The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

NORTHLAKE BEHAVIORAL HEALTH SYSTEM 23515 HIGHWAY 190 MANDEVILLE, LA May 23, 2013
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on records review and interviews, the hospital failed to ensure that each patient was free from all forms of abuse. The hospital failed to ensure its abuse policy required an employee with an allegation of patient abuse to be removed immediately from providing direct patient care. This resulted in S19MHT being observed on 05/07/13 by S10RN to have pushed Patient #8. S19MHT was not removed from patient care duties until 05/09/13 when the allegation was confirmed by viewing the video recording of the incident.

Findings:

Review of the hospital policy titled "Abuse/Neglect of Patients/reporting Allegations", policy number RI-0800, effective 01/02/13, and presented as a current policy by S12Director of Risk Management and P.I. (performance improvement), revealed that physical abuse consisted of physical contact such as hitting, slapping, pinching, choking, scratching, pushing, twisting of head, arms, or legs, or tripping.

Further review revealed that the Unit Charge Nurse would contact the RN Supervisor by telephone immediately or no later than one hour after discovery of the incident. The accused staff member was to be reassigned to protect the patient from retaliation and the employee from further allegations. If the allegation warranted no clinical contact, the policy stated that the employee may be sent home after conferring with the CEO (Chief Executive Officer).

Further review revealed an e-mail notification of reassignment would be sent to the DON (director of nursing), CEO, other RNs, and the CRO (patient rights officer).

Further review of the policy revealed that during an investigation of any allegation of abuse or neglect, the accused is removed from the unit to prevent further patient abuse.

Further review revealed that it was the responsibility of the CEO to assure that the appropriate corrective, remedial, or disciplinary action occurred. There was no documented evidence that the policy required the alleged abuser to be removed immediately from direct patient contact while the investigation took place.

Review of the "Client Incident, Injury And Data Reporting Form" signed by S10RN on 05/08/13 revealed that the incident occurred on 05/07/13 at 6:00 p.m., and the incident was discovered on 05/08/13 (S10RN witnessed the incident on 05/07/13). Further review revealed that S10RN documented that Patient #8 was being escorted to his bedroom by S19MHT secondary to challenging behavior and resisting redirection when S10RN saw S19MHT shove Patient #8 in the direction of his room. Further review revealed that there was no injury as a result of this incident.

Review of the "Description of Incident", with no documented evidence of a signature of the author of this report, revealed the following information:

05/08/13 - S10RN reported that on 05/07/13 between 6:00 p.m. and 6:30 p.m. on Unit 1, Patient #8 was being escorted to his bedroom by S19MHT secondary to challenging behavior and resisting redirection; while being escorted S19MHT shoved Patient #8 in the direction of his room; no injury occurred;

Upon receiving this report S11Patient Rights Officer and S5RN reassigned S19MHT to Unit 3 pending the outcome of the investigation;

05/08/13 at 5:30 p.m. - S11Patient Rights Officer interviewed S10RN who stated that after she witnessed S19MHT shove Patient #8, S10RN verbally counseled S19MHT regarding his inappropriate behavior;

05/08/13 at 5:50 p.m. - S11Patient Rights Officer interviewed Patient #8 on Unit 1. Patient #8 he stated that he was scared of S19MHT because S19MHT was standing very close to him and "invaded my personal space." Patient #8 stated that S19MHT was talking to him and denied that S19MHT had pushed him;

05/08/13 at 6:15 p.m. - S11Patient Rights Officer interviewed S19MHT who provided the following statement: "During the hour of 6:00 p.m. to 6:30 p.m., Patient #8 was in the shower room. He came to the door 3 times to ask staff to come see the shower drain. 2 times he came to the door with no clothes on. The 3rd time, he had a towel around his body. Staff asked him to put clothes on as well as gave him a directive (Sex 1). Staff told Patient #8 to put his clothes on cause it was time to get out. Patient #8 was in the shower 40+ minutes. After he came out, he was escorted to his room by S19MHT while in there, staff explained to him that he could not do that and it was inappropriate. No further problems throughout the rest of the night.";

05/08/13 at 6:35 p.m. - S11Patient Rights Officer interviewed S7MHT who was assigned to Unit 1 on 05/07/13. S7MHT stated that Patient #8 came out the shower several times without clothes on and received a Sex 1 restriction. She stated that S19MHT directed Patient #8 to go to his room and placed his hand on Patient #8's shoulder and escorted him in the room. S7MHT denied that S19MHT pushed Patient #8.

Review of "Additional Information" revealed that S11Patient Rights Officer was unable to view video footage on 05/08/13. S11Patient Rights Officer was able to obtain the video of the incident on 05/09/13 which showed that at 6:25 p.m. on 05/07/13 Patient #8 exited the shower and was walking around the unit.

Further observation of the video by S11Patient Rights Officer revealed that Patient #8 entered another patient's room, and staff appeared to talk to Patient #8 at which time Patient #8 began walking in the direction of his bedroom.

Further observation by S11Patient Rights Officer revealed that S19MHT followed behind Patient #8, and S19MHT pushed Patient #8 toward his bedroom, then grabbed his shoulder and clothing to further bring him toward his bedroom.

Further observation of the video by S11Patient Rights Officer revealed when Patient #8 and S19MHT reached Patient #8's bedroom, S19MHT is seen pushing Patient #8 into the room.

Further review of the "Additional Information" revealed that after viewing the video, S11Patient Rights Officer notified S3DON who met with S19MHT and provided him written notification of his suspension pending full investigation.

Review of "Conclusion and Action Plans" revealed no documented evidence of a conclusion or action plans.

Review of the "Corrective Action Form" dated 05/09/13 and signed by S10RN and S5RN revealed that S10RN was informed that she should have reported the incident related to Patient #8 and S19MHT at the time of the occurrence. Further review revealed "Additional Counseling/Training Needed" was checked as "Yes", and review of policy was the recommended training.

Review of the "Corrective Action Form" for S19MHT, with no documented evidence of a signature by S19MHT, his supervisor, or Witness/Human Resources, revealed the following typed statements: "You are being placed on suspension pending further investigation of physical abuse of a client. It was witnessed by a staff member and verified by video camera that you pushed a client. You are being placed on suspension pending full investigation. You will be notified when to return to work."

In a face-to-face interview on 05/22/13 at 11:20 p.m., S11Patient Rights Officer confirmed that she had documented the "Description of Incident". She indicated S19MHT remained suspended as of the day of this interview. She further indicated S2Administrator, S3DON, and Human Resources were meeting and were leaning toward terminating S19MHT. She further indicated the allegation of abuse was substantiated. When asked about S19MHT being reassigned to Unit 3 and not removed from contact with patients, S11Patient Rights Officer indicated she found out about the allegation of abuse the day after it had occurred, and she wanted to interview S10RN, Patient #8, and S19MHT. She further indicated the hospital always reassigned to another patient unit, because it was an allegation, and it was an unclear allegation at that point.

In a face-to-face interview on 05/23/13 at 4:45 p.m., S2Administrator indicated it was just paperwork that needed completion before terminating S19MHT. He further indicated the decision to terminate had been made, and they were waiting for their legal department to approve the termination. When informed that the hospital policy allowed for an employee accused of patient abuse to be transferred to another patient unit, S2Administrator indicated S19MHT should have been removed immediately. He did not explain why the hospital's policy did not require that the alleged perpetrator of abuse be removed immediately from direct patient care.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observations, records review, and interviews, the hospital failed to meet the requirements of the Condition of participation for Nursing Services as evidenced by:

1a) Failing to ensure that an RN (Registered Nurse) was assigned to each unit of the DNP (Developmental Neuropsychiatric Program) and was immediately available to provide nursing care to all patients as needed. This failed practice was evidenced by having one RN assigned to cover Unit 1 and Unit 2 of the DNP that was divided into 2 distinct sides with 3 locked passageways between the 2 sides for 125 of 129 shifts from 03/15/13 to 04/04/13 and 04/29/13 to (with observation on) 05/20/13.

1b) Failing to ensure the staff-to-patient ratio for MHTs was maintained in accordance with hospital policy as evidenced by MHTs (mental health tech) being assigned more than 5 patients on the day, evening, or night shift for 42 shifts from 03/15/13 through 05/15/13 and by current observation on 05/20/13 at 9:45 p.m. The hospital's policy for staff-to-patient ratio was 1 staff to 4 patients with the ability to increase to 5 patients.
(see findings in tag A0392)

2) Failing to ensure that an RN supervised and evaluated each patient's care needs and provided a safe environment for patients and staff. The RN failed to assess patients prior to and after incidents involving patient-to-patient altercations, patient-to-staff aggression, and damage to hospital property by patients and after reports by the MHT (mental health tech) of potential patient injury. This failed practice was evidenced by 40 reported incidents on the DNP unit for the months of March, April and May 2013 involving 7 of 10 sampled patients whose medical records were reviewed from a total DNP unit census of 15 (#1, #2, #5, #6, #7, #8, #10) (see findings in tag A0395).
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observations, records review, and interviews the hospital failed to:

1) Ensure than an RN (Registered Nurse) was assigned to each unit of the DNP (Developmental Neuropsychiatric Program) and was immediately available to provide nursing care to all patients as needed. This failed practice was evidenced by having one RN assigned to cover Unit 1 and Unit 2 of the DNP that was divided into 2 distinct sides with 3 locked passageways between the 2 sides for 125 of 129 shifts from 03/15/13 to 04/04/13 and 04/29/13 to (with observation on) 05/20/13 and

2) Ensure the staff-to-patient ratio for MHTs was maintained in accordance with hospital policy as evidenced by MHTs (mental health tech) being assigned more than 5 patients on the day, evening, or night shift for 42 shifts from 03/15/13 through 05/15/13 and by current observation on 05/20/13 at 9:45 p.m. The hospital's policy for staff-to-patient ratio was 1 staff to 4 patients with the ability to increase to 5 patients.

Findings:

1) Ensure than an RN was assigned to each unit of the DNP and was immediately available to provide nursing care to all patients as needed:

Review of the hospital policy titled "Nursing Staffing Plan", policy number NS-1005, effective 01/02/13, and presented as a current policy by S12Director of Risk Management and P.I. (performance improvement), revealed that staffing ratios were established to determine the required number of staff for shift coverage on each Unit. Further review revealed that the staffing ratios were based on the population served, the level of care (acute or intermediate), and the geography of the unit, such as distance between units, location of the nurses' station, and visibility of the patient care areas. Basic coverage included a RN charge nurse, and the allotted number of staff was based on established ratios outlined in the staffing calculation table. The nurse could be included in the ratio, and staff in orientation were not included in the ratio. Further review of the policy revealed that a RN must be assigned to each unit. Review of the attached "Nursing Service Department" DNP/Adolescent Mix ratio included basic coverage for the Units were 1 RN on Unit 1 and 2 on the day shift (7:00 a.m. to 7:00 p.m.) and 1 RN on Unit 1 and Unit 2 on the night shift (7:00 p.m. to 7:00 a.m.).

Review of the nurse staffing pattern presented by S3DON for 03/15/13 to 04/04/13 (12 patients between the 2 units except when some patients were on pass) and 04/29/13 to 05/20/13 (14 to 15 patients between the 2 units except when some patients were on pass) revealed 1 RN was assigned to Unit 1 and Unit 2 for all shifts except for the following days:
05/06/13 - 2 RNs on day shift and 1.5 RNs on evening shift;
05/09/13 - 2 RNs on day shift and 1.5 RNs on evening shift;
05/10/13 - 2 RNs on day shift and 1.5 RNs on evening shift;
05/19/13 - 2 RNs on day shift and 1.5 RNs on evening shift.

Observation on Unit 1 and Unit 2 on 05/20/13 at 9:50 p.m. revealed there was a wall dividing Unit 1 and Unit 2 with 3 locked doors that allowed entrance from one unit to the other. Further observation while in Unit 1, when facing the wall that divided the two units revealed the following entrances:

Locked door to the left (nearest the locked door leading from the outside hall of Unit 1) of the medication room - entry to a passageway between Unit 1 and Unit2;

Center locked door - entry to the medication room that contained medications for patients on Unit 1 and Unit 2;

Locked door to the right of the medication room - entry to the nourishment room that was used by both Units 1 and 2.

On 05/20/13 between 9:45 p.m and 11:30 p.m observations were made on Unit 2. On entering Unit 2 at 9:45 p.m. on 05/20/13, two staff personnel identified themselves as S7MHT and S8MHT and indicated they were assigned to Unit 2. Both MHTs (mental health tech) were continuously observed on Unit 2 until they were relieved by 2 other MHTs at 11:15 p.m. There were no other staff present on Unit 2 from 9:45 p.m. to 10:20 p.m. 8 patients were observed to be laying in their beds in their room with the doors open. The 2 MHTs were observed monitoring the patients and attending to patient needs during this time frame. At 10:20 p.m., S5RN entered Unit 2 and identified himself as the RN charge nurse for Units 1 and 2. He entered Unit 2 by unlocking the locked door to the passageway between Units 1 and 2. S5RN was observed talking to the MHTs on Unit 2 for 10 minutes and left Unit 2 at 10:30 p.m. through the locked passageway and S5RN did not return to Unit 2 again until 11:15 p.m.

On 05/20/13 at 10:00 p.m., an interview was conducted with S7MHT. She indicated there were presently 8 patients on Unit 2 and indicated she was assigned to 4 of the patients and S8MHT was assigned to the other 4 patients. She indicated the MHTs are to check patients every 15 minutes on their shift and document patient activity on the observation sheets and take care of patients' needs. S7MHT was asked who was the RN charge nurse for the shift. She indicated that S5RN was the charge nurse. She indicated that he was on Unit 1 of the DNP since there were 7 patients on Unit 1 and there was only 1 MHT present on that side this shift. She further indicated that the nurse had to be counted in the 1:4 staff-to-patient ratio. S7MHT was asked how she contacted the RN charge nurse when help was needed with patients. She indicated they would have to go through the locked passageway between the 2 sides and call for the RN. She indicated that when patients went to bed at 9:00 p.m., Unit 2 became more quiet. She indicated that the hours between 3:00 p.m. and 9:00 p.m could sometimes be a problem because patients are awake and they often require extra assistance with patient aggression-type problems.

Observation of Unit 1 on 05/20/13 at 9:50 p.m. revealed S5RN, S6LPN (licensed practical nurse), and S4MHT were present.

In a face-to-face interview on 05/20/13 at 9:50 p.m., S5RN indicated that he was the RN Manager of DNP and Youth Services and was filling in as the RN on Units 1 and 2 from 6:45 a.m. to 3:00 p.m. and from 7:00 p.m. to 11:00 p.m. on 05/20/13. He further indicated S6LPN worked on the adult acute unit but was "loaned here" on 05/19/13 and 05/20/13 to give medications to patients on Units 1 and 2. S5RN confirmed that he was the RN assigned to both Units 1 and 2. He further indicated S4MHT was assigned to Unit 1, and S7MHT and S8MHT were assigned to Unit 2. He indicated there were 7 patients on Unit 1 and 8 patients on Unit 2. S5RN indicated there were 2 MHTs assigned to Unit 2, because the staffing ratio was 1:4. He did not explain why only 1 MHT was assigned to Unit 1 when Unit 1 had 7 patients.

In a face-to-face interview on 05/20/13 at 10:05 p.m., S4MHT indicated that she was usually assigned to Unit 1. She further indicated that when the RN was on Unit 2, she was alone on Unit 1 with the patients. When asked how often this happens, S4MHT indicated "we need more staff" (would never answer how often it happened after being asked several times). She further indicated that it could get out of hand with a group of boys yelling and altercations between peers happen. She indicated that when this happened, she would call for help on the intercom, and people from other units would come. When asked how long it could take for help to arrive, S4MHT answered "a couple of minutes".

Observation on 05/20/13 at 10:10 p.m., while on Unit 1 revealed S5RN and S4MHT were in the storage room of Unit 1 and S6LPN was in the medication room. There was no RN present on Unit 2 at this time.

Observation on 05/20/13 at 10:40 p.m. on Unit 1 revealed S5RN left Unit 1 and entered Unit 2 to get the oncoming MHTs to go off the unit for report. This left no RN on Unit1 or Unit 2.

Observation on 05/20/13 at 11:20 p.m. while on Unit 1 revealed S3DON (director of nursing) and S5RN arrived on Unit 1. Continuous observation from 10:40 p.m. to 11:20 p.m. on Unit 1 revealed that there was no RN on Unit 1 for 40 minutes.

Observation on Unit 1 on 05/21/13 at 9:15 a.m. with S9Executive Director of DNP present revealed 7 patients in the day room with 3 MHTs present. Further observation revealed there was no RN present during this observation.

In a face-to-face interview on 05/21/13 at 9:15 a.m., S9Executive Director of DNP confirmed there was no RN present on Unit 1 during the time of this interview.

In a face-to-face interview on 05/21/13 at 9:28 a.m., S10RN indicated that there was not always an RN on Unit 1 and Unit 2 at the same time (meaning 1 RN was scheduled for Unit 1 and Unit 2).

In a face-to-face interview on 05/21/13 at 4:15 p.m., S3DON indicated that they have always viewed Unit 1 and Unit 2 as one unit and had 1 RN scheduled to cover both units. She further indicated that the staffing ratio on days and evenings was 1 MHT to 4 patients and on nights 1 MHT to 5 patients. S3DON indicated the staffing grid did not break Unit 1 and Unit 2 into 2 units but referred to them as 1 unit. She further indicated the RN could be counted in the ratio and was designated by "*" on the staffing assignment when the RN was included in the ratio.

In a face-to-face interview on 05/23/13 at 8:55 a.m., S10RN indicated that there had been times when patients on both Unit 1 and Unit 2 escalated at the same time, and "I can't be in 2 places at 1 time to de-escalate" patients. She further indicated that there has been a time that she had a crisis on 1 unit, and the MHT from the other unit came to help leaving the other unit with 1 MHT alone with all the patients on that unit.

In a face-to-face interview on 05/23/13 at 10:55 a.m., S15RN indicated that the staffing on Unit 1 and Unit 2 today was 1 RN with 2 MHTs on 1 unit with 6 patients and 1 MHT on the other unit with 8 patients. She further indicated that there had been "a lot of days" with 1 MHT on each unit.

In a face-to-face interview on 05/23/13 at 11:55 a.m., S9Executive Director of DNP and a Psychologist indicated that the DNP was a behavioral program for 12 1/2 to [AGE] year old adolescents who were dually diagnosed with a developmental disability and a psychiatric diagnosis. She further indicated the program had "the worse patients in the state and they were all in one place". She further indicated that last fall they were told the hospital was closing. S9Executive Director of DNP indicated that since they were told they were staying open, the DNP now had an influx of new patients (meaning the patients had not been together as long as in the past and were adjusting to the changes of new patients being admitted ). When asked if 2 MHTs on the unit were enough to handle the volume of patient-to-patient altercations, staff attacks by patients, and property destruction, S9Executive Director of DNP indicated it worked best when the staffing ratio was 1 staff to 2 patients. When asked if she was saying that 1:2 staffing ratio was what was required to address patient needs and safety, she indicated that she didn't think 1:4 ratio was a "bad ratio". When asked about having 1 RN assigned to Unit 1 and Unit 2 who had no psychiatric background, S9Executive Director of DNP indicated she thought it the temperament of the RN was more important than having a background in psychiatric nursing. She further indicated Unit 1 and Unit 2 had always been staffed with 1 RN for both units and felt it was more important to have MHTs on both sides than the RN. S9Executive Director of DNP explained this statement by saying that she viewed the "RN role as more medication management and the MHT as milieu management". She further indicated the psychologists work more closely with the MHTs, because the nurses handle the "medical side" of the patient.

In a face-to-face interview on 05/23/13 at 3:10 p.m., S3DON indicated, when informed of S9Executive Director of DNP's view of the RN and MHT roles on Unit 1 and Unit 2, she told the nurses that they're responsible for everything on the unit as well as the milieu management. She further indicated there have been times that the nurses complained of frustration of not being able to be in 2 places at one time.

2) Ensure the staffing ratio of staff-to-patient was maintained in accordance with hospital policy as evidenced by MHTs being assigned more than 5 patients on the day, evening, or night shift:

Review of the hospital policy titled "Nursing Staffing Plan", policy number NS-1005, effective 01/02/13, and presented as a current policy by S12Director of Risk Management and P.I., revealed that staffing ratios were established to determine the required number of staff for shift coverage on each Unit.

Further review revealed that the staffing ratios were based on the population served, the level of care (acute or intermediate), and the geographics of the unit, such as distance between units, location of the nurses' station, and visibility of the patient care areas. Basic coverage included a RN charge nurse, and the allotted number of staff was based on established ratios outlined in the staffing calculation table. The nurse could be included in the ratio, and staff in orientation were not included in the ratio. Review of the attached "Nursing Service Department" DNP/Adolescent Mix ratio included basic coverage for the Units was 1 RN for Unit 1 and 2 on the day shift (7:00 a.m. to 7:00 p.m.) and 1 RN for Unit 1 and Unit 2 on the night shift (7:00 p.m. to 7:00 a.m.). and the staff-to-patient ratio was 1 staff to 4 patients (1:4) on days and may increase to 5 patients (7:00 a.m. to 3:00 p.m.), 1:4 on evenings (3:00 p.m. to 11:00 p.m.) and may increase to 5 patients, and 1:5 on nights (11:00 p.m. to 7:00 a.m.) and may decrease to 4 patients.

Review of the hospital policy titled "Staff Assignments", policy number NS.1065, effective 01/02/13, and presented as a current policy by S12Director of Risk Management and P.I., revealed the purpose of the policy was to assure the accountability and delivery of individualized nursing care in accordance to patient need.

Further review revealed that the RN was responsible for the appropriateness, completeness, and accuracy of the assignment sheet and verified this status by his/her signature. Review of the process revealed that the MHT assigned to the desk would make immediate assignment of high risk patients in order for transfer of assignments to occur. High risk patients included patients in restraint or seclusion, patients on special precautions (visual contact, suicide, seizure, elopement, withdrawal, and so on), and 1-to-1 assignments. Further review revealed the MHT assigned to the desk initiated the assignment sheet, and the RN Charge Nurse must review the assignments for completeness and appropriateness and sign as approving the delegation of these functions.

Review of the staffing assignment sheets presented by S3DON for 03/15/13 to 05/15/13 revealed 42 shifts that the MHT was assigned more than 5 patients to observe, sometimes as many as 8 patients. Further review revealed 21 shifts that the staffing assignment sheet was incomplete, and the MHT-to-patient ratio could not be determined.

Observation of Unit 1 on 05/20/13 at 9:50 p.m. revealed S5RN, S6LPN (licensed practical nurse), and S4MHT were present.

In a face-to-face interview on 05/20/13 at 9:50 p.m., S5RN indicated that he was the RN Manager of DNP and Youth Services and was filling in as the RN for Units 1 and 2 from 6:45 a.m. to 3:00 p.m. and from 7:00 p.m. to 11:00 p.m. on 05/20/13. He further indicated S6LPN worked on the adult acute unit but was "loaned here" on 05/19/13 and 05/20/13 to give medications to patients on Units 1 and 2. S5RN confirmed that he was the RN assigned to both Units 1 and 2. He further indicated that S4MHT was assigned to Unit 1, and S7MHT and S8MHT were assigned to Unit 2. He indicated that there were 7 patients on Unit 1 and 8 patients on Unit 2. S5RN indicated that there were 2 MHTs assigned to Unit 2, because the staffing ratio was 1:4. He did not explain why only 1 MHT was assigned to Unit 1 when Unit 1 had 7 patients.

In a face-to-face interview on 05/20/13 at 10:05 p.m., S4MHT indicated that she was usually assigned to Unit 1. She further indicated that when the RN was on Unit 2, she was alone on Unit 1 with the patients. When asked how often this happens, S4MHT indicated "we need more staff" (would never answer how often it happened after being asked several times). She further indicated that it could get out of hand with a group of boys yelling and altercations between peers happen. She indicated that when this happened, she would call for help on the intercom, and people from other units would come. When asked how long it could take for help to arrive, S4MHT answered "a couple of minutes".

In a face-to-face interview on 05/21/13 at 4:15 p.m., S3DON indicated the MHT-to-patient staffing ratio is 1 MHT to 4 patients on the day and evening shift and 1 MHT to 5 patients on the night shift. She further indicated that the RN could be counted into the ratio but did not explain how the RN who covered both Unit 1 and Unit 2 could be figured into the staffing ratio for both units.

In a face-to-face interview on 05/23/13 at 8:55 a.m., S10RN indicated that there have been times recently when a patient on one side (Unit 1 or Unit 2) had a crisis, and one of the two MHTs from the other side would come to help. She further indicated that when this happens it leaves 1 MHT alone with all the patients on the other side.

In a face-to-face interview on 05/23/13 at 3:25 p.m., S17MHT indicated that Unit 1 and Unit 2 of DNP have been "understaffed for nurses", and she'd been on one of the units with as many as 8 patients as the only MHT and the RN not always present. She further indicated that she had refused to work Unit 1 sometime in March or April until they could send her more help. S17MHT indicated that on the previous weekend only herself and one other MHT were on the schedule to cover Unit 1, Unit 2, and the Girls' unit. She further indicated administration ended up pulling people, but "they just sent warm bodies."

In a face-to-face interview on 05/23/13 at 3:10 p.m., S3DON indicated the staffing assignment sheets were filed in Nursing Administration. When asked about the staffing ratio for MHTs-to-patients being greater than the policy allowed, she indicated she was not aware of the incomplete staffing assignment sheets. She further indicated that the RN Manager and the RN House Supervisor should spot check them, but she should also be reviewing them and had not been doing so. She indicated the staffing ratio was 1 MHT to 4 patients, and the RN could be used as part of the ratio. She offered no explanation for MHTs being assigned as many as 8 patients on Unit 1 and Unit 2.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**







Based on interviews and records review, the hospital failed to ensure that an RN (Registered Nurse) supervised and evaluated each patient's care needs and provided a safe environment for patients and staff.

The RN failed to assess patients prior to and after incidents involving patient-to-patient altercations, patient-to-staff aggression, and damage to hospital property by patients and after reports by the MHT (mental health tech) of potential patient injury. This failed practice was evidenced by 40 reported incidents on the DNP (Developmental Neuropsychiatric Program) unit for the months of March, April and May 2013 involving 7 of 10 sampled patients whose medical records were reviewed from a total DNP unit census of 15 with no documented evidence in the nurses' progress notes of a nursing assessment, evaluation, and patient response to nursing interventions after the incidents (#1, #2, #5, #6, #7, #8, #10).

Findings:

Review of the hospital policy titled "Assessments", policy number PE-0100, revised 04/10/13, and provided as a current policy by S20House Manager, revealed that a client was assessed routinely at least every 96 hours by a physician, social worker, occupational therapist, recreational therapist, mental health tech (MHT), nursing, and other disciplines included in the treatment plan. Further review revealed that additional assessment is conducted when there is a significant change in the client's status, condition, or diagnosis.

Review of the "Client Incident, Injury And Data Reporting Form" for March, April, and May (through 05/19/13) 2013 revealed that there were 13 incidents in March, 13 incidents in April, and 14 incidents in May that involved patient-to-patient altercations, patient-to-staff aggression, and damage to hospital property by patients.

In a face-to-face interview on 05/21/13 at 9:50 a.m. with S10RN and S20House Manager present, S10RN indicated that some discipline is to document in the patient's progress notes daily for the first 60 days for new admits. S20House Manager indicated there could be a day without RN documentation on the chart as long as one of the disciplines documents daily.

Patient #1

Review of Patient #1's medical record revealed that he was a [AGE] year old male admitted on [DATE] with diagnoses of Asperger's Syndrome and Bipolar Affective Disorder. Review of his Psychiatric Evaluation performed on 05/16/13 at 11:30 a.m. by S16Psychiatrist revealed Patient #1 was to receive ward milieu, individual therapy, group therapy, occupational and recreational therapy, family therapy, and a school program.

Review of Patient #1's "Progress Notes" revealed an entry by S17MHT on 05/18/13 at 1:40 p.m. that Patient 31 began pacing with clenched fists when he heard another patient on Unit 1 crying and yelling. Further review revealed that S17MHT asked Patient #1 if everything was o.k., and he "angrily said he can't take the noise anymore." Further review revealed that Patient #1 went into the unlocked seclusion room and paced for about 10 minutes. Review revealed that when S17MHT asked Patient #1 if he felt better when he came out the unlocked seclusion room, Patient #1 answered "Yes". Review of the entire documentation revealed no documented evidence that Patient #1's escalating behavior was reported to an RN. There was no documented evidence of an RN assessment of Patient #1 until 11:00 p.m. on 05/18/13, 9 hours and 20 minutes after his behavior of clenched fists and pacing was observed.

Review of Patient #1's "Progress Notes" revealed an entry by S21MHT on 05/19/13 at 3:28 p.m. that at approximately 1:30 p.m. Patient #10 came from his bedroom and said that Patient 31 was trying to "kill himself and that he was afraid to be alone with him in the room". S21MHT documented that she entered Patient 31's room and found him "laying in bed with blankets pulled tightly around his face with exacerbated breathing. Client was asked what he was doing and if he was trying to harm himself. The client responded 'I am just laying in bed'. He also denied trying to hurt himself". S21MHT documented that this was reported to the nurse with no documented evidence of which nurse received the report. Further review revealed on 05/19/13 at 5:30 p.m., 4 hours after the incident was reported, S14RN documented that she spoke with Patient #1 and asked if he's having suicidal thoughts, and Patient #1 immediately started laughing and smiling, stating "No, I was just trying to get comfortable in the bed".

In a face-to-face interview on 05/23/13 at 10:20 a.m., S14RN indicated she began working at this hospital on [DATE] and had no previous psychiatric experience. She further indicated she called the House Supervisor about 1 hour after the report by S21MHT that Patient #1 was trying to suffocate himself "to ask what to do about the situation". She further indicated she saw Patient #1 walking around the dayroom, but she had not spoken with him about the incident. S14RN then indicated she asked Patient #1 if he was o.k.. When asked which she had done, not spoken to him or asked him if he was o.k., S14RN indicated she really didn't remember. S14RN indicated the House Supervisor told her that she should talk with the patient. When asked about the 4 hour delay, she indicated she's a new psychiatric RN and "guess I should have done it sooner" (meaning the charting). When asked if she felt comfortable on Unit 1, she answered "I'm learning as I go and of course I don't feel comfortable, it's a new job".

In a face-to-face interview on 05/23/13 at 3:25 p.m., S17MHT indicated when she observes a patient with clenched fists and pacing she usually reports the behavior to the nurse. She further indicated she tries to write what she reports to the nurse, but she may not have done so on 05/18/13. S17MHT indicated she usually worked Unit 2 and not Unit 1. She further indicated she was the only core staff between Unit 1 and Unit 2 on 05/18/13. She defined core staff as a full-time person hired for the DNP unit.

Patient #2

Review of Patient #2's medical record revealed that he was a [AGE] year old male admitted on [DATE] with diagnoses of Intermittent Explosive Disorder, Pervasive Developmental Disorder, Mood Disorder, Oppositional Defiant Disorder, and Phonological Disorder. His treatment plan consisted of medication management, ward milieu, individual and group therapy, recreational therapy, school program, and occupational therapy.

Review of Patient #2's progress notes for 03/26/13 at 6:00 p.m. revealed an entry by S22MHT that Patient #2 began spitting at staff, throwing his shoes at staff, cursing and climbing over furniture, trying to break the television, and running around the unit yelling and screaming and trying to open any door that he could open. Further review revealed no documented evidence of an assessment and intervention by the RN.

Review of a "Client Incident, Injury And Data Reporting Form" dated 05/18/13 at 5:08 p.m. revealed Patient #2 scratched 2 nurses on the hand and arm breaking skin and causing bleeding while being put in manual hold and locked seclusion.

Review of the progress notes dated 05/18/13 at 11:30 p.m. revealed a late entry was made for 5:00 p.m. by S23MHT of the following incident: Patient #2 was yelling and screaming upon S23MHT's arrival on Unit 1. Patient #2 began spitting at staff, crawling around on his hands and knees, growling like an animal, attempting to chase staff and grab their feet and ankles, ran into his room and slammed the door and ran under his bed. He refused staff directives to get out from under his bed; staff was able to move the bed to provide an open, safe access for Patient #2 to get off the floor. Patient #2 then placed a piece of trash in his mouth, chewing it and threatening to swallow it. After staff made multiple attempts to redirect Patient #2, he removed the trash from his mouth. He again began yelling, cursing at staff, and became combative. He began fighting staff, kicking, hitting, and attempted to bite and spit. Patient #2 required a manual hold and was placed in locked seclusion. While escorting Patient #2 to locked seclusion, he scratched S23MHT and S24RN bruising, breaking the skin, and drawing blood. Further review of the progress notes revealed no documented evidence of an assessment by an RN during this incident.

Review of a "Client Incident, Injury And Data Reporting Form" dated 05/19/13 at 8:35 a.m. written by S21MHT and signed by S14RN revealed that Patient #2 became aggressive after realizing he didn't have unit privileges and had to write lines.

Further review revealed that the aggression initially manifested through cursing and crying and eventually developed into spitting and biting Patient #10.

Review of the progress notes revealed S21MHT documented the incident at 9:05 a.m. Further review revealed S17MHT documented on 05/19/13 at 11:30 a.m., that Patient #2 was in the dayroom clapping his hands loudly which agitated his peers. When his peers asked him to quit clapping, Patient #2 hit Patient #10. Patient #10 hit Patient #2 on his arm. Patient #2 continued clapping, and his peers began yelling at him to stop.

Further review revealed that staff intervened by verbally de-escalating which worked for all peers except Patient #2. Patient #2 then went into his room, stood on his bed and tried to remove the window screen, and climbed under the metal bed. Staff were able to pick up the bed to remove Patient #2 while he yelled, cursed, spit, and tried to bite staff. Patient #2 was told to go to the seclusion room and went reluctantly while spitting at staff again.

Further review of the progress notes revealed S14RN documented 2 late entries at 1:40 p.m. One entry was for 9:45 a.m. that she had administered medication for "whining, agitation, and spitting." The second entry was for 10:15 a.m. that medication was administered (no documented evidence of what medication was administered) since the previous medication was not effective. There was no documented evidence of an assessment of Patient #2 by S14RN during the behaviors exhibited at 8:35 a.m. and 11:30 a.m.

In a face-to-face interview on 05/23/13 at 11:25 a.m., S16Psychiatrist, when told of the above behaviors exhibited by Patient #2, indicated that Patient #2's treatment plan included a reward system. When asked about planning for distances between patients exhibiting aggression to peers, S16Psychiatrist indicated she usually put patients off limits to peers for inappropriate sexual behavior and aggressive altercations. When informed that the medical record review of Patient #2's record didn't reveal that he was care planned to be off limits to any of his peers, she indicated that she usually put it as an order. When informed that an order had not been found for Patient #2 to be off limits to peers, S16Psychiatrist indicated she could not put Patient #2 off limits to all his peers, because it was not an ideal plan. She further indicated Patient #2 was "not an ideal candidate for the DNP, because he's cognitively challenged, like a 3 year old."

In a face-to-face interview on 05/23/13 at 3:23 p.m., S17MHT was asked about her documentation on Patient #2's progress notes for 05/19/13. She indicated Patient #2 had escalating behaviors, and she was having to tell the RN what to do. She further indicated that the RNs only have a week of orientation and then "are thrown out there."

Patient #5

A review of Patient #5's medical record revealed that the patient was a [AGE] year old adolescent male who was admitted on [DATE] with diagnoses to include in part: disruptive behavior disorder, oppositional behavior and aggression. Patient #5 was admitted to the DNP unit for treatment to include in part: individual therapy, group therapy, recreational therapy and medication management.

A review of the "Client Incident, Injury and Data Reporting Form" dated 05/10/13 revealed that Patient #5 was involved in a patient-to-patient alteration by punching Patient #3 twice, a patient-to-staff aggression involving S17MHT by pushing her into a wall, and damage to hospital property by breaking a computer.

A review of the nurses' progress notes dated 05/10/13 revealed documentation by S17MHT involving the details of the incidents on 05/10/13. A further review of the nurses' progress notes revealed no documented evidence of an RN assessment or evaluation of Patient #5's incident other than an intervention of a PRN (as needed) medication given to Patient #5 to assist in calming the patient.

Patient #6

Review of Patient #6's medical record revealed that he was a [AGE] year old male admitted on [DATE] with diagnoses of Oppositional Defiant Disorder, Rule Out Attention Deficit Hyperactive Disorder, and Moderate Mental Retardation.

Review of a "Client Incident, Injury And Data Reporting Form" dated 04/21/13 at 9:20 p.m. revealed while placing Patient #6 in a manual hold, he scratched S25RN's skin and caused a small cut to S25RN's outer right eye.

Review of Patient #6's progress notes revealed an entry by a MHT on 04/21/13 at 11:00 p.m. as a late entry for 9:15 p.m. Further review revealed Patient #6 started to threaten Patient #7 with a pencil. Patient #6 stole a pen from a staff member's pocket, and when the staff tried to get the pen back, Patient #6 struggled and punched the staff member in the mouth. Patient #6 continued to threaten staff and other patients and stole a chart (patient medical record) and ran in his room. Further review revealed that while Patient #6 was in a manual hold to retrieve the chart, pen, and monopoly pieces, he punched the RN in the face. He continued to threaten staff and ran into Patient #Patient #7's room and then ran into the nurse's station. Patient #6 was eventually escorted into locked seclusion. Review of the medical record revealed no documented evidence of an assessment and the interventions implemented by the RN.

Patient #7

A review of Patient #7's medical record revealed that the patient was a [AGE] year old adolescent male who was admitted on [DATE] with diagnoses to include in part: impulsive control disorder, post-traumatic stress disorder, and attention deficit hyperactivity disorder. Patient #7 was admitted to the DNP unit for treatment to include in part: individual therapy, group therapy, recreational therapy and medication management.

A review of 2 "Client Incident, Injury and Data Reporting Forms", both dated 04/13/13, revealed 2 incidents involving Patient #7. A review of the first incident revealed Patient #7 threatened Random Patient R1, threatened to harm S10RN with a syringe needle when he entered the unsecured medication room, and damaged the computer keyboard in the medication room. Patient #7 was placed in locked seclusion until calm. The 2nd incident on 04/13/13 revealed Patient #7 became extremely agitated again an hour after leaving locked seclusion, and a further review of the 2nd incident revealed Patient #7 threw furniture and pulled the fire alarm off the wall. Patient #7 was again placed in locked seclusion until calm.

A review of the nurses' progress notes on 04/13/13 revealed detailed documentation of the incidents by the MHT's. A further review of the nurses' progress notes revealed documentation of the details of the incidents with no documented evidence of an RN assessment, evaluation, or interventions.

In a face-to-face interview on 05/23/13 at 8:55 a.m., S10RN indicated that the incident with Patient #7 trying to harm her with a syringe needle occurred after her shift while she was still on Unit 1. She indicated that the staff was trying to de-escalate Patient #6 who had taken a pen from a staff member. She further indicated a team was called to assist with Patient #6. S10RN indicated that while she was in Patient #6's room, she heard a MHT scream and heard what sounded like the unit was being torn apart. She indicated that when the nurses (doesn't know which nurse) left the medication room from getting medication for Patient #6, the medication room door was either not closed all the way or was left open. She further indicated she found Patient #7 in the medication room with his back facing Unit 2 while he faced S10RN. S10RN indicated that Patient #7 had the faucet from the sink in one hand and a syringe with an exposed needle in the other hand. She offered no explanation for not having documenting an assessment of Patient #7's behavior during this incident and the interventions implemented.

In a face-to-face interview on 05/23/13 at 9:40 a.m., S13RN indicated he was with Patient #6 who had a pen in his pocket on 04/13/13 when the incident with Patient #7 occurred. He further indicated that while everyone was involved with Patient #6, Patient #7 jumped up and darted into the medication room. He further indicated that the medication room door was left open after 3 nurses had been in the medication room. S13RN indicated there were times that when something's going on one unit and MHTs are alone on the other unit with patients. When asked if it was a problem having 1 RN responsible to cover Unit 1 and Unit 2, S13RN indicated he didn't see it as a problem with 1 RN but rather as needing more or better trained staff to handle the clients on the DNP units.

Patient #8

Review of Patient #8's medical record revealed that he was a [AGE] year old male admitted on [DATE] with diagnoses of Autism, Impulse Control Disorder, Oppositional Defiant Disorder, Rule Out Conduct Disorder, Attention Deficit Hyperactivity Disorder by History, and Mild Mental Retardation.

Review of Patient #8's progress notes revealed an entry on 05/09/13 at 9:15 p.m. of a late entry for 8:45 p.m. by S27MHT that revealed Patient #8 was in the bathroom and flooded the sink, toilet, and bathtub/shower with toilet paper. The floor and his clothing was soaked. Patient #8 came out of the bathroom and stated "Let me see what else I can destroy!" and ran in his room and flipped both closets/dressers breaking the hinges of his own closet/dresser. Patient #8 then threw another patient's toys all over the floor. Patient was redirected and took a quiet time out in the unlocked seclusion room. When Patient #8 came out the unlocked seclusion room, he ran into his room, screamed at staff, knocked the dresser down again and almost dropped it on his roommate purposefully. Patient #8 then walked into locked seclusion at 9:10 p.m. Review of the "Seclusion/Restraint Order" dated 05/09/13 at 9:10 p.m. and received by S26RN revealed the intervention was due to Patient #8 being a danger to others, throwing furniture, and destroying property. There was no documented evidence of an assessment of Patient #8 during this incident by an RN.

Review of Patient #8's progress note documented by S28MHT as a late entry for 10:00 a.m. (no documented evidence of the date and time the entry was written; included in documentation on 05/10/13) revealed Patient #8 "plucked" another patient in the head and continued to escalate and flipped a sofa on Unit 1. He then began to push the sofa towards the entrance door to block other staff from entering Unit 1. Further review revealed that as S28MHT intervened, Patient #8 lunged and hit S28MHT. Review of the "Seclusion/Restraint Order" dated 05/10/13 at 10:05 a.m. revealed S14RN documented Patient #8 was placed in locked seclusion and physically restrained due to anger, picking up furniture, biting staff, hitting peers, and blocking doors with furniture. Review of Patient #8's progress notes revealed no documented evidence of an assessment by S14RN of his behaviors that warranted the interventions of physical restraints and locked seclusion.

Patient #10

Review of Patient #10's medical record revealed that he was a [AGE] year old male admitted on [DATE] with diagnoses of Impulsive Control Disorder, Oppositional Defiant Disorder, Rule Out Conduct Disorder, and Mild Mental Retardation.

Review of Patient #10's progress notes revealed an entry on 05/09/13 at 7:25 p.m. as a late entry for 4:45 p.m. by S27MHT that Patient #2 became agitated and when Patient #10 tried to calm Patient #2, Patient #2 punched Patient #10 in the stomach. There was no documented evidence that the behaviors exhibited by Patient #2 and Patient #10 were reported to the RN and that the RN assessed each patient for injury.

Review of the "Client Incident, Injury and Data Reporting Form" dated 05/19/13 at 8:35 a.m. and written by S21MHT and signed by S14RN revealed Patient #2 became aggressive and eventually spit at Patient #10. Patient 310 became upset and started cursing and calling Patient #2 names. This provoked Patient #2 to run after Patient #10 and bite and scratch him.

Review of Patient #10's progress note of 05/19/13 from 6:25 a.m. until 11:00 p.m. revealed no documented evidence that Patient #10 was assessed for injury by an RN after being bitten and scratched by Patient #2.

In a face-to-face interview on 05/23/13 at 11:55 a.m., S9Executive Director of DNP and a Psychologist indicated taht DNP was a behavioral program for 12 1/2 to [AGE] year old adolescents who were dually diagnosed with a developmental disability and a psychiatric diagnosis. She further indicated that the program had "the worse patients in the state and they were all in one place". When asked about having 1 RN assigned to Unit 1 and Unit 2 who had no psychiatric background, S9Executive Director of DNP indicated she thought the temperament of the RN was more important than having a background in psychiatric nursing. She further indicated Unit 1 and Unit 2 had always been staffed with 1 RN for both units and felt it was more important to have MHTs on both sides than the RN. S9Executive Director of DNP explained this statement by saying she viewed the "RN role as more medication management and the MHT as milieu management". She further indicated the psychologists work more closely with the MHTs, because the nurses handle the "medical side" of the patient.

In a face-to-face interview on 05/23/13 at 3:10 p.m., S3DON indicated, when informed of S9Executive Director of DNP's view of the RN and MHT roles on Unit 1 and Unit 2, she told the nurses that they're responsible for everything on the unit as well as the milieu management. She further indicated there have been times that the nurses complained of frustration of not being able to be in 2 places at one time. When asked about the trend of increased property destruction, patient-to-patent altercation, and patient-to-staff aggression on Unit 1 and Unit 2 as noted in the above patients, S3DON (director of nursing) indicated the hospital was still in developmental programmatic changes at the leadership level since the new ownership in January 2013.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on records review and interviews, the hospital failed to ensure that an RN (Registered Nurse) assigned the nursing care of each patient to other nursing personnel according to the patients' needs and the competencies of the nursing staff available. This failed practice was evidenced by RN's and MHT's (Mental Health Technicians) acknowledgement through staff interviews that patient assignments were made by the MHT's on the DNP (Developmental Neuropsychiatric Program) unit with a current patient census of 15.

Findings:

Review of the hospital policy titled "Staff Assignments", policy number NS.1065, effective 01/02/13, and presented as a current policy by S12Director of Risk Management and P.I. (performance improvement), revealed the purpose of the policy was to assure that accountability and delivery of individualized nursing care in accordance to patient need.

Further review revealed that the RN was responsible for the appropriateness, completeness, and accuracy of the assignment sheet and verified this status by his/her signature.

Review of the process revealed that the MHT assigned to the desk would make immediate assignment of high risk patients in order for transfer of assignments to occur. High risk patients included patients in restraint or seclusion, patients on special precautions (visual contact, suicide, seizure, elopement, withdrawal, and so on), and 1-to-1 assignments. Further review revealed the MHT assigned to the desk initiated the assignment sheet, and the RN Charge Nurse must review the assignments for completeness and appropriateness and sign as approving the delegation of these functions.

Review of the staffing assignment sheets presented by S3DON for 03/15/13 to 05/15/13 revealed 42 shifts that the MHT was assigned more than 5 patients to observe, sometimes as many as 8 patients. Further review revealed 21 shifts that the staffing assignment sheet was incomplete, and the MHT-to-patient ratio could not be determined.

On 05/20/13 at 9:45 p.m. an interview was conducted with S7MHT. She indicated she worked the 3-11 pm shift on the DNP unit. She indicated the MHT's assigned to the DNP unit would make the patient assignments for themselves based on the information given to them at shift change by the oncoming RN charge nurse and by the outgoing MHTs. She indicated the MHT's used a 1 : 4 staff-to-patient ratio. She further indicated that when the MHTs were understaffed, one MHT would have to be assigned more than 4 patients. S8MHT who was present during the interview with S7MHT confirmed the above.

On 05/21/13 at 10:15 a.m. an interview was conducted with S18MHT. She was asked about her assignment on the DNP unit. S18MHT indicated she usually worked the adult unit and would work the DNP unit occasionally when the DNP unit needed another MHT to meet the staff-to-patient ratio of 1 : 4. When asked if she completed a DNP unit competency checklist, S18MHT indicated she had not completed a DNP competency checklist and only had the required CPI (crisis prevention intervention) training that all staff had to complete annually.

In a face-to-face interview on 05/23/13 at 9:40 a.m., S13RN indicated that the MHTs make their own assignment. He further indicated if there was a conflict over the MHT's assignment or if patients were ordered to be on 1 to 1 observation, he would review the assignment after the MHTs made the assignments.

In a face-to-face interview on 05/23/13 at 3:10 p.m., S3DON (director of nursing) indicated the lead MHT can fill out the assignment sheet, but the nurse needs to approve it. S3DON indicated the staffing assignment sheets were filed in Nursing Administration. When asked about the staffing ratio for MHTs-to-patients being greater than the policy allowed, she indicated she was not aware of the incomplete staffing assignment sheets. She further indicated the RN Manager and the RN House Supervisor should spot check them, but she should also be reviewing them and had not been doing so. She indicated the staffing ratio was 1 MHT to 4 patients, and the RN could be used as part of the ratio. She offered no explanation for MHTs being assigned as many as 8 patients on Unit 1 and Unit 2.