HospitalInspections.org

Based on document review and interview, the Hospital failed to ensure in 1 of 2 (Pt #1) clinical records reviewed of patients with documented complaints, that the patient and/or family member were informed in writing of the Hospital's resolution regarding the complaint.

Findings include:

1. Hospital policy entitled "Patient Complaints / Concerns," (reviewed 6/12) required, " Action Steps...5. Patient Advocate:..F. Ensures that patient and/or family member(s) are informed regarding analysis of complaint/concerns, and of any corrective action that is taken as soon as possible, but no longer than five (5) days from when the complaint was received."

2. The clinical record of Pt #1 was reviewed on 6/11/13 at approximately 10:30 AM. Pt #1 was an 11 year old female admitted on 4/30/13 with diagnoses of severe major depression and suicidal ideation. Upon admission Pt #1 was placed on suicide, assault, and elopement precautions. As per policy entitled "Precautions and Observations," Pt #1 was monitored every 15 minutes with location and behavior documented, as required. Pt #1's clinical record lacked documentation of inappropriate sexual behavior while in the Hospital.

3. The Hospital's incident reports were reviewed on 6/11/13 at approximately 1:00 PM. The reports included Pt #1. The report dated 5/8/13 (2 days after discharge) stated, "Hospital staff received a call from pt's mother on 5/8/13. Mother reported that pt made an allegation to her school counselor this week. Writer spoke with pt's school counselor... on 5/9/13. Ms ...reported that pt alleged a female peer asked pt to kiss her and take her clothes off while they were in their room together while hospitalized ....Writer left message for pt's father on 5/9/13. No return call..." The incident report lacked documentation that the patient/family were made aware of the Hospital's findings and of any corrective action taken.

4. The findings were verified with the Chief Compliance/Nursing Officer and Patient Advocate during an interview on 6/11 13 at approximately 1:15 PM.

Based on document review and interview, it was determined that for 2 of 2 (1 West and 2 Central) psychiatric units, the Hospital failed to ensure adequate staffing.

Findings include:

1. Hospital policy entitled, "Acuity and Staffing Factors," (reviewed 1/12) required, "Policy Statement: It is policy of this facility to maintain a staffing level which supports safe and therapeutic care for each facility program."

2. Hospital policy entitled, "Staffing Program Plan / Staffing the Patient Units," (reviewed 1/12) required, "Policy Statement: Staffing is based on a staffing grid and a current patient acuity. A Registered Nurse must be on duty on each unit 24 hours a day."

3. The Hospital's staffing matrix for the 1 West Unit (Pt #1's unit) (revised 1/12) was reviewed on 6/13/13 at approximately 9:30 AM and required, "for 17 patients - days 1 RN, an additional RN/LPN, and 2 MHWs, evenings 1 RN, and additional RN/LPN, and 2 MHWs." The Hospital's staffing matrix for the 2 Central Unit (revised 1/12) was reviewed on 6/13/13 at approximately 9:30 AM and required, "for 7 patients - days 1 RN and 1 MHW, evenings 1 RN and 1 MHW and nights 1 RN and 1 MHW. for 10 - days 1 RN and 1 MHW."


4. On 6/13/13 at approximately 9:00 AM the Hospital's staffing schedules for 4/13/13 to 4/20/13 were reviewed for 2 Central. The schedules included dates and shifts that were short of the required number of staff. Examples include: 5/4/13, 7:00 AM to 3:00 PM with a census of 17, did not have the required additional RN/LPN on duty, 5/15/13, 7:00 AM to 3:00 PM with census of 17 did not have the required additional RN/LPN on duty; 5/16/13 - 3:00 PM to 11:00 PM did not have the required additional RN on duty; and 7/17/13 with census of 17 did not have the required additional RN/LPN on duty.
On 6/13/13 at approximately 9:00 AM the Hospital's staffing schedules for 4/13/13 to 4/20/13 were reviewed for 1West. The schedules included dates and shifts that were short of the required number of staff. Examples include: 5/4/13, 7:00 AM to 3:00 PM with census of 17, did not have the required additional RN/LPN on duty; 5/15/13, 7:00AM to 3:00 PM with census of 17 did not have the required RN/LPN on duty. 5/16/13 3:00PM to 11:00 PM did not have the required additional RN on duty; and 7/17/13 with census of 17 did not have the required additional RN/LPN on duty.

5. The findings were verified with the Chief Compliance/Nursing Officer during an interview on 6/13/13 at approximately 10:30 AM.