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OPTIONS BEHAVIORAL HEALTH SYSTEM 5602 CAITO DRIVE INDIANAPOLIS, IN 46226 May 5, 2014
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on policy and procedure review, staffing form review, and staff interview, the nurse manager failed to implement the facility staffing policy, regarding a minimum number of staff present regardless of census, on 2 of 3 units (adult and child/adolescent units).

Findings:
1. Review of the policy "Staffing Patterns", policy number NR 10.17, with a review date of 1/23/14, indicated:
a. under "Procedure", it reads: "...5. A minimum of two staff will be used at all times, regardless of census."

2. Review of four weeks' staffing for February, 2014 indicated:
a. on the adult unit (unit #4):
A. there was 0.5 FTE (full time equivalent) RN (registered nurse) on the night shift for the four weeks
B. there was only 1 CNA/MHT (certified nursing assistant/mental health tech) scheduled on 2/2/14 (census 3), 2/3/14 (census 4), 2/11/14 (census 8), 2/24/14 (census 7), 2/27/14 (census 5), 2/28/14 (census 2), and 3/1/14 (census 2) on the night shift
b. on the child/adolescent unit (unit #5)
A. there was 0.5 FTE (full time equivalent) RN (registered nurse) on the night shift for the four weeks
B. there was only 1 CNA/MHT scheduled for 21 of 28 days on the night shift with the census between 4 and 12, 12 being highest.

3. Interview with staff member #62, the director of nursing, at 5:00 PM on 5/5/14, indicated:
a. the RNs supervise the LPNs on the floor above (in the PRTF = psychiatric treatment facility) and could be called up to that unit for a restraint event, for observation, or for a one hour face to face evaluation--this can make the first floor nursing units even shorter staffed
b. the CNA/MHTs noted as present on the "evening" shift portion of the staffing forms, work a 3 to 11:30 PM shift, which would leave less staff between 11:30 PM and 7:00 AM, and not meet facility policy staffing levels
c. with one RN shared on the night shift between the adult and child units, the staffing does not meet the policy requiring a minimum of two staff per unit regardless of census
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on policy and procedure review, medical record review, and interview, the nurse executive failed to ensure that nursing staff evaluated patients, per the "Fall Precaution" policy regarding fall assessment after a fall occurs, for 2 of 2 patients who experienced a fall (pts. #1 and #3).

Findings:
1. Review of the policy and procedure "Fall Precaution", policy number NR 10.9, with a last review date of "1-24-2014", indicated:
a. on page one, under "Policy", it reads: "...In the event of a fall occurrence,...the patient will be re-assessed every day until the patient scores below 6 on the fall assessment..."
b. under "Procedure", on page two in item 6., it reads: "Re-assessment after a Fall - Charge RN (registered nurse) / Primary RN:...Re-Assess fall risk every day..."

2. Review of patient medical records indicated:
a. pt. #1:
A. had falls on the following days: 2/14/14 at 2:00 AM when the bed alarm sounded and the patient was found "sitting on the floor"; 2/17/14 at at 11:50 PM where a "dime sized" skin tear was noted on the patient's right elbow--vital signs were "stable" and the patient was sent to a local ED (emergency department) for a thorough evaluation with no injuries found; 2/19/14 at 7:00 PM when the patient "slid out of chair"--vital signs were stable and there were "no signs of distress"; and on 2/22/14 at 5:00 PM and 11:20 PM
B. had completed "Fall Assessment" forms on 2/17/14 at 12:15 AM in which the patient scored at 24; on 2/22/14 at 11:45 PM where the patient scored a 23; and one with no date or time of completion in which the patient scored at 26
C. lacked completion of the form "Fall Assessment" for each day beginning after the first fall of 2/14/14, as required per facility policy (discharge was on 3/10/14 so that at least 20 days of assessment were missing)

b. pt. #3:
A. had a fall on 2/2/14 at 10:00 PM where the patient was found in their room "on hands and knees" by their bed; and on 2/3/14 at 9:30 AM when the patient fell forward from a chair with a bruise and hematoma on the forehead--the patient was seen in a local ED for a CT (computed tomography) of the head--no abnormalities were noted and the patient returned to this facility with final discharge on 2/9/14
B. had two "Fall Assessment" forms completed on 2/3/14 (no times noted) with the patient scoring 25 and 27
C. lacked the completion of the form "Fall Assessment" for each day after the falls of 2/2/14 and 2/3/14 until their discharge on 2/9/14, as required per facility policy

3. Interview with staff member #50, the director of performance improvement and risk, at 4:00 PM on 5/5/14, indicated:
a. only 3 "Fall Assessment" forms can be found for pt. #1 and the chart is lacking one for each day after the first fall on 2/14/14
b. pt. #3 has only 2 "Fall Assessment" forms and is lacking one for each day after the falls of 2/2/14 and 2/3/14, as per facility policy
c. nursing failed to follow the "Fall Precaution" policy for pts. #1 and #3 related to the completion, each day after a fall, of the "Fall Assessment" form until a score of 6 or less is achieved
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on medical record review and interview, the facility failed to ensure that physician orders were implemented by nursing staff, as per standards of practice, for one patient (pt. #1).

Findings:
1. Review of patient medical records indicated that pt. #1:
a. had an admission order on 2/9/14 for Sinemet Enta 200 mg one tab qid (four times/day)
b. had documentation on the MAR (medication administration record) that this was given at 8 AM,
12 PM, and 4 PM on 2/9/14 (Not documented as given at 8 PM)
c. had an order written at 1:30 PM on 2/9/14 for Sinemet 25/250 mg qid
d. had Sinemet 25/250 on the MAR for a 4 PM and 8 PM dose for 2/9/14 with no documentation by nursing that this was given, refused, or held
e. lacked documentation of being administered the Sinemet 25/250 on 2/10/14 and 2/11/14 for the qid doses (the Sinemet Enta 20 mg one tab orally qid was not noted as discontinued on the MAR)
f. at 12:40 PM on 2/11/14, had the Sinemet 25/250 order changed to tid (three times/day) from qid (but as stated in e., no Sinemet was documented as being administered on 2/11/14)
g. had on the MARs, on 2/12/14, a notation that the patient was given Sinemet 25/250 at 8 AM, 12 PM, and 4 PM and was also given Sinemet 25/100 two tabs at 8 AM with the 4 PM dose not marked and 8 PM dose circled as not given (Sinemet 25/100 was not ordered until 2/18/14)
h. had Sinemet 25/100 given tid on 2/13/14, 2/14/14, and 2/15/14 with no order for this dosage written (should have still been on Sinemet 25/250 as Sinemet 25/100 was not ordered until 2/18/14 a 4:54 PM-as stated in g. above)
i. had no Sinemet documented as administered on 2/21/14 for the 12 PM and 4 PM doses
j. had no documentation with the 4 PM dose on 2/24/14 that the medication was given and the 12 PM does on 2/28/14 was scribbled out with no explanation whether it was given, held, or refused
k. had an order at 9:30 AM on 3/3/14 to "hold all meds", but Sinemet was given at 12 PM and 4 PM and given again on 3/4/14 at 8 AM, 12 PM, and 4 PM until an order was written specifically to stop the Sinemt, Risperdal and Depakote

2. Interview with staff member #62, the director of nursing, at 5:00 PM on 5/5/14, indicated:
a. it is unclear why there is no documentation for pt. #1 related to the administration of the Sinemet ordered qid as the patient was noted by nursing staff as being "compliant with medications" (on 2/9/14, 2/11/14, 2/21/14, and 2/24/14 when nursing failed to indicate on the MAR that the medication was given, held, refused, etc.)
b. this staff member is "confused" regarding Sinemet orders being duplicative and the lack of nursing documentation as to whether Sinemet was "held, refused, omitted" or some other reason it was not noted as being administered as per physician orders
c. this staff member does not know why the Sinemet dosages were duplicative on the MARs
d. it is not known why nursing failed to complete the MAR per physician orders
e. it does not appear that the patient received Sinemet as per physician orders while a patient at the facility

3. Interview with staff member #50, the director of performance improvement and risk, and #62, the director of nursing, at 5:55 PM on 5/5/14, indicated:
a. the facility has no policy requiring nursing staff to follow/implement physician orders, however, this is a standard of nursing practice, and expected at this facility
b. the facility has no policy related to how to create, make changes to, or document on the MAR
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observation and interview, the facility failed to ensure the safety and well being of patients, related to patient call lights, in 3 of 3 rooms with call lights (rooms 312, 313, and 315).

Findings:
1. At 10:15 AM and 4:55 PM on 5/5/14, while on tour of the geriatric unit (unit #6), in the company of staff member #50, the director of performance improvement and risk, it was observed that the patient call lights in rooms 312, 313 and 315 (two call lights/room for two beds/room) did not light up in the hallway and had a very low level of sounding, making it difficult, or impossible, for staff to know that patients needed assistance. There were no patients assigned to rooms 312, 313 and 315 on 5/5/14.

2. Interview with staff member #50 at 5:40 PM on 5/5/14, indicated:
a. the call lights are new in the last few weeks/months
b. it was unknown that the call lights were malfunctioning