HospitalInspections.org

Based upon review of adverse occurrence investigations, medical record review, and interview, the hospital failed to ensure investigations of adverse occurrences reported to the Health Standards Section of the Department of Health and Hospitals were accurate. This was evidenced by:
1) failure to identify the correct observation levels on the Youth Enhanced Unit (YEU) on 5/25/14 related to their investigation of alleged physical abuse reported by patient #F13 against SF13 Mental Health Technician (MHT); and
2) failure to identify observation levels of the patients on the YEU who were involved with patient/s (#F2, F3) on patient (#F1) abuse on 05/18/14 and 05/19/14. Findings:

1) Review of the investigation, dated 05/30/14, of allegations of physical abuse made by patient #F13 against SF13 MHT revealed "Conclusion: There were two staff members on the unit at the time of the incident. One staff member was on a break at the time of the incident. The census was 10 patients with all regular observation levels with no Close Visual Observations (CVO) or 1-on-1's...".

On 6/3/14, the staffing and patient observation levels was requested for 5/25/14. Review of the patient observation levels and interview with SF5/RN Interim Director of Nursing (DON) on 6/3/14 at 10:05 a.m. revealed on 5/25/14, there was one patient on Constant Visual Observations and two patients on Constant Visual Observations While Awake.

Further interview with SF5/RN Interim DON and SF8 Patient Advocate on 6/4/14 at 8:50 a.m. revealed when asked about the investigation conclusion which identified there were no patients on CVO observation levels, SF8 Patient Advocate responded that he thought he had heard someone say there were no patients on the YEU that were on Constant Visual Observations. There failed to be evidence the investigative report was reviewed by the Director of Nursing to ensure the information reported was accurate.

2) Review of the investigative report, staffing levels and patient observation levels on the YEU (for the incident that occurred on 05/19/14 and reported to the State) revealed, a census of 8 with 3 staff members assigned; however there were two patients (F2, F22) who were on observation levels of CVO. Continued review of the investigative report failed to indicate that there were 2 patients on CVO as identified in the above sentence.

According to an interview, 06/03/14 at 3:15pm with SF11RN, there were 2 patients (from the census of 8) on Constant Visual Observation level (F2, F22) on 05/19/14 in the YEU. SF11RN stated she had left the unit, leaving SF9MHT and SF10LPN to watch the 8 patients present. SF11RN further stated that SF12LAC was also present and had started the 9:00am group session when she left the unit. SF11RN stated Patient F1 was sitting next to SF9MHT (during the group session at 9:00am), when patient F3 came out of her room and began hitting patient F1 with her closed fist. At this time SF10LPN interceded and escorted patient F3 back to her room; however as this was happening, patient F2 began hitting patient F1. SF9MHT inserted herself between patients F1 and F2 and it was at this time SF12LAC called a Code Green (code used to notify all hospital staff that additional staff required due to patient/s causing incident/s) to the YEU.

Review of the investigation, dated 05/27/14, and noted as the final report, revealed "Staff members on duty for the Youth Enhanced Unit at the time of the incident: (name)SF9MHT, (name)SF10LPN, (name)SF12LAC-Licensed Addition Counselor, and (name)SF11RN (was off the unit at the cafeteria)...The patients were on appropriate levels of precaution, adequate and appropriately trained staff were present in the room during the event and witnessed the episode, the event occurred too quickly for the staff to have prevented it, and the staff responded appropriately in addressing the incident..." The investigative report failed to indicate that there were 2 patients (F2, F22), on CVO.

Interviews, 06/04/14 at 8:40am, with SF5 Director of Nursing (DON) and SF8 Patient Advocate confirmed the final report did not accurately state what happened during the incident relative to adequate staffing and the levels of precautions (there were 2 patients on CVO), especially when one of the patients on CVO (patient F2) was also involved in the incident as one of the attackers.


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Based on record reviews and interview the hospital failed to be in compliance with the Condition of Participation for Nursing Services as evidenced by:

I) Failure to ensure the nursing service had adequate numbers of licensed registered nurses, licensed practical nurses, and mental health technicians to provide safe and efficient nursing care to all patients as needed as evidenced by:
1) On the Adolescent Unit, the 11p-7a shift, on 06/01/14-06/02/14, had a total of 4 staff members to provide care for 39 adolescent patients, when 3 (F19, F22, F23) of the 39 Adolescent patients were on Constant Visual Observation (CVO) and 4 patients were on Elopement Precautions (F22, F23, F24, F25); and the 7a-3p shift, 06/05/14, had a total of 4 staff members on the Adolescent Unit--girls side for a census of 22 with 4 of the 22 on CVO (patients F19, F20, F21, F22); (A0392) and
2) On the Youth Enhanced Unit (YEU), on 05/19/14 a patient (F1) was physically attacked by two other patients (F2, F3) while F2 (identified as one of the attackers) was ordered on Constant Visual Observation.

Interview, 06/04/14 at 2:45pm, with SF5 Director of Nursing (DON) confirmed the above staffing was based on the staffing grid utilized by the hospital. When asked what the staffing should be if there were 2 CVO patients out of the census of 22 adolescent girls, SF5 DON stated the staffing would be the same. Further questioning of SF5 DON revealed when asked how the CVO patients would be cared for, SF5 DON stated like the other patients. SF5 DON stated additional staff was usually present when there were 4-5 CVOs on any given unit. (A0392)

Based on observations, record reviews and staff interviews, the hospital failed to ensure there were adequate numbers of registered nurses (RN), licensed practical nurses (LPN), and mental health technicians (MHT) to provide safe and efficient nursing care to all patients as needed as evidenced by:
1) On the Adolescent Unit, the 11p-7a shift, on 06/01/14-06/02/14, had a total of 4 staff members to provide care for 39 adolescent patients, when 3 (F19, F22, F23) of the 39 Adolescent patients were on Constant Visual Observation (CVO) and 4 patients were on Elopement Precautions (F22, F23, F24, F25); and the 7a-3p shift, on 06/05/14, had a total of 4 staff members on the Adolescent Unit--girls side for a census of 22 with 4 of the 22 on CVO (patients F19, F20, F21, F22); and
2) On the Youth Enhanced Unit (YEU), on 05/19/14 a patient (F1) was physically attacked by two other patients (F2, F3) while F2 (identified as one of the attackers) was ordered on Constant Visual Observation.
Findings:

1) Observations conducted, 06/02/14 at 5:00am, on the open Adolescent Unit (ADOL) revealed a census of 39 (22 girls and 17 boys), and 4 staff members (1RN and 1LPN on the boys side; 1RN and 1MHT on the girls side).

Review of the census board (located in the nurses station), revealed 2 girls, patients F19 and F22, were identified as Constant Visual Observation (CVO). It was noted that patient F22 was also on Elopement Precautions. On the boys side, patient F23 was identified as CVO and patients F24 and F25 were on Elopement Precautions.

In an interview, on 06/02/14 at 5:10am, SF21 RN indicated that there were 4 staff members and 39 patients on the unit with 3 of the 39 patients ordered to be on CVO and 3 of the 39 patients ordered to be on Elopement Precautions. There was no evidence to indicate that direct care staffing levels were adjusted upwards to account for the increased observation levels that were ordered.

Interview, on 06/02/14 at 5:10am, with SF21 RN, confirmed the above patients were on CVO and Elopement Precautions.

Observations, 06/05/14 at 9:20am, revealed on the Adolescent girls side there were 22 patients. Review of the census board (located in the nurses station), revealed 4 girls, patients F19, F20, F21 and F22 were identified as CVO.

Review of a "Patient Assignment Sheet" revealed 4 patients (#s F19, F20, F21, F22) out of the total census of 22 girls were on CVO. Review of the Daily Staffing Worksheet revealed there were 4 staff members present for the 22 girls; however 4 patients out of 22 also required constant visual observation.

Interview, 06/05/14 at 10:45am, with SF23 RN confirmed the census was 22 girls and 4 of the 22 were on CVO and there was only 4 staff members to provide care.

Interview, 06/04/14 at 2:45pm, with SF5 DON revealed when patients were "asleep" the CVO "really did not apply".

Review of patient F19's medical record revealed a physician's order, dated 06/02/14 at 3:30pm, for "change CVO while awake", telephone order per SF18 Psychiatrist.

Review of patient F20's medical record revealed a physician's order, dated 06/03/14 at 5:00pm, "CVO + SI" (positive suicidal ideation), per telephone order SF19 Psychiatrist.

Review of patient F21's medical record revealed a physician's order, dated 06/04/14 at 8:30pm, "CVO status" per telephone order SF7 Psychiatrist.

Review of patient F22's medical record revealed a physician's order, dated 06/02/14 at 3:30pm, for "change CVO while awake", telephone order per SF18 Psychiatrist.

Prior to the change in CVO status to "while awake" for patients F19 and F22, the physician orders were CVO. This means, according to the hospital's policy (Patient Monitoring System), constant visual contact at all times.

Review of hospital policy titled "Patient Monitoring System" revealed the following: "Patients are placed on one of the following levels on admission and the level is adjusted...by the treatment team...levels are characterized by the following:
1. Close Observations: 1.1 Patient Criteria...
2. Constant Visual Observation:
2.1 Patient Criteria Patient is actively suicidal/homicidal with clear expectation that an attempt will be made....
2.2 Patient Care Elements The patient must be maintained within the visual contact of the staff at all times. The patient is not able to leave the unit. At any given time, the staff assigned to provide visual contact must insure that another staff member will assume this responsibility if he/she must leave the presence of the patient (i.e. lunch breaks, etc.). This visual contact extends to a requirement for complete supervision of the patient in routine daily care...
3. One-to-One Order Criteria:
3.1 Patient Criteria Suicidal 'Actively suicidal with plan and means or attempt to seriously injure/harm self' Homicidal/Violent 'Demonstrates physical violence toward peer/staff/inanimate object'...Sexually Acting Out 'Demonstrated sexual behavior/action' Elopement Risk 'Attempted elopement'
3.2 Patient Care Elements The patient must be maintained within the visual contact/arm's reach of staff at all times...At any given time, the staff assigned to provide visual contact/arm's reach must insure that another staff member will assume this responsibility if he/she must leave the presence of the patient...Night Shift Adherence: MD Order: 'One-to-One while awake' (status automatically changes to CVO at night) 'One-to-One at all times' (status continues at night)..."

Review of a Staffing Grid (identified by SF5 Director of Nursing as the "new" staffing grid based on the hospital's Plan of Correction for A0392 cited on 04/11/14 survey), revealed staffing was based on the number of patients on any given unit. Note that the Staffing Grid did not take into consideration the increased acuity levels of the patients (i.e. CVO).

Review of hospital policy titled "Acuity Staffing Plan" revealed: "I. POLICY This hospital maintains a nursing staffing level that supports safe and efficient care for each patient on the unit. Daily, as well as shift-to-shift, the acuity staffing patterns are reviewed and subject to revision as the need arises...The prescribed nursing staffing ratio in this policy does not include any other professional staff persons, including the Managers, psychiatrists visiting their patients, social workers assigned to the unit, etc., who are frequently on the treatment units providing direct supervision, treatment, assessment and other care for patients... II. PROCEDURE 1.0...Changes to the daily assignment of hours and duties, either additions or deletions, are based on patient acuity and the current census of the unit...3.0 Staffing needs for each unit are reassessed at least once per shift...based on the following information sources: Milieu Dynamics, Admissions scheduled, Discharges scheduled, Transportation needs/outside consults...Individualized treatment plans and individual patient needs...Volume of patients. 4.0 ...staffing patterns...reviewed on a regular basis..."

Interview, 06/04/14 at 2:45pm, with SF5 Director of Nursing (DON) confirmed the above staffing was based on the staffing grid utilized by the hospital. When asked what the staffing should be if there were 2 CVO patients out of the census of 22 adolescent girls, SF5 DON stated the staffing would be the same. Further questioning of SF5 DON revealed when asked how the CVO patients would be cared for, SF5 DON stated like the other patients. SF5 DON stated additional staff was usually present when there were 4-5 CVOs on any given unit.

2) Reviews of an investigative report (dated 05/27/14), staffing levels and patient observation levels on the YEU (for an incident that occurred on 05/19/14 and reported to the State) revealed, a census of 8 with 3 staff members assigned; however there were two patients (F2, F22) who were on observation levels of CVO.

According to an interview, 06/03/14 at 3:15pm with SF11RN, there were 2 patients (from the census of 8) on Constant Visual Observation level (F2, F22) on 05/19/14 in the YEU. SF11RN stated she had left the unit, leaving SF9MHT and SF10LPN to watch the 8 patients present. SF11RN further stated that SF12LAC (Licensed Addiction Counselor) was also present and had started the 9:00am group session when she left the unit. SF11RN stated Patient F1 was sitting next to SF9MHT (during the group session at 9:00am), when patient F3 came out of her room and began hitting patient F1 with her closed fist. At this time SF10LPN interceded and escorted patient F3 back to her room; however as this was happening, another patient (F2) began hitting patient F1. SF9MHT inserted herself between patients F1 and F2 and it was at this time SF12LAC called a Code Green (code used to notify all hospital staff that additional staff required due to patient/s causing incident/s) to the YEU.

Based on the explanation made by SF5 DON, the hospital failed to ensure the nursing staffing levels were at the required level to ensure all patients received safe and efficient care based on the policies/procedures (see above policies for Patient Monitoring System 2.0 Constant Visual Observation-CVO; and Acuity Staffing Plan II Procedure 1.0 either additions or deletions are based on patient acuity and census).


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