HospitalInspections.org

Based on reviews, observation, and interviews the facility failed to;


1.) Discharge the patient or initiate a commitment warrant after a discharge request was initiated.
Properly fill out the four hour discharge notice, notify the physician within four hours of signing the four hour discharge notice, have a plan in place to file for court ordered care, and a physician order to hold the patient to complete the court ordered paperwork in 2 (#1 and 9) of 2 charts reviewed.

Refer to Tag A0131

2.) Based on record review and interview, the facility failed to
appropriately supervise and keep patients safe from harm in 4 (patients #16 through #19) out of 9 (patients #13 through #21) patient records reviewed.
ensure the policy and procedures were followed for chemical restraints, orders were completed and signed by the physician, physical assessments and medication administration were documented. The physician failed to document less intrusive forms of treatment that the physician evaluated but rejected and the administration of the psychoactive medication would be provided in a manner, consistent with clinically appropriate medical care, and least restrictive of the patient's personal liberty in 1(#6) of 3( #1, 6, and 22) charts reviewed.

The CNO failed to have a clear understanding of a chemical restraint and was unable to educate the staff appropriately.

provide safety grab bars in the shower area in 17 (room #109, 110, 111, 112, 113, 114, 115, 117, 118, 119, 120, 121, 122, 123, 124, 126 and 127) out of 19 adult patient rooms to protect patients from falling who were identified as being at risk for fall.


protect adolescents from sharing personal contact information and obscenities in the form of graffiti.


provide a plan for protection patients from wasps, controlling, and removing wasps from the gym.


provide safe outdoor furniture for patient use.

Refer to Tag A0144



3.) Based on review of the Quality Assessment Performance Improvement (QAPI) data the facility failed to follow the written plan. The facility failed to develop a performance improvement team and re-train employees on fall risk identifiers.

Refer to Tag A0286



4.) follow the written plan. The facility failed to develop a performance improvement team and re-train employees on fall risk identifiers.

Refer to Tag A0286


5.) ensure that infection control problems were identified and reported to hospital leadership, medical staff, and governing body. The facility failed to identify infection control issues found in the facility, develop corrective actions, and implement those actions.

Refer to Tag A0308


6.) ensure all hospital units were staffed appropriately with licensed nurses and, according to the facility's approved policy and staffing grid for 13 (10/15, 10/16, 10/17 x 2 shifts, 10/19, 10/21, 10/27 x 2 shifts, 10/29, 10/30, 11/2, 11/9, and 11/13) of 180 (10/15 through 11/14) shifts reviewed.
Refer to Tag A0392

7.) develop and implement an effective process for ensuring 1 nurse (Staff #35) out of 4 nursing personnel files reviewed had a valid and current license. The facility failed to follow approved policy and procedure.
Refer to A0394


8.) ensure all patients received a physical assessment by a Registered Nurse (RN) at least every 12 hours after the initial comprehensive admission nursing assessment in 14 (patients #1 and #10- #22) of 14 (patients #1 and #10- #22) patient records reviewed.

Nursing failed to assess patient with changes in condition in elevated blood sugars or elevated blood pressures. Failed to document correct times and dates in the patients medical record.

ensure there was nursing documentation on how the patient tolerated the insulin, vital signs, if there were s/sx of hyperglycemia, duration of pain, or if any interventions were given to relieve the pain.

ensure the patients was given safety equipment in the shower to prevent falls.
Refer to Tag A395


9.) ensure infection control problems were identified and reported to hospital leadership, medical staff, and governing body. The facility failed to identify infection control issues found in the facility, develop corrective actions, and implement those actions.

Refer to Tag A0756

Based on reviews and interviews the facility failed to;
1.) A. Discharge the patient or initiate a commitment warrant after a discharge request was initiated.
B. Properly fill out the four hour discharge notice, notify the physician within four hours of signing the four hour discharge notice, have a plan in place to file for court ordered care, and a physician order to hold the patient to complete the court ordered paperwork in 2 (#1 and 9) of 2 charts reviewed.

Refer to Tag A0131

2.) Based on record review and interview, the facility failed to
A.) appropriately supervise and keep patients safe from harm in 4 (patients #16 through #19) out of 9 (patients #13 through #21) patient records reviewed.
B.) ensure the policy and procedures were followed for chemical restraints, orders were completed and signed by the physician, physical assessments and medication administration were documented. The physician failed to document less intrusive forms of treatment that the physician evaluated but rejected and the administration of the psychoactive medication would be provided in a manner, consistent with clinically appropriate medical care, and least restrictive of the patient's personal liberty in 1(#6) of 3( #1, 6, and 22) charts reviewed.
C.) The CNO failed to have a clear understanding of a chemical restraint and was unable to educate the staff appropriately.

D. provide safety grab bars in the shower area in 17 (room #109, 110, 111, 112, 113, 114, 115, 117, 118, 119, 120, 121, 122, 123, 124, 126 and 127) out of 19 adult patient rooms to protect patients from falling who were identified as being at risk for fall.

E. protect adolescents from sharing personal contact information and obscenities in the form of graffiti.

F. provide a plan for protection patients from wasps, controlling, and removing wasps from the gym.

G. provide safe outdoor furniture for patient use.

Refer to Tag A0144

3.) Based on review of the Quality Assessment Performance Improvement (QAPI) data the facility failed to follow the written plan. The facility failed to develop a performance improvement team and re-train employees on fall risk identifiers.

Refer to Tag A0286

Based on chart reviews the facility failed to;
A. Discharge the patient or initiate a commitment warrant after a discharge request was initiated.
B. Properly fill out the four hour discharge notice, notify the physician within four hours of signing the four hour discharge notice, have a plan in place to file for court ordered care, and a physician order to hold the patient to complete the court ordered paperwork in 2 (#1 and 9) of 2 charts reviewed.
Review of patient #1's physician order reveals the patient was admitted on 9/26/16 at 1645. There was no physician order to state if the patient was voluntary or involuntary. Review of the patient consents revealed the patient came into the facility voluntarily.
Review of patient #1's physician progress notes revealed the psychiatrist had seen the patient on 9/29/16 at 13:11 (1:11PM). The psychiatrist describes the patient as "angry" and "endorsing suicidal ruminations." Patient #1 had "stormed out" of the psychiatrist office after demanding to be discharged. The psychiatrist felt the patient was not ready for discharge and advised the patient that he was "very clear cut risk for suicide and will hold off on discharge and file for court order and then try to establish a more firmer therapeutic alliance." (SIC)
Review of patient #1's chart revealed a four hour discharge notice was filled out on 9/29/16 at 1358 (1:58). It was filled out after the patient had seen the psychiatrist. The patient had requested to leave to be with his father during surgery. In the section for the nurses signature (staff nurse accepting request), it was signed by staff #39 a Mental Health Technician (MHT). There was a signature line under the MHT's signature that stated, "Notification made to: ___, at (Time) ___, on: (Date) ____by (Name & Title) ___. " The information was left blank. There was no notification documented on the form that a nurse or physician was notified. On the bottom of the form was a place where the patient can cancel their request for immediate discharge. The patient wrote, "My father having surgery 9/30/16 need to be there." Then above that in different ink it said "continue treatment" The patient signed it on 9/29/16 at 2:15PM. The staff signature, date and time were blank.
Review of the psychiatrist progress note on 9/30/16 at 11:12AM stated, "Patient is irritable and angry. Refused medication last night, very focused on discharge and put in a request for discharge yesterday. Advised him given his recent overdose and short stay is obvious significant risk factors with no stable home environment, substance abuse. I did not feel comfortable with his discharge without a better treatment plan. Discharge plan in place and for now we will file for court ordered care." There was no found evidence that court ordered care was ever started.
Review of patient #1's chart revealed there was no documentation of a court order in process or that the physician or RN was aware he signed the four hour discharge notice until 9/30/16 at 11:12AM. There was no physician order to hold the patient for a court commitment. Review of the RN notes revealed the patient told the RN he wanted to leave the facility but there was no documentation that the physician was notified and what time he told the nurse he wanted to leave.
Review of the policy and procedure FOUR HOUR REQUEST FOR DISCHARGE stated, "4.2 Requests for discharge may be verbal or in writing. Upon the patient making the request for discharge to any employee or contractor of Glen Oaks with authority for charting progress notes in the medical record, such person shall immediately notify a Registered Nurse, who will then assist the patient with completion of request of discharge form. 4.2.1.1 The Registered Nurse will also document in the Progress Note the circumstances of the request, including the manner of request, the time of the request and the presentation of the request for discharge form. 4.2.2. The Registered Nurse will immediately notify the attending physician or the first available physician of the patient's request for discharge and document in the medical record that the physician has been notified and the time the physician was notified."
Review of Patient #9's chart revealed the patient was admitted as a voluntary patient on 10/12/16 with a diagnosis of schizophrenia. Review of the chart revealed the patient had signed a Request for Discharge form on 10/15/16 at 6:00AM. The patient stated she wanted to be discharged because "The rules and regulations are prohibiting my religious and smoking preferences." The DPN staff #4 documented on the form that the physician was notified at 5:30AM on 10/15/16. An order was found to detain the patient for a face to face with physician within 24 hours. Review of the chart revealed there was no nursing documentation about the request for discharge. There was no mention found of why the patient was upset or if any nursing interventions were done.
Review of physician progress note dated 10/15/16 at 1:30PM revealed the physician did not fill out the progress form that a mental status exam was performed. The change in medications section was left blank and the section "patient has capacity to make an informed decision regarding admission status Yes__ or No__" was left blank. There was no documentation found concerning the request for discharge. There was no orders or documentation to detain the patient for court ordered commitment. The patient was not discharged from the facility nor did the patient rescind the discharge request.
Review of patient #9's chart revealed another Request for Discharge dated 10/18/16 at 11:25PM. The patient documented, "I am being rattled teased ignored and defied by all staff members even the MD's PhD's and CEO." The patient signed in the patient signature to cancel the request but there was no documentation that the patient was aware that was to cancel the request. There was no nursing documentation concerning the discharge request. A physician order to hold the patient for 24 hours to see physician was found on 10/18/16 at 2329 (11:29PM).
Review of the physician progress note dated 10/19/16 at 9:07AM revealed there was no documentation concerning the patients discharge request. The physician documented, "Patient remains intrusive, inappropriate, and very mechanically elevated at this point. She is not responding well to medications and refusing all medications significant worsening motor activity today. For now I would characterize her level of mania at catatonically agitated and we will try to intervene with Ativan and started her on fairly substantial dose at 2mg t.i.d. and we will assess response to that. Failing that, we will need to apply for court order meds with patient refusing basically all medication strategies." There was no documentation in the patient's chart that any paperwork was initiated for court commitment. There was no physician order to hold the patient or change the status to involuntary. The patient was not discharged.

Based on record review and interview, the facility failed to
A.) appropriately supervise and keep patients safe from harm in 4 (patients #16 through #19) out of 9 (patients #13 through #21) patient records reviewed.
B.) ensure the policy and procedures were followed for chemical restraints, orders were completed and signed by the physician, physical assessments and medication administration were documented. The physician failed to document less intrusive forms of treatment that the physician evaluated but rejected and the administration of the psychoactive medication would be provided in a manner, consistent with clinically appropriate medical care, and least restrictive of the patient's personal liberty in 1(#6) of 3( #1, 6, and 22) charts reviewed.
C.) The CNO failed to have a clear understanding of a chemical restraint and was unable to educate the staff appropriately.

D. provide safety grab bars in the shower area in 17 (room #109, 110, 111, 112, 113, 114, 115, 117, 118, 119, 120, 121, 122, 123, 124, 126 and 127) out of 19 adult patient rooms to protect patients from falling who were identified as being at risk for fall.

E. protect adolescents from sharing personal contact information and obscenities in the form of graffiti.

F. provide a plan for protection patients from wasps, controlling, and removing wasps from the gym.

G. provide safe outdoor furniture for patient use.



The deficient practice caused minor injuries to patients and had the potential of causing serious injury to patients.
A review of the facility's "HEALTHCARE PEER REVIEW REPORT" revealed the following information:
Reports for patient's #16 through #19, dated 10/25/2016, documented all 4 patients received self-inflicted injuries while in the facility's gym, under the supervision of staff #41, Mental Health Tech (MHT). According to the reports, the patients were punching and kicking a padded gym wall. Patients #16, #17 and #19, sustained pain, redness, swelling and bruising to the right hand. Patient #18 sustained pain, redness, swelling and bruising to the right knee. All 4 patients returned to the Youth Care Unit (YCU) and complained to staff #32, Registered Nurse (RN) on duty. Staff #32 assessed each patient's injury and provided ice packs to treat the swelling.
An interview with staff #2 and #4 was conducted on 11/16/2016. Staff #2 and #4 revealed the incident was witnessed by the MHT, staff #41, who was supervising the YCU patients in the gym. Staff #2 revealed staff #41 had allowed the patients to punch and kick the gym wall.
There was no documentation that staff #41 received reprimand or disciplinary action from the facility's administration for allowing the patients to hit and kick the gym wall.



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Review of patient #6 revealed the patient was admitted to the facility on 10/26/16. The patient's demographic sheet states the patient was admitted voluntarily. There was no physician order for the patient status. The patient was brought to the unit on an Emergency Detention Warrant (EDW). Review of patient #6's nurses notes revealed on 10/31/16 at 1632 (4:32PM) the patient was "in the hallway agitated, yelling, screaming, punching walls and attempted to charge staff. Patient placed in a physical restraint to avoid danger to self and others. Encouraged patient to calm so restraint could be lifted. Patient calmed once started talking with staff verbalizing why she was upset/aggressive. Offered patient support, encouragement, reinforce coping skills."
Review of patient #6's telephone physician order dated 10/31/16 at 1640PM stated, "Ativan 2 mg IM now -anxiety. Thorazine 50mg IM 1 now- delusional reactivity." There was no physician signature noted.
Review of patient #6's chart revealed a three page "Restraint/Seclusion/Emergency Medication Order" revealed an order was started for a physical restraint at 1620 (4:20PM) and ended 1632 (4:32PM). The emergency medication section was blank with no physician signature. Review of patient #6's Medication Administration record (MAR) revealed the patient was given the IM Thorazine and IM Ativan on 10/31/16 at 1645 (4:45PM).
Review of the nurses notes revealed the patient was in the dayroom calm on 10/31/16 at 1700 (5:00PM). There is no further documentation that the medication was effective or the patient's reaction to the restraint and emergency medication. There was no further assessment documented on the patient until 8:00PM on 10/31/16.
Review of the physician progress note dated 11/01/2016 revealed the the physician did not document less intrusive forms of treatment that the physician evaluated but rejected and the administration of the psychoactive medication would be provided in a manner, consistent with clinically appropriate medical care, and least restrictive of the patient's personal liberty.
An interview was conducted with staff #4 CNO on 10/17/16. The CNO stated that they do not do chemical restraints at their facility. Staff #4 stated they just do emergency behavioral medications. Staff #4 was not clear what the definition of a chemical restraint was. Staff #4 confirmed he was not clear on the definition of a chemical restraint and staff #4 had been doing all the restraint training with the staff.










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Findings include:

A. On the morning of 11-18-2016 a tour with Staff # 1 was conducted of the patient room's bathrooms on the adult unit (rooms 109 through 127). The tour revealed that only two rooms (room #116 and room #125) had grab bars in the shower area to protect patients who were at risk of falling. The two rooms could house two patients each for a total of four patients having access to the protective equipment.

An interview was conducted following the tour in the nursing station on the adult unit with Staff #36. Staff #36 confirmed, based on the census board and falling leaf markers on patient doorways, there were eight patients who were identified as at risk to fall. Staff #36 confirmed the patient in room #126 was identified as at risk to fall and the patient in room #125 was not identified at risk to fall. When it was pointed out that the patient in room #126 was in need of the additional safety equipment, Staff #36 could not explain how the rooms were assigned.

B. On the afternoon of 11-17-2016 a tour of the patio area outside of the Adolescent Unit day room revealed the following:

The patio area was enclosed on three side by a wooden fence. The wooden fence was covered in graffiti on all three sides. The graffiti included personal contact information to include full names, phone numbers, skype numbers, twitter accounts, Instagram accounts, obscenities, and drawings of genitalia.

Staff #36 was interviewed and stated that he never went out there. Staff #1 and Staff #2 were interviewed. They stated they were aware of the graffiti, but did not know it contained personal contact information and obscenities.

C. On the morning of 11-17-2016 a tour of the gymnasium was conducted. The floor of the gymnasium had 16 dead or dying wasps scattered across the carpeting presenting a risk for patients to receive stings and potential life threatening reactions to those stings.

An interview was conducted with Staff #3 after the tour. Staff #3 stated that it was known there was a wasp problem. Staff #3 stated that the exterminator had not been able to find the source so the only plan was to call again when the wasps start to appear. Staff #3 was not sure when the last time the exterminator had been out. Staff #3 did not have a plan of action for staff to report new wasp sightings, protect patients when wasps return to the gymnasium, or to clean up the dead wasps.

D. On the morning of 11-27-2016 a tour of the courtyard between the main building and they gymnasium was conducted. The courtyard contained two wooden picnic tables that were made from unprotected wood. The wood was splintered, warped, and growing fungus.

An interview with Staff # 3 was conducted after the tour. Staff #3 stated he was unaware that the picnic tables were untreated and needed to be replaced.

Based on review of the Quality Assessment Performance Improvement (QAPI) data the facility failed to;

A. follow the written plan. The facility failed to develop a performance improvement team and re-train employees on fall risk identifiers.

Refer to Tag A0286

B.) ensure that infection control problems were identified and reported to hospital leadership, medical staff, and governing body. The facility failed to identify infection control issues found in the facility, develop corrective actions, and implement those actions.

Refer to Tag A0308

Based on review of the Quality Assessment Performance Improvement (QAPI) data the facility failed to follow the written plan. The facility failed to develop a performance improvement team and re-train employees on fall risk identifiers.

Review of the Quality Assessment Performance Improvement (QAPI) presented to the Hospital Quality Council Meeting dated October 20th 2016 revealed the facility had reported falls for the last quarter. However there was no current data for October-December 2016.

Review of the QAPI council meeting notes revealed the facility had logged 7 falls for September 2016. It was an increase from 6 patient falls reported in August 2016. Staff #2 reported there had been more than 7 falls in October. The plan was to have a post -fall conference completed for all patient falls and Yellow "fall" leaves will be placed on the patients door along with yellow bracelets and non-slip socks. Staff would be retrained to the risk identifiers.

Review of the Topic for Discussion stated, "A task force has been organized at this time. If there is no marked improvement in the next couple of months, this will become a PI Team." Staff #2 reported that they are closely looking at falls but there was no PI team in place at this time.

Review of staff employee files and staff training revealed there had been no staff re-training to falls.

Based on review of the Quality Assessment Performance Improvement (QAPI) data and interview, the facility failed to ensure that infection control problems were identified and reported to hospital leadership, medical staff, and governing body. The facility failed to identify infection control issues found in the facility, develop corrective actions, and implement those actions.


Review of the Quality Assessment Performance Improvement (QAPI) presented to the Hospital Quality Council Meeting dated October 20th 2016 revealed the Departmental PI Reports for Infection Control was "Deferred to MEC October 27 2016." There was no further mention of infection control to the Quality Council.


Review of the Medical Executive Committee (MEC) meeting minutes dated October 20, 2016 revealed there was no data or mention of infection control in the meeting minutes.


Review of the Medical Executive Committee (MEC) meeting minutes dated October 20, 2016 revealed total infections and number of acquired infections was the only thing reported. There was an action for infection control nurse to conduct weekly rounds. There was no measurable PI process found for infection control.


An interview was conducted with staff #2 11/17/16. Staff #2 reported that she had not been doing infection control and that job had been turned over to staff #5. Staff #2 reported that staff #5 was new in her position and staff #2 would need to assist staff #5 with the QAPI data. Staff #2 could not provide the surveyor with any further infection control QAPI.

Based on record review and interview, the facility failed to:
1.) A. ensure all hospital units were staffed appropriately with licensed nurses and, according to the facility's approved policy and staffing grid for 13 (10/15, 10/16, 10/17 x 2 shifts, 10/19, 10/21, 10/27 x 2 shifts, 10/29, 10/30, 11/2, 11/9, and 11/13) of 180 (10/15 through 11/14) shifts reviewed.
Refer to Tag A0392

2.) develop and implement an effective process for ensuring 1 nurse (Staff #35) out of 4 nursing personnel files reviewed had a valid and current license. The facility failed to follow approved policy and procedure.
Refer to A0394

3.) A. ensure all patients received a physical assessment by a Registered Nurse (RN) at least every 12 hours after the initial comprehensive admission nursing assessment in 14 (patients #1 and #10- #22) of 14 (patients #1 and #10- #22) patient records reviewed.
B. Nursing failed to assess patient with changes in condition in elevated blood sugars or elevated blood pressures. Failed to document correct times and dates in the patients medical record.
C. ensure there was nursing documentation on how the patient tolerated the insulin, vital signs, if there were s/sx of hyperglycemia, duration of pain, or if any interventions were given to relieve the pain.
D. ensure the patients was given safety equipment in the shower to prevent falls.
Refer to Tag A395

Based on record review and interview, the facility failed to:
A. ensure all hospital units were staffed appropriately with licensed nurses and, according to the facility's approved policy and staffing grid for 13 (10/15, 10/16, 10/17 x 2 shifts, 10/19, 10/21, 10/27 x 2 shifts, 10/29, 10/30, 11/2, 11/9, and 11/13) of 180 (10/15 through 11/14) shifts reviewed.
The facility housed 3 separate patient care units named Progressive Care Unit (PCU), Special Care Unit (SCU) and Youth Care Unit (YCU). Each unit's nursing staff were normally scheduled for a 12 hour shift, either 7 a.m. until 7 p.m. (day shift) or, 7 p.m. until 7 a.m. (night shift).

A review of the facility's staffing and assignment forms revealed the following information:
10/15/2016 - PCU was short 1 RN (registered nurse) from 11 p.m. until 7 a.m. with a patient census of 18.
10/16/2016 - PCU and SCU showed the same RN was working on both units from 7 p.m. until 11 p.m. with a patient census of 18 patients on each unit.
10/17/2016 - PCU was short 1 nurse from 7 a.m. until 7 p.m. with a patient census of 15.
10/17/2016 - SCU was short 1 nurse from 7 p.m. until 7 a.m. with a patient census of 16.
10/19/2016 - SCU was short 1 nurse from 7 p.m. until 7 a.m. with a patient census of 12.
10/21/2016 - PCU was short 1 nurse from 7 p.m. until 7 a.m. with a patient census of 17.
10/27/2016 - PCU was short 1 nurse from 7 p.m. until 7 a.m. with a patient census of 17.
10/27/2016 - SCU was short 1 nurse from 7 p.m. until 7 a.m. with a patient census of 14.
10/29/2016 - SCU was short 1 nurse from 7 a.m. until 7 p.m. with a patient census of 16.
10/30/2016 - SCU was short 1 nurse from 7 p.m. until 7 a.m. with a patient census of 16.
11/02/2016 - SCU was short 1 nurse from 7 p.m. until 7 a.m. with a patient census of 13.
11/09/2016 - PCU was short 1 nurse from 7 p.m. until 7 a.m. with a patient census of 20.
11/13/2016 - SCU was short 1 nurse from 7 p.m. until 7 a.m. with a patient census of 14.

A review of the facility's staffing grid revealed the following minimum nursing staff required for the number of patients present per unit:
PCU 7 a.m. to 7 p.m. shift with a census of 10 to 14 patients - 1 RN required.
PCU 7 a.m. to 7 p.m. shift with a census of 15 to 22 patients - 1 RN and 1 RN or LVN (licensed vocational nurse) required.
PCU 7 p.m. to 7 a.m. shift with a census of 10 to 15 patients - 1 RN required.
PCU 7 p.m. to 7 a.m. shift with a census of 16 to 22 patients - 1 RN and 1 RN or LVN required.
SCU 7 a.m. to 7 p.m. shift with a census of 7 to 11 patients - 1 RN required.
SCU 7 a.m. to 7 p.m. shift with a census of 12 to 16 patients - 1 RN and 1 RN or LVN required.
SCU 7 p.m. to 7 a.m. shift with a census of 7 to 11 patients - 1 RN required.
SCU 7 p.m. to 7 a.m. shift with a census of 12 to 16 patients - 1 RN and 1 RN or LVN required.

A review of the facility's policy titled, "Nurse Staffing Plan", revealed the following information:
" ...It is the policy of Glen Oaks Hospital that the nursing staff will be scheduled according to patients' needs and will provide a safe and effective milieu. ...Whenever any unit has patients, an RN will be present on that unit. Whenever any unit has patients, there will be scheduled a minimum of 1 nurse and 1 MHT." (Mental Health Tech)
An interview with the facility's Director of Nursing (DON), staff #4, confirmed the facility's administration was aware of nurse staffing shortages.


B. ensure the Youth Care Unit (YCU) was staffed appropriately with Mental Health Techs (MHTs) and, according to the facility's approved policy and staffing grid for 3 (10/15, 11/4, and 11/5) of 60 (10/15 through 11/14) shifts reviewed.

The condition and deficient practices were identified and determined to pose Immediate Jeopardy to patient health and safety and placed all patients at risk for the likelihood of harm, serious injury, and possibly subsequent death.

A review of the facility's staffing and assignment forms revealed the following information:
10/15/2016 - YCU was short 1 MHT from 7 p.m. until 7 a.m. with a patient census of 15.
11/04/2016 - YCU was short 1 MHT from 7 a.m. until 7 p.m. with a patient census of 16.
11/05/2016 - YCU was short 1 MHT from 12 p.m. until 7 p.m. with a patient census of 14.
A review of the facility's staffing and assignment forms revealed the following information:
YCU 7 a.m. to 7 p.m. shift with a census of 4 to 9 patients - 1 MHT required.
YCU 7 a.m. to 7 p.m. shift with a census of 10 to 16 patients - 2 MHTs required.
YCU 7 p.m. to 7 a.m. shift with a census of 4 to 7 patients - 1 MHT required.
YCU 7 p.m. to 7 a.m. shift with a census of 8 to 16 patients - 2 MHTs required.
"The 2nd MHT on nights is the hall monitor for YC when census above 7."
Further review of the facility's staffing and assignment forms revealed the staffing coordinator was not consistently documenting the MHTs assigned to the YCU "hall monitor" duties.

A review of the facility's policy titled, "Nurse Staffing Plan", revealed the following information:
" ...It is the policy of Glen Oaks Hospital that the nursing staff will be scheduled according to patients' needs and will provide a safe and effective milieu. ...Whenever any unit has patients, an RN will be present on that unit. Whenever any unit has patients, there will be scheduled a minimum of 1 nurse and 1 MHT." (Mental Health Tech) "On the Youth Care unit, there will be an additional MHT scheduled during patient's hours of sleep to serve as a hall monitor for patient safety."
An interview with the facility's Director of Nursing (DON), staff #4, confirmed the facility's administration was aware of MHT staffing shortages and the need for more accurate detailed documentation of staff assignments.
Staff #4 further revealed the facility had recently appointed staff #40 to the position of Staffing Coordinator. Staff #40's previous position at the facility was MHT.




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Review of the policy and procedure "Monitoring of the Youth Care Hallway" stated,
"Policy: The nursing staff will provide continuous monitoring of the Youth Care hallway under the supervision of a charge nurse.
Procedure:
3.1 Staff will supervise the patient hallway anytime that patients are in their assigned room.
3.2 Staff will position a chair and sit in a strategic location in the hallway to provide direct observation of the hallway and dayroom and walk the hallways at intervals and as needed. (SIC)
3.3 The charge nurse will be responsible for assuring that nursing staff are relieved for scheduled breaks and replaced ...at no time will the hallway be left unattended.
3.4 Staff will make rounds at least every 15 minutes or more frequently as needed and document this information on the q 15 minute check sheet."

An interview was conducted with staff #1, #2, #4 on 11/17/18. Staff #1, #2 and #4 revealed the youth care unit would have a monitor in the hallway anytime the patient room doors were open to ensure patient safety.

On 11/17/16 at 8:40PM a tour was performed of the youth care unit. The charge nurse was in the nursing station, a MHT was taking vital signs of the patients, and another MHT was in the laundry room assisting patients. Four patient rooms were found unlocked with the doors open and patients walking around in the hallway unmonitored. The charge nurse stated that the patients are allowed to go take showers one at a time and the hall monitor would sit in the hallway after all the patients have gone to bed. Interview with staff #40 on 11/17/16 revealed he had to fill in for the youth care MHT due to lack of staffing. Staff #40 had worked the day shift before coming on for 12 more hours to fill in.

An interview was conducted with staff #1 and #2 on 11/18/16. The staff was informed of the tour to the youth care unit and findings on 11/17/16 during the night shift. Staff #1 and #2 confirmed that the shift was short and staff #40 had to work a double shift. Staff #1 and #2 reviewed the video of the hallway and the surveyors the evening of 11/17/16 and confirmed the children were in the hallway with open rooms and no direct supervision.

Based on review of records and interview, the facility failed to develop and implement an effective process for ensuring 1 nurse (Staff #35) out of 4 nursing personnel files reviewed had a valid and current license. The facility failed to follow approved policy and procedure.

A review of nursing personnel files showed that one nurse (Staff #35) had a license that had expired 10/31/2016. The license verification had been completed using the Staff #35's name only. The verification that was printed and put in the file did not contain the license number.

Staff #37 was interviewed and asked about the license expiration. She stated that she thought everyone's license had been checked and was current and that she would check with this staff member. Upon return, she explained that this staff member did have a current license. It was under a different name. She stated that when a potential employee inquires about a nursing position, they check the license prior to application and conditional job offer based off of the name. The name on the license verification was similar to Staff #35's so they assumed it was her. When Staff #37 was asked why she didn't submit the inquiry using the actual license number or date of birth with last 4 of the social security number to ensure she has the right person, she replied that most nurses don't know their license number and she checks the licensure before she has an application with date of birth and social security number on it.

Review of Glen Oaks Hospital Policies & Procedures, Policy No. HR II-03 Revision #4, page 2 states the following:

"B. Conditional Job Offers and Background Checks:
1. HR shall initiate the background investigation(s) after a conditional job offer has been made.
2. All applicants for whom a conditional job offer has been made will have a background investigation consisting of all items listed in Level I:

Level I

· Social Security number trace
· Criminal history (i.e., county(s) or state-wide) and or federal (as necessary)
· Education verification (if position requires a degree, verify highest level of education)
· Professional license verification (if the position requires a license)"

Based on record review and interviews, nursing failed to:
A. ensure all patients received a physical assessment by a Registered Nurse (RN) at least every 12 hours after the initial comprehensive admission nursing assessment in 14 (patients #1 and #10- #22) of 14 (patients #1 and #10- #22) patient records reviewed.
B. Nursing failed to assess patient with changes in condition in elevated blood sugars or elevated blood pressures. Failed to document correct times and dates in the patients medical record.
C. ensure there was nursing documentation on how the patient tolerated the insulin, vital signs, if there were s/sx of hyperglycemia, duration of pain, or if any interventions were given to relieve the pain.
D. ensure the patients was given safety equipment in the shower to prevent falls.

A review of the records of patients #10 through #22 revealed, multiple forms titled, "Daily Nursing Flow Sheet". The forms contained multiple assessment check boxes related to the patient's psychosocial state. The form contained a small area for documentation of the patient's physical/medical issues that covered wound care and elimination assessment only. The bottom of the form contained an area for pain assessment but, did not cover any nursing interventions or patient response.
A review of the Texas Nurse Practice Act revealed the following statement:
"The RN takes responsibility and accepts accountability for practicing within the legal scope of practice and is prepared to work in all health care settings, and may engage in independent nursing practice without supervision by another health care provider. The RN, with a focus on patient safety, is required to function within the parameters of the legal scope of practice and in accordance with the federal, state, and local laws; rules and regulations; and policies, procedures and guidelines of the employing health care institution or practice setting. The RN is responsible for providing safe, compassionate, and comprehensive nursing care to patients and their families with complex healthcare needs."
A review of the facility's policy titled, "Assessment and Reassessment of Patients" revealed the following information:
"SCOPE: All RNs on all nursing units.
PURPOSE: To utilize the Nursing Process and assess all patient at a minimum of every shift and document findings.
DEFINITION: The Admission Nursing Assessment is done to discover medical problems, psychosocial problems, and functional levels from which to gauge improvement and progression toward a healthier state, or to gauge a decline in health. Reassessments are performed frequently, at a minimum of once every nursing shift in order to determine progress or decline in a given patient."
An interview was conducted on 11/15/2016, with staff #32, the charge RN on the Youth Care Unit (YCU). At the time of the interview, the YCU patient census was 13 and was staffed with 2 RNs and 1 Mental Health Tech (MHT). During the interview, staff #32 revealed the patient assessments and overall care was the charge RN's responsibility and medication administration was assigned to the 2nd nurse, which could be an RN or LVN. Staff #32 was asked to explain how she was able to perform physical assessments and document on 13 patients during a 12 hour shift. Staff #32 stated, "I don't do a full assessment on them. I just talk to them and I can usually tell if there is anything going on with them." Staff #32 further explained that in order to complete her nursing documentation on each patient, she frequently works several hours past her shift end time. Staff #32 was questioned if she was scheduled as the only nurse for the YCU unit at times. Staff #32 responded, "yes, I usually am the only nurse here", (on the YCU unit).


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1.) Patient #1 was admitted to the facility on 9/26/16 with a diagnosis of depression, Hypertension, and insulin dependent Diabetes. Review of the Initial Nursing Assessment dated 9/26/16 revealed the patient was admitted but there was no time documented on the nursing assessment. Review of the admitting physician order dated 9/26/16 revealed a time of 1645 (4:45PM) as official admission time.

Review of the narrative nursing admission note revealed a date of 9/27/16 with no time. The nursing assessment revealed patient #1 was given insulin during the admission at 10:50PM. However the patient was admitted on 9/26/16. Review of the Admissions 15 Minute Safety Check Sheet revealed the patient was monitored in admissions from 1645- 2345. Review of patient #1's chart revealed there was no clarification of when the patient arrived on the unit or why the patient was in admissions for 7 hours.

Review of the nursing admission note dated 9/27/16 (no time documented) revealed the patient had an elevated blood sugar of "415" in admissions and was given 8 units of regular insulin. There was no nursing documentation that the physician was notified. A telephone physician order was found dated 9/26 at 2250 (10:50PM) to administer Humulin R 8 units x1 now for BS greater than 400. Review of the MAR revealed the patient received 8 units of Humulin R on 9/26/16 at 2310 (11:10PM) for a blood sugar of "417." There was no further information on how the patient tolerated the insulin, vital signs, if there were s/sx of hyperglycemia, or any nursing interventions.

Review of the Nursing Admission note dated 9/27/16 (no time documented) revealed once on the unit patient #1 had a blood sugar of 351 and was given 5 units of regular insulin. Review of the physician orders revealed a telephone order for Humulin R 5 units now for BS of 315 and before meals. The MAR revealed patient #1 received 5 units sq. now on 9/27/16 at 2:00AM. There was no further documentation on the patient until 9/27/16 at 7:50AM. There was no assessment or blood sugar documented after the 2:00AM dose; 6 hours later.

Review of patient #1's Nursing Flow Sheet dated 9/27/16 at 7:50AM revealed the patient was having "back pain 8/10 due to herniated disk. HTN monitored with v/s 99% 02 sat. 192/91, 97.9, 71, 18 medications as ordered. 0950 blood pressure rechecked with reading of 152/69. Will continue to monitor." There was no documentation that the physician was made aware of the elevated blood pressure of 192/91 or his pain level of 8 out of 10 (10 being the worst pain.) Review of the MAR for 9/27/16 revealed the patient was not given any PRN medication for pain. Patient #1 was not administered his blood pressure medications until 9:00AM; one hour after elevated blood pressure noted. There was no further documentation on pain or blood pressure until 9/28/16 at 8:00AM.

Review of the patients daily nursing flow sheet on 9/29/16 7:00AM-7:00PM revealed the nurse never signed the note. The nurse put in the narrative note that the patient's pain level was 8 out of 10 on the pain scale. The pain scale on the flow sheet was left blank. There was no further information documented on the duration of pain or if any interventions were given to relieve the pain.

Review of patient #1's chart revealed he had complained to the nursing staff on 9/30/16 of a fall in the shower and increased back pain. On 9/30/16 1615 (4:15PM) the nurse documented, "Pt reports he told staff all day he had fallen in shower went to room to examine. When questioned why he had not informed me or med nurse he stated he had. When I explained he had not reported to me he explained, "he had told somebody and the state too!" he told me he had hurt his back trying not to fall. Upon assessment, no bruising, swelling, or abrasion is noted. Pt ambulated to room and meals without a limp or (illegible word), or painful gait. Pt is demanding to go to ER. MD contacted and report given. MD recommended med consult in AM. Pt informed and became angry stating his needs were not being met."(SIC) MD was called and the patient was sent to ER for further care on 9/30/16 at 1745 (5:45PM).

Patient #1 was seen in the ER and returned to the facility on 9/30/16 with a diagnosis of lumbar strain. There was no nursing documentation of any nursing interventions to prevent falls in shower or in the facility until 10/2/16, 2 days after the accident. Review of the nursing flow sheet dated 10/2/16 at 8:00AM patient was "prescribed green leaf fall risk on door, nonskid foot wear." There was no documentation that the patient was given safety equipment in the shower where he was injured initially.

An interview with staff #2 on 11/17/16 revealed an incident report was found on the patients near fall and injury in the shower. Staff #2 stated only a few of the rooms were equipped with safety bars in the showers. Staff #2 stated that she was sure he was in one of those rooms. When asked what room he was in staff #2 was unable to give us the room number. There was no documented proof of what room the patient was in. Staff #1 and #2 confirmed the facility never documents what room the patients are in.

Based on interview and review of record, the facility failed to implement a process of author identification per the facility policy.

Staff # 29 was interviewed on 11-15-2016. Staff #29 denied having staff signatures on file for author identification. When asked how she could verify a signature, Staff #29 stated that the medical records staff reviews the records on a daily basis and knows whose signature is whose.

Review of Glen Oaks Hospital HIM Services Policy Title: Authentication of all Record Entries (Signature Cards) revealed the hospital's policy was:

" I. Policy:
To verify authorization of Physicians/Professional Staff entries in the Medical Record

II. Procedure:
All Physicians/Professional Staff will sign a 3" x 5" index card that will be kept in the Medical Records Department in a file box.

The Medical Records Director will obtain a signature card on all staff members during orientation and the Medical Staff Coordinator will obtain signature cards from Physicians and Professional Staff. "

Based on observation and interview, the facility failed to store patient supplies and belongings in a manner that reduces the risk for contamination of supplies in 3 out of 3 zones.

On the afternoon of 11-15-16 a facility tour was conducted with Staff #3. A storage area near the facility kitchen was toured. There were patient supplies stored with chemicals, equipment, and maintenance supplies. Shipping boxes were being stored on the concrete floor. Trash was found on the floor. The storage room was also being used as a monitor room for the security cameras.

On the afternoon of 11-17-2016 a facility tour was conducted. The Progressive Care patient laundry room was toured. The patient laundry room contained two washers and two dryers for patient use to wash their own clothes under supervision of the staff. One dryer contained clean and dry patient clothing. The facility was also using the patient laundry room to store dirty linen from the patient beds. The dirty linen was uncovered and overflowing onto the floor. There was a plunger for unclogging drains stored in the patient laundry room inside of a red biohazard bag on the floor between the washer and dryer. A dirty plastic trashcan was sitting on top of a dryer. A bedside commode was being stored under the open counter. Inside the sink was a large open bucket of clothing soap. There was a covered plastic box containing a patient's personal hygiene items (toothbrush, toothpaste, lotion and deodorant) on the counter beside the sink. Next to covered container was an open container that contained an open and partially used roll of toilet paper, an opened full roll of toilet paper, a used comb and hair trimmer with hair stubble on it, and other items. A storage locker was next to the counter and beside the dirty linen that was overflowing. Inside the locker was plastic containers with all of the patients' personal hygiene items.

Interview with Staff #38 was conducted during the tour. Staff #38 stated that patients went into the laundry room to do their laundry. He stated that staff put the soap into the washing machine. He stated that the reason the patient lines were overflowing was because he had 5 patients discharge that morning and didn't have enough room in the containers for all of the lines. He stated it was housekeeping's responsibility to pick the linen up. He stated he had only been working at the facility for four days.

On the afternoon of 11-17-2016 a tour of the Adolescent Unit was made. In the storage area Clean patient supplies were stored with chemicals, office supplies, nursing supplies, recreational supplies and patient belongings. Liquid hand soap and hand sanitizer was stored next to toilet paper and over patient recreational supplies representing a contamination hazard. Bleach wipes were stored next to paper towels. Liquid items stored over paper scrubs for patient use. Patient belongings were stored on top of the patient belongings lockers next to recreational items. Patient belongings were piled up on top of recreational items.

An interview with Staff #3 was conducted later in the day on 11-17-16 about the findings on the Progressive Care and Adolescent Units. Staff #3 stated that linen was supposed to be contained in a blue plastic bag and removed from the container when the container became full. Staff #3 stated that nursing staff was supposed to contact housekeeping to remove the linens in a situation where nursing staff had to change out blue bags. Staff #3 did not know why nursing staff had not contained the linens and contacted housekeeping. Staff #3 stated he was aware that liquids and chemicals should be stored separately from other supplies and was not aware of the storage problems on the Adolescent Unit as he had only recently been promoted to his current position.

Based on review and interview, the facility failed to;

A. ensure infection control problems were identified and reported to hospital leadership, medical staff, and governing body. The facility failed to identify infection control issues found in the facility, develop corrective actions, and implement those actions.

Refer to Tag A0756




Based on observation the facility failed to provide sanitary conditions in area's of the kitchen, maintenance, and patient medical supplies storage area.

During a tour of the facility on 11/16/16 the following items were found in the kitchen;
1.) Card board shipping boxes were found in the kitchen next to food products and serving pieces.
2.) Cardboard shipping boxes were found in the coolers and freezers.
3.) Mold and mildew was found in the main ice machine in the kitchen
4.) large trash cans in the kitchen were rolled out of the clean area of the kitchen through the hallways, and onto the loading docks to remove trash. The trash cans were then rolled back into the clean kitchen area. #8 carboard shipping boxes were found in the food supply room of the kitchen.
5.) Shipping boxes in the kitchen freezer.
6.) The large mixer was soiled and rusted.
7.) 10 Pans were found stacked wet.

Outside grounds and maintenance area;
8.) The outside dumpsters were found open with trash hanging out.
9.) large water bottles were found in a outside storage unit. The bottles were dirty and dusty with no dates. The safety office was not sure if that was the emergency water or not.
10.) A large tub of standing green water was found next to the dumpsters and between the storage sheds.
11.) Rolls of wet insulation was found on the ground.
12.) A large tub of standing green water was found next to the dumpsters and between the storage sheds.
13.) Old plastic chairs were stacked out by the loading dock with green water and debris found in the seats.

Patient clean supplies storage area;
14.) Cleaning supplies and patient supplies sitting on dirty dock.
15.) The storage room for clean patient supplies had a rolling cart that was taken out of the room daily, O2 cylinders that went in and out of patient rooms, Video equipment, tools, and cardboard shipping boxes boxes, old broken frames and glass. The room was dusty and the floors were soiled with heavy dust and debris.






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An interview was conducted with Staff #5 on the afternoon of 11-15-2016. Staff #5 stated she had only been the Infection Control Preventionist for about a month. Staff #5 stated she had joined the Association for Practitioners in Infection Control (APIC) organization as a member. She stated she had not attended any APIC training classes up to this point. She stated she is being trained by the previous Infection Control Preventionist.

Review of the Position Description for the Infection Control Preventionist revealed the experience required for the position was listed as follows, "A minimum of three (3) years experience as a registered nurse in a Psychiatric health-care facility preferred with at least one (1) year direct infection control experience."

Review of Staff #5's personnel file revealed she had less than two years total nursing experience without any direct infection control experience.

Based on review of the Quality Assessment Performance Improvement (QAPI) data and interview, the facility failed to ensure that infection control problems were identified and reported to hospital leadership, medical staff, and governing body. The facility failed to identify infection control issues found in the facility, develop corrective actions, and implement those actions.


Review of the Quality Assessment Performance Improvement (QAPI) presented to the Hospital Quality Council Meeting dated October 20th 2016 revealed the Departmental PI Reports for Infection Control was "Deferred to MEC October 27 2016." There was no further mention of infection control to the Quality Council.


Review of the Medical Executive Committee (MEC) meeting minutes dated October 20, 2016 revealed there was no data or mention of infection control in the meeting minutes.


Review of the Medical Executive Committee (MEC) meeting minutes dated October 20, 2016 revealed total infections and number of acquired infections was the only thing reported. There was an action for infection control nurse to conduct weekly rounds. There was no measurable PI process found for infection control.


An interview was conducted with staff #2 11/17/16. Staff #2 reported that she had not been doing infection control and that job had been turned over to staff #5. Staff #2 reported that staff #5 was new in her position and staff #2 would need to assist staff #5 with the QAPI data. Staff #2 could not provide the surveyor with any further infection control QAPI.