HospitalInspections.org

Based on policy and procedure review, review of staffing sheets, occurrence reports and seclusion log, it was determined that the hospital did not have an organized nursing service in that a Registered Nurse was not available to provide supervision and evaluation of the nursing needs of patients to ensure their safety and to prevent assaultive behaviors of patients. This failed practice had the potential to affect all patients in the facility. See deficiencies cited at A0392 and A0395.

Based on policy review, review of staffing sheets, review of occurrence reports, and review of the seclusion log, it was determined that patients were not receiving care in a safe setting in that there was not a Registered Nurse for each Youth Program to monitor and prevent altercations between patients and patient to staff. This failed practice had the potential to affect all patients and staff in the facility. The findings follow:

A. Policy and procedure #4104 Nursing Services Staffing Plan-Procedure "...Core staffing for each unit includes: Adolescent Program a ratio of 1 staff to 5 patients. .........A minimum of one RN (Registered Nurse) will be scheduled each shift for each program on Youth Services (Child and Adolescent)."

B. Policy and procedure #4601 Nursing Services-Acuity of Patients revealed-"POLICY- It is the policy of Vista Health to increase staffing above the care level according to criteria based on indicators used to evaluate the need for increased staffing. PURPOSE-To provide a level of staffing sufficient to provide quality patient care in a safe setting.
PROCEDURE-
1. The following events may be reason to increase staffing above the core level.
a) Patient on constant 1:1 observation.
b) Patient on suicide precautions
c) Patient requiring 8-10 time outs per shift.
d) Patient threatening or demonstrating gross disorientation, hallucinations and severe impairment in judgement.
2. The preceding events of situations require an evaluation of the core staffing pattern to determine whether the number of staff is sufficient to meet the patient nursing care needs."

C. Review of the Daily Staffing Sheet from 03-20-11 to 04-10-11 revealed there was not a RN present on each Program for Youth Services as follows:

There was only one Registered Nurse to cover for both the Adolescent Acute Unit and the Adolescent Subacute Unit from 03-20-11 thru 03-31-11, 04-02-11, 04-05-11, 04-08-11 thru 04-10-11 for each shift. The Adolescent Acute Unit and Adolescent Subacute Unit had a combined average patient census of 22 patients. Supporting staff included one to two patient technicians and one Licensed Practical Nurse on the 7AM-3PM and 3PM-11PM shift.

D. Review of 42 Occurrence Reports from 03-20-11 thru 04-10-11 (22 days) revealed the following:

1) 1 occurrence happened on 04-06-11 at 1925 on the Youth Acute Unit regarding self harm

2) 1 occurrence happened on 03-27-11 at 0400 on the Child Acute Unit regarding swollen lip

Neither of the above occurrences involved more than one patient.

3) 40 occurrences happened on the Adolescent Acute and Subacute Units. All 40 occurrences involved physical altercations between one or more patients. Fifteen occurrences happened between 0700-1500. 25 occurrences happened between 1500 and 2300.

4) At the time of the following occurrences the Adolescent Acute and Subacute Patient Schedule reflected the patients were to be in Rehab Group from 1815 to 1915; from 1915 to 2000 wrap up/meds/snacks; from 2000 to 2030 showers/meds/snacks/lights out and; from 2000 to 2030 quiet time/TV/lights out.

a) 04-03-11 at 1820 (L) (14 year old male) assaulted a peer took a shoe string from a pair of athletic shorts and attempted to chock peer. Staff intervened preventing any injury.

b) 04-03-11 at 1950 (J) (15 year old female) became verbally aggressive toward staff and peers screaming obscenities and threats. Patient escorted to seclusion room.

c) 04-03-11 at 1954 (A) (13 year old female) was asked by (B) to go to room. (A) refused and (B) wanted her taken to room which resulted in her getting aggressive and having to be restrained.

d) 04-03-11 at 2012 (J)(15 year old female) while attempting to release patient from seclusion, patient became aggressive and threatening toward staff, pushing staff member and pulling back fist. Patient was placed in PRT (Primary Restraint Technique) until calm.

e) The Restraint and Seclusion Data sheet did not reflect any of the events that happened on 04-03-11.

5) At the time of the following occurrences the Adolescent Acute and Subacute Patient Schedule reflected the patients were to be doing showers/meds/snacks/lights out from 1915-2000; from 2000-2100 patients were to be doing quiet time/TV/lights out:

a) 04-09-11 at 1920 (M) (16 year old female) was involved in a physical altercation with (J) (15 year old female) the incident started with verbal threats leading to physical blows being exchanged . Staff intervened using PRT to prevent further injury. (M)(16 year old female) receives a split lip from blows delivered by (J)(15 year old).

b) 04-09-11 at 1920 (J) (15 year old) started fighting with (M)(16 year old) in day area. (J) hit (M)(16 year old female)in the mouth cutting the side of her mouth. Staff intervened PRT preventing further injury.

c ) 04-09-11 at 1920 (T) (15 year old female) was involved in a physical altercation with peers. Started with an exchange of verbal threats and progressed to an exchange of blows. Staff intervened to prevent further injury (PRT)

d) 04-09-11 at 1920 (L) (16 year old female) became involved in a physical altercation with (T) (15 year old female). Starting with verbal threats resulting in blows being exchanged. Staff intervened by using PRT to prevent further harm.

e) 04-09-11 at 2100 During physical altercation between two of her peers, (M) (16 year old female) became verbally aggressive and started fighting with other peers.

f) 04-09-11 at 2100 (L) (16 year old female) walked over to (T)(15 year old female) and hit (T) (16 year old female). Fight started between (T) (16 year old female and (L)(16 year old female). (T) (16 year old female) placed in a PRT by (B) RN who was hit by patient (K)(12 year old female). (T) (16 year old female) kicked in head by peer (H)(13 year old female).

g) 04-09-11 at 2100 During physical altercation between two of her peers (J)(16 year old female) became verbally aggressive and started fighting with other peers. (J)(16 year old female) took her top off and started running around in day area.

h) 04-09-11 at 2100 (H) (13 year old female) walked over and kicked peer (T) (15 year old female) in the head. Staff (A) LPN pulled (H) (13 year old female) away from (T) (15 year old female).

i) The Restraint and Seclusion Data for 04-09-11 revealed the following:
A. At 1920 (J)(16 year old female) was restrained by (B)(RN) no time of release was documented.
B. At 2100 (J)(16 year old female) was restrained by (B)(RN) no time of release was documented.
C. At 2100 (T)(16 year old female) was restrained by (B)(RN) and released at 2103. 3 minutes.
D. At 1920 (T)(16 year old female) was restrained by (B)(RN) and released at 1921. 1 minute.
E. At 1920 (M)(16 year old female) was restrained by (B)(RN) and released at 1921. 1 minute.
F. At 2100 (M)(16 year old female) was restrained by (B)(RN) and released at 2103. 3 minutes.
G. At 2100 (H)(13 year old female) was restrained by no name and released at 2102. 2 minutes.
H. At 2010 (L)(16 year old female) was restrained by (B)(RN) and released at 2045. 35 minutes
I. At 2100 (L)(16 year old female) was restrained by (B)(RN) and released at 2102. 2 minutes.
J. At 2100 (K)(12 year old female) was restrained by (B)(RN) and released at 2115. 15 minutes.

6) The following Occurrence Reports which reflected the need for a PRT hold were not recorded on the Restraint and Seclusion Data sheets.
A) 03-19-11-0730-(T)(12 year old male) and (L)(14 year old male) had a verbal altercation in the Activity room area, then client (T) struck client (L) in the face with a closed fist. Psychiatric Tech (R) placed client (T) in a PRT.
B) 03-29-11 -0920-Patient (T) was placed in a two arm escort and escorted back to the Unit because of being a serious disruption in class and making physical threats to staff.
C) 03-30-11-0345-Patient (C) (16 year old male) walked over and punched another patient in the face. Patient was then escorted to the quiet room.
D) 03-31-11-0940-Patient (A)(17 year old female) was in time out for a serious disruption. Patient refused to take her coat off in the time out because of being a safety hazard. After several requests to comply, staff attempted to remove the jacket. Patient became physically aggressive and started punching staff with closed fist. Patient was placed in a PRT.
E) 03-31-11-0950-After being secluded for physical aggression Patient (A) ran and aggressively punched the quiet room window (plastic) and busted it. Patient (A) than began ripping the remaining plastic pieces out of the door. Patient was then placed in a standing PRT.
F ) 04-02-11-0015-Patient (T)(15 year old female) was asked by staff several times not to talk to residential females. Patient ignored staff directives and continued to talk and walk over to the residential table. Patient was asked again by staff not to talk to the others and be quiet, she refused and became verbally and physically assertive with staff. Patient was placed in PRT according to handle with care policy and procedure.
G) 04-03-11-2012-While attempting to release patient (J)(15 year old female) from seclusion Patient became aggressive and threatening toward staff pushing staff member and pulling back fist. Patient was placed in PRT until calm.
H) 04-03-11-1950-Patient (J)(15 year old female) became aggressive toward staff and peers screaming obscenities and threats. Patient was escorted to seclusion room.
I) 04-03-11-1954-(A)(15 year old female) was asked by (B) to go to room refused and (B) wanted her taken to room which resulted in her getting aggressive and having to be restrained.

Based on policy review, review staffing sheets, review of occurrence reports and review of the seclusion log, it was determined there was not a Registered Nurse available to supervise and evaluate the nursing care for each pateint that was not involved in an altercation. This failed practice affected all patients and staff in the facility. The findings follow:

A. Policy and procedure #4104 Nursing Services Staffing Plan-Procedure "...Core staffing for each unit includes: Adolescent Program a ratio of 1 staff to 5 patients. .........A minimum of one RN (Registered Nurse) will be scheduled each shift for each program on Youth Services (Child and Adolescent)."

B. Policy and procedure #4601 Nursing Services-Acuity of Patients revealed-"POLICY- It is the policy of Vista Health to increase staffing above the care level according to criteria based on indicators used to evaluate the need for increased staffing. PURPOSE-To provide a level of staffing sufficient to provide quality patient care in a safe setting.
PROCEDURE-
1. The following events may be reason to increase staffing above the core level.
a) Patient on constant 1:1 observation.
b) Patient on suicide precautions
c) Patient requiring 8-10 time outs per shift.
d) Patient threatening or demonstrating gross disorientation, hallucinations and severe impairment in judgement.
2. The preceding events of situations require an evaluation of the core staffing pattern to determine whether the number of staff is sufficient to meet the patient nursing care needs."

C. Review of the Daily Staffing Sheet from 03-20-11 to 04-10-11 revealed there was not a RN present on each Program for Youth Services as follows:
There was only one Registered Nurse to cover for both the Adolescent Acute Unit and the Adolescent Subacute Unit from 03-20-11 thru 03-31-11, 04-02-11, 04-05-11, 04-08-11 thru 04-10-11 for each shift. The Adolescent Acute Unit and Adolescent Subacute Unit had a combined average patient census of 22 patients. Supporting staff included one to two patient technicians and one Licensed Practical Nurse on the 7AM-3PM and 3PM-11PM shift.

D. Review of 42 Occurrence Reports from 03-20-11 thru 04-10-11 (22 days) revealed the following:
1) 1 occurrence happened on 04-06-11 at 1925 on the Youth Acute Unit regarding self harm
2) 1 occurrence happened on 03-27-11 at 0400 on the Child Acute Unit regarding swollen lip
Neither of the above occurrences involved more than one patient.
3) 40 occurrences happened on the Adolescent Acute and Subacute Units. All 40 occurrences involved physical altercations between one or more patients. Fifteen occurrences happened between 0700-1500. 25 occurrences happened between 1500 and 2300.
4) At the time of the following occurrences the Adolescent Acute and Subacute Patient Schedule reflected the patients were to be in Rehab Group from 1815 to 1915; from 1915 to 2000 wrap up/meds/snacks; from 2000 to 2030 showers/meds/snacks/lights out and; from 2000 to 2030 quiet time/TV/lights out.
a) 04-03-11 at 1820 (L) (14 year old male) assaulted a peer took a shoe string from a pair of athletic shorts and attempted to chock peer. Staff intervened preventing any injury.
b) 04-03-11 at 1950 (J) (15 year old female) became verbally aggressive toward staff and peers screaming obscenities and threats. Patient escorted to seclusion room.
c) 04-03-11 at 1954 (A) (13 year old female) was asked by (B)to go to room (A) refused and (B) wanted her taken to room which resulted in her getting aggressive and having to be restrained.
d) 04-03-11 at 2012 (J)(15 year old female) while attempting to release patient from seclusion, patient became aggressive and threatening toward staff, pushing staff member and pulling back fist. Patient was placed in PRT (Primary Restraint Technique) until calm.
e) The Restraint and Seclusion Data sheet did not reflect any of the events that happened on 04-03-11.
5) At the time of the following occurrences the Adolescent Acute and Subacute Patient Schedule reflected the patients were to be doing showers/meds/snacks/lights out from 1915-2000; from 2000-2100 patients were to be doing quiet time/TV/lights out:
a) 04-09-11 at 1920 (M) (16 year old female) was involved in a physical altercation with (J) (15 year old female) the incident started with verbal threats leading to physical blows being exchanged . Staff intervened using PRT to prevent further injury. (M)(16 year old female) receives a split lip from blows delivered by (J)(15 year old).
b) 04-09-11 at 1920 (J) (15 year old) started fighting with (M)(16 year old) in day area hitting (M) (16 year old female)in the mouth cutting the side of her mouth. Staff intervened PRT preventing further injury.
c ) 04-09-11 at 1920 (T) (15 year old female) was involved in a physical altercation with peers. Started with an exchange of verbal threats and progressed to an exchange of blows. Staff intervened to prevent further injury (PRT)
d) 04-09-11 at 1920 (L) (16 year old female) became involved in a physical altercation with (T) (15 year old female). Starting with verbal threats resulting in blows being exchanged. Staff intervened by using PRT to prevent further harm.
e) 04-09-11 at 2100 During physical altercation between two of her peers, (M) (16 year old female) became verbally aggressive and started fighting with other peers.
f) 04-09-11 at 2100 Arguing with peer (L) (16 year old female) who walked over to (T)(15 year old female) and hit (T) (16 year old female). Fight started between (T) (16 year old female and (L)(16 year old female). (T) (16 year old female) placed in a PRT by (B) RN who was hit by patient (K)(12 year old female). (T) (16 year old female) kicked in head by peer (H)(13 year old female).
g) 04-09-11 at 2100 During physical altercation between two of her peers (J) (16 year old female) became verbally aggressive and started fighting with other peers. (J) (16 year old female) took her top off and started running around in day area.
h) 04-09-11 at 2100 (H) (13 year old female) walked over and kicked peer (T) (15 year old female) in the head. Staff (A) LPN pulled (H) (13 year old female) away from (T) (15 year old female).
i) The Restraint and Seclusion Data for 04-09-11 revealed the following:
1. At 1920 (J)(16 year old female) was restrained by (B)(RN) no time of release was documented.
2. At 2100 (J)(16 year old female) was restrained by (B)(RN) no time of release was documented.
3. At 2100 (T)(16 year old female) was restrained by (B)(RN) and released at 2103. 3 minutes.
4. At 1920 (T)(16 year old female) was restrained by (B)(RN) and released at 1921. 1 minute.
5. At 1920 (M)(16 year old female) was restrained by (B)(RN) and released at 1921. 1 minute.
6. At 2100 (M)(16 year old female) was restrained by (B)(RN) and released at 2103. 3 minutes.
7. At 2100 (H)(13 year old female) was restrained by no name and released at 2102. 2 minutes.
8. At 2010 (L)(16 year old female) was restrained by (B)(RN) and released at 2045. 35 minutes
9. At 2100 (L)(16 year old female) was restrained by (B)(RN) and released at 2102. 2 minutes.
10. At 2100 (K)(12 year old female) was restrained by (B)(RN) and released at 2115. 15 minutes.
6) The following Occurrence Reports which reflected the need for a PRT hold were not recorded on the Restraint and Seclusion Data sheets.
a) 03-19-11-0730-(T)(12 year old male) and (L)(14 year old male) had a verbal altercation in the Activity room area, then client (T) struck client (L) in the face with a closed fist. Psychiatric Tech (R) placed client (T) in a PRT.
b) 03-29-11 -0920-Patient (T) was placed in a two arm escort and escorted back to the Unit because of being a serious disruption in class and making physical threats to staff.
c ) 03-30-11-0345-Patient (C) (16 year old male) walked over and punched another patient in the face. Patient was then escorted to the quiet room.
d) 03-31-11-0940-Patient (A)(17 year old female) was in time out for a serious disruption. Patient refused to take her coat off in the time out because of being a safety hazard. After several requests to comply, staff attempted to remove the jacket. Patient became physically aggressive and started punching staff with closed fist. Patient was placed in a PRT.
e) 03-31-11-0950-After being secluded for physical aggression Patient (A) ran and aggressively punched the quiet room window (plastic) and busted it. Patient (A) than began ripping the remaining plastic pieces out of the door. Patient was then placed in a standing PRT.
f ) 04-02-11-0015-Patient (T)(15 year old female) was asked by staff several times not to talk to residential females. Patient ignored staff directives and continued to talk and walk over to the residential table. Patient was asked again by staff not to talk to the others and be quiet, she refused and became verbally and physically assertive with staff. Patient was placed in PRT according to handle with care policy and procedure.
g) 04-03-11-2012-While attempting to release patient (J)(15 year old female) from seclusion Patient became aggressive and threatening toward staff pushing staff member and pulling back fist. Patient was placed in PRT until calm.
h) 04-03-11-1950-Patient (J)(15 year old female) became aggressive toward staff and peers screaming obscenities and threats. Patient was escorted to seclusion room.
i) 04-03-11-1954-(A)(15 year old female) was asked by (B) to go to room refused and (B) wanted her taken to room which resulted in her getting aggressive and having to be restrained.