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 July 17, 2013
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
Based on review of Governing Board (GB) minutes and interviews, the GB failed to appoint a chief executive officer (CEO) to provide a hospital-wide oversight of the hospital.


Review of the GB bylaws revealed, "Article V ADMINISTRATION OF THE HOSPITAL. Section 501 The Administrator shall be appointed by the GB from a list of qualified candidates. The Administrator shall serve until she/he resigns or is removed for good cause."


Review of the documented GB minutes for 2013 showed that the last documented meeting was on 4/24/2013. There were no documented GB minutes that included appointment of staff #1 as the CEO.


Interview with Staff#1, Staff#2, and Staff#3 on 7/16/13, confirmed that there had been no GB meeting to appoint the CEO to manage the hospital. Staff #1 reported that he had been in the CEO position for 55 days.
VIOLATION: RN/LPN STAFFING Tag No: A0393
Based on review of staffing schedules, observations, and interviews, the facility failed to follow its own policy and procedures to have a Registered Nurse (RN) on each unit to supervise and evaluate staff and patients.

Review of the facility's policy and procedure,"Staffing Patterns and Guidelines Nursing," revealed the following:

"1. A sufficient number of qualified registered nurses, licensed practical nurses and mental health technicians will be available at all times to each patient care area to provide a safe and therapeutic environment.

2. Staffing patterns have been established in collaboration with the Executive Director and the Director of Nursing with input from charge nurse.

3. Staffing determinations are based on several factors, including but not limited to:
A. Number of patients requiring special precautions and the severity of those precautions.
B. Number, frequency, and the length of time special treatment procedures are required.
C. Special medical care needs (transports for special medical care and physical illnesses requiring extraordinary staff time).
D. Number of patients requiring behavioral intervention.
E. Number of patients who are admitted and who are considered emergency admissions.
F. Number of patients who are admitted and who are considered scheduled admissions.

4. The established nursing staff-patient ratio will be approximately six (6) patients to every one (1) staff member.

5. At all times, the minimum number of nursing staff on the day and evening shifts will be two registered nurses and/or licensed practical nurses with one mental health technician per shift, per program area

6. On the night shift, the minimum number of nursing staff will be one registered nurse and/or licensed practical nurse and one mental health technician per shift per program area.

7. There will be at least one registered nurse on the night shift at all times.

8. Staffing needs are reassessed every shift as well as weekly to determine patient status which would warrant alterations in the staffing pattern.

9. Determination of additional staff will be at the discretion of the charge nurse with approval of the Director of Nursing and/or Executive Director.

10. A relief pool of nursing staff (registered nurses, licensed practical nurses, mental health technicians) has been established to assist with extra staffing requirements. Overtime pay may also be granted to regular nursing staff if extra staffing becomes necessary.

11. Due to the special needs of our patients, it is the policy of Behavioral Hospital of Longview not to use the services of agency personnel for nursing staff."

Review of the staffing grid revealed a patient census of 1-8 patients should have one RN, one LVN, and one MHT. A patient census of 9-24 patients should have one RN, one LVN, and two MHT's per unit. There will be a RN house supervisor per shift to perform admissions.

Review of the staffing schedules 4/13-7/13, 2013, revealed that shifts had not been covered with sufficient personnel according to the hospital's staffing grid. RN House Supervisors are responsible to perform the admission process. The House Supervisor must leave the unit and go to the admissions office to conduct a patient admission. Telemedicine (a process where the physician performs the psychiatric evaluation and interview from an offsite location) is performed during the admission process and the patient's belongings are searched in the admissions office. The House Supervisor is to take the patient to the unit after the completion of the admission process.

Review of staffing schedule 6/4/2013, revealed Staff #9 was scheduled as the RN House Supervisor. Staff #9 was pulled at the beginning of the shift to work in the LVN (Licensed Vocational Nurse) slot from 7:00PM-7:00AM on Unit 2. Unit 2 had 15 patients, a one patient on 1:1 staff-patient (one staff member to one patient), and 1 admission at 7:30PM. Staff #9 had to leave the unit to perform the admission process. This left the unit without RN supervision.

Review of staffing schedule 6/5/2013, revealed Unit 2 had 14 patients. Staff #10 was scheduled to work as a MHT (Mental Health Technician) for the 7AM-7PM shift. Notation on schedule states, "6/4/2013 850-Staff #10's car won't start. Staff #12 will cover starting at 12:30PM on 6/5/13." Unit 2 was short of a MHT for two hours. Unit one had 14 patients. 1- RN, 1- LVN, and 1- MHT. The unit was short 1- MHT on the 7:00PM-7:00AM shift.

Review of staffing schedule 6/10/2013, revealed staff #7 was scheduled to be the RN House Supervisor. Staff #9 was pulled to Unit 2 to work as the charge nurse and House Supervisor. Staff #7 had a patient admission at 11:18AM, leaving unit 2 without an RN on the unit. Unit 3 had 16 patients on the 7:00PM to 7:00AM shift. Staff #24 worked as an LVN from 7:00PM until 11:00PM. There was no documentation that this position was covered after 11:00PM, leaving unit 3 with 1-RN, and 2-MHT's.

Review of staffing schedule 7/1/2013, revealed staff #9 was assigned as the House Supervisor. She was reassigned to unit 2 as the RN with a census of 15 on the 7:00PM-7:00AM shift. Staff #9 had two admissions this shift. This left the unit without RN supervision while the admissions were processed.

The 7/14/2013, nursing schedule revealed staff #2 was assigned as the house supervisor. She was reassigned to unit 1 as the RN on the 7:00PM-7:00AM shift. The unit had 8 patients. Staff #2 had two admissions this shift. The RN left one LVN and one MHT on the unit while admitting those patients.

Interview with staff #2 on 7/16/2013, confirmed that the house supervisor is pulled frequently to work as a charge nurse when the units are short. Staff #2 stated that they have to use agency nurses sometimes. Staff #2 stated, "I have to work all day and sometimes pull the night shift due to no staff." Staff #2 stated, "Corporate does not want us to pay overtime."

In an interview with staff #7 on 7/16/2013, she reported that she had to work as a charge nurse often, which leaves no House Supervisor. When an admission comes in she still has to do the admissions. Staff #7 has to leave the floor and go to the admissions department. The paperwork, Telemed, and personal search is done there. It takes 1-1 1/2 hours to perform this task. Staff #7 confirmed she has to leave the unit and is unaware of the unit situation until she returns.

The failure of the hospital to provide adequate staff in accordance with its policy and procedure compromises patient care and safety.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on review of staffing schedules, observations and interviews, the facility failed to follow its own policy and procedures to have a Registered Nurse (RN) on each unit to supervise and evaluate staff and patients.

Review of the facility's policy and procedure,"Staffing Patterns and Guidelines Nursing," revealed the following:
"1. A sufficient number of qualified registered nurses, licensed practical nurses and mental health technicians will be available at all times to each patient care area to provide a safe and therapeutic environment.

2. Staffing patterns have been established in collaboration with the Executive Director and the Director of Nursing with input from charge nurse.

3. Staffing determinations are based on several factors, including but not limited to:
A. Number of patients requiring special precautions and the severity of those precautions.
B. Number, frequency, and the length of time special treatment procedures are required.
C. Special medical care needs (transports for special medical care and physical illnesses requiring extraordinary staff time).
D. Number of patients requiring behavioral intervention.
E. Number of patients who are admitted and who are considered emergency admissions.
F. Number of patients who are admitted and who are considered scheduled admissions.

4. The established nursing staff-patient ratio will be approximately six (6) patients to every one (1) staff member.

5. At all times, the minimum number of nursing staff on the day and evening shifts will be two registered nurses and/or licensed practical nurses with one mental health technician per shift, per program area.

6. On the night shift, the minimum number of nursing staff will be one registered nurse and/or licensed practical nurse and one mental health technician per shift per program area.

7. There will be at least one registered nurse on the night shift at all times.

8. Staffing needs are reassessed every shift as well as weekly to determine patient status which would warrant alterations in the staffing pattern.

9. Determination of additional staff will be at the discretion of the charge nurse with approval of the Director of Nursing and/or Executive Director.

10. A relief pool of nursing staff (registered nurses, licensed practical nurses, mental health technicians) has been established to assist with extra staffing requirements. Overtime pay may also be granted to regular nursing staff if extra staffing becomes necessary.

11. Due to the special needs of our patients, it is the policy of Behavioral Hospital of Longview not to use the services of agency personnel for nursing staff."

Review of the staffing grid revealed a patient census of 1-8 patients should have one RN, one LVN, and one MHT. A patient census of 9-24 patients should have one RN, one LVN, and two MHT's per unit. There will be a RN house supervisor per shift to perform admissions.

Review of the staffing schedules 4/13-7/13, 2013, revealed that shifts had not been covered with sufficient personnel according to the staffing grid. RN House Supervisors are responsible to perform the admission process. The House Supervisor must leave the unit and go to the admissions office to conduct a patient admission. Telemedicine (a process where the physician performs the psychiatric evaluation and interview from an offsite location) is performed during the admission process and the patient's belongings are searched in the admissions office. The House Supervisor is to take the patient to the unit after the completion of the admission process.

Review of staffing schedule 6/4/2013, revealed Staff #9 was scheduled as the RN House Supervisor. Staff #9 was pulled at the beginning of the shift to work in the LVN (Licensed Vocational Nurse) slot from 7:00PM-7:00AM on Unit 2. Unit 2 had 15 patients, one patient on 1:1 staff-patient (one staff member to one patient), and 1 admission at 7:30PM. Staff #9 had to leave the unit to perform the admission process. This left the unit without RN supervision.

Review of staffing schedule 6/5/2013, revealed Unit 2 had 14 patients. Staff #10 was scheduled to work as a MHT (Mental Health Technician) for the 7AM-7PM shift. Notation on schedule states, "6/4/2013 850-Staff #10's car won't start. Staff #12 will cover starting at 12:30PM on 6/5/13." Unit 2 was short a MHT for two hours. Unit one had 14 patients. 1- RN, 1- LVN, and 1- MHT. The unit was short 1- MHT on the 7:00PM-7:00AM shift.

Review of staffing schedule 6/10/2013, revealed staff #7 was scheduled to be the RN House Supervisor. Staff #9 was pulled to Unit 2 to work as the charge nurse and House Supervisor. Staff #7 had a patient admission at 11:18AM, leaving unit 2 without an RN on the unit. Unit 3 had 16 patients on the 7:00PM to 7:00AM shift. Staff #24 worked as an LVN from 7:00PM until 11:00PM. There was no documentation that this position was covered after 11:00PM, leaving unit 3 with 1-RN, and 2-MHT's.

Review of staffing schedule 7/1/2013, revealed staff #9 was assigned as the House Supervisor. She was reassigned to unit 2 as the RN with a census of 15 on the 7:00PM-7:00AM shift. Staff #9 had two admissions this shift. This left the unit without RN supervision while the admissions were processed.

The 7/14/2013, nursing schedule revealed staff #2 was assigned as the house supervisor. She was reassigned to unit 1 as the RN on the 7:00PM-7:00AM shift. The unit had 8 patients. Staff #2 had two admissions this shift. The RN left one LVN and one MHT on the unit while admitting those patients.

Interview with staff #2 on 7/16/2013, confirmed that the house supervisor is pulled frequently to work as a charge nurse when they are short. Staff #2 stated that they have to use agency nurses sometimes. Staff #2 stated, "I have to work all day and sometimes pull the night shift due to no staff." Staff #2 stated, "Corporate does not want us to pay overtime."

In an interview with staff #7 on 7/16/2013, she reported that she had to work as a charge nurse often, which leaves no House Supervisor. When an admission comes in she still has to do the admissions. Staff #7 has to leave the floor and go to the admissions department. The paperwork, Telemed, and personal search is done there. It takes 1-1 1/2 hours to perform this task. Staff #7 confirmed she has to leave the unit and is unaware of the unit situation until she returns.

Failure of the hospital to staff the nursing units with adequate staff in accordance with its own policy and procedure compromises the ongoing assessments of patients' needs and care provision.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on interviews, and document review of Governing Body (GB) bylaws, policy, and procedures, the GB failed to follow its bylaws to appoint a hospital administrator/Chief Executive Officer(CEO) responsible for the conduct of the hospital operations.

Refer to Tags A0057.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on staffing schedules and interviews, the facility failed to staff the nursing units with adequate staff in accordance with its own policy and procedure for staffing and scheduling. The facility failed to ensure that each nursing unit have a Registered Nurse (RN) on the units at all times to provide an ongoing assessments of patients and supervise patient care at all times in order to meet patients' care needs.

Refer to Tags A0393 and A0395