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Based on observation, interview, and record review, the facility failed to ensure compliance with the Governing Body (GB) Condition of Participation when it failed to ensure the GB effectively carried out the responsibilities for the conduct of the facility.


1. The GB did not ensure the removal of the ligature risks (anything that could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation) in the Child Inpatient (CIP) Unit after they were identified by the facility. (Refer to A 115)

2. The GB did not ensure one (1) of two (2) emergency doors alarm system was in operating condition. (Refer to A 115).

3. The GB did not ensure the development, implementation, and maintenance of an effective, ongoing, hospital-wide, data driven quality assessment and performance improvement program (QAPI). (Refer to A 263)

The cumulative effect of these systemic failures resulted in the Governing Body's inability to ensure provision of quality healthcare in a safe environment.

Based on observation, interview, and record review, the facility failed to ensure compliance with the Patient Rights Condition of Participation when it:

1. Did not remove ligature risks (anything that could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation) in the Child Inpatient (CIP) Unit after they were identified by the facility. (Refer to A 144)

2. Did not maintain one (1) of two (2) emergency doors alarm system in operating condition. (Refer to A 144)

The cumulative effect of these systemic practices resulted in the facility's inability to provide high quality healthcare in a safe setting.

Based on interview and record review, the facility failed to ensure compliance with the QAPI Condition of Participation when it did not develop, implement, and maintain an effective, ongoing, hospital-wide, data driven quality assessment and performance improvement program, and also failed to collect and analyze quality indicator data. There was no ongoing program to show measurable improvement in indicators and program data for which there was evidence that will improve health outcomes. (Refer to A 273)

The cumulative effect of these systemic practices resulted in the facility's inability to provide its patients high quality healthcare in a safe setting.

Based on observation, interview, and record review, the facility failed to ensure 12 of 12 patients in the Child Inpatient (CIP) Unit received care in a safe setting when it:

1. Did not remove ligature risk (anything that could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation) after they were identified.

2. Failed to maintain one of two emergency doors alarm system in operating condition, which posed the risk for patient elopement (a patient who is incapable of adequately protecting himself, and who departs the health care facility unsupervised and undetected).

These failures had the potential to place all the patients in the CIP Unit at risk for harm.

Findings:

1. On 11/4/19 at 11 AM, a tour of the CIP Unit was conducted with the Director of Facilities Management & Safety (DFMS). The following ligature risks were observed:

a. In three (3) of four (4) bathrooms there were shower valve knobs that mixed hot and cold water.

b. In two (2) of four (4) bathrooms there were shower valve handles.

c. In the main hallway, accessible to patients, there were four (4) door knobs.

d. In the main hallway, accessible to patients, there were two (2) security convex mirrors mounted on wall with long curved projected brackets.

The DFMS stated shower valve knobs, shower valve handles, door knobs, and long curved projected brackets were ligature risks, because there was enough clearance for something to be tied around them and held in place without slippage.

During an interview with the Director of Engineering on 11/4/19 at 11:15 AM, he stated the ligature risks had been identified previously, but not removed.

During an interview with the Corporate President on 11/6/19 at 11 AM, he stated they were aware of the ligature risks, but they did have the funds to replace what was necessary in the patient care area.

2. On 11/4/19 at 11:30 AM, the entry door to the CIP Unit was observed to have a sign posted indicating, "Children's Hospital & Elopement Risk."

On 11/4/19 at 11 AM, a tour of the CIP Unit was conducted with the Director of Facilities Management & Safety (DFMS). The DFMS identified that one (1) of two (2) emergency exit doors alarm system did not alarm. The DFMS stated that the facility did not reset the alarm after the last fire drill.

Review of the facility's P&P titled, "Fire Alarm System," undated, showed in part, "daily inspections of the panel for normal operation of the system. Where provided, check that the connection to the monitoring center is functioning correctly. Weekly test by user. Carry out a test and examination to ensure the system is capable of operating under alarm conditions. Quarterly inspection of batteries."

Based on interview and record review, the facility failed to collect and analyze quality indicator data. There was no ongoing program that showed measurable improvement in indicators and program data for which there was evidence that it would improve health outcomes and patient safety.

This failure had the potential to result in substandard quality of care for the facility's patients.

Findings:

1. On 11/4/19 at 11 AM, a tour of the Child Inpatient (CIP) Unit was conducted with the Director of Facilities Management & Safety (DFMS). The following ligature risks were observed:

a. In three (3) of four (4) bathrooms there were shower valve knobs that mixed hot and cold water.

b. In two (2) of four (4) bathrooms there were shower valve handles.

c. In the main hallway, accessible to patients, there were four (4) door knobs.

d. In the main hallway, accessible to patients, there were two (2) security convex mirrors mounted on wall with long curved projected brackets.

During a concurrent interview with the DFMS confirmed the findings and stated they were ligature risk, because there was enough clearance for something to be tied around them and held in place without slippage.

During an interview with the Director of Engineering on 11/4/19 at 11:15 AM, he stated the ligature risk had been identified previously, but not removed.

During an interview with the Corporate President on 11/6/19 at 11 AM, he stated they were aware of the ligature risks, but they have no funds to replace what was necessary in the patient care area.

There was no documented evidence that the identified ligature risks in the CIP Unit were included in the facility's quality indicator data.

2. Review of the facility's Incident Report Log from 4/2019 to 7/2019, showed 24 incident reports of patients' aggressive behaviors/physical altercations, resulting in injuries requiring first aid treatment.

There was no documented evidence that the incident reports of patients' aggressive behaviors/physical altercations were included in the facility's quality indicator data.

During interview was conducted on 11/6/19 at 9:20 AM, with the CEO. When the QAPI Committee Minutes were requested, the CEO was unable to provide the requested documents. The CEO stated the QAPI Director resigned last week. The CEO stated the previous QAPI Director did not implement the QAPI program in the hospital. The CEO also stated the facility did not collect and analyze quality indicator data to improve health outcomes and patient safety.

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Based on interview and record review, the facility failed to:

1. Ensure adequate staffing on all patient care units.

2. Ensure the Registered Nurse (RN) directly conducted the nursing assessments and reviewed patients' care plans for 6 of 16 sampled (Patients 5, 6, 10, 11, 12, and 13).

This failure had the potential to result in substandard quality of care for the facility's patients.

(CA00632446, CA00632545, CA00636292, CA00636500, CA00636507, CA00636555, CA00636569, CA00636706, CA00660774)

Findings:

1 a. Review of the "Kedren Health Acute Psychiatric Hospital Multi-Disciplinary Staffing Protocol, dated 1/2/2019, indicated, Licensed nurses' caseloads will adhere to the 6:1 nurse to patient ratio (one licensed nurse assigned to provide nursing care for no more than six patients), and that nurse staffing hours will be determined according to patient acuity (The measurement of the intensity of nursing care that is required by a patient. An acuity-based staffing system regulates the number of nurses on a shift according to the patients' needs and not according to raw patient numbers.) levels.

On 11/5/19 at 9:15 AM, an interview was conducted with Registered Nurse 1 (RN 1), RN 1 was asked how she had made the staff assignments on the locked Adult Inpatient (AIP 1[male patients] & 2 [female patients]) Units. RN 1 stated they were not currently using patient acuity levels to make the patient care assignments. She stated that they just try to staff at a 1:6 (one licensed nurse assigned to provide nursing care for no more than six patients) licensed nurse to patient ratio.

On 11/6/19 at 3:40 PM, during an interview with the DON (Director of Nursing), the DON stated that there was not a patient acuity method currently being used to determine licensed nurse staffing needs for patient care assignments.

During an interview with the DON on 11/5/19 at 2:10 PM, she acknowledged there were numerous complaints from staff nurses concerning inadequate staffing levels on the nursing units. The DON stated the Nursing Patient Classification P&P needed to be reviewed and followed.

Review of the facility's policy and procedure (P&P) titled, "Nursing Patient Classification," last revised 9/2015 (four years ago), showed in part, the purpose of the classification of patients was to provide a method for determining the amount of nursing care each patient requires (acuity). Staffing levels should be developed according to acuity levels. Staffing needs are closely monitored through the use of the classification system and the daily census report.

b. Review of the "DAILY ASSIGNMENT - AIP 1 - DAY SHIFT" form for 11/5/19, it indicated that RN 5 had two patients on the unit. The AIP Unit 1 Assignment Sheet also showed that all the licensed nurses assigned to AIP Units were to take turns leaving the units to administer outpatient medication injections when required in the Outpatient Clinic.

On 11/5/19 at 9:30 AM, during interview with RN 1, RN 1 stated RN 5 only had two patients on the AIP Unit 1, because she also had patients on AIP Unit 2.

On 11/5/19 at 3:35 PM, during interview with the DON (Director of Nursing), she agreed that the facility needed more registered nurses.

c. During an interview with RN 1(Charge Nurse) on 11/4/19 at 10 AM, RN 1 stated her duties included making patient rounds, facilitating patients care, calling physicians, admitting and discharging patients, and generally managing the nursing on the unit. RN 1 also stated she accepted a full load of patient assignments and provided direct patient care, while managing the units.

During an interview with the Director of Nursing (DON) on 11/5/19 at 2 PM, the DON stated the hospital's current full time staffing pool consisted of 13 Registered Nurses, 12 Licensed Vocational Nurses, 6 Licensed Psychiatric Technician, 13 Certified Nursing Assistants, and 12 Mental Health Workers. She stated the hospital used Nurse Staffing Agencies when the patients required more care, and when they did not have enough licensed nurses. The DON stated RNs' breaks were covered, by another RN from another unit.

Review of the Daily Schedule for April 2019, indicated insufficient RN staffing to cover for the RNs breaks in both AIP Units and CIP Unit from 4/8/19 through 4/30/19 as follows:

There was only one RN working on both AIP Units and CIP Unit at the same time for 23 shifts (4/8, 4/9, 4/10, 4/11, 4/12, 4/13, 4/14, 4/15, 4/16, 4/17, 4/18, 4/19, 4/20, 4/21, 4/22, 4/23, 4/24, 4/25, 4/26, 4/27, 4/28, 4/29, and 4/30).

During an interview with the DON on 11/5/19 at 2:10 PM, she acknowledged there were numerous complaints from staff nurses concerning inadequate staffing levels on the nursing units. The DON stated there should have been one RN present in each nursing unit.

2. Review of Patients 5, 6, 10, 11, 12, and 13 medical records failed to show documented evidence that a RN conducted the nursing assessments and reviewed the patients' care plan.

Review of the facility's P&P titled, "Documentation Standards for Inpatient Services," undated, showed under Nursing, the Nursing Assessment will be completed on each admission, within 24 hours. A week summary note which includes, the level of participation in the milieu, and assessment of patient's status.

During an interview with RN 2 on 11/5/19 at 10 AM, RN 2 acknowledged that they did not use an acuity method to determine patient care needs prior to delegating the care of the patients.

Based on interview and record review, the facility failed to ensure that all dictated medical records were dated, timed and authenticated for four Patients (Patients 1, 2, 3 and 4). This failure resulted in an incomplete medical record for each patient after admission to the facility.

Findings:

1. During a review of the clinical record for Patient 3 on 11/5/19 at 10:30 AM, the face sheet (demographic information of patient and partial medical history) indicated Patient 3 was admitted to the facility on 10/29/19 for a 5150 hold (involuntary hold) due to being a danger to self and a danger to others.

Review of Patient 3's dictated Psychiatric and Mental Status Evaluation, indicated that it was not signed, dated or timed by the Nurse Practitioner (NP).

During an interview with RN 1 on 11/5/19 at 10:45 AM, she stated that Patient 3's dictated Psychiatric and Mental Status Evaluation should have been signed by now, but she did not know why it had not been signed, yet.

2. During a review of the clinical record for Patient 4 on 11/5/19 at 10:34 AM, the face sheet (demographic information of patient and partial medical history) indicated Patient 4 was admitted to the facility on 10/28/19 for a 5150 hold (involuntary hold) due to being gravely disabled (unable to care for himself).

Review of Patient 4's dictated History and Physical (H&P) Examination, indicated the dictated H&P was not signed or dated by Medical Doctor (MD 1).

During an interview with RN 1 on 11/5/2019 at 10:46 AM, she stated that Patient 4's dictated H&P should have been signed by now, but she did not know why it had not been signed, yet.


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3. Patient 2's clinical record was reviewed on 11/5/19. It was noted that Patient 2 had been admitted to the facility for treatment on 10/17/19. His physician had dictated an H&P Examination on 10/18/19. As of 11/5/19, the physician had yet to authenticate the document with his signature and date of authentication.

During an interview with RN 1 (Registered Nurse 1) on 11/5/19 at 10:50 AM, she stated that Patient 2's dictated H&P Examination should have been signed and dated by now, but offered no reason as to why it had not been done.

4. Patient 1's clinical record was reviewed on 11/5/19. It was noted that he had been admitted to the facility for treatment on 7/10/19, and his physician dictated an H&P (history and physical examination) on 7/10/19. The physician who dictated the H&P had signed it, but failed to include the date of his signature.

During an interview with RN 1 (Registered Nurse 1) on 11/5/19 at 10:52 AM, she stated that Patient 1's dictated H&P Examination should have also included the date of the physician's signature.

Review of the facility's policy and procedure (P&P) titled, "Medical History and Physical Examination," dated, 10/2019, did not indicate when a dictated H&P should be signed and dated by the practitioner.

Based on observation and interview, the facility failed to ensure the Child Inpatient (CIP) Unit was maintained for the safety and well-being of patients. Furniture in the Activity Room (AR) was in need of repair. This failure had the potential to result in avoidable injuries for patients.

Findings:

During a tour of the CIP Unit's Activity Room (where the children spend most of the time), conducted on 11/4/19 between 11 AM and 12:30 PM, accompanied by the Director of Facility Management & Safety (DFMS). The following was observed:

a. An orange colored sofa's armrest upholstery was peeling.
b. A hard plastic chair had holes measuring approximately 2 centimeters (cm) in diameter.
c. An office chair's armrest and backrest had peeling upholstery.
d. A table had peeling material.

The DFMS confirmed the findings.