HospitalInspections.org

Based on a review of documentation, interviews with staff, observation and a tour of the facility, the governing body failed to ensure that the facility was managed to ensure patient safety, and provide the number of staff necessary for patient care.

Findings were:

I.
In an interview with Staff #7 on 12/17/2014 at 10:43 am she stated, "I noticed [Staff #2, Mental Health Technician] was allowing patients to use the staff bathroom. I asked [Staff # 2] why he was allowing the patients to use the staff bathroom. [Staff # 2] replied '[Staff # 1, Registered Nurse] said it was okay'". Staff #7 then stated that she "pointed out to [Staff # 2] that the staff bathroom was not safe for patients to use because it has a glass mirror, a coat hanger on the back of the door and exposed pipes." These were patients receiving active psychiatric treatment.

A tour of the facility on 12/15/2014 revealed the following potential safety hazards in the aforementioned staff bathrooms that were being used by patients:

The staff bathrooms are equipped with a glass mirror mounted above the sink area that could potentially be broken, swallowed by an unattended patient and/or used to cut themselves, their peers or staff members possibly causing severe harm or death.
There are two metal grab bars mounted on the wall to the left of the toilet and behind the toilet and exposed pipes underneath the sink that could be used as a base for the use of a ligature.
There are no windows or openings on the staff bathroom door that would allow staff to visually observe the patient while in the bathroom allowing for a patient to use any of the above mentioned objects to cause harm or death to themselves, their peers and staff members.
Based on the above observations, staff bathrooms are an unsafe and potentially deadly area to allow patients access to, especially out of the view of a trained mental health professionals.
Interviews with facility staff members confirmed that patients on the adult unit were allowed unsupervised access to the staff bathroom on 09/29/14.
In interviews on 12/15/14, staff members # 1 and # 2 confirmed that patients were allowed unsupervised access to the staff bathroom on 9/29/2014 for approximately 1 and 1/2 hours.

A review of the facility Environment of Care/Performance Improvement Minute Meetings and Maintenance Work Order Records reveals no mention of or follow-up regarding this incident, which posed a safety hazard to patients. Additionally, no education was provided to staff or policies implemented to ensure that patients would not be allowed access to staff bathrooms, and potentially hazardous fixtures located within.

The above was confirmed in an exit conference with the facility Director of Risk Management/Performance Improvement, Director of Business Development, Director of Nursing and Divisional Director of Clinical Services on the afternoon of 12-17-14 in the facility conference room.

II.
Facility policy NR-3 titled "Change of Shift Report, Staffing Levels and Acuity Levels" states, in part:
"Policy:
The Austin Oaks Hospital Chief Nursing Officer oversees the nursing staffing through a systematic approach to change of shift report, monitoring the acuity [sic] units and communication with Charge Nurses and Supervisors.

Procedures:
1. Change of shift report provides a consistent method for the communication of pertinent patient information, to ensure staffing levels are adequate based on unit acuity levels.
2. Monitoring of staffing and unity [sic] acuity levels ensures the safety of patient and staff through the monitoring of the environment of care on the units.
3. It is the policy of Austin Oaks Hospital to maintain a minimum staff to patient ratio of 1:5 during awake hours, and 1:10 during sleeping hours."

In an interview with staff #8 (Registered Nurse, House Supervisor) on 12-16-14 at 10:00 am, she was asked to assist this surveyor in reviewing the "Staff Assignment Sheet" and "Nursing Assignment Sheets" for the month of November 2014.

Staff #8 confirmed that nurses work 12 hour shifts (7 AM-7 PM and 7 PM-7AM) and MHTs work 8 hour shifts (7 AM-3 PM, 3 PM-11 PM, and 11 PM-7 AM). Staff #8 confirmed that the assignment sheets are from 7 AM-7 PM and 7 PM-7AM, which results in a failure to account for the Mental Health Technicians (MHT) that are assigned to work the 3 PM-11 PM shift.

Staff #8 was asked how the facility was able to determine what MHTs were assigned to what unit and/or patients from 3 PM-11 PM. Staff #8 stated, "I don't know. We had a lot of transition recently and got handed a mess with these sheets." Staff #8 was unable to demonstrate that the 3PM-11PM shift was adequately staffed by MHTs as required in the facility's policy.

Staff #8 was also asked why some staff assignment sheets had an area to document special precautions, (such as 1:1 patient monitoring for patients at high risk for suicide, etc.) and others did not. Staff #8 replied, "We were re-doing the sheet and some old sheets got out on the unit and used." Staff #8 stated that the current assignment sheets used at the facility do not have an area to indicate special precautions (such as 1:1 monitoring). Without an area to indicate any staff assignments for patients on special precautions, the facility is unable to demonstrate which staff members were responsible for such monitoring. The facility was also unable to establish if the unit was appropriately staffed for the acuity of the patient population, including patients that required 1:1 monitoring.

In an interview with Staff #7 (Registered Nurse, House Supervisor) on 12-17-14 at 10:20 am, she confirmed that the assignment sheets do not indicate census numbers for the unit and or any special precautions (such as 1:1 monitoring), which would help determine unit acuity the potential need for extra staffing. Staff #7 stated that indicators such as census and 1:1 patient status would be useful on these forms.

Staff #7 was asked why the assignment sheets are only from 7 AM-7 PM and 7 PM-7AM, when the Mental Health Technicians are assigned to 8 hour shifts, she said that the "3 PM-11 PM shift gets missed". Staff #7 confirmed that the current nursing assignment sheets utilized at the facility do not accurately reflect the 3 eight-hour shifts worked by the MHTs at the facility.

Staff #7 was asked to review the "Nursing Assignment Sheets" and "Staff Assignment Sheet" for December 2014 to see if she could explain what MHT staff members were present for each of the scheduled shifts (7AM-3PM, 3PM-11PM and 11PM-7AM). She stated, "I can guess from the paperwork where they are, but I can't say for sure." She was asked if she could determine if the staffing was sufficient for the three shifts to meet the facility-provided staffing grid and patient safety. The staff member stated, "Not exactly, I could make an educated guess, because we are missing some information." Staff #7 confirmed that staffing forms currently utilized to staff the unit do not accurately reflect staffing assignments on the units. Due to this, Staff #7 was unable to verify or demonstrate that, in December 2014, the units of the facility were staffed according the staffing grid.

Observation of the child/adolescent unit was conducted on 12-17-14, shortly after 3:00 PM. The child/adolescent unit contained 3 children and 18 adolescents for a total of 21 patients. The unit was staffed with 3 MHTs, 1 Registered Nurse and 1 Licensed Vocational Nurse. Since 7:00 AM that morning, 1 patient had been admitted to the unit and another admission was expected to arrive soon. 1 patient had been discharged and another discharge was expected prior to the end of the shift. The 2 nurses assigned to the unit were not observed providing any direct patient care, as the majority of their time was spent tending to administrative duties.

Observation of the adult unit was conducted on 12-17-14 following the tour of the child/adolescent unit. The adult unit contained 14 patients. The unit was staffed with 2 MHTs and 2 Registered Nurses. Since 7:00 that morning, 1 patient had been admitted to the unit and 3 patients had been discharged. The 2 nurses assigned to the unit were not observed providing any direct patient care, as the majority of their time was spent tending to administrative duties.

Facility policy NR-8 titled "Nurse Staffing Committee", states, in part:
"Policy:
Austin Oaks Hospital shall establish and maintain a nurse staffing committee, approved by the Governing Board, to assist in the development and evaluation of the Hospital's Nurse Staffing Plan.

Procedure:
1. Austin Oaks Hospital will establish a nurse staffing committee as a standing hospital committee.
C. The committee shall meet at least quarterly."

A review of Nurse Staffing Committee Meeting Minutes revealed that there were only 2 meetings held in 2013 and 2014, on the following dates: 10-28-13 and, 4-16-14.
Staff was unable to provide the surveyors with documentation of any Nurse Staffing Committee meetings held after 4-16-14.

The above was confirmed in an exit conference with the facility Director of Risk Management/Performance Improvement, Director of Business Development, Director of Nursing and Divisional Director of Clinical Services on the afternoon of 12-17-14 in the facility conference room.

Based on a review of documentation, interviews with staff, observation and a tour of the facility, the facility's director of nursing failed to ensure that patient care was executed in a safe manner, as a registered nurse allowed an unlicensed mental health technician to give psychiatric patients access to the staff bathroom, which posed a potential safety hazard, for an hour and a half.

Findings were:

In an interview with Staff #7 on 12/17/2014 at 10:43 am she stated, "I noticed [Staff #2, Mental Health Technician] was allowing patients to use the staff bathroom. I asked [Staff # 2] why he was allowing the patients to use the staff bathroom. [Staff # 2] replied '[Staff # 1, Registered Nurse] said it was okay'". Staff #7 then stated that she "pointed out to [Staff # 2] that the staff bathroom was not safe for patients to use because it has a glass mirror, a coat hanger on the back of the door and exposed pipes." These were patients receiving active psychiatric treatment.

A tour of the facility on 12/15/2014 revealed the following potential safety hazards in the aforementioned staff bathrooms that were being used by patients:

The staff bathrooms are equipped with a glass mirror mounted above the sink area that could potentially be broken, swallowed by an unattended patient and/or used to cut themselves, their peers or staff members possibly causing severe harm or death.
There are two metal grab bars mounted on the wall to the left of the toilet and behind the toilet and exposed pipes underneath the sink that could be used as a base for the use of a ligature.
There are no windows or openings on the staff bathroom door that would allow staff to visually observe the patient while in the bathroom allowing for a patient to use any of the above mentioned objects to cause harm or death to themselves, their peers and staff members.
Based on the above observations, staff bathrooms are an unsafe and potentially deadly area to allow patients access to, especially out of the view of a trained mental health professionals.
Interviews with facility staff members confirmed that patients on the adult unit were allowed unsupervised access to the staff bathroom on 09/29/14.
In interviews on 12/15/14, staff members # 1 and # 2 confirmed that patients were allowed unsupervised access to the staff bathroom on 9/29/2014 for approximately 1 and 1/2 hours.

A review of the facility Environment of Care/Performance Improvement Minute Meetings and Maintenance Work Order Records reveals no mention of or follow-up regarding this incident, which posed a safety hazard to patients. Additionally, no education was provided to staff or policies implemented to ensure that patients would not be allowed access to staff bathrooms, and potentially hazardous fixtures located within.

The above was confirmed in an exit conference with the facility Director of Risk Management/Performance Improvement, Director of Business Development, Director of Nursing and Divisional Director of Clinical Services on the afternoon of 12-17-14 in the facility conference room.

Based on a review of documentation, interviews with staff, observation and a tour of the facility, the facility failed to demonstrate that there were an adequate number of personnel to provide patient care.

Findings were:

Facility policy NR-3 titled "Change of Shift Report, Staffing Levels and Acuity Levels" states, in part:
"Policy:
The Austin Oaks Hospital Chief Nursing Officer oversees the nursing staffing through a systematic approach to change of shift report, monitoring the acuity [sic] units and communication with Charge Nurses and Supervisors.

Procedures:
1. Change of shift report provides a consistent method for the communication of pertinent patient information, to ensure staffing levels are adequate based on unit acuity levels.
2. Monitoring of staffing and unity [sic] acuity levels ensures the safety of patient and staff through the monitoring of the environment of care on the units.
3. It is the policy of Austin Oaks Hospital to maintain a minimum staff to patient ratio of 1:5 during awake hours, and 1:10 during sleeping hours."

In an interview with staff #8 (Registered Nurse, House Supervisor) on 12-16-14 at 10:00 am, she was asked to assist this surveyor in reviewing the "Staff Assignment Sheet" and "Nursing Assignment Sheets" for the month of November 2014.

Staff #8 confirmed that nurses work 12 hour shifts (7 AM-7 PM and 7 PM-7AM) and MHTs work 8 hour shifts (7 AM-3 PM, 3 PM-11 PM, and 11 PM-7 AM). Staff #8 confirmed that the assignment sheets are from 7 AM-7 PM and 7 PM-7AM, which results in a failure to account for the Mental Health Technicians (MHT) that are assigned to work the 3 PM-11 PM shift.

Staff #8 was asked how the facility was able to determine what MHTs were assigned to what unit and/or patients from 3 PM-11 PM. Staff #8 stated, "I don't know. We had a lot of transition recently and got handed a mess with these sheets." Staff #8 was unable to demonstrate that the 3PM-11PM shift was adequately staffed by MHTs as required in the facility's policy.

Staff #8 was also asked why some staff assignment sheets had an area to document special precautions, (such as 1:1 patient monitoring for patients at high risk for suicide, etc.) and others did not. Staff #8 replied, "We were re-doing the sheet and some old sheets got out on the unit and used." Staff #8 stated that the current assignment sheets used at the facility do not have an area to indicate special precautions (such as 1:1 monitoring). Without an area to indicate any staff assignments for patients on special precautions, the facility is unable to demonstrate which staff members were responsible for such monitoring. The facility was also unable to establish if the unit was appropriately staffed for the acuity of the patient population, including patients that required 1:1 monitoring.

In an interview with Staff #7 (Registered Nurse, House Supervisor) on 12-17-14 at 10:20 am, she confirmed that the assignment sheets do not indicate census numbers for the unit and or any special precautions (such as 1:1 monitoring), which would help determine unit acuity the potential need for extra staffing. Staff #7 stated that indicators such as census and 1:1 patient status would be useful on these forms.

Staff #7 was asked why the assignment sheets are only from 7 AM-7 PM and 7 PM-7AM, when the Mental Health Technicians are assigned to 8 hour shifts, she said that the "3 PM-11 PM shift gets missed". Staff #7 confirmed that the current nursing assignment sheets utilized at the facility do not accurately reflect the 3 eight-hour shifts worked by the MHTs at the facility.

Staff #7 was asked to review the "Nursing Assignment Sheets" and "Staff Assignment Sheet" for December 2014 to see if she could explain what MHT staff members were present for each of the scheduled shifts (7AM-3PM, 3PM-11PM and 11PM-7AM). She stated, "I can guess from the paperwork where they are, but I can't say for sure." She was asked if she could determine if the staffing was sufficient for the three shifts to meet the facility-provided staffing grid and patient safety. The staff member stated, "Not exactly, I could make an educated guess, because we are missing some information." Staff #7 confirmed that staffing forms currently utilized to staff the unit do not accurately reflect staffing assignments on the units. Due to this, Staff #7 was unable to verify or demonstrate that, in December 2014, the units of the facility were staffed according the staffing grid.

Observation of the child/adolescent unit was conducted on 12-17-14, shortly after 3:00 PM. The child/adolescent unit contained 3 children and 18 adolescents for a total of 21 patients. The unit was staffed with 3 MHTs, 1 Registered Nurse and 1 Licensed Vocational Nurse. Since 7:00 AM that morning, 1 patient had been admitted to the unit and another admission was expected to arrive soon. 1 patient had been discharged and another discharge was expected prior to the end of the shift. The 2 nurses assigned to the unit were not observed providing any direct patient care, as the majority of their time was spent tending to administrative duties.

Observation of the adult unit was conducted on 12-17-14 following the tour of the child/adolescent unit. The adult unit contained 14 patients. The unit was staffed with 2 MHTs and 2 Registered Nurses. Since 7:00 that morning, 1 patient had been admitted to the unit and 3 patients had been discharged. The 2 nurses assigned to the unit were not observed providing any direct patient care, as the majority of their time was spent tending to administrative duties.

Facility policy NR-8 titled "Nurse Staffing Committee", states, in part:
"Policy:
Austin Oaks Hospital shall establish and maintain a nurse staffing committee, approved by the Governing Board, to assist in the development and evaluation of the Hospital's Nurse Staffing Plan.

Procedure:
1. Austin Oaks Hospital will establish a nurse staffing committee as a standing hospital committee.
C. The committee shall meet at least quarterly."

A review of Nurse Staffing Committee Meeting Minutes revealed that there were only 2 meetings held in 2013 and 2014, on the following dates: 10-28-13 and, 4-16-14.
Staff was unable to provide the surveyors with documentation of any Nurse Staffing Committee meetings held after 4-16-14.

The above was confirmed in an exit conference with the facility Director of Risk Management/Performance Improvement, Director of Business Development, Director of Nursing and Divisional Director of Clinical Services on the afternoon of 12-17-14 in the facility conference room.