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.

WEST OAKS HOSPITAL 6500 HORNWOOD HOUSTON, TX Oct. 21, 2015
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview and record review the facility failed to ensure that 1 of 1 patients was assessed by a professional medical staff as soon as possible after her reported injury. The actions of staff did not provide a humane and safe treatment environment for 14-hours following a fall.

Findings included:

Record review of RN Narrative by RN #64 dated 08/09/15 at 2200 revealed: " Found Patient #1 on her back on the floor ... (S)tated she slipped in water on the floor ... Staff offer (sic) assist patient to get up ... Patient #1 refused and asked for 911 to be called. Attending MD #61 ... Internist MD #63 and Nursing Supervisor #65 ... called. Supervisor came to unit ... Patient #1 refused to be assisted up to be assessed but stated her back was broken ... MD #63 order [sic] lumbar spine x-ray STAT to rule out fracture. Patient #1 refused [x-ray]. Nursing Supervisor RN #65 and MD #63 notified ... Patient #1 stated she ' ll urinate and defecate on the floor if she needs. "

Record review of Written Statement by RN #64 dated 08/12/15 [not dated] revealed: " An alleged fall ... unwitnessed ... [in] the TV dayroom ... on 08/09/15 around 1915 ... Patient refused attempts to be assisted off the floor repeatedly on multiple occasions ... Patient also refused interventions ordered by the MD ... She did not want to be touched and everyone should stay away from her. "

In an interview with RN #64 on 10/21/15 at 1320, she stated she was the charge nurse on the evening Patient #1 stated she fell (08/09/15). She stated that the patient never told her she wanted to go to an emergency room . [RN #64 was shown her note from the chart that stated the patient asked for 911 and complained of her back being broken.] She stated she did not know that the patient had renal insufficiency and recent critical lab values.

Record review of Diabetic Record for Patient #1 by Nurse #66 dated 08/09/15 revealed:
At 1630: Blood glucose was 138.
At 2100: Patient refused her Lantus [a long-acting insulin].

Record review of Medication Administration Record for Patient #1 dated 08/09/15 revealed the following medications were not administered after the alleged fall: Lantus insulin, Cozaar [blood pressure medication], trazodone, Albuterol, Cogentin and Coreg [blood pressure medication] at 2100.

Record review of Interview with Supervisor RN #65 by RM #52 on 08/10/15 at 1800 revealed she received a call on 08/09/15 at " around 1915 " from RN #64 on PICU about the Patient #1 ' s fall. RN #65 was on Unit 7 providing a dinner break for staff. She left the unit when she found staff to relieve her and went to PICU. Patient #1 " complained that her back was broke and that she was not going to get up ... until 911 was called ... MD #61 was called and no orders were given. MD #63 ordered STAT lumbar spine x-ray ... The x-ray tech arrived at 2140 ... I gave the 11-7 Supervisor RN #76 report and did not think he would leave the patient on the floor all night. "

Record review of the Policy & Procedure, Suspected Abuse, Neglect and Sexual Exploitation, last reviewed 06/2015, revealed: " The investigation will be initiated immediately by the Nurse Manager/Program Director or Nursing Supervisor, and shall include interviews documented, dated and signed by the person conducting the interview ... "

In an interview with Supervisor RN #65 on 10/20/15 at 1030, she stated she got a call from the Psychiatric Intensive Care Unit about Patient #1 on 08/09/15 at 1855. She was covering a staff member ' s dinner break and was unable to go see about the patient until she got relief. She arrived on the unit at 1915. " I normally cover breaks for other people. On the unit I was on, the staffing grid calls for one nurse and one tech. I may have to cover. " When questioned about a code blue, " I would have had to get another staff member to relieve me. "

Record review of Written Statement by RN Supervisor #76 on 08/10/15 [not timed] revealed he got report from RN Supervisor #65. He wrote, " Charge nurse RN #64 then called MD #63 the medical doctor but didn ' t give the order to send the patient out, rather instructed patient be given her pain medication ... She ... complained of shortness of breath. MD #63 was called again ... Albuterol Inhaler was ordered. "

Record review of RN Narrative by RN #55 dated 08/10/15 revealed: At 0800, " Patient #1 lying on the floor ... refused to get off floor ... (B)een on the floor from last shift with blanket and a pillow ... (S)ays her back hurts ... (V)ital signs ... 145/92, 75, 18. MD #63 was called. Gave verbal order to send patient to emergency room (ER) ... Patient #1 says she will go. "

In an interview with RN #55 on 10/21/15 at 1050, she stated she worked Unit 1 on 08/10/15. Patient #1 was on the floor when she arrived to the unit that morning. She stated, " I think they should have called the ambulance the night before. "

Record review of Written Statement by MHT #77 dated 08/10/15 [not timed] revealed that he found Patient #1 on the floor, refusing all help. MHT #77 " stopped a few times to converse. " Patient #1 stated, " ' I ' m about to piss and shit on myself. ' " MHT #77 replied, " ' Well, before you get to pissing, let ' s go to your room. ' Again she refused ... yelling and cussing ... banging chairs, slapping the floor - looking for attention, of course. I had walked passed her several times to look for snacks, do my environmental rounds and at times go to check on my phone, also check on her for my every 15-minute rounds. I didn ' t disrespect this lady. I had 17 other patients I had to look after. She was disrespectful to me, calling me bitches, hoes, called me gay, all types of crazy names ... She complained about being hungry and I told her we don ' t have any snack, we don ' t have nothing and I just kept walking. RN #67 eventually left the unit in search for snacks. Meanwhile we have other patients acting out having episode. So I was all over the place last night. My attention was just not on one patient. "

Record review of Written Statement by MHT #78 dated 08/18/15 [not timed] revealed that MHT #78 informed the CNO #79 that the patient was upset because MHT #77 called her a " fat black bitch. " MHT #78 concluded: CNO #79 " laughed and asked if the patient was black. I responded ' yes ' and that I did not witness any aggressive behavior or language from MHT #77 all night. I speculated to him [CNO #79] it may have been a male patient on the unit because several male patients were wake talking, yelling, cursing and walking around all night. " CNO #79 " agreed this was not in MHT #77 ' s character " ... " and that since the statement was said behind a closed door and not witnessed, it would be unsubstantiated. "

Record review of Written Statement by MHT #80 on 08/11/15 [not timed] revealed: Patient #1 asked for her breakfast. " I told her that she had to get up because of the choking hazard of lying down eating. I asked her could she push herself up against a chair to eat. She stated she couldn ' t move. " MHT #80 escorted the patient to the ER. " Patient told everybody that would listen at hospital how she was left on floor at the psych hospital ... She wanted me to apologize for not giving her the breakfast. I told her about choking reason. "

Record review of Radiology Report by MD #69 dated 08/10/15 at 1047 revealed: " Small triangular fragment is seen at the anterior tip of the tibia. Adjacent soft tissue swelling is seen ... Minimally displaced fracture of the anterior tip of the tibia. "

In an interview with CEO #51 on 10/20/15 at 0915, he stated Patient #1 should have been sent to a medical hospital the evening of the alleged fall.

In an interview with RN #81 on 10/20/15 at 0905, she stated that a peer review was done on RN #64, RN #65, RN #76 and RN #67 on 09/03/15. These four RNs had been terminated but " corporate decided to allow them to return. "

In an interview with RN #81 on 10/20/15 at 0905, she stated that a peer review was done on RN #64, RN #65, RN #76 and RN #67 on 09/03/15. These four RNs had been terminated but " corporate decided to allow them to return. "

In an interview with RN #81 on 10/21/15 at 1455, she stated, " There ' s a culture here that needs to be changed. Nurses need to know that patient care comes first and act on the patient ' s needs. " She stated that the training outlined in the Root Cause Analysis plan of correction did not address the real problem. The abuse and neglect policy was covered in the training. She also stated that critical thinking skills and following the policies and procedures were not discussed with the RNs. She also stated that RN #64, RN #76 and RN #67 had not had the required training but were working the units.

Record review on 10/21/15 of Crisis Prevention Institute (CPI) training in four Personnel Files revealed RN #64 expired 10/07/15 and RN #67 expired 10/11/15.

In an interview with Human Resources Director #82 on 10/21/15 at 1300, she stated that Crisis Prevention training is a mandatory annual training. She also stated three RNs were terminated and then reinstated with no break in service. CEO #51 " reinstated the staff. " She concluded, " There needs to be a culture change here for nurses to feel empowered. "

In an interview with Medical Director MD #73 on 10/21/15 at 0900, he stated he was concerned that the staff didn ' t send Patient #1 to be evaluated earlier, " especially in view of the medical history. " He stated that he usually gets calls about such matters as this incident but staff did not phone him. " I would have sent the patient to the hospital immediately. " He stated, " I think that because of staffing shortages, it is an expectation that the nursing supervisor covers for staff breaks. "

Record review of the Policy & Procedure, Patient Safety / Injury, last reviewed 12/2014, revealed: " It is the policy of Texas West Oaks Hospital that patient safety is the top priority and every reasonable measure will be taken to ensure patient safety ... When a patient receives an injury while at West Oaks Hospital, that patient shall be assessed by professional medical staff as soon as possible after the injury is observed or reported ... The House Supervisor, Administrator on Call and Medical Director shall be notified ... If in the professional opinion of the RN, a more comprehensive assessment is warranted, a physician shall be contacted to assess the injury ... "

Record review of Policy & Procedure, Plan for the Provision of Nursing Care, last reviewed 12/2014, revealed:
" Oversight Process ... In consultation with admitting staff and unit staff, patient care needs and staffing resources are matched. Consultation includes, but is not limited to, the following: Census, admissions, discharges, transfers, 1:1 precautions, and other special patient needs ...
Nursing Services Objectives ... Providing individualized care and protecting the rights of each individual patient so that dignity and respect are maintained ...
Provision of Care Guidelines ... Safety related task assignments are made each shift, which designate who will make patient rounds ... When there are problems with assignments which cannot be handled by on-duty unit staff, the Nurse Supervisor is notified and consulted for support / recommendations. "

Record review of Policy & Procedure, Patient Rights and Responsibilities, last reviewed 03/2015, revealed: 3. The right to a humane treatment environment that ensures protection from harm, provides privacy to as great a degree as possible with regard to personal needs as well as promotes dignity for each individual ... 24. The right to be free from mistreatment, abuse, neglect and exploitation. "

Record review of Policy & Procedure, Job Description: Nursing Supervisor, last revised 06/2014, revealed: " Key Responsibilities ... Purpose: To provide direct supervision for all nursing personnel ... 1. To provide leadership and direction to all Registered Nurses, Licensed Vocational Nurses and Mental Health Workers as well as clinical/administrative support for facility during his/her shift ... 3. To ensure the hospital maintains proper staffing levels while on duty ... Standard #1 ... Effectively asses the delivery of patient care ... Standard #2 ... Initiates appropriate and efficient intervention in the delivery of patient care and during medical psychiatric emergencies ... Customer Service Excellence Standards ... 2 ... Displays dignity, respect, and a customer care attitude toward patients. "
VIOLATION: NURSING SERVICES Tag No: A0385
Based on interview and record review, the facility failed to ensure that:


1. 1 of 1 patients (Patient #1) was assessed by a professional medical staff as soon as possible after her reported injury. The actions of staff did not provide a humane and safe treatment environment as the patient laid in the floor for 14-hours following a fall.


2. 2 of 2 units were adequately staffed with RNs and Mental Health Technicians (MHT).


3. 1 of 1 units was adequately staffed to allow the Nursing Supervisor immediacy to provide leadership and direction to staff in order to address the medical needs of 1 of 1 patients.


4. 3 of 3 RNs involved in allegations of abuse and neglect toward a patient were provided training prior to returning them to duty.


5. 2 of 4 RNs were trained annually in crisis training.


Findings included:


Record review of RN Narrative by RN #64 dated 08/09/15, at 2200, revealed: "Found Patient #1 on her back on the floor ... (S)tated she slipped in water on the floor ... Staff offer (sic) assist patient to get up ... Patient #1 refused and asked for 911 to be called. Attending MD #61 ... Internist MD #63 and Nursing Supervisor #65 ... called. Supervisor came to unit ... Patient #1 refused to be assisted up to be assessed but stated her back was broken ... MD #63 order [sic] lumbar spine x-ray STAT to rule out fracture. Patient #1 refused [x-ray]. Nursing Supervisor RN #65 and MD #63 notified ... Patient #1 stated she ' ll urinate and defecate on the floor if she needs."


Record review of Written Statement by RN #64 dated 08/12/15, [not timed] revealed: "An alleged fall ... unwitnessed ... [in] the TV dayroom ... on 08/09/15 around 1915 ... Patient refused attempts to be assisted off the floor repeatedly on multiple occasions ... Patient also refused interventions ordered by the MD ... She did not want to be touched and everyone should stay away from her."


In an interview with RN #64 on 10/21/15, at 1320, she stated she was the charge nurse on the evening Patient #1 stated she fell (08/09/15). She stated that the patient never told her she wanted to go to an emergency room . [RN #64 was shown her note from the chart that stated the patient asked for 911 and complained of her back being broken.] She stated she did not know that the patient had renal insufficiency and recent critical lab values.


Record review of Diabetic Record for Patient #1 by Nurse #66 dated 08/09/15, revealed:

At 1630: Blood glucose was 138.
At 2100: Patient refused her Lantus [a long-acting insulin].


Record review of Medication Administration Record for Patient #1 dated 08/09/15, revealed the following medications were not administered after the alleged fall: Lantus insulin, Cozaar [blood pressure medication], trazodone, Albuterol, Cogentin and Coreg [blood pressure medication] at 2100.


Record review of Interview with Supervisor RN #65 by RM #52 on 08/10/15, at 1800, revealed she received a call on 08/09/15 at "around 1915" from RN #64 on PICU about the Patient #1's fall. RN #65 was on Unit 7 providing a dinner break for staff. She left the unit when she found staff to relieve her and went to PICU. Patient #1 "complained that her back was broke and that she was not going to get up ... until 911 was called ... MD #61 was called and no orders were given. MD #63 ordered STAT lumbar spine x-ray ... The x-ray tech arrived at 2140 ... I gave the 11-7 Supervisor RN #76 report and did not think he would leave the patient on the floor all night."


Record review of the Policy & Procedure, Suspected Abuse, Neglect and Sexual Exploitation, last reviewed 06/2015, revealed: "The investigation will be initiated immediately by the Nurse Manager/Program Director or Nursing Supervisor, and shall include interviews documented, dated and signed by the person conducting the interview ... "


In an interview with Supervisor RN #65 on 10/20/15, at 1030, she stated she got a call from the Psychiatric Intensive Care Unit about Patient #1 on 08/09/15, at 1855. She was covering a staff member's dinner break and was unable to go see about the patient until she got relief. She arrived on the unit at 1915. "I normally cover breaks for other people. On the unit I was on, the staffing grid calls for one nurse and one tech. I may have to cover." When questioned about a code blue, "I would have had to get another staff member to relieve me."


Record review of Written Statement by RN Supervisor #76 on 08/10/15 [not timed] revealed, he got report from RN Supervisor #65. He wrote, "Charge nurse RN #64 then called MD #63 the medical doctor (MD #63) but didn't give the order to send the patient out, rather instructed patient be given her pain medication ... She ... complained of shortness of breath. MD #63 was called again ... Albuterol Inhaler was ordered "


Record review of RN Narrative by RN #55 dated 08/10/15, revealed: At 0800, "Patient #1 lying on the floor ... refused to get off floor ... (B)een on the floor from last shift with blanket and a pillow ... (S)ays her back hurts ... (V)ital signs ... 145/92, 75, 18. MD #63 was called. Gave verbal order to send patient to emergency room (ER) ... Patient #1 says she will go."


In an interview with RN #55 on 10/21/15, at 1050, she stated she worked Unit 1 on 08/10/15. Patient #1 was on the floor when she arrived to the unit that morning. She stated, "I think they should have called the ambulance the night before."


Record review of Written Statement by MHT #77 dated 08/10/15 [not timed] revealed that he found Patient #1 on the floor, refusing all help. MHT #77 "stopped a few times to converse." Patient #1 stated, "I'm about to piss and shit on myself." MHT #77 replied, "Well, before you get to pissing, let's go to your room. Again she refused ... yelling and cussing ... banging chairs, slapping the floor - looking for attention, of course. I had walked passed her several times to look for snacks, do my environmental rounds and at times go to check on my phone, also check on her for my every 15-minute rounds. I didn't disrespect this lady. I had 17 other patients I had to look after. She was disrespectful to me, calling me bitches, hoes, called me gay, all types of crazy names ... She complained about being hungry and I told her we don ' t have any snack, we don't have nothing and I just kept walking. RN #67 eventually left the unit in search for snacks. Meanwhile we have other patients acting out having episode. So I was all over the place last night. My attention was just not on one patient."


Record review of Written Statement by MHT #78 dated 08/18/15 [not timed] revealed that MHT #78 informed the CNO #79 that the patient was upset because MHT #77 called her a "fat black bitch." MHT #78 concluded: CNO #79 "laughed and asked if the patient was black. I responded 'yes' and that I did not witness any aggressive behavior or language from MHT #77 all night. I speculated to him [CNO #79] it may have been a male patient on the unit because several male patients were wake talking, yelling, cursing and walking around all night." CNO #79 "agreed this was not in MHT #77's character" ... "and that since the statement was said behind a closed door and not witnessed, it would be unsubstantiated."


Record review of Written Statement by MHT #80 on 08/11/15 [not timed] revealed: Patient #1 asked for her breakfast. "I told her that she had to get up because of the choking hazard of lying down eating. I asked her could she push herself up against a chair to eat. She stated she couldn't move." MHT #80 escorted the Patient #1 to the ER. "Patient told everybody that would listen at hospital how she was left on floor at the psych hospital ... She wanted me to apologize for not giving her the breakfast. I told her about choking reason."


Record review of Radiology Report by MD #69 dated 08/10/15, at 1047, revealed: "Small triangular fragment is seen at the anterior tip of the tibia. Adjacent soft tissue swelling is seen ... Minimally displaced fracture of the anterior tip of the tibia."


In an interview with CEO #51 on 10/20/15, at 0915, he stated Patient #1 should have been sent to a medical hospital the evening of the alleged fall.


In an interview with RN #81 on 10/20/15, at 0905, she stated that a peer review was done on RN #64, RN #65, RN #76 and RN #67 on 09/03/15. These four RNs had been terminated but "corporate decided to allow them to return."


In an interview with RN #81 on 10/21/15 at 1455, she stated, "There's a culture here that needs to be changed. Nurses need to know that patient care comes first and act on the patient's needs." She stated that the training outlined in the Root Cause Analysis plan of correction did not address the real problem. The abuse and neglect policy was covered in the training. She also stated that critical thinking skills and following the policies and procedures were not discussed with the RNs. She also stated that RN #64, RN #76 and RN #67 had not had the required training but were working the units.


Record review on 10/21/15, of Crisis Prevention Institute (CPI) training in four Personnel Files revealed RN #64 expired 10/07/15, and RN #67 expired 10/11/15.


In an interview with Human Resources Director #82 on 10/21/15, at 1300, she stated that Crisis Prevention training is a mandatory annual training. She also stated three RNs were terminated and then reinstated with no break in service. CEO #51 "reinstated the staff." She concluded, "There needs to be a culture change here for nurses to feel empowered."


In an interview with Medical Director MD #73 on 10/21/15, at 0900, he stated he was concerned that the staff didn't send Patient #1 to be evaluated earlier, "especially in view of the medical history." He stated that he usually gets calls about such matters as this incident but staff did not phone him. "I would have sent the patient to the hospital immediately." He stated, "I think that because of staffing shortages, it is an expectation that the nursing supervisor covers for staff breaks."


Record review of the Policy & Procedure, Patient Safety / Injury, last reviewed 12/2014, revealed: "It is the policy of Texas West Oaks Hospital that patient safety is the top priority and every reasonable measure will be taken to ensure patient safety ... When a patient receives an injury while at West Oaks Hospital, that patient shall be assessed by professional medical staff as soon as possible after the injury is observed or reported ... The House Supervisor, Administrator on Call and Medical Director shall be notified ... If in the professional opinion of the RN, a more comprehensive assessment is warranted, a physician shall be contacted to assess the injury ..."


Record review of Policy & Procedure, Plan for the Provision of Nursing Care, last reviewed 12/2014, revealed:

"Oversight Process ... In consultation with admitting staff and unit staff, patient care needs and staffing resources are matched. Consultation includes, but is not limited to, the following: Census, admissions, discharges, transfers, 1:1 precautions, and other special patient needs ...

Nursing Services Objectives ... Providing individualized care and protecting the rights of each individual patient so that dignity and respect are maintained ...
Provision of Care Guidelines ... Safety related task assignments are made each shift, which designate who will make patient rounds ... When there are problems with assignments which cannot be handled by on-duty unit staff, the Nurse Supervisor is notified and consulted for support / recommendations."


Record review of Policy & Procedure, Patient Rights and Responsibilities, last reviewed 03/2015, revealed: 3. The right to a humane treatment environment that ensures protection from harm, provides privacy to as great a degree as possible with regard to personal needs as well as promotes dignity for each individual ... 24. The right to be free from mistreatment, abuse, neglect and exploitation."


Record review of Policy & Procedure, Job Description: Nursing Supervisor, last revised 06/2014, revealed: "Key Responsibilities ... Purpose: To provide direct supervision for all nursing personnel ... 1. To provide leadership and direction to all Registered Nurses, Licensed Vocational Nurses and Mental Health Workers as well as clinical/administrative support for facility during his/her shift ... 3. To ensure the hospital maintains proper staffing levels while on duty ... Standard #1 ... Effectively asses the delivery of patient care ... Standard #2 ... Initiates appropriate and efficient intervention in the delivery of patient care and during medical psychiatric emergencies ... Customer Service Excellence Standards ... 2 ... Displays dignity, respect, and a customer care attitude toward patients."


Staffing Issues.

Psychiatric Intensive Care Unit (PICU) - Groups not being conducted.


Observation of the PICU on 10/21/15, at 1040, revealed two RNs (RN #55 and RN #56) and two MHTs (MHT #57 and MHT #85). There were 15 patients on the unit. Most of the patients were in their rooms and several were in the dayroom, TV room or being seen by clinicians. Both of the RNs were at the Nurse's Station doing paperwork.


Record review of the unit schedule (posted on the wall) revealed a Nursing Group scheduled for 1030-1100.


In an interview with MHT #57 on 10/21/15, at 1040, he stated that earlier in the morning there had been an incident with Patient #2 and that the group was not done because of the paperwork that had to be completed.


Unit Two - Rounds Sheets.


Observation of Unit Two (an adult stepdown to PICU) on 10/21/15, at 1130, revealed two RNs (RN #58 and RN #59) and one MHT (MHT #60). There were 13 patients on the unit. All but one of the patients was in a group session with LCDC #86. That one patient not in group was wandering the unit. The RNs #58 and #59 were at the Nurse ' s Station doing paperwork. MHT #60 was writing on the rounds sheets.


Record review of the 15-minute rounds sheets showed that 9 of the 13 rounds sheets had not been charted on for 30 minutes.


In an interview with MHT #60 on 10/21/15, at 1130, she stated that she had stepped off the unit to go to the bathroom and was trying to get the round sheets caught up. She stated she gave the rounds sheets to RN #59 who did not document the 1015 rounds. MHT #60 stated she was getting the rounds sheets caught up. She also stated that Unit Two did not get another MHT until the census was 16 patients.


In an interview with RN #59 on 10/21/15, at 1140, she stated that MHT #60 gave her the rounds sheets when MHT #60 left the unit. RN #59 did not document the whereabouts of the patients on the rounds sheets. " The patients were in the group room. I had to get a script for a doctor. " She also stated she did not have enough staff with 13 patients and that she got a second MHT when the unit census reached 16 patients.


In an interview with Medical Director MD #73 on 10/21/15, at 0900, he stated, "I think that because of staffing shortages, it is an expectation that the nursing supervisor covers for staff breaks."


Record review of Policy & Procedure, Plan for the Provision of Nursing Care, last reviewed 12/2014, revealed:

"Oversight Process ... In consultation with admitting staff and unit staff, patient care needs and staffing resources are matched. Consultation includes, but is not limited to, the following: Census, admissions, discharges, transfers, 1:1 precautions, and other special patient needs ...

Nursing Services Objectives ... Providing individualized care and protecting the rights of each individual patient so that dignity and respect are maintained ...

Provision of Care Guidelines ... Safety related task assignments are made each shift, which designate who will make patient rounds ... When there are problems with assignments which cannot be handled by on-duty unit staff, the Nurse Supervisor is notified and consulted for support / recommendations."


Record review of Policy & Procedure, Levels of Observation, last reviewed 12/2014, revealed: "15 minute observations are the minimum level of observation for all patients ... Staff shall observe patient and document on the patient Observation Record every 15 minutes ... The RNs on the unit will be responsible for overseeing that observations are conducted as scheduled ... Assigned staff will make direct visual contact with patients and confirm they are in no danger or distress."


Record review of Policy & Procedure, Staffing Patterns for Nursing, last reviewed 12/2014, revealed: " The mix of Registered Nurses, Licensed Vocational Nurses, and Psychiatric Technicians shall be determined each shift based upon the patient care needs of the patients, capabilities/qualifications of the staff and availability of staff. Determining the appropriate staffing mix is the responsibility of the Program Directors, or Nursing Supervisor, with oversight by the Chief Nursing Officer.


Record review of Policy & Procedure, Job Description: Nursing Supervisor, last revised 06/2014, revealed: "Key Responsibilities ... Purpose: To provide direct supervision for all nursing personnel ... 1. To provide leadership and direction to all Registered Nurses, Licensed Vocational Nurses and Mental Health Workers as well as clinical/administrative support for facility during his/her shift ... 3. To ensure the hospital maintains proper staffing levels while on duty ... Standard #1 ... Effectively asses the delivery of patient care ... Standard #2 ... Initiates appropriate and efficient intervention in the delivery of patient care and during medical psychiatric emergencies ... Customer Service Excellence Standards ... 2 ... Displays dignity, respect, and a customer care attitude toward patients."


In an interview with Supervisor RN #65 on 10/20/15, at 1030, she stated she got a call from the Psychiatric Intensive Care Unit about Patient #1 on 08/09/15, at 1855. She was covering a staff member's dinner break and was unable to go see about the patient until she got relief. She arrived on the unit at 1915. "I normally cover breaks for other people. On the unit I was on, the staffing grid calls for one nurse and one tech. I may have to cover." When questioned about a code blue, "I would have had to get another staff member to relieve me."


In an interview with Medical Director MD #73 on 10/21/15, at 0900, he stated he was concerned that the staff didn't send Patient #1 to be evaluated earlier, "especially in view of the medical history." He stated that he usually gets calls about such matters as this incident but staff did not phone him. "I would have sent the patient to the hospital immediately." He stated, "I think that because of staffing shortages, it is an expectation that the nursing supervisor covers for staff breaks."


In an interview with Medical Director MD #73 on 10/21/15, at 0900, he stated, "I think that because of staffing shortages, it is an expectation that the nursing supervisor covers for staff breaks."


Record review of Policy & Procedure, Job Description: Nursing Supervisor, last revised 06/2014, revealed: "Key Responsibilities ... Purpose: To provide direct supervision for all nursing personnel ... 1. To provide leadership and direction to all Registered Nurses, Licensed Vocational Nurses and Mental Health Workers as well as clinical/administrative support for facility during his/her shift ... 3. To ensure the hospital maintains proper staffing levels while on duty ... Standard #1 ... Effectively asses the delivery of patient care ... Standard #2 ... Initiates appropriate and efficient intervention in the delivery of patient care and during medical psychiatric emergencies ... Customer Service Excellence Standards ... 2 ... Displays dignity, respect, and a customer care attitude toward patients."


Training Issues.

In an interview with RN #81 on 10/20/15, at 0905, she stated that a peer review was done on RN #64, RN #65, RN #76 and RN #67 on 09/03/15. These four RNs had been terminated but "corporate decided to allow them to return."


Record review of Intensive Analysis Action Plan (dated 08/24/15) by RM #52 and CNO #79 revealed:

Actions to prevent incident from reoccurring: 100% of staff in all department will receive additional training on abuse, neglect and exploitation. Staff will be able to identify abuse, neglect and exploitation [and] how to make an internal and external report of abuse, neglect and exploitation ... Training to be completed by 09/12/15.


In an interview with RN #81 on 10/21/15, at 1455, she stated, " There's a culture here that needs to be changed. Nurses need to know that patient care comes first and act on the patient's needs." She stated that the training outlined in the Root Cause Analysis plan of correction did not address the real problem. The abuse and neglect policy was covered in the training. She also stated that critical thinking skills and following the policies and procedures were not discussed with the RNs. She also stated that RN #64, RN #76, and RN #67 had not had the required training but were working the units.


In an interview with Human Resources Director #82 on 10/21/15, at 1300, she stated that Crisis Prevention training is a mandatory annual training. She also stated three RNs were terminated and then reinstated with no break in service. CEO #51 "reinstated the staff." She concluded, "There needs to be a culture change here for nurses to feel empowered."


Record review on 10/21/15, of Crisis Prevention Institute (CPI) training in four Personnel Files revealed RN #64 expired 10/07/15 and RN #67 expired 10/11/15.


In an interview with Human Resources Director #82 on 10/21/15, at 1430, she confirmed these dates and stated it was an annual requirement to complete CPI training.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on observation, interview and record review, the facility failed to ensure that staff members responsible for monitoring patients every 15 minutes documented their observations for 13 of 13 charts.

Findings included:

Unit Two - Rounds Sheets.

Observation of Unit Two (an adult stepdown to PICU) on 10/21/15 at 1130 revealed two RNs (RN #58 and RN #59) and one MHT (MHT #60). There were 13 patients on the unit. All but one of the patients was in a group session with LCDC #86. That one patient not in group was wandering the unit. The RNs #58 and #59 were at the Nurse ' s Station doing paperwork. MHT #60 was writing on the rounds sheets.

Record review of the 15-minute rounds sheets showed that 9 of the 13 (Patients #13, 14, 15, 16, 17, 18, 19, 20 and Patient #21) rounds sheets had not been charted on for 30 minutes.

In an interview with MHT #60 on 10/21/15 at 1130, she stated that she had stepped off the unit to go to the bathroom. She stated she gave the rounds sheets to RN #59 who did not document the 1015 rounds. MHT #60 stated she was getting the rounds sheets caught up.

In an interview with RN #59 on 10/21/15 at 1140, she stated that MHT #60 gave her the rounds sheets when MHT #60 left the unit. RN #59 did not document the whereabouts of the patients on the rounds sheets. " The patients were in the group room. I had to get a script for a doctor. "
VIOLATION: CONTENT OF RECORD - DISCHARGE DIAGNOSIS Tag No: A0469
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the facility failed to ensure that Discharge Summaries were promptly completed in 4 of 11 closed charts.

Findings included:

Record review of 11 closed charts (Patients #1, 3, 4, 5, 6, 7, 8, 9, 10, 11 and Patient #12) revealed that four had incomplete Discharge Summaries.
Patient #1 - discharged [DATE] - No discharge diagnosis and no MD signature.
Patient #8 - discharged [DATE] - Mental Status Exam left blank.
Patient #3 - discharged [DATE] - Mental Status Exam left blank.
Patient #12 - discharged [DATE] - Not dated or timed.

Record review of Policy & Procedure, Entries Made into the Medical Record, last reviewed 2012, revealed: " All entries shall be timed, dated and authenticated with practitioner ' s signature and credential ... Final diagnoses shall be made utilizing the Diagnostic Statistical Manual - IV (DSM) Diagnostic Coding System. "
VIOLATION: DIETS Tag No: A0630
Based on interview and record review, the facility failed to ensure that:
the nutritional needs of patients were met on 2 of 5 adult units and
1 of 1 patients was provided snacks or breakfast after having laid in the floor all night following a fall.

Findings included:

Record review of Written Statement by MHT #77 dated 08/10/15 [not timed] revealed: " I didn ' t disrespect this lady. I had 17 other patients I had to look after. She was disrespectful to me, calling me bitches, hoes, called me gay, all types of crazy names ... She complained about being hungry and I told her we don ' t have any snack, we don ' t have nothing and I just kept walking. RN #67 eventually left the unit in search for snacks. "

In an interview with Dietary Manager #83 on 10/21/150 at 1000, he stated that staff sometimes eat the patient ' s snacks. Sometimes the nurses complain that there ' s not enough snacks. Snacks include cereal, milk, cheese, chips, cookies, granola, popcorn and fruit.

In an interview with Dietary Cook #84 on 10/21/15 at 1005, she stated that sometimes there are complaints of not enough snacks, especially on two of the adult units. There are five adult units.

In interviews with RN #55 and RN #56 on 10/21/15 at 1015, both stated that sometimes there are not enough snacks, especially at night. Both stated that patients sometimes complain of not enough snacks.

Record review of Policy & Procedure, Administrative Policy and Procedures on Food and Nutrition Services, last reviewed 02/2014, revealed: " The following service shall be provided by the Food and Nutrition Services Department ... 2 ...j. Snacks for patients ... 29. Patients shall not be denied regularly scheduled meals nor shall staff use the threat of withholding meals in an attempt to change the patient ' s behavior.