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.

BEHAVIORAL HOSPITAL OF LONGVIEW 22 BERMUDA LANE LONGVIEW, TX Oct. 3, 2012
VIOLATION: NURSING SERVICES Tag No: A0385
Based upon observations, records review, and interviews, the facility failed to:

A. Follow its own staffing plan and staffing grid to ensure there was adequate nursing staff on patient care units to meet the needs of the patients on 3 of 3 patient care units. The facility also failed to provide adequate nurse staffing to provide special levels of precaution for patients determined to need intensified patient supervision. This practice created the potential for harm for all patients due to lack of safe patient supervision.

Refer to A392

B. Protect the patients from abuse and harassment. 6 of 19 (#8, #9, #10, #12, #13, #17) patients were strip searched by staff during a contraband search for illicit medications. This practice caused actual harm to the patients who were stripped searched. This practice also posed a potential threat of harm to all patients in the facility.

Refer to A145
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based upon observations, records review, and interviews, the facility failed to follow its own staffing plan and staffing grid to ensure there was adequate nursing staff on patient care units to meet the needs of the patients on 3 of 3 patient care units. The facility also failed to provide adequate nurse staffing to provide special levels of precaution for patients determined to need intensified patient supervision. This practice created the potential for harm for all patients due to lack of safe patient supervision.

Review of the facility policy titled "Nurse Staffing Plan and Nurse Staffing Committee" revealed the following information:

"Staffing Procedure: A. General Staffing - Staffing patterns are determined by a combination of employees per occupied bed ratio (In Patient) and a patient acuity system, with consideration given to individual patient needs in each program. A core staff level is determined for each inpatient unit consisting of a charge nurse, mental health technicians, social workers, and activity therapists. Each addictive disease program also has a chemical dependency counselor. Adjustments to the core staffing levels are made on the basis of acuity. Such adjustments for planned staffing are made several times daily by the Director of Nursing or his/her designee. The staffing for each unit is based on several critical factors: Patient characteristics and number of patients; Acuity level of the patients; Variability of patient care across the unit; Scope of services provided by each unit; The anticipated admissions, discharges, and transfers; Nursing staff competency, experience and other pertinent factors."

Further review of the policy "Nurse Staffing Plan" revealed there were no guidelines for determining the acuity of the patients and how adjustments to staffing would be determined based upon the acuity of the patients. The plan also had no provisions for additional staffing when patients required 1:1 or "line of sight" monitoring.

Review of the "Staffing Grid", with effective date of 7/9/12, revealed a core staffing level that determined the number of RNs(Registered Nurse), LVNs(Licensed Vocational Nurse, and MHTs(Mental Health Technician) needed on each unit based upon the number of patients on each unit.

A review was conducted of the actual staffing sheets, which is a daily working document that includes the patient census per unit and the assigned nursing staff for each shift. The staffing sheets were reviewed with the staffing grid to determine if the facility had adequate staffing. Staffing sheets were requested for a 3 month period (June, July, and August, 2012) but the only staffing sheets provided by the facility were for the time period of 7/13/12 - 7/25/12 (12 days), and the time period of 8/1/12 - 8/23/12 (22 days). During the 12 day time period of 7/13/12 - 7/25/12, there were 42 shifts that were understaffed based upon the staffing grid that is presently being used.

Further review revealed that additional staff was not added to the original staffing pattern when patients required 1:1 or "line of sight" monitoring for 39 of those 42 shifts. (1:1 monitoring is a staff member present with reaching distance at all times, and "line of sight" monitoring is a staff member providing constant observation at all times but does not have to be within reaching distance.)

During the 22 day time period of 8/1/12 - 8/23/12, there were 61 shifts that were understaffed based upon the staffing grid that is presently being used. Further review revealed additional staff was not added to the original staffing pattern when patients required 1:1 or "line of sight" monitoring for 21 of those 61 shifts.

An observational tour was conducted on the date of the survey, 9/7/12, to determine the census on the treatment units and the number of nursing staff providing direct patient care. At approximately 11:15 AM on Unit 2 (Dual Diagnosis Unit), the nurse staffing was observed to be 1 RN and 1 MHT and the patient census was 13. The staffing grid reflected that the core staff for Unit 2 with a patient census of 11-15 would be one RN and two MHT. At approximately 11:30 AM on Unit 4 (Dual Diagnosis Unit), the nurse staffing was 1 RN and 1 MHT and the patient census was 14. The required number of staff for Unit 4, based upon the core staffing grid, with 11 - 15 patients was 1 RN and 2 MHTs. Therefore, Unit 2 and Unit 4 were not adequately staffed.

An interview was conducted with the Administrator on 9/7/12 at approximately 11:30 AM during the tour. The Administrator reported that an RN and MHT were staffed on Unit 2 and Unit 4 because the acuity was low on the dual diagnosis unit. When asked how the acuity was determined, the Administrator reported that is was based on the patient care needs. The administrator further reported that the facility has had 2 staffing coordinators in recent months that weren't doing their job so they were terminated. The Administrator reported that she did staffing for a while but it was now the responsibility of the Director of Nurses. Staffing sheets were reviewed with the Administrator with focus on inadequate staffing on different shifts and additional staff not added when patients needed 1:1 or line of sight monitoring. The Administrator responded by saying "What can I say, it is what it is".

Review of the facility policy titled "Observation of Patients" revealed the following procedure: " 7. Special Precaution Levels and protocol guidelines that may be ordered include:

A. One to One

Guidelines for implementation of this level of precaution include, but are not limited to the following:
1) Patient is restricted to a secure, locked unit except in case of fire, medical or other emergencies.
2) 1:1 staff presence is required at all times - defined as within reaching distance including times for personal hygiene, toileting and other self-care needs. When necessary, arrangements should be made for same sex staff to accompany the patient during times
of personal hygiene, toileting and other self-care needs.
3) Access to sharps, belts, cords, laces or other personal items - which may increase risk - should be denied.
4) Patients may not leave the facility unless in an emergency at which time a staff member must be assigned to accompany and continue the one to one level of precaution.
5) A Patient Rounds Sheet, which reflects the patient's location and observed behaviors every 5 minutes, is maintained.
6) Reassessment by a physician should be completed and documented at least every 24 hours with clinical justification for renewal, modification or discontinuation of orders for 1:1. The order for 1:1 should be renewed every 24 hours.

B. Constant Observation (Line of Sight)

Guidelines for implementation of this level of precaution include but are
not limited to the following:
1) Patient is restricted to a secure, locked unit except in case of fire,
medical or other emergencies. Smoking is allowed only in a secured area.
2) During times for personal hygiene, toileting and other self-care needs, the staff should be in visual and hearing range of the bathroom door.
3) When necessary arrangements should be made for same sex staff to accompany the patient during times of personal hygiene, toileting and other self-care needs.
4) Meals are provided on the unit.
5) A physician may order the status to close observation after a patient is asleep (anytime day or night). If this is the case, once asleep the status will change to close observation.
Constant Observation will resume when awake.
6)Patients may not leave the facility unless in an emergency at which time a staff member must be assigned to accompany.
7) A Patient Rounds Sheet which reflects the patient's location and observed behaviors every 5 minutes is maintained."

A revisit was conducted to the facility on [DATE] after receiving an Immediate Jeopardy triaged complaint related to inadequate staffing and patient abuse. Review of staffing sheets was conducted for staffing dated 8/24/12 - 9/6/12 and 9/14/12 - 9/24/12. Review of staffing sheets for these time periods combined revealed 49 of 84 shifts were inadequately staffed based upon the facility's minimal core staffing grid. Six of those 49 shifts were inadequately staffed due to not adding additional staff when a patient required 1:1 staffing.

An interview was conducted with the Administrator on 9/26/2012 at 8:20 AM in the conference room. The Administrator was informed of the inadequate staffing for the facility and lack of additional staffing provided when patients required 1:1 monitoring. The Administrator reported she has been here for nine months and that she was not aware of adding staff for 1:1 or "line of sight" monitoring. The facility policy was read aloud to the Administrator and her response was "ok" .
VIOLATION: GOVERNING BODY Tag No: A0043
Based upon observation, record review, and interview, the facility failed to have an effective Governing Body based upon the deficiencies cited on the complaint investigation conducted on 9/7/2012, 9/25/2012, and 10/3/2012. This failed practice had the potential to affect all patients admitted to the facility.

A. Follow its own staffing plan and staffing grid to ensure there was adequate nursing staff on patient care units to meet the needs of the patients on 3 of 3 patient care units. The facility also failed to provide adequate nurse staffing to provide special levels of precaution for patients determined to need intensified patient supervision. This practice created the potential for harm for all patients due to lack of safe patient supervision.

Refer to A392

B. Protect the patients from abuse and harassment. 6 of 19 (#8, #9, #10, #12, #13, #17) patients were strip searched by nursing staff during a contraband search for illicit medications. This practice caused actual harm to the patients who were stripped searched. This practice also posed a potential threat of harm to all patients in the facility.

Refer to A145
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observations, records review, and interviews, the facility failed to:

A. Protect the patients from abuse and harassment. 6 of 19 (#8, #9, #10, #12, #13, #17) patients were strip searched by staff during a contraband search for illicit medications. This practice caused actual harm to the patients who were stripped searched. This practice also posed a potential threat of harm to all patients in the facility.

Refer to A145

B. Follow its own staffing plan and staffing grid to ensure there was adequate nursing staff on patient care units to meet the needs of the patients on 3 of 3 patient care units. The facility also failed to provide adequate nurse staffing to provide special levels of precaution for patients determined to need intensified patient supervision. This practice created the potential for harm for all patients due to lack of safe patient supervision.

Refer to A392
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on records review and interviews, the facility failed to ensure 6 of 19 (#8, #9, #10, #12, #13, #17) patients were free from abuse in the facility. The patients were strip searched by staff during a contraband search for illicit medications in 6 of 19 (#8, #9, #10, #12, #13, #17) sampled patients . This practice caused actual harm to the patients who were stripped searched. This practice also posed a potential threat of harm to all patients in the facility.

An interview was conducted with Staff #8 (Quality/Risk Manager) on 9/25/12 at 4:25 pm in the conference room. Staff #8 reported being the Administrator on Call on Sunday, September 16, 2012. Staff #8 received a call from Staff #2 that she had been informed the patients were talking in group and reported that Patient #1 had brought in medication and given it to several patients. Staff #8 reported she instructed Staff #2 to have the patients involved to give a statement as to what had happened and to also conduct a thorough contraband search to ensure there were no other medications. Instructions were given to staff #2 to explain to the patients that the search would be done and why. Instructions were also given that the search consisted of taking socks and shoes off and shaking them out, turning all pockets inside out, checking the waistbands of pants, and females were to loosen their bra and shake it out. Staff #2 reported to Staff #8 that patient #1 had admitted to having 1 tablet of Soma and 3 tablets of Oxycontin. Patient #1 admitted giving the Soma to patient #2 and giving 2 tablets of Oxycontin to patient #10. Staff #2 also reported that nothing was found in the contraband search. There was one Oxycontin tablet that was never found.

An interview was conducted with the Administrator on 9/26/12 at 8:20 AM in the conference room. The Administrator reported she went to have a unit meeting on 9/17/12 at approximately 3:00 PM with patients because they were disgruntled about smoke breaks and having access to cigarettes. It was in the meeting with the patients that a patient in the group asked if it was legal to strip search patients. The Administrator reported the patient was told no and after the patient shared the details she apologized to the patient for that occurrence and assured the patient she would have it investigated. On 9/18/12 at 8:00 AM, the Administrator instructed Staff #8 to conduct an investigation and determine what had occurred and to what extent.

Review of a timeline provided by the Staff #8 on 9/25/12 revealed that on 9/18/12, the Administrator instructed Staff #8 to conduct an investigation of the allegations. The timeline revealed that Staff #8 went immediately to the unit and interviewed all patients and was able to determine that patients #8, #9, #10, #12, #13, and #17 had all been strip searched. The report revealed all 6 patients were males and they were told to go into the bathroom of their room, remove their clothing, cup their testicles, squat down, and cough. The same information was provided by all 6 patients.

An interview was conducted on 9/25/12 at 3:00 PM in the conference room with staff #2 who was the Charge Nurse on 9/16/12 when the incident occurred. Staff #2 reported that Staff #1 came to her and reported that during the group therapy, someone brought up that a female patient had brought in medication and had given it out to other patients. Staff #2 reported that she called Staff #8 who was the Administrator on Call and reported the information provided. Staff #2 reported that Staff #8 instructed to do a thorough search for contraband. Staff #2 reported to Staff #8 that she did not know what that meant and Staff #8 instructed to take shoes and socks off and shake out, pull out their pockets, and females were to pull their bras out and shake them out. Staff #2 reported that Staff #5, a male Mental Health Technician (MHT), was sent from another unit to assist with the search. The MHTs were to take the patients 2 at a time in their room and go through their personal belongings. Staff #2 reported she was not assisting with the searches because the other patients on the unit were upset and they were trying to keep them in one area while the searches were conducted. Staff #2 reported she was unaware of strip searches until 9/19/12 when she received a call at home asking her to provide a statement of what occurred on 9/16/12.

An interview was conducted on 9/26/12 at 9:30 AM with staff #5, who was the male Mental Health Technician (MHT) that came from another unit to assist with the contraband search. Staff #5 reported on arrival to the unit that he met with staff #2 who instructed him to search the patients for medications by pulling their pockets inside out, take off their shoes and socks, and check the waist band of their pants. Staff #5 reported that another MHT(staff #6) came to the unit to assist with the searches and came into the room and instructed that each male patient was to be taken to the bathroom and stripped searched. Staff #5 reported that he questioned staff #6 as to why and was told that was how a contraband search was done. Staff #5 reported that staff #6 instructed him to take the male patient to the bathroom and have them remove their clothes, cup their testicles, squat and cough. Staff #5 reported not all patients were strip searched. Staff #5 reported that the search was called off when patients confessed to having taken the medications that were brought in.

An interview was conducted on 9/26/12 at10:30 AM with staff #6. Staff #6 reported that she was asked by Staff #8, Quality/Risk Manager, to assist with the contraband search. Staff #6 reported that she was told to find illegal drugs on the unit no matter what. Staff #6 reported that the searches had already started and Staff #3 and Staff #5 were having the patients turn their pockets inside out, shoes and socks off. Staff #6 reported that she instructed Staff #5 to take the men in the bathroom and check their underwear. Staff #6 reported the patients were not stripped searched. When Staff #6 was asked if she instructed the other MHTs to have patients remove their clothes, cup their testicles, squat, and cough, staff #6 reported yes, that was done. Staff #6 reported that she had been told they were to find the drugs no matter what. Staff #6 reported that she did not consider that a strip search; that she considered a strip search was putting on gloves and searching cavities.

An interview was conducted on 9/26/12 at 10:40 AM with staff #3. Staff #3 reported that staff #1 and staff #2 decided that a contraband search needed to be done due to the reports that a patient had brought medications into the facility and was giving it to patients. Staff #3 reported that staff #5 was to search the males and staff #3 and #4 were to search the females. Staff #3 reported that staff #6 came to the unit to assist with the searches and instructed staff #5 to strip search the men in the bathroom and the other MHTs would search the room and go through their belongings. Staff #3 reported that she had worked in the prison system and she knew that type of search was not an appropriate search and decided she would only be involved in the room and belongings search.

Review of the facility's policy and procedure manual revealed a policy #CL-3:002, titled Contraband that was revised 3/9/11. The policy stated "It is the policy of Behavioral Hospital of Longview that contraband not be brought into the hospital." The procedure for the policy dealt with the confiscation of contraband and proper determination of disposal and is to be documented in the patients' record. The policy did not address contraband searches and there was no guidance as to what would be considered contraband.

Review of the facility's policy #NUR-7.106 titled Search and Seizure of Contraband, Effective 5/10/12 revealed the following: "Policy: It is the policy of this facility to ensure the safety and health of clients. The Intensive Residential Treatment and Detox Unit may invoke it's right to conduct a search and seizure if there is probable cause to believe that illegal substances, objects or other contraband are in the possession of clients or present in the facility." This document contained this policy statement but did not contain procedures as to how these searches were to be conducted. The facility does not even have Intensive Residential Treatment or a Detox Unit. It has short term dual diagnoses (Chemical Dependency/Psychiatric) programs. Further review of policies revealed there was no policy related to when and how to conduct contraband searches. Review of employee orientation manual revealed no training or instructions regarding contraband searches.

Interviews with staff #2, #3, #4, #5, and #6 on 9/26/12 between 8:30 - 11:00 AM revealed none of the staff had received training on how to conduct a contraband search. Review of personnel files for staff #2, #3, #4, #5, and #6 revealed no documentation of training relating to contraband searches.