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Based on observation, review of medical records and documents and staff interview it was determined the hospital failed to provide care in a safe setting on the Child/Adolescent Unit when an adult patient (patient #9) was admitted without a plan for maintaining the safety of the child and adolescent population. This failed practice involved one (1) of one (1) adult patients who was admitted during the course of the survey. This failure has the potential to adversely impact the safety and condition of all patients on the Child/Adolescent Unit.

Findings include:

1. Ohio Valley Medical Center (OVMC) has four (4) inpatient behavioral health units. Three (3) of these units admit adults and one (1) unit admits children and adolescents.

2. Review of the 6/13/12 census for the Child/Adolescent Unit revealed an eighteen (18) year old male (patient #9) was admitted to the unit the evening of 6/12/12. The census revealed there were eight (8) other patients on the unit who ranged in age from six (6) to seventeen (17).

3. Observation at 0920 on 6/13/12 revealed patient #9 to be sitting in an activity room with patients who ranged in age from fourteen (14) to seventeen (17).

4. Observation at 0920 on 6/13/12 revealed the room next to where patient #9 was sitting was an activity room with four (4) patients who ranged in age from six (6) to nine (9).

5. The RN on duty, RN #2, was interviewed at 0930 on 6/13/12. He confirmed the Child/Adolescent Unit has on occasion admitted eighteen (18) year olds. He stated he and other staff have concerns about maintaining the safety of the children and adolescents when this occurs. He was asked for any directions or guidelines that have been provided to staff related to how to handle this type of admission, RN #2 stated staff had received no directions or guidelines.

6. Review of the medical record for patient #9 revealed he was brought to the Emergency Room (ED) the prior evening for admission. Review of both the ED records and the Behavioral Health Unit record revealed the patient was verbalizing homicidal thoughts related to the children in his residential placement, reporting he wanted to hurt or hit them.

Review of the behavioral health nursing admission assessment, documented at 0716 on 6/12/12, revealed the patient stated: "I know if I hit them I could really hurt them bad or they could even die." Further review of this assessment revealed the nurse recorded the patient's weight and height as two-hundred twenty-two (222) pounds and five (5) feet nine (9) inches.

Review of the 6/12/12 admission orders for patient #9 revealed a Routine Order Set Sheet was implemented by the nurse per verbal order by the On-call/Attending Psychiatrist. There were no orders for a higher than routine level of supervision or a private room or any directive related to room placement or special safety precautions.

The Psychiatric Evaluation and History and Physical had not yet been completed on this patient.

7. Interview and observation, at 0940 on 6/13/12, with RN #2 revealed patient #9 was assigned to a semi-private room but had no roommate. RN #2 confirmed patient #9 was placed in a room without a roommate per nursing decision. The surveyor observed the room to be directly across the hallway from the room which was assigned to the one (1) six (6) year old patient on the unit. RN #2 confirmed the room directly across the hallway from patient #9 was the room of the six (6) year old patient.

8. At 1000 6/13/12 the Director of the Child/Adolescent Unit arrived on the unit. He was asked for the Admission Criteria for the Child/Adolescent Unit and any documentation related to caring for an eighteen (18) year old on the Child/Adolescent Unit. He was also asked about the admission of patient #9. He acknowledged he was not aware this patient had been admitted to the unit.

9. At 1015 the Nurse Manager provided the policy/procedure: "Admission Criteria" effective January 2010 for review. The policy states in part: "Minors will be accepted for diagnostic or evaluation services and either treated at OVMC or referred to the appropriate treatment setting." There were no other age guidelines in the policy. There was no reference to circumstances when admission of an adult would be appropriate or how staff would make this determination and maintain the safety of the children and adolescents in the unit.

The Nurse Manager acknowledged that on occasion an eighteen (18) year old, who was still in school, would be admitted to the unit. She also acknowledged the Admission Criteria made no reference to circumstances when this would be appropriate. After review of the record of patient #9 she agreed this patient presented safety concerns on the Child/Adolescent Unit.

She stated the decision to admit an adult was up to the discretion of the admitting psychiatrist. The Nurse Manager acknowledged the Admission Criteria needed to be more specific and include the process for making a determination of the appropriateness for admission of any potential patient which is outside the parameters for Child or Adolescent patients. She concurred that safety of the other patients on the unit would need to be considered and maintained.

10. At 1020 the On Call/Attending Psychiatrist who admitted the patient the prior evening was asked about the admission of patient #9. He stated he hadn't yet seen the patient and was not aware of any concerns. He then took the patient's chart into his office.

11. At 1025 on 6/13/12 a joint interview was conducted with the RN who was on duty the evening of 6/12/12 (RN#1) and the Clinical Assessment Coordinator, who assessed the patient in the ED on 6/12/12. Both indicated they felt the patient should have been admitted to an Adult Unit and acknowledged the safety concerns he posed on the Child/Adolescent Unit. The Clinical Assessment Coordinator stated she "lobbied" for patient #9 to be admitted to the Adult Unit.

The Clinical Assessment Coordinator provided the Individual Crisis Management Plan which she completed on 6/12/12. Under Safety Concerns/Predisposing Factors/Behaviors she marked: "Known history of violence, Overwhelming Anger, Command Hallucination (1 year ago) and Poor impulse control (management)." Beside this section she noted: "cycling per therapist, needed help or was going to hurt someone, and 11 years history of violence toward."

Review of the current Position Description for the Psych Clinical Assessment Coordinator revealed the following under Position Summary: "The Psych Clinical Assessment Coordinator, in conjunction with the unit's Program Director may coordinate the referral development and pre-admission patient assessment process and provide clinical assessments for potential clients."

12. At 1100 on 6/13/12 these findings were reviewed and discussed with the Director of Nursing. She acknowledged that patient #9 posed a safety concern for the other patients on the Child/Adolescent Unit. She also indicated the Admission Criteria needed to include the process for making a determination about an admission of a patient who does not fit the usual criteria. She acknowledged this should include an evaluation of the ability to provide care while maintaining the safety of the child and adolescent population on the unit.

13. At 1110 on 6/13/12 these finding were reviewed and discussed again with the On-Call/Attending Psychiatrist. He stated he chose to admit patient #9 to the Child/Adolescent Unit, instead of an Adult Unit, because he was still in school and felt he would benefit from the programming on the Child/Adolescent Unit. He stated the age criteria for admission to the Child/Adolescent Unit was five (5) through seventeen (17). The Psychiatrist then noted there is a fine line between patients who are seventeen (17) and eighteen (18) and at times an eighteen year (18) old is admitted. He acknowledged there was no policy or procedure for staff to follow in these circumstances.

The Psychiatrist confirmed there were no special precautions ordered or implemented to ensure the safety of the other patients on the unit. He stated that room assignments are usually done at the discretion of the nursing staff.

The Psychiatrist stated he understood the surveyor's concerns and indicated the unit should have had a safety plan in place at the time of the patient's admission. He also stated he did not speak with the Clinical Assessment Coordinator regarding this admission and was not aware of her recommendation the patient be admitted to the Adult Unit. At the conclusion of the interview, the Psychiatrist wrote an order for patient #9 to have no roommate.

Based on record review, review of medical staff bylaws and staff interview it was determined the medical staff failed to enforce the bylaw requirement for dating all medical record entries and signing verbal orders within forty-eight (48) hours. This failed practice impacted eight (8) of ten (10) records reviewed (patients #1, 2, 3, 6, 7, 8, 9 and 10). This failure creates a potential for the safety and quality of care for all patients to be negatively impacted.

Findings include:

1. Review of the Medical Staff Bylaws, Rules and Regulations, last reviewed March 2010, revealed the following at Section F, Medical Records, F-1-10. "All entries in the medical record shall be dated, timed and signed when written. Verbal and telephone orders shall be counter-signed by the attending or consulting physician."

2. Review of the medical record for patient #1 revealed untimed physician orders written on 5/2/12, 5/3/12 and 5/7/12.

3. Review of the medical record for patient #2 revealed untimed physician orders written on 5/31/12, 6/4/12, 6/5/12, 6/7/12 and 6/11/12.

Additionally, the medical record for patient #2 had two (2) unsigned telephone orders for restraint which were written on 5/30/12 and 5/31/12.

4. This record was reviewed with the Nurse Manager at 0945 on 6/13/12 and she agreed with these findings.

5. Review of the medical record for patient #3 revealed untimed physician orders written on 6/8/12 and 6/9/12.

6. Review of the medical record for patient #6 revealed untimed physician orders written on 6/11/12 and 6/12/12.

7. These orders were reviewed and discussed with the Clinical Assessment Coordinator at 1530 on 6/12/12 and she agreed with this finding.

8. Review of the medical record for patient #7 revealed untimed physician orders written on 6/8/12, 6/9/12 and 6/11/12.

9. These orders were reviewed with the Nurse Manager at 0945 on 6/13/12 and she agreed with this finding.

10. Review of the medical record for patient #8 revealed untimed physician orders written on 6/4/12 and 6/6/12.

11. Review of the medical record for patient #9 revealed four (4) physician orders written on 6/13/12. None of these entries were timed.

12. Review of the medical record for patient #10 revealed an untimed physician order written on 6/11/12.

13. These findings were discussed with the Attending Psychiatrist at 1110 on 6/13/12. He stated he was aware of the requirement for timing all entries in the medical record.

14. These findings were discussed with the Nurse Manager at 1400 on 6/13/12. She stated the findings had been discussed with the Clinical Director and would be addressed with the rest of the medical staff.

Based on observation, review of documents and staff interview it was determined the hospital failed to ensure adequate numbers of licensed registered nurses and mental health technicians were maintained per the hospital Staffing Guidelines and Staffing Grid in the Child/Adolescent Unit. This failed practice involved a total of seventeen (17) days and twenty-one (21) shifts in May and June of 2012. This failure creates the potential for the care and condition of all patients on the Child/Adolescent Unit to be adversely impacted.

Findings include:

1. A tour and observation was conducted on the Child/Adolescent Unit at 0930 on 6/11/12. There were nine (9) patients on the unit at this time. One (1) of these patients was ordered to be on one to one (1:1) staff observation. There was one (1) Registered Nurse (RN) (plus one (1) RN orientee) and three (3) Mental Health Technicians (MHTs) on duty.

2. A request was made for the policy which is utilized to determine adequate staffing ratios for patient care. The Staffing Guidelines, dated 5/11 and Staffing Grid and for the Child/Adolescent Unit, last revised 3/18/11, were provided. Review of the guidelines and grid revealed the Adolescent Unit was short one (1) MHT at the time of the surveyor observation.

3. Staffing Reports for the Child/Adolescent Unit were reviewed for May and June 2012. Review of these Staffing Reports and the Staffing Grid revealed the Child/Adolescent Unit was understaffed on nine (9) dates in May affecting a total of eleven (11) shifts and seven (7) dates in June affecting a total of ten (10) shifts.

Review of the Staffing Guidelines/Grid and Staffing Reports revealed the Child/Adolescent Unit was understaffed on the following dates and shifts:

5/8/12 Day
5/10/12 Day and Evening
5/12/12 Day
5/14/12 Day
5/15/12 Evening
5/19/12 Day and Evening
5/21/12 Day
5/27/12 Night
5/31/12 Evening
6/2/12 Day
6/5/12 Day and Evening
6/7/12 Evening
6/8/12 Day and Evening
6/9/12 Evening
6/10/12 Day and Evening
6/12/12 Day

4. This information was reviewed and discussed with the Nurse Manager at 0830 on 6/12/12. She agreed with these findings. The Nurse Manager stated there have been several staff resignations. She stated Administration had obtained approval to add two (2) RN and two (2) MHT positions on May 16, 2012. The Nurse Manager stated the Behavioral Health Unit is in the process of filling the vacant and new positions. She noted that some staff are preparing to finish orientation, some are just beginning orientation and some new staff are scheduled to start orientation soon. The Nurse Manager also stated that admissions/census for the Child/Adolescent Unit would be capped at nine (9) patients until adequate staffing numbers could be provided and maintained.

Based on medical record review and staff interview it was determined the Registered Nurse (RN) failed to supervise and evaluate nursing care by failing to complete an admission assessment, failing to complete shift assessments and failing to provide instruction regarding discharge medications . This failed practice affected three (3) of ten (10) patients reviewed (patients #1, 2 and 4). This failure has the potential to adversely affect the care and condition of all patients.

Findings include:

1. On 6/12/12 at 1400 the Nurse Manager stated the nurse is expected to complete an assessment of all patients on the Behavioral Health Units on every shift (day, evening and nights).

2. Review of the closed record for patient #1 revealed the patient was admitted on 5/1/12 and discharged on 5/8/12. Review of the nursing admission assessment, initiated at 2315 on 5/1/12 revealed it was not completed.

3. Review of the 5/5/12 Psychiatric Nursing (shift) Assessment for patient #1 revealed the evening shift assessment was not completed. Review of the Sleep portion of the assessment revealed this was not completed by the night shift nurse.

4. Review of the nursing assessments for patient #1 for 5/8/12 (date of discharge) revealed the last assessment was completed at 0940. The patient was discharge at 1900, nearly nine (9) and a half hours later. The nurse failed to complete an assessment of the patient on evening shift nor did the nurse chart an assessment of the patient's condition at discharge.

5. Review of the 5/8/12 discharge instructions and discharge medication order sheets revealed the nurse failed to instruct the patient on medication as ordered by the physician. While hospitalized the patient was placed on new medications Abilify and Bactroban. Both of these medications were ordered to be continued at discharge. Review of the 5/8/12 Home Medication sheet revealed no documentation the nurse provided instruction regarding the new medications. The record lacked documentation regarding whether any prescriptions were provided.

6. This record was reviewed and discussed with the Nurse Manager at 1100 on 6/12/12. She agreed with these findings.

7. Review of the 5/31/12 Psychiatric Nursing Assessment for patient #2 revealed the day and evening shift assessments were not completed.

8. This record was reviewed and discussed with RN #1 at 1415 on 6/12/12. She agreed with this finding.

9. Review of the 5/10/12 Psychiatric Nursing Assessment for patient #4 revealed the dayshift assessment was not completed. Review of the 5/31/12 Psychiatric Nursing Assessment revealed the nightshift assessment was not completed.

10. These findings were discussed with the Nurse Manager at 1300 on 6/13/12. She indicated the expectations for patient assessment and documentation of shift assessments would be addressed with nursing staff.