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.

Based on review of hospital policies and procedures, hospital documents, patient #'s medical record, and staff interviews, it was determined hospital staff failed to follow the "Belongings, Patient" policy. This deficient practice poses the potential risk that patients would not be discharged with belongings that are needed post discharge.

Findings Include:

The "Belongings, Patient" policy, approved 08/2017, requires the following: "...Once all belongings are inventoried and listed the form is signed by the employee completing the inventory and patient/legal representative...At discharge the release of property section will be completed and signed by the patient or patient representative...In the event staff are unable to locate the item an incident report will be initiated and the patient advocate will be notified in order to ensure follow-up occurs...."

Patient #4's medical record contained the "Patient Belongings Inventory", completed on 4/1/2019 and 4/10/2019. These documents have a "Patient Signature" on Arrival and at discharge. The Patient Belongings Inventory did not have the name of the legal guardian documented on the form.

The medical record contained a copy of the "Order Appointing Temporary Guardian with Authority to Consent to Inpatient Mental Health Care and Treatment Including Placement".

Employee # 3 reviewed the Guardianship documents, and confirmed in an interview conducted on 7/15/2019 that the patient was declared incapacitated; therefore, a patient representative should have signed the belongings inventory document.
Based on review of policies and procedures, facility documents, and staff interviews, it was determined that two of two registered nurses failed to ensure patient assignments were based on the individual needs of each patient. Failure to do so poses the risk that nursing personnel assignments are not based upon the acuity and needs of the patients, therefore potentially jeopardizing the quality of care delivered to the patients.

Findings include:

The "Levels of Observation and Special Precautions" policy, approved 06/2019, requires the following: "...No more than six (6) Q 5 patients will be assigned to one staff member...A single staff member will not provide line of sight observation for more than three (3) patients at a time...."

The "Acuity Based Staffing" policy, approved 01/2018, requires the following: "...Each hospital has a core level of staffing that is based on how the milieu and patients are expected to present at admission...The acuity tool provides a framework for the nursing department to adjust staffing based on whether patients on the unit appear to be exceeding average acuity or reducing the acuity on the unit...The patient acuity score will reset to and average score daily, at midnight. Nursing leaders will need to reassess patient acuity to determine the overall acuity for the milieu daily...Nursing leaders will add in comments for any intended variance from recommended staffing versus what is actually planned and scheduled...."

The "Nursing Services" policy, approved 02/2019, requires the following: " ...The minimum staffing needed for each skill determined by the nurse-patient ratio guidelines and patient care needs...Staffing is planned based on average daily census and average patient acuity.... "

Employee #1 confirmed in an interview conducted on 7/15/2019 that s/he was not aware that the observation policy limited the number of 5 minute observation patients and line of sight patients that one staff member could be assigned. Employee #1 was unable to identify how this is worked into the acuity plan.

Employee #13 confirmed in an interview conducted on 7/15/2019, that s/he developed the program for the acuity plan. Employee #13 confirmed that the acuity plan does not take into account the line of sight or q 5 minute observation patients.

Employee #1 and Employee #13 confirmed in an interview conducted on 7/15/2019 that the "Core staffing" criteria was not identified in the Acuity Based Staffing policy.

Two of two nurses interviewed on 7/9/2019 and 7/15/2019 were unable to explain the acuity plan (employee #14 and employee #15).

Two of two nurses interviewed on 7/9/2019 confirmed that the nursing assignments are made by "splitting the unit in half " (Employee #15 and #16). The acuity of the patients are not utilized when making the RN assignments on the units.