MD # 3) that signed the attendance list out of eight attendees. The other seven attendees were non-physicians, to include the CEO, the CFO, the Chief Operating Officer of the Behavioral Health Inpatient Facility, the Director of Quality/Risk, the DON, the Director of Utilization Management, and the Executive Administrative Assistant.

Review of the Medical Executive Meeting/ Medical Staff Committee minutes dated September 9, 2015 revealed that there were five physicians (MD # 3, 6, 7, 11, and # 12) that signed the attendance list out of eleven attendees. The other six were non-physicians, to include the CEO, the Director of Quality, the DON, the HIMS Director, the Clinical Director of the Behavioral Health Inpatient Facility, and the Executive Administrative Assistant.

Review of the Medical Executive Meeting/ Medical Staff Committee minutes dated December 17, 2015 revealed that there were five physicians (MD # 3, 6, 11, 12 and # 13) that signed the attendance list out of sixteen attendees. The other eleven were non-physicians, to include the CEO, the Director of Quality, the DON, the Director of Social Services, the Director of Human Resources, the Executive Director of the Behavioral Health Inpatient Facility, the Clinical Director of the Behavioral Health Inpatient Facility, NP # 9, PA #1, PA #2, and the Executive Administrative Assistant.

The Director of Quality and Risk Management confirmed during a confidential interview conducted on April 13, 2016 that there is not a majority of physicians on the Medical Executive Committee. She also confirmed that MD # 3 is the only Physician on the Medical Executive Committee for 2016. She also stated that she does not know who holds the positions of the President of the Staff, the Vice President of the Staff, and the Secretary-Treasurer of the Staff on the Medical Executive Committee according to the Medical Staff Bylaws.

The Medical Director #3 confirmed during a confidential interview conducted on April 13, 2016 that there is not a majority of physicians on the Medical Executive Committee. He also confirmed that he along with MD # 14 are the Physicians on the Medical Executive Committee. He also stated that he is not aware that the Bylaws require the physician members of the Medical Executive Committee to hold offices as the President of the Staff, the Vice President of the Staff, and the Secretary-Treasurer of the Staff.

Based on review of Rules and Regulations of the Medical Staff, hospital policy/procedure, medical records and interviews it was determined the medical staff failed to enforce the Rules and Regulations when Psychiatrist/Provider #3 failed to authenticate his verbal admission orders for 2 of 2 patients who were admitted to the hospital. (current Patient #'s 23 and 24)

This failure poses a high potential risk of incorrect implementation of orders and risk to health and safety of patients.

Findings include:

Review of the Rules and Regulations of the Medical Staff revealed: "...Each Clinical Practitioner will adhere to all written Hospital policies, procedures, protocols, and guidelines...Verbal orders, if used, must be authenticated...Special Hospital: within 48 hours by a medical staff member or medical practitioner...."

Hospital policy/procedure titled "Authentication By Clinicians" requires: "...Verbal orders or telephone orders must be authenticated within 48 hours...."

Inpatient Admit Order revealed Patient #23 was admitted to the hospital on 03/29/16 at 1650 by Psychiatrist/Provider #3.

Inpatient Admit Order revealed Patient #24 was admitted to the hospital on 04/01/16 at 1542 by Psychiatrist/Provider #3.

The Director of Nursing and the Director of Risk/Quality Management confirmed during separate and confidential interviews conducted on 04/12/16, that the above Patients orders have not yet been authenticated.

Based on review of hospital policies/procedures, hospital documents, medical records and interviews, it was determined that the hospital failed to provide an organized nursing service 24-hours per day with an adequate number of registered nurses to assess patients' care needs and deliver, assign and supervise the care required by each patient as evidenced by:

(A386) failure to determine the number and type of nursing personnel necessary to provide nursing care to all areas of the hospital, as evidenced by:

1. failing to implement a method to determine the number and type of nursing personnel required to meet patient needs, posing a risk to patient safety due to patient care needs failing to be met; and

2. failing to include the patient care needs of patients assessed at high risk or on specific precautions in the scoring categories used to determine the required number and type of nursing personnel to meet the patient care needs, posing a risk to patient safety.

(A392) failure to have adequate numbers of licensed registered nurses to provide the nursing care required by all patients, as evidenced by:

1. failing to assign an RN to every patient as required by policy, posing a high risk that patients' clinical needs will remain unassessed and unmet; and

2. failing to have an RN present on a unit at all times to meet patient care needs, posing a high potential risk to patient health and safety.

(A395) failure to require that a registered nurse supervise and evaluate the care of each patient as evidenced by:

1. failing to implement Levels of Precautions and Levels of Observation, per hospital policy/procedure, for 4 of 4 minor patients who eloped from the facility (Pt #s 1, 2, 3 and 4);

2. failing to implement Level of Observation, per hospital policy/procedure, for 1 of 1 patient who required 1:1 Supervision ( Pt # 5); and

3. failing to provide ongoing RN assessment each shift for 1 of 4 patients who eloped from the facility (Pt # 3), posing a high risk of unassessed/unmet patient care needs; and

4. failing to assign an RN to each patient for supervision and evaluation of care, posing a high risk of unassessed/unmet patient care needs.

(A397) failure to ensure that a Registered Nurse assign the nursing care of each patient in accordance with the individual patients' needs and staff skill, posing a high risk of unmet patient care needs and risk to health and safety.

(A405) failure to ensure that physician-ordered medications were documented on the Medication Administration Record according to hospital policy, posing a risk of medication administration error.

The cumulative effect of these systemic problems resulted in the hospital's failure to provide an adequate, organized nursing service.

Based on review of hospital policies/procedures, hospital documents and interviews, it was determined that the Director of Nursing Services failed to determine the number and type of nursing personnel necessary to provide nursing care to all areas of the hospital, as evidenced by:

1. failing to implement a method to determine the number and type of nursing personnel required to meet patient needs, posing a risk to patient safety due to patient care needs failing to be met; and

2. failing to include the patient care needs of patients assessed at high risk or on specific precautions in the scoring categories used to determine the required number and type of nursing personnel to meet the patient care needs, posing a risk to patient safety.

Findings include:

Review of hospital policy/procedure titled Patient Acuity revealed: "...Oasis Behavioral Health is dedicated to the provision of quality nursing care and maintenance of a safe environment for patients. The staffing and acuity plan development, implementation and documentation are the responsibility of the Director of Nursing...Daily implementation of the plan is the responsibility of the nursing supervisors and unit nurses...Staffing for patient care is based on acuity and level of care needed for the psychiatric patient...To provide an assessment tool based on patient behaviors and needs for the psychiatric patient...To provide a framework for nursing staff to evaluate the nurse-to-patient ratio and nursing level of care needed...To provide for adequate coverage and ensure/maximize a safe therapeutic environment...The staffing and acuity plan is the hospital's method for establishing nursing personnel requirements needed to meet the patient needs/acuity...Each unit has a pre-determined maximum patient to staff ratio used as a guideline...(Staffing Matrix)...The hospital utilizes eight (8) hour shifts to provide continuous twenty-four (24) hour coverage. The Registered Nurse on each patient unit completes the acuity classification for each patient prior to the final determination of staffing for the next shift...Shift...Days...Shift Hours...0630-1500...Evenings...1430-2300...Nights...2230-0700...The maximum acuity score per staff member is RN: 60 per staff member and BHT: 40 per staff member. It is the responsibility of the Registered Nurse on the nursing unit to make the nurse/patient shift assignments...The total number of staff is determined by totaling the acuity hours on the Unit Summary Acuity Report...An RN oversees all patient care...The acuity patient category system will be completed on each eight (8) hour shift, two (2) hours prior to the end of the shift...The acuity report will be given to the nursing supervisor at two (2) hours prior to the next shift for review...At all times the Nursing Administration has ultimate responsibility for providing adequate staff coverage to provide a safe therapeutic environment...The physical environment...staff makeup, staff experience, staff qualifications, patient diagnoses, patient co-occurring conditions, patient ages, and patient developmental functioning all may have an effect on the acuity of the units and therefore on the staffing levels...."

Review of the Staffing Matrix revealed:

Inpatient Programs Day/Evening:

0-5 Patients: 1 RN and 1BHT
6-12 Patients: 1 RN and 1 BHT
13-20 Patients: 2 RN and 2 BHT

Inpatient Programs Night:

0-5 Patients: 1 RN and 1 BHT
6-12 Patients: 1 RN and 1 BHT
13-20 Patients: 1.5 RN and 1.5 BHT

1. The Acuity Plan, which was used to determine required number and type of nursing personnel to meet patient care needs, was based on 3 shifts. It includes minimum staffing (Staffing Matrix) for Day/Evening Shift, with Day Shift starting at 0630 and ending at 1500, Evening Shift starting at 1430 and ending at 2300, and the Night Shift commencing at 2230 and ending at 0700. The hospital currently is staffed with 12 hour shifts, with the Day Shift starting at 0630 and ending at 1900 and the Night Shift commencing at 1830 and ending at 0700.

Direct observation during survey and review of Shift Assignment Sheets from 3/1/16 through 4/15/16, revealed that the Cholla Unit, with a patient census of 16, and the Ocotillo Unit, with a patient census of 19, were routinely staffed with 1.5 RNs and 2 BHTs on the current 12-hour Day Shift and 12-hour Night Shift. Additional BHTs were added when patients required 1:1 supervision.

The DON confirmed, during interview conducted on 3/23/16, that the current shifts are 12 hours in length and the acuity plan is based on 8 hour shifts.

RN #s 5 and 6 confirmed, during interview conducted on 3/24/16, that 1.5 RN's are routinely assigned to work on Cholla and Ocotillo on the current 12-hour Day Shift and Night Shift.

RN # 7 confirmed, during interview conducted on 3/23/16, that 1.5 RN's are routinely assigned to work on Cholla and Ocotillo on the current 12-hour Day Shift and Night Shift.

RN # 18 confirmed, during interview conducted on 4/6/16, that 2 RN's are not assigned to work on Cholla or Ocotillo on the Day Shift which extends from 0630 until 1900. One RN is assigned to 12 patients on Cholla; one RN is assigned to 12 patients on Ocotillo; and one RN is "split" between the two units. 2 BHTs routinely work on each of the units. A BHT is added to the staffing when a patient requires 1:1 supervision.

RN # 5 confirmed, during interview conducted on 3/24/15, that the Day Shift starts at 0630 and ends at 1900. The Night Shift starts at 1830 and ends at 0700. S/he stated that the time frame from 1900 to 2030 is very difficult in terms of patient needs and staffing on the Ocotillo Unit. Visitation occurs off the unit. One BHT leaves the unit to accompany patients to the cafeteria to visit with family, etc. Patients remaining on the unit are making phone calls in the hallway and/or needing staff attention. Adolescent patients are required to remain out of their rooms. Nurses are preparing medication. One BHT may offer an activity in the Day Room. On the evening of the elopement of 4 adolescent patients, the BHT assigned to a patient who required 1:1 staff, supervised visitation off the unit. Pt #s 1, 2, 3 and 4 eloped at 1950.

The number of RN's assigned to the Cholla and Ocotillo Units does not meet the basic minimum staffing, per policy, based on patient census.

On 3/23/16, the DON and surveyor added the patient acuity scores, which were used to determine patient care needs, for patients on the Ocotillo and Cholla Units on the Day Shift of 3/14/16. The scores listed on the Shift Assignment Sheet did not coincide with the scores recorded on the Patient Needs Assessment Sheet to determine staffing. The maximum patient acuity score per RN is 60. The RN with the split assignment of patients on both of the units was assigned to patients with corrected total acuity scores of 72.

The DON confirmed, on 3/23/16, that the patient acuity scores listed on the Shift Assignment Sheet on Day Shift, 3/14/16, did not coincide with the Patient Needs Assessment Sheet. The scores on the assignment sheet were inaccurate for 14 of the 19 patients. She also confirmed that RN # 37, who was assigned to provide care for 7 patients on the Ocotillo Unit and 4 patients on the Cholla Unit had a total score of 72 which exeeds the maximum allowed for an RN. No variance was documented with an explanation. The policy/procedure for determining the number and type of nursing personnel to meet patients' needs was not implemented as required.

On 4/15/16, the surveyor and RN # 36 reviewed the patient acuity scores, which were used to determine the patient care needs for patients on the Ocotillo and Cholla Units on the Day Shift of 4/10/16. The scores listed on the Shift Assignment Sheet did not coincide with the scores recorded on the Patient Needs Assessment Sheet to determine staffing. The Patient Needs Assessment Sheets did not include patient names or initials for rooms 311 B and 312 B. Scores were listed beneath the blank spaces where patient initials should have been entered. Shift Assignment Sheets included names by the same room numbers. Patient initials entered on the Patient Needs Assessment Sheet for room 313 B were SB. The patient name listed on the Assignment Sheet for that room included a last name beginning with the initial K.

RN # 36 confirmed that the Patient Needs Assessment Sheets contained acuity scores for empty patient rooms and for patients with different initials. She confirmed that the information on the Patient Needs Assessment Sheets, used to determine patient care needs, did not correspond with the Shift Assignment Sheets.

RN # 6 confirmed, during interview conducted on 3/24/16, that the patient acuity scoring does not affect staffing. The acuity worksheets are completed at the end of the shift and are not used to plan staffing for the next shift.

RN # 7 stated, during interview conducted on 3/23/16, that acuity worksheets are completed 1 hour after the shift starts and can change later. They are placed in the notebook for the supervisor at the end of the shift.

RN # 4 confirmed, during interview conducted on 3/24/16, that frequently the nurses are too busy to accurately record the acuity scores for patients. The scores may be the scores recorded by the previous shift or, if a patient was discharged and a new patient was admitted to the vacated room and bed, the scores may not have been changed from the previous patient. S/he also confirmed that the method for determining the scores, which are to reflect patient care needs, varies between nurses.

2. Review of the Patient Needs Assessment worksheets titled RN and BHT Task Sheets, revealed that they are utilized by nursing to score each patient's care needs. These worksheets include tasks that RNs or BHTs are responsible to complete for patients. These worksheets do not include acuity scores for patients assessed at high risk for Self Harm, Vulnerability, AWOL, Danger to Others (DTO) Nutrition Hydration, Fall and/or Sexually Acting Out. The worksheets do not include acuity scores for patients placed on Precaution Levels, including Self Harm, DTO, Sexual Acting Out, AWOL/Elopement, Vulnerability and/or Fall, unless the patient requires redirection/de-escalation, additional medication, or requires specific task completion by a staff member. Scoring is included if a patient is placed on Close Observation or 1:1, but if a patient is at high risk and/or assigned a precaution level, without being placed on a 1:1 or Close Observation, his/her acuity score does not include those indications of patient care needs.

RN # 4 confirmed, during interview conducted on 3/24/16, and the CNO confirmed, during an interview conducted on 3/24/16, that the patient acuity scoring categories do not take into account the above risk factors or precaution levels, which reflect patient care needs for additional supervision and staffing.

RN # 5 confirmed, during interview conducted on 3/24/16 that the patient acuity scoring categories do not take into account patients' high risk factors. If an RN assesses a patient at high risk for any of the above categories, nursing intervention and/or increased monitoring is required, but the RN Task Sheet and BHT Task Sheet do not include high risk categories or precautions.

RN # 6 stated, during interview conducted on 3/24/16, that all of the 4 patients who eloped on 3/15/16, were on Close Observation, "per nursing judgment." RN # 7 stated, during interview conducted on 3/23/16, that all of the 4 patients were on Close Observation "per nursing judgment." Two different BHT Task Sheets (Patient Needs Assessment Task Sheets) were provided to the surveyor on 3/23/16, for the Day Shift of 3/15/16. One did not have any patients scored as requiring Close Observation. The second sheet had Pt #s 1 and 2 on Close Observation. Pt # 3 had a provider order for Close Observation and this was not reflected on the Night Shift or Day Shift BHT Task Sheets.

RN # 7 confirmed the discrepancies between the Task Sheets on the same dates and shifts. S/he stated that changes must have been made after the onset of the shifts.

Based on review of hospital policy/procedure, hospital documents, medical records and interviews, it was determined that the nursing service failed to have adequate numbers of licensed registered nurses to provide the nursing care required by all patients, as evidenced by:

1. failing to assign an RN to every patient as required by policy, posing a high risk that patients' clinical needs will remain unassessed and unmet; and

2. failing to have an RN present on a unit at all times to meet patient care needs, posing a high potential risk to patient health and safety.

Findings include:

Review of hospital policy/procedure titled Patient Acuity revealed: "...The staffing and acuity plan is the hospital's method for establishing nursing personnel requirements needed to meet the patient needs/acuity...Every patient is assigned an RN and a BHT...." The policy/procedure did not include the use of LPNs for patient care.

Review of the hospital document titled Shift Assignment Sheet revealed that it is used to indicate which staff is assigned to provide care for each individual patient. Columns on the sheet include a "Patient" column with all patient names listed vertically; a "Room" column, with room numbers listed vertically; a "Scores" column with the patient acuity scores listed as RN/BHT indicating the patient care needs met by an RN and the patient care needs met by a BHT; an "RN" column with the RN names listed vertically, indicating the RN assigned to each patient; and a "BHT" column with the names of BHTs listed vertically, indicating the BHT assigned to each patient. The Shift Assignment Sheet did not have a space for LPNs.

Review of Shift Assignment Sheets reviewed:

3/10/16, Ocotillo Unit, Night Shift: LPN # 28 was assigned to 7 patients from room 307 A through 310 A.
3/10/16, Cholla Unit, Night Shift: LPN # 28 was assigned to 4 patients from room 107 A through 108 B.
3/11/16, Ocotillo Unit, Night Shift: LPN # 28 was assigned to 7 patients from room 307 A through 310 A.
3/12/16, Ocotillo Unit, Night Shift: LPN # 28 was assigned to 7 patients from room 307 A through 310 A.
3/12/16, Ocotillo Unit, Night Shift: LPN # 33 was assigned to 12 patients from room 310 B through 316 B.
3/12/16, Cholla Unit, Night Shift: LPN # 28 was assigned to 4 patients from room 107 A through 108 B.
3/12/16, Cholla Unit, Day Shift: LPN # 28 was assigned to 4 patients from room 107 A through 108 B.
3/13/16, Ocotillo Unit, Day Shift: LPN # 28 was assigned to 7 patients for half of the shift from room 307 A through 310 A.
3/13/16, Cholla Unit, Day Shift: LPN # 28 was assigned to 4 patients for half of the shift from room 107 A through 108 B.
3/13/16, Cholla Unit, Night Shift: LPN # 28 was assigned to 4 patients from room 107 A through 108 B.
3/16/16, Mesquite Unit, Day Shift: No RN or BHT was listed on the Shift Assignment Sheet.
3/16/16, Cholla Unit, Night Shift: LPN # 28 was assigned to 3 patients from room 107 A through 108 A.
3/16/16, Ocotillo Unit, Night Shift: LPN # 32 was assigned to 7 patients from room 307 A through 310 A.
3/16/16, Ocotillo Unit, Night Shift: LPN # 28 was assigned to 11 patients from room 310 B through 316A.
3/17/16, Ocotillo Unit, Night Shift: LPN # 32 was assigned to 7 patients from room 307 A through 310 A.
3/17/16, Ocotillo Unit, Night Shift: LPN # 28 was assigned to 12 patients from room 310 B through 316 B.
3/17/16, Cholla Unit, Night Shift: LPN # 28 was assigned to 4 patients from room 107 A through 108 B.
3/18/16, Ocotillo Unit, Night Shift: LPN # 28 was assigned to 12 patients from room 310 B through 316 B.
3/21/16, Cholla Unit, Night Shift: LPN # 32 was assigned to 12 patients from room 109 A through 114 B.
3/22/16, Cholla Unit Night Shift: LPN # 32 was assigned to 12 patients from room 109 A through 114 B.
3/23/16, Ocotillo Unit Night Shift: LPN # 28 was assigned to 12 patients from room 310 B through 316 B.
4/8/16, Cholla Unit Night Shift: LPN # 28 was assigned to 4 patients.
4/8/16, Ocotillo Unit Night Shift: LPN # 28 was assigned to 7 patients from room 307 A through 310 A.
4/9/16, Cholla Unit Night Shift: LPN # 28 was assigned to 3 patients.
4/9/16, Ocotillo Unit Night Shift: LPN # 28 was assigned to 7 patients from room 307 A through 310A.
4/10/16, Cholla Unit Night Shift: LPN # 28 was assigned to 4 patients.
4/10/16, Ocotillo Unit Night Shift: LPN# 28 was assigned to 6 patients.

An RN was not assigned to any patients assigned to an LPN. The LPNs were listed with first name only in the columns designated for RN names on the Shift Assignment Sheets. The Patient Acuity Policy does not include the use of LPNs in the Staffing Plan. An RN was not assigned to any patients on the Ocotillo Unit on the Night Shifts on 3/12/16, 3/16/16 and 3/17/16.

The Director of Nursing confirmed, during an interview conducted on 4/7/16, that the patients assigned to the LPNs listed above are not assigned to an RN. She confirmed on 4/12/16, that the Acuity Policy does not include the use of LPNs in the Staffing Plan.

The Director of Quality and Risk Management confirmed that an RN was not assigned to every patient on every shift on the Ocotillo and Cholla Unit, as required by hospital policy. She also confirmed that the Ocotillo Unit was staffed with only LPNs on shifts identified above.

2. Direct observation and review of Shift Assignment Sheet for the Mesquite Unit on 4/6/16, revealed that one RN and one BHT were assigned to provide care to the 12 patients on the Mesquite Unit.

RN # 34 confirmed, during interview conducted on 4/6/16, that the Shift Assignment Sheet is reflective of the typical staffing on the unit. A second BHT will be added if a patient requires 1:1 supervision; RN's are not added. When the RN leaves the unit for a half hour meal break, the unit does not have an RN present to provide care to the patients if needed on an immediate basis. The BHT remains on the unit and would call for assistance from an RN with patient care assignments on another unit.

BHT # 35 confirmed, during interview conducted on 4/6/16, that s/he is the only staff available to patients on the unit when the RN takes a meal break each day.

Based on review of job descriptions, hospital policy/procedure, medical records and interviews, it was determined that the hospital failed to require that a registered nurse supervise and evaluate the care of each patient as evidenced by:

1. failing to implement Levels of Precautions and Levels of Observation, per hospital policy/procedure, for 4 of 4 minor patients who eloped from the facility (Pt #s 1, 2, 3 and 4);

2. failing to implement Level of Observation, per hospital policy/procedure, for 1 of 1 patient who required 1:1 Supervision ( Pt # 5); and

3. failing to provide ongoing RN assessment each shift for 1 of 4 patients who eloped from the facility (Pt # 3), posing a high risk of unassessed/unmet patient care needs; and

4. failing to assign an RN to each patient for supervision and evaluation of care, posing a high risk of unassessed/unmet patient care needs.

Findings include:

Review of Registered Nurse Job Description revealed: "...provides age specific patient assessment, planning, evaluation, and implementation of patient care...Delivers nursing care, observes, records and reports changes in patient's condition...Evaluates patient's behavior changes and choices...Assumes shift change responsibilities, directs and supervises nursing activities of team members...Evaluates intervention outcomes...."

Review of Behavioral Health Technician (BHT) Job Description revealed: "...Maintains a safe and efficient working and treatment environment per facility policies and procedures...Report Changes in patients (sic) condition or behavior to the Nurse, including agitation, high-risk behaviors...Act to preserve patient and family dignity and safety...."

1. Review of hospital policy/procedure titled Level of Precautions revealed: "...All patients admitted to Oasis Behavioral Health (OBH) will be assessed for needs of various precautions...Staff responsible for monitoring precautions shall maintain the patient in a safe environment and take measures to protect the patient...AWOL/Elopement Precautions...All patients admitted to OBHH (Oasis Behavioral Health Hospital) will be assessed at admission and throughout stay for risk factors of AWOL(Absent Without Leave)/elopement from the facility. Level of risk is based on assessment of history, behavior and patient statements...An RN may increase to a more restrictive level of observation prior to obtaining a provider order, but a provider order should be obtained as soon as possible...Precautions for AWOL/Elopement may include: a. Maintaining close proximity to the patient...b. Redirecting patient away from doors, exits, or fences...c. Ensure communication to all staff of high risk...d. Confiscate shoes or coats. Limiting access to personal items that are not ordinarily condsidered contraband is a denial of rights and requires a provider order and clear documentation of just cause...g. Meals and activities should be on the unit except by provider order...h. Thorough and accurate communication and documentation...Vulnerability Precautions...RN will notify provider of patients at High Risk of exploitation and warranting vulnerability precautions...Precautions for vulnerability risk may include:...a. Place patient in room within close proximity of the nursing station...b. Patient should not be placed in a room with a patient on DTO (Danger to Others) or SAO (Sexual Acting Out) precautions...c. Staff will maintain vigilance and enforce strict boundaries between this patient and patients on DTO or SAO precautions...d. Comprehensive hand off communication including risk of exploitation to all staff assuming care for this patient...."

Review of hospital policy/procedure titled Level of Observation revealed: "...Purpose:...In addition to recording the whereabouts of patients at ordered intervals, the purpose of observations is to provide a system of progressive intensity of patient observation and oversight based on patient acuity, severity/type of symptoms, and overall needs...Close Observation: a. Unit restriction: patient is not permitted to leave unit for off unit activities or outside patio use until cleared by provider...b. Staff will engage patient to remain in common unit areas and discourage extensive stay in patient room...Routine 15 minute observations: a. Minimum level of observation for all patients...At any time an RN based on clinical judgment can institute a more restrictive observation level, but must obtain an official order from a provider as soon as possible...The unit RN will assign staff to perform routine observations on a designated set of patients. a. Any special precautions...shall be identified to the assigned staff member...."

Review of Patient # 1's medical record revealed:

Pt # 1 was a minor with a history of threatening harm to others, suicidal ideation, substance abuse and multiple episodes of running away from home and treatment facilities. S/he had been expelled from school. Pt # 1's Multidisciplinary Treatment Plan signed by the provider on 3/9/16, at 0800, included a nursing intervention: "Close Observation due to AWOL risk". The order for Close Observation was discontinued on 3/9/16, at 1000.

On 3/14/16, at 1200, PA-C # 2 (Physician's Assistant-Certified) documented that a fellow patient reported to staff that Pt # 1 and 2 other male patients were planning to attack a staff worker and steal keys to AWOL. Pt # 1 and one of the 2 other male patients, who were identified as planning to AWOL, shared a room. This room was the closest room to the fire doors.

On 3/14/16, at 1415, RN # 6 documented Pt # 1's AWOL risk score of "10" (with 10+ = High Risk) and documented nursing interventions: "AWOL precautions met 1:1 w/ patient".

Pt # 1's medical record did not contain documentation that RN # 6 contacted the provider for an order for AWOL Precautions, as required, after nursing implementation of precautions.

The RN did not obtain an order and the medical record did not contain documentation that specific precautions were in place.

On 3/15/16, at 1050, RN # 6 documented Pt # 1's AWOL risk score of "10" and documented nursing interventions: "Close Obs". The RN did not obtain an order for Close Observations or AWOL Precautions.

Pt # 1's Q15 Patient Observation Records, dated 3/14/16 and 3/15/16 did not contain documentation that Pt # 1 was on AWOL Precautions or Close Observation.

On 3/16/16, RN # 5 completed her shift documentation at 0153 and documented: "...At approximately 1950 (on 3/15/16), pt AWOLed from the facility."

Review of Patient # 2's medical record revealed:

Pt # 2 was a minor who had a history of self harm, with multiple self-inflicted lacerations. S/he had been expelled from school. S/he had thoughts to harm others and a prior suicide attempt.

On 3/13/16, an RN documented that Pt # 2 stated that he "doesn't care about his/her life anymore."

On 3/14/16, at 1300, PA-C # 2 documented that a fellow patient reported to staff that Pt # 2 and 2 other male patients were planning to attack a staff worker and steal keys to AWOL. Pt # 2 and Pt # 1, one of the 2 other male patients who were identified as planning to AWOL, shared a room. This room was the closest room to the fire doors.

On 3/14/16, at 1400, RN # 6 documented an AWOL risk score of "10" (with 10+ = High Risk) for Pt # 2 and documented nursing interventions: "Peer reported pt is involved in a plan to AWOL, precautions in effect." Pt # 2's medical record did not contain documentation that RN # 6 contacted the provider for an order for AWOL Precautions, as required, after nursing implementation of precautions. The RN did not obtain an order and the medical record did not contain documentation that specific precautions were in place.

On 3/15/16, at 0217, RN # 5 documented an AWOL risk score for Pt # 2 of "10" with nursing interventions: "Monitor pt near doorways." The RN did not obtain an order for Close Observations or AWOL Precautions. S/he documented the intervention was "effective."

On 3/15/16, at 1000, RN # 6 documented Pt # 2's AWOL risk score of "10" and documented nursing interventions: "Close Obs". The RN did not obtain an order for Close Observation or AWOL Precautions.

Pt # 2's Q15 Patient Observation Record for 3/15/16 did not contain documentation that Pt # 2 was on AWOL Precautions or Close Observation.

On 3/16/16, RN # 5 completed her shift documentation at 0147 and rated Pt # 2's AWOL risk "10". The RN documented: "Monitor pt in hallways." S/he documented the intervention was "Ineffective- pt AWOL."

Review of Pt # 3's medical record revealed:

Pt # 3 was a minor who was admitted due to Suicidal Ideation with plans and intent to overdose or shoot himself/herself. A friend had committed suicide the previous week. S/he was suspended from school. S/he had thoughts of hopelessness and was increasingly socially isolated.

On 3/14/16, at 1500, PA-C # 2 documented that a fellow patient reported to staff that Pt # 3 and 2 other male patients were planning to attack a staff worker and steal keys to AWOL.

On 3/15/16, at 1400, an RN recorded PA-C # 1's verbal order to place Pt # 3 on Close Observation due to AWOL Risk. Pt # 3's medical record did not contain an order for AWOL Precautions. Nursing did not assess Pt # 3 as a high risk to AWOL.

Pt # 3's Q15 Patient Observation Record for 3/15/16 contained documentation that Pt # 3 was on Close Observation with Precaution Orders for Danger to Self. Pt # 3's medical record did not contain documentation that s/he was on AWOL Precautions or was a Danger to Others.

Review of Pt # 4's medical record revealed:

Pt # 4 was a minor who had been admitted to the hospital with a history of running away from a Group Home, threats of suicide and previous suicide attempts. S/he stated at the time of admission that s/he did not want to be in the facility.

On 3/14/16, at 1630, RN # 6 documented in Pt # 4's Nursing Admission Assessment a Vulnerability Risk Score of "10" (with 10+=High Risk). Pt # 4's medical record did not contain documentation that nursing implemented precautions or contacted the provider regarding implementing precautions. Pt # 4's medical record contained a provider's order for Close Observations on 3/14/16. Close Observations were discontinued on 3/15/16, at 1350.

RN # 6 stated during interview conducted on 3/24/16 that s/he was unaware that "Vulnerability Precautions" were different from Close Observations.

Pt # 4's Multidisciplinary Treatment Plan was initiated on 3/15/16, at 1055 and was unsigned by the provider. It contained documentation that Pt # 4 had run away from a Group Home.

RN # 7 stated during interview conducted on 3/23/16, that "everyone was alert" to the risk of elopement of Pts # 1, 2, and 3. They were first aware of the risk, on Sunday, 3/13/16. RN # 7 stated that Nursing had placed the patients on Close Observation "per nursing judgment" but did not obtain provider orders for Close Observation or AWOL Precautions. Pt # 3 was on Close Observation per provider order, effective 3/15/16. Nursing did not obtain provider orders for AWOL Precautions for any of the 3 patients. RN # 7 stated that s/he was not aware that nursing staff was required to obtain an order "as soon as possible" after placing a patient on Close Observation. She stated that she told the BHT to be alert when she observed that Pt # 2 was putting on his jacket at the beginning of the night shift (approximately 1900) on 3/15/16. S/he did not suggest obtaining an order for AWOL Precautions and/or implementing the requirements of AWOL Precautions.

RN # 6 stated, in an interview conducted on 3/24/16, that s/he was unaware of any difference between AWOL Precautions and Close Observation.

RN # 5 stated, during an interview conducted on 3/24/16, that there is no specific way to ensure that precautions are implemented since they are not written on the white board where levels of observations are written. She stated that she was unaware that an order was required "as soon as possible" after a nurse implemented Close Observation or AWOL Precautions. She stated that "close proximity", as stated in the AWOL Precautions, means within sight. Staff could be on the other end of the hall and be within close proximity.

RN # 4 stated, during interview conducted on 3/24/16 that s/he was unaware that when a nurse implements precautions per nursing judgment, that s/he is required to obtain a provider's order as soon as possible. S/he stated that "close proximity" means within arm's reach or close enough to physically intervene.

RNs # 4, 5, 6 and 7 confirmed that the policies/procedures for AWOL Precautions, Close Observation and Vulnerability Precautions were not implemented as required.

2. Review of hospital policy/procedure titled Level of Observation revealed: "...The three levels of observation in the facility are: 1:1 Supervision...Specified and dedicated staff member is assigned to the patient. Staff member will remain within one arm's length from the patient at all times...a specific provider order is needed for a patient on level 1 observation to leave the unit or to use the outside patio areas...."

Review of Pt # 5's medical record revealed:

Pt # 5 was a minor who was admitted due to intrusive thoughts of suicide by overdose.

On 3/15/16, at 1100, PA-C wrote an order: "place pt on 1:1 due to SI (Suicidal Ideation) staff to stay until pat is sleeping."

On 3/16/15 at 1330, an RN documented a telephone order from PA-C # 1: "...Continue 1:1 for pt. while awake...."

On 3/18/16, at 1210, a PA-C wrote an order to discontinue the 1:1.

Review of the Q15 Patient Observation Record for 3/15/16, revealed documentation that Pt # 5 was off the unit, in the Cafeteria visiting, from 1900 through 2000. The spaces for documentation of Special Observation Level, 1:1 Start Time were blank.

Review of the Q15 Patient Observation Record for 3/16/16, revealed documentation that Pt # 5 was off the unit in the Cafeteria from 0815 through 0845; off the unit in the Gymnasium from 1015 through 1100; off the unit in the Cafeteria from 1230 through 1245; off the unit in the Gymnasium from 1630 through 1645; and off the unit in the Cafeteria from 1700 through 1715. The space for documentation of Special Observation Level was marked for 1:1 with Start Time "6:30 PM". The order for 1:1 Special Observation Level had been written on 3/15/16 and continued through 3/16/16.

Review of the Q15 Patient Observation Record for 3/17/16, revealed documentation that Pt # 5 was off the unit in the Cafeteria from 0830 through 0845; off the unit in the Gymnasium from 1030 through 1100; off the unit in the Cafeteria from 1230 through 1245 and off the unit in the Cafeteria from 1700 through 1715.

Review of the Q 15 Patient Observation Record for 3/18/16, revealed documentation that Pt # 5 was off the unit in the Cafeteria from 0830 through 0845 and off the unit in the Gymnasium from 1030 through 1215. The space for documentation of Special Observation Level contained a Start Time of "7 AM" and an End Time of "10 PM". The order for 1:1 Special Observation Level had been continued on 3/16/16 at 1330 and discontinued on 3/18/16 at 1210.

The Director of Social Services and the Director of Quality and Risk Management confirmed, during an interview conducted on 3/23/16, that patients are not allowed off the unit when they require 1:1 Observation, unless a provider writes a specific order allowing the patient to be off the unit with his/her 1:1 staff. The Director of Quality and Risk Management confirmed, on 4/7/16, that Pt # 5 was allowed off the nursing unit while requiring 1:1 Observation and without a specific provider order. Nursing did not follow the hospital policy.

3. Review of hospital policy/procedure titled Assessments revealed: "...The admission nursing assessment must be completed by an RN within 8 hours of admission...The medical record must also include evidence of ongoing RN assessment of the patient, and the nursing care furnished to the patient every shift...."

Review of Pt # 3's medical record revealed:

Pt # 3 was a minor who was admitted due to Suicidal Ideation with plans and intent to overdose or shoot himself/herself. A friend had committed suicide the previous week. S/he was suspended from school. S/he had thoughts of hopelessness and was increasingly socially isolated.

Pt # 3 was admitted on 3/11/16. An RN completed his Nursing Admission Assessment at 1330. Pt # 3's medical record did not contain documentation of an RN assessment on the night shift commencing on 3/11/16 at 1830, through 3/12/16 at 0700, the day shift, commencing on 3/12/16 at 0630, through 1900 and the night shift commencing on 3/12/16 at 1830, through 3/13/16 at 0700. Pt # 3 was not assessed by an RN for three 12-hour shifts. LPN's were assigned to provide care for Pt # 3 with no RNs assigned to the patient during the night shift beginning on 3/11/16 through the AM of 3/12/16; the day shift of 3/12/16 and the night shift beginning on 3/12/16 through the AM of 3/13/16.

The Director of Quality and Risk Management confirmed, during interview conducted on 4/8/16, that Pt # 3 did not receive the required RN assessments.

4. Cross reference Tag 0392 # 1 for information regarding failure of nursing services to assign an RN to each patient for the supervision and evaluation of care.

Based on review of hospital policy/procedures, hospital documents and interviews, it was determined that the hospital failed to assign the nursing care of patients in accordance with the patients needs and staff skill, posing a high risk of unmet patient care needs and risk to health and safety.

Findings include:

Review of hospital policy/procedure titled Patient Acuity revealed: "...Staffing for patient care is based on acuity and level of care needed for the psychiatric patient...The staffing and acuity plan is the hospital's method for establishing nursing personnel requirements needed to meet the patient needs/acuity...The Registered Nurse on each patient unit completes the acuity classification for each patient prior to the final determination of staffing for the next shift...The maximum acuity score per staff member is RN: 60 per staff member and BHT: 40 per staff member...It is the responsibility of the Registered Nurse on the nursing unit to make the nurse/patient shift assignments...."

The hospital provided the job description titled "Nurse Manager" when surveyors requested the job description for the RN Supervisor. Review of Job Description: Nurse Manager revealed: "...Leadership/Teamwork:...Applies an organized and systematic approach in carrying out assignments and bases patient care assignments on level of care needed and ability of staff on duty.

Review of Job Description: Registered Nurse revealed: "...Leadership/Teamwork...Applies an organized and systematic approach in carrying out assignments and bases patient care assignments on level of care needed and ability of staff on duty...."

Direct observation conducted on 4/6/16, revealed that the psychiatric hospital has three nursing units: Mesquite Unit is a 12-bed adult unit, Ocotillo Unit is a 19-bed adolescent unit and Cholla is a 16-bed adult unit. Cholla and Ocotillo share a common nurses' station. Nurses and BHTs work 12-hour shifts: 0630 through 1900 and 1830 through 0700.

Review of shift assignment sheets for the Mesquite Unit for March 1, 2016 through April 14, 2016, revealed that one RN and one BHT were each assigned to all 12 patients. Review of shift assignment sheets for the Ocotillo Unit revealed that one nurse was assigned to patients in rooms numbered 310 B through 316 B and one nurse was assigned to patients in rooms numbered 307 A through 310 A. Review of shift assgnment sheets for the Cholla Unit revealed that one nurse was assigned to patients in rooms numbered 109 A through 114 B and the nurse assigned to Ocotillo patients in rooms 307 A through 310 A was also assigned to Cholla patients in rooms numbered 107 A through 108 A. A BHT was assigned to patients on the Ocotillo Unit in rooms numbered 307 A through 311 A and a second BHT was assigned to patients in rooms numbered 311 B through 316 B. A BHT was assigned to Cholla patients in rooms numbered 107 A through 110 A and a second BHT was assigned to patients in rooms numbered 110 B through 114 B. An additional BHT was assigned to any patient that required 1:1 supervision on any of the three units.

RN #s 5 and 6 confirmed during interview, conducted on 3/24/16, that patient care assignments for night shift are made by the the night shift supervisor on the preceding night. Sometimes patient care assignments are made by the day shift supervisor for the night shift. The supervisor assigns three nurses to be responsible for Cholla and Ocotillo. One nurse is assigned to Cholla and s/he takes the patients in the "bottom" 12 beds. One nurse is assigned to Ocotillo and s/he takes the patients in the "bottom" 12 beds. The third nurse is "split" and s/he takes the "top" 4 patients on Cholla and the "top" 7 patients on Ocotillo. The BHTs divide the patients on Ocotillo and Cholla to determine who is responsible for documenting the 15" observations. The BHTs also decide which BHT will conduct the Unit Safety Check and which BHT will supervise visitation on the night shift. Frequently the information recorded to determine patients' care needs is not updated from previous shifts or from the patient who was last admitted to the room/bed number.

Both RNs confirmed that patient assignments are not made based on patient care needs and staff skill.
They are based on dividing patient room/bed #s.

Based on review of facility's policies and procedures, medical records and staff interviews, it was determined for one of one patient (Patient #30), the hospital failed to ensure physician ordered medications were documented on the Medication Administration Record (MAR) according to the facility's policies and procedures.

This failure poses a high potential health and safety risk for a medication error, and for poor quality nursing care and services to the patient.

Findings include:


The hospital policy and procedure " Administration and Documentation of Medications " revealed: "...Check patient's Medication Administration Record (MAR) to ensure that the order is accurate...Document on the MAR the following information in the appropriate column: dose, time, site (if appropriate), and initials...Administer the drug...."

The Insulin Administration Log revealed Patient # 30's blood sugars were as follows:
on 3/15/16 dinner was 386, bedtime was 418;
on 3/16/16 breakfast was 186, lunch was 159, dinner was 296 and bedtime was 218;
on 3/17/16 breakfast was 167, lunch 166, dinner was 161, and bedtime was 149; and
on 3/18/16 breakfast was 207.

Patient # 30 was discharged on 3/18/16.

Patient # 30 ' s medical record revealed that the mild sliding scale insulin was ordered by MD #14 on March 15, 2016 at 2310. There is no documentation on the Medication Administration Record (MAR) for March 15, 2016 and March 16, 2016 that the order for the mild sliding scale insulin was documented , dose administered, timed, site and initials. The sliding scale insulin was documented as an order on the MAR for March 17, 2016 and March 18, 2016. The MAR did not have the dose administered, and site for the 1230 and 1600 doses. There was no documentation on the 3/17/16 MAR of the sliding scale insulin being administered at breakfast and at bedtime. There was no documentation on the 3/18/16 MAR of the sliding scale insulin being administered at breakfast.

RN #26 confirmed in a confidential interview conducted on April 15, 2016 that the sliding scale insulin should be documented on the MAR.

Pharmacist # 13 confirmed in a confidential interview conducted on April 15, 2016 that the sliding scale insulin is a medication, and should be documented on the MAR. She also confirmed that the sliding scale insulin was not documented on Patient #30's MAR as per the facility's policies and procedures.

DON # 2 confirmed in a confidential interview conducted on April 15, 2016 that the sliding scale insulin was not documented on Patient #30's MAR .

The Director of Quality and Risk Management confirmed during a confidential interview conducted on on April 15, 2016 that the sliding scale insulin was not documented on Patient #30's MAR as per the facility's policies and procedures.