HospitalInspections.org

Based on review of meeting minutes and interviews, it was determined that the hospital failed to comply with the provisions of the Governing Body, that require the Governing body to assume responsibility for the hospital as a separately certified institution, and holding it accountable for the quality of care, as demonstrated by the hospital's failure to maintain a separate governing body to ensure focus on the hospital's individual issues. The hospital shared a single governance with multiple owned/operated facilities, and separately certified hospitals.

This citation does NOT raise to CONDITION level.

This deficient practice resulted in the hospital's failure to meet the requirements of the Condition of Participation (COP) for the Governing Body.

Findings include:

The hospital's administration/management confirmed during the entrance conference conducted on 02/25/13, that medical facility is separately certified and licensed from other Carondelet hospitals/entities in the network. The surveyor requested the most recent minutes related to the medical facility. The following were provided:

The "Carondelet Health Network Carondelet Heart & Vascular Institute Board of Directors Minutes of the April 19, 2012 Meeting" was called to order at 7:34 am an adjourned at 1:15 pm. This 8 page report revealed the following:

1. Gathering Items: call to order, Reflection, Approval of agenda, and Declaration of conflicts.
2. Consent Agenda.
3. Information Items: Mercy Care Behavioral Health Initiative; Management Reports: CEO Reports: the CEO (Chief Executive Officer) report covered in the packet; COO (Chief Operating Officer) Report, an overview of the Carondelet's operational improvements and initiatives as they relate to the overall strategy of the Network; CFO (Chief Financial Officer) Stewardship Report: a financial overview for the Carondelet Network; Chief Quality Officer Report: report covered in the packet for the network.
4. Committee Reports: Governance and Nominating Committee: New Board Member Nominations: Mercy Care Board Appointment: Discussion and motion to approve new board members; Audit Committees; Finance Committee: overview of the committee given; Strategic Planning Committee: summary of topics given and reviewed from the committee meeting; Quality and Patient Safety Committee: Report given about what's going on with the organization; Physician Transaction Review Committee.
5. Action Items: Signature Authority: request from the Board for signing authority to be granted for a new CFO as well as signor for the Network; Mercy Care Behavioral Health Initiative: discussion about restructuring Mercy Care; CHVI (Carondelet Heart & Vascular Institute) Repositioning: relocation of CHVI; ISOFP Final Recommendation: discussion of budget and Financial plan throughout the network; and Capital Investments and Line of Credit Approval: (financial).
6. Executive Session: Discussion of audits, and orientation of new Board Members.
7. Adjournment.

Additional similar meetings of the "Carondelet Health Network Carondelet Heart & Vascular Institute Board of Directors" occurred June 14, 2012; September 12-13, 2012; November 15, 2012

The meeting minutes confirmed that multiple separately certified hospitals were discussed at the same times, at the same meetings, and did not focus on medical facility's specific issues, as a separately certified hospital. Interview with CEO on 2/28/13 at 1325, confirmed that the minutes do not break down the individual hospitals separately, but discusses the network and the medical facility together.

Based on direct observation, review of facility policy/procedure and interviews, it was determined that the hospital failed to ensure that Behavioral Health patients receive care in a safe setting as evidenced by the bathrooms in the Behavioral Health Unit and in the Emergency Department Behavioral Health Annex containing equipment that could be used for self-injury or suicide.

Findings include:

Review of hospital policy/procedure titled Patient Rights and Responsibilities revealed: "...Patient Rights...Every patient at a (name of healthcare network) facility...shall have the right to:...A safe environment...."

The survey team directly observed the following environmental safety hazards while on site from 2/25/13 through 2/28/13:

Behavioral Health inpatient facility downstairs, Palo Verde Room, men's restroom:

Disability "grab" bars behind the toilet and on the wall to the side of the toilet; faucet and faucet handles and plumbing fixtures under the sink all provide surfaces for ligatures.

Behavioral Health inpatient facility downstairs, women's restroom:

Disability "grab" bars behind the toilet and on the wall to the side of the toilet; faucet; plumbing fixtures under the sink and the door closing fixture above the inside of the door all provide surfaces for ligatures.

The Manager and Director of Behavioral Health Services confirmed during interview conducted on 2/25/13, that the Behavioral Health inpatients utilize the bathrooms independently and are observed every 15 minutes. They confirmed that the bathrooms contain safety hazards for patients since they contain equipment which can be used for self-injury or suicide.

Bathroom located in the Emergency Department area designated as the Behavioral Health Annex:

Exposed toilet plumbing; shower head and "on/off" valve; plumbing fixture under the sink and lever style door handle all provide surfaces for ligatures.

RN #36 confirmed during interview conducted on 2/27/13 that patients in the Behavioral Health Annex utilize the bathroom independently, with 15 minute "checks." She confirmed that the bathroom contains safety hazards for patients since it contains equipment which can be used for self-injury or suicide.

Based on review of hospital policy/procedure, medical records and interviews, it was determined that the hospital failed to require that restraints be used in accordance with the order of a physician or other licensed independent practitioner for 1 of 1 patient restrained for the management of violent or self-destructive behavior (Pt # 29).

Findings include:

Review of hospital policy/procedure titled Restraints/Seclusion; Use of revealed: "...Definitions...Licensed Independent Practitioner (LIP)...Only Physicians are considered an LIP at (Name of Hospital Network) as defined by Hospital Professional Staff Rules and Regulations...PROCEDURE for the Use of Restraints for VIOLENT AND SELF DESTRUCTIVE Behaviors...Initial Physician Order...A LIP orders restraints...Each episode of restraint must be initiated in accordance with a LIP order. If a patient was recently released from restraint and exhibits behavior that can only be handled through reapplication of restraint, a new order is required...."

Review of Pt # 29's medical record revealed:

A physician ordered "Violent Restraints" on 2/4/13 at 2236. Nursing applied restraints as ordered and released the restraints at 2245. Nursing reapplied restraints on 2/5/13 at 0430 due to the patient being "combative" and "agitated." The medical record did not contain a physician's order for restraints at 0430. At 0627, Physician's Assistant (PA-C) # 4 ordered restraints. The patient was released from restraints at 0730.

The Director of the Emergency Department confirmed during interview conducted on 2/27/13, that nursing reapplied restraints to the patient without the required order and that the PA-C that ordered restraints at 0627 is not an LIP and does not have privileges to order restraints.

Based on review of hospital policy/procedure, medical record and interview, it was determined that the hospital failed to prohibit the use of standing orders for restraint for 1 of 2 non-violent, non-self-destructive patients (Pt # 30).

Findings include:

Review of hospital policy/procedure titled Restraint/Seclusion; Use of revealed: "...PROCEDURE for Use of Restraints for NON-VIOLENT, NON-SELF DESTRUCTIVE patients...A restraint order may not be written as a standing order or on an as needed basis (PRN)...."

Review of Pt # 30's medical record revealed:

On 1/29/13, at 0800, an RN recorded a physician's order for Non-Violent/Non-Self Destructive restraint on the Restraint Order Form. The form contained a check mark in the box to indicate that the patient: "...has a tracheal/endotracheal tube, invasive catheter, lines, or tubes necessary to maintain nutrition or medication, and is unable to follow verbal instructions and/or understand the risk, benefits, and alternative treatments for which the tube/line has been placed. The patient exhibits lack of decision making ability and is confused, delirious, agitated or combative and is grabbing and pulling at the tube/lines in an attempt to dislodge them...."

The form contained check marks to indicate alternatives attempted: "...Position with pillows or wedges...Concealing devices...."

The form contained check marks to indicate the type of restraint: "wrist" and sites: "Upper extremity...Left...Right...."

The form contained pre-printed information that the order was time-limited to 24 hours.

A physician signed the order on 1/29/13 at 1645.

The Restraint Flow Sheet contained documentation that restraint was initiated on 1/29/13 at 1645. Nursing staff completed documentation on the flow sheet at 1800, 2000, 2400, 0200, 0400, and 0600.

On 1/29/13 at 0810, an RN documented: "...0730 Patient A & O x 3 (Alert and Oriented to date, place and person) speech clear. Negative assessment...0755 Transport @ bedside Patient...escorted to OR (Operating Room)...."

The Anesthesia Record dated 1/29/13, contained documentation that anesthesia "Start" was 0908 and "Finish" was 1753.

On 1/29/13 at 1900, an RN documented: "...patient arrived back to neuro critical care...Bedside assessment performed. Patient intubated and sedated...."

On 1/29/13 at 1950, an RN documented: "...Pt opened eyes spontaneously and attempted to extubate herself...held pt down-attempts to get pt to calm down unsuccessful-Fentanyl bolus given per MD order. Versed titrated (up)...."

On 1/29/13 at 2040, an RN documented: "...Pt (with) second episode of spontaneous agitation, and attempt to pull (at) lines and tubes...."

The Manager of Special Procedures Area and Observation Unit confirmed during interview conducted on 2/27/13, that the RN recorded the physician's order 8 hours before the restraints were initiated. The physician signed the order one hour before anesthesia was "finished" and 3 hours before the RN documented the patient's attempt to extubate herself.

The Interim Manager of Neuro Science confirmed during interview conducted on 2/28/13, that the physician signed the order for restraint when he completed the post-operative orders packet.

Based on review of hospital policies/procedures, hospital document, medical records and interviews, it was determined that the hospital failed to require that a registered nurse supervise and evaluate the nursing care provided to 2 of 2 patients admitted to the Behavioral Health inpatient unit for alcohol detoxification (Pts # 31 and 32).

Findings include:

Review of the hospital Behavioral Health Department Policy titled Detoxification Protocol- CIWA-Ar (Clinical Institute of Withdrawal Assessment-Alcohol revised) revealed: "...RN-Assesses and monitors the patient; administers the CIWA-Ar per policy. Response is documented in the medical record...If the CIWA-Ar protocol is utilized, the following should be considered: The CIWA-Ar is completed every 2 to 4 hours during treatment...The categories should each be scored based on the RN's observation and the client's response to questions...The RN scores the CIWA-Ar and records the score and initials the column...The CIWA-Ar total score is used to determine the appropriate dose of medication according to the dosage scale indicated on the detoxification orders that accompany the CIWA-Ar assessment tool...."

The protocol did not contain instructions to delay assessment when the patient is asleep.

Review of the hospital form titled Addiction Withdrawal Assessment - Alcohol (CIWA-Ar) revealed: "Rating Scale...Greater than 25 - severe withdrawal...20 to 25 - moderate withdrawal...10 to 19 - mild to moderate withdrawal...Less than 10 -stable...CIWA Dosing Scale...CIWA Score...20 - 25...Ativan 2 mg....15 - 19...Ativan 1 - 2 mg....10 - 14...Ativan 0.5 - 1 mg....Below 10...None...."

Review of hospital policy/procedure titled Medication Administration revealed: "...It is the expectation that the process for medication administration will result in the delivery of the right medication, in the right dosage, to the right patient, by the right route at the right time...Documentation of medication administration should include: Medication name, dose, time, date, route, and site of injection...if applicable...If a dose of medication is not given, the time must be circled and rationale for the missed dose must be documented in the nursing progress note or utilize key code documentation directly on MAR (Medication Administration Record)...."

Review of Pt # 31's medical record revealed:

Pt # 31 was admitted on 2/17/13.
On 2/18/13, a physician documented: "...has been drinking in excess of a fifth of rum per day...does have a history of withdrawal seizures and low-grade hallucinosis...does have a history of previous detoxifications on this unit...Treatment Plan: 1. Detox protocol...."

On 2/18/13 at 0015, an RN recorded a physician's telephone order on the form titled Behavioral Health Detox: "...Lorazepam (Ativan) Protocol: Lorazepam (Ativan) 0.5 - 2mg...po (by mouth)...IM (intramuscularly) every 1 hour per Clinical Institute Withdrawal Assessment...."

On 2/18/13 at 1230, an RN recorded the patient's CIWA score of 14 and documented administration of 2 mg of Ativan. The required dose was .5 - 1mg.

On 2/18/13 at 2036, an RN recorded the patient's CIWA score of 9. The RN completed the next assessment on 2/19/13 at 0810; 11 hrs and 34 min. later. The patient's score was 11 at 0810. The patient appeared to be asleep from 2300 - 0745.

On 2/19/13 at 1440, the RN recorded the patient's CIWA score of 13. The RN completed the next assessment at 2020; 5 hrs and 40 min. later. The patient's score was 16 at that time. The maximum interval between assessments per policy is 4 hours. The medical record contained documentation that the patient was awake during the 5 hr and 40 min time frame.

The RN completed the next assessment on 2/20/13 at 0840; 11 hrs and 50 min. later. The patient appeared to be asleep from 2300 until 0800. The RN recorded the patient's score at 0840 as 9, which did not require medication. The RN completed the next assessment on 2/20/13 at 1730; 8 hrs and 50 min later. The patient was awake during the 8 hr and 50 min time frame. The patient's score at 1730 was 12 which required Ativan 0.5 - 1 mg. An RN wrote on the MAR on 2/20/13: "0840; 1240; 1741." The RN did not record a dose of medication administered at the above times. The RN did not record a CIWA score at 1240.

On 2/21/13 at 0840, an RN recorded the patient's CIWA score as 9. The RN completed the next assessment on 2/21/13 at 1840; 10 hrs later. The patient was awake during the 10 hour time frame.

On 2/21/13 at 2030, the RN recorded the patient's score of 5. The RN completed the next assessment on 2/22/13 at 0500; 8 hrs and 30 min. later. The RN recorded the patient's score of 11 at that time. The patient was asleep from 2300 until 0500. The RN completed the next assessment on 2/22/13 at 1000; 5 hrs later. The patient was asleep from 0600-0700. The RN completed the next assessment on 2/22/13 at 2000; 10 hrs later. The patient was asleep from 1400-1500.

The RN recorded the next assessment on 2/23/13 at 0415; 8 hrs and 15 min later. The patient was asleep from 2200 until 0400.

The RN recorded the patient's CIWA score on 2/23/13 at 2030. The RN recorded the next assessment at 0500; 8hr and 15 min later. On 2/23/13 at 1630, an RN recorded the patient's CIWA score as 12. The RN completed the next assessment at 2100; 4 hrs and 30 min later. The patient's score was 11 at that time.

The Manager of Behavioral Health Services confirmed during an interview conducted on 2/26/13, that the RN did not assess the patient as required by protocol; did not medicate the patient according to protocol and did not record the dose of medication administered as required by hospital policy.

Pharmacist #31 confirmed during interview conducted on 2/26/13, that the RN did not document administration of medication correctly on 2/20/13.

Review of Pt # 32's medical record revealed:

Pt # 32 was admitted on 2/23/13.
On 2/24/13, a physician documented: "...has been consuming on average a 12-pack of beer a day or hard liquor. This is...third detox...Alcohol withdrawal symptoms...Treatment Plan: Safe detoxification...."

On 2/23/13 at 1800, an RN recorded a physician's telephone order on the form titled Behavioral Health Detox: "...Lorazepam (Ativan) Protocol: Lorazepam (Ativan) 0.5 - 2mg...po (by mouth)...IM (intramuscularly) every 1 hour per Clinical Institute Withdrawal Assessment...."

On 2/23/13 at 2035, an RN recorded the patient's CIWA score as 15 and administered 2 mg Ativan. The RN completed the next assessment on 2/24/13 at 0230; 5 hrs and 55 minutes later. The patient's score at that time was 15. The patient was asleep from 2130 until 0230. The RN completed the next assessment on 2/24/13 at 0700, and recorded the CIWA score as 18. The RN did not record administration of medication until 0840, when the RN documented administration of 2 mg Ativan which was the required dose at 0700. The RN recorded a CIWA score of 15 at 0900 on 2/24/13, and did not document administration of medication. At 1230, the RN recorded a CIWA score of 11 and administered the correct dose of 1 mg. At 1530, the RN recorded a CIWA score of 12 and did not document administration of the required .5 - 1 mg of Ativan.

On 2/24/13 at 2000, the RN assessed the patient and recorded a CIWA score of 5. The RN completed the next assessment on 2/25/13 at 0930; 13 hrs and 30 min later. The score at that time was 13. The patient appeared to be asleep from 2400 until 0730.

The Manager of Behavioral Health Services confirmed during interview conducted on 2/26/13, that the RN did not administer medication as required by protocol.

In addition, the CIWA Protocol itself differed from the physician orders and preprinted MAR with regard to time interval for assessment and medication administration i.e., the physician orders and MAR contained instructions for administration of medication: "...every 1 hour per Clinical Institute Withdrawal Assessment..." and the protocol included: "...The CIWA-Ar is completed every 2 to 4 hours during treatment...."

Based on review of hospital documents and interviews, it was determined that the hospital failed to require that a registered nurse assign the nursing care of each patient to other nursing personnel in the Behavioral Health inpatient unit.

Findings include:

Review of hospital document titled (Name of Hospital Network) Behavioral Health Staffing Guidelines/Assumptions revealed: "...Staffing patterns will take into consideration, but are not limited to the following:...The level of acuity of the specific patients on a unit. Based on admission criteria, acuity will be increased due to specific patient characteristics, and nursing care needs. This includes but is not limited to the following:...Number of suicidal/homicidal patients...Number of seclusion/restraint incidents...Number of admissions/discharges...Number of type of accidents and/or injuries...Number of unit assessments, transportation and consultations...Number of medical (physical) procedures...Amount and complexity of medication regime...Availability of RN's to supervise/consult with nursing/non-nursing personnel about patient care...Availability of RN's to assess and implement care in crisis situation...Availability of RN's to interact with patients in structured activities/treatment planning 7 days a week...The degree of experience and capability of staff...Program/milieu issues...."

Review of hospital document titled Activity/Patient Classification Systems revealed that it contained four patient classification categories. Each category contained four sections: "...Safety...Behavioral Symptoms...Functional...Discharge...." Each section contained descriptive criteria of patients who would warrant classification within that category.

Review of hospital document titled (Name of Behavioral Health Unit) Staffing Guidelines revealed that it contained the total number of RN's, Behavioral Health Technicians (BHT's), Therapists and Clinical Nurse Leaders required to staff the unit, depending on the total number of patients and total patient acuity scores. The scores were determined by adding the number of patients in each of the classification categories.
The Staffing Guidelines included the number of staff required for each of three shifts, i.e., "7a - 3p, 3p - 11p and 11p - 7a."

Review of hospital document titled (Name of Behavioral Health Unit) Daily Assignment Sheet revealed: "...The charge RN is responsible for completing the daily assignment sheet every shift. Please use the codes below to signify client special needs...."

On 2/25/13, the surveyor asked the Charge RN to review the patient assignments and rationale for each. The Charge RN provided an assignment sheet which contained the names of staff and blank spaces for client names. S/he explained that s/he is responsible for all 14 patients and the second RN is responsible to administer all medications. The BHT's alternate responsibility for the 15 minute patient rounds and share responsibility for supervising all of the 14 patients.

The Manager of Behavioral Health Services provided Staffing Sheets, Daily Assignment Sheets, and Patient Census Worksheets for 2/18/13 through 2/24/13. She confirmed that the staff work 12 hour shifts: 0700 - 1930 and 1900 - 0730.

Review of all fourteen Daily Assignment Sheets revealed that they did not contain patient names. All fourteen Patient Census Sheets contained the names of all patients present in the unit during the twelve hour shift with patient classification scores written next to each patient's name.

Review of the Patient Census Sheets revealed:
On 2/18/13, day shift, 15 patients were present. Four of those patients were listed with classification scores of 4, indicating the highest acuity; 9 patients were listed with scores of 3 and 2 patients were listed with scores of 2.
On 2/18/13, night shift, 15 patients were present, with one patient classified as "4"; 8 patients were listed with scores of 3 and 6 patients were listed with scores of 2.

On 2/19/13, day shift, 15 patients were present. Two of those patients were listed with classification scores of 4; 7 patients were listed with scores of 3 and 6 patients were listed with scores of 2.
On 2/19/13, night shift, 13 patients were present. One patient was listed with a classification score of 4; 5 patients were listed with scores of 3 and 7 patients were listed with scores of 2.

On 2/20/13, day shift, 15 patients were present. Ten of those patients were listed with classification scores of 3 and five patients were listed with scores of 2.
On 2/20/13, night shift, 15 patients were present. Six of those patients were listed with scores of 3 and 9 patients were listed with scores of 2.

On 2/21/13, day shift, 15 patients were present. Twelve of those patients were listed with scores of 3 and 3 patients were listed with scores of 2.
On 2/21/13, night shift, 15 patients were present. One of those patients was listed with a score of 4, 2 patients were listed with scores of 3; 9 patients were listed with scores of 2 and 3 patients were listed with scores of 1.

On 2/22/13, day shift, 16 patients were present. Eight of those patients were listed with scores of 3 and 8 patients were listed with scores of 2.
On 2/22/13, night shift, 13 patients were present. Two of those patients were listed with scores of 4, 1 patient was listed with a score of 3; 9 patients were listed with scores of 2 and 1 patient was listed with a score of 1.

On 2/23/13, day shift, 14 patients were present. Two of those patients were listed with scores of 4; 5 patients were listed with scores of 3 and 7 patients were listed with scores of 2.
On 2/23/13, night shift, 13 patients were present. Two of those patients were listed with scores of 4; 2 patients were listed with scores of 3 and 9 patients were listed with scores of 2.

On 2/24/13, day shift, 15 patients were present. Two of those patients were listed with scores of 4; 4 patients were listed with scores of 3 and 9 patients were listed with scores of 2.
On 2/24/13, night shift, 15 patients were present. Two of those patients were listed with scores of 4; 5 patients were listed with scores of 3 and 8 patients were listed with scores of 2.

The Manager of Behavioral Health Services explained during interviews conducted on 3/26/13 and 3/27/13, that the Charge Nurse does not assign nursing staff to each patient.

Based on the Life Safety Code inspection conducted on 3/6/13, it was determined that the hospital failed to meet the Condition of Participation for the Physical Environment as evidenced by non-compliance with the following:

The hospital failed to:

K018 Standard: Maintain corridor doors to resist the passage of heat/smoke.

K029 Standard: Maintain the integrity, smoke resistance, of doors in hazardous areas.

K039 Standard: Keep exit corridors and exit access clear.

K046 Standard: Maintain battery operated emergency lighting.

K047 Standard: Assure that exits from the building were each illuminated by more than a single light source.

K062 Standard: Maintain the sprinkler heads and assure that all parts of the sprinkler system were in accordance with the UL Listing.

K069 Standard: Clean the kitchen exhaust hood system, filters and grease drip tray.

K076 Standard: Mount an electrical light switch five feet above the floor in the oxygen storage rooms and keep the oxygen bottles free of combustible materials.

K147 Standard: Prevent overload of the electrical system and fire hazard by the use of multiple outlet adapters and power strips and did not use wall outlet receptacles for appliances or guards on the light bulbs.

K154 Condition of Participation: Provide a written policy for staff members to follow, when an automatic sprinkler system is out of service and document the Fire Watch.

K155 Condition of Participation: Provide a written policy for staff members to follow, when a fire alarm system is out of service and document the Fire Watch.

Additionally,

A701 The hospital failed to maintain the cleanliness of the laundry facility utilized by Behavioral Health inpatients.

The cumulative effect of these deficient practices resulted in the hospital's failure to provide a physical environment that ensures patient safety.

Based on direct observation, review of facility policy/procedure and interview, it was determined that the hospital failed to maintain the cleanliness of the laundry facility utilized by Behavioral Health inpatients.

Findings include:

During tour of the Behavioral Health inpatient facility conducted on 2/25/13, the surveyor found visible soil and debris on the floor, around the baseboard, behind the washer, and in the ceiling vent of the laundry room. The lid of the washing machine contained visible soil along the inside edge.

Review of the hospital policy/procedure titled Laundering and Handling of Patient Care Related Items revealed: "...Purpose...To establish policies and procedures to minimize potential cross infection from patient clothing or other items to be laundered...The laundry area should be a designated, separate area from the patient care areas...The area should be cleaned at least daily, with the floor, walls, outside of machines, and shelves wiped down each day with a hospital approved disinfectant solution. Any soiling of this area should be immediately cleaned...."

The Behavioral Health Manager and Director of Behavioral Health stated during interview conducted on 2/25/13, that patients utilize the laundry facilities for their clothing. Patients do their laundry independently or with staff assistance as needed. Staff clean the laundry room and sanitize the washer every night by adding bleach to a full hot water load. They confirmed the presence of accumulated soil and debris on the floor, in the vent and in the lid of the washer.

The Infection Preventionist confirmed during interview conducted on 2/27/13, that she has not included the Behavioral Health inpatient facility laundry room in her rounds.

Based on observations, interviews and review of hospital documents, it was determined that the hospital failed to require policies and procedures governing medical care provided in the emergency services department were established and a continuing responsibility of the medical staff for the patients in the Emergency Department Behavioral Health Annex.

Findings include:

The "Annex" is the last room at the south eastern end of the Emergency Department. This room is distant from the main Emergency Department working desk for physicians and nurses. The room measured 12 feet by 16 feet and contained 4 patient gurneys that were no more than 4 inches apart in some places. The room housed both male and female behavioral health patients who were considered "medically cleared" of acute medical problems and were awaiting transport to the inpatient facility or transfer to another facility.

At the time of the surveyor's first observation on 2/26/13 at approximately 11 a.m., the patients in the Annex included a female patient (Patient #44) who had been there 16 hours and a male patient who was stated to have been there 15 hours (Patient #43), plus one additional male patient (Patient #42) who had been transferred from the main Emergency Department at approximately 10 a.m. that day, and one empty gurney.

A request was made to see the policies and procedures for the care and services of these Behavioral Health Annex patients. Both the Manager of the Emergency Department and the Manager of Behavioral Health Services stated that there were no policies/procedures for the care of the behavioral health patients in the Annex.

The Behavioral Health Director produced a document entitled "Behavioral Health Annex Protocol & Guidelines 2011 and 2012" which she stated was not a policy and procedure and had not been through any approval process such as was required for hospital policies and procedures. This document revealed the staffing was by "1 Licensed staff member" which the Director stated had previously been a Licensed Practical Nurse part of the time but was now always by a registered nurse.

A review was conducted of "Behavioral Health Department Policies" which revealed the "Policies" were in a format that matched the hospital's format for policies and procedures; were dated with an "Effective Date" and "Revision Dates"; included a management signature; were concluded with an "Approval" box showing approval by committee through physician departments. The "Guidelines 2011 and 2012" revealed they had not been through the hospital policy and procedure process as the Behavior Health Director had confirmed.

Based on observations, record reviews, registered nurse competency forms, and interviews, it was determined that the hospital failed to require adequate, qualified nursing personnel to meet the needs of the psychiatric patients located in the Behavioral Health Annex of the Emergency Department.

Findings include:

The Manager of Behavioral Health Services stated during interview conducted on 2/27/13, that she staffs the Annex with two employees: one psychiatric RN and one Behavioral Health Technician to provide care for up to 4 patients. When questioned regarding patient acuity requiring additional staff, the Manager of Behavioral Health Services stated that if additional staff were required to meet the patients' needs, the Annex RN would have to get additional help from the Emergency Department.

The surveyor's first observation of the Annex occurred on 2/26/13 at approximately 11 a.m., which revealed the Annex was staffed by an experienced psychiatric RN and a "tech from the hospital Float Pool." The RN was caring for 3 patients and was orienting a new RN to the Annex. The Float Pool tech was described to have recently attended a "nursing program," but that it was not a psychiatric nursing program.

The Annex R.N. stated, during an interview 2/26/13, that she was alone with the patients when the "tech" took a patient to be admitted to the psychiatric hospital next door or to an inpatient bed in the hospital. The Annex R.N. stated she was also alone with the patients when the tech went to the 1/2 hour lunch break.

At the time of the surveyor's second observation on 2/26/13 at approximately 3 p.m., Patient #44 was being moved to the psychiatric hospital next door by the "float pool tech" and a security guard after spending approximately 23 hours in the Annex. The Annex R.N. stated that this patient had had an "IV" (intravenous fluids) running when she (the R.N.) came on duty that a.m. but the IV had been completed, and she discontinued it.

The Annex R.N. stated that Patient #42 had been admitted to the Annex from the Emergency Department at approximately 10 a.m. on 2/26/13 and was "detoxing." The Annex R.N. stated that Patient #42 was "escalating" with symptoms that included difficulty walking due to severe withdrawal tremors. Patient #42 needed an IV started and the Annex R.N. stated that she was unable to start an IV but the R.N. she was orienting had IV skills and had been able to start the IV. A person dressed in scrubs brought an IV bag containing yellow fluid to the door of the Annex and the Annex R.N. took it to Patient #42. Pt #42 remained in the Behavioral Health Annex until later in the afternoon, when he was transferred back to the main Emergency Department. He was admitted to a medical inpatient bed at approximately 6 p.m.

Cross reference Tag A1104 for description of the Annex environment, medically cleared patients in the Annex and lack of policies/procedures for care of Annex patients.

The Emergency Department Manager was asked if any situation had happened in the Annex where a patient's behavior had become uncontrolled. The record of Patient #56 was reviewed which revealed that Patient #56 had been brought in by the police at 5:24 p.m. on 12/9/12, had been placed in 4 point restraints and a "spit mask" while in the main Emergency Department; chemically restrained, and then transferred to the Annex at 11:08 p.m. The patient's behavior became uncontrolled according to the patient record; the patient "assaulted numerous staff "in the Annex, assaulting a nurse in the Annex at approximately 7:00 a.m. on 12/10/12, and a physician in the Annex at approximately 3:43 p.m. by "striking them in the face with a fist." Patient #56 was arrested by the police and taken to jail at approximately 6:51 p.m.

A review of the staff provided by the Manager of Behavioral Health Services revealed that they were required to have competency based behavioral health skills including: assessment and documentation, admission procedures for the inpatient unit, Annex purpose and goals and care of assaultive patients.

A review of the staff provided by the Manager of the Emergency Department revealed that they were required to have competency based emergency care skills including: neurological signs, code arrests, central lines, infusions, and recognition of patient emergencies.

The Manager of the Emergency Department acknowledged that the Emergency Department staff who provided assistance to the Annex staff were not specifically trained for the care of psychiatric patients and Annex staff did not have documented competency for the care of patients who require intravenous infusions and other nursing care required for acute medical patients.