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Based on observation, record review, and interview, the hospital failed to ensure the patient's right to receive care in a safe setting. This deficient practice was evidenced by:
1) failure of the nursing staff to ensure MHT's were performing observations on 3 (#1-#3) of 3 (#1-#3) patients reviewed;
2) failure to ensure employees were CPR certified in 4 (S4RN, S6MHT, S7MHT, S8MHT) of 7 (S2RMQ, S4RN, S5RN, S6MHT, S7MHT, S8MHT, S9LPN) personnel files reviewed; and
3) failure to ensure employees were trained in crisis intervention in 3 (S5RN, S6MHT, S7MHT) of 7 (S2RMQ, S4RN, S5RN, S6MHT, S7MHT, S8MHT, S9LPN) personnel files reviewed.
Findings:

1) Failure of the nursing staff to ensure MHT's were performing observations on 3 (#1-#3) of 3 (#1-#3) patients reviewed.

A review of hospital policy No. EOC 1.18, titled "Observation Precaution," date originated 01/04/2021, no last date revised, revealed in part: "PURPOSE: To promote safety and ensure that the patient is being treated in the least restrictive environment that is clinically permitted. DOCUMENTATION: The charge nurse will be responsible, for assignment of staff to carry out ordered status. Staff assignments will be recorded on the MHT Team Assignment Form by the Charge RN. Charge nurse or designee will make rounds every 2 hours and sign the Observation Sheet to ensure that the MHT's are observing their assigned patient, filling the form out correctly and not charting ahead."

Patient #1
Review of Patient #1's medical record revealed Patient #1 was admitted on 07/15/2024 for Schizophrenia and Bipolar Disorder.

Review of the Close Observation sheets for Patient #1 revealed the following:
03/07/2025 missing observation for 3:45 PM.
03/08/2025 missing RN initials for 8:00 AM-11:45 AM and 12:00PM-3:45 PM.

Further review of Patient #1's medical record failed to reveal documentation that the RN rounded on the patient every 2 hours per hospital policy.

In an interview on 04/01/2025 at 10:00 AM, S2RMQ verified observation at 3:45 PM on 03/07/2025 was not completed, and on 03/08/2025 two RN initials were not completed for 8:00 AM-11:45 AM and 12:00 PM-5:45 PM. S2RMQ also verified all of the above should have been completed and they were not. S2RMQ further reported RN observation checks were to be completed every two hours per policy and the checks were not completed.


Patient #2
Review of Patient #2's medical record revealed Patient #2 was admitted on 03/23/2025 for Bipolar, Depression, and SI. On admit Patient #2 was placed on Q15 minute observations and placed on LOS on 03/25/2025.

Review of the Close Observation sheets for Patient #2 revealed the following:
03/25/2025 missing RN initials for 8:00 PM
03/28/2025 missing RN initials for 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM

Further review of Patient #2's medical record failed to reveal documentation that the RN rounded on the patient every 2 hours per hospital policy.

Patient #3
Review of Patient #3's medical record revealed Patient #3 was admitted on 03/24/2025 with Bipolar, Opioid Dependence, and Stimulant Dependence. On admit Patient #3 was placed on Q15 minute observations.

Review of the Close Observation sheets for Patient #2 revealed the following:
03/24/2025 missing RN initials for 8:00 PM
03/26/2025 missing RN initials for 8:00 AM

Further review of Patient #3's medical record failed to reveal documentation that the RN rounded on the patient every 2 hours per hospital policy.

In an interview on 04/01/2025 at 10:08 AM, S1DON confirmed the above mentioned findings. S1DON stated the RN initials blank on the close observation sheet is for the RN to initial, verifying the MHT's are performing their observations as ordered. S1DON also confirmed the RN did not document anywhere that they performed their rounds every 2 hours as per policy.

2) Failure to ensure employees were CPR (Cardio-Pulmonary Resuscitation) certified in 4 (S4RN, S6MHT, S7MHT, S8MHT) of 7 (S2RMQ, S4RN, S5RN, S6MHT, S7MHT, S8MHT, S9LPN) personnel files reviewed.

A review of the hospital policy No. 314, titled "Medical Emergencies," date adopted: 05/2024, revealed in part: "PROCEDURE: Nursing: In an Emergent Medical Crisis: Acts to Preserve Life: As indicated initiates, as appropriate, CPR or other intern medical treatment while other staff are directed to activate the EMS system. Staff Training: Nursing staff are certified in the BCLS, First Aid, and the Use of an AED."

A review of the provided job description for Registered Nurse revealed in part: "Duties and Expectations: Adheres to established nursing practices and standards of care."

A review of the provided job description for Mental Health Technician revealed in part: "QUALIFICATIONS: Must have valid Driver's License, Crisis Intervention and CPR."

A review of employee personnel records S4RN, S6MHT, S7MHT, and S8MHT failed to reveal documented CPR certification.

In an interview on 04/01/2025 at 9:58 AM, S3HR confirmed S4RN, S6MHT, S7MHT, and S8MHT did not have documented CPR certification in their employee files. S3HR also confirmed that all staff should have a current CPR certification in their employee files.

In an interview on 04/01/2025 at 10:08 AM, S1DON confirmed that all nurses and MHT's should have current CPR certification to provide a safe patient environment.


3) Failure to ensure employees were trained in crisis intervention in 3 (S5RN, S6MHT, S7MHT) of 7 (S2RMQ, S4RN, S5RN, S6MHT, S7MHT, S8MHT, S9LPN) personnel files reviewed.

A review of employee personnel records for S5RN, S6MHT and S7MHT failed to reveal documented crisis intervention training.

In an interview on 04/01/2025 at 9:58 AM, S3HR confirmed S5RN, S6MHT, and S7MHT did not have documented crisis intervention training in their employee file. S3HR stated this training is included in their PEACE training and should be done upon hire and then annually. S3HR further stated that the above mentioned employees failed to attend the last class offered for crisis intervention training.

In an interview on 04/01/2025 at 10:08 AM, S1DON confirmed that all nurses and MHT's should have current education in crisis intervention to provide a safe patient environment.

Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by the failure of the nursing staff to document vital signs as ordered by the physician for 1 (#3) of 3 (#1-#3) patient medical records reviewed.
Findings:

A review of hospital policy No. PC 11.71, titled "Vital Signs and Weights," date originated 01/04/2021, no last date revised, revealed in part: "POLICY: All patients will have their vital signs, including pain assessment, weight and height, taken on admission. Vital signs will be taken a minimum of twice a day thereafter, unless the physician orders a more frequent schedule."

Review of Patient #3's medical record revealed Patient #3 was admitted on 03/24/2025 with Bipolar, Opioid Dependence, and Stimulant Dependence. Patient #3 was discharged on 03/26/2025.

Review of Patient #3's admit orders initiated on 03/24/2025 at 6:45 PM revealed an order for vital signs to be obtained on admit, then BID.

Review of Patient #3's Vital Sign Graphic Flowsheet revealed vital signs were obtained the following times:
03/24/2025 at 10:00 PM
03/25/2025 at 10:00 PM
Further review failed to reveal that vital signs were obtained BID as ordered by the physician.

In an interview on 04/01/2025 at 10:08 AM, S1DON confirmed the above mentioned findings.

Based on record review and interview, the hospital failed to administer drugs in accordance with accepted standards of practice. This deficient practice was evidenced by the failure to document the effects of an administered as needed medication in 1 (#3) of 3 (#1 - #3) patient medical records reviewed.
Findings:

A review of hospital policy No. 401 titled, "Medication Administration," with a last revised date of 07/17/2024, did not reveal a procedure for the documentation of the effectiveness after an as needed medication was administered. Further the hospital was unable to produce a policy and procedure related to the documentation of the effectiveness after an as needed medication was administered.

Review of Patient #3's medical record revealed Patient #3 was admitted on 03/24/2025 with Bipolar, Opioid Dependence, and Stimulant Dependence.

Review of Patient #3's Medication Administration Record revealed the following PRN order:
Clonidine 0.1 mg PO every 8 hours PRN for SBP greater than 160, DBP greater than 100
Further review of Patient #3's MAR revealed that Patient #3 was given Clonidine 0.1mg PO on 03/24/2025 at 10:00 PM.

Review of Patient #3's Vital Sign Graphic Flowsheet revealed the following vital signs on 03/24/2025 at 10:00 PM:
BP 169/99 and Pulse 68
Further review failed to reveal repeat vital signs or documentation of the effects of the as needed Clonidine.

In an interview on 04/01/2025 at 10:08 AM, S1DON confirmed the above mentioned findings.