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.

STRATEGIC BEHAVORIAL CENTER-GARNER 3200 WATERFIELD DRIVE GARNER, NC 27529 Dec. 19, 2016
VIOLATION: NURSING SERVICES Tag No: A0385
Based on policy and procedure review, medical record review, hospital staffing data, hospital video monitoring review, and staff interviews, the hospital's nursing staff failed to supervise and evaluate patient care by failing to ensure staffing and observation of behavioral health patients for patient safety. (Pt #3).

The findings include:

1. Hospital staff failed to ensure the immediate availability of a Registered Nurse (RN) and other licensed nursing staff to supervise and monitor care for patient safety.

~cross refer to 482.23(b) Nursing Standard Tag A0392

2. Hospital staff failed to supervise and evaluate care for patient safety by failing to continuously closely monitor a patient who was ordered continuous close observation (#3) .
~cross refer to 482.23(b)(3) Nursing Standard Tag A0395
VIOLATION: GOVERNING BODY Tag No: A0043
Based on policy and procedure review, medical record review, assignment sheet review, video monitoring review, and staff interviews, the hospital's leadership failed to provide oversight and have systems in place to ensure the protection and promotion of Patient's Rights to ensure a safe environment for behavioral health patients and failed to have an organized Nursing Service to meet patient care and safety needs.

The findings include:

1. The hospital failed to protect patient rights and provide care in a safe setting by failing to provide licensed staff in the facility at all times and ensure staff were available to monitor and provide continuous close observation of a behavioral health patient (#3) as ordered.

~cross refer to 482.13 Patient's Rights Condition: Tag A0115

2. The hospital's nursing staff failed to have an effective nursing service by failing to provide a Registered Nurse at all times and licensed staff to supervise and evaluate care and failing to provide continuous observation at the level required for patient safety.

~cross refer to 482.23 Nursing Service Condition: Tag A0385
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on policy and procedure review, medical record review, assignment sheet review, video monitoring review, and staff interviews, the hospital failed to protect patient rights and provide care in a safe setting by failing to ensure licensed staffing and patient observation at the level ordered by a physician increasing the risk of a serious adverse event occurring.

The findings include:

1. The hospital staff failed to provide care in a safe setting by failing to provide licensed nursing staff for supervising and monitoring care of behavioral health patients and failing to continuously closely observe a patient (# 3) ordered on close observation at all times.

~cross refer to 482.13(c)(2) Patient's Rights Standard: Tag A0144
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure review, medical record review, assignment sheet review, video monitoring review and staff interviews, the hospital failed to provide care in a safe setting by failing to provide licensed staff for supervising and monitoring care of behavioral health patients and failing to continuously closely observe a patient (# 3) ordered on continuous close observation.

The findings include:

1. Review of hospital policy "Hospital Plan for Provision of Nursing Care", reviewed/revised 05/24/2016, revealed "...Role of the Registered Nurse Registered Nurses....are responsible and accountable for assessment....coordination, and delegation of nursing care....All other nursing personnel work under the direct supervision of a registered nurse.... VIII. UTILIZATION OF STAFF AND STAFFING A. Quantity 1. Staffing, both in numbers and competency, will be sufficient to ensure that....a. A registered nurse defines, directs, supervises, and evaluates, prescribes, delegates,a dn coordinates the nursing care of each patient. b. All patient assignments given to non-registered nurse care givers will be co-assigned to a registered nurse.... d. Each functional area is staffed by at least one registered nurse per shift. Additional staff may be comprised of licensed practical nurses.... Support staff are assigned based on population needs....B. Patient Classification System ....2...c. One RN is scheduled per shift, per unit, dependent on census and acuity needs. d. The unit ratio is 1:12. ..."

Review of scheduled staff on the "Acute Matrix", dated 11/20/2016 for 3rd shift (2300-0700) revealed one RN name scheduled (RN #4) on all three acute care units. Review did not reveal names of other RNs or LPNs (Licensed Practical Nurses) scheduled to work that shift.

Review of Assignment Sheets for the acute hospital on [DATE] on 3rd shift (2300-0700) revealed an assignment sheet for two of the three acute nursing units. Review failed to find an assignment sheet for the third unit prior to exit on 12/19/2016 at 1815. At the top of both assignment sheets was the first name of RN #4 and a note stating "11p-3a" (2300-0300). The assignment sheets did not reveal another RN or LPN working on either acute unit from 0300-0700.

Interview with RN #4, on 12/15/2016 at 1510, revealed she believed she left the hospital between 0300 and 0400 that night because 2300 to 0300 are her scheduled hours. RN #4 stated she has to leave early so that children are not left home alone. Interview revealed RN #4 would contact the DON before leaving either by text or phone.

Interview with LPN #7, on 12/16/2016 at 0910, revealed LPN #7 recalled working the night of 11/20/2016 and covered three halls (units) in PRTF from 2300-0700. Interview revealed LPN #7 thought she recalled RN #4 working part of the night and leaving early. LPN #7 stated there was no nursing supervisor in the facility that night.

Interview with AS #2, on 12/19/2016 at 0920, revealed RN # 4 recently switched work hours and did leave at 0300 now. AS #2 stated it appeared RN #4 left at 0300 on the night of 11/20/2016, which meant there was not a RN in the facility from 0300 to 0700. Further interview revealed the facility was supposed to have a RN at all times.

2. Review of policy NS 2.3.8 Level of Patient Observation, subject Scope of Care, effective date 07/02/2012 and reviewed/revised 05/24/2016, revealed "...Definitions:....Close observation (Line of Sight observation): The resident must be in the sight of the staff at all times including bathing/toileting. The staff is within a proximity that allows him/her to implement immediate action if necessary. ..."
Review of policy NS 1300.2.3.9 Level of Patient Observation, subject Scope of Care, effective 05/24/2015 and reviewed/revised 03/03/2016, which was received from the hospital via electronic mail on 12/21/2016, revealed "...Definitions...Close Observation (Line of sight observation): The assigned staff maintains a full, unobstructed view of the client at all times including bathing/toileting. The staff is within a proximity that allows them to implement immediate action if necessary. Staff observes and documents location, behavior, and activities of the client every 15 minutes. ..."
Medical record review of Patient #3, on 12/15-16/2016, revealed the [AGE] year old female was admitted on [DATE] with diagnoses including Major Depressive Disorder and Oppositional Defiant Disorder (ODD - childhood disorder involving angry mood, defiant behaviors). Review of Physician Orders, dated 11/30/2016 at 0825, revealed "...continue close observation at all times for safety... ." Review of Physician Orders on 12/12/2015 at 1315, revealed "1:1 (one to one) (with) staff for safety". Nursing Progress Notes, on 12/12/2016 at 1400, stated "...Reported to therapist that she was sexually assaulted by a peer. Pt (Patient) states this incident happened two weeks ago while in the dayroom. Pt tearful throughout the shift. Investigation ongoing per (first name) patient advocate....Pt placed on 1:1 per MD orders. ..." Nursing Progress Note review, on 12/13/2016 at 1500, revealed "...Pt was transported to (hospital name) ER (emergency room ) by EMS (Emergency Medical Services) at 1430 (24.5 hours later) to be examined by physician. ..." At 2000 on 12/13/2016, review revealed "Pt returned from ER. Follow up information was given....reported a rape kit was done & (and) information will be given to her MD as test results come back. No injury. ..." Review of Case Management Note, on 12/14/2016 at 1056, revealed the therapist spoke with Pt # 3 when she returned from the hospital around 1950 on 12/13/2016. Note review revealed "...(Pt # 3) shared....were three incidents on last Friday, Thursday, and Monday... ."
Review of Hospital Incident Report, dated 12/12/2016, revealed Pt #3 reported the incident to Special Counsel. Incident report review revealed it happened "...around 7:30 pm Thursday before last were in dayroom alone with two other peers. ..." Review revealed the date/time of the incident was listed as "[DATE]st also check [DATE]th".
Review of video supplied by facility, on 12/16/2016 at 1330, revealed a date of 12/08/2016 and covering the time period from 1921 - 1946. Review revealed Pt #3 entered the hallway and walked toward her room accompanied by a staff member. At 1922, review revealed Pt # 3 entered the room and the staff member departed. At 1931, video observation revealed a visual check was completed when a staff member walked to the door of the patient's room and looked inside. The video stopped at 1946, without anyone else approaching Pt # 3's room and peering inside. Pt # 3 remained in her room throughout the video. An updated video received from the facility extended the observation time to 2000. Video reviews did not reveal any patient entering Pt # 3's room. Video reviews revealed Pt # 3 was not continuously closely observed.
Review of video, on 12/16/2016, from 12/09/2016 covering time period from 1030 to 1200 revealed Pt # 3 in her room and also entering and exiting the Day Room. Video did not cover inside the Day Room, only the hallway outside of it. Video review did not reveal continuous close observation of Pt # 3 during the time period covered.
Review of another video, on 12/19/2016 around 1345, revealed it was from 12/01/2016 from 1800 - 2000. Review of the hallway revealed multiple children going in and out of the Day Room, including Pt # 3. Hospital staff were viewed going in and out of the Day Room, patient rooms, and walking around the hallway. Review revealed Pt # 3 was not under continuous close observation.
Interview, on 12/16/2016 around 1330, with Administrative Staff (AS) #4, who viewed parts of the 12/08/2016 video with surveyors, revealed it appeared staff was treating this (Pt #3's observation) as every 15 minute observation, not constant close observation.
Interview on 12/19/2016 at 1400, with AS #5, who viewed a portion of the 12/01/2016 video with the surveyors, revealed that close observation is watching the patient all the time. Interview revealed that on the video, covering time periods on 12/01/2016 from 1800-2000, close observation was "not happening" for Pt #3. Interview revealed that "Probably the biggest problem is acute (the acute hospital side of the facility)" because the acute side does "not have as much staff". Interview revealed at that time there were two Mental Health Techs assigned to the hall.
Interview, on 12/19/2016 at 1008, with Administrative Staff (AS) #3, revealed AS #3 completed the investigation on the incident involving Pt # 3. Interview revealed AS #3 met with the patient to discuss the concern. AS #3 stated three incidents were discussed, the first on 12/08/2016 at 1930, the second on 12/09/2016 on 1st shift (0700-1500), and the third 2-3 weeks before, but no other details of date or time. AS #3 stated 12/01/2016 was not included in the investigation because Pt #3 was "adamant when I spoke with her that it was December 8th." Interview revealed AS #3 reviewed video from 12/08/2016 and Pt #3 remained in her room after about 1900. AS #3 stated on review she paid attention to whether the patient was closely observed on 12/08/2016 and "she was not". Further, interview revealed AS #3 was still reviewing the video for 12/09/2016, but at this point felt confident in believing nothing happened between the two patients. AS #3 stated video review from 12/09/2016 revealed the patient was "intermittently" closely observed, but not closely observed at all times.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on policy and procedure review, medical record reviews, and staff interviews, the hospital failed to ensure a physician authenticated and signed a verbal order for a restrictive intervention within 24 hours per policy for 2 of 3 patients with restrictive interventions reviewed (#3, #4)

The findings include:

Review of Policy and Procedure, subject Physician's Orders, reviewed/revised 05/24/2016, revealed "...Verbal Orders:....3. Verbal orders for behavioral restrictive interventions must be countersigned within 24 hours....The physician must indicate the date and time of countersigning."

1. Medical record review for Patient #3 revealed a "Physician Order for Restrictive Intervention for Behaviors" form dated 12/14/2016 at 1809. Review revealed the restrictive intervention was a manual hold for "hitting and kicking staff and peers" with a telephone order obtained at 1810. Record review on 12/16/2016 (more than 36 hours after the restraint order was obtained) did not reveal a physician signed the order.

Interview with Administrative Staff (AS) # 2 on 12/19/2016 at 1325 revealed policy was not met.

2. Medical record review for Patient #4 revealed a telephone order for a restrictive intervention for "trying to attack a peer". Review revealed a telephone order was obtained at 0805 on 12/06/2016. Review on 12/16/2016 (10 days after the restraint order was obtained) did not reveal a physician signature on the order sheet.

Interview with AS # 2 on 12/19/2016 at 1325 revealed policy was not met.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy and procedure review, hospital document reviews, and staff interviews hospital staff failed to ensure the immediate availability of a Registered Nurse (RN) and other licensed nursing staff to supervise and monitor care for patient safety.

The findings include:

Review of hospital policy "Hospital Plan for Provision of Nursing Care", reviewed/revised 05/24/2016, revealed "...VIII. UTILIZATION OF STAFF AND STAFFING A. Quantity 1. Staffing, both in numbers and competency, will be sufficient to ensure that.... d. Each functional area is staffed by at least one registered nurse per shift. Additional staff may be comprised of licensed practical nurses....B....2...c. One RN is scheduled per shift, per unit, dependent on census and acuity needs. d. The unit ratio is 1:12. ..."

Review of scheduled staff on an "Acute Matrix", dated 11/20/2016 for 3rd shift (2300-0700) revealed one RN name (RN # 4) scheduled on all three acute care units. Further review did not reveal any other names of RNs or LPNs scheduled to work on the three units that shift.

Review of Assignment Sheets for the acute hospital on [DATE] on 3rd shift (2300-0700) revealed an assignment sheet for two of the three acute nursing units. Review failed to reveal an assignment sheet for the third unit. At the top of both assignment sheets was the first name of RN # 4 and a note stating "11p-3a" (2300-0300). Reviews of the assignment sheets failed to reveal another RN working in the acute hospital and failed to reveal evidence of LPNs working the acute units.

Interview with RN # 4, on 12/15/2016 at 1510, revealed the RN believed she left the hospital between 0300 and 0400 that night (11/20-21/2016) because 2300 to 0300 are her scheduled hours. RN # 4 stated it would have been known in advance that she could only work 2300 to 0300. Interview revealed RN # 4 leaves early so children are not left home alone. RN #4 stated she would notify the DON when she left either by text or phone.

Interview with LPN #7, on 12/16/2016 at 0910, revealed LPN #7 recalled working the night of 11/20/2016 and covered three halls (units) in PRTF from 2300-0700. Interview revealed LPN #7 thought she recalled RN #4 worked part of the night and left early. LPN #7 stated there was no nursing supervisor in the facility that night.

Interview with AS #2, on 12/19/2016 at 0920, revealed RN #4 recently switched her work hours and now left at 0300 instead of 0700. AS #2 stated it appeared RN #4 left at 0300 the night of 11/20/2016, which meant there was not a RN in the facility from 0300 to 0700. Further interview revealed the facility was supposed to have a RN at all times.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on Policy and Procedure review, medical record review, incident report review, video monitoring review, and staff interviews, hospital staff failed to supervise and evaluate care for patient safety by failing to closely monitor a patient at all times who was ordered continuous close observation (#3) .
The findings include:
1. Review of policy NS 2.3.8 Level of Patient Observation, subject Scope of Care, effective date 07/02/2012 and reviewed/revised 05/24/2016, revealed "...Definitions:....Close observation (Line of Sight observation): The resident must be in the sight of the staff at all times including bathing/toileting. The staff is within a proximity that allows him/her to implement immediate action if necessary. ..."
Review of policy NS 1300.2.3.9 Level of Patient Observation, subject Scope of Care, effective 05/24/2015 and reviewed/revised 03/03/2016, which was received from the hospital via electronic mail on 12/21/2016, revealed "...Definitions...Close Observation (Line of sight observation): The assigned staff maintains a full, unobstructed view of the client at all times including bathing/toileting. The staff is within a proximity that allows them to implement immediate action if necessary. Staff observes and documents location, behavior, and activities of the client every 15 minutes. ..."
Medical record review of Patient # 3, on 12/15-16/2016, revealed the [AGE] year old female was admitted on [DATE] with diagnoses including Major Depressive Disorder and Oppositional Defiant Disorder (ODD - childhood disorder involving angry mood, defiant behaviors). Review of Physician Orders, dated 11/30/2016 at 0825, revealed "...continue close observation at all times for safety... ." Review of Observation Sheets on 12/01/2016, 12/08/2016, and 12/09/2016 revealed a handwritten note at the top of front page of the sheet which stated "close observation @ (at) all times". Review of handwritten notes on the back of the 12/01/2016 Observation Sheet, at 1430, revealed "...Staff monitored resident every 15 minutes to ensure safety... ." On 12/08/2016 on 2nd shift, sometime after 2200 (3rd number was not able to be read) Observation sheet notes revealed "... was monitored as well every 15 mins (minutes) and on 12/09/2016 at 1430, notes read "...Staff monitored resident every 15 minutes to ensure safety and compliance with....rules and expectations. ..." Hand written notes stating close observation on those days were on third shift. Review revealed on 12/01/2016 at 0600, the note stated "...Staff monitored (First name of patient) under close observation through the night..." and the third shift (2300-0700) note on 12/09/2015, no time noted, "...Monitored resident on close observation @ all times to ensure safety. ..."
Case Management Note, dated 12/13/2016 at 2030, revealed "...December 12, 2016; Therapist was going to do group around 1200 or so, when the special counsel (Name), waved therapist over.... (Name) shared that (Pt name) had just informed her that there had been inappropriate touching between (Pt name) and (Pt name) in the day room the previous Thursday.... Weekend therapist came onto the unit and received (Pt #3) and (Special Counsel name) to go address the situation .... Therapist went to speak to weekend therapist; Assistant Clinical Director was in the room and therapist let him know what was going on. Therapist was told that Ms. (first name of Pt Advocate) was aware of the situation and (Pt #3) had shared that she had sex with (Pt name) in the dayroom. Therapist said something implying it was forced and weekend therapist responded that (Pt) had said it was consensual .... (Name of accused pt) was placed on close observations....and (named Pt) transferred to (name of another unit) on 1:1. Therapist spoke with Ms. (name of Pt Advocate) later that day to find that the situation was 'unsubstantiated'. ..." Review of Physician Orders on 12/12/2015 at 1315, revealed "1:1 (one to one) (with) staff for safety". Nursing Progress Notes, on 12/12/2016 at 1400, stated "...Reported to therapist that she was sexually assaulted by a peer. Pt (Patient) states this incident happened two weeks ago while in the dayroom. Pt tearful throughout the shift. Investigation ongoing per (first name) patient advocate....Pt placed on 1:1 per MD orders. ..." Nursing Progress Note review, on 12/13/2016 at 1500, revealed "...Pt was transported to (hospital name) ER (emergency room ) by EMS (Emergency Medical Services) at 1430 (24.5 hours later) to be examined by physician. ..." At 2000 on 12/13/2016, review revealed "Pt returned from ER. Follow up information was given....reported a rape kit was done & (and) information will be given to her MD as test results come back. No injury. ..." Review of Case Management Note, on 12/14/2016 at 1056, revealed "12/13/2016: Therapist met with (Pt # 3) when she returned from the hospital around 7:50PM. ..." Note review revealed "...(Pt # 3) shared....were three incidents on last Friday, Thursday, and Monday. (Pt # 3) shared that on Friday before last....(Pt name) had made her go into the day room, where he made her pull her pants down and he 'stuck it inside of me....it happened sometime in the afternoon'. The next incident....was on 'the last Thursday, 2nd shift around 7:00 o'clock' and (Name) had kissed (Pt # 3) and they were touching each other....(Pt # 3) shared that two peers had witnessed it. ..."
Review of Hospital Incident Report, dated 12/12/2016, revealed Pt # 3 reported the incident to Special Counsel. Incident report review revealed it happened "...around 7:30 pm Thursday before last were in dayroom alone with two other peers. ..." Review revealed the date/time of the incident was listed as "[DATE]st also check [DATE]th".
Review of video supplied by facility, on 12/16/2016 at 1330, revealed a date of 12/08/2016 covering the time period from 1921 to 1946. Review revealed Pt #3 entered the hallway and walked toward her room accompanied by a staff member. At 1922, review revealed Pt # 3 entered the room and the staff member departed. At 1931, video observation revealed a visual check was completed inside the room when a staff member walked up and looked inside. The video stopped at 1946, without anyone else approaching Pt # 3's room and peering inside. Pt # 3 remained in her room throughout the video and no male patients entered the room. An updated video received from the facility extended the observation time to 2000. Video review did not reveal continuous close observation on Pt # 3.
Review of video, on 12/16/2016, from 12/09/2016 covering time period from 1030 to 1200 revealed Pt # 3 in her room and also entering and exiting the Day Room. Video did not cover inside the dayroom, only the hallway leading into it. Video review did not reveal continuous close observation of Pt # 3.
Review of another video, on 12/19/2016 around 1345, revealed it was from 12/01/2016 from 1800 to 2000. Review of the hallway revealed children going in and out of the dayroom, including Pt # 3 and the other involved child. Hospital staff were viewed going in and out of the Day Room, patient rooms, and walking up and down the hallway. Review did not reveal constant close observation of Pt # 3.
Interview, on 12/16/2016 around 1330, with Administrative Staff (AS) # 4, who viewed parts of the 12/08/2016 video with surveyors, revealed it appeared staff was treating this (Pt #3's observation) as every 15 minute observation.
Interview on 12/19/2016 at 1400, with AS # 5, who viewed a portion of the 12/01/2016 video with the surveyors, revealed that close observation is watching the patient all the time. Interview revealed that on the video, covering time periods on 12/01/2016 from 1800-2000, close observation was "not happening" for Pt # 3. Interview revealed that "Probably the biggest problem is acute (the acute hospital side of the facility)" because the acute side does "not have as much staff". Interview revealed at that time there were two Mental Health Techs assigned to the hall.
Interview, on 12/19/2016 at 1008, with Administrative Staff (AS) # 3, revealed AS # 3 completed the investigation on the incident involving Pt # 3. Interview revealed AS # 3 met with the patient to discuss the concern. AS # 3 stated three incidents were discussed, the first on 12/08/2016 at 1930, the second on 12/09/2016 on 1st shift (0700-1500), and the third 2-3 weeks before, but no other details of date or time. AS # 3 stated 12/01/2016 was not included in the investigation because Pt # 3 was "adamant when I spoke with her that it was December 8th." Interview revealed AS #3 reviewed videos on 12/08/2016 and Pt # 3 remained in her room after about 1900. AS # 3 stated on review she paid attention to whether the patient was closely observed on 12/08/2016 and "she was not". Further, interview revealed AS # 3 was still reviewing the video from 12/09/2016, but at this point felt confident in believing nothing happened between the two patients. AS # 3 stated the patient was closely observed "intermittently" on 12/09/2016.
NC 572, NC 207, NC 135, NC 985