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Based on review of facility policies, Geriatric Staffing Plan, Time Detail report, Facility's credible allegation of compliance submitted to the surveyors on 10/4/18 and interviews, it was determined the facility failed to ensure patients were cared for in an environment which promoted a safe environment to decrease the risk for falls and / or injuries. This had the potential to negatively affect all patients admitted to the facility's Geri-psychiatric Unit (GPU).


Findings include:

Facility policy:
Title: Staffing Plan
Effective Date 1/1/2007

Policy:

... C. The staffing is reviewed and changes are made as patient volume and acuity dictates at a management level, Routine staffing schedules are established. The Nurse Director is responsible for coordinating staffing needs. If additional staff is required, i.e. 1:1's, special consideration will be taken when scheduling staff.

D. Every effort shall be made to provide additional staffing when required by:

1. Reviewing staffing schedules, "on-call" schedules and contacting available staff to the unit.

2. Reviewing staffing schedules and contacting available staff from other areas that are oriented to the unit. The Nurse Director and Nursing Administration will maintain a list of cross-trained staff for reference...

E. Recommended staffing ratios: 12.21 x census.

Note: Since G/P (Geri-psych) is a restraint free unit, staffing is adjusted to accommodate one on one when indicated.

Purpose:

The Staffing Plan is based on Patient census and acuity...

Review of the Geriatric Staffing Plan revealed the following staff:patient ratios for each shift:
Census: 1to 2 = (2) Licensed staff members for 7 AM to 7 PM and 7 PM to 7 AM shifts
Census: 3 to 9 = (2) Licensed staff members, (1) Tech for 7 AM to 7 PM and 7 PM to 7 AM shifts
Census: 10 to 14 = (2) Licensed staff members, (2) Tech for 7 AM to 7 PM and 7 PM to 7 AM shifts
Census: 15 = (2) Licensed staff members, (3) Tech for 7 AM to 7 PM and 7 PM to 7 AM shifts
Census: 16 to 18 = (3) Licensed staff members, (3) Tech for 7 AM to 7 PM and 7 PM to 7 AM shifts

Review of the Staffing Sheet dated 9/26/18 for 7 PM to 7 AM revealed there were a total of 13 patients with the following staff assigned for the shift: (1) Registered Nurse (RN) from 7 PM to 10:30 PM, (2) Licensed Practical Nurses (LPNs) and (1) Mental Health Technician (MHT). According to the Geriatric Staffing Plan above, there should have been at least (2) Licensed Staff Members and (2) Techs and from 10:30 PM to 7 AM there were only (2) Licensed staff members and (1) Tech to care for 13 patients.

Review of the Time Detail report dated 9/26/18 revealed the RN's actual time clocked in was from 7:00 PM to 11:00 PM, MHT's time was from 9:01 PM to 6:59 AM, (1) LPN's time was from 6:20 PM to 7:21 AM, (2) LPN's time was from 6:41 PM to 7:21 AM. There was an additional RN who clocked in at 4:00 PM to 8:14 PM. According to the Time Detail report, there were (2) LPNs and (1) MHT from 11:00 PM until 7 AM shift arrived to provide care for 13 patients.

Review of the Staffing Sheet dated 9/27/18 for 7 PM to 7 AM revealed there were a total of 10 patients with the following staff assigned for the shift: (1) RN, (1) LPN and (1) MHT. Review of the Time Detail report dated 9/27/18 revealed the staff members present and clocked in from 7 PM to 7 AM were (1) RN, (1) LPN and (1) MHT to care for 10 patients. According to the Geriatric Staffing Plan above, there should have been at least (2) Licensed Staff Members and (2) Techs to care for 10 patients.

Review of the Time Detail report dated 9/29/18 revealed the staff members present and clocked in from 7 PM to 7AM were (2) RN and (1) MHT to care for 12 patients. According to the Geriatric Staffing Plan above, there should have been at least (2) Licensed Staff Members and (2) Techs to care for 12 patients.

Review of the Staffing Sheet dated 9/30/18 for 7 PM to 7 AM revealed there were a total of 12 patients with the following staff assigned for the shift: (3) LPNs (1 of which was placed in the MHT slot). Review of the Time Detail report dated 9/30/18 revealed the staff members present and clocked in from 7 PM to 7 PM were (3) LPNs to care for 12 patients. According to the Geriatric Staffing Plan above, there should have been at least (2) Licensed Staff Members and (2) Techs to care for 12 patients.

An interview was conducted on 10/4/18 at 8:25 AM with Employee Identifier (EI) # 6, LPN. The surveyors asked, "How are the MHTs assigned patients?" EI # 6 stated, "If there are 8 patients and 1 MHT - the MHT does everything. If there are 2 MHTs, they decide how they want to split it up. They take breaks when they can." When questioned about the number of staff on her shift, EI # 6 stated there are usually 3 staff members present, 1 RN, 1 LPN and 1 MHT depending on the number of patients, if there are more patients then there are more staff present.

An interview was conducted on 10/4/18 at 9:00 AM with EI # 7, RN. The surveyors asked, "How are the MHTs assigned patients?" EI # 7 stated, "If there are 2 MHTs, they work together. They split the paper load, but they don't take certain patients." When questioned about the number of staff on her shift, EI # 7 stated, "normally 1 RN, 1 LPN and 1 or 2 MHT, if staff are available to work, then we have 2 MHTs." The surveyors asked EI # 7 to explain observation levels. EI # 7 stated the Techs (MHTs) usually have eyes on the patients. When questioned about 1:1 patients, EI # 7 stated that if she is in charge, "we group all 1:1's together and 1 MHT watches all 1:1's together while the other tech does other jobs. Sometime we call other floors to get help. If there is only 1 MHT, patients are brought to the nursing desk and one of the nurses watches the patient." When questioned if the GPU ever does 1:1 observation, EI # 7 stated that sometime they will do 1:1 observation on patients who are high risk. "If there is no order for 1:1; then extra staff are not scheduled."

An interview was conducted on 10/4/18 at 9:25 AM with EI # 5, MHT. The surveyors asked, "How are the MHTs assigned patients?" EI # 5 stated, "We all do everything. We only split the paperwork. When questioned about the number of staff on her shift, EI # 5 stated, "1 MHT, 1 RN, 1 LPN." The surveyors asked if she has a 1:1 patient, is she allowed to watch other patients. EI # 5 stated, "Yes. I will take the 1:1 into the activity room & bring other patients in there"

An interview was conducted on 10/4/18 at 9:40 AM with EI # 3, MHT. When questioned about the number of staff on her shift, EI # 3 stated, "1 MHT, sometimes 1 RN, 1 LPN or 2 LPNs." The surveyors asked, "How are the MHTs assigned patients?" EI # 3 stated, "It depends if 1:1. Someone sits with 1:1 for an hour and the other MHT does other things then we switch out." The surveyors asked if there is only 1 MHT and more than (1) - 1:1 patient how is that accomplished? EI # 3 stated that the MHT takes all 1:1's into the group room and the MHT watches them while the nurses watch the rest of the patients. When questioned why patients are 1:1, EI # 3 stated, "because they can't walk and try to get up."

On 10/4/18 at 11:25 AM, the surveyors met with EI # 1, Director of Senior Care Services, EI # 2, Interim Chief Nursing Officer and EI # 8, Chief Executive Officer to discuss the problems of not having enough staff available to safely care for patients in the GPU and staffing not being provided according to the GPU staffing grid. The surveyors identified the GPU had net been staffed according to the staffing grid and requested a credible allegation of compliance.

Review of the Facility's credible allegation of compliance dated and signed by the Chief Executive Officer on 10/4/18 revealed the following corrective actions related to inadequate staffing to meet the acuity needs of patients: Plan of Correction: 1) Immediate corrective actions include: acuity assessments of patients on unit and staffing increased based on acuity review; appropriate unit staffing ensured by adding 2 MHTs; staff called in and ensured that there is adequate staffing to meet the needs of the current patient load and acuity thru Sunday 10/7/18. 2) Appropriate staffing for the next six weeks will be included on the current schedule which concludes 10/27/18; this schedule will be updated by Sunday 10/7/18. Review and update staffing metrics and guidelines related to patient acuity, effective 10/8/18. 4) An updated acuity scale is to be added to the Geripsych staffing plan (see attached policy), to include a scale rating system from 1-5. High falls risk patients will be rated a 4. Any patient with a rating greater than or equal to a 4 will be a 1:1 observation patient. Completed 10/4/18. 5) Department Director/Charge Nurse will assess staffing plan and will determine acuity scale for Geripsych patients. They will staff based on the acuity scale and staffing plan 4 hours prior to next shift. 6) All Geripsych staff/Department Director's/Charge Nurses will be educated by reviewing the current acuity grid and 1:1 policy. Department Director will have mandatory staff meetings with all shifts to educate on policies and procedures related to staffing by 11/1/18; any staff on the schedule before end of current schedule will be educated before they report to shift.

Review of the Staffing Plan Exhibit A - Geriatric Staffing Plan which was included in the Facility's credible allegation of compliance revealed an acuity scale which included 1 through 5, with (4) High Fall Risk with repeated fall and (5) 1:1 (one to one) staffing and "... All scores greater than or equal to 4 will be considered (A One On One)..."

Based on review of medical records (MR), facility policy and interview, it was determined the facility failed to ensure all adverse patient events were reported and were included in the performance improvement activities for the hospital. This affected 1 of 13 MRs reviewed, including Patient Identifier (PI) # 3 and had the potential to negatively affect all patients admitted to this facility.

Findings include:

Policy: Incident Reporting
Effective Date: 12/1/2000

Policy:

Incidents to be reported on an Risk Management Incident Report Form include those involving patients, visitors, volunteers, and independent contractors (for non-work related injuries), medical staff members (i.e. physicians and mid-level employees) and students...

Medical Center Barbour's Risk Manager and others determined by the Risk Manager will investigate risk events.

Risk Management incident report forms should be utilized in the following (this is not an all inclusive list):

Physical injury of patients, visitors, medical staff or students
Hospital acquired skin breakdown or ulcers
Falls
Elopement (Patient disappears from hospital) without notifying staff
AMA (patient leaves Against Medical Advice)...

1. PI # 3 was admitted to the facility's GPU on 5/24/18 with diagnosis of major cognitive disorder secondary to stroke.

Review of the Patient Care Note dated 6/13/18 at 10:22 AM revealed the LPN (Licensed Practical Nurse) documented, "... PRN (as needed) medications at this time due to agitation, aggression, being combative and attempting to cause harm to self after being redirected. Patient was sitting at table in dining room attempting to rock in wheelchair with wheels unlocked. After informing (him/her) could hurt (self), (he/she) locked the wheels and began to rock chair harder causing chair to go backwards. Patient almost hit the floor but was caught by staff. Chair was moved away from the table... (patient) yelled out and forcefully threw (his/her) body weight forward between legs attempting to get out of chair. Patient was prevented from falling..."

There was no documentation an incident report had been completed for 6/13/18 near fall event.

Review of the NP (Nurse Practitioner) Progress Note dated 7/1/18 (electronically signed at 9:25 AM) revealed the NP documented, "... Muscle skeletal... left 5th finger appears to be swollen. There is no bruising. Is able to move all extremities... Plan... Swelling of left 5th finger. It is painful to touch. No obvious evidence of trauma, skin break or bruising. Will obtain plain film..."

Review of the Patient Care Notes dated 7/1/18 at 12:10 PM revealed the LPN documented, "... Physician Notified: (NP) Notified about: Dislocated finger, Orders received: Coming to take pt (patient) to ER (Emergency Room)..." On 7/1/18 at 12:33 PM, the LPN documented, "... Pt transported to ER by staff via w/c accompanied by... NP..."

The patient was taken to the Emergency Department (ED). According to the Procedural Note dated 7/1/18, a reduction of the closed, nonfractured, volar dislocation of the 5th left finger was performed by the NP and the ED Physician and a splint was placed but, the patient would not leave the splint in place.

There was no documentation an event report had been completed for the unexplained injury to the patient's finger on 7/1/18.

An interview was conducted on 10/3/18 at 3:25 PM with Employee Identifier # 1, Director, Senior Care Center, who verified the above findings.

This condition level deficiency was cited based on review of medical records, facility policies, Facility's Corrective Action Plan submitted to the surveyors on 10/4/18 and interviews, it was determined the facility failed to ensure:

1.T he geri-psych unit (GPU) was staffed to ensure all patients' nursing needs were met to include 1:1 observations for patients who were high risk for falls.

2. Patient care assignments were assigned to the Mental Health Technicians (MHT) by the Registered Nurse.

Findings include:

Refer to A392 and A397 for individual findings.

Based on review of facility policies, medical records (MR), facility's credible allegation of compliance submitted to the surveyors on 10/4/18 and interviews, it was determined the facility failed to ensure the geri-psych unit (GPU) was staffed to ensure all patients' nursing needs were met to include 1:1 observations for patients who were high risk for falls. This affected 4 of 13 patients, including Patient Identifier (PI) # 3, PI # 1, PI # 2, and PI # 4 and had the potential to negatively affect all patients admitted to the GPU.

Findings include:
Facility policy
Title: Staffing Plan
Effective Date 1/1/2007

Policy:

... C. The staffing is reviewed and changes are made as patient volume and acuity dictates at a management level, Routine staffing schedules are established. The Nurse Director is responsible for coordinating staffing needs. If additional staff is required, i.e. 1:1's, special consideration will be taken when scheduling staff.

D. Every effort shall be made to provide additional staffing when required by:

1. Reviewing staffing schedules, "on-call" schedules and contacting available staff to the unit.

2. Reviewing staffing schedules and contacting available staff from other areas that are oriented to the unit. The Nurse Director and Nursing Administration will maintain a list of cross-trained staff for reference...

E. Recommended staffing ratios: 12.21 x census.

Note: Since G/P (Geri-psych) is a restraint free unit, staffing is adjusted to accommodate one on one when indicated.

Purpose:

The Staffing Plan is based on Patient census and acuity...

Review of the Geriatric Staffing Plan revealed the following staff:patient ratios for each shift:
Census: 1 to 2 = (2) Licensed staff members for 7 AM to 7 PM and 7 PM to 7 AM shifts
Census: 3 to 9 = (2) Licensed staff members, (1) Tech for 7 AM to 7 PM and 7 PM to 7 AM shifts
Census: 10 to 14 = (2) Licensed staff members, (2) Tech for 7 AM to 7 PM and 7 PM to 7 AM shifts
Census: 15 = (2) Licensed staff members, (3) Tech for 7 AM to 7 PM and 7 PM to 7 AM shifts
Census: 16 to 18 = (3) Licensed staff members, (3) Tech for 7 AM to 7 PM and 7 PM to 7 AM shifts

Facility Policy
Title: Observation: One-to-One
Effective Date: 7/1/2007

Policy
One-to-One Observation shall be initiated for:
Patients displaying a high degree of impulsive or irresponsible behavior, or those who present themselves as a danger to themselves or others and have expressed either intent or a plan of action. This would include, but is not limited to... fall risks with repeated fall...

One-to-One Observation is to be used only when all other less restrictive means have been utilized and have been unsuccessful in keeping the patient safe.

The staff member assigned to the "One-to-One" must be within one (1) arms length of the patient at all times...

An order from the psychiatrist shall be obtained within two (2) hours of initiating the "One-to-One."

... The continued need for a "One-to-One" shall be reviewed and documented at a minimum every (48) hours by the psychiatrist and the order rewritten as appropriate.

Only the psychiatrist can discontinue "One-to-One" Observation.

Upon discontinuation of the "One-to-One" the patient will be placed on Close Observation/Special Precautions...

The Special Observation Record will be maintained every fifteen (15) minutes by the staff member assigned to the "One-to-One".

Purpose: To provide a mechanism, based on clinical justification, to monitor a patient continuously for safety reasons...

Facility Policy
Title: Fall Risk Assessment and Intervention
Effective Date: 2/1/2004

Responsibility:

It is the responsibility of the admitting Registered Nurse to perform a "fall risk assessment" on the patient and implement nursing interventions applicable for the patient and their level of risk.

It is the responsibility of the patient's nurse to routinely assess the patient for the need for appropriate interventions related to fall prevention throughout their hospital stay.

A low risk to fall patient is to be assessed when there is a significant change in their mental status, gait or mobility, medications and no less than every 24 hours.

An at risk to fall patient is to be assessed no less than every shift.

All levels of risk to fall: The patient's nurse should assess the patient when there is a change in patient's condition or environment. Appropriate interventions should be implemented, communicated and documented.

It is the responsibility of all employees to observe and monitor patients identified At Risk for Falls.

Definition:

A fall is defined as:

Any observed fall of a patient from one surface level to another...
Any unobserved fall reported by a patient.
Any patient found on the floor and there is reason to believe the patient fell as opposed to sitting on his or her own accord.
Any patient assisted to the floor by the staff.

Fall Risk Assessment and Intervention:

Fall prevention and patient safety is defined as:

The identification of At Risk to Fall patients.
Implemention of preventive techniques to reduce their risk.

Purpose:

Targeted (Re) Assessment fr identification of Patients at Risk to Fall.

Targeted Interventions to prevent fall for patients identified as Low or At Risk to fall.
Reduce patient falls.
Reduce severity of injury related to falls.
Reduce repeat falls...

Procedure:

At Risk to fall: (Final risk score 10 or greater)

Apply yellow arm band to patient.
Keep needed items within reach.
Evaluate the need to move the patient closer to the nurse's station.
Orient to environment frequently.
Side rails up at all times (half up as patient assessment indicates)...
Observe patient frequently...

1. PI # 3 was admitted to the facility's GPU on 5/24/18 with diagnosis of major cognitive disorder secondary to stroke. Review of the Psychiatrist's History and Physical (H & P) dated 5/25/18 revealed the patient had no prior history of mental illness, had recently had a cerebral vascular accident (CVA) with hemiplegia. The psychiatrist further documented, "... At the time of my evaluation patient is confused, unable to give much information... Patient is a risk for fall... also been restless and agitated... significant cognitive impairment... unable to care for (himself/herself)... Insight and judgment is poor..."

Review of the Nurse Practitioner's (NP) H & P dated 5/25/18 revealed, "... (patient) had stroke like symptoms... Upon further evaluation at (Hospital # 2)... was diagnoses with acute CVA with dysarthria and some mild hemiplegia... also had difficulty with encephalopathy... review of symptoms: Neuro. Alert and Oriented person and year...is able to follow some simple commands,.. answer yes or no questions... does have some degree of confusion... Assessment and Plan: Ischemia CVA. This occurred within the past couple of weeks.... aphasia and some degree of mild hemiplegia..."

Review of the Falls Risk Assessment Scoring Tool dated 5/25/18 revealed the patient's fall risk score was 26 - "At Risk" for fall.

Review of the medical record revealed the patient sustained falls on 5/27/18 at 7:40 PM and a second incident at 10:00 PM, in which the patient was trying to get up from the wheelchair, turned the wheelchair onto it's side and the patient fell onto the floor.

Review of the Patient Care Note dated 6/1/18 at 1:39 PM revealed the LPN documented, "... Patient found on floor in front of...w/c (wheelchair) on knees. Redness to bil (bilateral) knees observed. Small skin tear to upper left arm..." Review of the Patient Care Note dated 6/1/18 at 3:58 PM revealed the LPN documented, "... Resident found in hallway on floor by staff. Patient denies knowing how (he/she) got onto the floor... Patient continues to remove lap buddy and other safety measures put in place for (his/her) safety... continues to lean forward while in wheelchair. Patient is now in dining room in wheelchair, MHT (Mental Health Technician) is observing (him/her)..." On 6/1/18 at 7:15 PM, the LPN documented, "... (Psychiatrist) ordered a mattress to be place on floor for resident to reduce falls..."

Review of the Patient Care Notes revealed the nurses documented the following patient falls/incidents: 6/2/18 at 7:10 PM (from geri-chair); 6/4/18 at 2:25 AM (unobserved fall - patient found on lying on floor, in wheelchair on right side); 6/4/18 - (patient was trying to stand up from wheelchair, redirected to sit back down and slid out to floor).

Review of the Psychiatrist's Progress Note dated 6/4/18 revealed the psychiatrist documented, "... has been restless and agitated at times... slept only 3 hrs (hours)... trying to get out of... chair and bed... needs constant redirection... is a fall risk..."

Review of the Patient Care Notes revealed the nurses documented the following patient falls/incidents: 6/5/18 4:39 (patient slid to floor from wheelchair) and 6/5/18 at 5:05 PM (witnessed fall in dining room).

Review of the Psychiatrist's Progress Note dated 6/6/18 revealed the psychiatrist documented, "... restless agitated and appears to be responding to internal stimuli... resisting care and fighting staff... a high risk for fall... Insight and judgement poor... is a danger to self and others... Plan... is on fall precaution..."

Review of the Psychiatrist's Progress Note dated 6/8/18 revealed the psychiatrist documented, "... has been confused and restless... has been resisting care... has periods of confusion alternating with lucid intervals... has been agitated and threw the furniture on the floor... Plan... Patient will be on fall precaution..."

Review of the Psychiatrist's Progress Note dated 6/11/18 revealed the psychiatrist documented, "... has been trying to crawl out of (his/her) bed... restless and at times agitated... slept 7.5 hours last night... is on fall precaution. Insight and judgment is poor..."

Review of the Patient Care Note dated 6/13/18 at 10:22 AM revealed the LPN documented, "... PRN (as needed) medications at this time due to agitation, aggression, being combative and attempting to cause harm to self after being redirected. Patient was sitting at table in dining room attempting to rock in wheelchair with wheels unlocked. After informing (him/her) could hurt (self), (he/she) locked the wheels and began to rock chair harder causing chair to go backwards. Patient almost hit the floor but was caught by staff. Chair was moved away from the table... (patient) yelled out and forcefully threw (his/her) body weight forward between legs attempting to get out of chair. Patient was prevented from falling..."

Review of the Psychiatrist's Progress Note dated 6/17/18 revealed the psychiatrist documented, "... patient was evaluated this morning... is confused and restless... is a fall risk... needs one to one observation..."

Review of the Psychiatrist's Progress Note dated 6/21/18 revealed the psychiatrist documented, "... confused and restless and agitated... needs total care... alert and oriented to person only. Psychomotor activity decreased. Thought process loose and disorganized. Attention and concentration poor... Plan... is on fall precaution... is one-to-one most of the time..."

Review of the Psychiatrist's Progress Note dated 6/22/18 revealed the psychiatrist documented, "... is one-to-one... is high risk for falls..."

Review of the Patient Care Notes revealed the nurses documented on 6/22/18 at 9:37 AM the patient held up right leg, noted large raised hard area to the right lower shin area.

Review of the Special Observation Lists dated 6/22/18 at 9:30 AM revealed Employee Identifier (EI) # 4, Mental Health Technician (MHT) performed observations on the following patients in the following locations: PI # 3 - Activity Room, PI # 6 - Group Room, PI # 7 - Patient Room # 101A, PI # 8 - Patient Room # 104A, PI # 9 - Hallway, PI # 10 - Patient Room # 103B, PI # 11 - Patient Room # 102A, PI # 12 - Group Room and PI # 13 - Group Room. All of these observations were documented as Every 15 minutes. There was no documentation PI # 3 was placed on One-to-One observation on 6/22/18.

Review of the Patient Care Notes dated 6/23/18 at 10:00 AM revealed the nurse documented, "... patient had fall from wheelchair onto floor...MD (Medical Doctor) notified and (NP) also (notified) ..."

Review of the Special Observation Lists dated 6/23/18 at 10:00 AM revealed EI # 3, MHT performed observations on the following patients in the following locations: PI # 3 - Activity Room, PI # 7 - Hallway, PI # 9 - Hallway, PI # 10 - Patient Room # 103B, PI # 11 - Hallway, PI # 12 - Group Room and PI # 13 - Dining Room. All of these observations were documented as Every 15 minutes. There was no documentation on the Special Observation List that PI # 3 was placed on One-to-One observation on 6/23/18.

Review of the Psychiatrist's Progress Note dated 6/24/18 revealed the psychiatrist documented, "... had a fall and has a black eye... Plan... is on fall precaution..."

Review of the NP Progress Note dated 6/24/18 revealed the NP documented, "... Physical Exam... Skin... Bruising noted to the left zygomatic arch and under left eye... Fall with another closed head injury. We have applied ice.. . is on fall precautions and requires constant supervision..."

Review of the Patient Care Note dated 6/27/18 at 10:28 AM, 12:13 PM and 2:04 PM revealed the LPN documented the patient was one on one with staff. On 6/27/18 at 3:20 PM, the LPN documented the patient was sliding out of chair, combative with staff and refusing to stay in wheelchair, safety measures were in place and the patient had one on one staff. There was no documentation on the Special Observations List dated 6/27/18 the patient was on one to one observation.

Review of the Special Observation Lists dated 7/1/18 revealed EI # 5, MHT performed every 15 minute observations from 7:00 AM to 9:30 AM on the following patients in various locations: PI # 3, PI # 7, PI # 13, PI # 14 and PI # 15. There was no documentation on the Special Observation List that PI # 3 was placed on One-to-One observation on 6/22/18.

Review of the NP Progress Note dated 7/1/18 (electronically signed at 9:25 AM) revealed the NP documented, "... Muscle skeletal... left 5th finger appears to be swollen. There is no bruising. Is able to move all extremities... Plan... Swelling of left 5th finger. It is painful to touch. No obvious evidence of trauma, skin break of bruising. Will obtain plain film..."

Review of the Patient Care Notes dated 7/1/18 at 12:10 PM revealed the LPN documented, "... Physician Notified: (NP) Notified about: Dislocated finger, Orders received: Coming to take pt (patient) to ER (Emergency Room)..." On 7/1/18 at 12:33 PM, the LPN documented, "... Pt transported to ER by staff via w/c (wheelchair) accompanied by... NP..."

The patient was taken to the Emergency Department (ED). According to the Procedural Note dated 7/1/18, a reduction of the closed, nonfractured, volar dislocation of the 5th left finger was performed by the NP and the ED Physician and a splint was placed but, the patient would not leave the splint in place.

Review of the medical record revealed the patient sustained a fall on 7/6/18 at 5:44 PM.

There was no documentation additional plans were implemented for this patient with multiple falls and injuries to prevent these falls and/or injuries. Throughout the medical record, the psychiatrist and nursing staff documented the patient was one on one. There was no documentation which staff was performing one to one observation. The Special Observation Lists by the MHTs revealed the patient's level of observation was every 15 minutes and the same MHT was performed observations for multiple patients at the same time as observing PI # 3. There was no documentation the nursing staff implemented 1:1 observation for this patient who was at high risk for falls, nor was there documentation the staff performed 1:1 observation, even though the psychiatrist documented the patient "needed" one to one observation.



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2. PI # 1 was admitted to the GPS unit on 9/21/18 with admitting diagnoses of AMS (Altered Mental Status) Unspecified, Dementia With Behavioral Disturbance.

Review of the Initial Psychiatric Evaluation dated 9/21/18 revealed the psychiatrist documented as past psychiatric history the patient had been diagnosed with Dementia and patient denies any history of mental health problems. Further review of the assessment documentation by the psychiatrist revealed major neurocognitive disorder, severe, with behavioral disturbances.

Review of the mental status examination dated 9/21/18 by the psychiatrist revealed patient alert,oriented to self, confused...He/she appears to respond to internal stimuli. Guarded. Patient is a danger to himself / herself and to others. Attention and concentration is limited to poor. Memory is poor. Insite and judgement is poor.

Plan: ...Prognosis is poor and guarded.

Review of the Senior Care Unit Admitting Orders dated 9/21/18 revealed under Special Precautions/Observations the patient was a fall risk and had agitation.

Review of the Patient Care Note dated 9/21/18 revealed the patient was admitted to the GPU at 7:30 PM and was difficult to arouse. Taken to room and placed in bed. Patient then was awake, irritable and restless in bed.

Review of the medical doctor's admission history and physical dated 9/22/18 revealed the patient's cognitive status as difficulty processing information and difficulty reasoning and functional status as dependent ADL's (Activities of Daily Living).

Review of the Patient Care Notes dated 9/23/18 at 4:00 AM revealed the nurse responded to a yell by the patient. The patient was found lying beside the bed, legs outstretched and head on the floor. The nurse documented the patient was confused to time and place. Patient was assisted off the floor with assistance of 2 staff members and patient was guarding left leg and could not stand without assistance.

Review of the Event Submission Report dated 9/23/18 with no time documented revealed the patient had a fall on the GPU. Description of incident revealed the patient found lying with head on the floor and legs extended outward in room. VS (vital signs) taken, patient shows s/s (signs and symptoms) of left side leg weakness. Patient denies striking head. Patient is confused most of the time...

Review of the Patient Care Note dated 9/23/18 at 22:00 (10:00 PM) revealed the nurse documented ...Staff sitting 1:1 with patient.

Review of the 9/23/18 Special Observation List revealed the patient was on Q 15 minute observations and on fall precautions and not the 1:1 observation as mentioned in the Patient Care Note at 10:00 PM. Further review of the Special Observation List revealed at 12:00 AM patient was asleep in room and observations were Q 15 minutes with fall precautions not 1:1 observation as mentioned in the Patient Care Note.

Review of the patient census on 9/23/18 for the 7 AM to 7 PM shift the census was 13 and for the 7 PM to 7 AM shift the census was 14.

Review of the staffing grid presented to the surveyor revealed for a census of 13 staffing should have been 2 licensed staff and 2 techs (technicians) and also for a census of 14.

Review of the staffing for the 7 AM to 7 PM shift dated 9/23/18 there was 1 RN (Registered Nurse), 1 LPN (Licensed Practical Nurse) , 1 tech for entire shift and 1 tech from 12:45 PM to 7 PM. Further review revealed for the 7 PM to 7 AM shift was 1 RN, 1 LPN, 1 tech for entire shift and 1 tech from 7 PM to 12 AM.

Review of the Patient Care Note dated 9/24/18 at 00:00 (12:00 AM) revealed the nurse documented ...Staff sitting 1:1 with pt.(patient).

Review of the Patient Care Note dated 9/24/18 at 1:35 AM revealed the nurse documented patient is in his/her room agitated. Medicated with Haldol po (by mouth) prn (as needed).

Review of the psychiatric progress note dated 9/24/18 revealed patient is evaluated and confused...per staff slept 3 hours..patient today was found on the floor. Patient with left hip pain and was followed by nurse practitioner and had hip x-ray done...

Review of the Event Submission Report dated 9/24/18 at 1:00 PM revealed the patient had a fall on the GPU. Description of incident revealed the patient found on floor by the quiet room.

Review of the event report dated 9/24/18 revealed the patient had a history of falls, was sensory impaired and was ambulating without assistance or without an assistive device. The fall was unassisted and unwitnessed.

Review of the Patient Care Note dated 9/24/18 at 15:41 (3:41 PM) revealed the nurse documented pt was propelling self in w/c (wheelchair) without difficulty...Will continue to monitor, eyesight observation.

Review of the 9/24/18 Special Observation List the staff documented the patient was on Q 15 minute observations and fall precautions not with in eye sight as documented in the Patient Care Notes at 3:41 PM.

Review of all the Special Observation List from 9/21/18 to 10/1/18 revealed the patient was on Q (every) 15 minute observations and on Fall Precautions.

Review of the patient census on 9/24/18 revealed for the 7 AM to 7 PM shift the census was 14 patients and for the 7 PM to 7 AM shift census was 12.

Review of the staffing grid revealed for a census of 14 staffing should have been 2 licensed staff and 2 techs.

Review of the staffing sheet for the 7 AM to 7 PM shift there was 3 RN with one scheduled from 11 AM to 7 PM and 1 tech.

Review of the staffing sheet for the 7 PM to 7 AM shift there was 1 RN, 1 LPN, 1 tech the entire shift and 1 tech from 7 PM to 6 AM.

3. PI # 2 was admitted to the facility on 7/3/18 with an admitting diagnosis of Major
Neurocognitive Disorder with Psychosis and Behavioral Disturbance.

Review of the initial psychiatric assessment dated 7/4/18 revealed the patient has a history of Major Neurocognitive Disorder. Patient at this time is confused and restless...Patient is a fall risk and unable to give history. Appears to be responding to internal stimuli...Patient is paranoid. Thought processes loose and disorganized. Memory poor insite and judgement is poor. Patient is a danger to self as well as others.

Review of the mental status examination section of the initial assessment revealed ..alert and oriented to person only. Psychomotor activity increased. Mood irritable and affect blunt. Thought process loose and disorganized. Speech is under-productive, appears to be responding to internal stimuli and is a danger to self and others. Memory poor, insite and judgement poor.

Review of the psychiatrist progress note dated 7/7/18 revealed under the mental status examination the patient is oriented to person only. Psychomotor activity increased. Mood irritable and affect labile. Thought process loose and disorganized...appears to be responding to internal stimuli, and is a danger to self not others...Plan will continue the medications, and is on fall precautions.

Review of the Interdisciplinary Treatment Plan Data Base dated 7/13/18 revealed the following problems initiated a). Psychosis c) Falls...

Review of the treatment plan for psychosis reveled the patient was on Q (every) 15 minute observations daily times 10 days.

Review of the Patient Assessment Report dated 7/4/18 at 7:56 AM revealed the patient's fall risk score was 16. Further review revealed at 12:45 AM the fall risk score was 13.0 and at 8:52 PM the fall risk score was 15.0.

Review of the documentation on the Patient Assessment Report revealed a score of greater than 10 the patient is at high risk for fall.

Review of the treatment plan for falls revealed patient will have o falls by 7/10/18 and the patient will have Q shift safety awareness education 3 times daily. Further review revealed the goal for falls were documented as "Patient will have no falls".

Review of the Patient Care Note dated 7/5/18 at 22:00 (10:00 PM) revealed the patient was attempting to get out of bed and is combative. Staff is 1:1.

Review of the Patient Care Notes dated 7/8/18 at 18:43 (6:43 PM) patient became combative and pulled IV (intravenous) out, restless...will continue to monitor.

Review of the Patient Care Note dated 7/8/18 at 21:50 (9:50 PM) patient found sitting on floor beside bed, awake, alert...no injuries noted. Patient assisted to bed.

Review of the Patient Care Note dated 7/10/18 at 00:31 (12: 31 AM) revealed staff is 1:1. At 02:56 (2:56 AM) revealed staff is 1:1. Further review revealed at 0400 (4:00 AM) Staff 1:1 for patient safety. At 21:30 (9:30 PM) patient yelling out and agitated. Staff is sitting 1:1.

Review of the 7/10/18 Patient Care Note revealed at 23:03 (11:03 PM) the nurse documented Staff is 1:1. Further review revealed at 23:55 (11:55 PM) the patient continues to be restless, combative... Staff is 1:1.

Review of the Patient Care Note dated 7/19/18 at 20:15 (8:15 PM) revealed ...patient continuing to get up by self and patient is hard to redirect, staff sitting 1:1 with patient.

Review of the Patient Care Note dated 7/23/18 at 10:00 PM revealed the nurse documented patient found lying on pillow on floor in room, patient assisted to bed, no injuries noted, no distress noted...

Review of the Patient Care Note dated 7/23/18 at 23:30 (11:30 PM) the nurse documented patient is restless, agitated and yelling out. Patient is combative with staff when he is redirected. Staff 1:1.

Review of the Patient Care Note dated 7/24/18 at 20:10 (8:10 PM) revealed staff assisted patient from room to the dining room via wheelchair to sit 1:1. Further review revealed at 21:36 (11:36 PM) staff is sitting 1:1.

Review of the Patient Care Note dated 7/25/18 at 00:15 (12:15 AM) revealed staff sitting 1:1. Further review revealed at 02:16 (2:16 AM) and at 04:00 (4:00 AM) the staff documented Staff is 1:1 with the patient.

Review of all the Special Observation List forms from 7/3/18 to 7/28/18 revealed the patient was on Q 15 minute observations and was on fall precautions. Further review revealed no documentation the patient was on 1:1 observations at any time.

Review of the staffing sheet dated 7/8/18 for 7 PM to 7 AM shift revealed there was 1 RN, 1 LPN, 1 tech for the full shift, 1 tech from 1 PM to 5 AM and 1 tech from 7 PM to 11 PM and the census was 11.

Review of the staffing grid presented to the surveyor revealed the census: 10 to 14 = (2) Licensed staff members, (2) Tech for 7 AM to 7 PM and 7 PM to 7 AM shifts

Review of the staffing sheet dated 7/23/18 for the 7 PM to 7 AM shift revealed there was 1 RN, 1 LPN, 1 tech and 1 tech orientee and the census was 12.

Review of the staffing grid presented to the surveyor revealed the census: 10 to 14 = (2) Licensed staff members, (2) Tech for 7 AM to 7 PM and 7 PM to 7 AM shifts

4. PI # 4 was admitted to the facility on 7/10/18 with admitting diagnoses of Unspecified Dementia with Behavioral Disturbance and Alzheimer's Disease Unspecified.

Review of the psychiatrist History and Physical dated 7/11/18 at 9:33 PM revealed the patient had a history of Major Neurocognitive disorder. Patient was brought to the Emergency Room with increased confusion and agitation. He is restless and confused. He appears to be responding to internal stimuli and has had a fall recently. The patient has significant cognitive impairment. He is a danger to self and others...He is a fall risk.

Review of the mental status exam dated 7/11/18 revealed the patient is alert and oriented to person only, psychomotor activity is decreased, thought process is delayed, speech is rambling, thought process is delayed, mood is irritable, affect is labile and positive for paranoia. The patient has delusional thoughts and appears to be responding to internal stimuli. Memory is poor and he is a danger to self not others and insite and judgement is poor.

Review of the Interdisciplinary Treatment Plan Data Base dated 7/10/18 revealed the following problems: 1. Psychosis 3. Falls.

Review of the treatment plan revealed under psychosis the patient will be oriented to 1 spheres all day for 3 days, Improved ability to concentrate, follow simple topics of conversation and improved ability to manage frustration/anger without acting out. Further review revealed the patient will be on 15 minute checks daily for 10 days.

Review of the treatment plan for falls revealed the goal is no falls by 7/17/18 and patient will have Q shift safety awareness education 3 times daily.

Review of the Fall Risk Assessment Form revealed the form stated Fall Risk Level: At risk (total at fall score 10 or greater).

Review of the Fall Risk Assessment dated 7/11/18 at 9:26 AM the patient scored 20. Further review revealed at 11:28 PM the patient's fall risk score was 21.

On 7/12/18 at 8:22 AM the patient's fall risk assessment was documented as 23 and at 8:03 PM the fall risk score was 22.

Review of the Fall Risk Assessment score on 7/23/18 at 8:02 AM revealed the patient's fall risk score was 22 and at 8:15 PM the fall risk score was 21.

Review of the Fall Risk Assessment dated 7/24/18 at 8:30 AM revealed the patient's fall risk score was 23 and at 9:20 PM the fall risk score was documented as 20.

Review of the Patient Care Notes dated 7/11/18 at 1:00 PM revealed the patient continues to ambulate unassisted. Patient's gait is unsteady. Patient very confused and hard to re-direct. Patient becomes combative... Further review revealed at 1:10 PM the physician was notified and an order was received for Zyprexa 5 mg (milligrams) PO (by mouth) or IM (intramuscular) PRN (as needed) for severe agitation or aggression. New orders carried out. At 1:10 PM the medication was given to the patient as an IM injection.

Review of the Patient Care Note dated 7/11/18 at 2:10 PM revealed the nurse documented the patient noted on floor in hallway by bathroom. The patient stated "I did not fall and then said "I did fall". No visible injury noted upon assessment...

Review of the Patient Care Note dated 7/17/18 at 3:07 PM the patient was 1:1 at the nurses station and at 3:42 PM the patient continued to be 1:1 and staff had a hard time re-directing patient.

Review of the Patient Care Note dated 7/24/18 at 6:01 PM revealed the nurse documented patient found on floor in dining room, no visible injuries noted upon assessment. Patient assisted to wheelchair and taken to hallway by nurses station for eyesight observation.

Review of all the Special Observation List forms fated 7/10/18 to 7/31/18 revealed the patient was on Q 15 minute observations and Fall Precautions. There is no documentation of any 1:1 observation documentation on the forms.

Review of the staffing sheet for 7/11/18 for the 7 AM to 7 PM shift revealed the following staff were scheduled: 1 RN, 1 LPN, 2 techs and 1 tech from 9 AM it 4:30 PM. The census for 7/11/18 on the 7 PM to 7 AM shift was 13 patients with 1 patient with an acuity of 4.

Review of the staffing grid presented to the surveyor revealed the census: 10 to 14 = (2) Licensed staff members, (2) Tech for 7 AM to 7 PM and 7 PM to 7 AM shifts

Review of the staffing sheet for 7/24/18 for the 7 AM to 7 PM shift revealed the following staff were scheduled: 1 RN, 1 LPN, 2 tech. The census for 7/24/18 on the 7 PM to 7 AM shift was 12 patients with 2 patient with an acuity of 4.

Review of the staffing grid presented to the surveyor revealed the census: 10 to 14 = (2) Licensed staff members, (2) Tech for 7 AM to 7 PM and 7 PM to 7 AM shifts

Review of the Facility's credible allegation of compliance dated and signed by the Chief Executive Officer on 10/4/18 revealed the following corrective actions related to inadequate staffing to meet the acuity needs of patients: Plan of Correction: 1) Immediate corrective actions include: acuity assessments of patients on unit and staffing increased based on acuity review; appropriate unit staffing ensured by adding 2 MHTs; staff called in and ensured that there is adequate staffing to meet the needs of the current patient load and acuity thru Sunday 10/7/18. 2) Appropriate staffing for the next six weeks will be included on the current schedule which concludes 10/27/18; this schedule will be updated by Sunday 10/7/18. Review and update staffing metrics and guidelines related to patient acuity, effective 10/8/18. 4) An updated acuity scale is to be added to the Geripsych staffing plan (see attached policy), to include a scale rating system from 1-5. High falls risk patients will be rated a 4. Any patient with a rating greater than or equal to a 4 will be a 1:1 observation patient. Completed 10/4/18. 5) Department Director/Charge Nurse will assess staffing plan and will determine acuity scale for Geripsych patients. They will staff based on the acuity scale and staffing

Based on interviews, it was determined the nursing staff failed to ensure patient care assignments were assigned to the Mental Health Technicians (MHT) by the Registered Nurse (RN). This had the potential to negatively affect all patients admitted to the Geri-Psychiatric Unit (GPU).

Findings include:

An interview was conducted on 10/4/18 at 8:25 AM with Employee Identifier (EI) # 6, Licensed Practical Nurse (LPN). The surveyors asked, How are the Mental Health Technicians (MHT) assigned patients?" EI # 6 stated, "If there are 8 patients and 1 MHT - the MHT does everything. If there are 2 MHTs, they decide how they want to split it up. They take breaks when they can." When questioned about the number of staff on her shift, EI # 6 stated there are usually 3 staff members present, 1 RN, 1 LPN and 1 MHT depending on the number of patients, if there are more patients then there are more staff present.

An interview was conducted on 10/4/18 at 9:00 AM with EI # 7, RN. The surveyors asked, "How are the MHTs assigned patients?" EI # 7 stated, "If there are 2 MHTs, they work together. They split the paper load, but they don't take certain patients." When questioned about the number of staff on her shift, EI # 6 stated, "normally 1 RN, 1 LPN and 1 or 2 MHT, if staff are available to work, then we have 2 MHTs." The surveyors asked EI # 7 to explain observation levels. EI # 7 stated the Techs (MHTs) usually have eyes on the patients. When questioned about 1:1 patients, EI # 7 stated that if she is in charge, "we group all 1:1's together and 1 MHT watches all 1:1's together while the other tech does other jobs. Sometime we call other floors to get help. If there is only 1 MHT, patients are brought to the nursing desk and one of the nurses watches the patient." When questioned if the GPU ever does 1:1 observation, EI # 7 stated that sometime they will do 1:1 observation on patients who are high risk. "If there is no order for 1:1; then extra staff are not scheduled."

An interview was conducted on 10/4/18 at 9:25 AM with EI # 5, MHT. The surveyors asked, "How are the MHTs assigned patients?" EI # 5 stated, "We all do everything. We only split the paperwork. When questioned about the number of staff on her shift, EI # 5 stated, "1 MHT, 1 RN, 1 LPN." The surveyors asked if she has a 1:1 patient, is she allowed to watch other patients. EI # 5 stated, "Yes. I will take the 1:1 into the activity room & bring other patients in there"

An interview was conducted on 10/4/18 at 9:40 AM with EI # 3, MHT. When questioned about the number of staff on her shift, EI # 3 stated, "1 MHT, Sometimes 1 RN, 1 LPN or 2 LPNs." The surveyors asked, "How are the MHTs assigned patients?" EI # 3 stated, "It depends if 1:1. Someone sits with 1:1 for an hour and the other MHT does other things then we switch out." The surveyors asked if there is only 1 MHT and more than (1) - 1:1 patient how is that accomplished? EI # 3 stated that the MHT takes all 1:1's into the group room and the MHT watches them while the nurses watches the rest of the patients. When questioned why patients are 1:1, EI # 3 stated, "because they can't walk and try to get up."