HospitalInspections.org

Based on interview, policy review and review of incident reports the hospital failed to establish a standard for patient observation (Patient #1), adequate staffing for patient observation, and failed to ensure staff followed hospital policy for incident reporting (Patient #1). The hospital has 114 inpatient beds and the current census at the time of the survey was 108.

Findings include:

An incident report dated 5/02/17 at 1:00 PM authored by facility staff revealed Patient #1 reported a sexual assault that occurred "a few weeks ago" with another male patient (Patient #3). Patient #1 reported that Patient #3 sexually assaulted her in the bathroom. Patient #1 reported Patient #3 "dragged me into the bathroom, took my clothes off and I didn't really fight him. He did not kiss me but we did have sex. It was not something I wanted to do. I think it happened in the middle of April in the afternoon."

On 5/03/17 hospital leadership performed an initial review of Patient #1's reported incident. The initial review identified that although Patient #1 was initially ordered to be on every 15 minute observation for her own protection, the order for every 30 minute observation was obtained by staff who determined the patient could be maintained safely being observed every 30 minutes.

Interview with Staff A on 6/05/17 at 1:20 PM revealed the hospital currently has no standard criteria the patient must meet to change observation status. Staff A reported that the psychiatrist who did Patient #1's initial assessment ordered the every 15 minute observation. The weekend following the patient's admission when a different psychiatrist was on duty, staff relayed their belief the patient could be safely maintained being observed every 30 minutes and the psychiatrist wrote the order for it.

The initial review conducted by hospital leadership on 5/03/17 of Patient #1's reported incident revealed staff incident reporting was not timely in accordance with hospital policy. The initial review report dated 5/03/17 revealed, "Staff were aware on 5/01/17 that sexual intercourse was non-consensual, yet no action was taken, nothing was documented, no IR (Incident Report) was completed, and it was not reported to leadership until 3:15 PM on 5/02/17."

Review of Policy 06.08 - Incident Reporting with an effective date of 6/09/16 was reviewed on 6/07/17 at 1:30 PM. Subtitle, "Reporting Procedures for All Incidents" directs "the report is to be completed before the employee clocks out or off duty".

A review of nurse staffing on all units was conducted by the Federal surveyors on 5/31/17. The review performed by Federal surveyors revealed inadequate numbers of nursing staff personnel on the unit to observe and care for all patients.

Please refer to B-150 for failure to ensure sufficient numbers of nursing personnel.

Based on staff interview and review of the Incident Reporting log the facility failed to protect patients from physical and sexual abuse. This affected 22 different patients during the months of March, April and May, 2017. Seven incident reports were reviewed involving six different victims (victims 1, 2, 3, 4, 5, and 6) and patients (Patients #1, 2, 3, 4, and 5). The facility is a 114 bed psychiatric hospital with a census of 108 at the time of the survey.

Findings include:

On 06/02/17 the facility provided a list of all patient to patient physical contact occurrences during the months of March, April and May, 2017. The list contained 26 incidences of physical or sexual contact between patients. Two of the 26 were described as sexual assaults and reported to the Ohio State Highway Patrol.

1. On 3/14/17 the facility learned of two instances of sexual assault on a female patient (Victim -1) that had occurred in January of 2017. An incident report dated 3/14/17 reveals "There was an investigation on 1/15/17 completed that was then turned over to the Ohio State Police." At the time upon which the facility learned of the incidents on 3/14/17, the female patient had been discharged. On 3/15/17 the CEO recommended no further action and wrote, "case previously turned over to OSHP."

2. On 4/20/17 facility staff observed a male patient (Patient #2) kiss a female patient (Patient # 1 and Victim-2) and "rub her thigh and private area." A short time later Patient #2 and Patient #1 were witnessed by staff with "his hand in her lap and then her hand on his lap." Patient #2 was transferred to another unit away from Patient #1 on the day of the incident. On 4/21/17 the CEO recommended no further action and signed the incident report.

3. An incident report dated 5/02/17 at 1:00 PM authored by facility staff revealed Patient #1 reported a sexual assault that occurred "a few weeks ago" with another male patient (Patient #3). Patient #1 reported that Patient #3 sexually assaulted her in the bathroom. Patient #1 reported Patient #3 "dragged me into the bathroom, took my clothes off and I didn't really fight him. He did not kiss me but we did have sex. It was not something I wanted to do. I think it happened in the middle of April in the afternoon."

4. An incident report dated 4/15/17 at 3:25 PM describes an incident between Patient #4 physically assaulting a male peer (Patient #5 and Victim-3) on the 300 unit. Patient #4 punched Patient #5 in the face causing Patient #5 to become unconscious. A code blue was called and Patient #5 was transported to a local medical hospital emergency room where he was diagnosed with a fractured nose. Patient #4 was transferred to another unit (Unit 400).

5. An incident report dated 4/15/17 at 4:02 PM revealed Patient #4 assaulted another patient (Victim-4). At this incident a "Code Violet" (code for a violent event) was called, Patient #4 was escorted to locked seclusion and received medications intramuscularly. The victim incurred a "loose tooth and bloody mouth".

6. An incident report dated 4/15/17 at 5:15 PM reveals a Code Violet was called as another male patient on the 400 unit was attacking Patient #4 (Victim-5) in this incident. The incident report reveals the two patients were easily separated and both denied injuries from the altercation and Patient #4 was transferred to the 200 unit.

7. An incident report dated 4/16/17 at 4:58 PM reveals a Code Violet was called as Patient #4, unprovoked, hit a male peer (Victim-6) in the mouth causing the peer's upper lip to split open and bleed. Patient #4 continued with aggressive behavior and hit another male peer on the unit. Patient #4, still agitated, struck a security officer in the jaw. According to the incident report, Patient #4 was escorted to seclusion by security staff. Before security staff could exit the seclusion room, Patient #4 stood up and assaulted a second security officer. Emergency medications were ordered by the Medical Doctor on duty and an order for four point restraints was obtained.

Interview with Staff A on 6/02/17 at 9:40 AM confirmed the facility currently has no "Code Violet" policy.

Interview with Staff A on 6/05/17 at 1:20 PM revealed Incident Reports are reviewed by hospital leadership every weekday morning. Incidents occurring on a weekend are reviewed on Monday morning. Staff A confirmed these incidents occurred and hospital leadership were aware of each incident.

Interview with Staff C on 6/06/17 at 1:30 PM revealed the hospital is required to report all incidents that involve felonious assault to Ohio State Highway Patrol.

Based on medical record review, staff interview, and policy review it was determined the facility failed to ensure sexual behaviors were documented in the interdisciplinary treatment plan. This affected one (Patient #1) of eleven medical records reviewed. The active census was 108.

Findings include:

Review of the hospital's policy titled "Sexual Behavior Policy and Procedure" Number: 02.20 with effective date 09/14/15 states the facility recognizes that the issue of patient sexual behavior in a long term psychiatric hospital is complex. Sexual Behavior is defined as sexual conduct, sexual contact, or sexual activity, per Ohio Revised Code Section 2907.01 (A), (B), and (C). c). Sexual activity means sexual conduct or sexual contact, or both. In the event staff members observe sexual behavior, staff members will determine an individual action plan and document sexual behavior in the patient's treatment plan as warranted.

Review of the medical record for Patient #1 revealed the patient was involuntarily admitted on 03/30/17 for major depression with psychosis after police found him/her wandering the streets with knives and a meat cleaver. The comprehensive psychiatric exam documented the patient was catatonic and was unable to participate in formal cognitive screening questions.

An incident report was documented on 04/20/17 which stated a therapeutic program worker witnessed a male peer kiss the side of the female patient's mouth and was rubbing her thigh. The patients were redirected and both patients were later found in the television area having their hands in each others lap. The female quickly pulled her hand away once staff witnessed the incident. The male patient was moved to another unit and his treatment plan was updated to reflect sexual behaviors.

Review of an internal investigation revealed Patient #1 reported a male peer entered her room and attempted anal intercourse which ended in vaginal intercourse. On 05/01/17 this sexual behavior was reported to the treatment team and was found to be non- consensual. Review of the medical record lacked evidence the interdisciplinary treatment plan was updated reflecting sexual behaviors on 04/20/17 and/or was updated following the treatment team meeting on 05/01/17. Staff A confirmed the treatment plan failed to identify sexual behaviors and/or interventions on 06/07/17 at 9:45 AM.

On 06/07/17 at 10:45 AM Staff B reported the assigned nurse failed to review/update the medical record following leadership review of the incident reported on 05/01/17. This incident was reported the Ohio State Highway patrol for further investigation.

Based on medical record review, staff interview, and policy review it was determined the facility failed to ensure a code blue log and the clinical indication for transferring patients to another unit was documented. This affected two ( Patient's # 3 and # 5) of eleven records reviewed. The active census was 108.


Review of the Patient Transfer within NOPH Policy: 02.06 with effective date 09/14/15 states the transfer of patients between clinical units within NOPH originates in the need for placing patients in the most appropriate therapeutic environment for their particular treatment requirements. There must exist a clear, specific clinical indication in order to request the transfer of a patient to another unit, or the transfer must meet an administrative need.


Review of the Code Blue Policy: 02.19 with effective date 07/07/15 states all code blue logs will be observed by nursing supervisors and the nurse executive. The monthly and quarterly nursing performance improvement report will reflect the data analysis of all code blues. A code blue log will be completed for every code blue. The original log is to be maintained on the unit of occurrence. A copy of the log provided to the nursing office.


Findings include:


1. Review of the medical record for Patient #3 revealed a physicians order on 04/15/17 to move patient from unit A 400 to unit A 100. The medical record lacked a clear and concise indication as to why the patient was transferred to another unit as per policy. The patient was moved to A 100 at approximately 3:00 PM. This finding was confirmed with Staff A on 06/07/17 at 12:32 PM.


2. Review of the medical record and incident report for Patient #5 revealed on 04/15/17 at 3:35 PM the patient was struck in the face by a male peer on unit A 300 and was found unconscious. The patient was transferred via emergency medical services to a local hospital in which a nasal fracture was confirmed. The facility staff initiated a code blue when the patient was found unresponsive. Review of the record lacked evidence the code blue log was completed as per policy. This finding was confirmed with Staff A on 06/07/17 at 11:00 AM.

Based on record review and interview the facility failed to review and update treatment plans of two (2) of 10 active sample patients (B8 and E15) in a timely manner. This failure jeopardizes a timely, coordinated, responsive treatment process.

Findings include:

A. Record Review

1. Patient B8's treatment plan was last revised on 9/3/16. As of 6/2/17, there was no documented update of this treatment plan to ensure revision of goals and interventions based on current needs and behaviors.

2. Patient E15's treatment plan was last revised on 2/8/17. As of 6/2/17, there was no documented update of this treatment plan to ensure revision of goals and interventions based on current needs and behaviors.

B. Interview

In an interview on 6/1/17 at 1:30 p.m. with Clinical Service Director, Rehabilitation Supervisor and RN7 treatment plans were discussed. They did not dispute the findings as documented above.

Based on interview and document review, the facility failed to:

1. Ensure that Registered nurses (RN) are present at all times and on all shifts for five (5) of five (5) patient care units (A100, A200, A300, A400 and A500). During the week of May 25, 2017 through 5/31/17 (first day of the survey) there was only one (1) RN assigned to cover evening and night shifts on several occasions on each of the five (5) patient care units. RN duties that require their absence from the assigned units include attending Code Blues and Medical Assist codes, meetings, and lunch breaks which lasted for one (1) hour per shift. During these absences, there was no scheduled RN relief; instead RN's are required to call the nearest unit and make arrangements with that RN to cover for the RN who is about to be absent. This pattern of staffing resulted in one (1) unit being without a RN to assess and monitor patient care, provide immediate response to crisis interventions and supervise and direct/guide para-professionals (LPNs and Mental Health Technicians) in their performance of nursing care duties. This failure affects the quality of patient care, increases the timeliness for crisis resolution and is a safety risk for the patients and staff. (Refer to B150, Section II)

II. Ensure that a sufficient number of nursing personnel (RNs, LPNs and Mental Health Technicians) are assigned to five (5) of five (5) certified Units (100, 200, 300, 400 and 500) to provide safe care to the patients on all shifts of duty. Due to the acuity of patients, various off ward duties performed by nursing personnel (patient escort, behavioral and medical codes, meal breaks) many shifts on all five (5) units were not sufficiently staffed. This failure hinders quality patient care and results in a safety risk for all patients and staff on these certified units. (Refer to B150, Section III)

In addition,

III. The Director of Clinical Services failed to monitor and take corrective action to ensure the development and update of Master Treatment Plans that included measurable long and short-term goals and clearly delineated interventions to address the specific treatment needs of nine (9) of 10 active sample patients (A1, B8, B14, C5, C11, D1, D2, E10 and E15). This resulted in treatment plans that failed to reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment. (Refer to B144)

IV. The Director of Nursing failed to ensure that nursing interventions were included in the treatment plans especially those necessary to guide personnel in the care of patients presenting safety issues in the clinical areas. This resulted in treatment plans that failed to reflect a comprehensive, integrated, individualized approach to multidisciplinary treatment. (Refer to B148, Section I)

Based on interview and document review, the Director of Nursing failed to:

1. Ensure that Registered nurses (RN) are present at all times and on all shifts for five (5) of five (5) patient care units (A100, A200, A300, A400 and A500). During the week of May 25, 2017 through 5/31/17 (first day of the survey) there was only one (1) RN assigned to cover evening and night shifts on several occasions on each of the five (5) patient care units. RN duties that required their absence from the assigned units included attending Code Blues and Medical Asssist codes, meetings, and lunch breaks which lasted for one hour per shift. During these absences there was no scheduled RN relief; instead RN's were required to call the nearest unit and make arrangements with that RN to cover for the RN who was about to be absent. This pattern of staffing resulted in one unit being without a RN to assess and monitor patient care, provide immediate response to crisis interventions and supervise and direct/guide para-professionals (LPNs and Mental Health Technicians) in their performance of nursing care duties. This failure affects the quality of patient care, increases the timeliness for crisis resolution and is a safety risk for the patients and staff.

II. Ensure that a sufficient number of nursing personnel (RNs, LPNs and Mental Health Technicians) are assigned to five (5) of five (5) certified Units (100, 200, 300, 400 and 500) to provide safe care to the patients on all shifts of duty. Due to the acuity of patients and various off ward duties performed by nursing personnel (patient escort, behavioral and medical codes, meal breaks, etc.), many shifts on all five (5) units were not sufficiently staffed. This failure hinders quality patient care and results in a safety risk for all patients and staff on these certified units.

Findings include:

I. Failure to ensure presence of RN on each unit at all times:

A. Specific Unit Findings
1. Unit 100 is a 20-bed adult co-ed civil admissions unit with a census of 16 on the first day of the survey (5/31/17). This unit had patient rooms on one hallway with male and female patients assigned on this one hallway.

2. Unit 200 is a 24-bed adult forensic unit for males with issues such as aggression to others, sexual behaviors towards others and who present with major personality or psychotic disorders. This unit had a census of 24 on the first date of the survey (5/31/17).

3. Unit 300 is a 20-bed adult co-ed civil admissions unit with a census of 17 on the first day of the survey (5/31/17). This unit had patient rooms on one hallway with male and female patients assigned on this one hallway.

4. Unit 400 is a 24-bed adult co-ed unit for forensic patients with a census of 25 on the first day of the survey (5/31/17). This unit had patient rooms on one hallway with male
and female patients assigned on this same hallway.

5. Unit 500 is a 26-bed adult co-ed unit for forensic patients hospitalized due to Not Guilty by Reason of Insanity. This unit had a census of 26 on the first day of the survey (5/31/17). This unit had patient rooms on one hallway with male and female patients assigned on this same hallway.

B. Review of the "Direct Nursing Staffing Form" completed by a RN for a seven (7)-day period starting with 5/25/17 and ending with 5/31/17 (the first day of the survey), revealed a lack of adequate RN relief for meals and other duties that may take them off their assigned units on the afternoon and night shifts.

a. Unit A100: Five (5) of seven (7) night shifts had one (1) RN assigned (5/26/17, 5/27/17, 5/28/17, 5/29/17, and 5/31/17).

b. Unit A200: Six (6) of seven (7) evening shifts had one (1) RN assigned (5/25/17, 5/26/17, 5/27/17, 5/28/17, 5/30/17 and 5/31/17) and Six (6) of seven (7) night shifts had one (1) RN assigned, (5/25/17, 5/26/17, 5/28/17, 5/29/17, 5/30/17 and 5/31/17).

c. Unit A300: One (1) of seven (7)-night shifts had one (1) RN assigned (5/30/17).

d. Unit A400: One (1) of seven (7) evening shifts had one RN assigned (5/26/17) and seven (7) of seven (7) night shifts had One (1) RN assigned (5/25/17, 5/26/17, /5/27/17, 5/28/17, 5/29/17, /5/30/17 and 5/31/17).

e. Unit A500: Six (6) of seven (7) evening shifts had one (1) RN assigned (5/26/17, 5/27/17, 5/28/17, 5/29/17, 5/30/17 and 5/31/17) and seven (7) of seven (7) night shifts had one (1) RN assigned, (5/25/17, 5/26/17, 5/27/17, 5/28/17, 5/29/17, 5/30/17 and 5/31/17).

C. Interviews:

1. During interview on 5/31/17 at 2:00 p.m., RN5 stated s/he was the only RN assigned to the shift and s/he left the unit for a one-hour break. RN5 also acknowledged s/he did not call another RN to cover the RN5 absence from the unit, as the LPN covered for medication and would call the supervisor or another RN if needed.

2. During interview on 6/1/17 at 9:30 a.m. RN8 and RN9 reported that Nursing Supervisors are not called when RN coverage is needed for their units (for meal breaks, etc.).

3. During interview on 6/1/17 at 4:00 p.m. with Director of Nursing (DON), insufficient numbers of nursing staff on unit and the lacked of RN coverage for meals was discussed. She did not dispute the findings but stated the RN is supposed to contact the nursing supervisors for coverage.

4. During an interview on 6/2/17 at 9:35 with the Chief Executive Officer (CEO), she stated the staffing model requires two RNs on each unit for coverage, and that the facility was aware of the need.

D. Policy

1. Policy "03.06 - Unit Coverage by Nursing Staff," states "The Supervisors and the charge nurses on the units will arrange coverage that involves staff leaving his or her assigned unit. It is essential that the supervisors know who is providing coverage where, for whom, and for how long," During interview on 5/1/17 at 9:30 a.m. RN 8 and RN 9 reported that the Nursing Supervisor is not called when they provide RN coverage for another unit.

2.Review of Policy "02:19 - Code Blue," revealed that the policy does not direct which members of nursing personnel attend a medical code except for the following assignment, "Nursing supervisor reports to all "CODE BLUES."

3. Policy, "02.01 - emergency Codes and Reporting," lists "Code Blue" as an emergency code for the facility. It states, "Physicians, nurses, First Aid/CPR trained staff respond to the scene and assist."

II. Failure to staff a sufficient number of total nursing personnel:

A. Specific Unit Findings

1. Unit 100 is a 20-bed adult co-ed civil admissions unit with a census of 16 on the first day of the survey (5/31/17). This unit had patient rooms on one hallway with male and female patients assigned on this one hallway.

2. Unit 200 is a 24-bed adult forensic unit for males with issues such as aggression to others, sexual behaviors towards others and who present with major personality or psychotic disorders. The census on the first day of the survey (5/31/17) was 24.

3. Unit 300 is a 20-bed adult co-ed civil admissions unit with a census of 17 on the first day of the survey (5/31/17). This unit had patient rooms on one hallway with male and female patients assigned on this one hallway.

4. Unit 400 is a 24-bed adult co-ed unit for forensic patients with a census of 25 on the first day of the survey (5/31/17). This unit had patient rooms on one hallway with male and female patients assigned on this same hallway.

5. Unit 500 is a 26-bed adult co-ed unit for forensic patients hospitalized due to Not Guilt by Reason of Insanity. This unit had a census of 26 on the first day of the survey (5/31/17). This unit had patient rooms on one hallway with male and female patients assigned on this same hallway.

B. Review of Nursing Staffing Forms

a. Units 100, 200, 300 and 400

Even though the "Direct Nursing Staffing Form" completed by a RN for a seven (7) day period, including the first day of the survey (5/31/17), for Units 100, 200, 300 and 400 revealed that all shifts of duty were adequately staffed to care for the assigned patient population, this staffing was greatly impacted by assignments/tasks requiring nursing personnel to leave their assigned wards on all three (3) shifts of duty. These tasks included covering other units when staff were absent, assisting in the hospital beauty shop, "detail" assignments such as escorting patients to appointments, attending codes (behavioral and medical) in other parts of the facility and going off-ward for meal breaks (total of one (1) hour on each eight (8) hour shift of duty). The absence of even one (1) staff member on many shifts of duty would hinder staff in ensuring proper monitoring of the patients and to provide crisis intervention to prevent escalation of negative patient behaviors.

b. Unit 500

Review of the "Direct Nursing Staffing Form" completed by a RN for a seven (7) day period for Unit 500 revealed that all night shifts of duty (5/25/17, 5/26/17, 5/27/17, 5/28/17, 5/29/17, 5/30/17 and 5/31/17) were staffed with a total of only three (3) nursing personnel. This staffing did not allow for meal breaks as there would not be a sufficient number of nursing personnel to provide required monitoring of patient areas to ensure safety of patients and staff.

B. Interviews

1. During interview on 5/31/17 at 1:25 p.m., RN 4 reported that on all shifts of duty on the 100-unit staff were sent on breaks (30 minutes meal and two (2) 15-minute breaks for a total of one (1) hour each). Therefore, if there were five (5) on duty, the unit was down one assigned staff member -on day shift that was usually from 10:00 to 3:00 p.m. In addition, a technician might be sent to the beauty shop or court held in the hospital for several hours weekly; a technician might be sent to take patients for off unit appointments. S/he reported that all RNs on duty were to attend medical codes in other units and at least one technician was supposed to attend any behavioral codes called in the other units.

2. During interview on 5/31/17 at 2:45 p.m., RN 3 reported that there were two (2) RNs, one (1) LPN and two (2) technicians on duty on Unit 200. S/he explained that it took from 10:30 a.m. until after 2:30 p.m. for the nursing personnel to take their shift breaks. RN 3 reported that sometimes this unit was down to two (2) nursing personnel due to assignments as escort service, breaks, etc. S/he reported that when there are only three (3) staff on the unit, the RN may be documenting on the computer and the LPN may have to close the medication room door to ensure safety while preparing medications. This staffing allowance means that the third (3rd) staff member who is out in the milieu monitoring the patients is not within sight of another personnel member. S/he reported that she did not feel this was a safe practice.

3. During interview on 5/31/17 at 3:30 p.m., RN 6 and RN 7 verified that all nursing personnel receive a one (1)-hour break on each shift of duty. They verified that the beauty shop, patient hospital court coverage and patient escort assignments are provided by the unit staff. The nursing supervisors on each shift of duty make these assignments.

4. During interview on 6/1/17 at 9:30 a.m. RN 8 and RN 9 stated that RNs leave their assigned units for meetings off the unit, meal breaks and medical codes in other units. They verified that both RNs assigned to a unit might leave the unit for medical codes. They reported that technicians and LPNs might be sent to another unit to assist in a behavioral code. They reported that when there are two (2) RNs assigned to Unit 400, one RN is "usually pulled" when needed on one of the civil units (100 and 300 Units). RN 8 and RN 9 reported that when six (6) staff are assigned to Unit 300, one (1) staff may be reassigned to "detail" (patient escort) and one (1) might be assigned to cover another unit. They added, "When this occurs the unit is down to 3 staff when one goes on meal break." They added they might be down to 2 if someone had to be sent to a medical code. They clarified, "a Unit is never to go below 2 nursing personnel on any shift."

5. During interview on 5/31/17 at 4:20 p.m., on 6/1/17 at 2:40 p.m. and on 6/2/17 at 10:00 a.m. the DON reported that the units are supposed to call if they need additional coverage. She added that one should always be out in the milieu, rather than all being in the office. These staff members should talk to patients, etc.

6. During interview on 6/2/17 at 9:30 a.m., the CEO stated about staffing, "There is definitely work to be done."

E. Policy

1.Review of Policy "02:19 - Code Blue," revealed that the policy does not direct which members of nursing personnel attend a medical code except for the following assignment, "Nursing supervisor reports to all "CODE BLUES."

Policy, "02.01 - emergency Codes and Reporting," lists "Code Blue" as an emergency code for the facility. It states, "Physicians, nurses, First Aid/CPR trained staff respond to the scene and assist."

2. Policy "06.18 - Assistance Team (A Team)," states "The Assistance Team objective is to provide injury-free resolution through verbal de-escalation skills to defuse an impending crisis .... Staff are to call for peers for assistance whenever a client is considered to be in a pre-crisis situation that could potentially escalate into a volatile situation. Response to A-team call is a multi-disciplinary effort." This policy does not direct which staff members are to attend an A Team code. One procedural statement is "All clinical personnel are expected to respond to A-Team calls on the designated area. It is not clear whether this means on the staff's assigned unit or the "designated "unit might be another unit where the code has been called.

3. Policy, "02.91 - Shift Responsibility," states "The nurse supervisor assigns a staff member to respond to a Code Blue, Special Team, or which (sic) may occur during the shift." It is not clear whether "Special Team," refers to the Code Blue team or one of the other teams. It is also unclear whether this assignment is from one (1) unit or each of the five (5) units.

4. Policy, "02.01 - emergency Codes and Reporting," lists "Code Violet." This policy states "Response: All available staff responds to scene to assist." Administration described this code as a team to assist unit staff when there is a patient crisis such as aggression. On 6/2/17 at 10:30 a.m., the CEO verified the facility does not currently have a policy for use of this code team. When asked about a policy related to "Code Violet," she verified there is no policy, stating, "We will need to contact central office."