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 BEHAVIORAL CENTER-LELAND 2050 MERCANTILE DRIVE LELAND, NC Feb. 15, 2018
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on review of hospital policies and procedures, personnel files and staff interviews the hospital failed to assign patients to employed registered nurses who had demonstrated competency requirements for 2 of 2 (Registered Nurse, RN #2, and RN #3).

The findings included:

Review of the hospital policy "New Hire Orientation and On-Boarding", effective 04/01/2016, revealed "Job Specific Orientation Upon completion of the "General Employee Orientation" and satisfactory meeting competency requirements, all employees receive a discipline/job specific orientation with job shadowing opportunities. Job specific competencies are reviewed, verified and documented ..."

1. Review of registered nurse (RN) #2's personnel file revealed the RN was hired on 06/19/2017. File review revealed no documentation of a Registered Nurse Skills/Competency checklist.

Interview with RN #3 on 02/14/2018 at 1450 revealed RN #3 received on day of job shadowing on the unit. Interview revealed RN #3 assumed a full assignment on her second day on the unit. Interview revealed RN #3 "did not receive enough training to provide safe care and had no resources to turn to during the shift. Learn as you go". Additional interview revealed "the orientation check list was never checked off because there was no one to train me".

Interview with the Director of Human Resources on 02/15/2018 at 1045 revealed a new employee orientation packet is given to every employee on week one of orientation. Interview revealed "the staff were to complete the packet and return to management after they are done with orientation, but often, they don't return the packet." Interview confirmed there was no Registered Nurse Skills/Competency checklist in RN #2 personnel file.

2. Review of registered nurse (RN) #3's personnel file revealed the RN was hired on 11/05/2017. File review revealed no documentation of a Registered Nurse Skills/Competency checklist.

Interview with RN #3 on 02/14/2018 at 1450 revealed RN #3 received on day of job shadowing on the unit. Interview revealed RN #3 assumed a full assignment on her second day on the unit. Interview revealed RN #3 "did not receive enough training to provide safe care and had no resources to turn to during the shift. Learn as you go". Additional interview revealed "the orientation check list was never checked off because there was no one to train me".

Interview with the Director of Human Resources on 02/15/2018 at 1045 revealed a new employee orientation packet is given to every employee on week one of orientation. Interview revealed "the staff were to complete the packet and return to management after they are done with orientation, but often, they don't return the packet." Interview confirmed there was no Registered Nurse Skills/Competency checklist in RN #3 personnel file.
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy review, medical record review and staff interview, the facility failed to ensure effective operation of the grievance process in 1 of 1 patients (or patient representatives) that registered a verbal grievance (Patient #5).

The findings included:

Review of hospital policy titled "Patient Grievance/Complaint" reviewed/revised: 06/01/2016, revealed, "...Patient grievances whether written or verbal shall be documented on a Compliment, Complaint, Suggestion Form ... Definitions: A 'patient grievance' is defined as a formal, written or verbal grievance which is filed by a patient, when a patient issue cannot be resolved promptly by staff present..."

Closed medical record review conducted on 02/13/2018 revealed Patient #5 was a [AGE]-year-old male patient admitted under Involuntary Commitment on 01/29/2018, for treatment of Autism Spectrum Disorder. Review revealed Patient #5 was placed in a therapeutic manual hold (TMH) due to uncontrollable behavior, including throwing items within his reach, and hitting and kicking facility staff. Review revealed after the TMH, Patient #5 complained of left shoulder pain, and was found to have a left humerus fracture, for which he was sent to an area emergency room and treated.

Interview conducted on 02/14/2018 at 1610 with the Director of Risk Management (DRM) revealed Patient #5's grandmother (his legal representative) was upset upon being informed by telephone that his arm was fractured. The grandmother was provided the telephone number for the DRM, whom she made telephone contact with. Patient #5's grandmother voiced concern about the treatment of Patient #5, requested the staff involved not be involved in Patient #5's care anymore, and requested to see the video footage of the TMH episode. Interview revealed the incident was investigated by the facility, and it was determined there was no wrongdoing on the part of facility staff. Interview revealed the grandmother's concerns regarding Patient #5's treatment was not considered a grievance, because she never explicitly requested to file a grievance, so the grievance policy was not followed.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policies and procedures review, observation, medical record review, and staff interview, the facility failed to ensure RN (Registered Nurse) supervision of nursing care by failure of fall risk precaution nursing interventions being implemented in 7 of 7 sampled patients documented as risk of fall (Patient's #6, #14, #18, #17, #16,#19,#15)

The findings included:

Review on 02/14/2018 of the facility's policy "Fall Risk Precautions" (Revised: 06/12/2015) revealed "Policy: All patients will be assessed for the potential to fall and will be placed on an appropriate prevention program upon admission. Procedure: Nursing staff will assess and determine risk of adult patients with regard to falls utilizing the Fall Risk Assessment tool. Based on the score on the Fall Risk Assessment, nursing judgment and/or physician input, patients will be placed on Fall Precaution.
Nursing Interventions:

-Instruct patient to wear non-slip footwear,
-Reassess and observe every 2 hours after medication change or as condition worsens,
-Remind patient to call for assistance to go to the bathroom at night,
-Communicate patient's "Fall Risk" during nursing shift report,
-Identify the patient's "Fall Risk" on patient door with a yellow star and a fall label on the patient's chart."

The review of the facility policy revealed no requirement for a yellow armband or bed alarms for fall precautions.

1. Review on 02/13/2018 of the closed medical record for Patient #6 revealed a [AGE] year old female admitted on [DATE] until 12/28/2017 with a diagnosis of "Major Depressive Disorder." Review of the "Edmonson Psychiatric Fall Risk Assessment" (Facility's Designated Fall Risk Assessment Tool) dated 12/20/2017 revealed "Complete Daily & upon admission ..." Review revealed the "Edmonson Psychiatric Fall Risk Assessment" was completed on 12/2/2017 (admission) and the nursing documentation revealed that Patient #6 scored a 82 (fall risk considered 90 or greater). Further review of Patient #6's chart failed to review any additional fall risk assessments completed. Review of the nursing note in the patient record on 12/26/2017 at 0910 revealed documentation as "She had a fall overnight, but voices no complaints." Another nurse's note on 12/27/2017 at 0200 revealed "Pt alarm sounded. When staff arrived [sic] pt was seen falling on to left side. No injury. VSS, MD Notified. No new orders." Review of the medical record "Physician's Order Sheet" dated 12/26/2017 at 0930 revealed "Fall Precautions, Mobile X-ray R. Hip, LS Spine (Fall)" signed and authenticated by PA #1. On 12/26/2017 at 1035 another order was documented as a telephone order by the facility's nursing staff as "Clarification X-ray Right Hip s/p fall" with a telephone order authenticated from RN #11. Review of documentation from the facility's PA (Physician Assistant) #2 on 12/26/2017 at 1622 revealed "Nursing reports fall last night. Right Hip X-ray Negative. Balance remains fair to poor at times." Another facility PA #2 documentation on 12/28/2017 at 1237 revealed "Night shift reports patient fell again last night." Review of the medical record documentation revealed that the facility staff did not document any fall precaution nursing interventions for Patient # 6 before or after the patient's documented falls.

Interview on 02/14/2018 at 1002 with the facility's DON (Director of Nursing) revealed that currently there is no documentation found to indicate whether or not that fall precaution nursing interventions are documented as completed for patients at fall for risk including Patient #6. The interview revealed that the facility's nursing staff could improve on more detail in assessments.

Interview on 02/14/2018 at 1628 with the facility's RN #2 revealed that Patient #6 was on close observation due to falling a lot. The interview also revealed the patient had trouble getting out of bed after a reported fall for her medications and that she had planned to take medications to her room instead of requiring her to walk (Date not remembered). The interview revealed that had thought the patient was having a "TIA" and called physician who had ordered EMS to take the patient to the ED (Emergency Department) where she was found to have five fractured ribs. The interview revealed that she considered the patients to have been on fall precautions but also revealed they are not documented. The interview also revealed that she did not think that facility staff knows the fall precautions policy and procedure.

Interview on 02/15/2018 at 0905 with the facility's Nurse Manager revealed that "Head to toe assessments" should be done every shift. The interview also revealed that she was not sure on fall assessments and would obtain the answer.

2. An interview on 02/13/2018 at 1605 with CNA (Certified Nursing Assistant) #1 while touring and observing patient care on the facility's "700 Hall" revealed that Patient #14 had not been a falls risk but did have a fall today (02/13/2018). Interview revealed CNA #1 did not know if Patient #14 was a falls risk now because "it is up to the nurse." The interview revealed the CNA did not provide any further information about the specifics of Patient #14's fall on 02/13/2018.

Review on 02/14/2018 of the open medical record for Patient #14 revealed a [AGE] year old female admitted on [DATE] for increased agitated behavior. Review of the "Edmonson Psychiatric Fall Risk Assessment" dated 01/06/2018 revealed "Complete Daily & upon admission ..." Review revealed the "Edmonson Psychiatric Fall Risk Assessment" was completed on 01/06/2018 (admission) and the nursing documentation revealed that Patient #14 scored a 75 (fall risk considered 90 or greater). Further review of Patient #14's chart failed to review any additional fall risk assessments completed.

Review of the nursing note in the patient record on 02/13/2018 at 1215 failed to reveal a note about Patient #14's fall on 02/13/2018. Review of a nursing note on 02/13/2018 from 1900-0700 revealed under precautions falls was not checked on the form as implemented. Review failed to reveal any interventions done due to Patient #14 falling on 02/13/2018. Review of the nursing note dated 02/14/2018 at 1330 revealed under precautions fall was not checked as implemented; however, further review of the nursing note revealed "Fall precaution: non-skid socks/yellow armband on, bed alarm on ..." Review of the nursing report sheet dated 02/14/2018 revealed Patient #14 was a falls risk and had a fall on 02/13/2018.

Interview on 02/13/2018 at 1150 with RN #1 revealed a falls assessment was done on admission and that would determine if a patient was a falls risk. Interview revealed if a patient was a falls risk then they would be placed on the fall protocol which included a yellow armband, socks, and a yellow star at their door.

Interview on 02/14/2018 at 1002 with the facility's DON revealed that RN's should perform checks for range of motion, head to toe, and checking for injuries. The interview revealed the facility "Could improve on more detail in assessments."

Interview on 02/15/2018 at 0905 with the facility's Nurse Manager revealed that "Head to toe assessments" should be done every shift. The interview also revealed that she was not sure on fall assessments and would obtain the answer.

3. Review on 02/14/2018 of the open medical record for Patient #18 revealed a [AGE] year old female admitted on [DATE]. Review of the "Edmonson Psychiatric Fall Risk Assessment" dated 01/22/2018 revealed "Complete Daily & upon admission ..." Review of the "Edmonson Psychiatric Fall Risk Assessment" revealed it was completed on 01/22/ and Patient #18 scored an "82" (fall risk considered 90 or greater). Review revealed additional "Edmonson Psychiatric Fall Risk Assessment" was done from 02/01/2018 to 02/03/2018 and Patient #18 scored an "83." Further review failed to reveal daily fall risk assessments. Record review revealed on 02/11/2018 that Patient #18 fell with no other specific documented details of the fall noted. Review of the "Observation Sheet" notes revealed Patient #18 was placed on close observation at 2015 and 1:1 observation at 2022.

Review of a nursing note by the facility's nursing staff dated 02/11/2018 with no time revealed "...Patient had a [sic] unobserved fall in milieu. Patient reported I bumped my head ..." Review of a nursing note on 02/12/2018 with no time revealed Patient #18 was transported to a tertiary hospital for altered mental status. Review revealed Patient #18 returned to the facility on [DATE]. Review of nursing notes dated 02/12/2018 to 02/13/2018 revealed under precautions that falls was not checked as implemented.

Observation on the facility's "700 Hall" unit on 02/14/2018 at 0950 revealed that Patient #18 was laying in bed with CNA #2 observing her as a 1:1. Observation on 02/14/2018 at 1010 of the geriatric unit revealed Patient #18 walking barefoot with CNA #2 to the nurse's station. During the observation at 1015, CNA #2 was observed to place nonskid footwear on Patient #18.

Interview on 02/13/2018 at 1150 with RN #1 revealed a falls assessment was done on admission and that would determine if a patient was a falls risk. Interview revealed if a patient was a falls risk then they would be placed on the fall protocol which included a yellow armband, socks, and a yellow star at their door.

Interview on 02/14/2018 at 0950 with CNA #2 revealed Patient #18 was on 1:1 observation because of a fall. Interview revealed she has worked at the facility since 04/2017. Interview revealed when asked how to know if a patient was a falls risk she stated "When they fall." Interview revealed sometimes patient have on socks and armbands but not all of the time.

Interview on 02/14/2018 at 1002 with the facility's DON revealed that RN's should perform checks for range of motion, head to toe, and checking for injuries. The interview revealed the facility "Could improve on more detail in assessments."

Interview on 02/15/2018 at 0905 with the facility's Nurse Manager revealed that "Head to toe assessments" should be done every shift. The interview also revealed that she was not sure on fall assessments and would obtain the answer.

4. Review on 02/14/2018 of the open medical record for Patient #15 revealed a [AGE] year old male admitted on [DATE] for suicidal ideations. Review of the "High Risk/High Alert Handoff" dated 01/30/2018 revealed falls was checked with a note that stated "several recent." Review of the "Comprehensive/Psychosocial Assessment Tool" revealed Patient #15 had several recent falls. Review of the "Edmonson Psychiatric Fall Risk Assessment" dated 01/30/2018 revealed "Complete Daily & upon admission ..." Review of the "Edmonson Psychiatric Fall Risk Assessment" revealed it was completed on 01/30/2018 and Patient #15 scored an 89 (fall risk considered 90 or greater). Review failed to reveal daily fall risk assessments were completed. Review of the admission orders dated 01/30/2018 revealed under precautions falls was not checked and Patient #15 was placed on every 15 minute checks. Review of a nursing note dated 02/12/2018 revealed under precautions falls was not checked and Patient #15 was on 1:1 observation. Further review failed to reveal if Patient #15 had on nonskid footwear. Review of a nursing note on 02/13/2018 at 1030 revealed under precautions falls was not checked. Further review revealed "Fall Risk (on 1:1) ..." Continued review failed to reveal if Patient #15 had nonskid footwear. Review of a nursing note dated 02/13/2018 from 1900-0700 revealed under precautions falls was not checked. Further review failed to reveal if Patient #15 was wearing any nonskid footwear.

Interview on 02/13/2018 at 1150 with RN #1 revealed a falls assessment was done on admission and that would determine if a patient was a falls risk. Interview revealed if a patient was a falls risk then they would be placed on the fall protocol which included a yellow armband, socks, and a yellow star at their door.

Interview on 02/14/2018 at 1002 with the facility's DON revealed that RN's should perform checks for range of motion, head to toe, and checking for injuries. The interview revealed the facility "Could improve on more detail in assessments."

Interview on 02/15/2018 at 0905 with the facility's Nurse Manager revealed that "Head to toe assessments" should be done every shift. The interview also revealed that she was not sure on fall assessments and would obtain the answer.

5. Review on 02/14/2018 of the open medical record of Patient #17 revealed a [AGE] year old female admitted on [DATE]. Review Review of the "Edmonson Psychiatric Fall Risk Assessment" dated 01/22/2018 revealed "Complete Daily & upon admission ..." Review of the "Edmonson Psychiatric Fall Risk Assessment" revealed it was completed on 01/09/2018 and scored a 64 (fall risk considered 90 or greater). Review of additional falls assessments revealed they were completed daily from 01/16/2018 to 01/22/2018 and Patient #17 scored 103 (considered a falls risk). Review failed to reveal any falls assessments completed from 01/09/2018 to 01/16/2018. Review of the documentation revealed Patient #17 had a fall at the facility on 01/16/2018. Review of the nursing shift report sheet dated 02/14/2018 revealed Patient #17 was a "FALLS RISK." The review revealed no falls risk sticker was placed on the outside cover on her hard chart cover of paper medical record. Review of nursing notes from 02/13/2018 to 02/14/2018 revealed under precautions falls was not checked as implemented. Further review revealed no documentation of Patient #17 wearing any nonskid footwear.

Interview on 02/13/2018 at 1150 with RN #1 revealed a falls assessment was done on admission and that would determine if a patient was a falls risk. Interview revealed if a patient was a falls risk then they would be placed on the fall protocol which included a yellow armband, socks, and a yellow star at their door.

Interview on 02/14/2018 at 1002 with the facility's DON revealed that RN's should perform checks for range of motion, head to toe, and checking for injuries. The interview revealed the facility "Could improve on more detail in assessments."

Interview on 02/15/2018 at 0905 with the facility's Nurse Manager revealed that "Head to toe assessments" should be done every shift. The interview also revealed that she was not sure on fall assessments and would obtain the answer.


6. Review on 02/14/2018 of the open medical record of Patient #16 revealed a [AGE] year old male admitted on [DATE]. Review of the "Nursing Assessment" dated 01/20/2018 with no time revealed " ...Pt is on 1:1 observation for fall risk, very unsteady when attempts to stand during walking ..." Review of the "Edmonson Psychiatric Fall Risk Assessment" dated 01/20/2018 revealed "Complete Daily & upon admission ..." Review of the "Edmonson Psychiatric Fall Risk Assessment" revealed it was completed on 01/20/2018 and Patient #16 scored an 87 (fall risk considered 90 or greater). Review revealed the "Edmonson Psychiatric Fall Risk Assessment" was done daily. Review of the nursing notes from 02/13/2018 revealed under precautions falls was not checked as implemented and there was no documentation if Patient #16 wearing any nonskid footwear.

Observation on the facility's "700 Hall" unit on 02/14/2018 at 10:10 revealed Patient #16 laying in a recliner with a yellow falls risk armband and regular white socks. The observation revealed Patient #16 was not wearing any nonskid footwear.

Interview on 02/13/2018 at 1150 with RN #1 revealed a falls assessment was done on admission and that would determine if a patient was a falls risk. Interview revealed if a patient was a falls risk then they would be placed on the fall protocol which included a yellow armband, socks, and a yellow star at their door.

Interview on 02/14/2018 at 1002 with the facility's DON revealed that RN's should perform checks for range of motion, head to toe, and checking for injuries. The interview revealed the facility "Could improve on more detail in assessments."

Interview on 02/15/2018 at 0905 with the facility's Nurse Manager revealed that "Head to toe assessments" should be done every shift. The interview also revealed that she was not sure on fall assessments and would obtain the answer.

7 .Review on 02/14/2018 of the open medical record of Patient #19 revealed an [AGE] year old male admitted on [DATE]. Review of the admission "Nursing Assessment" revealed "...Patient arrived to unit via wheel chair due to unsteady gait and high fall risk. Patient is to be on 1:1 observation for safety of falls ..." Review of the "Edmonson Psychiatric Fall Risk Assessment" dated 01/07/2018 revealed "Complete Daily & upon admission ..." Review of the "Edmonson Psychiatric Fall Risk Assessment" revealed it was completed on 01/07/2018 and Patient #19 scored a 113 (considered a fall risk). Review of additional falls assessments revealed they were done daily from 01/29/2018 to 02/12/2018 and Patient #19 scored a 109-111. Review failed to reveal falls assessments from 01/07/2018 to 01/29/2018. Review of the physician orders on 01/23/2018 at 1030 revealed "Bed and chair alarms for safety ..." Review of nursing notes from 02/13/2018 to 02/14/2018 revealed under precautions falls was not checked as implemented. Further review of two nursing notes from 02/13/2018 failed to reveal any documentation of Patient #19's nonskid footwear or a bed and chair alarm being on.

Interview on 02/13/2018 at 1150 with RN #1 revealed a falls assessment was done on admission and that would determine if a patient was a falls risk. Interview revealed if a patient was a falls risk then they would be placed on the fall protocol which included a yellow armband, socks, and a yellow star at their door.

Interview on 02/14/2018 at 1002 with the facility's DON revealed that RN's should perform checks for range of motion, head to toe, and checking for injuries. The interview revealed the facility "Could improve on more detail in assessments."

Interview on 02/15/2018 at 0905 with the facility's Nurse Manager revealed that "Head to toe assessments" should be done every shift. The interview also revealed that she was not sure on fall assessments and would obtain the answer.
VIOLATION: SUPERVISION OF CONTRACT STAFF Tag No: A0398
Based on review of hospital policies and procedures, personnel files and staff interviews the hospital failed to ensure that a non-employed registered nurse's competencies were documented and kept in personnel files for 1 of 1 (Registered Nurse, RN #11).

The findings included:

Review of the hospital policy "New Hire Orientation and On-Boarding", effective 04/01/2016, revealed "Job Specific Orientation Upon completion of the "General Employee Orientation" and satisfactory meeting competency requirements, all employees receive a discipline/job specific orientation with job shadowing opportunities. Job specific competencies are reviewed, verified and documented ... 2. Contracted nursing/clinical personnel will attend general employee orientation as described above and met equivalent requirements to employed counterparts."

Review of registered nurse (RN) #11's personnel file revealed the RN was hired as an agency contract on 12/22/17. File review revealed the agency contract was ongoing. File review revealed no documentation of a Registered Nurse Skills/Competency checklist.

Interview with the Director of Human Resources on 02/15/2018 at 1045 revealed a new employee orientation packet is given to every employee on week one of orientation. Interview revealed "the staff were to complete the packet and return to management after they are done with orientation, but often, they don't return the packet." Interview confirmed there was no Registered Nurse Skills/Competency checklist in RN #11 personnel file.

NC 592, NC 006, NC 163, NC 062, NC 044, NC 396, and NC 490