HospitalInspections.org

Based on direct observation, review of hospital document, hospital policy/procedure and interviews, it was determined that the hospital failed to provide for the initial treatment of emergencies for patients admitted to the Sage Unit as evidenced by:

1. failure to ensure that the emergency cart located on the Sage Unit contained supplies and equipment as specified in hospital document and for response to Code Blue, which posed a risk to patient health and safety; and

2. failure to ensure the availability of a stocked emergency cart to the Sage Unit which posed a risk to patient health and safety.

Findings include:

Review of hospital document titled Emergency Cart Inventory & After Use Inventory revealed a list of equipment required in the emergency cart. Equipment list included: "...Suction machine, AED (Automated External Defibrillator)...gloves...CPR clear mouth barrier...Ambu-bag, Adult O2 mask...Adult nasal cannula...Lancets, Box ammonia inhalants...Adult BP cuff, Stethoscope...bandages...gauze...tongue blades...."

Review of hospital policy titled Code Blue Response revealed "...Personnel from department calling the Code Blue:...Obtains emergency cart...Attaches monitor leads...Designated nurse with appropriate training...defibrillates according to appropriate guidelines...."

1. On 6/28/16, direct observation of the Emergency Cart, located in the Sage Unit Nurses' Station, revealed that it was not stocked with equipment including a Suction machine and AED.

The DON confirmed, during interview conducted on 6/28/16, that the emergency cart, located on the Sage Unit, did not contain the required emergency equipment. The DON also confirmed that patients had been located on the 19-bed Sage Unit since 6/23/16.

2. Direct observation, conducted on 6/28/16 at approximately 2000, revealed that the emergency cart located on the Sage Unit was not stocked with supplies, including a suction machine and AED machine. The DON stated, during interview conducted on 6/28/16, that the staff would utilize the emergency cart located on the Ocotillo/Cholla Unit for an emergency on the Sage Unit. Direct observation revealed that if the Sage Unit staff obtained the cart, it would require them to exit/enter 5 locked doors and an elevator to obtain the cart and then return to the Sage Unit via 5 locked doors and the elevator. If the Ocotillo/Cholla staff brought the cart to the Sage Unit, they would be required to exit/enter 5 locked doors and an elevator to make the cart available to the Sage Unit.

The emergency cart was not available to the Sage Unit.

The DON confirmed, during interview conducted 6/28/16, that access to a stocked emergency cart, with suction and AED, for the Sage Unit required staff to enter and exit locked doors and an elevator which limited its availability. The CEO, COO, and Director of Quality and Risk acknowledged, during the Provider Meeting conducted on 6/28/16, at 2300 that the emergency cart which would be used for the Sage Unit, had limited availability, due to its location behind locked doors and on a different hospital floor.

Based on review of hospital policy/procedure, 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 implement a staffing plan that determines the type and numbers of nursing personnel necessary to provide nursing care for all areas of the hospital, which posed a risk that the psychiatric and medical needs of the patients who require hospitalization would go unmet;

(A392) failure to have adequate numbers of registered nurses and supervisory staff to ensure the immediate availability of a registered nurse to meet the needs of all patients, posing a risk to patient safety; and

(A395) failure to ensure that a registered nurse supervise and evaluate a patient's requirement for behavioral intervention and restraint for 1 of 1 patient (Pt # 3) who repeatedly and forcefully kicked open a hospital exit door, allowing another patient (Pt # 2) to elope through the door.

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 policy/procedure, hospital documents and interview, it was determined that the nurse executive failed to implement a staffing plan that determines the type and numbers of nursing personnel necessary to provide nursing care for all areas of the hospital, which posed a risk that the psychiatric and medical needs of the patients who require hospitalization would go unmet.

Findings include:

Review of hospital policy/procedure titled Patient Acuity, Revision Date 6/1/16, revealed: "...to define the established acuity/staffing plan to meet patient care needs...Staffing for patient care is based on acuity and level of care needed for the inpatient psychiatric patient...To provide a framework for nursing staff to evaluate the nurse-to-patient ratio and nursing level of care needed...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 established number of staff by discipline as identified by the staffing matrix...Staffing is based on the unit census, patient acuity, care need(s) for the psychiatric patient, knowledge, skill and abilities of nursing staff...The acuity report will be reviewed by the Nursing Supervisor (4) hours prior to the next shift. At this time...staffing levels will be reconciled and adjustments made for additional staff made accordingly. The maximum acuity score per staff member is RN: 80 and BHT/LPN: 60. After reconciliation to assure staffing to acuity the assignment sheet will be posted for staff review...It is the responsibility of the Nursing Supervisor to make the patient care shift assignments...A Nursing Supervisor is available 24 hours a day to evaluate the need for making staffing changes...The physical environment, seclusion/restraint, other crises, staff makeup, staff experience, staff qualifications, patient diagnoses, patient co-occurring conditions, patient ages, and developmental functioning all may have an effect on the acuity of the units and therefore on the staffing levels...Variations from staffing plans are documented with explanation and the Director of Nursing is notified...Staffing Matrix...0-5 Patients: 1 RN; 1 BHT or 1 LPN...6-12 Patients: 1 RN; 1 BHT or 1 LPN...13-20 Patients: 2 RN; 2 BHTor 1 BHT & 1 LPN...."

At the time of the survey, on 6/28/16, at 1930, the DON was functioning as Shift Supervisor. She had not completed the Shift Assignment Sheets which included individual patient assignments, although the shift started at 1830. Patient acuity and staffing was to be determined 4 hours prior to the beginning of the shift.

Review of the completed Shift Assignment Sheets, at approximately 2230, revealed that the DON was assigned to Shift Supervisor responsibilities. RN # 21, who was originally scheduled to complete orientation to Shift Supervisor functions, was the only RN on the Ocotillo Unit, assigned to all 17 adolescent patients, with a total Acuity Score of 138. RN # 6, who was originally scheduled to assist with completion of RN # 21's orientation, was the only RN on the Cholla Unit, assigned to all 12 patients, with a total Acuity Score of 58. RN # 8 was the only RN on the Sage Unit, assigned to all 16 patients, with a total Acuity Score of 135. The staffing did not meet the required number of RNs based on patient census or patient acuity.

Pt # 2 had eloped from the Ocotillo Unit at approximately 1400, during the Day Shift, 6/28/16, and Pt # 3 had kicked the Ocotillo Unit Exit Doors repeatedly and forcefully until the doors broke open. Pt # 3 required restraint at the time that Pt # 2 eloped through the Exit Doors. Pt # 2 was returned to the unit by police, at 2230, which increased RN # 21's Acuity Score to 157.

The DON confirmed, on 6/28/16, that the staffing for the Night Shift, on 6/28/16, did not meet the Staffing Matrix, based on patient census and did not meet the patient acuity requirements.

The 19-bed Sage Unit had opened on 6/23/16 and patients were transferred and/or admitted to that unit by 6/23/16, at 1400.

The hospital Pharmacist confirmed, during interview conducted on 6/30/16, that the MedDispense machine was not functional on the Sage Unit from 6/23/16 until 6/27/16 at 1600. It was operational on the Mesquite Unit which is located downstairs from the Sage Unit and was closed when the Sage Unit opened. Nursing was required to obtain all medications for Sage patients from either the Mesquite Unit Medication Room or the Ocotillo/Cholla Medication Room. Both Medication Rooms were downstairs from Sage and required exiting/entering 7 locked doors and an elevator to obtain medications and then return to the Unit via the same doors and elevators to administer the medications to the patients.

The hospital Pharmacist drew a diagram, on 6/30/16, confirming the number of locked doors required for an RN to exit/enter the Sage Unit to obtain medications from the downstairs Units and return to the Sage Unit.

Review of the Shift Assignment Sheet for Night Shift of 6/24/16 revealed:

RN # 3 was the only RN on the Sage Unit, assigned to all 14 patients, with a total Acuity Score of 100. The Night Shift Supervisor, RN # 6, was assigned to 12 patients on the Cholla Unit and had a total Acuity Score of 68, plus Shift Supervisor responsibilities, which included relieving RN #s 3, 7 and 8 for breaks and covering the Sage Unit while RN # 3 obtained medications from another unit for his/her patients.

Review of the Shift Assignment Sheet for Day Shift of 6/25/16 revealed:

The Shift Supervisor, RN # 9, was assigned to 4 patients on the Cholla Unit and 7 patients on the Ocotillo Unit, with a total Acuity Score of 86, plus Shift Supervisor responsibilities which included relieving RN # s 10, 12, 13 and LPN # 11 for breaks. LPN # 11 was assigned to the same patients as RN # 9, for medication administration.

Review of the Shift Assignment Sheet for Night Shift of 6/25/16 revealed:

RN # 4 was the only RN on the Sage Unit, assigned to all 19 patients, with a total Acuity Score of 170. The Shift Supervisor was assigned to 12 patients on the Cholla Unit with a total Acuity Score of 81, plus Shift Supervisor responsibilities which included relieving RN # s 7, 4 and 16 for breaks and covering the Sage Unit while RN # 4 obtained medications from another unit for her patients.

Review of the Shift Assignment Sheet for Day Shift of 6/26/16 revealed:

The Shift Supervisor, RN # 7, was assigned to 13 patients on the Cholla Unit with a total Acuity Score of 73, plus Shift Supervisor responsibilities which included relieving RN # s 17, 18, 19 and 20 for breaks.

Review of the Shift Assignment Sheet for Night Shift of 6/26/16 revealed:

RN # 10 was assigned to 7 patients on the Ocotillo Unit and 4 patients on the Cholla Unit with a total Acuity Score of 106. The Shift Supervisor, RN # 6, was assigned to 12 patients on the Cholla Unit with a total Acuity Score of 53, plus Shift Supervisor responsibilities which included orienting RN # 21 and relieving RN # s 10, 4, and 22 for breaks.

Three adolescent patients eloped from the Ocotillo Unit on 6/26/16, at approximately 2150.

Review of the Shift Assignment Sheet for Day Shift on 6/27/16 revealed:

The Shift Supervisor, RN # 12 was assigned to 2 patients on the Ocotillo Unit with a total Acuity Score of 38, plus Shift Supervisor responsibilities, which included relieving RN # s 7, 19 and 23 for breaks.

Review of the Shift Assignment Sheet for Night Shift on 6/27/16 revealed:

There was no Shift Supervisor scheduled. RN # 24 was the only RN on the Sage Unit, assigned to all 19 patients, with a total Acuity Score of 161. RN # 6 was the only RN on the Cholla Unit, assigned to all 12 patients, with a total Acuity Score of 108. A shift supervisor was assigned to relieve the nurses on duty for their breaks on the Night Shift of 6/27/16, when there was no Shift Supervisor scheduled.

On the Day Shifts of 6/25/16, 6/26/16 and 6/27/16 and the Night Shifts of 6/24/16, 6/25/16 and 6/26/16 the Shift Supervisor had a patient assignment. There was no Shift Supervisor scheduled on the Night Shift of 6/27/16. The Acuity Plan required that the Shift Supervisor be available 24 hours a day to evaluate the need for making staffing changes. The Shift Supervisor was routinely assigned to relieve all the nurses on duty for their breaks, including nurses who were assigned to patients on two units. On the Night Shift of 6/27/16, when there was no Shift Supervisor scheduled, the Shift "Supervisor" was responsible to relieve the nurses on duty for their breaks.

In addition to the use of Shift Supervisors for direct patient care assignments, while assigned to supervisory functions, the staffing did not meet the staffing requirements, based on patient census and/or acuity on the Day Shift of 6/26/16 and the Night Shifts of 6/24/16, 6/25/16, 6/26/16, 6/27/16 and 6/28/16.

On 6/29/16, the DON confirmed that staffing did not meet the requirements of the Acuity Plan for the Day Shifts of 6/25/16 through 6/27/16 and the Night Shifts of 6/24/16 through 6/28/16.

Based on review of hospital policy/procedure, hospital documents and interview, it was determined that the hospital failed to have adequate numbers of registered nurses and supervisory staff to ensure the immediate availability of a registered nurse to meet the needs of all patients, posing a risk to patient safety.

Findings include:

Review of hospital policy/procedure titled Patient Acuity, Revision Date 6/1/16, revealed: "...The acuity report will be reviewed by the Nursing Supervisor (4) hours prior to the next shift. At this time...staffing levels will be reconciled and adjustments made for additional staff made accordingly...After reconciliation to assure staffing to acuity the assignment sheet will be posted for staff review...It is the responsibility of the Nursing Supervisor to make the patient care shift assignments...A Nursing Supervisor is available 24 hours a day to evaluate the need for making staffing changes...Variations from staffing plans are documented with explanation and the Director of Nursing is notified...."

Review of the Shift Assignment Sheets from Day Shift, 6/23/16 through Night Shift 6/28/16 revealed that RN Shift Supervisors were scheduled for 10 of the 12 shifts. Shifts are 12 hours in length. No Shift Supervisor was scheduled for the Night Shift of 6/27/16. The DON functioned as Shift Supervisor for the Night Shift of 6/28/16.

Shift Supervisors scheduled for 6 of the 10 shifts were also assigned to direct patient care responsibilities and assigned to relieve all of the other nurses on duty for their meal breaks.

Review of hospital documents revealed:

On 6/26/16, at 2150, two female adolescent patients required staff intervention when one patient was described as "going after" the other patient. While staff were focused on the two female adolescents, Pt # 1 "grabbed" a BHT's name badge and was able to exit through the unit doors, into the hallway and out of the building. Pt # s 2 and 3 followed Pt # 1, but were found hiding inside the building. Pt # 1 never returned to the facility. On the Night Shift of 6/26/16, the Shift Supervisor was assigned to 12 patients for direct patient care, in addition to Shift Supervisor responsibilities. S/he was also assigned to orient RN # 21 and relieve three other RN 's for meal breaks. One of the RNs requiring relief was assigned to patients on 2 units, including the adolescent unit.

The DON functioned as Shift Supervisor for the Night Shift of 6/28/16, after assisting with supervisory functions on the Day Shift. RN # 6 was originally scheduled to function as Shift Supervisor and complete the orientation of RN # 21 to Shift Supervisor. On 6/28/16, Night Shift, RN # 6 was the only RN on the Cholla Unit, assigned to14 patients. RN # 21 was the only RN on the Ocotillo (adolescent) Unit, assigned to 17 patients at the onset of the shift. When Pt # 2 returned to the Unit at 2230, after elopement during the Day Shift, the census increased to 18 patients.

On 6/29/16, the DON confirmed that the staffing did not meet the requirements of the Acuity Plan for the Day Shifts of 6/25/16 through 6/27/16 and the Night Shifts of 6/24/16 through 6/28/16, including the assignment of the Shift Supervisor for direct patient care as well as supervisory responsibilities.

Based on review of hospital policy/procedure, medical record, hospital document and interview, it was determined that the hospital failed to ensure that a registered nurse supervise and evaluate a patient's requirement for behavioral intervention and restraint for 1 of 1 patient (Pt # 3) who repeatedly and forcefully kicked open a hospital exit door, allowing another patient (Pt # 2) to elope through the door.

Findings include:

Review of hospital policy/procedure titled Seclusion and Restraint revealed: "...Patients are assessed upon admission and on a continual basis throughout their hospitalization...for behaviors that are potentially dangerous to self or others. Seclusion and Restraint use is implemented as a last resort to ensure the safety of patients and others...early identification and intervention of high-risk behaviors or events...implemented...as a last resort to support patient safety when behaviors pose a risk of imminent harm to the patient or others...All patients have the right to be free from S/R of any form that is imposed as a means of coercion, discipline, convenience or retaliation by staff...training and competency protocols...required for all clinical staff...competencies focus on implementation, assessment, monitoring and application...The RN assesses patient behavior on admission and continuously to determine any imminent risk of the patient physically harming self or others...."

Review of Pt # 3's medical record revealed:

An RN documented, on 6/28/16, at 1730: "...Pt became agitated approximately 1350 and began kicking unit door as hard as he could. RN, RN Supervisor and multiple BHTs attempted to talk to pt to deescalate (sic) the situation. Pt was offered gatorade, ensure, & radio to help deescalate (sic) pt refused to communicate and continued to kick unit doors. BHT attempted to talk to pt 1:1 and take him for a walk to talk. Pt again refused to communicate. Pt ran to exit door and began kicking as hard as he could. Exit door broke open. Pt escorted to seclusion room approximately 1401...."

Review of hospital document revealed:

Patient (Pt # 2) AWOLED out of back door on unit after another peer continually kicked door til lock released, patient ran out of door staff followed and searched but could not find on property...."

On 6/28/16, the hospital CEO confirmed, during Provider Agreement Meeting, that staff should have intervened earlier to protect patient safety, while Pt # 3 was kicking the exit door.

The Director of Quality/Regulatory/Risk Management confirmed, during interview conducted on 6/29/16, that staff needed to physically intervene earlier for patient safety, to prevent Pt # 3 from continuing to kick the door until he broke it open.