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Based on document review, observations and staff interviews, the facility failed to ensure an RN supervised and evaluated patient care (A0395) on the behavioral health unit (BHU) for three (3) of ten (10) medical records reviewed (patients #1, 9 & 10).

The cumulative effect of this problem resulted in the hospitals inability to ensure the provision of quality healthcare in a safe environment.

Based on observation, the facility failed to ensure the patient's personal privacy right in three (3) of three (3) instances.

Findings:

1. The following was observed during tour of the BHU beginning at 10:45 a.m.:
(A) Patient #6 was in a geri-chair in front of the nurse station and among approximately fifteen (15) other patients with a hospital gown on, one (1) sock, and an incontinence brief exposed.
(B) Two patients (#11 and 12) wearing glasses were observed with a name label used in the medical record to identify the patient attached to the arm of their glasses and hanging on the side of the arm of the glasses.

Based on document review, observation and interviews, the facility failed to ensure a registered nurse evaluated/supervised the care provided to 3 of 10 patients. The registered nurse on the behavioral health unit (BHU) failed to assure timely notification of patient change in condition to physician for patient #10, failed to assure the optimum mobility and attendance at group therapy for patient #9 and failed to assure a urinalysis was obtained for patient #1.

Findings include:

1. Review of patient #10 medical record indicated the following:
(A) The patient was admitted to the BHU on 3/9/10. He/she was ambulatory on the unit prior to incident.
(B) Nurse notes dated 4/3/10 at 10:30 p.m. stated "found pt on floor in back part of lounge near dining rm. knot noted on back of head bleeding. No skin tear. The knot has abrasion as if scrapped. Pt able to move extremities well x 4. Pt talkative. Eyes are PERRL.........."
(C) The physician was notified at 10:40 p.m. and an order received for neuro checks. (No specific number of neuro checks or a time limit of checks.)
(D) The neurological assessment form indicated that the patient's neuro checks were within normal limits (WNL) with brisk pupil reaction and strong upper and lower extremity strength at 10:30 p.m., 10:45 p.m. and 11:00 p.m. The neurological assessment indicated that at 11:15 p.m. the patient's pupils were sluggish bilaterally and his/her upper and lower extremity strength was weak. The assessment was documented as the same with sluggish pupils and extremity weakness at 11:30 p.m. The physician was not notified of the change in the patient's neuro status. No neuro checks were completed again until 12:30 a.m., a lapse of one hour after a change in neuro status. At that time, the assessment indicated that the patient did not open his/her eyes, had no verbal or motor response, extremities were flaccid, and pupils were non-reactive. Nurse notes at 12:30 a.m. indicated the LPN on duty (staff member #13) called an RN from the emergency department (ED) to come and evaluate the patient. The notes indicated the evaluation was the same.
(E) The physician was paged at 12:50 a.m., 20 minutes after patient was first noted to have no verbal or motor response and pupils non-reactive, and orders were received for stat CT of the head.
(F) The patient was taken to radiology at 1:10 a.m. and the results of the CT indicated the patient had a large subdural hematoma (L) side with trans-herniation of brain.
(G) The patient was transferred to another acute care facility at 2:35 a.m.

2. Review of patient #9 medical record indicated the following:
(A) The patient (48 y/o) was admitted to the BHU on 7/1/10.
(B) The H&P indicated he/she was a quadriplegic.
(C) An assessment dated 7/1/10 and completed by staff member #3 indicated that the patient required a Hoyer lift.
(D) The transfer form from the LTC facility indicated that the patient was transferred with a mechanical lift.
(E) the patient did not participant in group therapy because he/she was unable to attend because they were in bed.

3. The following was observed during tour of the BHU beginning at 10:45 a.m.:
(A) Patient #9 was observed in his/her bed in the doorway of his/her room (staff indicated the patient is in a Hoyer lift and likes to "look around"). The patient was later taken to the lounge area in his/her bed with the other patients to watch T.V.

4. Patient #9 (alert and oriented per record review) indicated the following in interview in the lounge area at 12:00 p.m.:
(A) He/she indicated they are "stuck" in the bed because the facility has no means to move them because they have a Hoyer lift for transfers and facility "lost the harness".
(B) He/she has not been out of bed since admission "last week".

5. Staff member #3 indicated the following in interview during observation/tour in the BHU beginning at 10:45 a.m.:
(A) The Hoyer lift was broken and had been sent for repair. The Hoyer worked, however could not be used because there was not a sling for it. He/she is "assuming" the sling is lost. The Hoyer has been out of service for about a month.

6. Staff member #2 indicated the following in interview at 1:20 p.m.:
(A) The Hoyer from the BHU was "downstairs" for repair for 2 days. It was repaired and returned to the unit on Thursday.
(B) The facility has no other Hoyer lifts.
(C) The sling to the Hoyer has a torn strap and needs replaced. He/she does not know how long the sling had been in the maintenance department.

7. Review of patient #1 medical record indicated the following:
(A) The patient was admitted to the BHU 1/18/2010.
(B) A behavior health screening was ordered in the emergency department on day of admission which included a urinalysis. The record lacked documentation that the urinalysis was ever obtained.

8. Staff member #1 indicated the following in interview at 4:20 p.m.:
(A) All patients being admitted to the BHU have screening test performed which includes a urinalysis.
(B) He/she verified that patient #1 did not have a urinalysis and did not know why they did not.

Based on document review, the facility failed to ensure documentation of the patient's progress accurately for 1 of 10 patients (patient #1).

Findings include:

1. Review of patient #1 medical record indicated the following:
(A) The patient was admitted to the behavioral health unit (BHU) 1/18/2010.
(B) The patient's discharge summary dictated by M.D. #1 was not accurate. The discharge summary stated "After medication adjustments, there was zero agitation noted 24 hours prior to discharge." Review of nurse notes indicated that the patient was agitated and aggressive with staff up until 11:00 p.m. on 2/2/10 (patient discharged 2/3/10 at 9:51 a.m.).

Based on document review, interviews, and observation, the facility failed to ensure a clean environment and failed to make needed repairs and replace broken equipment when needed for one (1) behavioral health unit (BHU) toured.

Findings include:

1. During tour of the BHU beginning at 10:45 a.m., Patient #9 was observed in his/her bed in the doorway of his/her room (staff indicated he/she is in a Hoyer lift and likes to "look around") He/she was later taken to the lounge area in his/her bed with the other patients to watch TV

2. Review of patient #9 medical record indicated the following:
(A) The patient (48 y/o) was admitted to the BHU on 7/1/10.
(B) The H&P indicated he/she was a quadriplegic.
(C) An assessment dated 7/1/10 and completed by staff member #3 indicated that the patient required a Hoyer lift.
(D) The transfer form from the LTC facility indicated that the patient was transferred with a mechanical lift.
(E) the patient did not participant in group therapy because he/she was unable to attend because they were in bed.

3. Patient #9 (alert and oriented per record review) indicated the following in interview in the lounge area at 12:00 p.m.:
(A) He/she indicated they are "stuck" in the bed because the facility has no means to move him/her because they have a Hoyer lift for transfers and facility "lost the harness".

4. Staff member #3 indicated the following in interview during observation/tour in the BHU beginning at 10:45 a.m.:
(A) The Hoyer lift was broken and had been sent for repair. The Hoyer worked, however could not be used because there was not a sling for it. He/she is "assuming" the sling is lost. The Hoyer has been out of service for about a month.

5. Staff member #4 (CNA) indicated the following in interview beginning at 11:45 a.m.:
(A) The Hoyer lift sling is "out of order". Patient #9 is brought to the lounge area in his/her bed.

6. Staff member #2 indicated the following in interview at 1:20 p.m.:
(A) The Hoyer from the BHU was "downstairs" for repair for 2 days. It was repaired and returned to the unit on Thursday.
(B) The facility has no other Hoyer lifts.
(C) The sling to the Hoyer has a torn strap and needs replaced. He/she does not know how long the sling had been in the maintenance department.

7. Staff member #NN3 (CNA) indicated the following in phone interview at 6:15 a.m. on 7/7/10:
(A) The Hoyer lift has been broken for a couple months and the sling was sent for repair at least a month ago.

8. Staff member #NN6 (CNA) indicated the following in phone interview at 6:30 a.m. on 7/7/10:
(A) The Hoyer lift has been broken for at least a month and he/she received different stories about the sling for the Hoyer.

9. The Hoyer lift was observed on tour of the BHU beginning at 10:45 a.m. on 07/06/10 in a storage closet near the dining room area. The lift was functional, however there was no sling/harness to the Hoyer. The sling/harness is required for operation.

10. During tour of the BHU beginning at 10:45 a.m., the following was also observed:
(A) The floors adjacent to the lounge area and in front of the nurse station were very soiled with a black powdery type substance throughout the area.
(B) The baseboard trim was peeled away from the wall across from the nurse station.
(C) The walls throughout the lounge/hall area near the nurse station were heavily marred.
(D) Paint was chipped from doorways throughout the lounge/nurse station area.
(E) Three (3) of four (4) overbed tables in the hall outside the nurse station were soiled on top with dried liquid.

11. Staff member #2 indicated the following in interview at 1:20 p.m.:
(A) The floors in the nurse station and lounge area are the responsibility of the second shift housekeeper. The facility only has one (1) second shift housekeeper (staff member #14) that is assigned to floors. There is no one to cover on his/her days off.
(B) He/she verified that the cleaning logs are completed on the days that the second shift housekeeper works.

12. Facility policy titled "Cleaning Behavioral Health Unit" last reviewed/revised 7/08 states under policy on page 1: "The Environmental Services personnel will clean all areas of the Behavioral Health Unit daily, .....".

13. Review of cleaning logs titled "duty report" completed by staff member #14 (second shift housekeeper) for 6/18-7/5 indicated the following:
(A) The logs indicated what duties were completed throughout the shift.
(B) There were no logs for 6/18, 6/19, 6/20, 6/26, 6/27, 7/2, 7/4 and 7/5.
(C) Of the logs completed, on 6/25 the floors on BHU were only "spot mopped" and on 6/29, the floors on BHU were not documented as cleaned at all.

14. Staff #3 indicated by interview at 10:45 a.m. on 07/06/10 that the camera to the restraint/seclusion room had been broken as of a month ago.